|
ampicillin-sulbactam 1 .5 g Inj [CQCH]
|
Facility
|
OP
|
$1.49
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
105911169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$4.34 |
| Rate for Payer: Aetna of AZ Commercial |
$1.34
|
| Rate for Payer: Aetna of AZ Medicare |
$0.42
|
| Rate for Payer: AHCCCS Medicaid |
$4.34
|
| Rate for Payer: Allwell Medicaid |
$4.34
|
| Rate for Payer: Allwell Medicare |
$0.22
|
| Rate for Payer: Amerigroup Medicare |
$0.22
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.56
|
| Rate for Payer: AZCH Complete Medicaid |
$4.34
|
| Rate for Payer: AZCH Complete Medicare |
$0.22
|
| Rate for Payer: Banner UC Health Medicaid |
$4.34
|
| Rate for Payer: Banner UC Health Medicare |
$0.22
|
| Rate for Payer: Bisbee Police All Plans |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.01
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cigna of AZ Commercial |
$0.97
|
| Rate for Payer: Copperpoint Commercial |
$0.37
|
| Rate for Payer: Health Net of AZ Commercial |
$0.89
|
| Rate for Payer: Health Net of AZ Medicare |
$0.42
|
| Rate for Payer: Humana of AZ Medicare |
$0.22
|
| Rate for Payer: Mercy Care Medicaid |
$4.34
|
| Rate for Payer: Self Pay Self Pay |
$1.19
|
| Rate for Payer: TriWest Medicare |
$0.22
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.87
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.27
|
|
|
ampicillin-sulbactam 3 g Inj [CQCH]
|
Facility
|
IP
|
$5.20
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
105911242
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna of AZ Commercial |
$4.68
|
| Rate for Payer: Bisbee Police All Plans |
$1.35
|
| Rate for Payer: Cash Price |
$4.16
|
| Rate for Payer: Self Pay Self Pay |
$4.16
|
|
|
ampicillin-sulbactam 3 g Inj [CQCH]
|
Facility
|
OP
|
$5.20
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
105911242
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna of AZ Commercial |
$4.68
|
| Rate for Payer: Aetna of AZ Medicare |
$1.46
|
| Rate for Payer: AHCCCS Medicaid |
$4.34
|
| Rate for Payer: Allwell Medicaid |
$4.34
|
| Rate for Payer: Allwell Medicare |
$0.78
|
| Rate for Payer: Amerigroup Medicare |
$0.78
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1.94
|
| Rate for Payer: AZCH Complete Medicaid |
$4.34
|
| Rate for Payer: AZCH Complete Medicare |
$0.78
|
| Rate for Payer: Banner UC Health Medicaid |
$4.34
|
| Rate for Payer: Banner UC Health Medicare |
$0.78
|
| Rate for Payer: Bisbee Police All Plans |
$1.35
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$3.54
|
| Rate for Payer: Cash Price |
$4.16
|
| Rate for Payer: Cash Price |
$4.16
|
| Rate for Payer: Cigna of AZ Commercial |
$3.38
|
| Rate for Payer: Copperpoint Commercial |
$1.29
|
| Rate for Payer: Health Net of AZ Commercial |
$3.12
|
| Rate for Payer: Health Net of AZ Medicare |
$1.46
|
| Rate for Payer: Humana of AZ Medicare |
$0.78
|
| Rate for Payer: Mercy Care Medicaid |
$4.34
|
| Rate for Payer: Self Pay Self Pay |
$4.16
|
| Rate for Payer: TriWest Medicare |
$0.78
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3.03
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.94
|
|
|
AMPUTATION METATARSAL WITH TOE SINGLE
|
Facility
|
OP
|
$2,086.00
|
|
|
Service Code
|
CPT 28810
|
| Hospital Charge Code |
24043301
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$312.90 |
