|
DILATION OF URETHRA USING AN ENDOSCOPE Tech
|
Facility
|
OP
|
$790.00
|
|
|
Service Code
|
CPT 52281
|
| Hospital Charge Code |
27927129
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$126.40 |
| Max. Negotiated Rate |
$2,909.00 |
| Rate for Payer: Aetna of AZ Commercial |
$711.00
|
| Rate for Payer: Aetna of AZ Medicare |
$221.20
|
| Rate for Payer: AHCCCS Medicaid |
$1,299.92
|
| Rate for Payer: Allwell Medicaid |
$1,299.92
|
| Rate for Payer: Allwell Medicare |
$126.40
|
| Rate for Payer: Amerigroup Medicare |
$126.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$295.06
|
| Rate for Payer: AZCH Complete Medicaid |
$1,299.92
|
| Rate for Payer: AZCH Complete Medicare |
$126.40
|
| Rate for Payer: Banner UC Health Medicaid |
$1,299.92
|
| Rate for Payer: Banner UC Health Medicare |
$126.40
|
| Rate for Payer: Bisbee Police All Plans |
$205.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$537.20
|
| Rate for Payer: Cash Price |
$632.00
|
| Rate for Payer: Cash Price |
$632.00
|
| Rate for Payer: Cigna of AZ Commercial |
$395.00
|
| Rate for Payer: Copperpoint Commercial |
$195.53
|
| Rate for Payer: Health Net of AZ Commercial |
$474.00
|
| Rate for Payer: Health Net of AZ Medicare |
$221.20
|
| Rate for Payer: Humana of AZ Medicare |
$126.40
|
| Rate for Payer: Mercy Care Medicaid |
$1,299.92
|
| Rate for Payer: Self Pay Self Pay |
$632.00
|
| Rate for Payer: TriWest Medicare |
$126.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,909.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$142.20
|
|
|
DILATION OF URETHRA USING AN ENDOSCOPE Tech
|
Facility
|
IP
|
$790.00
|
|
|
Service Code
|
CPT 52281
|
| Hospital Charge Code |
27927129
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$205.40 |
| Max. Negotiated Rate |
$711.00 |
| Rate for Payer: Aetna of AZ Commercial |
$711.00
|
| Rate for Payer: Bisbee Police All Plans |
$205.40
|
| Rate for Payer: Cash Price |
$632.00
|
| Rate for Payer: Self Pay Self Pay |
$632.00
|
|
|
DILATOR URETERAL 6X4 BALLOON
|
Facility
|
IP
|
$802.00
|
|
| Hospital Charge Code |
22354207
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$208.52 |
| Max. Negotiated Rate |
$721.80 |
| Rate for Payer: Aetna of AZ Commercial |
$721.80
|
| Rate for Payer: Bisbee Police All Plans |
$208.52
|
| Rate for Payer: Cash Price |
$641.60
|
| Rate for Payer: Self Pay Self Pay |
$641.60
|
|
|
DILATOR URETERAL 6X4 BALLOON
|
Facility
|
OP
|
$802.00
|
|
| Hospital Charge Code |
22354207
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$128.32 |
| Max. Negotiated Rate |
$721.80 |
| Rate for Payer: Aetna of AZ Commercial |
$721.80
|
| Rate for Payer: Aetna of AZ Medicare |
$224.56
|
| Rate for Payer: Allwell Medicare |
$128.32
|
| Rate for Payer: Amerigroup Medicare |
$128.32
|
| Rate for Payer: APIPA Medicare/Medicaid |
$299.55
|
| Rate for Payer: AZCH Complete Medicare |
$128.32
|
| Rate for Payer: Banner UC Health Medicare |
$128.32
|
| Rate for Payer: Bisbee Police All Plans |
$208.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$545.36
|
| Rate for Payer: Cash Price |
$641.60
|
| Rate for Payer: Cigna of AZ Commercial |
$561.40
|
| Rate for Payer: Copperpoint Commercial |
$198.50
|
| Rate for Payer: Health Net of AZ Commercial |
$481.20
|
| Rate for Payer: Health Net of AZ Medicare |
$224.56
|
| Rate for Payer: Humana of AZ Medicare |
$128.32
|
| Rate for Payer: Self Pay Self Pay |
$641.60
|
| Rate for Payer: TriWest Medicare |
$128.32
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$467.57
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$144.36
|
|
|
dilTIAZem 100 mg IV Inj (ADD-Vantage) [CQCH]
|
Facility
|
OP
|
$10.71
|
|
|
Service Code
|
NDC 409435003
|
| Hospital Charge Code |
105919232
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$1.71 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: Aetna of AZ Commercial |
$9.64
|
| Rate for Payer: Aetna of AZ Medicare |
$3.00
|
| Rate for Payer: Allwell Medicare |
$1.71
|
| Rate for Payer: Amerigroup Medicare |
$1.71
|
| Rate for Payer: APIPA Medicare/Medicaid |
$4.00
|
| Rate for Payer: AZCH Complete Medicare |
$1.71
|
| Rate for Payer: Banner UC Health Medicare |
$1.71
|
| Rate for Payer: Bisbee Police All Plans |
$2.78
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$7.28
|
| Rate for Payer: Cash Price |
$8.56
|
