Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Rectovaginal Fistula with colostomy

Facility

$5,535.00

Service Code	CPT 57307
Hospital Charge Code	27267821
Hospital Revenue Code	360
Min. Negotiated Rate	$1,439.10
Max. Negotiated Rate	$4,981.50
Rate for Payer: Aetna of AZ Commercial	$4,981.50
Rate for Payer: Bisbee Police All Plans	$1,439.10
Rate for Payer: Cash Price	$4,428.00
Rate for Payer: Self Pay Self Pay	$4,428.00

Rectovaginal Fistula with colostomy

Facility

$5,535.00

Service Code	CPT 57307
Hospital Charge Code	27267821
Hospital Revenue Code	360
Min. Negotiated Rate	$885.60
Max. Negotiated Rate	$4,981.50
Rate for Payer: Aetna of AZ Commercial	$4,981.50
Rate for Payer: Aetna of AZ Medicare	$1,549.80
Rate for Payer: Allwell Medicare	$885.60
Rate for Payer: Amerigroup Medicare	$885.60
Rate for Payer: APIPA Medicare/Medicaid	$2,067.32
Rate for Payer: AZCH Complete Medicare	$885.60
Rate for Payer: Banner UC Health Medicare	$885.60
Rate for Payer: Bisbee Police All Plans	$1,439.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,763.80
Rate for Payer: Cash Price	$4,428.00
Rate for Payer: Cash Price	$4,428.00
Rate for Payer: Cigna of AZ Commercial	$2,767.50
Rate for Payer: Copperpoint Commercial	$1,369.91
Rate for Payer: Health Net of AZ Commercial	$3,321.00
Rate for Payer: Health Net of AZ Medicare	$1,549.80
Rate for Payer: Humana of AZ Medicare	$885.60
Rate for Payer: Self Pay Self Pay	$4,428.00
Rate for Payer: TriWest Medicare	$885.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,373.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$996.30

REF Ab Titer

Facility

$107.00

Service Code	CPT 86886
Hospital Charge Code	22248796
Hospital Revenue Code	302
Min. Negotiated Rate	$17.12
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Aetna of AZ Medicare	$29.96
Rate for Payer: Allwell Medicare	$17.12
Rate for Payer: Amerigroup Medicare	$17.12
Rate for Payer: APIPA Medicare/Medicaid	$39.96
Rate for Payer: AZCH Complete Medicare	$17.12
Rate for Payer: Banner UC Health Medicare	$17.12
Rate for Payer: Bisbee Police All Plans	$27.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$72.76
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cigna of AZ Commercial	$69.55
Rate for Payer: Copperpoint Commercial	$26.48
Rate for Payer: Health Net of AZ Commercial	$64.20
Rate for Payer: Health Net of AZ Medicare	$29.96
Rate for Payer: Humana of AZ Medicare	$17.12
Rate for Payer: Self Pay Self Pay	$85.60
Rate for Payer: TriWest Medicare	$17.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$62.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.26

REF Ab Titer

Facility

$107.00

Service Code	CPT 86886
Hospital Charge Code	22248796
Hospital Revenue Code	302
Min. Negotiated Rate	$27.82
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Bisbee Police All Plans	$27.82
Rate for Payer: Cash Price	$85.60
Rate for Payer: Self Pay Self Pay	$85.60

REF BB ANTIBODY ID ADDT'L AB

Facility

$249.00

Service Code	CPT 86870
Hospital Charge Code	22373731
Hospital Revenue Code	302
Min. Negotiated Rate	$39.84
Max. Negotiated Rate	$224.10
Rate for Payer: Aetna of AZ Commercial	$224.10
Rate for Payer: Aetna of AZ Medicare	$69.72
Rate for Payer: Allwell Medicare	$39.84
Rate for Payer: Amerigroup Medicare	$39.84
Rate for Payer: APIPA Medicare/Medicaid	$93.00
Rate for Payer: AZCH Complete Medicare	$39.84
Rate for Payer: Banner UC Health Medicare	$39.84
Rate for Payer: Bisbee Police All Plans	$64.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$169.32
Rate for Payer: Cash Price	$199.20
Rate for Payer: Cigna of AZ Commercial	$161.85
Rate for Payer: Copperpoint Commercial	$61.63
Rate for Payer: Health Net of AZ Commercial	$149.40
Rate for Payer: Health Net of AZ Medicare	$69.72
Rate for Payer: Humana of AZ Medicare	$39.84
Rate for Payer: Self Pay Self Pay	$199.20
Rate for Payer: TriWest Medicare	$39.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$145.17
Rate for Payer: UnitedHealth Group of AZ Medicare	$44.82

