|
GLOVE BIOGEL 6.00
|
Facility
|
OP
|
$11.00
|
|
| Hospital Charge Code |
22543188
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.76 |
| 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 |
$1.76
|
| Rate for Payer: Amerigroup Medicare |
$1.76
|
| Rate for Payer: APIPA Medicare/Medicaid |
$4.11
|
| Rate for Payer: AZCH Complete Medicare |
$1.76
|
| Rate for Payer: Banner UC Health Medicare |
$1.76
|
| 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 |
$1.76
|
| Rate for Payer: Self Pay Self Pay |
$8.80
|
| Rate for Payer: TriWest Medicare |
$1.76
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$6.41
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$1.98
|
|
|
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
|
|
|
glucagon 1 mg Inj [CQCH]
|
Facility
|
IP
|
$233.41
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
105924472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.69 |
| Max. Negotiated Rate |
$210.07 |
| Rate for Payer: Aetna of AZ Commercial |
$210.07
|
| Rate for Payer: Bisbee Police All Plans |
$60.69
|
| Rate for Payer: Cash Price |
$186.73
|
| Rate for Payer: Self Pay Self Pay |
$186.73
|
|
|
glucagon 1 mg Inj [CQCH]
|
Facility
|
OP
|
$233.41
|
|
|
Service Code
|
HCPCS J1610
|
| Hospital Charge Code |
105924472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.35 |
| Max. Negotiated Rate |
$210.07 |
| Rate for Payer: Aetna of AZ Commercial |
$210.07
|
| Rate for Payer: Aetna of AZ Medicare |
$65.35
|
| Rate for Payer: Allwell Medicare |
$37.35
|
| Rate for Payer: Amerigroup Medicare |
$37.35
|
| Rate for Payer: APIPA Medicare/Medicaid |
$87.18
|
| Rate for Payer: AZCH Complete Medicare |
$37.35
|
| Rate for Payer: Banner UC Health Medicare |
$37.35
|
| Rate for Payer: Bisbee Police All Plans |
$60.69
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$158.72
|
| Rate for Payer: Cash Price |
$186.73
|
| Rate for Payer: Cigna of AZ Commercial |
$151.72
|
| Rate for Payer: Copperpoint Commercial |
$57.77
|
| Rate for Payer: Health Net of AZ Commercial |
$140.05
|
| Rate for Payer: Health Net of AZ Medicare |
$65.35
|
| Rate for Payer: Humana of AZ Medicare |
$37.35
|
| Rate for Payer: Self Pay Self Pay |
$186.73
|
| Rate for Payer: TriWest Medicare |
$37.35
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$136.08
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$42.01
|
|
|
Glucose 2 Hour Post Prandial
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
CPT 82950
|
| Hospital Charge Code |
633598
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.28 |
| Max. Negotiated Rate |
$74.70 |
| Rate for Payer: Aetna of AZ Commercial |
$74.70
|
| Rate for Payer: Aetna of AZ Medicare |
$23.24
|
| Rate for Payer: Allwell Medicare |
$13.28
|
| Rate for Payer: Amerigroup Medicare |
$13.28
|
| Rate for Payer: APIPA Medicare/Medicaid |
$31.00
|
| Rate for Payer: AZCH Complete Medicare |
$13.28
|
| Rate for Payer: Banner UC Health Medicare |
$13.28
|
| Rate for Payer: Bisbee Police All Plans |
$21.58
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$56.44
|
| Rate for Payer: Cash Price |
$66.40
|
| Rate for Payer: Cigna of AZ Commercial |
$53.95
|
| Rate for Payer: Copperpoint Commercial |
$20.54
|
| Rate for Payer: Health Net of AZ Commercial |
$49.80
|
| Rate for Payer: Health Net of AZ Medicare |
$23.24
|
| Rate for Payer: Humana of AZ Medicare |
$13.28
|
| Rate for Payer: Self Pay Self Pay |
$66.40
|
| Rate for Payer: TriWest Medicare |
$13.28
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$48.39
