Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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	$391.25
Max. Negotiated Rate	$2,646.08
Rate for Payer: Aetna of AZ Commercial	$2,223.00
Rate for Payer: Arizona Complete Health Allwell	$395.20
Rate for Payer: Banner UC Health Medicare	$395.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,679.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$395.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$395.20
Rate for Payer: Cash Price	$1,976.00
Rate for Payer: Cash Price	$1,976.00
Rate for Payer: Cigna of AZ Commercial	$1,605.50
Rate for Payer: Devoted Health Medicare	$444.60
Rate for Payer: Humana of AZ Medicare	$395.20
Rate for Payer: Seven Corners Travel Insurance	$2,646.08
Rate for Payer: Southwest Service Administrators UFCW	$1,679.60
Rate for Payer: TriWest Medicare	$395.20
Rate for Payer: United Healthcare Commercial	$1,412.84
Rate for Payer: United Healthcare Medicare	$395.20
Rate for Payer: Veterans Affairs TRICARE	$391.25

GENE ANALYSIS (CALRETICULIN), COMMON VARIANTS

Facility

$608.00

Service Code	CPT 81219
Hospital Charge Code	28010049
Hospital Revenue Code	302
Min. Negotiated Rate	$547.20
Max. Negotiated Rate	$547.20
Rate for Payer: Aetna of AZ Commercial	$547.20
Rate for Payer: Cash Price	$486.40

GENE ANALYSIS (CALRETICULIN), COMMON VARIANTS

Facility

$608.00

Service Code	CPT 81219
Hospital Charge Code	28010049
Hospital Revenue Code	302
Min. Negotiated Rate	$96.31
Max. Negotiated Rate	$547.20
Rate for Payer: Aetna of AZ Commercial	$547.20
Rate for Payer: Arizona Complete Health Allwell	$97.28
Rate for Payer: Banner UC Health Medicare	$97.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$413.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$97.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$97.28
Rate for Payer: Cash Price	$486.40
Rate for Payer: Cash Price	$486.40
Rate for Payer: Cigna of AZ Commercial	$395.20
Rate for Payer: Devoted Health Medicare	$109.44
Rate for Payer: Humana of AZ Medicare	$97.28
Rate for Payer: Seven Corners Travel Insurance	$176.36
Rate for Payer: Southwest Service Administrators UFCW	$413.44
Rate for Payer: TriWest Medicare	$97.28
Rate for Payer: United Healthcare Commercial	$347.78
Rate for Payer: United Healthcare Medicare	$97.28
Rate for Payer: Veterans Affairs TRICARE	$96.31

General Lab

Facility

$37.00

Service Code	CPT 87220
Hospital Charge Code	22031562
Hospital Revenue Code	301
Min. Negotiated Rate	$5.86
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Arizona Complete Health Allwell	$5.92
Rate for Payer: Banner UC Health Medicare	$5.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$25.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.92
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cigna of AZ Commercial	$24.05
Rate for Payer: Devoted Health Medicare	$6.66
Rate for Payer: Humana of AZ Medicare	$5.92
Rate for Payer: Seven Corners Travel Insurance	$6.19
Rate for Payer: Southwest Service Administrators UFCW	$25.16
Rate for Payer: TriWest Medicare	$5.92
Rate for Payer: United Healthcare Commercial	$21.16
Rate for Payer: United Healthcare Medicare	$5.92
Rate for Payer: Veterans Affairs TRICARE	$5.86

General Lab

Facility

$201.00

Service Code	CPT 82105
Hospital Charge Code	1902313
Hospital Revenue Code	301
Min. Negotiated Rate	$24.32
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of AZ Commercial	$180.90
Rate for Payer: Arizona Complete Health Allwell	$32.16
Rate for Payer: Banner UC Health Medicare	$32.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$136.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.16
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cigna of AZ Commercial	$130.65
Rate for Payer: Devoted Health Medicare	$36.18
Rate for Payer: Humana of AZ Medicare	$32.16
Rate for Payer: Seven Corners Travel Insurance	$24.32
Rate for Payer: Southwest Service Administrators UFCW	$136.68
Rate for Payer: TriWest Medicare	$32.16
Rate for Payer: United Healthcare Commercial	$114.97
Rate for Payer: United Healthcare Medicare	$32.16
Rate for Payer: Veterans Affairs TRICARE	$31.84

