|
PHALANGEAL INSERT 1.5MM OFFSET 3.6MM THICK
|
Facility
|
OP
|
$4,914.00
|
|
| Hospital Charge Code |
24129932
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$737.10 |
| Max. Negotiated Rate |
$4,422.60 |
| Rate for Payer: Aetna of AZ Commercial |
$4,422.60
|
| Rate for Payer: Aetna of AZ Medicare |
$1,375.92
|
| Rate for Payer: Allwell Medicare |
$737.10
|
| Rate for Payer: Amerigroup Medicare |
$737.10
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,835.38
|
| Rate for Payer: AZCH Complete Medicare |
$737.10
|
| Rate for Payer: Banner UC Health Medicare |
$737.10
|
| Rate for Payer: Bisbee Police All Plans |
$1,277.64
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$3,341.52
|
| Rate for Payer: Cash Price |
$3,931.20
|
| Rate for Payer: Cigna of AZ Commercial |
$3,439.80
|
| Rate for Payer: Copperpoint Commercial |
$1,216.22
|
| Rate for Payer: Health Net of AZ Commercial |
$2,948.40
|
| Rate for Payer: Health Net of AZ Medicare |
$1,375.92
|
| Rate for Payer: Humana of AZ Medicare |
$737.10
|
| Rate for Payer: Self Pay Self Pay |
$3,931.20
|
| Rate for Payer: TriWest Medicare |
$737.10
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,864.86
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$884.52
|
|
|
PHALANGECTOMY TOE EACH TOE
|
Facility
|
OP
|
$1,365.00
|
|
|
Service Code
|
CPT 28150
|
| Hospital Charge Code |
24043335
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$204.75 |
| Max. Negotiated Rate |
$4,104.08 |
| Rate for Payer: Aetna of AZ Commercial |
$1,228.50
|
| Rate for Payer: Aetna of AZ Medicare |
$382.20
|
| Rate for Payer: AHCCCS Medicaid |
$4,104.08
|
| Rate for Payer: Allwell Medicaid |
$4,104.08
|
| Rate for Payer: Allwell Medicare |
$204.75
|
| Rate for Payer: Amerigroup Medicare |
$204.75
|
| Rate for Payer: APIPA Medicare/Medicaid |
$509.83
|
| Rate for Payer: AZCH Complete Medicaid |
$4,104.08
|
| Rate for Payer: AZCH Complete Medicare |
$204.75
|
| Rate for Payer: Banner UC Health Medicaid |
$4,104.08
|
| Rate for Payer: Banner UC Health Medicare |
$204.75
|
| Rate for Payer: Bisbee Police All Plans |
$354.90
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$928.20
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Cigna of AZ Commercial |
$682.50
|
| Rate for Payer: Copperpoint Commercial |
$337.84
|
| Rate for Payer: Health Net of AZ Commercial |
$819.00
|
| Rate for Payer: Health Net of AZ Medicare |
$382.20
|
| Rate for Payer: Humana of AZ Medicare |
$204.75
|
| Rate for Payer: Mercy Care Medicaid |
$4,104.08
|
| Rate for Payer: Self Pay Self Pay |
$1,092.00
|
| Rate for Payer: TriWest Medicare |
$204.75
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,373.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$245.70
|
|
|
PHALANGECTOMY TOE EACH TOE
|
Facility
|
IP
|
$1,365.00
|
|
|
Service Code
|
CPT 28150
|
| Hospital Charge Code |
24043335
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$354.90 |
| Max. Negotiated Rate |
$1,228.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,228.50
|
| Rate for Payer: Bisbee Police All Plans |
$354.90
|
| Rate for Payer: Cash Price |
$1,092.00
|
| Rate for Payer: Self Pay Self Pay |
$1,092.00
|
|
|
phenazopyridine 200 mg Tab[CQCH]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 65162068210
|
| Hospital Charge Code |
219324821
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of AZ Commercial |
$0.31
|
| Rate for Payer: Bisbee Police All Plans |
$0.09
