Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

CLIENT DRUG SCREEN NON DOT 10 PANEL

Facility

$80.00

Service Code	CPT 80100
Hospital Charge Code	22331243
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 NON DOT 10 PANEL

Facility

$80.00

Service Code	CPT 80100
Hospital Charge Code	22331243
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 NON DOT 5 PANEL

Facility

$63.00

Service Code	CPT 80100
Hospital Charge Code	22331244
Hospital Revenue Code	301
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$56.70
Rate for Payer: Aetna of AZ Commercial	$56.70
Rate for Payer: Cash Price	$50.40

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	$9.98
Max. Negotiated Rate	$56.70
Rate for Payer: Aetna of AZ Commercial	$56.70
Rate for Payer: Arizona Complete Health Allwell	$10.08
Rate for Payer: Banner UC Health Medicare	$10.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$42.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.08
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna of AZ Commercial	$40.95
Rate for Payer: Devoted Health Medicare	$11.34
Rate for Payer: Humana of AZ Medicare	$10.08
Rate for Payer: Southwest Service Administrators UFCW	$42.84
Rate for Payer: TriWest Medicare	$10.08
Rate for Payer: United Healthcare Commercial	$36.04
Rate for Payer: United Healthcare Medicare	$10.08
Rate for Payer: Veterans Affairs TRICARE	$9.98

CLIENT DRUG SCREEN RAPID

Facility

$52.00

Service Code	CPT 80100
Hospital Charge Code	22331245
Hospital Revenue Code	301
Min. Negotiated Rate	$46.80
Max. Negotiated Rate	$46.80
Rate for Payer: Aetna of AZ Commercial	$46.80
Rate for Payer: Cash Price	$41.60

CLIENT DRUG SCREEN RAPID

Facility

$52.00

Service Code	CPT 80100
Hospital Charge Code	22331245
Hospital Revenue Code	301
Min. Negotiated Rate	$8.24
Max. Negotiated Rate	$46.80
Rate for Payer: Aetna of AZ Commercial	$46.80
Rate for Payer: Arizona Complete Health Allwell	$8.32
Rate for Payer: Banner UC Health Medicare	$8.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$35.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.32
Rate for Payer: Cash Price	$41.60
Rate for Payer: Cigna of AZ Commercial	$33.80
Rate for Payer: Devoted Health Medicare	$9.36
Rate for Payer: Humana of AZ Medicare	$8.32
Rate for Payer: Southwest Service Administrators UFCW	$35.36
Rate for Payer: TriWest Medicare	$8.32
Rate for Payer: United Healthcare Commercial	$29.74
Rate for Payer: United Healthcare Medicare	$8.32
Rate for Payer: Veterans Affairs TRICARE	$8.24

CLIENT EKG (12 LEAD)

Facility

$103.00

Service Code	CPT 93005
Hospital Charge Code	22331249
Hospital Revenue Code	730
Min. Negotiated Rate	$16.32
Max. Negotiated Rate	$92.70
Rate for Payer: Aetna of AZ Commercial	$92.70
Rate for Payer: Arizona Complete Health Allwell	$16.48
Rate for Payer: Banner UC Health Medicare	$16.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$70.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.48
Rate for Payer: Cash Price	$82.40
Rate for Payer: Cash Price	$82.40
Rate for Payer: Cigna of AZ Commercial	$72.10
Rate for Payer: Devoted Health Medicare	$18.54
Rate for Payer: Humana of AZ Medicare	$16.48
Rate for Payer: Seven Corners Travel Insurance	$91.28
Rate for Payer: Southwest Service Administrators UFCW	$70.04
Rate for Payer: TriWest Medicare	$16.48
Rate for Payer: United Healthcare Commercial	$58.92
Rate for Payer: United Healthcare Medicare	$16.48
Rate for Payer: United Healthcare New Mexico Commercial	$19.57
Rate for Payer: Veterans Affairs TRICARE	$16.32

CLIENT EKG (12 LEAD)

