Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

hCG Qual w/ Reflex to Beta hCG

Facility

$16.00

Service Code	CPT 84703
Hospital Charge Code	24319555
Hospital Revenue Code	300
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Aetna of AZ Medicare	$4.48
Rate for Payer: Allwell Medicare	$2.56
Rate for Payer: Amerigroup Medicare	$2.56
Rate for Payer: APIPA Medicare/Medicaid	$5.98
Rate for Payer: AZCH Complete Medicare	$2.56
Rate for Payer: Banner UC Health Medicare	$2.56
Rate for Payer: Bisbee Police All Plans	$4.16
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$10.88
Rate for Payer: Cash Price	$12.80
Rate for Payer: Cigna of AZ Commercial	$10.40
Rate for Payer: Copperpoint Commercial	$3.96
Rate for Payer: Health Net of AZ Commercial	$9.60
Rate for Payer: Health Net of AZ Medicare	$4.48
Rate for Payer: Humana of AZ Medicare	$2.56
Rate for Payer: Self Pay Self Pay	$12.80
Rate for Payer: TriWest Medicare	$2.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$9.33
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.88

hCG Quantitative

Facility

$204.00

Service Code	CPT 84702
Hospital Charge Code	1019534
Hospital Revenue Code	301
Min. Negotiated Rate	$32.64
Max. Negotiated Rate	$183.60
Rate for Payer: Aetna of AZ Commercial	$183.60
Rate for Payer: Aetna of AZ Medicare	$57.12
Rate for Payer: Allwell Medicare	$32.64
Rate for Payer: Amerigroup Medicare	$32.64
Rate for Payer: APIPA Medicare/Medicaid	$76.19
Rate for Payer: AZCH Complete Medicare	$32.64
Rate for Payer: Banner UC Health Medicare	$32.64
Rate for Payer: Bisbee Police All Plans	$53.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$138.72
Rate for Payer: Cash Price	$163.20
Rate for Payer: Cigna of AZ Commercial	$132.60
Rate for Payer: Copperpoint Commercial	$50.49
Rate for Payer: Health Net of AZ Commercial	$122.40
Rate for Payer: Health Net of AZ Medicare	$57.12
Rate for Payer: Humana of AZ Medicare	$32.64
Rate for Payer: Self Pay Self Pay	$163.20
Rate for Payer: TriWest Medicare	$32.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$118.93
Rate for Payer: UnitedHealth Group of AZ Medicare	$36.72

hCG Quantitative

Facility

$204.00

Service Code	CPT 84702
Hospital Charge Code	1019534
Hospital Revenue Code	301
Min. Negotiated Rate	$53.04
Max. Negotiated Rate	$183.60
Rate for Payer: Aetna of AZ Commercial	$183.60
Rate for Payer: Bisbee Police All Plans	$53.04
Rate for Payer: Cash Price	$163.20
Rate for Payer: Self Pay Self Pay	$163.20

HCV Antibody LC

Facility

$377.00

Service Code	CPT 86803
Hospital Charge Code	1285627
Hospital Revenue Code	302
Min. Negotiated Rate	$60.32
Max. Negotiated Rate	$339.30
Rate for Payer: Aetna of AZ Commercial	$339.30
Rate for Payer: Aetna of AZ Medicare	$105.56
Rate for Payer: Allwell Medicare	$60.32
Rate for Payer: Amerigroup Medicare	$60.32
Rate for Payer: APIPA Medicare/Medicaid	$140.81
Rate for Payer: AZCH Complete Medicare	$60.32
Rate for Payer: Banner UC Health Medicare	$60.32
Rate for Payer: Bisbee Police All Plans	$98.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$256.36
Rate for Payer: Cash Price	$301.60
Rate for Payer: Cigna of AZ Commercial	$245.05
Rate for Payer: Copperpoint Commercial	$93.31
Rate for Payer: Health Net of AZ Commercial	$226.20
Rate for Payer: Health Net of AZ Medicare	$105.56
Rate for Payer: Humana of AZ Medicare	$60.32
Rate for Payer: Self Pay Self Pay	$301.60
Rate for Payer: TriWest Medicare	$60.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$219.79
Rate for Payer: UnitedHealth Group of AZ Medicare	$67.86

