|
Ovary cystectomy
|
Facility
|
OP
|
$3,960.00
|
|
|
Service Code
|
CPT 58925
|
| Hospital Charge Code |
27267812
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$594.00 |
| Max. Negotiated Rate |
$6,393.84 |
| Rate for Payer: Aetna of AZ Commercial |
$3,564.00
|
| Rate for Payer: Aetna of AZ Medicare |
$1,108.80
|
| Rate for Payer: AHCCCS Medicaid |
$6,393.84
|
| Rate for Payer: Allwell Medicaid |
$6,393.84
|
| Rate for Payer: Allwell Medicare |
$594.00
|
| Rate for Payer: Amerigroup Medicare |
$594.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,479.06
|
| Rate for Payer: AZCH Complete Medicaid |
$6,393.84
|
| Rate for Payer: AZCH Complete Medicare |
$594.00
|
| Rate for Payer: Banner UC Health Medicaid |
$6,393.84
|
| Rate for Payer: Banner UC Health Medicare |
$594.00
|
| Rate for Payer: Bisbee Police All Plans |
$1,029.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2,692.80
|
| Rate for Payer: Cash Price |
$3,168.00
|
| Rate for Payer: Cash Price |
$3,168.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,980.00
|
| Rate for Payer: Copperpoint Commercial |
$980.10
|
| Rate for Payer: Health Net of AZ Commercial |
$2,376.00
|
| Rate for Payer: Health Net of AZ Medicare |
$1,108.80
|
| Rate for Payer: Humana of AZ Medicare |
$594.00
|
| Rate for Payer: Mercy Care Medicaid |
$6,393.84
|
| Rate for Payer: Self Pay Self Pay |
$3,168.00
|
| Rate for Payer: TriWest Medicare |
$594.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,914.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$712.80
|
|
|
Oxalate, Quant, 24-Hour Urine LC
|
Facility
|
OP
|
$181.00
|
|
|
Service Code
|
CPT 83945
|
| Hospital Charge Code |
2029209
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$162.90 |
| Rate for Payer: Aetna of AZ Commercial |
$162.90
|
| Rate for Payer: Aetna of AZ Medicare |
$50.68
|
| Rate for Payer: AHCCCS Medicaid |
$14.45
|
| Rate for Payer: Allwell Medicaid |
$14.45
|
| Rate for Payer: Allwell Medicare |
$27.15
|
| Rate for Payer: Amerigroup Medicare |
$27.15
|
| Rate for Payer: APIPA Medicare/Medicaid |
$67.60
|
| Rate for Payer: AZCH Complete Medicaid |
$14.45
|
| Rate for Payer: AZCH Complete Medicare |
$27.15
|
| Rate for Payer: Banner UC Health Medicaid |
$14.45
|
| Rate for Payer: Banner UC Health Medicare |
$27.15
|
| Rate for Payer: Bisbee Police All Plans |
$47.06
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$123.08
|
| Rate for Payer: Cash Price |
$144.80
|
| Rate for Payer: Cash Price |
$144.80
|
| Rate for Payer: Cigna of AZ Commercial |
$117.65
|
| Rate for Payer: Copperpoint Commercial |
$44.80
|
| Rate for Payer: Health Net of AZ Commercial |
$108.60
|
| Rate for Payer: Health Net of AZ Medicare |
$50.68
|
| Rate for Payer: Humana of AZ Medicare |
$27.15
|
| Rate for Payer: Mercy Care Medicaid |
$14.45
|
| Rate for Payer: Self Pay Self Pay |
$144.80
|
| Rate for Payer: TriWest Medicare |
$27.15
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$105.52
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$32.58
|
|
|
Oxalate, Quant, 24-Hour Urine LC
|
Facility
|
IP
|
$181.00
|
|
|
Service Code
|
CPT 83945
|
| Hospital Charge Code |
2029209
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.06 |
| Max. Negotiated Rate |
$162.90 |
| Rate for Payer: Aetna of AZ Commercial |
$162.90
|
| Rate for Payer: Bisbee Police All Plans |
$47.06
|
| Rate for Payer: Cash Price |
$144.80
|
| Rate for Payer: Self Pay Self Pay |
$144.80
|
|
|
OXcarbazepine 600 mg Tab [CQCH]
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 50268068115
|
| Hospital Charge Code |
110527678
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna of AZ Commercial |
$0.85
|
| 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 |
$0.64
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Cigna of AZ Commercial |
$0.61
|
| 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 |
$0.75
|
| Rate for Payer: TriWest Medicare |
$0.14
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.55
