|
UNNA BOOT 3X10
|
Facility
|
OP
|
$38.00
|
|
| Hospital Charge Code |
22355140
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.02 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Aetna of AZ Commercial |
$34.20
|
| Rate for Payer: Arizona Complete Health Allwell |
$6.08
|
| Rate for Payer: Banner UC Health Medicare |
$6.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$25.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$6.08
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$6.08
|
| Rate for Payer: Cash Price |
$30.40
|
| Rate for Payer: Cigna of AZ Commercial |
$26.60
|
| Rate for Payer: Devoted Health Medicare |
$6.84
|
| Rate for Payer: Humana of AZ Medicare |
$6.08
|
| Rate for Payer: Southwest Service Administrators UFCW |
$25.84
|
| Rate for Payer: TriWest Medicare |
$6.08
|
| Rate for Payer: United Healthcare Commercial |
$21.74
|
| Rate for Payer: United Healthcare Medicare |
$6.08
|
| Rate for Payer: Veterans Affairs TRICARE |
$6.02
|
|
|
UNNA BOOT 3X10
|
Facility
|
IP
|
$38.00
|
|
| Hospital Charge Code |
22355140
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$34.20 |
| Max. Negotiated Rate |
$34.20 |
| Rate for Payer: Aetna of AZ Commercial |
$34.20
|
| Rate for Payer: Cash Price |
$30.40
|
|
|
UNNA Boot Application Charge
|
Facility
|
OP
|
$149.00
|
|
|
Service Code
|
CPT 29580
|
| Hospital Charge Code |
872059
|
| Min. Negotiated Rate |
$23.60 |
| Max. Negotiated Rate |
$251.43 |
| Rate for Payer: Aetna of AZ Commercial |
$134.10
|
| Rate for Payer: Arizona Complete Health Allwell |
$23.84
|
| Rate for Payer: Banner UC Health Medicare |
$23.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$101.32
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$39.69
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$23.84
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$23.84
|
| Rate for Payer: Cash Price |
$119.20
|
| Rate for Payer: Cash Price |
$119.20
|
| Rate for Payer: Cigna of AZ Commercial |
$104.30
|
| Rate for Payer: Devoted Health Medicare |
$26.82
|
| Rate for Payer: Humana of AZ Medicare |
$23.84
|
| Rate for Payer: Mercy Care Medicaid |
$39.69
|
| Rate for Payer: NaphCare Correctional Healthcare |
$39.69
|
| Rate for Payer: Seven Corners Travel Insurance |
$251.43
|
| Rate for Payer: Southwest Service Administrators UFCW |
$101.32
|
| Rate for Payer: TriWest Medicare |
$23.84
|
| Rate for Payer: United Healthcare Commercial |
$85.23
|
| Rate for Payer: United Healthcare Medicare |
$23.84
|
| Rate for Payer: Veterans Affairs TRICARE |
$23.60
|
|
|
UNNA Boot Application Charge
|
Facility
|
IP
|
$149.00
|
|
|
Service Code
|
CPT 29580
|
| Hospital Charge Code |
872059
|
| Min. Negotiated Rate |
$134.10 |
| Max. Negotiated Rate |
$134.10 |
| Rate for Payer: Aetna of AZ Commercial |
$134.10
|
| Rate for Payer: Cash Price |
$119.20
|
|
|
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC
|
Facility
|
IP
|
$21,943.92
|
|
|
Service Code
|
MSDRG 256
|
| Min. Negotiated Rate |
$21,943.92 |
| Max. Negotiated Rate |
$21,943.92 |
| Rate for Payer: Seven Corners Travel Insurance |
$21,943.92
|
|
|
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC
|
Facility
|
IP
|
$34,861.58
|
|
|
Service Code
|
MSDRG 255
|
| Min. Negotiated Rate |
$34,861.58 |
| Max. Negotiated Rate |
