|
.Fungal Cult LC
|
Facility
|
OP
|
$243.00
|
|
|
Service Code
|
CPT 87101
|
| Hospital Charge Code |
9228407
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$218.70 |
| Rate for Payer: Aetna of AZ Commercial |
$218.70
|
| Rate for Payer: Aetna of AZ Medicare |
$68.04
|
| Rate for Payer: AHCCCS Medicaid |
$7.71
|
| Rate for Payer: Allwell Medicaid |
$7.71
|
| Rate for Payer: Allwell Medicare |
$36.45
|
| Rate for Payer: Amerigroup Medicare |
$36.45
|
| Rate for Payer: APIPA Medicare/Medicaid |
$90.76
|
| Rate for Payer: AZCH Complete Medicaid |
$7.71
|
| Rate for Payer: AZCH Complete Medicare |
$36.45
|
| Rate for Payer: Banner UC Health Medicaid |
$7.71
|
| Rate for Payer: Banner UC Health Medicare |
$36.45
|
| Rate for Payer: Bisbee Police All Plans |
$63.18
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$165.24
|
| Rate for Payer: Cash Price |
$194.40
|
| Rate for Payer: Cash Price |
$194.40
|
| Rate for Payer: Cigna of AZ Commercial |
$157.95
|
| Rate for Payer: Copperpoint Commercial |
$60.14
|
| Rate for Payer: Health Net of AZ Commercial |
$145.80
|
| Rate for Payer: Health Net of AZ Medicare |
$68.04
|
| Rate for Payer: Humana of AZ Medicare |
$36.45
|
| Rate for Payer: Mercy Care Medicaid |
$7.71
|
| Rate for Payer: Self Pay Self Pay |
$194.40
|
| Rate for Payer: TriWest Medicare |
$36.45
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$141.67
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$43.74
|
|
|
Fungus (Mycology) Culture LC
|
Facility
|
OP
|
$255.00
|
|
|
Service Code
|
CPT 87101
|
| Hospital Charge Code |
1905615
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$7.71 |
| Max. Negotiated Rate |
$229.50 |
| Rate for Payer: Aetna of AZ Commercial |
$229.50
|
| Rate for Payer: Aetna of AZ Medicare |
$71.40
|
| Rate for Payer: AHCCCS Medicaid |
$7.71
|
| Rate for Payer: Allwell Medicaid |
$7.71
|
| Rate for Payer: Allwell Medicare |
$38.25
|
| Rate for Payer: Amerigroup Medicare |
$38.25
|
| Rate for Payer: APIPA Medicare/Medicaid |
$95.24
|
| Rate for Payer: AZCH Complete Medicaid |
$7.71
|
| Rate for Payer: AZCH Complete Medicare |
$38.25
|
| Rate for Payer: Banner UC Health Medicaid |
$7.71
|
| Rate for Payer: Banner UC Health Medicare |
$38.25
|
| Rate for Payer: Bisbee Police All Plans |
$66.30
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$173.40
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Cigna of AZ Commercial |
$165.75
|
| Rate for Payer: Copperpoint Commercial |
$63.11
|
| Rate for Payer: Health Net of AZ Commercial |
$153.00
|
| Rate for Payer: Health Net of AZ Medicare |
$71.40
|
| Rate for Payer: Humana of AZ Medicare |
$38.25
|
| Rate for Payer: Mercy Care Medicaid |
$7.71
|
| Rate for Payer: Self Pay Self Pay |
$204.00
|
| Rate for Payer: TriWest Medicare |
$38.25
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$148.66
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$45.90
|
|
|
Fungus (Mycology) Culture LC
|
Facility
|
IP
|
$255.00
|
|
|
Service Code
|
CPT 87101
|
| Hospital Charge Code |
1905615
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$66.30 |
| Max. Negotiated Rate |
$229.50 |
| Rate for Payer: Aetna of AZ Commercial |
$229.50
|
| Rate for Payer: Bisbee Police All Plans |
$66.30
|
| Rate for Payer: Cash Price |
$204.00
|
| Rate for Payer: Self Pay Self Pay |
$204.00
|
|
|
furosemide 20 mg/2 mL Inj Sol [CQCH]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
105923463
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of AZ Commercial |
$0.48
|
| 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
|
|
|
furosemide 20 mg/2 mL Inj Sol [CQCH]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
105923463
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna of AZ Commercial |
$0.48
|
| Rate for Payer: Aetna of AZ Medicare |
$0.15
|
| Rate for Payer: AHCCCS Medicaid |
$1.26
|
