Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Arterial Blood Gas Standard

Facility

$306.00

Service Code	CPT 82803
Hospital Charge Code	22146116
Hospital Revenue Code	301
Min. Negotiated Rate	$48.96
Max. Negotiated Rate	$275.40
Rate for Payer: Aetna of AZ Commercial	$275.40
Rate for Payer: Aetna of AZ Medicare	$85.68
Rate for Payer: Allwell Medicare	$48.96
Rate for Payer: Amerigroup Medicare	$48.96
Rate for Payer: APIPA Medicare/Medicaid	$114.29
Rate for Payer: AZCH Complete Medicare	$48.96
Rate for Payer: Banner UC Health Medicare	$48.96
Rate for Payer: Bisbee Police All Plans	$79.56
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$208.08
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cigna of AZ Commercial	$198.90
Rate for Payer: Copperpoint Commercial	$75.73
Rate for Payer: Health Net of AZ Commercial	$183.60
Rate for Payer: Health Net of AZ Medicare	$85.68
Rate for Payer: Humana of AZ Medicare	$48.96
Rate for Payer: Self Pay Self Pay	$244.80
Rate for Payer: TriWest Medicare	$48.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$178.40
Rate for Payer: UnitedHealth Group of AZ Medicare	$55.08

ARTHRODESIS MIDTARSAL OR TARSOMETATARSAL MULTIPLE OR TRANSVERSE

Facility

$3,571.00

Service Code	CPT 28730
Hospital Charge Code	24043324
Hospital Revenue Code	360
Min. Negotiated Rate	$571.36
Max. Negotiated Rate	$8,928.20
Rate for Payer: Aetna of AZ Commercial	$3,213.90
Rate for Payer: Aetna of AZ Medicare	$999.88
Rate for Payer: AHCCCS Medicaid	$8,928.20
Rate for Payer: Allwell Medicaid	$8,928.20
Rate for Payer: Allwell Medicare	$571.36
Rate for Payer: Amerigroup Medicare	$571.36
Rate for Payer: APIPA Medicare/Medicaid	$1,333.77
Rate for Payer: AZCH Complete Medicaid	$8,928.20
Rate for Payer: AZCH Complete Medicare	$571.36
Rate for Payer: Banner UC Health Medicaid	$8,928.20
Rate for Payer: Banner UC Health Medicare	$571.36
Rate for Payer: Bisbee Police All Plans	$928.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,428.28
Rate for Payer: Cash Price	$2,856.80
Rate for Payer: Cash Price	$2,856.80
Rate for Payer: Cigna of AZ Commercial	$1,785.50
Rate for Payer: Copperpoint Commercial	$883.82
Rate for Payer: Health Net of AZ Commercial	$2,142.60
Rate for Payer: Health Net of AZ Medicare	$999.88
Rate for Payer: Humana of AZ Medicare	$571.36
Rate for Payer: Mercy Care Medicaid	$8,928.20
Rate for Payer: Self Pay Self Pay	$2,856.80
Rate for Payer: TriWest Medicare	$571.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$5,265.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$642.78

ARTHRODESIS MIDTARSAL OR TARSOMETATARSAL MULTIPLE OR TRANSVERSE

Facility

$3,571.00

Service Code	CPT 28730
Hospital Charge Code	24043324
Hospital Revenue Code	360
Min. Negotiated Rate	$928.46
Max. Negotiated Rate	$3,213.90
Rate for Payer: Aetna of AZ Commercial	$3,213.90
Rate for Payer: Bisbee Police All Plans	$928.46
Rate for Payer: Cash Price	$2,856.80
Rate for Payer: Self Pay Self Pay	$2,856.80

ARTHROSCOPIC PACK

Facility

$242.00

Hospital Charge Code	22354803
Hospital Revenue Code	270
Min. Negotiated Rate	$38.72
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Aetna of AZ Medicare	$67.76
Rate for Payer: Allwell Medicare	$38.72
Rate for Payer: Amerigroup Medicare	$38.72
Rate for Payer: APIPA Medicare/Medicaid	$90.39
Rate for Payer: AZCH Complete Medicare	$38.72
Rate for Payer: Banner UC Health Medicare	$38.72
Rate for Payer: Bisbee Police All Plans	$62.92
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$164.56
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cigna of AZ Commercial	$169.40
Rate for Payer: Copperpoint Commercial	$59.90
Rate for Payer: Health Net of AZ Commercial	$145.20
Rate for Payer: Health Net of AZ Medicare	$67.76
Rate for Payer: Humana of AZ Medicare	$38.72
Rate for Payer: Self Pay Self Pay	$193.60
Rate for Payer: TriWest Medicare	$38.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$141.09
Rate for Payer: UnitedHealth Group of AZ Medicare	$43.56