$34,861.58 |
| Rate for Payer: Seven Corners Travel Insurance |
$34,861.58
|
|
|
UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC
|
Facility
|
IP
|
$14,194.89
|
|
|
Service Code
|
MSDRG 257
|
| Min. Negotiated Rate |
$14,194.89 |
| Max. Negotiated Rate |
$14,194.89 |
| Rate for Payer: Seven Corners Travel Insurance |
$14,194.89
|
|
|
UREA NITROGEN LEVEL TO ASSESS KIDNEY FUNCTION, CLEARANCE
|
Facility
|
OP
|
$35.95
|
|
|
Service Code
|
CPT 84545
|
| Hospital Charge Code |
28011457
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.69 |
| Max. Negotiated Rate |
$32.35 |
| Rate for Payer: Aetna of AZ Commercial |
$32.35
|
| Rate for Payer: Arizona Complete Health Allwell |
$5.75
|
| Rate for Payer: Banner UC Health Medicare |
$5.75
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$24.45
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$5.75
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$5.75
|
| Rate for Payer: Cash Price |
$28.76
|
| Rate for Payer: Cash Price |
$28.76
|
| Rate for Payer: Cigna of AZ Commercial |
$23.37
|
| Rate for Payer: Devoted Health Medicare |
$6.47
|
| Rate for Payer: Humana of AZ Medicare |
$5.75
|
| Rate for Payer: Seven Corners Travel Insurance |
$10.44
|
| Rate for Payer: Southwest Service Administrators UFCW |
$24.45
|
| Rate for Payer: TriWest Medicare |
$5.75
|
| Rate for Payer: United Healthcare Commercial |
$20.56
|
| Rate for Payer: United Healthcare Medicare |
$5.75
|
| Rate for Payer: Veterans Affairs TRICARE |
$5.69
|
|
|
UREA NITROGEN LEVEL TO ASSESS KIDNEY FUNCTION, CLEARANCE
|
Facility
|
IP
|
$35.95
|
|
|
Service Code
|
CPT 84545
|
| Hospital Charge Code |
28011457
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$32.35 |
| Max. Negotiated Rate |
$32.35 |
| Rate for Payer: Aetna of AZ Commercial |
$32.35
|
| Rate for Payer: Cash Price |
$28.76
|
|
|
URETERAL OPTIMA STENT 6FR 24CM
|
Facility
|
OP
|
$1,431.00
|
|
| Hospital Charge Code |
27744361
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$226.67 |
| Max. Negotiated Rate |
$1,287.90 |
| Rate for Payer: Aetna of AZ Commercial |
$1,287.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$228.96
|
| Rate for Payer: Banner UC Health Medicare |
$228.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$973.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$228.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$228.96
|
| Rate for Payer: Cash Price |
$1,144.80
|
| Rate for Payer: Cigna of AZ Commercial |
$1,001.70
|
| Rate for Payer: Devoted Health Medicare |
$257.58
|
| Rate for Payer: Humana of AZ Medicare |
$228.96
|
| Rate for Payer: Southwest Service Administrators UFCW |
$973.08
|
| Rate for Payer: TriWest Medicare |
$228.96
|
| Rate for Payer: United Healthcare Commercial |
$818.53
|
| Rate for Payer: United Healthcare Medicare |
$228.96
|
| Rate for Payer: Veterans Affairs TRICARE |
$226.67
|
|
|
URETERAL OPTIMA STENT 6FR 24CM
|
Facility
|
IP
|
$1,431.00
|
|
| Hospital Charge Code |
27744361
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,287.90 |
| Max. Negotiated Rate |
$1,287.90 |
| Rate for Payer: Aetna of AZ Commercial |
$1,287.90
|
| Rate for Payer: Cash Price |
$1,144.80
|
|
|
URETERAL OPTIMA STENT 6FR 26CM
|
Facility
|
OP
|
$1,431.00
|
|
| Hospital Charge Code |
27744363
