|
Thawed Plasma CPDA1
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
CPT P9017
|
| Hospital Charge Code |
22316428
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$26.55 |
| Max. Negotiated Rate |
$159.30 |
| Rate for Payer: Aetna of AZ Commercial |
$159.30
|
| Rate for Payer: Aetna of AZ Medicare |
$49.56
|
| Rate for Payer: AHCCCS Medicaid |
$119.86
|
| Rate for Payer: Allwell Medicaid |
$119.86
|
| Rate for Payer: Allwell Medicare |
$26.55
|
| Rate for Payer: Amerigroup Medicare |
$26.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$66.11
|
| Rate for Payer: AZCH Complete Medicaid |
$119.86
|
| Rate for Payer: AZCH Complete Medicare |
$26.55
|
| Rate for Payer: Banner UC Health Medicaid |
$119.86
|
| Rate for Payer: Banner UC Health Medicare |
$26.55
|
| Rate for Payer: Bisbee Police All Plans |
$46.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$120.36
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cigna of AZ Commercial |
$115.05
|
| Rate for Payer: Copperpoint Commercial |
$43.81
|
| Rate for Payer: Health Net of AZ Commercial |
$106.20
|
| Rate for Payer: Health Net of AZ Medicare |
$49.56
|
| Rate for Payer: Humana of AZ Medicare |
$26.55
|
| Rate for Payer: Mercy Care Medicaid |
$119.86
|
| Rate for Payer: Self Pay Self Pay |
$141.60
|
| Rate for Payer: TriWest Medicare |
$26.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$103.19
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$31.86
|
|
|
Thawed Plasma CPDA1
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
CPT P9017
|
| Hospital Charge Code |
22316428
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$46.02 |
| Max. Negotiated Rate |
$159.30 |
| Rate for Payer: Aetna of AZ Commercial |
$159.30
|
| Rate for Payer: Bisbee Police All Plans |
$46.02
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Self Pay Self Pay |
$141.60
|
|
|
Thawed Plasma CPDA1 Irr
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
CPT P9017
|
| Hospital Charge Code |
22316426
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$26.55 |
| Max. Negotiated Rate |
$159.30 |
| Rate for Payer: Aetna of AZ Commercial |
$159.30
|
| Rate for Payer: Aetna of AZ Medicare |
$49.56
|
| Rate for Payer: AHCCCS Medicaid |
$119.86
|
| Rate for Payer: Allwell Medicaid |
$119.86
|
| Rate for Payer: Allwell Medicare |
$26.55
|
| Rate for Payer: Amerigroup Medicare |
$26.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$66.11
|
| Rate for Payer: AZCH Complete Medicaid |
$119.86
|
| Rate for Payer: AZCH Complete Medicare |
$26.55
|
| Rate for Payer: Banner UC Health Medicaid |
$119.86
|
| Rate for Payer: Banner UC Health Medicare |
$26.55
|
| Rate for Payer: Bisbee Police All Plans |
$46.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$120.36
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cigna of AZ Commercial |
$115.05
|
| Rate for Payer: Copperpoint Commercial |
$43.81
|
| Rate for Payer: Health Net of AZ Commercial |
$106.20
|
| Rate for Payer: Health Net of AZ Medicare |
$49.56
|
| Rate for Payer: Humana of AZ Medicare |
$26.55
|
| Rate for Payer: Mercy Care Medicaid |
$119.86
|
| Rate for Payer: Self Pay Self Pay |
$141.60
|
| Rate for Payer: TriWest Medicare |
$26.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$103.19
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$31.86
|
|
|
Thawed Plasma CPDA1 Irr
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
CPT P9017
|
| Hospital Charge Code |
22316426
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$46.02 |
| Max. Negotiated Rate |
$159.30 |
| Rate for Payer: Aetna of AZ Commercial |
$159.30
|
| Rate for Payer: Bisbee Police All Plans |
$46.02
