Allogeneic Bone Marrow Transplant
|
Facility
|
IP
|
$137,807.57
|
|
Service Code
|
APR-DRG 0074
|
Hospital Charge Code |
APRDRG0073
|
Min. Negotiated Rate |
$137,807.57 |
Max. Negotiated Rate |
$137,807.57 |
Rate for Payer: AHCCCS Medicaid |
$137,807.57
|
Rate for Payer: Allwell Medicaid |
$137,807.57
|
Rate for Payer: AZCH Complete Medicaid |
$137,807.57
|
Rate for Payer: Banner UC Health Medicaid |
$137,807.57
|
Rate for Payer: Mercy Care Medicaid |
$137,807.57
|
|
allopurinol 100 mg Tab [CQCH]
|
Facility
|
IP
|
$0.26
|
|
Service Code
|
NDC 51079020520
|
Hospital Charge Code |
105909905
|
Hospital Revenue Code
|
251
|
Min. Negotiated Rate |
$0.07 |
Max. Negotiated Rate |
$0.23 |
Rate for Payer: Aetna of AZ Commercial |
$0.23
|
Rate for Payer: Bisbee Police All Plans |
$0.07
|
Rate for Payer: Cash Price |
$0.21
|
Rate for Payer: Self Pay Self Pay |
$0.21
|
|
allopurinol 100 mg Tab [CQCH]
|
Facility
|
OP
|
$0.26
|
|
Service Code
|
NDC 51079020520
|
Hospital Charge Code |
105909905
|
Hospital Revenue Code
|
251
|
Min. Negotiated Rate |
$0.04 |
Max. Negotiated Rate |
$0.23 |
Rate for Payer: Aetna of AZ Commercial |
$0.23
|
Rate for Payer: Aetna of AZ Medicare |
$0.07
|
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 |
$0.21
|
Rate for Payer: Cigna of AZ Commercial |
$0.17
|
Rate for Payer: Copperpoint Commercial |
$0.06
|
Rate for Payer: Health Net of AZ Commercial |
$0.16
|
Rate for Payer: Health Net of AZ Medicare |
$0.07
|
Rate for Payer: Humana of AZ Medicare |
$0.04
|
Rate for Payer: Self Pay Self Pay |
$0.21
|
Rate for Payer: TriWest Medicare |
$0.04
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.15
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.05
|
|
ALPHA-1-ANTITRYPSIN (PROTEIN) BLOOD TEST, PHENOTYPE
|
Facility
|
OP
|
$72.25
|
|
Service Code
|
CPT 82104
|
Hospital Charge Code |
28008412
|
Hospital Revenue Code
|
302
|
Min. Negotiated Rate |
$11.56 |
Max. Negotiated Rate |
$65.03 |
Rate for Payer: Aetna of AZ Commercial |
$65.03
|
Rate for Payer: Aetna of AZ Medicare |
$20.23
|
Rate for Payer: Allwell Medicare |
$11.56
|
Rate for Payer: Amerigroup Medicare |
$11.56
|
Rate for Payer: APIPA Medicare/Medicaid |
$26.99
|
Rate for Payer: AZCH Complete Medicare |
$11.56
|
Rate for Payer: Banner UC Health Medicare |
$11.56
|
Rate for Payer: Bisbee Police All Plans |
$18.79
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$49.13
|
Rate for Payer: Cash Price |
$57.80
|
Rate for Payer: Cigna of AZ Commercial |
$46.96
|
Rate for Payer: Copperpoint Commercial |
$17.88
|
Rate for Payer: Health Net of AZ Commercial |
$43.35
|
Rate for Payer: Health Net of AZ Medicare |
$20.23
|
Rate for Payer: Humana of AZ Medicare |
$11.56
|
Rate for Payer: Self Pay Self Pay |
$57.80
|
Rate for Payer: TriWest Medicare |
$11.56
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$42.12
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$13.01
|
|
ALPHA-1-ANTITRYPSIN (PROTEIN) BLOOD TEST, PHENOTYPE
|
Facility
|
IP
|
$72.25
