|
Arthrocentesis, Aspirtn and/or Inj; Small Joint or Bursa (eg, Fingers, toes) Cha
|
Facility
|
OP
|
$239.00
|
|
|
Service Code
|
CPT 20600
|
| Hospital Charge Code |
729203
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$18.83 |
| Max. Negotiated Rate |
$474.93 |
| Rate for Payer: Aetna of AZ Commercial |
$215.10
|
| Rate for Payer: Arizona Complete Health Allwell |
$38.24
|
| Rate for Payer: Banner UC Health Medicare |
$38.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$162.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$18.83
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$38.24
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$38.24
|
| Rate for Payer: Cash Price |
$191.20
|
| Rate for Payer: Cash Price |
$191.20
|
| Rate for Payer: Cigna of AZ Commercial |
$167.30
|
| Rate for Payer: Devoted Health Medicare |
$43.02
|
| Rate for Payer: Humana of AZ Medicare |
$38.24
|
| Rate for Payer: Mercy Care Medicaid |
$18.83
|
| Rate for Payer: NaphCare Correctional Healthcare |
$18.83
|
| Rate for Payer: Seven Corners Travel Insurance |
$474.93
|
| Rate for Payer: Southwest Service Administrators UFCW |
$162.52
|
| Rate for Payer: TriWest Medicare |
$38.24
|
| Rate for Payer: United Healthcare Commercial |
$136.71
|
| Rate for Payer: United Healthcare Medicare |
$38.24
|
| Rate for Payer: Veterans Affairs TRICARE |
$37.86
|
|
|
ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT
|
Facility
|
OP
|
$11,227.32
|
|
|
Service Code
|
CPT 28750
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$198.04 |
| Max. Negotiated Rate |
$11,227.32 |
| Rate for Payer: Banner UC Health Medicare |
$3,842.26
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$198.04
|
| Rate for Payer: Mercy Care Medicaid |
$198.04
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,842.26
|
| Rate for Payer: Seven Corners Travel Insurance |
$11,227.32
|
| Rate for Payer: United Healthcare Commercial |
$6,508.00
|
|
|
ARTHRODESIS MIDTARSAL OR TARSOMETATARSAL MULTIPLE OR TRANSVERSE
|
Facility
|
IP
|
$3,571.00
|
|
|
Service Code
|
CPT 28730
|
| Hospital Charge Code |
24043324
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,213.90 |
| Max. Negotiated Rate |
$3,213.90 |
| Rate for Payer: Aetna of AZ Commercial |
$3,213.90
|
| Rate for Payer: Cash Price |
$2,856.80
|
|
|
ARTHRODESIS MIDTARSAL OR TARSOMETATARSAL MULTIPLE OR TRANSVERSE
|
Facility
|
OP
|
$3,571.00
|
|
|
Service Code
|
CPT 28730
|
| Hospital Charge Code |
24043324
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$565.65 |
| Max. Negotiated Rate |
$19,864.90 |
| Rate for Payer: Aetna of AZ Commercial |
$3,213.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$571.36
|
| Rate for Payer: Banner UC Health Medicare |
$8,354.17
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$2,428.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$571.36
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$571.36
|
| Rate for Payer: Cash Price |
$2,856.80
|
| Rate for Payer: Cash Price |
$2,856.80
|
| Rate for Payer: Cash Price |
$2,856.80
|
| Rate for Payer: Cigna of AZ Commercial |
$1,785.50
|
| Rate for Payer: Devoted Health Medicare |
$642.78
|
| Rate for Payer: Humana of AZ Medicare |
$571.36
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8,354.17
|
| Rate for Payer: Seven Corners Travel Insurance |
$19,864.90
|
| Rate for Payer: Southwest Service Administrators UFCW |
$2,428.28
|
| Rate for Payer: TriWest Medicare |
$571.36
|
| Rate for Payer: United Healthcare Commercial |
$6,508.00
|
| Rate for Payer: United Healthcare Medicare |
$571.36
|
| Rate for Payer: Veterans Affairs TRICARE |
$565.65
|
|
|
ARTHROSCOPIC PACK
|
Facility
|
IP
|
$242.00
|
|
| Hospital Charge Code |
22354803
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$217.80 |
