Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

RESTRAINT LIMB

Facility

$19.00

Hospital Charge Code	22354291
Hospital Revenue Code	270
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$17.10
Rate for Payer: Aetna of AZ Commercial	$17.10
Rate for Payer: Aetna of AZ Medicare	$5.32
Rate for Payer: Allwell Medicare	$2.85
Rate for Payer: Amerigroup Medicare	$2.85
Rate for Payer: APIPA Medicare/Medicaid	$7.10
Rate for Payer: AZCH Complete Medicare	$2.85
Rate for Payer: Banner UC Health Medicare	$2.85
Rate for Payer: Bisbee Police All Plans	$4.94
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$12.92
Rate for Payer: Cash Price	$15.20
Rate for Payer: Cigna of AZ Commercial	$13.30
Rate for Payer: Copperpoint Commercial	$4.70
Rate for Payer: Health Net of AZ Commercial	$11.40
Rate for Payer: Health Net of AZ Medicare	$5.32
Rate for Payer: Humana of AZ Medicare	$2.85
Rate for Payer: Self Pay Self Pay	$15.20
Rate for Payer: TriWest Medicare	$2.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$11.08
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.42

RESUSCITATION

Facility

$258.00

Service Code	CPT 92950
Hospital Charge Code	1886871
Hospital Revenue Code	480
Min. Negotiated Rate	$67.08
Max. Negotiated Rate	$232.20
Rate for Payer: Aetna of AZ Commercial	$232.20
Rate for Payer: Bisbee Police All Plans	$67.08
Rate for Payer: Cash Price	$206.40
Rate for Payer: Self Pay Self Pay	$206.40

RESUSCITATION

Facility

$258.00

Service Code	CPT 92950
Hospital Charge Code	1886871
Hospital Revenue Code	480
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$383.46
Rate for Payer: Aetna of AZ Commercial	$232.20
Rate for Payer: Aetna of AZ Medicare	$72.24
Rate for Payer: AHCCCS Medicaid	$383.46
Rate for Payer: Allwell Medicaid	$383.46
Rate for Payer: Allwell Medicare	$38.70
Rate for Payer: Amerigroup Medicare	$38.70
Rate for Payer: APIPA Medicare/Medicaid	$96.36
Rate for Payer: AZCH Complete Medicaid	$383.46
Rate for Payer: AZCH Complete Medicare	$38.70
Rate for Payer: Banner UC Health Medicaid	$383.46
Rate for Payer: Banner UC Health Medicare	$38.70
Rate for Payer: Bisbee Police All Plans	$67.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$175.44
Rate for Payer: Cash Price	$206.40
Rate for Payer: Cash Price	$206.40
Rate for Payer: Cigna of AZ Commercial	$180.60
Rate for Payer: Copperpoint Commercial	$63.86
Rate for Payer: Health Net of AZ Commercial	$154.80
Rate for Payer: Health Net of AZ Medicare	$72.24
Rate for Payer: Humana of AZ Medicare	$38.70
Rate for Payer: Mercy Care Medicaid	$383.46
Rate for Payer: Self Pay Self Pay	$206.40
Rate for Payer: TriWest Medicare	$38.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$150.41
Rate for Payer: UnitedHealth Group of AZ Medicare	$46.44

Reticulocyte Count LC

Facility

$58.00

Service Code	CPT 85045
Hospital Charge Code	1909555
Hospital Revenue Code	305
Min. Negotiated Rate	$3.99
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of AZ Commercial	$52.20
Rate for Payer: Aetna of AZ Medicare	$16.24
Rate for Payer: AHCCCS Medicaid	$3.99
Rate for Payer: Allwell Medicaid	$3.99
Rate for Payer: Allwell Medicare	$8.70
Rate for Payer: Amerigroup Medicare	$8.70
Rate for Payer: APIPA Medicare/Medicaid	$21.66
Rate for Payer: AZCH Complete Medicaid	$3.99
Rate for Payer: AZCH Complete Medicare	$8.70
Rate for Payer: Banner UC Health Medicaid	$3.99
Rate for Payer: Banner UC Health Medicare	$8.70
Rate for Payer: Bisbee Police All Plans	$15.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$39.44
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cigna of AZ Commercial	$37.70
Rate for Payer: Copperpoint Commercial	$14.36
Rate for Payer: Health Net of AZ Commercial	$34.80
Rate for Payer: Health Net of AZ Medicare	$16.24
Rate for Payer: Humana of AZ Medicare	$8.70
Rate for Payer: Mercy Care Medicaid	$3.99
Rate for Payer: Self Pay Self Pay	$46.40
Rate for Payer: TriWest Medicare	$8.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$33.81
Rate for Payer: UnitedHealth Group of AZ Medicare	$10.44

