|
LEOS PLATE TACK 10MM
|
Facility
|
OP
|
$1,260.00
|
|
| Hospital Charge Code |
27595626
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$189.00 |
| Max. Negotiated Rate |
$1,134.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,134.00
|
| Rate for Payer: Aetna of AZ Medicare |
$352.80
|
| Rate for Payer: Allwell Medicare |
$189.00
|
| Rate for Payer: Amerigroup Medicare |
$189.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$470.61
|
| Rate for Payer: AZCH Complete Medicare |
$189.00
|
| Rate for Payer: Banner UC Health Medicare |
$189.00
|
| Rate for Payer: Bisbee Police All Plans |
$327.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$856.80
|
| Rate for Payer: Cash Price |
$1,008.00
|
| Rate for Payer: Cigna of AZ Commercial |
$882.00
|
| Rate for Payer: Copperpoint Commercial |
$311.85
|
| Rate for Payer: Health Net of AZ Commercial |
$756.00
|
| Rate for Payer: Health Net of AZ Medicare |
$352.80
|
| Rate for Payer: Humana of AZ Medicare |
$189.00
|
| Rate for Payer: Self Pay Self Pay |
$1,008.00
|
| Rate for Payer: TriWest Medicare |
$189.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$734.58
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$226.80
|
|
|
LEOS PLATE TACK 10MM
|
Facility
|
IP
|
$1,260.00
|
|
| Hospital Charge Code |
27595626
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$327.60 |
| Max. Negotiated Rate |
$1,134.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,134.00
|
| Rate for Payer: Bisbee Police All Plans |
$327.60
|
| Rate for Payer: Cash Price |
$1,008.00
|
| Rate for Payer: Self Pay Self Pay |
$1,008.00
|
|
|
LEOS PLATE TACK 20MM
|
Facility
|
IP
|
$1,245.00
|
|
| Hospital Charge Code |
27702569
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$323.70 |
| Max. Negotiated Rate |
$1,120.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,120.50
|
| Rate for Payer: Bisbee Police All Plans |
$323.70
|
| Rate for Payer: Cash Price |
$996.00
|
| Rate for Payer: Self Pay Self Pay |
$996.00
|
|
|
LEOS PLATE TACK 20MM
|
Facility
|
OP
|
$1,245.00
|
|
| Hospital Charge Code |
27702569
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$186.75 |
| Max. Negotiated Rate |
$1,120.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,120.50
|
| Rate for Payer: Aetna of AZ Medicare |
$348.60
|
| Rate for Payer: Allwell Medicare |
$186.75
|
| Rate for Payer: Amerigroup Medicare |
$186.75
|
| Rate for Payer: APIPA Medicare/Medicaid |
$465.01
|
| Rate for Payer: AZCH Complete Medicare |
$186.75
|
| Rate for Payer: Banner UC Health Medicare |
$186.75
|
| Rate for Payer: Bisbee Police All Plans |
$323.70
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$846.60
|
| Rate for Payer: Cash Price |
$996.00
|
| Rate for Payer: Cigna of AZ Commercial |
$871.50
|
| Rate for Payer: Copperpoint Commercial |
$308.14
|
| Rate for Payer: Health Net of AZ Commercial |
$747.00
|
| Rate for Payer: Health Net of AZ Medicare |
$348.60
|
| Rate for Payer: Humana of AZ Medicare |
$186.75
|
| Rate for Payer: Self Pay Self Pay |
$996.00
|
| Rate for Payer: TriWest Medicare |
$186.75
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$725.84
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$224.10
|
|
|
LETs Topical Gel[CQCH]
|
Facility
|
OP
|
$3.93
|
|
|
Service Code
|
NDC 51552153601
|
| Hospital Charge Code |
138784370
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$3.54 |
| Rate for Payer: Aetna of AZ Commercial |
$3.54
|
| Rate for Payer: Aetna of AZ Medicare |
$1.10
|
| Rate for Payer: Allwell Medicare |
$0.59
|
| Rate for Payer: Amerigroup Medicare |
$0.59
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1.47
|
| Rate for Payer: AZCH Complete Medicare |
$0.59
|
| Rate for Payer: Banner UC Health Medicare |
$0.59
|
| Rate for Payer: Bisbee Police All Plans |
$1.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2.67
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cigna of AZ Commercial |
$2.55
|
| Rate for Payer: Copperpoint Commercial |
$0.97
|
| Rate for Payer: Health Net of AZ Commercial |
$2.36
|
| Rate for Payer: Health Net of AZ Medicare |
$1.10
|