HCV Antibody LC

Facility

$377.00

Service Code	CPT 86803
Hospital Charge Code	1285627
Hospital Revenue Code	302
Min. Negotiated Rate	$98.02
Max. Negotiated Rate	$339.30
Rate for Payer: Aetna of AZ Commercial	$339.30
Rate for Payer: Bisbee Police All Plans	$98.02
Rate for Payer: Cash Price	$301.60
Rate for Payer: Self Pay Self Pay	$301.60

HCV FibroSure LC

Facility

$150.00

Service Code	CPT 82977
Hospital Charge Code	22200129
Hospital Revenue Code	301
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of AZ Commercial	$135.00
Rate for Payer: Aetna of AZ Medicare	$42.00
Rate for Payer: Allwell Medicare	$24.00
Rate for Payer: Amerigroup Medicare	$24.00
Rate for Payer: APIPA Medicare/Medicaid	$56.02
Rate for Payer: AZCH Complete Medicare	$24.00
Rate for Payer: Banner UC Health Medicare	$24.00
Rate for Payer: Bisbee Police All Plans	$39.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$102.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cigna of AZ Commercial	$97.50
Rate for Payer: Copperpoint Commercial	$37.12
Rate for Payer: Health Net of AZ Commercial	$90.00
Rate for Payer: Health Net of AZ Medicare	$42.00
Rate for Payer: Humana of AZ Medicare	$24.00
Rate for Payer: Self Pay Self Pay	$120.00
Rate for Payer: TriWest Medicare	$24.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$87.45
Rate for Payer: UnitedHealth Group of AZ Medicare	$27.00

HCV FibroSure LC

Facility

$150.00

Service Code	CPT 82977
Hospital Charge Code	22200129
Hospital Revenue Code	301
Min. Negotiated Rate	$39.00
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of AZ Commercial	$135.00
Rate for Payer: Bisbee Police All Plans	$39.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Self Pay Self Pay	$120.00

HCV Genotyping Non Reflex LC

Facility

$3,199.00

Service Code	CPT 87902
Hospital Charge Code	2029260
Hospital Revenue Code	306
Min. Negotiated Rate	$511.84
Max. Negotiated Rate	$2,879.10
Rate for Payer: Aetna of AZ Commercial	$2,879.10
Rate for Payer: Aetna of AZ Medicare	$895.72
Rate for Payer: Allwell Medicare	$511.84
Rate for Payer: Amerigroup Medicare	$511.84
Rate for Payer: APIPA Medicare/Medicaid	$1,194.83
Rate for Payer: AZCH Complete Medicare	$511.84
Rate for Payer: Banner UC Health Medicare	$511.84
Rate for Payer: Bisbee Police All Plans	$831.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,175.32
Rate for Payer: Cash Price	$2,559.20
Rate for Payer: Cigna of AZ Commercial	$2,079.35
Rate for Payer: Copperpoint Commercial	$791.75
Rate for Payer: Health Net of AZ Commercial	$1,919.40
Rate for Payer: Health Net of AZ Medicare	$895.72
Rate for Payer: Humana of AZ Medicare	$511.84
Rate for Payer: Self Pay Self Pay	$2,559.20
Rate for Payer: TriWest Medicare	$511.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,865.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$575.82

HCV Genotyping Non Reflex LC

Facility

$3,199.00

Service Code	CPT 87902
Hospital Charge Code	2029260
Hospital Revenue Code	306
Min. Negotiated Rate	$831.74
Max. Negotiated Rate	$2,879.10
Rate for Payer: Aetna of AZ Commercial	$2,879.10
Rate for Payer: Bisbee Police All Plans	$831.74
Rate for Payer: Cash Price	$2,559.20
Rate for Payer: Self Pay Self Pay	$2,559.20

.HCV RNA (International Units) LC

Facility

$430.00

Service Code	CPT 87521
Hospital Charge Code	1285759
Hospital Revenue Code	306
Min. Negotiated Rate	$68.80
Max. Negotiated Rate	$387.00
Rate for Payer: Aetna of AZ Commercial	$387.00
Rate for Payer: Aetna of AZ Medicare	$120.40
Rate for Payer: Allwell Medicare	$68.80
Rate for Payer: Amerigroup Medicare	$68.80
Rate for Payer: APIPA Medicare/Medicaid	$160.60
Rate for Payer: AZCH Complete Medicare	$68.80
Rate for Payer: Banner UC Health Medicare	$68.80
Rate for Payer: Bisbee Police All Plans	$111.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$292.40
Rate for Payer: Cash Price	$344.00
Rate for Payer: Cigna of AZ Commercial	$279.50
Rate for Payer: Copperpoint Commercial	$106.42
Rate for Payer: Health Net of AZ Commercial	$258.00
Rate for Payer: Health Net of AZ Medicare	$120.40
Rate for Payer: Humana of AZ Medicare	$68.80
Rate for Payer: Self Pay Self Pay	$344.00
Rate for Payer: TriWest Medicare	$68.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$250.69
Rate for Payer: UnitedHealth Group of AZ Medicare	$77.40

