Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

CLL FISH Panel LC

Facility

$205.00

Service Code	CPT 88271
Hospital Charge Code	2029268
Hospital Revenue Code	310
Min. Negotiated Rate	$21.42
Max. Negotiated Rate	$184.50
Rate for Payer: Aetna of AZ Commercial	$184.50
Rate for Payer: Aetna of AZ Medicare	$57.40
Rate for Payer: AHCCCS Medicaid	$21.42
Rate for Payer: Allwell Medicaid	$21.42
Rate for Payer: Allwell Medicare	$30.75
Rate for Payer: Amerigroup Medicare	$30.75
Rate for Payer: APIPA Medicare/Medicaid	$76.57
Rate for Payer: AZCH Complete Medicaid	$21.42
Rate for Payer: AZCH Complete Medicare	$30.75
Rate for Payer: Banner UC Health Medicaid	$21.42
Rate for Payer: Banner UC Health Medicare	$30.75
Rate for Payer: Bisbee Police All Plans	$53.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$139.40
Rate for Payer: Cash Price	$164.00
Rate for Payer: Cash Price	$164.00
Rate for Payer: Cigna of AZ Commercial	$133.25
Rate for Payer: Copperpoint Commercial	$50.74
Rate for Payer: Health Net of AZ Commercial	$123.00
Rate for Payer: Health Net of AZ Medicare	$57.40
Rate for Payer: Humana of AZ Medicare	$30.75
Rate for Payer: Mercy Care Medicaid	$21.42
Rate for Payer: Self Pay Self Pay	$164.00
Rate for Payer: TriWest Medicare	$30.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$119.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$36.90

clonazePAM 0.5 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 228300311
Hospital Charge Code	105916868
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Self Pay Self Pay	$0.02

clonazePAM 0.5 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 228300311
Hospital Charge Code	105916868
Hospital Revenue Code	251
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
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	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of AZ Commercial	$0.02
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.02
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	$0.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

clonazePAM 1 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 51079088220
Hospital Charge Code	105916803
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Aetna of AZ Medicare	$0.02
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.02
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.04
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of AZ Commercial	$0.04
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.04
Rate for Payer: Health Net of AZ Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Self Pay Self Pay	$0.05
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

clonazePAM 1 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 51079088220
Hospital Charge Code	105916803
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Cash Price	$0.05
Rate for Payer: Self Pay Self Pay	$0.05

cloNIDine 0.1 mg/24 hr Transderm Patch [CQCH]

Facility

$15.51

Service Code	NDC 378087199
Hospital Charge Code	105916933
Hospital Revenue Code	251
Min. Negotiated Rate	$2.33
Max. Negotiated Rate	$13.96
Rate for Payer: Aetna of AZ Commercial	$13.96
Rate for Payer: Aetna of AZ Medicare	$4.34
Rate for Payer: Allwell Medicare	$2.33
Rate for Payer: Amerigroup Medicare	$2.33
Rate for Payer: APIPA Medicare/Medicaid	$5.79
Rate for Payer: AZCH Complete Medicare	$2.33
Rate for Payer: Banner UC Health Medicare	$2.33
Rate for Payer: Bisbee Police All Plans	$4.03
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$10.55
Rate for Payer: Cash Price	$12.40
Rate for Payer: Cigna of AZ Commercial	$10.08
Rate for Payer: Copperpoint Commercial	$3.84
Rate for Payer: Health Net of AZ Commercial	$9.31
Rate for Payer: Health Net of AZ Medicare	$4.34
Rate for Payer: Humana of AZ Medicare	$2.33
Rate for Payer: Self Pay Self Pay	$12.41
Rate for Payer: TriWest Medicare	$2.33
Rate for Payer: UnitedHealth Group of AZ Commercial	$9.04
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.79

cloNIDine 0.1 mg/24 hr Transderm Patch [CQCH]

