|
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 |
$154.84 |
| Max. Negotiated Rate |
$998.10 |
| Rate for Payer: Aetna of AZ Commercial |
$998.10
|
| Rate for Payer: Arizona Complete Health Allwell |
$177.44
|
| Rate for Payer: Banner UC Health Medicare |
$177.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$754.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$154.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$177.44
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$177.44
|
| 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: Devoted Health Medicare |
$199.62
|
| Rate for Payer: Humana of AZ Medicare |
$177.44
|
| Rate for Payer: Mercy Care Medicaid |
$154.84
|
| Rate for Payer: NaphCare Correctional Healthcare |
$154.84
|
| Rate for Payer: Seven Corners Travel Insurance |
$629.00
|
| Rate for Payer: Southwest Service Administrators UFCW |
$754.12
|
| Rate for Payer: TriWest Medicare |
$177.44
|
| Rate for Payer: United Healthcare Commercial |
$634.35
|
| Rate for Payer: United Healthcare Medicare |
$177.44
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$210.71
|
| Rate for Payer: Veterans Affairs TRICARE |
$175.67
|
|
|
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 |
$1,197.00 |
| Max. Negotiated Rate |
$1,197.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,197.00
|
| Rate for Payer: Cash Price |
$1,064.00
|
|
|
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 |
$178.45 |
| Max. Negotiated Rate |
$1,197.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,197.00
|
| Rate for Payer: Arizona Complete Health Allwell |
$212.80
|
| Rate for Payer: Banner UC Health Medicare |
$212.80
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$904.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$178.45
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$212.80
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$212.80
|
| 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: Devoted Health Medicare |
$239.40
|
| Rate for Payer: Humana of AZ Medicare |
$212.80
|
| Rate for Payer: Mercy Care Medicaid |
$178.45
|
| Rate for Payer: NaphCare Correctional Healthcare |
$178.45
|
| Rate for Payer: Seven Corners Travel Insurance |
$629.00
|
| Rate for Payer: Southwest Service Administrators UFCW |
$904.40
|
| Rate for Payer: TriWest Medicare |
$212.80
|
| Rate for Payer: United Healthcare Commercial |
$760.76
|
| Rate for Payer: United Healthcare Medicare |
$212.80
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$252.70
|
| Rate for Payer: Veterans Affairs TRICARE |
$210.67
|
|
|
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 |
$45.78 |
| Max. Negotiated Rate |
$585.00 |
| Rate for Payer: Aetna of AZ Commercial |
$585.00
|
| Rate for Payer: Arizona Complete Health Allwell |
$104.00
|
| Rate for Payer: Banner UC Health Medicare |
$104.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$442.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$45.78
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$104.00
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$104.00
|
| 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: Devoted Health Medicare |
$117.00
|
| Rate for Payer: Humana of AZ Medicare |
$104.00
|
| Rate for Payer: Mercy Care Medicaid |
$45.78
|
| Rate for Payer: NaphCare Correctional Healthcare |
$45.78
|
| Rate for Payer: Southwest Service Administrators UFCW |
$442.00
|
| Rate for Payer: TriWest Medicare |
$104.00
|
| Rate for Payer: United Healthcare Commercial |
$371.80
|
| Rate for Payer: United Healthcare Medicare |
$104.00
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$123.50
|
| Rate for Payer: Veterans Affairs TRICARE |
$102.96
|
|
|
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 |
$585.00 |
| Max. Negotiated Rate |
$585.00 |
| Rate for Payer: Aetna of AZ Commercial |
$585.00
|
| Rate for Payer: Cash Price |
$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 |
$195.31 |
| Max. Negotiated Rate |
$1,109.70 |
| Rate for Payer: Aetna of AZ Commercial |
$1,109.70
|
| Rate for Payer: Arizona Complete Health Allwell |
$197.28
|
| Rate for Payer: Banner UC Health Medicare |
$197.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$838.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$197.28
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$197.28
|
| Rate for Payer: Cash Price |
$986.40
|
| Rate for Payer: Cigna of AZ Commercial |
$863.10
|
| Rate for Payer: Devoted Health Medicare |
$221.94
|
| Rate for Payer: Humana of AZ Medicare |
$197.28
|
| Rate for Payer: Southwest Service Administrators UFCW |
