Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

H. pylori Breath Test LC

Facility

$797.00

Service Code	CPT 83013
Hospital Charge Code	22240929
Hospital Revenue Code	301
Min. Negotiated Rate	$127.52
Max. Negotiated Rate	$717.30
Rate for Payer: Aetna of AZ Commercial	$717.30
Rate for Payer: Aetna of AZ Medicare	$223.16
Rate for Payer: Allwell Medicare	$127.52
Rate for Payer: Amerigroup Medicare	$127.52
Rate for Payer: APIPA Medicare/Medicaid	$297.68
Rate for Payer: AZCH Complete Medicare	$127.52
Rate for Payer: Banner UC Health Medicare	$127.52
Rate for Payer: Bisbee Police All Plans	$207.22
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$541.96
Rate for Payer: Cash Price	$637.60
Rate for Payer: Cigna of AZ Commercial	$518.05
Rate for Payer: Copperpoint Commercial	$197.26
Rate for Payer: Health Net of AZ Commercial	$478.20
Rate for Payer: Health Net of AZ Medicare	$223.16
Rate for Payer: Humana of AZ Medicare	$127.52
Rate for Payer: Self Pay Self Pay	$637.60
Rate for Payer: TriWest Medicare	$127.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$464.65
Rate for Payer: UnitedHealth Group of AZ Medicare	$143.46

H. pylori Breath Test LC

Facility

$797.00

Service Code	CPT 83013
Hospital Charge Code	22240929
Hospital Revenue Code	301
Min. Negotiated Rate	$207.22
Max. Negotiated Rate	$717.30
Rate for Payer: Aetna of AZ Commercial	$717.30
Rate for Payer: Bisbee Police All Plans	$207.22
Rate for Payer: Cash Price	$637.60
Rate for Payer: Self Pay Self Pay	$637.60

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 IgG, Abs LC

Facility

$212.00

Service Code	CPT 86677
Hospital Charge Code	1285629
Hospital Revenue Code	302
Min. Negotiated Rate	$33.92
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: Allwell Medicare	$33.92
Rate for Payer: Amerigroup Medicare	$33.92
Rate for Payer: APIPA Medicare/Medicaid	$79.18
Rate for Payer: AZCH Complete Medicare	$33.92
Rate for Payer: Banner UC Health Medicare	$33.92
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: 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	$33.92
Rate for Payer: Self Pay Self Pay	$169.60
Rate for Payer: TriWest Medicare	$33.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$123.60
Rate for Payer: UnitedHealth Group of AZ Medicare	$38.16

H Pylori Rapid Urease

Facility

$201.00

Service Code	CPT 86677
Hospital Charge Code	22352509
Hospital Revenue Code	306
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

H Pylori Rapid Urease

Facility

$201.00

Service Code	CPT 86677
Hospital Charge Code	22352509
Hospital Revenue Code	306
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

H. pylori Stool Ag, EIA LC

Facility

$407.00

Service Code	CPT 87338
Hospital Charge Code	2029222
Hospital Revenue Code	306
Min. Negotiated Rate	$65.12
Max. Negotiated Rate	$366.30
Rate for Payer: Aetna of AZ Commercial	$366.30
Rate for Payer: Aetna of AZ Medicare	$113.96
Rate for Payer: Allwell Medicare	$65.12
Rate for Payer: Amerigroup Medicare	$65.12
Rate for Payer: APIPA Medicare/Medicaid	$152.01
Rate for Payer: AZCH Complete Medicare	$65.12
Rate for Payer: Banner UC Health Medicare	$65.12
Rate for Payer: Bisbee Police All Plans	$105.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$276.76
Rate for Payer: Cash Price	$325.60
Rate for Payer: Cigna of AZ Commercial	$264.55
Rate for Payer: Copperpoint Commercial	$100.73
Rate for Payer: Health Net of AZ Commercial	$244.20
Rate for Payer: Health Net of AZ Medicare	$113.96
Rate for Payer: Humana of AZ Medicare	$65.12
Rate for Payer: Self Pay Self Pay	$325.60
Rate for Payer: TriWest Medicare	$65.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$237.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$73.26

H. pylori Stool Ag, EIA LC

Facility

$407.00

Service Code	CPT 87338
Hospital Charge Code	2029222
Hospital Revenue Code	306
Min. Negotiated Rate	$105.82
Max. Negotiated Rate	$366.30
Rate for Payer: Aetna of AZ Commercial	$366.30
Rate for Payer: Bisbee Police All Plans	$105.82
Rate for Payer: Cash Price	$325.60
Rate for Payer: Self Pay Self Pay	$325.60

