|
apixaban 5 mg Tab UD[CQCH]
|
Facility
|
IP
|
$5.47
|
|
|
Service Code
|
NDC 3089431
|
| Hospital Charge Code |
130114009
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$4.92 |
| Rate for Payer: Aetna of AZ Commercial |
$4.92
|
| Rate for Payer: Bisbee Police All Plans |
$1.42
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Self Pay Self Pay |
$4.38
|
|
|
apixaban 5 mg Tab UD[CQCH]
|
Facility
|
OP
|
$5.47
|
|
|
Service Code
|
NDC 3089431
|
| Hospital Charge Code |
130114009
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$4.92 |
| Rate for Payer: Aetna of AZ Commercial |
$4.92
|
| Rate for Payer: Aetna of AZ Medicare |
$1.53
|
| Rate for Payer: Allwell Medicare |
$0.82
|
| Rate for Payer: Amerigroup Medicare |
$0.82
|
| Rate for Payer: APIPA Medicare/Medicaid |
$2.04
|
| Rate for Payer: AZCH Complete Medicare |
$0.82
|
| Rate for Payer: Banner UC Health Medicare |
$0.82
|
| Rate for Payer: Bisbee Police All Plans |
$1.42
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$3.72
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Cigna of AZ Commercial |
$3.56
|
| Rate for Payer: Copperpoint Commercial |
$1.35
|
| Rate for Payer: Health Net of AZ Commercial |
$3.28
|
| Rate for Payer: Health Net of AZ Medicare |
$1.53
|
| Rate for Payer: Humana of AZ Medicare |
$0.82
|
| Rate for Payer: Self Pay Self Pay |
$4.38
|
| Rate for Payer: TriWest Medicare |
$0.82
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3.19
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.98
|
|
|
APLIGRAF 44 SQ CM
|
Facility
|
OP
|
$3,713.00
|
|
| Hospital Charge Code |
22354189
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$556.95 |
| Max. Negotiated Rate |
$3,341.70 |
| Rate for Payer: Aetna of AZ Commercial |
$3,341.70
|
| Rate for Payer: Aetna of AZ Medicare |
$1,039.64
|
| Rate for Payer: Allwell Medicare |
$556.95
|
| Rate for Payer: Amerigroup Medicare |
$556.95
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,386.81
|
| Rate for Payer: AZCH Complete Medicare |
$556.95
|
| Rate for Payer: Banner UC Health Medicare |
$556.95
|
| Rate for Payer: Bisbee Police All Plans |
$965.38
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2,524.84
|
| Rate for Payer: Cash Price |
$2,970.40
|
| Rate for Payer: Cigna of AZ Commercial |
$2,599.10
|
| Rate for Payer: Copperpoint Commercial |
$918.97
|
| Rate for Payer: Health Net of AZ Commercial |
$2,227.80
|
| Rate for Payer: Health Net of AZ Medicare |
$1,039.64
|
| Rate for Payer: Humana of AZ Medicare |
$556.95
|
| Rate for Payer: Self Pay Self Pay |
$2,970.40
|
| Rate for Payer: TriWest Medicare |
$556.95
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,164.68
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$668.34
|
|
|
APLIGRAF 44 SQ CM
|
Facility
|
IP
|
$3,713.00
|
|
| Hospital Charge Code |
22354189
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$965.38 |
| Max. Negotiated Rate |
$3,341.70 |
| Rate for Payer: Aetna of AZ Commercial |
$3,341.70
|
| Rate for Payer: Bisbee Police All Plans |
$965.38
|
| Rate for Payer: Cash Price |
$2,970.40
|
| Rate for Payer: Self Pay Self Pay |
$2,970.40
|
|
|
APLIGRAF, PER SQUARE CENTIMETER
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
24049285
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.60 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna of AZ Commercial |
$147.60
|
| Rate for Payer: Aetna of AZ Medicare |
$45.92
|
| Rate for Payer: AHCCCS Medicaid |
$57.68
|
| Rate for Payer: Allwell Medicaid |
$57.68
|
| Rate for Payer: Allwell Medicare |
$24.60
|
| Rate for Payer: Amerigroup Medicare |
$24.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$61.25
|
| Rate for Payer: AZCH Complete Medicaid |
$57.68
|
