Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Adrenal Procedures

Facility

$8,435.74

Service Code	APR-DRG 4011
Hospital Charge Code	APRDRG4014
Min. Negotiated Rate	$8,435.74
Max. Negotiated Rate	$8,435.74
Rate for Payer: AHCCCS Medicaid	$8,435.74
Rate for Payer: Allwell Medicaid	$8,435.74
Rate for Payer: AZCH Complete Medicaid	$8,435.74
Rate for Payer: Banner UC Health Medicaid	$8,435.74
Rate for Payer: Mercy Care Medicaid	$8,435.74

Adrenal Procedures

Facility

$8,435.74

Service Code	APR-DRG 4011
Hospital Charge Code	APRDRG4011
Min. Negotiated Rate	$8,435.74
Max. Negotiated Rate	$8,435.74
Rate for Payer: AHCCCS Medicaid	$8,435.74
Rate for Payer: Allwell Medicaid	$8,435.74
Rate for Payer: AZCH Complete Medicaid	$8,435.74
Rate for Payer: Banner UC Health Medicaid	$8,435.74
Rate for Payer: Mercy Care Medicaid	$8,435.74

ADULT AMBU BAG

Facility

$135.00

Hospital Charge Code	22354982
Hospital Revenue Code	270
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of AZ Commercial	$121.50
Rate for Payer: Bisbee Police All Plans	$35.10
Rate for Payer: Cash Price	$108.00
Rate for Payer: Self Pay Self Pay	$108.00

ADULT AMBU BAG

Facility

$135.00

Hospital Charge Code	22354982
Hospital Revenue Code	270
Min. Negotiated Rate	$20.25
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of AZ Commercial	$121.50
Rate for Payer: Aetna of AZ Medicare	$37.80
Rate for Payer: Allwell Medicare	$20.25
Rate for Payer: Amerigroup Medicare	$20.25
Rate for Payer: APIPA Medicare/Medicaid	$50.42
Rate for Payer: AZCH Complete Medicare	$20.25
Rate for Payer: Banner UC Health Medicare	$20.25
Rate for Payer: Bisbee Police All Plans	$35.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$91.80
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna of AZ Commercial	$94.50
Rate for Payer: Copperpoint Commercial	$33.41
Rate for Payer: Health Net of AZ Commercial	$81.00
Rate for Payer: Health Net of AZ Medicare	$37.80
Rate for Payer: Humana of AZ Medicare	$20.25
Rate for Payer: Self Pay Self Pay	$108.00
Rate for Payer: TriWest Medicare	$20.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$78.70
Rate for Payer: UnitedHealth Group of AZ Medicare	$24.30

AEROSOL DRAIN SYSTEM WITH WYE 750CC

Facility

$13.00

Hospital Charge Code	22354765
Hospital Revenue Code	271
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$11.70
Rate for Payer: Aetna of AZ Commercial	$11.70
Rate for Payer: Bisbee Police All Plans	$3.38
Rate for Payer: Cash Price	$10.40
Rate for Payer: Self Pay Self Pay	$10.40

AEROSOL DRAIN SYSTEM WITH WYE 750CC

Facility

$13.00

Hospital Charge Code	22354765
Hospital Revenue Code	271
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$11.70
Rate for Payer: Aetna of AZ Commercial	$11.70
Rate for Payer: Aetna of AZ Medicare	$3.64
Rate for Payer: Allwell Medicare	$1.95
Rate for Payer: Amerigroup Medicare	$1.95
Rate for Payer: APIPA Medicare/Medicaid	$4.86
Rate for Payer: AZCH Complete Medicare	$1.95
Rate for Payer: Banner UC Health Medicare	$1.95
Rate for Payer: Bisbee Police All Plans	$3.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$8.84
Rate for Payer: Cash Price	$10.40
Rate for Payer: Cigna of AZ Commercial	$9.10
Rate for Payer: Copperpoint Commercial	$3.22
Rate for Payer: Health Net of AZ Commercial	$7.80
Rate for Payer: Health Net of AZ Medicare	$3.64
Rate for Payer: Humana of AZ Medicare	$1.95
Rate for Payer: Self Pay Self Pay	$10.40
Rate for Payer: TriWest Medicare	$1.95
Rate for Payer: UnitedHealth Group of AZ Commercial	$7.58
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.34

