Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

28490 CLSD TX FX GR TOE W/O MA

Facility

$457.00

Service Code	CPT 28490
Hospital Charge Code	22282872
Hospital Revenue Code	450
Min. Negotiated Rate	$18.13
Max. Negotiated Rate	$411.30
Rate for Payer: Aetna of AZ Commercial	$411.30
Rate for Payer: Arizona Complete Health Allwell	$73.12
Rate for Payer: Banner UC Health Medicare	$73.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$310.76
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$18.13
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$73.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$73.12
Rate for Payer: Cash Price	$365.60
Rate for Payer: Cash Price	$365.60
Rate for Payer: Cigna of AZ Commercial	$319.90
Rate for Payer: Devoted Health Medicare	$82.26
Rate for Payer: Humana of AZ Medicare	$73.12
Rate for Payer: Mercy Care Medicaid	$18.13
Rate for Payer: NaphCare Correctional Healthcare	$18.13
Rate for Payer: Seven Corners Travel Insurance	$381.65
Rate for Payer: Southwest Service Administrators UFCW	$310.76
Rate for Payer: TriWest Medicare	$73.12
Rate for Payer: United Healthcare Commercial	$261.40
Rate for Payer: United Healthcare Medicare	$73.12
Rate for Payer: United Healthcare New Mexico Commercial	$86.83
Rate for Payer: Veterans Affairs TRICARE	$72.39

28495 CLSD TX FX GR TOE W/MANI

Facility

$580.00

Service Code	CPT 28495
Hospital Charge Code	22282873
Hospital Revenue Code	450
Min. Negotiated Rate	$32.08
Max. Negotiated Rate	$522.00
Rate for Payer: Aetna of AZ Commercial	$522.00
Rate for Payer: Arizona Complete Health Allwell	$92.80
Rate for Payer: Banner UC Health Medicare	$92.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$394.40
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$32.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$92.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$92.80
Rate for Payer: Cash Price	$464.00
Rate for Payer: Cash Price	$464.00
Rate for Payer: Cigna of AZ Commercial	$406.00
Rate for Payer: Devoted Health Medicare	$104.40
Rate for Payer: Humana of AZ Medicare	$92.80
Rate for Payer: Mercy Care Medicaid	$32.08
Rate for Payer: NaphCare Correctional Healthcare	$32.08
Rate for Payer: Seven Corners Travel Insurance	$381.65
Rate for Payer: Southwest Service Administrators UFCW	$394.40
Rate for Payer: TriWest Medicare	$92.80
Rate for Payer: United Healthcare Commercial	$331.76
Rate for Payer: United Healthcare Medicare	$92.80
Rate for Payer: United Healthcare New Mexico Commercial	$110.20
Rate for Payer: Veterans Affairs TRICARE	$91.87

28495 CLSD TX FX GR TOE W/MANI

Facility

$580.00

Service Code	CPT 28495
Hospital Charge Code	22282873
Hospital Revenue Code	450
Min. Negotiated Rate	$522.00
Max. Negotiated Rate	$522.00
Rate for Payer: Aetna of AZ Commercial	$522.00
Rate for Payer: Cash Price	$464.00

28660 REDUCTION DISLOCATED TOE

Facility

$397.00

Service Code	CPT 28660
Hospital Charge Code	22282874
Hospital Revenue Code	450
Min. Negotiated Rate	$357.30
Max. Negotiated Rate	$357.30
Rate for Payer: Aetna of AZ Commercial	$357.30
Rate for Payer: Cash Price	$317.60