.HCV RNA (International Units) LC

Facility

$430.00

Service Code	CPT 87521
Hospital Charge Code	1285759
Hospital Revenue Code	306
Min. Negotiated Rate	$111.80
Max. Negotiated Rate	$387.00
Rate for Payer: Aetna of AZ Commercial	$387.00
Rate for Payer: Bisbee Police All Plans	$111.80
Rate for Payer: Cash Price	$344.00
Rate for Payer: Self Pay Self Pay	$344.00

.HCV RNA IU LC

Facility

$749.00

Service Code	CPT 87522
Hospital Charge Code	6782346
Hospital Revenue Code	301
Min. Negotiated Rate	$119.84
Max. Negotiated Rate	$674.10
Rate for Payer: Aetna of AZ Commercial	$674.10
Rate for Payer: Aetna of AZ Medicare	$209.72
Rate for Payer: Allwell Medicare	$119.84
Rate for Payer: Amerigroup Medicare	$119.84
Rate for Payer: APIPA Medicare/Medicaid	$279.75
Rate for Payer: AZCH Complete Medicare	$119.84
Rate for Payer: Banner UC Health Medicare	$119.84
Rate for Payer: Bisbee Police All Plans	$194.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$509.32
Rate for Payer: Cash Price	$599.20
Rate for Payer: Cigna of AZ Commercial	$486.85
Rate for Payer: Copperpoint Commercial	$185.38
Rate for Payer: Health Net of AZ Commercial	$449.40
Rate for Payer: Health Net of AZ Medicare	$209.72
Rate for Payer: Humana of AZ Medicare	$119.84
Rate for Payer: Self Pay Self Pay	$599.20
Rate for Payer: TriWest Medicare	$119.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$436.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$134.82

.HCV RNA IU LC

Facility

$749.00

Service Code	CPT 87522
Hospital Charge Code	6782346
Hospital Revenue Code	301
Min. Negotiated Rate	$194.74
Max. Negotiated Rate	$674.10
Rate for Payer: Aetna of AZ Commercial	$674.10
Rate for Payer: Bisbee Police All Plans	$194.74
Rate for Payer: Cash Price	$599.20
Rate for Payer: Self Pay Self Pay	$599.20

HCV RNA, PCR, Quant (Reflex to Genotyping LC

Facility

$651.00

Service Code	CPT 87522
Hospital Charge Code	6676609
Hospital Revenue Code	306
Min. Negotiated Rate	$104.16
Max. Negotiated Rate	$585.90
Rate for Payer: Aetna of AZ Commercial	$585.90
Rate for Payer: Aetna of AZ Medicare	$182.28
Rate for Payer: Allwell Medicare	$104.16
Rate for Payer: Amerigroup Medicare	$104.16
Rate for Payer: APIPA Medicare/Medicaid	$243.15
Rate for Payer: AZCH Complete Medicare	$104.16
Rate for Payer: Banner UC Health Medicare	$104.16
Rate for Payer: Bisbee Police All Plans	$169.26
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$442.68
Rate for Payer: Cash Price	$520.80
Rate for Payer: Cigna of AZ Commercial	$423.15
Rate for Payer: Copperpoint Commercial	$161.12
Rate for Payer: Health Net of AZ Commercial	$390.60
Rate for Payer: Health Net of AZ Medicare	$182.28
Rate for Payer: Humana of AZ Medicare	$104.16
Rate for Payer: Self Pay Self Pay	$520.80
Rate for Payer: TriWest Medicare	$104.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$379.53
Rate for Payer: UnitedHealth Group of AZ Medicare	$117.18

HCV RNA, PCR, Quant (Reflex to Genotyping LC

Facility

$651.00

Service Code	CPT 87522
Hospital Charge Code	6676609
Hospital Revenue Code	306
Min. Negotiated Rate	$169.26
Max. Negotiated Rate	$585.90
Rate for Payer: Aetna of AZ Commercial	$585.90
Rate for Payer: Bisbee Police All Plans	$169.26
Rate for Payer: Cash Price	$520.80
Rate for Payer: Self Pay Self Pay	$520.80

