|
MAGNESIUM RBC
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
22481492
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of AZ Commercial |
$93.60
|
| Rate for Payer: Aetna of AZ Medicare |
$29.12
|
| Rate for Payer: AHCCCS Medicaid |
$5.18
|
| Rate for Payer: Allwell Medicaid |
$5.18
|
| Rate for Payer: Allwell Medicare |
$15.60
|
| Rate for Payer: Amerigroup Medicare |
$15.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$38.84
|
| Rate for Payer: AZCH Complete Medicaid |
$5.18
|
| Rate for Payer: AZCH Complete Medicare |
$15.60
|
| Rate for Payer: Banner UC Health Medicaid |
$5.18
|
| Rate for Payer: Banner UC Health Medicare |
$15.60
|
| Rate for Payer: Bisbee Police All Plans |
$27.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$70.72
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Cigna of AZ Commercial |
$67.60
|
| Rate for Payer: Copperpoint Commercial |
$25.74
|
| Rate for Payer: Health Net of AZ Commercial |
$62.40
|
| Rate for Payer: Health Net of AZ Medicare |
$29.12
|
| Rate for Payer: Humana of AZ Medicare |
$15.60
|
| Rate for Payer: Mercy Care Medicaid |
$5.18
|
| Rate for Payer: Self Pay Self Pay |
$83.20
|
| Rate for Payer: TriWest Medicare |
$15.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$60.63
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$18.72
|
|
|
Magnesium, RBC LC
|
Facility
|
IP
|
$194.00
|
|
|
Service Code
|
CPT 83735
|
| Hospital Charge Code |
22311200
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$50.44 |
| Max. Negotiated Rate |
$174.60 |
| Rate for Payer: Aetna of AZ Commercial |
$174.60
|
| Rate for Payer: Bisbee Police All Plans |
$50.44
|
| Rate for Payer: Cash Price |
$155.20
|
| Rate for Payer: Self Pay Self Pay |
$155.20
|
|
|
Magnesium, RBC LC
|
Facility
|
OP
|
$194.00
|
|
|
Service Code
|
CPT 83735
|
| Hospital Charge Code |
22311200
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$174.60 |
| Rate for Payer: Aetna of AZ Commercial |
$174.60
|
| Rate for Payer: Aetna of AZ Medicare |
$54.32
|
| Rate for Payer: AHCCCS Medicaid |
$6.70
|
| Rate for Payer: Allwell Medicaid |
$6.70
|
| Rate for Payer: Allwell Medicare |
$29.10
|
| Rate for Payer: Amerigroup Medicare |
$29.10
|
| Rate for Payer: APIPA Medicare/Medicaid |
$72.46
|
| Rate for Payer: AZCH Complete Medicaid |
$6.70
|
| Rate for Payer: AZCH Complete Medicare |
$29.10
|
| Rate for Payer: Banner UC Health Medicaid |
$6.70
|
| Rate for Payer: Banner UC Health Medicare |
$29.10
|
| Rate for Payer: Bisbee Police All Plans |
$50.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$131.92
|
| Rate for Payer: Cash Price |
$155.20
|
| Rate for Payer: Cash Price |
$155.20
|
| Rate for Payer: Cigna of AZ Commercial |
$126.10
|
| Rate for Payer: Copperpoint Commercial |
$48.02
|
| Rate for Payer: Health Net of AZ Commercial |
$116.40
|
| Rate for Payer: Health Net of AZ Medicare |
$54.32
|
| Rate for Payer: Humana of AZ Medicare |
$29.10
|
| Rate for Payer: Mercy Care Medicaid |
$6.70
|
| Rate for Payer: Self Pay Self Pay |
$155.20
|
| Rate for Payer: TriWest Medicare |
$29.10
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$113.10
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$34.92
|
|
|
magnesium sulfate 1 gm/100 ml Sol[CQCH]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
169584435
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Self Pay Self Pay |
$0.02
|
|
|
magnesium sulfate 1 gm/100 ml Sol[CQCH]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
169584435
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Aetna of AZ Medicare |
$0.01
|
| Rate for Payer: AHCCCS Medicaid |
$1.26
|
| Rate for Payer: Allwell Medicaid |
$1.26
|
| 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 Medicaid |
$1.26
|
| Rate for Payer: AZCH Complete Medicare |
$0.00
|
