|
TELEHEALTH CONSULTATION, EMERGENCY DEPT OR INPATIENT TYPICAL
|
Facility
|
OP
|
$912.00
|
|
|
Service Code
|
HCPCS G0427
|
| Hospital Charge Code |
24270136
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$144.46 |
| Max. Negotiated Rate |
$820.80 |
| Rate for Payer: Aetna of AZ Commercial |
$820.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$145.92
|
| Rate for Payer: Banner UC Health Medicare |
$145.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$620.16
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$145.92
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$145.92
|
| Rate for Payer: Cash Price |
$729.60
|
| Rate for Payer: Cigna of AZ Commercial |
$638.40
|
| Rate for Payer: Devoted Health Medicare |
$164.16
|
| Rate for Payer: Humana of AZ Medicare |
$145.92
|
| Rate for Payer: Southwest Service Administrators UFCW |
$620.16
|
| Rate for Payer: TriWest Medicare |
$145.92
|
| Rate for Payer: United Healthcare Commercial |
$521.66
|
| Rate for Payer: United Healthcare Medicare |
$145.92
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$173.28
|
| Rate for Payer: Veterans Affairs TRICARE |
$144.46
|
|
|
TELEHEALTH CONSULTATION, EMERGENCY DEPT OR INPATIENT TYPICAL
|
Facility
|
OP
|
$642.00
|
|
|
Service Code
|
HCPCS G0426
|
| Hospital Charge Code |
24270135
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$101.69 |
| Max. Negotiated Rate |
$577.80 |
| Rate for Payer: Aetna of AZ Commercial |
$577.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$102.72
|
| Rate for Payer: Banner UC Health Medicare |
$102.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$436.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$102.72
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$102.72
|
| Rate for Payer: Cash Price |
$513.60
|
| Rate for Payer: Cigna of AZ Commercial |
$449.40
|
| Rate for Payer: Devoted Health Medicare |
$115.56
|
| Rate for Payer: Humana of AZ Medicare |
$102.72
|
| Rate for Payer: Southwest Service Administrators UFCW |
$436.56
|
| Rate for Payer: TriWest Medicare |
$102.72
|
| Rate for Payer: United Healthcare Commercial |
$367.22
|
| Rate for Payer: United Healthcare Medicare |
$102.72
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$121.98
|
| Rate for Payer: Veterans Affairs TRICARE |
$101.69
|
|
|
TELEHEALTH CONSULTATION, EMERGENCY DEPT OR INPATIENT TYPICAL
|
Facility
|
IP
|
$642.00
|
|
|
Service Code
|
HCPCS G0426
|
| Hospital Charge Code |
24270135
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$577.80 |
| Max. Negotiated Rate |
$577.80 |
| Rate for Payer: Aetna of AZ Commercial |
$577.80
|
| Rate for Payer: Cash Price |
$513.60
|
|
|
TELEHEALTH CONSULTATION, EMERGENCY DEPT OR INPATIENT TYPICAL
|
Facility
|
IP
|
$473.00
|
|
|
Service Code
|
HCPCS G0425
|
| Hospital Charge Code |
24270131
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$425.70 |
| Max. Negotiated Rate |
$425.70 |
| Rate for Payer: Aetna of AZ Commercial |
$425.70
|
| Rate for Payer: Cash Price |
$378.40
|
|
|
TELEHEALTH CONSULTATION, EMERGENCY DEPT OR INPATIENT TYPICAL
|
Facility
|
IP
|
$912.00
|
|
|
Service Code
|
HCPCS G0427
|
| Hospital Charge Code |
24270136
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$820.80 |
| Max. Negotiated Rate |
$820.80 |
| Rate for Payer: Aetna of AZ Commercial |
$820.80
|
| Rate for Payer: Cash Price |
$729.60
|
|
|
TELEHEALTH CONSULTATION, EMERGENCY DEPT OR INPATIENT TYPICAL
|
Facility
|
OP
|
$473.00
|
|
|
Service Code
|
HCPCS G0425
|
| Hospital Charge Code |
24270131
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$74.92 |
| Max. Negotiated Rate |
$425.70 |
| Rate for Payer: Aetna of AZ Commercial |