HSV 1/2 PCR LC

Facility

$475.00

Service Code	CPT 87529
Hospital Charge Code	2087612
Hospital Revenue Code	301
Min. Negotiated Rate	$76.00
Max. Negotiated Rate	$427.50
Rate for Payer: Aetna of AZ Commercial	$427.50
Rate for Payer: Aetna of AZ Medicare	$133.00
Rate for Payer: Allwell Medicare	$76.00
Rate for Payer: Amerigroup Medicare	$76.00
Rate for Payer: APIPA Medicare/Medicaid	$177.41
Rate for Payer: AZCH Complete Medicare	$76.00
Rate for Payer: Banner UC Health Medicare	$76.00
Rate for Payer: Bisbee Police All Plans	$123.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$323.00
Rate for Payer: Cash Price	$380.00
Rate for Payer: Cigna of AZ Commercial	$308.75
Rate for Payer: Copperpoint Commercial	$117.56
Rate for Payer: Health Net of AZ Commercial	$285.00
Rate for Payer: Health Net of AZ Medicare	$133.00
Rate for Payer: Humana of AZ Medicare	$76.00
Rate for Payer: Self Pay Self Pay	$380.00
Rate for Payer: TriWest Medicare	$76.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$276.93
Rate for Payer: UnitedHealth Group of AZ Medicare	$85.50

HSV 1/2 PCR LC

Facility

$475.00

Service Code	CPT 87529
Hospital Charge Code	2087612
Hospital Revenue Code	301
Min. Negotiated Rate	$123.50
Max. Negotiated Rate	$427.50
Rate for Payer: Aetna of AZ Commercial	$427.50
Rate for Payer: Bisbee Police All Plans	$123.50
Rate for Payer: Cash Price	$380.00
Rate for Payer: Self Pay Self Pay	$380.00

HSV 1 and 2 IgM Abs, Indirect LC

Facility

$601.00

Service Code	CPT 87529
Hospital Charge Code	2029112
Hospital Revenue Code	301
Min. Negotiated Rate	$96.16
Max. Negotiated Rate	$540.90
Rate for Payer: Aetna of AZ Commercial	$540.90
Rate for Payer: Aetna of AZ Medicare	$168.28
Rate for Payer: Allwell Medicare	$96.16
Rate for Payer: Amerigroup Medicare	$96.16
Rate for Payer: APIPA Medicare/Medicaid	$224.47
Rate for Payer: AZCH Complete Medicare	$96.16
Rate for Payer: Banner UC Health Medicare	$96.16
Rate for Payer: Bisbee Police All Plans	$156.26
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$408.68
Rate for Payer: Cash Price	$480.80
Rate for Payer: Cigna of AZ Commercial	$390.65
Rate for Payer: Copperpoint Commercial	$148.75
Rate for Payer: Health Net of AZ Commercial	$360.60
Rate for Payer: Health Net of AZ Medicare	$168.28
Rate for Payer: Humana of AZ Medicare	$96.16
Rate for Payer: Self Pay Self Pay	$480.80
Rate for Payer: TriWest Medicare	$96.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$350.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$108.18

HSV 1 and 2 IgM Abs, Indirect LC

Facility

$601.00

Service Code	CPT 87529
Hospital Charge Code	2029112
Hospital Revenue Code	301
Min. Negotiated Rate	$156.26
Max. Negotiated Rate	$540.90
Rate for Payer: Aetna of AZ Commercial	$540.90
Rate for Payer: Bisbee Police All Plans	$156.26
Rate for Payer: Cash Price	$480.80
Rate for Payer: Self Pay Self Pay	$480.80

HSV 1 and 2-Specific Ab, IgG LC

Facility

$155.00

Service Code	CPT 86695
Hospital Charge Code	1285647
Hospital Revenue Code	302
Min. Negotiated Rate	$24.80
Max. Negotiated Rate	$139.50
Rate for Payer: Aetna of AZ Commercial	$139.50
Rate for Payer: Aetna of AZ Medicare	$43.40
Rate for Payer: Allwell Medicare	$24.80
Rate for Payer: Amerigroup Medicare	$24.80
Rate for Payer: APIPA Medicare/Medicaid	$57.89
Rate for Payer: AZCH Complete Medicare	$24.80
Rate for Payer: Banner UC Health Medicare	$24.80
Rate for Payer: Bisbee Police All Plans	$40.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$105.40
Rate for Payer: Cash Price	$124.00
Rate for Payer: Cigna of AZ Commercial	$100.75
Rate for Payer: Copperpoint Commercial	$38.36
Rate for Payer: Health Net of AZ Commercial	$93.00
Rate for Payer: Health Net of AZ Medicare	$43.40
Rate for Payer: Humana of AZ Medicare	$24.80
Rate for Payer: Self Pay Self Pay	$124.00
Rate for Payer: TriWest Medicare	$24.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$90.36
Rate for Payer: UnitedHealth Group of AZ Medicare	$27.90

