Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

nystatin Top Cream 100,000 units/g [CQCH]

Facility

$0.41

Service Code	NDC 45802005911
Hospital Charge Code	105934540
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of AZ Commercial	$0.37
Rate for Payer: Aetna of AZ Medicare	$0.11
Rate for Payer: Allwell Medicare	$0.06
Rate for Payer: Amerigroup Medicare	$0.06
Rate for Payer: APIPA Medicare/Medicaid	$0.15
Rate for Payer: AZCH Complete Medicare	$0.06
Rate for Payer: Banner UC Health Medicare	$0.06
Rate for Payer: Bisbee Police All Plans	$0.11
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.28
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna of AZ Commercial	$0.27
Rate for Payer: Copperpoint Commercial	$0.10
Rate for Payer: Health Net of AZ Commercial	$0.25
Rate for Payer: Health Net of AZ Medicare	$0.11
Rate for Payer: Humana of AZ Medicare	$0.06
Rate for Payer: Self Pay Self Pay	$0.33
Rate for Payer: TriWest Medicare	$0.06
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.24
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.07

nystatin Top Cream 100,000 units/g [CQCH]

Facility

$0.41

Service Code	NDC 45802005911
Hospital Charge Code	105934540
Hospital Revenue Code	251
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of AZ Commercial	$0.37
Rate for Payer: Bisbee Police All Plans	$0.11
Rate for Payer: Cash Price	$0.33
Rate for Payer: Self Pay Self Pay	$0.33

O2 MASK SIMPLE

Facility

$8.00

Hospital Charge Code	22355406
Hospital Revenue Code	270
Min. Negotiated Rate	$2.08
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Bisbee Police All Plans	$2.08
Rate for Payer: Cash Price	$6.40
Rate for Payer: Self Pay Self Pay	$6.40

O2 MASK SIMPLE

Facility

$8.00

Hospital Charge Code	22355406
Hospital Revenue Code	270
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Aetna of AZ Medicare	$2.24
Rate for Payer: Allwell Medicare	$1.20
Rate for Payer: Amerigroup Medicare	$1.20
Rate for Payer: APIPA Medicare/Medicaid	$2.99
Rate for Payer: AZCH Complete Medicare	$1.20
Rate for Payer: Banner UC Health Medicare	$1.20
Rate for Payer: Bisbee Police All Plans	$2.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$5.44
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cigna of AZ Commercial	$5.60
Rate for Payer: Copperpoint Commercial	$1.98
Rate for Payer: Health Net of AZ Commercial	$4.80
Rate for Payer: Health Net of AZ Medicare	$2.24
Rate for Payer: Humana of AZ Medicare	$1.20
Rate for Payer: Self Pay Self Pay	$6.40
Rate for Payer: TriWest Medicare	$1.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$4.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.44

Occult Blood, Gastric

Facility

$133.00

Service Code	CPT 82271
Hospital Charge Code	22146128
Hospital Revenue Code	301
Min. Negotiated Rate	$34.58
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of AZ Commercial	$119.70
Rate for Payer: Bisbee Police All Plans	$34.58
Rate for Payer: Cash Price	$106.40
Rate for Payer: Self Pay Self Pay	$106.40

Occult Blood, Gastric

Facility

$133.00

Service Code	CPT 82271
Hospital Charge Code	22146128
Hospital Revenue Code	301
Min. Negotiated Rate	$5.32
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of AZ Commercial	$119.70
Rate for Payer: Aetna of AZ Medicare	$37.24
Rate for Payer: AHCCCS Medicaid	$5.32
Rate for Payer: Allwell Medicaid	$5.32
Rate for Payer: Allwell Medicare	$19.95
Rate for Payer: Amerigroup Medicare	$19.95
Rate for Payer: APIPA Medicare/Medicaid	$49.68
Rate for Payer: AZCH Complete Medicaid	$5.32
Rate for Payer: AZCH Complete Medicare	$19.95
Rate for Payer: Banner UC Health Medicaid	$5.32
Rate for Payer: Banner UC Health Medicare	$19.95
Rate for Payer: Bisbee Police All Plans	$34.58
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$90.44
Rate for Payer: Cash Price	$106.40
Rate for Payer: Cash Price	$106.40
Rate for Payer: Cigna of AZ Commercial	$86.45
Rate for Payer: Copperpoint Commercial	$32.92
Rate for Payer: Health Net of AZ Commercial	$79.80
Rate for Payer: Health Net of AZ Medicare	$37.24
Rate for Payer: Humana of AZ Medicare	$19.95
Rate for Payer: Mercy Care Medicaid	$5.32
Rate for Payer: Self Pay Self Pay	$106.40
Rate for Payer: TriWest Medicare	$19.95
Rate for Payer: UnitedHealth Group of AZ Commercial	$77.54
Rate for Payer: UnitedHealth Group of AZ Medicare	$23.94

