|
simvastatin 20 mg Tab [CQCH]
|
Facility
|
OP
|
$0.24
|
|
|
Service Code
|
NDC 68084051201
|
| Hospital Charge Code |
105940605
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of AZ Commercial |
$0.22
|
| Rate for Payer: Aetna of AZ Medicare |
$0.07
|
| Rate for Payer: Allwell Medicare |
$0.04
|
| Rate for Payer: Amerigroup Medicare |
$0.04
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.09
|
| Rate for Payer: AZCH Complete Medicare |
$0.04
|
| Rate for Payer: Banner UC Health Medicare |
$0.04
|
| Rate for Payer: Bisbee Police All Plans |
$0.06
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of AZ Commercial |
$0.16
|
| Rate for Payer: Copperpoint Commercial |
$0.06
|
| Rate for Payer: Health Net of AZ Commercial |
$0.14
|
| Rate for Payer: Health Net of AZ Medicare |
$0.07
|
| Rate for Payer: Humana of AZ Medicare |
$0.04
|
| Rate for Payer: Self Pay Self Pay |
$0.19
|
| Rate for Payer: TriWest Medicare |
$0.04
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.14
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.04
|
|
|
simvastatin 20 mg Tab [CQCH]
|
Facility
|
IP
|
$0.24
|
|
|
Service Code
|
NDC 68084051201
|
| Hospital Charge Code |
105940605
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Aetna of AZ Commercial |
$0.22
|
| Rate for Payer: Bisbee Police All Plans |
$0.06
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Self Pay Self Pay |
$0.19
|
|
|
SINGLE USE BITE BLOCK
|
Facility
|
IP
|
$8.00
|
|
| Hospital Charge Code |
22355557
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$2.08 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Aetna of AZ Commercial |
$7.20
|
| Rate for Payer: Bisbee Police All Plans |
$2.08
|
| Rate for Payer: Cash Price |
$6.40
|
| Rate for Payer: Self Pay Self Pay |
$6.40
|
|
|
SINGLE USE BITE BLOCK
|
Facility
|
OP
|
$8.00
|
|
| Hospital Charge Code |
22355557
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$7.20 |
| Rate for Payer: Aetna of AZ Commercial |
$7.20
|
| Rate for Payer: Aetna of AZ Medicare |
$2.24
|
| Rate for Payer: Allwell Medicare |
$1.20
|
| Rate for Payer: Amerigroup Medicare |
$1.20
|
| Rate for Payer: APIPA Medicare/Medicaid |
$2.99
|
| Rate for Payer: AZCH Complete Medicare |
$1.20
|
| Rate for Payer: Banner UC Health Medicare |
$1.20
|
| Rate for Payer: Bisbee Police All Plans |
$2.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$5.44
|
| Rate for Payer: Cash Price |
$6.40
|
| Rate for Payer: Cigna of AZ Commercial |
$5.60
|
| Rate for Payer: Copperpoint Commercial |
$1.98
|
| Rate for Payer: Health Net of AZ Commercial |
$4.80
|
| Rate for Payer: Health Net of AZ Medicare |
$2.24
|
| Rate for Payer: Humana of AZ Medicare |
$1.20
|
| Rate for Payer: Self Pay Self Pay |
$6.40
|
| Rate for Payer: TriWest Medicare |
$1.20
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$4.66
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$1.44
|
|
|
SIROLIMUS (RAPAMUNE)
|
Facility
|
OP
|
$331.00
|
|
|
Service Code
|
CPT 80195
|
| Hospital Charge Code |
23603249
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.73 |
| Max. Negotiated Rate |
$297.90 |
| Rate for Payer: Aetna of AZ Commercial |
$297.90
|
| Rate for Payer: Aetna of AZ Medicare |
$92.68
|
| Rate for Payer: AHCCCS Medicaid |
$13.73
|
| Rate for Payer: Allwell Medicaid |
$13.73
|
| Rate for Payer: Allwell Medicare |
$49.65
|
| Rate for Payer: Amerigroup Medicare |
$49.65
|
| Rate for Payer: APIPA Medicare/Medicaid |
$123.63
|
| Rate for Payer: AZCH Complete Medicaid |
$13.73
|
| Rate for Payer: AZCH Complete Medicare |
$49.65
|
