Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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	$75.60
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Cash Price	$67.20

84392 - Litholink 24-Hour Urine, KS LC

Facility

$28.00

Service Code	CPT 84392
Hospital Charge Code	28265620
Hospital Revenue Code	301
Min. Negotiated Rate	$4.44
Max. Negotiated Rate	$25.20
Rate for Payer: Aetna of AZ Commercial	$25.20
Rate for Payer: Arizona Complete Health Allwell	$4.48
Rate for Payer: Banner UC Health Medicare	$4.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$19.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.48
Rate for Payer: Cash Price	$22.40
Rate for Payer: Cash Price	$22.40
Rate for Payer: Cigna of AZ Commercial	$18.20
Rate for Payer: Devoted Health Medicare	$5.04
Rate for Payer: Humana of AZ Medicare	$4.48
Rate for Payer: Seven Corners Travel Insurance	$7.96
Rate for Payer: Southwest Service Administrators UFCW	$19.04
Rate for Payer: TriWest Medicare	$4.48
Rate for Payer: United Healthcare Commercial	$16.02
Rate for Payer: United Healthcare Medicare	$4.48
Rate for Payer: Veterans Affairs TRICARE	$4.44

84392 - Litholink 24-Hour Urine, KS LC

Facility

$28.00

Service Code	CPT 84392
Hospital Charge Code	28265620
Hospital Revenue Code	301
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$25.20
Rate for Payer: Aetna of AZ Commercial	$25.20
Rate for Payer: Cash Price	$22.40

84449 Cortisol, Free, Total With CBG LC

Facility

$90.00

Service Code	CPT 84449
Hospital Charge Code	28059772
Hospital Revenue Code	302
Min. Negotiated Rate	$14.26
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna of AZ Commercial	$81.00
Rate for Payer: Arizona Complete Health Allwell	$14.40
Rate for Payer: Banner UC Health Medicare	$14.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$61.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna of AZ Commercial	$58.50
Rate for Payer: Devoted Health Medicare	$16.20
Rate for Payer: Humana of AZ Medicare	$14.40
Rate for Payer: Seven Corners Travel Insurance	$26.10
Rate for Payer: Southwest Service Administrators UFCW	$61.20
Rate for Payer: TriWest Medicare	$14.40
Rate for Payer: United Healthcare Commercial	$51.48
Rate for Payer: United Healthcare Medicare	$14.40
Rate for Payer: Veterans Affairs TRICARE	$14.26

84449 Cortisol, Free, Total With CBG LC

Facility

$90.00

Service Code	CPT 84449
Hospital Charge Code	28059772
Hospital Revenue Code	302
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna of AZ Commercial	$81.00
Rate for Payer: Cash Price	$72.00

84540 - Litholink 24-Hour Urine, KS LC

Facility

$28.00

Service Code	CPT 84540
Hospital Charge Code	28265621
Hospital Revenue Code	301
Min. Negotiated Rate	$4.44
Max. Negotiated Rate	$25.20
Rate for Payer: Aetna of AZ Commercial	$25.20
Rate for Payer: Arizona Complete Health Allwell	$4.48
Rate for Payer: Banner UC Health Medicare	$4.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$19.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.48
Rate for Payer: Cash Price	$22.40
Rate for Payer: Cash Price	$22.40
Rate for Payer: Cigna of AZ Commercial	$18.20
Rate for Payer: Devoted Health Medicare	$5.04
Rate for Payer: Humana of AZ Medicare	$4.48
Rate for Payer: Seven Corners Travel Insurance	$8.06
Rate for Payer: Southwest Service Administrators UFCW	$19.04
Rate for Payer: TriWest Medicare	$4.48
Rate for Payer: United Healthcare Commercial	$16.02
Rate for Payer: United Healthcare Medicare	$4.48
Rate for Payer: Veterans Affairs TRICARE	$4.44

84540 - Litholink 24-Hour Urine, KS LC

Facility

$28.00

Service Code	CPT 84540
Hospital Charge Code	28265621
Hospital Revenue Code	301
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$25.20
Rate for Payer: Aetna of AZ Commercial	$25.20
Rate for Payer: Cash Price	$22.40

84560 - Litholink 24-Hour Urine, KS LC

Facility

$61.00

Service Code	CPT 84560
Hospital Charge Code	28267019
Hospital Revenue Code	301
Min. Negotiated Rate	$54.90
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of AZ Commercial	$54.90
Rate for Payer: Cash Price	$48.80