$425.70
|
| Rate for Payer: Arizona Complete Health Allwell |
$75.68
|
| Rate for Payer: Banner UC Health Medicare |
$75.68
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$321.64
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$75.68
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$75.68
|
| Rate for Payer: Cash Price |
$378.40
|
| Rate for Payer: Cigna of AZ Commercial |
$331.10
|
| Rate for Payer: Devoted Health Medicare |
$85.14
|
| Rate for Payer: Humana of AZ Medicare |
$75.68
|
| Rate for Payer: Southwest Service Administrators UFCW |
$321.64
|
| Rate for Payer: TriWest Medicare |
$75.68
|
| Rate for Payer: United Healthcare Commercial |
$270.56
|
| Rate for Payer: United Healthcare Medicare |
$75.68
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$89.87
|
| Rate for Payer: Veterans Affairs TRICARE |
$74.92
|
|
|
TELEHEALTH NEURO SITE FACILITY FEE
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
22247982
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$53.10 |
| Rate for Payer: Aetna of AZ Commercial |
$53.10
|
| Rate for Payer: Arizona Complete Health Allwell |
$9.44
|
| Rate for Payer: Banner UC Health Medicare |
$9.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$40.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$9.44
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$9.44
|
| Rate for Payer: Cash Price |
$47.20
|
| Rate for Payer: Cigna of AZ Commercial |
$41.30
|
| Rate for Payer: Devoted Health Medicare |
$10.62
|
| Rate for Payer: Humana of AZ Medicare |
$9.44
|
| Rate for Payer: Southwest Service Administrators UFCW |
$40.12
|
| Rate for Payer: TriWest Medicare |
$9.44
|
| Rate for Payer: United Healthcare Commercial |
$33.75
|
| Rate for Payer: United Healthcare Medicare |
$9.44
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$11.21
|
| Rate for Payer: Veterans Affairs TRICARE |
$9.35
|
|
|
TELEHEALTH NEURO SITE FACILITY FEE
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
22247982
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$53.10 |
| Max. Negotiated Rate |
$53.10 |
| Rate for Payer: Aetna of AZ Commercial |
$53.10
|
| Rate for Payer: Cash Price |
$47.20
|
|
|
TELEHEALTH PULMON SITE FACILITY FEE
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
22247984
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$55.80 |
| Max. Negotiated Rate |
$55.80 |
| Rate for Payer: Aetna of AZ Commercial |
$55.80
|
| Rate for Payer: Cash Price |
$49.60
|
|
|
TELEHEALTH PULMON SITE FACILITY FEE
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
22247984
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$9.82 |
| Max. Negotiated Rate |
$55.80 |
| Rate for Payer: Aetna of AZ Commercial |
$55.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$9.92
|
| Rate for Payer: Banner UC Health Medicare |
$9.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$42.16
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$9.92
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$9.92
|
| Rate for Payer: Cash Price |
$49.60
|
| Rate for Payer: Cigna of AZ Commercial |
$43.40
|
| Rate for Payer: Devoted Health Medicare |
$11.16
|
| Rate for Payer: Humana of AZ Medicare |
$9.92
|
| Rate for Payer: Southwest Service Administrators UFCW |
$42.16
|
| Rate for Payer: TriWest Medicare |
$9.92
|
| Rate for Payer: United Healthcare Commercial |
$35.46
|
| Rate for Payer: United Healthcare Medicare |
$9.92
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$11.78
|
| Rate for Payer: Veterans Affairs TRICARE |
$9.82
|
|
|
Telemedicine Facility Fee
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
21399811