| Rate for Payer: Humana of AZ Medicare |
$0.59
|
| Rate for Payer: Self Pay Self Pay |
$3.14
|
| Rate for Payer: TriWest Medicare |
$0.59
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2.29
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.71
|
|
|
LETs Topical Gel[CQCH]
|
Facility
|
IP
|
$3.93
|
|
|
Service Code
|
NDC 51552153601
|
| Hospital Charge Code |
138784370
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$3.54 |
| Rate for Payer: Aetna of AZ Commercial |
$3.54
|
| Rate for Payer: Bisbee Police All Plans |
$1.02
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Self Pay Self Pay |
$3.14
|
|
|
levalbuterol 1.25 mg/0.5 mL Inh Sol UD [CQCH]
|
Facility
|
IP
|
$1.51
|
|
|
Service Code
|
HCPCS J7614
|
| Hospital Charge Code |
105927907
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Aetna of AZ Commercial |
$1.36
|
| Rate for Payer: Bisbee Police All Plans |
$0.39
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Self Pay Self Pay |
$1.21
|
|
|
levalbuterol 1.25 mg/0.5 mL Inh Sol UD [CQCH]
|
Facility
|
OP
|
$1.51
|
|
|
Service Code
|
HCPCS J7614
|
| Hospital Charge Code |
105927907
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$1.36 |
| Rate for Payer: Aetna of AZ Commercial |
$1.36
|
| Rate for Payer: Aetna of AZ Medicare |
$0.42
|
| Rate for Payer: AHCCCS Medicaid |
$0.10
|
| Rate for Payer: Allwell Medicaid |
$0.10
|
| Rate for Payer: Allwell Medicare |
$0.23
|
| Rate for Payer: Amerigroup Medicare |
$0.23
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.56
|
| Rate for Payer: AZCH Complete Medicaid |
$0.10
|
| Rate for Payer: AZCH Complete Medicare |
$0.23
|
| Rate for Payer: Banner UC Health Medicaid |
$0.10
|
| Rate for Payer: Banner UC Health Medicare |
$0.23
|
| Rate for Payer: Bisbee Police All Plans |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.03
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Cash Price |
$1.21
|
| Rate for Payer: Cigna of AZ Commercial |
$0.98
|
| Rate for Payer: Copperpoint Commercial |
$0.37
|
| Rate for Payer: Health Net of AZ Commercial |
$0.91
|
| Rate for Payer: Health Net of AZ Medicare |
$0.42
|
| Rate for Payer: Humana of AZ Medicare |
$0.23
|
| Rate for Payer: Mercy Care Medicaid |
$0.10
|
| Rate for Payer: Self Pay Self Pay |
$1.21
|
| Rate for Payer: TriWest Medicare |
$0.23
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.88
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.27
|
|
|
levETIRAcetam 500 mg/ 5 mL Oral Sol UD [CQCH]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 603138458
|
| Hospital Charge Code |
105927980
|
|
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
|
|
|
levETIRAcetam 500 mg/ 5 mL Oral Sol UD [CQCH]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 603138458
|
| Hospital Charge Code |
105927980
|
|
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
|
|
|
levETIRAcetam 500 mg Inj 5 mL [CQCH]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
108073828
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of AZ Commercial |
$0.26
|
| Rate for Payer: Aetna of AZ Medicare |
$0.08
|
| Rate for Payer: AHCCCS Medicaid |
$0.16
|
| Rate for Payer: Allwell Medicaid |
$0.16
|
| Rate for Payer: Allwell Medicare |
$0.04
|
| Rate for Payer: Amerigroup Medicare |
$0.04
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.11
|
| Rate for Payer: AZCH Complete Medicaid |
$0.16
|
| Rate for Payer: AZCH Complete Medicare |
$0.04
|
| Rate for Payer: Banner UC Health Medicaid |
$0.16
|
| Rate for Payer: Banner UC Health Medicare |
$0.04
|
| 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 |
$0.23
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of AZ Commercial |
$0.19
|
| Rate for Payer: Copperpoint Commercial |
$0.07
|
| Rate for Payer: Health Net of AZ Commercial |
$0.17
|
| Rate for Payer: Health Net of AZ Medicare |
$0.08
|
| Rate for Payer: Humana of AZ Medicare |
$0.04
|
| Rate for Payer: Mercy Care Medicaid |
$0.16
|
| Rate for Payer: Self Pay Self Pay |
$0.23
|
| Rate for Payer: TriWest Medicare |
$0.04
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.17
