|
HSV 2 IGG
|
Facility
|
IP
|
$241.00
|
|
|
Service Code
|
CPT 86696
|
| Hospital Charge Code |
22481479
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$62.66 |
| Max. Negotiated Rate |
$216.90 |
| Rate for Payer: Aetna of AZ Commercial |
$216.90
|
| Rate for Payer: Bisbee Police All Plans |
$62.66
|
| Rate for Payer: Cash Price |
$192.80
|
| Rate for Payer: Self Pay Self Pay |
$192.80
|
|
|
HSV Culture and Typing LC
|
Facility
|
IP
|
$323.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
1906898
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$83.98 |
| Max. Negotiated Rate |
$290.70 |
| Rate for Payer: Aetna of AZ Commercial |
$290.70
|
| Rate for Payer: Bisbee Police All Plans |
$83.98
|
| Rate for Payer: Cash Price |
$258.40
|
| Rate for Payer: Self Pay Self Pay |
$258.40
|
|
|
HSV Culture and Typing LC
|
Facility
|
OP
|
$323.00
|
|
|
Service Code
|
CPT 87254
|
| Hospital Charge Code |
1906898
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$19.56 |
| Max. Negotiated Rate |
$290.70 |
| Rate for Payer: Aetna of AZ Commercial |
$290.70
|
| Rate for Payer: Aetna of AZ Medicare |
$90.44
|
| Rate for Payer: AHCCCS Medicaid |
$19.56
|
| Rate for Payer: Allwell Medicaid |
$19.56
|
| Rate for Payer: Allwell Medicare |
$48.45
|
| Rate for Payer: Amerigroup Medicare |
$48.45
|
| Rate for Payer: APIPA Medicare/Medicaid |
$120.64
|
| Rate for Payer: AZCH Complete Medicaid |
$19.56
|
| Rate for Payer: AZCH Complete Medicare |
$48.45
|
| Rate for Payer: Banner UC Health Medicaid |
$19.56
|
| Rate for Payer: Banner UC Health Medicare |
$48.45
|
| Rate for Payer: Bisbee Police All Plans |
$83.98
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$219.64
|
| Rate for Payer: Cash Price |
$258.40
|
| Rate for Payer: Cash Price |
$258.40
|
| Rate for Payer: Cigna of AZ Commercial |
$209.95
|
| Rate for Payer: Copperpoint Commercial |
$79.94
|
| Rate for Payer: Health Net of AZ Commercial |
$193.80
|
| Rate for Payer: Health Net of AZ Medicare |
$90.44
|
| Rate for Payer: Humana of AZ Medicare |
$48.45
|
| Rate for Payer: Mercy Care Medicaid |
$19.56
|
| Rate for Payer: Self Pay Self Pay |
$258.40
|
| Rate for Payer: TriWest Medicare |
$48.45
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$188.31
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$58.14
|
|
|
HSV Type 1-Specific Ab, IgG LC
|
Facility
|
IP
|
$163.00
|
|
|
Service Code
|
CPT 86695
|
| Hospital Charge Code |
2087613
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$42.38 |
| Max. Negotiated Rate |
$146.70 |
| Rate for Payer: Aetna of AZ Commercial |
$146.70
|
| Rate for Payer: Bisbee Police All Plans |
$42.38
|
| Rate for Payer: Cash Price |
$130.40
|
| Rate for Payer: Self Pay Self Pay |
$130.40
|
|
|
HSV Type 1-Specific Ab, IgG LC
|
Facility
|
OP
|
$163.00
|
|
|
Service Code
|
CPT 86695
|
| Hospital Charge Code |
2087613
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$13.19 |
| Max. Negotiated Rate |
$146.70 |
| Rate for Payer: Aetna of AZ Commercial |
$146.70
|
| Rate for Payer: Aetna of AZ Medicare |
$45.64
|
| Rate for Payer: AHCCCS Medicaid |
$13.19
|
| Rate for Payer: Allwell Medicaid |
$13.19
|
| Rate for Payer: Allwell Medicare |
$24.45
|
| Rate for Payer: Amerigroup Medicare |
$24.45
|
| Rate for Payer: APIPA Medicare/Medicaid |
$60.88
|
| Rate for Payer: AZCH Complete Medicaid |
$13.19
|
| Rate for Payer: AZCH Complete Medicare |
$24.45
|
| Rate for Payer: Banner UC Health Medicaid |
$13.19
|
| Rate for Payer: Banner UC Health Medicare |
$24.45
|
| Rate for Payer: Bisbee Police All Plans |
$42.38
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$110.84
|
| Rate for Payer: Cash Price |
$130.40
|
| Rate for Payer: Cash Price |