General Lab

Facility

$120.00

Service Code	CPT 89300
Hospital Charge Code	22334780
Hospital Revenue Code	309
Min. Negotiated Rate	$14.27
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Arizona Complete Health Allwell	$19.20
Rate for Payer: Banner UC Health Medicare	$19.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$81.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$19.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$19.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cigna of AZ Commercial	$78.00
Rate for Payer: Devoted Health Medicare	$21.60
Rate for Payer: Humana of AZ Medicare	$19.20
Rate for Payer: Seven Corners Travel Insurance	$14.27
Rate for Payer: Southwest Service Administrators UFCW	$81.60
Rate for Payer: TriWest Medicare	$19.20
Rate for Payer: United Healthcare Commercial	$68.64
Rate for Payer: United Healthcare Medicare	$19.20
Rate for Payer: Veterans Affairs TRICARE	$19.01

General Lab

Facility

$201.00

Service Code	CPT 82105
Hospital Charge Code	1902313
Hospital Revenue Code	301
Min. Negotiated Rate	$180.90
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of AZ Commercial	$180.90
Rate for Payer: Cash Price	$160.80

General Lab

Facility

$37.00

Service Code	CPT 87220
Hospital Charge Code	22031562
Hospital Revenue Code	301
Min. Negotiated Rate	$33.30
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Cash Price	$29.60

General Lab

Facility

$120.00

Service Code	CPT 89300
Hospital Charge Code	22334780
Hospital Revenue Code	309
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Cash Price	$96.00

Genital Culture

Facility

$162.00

Service Code	CPT 87081
Hospital Charge Code	633894
Hospital Revenue Code	306
Min. Negotiated Rate	$9.61
Max. Negotiated Rate	$145.80
Rate for Payer: Aetna of AZ Commercial	$145.80
Rate for Payer: Aetna of AZ Commercial	$108.90
Rate for Payer: Arizona Complete Health Allwell	$19.36
Rate for Payer: Arizona Complete Health Allwell	$25.92
Rate for Payer: Banner UC Health Medicare	$19.36
Rate for Payer: Banner UC Health Medicare	$25.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$110.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$82.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$19.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$25.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$19.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$25.92
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cigna of AZ Commercial	$105.30
Rate for Payer: Cigna of AZ Commercial	$78.65
Rate for Payer: Devoted Health Medicare	$29.16
Rate for Payer: Devoted Health Medicare	$21.78
Rate for Payer: Humana of AZ Medicare	$19.36
Rate for Payer: Humana of AZ Medicare	$25.92
Rate for Payer: Seven Corners Travel Insurance	$9.61
Rate for Payer: Seven Corners Travel Insurance	$9.61
Rate for Payer: Southwest Service Administrators UFCW	$82.28
Rate for Payer: Southwest Service Administrators UFCW	$110.16
Rate for Payer: TriWest Medicare	$19.36
Rate for Payer: TriWest Medicare	$25.92
Rate for Payer: United Healthcare Commercial	$92.66
Rate for Payer: United Healthcare Commercial	$69.21
Rate for Payer: United Healthcare Medicare	$19.36
Rate for Payer: United Healthcare Medicare	$25.92
Rate for Payer: Veterans Affairs TRICARE	$25.66
Rate for Payer: Veterans Affairs TRICARE	$19.17

Genital Culture

Facility

$121.00

Service Code	CPT 87081
Hospital Charge Code	633894
Hospital Revenue Code	306
Min. Negotiated Rate	$108.90
Max. Negotiated Rate	$108.90
Rate for Payer: Aetna of AZ Commercial	$108.90
Rate for Payer: Aetna of AZ Commercial	$145.80
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cash Price	$129.60

