|
lidocaine 2% Inj Sol 20 mL [CQCH]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
105928879
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of AZ Commercial |
$0.18
|
| Rate for Payer: Bisbee Police All Plans |
$0.05
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Self Pay Self Pay |
$0.16
|
|
|
lidocaine 2% Inj Sol 20 mL [CQCH]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
105928879
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Aetna of AZ Commercial |
$0.18
|
| Rate for Payer: Aetna of AZ Medicare |
$0.06
|
| Rate for Payer: AHCCCS Medicaid |
$0.04
|
| Rate for Payer: Allwell Medicaid |
$0.04
|
| Rate for Payer: Allwell Medicare |
$0.03
|
| Rate for Payer: Amerigroup Medicare |
$0.03
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.07
|
| Rate for Payer: AZCH Complete Medicaid |
$0.04
|
| Rate for Payer: AZCH Complete Medicare |
$0.03
|
| Rate for Payer: Banner UC Health Medicaid |
$0.04
|
| 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 |
$0.16
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of AZ Commercial |
$0.13
|
| Rate for Payer: Copperpoint Commercial |
$0.05
|
| Rate for Payer: Health Net of AZ Commercial |
$0.12
|
| Rate for Payer: Health Net of AZ Medicare |
$0.06
|
| Rate for Payer: Humana of AZ Medicare |
$0.03
|
| Rate for Payer: Mercy Care Medicaid |
$0.04
|
| Rate for Payer: Self Pay Self Pay |
$0.16
|
| 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
|
|
|
lidocaine drip 2 gm in 500 ml [CQCH]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
207791435
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of AZ Commercial |
$0.01
|
| Rate for Payer: Bisbee Police All Plans |
$0.00
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Self Pay Self Pay |
$0.01
|
|
|
lidocaine drip 2 gm in 500 ml [CQCH]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
207791435
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of AZ Commercial |
$0.01
|
| Rate for Payer: Aetna of AZ Medicare |
$0.00
|
| Rate for Payer: AHCCCS Medicaid |
$0.04
|
| Rate for Payer: Allwell Medicaid |
$0.04
|
| Rate for Payer: Allwell Medicare |
$0.00
|
| Rate for Payer: Amerigroup Medicare |
$0.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.00
|
| Rate for Payer: AZCH Complete Medicaid |
$0.04
|
| Rate for Payer: AZCH Complete Medicare |
$0.00
|
| Rate for Payer: Banner UC Health Medicaid |
$0.04
|
| Rate for Payer: Banner UC Health Medicare |
$0.00
|
| Rate for Payer: Bisbee Police All Plans |
$0.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Cigna of AZ Commercial |
$0.01
|
| Rate for Payer: Copperpoint Commercial |
$0.00
|
| Rate for Payer: Health Net of AZ Commercial |
$0.01
|
| Rate for Payer: Health Net of AZ Medicare |
$0.00
|
| Rate for Payer: Humana of AZ Medicare |
$0.00
|
| Rate for Payer: Mercy Care Medicaid |
$0.04
|
| Rate for Payer: Self Pay Self Pay |
$0.01
|
| Rate for Payer: TriWest Medicare |
$0.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.01
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.00
|
|
|
lidocaine inj 100 mg pre-filled syringe [CQCH]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
112812649
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of AZ Commercial |
$0.42
|
| Rate for Payer: Bisbee Police All Plans |
$0.12
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Self Pay Self Pay |
$0.38
|
|
|
lidocaine inj 100 mg pre-filled syringe [CQCH]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
112812649
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Aetna of AZ Commercial |
$0.42
|
| Rate for Payer: Aetna of AZ Medicare |
$0.13
|
| Rate for Payer: AHCCCS Medicaid |
$0.04
|
| Rate for Payer: Allwell Medicaid |
$0.04
|
| Rate for Payer: Allwell Medicare |
$0.07
|
| Rate for Payer: Amerigroup Medicare |
$0.07
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.18