$130.40
|
| Rate for Payer: Cigna of AZ Commercial |
$105.95
|
| Rate for Payer: Copperpoint Commercial |
$40.34
|
| Rate for Payer: Health Net of AZ Commercial |
$97.80
|
| Rate for Payer: Health Net of AZ Medicare |
$45.64
|
| Rate for Payer: Humana of AZ Medicare |
$24.45
|
| Rate for Payer: Mercy Care Medicaid |
$13.19
|
| Rate for Payer: Self Pay Self Pay |
$130.40
|
| Rate for Payer: TriWest Medicare |
$24.45
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$95.03
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$29.34
|
|
|
HSV Type 2-Specific Ab, IgG LC
|
Facility
|
OP
|
$253.00
|
|
|
Service Code
|
CPT 86696
|
| Hospital Charge Code |
1906902
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$19.35 |
| Max. Negotiated Rate |
$227.70 |
| Rate for Payer: Aetna of AZ Commercial |
$227.70
|
| Rate for Payer: Aetna of AZ Medicare |
$70.84
|
| Rate for Payer: AHCCCS Medicaid |
$19.35
|
| Rate for Payer: Allwell Medicaid |
$19.35
|
| Rate for Payer: Allwell Medicare |
$37.95
|
| Rate for Payer: Amerigroup Medicare |
$37.95
|
| Rate for Payer: APIPA Medicare/Medicaid |
$94.50
|
| Rate for Payer: AZCH Complete Medicaid |
$19.35
|
| Rate for Payer: AZCH Complete Medicare |
$37.95
|
| Rate for Payer: Banner UC Health Medicaid |
$19.35
|
| Rate for Payer: Banner UC Health Medicare |
$37.95
|
| Rate for Payer: Bisbee Police All Plans |
$65.78
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$172.04
|
| Rate for Payer: Cash Price |
$202.40
|
| Rate for Payer: Cash Price |
$202.40
|
| Rate for Payer: Cigna of AZ Commercial |
$164.45
|
| Rate for Payer: Copperpoint Commercial |
$62.62
|
| Rate for Payer: Health Net of AZ Commercial |
$151.80
|
| Rate for Payer: Health Net of AZ Medicare |
$70.84
|
| Rate for Payer: Humana of AZ Medicare |
$37.95
|
| Rate for Payer: Mercy Care Medicaid |
$19.35
|
| Rate for Payer: Self Pay Self Pay |
$202.40
|
| Rate for Payer: TriWest Medicare |
$37.95
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$147.50
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$45.54
|
|
|
HSV Type 2-Specific Ab, IgG LC
|
Facility
|
IP
|
$253.00
|
|
|
Service Code
|
CPT 86696
|
| Hospital Charge Code |
1906902
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$65.78 |
| Max. Negotiated Rate |
$227.70 |
| Rate for Payer: Aetna of AZ Commercial |
$227.70
|
| Rate for Payer: Bisbee Police All Plans |
$65.78
|
| Rate for Payer: Cash Price |
$202.40
|
| Rate for Payer: Self Pay Self Pay |
$202.40
|
|
|
Human Epididymis Protein 4 LC
|
Facility
|
IP
|
$377.00
|
|
|
Service Code
|
CPT 86304
|
| Hospital Charge Code |
22201907
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$98.02 |
| Max. Negotiated Rate |
$339.30 |
| Rate for Payer: Aetna of AZ Commercial |
$339.30
|
| Rate for Payer: Bisbee Police All Plans |
$98.02
|
| Rate for Payer: Cash Price |
$301.60
|
| Rate for Payer: Self Pay Self Pay |
$301.60
|
|
|
Human Epididymis Protein 4 LC
|
Facility
|
OP
|
$377.00
|
|
|
Service Code
|
CPT 86304
|
| Hospital Charge Code |
22201907
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.81 |
| Max. Negotiated Rate |
$339.30 |
| Rate for Payer: Aetna of AZ Commercial |
$339.30
|
| Rate for Payer: Aetna of AZ Medicare |
$105.56
|
| Rate for Payer: AHCCCS Medicaid |
$20.81
|
| Rate for Payer: Allwell Medicaid |
$20.81
|
| Rate for Payer: Allwell Medicare |
$56.55
|
| Rate for Payer: Amerigroup Medicare |
$56.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$140.81
|
| Rate for Payer: AZCH Complete Medicaid |
$20.81
|
| Rate for Payer: AZCH Complete Medicare |
$56.55
|
| Rate for Payer: Banner UC Health Medicaid |
$20.81
|
| Rate for Payer: Banner UC Health Medicare |
$56.55
|
