Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

XR Calcaneus Left

Facility

$488.00

Service Code	CPT 73650 LT
Hospital Charge Code	22147265
Hospital Revenue Code	320
Min. Negotiated Rate	$73.20
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Aetna of AZ Medicare	$136.64
Rate for Payer: Allwell Medicare	$73.20
Rate for Payer: Amerigroup Medicare	$73.20
Rate for Payer: APIPA Medicare/Medicaid	$182.27
Rate for Payer: AZCH Complete Medicare	$73.20
Rate for Payer: Banner UC Health Medicare	$73.20
Rate for Payer: Bisbee Police All Plans	$126.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$331.84
Rate for Payer: Cash Price	$390.40
Rate for Payer: Cigna of AZ Commercial	$317.20
Rate for Payer: Copperpoint Commercial	$120.78
Rate for Payer: Health Net of AZ Commercial	$292.80
Rate for Payer: Health Net of AZ Medicare	$136.64
Rate for Payer: Humana of AZ Medicare	$73.20
Rate for Payer: Self Pay Self Pay	$390.40
Rate for Payer: TriWest Medicare	$73.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$284.50
Rate for Payer: UnitedHealth Group of AZ Medicare	$87.84

XR Calcaneus Right

Facility

$488.00

Service Code	CPT 73650 RT
Hospital Charge Code	22147268
Hospital Revenue Code	320
Min. Negotiated Rate	$126.88
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Bisbee Police All Plans	$126.88
Rate for Payer: Cash Price	$390.40
Rate for Payer: Self Pay Self Pay	$390.40

XR Calcaneus Right

Facility

$488.00

Service Code	CPT 73650 RT
Hospital Charge Code	22147268
Hospital Revenue Code	320
Min. Negotiated Rate	$73.20
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Aetna of AZ Medicare	$136.64
Rate for Payer: Allwell Medicare	$73.20
Rate for Payer: Amerigroup Medicare	$73.20
Rate for Payer: APIPA Medicare/Medicaid	$182.27
Rate for Payer: AZCH Complete Medicare	$73.20
Rate for Payer: Banner UC Health Medicare	$73.20
Rate for Payer: Bisbee Police All Plans	$126.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$331.84
Rate for Payer: Cash Price	$390.40
Rate for Payer: Cigna of AZ Commercial	$317.20
Rate for Payer: Copperpoint Commercial	$120.78
Rate for Payer: Health Net of AZ Commercial	$292.80
Rate for Payer: Health Net of AZ Medicare	$136.64
Rate for Payer: Humana of AZ Medicare	$73.20
Rate for Payer: Self Pay Self Pay	$390.40
Rate for Payer: TriWest Medicare	$73.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$284.50
Rate for Payer: UnitedHealth Group of AZ Medicare	$87.84

XR Chest 1 View

Facility

$352.00

Service Code	CPT 71045
Hospital Charge Code	823510
Hospital Revenue Code	324
Min. Negotiated Rate	$91.52
Max. Negotiated Rate	$316.80
Rate for Payer: Aetna of AZ Commercial	$316.80
Rate for Payer: Bisbee Police All Plans	$91.52
Rate for Payer: Cash Price	$281.60
Rate for Payer: Self Pay Self Pay	$281.60

XR Chest 1 View

Facility

$352.00

Service Code	CPT 71045
Hospital Charge Code	823510
Hospital Revenue Code	324
Min. Negotiated Rate	$52.80
Max. Negotiated Rate	$316.80
Rate for Payer: Aetna of AZ Commercial	$316.80
Rate for Payer: Aetna of AZ Medicare	$98.56
Rate for Payer: AHCCCS Medicaid	$117.30
Rate for Payer: Allwell Medicaid	$117.30
Rate for Payer: Allwell Medicare	$52.80
Rate for Payer: Amerigroup Medicare	$52.80
Rate for Payer: APIPA Medicare/Medicaid	$131.47
Rate for Payer: AZCH Complete Medicaid	$117.30
Rate for Payer: AZCH Complete Medicare	$52.80
Rate for Payer: Banner UC Health Medicaid	$117.30
Rate for Payer: Banner UC Health Medicare	$52.80
Rate for Payer: Bisbee Police All Plans	$91.52
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$239.36
Rate for Payer: Cash Price	$281.60
Rate for Payer: Cash Price	$281.60
Rate for Payer: Cigna of AZ Commercial	$228.80
Rate for Payer: Copperpoint Commercial	$87.12
Rate for Payer: Health Net of AZ Commercial	$211.20
Rate for Payer: Health Net of AZ Medicare	$98.56
Rate for Payer: Humana of AZ Medicare	$52.80
Rate for Payer: Mercy Care Medicaid	$117.30
Rate for Payer: Self Pay Self Pay	$281.60
Rate for Payer: TriWest Medicare	$52.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$205.22
Rate for Payer: UnitedHealth Group of AZ Medicare	$63.36

