|
DISP BIOPSY FORCEP 2.8MM
|
Facility
|
OP
|
$41.00
|
|
| Hospital Charge Code |
22355304
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.56 |
| Max. Negotiated Rate |
$36.90 |
| Rate for Payer: Aetna of AZ Commercial |
$36.90
|
| Rate for Payer: Aetna of AZ Medicare |
$11.48
|
| Rate for Payer: Allwell Medicare |
$6.56
|
| Rate for Payer: Amerigroup Medicare |
$6.56
|
| Rate for Payer: APIPA Medicare/Medicaid |
$15.31
|
| Rate for Payer: AZCH Complete Medicare |
$6.56
|
| Rate for Payer: Banner UC Health Medicare |
$6.56
|
| Rate for Payer: Bisbee Police All Plans |
$10.66
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$27.88
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Cigna of AZ Commercial |
$28.70
|
| Rate for Payer: Copperpoint Commercial |
$10.15
|
| Rate for Payer: Health Net of AZ Commercial |
$24.60
|
| Rate for Payer: Health Net of AZ Medicare |
$11.48
|
| Rate for Payer: Humana of AZ Medicare |
$6.56
|
| Rate for Payer: Self Pay Self Pay |
$32.80
|
| Rate for Payer: TriWest Medicare |
$6.56
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$23.90
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$7.38
|
|
|
DISP INJECTION NEEDLE
|
Facility
|
IP
|
$109.00
|
|
| Hospital Charge Code |
22354820
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$28.34 |
| Max. Negotiated Rate |
$98.10 |
| Rate for Payer: Aetna of AZ Commercial |
$98.10
|
| Rate for Payer: Bisbee Police All Plans |
$28.34
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Self Pay Self Pay |
$87.20
|
|
|
DISP INJECTION NEEDLE
|
Facility
|
OP
|
$109.00
|
|
| Hospital Charge Code |
22354820
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.44 |
| Max. Negotiated Rate |
$98.10 |
| Rate for Payer: Aetna of AZ Commercial |
$98.10
|
| Rate for Payer: Aetna of AZ Medicare |
$30.52
|
| Rate for Payer: Allwell Medicare |
$17.44
|
| Rate for Payer: Amerigroup Medicare |
$17.44
|
| Rate for Payer: APIPA Medicare/Medicaid |
$40.71
|
| Rate for Payer: AZCH Complete Medicare |
$17.44
|
| Rate for Payer: Banner UC Health Medicare |
$17.44
|
| Rate for Payer: Bisbee Police All Plans |
$28.34
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$74.12
|
| Rate for Payer: Cash Price |
$87.20
|
| Rate for Payer: Cigna of AZ Commercial |
$76.30
|
| Rate for Payer: Copperpoint Commercial |
$26.98
|
| Rate for Payer: Health Net of AZ Commercial |
$65.40
|
| Rate for Payer: Health Net of AZ Medicare |
$30.52
|
| Rate for Payer: Humana of AZ Medicare |
$17.44
|
| Rate for Payer: Self Pay Self Pay |
$87.20
|
| Rate for Payer: TriWest Medicare |
$17.44
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$63.55
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$19.62
|
|
|
DISPOSABLE CORE BIOPSY INSTRUMENT
|
Facility
|
IP
|
$125.44
|
|
| Hospital Charge Code |
27750233
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$32.61 |
| Max. Negotiated Rate |
$112.90 |
| Rate for Payer: Aetna of AZ Commercial |
$112.90
|
| Rate for Payer: Bisbee Police All Plans |
$32.61
|
| Rate for Payer: Cash Price |
$100.35
|
| Rate for Payer: Self Pay Self Pay |
$100.35
|
|
|
DISPOSABLE CORE BIOPSY INSTRUMENT
|
Facility
|
OP
|
$125.44
|
|
| Hospital Charge Code |
27750233
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$20.07 |
| Max. Negotiated Rate |
$112.90 |
| Rate for Payer: Aetna of AZ Commercial |
$112.90
|
| Rate for Payer: Aetna of AZ Medicare |
$35.12
|
| Rate for Payer: Allwell Medicare |
$20.07
|
| Rate for Payer: Amerigroup Medicare |
$20.07
|
| Rate for Payer: APIPA Medicare/Medicaid |
$46.85
|
| Rate for Payer: AZCH Complete Medicare |
$20.07
|
| Rate for Payer: Banner UC Health Medicare |
$20.07
|
| Rate for Payer: Bisbee Police All Plans |
$32.61
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$85.30
|
| Rate for Payer: Cash Price |