| Rate for Payer: Banner UC Health Medicaid |
$13.73
|
| Rate for Payer: Banner UC Health Medicare |
$49.65
|
| Rate for Payer: Bisbee Police All Plans |
$86.06
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$225.08
|
| Rate for Payer: Cash Price |
$264.80
|
| Rate for Payer: Cash Price |
$264.80
|
| Rate for Payer: Cigna of AZ Commercial |
$215.15
|
| Rate for Payer: Copperpoint Commercial |
$81.92
|
| Rate for Payer: Health Net of AZ Commercial |
$198.60
|
| Rate for Payer: Health Net of AZ Medicare |
$92.68
|
| Rate for Payer: Humana of AZ Medicare |
$49.65
|
| Rate for Payer: Mercy Care Medicaid |
$13.73
|
| Rate for Payer: Self Pay Self Pay |
$264.80
|
| Rate for Payer: TriWest Medicare |
$49.65
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$192.97
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$59.58
|
|
|
SIROLIMUS (RAPAMUNE)
|
Facility
|
IP
|
$331.00
|
|
|
Service Code
|
CPT 80195
|
| Hospital Charge Code |
23603249
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$86.06 |
| Max. Negotiated Rate |
$297.90 |
| Rate for Payer: Aetna of AZ Commercial |
$297.90
|
| Rate for Payer: Bisbee Police All Plans |
$86.06
|
| Rate for Payer: Cash Price |
$264.80
|
| Rate for Payer: Self Pay Self Pay |
$264.80
|
|
|
Sirolimus (Rapamune), Blood LC
|
Facility
|
OP
|
$331.00
|
|
|
Service Code
|
CPT 80195
|
| Hospital Charge Code |
2029238
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.73 |
| Max. Negotiated Rate |
$297.90 |
| Rate for Payer: Aetna of AZ Commercial |
$297.90
|
| Rate for Payer: Aetna of AZ Medicare |
$92.68
|
| Rate for Payer: AHCCCS Medicaid |
$13.73
|
| Rate for Payer: Allwell Medicaid |
$13.73
|
| Rate for Payer: Allwell Medicare |
$49.65
|
| Rate for Payer: Amerigroup Medicare |
$49.65
|
| Rate for Payer: APIPA Medicare/Medicaid |
$123.63
|
| Rate for Payer: AZCH Complete Medicaid |
$13.73
|
| Rate for Payer: AZCH Complete Medicare |
$49.65
|
| Rate for Payer: Banner UC Health Medicaid |
$13.73
|
| Rate for Payer: Banner UC Health Medicare |
$49.65
|
| Rate for Payer: Bisbee Police All Plans |
$86.06
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$225.08
|
| Rate for Payer: Cash Price |
$264.80
|
| Rate for Payer: Cash Price |
$264.80
|
| Rate for Payer: Cigna of AZ Commercial |
$215.15
|
| Rate for Payer: Copperpoint Commercial |
$81.92
|
| Rate for Payer: Health Net of AZ Commercial |
$198.60
|
| Rate for Payer: Health Net of AZ Medicare |
$92.68
|
| Rate for Payer: Humana of AZ Medicare |
$49.65
|
| Rate for Payer: Mercy Care Medicaid |
$13.73
|
| Rate for Payer: Self Pay Self Pay |
$264.80
|
| Rate for Payer: TriWest Medicare |
$49.65
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$192.97
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$59.58
|
|
|
Sirolimus (Rapamune), Blood LC
|
Facility
|
IP
|
$331.00
|
|
|
Service Code
|
CPT 80195
|
| Hospital Charge Code |
2029238
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$86.06 |
| Max. Negotiated Rate |
$297.90 |
| Rate for Payer: Aetna of AZ Commercial |
$297.90
|
| Rate for Payer: Bisbee Police All Plans |
$86.06
|
| Rate for Payer: Cash Price |
$264.80
|
| Rate for Payer: Self Pay Self Pay |
$264.80
|
|
|
SITZ BATH
|
Facility
|
IP
|
$13.00
|
|
| Hospital Charge Code |
22355310
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$3.38 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Aetna of AZ Commercial |
$11.70
|
| Rate for Payer: Bisbee Police All Plans |
$3.38
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Self Pay Self Pay |
$10.40
|
|
|
SITZ BATH
|
Facility
|
OP
|
$13.00
|
|
| Hospital Charge Code |
