|
Phospholipid neutralization; hexagonal phospholipid
|
Facility
|
OP
|
$224.00
|
|
|
Service Code
|
CPT 85598
|
| Hospital Charge Code |
22481494
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.98 |
| Max. Negotiated Rate |
$201.60 |
| Rate for Payer: Aetna of AZ Commercial |
$201.60
|
| Rate for Payer: Aetna of AZ Medicare |
$62.72
|
| Rate for Payer: AHCCCS Medicaid |
$17.98
|
| Rate for Payer: Allwell Medicaid |
$17.98
|
| Rate for Payer: Allwell Medicare |
$33.60
|
| Rate for Payer: Amerigroup Medicare |
$33.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$83.66
|
| Rate for Payer: AZCH Complete Medicaid |
$17.98
|
| Rate for Payer: AZCH Complete Medicare |
$33.60
|
| Rate for Payer: Banner UC Health Medicaid |
$17.98
|
| Rate for Payer: Banner UC Health Medicare |
$33.60
|
| Rate for Payer: Bisbee Police All Plans |
$58.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$152.32
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: Cigna of AZ Commercial |
$145.60
|
| Rate for Payer: Copperpoint Commercial |
$55.44
|
| Rate for Payer: Health Net of AZ Commercial |
$134.40
|
| Rate for Payer: Health Net of AZ Medicare |
$62.72
|
| Rate for Payer: Humana of AZ Medicare |
$33.60
|
| Rate for Payer: Mercy Care Medicaid |
$17.98
|
| Rate for Payer: Self Pay Self Pay |
$179.20
|
| Rate for Payer: TriWest Medicare |
$33.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$130.59
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$40.32
|
|
|
Phospholipid neutralization; hexagonal phospholipid
|
Facility
|
IP
|
$224.00
|
|
|
Service Code
|
CPT 85598
|
| Hospital Charge Code |
22481494
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$58.24 |
| Max. Negotiated Rate |
$201.60 |
| Rate for Payer: Aetna of AZ Commercial |
$201.60
|
| Rate for Payer: Bisbee Police All Plans |
$58.24
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: Self Pay Self Pay |
$179.20
|
|
|
Phosphorus, 24 hr Urine LC
|
Facility
|
IP
|
$73.00
|
|
|
Service Code
|
CPT 84105
|
| Hospital Charge Code |
2029252
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.98 |
| Max. Negotiated Rate |
$65.70 |
| Rate for Payer: Aetna of AZ Commercial |
$65.70
|
| Rate for Payer: Bisbee Police All Plans |
$18.98
|
| Rate for Payer: Cash Price |
$58.40
|
| Rate for Payer: Self Pay Self Pay |
$58.40
|
|
|
Phosphorus, 24 hr Urine LC
|
Facility
|
OP
|
$73.00
|
|
|
Service Code
|
CPT 84105
|
| Hospital Charge Code |
2029252
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.78 |
| Max. Negotiated Rate |
$65.70 |
| Rate for Payer: Aetna of AZ Commercial |
$65.70
|
| Rate for Payer: Aetna of AZ Medicare |
$20.44
|
| Rate for Payer: AHCCCS Medicaid |
$5.78
|
| Rate for Payer: Allwell Medicaid |
$5.78
|
| Rate for Payer: Allwell Medicare |
$10.95
|
| Rate for Payer: Amerigroup Medicare |
$10.95
|
| Rate for Payer: APIPA Medicare/Medicaid |
$27.27
|
| Rate for Payer: AZCH Complete Medicaid |
$5.78
|
| Rate for Payer: AZCH Complete Medicare |
$10.95
|
| Rate for Payer: Banner UC Health Medicaid |
$5.78
|
| Rate for Payer: Banner UC Health Medicare |
$10.95
|
| Rate for Payer: Bisbee Police All Plans |
$18.98
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$49.64
|
| Rate for Payer: Cash Price |
$58.40
|
| Rate for Payer: Cash Price |
$58.40
|
| Rate for Payer: Cigna of AZ Commercial |
$47.45
|
| Rate for Payer: Copperpoint Commercial |
$18.07
|
| Rate for Payer: Health Net of AZ Commercial |
$43.80
|
| Rate for Payer: Health Net of AZ Medicare |
$20.44
|
| Rate for Payer: Humana of AZ Medicare |
$10.95
|
| Rate for Payer: Mercy Care Medicaid |
$5.78
|
| Rate for Payer: Self Pay Self Pay |
