|
bacitracin/neomycin/polymyxin B Top Oint [CQCH]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 45802014370
|
| Hospital Charge Code |
105912512
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of AZ Commercial |
$0.13
|
| Rate for Payer: Aetna of AZ Medicare |
$0.04
|
| Rate for Payer: Allwell Medicare |
$0.02
|
| Rate for Payer: Amerigroup Medicare |
$0.02
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.05
|
| Rate for Payer: AZCH Complete Medicare |
$0.02
|
| Rate for Payer: Banner UC Health Medicare |
$0.02
|
| Rate for Payer: Bisbee Police All Plans |
$0.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of AZ Commercial |
$0.09
|
| Rate for Payer: Copperpoint Commercial |
$0.03
|
| Rate for Payer: Health Net of AZ Commercial |
$0.08
|
| Rate for Payer: Health Net of AZ Medicare |
$0.04
|
| Rate for Payer: Humana of AZ Medicare |
$0.02
|
| Rate for Payer: Self Pay Self Pay |
$0.11
|
| Rate for Payer: TriWest Medicare |
$0.02
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.08
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.03
|
|
|
bacitracin topical 500 units/g Oin[CQCH]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 713028031
|
| Hospital Charge Code |
168975217
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of AZ Commercial |
$0.18
|
| Rate for Payer: Bisbee Police All Plans |
$0.05
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Self Pay Self Pay |
$0.16
|
|
|
bacitracin topical 500 units/g Oin[CQCH]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 713028031
|
| Hospital Charge Code |
168975217
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of AZ Commercial |
$0.18
|
| Rate for Payer: Aetna of AZ Medicare |
$0.06
|
| Rate for Payer: Allwell Medicare |
$0.03
|
| Rate for Payer: Amerigroup Medicare |
$0.03
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.07
|
| Rate for Payer: AZCH Complete Medicare |
$0.03
|
| Rate for Payer: Banner UC Health Medicare |
$0.03
|
| Rate for Payer: Bisbee Police All Plans |
$0.05
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.14
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of AZ Commercial |
$0.13
|
| Rate for Payer: Copperpoint Commercial |
$0.05
|
| Rate for Payer: Health Net of AZ Commercial |
$0.12
|
| Rate for Payer: Health Net of AZ Medicare |
$0.06
|
| Rate for Payer: Humana of AZ Medicare |
$0.03
|
| Rate for Payer: Self Pay Self Pay |
$0.16
|
| Rate for Payer: TriWest Medicare |
$0.03
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.12
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.04
|
|
|
baclofen 10 mg Tab [CQCH]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 63739047910
|
| Hospital Charge Code |
105965598
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of AZ Commercial |
$0.30
|
| Rate for Payer: Aetna of AZ Medicare |
$0.09
|
| Rate for Payer: Allwell Medicare |
$0.05
|
| Rate for Payer: Amerigroup Medicare |
$0.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.12
|
| Rate for Payer: AZCH Complete Medicare |
$0.05
|
| Rate for Payer: Banner UC Health Medicare |
$0.05
|
| Rate for Payer: Bisbee Police All Plans |
$0.09
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of AZ Commercial |
$0.21
|
| Rate for Payer: Copperpoint Commercial |
$0.08
|
| Rate for Payer: Health Net of AZ Commercial |
$0.20
|
| Rate for Payer: Health Net of AZ Medicare |
$0.09
|
| Rate for Payer: Humana of AZ Medicare |
$0.05
|
| Rate for Payer: Self Pay Self Pay |
$0.26
|
| Rate for Payer: TriWest Medicare |
$0.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.19
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.06
|
|
|
baclofen 10 mg Tab [CQCH]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 63739047910
