Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

GC ANTIBODY

Facility

$353.00

Service Code	CPT 86609
Hospital Charge Code	23092679
Hospital Revenue Code	302
Min. Negotiated Rate	$91.78
Max. Negotiated Rate	$317.70
Rate for Payer: Aetna of AZ Commercial	$317.70
Rate for Payer: Bisbee Police All Plans	$91.78
Rate for Payer: Cash Price	$282.40
Rate for Payer: Self Pay Self Pay	$282.40

GC ANTIBODY

Facility

$353.00

Service Code	CPT 86609
Hospital Charge Code	23092679
Hospital Revenue Code	302
Min. Negotiated Rate	$56.48
Max. Negotiated Rate	$317.70
Rate for Payer: Aetna of AZ Commercial	$317.70
Rate for Payer: Aetna of AZ Medicare	$98.84
Rate for Payer: Allwell Medicare	$56.48
Rate for Payer: Amerigroup Medicare	$56.48
Rate for Payer: APIPA Medicare/Medicaid	$131.85
Rate for Payer: AZCH Complete Medicare	$56.48
Rate for Payer: Banner UC Health Medicare	$56.48
Rate for Payer: Bisbee Police All Plans	$91.78
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$240.04
Rate for Payer: Cash Price	$282.40
Rate for Payer: Cigna of AZ Commercial	$229.45
Rate for Payer: Copperpoint Commercial	$87.37
Rate for Payer: Health Net of AZ Commercial	$211.80
Rate for Payer: Health Net of AZ Medicare	$98.84
Rate for Payer: Humana of AZ Medicare	$56.48
Rate for Payer: Self Pay Self Pay	$282.40
Rate for Payer: TriWest Medicare	$56.48
Rate for Payer: UnitedHealth Group of AZ Commercial	$205.80
Rate for Payer: UnitedHealth Group of AZ Medicare	$63.54

gemfibrozil 600 mg Tab [CQCH]

Facility

$0.19

Service Code	NDC 60687022401
Hospital Charge Code	105923934
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of AZ Commercial	$0.17
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	$0.07
Rate for Payer: AZCH Complete Medicare	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Bisbee Police All Plans	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.13
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of AZ Commercial	$0.12
Rate for Payer: Copperpoint Commercial	$0.05
Rate for Payer: Health Net of AZ Commercial	$0.11
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	$0.15
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.11
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.03

gemfibrozil 600 mg Tab [CQCH]

Facility

$0.19

Service Code	NDC 60687022401
Hospital Charge Code	105923934
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of AZ Commercial	$0.17
Rate for Payer: Bisbee Police All Plans	$0.05
Rate for Payer: Cash Price	$0.15
Rate for Payer: Self Pay Self Pay	$0.15

GENE ANALYSIS (BREAST CANCER 1 AND 2) FULL SEQUENCE AND DUPL

Facility

$2,470.00

Service Code	CPT 81162
Hospital Charge Code	24077031
Hospital Revenue Code	301
Min. Negotiated Rate	$395.20
Max. Negotiated Rate	$2,223.00
Rate for Payer: Aetna of AZ Commercial	$2,223.00
Rate for Payer: Aetna of AZ Medicare	$691.60
Rate for Payer: Allwell Medicare	$395.20
Rate for Payer: Amerigroup Medicare	$395.20
Rate for Payer: APIPA Medicare/Medicaid	$922.54
Rate for Payer: AZCH Complete Medicare	$395.20
Rate for Payer: Banner UC Health Medicare	$395.20
Rate for Payer: Bisbee Police All Plans	$642.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,679.60
Rate for Payer: Cash Price	$1,976.00
Rate for Payer: Cigna of AZ Commercial	$1,605.50
Rate for Payer: Copperpoint Commercial	$611.33
Rate for Payer: Health Net of AZ Commercial	$1,482.00
Rate for Payer: Health Net of AZ Medicare	$691.60
Rate for Payer: Humana of AZ Medicare	$395.20
Rate for Payer: Self Pay Self Pay	$1,976.00
Rate for Payer: TriWest Medicare	$395.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,440.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$444.60

