|
RECONSTRUCTION (ADVANCEMENT) POSTERIOR TIBIAL TENDON WITH EXCISION OF
|
Facility
|
OP
|
$2,375.00
|
|
|
Service Code
|
CPT 28238
|
| Hospital Charge Code |
24043294
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$356.25 |
| Max. Negotiated Rate |
$9,084.18 |
| Rate for Payer: Aetna of AZ Commercial |
$2,137.50
|
| Rate for Payer: Aetna of AZ Medicare |
$665.00
|
| Rate for Payer: AHCCCS Medicaid |
$9,084.18
|
| Rate for Payer: Allwell Medicaid |
$9,084.18
|
| Rate for Payer: Allwell Medicare |
$356.25
|
| Rate for Payer: Amerigroup Medicare |
$356.25
|
| Rate for Payer: APIPA Medicare/Medicaid |
$887.06
|
| Rate for Payer: AZCH Complete Medicaid |
$9,084.18
|
| Rate for Payer: AZCH Complete Medicare |
$356.25
|
| Rate for Payer: Banner UC Health Medicaid |
$9,084.18
|
| Rate for Payer: Banner UC Health Medicare |
$356.25
|
| Rate for Payer: Bisbee Police All Plans |
$617.50
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,615.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,187.50
|
| Rate for Payer: Copperpoint Commercial |
$587.81
|
| Rate for Payer: Health Net of AZ Commercial |
$1,425.00
|
| Rate for Payer: Health Net of AZ Medicare |
$665.00
|
| Rate for Payer: Humana of AZ Medicare |
$356.25
|
| Rate for Payer: Mercy Care Medicaid |
$9,084.18
|
| Rate for Payer: Self Pay Self Pay |
$1,900.00
|
| Rate for Payer: TriWest Medicare |
$356.25
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$5,265.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$427.50
|
|
|
RECONSTRUCTION (ADVANCEMENT) POSTERIOR TIBIAL TENDON WITH EXCISION OF
|
Facility
|
IP
|
$2,375.00
|
|
|
Service Code
|
CPT 28238
|
| Hospital Charge Code |
24043294
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$617.50 |
| Max. Negotiated Rate |
$2,137.50 |
| Rate for Payer: Aetna of AZ Commercial |
$2,137.50
|
| Rate for Payer: Bisbee Police All Plans |
$617.50
|
| Rate for Payer: Cash Price |
$1,900.00
|
| Rate for Payer: Self Pay Self Pay |
$1,900.00
|
|
|
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCEDURES ONLY
|
Facility
|
IP
|
$1,644.00
|
|
|
Service Code
|
CPT 28313
|
| Hospital Charge Code |
24043320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$427.44 |
| Max. Negotiated Rate |
$1,479.60 |
| Rate for Payer: Aetna of AZ Commercial |
$1,479.60
|
| Rate for Payer: Bisbee Police All Plans |
$427.44
|
| Rate for Payer: Cash Price |
$1,315.20
|
| Rate for Payer: Self Pay Self Pay |
$1,315.20
|
|
|
RECONSTRUCTION ANGULAR DEFORMITY OF TOE SOFT TISSUE PROCEDURES ONLY
|
Facility
|
OP
|
$1,644.00
|
|
|
Service Code
|
CPT 28313
|
| Hospital Charge Code |
24043320
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$246.60 |
| Max. Negotiated Rate |
$4,104.08 |
| Rate for Payer: Aetna of AZ Commercial |
$1,479.60
|
| Rate for Payer: Aetna of AZ Medicare |
$460.32
|
| Rate for Payer: AHCCCS Medicaid |
$4,104.08
|
| Rate for Payer: Allwell Medicaid |
$4,104.08
|
| Rate for Payer: Allwell Medicare |
$246.60
|
| Rate for Payer: Amerigroup Medicare |
$246.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$614.03
|
| Rate for Payer: AZCH Complete Medicaid |
$4,104.08
|
| Rate for Payer: AZCH Complete Medicare |
$246.60
|
| Rate for Payer: Banner UC Health Medicaid |
$4,104.08
|
| Rate for Payer: Banner UC Health Medicare |
$246.60
|
| Rate for Payer: Bisbee Police All Plans |
$427.44
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,117.92
|
| Rate for Payer: Cash Price |
$1,315.20
|
| Rate for Payer: Cash Price |
$1,315.20
|
| Rate for Payer: Cigna of AZ Commercial |
