|
CHECKMATE EXTENSION SET ANESTHESIA
|
Facility
|
OP
|
$63.00
|
|
| Hospital Charge Code |
22355567
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$56.70 |
| Rate for Payer: Aetna of AZ Commercial |
$56.70
|
| Rate for Payer: Aetna of AZ Medicare |
$17.64
|
| Rate for Payer: Allwell Medicare |
$10.08
|
| Rate for Payer: Amerigroup Medicare |
$10.08
|
| Rate for Payer: APIPA Medicare/Medicaid |
$23.53
|
| Rate for Payer: AZCH Complete Medicare |
$10.08
|
| Rate for Payer: Banner UC Health Medicare |
$10.08
|
| Rate for Payer: Bisbee Police All Plans |
$16.38
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$42.84
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of AZ Commercial |
$44.10
|
| Rate for Payer: Copperpoint Commercial |
$15.59
|
| Rate for Payer: Health Net of AZ Commercial |
$37.80
|
| Rate for Payer: Health Net of AZ Medicare |
$17.64
|
| Rate for Payer: Humana of AZ Medicare |
$10.08
|
| Rate for Payer: Self Pay Self Pay |
$50.40
|
| Rate for Payer: TriWest Medicare |
$10.08
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$36.73
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$11.34
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6952
|
| Hospital Charge Code |
APRDRG6952
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: AHCCCS Medicaid |
$6,175.13
|
| Rate for Payer: Allwell Medicaid |
$6,175.13
|
| Rate for Payer: AZCH Complete Medicaid |
$6,175.13
|
| Rate for Payer: Banner UC Health Medicaid |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$16,241.62
|
|
|
Service Code
|
APR-DRG 6953
|
| Hospital Charge Code |
APRDRG6953
|
| Min. Negotiated Rate |
$16,241.62 |
| Max. Negotiated Rate |
$16,241.62 |
| Rate for Payer: AHCCCS Medicaid |
$16,241.62
|
| Rate for Payer: Allwell Medicaid |
$16,241.62
|
| Rate for Payer: AZCH Complete Medicaid |
$16,241.62
|
| Rate for Payer: Banner UC Health Medicaid |
$16,241.62
|
| Rate for Payer: Mercy Care Medicaid |
$16,241.62
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$16,241.62
|
|
|
Service Code
|
APR-DRG 6953
|
| Hospital Charge Code |
APRDRG6951
|
| Min. Negotiated Rate |
$16,241.62 |
| Max. Negotiated Rate |
$16,241.62 |
| Rate for Payer: AHCCCS Medicaid |
$16,241.62
|
| Rate for Payer: Allwell Medicaid |
$16,241.62
|
| Rate for Payer: AZCH Complete Medicaid |
$16,241.62
|
| Rate for Payer: Banner UC Health Medicaid |
$16,241.62
|
| Rate for Payer: Mercy Care Medicaid |
$16,241.62
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6951
|
| Hospital Charge Code |
APRDRG6954
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: AHCCCS Medicaid |
$6,175.13
|
| Rate for Payer: Allwell Medicaid |
$6,175.13
|
| Rate for Payer: AZCH Complete Medicaid |
$6,175.13
|
| Rate for Payer: Banner UC Health Medicaid |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6952
|
| Hospital Charge Code |
APRDRG6954
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: AHCCCS Medicaid |
$6,175.13
|
| Rate for Payer: Allwell Medicaid |
$6,175.13
|
| Rate for Payer: AZCH Complete Medicaid |
$6,175.13
|
| Rate for Payer: Banner UC Health Medicaid |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$44,263.25
|
|
|
Service Code
|
APR-DRG 6954
|
| Hospital Charge Code |
APRDRG6954
|
| Min. Negotiated Rate |
$44,263.25 |
| Max. Negotiated Rate |
$44,263.25 |
| Rate for Payer: AHCCCS Medicaid |
$44,263.25
|
| Rate for Payer: Allwell Medicaid |
$44,263.25
|
| Rate for Payer: AZCH Complete Medicaid |
$44,263.25
|
| Rate for Payer: Banner UC Health Medicaid |
$44,263.25
|
| Rate for Payer: Mercy Care Medicaid |
$44,263.25
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$16,241.62
|
|
|
Service Code
|
APR-DRG 6953
|
| Hospital Charge Code |
APRDRG6954
|
| Min. Negotiated Rate |
$16,241.62 |
| Max. Negotiated Rate |
$16,241.62 |
