12035 LYR SPL 12.6CM-20.0CM
|
Facility
OP
|
$1,100.00
|
|
Service Code
|
CPT 12035
|
Hospital Charge Code |
22282785
|
Hospital Revenue Code
|
450
|
Min. Negotiated Rate |
$165.00 |
Max. Negotiated Rate |
$2,161.00 |
Rate for Payer: Aetna of AZ Commercial |
$990.00
|
Rate for Payer: Aetna of AZ Medicare |
$308.00
|
Rate for Payer: AHCCCS Medicaid |
$501.46
|
Rate for Payer: Allwell Medicaid |
$501.46
|
Rate for Payer: Allwell Medicare |
$165.00
|
Rate for Payer: Amerigroup Medicare |
$165.00
|
Rate for Payer: APIPA Medicare/Medicaid |
$410.85
|
Rate for Payer: AZCH Complete Medicaid |
$501.46
|
Rate for Payer: AZCH Complete Medicare |
$165.00
|
Rate for Payer: Banner UC Health Medicaid |
$501.46
|
Rate for Payer: Banner UC Health Medicare |
$165.00
|
Rate for Payer: Bisbee Police All Plans |
$286.00
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$748.00
|
Rate for Payer: Cash Price |
$880.00
|
Rate for Payer: Cash Price |
$880.00
|
Rate for Payer: Cigna of AZ Commercial |
$770.00
|
Rate for Payer: Copperpoint Commercial |
$272.25
|
Rate for Payer: Health Net of AZ Commercial |
$660.00
|
Rate for Payer: Health Net of AZ Medicare |
$308.00
|
Rate for Payer: Humana of AZ Medicare |
$165.00
|
Rate for Payer: Mercy Care Medicaid |
$501.46
|
Rate for Payer: Self Pay Self Pay |
$880.00
|
Rate for Payer: TriWest Medicare |
$165.00
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$198.00
|
|
12036 LYR S/P AXL TNK 20.1-30
|
Facility
IP
|
$1,348.00
|
|
Service Code
|
CPT 12036
|
Hospital Charge Code |
22282786
|
Hospital Revenue Code
|
450
|
Min. Negotiated Rate |
$350.48 |
Max. Negotiated Rate |
$1,213.20 |
Rate for Payer: Aetna of AZ Commercial |
$1,213.20
|
Rate for Payer: Bisbee Police All Plans |
$350.48
|
Rate for Payer: Cash Price |
$1,078.40
|
Rate for Payer: Self Pay Self Pay |
$1,078.40
|
|
12036 LYR S/P AXL TNK 20.1-30
|
Facility
OP
|
$1,348.00
|
|
Service Code
|
CPT 12036
|
Hospital Charge Code |
22282786
|
Hospital Revenue Code
|
450
|
Min. Negotiated Rate |
$202.20 |
Max. Negotiated Rate |
$2,161.00 |
Rate for Payer: Aetna of AZ Commercial |
$1,213.20
|
Rate for Payer: Aetna of AZ Medicare |
$377.44
|
Rate for Payer: AHCCCS Medicaid |
$760.04
|
Rate for Payer: Allwell Medicaid |
$760.04
|
Rate for Payer: Allwell Medicare |
$202.20
|
Rate for Payer: Amerigroup Medicare |
$202.20
|
Rate for Payer: APIPA Medicare/Medicaid |
$503.48
|
Rate for Payer: AZCH Complete Medicaid |
$760.04
|
Rate for Payer: AZCH Complete Medicare |
$202.20
|
Rate for Payer: Banner UC Health Medicaid |
$760.04
|
Rate for Payer: Banner UC Health Medicare |
$202.20
|
Rate for Payer: Bisbee Police All Plans |
$350.48
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$916.64
|
Rate for Payer: Cash Price |
$1,078.40
|
Rate for Payer: Cash Price |
$1,078.40
|
Rate for Payer: Cigna of AZ Commercial |
$943.60
|
Rate for Payer: Copperpoint Commercial |
$333.63
|
Rate for Payer: Health Net of AZ Commercial |
$808.80
|
Rate for Payer: Health Net of AZ Medicare |
$377.44
|
Rate for Payer: Humana of AZ Medicare |
$202.20
|
Rate for Payer: Mercy Care Medicaid |
$760.04
|
Rate for Payer: Self Pay Self Pay |
$1,078.40
|
Rate for Payer: TriWest Medicare |
$202.20
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$242.64
|
|
12037 LYR S/P AXL TNK>30
|
Facility
IP
|
$1,600.00
|
|
Service Code
|
CPT 12037
|
Hospital Charge Code |
22282787
|
Hospital Revenue Code
|
450
|
Min. Negotiated Rate |
$416.00 |
Max. Negotiated Rate |
$1,440.00 |
Rate for Payer: Aetna of AZ Commercial |
$1,440.00
|
Rate for Payer: Bisbee Police All Plans |
$416.00
|
