Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

CLIENT BLOOD COLLECT SQ

Facility

$13.00

Service Code	CPT 36415
Hospital Charge Code	22331169
Hospital Revenue Code	300
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$11.70
Rate for Payer: Aetna of AZ Commercial	$11.70
Rate for Payer: Bisbee Police All Plans	$3.38
Rate for Payer: Cash Price	$10.40
Rate for Payer: Self Pay Self Pay	$10.40

CLIENT CARTRIDGE RESPIRATOR FIT TEST

Facility

$48.00

Hospital Charge Code	22331178
Hospital Revenue Code	999
Min. Negotiated Rate	$12.48
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of AZ Commercial	$43.20
Rate for Payer: Bisbee Police All Plans	$12.48
Rate for Payer: Cash Price	$38.40
Rate for Payer: Self Pay Self Pay	$38.40

CLIENT CARTRIDGE RESPIRATOR FIT TEST

Facility

$48.00

Hospital Charge Code	22331178
Hospital Revenue Code	999
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of AZ Commercial	$43.20
Rate for Payer: Aetna of AZ Medicare	$13.44
Rate for Payer: Allwell Medicare	$7.20
Rate for Payer: Amerigroup Medicare	$7.20
Rate for Payer: APIPA Medicare/Medicaid	$17.93
Rate for Payer: AZCH Complete Medicare	$7.20
Rate for Payer: Banner UC Health Medicare	$7.20
Rate for Payer: Bisbee Police All Plans	$12.48
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$32.64
Rate for Payer: Cash Price	$38.40
Rate for Payer: Cigna of AZ Commercial	$33.60
Rate for Payer: Copperpoint Commercial	$11.88
Rate for Payer: Health Net of AZ Commercial	$28.80
Rate for Payer: Health Net of AZ Medicare	$13.44
Rate for Payer: Humana of AZ Medicare	$7.20
Rate for Payer: Self Pay Self Pay	$38.40
Rate for Payer: TriWest Medicare	$7.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$27.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$8.64

CLIENT CATH URETHRA COMPLEX

Facility

$315.00

Service Code	CPT 51703
Hospital Charge Code	22331180
Hospital Revenue Code	450
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of AZ Commercial	$283.50
Rate for Payer: Bisbee Police All Plans	$81.90
Rate for Payer: Cash Price	$252.00
Rate for Payer: Self Pay Self Pay	$252.00

CLIENT CATH URETHRA COMPLEX

Facility

$315.00

Service Code	CPT 51703
Hospital Charge Code	22331180
Hospital Revenue Code	450
Min. Negotiated Rate	$47.25
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$283.50
Rate for Payer: Aetna of AZ Medicare	$88.20
Rate for Payer: AHCCCS Medicaid	$202.34
Rate for Payer: Allwell Medicaid	$202.34
Rate for Payer: Allwell Medicare	$47.25
Rate for Payer: Amerigroup Medicare	$47.25
Rate for Payer: APIPA Medicare/Medicaid	$117.65
Rate for Payer: AZCH Complete Medicaid	$202.34
Rate for Payer: AZCH Complete Medicare	$47.25
Rate for Payer: Banner UC Health Medicaid	$202.34
Rate for Payer: Banner UC Health Medicare	$47.25
Rate for Payer: Bisbee Police All Plans	$81.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$214.20
Rate for Payer: Cash Price	$252.00
Rate for Payer: Cash Price	$252.00
Rate for Payer: Cigna of AZ Commercial	$220.50
Rate for Payer: Copperpoint Commercial	$77.96
Rate for Payer: Health Net of AZ Commercial	$189.00
Rate for Payer: Health Net of AZ Medicare	$88.20
Rate for Payer: Humana of AZ Medicare	$47.25
Rate for Payer: Mercy Care Medicaid	$202.34
Rate for Payer: Self Pay Self Pay	$252.00
Rate for Payer: TriWest Medicare	$47.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$56.70

