Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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

CLIENT IV-LACTATED RINGERS : 1000 ML

Facility

$30.00

Hospital Charge Code	22331338
Hospital Revenue Code	250
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 IV-LACTATED RINGERS : 1000 ML

Facility

$30.00

Hospital Charge Code	22331338
Hospital Revenue Code	250
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 KNEE LIMITED RT

Facility

$538.00

Service Code	CPT 73560 RT
Hospital Charge Code	22331345
Hospital Revenue Code	320
Min. Negotiated Rate	$484.20
Max. Negotiated Rate	$484.20
Rate for Payer: Aetna of AZ Commercial	$484.20
Rate for Payer: Cash Price	$430.40

CLIENT KNEE LIMITED RT

Facility

$538.00

Service Code	CPT 73560 RT
Hospital Charge Code	22331345
Hospital Revenue Code	320
Min. Negotiated Rate	$32.51
Max. Negotiated Rate	$484.20
Rate for Payer: Aetna of AZ Commercial	$484.20
Rate for Payer: Arizona Complete Health Allwell	$86.08
Rate for Payer: Banner UC Health Medicare	$86.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$365.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$86.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.51
Rate for Payer: Cash Price	$430.40
Rate for Payer: Cash Price	$430.40
Rate for Payer: Cigna of AZ Commercial	$349.70
Rate for Payer: Devoted Health Medicare	$96.84
Rate for Payer: Humana of AZ Medicare	$86.08
Rate for Payer: Southwest Service Administrators UFCW	$365.84
Rate for Payer: TriWest Medicare	$86.08
Rate for Payer: United Healthcare Commercial	$307.74
Rate for Payer: United Healthcare Medicare	$86.08
Rate for Payer: Veterans Affairs TRICARE	$85.22

CLIENT MMR VACCINE

Facility

$69.00

Hospital Charge Code	22331364
Hospital Revenue Code	636
Min. Negotiated Rate	$10.93
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Arizona Complete Health Allwell	$11.04
Rate for Payer: Banner UC Health Medicare	$11.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$46.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.04
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cigna of AZ Commercial	$48.30
Rate for Payer: Devoted Health Medicare	$12.42
Rate for Payer: Humana of AZ Medicare	$11.04
Rate for Payer: Southwest Service Administrators UFCW	$46.92
Rate for Payer: TriWest Medicare	$11.04
Rate for Payer: United Healthcare Commercial	$39.47
Rate for Payer: United Healthcare Medicare	$11.04
Rate for Payer: United Healthcare New Mexico Commercial	$13.11
Rate for Payer: Veterans Affairs TRICARE	$10.93

CLIENT MMR VACCINE

Facility

$69.00

Hospital Charge Code	22331364
Hospital Revenue Code	636
Min. Negotiated Rate	$62.10
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Cash Price	$55.20

CLIENT NON DOT CDC UDS COLLECTION

Facility

$21.00

Hospital Charge Code	22331418
Hospital Revenue Code	301
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Arizona Complete Health Allwell	$3.36
Rate for Payer: Banner UC Health Medicare	$3.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$14.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.36
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna of AZ Commercial	$13.65
Rate for Payer: Devoted Health Medicare	$3.78
Rate for Payer: Humana of AZ Medicare	$3.36
Rate for Payer: Southwest Service Administrators UFCW	$14.28
Rate for Payer: TriWest Medicare	$3.36
Rate for Payer: United Healthcare Commercial	$12.01
Rate for Payer: United Healthcare Medicare	$3.36
Rate for Payer: Veterans Affairs TRICARE	$3.33

CLIENT NON DOT CDC UDS COLLECTION

Facility

$21.00

Hospital Charge Code	22331418
Hospital Revenue Code	301
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Cash Price	$16.80

CLIENT PFT PRE/POST

Facility

$108.00

Service Code	CPT 94060
Hospital Charge Code	22331441
Hospital Revenue Code	460
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 PFT PRE/POST

