Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

TI6 DIGITAL SCREW 2MMX40MM

Facility

$2,549.00

Hospital Charge Code	27567203
Hospital Revenue Code	270
Min. Negotiated Rate	$382.35
Max. Negotiated Rate	$2,294.10
Rate for Payer: Aetna of AZ Commercial	$2,294.10
Rate for Payer: Aetna of AZ Medicare	$713.72
Rate for Payer: Allwell Medicare	$382.35
Rate for Payer: Amerigroup Medicare	$382.35
Rate for Payer: APIPA Medicare/Medicaid	$952.05
Rate for Payer: AZCH Complete Medicare	$382.35
Rate for Payer: Banner UC Health Medicare	$382.35
Rate for Payer: Bisbee Police All Plans	$662.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,733.32
Rate for Payer: Cash Price	$2,039.20
Rate for Payer: Cigna of AZ Commercial	$1,784.30
Rate for Payer: Copperpoint Commercial	$630.88
Rate for Payer: Health Net of AZ Commercial	$1,529.40
Rate for Payer: Health Net of AZ Medicare	$713.72
Rate for Payer: Humana of AZ Medicare	$382.35
Rate for Payer: Self Pay Self Pay	$2,039.20
Rate for Payer: TriWest Medicare	$382.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,486.07
Rate for Payer: UnitedHealth Group of AZ Medicare	$458.82

TI6 LOW PROFILE 3.0MMX22MM BONE SCREW

Facility

$1,915.00

Hospital Charge Code	27519878
Hospital Revenue Code	270
Min. Negotiated Rate	$287.25
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Aetna of AZ Medicare	$536.20
Rate for Payer: Allwell Medicare	$287.25
Rate for Payer: Amerigroup Medicare	$287.25
Rate for Payer: APIPA Medicare/Medicaid	$715.25
Rate for Payer: AZCH Complete Medicare	$287.25
Rate for Payer: Banner UC Health Medicare	$287.25
Rate for Payer: Bisbee Police All Plans	$497.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,302.20
Rate for Payer: Cash Price	$1,532.00
Rate for Payer: Cigna of AZ Commercial	$1,340.50
Rate for Payer: Copperpoint Commercial	$473.96
Rate for Payer: Health Net of AZ Commercial	$1,149.00
Rate for Payer: Health Net of AZ Medicare	$536.20
Rate for Payer: Humana of AZ Medicare	$287.25
Rate for Payer: Self Pay Self Pay	$1,532.00
Rate for Payer: TriWest Medicare	$287.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,116.44
Rate for Payer: UnitedHealth Group of AZ Medicare	$344.70

TI6 LOW PROFILE 3.0MMX22MM BONE SCREW

Facility

$1,915.00

Hospital Charge Code	27519878
Hospital Revenue Code	270
Min. Negotiated Rate	$497.90
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Bisbee Police All Plans	$497.90
Rate for Payer: Cash Price	$1,532.00
Rate for Payer: Self Pay Self Pay	$1,532.00

TI6 LOW PROFILE 3.0MM X 24MM BONE SCREW

Facility

$1,196.00

Hospital Charge Code	24127796
Hospital Revenue Code	270
Min. Negotiated Rate	$310.96
Max. Negotiated Rate	$1,076.40
Rate for Payer: Aetna of AZ Commercial	$1,076.40
Rate for Payer: Bisbee Police All Plans	$310.96
Rate for Payer: Cash Price	$956.80
Rate for Payer: Self Pay Self Pay	$956.80

TI6 LOW PROFILE 3.0MM X 24MM BONE SCREW

Facility

$1,196.00

Hospital Charge Code	24127796
Hospital Revenue Code	270
Min. Negotiated Rate	$179.40
Max. Negotiated Rate	$1,076.40
Rate for Payer: Aetna of AZ Commercial	$1,076.40
Rate for Payer: Aetna of AZ Medicare	$334.88
Rate for Payer: Allwell Medicare	$179.40
Rate for Payer: Amerigroup Medicare	$179.40
Rate for Payer: APIPA Medicare/Medicaid	$446.71
Rate for Payer: AZCH Complete Medicare	$179.40
Rate for Payer: Banner UC Health Medicare	$179.40
Rate for Payer: Bisbee Police All Plans	$310.96
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$813.28
Rate for Payer: Cash Price	$956.80
Rate for Payer: Cigna of AZ Commercial	$837.20
Rate for Payer: Copperpoint Commercial	$296.01
Rate for Payer: Health Net of AZ Commercial	$717.60
Rate for Payer: Health Net of AZ Medicare	$334.88
Rate for Payer: Humana of AZ Medicare	$179.40
Rate for Payer: Self Pay Self Pay	$956.80
Rate for Payer: TriWest Medicare	$179.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$697.27
Rate for Payer: UnitedHealth Group of AZ Medicare	$215.28