| Rate for Payer: Allwell Medicaid |
$1.26
|
| Rate for Payer: Allwell Medicare |
$0.08
|
| Rate for Payer: Amerigroup Medicare |
$0.08
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.20
|
| Rate for Payer: AZCH Complete Medicaid |
$1.26
|
| Rate for Payer: AZCH Complete Medicare |
$0.08
|
| Rate for Payer: Banner UC Health Medicaid |
$1.26
|
| 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 |
$0.36
|
| Rate for Payer: Cash Price |
$0.42
|
| 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 |
$0.32
|
| Rate for Payer: Health Net of AZ Medicare |
$0.15
|
| Rate for Payer: Humana of AZ Medicare |
$0.08
|
| Rate for Payer: Mercy Care Medicaid |
$1.26
|
| Rate for Payer: Self Pay Self Pay |
$0.42
|
| Rate for Payer: TriWest Medicare |
$0.08
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.31
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.10
|
|
|
furosemide 20 mg Tab [CQCH]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 54829725
|
| Hospital Charge Code |
105923674
|
|
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 |
$0.03
|
| Rate for Payer: Self Pay Self Pay |
$0.02
|
|
|
furosemide 20 mg Tab [CQCH]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 54829725
|
| Hospital Charge Code |
105923674
|
|
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 |
$0.03
|
| 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
|
|
|
furosemide 40 mg/ 4 mL Inj Sol [CQCH]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
105923534
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of AZ Commercial |
$0.41
|
| Rate for Payer: Bisbee Police All Plans |
$0.12
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Self Pay Self Pay |
$0.36
|
|
|
furosemide 40 mg/ 4 mL Inj Sol [CQCH]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
HCPCS J1940
|
| Hospital Charge Code |
105923534
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$1.26 |
| Rate for Payer: Aetna of AZ Commercial |
$0.41
|
| Rate for Payer: Aetna of AZ Medicare |
$0.13
|
| Rate for Payer: AHCCCS Medicaid |
$1.26
|
| Rate for Payer: Allwell Medicaid |
$1.26
|
| Rate for Payer: Allwell Medicare |
$0.07
|
| Rate for Payer: Amerigroup Medicare |
$0.07
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.17
|
| Rate for Payer: AZCH Complete Medicaid |
$1.26
|
| Rate for Payer: AZCH Complete Medicare |
$0.07
|
| Rate for Payer: Banner UC Health Medicaid |
$1.26
|
| Rate for Payer: Banner UC Health Medicare |
$0.07
|
| Rate for Payer: Bisbee Police All Plans |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.31
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of AZ Commercial |
$0.29
|
| Rate for Payer: Copperpoint Commercial |
$0.11
|
| Rate for Payer: Health Net of AZ Commercial |
$0.27
|
| Rate for Payer: Health Net of AZ Medicare |
$0.13
|
| Rate for Payer: Humana of AZ Medicare |
$0.07
|
| Rate for Payer: Mercy Care Medicaid |
$1.26
|
| Rate for Payer: Self Pay Self Pay |
$0.36
|
| 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
|
|
|
furosemide 40 mg Tab [CQCH]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 54829925
|
| Hospital Charge Code |
105923609
|
|
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
|
|
|
furosemide 40 mg Tab [CQCH]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 54829925
|
| Hospital Charge Code |
105923609
|
|
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
|
|
|
G0168 WOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLY
|
Facility
|
IP
|
$527.00
|
|
|
Service Code
|
CPT G0168
|
| Hospital Charge Code |
24599672
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$137.02 |
| Max. Negotiated Rate |
$474.30 |
| Rate for Payer: Aetna of AZ Commercial |
$474.30
|
| Rate for Payer: Bisbee Police All Plans |
$137.02
|
| Rate for Payer: Cash Price |
$421.60
|
| Rate for Payer: Self Pay Self Pay |
$421.60
|
|
|
G0168 WOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLY
