|
XR Mandible Partial Less Than 4 Views
|
Facility
IP
|
$488.00
|
|
|
Service Code
|
CPT 70100
|
| Hospital Charge Code |
1008013
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$126.88 |
| Max. Negotiated Rate |
$439.20 |
| Rate for Payer: Aetna of AZ Commercial |
$439.20
|
| Rate for Payer: Bisbee Police All Plans |
$126.88
|
| Rate for Payer: Cash Price |
$390.40
|
| Rate for Payer: Self Pay Self Pay |
$390.40
|
|
|
XR Mandible Partial Less Than 4 Views
|
Facility
OP
|
$488.00
|
|
|
Service Code
|
CPT 70100
|
| Hospital Charge Code |
1008013
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$73.20 |
| Max. Negotiated Rate |
$439.20 |
| Rate for Payer: Aetna of AZ Commercial |
$439.20
|
| Rate for Payer: Aetna of AZ Medicare |
$136.64
|
| Rate for Payer: AHCCCS Medicaid |
$117.30
|
| Rate for Payer: Allwell Medicaid |
$117.30
|
| Rate for Payer: Allwell Medicare |
$73.20
|
| Rate for Payer: Amerigroup Medicare |
$73.20
|
| Rate for Payer: APIPA Medicare/Medicaid |
$182.27
|
| Rate for Payer: AZCH Complete Medicaid |
$117.30
|
| Rate for Payer: AZCH Complete Medicare |
$73.20
|
| Rate for Payer: Banner UC Health Medicaid |
$117.30
|
| Rate for Payer: Banner UC Health Medicare |
$73.20
|
| Rate for Payer: Bisbee Police All Plans |
$126.88
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$331.84
|
| Rate for Payer: Cash Price |
$390.40
|
| Rate for Payer: Cash Price |
$390.40
|
| Rate for Payer: Cigna of AZ Commercial |
$317.20
|
| Rate for Payer: Copperpoint Commercial |
$120.78
|
| Rate for Payer: Health Net of AZ Commercial |
$292.80
|
| Rate for Payer: Health Net of AZ Medicare |
$136.64
|
| Rate for Payer: Humana of AZ Medicare |
$73.20
|
| Rate for Payer: Mercy Care Medicaid |
$117.30
|
| Rate for Payer: Self Pay Self Pay |
$390.40
|
| Rate for Payer: TriWest Medicare |
$73.20
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$284.50
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$87.84
|
|
|
XR Mastoids < 3 Views Bilateral
|
Facility
OP
|
$488.00
|
|
|
Service Code
|
CPT 70120 50
|
| Hospital Charge Code |
1008015
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$73.20 |
| Max. Negotiated Rate |
$439.20 |
| Rate for Payer: Aetna of AZ Commercial |
$439.20
|
| Rate for Payer: Aetna of AZ Medicare |
$136.64
|
| Rate for Payer: Allwell Medicare |
$73.20
|
| Rate for Payer: Amerigroup Medicare |
$73.20
|
| Rate for Payer: APIPA Medicare/Medicaid |
$182.27
|
| Rate for Payer: AZCH Complete Medicare |
$73.20
|
| Rate for Payer: Banner UC Health Medicare |
$73.20
|
| Rate for Payer: Bisbee Police All Plans |
$126.88
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$331.84
|
| Rate for Payer: Cash Price |
$390.40
|
| Rate for Payer: Cigna of AZ Commercial |
$317.20
|
| Rate for Payer: Copperpoint Commercial |
$120.78
|
| Rate for Payer: Health Net of AZ Commercial |
$292.80
|
| Rate for Payer: Health Net of AZ Medicare |
$136.64
|
| Rate for Payer: Humana of AZ Medicare |
$73.20
|
| Rate for Payer: Self Pay Self Pay |
$390.40
|
| Rate for Payer: TriWest Medicare |
$73.20
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$284.50
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$87.84
|
|
|
XR Mastoids < 3 Views Bilateral
|
Facility
IP
|
$488.00
|
|
|
Service Code
|
CPT 70120 50
|
| Hospital Charge Code |
1008015
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$126.88 |
| Max. Negotiated Rate |
$439.20 |
| Rate for Payer: Aetna of AZ Commercial |
$439.20
|
| Rate for Payer: Bisbee Police All Plans |
$126.88
|
| Rate for Payer: Cash Price |
$390.40
|
| Rate for Payer: Self Pay Self Pay |
$390.40
|
|
|
XR Mastoids < 3 Views Left
|
Facility
IP
|
$488.00
