|
13120 REPAIR COMPLEX WND 1.1CM TO 2.5
|
Facility
|
OP
|
$1,528.00
|
|
|
Service Code
|
CPT 13120
|
| Hospital Charge Code |
22282804
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$244.48 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,375.20
|
| Rate for Payer: Aetna of AZ Medicare |
$427.84
|
| Rate for Payer: AHCCCS Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicare |
$244.48
|
| Rate for Payer: Amerigroup Medicare |
$244.48
|
| Rate for Payer: APIPA Medicare/Medicaid |
$570.71
|
| Rate for Payer: AZCH Complete Medicaid |
$380.02
|
| Rate for Payer: AZCH Complete Medicare |
$244.48
|
| Rate for Payer: Banner UC Health Medicaid |
$380.02
|
| Rate for Payer: Banner UC Health Medicare |
$244.48
|
| Rate for Payer: Bisbee Police All Plans |
$397.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,039.04
|
| Rate for Payer: Cash Price |
$1,222.40
|
| Rate for Payer: Cash Price |
$1,222.40
|
| Rate for Payer: Cigna of AZ Commercial |
$1,069.60
|
| Rate for Payer: Copperpoint Commercial |
$378.18
|
| Rate for Payer: Health Net of AZ Commercial |
$916.80
|
| Rate for Payer: Health Net of AZ Medicare |
$427.84
|
| Rate for Payer: Humana of AZ Medicare |
$244.48
|
| Rate for Payer: Mercy Care Medicaid |
$380.02
|
| Rate for Payer: Self Pay Self Pay |
$1,222.40
|
| Rate for Payer: TriWest Medicare |
$244.48
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$275.04
|
|
|
13120 REPAIR COMPLEX WND 1.1CM TO 2.5
|
Facility
|
IP
|
$1,528.00
|
|
|
Service Code
|
CPT 13120
|
| Hospital Charge Code |
22282804
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$397.28 |
| Max. Negotiated Rate |
$1,375.20 |
| Rate for Payer: Aetna of AZ Commercial |
$1,375.20
|
| Rate for Payer: Bisbee Police All Plans |
$397.28
|
| Rate for Payer: Cash Price |
$1,222.40
|
| Rate for Payer: Self Pay Self Pay |
$1,222.40
|
|
|
13121 REPAIR COMPLEX WND 2.6CM-7.5CM
|
Facility
|
IP
|
$2,083.00
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
22282805
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$541.58 |
| Max. Negotiated Rate |
$1,874.70 |
| Rate for Payer: Aetna of AZ Commercial |
$1,874.70
|
| Rate for Payer: Bisbee Police All Plans |
$541.58
|
| Rate for Payer: Cash Price |
$1,666.40
|
| Rate for Payer: Self Pay Self Pay |
$1,666.40
|
|
|
13121 REPAIR COMPLEX WND 2.6CM-7.5CM
|
Facility
|
OP
|
$2,083.00
|
|
|
Service Code
|
CPT 13121
|
| Hospital Charge Code |
22282805
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$333.28 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,874.70
|
| Rate for Payer: Aetna of AZ Medicare |
$583.24
|
| Rate for Payer: AHCCCS Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicare |
$333.28
|
| Rate for Payer: Amerigroup Medicare |
$333.28
|
| Rate for Payer: APIPA Medicare/Medicaid |
$778.00
|
| Rate for Payer: AZCH Complete Medicaid |
$380.02
|
| Rate for Payer: AZCH Complete Medicare |
$333.28
|
| Rate for Payer: Banner UC Health Medicaid |
$380.02
|
| Rate for Payer: Banner UC Health Medicare |
$333.28
|
| Rate for Payer: Bisbee Police All Plans |
$541.58
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,416.44
|
| Rate for Payer: Cash Price |
$1,666.40
|
| Rate for Payer: Cash Price |
$1,666.40
|
| Rate for Payer: Cigna of AZ Commercial |
$1,458.10
|
| Rate for Payer: Copperpoint Commercial |
$515.54
|
| Rate for Payer: Health Net of AZ Commercial |
$1,249.80
|
| Rate for Payer: Health Net of AZ Medicare |
$583.24
|
| Rate for Payer: Humana of AZ Medicare |
$333.28
|
| Rate for Payer: Mercy Care Medicaid |
$380.02
|
| Rate for Payer: Self Pay Self Pay |
$1,666.40
|
| Rate for Payer: TriWest Medicare |
$333.28
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$374.94
|
|
|
