Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

CYTOPATH SMEAR OTH SOURCE 3

Facility

$297.00

Service Code	CPT 88162
Hospital Charge Code	22545737
Hospital Revenue Code	310
Min. Negotiated Rate	$36.08
Max. Negotiated Rate	$267.30
Rate for Payer: Aetna of AZ Commercial	$267.30
Rate for Payer: Aetna of AZ Medicare	$83.16
Rate for Payer: AHCCCS Medicaid	$36.08
Rate for Payer: Allwell Medicaid	$36.08
Rate for Payer: Allwell Medicare	$44.55
Rate for Payer: Amerigroup Medicare	$44.55
Rate for Payer: APIPA Medicare/Medicaid	$110.93
Rate for Payer: AZCH Complete Medicaid	$36.08
Rate for Payer: AZCH Complete Medicare	$44.55
Rate for Payer: Banner UC Health Medicaid	$36.08
Rate for Payer: Banner UC Health Medicare	$44.55
Rate for Payer: Bisbee Police All Plans	$77.22
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$201.96
Rate for Payer: Cash Price	$237.60
Rate for Payer: Cash Price	$237.60
Rate for Payer: Cigna of AZ Commercial	$193.05
Rate for Payer: Copperpoint Commercial	$73.51
Rate for Payer: Health Net of AZ Commercial	$178.20
Rate for Payer: Health Net of AZ Medicare	$83.16
Rate for Payer: Humana of AZ Medicare	$44.55
Rate for Payer: Mercy Care Medicaid	$36.08
Rate for Payer: Self Pay Self Pay	$237.60
Rate for Payer: TriWest Medicare	$44.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$173.15
Rate for Payer: UnitedHealth Group of AZ Medicare	$53.46

CYTP DX EVAL FNA 1ST EA SITE

Facility

$93.00

Service Code	CPT 88172
Hospital Charge Code	22545708
Hospital Revenue Code	310
Min. Negotiated Rate	$24.18
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Bisbee Police All Plans	$24.18
Rate for Payer: Cash Price	$74.40
Rate for Payer: Self Pay Self Pay	$74.40

CYTP DX EVAL FNA 1ST EA SITE

Facility

$93.00

Service Code	CPT 88172
Hospital Charge Code	22545708
Hospital Revenue Code	310
Min. Negotiated Rate	$13.95
Max. Negotiated Rate	$108.14
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Aetna of AZ Medicare	$26.04
Rate for Payer: AHCCCS Medicaid	$108.14
Rate for Payer: Allwell Medicaid	$108.14
Rate for Payer: Allwell Medicare	$13.95
Rate for Payer: Amerigroup Medicare	$13.95
Rate for Payer: APIPA Medicare/Medicaid	$34.74
Rate for Payer: AZCH Complete Medicaid	$108.14
Rate for Payer: AZCH Complete Medicare	$13.95
Rate for Payer: Banner UC Health Medicaid	$108.14
Rate for Payer: Banner UC Health Medicare	$13.95
Rate for Payer: Bisbee Police All Plans	$24.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$63.24
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cigna of AZ Commercial	$60.45
Rate for Payer: Copperpoint Commercial	$23.02
Rate for Payer: Health Net of AZ Commercial	$55.80
Rate for Payer: Health Net of AZ Medicare	$26.04
Rate for Payer: Humana of AZ Medicare	$13.95
Rate for Payer: Mercy Care Medicaid	$108.14
Rate for Payer: Self Pay Self Pay	$74.40
Rate for Payer: TriWest Medicare	$13.95
Rate for Payer: UnitedHealth Group of AZ Commercial	$54.22
Rate for Payer: UnitedHealth Group of AZ Medicare	$16.74