|
|
|
Service Code
|
CPT 70120 LT
|
| Hospital Charge Code |
3381503
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$126.88 |
| Max. Negotiated Rate |
$439.20 |
| Rate for Payer: Aetna of AZ Commercial |
$439.20
|
| Rate for Payer: Bisbee Police All Plans |
$126.88
|
| Rate for Payer: Cash Price |
$390.40
|
| Rate for Payer: Self Pay Self Pay |
$390.40
|
|
|
XR Mastoids < 3 Views Left
|
Facility
OP
|
$488.00
|
|
|
Service Code
|
CPT 70120 LT
|
| Hospital Charge Code |
3381503
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$73.20 |
| Max. Negotiated Rate |
$439.20 |
| Rate for Payer: Aetna of AZ Commercial |
$439.20
|
| Rate for Payer: Aetna of AZ Medicare |
$136.64
|
| Rate for Payer: Allwell Medicare |
$73.20
|
| Rate for Payer: Amerigroup Medicare |
$73.20
|
| Rate for Payer: APIPA Medicare/Medicaid |
$182.27
|
| Rate for Payer: AZCH Complete Medicare |
$73.20
|
| Rate for Payer: Banner UC Health Medicare |
$73.20
|
| Rate for Payer: Bisbee Police All Plans |
$126.88
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$331.84
|
| Rate for Payer: Cash Price |
$390.40
|
| Rate for Payer: Cigna of AZ Commercial |
$317.20
|
| Rate for Payer: Copperpoint Commercial |
$120.78
|
| Rate for Payer: Health Net of AZ Commercial |
$292.80
|
| Rate for Payer: Health Net of AZ Medicare |
$136.64
|
| Rate for Payer: Humana of AZ Medicare |
$73.20
|
| Rate for Payer: Self Pay Self Pay |
$390.40
|
| Rate for Payer: TriWest Medicare |
$73.20
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$284.50
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$87.84
|
|
|
XR Mastoids < 3 Views Right
|
Facility
OP
|
$488.00
|
|
|
Service Code
|
CPT 70120 RT
|
| Hospital Charge Code |
3381505
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$73.20 |
| Max. Negotiated Rate |
$439.20 |
| Rate for Payer: Aetna of AZ Commercial |
$439.20
|
| Rate for Payer: Aetna of AZ Medicare |
$136.64
|
| Rate for Payer: Allwell Medicare |
$73.20
|
| Rate for Payer: Amerigroup Medicare |
$73.20
|
| Rate for Payer: APIPA Medicare/Medicaid |
$182.27
|
| Rate for Payer: AZCH Complete Medicare |
$73.20
|
| Rate for Payer: Banner UC Health Medicare |
$73.20
|
| Rate for Payer: Bisbee Police All Plans |
$126.88
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$331.84
|
| Rate for Payer: Cash Price |
$390.40
|
| Rate for Payer: Cigna of AZ Commercial |
$317.20
|
| Rate for Payer: Copperpoint Commercial |
$120.78
|
| Rate for Payer: Health Net of AZ Commercial |
$292.80
|
| Rate for Payer: Health Net of AZ Medicare |
$136.64
|
| Rate for Payer: Humana of AZ Medicare |
$73.20
|
| Rate for Payer: Self Pay Self Pay |
$390.40
|
| Rate for Payer: TriWest Medicare |
$73.20
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$284.50
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$87.84
|
|
|
XR Mastoids < 3 Views Right
|
Facility
IP
|
$488.00
|
|
|
Service Code
|
CPT 70120 RT
|
| Hospital Charge Code |
3381505
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$126.88 |
| Max. Negotiated Rate |
$439.20 |
| Rate for Payer: Aetna of AZ Commercial |
$439.20
|
| Rate for Payer: Bisbee Police All Plans |
$126.88
|
| Rate for Payer: Cash Price |
$390.40
|
| Rate for Payer: Self Pay Self Pay |
$390.40
|
|
|
XR Mastoids Complete Bilateral
|
Facility
OP
|
$972.00
|
|
|
Service Code
|
CPT 70130 50
|
| Hospital Charge Code |
1008017
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$145.80 |
| Max. Negotiated Rate |
$874.80 |
| Rate for Payer: Aetna of AZ Commercial |
$874.80
|
| Rate for Payer: Aetna of AZ Medicare |
$272.16
|
| Rate for Payer: Allwell Medicare |
$145.80
|
| Rate for Payer: Amerigroup Medicare |
