|
BREATHING CIRCUIT
|
Facility
|
IP
|
$27.00
|
|
| Hospital Charge Code |
22355324
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.02 |
| Max. Negotiated Rate |
$24.30 |
| Rate for Payer: Aetna of AZ Commercial |
$24.30
|
| Rate for Payer: Bisbee Police All Plans |
$7.02
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Self Pay Self Pay |
$21.60
|
|
|
BREATHING CIRCUIT PED
|
Facility
|
OP
|
$96.00
|
|
| Hospital Charge Code |
22355318
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.40 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna of AZ Commercial |
$86.40
|
| Rate for Payer: Aetna of AZ Medicare |
$26.88
|
| Rate for Payer: Allwell Medicare |
$14.40
|
| Rate for Payer: Amerigroup Medicare |
$14.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$35.86
|
| Rate for Payer: AZCH Complete Medicare |
$14.40
|
| Rate for Payer: Banner UC Health Medicare |
$14.40
|
| Rate for Payer: Bisbee Police All Plans |
$24.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$65.28
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Cigna of AZ Commercial |
$67.20
|
| Rate for Payer: Copperpoint Commercial |
$23.76
|
| Rate for Payer: Health Net of AZ Commercial |
$57.60
|
| Rate for Payer: Health Net of AZ Medicare |
$26.88
|
| Rate for Payer: Humana of AZ Medicare |
$14.40
|
| Rate for Payer: Self Pay Self Pay |
$76.80
|
| Rate for Payer: TriWest Medicare |
$14.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$55.97
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$17.28
|
|
|
BREATHING CIRCUIT PED
|
Facility
|
IP
|
$96.00
|
|
| Hospital Charge Code |
22355318
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.96 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna of AZ Commercial |
$86.40
|
| Rate for Payer: Bisbee Police All Plans |
$24.96
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Self Pay Self Pay |
$76.80
|
|
|
brompheniramine-pseudoephedrine 118 mL Bulk Liq [CQCH]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 603085194
|
| Hospital Charge Code |
107994381
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of AZ Commercial |
$0.06
|
| 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 |
$0.04
|
| 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 |
$0.04
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.01
|
|
|
brompheniramine-pseudoephedrine 118 mL Bulk Liq [CQCH]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 603085194
|
| Hospital Charge Code |
107994381
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of AZ Commercial |
$0.06
|
| 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
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$12,683.42
|
|
|
Service Code
|
APR-DRG 1384
|
| Hospital Charge Code |
APRDRG1381
|
| Min. Negotiated Rate |
$12,683.42 |
| Max. Negotiated Rate |
$12,683.42 |
| Rate for Payer: AHCCCS Medicaid |
$12,683.42
|
| Rate for Payer: Allwell Medicaid |
$12,683.42
|
| Rate for Payer: AZCH Complete Medicaid |
$12,683.42
|
| Rate for Payer: Banner UC Health Medicaid |
$12,683.42
|
| Rate for Payer: Mercy Care Medicaid |
$12,683.42
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$2,151.19
|
|
|
Service Code
|
APR-DRG 1381
|
| Hospital Charge Code |
APRDRG1382
|
| Min. Negotiated Rate |
$2,151.19 |
| Max. Negotiated Rate |
$2,151.19 |
| Rate for Payer: AHCCCS Medicaid |
$2,151.19
|
| Rate for Payer: Allwell Medicaid |
$2,151.19
|
