Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

51703 CATH URETHRA COMPLEX

Facility

$425.00

Service Code	CPT 51703
Hospital Charge Code	22282922
Hospital Revenue Code	450
Min. Negotiated Rate	$110.50
Max. Negotiated Rate	$382.50
Rate for Payer: Aetna of AZ Commercial	$382.50
Rate for Payer: Bisbee Police All Plans	$110.50
Rate for Payer: Cash Price	$340.00
Rate for Payer: Self Pay Self Pay	$340.00

54161-REMOVAL OF FORESKIN (OLDER THAN 28 DAYS)

Facility

$1,039.00

Service Code	CPT 54161
Hospital Charge Code	28004352
Hospital Revenue Code	360
Min. Negotiated Rate	$270.14
Max. Negotiated Rate	$935.10
Rate for Payer: Aetna of AZ Commercial	$935.10
Rate for Payer: Bisbee Police All Plans	$270.14
Rate for Payer: Cash Price	$831.20
Rate for Payer: Self Pay Self Pay	$831.20

54161-REMOVAL OF FORESKIN (OLDER THAN 28 DAYS)

Facility

$1,039.00

Service Code	CPT 54161
Hospital Charge Code	28004352
Hospital Revenue Code	360
Min. Negotiated Rate	$166.24
Max. Negotiated Rate	$3,373.00
Rate for Payer: Aetna of AZ Commercial	$935.10
Rate for Payer: Aetna of AZ Medicare	$290.92
Rate for Payer: AHCCCS Medicaid	$1,299.92
Rate for Payer: Allwell Medicaid	$1,299.92
Rate for Payer: Allwell Medicare	$166.24
Rate for Payer: Amerigroup Medicare	$166.24
Rate for Payer: APIPA Medicare/Medicaid	$388.07
Rate for Payer: AZCH Complete Medicaid	$1,299.92
Rate for Payer: AZCH Complete Medicare	$166.24
Rate for Payer: Banner UC Health Medicaid	$1,299.92
Rate for Payer: Banner UC Health Medicare	$166.24
Rate for Payer: Bisbee Police All Plans	$270.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$706.52
Rate for Payer: Cash Price	$831.20
Rate for Payer: Cash Price	$831.20
Rate for Payer: Cigna of AZ Commercial	$519.50
Rate for Payer: Copperpoint Commercial	$257.15
Rate for Payer: Health Net of AZ Commercial	$623.40
Rate for Payer: Health Net of AZ Medicare	$290.92
Rate for Payer: Humana of AZ Medicare	$166.24
Rate for Payer: Mercy Care Medicaid	$1,299.92
Rate for Payer: Self Pay Self Pay	$831.20
Rate for Payer: TriWest Medicare	$166.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,373.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$187.02

54300-REPAIR OF CURVED PENIS

Facility

$3,389.00

Service Code	CPT 54300
Hospital Charge Code	28004351
Hospital Revenue Code	360
Min. Negotiated Rate	$881.14
Max. Negotiated Rate	$3,050.10
Rate for Payer: Aetna of AZ Commercial	$3,050.10
Rate for Payer: Bisbee Police All Plans	$881.14
Rate for Payer: Cash Price	$2,711.20
Rate for Payer: Self Pay Self Pay	$2,711.20