REF BB ANTIBODY ID ADDT'L AB

Facility

$249.00

Service Code	CPT 86870
Hospital Charge Code	22373731
Hospital Revenue Code	302
Min. Negotiated Rate	$64.74
Max. Negotiated Rate	$224.10
Rate for Payer: Aetna of AZ Commercial	$224.10
Rate for Payer: Bisbee Police All Plans	$64.74
Rate for Payer: Cash Price	$199.20
Rate for Payer: Self Pay Self Pay	$199.20

REF DAT

Facility

$237.00

Service Code	CPT 86880
Hospital Charge Code	5562972
Hospital Revenue Code	302
Min. Negotiated Rate	$37.92
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Aetna of AZ Medicare	$66.36
Rate for Payer: Allwell Medicare	$37.92
Rate for Payer: Amerigroup Medicare	$37.92
Rate for Payer: APIPA Medicare/Medicaid	$88.52
Rate for Payer: AZCH Complete Medicare	$37.92
Rate for Payer: Banner UC Health Medicare	$37.92
Rate for Payer: Bisbee Police All Plans	$61.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$161.16
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cigna of AZ Commercial	$154.05
Rate for Payer: Copperpoint Commercial	$58.66
Rate for Payer: Health Net of AZ Commercial	$142.20
Rate for Payer: Health Net of AZ Medicare	$66.36
Rate for Payer: Humana of AZ Medicare	$37.92
Rate for Payer: Self Pay Self Pay	$189.60
Rate for Payer: TriWest Medicare	$37.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$138.17
Rate for Payer: UnitedHealth Group of AZ Medicare	$42.66

REF DAT

Facility

$237.00

Service Code	CPT 86880
Hospital Charge Code	5562972
Hospital Revenue Code	302
Min. Negotiated Rate	$61.62
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Bisbee Police All Plans	$61.62
Rate for Payer: Cash Price	$189.60
Rate for Payer: Self Pay Self Pay	$189.60

Reference ABID

Facility

$1,022.00

Service Code	CPT 86870
Hospital Charge Code	1165545
Hospital Revenue Code	302
Min. Negotiated Rate	$163.52
Max. Negotiated Rate	$919.80
Rate for Payer: Aetna of AZ Commercial	$919.80
Rate for Payer: Aetna of AZ Medicare	$286.16
Rate for Payer: Allwell Medicare	$163.52
Rate for Payer: Amerigroup Medicare	$163.52
Rate for Payer: APIPA Medicare/Medicaid	$381.72
Rate for Payer: AZCH Complete Medicare	$163.52
Rate for Payer: Banner UC Health Medicare	$163.52
Rate for Payer: Bisbee Police All Plans	$265.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$694.96
Rate for Payer: Cash Price	$817.60
Rate for Payer: Cigna of AZ Commercial	$664.30
Rate for Payer: Copperpoint Commercial	$252.94
Rate for Payer: Health Net of AZ Commercial	$613.20
Rate for Payer: Health Net of AZ Medicare	$286.16
Rate for Payer: Humana of AZ Medicare	$163.52
Rate for Payer: Self Pay Self Pay	$817.60
Rate for Payer: TriWest Medicare	$163.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$595.83
Rate for Payer: UnitedHealth Group of AZ Medicare	$183.96

Reference ABID

Facility

$1,022.00

Service Code	CPT 86870
Hospital Charge Code	1165545
Hospital Revenue Code	302
Min. Negotiated Rate	$265.72
Max. Negotiated Rate	$919.80
Rate for Payer: Aetna of AZ Commercial	$919.80
Rate for Payer: Bisbee Police All Plans	$265.72
Rate for Payer: Cash Price	$817.60
Rate for Payer: Self Pay Self Pay	$817.60