| Rate for Payer: AZCH Complete Medicaid |
$2,151.19
|
| Rate for Payer: Banner UC Health Medicaid |
$2,151.19
|
| Rate for Payer: Mercy Care Medicaid |
$2,151.19
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$2,151.19
|
|
|
Service Code
|
APR-DRG 1381
|
| Hospital Charge Code |
APRDRG1383
|
| Min. Negotiated Rate |
$2,151.19 |
| Max. Negotiated Rate |
$2,151.19 |
| Rate for Payer: AHCCCS Medicaid |
$2,151.19
|
| Rate for Payer: Allwell Medicaid |
$2,151.19
|
| Rate for Payer: AZCH Complete Medicaid |
$2,151.19
|
| Rate for Payer: Banner UC Health Medicaid |
$2,151.19
|
| Rate for Payer: Mercy Care Medicaid |
$2,151.19
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$12,683.42
|
|
|
Service Code
|
APR-DRG 1384
|
| Hospital Charge Code |
APRDRG1383
|
| Min. Negotiated Rate |
$12,683.42 |
| Max. Negotiated Rate |
$12,683.42 |
| Rate for Payer: AHCCCS Medicaid |
$12,683.42
|
| Rate for Payer: Allwell Medicaid |
$12,683.42
|
| Rate for Payer: AZCH Complete Medicaid |
$12,683.42
|
| Rate for Payer: Banner UC Health Medicaid |
$12,683.42
|
| Rate for Payer: Mercy Care Medicaid |
$12,683.42
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$5,424.63
|
|
|
Service Code
|
APR-DRG 1383
|
| Hospital Charge Code |
APRDRG1382
|
| Min. Negotiated Rate |
$5,424.63 |
| Max. Negotiated Rate |
$5,424.63 |
| Rate for Payer: AHCCCS Medicaid |
$5,424.63
|
| Rate for Payer: Allwell Medicaid |
$5,424.63
|
| Rate for Payer: AZCH Complete Medicaid |
$5,424.63
|
| Rate for Payer: Banner UC Health Medicaid |
$5,424.63
|
| Rate for Payer: Mercy Care Medicaid |
$5,424.63
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$5,424.63
|
|
|
Service Code
|
APR-DRG 1383
|
| Hospital Charge Code |
APRDRG1381
|
| Min. Negotiated Rate |
$5,424.63 |
| Max. Negotiated Rate |
$5,424.63 |
| Rate for Payer: AHCCCS Medicaid |
$5,424.63
|
| Rate for Payer: Allwell Medicaid |
$5,424.63
|
| Rate for Payer: AZCH Complete Medicaid |
$5,424.63
|
| Rate for Payer: Banner UC Health Medicaid |
$5,424.63
|
| Rate for Payer: Mercy Care Medicaid |
$5,424.63
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$5,424.63
|
|
|
Service Code
|
APR-DRG 1383
|
| Hospital Charge Code |
APRDRG1384
|
| Min. Negotiated Rate |
$5,424.63 |
| Max. Negotiated Rate |
$5,424.63 |
| Rate for Payer: AHCCCS Medicaid |
$5,424.63
|
| Rate for Payer: Allwell Medicaid |
$5,424.63
|
| Rate for Payer: AZCH Complete Medicaid |
$5,424.63
|
| Rate for Payer: Banner UC Health Medicaid |
$5,424.63
|
| Rate for Payer: Mercy Care Medicaid |
$5,424.63
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$5,424.63
|
|
|
Service Code
|
APR-DRG 1383
|
| Hospital Charge Code |
APRDRG1383
|
| Min. Negotiated Rate |
$5,424.63 |
| Max. Negotiated Rate |
$5,424.63 |
| Rate for Payer: AHCCCS Medicaid |
$5,424.63
|
| Rate for Payer: Allwell Medicaid |
$5,424.63
|
| Rate for Payer: AZCH Complete Medicaid |
$5,424.63
|
| Rate for Payer: Banner UC Health Medicaid |
$5,424.63
|
| Rate for Payer: Mercy Care Medicaid |
$5,424.63
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$12,683.42
|
|
|
Service Code
|
APR-DRG 1384
|
| Hospital Charge Code |
APRDRG1384
|
| Min. Negotiated Rate |
$12,683.42 |
| Max. Negotiated Rate |
$12,683.42 |
| Rate for Payer: AHCCCS Medicaid |
$12,683.42
|
| Rate for Payer: Allwell Medicaid |
$12,683.42
|
| Rate for Payer: AZCH Complete Medicaid |
$12,683.42
|
| Rate for Payer: Banner UC Health Medicaid |
$12,683.42