$822.00
|
| Rate for Payer: Copperpoint Commercial |
$406.89
|
| Rate for Payer: Health Net of AZ Commercial |
$986.40
|
| Rate for Payer: Health Net of AZ Medicare |
$460.32
|
| Rate for Payer: Humana of AZ Medicare |
$246.60
|
| Rate for Payer: Mercy Care Medicaid |
$4,104.08
|
| Rate for Payer: Self Pay Self Pay |
$1,315.20
|
| Rate for Payer: TriWest Medicare |
$246.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,373.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$295.92
|
|
|
Rectovaginal Fistula closure abdominal
|
Facility
|
IP
|
$5,324.00
|
|
|
Service Code
|
CPT 57305
|
| Hospital Charge Code |
27291797
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,384.24 |
| Max. Negotiated Rate |
$4,791.60 |
| Rate for Payer: Aetna of AZ Commercial |
$4,791.60
|
| Rate for Payer: Bisbee Police All Plans |
$1,384.24
|
| Rate for Payer: Cash Price |
$4,259.20
|
| Rate for Payer: Self Pay Self Pay |
$4,259.20
|
|
|
Rectovaginal Fistula closure abdominal
|
Facility
|
OP
|
$5,324.00
|
|
|
Service Code
|
CPT 57305
|
| Hospital Charge Code |
27291797
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$4,791.60 |
| Rate for Payer: Aetna of AZ Commercial |
$4,791.60
|
| Rate for Payer: Aetna of AZ Medicare |
$1,490.72
|
| Rate for Payer: AHCCCS Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicare |
$798.60
|
| Rate for Payer: Amerigroup Medicare |
$798.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,988.51
|
| Rate for Payer: AZCH Complete Medicaid |
$0.13
|
| Rate for Payer: AZCH Complete Medicare |
$798.60
|
| Rate for Payer: Banner UC Health Medicaid |
$0.13
|
| Rate for Payer: Banner UC Health Medicare |
$798.60
|
| Rate for Payer: Bisbee Police All Plans |
$1,384.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$3,620.32
|
| Rate for Payer: Cash Price |
$4,259.20
|
| Rate for Payer: Cash Price |
$4,259.20
|
| Rate for Payer: Cigna of AZ Commercial |
$2,662.00
|
| Rate for Payer: Copperpoint Commercial |
$1,317.69
|
| Rate for Payer: Health Net of AZ Commercial |
$3,194.40
|
| Rate for Payer: Health Net of AZ Medicare |
$1,490.72
|
| Rate for Payer: Humana of AZ Medicare |
$798.60
|
| Rate for Payer: Mercy Care Medicaid |
$0.13
|
| Rate for Payer: Self Pay Self Pay |
$4,259.20
|
| Rate for Payer: TriWest Medicare |
$798.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,373.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$958.32
|
|
|
Rectovaginal Fistula closure vaginal
|
Facility
|
OP
|
$3,287.00
|
|
|
Service Code
|
CPT 57300
|
| Hospital Charge Code |
27291796
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$493.05 |
| Max. Negotiated Rate |
$3,803.66 |
| Rate for Payer: Aetna of AZ Commercial |
$2,958.30
|
| Rate for Payer: Aetna of AZ Medicare |
$920.36
|
| Rate for Payer: AHCCCS Medicaid |
$3,803.66
|
| Rate for Payer: Allwell Medicaid |
$3,803.66
|
| Rate for Payer: Allwell Medicare |
$493.05
|
| Rate for Payer: Amerigroup Medicare |
$493.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$1,227.69
|
| Rate for Payer: AZCH Complete Medicaid |
$3,803.66
|
| Rate for Payer: AZCH Complete Medicare |
$493.05
|
| Rate for Payer: Banner UC Health Medicaid |
$3,803.66
|
| Rate for Payer: Banner UC Health Medicare |
$493.05
|
| Rate for Payer: Bisbee Police All Plans |
$854.62
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$2,235.16
|
| Rate for Payer: Cash Price |
$2,629.60
|
| Rate for Payer: Cash Price |
$2,629.60
|
| Rate for Payer: Cigna of AZ Commercial |
$1,643.50
|
