Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

PROT EL 24 HR

Facility

$808.00

Service Code	CPT 84166
Hospital Charge Code	22481495
Hospital Revenue Code	301
Min. Negotiated Rate	$17.83
Max. Negotiated Rate	$727.20
Rate for Payer: Aetna of AZ Commercial	$727.20
Rate for Payer: Aetna of AZ Medicare	$226.24
Rate for Payer: AHCCCS Medicaid	$17.83
Rate for Payer: Allwell Medicaid	$17.83
Rate for Payer: Allwell Medicare	$121.20
Rate for Payer: Amerigroup Medicare	$121.20
Rate for Payer: APIPA Medicare/Medicaid	$301.79
Rate for Payer: AZCH Complete Medicaid	$17.83
Rate for Payer: AZCH Complete Medicare	$121.20
Rate for Payer: Banner UC Health Medicaid	$17.83
Rate for Payer: Banner UC Health Medicare	$121.20
Rate for Payer: Bisbee Police All Plans	$210.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$549.44
Rate for Payer: Cash Price	$646.40
Rate for Payer: Cash Price	$646.40
Rate for Payer: Cigna of AZ Commercial	$525.20
Rate for Payer: Copperpoint Commercial	$199.98
Rate for Payer: Health Net of AZ Commercial	$484.80
Rate for Payer: Health Net of AZ Medicare	$226.24
Rate for Payer: Humana of AZ Medicare	$121.20
Rate for Payer: Mercy Care Medicaid	$17.83
Rate for Payer: Self Pay Self Pay	$646.40
Rate for Payer: TriWest Medicare	$121.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$471.06
Rate for Payer: UnitedHealth Group of AZ Medicare	$145.44

PROT EL 24 HR

Facility

$808.00

Service Code	CPT 84166
Hospital Charge Code	22481495
Hospital Revenue Code	301
Min. Negotiated Rate	$210.08
Max. Negotiated Rate	$727.20
Rate for Payer: Aetna of AZ Commercial	$727.20
Rate for Payer: Bisbee Police All Plans	$210.08
Rate for Payer: Cash Price	$646.40
Rate for Payer: Self Pay Self Pay	$646.40

PROT EL R UR

Facility

$808.00

Service Code	CPT 84166
Hospital Charge Code	22481496
Hospital Revenue Code	301
Min. Negotiated Rate	$210.08
Max. Negotiated Rate	$727.20
Rate for Payer: Aetna of AZ Commercial	$727.20
Rate for Payer: Bisbee Police All Plans	$210.08
Rate for Payer: Cash Price	$646.40
Rate for Payer: Self Pay Self Pay	$646.40

PROT EL R UR

Facility

$808.00

Service Code	CPT 84166
Hospital Charge Code	22481496
Hospital Revenue Code	301
Min. Negotiated Rate	$17.83
Max. Negotiated Rate	$727.20
Rate for Payer: Aetna of AZ Commercial	$727.20
Rate for Payer: Aetna of AZ Medicare	$226.24
Rate for Payer: AHCCCS Medicaid	$17.83
Rate for Payer: Allwell Medicaid	$17.83
Rate for Payer: Allwell Medicare	$121.20
Rate for Payer: Amerigroup Medicare	$121.20
Rate for Payer: APIPA Medicare/Medicaid	$301.79
Rate for Payer: AZCH Complete Medicaid	$17.83
Rate for Payer: AZCH Complete Medicare	$121.20
Rate for Payer: Banner UC Health Medicaid	$17.83
Rate for Payer: Banner UC Health Medicare	$121.20
Rate for Payer: Bisbee Police All Plans	$210.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$549.44
Rate for Payer: Cash Price	$646.40
Rate for Payer: Cash Price	$646.40
Rate for Payer: Cigna of AZ Commercial	$525.20
Rate for Payer: Copperpoint Commercial	$199.98
Rate for Payer: Health Net of AZ Commercial	$484.80
Rate for Payer: Health Net of AZ Medicare	$226.24
Rate for Payer: Humana of AZ Medicare	$121.20
Rate for Payer: Mercy Care Medicaid	$17.83
Rate for Payer: Self Pay Self Pay	$646.40
Rate for Payer: TriWest Medicare	$121.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$471.06
Rate for Payer: UnitedHealth Group of AZ Medicare	$145.44

prothrombin complex - REC[CQCH]

