|
Seizure
|
Facility
|
IP
|
$5,959.80
|
|
|
Service Code
|
APR-DRG 0533
|
| Hospital Charge Code |
APRDRG0533
|
| Min. Negotiated Rate |
$5,959.80 |
| Max. Negotiated Rate |
$5,959.80 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,959.80
|
| Rate for Payer: Mercy Care Medicaid |
$5,959.80
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,959.80
|
|
|
Seizure
|
Facility
|
IP
|
$14,885.11
|
|
|
Service Code
|
APR-DRG 0534
|
| Hospital Charge Code |
APRDRG0531
|
| Min. Negotiated Rate |
$14,885.11 |
| Max. Negotiated Rate |
$14,885.11 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$14,885.11
|
| Rate for Payer: Mercy Care Medicaid |
$14,885.11
|
| Rate for Payer: NaphCare Correctional Healthcare |
$14,885.11
|
|
|
Seizure
|
Facility
|
IP
|
$5,959.80
|
|
|
Service Code
|
APR-DRG 0533
|
| Hospital Charge Code |
APRDRG0531
|
| Min. Negotiated Rate |
$5,959.80 |
| Max. Negotiated Rate |
$5,959.80 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,959.80
|
| Rate for Payer: Mercy Care Medicaid |
$5,959.80
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,959.80
|
|
|
Seizure
|
Facility
|
IP
|
$5,959.80
|
|
|
Service Code
|
APR-DRG 0533
|
| Hospital Charge Code |
APRDRG0532
|
| Min. Negotiated Rate |
$5,959.80 |
| Max. Negotiated Rate |
$5,959.80 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,959.80
|
| Rate for Payer: Mercy Care Medicaid |
$5,959.80
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,959.80
|
|
|
Seizure
|
Facility
|
IP
|
$4,510.70
|
|
|
Service Code
|
APR-DRG 0532
|
| Hospital Charge Code |
APRDRG0532
|
| Min. Negotiated Rate |
$4,510.70 |
| Max. Negotiated Rate |
$4,510.70 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,510.70
|
| Rate for Payer: Mercy Care Medicaid |
$4,510.70
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,510.70
|
|
|
Seizure
|
Facility
|
IP
|
$5,959.80
|
|
|
Service Code
|
APR-DRG 0533
|
| Hospital Charge Code |
APRDRG0534
|
| Min. Negotiated Rate |
$5,959.80 |
| Max. Negotiated Rate |
$5,959.80 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,959.80
|
| Rate for Payer: Mercy Care Medicaid |
$5,959.80
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,959.80
|
|
|
Seizure
|
Facility
|
IP
|
$14,885.11
|
|
|
Service Code
|
APR-DRG 0534
|
| Hospital Charge Code |
APRDRG0532
|
| Min. Negotiated Rate |
$14,885.11 |
| Max. Negotiated Rate |
$14,885.11 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$14,885.11
|
| Rate for Payer: Mercy Care Medicaid |
$14,885.11
|
| Rate for Payer: NaphCare Correctional Healthcare |
$14,885.11
|
|
|
Seizure
|
Facility
|
IP
|
$3,695.68
|
|
|
Service Code
|
APR-DRG 0531
|
| Hospital Charge Code |
APRDRG0531
|
| Min. Negotiated Rate |
$3,695.68 |
| Max. Negotiated Rate |
$3,695.68 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,695.68
|
| Rate for Payer: Mercy Care Medicaid |
$3,695.68
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,695.68
|
|
|
Seizure
|
Facility
|
IP
|
$3,695.68
|
|
|
Service Code
|
APR-DRG 0531
|
| Hospital Charge Code |
APRDRG0534
|
| Min. Negotiated Rate |
$3,695.68 |
| Max. Negotiated Rate |
$3,695.68 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,695.68
|
| Rate for Payer: Mercy Care Medicaid |
$3,695.68
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,695.68
|
|
|
Seizure
|
Facility
|
IP
|
$14,885.11
|
|
|
Service Code
|
APR-DRG 0534
|
| Hospital Charge Code |
APRDRG0534
|
| Min. Negotiated Rate |
$14,885.11 |
| Max. Negotiated Rate |
$14,885.11 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$14,885.11
|
| Rate for Payer: Mercy Care Medicaid |
$14,885.11
|
| Rate for Payer: NaphCare Correctional Healthcare |
$14,885.11
|
|
|
Seizure
|
Facility
|
IP
|
$3,695.68
|
|
|
Service Code
|
APR-DRG 0531
|
| Hospital Charge Code |
APRDRG0533
|
| Min. Negotiated Rate |
$3,695.68 |