ARTHROSCOPIC PACK

Facility

$242.00

Hospital Charge Code	22354803
Hospital Revenue Code	270
Min. Negotiated Rate	$62.92
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Bisbee Police All Plans	$62.92
Rate for Payer: Cash Price	$193.60
Rate for Payer: Self Pay Self Pay	$193.60

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND L

Facility

$3,056.00

Service Code	CPT 29880
Hospital Charge Code	27357092
Hospital Revenue Code	362
Min. Negotiated Rate	$794.56
Max. Negotiated Rate	$2,750.40
Rate for Payer: Aetna of AZ Commercial	$2,750.40
Rate for Payer: Bisbee Police All Plans	$794.56
Rate for Payer: Cash Price	$2,444.80
Rate for Payer: Self Pay Self Pay	$2,444.80

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND L

Facility

$3,056.00

Service Code	CPT 29880
Hospital Charge Code	27357092
Hospital Revenue Code	362
Min. Negotiated Rate	$488.96
Max. Negotiated Rate	$3,914.00
Rate for Payer: Aetna of AZ Commercial	$2,750.40
Rate for Payer: Aetna of AZ Medicare	$855.68
Rate for Payer: AHCCCS Medicaid	$2,052.04
Rate for Payer: Allwell Medicaid	$2,052.04
Rate for Payer: Allwell Medicare	$488.96
Rate for Payer: Amerigroup Medicare	$488.96
Rate for Payer: APIPA Medicare/Medicaid	$1,141.42
Rate for Payer: AZCH Complete Medicaid	$2,052.04
Rate for Payer: AZCH Complete Medicare	$488.96
Rate for Payer: Banner UC Health Medicaid	$2,052.04
Rate for Payer: Banner UC Health Medicare	$488.96
Rate for Payer: Bisbee Police All Plans	$794.56
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,078.08
Rate for Payer: Cash Price	$2,444.80
Rate for Payer: Cash Price	$2,444.80
Rate for Payer: Cigna of AZ Commercial	$1,986.40
Rate for Payer: Copperpoint Commercial	$756.36
Rate for Payer: Health Net of AZ Commercial	$1,833.60
Rate for Payer: Health Net of AZ Medicare	$855.68
Rate for Payer: Humana of AZ Medicare	$488.96
Rate for Payer: Mercy Care Medicaid	$2,052.04
Rate for Payer: Self Pay Self Pay	$2,444.80
Rate for Payer: TriWest Medicare	$488.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,914.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$550.08

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LA

Facility

$2,945.00

Service Code	CPT 29881
Hospital Charge Code	27357091
Hospital Revenue Code	360
Min. Negotiated Rate	$471.20
Max. Negotiated Rate	$3,914.00
Rate for Payer: Aetna of AZ Commercial	$2,650.50
Rate for Payer: Aetna of AZ Medicare	$824.60
Rate for Payer: AHCCCS Medicaid	$2,052.04
Rate for Payer: Allwell Medicaid	$2,052.04
Rate for Payer: Allwell Medicare	$471.20
Rate for Payer: Amerigroup Medicare	$471.20
Rate for Payer: APIPA Medicare/Medicaid	$1,099.96
Rate for Payer: AZCH Complete Medicaid	$2,052.04
Rate for Payer: AZCH Complete Medicare	$471.20
Rate for Payer: Banner UC Health Medicaid	$2,052.04
Rate for Payer: Banner UC Health Medicare	$471.20
Rate for Payer: Bisbee Police All Plans	$765.70
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,002.60
Rate for Payer: Cash Price	$2,356.00
Rate for Payer: Cash Price	$2,356.00
Rate for Payer: Cigna of AZ Commercial	$1,472.50
Rate for Payer: Copperpoint Commercial	$728.89
Rate for Payer: Health Net of AZ Commercial	$1,767.00
Rate for Payer: Health Net of AZ Medicare	$824.60
Rate for Payer: Humana of AZ Medicare	$471.20
Rate for Payer: Mercy Care Medicaid	$2,052.04
Rate for Payer: Self Pay Self Pay	$2,356.00
Rate for Payer: TriWest Medicare	$471.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,914.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$530.10

ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LA

Facility

$2,945.00

Service Code	CPT 29881
Hospital Charge Code	27357091
Hospital Revenue Code	360
Min. Negotiated Rate	$765.70
Max. Negotiated Rate	$2,650.50
Rate for Payer: Aetna of AZ Commercial	$2,650.50
Rate for Payer: Bisbee Police All Plans	$765.70
Rate for Payer: Cash Price	$2,356.00
Rate for Payer: Self Pay Self Pay	$2,356.00

ARTHROTOMY ANKLE WITH JOINT EXPLORATION WITH OR WITHOUT BIOPSY WITH OR WITHO

Facility

$2,190.00

Service Code	CPT 27620
Hospital Charge Code	24043333
Hospital Revenue Code	360
Min. Negotiated Rate	$569.40
Max. Negotiated Rate	$1,971.00
Rate for Payer: Aetna of AZ Commercial	$1,971.00
Rate for Payer: Bisbee Police All Plans	$569.40
Rate for Payer: Cash Price	$1,752.00
Rate for Payer: Self Pay Self Pay	$1,752.00

ARTHROTOMY ANKLE WITH JOINT EXPLORATION WITH OR WITHOUT BIOPSY WITH OR WITHO

Facility

$2,190.00

Service Code	CPT 27620
Hospital Charge Code	24043333
Hospital Revenue Code	360
Min. Negotiated Rate	$350.40
Max. Negotiated Rate	$3,914.00
Rate for Payer: Aetna of AZ Commercial	$1,971.00
Rate for Payer: Aetna of AZ Medicare	$613.20
Rate for Payer: AHCCCS Medicaid	$2,052.04
Rate for Payer: Allwell Medicaid	$2,052.04
Rate for Payer: Allwell Medicare	$350.40
Rate for Payer: Amerigroup Medicare	$350.40
Rate for Payer: APIPA Medicare/Medicaid	$817.97
Rate for Payer: AZCH Complete Medicaid	$2,052.04
Rate for Payer: AZCH Complete Medicare	$350.40
Rate for Payer: Banner UC Health Medicaid	$2,052.04
Rate for Payer: Banner UC Health Medicare	$350.40
Rate for Payer: Bisbee Police All Plans	$569.40
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,489.20
Rate for Payer: Cash Price	$1,752.00
Rate for Payer: Cash Price	$1,752.00
Rate for Payer: Cigna of AZ Commercial	$1,095.00
Rate for Payer: Copperpoint Commercial	$542.02
Rate for Payer: Health Net of AZ Commercial	$1,314.00
Rate for Payer: Health Net of AZ Medicare	$613.20
Rate for Payer: Humana of AZ Medicare	$350.40
Rate for Payer: Mercy Care Medicaid	$2,052.04
Rate for Payer: Self Pay Self Pay	$1,752.00
Rate for Payer: TriWest Medicare	$350.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,914.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$394.20

ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF LOOSE OR FOREIGN

Facility

$1,474.00

Service Code	CPT 28024
Hospital Charge Code	24043319
Hospital Revenue Code	360
Min. Negotiated Rate	$383.24
Max. Negotiated Rate	$1,326.60
Rate for Payer: Aetna of AZ Commercial	$1,326.60
Rate for Payer: Bisbee Police All Plans	$383.24
Rate for Payer: Cash Price	$1,179.20
Rate for Payer: Self Pay Self Pay	$1,179.20

ARTHROTOMY INCLUDING EXPLORATION DRAINAGE OR REMOVAL OF LOOSE OR FOREIGN

Facility

$1,474.00

Service Code	CPT 28024
Hospital Charge Code	24043319
Hospital Revenue Code	360
Min. Negotiated Rate	$235.84
Max. Negotiated Rate	$3,373.00
Rate for Payer: Aetna of AZ Commercial	$1,326.60
Rate for Payer: Aetna of AZ Medicare	$412.72
Rate for Payer: AHCCCS Medicaid	$1,009.45
Rate for Payer: Allwell Medicaid	$1,009.45
Rate for Payer: Allwell Medicare	$235.84
Rate for Payer: Amerigroup Medicare	$235.84
Rate for Payer: APIPA Medicare/Medicaid	$550.54
Rate for Payer: AZCH Complete Medicaid	$1,009.45
Rate for Payer: AZCH Complete Medicare	$235.84
Rate for Payer: Banner UC Health Medicaid	$1,009.45
Rate for Payer: Banner UC Health Medicare	$235.84
Rate for Payer: Bisbee Police All Plans	$383.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,002.32
Rate for Payer: Cash Price	$1,179.20
Rate for Payer: Cash Price	$1,179.20
Rate for Payer: Cigna of AZ Commercial	$737.00
Rate for Payer: Copperpoint Commercial	$364.81
Rate for Payer: Health Net of AZ Commercial	$884.40
Rate for Payer: Health Net of AZ Medicare	$412.72
Rate for Payer: Humana of AZ Medicare	$235.84
Rate for Payer: Mercy Care Medicaid	$1,009.45
Rate for Payer: Self Pay Self Pay	$1,179.20
Rate for Payer: TriWest Medicare	$235.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,373.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$265.32

artificial tear ointment [CQCH]