Facility

$1,910.00

Service Code	HCPCS C9132
Hospital Charge Code	182934642
Hospital Revenue Code	250
Min. Negotiated Rate	$496.60
Max. Negotiated Rate	$1,719.00
Rate for Payer: Aetna of AZ Commercial	$1,719.00
Rate for Payer: Bisbee Police All Plans	$496.60
Rate for Payer: Cash Price	$1,528.00
Rate for Payer: Self Pay Self Pay	$1,528.00

prothrombin complex - REC[CQCH]

Facility

$1,910.00

Service Code	HCPCS C9132
Hospital Charge Code	182934642
Hospital Revenue Code	250
Min. Negotiated Rate	$286.50
Max. Negotiated Rate	$1,719.00
Rate for Payer: Aetna of AZ Commercial	$1,719.00
Rate for Payer: Aetna of AZ Medicare	$534.80
Rate for Payer: Allwell Medicare	$286.50
Rate for Payer: Amerigroup Medicare	$286.50
Rate for Payer: APIPA Medicare/Medicaid	$713.38
Rate for Payer: AZCH Complete Medicare	$286.50
Rate for Payer: Banner UC Health Medicare	$286.50
Rate for Payer: Bisbee Police All Plans	$496.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,298.80
Rate for Payer: Cash Price	$1,528.00
Rate for Payer: Cigna of AZ Commercial	$1,241.50
Rate for Payer: Copperpoint Commercial	$472.72
Rate for Payer: Health Net of AZ Commercial	$1,146.00
Rate for Payer: Health Net of AZ Medicare	$534.80
Rate for Payer: Humana of AZ Medicare	$286.50
Rate for Payer: Self Pay Self Pay	$1,528.00
Rate for Payer: TriWest Medicare	$286.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,113.53
Rate for Payer: UnitedHealth Group of AZ Medicare	$343.80

Prothrombin/INR POC

Facility

$71.00

Service Code	CPT 85610 QW
Hospital Charge Code	714167
Hospital Revenue Code	305
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Aetna of AZ Medicare	$19.88
Rate for Payer: Allwell Medicare	$10.65
Rate for Payer: Amerigroup Medicare	$10.65
Rate for Payer: APIPA Medicare/Medicaid	$26.52
Rate for Payer: AZCH Complete Medicare	$10.65
Rate for Payer: Banner UC Health Medicare	$10.65
Rate for Payer: Bisbee Police All Plans	$18.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$48.28
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cigna of AZ Commercial	$46.15
Rate for Payer: Copperpoint Commercial	$17.57
Rate for Payer: Health Net of AZ Commercial	$42.60
Rate for Payer: Health Net of AZ Medicare	$19.88
Rate for Payer: Humana of AZ Medicare	$10.65
Rate for Payer: Self Pay Self Pay	$56.80
Rate for Payer: TriWest Medicare	$10.65
Rate for Payer: UnitedHealth Group of AZ Commercial	$41.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.78

Prothrombin/INR POC

Facility

$71.00

Service Code	CPT 85610 QW
Hospital Charge Code	714167
Hospital Revenue Code	305
Min. Negotiated Rate	$18.46
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Bisbee Police All Plans	$18.46
Rate for Payer: Cash Price	$56.80
Rate for Payer: Self Pay Self Pay	$56.80