CYTP FNA EVAL EA ADDL

Facility

$42.00

Service Code	CPT 88177
Hospital Charge Code	22545738
Hospital Revenue Code	310
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Aetna of AZ Medicare	$11.76
Rate for Payer: AHCCCS Medicaid	$12.26
Rate for Payer: Allwell Medicaid	$12.26
Rate for Payer: Allwell Medicare	$6.30
Rate for Payer: Amerigroup Medicare	$6.30
Rate for Payer: APIPA Medicare/Medicaid	$15.69
Rate for Payer: AZCH Complete Medicaid	$12.26
Rate for Payer: AZCH Complete Medicare	$6.30
Rate for Payer: Banner UC Health Medicaid	$12.26
Rate for Payer: Banner UC Health Medicare	$6.30
Rate for Payer: Bisbee Police All Plans	$10.92
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$28.56
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cigna of AZ Commercial	$27.30
Rate for Payer: Copperpoint Commercial	$10.40
Rate for Payer: Health Net of AZ Commercial	$25.20
Rate for Payer: Health Net of AZ Medicare	$11.76
Rate for Payer: Humana of AZ Medicare	$6.30
Rate for Payer: Mercy Care Medicaid	$12.26
Rate for Payer: Self Pay Self Pay	$33.60
Rate for Payer: TriWest Medicare	$6.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$24.49
Rate for Payer: UnitedHealth Group of AZ Medicare	$7.56

CYTP FNA EVAL EA ADDL

Facility

$42.00

Service Code	CPT 88177
Hospital Charge Code	22545738
Hospital Revenue Code	310
Min. Negotiated Rate	$10.92
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Bisbee Police All Plans	$10.92
Rate for Payer: Cash Price	$33.60
Rate for Payer: Self Pay Self Pay	$33.60

D16 LOW PROFILE 3MM X 30MM BONE SCREW

Facility

$1,915.00

Hospital Charge Code	27663809
Hospital Revenue Code	270
Min. Negotiated Rate	$497.90
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Bisbee Police All Plans	$497.90
Rate for Payer: Cash Price	$1,532.00
Rate for Payer: Self Pay Self Pay	$1,532.00

D16 LOW PROFILE 3MM X 30MM BONE SCREW

Facility

$1,915.00

Hospital Charge Code	27663809
Hospital Revenue Code	270
Min. Negotiated Rate	$287.25
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Aetna of AZ Medicare	$536.20
Rate for Payer: Allwell Medicare	$287.25
Rate for Payer: Amerigroup Medicare	$287.25
Rate for Payer: APIPA Medicare/Medicaid	$715.25
Rate for Payer: AZCH Complete Medicare	$287.25
Rate for Payer: Banner UC Health Medicare	$287.25
Rate for Payer: Bisbee Police All Plans	$497.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,302.20
Rate for Payer: Cash Price	$1,532.00
Rate for Payer: Cigna of AZ Commercial	$1,340.50
Rate for Payer: Copperpoint Commercial	$473.96
Rate for Payer: Health Net of AZ Commercial	$1,149.00
Rate for Payer: Health Net of AZ Medicare	$536.20
Rate for Payer: Humana of AZ Medicare	$287.25
Rate for Payer: Self Pay Self Pay	$1,532.00
Rate for Payer: TriWest Medicare	$287.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,116.44
Rate for Payer: UnitedHealth Group of AZ Medicare	$344.70

dantrolene 20 mg IV Inj [CQCH]

Facility

$64.25

Service Code	NDC 42023012306
Hospital Charge Code	105917797
Hospital Revenue Code	250
Min. Negotiated Rate	$16.70
Max. Negotiated Rate	$57.82
Rate for Payer: Aetna of AZ Commercial	$57.82
Rate for Payer: Bisbee Police All Plans	$16.70
Rate for Payer: Cash Price	$51.40
Rate for Payer: Self Pay Self Pay	$51.40

dantrolene 20 mg IV Inj [CQCH]