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.17
|
|
|
OXcarbazepine 600 mg Tab [CQCH]
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 50268068115
|
| Hospital Charge Code |
110527678
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Aetna of AZ Commercial |
$0.85
|
| Rate for Payer: Bisbee Police All Plans |
$0.24
|
| Rate for Payer: Cash Price |
$0.75
|
| Rate for Payer: Self Pay Self Pay |
$0.75
|
|
|
Oxcarbazepine (Trileptal), LC
|
Facility
|
OP
|
$246.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1285602
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$221.40 |
| Rate for Payer: Aetna of AZ Commercial |
$221.40
|
| Rate for Payer: Aetna of AZ Medicare |
$68.88
|
| Rate for Payer: AHCCCS Medicaid |
$18.64
|
| Rate for Payer: Allwell Medicaid |
$18.64
|
| Rate for Payer: Allwell Medicare |
$36.90
|
| Rate for Payer: Amerigroup Medicare |
$36.90
|
| Rate for Payer: APIPA Medicare/Medicaid |
$91.88
|
| Rate for Payer: AZCH Complete Medicaid |
$18.64
|
| Rate for Payer: AZCH Complete Medicare |
$36.90
|
| Rate for Payer: Banner UC Health Medicaid |
$18.64
|
| Rate for Payer: Banner UC Health Medicare |
$36.90
|
| Rate for Payer: Bisbee Police All Plans |
$63.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$167.28
|
| Rate for Payer: Cash Price |
$196.80
|
| Rate for Payer: Cash Price |
$196.80
|
| Rate for Payer: Cigna of AZ Commercial |
$159.90
|
| Rate for Payer: Copperpoint Commercial |
$60.88
|
| Rate for Payer: Health Net of AZ Commercial |
$147.60
|
| Rate for Payer: Health Net of AZ Medicare |
$68.88
|
| Rate for Payer: Humana of AZ Medicare |
$36.90
|
| Rate for Payer: Mercy Care Medicaid |
$18.64
|
| Rate for Payer: Self Pay Self Pay |
$196.80
|
| Rate for Payer: TriWest Medicare |
$36.90
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$143.42
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$44.28
|
|
|
Oxcarbazepine (Trileptal), LC
|
Facility
|
IP
|
$246.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
1285602
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$63.96 |
| Max. Negotiated Rate |
$221.40 |
| Rate for Payer: Aetna of AZ Commercial |
$221.40
|
| Rate for Payer: Bisbee Police All Plans |
$63.96
|
| Rate for Payer: Cash Price |
$196.80
|
| Rate for Payer: Self Pay Self Pay |
$196.80
|
|
|
OXIMAX
|
Facility
|
OP
|
$56.00
|
|
| Hospital Charge Code |
24157864
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna of AZ Commercial |
$50.40
|
| Rate for Payer: Aetna of AZ Medicare |
$15.68
|
| Rate for Payer: Allwell Medicare |
$8.40
|
| Rate for Payer: Amerigroup Medicare |
$8.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$20.92
|
| Rate for Payer: AZCH Complete Medicare |
$8.40
|
| Rate for Payer: Banner UC Health Medicare |
$8.40
|
| Rate for Payer: Bisbee Police All Plans |
$14.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$38.08
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Cigna of AZ Commercial |
$39.20
|
| Rate for Payer: Copperpoint Commercial |
$13.86
|
| Rate for Payer: Health Net of AZ Commercial |
$33.60
|
| Rate for Payer: Health Net of AZ Medicare |
$15.68
|
| Rate for Payer: Humana of AZ Medicare |
$8.40
|
| Rate for Payer: Self Pay Self Pay |
$44.80
|
| Rate for Payer: TriWest Medicare |
$8.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$32.65
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$10.08
|
|
|
OXIMAX
|
Facility
|
IP
|
$56.00
|
|
| Hospital Charge Code |
24157864
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$14.56 |
| Max. Negotiated Rate |
$50.40 |
| Rate for Payer: Aetna of AZ Commercial |
$50.40
|
| Rate for Payer: Bisbee Police All Plans |
$14.56
|
| Rate for Payer: Cash Price |
$44.80
|
| Rate for Payer: Self Pay Self Pay |
$44.80
|
|
|
OXIMTRY RST/EXR
|
Facility
|
IP
|
$126.00
|
|
|
Service Code
|
CPT 94761
|
| Hospital Charge Code |
1886885
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$32.76 |
| Max. Negotiated Rate |
$113.40 |