13122 RPR WND EA ADDL 5CM
|
Facility
|
OP
|
$432.00
|
|
|
Service Code
|
CPT 13122
|
| Hospital Charge Code |
22282806
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$69.12 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$388.80
|
| Rate for Payer: Aetna of AZ Medicare |
$120.96
|
| Rate for Payer: AHCCCS Medicaid |
$82.69
|
| Rate for Payer: Allwell Medicaid |
$82.69
|
| Rate for Payer: Allwell Medicare |
$69.12
|
| Rate for Payer: Amerigroup Medicare |
$69.12
|
| Rate for Payer: APIPA Medicare/Medicaid |
$161.35
|
| Rate for Payer: AZCH Complete Medicaid |
$82.69
|
| Rate for Payer: AZCH Complete Medicare |
$69.12
|
| Rate for Payer: Banner UC Health Medicaid |
$82.69
|
| Rate for Payer: Banner UC Health Medicare |
$69.12
|
| Rate for Payer: Bisbee Police All Plans |
$112.32
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$293.76
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Cigna of AZ Commercial |
$302.40
|
| Rate for Payer: Copperpoint Commercial |
$106.92
|
| Rate for Payer: Health Net of AZ Commercial |
$259.20
|
| Rate for Payer: Health Net of AZ Medicare |
$120.96
|
| Rate for Payer: Humana of AZ Medicare |
$69.12
|
| Rate for Payer: Mercy Care Medicaid |
$82.69
|
| Rate for Payer: Self Pay Self Pay |
$345.60
|
| Rate for Payer: TriWest Medicare |
$69.12
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$77.76
|
|
|
13122 RPR WND EA ADDL 5CM
|
Facility
|
IP
|
$432.00
|
|
|
Service Code
|
CPT 13122
|
| Hospital Charge Code |
22282806
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$112.32 |
| Max. Negotiated Rate |
$388.80 |
| Rate for Payer: Aetna of AZ Commercial |
$388.80
|
| Rate for Payer: Bisbee Police All Plans |
$112.32
|
| Rate for Payer: Cash Price |
$345.60
|
| Rate for Payer: Self Pay Self Pay |
$345.60
|
|
|
13131 RPCLX FRHD ETC 1.1-2.5CM
|
Facility
|
OP
|
$1,109.00
|
|
|
Service Code
|
CPT 13131
|
| Hospital Charge Code |
22282807
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$177.44 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$998.10
|
| Rate for Payer: Aetna of AZ Medicare |
$310.52
|
| Rate for Payer: AHCCCS Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicare |
$177.44
|
| Rate for Payer: Amerigroup Medicare |
$177.44
|
| Rate for Payer: APIPA Medicare/Medicaid |
$414.21
|
| Rate for Payer: AZCH Complete Medicaid |
$250.73
|
| Rate for Payer: AZCH Complete Medicare |
$177.44
|
| Rate for Payer: Banner UC Health Medicaid |
$250.73
|
| Rate for Payer: Banner UC Health Medicare |
$177.44
|
| Rate for Payer: Bisbee Police All Plans |
$288.34
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$754.12
|
| Rate for Payer: Cash Price |
$887.20
|
| Rate for Payer: Cash Price |
$887.20
|
| Rate for Payer: Cigna of AZ Commercial |
$776.30
|
| Rate for Payer: Copperpoint Commercial |
$274.48
|
| Rate for Payer: Health Net of AZ Commercial |
$665.40
|
| Rate for Payer: Health Net of AZ Medicare |
$310.52
|
| Rate for Payer: Humana of AZ Medicare |
$177.44
|
| Rate for Payer: Mercy Care Medicaid |
$250.73
|
| Rate for Payer: Self Pay Self Pay |
$887.20
|
| Rate for Payer: TriWest Medicare |
$177.44
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$199.62
|
|
|
13131 RPCLX FRHD ETC 1.1-2.5CM
|
Facility
|
IP
|
$1,109.00
|
|
|
Service Code
|
CPT 13131
|
| Hospital Charge Code |
22282807
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$288.34 |
| Max. Negotiated Rate |
$998.10 |
| Rate for Payer: Aetna of AZ Commercial |
$998.10
|
| Rate for Payer: Bisbee Police All Plans |
$288.34
|
| Rate for Payer: Cash Price |
$887.20
|
| Rate for Payer: Self Pay Self Pay |
$887.20
|
|
|
13132 RP CLX FHD ETC 2.6-7.5CM
|
Facility
|
OP
|
$1,330.00
|
|
|
Service Code
|
CPT 13132
|
| Hospital Charge Code |
