|
gentamicin PF 20 mg/2 mL Inj Sol [CQCH]
|
Facility
|
IP
|
$0.70
|
|
|
Service Code
|
HCPCS J1580
|
| Hospital Charge Code |
105924078
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Aetna of AZ Commercial |
$0.63
|
| Rate for Payer: Bisbee Police All Plans |
$0.18
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Self Pay Self Pay |
$0.56
|
|
|
GENTAMICIN, RANDOM
|
Facility
|
OP
|
$256.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
23122403
|
|
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, RANDOM
|
Facility
|
IP
|
$256.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
23122403
|
|
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 Trough
|
Facility
|
IP
|
$256.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
23122404
|
|
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 Trough
|
Facility
|
OP
|
$256.00
|
|
|
Service Code
|
CPT 80170
|
| Hospital Charge Code |
23122404
|
|
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
|
|
|
GGT Gammaglobulin (immunoglobulin); immunoglobulin subclasse
|
Facility
|
OP
|
$199.00
|
|
|
Service Code
|
CPT 82787
|
| Hospital Charge Code |
22537397
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.02 |
| Max. Negotiated Rate |
$179.10 |
| Rate for Payer: Aetna of AZ Commercial |
$179.10
|
| Rate for Payer: Aetna of AZ Medicare |
$55.72
|
| Rate for Payer: AHCCCS Medicaid |
$8.02
|
| Rate for Payer: Allwell Medicaid |
$8.02
|
| Rate for Payer: Allwell Medicare |
$29.85
|
| Rate for Payer: Amerigroup Medicare |
$29.85
|
| Rate for Payer: APIPA Medicare/Medicaid |
$74.33
|
| Rate for Payer: AZCH Complete Medicaid |
$8.02
|
| Rate for Payer: AZCH Complete Medicare |
$29.85
|
| Rate for Payer: Banner UC Health Medicaid |
$8.02
|
| Rate for Payer: Banner UC Health Medicare |
$29.85
|
| Rate for Payer: Bisbee Police All Plans |
$51.74
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$135.32
|
| Rate for Payer: Cash Price |
$159.20
|
| Rate for Payer: Cash Price |
$159.20
|
| Rate for Payer: Cigna of AZ Commercial |
$129.35
|
| Rate for Payer: Copperpoint Commercial |
$49.25
|
| Rate for Payer: Health Net of AZ Commercial |
$119.40
|
| Rate for Payer: Health Net of AZ Medicare |
$55.72
|
| Rate for Payer: Humana of AZ Medicare |
$29.85
|
| Rate for Payer: Mercy Care Medicaid |
$8.02
|
| Rate for Payer: Self Pay Self Pay |
$159.20
|
| Rate for Payer: TriWest Medicare |
$29.85
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$116.02
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$35.82
|
|
|
GGT Gammaglobulin (immunoglobulin); immunoglobulin subclasse
|
Facility
|
IP
|
$199.00
|
|
|
Service Code
|
CPT 82787
|
| Hospital Charge Code |
22537397
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$51.74 |
| Max. Negotiated Rate |
$179.10 |
| Rate for Payer: Aetna of AZ Commercial |
$179.10
|
| Rate for Payer: Bisbee Police All Plans |
$51.74
|
| Rate for Payer: Cash Price |
$159.20
|
| Rate for Payer: Self Pay Self Pay |
$159.20
|
|
|
GGT LC
|
Facility
|
IP
|
$166.00
|
|
|
Service Code
|
CPT 82977
|
| Hospital Charge Code |
1902205
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$43.16 |
| Max. Negotiated Rate |
$149.40 |
| Rate for Payer: Aetna of AZ Commercial |
$149.40
|
| Rate for Payer: Bisbee Police All Plans |
$43.16
|
| Rate for Payer: Cash Price |
$132.80
|
| Rate for Payer: Self Pay Self Pay |
$132.80
|
|
|
GGT LC
|
Facility
|
OP
|
$166.00
|
|
|
Service Code
|
CPT 82977
|
| Hospital Charge Code |
1902205
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$149.40 |
| Rate for Payer: Aetna of AZ Commercial |
$149.40
|
| Rate for Payer: Aetna of AZ Medicare |
$46.48
|
| Rate for Payer: AHCCCS Medicaid |
