Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

30300 RMV FB NOSE

Facility

$389.00

Service Code	CPT 30300
Hospital Charge Code	22282892
Hospital Revenue Code	450
Min. Negotiated Rate	$62.24
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$350.10
Rate for Payer: Aetna of AZ Medicare	$108.92
Rate for Payer: Allwell Medicare	$62.24
Rate for Payer: Amerigroup Medicare	$62.24
Rate for Payer: APIPA Medicare/Medicaid	$145.29
Rate for Payer: AZCH Complete Medicare	$62.24
Rate for Payer: Banner UC Health Medicare	$62.24
Rate for Payer: Bisbee Police All Plans	$101.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$264.52
Rate for Payer: Cash Price	$311.20
Rate for Payer: Cash Price	$311.20
Rate for Payer: Cigna of AZ Commercial	$272.30
Rate for Payer: Copperpoint Commercial	$96.28
Rate for Payer: Health Net of AZ Commercial	$233.40
Rate for Payer: Health Net of AZ Medicare	$108.92
Rate for Payer: Humana of AZ Medicare	$62.24
Rate for Payer: Self Pay Self Pay	$311.20
Rate for Payer: TriWest Medicare	$62.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$70.02

3044F HbA1C less than 7%

Facility

$0.01

Service Code	CPT 3044F
Hospital Charge Code	21279300
Hospital Revenue Code	3101
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.01

3044F HbA1C less than 7%

Facility

$0.01

Service Code	CPT 3044F
Hospital Charge Code	21279300
Hospital Revenue Code	3101
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

3044 Most recent hemoglobin A1c level <7.0% Charge

Facility

$0.01

Service Code	CPT 3044F
Hospital Charge Code	794684
Hospital Revenue Code	301
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

3044 Most recent hemoglobin A1c level <7.0% Charge

Facility

$0.01

Service Code	CPT 3044F
Hospital Charge Code	794684
Hospital Revenue Code	301
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.01

3045F HbA1C 7.0% to 9.0%

Facility

$0.01

Service Code	CPT 3046F
Hospital Charge Code	21279301
Hospital Revenue Code	301
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.01

3045F HbA1C 7.0% to 9.0%

Facility

$0.01

Service Code	CPT 3046F
Hospital Charge Code	21279301
Hospital Revenue Code	301
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

3046F HbA1C greater than 9%

Facility

$0.01

Service Code	CPT 3046F
Hospital Charge Code	21279302
Hospital Revenue Code	301
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

3046F HbA1C greater than 9%

Facility

$0.01

Service Code	CPT 3046F
Hospital Charge Code	21279302
Hospital Revenue Code	301
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.01

3051 Most HbA1c >= 7.0% and <= 8.0%

Facility

$0.01

Service Code	CPT 3051F
Hospital Charge Code	27397694
Hospital Revenue Code	301
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.01

3051 Most HbA1c >= 7.0% and <= 8.0%

Facility

$0.01

Service Code	CPT 3051F
Hospital Charge Code	27397694
Hospital Revenue Code	301
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

30901 TX EPISTAXIS ANT SIMPLE

Facility

$682.00

Service Code	CPT 30901
Hospital Charge Code	22282893
Hospital Revenue Code	450
Min. Negotiated Rate	$81.16
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$613.80
Rate for Payer: Aetna of AZ Medicare	$190.96
Rate for Payer: AHCCCS Medicaid	$81.16
Rate for Payer: Allwell Medicaid	$81.16
Rate for Payer: Allwell Medicare	$109.12
Rate for Payer: Amerigroup Medicare	$109.12
Rate for Payer: APIPA Medicare/Medicaid	$254.73
Rate for Payer: AZCH Complete Medicaid	$81.16
Rate for Payer: AZCH Complete Medicare	$109.12
Rate for Payer: Banner UC Health Medicaid	$81.16
Rate for Payer: Banner UC Health Medicare	$109.12
Rate for Payer: Bisbee Police All Plans	$177.32
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$463.76
Rate for Payer: Cash Price	$545.60
Rate for Payer: Cash Price	$545.60
Rate for Payer: Cigna of AZ Commercial	$477.40
Rate for Payer: Copperpoint Commercial	$168.79
Rate for Payer: Health Net of AZ Commercial	$409.20
Rate for Payer: Health Net of AZ Medicare	$190.96
Rate for Payer: Humana of AZ Medicare	$109.12
Rate for Payer: Mercy Care Medicaid	$81.16
Rate for Payer: Self Pay Self Pay	$545.60
Rate for Payer: TriWest Medicare	$109.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$122.76

