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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

Colposcopy of the cervix incuding upper/adjacent vagina

Facility

IP

$911.00

Service Code	CPT 57452
Hospital Charge Code	22664756
Hospital Revenue Code	360
Min. Negotiated Rate	$819.90
Max. Negotiated Rate	$819.90
Rate for Payer: Aetna of AZ Commercial	$819.90
Rate for Payer: Cash Price	$728.80

Colposcopy of the cervix incuding upper/adjacent vagina with

Facility

OP

$1,232.00

Service Code	CPT 57456
Hospital Charge Code	22664759
Hospital Revenue Code	360
Min. Negotiated Rate	$43.71
Max. Negotiated Rate	$2,671.00
Rate for Payer: Aetna of AZ Commercial	$1,108.80
Rate for Payer: Arizona Complete Health Allwell	$197.12
Rate for Payer: Banner UC Health Medicare	$43.71
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$837.76
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$52.30
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$197.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$197.12
Rate for Payer: Cash Price	$985.60
Rate for Payer: Cash Price	$985.60
Rate for Payer: Cash Price	$985.60
Rate for Payer: Cigna of AZ Commercial	$616.00
Rate for Payer: Devoted Health Medicare	$221.76
Rate for Payer: Humana of AZ Medicare	$197.12
Rate for Payer: Mercy Care Medicaid	$52.30
Rate for Payer: NaphCare Correctional Healthcare	$43.71
Rate for Payer: Seven Corners Travel Insurance	$471.50
Rate for Payer: Southwest Service Administrators UFCW	$837.76
Rate for Payer: TriWest Medicare	$197.12
Rate for Payer: United Healthcare Commercial	$2,671.00
Rate for Payer: United Healthcare Medicare	$197.12
Rate for Payer: Veterans Affairs TRICARE	$195.15

Colposcopy of the cervix incuding upper/adjacent vagina with

Facility

IP

$1,236.00

Service Code	CPT 57455
Hospital Charge Code	22664758
Hospital Revenue Code	750
Min. Negotiated Rate	$1,112.40
Max. Negotiated Rate	$1,112.40
Rate for Payer: Aetna of AZ Commercial	$1,112.40
Rate for Payer: Cash Price	$988.80

Colposcopy of the cervix incuding upper/adjacent vagina with

Facility

OP

$1,236.00

Service Code	CPT 57455
Hospital Charge Code	22664758
Hospital Revenue Code	750
Min. Negotiated Rate	$46.28
Max. Negotiated Rate	$2,671.00
Rate for Payer: Aetna of AZ Commercial	$1,112.40
Rate for Payer: Arizona Complete Health Allwell	$197.76
Rate for Payer: Banner UC Health Medicare	$46.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$840.48
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$54.05
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$197.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$197.76
Rate for Payer: Cash Price	$988.80
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: Devoted Health Medicare	$222.48
Rate for Payer: Humana of AZ Medicare	$197.76
Rate for Payer: Mercy Care Medicaid	$54.05
Rate for Payer: NaphCare Correctional Healthcare	$46.28
Rate for Payer: Seven Corners Travel Insurance	$471.50
Rate for Payer: Southwest Service Administrators UFCW	$840.48
Rate for Payer: TriWest Medicare	$197.76
Rate for Payer: United Healthcare Commercial	$2,671.00
Rate for Payer: United Healthcare Medicare	$197.76
Rate for Payer: United Healthcare New Mexico Commercial	$234.84
Rate for Payer: Veterans Affairs TRICARE	$195.78

Colposcopy of the cervix incuding upper/adjacent vagina with

Facility

IP

$1,232.00

Service Code	CPT 57456
Hospital Charge Code	22664759
Hospital Revenue Code	360
Min. Negotiated Rate	$1,108.80
Max. Negotiated Rate	$1,108.80
Rate for Payer: Aetna of AZ Commercial	$1,108.80
Rate for Payer: Cash Price	$985.60

Colposcopy of the cervix incuding upper/adjacent vagina with

Facility

IP

$1,236.00

Service Code	CPT 57454
Hospital Charge Code	22664757
Hospital Revenue Code	360
Min. Negotiated Rate	$1,112.40
Max. Negotiated Rate	$1,112.40
Rate for Payer: Aetna of AZ Commercial	$1,112.40
Rate for Payer: Cash Price	$988.80

