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All Charges

Charge Type Price  
Service Code NDC 58160082311
Hospital Charge Code 136004511
Hospital Revenue Code 250
Min. Negotiated Rate $20.10
Max. Negotiated Rate $120.59
Rate for Payer: Aetna of AZ Commercial $120.59
Rate for Payer: Aetna of AZ Medicare $37.52
Rate for Payer: Allwell Medicare $20.10
Rate for Payer: Amerigroup Medicare $20.10
Rate for Payer: APIPA Medicare/Medicaid $50.05
Rate for Payer: AZCH Complete Medicare $20.10
Rate for Payer: Banner UC Health Medicare $20.10
Rate for Payer: Bisbee Police All Plans $34.84
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial $91.11
Rate for Payer: Cash Price $107.19
Rate for Payer: Cigna of AZ Commercial $87.09
Rate for Payer: Copperpoint Commercial $33.16
Rate for Payer: Health Net of AZ Commercial $80.39
Rate for Payer: Health Net of AZ Medicare $37.52
Rate for Payer: Humana of AZ Medicare $20.10
Rate for Payer: Self Pay Self Pay $107.19
Rate for Payer: TriWest Medicare $20.10
Rate for Payer: UnitedHealth Group of AZ Commercial $78.12
Rate for Payer: UnitedHealth Group of AZ Medicare $24.12