|
Progesterone LC
|
Facility
|
IP
|
$573.00
|
|
|
Service Code
|
CPT 84144
|
| Hospital Charge Code |
1909537
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$148.98 |
| Max. Negotiated Rate |
$515.70 |
| Rate for Payer: Aetna of AZ Commercial |
$515.70
|
| Rate for Payer: Bisbee Police All Plans |
$148.98
|
| Rate for Payer: Cash Price |
$458.40
|
| Rate for Payer: Self Pay Self Pay |
$458.40
|
|
|
Progesterone LC
|
Facility
|
OP
|
$573.00
|
|
|
Service Code
|
CPT 84144
|
| Hospital Charge Code |
1909537
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.86 |
| Max. Negotiated Rate |
$515.70 |
| Rate for Payer: Aetna of AZ Commercial |
$515.70
|
| Rate for Payer: Aetna of AZ Medicare |
$160.44
|
| Rate for Payer: AHCCCS Medicaid |
$20.86
|
| Rate for Payer: Allwell Medicaid |
$20.86
|
| Rate for Payer: Allwell Medicare |
$85.95
|
| Rate for Payer: Amerigroup Medicare |
$85.95
|
| Rate for Payer: APIPA Medicare/Medicaid |
$214.02
|
| Rate for Payer: AZCH Complete Medicaid |
$20.86
|
| Rate for Payer: AZCH Complete Medicare |
$85.95
|
| Rate for Payer: Banner UC Health Medicaid |
$20.86
|
| Rate for Payer: Banner UC Health Medicare |
$85.95
|
| Rate for Payer: Bisbee Police All Plans |
$148.98
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$389.64
|
| Rate for Payer: Cash Price |
$458.40
|
| Rate for Payer: Cash Price |
$458.40
|
| Rate for Payer: Cigna of AZ Commercial |
$372.45
|
| Rate for Payer: Copperpoint Commercial |
$141.82
|
| Rate for Payer: Health Net of AZ Commercial |
$343.80
|
| Rate for Payer: Health Net of AZ Medicare |
$160.44
|
| Rate for Payer: Humana of AZ Medicare |
$85.95
|
| Rate for Payer: Mercy Care Medicaid |
$20.86
|
| Rate for Payer: Self Pay Self Pay |
$458.40
|
| Rate for Payer: TriWest Medicare |
$85.95
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$334.06
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$103.14
|
|
|
Programming State II
|
Facility
|
IP
|
$210.00
|
|
|
Service Code
|
CPT 95972
|
| Hospital Charge Code |
27281906
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$54.60 |
| Max. Negotiated Rate |
$189.00 |
| Rate for Payer: Aetna of AZ Commercial |
$189.00
|
| Rate for Payer: Bisbee Police All Plans |
$54.60
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Self Pay Self Pay |
$168.00
|
|
|
Programming State II
|
Facility
|
OP
|
$210.00
|
|
|
Service Code
|
CPT 95972
|
| Hospital Charge Code |
27281906
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$31.50 |
| Max. Negotiated Rate |
$189.00 |
| Rate for Payer: Aetna of AZ Commercial |
$189.00
|
| Rate for Payer: Aetna of AZ Medicare |
$58.80
|
| Rate for Payer: AHCCCS Medicaid |
$145.44
|
| Rate for Payer: Allwell Medicaid |
$145.44
|
| Rate for Payer: Allwell Medicare |
$31.50
|
| Rate for Payer: Amerigroup Medicare |
$31.50
|
| Rate for Payer: APIPA Medicare/Medicaid |
$78.44
|
| Rate for Payer: AZCH Complete Medicaid |
$145.44
|
| Rate for Payer: AZCH Complete Medicare |
$31.50
|
| Rate for Payer: Banner UC Health Medicaid |
$145.44
|
| Rate for Payer: Banner UC Health Medicare |
$31.50
|
| Rate for Payer: Bisbee Police All Plans |
$54.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$142.80
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cigna of AZ Commercial |
$105.00
|
| Rate for Payer: Copperpoint Commercial |
$51.98
|
| Rate for Payer: Health Net of AZ Commercial |
$126.00
|
| Rate for Payer: Health Net of AZ Medicare |
$58.80
|
| Rate for Payer: Humana of AZ Medicare |
$31.50
|
| Rate for Payer: Mercy Care Medicaid |
$145.44
|
| Rate for Payer: Self Pay Self Pay |
$168.00
|
| Rate for Payer: TriWest Medicare |
$31.50
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$122.43
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$37.80
|
|
|
PROINSULIN
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
CPT 84206
|
| Hospital Charge Code |
