|
Influenza AB Rapid
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
CPT 87804
|
| Hospital Charge Code |
5696971
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$175.50 |
| Rate for Payer: Aetna of AZ Commercial |
$175.50
|
| Rate for Payer: Aetna of AZ Medicare |
$54.60
|
| Rate for Payer: Allwell Medicare |
$31.20
|
| Rate for Payer: Amerigroup Medicare |
$31.20
|
| Rate for Payer: APIPA Medicare/Medicaid |
$72.83
|
| Rate for Payer: AZCH Complete Medicare |
$31.20
|
| Rate for Payer: Banner UC Health Medicare |
$31.20
|
| Rate for Payer: Bisbee Police All Plans |
$50.70
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$132.60
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Cigna of AZ Commercial |
$126.75
|
| Rate for Payer: Copperpoint Commercial |
$48.26
|
| Rate for Payer: Health Net of AZ Commercial |
$117.00
|
| Rate for Payer: Health Net of AZ Medicare |
$54.60
|
| Rate for Payer: Humana of AZ Medicare |
$31.20
|
| Rate for Payer: Self Pay Self Pay |
$156.00
|
| Rate for Payer: TriWest Medicare |
$31.20
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$113.69
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$35.10
|
|
|
Influenza AB Rapid
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
CPT 87804
|
| Hospital Charge Code |
5696971
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$50.70 |
| Max. Negotiated Rate |
$175.50 |
| Rate for Payer: Aetna of AZ Commercial |
$175.50
|
| Rate for Payer: Bisbee Police All Plans |
$50.70
|
| Rate for Payer: Cash Price |
$156.00
|
| Rate for Payer: Self Pay Self Pay |
$156.00
|
|
|
influenza virus vaccine 2024-2025, inactivated preservative-free trivalent Sus UD[CQCH]
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
NDC 19515081052
|
| Hospital Charge Code |
242320050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.37 |
| Max. Negotiated Rate |
$13.32 |
| Rate for Payer: Aetna of AZ Commercial |
$13.32
|
| Rate for Payer: Aetna of AZ Medicare |
$4.14
|
| Rate for Payer: Allwell Medicare |
$2.37
|
| Rate for Payer: Amerigroup Medicare |
$2.37
|
| Rate for Payer: APIPA Medicare/Medicaid |
$5.53
|
| Rate for Payer: AZCH Complete Medicare |
$2.37
|
| Rate for Payer: Banner UC Health Medicare |
$2.37
|
| Rate for Payer: Bisbee Police All Plans |
$3.85
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$10.06
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cigna of AZ Commercial |
$9.62
|
| Rate for Payer: Copperpoint Commercial |
$3.66
|
| Rate for Payer: Health Net of AZ Commercial |
$8.88
|
| Rate for Payer: Health Net of AZ Medicare |
$4.14
|
| Rate for Payer: Humana of AZ Medicare |
$2.37
|
| Rate for Payer: Self Pay Self Pay |
$11.84
|
| Rate for Payer: TriWest Medicare |
$2.37
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$8.63
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$2.66
|
|
|
influenza virus vaccine 2024-2025, inactivated preservative-free trivalent Sus UD[CQCH]
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
NDC 19515081052
|
| Hospital Charge Code |
242320050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$13.32 |
| Rate for Payer: Aetna of AZ Commercial |
$13.32
|
| Rate for Payer: Bisbee Police All Plans |
$3.85
