|
12045 LR NK HD FT XGN 12.5-20.
|
Facility
|
OP
|
$1,179.00
|
|
|
Service Code
|
CPT 12045
|
| Hospital Charge Code |
22282791
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$188.64 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,061.10
|
| Rate for Payer: Aetna of AZ Medicare |
$330.12
|
| Rate for Payer: AHCCCS Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicare |
$188.64
|
| Rate for Payer: Amerigroup Medicare |
$188.64
|
| Rate for Payer: APIPA Medicare/Medicaid |
$440.36
|
| Rate for Payer: AZCH Complete Medicaid |
$380.02
|
| Rate for Payer: AZCH Complete Medicare |
$188.64
|
| Rate for Payer: Banner UC Health Medicaid |
$380.02
|
| Rate for Payer: Banner UC Health Medicare |
$188.64
|
| Rate for Payer: Bisbee Police All Plans |
$306.54
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$801.72
|
| Rate for Payer: Cash Price |
$943.20
|
| Rate for Payer: Cash Price |
$943.20
|
| Rate for Payer: Cigna of AZ Commercial |
$825.30
|
| Rate for Payer: Copperpoint Commercial |
$291.80
|
| Rate for Payer: Health Net of AZ Commercial |
$707.40
|
| Rate for Payer: Health Net of AZ Medicare |
$330.12
|
| Rate for Payer: Humana of AZ Medicare |
$188.64
|
| Rate for Payer: Mercy Care Medicaid |
$380.02
|
| Rate for Payer: Self Pay Self Pay |
$943.20
|
| Rate for Payer: TriWest Medicare |
$188.64
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$212.22
|
|
|
12046 LR NK HD FT XGN 20.-30.
|
Facility
|
OP
|
$1,541.00
|
|
|
Service Code
|
CPT 12046
|
| Hospital Charge Code |
22282792
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$246.56 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,386.90
|
| Rate for Payer: Aetna of AZ Medicare |
$431.48
|
| Rate for Payer: AHCCCS Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicare |
