|
Pelvic Evisceration, Radical Hysterectomy And Other Radical Gynecological Procedures
|
Facility
|
IP
|
$8,637.04
|
|
|
Service Code
|
APR-DRG 5101
|
| Hospital Charge Code |
APRDRG5104
|
| 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
|
$10,957.27
|
|
|
Service Code
|
APR-DRG 5102
|
| Hospital Charge Code |
APRDRG5101
|
| 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
|
$10,957.27
|
|
|
Service Code
|
APR-DRG 5102
|
| Hospital Charge Code |
APRDRG5102
|
| 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 exam under anesthesia
|
Facility
|
OP
|
$680.00
|
|
|
Service Code
|
CPT 57400
|
| Hospital Charge Code |
27291800
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$102.00 |
| Max. Negotiated Rate |
$3,803.66 |
| Rate for Payer: Aetna of AZ Commercial |
$612.00
|
| Rate for Payer: Aetna of AZ Medicare |
$190.40
|
| Rate for Payer: AHCCCS Medicaid |
$3,803.66
|
| Rate for Payer: Allwell Medicaid |
$3,803.66
|
| Rate for Payer: Allwell Medicare |
$102.00
|
| Rate for Payer: Amerigroup Medicare |
$102.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$253.98
|
| Rate for Payer: AZCH Complete Medicaid |
$3,803.66
|
| Rate for Payer: AZCH Complete Medicare |
$102.00
|
| Rate for Payer: Banner UC Health Medicaid |
$3,803.66
|
| Rate for Payer: Banner UC Health Medicare |
$102.00
|
| Rate for Payer: Bisbee Police All Plans |
$176.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$462.40
|
| Rate for Payer: Cash Price |
$544.00
|
| Rate for Payer: Cash Price |
$544.00
|
| Rate for Payer: Cigna of AZ Commercial |
$340.00
|
| Rate for Payer: Copperpoint Commercial |
$168.30
|
| Rate for Payer: Health Net of AZ Commercial |
$408.00
|
| Rate for Payer: Health Net of AZ Medicare |
$190.40
|
| Rate for Payer: Humana of AZ Medicare |
$102.00
|
| Rate for Payer: Mercy Care Medicaid |
$3,803.66
|
| Rate for Payer: Self Pay Self Pay |
$544.00
|
| Rate for Payer: TriWest Medicare |
$102.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,373.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$122.40
|
|
|
Pelvic exam under anesthesia
|
Facility
|
IP
|
$680.00
|
|
|
Service Code
|
CPT 57400
|
| Hospital Charge Code |
27291800
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$176.80 |
| Max. Negotiated Rate |
$612.00 |
| Rate for Payer: Aetna of AZ Commercial |
$612.00
|
| Rate for Payer: Bisbee Police All Plans |
$176.80
|
| Rate for Payer: Cash Price |
$544.00
|
| Rate for Payer: Self Pay Self Pay |
$544.00
|
|
|
Penicillin G 5,000,000 units inj REC [CQCH]
|
Facility
|
IP
|
$5.48
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
105935952
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$4.93 |
| Rate for Payer: Aetna of AZ Commercial |
$4.93
|
| Rate for Payer: Bisbee Police All Plans |
$1.42
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Self Pay Self Pay |
$4.38
|
|
|
Penicillin G 5,000,000 units inj REC [CQCH]
|
Facility
|
OP
|
$5.48
|
|
|
Service Code
|
HCPCS J2540
|
| Hospital Charge Code |
105935952
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$4.93 |
| Rate for Payer: Aetna of AZ Commercial |
$4.93
|
| Rate for Payer: Aetna of AZ Medicare |
$1.53
|
| Rate for Payer: AHCCCS Medicaid |
$1.48
|
| Rate for Payer: Allwell Medicaid |
$1.48
|
| Rate for Payer: Allwell Medicare |
$0.82
|
| Rate for Payer: Amerigroup Medicare |
$0.82
|
| Rate for Payer: APIPA Medicare/Medicaid |
$2.05
|
| Rate for Payer: AZCH Complete Medicaid |
$1.48
|
| Rate for Payer: AZCH Complete Medicare |
$0.82
|
| Rate for Payer: Banner UC Health Medicaid |
$1.48
|
| Rate for Payer: Banner UC Health Medicare |
