|
INSORB STAPLER
|
Facility
|
IP
|
$121.00
|
|
| Hospital Charge Code |
22598339
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.46 |
| Max. Negotiated Rate |
$108.90 |
| Rate for Payer: Aetna of AZ Commercial |
$108.90
|
| Rate for Payer: Bisbee Police All Plans |
$31.46
|
| Rate for Payer: Cash Price |
$96.80
|
| Rate for Payer: Self Pay Self Pay |
$96.80
|
|
|
insulin 70-30 100 units/mL 3 mL Inj [CQCH]
|
Facility
|
IP
|
$4.49
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
105926789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$4.04 |
| Rate for Payer: Aetna of AZ Commercial |
$4.04
|
| Rate for Payer: Bisbee Police All Plans |
$1.17
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Self Pay Self Pay |
$3.59
|
|
|
insulin 70-30 100 units/mL 3 mL Inj [CQCH]
|
Facility
|
OP
|
$4.49
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
105926789
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.04 |
| Rate for Payer: Aetna of AZ Commercial |
$4.04
|
| Rate for Payer: Aetna of AZ Medicare |
$1.26
|
| Rate for Payer: AHCCCS Medicaid |
$1.70
|
| Rate for Payer: Allwell Medicaid |
$1.70
|
| Rate for Payer: Allwell Medicare |
$0.67
|
| Rate for Payer: Amerigroup Medicare |
$0.67
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1.68
|
| Rate for Payer: AZCH Complete Medicaid |
$1.70
|
| Rate for Payer: AZCH Complete Medicare |
$0.67
|
| Rate for Payer: Banner UC Health Medicaid |
$1.70
|
| Rate for Payer: Banner UC Health Medicare |
$0.67
|
| Rate for Payer: Bisbee Police All Plans |
$1.17
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$3.05
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Cigna of AZ Commercial |
$2.92
|
| Rate for Payer: Copperpoint Commercial |
$1.11
|
| Rate for Payer: Health Net of AZ Commercial |
$2.69
|
| Rate for Payer: Health Net of AZ Medicare |
$1.26
|
| Rate for Payer: Humana of AZ Medicare |
$0.67
|
| Rate for Payer: Mercy Care Medicaid |
$1.70
|
| Rate for Payer: Self Pay Self Pay |
$3.59
|
| Rate for Payer: TriWest Medicare |
$0.67
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2.62
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.81
|
|
|
Insulin 70 units-30 units/mL 10 ml Sus[CQCH]
|
Facility
|
IP
|
$1.74
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
233245743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.57 |
| Rate for Payer: Aetna of AZ Commercial |
$1.57
|
| Rate for Payer: Bisbee Police All Plans |
$0.45
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Self Pay Self Pay |
$1.39
|
|
|
Insulin 70 units-30 units/mL 10 ml Sus[CQCH]
|
Facility
|
OP
|
$1.74
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
233245743
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Aetna of AZ Commercial |
$1.57
|
| Rate for Payer: Aetna of AZ Medicare |
$0.49
|
| Rate for Payer: AHCCCS Medicaid |
$1.70
|
| Rate for Payer: Allwell Medicaid |
$1.70
|
| Rate for Payer: Allwell Medicare |
$0.26
|
| Rate for Payer: Amerigroup Medicare |
$0.26
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.65
|
| Rate for Payer: AZCH Complete Medicaid |
$1.70
|
| Rate for Payer: AZCH Complete Medicare |
$0.26
|
| Rate for Payer: Banner UC Health Medicaid |
$1.70
|
| Rate for Payer: Banner UC Health Medicare |
$0.26
|
| Rate for Payer: Bisbee Police All Plans |
$0.45
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.18
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Cigna of AZ Commercial |
