Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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

GlycoMark(R)(1,5 AG) LC

Facility

$78.00

Service Code	CPT 82945
Hospital Charge Code	2270019
Hospital Revenue Code	301
Min. Negotiated Rate	$20.28
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Bisbee Police All Plans	$20.28
Rate for Payer: Cash Price	$62.40
Rate for Payer: Self Pay Self Pay	$62.40

GlycoMark(R)(1,5 AG) LC

Facility

$78.00

Service Code	CPT 82945
Hospital Charge Code	2270019
Hospital Revenue Code	301
Min. Negotiated Rate	$3.93
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Aetna of AZ Medicare	$21.84
Rate for Payer: AHCCCS Medicaid	$3.93
Rate for Payer: Allwell Medicaid	$3.93
Rate for Payer: Allwell Medicare	$11.70
Rate for Payer: Amerigroup Medicare	$11.70
Rate for Payer: APIPA Medicare/Medicaid	$29.13
Rate for Payer: AZCH Complete Medicaid	$3.93
Rate for Payer: AZCH Complete Medicare	$11.70
Rate for Payer: Banner UC Health Medicaid	$3.93
Rate for Payer: Banner UC Health Medicare	$11.70
Rate for Payer: Bisbee Police All Plans	$20.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$53.04
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cigna of AZ Commercial	$50.70
Rate for Payer: Copperpoint Commercial	$19.30
Rate for Payer: Health Net of AZ Commercial	$46.80
Rate for Payer: Health Net of AZ Medicare	$21.84
Rate for Payer: Humana of AZ Medicare	$11.70
Rate for Payer: Mercy Care Medicaid	$3.93
Rate for Payer: Self Pay Self Pay	$62.40
Rate for Payer: TriWest Medicare	$11.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$45.47
Rate for Payer: UnitedHealth Group of AZ Medicare	$14.04

glycopyrrolate 0.2 mg/mL Inj Sol [CQCH]

Facility

$2.72

Service Code	HCPCS J7642
Hospital Charge Code	105924820
Hospital Revenue Code	250
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$2.45
Rate for Payer: Aetna of AZ Commercial	$2.45
Rate for Payer: Bisbee Police All Plans	$0.71
Rate for Payer: Cash Price	$2.17
Rate for Payer: Self Pay Self Pay	$2.18

glycopyrrolate 0.2 mg/mL Inj Sol [CQCH]

Facility

$2.72

Service Code	HCPCS J7642
Hospital Charge Code	105924820
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$59.06
Rate for Payer: Aetna of AZ Commercial	$2.45
Rate for Payer: Aetna of AZ Medicare	$0.76
Rate for Payer: AHCCCS Medicaid	$59.06
Rate for Payer: Allwell Medicaid	$59.06
Rate for Payer: Allwell Medicare	$0.41
Rate for Payer: Amerigroup Medicare	$0.41
Rate for Payer: APIPA Medicare/Medicaid	$1.02
Rate for Payer: AZCH Complete Medicaid	$59.06
Rate for Payer: AZCH Complete Medicare	$0.41
Rate for Payer: Banner UC Health Medicaid	$59.06
Rate for Payer: Banner UC Health Medicare	$0.41
Rate for Payer: Bisbee Police All Plans	$0.71
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.85
Rate for Payer: Cash Price	$2.17
Rate for Payer: Cash Price	$2.17
Rate for Payer: Cigna of AZ Commercial	$1.77
Rate for Payer: Copperpoint Commercial	$0.67
Rate for Payer: Health Net of AZ Commercial	$1.63
Rate for Payer: Health Net of AZ Medicare	$0.76
Rate for Payer: Humana of AZ Medicare	$0.41
Rate for Payer: Mercy Care Medicaid	$59.06
Rate for Payer: Self Pay Self Pay	$2.18
Rate for Payer: TriWest Medicare	$0.41
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.59
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.49

golimumab 50 mg/4 mL Sol[CQCH]

Facility

$484.56

Service Code	HCPCS J1602
Hospital Charge Code	199590300
Hospital Revenue Code	250
Min. Negotiated Rate	$125.99
Max. Negotiated Rate	$436.10
Rate for Payer: Aetna of AZ Commercial	$436.10
Rate for Payer: Bisbee Police All Plans	$125.99
Rate for Payer: Cash Price	$387.65
Rate for Payer: Self Pay Self Pay	$387.65

golimumab 50 mg/4 mL Sol[CQCH]