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$10.30 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna of AZ Commercial |
$58.50
|
| Rate for Payer: Aetna of AZ Commercial |
$169.20
|
| Rate for Payer: Arizona Complete Health Allwell |
$30.08
|
| Rate for Payer: Arizona Complete Health Allwell |
$10.40
|
| Rate for Payer: Banner UC Health Medicare |
$30.08
|
| Rate for Payer: Banner UC Health Medicare |
$10.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$44.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$127.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$10.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$30.08
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$30.08
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$10.40
|
| Rate for Payer: Cash Price |
$150.40
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cigna of AZ Commercial |
$45.50
|
| Rate for Payer: Cigna of AZ Commercial |
$131.60
|
| Rate for Payer: Devoted Health Medicare |
$33.84
|
| Rate for Payer: Devoted Health Medicare |
$11.70
|
| Rate for Payer: Humana of AZ Medicare |
$30.08
|
| Rate for Payer: Humana of AZ Medicare |
$10.40
|
| Rate for Payer: Southwest Service Administrators UFCW |
$127.84
|
| Rate for Payer: Southwest Service Administrators UFCW |
$44.20
|
| Rate for Payer: TriWest Medicare |
$30.08
|
| Rate for Payer: TriWest Medicare |
$10.40
|
| Rate for Payer: United Healthcare Commercial |
$107.54
|
| Rate for Payer: United Healthcare Commercial |
$37.18
|
| Rate for Payer: United Healthcare Medicare |
$30.08
|
| Rate for Payer: United Healthcare Medicare |
$10.40
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$12.35
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$35.72
|
| Rate for Payer: Veterans Affairs TRICARE |
$10.30
|
| Rate for Payer: Veterans Affairs TRICARE |
$29.78
|
|
|
Telemedicine Facility Fee
|
Facility
|
IP
|
$188.00
|
|
|
Service Code
|
HCPCS Q3014
|
| Hospital Charge Code |
21399811
|
|
Hospital Revenue Code
|
780
|
| Min. Negotiated Rate |
$169.20 |
| Max. Negotiated Rate |
$169.20 |
| Rate for Payer: Aetna of AZ Commercial |
$169.20
|
| Rate for Payer: Aetna of AZ Commercial |
$58.50
|
| Rate for Payer: Cash Price |
$150.40
|
| Rate for Payer: Cash Price |
$52.00
|
|
|
temazepam 15 mg Cap [CQCH]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 67877014601
|
| Hospital Charge Code |
105943112
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of AZ Commercial |
$0.07
|
| 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 |
$0.05
|
| 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 |
$0.07
|
| Rate for Payer: Cigna of AZ Commercial |
$0.05
|
| Rate for Payer: Devoted Health Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.01
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.05
|
| Rate for Payer: TriWest Medicare |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.01
|
|
|
temazepam 15 mg Cap [CQCH]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 67877014601
|
| Hospital Charge Code |
105943112
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of AZ Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.07
|
|
|
TENDONITIS, MYOSITIS AND BURSITIS WITH MCC
|
Facility
|
IP
|
$19,216.89
|
|
|
Service Code
|
MSDRG 557
|
| Min. Negotiated Rate |
$19,216.89 |
| Max. Negotiated Rate |
$19,216.89 |
| Rate for Payer: Seven Corners Travel Insurance |
$19,216.89
|
|
|
TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC
|
Facility
|
IP
|
$11,673.33
|
|
|
Service Code
|
MSDRG 558
|
| Min. Negotiated Rate |
$11,673.33 |
| Max. Negotiated Rate |
$11,673.33 |
| Rate for Payer: Seven Corners Travel Insurance |
$11,673.33
|
|
|
