Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

COLONOSCOPY W POLYPECT

Facility

$1,734.00

Hospital Charge Code	1296770
Hospital Revenue Code	750
Min. Negotiated Rate	$260.10
Max. Negotiated Rate	$1,560.60
Rate for Payer: Aetna of AZ Commercial	$1,560.60
Rate for Payer: Aetna of AZ Medicare	$485.52
Rate for Payer: Allwell Medicare	$260.10
Rate for Payer: Amerigroup Medicare	$260.10
Rate for Payer: APIPA Medicare/Medicaid	$647.65
Rate for Payer: AZCH Complete Medicare	$260.10
Rate for Payer: Banner UC Health Medicare	$260.10
Rate for Payer: Bisbee Police All Plans	$450.84
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,179.12
Rate for Payer: Cash Price	$1,387.20
Rate for Payer: Cigna of AZ Commercial	$1,213.80
Rate for Payer: Copperpoint Commercial	$429.16
Rate for Payer: Health Net of AZ Commercial	$1,040.40
Rate for Payer: Health Net of AZ Medicare	$485.52
Rate for Payer: Humana of AZ Medicare	$260.10
Rate for Payer: Self Pay Self Pay	$1,387.20
Rate for Payer: TriWest Medicare	$260.10
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,010.92
Rate for Payer: UnitedHealth Group of AZ Medicare	$312.12

COLONOSCOPY W POLYPECT

Facility

$1,734.00

Hospital Charge Code	1296770
Hospital Revenue Code	750
Min. Negotiated Rate	$450.84
Max. Negotiated Rate	$1,560.60
Rate for Payer: Aetna of AZ Commercial	$1,560.60
Rate for Payer: Bisbee Police All Plans	$450.84
Rate for Payer: Cash Price	$1,387.20
Rate for Payer: Self Pay Self Pay	$1,387.20

COLONOSCOPY W POLYPECT ADD ON CHARGE

Facility

$226.00

Hospital Charge Code	22331687
Hospital Revenue Code	750
Min. Negotiated Rate	$58.76
Max. Negotiated Rate	$203.40
Rate for Payer: Aetna of AZ Commercial	$203.40
Rate for Payer: Bisbee Police All Plans	$58.76
Rate for Payer: Cash Price	$180.80
Rate for Payer: Self Pay Self Pay	$180.80

COLONOSCOPY W POLYPECT ADD ON CHARGE

Facility

$226.00

Hospital Charge Code	22331687
Hospital Revenue Code	750
Min. Negotiated Rate	$33.90
Max. Negotiated Rate	$203.40
Rate for Payer: Aetna of AZ Commercial	$203.40
Rate for Payer: Aetna of AZ Medicare	$63.28
Rate for Payer: Allwell Medicare	$33.90
Rate for Payer: Amerigroup Medicare	$33.90
Rate for Payer: APIPA Medicare/Medicaid	$84.41
Rate for Payer: AZCH Complete Medicare	$33.90
Rate for Payer: Banner UC Health Medicare	$33.90
Rate for Payer: Bisbee Police All Plans	$58.76
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$153.68
Rate for Payer: Cash Price	$180.80
Rate for Payer: Cigna of AZ Commercial	$158.20
Rate for Payer: Copperpoint Commercial	$55.94
Rate for Payer: Health Net of AZ Commercial	$135.60
Rate for Payer: Health Net of AZ Medicare	$63.28
Rate for Payer: Humana of AZ Medicare	$33.90
Rate for Payer: Self Pay Self Pay	$180.80
Rate for Payer: TriWest Medicare	$33.90
Rate for Payer: UnitedHealth Group of AZ Commercial	$131.76
Rate for Payer: UnitedHealth Group of AZ Medicare	$40.68

