Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

CLIENT CARTRIDGE RESPIRATOR FIT TEST

Facility

$48.00

Hospital Charge Code	22331178
Hospital Revenue Code	999
Min. Negotiated Rate	$43.20
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of AZ Commercial	$43.20
Rate for Payer: Cash Price	$38.40

CLIENT CATH URETHRA COMPLEX

Facility

$315.00

Service Code	CPT 51703
Hospital Charge Code	22331180
Hospital Revenue Code	450
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of AZ Commercial	$283.50
Rate for Payer: Cash Price	$252.00

CLIENT CATH URETHRA COMPLEX

Facility

$315.00

Service Code	CPT 51703
Hospital Charge Code	22331180
Hospital Revenue Code	450
Min. Negotiated Rate	$49.90
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of AZ Commercial	$283.50
Rate for Payer: Arizona Complete Health Allwell	$50.40
Rate for Payer: Banner UC Health Medicare	$50.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$214.20
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$73.57
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$50.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$50.40
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: Devoted Health Medicare	$56.70
Rate for Payer: Humana of AZ Medicare	$50.40
Rate for Payer: Mercy Care Medicaid	$73.57
Rate for Payer: NaphCare Correctional Healthcare	$73.57
Rate for Payer: Seven Corners Travel Insurance	$199.09
Rate for Payer: Southwest Service Administrators UFCW	$214.20
Rate for Payer: TriWest Medicare	$50.40
Rate for Payer: United Healthcare Commercial	$180.18
Rate for Payer: United Healthcare Medicare	$50.40
Rate for Payer: United Healthcare New Mexico Commercial	$59.85
Rate for Payer: Veterans Affairs TRICARE	$49.90

CLIENT CATH URETHRA SIMPLE

Facility

$106.00

Service Code	CPT 51701
Hospital Charge Code	22331181
Hospital Revenue Code	450
Min. Negotiated Rate	$95.40
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of AZ Commercial	$95.40
Rate for Payer: Cash Price	$84.80

CLIENT CATH URETHRA SIMPLE

Facility

$106.00

Service Code	CPT 51701
Hospital Charge Code	22331181
Hospital Revenue Code	450
Min. Negotiated Rate	$16.79
Max. Negotiated Rate	$205.86
Rate for Payer: Aetna of AZ Commercial	$95.40
Rate for Payer: Arizona Complete Health Allwell	$16.96
Rate for Payer: Banner UC Health Medicare	$16.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$72.08
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$19.18
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.96
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: Devoted Health Medicare	$19.08
Rate for Payer: Humana of AZ Medicare	$16.96
Rate for Payer: Mercy Care Medicaid	$19.18
Rate for Payer: NaphCare Correctional Healthcare	$19.18
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$72.08
Rate for Payer: TriWest Medicare	$16.96
Rate for Payer: United Healthcare Commercial	$60.63
Rate for Payer: United Healthcare Medicare	$16.96
Rate for Payer: United Healthcare New Mexico Commercial	$20.14
Rate for Payer: Veterans Affairs TRICARE	$16.79

CLIENT CHAIN OF CUST URINE

Facility

$30.00

Hospital Charge Code	22331187
Hospital Revenue Code	302
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Cash Price	$24.00

CLIENT CHAIN OF CUST URINE

Facility

$30.00

Hospital Charge Code	22331187
Hospital Revenue Code	302
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Arizona Complete Health Allwell	$4.80
Rate for Payer: Banner UC Health Medicare	$4.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$20.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna of AZ Commercial	$19.50
Rate for Payer: Devoted Health Medicare	$5.40
Rate for Payer: Humana of AZ Medicare	$4.80
Rate for Payer: Southwest Service Administrators UFCW	$20.40
Rate for Payer: TriWest Medicare	$4.80
Rate for Payer: United Healthcare Commercial	$17.16
Rate for Payer: United Healthcare Medicare	$4.80
Rate for Payer: Veterans Affairs TRICARE	$4.75

CLIENT CHEST TWO VIEW

Facility

$72.00

Service Code	CPT 71046
Hospital Charge Code	22331193
Hospital Revenue Code	324
Min. Negotiated Rate	$11.40
Max. Negotiated Rate	$134.65
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Arizona Complete Health Allwell	$11.52
Rate for Payer: Banner UC Health Medicare	$11.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$48.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.86
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna of AZ Commercial	$46.80
Rate for Payer: Devoted Health Medicare	$12.96
Rate for Payer: Humana of AZ Medicare	$11.52
Rate for Payer: Seven Corners Travel Insurance	$134.65
Rate for Payer: Southwest Service Administrators UFCW	$48.96
Rate for Payer: TriWest Medicare	$11.52
Rate for Payer: United Healthcare Commercial	$41.18
Rate for Payer: United Healthcare Medicare	$11.52
Rate for Payer: Veterans Affairs TRICARE	$11.40