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Self Pay Self Pay |
$0.27
|
|
|
phenazopyridine 200 mg Tab[CQCH]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 65162068210
|
| Hospital Charge Code |
219324821
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Aetna of AZ Commercial |
$0.31
|
| Rate for Payer: Aetna of AZ Medicare |
$0.10
|
| Rate for Payer: Allwell Medicare |
$0.05
|
| Rate for Payer: Amerigroup Medicare |
$0.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.13
|
| Rate for Payer: AZCH Complete Medicare |
$0.05
|
| Rate for Payer: Banner UC Health Medicare |
$0.05
|
| Rate for Payer: Bisbee Police All Plans |
$0.09
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.23
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of AZ Commercial |
$0.22
|
| Rate for Payer: Copperpoint Commercial |
$0.08
|
| Rate for Payer: Health Net of AZ Commercial |
$0.20
|
| Rate for Payer: Health Net of AZ Medicare |
$0.10
|
| Rate for Payer: Humana of AZ Medicare |
$0.05
|
| Rate for Payer: Self Pay Self Pay |
$0.27
|
| Rate for Payer: TriWest Medicare |
$0.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.20
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.06
|
|
|
PHENobarbital 130 mg/1 mL Inj Sol [CQCH]
|
Facility
|
IP
|
$50.21
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
105936151
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.05 |
| Max. Negotiated Rate |
$45.19 |
| Rate for Payer: Aetna of AZ Commercial |
$45.19
|
| Rate for Payer: Bisbee Police All Plans |
$13.05
|
| Rate for Payer: Cash Price |
$40.17
|
| Rate for Payer: Self Pay Self Pay |
$40.17
|
|
|
PHENobarbital 130 mg/1 mL Inj Sol [CQCH]
|
Facility
|
OP
|
$50.21
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
105936151
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.53 |
| Max. Negotiated Rate |
$73.36 |
| Rate for Payer: Aetna of AZ Commercial |
$45.19
|
| Rate for Payer: Aetna of AZ Medicare |
$14.06
|
| Rate for Payer: AHCCCS Medicaid |
$73.36
|
| Rate for Payer: Allwell Medicaid |
$73.36
|
| Rate for Payer: Allwell Medicare |
$7.53
|
| Rate for Payer: Amerigroup Medicare |
$7.53
|
| Rate for Payer: APIPA Medicare/Medicaid |
$18.75
|
| Rate for Payer: AZCH Complete Medicaid |
$73.36
|
| Rate for Payer: AZCH Complete Medicare |
$7.53
|
| Rate for Payer: Banner UC Health Medicaid |
$73.36
|
| Rate for Payer: Banner UC Health Medicare |
$7.53
|
| Rate for Payer: Bisbee Police All Plans |
$13.05
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$34.14
|
| Rate for Payer: Cash Price |
$40.17
|
| Rate for Payer: Cash Price |
$40.17
|
| Rate for Payer: Cigna of AZ Commercial |
$32.64
|
| Rate for Payer: Copperpoint Commercial |
$12.43
|
| Rate for Payer: Health Net of AZ Commercial |
$30.13
|
| Rate for Payer: Health Net of AZ Medicare |
$14.06
|
| Rate for Payer: Humana of AZ Medicare |
$7.53
|
| Rate for Payer: Mercy Care Medicaid |
$73.36
|
| Rate for Payer: Self Pay Self Pay |
$40.17
|
| Rate for Payer: TriWest Medicare |
$7.53
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$29.27
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$9.04
|
|
|
PHENobarbital 32.4 mg Tab [CQCH]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 904657561
|
| Hospital Charge Code |
105936220
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of AZ Commercial |
$0.24
|
| Rate for Payer: Bisbee Police All Plans |
$0.07
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Self Pay Self Pay |