GENE ANALYSIS (BREAST CANCER 1 AND 2) FULL SEQUENCE AND DUPL

Facility

$2,470.00

Service Code	CPT 81162
Hospital Charge Code	24077031
Hospital Revenue Code	301
Min. Negotiated Rate	$642.20
Max. Negotiated Rate	$2,223.00
Rate for Payer: Aetna of AZ Commercial	$2,223.00
Rate for Payer: Bisbee Police All Plans	$642.20
Rate for Payer: Cash Price	$1,976.00
Rate for Payer: Self Pay Self Pay	$1,976.00

GENE ANALYSIS (CALRETICULIN), COMMON VARIANTS

Facility

$608.00

Service Code	CPT 81219
Hospital Charge Code	28010049
Hospital Revenue Code	302
Min. Negotiated Rate	$97.28
Max. Negotiated Rate	$547.20
Rate for Payer: Aetna of AZ Commercial	$547.20
Rate for Payer: Aetna of AZ Medicare	$170.24
Rate for Payer: Allwell Medicare	$97.28
Rate for Payer: Amerigroup Medicare	$97.28
Rate for Payer: APIPA Medicare/Medicaid	$227.09
Rate for Payer: AZCH Complete Medicare	$97.28
Rate for Payer: Banner UC Health Medicare	$97.28
Rate for Payer: Bisbee Police All Plans	$158.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$413.44
Rate for Payer: Cash Price	$486.40
Rate for Payer: Cigna of AZ Commercial	$395.20
Rate for Payer: Copperpoint Commercial	$150.48
Rate for Payer: Health Net of AZ Commercial	$364.80
Rate for Payer: Health Net of AZ Medicare	$170.24
Rate for Payer: Humana of AZ Medicare	$97.28
Rate for Payer: Self Pay Self Pay	$486.40
Rate for Payer: TriWest Medicare	$97.28
Rate for Payer: UnitedHealth Group of AZ Commercial	$354.46
Rate for Payer: UnitedHealth Group of AZ Medicare	$109.44

GENE ANALYSIS (CALRETICULIN), COMMON VARIANTS

Facility

$608.00

Service Code	CPT 81219
Hospital Charge Code	28010049
Hospital Revenue Code	302
Min. Negotiated Rate	$158.08
Max. Negotiated Rate	$547.20
Rate for Payer: Aetna of AZ Commercial	$547.20
Rate for Payer: Bisbee Police All Plans	$158.08
Rate for Payer: Cash Price	$486.40
Rate for Payer: Self Pay Self Pay	$486.40

General Lab

Facility

$120.00

Service Code	CPT 89300
Hospital Charge Code	22334780
Hospital Revenue Code	309
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Aetna of AZ Medicare	$33.60
Rate for Payer: Allwell Medicare	$19.20
Rate for Payer: Amerigroup Medicare	$19.20
Rate for Payer: APIPA Medicare/Medicaid	$44.82
Rate for Payer: AZCH Complete Medicare	$19.20
Rate for Payer: Banner UC Health Medicare	$19.20
Rate for Payer: Bisbee Police All Plans	$31.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$81.60
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cigna of AZ Commercial	$78.00
Rate for Payer: Copperpoint Commercial	$29.70
Rate for Payer: Health Net of AZ Commercial	$72.00
Rate for Payer: Health Net of AZ Medicare	$33.60
Rate for Payer: Humana of AZ Medicare	$19.20
Rate for Payer: Self Pay Self Pay	$96.00
Rate for Payer: TriWest Medicare	$19.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$69.96
Rate for Payer: UnitedHealth Group of AZ Medicare	$21.60