|
| Hospital Charge Code |
105965598
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of AZ Commercial |
$0.30
|
| Rate for Payer: Bisbee Police All Plans |
$0.09
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Self Pay Self Pay |
$0.26
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$16,798.53
|
|
|
Service Code
|
APR-DRG 0493
|
| Hospital Charge Code |
APRDRG0494
|
| Min. Negotiated Rate |
$16,798.53 |
| Max. Negotiated Rate |
$16,798.53 |
| Rate for Payer: AHCCCS Medicaid |
$16,798.53
|
| Rate for Payer: Allwell Medicaid |
$16,798.53
|
| Rate for Payer: AZCH Complete Medicaid |
$16,798.53
|
| Rate for Payer: Banner UC Health Medicaid |
$16,798.53
|
| Rate for Payer: Mercy Care Medicaid |
$16,798.53
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$5,850.38
|
|
|
Service Code
|
APR-DRG 0491
|
| Hospital Charge Code |
APRDRG0491
|
| Min. Negotiated Rate |
$5,850.38 |
| Max. Negotiated Rate |
$5,850.38 |
| Rate for Payer: AHCCCS Medicaid |
$5,850.38
|
| Rate for Payer: Allwell Medicaid |
$5,850.38
|
| Rate for Payer: AZCH Complete Medicaid |
$5,850.38
|
| Rate for Payer: Banner UC Health Medicaid |
$5,850.38
|
| Rate for Payer: Mercy Care Medicaid |
$5,850.38
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$27,128.05
|
|
|
Service Code
|
APR-DRG 0494
|
| Hospital Charge Code |
APRDRG0491
|
| Min. Negotiated Rate |
$27,128.05 |
| Max. Negotiated Rate |
$27,128.05 |
| Rate for Payer: AHCCCS Medicaid |
$27,128.05
|
| Rate for Payer: Allwell Medicaid |
$27,128.05
|
| Rate for Payer: AZCH Complete Medicaid |
$27,128.05
|
| Rate for Payer: Banner UC Health Medicaid |
$27,128.05
|
| Rate for Payer: Mercy Care Medicaid |
$27,128.05
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$27,128.05
|
|
|
Service Code
|
APR-DRG 0494
|
| Hospital Charge Code |
APRDRG0494
|
| Min. Negotiated Rate |
$27,128.05 |
| Max. Negotiated Rate |
$27,128.05 |
| Rate for Payer: AHCCCS Medicaid |
$27,128.05
|
| Rate for Payer: Allwell Medicaid |
$27,128.05
|
| Rate for Payer: AZCH Complete Medicaid |
$27,128.05
|
| Rate for Payer: Banner UC Health Medicaid |
$27,128.05
|
| Rate for Payer: Mercy Care Medicaid |
$27,128.05
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$5,850.38
|
|
|
Service Code
|
APR-DRG 0491
|
| Hospital Charge Code |
APRDRG0492
|
| Min. Negotiated Rate |
$5,850.38 |
| Max. Negotiated Rate |
$5,850.38 |
| Rate for Payer: AHCCCS Medicaid |
$5,850.38
|
| Rate for Payer: Allwell Medicaid |
$5,850.38
|
| Rate for Payer: AZCH Complete Medicaid |
$5,850.38
|
| Rate for Payer: Banner UC Health Medicaid |
$5,850.38
|
| Rate for Payer: Mercy Care Medicaid |
$5,850.38
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$27,128.05
|
|
|
Service Code
|
APR-DRG 0494
|
| Hospital Charge Code |
APRDRG0492
|
| Min. Negotiated Rate |
$27,128.05 |
| Max. Negotiated Rate |
$27,128.05 |
| Rate for Payer: AHCCCS Medicaid |
$27,128.05
|
| Rate for Payer: Allwell Medicaid |
$27,128.05
|
| Rate for Payer: AZCH Complete Medicaid |
$27,128.05
|
| Rate for Payer: Banner UC Health Medicaid |
$27,128.05
|
| Rate for Payer: Mercy Care Medicaid |
$27,128.05
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$12,705.16
|
|
|
Service Code
|
APR-DRG 0492
|
| Hospital Charge Code |
APRDRG0494
|
| Min. Negotiated Rate |
$12,705.16 |
| Max. Negotiated Rate |
$12,705.16 |
| Rate for Payer: AHCCCS Medicaid |
$12,705.16
|
| Rate for Payer: Allwell Medicaid |
$12,705.16
|
| Rate for Payer: AZCH Complete Medicaid |
$12,705.16
|
| Rate for Payer: Banner UC Health Medicaid |
$12,705.16
|
| Rate for Payer: Mercy Care Medicaid |
$12,705.16
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$5,850.38
