|
Tonsil And Adenoid Procedures
|
Facility
|
IP
|
$3,787.56
|
|
|
Service Code
|
APR-DRG 0971
|
| Hospital Charge Code |
APRDRG0973
|
| Min. Negotiated Rate |
$3,787.56 |
| Max. Negotiated Rate |
$3,787.56 |
| Rate for Payer: AHCCCS Medicaid |
$3,787.56
|
| Rate for Payer: Allwell Medicaid |
$3,787.56
|
| Rate for Payer: AZCH Complete Medicaid |
$3,787.56
|
| Rate for Payer: Banner UC Health Medicaid |
$3,787.56
|
| Rate for Payer: Mercy Care Medicaid |
$3,787.56
|
|
|
Tonsil And Adenoid Procedures
|
Facility
|
IP
|
$5,522.12
|
|
|
Service Code
|
APR-DRG 0972
|
| Hospital Charge Code |
APRDRG0972
|
| Min. Negotiated Rate |
$5,522.12 |
| Max. Negotiated Rate |
$5,522.12 |
| Rate for Payer: AHCCCS Medicaid |
$5,522.12
|
| Rate for Payer: Allwell Medicaid |
$5,522.12
|
| Rate for Payer: AZCH Complete Medicaid |
$5,522.12
|
| Rate for Payer: Banner UC Health Medicaid |
$5,522.12
|
| Rate for Payer: Mercy Care Medicaid |
$5,522.12
|
|
|
Tonsil And Adenoid Procedures
|
Facility
|
IP
|
$5,522.12
|
|
|
Service Code
|
APR-DRG 0972
|
| Hospital Charge Code |
APRDRG0973
|
| Min. Negotiated Rate |
$5,522.12 |
| Max. Negotiated Rate |
$5,522.12 |
| Rate for Payer: AHCCCS Medicaid |
$5,522.12
|
| Rate for Payer: Allwell Medicaid |
$5,522.12
|
| Rate for Payer: AZCH Complete Medicaid |
$5,522.12
|
| Rate for Payer: Banner UC Health Medicaid |
$5,522.12
|
| Rate for Payer: Mercy Care Medicaid |
$5,522.12
|
|
|
Tonsil And Adenoid Procedures
|
Facility
|
IP
|
$9,659.68
|
|
|
Service Code
|
APR-DRG 0973
|
| Hospital Charge Code |
APRDRG0972
|
| Min. Negotiated Rate |
$9,659.68 |
| Max. Negotiated Rate |
$9,659.68 |
| Rate for Payer: AHCCCS Medicaid |
$9,659.68
|
| Rate for Payer: Allwell Medicaid |
$9,659.68
|
| Rate for Payer: AZCH Complete Medicaid |
$9,659.68
|
| Rate for Payer: Banner UC Health Medicaid |
$9,659.68
|
| Rate for Payer: Mercy Care Medicaid |
$9,659.68
|
|
|
Tonsil And Adenoid Procedures
|
Facility
|
IP
|
$17,184.30
|
|
|
Service Code
|
APR-DRG 0974
|
| Hospital Charge Code |
APRDRG0972
|
| Min. Negotiated Rate |
$17,184.30 |
| Max. Negotiated Rate |
$17,184.30 |
| Rate for Payer: AHCCCS Medicaid |
$17,184.30
|
| Rate for Payer: Allwell Medicaid |
$17,184.30
|
| Rate for Payer: AZCH Complete Medicaid |
$17,184.30
|
| Rate for Payer: Banner UC Health Medicaid |
$17,184.30
|
| Rate for Payer: Mercy Care Medicaid |
$17,184.30
|
|
|
TONSIL DAVIS NEEDLES
|
Facility
|
IP
|
$22.03
|
|
| Hospital Charge Code |
27485971
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.73 |
| Max. Negotiated Rate |
$19.83 |
| Rate for Payer: Aetna of AZ Commercial |
$19.83
|
| Rate for Payer: Bisbee Police All Plans |
$5.73
|
| Rate for Payer: Cash Price |
$17.62
|
| Rate for Payer: Self Pay Self Pay |
$17.62
|
|
|
TONSIL DAVIS NEEDLES
|
Facility
|
OP
|
$22.03
|
|
| Hospital Charge Code |
27485971
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.52 |
| Max. Negotiated Rate |
$19.83 |
| Rate for Payer: Aetna of AZ Commercial |
$19.83
|
| Rate for Payer: Aetna of AZ Medicare |
$6.17
|
| Rate for Payer: Allwell Medicare |
$3.52
|
| Rate for Payer: Amerigroup Medicare |
$3.52
|
| Rate for Payer: APIPA Medicare/Medicaid |
$8.23
|
| Rate for Payer: AZCH Complete Medicare |
$3.52
|
| Rate for Payer: Banner UC Health Medicare |
$3.52
|
| Rate for Payer: Bisbee Police All Plans |
$5.73
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$14.98
|
| Rate for Payer: Cash Price |
$17.62
|
| Rate for Payer: Cigna of AZ Commercial |
$15.42
|
| Rate for Payer: Copperpoint Commercial |
$5.45
|
| Rate for Payer: Health Net of AZ Commercial |
$13.22
|
| Rate for Payer: Health Net of AZ Medicare |
$6.17
|
| Rate for Payer: Humana of AZ Medicare |