Colpoclesis

Facility

$2,877.00

Service Code	CPT 57120
Hospital Charge Code	27267824
Hospital Revenue Code	360
Min. Negotiated Rate	$431.55
Max. Negotiated Rate	$6,393.84
Rate for Payer: Aetna of AZ Commercial	$2,589.30
Rate for Payer: Aetna of AZ Medicare	$805.56
Rate for Payer: AHCCCS Medicaid	$6,393.84
Rate for Payer: Allwell Medicaid	$6,393.84
Rate for Payer: Allwell Medicare	$431.55
Rate for Payer: Amerigroup Medicare	$431.55
Rate for Payer: APIPA Medicare/Medicaid	$1,074.56
Rate for Payer: AZCH Complete Medicaid	$6,393.84
Rate for Payer: AZCH Complete Medicare	$431.55
Rate for Payer: Banner UC Health Medicaid	$6,393.84
Rate for Payer: Banner UC Health Medicare	$431.55
Rate for Payer: Bisbee Police All Plans	$748.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,956.36
Rate for Payer: Cash Price	$2,301.60
Rate for Payer: Cash Price	$2,301.60
Rate for Payer: Cigna of AZ Commercial	$1,438.50
Rate for Payer: Copperpoint Commercial	$712.06
Rate for Payer: Health Net of AZ Commercial	$1,726.20
Rate for Payer: Health Net of AZ Medicare	$805.56
Rate for Payer: Humana of AZ Medicare	$431.55
Rate for Payer: Mercy Care Medicaid	$6,393.84
Rate for Payer: Self Pay Self Pay	$2,301.60
Rate for Payer: TriWest Medicare	$431.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,914.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$517.86

Colpoclesis

Facility

$2,877.00

Service Code	CPT 57120
Hospital Charge Code	27267824
Hospital Revenue Code	360
Min. Negotiated Rate	$748.02
Max. Negotiated Rate	$2,589.30
Rate for Payer: Aetna of AZ Commercial	$2,589.30
Rate for Payer: Bisbee Police All Plans	$748.02
Rate for Payer: Cash Price	$2,301.60
Rate for Payer: Self Pay Self Pay	$2,301.60

Colpoperineorrhaphy

Facility

$2,126.00

Service Code	CPT 57210
Hospital Charge Code	27267808
Hospital Revenue Code	360
Min. Negotiated Rate	$318.90
Max. Negotiated Rate	$3,803.66
Rate for Payer: Aetna of AZ Commercial	$1,913.40
Rate for Payer: Aetna of AZ Medicare	$595.28
Rate for Payer: AHCCCS Medicaid	$3,803.66
Rate for Payer: Allwell Medicaid	$3,803.66
Rate for Payer: Allwell Medicare	$318.90
Rate for Payer: Amerigroup Medicare	$318.90
Rate for Payer: APIPA Medicare/Medicaid	$794.06
Rate for Payer: AZCH Complete Medicaid	$3,803.66
Rate for Payer: AZCH Complete Medicare	$318.90
Rate for Payer: Banner UC Health Medicaid	$3,803.66
Rate for Payer: Banner UC Health Medicare	$318.90
Rate for Payer: Bisbee Police All Plans	$552.76
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,445.68
Rate for Payer: Cash Price	$1,700.80
Rate for Payer: Cash Price	$1,700.80
Rate for Payer: Cigna of AZ Commercial	$1,063.00
Rate for Payer: Copperpoint Commercial	$526.18
Rate for Payer: Health Net of AZ Commercial	$1,275.60
Rate for Payer: Health Net of AZ Medicare	$595.28
Rate for Payer: Humana of AZ Medicare	$318.90
Rate for Payer: Mercy Care Medicaid	$3,803.66
Rate for Payer: Self Pay Self Pay	$1,700.80
Rate for Payer: TriWest Medicare	$318.90
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,373.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$382.68

Colpoperineorrhaphy

Facility

$2,126.00

Service Code	CPT 57210
Hospital Charge Code	27267808
Hospital Revenue Code	360
Min. Negotiated Rate	$552.76
Max. Negotiated Rate	$1,913.40
Rate for Payer: Aetna of AZ Commercial	$1,913.40
Rate for Payer: Bisbee Police All Plans	$552.76
Rate for Payer: Cash Price	$1,700.80
Rate for Payer: Self Pay Self Pay	$1,700.80

Colpopexy(abdominal sacral uterosacral)

