Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

65210 REMOVE FB EXT EYE ENBEDD

Facility

$233.00

Service Code	CPT 65210
Hospital Charge Code	22282925
Hospital Revenue Code	450
Min. Negotiated Rate	$209.70
Max. Negotiated Rate	$209.70
Rate for Payer: Aetna of AZ Commercial	$209.70
Rate for Payer: Cash Price	$186.40

65220 RMVL FB CORNEAL W/O LAMP

Facility

$197.00

Service Code	CPT 65220
Hospital Charge Code	12047487
Hospital Revenue Code	521
Min. Negotiated Rate	$177.30
Max. Negotiated Rate	$177.30
Rate for Payer: Aetna of AZ Commercial	$177.30
Rate for Payer: Cash Price	$157.60

65220 RMVL FB CORNEAL W/O LAMP

Facility

$197.00

Service Code	CPT 65220
Hospital Charge Code	12047487
Hospital Revenue Code	521
Min. Negotiated Rate	$19.87
Max. Negotiated Rate	$691.20
Rate for Payer: Aetna of AZ Commercial	$177.30
Rate for Payer: Arizona Complete Health Allwell	$31.52
Rate for Payer: Banner UC Health Medicare	$31.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$133.96
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$19.87
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$31.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.52
Rate for Payer: Cash Price	$157.60
Rate for Payer: Cash Price	$157.60
Rate for Payer: Cigna of AZ Commercial	$137.90
Rate for Payer: Devoted Health Medicare	$35.46
Rate for Payer: Humana of AZ Medicare	$31.52
Rate for Payer: Mercy Care Medicaid	$19.87
Rate for Payer: NaphCare Correctional Healthcare	$19.87
Rate for Payer: Seven Corners Travel Insurance	$691.20
Rate for Payer: Southwest Service Administrators UFCW	$133.96
Rate for Payer: TriWest Medicare	$31.52
Rate for Payer: United Healthcare Commercial	$112.68
Rate for Payer: United Healthcare Medicare	$31.52
Rate for Payer: Veterans Affairs TRICARE	$31.20

65222 FOREIGN BODY CORNEAL WITH SLITLAMP Clinic Charge

Facility

$196.00

Service Code	CPT 65222
Hospital Charge Code	10197712
Hospital Revenue Code	521
Min. Negotiated Rate	$18.48
Max. Negotiated Rate	$205.86
Rate for Payer: Aetna of AZ Commercial	$176.40
Rate for Payer: Arizona Complete Health Allwell	$31.36
Rate for Payer: Banner UC Health Medicare	$31.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$133.28
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$18.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$31.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.36
Rate for Payer: Cash Price	$156.80
Rate for Payer: Cash Price	$156.80
Rate for Payer: Cigna of AZ Commercial	$137.20
Rate for Payer: Devoted Health Medicare	$35.28
Rate for Payer: Humana of AZ Medicare	$31.36
Rate for Payer: Mercy Care Medicaid	$18.48
Rate for Payer: NaphCare Correctional Healthcare	$18.48
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$133.28
Rate for Payer: TriWest Medicare	$31.36
Rate for Payer: United Healthcare Commercial	$112.11
Rate for Payer: United Healthcare Medicare	$31.36
Rate for Payer: Veterans Affairs TRICARE	$31.05

65222 FOREIGN BODY CORNEAL WITH SLITLAMP Clinic Charge

Facility

$196.00

Service Code	CPT 65222
Hospital Charge Code	10197712
Hospital Revenue Code	521
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$176.40
Rate for Payer: Aetna of AZ Commercial	$176.40
Rate for Payer: Cash Price	$156.80

65235 REMOVE FB INTRAOCULAR

Facility

$2,337.00

Service Code	CPT 65235
Hospital Charge Code	22282926
Hospital Revenue Code	450
Min. Negotiated Rate	$370.18
Max. Negotiated Rate	$3,570.83
Rate for Payer: Aetna of AZ Commercial	$2,103.30
Rate for Payer: Arizona Complete Health Allwell	$373.92
Rate for Payer: Banner UC Health Medicare	$373.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,589.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$373.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$373.92
Rate for Payer: Cash Price	$1,869.60
Rate for Payer: Cash Price	$1,869.60
Rate for Payer: Cigna of AZ Commercial	$1,635.90
Rate for Payer: Devoted Health Medicare	$420.66
Rate for Payer: Humana of AZ Medicare	$373.92
Rate for Payer: Seven Corners Travel Insurance	$3,570.83
Rate for Payer: Southwest Service Administrators UFCW	$1,589.16
Rate for Payer: TriWest Medicare	$373.92
Rate for Payer: United Healthcare Commercial	$1,336.76
Rate for Payer: United Healthcare Medicare	$373.92
Rate for Payer: United Healthcare New Mexico Commercial	$444.03
Rate for Payer: Veterans Affairs TRICARE	$370.18