Facility

$64.25

Service Code	NDC 42023012306
Hospital Charge Code	105917797
Hospital Revenue Code	250
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$57.82
Rate for Payer: Aetna of AZ Commercial	$57.82
Rate for Payer: Aetna of AZ Medicare	$17.99
Rate for Payer: Allwell Medicare	$9.64
Rate for Payer: Amerigroup Medicare	$9.64
Rate for Payer: APIPA Medicare/Medicaid	$24.00
Rate for Payer: AZCH Complete Medicare	$9.64
Rate for Payer: Banner UC Health Medicare	$9.64
Rate for Payer: Bisbee Police All Plans	$16.70
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$43.69
Rate for Payer: Cash Price	$51.40
Rate for Payer: Cigna of AZ Commercial	$41.76
Rate for Payer: Copperpoint Commercial	$15.90
Rate for Payer: Health Net of AZ Commercial	$38.55
Rate for Payer: Health Net of AZ Medicare	$17.99
Rate for Payer: Humana of AZ Medicare	$9.64
Rate for Payer: Self Pay Self Pay	$51.40
Rate for Payer: TriWest Medicare	$9.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$37.46
Rate for Payer: UnitedHealth Group of AZ Medicare	$11.56

dantrolene 250 mg vial [CQCH]

Facility

$2,791.83

Service Code	NDC 42367054032
Hospital Charge Code	118269942
Hospital Revenue Code	250
Min. Negotiated Rate	$725.88
Max. Negotiated Rate	$2,512.65
Rate for Payer: Aetna of AZ Commercial	$2,512.65
Rate for Payer: Bisbee Police All Plans	$725.88
Rate for Payer: Cash Price	$2,233.46
Rate for Payer: Self Pay Self Pay	$2,233.46

dantrolene 250 mg vial [CQCH]

Facility

$2,791.83

Service Code	NDC 42367054032
Hospital Charge Code	118269942
Hospital Revenue Code	250
Min. Negotiated Rate	$418.77
Max. Negotiated Rate	$2,512.65
Rate for Payer: Aetna of AZ Commercial	$2,512.65
Rate for Payer: Aetna of AZ Medicare	$781.71
Rate for Payer: Allwell Medicare	$418.77
Rate for Payer: Amerigroup Medicare	$418.77
Rate for Payer: APIPA Medicare/Medicaid	$1,042.75
Rate for Payer: AZCH Complete Medicare	$418.77
Rate for Payer: Banner UC Health Medicare	$418.77
Rate for Payer: Bisbee Police All Plans	$725.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,898.44
Rate for Payer: Cash Price	$2,233.46
Rate for Payer: Cigna of AZ Commercial	$1,814.69
Rate for Payer: Copperpoint Commercial	$690.98
Rate for Payer: Health Net of AZ Commercial	$1,675.10
Rate for Payer: Health Net of AZ Medicare	$781.71
Rate for Payer: Humana of AZ Medicare	$418.77
Rate for Payer: Self Pay Self Pay	$2,233.46
Rate for Payer: TriWest Medicare	$418.77
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,627.64
Rate for Payer: UnitedHealth Group of AZ Medicare	$502.53

dapsone 100 mg Tab[CQCH]

Facility

$0.69

Service Code	NDC 70954013620
Hospital Charge Code	146921850
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of AZ Commercial	$0.62
Rate for Payer: Aetna of AZ Medicare	$0.19
Rate for Payer: Allwell Medicare	$0.10
Rate for Payer: Amerigroup Medicare	$0.10
Rate for Payer: APIPA Medicare/Medicaid	$0.26
Rate for Payer: AZCH Complete Medicare	$0.10
Rate for Payer: Banner UC Health Medicare	$0.10
Rate for Payer: Bisbee Police All Plans	$0.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.47
Rate for Payer: Cash Price	$0.55
Rate for Payer: Cigna of AZ Commercial	$0.45
Rate for Payer: Copperpoint Commercial	$0.17
Rate for Payer: Health Net of AZ Commercial	$0.41
Rate for Payer: Health Net of AZ Medicare	$0.19
Rate for Payer: Humana of AZ Medicare	$0.10
Rate for Payer: Self Pay Self Pay	$0.55
Rate for Payer: TriWest Medicare	$0.10
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.40
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.12

dapsone 100 mg Tab[CQCH]