$246.56
|
| Rate for Payer: Amerigroup Medicare |
$246.56
|
| Rate for Payer: APIPA Medicare/Medicaid |
$575.56
|
| Rate for Payer: AZCH Complete Medicaid |
$380.02
|
| Rate for Payer: AZCH Complete Medicare |
$246.56
|
| Rate for Payer: Banner UC Health Medicaid |
$380.02
|
| Rate for Payer: Banner UC Health Medicare |
$246.56
|
| Rate for Payer: Bisbee Police All Plans |
$400.66
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,047.88
|
| Rate for Payer: Cash Price |
$1,232.80
|
| Rate for Payer: Cash Price |
$1,232.80
|
| Rate for Payer: Cigna of AZ Commercial |
$1,078.70
|
| Rate for Payer: Copperpoint Commercial |
$381.40
|
| Rate for Payer: Health Net of AZ Commercial |
$924.60
|
| Rate for Payer: Health Net of AZ Medicare |
$431.48
|
| Rate for Payer: Humana of AZ Medicare |
$246.56
|
| Rate for Payer: Mercy Care Medicaid |
$380.02
|
| Rate for Payer: Self Pay Self Pay |
$1,232.80
|
| Rate for Payer: TriWest Medicare |
$246.56
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$277.38
|
|
|
12046 LR NK HD FT XGN 20.-30.
|
Facility
|
IP
|
$1,541.00
|
|
|
Service Code
|
CPT 12046
|
| Hospital Charge Code |
22282792
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$400.66 |
| Max. Negotiated Rate |
$1,386.90 |
| Rate for Payer: Aetna of AZ Commercial |
$1,386.90
|
| Rate for Payer: Bisbee Police All Plans |
$400.66
|
| Rate for Payer: Cash Price |
$1,232.80
|
| Rate for Payer: Self Pay Self Pay |
$1,232.80
|
|
|
12047 LR NK HD FT XGN >30
|
Facility
|
OP
|
$1,815.00
|
|
|
Service Code
|
CPT 12047
|
| Hospital Charge Code |
22282793
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$290.40 |
| Max. Negotiated Rate |
$2,909.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,633.50
|
| Rate for Payer: Aetna of AZ Medicare |
$508.20
|
| Rate for Payer: AHCCCS Medicaid |
$1,243.64
|
| Rate for Payer: Allwell Medicaid |
$1,243.64
|
| Rate for Payer: Allwell Medicare |
$290.40
|
| Rate for Payer: Amerigroup Medicare |
$290.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$677.90
|
| Rate for Payer: AZCH Complete Medicaid |
$1,243.64
|
| Rate for Payer: AZCH Complete Medicare |
$290.40
|
| Rate for Payer: Banner UC Health Medicaid |
$1,243.64
|
| Rate for Payer: Banner UC Health Medicare |
$290.40
|
| Rate for Payer: Bisbee Police All Plans |
$471.90
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,234.20
|
| Rate for Payer: Cash Price |
$1,452.00
|
| Rate for Payer: Cash Price |
$1,452.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,270.50
|
| Rate for Payer: Copperpoint Commercial |
$449.21
|
| Rate for Payer: Health Net of AZ Commercial |
$1,089.00
|
| Rate for Payer: Health Net of AZ Medicare |
$508.20
|
| Rate for Payer: Humana of AZ Medicare |
$290.40
|
| Rate for Payer: Mercy Care Medicaid |
$1,243.64
|
| Rate for Payer: Self Pay Self Pay |
$1,452.00
|
| Rate for Payer: TriWest Medicare |
$290.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,909.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$326.70
|
|
|
12047 LR NK HD FT XGN >30
|
Facility
|
IP
|
$1,815.00
|
|
|
Service Code
|
CPT 12047
|
| Hospital Charge Code |
22282793
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$471.90 |
| Max. Negotiated Rate |
$1,633.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,633.50
|
| Rate for Payer: Bisbee Police All Plans |
$471.90
|
| Rate for Payer: Cash Price |
$1,452.00
|
| Rate for Payer: Self Pay Self Pay |
$1,452.00
|
|
|
12051 LR FACE MUC MEMB 2.5
|
Facility
|
IP
|
$707.00
|
|
|
Service Code
|
CPT 12051
|
| Hospital Charge Code |
22282794
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$183.82 |
