|
12011 SPL FACE MUC MEMB 2.5
|
Facility
IP
|
$540.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
22282773
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$140.40 |
| Max. Negotiated Rate |
$486.00 |
| Rate for Payer: Aetna of AZ Commercial |
$486.00
|
| Rate for Payer: Bisbee Police All Plans |
$140.40
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Self Pay Self Pay |
$432.00
|
|
|
12011 SPL FACE MUC MEMB 2.5
|
Facility
OP
|
$540.00
|
|
|
Service Code
|
CPT 12011
|
| Hospital Charge Code |
22282773
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$81.00 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$486.00
|
| Rate for Payer: Aetna of AZ Medicare |
$151.20
|
| Rate for Payer: AHCCCS Medicaid |
$260.34
|
| Rate for Payer: Allwell Medicaid |
$260.34
|
| Rate for Payer: Allwell Medicare |
$81.00
|
| Rate for Payer: Amerigroup Medicare |
$81.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$201.69
|
| Rate for Payer: AZCH Complete Medicaid |
$260.34
|
| Rate for Payer: AZCH Complete Medicare |
$81.00
|
| Rate for Payer: Banner UC Health Medicaid |
$260.34
|
| Rate for Payer: Banner UC Health Medicare |
$81.00
|
| Rate for Payer: Bisbee Police All Plans |
$140.40
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$367.20
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cash Price |
$432.00
|
| Rate for Payer: Cigna of AZ Commercial |
$378.00
|
| Rate for Payer: Copperpoint Commercial |
$133.65
|
| Rate for Payer: Health Net of AZ Commercial |
$324.00
|
| Rate for Payer: Health Net of AZ Medicare |
$151.20
|
| Rate for Payer: Humana of AZ Medicare |
$81.00
|
| Rate for Payer: Mercy Care Medicaid |
$260.34
|
| Rate for Payer: Self Pay Self Pay |
$432.00
|
| Rate for Payer: TriWest Medicare |
$81.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$97.20
|
|
|
12013 SPL FACE MUCMEMB 2.6-5.0
|
Facility
IP
|
$625.00
|
|
|
Service Code
|
CPT 12013
|
| Hospital Charge Code |
22282774
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$162.50 |
| Max. Negotiated Rate |
$562.50 |
| Rate for Payer: Aetna of AZ Commercial |
$562.50
|
| Rate for Payer: Bisbee Police All Plans |
$162.50
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Self Pay Self Pay |
$500.00
|
|
|
12013 SPL FACE MUCMEMB 2.6-5.0
|
Facility
OP
|
$625.00
|
|
|
Service Code
|
CPT 12013
|
| Hospital Charge Code |
22282774
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$93.75 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$562.50
|
| Rate for Payer: Aetna of AZ Medicare |
$175.00
|
| Rate for Payer: AHCCCS Medicaid |
$260.34
|
| Rate for Payer: Allwell Medicaid |
$260.34
|
| Rate for Payer: Allwell Medicare |
$93.75
|
| Rate for Payer: Amerigroup Medicare |
$93.75
|
| Rate for Payer: APIPA Medicare/Medicaid |
$233.44
|
| Rate for Payer: AZCH Complete Medicaid |
$260.34
|
| Rate for Payer: AZCH Complete Medicare |
$93.75
|
| Rate for Payer: Banner UC Health Medicaid |
$260.34
|
| Rate for Payer: Banner UC Health Medicare |
$93.75
|
| Rate for Payer: Bisbee Police All Plans |
$162.50
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$425.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cash Price |
$500.00
|
| Rate for Payer: Cigna of AZ Commercial |
