|
MINI QUICKANCHOR PLUS KIT
|
Facility
|
IP
|
$2,069.00
|
|
| Hospital Charge Code |
27434247
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$537.94 |
| Max. Negotiated Rate |
$1,862.10 |
| Rate for Payer: Aetna of AZ Commercial |
$1,862.10
|
| Rate for Payer: Bisbee Police All Plans |
$537.94
|
| Rate for Payer: Cash Price |
$1,655.20
|
| Rate for Payer: Self Pay Self Pay |
$1,655.20
|
|
|
mirtazapine 15 mg Tab [CQCH]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 63739009810
|
| Hospital Charge Code |
105932503
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of AZ Commercial |
$0.12
|
| Rate for Payer: Bisbee Police All Plans |
$0.03
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Self Pay Self Pay |
$0.10
|
|
|
mirtazapine 15 mg Tab [CQCH]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 63739009810
|
| Hospital Charge Code |
105932503
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of AZ Commercial |
$0.12
|
| Rate for Payer: Aetna of AZ Medicare |
$0.04
|
| Rate for Payer: Allwell Medicare |
$0.02
|
| Rate for Payer: Amerigroup Medicare |
$0.02
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.05
|
| Rate for Payer: AZCH Complete Medicare |
$0.02
|
| Rate for Payer: Banner UC Health Medicare |
$0.02
|
| Rate for Payer: Bisbee Police All Plans |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of AZ Commercial |
$0.08
|
| Rate for Payer: Copperpoint Commercial |
$0.03
|
| Rate for Payer: Health Net of AZ Commercial |
$0.08
|
| Rate for Payer: Health Net of AZ Medicare |
$0.04
|
| Rate for Payer: Humana of AZ Medicare |
$0.02
|
| Rate for Payer: Self Pay Self Pay |
$0.10
|
| Rate for Payer: TriWest Medicare |
$0.02
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.08
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.02
|
|
|
miSOPROStol 100 mcg Tab UD [CQCH]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
NDC 68084004001
|
| Hospital Charge Code |
123200105
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of AZ Commercial |
$0.82
|
| Rate for Payer: Aetna of AZ Medicare |
$0.25
|
| Rate for Payer: Allwell Medicare |
$0.15
|
| Rate for Payer: Amerigroup Medicare |
$0.15
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.34
|
| Rate for Payer: AZCH Complete Medicare |
$0.15
|
| Rate for Payer: Banner UC Health Medicare |
$0.15
|
| Rate for Payer: Bisbee Police All Plans |
$0.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.62
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of AZ Commercial |
$0.59
|
| Rate for Payer: Copperpoint Commercial |
$0.23
|
| Rate for Payer: Health Net of AZ Commercial |
$0.55
|
| Rate for Payer: Health Net of AZ Medicare |
$0.25
|
| Rate for Payer: Humana of AZ Medicare |
$0.15
|
| Rate for Payer: Self Pay Self Pay |
$0.73
|
| Rate for Payer: TriWest Medicare |
$0.15
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.53
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.16
|
|
|
miSOPROStol 100 mcg Tab UD [CQCH]
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
NDC 68084004001
|
| Hospital Charge Code |
123200105
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of AZ Commercial |
$0.82
|
| Rate for Payer: Bisbee Police All Plans |
$0.24
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Self Pay Self Pay |
$0.73
|
|
|
Mitochondrial (M2) Antibody LC
|
Facility
|
OP
|
$249.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
