|
HCV RT-PCR, Quant (Non-Graph) LC
|
Facility
|
IP
|
$786.00
|
|
|
Service Code
|
CPT 87522
|
| Hospital Charge Code |
1285758
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$204.36 |
| Max. Negotiated Rate |
$707.40 |
| Rate for Payer: Aetna of AZ Commercial |
$707.40
|
| Rate for Payer: Bisbee Police All Plans |
$204.36
|
| Rate for Payer: Cash Price |
$628.80
|
| Rate for Payer: Self Pay Self Pay |
$628.80
|
|
|
HCV RT-PCR, Quant (Non-Graph) LC
|
Facility
|
OP
|
$786.00
|
|
|
Service Code
|
CPT 87522
|
| Hospital Charge Code |
1285758
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$42.84 |
| Max. Negotiated Rate |
$707.40 |
| Rate for Payer: Aetna of AZ Commercial |
$707.40
|
| Rate for Payer: Aetna of AZ Medicare |
$220.08
|
| Rate for Payer: AHCCCS Medicaid |
$42.84
|
| Rate for Payer: Allwell Medicaid |
$42.84
|
| Rate for Payer: Allwell Medicare |
$117.90
|
| Rate for Payer: Amerigroup Medicare |
$117.90
|
| Rate for Payer: APIPA Medicare/Medicaid |
$293.57
|
| Rate for Payer: AZCH Complete Medicaid |
$42.84
|
| Rate for Payer: AZCH Complete Medicare |
$117.90
|
| Rate for Payer: Banner UC Health Medicaid |
$42.84
|
| Rate for Payer: Banner UC Health Medicare |
$117.90
|
| Rate for Payer: Bisbee Police All Plans |
$204.36
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$534.48
|
| Rate for Payer: Cash Price |
$628.80
|
| Rate for Payer: Cash Price |
$628.80
|
| Rate for Payer: Cigna of AZ Commercial |
$510.90
|
| Rate for Payer: Copperpoint Commercial |
$194.54
|
| Rate for Payer: Health Net of AZ Commercial |
$471.60
|
| Rate for Payer: Health Net of AZ Medicare |
$220.08
|
| Rate for Payer: Humana of AZ Medicare |
$117.90
|
| Rate for Payer: Mercy Care Medicaid |
$42.84
|
| Rate for Payer: Self Pay Self Pay |
$628.80
|
| Rate for Payer: TriWest Medicare |
$117.90
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$458.24
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$141.48
|
|
|
HCV with Drug Resistance
|
Facility
|
IP
|
$999.00
|
|
|
Service Code
|
CPT 87900
|
| Hospital Charge Code |
22907367
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$259.74 |
| Max. Negotiated Rate |
$899.10 |
| Rate for Payer: Aetna of AZ Commercial |
$899.10
|
| Rate for Payer: Bisbee Police All Plans |
$259.74
|
| Rate for Payer: Cash Price |
$799.20
|
| Rate for Payer: Self Pay Self Pay |
$799.20
|
|
|
HCV with Drug Resistance
|
Facility
|
OP
|
$999.00
|
|
|
Service Code
|
CPT 87901
|
| Hospital Charge Code |
23173795
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$149.85 |
| Max. Negotiated Rate |
$899.10 |
| Rate for Payer: Aetna of AZ Commercial |
$899.10
|
| Rate for Payer: Aetna of AZ Medicare |
$279.72
|
| Rate for Payer: AHCCCS Medicaid |
$257.45
|
| Rate for Payer: Allwell Medicaid |
$257.45
|
| Rate for Payer: Allwell Medicare |
$149.85
|
| Rate for Payer: Amerigroup Medicare |
$149.85
|
| Rate for Payer: APIPA Medicare/Medicaid |
$373.13
|
| Rate for Payer: AZCH Complete Medicaid |
$257.45
|
| Rate for Payer: AZCH Complete Medicare |
$149.85
|
| Rate for Payer: Banner UC Health Medicaid |
$257.45
|
| Rate for Payer: Banner UC Health Medicare |
$149.85
|
| Rate for Payer: Bisbee Police All Plans |
$259.74
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$679.32
|