XR Chest 1 View Special

Facility

$352.00

Service Code	CPT 71045
Hospital Charge Code	3642285
Hospital Revenue Code	324
Min. Negotiated Rate	$52.80
Max. Negotiated Rate	$316.80
Rate for Payer: Aetna of AZ Commercial	$316.80
Rate for Payer: Aetna of AZ Medicare	$98.56
Rate for Payer: AHCCCS Medicaid	$117.30
Rate for Payer: Allwell Medicaid	$117.30
Rate for Payer: Allwell Medicare	$52.80
Rate for Payer: Amerigroup Medicare	$52.80
Rate for Payer: APIPA Medicare/Medicaid	$131.47
Rate for Payer: AZCH Complete Medicaid	$117.30
Rate for Payer: AZCH Complete Medicare	$52.80
Rate for Payer: Banner UC Health Medicaid	$117.30
Rate for Payer: Banner UC Health Medicare	$52.80
Rate for Payer: Bisbee Police All Plans	$91.52
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$239.36
Rate for Payer: Cash Price	$281.60
Rate for Payer: Cash Price	$281.60
Rate for Payer: Cigna of AZ Commercial	$228.80
Rate for Payer: Copperpoint Commercial	$87.12
Rate for Payer: Health Net of AZ Commercial	$211.20
Rate for Payer: Health Net of AZ Medicare	$98.56
Rate for Payer: Humana of AZ Medicare	$52.80
Rate for Payer: Mercy Care Medicaid	$117.30
Rate for Payer: Self Pay Self Pay	$281.60
Rate for Payer: TriWest Medicare	$52.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$205.22
Rate for Payer: UnitedHealth Group of AZ Medicare	$63.36

XR Chest 1 View Special

Facility

$352.00

Service Code	CPT 71045
Hospital Charge Code	3642285
Hospital Revenue Code	324
Min. Negotiated Rate	$91.52
Max. Negotiated Rate	$316.80
Rate for Payer: Aetna of AZ Commercial	$316.80
Rate for Payer: Bisbee Police All Plans	$91.52
Rate for Payer: Cash Price	$281.60
Rate for Payer: Self Pay Self Pay	$281.60

XR Chest 2 Views

Facility

$488.00

Service Code	CPT 71046
Hospital Charge Code	823512
Hospital Revenue Code	324
Min. Negotiated Rate	$126.88
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Bisbee Police All Plans	$126.88
Rate for Payer: Cash Price	$390.40
Rate for Payer: Self Pay Self Pay	$390.40

XR Chest 2 Views

Facility

$488.00

Service Code	CPT 71046
Hospital Charge Code	823512
Hospital Revenue Code	324
Min. Negotiated Rate	$73.20
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Aetna of AZ Medicare	$136.64
Rate for Payer: AHCCCS Medicaid	$117.30
Rate for Payer: Allwell Medicaid	$117.30
Rate for Payer: Allwell Medicare	$73.20
Rate for Payer: Amerigroup Medicare	$73.20
Rate for Payer: APIPA Medicare/Medicaid	$182.27
Rate for Payer: AZCH Complete Medicaid	$117.30
Rate for Payer: AZCH Complete Medicare	$73.20
Rate for Payer: Banner UC Health Medicaid	$117.30
Rate for Payer: Banner UC Health Medicare	$73.20
Rate for Payer: Bisbee Police All Plans	$126.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$331.84
Rate for Payer: Cash Price	$390.40
Rate for Payer: Cash Price	$390.40
Rate for Payer: Cigna of AZ Commercial	$317.20
Rate for Payer: Copperpoint Commercial	$120.78
Rate for Payer: Health Net of AZ Commercial	$292.80
Rate for Payer: Health Net of AZ Medicare	$136.64
Rate for Payer: Humana of AZ Medicare	$73.20
Rate for Payer: Mercy Care Medicaid	$117.30
Rate for Payer: Self Pay Self Pay	$390.40
Rate for Payer: TriWest Medicare	$73.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$284.50
Rate for Payer: UnitedHealth Group of AZ Medicare	$87.84