| Rate for Payer: AZCH Complete Medicare |
$24.60
|
| Rate for Payer: Banner UC Health Medicaid |
$57.68
|
| Rate for Payer: Banner UC Health Medicare |
$24.60
|
| Rate for Payer: Bisbee Police All Plans |
$42.64
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$111.52
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Cigna of AZ Commercial |
$114.80
|
| Rate for Payer: Copperpoint Commercial |
$40.59
|
| Rate for Payer: Health Net of AZ Commercial |
$98.40
|
| Rate for Payer: Health Net of AZ Medicare |
$45.92
|
| Rate for Payer: Humana of AZ Medicare |
$24.60
|
| Rate for Payer: Mercy Care Medicaid |
$57.68
|
| Rate for Payer: Self Pay Self Pay |
$131.20
|
| Rate for Payer: TriWest Medicare |
$24.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$95.61
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$29.52
|
|
|
APLIGRAF, PER SQUARE CENTIMETER
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
24049285
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.64 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna of AZ Commercial |
$147.60
|
| Rate for Payer: Bisbee Police All Plans |
$42.64
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Self Pay Self Pay |
$131.20
|
|
|
APLIGRAPH
|
Facility
|
OP
|
$231.82
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
24358081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.77 |
| Max. Negotiated Rate |
$208.64 |
| Rate for Payer: Aetna of AZ Commercial |
$208.64
|
| Rate for Payer: Aetna of AZ Medicare |
$64.91
|
| Rate for Payer: AHCCCS Medicaid |
$57.68
|
| Rate for Payer: Allwell Medicaid |
$57.68
|
| Rate for Payer: Allwell Medicare |
$34.77
|
| Rate for Payer: Amerigroup Medicare |
$34.77
|
| Rate for Payer: APIPA Medicare/Medicaid |
$86.58
|
| Rate for Payer: AZCH Complete Medicaid |
$57.68
|
| Rate for Payer: AZCH Complete Medicare |
$34.77
|
| Rate for Payer: Banner UC Health Medicaid |
$57.68
|
| Rate for Payer: Banner UC Health Medicare |
$34.77
|
| Rate for Payer: Bisbee Police All Plans |
$60.27
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$157.64
|
| Rate for Payer: Cash Price |
$185.46
|
| Rate for Payer: Cash Price |
$185.46
|
| Rate for Payer: Cigna of AZ Commercial |
$162.27
|
| Rate for Payer: Copperpoint Commercial |
$57.38
|
| Rate for Payer: Health Net of AZ Commercial |
$139.09
|
| Rate for Payer: Health Net of AZ Medicare |
$64.91
|
| Rate for Payer: Humana of AZ Medicare |
$34.77
|
| Rate for Payer: Mercy Care Medicaid |
$57.68
|
| Rate for Payer: Self Pay Self Pay |
$185.46
|
| Rate for Payer: TriWest Medicare |
$34.77
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$135.15
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$41.73
|
|
|
APLIGRAPH
|
Facility
|
IP
|
$231.82
|
|
|
Service Code
|
CPT Q4101
|
| Hospital Charge Code |
24358081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$60.27 |
| Max. Negotiated Rate |
$208.64 |
| Rate for Payer: Aetna of AZ Commercial |
$208.64
|
| Rate for Payer: Bisbee Police All Plans |
$60.27
|
| Rate for Payer: Cash Price |
$185.46
|
| Rate for Payer: Self Pay Self Pay |
$185.46
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$12,458.97
|
|
|
Service Code
|
APR-DRG 2333
|
| Hospital Charge Code |
APRDRG2334
|
| Min. Negotiated Rate |
$12,458.97 |
| Max. Negotiated Rate |
$12,458.97 |
| Rate for Payer: AHCCCS Medicaid |
$12,458.97
|
| Rate for Payer: Allwell Medicaid |
$12,458.97
|
| Rate for Payer: AZCH Complete Medicaid |
$12,458.97
|
| Rate for Payer: Banner UC Health Medicaid |
$12,458.97
|
| Rate for Payer: Mercy Care Medicaid |
$12,458.97
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$20,985.19
|
|
|
Service Code
|
APR-DRG 2334
|
| Hospital Charge Code |
APRDRG2332
|
| Min. Negotiated Rate |
$20,985.19 |