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Self Pay Self Pay |
$141.60
|
|
|
Thawed Plasma CPD Irr
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
CPT P9017
|
| Hospital Charge Code |
22316431
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$46.02 |
| Max. Negotiated Rate |
$159.30 |
| Rate for Payer: Aetna of AZ Commercial |
$159.30
|
| Rate for Payer: Bisbee Police All Plans |
$46.02
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Self Pay Self Pay |
$141.60
|
|
|
Thawed Plasma CPD Irr
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
CPT P9017
|
| Hospital Charge Code |
22316431
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$26.55 |
| Max. Negotiated Rate |
$159.30 |
| Rate for Payer: Aetna of AZ Commercial |
$159.30
|
| Rate for Payer: Aetna of AZ Medicare |
$49.56
|
| Rate for Payer: AHCCCS Medicaid |
$119.86
|
| Rate for Payer: Allwell Medicaid |
$119.86
|
| Rate for Payer: Allwell Medicare |
$26.55
|
| Rate for Payer: Amerigroup Medicare |
$26.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$66.11
|
| Rate for Payer: AZCH Complete Medicaid |
$119.86
|
| Rate for Payer: AZCH Complete Medicare |
$26.55
|
| Rate for Payer: Banner UC Health Medicaid |
$119.86
|
| Rate for Payer: Banner UC Health Medicare |
$26.55
|
| Rate for Payer: Bisbee Police All Plans |
$46.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$120.36
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cigna of AZ Commercial |
$115.05
|
| Rate for Payer: Copperpoint Commercial |
$43.81
|
| Rate for Payer: Health Net of AZ Commercial |
$106.20
|
| Rate for Payer: Health Net of AZ Medicare |
$49.56
|
| Rate for Payer: Humana of AZ Medicare |
$26.55
|
| Rate for Payer: Mercy Care Medicaid |
$119.86
|
| Rate for Payer: Self Pay Self Pay |
$141.60
|
| Rate for Payer: TriWest Medicare |
$26.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$103.19
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$31.86
|
|
|
Thawed Plasma NaCitrate Irr <= 24h
|
Facility
|
IP
|
$177.00
|
|
|
Service Code
|
CPT P9017
|
| Hospital Charge Code |
22316429
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$46.02 |
| Max. Negotiated Rate |
$159.30 |
| Rate for Payer: Aetna of AZ Commercial |
$159.30
|
| Rate for Payer: Bisbee Police All Plans |
$46.02
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Self Pay Self Pay |
$141.60
|
|
|
Thawed Plasma NaCitrate Irr <= 24h
|
Facility
|
OP
|
$177.00
|
|
|
Service Code
|
CPT P9017
|
| Hospital Charge Code |
22316429
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$26.55 |
| Max. Negotiated Rate |
$159.30 |
| Rate for Payer: Aetna of AZ Commercial |
$159.30
|
| Rate for Payer: Aetna of AZ Medicare |
$49.56
|
| Rate for Payer: AHCCCS Medicaid |
$119.86
|
| Rate for Payer: Allwell Medicaid |
$119.86
|
| Rate for Payer: Allwell Medicare |
$26.55
|
| Rate for Payer: Amerigroup Medicare |
$26.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$66.11
|
| Rate for Payer: AZCH Complete Medicaid |
$119.86
|
| Rate for Payer: AZCH Complete Medicare |
$26.55
|
| Rate for Payer: Banner UC Health Medicaid |
$119.86
|
| Rate for Payer: Banner UC Health Medicare |
$26.55
|
| Rate for Payer: Bisbee Police All Plans |
$46.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$120.36
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cash Price |
$141.60
|
| Rate for Payer: Cigna of AZ Commercial |
$115.05
|
| Rate for Payer: Copperpoint Commercial |
$43.81
|
| Rate for Payer: Health Net of AZ Commercial |
$106.20
|
| Rate for Payer: Health Net of AZ Medicare |
$49.56
|
| Rate for Payer: Humana of AZ Medicare |
$26.55
|
| Rate for Payer: Mercy Care Medicaid |
$119.86
|
