|
OT EVAL 30 MIN
|
Facility
|
OP
|
$358.00
|
|
|
Service Code
|
CPT 97165 GO
|
| Hospital Charge Code |
22528841
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$56.71 |
| Max. Negotiated Rate |
$322.20 |
| Rate for Payer: Aetna of AZ Commercial |
$322.20
|
| Rate for Payer: Arizona Complete Health Allwell |
$57.28
|
| Rate for Payer: Banner UC Health Medicare |
$57.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$243.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$57.28
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$104.81
|
| Rate for Payer: Cash Price |
$286.40
|
| Rate for Payer: Cash Price |
$286.40
|
| Rate for Payer: Cigna of AZ Commercial |
$250.60
|
| Rate for Payer: Devoted Health Medicare |
$64.44
|
| Rate for Payer: Humana of AZ Medicare |
$57.28
|
| Rate for Payer: Southwest Service Administrators UFCW |
$243.44
|
| Rate for Payer: TriWest Medicare |
$57.28
|
| Rate for Payer: United Healthcare Commercial |
$204.78
|
| Rate for Payer: United Healthcare Medicare |
$57.28
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$68.02
|
| Rate for Payer: Veterans Affairs TRICARE |
$56.71
|
|
|
OT EVAL 45MIN
|
Facility
|
IP
|
$662.00
|
|
|
Service Code
|
CPT 97166 GO
|
| Hospital Charge Code |
22528987
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$595.80 |
| Max. Negotiated Rate |
$595.80 |
| Rate for Payer: Aetna of AZ Commercial |
$595.80
|
| Rate for Payer: Cash Price |
$529.60
|
|
|
OT EVAL 45MIN
|
Facility
|
OP
|
$662.00
|
|
|
Service Code
|
CPT 97166 GO
|
| Hospital Charge Code |
22528987
|
|
Hospital Revenue Code
|
434
|
| Min. Negotiated Rate |
$104.81 |
| Max. Negotiated Rate |
$595.80 |
| Rate for Payer: Aetna of AZ Commercial |
$595.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$105.92
|
| Rate for Payer: Banner UC Health Medicare |
$105.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$450.16
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$105.92
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$104.81
|
| Rate for Payer: Cash Price |
$529.60
|
| Rate for Payer: Cash Price |
$529.60
|
| Rate for Payer: Cigna of AZ Commercial |
$463.40
|
| Rate for Payer: Devoted Health Medicare |
$119.16
|
| Rate for Payer: Humana of AZ Medicare |
$105.92
|
| Rate for Payer: Southwest Service Administrators UFCW |
$450.16
|
| Rate for Payer: TriWest Medicare |
$105.92
|
| Rate for Payer: United Healthcare Commercial |
$378.66
|
| Rate for Payer: United Healthcare Medicare |
$105.92
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$125.78
|
| Rate for Payer: Veterans Affairs TRICARE |
$104.86
|
|
|
OT EVAL 45MIN
|
Facility
|
OP
|
$537.00
|
|
| Hospital Charge Code |
22528845
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$85.06 |
| Max. Negotiated Rate |
$483.30 |
| Rate for Payer: Aetna of AZ Commercial |
$483.30
|
| Rate for Payer: Arizona Complete Health Allwell |
$85.92
|
| Rate for Payer: Banner UC Health Medicare |
$85.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$365.16
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$85.92
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$85.92
|
| Rate for Payer: Cash Price |
$429.60
|
| Rate for Payer: Cigna of AZ Commercial |
$375.90
|
| Rate for Payer: Devoted Health Medicare |
$96.66
|
| Rate for Payer: Humana of AZ Medicare |
$85.92
|
| Rate for Payer: Southwest Service Administrators UFCW |
$365.16
|
| Rate for Payer: TriWest Medicare |
$85.92
|
| Rate for Payer: United Healthcare Commercial |
$307.16
|
| Rate for Payer: United Healthcare Medicare |
$85.92
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$102.03
|
| Rate for Payer: Veterans Affairs TRICARE |
$85.06
|
|
|
OT EVAL 45MIN
|
Facility
|
IP
|
$537.00
|
|
| Hospital Charge Code |
22528845
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$483.30 |
| Max. Negotiated Rate |
$483.30 |
| Rate for Payer: Aetna of AZ Commercial |
$483.30
|
| Rate for Payer: Cash Price |
$429.60
|
|
|
OT EVAL 60 MIN
|
Facility
|
OP
|
$662.00
|
|
|
Service Code
|
CPT 97167 GO
|
| Hospital Charge Code |
22528868
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$104.81 |
| Max. Negotiated Rate |
$595.80 |
| Rate for Payer: Aetna of AZ Commercial |
$595.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$105.92
|
| Rate for Payer: Banner UC Health Medicare |
$105.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$450.16
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$105.92
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$104.81
|
| Rate for Payer: Cash Price |
$529.60
|
| Rate for Payer: Cash Price |
$529.60
|
| Rate for Payer: Cigna of AZ Commercial |
$463.40
|
| Rate for Payer: Devoted Health Medicare |
$119.16
|
| Rate for Payer: Humana of AZ Medicare |
$105.92
|
| Rate for Payer: Southwest Service Administrators UFCW |
$450.16
|
| Rate for Payer: TriWest Medicare |
$105.92
|
| Rate for Payer: United Healthcare Commercial |
$378.66
|
| Rate for Payer: United Healthcare Medicare |
$105.92
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$125.78
|