CLIENT CATH URETHRA SIMPLE

Facility

$106.00

Service Code	CPT 51701
Hospital Charge Code	22331181
Hospital Revenue Code	450
Min. Negotiated Rate	$27.56
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of AZ Commercial	$95.40
Rate for Payer: Bisbee Police All Plans	$27.56
Rate for Payer: Cash Price	$84.80
Rate for Payer: Self Pay Self Pay	$84.80

CLIENT CATH URETHRA SIMPLE

Facility

$106.00

Service Code	CPT 51701
Hospital Charge Code	22331181
Hospital Revenue Code	450
Min. Negotiated Rate	$15.90
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$95.40
Rate for Payer: Aetna of AZ Medicare	$29.68
Rate for Payer: AHCCCS Medicaid	$162.32
Rate for Payer: Allwell Medicaid	$162.32
Rate for Payer: Allwell Medicare	$15.90
Rate for Payer: Amerigroup Medicare	$15.90
Rate for Payer: APIPA Medicare/Medicaid	$39.59
Rate for Payer: AZCH Complete Medicaid	$162.32
Rate for Payer: AZCH Complete Medicare	$15.90
Rate for Payer: Banner UC Health Medicaid	$162.32
Rate for Payer: Banner UC Health Medicare	$15.90
Rate for Payer: Bisbee Police All Plans	$27.56
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$72.08
Rate for Payer: Cash Price	$84.80
Rate for Payer: Cash Price	$84.80
Rate for Payer: Cigna of AZ Commercial	$74.20
Rate for Payer: Copperpoint Commercial	$26.24
Rate for Payer: Health Net of AZ Commercial	$63.60
Rate for Payer: Health Net of AZ Medicare	$29.68
Rate for Payer: Humana of AZ Medicare	$15.90
Rate for Payer: Mercy Care Medicaid	$162.32
Rate for Payer: Self Pay Self Pay	$84.80
Rate for Payer: TriWest Medicare	$15.90
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.08

CLIENT CHAIN OF CUST URINE

Facility

$24.00

Hospital Charge Code	22331187
Hospital Revenue Code	302
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna of AZ Commercial	$21.60
Rate for Payer: Bisbee Police All Plans	$6.24
Rate for Payer: Cash Price	$19.20
Rate for Payer: Self Pay Self Pay	$19.20

CLIENT CHAIN OF CUST URINE

Facility

$24.00

Hospital Charge Code	22331187
Hospital Revenue Code	302
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna of AZ Commercial	$21.60
Rate for Payer: Aetna of AZ Medicare	$6.72
Rate for Payer: Allwell Medicare	$3.60
Rate for Payer: Amerigroup Medicare	$3.60
Rate for Payer: APIPA Medicare/Medicaid	$8.96
Rate for Payer: AZCH Complete Medicare	$3.60
Rate for Payer: Banner UC Health Medicare	$3.60
Rate for Payer: Bisbee Police All Plans	$6.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$16.32
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cigna of AZ Commercial	$15.60
Rate for Payer: Copperpoint Commercial	$5.94
Rate for Payer: Health Net of AZ Commercial	$14.40
Rate for Payer: Health Net of AZ Medicare	$6.72
Rate for Payer: Humana of AZ Medicare	$3.60
Rate for Payer: Self Pay Self Pay	$19.20
Rate for Payer: TriWest Medicare	$3.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$13.99
Rate for Payer: UnitedHealth Group of AZ Medicare	$4.32

CLIENT COLOR VISION 12 PLATE ISHIHARA

Facility

$15.00

Hospital Charge Code	22331203
Hospital Revenue Code	301
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of AZ Commercial	$13.50
Rate for Payer: Aetna of AZ Medicare	$4.20
Rate for Payer: Allwell Medicare	$2.25
Rate for Payer: Amerigroup Medicare	$2.25
Rate for Payer: APIPA Medicare/Medicaid	$5.60
Rate for Payer: AZCH Complete Medicare	$2.25
Rate for Payer: Banner UC Health Medicare	$2.25
Rate for Payer: Bisbee Police All Plans	$3.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$10.20
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cigna of AZ Commercial	$9.75
Rate for Payer: Copperpoint Commercial	$3.71
Rate for Payer: Health Net of AZ Commercial	$9.00
Rate for Payer: Health Net of AZ Medicare	$4.20
Rate for Payer: Humana of AZ Medicare	$2.25
Rate for Payer: Self Pay Self Pay	$12.00
Rate for Payer: TriWest Medicare	$2.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$8.74
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.70