$100.35
|
| Rate for Payer: Cigna of AZ Commercial |
$87.81
|
| Rate for Payer: Copperpoint Commercial |
$31.05
|
| Rate for Payer: Health Net of AZ Commercial |
$75.26
|
| Rate for Payer: Health Net of AZ Medicare |
$35.12
|
| Rate for Payer: Humana of AZ Medicare |
$20.07
|
| Rate for Payer: Self Pay Self Pay |
$100.35
|
| Rate for Payer: TriWest Medicare |
$20.07
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$73.13
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$22.58
|
|
|
DISP SOFT SNARE
|
Facility
|
IP
|
$49.00
|
|
| Hospital Charge Code |
22354920
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.74 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna of AZ Commercial |
$44.10
|
| Rate for Payer: Bisbee Police All Plans |
$12.74
|
| Rate for Payer: Cash Price |
$39.20
|
| Rate for Payer: Self Pay Self Pay |
$39.20
|
|
|
DISP SOFT SNARE
|
Facility
|
OP
|
$49.00
|
|
| Hospital Charge Code |
22354920
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.84 |
| Max. Negotiated Rate |
$44.10 |
| Rate for Payer: Aetna of AZ Commercial |
$44.10
|
| Rate for Payer: Aetna of AZ Medicare |
$13.72
|
| Rate for Payer: Allwell Medicare |
$7.84
|
| Rate for Payer: Amerigroup Medicare |
$7.84
|
| Rate for Payer: APIPA Medicare/Medicaid |
$18.30
|
| Rate for Payer: AZCH Complete Medicare |
$7.84
|
| Rate for Payer: Banner UC Health Medicare |
$7.84
|
| Rate for Payer: Bisbee Police All Plans |
$12.74
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$33.32
|
| Rate for Payer: Cash Price |
$39.20
|
| Rate for Payer: Cigna of AZ Commercial |
$34.30
|
| Rate for Payer: Copperpoint Commercial |
$12.13
|
| Rate for Payer: Health Net of AZ Commercial |
$29.40
|
| Rate for Payer: Health Net of AZ Medicare |
$13.72
|
| Rate for Payer: Humana of AZ Medicare |
$7.84
|
| Rate for Payer: Self Pay Self Pay |
$39.20
|
| Rate for Payer: TriWest Medicare |
$7.84
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$28.57
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$8.82
|
|
|
divalproex sodium 125 mg DR Tablet[CQCH]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
NDC 62756079688
|
| Hospital Charge Code |
130345400
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of AZ Commercial |
$0.05
|
| Rate for Payer: Aetna of AZ Medicare |
$0.01
|
| Rate for Payer: Allwell Medicare |
$0.01
|
| Rate for Payer: Amerigroup Medicare |
$0.01
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.02
|
| Rate for Payer: AZCH Complete Medicare |
$0.01
|
| Rate for Payer: Banner UC Health Medicare |
$0.01
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of AZ Commercial |
$0.03
|
| Rate for Payer: Copperpoint Commercial |
$0.01
|
| Rate for Payer: Health Net of AZ Commercial |
$0.03
|
| Rate for Payer: Health Net of AZ Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Self Pay Self Pay |
$0.04
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.03
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.01
|
|
|
divalproex sodium 125 mg DR Tablet[CQCH]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 62756079688
|
| Hospital Charge Code |
130345400
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of AZ Commercial |
$0.05
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Self Pay Self Pay |
$0.04
|
|
|
divalproex sodium 250 mg Oral DR Tab [CQCH]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 68084077601
|
| Hospital Charge Code |
105919506
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of AZ Commercial |
$0.15
|
| Rate for Payer: Bisbee Police All Plans |
$0.04
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Self Pay Self Pay |
$0.14
|
|
|
divalproex sodium 250 mg Oral DR Tab [CQCH]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 68084077601
|
| Hospital Charge Code |
105919506