Facility

$15.51

Service Code	NDC 378087199
Hospital Charge Code	105916933
Hospital Revenue Code	251
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$13.96
Rate for Payer: Aetna of AZ Commercial	$13.96
Rate for Payer: Bisbee Police All Plans	$4.03
Rate for Payer: Cash Price	$12.40
Rate for Payer: Self Pay Self Pay	$12.41

cloNIDine 0.1 mg Tab [CQCH]

Facility

$0.04

Service Code	NDC 228212710
Hospital Charge Code	105916998
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.03
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of AZ Commercial	$0.03
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.02
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Self Pay Self Pay	$0.03
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

cloNIDine 0.1 mg Tab [CQCH]

Facility

$0.04

Service Code	NDC 228212710
Hospital Charge Code	105916998
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.03
Rate for Payer: Self Pay Self Pay	$0.03

clopidogrel 75 mg Tab [CQCH]

Facility

$0.17

Service Code	NDC 904629461
Hospital Charge Code	105917063
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Cash Price	$0.14
Rate for Payer: Self Pay Self Pay	$0.14

clopidogrel 75 mg Tab [CQCH]

Facility

$0.17

Service Code	NDC 904629461
Hospital Charge Code	105917063
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
Rate for Payer: Aetna of AZ Medicare	$0.05
Rate for Payer: Allwell Medicare	$0.03
Rate for Payer: Amerigroup Medicare	$0.03
Rate for Payer: APIPA Medicare/Medicaid	$0.06
Rate for Payer: AZCH Complete Medicare	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.12
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of AZ Commercial	$0.11
Rate for Payer: Copperpoint Commercial	$0.04
Rate for Payer: Health Net of AZ Commercial	$0.10
Rate for Payer: Health Net of AZ Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Self Pay Self Pay	$0.14
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.10
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.03

CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION; REQUIRING ANESTHESIA

Facility

$609.00

Service Code	CPT 28665
Hospital Charge Code	24043326
Hospital Revenue Code	360
Min. Negotiated Rate	$91.35
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$548.10
Rate for Payer: Aetna of AZ Medicare	$170.52
Rate for Payer: AHCCCS Medicaid	$349.70
Rate for Payer: Allwell Medicaid	$349.70
Rate for Payer: Allwell Medicare	$91.35
Rate for Payer: Amerigroup Medicare	$91.35
Rate for Payer: APIPA Medicare/Medicaid	$227.46
Rate for Payer: AZCH Complete Medicaid	$349.70
Rate for Payer: AZCH Complete Medicare	$91.35
Rate for Payer: Banner UC Health Medicaid	$349.70
Rate for Payer: Banner UC Health Medicare	$91.35
Rate for Payer: Bisbee Police All Plans	$158.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$414.12
Rate for Payer: Cash Price	$487.20
Rate for Payer: Cash Price	$487.20
Rate for Payer: Cigna of AZ Commercial	$304.50
Rate for Payer: Copperpoint Commercial	$150.73
Rate for Payer: Health Net of AZ Commercial	$365.40
Rate for Payer: Health Net of AZ Medicare	$170.52
Rate for Payer: Humana of AZ Medicare	$91.35
Rate for Payer: Mercy Care Medicaid	$349.70
Rate for Payer: Self Pay Self Pay	$487.20
Rate for Payer: TriWest Medicare	$91.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$109.62

CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION; REQUIRING ANESTHESIA

Facility

$609.00

Service Code	CPT 28665
Hospital Charge Code	24043326
Hospital Revenue Code	360
Min. Negotiated Rate	$158.34
Max. Negotiated Rate	$548.10
Rate for Payer: Aetna of AZ Commercial	$548.10
Rate for Payer: Bisbee Police All Plans	$158.34
Rate for Payer: Cash Price	$487.20
Rate for Payer: Self Pay Self Pay	$487.20