22576579
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.75 |
| Max. Negotiated Rate |
$112.50 |
| Rate for Payer: Aetna of AZ Commercial |
$112.50
|
| Rate for Payer: Aetna of AZ Medicare |
$35.00
|
| Rate for Payer: AHCCCS Medicaid |
$26.69
|
| Rate for Payer: Allwell Medicaid |
$26.69
|
| Rate for Payer: Allwell Medicare |
$18.75
|
| Rate for Payer: Amerigroup Medicare |
$18.75
|
| Rate for Payer: APIPA Medicare/Medicaid |
$46.69
|
| Rate for Payer: AZCH Complete Medicaid |
$26.69
|
| Rate for Payer: AZCH Complete Medicare |
$18.75
|
| Rate for Payer: Banner UC Health Medicaid |
$26.69
|
| Rate for Payer: Banner UC Health Medicare |
$18.75
|
| Rate for Payer: Bisbee Police All Plans |
$32.50
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$85.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna of AZ Commercial |
$81.25
|
| Rate for Payer: Copperpoint Commercial |
$30.94
|
| Rate for Payer: Health Net of AZ Commercial |
$75.00
|
| Rate for Payer: Health Net of AZ Medicare |
$35.00
|
| Rate for Payer: Humana of AZ Medicare |
$18.75
|
| Rate for Payer: Mercy Care Medicaid |
$26.69
|
| Rate for Payer: Self Pay Self Pay |
$100.00
|
| Rate for Payer: TriWest Medicare |
$18.75
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$72.88
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$22.50
|
|
|
PROINSULIN
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
CPT 84206
|
| Hospital Charge Code |
22576579
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$32.50 |
| Max. Negotiated Rate |
$112.50 |
| Rate for Payer: Aetna of AZ Commercial |
$112.50
|
| Rate for Payer: Bisbee Police All Plans |
$32.50
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Self Pay Self Pay |
$100.00
|
|
|
Prolactin LC
|
Facility
|
IP
|
$253.00
|
|
|
Service Code
|
CPT 84146
|
| Hospital Charge Code |
1285574
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$65.78 |
| Max. Negotiated Rate |
$227.70 |
| Rate for Payer: Aetna of AZ Commercial |
$227.70
|
| Rate for Payer: Bisbee Police All Plans |
$65.78
|
| Rate for Payer: Cash Price |
$202.40
|
| Rate for Payer: Self Pay Self Pay |
$202.40
|
|
|
Prolactin LC
|
Facility
|
OP
|
$253.00
|
|
|
Service Code
|
CPT 84146
|
| Hospital Charge Code |
1285574
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.38 |
| Max. Negotiated Rate |
$227.70 |
| Rate for Payer: Aetna of AZ Commercial |
$227.70
|
| Rate for Payer: Aetna of AZ Medicare |
$70.84
|
| Rate for Payer: AHCCCS Medicaid |
$19.38
|
| Rate for Payer: Allwell Medicaid |
$19.38
|
| Rate for Payer: Allwell Medicare |
$37.95
|
| Rate for Payer: Amerigroup Medicare |
$37.95
|
| Rate for Payer: APIPA Medicare/Medicaid |
$94.50
|
| Rate for Payer: AZCH Complete Medicaid |
$19.38
|
| Rate for Payer: AZCH Complete Medicare |
$37.95
|
| Rate for Payer: Banner UC Health Medicaid |
$19.38
|
| Rate for Payer: Banner UC Health Medicare |
$37.95
|
| Rate for Payer: Bisbee Police All Plans |
$65.78
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$172.04
|
| Rate for Payer: Cash Price |
$202.40
|
| Rate for Payer: Cash Price |
$202.40
|
| Rate for Payer: Cigna of AZ Commercial |
$164.45
|
| Rate for Payer: Copperpoint Commercial |
$62.62
|
| Rate for Payer: Health Net of AZ Commercial |
$151.80
|
| Rate for Payer: Health Net of AZ Medicare |
$70.84
|
| Rate for Payer: Humana of AZ Medicare |
$37.95
|
| Rate for Payer: Mercy Care Medicaid |
$19.38
|
| Rate for Payer: Self Pay Self Pay |
$202.40
|
| Rate for Payer: TriWest Medicare |
$37.95
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$147.50
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$45.54
|
|
|
promethazine 25 mg/ 1mL Inj Sol [CQCH]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
105938466
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$6.12 |
| Rate for Payer: Aetna of AZ Commercial |
$0.76
|
| Rate for Payer: Aetna of AZ Medicare |
