Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

HLA B 27 Disease Association LC

Facility

$358.00

Service Code	CPT 86812
Hospital Charge Code	1906894
Hospital Revenue Code	302
Min. Negotiated Rate	$25.81
Max. Negotiated Rate	$322.20
Rate for Payer: Aetna of AZ Commercial	$322.20
Rate for Payer: Aetna of AZ Medicare	$100.24
Rate for Payer: AHCCCS Medicaid	$25.81
Rate for Payer: Allwell Medicaid	$25.81
Rate for Payer: Allwell Medicare	$53.70
Rate for Payer: Amerigroup Medicare	$53.70
Rate for Payer: APIPA Medicare/Medicaid	$133.71
Rate for Payer: AZCH Complete Medicaid	$25.81
Rate for Payer: AZCH Complete Medicare	$53.70
Rate for Payer: Banner UC Health Medicaid	$25.81
Rate for Payer: Banner UC Health Medicare	$53.70
Rate for Payer: Bisbee Police All Plans	$93.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$243.44
Rate for Payer: Cash Price	$286.40
Rate for Payer: Cash Price	$286.40
Rate for Payer: Cigna of AZ Commercial	$232.70
Rate for Payer: Copperpoint Commercial	$88.60
Rate for Payer: Health Net of AZ Commercial	$214.80
Rate for Payer: Health Net of AZ Medicare	$100.24
Rate for Payer: Humana of AZ Medicare	$53.70
Rate for Payer: Mercy Care Medicaid	$25.81
Rate for Payer: Self Pay Self Pay	$286.40
Rate for Payer: TriWest Medicare	$53.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$208.71
Rate for Payer: UnitedHealth Group of AZ Medicare	$64.44

HLA B 27 Disease Association LC

Facility

$358.00

Service Code	CPT 86812
Hospital Charge Code	1906894
Hospital Revenue Code	302
Min. Negotiated Rate	$93.08
Max. Negotiated Rate	$322.20
Rate for Payer: Aetna of AZ Commercial	$322.20
Rate for Payer: Bisbee Police All Plans	$93.08
Rate for Payer: Cash Price	$286.40
Rate for Payer: Self Pay Self Pay	$286.40

HLA B5701 Test LC

Facility

$2,217.00

Service Code	CPT 81381
Hospital Charge Code	22311194
Hospital Revenue Code	301
Min. Negotiated Rate	$169.90
Max. Negotiated Rate	$1,995.30
Rate for Payer: Aetna of AZ Commercial	$1,995.30
Rate for Payer: Aetna of AZ Medicare	$620.76
Rate for Payer: AHCCCS Medicaid	$169.90
Rate for Payer: Allwell Medicaid	$169.90
Rate for Payer: Allwell Medicare	$332.55
Rate for Payer: Amerigroup Medicare	$332.55
Rate for Payer: APIPA Medicare/Medicaid	$828.05
Rate for Payer: AZCH Complete Medicaid	$169.90
Rate for Payer: AZCH Complete Medicare	$332.55
Rate for Payer: Banner UC Health Medicaid	$169.90
Rate for Payer: Banner UC Health Medicare	$332.55
Rate for Payer: Bisbee Police All Plans	$576.42
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,507.56
Rate for Payer: Cash Price	$1,773.60
Rate for Payer: Cash Price	$1,773.60
Rate for Payer: Cigna of AZ Commercial	$1,441.05
Rate for Payer: Copperpoint Commercial	$548.71
Rate for Payer: Health Net of AZ Commercial	$1,330.20
Rate for Payer: Health Net of AZ Medicare	$620.76
Rate for Payer: Humana of AZ Medicare	$332.55
Rate for Payer: Mercy Care Medicaid	$169.90
Rate for Payer: Self Pay Self Pay	$1,773.60
Rate for Payer: TriWest Medicare	$332.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,292.51
Rate for Payer: UnitedHealth Group of AZ Medicare	$399.06

HLA B5701 Test LC

Facility

$2,217.00

Service Code	CPT 81381
Hospital Charge Code	22311194
Hospital Revenue Code	301
Min. Negotiated Rate	$576.42
Max. Negotiated Rate	$1,995.30
Rate for Payer: Aetna of AZ Commercial	$1,995.30
Rate for Payer: Bisbee Police All Plans	$576.42
Rate for Payer: Cash Price	$1,773.60
Rate for Payer: Self Pay Self Pay	$1,773.60

