|
DERMAGRAFT, PER SQUARE CENTIMETER
|
Facility
|
OP
|
$170.00
|
|
|
Service Code
|
CPT Q4106
|
| Hospital Charge Code |
24049286
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.20 |
| Max. Negotiated Rate |
$153.00 |
| Rate for Payer: Aetna of AZ Commercial |
$153.00
|
| Rate for Payer: Aetna of AZ Medicare |
$47.60
|
| Rate for Payer: Allwell Medicare |
$27.20
|
| Rate for Payer: Amerigroup Medicare |
$27.20
|
| Rate for Payer: APIPA Medicare/Medicaid |
$63.49
|
| Rate for Payer: AZCH Complete Medicare |
$27.20
|
| Rate for Payer: Banner UC Health Medicare |
$27.20
|
| Rate for Payer: Bisbee Police All Plans |
$44.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$115.60
|
| Rate for Payer: Cash Price |
$136.00
|
| Rate for Payer: Cigna of AZ Commercial |
$119.00
|
| Rate for Payer: Copperpoint Commercial |
$42.08
|
| Rate for Payer: Health Net of AZ Commercial |
$102.00
|
| Rate for Payer: Health Net of AZ Medicare |
$47.60
|
| Rate for Payer: Humana of AZ Medicare |
$27.20
|
| Rate for Payer: Self Pay Self Pay |
$136.00
|
| Rate for Payer: TriWest Medicare |
$27.20
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$99.11
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$30.60
|
|
|
DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,
|
Facility
|
IP
|
$334.00
|
|
|
Service Code
|
CPT 17110
|
| Hospital Charge Code |
24049519
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$86.84 |
| Max. Negotiated Rate |
$300.60 |
| Rate for Payer: Aetna of AZ Commercial |
$300.60
|
| Rate for Payer: Bisbee Police All Plans |
$86.84
|
| Rate for Payer: Cash Price |
$267.20
|
| Rate for Payer: Self Pay Self Pay |
$267.20
|
|
|
DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,
|
Facility
|
OP
|
$334.00
|
|
|
Service Code
|
CPT 17110
|
| Hospital Charge Code |
24049519
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$53.44 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$300.60
|
| Rate for Payer: Aetna of AZ Medicare |
$93.52
|
| Rate for Payer: AHCCCS Medicaid |
$130.17
|
| Rate for Payer: Allwell Medicaid |
$130.17
|
| Rate for Payer: Allwell Medicare |
$53.44
|
| Rate for Payer: Amerigroup Medicare |
$53.44
|
| Rate for Payer: APIPA Medicare/Medicaid |
$124.75
|
| Rate for Payer: AZCH Complete Medicaid |
$130.17
|
| Rate for Payer: AZCH Complete Medicare |
$53.44
|
| Rate for Payer: Banner UC Health Medicaid |
$130.17
|
| Rate for Payer: Banner UC Health Medicare |
$53.44
|
| Rate for Payer: Bisbee Police All Plans |
$86.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$227.12
|
| Rate for Payer: Cash Price |
$267.20
|
| Rate for Payer: Cash Price |
$267.20
|
| Rate for Payer: Cigna of AZ Commercial |
$167.00
|
| Rate for Payer: Copperpoint Commercial |
$82.67
|
| Rate for Payer: Health Net of AZ Commercial |
$200.40
|
| Rate for Payer: Health Net of AZ Medicare |
$93.52
|
| Rate for Payer: Humana of AZ Medicare |
$53.44
|
| Rate for Payer: Mercy Care Medicaid |
$130.17
|
| Rate for Payer: Self Pay Self Pay |
$267.20
|
| Rate for Payer: TriWest Medicare |
$53.44
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$60.12
|
|
|
DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,
|
Facility
|
OP
|
$410.00
|
|
|
Service Code
|
CPT 17111
|
| Hospital Charge Code |
24049520
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$65.60 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$369.00
|
| Rate for Payer: Aetna of AZ Medicare |
$114.80
|
| Rate for Payer: AHCCCS Medicaid |
$130.17
|
| Rate for Payer: Allwell Medicaid |
$130.17
|
| Rate for Payer: Allwell Medicare |
$65.60
|
| Rate for Payer: Amerigroup Medicare |
$65.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$153.13
|
| Rate for Payer: AZCH Complete Medicaid |
$130.17
|
| Rate for Payer: AZCH Complete Medicare |
$65.60
|
| Rate for Payer: Banner UC Health Medicaid |
$130.17
|
| Rate for Payer: Banner UC Health Medicare |
