|
Sirolimus (Rapamune), Blood LC
|
Facility
|
OP
|
$314.00
|
|
|
Service Code
|
CPT 80195
|
| Hospital Charge Code |
2029238
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.91 |
| Max. Negotiated Rate |
$282.60 |
| Rate for Payer: Aetna of AZ Commercial |
$282.60
|
| Rate for Payer: Arizona Complete Health Allwell |
$50.24
|
| Rate for Payer: Banner UC Health Medicare |
$50.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$213.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$50.24
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$50.24
|
| Rate for Payer: Cash Price |
$251.20
|
| Rate for Payer: Cash Price |
$251.20
|
| Rate for Payer: Cigna of AZ Commercial |
$204.10
|
| Rate for Payer: Devoted Health Medicare |
$56.52
|
| Rate for Payer: Humana of AZ Medicare |
$50.24
|
| Rate for Payer: Seven Corners Travel Insurance |
$19.91
|
| Rate for Payer: Southwest Service Administrators UFCW |
$213.52
|
| Rate for Payer: TriWest Medicare |
$50.24
|
| Rate for Payer: United Healthcare Commercial |
$179.61
|
| Rate for Payer: United Healthcare Medicare |
$50.24
|
| Rate for Payer: Veterans Affairs TRICARE |
$49.74
|
|
|
Sirolimus (Rapamune), Blood LC
|
Facility
|
IP
|
$314.00
|
|
|
Service Code
|
CPT 80195
|
| Hospital Charge Code |
2029238
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$282.60 |
| Max. Negotiated Rate |
$282.60 |
| Rate for Payer: Aetna of AZ Commercial |
$282.60
|
| Rate for Payer: Cash Price |
$251.20
|
|
|
SITZ BATH
|
Facility
|
IP
|
$13.00
|
|
| Hospital Charge Code |
22355310
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.70 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Aetna of AZ Commercial |
$11.70
|
| Rate for Payer: Cash Price |
$10.40
|
|
|
SITZ BATH
|
Facility
|
OP
|
$13.00
|
|
| Hospital Charge Code |
22355310
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Aetna of AZ Commercial |
$11.70
|
| Rate for Payer: Arizona Complete Health Allwell |
$2.08
|
| Rate for Payer: Banner UC Health Medicare |
$2.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$8.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$2.08
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$2.08
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Cigna of AZ Commercial |
$9.10
|
| Rate for Payer: Devoted Health Medicare |
$2.34
|
| Rate for Payer: Humana of AZ Medicare |
$2.08
|
| Rate for Payer: Southwest Service Administrators UFCW |
$8.84
|
| Rate for Payer: TriWest Medicare |
$2.08
|
| Rate for Payer: United Healthcare Commercial |
$7.44
|
| Rate for Payer: United Healthcare Medicare |
$2.08
|
| Rate for Payer: Veterans Affairs TRICARE |
$2.06
|
|
|
Sjogren's Ab, Anti-SS-A/-SS-B LC
|
Facility
|
IP
|
$182.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
1285798
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$163.80 |
| Max. Negotiated Rate |
$163.80 |
| Rate for Payer: Aetna of AZ Commercial |
$163.80
|
| Rate for Payer: Cash Price |
$145.60
|
|
|
Sjogren's Ab, Anti-SS-A/-SS-B LC
|
Facility
|
OP
|
$182.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
1285798
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$163.80 |
| Rate for Payer: Aetna of AZ Commercial |
$163.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$29.12
|
| Rate for Payer: Banner UC Health Medicare |
$29.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$123.76
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$29.12
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$29.12
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Cash Price |
$145.60
|
| Rate for Payer: Cigna of AZ Commercial |
$118.30
|
| Rate for Payer: Devoted Health Medicare |
$32.76
|
| Rate for Payer: Humana of AZ Medicare |
$29.12
|
| Rate for Payer: Seven Corners Travel Insurance |
$26.00
|
| Rate for Payer: Southwest Service Administrators UFCW |
$123.76
|
| Rate for Payer: TriWest Medicare |
$29.12
|
| Rate for Payer: United Healthcare Commercial |
$104.10
|
| Rate for Payer: United Healthcare Medicare |
$29.12
|
| Rate for Payer: Veterans Affairs TRICARE |
$28.83
|
|
|
.Sjoren's SSA LC