$3.52
|
| Rate for Payer: Self Pay Self Pay |
$17.62
|
| Rate for Payer: TriWest Medicare |
$3.52
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$12.84
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$3.97
|
|
|
topiramate 200 mg Tab [CQCH]
|
Facility
|
IP
|
$0.48
|
|
|
Service Code
|
NDC 68084034521
|
| Hospital Charge Code |
105944129
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of AZ Commercial |
$0.43
|
| Rate for Payer: Bisbee Police All Plans |
$0.12
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Self Pay Self Pay |
$0.38
|
|
|
topiramate 200 mg Tab [CQCH]
|
Facility
|
OP
|
$0.48
|
|
|
Service Code
|
NDC 68084034521
|
| Hospital Charge Code |
105944129
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of AZ Commercial |
$0.43
|
| Rate for Payer: Aetna of AZ Medicare |
$0.13
|
| Rate for Payer: Allwell Medicare |
$0.08
|
| Rate for Payer: Amerigroup Medicare |
$0.08
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.18
|
| Rate for Payer: AZCH Complete Medicare |
$0.08
|
| Rate for Payer: Banner UC Health Medicare |
$0.08
|
| Rate for Payer: Bisbee Police All Plans |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.33
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of AZ Commercial |
$0.31
|
| Rate for Payer: Copperpoint Commercial |
$0.12
|
| Rate for Payer: Health Net of AZ Commercial |
$0.29
|
| Rate for Payer: Health Net of AZ Medicare |
$0.13
|
| Rate for Payer: Humana of AZ Medicare |
$0.08
|
| Rate for Payer: Self Pay Self Pay |
$0.38
|
| Rate for Payer: TriWest Medicare |
$0.08
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.28
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.09
|
|
|
topiramate 25 mg Tab [CQCH]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 68084034201
|
| Hospital Charge Code |
105944064
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of AZ Commercial |
$0.10
|
| Rate for Payer: Aetna of AZ Medicare |
$0.03
|
| Rate for Payer: Allwell Medicare |
$0.02
|
| Rate for Payer: Amerigroup Medicare |
$0.02
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.04
|
| 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 |
$0.07
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of AZ Commercial |
$0.07
|
| Rate for Payer: Copperpoint Commercial |
$0.03
|
| Rate for Payer: Health Net of AZ Commercial |
$0.07
|
| Rate for Payer: Health Net of AZ Medicare |
$0.03
|
| Rate for Payer: Humana of AZ Medicare |
$0.02
|
| Rate for Payer: Self Pay Self Pay |
$0.09
|
| Rate for Payer: TriWest Medicare |
$0.02
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.06
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.02
|
|
|
topiramate 25 mg Tab [CQCH]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 68084034201
|
| Hospital Charge Code |
105944064
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of AZ Commercial |
$0.10
|
| Rate for Payer: Bisbee Police All Plans |
$0.03
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Self Pay Self Pay |
$0.09
|
|
|
Topiramate (Topamax), Serum LC
|
Facility
|
OP
|
$303.00
|
|
|
Service Code
|
CPT 80201
|
| Hospital Charge Code |
2029223
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$48.48 |
| Max. Negotiated Rate |
$272.70 |
| Rate for Payer: Aetna of AZ Commercial |
$272.70
|
| Rate for Payer: Aetna of AZ Medicare |
$84.84
|
| Rate for Payer: Allwell Medicare |
$48.48
|
| Rate for Payer: Amerigroup Medicare |
$48.48
|
| Rate for Payer: APIPA Medicare/Medicaid |
$113.17
|
| Rate for Payer: AZCH Complete Medicare |
$48.48
|
| Rate for Payer: Banner UC Health Medicare |
$48.48
|
| Rate for Payer: Bisbee Police All Plans |
$78.78