$1.13
|
| Rate for Payer: Copperpoint Commercial |
$0.43
|
| Rate for Payer: Health Net of AZ Commercial |
$1.04
|
| Rate for Payer: Health Net of AZ Medicare |
$0.49
|
| Rate for Payer: Humana of AZ Medicare |
$0.26
|
| Rate for Payer: Mercy Care Medicaid |
$1.70
|
| Rate for Payer: Self Pay Self Pay |
$1.39
|
| Rate for Payer: TriWest Medicare |
$0.26
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1.01
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.31
|
|
|
INSULIN AB
|
Facility
|
IP
|
$389.00
|
|
|
Service Code
|
CPT 86337
|
| Hospital Charge Code |
23603250
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$101.14 |
| Max. Negotiated Rate |
$350.10 |
| Rate for Payer: Aetna of AZ Commercial |
$350.10
|
| Rate for Payer: Bisbee Police All Plans |
$101.14
|
| Rate for Payer: Cash Price |
$311.20
|
| Rate for Payer: Self Pay Self Pay |
$311.20
|
|
|
INSULIN AB
|
Facility
|
OP
|
$389.00
|
|
|
Service Code
|
CPT 86337
|
| Hospital Charge Code |
23603250
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$21.41 |
| Max. Negotiated Rate |
$350.10 |
| Rate for Payer: Aetna of AZ Commercial |
$350.10
|
| Rate for Payer: Aetna of AZ Medicare |
$108.92
|
| Rate for Payer: AHCCCS Medicaid |
$21.41
|
| Rate for Payer: Allwell Medicaid |
$21.41
|
| Rate for Payer: Allwell Medicare |
$58.35
|
| Rate for Payer: Amerigroup Medicare |
$58.35
|
| Rate for Payer: APIPA Medicare/Medicaid |
$145.29
|
| Rate for Payer: AZCH Complete Medicaid |
$21.41
|
| Rate for Payer: AZCH Complete Medicare |
$58.35
|
| Rate for Payer: Banner UC Health Medicaid |
$21.41
|
| Rate for Payer: Banner UC Health Medicare |
$58.35
|
| Rate for Payer: Bisbee Police All Plans |
$101.14
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$264.52
|
| Rate for Payer: Cash Price |
$311.20
|
| Rate for Payer: Cash Price |
$311.20
|
| Rate for Payer: Cigna of AZ Commercial |
$252.85
|
| Rate for Payer: Copperpoint Commercial |
$96.28
|
| Rate for Payer: Health Net of AZ Commercial |
$233.40
|
| Rate for Payer: Health Net of AZ Medicare |
$108.92
|
| Rate for Payer: Humana of AZ Medicare |
$58.35
|
| Rate for Payer: Mercy Care Medicaid |
$21.41
|
| Rate for Payer: Self Pay Self Pay |
$311.20
|
| Rate for Payer: TriWest Medicare |
$58.35
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$226.79
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$70.02
|
|
|
insulin glargine 100 units/mL 10 mL MDV [CQCH]
|
Facility
|
OP
|
$8.33
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
105926643
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.25 |
| Max. Negotiated Rate |
$7.50 |
| Rate for Payer: Aetna of AZ Commercial |
$7.50
|
| Rate for Payer: Aetna of AZ Medicare |
$2.33
|
| Rate for Payer: AHCCCS Medicaid |
$1.70
|
| Rate for Payer: Allwell Medicaid |
$1.70
|
| Rate for Payer: Allwell Medicare |
$1.25
|
| Rate for Payer: Amerigroup Medicare |
$1.25
|
| Rate for Payer: APIPA Medicare/Medicaid |
$3.11
|
| Rate for Payer: AZCH Complete Medicaid |
$1.70
|
| Rate for Payer: AZCH Complete Medicare |
$1.25
|
| Rate for Payer: Banner UC Health Medicaid |
$1.70
|
| Rate for Payer: Banner UC Health Medicare |
$1.25
|
| Rate for Payer: Bisbee Police All Plans |
$2.17
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$5.66
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Cigna of AZ Commercial |
$5.41
|