CLIENT COLOR VISION 12 PLATE ISHIHARA

Facility

$15.00

Hospital Charge Code	22331203
Hospital Revenue Code	301
Min. Negotiated Rate	$3.90
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of AZ Commercial	$13.50
Rate for Payer: Bisbee Police All Plans	$3.90
Rate for Payer: Cash Price	$12.00
Rate for Payer: Self Pay Self Pay	$12.00

CLIENT COLOR VISION 24 PLATE ISHIHARA

Facility

$16.00

Hospital Charge Code	22331204
Hospital Revenue Code	301
Min. Negotiated Rate	$4.16
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Bisbee Police All Plans	$4.16
Rate for Payer: Cash Price	$12.80
Rate for Payer: Self Pay Self Pay	$12.80

CLIENT COLOR VISION 24 PLATE ISHIHARA

Facility

$16.00

Hospital Charge Code	22331204
Hospital Revenue Code	301
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Aetna of AZ Medicare	$4.48
Rate for Payer: Allwell Medicare	$2.40
Rate for Payer: Amerigroup Medicare	$2.40
Rate for Payer: APIPA Medicare/Medicaid	$5.98
Rate for Payer: AZCH Complete Medicare	$2.40
Rate for Payer: Banner UC Health Medicare	$2.40
Rate for Payer: Bisbee Police All Plans	$4.16
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$10.88
Rate for Payer: Cash Price	$12.80
Rate for Payer: Cigna of AZ Commercial	$10.40
Rate for Payer: Copperpoint Commercial	$3.96
Rate for Payer: Health Net of AZ Commercial	$9.60
Rate for Payer: Health Net of AZ Medicare	$4.48
Rate for Payer: Humana of AZ Medicare	$2.40
Rate for Payer: Self Pay Self Pay	$12.80
Rate for Payer: TriWest Medicare	$2.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$9.33
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.88

CLIENT COMPLEX EXAM

Facility

$108.00

Hospital Charge Code	22331210
Hospital Revenue Code	301
Min. Negotiated Rate	$28.08
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of AZ Commercial	$97.20
Rate for Payer: Bisbee Police All Plans	$28.08
Rate for Payer: Cash Price	$86.40
Rate for Payer: Self Pay Self Pay	$86.40

CLIENT COMPLEX EXAM

Facility

$108.00

Hospital Charge Code	22331210
Hospital Revenue Code	301
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of AZ Commercial	$97.20
Rate for Payer: Aetna of AZ Medicare	$30.24
Rate for Payer: Allwell Medicare	$16.20
Rate for Payer: Amerigroup Medicare	$16.20
Rate for Payer: APIPA Medicare/Medicaid	$40.34
Rate for Payer: AZCH Complete Medicare	$16.20
Rate for Payer: Banner UC Health Medicare	$16.20
Rate for Payer: Bisbee Police All Plans	$28.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$73.44
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna of AZ Commercial	$70.20
Rate for Payer: Copperpoint Commercial	$26.73
Rate for Payer: Health Net of AZ Commercial	$64.80
Rate for Payer: Health Net of AZ Medicare	$30.24
Rate for Payer: Humana of AZ Medicare	$16.20
Rate for Payer: Self Pay Self Pay	$86.40
Rate for Payer: TriWest Medicare	$16.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$62.96
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.44

CLIENT CT HEAD WO CONTR

Facility

$302.24

Service Code	CPT 70450
Hospital Charge Code	22331223
Hospital Revenue Code	351
Min. Negotiated Rate	$78.58
Max. Negotiated Rate	$272.02
Rate for Payer: Aetna of AZ Commercial	$272.02
Rate for Payer: Bisbee Police All Plans	$78.58
Rate for Payer: Cash Price	$241.79
Rate for Payer: Self Pay Self Pay	$241.79