| Rate for Payer: Cash Price |
$799.20
|
| Rate for Payer: Cash Price |
$799.20
|
| Rate for Payer: Cigna of AZ Commercial |
$649.35
|
| Rate for Payer: Copperpoint Commercial |
$247.25
|
| Rate for Payer: Health Net of AZ Commercial |
$599.40
|
| Rate for Payer: Health Net of AZ Medicare |
$279.72
|
| Rate for Payer: Humana of AZ Medicare |
$149.85
|
| Rate for Payer: Mercy Care Medicaid |
$257.45
|
| Rate for Payer: Self Pay Self Pay |
$799.20
|
| Rate for Payer: TriWest Medicare |
$149.85
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$582.42
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$179.82
|
|
|
HCV with Drug Resistance
|
Facility
|
IP
|
$999.00
|
|
|
Service Code
|
CPT 87901
|
| Hospital Charge Code |
23173795
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$259.74 |
| Max. Negotiated Rate |
$899.10 |
| Rate for Payer: Aetna of AZ Commercial |
$899.10
|
| Rate for Payer: Bisbee Police All Plans |
$259.74
|
| Rate for Payer: Cash Price |
$799.20
|
| Rate for Payer: Self Pay Self Pay |
$799.20
|
|
|
HCV with Drug Resistance
|
Facility
|
OP
|
$999.00
|
|
|
Service Code
|
CPT 87900
|
| Hospital Charge Code |
22907367
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$130.35 |
| Max. Negotiated Rate |
$899.10 |
| Rate for Payer: Aetna of AZ Commercial |
$899.10
|
| Rate for Payer: Aetna of AZ Medicare |
$279.72
|
| Rate for Payer: AHCCCS Medicaid |
$130.35
|
| Rate for Payer: Allwell Medicaid |
$130.35
|
| Rate for Payer: Allwell Medicare |
$149.85
|
| Rate for Payer: Amerigroup Medicare |
$149.85
|
| Rate for Payer: APIPA Medicare/Medicaid |
$373.13
|
| Rate for Payer: AZCH Complete Medicaid |
$130.35
|
| Rate for Payer: AZCH Complete Medicare |
$149.85
|
| Rate for Payer: Banner UC Health Medicaid |
$130.35
|
| Rate for Payer: Banner UC Health Medicare |
$149.85
|
| Rate for Payer: Bisbee Police All Plans |
$259.74
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$679.32
|
| Rate for Payer: Cash Price |
$799.20
|
| Rate for Payer: Cash Price |
$799.20
|
| Rate for Payer: Cigna of AZ Commercial |
$649.35
|
| Rate for Payer: Copperpoint Commercial |
$247.25
|
| Rate for Payer: Health Net of AZ Commercial |
$599.40
|
| Rate for Payer: Health Net of AZ Medicare |
$279.72
|
| Rate for Payer: Humana of AZ Medicare |
$149.85
|
| Rate for Payer: Mercy Care Medicaid |
$130.35
|
| Rate for Payer: Self Pay Self Pay |
$799.20
|
| Rate for Payer: TriWest Medicare |
$149.85
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$582.42
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$179.82
|
|
|
.HDL Comment LC
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
CPT 83718
|
| Hospital Charge Code |
22311129
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.19 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of AZ Commercial |
$93.60
|
| Rate for Payer: Aetna of AZ Medicare |
$29.12
|
| Rate for Payer: AHCCCS Medicaid |
$8.19
|
| Rate for Payer: Allwell Medicaid |
$8.19
|
| Rate for Payer: Allwell Medicare |
$15.60
|
| Rate for Payer: Amerigroup Medicare |
$15.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$38.84
|
| Rate for Payer: AZCH Complete Medicaid |
$8.19
|
| Rate for Payer: AZCH Complete Medicare |
$15.60
|
| Rate for Payer: Banner UC Health Medicaid |
$8.19
|