| Max. Negotiated Rate |
$636.30 |
| Rate for Payer: Aetna of AZ Commercial |
$636.30
|
| Rate for Payer: Bisbee Police All Plans |
$183.82
|
| Rate for Payer: Cash Price |
$565.60
|
| Rate for Payer: Self Pay Self Pay |
$565.60
|
|
|
12051 LR FACE MUC MEMB 2.5
|
Facility
|
OP
|
$707.00
|
|
|
Service Code
|
CPT 12051
|
| Hospital Charge Code |
22282794
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$113.12 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$636.30
|
| Rate for Payer: Aetna of AZ Medicare |
$197.96
|
| Rate for Payer: AHCCCS Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicare |
$113.12
|
| Rate for Payer: Amerigroup Medicare |
$113.12
|
| Rate for Payer: APIPA Medicare/Medicaid |
$264.06
|
| Rate for Payer: AZCH Complete Medicaid |
$250.73
|
| Rate for Payer: AZCH Complete Medicare |
$113.12
|
| Rate for Payer: Banner UC Health Medicaid |
$250.73
|
| Rate for Payer: Banner UC Health Medicare |
$113.12
|
| Rate for Payer: Bisbee Police All Plans |
$183.82
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$480.76
|
| Rate for Payer: Cash Price |
$565.60
|
| Rate for Payer: Cash Price |
$565.60
|
| Rate for Payer: Cigna of AZ Commercial |
$494.90
|
| Rate for Payer: Copperpoint Commercial |
$174.98
|
| Rate for Payer: Health Net of AZ Commercial |
$424.20
|
| Rate for Payer: Health Net of AZ Medicare |
$197.96
|
| Rate for Payer: Humana of AZ Medicare |
$113.12
|
| Rate for Payer: Mercy Care Medicaid |
$250.73
|
| Rate for Payer: Self Pay Self Pay |
$565.60
|
| Rate for Payer: TriWest Medicare |
$113.12
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$127.26
|
|
|
12052 LR FACE MUC MEMB 2.6-5.0
|
Facility
|
OP
|
$997.00
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
22282795
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$159.52 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$897.30
|
| Rate for Payer: Aetna of AZ Medicare |
$279.16
|
| Rate for Payer: AHCCCS Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicare |
$159.52
|
| Rate for Payer: Amerigroup Medicare |
$159.52
|
| Rate for Payer: APIPA Medicare/Medicaid |
$372.38
|
| Rate for Payer: AZCH Complete Medicaid |
$250.73
|
| Rate for Payer: AZCH Complete Medicare |
$159.52
|
| Rate for Payer: Banner UC Health Medicaid |
$250.73
|
| Rate for Payer: Banner UC Health Medicare |
$159.52
|
| Rate for Payer: Bisbee Police All Plans |
$259.22
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$677.96
|
| Rate for Payer: Cash Price |
$797.60
|
| Rate for Payer: Cash Price |
$797.60
|
| Rate for Payer: Cigna of AZ Commercial |
$697.90
|
| Rate for Payer: Copperpoint Commercial |
$246.76
|
| Rate for Payer: Health Net of AZ Commercial |
$598.20
|
| Rate for Payer: Health Net of AZ Medicare |
$279.16
|
| Rate for Payer: Humana of AZ Medicare |
$159.52
|
| Rate for Payer: Mercy Care Medicaid |
$250.73
|
| Rate for Payer: Self Pay Self Pay |
$797.60
|
| Rate for Payer: TriWest Medicare |
$159.52
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$179.46
|
|
|
12052 LR FACE MUC MEMB 2.6-5.0
|
Facility
|
IP
|
$997.00
|
|
|
Service Code
|
CPT 12052
|
| Hospital Charge Code |
22282795
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$259.22 |
| Max. Negotiated Rate |
$897.30 |
| Rate for Payer: Aetna of AZ Commercial |
$897.30
|
| Rate for Payer: Bisbee Police All Plans |
$259.22
|
| Rate for Payer: Cash Price |
$797.60
|
| Rate for Payer: Self Pay Self Pay |
$797.60
|
|
|
12053 LR FACE MUC MEMB 5.1-7.5
|
Facility
|
OP
|
$990.00
|
|
|
Service Code
|
CPT 12053
|
| Hospital Charge Code |
22282796