1285785
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$39.84 |
| Max. Negotiated Rate |
$224.10 |
| Rate for Payer: Aetna of AZ Commercial |
$224.10
|
| Rate for Payer: Aetna of AZ Medicare |
$69.72
|
| Rate for Payer: Allwell Medicare |
$39.84
|
| Rate for Payer: Amerigroup Medicare |
$39.84
|
| Rate for Payer: APIPA Medicare/Medicaid |
$93.00
|
| Rate for Payer: AZCH Complete Medicare |
$39.84
|
| Rate for Payer: Banner UC Health Medicare |
$39.84
|
| Rate for Payer: Bisbee Police All Plans |
$64.74
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$169.32
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Cigna of AZ Commercial |
$161.85
|
| Rate for Payer: Copperpoint Commercial |
$61.63
|
| Rate for Payer: Health Net of AZ Commercial |
$149.40
|
| Rate for Payer: Health Net of AZ Medicare |
$69.72
|
| Rate for Payer: Humana of AZ Medicare |
$39.84
|
| Rate for Payer: Self Pay Self Pay |
$199.20
|
| Rate for Payer: TriWest Medicare |
$39.84
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$145.17
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$44.82
|
|
|
Mitochondrial (M2) Antibody LC
|
Facility
|
IP
|
$249.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
1285785
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$64.74 |
| Max. Negotiated Rate |
$224.10 |
| Rate for Payer: Aetna of AZ Commercial |
$224.10
|
| Rate for Payer: Bisbee Police All Plans |
$64.74
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Self Pay Self Pay |
$199.20
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$28,319.03
|
|
|
Service Code
|
APR-DRG 7934
|
| Hospital Charge Code |
APRDRG7931
|
| Min. Negotiated Rate |
$28,319.03 |
| Max. Negotiated Rate |
$28,319.03 |
| Rate for Payer: AHCCCS Medicaid |
$28,319.03
|
| Rate for Payer: Allwell Medicaid |
$28,319.03
|
| Rate for Payer: AZCH Complete Medicaid |
$28,319.03
|
| Rate for Payer: Banner UC Health Medicaid |
$28,319.03
|
| Rate for Payer: Mercy Care Medicaid |
$28,319.03
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$6,242.46
|
|
|
Service Code
|
APR-DRG 7931
|
| Hospital Charge Code |
APRDRG7931
|
| Min. Negotiated Rate |
$6,242.46 |
| Max. Negotiated Rate |
$6,242.46 |
| Rate for Payer: AHCCCS Medicaid |
$6,242.46
|
| Rate for Payer: Allwell Medicaid |
$6,242.46
|
| Rate for Payer: AZCH Complete Medicaid |
$6,242.46
|
| Rate for Payer: Banner UC Health Medicaid |
$6,242.46
|
| Rate for Payer: Mercy Care Medicaid |
$6,242.46
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$8,863.59
|
|
|
Service Code
|
APR-DRG 7932
|
| Hospital Charge Code |
APRDRG7934
|
| Min. Negotiated Rate |
$8,863.59 |
| Max. Negotiated Rate |
$8,863.59 |
| Rate for Payer: AHCCCS Medicaid |
$8,863.59
|
| Rate for Payer: Allwell Medicaid |
$8,863.59
|
| Rate for Payer: AZCH Complete Medicaid |
$8,863.59
|
| Rate for Payer: Banner UC Health Medicaid |
$8,863.59
|
| Rate for Payer: Mercy Care Medicaid |
$8,863.59
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$28,319.03
|
|
|
Service Code
|
APR-DRG 7934
|
| Hospital Charge Code |
APRDRG7932
|
| Min. Negotiated Rate |
$28,319.03 |
| Max. Negotiated Rate |
$28,319.03 |
| Rate for Payer: AHCCCS Medicaid |
$28,319.03
|
| Rate for Payer: Allwell Medicaid |
$28,319.03
|
| Rate for Payer: AZCH Complete Medicaid |
$28,319.03
|
| Rate for Payer: Banner UC Health Medicaid |
$28,319.03
|
| Rate for Payer: Mercy Care Medicaid |
