|
eptifibatide 2 mg/mL IV Sol [CQCH]
|
Facility
|
IP
|
$1.93
|
|
|
Service Code
|
HCPCS J1327
|
| Hospital Charge Code |
105921282
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$1.74 |
| Rate for Payer: Aetna of AZ Commercial |
$1.74
|
| Rate for Payer: Bisbee Police All Plans |
$0.50
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Self Pay Self Pay |
$1.54
|
|
|
eptifibatide 2 mg/mL IV Sol [CQCH]
|
Facility
|
OP
|
$1.93
|
|
|
Service Code
|
HCPCS J1327
|
| Hospital Charge Code |
105921282
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$21.80 |
| Rate for Payer: Aetna of AZ Commercial |
$1.74
|
| Rate for Payer: Aetna of AZ Medicare |
$0.54
|
| Rate for Payer: AHCCCS Medicaid |
$21.80
|
| Rate for Payer: Allwell Medicaid |
$21.80
|
| Rate for Payer: Allwell Medicare |
$0.29
|
| Rate for Payer: Amerigroup Medicare |
$0.29
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.72
|
| Rate for Payer: AZCH Complete Medicaid |
$21.80
|
| Rate for Payer: AZCH Complete Medicare |
$0.29
|
| Rate for Payer: Banner UC Health Medicaid |
$21.80
|
| Rate for Payer: Banner UC Health Medicare |
$0.29
|
| Rate for Payer: Bisbee Police All Plans |
$0.50
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.31
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Cash Price |
$1.55
|
| Rate for Payer: Cigna of AZ Commercial |
$1.25
|
| Rate for Payer: Copperpoint Commercial |
$0.48
|
| Rate for Payer: Health Net of AZ Commercial |
$1.16
|
| Rate for Payer: Health Net of AZ Medicare |
$0.54
|
| Rate for Payer: Humana of AZ Medicare |
$0.29
|
| Rate for Payer: Mercy Care Medicaid |
$21.80
|
| Rate for Payer: Self Pay Self Pay |
$1.54
|
| Rate for Payer: TriWest Medicare |
$0.29
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1.13
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.35
|
|
|
ERBE FIAPC PROBE REF#20132-218
|
Facility
|
IP
|
$738.00
|
|
| Hospital Charge Code |
23152397
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$191.88 |
| Max. Negotiated Rate |
$664.20 |
| Rate for Payer: Aetna of AZ Commercial |
$664.20
|
| Rate for Payer: Bisbee Police All Plans |
$191.88
|
| Rate for Payer: Cash Price |
$590.40
|
| Rate for Payer: Self Pay Self Pay |
$590.40
|
|
|
ERBE FIAPC PROBE REF#20132-218
|
Facility
|
OP
|
$738.00
|
|
| Hospital Charge Code |
23152397
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$110.70 |
| Max. Negotiated Rate |
$664.20 |
| Rate for Payer: Aetna of AZ Commercial |
$664.20
|
| Rate for Payer: Aetna of AZ Medicare |
$206.64
|
| Rate for Payer: Allwell Medicare |
$110.70
|
| Rate for Payer: Amerigroup Medicare |
$110.70
|
| Rate for Payer: APIPA Medicare/Medicaid |
$275.64
|
| Rate for Payer: AZCH Complete Medicare |
$110.70
|
| Rate for Payer: Banner UC Health Medicare |
$110.70
|
| Rate for Payer: Bisbee Police All Plans |
$191.88
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$501.84
|
| Rate for Payer: Cash Price |
$590.40
|
| Rate for Payer: Cigna of AZ Commercial |
$516.60
|
| Rate for Payer: Copperpoint Commercial |
$182.66
|
| Rate for Payer: Health Net of AZ Commercial |
$442.80
|
| Rate for Payer: Health Net of AZ Medicare |
$206.64
|
| Rate for Payer: Humana of AZ Medicare |
$110.70
|
| Rate for Payer: Self Pay Self Pay |
$590.40
|
| Rate for Payer: TriWest Medicare |
$110.70
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$430.25
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$132.84