XR Chest 4 Views w/ Obliques

Facility

$1,166.00

Service Code	CPT 71048
Hospital Charge Code	1780010
Hospital Revenue Code	324
Min. Negotiated Rate	$303.16
Max. Negotiated Rate	$1,049.40
Rate for Payer: Aetna of AZ Commercial	$1,049.40
Rate for Payer: Bisbee Police All Plans	$303.16
Rate for Payer: Cash Price	$932.80
Rate for Payer: Self Pay Self Pay	$932.80

XR Chest 4 Views w/ Obliques

Facility

$1,166.00

Service Code	CPT 71048
Hospital Charge Code	1780010
Hospital Revenue Code	324
Min. Negotiated Rate	$158.00
Max. Negotiated Rate	$1,049.40
Rate for Payer: Aetna of AZ Commercial	$1,049.40
Rate for Payer: Aetna of AZ Medicare	$326.48
Rate for Payer: AHCCCS Medicaid	$158.00
Rate for Payer: Allwell Medicaid	$158.00
Rate for Payer: Allwell Medicare	$174.90
Rate for Payer: Amerigroup Medicare	$174.90
Rate for Payer: APIPA Medicare/Medicaid	$435.50
Rate for Payer: AZCH Complete Medicaid	$158.00
Rate for Payer: AZCH Complete Medicare	$174.90
Rate for Payer: Banner UC Health Medicaid	$158.00
Rate for Payer: Banner UC Health Medicare	$174.90
Rate for Payer: Bisbee Police All Plans	$303.16
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$792.88
Rate for Payer: Cash Price	$932.80
Rate for Payer: Cash Price	$932.80
Rate for Payer: Cigna of AZ Commercial	$757.90
Rate for Payer: Copperpoint Commercial	$288.58
Rate for Payer: Health Net of AZ Commercial	$699.60
Rate for Payer: Health Net of AZ Medicare	$326.48
Rate for Payer: Humana of AZ Medicare	$174.90
Rate for Payer: Mercy Care Medicaid	$158.00
Rate for Payer: Self Pay Self Pay	$932.80
Rate for Payer: TriWest Medicare	$174.90
Rate for Payer: UnitedHealth Group of AZ Commercial	$679.78
Rate for Payer: UnitedHealth Group of AZ Medicare	$209.88

XR Child Nose-Rectum For FB

Facility

$370.00

Service Code	CPT 76010
Hospital Charge Code	1007907
Hospital Revenue Code	320
Min. Negotiated Rate	$96.20
Max. Negotiated Rate	$333.00
Rate for Payer: Aetna of AZ Commercial	$333.00
Rate for Payer: Bisbee Police All Plans	$96.20
Rate for Payer: Cash Price	$296.00
Rate for Payer: Self Pay Self Pay	$296.00

