|
gemfibrozil 600 mg Tab [CQCH]
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 60687022401
|
| Hospital Charge Code |
105923934
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of AZ Commercial |
$0.17
|
| Rate for Payer: Aetna of AZ Medicare |
$0.05
|
| 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 Medicare |
$0.03
|
| 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: 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: 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
|
|
|
gemfibrozil 600 mg Tab [CQCH]
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 60687022401
|
| Hospital Charge Code |
105923934
|
|
Hospital Revenue Code
|
251
|
| 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
|
|
|
GENE ANALYSIS (BREAST CANCER 1 AND 2) FULL SEQUENCE AND DUPL
|
Facility
|
IP
|
$22,676.00
|
|
|
Service Code
|
CPT 81162
|
| Hospital Charge Code |
24077031
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5,895.76 |
| Max. Negotiated Rate |
$20,408.40 |
| Rate for Payer: Aetna of AZ Commercial |
$20,408.40
|
| Rate for Payer: Bisbee Police All Plans |
$5,895.76
|
| Rate for Payer: Cash Price |
$18,140.80
|
| Rate for Payer: Self Pay Self Pay |
$18,140.80
|
|
|
GENE ANALYSIS (BREAST CANCER 1 AND 2) FULL SEQUENCE AND DUPL
|
Facility
|
OP
|
$22,676.00
|
|
|
Service Code
|
CPT 81162
|
| Hospital Charge Code |
24077031
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1,824.88 |
| Max. Negotiated Rate |
$20,408.40 |
| Rate for Payer: Aetna of AZ Commercial |
$20,408.40
|
| Rate for Payer: Aetna of AZ Medicare |
$6,349.28
|
| Rate for Payer: AHCCCS Medicaid |
$1,824.88
|
| Rate for Payer: Allwell Medicaid |
$1,824.88
|
| Rate for Payer: Allwell Medicare |
$3,401.40
|
| Rate for Payer: Amerigroup Medicare |
$3,401.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$8,469.49
|
| Rate for Payer: AZCH Complete Medicaid |
$1,824.88
|
| Rate for Payer: AZCH Complete Medicare |
$3,401.40
|
| Rate for Payer: Banner UC Health Medicaid |
$1,824.88
|
| Rate for Payer: Banner UC Health Medicare |
$3,401.40
|
| Rate for Payer: Bisbee Police All Plans |
$5,895.76
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$15,419.68
|
| Rate for Payer: Cash Price |
$18,140.80
|
| Rate for Payer: Cash Price |
$18,140.80
|
| Rate for Payer: Cigna of AZ Commercial |
$14,739.40
|
| Rate for Payer: Copperpoint Commercial |
$5,612.31
|
| Rate for Payer: Health Net of AZ Commercial |
$13,605.60
|
| Rate for Payer: Health Net of AZ Medicare |
$6,349.28
|
| Rate for Payer: Humana of AZ Medicare |
$3,401.40
|
| Rate for Payer: Mercy Care Medicaid |
$1,824.88
|
| Rate for Payer: Self Pay Self Pay |
$18,140.80
|
| Rate for Payer: TriWest Medicare |
$3,401.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$13,220.11
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$4,081.68
|
|
|
General Lab
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 89300
|
| Hospital Charge Code |
22334780
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna of AZ Commercial |
$108.00
|
| Rate for Payer: Bisbee Police All Plans |
$31.20
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Self Pay Self Pay |
$96.00
|
|
|
General Lab
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 89300
|
| Hospital Charge Code |
22334780
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$108.00 |
| Rate for Payer: Aetna of AZ Commercial |
$108.00
|
| Rate for Payer: Aetna of AZ Medicare |
$33.60
|
| Rate for Payer: Allwell Medicare |
$18.00
|
| Rate for Payer: Amerigroup Medicare |