$437.50
|
| Rate for Payer: Copperpoint Commercial |
$154.69
|
| Rate for Payer: Health Net of AZ Commercial |
$375.00
|
| Rate for Payer: Health Net of AZ Medicare |
$175.00
|
| Rate for Payer: Humana of AZ Medicare |
$93.75
|
| Rate for Payer: Mercy Care Medicaid |
$260.34
|
| Rate for Payer: Self Pay Self Pay |
$500.00
|
| Rate for Payer: TriWest Medicare |
$93.75
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$112.50
|
|
|
12014 SPL FACE MUC MEM 5.1-7.5
|
Facility
IP
|
$760.00
|
|
|
Service Code
|
CPT 12014
|
| Hospital Charge Code |
22282775
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$197.60 |
| Max. Negotiated Rate |
$684.00 |
| Rate for Payer: Aetna of AZ Commercial |
$684.00
|
| Rate for Payer: Bisbee Police All Plans |
$197.60
|
| Rate for Payer: Cash Price |
$608.00
|
| Rate for Payer: Self Pay Self Pay |
$608.00
|
|
|
12014 SPL FACE MUC MEM 5.1-7.5
|
Facility
OP
|
$760.00
|
|
|
Service Code
|
CPT 12014
|
| Hospital Charge Code |
22282775
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$114.00 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$684.00
|
| Rate for Payer: Aetna of AZ Medicare |
$212.80
|
| Rate for Payer: AHCCCS Medicaid |
$260.34
|
| Rate for Payer: Allwell Medicaid |
$260.34
|
| Rate for Payer: Allwell Medicare |
$114.00
|
| Rate for Payer: Amerigroup Medicare |
$114.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$283.86
|
| Rate for Payer: AZCH Complete Medicaid |
$260.34
|
| Rate for Payer: AZCH Complete Medicare |
$114.00
|
| Rate for Payer: Banner UC Health Medicaid |
$260.34
|
| Rate for Payer: Banner UC Health Medicare |
$114.00
|
| Rate for Payer: Bisbee Police All Plans |
$197.60
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$516.80
|
| Rate for Payer: Cash Price |
$608.00
|
| Rate for Payer: Cash Price |
$608.00
|
| Rate for Payer: Cigna of AZ Commercial |
$532.00
|
| Rate for Payer: Copperpoint Commercial |
$188.10
|
| Rate for Payer: Health Net of AZ Commercial |
$456.00
|
| Rate for Payer: Health Net of AZ Medicare |
$212.80
|
| Rate for Payer: Humana of AZ Medicare |
$114.00
|
| Rate for Payer: Mercy Care Medicaid |
$260.34
|
| Rate for Payer: Self Pay Self Pay |
$608.00
|
| Rate for Payer: TriWest Medicare |
$114.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$136.80
|
|
|
12015 SPL FACE MUC MEM7.6-12.5
|
Facility
IP
|
$977.00
|
|
|
Service Code
|
CPT 12015
|
| Hospital Charge Code |
22282776
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$254.02 |
| Max. Negotiated Rate |
$879.30 |
| Rate for Payer: Aetna of AZ Commercial |
$879.30
|
| Rate for Payer: Bisbee Police All Plans |
$254.02
|
| Rate for Payer: Cash Price |
$781.60
|
| Rate for Payer: Self Pay Self Pay |
$781.60
|
|
|
12015 SPL FACE MUC MEM7.6-12.5
|
Facility
OP
|
$977.00
|
|
|
Service Code
|
CPT 12015
|
| Hospital Charge Code |
22282776
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$146.55 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$879.30
|
| Rate for Payer: Aetna of AZ Medicare |
$273.56
|
| Rate for Payer: AHCCCS Medicaid |
$260.34
|
| Rate for Payer: Allwell Medicaid |
$260.34
|
| Rate for Payer: Allwell Medicare |
$146.55
|
| Rate for Payer: Amerigroup Medicare |