| Rate for Payer: Self Pay Self Pay |
$141.60
|
| Rate for Payer: TriWest Medicare |
$26.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$103.19
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$31.86
|
|
|
Thawed Pooled Cryo
|
Facility
|
IP
|
$480.00
|
|
|
Service Code
|
CPT P9044
|
| Hospital Charge Code |
22316447
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$124.80 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna of AZ Commercial |
$432.00
|
| Rate for Payer: Bisbee Police All Plans |
$124.80
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Self Pay Self Pay |
$384.00
|
|
|
Thawed Pooled Cryo
|
Facility
|
OP
|
$480.00
|
|
|
Service Code
|
CPT P9044
|
| Hospital Charge Code |
22316447
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$72.00 |
| Max. Negotiated Rate |
$432.00 |
| Rate for Payer: Aetna of AZ Commercial |
$432.00
|
| Rate for Payer: Aetna of AZ Medicare |
$134.40
|
| Rate for Payer: AHCCCS Medicaid |
$95.26
|
| Rate for Payer: Allwell Medicaid |
$95.26
|
| Rate for Payer: Allwell Medicare |
$72.00
|
| Rate for Payer: Amerigroup Medicare |
$72.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$179.28
|
| Rate for Payer: AZCH Complete Medicaid |
$95.26
|
| Rate for Payer: AZCH Complete Medicare |
$72.00
|
| Rate for Payer: Banner UC Health Medicaid |
$95.26
|
| Rate for Payer: Banner UC Health Medicare |
$72.00
|
| Rate for Payer: Bisbee Police All Plans |
$124.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$326.40
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cash Price |
$384.00
|
| Rate for Payer: Cigna of AZ Commercial |
$312.00
|
| Rate for Payer: Copperpoint Commercial |
$118.80
|
| Rate for Payer: Health Net of AZ Commercial |
$288.00
|
| Rate for Payer: Health Net of AZ Medicare |
$134.40
|
| Rate for Payer: Humana of AZ Medicare |
$72.00
|
| Rate for Payer: Mercy Care Medicaid |
$95.26
|
| Rate for Payer: Self Pay Self Pay |
$384.00
|
| Rate for Payer: TriWest Medicare |
$72.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$279.84
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$86.40
|
|
|
THEOPHYLLINE
|
Facility
|
IP
|
$165.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
23603248
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$42.90 |
| Max. Negotiated Rate |
$148.50 |
| Rate for Payer: Aetna of AZ Commercial |
$148.50
|
| Rate for Payer: Bisbee Police All Plans |
$42.90
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Self Pay Self Pay |
$132.00
|
|
|
THEOPHYLLINE
|
Facility
|
OP
|
$165.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
23603248
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.14 |
| Max. Negotiated Rate |
$148.50 |
| Rate for Payer: Aetna of AZ Commercial |
$148.50
|
| Rate for Payer: Aetna of AZ Medicare |
$46.20
|
| Rate for Payer: AHCCCS Medicaid |
$14.14
|
| Rate for Payer: Allwell Medicaid |
$14.14
|
| Rate for Payer: Allwell Medicare |
$24.75
|
| Rate for Payer: Amerigroup Medicare |
$24.75
|
| Rate for Payer: APIPA Medicare/Medicaid |
$61.63
|
| Rate for Payer: AZCH Complete Medicaid |
$14.14
|
| Rate for Payer: AZCH Complete Medicare |
$24.75
|
| Rate for Payer: Banner UC Health Medicaid |
$14.14
|
| Rate for Payer: Banner UC Health Medicare |
$24.75
|
| Rate for Payer: Bisbee Police All Plans |
$42.90
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$112.20
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cash Price |
$132.00
|
| Rate for Payer: Cigna of AZ Commercial |
$107.25
|
| Rate for Payer: Copperpoint Commercial |
$40.84
|
| Rate for Payer: Health Net of AZ Commercial |
$99.00
|
| Rate for Payer: Health Net of AZ Medicare |
$46.20
|
| Rate for Payer: Humana of AZ Medicare |
