Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

VALVE ANTI-REFLUX

Facility

$41.00

Hospital Charge Code	22355083
Hospital Revenue Code	272
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of AZ Commercial	$36.90
Rate for Payer: Bisbee Police All Plans	$10.66
Rate for Payer: Cash Price	$32.80
Rate for Payer: Self Pay Self Pay	$32.80

VALVE FLUTTER ACAPELLA

Facility

$217.00

Hospital Charge Code	22355242
Hospital Revenue Code	270
Min. Negotiated Rate	$32.55
Max. Negotiated Rate	$195.30
Rate for Payer: Aetna of AZ Commercial	$195.30
Rate for Payer: Aetna of AZ Medicare	$60.76
Rate for Payer: Allwell Medicare	$32.55
Rate for Payer: Amerigroup Medicare	$32.55
Rate for Payer: APIPA Medicare/Medicaid	$81.05
Rate for Payer: AZCH Complete Medicare	$32.55
Rate for Payer: Banner UC Health Medicare	$32.55
Rate for Payer: Bisbee Police All Plans	$56.42
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$147.56
Rate for Payer: Cash Price	$173.60
Rate for Payer: Cigna of AZ Commercial	$151.90
Rate for Payer: Copperpoint Commercial	$53.71
Rate for Payer: Health Net of AZ Commercial	$130.20
Rate for Payer: Health Net of AZ Medicare	$60.76
Rate for Payer: Humana of AZ Medicare	$32.55
Rate for Payer: Self Pay Self Pay	$173.60
Rate for Payer: TriWest Medicare	$32.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$126.51
Rate for Payer: UnitedHealth Group of AZ Medicare	$39.06

VALVE FLUTTER ACAPELLA

Facility

$217.00

Hospital Charge Code	22355242
Hospital Revenue Code	270
Min. Negotiated Rate	$56.42
Max. Negotiated Rate	$195.30
Rate for Payer: Aetna of AZ Commercial	$195.30
Rate for Payer: Bisbee Police All Plans	$56.42
Rate for Payer: Cash Price	$173.60
Rate for Payer: Self Pay Self Pay	$173.60

vancomycin 1000 mg IV Inj [CQCH]

Facility

$2.60

Service Code	HCPCS J3370
Hospital Charge Code	105944736
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$5.42
Rate for Payer: Aetna of AZ Commercial	$2.34
Rate for Payer: Aetna of AZ Medicare	$0.73
Rate for Payer: AHCCCS Medicaid	$5.42
Rate for Payer: Allwell Medicaid	$5.42
Rate for Payer: Allwell Medicare	$0.39
Rate for Payer: Amerigroup Medicare	$0.39
Rate for Payer: APIPA Medicare/Medicaid	$0.97
Rate for Payer: AZCH Complete Medicaid	$5.42
Rate for Payer: AZCH Complete Medicare	$0.39
Rate for Payer: Banner UC Health Medicaid	$5.42
Rate for Payer: Banner UC Health Medicare	$0.39
Rate for Payer: Bisbee Police All Plans	$0.68
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.77
Rate for Payer: Cash Price	$2.08
Rate for Payer: Cash Price	$2.08
Rate for Payer: Cigna of AZ Commercial	$1.69
Rate for Payer: Copperpoint Commercial	$0.64
Rate for Payer: Health Net of AZ Commercial	$1.56
Rate for Payer: Health Net of AZ Medicare	$0.73
Rate for Payer: Humana of AZ Medicare	$0.39
Rate for Payer: Mercy Care Medicaid	$5.42
Rate for Payer: Self Pay Self Pay	$2.08
Rate for Payer: TriWest Medicare	$0.39
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.47

vancomycin 1000 mg IV Inj [CQCH]

Facility

$2.60

Service Code	HCPCS J3370
Hospital Charge Code	105944736
Hospital Revenue Code	250
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$2.34
Rate for Payer: Aetna of AZ Commercial	$2.34
Rate for Payer: Bisbee Police All Plans	$0.68
Rate for Payer: Cash Price	$2.08
Rate for Payer: Self Pay Self Pay	$2.08

vancomycin 125 mg Cap UD [CQCH]

