|
EPIFIX 4 X 4.5CM
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
27592021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$312.00 |
| Max. Negotiated Rate |
$1,080.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,080.00
|
| Rate for Payer: Bisbee Police All Plans |
$312.00
|
| Rate for Payer: Cash Price |
$960.00
|
| Rate for Payer: Self Pay Self Pay |
$960.00
|
|
|
EPIFIX 5CM X 6CM GRAPH
|
Facility
|
IP
|
$1,519.60
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
23914856
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$395.10 |
| Max. Negotiated Rate |
$1,367.64 |
| Rate for Payer: Aetna of AZ Commercial |
$1,367.64
|
| Rate for Payer: Bisbee Police All Plans |
$395.10
|
| Rate for Payer: Cash Price |
$1,215.68
|
| Rate for Payer: Self Pay Self Pay |
$1,215.68
|
|
|
EPIFIX 5CM X 6CM GRAPH
|
Facility
|
OP
|
$1,519.60
|
|
|
Service Code
|
CPT Q4186
|
| Hospital Charge Code |
23914856
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$227.94 |
| Max. Negotiated Rate |
$1,367.64 |
| Rate for Payer: Aetna of AZ Commercial |
$1,367.64
|
| Rate for Payer: Aetna of AZ Medicare |
$425.49
|
| Rate for Payer: Allwell Medicare |
$227.94
|
| Rate for Payer: Amerigroup Medicare |
$227.94
|
| Rate for Payer: APIPA Medicare/Medicaid |
$567.57
|
| Rate for Payer: AZCH Complete Medicare |
$227.94
|
| Rate for Payer: Banner UC Health Medicare |
$227.94
|
| Rate for Payer: Bisbee Police All Plans |
$395.10
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,033.33
|
| Rate for Payer: Cash Price |
$1,215.68
|
| Rate for Payer: Cigna of AZ Commercial |
$1,063.72
|
| Rate for Payer: Copperpoint Commercial |
$376.10
|
| Rate for Payer: Health Net of AZ Commercial |
$911.76
|
| Rate for Payer: Health Net of AZ Medicare |
$425.49
|
| Rate for Payer: Humana of AZ Medicare |
$227.94
|
| Rate for Payer: Self Pay Self Pay |
$1,215.68
|
| Rate for Payer: TriWest Medicare |
$227.94
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$885.93
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$273.53
|
|
|
EPINEPHrine 0.1 mg/mL Inj PFS 10 mL [CQCH]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
HCPCS J0170
|
| Hospital Charge Code |
105920789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of AZ Commercial |
$0.40
|
| 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 |
$0.30
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Cigna of AZ Commercial |
$0.29
|
| 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 |
$0.35
|
| Rate for Payer: TriWest Medicare |
$0.07
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.26
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.08
|
|
|
EPINEPHrine 0.1 mg/mL Inj PFS 10 mL [CQCH]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
HCPCS J0170
|
| Hospital Charge Code |
105920789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of AZ Commercial |
$0.40
|
| Rate for Payer: Bisbee Police All Plans |
$0.11
|
| Rate for Payer: Cash Price |
$0.35
|
| Rate for Payer: Self Pay Self Pay |
$0.35
|
|
|
EPINEPHrine 1 mg/mL Inj Sol 1 mL [CQCH]
|
Facility
|
IP
|
$12.87
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
105920860
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$11.58 |
| Rate for Payer: Aetna of AZ Commercial |
$11.58
|
| Rate for Payer: Bisbee Police All Plans |
$3.35
|
| Rate for Payer: Cash Price |
$10.30
|
| Rate for Payer: Self Pay Self Pay |
$10.30
|
|
|
EPINEPHrine 1 mg/mL Inj Sol 1 mL [CQCH]
|
Facility
|
OP
|
$12.87
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
105920860
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$11.58 |
| Rate for Payer: Aetna of AZ Commercial |
$11.58
|
| Rate for Payer: Aetna of AZ Medicare |
$3.60
|
| Rate for Payer: AHCCCS Medicaid |