|
Facility
|
OP
|
$527.00
|
|
|
Service Code
|
CPT G0168
|
| Hospital Charge Code |
24599672
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$474.30 |
| Rate for Payer: Aetna of AZ Commercial |
$474.30
|
| Rate for Payer: Aetna of AZ Medicare |
$147.56
|
| Rate for Payer: AHCCCS Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicare |
$79.05
|
| Rate for Payer: Amerigroup Medicare |
$79.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$196.83
|
| Rate for Payer: AZCH Complete Medicaid |
$0.13
|
| Rate for Payer: AZCH Complete Medicare |
$79.05
|
| Rate for Payer: Banner UC Health Medicaid |
$0.13
|
| Rate for Payer: Banner UC Health Medicare |
$79.05
|
| Rate for Payer: Bisbee Police All Plans |
$137.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$358.36
|
| Rate for Payer: Cash Price |
$421.60
|
| Rate for Payer: Cash Price |
$421.60
|
| Rate for Payer: Cigna of AZ Commercial |
$368.90
|
| Rate for Payer: Copperpoint Commercial |
$130.43
|
| Rate for Payer: Health Net of AZ Commercial |
$316.20
|
| Rate for Payer: Health Net of AZ Medicare |
$147.56
|
| Rate for Payer: Humana of AZ Medicare |
$79.05
|
| Rate for Payer: Mercy Care Medicaid |
$0.13
|
| Rate for Payer: Self Pay Self Pay |
$421.60
|
| Rate for Payer: TriWest Medicare |
$79.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$307.24
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$94.86
|
|
|
G0378 ER OBSERVATION
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
22282939
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$19.95 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna of AZ Commercial |
$119.70
|
| Rate for Payer: Aetna of AZ Medicare |
$37.24
|
| Rate for Payer: AHCCCS Medicaid |
$60.00
|
| Rate for Payer: Allwell Medicaid |
$60.00
|
| Rate for Payer: Allwell Medicare |
$19.95
|
| Rate for Payer: Amerigroup Medicare |
$19.95
|
| Rate for Payer: APIPA Medicare/Medicaid |
$49.68
|
| Rate for Payer: AZCH Complete Medicaid |
$60.00
|
| Rate for Payer: AZCH Complete Medicare |
$19.95
|
| Rate for Payer: Banner UC Health Medicaid |
$60.00
|
| Rate for Payer: Banner UC Health Medicare |
$19.95
|
| Rate for Payer: Bisbee Police All Plans |
$34.58
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$90.44
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cigna of AZ Commercial |
$93.10
|
| Rate for Payer: Copperpoint Commercial |
$32.92
|
| Rate for Payer: Health Net of AZ Commercial |
$79.80
|
| Rate for Payer: Health Net of AZ Medicare |
$37.24
|
| Rate for Payer: Humana of AZ Medicare |
$19.95
|
| Rate for Payer: Mercy Care Medicaid |
$60.00
|
| Rate for Payer: Self Pay Self Pay |
$106.40
|
| Rate for Payer: TriWest Medicare |
$19.95
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$77.54
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$23.94
|
|
|
G0378 ER OBSERVATION
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
CPT G0378
|
| Hospital Charge Code |
22282939
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$34.58 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna of AZ Commercial |
$119.70
|
| Rate for Payer: Bisbee Police All Plans |
$34.58
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Self Pay Self Pay |
$106.40
|
|
|
G0379 DIRECT OBSERVATION
|
Facility
|
OP
|
$167.00
|
|
|
Service Code
|
CPT G0379
|
| Hospital Charge Code |
22282941
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$25.05 |
| Max. Negotiated Rate |
$150.30 |
| Rate for Payer: Aetna of AZ Commercial |
$150.30
|
| Rate for Payer: Aetna of AZ Medicare |
$46.76
|
| Rate for Payer: AHCCCS Medicaid |
$60.00
|
| Rate for Payer: Allwell Medicaid |
$60.00
|
| Rate for Payer: Allwell Medicare |
$25.05
|
| Rate for Payer: Amerigroup Medicare |
$25.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$62.37
|
| Rate for Payer: AZCH Complete Medicaid |
$60.00
|
