Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

GLOVE BIOGEL 7.5

Facility

$11.00

Hospital Charge Code	22355785
Hospital Revenue Code	272
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of AZ Commercial	$9.90
Rate for Payer: Aetna of AZ Medicare	$3.08
Rate for Payer: Allwell Medicare	$1.65
Rate for Payer: Amerigroup Medicare	$1.65
Rate for Payer: APIPA Medicare/Medicaid	$4.11
Rate for Payer: AZCH Complete Medicare	$1.65
Rate for Payer: Banner UC Health Medicare	$1.65
Rate for Payer: Bisbee Police All Plans	$2.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$7.48
Rate for Payer: Cash Price	$8.80
Rate for Payer: Cigna of AZ Commercial	$7.70
Rate for Payer: Copperpoint Commercial	$2.72
Rate for Payer: Health Net of AZ Commercial	$6.60
Rate for Payer: Health Net of AZ Medicare	$3.08
Rate for Payer: Humana of AZ Medicare	$1.65
Rate for Payer: Self Pay Self Pay	$8.80
Rate for Payer: TriWest Medicare	$1.65
Rate for Payer: UnitedHealth Group of AZ Commercial	$6.41
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.98

GLOVE BIOGEL 7.5

Facility

$11.00

Hospital Charge Code	22355785
Hospital Revenue Code	272
Min. Negotiated Rate	$2.86
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of AZ Commercial	$9.90
Rate for Payer: Bisbee Police All Plans	$2.86
Rate for Payer: Cash Price	$8.80
Rate for Payer: Self Pay Self Pay	$8.80

GLOVE BIOGEL 8.0

Facility

$12.00

Hospital Charge Code	22355786
Hospital Revenue Code	271
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$10.80
Rate for Payer: Aetna of AZ Commercial	$10.80
Rate for Payer: Aetna of AZ Medicare	$3.36
Rate for Payer: Allwell Medicare	$1.80
Rate for Payer: Amerigroup Medicare	$1.80
Rate for Payer: APIPA Medicare/Medicaid	$4.48
Rate for Payer: AZCH Complete Medicare	$1.80
Rate for Payer: Banner UC Health Medicare	$1.80
Rate for Payer: Bisbee Police All Plans	$3.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$8.16
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cigna of AZ Commercial	$8.40
Rate for Payer: Copperpoint Commercial	$2.97
Rate for Payer: Health Net of AZ Commercial	$7.20
Rate for Payer: Health Net of AZ Medicare	$3.36
Rate for Payer: Humana of AZ Medicare	$1.80
Rate for Payer: Self Pay Self Pay	$9.60
Rate for Payer: TriWest Medicare	$1.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$7.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.16

GLOVE BIOGEL 8.0

Facility

$12.00

Hospital Charge Code	22355786
Hospital Revenue Code	271
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$10.80
Rate for Payer: Aetna of AZ Commercial	$10.80
Rate for Payer: Bisbee Police All Plans	$3.12
Rate for Payer: Cash Price	$9.60
Rate for Payer: Self Pay Self Pay	$9.60

GLOVE BIOGEL 8.5

Facility

$10.00

Hospital Charge Code	22355787
Hospital Revenue Code	271
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna of AZ Commercial	$9.00
Rate for Payer: Bisbee Police All Plans	$2.60
Rate for Payer: Cash Price	$8.00
Rate for Payer: Self Pay Self Pay	$8.00

GLOVE BIOGEL 8.5

Facility

$10.00

Hospital Charge Code	22355787
Hospital Revenue Code	271
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna of AZ Commercial	$9.00
Rate for Payer: Aetna of AZ Medicare	$2.80
Rate for Payer: Allwell Medicare	$1.50
Rate for Payer: Amerigroup Medicare	$1.50
Rate for Payer: APIPA Medicare/Medicaid	$3.74
Rate for Payer: AZCH Complete Medicare	$1.50
Rate for Payer: Banner UC Health Medicare	$1.50
Rate for Payer: Bisbee Police All Plans	$2.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$6.80
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cigna of AZ Commercial	$7.00
Rate for Payer: Copperpoint Commercial	$2.48
Rate for Payer: Health Net of AZ Commercial	$6.00
Rate for Payer: Health Net of AZ Medicare	$2.80
Rate for Payer: Humana of AZ Medicare	$1.50
Rate for Payer: Self Pay Self Pay	$8.00
Rate for Payer: TriWest Medicare	$1.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$5.83
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.80

glucagon 1 mg Inj [CQCH]