Tendon, Muscle And Other Soft Tissue Procedures
|
Facility
|
IP
|
$27,861.71
|
|
|
Service Code
|
APR-DRG 3174
|
| Hospital Charge Code |
APRDRG3173
|
| Min. Negotiated Rate |
$27,861.71 |
| Max. Negotiated Rate |
$27,861.71 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$27,861.71
|
| Rate for Payer: Mercy Care Medicaid |
$27,861.71
|
| Rate for Payer: NaphCare Correctional Healthcare |
$27,861.71
|
|
|
Tendon, Muscle And Other Soft Tissue Procedures
|
Facility
|
IP
|
$14,282.61
|
|
|
Service Code
|
APR-DRG 3173
|
| Hospital Charge Code |
APRDRG3174
|
| Min. Negotiated Rate |
$14,282.61 |
| Max. Negotiated Rate |
$14,282.61 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$14,282.61
|
| Rate for Payer: Mercy Care Medicaid |
$14,282.61
|
| Rate for Payer: NaphCare Correctional Healthcare |
$14,282.61
|
|
|
Tendon, Muscle And Other Soft Tissue Procedures
|
Facility
|
IP
|
$27,861.71
|
|
|
Service Code
|
APR-DRG 3174
|
| Hospital Charge Code |
APRDRG3174
|
| Min. Negotiated Rate |
$27,861.71 |
| Max. Negotiated Rate |
$27,861.71 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$27,861.71
|
| Rate for Payer: Mercy Care Medicaid |
$27,861.71
|
| Rate for Payer: NaphCare Correctional Healthcare |
$27,861.71
|
|
|
Tendon, Muscle And Other Soft Tissue Procedures
|
Facility
|
IP
|
$8,805.38
|
|
|
Service Code
|
APR-DRG 3172
|
| Hospital Charge Code |
APRDRG3173
|
| Min. Negotiated Rate |
$8,805.38 |
| Max. Negotiated Rate |
$8,805.38 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$8,805.38
|
| Rate for Payer: Mercy Care Medicaid |
$8,805.38
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8,805.38
|
|
|
Tendon, Muscle And Other Soft Tissue Procedures
|
Facility
|
IP
|
$14,282.61
|
|
|
Service Code
|
APR-DRG 3173
|
| Hospital Charge Code |
APRDRG3173
|
| Min. Negotiated Rate |
$14,282.61 |
| Max. Negotiated Rate |
$14,282.61 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$14,282.61
|
| Rate for Payer: Mercy Care Medicaid |
$14,282.61
|
| Rate for Payer: NaphCare Correctional Healthcare |
$14,282.61
|
|
|
Tendon, Muscle And Other Soft Tissue Procedures
|
Facility
|
IP
|
$8,805.38
|
|
|
Service Code
|
APR-DRG 3172
|
| Hospital Charge Code |
APRDRG3171
|
| Min. Negotiated Rate |
$8,805.38 |
| Max. Negotiated Rate |
$8,805.38 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$8,805.38
|
| Rate for Payer: Mercy Care Medicaid |
$8,805.38
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8,805.38
|
|
|
Tendon, Muscle And Other Soft Tissue Procedures
|
Facility
|
IP
|
$6,375.02
|
|
|
Service Code
|
APR-DRG 3171
|
| Hospital Charge Code |
APRDRG3174
|
| Min. Negotiated Rate |
$6,375.02 |
| Max. Negotiated Rate |
$6,375.02 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,375.02
|
| Rate for Payer: Mercy Care Medicaid |
$6,375.02
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,375.02
|
|
|
Tendon, Muscle And Other Soft Tissue Procedures
|
Facility
|
IP
|
$8,805.38
|
|
|
Service Code
|
APR-DRG 3172
|
| Hospital Charge Code |
APRDRG3174
|
| Min. Negotiated Rate |
$8,805.38 |
| Max. Negotiated Rate |
$8,805.38 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$8,805.38
|
| Rate for Payer: Mercy Care Medicaid |
$8,805.38
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8,805.38
|
|
|
Tendon, Muscle And Other Soft Tissue Procedures
|
Facility
|
IP
|
$6,375.02
|
|
|
Service Code
|
APR-DRG 3171
|
| Hospital Charge Code |
APRDRG3171
|
| Min. Negotiated Rate |
$6,375.02 |
| Max. Negotiated Rate |
$6,375.02 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,375.02
|
| Rate for Payer: Mercy Care Medicaid |
$6,375.02
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,375.02
|
|