54300-REPAIR OF CURVED PENIS

Facility

$3,389.00

Service Code	CPT 54300
Hospital Charge Code	28004351
Hospital Revenue Code	360
Min. Negotiated Rate	$542.24
Max. Negotiated Rate	$3,050.10
Rate for Payer: Aetna of AZ Commercial	$3,050.10
Rate for Payer: Aetna of AZ Medicare	$948.92
Rate for Payer: AHCCCS Medicaid	$2,230.35
Rate for Payer: Allwell Medicaid	$2,230.35
Rate for Payer: Allwell Medicare	$542.24
Rate for Payer: Amerigroup Medicare	$542.24
Rate for Payer: APIPA Medicare/Medicaid	$1,265.79
Rate for Payer: AZCH Complete Medicaid	$2,230.35
Rate for Payer: AZCH Complete Medicare	$542.24
Rate for Payer: Banner UC Health Medicaid	$2,230.35
Rate for Payer: Banner UC Health Medicare	$542.24
Rate for Payer: Bisbee Police All Plans	$881.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,304.52
Rate for Payer: Cash Price	$2,711.20
Rate for Payer: Cash Price	$2,711.20
Rate for Payer: Cigna of AZ Commercial	$1,694.50
Rate for Payer: Copperpoint Commercial	$838.78
Rate for Payer: Health Net of AZ Commercial	$2,033.40
Rate for Payer: Health Net of AZ Medicare	$948.92
Rate for Payer: Humana of AZ Medicare	$542.24
Rate for Payer: Mercy Care Medicaid	$2,230.35
Rate for Payer: Self Pay Self Pay	$2,711.20
Rate for Payer: TriWest Medicare	$542.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,975.79
Rate for Payer: UnitedHealth Group of AZ Medicare	$610.02

55040-REMOVAL OF FLUID COLLECTION IN TESTICLE AND SPERM RESE

Facility

$1,790.00

Service Code	CPT 55040
Hospital Charge Code	28007318
Hospital Revenue Code	360
Min. Negotiated Rate	$465.40
Max. Negotiated Rate	$1,611.00
Rate for Payer: Aetna of AZ Commercial	$1,611.00
Rate for Payer: Bisbee Police All Plans	$465.40
Rate for Payer: Cash Price	$1,432.00
Rate for Payer: Self Pay Self Pay	$1,432.00

55040-REMOVAL OF FLUID COLLECTION IN TESTICLE AND SPERM RESE

Facility

$1,790.00

Service Code	CPT 55040
Hospital Charge Code	28007318
Hospital Revenue Code	360
Min. Negotiated Rate	$286.40
Max. Negotiated Rate	$2,307.97
Rate for Payer: Aetna of AZ Commercial	$1,611.00
Rate for Payer: Aetna of AZ Medicare	$501.20
Rate for Payer: AHCCCS Medicaid	$2,307.97
Rate for Payer: Allwell Medicaid	$2,307.97
Rate for Payer: Allwell Medicare	$286.40
Rate for Payer: Amerigroup Medicare	$286.40
Rate for Payer: APIPA Medicare/Medicaid	$668.57
Rate for Payer: AZCH Complete Medicaid	$2,307.97
Rate for Payer: AZCH Complete Medicare	$286.40
Rate for Payer: Banner UC Health Medicaid	$2,307.97
Rate for Payer: Banner UC Health Medicare	$286.40
Rate for Payer: Bisbee Police All Plans	$465.40
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,217.20
Rate for Payer: Cash Price	$1,432.00
Rate for Payer: Cash Price	$1,432.00
Rate for Payer: Cigna of AZ Commercial	$895.00
Rate for Payer: Copperpoint Commercial	$443.02
Rate for Payer: Health Net of AZ Commercial	$1,074.00
Rate for Payer: Health Net of AZ Medicare	$501.20
Rate for Payer: Humana of AZ Medicare	$286.40
Rate for Payer: Mercy Care Medicaid	$2,307.97
Rate for Payer: Self Pay Self Pay	$1,432.00
Rate for Payer: TriWest Medicare	$286.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,043.57
Rate for Payer: UnitedHealth Group of AZ Medicare	$322.20

551781 HIV-1 Genosure Archive

Facility

$1,244.00

Hospital Charge Code	23173814
Hospital Revenue Code	301
Min. Negotiated Rate	$323.44
Max. Negotiated Rate	$1,119.60
Rate for Payer: Aetna of AZ Commercial	$1,119.60
Rate for Payer: Bisbee Police All Plans	$323.44
Rate for Payer: Cash Price	$995.20
Rate for Payer: Self Pay Self Pay	$995.20