|
| Rate for Payer: Mercy Care Medicaid |
$12,683.42
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$3,197.68
|
|
|
Service Code
|
APR-DRG 1382
|
| Hospital Charge Code |
APRDRG1382
|
| Min. Negotiated Rate |
$3,197.68 |
| Max. Negotiated Rate |
$3,197.68 |
| Rate for Payer: AHCCCS Medicaid |
$3,197.68
|
| Rate for Payer: Allwell Medicaid |
$3,197.68
|
| Rate for Payer: AZCH Complete Medicaid |
$3,197.68
|
| Rate for Payer: Banner UC Health Medicaid |
$3,197.68
|
| Rate for Payer: Mercy Care Medicaid |
$3,197.68
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$2,151.19
|
|
|
Service Code
|
APR-DRG 1381
|
| Hospital Charge Code |
APRDRG1381
|
| Min. Negotiated Rate |
$2,151.19 |
| Max. Negotiated Rate |
$2,151.19 |
| Rate for Payer: AHCCCS Medicaid |
$2,151.19
|
| Rate for Payer: Allwell Medicaid |
$2,151.19
|
| Rate for Payer: AZCH Complete Medicaid |
$2,151.19
|
| Rate for Payer: Banner UC Health Medicaid |
$2,151.19
|
| Rate for Payer: Mercy Care Medicaid |
$2,151.19
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$12,683.42
|
|
|
Service Code
|
APR-DRG 1384
|
| Hospital Charge Code |
APRDRG1382
|
| Min. Negotiated Rate |
$12,683.42 |
| Max. Negotiated Rate |
$12,683.42 |
| Rate for Payer: AHCCCS Medicaid |
$12,683.42
|
| Rate for Payer: Allwell Medicaid |
$12,683.42
|
| Rate for Payer: AZCH Complete Medicaid |
$12,683.42
|
| Rate for Payer: Banner UC Health Medicaid |
$12,683.42
|
| Rate for Payer: Mercy Care Medicaid |
$12,683.42
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$2,151.19
|
|
|
Service Code
|
APR-DRG 1381
|
| Hospital Charge Code |
APRDRG1384
|
| Min. Negotiated Rate |
$2,151.19 |
| Max. Negotiated Rate |
$2,151.19 |
| Rate for Payer: AHCCCS Medicaid |
$2,151.19
|
| Rate for Payer: Allwell Medicaid |
$2,151.19
|
| Rate for Payer: AZCH Complete Medicaid |
$2,151.19
|
| Rate for Payer: Banner UC Health Medicaid |
$2,151.19
|
| Rate for Payer: Mercy Care Medicaid |
$2,151.19
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$3,197.68
|
|
|
Service Code
|
APR-DRG 1382
|
| Hospital Charge Code |
APRDRG1381
|
| Min. Negotiated Rate |
$3,197.68 |
| Max. Negotiated Rate |
$3,197.68 |
| Rate for Payer: AHCCCS Medicaid |
$3,197.68
|
| Rate for Payer: Allwell Medicaid |
$3,197.68
|
| Rate for Payer: AZCH Complete Medicaid |
$3,197.68
|
| Rate for Payer: Banner UC Health Medicaid |
$3,197.68
|
| Rate for Payer: Mercy Care Medicaid |
$3,197.68
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$3,197.68
|
|
|
Service Code
|
APR-DRG 1382
|
| Hospital Charge Code |
APRDRG1383
|
| Min. Negotiated Rate |
$3,197.68 |
| Max. Negotiated Rate |
$3,197.68 |
| Rate for Payer: AHCCCS Medicaid |
$3,197.68
|
| Rate for Payer: Allwell Medicaid |
$3,197.68
|
| Rate for Payer: AZCH Complete Medicaid |
$3,197.68
|
| Rate for Payer: Banner UC Health Medicaid |
$3,197.68
|
| Rate for Payer: Mercy Care Medicaid |
$3,197.68
|
|
|
Bronchiolitis And Rsv Pneumonia
|
Facility
|
IP
|
$3,197.68
|
|
|
Service Code
|
APR-DRG 1382
|
| Hospital Charge Code |
APRDRG1384
|
| Min. Negotiated Rate |
$3,197.68 |
| Max. Negotiated Rate |
$3,197.68 |
| Rate for Payer: AHCCCS Medicaid |
$3,197.68
|
| Rate for Payer: Allwell Medicaid |
$3,197.68
|
| Rate for Payer: AZCH Complete Medicaid |
$3,197.68
|
| Rate for Payer: Banner UC Health Medicaid |
$3,197.68
|
| Rate for Payer: Mercy Care Medicaid |
$3,197.68
|
|
|
BROSELOW EQUIPMENT PACK
|
Facility