Facility

$233.41

Service Code	HCPCS J1610
Hospital Charge Code	105924472
Hospital Revenue Code	250
Min. Negotiated Rate	$35.01
Max. Negotiated Rate	$278.04
Rate for Payer: Aetna of AZ Commercial	$210.07
Rate for Payer: Aetna of AZ Medicare	$65.35
Rate for Payer: AHCCCS Medicaid	$278.04
Rate for Payer: Allwell Medicaid	$278.04
Rate for Payer: Allwell Medicare	$35.01
Rate for Payer: Amerigroup Medicare	$35.01
Rate for Payer: APIPA Medicare/Medicaid	$87.18
Rate for Payer: AZCH Complete Medicaid	$278.04
Rate for Payer: AZCH Complete Medicare	$35.01
Rate for Payer: Banner UC Health Medicaid	$278.04
Rate for Payer: Banner UC Health Medicare	$35.01
Rate for Payer: Bisbee Police All Plans	$60.69
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$158.72
Rate for Payer: Cash Price	$186.73
Rate for Payer: Cash Price	$186.73
Rate for Payer: Cigna of AZ Commercial	$151.72
Rate for Payer: Copperpoint Commercial	$57.77
Rate for Payer: Health Net of AZ Commercial	$140.05
Rate for Payer: Health Net of AZ Medicare	$65.35
Rate for Payer: Humana of AZ Medicare	$35.01
Rate for Payer: Mercy Care Medicaid	$278.04
Rate for Payer: Self Pay Self Pay	$186.73
Rate for Payer: TriWest Medicare	$35.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$136.08
Rate for Payer: UnitedHealth Group of AZ Medicare	$42.01

glucagon 1 mg Inj [CQCH]

Facility

$233.41

Service Code	HCPCS J1610
Hospital Charge Code	105924472
Hospital Revenue Code	250
Min. Negotiated Rate	$60.69
Max. Negotiated Rate	$210.07
Rate for Payer: Aetna of AZ Commercial	$210.07
Rate for Payer: Bisbee Police All Plans	$60.69
Rate for Payer: Cash Price	$186.73
Rate for Payer: Self Pay Self Pay	$186.73

Glucose 2 Hour Post Prandial

Facility

$83.00

Service Code	CPT 82950
Hospital Charge Code	633598
Hospital Revenue Code	301
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of AZ Commercial	$74.70
Rate for Payer: Aetna of AZ Medicare	$23.24
Rate for Payer: AHCCCS Medicaid	$4.75
Rate for Payer: Allwell Medicaid	$4.75
Rate for Payer: Allwell Medicare	$12.45
Rate for Payer: Amerigroup Medicare	$12.45
Rate for Payer: APIPA Medicare/Medicaid	$31.00
Rate for Payer: AZCH Complete Medicaid	$4.75
Rate for Payer: AZCH Complete Medicare	$12.45
Rate for Payer: Banner UC Health Medicaid	$4.75
Rate for Payer: Banner UC Health Medicare	$12.45
Rate for Payer: Bisbee Police All Plans	$21.58
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$56.44
Rate for Payer: Cash Price	$66.40
Rate for Payer: Cash Price	$66.40
Rate for Payer: Cigna of AZ Commercial	$53.95
Rate for Payer: Copperpoint Commercial	$20.54
Rate for Payer: Health Net of AZ Commercial	$49.80
Rate for Payer: Health Net of AZ Medicare	$23.24
Rate for Payer: Humana of AZ Medicare	$12.45
Rate for Payer: Mercy Care Medicaid	$4.75
Rate for Payer: Self Pay Self Pay	$66.40
Rate for Payer: TriWest Medicare	$12.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$48.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$14.94