|
| Rate for Payer: AZCH Complete Medicaid |
$0.04
|
| Rate for Payer: AZCH Complete Medicare |
$0.07
|
| Rate for Payer: Banner UC Health Medicaid |
$0.04
|
| Rate for Payer: Banner UC Health Medicare |
$0.07
|
| Rate for Payer: Bisbee Police All Plans |
$0.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.32
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of AZ Commercial |
$0.31
|
| Rate for Payer: Copperpoint Commercial |
$0.12
|
| Rate for Payer: Health Net of AZ Commercial |
$0.28
|
| Rate for Payer: Health Net of AZ Medicare |
$0.13
|
| Rate for Payer: Humana of AZ Medicare |
$0.07
|
| Rate for Payer: Mercy Care Medicaid |
$0.04
|
| Rate for Payer: Self Pay Self Pay |
$0.38
|
| Rate for Payer: TriWest Medicare |
$0.07
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.27
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.08
|
|
|
lidocaine jelly 2% top 5 mL [CQCH]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 17478084005
|
| Hospital Charge Code |
105928950
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of AZ Commercial |
$0.39
|
| Rate for Payer: Aetna of AZ Medicare |
$0.12
|
| Rate for Payer: Allwell Medicare |
$0.06
|
| Rate for Payer: Amerigroup Medicare |
$0.06
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.16
|
| Rate for Payer: AZCH Complete Medicare |
$0.06
|
| Rate for Payer: Banner UC Health Medicare |
$0.06
|
| Rate for Payer: Bisbee Police All Plans |
$0.11
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.29
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Cigna of AZ Commercial |
$0.28
|
| Rate for Payer: Copperpoint Commercial |
$0.11
|
| Rate for Payer: Health Net of AZ Commercial |
$0.26
|
| Rate for Payer: Health Net of AZ Medicare |
$0.12
|
| Rate for Payer: Humana of AZ Medicare |
$0.06
|
| Rate for Payer: Self Pay Self Pay |
$0.34
|
| Rate for Payer: TriWest Medicare |
$0.06
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.25
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.08
|
|
|
lidocaine jelly 2% top 5 mL [CQCH]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 17478084005
|
| Hospital Charge Code |
105928950
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Aetna of AZ Commercial |
$0.39
|
| Rate for Payer: Bisbee Police All Plans |
$0.11
|
| Rate for Payer: Cash Price |
$0.34
|
| Rate for Payer: Self Pay Self Pay |
$0.34
|
|
|
lidocaine jelly (Uro-Jet) 2% Gel w/Appl [CQCH]
|
Facility
|
IP
|
$6.28
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
105929013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$5.65 |
| Rate for Payer: Aetna of AZ Commercial |
$5.65
|
| Rate for Payer: Bisbee Police All Plans |
$1.63
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Self Pay Self Pay |
$5.02
|
|
|
lidocaine jelly (Uro-Jet) 2% Gel w/Appl [CQCH]
|
Facility
|
OP
|
$6.28
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
105929013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$5.65 |
| Rate for Payer: Aetna of AZ Commercial |
$5.65
|
| Rate for Payer: Aetna of AZ Medicare |
$1.76
|
| Rate for Payer: AHCCCS Medicaid |
$0.04
|
| Rate for Payer: Allwell Medicaid |
$0.04
|
| Rate for Payer: Allwell Medicare |
$0.94
|
| Rate for Payer: Amerigroup Medicare |
$0.94
|
| Rate for Payer: APIPA Medicare/Medicaid |
$2.35
|
| Rate for Payer: AZCH Complete Medicaid |
$0.04
|
| Rate for Payer: AZCH Complete Medicare |
$0.94
|
| Rate for Payer: Banner UC Health Medicaid |
$0.04
|
| Rate for Payer: Banner UC Health Medicare |
$0.94
|
| Rate for Payer: Bisbee Police All Plans |
$1.63
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$4.27
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna of AZ Commercial |
$4.08
|
| Rate for Payer: Copperpoint Commercial |
$1.55
|
| Rate for Payer: Health Net of AZ Commercial |
$3.77
|
