|
methylPREDNISolone 125 mg Inj PF [CQCH]
|
Facility
|
OP
|
$7.21
|
|
|
Service Code
|
HCPCS J2930
|
| Hospital Charge Code |
105955507
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$11.30 |
| Rate for Payer: Aetna of AZ Commercial |
$6.49
|
| Rate for Payer: Aetna of AZ Medicare |
$2.02
|
| Rate for Payer: AHCCCS Medicaid |
$11.30
|
| Rate for Payer: Allwell Medicaid |
$11.30
|
| Rate for Payer: Allwell Medicare |
$1.08
|
| Rate for Payer: Amerigroup Medicare |
$1.08
|
| Rate for Payer: APIPA Medicare/Medicaid |
$2.69
|
| Rate for Payer: AZCH Complete Medicaid |
$11.30
|
| Rate for Payer: AZCH Complete Medicare |
$1.08
|
| Rate for Payer: Banner UC Health Medicaid |
$11.30
|
| Rate for Payer: Banner UC Health Medicare |
$1.08
|
| Rate for Payer: Bisbee Police All Plans |
$1.87
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$4.90
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Cash Price |
$5.77
|
| Rate for Payer: Cigna of AZ Commercial |
$4.69
|
| Rate for Payer: Copperpoint Commercial |
$1.78
|
| Rate for Payer: Health Net of AZ Commercial |
$4.33
|
| Rate for Payer: Health Net of AZ Medicare |
$2.02
|
| Rate for Payer: Humana of AZ Medicare |
$1.08
|
| Rate for Payer: Mercy Care Medicaid |
$11.30
|
| Rate for Payer: Self Pay Self Pay |
$5.77
|
| Rate for Payer: TriWest Medicare |
$1.08
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$4.20
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$1.30
|
|
|
methylPREDNISolone 1 gm Inj [CQCH]
|
Facility
|
OP
|
$22.30
|
|
|
Service Code
|
HCPCS J2930
|
| Hospital Charge Code |
105931449
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.34 |
| Max. Negotiated Rate |
$20.07 |
| Rate for Payer: Aetna of AZ Commercial |
$20.07
|
| Rate for Payer: Aetna of AZ Medicare |
$6.24
|
| Rate for Payer: AHCCCS Medicaid |
$11.30
|
| Rate for Payer: Allwell Medicaid |
$11.30
|
| Rate for Payer: Allwell Medicare |
$3.34
|
| Rate for Payer: Amerigroup Medicare |
$3.34
|
| Rate for Payer: APIPA Medicare/Medicaid |
$8.33
|
| Rate for Payer: AZCH Complete Medicaid |
$11.30
|
| Rate for Payer: AZCH Complete Medicare |
$3.34
|
| Rate for Payer: Banner UC Health Medicaid |
$11.30
|
| Rate for Payer: Banner UC Health Medicare |
$3.34
|
| Rate for Payer: Bisbee Police All Plans |
$5.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$15.16
|
| Rate for Payer: Cash Price |
$17.84
|
| Rate for Payer: Cash Price |
$17.84
|
| Rate for Payer: Cigna of AZ Commercial |
$14.50
|
| Rate for Payer: Copperpoint Commercial |
$5.52
|
| Rate for Payer: Health Net of AZ Commercial |
$13.38
|
| Rate for Payer: Health Net of AZ Medicare |
$6.24
|
| Rate for Payer: Humana of AZ Medicare |
$3.34
|
| Rate for Payer: Mercy Care Medicaid |
$11.30
|
| Rate for Payer: Self Pay Self Pay |
$17.84
|
| Rate for Payer: TriWest Medicare |
$3.34
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$13.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$4.01
|
|
|
methylPREDNISolone 1 gm Inj [CQCH]
|
Facility
|
IP
|
$22.30
|
|
|
Service Code
|
HCPCS J2930
|
| Hospital Charge Code |
105931449
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.80 |
| Max. Negotiated Rate |
$20.07 |
| Rate for Payer: Aetna of AZ Commercial |
$20.07
|
| Rate for Payer: Bisbee Police All Plans |
$5.80
|
| Rate for Payer: Cash Price |
$17.84
|
| Rate for Payer: Self Pay Self Pay |
$17.84
|
|
|
methylPREDNISolone 40 mg Inj PF [CQCH]
|
Facility
|
OP
|
$4.52
|
|
|
Service Code
|
HCPCS J2920
|
| Hospital Charge Code |
105963075
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.68 |
| Max. Negotiated Rate |
$7.76 |
| Rate for Payer: Aetna of AZ Commercial |
$4.07
|
| Rate for Payer: Aetna of AZ Medicare |
$1.27
|
| Rate for Payer: AHCCCS Medicaid |
$7.76
|
| Rate for Payer: Allwell Medicaid |
$7.76
|
| Rate for Payer: Allwell Medicare |
$0.68
|
| Rate for Payer: Amerigroup Medicare |
$0.68
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1.69
|