TI6 LOW PROFILE 3.0MM X 28MM BONE SCREW

Facility

$1,196.00

Hospital Charge Code	24127794
Hospital Revenue Code	270
Min. Negotiated Rate	$310.96
Max. Negotiated Rate	$1,076.40
Rate for Payer: Aetna of AZ Commercial	$1,076.40
Rate for Payer: Bisbee Police All Plans	$310.96
Rate for Payer: Cash Price	$956.80
Rate for Payer: Self Pay Self Pay	$956.80

TI6 LOW PROFILE 3.0MM X 28MM BONE SCREW

Facility

$1,196.00

Hospital Charge Code	24127794
Hospital Revenue Code	270
Min. Negotiated Rate	$179.40
Max. Negotiated Rate	$1,076.40
Rate for Payer: Aetna of AZ Commercial	$1,076.40
Rate for Payer: Aetna of AZ Medicare	$334.88
Rate for Payer: Allwell Medicare	$179.40
Rate for Payer: Amerigroup Medicare	$179.40
Rate for Payer: APIPA Medicare/Medicaid	$446.71
Rate for Payer: AZCH Complete Medicare	$179.40
Rate for Payer: Banner UC Health Medicare	$179.40
Rate for Payer: Bisbee Police All Plans	$310.96
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$813.28
Rate for Payer: Cash Price	$956.80
Rate for Payer: Cigna of AZ Commercial	$837.20
Rate for Payer: Copperpoint Commercial	$296.01
Rate for Payer: Health Net of AZ Commercial	$717.60
Rate for Payer: Health Net of AZ Medicare	$334.88
Rate for Payer: Humana of AZ Medicare	$179.40
Rate for Payer: Self Pay Self Pay	$956.80
Rate for Payer: TriWest Medicare	$179.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$697.27
Rate for Payer: UnitedHealth Group of AZ Medicare	$215.28

TI6 LOW PROFILE 3.99MMX18MM BONE SCREW

Facility

$1,196.00

Hospital Charge Code	24127772
Hospital Revenue Code	270
Min. Negotiated Rate	$179.40
Max. Negotiated Rate	$1,076.40
Rate for Payer: Aetna of AZ Commercial	$1,076.40
Rate for Payer: Aetna of AZ Medicare	$334.88
Rate for Payer: Allwell Medicare	$179.40
Rate for Payer: Amerigroup Medicare	$179.40
Rate for Payer: APIPA Medicare/Medicaid	$446.71
Rate for Payer: AZCH Complete Medicare	$179.40
Rate for Payer: Banner UC Health Medicare	$179.40
Rate for Payer: Bisbee Police All Plans	$310.96
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$813.28
Rate for Payer: Cash Price	$956.80
Rate for Payer: Cigna of AZ Commercial	$837.20
Rate for Payer: Copperpoint Commercial	$296.01
Rate for Payer: Health Net of AZ Commercial	$717.60
Rate for Payer: Health Net of AZ Medicare	$334.88
Rate for Payer: Humana of AZ Medicare	$179.40
Rate for Payer: Self Pay Self Pay	$956.80
Rate for Payer: TriWest Medicare	$179.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$697.27
Rate for Payer: UnitedHealth Group of AZ Medicare	$215.28

TI6 LOW PROFILE 3.99MMX18MM BONE SCREW

Facility

$1,196.00

Hospital Charge Code	24127772
Hospital Revenue Code	270
Min. Negotiated Rate	$310.96
Max. Negotiated Rate	$1,076.40
Rate for Payer: Aetna of AZ Commercial	$1,076.40
Rate for Payer: Bisbee Police All Plans	$310.96
Rate for Payer: Cash Price	$956.80
Rate for Payer: Self Pay Self Pay	$956.80

