Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

CLIENT CHAIN OF CUST URINE

Facility

$21.00

Hospital Charge Code	22331187
Hospital Revenue Code	302
Min. Negotiated Rate	$5.46
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Bisbee Police All Plans	$5.46
Rate for Payer: Cash Price	$16.80
Rate for Payer: Self Pay Self Pay	$16.80

CLIENT CHAIN OF CUST URINE

Facility

$21.00

Hospital Charge Code	22331187
Hospital Revenue Code	302
Min. Negotiated Rate	$3.36
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Aetna of AZ Medicare	$5.88
Rate for Payer: Allwell Medicare	$3.36
Rate for Payer: Amerigroup Medicare	$3.36
Rate for Payer: APIPA Medicare/Medicaid	$7.84
Rate for Payer: AZCH Complete Medicare	$3.36
Rate for Payer: Banner UC Health Medicare	$3.36
Rate for Payer: Bisbee Police All Plans	$5.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$14.28
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna of AZ Commercial	$13.65
Rate for Payer: Copperpoint Commercial	$5.20
Rate for Payer: Health Net of AZ Commercial	$12.60
Rate for Payer: Health Net of AZ Medicare	$5.88
Rate for Payer: Humana of AZ Medicare	$3.36
Rate for Payer: Self Pay Self Pay	$16.80
Rate for Payer: TriWest Medicare	$3.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$12.24
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.78

CLIENT CHEST TWO VIEW

Facility

$72.00

Service Code	CPT 71046
Hospital Charge Code	22331193
Hospital Revenue Code	324
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Aetna of AZ Medicare	$20.16
Rate for Payer: Allwell Medicare	$11.52
Rate for Payer: Amerigroup Medicare	$11.52
Rate for Payer: APIPA Medicare/Medicaid	$26.89
Rate for Payer: AZCH Complete Medicare	$11.52
Rate for Payer: Banner UC Health Medicare	$11.52
Rate for Payer: Bisbee Police All Plans	$18.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$48.96
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna of AZ Commercial	$46.80
Rate for Payer: Copperpoint Commercial	$17.82
Rate for Payer: Health Net of AZ Commercial	$43.20
Rate for Payer: Health Net of AZ Medicare	$20.16
Rate for Payer: Humana of AZ Medicare	$11.52
Rate for Payer: Self Pay Self Pay	$57.60
Rate for Payer: TriWest Medicare	$11.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$41.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.96

CLIENT CHEST TWO VIEW

Facility

$72.00

Service Code	CPT 71046
Hospital Charge Code	22331193
Hospital Revenue Code	324
Min. Negotiated Rate	$18.72
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Bisbee Police All Plans	$18.72
Rate for Payer: Cash Price	$57.60
Rate for Payer: Self Pay Self Pay	$57.60

CLIENT COLOR VISION 12 PLATE ISHIHARA

Facility

$14.00

Hospital Charge Code	22331203
Hospital Revenue Code	301
Min. Negotiated Rate	$2.24
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	$2.24
Rate for Payer: Amerigroup Medicare	$2.24
Rate for Payer: APIPA Medicare/Medicaid	$5.23
Rate for Payer: AZCH Complete Medicare	$2.24
Rate for Payer: Banner UC Health Medicare	$2.24
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	$9.10
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	$2.24
Rate for Payer: Self Pay Self Pay	$11.20
Rate for Payer: TriWest Medicare	$2.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$8.16
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.52

CLIENT COLOR VISION 12 PLATE ISHIHARA

Facility

$14.00

Hospital Charge Code	22331203
Hospital Revenue Code	301
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 COLOR VISION 24 PLATE ISHIHARA