$24.75
|
| Rate for Payer: Mercy Care Medicaid |
$14.14
|
| Rate for Payer: Self Pay Self Pay |
$132.00
|
| Rate for Payer: TriWest Medicare |
$24.75
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$96.20
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$29.70
|
|
|
Theophylline, Serum LC
|
Facility
|
IP
|
$173.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
1285596
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$155.70 |
| Rate for Payer: Aetna of AZ Commercial |
$155.70
|
| Rate for Payer: Bisbee Police All Plans |
$44.98
|
| Rate for Payer: Cash Price |
$138.40
|
| Rate for Payer: Self Pay Self Pay |
$138.40
|
|
|
Theophylline, Serum LC
|
Facility
|
OP
|
$173.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
1285596
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.14 |
| Max. Negotiated Rate |
$155.70 |
| Rate for Payer: Aetna of AZ Commercial |
$155.70
|
| Rate for Payer: Aetna of AZ Medicare |
$48.44
|
| Rate for Payer: AHCCCS Medicaid |
$14.14
|
| Rate for Payer: Allwell Medicaid |
$14.14
|
| Rate for Payer: Allwell Medicare |
$25.95
|
| Rate for Payer: Amerigroup Medicare |
$25.95
|
| Rate for Payer: APIPA Medicare/Medicaid |
$64.62
|
| Rate for Payer: AZCH Complete Medicaid |
$14.14
|
| Rate for Payer: AZCH Complete Medicare |
$25.95
|
| Rate for Payer: Banner UC Health Medicaid |
$14.14
|
| Rate for Payer: Banner UC Health Medicare |
$25.95
|
| Rate for Payer: Bisbee Police All Plans |
$44.98
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$117.64
|
| Rate for Payer: Cash Price |
$138.40
|
| Rate for Payer: Cash Price |
$138.40
|
| Rate for Payer: Cigna of AZ Commercial |
$112.45
|
| Rate for Payer: Copperpoint Commercial |
$42.82
|
| Rate for Payer: Health Net of AZ Commercial |
$103.80
|
| Rate for Payer: Health Net of AZ Medicare |
$48.44
|
| Rate for Payer: Humana of AZ Medicare |
$25.95
|
| Rate for Payer: Mercy Care Medicaid |
$14.14
|
| Rate for Payer: Self Pay Self Pay |
$138.40
|
| Rate for Payer: TriWest Medicare |
$25.95
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$100.86
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$31.14
|
|
|
Therapeutic Activities Charges
|
Facility
|
IP
|
$181.00
|
|
|
Service Code
|
CPT 97530 GP
|
| Hospital Charge Code |
692245
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$47.06 |
| Max. Negotiated Rate |
$162.90 |
| Rate for Payer: Aetna of AZ Commercial |
$162.90
|
| Rate for Payer: Bisbee Police All Plans |
$47.06
|
| Rate for Payer: Cash Price |
$144.80
|
| Rate for Payer: Self Pay Self Pay |
$144.80
|
|
|
Therapeutic Activities Charges
|
Facility
|
OP
|
$181.00
|
|
|
Service Code
|
CPT 97530 GP
|
| Hospital Charge Code |
692245
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$27.15 |
| Max. Negotiated Rate |
$162.90 |
| Rate for Payer: Aetna of AZ Commercial |
$162.90
|
| Rate for Payer: Aetna of AZ Medicare |
$50.68
|
| Rate for Payer: Allwell Medicare |
$27.15
|
| Rate for Payer: Amerigroup Medicare |
$27.15
|
| Rate for Payer: APIPA Medicare/Medicaid |
$67.60
|
| Rate for Payer: AZCH Complete Medicare |
$27.15
|
| Rate for Payer: Banner UC Health Medicare |
$27.15
|
| Rate for Payer: Bisbee Police All Plans |
$47.06
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$123.08
|
| Rate for Payer: Cash Price |
$144.80
|
| Rate for Payer: Cigna of AZ Commercial |
$126.70
|
| Rate for Payer: Copperpoint Commercial |
$44.80
|
| Rate for Payer: Health Net of AZ Commercial |
$108.60
|
| Rate for Payer: Health Net of AZ Medicare |
$50.68
|
| Rate for Payer: Humana of AZ Medicare |
$27.15
|
| Rate for Payer: Self Pay Self Pay |
$144.80
|
| Rate for Payer: TriWest Medicare |
$27.15
