Ammonia Level
|
Facility
|
OP
|
$181.00
|
|
Service Code
|
CPT 82140
|
Hospital Charge Code |
633648
|
Hospital Revenue Code
|
301
|
Min. Negotiated Rate |
$14.57 |
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: AHCCCS Medicaid |
$14.57
|
Rate for Payer: Allwell Medicaid |
$14.57
|
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 Medicaid |
$14.57
|
Rate for Payer: AZCH Complete Medicare |
$27.15
|
Rate for Payer: Banner UC Health Medicaid |
$14.57
|
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: Cash Price |
$144.80
|
Rate for Payer: Cigna of AZ Commercial |
$117.65
|
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: Mercy Care Medicaid |
$14.57
|
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
|
|
Ammonia Level
|
Facility
|
IP
|
$181.00
|
|
Service Code
|
CPT 82140
|
Hospital Charge Code |
633648
|
Hospital Revenue Code
|
301
|
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
|
|
AMNIOCORD 2X3CM
|
Facility
|
OP
|
$7,400.00
|
|
Hospital Charge Code |
27491238
|
Hospital Revenue Code
|
270
|
Min. Negotiated Rate |
$1,110.00 |
Max. Negotiated Rate |
$6,660.00 |
Rate for Payer: Aetna of AZ Commercial |
$6,660.00
|
Rate for Payer: Aetna of AZ Medicare |
$2,072.00
|
Rate for Payer: Allwell Medicare |
$1,110.00
|
Rate for Payer: Amerigroup Medicare |
$1,110.00
|
Rate for Payer: APIPA Medicare/Medicaid |
$2,763.90
|
Rate for Payer: AZCH Complete Medicare |
$1,110.00
|
Rate for Payer: Banner UC Health Medicare |
$1,110.00
|
Rate for Payer: Bisbee Police All Plans |
$1,924.00
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$5,032.00
|
Rate for Payer: Cash Price |
$5,920.00
|
Rate for Payer: Cigna of AZ Commercial |
$5,180.00
|
Rate for Payer: Copperpoint Commercial |
$1,831.50
|
Rate for Payer: Health Net of AZ Commercial |
$4,440.00
|
Rate for Payer: Health Net of AZ Medicare |
$2,072.00
|
Rate for Payer: Humana of AZ Medicare |
$1,110.00
|
Rate for Payer: Self Pay Self Pay |
$5,920.00
|
Rate for Payer: TriWest Medicare |
$1,110.00
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$4,314.20
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$1,332.00
|
|
AMNIOCORD 2X3CM
|
Facility
|
IP
|
$7,400.00
|
|
Hospital Charge Code |
27491238
|
Hospital Revenue Code
|
270
|
Min. Negotiated Rate |
$1,924.00 |
Max. Negotiated Rate |
$6,660.00 |
Rate for Payer: Aetna of AZ Commercial |
$6,660.00
|
Rate for Payer: Bisbee Police All Plans |
$1,924.00
|
Rate for Payer: Cash Price |
$5,920.00
|
Rate for Payer: Self Pay Self Pay |
$5,920.00
|
|
AMNIOFIX 4X6 CM
|
Facility
|
IP
|
$14,404.00
|
|
Hospital Charge Code |
27520626
|
Hospital Revenue Code
|
270
|
Min. Negotiated Rate |
$3,745.04 |
Max. Negotiated Rate |
$12,963.60 |
Rate for Payer: Aetna of AZ Commercial |
$12,963.60
|
Rate for Payer: Bisbee Police All Plans |
$3,745.04
|
Rate for Payer: Cash Price |
$11,523.20
|
Rate for Payer: Self Pay Self Pay |
$11,523.20
|
|
AMNIOFIX 4X6 CM
|
Facility
|
OP
|
$14,404.00
|
|
Hospital Charge Code |
27520626
|
Hospital Revenue Code
|
270
|
Min. Negotiated Rate |
$2,160.60 |
Max. Negotiated Rate |
$12,963.60 |
Rate for Payer: Aetna of AZ Commercial |
$12,963.60
|
Rate for Payer: Aetna of AZ Medicare |
$4,033.12
|
Rate for Payer: Allwell Medicare |
$2,160.60
|
Rate for Payer: Amerigroup Medicare |