Facility

$15.00

Hospital Charge Code	22331204
Hospital Revenue Code	301
Min. Negotiated Rate	$2.40
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	$2.40
Rate for Payer: Amerigroup Medicare	$2.40
Rate for Payer: APIPA Medicare/Medicaid	$5.60
Rate for Payer: AZCH Complete Medicare	$2.40
Rate for Payer: Banner UC Health Medicare	$2.40
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	$2.40
Rate for Payer: Self Pay Self Pay	$12.00
Rate for Payer: TriWest Medicare	$2.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$8.74
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.70

CLIENT COLOR VISION 24 PLATE ISHIHARA

Facility

$15.00

Hospital Charge Code	22331204
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 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	$17.28
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	$17.28
Rate for Payer: Amerigroup Medicare	$17.28
Rate for Payer: APIPA Medicare/Medicaid	$40.34
Rate for Payer: AZCH Complete Medicare	$17.28
Rate for Payer: Banner UC Health Medicare	$17.28
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	$17.28
Rate for Payer: Self Pay Self Pay	$86.40
Rate for Payer: TriWest Medicare	$17.28
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	$48.36
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: Allwell Medicare	$48.36
Rate for Payer: Amerigroup Medicare	$48.36
Rate for Payer: APIPA Medicare/Medicaid	$112.89
Rate for Payer: AZCH Complete Medicare	$48.36
Rate for Payer: Banner UC Health Medicare	$48.36
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: 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	$48.36
Rate for Payer: Self Pay Self Pay	$241.79
Rate for Payer: TriWest Medicare	$48.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$176.21
Rate for Payer: UnitedHealth Group of AZ Medicare	$54.40

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 DOT PHYS EXAM

Facility

$85.00

Service Code	CPT 99202 22
Hospital Charge Code	22331239
Hospital Revenue Code	982
Min. Negotiated Rate	$13.60
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	$13.60
Rate for Payer: Amerigroup Medicare	$13.60
Rate for Payer: APIPA Medicare/Medicaid	$31.75
Rate for Payer: AZCH Complete Medicare	$13.60
Rate for Payer: Banner UC Health Medicare	$13.60
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	$13.60
Rate for Payer: Self Pay Self Pay	$68.00
Rate for Payer: TriWest Medicare	$13.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$49.55
Rate for Payer: UnitedHealth Group of AZ Medicare	$15.30

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 DRSG TEGADERM 1X1.75

Facility

$14.00

Hospital Charge Code	22331240
Hospital Revenue Code	272
Min. Negotiated Rate	$2.24
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	$2.24
Rate for Payer: Amerigroup Medicare	$2.24
Rate for Payer: APIPA Medicare/Medicaid	$5.23
Rate for Payer: AZCH Complete Medicare	$2.24
Rate for Payer: Banner UC Health Medicare	$2.24
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	$2.24
Rate for Payer: Self Pay Self Pay	$11.20
Rate for Payer: TriWest Medicare	$2.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$8.16
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.52

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 DRUG SCREEN DOT 10 PANEL

Facility

$80.00

Service Code	CPT 80100
Hospital Charge Code	22331241
Hospital Revenue Code	301
Min. Negotiated Rate	$12.80
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	$12.80
Rate for Payer: Amerigroup Medicare	$12.80
Rate for Payer: APIPA Medicare/Medicaid	$29.88
Rate for Payer: AZCH Complete Medicare	$12.80
Rate for Payer: Banner UC Health Medicare	$12.80
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	$12.80
Rate for Payer: Self Pay Self Pay	$64.00
Rate for Payer: TriWest Medicare	$12.80
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

$60.00

Service Code	CPT 80100
Hospital Charge Code	22331242
Hospital Revenue Code	301
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Aetna of AZ Medicare	$16.80
Rate for Payer: Allwell Medicare	$9.60
Rate for Payer: Amerigroup Medicare	$9.60
Rate for Payer: APIPA Medicare/Medicaid	$22.41
Rate for Payer: AZCH Complete Medicare	$9.60
Rate for Payer: Banner UC Health Medicare	$9.60
Rate for Payer: Bisbee Police All Plans	$15.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$40.80
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cigna of AZ Commercial	$39.00
Rate for Payer: Copperpoint Commercial	$14.85
Rate for Payer: Health Net of AZ Commercial	$36.00
Rate for Payer: Health Net of AZ Medicare	$16.80
Rate for Payer: Humana of AZ Medicare	$9.60
Rate for Payer: Self Pay Self Pay	$48.00
Rate for Payer: TriWest Medicare	$9.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$34.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$10.80