$146.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$364.91
|
| Rate for Payer: AZCH Complete Medicaid |
$260.34
|
| Rate for Payer: AZCH Complete Medicare |
$146.55
|
| Rate for Payer: Banner UC Health Medicaid |
$260.34
|
| Rate for Payer: Banner UC Health Medicare |
$146.55
|
| Rate for Payer: Bisbee Police All Plans |
$254.02
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$664.36
|
| Rate for Payer: Cash Price |
$781.60
|
| Rate for Payer: Cash Price |
$781.60
|
| Rate for Payer: Cigna of AZ Commercial |
$683.90
|
| Rate for Payer: Copperpoint Commercial |
$241.81
|
| Rate for Payer: Health Net of AZ Commercial |
$586.20
|
| Rate for Payer: Health Net of AZ Medicare |
$273.56
|
| Rate for Payer: Humana of AZ Medicare |
$146.55
|
| Rate for Payer: Mercy Care Medicaid |
$260.34
|
| Rate for Payer: Self Pay Self Pay |
$781.60
|
| Rate for Payer: TriWest Medicare |
$146.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$175.86
|
|
|
12016 SPL FACE MUC MEM 12.6-20
|
Facility
OP
|
$1,236.00
|
|
|
Service Code
|
CPT 12016
|
| Hospital Charge Code |
22282777
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$185.40 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,112.40
|
| Rate for Payer: Aetna of AZ Medicare |
$346.08
|
| Rate for Payer: AHCCCS Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicare |
$185.40
|
| Rate for Payer: Amerigroup Medicare |
$185.40
|
| Rate for Payer: APIPA Medicare/Medicaid |
$461.65
|
| Rate for Payer: AZCH Complete Medicaid |
$501.46
|
| Rate for Payer: AZCH Complete Medicare |
$185.40
|
| Rate for Payer: Banner UC Health Medicaid |
$501.46
|
| Rate for Payer: Banner UC Health Medicare |
$185.40
|
| Rate for Payer: Bisbee Police All Plans |
$321.36
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$840.48
|
| Rate for Payer: Cash Price |
$988.80
|
| Rate for Payer: Cash Price |
$988.80
|
| Rate for Payer: Cigna of AZ Commercial |
$865.20
|
| Rate for Payer: Copperpoint Commercial |
$305.91
|
| Rate for Payer: Health Net of AZ Commercial |
$741.60
|
| Rate for Payer: Health Net of AZ Medicare |
$346.08
|
| Rate for Payer: Humana of AZ Medicare |
$185.40
|
| Rate for Payer: Mercy Care Medicaid |
$501.46
|
| Rate for Payer: Self Pay Self Pay |
$988.80
|
| Rate for Payer: TriWest Medicare |
$185.40
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$222.48
|
|
|
12016 SPL FACE MUC MEM 12.6-20
|
Facility
IP
|
$1,236.00
|
|
|
Service Code
|
CPT 12016
|
| Hospital Charge Code |
22282777
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$321.36 |
| Max. Negotiated Rate |
$1,112.40 |
| Rate for Payer: Aetna of AZ Commercial |
$1,112.40
|
| Rate for Payer: Bisbee Police All Plans |
$321.36
|
| Rate for Payer: Cash Price |
$988.80
|
| Rate for Payer: Self Pay Self Pay |
$988.80
|
|
|
12017 SPL FAC MUC MEM 20.1-30
|
Facility
OP
|
$1,589.00
|
|
|
Service Code
|
CPT 12017
|
| Hospital Charge Code |
22282778
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$238.35 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,430.10
|
| Rate for Payer: Aetna of AZ Medicare |
$444.92
|
| Rate for Payer: AHCCCS Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicare |
$238.35
|
| Rate for Payer: Amerigroup Medicare |
$238.35
|