| Rate for Payer: Banner UC Health Medicaid |
$1.26
|
| 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 |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of AZ Commercial |
$0.02
|
| Rate for Payer: Copperpoint Commercial |
$0.01
|
| Rate for Payer: Health Net of AZ Commercial |
$0.02
|
| Rate for Payer: Health Net of AZ Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.00
|
| Rate for Payer: Mercy Care Medicaid |
$1.26
|
| Rate for Payer: Self Pay Self Pay |
$0.02
|
| Rate for Payer: TriWest Medicare |
$0.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.02
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.01
|
|
|
magnesium sulfate 1 gm/2 mL inj Sol [CQCH]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
105930353
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna of AZ Commercial |
$0.24
|
| Rate for Payer: Aetna of AZ Medicare |
$0.08
|
| Rate for Payer: AHCCCS Medicaid |
$1.26
|
| Rate for Payer: Allwell Medicaid |
$1.26
|
| Rate for Payer: Allwell Medicare |
$0.04
|
| Rate for Payer: Amerigroup Medicare |
$0.04
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.10
|
| Rate for Payer: AZCH Complete Medicaid |
$1.26
|
| Rate for Payer: AZCH Complete Medicare |
$0.04
|
| Rate for Payer: Banner UC Health Medicaid |
$1.26
|
| Rate for Payer: Banner UC Health Medicare |
$0.04
|
| Rate for Payer: Bisbee Police All Plans |
$0.07
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.18
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of AZ Commercial |
$0.18
|
| Rate for Payer: Copperpoint Commercial |
$0.07
|
| Rate for Payer: Health Net of AZ Commercial |
$0.16
|
| Rate for Payer: Health Net of AZ Medicare |
$0.08
|
| Rate for Payer: Humana of AZ Medicare |
$0.04
|
| Rate for Payer: Mercy Care Medicaid |
$1.26
|
| Rate for Payer: Self Pay Self Pay |
$0.22
|
| Rate for Payer: TriWest Medicare |
$0.04
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.16
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.05
|
|
|
magnesium sulfate 1 gm/2 mL inj Sol [CQCH]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
105930353
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of AZ Commercial |
$0.24
|
| Rate for Payer: Bisbee Police All Plans |
$0.07
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Self Pay Self Pay |
$0.22
|
|
|
magnesium sulfate 20 gm/ 500 mL IV Sol [CQCH]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
105930207
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna of AZ Commercial |
$0.01
|
| Rate for Payer: Aetna of AZ Medicare |
$0.00
|
| Rate for Payer: AHCCCS Medicaid |
$1.26
|
| Rate for Payer: Allwell Medicaid |
$1.26
|
| Rate for Payer: Allwell Medicare |
$0.00
|
| Rate for Payer: Amerigroup Medicare |
$0.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.00
|
| Rate for Payer: AZCH Complete Medicaid |
$1.26
|
| Rate for Payer: AZCH Complete Medicare |
$0.00
|
| Rate for Payer: Banner UC Health Medicaid |
$1.26
|
| Rate for Payer: Banner UC Health Medicare |
$0.00
|
| Rate for Payer: Bisbee Police All Plans |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$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 |
$0.00
|
| Rate for Payer: Humana of AZ Medicare |
$0.00
|
| Rate for Payer: Mercy Care Medicaid |
$1.26
|
| Rate for Payer: Self Pay Self Pay |
$0.01
|
| 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
|
|
|
magnesium sulfate 20 gm/ 500 mL IV Sol [CQCH]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3475
|
| Hospital Charge Code |
105930207
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of AZ Commercial |
$0.01
|
| Rate for Payer: Bisbee Police All Plans |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Self Pay Self Pay |
$0.01
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$17,101.53
|
|
|
Service Code
|
APR-DRG 1691