GenoSure(R) MG LC

Facility

$1,502.00

Service Code	CPT 87901
Hospital Charge Code	22311193
Hospital Revenue Code	306
Min. Negotiated Rate	$1,351.80
Max. Negotiated Rate	$1,351.80
Rate for Payer: Aetna of AZ Commercial	$1,351.80
Rate for Payer: Cash Price	$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	$237.92
Max. Negotiated Rate	$1,351.80
Rate for Payer: Aetna of AZ Commercial	$1,351.80
Rate for Payer: Arizona Complete Health Allwell	$240.32
Rate for Payer: Banner UC Health Medicare	$240.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,021.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$240.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$240.32
Rate for Payer: Cash Price	$1,201.60
Rate for Payer: Cash Price	$1,201.60
Rate for Payer: Cigna of AZ Commercial	$976.30
Rate for Payer: Devoted Health Medicare	$270.36
Rate for Payer: Humana of AZ Medicare	$240.32
Rate for Payer: Seven Corners Travel Insurance	$373.30
Rate for Payer: Southwest Service Administrators UFCW	$1,021.36
Rate for Payer: TriWest Medicare	$240.32
Rate for Payer: United Healthcare Commercial	$859.14
Rate for Payer: United Healthcare Medicare	$240.32
Rate for Payer: Veterans Affairs TRICARE	$237.92

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	$0.76
Max. Negotiated Rate	$0.76
Rate for Payer: Aetna of AZ Commercial	$0.76
Rate for Payer: Cash Price	$0.67

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: Arizona Complete Health Allwell	$0.13
Rate for Payer: Banner UC Health Medicare	$0.13
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.57
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.13
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.13
Rate for Payer: Cash Price	$0.67
Rate for Payer: Cigna of AZ Commercial	$0.55
Rate for Payer: Devoted Health Medicare	$0.15
Rate for Payer: Humana of AZ Medicare	$0.13
Rate for Payer: Southwest Service Administrators UFCW	$0.57
Rate for Payer: TriWest Medicare	$0.13
Rate for Payer: United Healthcare Commercial	$0.48
Rate for Payer: United Healthcare Medicare	$0.13
Rate for Payer: Veterans Affairs TRICARE	$0.13

gentamicin 80 mg/ 2mL Sol [CQCH]

Facility

$0.30

Service Code	HCPCS J1580
Hospital Charge Code	107743160
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of AZ Commercial	$0.27
Rate for Payer: Cash Price	$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: Arizona Complete Health Allwell	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.05
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.05
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of AZ Commercial	$0.20
Rate for Payer: Devoted Health Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Southwest Service Administrators UFCW	$0.20
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: United Healthcare Commercial	$0.17
Rate for Payer: United Healthcare Medicare	$0.05
Rate for Payer: Veterans Affairs TRICARE	$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	$2.29
Max. Negotiated Rate	$2.29
Rate for Payer: Aetna of AZ Commercial	$2.29
Rate for Payer: Cash Price	$2.04

gentamicin Ophth 0.3% Oint [CQCH]

Facility

$2.55

Service Code	NDC 17478028435
Hospital Charge Code	105924145
Hospital Revenue Code	251
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$2.29
Rate for Payer: Aetna of AZ Commercial	$2.29
Rate for Payer: Arizona Complete Health Allwell	$0.41
Rate for Payer: Banner UC Health Medicare	$0.41
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.73
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.41
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.41
Rate for Payer: Cash Price	$2.04
Rate for Payer: Cigna of AZ Commercial	$1.66
Rate for Payer: Devoted Health Medicare	$0.46
Rate for Payer: Humana of AZ Medicare	$0.41
Rate for Payer: Southwest Service Administrators UFCW	$1.73
Rate for Payer: TriWest Medicare	$0.41
Rate for Payer: United Healthcare Commercial	$1.46
Rate for Payer: United Healthcare Medicare	$0.41
Rate for Payer: Veterans Affairs TRICARE	$0.40

gentamicin Ophth 0.3% Sol [CQCH]