| Rate for Payer: AZCH Complete Medicare |
$25.05
|
| Rate for Payer: Banner UC Health Medicaid |
$60.00
|
| Rate for Payer: Banner UC Health Medicare |
$25.05
|
| Rate for Payer: Bisbee Police All Plans |
$43.42
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$113.56
|
| Rate for Payer: Cash Price |
$133.60
|
| Rate for Payer: Cash Price |
$133.60
|
| Rate for Payer: Cigna of AZ Commercial |
$116.90
|
| Rate for Payer: Copperpoint Commercial |
$41.33
|
| Rate for Payer: Health Net of AZ Commercial |
$100.20
|
| Rate for Payer: Health Net of AZ Medicare |
$46.76
|
| Rate for Payer: Humana of AZ Medicare |
$25.05
|
| Rate for Payer: Mercy Care Medicaid |
$60.00
|
| Rate for Payer: Self Pay Self Pay |
$133.60
|
| Rate for Payer: TriWest Medicare |
$25.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$97.36
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$30.06
|
|
|
G0379 DIRECT OBSERVATION
|
Facility
|
IP
|
$167.00
|
|
|
Service Code
|
CPT G0379
|
| Hospital Charge Code |
22282941
|
|
Hospital Revenue Code
|
762
|
| Min. Negotiated Rate |
$43.42 |
| Max. Negotiated Rate |
$150.30 |
| Rate for Payer: Aetna of AZ Commercial |
$150.30
|
| Rate for Payer: Bisbee Police All Plans |
$43.42
|
| Rate for Payer: Cash Price |
$133.60
|
| Rate for Payer: Self Pay Self Pay |
$133.60
|
|
|
G0390 TRAUMA LEVEL 4
|
Facility
|
OP
|
$1,210.00
|
|
|
Service Code
|
CPT G0390
|
| Hospital Charge Code |
22282942
|
|
Hospital Revenue Code
|
684
|
| Min. Negotiated Rate |
$181.50 |
| Max. Negotiated Rate |
$1,089.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,089.00
|
| Rate for Payer: Aetna of AZ Medicare |
$338.80
|
| Rate for Payer: Allwell Medicare |
$181.50
|
| Rate for Payer: Amerigroup Medicare |
$181.50
|
| Rate for Payer: APIPA Medicare/Medicaid |
$451.94
|
| Rate for Payer: AZCH Complete Medicare |
$181.50
|
| Rate for Payer: Banner UC Health Medicare |
$181.50
|
| Rate for Payer: Bisbee Police All Plans |
$314.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$822.80
|
| Rate for Payer: Cash Price |
$968.00
|
| Rate for Payer: Cigna of AZ Commercial |
$847.00
|
| Rate for Payer: Copperpoint Commercial |
$299.48
|
| Rate for Payer: Health Net of AZ Commercial |
$726.00
|
| Rate for Payer: Health Net of AZ Medicare |
$338.80
|
| Rate for Payer: Humana of AZ Medicare |
$181.50
|
| Rate for Payer: Self Pay Self Pay |
$968.00
|
| Rate for Payer: TriWest Medicare |
$181.50
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$705.43
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$217.80
|
|
|
G0390 TRAUMA LEVEL 4
|
Facility
|
IP
|
$1,210.00
|
|
|
Service Code
|
CPT G0390
|
| Hospital Charge Code |
22282942
|
|
Hospital Revenue Code
|
684
|
| Min. Negotiated Rate |
$314.60 |
| Max. Negotiated Rate |
$1,089.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,089.00
|
| Rate for Payer: Bisbee Police All Plans |
$314.60
|
| Rate for Payer: Cash Price |
$968.00
|
| Rate for Payer: Self Pay Self Pay |
$968.00
|
|
|
.G-6-PD Comment LC
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
CPT 82955
|
| Hospital Charge Code |
22311146
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$53.56 |
| Max. Negotiated Rate |
$185.40 |
| Rate for Payer: Aetna of AZ Commercial |
$185.40
|
| Rate for Payer: Bisbee Police All Plans |
$53.56
|
| Rate for Payer: Cash Price |
$164.80
|
| Rate for Payer: Self Pay Self Pay |
$164.80
|
|
|
.G-6-PD Comment LC
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
CPT 82955
|
| Hospital Charge Code |
22311146
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.70 |
| Max. Negotiated Rate |
$185.40 |
| Rate for Payer: Aetna of AZ Commercial |
$185.40
|
| Rate for Payer: Aetna of AZ Medicare |
$57.68
|
| Rate for Payer: AHCCCS Medicaid |
$9.70
|
| Rate for Payer: Allwell Medicaid |
$9.70
|
| Rate for Payer: Allwell Medicare |
$30.90
|
| Rate for Payer: Amerigroup Medicare |