| Max. Negotiated Rate |
$217.80 |
| Rate for Payer: Aetna of AZ Commercial |
$217.80
|
| Rate for Payer: Cash Price |
$193.60
|
|
|
ARTHROSCOPIC PACK
|
Facility
|
OP
|
$242.00
|
|
| Hospital Charge Code |
22354803
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$38.33 |
| Max. Negotiated Rate |
$217.80 |
| Rate for Payer: Aetna of AZ Commercial |
$217.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$38.72
|
| Rate for Payer: Banner UC Health Medicare |
$38.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$164.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$38.72
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$38.72
|
| Rate for Payer: Cash Price |
$193.60
|
| Rate for Payer: Cigna of AZ Commercial |
$169.40
|
| Rate for Payer: Devoted Health Medicare |
$43.56
|
| Rate for Payer: Humana of AZ Medicare |
$38.72
|
| Rate for Payer: Southwest Service Administrators UFCW |
$164.56
|
| Rate for Payer: TriWest Medicare |
$38.72
|
| Rate for Payer: United Healthcare Commercial |
$138.42
|
| Rate for Payer: United Healthcare Medicare |
$38.72
|
| Rate for Payer: Veterans Affairs TRICARE |
$38.33
|
|
|
ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND L
|
Facility
|
IP
|
$3,056.00
|
|
|
Service Code
|
CPT 29880
|
| Hospital Charge Code |
27357092
|
|
Hospital Revenue Code
|
362
|
| Min. Negotiated Rate |
$2,750.40 |
| Max. Negotiated Rate |
$2,750.40 |
| Rate for Payer: Aetna of AZ Commercial |
$2,750.40
|
| Rate for Payer: Cash Price |
$2,444.80
|
|
|
ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND L
|
Facility
|
OP
|
$3,056.00
|
|
|
Service Code
|
CPT 29880
|
| Hospital Charge Code |
27357092
|
|
Hospital Revenue Code
|
362
|
| Min. Negotiated Rate |
$484.07 |
| Max. Negotiated Rate |
$5,062.66 |
| Rate for Payer: Aetna of AZ Commercial |
$2,750.40
|
| Rate for Payer: Arizona Complete Health Allwell |
$488.96
|
| Rate for Payer: Banner UC Health Medicare |
$488.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$2,078.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$488.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$488.96
|
| Rate for Payer: Cash Price |
$2,444.80
|
| Rate for Payer: Cash Price |
$2,444.80
|
| Rate for Payer: Cigna of AZ Commercial |
$1,986.40
|
| Rate for Payer: Devoted Health Medicare |
$550.08
|
| Rate for Payer: Humana of AZ Medicare |
$488.96
|
| Rate for Payer: Seven Corners Travel Insurance |
$5,062.66
|
| Rate for Payer: Southwest Service Administrators UFCW |
$2,078.08
|
| Rate for Payer: TriWest Medicare |
$488.96
|
| Rate for Payer: United Healthcare Commercial |
$1,748.03
|
| Rate for Payer: United Healthcare Medicare |
$488.96
|
| Rate for Payer: Veterans Affairs TRICARE |
$484.07
|
|
|
Arthroscopy, knee, surgical; with meniscectomy (medial and lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed
|
Facility
|
OP
|
$5,062.66
|
|
|
Service Code
|
CPT 29880
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,062.88 |
| Max. Negotiated Rate |
$5,062.66 |
| Rate for Payer: Banner UC Health Medicare |
$1,062.88
|
| Rate for Payer: NaphCare Correctional Healthcare |
$1,062.88
|
| Rate for Payer: Seven Corners Travel Insurance |
$5,062.66
|
| Rate for Payer: United Healthcare Commercial |
$4,838.00
|
|
|
ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LA
|
Facility
|
OP
|
$2,945.00
|
|
|
Service Code
|
CPT 29881
|
| Hospital Charge Code |
27357091
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$466.49 |
| Max. Negotiated Rate |
$5,062.66 |
| Rate for Payer: Aetna of AZ Commercial |
$2,650.50
|
| Rate for Payer: Arizona Complete Health Allwell |
$471.20
|
| Rate for Payer: Banner UC Health Medicare |
$1,062.88
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$2,002.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$471.20
