Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

raltegravir 400 mgTab [CQCH]

Facility

$23.26

Service Code	NDC 6022761
Hospital Charge Code	105939295
Hospital Revenue Code	251
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$20.93
Rate for Payer: Aetna of AZ Commercial	$20.93
Rate for Payer: Aetna of AZ Medicare	$6.51
Rate for Payer: Allwell Medicare	$3.49
Rate for Payer: Amerigroup Medicare	$3.49
Rate for Payer: APIPA Medicare/Medicaid	$8.69
Rate for Payer: AZCH Complete Medicare	$3.49
Rate for Payer: Banner UC Health Medicare	$3.49
Rate for Payer: Bisbee Police All Plans	$6.05
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$15.82
Rate for Payer: Cash Price	$18.61
Rate for Payer: Cigna of AZ Commercial	$15.12
Rate for Payer: Copperpoint Commercial	$5.76
Rate for Payer: Health Net of AZ Commercial	$13.96
Rate for Payer: Health Net of AZ Medicare	$6.51
Rate for Payer: Humana of AZ Medicare	$3.49
Rate for Payer: Self Pay Self Pay	$18.61
Rate for Payer: TriWest Medicare	$3.49
Rate for Payer: UnitedHealth Group of AZ Commercial	$13.56
Rate for Payer: UnitedHealth Group of AZ Medicare	$4.19

RAM NASAL OXYGEN CANNULA INFANT

Facility

$95.00

Hospital Charge Code	27554771
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

RAM NASAL OXYGEN CANNULA INFANT

Facility

$95.00

Hospital Charge Code	27554771
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

RAM NASAL OXYGEN CANNULA NEWBORN

Facility

$95.00

Hospital Charge Code	27554772
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

RAM NASAL OXYGEN CANNULA NEWBORN

Facility

$95.00

Hospital Charge Code	27554772
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

RAM NASAL OXYGEN CANNULA PREMMIE

Facility

$95.00

Hospital Charge Code	27554770
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

RAM NASAL OXYGEN CANNULA PREMMIE

Facility

$95.00

Hospital Charge Code	27554770
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

ravulizumab 100 mg/mL Sol[CQCH]

Facility

$2,134.67

Service Code	HCPCS J1303
Hospital Charge Code	212945258
Hospital Revenue Code	250
Min. Negotiated Rate	$320.20
Max. Negotiated Rate	$1,921.20
Rate for Payer: Aetna of AZ Commercial	$1,921.20
Rate for Payer: Aetna of AZ Medicare	$597.71
Rate for Payer: AHCCCS Medicaid	$356.30
Rate for Payer: Allwell Medicaid	$356.30
Rate for Payer: Allwell Medicare	$320.20
Rate for Payer: Amerigroup Medicare	$320.20
Rate for Payer: APIPA Medicare/Medicaid	$797.30
Rate for Payer: AZCH Complete Medicaid	$356.30
Rate for Payer: AZCH Complete Medicare	$320.20
Rate for Payer: Banner UC Health Medicaid	$356.30
Rate for Payer: Banner UC Health Medicare	$320.20
Rate for Payer: Bisbee Police All Plans	$555.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,451.58
Rate for Payer: Cash Price	$1,707.73
Rate for Payer: Cash Price	$1,707.73
Rate for Payer: Cigna of AZ Commercial	$1,387.54
Rate for Payer: Copperpoint Commercial	$528.33
Rate for Payer: Health Net of AZ Commercial	$1,280.80
Rate for Payer: Health Net of AZ Medicare	$597.71
Rate for Payer: Humana of AZ Medicare	$320.20
Rate for Payer: Mercy Care Medicaid	$356.30
Rate for Payer: Self Pay Self Pay	$1,707.74
Rate for Payer: TriWest Medicare	$320.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,244.51
Rate for Payer: UnitedHealth Group of AZ Medicare	$384.24

ravulizumab 100 mg/mL Sol[CQCH]

