|
80361 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
IP
|
$227.00
|
|
|
Service Code
|
CPT 80361
|
| Hospital Charge Code |
28077444
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$204.30 |
| Max. Negotiated Rate |
$204.30 |
| Rate for Payer: Aetna of AZ Commercial |
$204.30
|
| Rate for Payer: Cash Price |
$181.60
|
|
|
80364 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
CPT 80364
|
| Hospital Charge Code |
28075340
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$252.90 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Cash Price |
$224.80
|
|
|
80364 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
CPT 80364
|
| Hospital Charge Code |
28075340
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.51 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$44.96
|
| Rate for Payer: Banner UC Health Medicare |
$44.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$191.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$44.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$44.96
|
| Rate for Payer: Cash Price |
$224.80
|
| Rate for Payer: Cigna of AZ Commercial |
$182.65
|
| Rate for Payer: Devoted Health Medicare |
$50.58
|
| Rate for Payer: Humana of AZ Medicare |
$44.96
|
| Rate for Payer: Southwest Service Administrators UFCW |
$191.08
|
| Rate for Payer: TriWest Medicare |
$44.96
|
| Rate for Payer: United Healthcare Commercial |
$160.73
|
| Rate for Payer: United Healthcare Medicare |
$44.96
|
| Rate for Payer: Veterans Affairs TRICARE |
$44.51
|
|
|
80365 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
IP
|
$254.00
|
|
|
Service Code
|
CPT 80365
|
| Hospital Charge Code |
28077253
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$228.60 |
| Max. Negotiated Rate |
$228.60 |
| Rate for Payer: Aetna of AZ Commercial |
$228.60
|
| Rate for Payer: Cash Price |
$203.20
|
|
|
80365 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
OP
|
$254.00
|
|
|
Service Code
|
CPT 80365
|
| Hospital Charge Code |
28077253
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.23 |
| Max. Negotiated Rate |
$228.60 |
| Rate for Payer: Aetna of AZ Commercial |
$228.60
|
| Rate for Payer: Arizona Complete Health Allwell |
$40.64
|
| Rate for Payer: Banner UC Health Medicare |
$40.64
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$172.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$40.64
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$40.64
|
| Rate for Payer: Cash Price |
$203.20
|
| Rate for Payer: Cigna of AZ Commercial |
$165.10
|
| Rate for Payer: Devoted Health Medicare |
$45.72
|
| Rate for Payer: Humana of AZ Medicare |
$40.64
|
| Rate for Payer: Southwest Service Administrators UFCW |
$172.72
|
| Rate for Payer: TriWest Medicare |
$40.64
|
| Rate for Payer: United Healthcare Commercial |
$145.29
|
| Rate for Payer: United Healthcare Medicare |
$40.64
|
| Rate for Payer: Veterans Affairs TRICARE |
$40.23
|
|
|
80366 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
CPT 80366
|
| Hospital Charge Code |
28075341
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$252.90 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Cash Price |
$224.80
|
|
|
80366 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
CPT 80366
|
| Hospital Charge Code |
28075341
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.51 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$44.96
|
| Rate for Payer: Banner UC Health Medicare |
$44.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$191.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$44.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$44.96
|
| Rate for Payer: Cash Price |
$224.80
|
| Rate for Payer: Cigna of AZ Commercial |
$182.65
|
| Rate for Payer: Devoted Health Medicare |
$50.58
|
| Rate for Payer: Humana of AZ Medicare |
$44.96
|
| Rate for Payer: Southwest Service Administrators UFCW |
$191.08
|
| Rate for Payer: TriWest Medicare |
$44.96
|
| Rate for Payer: United Healthcare Commercial |
$160.73
|
| Rate for Payer: United Healthcare Medicare |
$44.96
|
| Rate for Payer: Veterans Affairs TRICARE |
$44.51
|
|
|
80367 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
CPT 80367
|
| Hospital Charge Code |
28077254
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$252.90 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Cash Price |
$224.80
|
|
|
80367 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
CPT 80367
|
| Hospital Charge Code |
28077254
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.51 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$44.96
|
| Rate for Payer: Banner UC Health Medicare |
$44.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$191.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$44.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$44.96
|
| Rate for Payer: Cash Price |
$224.80
|
| Rate for Payer: Cigna of AZ Commercial |
$182.65
|
| Rate for Payer: Devoted Health Medicare |
$50.58
|
| Rate for Payer: Humana of AZ Medicare |
$44.96
|
| Rate for Payer: Southwest Service Administrators UFCW |
$191.08
|
| Rate for Payer: TriWest Medicare |
$44.96
|
| Rate for Payer: United Healthcare Commercial |
$160.73
|
| Rate for Payer: United Healthcare Medicare |