551781 HIV-1 Genosure Archive

Facility

$1,244.00

Hospital Charge Code	23173814
Hospital Revenue Code	301
Min. Negotiated Rate	$199.04
Max. Negotiated Rate	$1,119.60
Rate for Payer: Aetna of AZ Commercial	$1,119.60
Rate for Payer: Aetna of AZ Medicare	$348.32
Rate for Payer: Allwell Medicare	$199.04
Rate for Payer: Amerigroup Medicare	$199.04
Rate for Payer: APIPA Medicare/Medicaid	$464.63
Rate for Payer: AZCH Complete Medicare	$199.04
Rate for Payer: Banner UC Health Medicare	$199.04
Rate for Payer: Bisbee Police All Plans	$323.44
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$845.92
Rate for Payer: Cash Price	$995.20
Rate for Payer: Cigna of AZ Commercial	$808.60
Rate for Payer: Copperpoint Commercial	$307.89
Rate for Payer: Health Net of AZ Commercial	$746.40
Rate for Payer: Health Net of AZ Medicare	$348.32
Rate for Payer: Humana of AZ Medicare	$199.04
Rate for Payer: Self Pay Self Pay	$995.20
Rate for Payer: TriWest Medicare	$199.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$725.25
Rate for Payer: UnitedHealth Group of AZ Medicare	$223.92

55831 PARTIAL REMOVAL OF PROSTATE (RETROPUBIC)

Facility

$4,501.00

Service Code	CPT 55831
Hospital Charge Code	28038099
Hospital Revenue Code	360
Min. Negotiated Rate	$1,170.26
Max. Negotiated Rate	$4,050.90
Rate for Payer: Aetna of AZ Commercial	$4,050.90
Rate for Payer: Bisbee Police All Plans	$1,170.26
Rate for Payer: Cash Price	$3,600.80
Rate for Payer: Self Pay Self Pay	$3,600.80

55831 PARTIAL REMOVAL OF PROSTATE (RETROPUBIC)

Facility

$4,501.00

Service Code	CPT 55831
Hospital Charge Code	28038099
Hospital Revenue Code	360
Min. Negotiated Rate	$720.16
Max. Negotiated Rate	$4,050.90
Rate for Payer: Aetna of AZ Commercial	$4,050.90
Rate for Payer: Aetna of AZ Medicare	$1,260.28
Rate for Payer: Allwell Medicare	$720.16
Rate for Payer: Amerigroup Medicare	$720.16
Rate for Payer: APIPA Medicare/Medicaid	$1,681.12
Rate for Payer: AZCH Complete Medicare	$720.16
Rate for Payer: Banner UC Health Medicare	$720.16
Rate for Payer: Bisbee Police All Plans	$1,170.26
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,060.68
Rate for Payer: Cash Price	$3,600.80
Rate for Payer: Cash Price	$3,600.80
Rate for Payer: Cigna of AZ Commercial	$2,250.50
Rate for Payer: Copperpoint Commercial	$1,114.00
Rate for Payer: Health Net of AZ Commercial	$2,700.60
Rate for Payer: Health Net of AZ Medicare	$1,260.28
Rate for Payer: Humana of AZ Medicare	$720.16
Rate for Payer: Self Pay Self Pay	$3,600.80
Rate for Payer: TriWest Medicare	$720.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,373.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$810.18

55840 REMOVAL OF PROSTATE

Facility

$6,110.00

Service Code	CPT 55840
Hospital Charge Code	28035919
Hospital Revenue Code	360
Min. Negotiated Rate	$977.60
Max. Negotiated Rate	$5,499.00
Rate for Payer: Aetna of AZ Commercial	$5,499.00
Rate for Payer: Aetna of AZ Medicare	$1,710.80
Rate for Payer: Allwell Medicare	$977.60
Rate for Payer: Amerigroup Medicare	$977.60
Rate for Payer: APIPA Medicare/Medicaid	$2,282.09
Rate for Payer: AZCH Complete Medicare	$977.60
Rate for Payer: Banner UC Health Medicare	$977.60
Rate for Payer: Bisbee Police All Plans	$1,588.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$4,154.80
Rate for Payer: Cash Price	$4,888.00
Rate for Payer: Cash Price	$4,888.00
Rate for Payer: Cigna of AZ Commercial	$3,055.00
Rate for Payer: Copperpoint Commercial	$1,512.22
Rate for Payer: Health Net of AZ Commercial	$3,666.00
Rate for Payer: Health Net of AZ Medicare	$1,710.80
Rate for Payer: Humana of AZ Medicare	$977.60
Rate for Payer: Self Pay Self Pay	$4,888.00
Rate for Payer: TriWest Medicare	$977.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,373.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,099.80