| Max. Negotiated Rate |
$3,695.68 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$3,695.68
|
| Rate for Payer: Mercy Care Medicaid |
$3,695.68
|
| Rate for Payer: NaphCare Correctional Healthcare |
$3,695.68
|
|
|
Seizure
|
Facility
|
IP
|
$14,885.11
|
|
|
Service Code
|
APR-DRG 0534
|
| Hospital Charge Code |
APRDRG0533
|
| Min. Negotiated Rate |
$14,885.11 |
| Max. Negotiated Rate |
$14,885.11 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$14,885.11
|
| Rate for Payer: Mercy Care Medicaid |
$14,885.11
|
| Rate for Payer: NaphCare Correctional Healthcare |
$14,885.11
|
|
|
Seizure
|
Facility
|
IP
|
$4,510.70
|
|
|
Service Code
|
APR-DRG 0532
|
| Hospital Charge Code |
APRDRG0533
|
| Min. Negotiated Rate |
$4,510.70 |
| Max. Negotiated Rate |
$4,510.70 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$4,510.70
|
| Rate for Payer: Mercy Care Medicaid |
$4,510.70
|
| Rate for Payer: NaphCare Correctional Healthcare |
$4,510.70
|
|
|
SEIZURES WITH MCC
|
Facility
|
IP
|
$25,031.48
|
|
|
Service Code
|
MSDRG 100
|
| Min. Negotiated Rate |
$25,031.48 |
| Max. Negotiated Rate |
$25,031.48 |
| Rate for Payer: Seven Corners Travel Insurance |
$25,031.48
|
|
|
SEIZURES WITHOUT MCC
|
Facility
|
IP
|
$11,792.44
|
|
|
Service Code
|
MSDRG 101
|
| Min. Negotiated Rate |
$11,792.44 |
| Max. Negotiated Rate |
$11,792.44 |
| Rate for Payer: Seven Corners Travel Insurance |
$11,792.44
|
|
|
senna 8.6 mg Tab [CQCH]
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
NDC 904725261
|
| Hospital Charge Code |
105940042
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of AZ Commercial |
$0.04
|
| Rate for Payer: Arizona Complete Health Allwell |
$0.01
|
| Rate for Payer: Banner UC Health Medicare |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$0.03
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$0.01
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$0.01
|
| Rate for Payer: Cash Price |
$0.03
|
| Rate for Payer: Cigna of AZ Commercial |
$0.03
|
| Rate for Payer: Devoted Health Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.03
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.02
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.01
|
|
|
senna 8.6 mg Tab [CQCH]
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
NDC 904725261
|
| Hospital Charge Code |
105940042
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.04 |
| Rate for Payer: Aetna of AZ Commercial |
$0.04
|
| Rate for Payer: Cash Price |
$0.03
|
|
|
SENSATION SHORT THROW 13MM
|
Facility
|
IP
|
$47.00
|
|
| Hospital Charge Code |
27497394
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$42.30 |
| Max. Negotiated Rate |
$42.30 |
| Rate for Payer: Aetna of AZ Commercial |
$42.30
|
| Rate for Payer: Cash Price |
$37.60
|
|
|
SENSATION SHORT THROW 13MM
|
Facility
|
OP
|
$47.00
|
|
| Hospital Charge Code |
27497394
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$7.44 |
| Max. Negotiated Rate |
$42.30 |
| Rate for Payer: Aetna of AZ Commercial |
$42.30
|
| Rate for Payer: Arizona Complete Health Allwell |
$7.52
|
| Rate for Payer: Banner UC Health Medicare |
$7.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$31.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$7.52
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$7.52
|
| Rate for Payer: Cash Price |
$37.60
|
| Rate for Payer: Cigna of AZ Commercial |
$32.90
|
| Rate for Payer: Devoted Health Medicare |
$8.46
|
| Rate for Payer: Humana of AZ Medicare |
$7.52
|
| Rate for Payer: Southwest Service Administrators UFCW |
$31.96
|
| Rate for Payer: TriWest Medicare |
$7.52
|
| Rate for Payer: United Healthcare Commercial |
$26.88
|
| Rate for Payer: United Healthcare Medicare |
$7.52
|
| Rate for Payer: Veterans Affairs TRICARE |
$7.44
|
|
|
SENSOR, NEONATAL/ADLT,OXIMAX
|
Facility
|