Occult Blood Stool 1-3

Facility

$94.00

Service Code	CPT 82270
Hospital Charge Code	22283360
Hospital Revenue Code	301
Min. Negotiated Rate	$24.44
Max. Negotiated Rate	$84.60
Rate for Payer: Aetna of AZ Commercial	$84.60
Rate for Payer: Bisbee Police All Plans	$24.44
Rate for Payer: Cash Price	$75.20
Rate for Payer: Self Pay Self Pay	$75.20

Occult Blood Stool 1-3

Facility

$94.00

Service Code	CPT 82270
Hospital Charge Code	22283360
Hospital Revenue Code	301
Min. Negotiated Rate	$4.38
Max. Negotiated Rate	$84.60
Rate for Payer: Aetna of AZ Commercial	$84.60
Rate for Payer: Aetna of AZ Medicare	$26.32
Rate for Payer: AHCCCS Medicaid	$4.38
Rate for Payer: Allwell Medicaid	$4.38
Rate for Payer: Allwell Medicare	$14.10
Rate for Payer: Amerigroup Medicare	$14.10
Rate for Payer: APIPA Medicare/Medicaid	$35.11
Rate for Payer: AZCH Complete Medicaid	$4.38
Rate for Payer: AZCH Complete Medicare	$14.10
Rate for Payer: Banner UC Health Medicaid	$4.38
Rate for Payer: Banner UC Health Medicare	$14.10
Rate for Payer: Bisbee Police All Plans	$24.44
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$63.92
Rate for Payer: Cash Price	$75.20
Rate for Payer: Cash Price	$75.20
Rate for Payer: Cigna of AZ Commercial	$61.10
Rate for Payer: Copperpoint Commercial	$23.26
Rate for Payer: Health Net of AZ Commercial	$56.40
Rate for Payer: Health Net of AZ Medicare	$26.32
Rate for Payer: Humana of AZ Medicare	$14.10
Rate for Payer: Mercy Care Medicaid	$4.38
Rate for Payer: Self Pay Self Pay	$75.20
Rate for Payer: TriWest Medicare	$14.10
Rate for Payer: UnitedHealth Group of AZ Commercial	$54.80
Rate for Payer: UnitedHealth Group of AZ Medicare	$16.92

ocrelizumab 300 mg/10 mL Sol[CQCH]

Facility

$1,877.56

Service Code	HCPCS J2350
Hospital Charge Code	215329113
Hospital Revenue Code	250
Min. Negotiated Rate	$488.17
Max. Negotiated Rate	$1,689.80
Rate for Payer: Aetna of AZ Commercial	$1,689.80
Rate for Payer: Bisbee Police All Plans	$488.17
Rate for Payer: Cash Price	$1,502.05
Rate for Payer: Self Pay Self Pay	$1,502.05

ocrelizumab 300 mg/10 mL Sol[CQCH]

Facility

$1,877.56

Service Code	HCPCS J2350
Hospital Charge Code	215329113
Hospital Revenue Code	250
Min. Negotiated Rate	$95.44
Max. Negotiated Rate	$1,689.80
Rate for Payer: Aetna of AZ Commercial	$1,689.80
Rate for Payer: Aetna of AZ Medicare	$525.72
Rate for Payer: AHCCCS Medicaid	$95.44
Rate for Payer: Allwell Medicaid	$95.44
Rate for Payer: Allwell Medicare	$281.63
Rate for Payer: Amerigroup Medicare	$281.63
Rate for Payer: APIPA Medicare/Medicaid	$701.27
Rate for Payer: AZCH Complete Medicaid	$95.44
Rate for Payer: AZCH Complete Medicare	$281.63
Rate for Payer: Banner UC Health Medicaid	$95.44
Rate for Payer: Banner UC Health Medicare	$281.63
Rate for Payer: Bisbee Police All Plans	$488.17
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,276.74
Rate for Payer: Cash Price	$1,502.05
Rate for Payer: Cash Price	$1,502.05
Rate for Payer: Cigna of AZ Commercial	$1,220.41
Rate for Payer: Copperpoint Commercial	$464.70
Rate for Payer: Health Net of AZ Commercial	$1,126.54
Rate for Payer: Health Net of AZ Medicare	$525.72
Rate for Payer: Humana of AZ Medicare	$281.63
Rate for Payer: Mercy Care Medicaid	$95.44
Rate for Payer: Self Pay Self Pay	$1,502.05
Rate for Payer: TriWest Medicare	$281.63
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,094.62
Rate for Payer: UnitedHealth Group of AZ Medicare	$337.96