Facility

$103.00

Service Code	CPT 93005
Hospital Charge Code	22331249
Hospital Revenue Code	730
Min. Negotiated Rate	$92.70
Max. Negotiated Rate	$92.70
Rate for Payer: Aetna of AZ Commercial	$92.70
Rate for Payer: Cash Price	$82.40

CLIENT EKG TRACING W/O INTERP

Facility

$50.00

Service Code	CPT 93041
Hospital Charge Code	22331254
Hospital Revenue Code	730
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$91.28
Rate for Payer: Aetna of AZ Commercial	$45.00
Rate for Payer: Arizona Complete Health Allwell	$8.00
Rate for Payer: Banner UC Health Medicare	$8.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$34.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cigna of AZ Commercial	$35.00
Rate for Payer: Devoted Health Medicare	$9.00
Rate for Payer: Humana of AZ Medicare	$8.00
Rate for Payer: Seven Corners Travel Insurance	$91.28
Rate for Payer: Southwest Service Administrators UFCW	$34.00
Rate for Payer: TriWest Medicare	$8.00
Rate for Payer: United Healthcare Commercial	$28.60
Rate for Payer: United Healthcare Medicare	$8.00
Rate for Payer: United Healthcare New Mexico Commercial	$9.50
Rate for Payer: Veterans Affairs TRICARE	$7.92

CLIENT EKG TRACING W/O INTERP

Facility

$50.00

Service Code	CPT 93041
Hospital Charge Code	22331254
Hospital Revenue Code	730
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna of AZ Commercial	$45.00
Rate for Payer: Cash Price	$40.00

CLIENT FLU VACCINE ADULT 0.5 ML

Facility

$97.00

Hospital Charge Code	22331274
Hospital Revenue Code	250
Min. Negotiated Rate	$87.30
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna of AZ Commercial	$87.30
Rate for Payer: Cash Price	$77.60

CLIENT FLU VACCINE ADULT 0.5 ML

Facility

$97.00

Hospital Charge Code	22331274
Hospital Revenue Code	250
Min. Negotiated Rate	$15.36
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna of AZ Commercial	$87.30
Rate for Payer: Arizona Complete Health Allwell	$15.52
Rate for Payer: Banner UC Health Medicare	$15.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$65.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$15.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.52
Rate for Payer: Cash Price	$77.60
Rate for Payer: Cigna of AZ Commercial	$63.05
Rate for Payer: Devoted Health Medicare	$17.46
Rate for Payer: Humana of AZ Medicare	$15.52
Rate for Payer: Southwest Service Administrators UFCW	$65.96
Rate for Payer: TriWest Medicare	$15.52
Rate for Payer: United Healthcare Commercial	$55.48
Rate for Payer: United Healthcare Medicare	$15.52
Rate for Payer: Veterans Affairs TRICARE	$15.36

CLIENT HAIR FOLLICLE TEST

Facility

$29.00

Hospital Charge Code	22331294
Hospital Revenue Code	302
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$26.10
Rate for Payer: Aetna of AZ Commercial	$26.10
Rate for Payer: Arizona Complete Health Allwell	$4.64
Rate for Payer: Banner UC Health Medicare	$4.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$19.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.64
Rate for Payer: Cash Price	$23.20
Rate for Payer: Cigna of AZ Commercial	$18.85
Rate for Payer: Devoted Health Medicare	$5.22
Rate for Payer: Humana of AZ Medicare	$4.64
Rate for Payer: Southwest Service Administrators UFCW	$19.72
Rate for Payer: TriWest Medicare	$4.64
Rate for Payer: United Healthcare Commercial	$16.59
Rate for Payer: United Healthcare Medicare	$4.64
Rate for Payer: Veterans Affairs TRICARE	$4.59

CLIENT HAIR FOLLICLE TEST

Facility

$29.00

Hospital Charge Code	22331294
Hospital Revenue Code	302
Min. Negotiated Rate	$26.10
Max. Negotiated Rate	$26.10
Rate for Payer: Aetna of AZ Commercial	$26.10
Rate for Payer: Cash Price	$23.20