Facility

$8.37

Service Code	NDC 47781072902
Hospital Charge Code	108082992
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$7.53
Rate for Payer: Aetna of AZ Commercial	$7.53
Rate for Payer: Aetna of AZ Medicare	$2.34
Rate for Payer: Allwell Medicare	$1.26
Rate for Payer: Amerigroup Medicare	$1.26
Rate for Payer: APIPA Medicare/Medicaid	$3.13
Rate for Payer: AZCH Complete Medicare	$1.26
Rate for Payer: Banner UC Health Medicare	$1.26
Rate for Payer: Bisbee Police All Plans	$2.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$5.69
Rate for Payer: Cash Price	$6.70
Rate for Payer: Cigna of AZ Commercial	$5.44
Rate for Payer: Copperpoint Commercial	$2.07
Rate for Payer: Health Net of AZ Commercial	$5.02
Rate for Payer: Health Net of AZ Medicare	$2.34
Rate for Payer: Humana of AZ Medicare	$1.26
Rate for Payer: Self Pay Self Pay	$6.70
Rate for Payer: TriWest Medicare	$1.26
Rate for Payer: UnitedHealth Group of AZ Commercial	$4.88
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.51

vancomycin 125 mg Cap UD [CQCH]

Facility

$8.37

Service Code	NDC 47781072902
Hospital Charge Code	108082992
Hospital Revenue Code	250
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$7.53
Rate for Payer: Aetna of AZ Commercial	$7.53
Rate for Payer: Bisbee Police All Plans	$2.18
Rate for Payer: Cash Price	$6.70
Rate for Payer: Self Pay Self Pay	$6.70

vancomycin 500 mg IV Inj [CQCH]

Facility

$2.06

Service Code	HCPCS J3370
Hospital Charge Code	105944667
Hospital Revenue Code	250
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$5.42
Rate for Payer: Aetna of AZ Commercial	$1.85
Rate for Payer: Aetna of AZ Medicare	$0.58
Rate for Payer: AHCCCS Medicaid	$5.42
Rate for Payer: Allwell Medicaid	$5.42
Rate for Payer: Allwell Medicare	$0.31
Rate for Payer: Amerigroup Medicare	$0.31
Rate for Payer: APIPA Medicare/Medicaid	$0.77
Rate for Payer: AZCH Complete Medicaid	$5.42
Rate for Payer: AZCH Complete Medicare	$0.31
Rate for Payer: Banner UC Health Medicaid	$5.42
Rate for Payer: Banner UC Health Medicare	$0.31
Rate for Payer: Bisbee Police All Plans	$0.54
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.40
Rate for Payer: Cash Price	$1.65
Rate for Payer: Cash Price	$1.65
Rate for Payer: Cigna of AZ Commercial	$1.34
Rate for Payer: Copperpoint Commercial	$0.51
Rate for Payer: Health Net of AZ Commercial	$1.24
Rate for Payer: Health Net of AZ Medicare	$0.58
Rate for Payer: Humana of AZ Medicare	$0.31
Rate for Payer: Mercy Care Medicaid	$5.42
Rate for Payer: Self Pay Self Pay	$1.65
Rate for Payer: TriWest Medicare	$0.31
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.20
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.37

vancomycin 500 mg IV Inj [CQCH]

Facility

$2.06

Service Code	HCPCS J3370
Hospital Charge Code	105944667
Hospital Revenue Code	250
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$1.85
Rate for Payer: Aetna of AZ Commercial	$1.85
Rate for Payer: Bisbee Police All Plans	$0.54
Rate for Payer: Cash Price	$1.65
Rate for Payer: Self Pay Self Pay	$1.65