| Max. Negotiated Rate |
$4,104.08 |
| Rate for Payer: Aetna of AZ Commercial |
$1,877.40
|
| Rate for Payer: Aetna of AZ Medicare |
$584.08
|
| Rate for Payer: AHCCCS Medicaid |
$4,104.08
|
| Rate for Payer: Allwell Medicaid |
$4,104.08
|
| Rate for Payer: Allwell Medicare |
$312.90
|
| Rate for Payer: Amerigroup Medicare |
$312.90
|
| Rate for Payer: APIPA Medicare/Medicaid |
$779.12
|
| Rate for Payer: AZCH Complete Medicaid |
$4,104.08
|
| Rate for Payer: AZCH Complete Medicare |
$312.90
|
| Rate for Payer: Banner UC Health Medicaid |
$4,104.08
|
| Rate for Payer: Banner UC Health Medicare |
$312.90
|
| Rate for Payer: Bisbee Police All Plans |
$542.36
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,418.48
|
| Rate for Payer: Cash Price |
$1,668.80
|
| Rate for Payer: Cash Price |
$1,668.80
|
| Rate for Payer: Cigna of AZ Commercial |
$1,043.00
|
| Rate for Payer: Copperpoint Commercial |
$516.28
|
| Rate for Payer: Health Net of AZ Commercial |
$1,251.60
|
| Rate for Payer: Health Net of AZ Medicare |
$584.08
|
| Rate for Payer: Humana of AZ Medicare |
$312.90
|
| Rate for Payer: Mercy Care Medicaid |
$4,104.08
|
| Rate for Payer: Self Pay Self Pay |
$1,668.80
|
| Rate for Payer: TriWest Medicare |
$312.90
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,373.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$375.48
|
|
|
AMPUTATION METATARSAL WITH TOE SINGLE
|
Facility
|
IP
|
$2,086.00
|
|
|
Service Code
|
CPT 28810
|
| Hospital Charge Code |
24043301
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$542.36 |
| Max. Negotiated Rate |
$1,877.40 |
| Rate for Payer: Aetna of AZ Commercial |
$1,877.40
|
| Rate for Payer: Bisbee Police All Plans |
$542.36
|
| Rate for Payer: Cash Price |
$1,668.80
|
| Rate for Payer: Self Pay Self Pay |
$1,668.80
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$14,950.34
|
|
|
Service Code
|
APR-DRG 3053
|
| Hospital Charge Code |
APRDRG3051
|
| Min. Negotiated Rate |
$14,950.34 |
| Max. Negotiated Rate |
$14,950.34 |
| Rate for Payer: AHCCCS Medicaid |
$14,950.34
|
| Rate for Payer: Allwell Medicaid |
$14,950.34
|
| Rate for Payer: AZCH Complete Medicaid |
$14,950.34
|
| Rate for Payer: Banner UC Health Medicaid |
$14,950.34
|
| Rate for Payer: Mercy Care Medicaid |
$14,950.34
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$14,950.34
|
|
|
Service Code
|
APR-DRG 3053
|
| Hospital Charge Code |
APRDRG3053
|
| Min. Negotiated Rate |
$14,950.34 |
| Max. Negotiated Rate |
$14,950.34 |
| Rate for Payer: AHCCCS Medicaid |
$14,950.34
|
| Rate for Payer: Allwell Medicaid |
$14,950.34
|
| Rate for Payer: AZCH Complete Medicaid |
$14,950.34
|
| Rate for Payer: Banner UC Health Medicaid |
$14,950.34
|
| Rate for Payer: Mercy Care Medicaid |
$14,950.34
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$9,240.95
|
|
|
Service Code
|
APR-DRG 3052
|
| Hospital Charge Code |
APRDRG3051
|
| Min. Negotiated Rate |
$9,240.95 |
| Max. Negotiated Rate |
$9,240.95 |
| Rate for Payer: AHCCCS Medicaid |
$9,240.95
|
| Rate for Payer: Allwell Medicaid |
$9,240.95
|
| Rate for Payer: AZCH Complete Medicaid |
$9,240.95
|
| Rate for Payer: Banner UC Health Medicaid |
$9,240.95
|
| Rate for Payer: Mercy Care Medicaid |
$9,240.95
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$9,240.95
|
|
|
Service Code
|
APR-DRG 3052
|
| Hospital Charge Code |
APRDRG3052