$2,160.60
|
Rate for Payer: APIPA Medicare/Medicaid |
$5,379.89
|
Rate for Payer: AZCH Complete Medicare |
$2,160.60
|
Rate for Payer: Banner UC Health Medicare |
$2,160.60
|
Rate for Payer: Bisbee Police All Plans |
$3,745.04
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$9,794.72
|
Rate for Payer: Cash Price |
$11,523.20
|
Rate for Payer: Cigna of AZ Commercial |
$10,082.80
|
Rate for Payer: Copperpoint Commercial |
$3,564.99
|
Rate for Payer: Health Net of AZ Commercial |
$8,642.40
|
Rate for Payer: Health Net of AZ Medicare |
$4,033.12
|
Rate for Payer: Humana of AZ Medicare |
$2,160.60
|
Rate for Payer: Self Pay Self Pay |
$11,523.20
|
Rate for Payer: TriWest Medicare |
$2,160.60
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$8,397.53
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$2,592.72
|
|
amoxicillin 250 mg/5 mL Oral Susp (80 mL after reconst.) [CQCH]
|
Facility
|
IP
|
$1.38
|
|
Service Code
|
NDC 93415579
|
Hospital Charge Code |
105910832
|
Hospital Revenue Code
|
251
|
Min. Negotiated Rate |
$0.36 |
Max. Negotiated Rate |
$1.24 |
Rate for Payer: Aetna of AZ Commercial |
$1.24
|
Rate for Payer: Bisbee Police All Plans |
$0.36
|
Rate for Payer: Cash Price |
$1.10
|
Rate for Payer: Self Pay Self Pay |
$1.10
|
|
amoxicillin 250 mg/5 mL Oral Susp (80 mL after reconst.) [CQCH]
|
Facility
|
OP
|
$1.38
|
|
Service Code
|
NDC 93415579
|
Hospital Charge Code |
105910832
|
Hospital Revenue Code
|
251
|
Min. Negotiated Rate |
$0.21 |
Max. Negotiated Rate |
$1.24 |
Rate for Payer: Aetna of AZ Commercial |
$1.24
|
Rate for Payer: Aetna of AZ Medicare |
$0.39
|
Rate for Payer: Allwell Medicare |
$0.21
|
Rate for Payer: Amerigroup Medicare |
$0.21
|
Rate for Payer: APIPA Medicare/Medicaid |
$0.52
|
Rate for Payer: AZCH Complete Medicare |
$0.21
|
Rate for Payer: Banner UC Health Medicare |
$0.21
|
Rate for Payer: Bisbee Police All Plans |
$0.36
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.94
|
Rate for Payer: Cash Price |
$1.10
|
Rate for Payer: Cigna of AZ Commercial |
$0.90
|
Rate for Payer: Copperpoint Commercial |
$0.34
|
Rate for Payer: Health Net of AZ Commercial |
$0.83
|
Rate for Payer: Health Net of AZ Medicare |
$0.39
|
Rate for Payer: Humana of AZ Medicare |
$0.21
|
Rate for Payer: Self Pay Self Pay |
$1.10
|
Rate for Payer: TriWest Medicare |
$0.21
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.80
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.25
|
|
amoxicillin 250 mg/5 mL Susp (100 mls after reconstitution)[CQCH]
|
Facility
|
IP
|
$0.02
|
|
Service Code
|
NDC 65862070701
|
Hospital Charge Code |
210809148
|
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
|
|
amoxicillin 250 mg/5 mL Susp (100 mls after reconstitution)[CQCH]
|
Facility
|
OP
|
$0.02
|
|
Service Code
|
NDC 65862070701
|
Hospital Charge Code |
210809148
|
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
|
|
amoxicillin 250 mg/5 mL Susp (150 ml after reconstitution)
|
Facility
|
IP
|
$0.10
|
|
Service Code
|
NDC 143988915
|
Hospital Charge Code |
209124903
|
Hospital Revenue Code
|
231
|
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
|
|
amoxicillin 250 mg/5 mL Susp (150 ml after reconstitution)
|
Facility
|
OP
|
$0.10
|
|
Service Code
|
NDC 143988915