$0.22
|
|
|
PHENobarbital 32.4 mg Tab [CQCH]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 904657561
|
| Hospital Charge Code |
105936220
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of AZ Commercial |
$0.24
|
| Rate for Payer: Aetna of AZ Medicare |
$0.08
|
| Rate for Payer: Allwell Medicare |
$0.04
|
| Rate for Payer: Amerigroup Medicare |
$0.04
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.10
|
| 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 |
$0.18
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of AZ Commercial |
$0.18
|
| Rate for Payer: Copperpoint Commercial |
$0.07
|
| Rate for Payer: Health Net of AZ Commercial |
$0.16
|
| Rate for Payer: Health Net of AZ Medicare |
$0.08
|
| Rate for Payer: Humana of AZ Medicare |
$0.04
|
| Rate for Payer: Self Pay Self Pay |
$0.22
|
| Rate for Payer: TriWest Medicare |
$0.04
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.16
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.05
|
|
|
PHENobarbital 65 mg/mL Sol[CQCH]
|
Facility
|
IP
|
$19.35
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
121708919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.03 |
| Max. Negotiated Rate |
$17.42 |
| Rate for Payer: Aetna of AZ Commercial |
$17.42
|
| Rate for Payer: Bisbee Police All Plans |
$5.03
|
| Rate for Payer: Cash Price |
$15.48
|
| Rate for Payer: Self Pay Self Pay |
$15.48
|
|
|
PHENobarbital 65 mg/mL Sol[CQCH]
|
Facility
|
OP
|
$19.35
|
|
|
Service Code
|
HCPCS J2560
|
| Hospital Charge Code |
121708919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$73.36 |
| Rate for Payer: Aetna of AZ Commercial |
$17.42
|
| Rate for Payer: Aetna of AZ Medicare |
$5.42
|
| Rate for Payer: AHCCCS Medicaid |
$73.36
|
| Rate for Payer: Allwell Medicaid |
$73.36
|
| Rate for Payer: Allwell Medicare |
$2.90
|
| Rate for Payer: Amerigroup Medicare |
$2.90
|
| Rate for Payer: APIPA Medicare/Medicaid |
$7.23
|
| Rate for Payer: AZCH Complete Medicaid |
$73.36
|
| Rate for Payer: AZCH Complete Medicare |
$2.90
|
| Rate for Payer: Banner UC Health Medicaid |
$73.36
|
| Rate for Payer: Banner UC Health Medicare |
$2.90
|
| Rate for Payer: Bisbee Police All Plans |
$5.03
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$13.16
|
| Rate for Payer: Cash Price |
$15.48
|
| Rate for Payer: Cash Price |
$15.48
|
| Rate for Payer: Cigna of AZ Commercial |
$12.58
|
| Rate for Payer: Copperpoint Commercial |
$4.79
|
| Rate for Payer: Health Net of AZ Commercial |
$11.61
|
| Rate for Payer: Health Net of AZ Medicare |
$5.42
|
| Rate for Payer: Humana of AZ Medicare |
$2.90
|
| Rate for Payer: Mercy Care Medicaid |
$73.36
|
| Rate for Payer: Self Pay Self Pay |
$15.48
|
| Rate for Payer: TriWest Medicare |
$2.90
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$11.28
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$3.48
|
|
|
Phenobarbital, Serum LC
|
Facility
|
IP
|
$217.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
1285609
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$56.42 |
| Max. Negotiated Rate |
$195.30 |
| Rate for Payer: Aetna of AZ Commercial |
$195.30
|
| Rate for Payer: Bisbee Police All Plans |
$56.42
|
| Rate for Payer: Cash Price |
$173.60
|
| Rate for Payer: Self Pay Self Pay |
$173.60
|
|
|
Phenobarbital, Serum LC
|
Facility
|
OP
|
$217.00
|
|
|
Service Code
|
CPT 80184
|
| Hospital Charge Code |
1285609
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$195.30 |