Colposcopy of the cervix incuding upper/adjacent vagina with

Facility

OP

$1,236.00

Service Code	CPT 57454
Hospital Charge Code	22664757
Hospital Revenue Code	360
Min. Negotiated Rate	$35.56
Max. Negotiated Rate	$2,671.00
Rate for Payer: Aetna of AZ Commercial	$1,112.40
Rate for Payer: Arizona Complete Health Allwell	$197.76
Rate for Payer: Banner UC Health Medicare	$42.43
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$840.48
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$35.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$197.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$197.76
Rate for Payer: Cash Price	$988.80
Rate for Payer: Cash Price	$988.80
Rate for Payer: Cash Price	$988.80
Rate for Payer: Cigna of AZ Commercial	$618.00
Rate for Payer: Devoted Health Medicare	$222.48
Rate for Payer: Humana of AZ Medicare	$197.76
Rate for Payer: Mercy Care Medicaid	$35.56
Rate for Payer: NaphCare Correctional Healthcare	$42.43
Rate for Payer: Seven Corners Travel Insurance	$471.50
Rate for Payer: Southwest Service Administrators UFCW	$840.48
Rate for Payer: TriWest Medicare	$197.76
Rate for Payer: United Healthcare Commercial	$2,671.00
Rate for Payer: United Healthcare Medicare	$197.76
Rate for Payer: Veterans Affairs TRICARE	$195.78

Colposcopy of the entire vagina, with cervix if present;

Facility

OP

$2,671.00

Service Code	CPT 57420
Hospital Revenue Code	750
Min. Negotiated Rate	$41.51
Max. Negotiated Rate	$2,671.00
Rate for Payer: Banner UC Health Medicare	$41.51
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$44.28
Rate for Payer: Mercy Care Medicaid	$44.28
Rate for Payer: NaphCare Correctional Healthcare	$41.51
Rate for Payer: Seven Corners Travel Insurance	$471.50
Rate for Payer: United Healthcare Commercial	$2,671.00

Colposcopy of the entire vagina with cervix with biopsies of

Facility

OP

$3,135.00

Service Code	CPT 57421
Hospital Charge Code	22664755
Hospital Revenue Code	750
Min. Negotiated Rate	$52.89
Max. Negotiated Rate	$3,098.00
Rate for Payer: Aetna of AZ Commercial	$2,821.50
Rate for Payer: Arizona Complete Health Allwell	$501.60
Rate for Payer: Banner UC Health Medicare	$52.89
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,131.80
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$56.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$501.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$501.60
Rate for Payer: Cash Price	$2,508.00
Rate for Payer: Cash Price	$2,508.00
Rate for Payer: Cash Price	$2,508.00
Rate for Payer: Cigna of AZ Commercial	$2,194.50
Rate for Payer: Devoted Health Medicare	$564.30
Rate for Payer: Humana of AZ Medicare	$501.60
Rate for Payer: Mercy Care Medicaid	$56.84
Rate for Payer: NaphCare Correctional Healthcare	$52.89
Rate for Payer: Seven Corners Travel Insurance	$1,425.12
Rate for Payer: Southwest Service Administrators UFCW	$2,131.80
Rate for Payer: TriWest Medicare	$501.60
Rate for Payer: United Healthcare Commercial	$3,098.00
Rate for Payer: United Healthcare Medicare	$501.60
Rate for Payer: United Healthcare New Mexico Commercial	$595.65
Rate for Payer: Veterans Affairs TRICARE	$496.58

Colposcopy of the entire vagina with cervix with biopsies of

Facility

IP

$3,135.00

Service Code	CPT 57421
Hospital Charge Code	22664755
Hospital Revenue Code	750
Min. Negotiated Rate	$2,821.50
Max. Negotiated Rate	$2,821.50
Rate for Payer: Aetna of AZ Commercial	$2,821.50
Rate for Payer: Cash Price	$2,508.00

COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITH MCC

Facility

IP

$116,441.34

Service Code	MSDRG 429
Min. Negotiated Rate	$116,441.34
Max. Negotiated Rate	$116,441.34
Rate for Payer: Seven Corners Travel Insurance	$116,441.34

COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC

Facility

IP

$74,534.81

Service Code	MSDRG 430
Min. Negotiated Rate	$74,534.81
Max. Negotiated Rate	$74,534.81
Rate for Payer: Seven Corners Travel Insurance	$74,534.81

Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed;

Facility

OP

$7,740.14

Service Code	CPT 57260
Hospital Revenue Code	360
Min. Negotiated Rate	$1,698.98
Max. Negotiated Rate	$7,740.14
Rate for Payer: Banner UC Health Medicare	$1,698.98
Rate for Payer: NaphCare Correctional Healthcare	$1,698.98
Rate for Payer: Seven Corners Travel Insurance	$7,740.14
Rate for Payer: United Healthcare Commercial	$4,838.00

Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed;

Facility

OP

$7,740.14

Service Code	CPT 57260
Hospital Revenue Code	490
Min. Negotiated Rate	$1,698.98
Max. Negotiated Rate	$7,740.14
Rate for Payer: Banner UC Health Medicare	$1,698.98
Rate for Payer: NaphCare Correctional Healthcare	$1,698.98
Rate for Payer: Seven Corners Travel Insurance	$7,740.14
Rate for Payer: United Healthcare Commercial	$4,838.00

COMPARTMENT PRESSURE MONITORING KIT

Facility

OP

$307.51

Hospital Charge Code	24335352
Min. Negotiated Rate	$48.71
Max. Negotiated Rate	$276.76
Rate for Payer: Aetna of AZ Commercial	$276.76
Rate for Payer: Arizona Complete Health Allwell	$49.20
Rate for Payer: Banner UC Health Medicare	$49.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$209.11
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$49.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$49.20
Rate for Payer: Cash Price	$246.01
Rate for Payer: Cigna of AZ Commercial	$215.26
Rate for Payer: Devoted Health Medicare	$55.35
Rate for Payer: Humana of AZ Medicare	$49.20
Rate for Payer: Southwest Service Administrators UFCW	$209.11
Rate for Payer: TriWest Medicare	$49.20
Rate for Payer: United Healthcare Commercial	$175.90
Rate for Payer: United Healthcare Medicare	$49.20
Rate for Payer: Veterans Affairs TRICARE	$48.71

COMPARTMENT PRESSURE MONITORING KIT

Facility

IP

$307.51

Hospital Charge Code	24335352
Min. Negotiated Rate	$276.76
Max. Negotiated Rate	$276.76
Rate for Payer: Aetna of AZ Commercial	$276.76
Rate for Payer: Cash Price	$246.01

Comp Assess, Care Planning by Physician of pt requiring chro

Facility

IP

$185.00

Service Code	HCPCS G0506
Hospital Charge Code	23889600
Hospital Revenue Code	521
Min. Negotiated Rate	$166.50
Max. Negotiated Rate	$166.50
Rate for Payer: Aetna of AZ Commercial	$166.50
Rate for Payer: Cash Price	$148.00

Comp Assess, Care Planning by Physician of pt requiring chro

Facility

OP

$185.00

Service Code	HCPCS G0506
Hospital Charge Code	23889600
Hospital Revenue Code	521
Min. Negotiated Rate	$29.30
Max. Negotiated Rate	$166.50
Rate for Payer: Aetna of AZ Commercial	$166.50
Rate for Payer: Arizona Complete Health Allwell	$29.60
Rate for Payer: Banner UC Health Medicare	$29.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$125.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$29.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$29.60
Rate for Payer: Cash Price	$148.00
Rate for Payer: Cigna of AZ Commercial	$129.50
Rate for Payer: Devoted Health Medicare	$33.30
Rate for Payer: Humana of AZ Medicare	$29.60
Rate for Payer: Southwest Service Administrators UFCW	$125.80
Rate for Payer: TriWest Medicare	$29.60
Rate for Payer: United Healthcare Commercial	$105.82
Rate for Payer: United Healthcare Medicare	$29.60
Rate for Payer: Veterans Affairs TRICARE	$29.30

Complement C3, Serum LC

Facility

IP

$258.00

Service Code	CPT 86160
Hospital Charge Code	1285557
Hospital Revenue Code	302
Min. Negotiated Rate	$232.20
Max. Negotiated Rate	$232.20
Rate for Payer: Aetna of AZ Commercial	$232.20
Rate for Payer: Cash Price	$206.40