octreotide 100 mcg/mL Inj Sol [CQCH]

Facility

$2.75

Service Code	HCPCS J2354
Hospital Charge Code	105934605
Hospital Revenue Code	250
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$2.48
Rate for Payer: Aetna of AZ Commercial	$2.48
Rate for Payer: Bisbee Police All Plans	$0.72
Rate for Payer: Cash Price	$2.20
Rate for Payer: Self Pay Self Pay	$2.20

octreotide 100 mcg/mL Inj Sol [CQCH]

Facility

$2.75

Service Code	HCPCS J2354
Hospital Charge Code	105934605
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$2.70
Rate for Payer: Aetna of AZ Commercial	$2.48
Rate for Payer: Aetna of AZ Medicare	$0.77
Rate for Payer: AHCCCS Medicaid	$2.70
Rate for Payer: Allwell Medicaid	$2.70
Rate for Payer: Allwell Medicare	$0.41
Rate for Payer: Amerigroup Medicare	$0.41
Rate for Payer: APIPA Medicare/Medicaid	$1.03
Rate for Payer: AZCH Complete Medicaid	$2.70
Rate for Payer: AZCH Complete Medicare	$0.41
Rate for Payer: Banner UC Health Medicaid	$2.70
Rate for Payer: Banner UC Health Medicare	$0.41
Rate for Payer: Bisbee Police All Plans	$0.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.87
Rate for Payer: Cash Price	$2.20
Rate for Payer: Cash Price	$2.20
Rate for Payer: Cigna of AZ Commercial	$1.79
Rate for Payer: Copperpoint Commercial	$0.68
Rate for Payer: Health Net of AZ Commercial	$1.65
Rate for Payer: Health Net of AZ Medicare	$0.77
Rate for Payer: Humana of AZ Medicare	$0.41
Rate for Payer: Mercy Care Medicaid	$2.70
Rate for Payer: Self Pay Self Pay	$2.20
Rate for Payer: TriWest Medicare	$0.41
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.60
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.50

octreotide 200 mcg/mL Sol [CQCH]

Facility

$4.41

Service Code	HCPCS J2354
Hospital Charge Code	206194616
Hospital Revenue Code	250
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$3.97
Rate for Payer: Aetna of AZ Commercial	$3.97
Rate for Payer: Aetna of AZ Medicare	$1.23
Rate for Payer: AHCCCS Medicaid	$2.70
Rate for Payer: Allwell Medicaid	$2.70
Rate for Payer: Allwell Medicare	$0.66
Rate for Payer: Amerigroup Medicare	$0.66
Rate for Payer: APIPA Medicare/Medicaid	$1.65
Rate for Payer: AZCH Complete Medicaid	$2.70
Rate for Payer: AZCH Complete Medicare	$0.66
Rate for Payer: Banner UC Health Medicaid	$2.70
Rate for Payer: Banner UC Health Medicare	$0.66
Rate for Payer: Bisbee Police All Plans	$1.15
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3.00
Rate for Payer: Cash Price	$3.53
Rate for Payer: Cash Price	$3.53
Rate for Payer: Cigna of AZ Commercial	$2.87
Rate for Payer: Copperpoint Commercial	$1.09
Rate for Payer: Health Net of AZ Commercial	$2.65
Rate for Payer: Health Net of AZ Medicare	$1.23
Rate for Payer: Humana of AZ Medicare	$0.66
Rate for Payer: Mercy Care Medicaid	$2.70
Rate for Payer: Self Pay Self Pay	$3.53
Rate for Payer: TriWest Medicare	$0.66
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.57
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.79

octreotide 200 mcg/mL Sol [CQCH]