| Rate for Payer: Aetna of AZ Commercial |
$195.30
|
| Rate for Payer: Aetna of AZ Medicare |
$60.76
|
| Rate for Payer: AHCCCS Medicaid |
$15.30
|
| Rate for Payer: Allwell Medicaid |
$15.30
|
| Rate for Payer: Allwell Medicare |
$32.55
|
| Rate for Payer: Amerigroup Medicare |
$32.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$81.05
|
| Rate for Payer: AZCH Complete Medicaid |
$15.30
|
| Rate for Payer: AZCH Complete Medicare |
$32.55
|
| Rate for Payer: Banner UC Health Medicaid |
$15.30
|
| Rate for Payer: Banner UC Health Medicare |
$32.55
|
| Rate for Payer: Bisbee Police All Plans |
$56.42
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$147.56
|
| Rate for Payer: Cash Price |
$173.60
|
| Rate for Payer: Cash Price |
$173.60
|
| Rate for Payer: Cigna of AZ Commercial |
$141.05
|
| Rate for Payer: Copperpoint Commercial |
$53.71
|
| Rate for Payer: Health Net of AZ Commercial |
$130.20
|
| Rate for Payer: Health Net of AZ Medicare |
$60.76
|
| Rate for Payer: Humana of AZ Medicare |
$32.55
|
| Rate for Payer: Mercy Care Medicaid |
$15.30
|
| Rate for Payer: Self Pay Self Pay |
$173.60
|
| Rate for Payer: TriWest Medicare |
$32.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$126.51
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$39.06
|
|
|
phenylephrine 10 mg/ 1 mL Inj Sol [CQCH]
|
Facility
|
OP
|
$3.68
|
|
|
Service Code
|
HCPCS J2370
|
| Hospital Charge Code |
105936354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$3.31 |
| Rate for Payer: Aetna of AZ Commercial |
$3.31
|
| Rate for Payer: Aetna of AZ Medicare |
$1.03
|
| Rate for Payer: Allwell Medicare |
$0.55
|
| Rate for Payer: Amerigroup Medicare |
$0.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1.37
|
| Rate for Payer: AZCH Complete Medicare |
$0.55
|
| Rate for Payer: Banner UC Health Medicare |
$0.55
|
| Rate for Payer: Bisbee Police All Plans |
$0.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2.50
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Cigna of AZ Commercial |
$2.39
|
| Rate for Payer: Copperpoint Commercial |
$0.91
|
| Rate for Payer: Health Net of AZ Commercial |
$2.21
|
| Rate for Payer: Health Net of AZ Medicare |
$1.03
|
| Rate for Payer: Humana of AZ Medicare |
$0.55
|
| Rate for Payer: Self Pay Self Pay |
$2.94
|
| Rate for Payer: TriWest Medicare |
$0.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2.15
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.66
|
|
|
phenylephrine 10 mg/ 1 mL Inj Sol [CQCH]
|
Facility
|
IP
|
$3.68
|
|
|
Service Code
|
HCPCS J2370
|
| Hospital Charge Code |
105936354
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$3.31 |
| Rate for Payer: Aetna of AZ Commercial |
$3.31
|
| Rate for Payer: Bisbee Police All Plans |
$0.96
|
| Rate for Payer: Cash Price |
$2.95
|
| Rate for Payer: Self Pay Self Pay |
$2.94
|
|
|
phenylephrine nasal 0.25% Sol 15 mL [CQCH]
|
Facility
|
IP
|
$0.21
|
|
|
Service Code
|
NDC 24134803
|
| Hospital Charge Code |
105936423
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of AZ Commercial |
$0.19
|
| Rate for Payer: Bisbee Police All Plans |
$0.05
|
| Rate for Payer: Cash Price |
$0.17
|
| Rate for Payer: Self Pay Self Pay |
$0.17
|
|
|
phenylephrine nasal 0.25% Sol 15 mL [CQCH]
|
Facility
|
OP
|
$0.21
|
|
|
Service Code
|
NDC 24134803
|
| Hospital Charge Code |
105936423
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of AZ Commercial |
$0.19
|
