|
PARoxetine 20 mg Tab [CQCH]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 904567761
|
| Hospital Charge Code |
105935810
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of AZ Commercial |
$0.13
|
| 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 |
$0.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of AZ Commercial |
$0.09
|
| 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 |
$0.11
|
| 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 |
$0.03
|
|
|
PARoxetine 20 mg Tab [CQCH]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 904567761
|
| Hospital Charge Code |
105935810
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of AZ Commercial |
$0.13
|
| Rate for Payer: Bisbee Police All Plans |
$0.04
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Self Pay Self Pay |
$0.11
|
|
|
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSECTOMY) BONEÿ
|
Facility
|
IP
|
$4,040.00
|
|
|
Service Code
|
CPT 27640
|
| Hospital Charge Code |
24043287
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,050.40 |
| Max. Negotiated Rate |
$3,636.00 |
| Rate for Payer: Aetna of AZ Commercial |
$3,636.00
|
| Rate for Payer: Bisbee Police All Plans |
$1,050.40
|
| Rate for Payer: Cash Price |
$3,232.00
|
| Rate for Payer: Self Pay Self Pay |
$3,232.00
|
|
|
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION OR DIAPHYSECTOMY) BONEÿ
|
Facility
|
OP
|
$4,040.00
|
|
|
Service Code
|
CPT 27640
|
| Hospital Charge Code |
24043287
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$646.40 |
| Max. Negotiated Rate |
$3,914.00 |
| Rate for Payer: Aetna of AZ Commercial |
$3,636.00
|
| Rate for Payer: Aetna of AZ Medicare |
$1,131.20
|
| Rate for Payer: AHCCCS Medicaid |
$2,052.04
|
| Rate for Payer: Allwell Medicaid |
$2,052.04
|
| Rate for Payer: Allwell Medicare |
$646.40
|
| Rate for Payer: Amerigroup Medicare |
$646.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,508.94
|
| Rate for Payer: AZCH Complete Medicaid |
$2,052.04
|
| Rate for Payer: AZCH Complete Medicare |
$646.40
|
| Rate for Payer: Banner UC Health Medicaid |
$2,052.04
|
| Rate for Payer: Banner UC Health Medicare |
$646.40
|
| Rate for Payer: Bisbee Police All Plans |
$1,050.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2,747.20
|
| Rate for Payer: Cash Price |
$3,232.00
|
| Rate for Payer: Cash Price |
$3,232.00
|
| Rate for Payer: Cigna of AZ Commercial |
$2,020.00
|
| Rate for Payer: Copperpoint Commercial |
$999.90
|
| Rate for Payer: Health Net of AZ Commercial |
$2,424.00
|
| Rate for Payer: Health Net of AZ Medicare |
$1,131.20
|
| Rate for Payer: Humana of AZ Medicare |
$646.40
|
| Rate for Payer: Mercy Care Medicaid |
$2,052.04
|
| Rate for Payer: Self Pay Self Pay |
$3,232.00
|
| Rate for Payer: TriWest Medicare |
$646.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,914.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$727.20
|
|
|
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION SEQUESTRECTOMY
|
Facility
|
IP
|
$2,146.00
|
|
|
Service Code
|
CPT 28122
|
| Hospital Charge Code |
24043291
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$557.96 |
| Max. Negotiated Rate |
$1,931.40 |
| Rate for Payer: Aetna of AZ Commercial |
$1,931.40
|
| Rate for Payer: Bisbee Police All Plans |
$557.96
|