$0.24
|
| Rate for Payer: AHCCCS Medicaid |
$6.12
|
| Rate for Payer: Allwell Medicaid |
$6.12
|
| Rate for Payer: Allwell Medicare |
$0.13
|
| Rate for Payer: Amerigroup Medicare |
$0.13
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.31
|
| Rate for Payer: AZCH Complete Medicaid |
$6.12
|
| Rate for Payer: AZCH Complete Medicare |
$0.13
|
| Rate for Payer: Banner UC Health Medicaid |
$6.12
|
| Rate for Payer: Banner UC Health Medicare |
$0.13
|
| Rate for Payer: Bisbee Police All Plans |
$0.22
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.57
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna of AZ Commercial |
$0.55
|
| Rate for Payer: Copperpoint Commercial |
$0.21
|
| Rate for Payer: Health Net of AZ Commercial |
$0.50
|
| Rate for Payer: Health Net of AZ Medicare |
$0.24
|
| Rate for Payer: Humana of AZ Medicare |
$0.13
|
| Rate for Payer: Mercy Care Medicaid |
$6.12
|
| Rate for Payer: Self Pay Self Pay |
$0.67
|
| Rate for Payer: TriWest Medicare |
$0.13
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.49
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.15
|
|
|
promethazine 25 mg/ 1mL Inj Sol [CQCH]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
105938466
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Aetna of AZ Commercial |
$0.76
|
| Rate for Payer: Bisbee Police All Plans |
$0.22
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Self Pay Self Pay |
$0.67
|
|
|
promethazine 25 mg Supp [CQCH]
|
Facility
|
OP
|
$3.03
|
|
|
Service Code
|
NDC 45802075930
|
| Hospital Charge Code |
105938401
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.73 |
| Rate for Payer: Aetna of AZ Commercial |
$2.73
|
| Rate for Payer: Aetna of AZ Medicare |
$0.85
|
| Rate for Payer: Allwell Medicare |
$0.45
|
| Rate for Payer: Amerigroup Medicare |
$0.45
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1.13
|
| Rate for Payer: AZCH Complete Medicare |
$0.45
|
| Rate for Payer: Banner UC Health Medicare |
$0.45
|
| Rate for Payer: Bisbee Police All Plans |
$0.79
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2.06
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cigna of AZ Commercial |
$1.97
|
| Rate for Payer: Copperpoint Commercial |
$0.75
|
| Rate for Payer: Health Net of AZ Commercial |
$1.82
|
| Rate for Payer: Health Net of AZ Medicare |
$0.85
|
| Rate for Payer: Humana of AZ Medicare |
$0.45
|
| Rate for Payer: Self Pay Self Pay |
$2.42
|
| Rate for Payer: TriWest Medicare |
$0.45
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1.77
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.55
|
|
|
promethazine 25 mg Supp [CQCH]
|
Facility
|
IP
|
$3.03
|
|
|
Service Code
|
NDC 45802075930
|
| Hospital Charge Code |
105938401
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$2.73 |
| Rate for Payer: Aetna of AZ Commercial |
$2.73
|
| Rate for Payer: Bisbee Police All Plans |
$0.79
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Self Pay Self Pay |
$2.42
|
|
|
promethazine 25 mg Tab [CQCH]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
105938332
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Aetna of AZ Commercial |
$0.10
|
| Rate for Payer: Aetna of AZ Medicare |
$0.03
|
| Rate for Payer: AHCCCS Medicaid |
$0.80
|
| Rate for Payer: Allwell Medicaid |
$0.80
|
| 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 Medicaid |
$0.80
|
| Rate for Payer: AZCH Complete Medicare |
$0.02
|
| Rate for Payer: Banner UC Health Medicaid |
$0.80
|
| 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 |
$0.09
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of AZ Commercial |
$0.07
|
| 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: Mercy Care Medicaid |
$0.80
|
| Rate for Payer: Self Pay Self Pay |
$0.09
|
| 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
|
|
|
promethazine 25 mg Tab [CQCH]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