$1.38
|
| Rate for Payer: Allwell Medicaid |
$1.38
|
| Rate for Payer: Allwell Medicare |
$1.93
|
| Rate for Payer: Amerigroup Medicare |
$1.93
|
| Rate for Payer: APIPA Medicare/Medicaid |
$4.81
|
| Rate for Payer: AZCH Complete Medicaid |
$1.38
|
| Rate for Payer: AZCH Complete Medicare |
$1.93
|
| Rate for Payer: Banner UC Health Medicaid |
$1.38
|
| Rate for Payer: Banner UC Health Medicare |
$1.93
|
| Rate for Payer: Bisbee Police All Plans |
$3.35
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$8.75
|
| Rate for Payer: Cash Price |
$10.30
|
| Rate for Payer: Cash Price |
$10.30
|
| Rate for Payer: Cigna of AZ Commercial |
$8.37
|
| Rate for Payer: Copperpoint Commercial |
$3.19
|
| Rate for Payer: Health Net of AZ Commercial |
$7.72
|
| Rate for Payer: Health Net of AZ Medicare |
$3.60
|
| Rate for Payer: Humana of AZ Medicare |
$1.93
|
| Rate for Payer: Mercy Care Medicaid |
$1.38
|
| Rate for Payer: Self Pay Self Pay |
$10.30
|
| Rate for Payer: TriWest Medicare |
$1.93
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$7.50
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$2.32
|
|
|
EPINEPHrine 1 mg/mL Inj Sol 30 mL [CQCH]
|
Facility
|
OP
|
$5.27
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
105920929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$4.74 |
| Rate for Payer: Aetna of AZ Commercial |
$4.74
|
| Rate for Payer: Aetna of AZ Medicare |
$1.48
|
| Rate for Payer: AHCCCS Medicaid |
$1.38
|
| Rate for Payer: Allwell Medicaid |
$1.38
|
| Rate for Payer: Allwell Medicare |
$0.79
|
| Rate for Payer: Amerigroup Medicare |
$0.79
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1.97
|
| Rate for Payer: AZCH Complete Medicaid |
$1.38
|
| Rate for Payer: AZCH Complete Medicare |
$0.79
|
| Rate for Payer: Banner UC Health Medicaid |
$1.38
|
| Rate for Payer: Banner UC Health Medicare |
$0.79
|
| Rate for Payer: Bisbee Police All Plans |
$1.37
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$3.58
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: Cigna of AZ Commercial |
$3.43
|
| Rate for Payer: Copperpoint Commercial |
$1.30
|
| Rate for Payer: Health Net of AZ Commercial |
$3.16
|
| Rate for Payer: Health Net of AZ Medicare |
$1.48
|
| Rate for Payer: Humana of AZ Medicare |
$0.79
|
| Rate for Payer: Mercy Care Medicaid |
$1.38
|
| Rate for Payer: Self Pay Self Pay |
$4.22
|
| Rate for Payer: TriWest Medicare |
$0.79
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3.07
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.95
|
|
|
EPINEPHrine 1 mg/mL Inj Sol 30 mL [CQCH]
|
Facility
|
IP
|
$5.27
|
|
|
Service Code
|
HCPCS J0171
|
| Hospital Charge Code |
105920929
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$4.74 |
| Rate for Payer: Aetna of AZ Commercial |
$4.74
|
| Rate for Payer: Bisbee Police All Plans |
$1.37
|
| Rate for Payer: Cash Price |
$4.22
|
| Rate for Payer: Self Pay Self Pay |
$4.22
|
|
|
EPINEPHrine-lidocaine 1:100000-1% 10 ml Sol [CQCH]
|
Facility
|
OP
|
$0.16
|
|
|
Service Code
|
NDC 63323048217
|
| Hospital Charge Code |
205015963
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| 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 |
$0.02
|
| Rate for Payer: Amerigroup Medicare |
$0.02
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.06
|
| 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 |
$0.11
|
| 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 |
$0.02
|
| Rate for Payer: Self Pay Self Pay |
$0.13
|
| Rate for Payer: TriWest Medicare |
$0.02
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.09
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.03
|
|
|
EPINEPHrine-lidocaine 1:100000-1% 10 ml Sol [CQCH]
|
Facility
|
IP
|
$0.16
|
|