| Rate for Payer: Copperpoint Commercial |
$2.06
|
| Rate for Payer: Health Net of AZ Commercial |
$5.00
|
| Rate for Payer: Health Net of AZ Medicare |
$2.33
|
| Rate for Payer: Humana of AZ Medicare |
$1.25
|
| Rate for Payer: Mercy Care Medicaid |
$1.70
|
| Rate for Payer: Self Pay Self Pay |
$6.66
|
| Rate for Payer: TriWest Medicare |
$1.25
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$4.86
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$1.50
|
|
|
insulin glargine 100 units/mL 10 mL MDV [CQCH]
|
Facility
|
IP
|
$8.33
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
105926643
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$7.50 |
| Rate for Payer: Aetna of AZ Commercial |
$7.50
|
| Rate for Payer: Bisbee Police All Plans |
$2.17
|
| Rate for Payer: Cash Price |
$6.67
|
| Rate for Payer: Self Pay Self Pay |
$6.66
|
|
|
Insulin LC
|
Facility
|
IP
|
$193.00
|
|
|
Service Code
|
CPT 83525
|
| Hospital Charge Code |
1285572
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$50.18 |
| Max. Negotiated Rate |
$173.70 |
| Rate for Payer: Aetna of AZ Commercial |
$173.70
|
| Rate for Payer: Bisbee Police All Plans |
$50.18
|
| Rate for Payer: Cash Price |
$154.40
|
| Rate for Payer: Self Pay Self Pay |
$154.40
|
|
|
Insulin LC
|
Facility
|
OP
|
$193.00
|
|
|
Service Code
|
CPT 83525
|
| Hospital Charge Code |
1285572
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.43 |
| Max. Negotiated Rate |
$173.70 |
| Rate for Payer: Aetna of AZ Commercial |
$173.70
|
| Rate for Payer: Aetna of AZ Medicare |
$54.04
|
| Rate for Payer: AHCCCS Medicaid |
$11.43
|
| Rate for Payer: Allwell Medicaid |
$11.43
|
| Rate for Payer: Allwell Medicare |
$28.95
|
| Rate for Payer: Amerigroup Medicare |
$28.95
|
| Rate for Payer: APIPA Medicare/Medicaid |
$72.09
|
| Rate for Payer: AZCH Complete Medicaid |
$11.43
|
| Rate for Payer: AZCH Complete Medicare |
$28.95
|
| Rate for Payer: Banner UC Health Medicaid |
$11.43
|
| Rate for Payer: Banner UC Health Medicare |
$28.95
|
| Rate for Payer: Bisbee Police All Plans |
$50.18
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$131.24
|
| Rate for Payer: Cash Price |
$154.40
|
| Rate for Payer: Cash Price |
$154.40
|
| Rate for Payer: Cigna of AZ Commercial |
$125.45
|
| Rate for Payer: Copperpoint Commercial |
$47.77
|
| Rate for Payer: Health Net of AZ Commercial |
$115.80
|
| Rate for Payer: Health Net of AZ Medicare |
$54.04
|
| Rate for Payer: Humana of AZ Medicare |
$28.95
|
| Rate for Payer: Mercy Care Medicaid |
$11.43
|
| Rate for Payer: Self Pay Self Pay |
$154.40
|
| Rate for Payer: TriWest Medicare |
$28.95
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$112.52
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$34.74
|
|
|
insulin lispro 100 units/mL 3 mL Inj [CQCH]
|
Facility
|
OP
|
$5.93
|
|
|
Service Code
|
HCPCS J1817
|
| Hospital Charge Code |
105926862
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: Banner UC Health Medicare |
$0.89
|
| Rate for Payer: Aetna of AZ Commercial |
$5.34
|
| Rate for Payer: Aetna of AZ Medicare |
$1.66
|
| Rate for Payer: AHCCCS Medicaid |
$16.04
|
| Rate for Payer: Allwell Medicaid |
$16.04
|
| Rate for Payer: Allwell Medicare |
$0.89
|
| Rate for Payer: Amerigroup Medicare |
$0.89
|
| Rate for Payer: APIPA Medicare/Medicaid |
$2.21
|
| Rate for Payer: AZCH Complete Medicaid |
$16.04
|
| Rate for Payer: AZCH Complete Medicare |
$0.89
|