CLOSED TREATMENT OF LUNATE DISLOCATION, WITH MANIPULATION

Facility

$5,787.00

Service Code	CPT 25690
Hospital Charge Code	3634335
Hospital Revenue Code	450
Min. Negotiated Rate	$868.05
Max. Negotiated Rate	$5,208.30
Rate for Payer: Aetna of AZ Commercial	$5,208.30
Rate for Payer: Aetna of AZ Medicare	$1,620.36
Rate for Payer: AHCCCS Medicaid	$2,018.90
Rate for Payer: Allwell Medicaid	$2,018.90
Rate for Payer: Allwell Medicare	$868.05
Rate for Payer: Amerigroup Medicare	$868.05
Rate for Payer: APIPA Medicare/Medicaid	$2,161.44
Rate for Payer: AZCH Complete Medicaid	$2,018.90
Rate for Payer: AZCH Complete Medicare	$868.05
Rate for Payer: Banner UC Health Medicaid	$2,018.90
Rate for Payer: Banner UC Health Medicare	$868.05
Rate for Payer: Bisbee Police All Plans	$1,504.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,935.16
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Cigna of AZ Commercial	$4,050.90
Rate for Payer: Copperpoint Commercial	$1,432.28
Rate for Payer: Health Net of AZ Commercial	$3,472.20
Rate for Payer: Health Net of AZ Medicare	$1,620.36
Rate for Payer: Humana of AZ Medicare	$868.05
Rate for Payer: Mercy Care Medicaid	$2,018.90
Rate for Payer: Self Pay Self Pay	$4,629.60
Rate for Payer: TriWest Medicare	$868.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,909.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,041.66

CLOSED TREATMENT OF LUNATE DISLOCATION, WITH MANIPULATION

Facility

$5,787.00

Service Code	CPT 25690
Hospital Charge Code	3634335
Hospital Revenue Code	450
Min. Negotiated Rate	$1,504.62
Max. Negotiated Rate	$5,208.30
Rate for Payer: Aetna of AZ Commercial	$5,208.30
Rate for Payer: Bisbee Police All Plans	$1,504.62
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Self Pay Self Pay	$4,629.60

clotrimazole Top 1% Crm [CQCH]

Facility

$3.48

Service Code	NDC 68462018117
Hospital Charge Code	105917130
Hospital Revenue Code	251
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$3.13
Rate for Payer: Aetna of AZ Commercial	$3.13
Rate for Payer: Bisbee Police All Plans	$0.90
Rate for Payer: Cash Price	$2.78
Rate for Payer: Self Pay Self Pay	$2.78

clotrimazole Top 1% Crm [CQCH]

Facility

$3.48

Service Code	NDC 68462018117
Hospital Charge Code	105917130
Hospital Revenue Code	251
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$3.13
Rate for Payer: Aetna of AZ Commercial	$3.13
Rate for Payer: Aetna of AZ Medicare	$0.97
Rate for Payer: Allwell Medicare	$0.52
Rate for Payer: Amerigroup Medicare	$0.52
Rate for Payer: APIPA Medicare/Medicaid	$1.30
Rate for Payer: AZCH Complete Medicare	$0.52
Rate for Payer: Banner UC Health Medicare	$0.52
Rate for Payer: Bisbee Police All Plans	$0.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2.37
Rate for Payer: Cash Price	$2.78
Rate for Payer: Cigna of AZ Commercial	$2.26
Rate for Payer: Copperpoint Commercial	$0.86
Rate for Payer: Health Net of AZ Commercial	$2.09
Rate for Payer: Health Net of AZ Medicare	$0.97
Rate for Payer: Humana of AZ Medicare	$0.52
Rate for Payer: Self Pay Self Pay	$2.78
Rate for Payer: TriWest Medicare	$0.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.63

CLOTTING; FACTOR VIII (AHG), ONE STAGE

Facility

$146.00

Service Code	CPT 85240
Hospital Charge Code	23090940
Hospital Revenue Code	301
Min. Negotiated Rate	$37.96
Max. Negotiated Rate	$131.40
Rate for Payer: Aetna of AZ Commercial	$131.40
Rate for Payer: Bisbee Police All Plans	$37.96
Rate for Payer: Cash Price	$116.80
Rate for Payer: Self Pay Self Pay	$116.80