AEROSTAT CHOLANGIOGRAPHY CATH 6FR

Facility

$238.00

Hospital Charge Code	27465745
Hospital Revenue Code	270
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$214.20
Rate for Payer: Aetna of AZ Commercial	$214.20
Rate for Payer: Aetna of AZ Medicare	$66.64
Rate for Payer: Allwell Medicare	$35.70
Rate for Payer: Amerigroup Medicare	$35.70
Rate for Payer: APIPA Medicare/Medicaid	$88.89
Rate for Payer: AZCH Complete Medicare	$35.70
Rate for Payer: Banner UC Health Medicare	$35.70
Rate for Payer: Bisbee Police All Plans	$61.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$161.84
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cigna of AZ Commercial	$166.60
Rate for Payer: Copperpoint Commercial	$58.90
Rate for Payer: Health Net of AZ Commercial	$142.80
Rate for Payer: Health Net of AZ Medicare	$66.64
Rate for Payer: Humana of AZ Medicare	$35.70
Rate for Payer: Self Pay Self Pay	$190.40
Rate for Payer: TriWest Medicare	$35.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$138.75
Rate for Payer: UnitedHealth Group of AZ Medicare	$42.84

AEROSTAT CHOLANGIOGRAPHY CATH 6FR

Facility

$238.00

Hospital Charge Code	27465745
Hospital Revenue Code	270
Min. Negotiated Rate	$61.88
Max. Negotiated Rate	$214.20
Rate for Payer: Aetna of AZ Commercial	$214.20
Rate for Payer: Bisbee Police All Plans	$61.88
Rate for Payer: Cash Price	$190.40
Rate for Payer: Self Pay Self Pay	$190.40

AFC GENERIC ADD-ON

Facility

$246.00

Service Code	CPT 86900
Hospital Charge Code	22543270
Hospital Revenue Code	302
Min. Negotiated Rate	$63.96
Max. Negotiated Rate	$221.40
Rate for Payer: Aetna of AZ Commercial	$221.40
Rate for Payer: Bisbee Police All Plans	$63.96
Rate for Payer: Cash Price	$196.80
Rate for Payer: Self Pay Self Pay	$196.80

AFC GENERIC ADD-ON

Facility

$215.00

Service Code	CPT 84702
Hospital Charge Code	22543273
Hospital Revenue Code	301
Min. Negotiated Rate	$15.05
Max. Negotiated Rate	$193.50
Rate for Payer: Aetna of AZ Commercial	$193.50
Rate for Payer: Aetna of AZ Medicare	$60.20
Rate for Payer: AHCCCS Medicaid	$15.05
Rate for Payer: Allwell Medicaid	$15.05
Rate for Payer: Allwell Medicare	$32.25
Rate for Payer: Amerigroup Medicare	$32.25
Rate for Payer: APIPA Medicare/Medicaid	$80.30
Rate for Payer: AZCH Complete Medicaid	$15.05
Rate for Payer: AZCH Complete Medicare	$32.25
Rate for Payer: Banner UC Health Medicaid	$15.05
Rate for Payer: Banner UC Health Medicare	$32.25
Rate for Payer: Bisbee Police All Plans	$55.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$146.20
Rate for Payer: Cash Price	$172.00
Rate for Payer: Cash Price	$172.00
Rate for Payer: Cigna of AZ Commercial	$139.75
Rate for Payer: Copperpoint Commercial	$53.21
Rate for Payer: Health Net of AZ Commercial	$129.00
Rate for Payer: Health Net of AZ Medicare	$60.20
Rate for Payer: Humana of AZ Medicare	$32.25
Rate for Payer: Mercy Care Medicaid	$15.05
Rate for Payer: Self Pay Self Pay	$172.00
Rate for Payer: TriWest Medicare	$32.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$125.34
Rate for Payer: UnitedHealth Group of AZ Medicare	$38.70

AFC GENERIC ADD-ON

Facility

$85.00

Service Code	CPT 86256
Hospital Charge Code	22543634
Hospital Revenue Code	302
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of AZ Commercial	$76.50
Rate for Payer: Bisbee Police All Plans	$22.10
Rate for Payer: Cash Price	$68.00
Rate for Payer: Self Pay Self Pay	$68.00

AFC GENERIC ADD-ON

Facility

$215.00

Service Code	CPT 84702
Hospital Charge Code	22543273
Hospital Revenue Code	301
Min. Negotiated Rate	$55.90
Max. Negotiated Rate	$193.50
Rate for Payer: Aetna of AZ Commercial	$193.50
Rate for Payer: Bisbee Police All Plans	$55.90
Rate for Payer: Cash Price	$172.00
Rate for Payer: Self Pay Self Pay	$172.00

