Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

82436 - Litholink 24-Hour Urine, KS LC

Facility

$71.00

Service Code	CPT 82436
Hospital Charge Code	28267015
Hospital Revenue Code	301
Min. Negotiated Rate	$8.34
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Arizona Complete Health Allwell	$11.36
Rate for Payer: Banner UC Health Medicare	$11.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$48.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.36
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cigna of AZ Commercial	$46.15
Rate for Payer: Devoted Health Medicare	$12.78
Rate for Payer: Humana of AZ Medicare	$11.36
Rate for Payer: Seven Corners Travel Insurance	$8.34
Rate for Payer: Southwest Service Administrators UFCW	$48.28
Rate for Payer: TriWest Medicare	$11.36
Rate for Payer: United Healthcare Commercial	$40.61
Rate for Payer: United Healthcare Medicare	$11.36
Rate for Payer: Veterans Affairs TRICARE	$11.25

82436 - Litholink 24-Hour Urine, KS LC

Facility

$71.00

Service Code	CPT 82436
Hospital Charge Code	28267015
Hospital Revenue Code	301
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Cash Price	$56.80

82507 - Litholink 24-Hour Urine, KS LC

Facility

$71.00

Service Code	CPT 82507
Hospital Charge Code	28268594
Hospital Revenue Code	301
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Cash Price	$56.80

82507 - Litholink 24-Hour Urine, KS LC

Facility

$71.00

Service Code	CPT 82507
Hospital Charge Code	28268594
Hospital Revenue Code	301
Min. Negotiated Rate	$11.25
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Arizona Complete Health Allwell	$11.36
Rate for Payer: Banner UC Health Medicare	$11.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$48.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.36
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cigna of AZ Commercial	$46.15
Rate for Payer: Devoted Health Medicare	$12.78
Rate for Payer: Humana of AZ Medicare	$11.36
Rate for Payer: Seven Corners Travel Insurance	$40.31
Rate for Payer: Southwest Service Administrators UFCW	$48.28
Rate for Payer: TriWest Medicare	$11.36
Rate for Payer: United Healthcare Commercial	$40.61
Rate for Payer: United Healthcare Medicare	$11.36
Rate for Payer: Veterans Affairs TRICARE	$11.25

82570 - Litholink 24-Hour Urine, KS LC

Facility

$94.00

Service Code	CPT 82570
Hospital Charge Code	28265617
Hospital Revenue Code	301
Min. Negotiated Rate	$7.51
Max. Negotiated Rate	$84.60
Rate for Payer: Aetna of AZ Commercial	$84.60
Rate for Payer: Arizona Complete Health Allwell	$15.04
Rate for Payer: Banner UC Health Medicare	$15.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$63.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$15.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.04
Rate for Payer: Cash Price	$75.20
Rate for Payer: Cash Price	$75.20
Rate for Payer: Cigna of AZ Commercial	$61.10
Rate for Payer: Devoted Health Medicare	$16.92
Rate for Payer: Humana of AZ Medicare	$15.04
Rate for Payer: Seven Corners Travel Insurance	$7.51
Rate for Payer: Southwest Service Administrators UFCW	$63.92
Rate for Payer: TriWest Medicare	$15.04
Rate for Payer: United Healthcare Commercial	$53.77
Rate for Payer: United Healthcare Medicare	$15.04
Rate for Payer: Veterans Affairs TRICARE	$14.89

82570 - Litholink 24-Hour Urine, KS LC

Facility

$94.00

Service Code	CPT 82570
Hospital Charge Code	28265617
Hospital Revenue Code	301
Min. Negotiated Rate	$84.60
Max. Negotiated Rate	$84.60
Rate for Payer: Aetna of AZ Commercial	$84.60
Rate for Payer: Cash Price	$75.20

82615 - Litholink 24-Hour Urine, KS LC

Facility

$48.00

Service Code	CPT 82615
Hospital Charge Code	28267016
Hospital Revenue Code	301
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	$13.85
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

82615 - Litholink 24-Hour Urine, KS LC

Facility

$48.00

Service Code	CPT 82615
Hospital Charge Code	28267016
Hospital Revenue Code	301
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

83735 LC#LC

Facility

$84.00

Service Code	CPT 83735
Hospital Charge Code	23173801
Hospital Revenue Code	301
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Cash Price	$67.20