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$206.04
|
| Rate for Payer: Cash Price |
$242.40
|
| Rate for Payer: Cigna of AZ Commercial |
$196.95
|
| Rate for Payer: Copperpoint Commercial |
$74.99
|
| Rate for Payer: Health Net of AZ Commercial |
$181.80
|
| Rate for Payer: Health Net of AZ Medicare |
$84.84
|
| Rate for Payer: Humana of AZ Medicare |
$48.48
|
| Rate for Payer: Self Pay Self Pay |
$242.40
|
| Rate for Payer: TriWest Medicare |
$48.48
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$176.65
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$54.54
|
|
|
Topiramate (Topamax), Serum LC
|
Facility
|
IP
|
$303.00
|
|
|
Service Code
|
CPT 80201
|
| Hospital Charge Code |
2029223
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$78.78 |
| Max. Negotiated Rate |
$272.70 |
| Rate for Payer: Aetna of AZ Commercial |
$272.70
|
| Rate for Payer: Bisbee Police All Plans |
$78.78
|
| Rate for Payer: Cash Price |
$242.40
|
| Rate for Payer: Self Pay Self Pay |
$242.40
|
|
|
TOTAL PROTEIN 24HR URINE
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 84156
|
| Hospital Charge Code |
22664814
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna of AZ Commercial |
$90.00
|
| Rate for Payer: Aetna of AZ Medicare |
$28.00
|
| Rate for Payer: Allwell Medicare |
$16.00
|
| Rate for Payer: Amerigroup Medicare |
$16.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$37.35
|
| Rate for Payer: AZCH Complete Medicare |
$16.00
|
| Rate for Payer: Banner UC Health Medicare |
$16.00
|
| Rate for Payer: Bisbee Police All Plans |
$26.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$68.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Cigna of AZ Commercial |
$65.00
|
| Rate for Payer: Copperpoint Commercial |
$24.75
|
| Rate for Payer: Health Net of AZ Commercial |
$60.00
|
| Rate for Payer: Health Net of AZ Medicare |
$28.00
|
| Rate for Payer: Humana of AZ Medicare |
$16.00
|
| Rate for Payer: Self Pay Self Pay |
$80.00
|
| Rate for Payer: TriWest Medicare |
$16.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$58.30
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$18.00
|
|
|
TOTAL PROTEIN 24HR URINE
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 84156
|
| Hospital Charge Code |
22664814
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Aetna of AZ Commercial |
$90.00
|
| Rate for Payer: Bisbee Police All Plans |
$26.00
|
| Rate for Payer: Cash Price |
$80.00
|
| Rate for Payer: Self Pay Self Pay |
$80.00
|
|
|
Toxic Effects Of Non-Medicinal Substances
|
Facility
|
IP
|
$5,035.35
|
|
|
Service Code
|
APR-DRG 8163
|
| Hospital Charge Code |
APRDRG8162
|
| Min. Negotiated Rate |
$5,035.35 |
| Max. Negotiated Rate |
$5,035.35 |
| Rate for Payer: AHCCCS Medicaid |
$5,035.35
|
| Rate for Payer: Allwell Medicaid |
$5,035.35
|
| Rate for Payer: AZCH Complete Medicaid |
$5,035.35
|
| Rate for Payer: Banner UC Health Medicaid |
$5,035.35
|
| Rate for Payer: Mercy Care Medicaid |
$5,035.35
|
|
|
Toxic Effects Of Non-Medicinal Substances
|
Facility
|
IP
|
$3,952.39
|
|
|
Service Code
|
APR-DRG 8162
|
| Hospital Charge Code |
APRDRG8164
|
| Min. Negotiated Rate |
$3,952.39 |
| Max. Negotiated Rate |
$3,952.39 |
| Rate for Payer: AHCCCS Medicaid |
$3,952.39
|
| Rate for Payer: Allwell Medicaid |
$3,952.39
|
| Rate for Payer: AZCH Complete Medicaid |
$3,952.39
|
| Rate for Payer: Banner UC Health Medicaid |
$3,952.39
|
| Rate for Payer: Mercy Care Medicaid |
$3,952.39
|
|
|
Toxic Effects Of Non-Medicinal Substances
|
Facility
|
IP
|
$5,035.35
|
|
|
Service Code
|
APR-DRG 8163
|
| Hospital Charge Code |
APRDRG8164
|
| Min. Negotiated Rate |
$5,035.35 |
| Max. Negotiated Rate |
$5,035.35 |