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$471.20
|
| Rate for Payer: Cash Price |
$2,356.00
|
| Rate for Payer: Cash Price |
$2,356.00
|
| Rate for Payer: Cash Price |
$2,356.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,472.50
|
| Rate for Payer: Devoted Health Medicare |
$530.10
|
| Rate for Payer: Humana of AZ Medicare |
$471.20
|
| Rate for Payer: NaphCare Correctional Healthcare |
$1,062.88
|
| Rate for Payer: Seven Corners Travel Insurance |
$5,062.66
|
| Rate for Payer: Southwest Service Administrators UFCW |
$2,002.60
|
| Rate for Payer: TriWest Medicare |
$471.20
|
| Rate for Payer: United Healthcare Commercial |
$4,838.00
|
| Rate for Payer: United Healthcare Medicare |
$471.20
|
| Rate for Payer: Veterans Affairs TRICARE |
$466.49
|
|
|
ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LA
|
Facility
|
IP
|
$2,945.00
|
|
|
Service Code
|
CPT 29881
|
| Hospital Charge Code |
27357091
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$2,650.50 |
| Max. Negotiated Rate |
$2,650.50 |
| Rate for Payer: Aetna of AZ Commercial |
$2,650.50
|
| Rate for Payer: Cash Price |
$2,356.00
|
|
|
ARTHROTOMY ANKLE WITH JOINT EXPLORATION WITH OR WITHOUT BIOPSY WITH OR WITHO
|
Facility
|
OP
|
$2,190.00
|
|
|
Service Code
|
CPT 27620
|
| Hospital Charge Code |
24043333
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$346.90 |
| Max. Negotiated Rate |
$5,062.66 |
| Rate for Payer: Aetna of AZ Commercial |
$1,971.00
|
| Rate for Payer: Arizona Complete Health Allwell |
$350.40
|
| Rate for Payer: Banner UC Health Medicare |
$1,062.88
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$1,489.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$350.40
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$350.40
|
| Rate for Payer: Cash Price |
$1,752.00
|
| Rate for Payer: Cash Price |
$1,752.00
|
| Rate for Payer: Cash Price |
$1,752.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,095.00
|
| Rate for Payer: Devoted Health Medicare |
$394.20
|
| Rate for Payer: Humana of AZ Medicare |
$350.40
|
| Rate for Payer: NaphCare Correctional Healthcare |
$1,062.88
|
| Rate for Payer: Seven Corners Travel Insurance |
$5,062.66
|
| Rate for Payer: Southwest Service Administrators UFCW |
$1,489.20
|
| Rate for Payer: TriWest Medicare |
$350.40
|
| Rate for Payer: United Healthcare Commercial |
$4,838.00
|
| Rate for Payer: United Healthcare Medicare |
$350.40
|
| Rate for Payer: Veterans Affairs TRICARE |
$346.90
|
|
|
ARTHROTOMY ANKLE WITH JOINT EXPLORATION WITH OR WITHOUT BIOPSY WITH OR WITHO
|
Facility
|
IP
|
$2,190.00
|
|
|
Service Code
|
CPT 27620
|
| Hospital Charge Code |
24043333
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,971.00 |
| Max. Negotiated Rate |
$1,971.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,971.00
|
| Rate for Payer: Cash Price |
$1,752.00
|
|
|
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF LOOSE OR FOREIGN
|
Facility
|
IP
|
$1,474.00
|
|
|
Service Code
|
CPT 28024
|
| Hospital Charge Code |
24043319
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,326.60 |
| Max. Negotiated Rate |
$1,326.60 |
| Rate for Payer: Aetna of AZ Commercial |
$1,326.60
|
| Rate for Payer: Cash Price |
$1,179.20
|
|
|
ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF LOOSE OR FOREIGN
|
Facility
|
OP
|
$1,474.00
|
|
|
Service Code
|
CPT 28024
|
| Hospital Charge Code |
24043319
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$149.58 |
| Max. Negotiated Rate |
$4,169.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,326.60
|
| Rate for Payer: Arizona Complete Health Allwell |
$235.84
|
| Rate for Payer: Banner UC Health Medicare |
$504.49
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$1,002.32
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$149.58