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Self Pay Self Pay |
$11.84
|
|
|
informaSeq(SM) Prenatal Test LC
|
Facility
|
IP
|
$232.00
|
|
|
Service Code
|
CPT 81420
|
| Hospital Charge Code |
22311195
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$60.32 |
| Max. Negotiated Rate |
$208.80 |
| Rate for Payer: Aetna of AZ Commercial |
$208.80
|
| Rate for Payer: Bisbee Police All Plans |
$60.32
|
| Rate for Payer: Cash Price |
$185.60
|
| Rate for Payer: Self Pay Self Pay |
$185.60
|
|
|
informaSeq(SM) Prenatal Test LC
|
Facility
|
OP
|
$232.00
|
|
|
Service Code
|
CPT 81420
|
| Hospital Charge Code |
22311195
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$37.12 |
| Max. Negotiated Rate |
$208.80 |
| Rate for Payer: Aetna of AZ Commercial |
$208.80
|
| Rate for Payer: Aetna of AZ Medicare |
$64.96
|
| Rate for Payer: Allwell Medicare |
$37.12
|
| Rate for Payer: Amerigroup Medicare |
$37.12
|
| Rate for Payer: APIPA Medicare/Medicaid |
$86.65
|
| Rate for Payer: AZCH Complete Medicare |
$37.12
|
| Rate for Payer: Banner UC Health Medicare |
$37.12
|
| Rate for Payer: Bisbee Police All Plans |
$60.32
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$157.76
|
| Rate for Payer: Cash Price |
$185.60
|
| Rate for Payer: Cigna of AZ Commercial |
$150.80
|
| Rate for Payer: Copperpoint Commercial |
$57.42
|
| Rate for Payer: Health Net of AZ Commercial |
$139.20
|
| Rate for Payer: Health Net of AZ Medicare |
$64.96
|
| Rate for Payer: Humana of AZ Medicare |
$37.12
|
| Rate for Payer: Self Pay Self Pay |
$185.60
|
| Rate for Payer: TriWest Medicare |
$37.12
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$135.26
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$41.76
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$21,389.19
|
|
|
Service Code
|
APR-DRG 2284
|
| Hospital Charge Code |
APRDRG2281
|
| Min. Negotiated Rate |
$21,389.19 |
| Max. Negotiated Rate |
$21,389.19 |
| Rate for Payer: AHCCCS Medicaid |
$21,389.19
|
| Rate for Payer: Allwell Medicaid |
$21,389.19
|
| Rate for Payer: AZCH Complete Medicaid |
$21,389.19
|
| Rate for Payer: Banner UC Health Medicaid |
$21,389.19
|
| Rate for Payer: Mercy Care Medicaid |
$21,389.19
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$11,253.26
|
|
|
Service Code
|
APR-DRG 2283
|
| Hospital Charge Code |
APRDRG2281
|
| Min. Negotiated Rate |
$11,253.26 |
| Max. Negotiated Rate |
$11,253.26 |
| Rate for Payer: AHCCCS Medicaid |
$11,253.26
|
| Rate for Payer: Allwell Medicaid |
$11,253.26
|
| Rate for Payer: AZCH Complete Medicaid |
$11,253.26
|
| Rate for Payer: Banner UC Health Medicaid |
$11,253.26
|
| Rate for Payer: Mercy Care Medicaid |
$11,253.26
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$21,389.19
|
|
|
Service Code
|
APR-DRG 2284
|
| Hospital Charge Code |
APRDRG2282
|
| Min. Negotiated Rate |
$21,389.19 |
| Max. Negotiated Rate |
$21,389.19 |
| Rate for Payer: AHCCCS Medicaid |
$21,389.19
|
| Rate for Payer: Allwell Medicaid |
$21,389.19
|
| Rate for Payer: AZCH Complete Medicaid |
$21,389.19
|
| Rate for Payer: Banner UC Health Medicaid |
$21,389.19
|
| Rate for Payer: Mercy Care Medicaid |
$21,389.19
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$11,253.26
|
|
|