HCV RT-PCR, Quant (Graph) LC

Facility

$749.00

Service Code	CPT 87522
Hospital Charge Code	2029096
Hospital Revenue Code	306
Min. Negotiated Rate	$119.84
Max. Negotiated Rate	$674.10
Rate for Payer: Aetna of AZ Commercial	$674.10
Rate for Payer: Aetna of AZ Medicare	$209.72
Rate for Payer: Allwell Medicare	$119.84
Rate for Payer: Amerigroup Medicare	$119.84
Rate for Payer: APIPA Medicare/Medicaid	$279.75
Rate for Payer: AZCH Complete Medicare	$119.84
Rate for Payer: Banner UC Health Medicare	$119.84
Rate for Payer: Bisbee Police All Plans	$194.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$509.32
Rate for Payer: Cash Price	$599.20
Rate for Payer: Cigna of AZ Commercial	$486.85
Rate for Payer: Copperpoint Commercial	$185.38
Rate for Payer: Health Net of AZ Commercial	$449.40
Rate for Payer: Health Net of AZ Medicare	$209.72
Rate for Payer: Humana of AZ Medicare	$119.84
Rate for Payer: Self Pay Self Pay	$599.20
Rate for Payer: TriWest Medicare	$119.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$436.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$134.82

HCV RT-PCR, Quant (Graph) LC

Facility

$749.00

Service Code	CPT 87522
Hospital Charge Code	2029096
Hospital Revenue Code	306
Min. Negotiated Rate	$194.74
Max. Negotiated Rate	$674.10
Rate for Payer: Aetna of AZ Commercial	$674.10
Rate for Payer: Bisbee Police All Plans	$194.74
Rate for Payer: Cash Price	$599.20
Rate for Payer: Self Pay Self Pay	$599.20

HCV RT-PCR, Quant (Non-Graph) LC

Facility

$747.00

Service Code	CPT 87522
Hospital Charge Code	1285758
Hospital Revenue Code	302
Min. Negotiated Rate	$119.52
Max. Negotiated Rate	$672.30
Rate for Payer: Aetna of AZ Commercial	$672.30
Rate for Payer: Aetna of AZ Medicare	$209.16
Rate for Payer: Allwell Medicare	$119.52
Rate for Payer: Amerigroup Medicare	$119.52
Rate for Payer: APIPA Medicare/Medicaid	$279.00
Rate for Payer: AZCH Complete Medicare	$119.52
Rate for Payer: Banner UC Health Medicare	$119.52
Rate for Payer: Bisbee Police All Plans	$194.22
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$507.96
Rate for Payer: Cash Price	$597.60
Rate for Payer: Cigna of AZ Commercial	$485.55
Rate for Payer: Copperpoint Commercial	$184.88
Rate for Payer: Health Net of AZ Commercial	$448.20
Rate for Payer: Health Net of AZ Medicare	$209.16
Rate for Payer: Humana of AZ Medicare	$119.52
Rate for Payer: Self Pay Self Pay	$597.60
Rate for Payer: TriWest Medicare	$119.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$435.50
Rate for Payer: UnitedHealth Group of AZ Medicare	$134.46

HCV RT-PCR, Quant (Non-Graph) LC

Facility

$747.00

Service Code	CPT 87522
Hospital Charge Code	1285758
Hospital Revenue Code	302
Min. Negotiated Rate	$194.22
Max. Negotiated Rate	$672.30
Rate for Payer: Aetna of AZ Commercial	$672.30
Rate for Payer: Bisbee Police All Plans	$194.22
Rate for Payer: Cash Price	$597.60
Rate for Payer: Self Pay Self Pay	$597.60

HCV with Drug Resistance

Facility

$999.00

Service Code	CPT 87901
Hospital Charge Code	23173795
Hospital Revenue Code	306
Min. Negotiated Rate	$259.74
Max. Negotiated Rate	$899.10
Rate for Payer: Aetna of AZ Commercial	$899.10
Rate for Payer: Bisbee Police All Plans	$259.74
Rate for Payer: Cash Price	$799.20
Rate for Payer: Self Pay Self Pay	$799.20