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.05
|
|
|
levETIRAcetam 500 mg Inj 5 mL [CQCH]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
108073828
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of AZ Commercial |
$0.26
|
| Rate for Payer: Bisbee Police All Plans |
$0.08
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Self Pay Self Pay |
$0.23
|
|
|
levETIRAcetam 500 mg Tab [CQCH]
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 68180011316
|
| Hospital Charge Code |
105928045
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Aetna of AZ Commercial |
$0.28
|
| Rate for Payer: Bisbee Police All Plans |
$0.08
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Self Pay Self Pay |
$0.25
|
|
|
levETIRAcetam 500 mg Tab [CQCH]
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 68180011316
|
| Hospital Charge Code |
105928045
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Aetna of AZ Commercial |
$0.28
|
| 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 |
$0.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of AZ Commercial |
$0.20
|
| Rate for Payer: Copperpoint Commercial |
$0.08
|
| Rate for Payer: Health Net of AZ Commercial |
$0.19
|
| 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 |
$0.25
|
| Rate for Payer: TriWest Medicare |
$0.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.18
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.06
|
|
|
Levetiracetam (Keppra), S LC
|
Facility
|
OP
|
$296.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1906919
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$266.40 |
| Rate for Payer: Aetna of AZ Commercial |
$266.40
|
| Rate for Payer: Aetna of AZ Medicare |
$82.88
|
| Rate for Payer: AHCCCS Medicaid |
$18.64
|
| Rate for Payer: Allwell Medicaid |
$18.64
|
| Rate for Payer: Allwell Medicare |
$44.40
|
| Rate for Payer: Amerigroup Medicare |
$44.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$110.56
|
| Rate for Payer: AZCH Complete Medicaid |
$18.64
|
| Rate for Payer: AZCH Complete Medicare |
$44.40
|
| Rate for Payer: Banner UC Health Medicaid |
$18.64
|
| Rate for Payer: Banner UC Health Medicare |
$44.40
|
| Rate for Payer: Bisbee Police All Plans |
$76.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$201.28
|
| Rate for Payer: Cash Price |
$236.80
|
| Rate for Payer: Cash Price |
$236.80
|
| Rate for Payer: Cigna of AZ Commercial |
$192.40
|
| Rate for Payer: Copperpoint Commercial |
$73.26
|
| Rate for Payer: Health Net of AZ Commercial |
$177.60
|
| Rate for Payer: Health Net of AZ Medicare |
$82.88
|
| Rate for Payer: Humana of AZ Medicare |
$44.40
|
| Rate for Payer: Mercy Care Medicaid |
$18.64
|
| Rate for Payer: Self Pay Self Pay |
$236.80
|
| Rate for Payer: TriWest Medicare |
$44.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$172.57
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$53.28
|
|
|
Levetiracetam (Keppra), S LC
|
Facility
|
IP
|
$296.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1906919
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$76.96 |
| Max. Negotiated Rate |
$266.40 |
| Rate for Payer: Aetna of AZ Commercial |
$266.40
|
| Rate for Payer: Bisbee Police All Plans |
$76.96
|
| Rate for Payer: Cash Price |
$236.80
|
| Rate for Payer: Self Pay Self Pay |
$236.80
|
|
|
levoFLOXacin 250 mg/50 mL Premix IVPB [CQCH]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
105928254
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
levoFLOXacin 250 mg/50 mL Premix IVPB [CQCH]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
105928254
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Aetna of AZ Medicare |
$0.01
|
| Rate for Payer: AHCCCS Medicaid |
$1.84
|
| Rate for Payer: Allwell Medicaid |
$1.84
|
| 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 Medicaid |
$1.84
|
| Rate for Payer: AZCH Complete Medicare |
$0.00
|
| Rate for Payer: Banner UC Health Medicaid |
$1.84
|
| 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: 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: Mercy Care Medicaid |
$1.84
|
| 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