$18.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$44.82
|
| Rate for Payer: AZCH Complete Medicare |
$18.00
|
| Rate for Payer: Banner UC Health Medicare |
$18.00
|
| Rate for Payer: Bisbee Police All Plans |
$31.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$81.60
|
| Rate for Payer: Cash Price |
$96.00
|
| Rate for Payer: Cigna of AZ Commercial |
$78.00
|
| Rate for Payer: Copperpoint Commercial |
$29.70
|
| Rate for Payer: Health Net of AZ Commercial |
$72.00
|
| Rate for Payer: Health Net of AZ Medicare |
$33.60
|
| Rate for Payer: Humana of AZ Medicare |
$18.00
|
| Rate for Payer: Self Pay Self Pay |
$96.00
|
| Rate for Payer: TriWest Medicare |
$18.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$69.96
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$21.60
|
|
|
General Lab
|
Facility
|
OP
|
$201.00
|
|
|
Service Code
|
CPT 82105
|
| Hospital Charge Code |
1902313
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.77 |
| Max. Negotiated Rate |
$180.90 |
| Rate for Payer: Aetna of AZ Commercial |
$180.90
|
| Rate for Payer: Aetna of AZ Medicare |
$56.28
|
| Rate for Payer: AHCCCS Medicaid |
$16.77
|
| Rate for Payer: Allwell Medicaid |
$16.77
|
| Rate for Payer: Allwell Medicare |
$30.15
|
| Rate for Payer: Amerigroup Medicare |
$30.15
|
| Rate for Payer: APIPA Medicare/Medicaid |
$75.07
|
| Rate for Payer: AZCH Complete Medicaid |
$16.77
|
| Rate for Payer: AZCH Complete Medicare |
$30.15
|
| Rate for Payer: Banner UC Health Medicaid |
$16.77
|
| Rate for Payer: Banner UC Health Medicare |
$30.15
|
| Rate for Payer: Bisbee Police All Plans |
$52.26
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$136.68
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Cigna of AZ Commercial |
$130.65
|
| Rate for Payer: Copperpoint Commercial |
$49.75
|
| Rate for Payer: Health Net of AZ Commercial |
$120.60
|
| Rate for Payer: Health Net of AZ Medicare |
$56.28
|
| Rate for Payer: Humana of AZ Medicare |
$30.15
|
| Rate for Payer: Mercy Care Medicaid |
$16.77
|
| Rate for Payer: Self Pay Self Pay |
$160.80
|
| Rate for Payer: TriWest Medicare |
$30.15
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$117.18
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$36.18
|
|
|
General Lab
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
22031562
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.27 |
| Max. Negotiated Rate |
$33.30 |
| Rate for Payer: Aetna of AZ Commercial |
$33.30
|
| Rate for Payer: Aetna of AZ Medicare |
$10.36
|
| Rate for Payer: AHCCCS Medicaid |
$4.27
|
| Rate for Payer: Allwell Medicaid |
$4.27
|
| Rate for Payer: Allwell Medicare |
$5.55
|
| Rate for Payer: Amerigroup Medicare |
$5.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$13.82
|
| Rate for Payer: AZCH Complete Medicaid |
$4.27
|
| Rate for Payer: AZCH Complete Medicare |
$5.55
|
| Rate for Payer: Banner UC Health Medicaid |
$4.27
|
| Rate for Payer: Banner UC Health Medicare |
$5.55
|
| Rate for Payer: Bisbee Police All Plans |
$9.62
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$25.16
|
| Rate for Payer: Cash Price |
$29.60
|
| Rate for Payer: Cash Price |
$29.60
|
| Rate for Payer: Cigna of AZ Commercial |
$24.05
|
| Rate for Payer: Copperpoint Commercial |
$9.16
|
| Rate for Payer: Health Net of AZ Commercial |
$22.20
|
| Rate for Payer: Health Net of AZ Medicare |
$10.36
|
| Rate for Payer: Humana of AZ Medicare |
$5.55
|
| Rate for Payer: Mercy Care Medicaid |
$4.27
|
| Rate for Payer: Self Pay Self Pay |
$29.60
|