|
| Hospital Charge Code |
APRDRG1691
|
| Min. Negotiated Rate |
$17,101.53 |
| Max. Negotiated Rate |
$17,101.53 |
| Rate for Payer: AHCCCS Medicaid |
$17,101.53
|
| Rate for Payer: Allwell Medicaid |
$17,101.53
|
| Rate for Payer: AZCH Complete Medicaid |
$17,101.53
|
| Rate for Payer: Banner UC Health Medicaid |
$17,101.53
|
| Rate for Payer: Mercy Care Medicaid |
$17,101.53
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$42,746.82
|
|
|
Service Code
|
APR-DRG 1694
|
| Hospital Charge Code |
APRDRG1693
|
| Min. Negotiated Rate |
$42,746.82 |
| Max. Negotiated Rate |
$42,746.82 |
| Rate for Payer: AHCCCS Medicaid |
$42,746.82
|
| Rate for Payer: Allwell Medicaid |
$42,746.82
|
| Rate for Payer: AZCH Complete Medicaid |
$42,746.82
|
| Rate for Payer: Banner UC Health Medicaid |
$42,746.82
|
| Rate for Payer: Mercy Care Medicaid |
$42,746.82
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$18,061.05
|
|
|
Service Code
|
APR-DRG 1692
|
| Hospital Charge Code |
APRDRG1692
|
| Min. Negotiated Rate |
$18,061.05 |
| Max. Negotiated Rate |
$18,061.05 |
| Rate for Payer: AHCCCS Medicaid |
$18,061.05
|
| Rate for Payer: Allwell Medicaid |
$18,061.05
|
| Rate for Payer: AZCH Complete Medicaid |
$18,061.05
|
| Rate for Payer: Banner UC Health Medicaid |
$18,061.05
|
| Rate for Payer: Mercy Care Medicaid |
$18,061.05
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$17,101.53
|
|
|
Service Code
|
APR-DRG 1691
|
| Hospital Charge Code |
APRDRG1692
|
| Min. Negotiated Rate |
$17,101.53 |
| Max. Negotiated Rate |
$17,101.53 |
| Rate for Payer: AHCCCS Medicaid |
$17,101.53
|
| Rate for Payer: Allwell Medicaid |
$17,101.53
|
| Rate for Payer: AZCH Complete Medicaid |
$17,101.53
|
| Rate for Payer: Banner UC Health Medicaid |
$17,101.53
|
| Rate for Payer: Mercy Care Medicaid |
$17,101.53
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$25,119.24
|
|
|
Service Code
|
APR-DRG 1693
|
| Hospital Charge Code |
APRDRG1694
|
| Min. Negotiated Rate |
$25,119.24 |
| Max. Negotiated Rate |
$25,119.24 |
| Rate for Payer: AHCCCS Medicaid |
$25,119.24
|
| Rate for Payer: Allwell Medicaid |
$25,119.24
|
| Rate for Payer: AZCH Complete Medicaid |
$25,119.24
|
| Rate for Payer: Banner UC Health Medicaid |
$25,119.24
|
| Rate for Payer: Mercy Care Medicaid |
$25,119.24
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$42,746.82
|
|
|
Service Code
|
APR-DRG 1694
|
| Hospital Charge Code |
APRDRG1694
|
| Min. Negotiated Rate |
$42,746.82 |
| Max. Negotiated Rate |
$42,746.82 |
| Rate for Payer: AHCCCS Medicaid |
$42,746.82
|
| Rate for Payer: Allwell Medicaid |
$42,746.82
|
| Rate for Payer: AZCH Complete Medicaid |
$42,746.82
|
| Rate for Payer: Banner UC Health Medicaid |
$42,746.82
|
| Rate for Payer: Mercy Care Medicaid |
$42,746.82
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$42,746.82
|
|
|
Service Code
|
APR-DRG 1694
|
| Hospital Charge Code |
APRDRG1692
|
| Min. Negotiated Rate |
$42,746.82 |
| Max. Negotiated Rate |
$42,746.82 |
| Rate for Payer: AHCCCS Medicaid |
$42,746.82
|
| Rate for Payer: Allwell Medicaid |
$42,746.82
|
| Rate for Payer: AZCH Complete Medicaid |
$42,746.82
|
| Rate for Payer: Banner UC Health Medicaid |
$42,746.82
|
| Rate for Payer: Mercy Care Medicaid |
$42,746.82
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$25,119.24
|
|
|
Service Code
|
APR-DRG 1693
|
| Hospital Charge Code |
APRDRG1692
|
| Min. Negotiated Rate |
$25,119.24 |
| Max. Negotiated Rate |
$25,119.24 |
| Rate for Payer: AHCCCS Medicaid |
$25,119.24
|
| Rate for Payer: Allwell Medicaid |
$25,119.24
|
| Rate for Payer: AZCH Complete Medicaid |
$25,119.24
|
| Rate for Payer: Banner UC Health Medicaid |
$25,119.24
|
| Rate for Payer: Mercy Care Medicaid |
$25,119.24
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$42,746.82