55840 REMOVAL OF PROSTATE

Facility

$6,110.00

Service Code	CPT 55840
Hospital Charge Code	28035919
Hospital Revenue Code	360
Min. Negotiated Rate	$1,588.60
Max. Negotiated Rate	$5,499.00
Rate for Payer: Aetna of AZ Commercial	$5,499.00
Rate for Payer: Bisbee Police All Plans	$1,588.60
Rate for Payer: Cash Price	$4,888.00
Rate for Payer: Self Pay Self Pay	$4,888.00

55866 LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICA

Facility

$6,235.00

Service Code	CPT 55866
Hospital Charge Code	28035922
Hospital Revenue Code	360
Min. Negotiated Rate	$1,621.10
Max. Negotiated Rate	$5,611.50
Rate for Payer: Aetna of AZ Commercial	$5,611.50
Rate for Payer: Bisbee Police All Plans	$1,621.10
Rate for Payer: Cash Price	$4,988.00
Rate for Payer: Self Pay Self Pay	$4,988.00

55866 LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICA

Facility

$6,235.00

Service Code	CPT 55866
Hospital Charge Code	28035922
Hospital Revenue Code	360
Min. Negotiated Rate	$997.60
Max. Negotiated Rate	$5,611.50
Rate for Payer: Aetna of AZ Commercial	$5,611.50
Rate for Payer: Aetna of AZ Medicare	$1,745.80
Rate for Payer: Allwell Medicare	$997.60
Rate for Payer: Amerigroup Medicare	$997.60
Rate for Payer: APIPA Medicare/Medicaid	$2,328.77
Rate for Payer: AZCH Complete Medicare	$997.60
Rate for Payer: Banner UC Health Medicare	$997.60
Rate for Payer: Bisbee Police All Plans	$1,621.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$4,239.80
Rate for Payer: Cash Price	$4,988.00
Rate for Payer: Cigna of AZ Commercial	$3,117.50
Rate for Payer: Copperpoint Commercial	$1,543.16
Rate for Payer: Health Net of AZ Commercial	$3,741.00
Rate for Payer: Health Net of AZ Medicare	$1,745.80
Rate for Payer: Humana of AZ Medicare	$997.60
Rate for Payer: Self Pay Self Pay	$4,988.00
Rate for Payer: TriWest Medicare	$997.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,635.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,122.30

56420 INCISION AND DRAINAGE OF FEMALE GENITAL GLAND ABSCESS

Facility

$694.00

Service Code	CPT 56420
Hospital Charge Code	23008151
Hospital Revenue Code	450
Min. Negotiated Rate	$180.44
Max. Negotiated Rate	$624.60
Rate for Payer: Aetna of AZ Commercial	$624.60
Rate for Payer: Bisbee Police All Plans	$180.44
Rate for Payer: Cash Price	$555.20
Rate for Payer: Self Pay Self Pay	$555.20

56420 INCISION AND DRAINAGE OF FEMALE GENITAL GLAND ABSCESS

Facility

$694.00

Service Code	CPT 56420
Hospital Charge Code	23008151
Hospital Revenue Code	450
Min. Negotiated Rate	$111.04
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$624.60
Rate for Payer: Aetna of AZ Medicare	$194.32
Rate for Payer: AHCCCS Medicaid	$123.48
Rate for Payer: Allwell Medicaid	$123.48
Rate for Payer: Allwell Medicare	$111.04
Rate for Payer: Amerigroup Medicare	$111.04
Rate for Payer: APIPA Medicare/Medicaid	$259.21
Rate for Payer: AZCH Complete Medicaid	$123.48
Rate for Payer: AZCH Complete Medicare	$111.04
Rate for Payer: Banner UC Health Medicaid	$123.48
Rate for Payer: Banner UC Health Medicare	$111.04
Rate for Payer: Bisbee Police All Plans	$180.44
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$471.92
Rate for Payer: Cash Price	$555.20
Rate for Payer: Cash Price	$555.20
Rate for Payer: Cigna of AZ Commercial	$485.80
Rate for Payer: Copperpoint Commercial	$171.76
Rate for Payer: Health Net of AZ Commercial	$416.40
Rate for Payer: Health Net of AZ Medicare	$194.32
Rate for Payer: Humana of AZ Medicare	$111.04
Rate for Payer: Mercy Care Medicaid	$123.48
Rate for Payer: Self Pay Self Pay	$555.20
Rate for Payer: TriWest Medicare	$111.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$124.92