105938332
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Aetna of AZ Commercial |
$0.10
|
| Rate for Payer: Bisbee Police All Plans |
$0.03
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Self Pay Self Pay |
$0.09
|
|
|
promethazine-dextromethorphan-6.25-15mg mg/5 mL Oral Syrup 118 mL [CQCH]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 60432060416
|
| Hospital Charge Code |
105918225
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of AZ Commercial |
$0.05
|
| Rate for Payer: Bisbee Police All Plans |
$0.02
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Self Pay Self Pay |
$0.05
|
|
|
promethazine-dextromethorphan-6.25-15mg mg/5 mL Oral Syrup 118 mL [CQCH]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 60432060416
|
| Hospital Charge Code |
105918225
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of AZ Commercial |
$0.05
|
| Rate for Payer: Aetna of AZ Medicare |
$0.02
|
| Rate for Payer: Allwell Medicare |
$0.01
|
| Rate for Payer: Amerigroup Medicare |
$0.01
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.02
|
| Rate for Payer: AZCH Complete Medicare |
$0.01
|
| Rate for Payer: Banner UC Health Medicare |
$0.01
|
| Rate for Payer: Bisbee Police All Plans |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of AZ Commercial |
$0.04
|
| Rate for Payer: Copperpoint Commercial |
$0.01
|
| Rate for Payer: Health Net of AZ Commercial |
$0.04
|
| Rate for Payer: Health Net of AZ Medicare |
$0.02
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Self Pay Self Pay |
$0.05
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.03
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.01
|
|
|
propafenone 150 mg Tab UD [CQCH]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 603544821
|
| Hospital Charge Code |
109867534
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of AZ Commercial |
$0.15
|
| 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 |
$0.06
|
| Rate for Payer: AZCH Complete Medicare |
$0.03
|
| Rate for Payer: Banner UC Health Medicare |
$0.03
|
| Rate for Payer: Bisbee Police All Plans |
$0.04
|
| 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 |
$0.11
|
| Rate for Payer: Copperpoint Commercial |
$0.04
|
| Rate for Payer: Health Net of AZ Commercial |
$0.10
|
| 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
|
|
|
propafenone 150 mg Tab UD [CQCH]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 603544821
|
| Hospital Charge Code |
109867534
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Aetna of AZ Commercial |
$0.15
|
| Rate for Payer: Bisbee Police All Plans |
$0.04
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Self Pay Self Pay |
$0.14
|
|
|
proparacaine Ophth 0.5% Sol [CQCH]
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
NDC 24208073006
|
| Hospital Charge Code |
105938535
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Aetna of AZ Commercial |
$1.95
|
| Rate for Payer: Bisbee Police All Plans |
$0.56
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Self Pay Self Pay |
$1.74
|
|
|
proparacaine Ophth 0.5% Sol [CQCH]
|
Facility
|
OP
|
$2.17
|
|
|
Service Code
|
NDC 24208073006
|
| Hospital Charge Code |
105938535
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Aetna of AZ Commercial |
$1.95
|
| Rate for Payer: Aetna of AZ Medicare |
$0.61
|
| Rate for Payer: Allwell Medicare |
$0.33
|
| Rate for Payer: Amerigroup Medicare |
$0.33
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.81
|
| Rate for Payer: AZCH Complete Medicare |
$0.33
|
| Rate for Payer: Banner UC Health Medicare |
$0.33
|
| Rate for Payer: Bisbee Police All Plans |
$0.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.48
|
| Rate for Payer: Cash Price |
$1.74
|
| Rate for Payer: Cigna of AZ Commercial |
$1.41
|
| Rate for Payer: Copperpoint Commercial |
$0.54
|
