|
CT Maxillofacial w/ Contrast
|
Facility
|
OP
|
$2,470.00
|
|
|
Service Code
|
CPT 70487
|
| Hospital Charge Code |
821346
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$258.90 |
| Max. Negotiated Rate |
$2,223.00 |
| Rate for Payer: Aetna of AZ Commercial |
$2,223.00
|
| Rate for Payer: Aetna of AZ Medicare |
$691.60
|
| Rate for Payer: AHCCCS Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicare |
$370.50
|
| Rate for Payer: Amerigroup Medicare |
$370.50
|
| Rate for Payer: APIPA Medicare/Medicaid |
$922.54
|
| Rate for Payer: AZCH Complete Medicaid |
$258.90
|
| Rate for Payer: AZCH Complete Medicare |
$370.50
|
| Rate for Payer: Banner UC Health Medicaid |
$258.90
|
| Rate for Payer: Banner UC Health Medicare |
$370.50
|
| Rate for Payer: Bisbee Police All Plans |
$642.20
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,679.60
|
| Rate for Payer: Cash Price |
$1,976.00
|
| Rate for Payer: Cash Price |
$1,976.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,605.50
|
| Rate for Payer: Copperpoint Commercial |
$611.32
|
| Rate for Payer: Health Net of AZ Commercial |
$1,482.00
|
| Rate for Payer: Health Net of AZ Medicare |
$691.60
|
| Rate for Payer: Humana of AZ Medicare |
$370.50
|
| Rate for Payer: Mercy Care Medicaid |
$258.90
|
| Rate for Payer: Self Pay Self Pay |
$1,976.00
|
| Rate for Payer: TriWest Medicare |
$370.50
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,440.01
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$444.60
|
|
|
CT Maxillofacial w/o Contrast
|
Facility
|
OP
|
$2,066.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
821348
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$158.00 |
| Max. Negotiated Rate |
$1,859.40 |
| Rate for Payer: Aetna of AZ Commercial |
$1,859.40
|
| Rate for Payer: Aetna of AZ Medicare |
$578.48
|
| Rate for Payer: AHCCCS Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicare |
$309.90
|
| Rate for Payer: Amerigroup Medicare |
$309.90
|
| Rate for Payer: APIPA Medicare/Medicaid |
$771.65
|
| Rate for Payer: AZCH Complete Medicaid |
$158.00
|
| Rate for Payer: AZCH Complete Medicare |
$309.90
|
| Rate for Payer: Banner UC Health Medicaid |
$158.00
|
| Rate for Payer: Banner UC Health Medicare |
$309.90
|
| Rate for Payer: Bisbee Police All Plans |
$537.16
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,404.88
|
| Rate for Payer: Cash Price |
$1,652.80
|
| Rate for Payer: Cash Price |
$1,652.80
|
| Rate for Payer: Cigna of AZ Commercial |
$1,342.90
|
| Rate for Payer: Copperpoint Commercial |
$511.34
|
| Rate for Payer: Health Net of AZ Commercial |
$1,239.60
|
| Rate for Payer: Health Net of AZ Medicare |
$578.48
|
| Rate for Payer: Humana of AZ Medicare |
$309.90
|
| Rate for Payer: Mercy Care Medicaid |
$158.00
|
| Rate for Payer: Self Pay Self Pay |
$1,652.80
|
| Rate for Payer: TriWest Medicare |
$309.90
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,204.48
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$371.88
|
|
|
CT Maxillofacial w/o Contrast
|
Facility
|
IP
|
$2,066.00
|
|
|
Service Code
|
CPT 70486
|
| Hospital Charge Code |
821348
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$537.16 |
| Max. Negotiated Rate |
$1,859.40 |
| Rate for Payer: Aetna of AZ Commercial |
$1,859.40
|
| Rate for Payer: Bisbee Police All Plans |
$537.16
|
| Rate for Payer: Cash Price |
$1,652.80
|
| Rate for Payer: Self Pay Self Pay |
$1,652.80
|
|
|
CT Maxillofacial w/ + w/o Contrast
|
Facility
|
OP
|
$3,728.00
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