Rate for Payer: Cash Price |
$1,280.00
|
Rate for Payer: Self Pay Self Pay |
$1,280.00
|
|
12037 LYR S/P AXL TNK>30
|
Facility
OP
|
$1,600.00
|
|
Service Code
|
CPT 12037
|
Hospital Charge Code |
22282787
|
Hospital Revenue Code
|
450
|
Min. Negotiated Rate |
$240.00 |
Max. Negotiated Rate |
$2,909.00 |
Rate for Payer: Aetna of AZ Commercial |
$1,440.00
|
Rate for Payer: Aetna of AZ Medicare |
$448.00
|
Rate for Payer: AHCCCS Medicaid |
$2,487.28
|
Rate for Payer: Allwell Medicaid |
$2,487.28
|
Rate for Payer: Allwell Medicare |
$240.00
|
Rate for Payer: Amerigroup Medicare |
$240.00
|
Rate for Payer: APIPA Medicare/Medicaid |
$597.60
|
Rate for Payer: AZCH Complete Medicaid |
$2,487.28
|
Rate for Payer: AZCH Complete Medicare |
$240.00
|
Rate for Payer: Banner UC Health Medicaid |
$2,487.28
|
Rate for Payer: Banner UC Health Medicare |
$240.00
|
Rate for Payer: Bisbee Police All Plans |
$416.00
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,088.00
|
Rate for Payer: Cash Price |
$1,280.00
|
Rate for Payer: Cash Price |
$1,280.00
|
Rate for Payer: Cigna of AZ Commercial |
$1,120.00
|
Rate for Payer: Copperpoint Commercial |
$396.00
|
Rate for Payer: Health Net of AZ Commercial |
$960.00
|
Rate for Payer: Health Net of AZ Medicare |
$448.00
|
Rate for Payer: Humana of AZ Medicare |
$240.00
|
Rate for Payer: Mercy Care Medicaid |
$2,487.28
|
Rate for Payer: Self Pay Self Pay |
$1,280.00
|
Rate for Payer: TriWest Medicare |
$240.00
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,909.00
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$288.00
|
|
12041 LYR NK HND FT EXGEN 2.5
|
Facility
IP
|
$664.00
|
|
Service Code
|
CPT 12041
|
Hospital Charge Code |
22282788
|
Hospital Revenue Code
|
450
|
Min. Negotiated Rate |
$172.64 |
Max. Negotiated Rate |
$597.60 |
Rate for Payer: Aetna of AZ Commercial |
$597.60
|
Rate for Payer: Bisbee Police All Plans |
$172.64
|
Rate for Payer: Cash Price |
$531.20
|
Rate for Payer: Self Pay Self Pay |
$531.20
|
|
12041 LYR NK HND FT EXGEN 2.5
|
Facility
OP
|
$664.00
|
|
Service Code
|
CPT 12041
|
Hospital Charge Code |
22282788
|
Hospital Revenue Code
|
450
|
Min. Negotiated Rate |
$99.60 |
Max. Negotiated Rate |
$2,161.00 |
Rate for Payer: Aetna of AZ Commercial |
$597.60
|
Rate for Payer: Aetna of AZ Medicare |
$185.92
|
Rate for Payer: AHCCCS Medicaid |
$501.46
|
Rate for Payer: Allwell Medicaid |
$501.46
|
Rate for Payer: Allwell Medicare |
$99.60
|
Rate for Payer: Amerigroup Medicare |
$99.60
|
Rate for Payer: APIPA Medicare/Medicaid |
$248.00
|
Rate for Payer: AZCH Complete Medicaid |
$501.46
|
Rate for Payer: AZCH Complete Medicare |
$99.60
|
Rate for Payer: Banner UC Health Medicaid |
$501.46
|
Rate for Payer: Banner UC Health Medicare |
$99.60
|
Rate for Payer: Bisbee Police All Plans |
$172.64
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$451.52
|
Rate for Payer: Cash Price |
$531.20
|
Rate for Payer: Cash Price |
$531.20
|
Rate for Payer: Cigna of AZ Commercial |
$464.80
|
Rate for Payer: Copperpoint Commercial |
$164.34
|
Rate for Payer: Health Net of AZ Commercial |
$398.40
|
Rate for Payer: Health Net of AZ Medicare |
$185.92
|
Rate for Payer: Humana of AZ Medicare |
$99.60
|
Rate for Payer: Mercy Care Medicaid |
$501.46
|
Rate for Payer: Self Pay Self Pay |
$531.20
|
Rate for Payer: TriWest Medicare |
$99.60
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$119.52
|
|
12042 LR NK HD FT XGEN 2.6-7.5
|
Facility
OP
|
$771.00
|
|
Service Code
|
CPT 12042
|
Hospital Charge Code |
22282789
|
Hospital Revenue Code
|
450
|
Min. Negotiated Rate |
$115.65 |