$65.60
|
| Rate for Payer: Bisbee Police All Plans |
$106.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$278.80
|
| Rate for Payer: Cash Price |
$328.00
|
| Rate for Payer: Cash Price |
$328.00
|
| Rate for Payer: Cigna of AZ Commercial |
$205.00
|
| Rate for Payer: Copperpoint Commercial |
$101.47
|
| Rate for Payer: Health Net of AZ Commercial |
$246.00
|
| Rate for Payer: Health Net of AZ Medicare |
$114.80
|
| Rate for Payer: Humana of AZ Medicare |
$65.60
|
| Rate for Payer: Mercy Care Medicaid |
$130.17
|
| Rate for Payer: Self Pay Self Pay |
$328.00
|
| Rate for Payer: TriWest Medicare |
$65.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$73.80
|
|
|
DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY,
|
Facility
|
IP
|
$410.00
|
|
|
Service Code
|
CPT 17111
|
| Hospital Charge Code |
24049520
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$106.60 |
| Max. Negotiated Rate |
$369.00 |
| Rate for Payer: Aetna of AZ Commercial |
$369.00
|
| Rate for Payer: Bisbee Police All Plans |
$106.60
|
| Rate for Payer: Cash Price |
$328.00
|
| Rate for Payer: Self Pay Self Pay |
$328.00
|
|
|
DETECTION OF ENDOMYSIAL ANTIBODY (EMA)
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT 86231
|
| Hospital Charge Code |
28010047
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna of AZ Commercial |
$54.00
|
| Rate for Payer: Aetna of AZ Medicare |
$16.80
|
| Rate for Payer: Allwell Medicare |
$9.60
|
| Rate for Payer: Amerigroup Medicare |
$9.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$22.41
|
| Rate for Payer: AZCH Complete Medicare |
$9.60
|
| Rate for Payer: Banner UC Health Medicare |
$9.60
|
| Rate for Payer: Bisbee Police All Plans |
$15.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$40.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna of AZ Commercial |
$39.00
|
| Rate for Payer: Copperpoint Commercial |
$14.85
|
| Rate for Payer: Health Net of AZ Commercial |
$36.00
|
| Rate for Payer: Health Net of AZ Medicare |
$16.80
|
| Rate for Payer: Humana of AZ Medicare |
$9.60
|
| Rate for Payer: Self Pay Self Pay |
$48.00
|
| Rate for Payer: TriWest Medicare |
$9.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$34.98
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$10.80
|
|
|
DETECTION OF ENDOMYSIAL ANTIBODY (EMA)
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT 86231
|
| Hospital Charge Code |
28010047
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna of AZ Commercial |
$54.00
|
| Rate for Payer: Bisbee Police All Plans |
$15.60
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Self Pay Self Pay |
$48.00
|
|
|
DETECTION OF GLIADIN (DEAMIDATED) (DGP) ANTIBODY
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT 86364
|
| Hospital Charge Code |
28008409
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$9.60 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna of AZ Commercial |
$54.00
|
| Rate for Payer: Aetna of AZ Medicare |
$16.80
|
| Rate for Payer: Allwell Medicare |
$9.60
|
| Rate for Payer: Amerigroup Medicare |
$9.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$22.41
|
| Rate for Payer: AZCH Complete Medicare |
$9.60
|
| Rate for Payer: Banner UC Health Medicare |
$9.60
|
| Rate for Payer: Bisbee Police All Plans |
$15.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$40.80
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Cigna of AZ Commercial |
$39.00
|
| Rate for Payer: Copperpoint Commercial |
$14.85
|
| Rate for Payer: Health Net of AZ Commercial |
$36.00
|
| Rate for Payer: Health Net of AZ Medicare |
$16.80
|
| Rate for Payer: Humana of AZ Medicare |
$9.60
|
| Rate for Payer: Self Pay Self Pay |
$48.00
|
| Rate for Payer: TriWest Medicare |
$9.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$34.98
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$10.80
|
|
|
DETECTION OF GLIADIN (DEAMIDATED) (DGP) ANTIBODY
