|
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 |
$239.85 |
| 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 |
$501.46
|
| Rate for Payer: Allwell Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicare |
$239.85
|
| Rate for Payer: Amerigroup Medicare |
$239.85
|
| Rate for Payer: APIPA Medicare/Medicaid |
$597.23
|
| Rate for Payer: AZCH Complete Medicaid |
$501.46
|
| Rate for Payer: AZCH Complete Medicare |
$239.85
|
| Rate for Payer: Banner UC Health Medicaid |
$501.46
|
| Rate for Payer: Banner UC Health Medicare |
$239.85
|
| 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 |
$239.85
|
| Rate for Payer: Mercy Care Medicaid |
$501.46
|
| Rate for Payer: Self Pay Self Pay |
$1,279.20
|
| Rate for Payer: TriWest Medicare |
$239.85
|
| 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
OP
|
$1,891.00
|
|
|
Service Code
|
CPT 12056
|
| Hospital Charge Code |
22282799
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$283.65 |
| 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 |
$501.46
|
| Rate for Payer: Allwell Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicare |
$283.65
|
| Rate for Payer: Amerigroup Medicare |
$283.65
|
| Rate for Payer: APIPA Medicare/Medicaid |
$706.29
|
| Rate for Payer: AZCH Complete Medicaid |
$501.46
|
| Rate for Payer: AZCH Complete Medicare |
$283.65
|
| Rate for Payer: Banner UC Health Medicaid |
$501.46
|
| Rate for Payer: Banner UC Health Medicare |
$283.65
|
| 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 |
$283.65
|
| Rate for Payer: Mercy Care Medicaid |
$501.46
|
| Rate for Payer: Self Pay Self Pay |
$1,512.80
|
| Rate for Payer: TriWest Medicare |
$283.65
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$340.38
|
|
|
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
|
|
|
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 |
$328.05 |
| 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 |
$501.46
|
| Rate for Payer: Allwell Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicare |
$328.05
|
| Rate for Payer: Amerigroup Medicare |
$328.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$816.84
|
| Rate for Payer: AZCH Complete Medicaid |
$501.46
|
| Rate for Payer: AZCH Complete Medicare |
$328.05
|
| Rate for Payer: Banner UC Health Medicaid |
$501.46
|
| Rate for Payer: Banner UC Health Medicare |
$328.05
|
| 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 |
$328.05
|
| Rate for Payer: Mercy Care Medicaid |
$501.46
|
| Rate for Payer: Self Pay Self Pay |
$1,749.60
|
| Rate for Payer: TriWest Medicare |
$328.05
|
| 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
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
|
|
|
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 |
$133.65 |
| 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 |
$760.04
|
| Rate for Payer: Allwell Medicaid |
$760.04
|
| Rate for Payer: Allwell Medicare |
$133.65
|
| Rate for Payer: Amerigroup Medicare |
$133.65
|
| Rate for Payer: APIPA Medicare/Medicaid |
$332.79
|
| Rate for Payer: AZCH Complete Medicaid |
$760.04
|
| Rate for Payer: AZCH Complete Medicare |
$133.65
|
| Rate for Payer: Banner UC Health Medicaid |
$760.04
|
| Rate for Payer: Banner UC Health Medicare |
$133.65
|
| 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 |
$133.65
|
| Rate for Payer: Mercy Care Medicaid |
$760.04
|
| Rate for Payer: Self Pay Self Pay |
$712.80
|
| Rate for Payer: TriWest Medicare |
$133.65
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$160.38
|
|
|
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 |
$171.00 |
| 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 |
$760.04
|
| Rate for Payer: Allwell Medicaid |
$760.04
|
| Rate for Payer: Allwell Medicare |
$171.00
|
| Rate for Payer: Amerigroup Medicare |
$171.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$425.79
|
| Rate for Payer: AZCH Complete Medicaid |
$760.04
|
| Rate for Payer: AZCH Complete Medicare |
$171.00
|
| Rate for Payer: Banner UC Health Medicaid |
$760.04
|
| Rate for Payer: Banner UC Health Medicare |
$171.00
|
| 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 |
$171.00
|
| Rate for Payer: Mercy Care Medicaid |
$760.04
|
| Rate for Payer: Self Pay Self Pay |
$912.00
|
| Rate for Payer: TriWest Medicare |
$171.00
|
| 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
OP
|
$516.00
|
|
|
Service Code
|
CPT 13102
|
| Hospital Charge Code |
22282803
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$77.40 |
| 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 |
$485.00
|
| Rate for Payer: Allwell Medicaid |
$485.00
|
| Rate for Payer: Allwell Medicare |
$77.40
|
| Rate for Payer: Amerigroup Medicare |
$77.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$192.73
|
| Rate for Payer: AZCH Complete Medicaid |
$485.00
|
| Rate for Payer: AZCH Complete Medicare |
$77.40
|
| Rate for Payer: Banner UC Health Medicaid |
$485.00
|
| Rate for Payer: Banner UC Health Medicare |
$77.40
|
| 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 |
$77.40
|
| Rate for Payer: Mercy Care Medicaid |
$485.00
|
| Rate for Payer: Self Pay Self Pay |
$412.80
|
| Rate for Payer: TriWest Medicare |
$77.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$92.88
|
|
|
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
|
|
|
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
|
|
|
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 |
$229.20 |