Facility

$484.56

Service Code	HCPCS J1602
Hospital Charge Code	199590300
Hospital Revenue Code	250
Min. Negotiated Rate	$22.16
Max. Negotiated Rate	$436.10
Rate for Payer: Aetna of AZ Commercial	$436.10
Rate for Payer: Aetna of AZ Medicare	$135.68
Rate for Payer: AHCCCS Medicaid	$22.16
Rate for Payer: Allwell Medicaid	$22.16
Rate for Payer: Allwell Medicare	$72.68
Rate for Payer: Amerigroup Medicare	$72.68
Rate for Payer: APIPA Medicare/Medicaid	$180.98
Rate for Payer: AZCH Complete Medicaid	$22.16
Rate for Payer: AZCH Complete Medicare	$72.68
Rate for Payer: Banner UC Health Medicaid	$22.16
Rate for Payer: Banner UC Health Medicare	$72.68
Rate for Payer: Bisbee Police All Plans	$125.99
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$329.50
Rate for Payer: Cash Price	$387.65
Rate for Payer: Cash Price	$387.65
Rate for Payer: Cigna of AZ Commercial	$314.96
Rate for Payer: Copperpoint Commercial	$119.93
Rate for Payer: Health Net of AZ Commercial	$290.74
Rate for Payer: Health Net of AZ Medicare	$135.68
Rate for Payer: Humana of AZ Medicare	$72.68
Rate for Payer: Mercy Care Medicaid	$22.16
Rate for Payer: Self Pay Self Pay	$387.65
Rate for Payer: TriWest Medicare	$72.68
Rate for Payer: UnitedHealth Group of AZ Commercial	$282.50
Rate for Payer: UnitedHealth Group of AZ Medicare	$87.22

gramicidin/neomycin/polymyxin B Ophth Sol [CQCH]

Facility

$47.44

Service Code	NDC 24208079062
Hospital Charge Code	105924896
Hospital Revenue Code	251
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$42.70
Rate for Payer: Aetna of AZ Commercial	$42.70
Rate for Payer: Bisbee Police All Plans	$12.33
Rate for Payer: Cash Price	$37.95
Rate for Payer: Self Pay Self Pay	$37.95

gramicidin/neomycin/polymyxin B Ophth Sol [CQCH]

Facility

$47.44

Service Code	NDC 24208079062
Hospital Charge Code	105924896
Hospital Revenue Code	251
Min. Negotiated Rate	$7.12
Max. Negotiated Rate	$42.70
Rate for Payer: Aetna of AZ Commercial	$42.70
Rate for Payer: Aetna of AZ Medicare	$13.28
Rate for Payer: Allwell Medicare	$7.12
Rate for Payer: Amerigroup Medicare	$7.12
Rate for Payer: APIPA Medicare/Medicaid	$17.72
Rate for Payer: AZCH Complete Medicare	$7.12
Rate for Payer: Banner UC Health Medicare	$7.12
Rate for Payer: Bisbee Police All Plans	$12.33
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$32.26
Rate for Payer: Cash Price	$37.95
Rate for Payer: Cigna of AZ Commercial	$30.84
Rate for Payer: Copperpoint Commercial	$11.74
Rate for Payer: Health Net of AZ Commercial	$28.46
Rate for Payer: Health Net of AZ Medicare	$13.28
Rate for Payer: Humana of AZ Medicare	$7.12
Rate for Payer: Self Pay Self Pay	$37.95
Rate for Payer: TriWest Medicare	$7.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$27.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$8.54

Gram Stain

Facility

$107.00

Service Code	CPT 87205
Hospital Charge Code	850753
Hospital Revenue Code	306
Min. Negotiated Rate	$27.82
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Bisbee Police All Plans	$27.82
Rate for Payer: Cash Price	$85.60
Rate for Payer: Self Pay Self Pay	$85.60

Gram Stain

Facility

$107.00

Service Code	CPT 87205
Hospital Charge Code	3426222
Hospital Revenue Code	306
Min. Negotiated Rate	$27.82
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Bisbee Police All Plans	$27.82
Rate for Payer: Cash Price	$85.60
Rate for Payer: Self Pay Self Pay	$85.60