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT 86364
|
| Hospital Charge Code |
28008409
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$15.60 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna of AZ Commercial |
$54.00
|
| Rate for Payer: Bisbee Police All Plans |
$15.60
|
| Rate for Payer: Cash Price |
$48.00
|
| Rate for Payer: Self Pay Self Pay |
$48.00
|
|
|
DETECTION TEST BY NUCLEIC ACID FOR DIGESTIVE TRACT PATHOGEN,
|
Facility
|
OP
|
$2,188.00
|
|
|
Service Code
|
CPT 87507
|
| Hospital Charge Code |
27658692
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$350.08 |
| Max. Negotiated Rate |
$1,969.20 |
| Rate for Payer: Aetna of AZ Commercial |
$1,969.20
|
| Rate for Payer: Aetna of AZ Medicare |
$612.64
|
| Rate for Payer: Allwell Medicare |
$350.08
|
| Rate for Payer: Amerigroup Medicare |
$350.08
|
| Rate for Payer: APIPA Medicare/Medicaid |
$817.22
|
| Rate for Payer: AZCH Complete Medicare |
$350.08
|
| Rate for Payer: Banner UC Health Medicare |
$350.08
|
| Rate for Payer: Bisbee Police All Plans |
$568.88
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,487.84
|
| Rate for Payer: Cash Price |
$1,750.40
|
| Rate for Payer: Cigna of AZ Commercial |
$1,422.20
|
| Rate for Payer: Copperpoint Commercial |
$541.53
|
| Rate for Payer: Health Net of AZ Commercial |
$1,312.80
|
| Rate for Payer: Health Net of AZ Medicare |
$612.64
|
| Rate for Payer: Humana of AZ Medicare |
$350.08
|
| Rate for Payer: Self Pay Self Pay |
$1,750.40
|
| Rate for Payer: TriWest Medicare |
$350.08
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,275.60
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$393.84
|
|
|
DETECTION TEST BY NUCLEIC ACID FOR DIGESTIVE TRACT PATHOGEN,
|
Facility
|
IP
|
$2,188.00
|
|
|
Service Code
|
CPT 87507
|
| Hospital Charge Code |
27658692
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$568.88 |
| Max. Negotiated Rate |
$1,969.20 |
| Rate for Payer: Aetna of AZ Commercial |
$1,969.20
|
| Rate for Payer: Bisbee Police All Plans |
$568.88
|
| Rate for Payer: Cash Price |
$1,750.40
|
| Rate for Payer: Self Pay Self Pay |
$1,750.40
|
|
|
dexamethasone 10 mg/mL Inj Sol [CQCH]
|
Facility
|
IP
|
$4.07
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
105918016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$3.66 |
| Rate for Payer: Aetna of AZ Commercial |
$3.66
|
| Rate for Payer: Bisbee Police All Plans |
$1.06
|
| Rate for Payer: Cash Price |
$3.26
|
| Rate for Payer: Self Pay Self Pay |
$3.26
|
|
|
dexamethasone 10 mg/mL Inj Sol [CQCH]
|
Facility
|
OP
|
$4.07
|
|
|
Service Code
|
HCPCS J1100
|
| Hospital Charge Code |
105918016
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$3.66 |
| Rate for Payer: Aetna of AZ Commercial |
$3.66
|
| Rate for Payer: Aetna of AZ Medicare |
$1.14
|
| Rate for Payer: Allwell Medicare |
$0.65
|
| Rate for Payer: Amerigroup Medicare |
$0.65
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1.52
|
| Rate for Payer: AZCH Complete Medicare |
$0.65
|
| Rate for Payer: Banner UC Health Medicare |
$0.65
|
| Rate for Payer: Bisbee Police All Plans |
$1.06
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2.77
|
| Rate for Payer: Cash Price |
$3.26
|
| Rate for Payer: Cigna of AZ Commercial |
$2.65
|
| Rate for Payer: Copperpoint Commercial |
$1.01
|
| Rate for Payer: Health Net of AZ Commercial |
$2.44
|
| Rate for Payer: Health Net of AZ Medicare |
$1.14
|
| Rate for Payer: Humana of AZ Medicare |
$0.65
|
| Rate for Payer: Self Pay Self Pay |
$3.26
|
| Rate for Payer: TriWest Medicare |
$0.65
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2.37
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.73
|
|
|
dexamethasone 1 mg Tab [CQCH]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
HCPCS J8540
|
| Hospital Charge Code |
105918089
|
|
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 |
$0.20
|