| Rate for Payer: Aetna of AZ Commercial |
$113.40
|
| Rate for Payer: Bisbee Police All Plans |
$32.76
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Self Pay Self Pay |
$100.80
|
|
|
OXIMTRY RST/EXR
|
Facility
|
OP
|
$126.00
|
|
|
Service Code
|
CPT 94761
|
| Hospital Charge Code |
1886885
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$113.40 |
| Rate for Payer: Aetna of AZ Commercial |
$113.40
|
| Rate for Payer: Aetna of AZ Medicare |
$35.28
|
| Rate for Payer: AHCCCS Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicare |
$18.90
|
| Rate for Payer: Amerigroup Medicare |
$18.90
|
| Rate for Payer: APIPA Medicare/Medicaid |
$47.06
|
| Rate for Payer: AZCH Complete Medicaid |
$0.13
|
| Rate for Payer: AZCH Complete Medicare |
$18.90
|
| Rate for Payer: Banner UC Health Medicaid |
$0.13
|
| Rate for Payer: Banner UC Health Medicare |
$18.90
|
| Rate for Payer: Bisbee Police All Plans |
$32.76
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$85.68
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna of AZ Commercial |
$88.20
|
| Rate for Payer: Copperpoint Commercial |
$31.18
|
| Rate for Payer: Health Net of AZ Commercial |
$75.60
|
| Rate for Payer: Health Net of AZ Medicare |
$35.28
|
| Rate for Payer: Humana of AZ Medicare |
$18.90
|
| Rate for Payer: Mercy Care Medicaid |
$0.13
|
| Rate for Payer: Self Pay Self Pay |
$100.80
|
| Rate for Payer: TriWest Medicare |
$18.90
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$73.46
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$22.68
|
|
|
oxybutynin 5 mg Tab [CQCH]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 904282161
|
| Hospital Charge Code |
105935217
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of AZ Commercial |
$0.53
|
| Rate for Payer: Aetna of AZ Medicare |
$0.17
|
| Rate for Payer: Allwell Medicare |
$0.09
|
| Rate for Payer: Amerigroup Medicare |
$0.09
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.22
|
| Rate for Payer: AZCH Complete Medicare |
$0.09
|
| Rate for Payer: Banner UC Health Medicare |
$0.09
|
| Rate for Payer: Bisbee Police All Plans |
$0.15
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.40
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna of AZ Commercial |
$0.38
|
| Rate for Payer: Copperpoint Commercial |
$0.15
|
| Rate for Payer: Health Net of AZ Commercial |
$0.35
|
| Rate for Payer: Health Net of AZ Medicare |
$0.17
|
| Rate for Payer: Humana of AZ Medicare |
$0.09
|
| Rate for Payer: Self Pay Self Pay |
$0.47
|
| Rate for Payer: TriWest Medicare |
$0.09
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.34
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.11
|
|
|
oxybutynin 5 mg Tab [CQCH]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 904282161
|
| Hospital Charge Code |
105935217
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.15 |
| Max. Negotiated Rate |
$0.53 |
| Rate for Payer: Aetna of AZ Commercial |
$0.53
|
| Rate for Payer: Bisbee Police All Plans |
$0.15
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Self Pay Self Pay |
$0.47
|
|
|
Oxycodone
|
Facility
|
IP
|
$267.00
|
|
|
Service Code
|
CPT 80365
|
| Hospital Charge Code |
23090937
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$69.42 |
| Max. Negotiated Rate |
$240.30 |
| Rate for Payer: Aetna of AZ Commercial |
$240.30
|
| Rate for Payer: Bisbee Police All Plans |
$69.42
|
| Rate for Payer: Cash Price |
$213.60
|
| Rate for Payer: Self Pay Self Pay |
$213.60
|
|
|
Oxycodone
|
Facility
|
OP
|
$267.00
|
|
|
Service Code
|
CPT 80365
|
| Hospital Charge Code |
23090937
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$240.30 |
| Rate for Payer: Aetna of AZ Commercial |
$240.30
|
| Rate for Payer: Aetna of AZ Medicare |
$74.76
|
| Rate for Payer: AHCCCS Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicare |
$40.05
|
| Rate for Payer: Amerigroup Medicare |
$40.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$99.72
|
