|
sodium chloride 23.4% IV Sol 30 mL [CQCH]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
HCPCS J7131
|
| Hospital Charge Code |
105941968
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of AZ Commercial |
$0.08
|
| Rate for Payer: Aetna of AZ Medicare |
$0.03
|
| Rate for Payer: AHCCCS Medicaid |
$0.84
|
| Rate for Payer: Allwell Medicaid |
$0.84
|
| 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 |
$0.84
|
| Rate for Payer: AZCH Complete Medicare |
$0.01
|
| Rate for Payer: Banner UC Health Medicaid |
$0.84
|
| 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 |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of AZ Commercial |
$0.06
|
| 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 |
$0.03
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Mercy Care Medicaid |
$0.84
|
| Rate for Payer: Self Pay Self Pay |
$0.07
|
| 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 |
$0.02
|
|
|
sodium chloride 23.4% IV Sol 30 mL [CQCH]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
HCPCS J7131
|
| Hospital Charge Code |
105941968
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of AZ Commercial |
$0.08
|
| Rate for Payer: Bisbee Police All Plans |
$0.02
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Self Pay Self Pay |
$0.07
|
|
|
Sodium Chloride 3% IV Sol (Hypertonic saline) 500 mL [CQCH]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 63323053075
|
| Hospital Charge Code |
112802150
|
|
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 |
$0.06
|
| Rate for Payer: Self Pay Self Pay |
$0.06
|
|
|
Sodium Chloride 3% IV Sol (Hypertonic saline) 500 mL [CQCH]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 63323053075
|
| Hospital Charge Code |
112802150
|
|
Hospital Revenue Code
|
250
|
| 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 nasal 0.65% Gel [CQCH]
|
Facility
|
OP
|
$2.39
|
|
|
Service Code
|
NDC 225052547
|
| Hospital Charge Code |
105942100
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Aetna of AZ Commercial |
$2.15
|
| Rate for Payer: Aetna of AZ Medicare |
$0.67
|
| Rate for Payer: Allwell Medicare |
$0.36
|
| Rate for Payer: Amerigroup Medicare |
$0.36
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.89
|
| Rate for Payer: AZCH Complete Medicare |
$0.36
|
| Rate for Payer: Banner UC Health Medicare |
$0.36
|
| Rate for Payer: Bisbee Police All Plans |
$0.62
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.63
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cigna of AZ Commercial |
$1.55
|
| Rate for Payer: Copperpoint Commercial |
$0.59
|
| Rate for Payer: Health Net of AZ Commercial |
$1.43
|
| Rate for Payer: Health Net of AZ Medicare |
$0.67
|
| Rate for Payer: Humana of AZ Medicare |
$0.36
|
| Rate for Payer: Self Pay Self Pay |
$1.91
|
| Rate for Payer: TriWest Medicare |
$0.36
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1.39
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.43
|
|
|
sodium chloride nasal 0.65% Gel [CQCH]
|
Facility
|
IP
|
$2.39
|
|
|
Service Code
|
NDC 225052547
|
| Hospital Charge Code |
105942100
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Aetna of AZ Commercial |
$2.15
|
| Rate for Payer: Bisbee Police All Plans |
$0.62
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Self Pay Self Pay |
$1.91
|
|
|
sodium hyaluronate 10 mg/mL Sol[CQCH]
|
Facility
|
OP
|
$86.89
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
205916563
|
| Min. Negotiated Rate |
$13.03 |
| Max. Negotiated Rate |
$149.50 |
| Rate for Payer: Aetna of AZ Commercial |
$78.20
|
| Rate for Payer: Aetna of AZ Medicare |
$24.33
|
| Rate for Payer: AHCCCS Medicaid |
$149.50
|
| Rate for Payer: Allwell Medicaid |
$149.50
|
| Rate for Payer: Allwell Medicare |
$13.03
|
| Rate for Payer: Amerigroup Medicare |
$13.03
|
| Rate for Payer: APIPA Medicare/Medicaid |
$32.45
|
