|
Magnesium Level
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
CPT 83735
|
| Hospital Charge Code |
633781
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.80 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna of AZ Commercial |
$72.00
|
| Rate for Payer: Aetna of AZ Medicare |
$22.40
|
| Rate for Payer: Allwell Medicare |
$12.80
|
| Rate for Payer: Amerigroup Medicare |
$12.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$29.88
|
| Rate for Payer: AZCH Complete Medicare |
$12.80
|
| Rate for Payer: Banner UC Health Medicare |
$12.80
|
| Rate for Payer: Bisbee Police All Plans |
$20.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$54.40
|
| Rate for Payer: Cash Price |
$64.00
|
| Rate for Payer: Cigna of AZ Commercial |
$52.00
|
| Rate for Payer: Copperpoint Commercial |
$19.80
|
| Rate for Payer: Health Net of AZ Commercial |
$48.00
|
| Rate for Payer: Health Net of AZ Medicare |
$22.40
|
| Rate for Payer: Humana of AZ Medicare |
$12.80
|
| Rate for Payer: Self Pay Self Pay |
$64.00
|
| Rate for Payer: TriWest Medicare |
$12.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$46.64
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$14.40
|
|
|
Magnesium Level
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
CPT 83735
|
| Hospital Charge Code |
633781
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna of AZ Commercial |
$72.00
|
| Rate for Payer: Bisbee Police All Plans |
$20.80
|
| Rate for Payer: Cash Price |
$64.00
|
| Rate for Payer: Self Pay Self Pay |
$64.00
|
|
|
magnesium oxide 400 mg Tab [CQCH]
|
Facility
|
OP
|
$0.07
|
|
|
Service Code
|
NDC 10006070028
|
| Hospital Charge Code |
105930142
|
|
Hospital Revenue Code
|
251
|
| 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 |
$0.05
|
| 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
|
|
|
magnesium oxide 400 mg Tab [CQCH]
|
Facility
|
IP
|
$0.07
|
|
|
Service Code
|
NDC 10006070028
|
| Hospital Charge Code |
105930142
|
|
Hospital Revenue Code
|
251
|
| 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 |
$0.05
|
| Rate for Payer: Self Pay Self Pay |
$0.06
|
|
|
MAGNESIUM RBC
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
22481492
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.64 |
| 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: Allwell Medicare |
$16.64
|
| Rate for Payer: Amerigroup Medicare |
$16.64
|
| Rate for Payer: APIPA Medicare/Medicaid |
$38.84
|
| Rate for Payer: AZCH Complete Medicare |
$16.64
|
| Rate for Payer: Banner UC Health Medicare |
$16.64
|
| 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: 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 |
$16.64
|
| Rate for Payer: Self Pay Self Pay |
$83.20
|
| Rate for Payer: TriWest Medicare |
$16.64
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$60.63
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$18.72
|
|
|
MAGNESIUM RBC
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
CPT 82570
|
| Hospital Charge Code |
22481492
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$27.04 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of AZ Commercial |
$93.60
|
| Rate for Payer: Bisbee Police All Plans |
$27.04
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Self Pay Self Pay |
$83.20
|
|
|
Magnesium, RBC LC
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
CPT 83735
|
| Hospital Charge Code |
22311200
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.72 |
| Max. Negotiated Rate |
$154.80 |
| Rate for Payer: Aetna of AZ Commercial |
$154.80
|
| Rate for Payer: Bisbee Police All Plans |
$44.72
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Self Pay Self Pay |
$137.60
|
|
|
Magnesium, RBC LC
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
CPT 83735
|
| Hospital Charge Code |
22311200
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$27.52 |
| Max. Negotiated Rate |
$154.80 |
| Rate for Payer: Aetna of AZ Commercial |
$154.80
|
| Rate for Payer: Aetna of AZ Medicare |
$48.16
|
| Rate for Payer: Allwell Medicare |
$27.52
|
| Rate for Payer: Amerigroup Medicare |
$27.52
|
| Rate for Payer: APIPA Medicare/Medicaid |
$64.24
|
| Rate for Payer: AZCH Complete Medicare |
$27.52
|
| Rate for Payer: Banner UC Health Medicare |
$27.52
|
| Rate for Payer: Bisbee Police All Plans |
$44.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$116.96
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Cigna of AZ Commercial |
$111.80
|
| Rate for Payer: Copperpoint Commercial |
$42.57
|
| Rate for Payer: Health Net of AZ Commercial |
$103.20
|
| Rate for Payer: Health Net of AZ Medicare |
$48.16
|
| Rate for Payer: Humana of AZ Medicare |
$27.52
|
| Rate for Payer: Self Pay Self Pay |
$137.60
|
| Rate for Payer: TriWest Medicare |
$27.52
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$100.28
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$30.96
|
|
|
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 |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| 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 |
$0.02
|
| 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: 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/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/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 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 |
$0.24 |
| Rate for Payer: Aetna of AZ Commercial |
$0.24
|
| Rate for Payer: Aetna of AZ Medicare |
$0.08
|
| 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 Medicare |
$0.04
|
| 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: 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: 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 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
|
|
|
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 |
$0.01 |
| Rate for Payer: Aetna of AZ Commercial |
$0.01
|
| Rate for Payer: Aetna of AZ Medicare |
$0.00
|
| 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 Medicare |
$0.00
|
| 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: 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: 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
|
|
|
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 |
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
|
$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
|
$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
|
$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
|
$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
|
$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
|
$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
|
$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
|
$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
|
$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
|
|