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of AZ Commercial |
$0.15
|
| Rate for Payer: Aetna of AZ Medicare |
$0.05
|
| Rate for Payer: Allwell Medicare |
$0.03
|
| Rate for Payer: Amerigroup Medicare |
$0.03
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.06
|
| Rate for Payer: AZCH Complete Medicare |
$0.03
|
| Rate for Payer: Banner UC Health Medicare |
$0.03
|
| Rate for Payer: Bisbee Police All Plans |
$0.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.12
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of AZ Commercial |
$0.11
|
| Rate for Payer: Copperpoint Commercial |
$0.04
|
| Rate for Payer: Health Net of AZ Commercial |
$0.10
|
| Rate for Payer: Health Net of AZ Medicare |
$0.05
|
| Rate for Payer: Humana of AZ Medicare |
$0.03
|
| Rate for Payer: Self Pay Self Pay |
$0.14
|
| Rate for Payer: TriWest Medicare |
$0.03
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.10
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.03
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$3,380.05
|
|
|
Service Code
|
APR-DRG 2441
|
| Hospital Charge Code |
APRDRG2441
|
| Min. Negotiated Rate |
$3,380.05 |
| Max. Negotiated Rate |
$3,380.05 |
| Rate for Payer: AHCCCS Medicaid |
$3,380.05
|
| Rate for Payer: Allwell Medicaid |
$3,380.05
|
| Rate for Payer: AZCH Complete Medicaid |
$3,380.05
|
| Rate for Payer: Banner UC Health Medicaid |
$3,380.05
|
| Rate for Payer: Mercy Care Medicaid |
$3,380.05
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$3,380.05
|
|
|
Service Code
|
APR-DRG 2441
|
| Hospital Charge Code |
APRDRG2443
|
| Min. Negotiated Rate |
$3,380.05 |
| Max. Negotiated Rate |
$3,380.05 |
| Rate for Payer: AHCCCS Medicaid |
$3,380.05
|
| Rate for Payer: Allwell Medicaid |
$3,380.05
|
| Rate for Payer: AZCH Complete Medicaid |
$3,380.05
|
| Rate for Payer: Banner UC Health Medicaid |
$3,380.05
|
| Rate for Payer: Mercy Care Medicaid |
$3,380.05
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$3,380.05
|
|
|
Service Code
|
APR-DRG 2441
|
| Hospital Charge Code |
APRDRG2442
|
| Min. Negotiated Rate |
$3,380.05 |
| Max. Negotiated Rate |
$3,380.05 |
| Rate for Payer: AHCCCS Medicaid |
$3,380.05
|
| Rate for Payer: Allwell Medicaid |
$3,380.05
|
| Rate for Payer: AZCH Complete Medicaid |
$3,380.05
|
| Rate for Payer: Banner UC Health Medicaid |
$3,380.05
|
| Rate for Payer: Mercy Care Medicaid |
$3,380.05
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$4,484.75
|
|
|
Service Code
|
APR-DRG 2442
|
| Hospital Charge Code |
APRDRG2441
|
| Min. Negotiated Rate |
$4,484.75 |
| Max. Negotiated Rate |
$4,484.75 |
| Rate for Payer: AHCCCS Medicaid |
$4,484.75
|
| Rate for Payer: Allwell Medicaid |
$4,484.75
|
| Rate for Payer: AZCH Complete Medicaid |
$4,484.75
|
| Rate for Payer: Banner UC Health Medicaid |
$4,484.75
|
| Rate for Payer: Mercy Care Medicaid |
$4,484.75
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$4,484.75
|
|
|
Service Code
|
APR-DRG 2442
|
| Hospital Charge Code |
APRDRG2443
|
| Min. Negotiated Rate |
$4,484.75 |
| Max. Negotiated Rate |
$4,484.75 |
| Rate for Payer: AHCCCS Medicaid |
$4,484.75
|
| Rate for Payer: Allwell Medicaid |
$4,484.75
|
| Rate for Payer: AZCH Complete Medicaid |
$4,484.75
|
| Rate for Payer: Banner UC Health Medicaid |
$4,484.75
|
| Rate for Payer: Mercy Care Medicaid |
$4,484.75
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$6,993.66
|
|
|
Service Code
|
APR-DRG 2443
|
| Hospital Charge Code |
APRDRG2444
|
| Min. Negotiated Rate |
$6,993.66 |
| Max. Negotiated Rate |
$6,993.66 |
| Rate for Payer: AHCCCS Medicaid |
$6,993.66
|
| Rate for Payer: Allwell Medicaid |
$6,993.66
|
| Rate for Payer: AZCH Complete Medicaid |
$6,993.66
|
| Rate for Payer: Banner UC Health Medicaid |
$6,993.66
|
| Rate for Payer: Mercy Care Medicaid |
$6,993.66