30901 TX EPISTAXIS ANT SIMPLE

Facility

$682.00

Service Code	CPT 30901
Hospital Charge Code	22282893
Hospital Revenue Code	450
Min. Negotiated Rate	$177.32
Max. Negotiated Rate	$613.80
Rate for Payer: Aetna of AZ Commercial	$613.80
Rate for Payer: Bisbee Police All Plans	$177.32
Rate for Payer: Cash Price	$545.60
Rate for Payer: Self Pay Self Pay	$545.60

30903 TX EPISTAXIS ANT COMPLEX

Facility

$1,305.00

Service Code	CPT 30903
Hospital Charge Code	22282894
Hospital Revenue Code	450
Min. Negotiated Rate	$339.30
Max. Negotiated Rate	$1,174.50
Rate for Payer: Aetna of AZ Commercial	$1,174.50
Rate for Payer: Bisbee Police All Plans	$339.30
Rate for Payer: Cash Price	$1,044.00
Rate for Payer: Self Pay Self Pay	$1,044.00

30903 TX EPISTAXIS ANT COMPLEX

Facility

$1,305.00

Service Code	CPT 30903
Hospital Charge Code	22282894
Hospital Revenue Code	450
Min. Negotiated Rate	$81.16
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$1,174.50
Rate for Payer: Aetna of AZ Medicare	$365.40
Rate for Payer: AHCCCS Medicaid	$81.16
Rate for Payer: Allwell Medicaid	$81.16
Rate for Payer: Allwell Medicare	$208.80
Rate for Payer: Amerigroup Medicare	$208.80
Rate for Payer: APIPA Medicare/Medicaid	$487.42
Rate for Payer: AZCH Complete Medicaid	$81.16
Rate for Payer: AZCH Complete Medicare	$208.80
Rate for Payer: Banner UC Health Medicaid	$81.16
Rate for Payer: Banner UC Health Medicare	$208.80
Rate for Payer: Bisbee Police All Plans	$339.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$887.40
Rate for Payer: Cash Price	$1,044.00
Rate for Payer: Cash Price	$1,044.00
Rate for Payer: Cigna of AZ Commercial	$913.50
Rate for Payer: Copperpoint Commercial	$322.99
Rate for Payer: Health Net of AZ Commercial	$783.00
Rate for Payer: Health Net of AZ Medicare	$365.40
Rate for Payer: Humana of AZ Medicare	$208.80
Rate for Payer: Mercy Care Medicaid	$81.16
Rate for Payer: Self Pay Self Pay	$1,044.00
Rate for Payer: TriWest Medicare	$208.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$234.90

30905 TX EPISTAXIS POST SIMPLE

Facility

$1,203.00

Service Code	CPT 30905
Hospital Charge Code	22282895
Hospital Revenue Code	450
Min. Negotiated Rate	$312.78
Max. Negotiated Rate	$1,082.70
Rate for Payer: Aetna of AZ Commercial	$1,082.70
Rate for Payer: Bisbee Police All Plans	$312.78
Rate for Payer: Cash Price	$962.40
Rate for Payer: Self Pay Self Pay	$962.40

