|
OT EVAL 30 MIN
|
Facility
|
IP
|
$358.00
|
|
|
Service Code
|
CPT 97165 GO
|
| Hospital Charge Code |
22528841
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$93.08 |
| Max. Negotiated Rate |
$322.20 |
| Rate for Payer: Aetna of AZ Commercial |
$322.20
|
| Rate for Payer: Bisbee Police All Plans |
$93.08
|
| Rate for Payer: Cash Price |
$286.40
|
| Rate for Payer: Self Pay Self Pay |
$286.40
|
|
|
OT EVAL 45MIN
|
Facility
|
OP
|
$537.00
|
|
| Hospital Charge Code |
22528845
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$80.55 |
| Max. Negotiated Rate |
$483.30 |
| Rate for Payer: Aetna of AZ Commercial |
$483.30
|
| Rate for Payer: Aetna of AZ Medicare |
$150.36
|
| Rate for Payer: Allwell Medicare |
$80.55
|
| Rate for Payer: Amerigroup Medicare |
$80.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$200.57
|
| Rate for Payer: AZCH Complete Medicare |
$80.55
|
| Rate for Payer: Banner UC Health Medicare |
$80.55
|
| Rate for Payer: Bisbee Police All Plans |
$139.62
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$365.16
|
| Rate for Payer: Cash Price |
$429.60
|
| Rate for Payer: Cigna of AZ Commercial |
$375.90
|
| Rate for Payer: Copperpoint Commercial |
$132.91
|
| Rate for Payer: Health Net of AZ Commercial |
$322.20
|
| Rate for Payer: Health Net of AZ Medicare |
$150.36
|
| Rate for Payer: Humana of AZ Medicare |
$80.55
|
| Rate for Payer: Self Pay Self Pay |
$429.60
|
| Rate for Payer: TriWest Medicare |
$80.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$313.07
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$96.66
|
|
|
OT EVAL 45MIN
|
Facility
|
IP
|
$537.00
|
|
| Hospital Charge Code |
22528845
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$139.62 |
| Max. Negotiated Rate |
$483.30 |
| Rate for Payer: Aetna of AZ Commercial |
$483.30
|
| Rate for Payer: Bisbee Police All Plans |
$139.62
|
| Rate for Payer: Cash Price |
$429.60
|
| Rate for Payer: Self Pay Self Pay |
$429.60
|
|
|
OT EVAL 45MIN
|
Facility
|
IP
|
$697.00
|
|
|
Service Code
|
CPT 97166 GO
|
| Hospital Charge Code |
22528987
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$181.22 |
| Max. Negotiated Rate |
$627.30 |
| Rate for Payer: Aetna of AZ Commercial |
$627.30
|
| Rate for Payer: Bisbee Police All Plans |
$181.22
|
| Rate for Payer: Cash Price |
$557.60
|
| Rate for Payer: Self Pay Self Pay |
$557.60
|
|
|
OT EVAL 45MIN
|
Facility
|
OP
|
$697.00
|
|
|
Service Code
|
CPT 97166 GO
|
| Hospital Charge Code |
22528987
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$627.30 |
| Rate for Payer: Aetna of AZ Commercial |
$627.30
|
| Rate for Payer: Aetna of AZ Medicare |
$195.16
|
| Rate for Payer: Allwell Medicare |
$104.55
|
| Rate for Payer: Amerigroup Medicare |
$104.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$260.33
|
| Rate for Payer: AZCH Complete Medicare |
$104.55
|
| Rate for Payer: Banner UC Health Medicare |
$104.55
|
| Rate for Payer: Bisbee Police All Plans |
$181.22
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$473.96
|
| Rate for Payer: Cash Price |
$557.60
|
| Rate for Payer: Cigna of AZ Commercial |
$487.90
|
| Rate for Payer: Copperpoint Commercial |
$172.51
|
| Rate for Payer: Health Net of AZ Commercial |
$418.20
|
| Rate for Payer: Health Net of AZ Medicare |
$195.16
|
| Rate for Payer: Humana of AZ Medicare |
$104.55
|
| Rate for Payer: Self Pay Self Pay |
$557.60
|
| Rate for Payer: TriWest Medicare |
$104.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$406.35
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$125.46
|
|
|
OT EVAL 60 MIN
|
Facility
|
OP
|
$697.00
|
|
|
Service Code
|
CPT 97167 GO
|
| Hospital Charge Code |
22528868
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$104.55 |
| Max. Negotiated Rate |