|
|
Service Code
|
CPT 82104
|
Hospital Charge Code |
28008412
|
Hospital Revenue Code
|
302
|
Min. Negotiated Rate |
$18.79 |
Max. Negotiated Rate |
$65.03 |
Rate for Payer: Aetna of AZ Commercial |
$65.03
|
Rate for Payer: Bisbee Police All Plans |
$18.79
|
Rate for Payer: Cash Price |
$57.80
|
Rate for Payer: Self Pay Self Pay |
$57.80
|
|
Alpha-1-Antitrypsin, Serum LC
|
Facility
|
OP
|
$172.00
|
|
Service Code
|
CPT 82103
|
Hospital Charge Code |
1905910
|
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
|
|
Alpha-1-Antitrypsin, Serum LC
|
Facility
|
IP
|
$172.00
|
|
Service Code
|
CPT 82103
|
Hospital Charge Code |
1905910
|
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
|
|
ALPRAZolam 0.25 mg Oral DIS Tab [CQCH]
|
Facility
|
IP
|
$0.75
|
|
Service Code
|
NDC 49884011074
|
Hospital Charge Code |
205191087
|
Hospital Revenue Code
|
251
|
Min. Negotiated Rate |
$0.20 |
Max. Negotiated Rate |
$0.68 |
Rate for Payer: Aetna of AZ Commercial |
$0.68
|
Rate for Payer: Bisbee Police All Plans |
$0.20
|
Rate for Payer: Cash Price |
$0.60
|
Rate for Payer: Self Pay Self Pay |
$0.60
|
|
ALPRAZolam 0.25 mg Oral DIS Tab [CQCH]
|
Facility
|
OP
|
$0.75
|
|
Service Code
|
NDC 49884011074
|
Hospital Charge Code |
205191087
|
Hospital Revenue Code
|
251
|
Min. Negotiated Rate |
$0.12 |
Max. Negotiated Rate |
$0.68 |
Rate for Payer: Aetna of AZ Commercial |
$0.68
|
Rate for Payer: Aetna of AZ Medicare |
$0.21
|
Rate for Payer: Allwell Medicare |
$0.12
|
Rate for Payer: Amerigroup Medicare |
$0.12
|
Rate for Payer: APIPA Medicare/Medicaid |
$0.28
|
Rate for Payer: AZCH Complete Medicare |
$0.12
|
Rate for Payer: Banner UC Health Medicare |
$0.12
|
Rate for Payer: Bisbee Police All Plans |
$0.20
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.51
|
Rate for Payer: Cash Price |
$0.60
|
Rate for Payer: Cigna of AZ Commercial |
$0.49
|
Rate for Payer: Copperpoint Commercial |
$0.19
|
Rate for Payer: Health Net of AZ Commercial |
$0.45
|
Rate for Payer: Health Net of AZ Medicare |
$0.21
|
Rate for Payer: Humana of AZ Medicare |
$0.12
|
Rate for Payer: Self Pay Self Pay |
$0.60
|
Rate for Payer: TriWest Medicare |
$0.12
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.44
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.14
|
|
ALPRAZolam 1 mg Tab [CQCH]
|
Facility
|
OP
|
$0.06
|
|
Service Code
|
NDC 904586061
|
Hospital Charge Code |
105910004
|
Hospital Revenue Code
|
251
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.05 |
Rate for Payer: Aetna of AZ Commercial |
$0.05
|
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 |
$0.02
|
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 |
$0.04
|
Rate for Payer: Cash Price |
$0.05
|
Rate for Payer: Cigna of AZ Commercial |
$0.04
|
Rate for Payer: Copperpoint Commercial |
$0.01
|
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 |
$0.05
|
Rate for Payer: TriWest Medicare |
$0.01
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.03