| Rate for Payer: Veterans Affairs TRICARE |
$104.86
|
|
|
OT EVAL 60 MIN
|
Facility
|
IP
|
$662.00
|
|
|
Service Code
|
CPT 97167 GO
|
| Hospital Charge Code |
22528868
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$595.80 |
| Max. Negotiated Rate |
$595.80 |
| Rate for Payer: Aetna of AZ Commercial |
$595.80
|
| Rate for Payer: Cash Price |
$529.60
|
|
|
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 |
$82.80 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna of AZ Commercial |
$82.80
|
| Rate for Payer: Cash Price |
$73.60
|
|
|
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 |
$14.57 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna of AZ Commercial |
$82.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$14.72
|
| Rate for Payer: Banner UC Health Medicare |
$14.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$62.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$14.72
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$18.77
|
| Rate for Payer: Cash Price |
$73.60
|
| Rate for Payer: Cash Price |
$73.60
|
| Rate for Payer: Cigna of AZ Commercial |
$64.40
|
| Rate for Payer: Devoted Health Medicare |
$16.56
|
| Rate for Payer: Humana of AZ Medicare |
$14.72
|
| Rate for Payer: Southwest Service Administrators UFCW |
$62.56
|
| Rate for Payer: TriWest Medicare |
$14.72
|
| Rate for Payer: United Healthcare Commercial |
$52.62
|
| Rate for Payer: United Healthcare Medicare |
$14.72
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$17.48
|
| Rate for Payer: Veterans Affairs TRICARE |
$14.57
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$9,010.89
|
| Rate for Payer: Mercy Care Medicaid |
$9,010.89
|
| Rate for Payer: NaphCare Correctional Healthcare |
$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: Blue Cross Blue Shield of Arizona Health Choice |
$9,211.49
|
| Rate for Payer: Mercy Care Medicaid |
$9,211.49
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,211.49
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$4,463.01
|
| Rate for Payer: Mercy Care Medicaid |
$4,463.01
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,463.01
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$9,010.89
|
| Rate for Payer: Mercy Care Medicaid |
$9,010.89
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,010.89
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$9,010.89
|
|
|
Service Code
|
APR-DRG 8623
|
| Hospital Charge Code |
APRDRG8621
|
| Min. Negotiated Rate |
$9,010.89 |
| Max. Negotiated Rate |
$9,010.89 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$9,010.89
|
| Rate for Payer: Mercy Care Medicaid |
$9,010.89
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,010.89
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$6,584.74
|
| Rate for Payer: Mercy Care Medicaid |
$6,584.74
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,584.74
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$6,584.74
|
| Rate for Payer: Mercy Care Medicaid |
$6,584.74
|
| Rate for Payer: NaphCare Correctional Healthcare |
$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: Blue Cross Blue Shield of Arizona Health Choice |
$9,211.49
|
| Rate for Payer: Mercy Care Medicaid |
$9,211.49
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,211.49
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$9,211.49
|
| Rate for Payer: Mercy Care Medicaid |
$9,211.49
|
| Rate for Payer: NaphCare Correctional Healthcare |
$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: Blue Cross Blue Shield of Arizona Health Choice |
$6,584.74
|
| Rate for Payer: Mercy Care Medicaid |
$6,584.74
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,584.74
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$4,463.01
|
| Rate for Payer: Mercy Care Medicaid |
$4,463.01
|
| Rate for Payer: NaphCare Correctional Healthcare |
$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: Blue Cross Blue Shield of Arizona Health Choice |
$4,463.01
|
| Rate for Payer: Mercy Care Medicaid |
$4,463.01
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,463.01
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$6,584.74
|
| Rate for Payer: Mercy Care Medicaid |
$6,584.74
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,584.74
|
|
|
Other Aftercare And Convalescence
|
Facility
|
IP
|
$9,211.49
|
|
|
Service Code
|
APR-DRG 8624
|
| Hospital Charge Code |
APRDRG8621
|
| Min. Negotiated Rate |
$9,211.49 |
| Max. Negotiated Rate |
$9,211.49 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$9,211.49
|
| Rate for Payer: Mercy Care Medicaid |
$9,211.49
|
| Rate for Payer: NaphCare Correctional Healthcare |
$9,211.49
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$9,010.89
|
| Rate for Payer: Mercy Care Medicaid |
$9,010.89
|
| Rate for Payer: NaphCare Correctional Healthcare |
$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: Blue Cross Blue Shield of Arizona Health Choice |
$4,463.01
|
| Rate for Payer: Mercy Care Medicaid |
$4,463.01
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,463.01
|
|