|
| Min. Negotiated Rate |
$9,240.95 |
| Max. Negotiated Rate |
$9,240.95 |
| Rate for Payer: AHCCCS Medicaid |
$9,240.95
|
| Rate for Payer: Allwell Medicaid |
$9,240.95
|
| Rate for Payer: AZCH Complete Medicaid |
$9,240.95
|
| Rate for Payer: Banner UC Health Medicaid |
$9,240.95
|
| Rate for Payer: Mercy Care Medicaid |
$9,240.95
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$9,240.95
|
|
|
Service Code
|
APR-DRG 3052
|
| Hospital Charge Code |
APRDRG3054
|
| Min. Negotiated Rate |
$9,240.95 |
| Max. Negotiated Rate |
$9,240.95 |
| Rate for Payer: AHCCCS Medicaid |
$9,240.95
|
| Rate for Payer: Allwell Medicaid |
$9,240.95
|
| Rate for Payer: AZCH Complete Medicaid |
$9,240.95
|
| Rate for Payer: Banner UC Health Medicaid |
$9,240.95
|
| Rate for Payer: Mercy Care Medicaid |
$9,240.95
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$6,739.05
|
|
|
Service Code
|
APR-DRG 3051
|
| Hospital Charge Code |
APRDRG3054
|
| Min. Negotiated Rate |
$6,739.05 |
| Max. Negotiated Rate |
$6,739.05 |
| Rate for Payer: AHCCCS Medicaid |
$6,739.05
|
| Rate for Payer: Allwell Medicaid |
$6,739.05
|
| Rate for Payer: AZCH Complete Medicaid |
$6,739.05
|
| Rate for Payer: Banner UC Health Medicaid |
$6,739.05
|
| Rate for Payer: Mercy Care Medicaid |
$6,739.05
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$29,803.89
|
|
|
Service Code
|
APR-DRG 3054
|
| Hospital Charge Code |
APRDRG3051
|
| Min. Negotiated Rate |
$29,803.89 |
| Max. Negotiated Rate |
$29,803.89 |
| Rate for Payer: AHCCCS Medicaid |
$29,803.89
|
| Rate for Payer: Allwell Medicaid |
$29,803.89
|
| Rate for Payer: AZCH Complete Medicaid |
$29,803.89
|
| Rate for Payer: Banner UC Health Medicaid |
$29,803.89
|
| Rate for Payer: Mercy Care Medicaid |
$29,803.89
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$29,803.89
|
|
|
Service Code
|
APR-DRG 3054
|
| Hospital Charge Code |
APRDRG3054
|
| Min. Negotiated Rate |
$29,803.89 |
| Max. Negotiated Rate |
$29,803.89 |
| Rate for Payer: AHCCCS Medicaid |
$29,803.89
|
| Rate for Payer: Allwell Medicaid |
$29,803.89
|
| Rate for Payer: AZCH Complete Medicaid |
$29,803.89
|
| Rate for Payer: Banner UC Health Medicaid |
$29,803.89
|
| Rate for Payer: Mercy Care Medicaid |
$29,803.89
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$29,803.89
|
|
|
Service Code
|
APR-DRG 3054
|
| Hospital Charge Code |
APRDRG3052
|
| Min. Negotiated Rate |
$29,803.89 |
| Max. Negotiated Rate |
$29,803.89 |
| Rate for Payer: AHCCCS Medicaid |
$29,803.89
|
| Rate for Payer: Allwell Medicaid |
$29,803.89
|
| Rate for Payer: AZCH Complete Medicaid |
$29,803.89
|
| Rate for Payer: Banner UC Health Medicaid |
$29,803.89
|
| Rate for Payer: Mercy Care Medicaid |
$29,803.89
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$29,803.89
|
|
|
Service Code
|
APR-DRG 3054
|
| Hospital Charge Code |
APRDRG3053
|
| Min. Negotiated Rate |
$29,803.89 |
| Max. Negotiated Rate |
$29,803.89 |
| Rate for Payer: AHCCCS Medicaid |
$29,803.89
|
| Rate for Payer: Allwell Medicaid |
$29,803.89
|
| Rate for Payer: AZCH Complete Medicaid |
$29,803.89
|
| Rate for Payer: Banner UC Health Medicaid |
$29,803.89
|
| Rate for Payer: Mercy Care Medicaid |
$29,803.89
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$9,240.95
|
|
|
Service Code
|
APR-DRG 3052
|
| Hospital Charge Code |
APRDRG3053
|
| Min. Negotiated Rate |