TI6 LOW PROFILE 3MMX16MM BONE SCREW

Facility

$1,915.00

Hospital Charge Code	24358104
Hospital Revenue Code	270
Min. Negotiated Rate	$287.25
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Aetna of AZ Medicare	$536.20
Rate for Payer: Allwell Medicare	$287.25
Rate for Payer: Amerigroup Medicare	$287.25
Rate for Payer: APIPA Medicare/Medicaid	$715.25
Rate for Payer: AZCH Complete Medicare	$287.25
Rate for Payer: Banner UC Health Medicare	$287.25
Rate for Payer: Bisbee Police All Plans	$497.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,302.20
Rate for Payer: Cash Price	$1,532.00
Rate for Payer: Cigna of AZ Commercial	$1,340.50
Rate for Payer: Copperpoint Commercial	$473.96
Rate for Payer: Health Net of AZ Commercial	$1,149.00
Rate for Payer: Health Net of AZ Medicare	$536.20
Rate for Payer: Humana of AZ Medicare	$287.25
Rate for Payer: Self Pay Self Pay	$1,532.00
Rate for Payer: TriWest Medicare	$287.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,116.44
Rate for Payer: UnitedHealth Group of AZ Medicare	$344.70

TI6 LOW PROFILE 3MMX16MM BONE SCREW

Facility

$1,915.00

Hospital Charge Code	24358104
Hospital Revenue Code	270
Min. Negotiated Rate	$497.90
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Bisbee Police All Plans	$497.90
Rate for Payer: Cash Price	$1,532.00
Rate for Payer: Self Pay Self Pay	$1,532.00

TI6 LOW PROFILE 3MMX20MM BONE SCREW

Facility

$1,915.00

Hospital Charge Code	24358110
Hospital Revenue Code	270
Min. Negotiated Rate	$497.90
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Bisbee Police All Plans	$497.90
Rate for Payer: Cash Price	$1,532.00
Rate for Payer: Self Pay Self Pay	$1,532.00

TI6 LOW PROFILE 3MMX20MM BONE SCREW

Facility

$1,915.00

Hospital Charge Code	24358110
Hospital Revenue Code	270
Min. Negotiated Rate	$287.25
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Aetna of AZ Medicare	$536.20
Rate for Payer: Allwell Medicare	$287.25
Rate for Payer: Amerigroup Medicare	$287.25
Rate for Payer: APIPA Medicare/Medicaid	$715.25
Rate for Payer: AZCH Complete Medicare	$287.25
Rate for Payer: Banner UC Health Medicare	$287.25
Rate for Payer: Bisbee Police All Plans	$497.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,302.20
Rate for Payer: Cash Price	$1,532.00
Rate for Payer: Cigna of AZ Commercial	$1,340.50
Rate for Payer: Copperpoint Commercial	$473.96
Rate for Payer: Health Net of AZ Commercial	$1,149.00
Rate for Payer: Health Net of AZ Medicare	$536.20
Rate for Payer: Humana of AZ Medicare	$287.25
Rate for Payer: Self Pay Self Pay	$1,532.00
Rate for Payer: TriWest Medicare	$287.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,116.44
Rate for Payer: UnitedHealth Group of AZ Medicare	$344.70

TI6 LOW PROFILE 3X14 BONE SCREW

Facility

$1,915.00

Hospital Charge Code	27738159
Hospital Revenue Code	270
Min. Negotiated Rate	$497.90
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Bisbee Police All Plans	$497.90
Rate for Payer: Cash Price	$1,532.00
Rate for Payer: Self Pay Self Pay	$1,532.00

TI6 LOW PROFILE 3X14 BONE SCREW

Facility

$1,915.00

Hospital Charge Code	27738159
Hospital Revenue Code	270
Min. Negotiated Rate	$287.25
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Aetna of AZ Medicare	$536.20
Rate for Payer: Allwell Medicare	$287.25
Rate for Payer: Amerigroup Medicare	$287.25
Rate for Payer: APIPA Medicare/Medicaid	$715.25
Rate for Payer: AZCH Complete Medicare	$287.25
Rate for Payer: Banner UC Health Medicare	$287.25
Rate for Payer: Bisbee Police All Plans	$497.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,302.20
Rate for Payer: Cash Price	$1,532.00
Rate for Payer: Cigna of AZ Commercial	$1,340.50
Rate for Payer: Copperpoint Commercial	$473.96
Rate for Payer: Health Net of AZ Commercial	$1,149.00
Rate for Payer: Health Net of AZ Medicare	$536.20
Rate for Payer: Humana of AZ Medicare	$287.25
Rate for Payer: Self Pay Self Pay	$1,532.00
Rate for Payer: TriWest Medicare	$287.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,116.44
Rate for Payer: UnitedHealth Group of AZ Medicare	$344.70

