|
Burch (secondary repair)
|
Facility
|
OP
|
$4,342.00
|
|
|
Service Code
|
CPT 51841
|
| Hospital Charge Code |
27267813
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$3,907.80 |
| Rate for Payer: Aetna of AZ Commercial |
$3,907.80
|
| Rate for Payer: Aetna of AZ Medicare |
$1,215.76
|
| Rate for Payer: AHCCCS Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicare |
$651.30
|
| Rate for Payer: Amerigroup Medicare |
$651.30
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,621.74
|
| Rate for Payer: AZCH Complete Medicaid |
$0.13
|
| Rate for Payer: AZCH Complete Medicare |
$651.30
|
| Rate for Payer: Banner UC Health Medicaid |
$0.13
|
| Rate for Payer: Banner UC Health Medicare |
$651.30
|
| Rate for Payer: Bisbee Police All Plans |
$1,128.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2,952.56
|
| Rate for Payer: Cash Price |
$3,473.60
|
| Rate for Payer: Cash Price |
$3,473.60
|
| Rate for Payer: Cigna of AZ Commercial |
$2,171.00
|
| Rate for Payer: Copperpoint Commercial |
$1,074.64
|
| Rate for Payer: Health Net of AZ Commercial |
$2,605.20
|
| Rate for Payer: Health Net of AZ Medicare |
$1,215.76
|
| Rate for Payer: Humana of AZ Medicare |
$651.30
|
| Rate for Payer: Mercy Care Medicaid |
$0.13
|
| Rate for Payer: Self Pay Self Pay |
$3,473.60
|
| Rate for Payer: TriWest Medicare |
$651.30
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,373.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$781.56
|
|
|
Burch urethropexy without TAH simple
|
Facility
|
OP
|
$3,570.00
|
|
|
Service Code
|
CPT 51840
|
| Hospital Charge Code |
27291787
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$535.50 |
| Max. Negotiated Rate |
$6,393.84 |
| Rate for Payer: Aetna of AZ Commercial |
$3,213.00
|
| Rate for Payer: Aetna of AZ Medicare |
$999.60
|
| Rate for Payer: AHCCCS Medicaid |
$6,393.84
|
| Rate for Payer: Allwell Medicaid |
$6,393.84
|
| Rate for Payer: Allwell Medicare |
$535.50
|
| Rate for Payer: Amerigroup Medicare |
$535.50
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,333.40
|
| Rate for Payer: AZCH Complete Medicaid |
$6,393.84
|
| Rate for Payer: AZCH Complete Medicare |
$535.50
|
| Rate for Payer: Banner UC Health Medicaid |
$6,393.84
|
| Rate for Payer: Banner UC Health Medicare |
$535.50
|
| Rate for Payer: Bisbee Police All Plans |
$928.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2,427.60
|
| Rate for Payer: Cash Price |
$2,856.00
|
| Rate for Payer: Cash Price |
$2,856.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,785.00
|
| Rate for Payer: Copperpoint Commercial |
$883.58
|
| Rate for Payer: Health Net of AZ Commercial |
$2,142.00
|
| Rate for Payer: Health Net of AZ Medicare |
$999.60
|
| Rate for Payer: Humana of AZ Medicare |
$535.50
|
| Rate for Payer: Mercy Care Medicaid |
$6,393.84
|
| Rate for Payer: Self Pay Self Pay |
$2,856.00
|
| Rate for Payer: TriWest Medicare |
$535.50
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,373.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$642.60
|
|
|
Burch urethropexy without TAH simple
|
Facility
|
IP
|
$3,570.00
|
|
|
Service Code
|
CPT 51840
|
| Hospital Charge Code |
27291787