22355310
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$11.70 |
| Rate for Payer: Aetna of AZ Commercial |
$11.70
|
| Rate for Payer: Aetna of AZ Medicare |
$3.64
|
| Rate for Payer: Allwell Medicare |
$1.95
|
| Rate for Payer: Amerigroup Medicare |
$1.95
|
| Rate for Payer: APIPA Medicare/Medicaid |
$4.86
|
| Rate for Payer: AZCH Complete Medicare |
$1.95
|
| Rate for Payer: Banner UC Health Medicare |
$1.95
|
| Rate for Payer: Bisbee Police All Plans |
$3.38
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$8.84
|
| Rate for Payer: Cash Price |
$10.40
|
| Rate for Payer: Cigna of AZ Commercial |
$9.10
|
| Rate for Payer: Copperpoint Commercial |
$3.22
|
| Rate for Payer: Health Net of AZ Commercial |
$7.80
|
| Rate for Payer: Health Net of AZ Medicare |
$3.64
|
| Rate for Payer: Humana of AZ Medicare |
$1.95
|
| Rate for Payer: Self Pay Self Pay |
$10.40
|
| Rate for Payer: TriWest Medicare |
$1.95
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$7.58
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$2.34
|
|
|
Sjogren's Ab, Anti-SS-A/-SS-B LC
|
Facility
|
OP
|
$224.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
1285798
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$17.93 |
| Max. Negotiated Rate |
$201.60 |
| Rate for Payer: Aetna of AZ Commercial |
$201.60
|
| Rate for Payer: Aetna of AZ Medicare |
$62.72
|
| Rate for Payer: AHCCCS Medicaid |
$17.93
|
| Rate for Payer: Allwell Medicaid |
$17.93
|
| Rate for Payer: Allwell Medicare |
$33.60
|
| Rate for Payer: Amerigroup Medicare |
$33.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$83.66
|
| Rate for Payer: AZCH Complete Medicaid |
$17.93
|
| Rate for Payer: AZCH Complete Medicare |
$33.60
|
| Rate for Payer: Banner UC Health Medicaid |
$17.93
|
| Rate for Payer: Banner UC Health Medicare |
$33.60
|
| Rate for Payer: Bisbee Police All Plans |
$58.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$152.32
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: Cigna of AZ Commercial |
$145.60
|
| Rate for Payer: Copperpoint Commercial |
$55.44
|
| Rate for Payer: Health Net of AZ Commercial |
$134.40
|
| Rate for Payer: Health Net of AZ Medicare |
$62.72
|
| Rate for Payer: Humana of AZ Medicare |
$33.60
|
| Rate for Payer: Mercy Care Medicaid |
$17.93
|
| Rate for Payer: Self Pay Self Pay |
$179.20
|
| Rate for Payer: TriWest Medicare |
$33.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$130.59
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$40.32
|
|
|
Sjogren's Ab, Anti-SS-A/-SS-B LC
|
Facility
|
IP
|
$224.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
1285798
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$58.24 |
| Max. Negotiated Rate |
$201.60 |
| Rate for Payer: Aetna of AZ Commercial |
$201.60
|
| Rate for Payer: Bisbee Police All Plans |
$58.24
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: Self Pay Self Pay |
$179.20
|
|
|
.Sjoren's SSA LC
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
22531159
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$30.94 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of AZ Commercial |
$107.10
|
| Rate for Payer: Bisbee Police All Plans |
$30.94
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Self Pay Self Pay |
$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 |
$17.85 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of AZ Commercial |
$107.10
|
| Rate for Payer: Aetna of AZ Medicare |
$33.32
|
| Rate for Payer: AHCCCS Medicaid |
$17.93
|
| Rate for Payer: Allwell Medicaid |
$17.93
|
| Rate for Payer: Allwell Medicare |