|
|
|
ertapenem 1 gm Inj [CQCH]
|
Facility
|
IP
|
$74.41
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
105921355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.35 |
| Max. Negotiated Rate |
$66.97 |
| Rate for Payer: Aetna of AZ Commercial |
$66.97
|
| Rate for Payer: Bisbee Police All Plans |
$19.35
|
| Rate for Payer: Cash Price |
$59.53
|
| Rate for Payer: Self Pay Self Pay |
$59.53
|
|
|
ertapenem 1 gm Inj [CQCH]
|
Facility
|
OP
|
$74.41
|
|
|
Service Code
|
HCPCS J1335
|
| Hospital Charge Code |
105921355
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.16 |
| Max. Negotiated Rate |
$66.97 |
| Rate for Payer: Aetna of AZ Commercial |
$66.97
|
| Rate for Payer: Aetna of AZ Medicare |
$20.83
|
| Rate for Payer: AHCCCS Medicaid |
$29.20
|
| Rate for Payer: Allwell Medicaid |
$29.20
|
| Rate for Payer: Allwell Medicare |
$11.16
|
| Rate for Payer: Amerigroup Medicare |
$11.16
|
| Rate for Payer: APIPA Medicare/Medicaid |
$27.79
|
| Rate for Payer: AZCH Complete Medicaid |
$29.20
|
| Rate for Payer: AZCH Complete Medicare |
$11.16
|
| Rate for Payer: Banner UC Health Medicaid |
$29.20
|
| Rate for Payer: Banner UC Health Medicare |
$11.16
|
| Rate for Payer: Bisbee Police All Plans |
$19.35
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$50.60
|
| Rate for Payer: Cash Price |
$59.53
|
| Rate for Payer: Cash Price |
$59.53
|
| Rate for Payer: Cigna of AZ Commercial |
$48.37
|
| Rate for Payer: Copperpoint Commercial |
$18.42
|
| Rate for Payer: Health Net of AZ Commercial |
$44.65
|
| Rate for Payer: Health Net of AZ Medicare |
$20.83
|
| Rate for Payer: Humana of AZ Medicare |
$11.16
|
| Rate for Payer: Mercy Care Medicaid |
$29.20
|
| Rate for Payer: Self Pay Self Pay |
$59.53
|
| Rate for Payer: TriWest Medicare |
$11.16
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$43.38
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$13.39
|
|
|
erythromycin base 250 mg Tab [CQCH]
|
Facility
|
IP
|
$6.98
|
|
|
Service Code
|
NDC 24338010213
|
| Hospital Charge Code |
105921514
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$6.28 |
| Rate for Payer: Aetna of AZ Commercial |
$6.28
|
| Rate for Payer: Bisbee Police All Plans |
$1.81
|
| Rate for Payer: Cash Price |
$5.58
|
| Rate for Payer: Self Pay Self Pay |
$5.58
|
|
|
erythromycin base 250 mg Tab [CQCH]
|
Facility
|
OP
|
$6.98
|
|
|
Service Code
|
NDC 24338010213
|
| Hospital Charge Code |
105921514
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$6.28 |
| Rate for Payer: Aetna of AZ Commercial |
$6.28
|
| Rate for Payer: Aetna of AZ Medicare |
$1.95
|
| Rate for Payer: Allwell Medicare |
$1.05
|
| Rate for Payer: Amerigroup Medicare |
$1.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$2.61
|
| Rate for Payer: AZCH Complete Medicare |
$1.05
|
| Rate for Payer: Banner UC Health Medicare |
$1.05
|
| Rate for Payer: Bisbee Police All Plans |
$1.81
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$4.75
|
| Rate for Payer: Cash Price |
$5.58
|
| Rate for Payer: Cigna of AZ Commercial |
$4.54
|
| Rate for Payer: Copperpoint Commercial |
$1.73
|
| Rate for Payer: Health Net of AZ Commercial |
$4.19
|
| Rate for Payer: Health Net of AZ Medicare |
$1.95
|
| Rate for Payer: Humana of AZ Medicare |
$1.05
|
| Rate for Payer: Self Pay Self Pay |
$5.58
|
| Rate for Payer: TriWest Medicare |
