|
MALIGNANT BREAST DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$10,104.64
|
|
|
Service Code
|
MSDRG 599
|
| Min. Negotiated Rate |
$10,104.64 |
| Max. Negotiated Rate |
$10,104.64 |
| Rate for Payer: Seven Corners Travel Insurance |
$10,104.64
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$4,259.60
|
|
|
Service Code
|
APR-DRG 4212
|
| Hospital Charge Code |
APRDRG4213
|
| Min. Negotiated Rate |
$4,259.60 |
| Max. Negotiated Rate |
$4,259.60 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,259.60
|
| Rate for Payer: Mercy Care Medicaid |
$4,259.60
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,259.60
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$6,868.81
|
|
|
Service Code
|
APR-DRG 4213
|
| Hospital Charge Code |
APRDRG4212
|
| Min. Negotiated Rate |
$6,868.81 |
| Max. Negotiated Rate |
$6,868.81 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,868.81
|
| Rate for Payer: Mercy Care Medicaid |
$6,868.81
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,868.81
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$15,381.00
|
|
|
Service Code
|
APR-DRG 4214
|
| Hospital Charge Code |
APRDRG4212
|
| Min. Negotiated Rate |
$15,381.00 |
| Max. Negotiated Rate |
$15,381.00 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$15,381.00
|
| Rate for Payer: Mercy Care Medicaid |
$15,381.00
|
| Rate for Payer: NaphCare Correctional Healthcare |
$15,381.00
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$15,381.00
|
|
|
Service Code
|
APR-DRG 4214
|
| Hospital Charge Code |
APRDRG4213
|
| Min. Negotiated Rate |
$15,381.00 |
| Max. Negotiated Rate |
$15,381.00 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$15,381.00
|
| Rate for Payer: Mercy Care Medicaid |
$15,381.00
|
| Rate for Payer: NaphCare Correctional Healthcare |
$15,381.00
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$6,868.81
|
|
|
Service Code
|
APR-DRG 4213
|
| Hospital Charge Code |
APRDRG4211
|
| Min. Negotiated Rate |
$6,868.81 |
| Max. Negotiated Rate |
$6,868.81 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,868.81
|
| Rate for Payer: Mercy Care Medicaid |
$6,868.81
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,868.81
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$3,281.15
|
|
|
Service Code
|
APR-DRG 4211
|
| Hospital Charge Code |
APRDRG4213
|
| Min. Negotiated Rate |
$3,281.15 |
| Max. Negotiated Rate |
$3,281.15 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,281.15
|
| Rate for Payer: Mercy Care Medicaid |
$3,281.15
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,281.15
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$4,259.60
|
|
|
Service Code
|
APR-DRG 4212
|
| Hospital Charge Code |
APRDRG4212
|
| Min. Negotiated Rate |
$4,259.60 |
| Max. Negotiated Rate |
$4,259.60 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,259.60
|
| Rate for Payer: Mercy Care Medicaid |
$4,259.60
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,259.60
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$4,259.60
|
|
|
Service Code
|
APR-DRG 4212
|
| Hospital Charge Code |
APRDRG4214
|
| Min. Negotiated Rate |
$4,259.60 |
| Max. Negotiated Rate |
$4,259.60 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,259.60
|
| Rate for Payer: Mercy Care Medicaid |
$4,259.60
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,259.60
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$3,281.15
|
|
|
Service Code
|
APR-DRG 4211
|
| Hospital Charge Code |
APRDRG4214
|
| Min. Negotiated Rate |
$3,281.15 |
| Max. Negotiated Rate |
$3,281.15 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,281.15
|
| Rate for Payer: Mercy Care Medicaid |
$3,281.15
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,281.15
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$3,281.15
|
|
|
Service Code
|
APR-DRG 4211
|
| Hospital Charge Code |
APRDRG4211
|
| Min. Negotiated Rate |
$3,281.15 |
| Max. Negotiated Rate |