CLIENT CT HEAD WO CONTR

Facility

$302.24

Service Code	CPT 70450
Hospital Charge Code	22331223
Hospital Revenue Code	351
Min. Negotiated Rate	$45.34
Max. Negotiated Rate	$272.02
Rate for Payer: Aetna of AZ Commercial	$272.02
Rate for Payer: Aetna of AZ Medicare	$84.63
Rate for Payer: AHCCCS Medicaid	$158.00
Rate for Payer: Allwell Medicaid	$158.00
Rate for Payer: Allwell Medicare	$45.34
Rate for Payer: Amerigroup Medicare	$45.34
Rate for Payer: APIPA Medicare/Medicaid	$112.89
Rate for Payer: AZCH Complete Medicaid	$158.00
Rate for Payer: AZCH Complete Medicare	$45.34
Rate for Payer: Banner UC Health Medicaid	$158.00
Rate for Payer: Banner UC Health Medicare	$45.34
Rate for Payer: Bisbee Police All Plans	$78.58
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$205.52
Rate for Payer: Cash Price	$241.79
Rate for Payer: Cash Price	$241.79
Rate for Payer: Cigna of AZ Commercial	$196.46
Rate for Payer: Copperpoint Commercial	$74.80
Rate for Payer: Health Net of AZ Commercial	$181.34
Rate for Payer: Health Net of AZ Medicare	$84.63
Rate for Payer: Humana of AZ Medicare	$45.34
Rate for Payer: Mercy Care Medicaid	$158.00
Rate for Payer: Self Pay Self Pay	$241.79
Rate for Payer: TriWest Medicare	$45.34
Rate for Payer: UnitedHealth Group of AZ Commercial	$176.21
Rate for Payer: UnitedHealth Group of AZ Medicare	$54.40

CLIENT DOT PHYS EXAM

Facility

$85.00

Service Code	CPT 99202 22
Hospital Charge Code	22331239
Hospital Revenue Code	982
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of AZ Commercial	$76.50
Rate for Payer: Bisbee Police All Plans	$22.10
Rate for Payer: Cash Price	$68.00
Rate for Payer: Self Pay Self Pay	$68.00

CLIENT DOT PHYS EXAM

Facility

$85.00

Service Code	CPT 99202 22
Hospital Charge Code	22331239
Hospital Revenue Code	982
Min. Negotiated Rate	$12.75
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of AZ Commercial	$76.50
Rate for Payer: Aetna of AZ Medicare	$23.80
Rate for Payer: Allwell Medicare	$12.75
Rate for Payer: Amerigroup Medicare	$12.75
Rate for Payer: APIPA Medicare/Medicaid	$31.75
Rate for Payer: AZCH Complete Medicare	$12.75
Rate for Payer: Banner UC Health Medicare	$12.75
Rate for Payer: Bisbee Police All Plans	$22.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$57.80
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cigna of AZ Commercial	$59.50
Rate for Payer: Copperpoint Commercial	$21.04
Rate for Payer: Health Net of AZ Commercial	$51.00
Rate for Payer: Health Net of AZ Medicare	$23.80
Rate for Payer: Humana of AZ Medicare	$12.75
Rate for Payer: Self Pay Self Pay	$68.00
Rate for Payer: TriWest Medicare	$12.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$49.56
Rate for Payer: UnitedHealth Group of AZ Medicare	$15.30

CLIENT DRSG TEGADERM 1X1.75

Facility

$14.00

Hospital Charge Code	22331240
Hospital Revenue Code	272
Min. Negotiated Rate	$3.64
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of AZ Commercial	$12.60
Rate for Payer: Bisbee Police All Plans	$3.64
Rate for Payer: Cash Price	$11.20
Rate for Payer: Self Pay Self Pay	$11.20