HOLDER ENDO NEOFIT

Facility

$102.00

Hospital Charge Code	22926451
Hospital Revenue Code	272
Min. Negotiated Rate	$26.52
Max. Negotiated Rate	$91.80
Rate for Payer: Aetna of AZ Commercial	$91.80
Rate for Payer: Bisbee Police All Plans	$26.52
Rate for Payer: Cash Price	$81.60
Rate for Payer: Self Pay Self Pay	$81.60

HOLDER ENDO NEOFIT

Facility

$102.00

Hospital Charge Code	22926451
Hospital Revenue Code	272
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$91.80
Rate for Payer: Aetna of AZ Commercial	$91.80
Rate for Payer: Aetna of AZ Medicare	$28.56
Rate for Payer: Allwell Medicare	$15.30
Rate for Payer: Amerigroup Medicare	$15.30
Rate for Payer: APIPA Medicare/Medicaid	$38.10
Rate for Payer: AZCH Complete Medicare	$15.30
Rate for Payer: Banner UC Health Medicare	$15.30
Rate for Payer: Bisbee Police All Plans	$26.52
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$69.36
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cigna of AZ Commercial	$71.40
Rate for Payer: Copperpoint Commercial	$25.24
Rate for Payer: Health Net of AZ Commercial	$61.20
Rate for Payer: Health Net of AZ Medicare	$28.56
Rate for Payer: Humana of AZ Medicare	$15.30
Rate for Payer: Self Pay Self Pay	$81.60
Rate for Payer: TriWest Medicare	$15.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$59.47
Rate for Payer: UnitedHealth Group of AZ Medicare	$18.36

Homocyst(e)ine, Plasma LC

Facility

$511.00

Service Code	CPT 83090
Hospital Charge Code	1905630
Hospital Revenue Code	301
Min. Negotiated Rate	$132.86
Max. Negotiated Rate	$459.90
Rate for Payer: Aetna of AZ Commercial	$459.90
Rate for Payer: Bisbee Police All Plans	$132.86
Rate for Payer: Cash Price	$408.80
Rate for Payer: Self Pay Self Pay	$408.80

Homocyst(e)ine, Plasma LC

Facility

$511.00

Service Code	CPT 83090
Hospital Charge Code	1905630
Hospital Revenue Code	301
Min. Negotiated Rate	$17.92
Max. Negotiated Rate	$459.90
Rate for Payer: Aetna of AZ Commercial	$459.90
Rate for Payer: Aetna of AZ Medicare	$143.08
Rate for Payer: AHCCCS Medicaid	$17.92
Rate for Payer: Allwell Medicaid	$17.92
Rate for Payer: Allwell Medicare	$76.65
Rate for Payer: Amerigroup Medicare	$76.65
Rate for Payer: APIPA Medicare/Medicaid	$190.86
Rate for Payer: AZCH Complete Medicaid	$17.92
Rate for Payer: AZCH Complete Medicare	$76.65
Rate for Payer: Banner UC Health Medicaid	$17.92
Rate for Payer: Banner UC Health Medicare	$76.65
Rate for Payer: Bisbee Police All Plans	$132.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$347.48
Rate for Payer: Cash Price	$408.80
Rate for Payer: Cash Price	$408.80
Rate for Payer: Cigna of AZ Commercial	$332.15
Rate for Payer: Copperpoint Commercial	$126.47
Rate for Payer: Health Net of AZ Commercial	$306.60
Rate for Payer: Health Net of AZ Medicare	$143.08
Rate for Payer: Humana of AZ Medicare	$76.65
Rate for Payer: Mercy Care Medicaid	$17.92
Rate for Payer: Self Pay Self Pay	$408.80
Rate for Payer: TriWest Medicare	$76.65
Rate for Payer: UnitedHealth Group of AZ Commercial	$297.91
Rate for Payer: UnitedHealth Group of AZ Medicare	$91.98

H Pylori AB IgM LC

Facility

$216.00

Service Code	CPT 86677
Hospital Charge Code	3658178
Hospital Revenue Code	302
Min. Negotiated Rate	$56.16
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of AZ Commercial	$194.40
Rate for Payer: Bisbee Police All Plans	$56.16
Rate for Payer: Cash Price	$172.80
Rate for Payer: Self Pay Self Pay	$172.80