| Max. Negotiated Rate |
$20,985.19 |
| Rate for Payer: AHCCCS Medicaid |
$20,985.19
|
| Rate for Payer: Allwell Medicaid |
$20,985.19
|
| Rate for Payer: AZCH Complete Medicaid |
$20,985.19
|
| Rate for Payer: Banner UC Health Medicaid |
$20,985.19
|
| Rate for Payer: Mercy Care Medicaid |
$20,985.19
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$8,406.98
|
|
|
Service Code
|
APR-DRG 2332
|
| Hospital Charge Code |
APRDRG2334
|
| Min. Negotiated Rate |
$8,406.98 |
| Max. Negotiated Rate |
$8,406.98 |
| Rate for Payer: AHCCCS Medicaid |
$8,406.98
|
| Rate for Payer: Allwell Medicaid |
$8,406.98
|
| Rate for Payer: AZCH Complete Medicaid |
$8,406.98
|
| Rate for Payer: Banner UC Health Medicaid |
$8,406.98
|
| Rate for Payer: Mercy Care Medicaid |
$8,406.98
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$6,466.91
|
|
|
Service Code
|
APR-DRG 2331
|
| Hospital Charge Code |
APRDRG2332
|
| Min. Negotiated Rate |
$6,466.91 |
| Max. Negotiated Rate |
$6,466.91 |
| Rate for Payer: AHCCCS Medicaid |
$6,466.91
|
| Rate for Payer: Allwell Medicaid |
$6,466.91
|
| Rate for Payer: AZCH Complete Medicaid |
$6,466.91
|
| Rate for Payer: Banner UC Health Medicaid |
$6,466.91
|
| Rate for Payer: Mercy Care Medicaid |
$6,466.91
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$6,466.91
|
|
|
Service Code
|
APR-DRG 2331
|
| Hospital Charge Code |
APRDRG2334
|
| Min. Negotiated Rate |
$6,466.91 |
| Max. Negotiated Rate |
$6,466.91 |
| Rate for Payer: AHCCCS Medicaid |
$6,466.91
|
| Rate for Payer: Allwell Medicaid |
$6,466.91
|
| Rate for Payer: AZCH Complete Medicaid |
$6,466.91
|
| Rate for Payer: Banner UC Health Medicaid |
$6,466.91
|
| Rate for Payer: Mercy Care Medicaid |
$6,466.91
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$20,985.19
|
|
|
Service Code
|
APR-DRG 2334
|
| Hospital Charge Code |
APRDRG2334
|
| Min. Negotiated Rate |
$20,985.19 |
| Max. Negotiated Rate |
$20,985.19 |
| Rate for Payer: AHCCCS Medicaid |
$20,985.19
|
| Rate for Payer: Allwell Medicaid |
$20,985.19
|
| Rate for Payer: AZCH Complete Medicaid |
$20,985.19
|
| Rate for Payer: Banner UC Health Medicaid |
$20,985.19
|
| Rate for Payer: Mercy Care Medicaid |
$20,985.19
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$8,406.98
|
|
|
Service Code
|
APR-DRG 2332
|
| Hospital Charge Code |
APRDRG2333
|
| Min. Negotiated Rate |
$8,406.98 |
| Max. Negotiated Rate |
$8,406.98 |
| Rate for Payer: AHCCCS Medicaid |
$8,406.98
|
| Rate for Payer: Allwell Medicaid |
$8,406.98
|
| Rate for Payer: AZCH Complete Medicaid |
$8,406.98
|
| Rate for Payer: Banner UC Health Medicaid |
$8,406.98
|
| Rate for Payer: Mercy Care Medicaid |
$8,406.98
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$12,458.97
|
|
|
Service Code
|
APR-DRG 2333
|
| Hospital Charge Code |
APRDRG2332
|
| Min. Negotiated Rate |
$12,458.97 |
| Max. Negotiated Rate |
$12,458.97 |
| Rate for Payer: AHCCCS Medicaid |
$12,458.97
|
| Rate for Payer: Allwell Medicaid |
$12,458.97
|
| Rate for Payer: AZCH Complete Medicaid |
$12,458.97
|
| Rate for Payer: Banner UC Health Medicaid |
$12,458.97
|
| Rate for Payer: Mercy Care Medicaid |
$12,458.97
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$20,985.19
|
|
|
Service Code
|
APR-DRG 2334
|
| Hospital Charge Code |
APRDRG2331
|
| Min. Negotiated Rate |
$20,985.19 |
| Max. Negotiated Rate |
$20,985.19 |
| Rate for Payer: AHCCCS Medicaid |
$20,985.19
|
| Rate for Payer: Allwell Medicaid |
$20,985.19
|
| Rate for Payer: AZCH Complete Medicaid |
$20,985.19
|
| Rate for Payer: Banner UC Health Medicaid |
$20,985.19
|
| Rate for Payer: Mercy Care Medicaid |
$20,985.19
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$8,406.98
|
|
|
Service Code
|
APR-DRG 2332
|