Facility

$0.69

Service Code	NDC 70954013620
Hospital Charge Code	146921850
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of AZ Commercial	$0.62
Rate for Payer: Bisbee Police All Plans	$0.18
Rate for Payer: Cash Price	$0.55
Rate for Payer: Self Pay Self Pay	$0.55

DAT Complement

Facility

$74.00

Service Code	CPT 86880
Hospital Charge Code	22244675
Hospital Revenue Code	302
Min. Negotiated Rate	$19.24
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Bisbee Police All Plans	$19.24
Rate for Payer: Cash Price	$59.20
Rate for Payer: Self Pay Self Pay	$59.20

DAT Complement

Facility

$74.00

Service Code	CPT 86880
Hospital Charge Code	22244675
Hospital Revenue Code	302
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Aetna of AZ Medicare	$20.72
Rate for Payer: AHCCCS Medicaid	$5.39
Rate for Payer: Allwell Medicaid	$5.39
Rate for Payer: Allwell Medicare	$11.10
Rate for Payer: Amerigroup Medicare	$11.10
Rate for Payer: APIPA Medicare/Medicaid	$27.64
Rate for Payer: AZCH Complete Medicaid	$5.39
Rate for Payer: AZCH Complete Medicare	$11.10
Rate for Payer: Banner UC Health Medicaid	$5.39
Rate for Payer: Banner UC Health Medicare	$11.10
Rate for Payer: Bisbee Police All Plans	$19.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$50.32
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cigna of AZ Commercial	$48.10
Rate for Payer: Copperpoint Commercial	$18.32
Rate for Payer: Health Net of AZ Commercial	$44.40
Rate for Payer: Health Net of AZ Medicare	$20.72
Rate for Payer: Humana of AZ Medicare	$11.10
Rate for Payer: Mercy Care Medicaid	$5.39
Rate for Payer: Self Pay Self Pay	$59.20
Rate for Payer: TriWest Medicare	$11.10
Rate for Payer: UnitedHealth Group of AZ Commercial	$43.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$13.32

DAT IgG

Facility

$74.00

Service Code	CPT 86880
Hospital Charge Code	14018312
Hospital Revenue Code	302
Min. Negotiated Rate	$19.24
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Bisbee Police All Plans	$19.24
Rate for Payer: Cash Price	$59.20
Rate for Payer: Self Pay Self Pay	$59.20

DAT IgG

Facility

$74.00

Service Code	CPT 86880
Hospital Charge Code	14018312
Hospital Revenue Code	302
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Aetna of AZ Medicare	$20.72
Rate for Payer: AHCCCS Medicaid	$5.39
Rate for Payer: Allwell Medicaid	$5.39
Rate for Payer: Allwell Medicare	$11.10
Rate for Payer: Amerigroup Medicare	$11.10
Rate for Payer: APIPA Medicare/Medicaid	$27.64
Rate for Payer: AZCH Complete Medicaid	$5.39
Rate for Payer: AZCH Complete Medicare	$11.10
Rate for Payer: Banner UC Health Medicaid	$5.39
Rate for Payer: Banner UC Health Medicare	$11.10
Rate for Payer: Bisbee Police All Plans	$19.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$50.32
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cigna of AZ Commercial	$48.10
Rate for Payer: Copperpoint Commercial	$18.32
Rate for Payer: Health Net of AZ Commercial	$44.40
Rate for Payer: Health Net of AZ Medicare	$20.72
Rate for Payer: Humana of AZ Medicare	$11.10
Rate for Payer: Mercy Care Medicaid	$5.39
Rate for Payer: Self Pay Self Pay	$59.20
Rate for Payer: TriWest Medicare	$11.10
Rate for Payer: UnitedHealth Group of AZ Commercial	$43.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$13.32