83735 LC#LC

Facility

$84.00

Service Code	CPT 83735
Hospital Charge Code	23173801
Hospital Revenue Code	301
Min. Negotiated Rate	$9.71
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Arizona Complete Health Allwell	$13.44
Rate for Payer: Banner UC Health Medicare	$13.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$57.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.44
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cigna of AZ Commercial	$54.60
Rate for Payer: Devoted Health Medicare	$15.12
Rate for Payer: Humana of AZ Medicare	$13.44
Rate for Payer: Seven Corners Travel Insurance	$9.71
Rate for Payer: Southwest Service Administrators UFCW	$57.12
Rate for Payer: TriWest Medicare	$13.44
Rate for Payer: United Healthcare Commercial	$48.05
Rate for Payer: United Healthcare Medicare	$13.44
Rate for Payer: Veterans Affairs TRICARE	$13.31

83735 - Litholink 24-Hour Urine, KS LC

Facility

$80.00

Service Code	CPT 83735
Hospital Charge Code	28267017
Hospital Revenue Code	301
Min. Negotiated Rate	$9.71
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: 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: Seven Corners Travel Insurance	$9.71
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

83735 - Litholink 24-Hour Urine, KS LC

Facility

$80.00

Service Code	CPT 83735
Hospital Charge Code	28267017
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

83945 - Litholink 24-Hour Urine, KS LC

Facility

$172.00

Service Code	CPT 83945
Hospital Charge Code	28265618
Hospital Revenue Code	301
Min. Negotiated Rate	$20.95
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Arizona Complete Health Allwell	$27.52
Rate for Payer: Banner UC Health Medicare	$27.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$116.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.52
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cigna of AZ Commercial	$111.80
Rate for Payer: Devoted Health Medicare	$30.96
Rate for Payer: Humana of AZ Medicare	$27.52
Rate for Payer: Seven Corners Travel Insurance	$20.95
Rate for Payer: Southwest Service Administrators UFCW	$116.96
Rate for Payer: TriWest Medicare	$27.52
Rate for Payer: United Healthcare Commercial	$98.38
Rate for Payer: United Healthcare Medicare	$27.52
Rate for Payer: Veterans Affairs TRICARE	$27.24

83945 - Litholink 24-Hour Urine, KS LC

Facility

$172.00

Service Code	CPT 83945
Hospital Charge Code	28265618
Hospital Revenue Code	301
Min. Negotiated Rate	$154.80
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Cash Price	$137.60

83951 DCP

Facility

$318.00

Service Code	CPT 83951
Hospital Charge Code	23187087
Hospital Revenue Code	302
Min. Negotiated Rate	$286.20
Max. Negotiated Rate	$286.20
Rate for Payer: Aetna of AZ Commercial	$286.20
Rate for Payer: Cash Price	$254.40

83951 DCP

Facility

$318.00

Service Code	CPT 83951
Hospital Charge Code	23187087
Hospital Revenue Code	302
Min. Negotiated Rate	$50.37
Max. Negotiated Rate	$286.20
Rate for Payer: Aetna of AZ Commercial	$286.20
Rate for Payer: Arizona Complete Health Allwell	$50.88
Rate for Payer: Banner UC Health Medicare	$50.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$216.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$50.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$50.88
Rate for Payer: Cash Price	$254.40
Rate for Payer: Cash Price	$254.40
Rate for Payer: Cigna of AZ Commercial	$206.70
Rate for Payer: Devoted Health Medicare	$57.24
Rate for Payer: Humana of AZ Medicare	$50.88
Rate for Payer: Seven Corners Travel Insurance	$93.39
Rate for Payer: Southwest Service Administrators UFCW	$216.24
Rate for Payer: TriWest Medicare	$50.88
Rate for Payer: United Healthcare Commercial	$181.90
Rate for Payer: United Healthcare Medicare	$50.88
Rate for Payer: Veterans Affairs TRICARE	$50.37