$838.44
|
| Rate for Payer: TriWest Medicare |
$197.28
|
| Rate for Payer: United Healthcare Commercial |
$705.28
|
| Rate for Payer: United Healthcare Medicare |
$197.28
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$234.27
|
| Rate for Payer: Veterans Affairs TRICARE |
$195.31
|
|
|
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 |
$1,109.70 |
| Max. Negotiated Rate |
$1,109.70 |
| Rate for Payer: Aetna of AZ Commercial |
$1,109.70
|
| Rate for Payer: Cash Price |
$986.40
|
|
|
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 |
$153.77 |
| Max. Negotiated Rate |
$1,143.54 |
| Rate for Payer: Aetna of AZ Commercial |
$979.20
|
| Rate for Payer: Arizona Complete Health Allwell |
$174.08
|
| Rate for Payer: Banner UC Health Medicare |
$174.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$739.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$153.77
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$174.08
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$174.08
|
| 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: Devoted Health Medicare |
$195.84
|
| Rate for Payer: Humana of AZ Medicare |
$174.08
|
| Rate for Payer: Mercy Care Medicaid |
$153.77
|
| Rate for Payer: NaphCare Correctional Healthcare |
$153.77
|
| Rate for Payer: Seven Corners Travel Insurance |
$1,143.54
|
| Rate for Payer: Southwest Service Administrators UFCW |
$739.84
|
| Rate for Payer: TriWest Medicare |
$174.08
|
| Rate for Payer: United Healthcare Commercial |
$622.34
|
| Rate for Payer: United Healthcare Medicare |
$174.08
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$206.72
|
| Rate for Payer: Veterans Affairs TRICARE |
$172.34
|
|
|
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 |
$979.20 |
| Max. Negotiated Rate |
$979.20 |
| Rate for Payer: Aetna of AZ Commercial |
$979.20
|
| Rate for Payer: Cash Price |
$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 |
$1,762.20 |
| Max. Negotiated Rate |
$1,762.20 |
| Rate for Payer: Aetna of AZ Commercial |
$1,762.20
|
| Rate for Payer: Cash Price |
$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 |
$171.66 |
| Max. Negotiated Rate |
$1,762.20 |
| Rate for Payer: Aetna of AZ Commercial |
$1,762.20
|
| Rate for Payer: Arizona Complete Health Allwell |
$313.28
|
| Rate for Payer: Banner UC Health Medicare |
$313.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$1,331.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$171.66
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$313.28
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$313.28
|
| 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: Devoted Health Medicare |
$352.44
|
| Rate for Payer: Humana of AZ Medicare |
$313.28
|
| Rate for Payer: Mercy Care Medicaid |
$171.66
|
| Rate for Payer: NaphCare Correctional Healthcare |
$171.66
|
| Rate for Payer: Seven Corners Travel Insurance |
$1,143.54
|
| Rate for Payer: Southwest Service Administrators UFCW |
$1,331.44
|
| Rate for Payer: TriWest Medicare |
$313.28
|
| Rate for Payer: United Healthcare Commercial |
$1,119.98
|
| Rate for Payer: United Healthcare Medicare |
$313.28
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$372.02
|
| Rate for Payer: Veterans Affairs TRICARE |
$310.15
|
|
|
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 |
$640.80 |
| Max. Negotiated Rate |
$640.80 |
| Rate for Payer: Aetna of AZ Commercial |
$640.80
|
| Rate for Payer: Cash Price |
$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 |
$52.21 |
| Max. Negotiated Rate |
$640.80 |
| Rate for Payer: Aetna of AZ Commercial |
$640.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$113.92
|
| Rate for Payer: Banner UC Health Medicare |
$113.92
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$484.16
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$52.21
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$113.92
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$113.92
|
| 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: Devoted Health Medicare |
$128.16
|
| Rate for Payer: Humana of AZ Medicare |
$113.92
|
| Rate for Payer: Mercy Care Medicaid |
$52.21
|
| Rate for Payer: NaphCare Correctional Healthcare |
$52.21
|
| Rate for Payer: Southwest Service Administrators UFCW |
$484.16
|
| Rate for Payer: TriWest Medicare |
$113.92
|
| Rate for Payer: United Healthcare Commercial |
$407.26
|
| Rate for Payer: United Healthcare Medicare |
$113.92
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$135.28
|
| Rate for Payer: Veterans Affairs TRICARE |