| Rate for Payer: TriWest Medicare |
$5.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$21.57
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$6.66
|
|
|
General Lab
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
CPT 87220
|
| Hospital Charge Code |
22031562
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$33.30 |
| Rate for Payer: Aetna of AZ Commercial |
$33.30
|
| Rate for Payer: Bisbee Police All Plans |
$9.62
|
| Rate for Payer: Cash Price |
$29.60
|
| Rate for Payer: Self Pay Self Pay |
$29.60
|
|
|
General Lab
|
Facility
|
IP
|
$201.00
|
|
|
Service Code
|
CPT 82105
|
| Hospital Charge Code |
1902313
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$52.26 |
| Max. Negotiated Rate |
$180.90 |
| Rate for Payer: Aetna of AZ Commercial |
$180.90
|
| Rate for Payer: Bisbee Police All Plans |
$52.26
|
| Rate for Payer: Cash Price |
$160.80
|
| Rate for Payer: Self Pay Self Pay |
$160.80
|
|
|
Genital Culture
|
Facility
|
OP
|
$127.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
633894
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$114.30 |
| Rate for Payer: Aetna of AZ Commercial |
$114.30
|
| Rate for Payer: Aetna of AZ Medicare |
$35.56
|
| Rate for Payer: AHCCCS Medicaid |
$6.63
|
| Rate for Payer: Allwell Medicaid |
$6.63
|
| Rate for Payer: Allwell Medicare |
$19.05
|
| Rate for Payer: Amerigroup Medicare |
$19.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$47.43
|
| Rate for Payer: AZCH Complete Medicaid |
$6.63
|
| Rate for Payer: AZCH Complete Medicare |
$19.05
|
| Rate for Payer: Banner UC Health Medicaid |
$6.63
|
| Rate for Payer: Banner UC Health Medicare |
$19.05
|
| Rate for Payer: Bisbee Police All Plans |
$33.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$86.36
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Cigna of AZ Commercial |
$82.55
|
| Rate for Payer: Copperpoint Commercial |
$31.43
|
| Rate for Payer: Health Net of AZ Commercial |
$76.20
|
| Rate for Payer: Health Net of AZ Medicare |
$35.56
|
| Rate for Payer: Humana of AZ Medicare |
$19.05
|
| Rate for Payer: Mercy Care Medicaid |
$6.63
|
| Rate for Payer: Self Pay Self Pay |
$101.60
|
| Rate for Payer: TriWest Medicare |
$19.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$74.04
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$22.86
|
|
|
Genital Culture
|
Facility
|
IP
|
$127.00
|
|
|
Service Code
|
CPT 87081
|
| Hospital Charge Code |
633894
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$33.02 |
| Max. Negotiated Rate |
$114.30 |
| Rate for Payer: Aetna of AZ Commercial |
$114.30
|
| Rate for Payer: Bisbee Police All Plans |
$33.02
|
| Rate for Payer: Cash Price |
$101.60
|
| Rate for Payer: Self Pay Self Pay |
$101.60
|
|
|
GenoSure(R) MG LC
|
Facility
|
IP
|
$1,502.00
|
|
|
Service Code
|
CPT 87901
|
| Hospital Charge Code |
22311193
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$390.52 |
| Max. Negotiated Rate |
$1,351.80 |
| Rate for Payer: Aetna of AZ Commercial |
$1,351.80
|
| Rate for Payer: Bisbee Police All Plans |
$390.52
|
| Rate for Payer: Cash Price |
$1,201.60
|
| Rate for Payer: Self Pay Self Pay |
$1,201.60
|
|
|
GenoSure(R) MG LC
|
Facility
|
OP
|
$1,502.00
|
|
|
Service Code
|
CPT 87901
|
| Hospital Charge Code |
22311193
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$225.30 |
| Max. Negotiated Rate |
$1,351.80 |
| Rate for Payer: Aetna of AZ Commercial |
$1,351.80
|
| Rate for Payer: Aetna of AZ Medicare |
$420.56
|
| Rate for Payer: AHCCCS Medicaid |
$257.45
|
