|
EXTRACTOR STONE 2.8F NTRAP
|
Facility
|
OP
|
$1,686.00
|
|
| Hospital Charge Code |
22354228
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$267.06 |
| Max. Negotiated Rate |
$1,517.40 |
| Rate for Payer: Aetna of AZ Commercial |
$1,517.40
|
| Rate for Payer: Arizona Complete Health Allwell |
$269.76
|
| Rate for Payer: Banner UC Health Medicare |
$269.76
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$1,146.48
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$269.76
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$269.76
|
| Rate for Payer: Cash Price |
$1,348.80
|
| Rate for Payer: Cigna of AZ Commercial |
$1,180.20
|
| Rate for Payer: Devoted Health Medicare |
$303.48
|
| Rate for Payer: Humana of AZ Medicare |
$269.76
|
| Rate for Payer: Southwest Service Administrators UFCW |
$1,146.48
|
| Rate for Payer: TriWest Medicare |
$269.76
|
| Rate for Payer: United Healthcare Commercial |
$964.39
|
| Rate for Payer: United Healthcare Medicare |
$269.76
|
| Rate for Payer: Veterans Affairs TRICARE |
$267.06
|
|
|
EXTRACTOR STONE NCIRCLE TIPLESS 2.2F
|
Facility
|
OP
|
$712.00
|
|
| Hospital Charge Code |
22354219
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$112.78 |
| Max. Negotiated Rate |
$640.80 |
| Rate for Payer: Aetna of AZ Commercial |
$640.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$113.92
|
| Rate for Payer: Banner UC Health Medicare |
$113.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$484.16
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$113.92
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$113.92
|
| Rate for Payer: Cash Price |
$569.60
|
| Rate for Payer: Cigna of AZ Commercial |
$498.40
|
| Rate for Payer: Devoted Health Medicare |
$128.16
|
| Rate for Payer: Humana of AZ Medicare |
$113.92
|
| Rate for Payer: Southwest Service Administrators UFCW |
$484.16
|
| Rate for Payer: TriWest Medicare |
$113.92
|
| Rate for Payer: United Healthcare Commercial |
$407.26
|
| Rate for Payer: United Healthcare Medicare |
$113.92
|
| Rate for Payer: Veterans Affairs TRICARE |
$112.78
|
|
|
EXTRACTOR STONE NCIRCLE TIPLESS 2.2F
|
Facility
|
IP
|
$712.00
|
|
| Hospital Charge Code |
22354219
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$640.80 |
| Max. Negotiated Rate |
$640.80 |
| Rate for Payer: Aetna of AZ Commercial |
$640.80
|
| Rate for Payer: Cash Price |
$569.60
|
|
|
EXTRACTOR STONE NCIRCLE TIPLESS 4.5F
|
Facility
|
IP
|
$818.00
|
|
| Hospital Charge Code |
22354217
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$736.20 |
| Max. Negotiated Rate |
$736.20 |
| Rate for Payer: Aetna of AZ Commercial |
$736.20
|
| Rate for Payer: Cash Price |
$654.40
|
|
|
EXTRACTOR STONE NCIRCLE TIPLESS 4.5F
|
Facility
|
OP
|
$818.00
|
|
| Hospital Charge Code |
22354217
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$129.57 |
| Max. Negotiated Rate |
$736.20 |
| Rate for Payer: Aetna of AZ Commercial |
$736.20
|
| Rate for Payer: Arizona Complete Health Allwell |
$130.88
|
| Rate for Payer: Banner UC Health Medicare |
$130.88
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$556.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$130.88
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$130.88
|
| Rate for Payer: Cash Price |
$654.40
|
| Rate for Payer: Cigna of AZ Commercial |
$572.60
|
| Rate for Payer: Devoted Health Medicare |
$147.24
|
| Rate for Payer: Humana of AZ Medicare |
$130.88
|
| Rate for Payer: Southwest Service Administrators UFCW |
$556.24
|
| Rate for Payer: TriWest Medicare |
$130.88
|
| Rate for Payer: United Healthcare Commercial |
$467.90
|
| Rate for Payer: United Healthcare Medicare |
$130.88
|
| Rate for Payer: Veterans Affairs TRICARE |
$129.57
|
|
|
EXTRACTOR STONE NCOMPASS 2.4F
|
Facility
|
OP
|
$752.00
|
|
| Hospital Charge Code |
22354227
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$119.12 |
| Max. Negotiated Rate |
$676.80 |