| Rate for Payer: Cigna of AZ Commercial |
$6.96
|
| Rate for Payer: Copperpoint Commercial |
$2.65
|
| Rate for Payer: Health Net of AZ Commercial |
$6.43
|
| Rate for Payer: Health Net of AZ Medicare |
$3.00
|
| Rate for Payer: Humana of AZ Medicare |
$1.71
|
| Rate for Payer: Self Pay Self Pay |
$8.57
|
| Rate for Payer: TriWest Medicare |
$1.71
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$6.24
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$1.93
|
|
|
dilTIAZem 100 mg IV Inj (ADD-Vantage) [CQCH]
|
Facility
|
IP
|
$10.71
|
|
|
Service Code
|
NDC 409435003
|
| Hospital Charge Code |
105919232
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$9.64 |
| Rate for Payer: Aetna of AZ Commercial |
$9.64
|
| Rate for Payer: Bisbee Police All Plans |
$2.78
|
| Rate for Payer: Cash Price |
$8.56
|
| Rate for Payer: Self Pay Self Pay |
$8.57
|
|
|
dilTIAZem 120 mg ER Cap [CQCH]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 60687019501
|
| Hospital Charge Code |
105919102
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of AZ Commercial |
$0.25
|
| Rate for Payer: Aetna of AZ Medicare |
$0.08
|
| 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 |
$0.19
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of AZ Commercial |
$0.18
|
| Rate for Payer: Copperpoint Commercial |
$0.07
|
| Rate for Payer: Health Net of AZ Commercial |
$0.17
|
| Rate for Payer: Health Net of AZ Medicare |
$0.08
|
| Rate for Payer: Humana of AZ Medicare |
$0.04
|
| Rate for Payer: Self Pay Self Pay |
$0.22
|
| Rate for Payer: TriWest Medicare |
$0.04
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.16
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.05
|
|
|
dilTIAZem 120 mg ER Cap [CQCH]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 60687019501
|
| Hospital Charge Code |
105919102
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Aetna of AZ Commercial |
$0.25
|
| Rate for Payer: Bisbee Police All Plans |
$0.07
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Self Pay Self Pay |
$0.22
|
|
|
dilTIAZem 125 mg/ 25 ml Sol [CQCH]
|
Facility
|
IP
|
$0.41
|
|
|
Service Code
|
NDC 17478093725
|
| Hospital Charge Code |
108382261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of AZ Commercial |
$0.37
|
| Rate for Payer: Bisbee Police All Plans |
$0.11
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Self Pay Self Pay |
$0.33
|
|
|
dilTIAZem 125 mg/ 25 ml Sol [CQCH]
|
Facility
|
OP
|
$0.41
|
|
|
Service Code
|
NDC 17478093725
|
| Hospital Charge Code |
108382261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of AZ Commercial |
$0.37
|
| Rate for Payer: Aetna of AZ Medicare |
$0.11
|
| Rate for Payer: Allwell Medicare |
$0.07
|
| Rate for Payer: Amerigroup Medicare |
$0.07
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.15
|
| Rate for Payer: AZCH Complete Medicare |
$0.07
|
| Rate for Payer: Banner UC Health Medicare |
$0.07
|
| Rate for Payer: Bisbee Police All Plans |
$0.11
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of AZ Commercial |
$0.27
|
| Rate for Payer: Copperpoint Commercial |
$0.10
|
| Rate for Payer: Health Net of AZ Commercial |
$0.25
|
| Rate for Payer: Health Net of AZ Medicare |
$0.11
|
| Rate for Payer: Humana of AZ Medicare |
$0.07
|
| Rate for Payer: Self Pay Self Pay |
$0.33
|
| Rate for Payer: TriWest Medicare |
$0.07
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.24
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.07
|
|
|
dilTIAZem 180 mg ER Cap [CQCH]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 63739001510
|
| Hospital Charge Code |
105919167
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of AZ Commercial |
$0.26
|
| Rate for Payer: Aetna of AZ Medicare |
$0.08
|
| Rate for Payer: Allwell Medicare |
$0.05
|
| Rate for Payer: Amerigroup Medicare |
$0.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.11
|
| Rate for Payer: AZCH Complete Medicare |
$0.05
|
| Rate for Payer: Banner UC Health Medicare |
$0.05
|
| Rate for Payer: Bisbee Police All Plans |
$0.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.20
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of AZ Commercial |
$0.19
|
| Rate for Payer: Copperpoint Commercial |
$0.07
|
| Rate for Payer: Health Net of AZ Commercial |
$0.17
|
| Rate for Payer: Health Net of AZ Medicare |
$0.08
|