| Rate for Payer: Copperpoint Commercial |
$813.53
|
| Rate for Payer: Health Net of AZ Commercial |
$1,972.20
|
| Rate for Payer: Health Net of AZ Medicare |
$920.36
|
| Rate for Payer: Humana of AZ Medicare |
$493.05
|
| Rate for Payer: Mercy Care Medicaid |
$3,803.66
|
| Rate for Payer: Self Pay Self Pay |
$2,629.60
|
| Rate for Payer: TriWest Medicare |
$493.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,373.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$591.66
|
|
|
Rectovaginal Fistula closure vaginal
|
Facility
|
IP
|
$3,287.00
|
|
|
Service Code
|
CPT 57300
|
| Hospital Charge Code |
27291796
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$854.62 |
| Max. Negotiated Rate |
$2,958.30 |
| Rate for Payer: Aetna of AZ Commercial |
$2,958.30
|
| Rate for Payer: Bisbee Police All Plans |
$854.62
|
| Rate for Payer: Cash Price |
$2,629.60
|
| Rate for Payer: Self Pay Self Pay |
$2,629.60
|
|
|
Rectovaginal Fistula with colostomy
|
Facility
|
IP
|
$5,535.00
|
|
|
Service Code
|
CPT 57307
|
| Hospital Charge Code |
27267821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,439.10 |
| Max. Negotiated Rate |
$4,981.50 |
| Rate for Payer: Aetna of AZ Commercial |
$4,981.50
|
| Rate for Payer: Bisbee Police All Plans |
$1,439.10
|
| Rate for Payer: Cash Price |
$4,428.00
|
| Rate for Payer: Self Pay Self Pay |
$4,428.00
|
|
|
Rectovaginal Fistula with colostomy
|
Facility
|
OP
|
$5,535.00
|
|
|
Service Code
|
CPT 57307
|
| Hospital Charge Code |
27267821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$4,981.50 |
| Rate for Payer: Aetna of AZ Commercial |
$4,981.50
|
| Rate for Payer: Aetna of AZ Medicare |
$1,549.80
|
| Rate for Payer: AHCCCS Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicaid |
$0.13
|
| Rate for Payer: Allwell Medicare |
$830.25
|
| Rate for Payer: Amerigroup Medicare |
$830.25
|
| Rate for Payer: APIPA Medicare/Medicaid |
$2,067.32
|
| Rate for Payer: AZCH Complete Medicaid |
$0.13
|
| Rate for Payer: AZCH Complete Medicare |
$830.25
|
| Rate for Payer: Banner UC Health Medicaid |
$0.13
|
| Rate for Payer: Banner UC Health Medicare |
$830.25
|
| Rate for Payer: Bisbee Police All Plans |
$1,439.10
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$3,763.80
|
| Rate for Payer: Cash Price |
$4,428.00
|
| Rate for Payer: Cash Price |
$4,428.00
|
| Rate for Payer: Cigna of AZ Commercial |
$2,767.50
|
| Rate for Payer: Copperpoint Commercial |
$1,369.91
|
| Rate for Payer: Health Net of AZ Commercial |
$3,321.00
|
| Rate for Payer: Health Net of AZ Medicare |
$1,549.80
|
| Rate for Payer: Humana of AZ Medicare |
$830.25
|
| Rate for Payer: Mercy Care Medicaid |
$0.13
|
| Rate for Payer: Self Pay Self Pay |
$4,428.00
|
| Rate for Payer: TriWest Medicare |
$830.25
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$3,373.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$996.30
|
|
|
REF Ab Titer
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
CPT 86886
|
| Hospital Charge Code |
22248796
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$27.82 |
| Max. Negotiated Rate |
$96.30 |
| Rate for Payer: Aetna of AZ Commercial |
$96.30
|
| Rate for Payer: Bisbee Police All Plans |
$27.82
|
| Rate for Payer: Cash Price |
$85.60
|
| Rate for Payer: Self Pay Self Pay |
$85.60
|
|
|
REF Ab Titer
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
CPT 86886
|
| Hospital Charge Code |
22248796
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.18 |
| Max. Negotiated Rate |
$96.30 |
| Rate for Payer: Aetna of AZ Commercial |