$28,319.03
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$8,863.59
|
|
|
Service Code
|
APR-DRG 7932
|
| Hospital Charge Code |
APRDRG7932
|
| Min. Negotiated Rate |
$8,863.59 |
| Max. Negotiated Rate |
$8,863.59 |
| Rate for Payer: AHCCCS Medicaid |
$8,863.59
|
| Rate for Payer: Allwell Medicaid |
$8,863.59
|
| Rate for Payer: AZCH Complete Medicaid |
$8,863.59
|
| Rate for Payer: Banner UC Health Medicaid |
$8,863.59
|
| Rate for Payer: Mercy Care Medicaid |
$8,863.59
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$14,150.75
|
|
|
Service Code
|
APR-DRG 7933
|
| Hospital Charge Code |
APRDRG7932
|
| Min. Negotiated Rate |
$14,150.75 |
| Max. Negotiated Rate |
$14,150.75 |
| Rate for Payer: AHCCCS Medicaid |
$14,150.75
|
| Rate for Payer: Allwell Medicaid |
$14,150.75
|
| Rate for Payer: AZCH Complete Medicaid |
$14,150.75
|
| Rate for Payer: Banner UC Health Medicaid |
$14,150.75
|
| Rate for Payer: Mercy Care Medicaid |
$14,150.75
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$8,863.59
|
|
|
Service Code
|
APR-DRG 7932
|
| Hospital Charge Code |
APRDRG7931
|
| Min. Negotiated Rate |
$8,863.59 |
| Max. Negotiated Rate |
$8,863.59 |
| Rate for Payer: AHCCCS Medicaid |
$8,863.59
|
| Rate for Payer: Allwell Medicaid |
$8,863.59
|
| Rate for Payer: AZCH Complete Medicaid |
$8,863.59
|
| Rate for Payer: Banner UC Health Medicaid |
$8,863.59
|
| Rate for Payer: Mercy Care Medicaid |
$8,863.59
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$14,150.75
|
|
|
Service Code
|
APR-DRG 7933
|
| Hospital Charge Code |
APRDRG7934
|
| Min. Negotiated Rate |
$14,150.75 |
| Max. Negotiated Rate |
$14,150.75 |
| Rate for Payer: AHCCCS Medicaid |
$14,150.75
|
| Rate for Payer: Allwell Medicaid |
$14,150.75
|
| Rate for Payer: AZCH Complete Medicaid |
$14,150.75
|
| Rate for Payer: Banner UC Health Medicaid |
$14,150.75
|
| Rate for Payer: Mercy Care Medicaid |
$14,150.75
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$8,863.59
|
|
|
Service Code
|
APR-DRG 7932
|
| Hospital Charge Code |
APRDRG7933
|
| Min. Negotiated Rate |
$8,863.59 |
| Max. Negotiated Rate |
$8,863.59 |
| Rate for Payer: AHCCCS Medicaid |
$8,863.59
|
| Rate for Payer: Allwell Medicaid |
$8,863.59
|
| Rate for Payer: AZCH Complete Medicaid |
$8,863.59
|
| Rate for Payer: Banner UC Health Medicaid |
$8,863.59
|
| Rate for Payer: Mercy Care Medicaid |
$8,863.59
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$14,150.75
|
|
|
Service Code
|
APR-DRG 7933
|
| Hospital Charge Code |
APRDRG7933
|
| Min. Negotiated Rate |
$14,150.75 |
| Max. Negotiated Rate |
$14,150.75 |
| Rate for Payer: AHCCCS Medicaid |
$14,150.75
|
| Rate for Payer: Allwell Medicaid |
$14,150.75
|
| Rate for Payer: AZCH Complete Medicaid |
$14,150.75
|
| Rate for Payer: Banner UC Health Medicaid |
$14,150.75
|
| Rate for Payer: Mercy Care Medicaid |
$14,150.75
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$6,242.46
|
|
|
Service Code
|
APR-DRG 7931
|
| Hospital Charge Code |
APRDRG7933
|
| Min. Negotiated Rate |
$6,242.46 |
| Max. Negotiated Rate |
$6,242.46 |
| Rate for Payer: AHCCCS Medicaid |
$6,242.46
|
| Rate for Payer: Allwell Medicaid |
$6,242.46
|
| Rate for Payer: AZCH Complete Medicaid |
$6,242.46
|
| Rate for Payer: Banner UC Health Medicaid |
$6,242.46
|
| Rate for Payer: Mercy Care Medicaid |
$6,242.46
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$14,150.75