22282808
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$212.80 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,197.00
|
| Rate for Payer: Aetna of AZ Medicare |
$372.40
|
| Rate for Payer: AHCCCS Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicare |
$212.80
|
| Rate for Payer: Amerigroup Medicare |
$212.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$496.75
|
| Rate for Payer: AZCH Complete Medicaid |
$380.02
|
| Rate for Payer: AZCH Complete Medicare |
$212.80
|
| Rate for Payer: Banner UC Health Medicaid |
$380.02
|
| Rate for Payer: Banner UC Health Medicare |
$212.80
|
| Rate for Payer: Bisbee Police All Plans |
$345.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$904.40
|
| Rate for Payer: Cash Price |
$1,064.00
|
| Rate for Payer: Cash Price |
$1,064.00
|
| Rate for Payer: Cigna of AZ Commercial |
$931.00
|
| Rate for Payer: Copperpoint Commercial |
$329.18
|
| Rate for Payer: Health Net of AZ Commercial |
$798.00
|
| Rate for Payer: Health Net of AZ Medicare |
$372.40
|
| Rate for Payer: Humana of AZ Medicare |
$212.80
|
| Rate for Payer: Mercy Care Medicaid |
$380.02
|
| Rate for Payer: Self Pay Self Pay |
$1,064.00
|
| Rate for Payer: TriWest Medicare |
$212.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$239.40
|
|
|
13132 RP CLX FHD ETC 2.6-7.5CM
|
Facility
|
IP
|
$1,330.00
|
|
|
Service Code
|
CPT 13132
|
| Hospital Charge Code |
22282808
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$345.80 |
| Max. Negotiated Rate |
$1,197.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,197.00
|
| Rate for Payer: Bisbee Police All Plans |
$345.80
|
| Rate for Payer: Cash Price |
$1,064.00
|
| Rate for Payer: Self Pay Self Pay |
$1,064.00
|
|
|
13133 RP CLX FORHD @ ADDL 5CM
|
Facility
|
IP
|
$650.00
|
|
|
Service Code
|
CPT 13133
|
| Hospital Charge Code |
22282809
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$169.00 |
| Max. Negotiated Rate |
$585.00 |
| Rate for Payer: Aetna of AZ Commercial |
$585.00
|
| Rate for Payer: Bisbee Police All Plans |
$169.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Self Pay Self Pay |
$520.00
|
|
|
13133 RP CLX FORHD @ ADDL 5CM
|
Facility
|
OP
|
$650.00
|
|
|
Service Code
|
CPT 13133
|
| Hospital Charge Code |
22282809
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$104.00 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$585.00
|
| Rate for Payer: Aetna of AZ Medicare |
$182.00
|
| Rate for Payer: AHCCCS Medicaid |
$242.50
|
| Rate for Payer: Allwell Medicaid |
$242.50
|
| Rate for Payer: Allwell Medicare |
$104.00
|
| Rate for Payer: Amerigroup Medicare |
$104.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$242.78
|
| Rate for Payer: AZCH Complete Medicaid |
$242.50
|
| Rate for Payer: AZCH Complete Medicare |
$104.00
|
| Rate for Payer: Banner UC Health Medicaid |
$242.50
|
| Rate for Payer: Banner UC Health Medicare |
$104.00
|
| Rate for Payer: Bisbee Police All Plans |
$169.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$442.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cash Price |
$520.00
|
| Rate for Payer: Cigna of AZ Commercial |
$455.00
|
| Rate for Payer: Copperpoint Commercial |
$160.88
|
| Rate for Payer: Health Net of AZ Commercial |
$390.00
|
| Rate for Payer: Health Net of AZ Medicare |
$182.00
|
| Rate for Payer: Humana of AZ Medicare |
$104.00
|
| Rate for Payer: Mercy Care Medicaid |
$242.50
|
| Rate for Payer: Self Pay Self Pay |
$520.00
|
| Rate for Payer: TriWest Medicare |
$104.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$117.00
|
|
|
13150 RP CLX EYLD ETC 1.0CM/<
|
Facility
|
IP
|
$1,233.00
|
|
|
Service Code
|
CPT 13150
|
| Hospital Charge Code |
22282810