| Rate for Payer: Bisbee Police All Plans |
$98.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$256.36
|
| Rate for Payer: Cash Price |
$301.60
|
| Rate for Payer: Cash Price |
$301.60
|
| Rate for Payer: Cigna of AZ Commercial |
$245.05
|
| Rate for Payer: Copperpoint Commercial |
$93.31
|
| Rate for Payer: Health Net of AZ Commercial |
$226.20
|
| Rate for Payer: Health Net of AZ Medicare |
$105.56
|
| Rate for Payer: Humana of AZ Medicare |
$56.55
|
| Rate for Payer: Mercy Care Medicaid |
$20.81
|
| Rate for Payer: Self Pay Self Pay |
$301.60
|
| Rate for Payer: TriWest Medicare |
$56.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$219.79
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$67.86
|
|
|
HUMIDIFIER REFILL 500 ML
|
Facility
|
IP
|
$22.00
|
|
| Hospital Charge Code |
22355209
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$19.80 |
| Rate for Payer: Aetna of AZ Commercial |
$19.80
|
| Rate for Payer: Bisbee Police All Plans |
$5.72
|
| Rate for Payer: Cash Price |
$17.60
|
| Rate for Payer: Self Pay Self Pay |
$17.60
|
|
|
HUMIDIFIER REFILL 500 ML
|
Facility
|
OP
|
$22.00
|
|
| Hospital Charge Code |
22355209
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$19.80 |
| Rate for Payer: Aetna of AZ Commercial |
$19.80
|
| Rate for Payer: Aetna of AZ Medicare |
$6.16
|
| Rate for Payer: Allwell Medicare |
$3.30
|
| Rate for Payer: Amerigroup Medicare |
$3.30
|
| Rate for Payer: APIPA Medicare/Medicaid |
$8.22
|
| Rate for Payer: AZCH Complete Medicare |
$3.30
|
| Rate for Payer: Banner UC Health Medicare |
$3.30
|
| Rate for Payer: Bisbee Police All Plans |
$5.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$14.96
|
| Rate for Payer: Cash Price |
$17.60
|
| Rate for Payer: Cigna of AZ Commercial |
$15.40
|
| Rate for Payer: Copperpoint Commercial |
$5.44
|
| Rate for Payer: Health Net of AZ Commercial |
$13.20
|
| Rate for Payer: Health Net of AZ Medicare |
$6.16
|
| Rate for Payer: Humana of AZ Medicare |
$3.30
|
| Rate for Payer: Self Pay Self Pay |
$17.60
|
| Rate for Payer: TriWest Medicare |
$3.30
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$12.83
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$3.96
|
|
|
hydrALAZINE 20 mg/ 1 mL Sol [CQCH]
|
Facility
|
IP
|
$3.15
|
|
|
Service Code
|
HCPCS J0360
|
| Hospital Charge Code |
122900854
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$2.84 |
| Rate for Payer: Aetna of AZ Commercial |
$2.84
|
| Rate for Payer: Bisbee Police All Plans |
$0.82
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Self Pay Self Pay |
$2.52
|
|
|
hydrALAZINE 20 mg/ 1 mL Sol [CQCH]
|
Facility
|
OP
|
$3.15
|
|
|
Service Code
|
HCPCS J0360
|
| Hospital Charge Code |
122900854
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$12.84 |
| Rate for Payer: Aetna of AZ Commercial |
$2.84
|
| Rate for Payer: Aetna of AZ Medicare |
$0.88
|
| Rate for Payer: AHCCCS Medicaid |
$12.84
|
| Rate for Payer: Allwell Medicaid |
$12.84
|
| Rate for Payer: Allwell Medicare |
$0.47
|
| Rate for Payer: Amerigroup Medicare |
$0.47
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1.18
|
| Rate for Payer: AZCH Complete Medicaid |
$12.84
|
| Rate for Payer: AZCH Complete Medicare |
$0.47
|
| Rate for Payer: Banner UC Health Medicaid |
$12.84
|
| Rate for Payer: Banner UC Health Medicare |
$0.47
|
| Rate for Payer: Bisbee Police All Plans |
$0.82
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2.14
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cash Price |
$2.52
|
| Rate for Payer: Cigna of AZ Commercial |
$2.05
|
| Rate for Payer: Copperpoint Commercial |
$0.78
|
| Rate for Payer: Health Net of AZ Commercial |
$1.89
|
| Rate for Payer: Health Net of AZ Medicare |