General Lab

Facility

$201.00

Service Code	CPT 82105
Hospital Charge Code	1902313
Hospital Revenue Code	301
Min. Negotiated Rate	$52.26
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of AZ Commercial	$180.90
Rate for Payer: Bisbee Police All Plans	$52.26
Rate for Payer: Cash Price	$160.80
Rate for Payer: Self Pay Self Pay	$160.80

General Lab

Facility

$37.00

Service Code	CPT 87220
Hospital Charge Code	22031562
Hospital Revenue Code	301
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Bisbee Police All Plans	$9.62
Rate for Payer: Cash Price	$29.60
Rate for Payer: Self Pay Self Pay	$29.60

General Lab

Facility

$37.00

Service Code	CPT 87220
Hospital Charge Code	22031562
Hospital Revenue Code	301
Min. Negotiated Rate	$5.92
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Aetna of AZ Medicare	$10.36
Rate for Payer: Allwell Medicare	$5.92
Rate for Payer: Amerigroup Medicare	$5.92
Rate for Payer: APIPA Medicare/Medicaid	$13.82
Rate for Payer: AZCH Complete Medicare	$5.92
Rate for Payer: Banner UC Health Medicare	$5.92
Rate for Payer: Bisbee Police All Plans	$9.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$25.16
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cigna of AZ Commercial	$24.05
Rate for Payer: Copperpoint Commercial	$9.16
Rate for Payer: Health Net of AZ Commercial	$22.20
Rate for Payer: Health Net of AZ Medicare	$10.36
Rate for Payer: Humana of AZ Medicare	$5.92
Rate for Payer: Self Pay Self Pay	$29.60
Rate for Payer: TriWest Medicare	$5.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$21.57
Rate for Payer: UnitedHealth Group of AZ Medicare	$6.66

General Lab

Facility

$201.00

Service Code	CPT 82105
Hospital Charge Code	1902313
Hospital Revenue Code	301
Min. Negotiated Rate	$32.16
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of AZ Commercial	$180.90
Rate for Payer: Aetna of AZ Medicare	$56.28
Rate for Payer: Allwell Medicare	$32.16
Rate for Payer: Amerigroup Medicare	$32.16
Rate for Payer: APIPA Medicare/Medicaid	$75.07
Rate for Payer: AZCH Complete Medicare	$32.16
Rate for Payer: Banner UC Health Medicare	$32.16
Rate for Payer: Bisbee Police All Plans	$52.26
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$136.68
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cigna of AZ Commercial	$130.65
Rate for Payer: Copperpoint Commercial	$49.75
Rate for Payer: Health Net of AZ Commercial	$120.60
Rate for Payer: Health Net of AZ Medicare	$56.28
Rate for Payer: Humana of AZ Medicare	$32.16
Rate for Payer: Self Pay Self Pay	$160.80
Rate for Payer: TriWest Medicare	$32.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$117.18
Rate for Payer: UnitedHealth Group of AZ Medicare	$36.18

General Lab

Facility

$120.00

Service Code	CPT 89300
Hospital Charge Code	22334780
Hospital Revenue Code	309
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Bisbee Police All Plans	$31.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Self Pay Self Pay	$96.00

Genital Culture

Facility

$121.00

Service Code	CPT 87081
Hospital Charge Code	633894
Hospital Revenue Code	306
Min. Negotiated Rate	$31.46
Max. Negotiated Rate	$108.90
Rate for Payer: Aetna of AZ Commercial	$108.90
Rate for Payer: Bisbee Police All Plans	$31.46
Rate for Payer: Cash Price	$96.80
Rate for Payer: Self Pay Self Pay	$96.80