| 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 |
$0.08
|
| 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 |
$0.17
|
| Rate for Payer: Cigna of AZ Commercial |
$0.14
|
| Rate for Payer: Copperpoint Commercial |
$0.05
|
| Rate for Payer: Health Net of AZ Commercial |
$0.13
|
| 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 |
$0.17
|
| 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
|
|
|
phenylephrine nasal 1% spray 15 mL [CQCH]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 24135202
|
| Hospital Charge Code |
105936488
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of AZ Commercial |
$0.21
|
| 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 |
$0.09
|
| Rate for Payer: AZCH Complete Medicare |
$0.03
|
| Rate for Payer: Banner UC Health Medicare |
$0.03
|
| Rate for Payer: Bisbee Police All Plans |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of AZ Commercial |
$0.15
|
| 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 |
$0.06
|
| Rate for Payer: Humana of AZ Medicare |
$0.03
|
| Rate for Payer: Self Pay Self Pay |
$0.18
|
| Rate for Payer: TriWest Medicare |
$0.03
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.13
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.04
|
|
|
phenylephrine nasal 1% spray 15 mL [CQCH]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 24135202
|
| Hospital Charge Code |
105936488
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Aetna of AZ Commercial |
$0.21
|
| Rate for Payer: Bisbee Police All Plans |
$0.06
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Self Pay Self Pay |
$0.18
|
|
|
phenytoin 100 mg ER Cap [CQCH]
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 68084037601
|
| Hospital Charge Code |
105936628
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of AZ Commercial |
$0.47
|
| Rate for Payer: Aetna of AZ Medicare |
$0.15
|
| Rate for Payer: Allwell Medicare |
$0.08
|
| Rate for Payer: Amerigroup Medicare |
$0.08
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.19
|
| Rate for Payer: AZCH Complete Medicare |
$0.08
|
| Rate for Payer: Banner UC Health Medicare |
$0.08
|
| Rate for Payer: Bisbee Police All Plans |
$0.14
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.35
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Cigna of AZ Commercial |
$0.34
|
| Rate for Payer: Copperpoint Commercial |
$0.13
|
| Rate for Payer: Health Net of AZ Commercial |
$0.31
|
| Rate for Payer: Health Net of AZ Medicare |
$0.15
|
| Rate for Payer: Humana of AZ Medicare |
$0.08
|
| Rate for Payer: Self Pay Self Pay |
$0.42
|
| Rate for Payer: TriWest Medicare |
$0.08
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.30
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.09
|
|
|
phenytoin 100 mg ER Cap [CQCH]
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 68084037601
|
| Hospital Charge Code |
105936628
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Aetna of AZ Commercial |
$0.47
|
| Rate for Payer: Bisbee Police All Plans |
$0.14
|
| Rate for Payer: Cash Price |
$0.41
|
| Rate for Payer: Self Pay Self Pay |
$0.42
|
|
|
Phenytoin, Free, Serum LC
|
Facility
|
OP
|
$318.00
|
|
|
Service Code
|
CPT 80186
|
| Hospital Charge Code |
2087633
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.76 |
| Max. Negotiated Rate |
$286.20 |
| Rate for Payer: Aetna of AZ Commercial |
$286.20
|
| Rate for Payer: Aetna of AZ Medicare |
$89.04
|