Facility

$108.00

Service Code	CPT 94060
Hospital Charge Code	22331441
Hospital Revenue Code	460
Min. Negotiated Rate	$17.11
Max. Negotiated Rate	$577.38
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: Cash Price	$86.40
Rate for Payer: Cigna of AZ Commercial	$75.60
Rate for Payer: Devoted Health Medicare	$19.44
Rate for Payer: Humana of AZ Medicare	$17.28
Rate for Payer: Seven Corners Travel Insurance	$577.38
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: United Healthcare New Mexico Commercial	$20.52
Rate for Payer: Veterans Affairs TRICARE	$17.11

CLIENT PHYSICAN EXAM FEMALE OVER 39

Facility

$125.00

Hospital Charge Code	22331443
Hospital Revenue Code	301
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$112.50
Rate for Payer: Aetna of AZ Commercial	$112.50
Rate for Payer: Arizona Complete Health Allwell	$20.00
Rate for Payer: Banner UC Health Medicare	$20.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$85.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.00
Rate for Payer: Cash Price	$100.00
Rate for Payer: Cigna of AZ Commercial	$81.25
Rate for Payer: Devoted Health Medicare	$22.50
Rate for Payer: Humana of AZ Medicare	$20.00
Rate for Payer: Southwest Service Administrators UFCW	$85.00
Rate for Payer: TriWest Medicare	$20.00
Rate for Payer: United Healthcare Commercial	$71.50
Rate for Payer: United Healthcare Medicare	$20.00
Rate for Payer: Veterans Affairs TRICARE	$19.80

CLIENT PHYSICAN EXAM FEMALE OVER 39

Facility

$125.00

Hospital Charge Code	22331443
Hospital Revenue Code	301
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Aetna of AZ Commercial	$112.50
Rate for Payer: Cash Price	$100.00

CLIENT PHYSICAN EXAM FEMALE UNDER 39

Facility

$72.00

Hospital Charge Code	22331444
Hospital Revenue Code	301
Min. Negotiated Rate	$11.40
Max. Negotiated Rate	$64.80
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	$11.52
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: 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 PHYSICAN EXAM FEMALE UNDER 39

Facility

$72.00

Hospital Charge Code	22331444
Hospital Revenue Code	301
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 PHYSICAN EXAM MALE OVER 39

Facility

$105.00

Hospital Charge Code	22331445
Hospital Revenue Code	301
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$94.50
Rate for Payer: Aetna of AZ Commercial	$94.50
Rate for Payer: Cash Price	$84.00

CLIENT PHYSICAN EXAM MALE OVER 39

Facility

$105.00

Hospital Charge Code	22331445
Hospital Revenue Code	301
Min. Negotiated Rate	$16.63
Max. Negotiated Rate	$94.50
Rate for Payer: Aetna of AZ Commercial	$94.50
Rate for Payer: Arizona Complete Health Allwell	$16.80
Rate for Payer: Banner UC Health Medicare	$16.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$71.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Cigna of AZ Commercial	$68.25
Rate for Payer: Devoted Health Medicare	$18.90
Rate for Payer: Humana of AZ Medicare	$16.80
Rate for Payer: Southwest Service Administrators UFCW	$71.40
Rate for Payer: TriWest Medicare	$16.80
Rate for Payer: United Healthcare Commercial	$60.06
Rate for Payer: United Healthcare Medicare	$16.80
Rate for Payer: Veterans Affairs TRICARE	$16.63

CLIENT PHYSICAN EXAM MALE UNDER 39

Facility

$70.00

Hospital Charge Code	22331451
Hospital Revenue Code	301
Min. Negotiated Rate	$11.09
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna of AZ Commercial	$63.00
Rate for Payer: Arizona Complete Health Allwell	$11.20
Rate for Payer: Banner UC Health Medicare	$11.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$47.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.20
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cigna of AZ Commercial	$45.50
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Humana of AZ Medicare	$11.20
Rate for Payer: Southwest Service Administrators UFCW	$47.60
Rate for Payer: TriWest Medicare	$11.20
Rate for Payer: United Healthcare Commercial	$40.04
Rate for Payer: United Healthcare Medicare	$11.20
Rate for Payer: Veterans Affairs TRICARE	$11.09