| Rate for Payer: Health Net of AZ Medicare |
$1.76
|
| Rate for Payer: Humana of AZ Medicare |
$0.94
|
| Rate for Payer: Mercy Care Medicaid |
$0.04
|
| Rate for Payer: Self Pay Self Pay |
$5.02
|
| Rate for Payer: TriWest Medicare |
$0.94
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3.66
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$1.13
|
|
|
lidocaine-prilocaine Top 2.5%-2.5% Crm [CQCH]
|
Facility
|
OP
|
$1.19
|
|
|
Service Code
|
NDC 115146860
|
| Hospital Charge Code |
105929212
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna of AZ Commercial |
$1.07
|
| Rate for Payer: Aetna of AZ Medicare |
$0.33
|
| Rate for Payer: Allwell Medicare |
$0.18
|
| Rate for Payer: Amerigroup Medicare |
$0.18
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.44
|
| Rate for Payer: AZCH Complete Medicare |
$0.18
|
| Rate for Payer: Banner UC Health Medicare |
$0.18
|
| Rate for Payer: Bisbee Police All Plans |
$0.31
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.81
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Cigna of AZ Commercial |
$0.77
|
| Rate for Payer: Copperpoint Commercial |
$0.29
|
| Rate for Payer: Health Net of AZ Commercial |
$0.71
|
| Rate for Payer: Health Net of AZ Medicare |
$0.33
|
| Rate for Payer: Humana of AZ Medicare |
$0.18
|
| Rate for Payer: Self Pay Self Pay |
$0.95
|
| Rate for Payer: TriWest Medicare |
$0.18
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.69
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.21
|
|
|
lidocaine-prilocaine Top 2.5%-2.5% Crm [CQCH]
|
Facility
|
IP
|
$1.19
|
|
|
Service Code
|
NDC 115146860
|
| Hospital Charge Code |
105929212
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna of AZ Commercial |
$1.07
|
| Rate for Payer: Bisbee Police All Plans |
$0.31
|
| Rate for Payer: Cash Price |
$0.95
|
| Rate for Payer: Self Pay Self Pay |
$0.95
|
|
|
lidocaine Top 4% Sol 50 mL [CQCH]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 54350547
|
| Hospital Charge Code |
105929084
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of AZ Commercial |
$0.12
|
| Rate for Payer: Bisbee Police All Plans |
$0.03
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Self Pay Self Pay |
$0.10
|
|
|
lidocaine Top 4% Sol 50 mL [CQCH]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 54350547
|
| Hospital Charge Code |
105929084
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.12 |
| Rate for Payer: Aetna of AZ Commercial |
$0.12
|
| Rate for Payer: Aetna of AZ Medicare |
$0.04
|
| Rate for Payer: Allwell Medicare |
$0.02
|
| Rate for Payer: Amerigroup Medicare |
$0.02
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.05
|
| 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 |
$0.09
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of AZ Commercial |
$0.08
|
| Rate for Payer: Copperpoint Commercial |
$0.03
|
| Rate for Payer: Health Net of AZ Commercial |
$0.08
|
| Rate for Payer: Health Net of AZ Medicare |
$0.04
|
| 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 |
$0.08
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.02
|
|
|
lidocaine viscous 2% Sol 15 mL UD [CQCH]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 50383077517
|
| Hospital Charge Code |
105955400
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of AZ Commercial |
$0.27
|
| Rate for Payer: Bisbee Police All Plans |
$0.08
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Self Pay Self Pay |
$0.24
|
|
|
lidocaine viscous 2% Sol 15 mL UD [CQCH]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 50383077517
|
| Hospital Charge Code |
105955400
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of AZ Commercial |
$0.27
|
| Rate for Payer: Aetna of AZ Medicare |
$0.08
|
| Rate for Payer: Allwell Medicare |
$0.05
|
| Rate for Payer: Amerigroup Medicare |
$0.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.11
