|
CT Soft Tissue Neck w/o Contrast
|
Facility
|
OP
|
$2,476.00
|
|
|
Service Code
|
CPT 70490
|
| Hospital Charge Code |
821370
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$158.00 |
| Max. Negotiated Rate |
$2,228.40 |
| Rate for Payer: Aetna of AZ Commercial |
$2,228.40
|
| Rate for Payer: Aetna of AZ Medicare |
$693.28
|
| Rate for Payer: AHCCCS Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicare |
$371.40
|
| Rate for Payer: Amerigroup Medicare |
$371.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$924.79
|
| Rate for Payer: AZCH Complete Medicaid |
$158.00
|
| Rate for Payer: AZCH Complete Medicare |
$371.40
|
| Rate for Payer: Banner UC Health Medicaid |
$158.00
|
| Rate for Payer: Banner UC Health Medicare |
$371.40
|
| Rate for Payer: Bisbee Police All Plans |
$643.76
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,683.68
|
| Rate for Payer: Cash Price |
$1,980.80
|
| Rate for Payer: Cash Price |
$1,980.80
|
| Rate for Payer: Cigna of AZ Commercial |
$1,609.40
|
| Rate for Payer: Copperpoint Commercial |
$612.81
|
| Rate for Payer: Health Net of AZ Commercial |
$1,485.60
|
| Rate for Payer: Health Net of AZ Medicare |
$693.28
|
| Rate for Payer: Humana of AZ Medicare |
$371.40
|
| Rate for Payer: Mercy Care Medicaid |
$158.00
|
| Rate for Payer: Self Pay Self Pay |
$1,980.80
|
| Rate for Payer: TriWest Medicare |
$371.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,443.51
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$445.68
|
|
|
CT Soft Tissue Neck w/o Contrast
|
Facility
|
IP
|
$2,476.00
|
|
|
Service Code
|
CPT 70490
|
| Hospital Charge Code |
821370
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$643.76 |
| Max. Negotiated Rate |
$2,228.40 |
| Rate for Payer: Aetna of AZ Commercial |
$2,228.40
|
| Rate for Payer: Bisbee Police All Plans |
$643.76
|
| Rate for Payer: Cash Price |
$1,980.80
|
| Rate for Payer: Self Pay Self Pay |
$1,980.80
|
|
|
CT Soft Tissue Neck w/ + w/o Contrast
|
Facility
|
IP
|
$3,560.00
|
|
|
Service Code
|
CPT 70492
|
| Hospital Charge Code |
821366
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$925.60 |
| Max. Negotiated Rate |
$3,204.00 |
| Rate for Payer: Aetna of AZ Commercial |
$3,204.00
|
| Rate for Payer: Bisbee Police All Plans |
$925.60
|
| Rate for Payer: Cash Price |
$2,848.00
|
| Rate for Payer: Self Pay Self Pay |
$2,848.00
|
|
|
CT Soft Tissue Neck w/ + w/o Contrast
|
Facility
|
OP
|
$3,560.00
|
|
|
Service Code
|
CPT 70492
|
| Hospital Charge Code |
821366
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$258.90 |
| Max. Negotiated Rate |
$3,204.00 |
| Rate for Payer: Aetna of AZ Commercial |
$3,204.00
|
| Rate for Payer: Aetna of AZ Medicare |
$996.80
|
| Rate for Payer: AHCCCS Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicare |
$534.00
|
| Rate for Payer: Amerigroup Medicare |
$534.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,329.66
|
| Rate for Payer: AZCH Complete Medicaid |
$258.90
|
| Rate for Payer: AZCH Complete Medicare |
$534.00
|
| Rate for Payer: Banner UC Health Medicaid |
$258.90
|
| Rate for Payer: Banner UC Health Medicare |
$534.00
|
| Rate for Payer: Bisbee Police All Plans |
$925.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2,420.80
|
| Rate for Payer: Cash Price |
$2,848.00
|
| Rate for Payer: Cash Price |
$2,848.00
|
| Rate for Payer: Cigna of AZ Commercial |
$2,314.00
|
| Rate for Payer: Copperpoint Commercial |
$881.10
|
| Rate for Payer: Health Net of AZ Commercial |