CLIENT DRUG SCREEN DOT 5 PANEL

Facility

$60.00

Service Code	CPT 80100
Hospital Charge Code	22331242
Hospital Revenue Code	301
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Bisbee Police All Plans	$15.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Self Pay Self Pay	$48.00

CLIENT DRUG SCREEN NON DOT 10 PANEL

Facility

$76.00

Service Code	CPT 80100
Hospital Charge Code	22331243
Hospital Revenue Code	301
Min. Negotiated Rate	$19.76
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of AZ Commercial	$68.40
Rate for Payer: Bisbee Police All Plans	$19.76
Rate for Payer: Cash Price	$60.80
Rate for Payer: Self Pay Self Pay	$60.80

CLIENT DRUG SCREEN NON DOT 10 PANEL

Facility

$76.00

Service Code	CPT 80100
Hospital Charge Code	22331243
Hospital Revenue Code	301
Min. Negotiated Rate	$12.16
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of AZ Commercial	$68.40
Rate for Payer: Aetna of AZ Medicare	$21.28
Rate for Payer: Allwell Medicare	$12.16
Rate for Payer: Amerigroup Medicare	$12.16
Rate for Payer: APIPA Medicare/Medicaid	$28.39
Rate for Payer: AZCH Complete Medicare	$12.16
Rate for Payer: Banner UC Health Medicare	$12.16
Rate for Payer: Bisbee Police All Plans	$19.76
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$51.68
Rate for Payer: Cash Price	$60.80
Rate for Payer: Cigna of AZ Commercial	$49.40
Rate for Payer: Copperpoint Commercial	$18.81
Rate for Payer: Health Net of AZ Commercial	$45.60
Rate for Payer: Health Net of AZ Medicare	$21.28
Rate for Payer: Humana of AZ Medicare	$12.16
Rate for Payer: Self Pay Self Pay	$60.80
Rate for Payer: TriWest Medicare	$12.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$44.31
Rate for Payer: UnitedHealth Group of AZ Medicare	$13.68

CLIENT DRUG SCREEN NON DOT 5 PANEL

Facility

$63.00

Service Code	CPT 80100
Hospital Charge Code	22331244
Hospital Revenue Code	301
Min. Negotiated Rate	$10.08
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	$10.08
Rate for Payer: Amerigroup Medicare	$10.08
Rate for Payer: APIPA Medicare/Medicaid	$23.53
Rate for Payer: AZCH Complete Medicare	$10.08
Rate for Payer: Banner UC Health Medicare	$10.08
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	$10.08
Rate for Payer: Self Pay Self Pay	$50.40
Rate for Payer: TriWest Medicare	$10.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$36.73
Rate for Payer: UnitedHealth Group of AZ Medicare	$11.34

CLIENT DRUG SCREEN NON DOT 5 PANEL

Facility

$63.00

Service Code	CPT 80100
Hospital Charge Code	22331244
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 RAPID

Facility

$52.00

Service Code	CPT 80100
Hospital Charge Code	22331245
Hospital Revenue Code	301
Min. Negotiated Rate	$13.52
Max. Negotiated Rate	$46.80
Rate for Payer: Aetna of AZ Commercial	$46.80
Rate for Payer: Bisbee Police All Plans	$13.52
Rate for Payer: Cash Price	$41.60
Rate for Payer: Self Pay Self Pay	$41.60

Know your out-of-pocket cost for care.

All Charges