|
sodium bicarbonate 4.2% (infant PFS)IV 10 mL [CQCH]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 409553434
|
| Hospital Charge Code |
105940804
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Aetna of AZ Commercial |
$0.76
|
| Rate for Payer: Aetna of AZ Medicare |
$0.24
|
| 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 Medicare |
$0.13
|
| 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: 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: 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
|
|
|
sodium bicarbonate 4% Soln 5 mL [CQCH]
|
Facility
|
OP
|
$1.24
|
|
|
Service Code
|
NDC 409660902
|
| Hospital Charge Code |
111111011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of AZ Commercial |
$1.12
|
| 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 |
$0.46
|
| Rate for Payer: AZCH Complete Medicare |
$0.19
|
| Rate for Payer: Banner UC Health Medicare |
$0.19
|
| Rate for Payer: Bisbee Police All Plans |
$0.32
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.84
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Cigna of AZ Commercial |
$0.81
|
| Rate for Payer: Copperpoint Commercial |
$0.31
|
| Rate for Payer: Health Net of AZ Commercial |
$0.74
|
| 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 |
$0.99
|
| Rate for Payer: TriWest Medicare |
$0.19
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.72
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.22
|
|
|
sodium bicarbonate 4% Soln 5 mL [CQCH]
|
Facility
|
IP
|
$1.24
|
|
|
Service Code
|
NDC 409660902
|
| Hospital Charge Code |
111111011
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$1.12 |
| Rate for Payer: Aetna of AZ Commercial |
$1.12
|
| Rate for Payer: Bisbee Police All Plans |
$0.32
|
| Rate for Payer: Cash Price |
$0.99
|
| Rate for Payer: Self Pay Self Pay |
$0.99
|
|
|
sodium bicarbonate 650 mg Tab [CQCH]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 536454410
|
| Hospital Charge Code |
105940670
|
|
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
|
|
|
sodium bicarbonate 650 mg Tab [CQCH]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 536454410
|
| Hospital Charge Code |
105940670
|
|
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
|
|
|
sodium bicarbonate 8.4% IV Sol (50 mL PFS) [CQCH]
|
Facility
|
OP
|
$0.17
|
|
|
Service Code
|
NDC 409663734
|
| Hospital Charge Code |
105940871
|
|
Hospital Revenue Code
|
251
|
| 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
|
|
|
sodium bicarbonate 8.4% IV Sol (50 mL PFS) [CQCH]
|
Facility
|
IP
|
$0.17
|
|
|
Service Code
|
NDC 409663734
|
| Hospital Charge Code |
105940871
|
|
Hospital Revenue Code
|
251
|
| 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
|
|
|
Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [CQCH]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
105941369
|
|
Hospital Revenue Code
|
258
|
| 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: Self Pay Self Pay |
$0.01
|
|
|
Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [CQCH]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J3480
|
| Hospital Charge Code |
105941369
|
|
Hospital Revenue Code
|
258
|
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of AZ Commercial |
$0.01
|
| Rate for Payer: Aetna of AZ Medicare |
$0.00
|
| Rate for Payer: AHCCCS Medicaid |
$0.26
|
| Rate for Payer: Allwell Medicaid |
$0.26
|
| 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 Medicaid |
$0.26
|
| Rate for Payer: AZCH Complete Medicare |
$0.00
|
| Rate for Payer: Banner UC Health Medicaid |
$0.26
|
| 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: 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: Mercy Care Medicaid |
$0.26
|
| 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
|
|
|
Sodium Chloride 0.9% 50 ML IV SOLN(CQCH)
|
Facility
|
IP
|
$2.29
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
121934599
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.06 |
| Rate for Payer: Aetna of AZ Commercial |
$2.06
|
| Rate for Payer: Bisbee Police All Plans |
$0.60
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Self Pay Self Pay |
$1.83
|
|
|
Sodium Chloride 0.9% 50 ML IV SOLN(CQCH)
|
Facility
|
OP
|
$2.29
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
121934599
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Aetna of AZ Commercial |
$2.06
|
| Rate for Payer: Aetna of AZ Medicare |
$0.64
|
| Rate for Payer: AHCCCS Medicaid |
$2.50
|
| Rate for Payer: Allwell Medicaid |
$2.50
|
| Rate for Payer: Allwell Medicare |
$0.34
|
| Rate for Payer: Amerigroup Medicare |
$0.34
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.86
|
| Rate for Payer: AZCH Complete Medicaid |
$2.50
|
| Rate for Payer: AZCH Complete Medicare |
$0.34
|
| Rate for Payer: Banner UC Health Medicaid |
$2.50
|
| Rate for Payer: Banner UC Health Medicare |
$0.34
|
| Rate for Payer: Bisbee Police All Plans |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.56
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Cigna of AZ Commercial |
$1.49
|
| Rate for Payer: Copperpoint Commercial |
$0.57
|
| Rate for Payer: Health Net of AZ Commercial |
$1.37
|
| Rate for Payer: Health Net of AZ Medicare |
$0.64
|
| Rate for Payer: Humana of AZ Medicare |
$0.34
|
| Rate for Payer: Mercy Care Medicaid |
$2.50
|
| Rate for Payer: Self Pay Self Pay |
$1.83
|
| Rate for Payer: TriWest Medicare |
$0.34
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1.34
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.41
|
|
|
sodium chloride 0.9% Inh Sol 3 mL [CQCH]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 487930103
|
| Hospital Charge Code |
105941436
|
|
Hospital Revenue Code
|
251
|
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| 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 |
$0.02
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of AZ Commercial |
$0.02
|
| Rate for Payer: Copperpoint Commercial |
$0.01
|
| Rate for Payer: Health Net of AZ Commercial |
$0.02