| Rate for Payer: AZCH Complete Medicaid |
$7.76
|
| Rate for Payer: AZCH Complete Medicare |
$0.68
|
| Rate for Payer: Banner UC Health Medicaid |
$7.76
|
| Rate for Payer: Banner UC Health Medicare |
$0.68
|
| Rate for Payer: Bisbee Police All Plans |
$1.18
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$3.07
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Cigna of AZ Commercial |
$2.94
|
| Rate for Payer: Copperpoint Commercial |
$1.12
|
| Rate for Payer: Health Net of AZ Commercial |
$2.71
|
| Rate for Payer: Health Net of AZ Medicare |
$1.27
|
| Rate for Payer: Humana of AZ Medicare |
$0.68
|
| Rate for Payer: Mercy Care Medicaid |
$7.76
|
| Rate for Payer: Self Pay Self Pay |
$3.62
|
| Rate for Payer: TriWest Medicare |
$0.68
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2.64
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.81
|
|
|
methylPREDNISolone 40 mg Inj PF [CQCH]
|
Facility
|
IP
|
$4.52
|
|
|
Service Code
|
HCPCS J2920
|
| Hospital Charge Code |
105963075
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$4.07 |
| Rate for Payer: Aetna of AZ Commercial |
$4.07
|
| Rate for Payer: Bisbee Police All Plans |
$1.18
|
| Rate for Payer: Cash Price |
$3.62
|
| Rate for Payer: Self Pay Self Pay |
$3.62
|
|
|
metoclopramide 10 mg/ Inj Sol [CQCH]
|
Facility
|
OP
|
$1.07
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
105931644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$2.10 |
| Rate for Payer: Aetna of AZ Commercial |
$0.96
|
| Rate for Payer: Aetna of AZ Medicare |
$0.30
|
| Rate for Payer: AHCCCS Medicaid |
$2.10
|
| Rate for Payer: Allwell Medicaid |
$2.10
|
| Rate for Payer: Allwell Medicare |
$0.16
|
| Rate for Payer: Amerigroup Medicare |
$0.16
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.40
|
| Rate for Payer: AZCH Complete Medicaid |
$2.10
|
| Rate for Payer: AZCH Complete Medicare |
$0.16
|
| Rate for Payer: Banner UC Health Medicaid |
$2.10
|
| Rate for Payer: Banner UC Health Medicare |
$0.16
|
| Rate for Payer: Bisbee Police All Plans |
$0.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.73
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of AZ Commercial |
$0.70
|
| Rate for Payer: Copperpoint Commercial |
$0.26
|
| Rate for Payer: Health Net of AZ Commercial |
$0.64
|
| Rate for Payer: Health Net of AZ Medicare |
$0.30
|
| Rate for Payer: Humana of AZ Medicare |
$0.16
|
| Rate for Payer: Mercy Care Medicaid |
$2.10
|
| Rate for Payer: Self Pay Self Pay |
$0.86
|
| Rate for Payer: TriWest Medicare |
$0.16
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.62
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.19
|
|
|
metoclopramide 10 mg/ Inj Sol [CQCH]
|
Facility
|
IP
|
$1.07
|
|
|
Service Code
|
HCPCS J2765
|
| Hospital Charge Code |
105931644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of AZ Commercial |
$0.96
|
| Rate for Payer: Bisbee Police All Plans |
$0.28
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Self Pay Self Pay |
$0.86
|
|
|
metoclopramide 10 mg Tab [CQCH]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 51079088820
|
| Hospital Charge Code |
105931579
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of AZ Commercial |
$0.11
|
| 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 |
$0.08
|
| 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 |
$0.07
|
| 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 |
$0.10
|
| Rate for Payer: TriWest Medicare |
$0.02
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.07
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.02
|
|
|
metoclopramide 10 mg Tab [CQCH]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 51079088820
|
| Hospital Charge Code |
105931579
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of AZ Commercial |
$0.11
|
| 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
|
|
|
metoclopramide 5 mg/5 mL UD oral Syr [CQCH]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
NDC 62559011016
|