$7.20
|
| Rate for Payer: Allwell Medicaid |
$7.20
|
| Rate for Payer: Allwell Medicare |
$24.90
|
| Rate for Payer: Amerigroup Medicare |
$24.90
|
| Rate for Payer: APIPA Medicare/Medicaid |
$62.00
|
| Rate for Payer: AZCH Complete Medicaid |
$7.20
|
| Rate for Payer: AZCH Complete Medicare |
$24.90
|
| Rate for Payer: Banner UC Health Medicaid |
$7.20
|
| Rate for Payer: Banner UC Health Medicare |
$24.90
|
| Rate for Payer: Bisbee Police All Plans |
$43.16
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$112.88
|
| Rate for Payer: Cash Price |
$132.80
|
| Rate for Payer: Cash Price |
$132.80
|
| Rate for Payer: Cigna of AZ Commercial |
$107.90
|
| Rate for Payer: Copperpoint Commercial |
$41.08
|
| Rate for Payer: Health Net of AZ Commercial |
$99.60
|
| Rate for Payer: Health Net of AZ Medicare |
$46.48
|
| Rate for Payer: Humana of AZ Medicare |
$24.90
|
| Rate for Payer: Mercy Care Medicaid |
$7.20
|
| Rate for Payer: Self Pay Self Pay |
$132.80
|
| Rate for Payer: TriWest Medicare |
$24.90
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$96.78
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$29.88
|
|
|
Giardia Lamblia Direct Detection EIA, LC
|
Facility
|
OP
|
$228.00
|
|
|
Service Code
|
CPT 87329
|
| Hospital Charge Code |
3601506
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$11.98 |
| Max. Negotiated Rate |
$205.20 |
| Rate for Payer: Aetna of AZ Commercial |
$205.20
|
| Rate for Payer: Aetna of AZ Medicare |
$63.84
|
| Rate for Payer: AHCCCS Medicaid |
$11.98
|
| Rate for Payer: Allwell Medicaid |
$11.98
|
| Rate for Payer: Allwell Medicare |
$34.20
|
| Rate for Payer: Amerigroup Medicare |
$34.20
|
| Rate for Payer: APIPA Medicare/Medicaid |
$85.16
|
| Rate for Payer: AZCH Complete Medicaid |
$11.98
|
| Rate for Payer: AZCH Complete Medicare |
$34.20
|
| Rate for Payer: Banner UC Health Medicaid |
$11.98
|
| Rate for Payer: Banner UC Health Medicare |
$34.20
|
| Rate for Payer: Bisbee Police All Plans |
$59.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$155.04
|
| Rate for Payer: Cash Price |
$182.40
|
| Rate for Payer: Cash Price |
$182.40
|
| Rate for Payer: Cigna of AZ Commercial |
$148.20
|
| Rate for Payer: Copperpoint Commercial |
$56.43
|
| Rate for Payer: Health Net of AZ Commercial |
$136.80
|
| Rate for Payer: Health Net of AZ Medicare |
$63.84
|
| Rate for Payer: Humana of AZ Medicare |
$34.20
|
| Rate for Payer: Mercy Care Medicaid |
$11.98
|
| Rate for Payer: Self Pay Self Pay |
$182.40
|
| Rate for Payer: TriWest Medicare |
$34.20
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$132.92
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$41.04
|
|
|
Giardia Lamblia Direct Detection EIA, LC
|
Facility
|
OP
|
$80.00
|
|
|
Service Code
|
CPT 87328
|
| Hospital Charge Code |
23173812
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna of AZ Commercial |
$72.00
|
| Rate for Payer: Aetna of AZ Medicare |
$22.40
|
| Rate for Payer: AHCCCS Medicaid |
$13.82
|
| Rate for Payer: Allwell Medicaid |
$13.82
|
| Rate for Payer: Allwell Medicare |
$12.00
|
| Rate for Payer: Amerigroup Medicare |
$12.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$29.88
|
| Rate for Payer: AZCH Complete Medicaid |
$13.82
|
| Rate for Payer: AZCH Complete Medicare |
$12.00
|
| Rate for Payer: Banner UC Health Medicaid |
$13.82
|
| Rate for Payer: Banner UC Health Medicare |
$12.00
|
| Rate for Payer: Bisbee Police All Plans |
$20.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$54.40
|
| Rate for Payer: Cash Price |
$64.00
|
| Rate for Payer: Cash Price |
$64.00
|
| Rate for Payer: Cigna of AZ Commercial |
$52.00
|
| Rate for Payer: Copperpoint Commercial |