$145.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$363.04
|
| Rate for Payer: AZCH Complete Medicare |
$145.80
|
| Rate for Payer: Banner UC Health Medicare |
$145.80
|
| Rate for Payer: Bisbee Police All Plans |
$252.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$660.96
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cigna of AZ Commercial |
$631.80
|
| Rate for Payer: Copperpoint Commercial |
$240.57
|
| Rate for Payer: Health Net of AZ Commercial |
$583.20
|
| Rate for Payer: Health Net of AZ Medicare |
$272.16
|
| Rate for Payer: Humana of AZ Medicare |
$145.80
|
| Rate for Payer: Self Pay Self Pay |
$777.60
|
| Rate for Payer: TriWest Medicare |
$145.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$566.68
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$174.96
|
|
|
XR Mastoids Complete Bilateral
|
Facility
IP
|
$972.00
|
|
|
Service Code
|
CPT 70130 50
|
| Hospital Charge Code |
1008017
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$252.72 |
| Max. Negotiated Rate |
$874.80 |
| Rate for Payer: Aetna of AZ Commercial |
$874.80
|
| Rate for Payer: Bisbee Police All Plans |
$252.72
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Self Pay Self Pay |
$777.60
|
|
|
XR Mastoids Complete Left
|
Facility
OP
|
$972.00
|
|
|
Service Code
|
CPT 70130 LT
|
| Hospital Charge Code |
1021647
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$145.80 |
| Max. Negotiated Rate |
$874.80 |
| Rate for Payer: Aetna of AZ Commercial |
$874.80
|
| Rate for Payer: Aetna of AZ Medicare |
$272.16
|
| Rate for Payer: Allwell Medicare |
$145.80
|
| Rate for Payer: Amerigroup Medicare |
$145.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$363.04
|
| Rate for Payer: AZCH Complete Medicare |
$145.80
|
| Rate for Payer: Banner UC Health Medicare |
$145.80
|
| Rate for Payer: Bisbee Police All Plans |
$252.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$660.96
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cigna of AZ Commercial |
$631.80
|
| Rate for Payer: Copperpoint Commercial |
$240.57
|
| Rate for Payer: Health Net of AZ Commercial |
$583.20
|
| Rate for Payer: Health Net of AZ Medicare |
$272.16
|
| Rate for Payer: Humana of AZ Medicare |
$145.80
|
| Rate for Payer: Self Pay Self Pay |
$777.60
|
| Rate for Payer: TriWest Medicare |
$145.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$566.68
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$174.96
|
|
|
XR Mastoids Complete Left
|
Facility
IP
|
$972.00
|
|
|
Service Code
|
CPT 70130 LT
|
| Hospital Charge Code |
1021647
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$252.72 |
| Max. Negotiated Rate |
$874.80 |
| Rate for Payer: Aetna of AZ Commercial |
$874.80
|
| Rate for Payer: Bisbee Police All Plans |
$252.72
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Self Pay Self Pay |
$777.60
|
|
|
XR Mastoids Complete Right
|
Facility
IP
|
$972.00
|
|
|
Service Code
|
CPT 70130 RT
|
| Hospital Charge Code |
1021649
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$252.72 |
| Max. Negotiated Rate |
$874.80 |
| Rate for Payer: Aetna of AZ Commercial |
$874.80
|
| Rate for Payer: Bisbee Police All Plans |
$252.72
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Self Pay Self Pay |
$777.60
|
|
|
XR Mastoids Complete Right
|
Facility
OP
|
$972.00
|
|
|
Service Code
|
CPT 70130 RT
|
| Hospital Charge Code |
1021649
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$145.80 |
| Max. Negotiated Rate |
$874.80 |
| Rate for Payer: Aetna of AZ Commercial |
$874.80
|
| Rate for Payer: Aetna of AZ Medicare |
$272.16
|
| Rate for Payer: Allwell Medicare |
$145.80
|