| Rate for Payer: APIPA Medicare/Medicaid |
$593.49
|
| Rate for Payer: AZCH Complete Medicaid |
$501.46
|
| Rate for Payer: AZCH Complete Medicare |
$238.35
|
| Rate for Payer: Banner UC Health Medicaid |
$501.46
|
| Rate for Payer: Banner UC Health Medicare |
$238.35
|
| Rate for Payer: Bisbee Police All Plans |
$413.14
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,080.52
|
| Rate for Payer: Cash Price |
$1,271.20
|
| Rate for Payer: Cash Price |
$1,271.20
|
| Rate for Payer: Cigna of AZ Commercial |
$1,112.30
|
| Rate for Payer: Copperpoint Commercial |
$393.28
|
| Rate for Payer: Health Net of AZ Commercial |
$953.40
|
| Rate for Payer: Health Net of AZ Medicare |
$444.92
|
| Rate for Payer: Humana of AZ Medicare |
$238.35
|
| Rate for Payer: Mercy Care Medicaid |
$501.46
|
| Rate for Payer: Self Pay Self Pay |
$1,271.20
|
| Rate for Payer: TriWest Medicare |
$238.35
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$286.02
|
|
|
12017 SPL FAC MUC MEM 20.1-30
|
Facility
IP
|
$1,589.00
|
|
|
Service Code
|
CPT 12017
|
| Hospital Charge Code |
22282778
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$413.14 |
| Max. Negotiated Rate |
$1,430.10 |
| Rate for Payer: Aetna of AZ Commercial |
$1,430.10
|
| Rate for Payer: Bisbee Police All Plans |
$413.14
|
| Rate for Payer: Cash Price |
$1,271.20
|
| Rate for Payer: Self Pay Self Pay |
$1,271.20
|
|
|
12018 SPL FACE MUC MEMB >30
|
Facility
OP
|
$1,969.00
|
|
|
Service Code
|
CPT 12018
|
| Hospital Charge Code |
22282779
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$260.34 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,772.10
|
| Rate for Payer: Aetna of AZ Medicare |
$551.32
|
| Rate for Payer: AHCCCS Medicaid |
$260.34
|
| Rate for Payer: Allwell Medicaid |
$260.34
|
| Rate for Payer: Allwell Medicare |
$295.35
|
| Rate for Payer: Amerigroup Medicare |
$295.35
|
| Rate for Payer: APIPA Medicare/Medicaid |
$735.42
|
| Rate for Payer: AZCH Complete Medicaid |
$260.34
|
| Rate for Payer: AZCH Complete Medicare |
$295.35
|
| Rate for Payer: Banner UC Health Medicaid |
$260.34
|
| Rate for Payer: Banner UC Health Medicare |
$295.35
|
| Rate for Payer: Bisbee Police All Plans |
$511.94
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,338.92
|
| Rate for Payer: Cash Price |
$1,575.20
|
| Rate for Payer: Cash Price |
$1,575.20
|
| Rate for Payer: Cigna of AZ Commercial |
$1,378.30
|
| Rate for Payer: Copperpoint Commercial |
$487.33
|
| Rate for Payer: Health Net of AZ Commercial |
$1,181.40
|
| Rate for Payer: Health Net of AZ Medicare |
$551.32
|
| Rate for Payer: Humana of AZ Medicare |
$295.35
|
| Rate for Payer: Mercy Care Medicaid |
$260.34
|
| Rate for Payer: Self Pay Self Pay |
$1,575.20
|
| Rate for Payer: TriWest Medicare |
$295.35
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$354.42
|
|
|
12018 SPL FACE MUC MEMB >30
|
Facility
IP
|
$1,969.00
|
|
|
Service Code
|
CPT 12018
|
| Hospital Charge Code |
22282779
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$511.94 |
| Max. Negotiated Rate |
$1,772.10 |
| Rate for Payer: Aetna of AZ Commercial |
$1,772.10
|
| Rate for Payer: Bisbee Police All Plans |
$511.94
|
| Rate for Payer: Cash Price |
$1,575.20
|
| Rate for Payer: Self Pay Self Pay |