CLIENT HEP B IMMUNIZATION

Facility

$75.00

Service Code	CPT 90636
Hospital Charge Code	22331305
Hospital Revenue Code	636
Min. Negotiated Rate	$11.88
Max. Negotiated Rate	$67.50
Rate for Payer: Aetna of AZ Commercial	$67.50
Rate for Payer: Arizona Complete Health Allwell	$12.00
Rate for Payer: Banner UC Health Medicare	$12.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$51.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Cigna of AZ Commercial	$52.50
Rate for Payer: Devoted Health Medicare	$13.50
Rate for Payer: Humana of AZ Medicare	$12.00
Rate for Payer: Southwest Service Administrators UFCW	$51.00
Rate for Payer: TriWest Medicare	$12.00
Rate for Payer: United Healthcare Commercial	$42.90
Rate for Payer: United Healthcare Medicare	$12.00
Rate for Payer: United Healthcare New Mexico Commercial	$14.25
Rate for Payer: Veterans Affairs TRICARE	$11.88

CLIENT HEP B IMMUNIZATION

Facility

$75.00

Service Code	CPT 90636
Hospital Charge Code	22331305
Hospital Revenue Code	636
Min. Negotiated Rate	$67.50
Max. Negotiated Rate	$67.50
Rate for Payer: Aetna of AZ Commercial	$67.50
Rate for Payer: Cash Price	$60.00

CLIENT HIP COMPLETE BILATERAL

Facility

$41.33

Service Code	CPT 73521
Hospital Charge Code	22331313
Hospital Revenue Code	320
Min. Negotiated Rate	$37.20
Max. Negotiated Rate	$37.20
Rate for Payer: Aetna of AZ Commercial	$37.20
Rate for Payer: Cash Price	$33.06

CLIENT HIP COMPLETE BILATERAL

Facility

$41.33

Service Code	CPT 73521
Hospital Charge Code	22331313
Hospital Revenue Code	320
Min. Negotiated Rate	$6.55
Max. Negotiated Rate	$161.76
Rate for Payer: Aetna of AZ Commercial	$37.20
Rate for Payer: Arizona Complete Health Allwell	$6.61
Rate for Payer: Banner UC Health Medicare	$6.61
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$28.10
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.61
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.94
Rate for Payer: Cash Price	$33.06
Rate for Payer: Cash Price	$33.06
Rate for Payer: Cigna of AZ Commercial	$26.86
Rate for Payer: Devoted Health Medicare	$7.44
Rate for Payer: Humana of AZ Medicare	$6.61
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$28.10
Rate for Payer: TriWest Medicare	$6.61
Rate for Payer: United Healthcare Commercial	$23.64
Rate for Payer: United Healthcare Medicare	$6.61
Rate for Payer: Veterans Affairs TRICARE	$6.55

CLIENT HIV

Facility

$48.00

Service Code	CPT 86701
Hospital Charge Code	22331316
Hospital Revenue Code	302
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 HIV

Facility

$48.00

Service Code	CPT 86701
Hospital Charge Code	22331316
Hospital Revenue Code	302
Min. Negotiated Rate	$7.60
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of AZ Commercial	$43.20
Rate for Payer: Arizona Complete Health Allwell	$7.68
Rate for Payer: Banner UC Health Medicare	$7.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$32.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.68
Rate for Payer: Cash Price	$38.40
Rate for Payer: Cash Price	$38.40
Rate for Payer: Cigna of AZ Commercial	$31.20
Rate for Payer: Devoted Health Medicare	$8.64
Rate for Payer: Humana of AZ Medicare	$7.68
Rate for Payer: Seven Corners Travel Insurance	$12.89
Rate for Payer: Southwest Service Administrators UFCW	$32.64
Rate for Payer: TriWest Medicare	$7.68
Rate for Payer: United Healthcare Commercial	$27.46
Rate for Payer: United Healthcare Medicare	$7.68
Rate for Payer: Veterans Affairs TRICARE	$7.60