| 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 |
$760.04
|
| Rate for Payer: Allwell Medicaid |
$760.04
|
| Rate for Payer: Allwell Medicare |
$229.20
|
| Rate for Payer: Amerigroup Medicare |
$229.20
|
| Rate for Payer: APIPA Medicare/Medicaid |
$570.71
|
| Rate for Payer: AZCH Complete Medicaid |
$760.04
|
| Rate for Payer: AZCH Complete Medicare |
$229.20
|
| Rate for Payer: Banner UC Health Medicaid |
$760.04
|
| Rate for Payer: Banner UC Health Medicare |
$229.20
|
| 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 |
$229.20
|
| Rate for Payer: Mercy Care Medicaid |
$760.04
|
| Rate for Payer: Self Pay Self Pay |
$1,222.40
|
| Rate for Payer: TriWest Medicare |
$229.20
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$275.04
|
|
|
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 |
$312.45 |
| 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 |
$760.04
|
| Rate for Payer: Allwell Medicaid |
$760.04
|
| Rate for Payer: Allwell Medicare |
$312.45
|
| Rate for Payer: Amerigroup Medicare |
$312.45
|
| Rate for Payer: APIPA Medicare/Medicaid |
$778.00
|
| Rate for Payer: AZCH Complete Medicaid |
$760.04
|
| Rate for Payer: AZCH Complete Medicare |
$312.45
|
| Rate for Payer: Banner UC Health Medicaid |
$760.04
|
| Rate for Payer: Banner UC Health Medicare |
$312.45
|
| 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 |
$312.45
|
| Rate for Payer: Mercy Care Medicaid |
$760.04
|
| Rate for Payer: Self Pay Self Pay |
$1,666.40
|
| Rate for Payer: TriWest Medicare |
$312.45
|
| 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 |
$64.80 |
| 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 |
$165.38
|
| Rate for Payer: Allwell Medicaid |
$165.38
|
| Rate for Payer: Allwell Medicare |
$64.80
|
| Rate for Payer: Amerigroup Medicare |
$64.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$161.35
|
| Rate for Payer: AZCH Complete Medicaid |
$165.38
|
| Rate for Payer: AZCH Complete Medicare |
$64.80
|
| Rate for Payer: Banner UC Health Medicaid |
$165.38
|
| Rate for Payer: Banner UC Health Medicare |
$64.80
|
| 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 |
$64.80
|
| Rate for Payer: Mercy Care Medicaid |
$165.38
|
| Rate for Payer: Self Pay Self Pay |
$345.60
|
| Rate for Payer: TriWest Medicare |
$64.80
|
| 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 |
$166.35 |
| 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 |
$501.46
|
| Rate for Payer: Allwell Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicare |
$166.35
|
| Rate for Payer: Amerigroup Medicare |
$166.35
|
| Rate for Payer: APIPA Medicare/Medicaid |
$414.21
|
| Rate for Payer: AZCH Complete Medicaid |
$501.46
|
| Rate for Payer: AZCH Complete Medicare |
$166.35
|
| Rate for Payer: Banner UC Health Medicaid |
$501.46
|
| Rate for Payer: Banner UC Health Medicare |
$166.35
|
| 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 |
$166.35
|
| Rate for Payer: Mercy Care Medicaid |
$501.46
|
| Rate for Payer: Self Pay Self Pay |
$887.20
|
| Rate for Payer: TriWest Medicare |
$166.35
|
| 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 |
$199.50 |
| 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 |
$760.04
|
| Rate for Payer: Allwell Medicaid |
$760.04
|
| Rate for Payer: Allwell Medicare |
$199.50
|
| Rate for Payer: Amerigroup Medicare |
$199.50
|
| Rate for Payer: APIPA Medicare/Medicaid |
$496.76
|
| Rate for Payer: AZCH Complete Medicaid |
$760.04
|
| Rate for Payer: AZCH Complete Medicare |
$199.50
|
| Rate for Payer: Banner UC Health Medicaid |
$760.04
|
| Rate for Payer: Banner UC Health Medicare |
$199.50
|
| 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 |
$199.50
|
| Rate for Payer: Mercy Care Medicaid |
$760.04
|
| Rate for Payer: Self Pay Self Pay |
$1,064.00
|
| Rate for Payer: TriWest Medicare |
$199.50
|
| 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
OP
|
$650.00
|
|
|
Service Code
|
CPT 13133
|
| Hospital Charge Code |
22282809
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$97.50 |
| 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 |
$485.00
|
| Rate for Payer: Allwell Medicaid |
$485.00
|
| Rate for Payer: Allwell Medicare |
$97.50
|
| Rate for Payer: Amerigroup Medicare |
$97.50
|
| Rate for Payer: APIPA Medicare/Medicaid |
$242.78
|
| Rate for Payer: AZCH Complete Medicaid |
$485.00
|
| Rate for Payer: AZCH Complete Medicare |
$97.50
|
| Rate for Payer: Banner UC Health Medicaid |
$485.00
|
| Rate for Payer: Banner UC Health Medicare |
$97.50
|
| 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 |
$97.50
|
| Rate for Payer: Mercy Care Medicaid |
$485.00
|
| Rate for Payer: Self Pay Self Pay |
$520.00
|
| Rate for Payer: TriWest Medicare |
$97.50
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$117.00
|
|
|
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
|
|
|
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 |
$184.95 |
| 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 |
$184.95
|
| Rate for Payer: Amerigroup Medicare |
$184.95
|
| Rate for Payer: APIPA Medicare/Medicaid |
$460.53
|
| Rate for Payer: AZCH Complete Medicare |
$184.95
|
| Rate for Payer: Banner UC Health Medicare |
$184.95
|
| 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 |
$184.95
|
| Rate for Payer: Self Pay Self Pay |
$986.40
|
| Rate for Payer: TriWest Medicare |
$184.95
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$718.84
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$221.94
|
|