| Rate for Payer: Amerigroup Medicare |
$145.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$363.04
|
| Rate for Payer: AZCH Complete Medicare |
$145.80
|
| Rate for Payer: Banner UC Health Medicare |
$145.80
|
| Rate for Payer: Bisbee Police All Plans |
$252.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$660.96
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cigna of AZ Commercial |
$631.80
|
| Rate for Payer: Copperpoint Commercial |
$240.57
|
| Rate for Payer: Health Net of AZ Commercial |
$583.20
|
| Rate for Payer: Health Net of AZ Medicare |
$272.16
|
| Rate for Payer: Humana of AZ Medicare |
$145.80
|
| Rate for Payer: Self Pay Self Pay |
$777.60
|
| Rate for Payer: TriWest Medicare |
$145.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$566.68
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$174.96
|
|
|
XR Nasal Bones Minimum 3 Views
|
Facility
IP
|
$584.00
|
|
|
Service Code
|
CPT 70160
|
| Hospital Charge Code |
823602
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$151.84 |
| Max. Negotiated Rate |
$525.60 |
| Rate for Payer: Aetna of AZ Commercial |
$525.60
|
| Rate for Payer: Bisbee Police All Plans |
$151.84
|
| Rate for Payer: Cash Price |
$467.20
|
| Rate for Payer: Self Pay Self Pay |
$467.20
|
|
|
XR Nasal Bones Minimum 3 Views
|
Facility
OP
|
$584.00
|
|
|
Service Code
|
CPT 70160
|
| Hospital Charge Code |
823602
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$87.60 |
| Max. Negotiated Rate |
$525.60 |
| Rate for Payer: Aetna of AZ Commercial |
$525.60
|
| Rate for Payer: Aetna of AZ Medicare |
$163.52
|
| Rate for Payer: AHCCCS Medicaid |
$117.30
|
| Rate for Payer: Allwell Medicaid |
$117.30
|
| Rate for Payer: Allwell Medicare |
$87.60
|
| Rate for Payer: Amerigroup Medicare |
$87.60
|
| Rate for Payer: APIPA Medicare/Medicaid |
$218.12
|
| Rate for Payer: AZCH Complete Medicaid |
$117.30
|
| Rate for Payer: AZCH Complete Medicare |
$87.60
|
| Rate for Payer: Banner UC Health Medicaid |
$117.30
|
| Rate for Payer: Banner UC Health Medicare |
$87.60
|
| Rate for Payer: Bisbee Police All Plans |
$151.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$397.12
|
| Rate for Payer: Cash Price |
$467.20
|
| Rate for Payer: Cash Price |
$467.20
|
| Rate for Payer: Cigna of AZ Commercial |
$379.60
|
| Rate for Payer: Copperpoint Commercial |
$144.54
|
| Rate for Payer: Health Net of AZ Commercial |
$350.40
|
| Rate for Payer: Health Net of AZ Medicare |
$163.52
|
| Rate for Payer: Humana of AZ Medicare |
$87.60
|
| Rate for Payer: Mercy Care Medicaid |
$117.30
|
| Rate for Payer: Self Pay Self Pay |
$467.20
|
| Rate for Payer: TriWest Medicare |
$87.60
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$340.47
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$105.12
|
|
|
XR Neck Soft Tissue
|
Facility
OP
|
$126.00
|
|
|
Service Code
|
CPT 70360
|
| Hospital Charge Code |
823604
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$117.30 |
| Rate for Payer: Aetna of AZ Commercial |
$113.40
|
| Rate for Payer: Aetna of AZ Medicare |
$35.28
|
| Rate for Payer: AHCCCS Medicaid |
$117.30
|
| Rate for Payer: Allwell Medicaid |
$117.30
|
| Rate for Payer: Allwell Medicare |
$18.90
|
| Rate for Payer: Amerigroup Medicare |
$18.90
|
| Rate for Payer: APIPA Medicare/Medicaid |
$47.06
|
| Rate for Payer: AZCH Complete Medicaid |
$117.30
|
| Rate for Payer: AZCH Complete Medicare |
$18.90
|
| Rate for Payer: Banner UC Health Medicaid |
$117.30
|
| Rate for Payer: Banner UC Health Medicare |
$18.90
|
| Rate for Payer: Bisbee Police All Plans |
$32.76
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$85.68
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Cigna of AZ Commercial |