1005185
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$258.90 |
| Max. Negotiated Rate |
$3,355.20 |
| Rate for Payer: Aetna of AZ Commercial |
$3,355.20
|
| Rate for Payer: Aetna of AZ Medicare |
$1,043.84
|
| Rate for Payer: AHCCCS Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicare |
$559.20
|
| Rate for Payer: Amerigroup Medicare |
$559.20
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,392.41
|
| Rate for Payer: AZCH Complete Medicaid |
$258.90
|
| Rate for Payer: AZCH Complete Medicare |
$559.20
|
| Rate for Payer: Banner UC Health Medicaid |
$258.90
|
| Rate for Payer: Banner UC Health Medicare |
$559.20
|
| Rate for Payer: Bisbee Police All Plans |
$969.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2,535.04
|
| Rate for Payer: Cash Price |
$2,982.40
|
| Rate for Payer: Cash Price |
$2,982.40
|
| Rate for Payer: Cigna of AZ Commercial |
$2,423.20
|
| Rate for Payer: Copperpoint Commercial |
$922.68
|
| Rate for Payer: Health Net of AZ Commercial |
$2,236.80
|
| Rate for Payer: Health Net of AZ Medicare |
$1,043.84
|
| Rate for Payer: Humana of AZ Medicare |
$559.20
|
| Rate for Payer: Mercy Care Medicaid |
$258.90
|
| Rate for Payer: Self Pay Self Pay |
$2,982.40
|
| Rate for Payer: TriWest Medicare |
$559.20
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,173.42
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$671.04
|
|
|
CT Maxillofacial w/ + w/o Contrast
|
Facility
|
IP
|
$3,728.00
|
|
|
Service Code
|
CPT 70488
|
| Hospital Charge Code |
1005185
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$969.28 |
| Max. Negotiated Rate |
$3,355.20 |
| Rate for Payer: Aetna of AZ Commercial |
$3,355.20
|
| Rate for Payer: Bisbee Police All Plans |
$969.28
|
| Rate for Payer: Cash Price |
$2,982.40
|
| Rate for Payer: Self Pay Self Pay |
$2,982.40
|
|
|
CT Orbit Sella etc. w/ Contrast
|
Facility
|
IP
|
$486.00
|
|
|
Service Code
|
CPT 70481
|
| Hospital Charge Code |
22862167
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$126.36 |
| Max. Negotiated Rate |
$437.40 |
| Rate for Payer: Aetna of AZ Commercial |
$437.40
|
| Rate for Payer: Bisbee Police All Plans |
$126.36
|
| Rate for Payer: Cash Price |
$388.80
|
| Rate for Payer: Self Pay Self Pay |
$388.80
|
|
|
CT Orbit Sella etc. w/ Contrast
|
Facility
|
OP
|
$486.00
|
|
|
Service Code
|
CPT 70481
|
| Hospital Charge Code |
22862167
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$72.90 |
| Max. Negotiated Rate |
$437.40 |
| Rate for Payer: Aetna of AZ Commercial |
$437.40
|
| Rate for Payer: Aetna of AZ Medicare |
$136.08
|
| Rate for Payer: AHCCCS Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicare |
$72.90
|
| Rate for Payer: Amerigroup Medicare |
$72.90
|
| Rate for Payer: APIPA Medicare/Medicaid |
$181.52
|
| Rate for Payer: AZCH Complete Medicaid |
$258.90
|
| Rate for Payer: AZCH Complete Medicare |
$72.90
|
| Rate for Payer: Banner UC Health Medicaid |
$258.90
|
| Rate for Payer: Banner UC Health Medicare |
$72.90
|
| Rate for Payer: Bisbee Police All Plans |
$126.36
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$330.48
|
| Rate for Payer: Cash Price |
$388.80
|
| Rate for Payer: Cash Price |
$388.80
|
| Rate for Payer: Cigna of AZ Commercial |
$340.20
|
| Rate for Payer: Copperpoint Commercial |
$120.28
|
| Rate for Payer: Health Net of AZ Commercial |
$291.60
|
| Rate for Payer: Health Net of AZ Medicare |
$136.08
|
| Rate for Payer: Humana of AZ Medicare |
$72.90
|
| Rate for Payer: Mercy Care Medicaid |