Reticulocyte Count LC

Facility

$58.00

Service Code	CPT 85045
Hospital Charge Code	1909555
Hospital Revenue Code	305
Min. Negotiated Rate	$15.08
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of AZ Commercial	$52.20
Rate for Payer: Bisbee Police All Plans	$15.08
Rate for Payer: Cash Price	$46.40
Rate for Payer: Self Pay Self Pay	$46.40

RETRACTOR BALLOON

Facility

$419.00

Hospital Charge Code	22354815
Hospital Revenue Code	270
Min. Negotiated Rate	$108.94
Max. Negotiated Rate	$377.10
Rate for Payer: Aetna of AZ Commercial	$377.10
Rate for Payer: Bisbee Police All Plans	$108.94
Rate for Payer: Cash Price	$335.20
Rate for Payer: Self Pay Self Pay	$335.20

RETRACTOR BALLOON

Facility

$419.00

Hospital Charge Code	22354815
Hospital Revenue Code	270
Min. Negotiated Rate	$62.85
Max. Negotiated Rate	$377.10
Rate for Payer: Aetna of AZ Commercial	$377.10
Rate for Payer: Aetna of AZ Medicare	$117.32
Rate for Payer: Allwell Medicare	$62.85
Rate for Payer: Amerigroup Medicare	$62.85
Rate for Payer: APIPA Medicare/Medicaid	$156.50
Rate for Payer: AZCH Complete Medicare	$62.85
Rate for Payer: Banner UC Health Medicare	$62.85
Rate for Payer: Bisbee Police All Plans	$108.94
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$284.92
Rate for Payer: Cash Price	$335.20
Rate for Payer: Cigna of AZ Commercial	$293.30
Rate for Payer: Copperpoint Commercial	$103.70
Rate for Payer: Health Net of AZ Commercial	$251.40
Rate for Payer: Health Net of AZ Medicare	$117.32
Rate for Payer: Humana of AZ Medicare	$62.85
Rate for Payer: Self Pay Self Pay	$335.20
Rate for Payer: TriWest Medicare	$62.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$244.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$75.42

RETRACTOR RING 31.8X18.3CM DISP

Facility

$267.00

Hospital Charge Code	22354167
Hospital Revenue Code	270
Min. Negotiated Rate	$40.05
Max. Negotiated Rate	$240.30
Rate for Payer: Aetna of AZ Commercial	$240.30
Rate for Payer: Aetna of AZ Medicare	$74.76
Rate for Payer: Allwell Medicare	$40.05
Rate for Payer: Amerigroup Medicare	$40.05
Rate for Payer: APIPA Medicare/Medicaid	$99.72
Rate for Payer: AZCH Complete Medicare	$40.05
Rate for Payer: Banner UC Health Medicare	$40.05
Rate for Payer: Bisbee Police All Plans	$69.42
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$181.56
Rate for Payer: Cash Price	$213.60
Rate for Payer: Cigna of AZ Commercial	$186.90
Rate for Payer: Copperpoint Commercial	$66.08
Rate for Payer: Health Net of AZ Commercial	$160.20
Rate for Payer: Health Net of AZ Medicare	$74.76
Rate for Payer: Humana of AZ Medicare	$40.05
Rate for Payer: Self Pay Self Pay	$213.60
Rate for Payer: TriWest Medicare	$40.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$155.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$48.06

RETRACTOR RING 31.8X18.3CM DISP

Facility

$267.00

Hospital Charge Code	22354167
Hospital Revenue Code	270
Min. Negotiated Rate	$69.42
Max. Negotiated Rate	$240.30
Rate for Payer: Aetna of AZ Commercial	$240.30
Rate for Payer: Bisbee Police All Plans	$69.42
Rate for Payer: Cash Price	$213.60
Rate for Payer: Self Pay Self Pay	$213.60