|
|
|
levoFLOXacin 500 mg/100 mL premix IVPB [CQCH]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
105928179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of AZ Commercial |
$0.04
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Self Pay Self Pay |
$0.03
|
|
|
levoFLOXacin 500 mg/100 mL premix IVPB [CQCH]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
105928179
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna of AZ Commercial |
$0.04
|
| Rate for Payer: Aetna of AZ Medicare |
$0.01
|
| Rate for Payer: AHCCCS Medicaid |
$1.84
|
| Rate for Payer: Allwell Medicaid |
$1.84
|
| Rate for Payer: Allwell Medicare |
$0.01
|
| Rate for Payer: Amerigroup Medicare |
$0.01
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.01
|
| Rate for Payer: AZCH Complete Medicaid |
$1.84
|
| Rate for Payer: AZCH Complete Medicare |
$0.01
|
| Rate for Payer: Banner UC Health Medicaid |
$1.84
|
| Rate for Payer: Banner UC Health Medicare |
$0.01
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of AZ Commercial |
$0.03
|
| 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 |
$0.01
|
| Rate for Payer: Mercy Care Medicaid |
$1.84
|
| Rate for Payer: Self Pay Self Pay |
$0.03
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.02
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.01
|
|
|
levoFLOXacin 500 mg Tab [CQCH]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 904635261
|
| Hospital Charge Code |
105928112
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of AZ Commercial |
$0.22
|
| 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 |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of AZ Commercial |
$0.16
|
| Rate for Payer: Copperpoint Commercial |
$0.06
|
| Rate for Payer: Health Net of AZ Commercial |
$0.14
|
| 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 |
$0.19
|
| Rate for Payer: TriWest Medicare |
$0.04
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.14
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.04
|
|
|
levoFLOXacin 500 mg Tab [CQCH]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 904635261
|
| Hospital Charge Code |
105928112
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of AZ Commercial |
$0.22
|
| Rate for Payer: Bisbee Police All Plans |
$0.06
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Self Pay Self Pay |
$0.19
|
|
|
levoFLOXacin 750 mg/150 mL premix IVBP [CQCH]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
105951033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna of AZ Commercial |
$0.04
|
| Rate for Payer: Aetna of AZ Medicare |
$0.01
|
| Rate for Payer: AHCCCS Medicaid |
$1.84
|
| Rate for Payer: Allwell Medicaid |
$1.84
|
| Rate for Payer: Allwell Medicare |
$0.01
|
| Rate for Payer: Amerigroup Medicare |
$0.01
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.01
|
| Rate for Payer: AZCH Complete Medicaid |
$1.84
|
| Rate for Payer: AZCH Complete Medicare |
$0.01
|
| Rate for Payer: Banner UC Health Medicaid |
$1.84
|
| Rate for Payer: Banner UC Health Medicare |
$0.01
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of AZ Commercial |
$0.03
|
| 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 |
$0.01
|
| Rate for Payer: Mercy Care Medicaid |
$1.84
|
| Rate for Payer: Self Pay Self Pay |
$0.03
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.02
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.01
|
|
|
levoFLOXacin 750 mg/150 mL premix IVBP [CQCH]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
105951033
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of AZ Commercial |
$0.04
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Self Pay Self Pay |
$0.03
|
|
|
levonorgestrel 1.5 mg Tab [CQCH]
|
Facility
|
IP
|
$32.01
|
|
|
Service Code
|
NDC 51285016288
|
| Hospital Charge Code |
105928328
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$8.32 |
| Max. Negotiated Rate |
$28.81 |
| Rate for Payer: Aetna of AZ Commercial |
$28.81
|
| Rate for Payer: Bisbee Police All Plans |
$8.32
|
| Rate for Payer: Cash Price |
$25.61
|
| Rate for Payer: Self Pay Self Pay |
$25.61
|
|