| Rate for Payer: Banner UC Health Medicaid |
$16.04
|
| Rate for Payer: Bisbee Police All Plans |
$1.54
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$4.03
|
| Rate for Payer: Cash Price |
$4.74
|
| Rate for Payer: Cash Price |
$4.74
|
| Rate for Payer: Cigna of AZ Commercial |
$3.85
|
| Rate for Payer: Copperpoint Commercial |
$1.47
|
| Rate for Payer: Health Net of AZ Commercial |
$3.56
|
| Rate for Payer: Health Net of AZ Medicare |
$1.66
|
| Rate for Payer: Humana of AZ Medicare |
$0.89
|
| Rate for Payer: Mercy Care Medicaid |
$16.04
|
| Rate for Payer: Self Pay Self Pay |
$4.74
|
| Rate for Payer: TriWest Medicare |
$0.89
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3.46
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$1.07
|
|
|
insulin lispro 100 units/mL 3 mL Inj [CQCH]
|
Facility
|
IP
|
$5.93
|
|
|
Service Code
|
HCPCS J1817
|
| Hospital Charge Code |
105926862
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$5.34 |
| Rate for Payer: Aetna of AZ Commercial |
$5.34
|
| Rate for Payer: Bisbee Police All Plans |
$1.54
|
| Rate for Payer: Cash Price |
$4.74
|
| Rate for Payer: Self Pay Self Pay |
$4.74
|
|
|
insulin NPH 100 units/mL 3 mL Inj [CQCH]
|
Facility
|
IP
|
$4.49
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
105926716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$4.04 |
| Rate for Payer: Aetna of AZ Commercial |
$4.04
|
| Rate for Payer: Bisbee Police All Plans |
$1.17
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Self Pay Self Pay |
$3.59
|
|
|
insulin NPH 100 units/mL 3 mL Inj [CQCH]
|
Facility
|
OP
|
$4.49
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
105926716
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.04 |
| Rate for Payer: Aetna of AZ Commercial |
$4.04
|
| Rate for Payer: Aetna of AZ Medicare |
$1.26
|
| Rate for Payer: AHCCCS Medicaid |
$1.70
|
| Rate for Payer: Allwell Medicaid |
$1.70
|
| Rate for Payer: Allwell Medicare |
$0.67
|
| Rate for Payer: Amerigroup Medicare |
$0.67
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1.68
|
| Rate for Payer: AZCH Complete Medicaid |
$1.70
|
| Rate for Payer: AZCH Complete Medicare |
$0.67
|
| Rate for Payer: Banner UC Health Medicaid |
$1.70
|
| Rate for Payer: Banner UC Health Medicare |
$0.67
|
| Rate for Payer: Bisbee Police All Plans |
$1.17
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$3.05
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Cigna of AZ Commercial |
$2.92
|
| Rate for Payer: Copperpoint Commercial |
$1.11
|
| Rate for Payer: Health Net of AZ Commercial |
$2.69
|
| Rate for Payer: Health Net of AZ Medicare |
$1.26
|
| Rate for Payer: Humana of AZ Medicare |
$0.67
|
| Rate for Payer: Mercy Care Medicaid |
$1.70
|
| Rate for Payer: Self Pay Self Pay |
$3.59
|
| Rate for Payer: TriWest Medicare |
$0.67
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2.62
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.81
|
|
|
insulin regular 100 units/mL 3 mL Inj [CQCH]
|
Facility
|
OP
|
$4.49
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
105926935
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$4.04 |
| Rate for Payer: Aetna of AZ Commercial |
$4.04
|
| Rate for Payer: Aetna of AZ Medicare |
$1.26
|
| Rate for Payer: AHCCCS Medicaid |
$1.70
|
| Rate for Payer: Allwell Medicaid |
$1.70
|
| Rate for Payer: Allwell Medicare |
$0.67
|
| Rate for Payer: Amerigroup Medicare |