| Rate for Payer: Allwell Medicaid |
$257.45
|
| Rate for Payer: Allwell Medicare |
$225.30
|
| Rate for Payer: Amerigroup Medicare |
$225.30
|
| Rate for Payer: APIPA Medicare/Medicaid |
$561.00
|
| Rate for Payer: AZCH Complete Medicaid |
$257.45
|
| Rate for Payer: AZCH Complete Medicare |
$225.30
|
| Rate for Payer: Banner UC Health Medicaid |
$257.45
|
| Rate for Payer: Banner UC Health Medicare |
$225.30
|
| Rate for Payer: Bisbee Police All Plans |
$390.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,021.36
|
| Rate for Payer: Cash Price |
$1,201.60
|
| Rate for Payer: Cash Price |
$1,201.60
|
| Rate for Payer: Cigna of AZ Commercial |
$976.30
|
| Rate for Payer: Copperpoint Commercial |
$371.74
|
| Rate for Payer: Health Net of AZ Commercial |
$901.20
|
| Rate for Payer: Health Net of AZ Medicare |
$420.56
|
| Rate for Payer: Humana of AZ Medicare |
$225.30
|
| Rate for Payer: Mercy Care Medicaid |
$257.45
|
| Rate for Payer: Self Pay Self Pay |
$1,201.60
|
| Rate for Payer: TriWest Medicare |
$225.30
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$875.67
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$270.36
|
|
|
gentamicin 40 mg/mL Inj Sol 20 mL [CQCH]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
105924007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Aetna of AZ Commercial |
$0.76
|
| Rate for Payer: Bisbee Police All Plans |
$0.22
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Self Pay Self Pay |
$0.67
|
|
|
gentamicin 40 mg/mL Inj Sol 20 mL [CQCH]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
105924007
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$5.30 |
| Rate for Payer: Aetna of AZ Commercial |
$0.76
|
| Rate for Payer: Aetna of AZ Medicare |
$0.24
|
| Rate for Payer: AHCCCS Medicaid |
$5.30
|
| Rate for Payer: Allwell Medicaid |
$5.30
|
| Rate for Payer: Allwell Medicare |
$0.13
|
| Rate for Payer: Amerigroup Medicare |
$0.13
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.31
|
| Rate for Payer: AZCH Complete Medicaid |
$5.30
|
| Rate for Payer: AZCH Complete Medicare |
$0.13
|
| Rate for Payer: Banner UC Health Medicaid |
$5.30
|
| Rate for Payer: Banner UC Health Medicare |
$0.13
|
| Rate for Payer: Bisbee Police All Plans |
$0.22
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.57
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of AZ Commercial |
$0.55
|
| Rate for Payer: Copperpoint Commercial |
$0.21
|
| Rate for Payer: Health Net of AZ Commercial |
$0.50
|
| Rate for Payer: Health Net of AZ Medicare |
$0.24
|
| Rate for Payer: Humana of AZ Medicare |
$0.13
|
| Rate for Payer: Mercy Care Medicaid |
$5.30
|
| Rate for Payer: Self Pay Self Pay |
$0.67
|
| Rate for Payer: TriWest Medicare |
$0.13
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.49
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.15
|
|
|
gentamicin 80 mg/ 2mL Sol [CQCH]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
107743160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$5.30 |
| Rate for Payer: Aetna of AZ Commercial |
$0.27
|
| Rate for Payer: Aetna of AZ Medicare |
$0.08
|
| Rate for Payer: AHCCCS Medicaid |
$5.30
|
| Rate for Payer: Allwell Medicaid |
$5.30
|
| 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 Medicaid |
$5.30
|
| Rate for Payer: AZCH Complete Medicare |
$0.05
|
| Rate for Payer: Banner UC Health Medicaid |
$5.30
|
| 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: Cash Price |
$0.24
|
| Rate for Payer: Cigna of AZ Commercial |
$0.20
|
| Rate for Payer: Copperpoint Commercial |