$58.40
|
| Rate for Payer: TriWest Medicare |
$10.95
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$42.56
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$13.14
|
|
|
Phosphorus Level
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
CPT 84100
|
| Hospital Charge Code |
633803
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.74 |
| Max. Negotiated Rate |
$109.80 |
| Rate for Payer: Aetna of AZ Commercial |
$109.80
|
| Rate for Payer: Aetna of AZ Medicare |
$34.16
|
| Rate for Payer: AHCCCS Medicaid |
$4.74
|
| Rate for Payer: Allwell Medicaid |
$4.74
|
| Rate for Payer: Allwell Medicare |
$18.30
|
| Rate for Payer: Amerigroup Medicare |
$18.30
|
| Rate for Payer: APIPA Medicare/Medicaid |
$45.57
|
| Rate for Payer: AZCH Complete Medicaid |
$4.74
|
| Rate for Payer: AZCH Complete Medicare |
$18.30
|
| Rate for Payer: Banner UC Health Medicaid |
$4.74
|
| Rate for Payer: Banner UC Health Medicare |
$18.30
|
| Rate for Payer: Bisbee Police All Plans |
$31.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$82.96
|
| Rate for Payer: Cash Price |
$97.60
|
| Rate for Payer: Cash Price |
$97.60
|
| Rate for Payer: Cigna of AZ Commercial |
$79.30
|
| Rate for Payer: Copperpoint Commercial |
$30.20
|
| Rate for Payer: Health Net of AZ Commercial |
$73.20
|
| Rate for Payer: Health Net of AZ Medicare |
$34.16
|
| Rate for Payer: Humana of AZ Medicare |
$18.30
|
| Rate for Payer: Mercy Care Medicaid |
$4.74
|
| Rate for Payer: Self Pay Self Pay |
$97.60
|
| Rate for Payer: TriWest Medicare |
$18.30
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$71.13
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$21.96
|
|
|
Phosphorus Level
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
CPT 84100
|
| Hospital Charge Code |
633803
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.72 |
| Max. Negotiated Rate |
$109.80 |
| Rate for Payer: Aetna of AZ Commercial |
$109.80
|
| Rate for Payer: Bisbee Police All Plans |
$31.72
|
| Rate for Payer: Cash Price |
$97.60
|
| Rate for Payer: Self Pay Self Pay |
$97.60
|
|
|
Physical fitness testing
|
Facility
|
OP
|
$48.00
|
|
|
Service Code
|
CPT 97799
|
| Hospital Charge Code |
27790993
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna of AZ Commercial |
$43.20
|
| Rate for Payer: Aetna of AZ Medicare |
$13.44
|
| Rate for Payer: AHCCCS Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicare |
$7.20
|
| Rate for Payer: Amerigroup Medicare |
$7.20
|
| Rate for Payer: APIPA Medicare/Medicaid |
$17.93
|
| Rate for Payer: AZCH Complete Medicaid |
$0.13
|
| Rate for Payer: AZCH Complete Medicare |
$7.20
|
| Rate for Payer: Banner UC Health Medicaid |
$0.13
|
| Rate for Payer: Banner UC Health Medicare |
$7.20
|
| Rate for Payer: Bisbee Police All Plans |
$12.48
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$32.64
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna of AZ Commercial |
$31.20
|
| Rate for Payer: Copperpoint Commercial |
$11.88
|
| Rate for Payer: Health Net of AZ Commercial |
$28.80
|
| Rate for Payer: Health Net of AZ Medicare |
$13.44
|
| Rate for Payer: Humana of AZ Medicare |
$7.20
|
| Rate for Payer: Mercy Care Medicaid |
$0.13
|
| Rate for Payer: Self Pay Self Pay |
$38.40
|
| Rate for Payer: TriWest Medicare |
$7.20
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$27.98
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$8.64
|
|
|
Physical fitness testing
|
Facility
|
IP
|
$48.00
|
|
|
Service Code
|
CPT 97799
|
| Hospital Charge Code |
27790993
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.48 |
| Max. Negotiated Rate |
$43.20 |