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$158.40 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$891.00
|
| Rate for Payer: Aetna of AZ Medicare |
$277.20
|
| Rate for Payer: AHCCCS Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicare |
$158.40
|
| Rate for Payer: Amerigroup Medicare |
$158.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$369.76
|
| Rate for Payer: AZCH Complete Medicaid |
$250.73
|
| Rate for Payer: AZCH Complete Medicare |
$158.40
|
| Rate for Payer: Banner UC Health Medicaid |
$250.73
|
| Rate for Payer: Banner UC Health Medicare |
$158.40
|
| Rate for Payer: Bisbee Police All Plans |
$257.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$673.20
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Cigna of AZ Commercial |
$693.00
|
| Rate for Payer: Copperpoint Commercial |
$245.03
|
| Rate for Payer: Health Net of AZ Commercial |
$594.00
|
| Rate for Payer: Health Net of AZ Medicare |
$277.20
|
| Rate for Payer: Humana of AZ Medicare |
$158.40
|
| Rate for Payer: Mercy Care Medicaid |
$250.73
|
| Rate for Payer: Self Pay Self Pay |
$792.00
|
| Rate for Payer: TriWest Medicare |
$158.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$178.20
|
|
|
12053 LR FACE MUC MEMB 5.1-7.5
|
Facility
|
IP
|
$990.00
|
|
|
Service Code
|
CPT 12053
|
| Hospital Charge Code |
22282796
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$257.40 |
| Max. Negotiated Rate |
$891.00 |
| Rate for Payer: Aetna of AZ Commercial |
$891.00
|
| Rate for Payer: Bisbee Police All Plans |
$257.40
|
| Rate for Payer: Cash Price |
$792.00
|
| Rate for Payer: Self Pay Self Pay |
$792.00
|
|
|
12054 LR FACE MUC MEB 7.6-12.5
|
Facility
|
OP
|
$1,245.00
|
|
|
Service Code
|
CPT 12054
|
| Hospital Charge Code |
22282797
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$199.20 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,120.50
|
| Rate for Payer: Aetna of AZ Medicare |
$348.60
|
| Rate for Payer: AHCCCS Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicare |
$199.20
|
| Rate for Payer: Amerigroup Medicare |
$199.20
|
| Rate for Payer: APIPA Medicare/Medicaid |
$465.01
|
| Rate for Payer: AZCH Complete Medicaid |
$250.73
|
| Rate for Payer: AZCH Complete Medicare |
$199.20
|
| Rate for Payer: Banner UC Health Medicaid |
$250.73
|
| Rate for Payer: Banner UC Health Medicare |
$199.20
|
| Rate for Payer: Bisbee Police All Plans |
$323.70
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$846.60
|
| Rate for Payer: Cash Price |
$996.00
|
| Rate for Payer: Cash Price |
$996.00
|
| Rate for Payer: Cigna of AZ Commercial |
$871.50
|
| Rate for Payer: Copperpoint Commercial |
$308.14
|
| Rate for Payer: Health Net of AZ Commercial |
$747.00
|
| Rate for Payer: Health Net of AZ Medicare |
$348.60
|
| Rate for Payer: Humana of AZ Medicare |
$199.20
|
| Rate for Payer: Mercy Care Medicaid |
$250.73
|
| Rate for Payer: Self Pay Self Pay |
$996.00
|
| Rate for Payer: TriWest Medicare |
$199.20
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$224.10
|
|
|
12054 LR FACE MUC MEB 7.6-12.5
|
Facility
|
IP
|
$1,245.00
|
|
|
Service Code
|
CPT 12054
|
| Hospital Charge Code |
22282797
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$323.70 |
| Max. Negotiated Rate |
$1,120.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,120.50
|
| Rate for Payer: Bisbee Police All Plans |
$323.70
|
| Rate for Payer: Cash Price |
$996.00
|
| Rate for Payer: Self Pay Self Pay |
$996.00
|
|
|
12055 LR FACE MUC MEN 12.6-20
|
Facility
|
OP
|
$1,599.00
|
|
|
Service Code
|
CPT 12055
|
| Hospital Charge Code |
22282798