CLIENT DRSG TEGADERM 1X1.75

Facility

$14.00

Hospital Charge Code	22331240
Hospital Revenue Code	272
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of AZ Commercial	$12.60
Rate for Payer: Aetna of AZ Medicare	$3.92
Rate for Payer: Allwell Medicare	$2.10
Rate for Payer: Amerigroup Medicare	$2.10
Rate for Payer: APIPA Medicare/Medicaid	$5.23
Rate for Payer: AZCH Complete Medicare	$2.10
Rate for Payer: Banner UC Health Medicare	$2.10
Rate for Payer: Bisbee Police All Plans	$3.64
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$9.52
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cigna of AZ Commercial	$9.80
Rate for Payer: Copperpoint Commercial	$3.46
Rate for Payer: Health Net of AZ Commercial	$8.40
Rate for Payer: Health Net of AZ Medicare	$3.92
Rate for Payer: Humana of AZ Medicare	$2.10
Rate for Payer: Self Pay Self Pay	$11.20
Rate for Payer: TriWest Medicare	$2.10
Rate for Payer: UnitedHealth Group of AZ Commercial	$8.16
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.52

CLIENT DRUG SCREEN DOT 10 PANEL

Facility

$80.00

Service Code	CPT 80100
Hospital Charge Code	22331241
Hospital Revenue Code	301
Min. Negotiated Rate	$12.00
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna of AZ Commercial	$72.00
Rate for Payer: Aetna of AZ Medicare	$22.40
Rate for Payer: Allwell Medicare	$12.00
Rate for Payer: Amerigroup Medicare	$12.00
Rate for Payer: APIPA Medicare/Medicaid	$29.88
Rate for Payer: AZCH Complete Medicare	$12.00
Rate for Payer: Banner UC Health Medicare	$12.00
Rate for Payer: Bisbee Police All Plans	$20.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$54.40
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cigna of AZ Commercial	$52.00
Rate for Payer: Copperpoint Commercial	$19.80
Rate for Payer: Health Net of AZ Commercial	$48.00
Rate for Payer: Health Net of AZ Medicare	$22.40
Rate for Payer: Humana of AZ Medicare	$12.00
Rate for Payer: Self Pay Self Pay	$64.00
Rate for Payer: TriWest Medicare	$12.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$46.64
Rate for Payer: UnitedHealth Group of AZ Medicare	$14.40

CLIENT DRUG SCREEN DOT 10 PANEL

Facility

$80.00

Service Code	CPT 80100
Hospital Charge Code	22331241
Hospital Revenue Code	301
Min. Negotiated Rate	$20.80
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna of AZ Commercial	$72.00
Rate for Payer: Bisbee Police All Plans	$20.80
Rate for Payer: Cash Price	$64.00
Rate for Payer: Self Pay Self Pay	$64.00

CLIENT DRUG SCREEN DOT 5 PANEL

Facility

$63.00

Service Code	CPT 80100
Hospital Charge Code	22331242
Hospital Revenue Code	301
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$56.70
Rate for Payer: Aetna of AZ Commercial	$56.70
Rate for Payer: Bisbee Police All Plans	$16.38
Rate for Payer: Cash Price	$50.40
Rate for Payer: Self Pay Self Pay	$50.40

CLIENT DRUG SCREEN DOT 5 PANEL

Facility

$63.00

Service Code	CPT 80100
Hospital Charge Code	22331242
Hospital Revenue Code	301
Min. Negotiated Rate	$9.45
Max. Negotiated Rate	$56.70
Rate for Payer: Aetna of AZ Commercial	$56.70
Rate for Payer: Aetna of AZ Medicare	$17.64
Rate for Payer: Allwell Medicare	$9.45
Rate for Payer: Amerigroup Medicare	$9.45
Rate for Payer: APIPA Medicare/Medicaid	$23.53
Rate for Payer: AZCH Complete Medicare	$9.45
Rate for Payer: Banner UC Health Medicare	$9.45
Rate for Payer: Bisbee Police All Plans	$16.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$42.84
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna of AZ Commercial	$40.95
Rate for Payer: Copperpoint Commercial	$15.59
Rate for Payer: Health Net of AZ Commercial	$37.80
Rate for Payer: Health Net of AZ Medicare	$17.64
Rate for Payer: Humana of AZ Medicare	$9.45
Rate for Payer: Self Pay Self Pay	$50.40
Rate for Payer: TriWest Medicare	$9.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$36.73
Rate for Payer: UnitedHealth Group of AZ Medicare	$11.34

Know your out-of-pocket cost for care.

All Charges