| Rate for Payer: AZCH Complete Medicaid |
$0.13
|
| Rate for Payer: AZCH Complete Medicare |
$40.05
|
| Rate for Payer: Banner UC Health Medicaid |
$0.13
|
| Rate for Payer: Banner UC Health Medicare |
$40.05
|
| Rate for Payer: Bisbee Police All Plans |
$69.42
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$181.56
|
| Rate for Payer: Cash Price |
$213.60
|
| Rate for Payer: Cash Price |
$213.60
|
| Rate for Payer: Cigna of AZ Commercial |
$173.55
|
| Rate for Payer: Copperpoint Commercial |
$66.08
|
| Rate for Payer: Health Net of AZ Commercial |
$160.20
|
| Rate for Payer: Health Net of AZ Medicare |
$74.76
|
| Rate for Payer: Humana of AZ Medicare |
$40.05
|
| Rate for Payer: Mercy Care Medicaid |
$0.13
|
| Rate for Payer: Self Pay Self Pay |
$213.60
|
| Rate for Payer: TriWest Medicare |
$40.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$155.66
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$48.06
|
|
|
oxyCODONE 10 mg ER Tab [CQCH]
|
Facility
|
OP
|
$3.31
|
|
|
Service Code
|
NDC 59011041020
|
| Hospital Charge Code |
105935475
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Aetna of AZ Commercial |
$2.98
|
| Rate for Payer: Aetna of AZ Medicare |
$0.93
|
| Rate for Payer: Allwell Medicare |
$0.50
|
| Rate for Payer: Amerigroup Medicare |
$0.50
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1.24
|
| Rate for Payer: AZCH Complete Medicare |
$0.50
|
| Rate for Payer: Banner UC Health Medicare |
$0.50
|
| Rate for Payer: Bisbee Police All Plans |
$0.86
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2.25
|
| Rate for Payer: Cash Price |
$2.65
|
| Rate for Payer: Cigna of AZ Commercial |
$2.15
|
| Rate for Payer: Copperpoint Commercial |
$0.82
|
| Rate for Payer: Health Net of AZ Commercial |
$1.99
|
| Rate for Payer: Health Net of AZ Medicare |
$0.93
|
| Rate for Payer: Humana of AZ Medicare |
$0.50
|
| Rate for Payer: Self Pay Self Pay |
$2.65
|
| Rate for Payer: TriWest Medicare |
$0.50
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1.93
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.60
|
|
|
oxyCODONE 10 mg ER Tab [CQCH]
|
Facility
|
IP
|
$3.31
|
|
|
Service Code
|
NDC 59011041020
|
| Hospital Charge Code |
105935475
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Aetna of AZ Commercial |
$2.98
|
| Rate for Payer: Bisbee Police All Plans |
$0.86
|
| Rate for Payer: Cash Price |
$2.65
|
| Rate for Payer: Self Pay Self Pay |
$2.65
|
|
|
oxyCODONE 15 mg Tab [CQCH]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 904674361
|
| Hospital Charge Code |
105935410
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of AZ Commercial |
$0.36
|
| Rate for Payer: Bisbee Police All Plans |
$0.10
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Self Pay Self Pay |
$0.32
|
|
|
oxyCODONE 15 mg Tab [CQCH]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 904674361
|
| Hospital Charge Code |
105935410
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Aetna of AZ Commercial |
$0.36
|
| Rate for Payer: Aetna of AZ Medicare |
$0.11
|
| Rate for Payer: Allwell Medicare |
$0.06
|
| Rate for Payer: Amerigroup Medicare |
$0.06
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.15
|
| Rate for Payer: AZCH Complete Medicare |
$0.06
|
| Rate for Payer: Banner UC Health Medicare |
$0.06
|
| Rate for Payer: Bisbee Police All Plans |
$0.10
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.27
|
| Rate for Payer: Cash Price |
$0.32
|
| Rate for Payer: Cigna of AZ Commercial |
$0.26
|
| Rate for Payer: Copperpoint Commercial |
$0.10
|
| Rate for Payer: Health Net of AZ Commercial |
$0.24
|
| Rate for Payer: Health Net of AZ Medicare |
$0.11
|
| Rate for Payer: Humana of AZ Medicare |
$0.06
|
| Rate for Payer: Self Pay Self Pay |
$0.32
|
| Rate for Payer: TriWest Medicare |
$0.06
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.23
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.07
|
|
|
oxyCODONE 5 mg Tab [CQCH]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 42858000110