28660 REDUCTION DISLOCATED TOE

Facility

$397.00

Service Code	CPT 28660
Hospital Charge Code	22282874
Hospital Revenue Code	450
Min. Negotiated Rate	$34.17
Max. Negotiated Rate	$381.65
Rate for Payer: Aetna of AZ Commercial	$357.30
Rate for Payer: Arizona Complete Health Allwell	$63.52
Rate for Payer: Banner UC Health Medicare	$63.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$269.96
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$34.17
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$63.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$63.52
Rate for Payer: Cash Price	$317.60
Rate for Payer: Cash Price	$317.60
Rate for Payer: Cigna of AZ Commercial	$277.90
Rate for Payer: Devoted Health Medicare	$71.46
Rate for Payer: Humana of AZ Medicare	$63.52
Rate for Payer: Mercy Care Medicaid	$34.17
Rate for Payer: NaphCare Correctional Healthcare	$34.17
Rate for Payer: Seven Corners Travel Insurance	$381.65
Rate for Payer: Southwest Service Administrators UFCW	$269.96
Rate for Payer: TriWest Medicare	$63.52
Rate for Payer: United Healthcare Commercial	$227.08
Rate for Payer: United Healthcare Medicare	$63.52
Rate for Payer: United Healthcare New Mexico Commercial	$75.43
Rate for Payer: Veterans Affairs TRICARE	$62.88

29105 APL LNG ARM SPLNT

Facility

$271.00

Service Code	CPT 29105
Hospital Charge Code	22282875
Hospital Revenue Code	450
Min. Negotiated Rate	$42.93
Max. Negotiated Rate	$251.43
Rate for Payer: Aetna of AZ Commercial	$243.90
Rate for Payer: Arizona Complete Health Allwell	$43.36
Rate for Payer: Banner UC Health Medicare	$43.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$184.28
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$44.98
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$43.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.36
Rate for Payer: Cash Price	$216.80
Rate for Payer: Cash Price	$216.80
Rate for Payer: Cigna of AZ Commercial	$189.70
Rate for Payer: Devoted Health Medicare	$48.78
Rate for Payer: Humana of AZ Medicare	$43.36
Rate for Payer: Mercy Care Medicaid	$44.98
Rate for Payer: NaphCare Correctional Healthcare	$44.98
Rate for Payer: Seven Corners Travel Insurance	$251.43
Rate for Payer: Southwest Service Administrators UFCW	$184.28
Rate for Payer: TriWest Medicare	$43.36
Rate for Payer: United Healthcare Commercial	$155.01
Rate for Payer: United Healthcare Medicare	$43.36
Rate for Payer: United Healthcare New Mexico Commercial	$51.49
Rate for Payer: Veterans Affairs TRICARE	$42.93

29105 APL LNG ARM SPLNT

Facility

$271.00

Service Code	CPT 29105
Hospital Charge Code	22282875
Hospital Revenue Code	450
Min. Negotiated Rate	$243.90
Max. Negotiated Rate	$243.90
Rate for Payer: Aetna of AZ Commercial	$243.90
Rate for Payer: Cash Price	$216.80

29125 APL SPLINT SHORT ARM

Facility

$304.00

Service Code	CPT 29125
Hospital Charge Code	22282876
Hospital Revenue Code	450
Min. Negotiated Rate	$273.60
Max. Negotiated Rate	$273.60
Rate for Payer: Aetna of AZ Commercial	$273.60
Rate for Payer: Cash Price	$243.20

29125 APL SPLINT SHORT ARM

Facility

$304.00

Service Code	CPT 29125
Hospital Charge Code	22282876
Hospital Revenue Code	450
Min. Negotiated Rate	$28.94
Max. Negotiated Rate	$273.60
Rate for Payer: Aetna of AZ Commercial	$273.60
Rate for Payer: Arizona Complete Health Allwell	$48.64
Rate for Payer: Banner UC Health Medicare	$48.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$206.72
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$28.94
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$48.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$48.64
Rate for Payer: Cash Price	$243.20
Rate for Payer: Cash Price	$243.20
Rate for Payer: Cigna of AZ Commercial	$212.80
Rate for Payer: Devoted Health Medicare	$54.72
Rate for Payer: Humana of AZ Medicare	$48.64
Rate for Payer: Mercy Care Medicaid	$28.94
Rate for Payer: NaphCare Correctional Healthcare	$28.94
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$206.72
Rate for Payer: TriWest Medicare	$48.64
Rate for Payer: United Healthcare Commercial	$173.89
Rate for Payer: United Healthcare Medicare	$48.64
Rate for Payer: United Healthcare New Mexico Commercial	$57.76
Rate for Payer: Veterans Affairs TRICARE	$48.15