Prothrombin Time

Facility

$71.00

Service Code	CPT 85610
Hospital Charge Code	633793
Hospital Revenue Code	305
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Aetna of AZ Medicare	$19.88
Rate for Payer: AHCCCS Medicaid	$4.29
Rate for Payer: Allwell Medicaid	$4.29
Rate for Payer: Allwell Medicare	$10.65
Rate for Payer: Amerigroup Medicare	$10.65
Rate for Payer: APIPA Medicare/Medicaid	$26.52
Rate for Payer: AZCH Complete Medicaid	$4.29
Rate for Payer: AZCH Complete Medicare	$10.65
Rate for Payer: Banner UC Health Medicaid	$4.29
Rate for Payer: Banner UC Health Medicare	$10.65
Rate for Payer: Bisbee Police All Plans	$18.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$48.28
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cigna of AZ Commercial	$46.15
Rate for Payer: Copperpoint Commercial	$17.57
Rate for Payer: Health Net of AZ Commercial	$42.60
Rate for Payer: Health Net of AZ Medicare	$19.88
Rate for Payer: Humana of AZ Medicare	$10.65
Rate for Payer: Mercy Care Medicaid	$4.29
Rate for Payer: Self Pay Self Pay	$56.80
Rate for Payer: TriWest Medicare	$10.65
Rate for Payer: UnitedHealth Group of AZ Commercial	$41.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.78

Prothrombin Time

Facility

$71.00

Service Code	CPT 85610
Hospital Charge Code	633793
Hospital Revenue Code	305
Min. Negotiated Rate	$18.46
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Bisbee Police All Plans	$18.46
Rate for Payer: Cash Price	$56.80
Rate for Payer: Self Pay Self Pay	$56.80

PROTIME

Facility

$71.00

Service Code	CPT 85610
Hospital Charge Code	22481498
Hospital Revenue Code	305
Min. Negotiated Rate	$18.46
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Bisbee Police All Plans	$18.46
Rate for Payer: Cash Price	$56.80
Rate for Payer: Self Pay Self Pay	$56.80

PROTIME

Facility

$71.00

Service Code	CPT 85610
Hospital Charge Code	22481498
Hospital Revenue Code	305
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Aetna of AZ Medicare	$19.88
Rate for Payer: AHCCCS Medicaid	$4.29
Rate for Payer: Allwell Medicaid	$4.29
Rate for Payer: Allwell Medicare	$10.65
Rate for Payer: Amerigroup Medicare	$10.65
Rate for Payer: APIPA Medicare/Medicaid	$26.52
Rate for Payer: AZCH Complete Medicaid	$4.29
Rate for Payer: AZCH Complete Medicare	$10.65
Rate for Payer: Banner UC Health Medicaid	$4.29
Rate for Payer: Banner UC Health Medicare	$10.65
Rate for Payer: Bisbee Police All Plans	$18.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$48.28
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cigna of AZ Commercial	$46.15
Rate for Payer: Copperpoint Commercial	$17.57
Rate for Payer: Health Net of AZ Commercial	$42.60
Rate for Payer: Health Net of AZ Medicare	$19.88
Rate for Payer: Humana of AZ Medicare	$10.65
Rate for Payer: Mercy Care Medicaid	$4.29
Rate for Payer: Self Pay Self Pay	$56.80
Rate for Payer: TriWest Medicare	$10.65
Rate for Payer: UnitedHealth Group of AZ Commercial	$41.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.78

Protime/PTT

Facility

$75.00

Service Code	CPT 85610
Hospital Charge Code	898512
Hospital Revenue Code	305
Min. Negotiated Rate	$19.50
Max. Negotiated Rate	$67.50
Rate for Payer: Aetna of AZ Commercial	$67.50
Rate for Payer: Bisbee Police All Plans	$19.50
Rate for Payer: Cash Price	$60.00
Rate for Payer: Self Pay Self Pay	$60.00