Complement C3, Serum LC

Facility

OP

$258.00

Service Code	CPT 86160
Hospital Charge Code	1285557
Hospital Revenue Code	302
Min. Negotiated Rate	$17.40
Max. Negotiated Rate	$232.20
Rate for Payer: Aetna of AZ Commercial	$232.20
Rate for Payer: Arizona Complete Health Allwell	$41.28
Rate for Payer: Banner UC Health Medicare	$41.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$175.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$41.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$41.28
Rate for Payer: Cash Price	$206.40
Rate for Payer: Cash Price	$206.40
Rate for Payer: Cigna of AZ Commercial	$167.70
Rate for Payer: Devoted Health Medicare	$46.44
Rate for Payer: Humana of AZ Medicare	$41.28
Rate for Payer: Seven Corners Travel Insurance	$17.40
Rate for Payer: Southwest Service Administrators UFCW	$175.44
Rate for Payer: TriWest Medicare	$41.28
Rate for Payer: United Healthcare Commercial	$147.58
Rate for Payer: United Healthcare Medicare	$41.28
Rate for Payer: Veterans Affairs TRICARE	$40.87

Complement C4, Serum LC

Facility

OP

$258.00

Service Code	CPT 86160
Hospital Charge Code	1285559
Hospital Revenue Code	302
Min. Negotiated Rate	$17.40
Max. Negotiated Rate	$232.20
Rate for Payer: Aetna of AZ Commercial	$232.20
Rate for Payer: Arizona Complete Health Allwell	$41.28
Rate for Payer: Banner UC Health Medicare	$41.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$175.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$41.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$41.28
Rate for Payer: Cash Price	$206.40
Rate for Payer: Cash Price	$206.40
Rate for Payer: Cigna of AZ Commercial	$167.70
Rate for Payer: Devoted Health Medicare	$46.44
Rate for Payer: Humana of AZ Medicare	$41.28
Rate for Payer: Seven Corners Travel Insurance	$17.40
Rate for Payer: Southwest Service Administrators UFCW	$175.44
Rate for Payer: TriWest Medicare	$41.28
Rate for Payer: United Healthcare Commercial	$147.58
Rate for Payer: United Healthcare Medicare	$41.28
Rate for Payer: Veterans Affairs TRICARE	$40.87

Complement C4, Serum LC

Facility

IP

$258.00

Service Code	CPT 86160
Hospital Charge Code	1285559
Hospital Revenue Code	302
Min. Negotiated Rate	$232.20
Max. Negotiated Rate	$232.20
Rate for Payer: Aetna of AZ Commercial	$232.20
Rate for Payer: Cash Price	$206.40

Complement, Total (CH50) LC

Facility

OP

$309.00

Service Code	CPT 86162
Hospital Charge Code	1906808
Hospital Revenue Code	302
Min. Negotiated Rate	$29.46
Max. Negotiated Rate	$278.10
Rate for Payer: Aetna of AZ Commercial	$278.10
Rate for Payer: Arizona Complete Health Allwell	$49.44
Rate for Payer: Banner UC Health Medicare	$49.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$210.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$49.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$49.44
Rate for Payer: Cash Price	$247.20
Rate for Payer: Cash Price	$247.20
Rate for Payer: Cigna of AZ Commercial	$200.85
Rate for Payer: Devoted Health Medicare	$55.62
Rate for Payer: Humana of AZ Medicare	$49.44
Rate for Payer: Seven Corners Travel Insurance	$29.46
Rate for Payer: Southwest Service Administrators UFCW	$210.12
Rate for Payer: TriWest Medicare	$49.44
Rate for Payer: United Healthcare Commercial	$176.75
Rate for Payer: United Healthcare Medicare	$49.44
Rate for Payer: Veterans Affairs TRICARE	$48.95

Complement, Total (CH50) LC

Facility

IP

$309.00

Service Code	CPT 86162
Hospital Charge Code	1906808
Hospital Revenue Code	302
Min. Negotiated Rate	$278.10
Max. Negotiated Rate	$278.10
Rate for Payer: Aetna of AZ Commercial	$278.10
Rate for Payer: Cash Price	$247.20

Complete Blood Count/Hemogram Standard

Facility

IP

$170.00

Service Code	CPT 85025
Hospital Charge Code	22141055
Hospital Revenue Code	305
Min. Negotiated Rate	$153.00
Max. Negotiated Rate	$153.00
Rate for Payer: Aetna of AZ Commercial	$153.00
Rate for Payer: Aetna of AZ Commercial	$214.20
Rate for Payer: Cash Price	$136.00
Rate for Payer: Cash Price	$190.40

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