$258.90
|
| Rate for Payer: Self Pay Self Pay |
$388.80
|
| Rate for Payer: TriWest Medicare |
$72.90
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$283.34
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$87.48
|
|
|
CT Orbit Sella etc. w/ Contrast
|
Facility
|
IP
|
$2,524.00
|
|
|
Service Code
|
CPT 70481
|
| Hospital Charge Code |
821350
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$656.24 |
| Max. Negotiated Rate |
$2,271.60 |
| Rate for Payer: Aetna of AZ Commercial |
$2,271.60
|
| Rate for Payer: Bisbee Police All Plans |
$656.24
|
| Rate for Payer: Cash Price |
$2,019.20
|
| Rate for Payer: Self Pay Self Pay |
$2,019.20
|
|
|
CT Orbit Sella etc. w/ Contrast
|
Facility
|
OP
|
$2,524.00
|
|
|
Service Code
|
CPT 70481
|
| Hospital Charge Code |
821350
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$258.90 |
| Max. Negotiated Rate |
$2,271.60 |
| Rate for Payer: Aetna of AZ Commercial |
$2,271.60
|
| Rate for Payer: Aetna of AZ Medicare |
$706.72
|
| Rate for Payer: AHCCCS Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicare |
$378.60
|
| Rate for Payer: Amerigroup Medicare |
$378.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$942.71
|
| Rate for Payer: AZCH Complete Medicaid |
$258.90
|
| Rate for Payer: AZCH Complete Medicare |
$378.60
|
| Rate for Payer: Banner UC Health Medicaid |
$258.90
|
| Rate for Payer: Banner UC Health Medicare |
$378.60
|
| Rate for Payer: Bisbee Police All Plans |
$656.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,716.32
|
| Rate for Payer: Cash Price |
$2,019.20
|
| Rate for Payer: Cash Price |
$2,019.20
|
| Rate for Payer: Cigna of AZ Commercial |
$1,640.60
|
| Rate for Payer: Copperpoint Commercial |
$624.69
|
| Rate for Payer: Health Net of AZ Commercial |
$1,514.40
|
| Rate for Payer: Health Net of AZ Medicare |
$706.72
|
| Rate for Payer: Humana of AZ Medicare |
$378.60
|
| Rate for Payer: Mercy Care Medicaid |
$258.90
|
| Rate for Payer: Self Pay Self Pay |
$2,019.20
|
| Rate for Payer: TriWest Medicare |
$378.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,471.49
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$454.32
|
|
|
CT Orbit Sella etc. w/o Contrast
|
Facility
|
OP
|
$415.00
|
|
|
Service Code
|
CPT 70480
|
| Hospital Charge Code |
22862166
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$62.25 |
| Max. Negotiated Rate |
$373.50 |
| Rate for Payer: Aetna of AZ Commercial |
$373.50
|
| Rate for Payer: Aetna of AZ Medicare |
$116.20
|
| Rate for Payer: AHCCCS Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicare |
$62.25
|
| Rate for Payer: Amerigroup Medicare |
$62.25
|
| Rate for Payer: APIPA Medicare/Medicaid |
$155.00
|
| Rate for Payer: AZCH Complete Medicaid |
$158.00
|
| Rate for Payer: AZCH Complete Medicare |
$62.25
|
| Rate for Payer: Banner UC Health Medicaid |
$158.00
|
| Rate for Payer: Banner UC Health Medicare |
$62.25
|
| Rate for Payer: Bisbee Police All Plans |
$107.90
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$282.20
|
| Rate for Payer: Cash Price |
$332.00
|
| Rate for Payer: Cash Price |
$332.00
|
| Rate for Payer: Cigna of AZ Commercial |
$290.50
|
| Rate for Payer: Copperpoint Commercial |
$102.71
|
| Rate for Payer: Health Net of AZ Commercial |
$249.00
|
| Rate for Payer: Health Net of AZ Medicare |
$116.20
|
| Rate for Payer: Humana of AZ Medicare |
$62.25
|
| Rate for Payer: Mercy Care Medicaid |
$158.00
|
| Rate for Payer: Self Pay Self Pay |
$332.00
|
| Rate for Payer: TriWest Medicare |