CLIENT CHEST TWO VIEW

Facility

$72.00

Service Code	CPT 71046
Hospital Charge Code	22331193
Hospital Revenue Code	324
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Cash Price	$57.60

CLIENT COLOR VISION 12 PLATE ISHIHARA

Facility

$14.00

Hospital Charge Code	22331203
Hospital Revenue Code	301
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of AZ Commercial	$12.60
Rate for Payer: Arizona Complete Health Allwell	$2.24
Rate for Payer: Banner UC Health Medicare	$2.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$9.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.24
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cigna of AZ Commercial	$9.10
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Humana of AZ Medicare	$2.24
Rate for Payer: Southwest Service Administrators UFCW	$9.52
Rate for Payer: TriWest Medicare	$2.24
Rate for Payer: United Healthcare Commercial	$8.01
Rate for Payer: United Healthcare Medicare	$2.24
Rate for Payer: Veterans Affairs TRICARE	$2.22

CLIENT COLOR VISION 12 PLATE ISHIHARA

Facility

$14.00

Hospital Charge Code	22331203
Hospital Revenue Code	301
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of AZ Commercial	$12.60
Rate for Payer: Cash Price	$11.20

CLIENT COLOR VISION 24 PLATE ISHIHARA

Facility

$15.00

Hospital Charge Code	22331204
Hospital Revenue Code	301
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of AZ Commercial	$13.50
Rate for Payer: Arizona Complete Health Allwell	$2.40
Rate for Payer: Banner UC Health Medicare	$2.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$10.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cigna of AZ Commercial	$9.75
Rate for Payer: Devoted Health Medicare	$2.70
Rate for Payer: Humana of AZ Medicare	$2.40
Rate for Payer: Southwest Service Administrators UFCW	$10.20
Rate for Payer: TriWest Medicare	$2.40
Rate for Payer: United Healthcare Commercial	$8.58
Rate for Payer: United Healthcare Medicare	$2.40
Rate for Payer: Veterans Affairs TRICARE	$2.38

CLIENT COLOR VISION 24 PLATE ISHIHARA

Facility

$15.00

Hospital Charge Code	22331204
Hospital Revenue Code	301
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of AZ Commercial	$13.50
Rate for Payer: Cash Price	$12.00

CLIENT COMPLEX EXAM

Facility

$108.00

Hospital Charge Code	22331210
Hospital Revenue Code	301
Min. Negotiated Rate	$97.20
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of AZ Commercial	$97.20
Rate for Payer: Cash Price	$86.40

CLIENT COMPLEX EXAM

Facility

$108.00

Hospital Charge Code	22331210
Hospital Revenue Code	301
Min. Negotiated Rate	$17.11
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of AZ Commercial	$97.20
Rate for Payer: Arizona Complete Health Allwell	$17.28
Rate for Payer: Banner UC Health Medicare	$17.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$73.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.28
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna of AZ Commercial	$70.20
Rate for Payer: Devoted Health Medicare	$19.44
Rate for Payer: Humana of AZ Medicare	$17.28
Rate for Payer: Southwest Service Administrators UFCW	$73.44
Rate for Payer: TriWest Medicare	$17.28
Rate for Payer: United Healthcare Commercial	$61.78
Rate for Payer: United Healthcare Medicare	$17.28
Rate for Payer: Veterans Affairs TRICARE	$17.11

CLIENT CT HEAD WO CONTR

Facility

$302.24

Service Code	CPT 70450
Hospital Charge Code	22331223
Hospital Revenue Code	351
Min. Negotiated Rate	$47.87
Max. Negotiated Rate	$272.02
Rate for Payer: Aetna of AZ Commercial	$272.02
Rate for Payer: Arizona Complete Health Allwell	$48.36
Rate for Payer: Banner UC Health Medicare	$48.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$205.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$48.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$48.36
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: Devoted Health Medicare	$54.40
Rate for Payer: Humana of AZ Medicare	$48.36
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$205.52
Rate for Payer: TriWest Medicare	$48.36
Rate for Payer: United Healthcare Commercial	$172.88
Rate for Payer: United Healthcare Medicare	$48.36
Rate for Payer: Veterans Affairs TRICARE	$47.87