Max. Negotiated Rate |
$2,161.00 |
Rate for Payer: Aetna of AZ Commercial |
$693.90
|
Rate for Payer: Aetna of AZ Medicare |
$215.88
|
Rate for Payer: AHCCCS Medicaid |
$501.46
|
Rate for Payer: Allwell Medicaid |
$501.46
|
Rate for Payer: Allwell Medicare |
$115.65
|
Rate for Payer: Amerigroup Medicare |
$115.65
|
Rate for Payer: APIPA Medicare/Medicaid |
$287.97
|
Rate for Payer: AZCH Complete Medicaid |
$501.46
|
Rate for Payer: AZCH Complete Medicare |
$115.65
|
Rate for Payer: Banner UC Health Medicaid |
$501.46
|
Rate for Payer: Banner UC Health Medicare |
$115.65
|
Rate for Payer: Bisbee Police All Plans |
$200.46
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$524.28
|
Rate for Payer: Cash Price |
$616.80
|
Rate for Payer: Cash Price |
$616.80
|
Rate for Payer: Cigna of AZ Commercial |
$539.70
|
Rate for Payer: Copperpoint Commercial |
$190.82
|
Rate for Payer: Health Net of AZ Commercial |
$462.60
|
Rate for Payer: Health Net of AZ Medicare |
$215.88
|
Rate for Payer: Humana of AZ Medicare |
$115.65
|
Rate for Payer: Mercy Care Medicaid |
$501.46
|
Rate for Payer: Self Pay Self Pay |
$616.80
|
Rate for Payer: TriWest Medicare |
$115.65
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$138.78
|
|
12042 LR NK HD FT XGEN 2.6-7.5
|
Facility
IP
|
$771.00
|
|
Service Code
|
CPT 12042
|
Hospital Charge Code |
22282789
|
Hospital Revenue Code
|
450
|
Min. Negotiated Rate |
$200.46 |
Max. Negotiated Rate |
$693.90 |
Rate for Payer: Aetna of AZ Commercial |
$693.90
|
Rate for Payer: Bisbee Police All Plans |
$200.46
|
Rate for Payer: Cash Price |
$616.80
|
Rate for Payer: Self Pay Self Pay |
$616.80
|
|
12044 LR NK HD FT XGN 7.5-12.5
|
Facility
OP
|
$991.00
|
|
Service Code
|
CPT 12044
|
Hospital Charge Code |
22282790
|
Hospital Revenue Code
|
450
|
Min. Negotiated Rate |
$148.65 |
Max. Negotiated Rate |
$2,161.00 |
Rate for Payer: Aetna of AZ Commercial |
$891.90
|
Rate for Payer: Aetna of AZ Medicare |
$277.48
|
Rate for Payer: AHCCCS Medicaid |
$760.04
|
Rate for Payer: Allwell Medicaid |
$760.04
|
Rate for Payer: Allwell Medicare |
$148.65
|
Rate for Payer: Amerigroup Medicare |
$148.65
|
Rate for Payer: APIPA Medicare/Medicaid |
$370.14
|
Rate for Payer: AZCH Complete Medicaid |
$760.04
|
Rate for Payer: AZCH Complete Medicare |
$148.65
|
Rate for Payer: Banner UC Health Medicaid |
$760.04
|
Rate for Payer: Banner UC Health Medicare |
$148.65
|
Rate for Payer: Bisbee Police All Plans |
$257.66
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$673.88
|
Rate for Payer: Cash Price |
$792.80
|
Rate for Payer: Cash Price |
$792.80
|
Rate for Payer: Cigna of AZ Commercial |
$693.70
|
Rate for Payer: Copperpoint Commercial |
$245.27
|
Rate for Payer: Health Net of AZ Commercial |
$594.60
|
Rate for Payer: Health Net of AZ Medicare |
$277.48
|
Rate for Payer: Humana of AZ Medicare |
$148.65
|
Rate for Payer: Mercy Care Medicaid |
$760.04
|
Rate for Payer: Self Pay Self Pay |
$792.80
|
Rate for Payer: TriWest Medicare |
$148.65
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$178.38
|
|
12044 LR NK HD FT XGN 7.5-12.5
|
Facility
IP
|
$991.00
|
|
Service Code
|
CPT 12044
|
Hospital Charge Code |
22282790
|
Hospital Revenue Code
|
450
|
Min. Negotiated Rate |
$257.66 |
Max. Negotiated Rate |
$891.90 |
Rate for Payer: Aetna of AZ Commercial |
$891.90
|
Rate for Payer: Bisbee Police All Plans |
$257.66
|
Rate for Payer: Cash Price |
$792.80
|
Rate for Payer: Self Pay Self Pay |
$792.80
|
|
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 |
$176.85 |
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 |