DAT Poly

Facility

$74.00

Service Code	CPT 86880
Hospital Charge Code	14018311
Hospital Revenue Code	302
Min. Negotiated Rate	$19.24
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Bisbee Police All Plans	$19.24
Rate for Payer: Cash Price	$59.20
Rate for Payer: Self Pay Self Pay	$59.20

DAT Poly

Facility

$74.00

Service Code	CPT 86880
Hospital Charge Code	14018311
Hospital Revenue Code	302
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Aetna of AZ Medicare	$20.72
Rate for Payer: AHCCCS Medicaid	$5.39
Rate for Payer: Allwell Medicaid	$5.39
Rate for Payer: Allwell Medicare	$11.10
Rate for Payer: Amerigroup Medicare	$11.10
Rate for Payer: APIPA Medicare/Medicaid	$27.64
Rate for Payer: AZCH Complete Medicaid	$5.39
Rate for Payer: AZCH Complete Medicare	$11.10
Rate for Payer: Banner UC Health Medicaid	$5.39
Rate for Payer: Banner UC Health Medicare	$11.10
Rate for Payer: Bisbee Police All Plans	$19.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$50.32
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cigna of AZ Commercial	$48.10
Rate for Payer: Copperpoint Commercial	$18.32
Rate for Payer: Health Net of AZ Commercial	$44.40
Rate for Payer: Health Net of AZ Medicare	$20.72
Rate for Payer: Humana of AZ Medicare	$11.10
Rate for Payer: Mercy Care Medicaid	$5.39
Rate for Payer: Self Pay Self Pay	$59.20
Rate for Payer: TriWest Medicare	$11.10
Rate for Payer: UnitedHealth Group of AZ Commercial	$43.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$13.32

D&C/GYN PACK

Facility

$36.00

Hospital Charge Code	22355298
Hospital Revenue Code	272
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$32.40
Rate for Payer: Aetna of AZ Commercial	$32.40
Rate for Payer: Aetna of AZ Medicare	$10.08
Rate for Payer: Allwell Medicare	$5.40
Rate for Payer: Amerigroup Medicare	$5.40
Rate for Payer: APIPA Medicare/Medicaid	$13.45
Rate for Payer: AZCH Complete Medicare	$5.40
Rate for Payer: Banner UC Health Medicare	$5.40
Rate for Payer: Bisbee Police All Plans	$9.36
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$24.48
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna of AZ Commercial	$25.20
Rate for Payer: Copperpoint Commercial	$8.91
Rate for Payer: Health Net of AZ Commercial	$21.60
Rate for Payer: Health Net of AZ Medicare	$10.08
Rate for Payer: Humana of AZ Medicare	$5.40
Rate for Payer: Self Pay Self Pay	$28.80
Rate for Payer: TriWest Medicare	$5.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$20.99
Rate for Payer: UnitedHealth Group of AZ Medicare	$6.48

D&C/GYN PACK

Facility

$36.00

Hospital Charge Code	22355298
Hospital Revenue Code	272
Min. Negotiated Rate	$9.36
Max. Negotiated Rate	$32.40
Rate for Payer: Aetna of AZ Commercial	$32.40
Rate for Payer: Bisbee Police All Plans	$9.36
Rate for Payer: Cash Price	$28.80
Rate for Payer: Self Pay Self Pay	$28.80