| Rate for Payer: Humana of AZ Medicare |
$0.05
|
| Rate for Payer: Self Pay Self Pay |
$0.23
|
| Rate for Payer: TriWest Medicare |
$0.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.17
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.05
|
|
|
dilTIAZem 180 mg ER Cap [CQCH]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 63739001510
|
| Hospital Charge Code |
105919167
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of AZ Commercial |
$0.26
|
| Rate for Payer: Bisbee Police All Plans |
$0.08
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Self Pay Self Pay |
$0.23
|
|
|
dilTIAZem 25 mg IV Sol [CQCH]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 17478093705
|
| Hospital Charge Code |
105966082
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of AZ Commercial |
$0.47
|
| Rate for Payer: Bisbee Police All Plans |
$0.14
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Self Pay Self Pay |
$0.42
|
|
|
dilTIAZem 25 mg IV Sol [CQCH]
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 17478093705
|
| Hospital Charge Code |
105966082
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of AZ Commercial |
$0.47
|
| Rate for Payer: Aetna of AZ Medicare |
$0.15
|
| Rate for Payer: Allwell Medicare |
$0.08
|
| Rate for Payer: Amerigroup Medicare |
$0.08
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.19
|
| Rate for Payer: AZCH Complete Medicare |
$0.08
|
| Rate for Payer: Banner UC Health Medicare |
$0.08
|
| Rate for Payer: Bisbee Police All Plans |
$0.14
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.35
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of AZ Commercial |
$0.34
|
| Rate for Payer: Copperpoint Commercial |
$0.13
|
| Rate for Payer: Health Net of AZ Commercial |
$0.31
|
| Rate for Payer: Health Net of AZ Medicare |
$0.15
|
| Rate for Payer: Humana of AZ Medicare |
$0.08
|
| Rate for Payer: Self Pay Self Pay |
$0.42
|
| Rate for Payer: TriWest Medicare |
$0.08
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.30
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.09
|
|
|
dilTIAZem 30 mg Tab [CQCH]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 60687071701
|
| Hospital Charge Code |
105919041
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of AZ Commercial |
$0.39
|
| Rate for Payer: Aetna of AZ Medicare |
$0.12
|
| Rate for Payer: Allwell Medicare |
$0.07
|
| Rate for Payer: Amerigroup Medicare |
$0.07
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.16
|
| Rate for Payer: AZCH Complete Medicare |
$0.07
|
| Rate for Payer: Banner UC Health Medicare |
$0.07
|
| Rate for Payer: Bisbee Police All Plans |
$0.11
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.29
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of AZ Commercial |
$0.28
|
| Rate for Payer: Copperpoint Commercial |
$0.11
|
| Rate for Payer: Health Net of AZ Commercial |
$0.26
|
| Rate for Payer: Health Net of AZ Medicare |
$0.12
|
| Rate for Payer: Humana of AZ Medicare |
$0.07
|
| Rate for Payer: Self Pay Self Pay |
$0.34
|
| Rate for Payer: TriWest Medicare |
$0.07
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.25
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.08
|
|
|
dilTIAZem 30 mg Tab [CQCH]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 60687071701
|
| Hospital Charge Code |
105919041
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of AZ Commercial |
$0.39
|
| Rate for Payer: Bisbee Police All Plans |
$0.11
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Self Pay Self Pay |
$0.34
|
|
|
diphenhydrAMINE 12.5 mg/5 mL Liq UD[CQCH]
|
Facility
|
OP
|
$0.32
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
127935116
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of AZ Commercial |
$0.29
|
| 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 |
$0.08
|
| 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 |
$0.19
|
| 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
|
|
|
diphenhydrAMINE 12.5 mg/5 mL Liq UD[CQCH]
|
Facility
|
IP
|
$0.32
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
127935116
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of AZ Commercial |
$0.29
|
| Rate for Payer: Bisbee Police All Plans |
$0.08
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Self Pay Self Pay |
$0.26
|
|
|