$760.04
|
Rate for Payer: Allwell Medicaid |
$760.04
|
Rate for Payer: Allwell Medicare |
$176.85
|
Rate for Payer: Amerigroup Medicare |
$176.85
|
Rate for Payer: APIPA Medicare/Medicaid |
$440.36
|
Rate for Payer: AZCH Complete Medicaid |
$760.04
|
Rate for Payer: AZCH Complete Medicare |
$176.85
|
Rate for Payer: Banner UC Health Medicaid |
$760.04
|
Rate for Payer: Banner UC Health Medicare |
$176.85
|
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 |
$176.85
|
Rate for Payer: Mercy Care Medicaid |
$760.04
|
Rate for Payer: Self Pay Self Pay |
$943.20
|
Rate for Payer: TriWest Medicare |
$176.85
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$212.22
|
|
12045 LR NK HD FT XGN 12.5-20.
|
Facility
IP
|
$1,179.00
|
|
Service Code
|
CPT 12045
|
Hospital Charge Code |
22282791
|
Hospital Revenue Code
|
450
|
Min. Negotiated Rate |
$306.54 |
Max. Negotiated Rate |
$1,061.10 |
Rate for Payer: Aetna of AZ Commercial |
$1,061.10
|
Rate for Payer: Bisbee Police All Plans |
$306.54
|
Rate for Payer: Cash Price |
$943.20
|
Rate for Payer: Self Pay Self Pay |
$943.20
|
|
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 |
$231.15 |
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 |
$760.04
|
Rate for Payer: Allwell Medicaid |
$760.04
|
Rate for Payer: Allwell Medicare |
$231.15
|
Rate for Payer: Amerigroup Medicare |
$231.15
|
Rate for Payer: APIPA Medicare/Medicaid |
$575.56
|
Rate for Payer: AZCH Complete Medicaid |
$760.04
|
Rate for Payer: AZCH Complete Medicare |
$231.15
|
Rate for Payer: Banner UC Health Medicaid |
$760.04
|
Rate for Payer: Banner UC Health Medicare |
$231.15
|
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 |
$231.15
|
Rate for Payer: Mercy Care Medicaid |
$760.04
|
Rate for Payer: Self Pay Self Pay |
$1,232.80
|
Rate for Payer: TriWest Medicare |
$231.15
|
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
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
|
|
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 |
$272.25 |
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 |
$2,487.28
|
Rate for Payer: Allwell Medicaid |
$2,487.28
|
Rate for Payer: Allwell Medicare |
$272.25
|
Rate for Payer: Amerigroup Medicare |
$272.25
|
Rate for Payer: APIPA Medicare/Medicaid |
$677.90
|
Rate for Payer: AZCH Complete Medicaid |
$2,487.28
|
Rate for Payer: AZCH Complete Medicare |
$272.25
|
Rate for Payer: Banner UC Health Medicaid |
$2,487.28
|
Rate for Payer: Banner UC Health Medicare |
$272.25
|
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 |
$272.25
|
Rate for Payer: Mercy Care Medicaid |
$2,487.28
|
Rate for Payer: Self Pay Self Pay |
$1,452.00
|
Rate for Payer: TriWest Medicare |
$272.25
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,909.00
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$326.70
|
|
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 |
$106.05 |
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 |
$501.46
|
Rate for Payer: Allwell Medicaid |
$501.46
|
Rate for Payer: Allwell Medicare |
$106.05
|
Rate for Payer: Amerigroup Medicare |
$106.05
|
Rate for Payer: APIPA Medicare/Medicaid |
$264.06
|
Rate for Payer: AZCH Complete Medicaid |
$501.46
|
Rate for Payer: AZCH Complete Medicare |
$106.05
|
Rate for Payer: Banner UC Health Medicaid |
$501.46
|
Rate for Payer: Banner UC Health Medicare |
$106.05
|
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 |
$106.05
|
Rate for Payer: Mercy Care Medicaid |
$501.46
|
Rate for Payer: Self Pay Self Pay |
$565.60
|
Rate for Payer: TriWest Medicare |
$106.05
|
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