| Rate for Payer: Aetna of AZ Commercial |
$676.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$120.32
|
| Rate for Payer: Banner UC Health Medicare |
$120.32
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$511.36
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$120.32
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$120.32
|
| Rate for Payer: Cash Price |
$601.60
|
| Rate for Payer: Cigna of AZ Commercial |
$526.40
|
| Rate for Payer: Devoted Health Medicare |
$135.36
|
| Rate for Payer: Humana of AZ Medicare |
$120.32
|
| Rate for Payer: Southwest Service Administrators UFCW |
$511.36
|
| Rate for Payer: TriWest Medicare |
$120.32
|
| Rate for Payer: United Healthcare Commercial |
$430.14
|
| Rate for Payer: United Healthcare Medicare |
$120.32
|
| Rate for Payer: Veterans Affairs TRICARE |
$119.12
|
|
|
EXTRACTOR STONE NCOMPASS 2.4F
|
Facility
|
IP
|
$752.00
|
|
| Hospital Charge Code |
22354227
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$676.80 |
| Max. Negotiated Rate |
$676.80 |
| Rate for Payer: Aetna of AZ Commercial |
$676.80
|
| Rate for Payer: Cash Price |
$601.60
|
|
|
EXTRAOCULAR PROCEDURES EXCEPT ORBIT
|
Facility
|
IP
|
$19,837.25
|
|
|
Service Code
|
MSDRG 115
|
| Min. Negotiated Rate |
$19,837.25 |
| Max. Negotiated Rate |
$19,837.25 |
| Rate for Payer: Seven Corners Travel Insurance |
$19,837.25
|
|
|
EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE
|
Facility
|
IP
|
$76,814.62
|
|
|
Service Code
|
MSDRG 790
|
| Min. Negotiated Rate |
$76,814.62 |
| Max. Negotiated Rate |
$76,814.62 |
| Rate for Payer: Seven Corners Travel Insurance |
$76,814.62
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$16,680.69
|
|
|
Service Code
|
APR-DRG 0824
|
| Hospital Charge Code |
APRDRG0824
|
| Min. Negotiated Rate |
$16,680.69 |
| Max. Negotiated Rate |
$16,680.69 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$16,680.69
|
| Rate for Payer: Mercy Care Medicaid |
$16,680.69
|
| Rate for Payer: NaphCare Correctional Healthcare |
$16,680.69
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$4,676.94
|
|
|
Service Code
|
APR-DRG 0822
|
| Hospital Charge Code |
APRDRG0821
|
| Min. Negotiated Rate |
$4,676.94 |
| Max. Negotiated Rate |
$4,676.94 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,676.94
|
| Rate for Payer: Mercy Care Medicaid |
$4,676.94
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,676.94
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$3,833.85
|
|
|
Service Code
|
APR-DRG 0821
|
| Hospital Charge Code |
APRDRG0821
|
| Min. Negotiated Rate |
$3,833.85 |
| Max. Negotiated Rate |
$3,833.85 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,833.85
|
| Rate for Payer: Mercy Care Medicaid |
$3,833.85
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,833.85
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$16,680.69
|
|
|
Service Code
|
APR-DRG 0824
|
| Hospital Charge Code |
APRDRG0823
|
| Min. Negotiated Rate |
$16,680.69 |
| Max. Negotiated Rate |
$16,680.69 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$16,680.69
|
| Rate for Payer: Mercy Care Medicaid |
$16,680.69
|
| Rate for Payer: NaphCare Correctional Healthcare |
$16,680.69
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$16,680.69
|
|
|
Service Code
|
APR-DRG 0824
|
| Hospital Charge Code |
APRDRG0821
|
| Min. Negotiated Rate |
$16,680.69 |
| Max. Negotiated Rate |
$16,680.69 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$16,680.69
|
| Rate for Payer: Mercy Care Medicaid |
$16,680.69
|
| Rate for Payer: NaphCare Correctional Healthcare |
$16,680.69
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$7,170.41
|
|
|
Service Code
|
APR-DRG 0823
|
| Hospital Charge Code |
APRDRG0821
|
| Min. Negotiated Rate |
$7,170.41 |
| Max. Negotiated Rate |
$7,170.41 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$7,170.41
|
| Rate for Payer: Mercy Care Medicaid |
$7,170.41
|