$2,136.00
|
| Rate for Payer: Health Net of AZ Medicare |
$996.80
|
| Rate for Payer: Humana of AZ Medicare |
$534.00
|
| Rate for Payer: Mercy Care Medicaid |
$258.90
|
| Rate for Payer: Self Pay Self Pay |
$2,848.00
|
| Rate for Payer: TriWest Medicare |
$534.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,075.48
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$640.80
|
|
|
CT Spine Cervical w/ Contrast
|
Facility
|
OP
|
$2,715.00
|
|
|
Service Code
|
CPT 72126
|
| Hospital Charge Code |
1005215
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$407.25 |
| Max. Negotiated Rate |
$2,443.50 |
| Rate for Payer: Aetna of AZ Commercial |
$2,443.50
|
| Rate for Payer: Aetna of AZ Medicare |
$760.20
|
| Rate for Payer: AHCCCS Medicaid |
$533.78
|
| Rate for Payer: Allwell Medicaid |
$533.78
|
| Rate for Payer: Allwell Medicare |
$407.25
|
| Rate for Payer: Amerigroup Medicare |
$407.25
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,014.05
|
| Rate for Payer: AZCH Complete Medicaid |
$533.78
|
| Rate for Payer: AZCH Complete Medicare |
$407.25
|
| Rate for Payer: Banner UC Health Medicaid |
$533.78
|
| Rate for Payer: Banner UC Health Medicare |
$407.25
|
| Rate for Payer: Bisbee Police All Plans |
$705.90
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,846.20
|
| Rate for Payer: Cash Price |
$2,172.00
|
| Rate for Payer: Cash Price |
$2,172.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,764.75
|
| Rate for Payer: Copperpoint Commercial |
$671.96
|
| Rate for Payer: Health Net of AZ Commercial |
$1,629.00
|
| Rate for Payer: Health Net of AZ Medicare |
$760.20
|
| Rate for Payer: Humana of AZ Medicare |
$407.25
|
| Rate for Payer: Mercy Care Medicaid |
$533.78
|
| Rate for Payer: Self Pay Self Pay |
$2,172.00
|
| Rate for Payer: TriWest Medicare |
$407.25
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,582.84
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$488.70
|
|
|
CT Spine Cervical w/ Contrast
|
Facility
|
IP
|
$2,715.00
|
|
|
Service Code
|
CPT 72126
|
| Hospital Charge Code |
1005215
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$705.90 |
| Max. Negotiated Rate |
$2,443.50 |
| Rate for Payer: Aetna of AZ Commercial |
$2,443.50
|
| Rate for Payer: Bisbee Police All Plans |
$705.90
|
| Rate for Payer: Cash Price |
$2,172.00
|
| Rate for Payer: Self Pay Self Pay |
$2,172.00
|
|
|
CT Spine Cervical w/o Contrast
|
Facility
|
OP
|
$3,104.00
|
|
|
Service Code
|
CPT 72125
|
| Hospital Charge Code |
821372
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$158.00 |
| Max. Negotiated Rate |
$2,793.60 |
| Rate for Payer: Aetna of AZ Commercial |
$2,793.60
|
| Rate for Payer: Aetna of AZ Medicare |
$869.12
|
| Rate for Payer: AHCCCS Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicare |
$465.60
|
| Rate for Payer: Amerigroup Medicare |
$465.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,159.34
|
| Rate for Payer: AZCH Complete Medicaid |
$158.00
|
| Rate for Payer: AZCH Complete Medicare |
$465.60
|
| Rate for Payer: Banner UC Health Medicaid |
$158.00
|
| Rate for Payer: Banner UC Health Medicare |
$465.60
|
| Rate for Payer: Bisbee Police All Plans |
$807.04
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2,110.72
|
| Rate for Payer: Cash Price |
$2,483.20
|
| Rate for Payer: Cash Price |
$2,483.20
|
| Rate for Payer: Cigna of AZ Commercial |
$2,017.60
|
| Rate for Payer: Copperpoint Commercial |
$768.24
|
| Rate for Payer: Health Net of AZ Commercial |
$1,862.40