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$14.94
|
|
|
Glucose 2 Hour Post Prandial
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
CPT 82950
|
| Hospital Charge Code |
633598
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.58 |
| Max. Negotiated Rate |
$74.70 |
| Rate for Payer: Aetna of AZ Commercial |
$74.70
|
| Rate for Payer: Bisbee Police All Plans |
$21.58
|
| Rate for Payer: Cash Price |
$66.40
|
| Rate for Payer: Self Pay Self Pay |
$66.40
|
|
|
Glucose 2 HR PP
|
Facility
|
IP
|
$83.00
|
|
|
Service Code
|
CPT 82950
|
| Hospital Charge Code |
22245891
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$21.58 |
| Max. Negotiated Rate |
$74.70 |
| Rate for Payer: Aetna of AZ Commercial |
$74.70
|
| Rate for Payer: Bisbee Police All Plans |
$21.58
|
| Rate for Payer: Cash Price |
$66.40
|
| Rate for Payer: Self Pay Self Pay |
$66.40
|
|
|
Glucose 2 HR PP
|
Facility
|
OP
|
$83.00
|
|
|
Service Code
|
CPT 82950
|
| Hospital Charge Code |
22245891
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$13.28 |
| Max. Negotiated Rate |
$74.70 |
| Rate for Payer: Aetna of AZ Commercial |
$74.70
|
| Rate for Payer: Aetna of AZ Medicare |
$23.24
|
| Rate for Payer: Allwell Medicare |
$13.28
|
| Rate for Payer: Amerigroup Medicare |
$13.28
|
| Rate for Payer: APIPA Medicare/Medicaid |
$31.00
|
| Rate for Payer: AZCH Complete Medicare |
$13.28
|
| Rate for Payer: Banner UC Health Medicare |
$13.28
|
| Rate for Payer: Bisbee Police All Plans |
$21.58
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$56.44
|
| Rate for Payer: Cash Price |
$66.40
|
| Rate for Payer: Cigna of AZ Commercial |
$53.95
|
| Rate for Payer: Copperpoint Commercial |
$20.54
|
| Rate for Payer: Health Net of AZ Commercial |
$49.80
|
| Rate for Payer: Health Net of AZ Medicare |
$23.24
|
| Rate for Payer: Humana of AZ Medicare |
$13.28
|
| Rate for Payer: Self Pay Self Pay |
$66.40
|
| Rate for Payer: TriWest Medicare |
$13.28
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$48.39
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$14.94
|
|
|
Glucose CSF
|
Facility
|
IP
|
$79.00
|
|
|
Service Code
|
CPT 82945
|
| Hospital Charge Code |
633604
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.54 |
| Max. Negotiated Rate |
$71.10 |
| Rate for Payer: Aetna of AZ Commercial |
$71.10
|
| Rate for Payer: Bisbee Police All Plans |
$20.54
|
| Rate for Payer: Cash Price |
$63.20
|
| Rate for Payer: Self Pay Self Pay |
$63.20
|
|
|
Glucose CSF
|
Facility
|
OP
|
$79.00
|
|
|
Service Code
|
CPT 82945
|
| Hospital Charge Code |
633604
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.64 |
| Max. Negotiated Rate |
$71.10 |
| Rate for Payer: Aetna of AZ Commercial |
$71.10
|
| Rate for Payer: Aetna of AZ Medicare |
$22.12
|
| Rate for Payer: Allwell Medicare |
$12.64
|
| Rate for Payer: Amerigroup Medicare |
$12.64
|
| Rate for Payer: APIPA Medicare/Medicaid |
$29.51
|
| Rate for Payer: AZCH Complete Medicare |
$12.64
|
| Rate for Payer: Banner UC Health Medicare |
$12.64
|
| Rate for Payer: Bisbee Police All Plans |
$20.54
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$53.72
|
| Rate for Payer: Cash Price |
$63.20
|
| Rate for Payer: Cigna of AZ Commercial |
$51.35
|
| Rate for Payer: Copperpoint Commercial |
$19.55
|
| Rate for Payer: Health Net of AZ Commercial |
$47.40
|
| Rate for Payer: Health Net of AZ Medicare |
$22.12
|
| Rate for Payer: Humana of AZ Medicare |
$12.64
|
| Rate for Payer: Self Pay Self Pay |
$63.20
|