$0.07
|
| Rate for Payer: Health Net of AZ Commercial |
$0.18
|
| Rate for Payer: Health Net of AZ Medicare |
$0.08
|
| Rate for Payer: Humana of AZ Medicare |
$0.05
|
| Rate for Payer: Mercy Care Medicaid |
$5.30
|
| Rate for Payer: Self Pay Self Pay |
$0.24
|
| 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
|
|
|
gentamicin 80 mg/ 2mL Sol [CQCH]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
107743160
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of AZ Commercial |
$0.27
|
| Rate for Payer: Bisbee Police All Plans |
$0.08
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Self Pay Self Pay |
$0.24
|
|
|
gentamicin Ophth 0.3% Oint [CQCH]
|
Facility
|
IP
|
$2.55
|
|
|
Service Code
|
NDC 17478028435
|
| Hospital Charge Code |
105924145
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna of AZ Commercial |
$2.30
|
| Rate for Payer: Bisbee Police All Plans |
$0.66
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Self Pay Self Pay |
$2.04
|
|
|
gentamicin Ophth 0.3% Oint [CQCH]
|
Facility
|
OP
|
$2.55
|
|
|
Service Code
|
NDC 17478028435
|
| Hospital Charge Code |
105924145
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna of AZ Commercial |
$2.30
|
| Rate for Payer: Aetna of AZ Medicare |
$0.71
|
| Rate for Payer: Allwell Medicare |
$0.38
|
| Rate for Payer: Amerigroup Medicare |
$0.38
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.95
|
| Rate for Payer: AZCH Complete Medicare |
$0.38
|
| Rate for Payer: Banner UC Health Medicare |
$0.38
|
| Rate for Payer: Bisbee Police All Plans |
$0.66
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.73
|
| Rate for Payer: Cash Price |
$2.04
|
| Rate for Payer: Cigna of AZ Commercial |
$1.66
|
| Rate for Payer: Copperpoint Commercial |
$0.63
|
| Rate for Payer: Health Net of AZ Commercial |
$1.53
|
| Rate for Payer: Health Net of AZ Medicare |
$0.71
|
| Rate for Payer: Humana of AZ Medicare |
$0.38
|
| Rate for Payer: Self Pay Self Pay |
$2.04
|
| Rate for Payer: TriWest Medicare |
$0.38
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1.49
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.46
|
|
|
gentamicin Ophth 0.3% Sol [CQCH]
|
Facility
|
IP
|
$32.95
|
|
|
Service Code
|
NDC 61314063305
|
| Hospital Charge Code |
105924210
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$8.57 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna of AZ Commercial |
$29.66
|
| Rate for Payer: Bisbee Police All Plans |
$8.57
|
| Rate for Payer: Cash Price |
$26.36
|
| Rate for Payer: Self Pay Self Pay |
$26.36
|
|
|
gentamicin Ophth 0.3% Sol [CQCH]
|
Facility
|
OP
|
$32.95
|
|
|
Service Code
|
NDC 61314063305
|
| Hospital Charge Code |
105924210
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$4.94 |
| Max. Negotiated Rate |
$29.66 |
| Rate for Payer: Aetna of AZ Commercial |
$29.66
|
| Rate for Payer: Aetna of AZ Medicare |
$9.23
|
| Rate for Payer: Allwell Medicare |
$4.94
|
| Rate for Payer: Amerigroup Medicare |
$4.94
|
| Rate for Payer: APIPA Medicare/Medicaid |
$12.31
|
| Rate for Payer: AZCH Complete Medicare |
$4.94
|
| Rate for Payer: Banner UC Health Medicare |
$4.94
|
| Rate for Payer: Bisbee Police All Plans |
$8.57
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$22.41
|
| Rate for Payer: Cash Price |
$26.36
|
| Rate for Payer: Cigna of AZ Commercial |
$21.42
|
| Rate for Payer: Copperpoint Commercial |
$8.16
|
| Rate for Payer: Health Net of AZ Commercial |
$19.77
|
| Rate for Payer: Health Net of AZ Medicare |
$9.23
|
| Rate for Payer: Humana of AZ Medicare |
