|
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
|
|
|
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 |
$130.17 |
| 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 |
$130.17
|
| Rate for Payer: Allwell Medicaid |
$130.17
|
| Rate for Payer: Allwell Medicare |
$315.04
|
| Rate for Payer: Amerigroup Medicare |
$315.04
|
| Rate for Payer: APIPA Medicare/Medicaid |
$735.42
|
| Rate for Payer: AZCH Complete Medicaid |
$130.17
|
| Rate for Payer: AZCH Complete Medicare |
$315.04
|
| Rate for Payer: Banner UC Health Medicaid |
$130.17
|
| Rate for Payer: Banner UC Health Medicare |
$315.04
|
| 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 |
$315.04
|
| Rate for Payer: Mercy Care Medicaid |
$130.17
|
| Rate for Payer: Self Pay Self Pay |
$1,575.20
|
| Rate for Payer: TriWest Medicare |
$315.04
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$354.42
|
|
|
12020 SUP WND DEHIS SMPL
|
Facility
|
OP
|
$839.00
|
|
|
Service Code
|
CPT 12020
|
| Hospital Charge Code |
22282780
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$134.24 |
| 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 |
$380.02
|
| Rate for Payer: Allwell Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicare |
$134.24
|
| Rate for Payer: Amerigroup Medicare |
$134.24
|
| Rate for Payer: APIPA Medicare/Medicaid |
$313.37
|
| Rate for Payer: AZCH Complete Medicaid |
$380.02
|
| Rate for Payer: AZCH Complete Medicare |
$134.24
|
| Rate for Payer: Banner UC Health Medicaid |
$380.02
|
| Rate for Payer: Banner UC Health Medicare |
$134.24
|
| 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 |
$134.24
|
| Rate for Payer: Mercy Care Medicaid |
$380.02
|
| Rate for Payer: Self Pay Self Pay |
$671.20
|
| Rate for Payer: TriWest Medicare |
$134.24
|
| 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
|
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
|
|
|
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 |
$85.92 |
| 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 |
$250.73
|
| Rate for Payer: Allwell Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicare |
$85.92
|
| Rate for Payer: Amerigroup Medicare |
$85.92
|
| Rate for Payer: APIPA Medicare/Medicaid |
$200.57
|
| Rate for Payer: AZCH Complete Medicaid |
$250.73
|
| Rate for Payer: AZCH Complete Medicare |
$85.92
|
| Rate for Payer: Banner UC Health Medicaid |
$250.73
|
| Rate for Payer: Banner UC Health Medicare |
$85.92
|
| 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 |
$85.92
|
| Rate for Payer: Mercy Care Medicaid |
$250.73
|
| Rate for Payer: Self Pay Self Pay |
$429.60
|
| Rate for Payer: TriWest Medicare |
$85.92
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$96.66
|
|
|
12031 REPAIR INTMD WND 2.5CM OR LESS
|
Facility
|
OP
|
$1,493.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
22282782
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$238.88 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,343.70
|
| Rate for Payer: Aetna of AZ Medicare |
$418.04
|
| Rate for Payer: AHCCCS Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicare |
$238.88
|
| Rate for Payer: Amerigroup Medicare |
$238.88
|
| Rate for Payer: APIPA Medicare/Medicaid |
$557.64
|
| Rate for Payer: AZCH Complete Medicaid |
$250.73
|
| Rate for Payer: AZCH Complete Medicare |
$238.88
|
| Rate for Payer: Banner UC Health Medicaid |
$250.73
|
| Rate for Payer: Banner UC Health Medicare |
$238.88
|
| Rate for Payer: Bisbee Police All Plans |
$388.18
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,015.24
|
| Rate for Payer: Cash Price |
$1,194.40
|
| Rate for Payer: Cash Price |
$1,194.40
|
| Rate for Payer: Cigna of AZ Commercial |
$1,045.10
|
| Rate for Payer: Copperpoint Commercial |
