|
PATIENT MUG
|
Facility
|
IP
|
$15.00
|
|
| Hospital Charge Code |
22355587
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.90 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna of AZ Commercial |
$13.50
|
| Rate for Payer: Bisbee Police All Plans |
$3.90
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Self Pay Self Pay |
$12.00
|
|
|
PATIENT MUG
|
Facility
|
OP
|
$15.00
|
|
| Hospital Charge Code |
22355587
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$13.50 |
| Rate for Payer: Aetna of AZ Commercial |
$13.50
|
| Rate for Payer: Aetna of AZ Medicare |
$4.20
|
| Rate for Payer: Allwell Medicare |
$2.25
|
| Rate for Payer: Amerigroup Medicare |
$2.25
|
| Rate for Payer: APIPA Medicare/Medicaid |
$5.60
|
| Rate for Payer: AZCH Complete Medicare |
$2.25
|
| Rate for Payer: Banner UC Health Medicare |
$2.25
|
| Rate for Payer: Bisbee Police All Plans |
$3.90
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$10.20
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna of AZ Commercial |
$10.50
|
| Rate for Payer: Copperpoint Commercial |
$3.71
|
| Rate for Payer: Health Net of AZ Commercial |
$9.00
|
| Rate for Payer: Health Net of AZ Medicare |
$4.20
|
| Rate for Payer: Humana of AZ Medicare |
$2.25
|
| Rate for Payer: Self Pay Self Pay |
$12.00
|
| Rate for Payer: TriWest Medicare |
$2.25
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$8.74
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$2.70
|
|
|
PATIENT PROGRAMER
|
Facility
|
IP
|
$6,823.00
|
|
|
Service Code
|
CPT C1787
|
| Hospital Charge Code |
22354563
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,773.98 |
| Max. Negotiated Rate |
$6,140.70 |
| Rate for Payer: Aetna of AZ Commercial |
$6,140.70
|
| Rate for Payer: Bisbee Police All Plans |
$1,773.98
|
| Rate for Payer: Cash Price |
$5,458.40
|
| Rate for Payer: Self Pay Self Pay |
$5,458.40
|
|
|
PATIENT PROGRAMER
|
Facility
|
OP
|
$6,823.00
|
|
|
Service Code
|
CPT C1787
|
| Hospital Charge Code |
22354563
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$6,140.70 |
| Rate for Payer: Aetna of AZ Commercial |
$6,140.70
|
| Rate for Payer: Aetna of AZ Medicare |
$1,910.44
|
| Rate for Payer: AHCCCS Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicare |
$1,023.45
|
| Rate for Payer: Amerigroup Medicare |
$1,023.45
|
| Rate for Payer: APIPA Medicare/Medicaid |
$2,548.39
|
| Rate for Payer: AZCH Complete Medicaid |
$0.13
|
| Rate for Payer: AZCH Complete Medicare |
$1,023.45
|
| Rate for Payer: Banner UC Health Medicaid |
$0.13
|
| Rate for Payer: Banner UC Health Medicare |
$1,023.45
|
| Rate for Payer: Bisbee Police All Plans |
$1,773.98
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$4,639.64
|
| Rate for Payer: Cash Price |
$5,458.40
|
| Rate for Payer: Cash Price |
$5,458.40
|
| Rate for Payer: Cigna of AZ Commercial |
$4,776.10
|
| Rate for Payer: Copperpoint Commercial |
$1,688.69
|
| Rate for Payer: Health Net of AZ Commercial |
$4,093.80
|
| Rate for Payer: Health Net of AZ Medicare |
$1,910.44
|
| Rate for Payer: Humana of AZ Medicare |
$1,023.45
|
| Rate for Payer: Mercy Care Medicaid |
$0.13
|
| Rate for Payer: Self Pay Self Pay |
$5,458.40
|
| Rate for Payer: TriWest Medicare |
$1,023.45