$4.94
|
| Rate for Payer: Self Pay Self Pay |
$26.36
|
| Rate for Payer: TriWest Medicare |
$4.94
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$19.21
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$5.93
|
|
|
Gentamicin Peak
|
Facility
|
OP
|
$256.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
23122406
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.38 |
| Max. Negotiated Rate |
$230.40 |
| Rate for Payer: Aetna of AZ Commercial |
$230.40
|
| Rate for Payer: Aetna of AZ Medicare |
$71.68
|
| Rate for Payer: AHCCCS Medicaid |
$16.38
|
| Rate for Payer: Allwell Medicaid |
$16.38
|
| Rate for Payer: Allwell Medicare |
$38.40
|
| Rate for Payer: Amerigroup Medicare |
$38.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$95.62
|
| Rate for Payer: AZCH Complete Medicaid |
$16.38
|
| Rate for Payer: AZCH Complete Medicare |
$38.40
|
| Rate for Payer: Banner UC Health Medicaid |
$16.38
|
| Rate for Payer: Banner UC Health Medicare |
$38.40
|
| Rate for Payer: Bisbee Police All Plans |
$66.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$174.08
|
| Rate for Payer: Cash Price |
$204.80
|
| Rate for Payer: Cash Price |
$204.80
|
| Rate for Payer: Cigna of AZ Commercial |
$166.40
|
| Rate for Payer: Copperpoint Commercial |
$63.36
|
| Rate for Payer: Health Net of AZ Commercial |
$153.60
|
| Rate for Payer: Health Net of AZ Medicare |
$71.68
|
| Rate for Payer: Humana of AZ Medicare |
$38.40
|
| Rate for Payer: Mercy Care Medicaid |
$16.38
|
| Rate for Payer: Self Pay Self Pay |
$204.80
|
| Rate for Payer: TriWest Medicare |
$38.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$149.25
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$46.08
|
|
|
Gentamicin Peak
|
Facility
|
IP
|
$256.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
23122406
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$66.56 |
| Max. Negotiated Rate |
$230.40 |
| Rate for Payer: Aetna of AZ Commercial |
$230.40
|
| Rate for Payer: Bisbee Police All Plans |
$66.56
|
| Rate for Payer: Cash Price |
$204.80
|
| Rate for Payer: Self Pay Self Pay |
$204.80
|
|
|
gentamicin PF 20 mg/2 mL Inj Sol [CQCH]
|
Facility
|
OP
|
$0.70
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
105924078
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$5.30 |
| Rate for Payer: Aetna of AZ Commercial |
$0.63
|
| Rate for Payer: Aetna of AZ Medicare |
$0.20
|
| Rate for Payer: AHCCCS Medicaid |
$5.30
|
| Rate for Payer: Allwell Medicaid |
$5.30
|
| Rate for Payer: Allwell Medicare |
$0.11
|
| Rate for Payer: Amerigroup Medicare |
$0.11
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.26
|
| Rate for Payer: AZCH Complete Medicaid |
$5.30
|
| Rate for Payer: AZCH Complete Medicare |
$0.11
|
| Rate for Payer: Banner UC Health Medicaid |
$5.30
|
| Rate for Payer: Banner UC Health Medicare |
$0.11
|
| Rate for Payer: Bisbee Police All Plans |
$0.18
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.48
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cigna of AZ Commercial |
$0.46
|
| Rate for Payer: Copperpoint Commercial |
$0.17
|
| Rate for Payer: Health Net of AZ Commercial |
$0.42
|
| Rate for Payer: Health Net of AZ Medicare |
$0.20
|
| Rate for Payer: Humana of AZ Medicare |
$0.11
|
| Rate for Payer: Mercy Care Medicaid |
$5.30
|
| Rate for Payer: Self Pay Self Pay |
$0.56
|
| Rate for Payer: TriWest Medicare |
$0.11
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.41
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.13
|
|