|
Hospital Charge Code |
209124903
|
Hospital Revenue Code
|
231
|
Min. Negotiated Rate |
$0.02 |
Max. Negotiated Rate |
$0.09 |
Rate for Payer: Aetna of AZ Commercial |
$0.09
|
Rate for Payer: Aetna of AZ Medicare |
$0.03
|
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 Medicare |
$0.02
|
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: 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: 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
|
|
amoxicillin 500 mg Cap [CQCH]
|
Facility
|
IP
|
$0.09
|
|
Service Code
|
NDC 16714029903
|
Hospital Charge Code |
105910767
|
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
|
|
amoxicillin 500 mg Cap [CQCH]
|
Facility
|
OP
|
$0.09
|
|
Service Code
|
NDC 16714029903
|
Hospital Charge Code |
105910767
|
Hospital Revenue Code
|
251
|
Min. Negotiated Rate |
$0.01 |
Max. Negotiated Rate |
$0.08 |
Rate for Payer: Aetna of AZ Commercial |
$0.08
|
Rate for Payer: Aetna of AZ Medicare |
$0.03
|
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 |
$0.06
|
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: 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
|
|
amoxicillin-clavulanate 500 mg-125 mg Tab [CQCH]
|
Facility
|
OP
|
$0.25
|
|
Service Code
|
NDC 16714049401
|
Hospital Charge Code |
105910897
|
Hospital Revenue Code
|
251
|
Min. Negotiated Rate |
$0.04 |
Max. Negotiated Rate |
$0.23 |
Rate for Payer: Aetna of AZ Commercial |
$0.23
|
Rate for Payer: Aetna of AZ Medicare |
$0.07
|
Rate for Payer: Allwell Medicare |
$0.04
|
Rate for Payer: Amerigroup Medicare |
$0.04
|
Rate for Payer: APIPA Medicare/Medicaid |
$0.09
|
Rate for Payer: AZCH Complete Medicare |
$0.04
|
Rate for Payer: Banner UC Health Medicare |
$0.04
|
Rate for Payer: Bisbee Police All Plans |
$0.07
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.17
|
Rate for Payer: Cash Price |
$0.20
|
Rate for Payer: Cigna of AZ Commercial |
$0.16
|
Rate for Payer: Copperpoint Commercial |
$0.06
|
Rate for Payer: Health Net of AZ Commercial |
$0.15
|
Rate for Payer: Health Net of AZ Medicare |
$0.07
|
Rate for Payer: Humana of AZ Medicare |
$0.04
|
Rate for Payer: Self Pay Self Pay |
$0.20
|
Rate for Payer: TriWest Medicare |
$0.04
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.15
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.05
|
|
amoxicillin-clavulanate 500 mg-125 mg Tab [CQCH]
|
Facility
|
IP
|
$0.25
|
|
Service Code
|
NDC 16714049401
|
Hospital Charge Code |
105910897
|
Hospital Revenue Code
|
251
|
Min. Negotiated Rate |
$0.07 |
Max. Negotiated Rate |
$0.23 |
Rate for Payer: Aetna of AZ Commercial |
$0.23
|
Rate for Payer: Bisbee Police All Plans |
$0.07
|
Rate for Payer: Cash Price |
$0.20
|
Rate for Payer: Self Pay Self Pay |
$0.20
|
|
amoxicillin-clavulanate 600 mg/5 mL Oral Liq (75 mL after reconst.) [CQCH]
|
Facility
|
OP
|
$3.12
|
|
Service Code
|
NDC 16714029401
|
Hospital Charge Code |
105910962
|
Hospital Revenue Code
|
251
|
Min. Negotiated Rate |
$0.47 |
Max. Negotiated Rate |
$2.81 |
Rate for Payer: Aetna of AZ Commercial |
$2.81
|
Rate for Payer: Aetna of AZ Medicare |
$0.87
|
Rate for Payer: Allwell Medicare |
$0.47
|
Rate for Payer: Amerigroup Medicare |
$0.47
|
Rate for Payer: APIPA Medicare/Medicaid |
$1.17
|
Rate for Payer: AZCH Complete Medicare |