30905 TX EPISTAXIS POST SIMPLE

Facility

$1,203.00

Service Code	CPT 30905
Hospital Charge Code	22282895
Hospital Revenue Code	450
Min. Negotiated Rate	$81.16
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$1,082.70
Rate for Payer: Aetna of AZ Medicare	$336.84
Rate for Payer: AHCCCS Medicaid	$81.16
Rate for Payer: Allwell Medicaid	$81.16
Rate for Payer: Allwell Medicare	$192.48
Rate for Payer: Amerigroup Medicare	$192.48
Rate for Payer: APIPA Medicare/Medicaid	$449.32
Rate for Payer: AZCH Complete Medicaid	$81.16
Rate for Payer: AZCH Complete Medicare	$192.48
Rate for Payer: Banner UC Health Medicaid	$81.16
Rate for Payer: Banner UC Health Medicare	$192.48
Rate for Payer: Bisbee Police All Plans	$312.78
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$818.04
Rate for Payer: Cash Price	$962.40
Rate for Payer: Cash Price	$962.40
Rate for Payer: Cigna of AZ Commercial	$842.10
Rate for Payer: Copperpoint Commercial	$297.74
Rate for Payer: Health Net of AZ Commercial	$721.80
Rate for Payer: Health Net of AZ Medicare	$336.84
Rate for Payer: Humana of AZ Medicare	$192.48
Rate for Payer: Mercy Care Medicaid	$81.16
Rate for Payer: Self Pay Self Pay	$962.40
Rate for Payer: TriWest Medicare	$192.48
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$216.54

30906 TX EPISTAXIS POST COMPLEX

Facility

$1,341.00

Service Code	CPT 30906
Hospital Charge Code	22282896
Hospital Revenue Code	450
Min. Negotiated Rate	$348.66
Max. Negotiated Rate	$1,206.90
Rate for Payer: Aetna of AZ Commercial	$1,206.90
Rate for Payer: Bisbee Police All Plans	$348.66
Rate for Payer: Cash Price	$1,072.80
Rate for Payer: Self Pay Self Pay	$1,072.80

30906 TX EPISTAXIS POST COMPLEX

Facility

$1,341.00

Service Code	CPT 30906
Hospital Charge Code	22282896
Hospital Revenue Code	450
Min. Negotiated Rate	$153.41
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$1,206.90
Rate for Payer: Aetna of AZ Medicare	$375.48
Rate for Payer: AHCCCS Medicaid	$153.41
Rate for Payer: Allwell Medicaid	$153.41
Rate for Payer: Allwell Medicare	$214.56
Rate for Payer: Amerigroup Medicare	$214.56
Rate for Payer: APIPA Medicare/Medicaid	$500.86
Rate for Payer: AZCH Complete Medicaid	$153.41
Rate for Payer: AZCH Complete Medicare	$214.56
Rate for Payer: Banner UC Health Medicaid	$153.41
Rate for Payer: Banner UC Health Medicare	$214.56
Rate for Payer: Bisbee Police All Plans	$348.66
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$911.88
Rate for Payer: Cash Price	$1,072.80
Rate for Payer: Cash Price	$1,072.80
Rate for Payer: Cigna of AZ Commercial	$938.70
Rate for Payer: Copperpoint Commercial	$331.90
Rate for Payer: Health Net of AZ Commercial	$804.60
Rate for Payer: Health Net of AZ Medicare	$375.48
Rate for Payer: Humana of AZ Medicare	$214.56
Rate for Payer: Mercy Care Medicaid	$153.41
Rate for Payer: Self Pay Self Pay	$1,072.80
Rate for Payer: TriWest Medicare	$214.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$241.38