$627.30 |
| Rate for Payer: Aetna of AZ Commercial |
$627.30
|
| Rate for Payer: Aetna of AZ Medicare |
$195.16
|
| Rate for Payer: Allwell Medicare |
$104.55
|
| Rate for Payer: Amerigroup Medicare |
$104.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$260.33
|
| Rate for Payer: AZCH Complete Medicare |
$104.55
|
| Rate for Payer: Banner UC Health Medicare |
$104.55
|
| Rate for Payer: Bisbee Police All Plans |
$181.22
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$473.96
|
| Rate for Payer: Cash Price |
$557.60
|
| Rate for Payer: Cigna of AZ Commercial |
$487.90
|
| Rate for Payer: Copperpoint Commercial |
$172.51
|
| Rate for Payer: Health Net of AZ Commercial |
$418.20
|
| Rate for Payer: Health Net of AZ Medicare |
$195.16
|
| Rate for Payer: Humana of AZ Medicare |
$104.55
|
| Rate for Payer: Self Pay Self Pay |
$557.60
|
| Rate for Payer: TriWest Medicare |
$104.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$406.35
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$125.46
|
|
|
OT EVAL 60 MIN
|
Facility
|
IP
|
$697.00
|
|
|
Service Code
|
CPT 97167 GO
|
| Hospital Charge Code |
22528868
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$181.22 |
| Max. Negotiated Rate |
$627.30 |
| Rate for Payer: Aetna of AZ Commercial |
$627.30
|
| Rate for Payer: Bisbee Police All Plans |
$181.22
|
| Rate for Payer: Cash Price |
$557.60
|
| Rate for Payer: Self Pay Self Pay |
$557.60
|
|
|
OT EVALUATION MODERATE COMPLEXITY
|
Facility
|
IP
|
$511.00
|
|
| Hospital Charge Code |
1230411
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$132.86 |
| Max. Negotiated Rate |
$459.90 |
| Rate for Payer: Aetna of AZ Commercial |
$459.90
|
| Rate for Payer: Bisbee Police All Plans |
$132.86
|
| Rate for Payer: Cash Price |
$408.80
|
| Rate for Payer: Self Pay Self Pay |
$408.80
|
|
|
OT EVALUATION MODERATE COMPLEXITY
|
Facility
|
OP
|
$511.00
|
|
| Hospital Charge Code |
1230411
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$76.65 |
| Max. Negotiated Rate |
$459.90 |
| Rate for Payer: Aetna of AZ Commercial |
$459.90
|
| Rate for Payer: Aetna of AZ Medicare |
$143.08
|
| Rate for Payer: Allwell Medicare |
$76.65
|
| Rate for Payer: Amerigroup Medicare |
$76.65
|
| Rate for Payer: APIPA Medicare/Medicaid |
$190.86
|
| Rate for Payer: AZCH Complete Medicare |
$76.65
|
| Rate for Payer: Banner UC Health Medicare |
$76.65
|
| Rate for Payer: Bisbee Police All Plans |
$132.86
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$347.48
|
| Rate for Payer: Cash Price |
$408.80
|
| Rate for Payer: Cigna of AZ Commercial |
$357.70
|
| Rate for Payer: Copperpoint Commercial |
$126.47
|
| Rate for Payer: Health Net of AZ Commercial |
$306.60
|
| Rate for Payer: Health Net of AZ Medicare |
$143.08
|
| Rate for Payer: Humana of AZ Medicare |
$76.65
|
| Rate for Payer: Self Pay Self Pay |
$408.80
|
| Rate for Payer: TriWest Medicare |
$76.65
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$297.91
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$91.98
|
|
|
OT GROUP THERAPY @ 15 MIN
|
Facility
|
OP
|
$92.00
|
|
|
Service Code
|
CPT 97150 GO
|
| Hospital Charge Code |
22329309
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$13.80 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna of AZ Commercial |
$82.80
|
| Rate for Payer: Aetna of AZ Medicare |
$25.76
|
| Rate for Payer: Allwell Medicare |
$13.80
|
| Rate for Payer: Amerigroup Medicare |
$13.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$34.36
|
| Rate for Payer: AZCH Complete Medicare |
$13.80
|
| Rate for Payer: Banner UC Health Medicare |
$13.80
|
| Rate for Payer: Bisbee Police All Plans |
$23.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$62.56
|
| Rate for Payer: Cash Price |