Vancomycin Lvl Peak 1

Facility

$185.00

Service Code	CPT 80202
Hospital Charge Code	9579711
Hospital Revenue Code	301
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$166.50
Rate for Payer: Aetna of AZ Commercial	$166.50
Rate for Payer: Aetna of AZ Medicare	$51.80
Rate for Payer: AHCCCS Medicaid	$13.54
Rate for Payer: Allwell Medicaid	$13.54
Rate for Payer: Allwell Medicare	$27.75
Rate for Payer: Amerigroup Medicare	$27.75
Rate for Payer: APIPA Medicare/Medicaid	$69.10
Rate for Payer: AZCH Complete Medicaid	$13.54
Rate for Payer: AZCH Complete Medicare	$27.75
Rate for Payer: Banner UC Health Medicaid	$13.54
Rate for Payer: Banner UC Health Medicare	$27.75
Rate for Payer: Bisbee Police All Plans	$48.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$125.80
Rate for Payer: Cash Price	$148.00
Rate for Payer: Cash Price	$148.00
Rate for Payer: Cigna of AZ Commercial	$120.25
Rate for Payer: Copperpoint Commercial	$45.79
Rate for Payer: Health Net of AZ Commercial	$111.00
Rate for Payer: Health Net of AZ Medicare	$51.80
Rate for Payer: Humana of AZ Medicare	$27.75
Rate for Payer: Mercy Care Medicaid	$13.54
Rate for Payer: Self Pay Self Pay	$148.00
Rate for Payer: TriWest Medicare	$27.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$107.86
Rate for Payer: UnitedHealth Group of AZ Medicare	$33.30

Vancomycin Lvl Peak 1

Facility

$185.00

Service Code	CPT 80202
Hospital Charge Code	9579711
Hospital Revenue Code	301
Min. Negotiated Rate	$48.10
Max. Negotiated Rate	$166.50
Rate for Payer: Aetna of AZ Commercial	$166.50
Rate for Payer: Bisbee Police All Plans	$48.10
Rate for Payer: Cash Price	$148.00
Rate for Payer: Self Pay Self Pay	$148.00

Vancomycin Lvl Random

Facility

$185.00

Service Code	CPT 80202
Hospital Charge Code	633868
Hospital Revenue Code	301
Min. Negotiated Rate	$48.10
Max. Negotiated Rate	$166.50
Rate for Payer: Aetna of AZ Commercial	$166.50
Rate for Payer: Bisbee Police All Plans	$48.10
Rate for Payer: Cash Price	$148.00
Rate for Payer: Self Pay Self Pay	$148.00

Vancomycin Lvl Random

Facility

$185.00

Service Code	CPT 80202
Hospital Charge Code	633868
Hospital Revenue Code	301
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$166.50
Rate for Payer: Aetna of AZ Commercial	$166.50
Rate for Payer: Aetna of AZ Medicare	$51.80
Rate for Payer: AHCCCS Medicaid	$13.54
Rate for Payer: Allwell Medicaid	$13.54
Rate for Payer: Allwell Medicare	$27.75
Rate for Payer: Amerigroup Medicare	$27.75
Rate for Payer: APIPA Medicare/Medicaid	$69.10
Rate for Payer: AZCH Complete Medicaid	$13.54
Rate for Payer: AZCH Complete Medicare	$27.75
Rate for Payer: Banner UC Health Medicaid	$13.54
Rate for Payer: Banner UC Health Medicare	$27.75
Rate for Payer: Bisbee Police All Plans	$48.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$125.80
Rate for Payer: Cash Price	$148.00
Rate for Payer: Cash Price	$148.00
Rate for Payer: Cigna of AZ Commercial	$120.25
Rate for Payer: Copperpoint Commercial	$45.79
Rate for Payer: Health Net of AZ Commercial	$111.00
Rate for Payer: Health Net of AZ Medicare	$51.80
Rate for Payer: Humana of AZ Medicare	$27.75
Rate for Payer: Mercy Care Medicaid	$13.54
Rate for Payer: Self Pay Self Pay	$148.00
Rate for Payer: TriWest Medicare	$27.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$107.86
Rate for Payer: UnitedHealth Group of AZ Medicare	$33.30