$1.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$4.07
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$1.26
|
|
|
erythromycin lactobionate 500 mg Inj [CQCH]
|
Facility
|
IP
|
$41.00
|
|
|
Service Code
|
HCPCS J1364
|
| Hospital Charge Code |
105921428
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.66 |
| Max. Negotiated Rate |
$36.90 |
| Rate for Payer: Aetna of AZ Commercial |
$36.90
|
| Rate for Payer: Bisbee Police All Plans |
$10.66
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Self Pay Self Pay |
$32.80
|
|
|
erythromycin lactobionate 500 mg Inj [CQCH]
|
Facility
|
OP
|
$41.00
|
|
|
Service Code
|
HCPCS J1364
|
| Hospital Charge Code |
105921428
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.15 |
| Max. Negotiated Rate |
$133.72 |
| Rate for Payer: Aetna of AZ Commercial |
$36.90
|
| Rate for Payer: Aetna of AZ Medicare |
$11.48
|
| Rate for Payer: AHCCCS Medicaid |
$133.72
|
| Rate for Payer: Allwell Medicaid |
$133.72
|
| Rate for Payer: Allwell Medicare |
$6.15
|
| Rate for Payer: Amerigroup Medicare |
$6.15
|
| Rate for Payer: APIPA Medicare/Medicaid |
$15.31
|
| Rate for Payer: AZCH Complete Medicaid |
$133.72
|
| Rate for Payer: AZCH Complete Medicare |
$6.15
|
| Rate for Payer: Banner UC Health Medicaid |
$133.72
|
| Rate for Payer: Banner UC Health Medicare |
$6.15
|
| Rate for Payer: Bisbee Police All Plans |
$10.66
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$27.88
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Cash Price |
$32.80
|
| Rate for Payer: Cigna of AZ Commercial |
$26.65
|
| Rate for Payer: Copperpoint Commercial |
$10.15
|
| Rate for Payer: Health Net of AZ Commercial |
$24.60
|
| Rate for Payer: Health Net of AZ Medicare |
$11.48
|
| Rate for Payer: Humana of AZ Medicare |
$6.15
|
| Rate for Payer: Mercy Care Medicaid |
$133.72
|
| Rate for Payer: Self Pay Self Pay |
$32.80
|
| Rate for Payer: TriWest Medicare |
$6.15
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$23.90
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$7.38
|
|
|
erythromycin Ophth 0.5% Oint 1gm Ud [CQCH]
|
Facility
|
IP
|
$7.82
|
|
|
Service Code
|
NDC 17478007031
|
| Hospital Charge Code |
105921579
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$7.04 |
| Rate for Payer: Aetna of AZ Commercial |
$7.04
|
| Rate for Payer: Bisbee Police All Plans |
$2.03
|
| Rate for Payer: Cash Price |
$6.26
|
| Rate for Payer: Self Pay Self Pay |
$6.26
|
|
|
erythromycin Ophth 0.5% Oint 1gm Ud [CQCH]
|
Facility
|
OP
|
$7.82
|
|
|
Service Code
|
NDC 17478007031
|
| Hospital Charge Code |
105921579
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$7.04 |
| Rate for Payer: Aetna of AZ Commercial |
$7.04
|
| Rate for Payer: Aetna of AZ Medicare |
$2.19
|
| Rate for Payer: Allwell Medicare |
$1.17
|
| Rate for Payer: Amerigroup Medicare |
$1.17
|
| Rate for Payer: APIPA Medicare/Medicaid |
$2.92
|
| Rate for Payer: AZCH Complete Medicare |
$1.17
|
| Rate for Payer: Banner UC Health Medicare |
$1.17
|
| Rate for Payer: Bisbee Police All Plans |
$2.03
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$5.32
|
| Rate for Payer: Cash Price |
$6.26
|
| Rate for Payer: Cigna of AZ Commercial |
$5.08
|
| Rate for Payer: Copperpoint Commercial |
$1.94
|
| Rate for Payer: Health Net of AZ Commercial |
$4.69
|
| Rate for Payer: Health Net of AZ Medicare |
$2.19
|
| Rate for Payer: Humana of AZ Medicare |
$1.17
|