|
| Rate for Payer: Health Net of AZ Medicare |
$869.12
|
| Rate for Payer: Humana of AZ Medicare |
$465.60
|
| Rate for Payer: Mercy Care Medicaid |
$158.00
|
| Rate for Payer: Self Pay Self Pay |
$2,483.20
|
| Rate for Payer: TriWest Medicare |
$465.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,809.63
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$558.72
|
|
|
CT Spine Cervical w/o Contrast
|
Facility
|
IP
|
$3,104.00
|
|
|
Service Code
|
CPT 72125
|
| Hospital Charge Code |
821372
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$807.04 |
| Max. Negotiated Rate |
$2,793.60 |
| Rate for Payer: Aetna of AZ Commercial |
$2,793.60
|
| Rate for Payer: Bisbee Police All Plans |
$807.04
|
| Rate for Payer: Cash Price |
$2,483.20
|
| Rate for Payer: Self Pay Self Pay |
$2,483.20
|
|
|
CT Spine Cervical w/ + w/o Contrast
|
Facility
|
OP
|
$1,643.00
|
|
|
Service Code
|
CPT 72127
|
| Hospital Charge Code |
1005213
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$246.45 |
| Max. Negotiated Rate |
$1,478.70 |
| Rate for Payer: Aetna of AZ Commercial |
$1,478.70
|
| Rate for Payer: Aetna of AZ Medicare |
$460.04
|
| Rate for Payer: AHCCCS Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicare |
$246.45
|
| Rate for Payer: Amerigroup Medicare |
$246.45
|
| Rate for Payer: APIPA Medicare/Medicaid |
$613.66
|
| Rate for Payer: AZCH Complete Medicaid |
$258.90
|
| Rate for Payer: AZCH Complete Medicare |
$246.45
|
| Rate for Payer: Banner UC Health Medicaid |
$258.90
|
| Rate for Payer: Banner UC Health Medicare |
$246.45
|
| Rate for Payer: Bisbee Police All Plans |
$427.18
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,117.24
|
| Rate for Payer: Cash Price |
$1,314.40
|
| Rate for Payer: Cash Price |
$1,314.40
|
| Rate for Payer: Cigna of AZ Commercial |
$1,067.95
|
| Rate for Payer: Copperpoint Commercial |
$406.64
|
| Rate for Payer: Health Net of AZ Commercial |
$985.80
|
| Rate for Payer: Health Net of AZ Medicare |
$460.04
|
| Rate for Payer: Humana of AZ Medicare |
$246.45
|
| Rate for Payer: Mercy Care Medicaid |
$258.90
|
| Rate for Payer: Self Pay Self Pay |
$1,314.40
|
| Rate for Payer: TriWest Medicare |
$246.45
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$957.87
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$295.74
|
|
|
CT Spine Cervical w/ + w/o Contrast
|
Facility
|
IP
|
$1,643.00
|
|
|
Service Code
|
CPT 72127
|
| Hospital Charge Code |
1005213
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$427.18 |
| Max. Negotiated Rate |
$1,478.70 |
| Rate for Payer: Aetna of AZ Commercial |
$1,478.70
|
| Rate for Payer: Bisbee Police All Plans |
$427.18
|
| Rate for Payer: Cash Price |
$1,314.40
|
| Rate for Payer: Self Pay Self Pay |
$1,314.40
|
|
|
CT Spine Lumbar w/ Contrast
|
Facility
|
IP
|
$3,296.00
|
|
|
Service Code
|
CPT 72132
|
| Hospital Charge Code |
1005219
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$856.96 |
| Max. Negotiated Rate |
$2,966.40 |
| Rate for Payer: Aetna of AZ Commercial |
$2,966.40
|
| Rate for Payer: Bisbee Police All Plans |
$856.96
|
| Rate for Payer: Cash Price |
$2,636.80
|
| Rate for Payer: Self Pay Self Pay |
$2,636.80
|
|
|
CT Spine Lumbar w/ Contrast
|
Facility
|
OP
|
$3,296.00
|
|
|
Service Code
|
CPT 72132
|
| Hospital Charge Code |
1005219
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$494.40 |
| Max. Negotiated Rate |
$2,966.40 |
| Rate for Payer: Aetna of AZ Commercial |
$2,966.40
|
| Rate for Payer: Aetna of AZ Medicare |