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$105.52
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$32.58
|
|
|
Therapeutic Exercise Charges
|
Facility
|
IP
|
$243.00
|
|
|
Service Code
|
CPT 97110 GO
|
| Hospital Charge Code |
23955327
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$63.18 |
| Max. Negotiated Rate |
$218.70 |
| Rate for Payer: Aetna of AZ Commercial |
$218.70
|
| Rate for Payer: Bisbee Police All Plans |
$63.18
|
| Rate for Payer: Cash Price |
$194.40
|
| Rate for Payer: Self Pay Self Pay |
$194.40
|
|
|
Therapeutic Exercise Charges
|
Facility
|
OP
|
$243.00
|
|
|
Service Code
|
CPT 97110 GO
|
| Hospital Charge Code |
691306
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$36.45 |
| Max. Negotiated Rate |
$218.70 |
| Rate for Payer: Aetna of AZ Commercial |
$218.70
|
| Rate for Payer: Aetna of AZ Medicare |
$68.04
|
| Rate for Payer: Allwell Medicare |
$36.45
|
| Rate for Payer: Amerigroup Medicare |
$36.45
|
| Rate for Payer: APIPA Medicare/Medicaid |
$90.76
|
| Rate for Payer: AZCH Complete Medicare |
$36.45
|
| Rate for Payer: Banner UC Health Medicare |
$36.45
|
| Rate for Payer: Bisbee Police All Plans |
$63.18
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$165.24
|
| Rate for Payer: Cash Price |
$194.40
|
| Rate for Payer: Cigna of AZ Commercial |
$170.10
|
| Rate for Payer: Copperpoint Commercial |
$60.14
|
| Rate for Payer: Health Net of AZ Commercial |
$145.80
|
| Rate for Payer: Health Net of AZ Medicare |
$68.04
|
| Rate for Payer: Humana of AZ Medicare |
$36.45
|
| Rate for Payer: Self Pay Self Pay |
$194.40
|
| Rate for Payer: TriWest Medicare |
$36.45
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$141.67
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$43.74
|
|
|
Therapeutic Exercise Charges
|
Facility
|
IP
|
$243.00
|
|
|
Service Code
|
CPT 97110 GO
|
| Hospital Charge Code |
691306
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$63.18 |
| Max. Negotiated Rate |
$218.70 |
| Rate for Payer: Aetna of AZ Commercial |
$218.70
|
| Rate for Payer: Bisbee Police All Plans |
$63.18
|
| Rate for Payer: Cash Price |
$194.40
|
| Rate for Payer: Self Pay Self Pay |
$194.40
|
|
|
Therapeutic Exercise Charges
|
Facility
|
OP
|
$243.00
|
|
|
Service Code
|
CPT 97110 GO
|
| Hospital Charge Code |
23955327
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$36.45 |
| Max. Negotiated Rate |
$218.70 |
| Rate for Payer: Aetna of AZ Commercial |
$218.70
|
| Rate for Payer: Aetna of AZ Medicare |
$68.04
|
| Rate for Payer: Allwell Medicare |
$36.45
|
| Rate for Payer: Amerigroup Medicare |
$36.45
|
| Rate for Payer: APIPA Medicare/Medicaid |
$90.76
|
| Rate for Payer: AZCH Complete Medicare |
$36.45
|
| Rate for Payer: Banner UC Health Medicare |
$36.45
|
| Rate for Payer: Bisbee Police All Plans |
$63.18
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$165.24
|
| Rate for Payer: Cash Price |
$194.40
|
| Rate for Payer: Cigna of AZ Commercial |
$170.10
|
| Rate for Payer: Copperpoint Commercial |
$60.14
|
| Rate for Payer: Health Net of AZ Commercial |
$145.80
|
| Rate for Payer: Health Net of AZ Medicare |
$68.04
|
| Rate for Payer: Humana of AZ Medicare |
$36.45
|
| Rate for Payer: Self Pay Self Pay |
$194.40
|
| Rate for Payer: TriWest Medicare |
$36.45
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$141.67
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$43.74
|
|
|
Therapeutic Phlebotomy 6
|
Facility
|
IP
|
$452.00
|
|
|
Service Code
|
CPT 99195
|
| Hospital Charge Code |
22309912
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$117.52 |
| Max. Negotiated Rate |
$406.80 |
| Rate for Payer: Aetna of AZ Commercial |