|
Service Code
|
NDC 63323048217
|
| Hospital Charge Code |
205015963
|
|
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
|
|
|
EPINEPHrine-lidocaine 1:100,000-1% Inj Sol 20 mL [CQCH]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 409317801
|
| Hospital Charge Code |
105920998
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of AZ Commercial |
$0.08
|
| Rate for Payer: Bisbee Police All Plans |
$0.02
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Self Pay Self Pay |
$0.07
|
|
|
EPINEPHrine-lidocaine 1:100,000-1% Inj Sol 20 mL [CQCH]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 409317801
|
| Hospital Charge Code |
105920998
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of AZ Commercial |
$0.08
|
| Rate for Payer: Aetna of AZ Medicare |
$0.03
|
| Rate for Payer: Allwell Medicare |
$0.01
|
| Rate for Payer: Amerigroup Medicare |
$0.01
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.03
|
| Rate for Payer: AZCH Complete Medicare |
$0.01
|
| Rate for Payer: Banner UC Health Medicare |
$0.01
|
| Rate for Payer: Bisbee Police All Plans |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of AZ Commercial |
$0.06
|
| Rate for Payer: Copperpoint Commercial |
$0.02
|
| Rate for Payer: Health Net of AZ Commercial |
$0.05
|
| Rate for Payer: Health Net of AZ Medicare |
$0.03
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Self Pay Self Pay |
$0.07
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.05
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.02
|
|
|
EPINEPHrine-lidocaine 1:100000-1% Sol 50 ml [CQCH]
|
Facility
|
IP
|
$135.12
|
|
|
Service Code
|
NDC 63323048257
|
| Hospital Charge Code |
205010803
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.13 |
| Max. Negotiated Rate |
$121.61 |
| Rate for Payer: Aetna of AZ Commercial |
$121.61
|
| Rate for Payer: Bisbee Police All Plans |
$35.13
|
| Rate for Payer: Cash Price |
$108.10
|
| Rate for Payer: Self Pay Self Pay |
$108.10
|
|
|
EPINEPHrine-lidocaine 1:100000-1% Sol 50 ml [CQCH]
|
Facility
|
OP
|
$135.12
|
|
|
Service Code
|
NDC 63323048257
|
| Hospital Charge Code |
205010803
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$121.61 |
| Rate for Payer: Aetna of AZ Commercial |
$121.61
|
| Rate for Payer: Aetna of AZ Medicare |
$37.83
|
| Rate for Payer: Allwell Medicare |
$20.27
|
| Rate for Payer: Amerigroup Medicare |
$20.27
|
| Rate for Payer: APIPA Medicare/Medicaid |
$50.47
|
| Rate for Payer: AZCH Complete Medicare |
$20.27
|
| Rate for Payer: Banner UC Health Medicare |
$20.27
|
| Rate for Payer: Bisbee Police All Plans |
$35.13
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$91.88
|
| Rate for Payer: Cash Price |
$108.10
|
| Rate for Payer: Cigna of AZ Commercial |
$87.83
|
| Rate for Payer: Copperpoint Commercial |
$33.44
|
| Rate for Payer: Health Net of AZ Commercial |
$81.07
|
| Rate for Payer: Health Net of AZ Medicare |
$37.83
|
| Rate for Payer: Humana of AZ Medicare |
$20.27
|
| Rate for Payer: Self Pay Self Pay |
$108.10
|
| Rate for Payer: TriWest Medicare |
$20.27
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$78.77
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$24.32
|
|
|
EPINEPHrine-lidocaine 1:100000-2% Sol 20 mL [CQCH]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
108918758
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of AZ Commercial |
$0.05
|
| Rate for Payer: Aetna of AZ Medicare |
$0.01
|
| Rate for Payer: AHCCCS Medicaid |
$0.04
|
| Rate for Payer: Allwell Medicaid |
$0.04
|
| Rate for Payer: Allwell Medicare |
$0.01
|
| Rate for Payer: Amerigroup Medicare |
$0.01
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.02
|
| Rate for Payer: AZCH Complete Medicaid |
$0.04
|