$922.88
|
| Rate for Payer: AHCCCS Medicaid |
$533.78
|
| Rate for Payer: Allwell Medicaid |
$533.78
|
| Rate for Payer: Allwell Medicare |
$494.40
|
| Rate for Payer: Amerigroup Medicare |
$494.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,231.06
|
| Rate for Payer: AZCH Complete Medicaid |
$533.78
|
| Rate for Payer: AZCH Complete Medicare |
$494.40
|
| Rate for Payer: Banner UC Health Medicaid |
$533.78
|
| Rate for Payer: Banner UC Health Medicare |
$494.40
|
| Rate for Payer: Bisbee Police All Plans |
$856.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2,241.28
|
| Rate for Payer: Cash Price |
$2,636.80
|
| Rate for Payer: Cash Price |
$2,636.80
|
| Rate for Payer: Cigna of AZ Commercial |
$2,142.40
|
| Rate for Payer: Copperpoint Commercial |
$815.76
|
| Rate for Payer: Health Net of AZ Commercial |
$1,977.60
|
| Rate for Payer: Health Net of AZ Medicare |
$922.88
|
| Rate for Payer: Humana of AZ Medicare |
$494.40
|
| Rate for Payer: Mercy Care Medicaid |
$533.78
|
| Rate for Payer: Self Pay Self Pay |
$2,636.80
|
| Rate for Payer: TriWest Medicare |
$494.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,921.57
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$593.28
|
|
|
CT Spine Lumbar w/o Contrast
|
Facility
|
IP
|
$2,085.00
|
|
|
Service Code
|
CPT 72131
|
| Hospital Charge Code |
821374
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$542.10 |
| Max. Negotiated Rate |
$1,876.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,876.50
|
| Rate for Payer: Bisbee Police All Plans |
$542.10
|
| Rate for Payer: Cash Price |
$1,668.00
|
| Rate for Payer: Self Pay Self Pay |
$1,668.00
|
|
|
CT Spine Lumbar w/o Contrast
|
Facility
|
OP
|
$2,085.00
|
|
|
Service Code
|
CPT 72131
|
| Hospital Charge Code |
821374
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$158.00 |
| Max. Negotiated Rate |
$1,876.50 |
| Rate for Payer: Aetna of AZ Commercial |
$1,876.50
|
| Rate for Payer: Aetna of AZ Medicare |
$583.80
|
| Rate for Payer: AHCCCS Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicare |
$312.75
|
| Rate for Payer: Amerigroup Medicare |
$312.75
|
| Rate for Payer: APIPA Medicare/Medicaid |
$778.75
|
| Rate for Payer: AZCH Complete Medicaid |
$158.00
|
| Rate for Payer: AZCH Complete Medicare |
$312.75
|
| Rate for Payer: Banner UC Health Medicaid |
$158.00
|
| Rate for Payer: Banner UC Health Medicare |
$312.75
|
| Rate for Payer: Bisbee Police All Plans |
$542.10
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,417.80
|
| Rate for Payer: Cash Price |
$1,668.00
|
| Rate for Payer: Cash Price |
$1,668.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,355.25
|
| Rate for Payer: Copperpoint Commercial |
$516.04
|
| Rate for Payer: Health Net of AZ Commercial |
$1,251.00
|
| Rate for Payer: Health Net of AZ Medicare |
$583.80
|
| Rate for Payer: Humana of AZ Medicare |
$312.75
|
| Rate for Payer: Mercy Care Medicaid |
$158.00
|
| Rate for Payer: Self Pay Self Pay |
$1,668.00
|
| Rate for Payer: TriWest Medicare |
$312.75
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,215.56
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$375.30
|
|
|
CT Spine Lumbar w/ + w/o Contrast
|
Facility
|
OP
|
$3,490.00
|
|
|
Service Code
|
CPT 72133
|
| Hospital Charge Code |
1005217
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$258.90 |
| Max. Negotiated Rate |
$3,141.00 |
| Rate for Payer: Aetna of AZ Commercial |
$3,141.00
|
| Rate for Payer: Aetna of AZ Medicare |