H Pylori AB IgM LC

Facility

$216.00

Service Code	CPT 86677
Hospital Charge Code	3658178
Hospital Revenue Code	302
Min. Negotiated Rate	$16.85
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of AZ Commercial	$194.40
Rate for Payer: Aetna of AZ Medicare	$60.48
Rate for Payer: AHCCCS Medicaid	$16.85
Rate for Payer: Allwell Medicaid	$16.85
Rate for Payer: Allwell Medicare	$32.40
Rate for Payer: Amerigroup Medicare	$32.40
Rate for Payer: APIPA Medicare/Medicaid	$80.68
Rate for Payer: AZCH Complete Medicaid	$16.85
Rate for Payer: AZCH Complete Medicare	$32.40
Rate for Payer: Banner UC Health Medicaid	$16.85
Rate for Payer: Banner UC Health Medicare	$32.40
Rate for Payer: Bisbee Police All Plans	$56.16
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$146.88
Rate for Payer: Cash Price	$172.80
Rate for Payer: Cash Price	$172.80
Rate for Payer: Cigna of AZ Commercial	$140.40
Rate for Payer: Copperpoint Commercial	$53.46
Rate for Payer: Health Net of AZ Commercial	$129.60
Rate for Payer: Health Net of AZ Medicare	$60.48
Rate for Payer: Humana of AZ Medicare	$32.40
Rate for Payer: Mercy Care Medicaid	$16.85
Rate for Payer: Self Pay Self Pay	$172.80
Rate for Payer: TriWest Medicare	$32.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$125.93
Rate for Payer: UnitedHealth Group of AZ Medicare	$38.88

H. pylori Breath Test LC

Facility

$839.00

Service Code	CPT 83013
Hospital Charge Code	22240929
Hospital Revenue Code	301
Min. Negotiated Rate	$67.36
Max. Negotiated Rate	$755.10
Rate for Payer: Aetna of AZ Commercial	$755.10
Rate for Payer: Aetna of AZ Medicare	$234.92
Rate for Payer: AHCCCS Medicaid	$67.36
Rate for Payer: Allwell Medicaid	$67.36
Rate for Payer: Allwell Medicare	$125.85
Rate for Payer: Amerigroup Medicare	$125.85
Rate for Payer: APIPA Medicare/Medicaid	$313.37
Rate for Payer: AZCH Complete Medicaid	$67.36
Rate for Payer: AZCH Complete Medicare	$125.85
Rate for Payer: Banner UC Health Medicaid	$67.36
Rate for Payer: Banner UC Health Medicare	$125.85
Rate for Payer: Bisbee Police All Plans	$218.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$570.52
Rate for Payer: Cash Price	$671.20
Rate for Payer: Cash Price	$671.20
Rate for Payer: Cigna of AZ Commercial	$545.35
Rate for Payer: Copperpoint Commercial	$207.65
Rate for Payer: Health Net of AZ Commercial	$503.40
Rate for Payer: Health Net of AZ Medicare	$234.92
Rate for Payer: Humana of AZ Medicare	$125.85
Rate for Payer: Mercy Care Medicaid	$67.36
Rate for Payer: Self Pay Self Pay	$671.20
Rate for Payer: TriWest Medicare	$125.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$489.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$151.02

H. pylori Breath Test LC

Facility

$839.00

Service Code	CPT 83013
Hospital Charge Code	22240929
Hospital Revenue Code	301
Min. Negotiated Rate	$218.14
Max. Negotiated Rate	$755.10
Rate for Payer: Aetna of AZ Commercial	$755.10
Rate for Payer: Bisbee Police All Plans	$218.14
Rate for Payer: Cash Price	$671.20
Rate for Payer: Self Pay Self Pay	$671.20