$73.60
|
| Rate for Payer: Cigna of AZ Commercial |
$64.40
|
| Rate for Payer: Copperpoint Commercial |
$22.77
|
| Rate for Payer: Health Net of AZ Commercial |
$55.20
|
| Rate for Payer: Health Net of AZ Medicare |
$25.76
|
| Rate for Payer: Humana of AZ Medicare |
$13.80
|
| Rate for Payer: Self Pay Self Pay |
$73.60
|
| Rate for Payer: TriWest Medicare |
$13.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$53.64
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$16.56
|
|
|
OT GROUP THERAPY @ 15 MIN
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
CPT 97150 GO
|
| Hospital Charge Code |
22329309
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$23.92 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna of AZ Commercial |
$82.80
|
| Rate for Payer: Bisbee Police All Plans |
$23.92
|
| Rate for Payer: Cash Price |
$73.60
|
| Rate for Payer: Self Pay Self Pay |
$73.60
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$9,010.89
|
|
|
Service Code
|
APR-DRG 8623
|
| Hospital Charge Code |
APRDRG8623
|
| Min. Negotiated Rate |
$9,010.89 |
| Max. Negotiated Rate |
$9,010.89 |
| Rate for Payer: AHCCCS Medicaid |
$9,010.89
|
| Rate for Payer: Allwell Medicaid |
$9,010.89
|
| Rate for Payer: AZCH Complete Medicaid |
$9,010.89
|
| Rate for Payer: Banner UC Health Medicaid |
$9,010.89
|
| Rate for Payer: Mercy Care Medicaid |
$9,010.89
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$9,211.49
|
|
|
Service Code
|
APR-DRG 8624
|
| Hospital Charge Code |
APRDRG8624
|
| Min. Negotiated Rate |
$9,211.49 |
| Max. Negotiated Rate |
$9,211.49 |
| Rate for Payer: AHCCCS Medicaid |
$9,211.49
|
| Rate for Payer: Allwell Medicaid |
$9,211.49
|
| Rate for Payer: AZCH Complete Medicaid |
$9,211.49
|
| Rate for Payer: Banner UC Health Medicaid |
$9,211.49
|
| Rate for Payer: Mercy Care Medicaid |
$9,211.49
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$9,010.89
|
|
|
Service Code
|
APR-DRG 8623
|
| Hospital Charge Code |
APRDRG8624
|
| Min. Negotiated Rate |
$9,010.89 |
| Max. Negotiated Rate |
$9,010.89 |
| Rate for Payer: AHCCCS Medicaid |
$9,010.89
|
| Rate for Payer: Allwell Medicaid |
$9,010.89
|
| Rate for Payer: AZCH Complete Medicaid |
$9,010.89
|
| Rate for Payer: Banner UC Health Medicaid |
$9,010.89
|
| Rate for Payer: Mercy Care Medicaid |
$9,010.89
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$4,463.01
|
|
|
Service Code
|
APR-DRG 8621
|
| Hospital Charge Code |
APRDRG8621
|
| Min. Negotiated Rate |
$4,463.01 |
| Max. Negotiated Rate |
$4,463.01 |
| Rate for Payer: AHCCCS Medicaid |
$4,463.01
|
| Rate for Payer: Allwell Medicaid |
$4,463.01
|
| Rate for Payer: AZCH Complete Medicaid |
$4,463.01
|
| Rate for Payer: Banner UC Health Medicaid |
$4,463.01
|
| Rate for Payer: Mercy Care Medicaid |
$4,463.01
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$4,463.01
|
|
|
Service Code
|
APR-DRG 8621
|
| Hospital Charge Code |
APRDRG8624
|
| Min. Negotiated Rate |
$4,463.01 |
| Max. Negotiated Rate |
$4,463.01 |
| Rate for Payer: AHCCCS Medicaid |
$4,463.01
|
| Rate for Payer: Allwell Medicaid |
$4,463.01
|
| Rate for Payer: AZCH Complete Medicaid |
$4,463.01
|
| Rate for Payer: Banner UC Health Medicaid |
$4,463.01
|
| Rate for Payer: Mercy Care Medicaid |
$4,463.01
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$9,010.89
|
|
|
Service Code
|
APR-DRG 8623
|
| Hospital Charge Code |
APRDRG8622
|
| Min. Negotiated Rate |
$9,010.89 |
| Max. Negotiated Rate |
$9,010.89 |
| Rate for Payer: AHCCCS Medicaid |
$9,010.89
|
| Rate for Payer: Allwell Medicaid |
$9,010.89
|
| Rate for Payer: AZCH Complete Medicaid |
$9,010.89
|
| Rate for Payer: Banner UC Health Medicaid |
$9,010.89
|
| Rate for Payer: Mercy Care Medicaid |
$9,010.89