Gram Stain

Facility

$107.00

Service Code	CPT 87205
Hospital Charge Code	3426222
Hospital Revenue Code	306
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Aetna of AZ Medicare	$29.96
Rate for Payer: AHCCCS Medicaid	$4.27
Rate for Payer: Allwell Medicaid	$4.27
Rate for Payer: Allwell Medicare	$16.05
Rate for Payer: Amerigroup Medicare	$16.05
Rate for Payer: APIPA Medicare/Medicaid	$39.96
Rate for Payer: AZCH Complete Medicaid	$4.27
Rate for Payer: AZCH Complete Medicare	$16.05
Rate for Payer: Banner UC Health Medicaid	$4.27
Rate for Payer: Banner UC Health Medicare	$16.05
Rate for Payer: Bisbee Police All Plans	$27.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$72.76
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cigna of AZ Commercial	$69.55
Rate for Payer: Copperpoint Commercial	$26.48
Rate for Payer: Health Net of AZ Commercial	$64.20
Rate for Payer: Health Net of AZ Medicare	$29.96
Rate for Payer: Humana of AZ Medicare	$16.05
Rate for Payer: Mercy Care Medicaid	$4.27
Rate for Payer: Self Pay Self Pay	$85.60
Rate for Payer: TriWest Medicare	$16.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$62.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.26

Gram Stain

Facility

$107.00

Service Code	CPT 87205
Hospital Charge Code	850753
Hospital Revenue Code	306
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Aetna of AZ Medicare	$29.96
Rate for Payer: AHCCCS Medicaid	$4.27
Rate for Payer: Allwell Medicaid	$4.27
Rate for Payer: Allwell Medicare	$16.05
Rate for Payer: Amerigroup Medicare	$16.05
Rate for Payer: APIPA Medicare/Medicaid	$39.96
Rate for Payer: AZCH Complete Medicaid	$4.27
Rate for Payer: AZCH Complete Medicare	$16.05
Rate for Payer: Banner UC Health Medicaid	$4.27
Rate for Payer: Banner UC Health Medicare	$16.05
Rate for Payer: Bisbee Police All Plans	$27.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$72.76
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cigna of AZ Commercial	$69.55
Rate for Payer: Copperpoint Commercial	$26.48
Rate for Payer: Health Net of AZ Commercial	$64.20
Rate for Payer: Health Net of AZ Medicare	$29.96
Rate for Payer: Humana of AZ Medicare	$16.05
Rate for Payer: Mercy Care Medicaid	$4.27
Rate for Payer: Self Pay Self Pay	$85.60
Rate for Payer: TriWest Medicare	$16.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$62.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.26

Gram Stain Report

Facility

$107.00

Service Code	CPT 87205
Hospital Charge Code	634217
Hospital Revenue Code	306
Min. Negotiated Rate	$27.82
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Bisbee Police All Plans	$27.82
Rate for Payer: Cash Price	$85.60
Rate for Payer: Self Pay Self Pay	$85.60

Gram Stain Report

Facility

$107.00

Service Code	CPT 87205
Hospital Charge Code	634217
Hospital Revenue Code	306
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Aetna of AZ Medicare	$29.96
Rate for Payer: AHCCCS Medicaid	$4.27
Rate for Payer: Allwell Medicaid	$4.27
Rate for Payer: Allwell Medicare	$16.05
Rate for Payer: Amerigroup Medicare	$16.05
Rate for Payer: APIPA Medicare/Medicaid	$39.96
Rate for Payer: AZCH Complete Medicaid	$4.27
Rate for Payer: AZCH Complete Medicare	$16.05
Rate for Payer: Banner UC Health Medicaid	$4.27
Rate for Payer: Banner UC Health Medicare	$16.05
Rate for Payer: Bisbee Police All Plans	$27.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$72.76
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cigna of AZ Commercial	$69.55
Rate for Payer: Copperpoint Commercial	$26.48
Rate for Payer: Health Net of AZ Commercial	$64.20
Rate for Payer: Health Net of AZ Medicare	$29.96
Rate for Payer: Humana of AZ Medicare	$16.05
Rate for Payer: Mercy Care Medicaid	$4.27
Rate for Payer: Self Pay Self Pay	$85.60
Rate for Payer: TriWest Medicare	$16.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$62.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.26