65235 REMOVE FB INTRAOCULAR

Facility

$2,337.00

Service Code	CPT 65235
Hospital Charge Code	22282926
Hospital Revenue Code	450
Min. Negotiated Rate	$2,103.30
Max. Negotiated Rate	$2,103.30
Rate for Payer: Aetna of AZ Commercial	$2,103.30
Rate for Payer: Cash Price	$1,869.60

6.6 POST REAMER

Facility

$964.00

Hospital Charge Code	22354197
Hospital Revenue Code	270
Min. Negotiated Rate	$152.70
Max. Negotiated Rate	$867.60
Rate for Payer: Aetna of AZ Commercial	$867.60
Rate for Payer: Arizona Complete Health Allwell	$154.24
Rate for Payer: Banner UC Health Medicare	$154.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$655.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$154.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$154.24
Rate for Payer: Cash Price	$771.20
Rate for Payer: Cigna of AZ Commercial	$674.80
Rate for Payer: Devoted Health Medicare	$173.52
Rate for Payer: Humana of AZ Medicare	$154.24
Rate for Payer: Southwest Service Administrators UFCW	$655.52
Rate for Payer: TriWest Medicare	$154.24
Rate for Payer: United Healthcare Commercial	$551.41
Rate for Payer: United Healthcare Medicare	$154.24
Rate for Payer: Veterans Affairs TRICARE	$152.70

6.6 POST REAMER

Facility

$964.00

Hospital Charge Code	22354197
Hospital Revenue Code	270
Min. Negotiated Rate	$867.60
Max. Negotiated Rate	$867.60
Rate for Payer: Aetna of AZ Commercial	$867.60
Rate for Payer: Cash Price	$771.20

6.6 x 20MM POST

Facility

$3,800.00

Service Code	HCPCS C1778
Hospital Charge Code	22354199
Hospital Revenue Code	270
Min. Negotiated Rate	$601.92
Max. Negotiated Rate	$3,420.00
Rate for Payer: Aetna of AZ Commercial	$3,420.00
Rate for Payer: Arizona Complete Health Allwell	$608.00
Rate for Payer: Banner UC Health Medicare	$608.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,584.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$608.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$608.00
Rate for Payer: Cash Price	$3,040.00
Rate for Payer: Cigna of AZ Commercial	$2,660.00
Rate for Payer: Devoted Health Medicare	$684.00
Rate for Payer: Humana of AZ Medicare	$608.00
Rate for Payer: Southwest Service Administrators UFCW	$2,584.00
Rate for Payer: TriWest Medicare	$608.00
Rate for Payer: United Healthcare Commercial	$2,173.60
Rate for Payer: United Healthcare Medicare	$608.00
Rate for Payer: Veterans Affairs TRICARE	$601.92

6.6 x 20MM POST

Facility

$3,800.00

Service Code	HCPCS C1778
Hospital Charge Code	22354199
Hospital Revenue Code	270
Min. Negotiated Rate	$3,420.00
Max. Negotiated Rate	$3,420.00
Rate for Payer: Aetna of AZ Commercial	$3,420.00
Rate for Payer: Cash Price	$3,040.00

69200 REMOVE FB EXT EAR

Facility

$344.00

Service Code	CPT 69200
Hospital Charge Code	22282927
Hospital Revenue Code	450
Min. Negotiated Rate	$35.05
Max. Negotiated Rate	$309.60
Rate for Payer: Aetna of AZ Commercial	$309.60
Rate for Payer: Arizona Complete Health Allwell	$55.04
Rate for Payer: Banner UC Health Medicare	$55.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$233.92
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$35.05
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$55.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$55.04
Rate for Payer: Cash Price	$275.20
Rate for Payer: Cash Price	$275.20
Rate for Payer: Cigna of AZ Commercial	$240.80
Rate for Payer: Devoted Health Medicare	$61.92
Rate for Payer: Humana of AZ Medicare	$55.04
Rate for Payer: Mercy Care Medicaid	$35.05
Rate for Payer: NaphCare Correctional Healthcare	$35.05
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$233.92
Rate for Payer: TriWest Medicare	$55.04
Rate for Payer: United Healthcare Commercial	$196.77
Rate for Payer: United Healthcare Medicare	$55.04
Rate for Payer: United Healthcare New Mexico Commercial	$65.36
Rate for Payer: Veterans Affairs TRICARE	$54.49