Facility

$5,261.00

Service Code	CPT 57280
Hospital Charge Code	27291792
Hospital Revenue Code	360
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$4,734.90
Rate for Payer: Aetna of AZ Commercial	$4,734.90
Rate for Payer: Aetna of AZ Medicare	$1,473.08
Rate for Payer: AHCCCS Medicaid	$0.13
Rate for Payer: Allwell Medicaid	$0.13
Rate for Payer: Allwell Medicare	$789.15
Rate for Payer: Amerigroup Medicare	$789.15
Rate for Payer: APIPA Medicare/Medicaid	$1,964.98
Rate for Payer: AZCH Complete Medicaid	$0.13
Rate for Payer: AZCH Complete Medicare	$789.15
Rate for Payer: Banner UC Health Medicaid	$0.13
Rate for Payer: Banner UC Health Medicare	$789.15
Rate for Payer: Bisbee Police All Plans	$1,367.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,577.48
Rate for Payer: Cash Price	$4,208.80
Rate for Payer: Cash Price	$4,208.80
Rate for Payer: Cigna of AZ Commercial	$2,630.50
Rate for Payer: Copperpoint Commercial	$1,302.10
Rate for Payer: Health Net of AZ Commercial	$3,156.60
Rate for Payer: Health Net of AZ Medicare	$1,473.08
Rate for Payer: Humana of AZ Medicare	$789.15
Rate for Payer: Mercy Care Medicaid	$0.13
Rate for Payer: Self Pay Self Pay	$4,208.80
Rate for Payer: TriWest Medicare	$789.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,373.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$946.98

Colpopexy(abdominal sacral uterosacral)

Facility

$5,261.00

Service Code	CPT 57280
Hospital Charge Code	27291792
Hospital Revenue Code	360
Min. Negotiated Rate	$1,367.86
Max. Negotiated Rate	$4,734.90
Rate for Payer: Aetna of AZ Commercial	$4,734.90
Rate for Payer: Bisbee Police All Plans	$1,367.86
Rate for Payer: Cash Price	$4,208.80
Rate for Payer: Self Pay Self Pay	$4,208.80

Colporrhaphy(repair injury site)

Facility

$1,780.00

Service Code	CPT 57200
Hospital Charge Code	27267807
Hospital Revenue Code	360
Min. Negotiated Rate	$462.80
Max. Negotiated Rate	$1,602.00
Rate for Payer: Aetna of AZ Commercial	$1,602.00
Rate for Payer: Bisbee Police All Plans	$462.80
Rate for Payer: Cash Price	$1,424.00
Rate for Payer: Self Pay Self Pay	$1,424.00

Colporrhaphy(repair injury site)

Facility

$1,780.00

Service Code	CPT 57200
Hospital Charge Code	27267807
Hospital Revenue Code	360
Min. Negotiated Rate	$267.00
Max. Negotiated Rate	$3,803.66
Rate for Payer: Aetna of AZ Commercial	$1,602.00
Rate for Payer: Aetna of AZ Medicare	$498.40
Rate for Payer: AHCCCS Medicaid	$3,803.66
Rate for Payer: Allwell Medicaid	$3,803.66
Rate for Payer: Allwell Medicare	$267.00
Rate for Payer: Amerigroup Medicare	$267.00
Rate for Payer: APIPA Medicare/Medicaid	$664.83
Rate for Payer: AZCH Complete Medicaid	$3,803.66
Rate for Payer: AZCH Complete Medicare	$267.00
Rate for Payer: Banner UC Health Medicaid	$3,803.66
Rate for Payer: Banner UC Health Medicare	$267.00
Rate for Payer: Bisbee Police All Plans	$462.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,210.40
Rate for Payer: Cash Price	$1,424.00
Rate for Payer: Cash Price	$1,424.00
Rate for Payer: Cigna of AZ Commercial	$890.00
Rate for Payer: Copperpoint Commercial	$440.55
Rate for Payer: Health Net of AZ Commercial	$1,068.00
Rate for Payer: Health Net of AZ Medicare	$498.40
Rate for Payer: Humana of AZ Medicare	$267.00
Rate for Payer: Mercy Care Medicaid	$3,803.66
Rate for Payer: Self Pay Self Pay	$1,424.00
Rate for Payer: TriWest Medicare	$267.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,373.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$320.40

Colposcopy of the cervix incuding upper/adjacent vagina

Facility

$693.00

Service Code	CPT 57452
Hospital Charge Code	22664756
Hospital Revenue Code	360
Min. Negotiated Rate	$103.95
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$623.70
Rate for Payer: Aetna of AZ Medicare	$194.04
Rate for Payer: AHCCCS Medicaid	$246.96
Rate for Payer: Allwell Medicaid	$246.96
Rate for Payer: Allwell Medicare	$103.95
Rate for Payer: Amerigroup Medicare	$103.95
Rate for Payer: APIPA Medicare/Medicaid	$258.84
Rate for Payer: AZCH Complete Medicaid	$246.96
Rate for Payer: AZCH Complete Medicare	$103.95
Rate for Payer: Banner UC Health Medicaid	$246.96
Rate for Payer: Banner UC Health Medicare	$103.95
Rate for Payer: Bisbee Police All Plans	$180.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$471.24
Rate for Payer: Cash Price	$554.40
Rate for Payer: Cash Price	$554.40
Rate for Payer: Cigna of AZ Commercial	$346.50
Rate for Payer: Copperpoint Commercial	$171.52
Rate for Payer: Health Net of AZ Commercial	$415.80
Rate for Payer: Health Net of AZ Medicare	$194.04
Rate for Payer: Humana of AZ Medicare	$103.95
Rate for Payer: Mercy Care Medicaid	$246.96
Rate for Payer: Self Pay Self Pay	$554.40
Rate for Payer: TriWest Medicare	$103.95
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$124.74