$96.30
|
| Rate for Payer: Aetna of AZ Medicare |
$29.96
|
| Rate for Payer: AHCCCS Medicaid |
$5.18
|
| Rate for Payer: Allwell Medicaid |
$5.18
|
| Rate for Payer: Allwell Medicare |
$16.05
|
| Rate for Payer: Amerigroup Medicare |
$16.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$39.96
|
| Rate for Payer: AZCH Complete Medicaid |
$5.18
|
| Rate for Payer: AZCH Complete Medicare |
$16.05
|
| Rate for Payer: Banner UC Health Medicaid |
$5.18
|
| Rate for Payer: Banner UC Health Medicare |
$16.05
|
| Rate for Payer: Bisbee Police All Plans |
$27.82
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$72.76
|
| Rate for Payer: Cash Price |
$85.60
|
| Rate for Payer: Cash Price |
$85.60
|
| Rate for Payer: Cigna of AZ Commercial |
$69.55
|
| Rate for Payer: Copperpoint Commercial |
$26.48
|
| Rate for Payer: Health Net of AZ Commercial |
$64.20
|
| Rate for Payer: Health Net of AZ Medicare |
$29.96
|
| Rate for Payer: Humana of AZ Medicare |
$16.05
|
| Rate for Payer: Mercy Care Medicaid |
$5.18
|
| Rate for Payer: Self Pay Self Pay |
$85.60
|
| Rate for Payer: TriWest Medicare |
$16.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$62.38
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$19.26
|
|
|
REF BB ANTIBODY ID ADDT'L AB
|
Facility
|
IP
|
$249.00
|
|
|
Service Code
|
CPT 86870
|
| Hospital Charge Code |
22373731
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$64.74 |
| Max. Negotiated Rate |
$224.10 |
| Rate for Payer: Aetna of AZ Commercial |
$224.10
|
| Rate for Payer: Bisbee Police All Plans |
$64.74
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Self Pay Self Pay |
$199.20
|
|
|
REF BB ANTIBODY ID ADDT'L AB
|
Facility
|
OP
|
$249.00
|
|
|
Service Code
|
CPT 86870
|
| Hospital Charge Code |
22373731
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$37.35 |
| Max. Negotiated Rate |
$224.10 |
| Rate for Payer: Aetna of AZ Commercial |
$224.10
|
| Rate for Payer: Aetna of AZ Medicare |
$69.72
|
| Rate for Payer: AHCCCS Medicaid |
$211.16
|
| Rate for Payer: Allwell Medicaid |
$211.16
|
| Rate for Payer: Allwell Medicare |
$37.35
|
| Rate for Payer: Amerigroup Medicare |
$37.35
|
| Rate for Payer: APIPA Medicare/Medicaid |
$93.00
|
| Rate for Payer: AZCH Complete Medicaid |
$211.16
|
| Rate for Payer: AZCH Complete Medicare |
$37.35
|
| Rate for Payer: Banner UC Health Medicaid |
$211.16
|
| Rate for Payer: Banner UC Health Medicare |
$37.35
|
| Rate for Payer: Bisbee Police All Plans |
$64.74
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$169.32
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Cash Price |
$199.20
|
| Rate for Payer: Cigna of AZ Commercial |
$161.85
|
| Rate for Payer: Copperpoint Commercial |
$61.63
|
| Rate for Payer: Health Net of AZ Commercial |
$149.40
|
| Rate for Payer: Health Net of AZ Medicare |
$69.72
|
| Rate for Payer: Humana of AZ Medicare |
$37.35
|
| Rate for Payer: Mercy Care Medicaid |
$211.16
|
| Rate for Payer: Self Pay Self Pay |
$199.20
|
| Rate for Payer: TriWest Medicare |
$37.35
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$145.17
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$44.82
|
|
|
REF DAT
|
Facility
|
IP
|
$237.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
5562972
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$61.62 |
| Max. Negotiated Rate |
$213.30 |
| Rate for Payer: Aetna of AZ Commercial |
$213.30
|
| Rate for Payer: Bisbee Police All Plans |
$61.62
|
| Rate for Payer: Cash Price |
$189.60
|
| Rate for Payer: Self Pay Self Pay |