RETRIEVAL TISSUE SYSTEM ANCHOR

Facility

$368.00

Hospital Charge Code	22354821
Hospital Revenue Code	270
Min. Negotiated Rate	$55.20
Max. Negotiated Rate	$331.20
Rate for Payer: Aetna of AZ Commercial	$331.20
Rate for Payer: Aetna of AZ Medicare	$103.04
Rate for Payer: Allwell Medicare	$55.20
Rate for Payer: Amerigroup Medicare	$55.20
Rate for Payer: APIPA Medicare/Medicaid	$137.45
Rate for Payer: AZCH Complete Medicare	$55.20
Rate for Payer: Banner UC Health Medicare	$55.20
Rate for Payer: Bisbee Police All Plans	$95.68
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$250.24
Rate for Payer: Cash Price	$294.40
Rate for Payer: Cigna of AZ Commercial	$257.60
Rate for Payer: Copperpoint Commercial	$91.08
Rate for Payer: Health Net of AZ Commercial	$220.80
Rate for Payer: Health Net of AZ Medicare	$103.04
Rate for Payer: Humana of AZ Medicare	$55.20
Rate for Payer: Self Pay Self Pay	$294.40
Rate for Payer: TriWest Medicare	$55.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$214.54
Rate for Payer: UnitedHealth Group of AZ Medicare	$66.24

RETRIEVAL TISSUE SYSTEM ANCHOR

Facility

$368.00

Hospital Charge Code	22354821
Hospital Revenue Code	270
Min. Negotiated Rate	$95.68
Max. Negotiated Rate	$331.20
Rate for Payer: Aetna of AZ Commercial	$331.20
Rate for Payer: Bisbee Police All Plans	$95.68
Rate for Payer: Cash Price	$294.40
Rate for Payer: Self Pay Self Pay	$294.40

Reverse T3 LC

Facility

$378.00

Service Code	CPT 84482
Hospital Charge Code	2087649
Hospital Revenue Code	301
Min. Negotiated Rate	$98.28
Max. Negotiated Rate	$340.20
Rate for Payer: Aetna of AZ Commercial	$340.20
Rate for Payer: Bisbee Police All Plans	$98.28
Rate for Payer: Cash Price	$302.40
Rate for Payer: Self Pay Self Pay	$302.40

Reverse T3 LC

Facility

$378.00

Service Code	CPT 84482
Hospital Charge Code	2087649
Hospital Revenue Code	301
Min. Negotiated Rate	$15.76
Max. Negotiated Rate	$340.20
Rate for Payer: Aetna of AZ Commercial	$340.20
Rate for Payer: Aetna of AZ Medicare	$105.84
Rate for Payer: AHCCCS Medicaid	$15.76
Rate for Payer: Allwell Medicaid	$15.76
Rate for Payer: Allwell Medicare	$56.70
Rate for Payer: Amerigroup Medicare	$56.70
Rate for Payer: APIPA Medicare/Medicaid	$141.18
Rate for Payer: AZCH Complete Medicaid	$15.76
Rate for Payer: AZCH Complete Medicare	$56.70
Rate for Payer: Banner UC Health Medicaid	$15.76
Rate for Payer: Banner UC Health Medicare	$56.70
Rate for Payer: Bisbee Police All Plans	$98.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$257.04
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cigna of AZ Commercial	$245.70
Rate for Payer: Copperpoint Commercial	$93.56
Rate for Payer: Health Net of AZ Commercial	$226.80
Rate for Payer: Health Net of AZ Medicare	$105.84
Rate for Payer: Humana of AZ Medicare	$56.70
Rate for Payer: Mercy Care Medicaid	$15.76
Rate for Payer: Self Pay Self Pay	$302.40
Rate for Payer: TriWest Medicare	$56.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$220.37
Rate for Payer: UnitedHealth Group of AZ Medicare	$68.04

RF Qualitative

Facility

$142.00

Service Code	CPT 86430
Hospital Charge Code	1051519
Hospital Revenue Code	302
Min. Negotiated Rate	$36.92
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Bisbee Police All Plans	$36.92
Rate for Payer: Cash Price	$113.60
Rate for Payer: Self Pay Self Pay	$113.60

RF Qualitative

Facility

$142.00

Service Code	CPT 86430
Hospital Charge Code	1051519
Hospital Revenue Code	302
Min. Negotiated Rate	$6.14
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Aetna of AZ Medicare	$39.76
Rate for Payer: AHCCCS Medicaid	$6.14
Rate for Payer: Allwell Medicaid	$6.14
Rate for Payer: Allwell Medicare	$21.30
Rate for Payer: Amerigroup Medicare	$21.30
Rate for Payer: APIPA Medicare/Medicaid	$53.04
Rate for Payer: AZCH Complete Medicaid	$6.14
Rate for Payer: AZCH Complete Medicare	$21.30
Rate for Payer: Banner UC Health Medicaid	$6.14
Rate for Payer: Banner UC Health Medicare	$21.30
Rate for Payer: Bisbee Police All Plans	$36.92
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$96.56
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cigna of AZ Commercial	$92.30
Rate for Payer: Copperpoint Commercial	$35.14
Rate for Payer: Health Net of AZ Commercial	$85.20
Rate for Payer: Health Net of AZ Medicare	$39.76
Rate for Payer: Humana of AZ Medicare	$21.30
Rate for Payer: Mercy Care Medicaid	$6.14
Rate for Payer: Self Pay Self Pay	$113.60
Rate for Payer: TriWest Medicare	$21.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$82.79
Rate for Payer: UnitedHealth Group of AZ Medicare	$25.56