| Rate for Payer: Cash Price |
$1,716.80
|
| Rate for Payer: Self Pay Self Pay |
$1,716.80
|
|
|
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION SEQUESTRECTOMY
|
Facility
|
OP
|
$2,146.00
|
|
|
Service Code
|
CPT 28122
|
| Hospital Charge Code |
24043291
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$343.36 |
| Max. Negotiated Rate |
$3,373.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,931.40
|
| Rate for Payer: Aetna of AZ Medicare |
$600.88
|
| Rate for Payer: AHCCCS Medicaid |
$2,052.04
|
| Rate for Payer: Allwell Medicaid |
$2,052.04
|
| Rate for Payer: Allwell Medicare |
$343.36
|
| Rate for Payer: Amerigroup Medicare |
$343.36
|
| Rate for Payer: APIPA Medicare/Medicaid |
$801.53
|
| Rate for Payer: AZCH Complete Medicaid |
$2,052.04
|
| Rate for Payer: AZCH Complete Medicare |
$343.36
|
| Rate for Payer: Banner UC Health Medicaid |
$2,052.04
|
| Rate for Payer: Banner UC Health Medicare |
$343.36
|
| Rate for Payer: Bisbee Police All Plans |
$557.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,459.28
|
| Rate for Payer: Cash Price |
$1,716.80
|
| Rate for Payer: Cash Price |
$1,716.80
|
| Rate for Payer: Cigna of AZ Commercial |
$1,073.00
|
| Rate for Payer: Copperpoint Commercial |
$531.13
|
| Rate for Payer: Health Net of AZ Commercial |
$1,287.60
|
| Rate for Payer: Health Net of AZ Medicare |
$600.88
|
| Rate for Payer: Humana of AZ Medicare |
$343.36
|
| Rate for Payer: Mercy Care Medicaid |
$2,052.04
|
| Rate for Payer: Self Pay Self Pay |
$1,716.80
|
| Rate for Payer: TriWest Medicare |
$343.36
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,373.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$386.28
|
|
|
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION SEQUESTRECTOMY - 28124
|
Facility
|
OP
|
$1,622.00
|
|
|
Service Code
|
CPT 28124
|
| Hospital Charge Code |
24043292
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$259.52 |
| Max. Negotiated Rate |
$3,373.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,459.80
|
| Rate for Payer: Aetna of AZ Medicare |
$454.16
|
| Rate for Payer: AHCCCS Medicaid |
$2,052.04
|
| Rate for Payer: Allwell Medicaid |
$2,052.04
|
| Rate for Payer: Allwell Medicare |
$259.52
|
| Rate for Payer: Amerigroup Medicare |
$259.52
|
| Rate for Payer: APIPA Medicare/Medicaid |
$605.82
|
| Rate for Payer: AZCH Complete Medicaid |
$2,052.04
|
| Rate for Payer: AZCH Complete Medicare |
$259.52
|
| Rate for Payer: Banner UC Health Medicaid |
$2,052.04
|
| Rate for Payer: Banner UC Health Medicare |
$259.52
|
| Rate for Payer: Bisbee Police All Plans |
$421.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,102.96
|
| Rate for Payer: Cash Price |
$1,297.60
|
| Rate for Payer: Cash Price |
$1,297.60
|
| Rate for Payer: Cigna of AZ Commercial |
$811.00
|
| Rate for Payer: Copperpoint Commercial |
$401.44
|
| Rate for Payer: Health Net of AZ Commercial |
$973.20
|
| Rate for Payer: Health Net of AZ Medicare |
$454.16
|
| Rate for Payer: Humana of AZ Medicare |
$259.52
|
| Rate for Payer: Mercy Care Medicaid |
$2,052.04
|
| Rate for Payer: Self Pay Self Pay |
$1,297.60
|
| Rate for Payer: TriWest Medicare |
$259.52
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,373.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$291.96
|
|
|
