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Charge Type Price  
Service Code NDC 58160082311
Hospital Charge Code 136004511
Hospital Revenue Code 250
Min. Negotiated Rate $34.84
Max. Negotiated Rate $120.59
Rate for Payer: Aetna of AZ Commercial $120.59
Rate for Payer: Bisbee Police All Plans $34.84
Rate for Payer: Cash Price $107.19
Rate for Payer: Self Pay Self Pay $107.19