Colposcopy of the cervix incuding upper/adjacent vagina

Facility

$693.00

Service Code	CPT 57452
Hospital Charge Code	22664756
Hospital Revenue Code	360
Min. Negotiated Rate	$180.18
Max. Negotiated Rate	$623.70
Rate for Payer: Aetna of AZ Commercial	$623.70
Rate for Payer: Bisbee Police All Plans	$180.18
Rate for Payer: Cash Price	$554.40
Rate for Payer: Self Pay Self Pay	$554.40

Colposcopy of the cervix incuding upper/adjacent vagina with

Facility

$1,236.00

Service Code	CPT 57454
Hospital Charge Code	22664757
Hospital Revenue Code	360
Min. Negotiated Rate	$185.40
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$1,112.40
Rate for Payer: Aetna of AZ Medicare	$346.08
Rate for Payer: AHCCCS Medicaid	$408.14
Rate for Payer: Allwell Medicaid	$408.14
Rate for Payer: Allwell Medicare	$185.40
Rate for Payer: Amerigroup Medicare	$185.40
Rate for Payer: APIPA Medicare/Medicaid	$461.65
Rate for Payer: AZCH Complete Medicaid	$408.14
Rate for Payer: AZCH Complete Medicare	$185.40
Rate for Payer: Banner UC Health Medicaid	$408.14
Rate for Payer: Banner UC Health Medicare	$185.40
Rate for Payer: Bisbee Police All Plans	$321.36
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$840.48
Rate for Payer: Cash Price	$988.80
Rate for Payer: Cash Price	$988.80
Rate for Payer: Cigna of AZ Commercial	$618.00
Rate for Payer: Copperpoint Commercial	$305.91
Rate for Payer: Health Net of AZ Commercial	$741.60
Rate for Payer: Health Net of AZ Medicare	$346.08
Rate for Payer: Humana of AZ Medicare	$185.40
Rate for Payer: Mercy Care Medicaid	$408.14
Rate for Payer: Self Pay Self Pay	$988.80
Rate for Payer: TriWest Medicare	$185.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$222.48

Colposcopy of the cervix incuding upper/adjacent vagina with

Facility

$1,236.00

Service Code	CPT 57456
Hospital Charge Code	22664759
Hospital Revenue Code	360
Min. Negotiated Rate	$185.40
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$1,112.40
Rate for Payer: Aetna of AZ Medicare	$346.08
Rate for Payer: AHCCCS Medicaid	$408.14
Rate for Payer: Allwell Medicaid	$408.14
Rate for Payer: Allwell Medicare	$185.40
Rate for Payer: Amerigroup Medicare	$185.40
Rate for Payer: APIPA Medicare/Medicaid	$461.65
Rate for Payer: AZCH Complete Medicaid	$408.14
Rate for Payer: AZCH Complete Medicare	$185.40
Rate for Payer: Banner UC Health Medicaid	$408.14
Rate for Payer: Banner UC Health Medicare	$185.40
Rate for Payer: Bisbee Police All Plans	$321.36
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$840.48
Rate for Payer: Cash Price	$988.80
Rate for Payer: Cash Price	$988.80
Rate for Payer: Cigna of AZ Commercial	$618.00
Rate for Payer: Copperpoint Commercial	$305.91
Rate for Payer: Health Net of AZ Commercial	$741.60
Rate for Payer: Health Net of AZ Medicare	$346.08
Rate for Payer: Humana of AZ Medicare	$185.40
Rate for Payer: Mercy Care Medicaid	$408.14
Rate for Payer: Self Pay Self Pay	$988.80
Rate for Payer: TriWest Medicare	$185.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$222.48