| Rate for Payer: TriWest Medicare |
$12.64
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$46.06
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$14.22
|
|
|
Glucose Fasting
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
CPT 82947
|
| Hospital Charge Code |
633593
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.28 |
| Max. Negotiated Rate |
$70.20 |
| Rate for Payer: Aetna of AZ Commercial |
$70.20
|
| Rate for Payer: Bisbee Police All Plans |
$20.28
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Self Pay Self Pay |
$62.40
|
|
|
Glucose Fasting
|
Facility
|
OP
|
$78.00
|
|
|
Service Code
|
CPT 82947
|
| Hospital Charge Code |
633593
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$70.20 |
| Rate for Payer: Aetna of AZ Commercial |
$70.20
|
| Rate for Payer: Aetna of AZ Medicare |
$21.84
|
| Rate for Payer: Allwell Medicare |
$12.48
|
| Rate for Payer: Amerigroup Medicare |
$12.48
|
| Rate for Payer: APIPA Medicare/Medicaid |
$29.13
|
| Rate for Payer: AZCH Complete Medicare |
$12.48
|
| Rate for Payer: Banner UC Health Medicare |
$12.48
|
| Rate for Payer: Bisbee Police All Plans |
$20.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$53.04
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Cigna of AZ Commercial |
$50.70
|
| Rate for Payer: Copperpoint Commercial |
$19.30
|
| Rate for Payer: Health Net of AZ Commercial |
$46.80
|
| Rate for Payer: Health Net of AZ Medicare |
$21.84
|
| Rate for Payer: Humana of AZ Medicare |
$12.48
|
| Rate for Payer: Self Pay Self Pay |
$62.40
|
| Rate for Payer: TriWest Medicare |
$12.48
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$45.47
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$14.04
|
|
|
Glucose Level
|
Facility
|
OP
|
$82.00
|
|
|
Service Code
|
CPT 82947
|
| Hospital Charge Code |
633594
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.12 |
| Max. Negotiated Rate |
$73.80 |
| Rate for Payer: Aetna of AZ Commercial |
$73.80
|
| Rate for Payer: Aetna of AZ Medicare |
$22.96
|
| Rate for Payer: Allwell Medicare |
$13.12
|
| Rate for Payer: Amerigroup Medicare |
$13.12
|
| Rate for Payer: APIPA Medicare/Medicaid |
$30.63
|
| Rate for Payer: AZCH Complete Medicare |
$13.12
|
| Rate for Payer: Banner UC Health Medicare |
$13.12
|
| Rate for Payer: Bisbee Police All Plans |
$21.32
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$55.76
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Cigna of AZ Commercial |
$53.30
|
| Rate for Payer: Copperpoint Commercial |
$20.30
|
| Rate for Payer: Health Net of AZ Commercial |
$49.20
|
| Rate for Payer: Health Net of AZ Medicare |
$22.96
|
| Rate for Payer: Humana of AZ Medicare |
$13.12
|
| Rate for Payer: Self Pay Self Pay |
$65.60
|
| Rate for Payer: TriWest Medicare |
$13.12
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$47.81
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$14.76
|
|
|
Glucose Level
|
Facility
|
IP
|
$82.00
|
|
|
Service Code
|
CPT 82947
|
| Hospital Charge Code |
633594
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.32 |
| Max. Negotiated Rate |
$73.80 |
| Rate for Payer: Aetna of AZ Commercial |
$73.80
|
| Rate for Payer: Bisbee Police All Plans |
$21.32
|
| Rate for Payer: Cash Price |
$65.60
|
| Rate for Payer: Self Pay Self Pay |
$65.60
|
|
|
glucose oral Gel 15 gm dextrose in 37.5 gm [CQCH]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 574006930
|
| Hospital Charge Code |
108473448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of AZ Commercial |
$0.19
|