Glucose 2 Hour Post Prandial

Facility

$83.00

Service Code	CPT 82950
Hospital Charge Code	633598
Hospital Revenue Code	301
Min. Negotiated Rate	$21.58
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of AZ Commercial	$74.70
Rate for Payer: Bisbee Police All Plans	$21.58
Rate for Payer: Cash Price	$66.40
Rate for Payer: Self Pay Self Pay	$66.40

Glucose 2 HR PP

Facility

$83.00

Service Code	CPT 82950
Hospital Charge Code	22245891
Hospital Revenue Code	302
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of AZ Commercial	$74.70
Rate for Payer: Aetna of AZ Medicare	$23.24
Rate for Payer: AHCCCS Medicaid	$4.75
Rate for Payer: Allwell Medicaid	$4.75
Rate for Payer: Allwell Medicare	$12.45
Rate for Payer: Amerigroup Medicare	$12.45
Rate for Payer: APIPA Medicare/Medicaid	$31.00
Rate for Payer: AZCH Complete Medicaid	$4.75
Rate for Payer: AZCH Complete Medicare	$12.45
Rate for Payer: Banner UC Health Medicaid	$4.75
Rate for Payer: Banner UC Health Medicare	$12.45
Rate for Payer: Bisbee Police All Plans	$21.58
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$56.44
Rate for Payer: Cash Price	$66.40
Rate for Payer: Cash Price	$66.40
Rate for Payer: Cigna of AZ Commercial	$53.95
Rate for Payer: Copperpoint Commercial	$20.54
Rate for Payer: Health Net of AZ Commercial	$49.80
Rate for Payer: Health Net of AZ Medicare	$23.24
Rate for Payer: Humana of AZ Medicare	$12.45
Rate for Payer: Mercy Care Medicaid	$4.75
Rate for Payer: Self Pay Self Pay	$66.40
Rate for Payer: TriWest Medicare	$12.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$48.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$14.94

Glucose 2 HR PP

Facility

$83.00

Service Code	CPT 82950
Hospital Charge Code	22245891
Hospital Revenue Code	302
Min. Negotiated Rate	$21.58
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of AZ Commercial	$74.70
Rate for Payer: Bisbee Police All Plans	$21.58
Rate for Payer: Cash Price	$66.40
Rate for Payer: Self Pay Self Pay	$66.40

Glucose CSF

Facility

$83.00

Service Code	CPT 82945
Hospital Charge Code	633604
Hospital Revenue Code	301
Min. Negotiated Rate	$21.58
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of AZ Commercial	$74.70
Rate for Payer: Bisbee Police All Plans	$21.58
Rate for Payer: Cash Price	$66.40
Rate for Payer: Self Pay Self Pay	$66.40

Glucose CSF

Facility

$83.00

Service Code	CPT 82945
Hospital Charge Code	633604
Hospital Revenue Code	301
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of AZ Commercial	$74.70
Rate for Payer: Aetna of AZ Medicare	$23.24
Rate for Payer: AHCCCS Medicaid	$3.93
Rate for Payer: Allwell Medicaid	$3.93
Rate for Payer: Allwell Medicare	$12.45
Rate for Payer: Amerigroup Medicare	$12.45
Rate for Payer: APIPA Medicare/Medicaid	$31.00
Rate for Payer: AZCH Complete Medicaid	$3.93
Rate for Payer: AZCH Complete Medicare	$12.45
Rate for Payer: Banner UC Health Medicaid	$3.93
Rate for Payer: Banner UC Health Medicare	$12.45
Rate for Payer: Bisbee Police All Plans	$21.58
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$56.44
Rate for Payer: Cash Price	$66.40
Rate for Payer: Cash Price	$66.40
Rate for Payer: Cigna of AZ Commercial	$53.95
Rate for Payer: Copperpoint Commercial	$20.54
Rate for Payer: Health Net of AZ Commercial	$49.80
Rate for Payer: Health Net of AZ Medicare	$23.24
Rate for Payer: Humana of AZ Medicare	$12.45
Rate for Payer: Mercy Care Medicaid	$3.93
Rate for Payer: Self Pay Self Pay	$66.40
Rate for Payer: TriWest Medicare	$12.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$48.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$14.94