$62.25
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$241.94
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$74.70
|
|
|
CT Orbit Sella etc. w/o Contrast
|
Facility
|
IP
|
$2,557.00
|
|
|
Service Code
|
CPT 70480
|
| Hospital Charge Code |
821352
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$664.82 |
| Max. Negotiated Rate |
$2,301.30 |
| Rate for Payer: Aetna of AZ Commercial |
$2,301.30
|
| Rate for Payer: Bisbee Police All Plans |
$664.82
|
| Rate for Payer: Cash Price |
$2,045.60
|
| Rate for Payer: Self Pay Self Pay |
$2,045.60
|
|
|
CT Orbit Sella etc. w/o Contrast
|
Facility
|
OP
|
$2,557.00
|
|
|
Service Code
|
CPT 70480
|
| Hospital Charge Code |
821352
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$158.00 |
| Max. Negotiated Rate |
$2,301.30 |
| Rate for Payer: Aetna of AZ Commercial |
$2,301.30
|
| Rate for Payer: Aetna of AZ Medicare |
$715.96
|
| Rate for Payer: AHCCCS Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicare |
$383.55
|
| Rate for Payer: Amerigroup Medicare |
$383.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$955.04
|
| Rate for Payer: AZCH Complete Medicaid |
$158.00
|
| Rate for Payer: AZCH Complete Medicare |
$383.55
|
| Rate for Payer: Banner UC Health Medicaid |
$158.00
|
| Rate for Payer: Banner UC Health Medicare |
$383.55
|
| Rate for Payer: Bisbee Police All Plans |
$664.82
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,738.76
|
| Rate for Payer: Cash Price |
$2,045.60
|
| Rate for Payer: Cash Price |
$2,045.60
|
| Rate for Payer: Cigna of AZ Commercial |
$1,662.05
|
| Rate for Payer: Copperpoint Commercial |
$632.86
|
| Rate for Payer: Health Net of AZ Commercial |
$1,534.20
|
| Rate for Payer: Health Net of AZ Medicare |
$715.96
|
| Rate for Payer: Humana of AZ Medicare |
$383.55
|
| Rate for Payer: Mercy Care Medicaid |
$158.00
|
| Rate for Payer: Self Pay Self Pay |
$2,045.60
|
| Rate for Payer: TriWest Medicare |
$383.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,490.73
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$460.26
|
|
|
CT Orbit Sella etc. w/o Contrast
|
Facility
|
IP
|
$415.00
|
|
|
Service Code
|
CPT 70480
|
| Hospital Charge Code |
22862166
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$107.90 |
| Max. Negotiated Rate |
$373.50 |
| Rate for Payer: Aetna of AZ Commercial |
$373.50
|
| Rate for Payer: Bisbee Police All Plans |
$107.90
|
| Rate for Payer: Cash Price |
$332.00
|
| Rate for Payer: Self Pay Self Pay |
$332.00
|
|
|
CT Orbit Sella etc. w/ + w/o Contrast
|
Facility
|
OP
|
$544.00
|
|
|
Service Code
|
CPT 70482
|
| Hospital Charge Code |
22862168
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$81.60 |
| Max. Negotiated Rate |
$489.60 |
| Rate for Payer: Aetna of AZ Commercial |
$489.60
|
| Rate for Payer: Aetna of AZ Medicare |
$152.32
|
| Rate for Payer: AHCCCS Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicare |
$81.60
|
| Rate for Payer: Amerigroup Medicare |
$81.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$203.18
|
| Rate for Payer: AZCH Complete Medicaid |
$258.90
|
| Rate for Payer: AZCH Complete Medicare |
$81.60
|
| Rate for Payer: Banner UC Health Medicaid |
$258.90
|
| Rate for Payer: Banner UC Health Medicare |
$81.60
|
| Rate for Payer: Bisbee Police All Plans |
$141.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$369.92
|
| Rate for Payer: Cash Price |
$435.20
|
| Rate for Payer: Cash Price |
$435.20
|
| Rate for Payer: Cigna of AZ Commercial |
$380.80
|
| Rate for Payer: Copperpoint Commercial |