3-0 Chromic Gut FS-1

Facility

$22.00

Hospital Charge Code	22926446
Hospital Revenue Code	272
Min. Negotiated Rate	$3.52
Max. Negotiated Rate	$19.80
Rate for Payer: Aetna of AZ Commercial	$19.80
Rate for Payer: Aetna of AZ Medicare	$6.16
Rate for Payer: Allwell Medicare	$3.52
Rate for Payer: Amerigroup Medicare	$3.52
Rate for Payer: APIPA Medicare/Medicaid	$8.22
Rate for Payer: AZCH Complete Medicare	$3.52
Rate for Payer: Banner UC Health Medicare	$3.52
Rate for Payer: Bisbee Police All Plans	$5.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$14.96
Rate for Payer: Cash Price	$17.60
Rate for Payer: Cigna of AZ Commercial	$15.40
Rate for Payer: Copperpoint Commercial	$5.45
Rate for Payer: Health Net of AZ Commercial	$13.20
Rate for Payer: Health Net of AZ Medicare	$6.16
Rate for Payer: Humana of AZ Medicare	$3.52
Rate for Payer: Self Pay Self Pay	$17.60
Rate for Payer: TriWest Medicare	$3.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$12.83
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.96

3-0 Chromic Gut FS-1

Facility

$22.00

Hospital Charge Code	22926446
Hospital Revenue Code	272
Min. Negotiated Rate	$5.72
Max. Negotiated Rate	$19.80
Rate for Payer: Aetna of AZ Commercial	$19.80
Rate for Payer: Bisbee Police All Plans	$5.72
Rate for Payer: Cash Price	$17.60
Rate for Payer: Self Pay Self Pay	$17.60

3-0 Chromic Gut FS-2

Facility

$21.00

Hospital Charge Code	22926445
Hospital Revenue Code	272
Min. Negotiated Rate	$5.46
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Bisbee Police All Plans	$5.46
Rate for Payer: Cash Price	$16.80
Rate for Payer: Self Pay Self Pay	$16.80

3-0 Chromic Gut FS-2

Facility

$21.00

Hospital Charge Code	22926445
Hospital Revenue Code	272
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Aetna of AZ Medicare	$5.88
Rate for Payer: Allwell Medicare	$3.36
Rate for Payer: Amerigroup Medicare	$3.36
Rate for Payer: APIPA Medicare/Medicaid	$7.84
Rate for Payer: AZCH Complete Medicare	$3.36
Rate for Payer: Banner UC Health Medicare	$3.36
Rate for Payer: Bisbee Police All Plans	$5.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$14.28
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna of AZ Commercial	$14.70
Rate for Payer: Copperpoint Commercial	$5.20
Rate for Payer: Health Net of AZ Commercial	$12.60
Rate for Payer: Health Net of AZ Medicare	$5.88
Rate for Payer: Humana of AZ Medicare	$3.36
Rate for Payer: Self Pay Self Pay	$16.80
Rate for Payer: TriWest Medicare	$3.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$12.24
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.78

3-0 Prolene FS-1

Facility

$18.00

Hospital Charge Code	22926432
Hospital Revenue Code	272
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$16.20
Rate for Payer: Aetna of AZ Commercial	$16.20
Rate for Payer: Aetna of AZ Medicare	$5.04
Rate for Payer: Allwell Medicare	$2.88
Rate for Payer: Amerigroup Medicare	$2.88
Rate for Payer: APIPA Medicare/Medicaid	$6.72
Rate for Payer: AZCH Complete Medicare	$2.88
Rate for Payer: Banner UC Health Medicare	$2.88
Rate for Payer: Bisbee Police All Plans	$4.68
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$12.24
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna of AZ Commercial	$12.60
Rate for Payer: Copperpoint Commercial	$4.46
Rate for Payer: Health Net of AZ Commercial	$10.80
Rate for Payer: Health Net of AZ Medicare	$5.04
Rate for Payer: Humana of AZ Medicare	$2.88
Rate for Payer: Self Pay Self Pay	$14.40
Rate for Payer: TriWest Medicare	$2.88
Rate for Payer: UnitedHealth Group of AZ Commercial	$10.49
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.24

3-0 Prolene FS-1

Facility

$18.00

Hospital Charge Code	22926432
Hospital Revenue Code	272
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$16.20
Rate for Payer: Aetna of AZ Commercial	$16.20
Rate for Payer: Bisbee Police All Plans	$4.68
Rate for Payer: Cash Price	$14.40
Rate for Payer: Self Pay Self Pay	$14.40

Know your out-of-pocket cost for care.

All Charges