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$226.67 |
| Max. Negotiated Rate |
$1,287.90 |
| Rate for Payer: Aetna of AZ Commercial |
$1,287.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$228.96
|
| Rate for Payer: Banner UC Health Medicare |
$228.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$973.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$228.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$228.96
|
| Rate for Payer: Cash Price |
$1,144.80
|
| Rate for Payer: Cigna of AZ Commercial |
$1,001.70
|
| Rate for Payer: Devoted Health Medicare |
$257.58
|
| Rate for Payer: Humana of AZ Medicare |
$228.96
|
| Rate for Payer: Southwest Service Administrators UFCW |
$973.08
|
| Rate for Payer: TriWest Medicare |
$228.96
|
| Rate for Payer: United Healthcare Commercial |
$818.53
|
| Rate for Payer: United Healthcare Medicare |
$228.96
|
| Rate for Payer: Veterans Affairs TRICARE |
$226.67
|
|
|
URETERAL OPTIMA STENT 6FR 26CM
|
Facility
|
IP
|
$1,431.00
|
|
| Hospital Charge Code |
27744363
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,287.90 |
| Max. Negotiated Rate |
$1,287.90 |
| Rate for Payer: Aetna of AZ Commercial |
$1,287.90
|
| Rate for Payer: Cash Price |
$1,144.80
|
|
|
URETERAL OPTIMA STENT 6FR 28CM
|
Facility
|
IP
|
$1,362.95
|
|
| Hospital Charge Code |
27744362
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1,226.65 |
| Max. Negotiated Rate |
$1,226.65 |
| Rate for Payer: Aetna of AZ Commercial |
$1,226.65
|
| Rate for Payer: Cash Price |
$1,090.36
|
|
|
URETERAL OPTIMA STENT 6FR 28CM
|
Facility
|
OP
|
$1,362.95
|
|
| Hospital Charge Code |
27744362
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$215.89 |
| Max. Negotiated Rate |
$1,226.65 |
| Rate for Payer: Aetna of AZ Commercial |
$1,226.65
|
| Rate for Payer: Arizona Complete Health Allwell |
$218.07
|
| Rate for Payer: Banner UC Health Medicare |
$218.07
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$926.81
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$218.07
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$218.07
|
| Rate for Payer: Cash Price |
$1,090.36
|
| Rate for Payer: Cigna of AZ Commercial |
$954.07
|
| Rate for Payer: Devoted Health Medicare |
$245.33
|
| Rate for Payer: Humana of AZ Medicare |
$218.07
|
| Rate for Payer: Southwest Service Administrators UFCW |
$926.81
|
| Rate for Payer: TriWest Medicare |
$218.07
|
| Rate for Payer: United Healthcare Commercial |
$779.61
|
| Rate for Payer: United Healthcare Medicare |
$218.07
|
| Rate for Payer: Veterans Affairs TRICARE |
$215.89
|
|
|
Urethral And Transurethral Procedures
|
Facility
|
IP
|
$20,260.64
|
|
|
Service Code
|
APR-DRG 4464
|
| Hospital Charge Code |
APRDRG4462
|
| Min. Negotiated Rate |
$20,260.64 |
| Max. Negotiated Rate |
$20,260.64 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$20,260.64
|
| Rate for Payer: Mercy Care Medicaid |
$20,260.64
|
| Rate for Payer: NaphCare Correctional Healthcare |
$20,260.64
|
|
|
Urethral And Transurethral Procedures
|
Facility
|
IP
|
$6,668.21
|
|
|
Service Code
|
APR-DRG 4462
|
| Hospital Charge Code |
APRDRG4461
|
| Min. Negotiated Rate |
$6,668.21 |
| Max. Negotiated Rate |
$6,668.21 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,668.21
|
| Rate for Payer: Mercy Care Medicaid |