Protime/PTT

Facility

$75.00

Service Code	CPT 85610
Hospital Charge Code	898512
Hospital Revenue Code	305
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$67.50
Rate for Payer: Aetna of AZ Commercial	$67.50
Rate for Payer: Aetna of AZ Medicare	$21.00
Rate for Payer: AHCCCS Medicaid	$4.29
Rate for Payer: Allwell Medicaid	$4.29
Rate for Payer: Allwell Medicare	$11.25
Rate for Payer: Amerigroup Medicare	$11.25
Rate for Payer: APIPA Medicare/Medicaid	$28.01
Rate for Payer: AZCH Complete Medicaid	$4.29
Rate for Payer: AZCH Complete Medicare	$11.25
Rate for Payer: Banner UC Health Medicaid	$4.29
Rate for Payer: Banner UC Health Medicare	$11.25
Rate for Payer: Bisbee Police All Plans	$19.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$51.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Cigna of AZ Commercial	$48.75
Rate for Payer: Copperpoint Commercial	$18.56
Rate for Payer: Health Net of AZ Commercial	$45.00
Rate for Payer: Health Net of AZ Medicare	$21.00
Rate for Payer: Humana of AZ Medicare	$11.25
Rate for Payer: Mercy Care Medicaid	$4.29
Rate for Payer: Self Pay Self Pay	$60.00
Rate for Payer: TriWest Medicare	$11.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$43.72
Rate for Payer: UnitedHealth Group of AZ Medicare	$13.50

PSA Diagnostic

Facility

$214.00

Service Code	CPT 84153
Hospital Charge Code	1019536
Hospital Revenue Code	301
Min. Negotiated Rate	$55.64
Max. Negotiated Rate	$192.60
Rate for Payer: Aetna of AZ Commercial	$192.60
Rate for Payer: Bisbee Police All Plans	$55.64
Rate for Payer: Cash Price	$171.20
Rate for Payer: Self Pay Self Pay	$171.20

PSA Diagnostic

Facility

$214.00

Service Code	CPT 84153
Hospital Charge Code	1019536
Hospital Revenue Code	301
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$192.60
Rate for Payer: Aetna of AZ Commercial	$192.60
Rate for Payer: Aetna of AZ Medicare	$59.92
Rate for Payer: AHCCCS Medicaid	$18.39
Rate for Payer: Allwell Medicaid	$18.39
Rate for Payer: Allwell Medicare	$32.10
Rate for Payer: Amerigroup Medicare	$32.10
Rate for Payer: APIPA Medicare/Medicaid	$79.93
Rate for Payer: AZCH Complete Medicaid	$18.39
Rate for Payer: AZCH Complete Medicare	$32.10
Rate for Payer: Banner UC Health Medicaid	$18.39
Rate for Payer: Banner UC Health Medicare	$32.10
Rate for Payer: Bisbee Police All Plans	$55.64
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$145.52
Rate for Payer: Cash Price	$171.20
Rate for Payer: Cash Price	$171.20
Rate for Payer: Cigna of AZ Commercial	$139.10
Rate for Payer: Copperpoint Commercial	$52.96
Rate for Payer: Health Net of AZ Commercial	$128.40
Rate for Payer: Health Net of AZ Medicare	$59.92
Rate for Payer: Humana of AZ Medicare	$32.10
Rate for Payer: Mercy Care Medicaid	$18.39
Rate for Payer: Self Pay Self Pay	$171.20
Rate for Payer: TriWest Medicare	$32.10
Rate for Payer: UnitedHealth Group of AZ Commercial	$124.76
Rate for Payer: UnitedHealth Group of AZ Medicare	$38.52

PSA Diagnostic.

Facility

$224.00

Service Code	CPT 84153
Hospital Charge Code	13095387
Hospital Revenue Code	301
Min. Negotiated Rate	$58.24
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of AZ Commercial	$201.60
Rate for Payer: Bisbee Police All Plans	$58.24
Rate for Payer: Cash Price	$179.20
Rate for Payer: Self Pay Self Pay	$179.20

PSA Diagnostic.