GRASPING FORCEPS

Facility

$1,075.00

Hospital Charge Code	27750225
Hospital Revenue Code	270
Min. Negotiated Rate	$279.50
Max. Negotiated Rate	$967.50
Rate for Payer: Aetna of AZ Commercial	$967.50
Rate for Payer: Bisbee Police All Plans	$279.50
Rate for Payer: Cash Price	$860.00
Rate for Payer: Self Pay Self Pay	$860.00

GRASPING FORCEPS

Facility

$1,075.00

Hospital Charge Code	27750225
Hospital Revenue Code	270
Min. Negotiated Rate	$161.25
Max. Negotiated Rate	$967.50
Rate for Payer: Aetna of AZ Commercial	$967.50
Rate for Payer: Aetna of AZ Medicare	$301.00
Rate for Payer: Allwell Medicare	$161.25
Rate for Payer: Amerigroup Medicare	$161.25
Rate for Payer: APIPA Medicare/Medicaid	$401.51
Rate for Payer: AZCH Complete Medicare	$161.25
Rate for Payer: Banner UC Health Medicare	$161.25
Rate for Payer: Bisbee Police All Plans	$279.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$731.00
Rate for Payer: Cash Price	$860.00
Rate for Payer: Cigna of AZ Commercial	$752.50
Rate for Payer: Copperpoint Commercial	$266.06
Rate for Payer: Health Net of AZ Commercial	$645.00
Rate for Payer: Health Net of AZ Medicare	$301.00
Rate for Payer: Humana of AZ Medicare	$161.25
Rate for Payer: Self Pay Self Pay	$860.00
Rate for Payer: TriWest Medicare	$161.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$626.72
Rate for Payer: UnitedHealth Group of AZ Medicare	$193.50

GREEN INTRAOSSEOUS MODULE PEDS

Facility

$362.00

Hospital Charge Code	23175130
Hospital Revenue Code	272
Min. Negotiated Rate	$54.30
Max. Negotiated Rate	$325.80
Rate for Payer: Aetna of AZ Commercial	$325.80
Rate for Payer: Aetna of AZ Medicare	$101.36
Rate for Payer: Allwell Medicare	$54.30
Rate for Payer: Amerigroup Medicare	$54.30
Rate for Payer: APIPA Medicare/Medicaid	$135.21
Rate for Payer: AZCH Complete Medicare	$54.30
Rate for Payer: Banner UC Health Medicare	$54.30
Rate for Payer: Bisbee Police All Plans	$94.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$246.16
Rate for Payer: Cash Price	$289.60
Rate for Payer: Cigna of AZ Commercial	$253.40
Rate for Payer: Copperpoint Commercial	$89.60
Rate for Payer: Health Net of AZ Commercial	$217.20
Rate for Payer: Health Net of AZ Medicare	$101.36
Rate for Payer: Humana of AZ Medicare	$54.30
Rate for Payer: Self Pay Self Pay	$289.60
Rate for Payer: TriWest Medicare	$54.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$211.05
Rate for Payer: UnitedHealth Group of AZ Medicare	$65.16

GREEN INTRAOSSEOUS MODULE PEDS

Facility

$362.00

Hospital Charge Code	23175130
Hospital Revenue Code	272
Min. Negotiated Rate	$94.12
Max. Negotiated Rate	$325.80
Rate for Payer: Aetna of AZ Commercial	$325.80
Rate for Payer: Bisbee Police All Plans	$94.12
Rate for Payer: Cash Price	$289.60
Rate for Payer: Self Pay Self Pay	$289.60

GREEN INTUBATION MODULE PEDS

Facility

$302.00

Hospital Charge Code	23175718
Hospital Revenue Code	272
Min. Negotiated Rate	$45.30
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of AZ Commercial	$271.80
Rate for Payer: Aetna of AZ Medicare	$84.56
Rate for Payer: Allwell Medicare	$45.30
Rate for Payer: Amerigroup Medicare	$45.30
Rate for Payer: APIPA Medicare/Medicaid	$112.80
Rate for Payer: AZCH Complete Medicare	$45.30
Rate for Payer: Banner UC Health Medicare	$45.30
Rate for Payer: Bisbee Police All Plans	$78.52
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$205.36
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cigna of AZ Commercial	$211.40
Rate for Payer: Copperpoint Commercial	$74.74
Rate for Payer: Health Net of AZ Commercial	$181.20
Rate for Payer: Health Net of AZ Medicare	$84.56
Rate for Payer: Humana of AZ Medicare	$45.30
Rate for Payer: Self Pay Self Pay	$241.60
Rate for Payer: TriWest Medicare	$45.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$176.07
Rate for Payer: UnitedHealth Group of AZ Medicare	$54.36