Vancomycin Lvl Trough 1

Facility

$185.00

Service Code	CPT 80202
Hospital Charge Code	9579712
Hospital Revenue Code	301
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$166.50
Rate for Payer: Aetna of AZ Commercial	$166.50
Rate for Payer: Aetna of AZ Medicare	$51.80
Rate for Payer: AHCCCS Medicaid	$13.54
Rate for Payer: Allwell Medicaid	$13.54
Rate for Payer: Allwell Medicare	$27.75
Rate for Payer: Amerigroup Medicare	$27.75
Rate for Payer: APIPA Medicare/Medicaid	$69.10
Rate for Payer: AZCH Complete Medicaid	$13.54
Rate for Payer: AZCH Complete Medicare	$27.75
Rate for Payer: Banner UC Health Medicaid	$13.54
Rate for Payer: Banner UC Health Medicare	$27.75
Rate for Payer: Bisbee Police All Plans	$48.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$125.80
Rate for Payer: Cash Price	$148.00
Rate for Payer: Cash Price	$148.00
Rate for Payer: Cigna of AZ Commercial	$120.25
Rate for Payer: Copperpoint Commercial	$45.79
Rate for Payer: Health Net of AZ Commercial	$111.00
Rate for Payer: Health Net of AZ Medicare	$51.80
Rate for Payer: Humana of AZ Medicare	$27.75
Rate for Payer: Mercy Care Medicaid	$13.54
Rate for Payer: Self Pay Self Pay	$148.00
Rate for Payer: TriWest Medicare	$27.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$107.86
Rate for Payer: UnitedHealth Group of AZ Medicare	$33.30

Vancomycin Lvl Trough 1

Facility

$185.00

Service Code	CPT 80202
Hospital Charge Code	9579712
Hospital Revenue Code	301
Min. Negotiated Rate	$48.10
Max. Negotiated Rate	$166.50
Rate for Payer: Aetna of AZ Commercial	$166.50
Rate for Payer: Bisbee Police All Plans	$48.10
Rate for Payer: Cash Price	$148.00
Rate for Payer: Self Pay Self Pay	$148.00

Vanillylmandelic Acid, 24-Hr U LC

Facility

$172.00

Service Code	CPT 84585
Hospital Charge Code	1909573
Hospital Revenue Code	301
Min. Negotiated Rate	$15.50
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Aetna of AZ Medicare	$48.16
Rate for Payer: AHCCCS Medicaid	$15.50
Rate for Payer: Allwell Medicaid	$15.50
Rate for Payer: Allwell Medicare	$25.80
Rate for Payer: Amerigroup Medicare	$25.80
Rate for Payer: APIPA Medicare/Medicaid	$64.24
Rate for Payer: AZCH Complete Medicaid	$15.50
Rate for Payer: AZCH Complete Medicare	$25.80
Rate for Payer: Banner UC Health Medicaid	$15.50
Rate for Payer: Banner UC Health Medicare	$25.80
Rate for Payer: Bisbee Police All Plans	$44.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$116.96
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cigna of AZ Commercial	$111.80
Rate for Payer: Copperpoint Commercial	$42.57
Rate for Payer: Health Net of AZ Commercial	$103.20
Rate for Payer: Health Net of AZ Medicare	$48.16
Rate for Payer: Humana of AZ Medicare	$25.80
Rate for Payer: Mercy Care Medicaid	$15.50
Rate for Payer: Self Pay Self Pay	$137.60
Rate for Payer: TriWest Medicare	$25.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$100.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$30.96

Vanillylmandelic Acid, 24-Hr U LC

Facility

$172.00

Service Code	CPT 84585
Hospital Charge Code	1909573
Hospital Revenue Code	301
Min. Negotiated Rate	$44.72
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Bisbee Police All Plans	$44.72
Rate for Payer: Cash Price	$137.60
Rate for Payer: Self Pay Self Pay	$137.60