$0.67
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1.68
|
| Rate for Payer: AZCH Complete Medicaid |
$1.70
|
| Rate for Payer: AZCH Complete Medicare |
$0.67
|
| Rate for Payer: Banner UC Health Medicaid |
$1.70
|
| Rate for Payer: Banner UC Health Medicare |
$0.67
|
| Rate for Payer: Bisbee Police All Plans |
$1.17
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$3.05
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Cigna of AZ Commercial |
$2.92
|
| Rate for Payer: Copperpoint Commercial |
$1.11
|
| Rate for Payer: Health Net of AZ Commercial |
$2.69
|
| Rate for Payer: Health Net of AZ Medicare |
$1.26
|
| Rate for Payer: Humana of AZ Medicare |
$0.67
|
| Rate for Payer: Mercy Care Medicaid |
$1.70
|
| Rate for Payer: Self Pay Self Pay |
$3.59
|
| Rate for Payer: TriWest Medicare |
$0.67
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2.62
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.81
|
|
|
insulin regular 100 units/mL 3 mL Inj [CQCH]
|
Facility
|
IP
|
$4.49
|
|
|
Service Code
|
HCPCS J1815
|
| Hospital Charge Code |
105926935
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$4.04 |
| Rate for Payer: Aetna of AZ Commercial |
$4.04
|
| Rate for Payer: Bisbee Police All Plans |
$1.17
|
| Rate for Payer: Cash Price |
$3.59
|
| Rate for Payer: Self Pay Self Pay |
$3.59
|
|
|
INSULIN TOTL
|
Facility
|
OP
|
$203.00
|
|
|
Service Code
|
CPT 83525
|
| Hospital Charge Code |
22481486
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.43 |
| Max. Negotiated Rate |
$182.70 |
| Rate for Payer: Aetna of AZ Commercial |
$182.70
|
| Rate for Payer: Aetna of AZ Medicare |
$56.84
|
| Rate for Payer: AHCCCS Medicaid |
$11.43
|
| Rate for Payer: Allwell Medicaid |
$11.43
|
| Rate for Payer: Allwell Medicare |
$30.45
|
| Rate for Payer: Amerigroup Medicare |
$30.45
|
| Rate for Payer: APIPA Medicare/Medicaid |
$75.82
|
| Rate for Payer: AZCH Complete Medicaid |
$11.43
|
| Rate for Payer: AZCH Complete Medicare |
$30.45
|
| Rate for Payer: Banner UC Health Medicaid |
$11.43
|
| Rate for Payer: Banner UC Health Medicare |
$30.45
|
| Rate for Payer: Bisbee Police All Plans |
$52.78
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$138.04
|
| Rate for Payer: Cash Price |
$162.40
|
| Rate for Payer: Cash Price |
$162.40
|
| Rate for Payer: Cigna of AZ Commercial |
$131.95
|
| Rate for Payer: Copperpoint Commercial |
$50.24
|
| Rate for Payer: Health Net of AZ Commercial |
$121.80
|
| Rate for Payer: Health Net of AZ Medicare |
$56.84
|
| Rate for Payer: Humana of AZ Medicare |
$30.45
|
| Rate for Payer: Mercy Care Medicaid |
$11.43
|
| Rate for Payer: Self Pay Self Pay |
$162.40
|
| Rate for Payer: TriWest Medicare |
$30.45
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$118.35
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$36.54
|
|
|
INSULIN TOTL
|
Facility
|
IP
|
$203.00
|
|
|
Service Code
|
CPT 83525
|
| Hospital Charge Code |
22481486
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$52.78 |
| Max. Negotiated Rate |
$182.70 |
| Rate for Payer: Aetna of AZ Commercial |
$182.70
|
| Rate for Payer: Bisbee Police All Plans |
$52.78
|
| Rate for Payer: Cash Price |
$162.40
|
| Rate for Payer: Self Pay Self Pay |
$162.40
|
|
|
INTEGRATED TUBING FOR FLUID MANAGEMENT
|
Facility
|
IP
|
$733.00
|
|
| Hospital Charge Code |
22354980
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$190.58 |