$17.85
|
| Rate for Payer: Amerigroup Medicare |
$17.85
|
| Rate for Payer: APIPA Medicare/Medicaid |
$44.45
|
| Rate for Payer: AZCH Complete Medicaid |
$17.93
|
| Rate for Payer: AZCH Complete Medicare |
$17.85
|
| Rate for Payer: Banner UC Health Medicaid |
$17.93
|
| Rate for Payer: Banner UC Health Medicare |
$17.85
|
| Rate for Payer: Bisbee Police All Plans |
$30.94
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$80.92
|
| 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: Copperpoint Commercial |
$29.45
|
| Rate for Payer: Health Net of AZ Commercial |
$71.40
|
| Rate for Payer: Health Net of AZ Medicare |
$33.32
|
| Rate for Payer: Humana of AZ Medicare |
$17.85
|
| Rate for Payer: Mercy Care Medicaid |
$17.93
|
| Rate for Payer: Self Pay Self Pay |
$95.20
|
| Rate for Payer: TriWest Medicare |
$17.85
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$69.38
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$21.42
|
|
|
.Sjoren's SSB LC
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
22531177
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$30.94 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of AZ Commercial |
$107.10
|
| Rate for Payer: Bisbee Police All Plans |
$30.94
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Self Pay Self Pay |
$95.20
|
|
|
.Sjoren's SSB LC
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
22531177
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of AZ Commercial |
$107.10
|
| Rate for Payer: Aetna of AZ Medicare |
$33.32
|
| Rate for Payer: AHCCCS Medicaid |
$17.93
|
| Rate for Payer: Allwell Medicaid |
$17.93
|
| Rate for Payer: Allwell Medicare |
$17.85
|
| Rate for Payer: Amerigroup Medicare |
$17.85
|
| Rate for Payer: APIPA Medicare/Medicaid |
$44.45
|
| Rate for Payer: AZCH Complete Medicaid |
$17.93
|
| Rate for Payer: AZCH Complete Medicare |
$17.85
|
| Rate for Payer: Banner UC Health Medicaid |
$17.93
|
| Rate for Payer: Banner UC Health Medicare |
$17.85
|
| Rate for Payer: Bisbee Police All Plans |
$30.94
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$80.92
|
| 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: Copperpoint Commercial |
$29.45
|
| Rate for Payer: Health Net of AZ Commercial |
$71.40
|
| Rate for Payer: Health Net of AZ Medicare |
$33.32
|
| Rate for Payer: Humana of AZ Medicare |
$17.85
|
| Rate for Payer: Mercy Care Medicaid |
$17.93
|
| Rate for Payer: Self Pay Self Pay |
$95.20
|
| Rate for Payer: TriWest Medicare |
$17.85
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$69.38
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$21.42
|
|
|
Sjoren's SSB LC
|
Facility
|
OP
|
$119.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
22531160
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$17.85 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of AZ Commercial |
$107.10
|
| Rate for Payer: Aetna of AZ Medicare |
$33.32
|
| Rate for Payer: AHCCCS Medicaid |
$17.93
|
| Rate for Payer: Allwell Medicaid |
$17.93
|
| Rate for Payer: Allwell Medicare |
$17.85
|
| Rate for Payer: Amerigroup Medicare |
$17.85
|
| Rate for Payer: APIPA Medicare/Medicaid |
$44.45
|
| Rate for Payer: AZCH Complete Medicaid |
$17.93
|
| Rate for Payer: AZCH Complete Medicare |
$17.85
|
| Rate for Payer: Banner UC Health Medicaid |
$17.93
|
| Rate for Payer: Banner UC Health Medicare |
$17.85
|
| Rate for Payer: Bisbee Police All Plans |
$30.94
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$80.92
|
| 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: Copperpoint Commercial |
$29.45
|