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$320.58 |
| Max. Negotiated Rate |
$1,109.70 |
| Rate for Payer: Aetna of AZ Commercial |
$1,109.70
|
| Rate for Payer: Bisbee Police All Plans |
$320.58
|
| Rate for Payer: Cash Price |
$986.40
|
| Rate for Payer: Self Pay Self Pay |
$986.40
|
|
|
13150 RP CLX EYLD ETC 1.0CM/<
|
Facility
|
OP
|
$1,233.00
|
|
|
Service Code
|
CPT 13150
|
| Hospital Charge Code |
22282810
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$197.28 |
| Max. Negotiated Rate |
$1,109.70 |
| Rate for Payer: Aetna of AZ Commercial |
$1,109.70
|
| Rate for Payer: Aetna of AZ Medicare |
$345.24
|
| Rate for Payer: Allwell Medicare |
$197.28
|
| Rate for Payer: Amerigroup Medicare |
$197.28
|
| Rate for Payer: APIPA Medicare/Medicaid |
$460.53
|
| Rate for Payer: AZCH Complete Medicare |
$197.28
|
| Rate for Payer: Banner UC Health Medicare |
$197.28
|
| Rate for Payer: Bisbee Police All Plans |
$320.58
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$838.44
|
| Rate for Payer: Cash Price |
$986.40
|
| Rate for Payer: Cigna of AZ Commercial |
$863.10
|
| Rate for Payer: Copperpoint Commercial |
$305.17
|
| Rate for Payer: Health Net of AZ Commercial |
$739.80
|
| Rate for Payer: Health Net of AZ Medicare |
$345.24
|
| Rate for Payer: Humana of AZ Medicare |
$197.28
|
| Rate for Payer: Self Pay Self Pay |
$986.40
|
| Rate for Payer: TriWest Medicare |
$197.28
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$718.84
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$221.94
|
|
|
13151 RP CLX EYLD ETC 1.1-2.5CM
|
Facility
|
OP
|
$1,088.00
|
|
|
Service Code
|
CPT 13151
|
| Hospital Charge Code |
22282811
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$174.08 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$979.20
|
| Rate for Payer: Aetna of AZ Medicare |
$304.64
|
| Rate for Payer: AHCCCS Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicare |
$174.08
|
| Rate for Payer: Amerigroup Medicare |
$174.08
|
| Rate for Payer: APIPA Medicare/Medicaid |
$406.37
|
| Rate for Payer: AZCH Complete Medicaid |
$380.02
|
| Rate for Payer: AZCH Complete Medicare |
$174.08
|
| Rate for Payer: Banner UC Health Medicaid |
$380.02
|
| Rate for Payer: Banner UC Health Medicare |
$174.08
|
| Rate for Payer: Bisbee Police All Plans |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$739.84
|
| Rate for Payer: Cash Price |
$870.40
|
| Rate for Payer: Cash Price |
$870.40
|
| Rate for Payer: Cigna of AZ Commercial |
$761.60
|
| Rate for Payer: Copperpoint Commercial |
$269.28
|
| Rate for Payer: Health Net of AZ Commercial |
$652.80
|
| Rate for Payer: Health Net of AZ Medicare |
$304.64
|
| Rate for Payer: Humana of AZ Medicare |
$174.08
|
| Rate for Payer: Mercy Care Medicaid |
$380.02
|
| Rate for Payer: Self Pay Self Pay |
$870.40
|
| Rate for Payer: TriWest Medicare |
$174.08
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$195.84
|
|
|
13151 RP CLX EYLD ETC 1.1-2.5CM
|
Facility
|
IP
|
$1,088.00
|
|
|
Service Code
|
CPT 13151
|
| Hospital Charge Code |
22282811
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$282.88 |
| Max. Negotiated Rate |
$979.20 |
| Rate for Payer: Aetna of AZ Commercial |
$979.20
|
| Rate for Payer: Bisbee Police All Plans |
$282.88
|
| Rate for Payer: Cash Price |
$870.40
|
| Rate for Payer: Self Pay Self Pay |
$870.40
|
|
|
13152 RP CLX EYLD 2.6-7.5CM
|
Facility
|
IP
|
$1,958.00
|
|
|
Service Code
|
CPT 13152
|
| Hospital Charge Code |
22282812
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$509.08 |
| Max. Negotiated Rate |
$1,762.20 |
| Rate for Payer: Aetna of AZ Commercial |
$1,762.20
|
| Rate for Payer: Bisbee Police All Plans |
$509.08
|
| Rate for Payer: Cash Price |
$1,566.40