Colposcopy of the cervix incuding upper/adjacent vagina with

Facility

$1,236.00

Service Code	CPT 57454
Hospital Charge Code	22664757
Hospital Revenue Code	360
Min. Negotiated Rate	$321.36
Max. Negotiated Rate	$1,112.40
Rate for Payer: Aetna of AZ Commercial	$1,112.40
Rate for Payer: Bisbee Police All Plans	$321.36
Rate for Payer: Cash Price	$988.80
Rate for Payer: Self Pay Self Pay	$988.80

Colposcopy of the cervix incuding upper/adjacent vagina with

Facility

$1,236.00

Service Code	CPT 57455
Hospital Charge Code	22664758
Hospital Revenue Code	750
Min. Negotiated Rate	$321.36
Max. Negotiated Rate	$1,112.40
Rate for Payer: Aetna of AZ Commercial	$1,112.40
Rate for Payer: Bisbee Police All Plans	$321.36
Rate for Payer: Cash Price	$988.80
Rate for Payer: Self Pay Self Pay	$988.80

Colposcopy of the cervix incuding upper/adjacent vagina with

Facility

$1,236.00

Service Code	CPT 57455
Hospital Charge Code	22664758
Hospital Revenue Code	750
Min. Negotiated Rate	$185.40
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$1,112.40
Rate for Payer: Aetna of AZ Medicare	$346.08
Rate for Payer: AHCCCS Medicaid	$408.14
Rate for Payer: Allwell Medicaid	$408.14
Rate for Payer: Allwell Medicare	$185.40
Rate for Payer: Amerigroup Medicare	$185.40
Rate for Payer: APIPA Medicare/Medicaid	$461.65
Rate for Payer: AZCH Complete Medicaid	$408.14
Rate for Payer: AZCH Complete Medicare	$185.40
Rate for Payer: Banner UC Health Medicaid	$408.14
Rate for Payer: Banner UC Health Medicare	$185.40
Rate for Payer: Bisbee Police All Plans	$321.36
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$840.48
Rate for Payer: Cash Price	$988.80
Rate for Payer: Cash Price	$988.80
Rate for Payer: Cigna of AZ Commercial	$865.20
Rate for Payer: Copperpoint Commercial	$305.91
Rate for Payer: Health Net of AZ Commercial	$741.60
Rate for Payer: Health Net of AZ Medicare	$346.08
Rate for Payer: Humana of AZ Medicare	$185.40
Rate for Payer: Mercy Care Medicaid	$408.14
Rate for Payer: Self Pay Self Pay	$988.80
Rate for Payer: TriWest Medicare	$185.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$222.48

Colposcopy of the cervix incuding upper/adjacent vagina with

Facility

$1,236.00

Service Code	CPT 57456
Hospital Charge Code	22664759
Hospital Revenue Code	360
Min. Negotiated Rate	$321.36
Max. Negotiated Rate	$1,112.40
Rate for Payer: Aetna of AZ Commercial	$1,112.40
Rate for Payer: Bisbee Police All Plans	$321.36
Rate for Payer: Cash Price	$988.80
Rate for Payer: Self Pay Self Pay	$988.80

Colposcopy of the entire vagina with cervix with biopsies of

Facility

$3,135.00

Service Code	CPT 57421
Hospital Charge Code	22664755
Hospital Revenue Code	750
Min. Negotiated Rate	$470.25
Max. Negotiated Rate	$2,821.50
Rate for Payer: Aetna of AZ Commercial	$2,821.50
Rate for Payer: Aetna of AZ Medicare	$877.80
Rate for Payer: AHCCCS Medicaid	$918.44
Rate for Payer: Allwell Medicaid	$918.44
Rate for Payer: Allwell Medicare	$470.25
Rate for Payer: Amerigroup Medicare	$470.25
Rate for Payer: APIPA Medicare/Medicaid	$1,170.92
Rate for Payer: AZCH Complete Medicaid	$918.44
Rate for Payer: AZCH Complete Medicare	$470.25
Rate for Payer: Banner UC Health Medicaid	$918.44
Rate for Payer: Banner UC Health Medicare	$470.25
Rate for Payer: Bisbee Police All Plans	$815.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,131.80
Rate for Payer: Cash Price	$2,508.00
Rate for Payer: Cash Price	$2,508.00
Rate for Payer: Cigna of AZ Commercial	$2,194.50
Rate for Payer: Copperpoint Commercial	$775.91
Rate for Payer: Health Net of AZ Commercial	$1,881.00
Rate for Payer: Health Net of AZ Medicare	$877.80
Rate for Payer: Humana of AZ Medicare	$470.25
Rate for Payer: Mercy Care Medicaid	$918.44
Rate for Payer: Self Pay Self Pay	$2,508.00
Rate for Payer: TriWest Medicare	$470.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,507.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$564.30