|
OP
|
$1,935.00
|
|
| Hospital Charge Code |
23175719
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$290.25 |
| Max. Negotiated Rate |
$1,741.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,741.50
|
| Rate for Payer: Aetna of AZ Medicare |
$541.80
|
| Rate for Payer: Allwell Medicare |
$290.25
|
| Rate for Payer: Amerigroup Medicare |
$290.25
|
| Rate for Payer: APIPA Medicare/Medicaid |
$722.72
|
| Rate for Payer: AZCH Complete Medicare |
$290.25
|
| Rate for Payer: Banner UC Health Medicare |
$290.25
|
| Rate for Payer: Bisbee Police All Plans |
$503.10
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,315.80
|
| Rate for Payer: Cash Price |
$1,548.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,354.50
|
| Rate for Payer: Copperpoint Commercial |
$478.91
|
| Rate for Payer: Health Net of AZ Commercial |
$1,161.00
|
| Rate for Payer: Health Net of AZ Medicare |
$541.80
|
| Rate for Payer: Humana of AZ Medicare |
$290.25
|
| Rate for Payer: Self Pay Self Pay |
$1,548.00
|
| Rate for Payer: TriWest Medicare |
$290.25
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,128.10
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$348.30
|
|
|
BROSELOW EQUIPMENT PACK
|
Facility
|
IP
|
$1,935.00
|
|
| Hospital Charge Code |
23175719
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$503.10 |
| Max. Negotiated Rate |
$1,741.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,741.50
|
| Rate for Payer: Bisbee Police All Plans |
$503.10
|
| Rate for Payer: Cash Price |
$1,548.00
|
| Rate for Payer: Self Pay Self Pay |
$1,548.00
|
|
|
budesonide 0.5 mg/2 mL Inh [CQCH]
|
Facility
|
OP
|
$6.16
|
|
|
Service Code
|
HCPCS J7626
|
| Hospital Charge Code |
105913304
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$5.54 |
| Rate for Payer: Aetna of AZ Commercial |
$5.54
|
| Rate for Payer: Aetna of AZ Medicare |
$1.72
|
| Rate for Payer: AHCCCS Medicaid |
$1.64
|
| Rate for Payer: Allwell Medicaid |
$1.64
|
| Rate for Payer: Allwell Medicare |
$0.92
|
| Rate for Payer: Amerigroup Medicare |
$0.92
|
| Rate for Payer: APIPA Medicare/Medicaid |
$2.30
|
| Rate for Payer: AZCH Complete Medicaid |
$1.64
|
| Rate for Payer: AZCH Complete Medicare |
$0.92
|
| Rate for Payer: Banner UC Health Medicaid |
$1.64
|
| Rate for Payer: Banner UC Health Medicare |
$0.92
|
| Rate for Payer: Bisbee Police All Plans |
$1.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$4.19
|
| Rate for Payer: Cash Price |
$4.93
|
| Rate for Payer: Cash Price |
$4.93
|
| Rate for Payer: Cigna of AZ Commercial |
$4.00
|
| Rate for Payer: Copperpoint Commercial |
$1.52
|
| Rate for Payer: Health Net of AZ Commercial |
$3.70
|
| Rate for Payer: Health Net of AZ Medicare |
$1.72
|
| Rate for Payer: Humana of AZ Medicare |
$0.92
|
| Rate for Payer: Mercy Care Medicaid |
$1.64
|
| Rate for Payer: Self Pay Self Pay |
$4.93
|
| Rate for Payer: TriWest Medicare |
$0.92
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3.59
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$1.11
|
|
|
budesonide 0.5 mg/2 mL Inh [CQCH]
|
Facility
|
IP
|
$6.16
|
|
|
Service Code
|
HCPCS J7626
|
| Hospital Charge Code |
105913304
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$5.54 |
| Rate for Payer: Aetna of AZ Commercial |
$5.54
|
| Rate for Payer: Bisbee Police All Plans |
$1.60
|
| Rate for Payer: Cash Price |
$4.93
|
| Rate for Payer: Self Pay Self Pay |
$4.93
|
|