| Rate for Payer: Health Net of AZ Commercial |
$71.40
|
| Rate for Payer: Health Net of AZ Medicare |
$33.32
|
| Rate for Payer: Humana of AZ Medicare |
$17.85
|
| Rate for Payer: Mercy Care Medicaid |
$17.93
|
| Rate for Payer: Self Pay Self Pay |
$95.20
|
| Rate for Payer: TriWest Medicare |
$17.85
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$69.38
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$21.42
|
|
|
Sjoren's SSB LC
|
Facility
|
IP
|
$119.00
|
|
|
Service Code
|
CPT 86235
|
| Hospital Charge Code |
22531160
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$30.94 |
| Max. Negotiated Rate |
$107.10 |
| Rate for Payer: Aetna of AZ Commercial |
$107.10
|
| Rate for Payer: Bisbee Police All Plans |
$30.94
|
| Rate for Payer: Cash Price |
$95.20
|
| Rate for Payer: Self Pay Self Pay |
$95.20
|
|
|
Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses
|
Facility
|
IP
|
$8,693.15
|
|
|
Service Code
|
APR-DRG 3121
|
| Hospital Charge Code |
APRDRG3121
|
| Min. Negotiated Rate |
$8,693.15 |
| Max. Negotiated Rate |
$8,693.15 |
| Rate for Payer: AHCCCS Medicaid |
$8,693.15
|
| Rate for Payer: Allwell Medicaid |
$8,693.15
|
| Rate for Payer: AZCH Complete Medicaid |
$8,693.15
|
| Rate for Payer: Banner UC Health Medicaid |
$8,693.15
|
| Rate for Payer: Mercy Care Medicaid |
$8,693.15
|
|
|
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: AHCCCS Medicaid |
$14,706.25
|
| Rate for Payer: Allwell Medicaid |
$14,706.25
|
| Rate for Payer: AZCH Complete Medicaid |
$14,706.25
|
| Rate for Payer: Banner UC Health Medicaid |
$14,706.25
|
| Rate for Payer: Mercy Care Medicaid |
$14,706.25
|
|
|
Skin Graft, Except Hand, For Musculoskeletal And Connective Tissue Diagnoses
|
Facility
|
IP
|
$24,992.99
|
|
|
Service Code
|
APR-DRG 3123
|
| Hospital Charge Code |
APRDRG3123
|
| Min. Negotiated Rate |
$24,992.99 |
| Max. Negotiated Rate |
$24,992.99 |
| Rate for Payer: AHCCCS Medicaid |
$24,992.99
|
| Rate for Payer: Allwell Medicaid |
$24,992.99
|
| Rate for Payer: AZCH Complete Medicaid |
$24,992.99
|
| Rate for Payer: Banner UC Health Medicaid |
$24,992.99
|
| Rate for Payer: Mercy Care Medicaid |
$24,992.99
|
|
|
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: AHCCCS Medicaid |
$14,706.25
|
| Rate for Payer: Allwell Medicaid |
$14,706.25
|
| Rate for Payer: AZCH Complete Medicaid |
$14,706.25
|
| Rate for Payer: Banner UC Health Medicaid |
$14,706.25
|
| Rate for Payer: Mercy Care Medicaid |
$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 |
APRDRG3123
|
| Min. Negotiated Rate |
$8,693.15 |
| Max. Negotiated Rate |
$8,693.15 |
| Rate for Payer: AHCCCS Medicaid |
$8,693.15
|
| Rate for Payer: Allwell Medicaid |
$8,693.15
|
| Rate for Payer: AZCH Complete Medicaid |
$8,693.15
|
| Rate for Payer: Banner UC Health Medicaid |
$8,693.15
|
| Rate for Payer: Mercy Care Medicaid |
$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 |
APRDRG3122
|
| Min. Negotiated Rate |
$47,114.44 |
| Max. Negotiated Rate |
$47,114.44 |
| Rate for Payer: AHCCCS Medicaid |
$47,114.44
|
| Rate for Payer: Allwell Medicaid |
$47,114.44
|
| Rate for Payer: AZCH Complete Medicaid |
$47,114.44
|
| Rate for Payer: Banner UC Health Medicaid |
$47,114.44
|
| Rate for Payer: Mercy Care Medicaid |
$47,114.44
|
|
|
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: AHCCCS Medicaid |
$47,114.44
|
| Rate for Payer: Allwell Medicaid |
$47,114.44
|
| Rate for Payer: AZCH Complete Medicaid |
$47,114.44
|
| Rate for Payer: Banner UC Health Medicaid |
$47,114.44
|
| Rate for Payer: Mercy Care Medicaid |
$47,114.44
|
|