$977.20
|
| Rate for Payer: AHCCCS Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicare |
$523.50
|
| Rate for Payer: Amerigroup Medicare |
$523.50
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,303.52
|
| Rate for Payer: AZCH Complete Medicaid |
$258.90
|
| Rate for Payer: AZCH Complete Medicare |
$523.50
|
| Rate for Payer: Banner UC Health Medicaid |
$258.90
|
| Rate for Payer: Banner UC Health Medicare |
$523.50
|
| Rate for Payer: Bisbee Police All Plans |
$907.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2,373.20
|
| Rate for Payer: Cash Price |
$2,792.00
|
| Rate for Payer: Cash Price |
$2,792.00
|
| Rate for Payer: Cigna of AZ Commercial |
$2,268.50
|
| Rate for Payer: Copperpoint Commercial |
$863.78
|
| Rate for Payer: Health Net of AZ Commercial |
$2,094.00
|
| Rate for Payer: Health Net of AZ Medicare |
$977.20
|
| Rate for Payer: Humana of AZ Medicare |
$523.50
|
| Rate for Payer: Mercy Care Medicaid |
$258.90
|
| Rate for Payer: Self Pay Self Pay |
$2,792.00
|
| Rate for Payer: TriWest Medicare |
$523.50
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,034.67
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$628.20
|
|
|
CT Spine Lumbar w/ + w/o Contrast
|
Facility
|
IP
|
$3,490.00
|
|
|
Service Code
|
CPT 72133
|
| Hospital Charge Code |
1005217
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$907.40 |
| Max. Negotiated Rate |
$3,141.00 |
| Rate for Payer: Aetna of AZ Commercial |
$3,141.00
|
| Rate for Payer: Bisbee Police All Plans |
$907.40
|
| Rate for Payer: Cash Price |
$2,792.00
|
| Rate for Payer: Self Pay Self Pay |
$2,792.00
|
|
|
CT Spine Thoracic w/ Contrast
|
Facility
|
OP
|
$1,998.00
|
|
|
Service Code
|
CPT 72129
|
| Hospital Charge Code |
1005223
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$258.90 |
| Max. Negotiated Rate |
$1,798.20 |
| Rate for Payer: Aetna of AZ Commercial |
$1,798.20
|
| Rate for Payer: Aetna of AZ Medicare |
$559.44
|
| Rate for Payer: AHCCCS Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicare |
$299.70
|
| Rate for Payer: Amerigroup Medicare |
$299.70
|
| Rate for Payer: APIPA Medicare/Medicaid |
$746.25
|
| Rate for Payer: AZCH Complete Medicaid |
$258.90
|
| Rate for Payer: AZCH Complete Medicare |
$299.70
|
| Rate for Payer: Banner UC Health Medicaid |
$258.90
|
| Rate for Payer: Banner UC Health Medicare |
$299.70
|
| Rate for Payer: Bisbee Police All Plans |
$519.48
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,358.64
|
| Rate for Payer: Cash Price |
$1,598.40
|
| Rate for Payer: Cash Price |
$1,598.40
|
| Rate for Payer: Cigna of AZ Commercial |
$1,298.70
|
| Rate for Payer: Copperpoint Commercial |
$494.50
|
| Rate for Payer: Health Net of AZ Commercial |
$1,198.80
|
| Rate for Payer: Health Net of AZ Medicare |
$559.44
|
| Rate for Payer: Humana of AZ Medicare |
$299.70
|
| Rate for Payer: Mercy Care Medicaid |
$258.90
|
| Rate for Payer: Self Pay Self Pay |
$1,598.40
|
| Rate for Payer: TriWest Medicare |
$299.70
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,164.83
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$359.64
|
|
|
CT Spine Thoracic w/ Contrast
|
Facility
|
IP
|
$1,998.00
|
|
|
Service Code
|
CPT 72129
|
| Hospital Charge Code |
1005223
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$519.48 |
| Max. Negotiated Rate |
$1,798.20 |
| Rate for Payer: Aetna of AZ Commercial |
$1,798.20
|
| Rate for Payer: Bisbee Police All Plans |
$519.48
|
| Rate for Payer: Cash Price |
$1,598.40
|