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$235.84
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$235.84
|
| Rate for Payer: Cash Price |
$1,179.20
|
| Rate for Payer: Cash Price |
$1,179.20
|
| Rate for Payer: Cash Price |
$1,179.20
|
| Rate for Payer: Cigna of AZ Commercial |
$737.00
|
| Rate for Payer: Devoted Health Medicare |
$265.32
|
| Rate for Payer: Humana of AZ Medicare |
$235.84
|
| Rate for Payer: Mercy Care Medicaid |
$149.58
|
| Rate for Payer: NaphCare Correctional Healthcare |
$504.49
|
| Rate for Payer: Seven Corners Travel Insurance |
$2,488.00
|
| Rate for Payer: Southwest Service Administrators UFCW |
$1,002.32
|
| Rate for Payer: TriWest Medicare |
$235.84
|
| Rate for Payer: United Healthcare Commercial |
$4,169.00
|
| Rate for Payer: United Healthcare Medicare |
$235.84
|
| Rate for Payer: Veterans Affairs TRICARE |
$233.48
|
|
|
artificial tear ointment [CQCH]
|
Facility
|
IP
|
$5.86
|
|
|
Service Code
|
NDC 17478006235
|
| Hospital Charge Code |
105934694
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$5.27 |
| Max. Negotiated Rate |
$5.27 |
| Rate for Payer: Aetna of AZ Commercial |
$5.27
|
| Rate for Payer: Cash Price |
$4.69
|
|
|
artificial tear ointment [CQCH]
|
Facility
|
OP
|
$5.86
|
|
|
Service Code
|
NDC 17478006235
|
| Hospital Charge Code |
105934694
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$5.27 |
| Rate for Payer: Aetna of AZ Commercial |
$5.27
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.94
|
| Rate for Payer: Banner UC Health Medicare |
$0.94
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$3.98
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.94
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.94
|
| Rate for Payer: Cash Price |
$4.69
|
| Rate for Payer: Cigna of AZ Commercial |
$3.81
|
| Rate for Payer: Devoted Health Medicare |
$1.05
|
| Rate for Payer: Humana of AZ Medicare |
$0.94
|
| Rate for Payer: Southwest Service Administrators UFCW |
$3.98
|
| Rate for Payer: TriWest Medicare |
$0.94
|
| Rate for Payer: United Healthcare Commercial |
$3.35
|
| Rate for Payer: United Healthcare Medicare |
$0.94
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.93
|
|
|
artificial tears ophth soln [CQCH]
|
Facility
|
IP
|
$4.97
|
|
|
Service Code
|
NDC 17478006012
|
| Hospital Charge Code |
105934755
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$4.47 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Aetna of AZ Commercial |
$4.47
|
| Rate for Payer: Cash Price |
$3.98
|
|
|
artificial tears ophth soln [CQCH]
|
Facility
|
OP
|
$4.97
|
|
|
Service Code
|
NDC 17478006012
|
| Hospital Charge Code |
105934755
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$4.47 |
| Rate for Payer: Aetna of AZ Commercial |
$4.47
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.80
|
| Rate for Payer: Banner UC Health Medicare |
$0.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$3.38
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.80
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.80
|
| Rate for Payer: Cash Price |
$3.98
|
| Rate for Payer: Cigna of AZ Commercial |
$3.23
|
| Rate for Payer: Devoted Health Medicare |
$0.89
|
| Rate for Payer: Humana of AZ Medicare |
$0.80
|
| Rate for Payer: Southwest Service Administrators UFCW |
$3.38
|
| Rate for Payer: TriWest Medicare |
$0.80
|
| Rate for Payer: United Healthcare Commercial |
$2.84
|
| Rate for Payer: United Healthcare Medicare |
$0.80
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.79
|
|
|
Ascend AQ Ureteral Dilation Baloon Catheter Set
|
Facility
|
OP
|
$1,685.00
|
|
| Hospital Charge Code |
22926476
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$266.90 |
| Max. Negotiated Rate |
$1,516.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,516.50