| Rate for Payer: Self Pay Self Pay |
$0.20
|
|
|
dexamethasone 1 mg Tab [CQCH]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
HCPCS J8540
|
| Hospital Charge Code |
105918089
|
|
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 |
$0.09
|
| 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 |
$0.17
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of AZ Commercial |
$0.16
|
| Rate for Payer: Copperpoint Commercial |
$0.06
|
| Rate for Payer: Health Net of AZ Commercial |
$0.15
|
| 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 |
$0.20
|
| 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
|
|
|
dexmedetomidine 100 mcg/mL Sol [CQCH]
|
Facility
|
IP
|
$1.51
|
|
|
Service Code
|
NDC 143953225
|
| Hospital Charge Code |
145588585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Aetna of AZ Commercial |
$1.36
|
| Rate for Payer: Bisbee Police All Plans |
$0.39
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Self Pay Self Pay |
$1.21
|
|
|
dexmedetomidine 100 mcg/mL Sol [CQCH]
|
Facility
|
OP
|
$1.51
|
|
|
Service Code
|
NDC 143953225
|
| Hospital Charge Code |
145588585
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Aetna of AZ Commercial |
$1.36
|
| 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 |
$1.03
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Cigna of AZ Commercial |
$0.98
|
| Rate for Payer: Copperpoint Commercial |
$0.37
|
| Rate for Payer: Health Net of AZ Commercial |
$0.91
|
| 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 |
$1.21
|
| Rate for Payer: TriWest Medicare |
$0.24
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.88
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.27
|
|
|
DEXTILE ANATOMICAL MESH LEFT
|
Facility
|
IP
|
$880.05
|
|
| Hospital Charge Code |
27820406
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$228.81 |
| Max. Negotiated Rate |
$792.04 |
| Rate for Payer: Aetna of AZ Commercial |
$792.04
|
| Rate for Payer: Bisbee Police All Plans |
$228.81
|
| Rate for Payer: Cash Price |
$704.04
|
| Rate for Payer: Self Pay Self Pay |
$704.04
|
|
|
DEXTILE ANATOMICAL MESH LEFT
|
Facility
|
OP
|
$880.05
|
|
| Hospital Charge Code |
27820406
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$140.81 |
| Max. Negotiated Rate |
$792.04 |
| Rate for Payer: Aetna of AZ Commercial |
$792.04
|
| Rate for Payer: Aetna of AZ Medicare |
$246.41
|
| Rate for Payer: Allwell Medicare |
$140.81
|
| Rate for Payer: Amerigroup Medicare |
$140.81
|
| Rate for Payer: APIPA Medicare/Medicaid |
$328.70
|
| Rate for Payer: AZCH Complete Medicare |
$140.81
|
| Rate for Payer: Banner UC Health Medicare |
$140.81
|
| Rate for Payer: Bisbee Police All Plans |
$228.81
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$598.43
|
| Rate for Payer: Cash Price |
$704.04
|
| Rate for Payer: Cigna of AZ Commercial |
$616.03
|
| Rate for Payer: Copperpoint Commercial |
$217.81
|
| Rate for Payer: Health Net of AZ Commercial |
$528.03
|
| Rate for Payer: Health Net of AZ Medicare |
$246.41
|
| Rate for Payer: Humana of AZ Medicare |
$140.81
|
| Rate for Payer: Self Pay Self Pay |
$704.04
|
| Rate for Payer: TriWest Medicare |
$140.81
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$513.07
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$158.41
|
|
|
DEXTILE ANATOMICAL MESH RIGHT
|
Facility
|
IP
|
$880.05
|
|
| Hospital Charge Code |
27820407
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$228.81 |
| Max. Negotiated Rate |
$792.04 |
| Rate for Payer: Aetna of AZ Commercial |
$792.04
|
| Rate for Payer: Bisbee Police All Plans |
$228.81
|
| Rate for Payer: Cash Price |
$704.04
|
| Rate for Payer: Self Pay Self Pay |
$704.04
|
|
|
DEXTILE ANATOMICAL MESH RIGHT
|
Facility
|
OP
|
$880.05
|
|
| Hospital Charge Code |
27820407
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$140.81 |
| Max. Negotiated Rate |
$792.04 |
| Rate for Payer: Aetna of AZ Commercial |