|
| 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 |
$0.02
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.01
|
|
|
sodium chloride 0.9% Inh Sol 3 mL [CQCH]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 487930103
|
| Hospital Charge Code |
105941436
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Self Pay Self Pay |
$0.02
|
|
|
sodium chloride 0.9% Inj Sol 10 mL [CQCH]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 409488810
|
| Hospital Charge Code |
105941657
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of AZ Commercial |
$0.07
|
| 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 |
$0.03
|
| 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 |
$0.05
|
| Rate for Payer: Cash Price |
$0.06
|
| 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: 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
|
|
|
sodium chloride 0.9% Inj Sol 10 mL [CQCH]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 409488810
|
| Hospital Charge Code |
105941657
|
|
Hospital Revenue Code
|
251
|
| 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 |
$0.06
|
| Rate for Payer: Self Pay Self Pay |
$0.06
|
|
|
Sodium Chloride 0.9% IV Sol 100 mL IVPB [CQCH]
|
Facility
|
OP
|
$0.05
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
105953385
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Aetna of AZ Commercial |
$0.05
|
| Rate for Payer: Aetna of AZ Medicare |
$0.01
|
| Rate for Payer: AHCCCS Medicaid |
$2.50
|
| Rate for Payer: Allwell Medicaid |
$2.50
|
| 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 Medicaid |
$2.50
|
| Rate for Payer: AZCH Complete Medicare |
$0.01
|
| Rate for Payer: Banner UC Health Medicaid |
$2.50
|
| Rate for Payer: Banner UC Health Medicare |
$0.01
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of AZ Commercial |
$0.03
|
| Rate for Payer: Copperpoint Commercial |
$0.01
|
| Rate for Payer: Health Net of AZ Commercial |
$0.03
|
| Rate for Payer: Health Net of AZ Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Mercy Care Medicaid |
$2.50
|
| Rate for Payer: Self Pay Self Pay |
$0.04
|
| 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
|
|
|
Sodium Chloride 0.9% IV Sol 100 mL IVPB [CQCH]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
105953385
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of AZ Commercial |
$0.05
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Self Pay Self Pay |
$0.04
|
|
|
Sodium Chloride 0.9% IV Sol 250 mL IVPB [CQCH]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
105953498
|
|
Hospital Revenue Code
|
250
|
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Aetna of AZ Commercial |
$0.02
|
| Rate for Payer: Aetna of AZ Medicare |
$0.01
|
| Rate for Payer: AHCCCS Medicaid |
$2.50
|
| Rate for Payer: Allwell Medicaid |
$2.50
|
| 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 Medicaid |
$2.50
|
| Rate for Payer: AZCH Complete Medicare |
$0.00
|
| Rate for Payer: Banner UC Health Medicaid |
$2.50
|
| 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 |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| 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: Mercy Care Medicaid |
$2.50
|
| 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
|
|
|
Sodium Chloride 0.9% IV Sol 250 mL IVPB [CQCH]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
105953498
|
|
Hospital Revenue Code
|
250
|
| 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 |
$0.02
|
| Rate for Payer: Self Pay Self Pay |
$0.02
|
|
|
Sodium Chloride 0.9% Sol 1000 mL [CQCH]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
108127272
|
|
Hospital Revenue Code
|
258
|
| 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: Self Pay Self Pay |
$0.01
|
|
|
Sodium Chloride 0.9% Sol 1000 mL [CQCH]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
108127272
|
|
Hospital Revenue Code
|
258
|
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Aetna of AZ Commercial |
$0.01
|
| Rate for Payer: Aetna of AZ Medicare |
$0.00
|
| Rate for Payer: AHCCCS Medicaid |
$2.50
|
| Rate for Payer: Allwell Medicaid |
$2.50
|
| 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 Medicaid |
$2.50
|
| Rate for Payer: AZCH Complete Medicare |
$0.00
|
| Rate for Payer: Banner UC Health Medicaid |
$2.50
|
| 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: 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: Mercy Care Medicaid |
$2.50
|
| 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
|
|
|
Sodium Chloride 0.9% Sol 500 mL [CQCH]
|
Facility
|
OP
|
$0.01
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
108127424
|
|
Hospital Revenue Code
|
258
|
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Aetna of AZ Commercial |
$0.01
|
| Rate for Payer: Aetna of AZ Medicare |
$0.00
|
| Rate for Payer: AHCCCS Medicaid |
$2.50
|
| Rate for Payer: Allwell Medicaid |
$2.50
|
| 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 Medicaid |
$2.50
|
| Rate for Payer: AZCH Complete Medicare |
$0.00
|
| Rate for Payer: Banner UC Health Medicaid |
$2.50
|
| 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: 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: Mercy Care Medicaid |
$2.50
|
| 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
|
|
|
Sodium Chloride 0.9% Sol 500 mL [CQCH]
|
Facility
|
IP
|
$0.01
|
|
|
Service Code
|
HCPCS J7040
|
| Hospital Charge Code |
108127424
|
|
Hospital Revenue Code
|
258
|
| 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
|
|
|
sodium chloride 1000 mg tab [CQCH]
|
Facility
|
IP
|
$0.06
|
|
|
Service Code
|
NDC 223176001
|
| Hospital Charge Code |
105941113
|
|
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 |
$0.05
|
| Rate for Payer: Self Pay Self Pay |
$0.05
|
|
|
sodium chloride 1000 mg tab [CQCH]
|
Facility
|
OP
|
$0.06
|
|
|
Service Code
|
NDC 223176001
|
| Hospital Charge Code |
105941113
|
|
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 |
$0.05
|
| 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
|
|
