|
Bacterial and tuberculous infections of nervous system without CC/MCC
|
Facility
|
IP
|
$51,200.00
|
|
|
Service Code
|
MSDRG 96
|
| Min. Negotiated Rate |
$18,346.93 |
| Max. Negotiated Rate |
$20,385.48 |
| Rate for Payer: AETNA-COVENTRY-COFINITY(First Health) MCR ADVANTAGE and GOVERNMENT PLANS |
$20,385.48
|
| Rate for Payer: American Health Plans Medicare Advantage |
$20,385.48
|
| Rate for Payer: BLUE CROSS OF UTAH/BLUE CARD Medicare Advantage |
$20,385.48
|
| Rate for Payer: CIGNA Medicare Advantage |
$20,385.48
|
| Rate for Payer: HealthChoice Utah Medicare Advantage |
$20,385.48
|
| Rate for Payer: Humana Medicare Advantage |
$20,385.48
|
| Rate for Payer: Medicare |
$20,385.48
|
| Rate for Payer: MOLINA (MARKETPLACE) COMMERCIAL |
$20,385.48
|
| Rate for Payer: MOLINA MEDICARE |
$20,385.48
|
| Rate for Payer: Pacific Source Medicare Advantage |
$20,385.48
|
| Rate for Payer: Select Health Medicare Advantage |
$20,385.48
|
| Rate for Payer: SELF PAY |
$25,600.00
|
| Rate for Payer: Tricare West Military |
$18,346.93
|
|
|
BALLARD INLINE 10FR #210
|
Facility
|
IP
|
$35.88
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.94 |
| Max. Negotiated Rate |
$17.94 |
| Rate for Payer: SELF PAY |
$17.94
|
|
|
BALLARD INLINE #2105
|
Facility
|
IP
|
$25.16
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.58 |
| Max. Negotiated Rate |
$12.58 |
| Rate for Payer: SELF PAY |
$12.58
|
|
|
BALLARD INLINE #2105 WP
|
Facility
|
IP
|
$25.16
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$12.58 |
| Max. Negotiated Rate |
$12.58 |
| Rate for Payer: SELF PAY |
$12.58
|
|
|
BALLARD INLINE #2155
|
Facility
|
IP
|
$27.44
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$13.72 |
| Rate for Payer: SELF PAY |
$13.72
|
|
|
BALLARD INLINE #2205
|
Facility
|
IP
|
$27.44
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$13.72 |
| Rate for Payer: SELF PAY |
$13.72
|
|
|
BALLARD INLINE #2205 WP
|
Facility
|
IP
|
$27.44
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$13.72 |
| Max. Negotiated Rate |
$13.72 |
| Rate for Payer: SELF PAY |
$13.72
|
|
|
BALLARD INLINE 6FR #206
|
Facility
|
IP
|
$65.16
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$32.58 |
| Max. Negotiated Rate |
$32.58 |
| Rate for Payer: SELF PAY |
$32.58
|
|
|
BALLARD INLINE 8FR #208
|
Facility
|
IP
|
$35.02
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$17.51 |
| Max. Negotiated Rate |
$17.51 |
| Rate for Payer: SELF PAY |
$17.51
|
|
|
Banatrol 60ml
|
Facility
|
IP
|
$12.96
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.48 |
| Max. Negotiated Rate |
$6.48 |
| Rate for Payer: SELF PAY |
$6.48
|
|
|
BANATROL PLUS POWDER
|
Facility
|
IP
|
$3.40
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: SELF PAY |
$1.70
|
|
|
BANDAID 1" CLOTH
|
Facility
|
IP
|
$0.06
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: SELF PAY |
$0.03
|
|
|
BANDAID 1" CLOTH WP
|
Facility
|
IP
|
$0.06
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: SELF PAY |
$0.03
|
|
|
BARIATRIC BEDPAN
|
Facility
|
IP
|
$31.14
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$15.57 |
| Max. Negotiated Rate |
$15.57 |
| Rate for Payer: SELF PAY |
$15.57
|
|
|
Bariatric Frame and Mattress
|
Facility
|
IP
|
$95.00
|
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$47.50 |
| Max. Negotiated Rate |
$47.50 |
| Rate for Payer: SELF PAY |
$47.50
|
|
|
Bariatric Overlay
|
Facility
|
IP
|
$66.00
|
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: SELF PAY |
$33.00
|
|
|
Bariatric Recliner
|
Facility
|
IP
|
$60.00
|
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$30.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: SELF PAY |
$30.00
|
|
|
Bariatric Visco Mattress
|
Facility
|
IP
|
$50.00
|
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$25.00 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: SELF PAY |
$25.00
|
|
|
Bari Custom Frame
|
Facility
|
IP
|
$52.00
|
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: SELF PAY |
$26.00
|
|
|
Bari Frame and Air matt
|
Facility
|
IP
|
$93.00
|
|
|
Hospital Revenue Code
|
290
|
| Min. Negotiated Rate |
$46.50 |
| Max. Negotiated Rate |
$46.50 |
| Rate for Payer: SELF PAY |
$46.50
|
|
|
BATTERY 9V
|
Facility
|
IP
|
$6.70
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.35 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: SELF PAY |
$3.35
|
|
|
BATTERY AA
|
Facility
|
IP
|
$1.98
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: SELF PAY |
$0.99
|
|
|
BATTERY AAA
|
Facility
|
IP
|
$0.92
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.46 |
| Rate for Payer: SELF PAY |
$0.46
|
|
|
BATTERY C
|
Facility
|
IP
|
$2.30
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$1.15 |
| Rate for Payer: SELF PAY |
$1.15
|
|
|
BATTERY D
|
Facility
|
IP
|
$4.16
|
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$2.08 |
| Rate for Payer: SELF PAY |
$2.08
|
|