| Rate for Payer: Self Pay Self Pay |
$6.26
|
| Rate for Payer: TriWest Medicare |
$1.17
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$4.56
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$1.41
|
|
|
Erythropoietin (EPO), Serum LC
|
Facility
|
IP
|
$379.00
|
|
|
Service Code
|
CPT 82668
|
| Hospital Charge Code |
1906839
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$98.54 |
| Max. Negotiated Rate |
$341.10 |
| Rate for Payer: Aetna of AZ Commercial |
$341.10
|
| Rate for Payer: Bisbee Police All Plans |
$98.54
|
| Rate for Payer: Cash Price |
$303.20
|
| Rate for Payer: Self Pay Self Pay |
$303.20
|
|
|
Erythropoietin (EPO), Serum LC
|
Facility
|
OP
|
$379.00
|
|
|
Service Code
|
CPT 82668
|
| Hospital Charge Code |
1906839
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.79 |
| Max. Negotiated Rate |
$341.10 |
| Rate for Payer: Aetna of AZ Commercial |
$341.10
|
| Rate for Payer: Aetna of AZ Medicare |
$106.12
|
| Rate for Payer: AHCCCS Medicaid |
$18.79
|
| Rate for Payer: Allwell Medicaid |
$18.79
|
| Rate for Payer: Allwell Medicare |
$56.85
|
| Rate for Payer: Amerigroup Medicare |
$56.85
|
| Rate for Payer: APIPA Medicare/Medicaid |
$141.56
|
| Rate for Payer: AZCH Complete Medicaid |
$18.79
|
| Rate for Payer: AZCH Complete Medicare |
$56.85
|
| Rate for Payer: Banner UC Health Medicaid |
$18.79
|
| Rate for Payer: Banner UC Health Medicare |
$56.85
|
| Rate for Payer: Bisbee Police All Plans |
$98.54
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$257.72
|
| Rate for Payer: Cash Price |
$303.20
|
| Rate for Payer: Cash Price |
$303.20
|
| Rate for Payer: Cigna of AZ Commercial |
$246.35
|
| Rate for Payer: Copperpoint Commercial |
$93.80
|
| Rate for Payer: Health Net of AZ Commercial |
$227.40
|
| Rate for Payer: Health Net of AZ Medicare |
$106.12
|
| Rate for Payer: Humana of AZ Medicare |
$56.85
|
| Rate for Payer: Mercy Care Medicaid |
$18.79
|
| Rate for Payer: Self Pay Self Pay |
$303.20
|
| Rate for Payer: TriWest Medicare |
$56.85
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$220.96
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$68.22
|
|
|
ESG PLASMALOOP LARGE 12
|
Facility
|
OP
|
$2,664.00
|
|
| Hospital Charge Code |
27748824
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$399.60 |
| Max. Negotiated Rate |
$2,397.60 |
| Rate for Payer: Aetna of AZ Commercial |
$2,397.60
|
| Rate for Payer: Aetna of AZ Medicare |
$745.92
|
| Rate for Payer: Allwell Medicare |
$399.60
|
| Rate for Payer: Amerigroup Medicare |
$399.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$995.00
|
| Rate for Payer: AZCH Complete Medicare |
$399.60
|
| Rate for Payer: Banner UC Health Medicare |
$399.60
|
| Rate for Payer: Bisbee Police All Plans |
$692.64
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,811.52
|
| Rate for Payer: Cash Price |
$2,131.20
|
| Rate for Payer: Cigna of AZ Commercial |
$1,864.80
|
| Rate for Payer: Copperpoint Commercial |
$659.34
|
| Rate for Payer: Health Net of AZ Commercial |
$1,598.40
|
| Rate for Payer: Health Net of AZ Medicare |
$745.92
|
| Rate for Payer: Humana of AZ Medicare |
$399.60
|
| Rate for Payer: Self Pay Self Pay |
$2,131.20
|
| Rate for Payer: TriWest Medicare |
$399.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,553.11
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$479.52
|
|
|
ESG PLASMALOOP LARGE 12
|
Facility
|
IP
|