H. pylori IgG, Abs LC

Facility

$212.00

Service Code	CPT 86677
Hospital Charge Code	1285629
Hospital Revenue Code	302
Min. Negotiated Rate	$16.85
Max. Negotiated Rate	$190.80
Rate for Payer: Aetna of AZ Commercial	$190.80
Rate for Payer: Aetna of AZ Medicare	$59.36
Rate for Payer: AHCCCS Medicaid	$16.85
Rate for Payer: Allwell Medicaid	$16.85
Rate for Payer: Allwell Medicare	$31.80
Rate for Payer: Amerigroup Medicare	$31.80
Rate for Payer: APIPA Medicare/Medicaid	$79.18
Rate for Payer: AZCH Complete Medicaid	$16.85
Rate for Payer: AZCH Complete Medicare	$31.80
Rate for Payer: Banner UC Health Medicaid	$16.85
Rate for Payer: Banner UC Health Medicare	$31.80
Rate for Payer: Bisbee Police All Plans	$55.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$144.16
Rate for Payer: Cash Price	$169.60
Rate for Payer: Cash Price	$169.60
Rate for Payer: Cigna of AZ Commercial	$137.80
Rate for Payer: Copperpoint Commercial	$52.47
Rate for Payer: Health Net of AZ Commercial	$127.20
Rate for Payer: Health Net of AZ Medicare	$59.36
Rate for Payer: Humana of AZ Medicare	$31.80
Rate for Payer: Mercy Care Medicaid	$16.85
Rate for Payer: Self Pay Self Pay	$169.60
Rate for Payer: TriWest Medicare	$31.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$123.60
Rate for Payer: UnitedHealth Group of AZ Medicare	$38.16

H. pylori IgG, Abs LC

Facility

$212.00

Service Code	CPT 86677
Hospital Charge Code	1285629
Hospital Revenue Code	302
Min. Negotiated Rate	$55.12
Max. Negotiated Rate	$190.80
Rate for Payer: Aetna of AZ Commercial	$190.80
Rate for Payer: Bisbee Police All Plans	$55.12
Rate for Payer: Cash Price	$169.60
Rate for Payer: Self Pay Self Pay	$169.60

H Pylori Rapid Urease

Facility

$212.00

Service Code	CPT 86677
Hospital Charge Code	22352509
Hospital Revenue Code	306
Min. Negotiated Rate	$55.12
Max. Negotiated Rate	$190.80
Rate for Payer: Aetna of AZ Commercial	$190.80
Rate for Payer: Bisbee Police All Plans	$55.12
Rate for Payer: Cash Price	$169.60
Rate for Payer: Self Pay Self Pay	$169.60

H Pylori Rapid Urease

Facility

$212.00

Service Code	CPT 86677
Hospital Charge Code	22352509
Hospital Revenue Code	306
Min. Negotiated Rate	$16.85
Max. Negotiated Rate	$190.80
Rate for Payer: Aetna of AZ Commercial	$190.80
Rate for Payer: Aetna of AZ Medicare	$59.36
Rate for Payer: AHCCCS Medicaid	$16.85
Rate for Payer: Allwell Medicaid	$16.85
Rate for Payer: Allwell Medicare	$31.80
Rate for Payer: Amerigroup Medicare	$31.80
Rate for Payer: APIPA Medicare/Medicaid	$79.18
Rate for Payer: AZCH Complete Medicaid	$16.85
Rate for Payer: AZCH Complete Medicare	$31.80
Rate for Payer: Banner UC Health Medicaid	$16.85
Rate for Payer: Banner UC Health Medicare	$31.80
Rate for Payer: Bisbee Police All Plans	$55.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$144.16
Rate for Payer: Cash Price	$169.60
Rate for Payer: Cash Price	$169.60
Rate for Payer: Cigna of AZ Commercial	$137.80
Rate for Payer: Copperpoint Commercial	$52.47
Rate for Payer: Health Net of AZ Commercial	$127.20
Rate for Payer: Health Net of AZ Medicare	$59.36
Rate for Payer: Humana of AZ Medicare	$31.80
Rate for Payer: Mercy Care Medicaid	$16.85
Rate for Payer: Self Pay Self Pay	$169.60
Rate for Payer: TriWest Medicare	$31.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$123.60
Rate for Payer: UnitedHealth Group of AZ Medicare	$38.16

H. pylori Stool Ag, EIA LC

Facility

$429.00

Service Code	CPT 87338
Hospital Charge Code	2029222
Hospital Revenue Code	306
Min. Negotiated Rate	$14.38
Max. Negotiated Rate	$386.10
Rate for Payer: Aetna of AZ Commercial	$386.10
Rate for Payer: Aetna of AZ Medicare	$120.12
Rate for Payer: AHCCCS Medicaid	$14.38
Rate for Payer: Allwell Medicaid	$14.38
Rate for Payer: Allwell Medicare	$64.35
Rate for Payer: Amerigroup Medicare	$64.35
Rate for Payer: APIPA Medicare/Medicaid	$160.23
Rate for Payer: AZCH Complete Medicaid	$14.38
Rate for Payer: AZCH Complete Medicare	$64.35
Rate for Payer: Banner UC Health Medicaid	$14.38
Rate for Payer: Banner UC Health Medicare	$64.35
Rate for Payer: Bisbee Police All Plans	$111.54
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$291.72
Rate for Payer: Cash Price	$343.20
Rate for Payer: Cash Price	$343.20
Rate for Payer: Cigna of AZ Commercial	$278.85
Rate for Payer: Copperpoint Commercial	$106.18
Rate for Payer: Health Net of AZ Commercial	$257.40
Rate for Payer: Health Net of AZ Medicare	$120.12
Rate for Payer: Humana of AZ Medicare	$64.35
Rate for Payer: Mercy Care Medicaid	$14.38
Rate for Payer: Self Pay Self Pay	$343.20
Rate for Payer: TriWest Medicare	$64.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$250.11
Rate for Payer: UnitedHealth Group of AZ Medicare	$77.22