$134.64
|
| Rate for Payer: Health Net of AZ Commercial |
$326.40
|
| Rate for Payer: Health Net of AZ Medicare |
$152.32
|
| Rate for Payer: Humana of AZ Medicare |
$81.60
|
| Rate for Payer: Mercy Care Medicaid |
$258.90
|
| Rate for Payer: Self Pay Self Pay |
$435.20
|
| Rate for Payer: TriWest Medicare |
$81.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$317.15
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$97.92
|
|
|
CT Orbit Sella etc. w/ + w/o Contrast
|
Facility
|
IP
|
$544.00
|
|
|
Service Code
|
CPT 70482
|
| Hospital Charge Code |
22862168
|
|
Hospital Revenue Code
|
972
|
| Min. Negotiated Rate |
$141.44 |
| Max. Negotiated Rate |
$489.60 |
| Rate for Payer: Aetna of AZ Commercial |
$489.60
|
| Rate for Payer: Bisbee Police All Plans |
$141.44
|
| Rate for Payer: Cash Price |
$435.20
|
| Rate for Payer: Self Pay Self Pay |
$435.20
|
|
|
CT Orbit Sella etc. w/ + w/o Contrast
|
Facility
|
OP
|
$2,789.00
|
|
|
Service Code
|
CPT 70482
|
| Hospital Charge Code |
1005187
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$258.90 |
| Max. Negotiated Rate |
$2,510.10 |
| Rate for Payer: Aetna of AZ Commercial |
$2,510.10
|
| Rate for Payer: Aetna of AZ Medicare |
$780.92
|
| Rate for Payer: AHCCCS Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicare |
$418.35
|
| Rate for Payer: Amerigroup Medicare |
$418.35
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,041.69
|
| Rate for Payer: AZCH Complete Medicaid |
$258.90
|
| Rate for Payer: AZCH Complete Medicare |
$418.35
|
| Rate for Payer: Banner UC Health Medicaid |
$258.90
|
| Rate for Payer: Banner UC Health Medicare |
$418.35
|
| Rate for Payer: Bisbee Police All Plans |
$725.14
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,896.52
|
| Rate for Payer: Cash Price |
$2,231.20
|
| Rate for Payer: Cash Price |
$2,231.20
|
| Rate for Payer: Cigna of AZ Commercial |
$1,812.85
|
| Rate for Payer: Copperpoint Commercial |
$690.28
|
| Rate for Payer: Health Net of AZ Commercial |
$1,673.40
|
| Rate for Payer: Health Net of AZ Medicare |
$780.92
|
| Rate for Payer: Humana of AZ Medicare |
$418.35
|
| Rate for Payer: Mercy Care Medicaid |
$258.90
|
| Rate for Payer: Self Pay Self Pay |
$2,231.20
|
| Rate for Payer: TriWest Medicare |
$418.35
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,625.99
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$502.02
|
|
|
CT Orbit Sella etc. w/ + w/o Contrast
|
Facility
|
IP
|
$2,789.00
|
|
|
Service Code
|
CPT 70482
|
| Hospital Charge Code |
1005187
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$725.14 |
| Max. Negotiated Rate |
$2,510.10 |
| Rate for Payer: Aetna of AZ Commercial |
$2,510.10
|
| Rate for Payer: Bisbee Police All Plans |
$725.14
|
| Rate for Payer: Cash Price |
$2,231.20
|
| Rate for Payer: Self Pay Self Pay |
$2,231.20
|
|
|
CT Pelvis w/ Contrast
|
Facility
|
IP
|
$3,040.00
|
|
|
Service Code
|
CPT 72193
|
| Hospital Charge Code |
821359
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$790.40 |
| Max. Negotiated Rate |
$2,736.00 |
| Rate for Payer: Aetna of AZ Commercial |
$2,736.00
|
| Rate for Payer: Bisbee Police All Plans |
$790.40
|
| Rate for Payer: Cash Price |
$2,432.00
|
| Rate for Payer: Self Pay Self Pay |
$2,432.00
|
|
|
CT Pelvis w/ Contrast
|
Facility
|
OP
|
$3,040.00
|
|
|
Service Code
|
CPT 72193
|
| Hospital Charge Code |
821359
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$258.90 |
| Max. Negotiated Rate |
$2,736.00 |
| Rate for Payer: Aetna of AZ Commercial |