|
|
|
Service Code
|
APR-DRG 7933
|
| Hospital Charge Code |
APRDRG7931
|
| Min. Negotiated Rate |
$14,150.75 |
| Max. Negotiated Rate |
$14,150.75 |
| Rate for Payer: AHCCCS Medicaid |
$14,150.75
|
| Rate for Payer: Allwell Medicaid |
$14,150.75
|
| Rate for Payer: AZCH Complete Medicaid |
$14,150.75
|
| Rate for Payer: Banner UC Health Medicaid |
$14,150.75
|
| Rate for Payer: Mercy Care Medicaid |
$14,150.75
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$28,319.03
|
|
|
Service Code
|
APR-DRG 7934
|
| Hospital Charge Code |
APRDRG7934
|
| Min. Negotiated Rate |
$28,319.03 |
| Max. Negotiated Rate |
$28,319.03 |
| Rate for Payer: AHCCCS Medicaid |
$28,319.03
|
| Rate for Payer: Allwell Medicaid |
$28,319.03
|
| Rate for Payer: AZCH Complete Medicaid |
$28,319.03
|
| Rate for Payer: Banner UC Health Medicaid |
$28,319.03
|
| Rate for Payer: Mercy Care Medicaid |
$28,319.03
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$6,242.46
|
|
|
Service Code
|
APR-DRG 7931
|
| Hospital Charge Code |
APRDRG7934
|
| Min. Negotiated Rate |
$6,242.46 |
| Max. Negotiated Rate |
$6,242.46 |
| Rate for Payer: AHCCCS Medicaid |
$6,242.46
|
| Rate for Payer: Allwell Medicaid |
$6,242.46
|
| Rate for Payer: AZCH Complete Medicaid |
$6,242.46
|
| Rate for Payer: Banner UC Health Medicaid |
$6,242.46
|
| Rate for Payer: Mercy Care Medicaid |
$6,242.46
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$6,242.46
|
|
|
Service Code
|
APR-DRG 7931
|
| Hospital Charge Code |
APRDRG7932
|
| Min. Negotiated Rate |
$6,242.46 |
| Max. Negotiated Rate |
$6,242.46 |
| Rate for Payer: AHCCCS Medicaid |
$6,242.46
|
| Rate for Payer: Allwell Medicaid |
$6,242.46
|
| Rate for Payer: AZCH Complete Medicaid |
$6,242.46
|
| Rate for Payer: Banner UC Health Medicaid |
$6,242.46
|
| Rate for Payer: Mercy Care Medicaid |
$6,242.46
|
|
|
Moderately Extensive O.R. Procedures For Other Complications Of Treatment
|
Facility
|
IP
|
$28,319.03
|
|
|
Service Code
|
APR-DRG 7934
|
| Hospital Charge Code |
APRDRG7933
|
| Min. Negotiated Rate |
$28,319.03 |
| Max. Negotiated Rate |
$28,319.03 |
| Rate for Payer: AHCCCS Medicaid |
$28,319.03
|
| Rate for Payer: Allwell Medicaid |
$28,319.03
|
| Rate for Payer: AZCH Complete Medicaid |
$28,319.03
|
| Rate for Payer: Banner UC Health Medicaid |
$28,319.03
|
| Rate for Payer: Mercy Care Medicaid |
$28,319.03
|
|
|
Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis
|
Facility
|
IP
|
$6,929.83
|
|
|
Service Code
|
APR-DRG 9511
|
| Hospital Charge Code |
APRDRG9513
|
| Min. Negotiated Rate |
$6,929.83 |
| Max. Negotiated Rate |
$6,929.83 |
| Rate for Payer: AHCCCS Medicaid |
$6,929.83
|
| Rate for Payer: Allwell Medicaid |
$6,929.83
|
| Rate for Payer: AZCH Complete Medicaid |
$6,929.83
|
| Rate for Payer: Banner UC Health Medicaid |
$6,929.83
|
| Rate for Payer: Mercy Care Medicaid |
$6,929.83
|
|
|
Moderately Extensive O.R. Procedure Unrelated To Principal Diagnosis
|
Facility
|
IP
|
$29,766.71
|
|
|
Service Code
|
APR-DRG 9514
|
| Hospital Charge Code |
APRDRG9511
|
| Min. Negotiated Rate |
$29,766.71 |
| Max. Negotiated Rate |
$29,766.71 |
| Rate for Payer: AHCCCS Medicaid |
$29,766.71
|
| Rate for Payer: Allwell Medicaid |
$29,766.71
|
| Rate for Payer: AZCH Complete Medicaid |
$29,766.71
|
| Rate for Payer: Banner UC Health Medicaid |
$29,766.71
|
| Rate for Payer: Mercy Care Medicaid |
$29,766.71
|
|