| Rate for Payer: AHCCCS Medicaid |
$16,241.62
|
| Rate for Payer: Allwell Medicaid |
$16,241.62
|
| Rate for Payer: AZCH Complete Medicaid |
$16,241.62
|
| Rate for Payer: Banner UC Health Medicaid |
$16,241.62
|
| Rate for Payer: Mercy Care Medicaid |
$16,241.62
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6952
|
| Hospital Charge Code |
APRDRG6953
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: AHCCCS Medicaid |
$6,175.13
|
| Rate for Payer: Allwell Medicaid |
$6,175.13
|
| Rate for Payer: AZCH Complete Medicaid |
$6,175.13
|
| Rate for Payer: Banner UC Health Medicaid |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6952
|
| Hospital Charge Code |
APRDRG6951
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: AHCCCS Medicaid |
$6,175.13
|
| Rate for Payer: Allwell Medicaid |
$6,175.13
|
| Rate for Payer: AZCH Complete Medicaid |
$6,175.13
|
| Rate for Payer: Banner UC Health Medicaid |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$44,263.25
|
|
|
Service Code
|
APR-DRG 6954
|
| Hospital Charge Code |
APRDRG6952
|
| Min. Negotiated Rate |
$44,263.25 |
| Max. Negotiated Rate |
$44,263.25 |
| Rate for Payer: AHCCCS Medicaid |
$44,263.25
|
| Rate for Payer: Allwell Medicaid |
$44,263.25
|
| Rate for Payer: AZCH Complete Medicaid |
$44,263.25
|
| Rate for Payer: Banner UC Health Medicaid |
$44,263.25
|
| Rate for Payer: Mercy Care Medicaid |
$44,263.25
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6951
|
| Hospital Charge Code |
APRDRG6951
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: AHCCCS Medicaid |
$6,175.13
|
| Rate for Payer: Allwell Medicaid |
$6,175.13
|
| Rate for Payer: AZCH Complete Medicaid |
$6,175.13
|
| Rate for Payer: Banner UC Health Medicaid |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$44,263.25
|
|
|
Service Code
|
APR-DRG 6954
|
| Hospital Charge Code |
APRDRG6953
|
| Min. Negotiated Rate |
$44,263.25 |
| Max. Negotiated Rate |
$44,263.25 |
| Rate for Payer: AHCCCS Medicaid |
$44,263.25
|
| Rate for Payer: Allwell Medicaid |
$44,263.25
|
| Rate for Payer: AZCH Complete Medicaid |
$44,263.25
|
| Rate for Payer: Banner UC Health Medicaid |
$44,263.25
|
| Rate for Payer: Mercy Care Medicaid |
$44,263.25
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$44,263.25
|
|
|
Service Code
|
APR-DRG 6954
|
| Hospital Charge Code |
APRDRG6951
|
| Min. Negotiated Rate |
$44,263.25 |
| Max. Negotiated Rate |
$44,263.25 |
| Rate for Payer: AHCCCS Medicaid |
$44,263.25
|
| Rate for Payer: Allwell Medicaid |
$44,263.25
|
| Rate for Payer: AZCH Complete Medicaid |
$44,263.25
|
| Rate for Payer: Banner UC Health Medicaid |
$44,263.25
|
| Rate for Payer: Mercy Care Medicaid |
$44,263.25
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6951
|
| Hospital Charge Code |
APRDRG6953
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: AHCCCS Medicaid |
$6,175.13
|
| Rate for Payer: Allwell Medicaid |
$6,175.13
|
| Rate for Payer: AZCH Complete Medicaid |
$6,175.13
|
| Rate for Payer: Banner UC Health Medicaid |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$16,241.62
|
|
|
Service Code
|
APR-DRG 6953
|
| Hospital Charge Code |
APRDRG6952
|
| Min. Negotiated Rate |
$16,241.62 |
| Max. Negotiated Rate |
$16,241.62 |
| Rate for Payer: AHCCCS Medicaid |
$16,241.62
|
| Rate for Payer: Allwell Medicaid |
$16,241.62
|
| Rate for Payer: AZCH Complete Medicaid |
$16,241.62
|
| Rate for Payer: Banner UC Health Medicaid |
$16,241.62
|
| Rate for Payer: Mercy Care Medicaid |
$16,241.62
|
|
|
Chemotherapy For Acute Leukemia
|
Facility
|
IP
|
$6,175.13
|
|
|
Service Code
|
APR-DRG 6951
|
| Hospital Charge Code |
APRDRG6952
|
| Min. Negotiated Rate |
$6,175.13 |
| Max. Negotiated Rate |
$6,175.13 |
| Rate for Payer: AHCCCS Medicaid |
$6,175.13
|
| Rate for Payer: Allwell Medicaid |
$6,175.13