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,977.81
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$1,228.14
|
|
|
PCA SET
|
Facility
|
IP
|
$45.00
|
|
| Hospital Charge Code |
22355387
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$40.50 |
| Rate for Payer: Aetna of AZ Commercial |
$40.50
|
| Rate for Payer: Bisbee Police All Plans |
$11.70
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Self Pay Self Pay |
$36.00
|
|
|
PCA SET
|
Facility
|
OP
|
$45.00
|
|
| Hospital Charge Code |
22355387
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.75 |
| Max. Negotiated Rate |
$40.50 |
| Rate for Payer: Aetna of AZ Commercial |
$40.50
|
| Rate for Payer: Aetna of AZ Medicare |
$12.60
|
| Rate for Payer: Allwell Medicare |
$6.75
|
| Rate for Payer: Amerigroup Medicare |
$6.75
|
| Rate for Payer: APIPA Medicare/Medicaid |
$16.81
|
| Rate for Payer: AZCH Complete Medicare |
$6.75
|
| Rate for Payer: Banner UC Health Medicare |
$6.75
|
| Rate for Payer: Bisbee Police All Plans |
$11.70
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$30.60
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna of AZ Commercial |
$31.50
|
| Rate for Payer: Copperpoint Commercial |
$11.14
|
| Rate for Payer: Health Net of AZ Commercial |
$27.00
|
| Rate for Payer: Health Net of AZ Medicare |
$12.60
|
| Rate for Payer: Humana of AZ Medicare |
$6.75
|
| Rate for Payer: Self Pay Self Pay |
$36.00
|
| Rate for Payer: TriWest Medicare |
$6.75
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$26.24
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$8.10
|
|
|
PEDIALYTE 1 LITER BOTTLE
|
Facility
|
IP
|
$60.00
|
|
| Hospital Charge Code |
22354906
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna of AZ Commercial |
$54.00
|
| Rate for Payer: Bisbee Police All Plans |
$15.60
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Self Pay Self Pay |
$48.00
|
|
|
PEDIALYTE 1 LITER BOTTLE
|
Facility
|
OP
|
$60.00
|
|
| Hospital Charge Code |
22354906
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.00 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna of AZ Commercial |
$54.00
|
| Rate for Payer: Aetna of AZ Medicare |
$16.80
|
| Rate for Payer: Allwell Medicare |
$9.00
|
| Rate for Payer: Amerigroup Medicare |
$9.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$22.41
|
| Rate for Payer: AZCH Complete Medicare |
$9.00
|
| Rate for Payer: Banner UC Health Medicare |
$9.00
|
| Rate for Payer: Bisbee Police All Plans |
$15.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$40.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna of AZ Commercial |
$42.00
|
| Rate for Payer: Copperpoint Commercial |
$14.85
|
| Rate for Payer: Health Net of AZ Commercial |
$36.00
|
| Rate for Payer: Health Net of AZ Medicare |
$16.80
|
| Rate for Payer: Humana of AZ Medicare |
$9.00
|
| Rate for Payer: Self Pay Self Pay |
$48.00
|
| Rate for Payer: TriWest Medicare |
$9.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$34.98
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$10.80
|
|
|
pedialyte oral electrolyte pwder pkt [CQCH]
|
Facility
|
IP
|
$1.00
|
|
|
Service Code
|
NDC 70074056091
|
| Hospital Charge Code |
105955114
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of AZ Commercial |
$0.90
|