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$250.73 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,439.10
|
| Rate for Payer: Aetna of AZ Medicare |
$447.72
|
| Rate for Payer: AHCCCS Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicare |
$255.84
|
| Rate for Payer: Amerigroup Medicare |
$255.84
|
| Rate for Payer: APIPA Medicare/Medicaid |
$597.23
|
| Rate for Payer: AZCH Complete Medicaid |
$250.73
|
| Rate for Payer: AZCH Complete Medicare |
$255.84
|
| Rate for Payer: Banner UC Health Medicaid |
$250.73
|
| Rate for Payer: Banner UC Health Medicare |
$255.84
|
| Rate for Payer: Bisbee Police All Plans |
$415.74
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,087.32
|
| Rate for Payer: Cash Price |
$1,279.20
|
| Rate for Payer: Cash Price |
$1,279.20
|
| Rate for Payer: Cigna of AZ Commercial |
$1,119.30
|
| Rate for Payer: Copperpoint Commercial |
$395.75
|
| Rate for Payer: Health Net of AZ Commercial |
$959.40
|
| Rate for Payer: Health Net of AZ Medicare |
$447.72
|
| Rate for Payer: Humana of AZ Medicare |
$255.84
|
| Rate for Payer: Mercy Care Medicaid |
$250.73
|
| Rate for Payer: Self Pay Self Pay |
$1,279.20
|
| Rate for Payer: TriWest Medicare |
$255.84
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$287.82
|
|
|
12055 LR FACE MUC MEN 12.6-20
|
Facility
|
IP
|
$1,599.00
|
|
|
Service Code
|
CPT 12055
|
| Hospital Charge Code |
22282798
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$415.74 |
| Max. Negotiated Rate |
$1,439.10 |
| Rate for Payer: Aetna of AZ Commercial |
$1,439.10
|
| Rate for Payer: Bisbee Police All Plans |
$415.74
|
| Rate for Payer: Cash Price |
$1,279.20
|
| Rate for Payer: Self Pay Self Pay |
$1,279.20
|
|
|
12056 LR FACE MUC MEMB 20.1-30
|
Facility
|
IP
|
$1,891.00
|
|
|
Service Code
|
CPT 12056
|
| Hospital Charge Code |
22282799
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$491.66 |
| Max. Negotiated Rate |
$1,701.90 |
| Rate for Payer: Aetna of AZ Commercial |
$1,701.90
|
| Rate for Payer: Bisbee Police All Plans |
$491.66
|
| Rate for Payer: Cash Price |
$1,512.80
|
| Rate for Payer: Self Pay Self Pay |
$1,512.80
|
|
|
12056 LR FACE MUC MEMB 20.1-30
|
Facility
|
OP
|
$1,891.00
|
|
|
Service Code
|
CPT 12056
|
| Hospital Charge Code |
22282799
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$250.73 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,701.90
|
| Rate for Payer: Aetna of AZ Medicare |
$529.48
|
| Rate for Payer: AHCCCS Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicare |
$302.56
|
| Rate for Payer: Amerigroup Medicare |
$302.56
|
| Rate for Payer: APIPA Medicare/Medicaid |
$706.29
|
| Rate for Payer: AZCH Complete Medicaid |
$250.73
|
| Rate for Payer: AZCH Complete Medicare |
$302.56
|
| Rate for Payer: Banner UC Health Medicaid |
$250.73
|
| Rate for Payer: Banner UC Health Medicare |
$302.56
|
| Rate for Payer: Bisbee Police All Plans |
$491.66
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,285.88
|
| Rate for Payer: Cash Price |
$1,512.80
|
| Rate for Payer: Cash Price |
$1,512.80
|
| Rate for Payer: Cigna of AZ Commercial |
$1,323.70
|
| Rate for Payer: Copperpoint Commercial |
$468.02
|
| Rate for Payer: Health Net of AZ Commercial |
$1,134.60
|
| Rate for Payer: Health Net of AZ Medicare |
$529.48
|
| Rate for Payer: Humana of AZ Medicare |
$302.56
|
| Rate for Payer: Mercy Care Medicaid |
$250.73
|
| Rate for Payer: Self Pay Self Pay |
$1,512.80
|
| Rate for Payer: TriWest Medicare |
$302.56
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$340.38
|
|
|
12057 LR FACE MUC MEM>30
|
Facility
|
OP
|
$2,187.00
|
|
|
Service Code
|
CPT 12057
|
| Hospital Charge Code |
22282800