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$928.20 |
| Max. Negotiated Rate |
$3,213.00 |
| Rate for Payer: Aetna of AZ Commercial |
$3,213.00
|
| Rate for Payer: Bisbee Police All Plans |
$928.20
|
| Rate for Payer: Cash Price |
$2,856.00
|
| Rate for Payer: Self Pay Self Pay |
$2,856.00
|
|
|
BURETTE SET BURETROL
|
Facility
|
OP
|
$95.00
|
|
| Hospital Charge Code |
22355314
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.25 |
| Max. Negotiated Rate |
$85.50 |
| Rate for Payer: Aetna of AZ Commercial |
$85.50
|
| Rate for Payer: Aetna of AZ Medicare |
$26.60
|
| Rate for Payer: Allwell Medicare |
$14.25
|
| Rate for Payer: Amerigroup Medicare |
$14.25
|
| Rate for Payer: APIPA Medicare/Medicaid |
$35.48
|
| Rate for Payer: AZCH Complete Medicare |
$14.25
|
| Rate for Payer: Banner UC Health Medicare |
$14.25
|
| Rate for Payer: Bisbee Police All Plans |
$24.70
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$64.60
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Cigna of AZ Commercial |
$66.50
|
| Rate for Payer: Copperpoint Commercial |
$23.51
|
| Rate for Payer: Health Net of AZ Commercial |
$57.00
|
| Rate for Payer: Health Net of AZ Medicare |
$26.60
|
| Rate for Payer: Humana of AZ Medicare |
$14.25
|
| Rate for Payer: Self Pay Self Pay |
$76.00
|
| Rate for Payer: TriWest Medicare |
$14.25
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$55.38
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$17.10
|
|
|
BURETTE SET BURETROL
|
Facility
|
IP
|
$95.00
|
|
| Hospital Charge Code |
22355314
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$24.70 |
| Max. Negotiated Rate |
$85.50 |
| Rate for Payer: Aetna of AZ Commercial |
$85.50
|
| Rate for Payer: Bisbee Police All Plans |
$24.70
|
| Rate for Payer: Cash Price |
$76.00
|
| Rate for Payer: Self Pay Self Pay |
$76.00
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$29,190.87
|
|
|
Service Code
|
APR-DRG 8423
|
| Hospital Charge Code |
APRDRG8421
|
| Min. Negotiated Rate |
$29,190.87 |
| Max. Negotiated Rate |
$29,190.87 |
| Rate for Payer: AHCCCS Medicaid |
$29,190.87
|
| Rate for Payer: Allwell Medicaid |
$29,190.87
|
| Rate for Payer: AZCH Complete Medicaid |
$29,190.87
|
| Rate for Payer: Banner UC Health Medicaid |
$29,190.87
|
| Rate for Payer: Mercy Care Medicaid |
$29,190.87
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$10,090.34
|
|
|
Service Code
|
APR-DRG 8421
|
| Hospital Charge Code |
APRDRG8424
|
| Min. Negotiated Rate |
$10,090.34 |
| Max. Negotiated Rate |
$10,090.34 |
| Rate for Payer: AHCCCS Medicaid |
$10,090.34
|
| Rate for Payer: Allwell Medicaid |
$10,090.34
|
| Rate for Payer: AZCH Complete Medicaid |
$10,090.34
|
| Rate for Payer: Banner UC Health Medicaid |
$10,090.34
|
| Rate for Payer: Mercy Care Medicaid |
$10,090.34
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$71,693.60
|
|
|
Service Code
|
APR-DRG 8424
|
| Hospital Charge Code |
APRDRG8422
|
| Min. Negotiated Rate |
$71,693.60 |
| Max. Negotiated Rate |
$71,693.60 |
| Rate for Payer: AHCCCS Medicaid |
$71,693.60
|
| Rate for Payer: Allwell Medicaid |
$71,693.60
|
| Rate for Payer: AZCH Complete Medicaid |
$71,693.60
|