| Rate for Payer: Bisbee Police All Plans |
$0.05
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Self Pay Self Pay |
$0.17
|
|
|
glucose oral Gel 15 gm dextrose in 37.5 gm [CQCH]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 574006930
|
| Hospital Charge Code |
108473448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of AZ Commercial |
$0.19
|
| Rate for Payer: Aetna of AZ Medicare |
$0.06
|
| Rate for Payer: Allwell Medicare |
$0.03
|
| Rate for Payer: Amerigroup Medicare |
$0.03
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.08
|
| 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 |
$0.14
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Cigna of AZ Commercial |
$0.14
|
| Rate for Payer: Copperpoint Commercial |
$0.05
|
| Rate for Payer: Health Net of AZ Commercial |
$0.13
|
| Rate for Payer: Health Net of AZ Medicare |
$0.06
|
| Rate for Payer: Humana of AZ Medicare |
$0.03
|
| Rate for Payer: Self Pay Self Pay |
$0.17
|
| Rate for Payer: TriWest Medicare |
$0.03
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.12
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.04
|
|
|
Glucose POC (Lab)
|
Facility
|
IP
|
$37.00
|
|
|
Service Code
|
CPT 82962
|
| Hospital Charge Code |
10456470
|
|
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
|
|
|
Glucose POC (Lab)
|
Facility
|
OP
|
$37.00
|
|
|
Service Code
|
CPT 82962
|
| Hospital Charge Code |
10456470
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.92 |
| 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: Allwell Medicare |
$5.92
|
| Rate for Payer: Amerigroup Medicare |
$5.92
|
| Rate for Payer: APIPA Medicare/Medicaid |
$13.82
|
| Rate for Payer: AZCH Complete Medicare |
$5.92
|
| Rate for Payer: Banner UC Health Medicare |
$5.92
|
| 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: 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 |
$5.92
|
| Rate for Payer: Self Pay Self Pay |
$29.60
|
| Rate for Payer: TriWest Medicare |
$5.92
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$21.57
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$6.66
|
|
|
glyBURIDE 5 mg Tab [CQCH]
|
Facility
|
IP
|
$0.33
|
|
|
Service Code
|
NDC 63739011910
|
| Hospital Charge Code |
105924688
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of AZ Commercial |
$0.30
|
| Rate for Payer: Bisbee Police All Plans |
$0.09
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Self Pay Self Pay |
$0.26
|
|
|
glyBURIDE 5 mg Tab [CQCH]
|
Facility
|
OP
|
$0.33
|
|
|
Service Code
|
NDC 63739011910
|
| Hospital Charge Code |
105924688
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.30 |
| Rate for Payer: Aetna of AZ Commercial |
$0.30
|
| Rate for Payer: Aetna of AZ Medicare |
$0.09
|
| Rate for Payer: Allwell Medicare |
$0.05
|
| Rate for Payer: Amerigroup Medicare |
$0.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.12
|
| Rate for Payer: AZCH Complete Medicare |
$0.05
|
| Rate for Payer: Banner UC Health Medicare |
$0.05
|
| Rate for Payer: Bisbee Police All Plans |
$0.09
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.22
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of AZ Commercial |
$0.21
|
| Rate for Payer: Copperpoint Commercial |
$0.08
|
| Rate for Payer: Health Net of AZ Commercial |
$0.20
|
| Rate for Payer: Health Net of AZ Medicare |
$0.09
|
| Rate for Payer: Humana of AZ Medicare |
$0.05
|
| Rate for Payer: Self Pay Self Pay |
$0.26
|
| Rate for Payer: TriWest Medicare |
$0.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.19
