|
Dental Diseases And Disorders
|
Facility
|
IP
|
$3,871.73
|
|
|
Service Code
|
APR-DRG 1142
|
| Hospital Charge Code |
APRDRG1141
|
| Min. Negotiated Rate |
$3,871.73 |
| Max. Negotiated Rate |
$3,871.73 |
| Rate for Payer: AHCCCS Medicaid |
$3,871.73
|
| Rate for Payer: Allwell Medicaid |
$3,871.73
|
| Rate for Payer: AZCH Complete Medicaid |
$3,871.73
|
| Rate for Payer: Banner UC Health Medicaid |
$3,871.73
|
| Rate for Payer: Mercy Care Medicaid |
$3,871.73
|
|
|
Dental Diseases And Disorders
|
Facility
|
IP
|
$6,513.20
|
|
|
Service Code
|
APR-DRG 1143
|
| Hospital Charge Code |
APRDRG1143
|
| Min. Negotiated Rate |
$6,513.20 |
| Max. Negotiated Rate |
$6,513.20 |
| Rate for Payer: AHCCCS Medicaid |
$6,513.20
|
| Rate for Payer: Allwell Medicaid |
$6,513.20
|
| Rate for Payer: AZCH Complete Medicaid |
$6,513.20
|
| Rate for Payer: Banner UC Health Medicaid |
$6,513.20
|
| Rate for Payer: Mercy Care Medicaid |
$6,513.20
|
|
|
Dental Diseases And Disorders
|
Facility
|
IP
|
$6,513.20
|
|
|
Service Code
|
APR-DRG 1143
|
| Hospital Charge Code |
APRDRG1142
|
| Min. Negotiated Rate |
$6,513.20 |
| Max. Negotiated Rate |
$6,513.20 |
| Rate for Payer: AHCCCS Medicaid |
$6,513.20
|
| Rate for Payer: Allwell Medicaid |
$6,513.20
|
| Rate for Payer: AZCH Complete Medicaid |
$6,513.20
|
| Rate for Payer: Banner UC Health Medicaid |
$6,513.20
|
| Rate for Payer: Mercy Care Medicaid |
$6,513.20
|
|
|
Dental Diseases And Disorders
|
Facility
|
IP
|
$3,871.73
|
|
|
Service Code
|
APR-DRG 1142
|
| Hospital Charge Code |
APRDRG1144
|
| Min. Negotiated Rate |
$3,871.73 |
| Max. Negotiated Rate |
$3,871.73 |
| Rate for Payer: AHCCCS Medicaid |
$3,871.73
|
| Rate for Payer: Allwell Medicaid |
$3,871.73
|
| Rate for Payer: AZCH Complete Medicaid |
$3,871.73
|
| Rate for Payer: Banner UC Health Medicaid |
$3,871.73
|
| Rate for Payer: Mercy Care Medicaid |
$3,871.73
|
|
|
Dental Diseases And Disorders
|
Facility
|
IP
|
$3,871.73
|
|
|
Service Code
|
APR-DRG 1142
|
| Hospital Charge Code |
APRDRG1143
|
| Min. Negotiated Rate |
$3,871.73 |
| Max. Negotiated Rate |
$3,871.73 |
| Rate for Payer: AHCCCS Medicaid |
$3,871.73
|
| Rate for Payer: Allwell Medicaid |
$3,871.73
|
| Rate for Payer: AZCH Complete Medicaid |
$3,871.73
|
| Rate for Payer: Banner UC Health Medicaid |
$3,871.73
|
| Rate for Payer: Mercy Care Medicaid |
$3,871.73
|
|
|
Dental Diseases And Disorders
|
Facility
|
IP
|
$15,899.34
|
|
|
Service Code
|
APR-DRG 1144
|
| Hospital Charge Code |
APRDRG1142
|
| Min. Negotiated Rate |
$15,899.34 |
| Max. Negotiated Rate |
$15,899.34 |
| Rate for Payer: AHCCCS Medicaid |
$15,899.34
|
| Rate for Payer: Allwell Medicaid |
$15,899.34
|
| Rate for Payer: AZCH Complete Medicaid |
$15,899.34
|
| Rate for Payer: Banner UC Health Medicaid |
$15,899.34
|
| Rate for Payer: Mercy Care Medicaid |
$15,899.34
|
|
|
Dental Diseases And Disorders
|
Facility
|
IP
|
$6,513.20
|
|
|
Service Code
|
APR-DRG 1143
|
| Hospital Charge Code |
APRDRG1141
|
| Min. Negotiated Rate |
$6,513.20 |
| Max. Negotiated Rate |
$6,513.20 |
| Rate for Payer: AHCCCS Medicaid |
$6,513.20
|
| Rate for Payer: Allwell Medicaid |
$6,513.20
|
| Rate for Payer: AZCH Complete Medicaid |
$6,513.20
|
| Rate for Payer: Banner UC Health Medicaid |
$6,513.20
|
| Rate for Payer: Mercy Care Medicaid |
$6,513.20
|
|
|
Dental Diseases And Disorders