| Rate for Payer: Banner UC Health Medicare |
$15.60
|
| Rate for Payer: Bisbee Police All Plans |
$27.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$70.72
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Cigna of AZ Commercial |
$67.60
|
| Rate for Payer: Copperpoint Commercial |
$25.74
|
| Rate for Payer: Health Net of AZ Commercial |
$62.40
|
| Rate for Payer: Health Net of AZ Medicare |
$29.12
|
| Rate for Payer: Humana of AZ Medicare |
$15.60
|
| Rate for Payer: Mercy Care Medicaid |
$8.19
|
| Rate for Payer: Self Pay Self Pay |
$83.20
|
| Rate for Payer: TriWest Medicare |
$15.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$60.63
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$18.72
|
|
|
.HDL Comment LC
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
CPT 83718
|
| Hospital Charge Code |
22311129
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$27.04 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of AZ Commercial |
$93.60
|
| Rate for Payer: Bisbee Police All Plans |
$27.04
|
| Rate for Payer: Cash Price |
$83.20
|
| Rate for Payer: Self Pay Self Pay |
$83.20
|
|
|
.HE4 Methodology LC
|
Facility
|
IP
|
$377.00
|
|
|
Service Code
|
CPT 86305
|
| Hospital Charge Code |
22311147
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$98.02 |
| Max. Negotiated Rate |
$339.30 |
| Rate for Payer: Aetna of AZ Commercial |
$339.30
|
| Rate for Payer: Bisbee Police All Plans |
$98.02
|
| Rate for Payer: Cash Price |
$301.60
|
| Rate for Payer: Self Pay Self Pay |
$301.60
|
|
|
.HE4 Methodology LC
|
Facility
|
OP
|
$377.00
|
|
|
Service Code
|
CPT 86305
|
| Hospital Charge Code |
22311147
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$56.55 |
| Max. Negotiated Rate |
$339.30 |
| Rate for Payer: Aetna of AZ Commercial |
$339.30
|
| Rate for Payer: Aetna of AZ Medicare |
$105.56
|
| Rate for Payer: Allwell Medicare |
$56.55
|
| Rate for Payer: Amerigroup Medicare |
$56.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$140.81
|
| Rate for Payer: AZCH Complete Medicare |
$56.55
|
| Rate for Payer: Banner UC Health Medicare |
$56.55
|
| Rate for Payer: Bisbee Police All Plans |
$98.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$256.36
|
| Rate for Payer: Cash Price |
$301.60
|
| Rate for Payer: Cigna of AZ Commercial |
$245.05
|
| Rate for Payer: Copperpoint Commercial |
$93.31
|
| Rate for Payer: Health Net of AZ Commercial |
$226.20
|
| Rate for Payer: Health Net of AZ Medicare |
$105.56
|
| Rate for Payer: Humana of AZ Medicare |
$56.55
|
| Rate for Payer: Self Pay Self Pay |
$301.60
|
| Rate for Payer: TriWest Medicare |
$56.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$219.79
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$67.86
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$20,073.37
|
|
|
Service Code
|
APR-DRG 0554
|
| Hospital Charge Code |
APRDRG0553
|
| Min. Negotiated Rate |
$20,073.37 |
| Max. Negotiated Rate |
$20,073.37 |
| Rate for Payer: AHCCCS Medicaid |
$20,073.37
|
| Rate for Payer: Allwell Medicaid |
$20,073.37
|
| Rate for Payer: AZCH Complete Medicaid |
$20,073.37
|
| Rate for Payer: Banner UC Health Medicaid |
$20,073.37
|
| Rate for Payer: Mercy Care Medicaid |
$20,073.37
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$20,073.37
|
|
|