5-HIAA,Quant.,24 Hr Urine LC

Facility

$245.00

Service Code	CPT 83497
Hospital Charge Code	2084298
Hospital Revenue Code	301
Min. Negotiated Rate	$63.70
Max. Negotiated Rate	$220.50
Rate for Payer: Aetna of AZ Commercial	$220.50
Rate for Payer: Bisbee Police All Plans	$63.70
Rate for Payer: Cash Price	$196.00
Rate for Payer: Self Pay Self Pay	$196.00

5-HIAA,Quant.,24 Hr Urine LC

Facility

$245.00

Service Code	CPT 83497
Hospital Charge Code	2084298
Hospital Revenue Code	301
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$220.50
Rate for Payer: Aetna of AZ Commercial	$220.50
Rate for Payer: Aetna of AZ Medicare	$68.60
Rate for Payer: Allwell Medicare	$39.20
Rate for Payer: Amerigroup Medicare	$39.20
Rate for Payer: APIPA Medicare/Medicaid	$91.51
Rate for Payer: AZCH Complete Medicare	$39.20
Rate for Payer: Banner UC Health Medicare	$39.20
Rate for Payer: Bisbee Police All Plans	$63.70
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$166.60
Rate for Payer: Cash Price	$196.00
Rate for Payer: Cigna of AZ Commercial	$159.25
Rate for Payer: Copperpoint Commercial	$60.64
Rate for Payer: Health Net of AZ Commercial	$147.00
Rate for Payer: Health Net of AZ Medicare	$68.60
Rate for Payer: Humana of AZ Medicare	$39.20
Rate for Payer: Self Pay Self Pay	$196.00
Rate for Payer: TriWest Medicare	$39.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$142.84
Rate for Payer: UnitedHealth Group of AZ Medicare	$44.10

62270 LUMBAR SPINAL TAP

Facility

$700.00

Service Code	CPT 62270
Hospital Charge Code	22282923
Hospital Revenue Code	450
Min. Negotiated Rate	$112.00
Max. Negotiated Rate	$2,507.00
Rate for Payer: Aetna of AZ Commercial	$630.00
Rate for Payer: Aetna of AZ Medicare	$196.00
Rate for Payer: AHCCCS Medicaid	$460.08
Rate for Payer: Allwell Medicaid	$460.08
Rate for Payer: Allwell Medicare	$112.00
Rate for Payer: Amerigroup Medicare	$112.00
Rate for Payer: APIPA Medicare/Medicaid	$261.45
Rate for Payer: AZCH Complete Medicaid	$460.08
Rate for Payer: AZCH Complete Medicare	$112.00
Rate for Payer: Banner UC Health Medicaid	$460.08
Rate for Payer: Banner UC Health Medicare	$112.00
Rate for Payer: Bisbee Police All Plans	$182.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$476.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Cigna of AZ Commercial	$490.00
Rate for Payer: Copperpoint Commercial	$173.25
Rate for Payer: Health Net of AZ Commercial	$420.00
Rate for Payer: Health Net of AZ Medicare	$196.00
Rate for Payer: Humana of AZ Medicare	$112.00
Rate for Payer: Mercy Care Medicaid	$460.08
Rate for Payer: Self Pay Self Pay	$560.00
Rate for Payer: TriWest Medicare	$112.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,507.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$126.00

62270 LUMBAR SPINAL TAP

Facility

$700.00

Service Code	CPT 62270
Hospital Charge Code	22282923
Hospital Revenue Code	450
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna of AZ Commercial	$630.00
Rate for Payer: Bisbee Police All Plans	$182.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Self Pay Self Pay	$560.00