$2,736.00
|
| Rate for Payer: Aetna of AZ Medicare |
$851.20
|
| Rate for Payer: AHCCCS Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicare |
$456.00
|
| Rate for Payer: Amerigroup Medicare |
$456.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,135.44
|
| Rate for Payer: AZCH Complete Medicaid |
$258.90
|
| Rate for Payer: AZCH Complete Medicare |
$456.00
|
| Rate for Payer: Banner UC Health Medicaid |
$258.90
|
| Rate for Payer: Banner UC Health Medicare |
$456.00
|
| Rate for Payer: Bisbee Police All Plans |
$790.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2,067.20
|
| Rate for Payer: Cash Price |
$2,432.00
|
| Rate for Payer: Cash Price |
$2,432.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,976.00
|
| Rate for Payer: Copperpoint Commercial |
$752.40
|
| Rate for Payer: Health Net of AZ Commercial |
$1,824.00
|
| Rate for Payer: Health Net of AZ Medicare |
$851.20
|
| Rate for Payer: Humana of AZ Medicare |
$456.00
|
| Rate for Payer: Mercy Care Medicaid |
$258.90
|
| Rate for Payer: Self Pay Self Pay |
$2,432.00
|
| Rate for Payer: TriWest Medicare |
$456.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,772.32
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$547.20
|
|
|
CT Pelvis w/o Contrast
|
Facility
|
OP
|
$2,056.00
|
|
|
Service Code
|
CPT 72192
|
| Hospital Charge Code |
821361
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$158.00 |
| Max. Negotiated Rate |
$1,850.40 |
| Rate for Payer: Aetna of AZ Commercial |
$1,850.40
|
| Rate for Payer: Aetna of AZ Medicare |
$575.68
|
| Rate for Payer: AHCCCS Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicare |
$308.40
|
| Rate for Payer: Amerigroup Medicare |
$308.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$767.92
|
| Rate for Payer: AZCH Complete Medicaid |
$158.00
|
| Rate for Payer: AZCH Complete Medicare |
$308.40
|
| Rate for Payer: Banner UC Health Medicaid |
$158.00
|
| Rate for Payer: Banner UC Health Medicare |
$308.40
|
| Rate for Payer: Bisbee Police All Plans |
$534.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,398.08
|
| Rate for Payer: Cash Price |
$1,644.80
|
| Rate for Payer: Cash Price |
$1,644.80
|
| Rate for Payer: Cigna of AZ Commercial |
$1,336.40
|
| Rate for Payer: Copperpoint Commercial |
$508.86
|
| Rate for Payer: Health Net of AZ Commercial |
$1,233.60
|
| Rate for Payer: Health Net of AZ Medicare |
$575.68
|
| Rate for Payer: Humana of AZ Medicare |
$308.40
|
| Rate for Payer: Mercy Care Medicaid |
$158.00
|
| Rate for Payer: Self Pay Self Pay |
$1,644.80
|
| Rate for Payer: TriWest Medicare |
$308.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,198.65
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$370.08
|
|
|
CT Pelvis w/o Contrast
|
Facility
|
IP
|
$2,056.00
|
|
|
Service Code
|
CPT 72192
|
| Hospital Charge Code |
821361
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$534.56 |
| Max. Negotiated Rate |
$1,850.40 |
| Rate for Payer: Aetna of AZ Commercial |
$1,850.40
|
| Rate for Payer: Bisbee Police All Plans |
$534.56
|
| Rate for Payer: Cash Price |
$1,644.80
|
| Rate for Payer: Self Pay Self Pay |
$1,644.80
|
|
|
CT Pelvis w/ + w/o Contrast
|
Facility
|
OP
|
$1,940.00
|
|
|
Service Code
|
CPT 72194
|
| Hospital Charge Code |
821357
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$258.90 |
| Max. Negotiated Rate |
$1,746.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,746.00
|
| Rate for Payer: Aetna of AZ Medicare |
$543.20
|