Service Code
|
APR-DRG 0554
|
| Hospital Charge Code |
APRDRG0554
|
| Min. Negotiated Rate |
$20,073.37 |
| Max. Negotiated Rate |
$20,073.37 |
| Rate for Payer: AHCCCS Medicaid |
$20,073.37
|
| Rate for Payer: Allwell Medicaid |
$20,073.37
|
| Rate for Payer: AZCH Complete Medicaid |
$20,073.37
|
| Rate for Payer: Banner UC Health Medicaid |
$20,073.37
|
| Rate for Payer: Mercy Care Medicaid |
$20,073.37
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$4,799.68
|
|
|
Service Code
|
APR-DRG 0551
|
| Hospital Charge Code |
APRDRG0554
|
| Min. Negotiated Rate |
$4,799.68 |
| Max. Negotiated Rate |
$4,799.68 |
| Rate for Payer: AHCCCS Medicaid |
$4,799.68
|
| Rate for Payer: Allwell Medicaid |
$4,799.68
|
| Rate for Payer: AZCH Complete Medicaid |
$4,799.68
|
| Rate for Payer: Banner UC Health Medicaid |
$4,799.68
|
| Rate for Payer: Mercy Care Medicaid |
$4,799.68
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$9,925.51
|
|
|
Service Code
|
APR-DRG 0553
|
| Hospital Charge Code |
APRDRG0552
|
| Min. Negotiated Rate |
$9,925.51 |
| Max. Negotiated Rate |
$9,925.51 |
| Rate for Payer: AHCCCS Medicaid |
$9,925.51
|
| Rate for Payer: Allwell Medicaid |
$9,925.51
|
| Rate for Payer: AZCH Complete Medicaid |
$9,925.51
|
| Rate for Payer: Banner UC Health Medicaid |
$9,925.51
|
| Rate for Payer: Mercy Care Medicaid |
$9,925.51
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$20,073.37
|
|
|
Service Code
|
APR-DRG 0554
|
| Hospital Charge Code |
APRDRG0551
|
| Min. Negotiated Rate |
$20,073.37 |
| Max. Negotiated Rate |
$20,073.37 |
| Rate for Payer: AHCCCS Medicaid |
$20,073.37
|
| Rate for Payer: Allwell Medicaid |
$20,073.37
|
| Rate for Payer: AZCH Complete Medicaid |
$20,073.37
|
| Rate for Payer: Banner UC Health Medicaid |
$20,073.37
|
| Rate for Payer: Mercy Care Medicaid |
$20,073.37
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$6,528.63
|
|
|
Service Code
|
APR-DRG 0552
|
| Hospital Charge Code |
APRDRG0552
|
| Min. Negotiated Rate |
$6,528.63 |
| Max. Negotiated Rate |
$6,528.63 |
| Rate for Payer: AHCCCS Medicaid |
$6,528.63
|
| Rate for Payer: Allwell Medicaid |
$6,528.63
|
| Rate for Payer: AZCH Complete Medicaid |
$6,528.63
|
| Rate for Payer: Banner UC Health Medicaid |
$6,528.63
|
| Rate for Payer: Mercy Care Medicaid |
$6,528.63
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$20,073.37
|
|
|
Service Code
|
APR-DRG 0554
|
| Hospital Charge Code |
APRDRG0552
|
| Min. Negotiated Rate |
$20,073.37 |
| Max. Negotiated Rate |
$20,073.37 |
| Rate for Payer: AHCCCS Medicaid |
$20,073.37
|
| Rate for Payer: Allwell Medicaid |
$20,073.37
|
| Rate for Payer: AZCH Complete Medicaid |
$20,073.37
|
| Rate for Payer: Banner UC Health Medicaid |
$20,073.37
|
| Rate for Payer: Mercy Care Medicaid |
$20,073.37
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$4,799.68
|
|
|
Service Code
|
APR-DRG 0551
|
| Hospital Charge Code |
APRDRG0551
|
| Min. Negotiated Rate |
$4,799.68 |
| Max. Negotiated Rate |
$4,799.68 |
| Rate for Payer: AHCCCS Medicaid |
$4,799.68
|
| Rate for Payer: Allwell Medicaid |
$4,799.68
|
| Rate for Payer: AZCH Complete Medicaid |
$4,799.68
|
| Rate for Payer: Banner UC Health Medicaid |
$4,799.68
|
| Rate for Payer: Mercy Care Medicaid |
$4,799.68