Genital Culture

Facility

$121.00

Service Code	CPT 87081
Hospital Charge Code	633894
Hospital Revenue Code	306
Min. Negotiated Rate	$19.36
Max. Negotiated Rate	$108.90
Rate for Payer: Aetna of AZ Commercial	$108.90
Rate for Payer: Aetna of AZ Medicare	$33.88
Rate for Payer: Allwell Medicare	$19.36
Rate for Payer: Amerigroup Medicare	$19.36
Rate for Payer: APIPA Medicare/Medicaid	$45.19
Rate for Payer: AZCH Complete Medicare	$19.36
Rate for Payer: Banner UC Health Medicare	$19.36
Rate for Payer: Bisbee Police All Plans	$31.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$82.28
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cigna of AZ Commercial	$78.65
Rate for Payer: Copperpoint Commercial	$29.95
Rate for Payer: Health Net of AZ Commercial	$72.60
Rate for Payer: Health Net of AZ Medicare	$33.88
Rate for Payer: Humana of AZ Medicare	$19.36
Rate for Payer: Self Pay Self Pay	$96.80
Rate for Payer: TriWest Medicare	$19.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$70.54
Rate for Payer: UnitedHealth Group of AZ Medicare	$21.78

GenoSure(R) MG LC

Facility

$1,502.00

Service Code	CPT 87901
Hospital Charge Code	22311193
Hospital Revenue Code	306
Min. Negotiated Rate	$390.52
Max. Negotiated Rate	$1,351.80
Rate for Payer: Aetna of AZ Commercial	$1,351.80
Rate for Payer: Bisbee Police All Plans	$390.52
Rate for Payer: Cash Price	$1,201.60
Rate for Payer: Self Pay Self Pay	$1,201.60

GenoSure(R) MG LC

Facility

$1,502.00

Service Code	CPT 87901
Hospital Charge Code	22311193
Hospital Revenue Code	306
Min. Negotiated Rate	$240.32
Max. Negotiated Rate	$1,351.80
Rate for Payer: Aetna of AZ Commercial	$1,351.80
Rate for Payer: Aetna of AZ Medicare	$420.56
Rate for Payer: Allwell Medicare	$240.32
Rate for Payer: Amerigroup Medicare	$240.32
Rate for Payer: APIPA Medicare/Medicaid	$561.00
Rate for Payer: AZCH Complete Medicare	$240.32
Rate for Payer: Banner UC Health Medicare	$240.32
Rate for Payer: Bisbee Police All Plans	$390.52
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,021.36
Rate for Payer: Cash Price	$1,201.60
Rate for Payer: Cigna of AZ Commercial	$976.30
Rate for Payer: Copperpoint Commercial	$371.75
Rate for Payer: Health Net of AZ Commercial	$901.20
Rate for Payer: Health Net of AZ Medicare	$420.56
Rate for Payer: Humana of AZ Medicare	$240.32
Rate for Payer: Self Pay Self Pay	$1,201.60
Rate for Payer: TriWest Medicare	$240.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$875.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$270.36

gentamicin 40 mg/mL Inj Sol 20 mL [CQCH]

Facility

$0.84

Service Code	HCPCS J1580
Hospital Charge Code	105924007
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.76
Rate for Payer: Aetna of AZ Commercial	$0.76
Rate for Payer: Aetna of AZ Medicare	$0.24
Rate for Payer: Allwell Medicare	$0.13
Rate for Payer: Amerigroup Medicare	$0.13
Rate for Payer: APIPA Medicare/Medicaid	$0.31
Rate for Payer: AZCH Complete Medicare	$0.13
Rate for Payer: Banner UC Health Medicare	$0.13
Rate for Payer: Bisbee Police All Plans	$0.22
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.57
Rate for Payer: Cash Price	$0.67
Rate for Payer: Cigna of AZ Commercial	$0.55
Rate for Payer: Copperpoint Commercial	$0.21
Rate for Payer: Health Net of AZ Commercial	$0.50
Rate for Payer: Health Net of AZ Medicare	$0.24
Rate for Payer: Humana of AZ Medicare	$0.13
Rate for Payer: Self Pay Self Pay	$0.67
Rate for Payer: TriWest Medicare	$0.13
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.49
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.15

gentamicin 40 mg/mL Inj Sol 20 mL [CQCH]