| Rate for Payer: Banner UC Health Medicaid |
$71,693.60
|
| Rate for Payer: Mercy Care Medicaid |
$71,693.60
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$15,824.99
|
|
|
Service Code
|
APR-DRG 8422
|
| Hospital Charge Code |
APRDRG8423
|
| Min. Negotiated Rate |
$15,824.99 |
| Max. Negotiated Rate |
$15,824.99 |
| Rate for Payer: AHCCCS Medicaid |
$15,824.99
|
| Rate for Payer: Allwell Medicaid |
$15,824.99
|
| Rate for Payer: AZCH Complete Medicaid |
$15,824.99
|
| Rate for Payer: Banner UC Health Medicaid |
$15,824.99
|
| Rate for Payer: Mercy Care Medicaid |
$15,824.99
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$29,190.87
|
|
|
Service Code
|
APR-DRG 8423
|
| Hospital Charge Code |
APRDRG8424
|
| Min. Negotiated Rate |
$29,190.87 |
| Max. Negotiated Rate |
$29,190.87 |
| Rate for Payer: AHCCCS Medicaid |
$29,190.87
|
| Rate for Payer: Allwell Medicaid |
$29,190.87
|
| Rate for Payer: AZCH Complete Medicaid |
$29,190.87
|
| Rate for Payer: Banner UC Health Medicaid |
$29,190.87
|
| Rate for Payer: Mercy Care Medicaid |
$29,190.87
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$10,090.34
|
|
|
Service Code
|
APR-DRG 8421
|
| Hospital Charge Code |
APRDRG8423
|
| Min. Negotiated Rate |
$10,090.34 |
| Max. Negotiated Rate |
$10,090.34 |
| Rate for Payer: AHCCCS Medicaid |
$10,090.34
|
| Rate for Payer: Allwell Medicaid |
$10,090.34
|
| Rate for Payer: AZCH Complete Medicaid |
$10,090.34
|
| Rate for Payer: Banner UC Health Medicaid |
$10,090.34
|
| Rate for Payer: Mercy Care Medicaid |
$10,090.34
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$10,090.34
|
|
|
Service Code
|
APR-DRG 8421
|
| Hospital Charge Code |
APRDRG8421
|
| Min. Negotiated Rate |
$10,090.34 |
| Max. Negotiated Rate |
$10,090.34 |
| Rate for Payer: AHCCCS Medicaid |
$10,090.34
|
| Rate for Payer: Allwell Medicaid |
$10,090.34
|
| Rate for Payer: AZCH Complete Medicaid |
$10,090.34
|
| Rate for Payer: Banner UC Health Medicaid |
$10,090.34
|
| Rate for Payer: Mercy Care Medicaid |
$10,090.34
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$15,824.99
|
|
|
Service Code
|
APR-DRG 8422
|
| Hospital Charge Code |
APRDRG8422
|
| Min. Negotiated Rate |
$15,824.99 |
| Max. Negotiated Rate |
$15,824.99 |
| Rate for Payer: AHCCCS Medicaid |
$15,824.99
|
| Rate for Payer: Allwell Medicaid |
$15,824.99
|
| Rate for Payer: AZCH Complete Medicaid |
$15,824.99
|
| Rate for Payer: Banner UC Health Medicaid |
$15,824.99
|
| Rate for Payer: Mercy Care Medicaid |
$15,824.99
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$15,824.99
|
|
|
Service Code
|
APR-DRG 8422
|
| Hospital Charge Code |
APRDRG8421
|
| Min. Negotiated Rate |
$15,824.99 |
| Max. Negotiated Rate |
$15,824.99 |
| Rate for Payer: AHCCCS Medicaid |
$15,824.99
|
| Rate for Payer: Allwell Medicaid |
$15,824.99
|
| Rate for Payer: AZCH Complete Medicaid |
$15,824.99
|
| Rate for Payer: Banner UC Health Medicaid |
$15,824.99
|
| Rate for Payer: Mercy Care Medicaid |
$15,824.99
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$29,190.87
|
|
|
Service Code
|
APR-DRG 8423
|
| Hospital Charge Code |
APRDRG8423
|
| Min. Negotiated Rate |
$29,190.87 |