84560 - Litholink 24-Hour Urine, KS LC

Facility

$61.00

Service Code	CPT 84560
Hospital Charge Code	28267019
Hospital Revenue Code	301
Min. Negotiated Rate	$7.37
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of AZ Commercial	$54.90
Rate for Payer: Arizona Complete Health Allwell	$9.76
Rate for Payer: Banner UC Health Medicare	$9.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$41.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.76
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cigna of AZ Commercial	$39.65
Rate for Payer: Devoted Health Medicare	$10.98
Rate for Payer: Humana of AZ Medicare	$9.76
Rate for Payer: Seven Corners Travel Insurance	$7.37
Rate for Payer: Southwest Service Administrators UFCW	$41.48
Rate for Payer: TriWest Medicare	$9.76
Rate for Payer: United Healthcare Commercial	$34.89
Rate for Payer: United Healthcare Medicare	$9.76
Rate for Payer: Veterans Affairs TRICARE	$9.66

84702 FIRST TRIMESTER SCREEN

Facility

$215.00

Service Code	CPT 84702
Hospital Charge Code	23294406
Hospital Revenue Code	301
Min. Negotiated Rate	$21.82
Max. Negotiated Rate	$193.50
Rate for Payer: Aetna of AZ Commercial	$193.50
Rate for Payer: Arizona Complete Health Allwell	$34.40
Rate for Payer: Banner UC Health Medicare	$34.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$146.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$34.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$34.40
Rate for Payer: Cash Price	$172.00
Rate for Payer: Cash Price	$172.00
Rate for Payer: Cigna of AZ Commercial	$139.75
Rate for Payer: Devoted Health Medicare	$38.70
Rate for Payer: Humana of AZ Medicare	$34.40
Rate for Payer: Seven Corners Travel Insurance	$21.82
Rate for Payer: Southwest Service Administrators UFCW	$146.20
Rate for Payer: TriWest Medicare	$34.40
Rate for Payer: United Healthcare Commercial	$122.98
Rate for Payer: United Healthcare Medicare	$34.40
Rate for Payer: Veterans Affairs TRICARE	$34.06

84702 FIRST TRIMESTER SCREEN

Facility

$215.00

Service Code	CPT 84702
Hospital Charge Code	23294406
Hospital Revenue Code	301
Min. Negotiated Rate	$193.50
Max. Negotiated Rate	$193.50
Rate for Payer: Aetna of AZ Commercial	$193.50
Rate for Payer: Cash Price	$172.00

85240 - Clotting; factor VIII (AHG), 1-stage

Facility

$89.00

Service Code	CPT 85240
Hospital Charge Code	23090952
Hospital Revenue Code	301
Min. Negotiated Rate	$80.10
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of AZ Commercial	$80.10
Rate for Payer: Cash Price	$71.20

85240 - Clotting; factor VIII (AHG), 1-stage

Facility

$89.00

Service Code	CPT 85240
Hospital Charge Code	23090952
Hospital Revenue Code	301
Min. Negotiated Rate	$14.10
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of AZ Commercial	$80.10
Rate for Payer: Arizona Complete Health Allwell	$14.24
Rate for Payer: Banner UC Health Medicare	$14.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$60.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.24
Rate for Payer: Cash Price	$71.20
Rate for Payer: Cash Price	$71.20
Rate for Payer: Cigna of AZ Commercial	$57.85
Rate for Payer: Devoted Health Medicare	$16.02
Rate for Payer: Humana of AZ Medicare	$14.24
Rate for Payer: Seven Corners Travel Insurance	$25.95
Rate for Payer: Southwest Service Administrators UFCW	$60.52
Rate for Payer: TriWest Medicare	$14.24
Rate for Payer: United Healthcare Commercial	$50.91
Rate for Payer: United Healthcare Medicare	$14.24
Rate for Payer: Veterans Affairs TRICARE	$14.10

86003 Allergens(14)

Facility

$62.00

Service Code	CPT 86003
Hospital Charge Code	28068400
Hospital Revenue Code	305
Min. Negotiated Rate	$7.57
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Arizona Complete Health Allwell	$9.92
Rate for Payer: Banner UC Health Medicare	$9.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$42.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.92
Rate for Payer: Cash Price	$49.60
Rate for Payer: Cash Price	$49.60
Rate for Payer: Cigna of AZ Commercial	$40.30
Rate for Payer: Devoted Health Medicare	$11.16
Rate for Payer: Humana of AZ Medicare	$9.92
Rate for Payer: Seven Corners Travel Insurance	$7.57
Rate for Payer: Southwest Service Administrators UFCW	$42.16
Rate for Payer: TriWest Medicare	$9.92
Rate for Payer: United Healthcare Commercial	$35.46
Rate for Payer: United Healthcare Medicare	$9.92
Rate for Payer: Veterans Affairs TRICARE	$9.82

86003 Allergens(14)

Facility

$62.00

Service Code	CPT 86003
Hospital Charge Code	28068400
Hospital Revenue Code	305
Min. Negotiated Rate	$55.80
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Cash Price	$49.60