Facility

$0.84

Service Code	HCPCS J1580
Hospital Charge Code	105924007
Hospital Revenue Code	250
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.76
Rate for Payer: Aetna of AZ Commercial	$0.76
Rate for Payer: Bisbee Police All Plans	$0.22
Rate for Payer: Cash Price	$0.67
Rate for Payer: Self Pay Self Pay	$0.67

gentamicin 80 mg/ 2mL Sol [CQCH]

Facility

$0.30

Service Code	HCPCS J1580
Hospital Charge Code	107743160
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of AZ Commercial	$0.27
Rate for Payer: Bisbee Police All Plans	$0.08
Rate for Payer: Cash Price	$0.24
Rate for Payer: Self Pay Self Pay	$0.24

gentamicin 80 mg/ 2mL Sol [CQCH]

Facility

$0.30

Service Code	HCPCS J1580
Hospital Charge Code	107743160
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of AZ Commercial	$0.27
Rate for Payer: Aetna of AZ Medicare	$0.08
Rate for Payer: Allwell Medicare	$0.05
Rate for Payer: Amerigroup Medicare	$0.05
Rate for Payer: APIPA Medicare/Medicaid	$0.11
Rate for Payer: AZCH Complete Medicare	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
Rate for Payer: Bisbee Police All Plans	$0.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.20
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of AZ Commercial	$0.20
Rate for Payer: Copperpoint Commercial	$0.07
Rate for Payer: Health Net of AZ Commercial	$0.18
Rate for Payer: Health Net of AZ Medicare	$0.08
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Self Pay Self Pay	$0.24
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.17
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.05

gentamicin Ophth 0.3% Oint [CQCH]

Facility

$2.55

Service Code	NDC 17478028435
Hospital Charge Code	105924145
Hospital Revenue Code	251
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$2.29
Rate for Payer: Aetna of AZ Commercial	$2.29
Rate for Payer: Aetna of AZ Medicare	$0.71
Rate for Payer: Allwell Medicare	$0.41
Rate for Payer: Amerigroup Medicare	$0.41
Rate for Payer: APIPA Medicare/Medicaid	$0.95
Rate for Payer: AZCH Complete Medicare	$0.41
Rate for Payer: Banner UC Health Medicare	$0.41
Rate for Payer: Bisbee Police All Plans	$0.66
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.73
Rate for Payer: Cash Price	$2.04
Rate for Payer: Cigna of AZ Commercial	$1.66
Rate for Payer: Copperpoint Commercial	$0.63
Rate for Payer: Health Net of AZ Commercial	$1.53
Rate for Payer: Health Net of AZ Medicare	$0.71
Rate for Payer: Humana of AZ Medicare	$0.41
Rate for Payer: Self Pay Self Pay	$2.04
Rate for Payer: TriWest Medicare	$0.41
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.49
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.46

gentamicin Ophth 0.3% Oint [CQCH]

Facility

$2.55

Service Code	NDC 17478028435
Hospital Charge Code	105924145
Hospital Revenue Code	251
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$2.29
Rate for Payer: Aetna of AZ Commercial	$2.29
Rate for Payer: Bisbee Police All Plans	$0.66
Rate for Payer: Cash Price	$2.04
Rate for Payer: Self Pay Self Pay	$2.04

gentamicin Ophth 0.3% Sol [CQCH]

Facility

$32.95

Service Code	NDC 61314063305
Hospital Charge Code	105924210
Hospital Revenue Code	251
Min. Negotiated Rate	$8.57
Max. Negotiated Rate	$29.66
Rate for Payer: Aetna of AZ Commercial	$29.66
Rate for Payer: Bisbee Police All Plans	$8.57
Rate for Payer: Cash Price	$26.36
Rate for Payer: Self Pay Self Pay	$26.36

Know your out-of-pocket cost for care.

All Charges