XR Child Nose-Rectum For FB

Facility

$370.00

Service Code	CPT 76010
Hospital Charge Code	1007907
Hospital Revenue Code	320
Min. Negotiated Rate	$55.50
Max. Negotiated Rate	$333.00
Rate for Payer: Aetna of AZ Commercial	$333.00
Rate for Payer: Aetna of AZ Medicare	$103.60
Rate for Payer: AHCCCS Medicaid	$117.30
Rate for Payer: Allwell Medicaid	$117.30
Rate for Payer: Allwell Medicare	$55.50
Rate for Payer: Amerigroup Medicare	$55.50
Rate for Payer: APIPA Medicare/Medicaid	$138.20
Rate for Payer: AZCH Complete Medicaid	$117.30
Rate for Payer: AZCH Complete Medicare	$55.50
Rate for Payer: Banner UC Health Medicaid	$117.30
Rate for Payer: Banner UC Health Medicare	$55.50
Rate for Payer: Bisbee Police All Plans	$96.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$251.60
Rate for Payer: Cash Price	$296.00
Rate for Payer: Cash Price	$296.00
Rate for Payer: Cigna of AZ Commercial	$240.50
Rate for Payer: Copperpoint Commercial	$91.58
Rate for Payer: Health Net of AZ Commercial	$222.00
Rate for Payer: Health Net of AZ Medicare	$103.60
Rate for Payer: Humana of AZ Medicare	$55.50
Rate for Payer: Mercy Care Medicaid	$117.30
Rate for Payer: Self Pay Self Pay	$296.00
Rate for Payer: TriWest Medicare	$55.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$215.71
Rate for Payer: UnitedHealth Group of AZ Medicare	$66.60

XR Cholangiogram in OR

Facility

$1,262.00

Service Code	CPT 74300
Hospital Charge Code	1021642
Hospital Revenue Code	320
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$1,135.80
Rate for Payer: Aetna of AZ Commercial	$1,135.80
Rate for Payer: Aetna of AZ Medicare	$353.36
Rate for Payer: AHCCCS Medicaid	$0.13
Rate for Payer: Allwell Medicaid	$0.13
Rate for Payer: Allwell Medicare	$189.30
Rate for Payer: Amerigroup Medicare	$189.30
Rate for Payer: APIPA Medicare/Medicaid	$471.36
Rate for Payer: AZCH Complete Medicaid	$0.13
Rate for Payer: AZCH Complete Medicare	$189.30
Rate for Payer: Banner UC Health Medicaid	$0.13
Rate for Payer: Banner UC Health Medicare	$189.30
Rate for Payer: Bisbee Police All Plans	$328.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$858.16
Rate for Payer: Cash Price	$1,009.60
Rate for Payer: Cash Price	$1,009.60
Rate for Payer: Cigna of AZ Commercial	$820.30
Rate for Payer: Copperpoint Commercial	$312.34
Rate for Payer: Health Net of AZ Commercial	$757.20
Rate for Payer: Health Net of AZ Medicare	$353.36
Rate for Payer: Humana of AZ Medicare	$189.30
Rate for Payer: Mercy Care Medicaid	$0.13
Rate for Payer: Self Pay Self Pay	$1,009.60
Rate for Payer: TriWest Medicare	$189.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$735.75
Rate for Payer: UnitedHealth Group of AZ Medicare	$227.16

XR Cholangiogram in OR

Facility

$1,262.00

Service Code	CPT 74300
Hospital Charge Code	1021642
Hospital Revenue Code	320
Min. Negotiated Rate	$328.12
Max. Negotiated Rate	$1,135.80
Rate for Payer: Aetna of AZ Commercial	$1,135.80
Rate for Payer: Bisbee Police All Plans	$328.12
Rate for Payer: Cash Price	$1,009.60
Rate for Payer: Self Pay Self Pay	$1,009.60

XR Cholangiogram OR w/ Existing Catheter

Facility

$700.00

Service Code	CPT 74305
Hospital Charge Code	1735705
Hospital Revenue Code	320
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna of AZ Commercial	$630.00
Rate for Payer: Bisbee Police All Plans	$182.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Self Pay Self Pay	$560.00