HCV with Drug Resistance

Facility

$999.00

Service Code	CPT 87900
Hospital Charge Code	22907367
Hospital Revenue Code	306
Min. Negotiated Rate	$159.84
Max. Negotiated Rate	$899.10
Rate for Payer: Aetna of AZ Commercial	$899.10
Rate for Payer: Aetna of AZ Medicare	$279.72
Rate for Payer: Allwell Medicare	$159.84
Rate for Payer: Amerigroup Medicare	$159.84
Rate for Payer: APIPA Medicare/Medicaid	$373.13
Rate for Payer: AZCH Complete Medicare	$159.84
Rate for Payer: Banner UC Health Medicare	$159.84
Rate for Payer: Bisbee Police All Plans	$259.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$679.32
Rate for Payer: Cash Price	$799.20
Rate for Payer: Cigna of AZ Commercial	$649.35
Rate for Payer: Copperpoint Commercial	$247.25
Rate for Payer: Health Net of AZ Commercial	$599.40
Rate for Payer: Health Net of AZ Medicare	$279.72
Rate for Payer: Humana of AZ Medicare	$159.84
Rate for Payer: Self Pay Self Pay	$799.20
Rate for Payer: TriWest Medicare	$159.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$582.42
Rate for Payer: UnitedHealth Group of AZ Medicare	$179.82

HCV with Drug Resistance

Facility

$999.00

Service Code	CPT 87900
Hospital Charge Code	22907367
Hospital Revenue Code	306
Min. Negotiated Rate	$259.74
Max. Negotiated Rate	$899.10
Rate for Payer: Aetna of AZ Commercial	$899.10
Rate for Payer: Bisbee Police All Plans	$259.74
Rate for Payer: Cash Price	$799.20
Rate for Payer: Self Pay Self Pay	$799.20

HCV with Drug Resistance

Facility

$999.00

Service Code	CPT 87901
Hospital Charge Code	23173795
Hospital Revenue Code	306
Min. Negotiated Rate	$159.84
Max. Negotiated Rate	$899.10
Rate for Payer: Aetna of AZ Commercial	$899.10
Rate for Payer: Aetna of AZ Medicare	$279.72
Rate for Payer: Allwell Medicare	$159.84
Rate for Payer: Amerigroup Medicare	$159.84
Rate for Payer: APIPA Medicare/Medicaid	$373.13
Rate for Payer: AZCH Complete Medicare	$159.84
Rate for Payer: Banner UC Health Medicare	$159.84
Rate for Payer: Bisbee Police All Plans	$259.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$679.32
Rate for Payer: Cash Price	$799.20
Rate for Payer: Cigna of AZ Commercial	$649.35
Rate for Payer: Copperpoint Commercial	$247.25
Rate for Payer: Health Net of AZ Commercial	$599.40
Rate for Payer: Health Net of AZ Medicare	$279.72
Rate for Payer: Humana of AZ Medicare	$159.84
Rate for Payer: Self Pay Self Pay	$799.20
Rate for Payer: TriWest Medicare	$159.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$582.42
Rate for Payer: UnitedHealth Group of AZ Medicare	$179.82

.HDL Comment LC

Facility

$104.00

Service Code	CPT 83718
Hospital Charge Code	22311129
Hospital Revenue Code	301
Min. Negotiated Rate	$16.64
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of AZ Commercial	$93.60
Rate for Payer: Aetna of AZ Medicare	$29.12
Rate for Payer: Allwell Medicare	$16.64
Rate for Payer: Amerigroup Medicare	$16.64
Rate for Payer: APIPA Medicare/Medicaid	$38.84
Rate for Payer: AZCH Complete Medicare	$16.64
Rate for Payer: Banner UC Health Medicare	$16.64
Rate for Payer: Bisbee Police All Plans	$27.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$70.72
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cigna of AZ Commercial	$67.60
Rate for Payer: Copperpoint Commercial	$25.74
Rate for Payer: Health Net of AZ Commercial	$62.40
Rate for Payer: Health Net of AZ Medicare	$29.12
Rate for Payer: Humana of AZ Medicare	$16.64
Rate for Payer: Self Pay Self Pay	$83.20
Rate for Payer: TriWest Medicare	$16.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$60.63
Rate for Payer: UnitedHealth Group of AZ Medicare	$18.72

.HDL Comment LC

Facility

$104.00

Service Code	CPT 83718
Hospital Charge Code	22311129
Hospital Revenue Code	301
Min. Negotiated Rate	$27.04
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of AZ Commercial	$93.60
Rate for Payer: Bisbee Police All Plans	$27.04
Rate for Payer: Cash Price	$83.20
Rate for Payer: Self Pay Self Pay	$83.20

Know your out-of-pocket cost for care.

All Charges