Reference Elution

Facility

$112.00

Service Code	CPT 86976
Hospital Charge Code	1165547
Hospital Revenue Code	302
Min. Negotiated Rate	$17.92
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of AZ Commercial	$100.80
Rate for Payer: Aetna of AZ Medicare	$31.36
Rate for Payer: Allwell Medicare	$17.92
Rate for Payer: Amerigroup Medicare	$17.92
Rate for Payer: APIPA Medicare/Medicaid	$41.83
Rate for Payer: AZCH Complete Medicare	$17.92
Rate for Payer: Banner UC Health Medicare	$17.92
Rate for Payer: Bisbee Police All Plans	$29.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$76.16
Rate for Payer: Cash Price	$89.60
Rate for Payer: Cigna of AZ Commercial	$72.80
Rate for Payer: Copperpoint Commercial	$27.72
Rate for Payer: Health Net of AZ Commercial	$67.20
Rate for Payer: Health Net of AZ Medicare	$31.36
Rate for Payer: Humana of AZ Medicare	$17.92
Rate for Payer: Self Pay Self Pay	$89.60
Rate for Payer: TriWest Medicare	$17.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$65.30
Rate for Payer: UnitedHealth Group of AZ Medicare	$20.16

Reference Elution

Facility

$107.00

Service Code	CPT 86976
Hospital Charge Code	2192233
Hospital Revenue Code	302
Min. Negotiated Rate	$27.82
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Bisbee Police All Plans	$27.82
Rate for Payer: Cash Price	$85.60
Rate for Payer: Self Pay Self Pay	$85.60

Reference Elution

Facility

$107.00

Service Code	CPT 86976
Hospital Charge Code	2192233
Hospital Revenue Code	302
Min. Negotiated Rate	$17.12
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Aetna of AZ Medicare	$29.96
Rate for Payer: Allwell Medicare	$17.12
Rate for Payer: Amerigroup Medicare	$17.12
Rate for Payer: APIPA Medicare/Medicaid	$39.96
Rate for Payer: AZCH Complete Medicare	$17.12
Rate for Payer: Banner UC Health Medicare	$17.12
Rate for Payer: Bisbee Police All Plans	$27.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$72.76
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cigna of AZ Commercial	$69.55
Rate for Payer: Copperpoint Commercial	$26.48
Rate for Payer: Health Net of AZ Commercial	$64.20
Rate for Payer: Health Net of AZ Medicare	$29.96
Rate for Payer: Humana of AZ Medicare	$17.12
Rate for Payer: Self Pay Self Pay	$85.60
Rate for Payer: TriWest Medicare	$17.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$62.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.26

Reference Elution

Facility

$112.00

Service Code	CPT 86976
Hospital Charge Code	1165547
Hospital Revenue Code	302
Min. Negotiated Rate	$29.12
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of AZ Commercial	$100.80
Rate for Payer: Bisbee Police All Plans	$29.12
Rate for Payer: Cash Price	$89.60
Rate for Payer: Self Pay Self Pay	$89.60

.Reflex to GenoSure(R) MG LC

Facility

$1,502.00

Service Code	CPT 87901
Hospital Charge Code	22311165
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

.Reflex to GenoSure(R) MG LC

Facility

$1,502.00

Service Code	CPT 87901
Hospital Charge Code	22311165
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

REF RBC OTHER THAN ABO

Facility

$237.00

Service Code	CPT 86905
Hospital Charge Code	22373722
Hospital Revenue Code	302
Min. Negotiated Rate	$61.62
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Bisbee Police All Plans	$61.62
Rate for Payer: Cash Price	$189.60
Rate for Payer: Self Pay Self Pay	$189.60

REF RBC OTHER THAN ABO

Facility

$237.00

Service Code	CPT 86905
Hospital Charge Code	22373722
Hospital Revenue Code	302
Min. Negotiated Rate	$37.92
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Aetna of AZ Medicare	$66.36
Rate for Payer: Allwell Medicare	$37.92
Rate for Payer: Amerigroup Medicare	$37.92
Rate for Payer: APIPA Medicare/Medicaid	$88.52
Rate for Payer: AZCH Complete Medicare	$37.92
Rate for Payer: Banner UC Health Medicare	$37.92
Rate for Payer: Bisbee Police All Plans	$61.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$161.16
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cigna of AZ Commercial	$154.05
Rate for Payer: Copperpoint Commercial	$58.66
Rate for Payer: Health Net of AZ Commercial	$142.20
Rate for Payer: Health Net of AZ Medicare	$66.36
Rate for Payer: Humana of AZ Medicare	$37.92
Rate for Payer: Self Pay Self Pay	$189.60
Rate for Payer: TriWest Medicare	$37.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$138.17
Rate for Payer: UnitedHealth Group of AZ Medicare	$42.66