| Rate for Payer: Aetna of AZ Commercial |
$43.20
|
| Rate for Payer: Bisbee Police All Plans |
$12.48
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Self Pay Self Pay |
$38.40
|
|
|
phytonadione 10 mg/ 1mL Inj Sol [CQCH]
|
Facility
|
OP
|
$34.78
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
105936764
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.22 |
| Max. Negotiated Rate |
$31.30 |
| Rate for Payer: Aetna of AZ Commercial |
$31.30
|
| Rate for Payer: Aetna of AZ Medicare |
$9.74
|
| Rate for Payer: AHCCCS Medicaid |
$6.06
|
| Rate for Payer: Allwell Medicaid |
$6.06
|
| Rate for Payer: Allwell Medicare |
$5.22
|
| Rate for Payer: Amerigroup Medicare |
$5.22
|
| Rate for Payer: APIPA Medicare/Medicaid |
$12.99
|
| Rate for Payer: AZCH Complete Medicaid |
$6.06
|
| Rate for Payer: AZCH Complete Medicare |
$5.22
|
| Rate for Payer: Banner UC Health Medicaid |
$6.06
|
| Rate for Payer: Banner UC Health Medicare |
$5.22
|
| Rate for Payer: Bisbee Police All Plans |
$9.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$23.65
|
| Rate for Payer: Cash Price |
$27.82
|
| Rate for Payer: Cash Price |
$27.82
|
| Rate for Payer: Cigna of AZ Commercial |
$22.61
|
| Rate for Payer: Copperpoint Commercial |
$8.61
|
| Rate for Payer: Health Net of AZ Commercial |
$20.87
|
| Rate for Payer: Health Net of AZ Medicare |
$9.74
|
| Rate for Payer: Humana of AZ Medicare |
$5.22
|
| Rate for Payer: Mercy Care Medicaid |
$6.06
|
| Rate for Payer: Self Pay Self Pay |
$27.82
|
| Rate for Payer: TriWest Medicare |
$5.22
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$20.28
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$6.26
|
|
|
phytonadione 10 mg/ 1mL Inj Sol [CQCH]
|
Facility
|
IP
|
$34.78
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
105936764
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.04 |
| Max. Negotiated Rate |
$31.30 |
| Rate for Payer: Aetna of AZ Commercial |
$31.30
|
| Rate for Payer: Bisbee Police All Plans |
$9.04
|
| Rate for Payer: Cash Price |
$27.82
|
| Rate for Payer: Self Pay Self Pay |
$27.82
|
|
|
phytonadione 1 mg/0.5 mL PFS Inj [CQCH]
|
Facility
|
IP
|
$38.70
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
105936693
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$34.83 |
| Rate for Payer: Aetna of AZ Commercial |
$34.83
|
| Rate for Payer: Bisbee Police All Plans |
$10.06
|
| Rate for Payer: Cash Price |
$30.96
|
| Rate for Payer: Self Pay Self Pay |
$30.96
|
|
|
phytonadione 1 mg/0.5 mL PFS Inj [CQCH]
|
Facility
|
OP
|
$38.70
|
|
|
Service Code
|
HCPCS J3430
|
| Hospital Charge Code |
105936693
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.80 |
| Max. Negotiated Rate |
$34.83 |
| Rate for Payer: Aetna of AZ Commercial |
$34.83
|
| Rate for Payer: Aetna of AZ Medicare |
$10.84
|
| Rate for Payer: AHCCCS Medicaid |
$6.06
|
| Rate for Payer: Allwell Medicaid |
$6.06
|
| Rate for Payer: Allwell Medicare |
$5.80
|
| Rate for Payer: Amerigroup Medicare |
$5.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$14.45
|
| Rate for Payer: AZCH Complete Medicaid |
$6.06
|
| Rate for Payer: AZCH Complete Medicare |
$5.80
|
| Rate for Payer: Banner UC Health Medicaid |
$6.06
|
| Rate for Payer: Banner UC Health Medicare |
$5.80
|
| Rate for Payer: Bisbee Police All Plans |
$10.06
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$26.32
|
| Rate for Payer: Cash Price |
$30.96
|
| Rate for Payer: Cash Price |
$30.96
|
| Rate for Payer: Cigna of AZ Commercial |
$25.16
|
| Rate for Payer: Copperpoint Commercial |
$9.58
|
| Rate for Payer: Health Net of AZ Commercial |
$23.22
|
| Rate for Payer: Health Net of AZ Medicare |
