|
ampicillin 1 g Inj [CQCH]
|
Facility
|
OP
|
$1.62
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
105911094
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Aetna of AZ Commercial |
$1.46
|
| Rate for Payer: Aetna of AZ Medicare |
$0.45
|
| Rate for Payer: Allwell Medicare |
$0.26
|
| Rate for Payer: Amerigroup Medicare |
$0.26
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.61
|
| Rate for Payer: AZCH Complete Medicare |
$0.26
|
| Rate for Payer: Banner UC Health Medicare |
$0.26
|
| Rate for Payer: Bisbee Police All Plans |
$0.42
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.10
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Cigna of AZ Commercial |
$1.05
|
| Rate for Payer: Copperpoint Commercial |
$0.40
|
| Rate for Payer: Health Net of AZ Commercial |
$0.97
|
| Rate for Payer: Health Net of AZ Medicare |
$0.45
|
| Rate for Payer: Humana of AZ Medicare |
$0.26
|
| Rate for Payer: Self Pay Self Pay |
$1.30
|
| Rate for Payer: TriWest Medicare |
$0.26
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.94
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.29
|
|
|
ampicillin 1 g Inj [CQCH]
|
Facility
|
IP
|
$1.62
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
105911094
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.46 |
| Rate for Payer: Aetna of AZ Commercial |
$1.46
|
| Rate for Payer: Bisbee Police All Plans |
$0.42
|
| Rate for Payer: Cash Price |
$1.29
|
| Rate for Payer: Self Pay Self Pay |
$1.30
|
|
|
ampicillin-sulbactam 1 .5 g Inj [CQCH]
|
Facility
|
IP
|
$1.49
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
105911169
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of AZ Commercial |
$1.34
|
| Rate for Payer: Bisbee Police All Plans |
$0.39
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Self Pay Self Pay |
$1.19
|
|
|
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 |
$0.24 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna of AZ Commercial |
$1.34
|
| Rate for Payer: Aetna of AZ Medicare |
$0.42
|
| Rate for Payer: Allwell Medicare |
$0.24
|
| Rate for Payer: Amerigroup Medicare |
$0.24
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.56
|
| Rate for Payer: AZCH Complete Medicare |
$0.24
|
| Rate for Payer: Banner UC Health Medicare |
$0.24
|
| 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: 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 |
$0.24
|
| Rate for Payer: Self Pay Self Pay |
$1.19
|
| Rate for Payer: TriWest Medicare |
$0.24
|
| 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
|
OP
|
$5.20
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
105911242
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.83 |
| 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: Allwell Medicare |
$0.83
|
| Rate for Payer: Amerigroup Medicare |
$0.83
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1.94
|
| Rate for Payer: AZCH Complete Medicare |
$0.83
|
| Rate for Payer: Banner UC Health Medicare |
$0.83
|
| 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: 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 |
$0.83
|
| Rate for Payer: Self Pay Self Pay |
$4.16
|
| Rate for Payer: TriWest Medicare |
$0.83
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3.03
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.94
|
|
|
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
|
|
|
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 |
$333.76 |
| Max. Negotiated Rate |
$3,373.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,877.40
|
| Rate for Payer: Aetna of AZ Medicare |
$584.08
|
| Rate for Payer: AHCCCS Medicaid |
$2,052.04
|
| Rate for Payer: Allwell Medicaid |
$2,052.04
|
| Rate for Payer: Allwell Medicare |
$333.76
|
| Rate for Payer: Amerigroup Medicare |
$333.76
|
| Rate for Payer: APIPA Medicare/Medicaid |
$779.12
|
| Rate for Payer: AZCH Complete Medicaid |
$2,052.04
|
| Rate for Payer: AZCH Complete Medicare |
$333.76
|
| Rate for Payer: Banner UC Health Medicaid |
$2,052.04
|
| Rate for Payer: Banner UC Health Medicare |
$333.76
|
| 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 |
$333.76
|
| Rate for Payer: Mercy Care Medicaid |
$2,052.04
|
| Rate for Payer: Self Pay Self Pay |
$1,668.80
|
| Rate for Payer: TriWest Medicare |
$333.76
|
| 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
|
$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 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
|
$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
|
$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
|
$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
|
$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
|
$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
|
$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
|
$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
|
$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
|
$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
|
$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 |
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
|
$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
|
$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
|
|
|
AMS 65ML RESERVOIR
|
Facility
|
IP
|
$6,130.00
|
|
| Hospital Charge Code |
22354149
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,593.80 |
| Max. Negotiated Rate |
$5,517.00 |
| Rate for Payer: Aetna of AZ Commercial |
$5,517.00
|
| Rate for Payer: Bisbee Police All Plans |
$1,593.80
|
| Rate for Payer: Cash Price |
$4,904.00
|
| Rate for Payer: Self Pay Self Pay |
$4,904.00
|
|