Facility

$2,134.67

Service Code	HCPCS J1303
Hospital Charge Code	212945258
Hospital Revenue Code	250
Min. Negotiated Rate	$555.01
Max. Negotiated Rate	$1,921.20
Rate for Payer: Aetna of AZ Commercial	$1,921.20
Rate for Payer: Bisbee Police All Plans	$555.01
Rate for Payer: Cash Price	$1,707.73
Rate for Payer: Self Pay Self Pay	$1,707.74

RBC CP2D AS3 500 LR

Facility

$799.00

Service Code	CPT P9016
Hospital Charge Code	857613
Hospital Revenue Code	390
Min. Negotiated Rate	$207.74
Max. Negotiated Rate	$719.10
Rate for Payer: Aetna of AZ Commercial	$719.10
Rate for Payer: Bisbee Police All Plans	$207.74
Rate for Payer: Cash Price	$639.20
Rate for Payer: Self Pay Self Pay	$639.20

RBC CP2D AS3 500 LR

Facility

$799.00

Service Code	CPT P9016
Hospital Charge Code	857613
Hospital Revenue Code	390
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$719.10
Rate for Payer: Aetna of AZ Commercial	$719.10
Rate for Payer: Aetna of AZ Medicare	$223.72
Rate for Payer: AHCCCS Medicaid	$273.34
Rate for Payer: Allwell Medicaid	$273.34
Rate for Payer: Allwell Medicare	$119.85
Rate for Payer: Amerigroup Medicare	$119.85
Rate for Payer: APIPA Medicare/Medicaid	$298.43
Rate for Payer: AZCH Complete Medicaid	$273.34
Rate for Payer: AZCH Complete Medicare	$119.85
Rate for Payer: Banner UC Health Medicaid	$273.34
Rate for Payer: Banner UC Health Medicare	$119.85
Rate for Payer: Bisbee Police All Plans	$207.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$543.32
Rate for Payer: Cash Price	$639.20
Rate for Payer: Cash Price	$639.20
Rate for Payer: Cigna of AZ Commercial	$519.35
Rate for Payer: Copperpoint Commercial	$197.75
Rate for Payer: Health Net of AZ Commercial	$479.40
Rate for Payer: Health Net of AZ Medicare	$223.72
Rate for Payer: Humana of AZ Medicare	$119.85
Rate for Payer: Mercy Care Medicaid	$273.34
Rate for Payer: Self Pay Self Pay	$639.20
Rate for Payer: TriWest Medicare	$119.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$465.82
Rate for Payer: UnitedHealth Group of AZ Medicare	$143.82

RBC CP2D AS3 500 LR Irr

Facility

$799.00

Service Code	CPT P9016
Hospital Charge Code	857635
Hospital Revenue Code	390
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$719.10
Rate for Payer: Aetna of AZ Commercial	$719.10
Rate for Payer: Aetna of AZ Medicare	$223.72
Rate for Payer: AHCCCS Medicaid	$273.34
Rate for Payer: Allwell Medicaid	$273.34
Rate for Payer: Allwell Medicare	$119.85
Rate for Payer: Amerigroup Medicare	$119.85
Rate for Payer: APIPA Medicare/Medicaid	$298.43
Rate for Payer: AZCH Complete Medicaid	$273.34
Rate for Payer: AZCH Complete Medicare	$119.85
Rate for Payer: Banner UC Health Medicaid	$273.34
Rate for Payer: Banner UC Health Medicare	$119.85
Rate for Payer: Bisbee Police All Plans	$207.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$543.32
Rate for Payer: Cash Price	$639.20
Rate for Payer: Cash Price	$639.20
Rate for Payer: Cigna of AZ Commercial	$519.35
Rate for Payer: Copperpoint Commercial	$197.75
Rate for Payer: Health Net of AZ Commercial	$479.40
Rate for Payer: Health Net of AZ Medicare	$223.72
Rate for Payer: Humana of AZ Medicare	$119.85
Rate for Payer: Mercy Care Medicaid	$273.34
Rate for Payer: Self Pay Self Pay	$639.20
Rate for Payer: TriWest Medicare	$119.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$465.82
Rate for Payer: UnitedHealth Group of AZ Medicare	$143.82