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION SEQUESTRECTOMY - 28124
|
Facility
|
IP
|
$1,622.00
|
|
|
Service Code
|
CPT 28124
|
| Hospital Charge Code |
24043292
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$421.72 |
| Max. Negotiated Rate |
$1,459.80 |
| Rate for Payer: Aetna of AZ Commercial |
$1,459.80
|
| Rate for Payer: Bisbee Police All Plans |
$421.72
|
| Rate for Payer: Cash Price |
$1,297.60
|
| Rate for Payer: Self Pay Self Pay |
$1,297.60
|
|
|
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION SEQUESTRECTOMY - Tech
|
Facility
|
IP
|
$2,309.00
|
|
|
Service Code
|
CPT 28120
|
| Hospital Charge Code |
24043309
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$600.34 |
| Max. Negotiated Rate |
$2,078.10 |
| Rate for Payer: Aetna of AZ Commercial |
$2,078.10
|
| Rate for Payer: Bisbee Police All Plans |
$600.34
|
| Rate for Payer: Cash Price |
$1,847.20
|
| Rate for Payer: Self Pay Self Pay |
$1,847.20
|
|
|
PARTIAL EXCISION (CRATERIZATION SAUCERIZATION SEQUESTRECTOMY - Tech
|
Facility
|
OP
|
$2,309.00
|
|
|
Service Code
|
CPT 28120
|
| Hospital Charge Code |
24043309
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$369.44 |
| Max. Negotiated Rate |
$3,373.00 |
| Rate for Payer: Aetna of AZ Commercial |
$2,078.10
|
| Rate for Payer: Aetna of AZ Medicare |
$646.52
|
| Rate for Payer: AHCCCS Medicaid |
$2,052.04
|
| Rate for Payer: Allwell Medicaid |
$2,052.04
|
| Rate for Payer: Allwell Medicare |
$369.44
|
| Rate for Payer: Amerigroup Medicare |
$369.44
|
| Rate for Payer: APIPA Medicare/Medicaid |
$862.41
|
| Rate for Payer: AZCH Complete Medicaid |
$2,052.04
|
| Rate for Payer: AZCH Complete Medicare |
$369.44
|
| Rate for Payer: Banner UC Health Medicaid |
$2,052.04
|
| Rate for Payer: Banner UC Health Medicare |
$369.44
|
| Rate for Payer: Bisbee Police All Plans |
$600.34
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,570.12
|
| Rate for Payer: Cash Price |
$1,847.20
|
| Rate for Payer: Cash Price |
$1,847.20
|
| Rate for Payer: Cigna of AZ Commercial |
$1,154.50
|
| Rate for Payer: Copperpoint Commercial |
$571.48
|
| Rate for Payer: Health Net of AZ Commercial |
$1,385.40
|
| Rate for Payer: Health Net of AZ Medicare |
$646.52
|
| Rate for Payer: Humana of AZ Medicare |
$369.44
|
| Rate for Payer: Mercy Care Medicaid |
$2,052.04
|
| Rate for Payer: Self Pay Self Pay |
$1,847.20
|
| Rate for Payer: TriWest Medicare |
$369.44
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,373.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$415.62
|
|
|
Partial Thickness Burns Without Skin Graft
|
Facility
|
IP
|
$8,655.28
|
|
|
Service Code
|
APR-DRG 8443
|
| Hospital Charge Code |
APRDRG8444
|
| Min. Negotiated Rate |
$8,655.28 |
| Max. Negotiated Rate |
$8,655.28 |
| Rate for Payer: AHCCCS Medicaid |
$8,655.28
|
| Rate for Payer: Allwell Medicaid |
$8,655.28
|
| Rate for Payer: AZCH Complete Medicaid |
$8,655.28
|
| Rate for Payer: Banner UC Health Medicaid |
$8,655.28
|
| Rate for Payer: Mercy Care Medicaid |
$8,655.28
|
|
|
Partial Thickness Burns Without Skin Graft
|
Facility
|
IP
|
$3,100.89
|
|
|
Service Code
|
APR-DRG 8441
|
| Hospital Charge Code |
APRDRG8441
|
| Min. Negotiated Rate |
$3,100.89 |
| Max. Negotiated Rate |
$3,100.89 |
| Rate for Payer: AHCCCS Medicaid |