| Rate for Payer: Self Pay Self Pay |
$1,598.40
|
|
|
CT Spine Thoracic w/o Contrast
|
Facility
|
OP
|
$2,022.00
|
|
|
Service Code
|
CPT 72128
|
| Hospital Charge Code |
821376
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$158.00 |
| Max. Negotiated Rate |
$1,819.80 |
| Rate for Payer: Aetna of AZ Commercial |
$1,819.80
|
| Rate for Payer: Aetna of AZ Medicare |
$566.16
|
| Rate for Payer: AHCCCS Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicaid |
$158.00
|
| Rate for Payer: Allwell Medicare |
$303.30
|
| Rate for Payer: Amerigroup Medicare |
$303.30
|
| Rate for Payer: APIPA Medicare/Medicaid |
$755.22
|
| Rate for Payer: AZCH Complete Medicaid |
$158.00
|
| Rate for Payer: AZCH Complete Medicare |
$303.30
|
| Rate for Payer: Banner UC Health Medicaid |
$158.00
|
| Rate for Payer: Banner UC Health Medicare |
$303.30
|
| Rate for Payer: Bisbee Police All Plans |
$525.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,374.96
|
| Rate for Payer: Cash Price |
$1,617.60
|
| Rate for Payer: Cash Price |
$1,617.60
|
| Rate for Payer: Cigna of AZ Commercial |
$1,314.30
|
| Rate for Payer: Copperpoint Commercial |
$500.44
|
| Rate for Payer: Health Net of AZ Commercial |
$1,213.20
|
| Rate for Payer: Health Net of AZ Medicare |
$566.16
|
| Rate for Payer: Humana of AZ Medicare |
$303.30
|
| Rate for Payer: Mercy Care Medicaid |
$158.00
|
| Rate for Payer: Self Pay Self Pay |
$1,617.60
|
| Rate for Payer: TriWest Medicare |
$303.30
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,178.83
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$363.96
|
|
|
CT Spine Thoracic w/o Contrast
|
Facility
|
IP
|
$2,022.00
|
|
|
Service Code
|
CPT 72128
|
| Hospital Charge Code |
821376
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$525.72 |
| Max. Negotiated Rate |
$1,819.80 |
| Rate for Payer: Aetna of AZ Commercial |
$1,819.80
|
| Rate for Payer: Bisbee Police All Plans |
$525.72
|
| Rate for Payer: Cash Price |
$1,617.60
|
| Rate for Payer: Self Pay Self Pay |
$1,617.60
|
|
|
CT Spine Thoracic w/ + w/o Contrast
|
Facility
|
OP
|
$3,078.00
|
|
|
Service Code
|
CPT 72130
|
| Hospital Charge Code |
1005221
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$258.90 |
| Max. Negotiated Rate |
$2,770.20 |
| Rate for Payer: Aetna of AZ Commercial |
$2,770.20
|
| Rate for Payer: Aetna of AZ Medicare |
$861.84
|
| Rate for Payer: AHCCCS Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicaid |
$258.90
|
| Rate for Payer: Allwell Medicare |
$461.70
|
| Rate for Payer: Amerigroup Medicare |
$461.70
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,149.63
|
| Rate for Payer: AZCH Complete Medicaid |
$258.90
|
| Rate for Payer: AZCH Complete Medicare |
$461.70
|
| Rate for Payer: Banner UC Health Medicaid |
$258.90
|
| Rate for Payer: Banner UC Health Medicare |
$461.70
|
| Rate for Payer: Bisbee Police All Plans |
$800.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2,093.04
|
| Rate for Payer: Cash Price |
$2,462.40
|
| Rate for Payer: Cash Price |
$2,462.40
|
| Rate for Payer: Cigna of AZ Commercial |
$2,000.70
|
| Rate for Payer: Copperpoint Commercial |
$761.80
|
| Rate for Payer: Health Net of AZ Commercial |
$1,846.80
|
| Rate for Payer: Health Net of AZ Medicare |
$861.84
|
| Rate for Payer: Humana of AZ Medicare |
$461.70
|
| Rate for Payer: Mercy Care Medicaid |
$258.90
|
| Rate for Payer: Self Pay Self Pay |
$2,462.40
|
| Rate for Payer: TriWest Medicare |
$461.70
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,794.47