$10.84
|
| Rate for Payer: Humana of AZ Medicare |
$5.80
|
| Rate for Payer: Mercy Care Medicaid |
$6.06
|
| Rate for Payer: Self Pay Self Pay |
$30.96
|
| Rate for Payer: TriWest Medicare |
$5.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$22.56
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$6.97
|
|
|
PICC KIT 3FR SL
|
Facility
|
IP
|
$1,209.00
|
|
| Hospital Charge Code |
23758900
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$314.34 |
| Max. Negotiated Rate |
$1,088.10 |
| Rate for Payer: Aetna of AZ Commercial |
$1,088.10
|
| Rate for Payer: Bisbee Police All Plans |
$314.34
|
| Rate for Payer: Cash Price |
$967.20
|
| Rate for Payer: Self Pay Self Pay |
$967.20
|
|
|
PICC KIT 3FR SL
|
Facility
|
OP
|
$1,209.00
|
|
| Hospital Charge Code |
23758900
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$181.35 |
| Max. Negotiated Rate |
$1,088.10 |
| Rate for Payer: Aetna of AZ Commercial |
$1,088.10
|
| Rate for Payer: Aetna of AZ Medicare |
$338.52
|
| Rate for Payer: Allwell Medicare |
$181.35
|
| Rate for Payer: Amerigroup Medicare |
$181.35
|
| Rate for Payer: APIPA Medicare/Medicaid |
$451.56
|
| Rate for Payer: AZCH Complete Medicare |
$181.35
|
| Rate for Payer: Banner UC Health Medicare |
$181.35
|
| Rate for Payer: Bisbee Police All Plans |
$314.34
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$822.12
|
| Rate for Payer: Cash Price |
$967.20
|
| Rate for Payer: Cigna of AZ Commercial |
$846.30
|
| Rate for Payer: Copperpoint Commercial |
$299.23
|
| Rate for Payer: Health Net of AZ Commercial |
$725.40
|
| Rate for Payer: Health Net of AZ Medicare |
$338.52
|
| Rate for Payer: Humana of AZ Medicare |
$181.35
|
| Rate for Payer: Self Pay Self Pay |
$967.20
|
| Rate for Payer: TriWest Medicare |
$181.35
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$704.85
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$217.62
|
|
|
PICC KIT 4FR DL
|
Facility
|
IP
|
$1,255.00
|
|
| Hospital Charge Code |
23758902
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$326.30 |
| Max. Negotiated Rate |
$1,129.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,129.50
|
| Rate for Payer: Bisbee Police All Plans |
$326.30
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Self Pay Self Pay |
$1,004.00
|
|
|
PICC KIT 4FR DL
|
Facility
|
OP
|
$1,255.00
|
|
| Hospital Charge Code |
23758902
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$188.25 |
| Max. Negotiated Rate |
$1,129.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,129.50
|
| Rate for Payer: Aetna of AZ Medicare |
$351.40
|
| Rate for Payer: Allwell Medicare |
$188.25
|
| Rate for Payer: Amerigroup Medicare |
$188.25
|
| Rate for Payer: APIPA Medicare/Medicaid |
$468.74
|
| Rate for Payer: AZCH Complete Medicare |
$188.25
|
| Rate for Payer: Banner UC Health Medicare |
$188.25
|
| Rate for Payer: Bisbee Police All Plans |
$326.30
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$853.40
|
| Rate for Payer: Cash Price |
$1,004.00
|
| Rate for Payer: Cigna of AZ Commercial |
$878.50
|
| Rate for Payer: Copperpoint Commercial |
$310.61
|
| Rate for Payer: Health Net of AZ Commercial |
$753.00
|
| Rate for Payer: Health Net of AZ Medicare |
$351.40
|
| Rate for Payer: Humana of AZ Medicare |
$188.25
|
| Rate for Payer: Self Pay Self Pay |
$1,004.00
|
| Rate for Payer: TriWest Medicare |
$188.25
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$731.66
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$225.90
|
|
|
PICC KIT 4FR SL
|
Facility
|
OP
|
$1,157.00
|
|
| Hospital Charge Code |
23758901
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$173.55 |