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$250.73 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,968.30
|
| Rate for Payer: Aetna of AZ Medicare |
$612.36
|
| Rate for Payer: AHCCCS Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicare |
$349.92
|
| Rate for Payer: Amerigroup Medicare |
$349.92
|
| Rate for Payer: APIPA Medicare/Medicaid |
$816.84
|
| Rate for Payer: AZCH Complete Medicaid |
$250.73
|
| Rate for Payer: AZCH Complete Medicare |
$349.92
|
| Rate for Payer: Banner UC Health Medicaid |
$250.73
|
| Rate for Payer: Banner UC Health Medicare |
$349.92
|
| Rate for Payer: Bisbee Police All Plans |
$568.62
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,487.16
|
| Rate for Payer: Cash Price |
$1,749.60
|
| Rate for Payer: Cash Price |
$1,749.60
|
| Rate for Payer: Cigna of AZ Commercial |
$1,530.90
|
| Rate for Payer: Copperpoint Commercial |
$541.28
|
| Rate for Payer: Health Net of AZ Commercial |
$1,312.20
|
| Rate for Payer: Health Net of AZ Medicare |
$612.36
|
| Rate for Payer: Humana of AZ Medicare |
$349.92
|
| Rate for Payer: Mercy Care Medicaid |
$250.73
|
| Rate for Payer: Self Pay Self Pay |
$1,749.60
|
| Rate for Payer: TriWest Medicare |
$349.92
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$393.66
|
|
|
12057 LR FACE MUC MEM>30
|
Facility
|
IP
|
$2,187.00
|
|
|
Service Code
|
CPT 12057
|
| Hospital Charge Code |
22282800
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$568.62 |
| Max. Negotiated Rate |
$1,968.30 |
| Rate for Payer: Aetna of AZ Commercial |
$1,968.30
|
| Rate for Payer: Bisbee Police All Plans |
$568.62
|
| Rate for Payer: Cash Price |
$1,749.60
|
| Rate for Payer: Self Pay Self Pay |
$1,749.60
|
|
|
13100 RPRELX TRUNK 1.1CM-2.5CM
|
Facility
|
OP
|
$891.00
|
|
|
Service Code
|
CPT 13100
|
| Hospital Charge Code |
22282801
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$142.56 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$801.90
|
| Rate for Payer: Aetna of AZ Medicare |
$249.48
|
| Rate for Payer: AHCCCS Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicare |
$142.56
|
| Rate for Payer: Amerigroup Medicare |
$142.56
|
| Rate for Payer: APIPA Medicare/Medicaid |
$332.79
|
| Rate for Payer: AZCH Complete Medicaid |
$380.02
|
| Rate for Payer: AZCH Complete Medicare |
$142.56
|
| Rate for Payer: Banner UC Health Medicaid |
$380.02
|
| Rate for Payer: Banner UC Health Medicare |
$142.56
|
| Rate for Payer: Bisbee Police All Plans |
$231.66
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$605.88
|
| Rate for Payer: Cash Price |
$712.80
|
| Rate for Payer: Cash Price |
$712.80
|
| Rate for Payer: Cigna of AZ Commercial |
$623.70
|
| Rate for Payer: Copperpoint Commercial |
$220.52
|
| Rate for Payer: Health Net of AZ Commercial |
$534.60
|
| Rate for Payer: Health Net of AZ Medicare |
$249.48
|
| Rate for Payer: Humana of AZ Medicare |
$142.56
|
| Rate for Payer: Mercy Care Medicaid |
$380.02
|
| Rate for Payer: Self Pay Self Pay |
$712.80
|
| Rate for Payer: TriWest Medicare |
$142.56
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$160.38
|
|
|
13100 RPRELX TRUNK 1.1CM-2.5CM
|
Facility
|
IP
|
$891.00
|
|
|
Service Code
|
CPT 13100
|
| Hospital Charge Code |
22282801
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$231.66 |
| Max. Negotiated Rate |
$801.90 |
| Rate for Payer: Aetna of AZ Commercial |
$801.90
|
| Rate for Payer: Bisbee Police All Plans |
$231.66
|
| Rate for Payer: Cash Price |
$712.80
|
| Rate for Payer: Self Pay Self Pay |
$712.80
|
|
|
13101 RPRELX TRUNK 2.6CM-7.5CM
|
Facility
|
OP
|
$1,140.00
|
|
|
Service Code
|