|
| Rate for Payer: AZCH Complete Medicaid |
$6,175.13
|
| Rate for Payer: Banner UC Health Medicaid |
$6,175.13
|
| Rate for Payer: Mercy Care Medicaid |
$6,175.13
|
|
|
Chest Pain
|
Facility
|
IP
|
$5,097.07
|
|
|
Service Code
|
APR-DRG 2033
|
| Hospital Charge Code |
APRDRG2032
|
| Min. Negotiated Rate |
$5,097.07 |
| Max. Negotiated Rate |
$5,097.07 |
| Rate for Payer: AHCCCS Medicaid |
$5,097.07
|
| Rate for Payer: Allwell Medicaid |
$5,097.07
|
| Rate for Payer: AZCH Complete Medicaid |
$5,097.07
|
| Rate for Payer: Banner UC Health Medicaid |
$5,097.07
|
| Rate for Payer: Mercy Care Medicaid |
$5,097.07
|
|
|
Chest Pain
|
Facility
|
IP
|
$3,615.02
|
|
|
Service Code
|
APR-DRG 2031
|
| Hospital Charge Code |
APRDRG2034
|
| Min. Negotiated Rate |
$3,615.02 |
| Max. Negotiated Rate |
$3,615.02 |
| Rate for Payer: AHCCCS Medicaid |
$3,615.02
|
| Rate for Payer: Allwell Medicaid |
$3,615.02
|
| Rate for Payer: AZCH Complete Medicaid |
$3,615.02
|
| Rate for Payer: Banner UC Health Medicaid |
$3,615.02
|
| Rate for Payer: Mercy Care Medicaid |
$3,615.02
|
|
|
Chest Pain
|
Facility
|
IP
|
$7,157.09
|
|
|
Service Code
|
APR-DRG 2034
|
| Hospital Charge Code |
APRDRG2032
|
| Min. Negotiated Rate |
$7,157.09 |
| Max. Negotiated Rate |
$7,157.09 |
| Rate for Payer: AHCCCS Medicaid |
$7,157.09
|
| Rate for Payer: Allwell Medicaid |
$7,157.09
|
| Rate for Payer: AZCH Complete Medicaid |
$7,157.09
|
| Rate for Payer: Banner UC Health Medicaid |
$7,157.09
|
| Rate for Payer: Mercy Care Medicaid |
$7,157.09
|
|
|
Chest Pain
|
Facility
|
IP
|
$5,097.07
|
|
|
Service Code
|
APR-DRG 2033
|
| Hospital Charge Code |
APRDRG2033
|
| Min. Negotiated Rate |
$5,097.07 |
| Max. Negotiated Rate |
$5,097.07 |
| Rate for Payer: AHCCCS Medicaid |
$5,097.07
|
| Rate for Payer: Allwell Medicaid |
$5,097.07
|
| Rate for Payer: AZCH Complete Medicaid |
$5,097.07
|
| Rate for Payer: Banner UC Health Medicaid |
$5,097.07
|
| Rate for Payer: Mercy Care Medicaid |
$5,097.07
|
|
|
Chest Pain
|
Facility
|
IP
|
$7,157.09
|
|
|
Service Code
|
APR-DRG 2034
|
| Hospital Charge Code |
APRDRG2033
|
| Min. Negotiated Rate |
$7,157.09 |
| Max. Negotiated Rate |
$7,157.09 |
| Rate for Payer: AHCCCS Medicaid |
$7,157.09
|
| Rate for Payer: Allwell Medicaid |
$7,157.09
|
| Rate for Payer: AZCH Complete Medicaid |
$7,157.09
|
| Rate for Payer: Banner UC Health Medicaid |
$7,157.09
|
| Rate for Payer: Mercy Care Medicaid |
$7,157.09
|
|
|
Chest Pain
|
Facility
|
IP
|
$5,097.07
|
|
|
Service Code
|
APR-DRG 2033
|
| Hospital Charge Code |
APRDRG2031
|
| Min. Negotiated Rate |
$5,097.07 |
| Max. Negotiated Rate |
$5,097.07 |
| Rate for Payer: AHCCCS Medicaid |
$5,097.07
|
| Rate for Payer: Allwell Medicaid |
$5,097.07
|
| Rate for Payer: AZCH Complete Medicaid |
$5,097.07
|
| Rate for Payer: Banner UC Health Medicaid |
$5,097.07
|
| Rate for Payer: Mercy Care Medicaid |
$5,097.07
|
|
|
Chest Pain
|
Facility
|
IP
|
$5,097.07
|
|
|
Service Code
|
APR-DRG 2033
|
| Hospital Charge Code |
APRDRG2034
|
| Min. Negotiated Rate |
$5,097.07 |
| Max. Negotiated Rate |
$5,097.07 |
| Rate for Payer: AHCCCS Medicaid |
$5,097.07
|
| Rate for Payer: Allwell Medicaid |
$5,097.07
|
| Rate for Payer: AZCH Complete Medicaid |
$5,097.07
|
| Rate for Payer: Banner UC Health Medicaid |
$5,097.07
|
| Rate for Payer: Mercy Care Medicaid |
$5,097.07
|
|
|
Chest Pain
|
Facility
|
IP
|
$3,615.02
|
|
|
Service Code
|
APR-DRG 2031
|
| Hospital Charge Code |
APRDRG2032
|
| Min. Negotiated Rate |
$3,615.02 |
| Max. Negotiated Rate |
$3,615.02 |
| Rate for Payer: AHCCCS Medicaid |
$3,615.02
|
| Rate for Payer: Allwell Medicaid |
$3,615.02
|
| Rate for Payer: AZCH Complete Medicaid |
$3,615.02
|
| Rate for Payer: Banner UC Health Medicaid |
$3,615.02
|
| Rate for Payer: Mercy Care Medicaid |
$3,615.02
|
|