Service Code
|
APR-DRG 2283
|
| Hospital Charge Code |
APRDRG2283
|
| Min. Negotiated Rate |
$11,253.26 |
| Max. Negotiated Rate |
$11,253.26 |
| Rate for Payer: AHCCCS Medicaid |
$11,253.26
|
| Rate for Payer: Allwell Medicaid |
$11,253.26
|
| Rate for Payer: AZCH Complete Medicaid |
$11,253.26
|
| Rate for Payer: Banner UC Health Medicaid |
$11,253.26
|
| Rate for Payer: Mercy Care Medicaid |
$11,253.26
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$5,855.99
|
|
|
Service Code
|
APR-DRG 2281
|
| Hospital Charge Code |
APRDRG2283
|
| Min. Negotiated Rate |
$5,855.99 |
| Max. Negotiated Rate |
$5,855.99 |
| Rate for Payer: AHCCCS Medicaid |
$5,855.99
|
| Rate for Payer: Allwell Medicaid |
$5,855.99
|
| Rate for Payer: AZCH Complete Medicaid |
$5,855.99
|
| Rate for Payer: Banner UC Health Medicaid |
$5,855.99
|
| Rate for Payer: Mercy Care Medicaid |
$5,855.99
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$11,253.26
|
|
|
Service Code
|
APR-DRG 2283
|
| Hospital Charge Code |
APRDRG2282
|
| Min. Negotiated Rate |
$11,253.26 |
| Max. Negotiated Rate |
$11,253.26 |
| Rate for Payer: AHCCCS Medicaid |
$11,253.26
|
| Rate for Payer: Allwell Medicaid |
$11,253.26
|
| Rate for Payer: AZCH Complete Medicaid |
$11,253.26
|
| Rate for Payer: Banner UC Health Medicaid |
$11,253.26
|
| Rate for Payer: Mercy Care Medicaid |
$11,253.26
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$11,253.26
|
|
|
Service Code
|
APR-DRG 2283
|
| Hospital Charge Code |
APRDRG2284
|
| Min. Negotiated Rate |
$11,253.26 |
| Max. Negotiated Rate |
$11,253.26 |
| Rate for Payer: AHCCCS Medicaid |
$11,253.26
|
| Rate for Payer: Allwell Medicaid |
$11,253.26
|
| Rate for Payer: AZCH Complete Medicaid |
$11,253.26
|
| Rate for Payer: Banner UC Health Medicaid |
$11,253.26
|
| Rate for Payer: Mercy Care Medicaid |
$11,253.26
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$21,389.19
|
|
|
Service Code
|
APR-DRG 2284
|
| Hospital Charge Code |
APRDRG2284
|
| Min. Negotiated Rate |
$21,389.19 |
| Max. Negotiated Rate |
$21,389.19 |
| Rate for Payer: AHCCCS Medicaid |
$21,389.19
|
| Rate for Payer: Allwell Medicaid |
$21,389.19
|
| Rate for Payer: AZCH Complete Medicaid |
$21,389.19
|
| Rate for Payer: Banner UC Health Medicaid |
$21,389.19
|
| Rate for Payer: Mercy Care Medicaid |
$21,389.19
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$7,529.53
|
|
|
Service Code
|
APR-DRG 2282
|
| Hospital Charge Code |
APRDRG2282
|
| Min. Negotiated Rate |
$7,529.53 |
| Max. Negotiated Rate |
$7,529.53 |
| Rate for Payer: AHCCCS Medicaid |
$7,529.53
|
| Rate for Payer: Allwell Medicaid |
$7,529.53
|
| Rate for Payer: AZCH Complete Medicaid |
$7,529.53
|
| Rate for Payer: Banner UC Health Medicaid |
$7,529.53
|
| Rate for Payer: Mercy Care Medicaid |
$7,529.53
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$5,855.99
|
|
|
Service Code
|
APR-DRG 2281
|
| Hospital Charge Code |
APRDRG2284
|
| Min. Negotiated Rate |
$5,855.99 |
| Max. Negotiated Rate |
$5,855.99 |
| Rate for Payer: AHCCCS Medicaid |
$5,855.99
|
| Rate for Payer: Allwell Medicaid |
$5,855.99
|
| Rate for Payer: AZCH Complete Medicaid |
$5,855.99
|
| Rate for Payer: Banner UC Health Medicaid |
$5,855.99
|