$0.47
|
Rate for Payer: Banner UC Health Medicare |
$0.47
|
Rate for Payer: Bisbee Police All Plans |
$0.81
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2.12
|
Rate for Payer: Cash Price |
$2.50
|
Rate for Payer: Cigna of AZ Commercial |
$2.03
|
Rate for Payer: Copperpoint Commercial |
$0.77
|
Rate for Payer: Health Net of AZ Commercial |
$1.87
|
Rate for Payer: Health Net of AZ Medicare |
$0.87
|
Rate for Payer: Humana of AZ Medicare |
$0.47
|
Rate for Payer: Self Pay Self Pay |
$2.50
|
Rate for Payer: TriWest Medicare |
$0.47
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$1.82
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.56
|
|
amoxicillin-clavulanate 600 mg/5 mL Oral Liq (75 mL after reconst.) [CQCH]
|
Facility
|
IP
|
$3.12
|
|
Service Code
|
NDC 16714029401
|
Hospital Charge Code |
105910962
|
Hospital Revenue Code
|
251
|
Min. Negotiated Rate |
$0.81 |
Max. Negotiated Rate |
$2.81 |
Rate for Payer: Aetna of AZ Commercial |
$2.81
|
Rate for Payer: Bisbee Police All Plans |
$0.81
|
Rate for Payer: Cash Price |
$2.50
|
Rate for Payer: Self Pay Self Pay |
$2.50
|
|
amoxicillin-clavulanate 875 mg-125 mg Tab [CQCH]
|
Facility
|
IP
|
$0.68
|
|
Service Code
|
NDC 16714047801
|
Hospital Charge Code |
105911029
|
Hospital Revenue Code
|
251
|
Min. Negotiated Rate |
$0.18 |
Max. Negotiated Rate |
$0.61 |
Rate for Payer: Aetna of AZ Commercial |
$0.61
|
Rate for Payer: Bisbee Police All Plans |
$0.18
|
Rate for Payer: Cash Price |
$0.55
|
Rate for Payer: Self Pay Self Pay |
$0.54
|
|
amoxicillin-clavulanate 875 mg-125 mg Tab [CQCH]
|
Facility
|
OP
|
$0.68
|
|
Service Code
|
NDC 16714047801
|
Hospital Charge Code |
105911029
|
Hospital Revenue Code
|
251
|
Min. Negotiated Rate |
$0.10 |
Max. Negotiated Rate |
$0.61 |
Rate for Payer: Aetna of AZ Commercial |
$0.61
|
Rate for Payer: Aetna of AZ Medicare |
$0.19
|
Rate for Payer: Allwell Medicare |
$0.10
|
Rate for Payer: Amerigroup Medicare |
$0.10
|
Rate for Payer: APIPA Medicare/Medicaid |
$0.25
|
Rate for Payer: AZCH Complete Medicare |
$0.10
|
Rate for Payer: Banner UC Health Medicare |
$0.10
|
Rate for Payer: Bisbee Police All Plans |
$0.18
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.46
|
Rate for Payer: Cash Price |
$0.55
|
Rate for Payer: Cigna of AZ Commercial |
$0.44
|
Rate for Payer: Copperpoint Commercial |
$0.17
|
Rate for Payer: Health Net of AZ Commercial |
$0.41
|
Rate for Payer: Health Net of AZ Medicare |
$0.19
|
Rate for Payer: Humana of AZ Medicare |
$0.10
|
Rate for Payer: Self Pay Self Pay |
$0.54
|
Rate for Payer: TriWest Medicare |
$0.10
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.40
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.12
|
|
.Amphetamines, GC/MS Confirm LC
|
Facility
|
OP
|
$194.00
|
|
Service Code
|
CPT 82145
|
Hospital Charge Code |
22311130
|
Hospital Revenue Code
|
301
|
Min. Negotiated Rate |
$29.10 |
Max. Negotiated Rate |
$174.60 |
Rate for Payer: Aetna of AZ Commercial |
$174.60
|
Rate for Payer: Aetna of AZ Medicare |
$54.32
|
Rate for Payer: Allwell Medicare |
$29.10
|
Rate for Payer: Amerigroup Medicare |
$29.10
|
Rate for Payer: APIPA Medicare/Medicaid |
$72.46
|
Rate for Payer: AZCH Complete Medicare |
$29.10
|
Rate for Payer: Banner UC Health Medicare |