CLIENT PHYSICAN EXAM MALE UNDER 39

Facility

$70.00

Hospital Charge Code	22331451
Hospital Revenue Code	301
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna of AZ Commercial	$63.00
Rate for Payer: Cash Price	$56.00

CLIENT RABIES VACCINE INJ (IM)

Facility

$484.00

Service Code	CPT 90675
Hospital Charge Code	22331466
Hospital Revenue Code	252
Min. Negotiated Rate	$435.60
Max. Negotiated Rate	$435.60
Rate for Payer: Aetna of AZ Commercial	$435.60
Rate for Payer: Cash Price	$387.20

CLIENT RABIES VACCINE INJ (IM)

Facility

$484.00

Service Code	CPT 90675
Hospital Charge Code	22331466
Hospital Revenue Code	252
Min. Negotiated Rate	$76.67
Max. Negotiated Rate	$481.37
Rate for Payer: Aetna of AZ Commercial	$435.60
Rate for Payer: Arizona Complete Health Allwell	$77.44
Rate for Payer: Banner UC Health Medicare	$77.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$329.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$77.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$77.44
Rate for Payer: Cash Price	$387.20
Rate for Payer: Cash Price	$387.20
Rate for Payer: Cigna of AZ Commercial	$314.60
Rate for Payer: Devoted Health Medicare	$87.12
Rate for Payer: Humana of AZ Medicare	$77.44
Rate for Payer: Seven Corners Travel Insurance	$481.37
Rate for Payer: Southwest Service Administrators UFCW	$329.12
Rate for Payer: TriWest Medicare	$77.44
Rate for Payer: United Healthcare Commercial	$276.85
Rate for Payer: United Healthcare Medicare	$77.44
Rate for Payer: Veterans Affairs TRICARE	$76.67

CLIENT RESPIRATOR FIT TEST

Facility

$21.00

Hospital Charge Code	22331471
Hospital Revenue Code	301
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Cash Price	$16.80

CLIENT RESPIRATOR FIT TEST

Facility

$21.00

Hospital Charge Code	22331471
Hospital Revenue Code	301
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Arizona Complete Health Allwell	$3.36
Rate for Payer: Banner UC Health Medicare	$3.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$14.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.36
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna of AZ Commercial	$13.65
Rate for Payer: Devoted Health Medicare	$3.78
Rate for Payer: Humana of AZ Medicare	$3.36
Rate for Payer: Southwest Service Administrators UFCW	$14.28
Rate for Payer: TriWest Medicare	$3.36
Rate for Payer: United Healthcare Commercial	$12.01
Rate for Payer: United Healthcare Medicare	$3.36
Rate for Payer: Veterans Affairs TRICARE	$3.33

CLIENT RESPITATOR QUESTIONNAIRE REVIEW

Facility

$20.00

Hospital Charge Code	22331472
Hospital Revenue Code	301
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Arizona Complete Health Allwell	$3.20
Rate for Payer: Banner UC Health Medicare	$3.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$13.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.20
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cigna of AZ Commercial	$13.00
Rate for Payer: Devoted Health Medicare	$3.60
Rate for Payer: Humana of AZ Medicare	$3.20
Rate for Payer: Southwest Service Administrators UFCW	$13.60
Rate for Payer: TriWest Medicare	$3.20
Rate for Payer: United Healthcare Commercial	$11.44
Rate for Payer: United Healthcare Medicare	$3.20
Rate for Payer: Veterans Affairs TRICARE	$3.17

CLIENT RESPITATOR QUESTIONNAIRE REVIEW

Facility

$20.00

Hospital Charge Code	22331472
Hospital Revenue Code	301
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Cash Price	$16.00

Know your out-of-pocket cost for care.

All Charges