$0.88
|
| Rate for Payer: Humana of AZ Medicare |
$0.47
|
| Rate for Payer: Mercy Care Medicaid |
$12.84
|
| Rate for Payer: Self Pay Self Pay |
$2.52
|
| Rate for Payer: TriWest Medicare |
$0.47
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1.84
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.57
|
|
|
hydrALAZINE 25 mg Tab [CQCH]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 63739032710
|
| Hospital Charge Code |
105925507
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of AZ Commercial |
$0.09
|
| Rate for Payer: Bisbee Police All Plans |
$0.03
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Self Pay Self Pay |
$0.08
|
|
|
hydrALAZINE 25 mg Tab [CQCH]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 63739032710
|
| Hospital Charge Code |
105925507
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of AZ Commercial |
$0.09
|
| 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 |
$0.07
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of AZ Commercial |
$0.07
|
| Rate for Payer: Copperpoint Commercial |
$0.02
|
| Rate for Payer: Health Net of AZ Commercial |
$0.06
|
| 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 |
$0.08
|
| Rate for Payer: TriWest Medicare |
$0.02
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.06
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.02
|
|
|
hydroCHLOROthiazide 25 mg Tab [CQCH]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 63739012810
|
| Hospital Charge Code |
105925572
|
|
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 |
$0.02
|
| 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
|
|
|
hydroCHLOROthiazide 25 mg Tab [CQCH]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 63739012810
|
| Hospital Charge Code |
105925572
|
|
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 |
$0.02
|
| Rate for Payer: Self Pay Self Pay |
$0.02
|
|
|
hydrocortisone 100 mg/2 mL Inj [CQCH]
|
Facility
|
IP
|
$13.65
|
|
|
Service Code
|
HCPCS J1720
|
| Hospital Charge Code |
105925704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$12.28 |
| Rate for Payer: Aetna of AZ Commercial |
$12.28
|
| Rate for Payer: Bisbee Police All Plans |
$3.55
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: Self Pay Self Pay |
$10.92
|
|
|
hydrocortisone 100 mg/2 mL Inj [CQCH]
|
Facility
|
OP
|
$13.65
|
|
|
Service Code
|
HCPCS J1720
|
| Hospital Charge Code |
105925704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$33.98 |
| Rate for Payer: Aetna of AZ Commercial |
$12.28
|
| Rate for Payer: Aetna of AZ Medicare |
$3.82
|
| Rate for Payer: AHCCCS Medicaid |
$33.98
|
| Rate for Payer: Allwell Medicaid |
$33.98
|
| Rate for Payer: Allwell Medicare |
$2.05
|
| Rate for Payer: Amerigroup Medicare |
$2.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$5.10
|
| Rate for Payer: AZCH Complete Medicaid |
$33.98
|
| Rate for Payer: AZCH Complete Medicare |
$2.05
|
| Rate for Payer: Banner UC Health Medicaid |
$33.98
|
| Rate for Payer: Banner UC Health Medicare |
$2.05
|
| Rate for Payer: Bisbee Police All Plans |
$3.55
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$9.28
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: Cigna of AZ Commercial |
$8.87
|
| Rate for Payer: Copperpoint Commercial |
$3.38
|
| Rate for Payer: Health Net of AZ Commercial |
$8.19
|
| Rate for Payer: Health Net of AZ Medicare |
$3.82
|
| Rate for Payer: Humana of AZ Medicare |
$2.05
|
| Rate for Payer: Mercy Care Medicaid |
$33.98
|
| Rate for Payer: Self Pay Self Pay |
$10.92
|
| Rate for Payer: TriWest Medicare |
$2.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$7.96
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$2.46
|
|
|