69200 REMOVE FB EXT EAR

Facility

$344.00

Service Code	CPT 69200
Hospital Charge Code	22282927
Hospital Revenue Code	450
Min. Negotiated Rate	$309.60
Max. Negotiated Rate	$309.60
Rate for Payer: Aetna of AZ Commercial	$309.60
Rate for Payer: Cash Price	$275.20

69210 REMOVE IMPACTED CERUMEN

Facility

$230.00

Service Code	CPT 69210
Hospital Charge Code	22282928
Hospital Revenue Code	450
Min. Negotiated Rate	$16.45
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna of AZ Commercial	$207.00
Rate for Payer: Arizona Complete Health Allwell	$36.80
Rate for Payer: Banner UC Health Medicare	$36.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$156.40
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$16.45
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.80
Rate for Payer: Cash Price	$184.00
Rate for Payer: Cash Price	$184.00
Rate for Payer: Cigna of AZ Commercial	$161.00
Rate for Payer: Devoted Health Medicare	$41.40
Rate for Payer: Humana of AZ Medicare	$36.80
Rate for Payer: Mercy Care Medicaid	$16.45
Rate for Payer: NaphCare Correctional Healthcare	$16.45
Rate for Payer: Seven Corners Travel Insurance	$91.28
Rate for Payer: Southwest Service Administrators UFCW	$156.40
Rate for Payer: TriWest Medicare	$36.80
Rate for Payer: United Healthcare Commercial	$131.56
Rate for Payer: United Healthcare Medicare	$36.80
Rate for Payer: United Healthcare New Mexico Commercial	$43.70
Rate for Payer: Veterans Affairs TRICARE	$36.43

69210 REMOVE IMPACTED CERUMEN

Facility

$230.00

Service Code	CPT 69210
Hospital Charge Code	22282928
Hospital Revenue Code	450
Min. Negotiated Rate	$207.00
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna of AZ Commercial	$207.00
Rate for Payer: Cash Price	$184.00

7.5FR ULTRA SLIM SINGLE USE URETEROSCOPE

Facility

$3,725.00

Hospital Charge Code	27887273
Hospital Revenue Code	270
Min. Negotiated Rate	$3,352.50
Max. Negotiated Rate	$3,352.50
Rate for Payer: Aetna of AZ Commercial	$3,352.50
Rate for Payer: Cash Price	$2,980.00

7.5FR ULTRA SLIM SINGLE USE URETEROSCOPE

Facility

$3,725.00

Hospital Charge Code	27887273
Hospital Revenue Code	270
Min. Negotiated Rate	$590.04
Max. Negotiated Rate	$3,352.50
Rate for Payer: Aetna of AZ Commercial	$3,352.50
Rate for Payer: Arizona Complete Health Allwell	$596.00
Rate for Payer: Banner UC Health Medicare	$596.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,533.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$596.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$596.00
Rate for Payer: Cash Price	$2,980.00
Rate for Payer: Cigna of AZ Commercial	$2,607.50
Rate for Payer: Devoted Health Medicare	$670.50
Rate for Payer: Humana of AZ Medicare	$596.00
Rate for Payer: Southwest Service Administrators UFCW	$2,533.00
Rate for Payer: TriWest Medicare	$596.00
Rate for Payer: United Healthcare Commercial	$2,130.70
Rate for Payer: United Healthcare Medicare	$596.00
Rate for Payer: Veterans Affairs TRICARE	$590.04

80307 - Drug test(s), presumptive, any number of drug classe

Facility

$282.00

Service Code	CPT 80307
Hospital Charge Code	23090951
Hospital Revenue Code	301
Min. Negotiated Rate	$44.67
Max. Negotiated Rate	$253.80
Rate for Payer: Aetna of AZ Commercial	$253.80
Rate for Payer: Arizona Complete Health Allwell	$45.12
Rate for Payer: Banner UC Health Medicare	$45.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$191.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$45.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$45.12
Rate for Payer: Cash Price	$225.60
Rate for Payer: Cash Price	$225.60
Rate for Payer: Cigna of AZ Commercial	$183.30
Rate for Payer: Devoted Health Medicare	$50.76
Rate for Payer: Humana of AZ Medicare	$45.12
Rate for Payer: Seven Corners Travel Insurance	$90.10
Rate for Payer: Southwest Service Administrators UFCW	$191.76
Rate for Payer: TriWest Medicare	$45.12
Rate for Payer: United Healthcare Commercial	$161.30
Rate for Payer: United Healthcare Medicare	$45.12
Rate for Payer: Veterans Affairs TRICARE	$44.67