RBC CP2D AS3 500 LR Irr

Facility

$799.00

Service Code	CPT P9016
Hospital Charge Code	857635
Hospital Revenue Code	390
Min. Negotiated Rate	$207.74
Max. Negotiated Rate	$719.10
Rate for Payer: Aetna of AZ Commercial	$719.10
Rate for Payer: Bisbee Police All Plans	$207.74
Rate for Payer: Cash Price	$639.20
Rate for Payer: Self Pay Self Pay	$639.20

RBC CPD 500 LR

Facility

$799.00

Service Code	CPT P9016
Hospital Charge Code	857651
Hospital Revenue Code	390
Min. Negotiated Rate	$207.74
Max. Negotiated Rate	$719.10
Rate for Payer: Aetna of AZ Commercial	$719.10
Rate for Payer: Bisbee Police All Plans	$207.74
Rate for Payer: Cash Price	$639.20
Rate for Payer: Self Pay Self Pay	$639.20

RBC CPD 500 LR

Facility

$799.00

Service Code	CPT P9016
Hospital Charge Code	857651
Hospital Revenue Code	390
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$719.10
Rate for Payer: Aetna of AZ Commercial	$719.10
Rate for Payer: Aetna of AZ Medicare	$223.72
Rate for Payer: AHCCCS Medicaid	$273.34
Rate for Payer: Allwell Medicaid	$273.34
Rate for Payer: Allwell Medicare	$119.85
Rate for Payer: Amerigroup Medicare	$119.85
Rate for Payer: APIPA Medicare/Medicaid	$298.43
Rate for Payer: AZCH Complete Medicaid	$273.34
Rate for Payer: AZCH Complete Medicare	$119.85
Rate for Payer: Banner UC Health Medicaid	$273.34
Rate for Payer: Banner UC Health Medicare	$119.85
Rate for Payer: Bisbee Police All Plans	$207.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$543.32
Rate for Payer: Cash Price	$639.20
Rate for Payer: Cash Price	$639.20
Rate for Payer: Cigna of AZ Commercial	$519.35
Rate for Payer: Copperpoint Commercial	$197.75
Rate for Payer: Health Net of AZ Commercial	$479.40
Rate for Payer: Health Net of AZ Medicare	$223.72
Rate for Payer: Humana of AZ Medicare	$119.85
Rate for Payer: Mercy Care Medicaid	$273.34
Rate for Payer: Self Pay Self Pay	$639.20
Rate for Payer: TriWest Medicare	$119.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$465.82
Rate for Payer: UnitedHealth Group of AZ Medicare	$143.82

RBC CPD 500 LR Irr

Facility

$799.00

Service Code	CPT P9016
Hospital Charge Code	857652
Hospital Revenue Code	390
Min. Negotiated Rate	$207.74
Max. Negotiated Rate	$719.10
Rate for Payer: Aetna of AZ Commercial	$719.10
Rate for Payer: Bisbee Police All Plans	$207.74
Rate for Payer: Cash Price	$639.20
Rate for Payer: Self Pay Self Pay	$639.20