$369.52
|
| Rate for Payer: Health Net of AZ Commercial |
$895.80
|
| Rate for Payer: Health Net of AZ Medicare |
$418.04
|
| Rate for Payer: Humana of AZ Medicare |
$238.88
|
| Rate for Payer: Mercy Care Medicaid |
$250.73
|
| Rate for Payer: Self Pay Self Pay |
$1,194.40
|
| Rate for Payer: TriWest Medicare |
$238.88
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$268.74
|
|
|
12031 REPAIR INTMD WND 2.5CM OR LESS
|
Facility
|
IP
|
$1,493.00
|
|
|
Service Code
|
CPT 12031
|
| Hospital Charge Code |
22282782
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$388.18 |
| Max. Negotiated Rate |
$1,343.70 |
| Rate for Payer: Aetna of AZ Commercial |
$1,343.70
|
| Rate for Payer: Bisbee Police All Plans |
$388.18
|
| Rate for Payer: Cash Price |
$1,194.40
|
| Rate for Payer: Self Pay Self Pay |
$1,194.40
|
|
|
12032 REPAIR INTMD WND 2.6CM TO 7.5CM
|
Facility
|
OP
|
$1,929.00
|
|
|
Service Code
|
CPT 12032
|
| Hospital Charge Code |
22282783
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$250.73 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,736.10
|
| Rate for Payer: Aetna of AZ Medicare |
$540.12
|
| Rate for Payer: AHCCCS Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicare |
$308.64
|
| Rate for Payer: Amerigroup Medicare |
$308.64
|
| Rate for Payer: APIPA Medicare/Medicaid |
$720.48
|
| Rate for Payer: AZCH Complete Medicaid |
$250.73
|
| Rate for Payer: AZCH Complete Medicare |
$308.64
|
| Rate for Payer: Banner UC Health Medicaid |
$250.73
|
| Rate for Payer: Banner UC Health Medicare |
$308.64
|
| Rate for Payer: Bisbee Police All Plans |
$501.54
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,311.72
|
| Rate for Payer: Cash Price |
$1,543.20
|
| Rate for Payer: Cash Price |
$1,543.20
|
| Rate for Payer: Cigna of AZ Commercial |
$1,350.30
|
| Rate for Payer: Copperpoint Commercial |
$477.43
|
| Rate for Payer: Health Net of AZ Commercial |
$1,157.40
|
| Rate for Payer: Health Net of AZ Medicare |
$540.12
|
| Rate for Payer: Humana of AZ Medicare |
$308.64
|
| Rate for Payer: Mercy Care Medicaid |
$250.73
|
| Rate for Payer: Self Pay Self Pay |
$1,543.20
|
| Rate for Payer: TriWest Medicare |
$308.64
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$347.22
|
|
|
12032 REPAIR INTMD WND 2.6CM TO 7.5CM
|
Facility
|
IP
|
$1,929.00
|
|
|
Service Code
|
CPT 12032
|
| Hospital Charge Code |
22282783
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$501.54 |
| Max. Negotiated Rate |
$1,736.10 |
| Rate for Payer: Aetna of AZ Commercial |
$1,736.10
|
| Rate for Payer: Bisbee Police All Plans |
$501.54
|
| Rate for Payer: Cash Price |
$1,543.20
|
| Rate for Payer: Self Pay Self Pay |
$1,543.20
|
|
|
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
|
|
|
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 |
$232.48 |
| 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 |
$250.73
|
| Rate for Payer: Allwell Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicare |
$232.48
|
| Rate for Payer: Amerigroup Medicare |
$232.48
|
| Rate for Payer: APIPA Medicare/Medicaid |
$542.70
|
| Rate for Payer: AZCH Complete Medicaid |
$250.73
|
| Rate for Payer: AZCH Complete Medicare |
$232.48
|
| Rate for Payer: Banner UC Health Medicaid |
$250.73
|
| Rate for Payer: Banner UC Health Medicare |
$232.48
|
| 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 |
$232.48
|
| Rate for Payer: Mercy Care Medicaid |
$250.73
|
| Rate for Payer: Self Pay Self Pay |
$1,162.40
|
| Rate for Payer: TriWest Medicare |
$232.48
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$261.54
|
|
|
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
|
|
|
12035 LYR SPL 12.6CM-20.0CM
|
Facility
|
OP
|
$1,100.00
|
|
|