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.06
|
|
|
GLYCATED PROTEIN
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
CPT 82985
|
| Hospital Charge Code |
28010053
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$21.84 |
| Max. Negotiated Rate |
$75.60 |
| Rate for Payer: Aetna of AZ Commercial |
$75.60
|
| Rate for Payer: Bisbee Police All Plans |
$21.84
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Self Pay Self Pay |
$67.20
|
|
|
GLYCATED PROTEIN
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
CPT 82985
|
| Hospital Charge Code |
28010053
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$75.60 |
| Rate for Payer: Aetna of AZ Commercial |
$75.60
|
| Rate for Payer: Aetna of AZ Medicare |
$23.52
|
| Rate for Payer: Allwell Medicare |
$13.44
|
| Rate for Payer: Amerigroup Medicare |
$13.44
|
| Rate for Payer: APIPA Medicare/Medicaid |
$31.37
|
| Rate for Payer: AZCH Complete Medicare |
$13.44
|
| Rate for Payer: Banner UC Health Medicare |
$13.44
|
| Rate for Payer: Bisbee Police All Plans |
$21.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$57.12
|
| Rate for Payer: Cash Price |
$67.20
|
| Rate for Payer: Cigna of AZ Commercial |
$54.60
|
| Rate for Payer: Copperpoint Commercial |
$20.79
|
| Rate for Payer: Health Net of AZ Commercial |
$50.40
|
| Rate for Payer: Health Net of AZ Medicare |
$23.52
|
| Rate for Payer: Humana of AZ Medicare |
$13.44
|
| Rate for Payer: Self Pay Self Pay |
$67.20
|
| Rate for Payer: TriWest Medicare |
$13.44
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$48.97
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$15.12
|
|
|
glycerin pediatric Supp [CQCH]
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 713010209
|
| Hospital Charge Code |
105924755
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna of AZ Commercial |
$0.60
|
| Rate for Payer: Bisbee Police All Plans |
$0.17
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Self Pay Self Pay |
$0.54
|
|
|
glycerin pediatric Supp [CQCH]
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 713010209
|
| Hospital Charge Code |
105924755
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna of AZ Commercial |
$0.60
|
| Rate for Payer: Aetna of AZ Medicare |
$0.19
|
| Rate for Payer: Allwell Medicare |
$0.11
|
| Rate for Payer: Amerigroup Medicare |
$0.11
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.25
|
| Rate for Payer: AZCH Complete Medicare |
$0.11
|
| Rate for Payer: Banner UC Health Medicare |
$0.11
|
| Rate for Payer: Bisbee Police All Plans |
$0.17
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.46
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of AZ Commercial |
$0.44
|
| Rate for Payer: Copperpoint Commercial |
$0.17
|
| Rate for Payer: Health Net of AZ Commercial |
$0.40
|
| Rate for Payer: Health Net of AZ Medicare |
$0.19
|
| Rate for Payer: Humana of AZ Medicare |
$0.11
|
| Rate for Payer: Self Pay Self Pay |
$0.54
|
| Rate for Payer: TriWest Medicare |
$0.11
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.39
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.12
|
|
|
GlycoMark(R)(1,5 AG) LC
|
Facility
|
IP
|
$78.00
|
|
|
Service Code
|
CPT 82945
|
| Hospital Charge Code |
2270019
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.28 |
| Max. Negotiated Rate |
$70.20 |
| Rate for Payer: Aetna of AZ Commercial |
$70.20
|
| Rate for Payer: Bisbee Police All Plans |
$20.28
|
| Rate for Payer: Cash Price |
$62.40
|
| Rate for Payer: Self Pay Self Pay |
$62.40
|
|