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.01
|
|
ALPRAZolam 1 mg Tab [CQCH]
|
Facility
|
IP
|
$0.06
|
|
Service Code
|
NDC 904586061
|
Hospital Charge Code |
105910004
|
Hospital Revenue Code
|
251
|
Min. Negotiated Rate |
$0.02 |
Max. Negotiated Rate |
$0.05 |
Rate for Payer: Aetna of AZ Commercial |
$0.05
|
Rate for Payer: Bisbee Police All Plans |
$0.02
|
Rate for Payer: Cash Price |
$0.05
|
Rate for Payer: Self Pay Self Pay |
$0.05
|
|
alteplase 100 mg IV Inj [CQCH]
|
Facility
|
OP
|
$9,069.76
|
|
Service Code
|
HCPCS J2997
|
Hospital Charge Code |
105910209
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$1,451.16 |
Max. Negotiated Rate |
$8,162.78 |
Rate for Payer: Aetna of AZ Commercial |
$8,162.78
|
Rate for Payer: Aetna of AZ Medicare |
$2,539.53
|
Rate for Payer: Allwell Medicare |
$1,451.16
|
Rate for Payer: Amerigroup Medicare |
$1,451.16
|
Rate for Payer: APIPA Medicare/Medicaid |
$3,387.56
|
Rate for Payer: AZCH Complete Medicare |
$1,451.16
|
Rate for Payer: Banner UC Health Medicare |
$1,451.16
|
Rate for Payer: Bisbee Police All Plans |
$2,358.14
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$6,167.44
|
Rate for Payer: Cash Price |
$7,255.81
|
Rate for Payer: Cigna of AZ Commercial |
$6,348.83
|
Rate for Payer: Copperpoint Commercial |
$2,244.77
|
Rate for Payer: Health Net of AZ Commercial |
$5,441.86
|
Rate for Payer: Health Net of AZ Medicare |
$2,539.53
|
Rate for Payer: Humana of AZ Medicare |
$1,451.16
|
Rate for Payer: Self Pay Self Pay |
$7,255.81
|
Rate for Payer: TriWest Medicare |
$1,451.16
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$5,287.67
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$1,632.56
|
|
alteplase 100 mg IV Inj [CQCH]
|
Facility
|
IP
|
$9,069.76
|
|
Service Code
|
HCPCS J2997
|
Hospital Charge Code |
105910209
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$2,358.14 |
Max. Negotiated Rate |
$8,162.78 |
Rate for Payer: Aetna of AZ Commercial |
$8,162.78
|
Rate for Payer: Bisbee Police All Plans |
$2,358.14
|
Rate for Payer: Cash Price |
$7,255.81
|
Rate for Payer: Self Pay Self Pay |
$7,255.81
|
|
alteplase 2 mg IV Inj [CQCH]
|
Facility
|
OP
|
$149.62
|
|
Service Code
|
HCPCS J2997
|
Hospital Charge Code |
105910142
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$23.94 |
Max. Negotiated Rate |
$134.66 |
Rate for Payer: Aetna of AZ Commercial |
$134.66
|
Rate for Payer: Aetna of AZ Medicare |
$41.89
|
Rate for Payer: Allwell Medicare |
$23.94
|
Rate for Payer: Amerigroup Medicare |
$23.94
|
Rate for Payer: APIPA Medicare/Medicaid |
$55.88
|
Rate for Payer: AZCH Complete Medicare |
$23.94
|
Rate for Payer: Banner UC Health Medicare |
$23.94
|
Rate for Payer: Bisbee Police All Plans |
$38.90
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$101.74
|
Rate for Payer: Cash Price |
$119.70
|
Rate for Payer: Cigna of AZ Commercial |
$97.25
|
Rate for Payer: Copperpoint Commercial |
$37.03
|
Rate for Payer: Health Net of AZ Commercial |
$89.77
|