GREEN INTUBATION MODULE PEDS

Facility

$302.00

Hospital Charge Code	23175718
Hospital Revenue Code	272
Min. Negotiated Rate	$78.52
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of AZ Commercial	$271.80
Rate for Payer: Bisbee Police All Plans	$78.52
Rate for Payer: Cash Price	$241.60
Rate for Payer: Self Pay Self Pay	$241.60

GREEN IV DELIVERY MODULE PEDS

Facility

$290.00

Hospital Charge Code	23175711
Hospital Revenue Code	272
Min. Negotiated Rate	$43.50
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna of AZ Commercial	$261.00
Rate for Payer: Aetna of AZ Medicare	$81.20
Rate for Payer: Allwell Medicare	$43.50
Rate for Payer: Amerigroup Medicare	$43.50
Rate for Payer: APIPA Medicare/Medicaid	$108.32
Rate for Payer: AZCH Complete Medicare	$43.50
Rate for Payer: Banner UC Health Medicare	$43.50
Rate for Payer: Bisbee Police All Plans	$75.40
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$197.20
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cigna of AZ Commercial	$203.00
Rate for Payer: Copperpoint Commercial	$71.78
Rate for Payer: Health Net of AZ Commercial	$174.00
Rate for Payer: Health Net of AZ Medicare	$81.20
Rate for Payer: Humana of AZ Medicare	$43.50
Rate for Payer: Self Pay Self Pay	$232.00
Rate for Payer: TriWest Medicare	$43.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$169.07
Rate for Payer: UnitedHealth Group of AZ Medicare	$52.20

GREEN IV DELIVERY MODULE PEDS

Facility

$290.00

Hospital Charge Code	23175711
Hospital Revenue Code	272
Min. Negotiated Rate	$75.40
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna of AZ Commercial	$261.00
Rate for Payer: Bisbee Police All Plans	$75.40
Rate for Payer: Cash Price	$232.00
Rate for Payer: Self Pay Self Pay	$232.00

GREEN OXYGEN DELIVERY MODULE PEDS

Facility

$121.00

Hospital Charge Code	23175704
Hospital Revenue Code	272
Min. Negotiated Rate	$31.46
Max. Negotiated Rate	$108.90
Rate for Payer: Aetna of AZ Commercial	$108.90
Rate for Payer: Bisbee Police All Plans	$31.46
Rate for Payer: Cash Price	$96.80
Rate for Payer: Self Pay Self Pay	$96.80

GREEN OXYGEN DELIVERY MODULE PEDS

Facility

$121.00

Hospital Charge Code	23175704
Hospital Revenue Code	272
Min. Negotiated Rate	$18.15
Max. Negotiated Rate	$108.90
Rate for Payer: Aetna of AZ Commercial	$108.90
Rate for Payer: Aetna of AZ Medicare	$33.88
Rate for Payer: Allwell Medicare	$18.15
Rate for Payer: Amerigroup Medicare	$18.15
Rate for Payer: APIPA Medicare/Medicaid	$45.19
Rate for Payer: AZCH Complete Medicare	$18.15
Rate for Payer: Banner UC Health Medicare	$18.15
Rate for Payer: Bisbee Police All Plans	$31.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$82.28
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cigna of AZ Commercial	$84.70
Rate for Payer: Copperpoint Commercial	$29.95
Rate for Payer: Health Net of AZ Commercial	$72.60
Rate for Payer: Health Net of AZ Medicare	$33.88
Rate for Payer: Humana of AZ Medicare	$18.15
Rate for Payer: Self Pay Self Pay	$96.80
Rate for Payer: TriWest Medicare	$18.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$70.54
Rate for Payer: UnitedHealth Group of AZ Medicare	$21.78

Know your out-of-pocket cost for care.

All Charges