| Rate for Payer: Mercy Care Medicaid |
$5,855.99
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$7,529.53
|
|
|
Service Code
|
APR-DRG 2282
|
| Hospital Charge Code |
APRDRG2283
|
| Min. Negotiated Rate |
$7,529.53 |
| Max. Negotiated Rate |
$7,529.53 |
| Rate for Payer: AHCCCS Medicaid |
$7,529.53
|
| Rate for Payer: Allwell Medicaid |
$7,529.53
|
| Rate for Payer: AZCH Complete Medicaid |
$7,529.53
|
| Rate for Payer: Banner UC Health Medicaid |
$7,529.53
|
| Rate for Payer: Mercy Care Medicaid |
$7,529.53
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$7,529.53
|
|
|
Service Code
|
APR-DRG 2282
|
| Hospital Charge Code |
APRDRG2284
|
| Min. Negotiated Rate |
$7,529.53 |
| Max. Negotiated Rate |
$7,529.53 |
| Rate for Payer: AHCCCS Medicaid |
$7,529.53
|
| Rate for Payer: Allwell Medicaid |
$7,529.53
|
| Rate for Payer: AZCH Complete Medicaid |
$7,529.53
|
| Rate for Payer: Banner UC Health Medicaid |
$7,529.53
|
| Rate for Payer: Mercy Care Medicaid |
$7,529.53
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$5,855.99
|
|
|
Service Code
|
APR-DRG 2281
|
| Hospital Charge Code |
APRDRG2282
|
| Min. Negotiated Rate |
$5,855.99 |
| Max. Negotiated Rate |
$5,855.99 |
| Rate for Payer: AHCCCS Medicaid |
$5,855.99
|
| Rate for Payer: Allwell Medicaid |
$5,855.99
|
| Rate for Payer: AZCH Complete Medicaid |
$5,855.99
|
| Rate for Payer: Banner UC Health Medicaid |
$5,855.99
|
| Rate for Payer: Mercy Care Medicaid |
$5,855.99
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$21,389.19
|
|
|
Service Code
|
APR-DRG 2284
|
| Hospital Charge Code |
APRDRG2283
|
| Min. Negotiated Rate |
$21,389.19 |
| Max. Negotiated Rate |
$21,389.19 |
| Rate for Payer: AHCCCS Medicaid |
$21,389.19
|
| Rate for Payer: Allwell Medicaid |
$21,389.19
|
| Rate for Payer: AZCH Complete Medicaid |
$21,389.19
|
| Rate for Payer: Banner UC Health Medicaid |
$21,389.19
|
| Rate for Payer: Mercy Care Medicaid |
$21,389.19
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$7,529.53
|
|
|
Service Code
|
APR-DRG 2282
|
| Hospital Charge Code |
APRDRG2281
|
| Min. Negotiated Rate |
$7,529.53 |
| Max. Negotiated Rate |
$7,529.53 |
| Rate for Payer: AHCCCS Medicaid |
$7,529.53
|
| Rate for Payer: Allwell Medicaid |
$7,529.53
|
| Rate for Payer: AZCH Complete Medicaid |
$7,529.53
|
| Rate for Payer: Banner UC Health Medicaid |
$7,529.53
|
| Rate for Payer: Mercy Care Medicaid |
$7,529.53
|
|
|
Inguinal, Femoral And Umbilical Hernia Procedures
|
Facility
|
IP
|
$5,855.99
|
|
|
Service Code
|
APR-DRG 2281
|
| Hospital Charge Code |
APRDRG2281
|
| Min. Negotiated Rate |
$5,855.99 |
| Max. Negotiated Rate |
$5,855.99 |
| Rate for Payer: AHCCCS Medicaid |
$5,855.99
|
| Rate for Payer: Allwell Medicaid |
$5,855.99
|
| Rate for Payer: AZCH Complete Medicaid |
$5,855.99
|
| Rate for Payer: Banner UC Health Medicaid |
$5,855.99
|
| Rate for Payer: Mercy Care Medicaid |
$5,855.99
|
|
|
INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANC
|
Facility
|
IP
|
$218.00
|
|
|
Service Code
|
CPT 64450
|
| Hospital Charge Code |
24049524
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$56.68 |
| Max. Negotiated Rate |
$196.20 |
| Rate for Payer: Aetna of AZ Commercial |
$196.20
|