Glucose Fasting

Facility

$82.00

Service Code	CPT 82947
Hospital Charge Code	633593
Hospital Revenue Code	301
Min. Negotiated Rate	$21.32
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Bisbee Police All Plans	$21.32
Rate for Payer: Cash Price	$65.60
Rate for Payer: Self Pay Self Pay	$65.60

Glucose Fasting

Facility

$82.00

Service Code	CPT 82947
Hospital Charge Code	633593
Hospital Revenue Code	301
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Aetna of AZ Medicare	$22.96
Rate for Payer: AHCCCS Medicaid	$3.93
Rate for Payer: Allwell Medicaid	$3.93
Rate for Payer: Allwell Medicare	$12.30
Rate for Payer: Amerigroup Medicare	$12.30
Rate for Payer: APIPA Medicare/Medicaid	$30.63
Rate for Payer: AZCH Complete Medicaid	$3.93
Rate for Payer: AZCH Complete Medicare	$12.30
Rate for Payer: Banner UC Health Medicaid	$3.93
Rate for Payer: Banner UC Health Medicare	$12.30
Rate for Payer: Bisbee Police All Plans	$21.32
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$55.76
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cigna of AZ Commercial	$53.30
Rate for Payer: Copperpoint Commercial	$20.30
Rate for Payer: Health Net of AZ Commercial	$49.20
Rate for Payer: Health Net of AZ Medicare	$22.96
Rate for Payer: Humana of AZ Medicare	$12.30
Rate for Payer: Mercy Care Medicaid	$3.93
Rate for Payer: Self Pay Self Pay	$65.60
Rate for Payer: TriWest Medicare	$12.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$47.81
Rate for Payer: UnitedHealth Group of AZ Medicare	$14.76

Glucose Level

Facility

$82.00

Service Code	CPT 82947
Hospital Charge Code	633594
Hospital Revenue Code	301
Min. Negotiated Rate	$21.32
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Bisbee Police All Plans	$21.32
Rate for Payer: Cash Price	$65.60
Rate for Payer: Self Pay Self Pay	$65.60

Glucose Level

Facility

$82.00

Service Code	CPT 82947
Hospital Charge Code	633594
Hospital Revenue Code	301
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Aetna of AZ Medicare	$22.96
Rate for Payer: AHCCCS Medicaid	$3.93
Rate for Payer: Allwell Medicaid	$3.93
Rate for Payer: Allwell Medicare	$12.30
Rate for Payer: Amerigroup Medicare	$12.30
Rate for Payer: APIPA Medicare/Medicaid	$30.63
Rate for Payer: AZCH Complete Medicaid	$3.93
Rate for Payer: AZCH Complete Medicare	$12.30
Rate for Payer: Banner UC Health Medicaid	$3.93
Rate for Payer: Banner UC Health Medicare	$12.30
Rate for Payer: Bisbee Police All Plans	$21.32
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$55.76
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cigna of AZ Commercial	$53.30
Rate for Payer: Copperpoint Commercial	$20.30
Rate for Payer: Health Net of AZ Commercial	$49.20
Rate for Payer: Health Net of AZ Medicare	$22.96
Rate for Payer: Humana of AZ Medicare	$12.30
Rate for Payer: Mercy Care Medicaid	$3.93
Rate for Payer: Self Pay Self Pay	$65.60
Rate for Payer: TriWest Medicare	$12.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$47.81
Rate for Payer: UnitedHealth Group of AZ Medicare	$14.76

glucose oral Gel 15 gm dextrose in 37.5 gm [CQCH]

Facility

$0.21

Service Code	NDC 574006930
Hospital Charge Code	108473448
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of AZ Commercial	$0.19
Rate for Payer: Aetna of AZ Medicare	$0.06
Rate for Payer: Allwell Medicare	$0.03
Rate for Payer: Amerigroup Medicare	$0.03
Rate for Payer: APIPA Medicare/Medicaid	$0.08
Rate for Payer: AZCH Complete Medicare	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Bisbee Police All Plans	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.14
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of AZ Commercial	$0.14
Rate for Payer: Copperpoint Commercial	$0.05
Rate for Payer: Health Net of AZ Commercial	$0.13
Rate for Payer: Health Net of AZ Medicare	$0.06
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Self Pay Self Pay	$0.17
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.12
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.04

glucose oral Gel 15 gm dextrose in 37.5 gm [CQCH]