Rate for Payer: Health Net of AZ Medicare |
$41.89
|
Rate for Payer: Humana of AZ Medicare |
$23.94
|
Rate for Payer: Self Pay Self Pay |
$119.70
|
Rate for Payer: TriWest Medicare |
$23.94
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$87.23
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$26.93
|
|
alteplase 2 mg IV Inj [CQCH]
|
Facility
|
IP
|
$149.62
|
|
Service Code
|
HCPCS J2997
|
Hospital Charge Code |
105910142
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$38.90 |
Max. Negotiated Rate |
$134.66 |
Rate for Payer: Aetna of AZ Commercial |
$134.66
|
Rate for Payer: Bisbee Police All Plans |
$38.90
|
Rate for Payer: Cash Price |
$119.70
|
Rate for Payer: Self Pay Self Pay |
$119.70
|
|
alteplase 50 mg REC[CQCH]
|
Facility
|
OP
|
$4,026.16
|
|
Service Code
|
HCPCS J2997
|
Hospital Charge Code |
193296755
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$644.19 |
Max. Negotiated Rate |
$3,623.54 |
Rate for Payer: Aetna of AZ Commercial |
$3,623.54
|
Rate for Payer: Aetna of AZ Medicare |
$1,127.32
|
Rate for Payer: Allwell Medicare |
$644.19
|
Rate for Payer: Amerigroup Medicare |
$644.19
|
Rate for Payer: APIPA Medicare/Medicaid |
$1,503.77
|
Rate for Payer: AZCH Complete Medicare |
$644.19
|
Rate for Payer: Banner UC Health Medicare |
$644.19
|
Rate for Payer: Bisbee Police All Plans |
$1,046.80
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2,737.79
|
Rate for Payer: Cash Price |
$3,220.93
|
Rate for Payer: Cigna of AZ Commercial |
$2,818.31
|
Rate for Payer: Copperpoint Commercial |
$996.47
|
Rate for Payer: Health Net of AZ Commercial |
$2,415.70
|
Rate for Payer: Health Net of AZ Medicare |
$1,127.32
|
Rate for Payer: Humana of AZ Medicare |
$644.19
|
Rate for Payer: Self Pay Self Pay |
$3,220.93
|
Rate for Payer: TriWest Medicare |
$644.19
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,347.25
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$724.71
|
|
alteplase 50 mg REC[CQCH]
|
Facility
|
IP
|
$4,026.16
|
|
Service Code
|
HCPCS J2997
|
Hospital Charge Code |
193296755
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$1,046.80 |
Max. Negotiated Rate |
$3,623.54 |
Rate for Payer: Aetna of AZ Commercial |
$3,623.54
|
Rate for Payer: Bisbee Police All Plans |
$1,046.80
|
Rate for Payer: Cash Price |
$3,220.93
|
Rate for Payer: Self Pay Self Pay |
$3,220.93
|
|
Alteration In Consciousness
|
Facility
|
IP
|
$4,524.03
|
|
Service Code
|
APR-DRG 0522
|
Hospital Charge Code |
APRDRG0524
|
Min. Negotiated Rate |
$4,524.03 |
Max. Negotiated Rate |
$4,524.03 |
Rate for Payer: AHCCCS Medicaid |
$4,524.03
|
Rate for Payer: Allwell Medicaid |
$4,524.03
|
Rate for Payer: AZCH Complete Medicaid |
$4,524.03
|
Rate for Payer: Banner UC Health Medicaid |
$4,524.03
|
Rate for Payer: Mercy Care Medicaid |
$4,524.03
|
|
Alteration In Consciousness
|
Facility
|
IP
|
$5,836.35
|
|
Service Code
|
APR-DRG 0523
|
Hospital Charge Code |
APRDRG0524
|
Min. Negotiated Rate |
$5,836.35 |
Max. Negotiated Rate |
$5,836.35 |