Facility

$32.95

Service Code	NDC 61314063305
Hospital Charge Code	105924210
Hospital Revenue Code	251
Min. Negotiated Rate	$29.66
Max. Negotiated Rate	$29.66
Rate for Payer: Aetna of AZ Commercial	$29.66
Rate for Payer: Cash Price	$26.36

gentamicin Ophth 0.3% Sol [CQCH]

Facility

$32.95

Service Code	NDC 61314063305
Hospital Charge Code	105924210
Hospital Revenue Code	251
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$29.66
Rate for Payer: Aetna of AZ Commercial	$29.66
Rate for Payer: Arizona Complete Health Allwell	$5.27
Rate for Payer: Banner UC Health Medicare	$5.27
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$22.41
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.27
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.27
Rate for Payer: Cash Price	$26.36
Rate for Payer: Cigna of AZ Commercial	$21.42
Rate for Payer: Devoted Health Medicare	$5.93
Rate for Payer: Humana of AZ Medicare	$5.27
Rate for Payer: Southwest Service Administrators UFCW	$22.41
Rate for Payer: TriWest Medicare	$5.27
Rate for Payer: United Healthcare Commercial	$18.85
Rate for Payer: United Healthcare Medicare	$5.27
Rate for Payer: Veterans Affairs TRICARE	$5.22

Gentamicin Peak

Facility

$256.00

Service Code	CPT 80170
Hospital Charge Code	23122406
Hospital Revenue Code	301
Min. Negotiated Rate	$23.75
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna of AZ Commercial	$230.40
Rate for Payer: Arizona Complete Health Allwell	$40.96
Rate for Payer: Banner UC Health Medicare	$40.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$174.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$40.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$40.96
Rate for Payer: Cash Price	$204.80
Rate for Payer: Cash Price	$204.80
Rate for Payer: Cigna of AZ Commercial	$166.40
Rate for Payer: Devoted Health Medicare	$46.08
Rate for Payer: Humana of AZ Medicare	$40.96
Rate for Payer: Seven Corners Travel Insurance	$23.75
Rate for Payer: Southwest Service Administrators UFCW	$174.08
Rate for Payer: TriWest Medicare	$40.96
Rate for Payer: United Healthcare Commercial	$146.43
Rate for Payer: United Healthcare Medicare	$40.96
Rate for Payer: Veterans Affairs TRICARE	$40.55

Gentamicin Peak

Facility

$256.00

Service Code	CPT 80170
Hospital Charge Code	23122406
Hospital Revenue Code	301
Min. Negotiated Rate	$230.40
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna of AZ Commercial	$230.40
Rate for Payer: Cash Price	$204.80

gentamicin PF 20 mg/2 mL Inj Sol [CQCH]

Facility

$0.70

Service Code	HCPCS J1580
Hospital Charge Code	105924078
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.63
Rate for Payer: Aetna of AZ Commercial	$0.63
Rate for Payer: Arizona Complete Health Allwell	$0.11
Rate for Payer: Banner UC Health Medicare	$0.11
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.11
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.11
Rate for Payer: Cash Price	$0.56
Rate for Payer: Cigna of AZ Commercial	$0.46
Rate for Payer: Devoted Health Medicare	$0.13
Rate for Payer: Humana of AZ Medicare	$0.11
Rate for Payer: Southwest Service Administrators UFCW	$0.48
Rate for Payer: TriWest Medicare	$0.11
Rate for Payer: United Healthcare Commercial	$0.40
Rate for Payer: United Healthcare Medicare	$0.11
Rate for Payer: Veterans Affairs TRICARE	$0.11

gentamicin PF 20 mg/2 mL Inj Sol [CQCH]

Facility

$0.70

Service Code	HCPCS J1580
Hospital Charge Code	105924078
Hospital Revenue Code	250
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.63
Rate for Payer: Aetna of AZ Commercial	$0.63
Rate for Payer: Cash Price	$0.56

Know your out-of-pocket cost for care.

All Charges