$1,575.20
|
|
|
12020 SUP WND DEHIS SMPL
|
Facility
OP
|
$839.00
|
|
|
Service Code
|
CPT 12020
|
| Hospital Charge Code |
22282780
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$125.85 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$755.10
|
| Rate for Payer: Aetna of AZ Medicare |
$234.92
|
| Rate for Payer: AHCCCS Medicaid |
$760.04
|
| Rate for Payer: Allwell Medicaid |
$760.04
|
| Rate for Payer: Allwell Medicare |
$125.85
|
| Rate for Payer: Amerigroup Medicare |
$125.85
|
| Rate for Payer: APIPA Medicare/Medicaid |
$313.37
|
| Rate for Payer: AZCH Complete Medicaid |
$760.04
|
| Rate for Payer: AZCH Complete Medicare |
$125.85
|
| Rate for Payer: Banner UC Health Medicaid |
$760.04
|
| Rate for Payer: Banner UC Health Medicare |
$125.85
|
| Rate for Payer: Bisbee Police All Plans |
$218.14
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$570.52
|
| Rate for Payer: Cash Price |
$671.20
|
| Rate for Payer: Cash Price |
$671.20
|
| Rate for Payer: Cigna of AZ Commercial |
$587.30
|
| Rate for Payer: Copperpoint Commercial |
$207.65
|
| Rate for Payer: Health Net of AZ Commercial |
$503.40
|
| Rate for Payer: Health Net of AZ Medicare |
$234.92
|
| Rate for Payer: Humana of AZ Medicare |
$125.85
|
| Rate for Payer: Mercy Care Medicaid |
$760.04
|
| Rate for Payer: Self Pay Self Pay |
$671.20
|
| Rate for Payer: TriWest Medicare |
$125.85
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$151.02
|
|
|
12020 SUP WND DEHIS SMPL
|
Facility
IP
|
$839.00
|
|
|
Service Code
|
CPT 12020
|
| Hospital Charge Code |
22282780
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$218.14 |
| Max. Negotiated Rate |
$755.10 |
| Rate for Payer: Aetna of AZ Commercial |
$755.10
|
| Rate for Payer: Bisbee Police All Plans |
$218.14
|
| Rate for Payer: Cash Price |
$671.20
|
| Rate for Payer: Self Pay Self Pay |
$671.20
|
|
|
12021 SUP WND DEHIS W/PACK
|
Facility
OP
|
$537.00
|
|
|
Service Code
|
CPT 12021
|
| Hospital Charge Code |
22282781
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$80.55 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$483.30
|
| Rate for Payer: Aetna of AZ Medicare |
$150.36
|
| Rate for Payer: AHCCCS Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicare |
$80.55
|
| Rate for Payer: Amerigroup Medicare |
$80.55
|
| Rate for Payer: APIPA Medicare/Medicaid |
$200.57
|
| Rate for Payer: AZCH Complete Medicaid |
$501.46
|
| Rate for Payer: AZCH Complete Medicare |
$80.55
|
| Rate for Payer: Banner UC Health Medicaid |
$501.46
|
| Rate for Payer: Banner UC Health Medicare |
$80.55
|
| Rate for Payer: Bisbee Police All Plans |
$139.62
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$365.16
|
| Rate for Payer: Cash Price |
$429.60
|
| Rate for Payer: Cash Price |
$429.60
|
| Rate for Payer: Cigna of AZ Commercial |
$375.90
|
| Rate for Payer: Copperpoint Commercial |
$132.91
|
| Rate for Payer: Health Net of AZ Commercial |
$322.20
|
| Rate for Payer: Health Net of AZ Medicare |
$150.36
|
| Rate for Payer: Humana of AZ Medicare |
$80.55
|
| Rate for Payer: Mercy Care Medicaid |
$501.46
|
| Rate for Payer: Self Pay Self Pay |
$429.60
|
| Rate for Payer: TriWest Medicare |
$80.55