Rate for Payer: AHCCCS Medicaid |
$5,836.35
|
Rate for Payer: Allwell Medicaid |
$5,836.35
|
Rate for Payer: AZCH Complete Medicaid |
$5,836.35
|
Rate for Payer: Banner UC Health Medicaid |
$5,836.35
|
Rate for Payer: Mercy Care Medicaid |
$5,836.35
|
|
Alteration In Consciousness
|
Facility
|
IP
|
$5,836.35
|
|
Service Code
|
APR-DRG 0523
|
Hospital Charge Code |
APRDRG0523
|
Min. Negotiated Rate |
$5,836.35 |
Max. Negotiated Rate |
$5,836.35 |
Rate for Payer: AHCCCS Medicaid |
$5,836.35
|
Rate for Payer: Allwell Medicaid |
$5,836.35
|
Rate for Payer: AZCH Complete Medicaid |
$5,836.35
|
Rate for Payer: Banner UC Health Medicaid |
$5,836.35
|
Rate for Payer: Mercy Care Medicaid |
$5,836.35
|
|
Alteration In Consciousness
|
Facility
|
IP
|
$5,836.35
|
|
Service Code
|
APR-DRG 0523
|
Hospital Charge Code |
APRDRG0522
|
Min. Negotiated Rate |
$5,836.35 |
Max. Negotiated Rate |
$5,836.35 |
Rate for Payer: AHCCCS Medicaid |
$5,836.35
|
Rate for Payer: Allwell Medicaid |
$5,836.35
|
Rate for Payer: AZCH Complete Medicaid |
$5,836.35
|
Rate for Payer: Banner UC Health Medicaid |
$5,836.35
|
Rate for Payer: Mercy Care Medicaid |
$5,836.35
|
|
Alteration In Consciousness
|
Facility
|
IP
|
$13,677.30
|
|
Service Code
|
APR-DRG 0524
|
Hospital Charge Code |
APRDRG0524
|
Min. Negotiated Rate |
$13,677.30 |
Max. Negotiated Rate |
$13,677.30 |
Rate for Payer: AHCCCS Medicaid |
$13,677.30
|
Rate for Payer: Allwell Medicaid |
$13,677.30
|
Rate for Payer: AZCH Complete Medicaid |
$13,677.30
|
Rate for Payer: Banner UC Health Medicaid |
$13,677.30
|
Rate for Payer: Mercy Care Medicaid |
$13,677.30
|
|
Alteration In Consciousness
|
Facility
|
IP
|
$13,677.30
|
|
Service Code
|
APR-DRG 0524
|
Hospital Charge Code |
APRDRG0521
|
Min. Negotiated Rate |
$13,677.30 |
Max. Negotiated Rate |
$13,677.30 |
Rate for Payer: AHCCCS Medicaid |
$13,677.30
|
Rate for Payer: Allwell Medicaid |
$13,677.30
|
Rate for Payer: AZCH Complete Medicaid |
$13,677.30
|
Rate for Payer: Banner UC Health Medicaid |
$13,677.30
|
Rate for Payer: Mercy Care Medicaid |
$13,677.30
|
|
Alteration In Consciousness
|
Facility
|
IP
|
$4,524.03
|
|
Service Code
|
APR-DRG 0522
|
Hospital Charge Code |
APRDRG0523
|
Min. Negotiated Rate |
$4,524.03 |
Max. Negotiated Rate |
$4,524.03 |
Rate for Payer: AHCCCS Medicaid |
$4,524.03
|
Rate for Payer: Allwell Medicaid |
$4,524.03
|
Rate for Payer: AZCH Complete Medicaid |
$4,524.03
|
Rate for Payer: Banner UC Health Medicaid |
$4,524.03
|
Rate for Payer: Mercy Care Medicaid |
$4,524.03
|
|
Alteration In Consciousness
|
Facility
|
IP
|
$13,677.30
|
|
Service Code
|
APR-DRG 0524
|
Hospital Charge Code |
APRDRG0523
|
Min. Negotiated Rate |
$13,677.30 |
Max. Negotiated Rate |
$13,677.30 |
Rate for Payer: AHCCCS Medicaid |
$13,677.30
|
Rate for Payer: Allwell Medicaid |
$13,677.30
|
Rate for Payer: AZCH Complete Medicaid |
$13,677.30
|
Rate for Payer: Banner UC Health Medicaid |
$13,677.30
|
Rate for Payer: Mercy Care Medicaid |
$13,677.30
|
|