IP
|
$117.00
|
|
| Hospital Charge Code |
23290390
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$105.30 |
| Max. Negotiated Rate |
$105.30 |
| Rate for Payer: Aetna of AZ Commercial |
$105.30
|
| Rate for Payer: Cash Price |
$93.60
|
|
|
SENSOR, NEONATAL/ADLT,OXIMAX
|
Facility
|
OP
|
$117.00
|
|
| Hospital Charge Code |
23290390
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.53 |
| Max. Negotiated Rate |
$105.30 |
| Rate for Payer: Aetna of AZ Commercial |
$105.30
|
| Rate for Payer: Arizona Complete Health Allwell |
$18.72
|
| Rate for Payer: Banner UC Health Medicare |
$18.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$79.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$18.72
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$18.72
|
| Rate for Payer: Cash Price |
$93.60
|
| Rate for Payer: Cigna of AZ Commercial |
$81.90
|
| Rate for Payer: Devoted Health Medicare |
$21.06
|
| Rate for Payer: Humana of AZ Medicare |
$18.72
|
| Rate for Payer: Southwest Service Administrators UFCW |
$79.56
|
| Rate for Payer: TriWest Medicare |
$18.72
|
| Rate for Payer: United Healthcare Commercial |
$66.92
|
| Rate for Payer: United Healthcare Medicare |
$18.72
|
| Rate for Payer: Veterans Affairs TRICARE |
$18.53
|
|
|
SENSOR SPO2 INFANT NELLCOR
|
Facility
|
OP
|
$54.00
|
|
| Hospital Charge Code |
22546699
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.55 |
| Max. Negotiated Rate |
$48.60 |
| Rate for Payer: Aetna of AZ Commercial |
$48.60
|
| Rate for Payer: Arizona Complete Health Allwell |
$8.64
|
| Rate for Payer: Banner UC Health Medicare |
$8.64
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$36.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$8.64
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$8.64
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of AZ Commercial |
$37.80
|
| Rate for Payer: Devoted Health Medicare |
$9.72
|
| Rate for Payer: Humana of AZ Medicare |
$8.64
|
| Rate for Payer: Southwest Service Administrators UFCW |
$36.72
|
| Rate for Payer: TriWest Medicare |
$8.64
|
| Rate for Payer: United Healthcare Commercial |
$30.89
|
| Rate for Payer: United Healthcare Medicare |
$8.64
|
| Rate for Payer: Veterans Affairs TRICARE |
$8.55
|
|
|
SENSOR SPO2 INFANT NELLCOR
|
Facility
|
IP
|
$54.00
|
|
| Hospital Charge Code |
22546699
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.60 |
| Max. Negotiated Rate |
$48.60 |
| Rate for Payer: Aetna of AZ Commercial |
$48.60
|
| Rate for Payer: Cash Price |
$43.20
|
|
|
SENSOR SPO2 PEDIATRIC NELLCOR
|
Facility
|
IP
|
$46.00
|
|
| Hospital Charge Code |
22546697
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$41.40 |
| Max. Negotiated Rate |
$41.40 |
| Rate for Payer: Aetna of AZ Commercial |
$41.40
|
| Rate for Payer: Cash Price |
$36.80
|
|
|
SENSOR SPO2 PEDIATRIC NELLCOR
|
Facility
|
OP
|
$46.00
|
|
| Hospital Charge Code |
22546697
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.29 |
| Max. Negotiated Rate |
$41.40 |
| Rate for Payer: Aetna of AZ Commercial |
$41.40
|
| Rate for Payer: Arizona Complete Health Allwell |
$7.36
|
| Rate for Payer: Banner UC Health Medicare |
$7.36
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$31.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$7.36
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$7.36
|
| Rate for Payer: Cash Price |
$36.80
|
| Rate for Payer: Cigna of AZ Commercial |
$32.20
|
| Rate for Payer: Devoted Health Medicare |
$8.28
|
| Rate for Payer: Humana of AZ Medicare |
$7.36
|
| Rate for Payer: Southwest Service Administrators UFCW |
$31.28
|
| Rate for Payer: TriWest Medicare |
$7.36
|
| Rate for Payer: United Healthcare Commercial |
$26.31
|
| Rate for Payer: United Healthcare Medicare |
$7.36
|
| Rate for Payer: Veterans Affairs TRICARE |
$7.29
|
|