CPT 13101
|
| Hospital Charge Code |
22282802
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$182.40 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,026.00
|
| Rate for Payer: Aetna of AZ Medicare |
$319.20
|
| Rate for Payer: AHCCCS Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicare |
$182.40
|
| Rate for Payer: Amerigroup Medicare |
$182.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$425.79
|
| Rate for Payer: AZCH Complete Medicaid |
$380.02
|
| Rate for Payer: AZCH Complete Medicare |
$182.40
|
| Rate for Payer: Banner UC Health Medicaid |
$380.02
|
| Rate for Payer: Banner UC Health Medicare |
$182.40
|
| Rate for Payer: Bisbee Police All Plans |
$296.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$775.20
|
| Rate for Payer: Cash Price |
$912.00
|
| Rate for Payer: Cash Price |
$912.00
|
| Rate for Payer: Cigna of AZ Commercial |
$798.00
|
| Rate for Payer: Copperpoint Commercial |
$282.15
|
| Rate for Payer: Health Net of AZ Commercial |
$684.00
|
| Rate for Payer: Health Net of AZ Medicare |
$319.20
|
| Rate for Payer: Humana of AZ Medicare |
$182.40
|
| Rate for Payer: Mercy Care Medicaid |
$380.02
|
| Rate for Payer: Self Pay Self Pay |
$912.00
|
| Rate for Payer: TriWest Medicare |
$182.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$205.20
|
|
|
13101 RPRELX TRUNK 2.6CM-7.5CM
|
Facility
|
IP
|
$1,140.00
|
|
|
Service Code
|
CPT 13101
|
| Hospital Charge Code |
22282802
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$296.40 |
| Max. Negotiated Rate |
$1,026.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,026.00
|
| Rate for Payer: Bisbee Police All Plans |
$296.40
|
| Rate for Payer: Cash Price |
$912.00
|
| Rate for Payer: Self Pay Self Pay |
$912.00
|
|
|
13102 REPAIR WOUND COMPLEX 5CM OR LESS
|
Facility
|
IP
|
$516.00
|
|
|
Service Code
|
CPT 13102
|
| Hospital Charge Code |
22282803
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$134.16 |
| Max. Negotiated Rate |
$464.40 |
| Rate for Payer: Aetna of AZ Commercial |
$464.40
|
| Rate for Payer: Bisbee Police All Plans |
$134.16
|
| Rate for Payer: Cash Price |
$412.80
|
| Rate for Payer: Self Pay Self Pay |
$412.80
|
|
|
13102 REPAIR WOUND COMPLEX 5CM OR LESS
|
Facility
|
OP
|
$516.00
|
|
|
Service Code
|
CPT 13102
|
| Hospital Charge Code |
22282803
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$82.56 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$464.40
|
| Rate for Payer: Aetna of AZ Medicare |
$144.48
|
| Rate for Payer: AHCCCS Medicaid |
$242.50
|
| Rate for Payer: Allwell Medicaid |
$242.50
|
| Rate for Payer: Allwell Medicare |
$82.56
|
| Rate for Payer: Amerigroup Medicare |
$82.56
|
| Rate for Payer: APIPA Medicare/Medicaid |
$192.73
|
| Rate for Payer: AZCH Complete Medicaid |
$242.50
|
| Rate for Payer: AZCH Complete Medicare |
$82.56
|
| Rate for Payer: Banner UC Health Medicaid |
$242.50
|
| Rate for Payer: Banner UC Health Medicare |
$82.56
|
| Rate for Payer: Bisbee Police All Plans |
$134.16
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$350.88
|
| Rate for Payer: Cash Price |
$412.80
|
| Rate for Payer: Cash Price |
$412.80
|
| Rate for Payer: Cigna of AZ Commercial |
$361.20
|
| Rate for Payer: Copperpoint Commercial |
$127.71
|
| Rate for Payer: Health Net of AZ Commercial |
$309.60
|
| Rate for Payer: Health Net of AZ Medicare |
$144.48
|
| Rate for Payer: Humana of AZ Medicare |
$82.56
|
| Rate for Payer: Mercy Care Medicaid |
$242.50
|
| Rate for Payer: Self Pay Self Pay |
$412.80
|
| Rate for Payer: TriWest Medicare |
$82.56
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$92.88
|
|