Facility

$0.21

Service Code	NDC 574006930
Hospital Charge Code	108473448
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of AZ Commercial	$0.19
Rate for Payer: Bisbee Police All Plans	$0.05
Rate for Payer: Cash Price	$0.17
Rate for Payer: Self Pay Self Pay	$0.17

Glucose POC (Lab)

Facility

$39.00

Service Code	CPT 82962
Hospital Charge Code	10456470
Hospital Revenue Code	301
Min. Negotiated Rate	$10.14
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Bisbee Police All Plans	$10.14
Rate for Payer: Cash Price	$31.20
Rate for Payer: Self Pay Self Pay	$31.20

Glucose POC (Lab)

Facility

$39.00

Service Code	CPT 82962
Hospital Charge Code	10456470
Hospital Revenue Code	301
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Aetna of AZ Medicare	$10.92
Rate for Payer: AHCCCS Medicaid	$3.28
Rate for Payer: Allwell Medicaid	$3.28
Rate for Payer: Allwell Medicare	$5.85
Rate for Payer: Amerigroup Medicare	$5.85
Rate for Payer: APIPA Medicare/Medicaid	$14.57
Rate for Payer: AZCH Complete Medicaid	$3.28
Rate for Payer: AZCH Complete Medicare	$5.85
Rate for Payer: Banner UC Health Medicaid	$3.28
Rate for Payer: Banner UC Health Medicare	$5.85
Rate for Payer: Bisbee Police All Plans	$10.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$26.52
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cigna of AZ Commercial	$25.35
Rate for Payer: Copperpoint Commercial	$9.65
Rate for Payer: Health Net of AZ Commercial	$23.40
Rate for Payer: Health Net of AZ Medicare	$10.92
Rate for Payer: Humana of AZ Medicare	$5.85
Rate for Payer: Mercy Care Medicaid	$3.28
Rate for Payer: Self Pay Self Pay	$31.20
Rate for Payer: TriWest Medicare	$5.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$22.74
Rate for Payer: UnitedHealth Group of AZ Medicare	$7.02

glyBURIDE 5 mg Tab [CQCH]

Facility

$0.33

Service Code	NDC 63739011910
Hospital Charge Code	105924688
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of AZ Commercial	$0.30
Rate for Payer: Aetna of AZ Medicare	$0.09
Rate for Payer: Allwell Medicare	$0.05
Rate for Payer: Amerigroup Medicare	$0.05
Rate for Payer: APIPA Medicare/Medicaid	$0.12
Rate for Payer: AZCH Complete Medicare	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
Rate for Payer: Bisbee Police All Plans	$0.09
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.22
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna of AZ Commercial	$0.21
Rate for Payer: Copperpoint Commercial	$0.08
Rate for Payer: Health Net of AZ Commercial	$0.20
Rate for Payer: Health Net of AZ Medicare	$0.09
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Self Pay Self Pay	$0.26
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.06

glyBURIDE 5 mg Tab [CQCH]

Facility

$0.33

Service Code	NDC 63739011910
Hospital Charge Code	105924688
Hospital Revenue Code	251
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of AZ Commercial	$0.30
Rate for Payer: Bisbee Police All Plans	$0.09
Rate for Payer: Cash Price	$0.26
Rate for Payer: Self Pay Self Pay	$0.26

glycerin pediatric Supp [CQCH]

Facility

$0.67

Service Code	NDC 713010209
Hospital Charge Code	105924755
Hospital Revenue Code	251
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of AZ Commercial	$0.60
Rate for Payer: Bisbee Police All Plans	$0.17
Rate for Payer: Cash Price	$0.54
Rate for Payer: Self Pay Self Pay	$0.54

Know your out-of-pocket cost for care.

All Charges