|
Ketone Serum
|
Facility
|
OP
|
$169.00
|
|
|
Service Code
|
CPT 82009
|
| Hospital Charge Code |
887702
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$27.04 |
| Max. Negotiated Rate |
$152.10 |
| Rate for Payer: Aetna of AZ Commercial |
$152.10
|
| Rate for Payer: Aetna of AZ Medicare |
$47.32
|
| Rate for Payer: Allwell Medicare |
$27.04
|
| Rate for Payer: Amerigroup Medicare |
$27.04
|
| Rate for Payer: APIPA Medicare/Medicaid |
$63.12
|
| Rate for Payer: AZCH Complete Medicare |
$27.04
|
| Rate for Payer: Banner UC Health Medicare |
$27.04
|
| Rate for Payer: Bisbee Police All Plans |
$43.94
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$114.92
|
| Rate for Payer: Cash Price |
$135.20
|
| Rate for Payer: Cigna of AZ Commercial |
$109.85
|
| Rate for Payer: Copperpoint Commercial |
$41.83
|
| Rate for Payer: Health Net of AZ Commercial |
$101.40
|
| Rate for Payer: Health Net of AZ Medicare |
$47.32
|
| Rate for Payer: Humana of AZ Medicare |
$27.04
|
| Rate for Payer: Self Pay Self Pay |
$135.20
|
| Rate for Payer: TriWest Medicare |
$27.04
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$98.53
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$30.42
|
|
|
Ketone Serum
|
Facility
|
IP
|
$169.00
|
|
|
Service Code
|
CPT 82009
|
| Hospital Charge Code |
887702
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$43.94 |
| Max. Negotiated Rate |
$152.10 |
| Rate for Payer: Aetna of AZ Commercial |
$152.10
|
| Rate for Payer: Bisbee Police All Plans |
$43.94
|
| Rate for Payer: Cash Price |
$135.20
|
| Rate for Payer: Self Pay Self Pay |
$135.20
|
|
|
ketorolac 15 mg Inj Sol [CQCH]
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
105927425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Aetna of AZ Commercial |
$1.62
|
| Rate for Payer: Aetna of AZ Medicare |
$0.50
|
| Rate for Payer: Allwell Medicare |
$0.29
|
| Rate for Payer: Amerigroup Medicare |
$0.29
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.67
|
| Rate for Payer: AZCH Complete Medicare |
$0.29
|
| Rate for Payer: Banner UC Health Medicare |
$0.29
|
| Rate for Payer: Bisbee Police All Plans |
$0.47
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.22
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna of AZ Commercial |
$1.17
|
| Rate for Payer: Copperpoint Commercial |
$0.45
|
| Rate for Payer: Health Net of AZ Commercial |
$1.08
|
| Rate for Payer: Health Net of AZ Medicare |
$0.50
|
| Rate for Payer: Humana of AZ Medicare |
$0.29
|
| Rate for Payer: Self Pay Self Pay |
$1.44
|
| Rate for Payer: TriWest Medicare |
$0.29
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1.05
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.32
|
|
|
ketorolac 15 mg Inj Sol [CQCH]
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
105927425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Aetna of AZ Commercial |
$1.62
|
| Rate for Payer: Bisbee Police All Plans |
$0.47
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Self Pay Self Pay |
$1.44
|
|
|
ketorolac 30 mg Inj Sol [CQCH]
|
Facility
|
OP
|
$0.88
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
105927498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Aetna of AZ Commercial |
$0.79
|
| Rate for Payer: Aetna of AZ Medicare |
$0.25
|
| Rate for Payer: Allwell Medicare |
$0.14
|
| Rate for Payer: Amerigroup Medicare |
$0.14
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.33
|
| Rate for Payer: AZCH Complete Medicare |
$0.14
|
| Rate for Payer: Banner UC Health Medicare |