TI6 LOW PROFILE 4MM X 50MM BONE

Facility

$1,266.00

Hospital Charge Code	27341821
Hospital Revenue Code	270
Min. Negotiated Rate	$329.16
Max. Negotiated Rate	$1,139.40
Rate for Payer: Aetna of AZ Commercial	$1,139.40
Rate for Payer: Bisbee Police All Plans	$329.16
Rate for Payer: Cash Price	$1,012.80
Rate for Payer: Self Pay Self Pay	$1,012.80

TI6 LOW PROFILE 4MM X 50MM BONE

Facility

$1,266.00

Hospital Charge Code	27341821
Hospital Revenue Code	270
Min. Negotiated Rate	$189.90
Max. Negotiated Rate	$1,139.40
Rate for Payer: Aetna of AZ Commercial	$1,139.40
Rate for Payer: Aetna of AZ Medicare	$354.48
Rate for Payer: Allwell Medicare	$189.90
Rate for Payer: Amerigroup Medicare	$189.90
Rate for Payer: APIPA Medicare/Medicaid	$472.85
Rate for Payer: AZCH Complete Medicare	$189.90
Rate for Payer: Banner UC Health Medicare	$189.90
Rate for Payer: Bisbee Police All Plans	$329.16
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$860.88
Rate for Payer: Cash Price	$1,012.80
Rate for Payer: Cigna of AZ Commercial	$886.20
Rate for Payer: Copperpoint Commercial	$313.34
Rate for Payer: Health Net of AZ Commercial	$759.60
Rate for Payer: Health Net of AZ Medicare	$354.48
Rate for Payer: Humana of AZ Medicare	$189.90
Rate for Payer: Self Pay Self Pay	$1,012.80
Rate for Payer: TriWest Medicare	$189.90
Rate for Payer: UnitedHealth Group of AZ Commercial	$738.08
Rate for Payer: UnitedHealth Group of AZ Medicare	$227.88

TI6 QUICKSNAP 2.0MM S 14MM SCREW

Facility

$1,377.00

Hospital Charge Code	24127775
Hospital Revenue Code	270
Min. Negotiated Rate	$358.02
Max. Negotiated Rate	$1,239.30
Rate for Payer: Aetna of AZ Commercial	$1,239.30
Rate for Payer: Bisbee Police All Plans	$358.02
Rate for Payer: Cash Price	$1,101.60
Rate for Payer: Self Pay Self Pay	$1,101.60

TI6 QUICKSNAP 2.0MM S 14MM SCREW

Facility

$1,377.00

Hospital Charge Code	24127775
Hospital Revenue Code	270
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$1,239.30
Rate for Payer: Aetna of AZ Commercial	$1,239.30
Rate for Payer: Aetna of AZ Medicare	$385.56
Rate for Payer: Allwell Medicare	$206.55
Rate for Payer: Amerigroup Medicare	$206.55
Rate for Payer: APIPA Medicare/Medicaid	$514.31
Rate for Payer: AZCH Complete Medicare	$206.55
Rate for Payer: Banner UC Health Medicare	$206.55
Rate for Payer: Bisbee Police All Plans	$358.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$936.36
Rate for Payer: Cash Price	$1,101.60
Rate for Payer: Cigna of AZ Commercial	$963.90
Rate for Payer: Copperpoint Commercial	$340.81
Rate for Payer: Health Net of AZ Commercial	$826.20
Rate for Payer: Health Net of AZ Medicare	$385.56
Rate for Payer: Humana of AZ Medicare	$206.55
Rate for Payer: Self Pay Self Pay	$1,101.60
Rate for Payer: TriWest Medicare	$206.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$802.79
Rate for Payer: UnitedHealth Group of AZ Medicare	$247.86

TI6 QUICKSNAP 2.0MM X 10MM SCREW

Facility

$1,377.00

Hospital Charge Code	24127795
Hospital Revenue Code	270
Min. Negotiated Rate	$358.02
Max. Negotiated Rate	$1,239.30
Rate for Payer: Aetna of AZ Commercial	$1,239.30
Rate for Payer: Bisbee Police All Plans	$358.02
Rate for Payer: Cash Price	$1,101.60
Rate for Payer: Self Pay Self Pay	$1,101.60