XR Cholangiogram OR w/ Existing Catheter

Facility

$700.00

Service Code	CPT 74305
Hospital Charge Code	1735705
Hospital Revenue Code	320
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna of AZ Commercial	$630.00
Rate for Payer: Aetna of AZ Medicare	$196.00
Rate for Payer: Allwell Medicare	$105.00
Rate for Payer: Amerigroup Medicare	$105.00
Rate for Payer: APIPA Medicare/Medicaid	$261.45
Rate for Payer: AZCH Complete Medicare	$105.00
Rate for Payer: Banner UC Health Medicare	$105.00
Rate for Payer: Bisbee Police All Plans	$182.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$476.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Cigna of AZ Commercial	$455.00
Rate for Payer: Copperpoint Commercial	$173.25
Rate for Payer: Health Net of AZ Commercial	$420.00
Rate for Payer: Health Net of AZ Medicare	$196.00
Rate for Payer: Humana of AZ Medicare	$105.00
Rate for Payer: Self Pay Self Pay	$560.00
Rate for Payer: TriWest Medicare	$105.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$408.10
Rate for Payer: UnitedHealth Group of AZ Medicare	$126.00

XR Clavicle Left

Facility

$507.00

Service Code	CPT 73000 LT
Hospital Charge Code	823516
Hospital Revenue Code	320
Min. Negotiated Rate	$131.82
Max. Negotiated Rate	$456.30
Rate for Payer: Aetna of AZ Commercial	$456.30
Rate for Payer: Bisbee Police All Plans	$131.82
Rate for Payer: Cash Price	$405.60
Rate for Payer: Self Pay Self Pay	$405.60

XR Clavicle Left

Facility

$507.00

Service Code	CPT 73000 LT
Hospital Charge Code	823516
Hospital Revenue Code	320
Min. Negotiated Rate	$76.05
Max. Negotiated Rate	$456.30
Rate for Payer: Aetna of AZ Commercial	$456.30
Rate for Payer: Aetna of AZ Medicare	$141.96
Rate for Payer: Allwell Medicare	$76.05
Rate for Payer: Amerigroup Medicare	$76.05
Rate for Payer: APIPA Medicare/Medicaid	$189.36
Rate for Payer: AZCH Complete Medicare	$76.05
Rate for Payer: Banner UC Health Medicare	$76.05
Rate for Payer: Bisbee Police All Plans	$131.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$344.76
Rate for Payer: Cash Price	$405.60
Rate for Payer: Cigna of AZ Commercial	$329.55
Rate for Payer: Copperpoint Commercial	$125.48
Rate for Payer: Health Net of AZ Commercial	$304.20
Rate for Payer: Health Net of AZ Medicare	$141.96
Rate for Payer: Humana of AZ Medicare	$76.05
Rate for Payer: Self Pay Self Pay	$405.60
Rate for Payer: TriWest Medicare	$76.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$295.58
Rate for Payer: UnitedHealth Group of AZ Medicare	$91.26

XR Clavicle Right

Facility

$507.00

Service Code	CPT 73000 RT
Hospital Charge Code	823518
Hospital Revenue Code	320
Min. Negotiated Rate	$76.05
Max. Negotiated Rate	$456.30
Rate for Payer: Aetna of AZ Commercial	$456.30
Rate for Payer: Aetna of AZ Medicare	$141.96
Rate for Payer: Allwell Medicare	$76.05
Rate for Payer: Amerigroup Medicare	$76.05
Rate for Payer: APIPA Medicare/Medicaid	$189.36
Rate for Payer: AZCH Complete Medicare	$76.05
Rate for Payer: Banner UC Health Medicare	$76.05
Rate for Payer: Bisbee Police All Plans	$131.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$344.76
Rate for Payer: Cash Price	$405.60
Rate for Payer: Cigna of AZ Commercial	$329.55
Rate for Payer: Copperpoint Commercial	$125.48
Rate for Payer: Health Net of AZ Commercial	$304.20
Rate for Payer: Health Net of AZ Medicare	$141.96
Rate for Payer: Humana of AZ Medicare	$76.05
Rate for Payer: Self Pay Self Pay	$405.60
Rate for Payer: TriWest Medicare	$76.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$295.58
Rate for Payer: UnitedHealth Group of AZ Medicare	$91.26

XR Clavicle Right

Facility

$507.00

Service Code	CPT 73000 RT
Hospital Charge Code	823518
Hospital Revenue Code	320
Min. Negotiated Rate	$131.82
Max. Negotiated Rate	$456.30
Rate for Payer: Aetna of AZ Commercial	$456.30
Rate for Payer: Bisbee Police All Plans	$131.82
Rate for Payer: Cash Price	$405.60
Rate for Payer: Self Pay Self Pay	$405.60