$3,281.15 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,281.15
|
| Rate for Payer: Mercy Care Medicaid |
$3,281.15
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,281.15
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$6,868.81
|
|
|
Service Code
|
APR-DRG 4213
|
| Hospital Charge Code |
APRDRG4214
|
| Min. Negotiated Rate |
$6,868.81 |
| Max. Negotiated Rate |
$6,868.81 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,868.81
|
| Rate for Payer: Mercy Care Medicaid |
$6,868.81
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,868.81
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$3,281.15
|
|
|
Service Code
|
APR-DRG 4211
|
| Hospital Charge Code |
APRDRG4212
|
| Min. Negotiated Rate |
$3,281.15 |
| Max. Negotiated Rate |
$3,281.15 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,281.15
|
| Rate for Payer: Mercy Care Medicaid |
$3,281.15
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,281.15
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$6,868.81
|
|
|
Service Code
|
APR-DRG 4213
|
| Hospital Charge Code |
APRDRG4213
|
| Min. Negotiated Rate |
$6,868.81 |
| Max. Negotiated Rate |
$6,868.81 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,868.81
|
| Rate for Payer: Mercy Care Medicaid |
$6,868.81
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,868.81
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$4,259.60
|
|
|
Service Code
|
APR-DRG 4212
|
| Hospital Charge Code |
APRDRG4211
|
| Min. Negotiated Rate |
$4,259.60 |
| Max. Negotiated Rate |
$4,259.60 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,259.60
|
| Rate for Payer: Mercy Care Medicaid |
$4,259.60
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,259.60
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$15,381.00
|
|
|
Service Code
|
APR-DRG 4214
|
| Hospital Charge Code |
APRDRG4211
|
| Min. Negotiated Rate |
$15,381.00 |
| Max. Negotiated Rate |
$15,381.00 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$15,381.00
|
| Rate for Payer: Mercy Care Medicaid |
$15,381.00
|
| Rate for Payer: NaphCare Correctional Healthcare |
$15,381.00
|
|
|
Malnutrition, Failure To Thrive And Other Nutritional Disorders
|
Facility
|
IP
|
$15,381.00
|
|
|
Service Code
|
APR-DRG 4214
|
| Hospital Charge Code |
APRDRG4214
|
| Min. Negotiated Rate |
$15,381.00 |
| Max. Negotiated Rate |
$15,381.00 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$15,381.00
|
| Rate for Payer: Mercy Care Medicaid |
$15,381.00
|
| Rate for Payer: NaphCare Correctional Healthcare |
$15,381.00
|
|
|
MA Mammogram Diagnostic Bilateral.
|
Facility
|
OP
|
$1,069.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
1181457
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$169.33 |
| Max. Negotiated Rate |
$962.10 |
| Rate for Payer: Aetna of AZ Commercial |
$962.10
|
| Rate for Payer: Arizona Complete Health Allwell |
$171.04
|
| Rate for Payer: Banner UC Health Medicare |
$171.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$726.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$171.04
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$171.04
|
| Rate for Payer: Cash Price |
$855.20
|
| Rate for Payer: Cigna of AZ Commercial |
$748.30
|
| Rate for Payer: Devoted Health Medicare |
$192.42
|
| Rate for Payer: Humana of AZ Medicare |
$171.04
|
| Rate for Payer: Southwest Service Administrators UFCW |
$726.92
|
| Rate for Payer: TriWest Medicare |
$171.04
|
| Rate for Payer: United Healthcare Commercial |
$611.47
|
| Rate for Payer: United Healthcare Medicare |
$171.04
|
| Rate for Payer: Veterans Affairs TRICARE |
$169.33
|
|
|
MA Mammogram Diagnostic Bilateral.
|
Facility
|
IP
|
$1,069.00
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
1181457
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$962.10 |
| Max. Negotiated Rate |
$962.10 |
| Rate for Payer: Aetna of AZ Commercial |
$962.10
|
| Rate for Payer: Cash Price |
$855.20
|
|
|
MA Mammogram Diagnostic Left.