$0.14
|
| Rate for Payer: Bisbee Police All Plans |
$0.23
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.60
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cigna of AZ Commercial |
$0.57
|
| Rate for Payer: Copperpoint Commercial |
$0.22
|
| Rate for Payer: Health Net of AZ Commercial |
$0.53
|
| Rate for Payer: Health Net of AZ Medicare |
$0.25
|
| Rate for Payer: Humana of AZ Medicare |
$0.14
|
| Rate for Payer: Self Pay Self Pay |
$0.70
|
| Rate for Payer: TriWest Medicare |
$0.14
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.51
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.16
|
|
|
ketorolac 30 mg Inj Sol [CQCH]
|
Facility
|
IP
|
$0.88
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
105927498
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.23 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Aetna of AZ Commercial |
$0.79
|
| Rate for Payer: Bisbee Police All Plans |
$0.23
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Self Pay Self Pay |
$0.70
|
|
|
ketorolac 60 mg Inj Sol [CQCH]
|
Facility
|
IP
|
$0.91
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
105927571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of AZ Commercial |
$0.82
|
| Rate for Payer: Bisbee Police All Plans |
$0.24
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Self Pay Self Pay |
$0.73
|
|
|
ketorolac 60 mg Inj Sol [CQCH]
|
Facility
|
OP
|
$0.91
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
105927571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.82 |
| Rate for Payer: Aetna of AZ Commercial |
$0.82
|
| Rate for Payer: Aetna of AZ Medicare |
$0.25
|
| Rate for Payer: Allwell Medicare |
$0.15
|
| Rate for Payer: Amerigroup Medicare |
$0.15
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.34
|
| Rate for Payer: AZCH Complete Medicare |
$0.15
|
| Rate for Payer: Banner UC Health Medicare |
$0.15
|
| Rate for Payer: Bisbee Police All Plans |
$0.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.62
|
| Rate for Payer: Cash Price |
$0.73
|
| Rate for Payer: Cigna of AZ Commercial |
$0.59
|
| Rate for Payer: Copperpoint Commercial |
$0.23
|
| Rate for Payer: Health Net of AZ Commercial |
$0.55
|
| Rate for Payer: Health Net of AZ Medicare |
$0.25
|
| Rate for Payer: Humana of AZ Medicare |
$0.15
|
| Rate for Payer: Self Pay Self Pay |
$0.73
|
| Rate for Payer: TriWest Medicare |
$0.15
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.53
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.16
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$9,414.89
|
|
|
Service Code
|
APR-DRG 4634
|
| Hospital Charge Code |
APRDRG4632
|
| Min. Negotiated Rate |
$9,414.89 |
| Max. Negotiated Rate |
$9,414.89 |
| Rate for Payer: AHCCCS Medicaid |
$9,414.89
|
| Rate for Payer: Allwell Medicaid |
$9,414.89
|
| Rate for Payer: AZCH Complete Medicaid |
$9,414.89
|
| Rate for Payer: Banner UC Health Medicaid |
$9,414.89
|
| Rate for Payer: Mercy Care Medicaid |
$9,414.89
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,173.84
|
|
|
Service Code
|
APR-DRG 4631
|
| Hospital Charge Code |
APRDRG4634
|
| Min. Negotiated Rate |
$3,173.84 |
| Max. Negotiated Rate |
$3,173.84 |
| Rate for Payer: AHCCCS Medicaid |
$3,173.84
|
| Rate for Payer: Allwell Medicaid |
$3,173.84
|
| Rate for Payer: AZCH Complete Medicaid |
$3,173.84
|
| Rate for Payer: Banner UC Health Medicaid |
$3,173.84
|
| Rate for Payer: Mercy Care Medicaid |
$3,173.84
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$5,325.73