|
Facility
|
IP
|
$2,844.88
|
|
|
Service Code
|
APR-DRG 1141
|
| Hospital Charge Code |
APRDRG1141
|
| Min. Negotiated Rate |
$2,844.88 |
| Max. Negotiated Rate |
$2,844.88 |
| Rate for Payer: AHCCCS Medicaid |
$2,844.88
|
| Rate for Payer: Allwell Medicaid |
$2,844.88
|
| Rate for Payer: AZCH Complete Medicaid |
$2,844.88
|
| Rate for Payer: Banner UC Health Medicaid |
$2,844.88
|
| Rate for Payer: Mercy Care Medicaid |
$2,844.88
|
|
|
Dental Diseases And Disorders
|
Facility
|
IP
|
$15,899.34
|
|
|
Service Code
|
APR-DRG 1144
|
| Hospital Charge Code |
APRDRG1144
|
| Min. Negotiated Rate |
$15,899.34 |
| Max. Negotiated Rate |
$15,899.34 |
| Rate for Payer: AHCCCS Medicaid |
$15,899.34
|
| Rate for Payer: Allwell Medicaid |
$15,899.34
|
| Rate for Payer: AZCH Complete Medicaid |
$15,899.34
|
| Rate for Payer: Banner UC Health Medicaid |
$15,899.34
|
| Rate for Payer: Mercy Care Medicaid |
$15,899.34
|
|
|
Dental Diseases And Disorders
|
Facility
|
IP
|
$3,871.73
|
|
|
Service Code
|
APR-DRG 1142
|
| Hospital Charge Code |
APRDRG1142
|
| Min. Negotiated Rate |
$3,871.73 |
| Max. Negotiated Rate |
$3,871.73 |
| Rate for Payer: AHCCCS Medicaid |
$3,871.73
|
| Rate for Payer: Allwell Medicaid |
$3,871.73
|
| Rate for Payer: AZCH Complete Medicaid |
$3,871.73
|
| Rate for Payer: Banner UC Health Medicaid |
$3,871.73
|
| Rate for Payer: Mercy Care Medicaid |
$3,871.73
|
|
|
Dental Diseases And Disorders
|
Facility
|
IP
|
$6,513.20
|
|
|
Service Code
|
APR-DRG 1143
|
| Hospital Charge Code |
APRDRG1144
|
| Min. Negotiated Rate |
$6,513.20 |
| Max. Negotiated Rate |
$6,513.20 |
| Rate for Payer: AHCCCS Medicaid |
$6,513.20
|
| Rate for Payer: Allwell Medicaid |
$6,513.20
|
| Rate for Payer: AZCH Complete Medicaid |
$6,513.20
|
| Rate for Payer: Banner UC Health Medicaid |
$6,513.20
|
| Rate for Payer: Mercy Care Medicaid |
$6,513.20
|
|
|
Dental Diseases And Disorders
|
Facility
|
IP
|
$15,899.34
|
|
|
Service Code
|
APR-DRG 1144
|
| Hospital Charge Code |
APRDRG1143
|
| Min. Negotiated Rate |
$15,899.34 |
| Max. Negotiated Rate |
$15,899.34 |
| Rate for Payer: AHCCCS Medicaid |
$15,899.34
|
| Rate for Payer: Allwell Medicaid |
$15,899.34
|
| Rate for Payer: AZCH Complete Medicaid |
$15,899.34
|
| Rate for Payer: Banner UC Health Medicaid |
$15,899.34
|
| Rate for Payer: Mercy Care Medicaid |
$15,899.34
|
|
|
Dental Diseases And Disorders
|
Facility
|
IP
|
$2,844.88
|
|
|
Service Code
|
APR-DRG 1141
|
| Hospital Charge Code |
APRDRG1142
|
| Min. Negotiated Rate |
$2,844.88 |
| Max. Negotiated Rate |
$2,844.88 |
| Rate for Payer: AHCCCS Medicaid |
$2,844.88
|
| Rate for Payer: Allwell Medicaid |
$2,844.88
|
| Rate for Payer: AZCH Complete Medicaid |
$2,844.88
|
| Rate for Payer: Banner UC Health Medicaid |
$2,844.88
|
| Rate for Payer: Mercy Care Medicaid |
$2,844.88
|
|
|
Dental Diseases And Disorders
|
Facility
|
IP
|
$2,844.88
|
|
|
Service Code
|
APR-DRG 1141
|
| Hospital Charge Code |
APRDRG1144
|
| Min. Negotiated Rate |
$2,844.88 |
| Max. Negotiated Rate |
$2,844.88 |
| Rate for Payer: AHCCCS Medicaid |
$2,844.88
|
| Rate for Payer: Allwell Medicaid |
$2,844.88
|
| Rate for Payer: AZCH Complete Medicaid |
$2,844.88
|
| Rate for Payer: Banner UC Health Medicaid |
$2,844.88
|
| Rate for Payer: Mercy Care Medicaid |
$2,844.88
|
|
|
DENTURE ADHESIVE
|
Facility
|
IP
|