| Rate for Payer: AZCH Complete Medicaid |
$149.50
|
| Rate for Payer: AZCH Complete Medicare |
$13.03
|
| Rate for Payer: Banner UC Health Medicaid |
$149.50
|
| Rate for Payer: Banner UC Health Medicare |
$13.03
|
| Rate for Payer: Bisbee Police All Plans |
$22.59
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$59.09
|
| Rate for Payer: Cash Price |
$69.51
|
| Rate for Payer: Cash Price |
$69.51
|
| Rate for Payer: Cigna of AZ Commercial |
$60.82
|
| Rate for Payer: Copperpoint Commercial |
$21.51
|
| Rate for Payer: Health Net of AZ Commercial |
$52.13
|
| Rate for Payer: Health Net of AZ Medicare |
$24.33
|
| Rate for Payer: Humana of AZ Medicare |
$13.03
|
| Rate for Payer: Mercy Care Medicaid |
$149.50
|
| Rate for Payer: Self Pay Self Pay |
$69.51
|
| Rate for Payer: TriWest Medicare |
$13.03
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$50.66
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$15.64
|
|
|
sodium hyaluronate 10 mg/mL Sol[CQCH]
|
Facility
|
IP
|
$86.89
|
|
|
Service Code
|
HCPCS J7321
|
| Hospital Charge Code |
205916563
|
| Min. Negotiated Rate |
$22.59 |
| Max. Negotiated Rate |
$78.20 |
| Rate for Payer: Aetna of AZ Commercial |
$78.20
|
| Rate for Payer: Bisbee Police All Plans |
$22.59
|
| Rate for Payer: Cash Price |
$69.51
|
| Rate for Payer: Self Pay Self Pay |
$69.51
|
|
|
Sodium Level
|
Facility
|
OP
|
$69.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
633611
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$62.10 |
| Rate for Payer: Aetna of AZ Commercial |
$62.10
|
| Rate for Payer: Aetna of AZ Medicare |
$19.32
|
| Rate for Payer: AHCCCS Medicaid |
$4.81
|
| Rate for Payer: Allwell Medicaid |
$4.81
|
| Rate for Payer: Allwell Medicare |
$10.35
|
| Rate for Payer: Amerigroup Medicare |
$10.35
|
| Rate for Payer: APIPA Medicare/Medicaid |
$25.77
|
| Rate for Payer: AZCH Complete Medicaid |
$4.81
|
| Rate for Payer: AZCH Complete Medicare |
$10.35
|
| Rate for Payer: Banner UC Health Medicaid |
$4.81
|
| Rate for Payer: Banner UC Health Medicare |
$10.35
|
| Rate for Payer: Bisbee Police All Plans |
$17.94
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$46.92
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cigna of AZ Commercial |
$44.85
|
| Rate for Payer: Copperpoint Commercial |
$17.08
|
| Rate for Payer: Health Net of AZ Commercial |
$41.40
|
| Rate for Payer: Health Net of AZ Medicare |
$19.32
|
| Rate for Payer: Humana of AZ Medicare |
$10.35
|
| Rate for Payer: Mercy Care Medicaid |
$4.81
|
| Rate for Payer: Self Pay Self Pay |
$55.20
|
| Rate for Payer: TriWest Medicare |
$10.35
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$40.23
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$12.42
|
|
|
Sodium Level
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
CPT 84295
|
| Hospital Charge Code |
633611
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.94 |
| Max. Negotiated Rate |
$62.10 |
| Rate for Payer: Aetna of AZ Commercial |
$62.10
|
| Rate for Payer: Bisbee Police All Plans |
$17.94
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Self Pay Self Pay |
$55.20
|
|
|
Sodium Level 24 Hour Urine
|
Facility
|
OP
|
$88.00
|
|
|
Service Code
|
CPT 84300
|
| Hospital Charge Code |
633613
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.06 |
| Max. Negotiated Rate |
$79.20 |
| Rate for Payer: Aetna of AZ Commercial |
$79.20
|
| Rate for Payer: Aetna of AZ Medicare |
$24.64
|
| Rate for Payer: AHCCCS Medicaid |
$5.06
|
| Rate for Payer: Allwell Medicaid |
$5.06
|
| Rate for Payer: Allwell Medicare |
$13.20
|
| Rate for Payer: Amerigroup Medicare |
$13.20
|
| Rate for Payer: APIPA Medicare/Medicaid |
$32.87
|
| Rate for Payer: AZCH Complete Medicaid |
$5.06
|
| Rate for Payer: AZCH Complete Medicare |
$13.20
|
| Rate for Payer: Banner UC Health Medicaid |
$5.06
|
| Rate for Payer: Banner UC Health Medicare |