$3,100.89
|
| Rate for Payer: Allwell Medicaid |
$3,100.89
|
| Rate for Payer: AZCH Complete Medicaid |
$3,100.89
|
| Rate for Payer: Banner UC Health Medicaid |
$3,100.89
|
| Rate for Payer: Mercy Care Medicaid |
$3,100.89
|
|
|
Partial Thickness Burns Without Skin Graft
|
Facility
|
IP
|
$19,419.66
|
|
|
Service Code
|
APR-DRG 8444
|
| Hospital Charge Code |
APRDRG8443
|
| Min. Negotiated Rate |
$19,419.66 |
| Max. Negotiated Rate |
$19,419.66 |
| Rate for Payer: AHCCCS Medicaid |
$19,419.66
|
| Rate for Payer: Allwell Medicaid |
$19,419.66
|
| Rate for Payer: AZCH Complete Medicaid |
$19,419.66
|
| Rate for Payer: Banner UC Health Medicaid |
$19,419.66
|
| Rate for Payer: Mercy Care Medicaid |
$19,419.66
|
|
|
Partial Thickness Burns Without Skin Graft
|
Facility
|
IP
|
$8,655.28
|
|
|
Service Code
|
APR-DRG 8443
|
| Hospital Charge Code |
APRDRG8441
|
| Min. Negotiated Rate |
$8,655.28 |
| Max. Negotiated Rate |
$8,655.28 |
| Rate for Payer: AHCCCS Medicaid |
$8,655.28
|
| Rate for Payer: Allwell Medicaid |
$8,655.28
|
| Rate for Payer: AZCH Complete Medicaid |
$8,655.28
|
| Rate for Payer: Banner UC Health Medicaid |
$8,655.28
|
| Rate for Payer: Mercy Care Medicaid |
$8,655.28
|
|
|
Partial Thickness Burns Without Skin Graft
|
Facility
|
IP
|
$5,268.92
|
|
|
Service Code
|
APR-DRG 8442
|
| Hospital Charge Code |
APRDRG8444
|
| Min. Negotiated Rate |
$5,268.92 |
| Max. Negotiated Rate |
$5,268.92 |
| Rate for Payer: AHCCCS Medicaid |
$5,268.92
|
| Rate for Payer: Allwell Medicaid |
$5,268.92
|
| Rate for Payer: AZCH Complete Medicaid |
$5,268.92
|
| Rate for Payer: Banner UC Health Medicaid |
$5,268.92
|
| Rate for Payer: Mercy Care Medicaid |
$5,268.92
|
|
|
Partial Thickness Burns Without Skin Graft
|
Facility
|
IP
|
$19,419.66
|
|
|
Service Code
|
APR-DRG 8444
|
| Hospital Charge Code |
APRDRG8441
|
| Min. Negotiated Rate |
$19,419.66 |
| Max. Negotiated Rate |
$19,419.66 |
| Rate for Payer: AHCCCS Medicaid |
$19,419.66
|
| Rate for Payer: Allwell Medicaid |
$19,419.66
|
| Rate for Payer: AZCH Complete Medicaid |
$19,419.66
|
| Rate for Payer: Banner UC Health Medicaid |
$19,419.66
|
| Rate for Payer: Mercy Care Medicaid |
$19,419.66
|
|
|
Partial Thickness Burns Without Skin Graft
|
Facility
|
IP
|
$8,655.28
|
|
|
Service Code
|
APR-DRG 8443
|
| Hospital Charge Code |
APRDRG8442
|
| Min. Negotiated Rate |
$8,655.28 |
| Max. Negotiated Rate |
$8,655.28 |
| Rate for Payer: AHCCCS Medicaid |
$8,655.28
|
| Rate for Payer: Allwell Medicaid |
$8,655.28
|
| Rate for Payer: AZCH Complete Medicaid |
$8,655.28
|
| Rate for Payer: Banner UC Health Medicaid |
$8,655.28
|
| Rate for Payer: Mercy Care Medicaid |
$8,655.28
|
|
|
Partial Thickness Burns Without Skin Graft
|
Facility
|
IP
|
$19,419.66
|
|
|
Service Code
|
APR-DRG 8444
|
| Hospital Charge Code |
APRDRG8442
|
| Min. Negotiated Rate |
$19,419.66 |
| Max. Negotiated Rate |
$19,419.66 |
| Rate for Payer: AHCCCS Medicaid |
$19,419.66
|
| Rate for Payer: Allwell Medicaid |
$19,419.66
|
| Rate for Payer: AZCH Complete Medicaid |
$19,419.66
|
| Rate for Payer: Banner UC Health Medicaid |
$19,419.66
|
| Rate for Payer: Mercy Care Medicaid |
$19,419.66
|
|
|
Partial Thickness Burns Without Skin Graft
|
Facility
|
IP
|
$5,268.92
|
|
|
Service Code
|
APR-DRG 8442
|