H. pylori Stool Ag, EIA LC

Facility

$429.00

Service Code	CPT 87338
Hospital Charge Code	2029222
Hospital Revenue Code	306
Min. Negotiated Rate	$111.54
Max. Negotiated Rate	$386.10
Rate for Payer: Aetna of AZ Commercial	$386.10
Rate for Payer: Bisbee Police All Plans	$111.54
Rate for Payer: Cash Price	$343.20
Rate for Payer: Self Pay Self Pay	$343.20

HSV 1/2 PCR LC

Facility

$500.00

Service Code	CPT 87529
Hospital Charge Code	2087612
Hospital Revenue Code	301
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna of AZ Commercial	$450.00
Rate for Payer: Aetna of AZ Medicare	$140.00
Rate for Payer: AHCCCS Medicaid	$35.09
Rate for Payer: Allwell Medicaid	$35.09
Rate for Payer: Allwell Medicare	$75.00
Rate for Payer: Amerigroup Medicare	$75.00
Rate for Payer: APIPA Medicare/Medicaid	$186.75
Rate for Payer: AZCH Complete Medicaid	$35.09
Rate for Payer: AZCH Complete Medicare	$75.00
Rate for Payer: Banner UC Health Medicaid	$35.09
Rate for Payer: Banner UC Health Medicare	$75.00
Rate for Payer: Bisbee Police All Plans	$130.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$340.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Cigna of AZ Commercial	$325.00
Rate for Payer: Copperpoint Commercial	$123.75
Rate for Payer: Health Net of AZ Commercial	$300.00
Rate for Payer: Health Net of AZ Medicare	$140.00
Rate for Payer: Humana of AZ Medicare	$75.00
Rate for Payer: Mercy Care Medicaid	$35.09
Rate for Payer: Self Pay Self Pay	$400.00
Rate for Payer: TriWest Medicare	$75.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$291.50
Rate for Payer: UnitedHealth Group of AZ Medicare	$90.00

HSV 1/2 PCR LC

Facility

$500.00

Service Code	CPT 87529
Hospital Charge Code	2087612
Hospital Revenue Code	301
Min. Negotiated Rate	$130.00
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna of AZ Commercial	$450.00
Rate for Payer: Bisbee Police All Plans	$130.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Self Pay Self Pay	$400.00

HSV 1 and 2 IgM Abs, Indirect LC

Facility

$633.00

Service Code	CPT 87529
Hospital Charge Code	2029112
Hospital Revenue Code	301
Min. Negotiated Rate	$35.09
Max. Negotiated Rate	$569.70
Rate for Payer: Aetna of AZ Commercial	$569.70
Rate for Payer: Aetna of AZ Medicare	$177.24
Rate for Payer: AHCCCS Medicaid	$35.09
Rate for Payer: Allwell Medicaid	$35.09
Rate for Payer: Allwell Medicare	$94.95
Rate for Payer: Amerigroup Medicare	$94.95
Rate for Payer: APIPA Medicare/Medicaid	$236.43
Rate for Payer: AZCH Complete Medicaid	$35.09
Rate for Payer: AZCH Complete Medicare	$94.95
Rate for Payer: Banner UC Health Medicaid	$35.09
Rate for Payer: Banner UC Health Medicare	$94.95
Rate for Payer: Bisbee Police All Plans	$164.58
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$430.44
Rate for Payer: Cash Price	$506.40
Rate for Payer: Cash Price	$506.40
Rate for Payer: Cigna of AZ Commercial	$411.45
Rate for Payer: Copperpoint Commercial	$156.67
Rate for Payer: Health Net of AZ Commercial	$379.80
Rate for Payer: Health Net of AZ Medicare	$177.24
Rate for Payer: Humana of AZ Medicare	$94.95
Rate for Payer: Mercy Care Medicaid	$35.09
Rate for Payer: Self Pay Self Pay	$506.40
Rate for Payer: TriWest Medicare	$94.95
Rate for Payer: UnitedHealth Group of AZ Commercial	$369.04
Rate for Payer: UnitedHealth Group of AZ Medicare	$113.94