Facility

$224.00

Service Code	CPT 84153
Hospital Charge Code	13095387
Hospital Revenue Code	301
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of AZ Commercial	$201.60
Rate for Payer: Aetna of AZ Medicare	$62.72
Rate for Payer: AHCCCS Medicaid	$18.39
Rate for Payer: Allwell Medicaid	$18.39
Rate for Payer: Allwell Medicare	$33.60
Rate for Payer: Amerigroup Medicare	$33.60
Rate for Payer: APIPA Medicare/Medicaid	$83.66
Rate for Payer: AZCH Complete Medicaid	$18.39
Rate for Payer: AZCH Complete Medicare	$33.60
Rate for Payer: Banner UC Health Medicaid	$18.39
Rate for Payer: Banner UC Health Medicare	$33.60
Rate for Payer: Bisbee Police All Plans	$58.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$152.32
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cigna of AZ Commercial	$145.60
Rate for Payer: Copperpoint Commercial	$55.44
Rate for Payer: Health Net of AZ Commercial	$134.40
Rate for Payer: Health Net of AZ Medicare	$62.72
Rate for Payer: Humana of AZ Medicare	$33.60
Rate for Payer: Mercy Care Medicaid	$18.39
Rate for Payer: Self Pay Self Pay	$179.20
Rate for Payer: TriWest Medicare	$33.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$130.59
Rate for Payer: UnitedHealth Group of AZ Medicare	$40.32

PSA Screen

Facility

$235.00

Service Code	CPT G0103
Hospital Charge Code	1019535
Hospital Revenue Code	301
Min. Negotiated Rate	$61.10
Max. Negotiated Rate	$211.50
Rate for Payer: Aetna of AZ Commercial	$211.50
Rate for Payer: Bisbee Police All Plans	$61.10
Rate for Payer: Cash Price	$188.00
Rate for Payer: Self Pay Self Pay	$188.00

PSA Screen

Facility

$235.00

Service Code	CPT G0103
Hospital Charge Code	1019535
Hospital Revenue Code	301
Min. Negotiated Rate	$35.25
Max. Negotiated Rate	$211.50
Rate for Payer: Aetna of AZ Commercial	$211.50
Rate for Payer: Aetna of AZ Medicare	$65.80
Rate for Payer: AHCCCS Medicaid	$38.62
Rate for Payer: Allwell Medicaid	$38.62
Rate for Payer: Allwell Medicare	$35.25
Rate for Payer: Amerigroup Medicare	$35.25
Rate for Payer: APIPA Medicare/Medicaid	$87.77
Rate for Payer: AZCH Complete Medicaid	$38.62
Rate for Payer: AZCH Complete Medicare	$35.25
Rate for Payer: Banner UC Health Medicaid	$38.62
Rate for Payer: Banner UC Health Medicare	$35.25
Rate for Payer: Bisbee Police All Plans	$61.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$159.80
Rate for Payer: Cash Price	$188.00
Rate for Payer: Cash Price	$188.00
Rate for Payer: Cigna of AZ Commercial	$152.75
Rate for Payer: Copperpoint Commercial	$58.16
Rate for Payer: Health Net of AZ Commercial	$141.00
Rate for Payer: Health Net of AZ Medicare	$65.80
Rate for Payer: Humana of AZ Medicare	$35.25
Rate for Payer: Mercy Care Medicaid	$38.62
Rate for Payer: Self Pay Self Pay	$188.00
Rate for Payer: TriWest Medicare	$35.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$137.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$42.30