|
|
|
Service Code
|
APR-DRG 0491
|
| Hospital Charge Code |
APRDRG0494
|
| Min. Negotiated Rate |
$5,850.38 |
| Max. Negotiated Rate |
$5,850.38 |
| Rate for Payer: AHCCCS Medicaid |
$5,850.38
|
| Rate for Payer: Allwell Medicaid |
$5,850.38
|
| Rate for Payer: AZCH Complete Medicaid |
$5,850.38
|
| Rate for Payer: Banner UC Health Medicaid |
$5,850.38
|
| Rate for Payer: Mercy Care Medicaid |
$5,850.38
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$12,705.16
|
|
|
Service Code
|
APR-DRG 0492
|
| Hospital Charge Code |
APRDRG0493
|
| Min. Negotiated Rate |
$12,705.16 |
| Max. Negotiated Rate |
$12,705.16 |
| Rate for Payer: AHCCCS Medicaid |
$12,705.16
|
| Rate for Payer: Allwell Medicaid |
$12,705.16
|
| Rate for Payer: AZCH Complete Medicaid |
$12,705.16
|
| Rate for Payer: Banner UC Health Medicaid |
$12,705.16
|
| Rate for Payer: Mercy Care Medicaid |
$12,705.16
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$5,850.38
|
|
|
Service Code
|
APR-DRG 0491
|
| Hospital Charge Code |
APRDRG0493
|
| Min. Negotiated Rate |
$5,850.38 |
| Max. Negotiated Rate |
$5,850.38 |
| Rate for Payer: AHCCCS Medicaid |
$5,850.38
|
| Rate for Payer: Allwell Medicaid |
$5,850.38
|
| Rate for Payer: AZCH Complete Medicaid |
$5,850.38
|
| Rate for Payer: Banner UC Health Medicaid |
$5,850.38
|
| Rate for Payer: Mercy Care Medicaid |
$5,850.38
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$12,705.16
|
|
|
Service Code
|
APR-DRG 0492
|
| Hospital Charge Code |
APRDRG0491
|
| Min. Negotiated Rate |
$12,705.16 |
| Max. Negotiated Rate |
$12,705.16 |
| Rate for Payer: AHCCCS Medicaid |
$12,705.16
|
| Rate for Payer: Allwell Medicaid |
$12,705.16
|
| Rate for Payer: AZCH Complete Medicaid |
$12,705.16
|
| Rate for Payer: Banner UC Health Medicaid |
$12,705.16
|
| Rate for Payer: Mercy Care Medicaid |
$12,705.16
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$16,798.53
|
|
|
Service Code
|
APR-DRG 0493
|
| Hospital Charge Code |
APRDRG0493
|
| Min. Negotiated Rate |
$16,798.53 |
| Max. Negotiated Rate |
$16,798.53 |
| Rate for Payer: AHCCCS Medicaid |
$16,798.53
|
| Rate for Payer: Allwell Medicaid |
$16,798.53
|
| Rate for Payer: AZCH Complete Medicaid |
$16,798.53
|
| Rate for Payer: Banner UC Health Medicaid |
$16,798.53
|
| Rate for Payer: Mercy Care Medicaid |
$16,798.53
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$12,705.16
|
|
|
Service Code
|
APR-DRG 0492
|
| Hospital Charge Code |
APRDRG0492
|
| Min. Negotiated Rate |
$12,705.16 |
| Max. Negotiated Rate |
$12,705.16 |
| Rate for Payer: AHCCCS Medicaid |
$12,705.16
|
| Rate for Payer: Allwell Medicaid |
$12,705.16
|
| Rate for Payer: AZCH Complete Medicaid |
$12,705.16
|
| Rate for Payer: Banner UC Health Medicaid |
$12,705.16
|
| Rate for Payer: Mercy Care Medicaid |
$12,705.16
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$16,798.53
|
|
|
Service Code
|
APR-DRG 0493
|
| Hospital Charge Code |
APRDRG0492
|
| Min. Negotiated Rate |
$16,798.53 |
| Max. Negotiated Rate |
$16,798.53 |
| Rate for Payer: AHCCCS Medicaid |
$16,798.53
|
| Rate for Payer: Allwell Medicaid |
$16,798.53
|
| Rate for Payer: AZCH Complete Medicaid |
$16,798.53
|
| Rate for Payer: Banner UC Health Medicaid |
$16,798.53
|
| Rate for Payer: Mercy Care Medicaid |
$16,798.53
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$16,798.53
|
|
|
Service Code
|
APR-DRG 0493
|
| Hospital Charge Code |
APRDRG0491
|
| Min. Negotiated Rate |
$16,798.53 |
| Max. Negotiated Rate |
$16,798.53 |
| Rate for Payer: AHCCCS Medicaid |
$16,798.53
|
| Rate for Payer: Allwell Medicaid |
$16,798.53
|
| Rate for Payer: AZCH Complete Medicaid |
$16,798.53
|