AFC GENERIC ADD-ON

Facility

$286.00

Service Code	CPT 86901
Hospital Charge Code	22543271
Hospital Revenue Code	302
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$257.40
Rate for Payer: Aetna of AZ Commercial	$257.40
Rate for Payer: Aetna of AZ Medicare	$80.08
Rate for Payer: AHCCCS Medicaid	$2.99
Rate for Payer: Allwell Medicaid	$2.99
Rate for Payer: Allwell Medicare	$42.90
Rate for Payer: Amerigroup Medicare	$42.90
Rate for Payer: APIPA Medicare/Medicaid	$106.82
Rate for Payer: AZCH Complete Medicaid	$2.99
Rate for Payer: AZCH Complete Medicare	$42.90
Rate for Payer: Banner UC Health Medicaid	$2.99
Rate for Payer: Banner UC Health Medicare	$42.90
Rate for Payer: Bisbee Police All Plans	$74.36
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$194.48
Rate for Payer: Cash Price	$228.80
Rate for Payer: Cash Price	$228.80
Rate for Payer: Cigna of AZ Commercial	$185.90
Rate for Payer: Copperpoint Commercial	$70.78
Rate for Payer: Health Net of AZ Commercial	$171.60
Rate for Payer: Health Net of AZ Medicare	$80.08
Rate for Payer: Humana of AZ Medicare	$42.90
Rate for Payer: Mercy Care Medicaid	$2.99
Rate for Payer: Self Pay Self Pay	$228.80
Rate for Payer: TriWest Medicare	$42.90
Rate for Payer: UnitedHealth Group of AZ Commercial	$166.74
Rate for Payer: UnitedHealth Group of AZ Medicare	$51.48

AFC GENERIC ADD-ON

Facility

$361.00

Service Code	CPT 82677
Hospital Charge Code	22543272
Hospital Revenue Code	301
Min. Negotiated Rate	$24.18
Max. Negotiated Rate	$324.90
Rate for Payer: Aetna of AZ Commercial	$324.90
Rate for Payer: Aetna of AZ Medicare	$101.08
Rate for Payer: AHCCCS Medicaid	$24.18
Rate for Payer: Allwell Medicaid	$24.18
Rate for Payer: Allwell Medicare	$54.15
Rate for Payer: Amerigroup Medicare	$54.15
Rate for Payer: APIPA Medicare/Medicaid	$134.83
Rate for Payer: AZCH Complete Medicaid	$24.18
Rate for Payer: AZCH Complete Medicare	$54.15
Rate for Payer: Banner UC Health Medicaid	$24.18
Rate for Payer: Banner UC Health Medicare	$54.15
Rate for Payer: Bisbee Police All Plans	$93.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$245.48
Rate for Payer: Cash Price	$288.80
Rate for Payer: Cash Price	$288.80
Rate for Payer: Cigna of AZ Commercial	$234.65
Rate for Payer: Copperpoint Commercial	$89.35
Rate for Payer: Health Net of AZ Commercial	$216.60
Rate for Payer: Health Net of AZ Medicare	$101.08
Rate for Payer: Humana of AZ Medicare	$54.15
Rate for Payer: Mercy Care Medicaid	$24.18
Rate for Payer: Self Pay Self Pay	$288.80
Rate for Payer: TriWest Medicare	$54.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$210.46
Rate for Payer: UnitedHealth Group of AZ Medicare	$64.98

AFC GENERIC ADD-ON

Facility

$243.00

Service Code	CPT 83520
Hospital Charge Code	22543633
Hospital Revenue Code	310
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$218.70
Rate for Payer: Aetna of AZ Commercial	$218.70
Rate for Payer: Aetna of AZ Medicare	$68.04
Rate for Payer: AHCCCS Medicaid	$17.27
Rate for Payer: Allwell Medicaid	$17.27
Rate for Payer: Allwell Medicare	$36.45
Rate for Payer: Amerigroup Medicare	$36.45
Rate for Payer: APIPA Medicare/Medicaid	$90.76
Rate for Payer: AZCH Complete Medicaid	$17.27
Rate for Payer: AZCH Complete Medicare	$36.45
Rate for Payer: Banner UC Health Medicaid	$17.27
Rate for Payer: Banner UC Health Medicare	$36.45
Rate for Payer: Bisbee Police All Plans	$63.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$165.24
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cigna of AZ Commercial	$157.95
Rate for Payer: Copperpoint Commercial	$60.14
Rate for Payer: Health Net of AZ Commercial	$145.80
Rate for Payer: Health Net of AZ Medicare	$68.04
Rate for Payer: Humana of AZ Medicare	$36.45
Rate for Payer: Mercy Care Medicaid	$17.27
Rate for Payer: Self Pay Self Pay	$194.40
Rate for Payer: TriWest Medicare	$36.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$141.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$43.74