|
|
|
Service Code
|
APR-DRG 1694
|
| Hospital Charge Code |
APRDRG1691
|
| Min. Negotiated Rate |
$42,746.82 |
| Max. Negotiated Rate |
$42,746.82 |
| Rate for Payer: AHCCCS Medicaid |
$42,746.82
|
| Rate for Payer: Allwell Medicaid |
$42,746.82
|
| Rate for Payer: AZCH Complete Medicaid |
$42,746.82
|
| Rate for Payer: Banner UC Health Medicaid |
$42,746.82
|
| Rate for Payer: Mercy Care Medicaid |
$42,746.82
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$17,101.53
|
|
|
Service Code
|
APR-DRG 1691
|
| Hospital Charge Code |
APRDRG1694
|
| Min. Negotiated Rate |
$17,101.53 |
| Max. Negotiated Rate |
$17,101.53 |
| Rate for Payer: AHCCCS Medicaid |
$17,101.53
|
| Rate for Payer: Allwell Medicaid |
$17,101.53
|
| Rate for Payer: AZCH Complete Medicaid |
$17,101.53
|
| Rate for Payer: Banner UC Health Medicaid |
$17,101.53
|
| Rate for Payer: Mercy Care Medicaid |
$17,101.53
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$18,061.05
|
|
|
Service Code
|
APR-DRG 1692
|
| Hospital Charge Code |
APRDRG1691
|
| Min. Negotiated Rate |
$18,061.05 |
| Max. Negotiated Rate |
$18,061.05 |
| Rate for Payer: AHCCCS Medicaid |
$18,061.05
|
| Rate for Payer: Allwell Medicaid |
$18,061.05
|
| Rate for Payer: AZCH Complete Medicaid |
$18,061.05
|
| Rate for Payer: Banner UC Health Medicaid |
$18,061.05
|
| Rate for Payer: Mercy Care Medicaid |
$18,061.05
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$25,119.24
|
|
|
Service Code
|
APR-DRG 1693
|
| Hospital Charge Code |
APRDRG1691
|
| Min. Negotiated Rate |
$25,119.24 |
| Max. Negotiated Rate |
$25,119.24 |
| Rate for Payer: AHCCCS Medicaid |
$25,119.24
|
| Rate for Payer: Allwell Medicaid |
$25,119.24
|
| Rate for Payer: AZCH Complete Medicaid |
$25,119.24
|
| Rate for Payer: Banner UC Health Medicaid |
$25,119.24
|
| Rate for Payer: Mercy Care Medicaid |
$25,119.24
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$18,061.05
|
|
|
Service Code
|
APR-DRG 1692
|
| Hospital Charge Code |
APRDRG1694
|
| Min. Negotiated Rate |
$18,061.05 |
| Max. Negotiated Rate |
$18,061.05 |
| Rate for Payer: AHCCCS Medicaid |
$18,061.05
|
| Rate for Payer: Allwell Medicaid |
$18,061.05
|
| Rate for Payer: AZCH Complete Medicaid |
$18,061.05
|
| Rate for Payer: Banner UC Health Medicaid |
$18,061.05
|
| Rate for Payer: Mercy Care Medicaid |
$18,061.05
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$18,061.05
|
|
|
Service Code
|
APR-DRG 1692
|
| Hospital Charge Code |
APRDRG1693
|
| Min. Negotiated Rate |
$18,061.05 |
| Max. Negotiated Rate |
$18,061.05 |
| Rate for Payer: AHCCCS Medicaid |
$18,061.05
|
| Rate for Payer: Allwell Medicaid |
$18,061.05
|
| Rate for Payer: AZCH Complete Medicaid |
$18,061.05
|
| Rate for Payer: Banner UC Health Medicaid |
$18,061.05
|
| Rate for Payer: Mercy Care Medicaid |
$18,061.05
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$17,101.53
|
|
|
Service Code
|
APR-DRG 1691
|
| Hospital Charge Code |
APRDRG1693
|
| Min. Negotiated Rate |
$17,101.53 |
| Max. Negotiated Rate |
$17,101.53 |
| Rate for Payer: AHCCCS Medicaid |
$17,101.53
|
| Rate for Payer: Allwell Medicaid |
$17,101.53
|
| Rate for Payer: AZCH Complete Medicaid |
$17,101.53
|
| Rate for Payer: Banner UC Health Medicaid |
$17,101.53
|
| Rate for Payer: Mercy Care Medicaid |
$17,101.53
|
|
|
Major Abdominal Vascular Procedures
|
Facility
|
IP
|
$25,119.24
|
|
|
Service Code
|
APR-DRG 1693
|
| Hospital Charge Code |
APRDRG1693
|
| Min. Negotiated Rate |
$25,119.24 |
| Max. Negotiated Rate |
$25,119.24 |
| Rate for Payer: AHCCCS Medicaid |
$25,119.24
|
| Rate for Payer: Allwell Medicaid |
$25,119.24
|
| Rate for Payer: AZCH Complete Medicaid |
$25,119.24
|
| Rate for Payer: Banner UC Health Medicaid |
$25,119.24
|
| Rate for Payer: Mercy Care Medicaid |
$25,119.24
|
|