| Rate for Payer: Banner UC Health Medicaid |
$16,798.53
|
| Rate for Payer: Mercy Care Medicaid |
$16,798.53
|
|
|
Bacterial And Tuberculous Infections Of Nervous System
|
Facility
|
IP
|
$27,128.05
|
|
|
Service Code
|
APR-DRG 0494
|
| Hospital Charge Code |
APRDRG0493
|
| Min. Negotiated Rate |
$27,128.05 |
| Max. Negotiated Rate |
$27,128.05 |
| Rate for Payer: AHCCCS Medicaid |
$27,128.05
|
| Rate for Payer: Allwell Medicaid |
$27,128.05
|
| Rate for Payer: AZCH Complete Medicaid |
$27,128.05
|
| Rate for Payer: Banner UC Health Medicaid |
$27,128.05
|
| Rate for Payer: Mercy Care Medicaid |
$27,128.05
|
|
|
BAG BILE
|
Facility
|
OP
|
$58.00
|
|
| Hospital Charge Code |
22355157
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.28 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of AZ Commercial |
$52.20
|
| Rate for Payer: Aetna of AZ Medicare |
$16.24
|
| Rate for Payer: Allwell Medicare |
$9.28
|
| Rate for Payer: Amerigroup Medicare |
$9.28
|
| Rate for Payer: APIPA Medicare/Medicaid |
$21.66
|
| Rate for Payer: AZCH Complete Medicare |
$9.28
|
| Rate for Payer: Banner UC Health Medicare |
$9.28
|
| Rate for Payer: Bisbee Police All Plans |
$15.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$39.44
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Cigna of AZ Commercial |
$40.60
|
| Rate for Payer: Copperpoint Commercial |
$14.36
|
| Rate for Payer: Health Net of AZ Commercial |
$34.80
|
| Rate for Payer: Health Net of AZ Medicare |
$16.24
|
| Rate for Payer: Humana of AZ Medicare |
$9.28
|
| Rate for Payer: Self Pay Self Pay |
$46.40
|
| Rate for Payer: TriWest Medicare |
$9.28
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$33.81
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$10.44
|
|
|
BAG BILE
|
Facility
|
IP
|
$58.00
|
|
| Hospital Charge Code |
22355157
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.08 |
| Max. Negotiated Rate |
$52.20 |
| Rate for Payer: Aetna of AZ Commercial |
$52.20
|
| Rate for Payer: Bisbee Police All Plans |
$15.08
|
| Rate for Payer: Cash Price |
$46.40
|
| Rate for Payer: Self Pay Self Pay |
$46.40
|
|
|
BAG CLOSED DRNG
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
CPT A4357
|
| Hospital Charge Code |
22355306
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.36 |
| Max. Negotiated Rate |
$32.40 |
| Rate for Payer: Aetna of AZ Commercial |
$32.40
|
| Rate for Payer: Bisbee Police All Plans |
$9.36
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Self Pay Self Pay |
$28.80
|
|
|
BAG CLOSED DRNG
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
CPT A4357
|
| Hospital Charge Code |
22355306
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.76 |
| Max. Negotiated Rate |
$32.40 |
| Rate for Payer: Aetna of AZ Commercial |
$32.40
|
| Rate for Payer: Aetna of AZ Medicare |
$10.08
|
| Rate for Payer: Allwell Medicare |
$5.76
|
| Rate for Payer: Amerigroup Medicare |
$5.76
|
| Rate for Payer: APIPA Medicare/Medicaid |
$13.45
|
| Rate for Payer: AZCH Complete Medicare |
$5.76
|
| Rate for Payer: Banner UC Health Medicare |
$5.76
|
| Rate for Payer: Bisbee Police All Plans |
$9.36
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$24.48
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna of AZ Commercial |
$25.20
|
| Rate for Payer: Copperpoint Commercial |
$8.91
|
| Rate for Payer: Health Net of AZ Commercial |
$21.60
|
| Rate for Payer: Health Net of AZ Medicare |
$10.08
|
| Rate for Payer: Humana of AZ Medicare |
$5.76
|
| Rate for Payer: Self Pay Self Pay |
$28.80
|
| Rate for Payer: TriWest Medicare |
$5.76
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$20.99
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$6.48
|
|