|
| Rate for Payer: Arizona Complete Health Allwell |
$269.60
|
| Rate for Payer: Banner UC Health Medicare |
$269.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$1,145.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$269.60
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$269.60
|
| Rate for Payer: Cash Price |
$1,348.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,179.50
|
| Rate for Payer: Devoted Health Medicare |
$303.30
|
| Rate for Payer: Humana of AZ Medicare |
$269.60
|
| Rate for Payer: Southwest Service Administrators UFCW |
$1,145.80
|
| Rate for Payer: TriWest Medicare |
$269.60
|
| Rate for Payer: United Healthcare Commercial |
$963.82
|
| Rate for Payer: United Healthcare Medicare |
$269.60
|
| Rate for Payer: Veterans Affairs TRICARE |
$266.90
|
|
|
Ascend AQ Ureteral Dilation Baloon Catheter Set
|
Facility
|
IP
|
$1,685.00
|
|
| Hospital Charge Code |
22926476
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,516.50 |
| Max. Negotiated Rate |
$1,516.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,516.50
|
| Rate for Payer: Cash Price |
$1,348.00
|
|
|
ASCOPE 4 CYSTO STANDARD DEFLECTION
|
Facility
|
OP
|
$175.00
|
|
| Hospital Charge Code |
27748825
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$27.72 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of AZ Commercial |
$157.50
|
| Rate for Payer: Arizona Complete Health Allwell |
$28.00
|
| Rate for Payer: Banner UC Health Medicare |
$28.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$119.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$28.00
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$28.00
|
| Rate for Payer: Cash Price |
$140.00
|
| Rate for Payer: Cigna of AZ Commercial |
$122.50
|
| Rate for Payer: Devoted Health Medicare |
$31.50
|
| Rate for Payer: Humana of AZ Medicare |
$28.00
|
| Rate for Payer: Southwest Service Administrators UFCW |
$119.00
|
| Rate for Payer: TriWest Medicare |
$28.00
|
| Rate for Payer: United Healthcare Commercial |
$100.10
|
| Rate for Payer: United Healthcare Medicare |
$28.00
|
| Rate for Payer: Veterans Affairs TRICARE |
$27.72
|
|
|
ASCOPE 4 CYSTO STANDARD DEFLECTION
|
Facility
|
IP
|
$175.00
|
|
| Hospital Charge Code |
27748825
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$157.50 |
| Max. Negotiated Rate |
$157.50 |
| Rate for Payer: Aetna of AZ Commercial |
$157.50
|
| Rate for Payer: Cash Price |
$140.00
|
|
|
ascorbic acid 500 mg/mL Sol[CQCH]
|
Facility
|
IP
|
$4.95
|
|
|
Service Code
|
NDC 67157010150
|
| Hospital Charge Code |
200236188
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$4.46 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna of AZ Commercial |
$4.46
|
| Rate for Payer: Cash Price |
$3.96
|
|
|
ascorbic acid 500 mg/mL Sol[CQCH]
|
Facility
|
OP
|
$4.95
|
|
|
Service Code
|
NDC 67157010150
|
| Hospital Charge Code |
200236188
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$4.46 |
| Rate for Payer: Aetna of AZ Commercial |
$4.46
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.79
|
| Rate for Payer: Banner UC Health Medicare |
$0.79
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$3.37
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.79
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.79
|
| Rate for Payer: Cash Price |
$3.96
|
| Rate for Payer: Cigna of AZ Commercial |
$3.22
|
| Rate for Payer: Devoted Health Medicare |
$0.89
|
| Rate for Payer: Humana of AZ Medicare |
$0.79
|
| Rate for Payer: Southwest Service Administrators UFCW |
$3.37
|
| Rate for Payer: TriWest Medicare |
$0.79
|
| Rate for Payer: United Healthcare Commercial |
$2.83
|
| Rate for Payer: United Healthcare Medicare |
$0.79
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.78
|
|