REF RBC PHENOTYPING

Facility

$249.00

Service Code	CPT 86906
Hospital Charge Code	1676008
Hospital Revenue Code	302
Min. Negotiated Rate	$64.74
Max. Negotiated Rate	$224.10
Rate for Payer: Aetna of AZ Commercial	$224.10
Rate for Payer: Bisbee Police All Plans	$64.74
Rate for Payer: Cash Price	$199.20
Rate for Payer: Self Pay Self Pay	$199.20

REF RBC PHENOTYPING

Facility

$249.00

Service Code	CPT 86906
Hospital Charge Code	1676008
Hospital Revenue Code	302
Min. Negotiated Rate	$39.84
Max. Negotiated Rate	$224.10
Rate for Payer: Aetna of AZ Commercial	$224.10
Rate for Payer: Aetna of AZ Medicare	$69.72
Rate for Payer: Allwell Medicare	$39.84
Rate for Payer: Amerigroup Medicare	$39.84
Rate for Payer: APIPA Medicare/Medicaid	$93.00
Rate for Payer: AZCH Complete Medicare	$39.84
Rate for Payer: Banner UC Health Medicare	$39.84
Rate for Payer: Bisbee Police All Plans	$64.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$169.32
Rate for Payer: Cash Price	$199.20
Rate for Payer: Cigna of AZ Commercial	$161.85
Rate for Payer: Copperpoint Commercial	$61.63
Rate for Payer: Health Net of AZ Commercial	$149.40
Rate for Payer: Health Net of AZ Medicare	$69.72
Rate for Payer: Humana of AZ Medicare	$39.84
Rate for Payer: Self Pay Self Pay	$199.20
Rate for Payer: TriWest Medicare	$39.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$145.17
Rate for Payer: UnitedHealth Group of AZ Medicare	$44.82

Rehabilitation

Facility

$9,792.25

Service Code	APR-DRG 8602
Hospital Charge Code	APRDRG8602
Min. Negotiated Rate	$9,792.25
Max. Negotiated Rate	$9,792.25
Rate for Payer: AHCCCS Medicaid	$9,792.25
Rate for Payer: Allwell Medicaid	$9,792.25
Rate for Payer: AZCH Complete Medicaid	$9,792.25
Rate for Payer: Banner UC Health Medicaid	$9,792.25
Rate for Payer: Mercy Care Medicaid	$9,792.25

Rehabilitation

Facility

$12,529.81

Service Code	APR-DRG 8603
Hospital Charge Code	APRDRG8602
Min. Negotiated Rate	$12,529.81
Max. Negotiated Rate	$12,529.81
Rate for Payer: AHCCCS Medicaid	$12,529.81
Rate for Payer: Allwell Medicaid	$12,529.81
Rate for Payer: AZCH Complete Medicaid	$12,529.81
Rate for Payer: Banner UC Health Medicaid	$12,529.81
Rate for Payer: Mercy Care Medicaid	$12,529.81

Rehabilitation

Facility

$15,792.02

Service Code	APR-DRG 8604
Hospital Charge Code	APRDRG8601
Min. Negotiated Rate	$15,792.02
Max. Negotiated Rate	$15,792.02
Rate for Payer: AHCCCS Medicaid	$15,792.02
Rate for Payer: Allwell Medicaid	$15,792.02
Rate for Payer: AZCH Complete Medicaid	$15,792.02
Rate for Payer: Banner UC Health Medicaid	$15,792.02
Rate for Payer: Mercy Care Medicaid	$15,792.02

Rehabilitation

Facility

$9,792.25

Service Code	APR-DRG 8602
Hospital Charge Code	APRDRG8601
Min. Negotiated Rate	$9,792.25
Max. Negotiated Rate	$9,792.25
Rate for Payer: AHCCCS Medicaid	$9,792.25
Rate for Payer: Allwell Medicaid	$9,792.25
Rate for Payer: AZCH Complete Medicaid	$9,792.25
Rate for Payer: Banner UC Health Medicaid	$9,792.25
Rate for Payer: Mercy Care Medicaid	$9,792.25

Rehabilitation

Facility

$7,453.78

Service Code	APR-DRG 8601
Hospital Charge Code	APRDRG8602
Min. Negotiated Rate	$7,453.78
Max. Negotiated Rate	$7,453.78
Rate for Payer: AHCCCS Medicaid	$7,453.78
Rate for Payer: Allwell Medicaid	$7,453.78
Rate for Payer: AZCH Complete Medicaid	$7,453.78
Rate for Payer: Banner UC Health Medicaid	$7,453.78
Rate for Payer: Mercy Care Medicaid	$7,453.78

Know your out-of-pocket cost for care.

All Charges