HSV 1 and 2-Specific Ab, IgG LC

Facility

$155.00

Service Code	CPT 86695
Hospital Charge Code	1285647
Hospital Revenue Code	302
Min. Negotiated Rate	$40.30
Max. Negotiated Rate	$139.50
Rate for Payer: Aetna of AZ Commercial	$139.50
Rate for Payer: Bisbee Police All Plans	$40.30
Rate for Payer: Cash Price	$124.00
Rate for Payer: Self Pay Self Pay	$124.00

HSV 2 IGG

Facility

$241.00

Service Code	CPT 86696
Hospital Charge Code	22481479
Hospital Revenue Code	301
Min. Negotiated Rate	$38.56
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: Allwell Medicare	$38.56
Rate for Payer: Amerigroup Medicare	$38.56
Rate for Payer: APIPA Medicare/Medicaid	$90.01
Rate for Payer: AZCH Complete Medicare	$38.56
Rate for Payer: Banner UC Health Medicare	$38.56
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: 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	$38.56
Rate for Payer: Self Pay Self Pay	$192.80
Rate for Payer: TriWest Medicare	$38.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$140.50
Rate for Payer: UnitedHealth Group of AZ Medicare	$43.38

HSV 2 IGG

Facility

$241.00

Service Code	CPT 86696
Hospital Charge Code	22481479
Hospital Revenue Code	301
Min. Negotiated Rate	$62.66
Max. Negotiated Rate	$216.90
Rate for Payer: Aetna of AZ Commercial	$216.90
Rate for Payer: Bisbee Police All Plans	$62.66
Rate for Payer: Cash Price	$192.80
Rate for Payer: Self Pay Self Pay	$192.80

HSV Culture and Typing LC

Facility

$307.00

Service Code	CPT 87254
Hospital Charge Code	1906898
Hospital Revenue Code	306
Min. Negotiated Rate	$49.12
Max. Negotiated Rate	$276.30
Rate for Payer: Aetna of AZ Commercial	$276.30
Rate for Payer: Aetna of AZ Medicare	$85.96
Rate for Payer: Allwell Medicare	$49.12
Rate for Payer: Amerigroup Medicare	$49.12
Rate for Payer: APIPA Medicare/Medicaid	$114.66
Rate for Payer: AZCH Complete Medicare	$49.12
Rate for Payer: Banner UC Health Medicare	$49.12
Rate for Payer: Bisbee Police All Plans	$79.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$208.76
Rate for Payer: Cash Price	$245.60
Rate for Payer: Cigna of AZ Commercial	$199.55
Rate for Payer: Copperpoint Commercial	$75.98
Rate for Payer: Health Net of AZ Commercial	$184.20
Rate for Payer: Health Net of AZ Medicare	$85.96
Rate for Payer: Humana of AZ Medicare	$49.12
Rate for Payer: Self Pay Self Pay	$245.60
Rate for Payer: TriWest Medicare	$49.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$178.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$55.26

HSV Culture and Typing LC

Facility

$307.00

Service Code	CPT 87254
Hospital Charge Code	1906898
Hospital Revenue Code	306
Min. Negotiated Rate	$79.82
Max. Negotiated Rate	$276.30
Rate for Payer: Aetna of AZ Commercial	$276.30
Rate for Payer: Bisbee Police All Plans	$79.82
Rate for Payer: Cash Price	$245.60
Rate for Payer: Self Pay Self Pay	$245.60

HSV Type 1-Specific Ab, IgG LC

Facility

$163.00

Service Code	CPT 86695
Hospital Charge Code	2087613
Hospital Revenue Code	302
Min. Negotiated Rate	$26.08
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: Allwell Medicare	$26.08
Rate for Payer: Amerigroup Medicare	$26.08
Rate for Payer: APIPA Medicare/Medicaid	$60.88
Rate for Payer: AZCH Complete Medicare	$26.08
Rate for Payer: Banner UC Health Medicare	$26.08
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: 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	$26.08
Rate for Payer: Self Pay Self Pay	$130.40
Rate for Payer: TriWest Medicare	$26.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$95.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$29.34