AFC GENERIC ADD-ON

Facility

$246.00

Service Code	CPT 86900
Hospital Charge Code	22543270
Hospital Revenue Code	302
Min. Negotiated Rate	$2.99
Max. Negotiated Rate	$221.40
Rate for Payer: Aetna of AZ Commercial	$221.40
Rate for Payer: Aetna of AZ Medicare	$68.88
Rate for Payer: AHCCCS Medicaid	$2.99
Rate for Payer: Allwell Medicaid	$2.99
Rate for Payer: Allwell Medicare	$36.90
Rate for Payer: Amerigroup Medicare	$36.90
Rate for Payer: APIPA Medicare/Medicaid	$91.88
Rate for Payer: AZCH Complete Medicaid	$2.99
Rate for Payer: AZCH Complete Medicare	$36.90
Rate for Payer: Banner UC Health Medicaid	$2.99
Rate for Payer: Banner UC Health Medicare	$36.90
Rate for Payer: Bisbee Police All Plans	$63.96
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$167.28
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cigna of AZ Commercial	$159.90
Rate for Payer: Copperpoint Commercial	$60.88
Rate for Payer: Health Net of AZ Commercial	$147.60
Rate for Payer: Health Net of AZ Medicare	$68.88
Rate for Payer: Humana of AZ Medicare	$36.90
Rate for Payer: Mercy Care Medicaid	$2.99
Rate for Payer: Self Pay Self Pay	$196.80
Rate for Payer: TriWest Medicare	$36.90
Rate for Payer: UnitedHealth Group of AZ Commercial	$143.42
Rate for Payer: UnitedHealth Group of AZ Medicare	$44.28

AFC GENERIC ADD-ON

Facility

$85.00

Service Code	CPT 86256
Hospital Charge Code	22543634
Hospital Revenue Code	302
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of AZ Commercial	$76.50
Rate for Payer: Aetna of AZ Medicare	$23.80
Rate for Payer: AHCCCS Medicaid	$12.05
Rate for Payer: Allwell Medicaid	$12.05
Rate for Payer: Allwell Medicare	$12.75
Rate for Payer: Amerigroup Medicare	$12.75
Rate for Payer: APIPA Medicare/Medicaid	$31.75
Rate for Payer: AZCH Complete Medicaid	$12.05
Rate for Payer: AZCH Complete Medicare	$12.75
Rate for Payer: Banner UC Health Medicaid	$12.05
Rate for Payer: Banner UC Health Medicare	$12.75
Rate for Payer: Bisbee Police All Plans	$22.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$57.80
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cigna of AZ Commercial	$55.25
Rate for Payer: Copperpoint Commercial	$21.04
Rate for Payer: Health Net of AZ Commercial	$51.00
Rate for Payer: Health Net of AZ Medicare	$23.80
Rate for Payer: Humana of AZ Medicare	$12.75
Rate for Payer: Mercy Care Medicaid	$12.05
Rate for Payer: Self Pay Self Pay	$68.00
Rate for Payer: TriWest Medicare	$12.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$49.56
Rate for Payer: UnitedHealth Group of AZ Medicare	$15.30

AFC GENERIC ADD-ON

Facility

$243.00

Service Code	CPT 83520
Hospital Charge Code	22543633
Hospital Revenue Code	310
Min. Negotiated Rate	$63.18
Max. Negotiated Rate	$218.70
Rate for Payer: Aetna of AZ Commercial	$218.70
Rate for Payer: Bisbee Police All Plans	$63.18
Rate for Payer: Cash Price	$194.40
Rate for Payer: Self Pay Self Pay	$194.40

AFC GENERIC ADD-ON

Facility

$286.00

Service Code	CPT 86901
Hospital Charge Code	22543271
Hospital Revenue Code	302
Min. Negotiated Rate	$74.36
Max. Negotiated Rate	$257.40
Rate for Payer: Aetna of AZ Commercial	$257.40
Rate for Payer: Bisbee Police All Plans	$74.36
Rate for Payer: Cash Price	$228.80
Rate for Payer: Self Pay Self Pay	$228.80