$30.90
|
| Rate for Payer: APIPA Medicare/Medicaid |
$76.94
|
| Rate for Payer: AZCH Complete Medicaid |
$9.70
|
| Rate for Payer: AZCH Complete Medicare |
$30.90
|
| Rate for Payer: Banner UC Health Medicaid |
$9.70
|
| Rate for Payer: Banner UC Health Medicare |
$30.90
|
| Rate for Payer: Bisbee Police All Plans |
$53.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$140.08
|
| Rate for Payer: Cash Price |
$164.80
|
| Rate for Payer: Cash Price |
$164.80
|
| Rate for Payer: Cigna of AZ Commercial |
$133.90
|
| Rate for Payer: Copperpoint Commercial |
$50.98
|
| Rate for Payer: Health Net of AZ Commercial |
$123.60
|
| Rate for Payer: Health Net of AZ Medicare |
$57.68
|
| Rate for Payer: Humana of AZ Medicare |
$30.90
|
| Rate for Payer: Mercy Care Medicaid |
$9.70
|
| Rate for Payer: Self Pay Self Pay |
$164.80
|
| Rate for Payer: TriWest Medicare |
$30.90
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$120.10
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$37.08
|
|
|
G6PDH Activity LC
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
CPT 82955
|
| Hospital Charge Code |
2769568
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$53.56 |
| Max. Negotiated Rate |
$185.40 |
| Rate for Payer: Aetna of AZ Commercial |
$185.40
|
| Rate for Payer: Bisbee Police All Plans |
$53.56
|
| Rate for Payer: Cash Price |
$164.80
|
| Rate for Payer: Self Pay Self Pay |
$164.80
|
|
|
G6PDH Activity LC
|
Facility
|
OP
|
$206.00
|
|
|
Service Code
|
CPT 82955
|
| Hospital Charge Code |
2769568
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.70 |
| Max. Negotiated Rate |
$185.40 |
| Rate for Payer: Aetna of AZ Commercial |
$185.40
|
| Rate for Payer: Aetna of AZ Medicare |
$57.68
|
| Rate for Payer: AHCCCS Medicaid |
$9.70
|
| Rate for Payer: Allwell Medicaid |
$9.70
|
| Rate for Payer: Allwell Medicare |
$30.90
|
| Rate for Payer: Amerigroup Medicare |
$30.90
|
| Rate for Payer: APIPA Medicare/Medicaid |
$76.94
|
| Rate for Payer: AZCH Complete Medicaid |
$9.70
|
| Rate for Payer: AZCH Complete Medicare |
$30.90
|
| Rate for Payer: Banner UC Health Medicaid |
$9.70
|
| Rate for Payer: Banner UC Health Medicare |
$30.90
|
| Rate for Payer: Bisbee Police All Plans |
$53.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$140.08
|
| Rate for Payer: Cash Price |
$164.80
|
| Rate for Payer: Cash Price |
$164.80
|
| Rate for Payer: Cigna of AZ Commercial |
$133.90
|
| Rate for Payer: Copperpoint Commercial |
$50.98
|
| Rate for Payer: Health Net of AZ Commercial |
$123.60
|
| Rate for Payer: Health Net of AZ Medicare |
$57.68
|
| Rate for Payer: Humana of AZ Medicare |
$30.90
|
| Rate for Payer: Mercy Care Medicaid |
$9.70
|
| Rate for Payer: Self Pay Self Pay |
$164.80
|
| Rate for Payer: TriWest Medicare |
$30.90
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$120.10
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$37.08
|
|
|
gabapentin 100 mg Cap [CQCH]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 904666561
|
| Hospital Charge Code |
105923739
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of AZ Commercial |
$0.07
|
| Rate for Payer: Aetna of AZ Medicare |
$0.02
|
| 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 |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of AZ Commercial |
$0.05
|
| 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 |
$0.02
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Self Pay Self Pay |
$0.06
|
| 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 |
$0.01
|
|
|
gabapentin 100 mg Cap [CQCH]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 904666561
|
| Hospital Charge Code |
105923739
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of AZ Commercial |
$0.07
|
| Rate for Payer: Bisbee Police All Plans |
$0.02
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Self Pay Self Pay |
$0.06
|
|