Facility

$99.00

Service Code	CPT 86901
Hospital Charge Code	22308645
Hospital Revenue Code	302
Min. Negotiated Rate	$2.99
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	$2.99
Rate for Payer: Allwell Medicaid	$2.99
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	$2.99
Rate for Payer: AZCH Complete Medicare	$14.85
Rate for Payer: Banner UC Health Medicaid	$2.99
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	$2.99
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

Facility

$99.00

Service Code	CPT 86901
Hospital Charge Code	22308645
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

Rheumatoid Arthritis Factor LC

Facility

$142.00

Service Code	CPT 86430
Hospital Charge Code	1285583
Hospital Revenue Code	302
Min. Negotiated Rate	$36.92
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Bisbee Police All Plans	$36.92
Rate for Payer: Cash Price	$113.60
Rate for Payer: Self Pay Self Pay	$113.60

Rheumatoid Arthritis Factor LC

Facility

$142.00

Service Code	CPT 86430
Hospital Charge Code	1285583
Hospital Revenue Code	302
Min. Negotiated Rate	$6.14
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Aetna of AZ Medicare	$39.76
Rate for Payer: AHCCCS Medicaid	$6.14
Rate for Payer: Allwell Medicaid	$6.14
Rate for Payer: Allwell Medicare	$21.30
Rate for Payer: Amerigroup Medicare	$21.30
Rate for Payer: APIPA Medicare/Medicaid	$53.04
Rate for Payer: AZCH Complete Medicaid	$6.14
Rate for Payer: AZCH Complete Medicare	$21.30
Rate for Payer: Banner UC Health Medicaid	$6.14
Rate for Payer: Banner UC Health Medicare	$21.30
Rate for Payer: Bisbee Police All Plans	$36.92
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$96.56
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cigna of AZ Commercial	$92.30
Rate for Payer: Copperpoint Commercial	$35.14
Rate for Payer: Health Net of AZ Commercial	$85.20
Rate for Payer: Health Net of AZ Medicare	$39.76
Rate for Payer: Humana of AZ Medicare	$21.30
Rate for Payer: Mercy Care Medicaid	$6.14
Rate for Payer: Self Pay Self Pay	$113.60
Rate for Payer: TriWest Medicare	$21.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$82.79
Rate for Payer: UnitedHealth Group of AZ Medicare	$25.56

RHEUMATOID FACTOR; QUANTITATIVE

Facility

$39.00

Service Code	CPT 86431
Hospital Charge Code	23603252
Hospital Revenue Code	301
Min. Negotiated Rate	$10.14
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Bisbee Police All Plans	$10.14
Rate for Payer: Cash Price	$31.20
Rate for Payer: Self Pay Self Pay	$31.20

RHEUMATOID FACTOR; QUANTITATIVE

Facility

$39.00

Service Code	CPT 86431
Hospital Charge Code	23603252
Hospital Revenue Code	301
Min. Negotiated Rate	$5.67
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Aetna of AZ Medicare	$10.92
Rate for Payer: AHCCCS Medicaid	$5.67
Rate for Payer: Allwell Medicaid	$5.67
Rate for Payer: Allwell Medicare	$5.85
Rate for Payer: Amerigroup Medicare	$5.85
Rate for Payer: APIPA Medicare/Medicaid	$14.57
Rate for Payer: AZCH Complete Medicaid	$5.67
Rate for Payer: AZCH Complete Medicare	$5.85
Rate for Payer: Banner UC Health Medicaid	$5.67
Rate for Payer: Banner UC Health Medicare	$5.85
Rate for Payer: Bisbee Police All Plans	$10.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$26.52
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cigna of AZ Commercial	$25.35
Rate for Payer: Copperpoint Commercial	$9.65
Rate for Payer: Health Net of AZ Commercial	$23.40
Rate for Payer: Health Net of AZ Medicare	$10.92
Rate for Payer: Humana of AZ Medicare	$5.85
Rate for Payer: Mercy Care Medicaid	$5.67
Rate for Payer: Self Pay Self Pay	$31.20
Rate for Payer: TriWest Medicare	$5.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$22.74
Rate for Payer: UnitedHealth Group of AZ Medicare	$7.02