PSA Total+% Free (Serial) LC

Facility

$270.00

Service Code	CPT 84154
Hospital Charge Code	1909550
Hospital Revenue Code	301
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of AZ Commercial	$243.00
Rate for Payer: Aetna of AZ Medicare	$75.60
Rate for Payer: AHCCCS Medicaid	$18.39
Rate for Payer: Allwell Medicaid	$18.39
Rate for Payer: Allwell Medicare	$40.50
Rate for Payer: Amerigroup Medicare	$40.50
Rate for Payer: APIPA Medicare/Medicaid	$100.84
Rate for Payer: AZCH Complete Medicaid	$18.39
Rate for Payer: AZCH Complete Medicare	$40.50
Rate for Payer: Banner UC Health Medicaid	$18.39
Rate for Payer: Banner UC Health Medicare	$40.50
Rate for Payer: Bisbee Police All Plans	$70.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$183.60
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna of AZ Commercial	$175.50
Rate for Payer: Copperpoint Commercial	$66.82
Rate for Payer: Health Net of AZ Commercial	$162.00
Rate for Payer: Health Net of AZ Medicare	$75.60
Rate for Payer: Humana of AZ Medicare	$40.50
Rate for Payer: Mercy Care Medicaid	$18.39
Rate for Payer: Self Pay Self Pay	$216.00
Rate for Payer: TriWest Medicare	$40.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$157.41
Rate for Payer: UnitedHealth Group of AZ Medicare	$48.60

PSA Total+% Free (Serial) LC

Facility

$270.00

Service Code	CPT 84154
Hospital Charge Code	1909550
Hospital Revenue Code	301
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of AZ Commercial	$243.00
Rate for Payer: Bisbee Police All Plans	$70.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Self Pay Self Pay	$216.00

PSA Ultra. W/Serial Monitor LC

Facility

$263.00

Service Code	CPT 84153
Hospital Charge Code	22311204
Hospital Revenue Code	301
Min. Negotiated Rate	$68.38
Max. Negotiated Rate	$236.70
Rate for Payer: Aetna of AZ Commercial	$236.70
Rate for Payer: Bisbee Police All Plans	$68.38
Rate for Payer: Cash Price	$210.40
Rate for Payer: Self Pay Self Pay	$210.40

PSA Ultra. W/Serial Monitor LC

Facility

$263.00

Service Code	CPT 84153
Hospital Charge Code	22311204
Hospital Revenue Code	301
Min. Negotiated Rate	$18.39
Max. Negotiated Rate	$236.70
Rate for Payer: Aetna of AZ Commercial	$236.70
Rate for Payer: Aetna of AZ Medicare	$73.64
Rate for Payer: AHCCCS Medicaid	$18.39
Rate for Payer: Allwell Medicaid	$18.39
Rate for Payer: Allwell Medicare	$39.45
Rate for Payer: Amerigroup Medicare	$39.45
Rate for Payer: APIPA Medicare/Medicaid	$98.23
Rate for Payer: AZCH Complete Medicaid	$18.39
Rate for Payer: AZCH Complete Medicare	$39.45
Rate for Payer: Banner UC Health Medicaid	$18.39
Rate for Payer: Banner UC Health Medicare	$39.45
Rate for Payer: Bisbee Police All Plans	$68.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$178.84
Rate for Payer: Cash Price	$210.40
Rate for Payer: Cash Price	$210.40
Rate for Payer: Cigna of AZ Commercial	$170.95
Rate for Payer: Copperpoint Commercial	$65.09
Rate for Payer: Health Net of AZ Commercial	$157.80
Rate for Payer: Health Net of AZ Medicare	$73.64
Rate for Payer: Humana of AZ Medicare	$39.45
Rate for Payer: Mercy Care Medicaid	$18.39
Rate for Payer: Self Pay Self Pay	$210.40
Rate for Payer: TriWest Medicare	$39.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$153.33
Rate for Payer: UnitedHealth Group of AZ Medicare	$47.34

pseudoephedrine 30 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 904505359
Hospital Charge Code	105938744
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Self Pay Self Pay	$0.02

Know your out-of-pocket cost for care.

All Charges