$189.60
|
|
|
REF DAT
|
Facility
|
OP
|
$237.00
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
5562972
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$213.30 |
| Rate for Payer: Aetna of AZ Commercial |
$213.30
|
| Rate for Payer: Aetna of AZ Medicare |
$66.36
|
| Rate for Payer: AHCCCS Medicaid |
$5.39
|
| Rate for Payer: Allwell Medicaid |
$5.39
|
| Rate for Payer: Allwell Medicare |
$35.55
|
| Rate for Payer: Amerigroup Medicare |
$35.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$88.52
|
| Rate for Payer: AZCH Complete Medicaid |
$5.39
|
| Rate for Payer: AZCH Complete Medicare |
$35.55
|
| Rate for Payer: Banner UC Health Medicaid |
$5.39
|
| Rate for Payer: Banner UC Health Medicare |
$35.55
|
| Rate for Payer: Bisbee Police All Plans |
$61.62
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$161.16
|
| Rate for Payer: Cash Price |
$189.60
|
| Rate for Payer: Cash Price |
$189.60
|
| Rate for Payer: Cigna of AZ Commercial |
$154.05
|
| Rate for Payer: Copperpoint Commercial |
$58.66
|
| Rate for Payer: Health Net of AZ Commercial |
$142.20
|
| Rate for Payer: Health Net of AZ Medicare |
$66.36
|
| Rate for Payer: Humana of AZ Medicare |
$35.55
|
| Rate for Payer: Mercy Care Medicaid |
$5.39
|
| Rate for Payer: Self Pay Self Pay |
$189.60
|
| Rate for Payer: TriWest Medicare |
$35.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$138.17
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$42.66
|
|
|
Reference ABID
|
Facility
|
OP
|
$761.00
|
|
|
Service Code
|
CPT 86870
|
| Hospital Charge Code |
1165545
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$114.15 |
| Max. Negotiated Rate |
$684.90 |
| Rate for Payer: Aetna of AZ Commercial |
$684.90
|
| Rate for Payer: Aetna of AZ Medicare |
$213.08
|
| Rate for Payer: AHCCCS Medicaid |
$211.16
|
| Rate for Payer: Allwell Medicaid |
$211.16
|
| Rate for Payer: Allwell Medicare |
$114.15
|
| Rate for Payer: Amerigroup Medicare |
$114.15
|
| Rate for Payer: APIPA Medicare/Medicaid |
$284.23
|
| Rate for Payer: AZCH Complete Medicaid |
$211.16
|
| Rate for Payer: AZCH Complete Medicare |
$114.15
|
| Rate for Payer: Banner UC Health Medicaid |
$211.16
|
| Rate for Payer: Banner UC Health Medicare |
$114.15
|
| Rate for Payer: Bisbee Police All Plans |
$197.86
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$517.48
|
| Rate for Payer: Cash Price |
$608.80
|
| Rate for Payer: Cash Price |
$608.80
|
| Rate for Payer: Cigna of AZ Commercial |
$494.65
|
| Rate for Payer: Copperpoint Commercial |
$188.35
|
| Rate for Payer: Health Net of AZ Commercial |
$456.60
|
| Rate for Payer: Health Net of AZ Medicare |
$213.08
|
| Rate for Payer: Humana of AZ Medicare |
$114.15
|
| Rate for Payer: Mercy Care Medicaid |
$211.16
|
| Rate for Payer: Self Pay Self Pay |
$608.80
|
| Rate for Payer: TriWest Medicare |
$114.15
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$443.66
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$136.98
|
|
|
Reference ABID
|
Facility
|
IP
|
$761.00
|
|
|
Service Code
|
CPT 86870
|
| Hospital Charge Code |
1165545
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$197.86 |
| Max. Negotiated Rate |
$684.90 |
| Rate for Payer: Aetna of AZ Commercial |
$684.90
|
| Rate for Payer: Bisbee Police All Plans |
$197.86
|
| Rate for Payer: Cash Price |
$608.80
|
| Rate for Payer: Self Pay Self Pay |
$608.80
|
|
|
Reference Elution
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 86976
|
| Hospital Charge Code |
1165547