$9,240.95 |
| Max. Negotiated Rate |
$9,240.95 |
| Rate for Payer: AHCCCS Medicaid |
$9,240.95
|
| Rate for Payer: Allwell Medicaid |
$9,240.95
|
| Rate for Payer: AZCH Complete Medicaid |
$9,240.95
|
| Rate for Payer: Banner UC Health Medicaid |
$9,240.95
|
| Rate for Payer: Mercy Care Medicaid |
$9,240.95
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$6,739.05
|
|
|
Service Code
|
APR-DRG 3051
|
| Hospital Charge Code |
APRDRG3052
|
| Min. Negotiated Rate |
$6,739.05 |
| Max. Negotiated Rate |
$6,739.05 |
| Rate for Payer: AHCCCS Medicaid |
$6,739.05
|
| Rate for Payer: Allwell Medicaid |
$6,739.05
|
| Rate for Payer: AZCH Complete Medicaid |
$6,739.05
|
| Rate for Payer: Banner UC Health Medicaid |
$6,739.05
|
| Rate for Payer: Mercy Care Medicaid |
$6,739.05
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$14,950.34
|
|
|
Service Code
|
APR-DRG 3053
|
| Hospital Charge Code |
APRDRG3052
|
| Min. Negotiated Rate |
$14,950.34 |
| Max. Negotiated Rate |
$14,950.34 |
| Rate for Payer: AHCCCS Medicaid |
$14,950.34
|
| Rate for Payer: Allwell Medicaid |
$14,950.34
|
| Rate for Payer: AZCH Complete Medicaid |
$14,950.34
|
| Rate for Payer: Banner UC Health Medicaid |
$14,950.34
|
| Rate for Payer: Mercy Care Medicaid |
$14,950.34
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$14,950.34
|
|
|
Service Code
|
APR-DRG 3053
|
| Hospital Charge Code |
APRDRG3054
|
| Min. Negotiated Rate |
$14,950.34 |
| Max. Negotiated Rate |
$14,950.34 |
| Rate for Payer: AHCCCS Medicaid |
$14,950.34
|
| Rate for Payer: Allwell Medicaid |
$14,950.34
|
| Rate for Payer: AZCH Complete Medicaid |
$14,950.34
|
| Rate for Payer: Banner UC Health Medicaid |
$14,950.34
|
| Rate for Payer: Mercy Care Medicaid |
$14,950.34
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$6,739.05
|
|
|
Service Code
|
APR-DRG 3051
|
| Hospital Charge Code |
APRDRG3053
|
| Min. Negotiated Rate |
$6,739.05 |
| Max. Negotiated Rate |
$6,739.05 |
| Rate for Payer: AHCCCS Medicaid |
$6,739.05
|
| Rate for Payer: Allwell Medicaid |
$6,739.05
|
| Rate for Payer: AZCH Complete Medicaid |
$6,739.05
|
| Rate for Payer: Banner UC Health Medicaid |
$6,739.05
|
| Rate for Payer: Mercy Care Medicaid |
$6,739.05
|
|
|
Amputation Of Lower Limb Except Toes
|
Facility
|
IP
|
$6,739.05
|
|
|
Service Code
|
APR-DRG 3051
|
| Hospital Charge Code |
APRDRG3051
|
| Min. Negotiated Rate |
$6,739.05 |
| Max. Negotiated Rate |
$6,739.05 |
| Rate for Payer: AHCCCS Medicaid |
$6,739.05
|
| Rate for Payer: Allwell Medicaid |
$6,739.05
|
| Rate for Payer: AZCH Complete Medicaid |
$6,739.05
|
| Rate for Payer: Banner UC Health Medicaid |
$6,739.05
|
| Rate for Payer: Mercy Care Medicaid |
$6,739.05
|
|
|
AMPUTATION TOE; INTERPHALANGEAL JOINT - Tech
|
Facility
|
OP
|
$1,802.00
|
|
|
Service Code
|
CPT 28825
|
| Hospital Charge Code |
24043304
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$270.30 |
| Max. Negotiated Rate |
$4,104.08 |
| Rate for Payer: Aetna of AZ Commercial |
$1,621.80
|
| Rate for Payer: Aetna of AZ Medicare |
$504.56
|
| Rate for Payer: AHCCCS Medicaid |
$4,104.08
|
| Rate for Payer: Allwell Medicaid |
$4,104.08
|
| Rate for Payer: Allwell Medicare |
$270.30
|
| Rate for Payer: Amerigroup Medicare |
$270.30
|
| Rate for Payer: APIPA Medicare/Medicaid |
$673.05
|
| Rate for Payer: AZCH Complete Medicaid |
$4,104.08
|