diphenhydrAMINE 25 mg/10 mL Oral Liq [CQCH]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
105919435
|
|
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
|
|
|
diphenhydrAMINE 25 mg/10 mL Oral Liq [CQCH]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
105919435
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of AZ Commercial |
$0.13
|
| Rate for Payer: Bisbee Police All Plans |
$0.04
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Self Pay Self Pay |
$0.11
|
|
|
diphenhydrAMINE 25 mg Cap [CQCH]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
105919293
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Self Pay Self Pay |
$0.02
|
|
|
diphenhydrAMINE 25 mg Cap [CQCH]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
HCPCS Q0163
|
| Hospital Charge Code |
105919293
|
|
Hospital Revenue Code
|
251
|
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Aetna of AZ Medicare |
$0.01
|
| Rate for Payer: Allwell Medicare |
$0.00
|
| Rate for Payer: Amerigroup Medicare |
$0.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.01
|
| Rate for Payer: AZCH Complete Medicare |
$0.00
|
| Rate for Payer: Banner UC Health Medicare |
$0.00
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of AZ Commercial |
$0.02
|
| Rate for Payer: Copperpoint Commercial |
$0.01
|
| Rate for Payer: Health Net of AZ Commercial |
$0.02
|
| Rate for Payer: Health Net of AZ Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.00
|
| Rate for Payer: Self Pay Self Pay |
$0.02
|
| Rate for Payer: TriWest Medicare |
$0.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.02
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.01
|
|
|
diphenhydrAMINE 50 mg/mL Inj Sol [CQCH]
|
Facility
|
IP
|
$0.81
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
105919362
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna of AZ Commercial |
$0.73
|
| Rate for Payer: Bisbee Police All Plans |
$0.21
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Self Pay Self Pay |
$0.65
|
|
|
diphenhydrAMINE 50 mg/mL Inj Sol [CQCH]
|
Facility
|
OP
|
$0.81
|
|
|
Service Code
|
HCPCS J1200
|
| Hospital Charge Code |
105919362
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.73 |
| Rate for Payer: Aetna of AZ Commercial |
$0.73
|
| Rate for Payer: Aetna of AZ Medicare |
$0.23
|
| Rate for Payer: Allwell Medicare |
$0.13
|
| Rate for Payer: Amerigroup Medicare |
$0.13
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.30
|
| Rate for Payer: AZCH Complete Medicare |
$0.13
|
| Rate for Payer: Banner UC Health Medicare |
$0.13
|
| Rate for Payer: Bisbee Police All Plans |
$0.21
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.55
|
| Rate for Payer: Cash Price |
$0.65
|
| Rate for Payer: Cigna of AZ Commercial |
$0.53
|
| Rate for Payer: Copperpoint Commercial |
$0.20
|
| Rate for Payer: Health Net of AZ Commercial |
$0.49
|
| Rate for Payer: Health Net of AZ Medicare |
$0.23
|
| Rate for Payer: Humana of AZ Medicare |
$0.13
|
| Rate for Payer: Self Pay Self Pay |
$0.65
|
| Rate for Payer: TriWest Medicare |
$0.13
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.47
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.15
|
|
|
Direct LDL
|
Facility
|
OP
|
$158.00
|
|
|
Service Code
|
CPT 83721
|
| Hospital Charge Code |
1735730
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$25.28 |
| Max. Negotiated Rate |
$142.20 |
| Rate for Payer: Aetna of AZ Commercial |
$142.20
|
| Rate for Payer: Aetna of AZ Medicare |
$44.24
|
| Rate for Payer: Allwell Medicare |
$25.28
|
| Rate for Payer: Amerigroup Medicare |
$25.28
|
| Rate for Payer: APIPA Medicare/Medicaid |
$59.01
|
| Rate for Payer: AZCH Complete Medicare |
$25.28
|
| Rate for Payer: Banner UC Health Medicare |
$25.28
|
| Rate for Payer: Bisbee Police All Plans |
$41.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$107.44
|
| Rate for Payer: Cash Price |
$126.40
|
| Rate for Payer: Cigna of AZ Commercial |
$102.70
|
| Rate for Payer: Copperpoint Commercial |
$39.10
|
| Rate for Payer: Health Net of AZ Commercial |
$94.80
|
| Rate for Payer: Health Net of AZ Medicare |
$44.24
|
| Rate for Payer: Humana of AZ Medicare |
$25.28
|
| Rate for Payer: Self Pay Self Pay |
$126.40
|
| Rate for Payer: TriWest Medicare |
$25.28
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$92.11
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$28.44
|
|