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$9,925.51
|
|
|
Service Code
|
APR-DRG 0553
|
| Hospital Charge Code |
APRDRG0553
|
| Min. Negotiated Rate |
$9,925.51 |
| Max. Negotiated Rate |
$9,925.51 |
| Rate for Payer: AHCCCS Medicaid |
$9,925.51
|
| Rate for Payer: Allwell Medicaid |
$9,925.51
|
| Rate for Payer: AZCH Complete Medicaid |
$9,925.51
|
| Rate for Payer: Banner UC Health Medicaid |
$9,925.51
|
| Rate for Payer: Mercy Care Medicaid |
$9,925.51
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$4,799.68
|
|
|
Service Code
|
APR-DRG 0551
|
| Hospital Charge Code |
APRDRG0553
|
| Min. Negotiated Rate |
$4,799.68 |
| Max. Negotiated Rate |
$4,799.68 |
| Rate for Payer: AHCCCS Medicaid |
$4,799.68
|
| Rate for Payer: Allwell Medicaid |
$4,799.68
|
| Rate for Payer: AZCH Complete Medicaid |
$4,799.68
|
| Rate for Payer: Banner UC Health Medicaid |
$4,799.68
|
| Rate for Payer: Mercy Care Medicaid |
$4,799.68
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$6,528.63
|
|
|
Service Code
|
APR-DRG 0552
|
| Hospital Charge Code |
APRDRG0554
|
| Min. Negotiated Rate |
$6,528.63 |
| Max. Negotiated Rate |
$6,528.63 |
| Rate for Payer: AHCCCS Medicaid |
$6,528.63
|
| Rate for Payer: Allwell Medicaid |
$6,528.63
|
| Rate for Payer: AZCH Complete Medicaid |
$6,528.63
|
| Rate for Payer: Banner UC Health Medicaid |
$6,528.63
|
| Rate for Payer: Mercy Care Medicaid |
$6,528.63
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$6,528.63
|
|
|
Service Code
|
APR-DRG 0552
|
| Hospital Charge Code |
APRDRG0553
|
| Min. Negotiated Rate |
$6,528.63 |
| Max. Negotiated Rate |
$6,528.63 |
| Rate for Payer: AHCCCS Medicaid |
$6,528.63
|
| Rate for Payer: Allwell Medicaid |
$6,528.63
|
| Rate for Payer: AZCH Complete Medicaid |
$6,528.63
|
| Rate for Payer: Banner UC Health Medicaid |
$6,528.63
|
| Rate for Payer: Mercy Care Medicaid |
$6,528.63
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$9,925.51
|
|
|
Service Code
|
APR-DRG 0553
|
| Hospital Charge Code |
APRDRG0554
|
| Min. Negotiated Rate |
$9,925.51 |
| Max. Negotiated Rate |
$9,925.51 |
| Rate for Payer: AHCCCS Medicaid |
$9,925.51
|
| Rate for Payer: Allwell Medicaid |
$9,925.51
|
| Rate for Payer: AZCH Complete Medicaid |
$9,925.51
|
| Rate for Payer: Banner UC Health Medicaid |
$9,925.51
|
| Rate for Payer: Mercy Care Medicaid |
$9,925.51
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$6,528.63
|
|
|
Service Code
|
APR-DRG 0552
|
| Hospital Charge Code |
APRDRG0551
|
| Min. Negotiated Rate |
$6,528.63 |
| Max. Negotiated Rate |
$6,528.63 |
| Rate for Payer: AHCCCS Medicaid |
$6,528.63
|
| Rate for Payer: Allwell Medicaid |
$6,528.63
|
| Rate for Payer: AZCH Complete Medicaid |
$6,528.63
|
| Rate for Payer: Banner UC Health Medicaid |
$6,528.63
|
| Rate for Payer: Mercy Care Medicaid |
$6,528.63
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$4,799.68
|
|
|
Service Code
|
APR-DRG 0551
|
| Hospital Charge Code |
APRDRG0552
|
| Min. Negotiated Rate |
$4,799.68 |
| Max. Negotiated Rate |
$4,799.68 |
| Rate for Payer: AHCCCS Medicaid |
$4,799.68
|
| Rate for Payer: Allwell Medicaid |
$4,799.68
|
| Rate for Payer: AZCH Complete Medicaid |
$4,799.68
|
| Rate for Payer: Banner UC Health Medicaid |
$4,799.68
|
| Rate for Payer: Mercy Care Medicaid |
$4,799.68
|
|
