|
HCV with Drug Resistance
|
Facility
|
IP
|
$999.00
|
|
|
Service Code
|
CPT 87900
|
| Hospital Charge Code |
22907367
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$899.10 |
| Max. Negotiated Rate |
$899.10 |
| Rate for Payer: Aetna of AZ Commercial |
$899.10
|
| Rate for Payer: Cash Price |
$799.20
|
|
|
HCV with Drug Resistance
|
Facility
|
IP
|
$999.00
|
|
|
Service Code
|
CPT 87901
|
| Hospital Charge Code |
23173795
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$899.10 |
| Max. Negotiated Rate |
$899.10 |
| Rate for Payer: Aetna of AZ Commercial |
$899.10
|
| Rate for Payer: Cash Price |
$799.20
|
|
|
.HDL Comment LC
|
Facility
|
OP
|
$104.00
|
|
|
Service Code
|
CPT 83718
|
| Hospital Charge Code |
22311129
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.88 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of AZ Commercial |
$93.60
|
| Rate for Payer: Arizona Complete Health Allwell |
$16.64
|
| Rate for Payer: Banner UC Health Medicare |
$16.64
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$70.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$16.64
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$16.64
|
| 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: Devoted Health Medicare |
$18.72
|
| Rate for Payer: Humana of AZ Medicare |
$16.64
|
| Rate for Payer: Seven Corners Travel Insurance |
$11.88
|
| Rate for Payer: Southwest Service Administrators UFCW |
$70.72
|
| Rate for Payer: TriWest Medicare |
$16.64
|
| Rate for Payer: United Healthcare Commercial |
$59.49
|
| Rate for Payer: United Healthcare Medicare |
$16.64
|
| Rate for Payer: Veterans Affairs TRICARE |
$16.47
|
|
|
.HDL Comment LC
|
Facility
|
IP
|
$104.00
|
|
|
Service Code
|
CPT 83718
|
| Hospital Charge Code |
22311129
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$93.60 |
| Max. Negotiated Rate |
$93.60 |
| Rate for Payer: Aetna of AZ Commercial |
$93.60
|
| Rate for Payer: Cash Price |
$83.20
|
|
|
HD SCREW 2MMX12MM
|
Facility
|
IP
|
$1,750.00
|
|
| Hospital Charge Code |
29522609
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,575.00 |
| Max. Negotiated Rate |
$1,575.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,575.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
|
|
HD SCREW 2MMX12MM
|
Facility
|
OP
|
$1,750.00
|
|
| Hospital Charge Code |
29522609
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$277.20 |
| Max. Negotiated Rate |
$1,575.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,575.00
|
| Rate for Payer: Arizona Complete Health Allwell |
$280.00
|
| Rate for Payer: Banner UC Health Medicare |
$280.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$1,190.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$280.00
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$280.00
|
| Rate for Payer: Cash Price |
$1,400.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,225.00
|
| Rate for Payer: Devoted Health Medicare |
$315.00
|
| Rate for Payer: Humana of AZ Medicare |
$280.00
|
| Rate for Payer: Southwest Service Administrators UFCW |
$1,190.00
|
| Rate for Payer: TriWest Medicare |
$280.00
|
| Rate for Payer: United Healthcare Commercial |
$1,001.00
|
| Rate for Payer: United Healthcare Medicare |
$280.00
|
| Rate for Payer: Veterans Affairs TRICARE |
$277.20
|
|
|
.HE4 Methodology LC
|
Facility
|
OP
|
$377.00
|
|
|
Service Code
|
CPT 86305
|
| Hospital Charge Code |
22311147
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$30.17 |
| Max. Negotiated Rate |
$339.30 |
| Rate for Payer: Aetna of AZ Commercial |
$339.30
|
| Rate for Payer: Arizona Complete Health Allwell |
$60.32
|
| Rate for Payer: Banner UC Health Medicare |
$60.32
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$256.36
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$60.32
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$60.32
|
| Rate for Payer: Cash Price |
$301.60
|
| Rate for Payer: Cash Price |
$301.60
|
| Rate for Payer: Cigna of AZ Commercial |
$245.05
|
| Rate for Payer: Devoted Health Medicare |
$67.86
|
| Rate for Payer: Humana of AZ Medicare |
$60.32
|
| Rate for Payer: Seven Corners Travel Insurance |
$30.17
|