$0.82
|
| Rate for Payer: Bisbee Police All Plans |
$1.42
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$3.73
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Cigna of AZ Commercial |
$3.56
|
| Rate for Payer: Copperpoint Commercial |
$1.36
|
| Rate for Payer: Health Net of AZ Commercial |
$3.29
|
| Rate for Payer: Health Net of AZ Medicare |
$1.53
|
| Rate for Payer: Humana of AZ Medicare |
$0.82
|
| Rate for Payer: Mercy Care Medicaid |
$1.48
|
| Rate for Payer: Self Pay Self Pay |
$4.38
|
| Rate for Payer: TriWest Medicare |
$0.82
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3.19
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.99
|
|
|
penicillin G benzathine 1,200,000 units/2 mL Sus [CQCH]
|
Facility
|
IP
|
$80.05
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
105935877
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.81 |
| Max. Negotiated Rate |
$72.04 |
| Rate for Payer: Aetna of AZ Commercial |
$72.04
|
| Rate for Payer: Bisbee Police All Plans |
$20.81
|
| Rate for Payer: Cash Price |
$64.04
|
| Rate for Payer: Self Pay Self Pay |
$64.04
|
|
|
penicillin G benzathine 1,200,000 units/2 mL Sus [CQCH]
|
Facility
|
OP
|
$80.05
|
|
|
Service Code
|
HCPCS J0561
|
| Hospital Charge Code |
105935877
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.01 |
| Max. Negotiated Rate |
$72.04 |
| Rate for Payer: Aetna of AZ Commercial |
$72.04
|
| Rate for Payer: Aetna of AZ Medicare |
$22.41
|
| Rate for Payer: AHCCCS Medicaid |
$28.98
|
| Rate for Payer: Allwell Medicaid |
$28.98
|
| Rate for Payer: Allwell Medicare |
$12.01
|
| Rate for Payer: Amerigroup Medicare |
$12.01
|
| Rate for Payer: APIPA Medicare/Medicaid |
$29.90
|
| Rate for Payer: AZCH Complete Medicaid |
$28.98
|
| Rate for Payer: AZCH Complete Medicare |
$12.01
|
| Rate for Payer: Banner UC Health Medicaid |
$28.98
|
| Rate for Payer: Banner UC Health Medicare |
$12.01
|
| Rate for Payer: Bisbee Police All Plans |
$20.81
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$54.43
|
| Rate for Payer: Cash Price |
$64.04
|
| Rate for Payer: Cash Price |
$64.04
|
| Rate for Payer: Cigna of AZ Commercial |
$52.03
|
| Rate for Payer: Copperpoint Commercial |
$19.81
|
| Rate for Payer: Health Net of AZ Commercial |
$48.03
|
| Rate for Payer: Health Net of AZ Medicare |
$22.41
|
| Rate for Payer: Humana of AZ Medicare |
$12.01
|
| Rate for Payer: Mercy Care Medicaid |
$28.98
|
| Rate for Payer: Self Pay Self Pay |
$64.04
|
| Rate for Payer: TriWest Medicare |
$12.01
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$46.67
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$14.41
|
|
|
Penicillin VK 250 mg Tab [CQCH]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 57237004001
|
| Hospital Charge Code |
105936021
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of AZ Commercial |
$0.07
|
| Rate for Payer: Aetna of AZ Medicare |
$0.02
|
| Rate for Payer: Allwell Medicare |
$0.01
|
| Rate for Payer: Amerigroup Medicare |
$0.01
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.03
|
| Rate for Payer: AZCH Complete Medicare |
$0.01
|
| Rate for Payer: Banner UC Health Medicare |
$0.01
|
| Rate for Payer: Bisbee Police All Plans |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of AZ Commercial |
$0.05
|
| Rate for Payer: Copperpoint Commercial |
$0.02
|
| Rate for Payer: Health Net of AZ Commercial |
$0.05
|
| Rate for Payer: Health Net of AZ Medicare |
$0.02
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Self Pay Self Pay |
$0.06
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.05