$81.90
|
| Rate for Payer: Copperpoint Commercial |
$31.18
|
| Rate for Payer: Health Net of AZ Commercial |
$75.60
|
| Rate for Payer: Health Net of AZ Medicare |
$35.28
|
| Rate for Payer: Humana of AZ Medicare |
$18.90
|
| Rate for Payer: Mercy Care Medicaid |
$117.30
|
| Rate for Payer: Self Pay Self Pay |
$100.80
|
| Rate for Payer: TriWest Medicare |
$18.90
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$73.46
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$22.68
|
|
|
XR Neck Soft Tissue
|
Facility
IP
|
$126.00
|
|
|
Service Code
|
CPT 70360
|
| Hospital Charge Code |
823604
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$32.76 |
| Max. Negotiated Rate |
$113.40 |
| Rate for Payer: Aetna of AZ Commercial |
$113.40
|
| Rate for Payer: Bisbee Police All Plans |
$32.76
|
| Rate for Payer: Cash Price |
$100.80
|
| Rate for Payer: Self Pay Self Pay |
$100.80
|
|
|
XR Optic Foramina
|
Facility
IP
|
$305.00
|
|
|
Service Code
|
CPT 70190
|
| Hospital Charge Code |
1008029
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$79.30 |
| Max. Negotiated Rate |
$274.50 |
| Rate for Payer: Aetna of AZ Commercial |
$274.50
|
| Rate for Payer: Bisbee Police All Plans |
$79.30
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Self Pay Self Pay |
$244.00
|
|
|
XR Optic Foramina
|
Facility
OP
|
$305.00
|
|
|
Service Code
|
CPT 70190
|
| Hospital Charge Code |
1008029
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$45.75 |
| Max. Negotiated Rate |
$274.50 |
| Rate for Payer: Aetna of AZ Commercial |
$274.50
|
| Rate for Payer: Aetna of AZ Medicare |
$85.40
|
| Rate for Payer: AHCCCS Medicaid |
$117.30
|
| Rate for Payer: Allwell Medicaid |
$117.30
|
| Rate for Payer: Allwell Medicare |
$45.75
|
| Rate for Payer: Amerigroup Medicare |
$45.75
|
| Rate for Payer: APIPA Medicare/Medicaid |
$113.92
|
| Rate for Payer: AZCH Complete Medicaid |
$117.30
|
| Rate for Payer: AZCH Complete Medicare |
$45.75
|
| Rate for Payer: Banner UC Health Medicaid |
$117.30
|
| Rate for Payer: Banner UC Health Medicare |
$45.75
|
| Rate for Payer: Bisbee Police All Plans |
$79.30
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$207.40
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cash Price |
$244.00
|
| Rate for Payer: Cigna of AZ Commercial |
$198.25
|
| Rate for Payer: Copperpoint Commercial |
$75.49
|
| Rate for Payer: Health Net of AZ Commercial |
$183.00
|
| Rate for Payer: Health Net of AZ Medicare |
$85.40
|
| Rate for Payer: Humana of AZ Medicare |
$45.75
|
| Rate for Payer: Mercy Care Medicaid |
$117.30
|
| Rate for Payer: Self Pay Self Pay |
$244.00
|
| Rate for Payer: TriWest Medicare |
$45.75
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$177.82
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$54.90
|
|
|
XR Orbits Complete Bilateral
|
Facility
OP
|
$972.00
|
|
|
Service Code
|
CPT 70200 50
|
| Hospital Charge Code |
823606
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$145.80 |
| Max. Negotiated Rate |
$874.80 |
| Rate for Payer: Aetna of AZ Commercial |
$874.80
|
| Rate for Payer: Aetna of AZ Medicare |
$272.16
|
| Rate for Payer: Allwell Medicare |
$145.80
|
| Rate for Payer: Amerigroup Medicare |
$145.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$363.04
|
| Rate for Payer: AZCH Complete Medicare |
$145.80
|
| Rate for Payer: Banner UC Health Medicare |
$145.80
|
| Rate for Payer: Bisbee Police All Plans |
$252.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$660.96
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cigna of AZ Commercial |
$631.80
|
| Rate for Payer: Copperpoint Commercial |