|
|
|
Service Code
|
APR-DRG 4633
|
| Hospital Charge Code |
APRDRG4633
|
| Min. Negotiated Rate |
$5,325.73 |
| Max. Negotiated Rate |
$5,325.73 |
| Rate for Payer: AHCCCS Medicaid |
$5,325.73
|
| Rate for Payer: Allwell Medicaid |
$5,325.73
|
| Rate for Payer: AZCH Complete Medicaid |
$5,325.73
|
| Rate for Payer: Banner UC Health Medicaid |
$5,325.73
|
| Rate for Payer: Mercy Care Medicaid |
$5,325.73
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,863.31
|
|
|
Service Code
|
APR-DRG 4632
|
| Hospital Charge Code |
APRDRG4631
|
| Min. Negotiated Rate |
$3,863.31 |
| Max. Negotiated Rate |
$3,863.31 |
| Rate for Payer: AHCCCS Medicaid |
$3,863.31
|
| Rate for Payer: Allwell Medicaid |
$3,863.31
|
| Rate for Payer: AZCH Complete Medicaid |
$3,863.31
|
| Rate for Payer: Banner UC Health Medicaid |
$3,863.31
|
| Rate for Payer: Mercy Care Medicaid |
$3,863.31
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$9,414.89
|
|
|
Service Code
|
APR-DRG 4634
|
| Hospital Charge Code |
APRDRG4631
|
| Min. Negotiated Rate |
$9,414.89 |
| Max. Negotiated Rate |
$9,414.89 |
| Rate for Payer: AHCCCS Medicaid |
$9,414.89
|
| Rate for Payer: Allwell Medicaid |
$9,414.89
|
| Rate for Payer: AZCH Complete Medicaid |
$9,414.89
|
| Rate for Payer: Banner UC Health Medicaid |
$9,414.89
|
| Rate for Payer: Mercy Care Medicaid |
$9,414.89
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$5,325.73
|
|
|
Service Code
|
APR-DRG 4633
|
| Hospital Charge Code |
APRDRG4634
|
| Min. Negotiated Rate |
$5,325.73 |
| Max. Negotiated Rate |
$5,325.73 |
| Rate for Payer: AHCCCS Medicaid |
$5,325.73
|
| Rate for Payer: Allwell Medicaid |
$5,325.73
|
| Rate for Payer: AZCH Complete Medicaid |
$5,325.73
|
| Rate for Payer: Banner UC Health Medicaid |
$5,325.73
|
| Rate for Payer: Mercy Care Medicaid |
$5,325.73
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,863.31
|
|
|
Service Code
|
APR-DRG 4632
|
| Hospital Charge Code |
APRDRG4634
|
| Min. Negotiated Rate |
$3,863.31 |
| Max. Negotiated Rate |
$3,863.31 |
| Rate for Payer: AHCCCS Medicaid |
$3,863.31
|
| Rate for Payer: Allwell Medicaid |
$3,863.31
|
| Rate for Payer: AZCH Complete Medicaid |
$3,863.31
|
| Rate for Payer: Banner UC Health Medicaid |
$3,863.31
|
| Rate for Payer: Mercy Care Medicaid |
$3,863.31
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$9,414.89
|
|
|
Service Code
|
APR-DRG 4634
|
| Hospital Charge Code |
APRDRG4634
|
| Min. Negotiated Rate |
$9,414.89 |
| Max. Negotiated Rate |
$9,414.89 |
| Rate for Payer: AHCCCS Medicaid |
$9,414.89
|
| Rate for Payer: Allwell Medicaid |
$9,414.89
|
| Rate for Payer: AZCH Complete Medicaid |
$9,414.89
|
| Rate for Payer: Banner UC Health Medicaid |
$9,414.89
|
| Rate for Payer: Mercy Care Medicaid |
$9,414.89
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$5,325.73
|
|
|
Service Code
|
APR-DRG 4633
|
| Hospital Charge Code |
APRDRG4632
|
| Min. Negotiated Rate |
$5,325.73 |
| Max. Negotiated Rate |
$5,325.73 |
| Rate for Payer: AHCCCS Medicaid |
$5,325.73
|
| Rate for Payer: Allwell Medicaid |
$5,325.73
|
| Rate for Payer: AZCH Complete Medicaid |
$5,325.73
|
| Rate for Payer: Banner UC Health Medicaid |
$5,325.73
|
| Rate for Payer: Mercy Care Medicaid |
$5,325.73
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$9,414.89
|
|
|
Service Code
|
APR-DRG 4634
|
| Hospital Charge Code |
APRDRG4633
|
| Min. Negotiated Rate |
$9,414.89 |
| Max. Negotiated Rate |
$9,414.89 |
| Rate for Payer: AHCCCS Medicaid |
$9,414.89
|