$112.78
|
|
|
15 18 CRE WIREGUDIED
|
Facility
|
OP
|
$1,082.00
|
|
| Hospital Charge Code |
22586871
|
| Min. Negotiated Rate |
$171.39 |
| Max. Negotiated Rate |
$973.80 |
| Rate for Payer: Aetna of AZ Commercial |
$973.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$173.12
|
| Rate for Payer: Banner UC Health Medicare |
$173.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$735.76
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$173.12
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$173.12
|
| Rate for Payer: Cash Price |
$865.60
|
| Rate for Payer: Cigna of AZ Commercial |
$757.40
|
| Rate for Payer: Devoted Health Medicare |
$194.76
|
| Rate for Payer: Humana of AZ Medicare |
$173.12
|
| Rate for Payer: Southwest Service Administrators UFCW |
$735.76
|
| Rate for Payer: TriWest Medicare |
$173.12
|
| Rate for Payer: United Healthcare Commercial |
$618.90
|
| Rate for Payer: United Healthcare Medicare |
$173.12
|
| Rate for Payer: Veterans Affairs TRICARE |
$171.39
|
|
|
15 18 CRE WIREGUDIED
|
Facility
|
IP
|
$1,082.00
|
|
| Hospital Charge Code |
22586871
|
| Min. Negotiated Rate |
$973.80 |
| Max. Negotiated Rate |
$973.80 |
| Rate for Payer: Aetna of AZ Commercial |
$973.80
|
| Rate for Payer: Cash Price |
$865.60
|
|
|
15271 app of skin sub graph, wound area up to 100sq cm, firs
|
Facility
|
IP
|
$431.00
|
|
|
Service Code
|
CPT 15271
|
| Hospital Charge Code |
24087058
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$387.90 |
| Max. Negotiated Rate |
$387.90 |
| Rate for Payer: Aetna of AZ Commercial |
$387.90
|
| Rate for Payer: Cash Price |
$344.80
|
|
|
15271 app of skin sub graph, wound area up to 100sq cm, firs
|
Facility
|
OP
|
$431.00
|
|
|
Service Code
|
CPT 15271
|
| Hospital Charge Code |
24087058
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$68.27 |
| Max. Negotiated Rate |
$1,143.54 |
| Rate for Payer: Aetna of AZ Commercial |
$387.90
|
| Rate for Payer: Arizona Complete Health Allwell |
$68.96
|
| Rate for Payer: Banner UC Health Medicare |
$68.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$293.08
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$70.43
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$68.96
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$68.96
|
| Rate for Payer: Cash Price |
$344.80
|
| Rate for Payer: Cash Price |
$344.80
|
| Rate for Payer: Cigna of AZ Commercial |
$301.70
|
| Rate for Payer: Devoted Health Medicare |
$77.58
|
| Rate for Payer: Humana of AZ Medicare |
$68.96
|
| Rate for Payer: Mercy Care Medicaid |
$70.43
|
| Rate for Payer: NaphCare Correctional Healthcare |
$70.43
|
| Rate for Payer: Seven Corners Travel Insurance |
$1,143.54
|
| Rate for Payer: Southwest Service Administrators UFCW |
$293.08
|
| Rate for Payer: TriWest Medicare |
$68.96
|
| Rate for Payer: United Healthcare Commercial |
$246.53
|
| Rate for Payer: United Healthcare Medicare |
$68.96
|
| Rate for Payer: Veterans Affairs TRICARE |
$68.27
|
|
|
15272 App of skin sub grapht each additional 25sq cm
|
Facility
|
IP
|
$575.00
|
|
|
Service Code
|
CPT 15272
|
| Hospital Charge Code |
24087061
|
| Min. Negotiated Rate |
$517.50 |
| Max. Negotiated Rate |
$517.50 |
| Rate for Payer: Aetna of AZ Commercial |
$517.50
|
| Rate for Payer: Cash Price |
$460.00
|
|
|
15272 App of skin sub grapht each additional 25sq cm
|
Facility
|
OP
|
$575.00
|
|
|
Service Code
|
CPT 15272
|
| Hospital Charge Code |
24087061
|
| Min. Negotiated Rate |
$8.02 |
| Max. Negotiated Rate |
$517.50 |
| Rate for Payer: Aetna of AZ Commercial |
$517.50
|
| Rate for Payer: Arizona Complete Health Allwell |
$92.00
|
| Rate for Payer: Banner UC Health Medicare |
$92.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$391.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$8.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$92.00
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$92.00
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cash Price |
$460.00
|
| Rate for Payer: Cigna of AZ Commercial |
$402.50
|
| Rate for Payer: Devoted Health Medicare |
$103.50
|
| Rate for Payer: Humana of AZ Medicare |
$92.00
|
| Rate for Payer: Mercy Care Medicaid |
$8.02
|
| Rate for Payer: NaphCare Correctional Healthcare |
$8.02
|
| Rate for Payer: Southwest Service Administrators UFCW |
$391.00
|
| Rate for Payer: TriWest Medicare |
$92.00
|
| Rate for Payer: United Healthcare Commercial |
$328.90
|
| Rate for Payer: United Healthcare Medicare |
$92.00
|
| Rate for Payer: Veterans Affairs TRICARE |
$91.08
|
|
|
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 |