$2,664.00
|
|
| Hospital Charge Code |
27748824
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$692.64 |
| Max. Negotiated Rate |
$2,397.60 |
| Rate for Payer: Aetna of AZ Commercial |
$2,397.60
|
| Rate for Payer: Bisbee Police All Plans |
$692.64
|
| Rate for Payer: Cash Price |
$2,131.20
|
| Rate for Payer: Self Pay Self Pay |
$2,131.20
|
|
|
ESG PLASMALOOP MEDIUM 12
|
Facility
|
OP
|
$1,594.00
|
|
| Hospital Charge Code |
23278406
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$239.10 |
| Max. Negotiated Rate |
$1,434.60 |
| Rate for Payer: Aetna of AZ Commercial |
$1,434.60
|
| Rate for Payer: Aetna of AZ Medicare |
$446.32
|
| Rate for Payer: Allwell Medicare |
$239.10
|
| Rate for Payer: Amerigroup Medicare |
$239.10
|
| Rate for Payer: APIPA Medicare/Medicaid |
$595.36
|
| Rate for Payer: AZCH Complete Medicare |
$239.10
|
| Rate for Payer: Banner UC Health Medicare |
$239.10
|
| Rate for Payer: Bisbee Police All Plans |
$414.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,083.92
|
| Rate for Payer: Cash Price |
$1,275.20
|
| Rate for Payer: Cigna of AZ Commercial |
$1,115.80
|
| Rate for Payer: Copperpoint Commercial |
$394.52
|
| Rate for Payer: Health Net of AZ Commercial |
$956.40
|
| Rate for Payer: Health Net of AZ Medicare |
$446.32
|
| Rate for Payer: Humana of AZ Medicare |
$239.10
|
| Rate for Payer: Self Pay Self Pay |
$1,275.20
|
| Rate for Payer: TriWest Medicare |
$239.10
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$929.30
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$286.92
|
|
|
ESG PLASMALOOP MEDIUM 12
|
Facility
|
IP
|
$1,594.00
|
|
| Hospital Charge Code |
23278406
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$414.44 |
| Max. Negotiated Rate |
$1,434.60 |
| Rate for Payer: Aetna of AZ Commercial |
$1,434.60
|
| Rate for Payer: Bisbee Police All Plans |
$414.44
|
| Rate for Payer: Cash Price |
$1,275.20
|
| Rate for Payer: Self Pay Self Pay |
$1,275.20
|
|
|
ESMARK 4''''
|
Facility
|
IP
|
$11.00
|
|
| Hospital Charge Code |
22926421
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.86 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Aetna of AZ Commercial |
$9.90
|
| Rate for Payer: Bisbee Police All Plans |
$2.86
|
| Rate for Payer: Cash Price |
$8.80
|
| Rate for Payer: Self Pay Self Pay |
$8.80
|
|
|
ESMARK 4''''
|
Facility
|
OP
|
$11.00
|
|
| Hospital Charge Code |
22926421
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$9.90 |
| Rate for Payer: Aetna of AZ Commercial |
$9.90
|
| Rate for Payer: Aetna of AZ Medicare |
$3.08
|
| Rate for Payer: Allwell Medicare |
$1.65
|
| Rate for Payer: Amerigroup Medicare |
$1.65
|
| Rate for Payer: APIPA Medicare/Medicaid |
$4.11
|
| Rate for Payer: AZCH Complete Medicare |
$1.65
|
| Rate for Payer: Banner UC Health Medicare |
$1.65
|
| Rate for Payer: Bisbee Police All Plans |
$2.86
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$7.48
|
| Rate for Payer: Cash Price |
$8.80
|
| Rate for Payer: Cigna of AZ Commercial |
$7.70
|
| Rate for Payer: Copperpoint Commercial |
$2.72
|
| Rate for Payer: Health Net of AZ Commercial |
$6.60
|
| Rate for Payer: Health Net of AZ Medicare |
$3.08
|
| Rate for Payer: Humana of AZ Medicare |
$1.65
|
| Rate for Payer: Self Pay Self Pay |
$8.80
|
| Rate for Payer: TriWest Medicare |
$1.65
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$6.41