29130 APL FNG SPLNT STATIC

Facility

$231.00

Service Code	CPT 29130
Hospital Charge Code	22282877
Hospital Revenue Code	450
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$207.90
Rate for Payer: Aetna of AZ Commercial	$207.90
Rate for Payer: Arizona Complete Health Allwell	$36.96
Rate for Payer: Banner UC Health Medicare	$36.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$157.08
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$14.30
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.96
Rate for Payer: Cash Price	$184.80
Rate for Payer: Cash Price	$184.80
Rate for Payer: Cigna of AZ Commercial	$161.70
Rate for Payer: Devoted Health Medicare	$41.58
Rate for Payer: Humana of AZ Medicare	$36.96
Rate for Payer: Mercy Care Medicaid	$14.30
Rate for Payer: NaphCare Correctional Healthcare	$14.30
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$157.08
Rate for Payer: TriWest Medicare	$36.96
Rate for Payer: United Healthcare Commercial	$132.13
Rate for Payer: United Healthcare Medicare	$36.96
Rate for Payer: United Healthcare New Mexico Commercial	$43.89
Rate for Payer: Veterans Affairs TRICARE	$36.59

29130 APL FNG SPLNT STATIC

Facility

$231.00

Service Code	CPT 29130
Hospital Charge Code	22282877
Hospital Revenue Code	450
Min. Negotiated Rate	$207.90
Max. Negotiated Rate	$207.90
Rate for Payer: Aetna of AZ Commercial	$207.90
Rate for Payer: Cash Price	$184.80

29131 APL FNG SPLNT DYNAMIC

Facility

$127.00

Service Code	CPT 29131
Hospital Charge Code	22282878
Hospital Revenue Code	450
Min. Negotiated Rate	$114.30
Max. Negotiated Rate	$114.30
Rate for Payer: Aetna of AZ Commercial	$114.30
Rate for Payer: Cash Price	$101.60

29131 APL FNG SPLNT DYNAMIC

Facility

$127.00

Service Code	CPT 29131
Hospital Charge Code	22282878
Hospital Revenue Code	450
Min. Negotiated Rate	$20.12
Max. Negotiated Rate	$114.30
Rate for Payer: Aetna of AZ Commercial	$114.30
Rate for Payer: Arizona Complete Health Allwell	$20.32
Rate for Payer: Banner UC Health Medicare	$20.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$86.36
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$21.10
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.32
Rate for Payer: Cash Price	$101.60
Rate for Payer: Cash Price	$101.60
Rate for Payer: Cigna of AZ Commercial	$88.90
Rate for Payer: Devoted Health Medicare	$22.86
Rate for Payer: Humana of AZ Medicare	$20.32
Rate for Payer: Mercy Care Medicaid	$21.10
Rate for Payer: NaphCare Correctional Healthcare	$21.10
Rate for Payer: Seven Corners Travel Insurance	$91.28
Rate for Payer: Southwest Service Administrators UFCW	$86.36
Rate for Payer: TriWest Medicare	$20.32
Rate for Payer: United Healthcare Commercial	$72.64
Rate for Payer: United Healthcare Medicare	$20.32
Rate for Payer: United Healthcare New Mexico Commercial	$24.13
Rate for Payer: Veterans Affairs TRICARE	$20.12

