Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

80338 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80338
Hospital Charge Code	28073687
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

80338 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80338
Hospital Charge Code	28073687
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

80341 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80341
Hospital Charge Code	28073688
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

80341 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80341
Hospital Charge Code	28073688
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

80344 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80344
Hospital Charge Code	28077248
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

80344 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80344
Hospital Charge Code	28077248
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

80347 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$104.00

Service Code	CPT 80347
Hospital Charge Code	28077249
Hospital Revenue Code	301
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of AZ Commercial	$93.60
Rate for Payer: Arizona Complete Health Allwell	$16.64
Rate for Payer: Banner UC Health Medicare	$16.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$70.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.64
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cigna of AZ Commercial	$67.60
Rate for Payer: Devoted Health Medicare	$18.72
Rate for Payer: Humana of AZ Medicare	$16.64
Rate for Payer: Southwest Service Administrators UFCW	$70.72
Rate for Payer: TriWest Medicare	$16.64
Rate for Payer: United Healthcare Commercial	$59.49
Rate for Payer: United Healthcare Medicare	$16.64
Rate for Payer: Veterans Affairs TRICARE	$16.47

80347 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$104.00

Service Code	CPT 80347
Hospital Charge Code	28077249
Hospital Revenue Code	301
Min. Negotiated Rate	$93.60
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of AZ Commercial	$93.60
Rate for Payer: Cash Price	$83.20

80348 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80348
Hospital Charge Code	28075338
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

80348 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80348
Hospital Charge Code	28075338
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

80353 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$239.00

Service Code	CPT 80353
Hospital Charge Code	28075339
Hospital Revenue Code	301
Min. Negotiated Rate	$37.86
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Arizona Complete Health Allwell	$38.24
Rate for Payer: Banner UC Health Medicare	$38.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$162.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.24
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cigna of AZ Commercial	$155.35
Rate for Payer: Devoted Health Medicare	$43.02
Rate for Payer: Humana of AZ Medicare	$38.24
Rate for Payer: Southwest Service Administrators UFCW	$162.52
Rate for Payer: TriWest Medicare	$38.24
Rate for Payer: United Healthcare Commercial	$136.71
Rate for Payer: United Healthcare Medicare	$38.24
Rate for Payer: Veterans Affairs TRICARE	$37.86

80353 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$239.00

Service Code	CPT 80353
Hospital Charge Code	28075339
Hospital Revenue Code	301
Min. Negotiated Rate	$215.10
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Cash Price	$191.20

80354 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80354
Hospital Charge Code	28073689
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

80354 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80354
Hospital Charge Code	28073689
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

80355 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80355
Hospital Charge Code	28077250
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

80355 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80355
Hospital Charge Code	28077250
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

80357 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80357
Hospital Charge Code	28073690
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

80357 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80357
Hospital Charge Code	28073690
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

80358 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$228.00

Service Code	CPT 80358
Hospital Charge Code	28077251
Hospital Revenue Code	301
Min. Negotiated Rate	$36.12
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna of AZ Commercial	$205.20
Rate for Payer: Arizona Complete Health Allwell	$36.48
Rate for Payer: Banner UC Health Medicare	$36.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$155.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.48
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cigna of AZ Commercial	$148.20
Rate for Payer: Devoted Health Medicare	$41.04
Rate for Payer: Humana of AZ Medicare	$36.48
Rate for Payer: Southwest Service Administrators UFCW	$155.04
Rate for Payer: TriWest Medicare	$36.48
Rate for Payer: United Healthcare Commercial	$130.42
Rate for Payer: United Healthcare Medicare	$36.48
Rate for Payer: Veterans Affairs TRICARE	$36.12

80358 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$228.00

Service Code	CPT 80358
Hospital Charge Code	28077251
Hospital Revenue Code	301
Min. Negotiated Rate	$205.20
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna of AZ Commercial	$205.20
Rate for Payer: Cash Price	$182.40

80359 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80359
Hospital Charge Code	28077252
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

80359 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80359
Hospital Charge Code	28077252
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

80360 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80360
Hospital Charge Code	28073691
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

80360 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 80360
Hospital Charge Code	28073691
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

80361 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$227.00

Service Code	CPT 80361
Hospital Charge Code	28077444
Hospital Revenue Code	301
Min. Negotiated Rate	$204.30
Max. Negotiated Rate	$204.30
Rate for Payer: Aetna of AZ Commercial	$204.30
Rate for Payer: Cash Price	$181.60

Know your out-of-pocket cost for care.

All Charges