|
| Rate for Payer: Self Pay Self Pay |
$1,566.40
|
|
|
13152 RP CLX EYLD 2.6-7.5CM
|
Facility
|
OP
|
$1,958.00
|
|
|
Service Code
|
CPT 13152
|
| Hospital Charge Code |
22282812
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$313.28 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,762.20
|
| Rate for Payer: Aetna of AZ Medicare |
$548.24
|
| Rate for Payer: AHCCCS Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicare |
$313.28
|
| Rate for Payer: Amerigroup Medicare |
$313.28
|
| Rate for Payer: APIPA Medicare/Medicaid |
$731.31
|
| Rate for Payer: AZCH Complete Medicaid |
$380.02
|
| Rate for Payer: AZCH Complete Medicare |
$313.28
|
| Rate for Payer: Banner UC Health Medicaid |
$380.02
|
| Rate for Payer: Banner UC Health Medicare |
$313.28
|
| Rate for Payer: Bisbee Police All Plans |
$509.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,331.44
|
| Rate for Payer: Cash Price |
$1,566.40
|
| Rate for Payer: Cash Price |
$1,566.40
|
| Rate for Payer: Cigna of AZ Commercial |
$1,370.60
|
| Rate for Payer: Copperpoint Commercial |
$484.61
|
| Rate for Payer: Health Net of AZ Commercial |
$1,174.80
|
| Rate for Payer: Health Net of AZ Medicare |
$548.24
|
| Rate for Payer: Humana of AZ Medicare |
$313.28
|
| Rate for Payer: Mercy Care Medicaid |
$380.02
|
| Rate for Payer: Self Pay Self Pay |
$1,566.40
|
| Rate for Payer: TriWest Medicare |
$313.28
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$352.44
|
|
|
13153 RP CLX EYLD ETC ADDL 5CM
|
Facility
|
IP
|
$712.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
22282813
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$185.12 |
| Max. Negotiated Rate |
$640.80 |
| Rate for Payer: Aetna of AZ Commercial |
$640.80
|
| Rate for Payer: Bisbee Police All Plans |
$185.12
|
| Rate for Payer: Cash Price |
$569.60
|
| Rate for Payer: Self Pay Self Pay |
$569.60
|
|
|
13153 RP CLX EYLD ETC ADDL 5CM
|
Facility
|
OP
|
$712.00
|
|
|
Service Code
|
CPT 13153
|
| Hospital Charge Code |
22282813
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$113.92 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$640.80
|
| Rate for Payer: Aetna of AZ Medicare |
$199.36
|
| Rate for Payer: AHCCCS Medicaid |
$242.50
|
| Rate for Payer: Allwell Medicaid |
$242.50
|
| Rate for Payer: Allwell Medicare |
$113.92
|
| Rate for Payer: Amerigroup Medicare |
$113.92
|
| Rate for Payer: APIPA Medicare/Medicaid |
$265.93
|
| Rate for Payer: AZCH Complete Medicaid |
$242.50
|
| Rate for Payer: AZCH Complete Medicare |
$113.92
|
| Rate for Payer: Banner UC Health Medicaid |
$242.50
|
| Rate for Payer: Banner UC Health Medicare |
$113.92
|
| Rate for Payer: Bisbee Police All Plans |
$185.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$484.16
|
| Rate for Payer: Cash Price |
$569.60
|
| Rate for Payer: Cash Price |
$569.60
|
| Rate for Payer: Cigna of AZ Commercial |
$498.40
|
| Rate for Payer: Copperpoint Commercial |
$176.22
|
| Rate for Payer: Health Net of AZ Commercial |
$427.20
|
| Rate for Payer: Health Net of AZ Medicare |
$199.36
|
| Rate for Payer: Humana of AZ Medicare |
$113.92
|
| Rate for Payer: Mercy Care Medicaid |
$242.50
|
| Rate for Payer: Self Pay Self Pay |
$569.60
|
| Rate for Payer: TriWest Medicare |
$113.92
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$128.16
|
|
|
15274 APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, L
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
CPT 15274
|
| Hospital Charge Code |
24053068
|
|
Hospital Revenue Code
|
760
|
| Min. Negotiated Rate |
$21.28 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$119.70
|
| Rate for Payer: Aetna of AZ Medicare |
$37.24
|
| Rate for Payer: AHCCCS Medicaid |
$242.50
|