Service Code
|
CPT 12035
|
| Hospital Charge Code |
22282785
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$176.00 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$990.00
|
| Rate for Payer: Aetna of AZ Medicare |
$308.00
|
| Rate for Payer: AHCCCS Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicare |
$176.00
|
| Rate for Payer: Amerigroup Medicare |
$176.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$410.85
|
| Rate for Payer: AZCH Complete Medicaid |
$250.73
|
| Rate for Payer: AZCH Complete Medicare |
$176.00
|
| Rate for Payer: Banner UC Health Medicaid |
$250.73
|
| Rate for Payer: Banner UC Health Medicare |
$176.00
|
| Rate for Payer: Bisbee Police All Plans |
$286.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$748.00
|
| Rate for Payer: Cash Price |
$880.00
|
| Rate for Payer: Cash Price |
$880.00
|
| Rate for Payer: Cigna of AZ Commercial |
$770.00
|
| Rate for Payer: Copperpoint Commercial |
$272.25
|
| Rate for Payer: Health Net of AZ Commercial |
$660.00
|
| Rate for Payer: Health Net of AZ Medicare |
$308.00
|
| Rate for Payer: Humana of AZ Medicare |
$176.00
|
| Rate for Payer: Mercy Care Medicaid |
$250.73
|
| Rate for Payer: Self Pay Self Pay |
$880.00
|
| Rate for Payer: TriWest Medicare |
$176.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$198.00
|
|
|
12036 LYR S/P AXL TNK 20.1-30
|
Facility
|
OP
|
$1,348.00
|
|
|
Service Code
|
CPT 12036
|
| Hospital Charge Code |
22282786
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$215.68 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,213.20
|
| Rate for Payer: Aetna of AZ Medicare |
$377.44
|
| Rate for Payer: AHCCCS Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicare |
$215.68
|
| Rate for Payer: Amerigroup Medicare |
$215.68
|
| Rate for Payer: APIPA Medicare/Medicaid |
$503.48
|
| Rate for Payer: AZCH Complete Medicaid |
$380.02
|
| Rate for Payer: AZCH Complete Medicare |
$215.68
|
| Rate for Payer: Banner UC Health Medicaid |
$380.02
|
| Rate for Payer: Banner UC Health Medicare |
$215.68
|
| Rate for Payer: Bisbee Police All Plans |
$350.48
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$916.64
|
| Rate for Payer: Cash Price |
$1,078.40
|
| Rate for Payer: Cash Price |
$1,078.40
|
| Rate for Payer: Cigna of AZ Commercial |
$943.60
|
| Rate for Payer: Copperpoint Commercial |
$333.63
|
| Rate for Payer: Health Net of AZ Commercial |
$808.80
|
| Rate for Payer: Health Net of AZ Medicare |
$377.44
|
| Rate for Payer: Humana of AZ Medicare |
$215.68
|
| Rate for Payer: Mercy Care Medicaid |
$380.02
|
| Rate for Payer: Self Pay Self Pay |
$1,078.40
|
| Rate for Payer: TriWest Medicare |
$215.68
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$242.64
|
|
|
12036 LYR S/P AXL TNK 20.1-30
|
Facility
|
IP
|
$1,348.00
|
|
|
Service Code
|
CPT 12036
|
| Hospital Charge Code |
22282786
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$350.48 |
| Max. Negotiated Rate |
$1,213.20 |
| Rate for Payer: Aetna of AZ Commercial |
$1,213.20
|
| Rate for Payer: Bisbee Police All Plans |
$350.48
|
| Rate for Payer: Cash Price |
$1,078.40
|
| Rate for Payer: Self Pay Self Pay |
$1,078.40
|
|
|
12037 LYR S/P AXL TNK>30
|
Facility
|
OP
|
$1,600.00
|
|
|
Service Code
|
CPT 12037
|
| Hospital Charge Code |
22282787
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$256.00 |
| Max. Negotiated Rate |
$2,909.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,440.00
|
| Rate for Payer: Aetna of AZ Medicare |
$448.00
|
| Rate for Payer: AHCCCS Medicaid |
$1,243.64
|
| Rate for Payer: Allwell Medicaid |
$1,243.64
|
| Rate for Payer: Allwell Medicare |
$256.00
|
| Rate for Payer: Amerigroup Medicare |
$256.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$597.60