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.01
|
|
|
Penicillin VK 250 mg Tab [CQCH]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 57237004001
|
| Hospital Charge Code |
105936021
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of AZ Commercial |
$0.07
|
| Rate for Payer: Bisbee Police All Plans |
$0.02
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Self Pay Self Pay |
$0.06
|
|
|
Penis, Testes And Scrotal Procedures
|
Facility
|
IP
|
$13,713.07
|
|
|
Service Code
|
APR-DRG 4833
|
| Hospital Charge Code |
APRDRG4832
|
| Min. Negotiated Rate |
$13,713.07 |
| Max. Negotiated Rate |
$13,713.07 |
| Rate for Payer: AHCCCS Medicaid |
$13,713.07
|
| Rate for Payer: Allwell Medicaid |
$13,713.07
|
| Rate for Payer: AZCH Complete Medicaid |
$13,713.07
|
| Rate for Payer: Banner UC Health Medicaid |
$13,713.07
|
| Rate for Payer: Mercy Care Medicaid |
$13,713.07
|
|
|
Penis, Testes And Scrotal Procedures
|
Facility
|
IP
|
$13,713.07
|
|
|
Service Code
|
APR-DRG 4833
|
| Hospital Charge Code |
APRDRG4831
|
| Min. Negotiated Rate |
$13,713.07 |
| Max. Negotiated Rate |
$13,713.07 |
| Rate for Payer: AHCCCS Medicaid |
$13,713.07
|
| Rate for Payer: Allwell Medicaid |
$13,713.07
|
| Rate for Payer: AZCH Complete Medicaid |
$13,713.07
|
| Rate for Payer: Banner UC Health Medicaid |
$13,713.07
|
| Rate for Payer: Mercy Care Medicaid |
$13,713.07
|
|
|
Penis, Testes And Scrotal Procedures
|
Facility
|
IP
|
$24,699.10
|
|
|
Service Code
|
APR-DRG 4834
|
| Hospital Charge Code |
APRDRG4832
|
| Min. Negotiated Rate |
$24,699.10 |
| Max. Negotiated Rate |
$24,699.10 |
| Rate for Payer: AHCCCS Medicaid |
$24,699.10
|
| Rate for Payer: Allwell Medicaid |
$24,699.10
|
| Rate for Payer: AZCH Complete Medicaid |
$24,699.10
|
| Rate for Payer: Banner UC Health Medicaid |
$24,699.10
|
| Rate for Payer: Mercy Care Medicaid |
$24,699.10
|
|
|
Penis, Testes And Scrotal Procedures
|
Facility
|
IP
|
$24,699.10
|
|
|
Service Code
|
APR-DRG 4834
|
| Hospital Charge Code |
APRDRG4833
|
| Min. Negotiated Rate |
$24,699.10 |
| Max. Negotiated Rate |
$24,699.10 |
| Rate for Payer: AHCCCS Medicaid |
$24,699.10
|
| Rate for Payer: Allwell Medicaid |
$24,699.10
|
| Rate for Payer: AZCH Complete Medicaid |
$24,699.10
|
| Rate for Payer: Banner UC Health Medicaid |
$24,699.10
|
| Rate for Payer: Mercy Care Medicaid |
$24,699.10
|
|
|
Penis, Testes And Scrotal Procedures
|
Facility
|
IP
|
$7,091.86
|
|
|
Service Code
|
APR-DRG 4831
|
| Hospital Charge Code |
APRDRG4834
|
| Min. Negotiated Rate |
$7,091.86 |
| Max. Negotiated Rate |
$7,091.86 |
| Rate for Payer: AHCCCS Medicaid |
$7,091.86
|
| Rate for Payer: Allwell Medicaid |
$7,091.86
|
| Rate for Payer: AZCH Complete Medicaid |
$7,091.86
|
| Rate for Payer: Banner UC Health Medicaid |
$7,091.86
|
| Rate for Payer: Mercy Care Medicaid |
$7,091.86
|
|
|
Penis, Testes And Scrotal Procedures
|
Facility
|
IP
|
$9,340.54
|
|
|
Service Code
|
APR-DRG 4832
|
| Hospital Charge Code |
APRDRG4833
|
| Min. Negotiated Rate |
$9,340.54 |
| Max. Negotiated Rate |
$9,340.54 |
| Rate for Payer: AHCCCS Medicaid |
$9,340.54
|
| Rate for Payer: Allwell Medicaid |
$9,340.54
|
| Rate for Payer: AZCH Complete Medicaid |
$9,340.54
|
| Rate for Payer: Banner UC Health Medicaid |
$9,340.54
|
| Rate for Payer: Mercy Care Medicaid |
$9,340.54
|
|
|
Penis, Testes And Scrotal Procedures
|
Facility
|
IP
|
$9,340.54
|
|
|
Service Code
|
APR-DRG 4832
|
| Hospital Charge Code |
APRDRG4831
|
| Min. Negotiated Rate |
$9,340.54 |
| Max. Negotiated Rate |
$9,340.54 |
| Rate for Payer: AHCCCS Medicaid |
$9,340.54
|