| Rate for Payer: Allwell Medicaid |
$9,414.89
|
| Rate for Payer: AZCH Complete Medicaid |
$9,414.89
|
| Rate for Payer: Banner UC Health Medicaid |
$9,414.89
|
| Rate for Payer: Mercy Care Medicaid |
$9,414.89
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,173.84
|
|
|
Service Code
|
APR-DRG 4631
|
| Hospital Charge Code |
APRDRG4633
|
| Min. Negotiated Rate |
$3,173.84 |
| Max. Negotiated Rate |
$3,173.84 |
| Rate for Payer: AHCCCS Medicaid |
$3,173.84
|
| Rate for Payer: Allwell Medicaid |
$3,173.84
|
| Rate for Payer: AZCH Complete Medicaid |
$3,173.84
|
| Rate for Payer: Banner UC Health Medicaid |
$3,173.84
|
| Rate for Payer: Mercy Care Medicaid |
$3,173.84
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,173.84
|
|
|
Service Code
|
APR-DRG 4631
|
| Hospital Charge Code |
APRDRG4631
|
| Min. Negotiated Rate |
$3,173.84 |
| Max. Negotiated Rate |
$3,173.84 |
| Rate for Payer: AHCCCS Medicaid |
$3,173.84
|
| Rate for Payer: Allwell Medicaid |
$3,173.84
|
| Rate for Payer: AZCH Complete Medicaid |
$3,173.84
|
| Rate for Payer: Banner UC Health Medicaid |
$3,173.84
|
| Rate for Payer: Mercy Care Medicaid |
$3,173.84
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,863.31
|
|
|
Service Code
|
APR-DRG 4632
|
| Hospital Charge Code |
APRDRG4632
|
| Min. Negotiated Rate |
$3,863.31 |
| Max. Negotiated Rate |
$3,863.31 |
| Rate for Payer: AHCCCS Medicaid |
$3,863.31
|
| Rate for Payer: Allwell Medicaid |
$3,863.31
|
| Rate for Payer: AZCH Complete Medicaid |
$3,863.31
|
| Rate for Payer: Banner UC Health Medicaid |
$3,863.31
|
| Rate for Payer: Mercy Care Medicaid |
$3,863.31
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,863.31
|
|
|
Service Code
|
APR-DRG 4632
|
| Hospital Charge Code |
APRDRG4633
|
| Min. Negotiated Rate |
$3,863.31 |
| Max. Negotiated Rate |
$3,863.31 |
| Rate for Payer: AHCCCS Medicaid |
$3,863.31
|
| Rate for Payer: Allwell Medicaid |
$3,863.31
|
| Rate for Payer: AZCH Complete Medicaid |
$3,863.31
|
| Rate for Payer: Banner UC Health Medicaid |
$3,863.31
|
| Rate for Payer: Mercy Care Medicaid |
$3,863.31
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$5,325.73
|
|
|
Service Code
|
APR-DRG 4633
|
| Hospital Charge Code |
APRDRG4631
|
| Min. Negotiated Rate |
$5,325.73 |
| Max. Negotiated Rate |
$5,325.73 |
| Rate for Payer: AHCCCS Medicaid |
$5,325.73
|
| Rate for Payer: Allwell Medicaid |
$5,325.73
|
| Rate for Payer: AZCH Complete Medicaid |
$5,325.73
|
| Rate for Payer: Banner UC Health Medicaid |
$5,325.73
|
| Rate for Payer: Mercy Care Medicaid |
$5,325.73
|
|
|
Kidney And Urinary Tract Infections
|
Facility
|
IP
|
$3,173.84
|
|
|
Service Code
|
APR-DRG 4631
|
| Hospital Charge Code |
APRDRG4632
|
| Min. Negotiated Rate |
$3,173.84 |
| Max. Negotiated Rate |
$3,173.84 |
| Rate for Payer: AHCCCS Medicaid |
$3,173.84
|
| Rate for Payer: Allwell Medicaid |
$3,173.84
|
| Rate for Payer: AZCH Complete Medicaid |
$3,173.84
|
| Rate for Payer: Banner UC Health Medicaid |
$3,173.84
|
| Rate for Payer: Mercy Care Medicaid |
$3,173.84
|
|
|
Kidney And Urinary Tract Malignancy
|
Facility
|
IP
|
$5,059.20
|
|
|
Service Code
|
APR-DRG 4611
|
| Hospital Charge Code |
APRDRG4613
|
| Min. Negotiated Rate |
$5,059.20 |
| Max. Negotiated Rate |
$5,059.20 |
| Rate for Payer: AHCCCS Medicaid |
$5,059.20
|
| Rate for Payer: Allwell Medicaid |
$5,059.20
|
| Rate for Payer: AZCH Complete Medicaid |
$5,059.20
|
| Rate for Payer: Banner UC Health Medicaid |
$5,059.20
|
| Rate for Payer: Mercy Care Medicaid |
$5,059.20
|
|