| Rate for Payer: Southwest Service Administrators UFCW |
$256.36
|
| Rate for Payer: TriWest Medicare |
$60.32
|
| Rate for Payer: United Healthcare Commercial |
$215.64
|
| Rate for Payer: United Healthcare Medicare |
$60.32
|
| Rate for Payer: Veterans Affairs TRICARE |
$59.72
|
|
|
.HE4 Methodology LC
|
Facility
|
IP
|
$377.00
|
|
|
Service Code
|
CPT 86305
|
| Hospital Charge Code |
22311147
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$339.30 |
| Max. Negotiated Rate |
$339.30 |
| Rate for Payer: Aetna of AZ Commercial |
$339.30
|
| Rate for Payer: Cash Price |
$301.60
|
|
|
HEADACHES WITH MCC
|
Facility
|
IP
|
$14,558.57
|
|
|
Service Code
|
MSDRG 102
|
| Min. Negotiated Rate |
$14,558.57 |
| Max. Negotiated Rate |
$14,558.57 |
| Rate for Payer: Seven Corners Travel Insurance |
$14,558.57
|
|
|
HEADACHES WITHOUT MCC
|
Facility
|
IP
|
$10,952.36
|
|
|
Service Code
|
MSDRG 103
|
| Min. Negotiated Rate |
$10,952.36 |
| Max. Negotiated Rate |
$10,952.36 |
| Rate for Payer: Seven Corners Travel Insurance |
$10,952.36
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$20,073.37
|
| Rate for Payer: Mercy Care Medicaid |
$20,073.37
|
| Rate for Payer: NaphCare Correctional Healthcare |
$20,073.37
|
|
|
Head Trauma With Coma > 1 Hour Or Hemorrhage
|
Facility
|
IP
|
$9,925.51
|
|
|
Service Code
|
APR-DRG 0553
|
| Hospital Charge Code |
APRDRG0551
|
| Min. Negotiated Rate |
$9,925.51 |
| Max. Negotiated Rate |
$9,925.51 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$9,925.51
|
| Rate for Payer: Mercy Care Medicaid |
$9,925.51
|
| Rate for Payer: NaphCare Correctional Healthcare |
$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: Blue Cross Blue Shield of Arizona Health Choice |
$4,799.68
|
| Rate for Payer: Mercy Care Medicaid |
$4,799.68
|
| Rate for Payer: NaphCare Correctional Healthcare |
$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: Blue Cross Blue Shield of Arizona Health Choice |
$6,528.63
|
| Rate for Payer: Mercy Care Medicaid |
$6,528.63
|
| Rate for Payer: NaphCare Correctional Healthcare |
$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: Blue Cross Blue Shield of Arizona Health Choice |
$6,528.63
|
| Rate for Payer: Mercy Care Medicaid |
$6,528.63
|
| Rate for Payer: NaphCare Correctional Healthcare |
$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: Blue Cross Blue Shield of Arizona Health Choice |
$20,073.37
|
| Rate for Payer: Mercy Care Medicaid |
$20,073.37
|
| Rate for Payer: NaphCare Correctional Healthcare |
$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: Blue Cross Blue Shield of Arizona Health Choice |
$6,528.63
|
| Rate for Payer: Mercy Care Medicaid |
$6,528.63
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,528.63
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$9,925.51
|
| Rate for Payer: Mercy Care Medicaid |
$9,925.51
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,925.51
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$4,799.68
|
| Rate for Payer: Mercy Care Medicaid |
$4,799.68
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,799.68
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$4,799.68
|
| Rate for Payer: Mercy Care Medicaid |
$4,799.68
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,799.68
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$4,799.68
|
| Rate for Payer: Mercy Care Medicaid |
$4,799.68
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,799.68
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$20,073.37
|
| Rate for Payer: Mercy Care Medicaid |
$20,073.37
|
| Rate for Payer: NaphCare Correctional Healthcare |
$20,073.37
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$6,528.63
|
| Rate for Payer: Mercy Care Medicaid |
$6,528.63
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,528.63
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$20,073.37
|
| Rate for Payer: Mercy Care Medicaid |
$20,073.37
|
| Rate for Payer: NaphCare Correctional Healthcare |
$20,073.37
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$9,925.51
|
| Rate for Payer: Mercy Care Medicaid |
$9,925.51
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,925.51
|
|