RBC CPD 500 LR Irr

Facility

$799.00

Service Code	CPT P9016
Hospital Charge Code	857652
Hospital Revenue Code	390
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$719.10
Rate for Payer: Aetna of AZ Commercial	$719.10
Rate for Payer: Aetna of AZ Medicare	$223.72
Rate for Payer: AHCCCS Medicaid	$273.34
Rate for Payer: Allwell Medicaid	$273.34
Rate for Payer: Allwell Medicare	$119.85
Rate for Payer: Amerigroup Medicare	$119.85
Rate for Payer: APIPA Medicare/Medicaid	$298.43
Rate for Payer: AZCH Complete Medicaid	$273.34
Rate for Payer: AZCH Complete Medicare	$119.85
Rate for Payer: Banner UC Health Medicaid	$273.34
Rate for Payer: Banner UC Health Medicare	$119.85
Rate for Payer: Bisbee Police All Plans	$207.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$543.32
Rate for Payer: Cash Price	$639.20
Rate for Payer: Cash Price	$639.20
Rate for Payer: Cigna of AZ Commercial	$519.35
Rate for Payer: Copperpoint Commercial	$197.75
Rate for Payer: Health Net of AZ Commercial	$479.40
Rate for Payer: Health Net of AZ Medicare	$223.72
Rate for Payer: Humana of AZ Medicare	$119.85
Rate for Payer: Mercy Care Medicaid	$273.34
Rate for Payer: Self Pay Self Pay	$639.20
Rate for Payer: TriWest Medicare	$119.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$465.82
Rate for Payer: UnitedHealth Group of AZ Medicare	$143.82

RBC CPD AS1 500 LR

Facility

$799.00

Service Code	CPT P9016
Hospital Charge Code	857663
Hospital Revenue Code	390
Min. Negotiated Rate	$119.85
Max. Negotiated Rate	$719.10
Rate for Payer: Aetna of AZ Commercial	$719.10
Rate for Payer: Aetna of AZ Medicare	$223.72
Rate for Payer: AHCCCS Medicaid	$273.34
Rate for Payer: Allwell Medicaid	$273.34
Rate for Payer: Allwell Medicare	$119.85
Rate for Payer: Amerigroup Medicare	$119.85
Rate for Payer: APIPA Medicare/Medicaid	$298.43
Rate for Payer: AZCH Complete Medicaid	$273.34
Rate for Payer: AZCH Complete Medicare	$119.85
Rate for Payer: Banner UC Health Medicaid	$273.34
Rate for Payer: Banner UC Health Medicare	$119.85
Rate for Payer: Bisbee Police All Plans	$207.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$543.32
Rate for Payer: Cash Price	$639.20
Rate for Payer: Cash Price	$639.20
Rate for Payer: Cigna of AZ Commercial	$519.35
Rate for Payer: Copperpoint Commercial	$197.75
Rate for Payer: Health Net of AZ Commercial	$479.40
Rate for Payer: Health Net of AZ Medicare	$223.72
Rate for Payer: Humana of AZ Medicare	$119.85
Rate for Payer: Mercy Care Medicaid	$273.34
Rate for Payer: Self Pay Self Pay	$639.20
Rate for Payer: TriWest Medicare	$119.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$465.82
Rate for Payer: UnitedHealth Group of AZ Medicare	$143.82

RBC CPD AS1 500 LR

Facility

$799.00

Service Code	CPT P9016
Hospital Charge Code	857663
Hospital Revenue Code	390
Min. Negotiated Rate	$207.74
Max. Negotiated Rate	$719.10
Rate for Payer: Aetna of AZ Commercial	$719.10
Rate for Payer: Bisbee Police All Plans	$207.74
Rate for Payer: Cash Price	$639.20
Rate for Payer: Self Pay Self Pay	$639.20

RBC CPD AS1 500 LR Irr

Facility

$761.00

Service Code	CPT P9016
Hospital Charge Code	857630
Hospital Revenue Code	390
Min. Negotiated Rate	$197.86
Max. Negotiated Rate	$684.90
Rate for Payer: Aetna of AZ Commercial	$684.90
Rate for Payer: Bisbee Police All Plans	$197.86
Rate for Payer: Cash Price	$608.80
Rate for Payer: Self Pay Self Pay	$608.80