DCP

Facility

$334.00

Service Code	CPT 83951
Hospital Charge Code	23185839
Hospital Revenue Code	302
Min. Negotiated Rate	$50.10
Max. Negotiated Rate	$300.60
Rate for Payer: Aetna of AZ Commercial	$300.60
Rate for Payer: Aetna of AZ Medicare	$93.52
Rate for Payer: AHCCCS Medicaid	$64.41
Rate for Payer: Allwell Medicaid	$64.41
Rate for Payer: Allwell Medicare	$50.10
Rate for Payer: Amerigroup Medicare	$50.10
Rate for Payer: APIPA Medicare/Medicaid	$124.75
Rate for Payer: AZCH Complete Medicaid	$64.41
Rate for Payer: AZCH Complete Medicare	$50.10
Rate for Payer: Banner UC Health Medicaid	$64.41
Rate for Payer: Banner UC Health Medicare	$50.10
Rate for Payer: Bisbee Police All Plans	$86.84
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$227.12
Rate for Payer: Cash Price	$267.20
Rate for Payer: Cash Price	$267.20
Rate for Payer: Cigna of AZ Commercial	$217.10
Rate for Payer: Copperpoint Commercial	$82.66
Rate for Payer: Health Net of AZ Commercial	$200.40
Rate for Payer: Health Net of AZ Medicare	$93.52
Rate for Payer: Humana of AZ Medicare	$50.10
Rate for Payer: Mercy Care Medicaid	$64.41
Rate for Payer: Self Pay Self Pay	$267.20
Rate for Payer: TriWest Medicare	$50.10
Rate for Payer: UnitedHealth Group of AZ Commercial	$194.72
Rate for Payer: UnitedHealth Group of AZ Medicare	$60.12

DCP

Facility

$334.00

Service Code	CPT 83951
Hospital Charge Code	23185839
Hospital Revenue Code	302
Min. Negotiated Rate	$86.84
Max. Negotiated Rate	$300.60
Rate for Payer: Aetna of AZ Commercial	$300.60
Rate for Payer: Bisbee Police All Plans	$86.84
Rate for Payer: Cash Price	$267.20
Rate for Payer: Self Pay Self Pay	$267.20

D-Dimer

Facility

$311.00

Service Code	CPT 85379
Hospital Charge Code	633718
Hospital Revenue Code	305
Min. Negotiated Rate	$80.86
Max. Negotiated Rate	$279.90
Rate for Payer: Aetna of AZ Commercial	$279.90
Rate for Payer: Bisbee Police All Plans	$80.86
Rate for Payer: Cash Price	$248.80
Rate for Payer: Self Pay Self Pay	$248.80

D-Dimer

Facility

$311.00

Service Code	CPT 85379
Hospital Charge Code	633718
Hospital Revenue Code	305
Min. Negotiated Rate	$10.18
Max. Negotiated Rate	$279.90
Rate for Payer: Aetna of AZ Commercial	$279.90
Rate for Payer: Aetna of AZ Medicare	$87.08
Rate for Payer: AHCCCS Medicaid	$10.18
Rate for Payer: Allwell Medicaid	$10.18
Rate for Payer: Allwell Medicare	$46.65
Rate for Payer: Amerigroup Medicare	$46.65
Rate for Payer: APIPA Medicare/Medicaid	$116.16
Rate for Payer: AZCH Complete Medicaid	$10.18
Rate for Payer: AZCH Complete Medicare	$46.65
Rate for Payer: Banner UC Health Medicaid	$10.18
Rate for Payer: Banner UC Health Medicare	$46.65
Rate for Payer: Bisbee Police All Plans	$80.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$211.48
Rate for Payer: Cash Price	$248.80
Rate for Payer: Cash Price	$248.80
Rate for Payer: Cigna of AZ Commercial	$202.15
Rate for Payer: Copperpoint Commercial	$76.97
Rate for Payer: Health Net of AZ Commercial	$186.60
Rate for Payer: Health Net of AZ Medicare	$87.08
Rate for Payer: Humana of AZ Medicare	$46.65
Rate for Payer: Mercy Care Medicaid	$10.18
Rate for Payer: Self Pay Self Pay	$248.80
Rate for Payer: TriWest Medicare	$46.65
Rate for Payer: UnitedHealth Group of AZ Commercial	$181.31
Rate for Payer: UnitedHealth Group of AZ Medicare	$55.98

Know your out-of-pocket cost for care.

All Charges