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$1.98
|
|
|
ESMARK 6''''
|
Facility
|
IP
|
$18.00
|
|
| Hospital Charge Code |
22926422
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$16.20 |
| Rate for Payer: Aetna of AZ Commercial |
$16.20
|
| Rate for Payer: Bisbee Police All Plans |
$4.68
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Self Pay Self Pay |
$14.40
|
|
|
ESMARK 6''''
|
Facility
|
OP
|
$18.00
|
|
| Hospital Charge Code |
22926422
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$16.20 |
| Rate for Payer: Aetna of AZ Commercial |
$16.20
|
| Rate for Payer: Aetna of AZ Medicare |
$5.04
|
| Rate for Payer: Allwell Medicare |
$2.70
|
| Rate for Payer: Amerigroup Medicare |
$2.70
|
| Rate for Payer: APIPA Medicare/Medicaid |
$6.72
|
| Rate for Payer: AZCH Complete Medicare |
$2.70
|
| Rate for Payer: Banner UC Health Medicare |
$2.70
|
| Rate for Payer: Bisbee Police All Plans |
$4.68
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$12.24
|
| Rate for Payer: Cash Price |
$14.40
|
| Rate for Payer: Cigna of AZ Commercial |
$12.60
|
| Rate for Payer: Copperpoint Commercial |
$4.46
|
| Rate for Payer: Health Net of AZ Commercial |
$10.80
|
| Rate for Payer: Health Net of AZ Medicare |
$5.04
|
| Rate for Payer: Humana of AZ Medicare |
$2.70
|
| Rate for Payer: Self Pay Self Pay |
$14.40
|
| Rate for Payer: TriWest Medicare |
$2.70
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$10.49
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$3.24
|
|
|
esmolol 10 mg/mL Sol[CQCH]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
HCPCS J1805
|
| Hospital Charge Code |
233028583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of AZ Commercial |
$0.17
|
| Rate for Payer: Aetna of AZ Medicare |
$0.05
|
| Rate for Payer: AHCCCS Medicaid |
$0.48
|
| Rate for Payer: Allwell Medicaid |
$0.48
|
| 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 Medicaid |
$0.48
|
| Rate for Payer: AZCH Complete Medicare |
$0.03
|
| Rate for Payer: Banner UC Health Medicaid |
$0.48
|
| 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 |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of AZ Commercial |
$0.12
|
| Rate for Payer: Copperpoint Commercial |
$0.05
|
| Rate for Payer: Health Net of AZ Commercial |
$0.11
|
| Rate for Payer: Health Net of AZ Medicare |
$0.05
|
| Rate for Payer: Humana of AZ Medicare |
$0.03
|
| Rate for Payer: Mercy Care Medicaid |
$0.48
|
| Rate for Payer: Self Pay Self Pay |
$0.15
|
| Rate for Payer: TriWest Medicare |
$0.03
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.11
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.03
|
|
|
esmolol 10 mg/mL Sol[CQCH]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
HCPCS J1805
|
| Hospital Charge Code |
233028583
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of AZ Commercial |
$0.17
|
| Rate for Payer: Bisbee Police All Plans |
$0.05
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Self Pay Self Pay |
$0.15
|
|
|
ESOPHAGEAL VARICIES BANDING
|
Facility
|
IP
|
$6,347.00
|
|
|
Service Code
|
CPT 43244
|
| Hospital Charge Code |
23598982
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$1,650.22 |
| Max. Negotiated Rate |
$5,712.30 |
| Rate for Payer: Aetna of AZ Commercial |
$5,712.30
|
| Rate for Payer: Bisbee Police All Plans |
$1,650.22
|
| Rate for Payer: Cash Price |
$5,077.60
|
| Rate for Payer: Self Pay Self Pay |
$5,077.60
|
|