| Max. Negotiated Rate |
$1,041.30 |
| Rate for Payer: Aetna of AZ Commercial |
$1,041.30
|
| Rate for Payer: Aetna of AZ Medicare |
$323.96
|
| Rate for Payer: Allwell Medicare |
$173.55
|
| Rate for Payer: Amerigroup Medicare |
$173.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$432.14
|
| Rate for Payer: AZCH Complete Medicare |
$173.55
|
| Rate for Payer: Banner UC Health Medicare |
$173.55
|
| Rate for Payer: Bisbee Police All Plans |
$300.82
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$786.76
|
| Rate for Payer: Cash Price |
$925.60
|
| Rate for Payer: Cigna of AZ Commercial |
$809.90
|
| Rate for Payer: Copperpoint Commercial |
$286.36
|
| Rate for Payer: Health Net of AZ Commercial |
$694.20
|
| Rate for Payer: Health Net of AZ Medicare |
$323.96
|
| Rate for Payer: Humana of AZ Medicare |
$173.55
|
| Rate for Payer: Self Pay Self Pay |
$925.60
|
| Rate for Payer: TriWest Medicare |
$173.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$674.53
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$208.26
|
|
|
PICC KIT 4FR SL
|
Facility
|
IP
|
$1,157.00
|
|
| Hospital Charge Code |
23758901
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$300.82 |
| Max. Negotiated Rate |
$1,041.30 |
| Rate for Payer: Aetna of AZ Commercial |
$1,041.30
|
| Rate for Payer: Bisbee Police All Plans |
$300.82
|
| Rate for Payer: Cash Price |
$925.60
|
| Rate for Payer: Self Pay Self Pay |
$925.60
|
|
|
PICO 7 DISPOSABLE WOUND THERAPY SYSTEM
|
Facility
|
OP
|
$1,659.00
|
|
| Hospital Charge Code |
24010984
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$248.85 |
| Max. Negotiated Rate |
$1,493.10 |
| Rate for Payer: Aetna of AZ Commercial |
$1,493.10
|
| Rate for Payer: Aetna of AZ Medicare |
$464.52
|
| Rate for Payer: Allwell Medicare |
$248.85
|
| Rate for Payer: Amerigroup Medicare |
$248.85
|
| Rate for Payer: APIPA Medicare/Medicaid |
$619.64
|
| Rate for Payer: AZCH Complete Medicare |
$248.85
|
| Rate for Payer: Banner UC Health Medicare |
$248.85
|
| Rate for Payer: Bisbee Police All Plans |
$431.34
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,128.12
|
| Rate for Payer: Cash Price |
$1,327.20
|
| Rate for Payer: Cigna of AZ Commercial |
$1,161.30
|
| Rate for Payer: Copperpoint Commercial |
$410.60
|
| Rate for Payer: Health Net of AZ Commercial |
$995.40
|
| Rate for Payer: Health Net of AZ Medicare |
$464.52
|
| Rate for Payer: Humana of AZ Medicare |
$248.85
|
| Rate for Payer: Self Pay Self Pay |
$1,327.20
|
| Rate for Payer: TriWest Medicare |
$248.85
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$967.20
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$298.62
|
|
|
PICO 7 DISPOSABLE WOUND THERAPY SYSTEM
|
Facility
|
IP
|
$1,659.00
|
|
| Hospital Charge Code |
24010984
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$431.34 |
| Max. Negotiated Rate |
$1,493.10 |
| Rate for Payer: Aetna of AZ Commercial |
$1,493.10
|
| Rate for Payer: Bisbee Police All Plans |
$431.34
|
| Rate for Payer: Cash Price |
$1,327.20
|
| Rate for Payer: Self Pay Self Pay |
$1,327.20
|
|
|
pilocarpine 5 mg Tab [CQCH]
|
Facility
|
IP
|
$1.26
|
|
|
Service Code
|
NDC 62856070510
|
| Hospital Charge Code |
105936837
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Aetna of AZ Commercial |
$1.13
|
| Rate for Payer: Bisbee Police All Plans |
$0.33
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Self Pay Self Pay |
$1.01
|
|
|
pilocarpine 5 mg Tab [CQCH]
|
Facility
|
OP
|
$1.26
|
|
|
Service Code
|
NDC 62856070510
|
| Hospital Charge Code |
105936837
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$1.13 |