| Rate for Payer: AHCCCS Medicaid |
$5,035.35
|
| Rate for Payer: Allwell Medicaid |
$5,035.35
|
| Rate for Payer: AZCH Complete Medicaid |
$5,035.35
|
| Rate for Payer: Banner UC Health Medicaid |
$5,035.35
|
| Rate for Payer: Mercy Care Medicaid |
$5,035.35
|
|
|
Toxic Effects Of Non-Medicinal Substances
|
Facility
|
IP
|
$3,952.39
|
|
|
Service Code
|
APR-DRG 8162
|
| Hospital Charge Code |
APRDRG8161
|
| Min. Negotiated Rate |
$3,952.39 |
| Max. Negotiated Rate |
$3,952.39 |
| Rate for Payer: AHCCCS Medicaid |
$3,952.39
|
| Rate for Payer: Allwell Medicaid |
$3,952.39
|
| Rate for Payer: AZCH Complete Medicaid |
$3,952.39
|
| Rate for Payer: Banner UC Health Medicaid |
$3,952.39
|
| Rate for Payer: Mercy Care Medicaid |
$3,952.39
|
|
|
Toxic Effects Of Non-Medicinal Substances
|
Facility
|
IP
|
$10,319.70
|
|
|
Service Code
|
APR-DRG 8164
|
| Hospital Charge Code |
APRDRG8164
|
| Min. Negotiated Rate |
$10,319.70 |
| Max. Negotiated Rate |
$10,319.70 |
| Rate for Payer: AHCCCS Medicaid |
$10,319.70
|
| Rate for Payer: Allwell Medicaid |
$10,319.70
|
| Rate for Payer: AZCH Complete Medicaid |
$10,319.70
|
| Rate for Payer: Banner UC Health Medicaid |
$10,319.70
|
| Rate for Payer: Mercy Care Medicaid |
$10,319.70
|
|
|
Toxic Effects Of Non-Medicinal Substances
|
Facility
|
IP
|
$10,319.70
|
|
|
Service Code
|
APR-DRG 8164
|
| Hospital Charge Code |
APRDRG8162
|
| Min. Negotiated Rate |
$10,319.70 |
| Max. Negotiated Rate |
$10,319.70 |
| Rate for Payer: AHCCCS Medicaid |
$10,319.70
|
| Rate for Payer: Allwell Medicaid |
$10,319.70
|
| Rate for Payer: AZCH Complete Medicaid |
$10,319.70
|
| Rate for Payer: Banner UC Health Medicaid |
$10,319.70
|
| Rate for Payer: Mercy Care Medicaid |
$10,319.70
|
|
|
Toxic Effects Of Non-Medicinal Substances
|
Facility
|
IP
|
$3,952.39
|
|
|
Service Code
|
APR-DRG 8161
|
| Hospital Charge Code |
APRDRG8162
|
| Min. Negotiated Rate |
$3,952.39 |
| Max. Negotiated Rate |
$3,952.39 |
| Rate for Payer: AHCCCS Medicaid |
$3,952.39
|
| Rate for Payer: Allwell Medicaid |
$3,952.39
|
| Rate for Payer: AZCH Complete Medicaid |
$3,952.39
|
| Rate for Payer: Banner UC Health Medicaid |
$3,952.39
|
| Rate for Payer: Mercy Care Medicaid |
$3,952.39
|
|
|
Toxic Effects Of Non-Medicinal Substances
|
Facility
|
IP
|
$3,952.39
|
|
|
Service Code
|
APR-DRG 8161
|
| Hospital Charge Code |
APRDRG8164
|
| Min. Negotiated Rate |
$3,952.39 |
| Max. Negotiated Rate |
$3,952.39 |
| Rate for Payer: AHCCCS Medicaid |
$3,952.39
|
| Rate for Payer: Allwell Medicaid |
$3,952.39
|
| Rate for Payer: AZCH Complete Medicaid |
$3,952.39
|
| Rate for Payer: Banner UC Health Medicaid |
$3,952.39
|
| Rate for Payer: Mercy Care Medicaid |
$3,952.39
|
|
|
Toxic Effects Of Non-Medicinal Substances
|
Facility
|
IP
|
$10,319.70
|
|
|
Service Code
|
APR-DRG 8164
|
| Hospital Charge Code |
APRDRG8163
|
| Min. Negotiated Rate |
$10,319.70 |
| Max. Negotiated Rate |
$10,319.70 |
| Rate for Payer: AHCCCS Medicaid |
$10,319.70
|
| Rate for Payer: Allwell Medicaid |
$10,319.70
|
| Rate for Payer: AZCH Complete Medicaid |
$10,319.70
|
| Rate for Payer: Banner UC Health Medicaid |
$10,319.70
|
| Rate for Payer: Mercy Care Medicaid |
$10,319.70
|
|
|
Toxic Effects Of Non-Medicinal Substances
|
Facility
|
IP
|
$3,952.39
|
|
|
Service Code
|
APR-DRG 8162
|
| Hospital Charge Code |
APRDRG8163
|
| Min. Negotiated Rate |
$3,952.39 |
| Max. Negotiated Rate |
$3,952.39 |
| Rate for Payer: AHCCCS Medicaid |
$3,952.39
|
| Rate for Payer: Allwell Medicaid |
$3,952.39
|
| Rate for Payer: AZCH Complete Medicaid |
$3,952.39
|
| Rate for Payer: Banner UC Health Medicaid |
$3,952.39
|
| Rate for Payer: Mercy Care Medicaid |
$3,952.39
|
|