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$96.66
|
|
|
12021 SUP WND DEHIS W/PACK
|
Facility
IP
|
$537.00
|
|
|
Service Code
|
CPT 12021
|
| Hospital Charge Code |
22282781
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$139.62 |
| Max. Negotiated Rate |
$483.30 |
| Rate for Payer: Aetna of AZ Commercial |
$483.30
|
| Rate for Payer: Bisbee Police All Plans |
$139.62
|
| Rate for Payer: Cash Price |
$429.60
|
| Rate for Payer: Self Pay Self Pay |
$429.60
|
|
|
12031 REPAIR INTMD WND 2.5CM OR LESS
|
Facility
OP
|
$1,106.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
22282782
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$165.90 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$995.40
|
| Rate for Payer: Aetna of AZ Medicare |
$309.68
|
| Rate for Payer: AHCCCS Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicare |
$165.90
|
| Rate for Payer: Amerigroup Medicare |
$165.90
|
| Rate for Payer: APIPA Medicare/Medicaid |
$413.09
|
| Rate for Payer: AZCH Complete Medicaid |
$501.46
|
| Rate for Payer: AZCH Complete Medicare |
$165.90
|
| Rate for Payer: Banner UC Health Medicaid |
$501.46
|
| Rate for Payer: Banner UC Health Medicare |
$165.90
|
| Rate for Payer: Bisbee Police All Plans |
$287.56
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$752.08
|
| Rate for Payer: Cash Price |
$884.80
|
| Rate for Payer: Cash Price |
$884.80
|
| Rate for Payer: Cigna of AZ Commercial |
$774.20
|
| Rate for Payer: Copperpoint Commercial |
$273.74
|
| Rate for Payer: Health Net of AZ Commercial |
$663.60
|
| Rate for Payer: Health Net of AZ Medicare |
$309.68
|
| Rate for Payer: Humana of AZ Medicare |
$165.90
|
| Rate for Payer: Mercy Care Medicaid |
$501.46
|
| Rate for Payer: Self Pay Self Pay |
$884.80
|
| Rate for Payer: TriWest Medicare |
$165.90
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$199.08
|
|
|
12031 REPAIR INTMD WND 2.5CM OR LESS
|
Facility
IP
|
$1,106.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
22282782
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$287.56 |
| Max. Negotiated Rate |
$995.40 |
| Rate for Payer: Aetna of AZ Commercial |
$995.40
|
| Rate for Payer: Bisbee Police All Plans |
$287.56
|
| Rate for Payer: Cash Price |
$884.80
|
| Rate for Payer: Self Pay Self Pay |
$884.80
|
|
|
12032 REPAIR INTMD WND 2.6CM TO 7.5CM
|
Facility
IP
|
$1,429.00
|
|
|
Service Code
|
CPT 12032
|
| Hospital Charge Code |
22282783
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$371.54 |
| Max. Negotiated Rate |
$1,286.10 |
| Rate for Payer: Aetna of AZ Commercial |
$1,286.10
|
| Rate for Payer: Bisbee Police All Plans |
$371.54
|
| Rate for Payer: Cash Price |
$1,143.20
|
| Rate for Payer: Self Pay Self Pay |
$1,143.20
|
|
|
12032 REPAIR INTMD WND 2.6CM TO 7.5CM
|
Facility
OP
|
$1,429.00
|
|
|
Service Code
|
CPT 12032
|
| Hospital Charge Code |
22282783
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$214.35 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,286.10
|
| Rate for Payer: Aetna of AZ Medicare |
$400.12
|
| Rate for Payer: AHCCCS Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicare |
$214.35
|
| Rate for Payer: Amerigroup Medicare |
$214.35
|
| Rate for Payer: APIPA Medicare/Medicaid |
$533.73
|