| Rate for Payer: AZCH Complete Medicare |
$0.01
|
| Rate for Payer: Banner UC Health Medicaid |
$0.04
|
| Rate for Payer: Banner UC Health Medicare |
$0.01
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of AZ Commercial |
$0.03
|
| Rate for Payer: Copperpoint Commercial |
$0.01
|
| Rate for Payer: Health Net of AZ Commercial |
$0.03
|
| Rate for Payer: Health Net of AZ Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Mercy Care Medicaid |
$0.04
|
| Rate for Payer: Self Pay Self Pay |
$0.04
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.03
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.01
|
|
|
EPINEPHrine-lidocaine 1:100000-2% Sol 20 mL [CQCH]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
108918758
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of AZ Commercial |
$0.05
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Self Pay Self Pay |
$0.04
|
|
|
EPINEPHrine-lidocaine 1:200,000-0.5% Inj Sol 50 mL [CQCH]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 63323048157
|
| Hospital Charge Code |
105921073
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of AZ Commercial |
$0.04
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Self Pay Self Pay |
$0.03
|
|
|
EPINEPHrine-lidocaine 1:200,000-0.5% Inj Sol 50 mL [CQCH]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 63323048157
|
| Hospital Charge Code |
105921073
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of AZ Commercial |
$0.04
|
| Rate for Payer: Aetna of AZ Medicare |
$0.01
|
| Rate for Payer: Allwell Medicare |
$0.01
|
| Rate for Payer: Amerigroup Medicare |
$0.01
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.01
|
| Rate for Payer: AZCH Complete Medicare |
$0.01
|
| Rate for Payer: Banner UC Health Medicare |
$0.01
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of AZ Commercial |
$0.03
|
| 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 |
$0.01
|
| Rate for Payer: Self Pay Self Pay |
$0.03
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.02
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.01
|
|
|
EPISTAXIS ANTERIOR/POSTERIOR
|
Facility
|
IP
|
$159.00
|
|
| Hospital Charge Code |
22354927
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$41.34 |
| Max. Negotiated Rate |
$143.10 |
| Rate for Payer: Aetna of AZ Commercial |
$143.10
|
| Rate for Payer: Bisbee Police All Plans |
$41.34
|
| Rate for Payer: Cash Price |
$127.20
|
| Rate for Payer: Self Pay Self Pay |
$127.20
|
|
|
EPISTAXIS ANTERIOR/POSTERIOR
|
Facility
|
OP
|
$159.00
|
|
| Hospital Charge Code |
22354927
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$23.85 |
| Max. Negotiated Rate |
$143.10 |
| Rate for Payer: Aetna of AZ Commercial |
$143.10
|
| Rate for Payer: Aetna of AZ Medicare |
$44.52
|
| Rate for Payer: Allwell Medicare |
$23.85
|
| Rate for Payer: Amerigroup Medicare |
$23.85
|
| Rate for Payer: APIPA Medicare/Medicaid |
$59.39
|
| Rate for Payer: AZCH Complete Medicare |
$23.85
|
| Rate for Payer: Banner UC Health Medicare |
$23.85
|
| Rate for Payer: Bisbee Police All Plans |
$41.34
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$108.12
|
| Rate for Payer: Cash Price |
$127.20
|
| Rate for Payer: Cigna of AZ Commercial |
$111.30
|
| Rate for Payer: Copperpoint Commercial |
$39.35
|
| Rate for Payer: Health Net of AZ Commercial |
$95.40
|
| Rate for Payer: Health Net of AZ Medicare |
$44.52
|
| Rate for Payer: Humana of AZ Medicare |
$23.85
|
| Rate for Payer: Self Pay Self Pay |
$127.20
|
| Rate for Payer: TriWest Medicare |
$23.85
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$92.70
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$28.62
|
|
|
epoetin alfa 40,000 units/mL preservative-free Sol[CQCH]
|
Facility