| Rate for Payer: Bisbee Police All Plans |
$0.26
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Self Pay Self Pay |
$0.80
|
|
|
pedialyte oral electrolyte pwder pkt [CQCH]
|
Facility
|
OP
|
$1.00
|
|
|
Service Code
|
NDC 70074056091
|
| Hospital Charge Code |
105955114
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of AZ Commercial |
$0.90
|
| Rate for Payer: Aetna of AZ Medicare |
$0.28
|
| Rate for Payer: Allwell Medicare |
$0.15
|
| Rate for Payer: Amerigroup Medicare |
$0.15
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.37
|
| Rate for Payer: AZCH Complete Medicare |
$0.15
|
| Rate for Payer: Banner UC Health Medicare |
$0.15
|
| Rate for Payer: Bisbee Police All Plans |
$0.26
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.68
|
| Rate for Payer: Cash Price |
$0.80
|
| Rate for Payer: Cigna of AZ Commercial |
$0.65
|
| Rate for Payer: Copperpoint Commercial |
$0.25
|
| Rate for Payer: Health Net of AZ Commercial |
$0.60
|
| Rate for Payer: Health Net of AZ Medicare |
$0.28
|
| Rate for Payer: Humana of AZ Medicare |
$0.15
|
| Rate for Payer: Self Pay Self Pay |
$0.80
|
| Rate for Payer: TriWest Medicare |
$0.15
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.58
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.18
|
|
|
PEDINEB PACIFIER NEBULIZERS
|
Facility
|
OP
|
$55.00
|
|
| Hospital Charge Code |
27728002
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.25 |
| Max. Negotiated Rate |
$49.50 |
| Rate for Payer: Aetna of AZ Commercial |
$49.50
|
| Rate for Payer: Aetna of AZ Medicare |
$15.40
|
| Rate for Payer: Allwell Medicare |
$8.25
|
| Rate for Payer: Amerigroup Medicare |
$8.25
|
| Rate for Payer: APIPA Medicare/Medicaid |
$20.54
|
| Rate for Payer: AZCH Complete Medicare |
$8.25
|
| Rate for Payer: Banner UC Health Medicare |
$8.25
|
| Rate for Payer: Bisbee Police All Plans |
$14.30
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$37.40
|
| Rate for Payer: Cash Price |
$44.00
|
| Rate for Payer: Cigna of AZ Commercial |
$38.50
|
| Rate for Payer: Copperpoint Commercial |
$13.61
|
| Rate for Payer: Health Net of AZ Commercial |
$33.00
|
| Rate for Payer: Health Net of AZ Medicare |
$15.40
|
| Rate for Payer: Humana of AZ Medicare |
$8.25
|
| Rate for Payer: Self Pay Self Pay |
$44.00
|
| Rate for Payer: TriWest Medicare |
$8.25
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$32.06
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$9.90
|
|
|
PEDINEB PACIFIER NEBULIZERS
|
Facility
|
IP
|
$55.00
|
|
| Hospital Charge Code |
27728002
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.30 |
| Max. Negotiated Rate |
$49.50 |
| Rate for Payer: Aetna of AZ Commercial |
$49.50
|
| Rate for Payer: Bisbee Police All Plans |
$14.30
|
| Rate for Payer: Cash Price |
$44.00
|
| Rate for Payer: Self Pay Self Pay |
$44.00
|
|
|
Pelvic Evisceration, Radical Hysterectomy And Other Radical Gynecological Procedures
|
Facility
|
IP
|
$34,134.33
|
|
|
Service Code
|
APR-DRG 5104
|
| Hospital Charge Code |
APRDRG5101
|
| Min. Negotiated Rate |
$34,134.33 |
| Max. Negotiated Rate |
$34,134.33 |
| Rate for Payer: AHCCCS Medicaid |
$34,134.33
|
| Rate for Payer: Allwell Medicaid |
$34,134.33
|
| Rate for Payer: AZCH Complete Medicaid |
$34,134.33
|