RHo (D) immune globulin 300 mcg Sol[CQCH]

Facility

$126.14

Service Code	HCPCS J2790
Hospital Charge Code	132649818
Hospital Revenue Code	250
Min. Negotiated Rate	$18.92
Max. Negotiated Rate	$155.36
Rate for Payer: Aetna of AZ Commercial	$113.53
Rate for Payer: Aetna of AZ Medicare	$35.32
Rate for Payer: AHCCCS Medicaid	$155.36
Rate for Payer: Allwell Medicaid	$155.36
Rate for Payer: Allwell Medicare	$18.92
Rate for Payer: Amerigroup Medicare	$18.92
Rate for Payer: APIPA Medicare/Medicaid	$47.11
Rate for Payer: AZCH Complete Medicaid	$155.36
Rate for Payer: AZCH Complete Medicare	$18.92
Rate for Payer: Banner UC Health Medicaid	$155.36
Rate for Payer: Banner UC Health Medicare	$18.92
Rate for Payer: Bisbee Police All Plans	$32.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$85.78
Rate for Payer: Cash Price	$100.91
Rate for Payer: Cash Price	$100.91
Rate for Payer: Cigna of AZ Commercial	$81.99
Rate for Payer: Copperpoint Commercial	$31.22
Rate for Payer: Health Net of AZ Commercial	$75.68
Rate for Payer: Health Net of AZ Medicare	$35.32
Rate for Payer: Humana of AZ Medicare	$18.92
Rate for Payer: Mercy Care Medicaid	$155.36
Rate for Payer: Self Pay Self Pay	$100.91
Rate for Payer: TriWest Medicare	$18.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$73.54
Rate for Payer: UnitedHealth Group of AZ Medicare	$22.71

RHo (D) immune globulin 300 mcg Sol[CQCH]

Facility

$126.14

Service Code	HCPCS J2790
Hospital Charge Code	132649818
Hospital Revenue Code	250
Min. Negotiated Rate	$32.80
Max. Negotiated Rate	$113.53
Rate for Payer: Aetna of AZ Commercial	$113.53
Rate for Payer: Bisbee Police All Plans	$32.80
Rate for Payer: Cash Price	$100.91
Rate for Payer: Self Pay Self Pay	$100.91

rifAMPin 600 mg REC[CQCH]

Facility

$73.42

Service Code	NDC 68059701
Hospital Charge Code	127193752
Hospital Revenue Code	250
Min. Negotiated Rate	$11.01
Max. Negotiated Rate	$66.08
Rate for Payer: Aetna of AZ Commercial	$66.08
Rate for Payer: Aetna of AZ Medicare	$20.56
Rate for Payer: Allwell Medicare	$11.01
Rate for Payer: Amerigroup Medicare	$11.01
Rate for Payer: APIPA Medicare/Medicaid	$27.42
Rate for Payer: AZCH Complete Medicare	$11.01
Rate for Payer: Banner UC Health Medicare	$11.01
Rate for Payer: Bisbee Police All Plans	$19.09
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$49.93
Rate for Payer: Cash Price	$58.74
Rate for Payer: Cigna of AZ Commercial	$47.72
Rate for Payer: Copperpoint Commercial	$18.17
Rate for Payer: Health Net of AZ Commercial	$44.05
Rate for Payer: Health Net of AZ Medicare	$20.56
Rate for Payer: Humana of AZ Medicare	$11.01
Rate for Payer: Self Pay Self Pay	$58.74
Rate for Payer: TriWest Medicare	$11.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$42.80
Rate for Payer: UnitedHealth Group of AZ Medicare	$13.22

rifAMPin 600 mg REC[CQCH]

Facility

$73.42

Service Code	NDC 68059701
Hospital Charge Code	127193752
Hospital Revenue Code	250
Min. Negotiated Rate	$19.09
Max. Negotiated Rate	$66.08
Rate for Payer: Aetna of AZ Commercial	$66.08
Rate for Payer: Bisbee Police All Plans	$19.09
Rate for Payer: Cash Price	$58.74
Rate for Payer: Self Pay Self Pay	$58.74

Know your out-of-pocket cost for care.

All Charges