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
22531159
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of AZ Commercial |
$107.10
|
| Rate for Payer: Cash Price |
$95.20
|
|
|
.Sjoren's SSA LC
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
22531159
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.85 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of AZ Commercial |
$107.10
|
| Rate for Payer: Arizona Complete Health Allwell |
$19.04
|
| Rate for Payer: Banner UC Health Medicare |
$19.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$80.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$19.04
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$19.04
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Cigna of AZ Commercial |
$77.35
|
| Rate for Payer: Devoted Health Medicare |
$21.42
|
| Rate for Payer: Humana of AZ Medicare |
$19.04
|
| Rate for Payer: Seven Corners Travel Insurance |
$26.00
|
| Rate for Payer: Southwest Service Administrators UFCW |
$80.92
|
| Rate for Payer: TriWest Medicare |
$19.04
|
| Rate for Payer: United Healthcare Commercial |
$68.07
|
| Rate for Payer: United Healthcare Medicare |
$19.04
|
| Rate for Payer: Veterans Affairs TRICARE |
$18.85
|
|
|
.Sjoren's SSB LC
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
22531177
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$18.85 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of AZ Commercial |
$107.10
|
| Rate for Payer: Arizona Complete Health Allwell |
$19.04
|
| Rate for Payer: Banner UC Health Medicare |
$19.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$80.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$19.04
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$19.04
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Cigna of AZ Commercial |
$77.35
|
| Rate for Payer: Devoted Health Medicare |
$21.42
|
| Rate for Payer: Humana of AZ Medicare |
$19.04
|
| Rate for Payer: Seven Corners Travel Insurance |
$26.00
|
| Rate for Payer: Southwest Service Administrators UFCW |
$80.92
|
| Rate for Payer: TriWest Medicare |
$19.04
|
| Rate for Payer: United Healthcare Commercial |
$68.07
|
| Rate for Payer: United Healthcare Medicare |
$19.04
|
| Rate for Payer: Veterans Affairs TRICARE |
$18.85
|
|
|
.Sjoren's SSB LC
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
22531177
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of AZ Commercial |
$107.10
|
| Rate for Payer: Cash Price |
$95.20
|
|
|
Sjoren's SSB LC
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
22531160
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$107.10 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of AZ Commercial |
$107.10
|
| Rate for Payer: Cash Price |
$95.20
|
|
|
Sjoren's SSB LC
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
22531160
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$18.85 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of AZ Commercial |
$107.10
|
| Rate for Payer: Arizona Complete Health Allwell |
$19.04
|
| Rate for Payer: Banner UC Health Medicare |
$19.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$80.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$19.04
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$19.04
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Cigna of AZ Commercial |
$77.35
|
| Rate for Payer: Devoted Health Medicare |
$21.42
|
| Rate for Payer: Humana of AZ Medicare |
$19.04
|
| Rate for Payer: Seven Corners Travel Insurance |
$26.00
|
| Rate for Payer: Southwest Service Administrators UFCW |
$80.92
|
| Rate for Payer: TriWest Medicare |
$19.04
|
| Rate for Payer: United Healthcare Commercial |
$68.07
|
| Rate for Payer: United Healthcare Medicare |
$19.04
|
| Rate for Payer: Veterans Affairs TRICARE |
$18.85
|
|
|
SKIN DEBRIDEMENT WITH CC
|
Facility
|
IP
|
$21,835.33
|
|
|
Service Code
|
MSDRG 571
|
| Min. Negotiated Rate |
$21,835.33 |
| Max. Negotiated Rate |
$21,835.33 |
| Rate for Payer: Seven Corners Travel Insurance |
$21,835.33
|
|
|
SKIN DEBRIDEMENT WITH MCC
|
Facility
|
IP
|
$38,011.20
|
|
|
Service Code
|
MSDRG 570
|