$21.07 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna of AZ Commercial |
$119.70
|
| Rate for Payer: Arizona Complete Health Allwell |
$21.28
|
| Rate for Payer: Banner UC Health Medicare |
$21.28
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$90.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$36.26
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$21.28
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$21.28
|
| 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: Devoted Health Medicare |
$23.94
|
| Rate for Payer: Humana of AZ Medicare |
$21.28
|
| Rate for Payer: Mercy Care Medicaid |
$36.26
|
| Rate for Payer: NaphCare Correctional Healthcare |
$36.26
|
| Rate for Payer: Southwest Service Administrators UFCW |
$90.44
|
| Rate for Payer: TriWest Medicare |
$21.28
|
| Rate for Payer: United Healthcare Commercial |
$76.08
|
| Rate for Payer: United Healthcare Medicare |
$21.28
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$25.27
|
| Rate for Payer: Veterans Affairs TRICARE |
$21.07
|
|
|
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 |
$119.70 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna of AZ Commercial |
$119.70
|
| Rate for Payer: Cash Price |
$106.40
|
|
|
15275 app of skin sub graft wound area up to 100 sq cm, firs
|
Facility
|
IP
|
$554.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
24087060
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$498.60 |
| Max. Negotiated Rate |
$498.60 |
| Rate for Payer: Aetna of AZ Commercial |
$498.60
|
| Rate for Payer: Cash Price |
$443.20
|
|
|
15275 app of skin sub graft wound area up to 100 sq cm, firs
|
Facility
|
OP
|
$554.00
|
|
|
Service Code
|
CPT 15275
|
| Hospital Charge Code |
24087060
|
|
Hospital Revenue Code
|
521
|
| Min. Negotiated Rate |
$66.60 |
| Max. Negotiated Rate |
$1,143.54 |
| Rate for Payer: Aetna of AZ Commercial |
$498.60
|
| Rate for Payer: Arizona Complete Health Allwell |
$88.64
|
| Rate for Payer: Banner UC Health Medicare |
$88.64
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$376.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$66.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$88.64
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$88.64
|
| Rate for Payer: Cash Price |
$443.20
|
| Rate for Payer: Cash Price |
$443.20
|
| Rate for Payer: Cigna of AZ Commercial |
$387.80
|
| Rate for Payer: Devoted Health Medicare |
$99.72
|
| Rate for Payer: Humana of AZ Medicare |
$88.64
|
| Rate for Payer: Mercy Care Medicaid |
$66.60
|
| Rate for Payer: NaphCare Correctional Healthcare |
$66.60
|
| Rate for Payer: Seven Corners Travel Insurance |
$1,143.54
|
| Rate for Payer: Southwest Service Administrators UFCW |
$376.72
|
| Rate for Payer: TriWest Medicare |
$88.64
|
| Rate for Payer: United Healthcare Commercial |
$316.89
|
| Rate for Payer: United Healthcare Medicare |
$88.64
|
| Rate for Payer: Veterans Affairs TRICARE |
$87.75
|
|
|
16000 TRT 1ST LOCAL
|
Facility
|
IP
|
$226.00
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
22282814
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$203.40 |
| Max. Negotiated Rate |
$203.40 |
| Rate for Payer: Aetna of AZ Commercial |
$203.40
|
| Rate for Payer: Cash Price |
$180.80
|
|
|
16000 TRT 1ST LOCAL
|
Facility
|
OP
|
$226.00
|
|
|
Service Code
|
CPT 16000
|
| Hospital Charge Code |
22282814
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$35.57 |
| Max. Negotiated Rate |
$310.43 |
| Rate for Payer: Aetna of AZ Commercial |
$203.40
|
| Rate for Payer: Arizona Complete Health Allwell |
$36.16
|
| Rate for Payer: Banner UC Health Medicare |
$36.16
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$153.68
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice |
$35.57
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$36.16
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$36.16
|
| 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: Devoted Health Medicare |
$40.68
|
| Rate for Payer: Humana of AZ Medicare |
$36.16
|
| Rate for Payer: Mercy Care Medicaid |
$35.57
|
| Rate for Payer: NaphCare Correctional Healthcare |
$35.57
|
| Rate for Payer: Seven Corners Travel Insurance |
$310.43
|
| Rate for Payer: Southwest Service Administrators UFCW |
$153.68
|
| Rate for Payer: TriWest Medicare |
$36.16
|
| Rate for Payer: United Healthcare Commercial |
$129.27
|
| Rate for Payer: United Healthcare Medicare |
$36.16
|
| Rate for Payer: United Healthcare New Mexico Commercial |
$42.94
|
| Rate for Payer: Veterans Affairs TRICARE |
$35.80
|
|