CLOTTING; FACTOR VIII (AHG), ONE STAGE

Facility

$146.00

Service Code	CPT 85240
Hospital Charge Code	23090940
Hospital Revenue Code	301
Min. Negotiated Rate	$17.90
Max. Negotiated Rate	$131.40
Rate for Payer: Aetna of AZ Commercial	$131.40
Rate for Payer: Aetna of AZ Medicare	$40.88
Rate for Payer: AHCCCS Medicaid	$17.90
Rate for Payer: Allwell Medicaid	$17.90
Rate for Payer: Allwell Medicare	$21.90
Rate for Payer: Amerigroup Medicare	$21.90
Rate for Payer: APIPA Medicare/Medicaid	$54.53
Rate for Payer: AZCH Complete Medicaid	$17.90
Rate for Payer: AZCH Complete Medicare	$21.90
Rate for Payer: Banner UC Health Medicaid	$17.90
Rate for Payer: Banner UC Health Medicare	$21.90
Rate for Payer: Bisbee Police All Plans	$37.96
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$99.28
Rate for Payer: Cash Price	$116.80
Rate for Payer: Cash Price	$116.80
Rate for Payer: Cigna of AZ Commercial	$94.90
Rate for Payer: Copperpoint Commercial	$36.14
Rate for Payer: Health Net of AZ Commercial	$87.60
Rate for Payer: Health Net of AZ Medicare	$40.88
Rate for Payer: Humana of AZ Medicare	$21.90
Rate for Payer: Mercy Care Medicaid	$17.90
Rate for Payer: Self Pay Self Pay	$116.80
Rate for Payer: TriWest Medicare	$21.90
Rate for Payer: UnitedHealth Group of AZ Commercial	$85.12
Rate for Payer: UnitedHealth Group of AZ Medicare	$26.28

Clozapine LC

Facility

$259.00

Service Code	CPT 80159
Hospital Charge Code	2669527
Hospital Revenue Code	301
Min. Negotiated Rate	$20.15
Max. Negotiated Rate	$233.10
Rate for Payer: Aetna of AZ Commercial	$233.10
Rate for Payer: Aetna of AZ Medicare	$72.52
Rate for Payer: AHCCCS Medicaid	$20.15
Rate for Payer: Allwell Medicaid	$20.15
Rate for Payer: Allwell Medicare	$38.85
Rate for Payer: Amerigroup Medicare	$38.85
Rate for Payer: APIPA Medicare/Medicaid	$96.74
Rate for Payer: AZCH Complete Medicaid	$20.15
Rate for Payer: AZCH Complete Medicare	$38.85
Rate for Payer: Banner UC Health Medicaid	$20.15
Rate for Payer: Banner UC Health Medicare	$38.85
Rate for Payer: Bisbee Police All Plans	$67.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$176.12
Rate for Payer: Cash Price	$207.20
Rate for Payer: Cash Price	$207.20
Rate for Payer: Cigna of AZ Commercial	$168.35
Rate for Payer: Copperpoint Commercial	$64.10
Rate for Payer: Health Net of AZ Commercial	$155.40
Rate for Payer: Health Net of AZ Medicare	$72.52
Rate for Payer: Humana of AZ Medicare	$38.85
Rate for Payer: Mercy Care Medicaid	$20.15
Rate for Payer: Self Pay Self Pay	$207.20
Rate for Payer: TriWest Medicare	$38.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$151.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$46.62

Clozapine LC

Facility

$259.00

Service Code	CPT 80159
Hospital Charge Code	2669527
Hospital Revenue Code	301
Min. Negotiated Rate	$67.34
Max. Negotiated Rate	$233.10
Rate for Payer: Aetna of AZ Commercial	$233.10
Rate for Payer: Bisbee Police All Plans	$67.34
Rate for Payer: Cash Price	$207.20
Rate for Payer: Self Pay Self Pay	$207.20

CMV PCR LC

Facility

$736.00

Service Code	CPT 87496
Hospital Charge Code	2087573
Hospital Revenue Code	301
Min. Negotiated Rate	$191.36
Max. Negotiated Rate	$662.40
Rate for Payer: Aetna of AZ Commercial	$662.40
Rate for Payer: Bisbee Police All Plans	$191.36
Rate for Payer: Cash Price	$588.80
Rate for Payer: Self Pay Self Pay	$588.80