| Rate for Payer: AZCH Complete Medicare |
$270.30
|
| Rate for Payer: Banner UC Health Medicaid |
$4,104.08
|
| Rate for Payer: Banner UC Health Medicare |
$270.30
|
| Rate for Payer: Bisbee Police All Plans |
$468.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,225.36
|
| Rate for Payer: Cash Price |
$1,441.60
|
| Rate for Payer: Cash Price |
$1,441.60
|
| Rate for Payer: Cigna of AZ Commercial |
$901.00
|
| Rate for Payer: Copperpoint Commercial |
$446.00
|
| Rate for Payer: Health Net of AZ Commercial |
$1,081.20
|
| Rate for Payer: Health Net of AZ Medicare |
$504.56
|
| Rate for Payer: Humana of AZ Medicare |
$270.30
|
| Rate for Payer: Mercy Care Medicaid |
$4,104.08
|
| Rate for Payer: Self Pay Self Pay |
$1,441.60
|
| Rate for Payer: TriWest Medicare |
$270.30
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,373.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$324.36
|
|
|
AMPUTATION TOE; INTERPHALANGEAL JOINT - Tech
|
Facility
|
IP
|
$1,802.00
|
|
|
Service Code
|
CPT 28825
|
| Hospital Charge Code |
24043304
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$468.52 |
| Max. Negotiated Rate |
$1,621.80 |
| Rate for Payer: Aetna of AZ Commercial |
$1,621.80
|
| Rate for Payer: Bisbee Police All Plans |
$468.52
|
| Rate for Payer: Cash Price |
$1,441.60
|
| Rate for Payer: Self Pay Self Pay |
$1,441.60
|
|
|
AMPUTATION TOE; METATARSOPHALANGEAL JOINT
|
Facility
|
OP
|
$1,917.00
|
|
|
Service Code
|
CPT 28820
|
| Hospital Charge Code |
24043303
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$287.55 |
| Max. Negotiated Rate |
$4,104.08 |
| Rate for Payer: Aetna of AZ Commercial |
$1,725.30
|
| Rate for Payer: Aetna of AZ Medicare |
$536.76
|
| Rate for Payer: AHCCCS Medicaid |
$4,104.08
|
| Rate for Payer: Allwell Medicaid |
$4,104.08
|
| Rate for Payer: Allwell Medicare |
$287.55
|
| Rate for Payer: Amerigroup Medicare |
$287.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$716.00
|
| Rate for Payer: AZCH Complete Medicaid |
$4,104.08
|
| Rate for Payer: AZCH Complete Medicare |
$287.55
|
| Rate for Payer: Banner UC Health Medicaid |
$4,104.08
|
| Rate for Payer: Banner UC Health Medicare |
$287.55
|
| Rate for Payer: Bisbee Police All Plans |
$498.42
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,303.56
|
| Rate for Payer: Cash Price |
$1,533.60
|
| Rate for Payer: Cash Price |
$1,533.60
|
| Rate for Payer: Cigna of AZ Commercial |
$958.50
|
| Rate for Payer: Copperpoint Commercial |
$474.46
|
| Rate for Payer: Health Net of AZ Commercial |
$1,150.20
|
| Rate for Payer: Health Net of AZ Medicare |
$536.76
|
| Rate for Payer: Humana of AZ Medicare |
$287.55
|
| Rate for Payer: Mercy Care Medicaid |
$4,104.08
|
| Rate for Payer: Self Pay Self Pay |
$1,533.60
|
| Rate for Payer: TriWest Medicare |
$287.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,373.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$345.06
|
|
|
AMPUTATION TOE; METATARSOPHALANGEAL JOINT
|
Facility
|
IP
|
$1,917.00
|
|
|
Service Code
|
CPT 28820
|
| Hospital Charge Code |
24043303
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$498.42 |
| Max. Negotiated Rate |
$1,725.30 |
| Rate for Payer: Aetna of AZ Commercial |
$1,725.30
|
| Rate for Payer: Bisbee Police All Plans |
$498.42
|
| Rate for Payer: Cash Price |
$1,533.60
|
| Rate for Payer: Self Pay Self Pay |
$1,533.60
|
|