| Rate for Payer: AHCCCS Medicaid |
$13.76
|
| Rate for Payer: Allwell Medicaid |
$13.76
|
| Rate for Payer: Allwell Medicare |
$47.70
|
| Rate for Payer: Amerigroup Medicare |
$47.70
|
| Rate for Payer: APIPA Medicare/Medicaid |
$118.77
|
| Rate for Payer: AZCH Complete Medicaid |
$13.76
|
| Rate for Payer: AZCH Complete Medicare |
$47.70
|
| Rate for Payer: Banner UC Health Medicaid |
$13.76
|
| Rate for Payer: Banner UC Health Medicare |
$47.70
|
| Rate for Payer: Bisbee Police All Plans |
$82.68
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$216.24
|
| Rate for Payer: Cash Price |
$254.40
|
| Rate for Payer: Cash Price |
$254.40
|
| Rate for Payer: Cigna of AZ Commercial |
$206.70
|
| Rate for Payer: Copperpoint Commercial |
$78.70
|
| Rate for Payer: Health Net of AZ Commercial |
$190.80
|
| Rate for Payer: Health Net of AZ Medicare |
$89.04
|
| Rate for Payer: Humana of AZ Medicare |
$47.70
|
| Rate for Payer: Mercy Care Medicaid |
$13.76
|
| Rate for Payer: Self Pay Self Pay |
$254.40
|
| Rate for Payer: TriWest Medicare |
$47.70
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$185.39
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$57.24
|
|
|
Phenytoin, Free, Serum LC
|
Facility
|
IP
|
$318.00
|
|
|
Service Code
|
CPT 80186
|
| Hospital Charge Code |
2087633
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$82.68 |
| Max. Negotiated Rate |
$286.20 |
| Rate for Payer: Aetna of AZ Commercial |
$286.20
|
| Rate for Payer: Bisbee Police All Plans |
$82.68
|
| Rate for Payer: Cash Price |
$254.40
|
| Rate for Payer: Self Pay Self Pay |
$254.40
|
|
|
Phenytoin Lvl
|
Facility
|
IP
|
$212.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
858788
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$55.12 |
| Max. Negotiated Rate |
$190.80 |
| Rate for Payer: Aetna of AZ Commercial |
$190.80
|
| Rate for Payer: Bisbee Police All Plans |
$55.12
|
| Rate for Payer: Cash Price |
$169.60
|
| Rate for Payer: Self Pay Self Pay |
$169.60
|
|
|
Phenytoin Lvl
|
Facility
|
OP
|
$212.00
|
|
|
Service Code
|
CPT 80185
|
| Hospital Charge Code |
858788
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$190.80 |
| Rate for Payer: Aetna of AZ Commercial |
$190.80
|
| Rate for Payer: Aetna of AZ Medicare |
$59.36
|
| Rate for Payer: AHCCCS Medicaid |
$13.25
|
| Rate for Payer: Allwell Medicaid |
$13.25
|
| Rate for Payer: Allwell Medicare |
$31.80
|
| Rate for Payer: Amerigroup Medicare |
$31.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$79.18
|
| Rate for Payer: AZCH Complete Medicaid |
$13.25
|
| Rate for Payer: AZCH Complete Medicare |
$31.80
|
| Rate for Payer: Banner UC Health Medicaid |
$13.25
|
| Rate for Payer: Banner UC Health Medicare |
$31.80
|
| Rate for Payer: Bisbee Police All Plans |
$55.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$144.16
|
| Rate for Payer: Cash Price |
$169.60
|
| Rate for Payer: Cash Price |
$169.60
|
| Rate for Payer: Cigna of AZ Commercial |
$137.80
|
| Rate for Payer: Copperpoint Commercial |
$52.47
|
| Rate for Payer: Health Net of AZ Commercial |
$127.20
|
| Rate for Payer: Health Net of AZ Medicare |
$59.36
|
| Rate for Payer: Humana of AZ Medicare |
$31.80
|
| Rate for Payer: Mercy Care Medicaid |
$13.25
|
| Rate for Payer: Self Pay Self Pay |
$169.60
|
| Rate for Payer: TriWest Medicare |
$31.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$123.60
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$38.16
|
|