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$29.12 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna of AZ Commercial |
$100.80
|
| Rate for Payer: Bisbee Police All Plans |
$29.12
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Self Pay Self Pay |
$89.60
|
|
|
Reference Elution
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 86976
|
| Hospital Charge Code |
1165547
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.80 |
| Max. Negotiated Rate |
$100.80 |
| Rate for Payer: Aetna of AZ Commercial |
$100.80
|
| Rate for Payer: Aetna of AZ Medicare |
$31.36
|
| Rate for Payer: AHCCCS Medicaid |
$17.89
|
| Rate for Payer: Allwell Medicaid |
$17.89
|
| Rate for Payer: Allwell Medicare |
$16.80
|
| Rate for Payer: Amerigroup Medicare |
$16.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$41.83
|
| Rate for Payer: AZCH Complete Medicaid |
$17.89
|
| Rate for Payer: AZCH Complete Medicare |
$16.80
|
| Rate for Payer: Banner UC Health Medicaid |
$17.89
|
| Rate for Payer: Banner UC Health Medicare |
$16.80
|
| Rate for Payer: Bisbee Police All Plans |
$29.12
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$76.16
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: Cigna of AZ Commercial |
$72.80
|
| Rate for Payer: Copperpoint Commercial |
$27.72
|
| Rate for Payer: Health Net of AZ Commercial |
$67.20
|
| Rate for Payer: Health Net of AZ Medicare |
$31.36
|
| Rate for Payer: Humana of AZ Medicare |
$16.80
|
| Rate for Payer: Mercy Care Medicaid |
$17.89
|
| Rate for Payer: Self Pay Self Pay |
$89.60
|
| Rate for Payer: TriWest Medicare |
$16.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$65.30
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$20.16
|
|
|
Reference Elution
|
Facility
|
OP
|
$107.00
|
|
|
Service Code
|
CPT 86976
|
| Hospital Charge Code |
2192233
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.05 |
| Max. Negotiated Rate |
$96.30 |
| Rate for Payer: Aetna of AZ Commercial |
$96.30
|
| Rate for Payer: Aetna of AZ Medicare |
$29.96
|
| Rate for Payer: AHCCCS Medicaid |
$17.89
|
| Rate for Payer: Allwell Medicaid |
$17.89
|
| Rate for Payer: Allwell Medicare |
$16.05
|
| Rate for Payer: Amerigroup Medicare |
$16.05
|
| Rate for Payer: APIPA Medicare/Medicaid |
$39.96
|
| Rate for Payer: AZCH Complete Medicaid |
$17.89
|
| Rate for Payer: AZCH Complete Medicare |
$16.05
|
| Rate for Payer: Banner UC Health Medicaid |
$17.89
|
| Rate for Payer: Banner UC Health Medicare |
$16.05
|
| Rate for Payer: Bisbee Police All Plans |
$27.82
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$72.76
|
| Rate for Payer: Cash Price |
$85.60
|
| Rate for Payer: Cash Price |
$85.60
|
| Rate for Payer: Cigna of AZ Commercial |
$69.55
|
| Rate for Payer: Copperpoint Commercial |
$26.48
|
| Rate for Payer: Health Net of AZ Commercial |
$64.20
|
| Rate for Payer: Health Net of AZ Medicare |
$29.96
|
| Rate for Payer: Humana of AZ Medicare |
$16.05
|
| Rate for Payer: Mercy Care Medicaid |
$17.89
|
| Rate for Payer: Self Pay Self Pay |
$85.60
|
| Rate for Payer: TriWest Medicare |
$16.05
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$62.38
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$19.26
|
|
|
Reference Elution
|
Facility
|
IP
|
$107.00
|
|
|
Service Code
|
CPT 86976
|
| Hospital Charge Code |
2192233
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$27.82 |
| Max. Negotiated Rate |
$96.30 |
| Rate for Payer: Aetna of AZ Commercial |
$96.30
|
| Rate for Payer: Bisbee Police All Plans |
$27.82
|
| Rate for Payer: Cash Price |