| Rate for Payer: Health Net of AZ Commercial |
$1.30
|
| Rate for Payer: Health Net of AZ Medicare |
$0.61
|
| Rate for Payer: Humana of AZ Medicare |
$0.33
|
| Rate for Payer: Self Pay Self Pay |
$1.74
|
| Rate for Payer: TriWest Medicare |
$0.33
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1.27
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.39
|
|
|
propofol 1000mg/100ml Emu (premix)(CQCH)
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
121933170
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of AZ Commercial |
$0.07
|
| Rate for Payer: Bisbee Police All Plans |
$0.02
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Self Pay Self Pay |
$0.06
|
|
|
propofol 1000mg/100ml Emu (premix)(CQCH)
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
121933170
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of AZ Commercial |
$0.07
|
| Rate for Payer: Aetna of AZ Medicare |
$0.02
|
| Rate for Payer: AHCCCS Medicaid |
$0.26
|
| Rate for Payer: Allwell Medicaid |
$0.26
|
| Rate for Payer: Allwell Medicare |
$0.01
|
| Rate for Payer: Amerigroup Medicare |
$0.01
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.03
|
| Rate for Payer: AZCH Complete Medicaid |
$0.26
|
| Rate for Payer: AZCH Complete Medicare |
$0.01
|
| Rate for Payer: Banner UC Health Medicaid |
$0.26
|
| Rate for Payer: Banner UC Health Medicare |
$0.01
|
| Rate for Payer: Bisbee Police All Plans |
$0.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of AZ Commercial |
$0.05
|
| Rate for Payer: Copperpoint Commercial |
$0.02
|
| Rate for Payer: Health Net of AZ Commercial |
$0.05
|
| Rate for Payer: Health Net of AZ Medicare |
$0.02
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Mercy Care Medicaid |
$0.26
|
| Rate for Payer: Self Pay Self Pay |
$0.06
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.05
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.01
|
|
|
propofol 200 mg/20 mL IV Emul [CQCH]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
105938600
|
|
Hospital Revenue Code
|
250
|
| 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
|
|
|
propofol 200 mg/20 mL IV Emul [CQCH]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
HCPCS J2704
|
| Hospital Charge Code |
105938600
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of AZ Commercial |
$0.09
|
| Rate for Payer: Aetna of AZ Medicare |
$0.03
|
| Rate for Payer: AHCCCS Medicaid |
$0.26
|
| Rate for Payer: Allwell Medicaid |
$0.26
|
| 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 Medicaid |
$0.26
|
| Rate for Payer: AZCH Complete Medicare |
$0.02
|
| Rate for Payer: Banner UC Health Medicaid |
$0.26
|
| 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: 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: Mercy Care Medicaid |
$0.26
|
| 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
|
|
|
propranolol 20 mg Tab [CQCH]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 60687059801
|
| Hospital Charge Code |
105953054
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: Aetna of AZ Commercial |
$0.41
|
| Rate for Payer: Aetna of AZ Medicare |
$0.13
|
| Rate for Payer: Allwell Medicare |
$0.07
|
| Rate for Payer: Amerigroup Medicare |
$0.07
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.17
|
| Rate for Payer: AZCH Complete Medicare |
$0.07
|
| 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 |
$0.31
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of AZ Commercial |
$0.29
|
| Rate for Payer: Copperpoint Commercial |
$0.11
|
| Rate for Payer: Health Net of AZ Commercial |
$0.27
|
| Rate for Payer: Health Net of AZ Medicare |
$0.13
|
| Rate for Payer: Humana of AZ Medicare |
$0.07
|
| Rate for Payer: Self Pay Self Pay |
$0.36
|
| Rate for Payer: TriWest Medicare |
$0.07
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.26
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.08
|
|