| Hospital Charge Code |
APRDRG2332
|
| Min. Negotiated Rate |
$8,406.98 |
| Max. Negotiated Rate |
$8,406.98 |
| Rate for Payer: AHCCCS Medicaid |
$8,406.98
|
| Rate for Payer: Allwell Medicaid |
$8,406.98
|
| Rate for Payer: AZCH Complete Medicaid |
$8,406.98
|
| Rate for Payer: Banner UC Health Medicaid |
$8,406.98
|
| Rate for Payer: Mercy Care Medicaid |
$8,406.98
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$12,458.97
|
|
|
Service Code
|
APR-DRG 2333
|
| Hospital Charge Code |
APRDRG2333
|
| Min. Negotiated Rate |
$12,458.97 |
| Max. Negotiated Rate |
$12,458.97 |
| Rate for Payer: AHCCCS Medicaid |
$12,458.97
|
| Rate for Payer: Allwell Medicaid |
$12,458.97
|
| Rate for Payer: AZCH Complete Medicaid |
$12,458.97
|
| Rate for Payer: Banner UC Health Medicaid |
$12,458.97
|
| Rate for Payer: Mercy Care Medicaid |
$12,458.97
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$6,466.91
|
|
|
Service Code
|
APR-DRG 2331
|
| Hospital Charge Code |
APRDRG2331
|
| Min. Negotiated Rate |
$6,466.91 |
| Max. Negotiated Rate |
$6,466.91 |
| Rate for Payer: AHCCCS Medicaid |
$6,466.91
|
| Rate for Payer: Allwell Medicaid |
$6,466.91
|
| Rate for Payer: AZCH Complete Medicaid |
$6,466.91
|
| Rate for Payer: Banner UC Health Medicaid |
$6,466.91
|
| Rate for Payer: Mercy Care Medicaid |
$6,466.91
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$12,458.97
|
|
|
Service Code
|
APR-DRG 2333
|
| Hospital Charge Code |
APRDRG2331
|
| Min. Negotiated Rate |
$12,458.97 |
| Max. Negotiated Rate |
$12,458.97 |
| Rate for Payer: AHCCCS Medicaid |
$12,458.97
|
| Rate for Payer: Allwell Medicaid |
$12,458.97
|
| Rate for Payer: AZCH Complete Medicaid |
$12,458.97
|
| Rate for Payer: Banner UC Health Medicaid |
$12,458.97
|
| Rate for Payer: Mercy Care Medicaid |
$12,458.97
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$6,466.91
|
|
|
Service Code
|
APR-DRG 2331
|
| Hospital Charge Code |
APRDRG2333
|
| Min. Negotiated Rate |
$6,466.91 |
| Max. Negotiated Rate |
$6,466.91 |
| Rate for Payer: AHCCCS Medicaid |
$6,466.91
|
| Rate for Payer: Allwell Medicaid |
$6,466.91
|
| Rate for Payer: AZCH Complete Medicaid |
$6,466.91
|
| Rate for Payer: Banner UC Health Medicaid |
$6,466.91
|
| Rate for Payer: Mercy Care Medicaid |
$6,466.91
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$20,985.19
|
|
|
Service Code
|
APR-DRG 2334
|
| Hospital Charge Code |
APRDRG2333
|
| Min. Negotiated Rate |
$20,985.19 |
| Max. Negotiated Rate |
$20,985.19 |
| Rate for Payer: AHCCCS Medicaid |
$20,985.19
|
| Rate for Payer: Allwell Medicaid |
$20,985.19
|
| Rate for Payer: AZCH Complete Medicaid |
$20,985.19
|
| Rate for Payer: Banner UC Health Medicaid |
$20,985.19
|
| Rate for Payer: Mercy Care Medicaid |
$20,985.19
|
|
|
Appendectomy With Complex Principal Diagnosis
|
Facility
|
IP
|
$8,406.98
|
|
|
Service Code
|
APR-DRG 2332
|
| Hospital Charge Code |
APRDRG2331
|
| Min. Negotiated Rate |
$8,406.98 |
| Max. Negotiated Rate |
$8,406.98 |
| Rate for Payer: AHCCCS Medicaid |
$8,406.98
|
| Rate for Payer: Allwell Medicaid |
$8,406.98
|
| Rate for Payer: AZCH Complete Medicaid |
$8,406.98
|
| Rate for Payer: Banner UC Health Medicaid |
$8,406.98
|
| Rate for Payer: Mercy Care Medicaid |
$8,406.98
|
|
|
Appendectomy Without Complex Principal Diagnosis
|
Facility
|
IP
|
$20,453.53
|
|
|
Service Code
|
APR-DRG 2344
|
| Hospital Charge Code |
APRDRG2343
|
| Min. Negotiated Rate |
$20,453.53 |
| Max. Negotiated Rate |
$20,453.53 |
| Rate for Payer: AHCCCS Medicaid |
$20,453.53
|
| Rate for Payer: Allwell Medicaid |
$20,453.53
|
| Rate for Payer: AZCH Complete Medicaid |
$20,453.53
|
| Rate for Payer: Banner UC Health Medicaid |
$20,453.53
|
| Rate for Payer: Mercy Care Medicaid |
$20,453.53
|
|