$406.80
|
| Rate for Payer: Bisbee Police All Plans |
$117.52
|
| Rate for Payer: Cash Price |
$361.60
|
| Rate for Payer: Self Pay Self Pay |
$361.60
|
|
|
Therapeutic Phlebotomy 6
|
Facility
|
OP
|
$452.00
|
|
|
Service Code
|
CPT 99195
|
| Hospital Charge Code |
22309912
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$67.80 |
| Max. Negotiated Rate |
$406.80 |
| Rate for Payer: Aetna of AZ Commercial |
$406.80
|
| Rate for Payer: Aetna of AZ Medicare |
$126.56
|
| Rate for Payer: AHCCCS Medicaid |
$162.32
|
| Rate for Payer: Allwell Medicaid |
$162.32
|
| Rate for Payer: Allwell Medicare |
$67.80
|
| Rate for Payer: Amerigroup Medicare |
$67.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$168.82
|
| Rate for Payer: AZCH Complete Medicaid |
$162.32
|
| Rate for Payer: AZCH Complete Medicare |
$67.80
|
| Rate for Payer: Banner UC Health Medicaid |
$162.32
|
| Rate for Payer: Banner UC Health Medicare |
$67.80
|
| Rate for Payer: Bisbee Police All Plans |
$117.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$307.36
|
| Rate for Payer: Cash Price |
$361.60
|
| Rate for Payer: Cash Price |
$361.60
|
| Rate for Payer: Cigna of AZ Commercial |
$293.80
|
| Rate for Payer: Copperpoint Commercial |
$111.87
|
| Rate for Payer: Health Net of AZ Commercial |
$271.20
|
| Rate for Payer: Health Net of AZ Medicare |
$126.56
|
| Rate for Payer: Humana of AZ Medicare |
$67.80
|
| Rate for Payer: Mercy Care Medicaid |
$162.32
|
| Rate for Payer: Self Pay Self Pay |
$361.60
|
| Rate for Payer: TriWest Medicare |
$67.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$263.52
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$81.36
|
|
|
thiamine 100 mg Tab [CQCH]
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
NDC 10006073020
|
| Hospital Charge Code |
105943723
|
|
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 |
$0.02
|
| Rate for Payer: Self Pay Self Pay |
$0.02
|
|
|
thiamine 100 mg Tab [CQCH]
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
NDC 10006073020
|
| Hospital Charge Code |
105943723
|
|
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 |
$0.02
|
| 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: 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
|
|
|
thiamine 200 mg/ 2 mL Inj Sol [CQCH]
|
Facility
|
OP
|
$2.61
|
|
|
Service Code
|
HCPCS J3411
|
| Hospital Charge Code |
105943788
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.39 |
| Max. Negotiated Rate |
$5.32 |
| Rate for Payer: Aetna of AZ Commercial |
$2.35
|
| Rate for Payer: Aetna of AZ Medicare |
$0.73
|
| Rate for Payer: AHCCCS Medicaid |
$5.32
|
| Rate for Payer: Allwell Medicaid |
$5.32
|
| Rate for Payer: Allwell Medicare |
$0.39
|
| Rate for Payer: Amerigroup Medicare |
$0.39
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.97
|
| Rate for Payer: AZCH Complete Medicaid |
$5.32
|
| Rate for Payer: AZCH Complete Medicare |
$0.39
|
| Rate for Payer: Banner UC Health Medicaid |
$5.32
|
| Rate for Payer: Banner UC Health Medicare |
$0.39
|
| Rate for Payer: Bisbee Police All Plans |
$0.68
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.77
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Cigna of AZ Commercial |
$1.70
|
| Rate for Payer: Copperpoint Commercial |
$0.65
|
| Rate for Payer: Health Net of AZ Commercial |
$1.57
|
| Rate for Payer: Health Net of AZ Medicare |
$0.73
|
| Rate for Payer: Humana of AZ Medicare |
$0.39
|
| Rate for Payer: Mercy Care Medicaid |
$5.32
|
| Rate for Payer: Self Pay Self Pay |
$2.09
|
| Rate for Payer: TriWest Medicare |
$0.39
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1.52
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.47
|
|