| Hospital Charge Code |
APRDRG8443
|
| Min. Negotiated Rate |
$5,268.92 |
| Max. Negotiated Rate |
$5,268.92 |
| Rate for Payer: AHCCCS Medicaid |
$5,268.92
|
| Rate for Payer: Allwell Medicaid |
$5,268.92
|
| Rate for Payer: AZCH Complete Medicaid |
$5,268.92
|
| Rate for Payer: Banner UC Health Medicaid |
$5,268.92
|
| Rate for Payer: Mercy Care Medicaid |
$5,268.92
|
|
|
Partial Thickness Burns Without Skin Graft
|
Facility
|
IP
|
$5,268.92
|
|
|
Service Code
|
APR-DRG 8442
|
| Hospital Charge Code |
APRDRG8441
|
| Min. Negotiated Rate |
$5,268.92 |
| Max. Negotiated Rate |
$5,268.92 |
| Rate for Payer: AHCCCS Medicaid |
$5,268.92
|
| Rate for Payer: Allwell Medicaid |
$5,268.92
|
| Rate for Payer: AZCH Complete Medicaid |
$5,268.92
|
| Rate for Payer: Banner UC Health Medicaid |
$5,268.92
|
| Rate for Payer: Mercy Care Medicaid |
$5,268.92
|
|
|
Partial Thickness Burns Without Skin Graft
|
Facility
|
IP
|
$3,100.89
|
|
|
Service Code
|
APR-DRG 8441
|
| Hospital Charge Code |
APRDRG8444
|
| Min. Negotiated Rate |
$3,100.89 |
| Max. Negotiated Rate |
$3,100.89 |
| Rate for Payer: AHCCCS Medicaid |
$3,100.89
|
| Rate for Payer: Allwell Medicaid |
$3,100.89
|
| Rate for Payer: AZCH Complete Medicaid |
$3,100.89
|
| Rate for Payer: Banner UC Health Medicaid |
$3,100.89
|
| Rate for Payer: Mercy Care Medicaid |
$3,100.89
|
|
|
Partial Thickness Burns Without Skin Graft
|
Facility
|
IP
|
$19,419.66
|
|
|
Service Code
|
APR-DRG 8444
|
| Hospital Charge Code |
APRDRG8444
|
| Min. Negotiated Rate |
$19,419.66 |
| Max. Negotiated Rate |
$19,419.66 |
| Rate for Payer: AHCCCS Medicaid |
$19,419.66
|
| Rate for Payer: Allwell Medicaid |
$19,419.66
|
| Rate for Payer: AZCH Complete Medicaid |
$19,419.66
|
| Rate for Payer: Banner UC Health Medicaid |
$19,419.66
|
| Rate for Payer: Mercy Care Medicaid |
$19,419.66
|
|
|
Partial Thickness Burns Without Skin Graft
|
Facility
|
IP
|
$5,268.92
|
|
|
Service Code
|
APR-DRG 8442
|
| Hospital Charge Code |
APRDRG8442
|
| Min. Negotiated Rate |
$5,268.92 |
| Max. Negotiated Rate |
$5,268.92 |
| Rate for Payer: AHCCCS Medicaid |
$5,268.92
|
| Rate for Payer: Allwell Medicaid |
$5,268.92
|
| Rate for Payer: AZCH Complete Medicaid |
$5,268.92
|
| Rate for Payer: Banner UC Health Medicaid |
$5,268.92
|
| Rate for Payer: Mercy Care Medicaid |
$5,268.92
|
|
|
Partial Thickness Burns Without Skin Graft
|
Facility
|
IP
|
$8,655.28
|
|
|
Service Code
|
APR-DRG 8443
|
| Hospital Charge Code |
APRDRG8443
|
| Min. Negotiated Rate |
$8,655.28 |
| Max. Negotiated Rate |
$8,655.28 |
| Rate for Payer: AHCCCS Medicaid |
$8,655.28
|
| Rate for Payer: Allwell Medicaid |
$8,655.28
|
| Rate for Payer: AZCH Complete Medicaid |
$8,655.28
|
| Rate for Payer: Banner UC Health Medicaid |
$8,655.28
|
| Rate for Payer: Mercy Care Medicaid |
$8,655.28
|
|
|
Partial Thickness Burns Without Skin Graft
|
Facility
|
IP
|
$3,100.89
|
|
|
Service Code
|
APR-DRG 8441
|
| Hospital Charge Code |
APRDRG8443
|
| Min. Negotiated Rate |
$3,100.89 |
| Max. Negotiated Rate |
$3,100.89 |
| Rate for Payer: AHCCCS Medicaid |
$3,100.89
|
| Rate for Payer: Allwell Medicaid |
$3,100.89
|
| Rate for Payer: AZCH Complete Medicaid |
$3,100.89
|
| Rate for Payer: Banner UC Health Medicaid |
$3,100.89
|
| Rate for Payer: Mercy Care Medicaid |
$3,100.89
|
|