$85.60
|
| Rate for Payer: Self Pay Self Pay |
$85.60
|
|
|
.Reflex to GenoSure(R) MG LC
|
Facility
|
OP
|
$1,502.00
|
|
|
Service Code
|
CPT 87901
|
| Hospital Charge Code |
22311165
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$225.30 |
| Max. Negotiated Rate |
$1,351.80 |
| Rate for Payer: Aetna of AZ Commercial |
$1,351.80
|
| Rate for Payer: Aetna of AZ Medicare |
$420.56
|
| Rate for Payer: AHCCCS Medicaid |
$257.45
|
| Rate for Payer: Allwell Medicaid |
$257.45
|
| Rate for Payer: Allwell Medicare |
$225.30
|
| Rate for Payer: Amerigroup Medicare |
$225.30
|
| Rate for Payer: APIPA Medicare/Medicaid |
$561.00
|
| Rate for Payer: AZCH Complete Medicaid |
$257.45
|
| Rate for Payer: AZCH Complete Medicare |
$225.30
|
| Rate for Payer: Banner UC Health Medicaid |
$257.45
|
| Rate for Payer: Banner UC Health Medicare |
$225.30
|
| Rate for Payer: Bisbee Police All Plans |
$390.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,021.36
|
| Rate for Payer: Cash Price |
$1,201.60
|
| Rate for Payer: Cash Price |
$1,201.60
|
| Rate for Payer: Cigna of AZ Commercial |
$976.30
|
| Rate for Payer: Copperpoint Commercial |
$371.74
|
| Rate for Payer: Health Net of AZ Commercial |
$901.20
|
| Rate for Payer: Health Net of AZ Medicare |
$420.56
|
| Rate for Payer: Humana of AZ Medicare |
$225.30
|
| Rate for Payer: Mercy Care Medicaid |
$257.45
|
| Rate for Payer: Self Pay Self Pay |
$1,201.60
|
| Rate for Payer: TriWest Medicare |
$225.30
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$875.67
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$270.36
|
|
|
.Reflex to GenoSure(R) MG LC
|
Facility
|
IP
|
$1,502.00
|
|
|
Service Code
|
CPT 87901
|
| Hospital Charge Code |
22311165
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$390.52 |
| Max. Negotiated Rate |
$1,351.80 |
| Rate for Payer: Aetna of AZ Commercial |
$1,351.80
|
| Rate for Payer: Bisbee Police All Plans |
$390.52
|
| Rate for Payer: Cash Price |
$1,201.60
|
| Rate for Payer: Self Pay Self Pay |
$1,201.60
|
|
|
REF RBC OTHER THAN ABO
|
Facility
|
OP
|
$237.00
|
|
|
Service Code
|
CPT 86905
|
| Hospital Charge Code |
22373722
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.83 |
| Max. Negotiated Rate |
$213.30 |
| Rate for Payer: Aetna of AZ Commercial |
$213.30
|
| Rate for Payer: Aetna of AZ Medicare |
$66.36
|
| Rate for Payer: AHCCCS Medicaid |
$3.83
|
| Rate for Payer: Allwell Medicaid |
$3.83
|
| Rate for Payer: Allwell Medicare |
$35.55
|
| Rate for Payer: Amerigroup Medicare |
$35.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$88.52
|
| Rate for Payer: AZCH Complete Medicaid |
$3.83
|
| Rate for Payer: AZCH Complete Medicare |
$35.55
|
| Rate for Payer: Banner UC Health Medicaid |
$3.83
|
| Rate for Payer: Banner UC Health Medicare |
$35.55
|
| Rate for Payer: Bisbee Police All Plans |
$61.62
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$161.16
|
| Rate for Payer: Cash Price |
$189.60
|
| Rate for Payer: Cash Price |
$189.60
|
| Rate for Payer: Cigna of AZ Commercial |
$154.05
|
| Rate for Payer: Copperpoint Commercial |
$58.66
|
| Rate for Payer: Health Net of AZ Commercial |
$142.20
|
| Rate for Payer: Health Net of AZ Medicare |
$66.36
|
| Rate for Payer: Humana of AZ Medicare |
$35.55
|
| Rate for Payer: Mercy Care Medicaid |
$3.83
|
| Rate for Payer: Self Pay Self Pay |
$189.60
|
| Rate for Payer: TriWest Medicare |
$35.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$138.17
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$42.66
|
|