$13.20
|
| Rate for Payer: Bisbee Police All Plans |
$22.88
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$59.84
|
| Rate for Payer: Cash Price |
$70.40
|
| Rate for Payer: Cash Price |
$70.40
|
| Rate for Payer: Cigna of AZ Commercial |
$57.20
|
| Rate for Payer: Copperpoint Commercial |
$21.78
|
| Rate for Payer: Health Net of AZ Commercial |
$52.80
|
| Rate for Payer: Health Net of AZ Medicare |
$24.64
|
| Rate for Payer: Humana of AZ Medicare |
$13.20
|
| Rate for Payer: Mercy Care Medicaid |
$5.06
|
| Rate for Payer: Self Pay Self Pay |
$70.40
|
| Rate for Payer: TriWest Medicare |
$13.20
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$51.30
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$15.84
|
|
|
Sodium Level 24 Hour Urine
|
Facility
|
IP
|
$88.00
|
|
|
Service Code
|
CPT 84300
|
| Hospital Charge Code |
633613
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$22.88 |
| Max. Negotiated Rate |
$79.20 |
| Rate for Payer: Aetna of AZ Commercial |
$79.20
|
| Rate for Payer: Bisbee Police All Plans |
$22.88
|
| Rate for Payer: Cash Price |
$70.40
|
| Rate for Payer: Self Pay Self Pay |
$70.40
|
|
|
Sodium Level Urine
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
CPT 84300
|
| Hospital Charge Code |
887730
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.92 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna of AZ Commercial |
$82.80
|
| Rate for Payer: Bisbee Police All Plans |
$23.92
|
| Rate for Payer: Cash Price |
$73.60
|
| Rate for Payer: Self Pay Self Pay |
$73.60
|
|
|
Sodium Level Urine
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
CPT 84300
|
| Hospital Charge Code |
887730
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.06 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna of AZ Commercial |
$82.80
|
| Rate for Payer: Aetna of AZ Medicare |
$25.76
|
| Rate for Payer: AHCCCS Medicaid |
$5.06
|
| Rate for Payer: Allwell Medicaid |
$5.06
|
| Rate for Payer: Allwell Medicare |
$13.80
|
| Rate for Payer: Amerigroup Medicare |
$13.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$34.36
|
| Rate for Payer: AZCH Complete Medicaid |
$5.06
|
| Rate for Payer: AZCH Complete Medicare |
$13.80
|
| Rate for Payer: Banner UC Health Medicaid |
$5.06
|
| Rate for Payer: Banner UC Health Medicare |
$13.80
|
| Rate for Payer: Bisbee Police All Plans |
$23.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$62.56
|
| Rate for Payer: Cash Price |
$73.60
|
| Rate for Payer: Cash Price |
$73.60
|
| Rate for Payer: Cigna of AZ Commercial |
$59.80
|
| Rate for Payer: Copperpoint Commercial |
$22.77
|
| Rate for Payer: Health Net of AZ Commercial |
$55.20
|
| Rate for Payer: Health Net of AZ Medicare |
$25.76
|
| Rate for Payer: Humana of AZ Medicare |
$13.80
|
| Rate for Payer: Mercy Care Medicaid |
$5.06
|
| Rate for Payer: Self Pay Self Pay |
$73.60
|
| Rate for Payer: TriWest Medicare |
$13.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$53.64
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$16.56
|
|
|
sodium polystyrene sulfonate - Pow[CQCH]
|
Facility
|
IP
|
$0.78
|
|
|
Service Code
|
NDC 11534016615
|
| Hospital Charge Code |
143761878
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Aetna of AZ Commercial |
$0.70
|
| Rate for Payer: Bisbee Police All Plans |
$0.20
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Self Pay Self Pay |
$0.62
|
|
|
sodium polystyrene sulfonate - Pow[CQCH]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 11534016615
|
| Hospital Charge Code |
143761878
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Aetna of AZ Commercial |
$0.70
|
| Rate for Payer: Aetna of AZ Medicare |
$0.22
|
| Rate for Payer: Allwell Medicare |
$0.12
|
| Rate for Payer: Amerigroup Medicare |
$0.12
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.29
|
| Rate for Payer: AZCH Complete Medicare |
$0.12
|