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$6,584.74
|
|
|
Service Code
|
APR-DRG 8622
|
| Hospital Charge Code |
APRDRG8623
|
| Min. Negotiated Rate |
$6,584.74 |
| Max. Negotiated Rate |
$6,584.74 |
| Rate for Payer: AHCCCS Medicaid |
$6,584.74
|
| Rate for Payer: Allwell Medicaid |
$6,584.74
|
| Rate for Payer: AZCH Complete Medicaid |
$6,584.74
|
| Rate for Payer: Banner UC Health Medicaid |
$6,584.74
|
| Rate for Payer: Mercy Care Medicaid |
$6,584.74
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$6,584.74
|
|
|
Service Code
|
APR-DRG 8622
|
| Hospital Charge Code |
APRDRG8621
|
| Min. Negotiated Rate |
$6,584.74 |
| Max. Negotiated Rate |
$6,584.74 |
| Rate for Payer: AHCCCS Medicaid |
$6,584.74
|
| Rate for Payer: Allwell Medicaid |
$6,584.74
|
| Rate for Payer: AZCH Complete Medicaid |
$6,584.74
|
| Rate for Payer: Banner UC Health Medicaid |
$6,584.74
|
| Rate for Payer: Mercy Care Medicaid |
$6,584.74
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$9,211.49
|
|
|
Service Code
|
APR-DRG 8624
|
| Hospital Charge Code |
APRDRG8623
|
| Min. Negotiated Rate |
$9,211.49 |
| Max. Negotiated Rate |
$9,211.49 |
| Rate for Payer: AHCCCS Medicaid |
$9,211.49
|
| Rate for Payer: Allwell Medicaid |
$9,211.49
|
| Rate for Payer: AZCH Complete Medicaid |
$9,211.49
|
| Rate for Payer: Banner UC Health Medicaid |
$9,211.49
|
| Rate for Payer: Mercy Care Medicaid |
$9,211.49
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$6,584.74
|
|
|
Service Code
|
APR-DRG 8622
|
| Hospital Charge Code |
APRDRG8622
|
| Min. Negotiated Rate |
$6,584.74 |
| Max. Negotiated Rate |
$6,584.74 |
| Rate for Payer: AHCCCS Medicaid |
$6,584.74
|
| Rate for Payer: Allwell Medicaid |
$6,584.74
|
| Rate for Payer: AZCH Complete Medicaid |
$6,584.74
|
| Rate for Payer: Banner UC Health Medicaid |
$6,584.74
|
| Rate for Payer: Mercy Care Medicaid |
$6,584.74
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$6,584.74
|
|
|
Service Code
|
APR-DRG 8622
|
| Hospital Charge Code |
APRDRG8624
|
| Min. Negotiated Rate |
$6,584.74 |
| Max. Negotiated Rate |
$6,584.74 |
| Rate for Payer: AHCCCS Medicaid |
$6,584.74
|
| Rate for Payer: Allwell Medicaid |
$6,584.74
|
| Rate for Payer: AZCH Complete Medicaid |
$6,584.74
|
| Rate for Payer: Banner UC Health Medicaid |
$6,584.74
|
| Rate for Payer: Mercy Care Medicaid |
$6,584.74
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$4,463.01
|
|
|
Service Code
|
APR-DRG 8621
|
| Hospital Charge Code |
APRDRG8622
|
| Min. Negotiated Rate |
$4,463.01 |
| Max. Negotiated Rate |
$4,463.01 |
| Rate for Payer: AHCCCS Medicaid |
$4,463.01
|
| Rate for Payer: Allwell Medicaid |
$4,463.01
|
| Rate for Payer: AZCH Complete Medicaid |
$4,463.01
|
| Rate for Payer: Banner UC Health Medicaid |
$4,463.01
|
| Rate for Payer: Mercy Care Medicaid |
$4,463.01
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$4,463.01
|
|
|
Service Code
|
APR-DRG 8621
|
| Hospital Charge Code |
APRDRG8623
|
| Min. Negotiated Rate |
$4,463.01 |
| Max. Negotiated Rate |
$4,463.01 |
| Rate for Payer: AHCCCS Medicaid |
$4,463.01
|
| Rate for Payer: Allwell Medicaid |
$4,463.01
|
| Rate for Payer: AZCH Complete Medicaid |
$4,463.01
|
| Rate for Payer: Banner UC Health Medicaid |
$4,463.01
|
| Rate for Payer: Mercy Care Medicaid |
$4,463.01
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$9,211.49
|
|
|
Service Code
|
APR-DRG 8624
|
| Hospital Charge Code |
APRDRG8622
|
| Min. Negotiated Rate |
$9,211.49 |
| Max. Negotiated Rate |
$9,211.49 |
| Rate for Payer: AHCCCS Medicaid |
$9,211.49
|
| Rate for Payer: Allwell Medicaid |
$9,211.49
|
| Rate for Payer: AZCH Complete Medicaid |
$9,211.49
|
| Rate for Payer: Banner UC Health Medicaid |
$9,211.49
|
| Rate for Payer: Mercy Care Medicaid |
$9,211.49
|
|