Facility

$5.86

Service Code	NDC 17478006235
Hospital Charge Code	105934694
Hospital Revenue Code	251
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$5.27
Rate for Payer: Aetna of AZ Commercial	$5.27
Rate for Payer: Aetna of AZ Medicare	$1.64
Rate for Payer: Allwell Medicare	$0.94
Rate for Payer: Amerigroup Medicare	$0.94
Rate for Payer: APIPA Medicare/Medicaid	$2.19
Rate for Payer: AZCH Complete Medicare	$0.94
Rate for Payer: Banner UC Health Medicare	$0.94
Rate for Payer: Bisbee Police All Plans	$1.52
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3.98
Rate for Payer: Cash Price	$4.69
Rate for Payer: Cigna of AZ Commercial	$3.81
Rate for Payer: Copperpoint Commercial	$1.45
Rate for Payer: Health Net of AZ Commercial	$3.52
Rate for Payer: Health Net of AZ Medicare	$1.64
Rate for Payer: Humana of AZ Medicare	$0.94
Rate for Payer: Self Pay Self Pay	$4.69
Rate for Payer: TriWest Medicare	$0.94
Rate for Payer: UnitedHealth Group of AZ Commercial	$3.42
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.05

artificial tear ointment [CQCH]

Facility

$5.86

Service Code	NDC 17478006235
Hospital Charge Code	105934694
Hospital Revenue Code	251
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$5.27
Rate for Payer: Aetna of AZ Commercial	$5.27
Rate for Payer: Bisbee Police All Plans	$1.52
Rate for Payer: Cash Price	$4.69
Rate for Payer: Self Pay Self Pay	$4.69

artificial tears ophth soln [CQCH]

Facility

$4.97

Service Code	NDC 17478006012
Hospital Charge Code	105934755
Hospital Revenue Code	251
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$4.47
Rate for Payer: Aetna of AZ Commercial	$4.47
Rate for Payer: Bisbee Police All Plans	$1.29
Rate for Payer: Cash Price	$3.98
Rate for Payer: Self Pay Self Pay	$3.98

artificial tears ophth soln [CQCH]

Facility

$4.97

Service Code	NDC 17478006012
Hospital Charge Code	105934755
Hospital Revenue Code	251
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$4.47
Rate for Payer: Aetna of AZ Commercial	$4.47
Rate for Payer: Aetna of AZ Medicare	$1.39
Rate for Payer: Allwell Medicare	$0.80
Rate for Payer: Amerigroup Medicare	$0.80
Rate for Payer: APIPA Medicare/Medicaid	$1.86
Rate for Payer: AZCH Complete Medicare	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Bisbee Police All Plans	$1.29
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3.38
Rate for Payer: Cash Price	$3.98
Rate for Payer: Cigna of AZ Commercial	$3.23
Rate for Payer: Copperpoint Commercial	$1.23
Rate for Payer: Health Net of AZ Commercial	$2.98
Rate for Payer: Health Net of AZ Medicare	$1.39
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Self Pay Self Pay	$3.98
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.90
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.89

Ascend AQ Ureteral Dilation Baloon Catheter Set

Facility

$1,685.00

Hospital Charge Code	22926476
Hospital Revenue Code	272
Min. Negotiated Rate	$438.10
Max. Negotiated Rate	$1,516.50
Rate for Payer: Aetna of AZ Commercial	$1,516.50
Rate for Payer: Bisbee Police All Plans	$438.10
Rate for Payer: Cash Price	$1,348.00
Rate for Payer: Self Pay Self Pay	$1,348.00