| Rate for Payer: Allwell Medicaid |
$242.50
|
| Rate for Payer: Allwell Medicare |
$21.28
|
| Rate for Payer: Amerigroup Medicare |
$21.28
|
| Rate for Payer: APIPA Medicare/Medicaid |
$49.68
|
| Rate for Payer: AZCH Complete Medicaid |
$242.50
|
| Rate for Payer: AZCH Complete Medicare |
$21.28
|
| Rate for Payer: Banner UC Health Medicaid |
$242.50
|
| Rate for Payer: Banner UC Health Medicare |
$21.28
|
| Rate for Payer: Bisbee Police All Plans |
$34.58
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$90.44
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cigna of AZ Commercial |
$93.10
|
| Rate for Payer: Copperpoint Commercial |
$32.92
|
| Rate for Payer: Health Net of AZ Commercial |
$79.80
|
| Rate for Payer: Health Net of AZ Medicare |
$37.24
|
| Rate for Payer: Humana of AZ Medicare |
$21.28
|
| Rate for Payer: Mercy Care Medicaid |
$242.50
|
| Rate for Payer: Self Pay Self Pay |
$106.40
|
| Rate for Payer: TriWest Medicare |
$21.28
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$23.94
|
|
|
15274 APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, L
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
CPT 15274
|
| Hospital Charge Code |
24053068
|
|
Hospital Revenue Code
|
760
|
| Min. Negotiated Rate |
$34.58 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna of AZ Commercial |
$119.70
|
| Rate for Payer: Bisbee Police All Plans |
$34.58
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Self Pay Self Pay |
$106.40
|
|
|
16000 TRT 1ST LOCAL
|
Facility
|
OP
|
$226.00
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
22282814
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$36.16 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$203.40
|
| Rate for Payer: Aetna of AZ Medicare |
$63.28
|
| Rate for Payer: AHCCCS Medicaid |
$130.17
|
| Rate for Payer: Allwell Medicaid |
$130.17
|
| Rate for Payer: Allwell Medicare |
$36.16
|
| Rate for Payer: Amerigroup Medicare |
$36.16
|
| Rate for Payer: APIPA Medicare/Medicaid |
$84.41
|
| Rate for Payer: AZCH Complete Medicaid |
$130.17
|
| Rate for Payer: AZCH Complete Medicare |
$36.16
|
| Rate for Payer: Banner UC Health Medicaid |
$130.17
|
| Rate for Payer: Banner UC Health Medicare |
$36.16
|
| Rate for Payer: Bisbee Police All Plans |
$58.76
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$153.68
|
| Rate for Payer: Cash Price |
$180.80
|
| Rate for Payer: Cash Price |
$180.80
|
| Rate for Payer: Cigna of AZ Commercial |
$158.20
|
| Rate for Payer: Copperpoint Commercial |
$55.94
|
| Rate for Payer: Health Net of AZ Commercial |
$135.60
|
| Rate for Payer: Health Net of AZ Medicare |
$63.28
|
| Rate for Payer: Humana of AZ Medicare |
$36.16
|
| Rate for Payer: Mercy Care Medicaid |
$130.17
|
| Rate for Payer: Self Pay Self Pay |
$180.80
|
| Rate for Payer: TriWest Medicare |
$36.16
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$40.68
|
|
|
16000 TRT 1ST LOCAL
|
Facility
|
IP
|
$226.00
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
22282814
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$58.76 |
| Max. Negotiated Rate |
$203.40 |
| Rate for Payer: Aetna of AZ Commercial |
$203.40
|
| Rate for Payer: Bisbee Police All Plans |
$58.76
|
| Rate for Payer: Cash Price |
$180.80
|
| Rate for Payer: Self Pay Self Pay |
$180.80
|
|
|
16010 DSG/DBD WANES SMALL
|
Facility
|
IP
|
$242.00
|
|
|
Service Code
|
CPT 16010
|
| Hospital Charge Code |
22282815
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$62.92 |
| Max. Negotiated Rate |
$217.80 |
| Rate for Payer: Aetna of AZ Commercial |
$217.80
|
| Rate for Payer: Bisbee Police All Plans |
$62.92
|
| Rate for Payer: Cash Price |
$193.60
|
| Rate for Payer: Self Pay Self Pay |
$193.60
|
|