80307 - Drug test(s), presumptive, any number of drug classe

Facility

$282.00

Service Code	CPT 80307
Hospital Charge Code	23090951
Hospital Revenue Code	301
Min. Negotiated Rate	$253.80
Max. Negotiated Rate	$253.80
Rate for Payer: Aetna of AZ Commercial	$253.80
Rate for Payer: Cash Price	$225.60

80326 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80326
Hospital Charge Code	28077245
Hospital Revenue Code	301
Min. Negotiated Rate	$252.90
Max. Negotiated Rate	$252.90
Rate for Payer: Aetna of AZ Commercial	$252.90
Rate for Payer: Cash Price	$224.80

80326 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80326
Hospital Charge Code	28077245
Hospital Revenue Code	301
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$252.90
Rate for Payer: Aetna of AZ Commercial	$252.90
Rate for Payer: Arizona Complete Health Allwell	$44.96
Rate for Payer: Banner UC Health Medicare	$44.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$191.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$44.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.88
Rate for Payer: Cash Price	$224.80
Rate for Payer: Cash Price	$224.80
Rate for Payer: Cigna of AZ Commercial	$182.65
Rate for Payer: Devoted Health Medicare	$50.58
Rate for Payer: Humana of AZ Medicare	$44.96
Rate for Payer: Southwest Service Administrators UFCW	$191.08
Rate for Payer: TriWest Medicare	$44.96
Rate for Payer: United Healthcare Commercial	$160.73
Rate for Payer: United Healthcare Medicare	$44.96
Rate for Payer: Veterans Affairs TRICARE	$44.51

80331 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80331
Hospital Charge Code	28077246
Hospital Revenue Code	301
Min. Negotiated Rate	$252.90
Max. Negotiated Rate	$252.90
Rate for Payer: Aetna of AZ Commercial	$252.90
Rate for Payer: Cash Price	$224.80

80331 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80331
Hospital Charge Code	28077246
Hospital Revenue Code	301
Min. Negotiated Rate	$44.51
Max. Negotiated Rate	$252.90
Rate for Payer: Aetna of AZ Commercial	$252.90
Rate for Payer: Arizona Complete Health Allwell	$44.96
Rate for Payer: Banner UC Health Medicare	$44.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$191.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$44.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$44.96
Rate for Payer: Cash Price	$224.80
Rate for Payer: Cigna of AZ Commercial	$182.65
Rate for Payer: Devoted Health Medicare	$50.58
Rate for Payer: Humana of AZ Medicare	$44.96
Rate for Payer: Southwest Service Administrators UFCW	$191.08
Rate for Payer: TriWest Medicare	$44.96
Rate for Payer: United Healthcare Commercial	$160.73
Rate for Payer: United Healthcare Medicare	$44.96
Rate for Payer: Veterans Affairs TRICARE	$44.51

80337 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80337
Hospital Charge Code	28073686
Hospital Revenue Code	301
Min. Negotiated Rate	$252.90
Max. Negotiated Rate	$252.90
Rate for Payer: Aetna of AZ Commercial	$252.90
Rate for Payer: Cash Price	$224.80

80337 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80337
Hospital Charge Code	28073686
Hospital Revenue Code	301
Min. Negotiated Rate	$44.51
Max. Negotiated Rate	$252.90
Rate for Payer: Aetna of AZ Commercial	$252.90
Rate for Payer: Arizona Complete Health Allwell	$44.96
Rate for Payer: Banner UC Health Medicare	$44.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$191.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$44.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$44.96
Rate for Payer: Cash Price	$224.80
Rate for Payer: Cigna of AZ Commercial	$182.65
Rate for Payer: Devoted Health Medicare	$50.58
Rate for Payer: Humana of AZ Medicare	$44.96
Rate for Payer: Southwest Service Administrators UFCW	$191.08
Rate for Payer: TriWest Medicare	$44.96
Rate for Payer: United Healthcare Commercial	$160.73
Rate for Payer: United Healthcare Medicare	$44.96
Rate for Payer: Veterans Affairs TRICARE	$44.51

Know your out-of-pocket cost for care.

All Charges