Facility

$4.41

Service Code	HCPCS J2354
Hospital Charge Code	206194616
Hospital Revenue Code	250
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$3.97
Rate for Payer: Aetna of AZ Commercial	$3.97
Rate for Payer: Bisbee Police All Plans	$1.15
Rate for Payer: Cash Price	$3.53
Rate for Payer: Self Pay Self Pay	$3.53

OLANZapine 10 mg Injection[CQCH]

Facility

$20.93

Service Code	NDC 781910572
Hospital Charge Code	168103443
Hospital Revenue Code	250
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$18.84
Rate for Payer: Aetna of AZ Commercial	$18.84
Rate for Payer: Aetna of AZ Medicare	$5.86
Rate for Payer: Allwell Medicare	$3.14
Rate for Payer: Amerigroup Medicare	$3.14
Rate for Payer: APIPA Medicare/Medicaid	$7.82
Rate for Payer: AZCH Complete Medicare	$3.14
Rate for Payer: Banner UC Health Medicare	$3.14
Rate for Payer: Bisbee Police All Plans	$5.44
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$14.23
Rate for Payer: Cash Price	$16.74
Rate for Payer: Cigna of AZ Commercial	$13.60
Rate for Payer: Copperpoint Commercial	$5.18
Rate for Payer: Health Net of AZ Commercial	$12.56
Rate for Payer: Health Net of AZ Medicare	$5.86
Rate for Payer: Humana of AZ Medicare	$3.14
Rate for Payer: Self Pay Self Pay	$16.74
Rate for Payer: TriWest Medicare	$3.14
Rate for Payer: UnitedHealth Group of AZ Commercial	$12.20
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.77

OLANZapine 10 mg Injection[CQCH]

Facility

$20.93

Service Code	NDC 781910572
Hospital Charge Code	168103443
Hospital Revenue Code	250
Min. Negotiated Rate	$5.44
Max. Negotiated Rate	$18.84
Rate for Payer: Aetna of AZ Commercial	$18.84
Rate for Payer: Bisbee Police All Plans	$5.44
Rate for Payer: Cash Price	$16.74
Rate for Payer: Self Pay Self Pay	$16.74

OLANZapine 5 mg Tab [CQCH]

Facility

$0.36

Service Code	NDC 60505311100
Hospital Charge Code	105969103
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of AZ Commercial	$0.32
Rate for Payer: Aetna of AZ Medicare	$0.10
Rate for Payer: Allwell Medicare	$0.05
Rate for Payer: Amerigroup Medicare	$0.05
Rate for Payer: APIPA Medicare/Medicaid	$0.13
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	$0.24
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of AZ Commercial	$0.23
Rate for Payer: Copperpoint Commercial	$0.09
Rate for Payer: Health Net of AZ Commercial	$0.22
Rate for Payer: Health Net of AZ Medicare	$0.10
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Self Pay Self Pay	$0.29
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.21
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.06

OLANZapine 5 mg Tab [CQCH]

Facility

$0.36

Service Code	NDC 60505311100
Hospital Charge Code	105969103
Hospital Revenue Code	251
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of AZ Commercial	$0.32
Rate for Payer: Bisbee Police All Plans	$0.09
Rate for Payer: Cash Price	$0.29
Rate for Payer: Self Pay Self Pay	$0.29

OLYMPUS SHOCKPULSE PROBE

Facility

$1,988.00

Hospital Charge Code	22619416
Hospital Revenue Code	272
Min. Negotiated Rate	$298.20
Max. Negotiated Rate	$1,789.20
Rate for Payer: Aetna of AZ Commercial	$1,789.20
Rate for Payer: Aetna of AZ Medicare	$556.64
Rate for Payer: Allwell Medicare	$298.20
Rate for Payer: Amerigroup Medicare	$298.20
Rate for Payer: APIPA Medicare/Medicaid	$742.52
Rate for Payer: AZCH Complete Medicare	$298.20
Rate for Payer: Banner UC Health Medicare	$298.20
Rate for Payer: Bisbee Police All Plans	$516.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,351.84
Rate for Payer: Cash Price	$1,590.40
Rate for Payer: Cigna of AZ Commercial	$1,391.60
Rate for Payer: Copperpoint Commercial	$492.03
Rate for Payer: Health Net of AZ Commercial	$1,192.80
Rate for Payer: Health Net of AZ Medicare	$556.64
Rate for Payer: Humana of AZ Medicare	$298.20
Rate for Payer: Self Pay Self Pay	$1,590.40
Rate for Payer: TriWest Medicare	$298.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,159.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$357.84