HSV 1 and 2 IgM Abs, Indirect LC

Facility

$633.00

Service Code	CPT 87529
Hospital Charge Code	2029112
Hospital Revenue Code	301
Min. Negotiated Rate	$164.58
Max. Negotiated Rate	$569.70
Rate for Payer: Aetna of AZ Commercial	$569.70
Rate for Payer: Bisbee Police All Plans	$164.58
Rate for Payer: Cash Price	$506.40
Rate for Payer: Self Pay Self Pay	$506.40

HSV 1 and 2-Specific Ab, IgG LC

Facility

$163.00

Service Code	CPT 86695
Hospital Charge Code	1285647
Hospital Revenue Code	302
Min. Negotiated Rate	$42.38
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Bisbee Police All Plans	$42.38
Rate for Payer: Cash Price	$130.40
Rate for Payer: Self Pay Self Pay	$130.40

HSV 1 and 2-Specific Ab, IgG LC

Facility

$163.00

Service Code	CPT 86695
Hospital Charge Code	1285647
Hospital Revenue Code	302
Min. Negotiated Rate	$13.19
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Aetna of AZ Medicare	$45.64
Rate for Payer: AHCCCS Medicaid	$13.19
Rate for Payer: Allwell Medicaid	$13.19
Rate for Payer: Allwell Medicare	$24.45
Rate for Payer: Amerigroup Medicare	$24.45
Rate for Payer: APIPA Medicare/Medicaid	$60.88
Rate for Payer: AZCH Complete Medicaid	$13.19
Rate for Payer: AZCH Complete Medicare	$24.45
Rate for Payer: Banner UC Health Medicaid	$13.19
Rate for Payer: Banner UC Health Medicare	$24.45
Rate for Payer: Bisbee Police All Plans	$42.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$110.84
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cigna of AZ Commercial	$105.95
Rate for Payer: Copperpoint Commercial	$40.34
Rate for Payer: Health Net of AZ Commercial	$97.80
Rate for Payer: Health Net of AZ Medicare	$45.64
Rate for Payer: Humana of AZ Medicare	$24.45
Rate for Payer: Mercy Care Medicaid	$13.19
Rate for Payer: Self Pay Self Pay	$130.40
Rate for Payer: TriWest Medicare	$24.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$95.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$29.34

HSV 2 IGG

Facility

$241.00

Service Code	CPT 86696
Hospital Charge Code	22481479
Hospital Revenue Code	301
Min. Negotiated Rate	$19.35
Max. Negotiated Rate	$216.90
Rate for Payer: Aetna of AZ Commercial	$216.90
Rate for Payer: Aetna of AZ Medicare	$67.48
Rate for Payer: AHCCCS Medicaid	$19.35
Rate for Payer: Allwell Medicaid	$19.35
Rate for Payer: Allwell Medicare	$36.15
Rate for Payer: Amerigroup Medicare	$36.15
Rate for Payer: APIPA Medicare/Medicaid	$90.01
Rate for Payer: AZCH Complete Medicaid	$19.35
Rate for Payer: AZCH Complete Medicare	$36.15
Rate for Payer: Banner UC Health Medicaid	$19.35
Rate for Payer: Banner UC Health Medicare	$36.15
Rate for Payer: Bisbee Police All Plans	$62.66
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$163.88
Rate for Payer: Cash Price	$192.80
Rate for Payer: Cash Price	$192.80
Rate for Payer: Cigna of AZ Commercial	$156.65
Rate for Payer: Copperpoint Commercial	$59.65
Rate for Payer: Health Net of AZ Commercial	$144.60
Rate for Payer: Health Net of AZ Medicare	$67.48
Rate for Payer: Humana of AZ Medicare	$36.15
Rate for Payer: Mercy Care Medicaid	$19.35
Rate for Payer: Self Pay Self Pay	$192.80
Rate for Payer: TriWest Medicare	$36.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$140.50
Rate for Payer: UnitedHealth Group of AZ Medicare	$43.38

Know your out-of-pocket cost for care.

All Charges