64405 Injection, Anesthetic agent; Facial Nerve

Facility

$549.00

Service Code	CPT 64405
Hospital Charge Code	22704948
Hospital Revenue Code	450
Min. Negotiated Rate	$87.84
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$494.10
Rate for Payer: Aetna of AZ Medicare	$153.72
Rate for Payer: AHCCCS Medicaid	$189.35
Rate for Payer: Allwell Medicaid	$189.35
Rate for Payer: Allwell Medicare	$87.84
Rate for Payer: Amerigroup Medicare	$87.84
Rate for Payer: APIPA Medicare/Medicaid	$205.05
Rate for Payer: AZCH Complete Medicaid	$189.35
Rate for Payer: AZCH Complete Medicare	$87.84
Rate for Payer: Banner UC Health Medicaid	$189.35
Rate for Payer: Banner UC Health Medicare	$87.84
Rate for Payer: Bisbee Police All Plans	$142.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$373.32
Rate for Payer: Cash Price	$439.20
Rate for Payer: Cash Price	$439.20
Rate for Payer: Cigna of AZ Commercial	$384.30
Rate for Payer: Copperpoint Commercial	$135.88
Rate for Payer: Health Net of AZ Commercial	$329.40
Rate for Payer: Health Net of AZ Medicare	$153.72
Rate for Payer: Humana of AZ Medicare	$87.84
Rate for Payer: Mercy Care Medicaid	$189.35
Rate for Payer: Self Pay Self Pay	$439.20
Rate for Payer: TriWest Medicare	$87.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$98.82

64405 Injection, Anesthetic agent; Facial Nerve

Facility

$549.00

Service Code	CPT 64405
Hospital Charge Code	22704948
Hospital Revenue Code	450
Min. Negotiated Rate	$142.74
Max. Negotiated Rate	$494.10
Rate for Payer: Aetna of AZ Commercial	$494.10
Rate for Payer: Bisbee Police All Plans	$142.74
Rate for Payer: Cash Price	$439.20
Rate for Payer: Self Pay Self Pay	$439.20

64430 INJECTION OF ANESTHETIC AGENT AND/OR STEROID INTO PUDE

Facility

$299.00

Service Code	CPT 64430
Hospital Charge Code	27410735
Hospital Revenue Code	360
Min. Negotiated Rate	$47.84
Max. Negotiated Rate	$2,507.00
Rate for Payer: Aetna of AZ Commercial	$269.10
Rate for Payer: Aetna of AZ Medicare	$83.72
Rate for Payer: AHCCCS Medicaid	$596.28
Rate for Payer: Allwell Medicaid	$596.28
Rate for Payer: Allwell Medicare	$47.84
Rate for Payer: Amerigroup Medicare	$47.84
Rate for Payer: APIPA Medicare/Medicaid	$111.68
Rate for Payer: AZCH Complete Medicaid	$596.28
Rate for Payer: AZCH Complete Medicare	$47.84
Rate for Payer: Banner UC Health Medicaid	$596.28
Rate for Payer: Banner UC Health Medicare	$47.84
Rate for Payer: Bisbee Police All Plans	$77.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$203.32
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cigna of AZ Commercial	$149.50
Rate for Payer: Copperpoint Commercial	$74.00
Rate for Payer: Health Net of AZ Commercial	$179.40
Rate for Payer: Health Net of AZ Medicare	$83.72
Rate for Payer: Humana of AZ Medicare	$47.84
Rate for Payer: Mercy Care Medicaid	$596.28
Rate for Payer: Self Pay Self Pay	$239.20
Rate for Payer: TriWest Medicare	$47.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,507.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$53.82

64430 INJECTION OF ANESTHETIC AGENT AND/OR STEROID INTO PUDE

Facility

$299.00

Service Code	CPT 64430
Hospital Charge Code	27410735
Hospital Revenue Code	360
Min. Negotiated Rate	$77.74
Max. Negotiated Rate	$269.10
Rate for Payer: Aetna of AZ Commercial	$269.10
Rate for Payer: Bisbee Police All Plans	$77.74
Rate for Payer: Cash Price	$239.20
Rate for Payer: Self Pay Self Pay	$239.20

Know your out-of-pocket cost for care.

All Charges