CLIENT CT HEAD WO CONTR

Facility

$302.24

Service Code	CPT 70450
Hospital Charge Code	22331223
Hospital Revenue Code	351
Min. Negotiated Rate	$272.02
Max. Negotiated Rate	$272.02
Rate for Payer: Aetna of AZ Commercial	$272.02
Rate for Payer: Cash Price	$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	$76.50
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of AZ Commercial	$76.50
Rate for Payer: Cash Price	$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	$13.46
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of AZ Commercial	$76.50
Rate for Payer: Arizona Complete Health Allwell	$13.60
Rate for Payer: Banner UC Health Medicare	$13.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$57.80
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$17.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.60
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cigna of AZ Commercial	$59.50
Rate for Payer: Devoted Health Medicare	$15.30
Rate for Payer: Humana of AZ Medicare	$13.60
Rate for Payer: Mercy Care Medicaid	$17.72
Rate for Payer: NaphCare Correctional Healthcare	$17.72
Rate for Payer: Southwest Service Administrators UFCW	$57.80
Rate for Payer: TriWest Medicare	$13.60
Rate for Payer: United Healthcare Commercial	$48.62
Rate for Payer: United Healthcare Medicare	$13.60
Rate for Payer: United Healthcare New Mexico Commercial	$16.15
Rate for Payer: Veterans Affairs TRICARE	$13.46

CLIENT DRSG TEGADERM 1X1.75

Facility

$14.00

Hospital Charge Code	22331240
Hospital Revenue Code	272
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of AZ Commercial	$12.60
Rate for Payer: Cash Price	$11.20

CLIENT DRSG TEGADERM 1X1.75

Facility

$14.00

Hospital Charge Code	22331240
Hospital Revenue Code	272
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of AZ Commercial	$12.60
Rate for Payer: Arizona Complete Health Allwell	$2.24
Rate for Payer: Banner UC Health Medicare	$2.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$9.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.24
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cigna of AZ Commercial	$9.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Humana of AZ Medicare	$2.24
Rate for Payer: Southwest Service Administrators UFCW	$9.52
Rate for Payer: TriWest Medicare	$2.24
Rate for Payer: United Healthcare Commercial	$8.01
Rate for Payer: United Healthcare Medicare	$2.24
Rate for Payer: Veterans Affairs TRICARE	$2.22

CLIENT DRUG SCREEN DOT 10 PANEL

Facility

$80.00

Service Code	CPT 80100
Hospital Charge Code	22331241
Hospital Revenue Code	301
Min. Negotiated Rate	$12.67
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna of AZ Commercial	$72.00
Rate for Payer: Arizona Complete Health Allwell	$12.80
Rate for Payer: Banner UC Health Medicare	$12.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$54.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.80
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cigna of AZ Commercial	$52.00
Rate for Payer: Devoted Health Medicare	$14.40
Rate for Payer: Humana of AZ Medicare	$12.80
Rate for Payer: Southwest Service Administrators UFCW	$54.40
Rate for Payer: TriWest Medicare	$12.80
Rate for Payer: United Healthcare Commercial	$45.76
Rate for Payer: United Healthcare Medicare	$12.80
Rate for Payer: Veterans Affairs TRICARE	$12.67

CLIENT DRUG SCREEN DOT 10 PANEL

Facility

$80.00

Service Code	CPT 80100
Hospital Charge Code	22331241
Hospital Revenue Code	301
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna of AZ Commercial	$72.00
Rate for Payer: Cash Price	$64.00

CLIENT DRUG SCREEN DOT 5 PANEL

Facility

$65.00

Service Code	CPT 80100
Hospital Charge Code	22331242
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of AZ Commercial	$58.50
Rate for Payer: Cash Price	$52.00

CLIENT DRUG SCREEN DOT 5 PANEL

Facility

$65.00

Service Code	CPT 80100
Hospital Charge Code	22331242
Hospital Revenue Code	301
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of AZ Commercial	$58.50
Rate for Payer: Arizona Complete Health Allwell	$10.40
Rate for Payer: Banner UC Health Medicare	$10.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$44.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.40
Rate for Payer: Cash Price	$52.00
Rate for Payer: Cigna of AZ Commercial	$42.25
Rate for Payer: Devoted Health Medicare	$11.70
Rate for Payer: Humana of AZ Medicare	$10.40
Rate for Payer: Southwest Service Administrators UFCW	$44.20
Rate for Payer: TriWest Medicare	$10.40
Rate for Payer: United Healthcare Commercial	$37.18
Rate for Payer: United Healthcare Medicare	$10.40
Rate for Payer: Veterans Affairs TRICARE	$10.30

Know your out-of-pocket cost for care.

All Charges