| Hospital Charge Code |
108074697
|
|
Hospital Revenue Code
|
251
|
| 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
|
|
|
metoclopramide 5 mg/5 mL UD oral Syr [CQCH]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
NDC 62559011016
|
| Hospital Charge Code |
108074697
|
|
Hospital Revenue Code
|
251
|
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Aetna of AZ Commercial |
$0.01
|
| Rate for Payer: Aetna of AZ Medicare |
$0.00
|
| 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 Medicare |
$0.00
|
| 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: 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: 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
|
|
|
metolazone 5 mg Tab [CQCH]
|
Facility
|
OP
|
$2.75
|
|
|
Service Code
|
NDC 51079002420
|
| Hospital Charge Code |
105931715
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$2.48 |
| Rate for Payer: Aetna of AZ Commercial |
$2.48
|
| Rate for Payer: Aetna of AZ Medicare |
$0.77
|
| Rate for Payer: Allwell Medicare |
$0.41
|
| Rate for Payer: Amerigroup Medicare |
$0.41
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1.03
|
| Rate for Payer: AZCH Complete Medicare |
$0.41
|
| Rate for Payer: Banner UC Health Medicare |
$0.41
|
| Rate for Payer: Bisbee Police All Plans |
$0.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.87
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cigna of AZ Commercial |
$1.79
|
| Rate for Payer: Copperpoint Commercial |
$0.68
|
| Rate for Payer: Health Net of AZ Commercial |
$1.65
|
| Rate for Payer: Health Net of AZ Medicare |
$0.77
|
| Rate for Payer: Humana of AZ Medicare |
$0.41
|
| Rate for Payer: Self Pay Self Pay |
$2.20
|
| Rate for Payer: TriWest Medicare |
$0.41
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1.60
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.50
|
|
|
metolazone 5 mg Tab [CQCH]
|
Facility
|
IP
|
$2.75
|
|
|
Service Code
|
NDC 51079002420
|
| Hospital Charge Code |
105931715
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.48 |
| Rate for Payer: Aetna of AZ Commercial |
$2.48
|
| Rate for Payer: Bisbee Police All Plans |
$0.72
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Self Pay Self Pay |
$2.20
|
|
|
metoprolol 5 mg/ 5 mL Inj Sol [CQCH]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 409177805
|
| Hospital Charge Code |
105931847
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of AZ Commercial |
$0.13
|
| 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 |
$0.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of AZ Commercial |
$0.09
|
| 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 |
$0.11
|
| 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 |
$0.03
|
|
|
metoprolol 5 mg/ 5 mL Inj Sol [CQCH]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 409177805
|
| Hospital Charge Code |
105931847
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.13 |
| Rate for Payer: Aetna of AZ Commercial |
$0.13
|
| Rate for Payer: Bisbee Police All Plans |
$0.04
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Self Pay Self Pay |
$0.11
|
|
|
metoprolol succinate 50 mg ER Tab [CQCH]
|
Facility
|
OP
|
$0.93
|
|
|
Service Code
|
NDC 904632361
|
| Hospital Charge Code |
105931780
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of AZ Commercial |
$0.84
|
| Rate for Payer: Aetna of AZ Medicare |
$0.26
|
| Rate for Payer: Allwell Medicare |
$0.14
|
| Rate for Payer: Amerigroup Medicare |
$0.14
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.35
|
| Rate for Payer: AZCH Complete Medicare |
$0.14
|
| Rate for Payer: Banner UC Health Medicare |
$0.14
|
| Rate for Payer: Bisbee Police All Plans |
$0.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.63
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Cigna of AZ Commercial |
$0.60
|
| Rate for Payer: Copperpoint Commercial |
$0.23
|
| Rate for Payer: Health Net of AZ Commercial |
$0.56
|
| Rate for Payer: Health Net of AZ Medicare |