HSV Type 1-Specific Ab, IgG LC

Facility

$163.00

Service Code	CPT 86695
Hospital Charge Code	2087613
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 Type 2-Specific Ab, IgG LC

Facility

$229.00

Service Code	CPT 86696
Hospital Charge Code	1906902
Hospital Revenue Code	302
Min. Negotiated Rate	$59.54
Max. Negotiated Rate	$206.10
Rate for Payer: Aetna of AZ Commercial	$206.10
Rate for Payer: Bisbee Police All Plans	$59.54
Rate for Payer: Cash Price	$183.20
Rate for Payer: Self Pay Self Pay	$183.20

HSV Type 2-Specific Ab, IgG LC

Facility

$229.00

Service Code	CPT 86696
Hospital Charge Code	1906902
Hospital Revenue Code	302
Min. Negotiated Rate	$36.64
Max. Negotiated Rate	$206.10
Rate for Payer: Aetna of AZ Commercial	$206.10
Rate for Payer: Aetna of AZ Medicare	$64.12
Rate for Payer: Allwell Medicare	$36.64
Rate for Payer: Amerigroup Medicare	$36.64
Rate for Payer: APIPA Medicare/Medicaid	$85.53
Rate for Payer: AZCH Complete Medicare	$36.64
Rate for Payer: Banner UC Health Medicare	$36.64
Rate for Payer: Bisbee Police All Plans	$59.54
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$155.72
Rate for Payer: Cash Price	$183.20
Rate for Payer: Cigna of AZ Commercial	$148.85
Rate for Payer: Copperpoint Commercial	$56.68
Rate for Payer: Health Net of AZ Commercial	$137.40
Rate for Payer: Health Net of AZ Medicare	$64.12
Rate for Payer: Humana of AZ Medicare	$36.64
Rate for Payer: Self Pay Self Pay	$183.20
Rate for Payer: TriWest Medicare	$36.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$133.51
Rate for Payer: UnitedHealth Group of AZ Medicare	$41.22

Human Epididymis Protein 4 LC

Facility

$358.00

Service Code	CPT 86304
Hospital Charge Code	22201907
Hospital Revenue Code	301
Min. Negotiated Rate	$57.28
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: Allwell Medicare	$57.28
Rate for Payer: Amerigroup Medicare	$57.28
Rate for Payer: APIPA Medicare/Medicaid	$133.71
Rate for Payer: AZCH Complete Medicare	$57.28
Rate for Payer: Banner UC Health Medicare	$57.28
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: Cigna of AZ Commercial	$232.70
Rate for Payer: Copperpoint Commercial	$88.61
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	$57.28
Rate for Payer: Self Pay Self Pay	$286.40
Rate for Payer: TriWest Medicare	$57.28
Rate for Payer: UnitedHealth Group of AZ Commercial	$208.71
Rate for Payer: UnitedHealth Group of AZ Medicare	$64.44

Human Epididymis Protein 4 LC

Facility

$358.00

Service Code	CPT 86304
Hospital Charge Code	22201907
Hospital Revenue Code	301
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

HUMIDIFIER REFILL 500 ML

Facility

$22.00

Hospital Charge Code	22355209
Hospital Revenue Code	270
Min. Negotiated Rate	$3.52
Max. Negotiated Rate	$19.80
Rate for Payer: Aetna of AZ Commercial	$19.80
Rate for Payer: Aetna of AZ Medicare	$6.16
Rate for Payer: Allwell Medicare	$3.52
Rate for Payer: Amerigroup Medicare	$3.52
Rate for Payer: APIPA Medicare/Medicaid	$8.22
Rate for Payer: AZCH Complete Medicare	$3.52
Rate for Payer: Banner UC Health Medicare	$3.52
Rate for Payer: Bisbee Police All Plans	$5.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$14.96
Rate for Payer: Cash Price	$17.60
Rate for Payer: Cigna of AZ Commercial	$15.40
Rate for Payer: Copperpoint Commercial	$5.45
Rate for Payer: Health Net of AZ Commercial	$13.20
Rate for Payer: Health Net of AZ Medicare	$6.16
Rate for Payer: Humana of AZ Medicare	$3.52
Rate for Payer: Self Pay Self Pay	$17.60
Rate for Payer: TriWest Medicare	$3.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$12.83
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.96

Know your out-of-pocket cost for care.

All Charges