$19.80
|
| Rate for Payer: Health Net of AZ Commercial |
$48.00
|
| Rate for Payer: Health Net of AZ Medicare |
$22.40
|
| Rate for Payer: Humana of AZ Medicare |
$12.00
|
| Rate for Payer: Mercy Care Medicaid |
$13.82
|
| Rate for Payer: Self Pay Self Pay |
$64.00
|
| Rate for Payer: TriWest Medicare |
$12.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$46.64
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$14.40
|
|
|
Giardia Lamblia Direct Detection EIA, LC
|
Facility
|
IP
|
$80.00
|
|
|
Service Code
|
CPT 87328
|
| Hospital Charge Code |
23173812
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.80 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna of AZ Commercial |
$72.00
|
| Rate for Payer: Bisbee Police All Plans |
$20.80
|
| Rate for Payer: Cash Price |
$64.00
|
| Rate for Payer: Self Pay Self Pay |
$64.00
|
|
|
Giardia Lamblia Direct Detection EIA, LC
|
Facility
|
IP
|
$228.00
|
|
|
Service Code
|
CPT 87329
|
| Hospital Charge Code |
3601506
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$59.28 |
| Max. Negotiated Rate |
$205.20 |
| Rate for Payer: Aetna of AZ Commercial |
$205.20
|
| Rate for Payer: Bisbee Police All Plans |
$59.28
|
| Rate for Payer: Cash Price |
$182.40
|
| Rate for Payer: Self Pay Self Pay |
$182.40
|
|
|
Gliadin IgG IgA Ab Prof LC
|
Facility
|
IP
|
$1,570.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
6781775
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$408.20 |
| Max. Negotiated Rate |
$1,413.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,413.00
|
| Rate for Payer: Bisbee Police All Plans |
$408.20
|
| Rate for Payer: Cash Price |
$1,256.00
|
| Rate for Payer: Self Pay Self Pay |
$1,256.00
|
|
|
Gliadin IgG IgA Ab Prof LC
|
Facility
|
OP
|
$1,570.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
6781775
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.53 |
| Max. Negotiated Rate |
$1,413.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,413.00
|
| Rate for Payer: Aetna of AZ Medicare |
$439.60
|
| Rate for Payer: AHCCCS Medicaid |
$11.53
|
| Rate for Payer: Allwell Medicaid |
$11.53
|
| Rate for Payer: Allwell Medicare |
$235.50
|
| Rate for Payer: Amerigroup Medicare |
$235.50
|
| Rate for Payer: APIPA Medicare/Medicaid |
$586.40
|
| Rate for Payer: AZCH Complete Medicaid |
$11.53
|
| Rate for Payer: AZCH Complete Medicare |
$235.50
|
| Rate for Payer: Banner UC Health Medicaid |
$11.53
|
| Rate for Payer: Banner UC Health Medicare |
$235.50
|
| Rate for Payer: Bisbee Police All Plans |
$408.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,067.60
|
| Rate for Payer: Cash Price |
$1,256.00
|
| Rate for Payer: Cash Price |
$1,256.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,020.50
|
| Rate for Payer: Copperpoint Commercial |
$388.58
|
| Rate for Payer: Health Net of AZ Commercial |
$942.00
|
| Rate for Payer: Health Net of AZ Medicare |
$439.60
|
| Rate for Payer: Humana of AZ Medicare |
$235.50
|
| Rate for Payer: Mercy Care Medicaid |
$11.53
|
| Rate for Payer: Self Pay Self Pay |
$1,256.00
|
| Rate for Payer: TriWest Medicare |
$235.50
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$915.31
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$282.60
|
|
|
glimepiride 2 mg Tab [CQCH]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 68084032601
|
| Hospital Charge Code |
105924275
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.48 |
| Rate for Payer: Aetna of AZ Commercial |
$0.48
|
| 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 |
$0.20
|
| 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 |
$0.36
|