$0.26
|
| Rate for Payer: Humana of AZ Medicare |
$0.14
|
| Rate for Payer: Self Pay Self Pay |
$0.74
|
| Rate for Payer: TriWest Medicare |
$0.14
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.54
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.17
|
|
|
metoprolol succinate 50 mg ER Tab [CQCH]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 904632361
|
| Hospital Charge Code |
105931780
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of AZ Commercial |
$0.84
|
| Rate for Payer: Bisbee Police All Plans |
$0.24
|
| Rate for Payer: Cash Price |
$0.74
|
| Rate for Payer: Self Pay Self Pay |
$0.74
|
|
|
metoprolol tartrate 25 mg Tab [CQCH]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 51079025520
|
| Hospital Charge Code |
105931963
|
|
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
|
|
|
metoprolol tartrate 25 mg Tab [CQCH]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 51079025520
|
| Hospital Charge Code |
105931963
|
|
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
|
|
|
metroNIDAZOLE 500 mg Premix IVPB Sol [CQCH]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 409781124
|
| Hospital Charge Code |
105932101
|
|
Hospital Revenue Code
|
251
|
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of AZ Commercial |
$0.02
|
| 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 |
$0.01
|
| 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 |
$0.01
|
| 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 |
$0.01
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.00
|
|
|
metroNIDAZOLE 500 mg Premix IVPB Sol [CQCH]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 409781124
|
| Hospital Charge Code |
105932101
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Aetna of AZ Commercial |
$0.02
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Cash Price |
$0.01
|
| Rate for Payer: Self Pay Self Pay |
$0.02
|
|
|
metroNIDAZOLE 500 mg Tab [CQCH]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 29300022701
|
| Hospital Charge Code |
105932030
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of AZ Commercial |
$0.16
|
| Rate for Payer: Bisbee Police All Plans |
$0.05
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Self Pay Self Pay |
$0.14
|
|
|
metroNIDAZOLE 500 mg Tab [CQCH]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 29300022701
|
| Hospital Charge Code |
105932030
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Aetna of AZ Commercial |
$0.16
|
| Rate for Payer: Aetna of AZ Medicare |
$0.05
|
| 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 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 |
$0.12
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of AZ Commercial |
$0.12
|
| Rate for Payer: Copperpoint Commercial |
$0.04
|
| Rate for Payer: Health Net of AZ Commercial |
$0.11
|
| Rate for Payer: Health Net of AZ Medicare |
$0.05
|
| Rate for Payer: Humana of AZ Medicare |
$0.03
|
| Rate for Payer: Self Pay Self Pay |
$0.14
|
| Rate for Payer: TriWest Medicare |
$0.03
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.10
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.03
|
|
|
miconazole 100 mg Vag Supp [CQCH]
|
Facility
|
IP
|
$0.42
|
|
|
Service Code
|
NDC 49348083361
|
| Hospital Charge Code |
105932229
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of AZ Commercial |
$0.38
|
| 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
|
|
|
miconazole 100 mg Vag Supp [CQCH]
|
Facility
|
OP
|
$0.42
|
|
|
Service Code
|
NDC 49348083361
|
| Hospital Charge Code |
105932229
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of AZ Commercial |
$0.38
|
| 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 |
$0.27
|
| Rate for Payer: Copperpoint Commercial |
$0.10
|
| Rate for Payer: Health Net of AZ Commercial |
$0.25
|
| 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 |
$0.24
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.08
|
|