| Max. Negotiated Rate |
$659.70 |
| Rate for Payer: Aetna of AZ Commercial |
$659.70
|
| Rate for Payer: Bisbee Police All Plans |
$190.58
|
| Rate for Payer: Cash Price |
$586.40
|
| Rate for Payer: Self Pay Self Pay |
$586.40
|
|
|
INTEGRATED TUBING FOR FLUID MANAGEMENT
|
Facility
|
OP
|
$733.00
|
|
| Hospital Charge Code |
22354980
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$109.95 |
| Max. Negotiated Rate |
$659.70 |
| Rate for Payer: Aetna of AZ Commercial |
$659.70
|
| Rate for Payer: Aetna of AZ Medicare |
$205.24
|
| Rate for Payer: Allwell Medicare |
$109.95
|
| Rate for Payer: Amerigroup Medicare |
$109.95
|
| Rate for Payer: APIPA Medicare/Medicaid |
$273.78
|
| Rate for Payer: AZCH Complete Medicare |
$109.95
|
| Rate for Payer: Banner UC Health Medicare |
$109.95
|
| Rate for Payer: Bisbee Police All Plans |
$190.58
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$498.44
|
| Rate for Payer: Cash Price |
$586.40
|
| Rate for Payer: Cigna of AZ Commercial |
$513.10
|
| Rate for Payer: Copperpoint Commercial |
$181.42
|
| Rate for Payer: Health Net of AZ Commercial |
$439.80
|
| Rate for Payer: Health Net of AZ Medicare |
$205.24
|
| Rate for Payer: Humana of AZ Medicare |
$109.95
|
| Rate for Payer: Self Pay Self Pay |
$586.40
|
| Rate for Payer: TriWest Medicare |
$109.95
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$427.34
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$131.94
|
|
|
Intentional Self-Harm And Attempted Suicide
|
Facility
|
IP
|
$3,187.16
|
|
|
Service Code
|
APR-DRG 8172
|
| Hospital Charge Code |
APRDRG8174
|
| Min. Negotiated Rate |
$3,187.16 |
| Max. Negotiated Rate |
$3,187.16 |
| Rate for Payer: AHCCCS Medicaid |
$3,187.16
|
| Rate for Payer: Allwell Medicaid |
$3,187.16
|
| Rate for Payer: AZCH Complete Medicaid |
$3,187.16
|
| Rate for Payer: Banner UC Health Medicaid |
$3,187.16
|
| Rate for Payer: Mercy Care Medicaid |
$3,187.16
|
|
|
Intentional Self-Harm And Attempted Suicide
|
Facility
|
IP
|
$5,210.00
|
|
|
Service Code
|
APR-DRG 8173
|
| Hospital Charge Code |
APRDRG8174
|
| Min. Negotiated Rate |
$5,210.00 |
| Max. Negotiated Rate |
$5,210.00 |
| Rate for Payer: AHCCCS Medicaid |
$5,210.00
|
| Rate for Payer: Allwell Medicaid |
$5,210.00
|
| Rate for Payer: AZCH Complete Medicaid |
$5,210.00
|
| Rate for Payer: Banner UC Health Medicaid |
$5,210.00
|
| Rate for Payer: Mercy Care Medicaid |
$5,210.00
|
|
|
Intentional Self-Harm And Attempted Suicide
|
Facility
|
IP
|
$2,520.13
|
|
|
Service Code
|
APR-DRG 8171
|
| Hospital Charge Code |
APRDRG8174
|
| Min. Negotiated Rate |
$2,520.13 |
| Max. Negotiated Rate |
$2,520.13 |
| Rate for Payer: AHCCCS Medicaid |
$2,520.13
|
| Rate for Payer: Allwell Medicaid |
$2,520.13
|
| Rate for Payer: AZCH Complete Medicaid |
$2,520.13
|
| Rate for Payer: Banner UC Health Medicaid |
$2,520.13
|
| Rate for Payer: Mercy Care Medicaid |
$2,520.13
|
|
|
Intentional Self-Harm And Attempted Suicide
|
Facility
|
IP
|
$3,187.16
|
|
|
Service Code
|
APR-DRG 8172
|
| Hospital Charge Code |
APRDRG8172
|
| Min. Negotiated Rate |
$3,187.16 |
| Max. Negotiated Rate |
$3,187.16 |
| Rate for Payer: AHCCCS Medicaid |
$3,187.16
|
| Rate for Payer: Allwell Medicaid |
$3,187.16
|
| Rate for Payer: AZCH Complete Medicaid |
$3,187.16
|
| Rate for Payer: Banner UC Health Medicaid |
$3,187.16
|
| Rate for Payer: Mercy Care Medicaid |
$3,187.16
|
|