RBC CPD AS1 500 LR Irr

Facility

$761.00

Service Code	CPT P9016
Hospital Charge Code	857630
Hospital Revenue Code	390
Min. Negotiated Rate	$114.15
Max. Negotiated Rate	$684.90
Rate for Payer: Aetna of AZ Commercial	$684.90
Rate for Payer: Aetna of AZ Medicare	$213.08
Rate for Payer: AHCCCS Medicaid	$273.34
Rate for Payer: Allwell Medicaid	$273.34
Rate for Payer: Allwell Medicare	$114.15
Rate for Payer: Amerigroup Medicare	$114.15
Rate for Payer: APIPA Medicare/Medicaid	$284.23
Rate for Payer: AZCH Complete Medicaid	$273.34
Rate for Payer: AZCH Complete Medicare	$114.15
Rate for Payer: Banner UC Health Medicaid	$273.34
Rate for Payer: Banner UC Health Medicare	$114.15
Rate for Payer: Bisbee Police All Plans	$197.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$517.48
Rate for Payer: Cash Price	$608.80
Rate for Payer: Cash Price	$608.80
Rate for Payer: Cigna of AZ Commercial	$494.65
Rate for Payer: Copperpoint Commercial	$188.35
Rate for Payer: Health Net of AZ Commercial	$456.60
Rate for Payer: Health Net of AZ Medicare	$213.08
Rate for Payer: Humana of AZ Medicare	$114.15
Rate for Payer: Mercy Care Medicaid	$273.34
Rate for Payer: Self Pay Self Pay	$608.80
Rate for Payer: TriWest Medicare	$114.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$443.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$136.98

RECHARGER BELT

Facility

$263.00

Hospital Charge Code	27400598
Hospital Revenue Code	270
Min. Negotiated Rate	$39.45
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: Allwell Medicare	$39.45
Rate for Payer: Amerigroup Medicare	$39.45
Rate for Payer: APIPA Medicare/Medicaid	$98.23
Rate for Payer: AZCH Complete Medicare	$39.45
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: Cigna of AZ Commercial	$184.10
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: 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

RECHARGER BELT

Facility

$263.00

Hospital Charge Code	27400598
Hospital Revenue Code	270
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

RECHARGER KIT

Facility

$7,088.00

Hospital Charge Code	27400597
Hospital Revenue Code	270
Min. Negotiated Rate	$1,063.20
Max. Negotiated Rate	$6,379.20
Rate for Payer: Aetna of AZ Commercial	$6,379.20
Rate for Payer: Aetna of AZ Medicare	$1,984.64
Rate for Payer: Allwell Medicare	$1,063.20
Rate for Payer: Amerigroup Medicare	$1,063.20
Rate for Payer: APIPA Medicare/Medicaid	$2,647.37
Rate for Payer: AZCH Complete Medicare	$1,063.20
Rate for Payer: Banner UC Health Medicare	$1,063.20
Rate for Payer: Bisbee Police All Plans	$1,842.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$4,819.84
Rate for Payer: Cash Price	$5,670.40
Rate for Payer: Cigna of AZ Commercial	$4,961.60
Rate for Payer: Copperpoint Commercial	$1,754.28
Rate for Payer: Health Net of AZ Commercial	$4,252.80
Rate for Payer: Health Net of AZ Medicare	$1,984.64
Rate for Payer: Humana of AZ Medicare	$1,063.20
Rate for Payer: Self Pay Self Pay	$5,670.40
Rate for Payer: TriWest Medicare	$1,063.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$4,132.30
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,275.84

RECHARGER KIT

Facility

$7,088.00

Hospital Charge Code	27400597
Hospital Revenue Code	270
Min. Negotiated Rate	$1,842.88
Max. Negotiated Rate	$6,379.20
Rate for Payer: Aetna of AZ Commercial	$6,379.20
Rate for Payer: Bisbee Police All Plans	$1,842.88
Rate for Payer: Cash Price	$5,670.40
Rate for Payer: Self Pay Self Pay	$5,670.40

Know your out-of-pocket cost for care.

All Charges