$44.96
|
| Rate for Payer: Veterans Affairs TRICARE |
$44.51
|
|
|
80368 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
CPT 80368
|
| Hospital Charge Code |
28075342
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$252.90 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Cash Price |
$224.80
|
|
|
80368 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
CPT 80368
|
| Hospital Charge Code |
28075342
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.51 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$44.96
|
| Rate for Payer: Banner UC Health Medicare |
$44.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$191.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$44.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$44.96
|
| Rate for Payer: Cash Price |
$224.80
|
| Rate for Payer: Cigna of AZ Commercial |
$182.65
|
| Rate for Payer: Devoted Health Medicare |
$50.58
|
| Rate for Payer: Humana of AZ Medicare |
$44.96
|
| Rate for Payer: Southwest Service Administrators UFCW |
$191.08
|
| Rate for Payer: TriWest Medicare |
$44.96
|
| Rate for Payer: United Healthcare Commercial |
$160.73
|
| Rate for Payer: United Healthcare Medicare |
$44.96
|
| Rate for Payer: Veterans Affairs TRICARE |
$44.51
|
|
|
80370 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
CPT 80370
|
| Hospital Charge Code |
28075343
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.51 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$44.96
|
| Rate for Payer: Banner UC Health Medicare |
$44.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$191.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$44.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$44.96
|
| Rate for Payer: Cash Price |
$224.80
|
| Rate for Payer: Cigna of AZ Commercial |
$182.65
|
| Rate for Payer: Devoted Health Medicare |
$50.58
|
| Rate for Payer: Humana of AZ Medicare |
$44.96
|
| Rate for Payer: Southwest Service Administrators UFCW |
$191.08
|
| Rate for Payer: TriWest Medicare |
$44.96
|
| Rate for Payer: United Healthcare Commercial |
$160.73
|
| Rate for Payer: United Healthcare Medicare |
$44.96
|
| Rate for Payer: Veterans Affairs TRICARE |
$44.51
|
|
|
80370 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
CPT 80370
|
| Hospital Charge Code |
28075343
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$252.90 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Cash Price |
$224.80
|
|
|
80371 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
CPT 80371
|
| Hospital Charge Code |
28075344
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$252.90 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Cash Price |
$224.80
|
|
|
80371 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
CPT 80371
|
| Hospital Charge Code |
28075344
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.51 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$44.96
|
| Rate for Payer: Banner UC Health Medicare |
$44.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$191.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$44.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$44.96
|
| Rate for Payer: Cash Price |
$224.80
|
| Rate for Payer: Cigna of AZ Commercial |
$182.65
|
| Rate for Payer: Devoted Health Medicare |
$50.58
|
| Rate for Payer: Humana of AZ Medicare |
$44.96
|
| Rate for Payer: Southwest Service Administrators UFCW |
$191.08
|
| Rate for Payer: TriWest Medicare |
$44.96
|
| Rate for Payer: United Healthcare Commercial |
$160.73
|
| Rate for Payer: United Healthcare Medicare |
$44.96
|
| Rate for Payer: Veterans Affairs TRICARE |
$44.51
|
|
|
80372 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
CPT 80372
|
| Hospital Charge Code |
28077255
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$252.90 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Cash Price |
$224.80
|
|
|
80372 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
CPT 80372
|
| Hospital Charge Code |
28077255
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.51 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$44.96
|
| Rate for Payer: Banner UC Health Medicare |
$44.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$191.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$44.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$44.96
|
| Rate for Payer: Cash Price |
$224.80
|
| Rate for Payer: Cigna of AZ Commercial |
$182.65
|
| Rate for Payer: Devoted Health Medicare |
$50.58
|
| Rate for Payer: Humana of AZ Medicare |
$44.96
|
| Rate for Payer: Southwest Service Administrators UFCW |
$191.08
|
| Rate for Payer: TriWest Medicare |
$44.96
|
| Rate for Payer: United Healthcare Commercial |
$160.73
|
| Rate for Payer: United Healthcare Medicare |
$44.96
|
| Rate for Payer: Veterans Affairs TRICARE |
$44.51
|
|
|
80373 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
OP
|
$239.00
|
|
|
Service Code
|
CPT 80373
|
| Hospital Charge Code |
28077256
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$37.86 |
| Max. Negotiated Rate |
$215.10 |
| Rate for Payer: Aetna of AZ Commercial |
$215.10
|
| Rate for Payer: Arizona Complete Health Allwell |
$38.24
|
| Rate for Payer: Banner UC Health Medicare |