| Rate for Payer: AZCH Complete Medicaid |
$501.46
|
| Rate for Payer: AZCH Complete Medicare |
$214.35
|
| Rate for Payer: Banner UC Health Medicaid |
$501.46
|
| Rate for Payer: Banner UC Health Medicare |
$214.35
|
| Rate for Payer: Bisbee Police All Plans |
$371.54
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$971.72
|
| Rate for Payer: Cash Price |
$1,143.20
|
| Rate for Payer: Cash Price |
$1,143.20
|
| Rate for Payer: Cigna of AZ Commercial |
$1,000.30
|
| Rate for Payer: Copperpoint Commercial |
$353.68
|
| Rate for Payer: Health Net of AZ Commercial |
$857.40
|
| Rate for Payer: Health Net of AZ Medicare |
$400.12
|
| Rate for Payer: Humana of AZ Medicare |
$214.35
|
| Rate for Payer: Mercy Care Medicaid |
$501.46
|
| Rate for Payer: Self Pay Self Pay |
$1,143.20
|
| Rate for Payer: TriWest Medicare |
$214.35
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$257.22
|
|
|
12034 REPAIR INTMD WND 7.6CM TO 12.5CM
|
Facility
OP
|
$1,453.00
|
|
|
Service Code
|
CPT 12034
|
| Hospital Charge Code |
22282784
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$217.95 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,307.70
|
| Rate for Payer: Aetna of AZ Medicare |
$406.84
|
| Rate for Payer: AHCCCS Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicaid |
$501.46
|
| Rate for Payer: Allwell Medicare |
$217.95
|
| Rate for Payer: Amerigroup Medicare |
$217.95
|
| Rate for Payer: APIPA Medicare/Medicaid |
$542.70
|
| Rate for Payer: AZCH Complete Medicaid |
$501.46
|
| Rate for Payer: AZCH Complete Medicare |
$217.95
|
| Rate for Payer: Banner UC Health Medicaid |
$501.46
|
| Rate for Payer: Banner UC Health Medicare |
$217.95
|
| Rate for Payer: Bisbee Police All Plans |
$377.78
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$988.04
|
| Rate for Payer: Cash Price |
$1,162.40
|
| Rate for Payer: Cash Price |
$1,162.40
|
| Rate for Payer: Cigna of AZ Commercial |
$1,017.10
|
| Rate for Payer: Copperpoint Commercial |
$359.62
|
| Rate for Payer: Health Net of AZ Commercial |
$871.80
|
| Rate for Payer: Health Net of AZ Medicare |
$406.84
|
| Rate for Payer: Humana of AZ Medicare |
$217.95
|
| Rate for Payer: Mercy Care Medicaid |
$501.46
|
| Rate for Payer: Self Pay Self Pay |
$1,162.40
|
| Rate for Payer: TriWest Medicare |
$217.95
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$261.54
|
|
|
12034 REPAIR INTMD WND 7.6CM TO 12.5CM
|
Facility
IP
|
$1,453.00
|
|
|
Service Code
|
CPT 12034
|
| Hospital Charge Code |
22282784
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$377.78 |
| Max. Negotiated Rate |
$1,307.70 |
| Rate for Payer: Aetna of AZ Commercial |
$1,307.70
|
| Rate for Payer: Bisbee Police All Plans |
$377.78
|
| Rate for Payer: Cash Price |
$1,162.40
|
| Rate for Payer: Self Pay Self Pay |
$1,162.40
|
|
|
12035 LYR SPL 12.6CM-20.0CM
|
Facility
IP
|
$1,100.00
|
|
|
Service Code
|
CPT 12035
|
| Hospital Charge Code |
22282785
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$286.00 |
| Max. Negotiated Rate |
$990.00 |
| Rate for Payer: Aetna of AZ Commercial |
$990.00
|
| Rate for Payer: Bisbee Police All Plans |
$286.00
|
| Rate for Payer: Cash Price |
$880.00
|
| Rate for Payer: Self Pay Self Pay |
$880.00
|
|