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$13,498.44
|
|
|
Service Code
|
APR-DRG 2444
|
| Hospital Charge Code |
APRDRG2441
|
| Min. Negotiated Rate |
$13,498.44 |
| Max. Negotiated Rate |
$13,498.44 |
| Rate for Payer: AHCCCS Medicaid |
$13,498.44
|
| Rate for Payer: Allwell Medicaid |
$13,498.44
|
| Rate for Payer: AZCH Complete Medicaid |
$13,498.44
|
| Rate for Payer: Banner UC Health Medicaid |
$13,498.44
|
| Rate for Payer: Mercy Care Medicaid |
$13,498.44
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$3,380.05
|
|
|
Service Code
|
APR-DRG 2441
|
| Hospital Charge Code |
APRDRG2444
|
| Min. Negotiated Rate |
$3,380.05 |
| Max. Negotiated Rate |
$3,380.05 |
| Rate for Payer: AHCCCS Medicaid |
$3,380.05
|
| Rate for Payer: Allwell Medicaid |
$3,380.05
|
| Rate for Payer: AZCH Complete Medicaid |
$3,380.05
|
| Rate for Payer: Banner UC Health Medicaid |
$3,380.05
|
| Rate for Payer: Mercy Care Medicaid |
$3,380.05
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$6,993.66
|
|
|
Service Code
|
APR-DRG 2443
|
| Hospital Charge Code |
APRDRG2441
|
| Min. Negotiated Rate |
$6,993.66 |
| Max. Negotiated Rate |
$6,993.66 |
| Rate for Payer: AHCCCS Medicaid |
$6,993.66
|
| Rate for Payer: Allwell Medicaid |
$6,993.66
|
| Rate for Payer: AZCH Complete Medicaid |
$6,993.66
|
| Rate for Payer: Banner UC Health Medicaid |
$6,993.66
|
| Rate for Payer: Mercy Care Medicaid |
$6,993.66
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$6,993.66
|
|
|
Service Code
|
APR-DRG 2443
|
| Hospital Charge Code |
APRDRG2442
|
| Min. Negotiated Rate |
$6,993.66 |
| Max. Negotiated Rate |
$6,993.66 |
| Rate for Payer: AHCCCS Medicaid |
$6,993.66
|
| Rate for Payer: Allwell Medicaid |
$6,993.66
|
| Rate for Payer: AZCH Complete Medicaid |
$6,993.66
|
| Rate for Payer: Banner UC Health Medicaid |
$6,993.66
|
| Rate for Payer: Mercy Care Medicaid |
$6,993.66
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$6,993.66
|
|
|
Service Code
|
APR-DRG 2443
|
| Hospital Charge Code |
APRDRG2443
|
| Min. Negotiated Rate |
$6,993.66 |
| Max. Negotiated Rate |
$6,993.66 |
| Rate for Payer: AHCCCS Medicaid |
$6,993.66
|
| Rate for Payer: Allwell Medicaid |
$6,993.66
|
| Rate for Payer: AZCH Complete Medicaid |
$6,993.66
|
| Rate for Payer: Banner UC Health Medicaid |
$6,993.66
|
| Rate for Payer: Mercy Care Medicaid |
$6,993.66
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$13,498.44
|
|
|
Service Code
|
APR-DRG 2444
|
| Hospital Charge Code |
APRDRG2442
|
| Min. Negotiated Rate |
$13,498.44 |
| Max. Negotiated Rate |
$13,498.44 |
| Rate for Payer: AHCCCS Medicaid |
$13,498.44
|
| Rate for Payer: Allwell Medicaid |
$13,498.44
|
| Rate for Payer: AZCH Complete Medicaid |
$13,498.44
|
| Rate for Payer: Banner UC Health Medicaid |
$13,498.44
|
| Rate for Payer: Mercy Care Medicaid |
$13,498.44
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$13,498.44
|
|
|
Service Code
|
APR-DRG 2444
|
| Hospital Charge Code |
APRDRG2443
|
| Min. Negotiated Rate |
$13,498.44 |
| Max. Negotiated Rate |
$13,498.44 |
| Rate for Payer: AHCCCS Medicaid |
$13,498.44
|
| Rate for Payer: Allwell Medicaid |
$13,498.44
|
| Rate for Payer: AZCH Complete Medicaid |
$13,498.44
|
| Rate for Payer: Banner UC Health Medicaid |
$13,498.44
|
| Rate for Payer: Mercy Care Medicaid |
$13,498.44
|
|
|
Diverticulitis And Diverticulosis
|
Facility
|
IP
|
$13,498.44
|
|
|
Service Code
|
APR-DRG 2444
|
| Hospital Charge Code |
APRDRG2444
|
| Min. Negotiated Rate |
$13,498.44 |
| Max. Negotiated Rate |
$13,498.44 |
| Rate for Payer: AHCCCS Medicaid |
$13,498.44
|
| Rate for Payer: Allwell Medicaid |
$13,498.44
|
| Rate for Payer: AZCH Complete Medicaid |
$13,498.44
|
| Rate for Payer: Banner UC Health Medicaid |
$13,498.44
|
| Rate for Payer: Mercy Care Medicaid |
$13,498.44
|
|