$14.00
|
|
| Hospital Charge Code |
22781968
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.64 |
| Max. Negotiated Rate |
$12.60 |
| Rate for Payer: Aetna of AZ Commercial |
$12.60
|
| Rate for Payer: Bisbee Police All Plans |
$3.64
|
| Rate for Payer: Cash Price |
$11.20
|
| Rate for Payer: Self Pay Self Pay |
$11.20
|
|
|
DENTURE ADHESIVE
|
Facility
|
OP
|
$14.00
|
|
| Hospital Charge Code |
22781968
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$12.60 |
| Rate for Payer: Aetna of AZ Commercial |
$12.60
|
| Rate for Payer: Aetna of AZ Medicare |
$3.92
|
| Rate for Payer: Allwell Medicare |
$2.10
|
| Rate for Payer: Amerigroup Medicare |
$2.10
|
| Rate for Payer: APIPA Medicare/Medicaid |
$5.23
|
| Rate for Payer: AZCH Complete Medicare |
$2.10
|
| Rate for Payer: Banner UC Health Medicare |
$2.10
|
| Rate for Payer: Bisbee Police All Plans |
$3.64
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$9.52
|
| Rate for Payer: Cash Price |
$11.20
|
| Rate for Payer: Cigna of AZ Commercial |
$9.80
|
| Rate for Payer: Copperpoint Commercial |
$3.46
|
| Rate for Payer: Health Net of AZ Commercial |
$8.40
|
| Rate for Payer: Health Net of AZ Medicare |
$3.92
|
| Rate for Payer: Humana of AZ Medicare |
$2.10
|
| Rate for Payer: Self Pay Self Pay |
$11.20
|
| Rate for Payer: TriWest Medicare |
$2.10
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$8.16
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$2.52
|
|
|
DEPO-Medrol 40 mg/1 mL Inj Susp [CQCH]
|
Facility
|
OP
|
$6.50
|
|
|
Service Code
|
HCPCS J1030
|
| Hospital Charge Code |
105931516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna of AZ Commercial |
$5.85
|
| Rate for Payer: Aetna of AZ Medicare |
$1.82
|
| Rate for Payer: AHCCCS Medicaid |
$15.30
|
| Rate for Payer: Allwell Medicaid |
$15.30
|
| Rate for Payer: Allwell Medicare |
$0.98
|
| Rate for Payer: Amerigroup Medicare |
$0.98
|
| Rate for Payer: APIPA Medicare/Medicaid |
$2.43
|
| Rate for Payer: AZCH Complete Medicaid |
$15.30
|
| Rate for Payer: AZCH Complete Medicare |
$0.98
|
| Rate for Payer: Banner UC Health Medicaid |
$15.30
|
| Rate for Payer: Banner UC Health Medicare |
$0.98
|
| Rate for Payer: Bisbee Police All Plans |
$1.69
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$4.42
|
| Rate for Payer: Cash Price |
$5.20
|
| Rate for Payer: Cash Price |
$5.20
|
| Rate for Payer: Cigna of AZ Commercial |
$4.22
|
| Rate for Payer: Copperpoint Commercial |
$1.61
|
| Rate for Payer: Health Net of AZ Commercial |
$3.90
|
| Rate for Payer: Health Net of AZ Medicare |
$1.82
|
| Rate for Payer: Humana of AZ Medicare |
$0.98
|
| Rate for Payer: Mercy Care Medicaid |
$15.30
|
| Rate for Payer: Self Pay Self Pay |
$5.20
|
| Rate for Payer: TriWest Medicare |
$0.98
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3.79
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$1.17
|
|
|
DEPO-Medrol 40 mg/1 mL Inj Susp [CQCH]
|
Facility
|
IP
|
$6.50
|
|
|
Service Code
|
HCPCS J1030
|
| Hospital Charge Code |
105931516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$5.85 |
| Rate for Payer: Aetna of AZ Commercial |
$5.85
|
| Rate for Payer: Bisbee Police All Plans |
$1.69
|
| Rate for Payer: Cash Price |
$5.20
|
| Rate for Payer: Self Pay Self Pay |
$5.20
|
|
|
Depression Except Major Depressive Disorder
|
Facility
|
IP
|
$2,837.16
|