hydrocortisone 25 mg Supp [CQCH]
|
Facility
|
OP
|
$1.69
|
|
|
Service Code
|
NDC 42494030112
|
| Hospital Charge Code |
105925771
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna of AZ Commercial |
$1.52
|
| Rate for Payer: Aetna of AZ Medicare |
$0.47
|
| Rate for Payer: Allwell Medicare |
$0.25
|
| Rate for Payer: Amerigroup Medicare |
$0.25
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.63
|
| Rate for Payer: AZCH Complete Medicare |
$0.25
|
| Rate for Payer: Banner UC Health Medicare |
$0.25
|
| Rate for Payer: Bisbee Police All Plans |
$0.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.15
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Cigna of AZ Commercial |
$1.10
|
| Rate for Payer: Copperpoint Commercial |
$0.42
|
| Rate for Payer: Health Net of AZ Commercial |
$1.01
|
| Rate for Payer: Health Net of AZ Medicare |
$0.47
|
| Rate for Payer: Humana of AZ Medicare |
$0.25
|
| Rate for Payer: Self Pay Self Pay |
$1.35
|
| Rate for Payer: TriWest Medicare |
$0.25
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.99
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.30
|
|
|
hydrocortisone 25 mg Supp [CQCH]
|
Facility
|
IP
|
$1.69
|
|
|
Service Code
|
NDC 42494030112
|
| Hospital Charge Code |
105925771
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.44 |
| Max. Negotiated Rate |
$1.52 |
| Rate for Payer: Aetna of AZ Commercial |
$1.52
|
| Rate for Payer: Bisbee Police All Plans |
$0.44
|
| Rate for Payer: Cash Price |
$1.35
|
| Rate for Payer: Self Pay Self Pay |
$1.35
|
|
|
hydrocortisone/neomycin/polymyxin B Otic Susp [CQCH]
|
Facility
|
OP
|
$8.26
|
|
|
Service Code
|
NDC 24208063110
|
| Hospital Charge Code |
105925901
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$7.43 |
| Rate for Payer: Aetna of AZ Commercial |
$7.43
|
| Rate for Payer: Aetna of AZ Medicare |
$2.31
|
| Rate for Payer: Allwell Medicare |
$1.24
|
| Rate for Payer: Amerigroup Medicare |
$1.24
|
| Rate for Payer: APIPA Medicare/Medicaid |
$3.09
|
| Rate for Payer: AZCH Complete Medicare |
$1.24
|
| Rate for Payer: Banner UC Health Medicare |
$1.24
|
| Rate for Payer: Bisbee Police All Plans |
$2.15
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$5.62
|
| Rate for Payer: Cash Price |
$6.61
|
| Rate for Payer: Cigna of AZ Commercial |
$5.37
|
| Rate for Payer: Copperpoint Commercial |
$2.04
|
| Rate for Payer: Health Net of AZ Commercial |
$4.96
|
| Rate for Payer: Health Net of AZ Medicare |
$2.31
|
| Rate for Payer: Humana of AZ Medicare |
$1.24
|
| Rate for Payer: Self Pay Self Pay |
$6.61
|
| Rate for Payer: TriWest Medicare |
$1.24
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$4.82
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$1.49
|
|
|
hydrocortisone/neomycin/polymyxin B Otic Susp [CQCH]
|
Facility
|
IP
|
$8.26
|
|
|
Service Code
|
NDC 24208063110
|
| Hospital Charge Code |
105925901
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$2.15 |
| Max. Negotiated Rate |
$7.43 |
| Rate for Payer: Aetna of AZ Commercial |
$7.43
|
| Rate for Payer: Bisbee Police All Plans |
$2.15
|
| Rate for Payer: Cash Price |
$6.61
|
| Rate for Payer: Self Pay Self Pay |
$6.61
|
|
|
hydrocortisone Top 1% Crm 28 gm [CQCH]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 603053550
|
| Hospital Charge Code |
105925836
|
|
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 |
$0.02
|
| Rate for Payer: Self Pay Self Pay |
$0.02
|
|
|
hydrocortisone Top 1% Crm 28 gm [CQCH]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 603053550
|
| Hospital Charge Code |
105925836
|
|
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 |
$0.02
|
| 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
|
|