| Rate for Payer: Aetna of AZ Commercial |
$1.13
|
| Rate for Payer: Aetna of AZ Medicare |
$0.35
|
| Rate for Payer: Allwell Medicare |
$0.19
|
| Rate for Payer: Amerigroup Medicare |
$0.19
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.47
|
| Rate for Payer: AZCH Complete Medicare |
$0.19
|
| Rate for Payer: Banner UC Health Medicare |
$0.19
|
| Rate for Payer: Bisbee Police All Plans |
$0.33
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cigna of AZ Commercial |
$0.82
|
| Rate for Payer: Copperpoint Commercial |
$0.31
|
| Rate for Payer: Health Net of AZ Commercial |
$0.76
|
| Rate for Payer: Health Net of AZ Medicare |
$0.35
|
| Rate for Payer: Humana of AZ Medicare |
$0.19
|
| Rate for Payer: Self Pay Self Pay |
$1.01
|
| Rate for Payer: TriWest Medicare |
$0.19
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.73
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.23
|
|
|
pilocarpine Ophth 2% Sol [CQCH]
|
Facility
|
IP
|
$1.97
|
|
|
Service Code
|
NDC 61314020315
|
| Hospital Charge Code |
105936902
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$1.77 |
| Rate for Payer: Aetna of AZ Commercial |
$1.77
|
| Rate for Payer: Bisbee Police All Plans |
$0.51
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: Self Pay Self Pay |
$1.58
|
|
|
pilocarpine Ophth 2% Sol [CQCH]
|
Facility
|
OP
|
$1.97
|
|
|
Service Code
|
NDC 61314020315
|
| Hospital Charge Code |
105936902
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$1.77 |
| Rate for Payer: Aetna of AZ Commercial |
$1.77
|
| Rate for Payer: Aetna of AZ Medicare |
$0.55
|
| Rate for Payer: Allwell Medicare |
$0.30
|
| Rate for Payer: Amerigroup Medicare |
$0.30
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.74
|
| Rate for Payer: AZCH Complete Medicare |
$0.30
|
| Rate for Payer: Banner UC Health Medicare |
$0.30
|
| Rate for Payer: Bisbee Police All Plans |
$0.51
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.34
|
| Rate for Payer: Cash Price |
$1.58
|
| Rate for Payer: Cigna of AZ Commercial |
$1.28
|
| Rate for Payer: Copperpoint Commercial |
$0.49
|
| Rate for Payer: Health Net of AZ Commercial |
$1.18
|
| Rate for Payer: Health Net of AZ Medicare |
$0.55
|
| Rate for Payer: Humana of AZ Medicare |
$0.30
|
| Rate for Payer: Self Pay Self Pay |
$1.58
|
| Rate for Payer: TriWest Medicare |
$0.30
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1.15
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.35
|
|
|
PIN KIT TACMOTION 1.5
|
Facility
|
OP
|
$360.00
|
|
| Hospital Charge Code |
24129934
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$54.00 |
| Max. Negotiated Rate |
$324.00 |
| Rate for Payer: Aetna of AZ Commercial |
$324.00
|
| Rate for Payer: Aetna of AZ Medicare |
$100.80
|
| Rate for Payer: Allwell Medicare |
$54.00
|
| Rate for Payer: Amerigroup Medicare |
$54.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$134.46
|
| Rate for Payer: AZCH Complete Medicare |
$54.00
|
| Rate for Payer: Banner UC Health Medicare |
$54.00
|
| Rate for Payer: Bisbee Police All Plans |
$93.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$244.80
|
| Rate for Payer: Cash Price |
$288.00
|
| Rate for Payer: Cigna of AZ Commercial |
$252.00
|
| Rate for Payer: Copperpoint Commercial |
$89.10
|
| Rate for Payer: Health Net of AZ Commercial |
$216.00
|
| Rate for Payer: Health Net of AZ Medicare |
$100.80
|
| Rate for Payer: Humana of AZ Medicare |
$54.00
|
| Rate for Payer: Self Pay Self Pay |
$288.00
|
| Rate for Payer: TriWest Medicare |
$54.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$209.88
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$64.80
|
|