AFC GENERIC ADD-ON

Facility

$99.00

Service Code	CPT 86336
Hospital Charge Code	22543274
Hospital Revenue Code	302
Min. Negotiated Rate	$14.85
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of AZ Commercial	$89.10
Rate for Payer: Aetna of AZ Medicare	$27.72
Rate for Payer: AHCCCS Medicaid	$15.59
Rate for Payer: Allwell Medicaid	$15.59
Rate for Payer: Allwell Medicare	$14.85
Rate for Payer: Amerigroup Medicare	$14.85
Rate for Payer: APIPA Medicare/Medicaid	$36.98
Rate for Payer: AZCH Complete Medicaid	$15.59
Rate for Payer: AZCH Complete Medicare	$14.85
Rate for Payer: Banner UC Health Medicaid	$15.59
Rate for Payer: Banner UC Health Medicare	$14.85
Rate for Payer: Bisbee Police All Plans	$25.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$67.32
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna of AZ Commercial	$64.35
Rate for Payer: Copperpoint Commercial	$24.50
Rate for Payer: Health Net of AZ Commercial	$59.40
Rate for Payer: Health Net of AZ Medicare	$27.72
Rate for Payer: Humana of AZ Medicare	$14.85
Rate for Payer: Mercy Care Medicaid	$15.59
Rate for Payer: Self Pay Self Pay	$79.20
Rate for Payer: TriWest Medicare	$14.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$57.72
Rate for Payer: UnitedHealth Group of AZ Medicare	$17.82

AFC GENERIC ADD-ON

Facility

$361.00

Service Code	CPT 82677
Hospital Charge Code	22543272
Hospital Revenue Code	301
Min. Negotiated Rate	$93.86
Max. Negotiated Rate	$324.90
Rate for Payer: Aetna of AZ Commercial	$324.90
Rate for Payer: Bisbee Police All Plans	$93.86
Rate for Payer: Cash Price	$288.80
Rate for Payer: Self Pay Self Pay	$288.80

AFC GENERIC ADD-ON

Facility

$99.00

Service Code	CPT 86336
Hospital Charge Code	22543274
Hospital Revenue Code	302
Min. Negotiated Rate	$25.74
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of AZ Commercial	$89.10
Rate for Payer: Bisbee Police All Plans	$25.74
Rate for Payer: Cash Price	$79.20
Rate for Payer: Self Pay Self Pay	$79.20

Affinity

Facility

$8,125.00

Service Code	CPT Q4159
Hospital Charge Code	24383280
Hospital Revenue Code	636
Min. Negotiated Rate	$2,112.50
Max. Negotiated Rate	$7,312.50
Rate for Payer: Aetna of AZ Commercial	$7,312.50
Rate for Payer: Bisbee Police All Plans	$2,112.50
Rate for Payer: Cash Price	$6,500.00
Rate for Payer: Self Pay Self Pay	$6,500.00

Affinity

Facility

$8,125.00

Service Code	CPT Q4159
Hospital Charge Code	24383280
Hospital Revenue Code	636
Min. Negotiated Rate	$874.96
Max. Negotiated Rate	$7,312.50
Rate for Payer: Aetna of AZ Commercial	$7,312.50
Rate for Payer: Aetna of AZ Medicare	$2,275.00
Rate for Payer: AHCCCS Medicaid	$874.96
Rate for Payer: Allwell Medicaid	$874.96
Rate for Payer: Allwell Medicare	$1,218.75
Rate for Payer: Amerigroup Medicare	$1,218.75
Rate for Payer: APIPA Medicare/Medicaid	$3,034.69
Rate for Payer: AZCH Complete Medicaid	$874.96
Rate for Payer: AZCH Complete Medicare	$1,218.75
Rate for Payer: Banner UC Health Medicaid	$874.96
Rate for Payer: Banner UC Health Medicare	$1,218.75
Rate for Payer: Bisbee Police All Plans	$2,112.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$5,525.00
Rate for Payer: Cash Price	$6,500.00
Rate for Payer: Cash Price	$6,500.00
Rate for Payer: Cigna of AZ Commercial	$5,687.50
Rate for Payer: Copperpoint Commercial	$2,010.94
Rate for Payer: Health Net of AZ Commercial	$4,875.00
Rate for Payer: Health Net of AZ Medicare	$2,275.00
Rate for Payer: Humana of AZ Medicare	$1,218.75
Rate for Payer: Mercy Care Medicaid	$874.96
Rate for Payer: Self Pay Self Pay	$6,500.00
Rate for Payer: TriWest Medicare	$1,218.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$4,736.88
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,462.50

AFP, Serum, Tumor Marker LC

Facility

$365.00

Service Code	CPT 82105
Hospital Charge Code	1905891
Hospital Revenue Code	301
Min. Negotiated Rate	$94.90
Max. Negotiated Rate	$328.50
Rate for Payer: Aetna of AZ Commercial	$328.50
Rate for Payer: Bisbee Police All Plans	$94.90
Rate for Payer: Cash Price	$292.00
Rate for Payer: Self Pay Self Pay	$292.00

Know your out-of-pocket cost for care.

All Charges