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$554.04
|
|
|
CT Spine Thoracic w/ + w/o Contrast
|
Facility
|
IP
|
$3,078.00
|
|
|
Service Code
|
CPT 72130
|
| Hospital Charge Code |
1005221
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$800.28 |
| Max. Negotiated Rate |
$2,770.20 |
| Rate for Payer: Aetna of AZ Commercial |
$2,770.20
|
| Rate for Payer: Bisbee Police All Plans |
$800.28
|
| Rate for Payer: Cash Price |
$2,462.40
|
| Rate for Payer: Self Pay Self Pay |
$2,462.40
|
|
|
CT Upper Extremity w/ Contrast Left
|
Facility
|
OP
|
$2,734.00
|
|
|
Service Code
|
CPT 73201 LT
|
| Hospital Charge Code |
821384
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$410.10 |
| Max. Negotiated Rate |
$2,460.60 |
| Rate for Payer: Aetna of AZ Commercial |
$2,460.60
|
| Rate for Payer: Aetna of AZ Medicare |
$765.52
|
| Rate for Payer: Allwell Medicare |
$410.10
|
| Rate for Payer: Amerigroup Medicare |
$410.10
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,021.15
|
| Rate for Payer: AZCH Complete Medicare |
$410.10
|
| Rate for Payer: Banner UC Health Medicare |
$410.10
|
| Rate for Payer: Bisbee Police All Plans |
$710.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,859.12
|
| Rate for Payer: Cash Price |
$2,187.20
|
| Rate for Payer: Cigna of AZ Commercial |
$1,777.10
|
| Rate for Payer: Copperpoint Commercial |
$676.66
|
| Rate for Payer: Health Net of AZ Commercial |
$1,640.40
|
| Rate for Payer: Health Net of AZ Medicare |
$765.52
|
| Rate for Payer: Humana of AZ Medicare |
$410.10
|
| Rate for Payer: Self Pay Self Pay |
$2,187.20
|
| Rate for Payer: TriWest Medicare |
$410.10
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,593.92
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$492.12
|
|
|
CT Upper Extremity w/ Contrast Left
|
Facility
|
IP
|
$2,734.00
|
|
|
Service Code
|
CPT 73201 LT
|
| Hospital Charge Code |
821384
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$710.84 |
| Max. Negotiated Rate |
$2,460.60 |
| Rate for Payer: Aetna of AZ Commercial |
$2,460.60
|
| Rate for Payer: Bisbee Police All Plans |
$710.84
|
| Rate for Payer: Cash Price |
$2,187.20
|
| Rate for Payer: Self Pay Self Pay |
$2,187.20
|
|
|
CT Upper Extremity w/ Contrast Right
|
Facility
|
OP
|
$2,734.00
|
|
|
Service Code
|
CPT 73201 RT
|
| Hospital Charge Code |
821386
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$410.10 |
| Max. Negotiated Rate |
$2,460.60 |
| Rate for Payer: Aetna of AZ Commercial |
$2,460.60
|
| Rate for Payer: Aetna of AZ Medicare |
$765.52
|
| Rate for Payer: Allwell Medicare |
$410.10
|
| Rate for Payer: Amerigroup Medicare |
$410.10
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,021.15
|
| Rate for Payer: AZCH Complete Medicare |
$410.10
|
| Rate for Payer: Banner UC Health Medicare |
$410.10
|
| Rate for Payer: Bisbee Police All Plans |
$710.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,859.12
|
| Rate for Payer: Cash Price |
$2,187.20
|
| Rate for Payer: Cigna of AZ Commercial |
$1,777.10
|
| Rate for Payer: Copperpoint Commercial |
$676.66
|
| Rate for Payer: Health Net of AZ Commercial |
$1,640.40
|
| Rate for Payer: Health Net of AZ Medicare |
$765.52
|
| Rate for Payer: Humana of AZ Medicare |
$410.10
|
| Rate for Payer: Self Pay Self Pay |
$2,187.20
|
| Rate for Payer: TriWest Medicare |
$410.10
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$1,593.92
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$492.12
|
|