|
| Rate for Payer: AZCH Complete Medicaid |
$1,243.64
|
| Rate for Payer: AZCH Complete Medicare |
$256.00
|
| Rate for Payer: Banner UC Health Medicaid |
$1,243.64
|
| Rate for Payer: Banner UC Health Medicare |
$256.00
|
| Rate for Payer: Bisbee Police All Plans |
$416.00
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$1,088.00
|
| Rate for Payer: Cash Price |
$1,280.00
|
| Rate for Payer: Cash Price |
$1,280.00
|
| Rate for Payer: Cigna of AZ Commercial |
$1,120.00
|
| Rate for Payer: Copperpoint Commercial |
$396.00
|
| Rate for Payer: Health Net of AZ Commercial |
$960.00
|
| Rate for Payer: Health Net of AZ Medicare |
$448.00
|
| Rate for Payer: Humana of AZ Medicare |
$256.00
|
| Rate for Payer: Mercy Care Medicaid |
$1,243.64
|
| Rate for Payer: Self Pay Self Pay |
$1,280.00
|
| Rate for Payer: TriWest Medicare |
$256.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,909.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$288.00
|
|
|
12037 LYR S/P AXL TNK>30
|
Facility
|
IP
|
$1,600.00
|
|
|
Service Code
|
CPT 12037
|
| Hospital Charge Code |
22282787
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$416.00 |
| Max. Negotiated Rate |
$1,440.00 |
| Rate for Payer: Aetna of AZ Commercial |
$1,440.00
|
| Rate for Payer: Bisbee Police All Plans |
$416.00
|
| Rate for Payer: Cash Price |
$1,280.00
|
| Rate for Payer: Self Pay Self Pay |
$1,280.00
|
|
|
12041 LYR NK HND FT EXGEN 2.5
|
Facility
|
IP
|
$896.00
|
|
|
Service Code
|
CPT 12041
|
| Hospital Charge Code |
22282788
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$232.96 |
| Max. Negotiated Rate |
$806.40 |
| Rate for Payer: Aetna of AZ Commercial |
$806.40
|
| Rate for Payer: Bisbee Police All Plans |
$232.96
|
| Rate for Payer: Cash Price |
$716.80
|
| Rate for Payer: Self Pay Self Pay |
$716.80
|
|
|
12041 LYR NK HND FT EXGEN 2.5
|
Facility
|
OP
|
$896.00
|
|
|
Service Code
|
CPT 12041
|
| Hospital Charge Code |
22282788
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$143.36 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$806.40
|
| Rate for Payer: Aetna of AZ Medicare |
$250.88
|
| Rate for Payer: AHCCCS Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicare |
$143.36
|
| Rate for Payer: Amerigroup Medicare |
$143.36
|
| Rate for Payer: APIPA Medicare/Medicaid |
$334.66
|
| Rate for Payer: AZCH Complete Medicaid |
$250.73
|
| Rate for Payer: AZCH Complete Medicare |
$143.36
|
| Rate for Payer: Banner UC Health Medicaid |
$250.73
|
| Rate for Payer: Banner UC Health Medicare |
$143.36
|
| Rate for Payer: Bisbee Police All Plans |
$232.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$609.28
|
| Rate for Payer: Cash Price |
$716.80
|
| Rate for Payer: Cash Price |
$716.80
|
| Rate for Payer: Cigna of AZ Commercial |
$627.20
|
| Rate for Payer: Copperpoint Commercial |
$221.76
|
| Rate for Payer: Health Net of AZ Commercial |
$537.60
|
| Rate for Payer: Health Net of AZ Medicare |
$250.88
|
| Rate for Payer: Humana of AZ Medicare |
$143.36
|
| Rate for Payer: Mercy Care Medicaid |
$250.73
|
| Rate for Payer: Self Pay Self Pay |
$716.80
|
| Rate for Payer: TriWest Medicare |
$143.36
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$161.28
|
|
|
12042 LR NK HD FT XGEN 2.6-7.5
|
Facility
|
OP
|
$771.00
|
|
|
Service Code
|
CPT 12042
|
| Hospital Charge Code |
22282789
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$123.36 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$693.90
|
| Rate for Payer: Aetna of AZ Medicare |
$215.88
|
| Rate for Payer: AHCCCS Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicaid |
$250.73
|
| Rate for Payer: Allwell Medicare |
$123.36
|
| Rate for Payer: Amerigroup Medicare |