| Min. Negotiated Rate |
$38,011.20 |
| Max. Negotiated Rate |
$38,011.20 |
| Rate for Payer: Seven Corners Travel Insurance |
$38,011.20
|
|
|
SKIN DEBRIDEMENT WITHOUT CC/MCC
|
Facility
|
IP
|
$14,880.41
|
|
|
Service Code
|
MSDRG 572
|
| Min. Negotiated Rate |
$14,880.41 |
| Max. Negotiated Rate |
$14,880.41 |
| Rate for Payer: Seven Corners Travel Insurance |
$14,880.41
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC
|
Facility
|
IP
|
$34,258.03
|
|
|
Service Code
|
MSDRG 577
|
| Min. Negotiated Rate |
$34,258.03 |
| Max. Negotiated Rate |
$34,258.03 |
| Rate for Payer: Seven Corners Travel Insurance |
$34,258.03
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC
|
Facility
|
IP
|
$63,343.79
|
|
|
Service Code
|
MSDRG 576
|
| Min. Negotiated Rate |
$63,343.79 |
| Max. Negotiated Rate |
$63,343.79 |
| Rate for Payer: Seven Corners Travel Insurance |
$63,343.79
|
|
|
SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC
|
Facility
|
IP
|
$20,761.32
|
|
|
Service Code
|
MSDRG 578
|
| Min. Negotiated Rate |
$20,761.32 |
| Max. Negotiated Rate |
$20,761.32 |
| Rate for Payer: Seven Corners Travel Insurance |
$20,761.32
|
|
|
Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses
|
Facility
|
IP
|
$14,706.25
|
|
|
Service Code
|
APR-DRG 3122
|
| Hospital Charge Code |
APRDRG3123
|
| Min. Negotiated Rate |
$14,706.25 |
| Max. Negotiated Rate |
$14,706.25 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$14,706.25
|
| Rate for Payer: Mercy Care Medicaid |
$14,706.25
|
| Rate for Payer: NaphCare Correctional Healthcare |
$14,706.25
|
|
|
Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses
|
Facility
|
IP
|
$8,693.15
|
|
|
Service Code
|
APR-DRG 3121
|
| Hospital Charge Code |
APRDRG3124
|
| Min. Negotiated Rate |
$8,693.15 |
| Max. Negotiated Rate |
$8,693.15 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$8,693.15
|
| Rate for Payer: Mercy Care Medicaid |
$8,693.15
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8,693.15
|
|
|
Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses
|
Facility
|
IP
|
$47,114.44
|
|
|
Service Code
|
APR-DRG 3124
|
| Hospital Charge Code |
APRDRG3123
|
| Min. Negotiated Rate |
$47,114.44 |
| Max. Negotiated Rate |
$47,114.44 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$47,114.44
|
| Rate for Payer: Mercy Care Medicaid |
$47,114.44
|
| Rate for Payer: NaphCare Correctional Healthcare |
$47,114.44
|
|
|
Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses
|
Facility
|
IP
|
$14,706.25
|
|
|
Service Code
|
APR-DRG 3122
|
| Hospital Charge Code |
APRDRG3122
|
| Min. Negotiated Rate |
$14,706.25 |
| Max. Negotiated Rate |
$14,706.25 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$14,706.25
|
| Rate for Payer: Mercy Care Medicaid |
$14,706.25
|
| Rate for Payer: NaphCare Correctional Healthcare |
$14,706.25
|
|
|
Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses
|
Facility
|
IP
|
$47,114.44
|
|
|
Service Code
|
APR-DRG 3124
|
| Hospital Charge Code |
APRDRG3124
|
| Min. Negotiated Rate |
$47,114.44 |
| Max. Negotiated Rate |
$47,114.44 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$47,114.44
|
| Rate for Payer: Mercy Care Medicaid |
$47,114.44
|
| Rate for Payer: NaphCare Correctional Healthcare |
$47,114.44
|
|
|
Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses
|
Facility
|
IP
|
$24,992.99
|
|
|
Service Code
|
APR-DRG 3123
|
| Hospital Charge Code |
APRDRG3124
|
| Min. Negotiated Rate |
$24,992.99 |
| Max. Negotiated Rate |
$24,992.99 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$24,992.99
|
| Rate for Payer: Mercy Care Medicaid |
$24,992.99
|
| Rate for Payer: NaphCare Correctional Healthcare |
$24,992.99
|
|
|
Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses
|
Facility
|
IP
|
$24,992.99
|
|
|
Service Code
|
APR-DRG 3123
|
| Hospital Charge Code |
APRDRG3121
|
| Min. Negotiated Rate |
$24,992.99 |
| Max. Negotiated Rate |
$24,992.99 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$24,992.99
|
| Rate for Payer: Mercy Care Medicaid |
$24,992.99
|
| Rate for Payer: NaphCare Correctional Healthcare |
$24,992.99
|
|