| Max. Negotiated Rate |
$29,190.87 |
| Rate for Payer: AHCCCS Medicaid |
$29,190.87
|
| Rate for Payer: Allwell Medicaid |
$29,190.87
|
| Rate for Payer: AZCH Complete Medicaid |
$29,190.87
|
| Rate for Payer: Banner UC Health Medicaid |
$29,190.87
|
| Rate for Payer: Mercy Care Medicaid |
$29,190.87
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$10,090.34
|
|
|
Service Code
|
APR-DRG 8421
|
| Hospital Charge Code |
APRDRG8422
|
| Min. Negotiated Rate |
$10,090.34 |
| Max. Negotiated Rate |
$10,090.34 |
| Rate for Payer: AHCCCS Medicaid |
$10,090.34
|
| Rate for Payer: Allwell Medicaid |
$10,090.34
|
| Rate for Payer: AZCH Complete Medicaid |
$10,090.34
|
| Rate for Payer: Banner UC Health Medicaid |
$10,090.34
|
| Rate for Payer: Mercy Care Medicaid |
$10,090.34
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$29,190.87
|
|
|
Service Code
|
APR-DRG 8423
|
| Hospital Charge Code |
APRDRG8422
|
| Min. Negotiated Rate |
$29,190.87 |
| Max. Negotiated Rate |
$29,190.87 |
| Rate for Payer: AHCCCS Medicaid |
$29,190.87
|
| Rate for Payer: Allwell Medicaid |
$29,190.87
|
| Rate for Payer: AZCH Complete Medicaid |
$29,190.87
|
| Rate for Payer: Banner UC Health Medicaid |
$29,190.87
|
| Rate for Payer: Mercy Care Medicaid |
$29,190.87
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$71,693.60
|
|
|
Service Code
|
APR-DRG 8424
|
| Hospital Charge Code |
APRDRG8423
|
| Min. Negotiated Rate |
$71,693.60 |
| Max. Negotiated Rate |
$71,693.60 |
| Rate for Payer: AHCCCS Medicaid |
$71,693.60
|
| Rate for Payer: Allwell Medicaid |
$71,693.60
|
| Rate for Payer: AZCH Complete Medicaid |
$71,693.60
|
| Rate for Payer: Banner UC Health Medicaid |
$71,693.60
|
| Rate for Payer: Mercy Care Medicaid |
$71,693.60
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$15,824.99
|
|
|
Service Code
|
APR-DRG 8422
|
| Hospital Charge Code |
APRDRG8424
|
| Min. Negotiated Rate |
$15,824.99 |
| Max. Negotiated Rate |
$15,824.99 |
| Rate for Payer: AHCCCS Medicaid |
$15,824.99
|
| Rate for Payer: Allwell Medicaid |
$15,824.99
|
| Rate for Payer: AZCH Complete Medicaid |
$15,824.99
|
| Rate for Payer: Banner UC Health Medicaid |
$15,824.99
|
| Rate for Payer: Mercy Care Medicaid |
$15,824.99
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$71,693.60
|
|
|
Service Code
|
APR-DRG 8424
|
| Hospital Charge Code |
APRDRG8421
|
| Min. Negotiated Rate |
$71,693.60 |
| Max. Negotiated Rate |
$71,693.60 |
| Rate for Payer: AHCCCS Medicaid |
$71,693.60
|
| Rate for Payer: Allwell Medicaid |
$71,693.60
|
| Rate for Payer: AZCH Complete Medicaid |
$71,693.60
|
| Rate for Payer: Banner UC Health Medicaid |
$71,693.60
|
| Rate for Payer: Mercy Care Medicaid |
$71,693.60
|
|
|
Burns With Skin Graft Except Extensive Third Degree Burns
|
Facility
|
IP
|
$71,693.60
|
|
|
Service Code
|
APR-DRG 8424
|
| Hospital Charge Code |
APRDRG8424
|
| Min. Negotiated Rate |
$71,693.60 |
| Max. Negotiated Rate |
$71,693.60 |
| Rate for Payer: AHCCCS Medicaid |
$71,693.60
|
| Rate for Payer: Allwell Medicaid |
$71,693.60
|
| Rate for Payer: AZCH Complete Medicaid |
$71,693.60
|
| Rate for Payer: Banner UC Health Medicaid |
$71,693.60
|