TI6 QUICKSNAP 2.0MM X 10MM SCREW

Facility

$1,377.00

Hospital Charge Code	24127795
Hospital Revenue Code	270
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$1,239.30
Rate for Payer: Aetna of AZ Commercial	$1,239.30
Rate for Payer: Aetna of AZ Medicare	$385.56
Rate for Payer: Allwell Medicare	$206.55
Rate for Payer: Amerigroup Medicare	$206.55
Rate for Payer: APIPA Medicare/Medicaid	$514.31
Rate for Payer: AZCH Complete Medicare	$206.55
Rate for Payer: Banner UC Health Medicare	$206.55
Rate for Payer: Bisbee Police All Plans	$358.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$936.36
Rate for Payer: Cash Price	$1,101.60
Rate for Payer: Cigna of AZ Commercial	$963.90
Rate for Payer: Copperpoint Commercial	$340.81
Rate for Payer: Health Net of AZ Commercial	$826.20
Rate for Payer: Health Net of AZ Medicare	$385.56
Rate for Payer: Humana of AZ Medicare	$206.55
Rate for Payer: Self Pay Self Pay	$1,101.60
Rate for Payer: TriWest Medicare	$206.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$802.79
Rate for Payer: UnitedHealth Group of AZ Medicare	$247.86

TI6 QUICKSNAP 2.0MM X 11MM SCREW

Facility

$1,377.00

Hospital Charge Code	24127787
Hospital Revenue Code	270
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$1,239.30
Rate for Payer: Aetna of AZ Commercial	$1,239.30
Rate for Payer: Aetna of AZ Medicare	$385.56
Rate for Payer: Allwell Medicare	$206.55
Rate for Payer: Amerigroup Medicare	$206.55
Rate for Payer: APIPA Medicare/Medicaid	$514.31
Rate for Payer: AZCH Complete Medicare	$206.55
Rate for Payer: Banner UC Health Medicare	$206.55
Rate for Payer: Bisbee Police All Plans	$358.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$936.36
Rate for Payer: Cash Price	$1,101.60
Rate for Payer: Cigna of AZ Commercial	$963.90
Rate for Payer: Copperpoint Commercial	$340.81
Rate for Payer: Health Net of AZ Commercial	$826.20
Rate for Payer: Health Net of AZ Medicare	$385.56
Rate for Payer: Humana of AZ Medicare	$206.55
Rate for Payer: Self Pay Self Pay	$1,101.60
Rate for Payer: TriWest Medicare	$206.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$802.79
Rate for Payer: UnitedHealth Group of AZ Medicare	$247.86

TI6 QUICKSNAP 2.0MM X 11MM SCREW

Facility

$1,377.00

Hospital Charge Code	24127787
Hospital Revenue Code	270
Min. Negotiated Rate	$358.02
Max. Negotiated Rate	$1,239.30
Rate for Payer: Aetna of AZ Commercial	$1,239.30
Rate for Payer: Bisbee Police All Plans	$358.02
Rate for Payer: Cash Price	$1,101.60
Rate for Payer: Self Pay Self Pay	$1,101.60

TI6 TC SERIES KWIRE 3.0/4.0 (1.1X120MM)

Facility

$98.00

Hospital Charge Code	24127773
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of AZ Commercial	$88.20
Rate for Payer: Aetna of AZ Medicare	$27.44
Rate for Payer: Allwell Medicare	$14.70
Rate for Payer: Amerigroup Medicare	$14.70
Rate for Payer: APIPA Medicare/Medicaid	$36.60
Rate for Payer: AZCH Complete Medicare	$14.70
Rate for Payer: Banner UC Health Medicare	$14.70
Rate for Payer: Bisbee Police All Plans	$25.48
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$66.64
Rate for Payer: Cash Price	$78.40
Rate for Payer: Cigna of AZ Commercial	$68.60
Rate for Payer: Copperpoint Commercial	$24.26
Rate for Payer: Health Net of AZ Commercial	$58.80
Rate for Payer: Health Net of AZ Medicare	$27.44
Rate for Payer: Humana of AZ Medicare	$14.70
Rate for Payer: Self Pay Self Pay	$78.40
Rate for Payer: TriWest Medicare	$14.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$57.13
Rate for Payer: UnitedHealth Group of AZ Medicare	$17.64

TI6 TC SERIES KWIRE 3.0/4.0 (1.1X120MM)

Facility

$98.00

Hospital Charge Code	24127773
Hospital Revenue Code	270
Min. Negotiated Rate	$25.48
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of AZ Commercial	$88.20
Rate for Payer: Bisbee Police All Plans	$25.48
Rate for Payer: Cash Price	$78.40
Rate for Payer: Self Pay Self Pay	$78.40

Know your out-of-pocket cost for care.

All Charges