29200 STRAPPING THORAX

Facility

$175.00

Service Code	CPT 29200
Hospital Charge Code	22282879
Hospital Revenue Code	450
Min. Negotiated Rate	$13.95
Max. Negotiated Rate	$251.43
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Arizona Complete Health Allwell	$28.00
Rate for Payer: Banner UC Health Medicare	$28.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$119.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13.95
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cigna of AZ Commercial	$122.50
Rate for Payer: Devoted Health Medicare	$31.50
Rate for Payer: Humana of AZ Medicare	$28.00
Rate for Payer: Mercy Care Medicaid	$13.95
Rate for Payer: NaphCare Correctional Healthcare	$13.95
Rate for Payer: Seven Corners Travel Insurance	$251.43
Rate for Payer: Southwest Service Administrators UFCW	$119.00
Rate for Payer: TriWest Medicare	$28.00
Rate for Payer: United Healthcare Commercial	$100.10
Rate for Payer: United Healthcare Medicare	$28.00
Rate for Payer: United Healthcare New Mexico Commercial	$33.25
Rate for Payer: Veterans Affairs TRICARE	$27.72

29200 STRAPPING THORAX

Facility

$175.00

Service Code	CPT 29200
Hospital Charge Code	22282879
Hospital Revenue Code	450
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Cash Price	$140.00

29220 STRAPPING LOW BACK

Facility

$158.00

Service Code	CPT 29220
Hospital Charge Code	22282880
Hospital Revenue Code	450
Min. Negotiated Rate	$142.20
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of AZ Commercial	$142.20
Rate for Payer: Cash Price	$126.40

29220 STRAPPING LOW BACK

Facility

$158.00

Service Code	CPT 29220
Hospital Charge Code	22282880
Hospital Revenue Code	450
Min. Negotiated Rate	$25.03
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of AZ Commercial	$142.20
Rate for Payer: Arizona Complete Health Allwell	$25.28
Rate for Payer: Banner UC Health Medicare	$25.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$107.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$25.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$25.28
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cigna of AZ Commercial	$110.60
Rate for Payer: Devoted Health Medicare	$28.44
Rate for Payer: Humana of AZ Medicare	$25.28
Rate for Payer: Southwest Service Administrators UFCW	$107.44
Rate for Payer: TriWest Medicare	$25.28
Rate for Payer: United Healthcare Commercial	$90.38
Rate for Payer: United Healthcare Medicare	$25.28
Rate for Payer: United Healthcare New Mexico Commercial	$30.02
Rate for Payer: Veterans Affairs TRICARE	$25.03

29240 STRAPPING SHOULDER.

Facility

$210.00

Service Code	CPT 29240
Hospital Charge Code	22282881
Hospital Revenue Code	450
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Cash Price	$168.00

29240 STRAPPING SHOULDER.

Facility

$210.00

Service Code	CPT 29240
Hospital Charge Code	22282881
Hospital Revenue Code	450
Min. Negotiated Rate	$12.87
Max. Negotiated Rate	$205.86
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Arizona Complete Health Allwell	$33.60
Rate for Payer: Banner UC Health Medicare	$33.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$142.80
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$12.87
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$33.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$33.60
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cigna of AZ Commercial	$147.00
Rate for Payer: Devoted Health Medicare	$37.80
Rate for Payer: Humana of AZ Medicare	$33.60
Rate for Payer: Mercy Care Medicaid	$12.87
Rate for Payer: NaphCare Correctional Healthcare	$12.87
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$142.80
Rate for Payer: TriWest Medicare	$33.60
Rate for Payer: United Healthcare Commercial	$120.12
Rate for Payer: United Healthcare Medicare	$33.60
Rate for Payer: United Healthcare New Mexico Commercial	$39.90
Rate for Payer: Veterans Affairs TRICARE	$33.26