| Rate for Payer: NaphCare Correctional Healthcare |
$7,170.41
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$3,833.85
|
|
|
Service Code
|
APR-DRG 0821
|
| Hospital Charge Code |
APRDRG0822
|
| Min. Negotiated Rate |
$3,833.85 |
| Max. Negotiated Rate |
$3,833.85 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,833.85
|
| Rate for Payer: Mercy Care Medicaid |
$3,833.85
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,833.85
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$3,833.85
|
|
|
Service Code
|
APR-DRG 0821
|
| Hospital Charge Code |
APRDRG0824
|
| Min. Negotiated Rate |
$3,833.85 |
| Max. Negotiated Rate |
$3,833.85 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,833.85
|
| Rate for Payer: Mercy Care Medicaid |
$3,833.85
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,833.85
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$4,676.94
|
|
|
Service Code
|
APR-DRG 0822
|
| Hospital Charge Code |
APRDRG0824
|
| Min. Negotiated Rate |
$4,676.94 |
| Max. Negotiated Rate |
$4,676.94 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,676.94
|
| Rate for Payer: Mercy Care Medicaid |
$4,676.94
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,676.94
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$7,170.41
|
|
|
Service Code
|
APR-DRG 0823
|
| Hospital Charge Code |
APRDRG0823
|
| Min. Negotiated Rate |
$7,170.41 |
| Max. Negotiated Rate |
$7,170.41 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$7,170.41
|
| Rate for Payer: Mercy Care Medicaid |
$7,170.41
|
| Rate for Payer: NaphCare Correctional Healthcare |
$7,170.41
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$7,170.41
|
|
|
Service Code
|
APR-DRG 0823
|
| Hospital Charge Code |
APRDRG0824
|
| Min. Negotiated Rate |
$7,170.41 |
| Max. Negotiated Rate |
$7,170.41 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$7,170.41
|
| Rate for Payer: Mercy Care Medicaid |
$7,170.41
|
| Rate for Payer: NaphCare Correctional Healthcare |
$7,170.41
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$4,676.94
|
|
|
Service Code
|
APR-DRG 0822
|
| Hospital Charge Code |
APRDRG0822
|
| Min. Negotiated Rate |
$4,676.94 |
| Max. Negotiated Rate |
$4,676.94 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,676.94
|
| Rate for Payer: Mercy Care Medicaid |
$4,676.94
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,676.94
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$3,833.85
|
|
|
Service Code
|
APR-DRG 0821
|
| Hospital Charge Code |
APRDRG0823
|
| Min. Negotiated Rate |
$3,833.85 |
| Max. Negotiated Rate |
$3,833.85 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,833.85
|
| Rate for Payer: Mercy Care Medicaid |
$3,833.85
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,833.85
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$16,680.69
|
|
|
Service Code
|
APR-DRG 0824
|
| Hospital Charge Code |
APRDRG0822
|
| Min. Negotiated Rate |
$16,680.69 |
| Max. Negotiated Rate |
$16,680.69 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$16,680.69
|
| Rate for Payer: Mercy Care Medicaid |
$16,680.69
|
| Rate for Payer: NaphCare Correctional Healthcare |
$16,680.69
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$7,170.41
|
|
|
Service Code
|
APR-DRG 0823
|
| Hospital Charge Code |
APRDRG0822
|
| Min. Negotiated Rate |
$7,170.41 |
| Max. Negotiated Rate |
$7,170.41 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$7,170.41
|
| Rate for Payer: Mercy Care Medicaid |
$7,170.41
|
| Rate for Payer: NaphCare Correctional Healthcare |
$7,170.41
|
|
|
Eye Infections And Other Eye Disorders
|
Facility
|
IP
|
$4,676.94
|
|
|
Service Code
|
APR-DRG 0822
|
| Hospital Charge Code |
APRDRG0823
|
| Min. Negotiated Rate |
$4,676.94 |
| Max. Negotiated Rate |
$4,676.94 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,676.94
|
| Rate for Payer: Mercy Care Medicaid |
$4,676.94
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,676.94
|
|