| Rate for Payer: Banner UC Health Medicaid |
$34,134.33
|
| Rate for Payer: Mercy Care Medicaid |
$34,134.33
|
|
|
Pelvic Evisceration, Radical Hysterectomy And Other Radical Gynecological Procedures
|
Facility
|
IP
|
$16,580.39
|
|
|
Service Code
|
APR-DRG 5103
|
| Hospital Charge Code |
APRDRG5103
|
| Min. Negotiated Rate |
$16,580.39 |
| Max. Negotiated Rate |
$16,580.39 |
| Rate for Payer: AHCCCS Medicaid |
$16,580.39
|
| Rate for Payer: Allwell Medicaid |
$16,580.39
|
| Rate for Payer: AZCH Complete Medicaid |
$16,580.39
|
| Rate for Payer: Banner UC Health Medicaid |
$16,580.39
|
| Rate for Payer: Mercy Care Medicaid |
$16,580.39
|
|
|
Pelvic Evisceration, Radical Hysterectomy And Other Radical Gynecological Procedures
|
Facility
|
IP
|
$10,957.27
|
|
|
Service Code
|
APR-DRG 5102
|
| Hospital Charge Code |
APRDRG5103
|
| Min. Negotiated Rate |
$10,957.27 |
| Max. Negotiated Rate |
$10,957.27 |
| Rate for Payer: AHCCCS Medicaid |
$10,957.27
|
| Rate for Payer: Allwell Medicaid |
$10,957.27
|
| Rate for Payer: AZCH Complete Medicaid |
$10,957.27
|
| Rate for Payer: Banner UC Health Medicaid |
$10,957.27
|
| Rate for Payer: Mercy Care Medicaid |
$10,957.27
|
|
|
Pelvic Evisceration, Radical Hysterectomy And Other Radical Gynecological Procedures
|
Facility
|
IP
|
$16,580.39
|
|
|
Service Code
|
APR-DRG 5103
|
| Hospital Charge Code |
APRDRG5104
|
| Min. Negotiated Rate |
$16,580.39 |
| Max. Negotiated Rate |
$16,580.39 |
| Rate for Payer: AHCCCS Medicaid |
$16,580.39
|
| Rate for Payer: Allwell Medicaid |
$16,580.39
|
| Rate for Payer: AZCH Complete Medicaid |
$16,580.39
|
| Rate for Payer: Banner UC Health Medicaid |
$16,580.39
|
| Rate for Payer: Mercy Care Medicaid |
$16,580.39
|
|
|
Pelvic Evisceration, Radical Hysterectomy And Other Radical Gynecological Procedures
|
Facility
|
IP
|
$34,134.33
|
|
|
Service Code
|
APR-DRG 5104
|
| Hospital Charge Code |
APRDRG5103
|
| Min. Negotiated Rate |
$34,134.33 |
| Max. Negotiated Rate |
$34,134.33 |
| Rate for Payer: AHCCCS Medicaid |
$34,134.33
|
| Rate for Payer: Allwell Medicaid |
$34,134.33
|
| Rate for Payer: AZCH Complete Medicaid |
$34,134.33
|
| Rate for Payer: Banner UC Health Medicaid |
$34,134.33
|
| Rate for Payer: Mercy Care Medicaid |
$34,134.33
|
|
|
Pelvic Evisceration, Radical Hysterectomy And Other Radical Gynecological Procedures
|
Facility
|
IP
|
$34,134.33
|
|
|
Service Code
|
APR-DRG 5104
|
| Hospital Charge Code |
APRDRG5104
|
| Min. Negotiated Rate |
$34,134.33 |
| Max. Negotiated Rate |
$34,134.33 |
| Rate for Payer: AHCCCS Medicaid |
$34,134.33
|
| Rate for Payer: Allwell Medicaid |
$34,134.33
|
| Rate for Payer: AZCH Complete Medicaid |
$34,134.33
|
| Rate for Payer: Banner UC Health Medicaid |
$34,134.33
|
| Rate for Payer: Mercy Care Medicaid |
$34,134.33
|
|
|
Pelvic Evisceration, Radical Hysterectomy And Other Radical Gynecological Procedures
|
Facility
|
IP
|
$16,580.39
|
|
|
Service Code
|
APR-DRG 5103
|
| Hospital Charge Code |
APRDRG5101
|
| Min. Negotiated Rate |
$16,580.39 |
| Max. Negotiated Rate |
$16,580.39 |
| Rate for Payer: AHCCCS Medicaid |
$16,580.39
|
| Rate for Payer: Allwell Medicaid |
$16,580.39
|
| Rate for Payer: AZCH Complete Medicaid |
$16,580.39
|
| Rate for Payer: Banner UC Health Medicaid |