29260 STRAPPING ELB/WRIST

Facility

$142.00

Service Code	CPT 29260
Hospital Charge Code	22282882
Hospital Revenue Code	450
Min. Negotiated Rate	$10.73
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Arizona Complete Health Allwell	$22.72
Rate for Payer: Banner UC Health Medicare	$22.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$96.56
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$10.73
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$22.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$22.72
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cigna of AZ Commercial	$99.40
Rate for Payer: Devoted Health Medicare	$25.56
Rate for Payer: Humana of AZ Medicare	$22.72
Rate for Payer: Mercy Care Medicaid	$10.73
Rate for Payer: NaphCare Correctional Healthcare	$10.73
Rate for Payer: Seven Corners Travel Insurance	$91.28
Rate for Payer: Southwest Service Administrators UFCW	$96.56
Rate for Payer: TriWest Medicare	$22.72
Rate for Payer: United Healthcare Commercial	$81.22
Rate for Payer: United Healthcare Medicare	$22.72
Rate for Payer: United Healthcare New Mexico Commercial	$26.98
Rate for Payer: Veterans Affairs TRICARE	$22.49

29260 STRAPPING ELB/WRIST

Facility

$142.00

Service Code	CPT 29260
Hospital Charge Code	22282882
Hospital Revenue Code	450
Min. Negotiated Rate	$127.80
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Cash Price	$113.60

29280 STRAPPING HAND/FINGER

Facility

$142.00

Service Code	CPT 29280
Hospital Charge Code	22282883
Hospital Revenue Code	450
Min. Negotiated Rate	$10.37
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Arizona Complete Health Allwell	$22.72
Rate for Payer: Banner UC Health Medicare	$22.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$96.56
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$10.37
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$22.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$22.72
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cigna of AZ Commercial	$99.40
Rate for Payer: Devoted Health Medicare	$25.56
Rate for Payer: Humana of AZ Medicare	$22.72
Rate for Payer: Mercy Care Medicaid	$10.37
Rate for Payer: NaphCare Correctional Healthcare	$10.37
Rate for Payer: Seven Corners Travel Insurance	$91.28
Rate for Payer: Southwest Service Administrators UFCW	$96.56
Rate for Payer: TriWest Medicare	$22.72
Rate for Payer: United Healthcare Commercial	$81.22
Rate for Payer: United Healthcare Medicare	$22.72
Rate for Payer: United Healthcare New Mexico Commercial	$26.98
Rate for Payer: Veterans Affairs TRICARE	$22.49

29280 STRAPPING HAND/FINGER

Facility

$142.00

Service Code	CPT 29280
Hospital Charge Code	22282883
Hospital Revenue Code	450
Min. Negotiated Rate	$127.80
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Cash Price	$113.60

29365 APPL CAST BRACE LNG LEG

Facility

$503.00

Service Code	CPT 29365
Hospital Charge Code	22282884
Hospital Revenue Code	450
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$452.70
Rate for Payer: Aetna of AZ Commercial	$452.70
Rate for Payer: Arizona Complete Health Allwell	$80.48
Rate for Payer: Banner UC Health Medicare	$80.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$342.04
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$40.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$80.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$80.48
Rate for Payer: Cash Price	$402.40
Rate for Payer: Cash Price	$402.40
Rate for Payer: Cigna of AZ Commercial	$352.10
Rate for Payer: Devoted Health Medicare	$90.54
Rate for Payer: Humana of AZ Medicare	$80.48
Rate for Payer: Mercy Care Medicaid	$40.80
Rate for Payer: NaphCare Correctional Healthcare	$40.80
Rate for Payer: Seven Corners Travel Insurance	$432.75
Rate for Payer: Southwest Service Administrators UFCW	$342.04
Rate for Payer: TriWest Medicare	$80.48
Rate for Payer: United Healthcare Commercial	$287.72
Rate for Payer: United Healthcare Medicare	$80.48
Rate for Payer: United Healthcare New Mexico Commercial	$95.57
Rate for Payer: Veterans Affairs TRICARE	$79.68

29365 APPL CAST BRACE LNG LEG

Facility

$503.00

Service Code	CPT 29365
Hospital Charge Code	22282884
Hospital Revenue Code	450
Min. Negotiated Rate	$452.70
Max. Negotiated Rate	$452.70
Rate for Payer: Aetna of AZ Commercial	$452.70
Rate for Payer: Cash Price	$402.40

Know your out-of-pocket cost for care.

All Charges