83986 - Litholink 24-Hour Urine, KS LC

Facility

$18.00

Service Code	CPT 83986
Hospital Charge Code	28265619
Hospital Revenue Code	301
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$16.20
Rate for Payer: Aetna of AZ Commercial	$16.20
Rate for Payer: Arizona Complete Health Allwell	$2.88
Rate for Payer: Banner UC Health Medicare	$2.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$12.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.88
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna of AZ Commercial	$11.70
Rate for Payer: Devoted Health Medicare	$3.24
Rate for Payer: Humana of AZ Medicare	$2.88
Rate for Payer: Seven Corners Travel Insurance	$5.19
Rate for Payer: Southwest Service Administrators UFCW	$12.24
Rate for Payer: TriWest Medicare	$2.88
Rate for Payer: United Healthcare Commercial	$10.30
Rate for Payer: United Healthcare Medicare	$2.88
Rate for Payer: Veterans Affairs TRICARE	$2.85

83986 - Litholink 24-Hour Urine, KS LC

Facility

$18.00

Service Code	CPT 83986
Hospital Charge Code	28265619
Hospital Revenue Code	301
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$16.20
Rate for Payer: Aetna of AZ Commercial	$16.20
Rate for Payer: Cash Price	$14.40

83992 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 83992
Hospital Charge Code	28075345
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

83992 Drug Analysis Profile, Comprehensive, Ur LC

Facility

$281.00

Service Code	CPT 83992
Hospital Charge Code	28075345
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

84105 - Litholink 24-Hour Urine, KS LC

Facility

$69.00

Service Code	CPT 84105
Hospital Charge Code	28267018
Hospital Revenue Code	301
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

84105 - Litholink 24-Hour Urine, KS LC

Facility

$69.00

Service Code	CPT 84105
Hospital Charge Code	28267018
Hospital Revenue Code	301
Min. Negotiated Rate	$8.38
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: Cash Price	$55.20
Rate for Payer: Cigna of AZ Commercial	$44.85
Rate for Payer: Devoted Health Medicare	$12.42
Rate for Payer: Humana of AZ Medicare	$11.04
Rate for Payer: Seven Corners Travel Insurance	$8.38
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: Veterans Affairs TRICARE	$10.93

84133 - Litholink 24-Hour Urine, KS LC

Facility

$67.00

Service Code	CPT 84133
Hospital Charge Code	28268595
Hospital Revenue Code	301
Min. Negotiated Rate	$6.86
Max. Negotiated Rate	$60.30
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Arizona Complete Health Allwell	$10.72
Rate for Payer: Banner UC Health Medicare	$10.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$45.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.72
Rate for Payer: Cash Price	$53.60
Rate for Payer: Cash Price	$53.60
Rate for Payer: Cigna of AZ Commercial	$43.55
Rate for Payer: Devoted Health Medicare	$12.06
Rate for Payer: Humana of AZ Medicare	$10.72
Rate for Payer: Seven Corners Travel Insurance	$6.86
Rate for Payer: Southwest Service Administrators UFCW	$45.56
Rate for Payer: TriWest Medicare	$10.72
Rate for Payer: United Healthcare Commercial	$38.32
Rate for Payer: United Healthcare Medicare	$10.72
Rate for Payer: Veterans Affairs TRICARE	$10.61

84133 - Litholink 24-Hour Urine, KS LC

Facility

$67.00

Service Code	CPT 84133
Hospital Charge Code	28268595
Hospital Revenue Code	301
Min. Negotiated Rate	$60.30
Max. Negotiated Rate	$60.30
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Cash Price	$53.60

84300 - Litholink 24-Hour Urine, KS LC

Facility

$84.00

Service Code	CPT 84300
Hospital Charge Code	28268596
Hospital Revenue Code	301
Min. Negotiated Rate	$7.34
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Arizona Complete Health Allwell	$13.44
Rate for Payer: Banner UC Health Medicare	$13.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$57.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.44
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cigna of AZ Commercial	$54.60
Rate for Payer: Devoted Health Medicare	$15.12
Rate for Payer: Humana of AZ Medicare	$13.44
Rate for Payer: Seven Corners Travel Insurance	$7.34
Rate for Payer: Southwest Service Administrators UFCW	$57.12
Rate for Payer: TriWest Medicare	$13.44
Rate for Payer: United Healthcare Commercial	$48.05
Rate for Payer: United Healthcare Medicare	$13.44
Rate for Payer: Veterans Affairs TRICARE	$13.31

Know your out-of-pocket cost for care.

All Charges