VAP Cholesterol Profile LC

Facility

$109.00

Service Code	CPT 84478
Hospital Charge Code	1909580
Hospital Revenue Code	301
Min. Negotiated Rate	$5.74
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Aetna of AZ Medicare	$30.52
Rate for Payer: AHCCCS Medicaid	$5.74
Rate for Payer: Allwell Medicaid	$5.74
Rate for Payer: Allwell Medicare	$16.35
Rate for Payer: Amerigroup Medicare	$16.35
Rate for Payer: APIPA Medicare/Medicaid	$40.71
Rate for Payer: AZCH Complete Medicaid	$5.74
Rate for Payer: AZCH Complete Medicare	$16.35
Rate for Payer: Banner UC Health Medicaid	$5.74
Rate for Payer: Banner UC Health Medicare	$16.35
Rate for Payer: Bisbee Police All Plans	$28.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$74.12
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cigna of AZ Commercial	$70.85
Rate for Payer: Copperpoint Commercial	$26.98
Rate for Payer: Health Net of AZ Commercial	$65.40
Rate for Payer: Health Net of AZ Medicare	$30.52
Rate for Payer: Humana of AZ Medicare	$16.35
Rate for Payer: Mercy Care Medicaid	$5.74
Rate for Payer: Self Pay Self Pay	$87.20
Rate for Payer: TriWest Medicare	$16.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$63.55
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.62

VAP Cholesterol Profile LC

Facility

$109.00

Service Code	CPT 84478
Hospital Charge Code	1909580
Hospital Revenue Code	301
Min. Negotiated Rate	$28.34
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Bisbee Police All Plans	$28.34
Rate for Payer: Cash Price	$87.20
Rate for Payer: Self Pay Self Pay	$87.20

Vapotherm Initial

Facility

$4,256.00

Service Code	CPT 94002
Hospital Charge Code	3882290
Hospital Revenue Code	410
Min. Negotiated Rate	$1,106.56
Max. Negotiated Rate	$3,830.40
Rate for Payer: Aetna of AZ Commercial	$3,830.40
Rate for Payer: Bisbee Police All Plans	$1,106.56
Rate for Payer: Cash Price	$3,404.80
Rate for Payer: Self Pay Self Pay	$3,404.80

Vapotherm Initial

Facility

$4,256.00

Service Code	CPT 94002
Hospital Charge Code	3882290
Hospital Revenue Code	410
Min. Negotiated Rate	$638.40
Max. Negotiated Rate	$3,830.40
Rate for Payer: Aetna of AZ Commercial	$3,830.40
Rate for Payer: Aetna of AZ Medicare	$1,191.68
Rate for Payer: AHCCCS Medicaid	$703.62
Rate for Payer: Allwell Medicaid	$703.62
Rate for Payer: Allwell Medicare	$638.40
Rate for Payer: Amerigroup Medicare	$638.40
Rate for Payer: APIPA Medicare/Medicaid	$1,589.62
Rate for Payer: AZCH Complete Medicaid	$703.62
Rate for Payer: AZCH Complete Medicare	$638.40
Rate for Payer: Banner UC Health Medicaid	$703.62
Rate for Payer: Banner UC Health Medicare	$638.40
Rate for Payer: Bisbee Police All Plans	$1,106.56
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,894.08
Rate for Payer: Cash Price	$3,404.80
Rate for Payer: Cash Price	$3,404.80
Rate for Payer: Cigna of AZ Commercial	$2,979.20
Rate for Payer: Copperpoint Commercial	$1,053.36
Rate for Payer: Health Net of AZ Commercial	$2,553.60
Rate for Payer: Health Net of AZ Medicare	$1,191.68
Rate for Payer: Humana of AZ Medicare	$638.40
Rate for Payer: Mercy Care Medicaid	$703.62
Rate for Payer: Self Pay Self Pay	$3,404.80
Rate for Payer: TriWest Medicare	$638.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,481.25
Rate for Payer: UnitedHealth Group of AZ Medicare	$766.08