| Rate for Payer: Bisbee Police All Plans |
$56.68
|
| Rate for Payer: Cash Price |
$174.40
|
| Rate for Payer: Self Pay Self Pay |
$174.40
|
|
|
INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANC
|
Facility
|
OP
|
$218.00
|
|
|
Service Code
|
CPT 64450
|
| Hospital Charge Code |
24049524
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$34.88 |
| Max. Negotiated Rate |
$2,507.00 |
| Rate for Payer: Aetna of AZ Commercial |
$196.20
|
| Rate for Payer: Aetna of AZ Medicare |
$61.04
|
| Rate for Payer: AHCCCS Medicaid |
$460.08
|
| Rate for Payer: Allwell Medicaid |
$460.08
|
| Rate for Payer: Allwell Medicare |
$34.88
|
| Rate for Payer: Amerigroup Medicare |
$34.88
|
| Rate for Payer: APIPA Medicare/Medicaid |
$81.42
|
| Rate for Payer: AZCH Complete Medicaid |
$460.08
|
| Rate for Payer: AZCH Complete Medicare |
$34.88
|
| Rate for Payer: Banner UC Health Medicaid |
$460.08
|
| Rate for Payer: Banner UC Health Medicare |
$34.88
|
| Rate for Payer: Bisbee Police All Plans |
$56.68
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$148.24
|
| Rate for Payer: Cash Price |
$174.40
|
| Rate for Payer: Cash Price |
$174.40
|
| Rate for Payer: Cigna of AZ Commercial |
$109.00
|
| Rate for Payer: Copperpoint Commercial |
$53.95
|
| Rate for Payer: Health Net of AZ Commercial |
$130.80
|
| Rate for Payer: Health Net of AZ Medicare |
$61.04
|
| Rate for Payer: Humana of AZ Medicare |
$34.88
|
| Rate for Payer: Mercy Care Medicaid |
$460.08
|
| Rate for Payer: Self Pay Self Pay |
$174.40
|
| Rate for Payer: TriWest Medicare |
$34.88
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,507.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$39.24
|
|
|
INJECTION OF ANESTHETIC AGENT AND/OR STEROID INTO RIB NERVE
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
CPT 64420
|
| Hospital Charge Code |
27927130
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$48.64 |
| Max. Negotiated Rate |
$2,507.00 |
| Rate for Payer: Aetna of AZ Commercial |
$273.60
|
| Rate for Payer: Aetna of AZ Medicare |
$85.12
|
| Rate for Payer: AHCCCS Medicaid |
$460.08
|
| Rate for Payer: Allwell Medicaid |
$460.08
|
| Rate for Payer: Allwell Medicare |
$48.64
|
| Rate for Payer: Amerigroup Medicare |
$48.64
|
| Rate for Payer: APIPA Medicare/Medicaid |
$113.54
|
| Rate for Payer: AZCH Complete Medicaid |
$460.08
|
| Rate for Payer: AZCH Complete Medicare |
$48.64
|
| Rate for Payer: Banner UC Health Medicaid |
$460.08
|
| Rate for Payer: Banner UC Health Medicare |
$48.64
|
| Rate for Payer: Bisbee Police All Plans |
$79.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$206.72
|
| Rate for Payer: Cash Price |
$243.20
|
| Rate for Payer: Cash Price |
$243.20
|
| Rate for Payer: Cigna of AZ Commercial |
$152.00
|
| Rate for Payer: Copperpoint Commercial |
$75.24
|
| Rate for Payer: Health Net of AZ Commercial |
$182.40
|
| Rate for Payer: Health Net of AZ Medicare |
$85.12
|
| Rate for Payer: Humana of AZ Medicare |
$48.64
|
| Rate for Payer: Mercy Care Medicaid |
$460.08
|
| Rate for Payer: Self Pay Self Pay |
$243.20
|
| Rate for Payer: TriWest Medicare |
$48.64
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,507.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$54.72
|
|