IP
|
$1,049.00
|
|
Service Code
|
CPT 12052
|
Hospital Charge Code |
22282795
|
Hospital Revenue Code
|
450
|
Min. Negotiated Rate |
$272.74 |
Max. Negotiated Rate |
$944.10 |
Rate for Payer: Aetna of AZ Commercial |
$944.10
|
Rate for Payer: Bisbee Police All Plans |
$272.74
|
Rate for Payer: Cash Price |
$839.20
|
Rate for Payer: Self Pay Self Pay |
$839.20
|
|
12052 LR FACE MUC MEMB 2.6-5.0
|
Facility
OP
|
$1,049.00
|
|
Service Code
|
CPT 12052
|
Hospital Charge Code |
22282795
|
Hospital Revenue Code
|
450
|
Min. Negotiated Rate |
$157.35 |
Max. Negotiated Rate |
$2,161.00 |
Rate for Payer: Aetna of AZ Commercial |
$944.10
|
Rate for Payer: Aetna of AZ Medicare |
$293.72
|
Rate for Payer: AHCCCS Medicaid |
$501.46
|
Rate for Payer: Allwell Medicaid |
$501.46
|
Rate for Payer: Allwell Medicare |
$157.35
|
Rate for Payer: Amerigroup Medicare |
$157.35
|
Rate for Payer: APIPA Medicare/Medicaid |
$391.80
|
Rate for Payer: AZCH Complete Medicaid |
$501.46
|
Rate for Payer: AZCH Complete Medicare |
$157.35
|
Rate for Payer: Banner UC Health Medicaid |
$501.46
|
Rate for Payer: Banner UC Health Medicare |
$157.35
|
Rate for Payer: Bisbee Police All Plans |
$272.74
|
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$713.32
|
Rate for Payer: Cash Price |
$839.20
|
Rate for Payer: Cash Price |
$839.20
|
Rate for Payer: Cigna of AZ Commercial |
$734.30
|
Rate for Payer: Copperpoint Commercial |
$259.63
|
Rate for Payer: Health Net of AZ Commercial |
$629.40
|
Rate for Payer: Health Net of AZ Medicare |
$293.72
|
Rate for Payer: Humana of AZ Medicare |
$157.35
|
Rate for Payer: Mercy Care Medicaid |
$501.46
|
Rate for Payer: Self Pay Self Pay |
$839.20
|
Rate for Payer: TriWest Medicare |
$157.35
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$188.82
|
|
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
|
|
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 |
$148.50 |
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 |
$501.46
|
Rate for Payer: Allwell Medicaid |
$501.46
|
Rate for Payer: Allwell Medicare |
$148.50
|
Rate for Payer: Amerigroup Medicare |
$148.50
|
Rate for Payer: APIPA Medicare/Medicaid |
$369.76
|
Rate for Payer: AZCH Complete Medicaid |
$501.46
|
Rate for Payer: AZCH Complete Medicare |
$148.50
|
Rate for Payer: Banner UC Health Medicaid |
$501.46
|
Rate for Payer: Banner UC Health Medicare |
$148.50
|
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 |
$245.02
|
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 |
$148.50
|
Rate for Payer: Mercy Care Medicaid |
$501.46
|
Rate for Payer: Self Pay Self Pay |
$792.00
|
Rate for Payer: TriWest Medicare |
$148.50
|
Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
Rate for Payer: UnitedHealth Group of AZ Medicare |
$178.20
|
|
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 |
$186.75 |
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 |
$501.46
|
Rate for Payer: Allwell Medicaid |
$501.46
|
Rate for Payer: Allwell Medicare |
$186.75
|
Rate for Payer: Amerigroup Medicare |
$186.75
|
Rate for Payer: APIPA Medicare/Medicaid |
$465.01
|
Rate for Payer: AZCH Complete Medicaid |
$501.46
|
Rate for Payer: AZCH Complete Medicare |
$186.75
|
Rate for Payer: Banner UC Health Medicaid |
$501.46
|
Rate for Payer: Banner UC Health Medicare |
$186.75
|
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 |
$186.75
|
Rate for Payer: Mercy Care Medicaid |
$501.46
|
Rate for Payer: Self Pay Self Pay |
$996.00
|
Rate for Payer: TriWest Medicare |
$186.75
|
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
|
|