|
|
Service Code
|
APR-DRG 7542
|
| Hospital Charge Code |
APRDRG7541
|
| Min. Negotiated Rate |
$2,837.16 |
| Max. Negotiated Rate |
$2,837.16 |
| Rate for Payer: AHCCCS Medicaid |
$2,837.16
|
| Rate for Payer: Allwell Medicaid |
$2,837.16
|
| Rate for Payer: AZCH Complete Medicaid |
$2,837.16
|
| Rate for Payer: Banner UC Health Medicaid |
$2,837.16
|
| Rate for Payer: Mercy Care Medicaid |
$2,837.16
|
|
|
Depression Except Major Depressive Disorder
|
Facility
|
IP
|
$4,831.94
|
|
|
Service Code
|
APR-DRG 7543
|
| Hospital Charge Code |
APRDRG7542
|
| Min. Negotiated Rate |
$4,831.94 |
| Max. Negotiated Rate |
$4,831.94 |
| Rate for Payer: AHCCCS Medicaid |
$4,831.94
|
| Rate for Payer: Allwell Medicaid |
$4,831.94
|
| Rate for Payer: AZCH Complete Medicaid |
$4,831.94
|
| Rate for Payer: Banner UC Health Medicaid |
$4,831.94
|
| Rate for Payer: Mercy Care Medicaid |
$4,831.94
|
|
|
Depression Except Major Depressive Disorder
|
Facility
|
IP
|
$2,042.48
|
|
|
Service Code
|
APR-DRG 7541
|
| Hospital Charge Code |
APRDRG7544
|
| Min. Negotiated Rate |
$2,042.48 |
| Max. Negotiated Rate |
$2,042.48 |
| Rate for Payer: AHCCCS Medicaid |
$2,042.48
|
| Rate for Payer: Allwell Medicaid |
$2,042.48
|
| Rate for Payer: AZCH Complete Medicaid |
$2,042.48
|
| Rate for Payer: Banner UC Health Medicaid |
$2,042.48
|
| Rate for Payer: Mercy Care Medicaid |
$2,042.48
|
|
|
Depression Except Major Depressive Disorder
|
Facility
|
IP
|
$2,042.48
|
|
|
Service Code
|
APR-DRG 7541
|
| Hospital Charge Code |
APRDRG7541
|
| Min. Negotiated Rate |
$2,042.48 |
| Max. Negotiated Rate |
$2,042.48 |
| Rate for Payer: AHCCCS Medicaid |
$2,042.48
|
| Rate for Payer: Allwell Medicaid |
$2,042.48
|
| Rate for Payer: AZCH Complete Medicaid |
$2,042.48
|
| Rate for Payer: Banner UC Health Medicaid |
$2,042.48
|
| Rate for Payer: Mercy Care Medicaid |
$2,042.48
|
|
|
Depression Except Major Depressive Disorder
|
Facility
|
IP
|
$2,042.48
|
|
|
Service Code
|
APR-DRG 7541
|
| Hospital Charge Code |
APRDRG7543
|
| Min. Negotiated Rate |
$2,042.48 |
| Max. Negotiated Rate |
$2,042.48 |
| Rate for Payer: AHCCCS Medicaid |
$2,042.48
|
| Rate for Payer: Allwell Medicaid |
$2,042.48
|
| Rate for Payer: AZCH Complete Medicaid |
$2,042.48
|
| Rate for Payer: Banner UC Health Medicaid |
$2,042.48
|
| Rate for Payer: Mercy Care Medicaid |
$2,042.48
|
|
|
Depression Except Major Depressive Disorder
|
Facility
|
IP
|
$2,042.48
|
|
|
Service Code
|
APR-DRG 7541
|
| Hospital Charge Code |
APRDRG7542
|
| Min. Negotiated Rate |
$2,042.48 |
| Max. Negotiated Rate |
$2,042.48 |
| Rate for Payer: AHCCCS Medicaid |
$2,042.48
|
| Rate for Payer: Allwell Medicaid |
$2,042.48
|
| Rate for Payer: AZCH Complete Medicaid |
$2,042.48
|
| Rate for Payer: Banner UC Health Medicaid |
$2,042.48
|
| Rate for Payer: Mercy Care Medicaid |
$2,042.48
|
|
|
Depression Except Major Depressive Disorder
|
Facility
|
IP
|
$10,887.13
|
|
|
Service Code
|
APR-DRG 7544
|
| Hospital Charge Code |
APRDRG7542
|
| Min. Negotiated Rate |
$10,887.13 |
| Max. Negotiated Rate |
$10,887.13 |
| Rate for Payer: AHCCCS Medicaid |
$10,887.13
|
| Rate for Payer: Allwell Medicaid |
$10,887.13
|
| Rate for Payer: AZCH Complete Medicaid |
$10,887.13
|
| Rate for Payer: Banner UC Health Medicaid |
$10,887.13
|
| Rate for Payer: Mercy Care Medicaid |
$10,887.13
|
|