CMV PCR LC

Facility

$736.00

Service Code	CPT 87496
Hospital Charge Code	2087573
Hospital Revenue Code	301
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$662.40
Rate for Payer: Aetna of AZ Commercial	$662.40
Rate for Payer: Aetna of AZ Medicare	$206.08
Rate for Payer: AHCCCS Medicaid	$35.09
Rate for Payer: Allwell Medicaid	$35.09
Rate for Payer: Allwell Medicare	$110.40
Rate for Payer: Amerigroup Medicare	$110.40
Rate for Payer: APIPA Medicare/Medicaid	$274.90
Rate for Payer: AZCH Complete Medicaid	$35.09
Rate for Payer: AZCH Complete Medicare	$110.40
Rate for Payer: Banner UC Health Medicaid	$35.09
Rate for Payer: Banner UC Health Medicare	$110.40
Rate for Payer: Bisbee Police All Plans	$191.36
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$500.48
Rate for Payer: Cash Price	$588.80
Rate for Payer: Cash Price	$588.80
Rate for Payer: Cigna of AZ Commercial	$478.40
Rate for Payer: Copperpoint Commercial	$182.16
Rate for Payer: Health Net of AZ Commercial	$441.60
Rate for Payer: Health Net of AZ Medicare	$206.08
Rate for Payer: Humana of AZ Medicare	$110.40
Rate for Payer: Mercy Care Medicaid	$35.09
Rate for Payer: Self Pay Self Pay	$588.80
Rate for Payer: TriWest Medicare	$110.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$429.09
Rate for Payer: UnitedHealth Group of AZ Medicare	$132.48

CMV Quant DNA PCR (Plasma) LC

Facility

$336.00

Service Code	CPT 87497
Hospital Charge Code	2029097
Hospital Revenue Code	300
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$302.40
Rate for Payer: Aetna of AZ Commercial	$302.40
Rate for Payer: Aetna of AZ Medicare	$94.08
Rate for Payer: AHCCCS Medicaid	$42.84
Rate for Payer: Allwell Medicaid	$42.84
Rate for Payer: Allwell Medicare	$50.40
Rate for Payer: Amerigroup Medicare	$50.40
Rate for Payer: APIPA Medicare/Medicaid	$125.50
Rate for Payer: AZCH Complete Medicaid	$42.84
Rate for Payer: AZCH Complete Medicare	$50.40
Rate for Payer: Banner UC Health Medicaid	$42.84
Rate for Payer: Banner UC Health Medicare	$50.40
Rate for Payer: Bisbee Police All Plans	$87.36
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$228.48
Rate for Payer: Cash Price	$268.80
Rate for Payer: Cash Price	$268.80
Rate for Payer: Cigna of AZ Commercial	$218.40
Rate for Payer: Copperpoint Commercial	$83.16
Rate for Payer: Health Net of AZ Commercial	$201.60
Rate for Payer: Health Net of AZ Medicare	$94.08
Rate for Payer: Humana of AZ Medicare	$50.40
Rate for Payer: Mercy Care Medicaid	$42.84
Rate for Payer: Self Pay Self Pay	$268.80
Rate for Payer: TriWest Medicare	$50.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$195.89
Rate for Payer: UnitedHealth Group of AZ Medicare	$60.48

CMV Quant DNA PCR (Plasma) LC

Facility

$336.00

Service Code	CPT 87497
Hospital Charge Code	2029097
Hospital Revenue Code	300
Min. Negotiated Rate	$87.36
Max. Negotiated Rate	$302.40
Rate for Payer: Aetna of AZ Commercial	$302.40
Rate for Payer: Bisbee Police All Plans	$87.36
Rate for Payer: Cash Price	$268.80
Rate for Payer: Self Pay Self Pay	$268.80

Know your out-of-pocket cost for care.

All Charges