| Rate for Payer: Mercy Care Medicaid |
$71,693.60
|
|
|
busPIRone 5 mg Tab [CQCH]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 64380074108
|
| Hospital Charge Code |
105913714
|
|
Hospital Revenue Code
|
251
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of AZ Commercial |
$0.02
|
| Rate for Payer: Aetna of AZ Medicare |
$0.01
|
| Rate for Payer: Allwell Medicare |
$0.00
|
| Rate for Payer: Amerigroup Medicare |
$0.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.01
|
| Rate for Payer: AZCH Complete Medicare |
$0.00
|
| Rate for Payer: Banner UC Health Medicare |
$0.00
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of AZ Commercial |
$0.01
|
| Rate for Payer: Copperpoint Commercial |
$0.00
|
| Rate for Payer: Health Net of AZ Commercial |
$0.01
|
| Rate for Payer: Health Net of AZ Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.00
|
| Rate for Payer: Self Pay Self Pay |
$0.02
|
| Rate for Payer: TriWest Medicare |
$0.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.01
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.00
|
|
|
busPIRone 5 mg Tab [CQCH]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 64380074108
|
| Hospital Charge Code |
105913714
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of AZ Commercial |
$0.02
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Self Pay Self Pay |
$0.02
|
|
|
butorphanol 1 mg/mL Inj Sol [CQCH]
|
Facility
|
IP
|
$3.53
|
|
|
Service Code
|
HCPCS J0595
|
| Hospital Charge Code |
105913781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$3.18 |
| Rate for Payer: Aetna of AZ Commercial |
$3.18
|
| Rate for Payer: Bisbee Police All Plans |
$0.92
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Self Pay Self Pay |
$2.82
|
|
|
butorphanol 1 mg/mL Inj Sol [CQCH]
|
Facility
|
OP
|
$3.53
|
|
|
Service Code
|
HCPCS J0595
|
| Hospital Charge Code |
105913781
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$6.72 |
| Rate for Payer: Aetna of AZ Commercial |
$3.18
|
| Rate for Payer: Aetna of AZ Medicare |
$0.99
|
| Rate for Payer: AHCCCS Medicaid |
$6.72
|
| Rate for Payer: Allwell Medicaid |
$6.72
|
| Rate for Payer: Allwell Medicare |
$0.53
|
| Rate for Payer: Amerigroup Medicare |
$0.53
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1.32
|
| Rate for Payer: AZCH Complete Medicaid |
$6.72
|
| Rate for Payer: AZCH Complete Medicare |
$0.53
|
| Rate for Payer: Banner UC Health Medicaid |
$6.72
|
| Rate for Payer: Banner UC Health Medicare |
$0.53
|
| Rate for Payer: Bisbee Police All Plans |
$0.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2.40
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cash Price |
$2.82
|
| Rate for Payer: Cigna of AZ Commercial |
$2.29
|
| Rate for Payer: Copperpoint Commercial |
$0.87
|
| Rate for Payer: Health Net of AZ Commercial |
$2.12
|
| Rate for Payer: Health Net of AZ Medicare |
$0.99
|
| Rate for Payer: Humana of AZ Medicare |
$0.53
|
| Rate for Payer: Mercy Care Medicaid |
$6.72
|
| Rate for Payer: Self Pay Self Pay |
$2.82
|
| Rate for Payer: TriWest Medicare |
$0.53
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2.06
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.64
|
|