| Rate for Payer: Banner UC Health Medicare |
$0.12
|
| Rate for Payer: Bisbee Police All Plans |
$0.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.53
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna of AZ Commercial |
$0.51
|
| Rate for Payer: Copperpoint Commercial |
$0.19
|
| Rate for Payer: Health Net of AZ Commercial |
$0.47
|
| Rate for Payer: Health Net of AZ Medicare |
$0.22
|
| Rate for Payer: Humana of AZ Medicare |
$0.12
|
| Rate for Payer: Self Pay Self Pay |
$0.62
|
| Rate for Payer: TriWest Medicare |
$0.12
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.45
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.14
|
|
|
SOLIDIFIER ISOSORB 3000
|
Facility
|
IP
|
$24.00
|
|
| Hospital Charge Code |
22354547
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$21.60 |
| Rate for Payer: Aetna of AZ Commercial |
$21.60
|
| Rate for Payer: Bisbee Police All Plans |
$6.24
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Self Pay Self Pay |
$19.20
|
|
|
SOLIDIFIER ISOSORB 3000
|
Facility
|
OP
|
$24.00
|
|
| Hospital Charge Code |
22354547
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3.60 |
| Max. Negotiated Rate |
$21.60 |
| Rate for Payer: Aetna of AZ Commercial |
$21.60
|
| Rate for Payer: Aetna of AZ Medicare |
$6.72
|
| Rate for Payer: Allwell Medicare |
$3.60
|
| Rate for Payer: Amerigroup Medicare |
$3.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$8.96
|
| Rate for Payer: AZCH Complete Medicare |
$3.60
|
| Rate for Payer: Banner UC Health Medicare |
$3.60
|
| Rate for Payer: Bisbee Police All Plans |
$6.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$16.32
|
| Rate for Payer: Cash Price |
$19.20
|
| Rate for Payer: Cigna of AZ Commercial |
$16.80
|
| Rate for Payer: Copperpoint Commercial |
$5.94
|
| Rate for Payer: Health Net of AZ Commercial |
$14.40
|
| Rate for Payer: Health Net of AZ Medicare |
$6.72
|
| Rate for Payer: Humana of AZ Medicare |
$3.60
|
| Rate for Payer: Self Pay Self Pay |
$19.20
|
| Rate for Payer: TriWest Medicare |
$3.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$13.99
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$4.32
|
|
|
SOL IRRG D/W 500 BOTTLE
|
Facility
|
IP
|
$30.00
|
|
| Hospital Charge Code |
22355366
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Aetna of AZ Commercial |
$27.00
|
| Rate for Payer: Bisbee Police All Plans |
$7.80
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Self Pay Self Pay |
$24.00
|
|
|
SOL IRRG D/W 500 BOTTLE
|
Facility
|
OP
|
$30.00
|
|
| Hospital Charge Code |
22355366
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Aetna of AZ Commercial |
$27.00
|
| Rate for Payer: Aetna of AZ Medicare |
$8.40
|
| Rate for Payer: Allwell Medicare |
$4.50
|
| Rate for Payer: Amerigroup Medicare |
$4.50
|
| Rate for Payer: APIPA Medicare/Medicaid |
$11.20
|
| Rate for Payer: AZCH Complete Medicare |
$4.50
|
| Rate for Payer: Banner UC Health Medicare |
$4.50
|
| Rate for Payer: Bisbee Police All Plans |
$7.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$20.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna of AZ Commercial |
$21.00
|
| Rate for Payer: Copperpoint Commercial |
$7.42
|
| Rate for Payer: Health Net of AZ Commercial |
$18.00
|
| Rate for Payer: Health Net of AZ Medicare |
$8.40
|
| Rate for Payer: Humana of AZ Medicare |
$4.50
|
| Rate for Payer: Self Pay Self Pay |
$24.00
|
| Rate for Payer: TriWest Medicare |
$4.50
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$17.49
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$5.40
|
|
|
SOL IRRIG 1000ML DW
|
Facility
|
OP
|
$32.00
|
|
| Hospital Charge Code |
24154073
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$28.80 |
| Rate for Payer: Aetna of AZ Commercial |
$28.80
|
| Rate for Payer: Aetna of AZ Medicare |
$8.96
|
| Rate for Payer: Allwell Medicare |
$4.80
|