| Rate for Payer: Allwell Medicaid |
$9,340.54
|
| Rate for Payer: AZCH Complete Medicaid |
$9,340.54
|
| Rate for Payer: Banner UC Health Medicaid |
$9,340.54
|
| Rate for Payer: Mercy Care Medicaid |
$9,340.54
|
|
|
Penis, Testes And Scrotal Procedures
|
Facility
|
IP
|
$24,699.10
|
|
|
Service Code
|
APR-DRG 4834
|
| Hospital Charge Code |
APRDRG4831
|
| Min. Negotiated Rate |
$24,699.10 |
| Max. Negotiated Rate |
$24,699.10 |
| Rate for Payer: AHCCCS Medicaid |
$24,699.10
|
| Rate for Payer: Allwell Medicaid |
$24,699.10
|
| Rate for Payer: AZCH Complete Medicaid |
$24,699.10
|
| Rate for Payer: Banner UC Health Medicaid |
$24,699.10
|
| Rate for Payer: Mercy Care Medicaid |
$24,699.10
|
|
|
Penis, Testes And Scrotal Procedures
|
Facility
|
IP
|
$9,340.54
|
|
|
Service Code
|
APR-DRG 4832
|
| Hospital Charge Code |
APRDRG4832
|
| Min. Negotiated Rate |
$9,340.54 |
| Max. Negotiated Rate |
$9,340.54 |
| Rate for Payer: AHCCCS Medicaid |
$9,340.54
|
| Rate for Payer: Allwell Medicaid |
$9,340.54
|
| Rate for Payer: AZCH Complete Medicaid |
$9,340.54
|
| Rate for Payer: Banner UC Health Medicaid |
$9,340.54
|
| Rate for Payer: Mercy Care Medicaid |
$9,340.54
|
|
|
Penis, Testes And Scrotal Procedures
|
Facility
|
IP
|
$7,091.86
|
|
|
Service Code
|
APR-DRG 4831
|
| Hospital Charge Code |
APRDRG4833
|
| Min. Negotiated Rate |
$7,091.86 |
| Max. Negotiated Rate |
$7,091.86 |
| Rate for Payer: AHCCCS Medicaid |
$7,091.86
|
| Rate for Payer: Allwell Medicaid |
$7,091.86
|
| Rate for Payer: AZCH Complete Medicaid |
$7,091.86
|
| Rate for Payer: Banner UC Health Medicaid |
$7,091.86
|
| Rate for Payer: Mercy Care Medicaid |
$7,091.86
|
|
|
Penis, Testes And Scrotal Procedures
|
Facility
|
IP
|
$7,091.86
|
|
|
Service Code
|
APR-DRG 4831
|
| Hospital Charge Code |
APRDRG4832
|
| Min. Negotiated Rate |
$7,091.86 |
| Max. Negotiated Rate |
$7,091.86 |
| Rate for Payer: AHCCCS Medicaid |
$7,091.86
|
| Rate for Payer: Allwell Medicaid |
$7,091.86
|
| Rate for Payer: AZCH Complete Medicaid |
$7,091.86
|
| Rate for Payer: Banner UC Health Medicaid |
$7,091.86
|
| Rate for Payer: Mercy Care Medicaid |
$7,091.86
|
|
|
Penis, Testes And Scrotal Procedures
|
Facility
|
IP
|
$7,091.86
|
|
|
Service Code
|
APR-DRG 4831
|
| Hospital Charge Code |
APRDRG4831
|
| Min. Negotiated Rate |
$7,091.86 |
| Max. Negotiated Rate |
$7,091.86 |
| Rate for Payer: AHCCCS Medicaid |
$7,091.86
|
| Rate for Payer: Allwell Medicaid |
$7,091.86
|
| Rate for Payer: AZCH Complete Medicaid |
$7,091.86
|
| Rate for Payer: Banner UC Health Medicaid |
$7,091.86
|
| Rate for Payer: Mercy Care Medicaid |
$7,091.86
|
|
|
Penis, Testes And Scrotal Procedures
|
Facility
|
IP
|
$9,340.54
|
|
|
Service Code
|
APR-DRG 4832
|
| Hospital Charge Code |
APRDRG4834
|
| Min. Negotiated Rate |
$9,340.54 |
| Max. Negotiated Rate |
$9,340.54 |
| Rate for Payer: AHCCCS Medicaid |
$9,340.54
|
| Rate for Payer: Allwell Medicaid |
$9,340.54
|
| Rate for Payer: AZCH Complete Medicaid |
$9,340.54
|
| Rate for Payer: Banner UC Health Medicaid |
$9,340.54
|
| Rate for Payer: Mercy Care Medicaid |
$9,340.54
|
|
|
Penis, Testes And Scrotal Procedures
|
Facility
|
IP
|
$13,713.07
|
|
|
Service Code
|
APR-DRG 4833
|
| Hospital Charge Code |
APRDRG4833
|
| Min. Negotiated Rate |
$13,713.07 |
| Max. Negotiated Rate |
$13,713.07 |
| Rate for Payer: AHCCCS Medicaid |
$13,713.07
|
| Rate for Payer: Allwell Medicaid |
$13,713.07
|
| Rate for Payer: AZCH Complete Medicaid |
$13,713.07
|
| Rate for Payer: Banner UC Health Medicaid |
$13,713.07
|
| Rate for Payer: Mercy Care Medicaid |
$13,713.07
|
|