$29.10
|
Rate for Payer: Bisbee Police All Plans |
$50.44
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$131.92
|
Rate for Payer: Cash Price |
$155.20
|
Rate for Payer: Cigna of AZ Commercial |
$126.10
|
Rate for Payer: Copperpoint Commercial |
$48.02
|
Rate for Payer: Health Net of AZ Commercial |
$116.40
|
Rate for Payer: Health Net of AZ Medicare |
$54.32
|
Rate for Payer: Humana of AZ Medicare |
$29.10
|
Rate for Payer: Self Pay Self Pay |
$155.20
|
Rate for Payer: TriWest Medicare |
$29.10
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$113.10
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$34.92
|
|
.Amphetamines, GC/MS Confirm LC
|
Facility
|
IP
|
$194.00
|
|
Service Code
|
CPT 82145
|
Hospital Charge Code |
22311130
|
Hospital Revenue Code
|
301
|
Min. Negotiated Rate |
$50.44 |
Max. Negotiated Rate |
$174.60 |
Rate for Payer: Aetna of AZ Commercial |
$174.60
|
Rate for Payer: Bisbee Police All Plans |
$50.44
|
Rate for Payer: Cash Price |
$155.20
|
Rate for Payer: Self Pay Self Pay |
$155.20
|
|
ampicillin 1 g Inj [CQCH]
|
Facility
|
IP
|
$1.62
|
|
Service Code
|
HCPCS J0290
|
Hospital Charge Code |
105911094
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$0.42 |
Max. Negotiated Rate |
$1.46 |
Rate for Payer: Aetna of AZ Commercial |
$1.46
|
Rate for Payer: Bisbee Police All Plans |
$0.42
|
Rate for Payer: Cash Price |
$1.29
|
Rate for Payer: Self Pay Self Pay |
$1.30
|
|
ampicillin 1 g Inj [CQCH]
|
Facility
|
OP
|
$1.62
|
|
Service Code
|
HCPCS J0290
|
Hospital Charge Code |
105911094
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$0.24 |
Max. Negotiated Rate |
$1.46 |
Rate for Payer: Aetna of AZ Commercial |
$1.46
|
Rate for Payer: Aetna of AZ Medicare |
$0.45
|
Rate for Payer: AHCCCS Medicaid |
$1.38
|
Rate for Payer: Allwell Medicaid |
$1.38
|
Rate for Payer: Allwell Medicare |
$0.24
|
Rate for Payer: Amerigroup Medicare |
$0.24
|
Rate for Payer: APIPA Medicare/Medicaid |
$0.61
|
Rate for Payer: AZCH Complete Medicaid |
$1.38
|
Rate for Payer: AZCH Complete Medicare |
$0.24
|
Rate for Payer: Banner UC Health Medicaid |
$1.38
|
Rate for Payer: Banner UC Health Medicare |
$0.24
|
Rate for Payer: Bisbee Police All Plans |
$0.42
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1.10
|
Rate for Payer: Cash Price |
$1.29
|
Rate for Payer: Cash Price |
$1.29
|
Rate for Payer: Cigna of AZ Commercial |
$1.05
|
Rate for Payer: Copperpoint Commercial |
$0.40
|
Rate for Payer: Health Net of AZ Commercial |
$0.97
|
Rate for Payer: Health Net of AZ Medicare |
$0.45
|
Rate for Payer: Humana of AZ Medicare |
$0.24
|
Rate for Payer: Mercy Care Medicaid |
$1.38
|
Rate for Payer: Self Pay Self Pay |
$1.30
|
Rate for Payer: TriWest Medicare |
$0.24
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.94
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.29
|
|
ampicillin-sulbactam 1 .5 g Inj [CQCH]
|
Facility
|
IP
|
$1.49
|
|
Service Code
|
HCPCS J0295
|
Hospital Charge Code |
105911169
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$0.39 |
Max. Negotiated Rate |
$1.34 |
Rate for Payer: Aetna of AZ Commercial |
$1.34
|
Rate for Payer: Bisbee Police All Plans |
$0.39
|
Rate for Payer: Cash Price |
$1.19
|
Rate for Payer: Self Pay Self Pay |
$1.19
|
|