| Rate for Payer: Amerigroup Medicare |
$4.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$11.95
|
| Rate for Payer: AZCH Complete Medicare |
$4.80
|
| Rate for Payer: Banner UC Health Medicare |
$4.80
|
| Rate for Payer: Bisbee Police All Plans |
$8.32
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$21.76
|
| Rate for Payer: Cash Price |
$25.60
|
| Rate for Payer: Cigna of AZ Commercial |
$22.40
|
| Rate for Payer: Copperpoint Commercial |
$7.92
|
| Rate for Payer: Health Net of AZ Commercial |
$19.20
|
| Rate for Payer: Health Net of AZ Medicare |
$8.96
|
| Rate for Payer: Humana of AZ Medicare |
$4.80
|
| Rate for Payer: Self Pay Self Pay |
$25.60
|
| Rate for Payer: TriWest Medicare |
$4.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$18.66
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$5.76
|
|
|
SOL IRRIG 1000ML DW
|
Facility
|
IP
|
$32.00
|
|
| Hospital Charge Code |
24154073
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$8.32 |
| Max. Negotiated Rate |
$28.80 |
| Rate for Payer: Aetna of AZ Commercial |
$28.80
|
| Rate for Payer: Bisbee Police All Plans |
$8.32
|
| Rate for Payer: Cash Price |
$25.60
|
| Rate for Payer: Self Pay Self Pay |
$25.60
|
|
|
SOL IRRIG 3000ML DW
|
Facility
|
IP
|
$72.00
|
|
| Hospital Charge Code |
24153497
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$18.72 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Aetna of AZ Commercial |
$64.80
|
| Rate for Payer: Bisbee Police All Plans |
$18.72
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Self Pay Self Pay |
$57.60
|
|
|
SOL IRRIG 3000ML DW
|
Facility
|
OP
|
$72.00
|
|
| Hospital Charge Code |
24153497
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.80 |
| Max. Negotiated Rate |
$64.80 |
| Rate for Payer: Aetna of AZ Commercial |
$64.80
|
| Rate for Payer: Aetna of AZ Medicare |
$20.16
|
| Rate for Payer: Allwell Medicare |
$10.80
|
| Rate for Payer: Amerigroup Medicare |
$10.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$26.89
|
| Rate for Payer: AZCH Complete Medicare |
$10.80
|
| Rate for Payer: Banner UC Health Medicare |
$10.80
|
| Rate for Payer: Bisbee Police All Plans |
$18.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$48.96
|
| Rate for Payer: Cash Price |
$57.60
|
| Rate for Payer: Cigna of AZ Commercial |
$50.40
|
| Rate for Payer: Copperpoint Commercial |
$17.82
|
| Rate for Payer: Health Net of AZ Commercial |
$43.20
|
| Rate for Payer: Health Net of AZ Medicare |
$20.16
|
| Rate for Payer: Humana of AZ Medicare |
$10.80
|
| Rate for Payer: Self Pay Self Pay |
$57.60
|
| Rate for Payer: TriWest Medicare |
$10.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$41.98
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$12.96
|
|
|
SOL IRRIG N/S 1000 BOTTLE
|
Facility
|
OP
|
$30.00
|
|
| Hospital Charge Code |
22355109
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$27.00 |
| Rate for Payer: Aetna of AZ Commercial |
$27.00
|
| Rate for Payer: Aetna of AZ Medicare |
$8.40
|
| Rate for Payer: Allwell Medicare |
$4.50
|
| Rate for Payer: Amerigroup Medicare |
$4.50
|
| Rate for Payer: APIPA Medicare/Medicaid |
$11.20
|
| Rate for Payer: AZCH Complete Medicare |
$4.50
|
| Rate for Payer: Banner UC Health Medicare |
$4.50
|
| Rate for Payer: Bisbee Police All Plans |
$7.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$20.40
|
| Rate for Payer: Cash Price |
$24.00
|
| Rate for Payer: Cigna of AZ Commercial |
$21.00
|
| Rate for Payer: Copperpoint Commercial |
$7.42
|
| Rate for Payer: Health Net of AZ Commercial |
$18.00
|
| Rate for Payer: Health Net of AZ Medicare |
$8.40
|
| Rate for Payer: Humana of AZ Medicare |
$4.50
|
| Rate for Payer: Self Pay Self Pay |
$24.00
|
| Rate for Payer: TriWest Medicare |
$4.50
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$17.49
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$5.40
|
|