$38.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$162.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$38.24
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$38.24
|
| Rate for Payer: Cash Price |
$191.20
|
| Rate for Payer: Cigna of AZ Commercial |
$155.35
|
| Rate for Payer: Devoted Health Medicare |
$43.02
|
| Rate for Payer: Humana of AZ Medicare |
$38.24
|
| Rate for Payer: Southwest Service Administrators UFCW |
$162.52
|
| Rate for Payer: TriWest Medicare |
$38.24
|
| Rate for Payer: United Healthcare Commercial |
$136.71
|
| Rate for Payer: United Healthcare Medicare |
$38.24
|
| Rate for Payer: Veterans Affairs TRICARE |
$37.86
|
|
|
80373 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
IP
|
$239.00
|
|
|
Service Code
|
CPT 80373
|
| Hospital Charge Code |
28077256
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$215.10 |
| Max. Negotiated Rate |
$215.10 |
| Rate for Payer: Aetna of AZ Commercial |
$215.10
|
| Rate for Payer: Cash Price |
$191.20
|
|
|
80377 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
OP
|
$281.00
|
|
|
Service Code
|
CPT 80377
|
| Hospital Charge Code |
28073693
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$44.51 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$44.96
|
| Rate for Payer: Banner UC Health Medicare |
$44.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$191.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$44.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$44.96
|
| Rate for Payer: Cash Price |
$224.80
|
| Rate for Payer: Cigna of AZ Commercial |
$182.65
|
| Rate for Payer: Devoted Health Medicare |
$50.58
|
| Rate for Payer: Humana of AZ Medicare |
$44.96
|
| Rate for Payer: Southwest Service Administrators UFCW |
$191.08
|
| Rate for Payer: TriWest Medicare |
$44.96
|
| Rate for Payer: United Healthcare Commercial |
$160.73
|
| Rate for Payer: United Healthcare Medicare |
$44.96
|
| Rate for Payer: Veterans Affairs TRICARE |
$44.51
|
|
|
80377 Drug Analysis Profile, Comprehensive, Ur LC
|
Facility
|
IP
|
$281.00
|
|
|
Service Code
|
CPT 80377
|
| Hospital Charge Code |
28073693
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$252.90 |
| Max. Negotiated Rate |
$252.90 |
| Rate for Payer: Aetna of AZ Commercial |
$252.90
|
| Rate for Payer: Cash Price |
$224.80
|
|
|
82107 HEPATOCELLULAR
|
Facility
|
IP
|
$226.00
|
|
|
Service Code
|
CPT 82107
|
| Hospital Charge Code |
23294379
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$203.40 |
| Max. Negotiated Rate |
$203.40 |
| Rate for Payer: Aetna of AZ Commercial |
$203.40
|
| Rate for Payer: Cash Price |
$180.80
|
|
|
82107 HEPATOCELLULAR
|
Facility
|
OP
|
$226.00
|
|
|
Service Code
|
CPT 82107
|
| Hospital Charge Code |
23294379
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$35.80 |
| Max. Negotiated Rate |
$203.40 |
| Rate for Payer: Aetna of AZ Commercial |
$203.40
|
| Rate for Payer: Arizona Complete Health Allwell |
$36.16
|
| Rate for Payer: Banner UC Health Medicare |
$36.16
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$153.68
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$36.16
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$36.16
|
| Rate for Payer: Cash Price |
$180.80
|
| Rate for Payer: Cash Price |
$180.80
|
| Rate for Payer: Cigna of AZ Commercial |
$146.90
|
| Rate for Payer: Devoted Health Medicare |
$40.68
|
| Rate for Payer: Humana of AZ Medicare |
$36.16
|
| Rate for Payer: Seven Corners Travel Insurance |
$93.39
|
| Rate for Payer: Southwest Service Administrators UFCW |
$153.68
|
| Rate for Payer: TriWest Medicare |
$36.16
|
| Rate for Payer: United Healthcare Commercial |
$129.27
|
| Rate for Payer: United Healthcare Medicare |
$36.16
|
| Rate for Payer: Veterans Affairs TRICARE |
$35.80
|
|
|
82140 - Litholink 24-Hour Urine, KS LC
|
Facility
|
IP
|
$171.00
|
|
|
Service Code
|
CPT 82140
|
| Hospital Charge Code |
28268593
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$153.90 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Aetna of AZ Commercial |
$153.90
|
| Rate for Payer: Cash Price |
$136.80
|
|
|
82140 - Litholink 24-Hour Urine, KS LC
|
Facility
|
OP
|
$171.00
|
|
|
Service Code
|
CPT 82140
|
| Hospital Charge Code |
28268593
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.13 |
| Max. Negotiated Rate |
$153.90 |
| Rate for Payer: Aetna of AZ Commercial |
$153.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$27.36
|
| Rate for Payer: Banner UC Health Medicare |
$27.36
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$116.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$27.36
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$27.36
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cash Price |
$136.80
|
| Rate for Payer: Cigna of AZ Commercial |
$111.15
|
| Rate for Payer: Devoted Health Medicare |
$30.78
|
| Rate for Payer: Humana of AZ Medicare |
$27.36
|
| Rate for Payer: Seven Corners Travel Insurance |
$21.13
|
| Rate for Payer: Southwest Service Administrators UFCW |
$116.28
|
| Rate for Payer: TriWest Medicare |
$27.36
|
| Rate for Payer: United Healthcare Commercial |
$97.81
|
| Rate for Payer: United Healthcare Medicare |
$27.36
|
| Rate for Payer: Veterans Affairs TRICARE |
$27.09
|
|