Ascend AQ Ureteral Dilation Baloon Catheter Set

Facility

$1,685.00

Hospital Charge Code	22926476
Hospital Revenue Code	272
Min. Negotiated Rate	$269.60
Max. Negotiated Rate	$1,516.50
Rate for Payer: Aetna of AZ Commercial	$1,516.50
Rate for Payer: Aetna of AZ Medicare	$471.80
Rate for Payer: Allwell Medicare	$269.60
Rate for Payer: Amerigroup Medicare	$269.60
Rate for Payer: APIPA Medicare/Medicaid	$629.35
Rate for Payer: AZCH Complete Medicare	$269.60
Rate for Payer: Banner UC Health Medicare	$269.60
Rate for Payer: Bisbee Police All Plans	$438.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,145.80
Rate for Payer: Cash Price	$1,348.00
Rate for Payer: Cigna of AZ Commercial	$1,179.50
Rate for Payer: Copperpoint Commercial	$417.04
Rate for Payer: Health Net of AZ Commercial	$1,011.00
Rate for Payer: Health Net of AZ Medicare	$471.80
Rate for Payer: Humana of AZ Medicare	$269.60
Rate for Payer: Self Pay Self Pay	$1,348.00
Rate for Payer: TriWest Medicare	$269.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$982.36
Rate for Payer: UnitedHealth Group of AZ Medicare	$303.30

ASCOPE 4 CYSTO STANDARD DEFLECTION

Facility

$175.00

Hospital Charge Code	27748825
Hospital Revenue Code	270
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Aetna of AZ Medicare	$49.00
Rate for Payer: Allwell Medicare	$28.00
Rate for Payer: Amerigroup Medicare	$28.00
Rate for Payer: APIPA Medicare/Medicaid	$65.36
Rate for Payer: AZCH Complete Medicare	$28.00
Rate for Payer: Banner UC Health Medicare	$28.00
Rate for Payer: Bisbee Police All Plans	$45.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$119.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cigna of AZ Commercial	$122.50
Rate for Payer: Copperpoint Commercial	$43.31
Rate for Payer: Health Net of AZ Commercial	$105.00
Rate for Payer: Health Net of AZ Medicare	$49.00
Rate for Payer: Humana of AZ Medicare	$28.00
Rate for Payer: Self Pay Self Pay	$140.00
Rate for Payer: TriWest Medicare	$28.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$102.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$31.50

ASCOPE 4 CYSTO STANDARD DEFLECTION

Facility

$175.00

Hospital Charge Code	27748825
Hospital Revenue Code	270
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Bisbee Police All Plans	$45.50
Rate for Payer: Cash Price	$140.00
Rate for Payer: Self Pay Self Pay	$140.00

ascorbic acid 500 mg/mL Sol[CQCH]

Facility

$4.95

Service Code	NDC 67157010150
Hospital Charge Code	200236188
Hospital Revenue Code	251
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$4.46
Rate for Payer: Aetna of AZ Commercial	$4.46
Rate for Payer: Aetna of AZ Medicare	$1.39
Rate for Payer: Allwell Medicare	$0.79
Rate for Payer: Amerigroup Medicare	$0.79
Rate for Payer: APIPA Medicare/Medicaid	$1.85
Rate for Payer: AZCH Complete Medicare	$0.79
Rate for Payer: Banner UC Health Medicare	$0.79
Rate for Payer: Bisbee Police All Plans	$1.29
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3.37
Rate for Payer: Cash Price	$3.96
Rate for Payer: Cigna of AZ Commercial	$3.22
Rate for Payer: Copperpoint Commercial	$1.23
Rate for Payer: Health Net of AZ Commercial	$2.97
Rate for Payer: Health Net of AZ Medicare	$1.39
Rate for Payer: Humana of AZ Medicare	$0.79
Rate for Payer: Self Pay Self Pay	$3.96
Rate for Payer: TriWest Medicare	$0.79
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.89
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.89

ascorbic acid 500 mg/mL Sol[CQCH]

Facility

$4.95

Service Code	NDC 67157010150
Hospital Charge Code	200236188
Hospital Revenue Code	251
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$4.46
Rate for Payer: Aetna of AZ Commercial	$4.46
Rate for Payer: Bisbee Police All Plans	$1.29
Rate for Payer: Cash Price	$3.96
Rate for Payer: Self Pay Self Pay	$3.96

ascorbic acid 500 mg Tab [CQCH]

Facility

$0.02

Service Code	NDC 904052380
Hospital Charge Code	105911388
Hospital Revenue Code	251
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

ascorbic acid 500 mg Tab [CQCH]

Facility

$0.02

Service Code	NDC 904052380
Hospital Charge Code	105911388
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.02

Know your out-of-pocket cost for care.

All Charges