|
| 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 |
$0.20
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of AZ Commercial |
$0.20
|
| Rate for Payer: Copperpoint Commercial |
$0.07
|
| Rate for Payer: Health Net of AZ Commercial |
$0.18
|
| Rate for Payer: Health Net of AZ Medicare |
$0.08
|
| Rate for Payer: Humana of AZ Medicare |
$0.05
|
| Rate for Payer: Self Pay Self Pay |
$0.24
|
| Rate for Payer: TriWest Medicare |
$0.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.17
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.05
|
|
|
lidoderm patch (5% lidocaine) [CQCH]
|
Facility
|
IP
|
$2.23
|
|
|
Service Code
|
NDC 42858011830
|
| Hospital Charge Code |
105929145
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Aetna of AZ Commercial |
$2.01
|
| Rate for Payer: Bisbee Police All Plans |
$0.58
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Self Pay Self Pay |
$1.78
|
|
|
lidoderm patch (5% lidocaine) [CQCH]
|
Facility
|
OP
|
$2.23
|
|
|
Service Code
|
NDC 42858011830
|
| Hospital Charge Code |
105929145
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$2.01 |
| Rate for Payer: Aetna of AZ Commercial |
$2.01
|
| Rate for Payer: Aetna of AZ Medicare |
$0.62
|
| Rate for Payer: Allwell Medicare |
$0.33
|
| Rate for Payer: Amerigroup Medicare |
$0.33
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.83
|
| Rate for Payer: AZCH Complete Medicare |
$0.33
|
| Rate for Payer: Banner UC Health Medicare |
$0.33
|
| Rate for Payer: Bisbee Police All Plans |
$0.58
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.52
|
| Rate for Payer: Cash Price |
$1.79
|
| Rate for Payer: Cigna of AZ Commercial |
$1.45
|
| Rate for Payer: Copperpoint Commercial |
$0.55
|
| Rate for Payer: Health Net of AZ Commercial |
$1.34
|
| Rate for Payer: Health Net of AZ Medicare |
$0.62
|
| Rate for Payer: Humana of AZ Medicare |
$0.33
|
| Rate for Payer: Self Pay Self Pay |
$1.78
|
| Rate for Payer: TriWest Medicare |
$0.33
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1.30
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.40
|
|
|
LIGACLIP ROTATING CLIP APPLIER
|
Facility
|
IP
|
$1,998.00
|
|
| Hospital Charge Code |
24055041
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$519.48 |
| Max. Negotiated Rate |
$1,798.20 |
| Rate for Payer: Aetna of AZ Commercial |
$1,798.20
|
| Rate for Payer: Bisbee Police All Plans |
$519.48
|
| Rate for Payer: Cash Price |
$1,598.40
|
| Rate for Payer: Self Pay Self Pay |
$1,598.40
|
|
|
LIGACLIP ROTATING CLIP APPLIER
|
Facility
|
OP
|
$1,998.00
|
|
| Hospital Charge Code |
24055041
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$299.70 |
| Max. Negotiated Rate |
$1,798.20 |
| Rate for Payer: Aetna of AZ Commercial |
$1,798.20
|
| Rate for Payer: Aetna of AZ Medicare |
$559.44
|
| Rate for Payer: Allwell Medicare |
$299.70
|
| Rate for Payer: Amerigroup Medicare |
$299.70
|
| Rate for Payer: APIPA Medicare/Medicaid |
$746.25
|
| Rate for Payer: AZCH Complete Medicare |
$299.70
|
| Rate for Payer: Banner UC Health Medicare |
$299.70
|
| Rate for Payer: Bisbee Police All Plans |
$519.48
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,358.64
|
| Rate for Payer: Cash Price |
$1,598.40
|
| Rate for Payer: Cigna of AZ Commercial |
$1,398.60
|
| Rate for Payer: Copperpoint Commercial |
$494.50
|
| Rate for Payer: Health Net of AZ Commercial |
$1,198.80
|
| Rate for Payer: Health Net of AZ Medicare |
$559.44
|
| Rate for Payer: Humana of AZ Medicare |
$299.70
|
| Rate for Payer: Self Pay Self Pay |
$1,598.40
|
| Rate for Payer: TriWest Medicare |
$299.70
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,164.83
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$359.64
|
|
|
LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); EXTREM
|
Facility
|
IP
|