|
IP
|
$559.94
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
239902997
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$145.58 |
| Max. Negotiated Rate |
$503.95 |
| Rate for Payer: Aetna of AZ Commercial |
$503.95
|
| Rate for Payer: Bisbee Police All Plans |
$145.58
|
| Rate for Payer: Cash Price |
$447.95
|
| Rate for Payer: Self Pay Self Pay |
$447.95
|
|
|
epoetin alfa 40,000 units/mL preservative-free Sol[CQCH]
|
Facility
|
OP
|
$559.94
|
|
|
Service Code
|
HCPCS J0885
|
| Hospital Charge Code |
239902997
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.20 |
| Max. Negotiated Rate |
$503.95 |
| Rate for Payer: Aetna of AZ Commercial |
$503.95
|
| Rate for Payer: Aetna of AZ Medicare |
$156.78
|
| Rate for Payer: AHCCCS Medicaid |
$13.20
|
| Rate for Payer: Allwell Medicaid |
$13.20
|
| Rate for Payer: Allwell Medicare |
$83.99
|
| Rate for Payer: Amerigroup Medicare |
$83.99
|
| Rate for Payer: APIPA Medicare/Medicaid |
$209.14
|
| Rate for Payer: AZCH Complete Medicaid |
$13.20
|
| Rate for Payer: AZCH Complete Medicare |
$83.99
|
| Rate for Payer: Banner UC Health Medicaid |
$13.20
|
| Rate for Payer: Banner UC Health Medicare |
$83.99
|
| Rate for Payer: Bisbee Police All Plans |
$145.58
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$380.76
|
| Rate for Payer: Cash Price |
$447.95
|
| Rate for Payer: Cash Price |
$447.95
|
| Rate for Payer: Cigna of AZ Commercial |
$363.96
|
| Rate for Payer: Copperpoint Commercial |
$138.59
|
| Rate for Payer: Health Net of AZ Commercial |
$335.96
|
| Rate for Payer: Health Net of AZ Medicare |
$156.78
|
| Rate for Payer: Humana of AZ Medicare |
$83.99
|
| Rate for Payer: Mercy Care Medicaid |
$13.20
|
| Rate for Payer: Self Pay Self Pay |
$447.95
|
| Rate for Payer: TriWest Medicare |
$83.99
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$326.45
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$100.79
|
|
|
eptifibatide 0.75 mg/mL IV Sol [CQCH]
|
Facility
|
IP
|
$0.58
|
|
|
Service Code
|
HCPCS J1327
|
| Hospital Charge Code |
105921209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Aetna of AZ Commercial |
$0.52
|
| Rate for Payer: Bisbee Police All Plans |
$0.15
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Self Pay Self Pay |
$0.46
|
|
|
eptifibatide 0.75 mg/mL IV Sol [CQCH]
|
Facility
|
OP
|
$0.58
|
|
|
Service Code
|
HCPCS J1327
|
| Hospital Charge Code |
105921209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$21.80 |
| Rate for Payer: Aetna of AZ Commercial |
$0.52
|
| Rate for Payer: Aetna of AZ Medicare |
$0.16
|
| Rate for Payer: AHCCCS Medicaid |
$21.80
|
| Rate for Payer: Allwell Medicaid |
$21.80
|
| Rate for Payer: Allwell Medicare |
$0.09
|
| Rate for Payer: Amerigroup Medicare |
$0.09
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.22
|
| Rate for Payer: AZCH Complete Medicaid |
$21.80
|
| Rate for Payer: AZCH Complete Medicare |
$0.09
|
| Rate for Payer: Banner UC Health Medicaid |
$21.80
|
| Rate for Payer: Banner UC Health Medicare |
$0.09
|
| Rate for Payer: Bisbee Police All Plans |
$0.15
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.39
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cash Price |
$0.46
|
| Rate for Payer: Cigna of AZ Commercial |
$0.38
|
| Rate for Payer: Copperpoint Commercial |
$0.14
|
| Rate for Payer: Health Net of AZ Commercial |
$0.35
|
| Rate for Payer: Health Net of AZ Medicare |
$0.16
|
| Rate for Payer: Humana of AZ Medicare |
$0.09
|
| Rate for Payer: Mercy Care Medicaid |
$21.80
|
| Rate for Payer: Self Pay Self Pay |
$0.46
|
| Rate for Payer: TriWest Medicare |
$0.09
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.34
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.10
|
|