|
| Hospital Charge Code |
105935278
|
|
Hospital Revenue Code
|
251
|
| 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
|
|
|
oxyCODONE 5 mg Tab [CQCH]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 42858000110
|
| Hospital Charge Code |
105935278
|
|
Hospital Revenue Code
|
251
|
| 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: 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 |
$0.14
|
| 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: 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
|
|
|
OXYGEN DAILY
|
Facility
|
IP
|
$358.00
|
|
| Hospital Charge Code |
1886880
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$93.08 |
| Max. Negotiated Rate |
$322.20 |
| Rate for Payer: Aetna of AZ Commercial |
$322.20
|
| Rate for Payer: Bisbee Police All Plans |
$93.08
|
| Rate for Payer: Cash Price |
$286.40
|
| Rate for Payer: Self Pay Self Pay |
$286.40
|
|
|
OXYGEN DAILY
|
Facility
|
OP
|
$358.00
|
|
| Hospital Charge Code |
1886880
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$53.70 |
| Max. Negotiated Rate |
$322.20 |
| Rate for Payer: Aetna of AZ Commercial |
$322.20
|
| Rate for Payer: Aetna of AZ Medicare |
$100.24
|
| Rate for Payer: Allwell Medicare |
$53.70
|
| Rate for Payer: Amerigroup Medicare |
$53.70
|
| Rate for Payer: APIPA Medicare/Medicaid |
$133.71
|
| Rate for Payer: AZCH Complete Medicare |
$53.70
|
| Rate for Payer: Banner UC Health Medicare |
$53.70
|
| Rate for Payer: Bisbee Police All Plans |
$93.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$243.44
|
| Rate for Payer: Cash Price |
$286.40
|
| Rate for Payer: Cigna of AZ Commercial |
$250.60
|
| Rate for Payer: Copperpoint Commercial |
$88.60
|
| Rate for Payer: Health Net of AZ Commercial |
$214.80
|
| Rate for Payer: Health Net of AZ Medicare |
$100.24
|
| Rate for Payer: Humana of AZ Medicare |
$53.70
|
| Rate for Payer: Self Pay Self Pay |
$286.40
|
| Rate for Payer: TriWest Medicare |
$53.70
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$208.71
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$64.44
|
|
|
Oxygen per hour
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
CPT 94644
|
| Hospital Charge Code |
1558431
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$4.16 |
| Max. Negotiated Rate |
$14.40 |
| Rate for Payer: Aetna of AZ Commercial |
$14.40
|
| Rate for Payer: Bisbee Police All Plans |
$4.16
|
| Rate for Payer: Cash Price |
$12.80
|
| Rate for Payer: Self Pay Self Pay |
$12.80
|
|
|
Oxygen per hour
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
CPT 94644
|
| Hospital Charge Code |
1558431
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$162.32 |
| Rate for Payer: Aetna of AZ Commercial |
$14.40
|
| Rate for Payer: Aetna of AZ Medicare |
$4.48
|
| Rate for Payer: AHCCCS Medicaid |
$162.32
|
| Rate for Payer: Allwell Medicaid |
$162.32
|
| Rate for Payer: Allwell Medicare |
$2.40
|
| Rate for Payer: Amerigroup Medicare |
$2.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$5.98
|
| Rate for Payer: AZCH Complete Medicaid |
$162.32
|
| Rate for Payer: AZCH Complete Medicare |
$2.40
|
| Rate for Payer: Banner UC Health Medicaid |
$162.32
|
| Rate for Payer: Banner UC Health Medicare |
$2.40
|
| Rate for Payer: Bisbee Police All Plans |
$4.16
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$10.88
|
| Rate for Payer: Cash Price |
$12.80
|
| Rate for Payer: Cash Price |
$12.80
|
| Rate for Payer: Cigna of AZ Commercial |
$11.20
|
| Rate for Payer: Copperpoint Commercial |
$3.96
|
| Rate for Payer: Health Net of AZ Commercial |
$9.60
|
| Rate for Payer: Health Net of AZ Medicare |
$4.48
|
| Rate for Payer: Humana of AZ Medicare |
$2.40
|
| Rate for Payer: Mercy Care Medicaid |
$162.32
|
| Rate for Payer: Self Pay Self Pay |
$12.80
|
| Rate for Payer: TriWest Medicare |
$2.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$9.33
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$2.88
|
|