CLIENT INCENTIVE SPIROMTRY

Facility

$165.00

Service Code	CPT 94799
Hospital Charge Code	22331327
Hospital Revenue Code	412
Min. Negotiated Rate	$148.50
Max. Negotiated Rate	$148.50
Rate for Payer: Aetna of AZ Commercial	$148.50
Rate for Payer: Cash Price	$132.00

CLIENT INCENTIVE SPIROMTRY

Facility

$165.00

Service Code	CPT 94799
Hospital Charge Code	22331327
Hospital Revenue Code	412
Min. Negotiated Rate	$26.14
Max. Negotiated Rate	$199.09
Rate for Payer: Aetna of AZ Commercial	$148.50
Rate for Payer: Arizona Complete Health Allwell	$26.40
Rate for Payer: Banner UC Health Medicare	$26.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$112.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$26.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$26.40
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cigna of AZ Commercial	$115.50
Rate for Payer: Devoted Health Medicare	$29.70
Rate for Payer: Humana of AZ Medicare	$26.40
Rate for Payer: Seven Corners Travel Insurance	$199.09
Rate for Payer: Southwest Service Administrators UFCW	$112.20
Rate for Payer: TriWest Medicare	$26.40
Rate for Payer: United Healthcare Commercial	$94.38
Rate for Payer: United Healthcare Medicare	$26.40
Rate for Payer: United Healthcare New Mexico Commercial	$31.35
Rate for Payer: Veterans Affairs TRICARE	$26.14

CLIENT INFLUENZA A SCREEN (RAPID)

Facility

$130.00

Service Code	CPT 87804
Hospital Charge Code	22331329
Hospital Revenue Code	306
Min. Negotiated Rate	$117.00
Max. Negotiated Rate	$117.00
Rate for Payer: Aetna of AZ Commercial	$117.00
Rate for Payer: Cash Price	$104.00

CLIENT INFLUENZA A SCREEN (RAPID)

Facility

$130.00

Service Code	CPT 87804
Hospital Charge Code	22331329
Hospital Revenue Code	306
Min. Negotiated Rate	$20.59
Max. Negotiated Rate	$117.00
Rate for Payer: Aetna of AZ Commercial	$117.00
Rate for Payer: Arizona Complete Health Allwell	$20.80
Rate for Payer: Banner UC Health Medicare	$20.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$88.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.80
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cigna of AZ Commercial	$84.50
Rate for Payer: Devoted Health Medicare	$23.40
Rate for Payer: Humana of AZ Medicare	$20.80
Rate for Payer: Seven Corners Travel Insurance	$24.00
Rate for Payer: Southwest Service Administrators UFCW	$88.40
Rate for Payer: TriWest Medicare	$20.80
Rate for Payer: United Healthcare Commercial	$74.36
Rate for Payer: United Healthcare Medicare	$20.80
Rate for Payer: Veterans Affairs TRICARE	$20.59

CLIENT .IRON BINDING CAPACITY

Facility

$339.00

Service Code	CPT 83550
Hospital Charge Code	22331086
Hospital Revenue Code	301
Min. Negotiated Rate	$12.67
Max. Negotiated Rate	$305.10
Rate for Payer: Aetna of AZ Commercial	$305.10
Rate for Payer: Arizona Complete Health Allwell	$54.24
Rate for Payer: Banner UC Health Medicare	$54.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$230.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$54.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$54.24
Rate for Payer: Cash Price	$271.20
Rate for Payer: Cash Price	$271.20
Rate for Payer: Cigna of AZ Commercial	$220.35
Rate for Payer: Devoted Health Medicare	$61.02
Rate for Payer: Humana of AZ Medicare	$54.24
Rate for Payer: Seven Corners Travel Insurance	$12.67
Rate for Payer: Southwest Service Administrators UFCW	$230.52
Rate for Payer: TriWest Medicare	$54.24
Rate for Payer: United Healthcare Commercial	$193.91
Rate for Payer: United Healthcare Medicare	$54.24
Rate for Payer: Veterans Affairs TRICARE	$53.70

Know your out-of-pocket cost for care.

All Charges