| Rate for Payer: AHCCCS Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicare |
$291.00
|
| Rate for Payer: Amerigroup Medicare |
$291.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$724.59
|
| Rate for Payer: AZCH Complete Medicaid |
$258.90
|
| Rate for Payer: AZCH Complete Medicare |
$291.00
|
| Rate for Payer: Banner UC Health Medicaid |
$258.90
|
| Rate for Payer: Banner UC Health Medicare |
$291.00
|
| Rate for Payer: Bisbee Police All Plans |
$504.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,319.20
|
| Rate for Payer: Cash Price |
$1,552.00
|
| Rate for Payer: Cash Price |
$1,552.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,261.00
|
| Rate for Payer: Copperpoint Commercial |
$480.15
|
| Rate for Payer: Health Net of AZ Commercial |
$1,164.00
|
| Rate for Payer: Health Net of AZ Medicare |
$543.20
|
| Rate for Payer: Humana of AZ Medicare |
$291.00
|
| Rate for Payer: Mercy Care Medicaid |
$258.90
|
| Rate for Payer: Self Pay Self Pay |
$1,552.00
|
| Rate for Payer: TriWest Medicare |
$291.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,131.02
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$349.20
|
|
|
CT Pelvis w/ + w/o Contrast
|
Facility
|
IP
|
$1,940.00
|
|
|
Service Code
|
CPT 72194
|
| Hospital Charge Code |
821357
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$504.40 |
| Max. Negotiated Rate |
$1,746.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,746.00
|
| Rate for Payer: Bisbee Police All Plans |
$504.40
|
| Rate for Payer: Cash Price |
$1,552.00
|
| Rate for Payer: Self Pay Self Pay |
$1,552.00
|
|
|
CT Soft Tissue Neck w/ Contrast
|
Facility
|
IP
|
$2,819.00
|
|
|
Service Code
|
CPT 70491
|
| Hospital Charge Code |
821368
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$732.94 |
| Max. Negotiated Rate |
$2,537.10 |
| Rate for Payer: Aetna of AZ Commercial |
$2,537.10
|
| Rate for Payer: Bisbee Police All Plans |
$732.94
|
| Rate for Payer: Cash Price |
$2,255.20
|
| Rate for Payer: Self Pay Self Pay |
$2,255.20
|
|
|
CT Soft Tissue Neck w/ Contrast
|
Facility
|
OP
|
$2,819.00
|
|
|
Service Code
|
CPT 70491
|
| Hospital Charge Code |
821368
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$258.90 |
| Max. Negotiated Rate |
$2,537.10 |
| Rate for Payer: Aetna of AZ Commercial |
$2,537.10
|
| Rate for Payer: Aetna of AZ Medicare |
$789.32
|
| Rate for Payer: AHCCCS Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicare |
$422.85
|
| Rate for Payer: Amerigroup Medicare |
$422.85
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,052.90
|
| Rate for Payer: AZCH Complete Medicaid |
$258.90
|
| Rate for Payer: AZCH Complete Medicare |
$422.85
|
| Rate for Payer: Banner UC Health Medicaid |
$258.90
|
| Rate for Payer: Banner UC Health Medicare |
$422.85
|
| Rate for Payer: Bisbee Police All Plans |
$732.94
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,916.92
|
| Rate for Payer: Cash Price |
$2,255.20
|
| Rate for Payer: Cash Price |
$2,255.20
|
| Rate for Payer: Cigna of AZ Commercial |
$1,832.35
|
| Rate for Payer: Copperpoint Commercial |
$697.70
|
| Rate for Payer: Health Net of AZ Commercial |
$1,691.40
|
| Rate for Payer: Health Net of AZ Medicare |
$789.32
|
| Rate for Payer: Humana of AZ Medicare |
$422.85
|
| Rate for Payer: Mercy Care Medicaid |
$258.90
|
| Rate for Payer: Self Pay Self Pay |
$2,255.20
|
| Rate for Payer: TriWest Medicare |
$422.85
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,643.48
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$507.42
|
|