| 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: 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
|
|
|
glimepiride 2 mg Tab [CQCH]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 68084032601
|
| Hospital Charge Code |
105924275
|
|
Hospital Revenue Code
|
251
|
| 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
|
|
|
glipiZIDE 5 mg Tab [CQCH]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 904663761
|
| Hospital Charge Code |
105924407
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of AZ Commercial |
$0.23
|
| Rate for Payer: Aetna of AZ Medicare |
$0.07
|
| Rate for Payer: Allwell Medicare |
$0.04
|
| Rate for Payer: Amerigroup Medicare |
$0.04
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.09
|
| 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 |
$0.17
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of AZ Commercial |
$0.16
|
| Rate for Payer: Copperpoint Commercial |
$0.06
|
| Rate for Payer: Health Net of AZ Commercial |
$0.15
|
| Rate for Payer: Health Net of AZ Medicare |
$0.07
|
| Rate for Payer: Humana of AZ Medicare |
$0.04
|
| Rate for Payer: Self Pay Self Pay |
$0.20
|
| Rate for Payer: TriWest Medicare |
$0.04
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.15
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.05
|
|
|
glipiZIDE 5 mg Tab [CQCH]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 904663761
|
| Hospital Charge Code |
105924407
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of AZ Commercial |
$0.23
|
| Rate for Payer: Bisbee Police All Plans |
$0.07
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Self Pay Self Pay |
$0.20
|
|
|
glipiZIDE XL 5 mg ER Tab [CQCH]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 64980028001
|
| Hospital Charge Code |
105924342
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of AZ Commercial |
$0.11
|
| Rate for Payer: Bisbee Police All Plans |
$0.03
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Self Pay Self Pay |
$0.10
|
|
|
glipiZIDE XL 5 mg ER Tab [CQCH]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 64980028001
|
| Hospital Charge Code |
105924342
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of AZ Commercial |
$0.11
|
| Rate for Payer: Aetna of AZ Medicare |
$0.03
|
| Rate for Payer: Allwell Medicare |
$0.02
|
| Rate for Payer: Amerigroup Medicare |
$0.02
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.04
|
| Rate for Payer: AZCH Complete Medicare |
$0.02
|
| Rate for Payer: Banner UC Health Medicare |
$0.02
|
| Rate for Payer: Bisbee Police All Plans |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.08
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of AZ Commercial |
$0.08
|
| Rate for Payer: Copperpoint Commercial |
$0.03
|
| Rate for Payer: Health Net of AZ Commercial |
$0.07
|
| Rate for Payer: Health Net of AZ Medicare |
$0.03
|
| Rate for Payer: Humana of AZ Medicare |
$0.02
|
| Rate for Payer: Self Pay Self Pay |
$0.10
|
| Rate for Payer: TriWest Medicare |
$0.02
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.07
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.02
|
|
|
GLOVE BIOGEL 6.00
|
Facility
|
IP
|
$11.00
|
|
| Hospital Charge Code |
22543188
|
|
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
|
|
|
GLOVE BIOGEL 6.00
|
Facility
|
OP
|
$11.00
|
|
| Hospital Charge Code |
22543188
|
|
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
|
|
|
GLOVE BIOGEL 7.0
|
Facility
|
IP
|
$11.00
|
|
| Hospital Charge Code |
22355783
|
|
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
|
|
|
GLOVE BIOGEL 7.0
|
Facility
|
OP
|
$11.00
|
|
| Hospital Charge Code |
22355783
|
|
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
|
|