$123.36
|
| Rate for Payer: APIPA Medicare/Medicaid |
$287.97
|
| Rate for Payer: AZCH Complete Medicaid |
$250.73
|
| Rate for Payer: AZCH Complete Medicare |
$123.36
|
| Rate for Payer: Banner UC Health Medicaid |
$250.73
|
| Rate for Payer: Banner UC Health Medicare |
$123.36
|
| Rate for Payer: Bisbee Police All Plans |
$200.46
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$524.28
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Cigna of AZ Commercial |
$539.70
|
| Rate for Payer: Copperpoint Commercial |
$190.82
|
| Rate for Payer: Health Net of AZ Commercial |
$462.60
|
| Rate for Payer: Health Net of AZ Medicare |
$215.88
|
| Rate for Payer: Humana of AZ Medicare |
$123.36
|
| Rate for Payer: Mercy Care Medicaid |
$250.73
|
| Rate for Payer: Self Pay Self Pay |
$616.80
|
| Rate for Payer: TriWest Medicare |
$123.36
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$138.78
|
|
|
12042 LR NK HD FT XGEN 2.6-7.5
|
Facility
|
IP
|
$771.00
|
|
|
Service Code
|
CPT 12042
|
| Hospital Charge Code |
22282789
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$200.46 |
| Max. Negotiated Rate |
$693.90 |
| Rate for Payer: Aetna of AZ Commercial |
$693.90
|
| Rate for Payer: Bisbee Police All Plans |
$200.46
|
| Rate for Payer: Cash Price |
$616.80
|
| Rate for Payer: Self Pay Self Pay |
$616.80
|
|
|
12044 LR NK HD FT XGN 7.5-12.5
|
Facility
|
OP
|
$991.00
|
|
|
Service Code
|
CPT 12044
|
| Hospital Charge Code |
22282790
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$158.56 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of AZ Commercial |
$891.90
|
| Rate for Payer: Aetna of AZ Medicare |
$277.48
|
| Rate for Payer: AHCCCS Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicaid |
$380.02
|
| Rate for Payer: Allwell Medicare |
$158.56
|
| Rate for Payer: Amerigroup Medicare |
$158.56
|
| Rate for Payer: APIPA Medicare/Medicaid |
$370.14
|
| Rate for Payer: AZCH Complete Medicaid |
$380.02
|
| Rate for Payer: AZCH Complete Medicare |
$158.56
|
| Rate for Payer: Banner UC Health Medicaid |
$380.02
|
| Rate for Payer: Banner UC Health Medicare |
$158.56
|
| Rate for Payer: Bisbee Police All Plans |
$257.66
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$673.88
|
| Rate for Payer: Cash Price |
$792.80
|
| Rate for Payer: Cash Price |
$792.80
|
| Rate for Payer: Cigna of AZ Commercial |
$693.70
|
| Rate for Payer: Copperpoint Commercial |
$245.27
|
| Rate for Payer: Health Net of AZ Commercial |
$594.60
|
| Rate for Payer: Health Net of AZ Medicare |
$277.48
|
| Rate for Payer: Humana of AZ Medicare |
$158.56
|
| Rate for Payer: Mercy Care Medicaid |
$380.02
|
| Rate for Payer: Self Pay Self Pay |
$792.80
|
| Rate for Payer: TriWest Medicare |
$158.56
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$2,161.00
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$178.38
|
|
|
12044 LR NK HD FT XGN 7.5-12.5
|
Facility
|
IP
|
$991.00
|
|
|
Service Code
|
CPT 12044
|
| Hospital Charge Code |
22282790
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$257.66 |
| Max. Negotiated Rate |
$891.90 |
| Rate for Payer: Aetna of AZ Commercial |
$891.90
|
| Rate for Payer: Bisbee Police All Plans |
$257.66
|
| Rate for Payer: Cash Price |
$792.80
|
| Rate for Payer: Self Pay Self Pay |
$792.80
|
|
|
12045 LR NK HD FT XGN 12.5-20.
|
Facility
|
IP
|
$1,179.00
|
|
|
Service Code
|
CPT 12045
|
| Hospital Charge Code |
22282791
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$306.54 |
| Max. Negotiated Rate |
$1,061.10 |
| Rate for Payer: Aetna of AZ Commercial |
$1,061.10
|
| Rate for Payer: Bisbee Police All Plans |
$306.54
|
| Rate for Payer: Cash Price |
$943.20
|
| Rate for Payer: Self Pay Self Pay |
$943.20
|
|