OLYMPUS SHOCKPULSE PROBE

Facility

$1,988.00

Hospital Charge Code	22619416
Hospital Revenue Code	272
Min. Negotiated Rate	$516.88
Max. Negotiated Rate	$1,789.20
Rate for Payer: Aetna of AZ Commercial	$1,789.20
Rate for Payer: Bisbee Police All Plans	$516.88
Rate for Payer: Cash Price	$1,590.40
Rate for Payer: Self Pay Self Pay	$1,590.40

OMNI JUG

Facility

$95.00

Hospital Charge Code	22354804
Hospital Revenue Code	270
Min. Negotiated Rate	$24.70
Max. Negotiated Rate	$85.50
Rate for Payer: Aetna of AZ Commercial	$85.50
Rate for Payer: Bisbee Police All Plans	$24.70
Rate for Payer: Cash Price	$76.00
Rate for Payer: Self Pay Self Pay	$76.00

OMNI JUG

Facility

$95.00

Hospital Charge Code	22354804
Hospital Revenue Code	270
Min. Negotiated Rate	$14.25
Max. Negotiated Rate	$85.50
Rate for Payer: Aetna of AZ Commercial	$85.50
Rate for Payer: Aetna of AZ Medicare	$26.60
Rate for Payer: Allwell Medicare	$14.25
Rate for Payer: Amerigroup Medicare	$14.25
Rate for Payer: APIPA Medicare/Medicaid	$35.48
Rate for Payer: AZCH Complete Medicare	$14.25
Rate for Payer: Banner UC Health Medicare	$14.25
Rate for Payer: Bisbee Police All Plans	$24.70
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$64.60
Rate for Payer: Cash Price	$76.00
Rate for Payer: Cigna of AZ Commercial	$66.50
Rate for Payer: Copperpoint Commercial	$23.51
Rate for Payer: Health Net of AZ Commercial	$57.00
Rate for Payer: Health Net of AZ Medicare	$26.60
Rate for Payer: Humana of AZ Medicare	$14.25
Rate for Payer: Self Pay Self Pay	$76.00
Rate for Payer: TriWest Medicare	$14.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$55.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$17.10

ondansetron 2 mg/mL Sol[CQCH]

Facility

$0.19

Service Code	HCPCS J2405
Hospital Charge Code	169831043
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.17
Rate for Payer: Aetna of AZ Medicare	$0.05
Rate for Payer: AHCCCS Medicaid	$0.18
Rate for Payer: Allwell Medicaid	$0.18
Rate for Payer: Allwell Medicare	$0.03
Rate for Payer: Amerigroup Medicare	$0.03
Rate for Payer: APIPA Medicare/Medicaid	$0.07
Rate for Payer: AZCH Complete Medicaid	$0.18
Rate for Payer: AZCH Complete Medicare	$0.03
Rate for Payer: Banner UC Health Medicaid	$0.18
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	$0.13
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of AZ Commercial	$0.12
Rate for Payer: Copperpoint Commercial	$0.05
Rate for Payer: Health Net of AZ Commercial	$0.11
Rate for Payer: Health Net of AZ Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Mercy Care Medicaid	$0.18
Rate for Payer: Self Pay Self Pay	$0.15
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.11
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.03

ondansetron 2 mg/mL Sol[CQCH]

Facility

$0.19

Service Code	HCPCS J2405
Hospital Charge Code	169831043
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of AZ Commercial	$0.17
Rate for Payer: Bisbee Police All Plans	$0.05
Rate for Payer: Cash Price	$0.16
Rate for Payer: Self Pay Self Pay	$0.15

ondansetron 4 mg Dis Tab [CQCH]

Facility

$0.23

Service Code	HCPCS Q0162
Hospital Charge Code	105934883
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of AZ Commercial	$0.21
Rate for Payer: Bisbee Police All Plans	$0.06
Rate for Payer: Cash Price	$0.19
Rate for Payer: Self Pay Self Pay	$0.18

Know your out-of-pocket cost for care.

All Charges