$1,772.00
|
|
|
Service Code
|
CPT 37618
|
| Hospital Charge Code |
2084137
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$460.72 |
| Max. Negotiated Rate |
$1,594.80 |
| Rate for Payer: Aetna of AZ Commercial |
$1,594.80
|
| Rate for Payer: Bisbee Police All Plans |
$460.72
|
| Rate for Payer: Cash Price |
$1,417.60
|
| Rate for Payer: Self Pay Self Pay |
$1,417.60
|
|
|
LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); EXTREM
|
Facility
|
OP
|
$1,772.00
|
|
|
Service Code
|
CPT 37618
|
| Hospital Charge Code |
2084137
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$3,373.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,594.80
|
| Rate for Payer: Aetna of AZ Medicare |
$496.16
|
| Rate for Payer: AHCCCS Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicare |
$265.80
|
| Rate for Payer: Amerigroup Medicare |
$265.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$661.84
|
| Rate for Payer: AZCH Complete Medicaid |
$0.13
|
| Rate for Payer: AZCH Complete Medicare |
$265.80
|
| Rate for Payer: Banner UC Health Medicaid |
$0.13
|
| Rate for Payer: Banner UC Health Medicare |
$265.80
|
| Rate for Payer: Bisbee Police All Plans |
$460.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,204.96
|
| Rate for Payer: Cash Price |
$1,417.60
|
| Rate for Payer: Cash Price |
$1,417.60
|
| Rate for Payer: Cigna of AZ Commercial |
$1,240.40
|
| Rate for Payer: Copperpoint Commercial |
$438.57
|
| Rate for Payer: Health Net of AZ Commercial |
$1,063.20
|
| Rate for Payer: Health Net of AZ Medicare |
$496.16
|
| Rate for Payer: Humana of AZ Medicare |
$265.80
|
| Rate for Payer: Mercy Care Medicaid |
$0.13
|
| Rate for Payer: Self Pay Self Pay |
$1,417.60
|
| Rate for Payer: TriWest Medicare |
$265.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,373.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$318.96
|
|
|
LIGHT WAND FLEXIBLE
|
Facility
|
OP
|
$197.00
|
|
| Hospital Charge Code |
22578012
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$29.55 |
| Max. Negotiated Rate |
$177.30 |
| Rate for Payer: Aetna of AZ Commercial |
$177.30
|
| Rate for Payer: Aetna of AZ Medicare |
$55.16
|
| Rate for Payer: Allwell Medicare |
$29.55
|
| Rate for Payer: Amerigroup Medicare |
$29.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$73.58
|
| Rate for Payer: AZCH Complete Medicare |
$29.55
|
| Rate for Payer: Banner UC Health Medicare |
$29.55
|
| Rate for Payer: Bisbee Police All Plans |
$51.22
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$133.96
|
| Rate for Payer: Cash Price |
$157.60
|
| Rate for Payer: Cigna of AZ Commercial |
$137.90
|
| Rate for Payer: Copperpoint Commercial |
$48.76
|
| Rate for Payer: Health Net of AZ Commercial |
$118.20
|
| Rate for Payer: Health Net of AZ Medicare |
$55.16
|
| Rate for Payer: Humana of AZ Medicare |
$29.55
|
| Rate for Payer: Self Pay Self Pay |
$157.60
|
| Rate for Payer: TriWest Medicare |
$29.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$114.85
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$35.46
|
|
|
LIGHT WAND FLEXIBLE
|
Facility
|
IP
|
$197.00
|
|
| Hospital Charge Code |
22578012
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$51.22 |
| Max. Negotiated Rate |
$177.30 |
| Rate for Payer: Aetna of AZ Commercial |
$177.30
|
| Rate for Payer: Bisbee Police All Plans |
$51.22
|
| Rate for Payer: Cash Price |
$157.60
|
| Rate for Payer: Self Pay Self Pay |
$157.60
|
|
|
LINEAR CUTTER ENDOSCOPIC 45MM
|
Facility
|
IP
|
$945.00
|
|
| Hospital Charge Code |
22951123
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$245.70 |
| Max. Negotiated Rate |
$850.50 |
| Rate for Payer: Aetna of AZ Commercial |
$850.50
|
| Rate for Payer: Bisbee Police All Plans |
$245.70
|
| Rate for Payer: Cash Price |
$756.00
|
| Rate for Payer: Self Pay Self Pay |
$756.00
|
|