$16,580.39
|
| Rate for Payer: Mercy Care Medicaid |
$16,580.39
|
|
|
Pelvic Evisceration, Radical Hysterectomy And Other Radical Gynecological Procedures
|
Facility
|
IP
|
$34,134.33
|
|
|
Service Code
|
APR-DRG 5104
|
| Hospital Charge Code |
APRDRG5102
|
| Min. Negotiated Rate |
$34,134.33 |
| Max. Negotiated Rate |
$34,134.33 |
| Rate for Payer: AHCCCS Medicaid |
$34,134.33
|
| Rate for Payer: Allwell Medicaid |
$34,134.33
|
| Rate for Payer: AZCH Complete Medicaid |
$34,134.33
|
| Rate for Payer: Banner UC Health Medicaid |
$34,134.33
|
| Rate for Payer: Mercy Care Medicaid |
$34,134.33
|
|
|
Pelvic Evisceration, Radical Hysterectomy And Other Radical Gynecological Procedures
|
Facility
|
IP
|
$10,957.27
|
|
|
Service Code
|
APR-DRG 5102
|
| Hospital Charge Code |
APRDRG5104
|
| Min. Negotiated Rate |
$10,957.27 |
| Max. Negotiated Rate |
$10,957.27 |
| Rate for Payer: AHCCCS Medicaid |
$10,957.27
|
| Rate for Payer: Allwell Medicaid |
$10,957.27
|
| Rate for Payer: AZCH Complete Medicaid |
$10,957.27
|
| Rate for Payer: Banner UC Health Medicaid |
$10,957.27
|
| Rate for Payer: Mercy Care Medicaid |
$10,957.27
|
|
|
Pelvic Evisceration, Radical Hysterectomy And Other Radical Gynecological Procedures
|
Facility
|
IP
|
$8,637.04
|
|
|
Service Code
|
APR-DRG 5101
|
| Hospital Charge Code |
APRDRG5101
|
| Min. Negotiated Rate |
$8,637.04 |
| Max. Negotiated Rate |
$8,637.04 |
| Rate for Payer: AHCCCS Medicaid |
$8,637.04
|
| Rate for Payer: Allwell Medicaid |
$8,637.04
|
| Rate for Payer: AZCH Complete Medicaid |
$8,637.04
|
| Rate for Payer: Banner UC Health Medicaid |
$8,637.04
|
| Rate for Payer: Mercy Care Medicaid |
$8,637.04
|
|
|
Pelvic Evisceration, Radical Hysterectomy And Other Radical Gynecological Procedures
|
Facility
|
IP
|
$8,637.04
|
|
|
Service Code
|
APR-DRG 5101
|
| Hospital Charge Code |
APRDRG5103
|
| Min. Negotiated Rate |
$8,637.04 |
| Max. Negotiated Rate |
$8,637.04 |
| Rate for Payer: AHCCCS Medicaid |
$8,637.04
|
| Rate for Payer: Allwell Medicaid |
$8,637.04
|
| Rate for Payer: AZCH Complete Medicaid |
$8,637.04
|
| Rate for Payer: Banner UC Health Medicaid |
$8,637.04
|
| Rate for Payer: Mercy Care Medicaid |
$8,637.04
|
|
|
Pelvic Evisceration, Radical Hysterectomy And Other Radical Gynecological Procedures
|
Facility
|
IP
|
$8,637.04
|
|
|
Service Code
|
APR-DRG 5101
|
| Hospital Charge Code |
APRDRG5102
|
| Min. Negotiated Rate |
$8,637.04 |
| Max. Negotiated Rate |
$8,637.04 |
| Rate for Payer: AHCCCS Medicaid |
$8,637.04
|
| Rate for Payer: Allwell Medicaid |
$8,637.04
|
| Rate for Payer: AZCH Complete Medicaid |
$8,637.04
|
| Rate for Payer: Banner UC Health Medicaid |
$8,637.04
|
| Rate for Payer: Mercy Care Medicaid |
$8,637.04
|
|
|
Pelvic Evisceration, Radical Hysterectomy And Other Radical Gynecological Procedures
|
Facility
|
IP
|
$16,580.39
|
|
|
Service Code
|
APR-DRG 5103
|
| Hospital Charge Code |
APRDRG5102
|
| Min. Negotiated Rate |
$16,580.39 |
| Max. Negotiated Rate |
$16,580.39 |
| Rate for Payer: AHCCCS Medicaid |
$16,580.39
|
| Rate for Payer: Allwell Medicaid |
$16,580.39
|
| Rate for Payer: AZCH Complete Medicaid |
$16,580.39
|
| Rate for Payer: Banner UC Health Medicaid |
$16,580.39
|
| Rate for Payer: Mercy Care Medicaid |
$16,580.39
|
|