XR Cystogram Non Voiding

Facility

$285.00

Service Code	CPT 74430
Hospital Charge Code	1319963
Hospital Revenue Code	320
Min. Negotiated Rate	$74.10
Max. Negotiated Rate	$256.50
Rate for Payer: Aetna of AZ Commercial	$256.50
Rate for Payer: Bisbee Police All Plans	$74.10
Rate for Payer: Cash Price	$228.00
Rate for Payer: Self Pay Self Pay	$228.00

XR Cystogram Non Voiding

Facility

$285.00

Service Code	CPT 74430
Hospital Charge Code	1319963
Hospital Revenue Code	320
Min. Negotiated Rate	$42.75
Max. Negotiated Rate	$483.64
Rate for Payer: Aetna of AZ Commercial	$256.50
Rate for Payer: Aetna of AZ Medicare	$79.80
Rate for Payer: AHCCCS Medicaid	$483.64
Rate for Payer: Allwell Medicaid	$483.64
Rate for Payer: Allwell Medicare	$42.75
Rate for Payer: Amerigroup Medicare	$42.75
Rate for Payer: APIPA Medicare/Medicaid	$106.45
Rate for Payer: AZCH Complete Medicaid	$483.64
Rate for Payer: AZCH Complete Medicare	$42.75
Rate for Payer: Banner UC Health Medicaid	$483.64
Rate for Payer: Banner UC Health Medicare	$42.75
Rate for Payer: Bisbee Police All Plans	$74.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$193.80
Rate for Payer: Cash Price	$228.00
Rate for Payer: Cash Price	$228.00
Rate for Payer: Cigna of AZ Commercial	$185.25
Rate for Payer: Copperpoint Commercial	$70.54
Rate for Payer: Health Net of AZ Commercial	$171.00
Rate for Payer: Health Net of AZ Medicare	$79.80
Rate for Payer: Humana of AZ Medicare	$42.75
Rate for Payer: Mercy Care Medicaid	$483.64
Rate for Payer: Self Pay Self Pay	$228.00
Rate for Payer: TriWest Medicare	$42.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$166.16
Rate for Payer: UnitedHealth Group of AZ Medicare	$51.30

XR Cystogram Voiding

Facility

$308.00

Service Code	CPT 51600
Hospital Charge Code	1319966
Hospital Revenue Code	320
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$277.20
Rate for Payer: Aetna of AZ Medicare	$86.24
Rate for Payer: AHCCCS Medicaid	$0.13
Rate for Payer: Allwell Medicaid	$0.13
Rate for Payer: Allwell Medicare	$46.20
Rate for Payer: Amerigroup Medicare	$46.20
Rate for Payer: APIPA Medicare/Medicaid	$115.04
Rate for Payer: AZCH Complete Medicaid	$0.13
Rate for Payer: AZCH Complete Medicare	$46.20
Rate for Payer: Banner UC Health Medicaid	$0.13
Rate for Payer: Banner UC Health Medicare	$46.20
Rate for Payer: Bisbee Police All Plans	$80.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$209.44
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cigna of AZ Commercial	$200.20
Rate for Payer: Copperpoint Commercial	$76.23
Rate for Payer: Health Net of AZ Commercial	$184.80
Rate for Payer: Health Net of AZ Medicare	$86.24
Rate for Payer: Humana of AZ Medicare	$46.20
Rate for Payer: Mercy Care Medicaid	$0.13
Rate for Payer: Self Pay Self Pay	$246.40
Rate for Payer: TriWest Medicare	$46.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$55.44

XR Cystogram Voiding

Facility

$308.00

Service Code	CPT 51600
Hospital Charge Code	1319966
Hospital Revenue Code	320
Min. Negotiated Rate	$80.08
Max. Negotiated Rate	$277.20
Rate for Payer: Aetna of AZ Commercial	$277.20
Rate for Payer: Bisbee Police All Plans	$80.08
Rate for Payer: Cash Price	$246.40
Rate for Payer: Self Pay Self Pay	$246.40

Know your out-of-pocket cost for care.

All Charges