$6,668.21
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,668.21
|
|
|
Urethral And Transurethral Procedures
|
Facility
|
IP
|
$20,260.64
|
|
|
Service Code
|
APR-DRG 4464
|
| Hospital Charge Code |
APRDRG4461
|
| Min. Negotiated Rate |
$20,260.64 |
| Max. Negotiated Rate |
$20,260.64 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$20,260.64
|
| Rate for Payer: Mercy Care Medicaid |
$20,260.64
|
| Rate for Payer: NaphCare Correctional Healthcare |
$20,260.64
|
|
|
Urethral And Transurethral Procedures
|
Facility
|
IP
|
$5,397.97
|
|
|
Service Code
|
APR-DRG 4461
|
| Hospital Charge Code |
APRDRG4462
|
| Min. Negotiated Rate |
$5,397.97 |
| Max. Negotiated Rate |
$5,397.97 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,397.97
|
| Rate for Payer: Mercy Care Medicaid |
$5,397.97
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,397.97
|
|
|
Urethral And Transurethral Procedures
|
Facility
|
IP
|
$5,397.97
|
|
|
Service Code
|
APR-DRG 4461
|
| Hospital Charge Code |
APRDRG4461
|
| Min. Negotiated Rate |
$5,397.97 |
| Max. Negotiated Rate |
$5,397.97 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,397.97
|
| Rate for Payer: Mercy Care Medicaid |
$5,397.97
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,397.97
|
|
|
Urethral And Transurethral Procedures
|
Facility
|
IP
|
$20,260.64
|
|
|
Service Code
|
APR-DRG 4464
|
| Hospital Charge Code |
APRDRG4463
|
| Min. Negotiated Rate |
$20,260.64 |
| Max. Negotiated Rate |
$20,260.64 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$20,260.64
|
| Rate for Payer: Mercy Care Medicaid |
$20,260.64
|
| Rate for Payer: NaphCare Correctional Healthcare |
$20,260.64
|
|
|
Urethral And Transurethral Procedures
|
Facility
|
IP
|
$11,218.19
|
|
|
Service Code
|
APR-DRG 4463
|
| Hospital Charge Code |
APRDRG4462
|
| Min. Negotiated Rate |
$11,218.19 |
| Max. Negotiated Rate |
$11,218.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$11,218.19
|
| Rate for Payer: Mercy Care Medicaid |
$11,218.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$11,218.19
|
|
|
Urethral And Transurethral Procedures
|
Facility
|
IP
|
$11,218.19
|
|
|
Service Code
|
APR-DRG 4463
|
| Hospital Charge Code |
APRDRG4463
|
| Min. Negotiated Rate |
$11,218.19 |
| Max. Negotiated Rate |
$11,218.19 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$11,218.19
|
| Rate for Payer: Mercy Care Medicaid |
$11,218.19
|
| Rate for Payer: NaphCare Correctional Healthcare |
$11,218.19
|
|
|
Urethral And Transurethral Procedures
|
Facility
|
IP
|
$6,668.21
|
|
|
Service Code
|
APR-DRG 4462
|
| Hospital Charge Code |
APRDRG4462
|
| Min. Negotiated Rate |
$6,668.21 |
| Max. Negotiated Rate |
$6,668.21 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$6,668.21
|
| Rate for Payer: Mercy Care Medicaid |
$6,668.21
|
| Rate for Payer: NaphCare Correctional Healthcare |
$6,668.21
|
|
|
Urethral And Transurethral Procedures
|
Facility
|
IP
|
$5,397.97
|
|
|
Service Code
|
APR-DRG 4461
|
| Hospital Charge Code |
APRDRG4463
|
| Min. Negotiated Rate |
$5,397.97 |
| Max. Negotiated Rate |
$5,397.97 |
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$5,397.97
|
| Rate for Payer: Mercy Care Medicaid |
$5,397.97
|
| Rate for Payer: NaphCare Correctional Healthcare |
$5,397.97
|
|