|
Facility
|
OP
|
$906.00
|
|
|
Service Code
|
CPT 77065 LT
|
| Hospital Charge Code |
1240707
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$143.51 |
| Max. Negotiated Rate |
$815.40 |
| Rate for Payer: Aetna of AZ Commercial |
$815.40
|
| Rate for Payer: Arizona Complete Health Allwell |
$144.96
|
| Rate for Payer: Banner UC Health Medicare |
$144.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$616.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$144.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$144.96
|
| Rate for Payer: Cash Price |
$724.80
|
| Rate for Payer: Cigna of AZ Commercial |
$634.20
|
| Rate for Payer: Devoted Health Medicare |
$163.08
|
| Rate for Payer: Humana of AZ Medicare |
$144.96
|
| Rate for Payer: Southwest Service Administrators UFCW |
$616.08
|
| Rate for Payer: TriWest Medicare |
$144.96
|
| Rate for Payer: United Healthcare Commercial |
$518.23
|
| Rate for Payer: United Healthcare Medicare |
$144.96
|
| Rate for Payer: Veterans Affairs TRICARE |
$143.51
|
|
|
MA Mammogram Diagnostic Left.
|
Facility
|
IP
|
$906.00
|
|
|
Service Code
|
CPT 77065 LT
|
| Hospital Charge Code |
1240707
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$815.40 |
| Max. Negotiated Rate |
$815.40 |
| Rate for Payer: Aetna of AZ Commercial |
$815.40
|
| Rate for Payer: Cash Price |
$724.80
|
|
|
MA Mammogram Diagnostic Right.
|
Facility
|
IP
|
$861.00
|
|
|
Service Code
|
CPT 77065 RT
|
| Hospital Charge Code |
1189738
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$774.90 |
| Max. Negotiated Rate |
$774.90 |
| Rate for Payer: Aetna of AZ Commercial |
$774.90
|
| Rate for Payer: Cash Price |
$688.80
|
|
|
MA Mammogram Diagnostic Right.
|
Facility
|
OP
|
$861.00
|
|
|
Service Code
|
CPT 77065 RT
|
| Hospital Charge Code |
1189738
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$136.38 |
| Max. Negotiated Rate |
$774.90 |
| Rate for Payer: Aetna of AZ Commercial |
$774.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$137.76
|
| Rate for Payer: Banner UC Health Medicare |
$137.76
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$585.48
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$137.76
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$137.76
|
| Rate for Payer: Cash Price |
$688.80
|
| Rate for Payer: Cigna of AZ Commercial |
$602.70
|
| Rate for Payer: Devoted Health Medicare |
$154.98
|
| Rate for Payer: Humana of AZ Medicare |
$137.76
|
| Rate for Payer: Southwest Service Administrators UFCW |
$585.48
|
| Rate for Payer: TriWest Medicare |
$137.76
|
| Rate for Payer: United Healthcare Commercial |
$492.49
|
| Rate for Payer: United Healthcare Medicare |
$137.76
|
| Rate for Payer: Veterans Affairs TRICARE |
$136.38
|
|
|
MA Mammogram Routine Screening Bilat.
|
Facility
|
IP
|
$828.00
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
1181460
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$745.20 |
| Max. Negotiated Rate |
$745.20 |
| Rate for Payer: Aetna of AZ Commercial |
$745.20
|
| Rate for Payer: Cash Price |
$662.40
|
|
|
MA Mammogram Routine Screening Bilat.
|
Facility
|
OP
|
$828.00
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
1181460
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$122.92 |
| Max. Negotiated Rate |
$745.20 |
| Rate for Payer: Aetna of AZ Commercial |
$745.20
|
| Rate for Payer: Arizona Complete Health Allwell |
$132.48
|
| Rate for Payer: Banner UC Health Medicare |
$132.48
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$563.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$132.48
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$132.48
|
| Rate for Payer: Cash Price |
$662.40
|
| Rate for Payer: Cash Price |
$662.40
|
| Rate for Payer: Cigna of AZ Commercial |
$579.60
|
| Rate for Payer: Devoted Health Medicare |
$149.04
|
| Rate for Payer: Humana of AZ Medicare |
$132.48
|
| Rate for Payer: Southwest Service Administrators UFCW |
$563.04
|
| Rate for Payer: TriWest Medicare |
$132.48
|
| Rate for Payer: United Healthcare Commercial |
$473.62
|
| Rate for Payer: United Healthcare Medicare |
$132.48
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$122.92
|
| Rate for Payer: Veterans Affairs TRICARE |
$131.16
|
|