Vapotherm Subsequent

Facility

$2,858.00

Service Code	CPT 94003
Hospital Charge Code	3882291
Hospital Revenue Code	410
Min. Negotiated Rate	$743.08
Max. Negotiated Rate	$2,572.20
Rate for Payer: Aetna of AZ Commercial	$2,572.20
Rate for Payer: Bisbee Police All Plans	$743.08
Rate for Payer: Cash Price	$2,286.40
Rate for Payer: Self Pay Self Pay	$2,286.40

Vapotherm Subsequent

Facility

$2,858.00

Service Code	CPT 94003
Hospital Charge Code	3882291
Hospital Revenue Code	410
Min. Negotiated Rate	$428.70
Max. Negotiated Rate	$2,572.20
Rate for Payer: Aetna of AZ Commercial	$2,572.20
Rate for Payer: Aetna of AZ Medicare	$800.24
Rate for Payer: AHCCCS Medicaid	$703.62
Rate for Payer: Allwell Medicaid	$703.62
Rate for Payer: Allwell Medicare	$428.70
Rate for Payer: Amerigroup Medicare	$428.70
Rate for Payer: APIPA Medicare/Medicaid	$1,067.46
Rate for Payer: AZCH Complete Medicaid	$703.62
Rate for Payer: AZCH Complete Medicare	$428.70
Rate for Payer: Banner UC Health Medicaid	$703.62
Rate for Payer: Banner UC Health Medicare	$428.70
Rate for Payer: Bisbee Police All Plans	$743.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,943.44
Rate for Payer: Cash Price	$2,286.40
Rate for Payer: Cash Price	$2,286.40
Rate for Payer: Cigna of AZ Commercial	$2,000.60
Rate for Payer: Copperpoint Commercial	$707.36
Rate for Payer: Health Net of AZ Commercial	$1,714.80
Rate for Payer: Health Net of AZ Medicare	$800.24
Rate for Payer: Humana of AZ Medicare	$428.70
Rate for Payer: Mercy Care Medicaid	$703.62
Rate for Payer: Self Pay Self Pay	$2,286.40
Rate for Payer: TriWest Medicare	$428.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,666.21
Rate for Payer: UnitedHealth Group of AZ Medicare	$514.44

Varicella-Zoster IgM Ab LC

Facility

$290.00

Service Code	CPT 86787
Hospital Charge Code	6780778
Hospital Revenue Code	302
Min. Negotiated Rate	$75.40
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna of AZ Commercial	$261.00
Rate for Payer: Bisbee Police All Plans	$75.40
Rate for Payer: Cash Price	$232.00
Rate for Payer: Self Pay Self Pay	$232.00

Varicella-Zoster IgM Ab LC

Facility

$290.00

Service Code	CPT 86787
Hospital Charge Code	6780778
Hospital Revenue Code	302
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna of AZ Commercial	$261.00
Rate for Payer: Aetna of AZ Medicare	$81.20
Rate for Payer: AHCCCS Medicaid	$12.88
Rate for Payer: Allwell Medicaid	$12.88
Rate for Payer: Allwell Medicare	$43.50
Rate for Payer: Amerigroup Medicare	$43.50
Rate for Payer: APIPA Medicare/Medicaid	$108.32
Rate for Payer: AZCH Complete Medicaid	$12.88
Rate for Payer: AZCH Complete Medicare	$43.50
Rate for Payer: Banner UC Health Medicaid	$12.88
Rate for Payer: Banner UC Health Medicare	$43.50
Rate for Payer: Bisbee Police All Plans	$75.40
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$197.20
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cigna of AZ Commercial	$188.50
Rate for Payer: Copperpoint Commercial	$71.78
Rate for Payer: Health Net of AZ Commercial	$174.00
Rate for Payer: Health Net of AZ Medicare	$81.20
Rate for Payer: Humana of AZ Medicare	$43.50
Rate for Payer: Mercy Care Medicaid	$12.88
Rate for Payer: Self Pay Self Pay	$232.00
Rate for Payer: TriWest Medicare	$43.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$169.07
Rate for Payer: UnitedHealth Group of AZ Medicare	$52.20

Know your out-of-pocket cost for care.

All Charges