$240.57
|
| Rate for Payer: Health Net of AZ Commercial |
$583.20
|
| Rate for Payer: Health Net of AZ Medicare |
$272.16
|
| Rate for Payer: Humana of AZ Medicare |
$145.80
|
| Rate for Payer: Self Pay Self Pay |
$777.60
|
| Rate for Payer: TriWest Medicare |
$145.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$566.68
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$174.96
|
|
|
XR Orbits Complete Bilateral
|
Facility
IP
|
$972.00
|
|
|
Service Code
|
CPT 70200 50
|
| Hospital Charge Code |
823606
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$252.72 |
| Max. Negotiated Rate |
$874.80 |
| Rate for Payer: Aetna of AZ Commercial |
$874.80
|
| Rate for Payer: Bisbee Police All Plans |
$252.72
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Self Pay Self Pay |
$777.60
|
|
|
XR Orbits Complete Left
|
Facility
IP
|
$972.00
|
|
|
Service Code
|
CPT 70200 LT
|
| Hospital Charge Code |
1163868
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$252.72 |
| Max. Negotiated Rate |
$874.80 |
| Rate for Payer: Aetna of AZ Commercial |
$874.80
|
| Rate for Payer: Bisbee Police All Plans |
$252.72
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Self Pay Self Pay |
$777.60
|
|
|
XR Orbits Complete Left
|
Facility
OP
|
$972.00
|
|
|
Service Code
|
CPT 70200 LT
|
| Hospital Charge Code |
1163868
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$145.80 |
| Max. Negotiated Rate |
$874.80 |
| Rate for Payer: Aetna of AZ Commercial |
$874.80
|
| Rate for Payer: Aetna of AZ Medicare |
$272.16
|
| Rate for Payer: Allwell Medicare |
$145.80
|
| Rate for Payer: Amerigroup Medicare |
$145.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$363.04
|
| Rate for Payer: AZCH Complete Medicare |
$145.80
|
| Rate for Payer: Banner UC Health Medicare |
$145.80
|
| Rate for Payer: Bisbee Police All Plans |
$252.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$660.96
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cigna of AZ Commercial |
$631.80
|
| Rate for Payer: Copperpoint Commercial |
$240.57
|
| Rate for Payer: Health Net of AZ Commercial |
$583.20
|
| Rate for Payer: Health Net of AZ Medicare |
$272.16
|
| Rate for Payer: Humana of AZ Medicare |
$145.80
|
| Rate for Payer: Self Pay Self Pay |
$777.60
|
| Rate for Payer: TriWest Medicare |
$145.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$566.68
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$174.96
|
|
|
XR Orbits Complete Right
|
Facility
OP
|
$972.00
|
|
|
Service Code
|
CPT 70200 RT
|
| Hospital Charge Code |
1163870
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$145.80 |
| Max. Negotiated Rate |
$874.80 |
| Rate for Payer: Aetna of AZ Commercial |
$874.80
|
| Rate for Payer: Aetna of AZ Medicare |
$272.16
|
| Rate for Payer: Allwell Medicare |
$145.80
|
| Rate for Payer: Amerigroup Medicare |
$145.80
|
| Rate for Payer: APIPA Medicare/Medicaid |
$363.04
|
| Rate for Payer: AZCH Complete Medicare |
$145.80
|
| Rate for Payer: Banner UC Health Medicare |
$145.80
|
| Rate for Payer: Bisbee Police All Plans |
$252.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$660.96
|
| Rate for Payer: Cash Price |
$777.60
|
| Rate for Payer: Cigna of AZ Commercial |
$631.80
|
| Rate for Payer: Copperpoint Commercial |
$240.57
|
| Rate for Payer: Health Net of AZ Commercial |
$583.20
|
| Rate for Payer: Health Net of AZ Medicare |
$272.16
|
| Rate for Payer: Humana of AZ Medicare |
$145.80
|
| Rate for Payer: Self Pay Self Pay |
$777.60
|
| Rate for Payer: TriWest Medicare |
$145.80
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$566.68
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$174.96
|
|