$792.04
|
| Rate for Payer: Aetna of AZ Medicare |
$246.41
|
| Rate for Payer: Allwell Medicare |
$140.81
|
| Rate for Payer: Amerigroup Medicare |
$140.81
|
| Rate for Payer: APIPA Medicare/Medicaid |
$328.70
|
| Rate for Payer: AZCH Complete Medicare |
$140.81
|
| Rate for Payer: Banner UC Health Medicare |
$140.81
|
| Rate for Payer: Bisbee Police All Plans |
$228.81
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$598.43
|
| Rate for Payer: Cash Price |
$704.04
|
| Rate for Payer: Cigna of AZ Commercial |
$616.03
|
| Rate for Payer: Copperpoint Commercial |
$217.81
|
| Rate for Payer: Health Net of AZ Commercial |
$528.03
|
| Rate for Payer: Health Net of AZ Medicare |
$246.41
|
| Rate for Payer: Humana of AZ Medicare |
$140.81
|
| Rate for Payer: Self Pay Self Pay |
$704.04
|
| Rate for Payer: TriWest Medicare |
$140.81
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$513.07
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$158.41
|
|
|
Dextrose 10% in Water 500 mL IV soln [CQCH]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 409793003
|
| Hospital Charge Code |
112006059
|
|
Hospital Revenue Code
|
258
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of AZ Commercial |
$0.01
|
| Rate for Payer: Aetna of AZ Medicare |
$0.00
|
| Rate for Payer: Allwell Medicare |
$0.00
|
| Rate for Payer: Amerigroup Medicare |
$0.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.00
|
| Rate for Payer: AZCH Complete Medicare |
$0.00
|
| Rate for Payer: Banner UC Health Medicare |
$0.00
|
| Rate for Payer: Bisbee Police All Plans |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of AZ Commercial |
$0.01
|
| Rate for Payer: Copperpoint Commercial |
$0.00
|
| Rate for Payer: Health Net of AZ Commercial |
$0.01
|
| Rate for Payer: Health Net of AZ Medicare |
$0.00
|
| Rate for Payer: Humana of AZ Medicare |
$0.00
|
| Rate for Payer: Self Pay Self Pay |
$0.01
|
| Rate for Payer: TriWest Medicare |
$0.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.01
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.00
|
|
|
Dextrose 10% in Water 500 mL IV soln [CQCH]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 409793003
|
| Hospital Charge Code |
112006059
|
|
Hospital Revenue Code
|
258
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of AZ Commercial |
$0.01
|
| Rate for Payer: Bisbee Police All Plans |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Self Pay Self Pay |
$0.01
|
|
|
dextrose 50% (25gm)IV Sol 50 mL [CQCH]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 409751716
|
| Hospital Charge Code |
105924619
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of AZ Commercial |
$0.14
|
| Rate for Payer: Aetna of AZ Medicare |
$0.04
|
| Rate for Payer: Allwell Medicare |
$0.03
|
| Rate for Payer: Amerigroup Medicare |
$0.03
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.06
|
| Rate for Payer: AZCH Complete Medicare |
$0.03
|
| Rate for Payer: Banner UC Health Medicare |
$0.03
|
| Rate for Payer: Bisbee Police All Plans |
$0.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of AZ Commercial |
$0.10
|
| Rate for Payer: Copperpoint Commercial |
$0.04
|
| Rate for Payer: Health Net of AZ Commercial |
$0.10
|
| Rate for Payer: Health Net of AZ Medicare |
$0.04
|
| Rate for Payer: Humana of AZ Medicare |
$0.03
|
| Rate for Payer: Self Pay Self Pay |
$0.13
|
| Rate for Payer: TriWest Medicare |
$0.03
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.09
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.03
|
|
|
dextrose 50% (25gm)IV Sol 50 mL [CQCH]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 409751716
|
| Hospital Charge Code |
105924619
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of AZ Commercial |
$0.14
|
| Rate for Payer: Bisbee Police All Plans |
$0.04
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Self Pay Self Pay |
$0.13
|
|