Colposcopy of the entire vagina with cervix with biopsies of

Facility

$3,135.00

Service Code	CPT 57421
Hospital Charge Code	22664755
Hospital Revenue Code	750
Min. Negotiated Rate	$815.10
Max. Negotiated Rate	$2,821.50
Rate for Payer: Aetna of AZ Commercial	$2,821.50
Rate for Payer: Bisbee Police All Plans	$815.10
Rate for Payer: Cash Price	$2,508.00
Rate for Payer: Self Pay Self Pay	$2,508.00

Complement C3, Serum LC

Facility

$272.00

Service Code	CPT 86160
Hospital Charge Code	1285557
Hospital Revenue Code	302
Min. Negotiated Rate	$70.72
Max. Negotiated Rate	$244.80
Rate for Payer: Aetna of AZ Commercial	$244.80
Rate for Payer: Bisbee Police All Plans	$70.72
Rate for Payer: Cash Price	$217.60
Rate for Payer: Self Pay Self Pay	$217.60

Complement C3, Serum LC

Facility

$272.00

Service Code	CPT 86160
Hospital Charge Code	1285557
Hospital Revenue Code	302
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$244.80
Rate for Payer: Aetna of AZ Commercial	$244.80
Rate for Payer: Aetna of AZ Medicare	$76.16
Rate for Payer: AHCCCS Medicaid	$12.00
Rate for Payer: Allwell Medicaid	$12.00
Rate for Payer: Allwell Medicare	$40.80
Rate for Payer: Amerigroup Medicare	$40.80
Rate for Payer: APIPA Medicare/Medicaid	$101.59
Rate for Payer: AZCH Complete Medicaid	$12.00
Rate for Payer: AZCH Complete Medicare	$40.80
Rate for Payer: Banner UC Health Medicaid	$12.00
Rate for Payer: Banner UC Health Medicare	$40.80
Rate for Payer: Bisbee Police All Plans	$70.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$184.96
Rate for Payer: Cash Price	$217.60
Rate for Payer: Cash Price	$217.60
Rate for Payer: Cigna of AZ Commercial	$176.80
Rate for Payer: Copperpoint Commercial	$67.32
Rate for Payer: Health Net of AZ Commercial	$163.20
Rate for Payer: Health Net of AZ Medicare	$76.16
Rate for Payer: Humana of AZ Medicare	$40.80
Rate for Payer: Mercy Care Medicaid	$12.00
Rate for Payer: Self Pay Self Pay	$217.60
Rate for Payer: TriWest Medicare	$40.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$158.58
Rate for Payer: UnitedHealth Group of AZ Medicare	$48.96

Complement C4, Serum LC

Facility

$272.00

Service Code	CPT 86160
Hospital Charge Code	1285559
Hospital Revenue Code	302
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$244.80
Rate for Payer: Aetna of AZ Commercial	$244.80
Rate for Payer: Aetna of AZ Medicare	$76.16
Rate for Payer: AHCCCS Medicaid	$12.00
Rate for Payer: Allwell Medicaid	$12.00
Rate for Payer: Allwell Medicare	$40.80
Rate for Payer: Amerigroup Medicare	$40.80
Rate for Payer: APIPA Medicare/Medicaid	$101.59
Rate for Payer: AZCH Complete Medicaid	$12.00
Rate for Payer: AZCH Complete Medicare	$40.80
Rate for Payer: Banner UC Health Medicaid	$12.00
Rate for Payer: Banner UC Health Medicare	$40.80
Rate for Payer: Bisbee Police All Plans	$70.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$184.96
Rate for Payer: Cash Price	$217.60
Rate for Payer: Cash Price	$217.60
Rate for Payer: Cigna of AZ Commercial	$176.80
Rate for Payer: Copperpoint Commercial	$67.32
Rate for Payer: Health Net of AZ Commercial	$163.20
Rate for Payer: Health Net of AZ Medicare	$76.16
Rate for Payer: Humana of AZ Medicare	$40.80
Rate for Payer: Mercy Care Medicaid	$12.00
Rate for Payer: Self Pay Self Pay	$217.60
Rate for Payer: TriWest Medicare	$40.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$158.58
Rate for Payer: UnitedHealth Group of AZ Medicare	$48.96

Know your out-of-pocket cost for care.

All Charges