86042 AChR Ab, Complete Profile

Facility

$92.00

Service Code	CPT 86042
Hospital Charge Code	28068387
Hospital Revenue Code	305
Min. Negotiated Rate	$14.57
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of AZ Commercial	$82.80
Rate for Payer: Arizona Complete Health Allwell	$14.72
Rate for Payer: Banner UC Health Medicare	$14.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$62.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.72
Rate for Payer: Cash Price	$73.60
Rate for Payer: Cash Price	$73.60
Rate for Payer: Cigna of AZ Commercial	$59.80
Rate for Payer: Devoted Health Medicare	$16.56
Rate for Payer: Humana of AZ Medicare	$14.72
Rate for Payer: Seven Corners Travel Insurance	$26.68
Rate for Payer: Southwest Service Administrators UFCW	$62.56
Rate for Payer: TriWest Medicare	$14.72
Rate for Payer: United Healthcare Commercial	$52.62
Rate for Payer: United Healthcare Medicare	$14.72
Rate for Payer: Veterans Affairs TRICARE	$14.57

86042 AChR Ab, Complete Profile

Facility

$92.00

Service Code	CPT 86042
Hospital Charge Code	28068387
Hospital Revenue Code	305
Min. Negotiated Rate	$82.80
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of AZ Commercial	$82.80
Rate for Payer: Cash Price	$73.60

86043 AChR Ab, Complete Profile

Facility

$60.00

Service Code	CPT 86043
Hospital Charge Code	28070397
Hospital Revenue Code	305
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Arizona Complete Health Allwell	$9.60
Rate for Payer: Banner UC Health Medicare	$9.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$40.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cigna of AZ Commercial	$39.00
Rate for Payer: Devoted Health Medicare	$10.80
Rate for Payer: Humana of AZ Medicare	$9.60
Rate for Payer: Seven Corners Travel Insurance	$17.47
Rate for Payer: Southwest Service Administrators UFCW	$40.80
Rate for Payer: TriWest Medicare	$9.60
Rate for Payer: United Healthcare Commercial	$34.32
Rate for Payer: United Healthcare Medicare	$9.60
Rate for Payer: Veterans Affairs TRICARE	$9.50

86043 AChR Ab, Complete Profile

Facility

$60.00

Service Code	CPT 86043
Hospital Charge Code	28070397
Hospital Revenue Code	305
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Cash Price	$48.00

86331 HYPERSENSITIVITY PNEUMONITIS PANEL

Facility

$94.00

Service Code	CPT 86671
Hospital Charge Code	23298039
Hospital Revenue Code	301
Min. Negotiated Rate	$14.89
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	$17.76
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

86331 HYPERSENSITIVITY PNEUMONITIS PANEL

Facility

$94.00

Service Code	CPT 86671
Hospital Charge Code	23298039
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

86331 HYPERSENSITIVITY PNEUMONITIS PANEL

Facility

$151.00

Service Code	CPT 86331
Hospital Charge Code	23298045
Hospital Revenue Code	301
Min. Negotiated Rate	$135.90
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of AZ Commercial	$135.90
Rate for Payer: Cash Price	$120.80

86331 HYPERSENSITIVITY PNEUMONITIS PANEL

Facility

$151.00

Service Code	CPT 86331
Hospital Charge Code	23298045
Hospital Revenue Code	301
Min. Negotiated Rate	$17.37
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of AZ Commercial	$135.90
Rate for Payer: Arizona Complete Health Allwell	$24.16
Rate for Payer: Banner UC Health Medicare	$24.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$102.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$24.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$24.16
Rate for Payer: Cash Price	$120.80
Rate for Payer: Cash Price	$120.80
Rate for Payer: Cigna of AZ Commercial	$98.15
Rate for Payer: Devoted Health Medicare	$27.18
Rate for Payer: Humana of AZ Medicare	$24.16
Rate for Payer: Seven Corners Travel Insurance	$17.37
Rate for Payer: Southwest Service Administrators UFCW	$102.68
Rate for Payer: TriWest Medicare	$24.16
Rate for Payer: United Healthcare Commercial	$86.37
Rate for Payer: United Healthcare Medicare	$24.16
Rate for Payer: Veterans Affairs TRICARE	$23.92

86356 MONONUCLEAR CELL ANTIGEN

Facility

$138.00

Service Code	CPT 86356
Hospital Charge Code	23568452
Hospital Revenue Code	301
Min. Negotiated Rate	$124.20
Max. Negotiated Rate	$124.20
Rate for Payer: Aetna of AZ Commercial	$124.20
Rate for Payer: Cash Price	$110.40

86356 MONONUCLEAR CELL ANTIGEN

Facility

$138.00

Service Code	CPT 86356
Hospital Charge Code	23568452
Hospital Revenue Code	301
Min. Negotiated Rate	$21.86
Max. Negotiated Rate	$124.20
Rate for Payer: Aetna of AZ Commercial	$124.20
Rate for Payer: Arizona Complete Health Allwell	$22.08
Rate for Payer: Banner UC Health Medicare	$22.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$93.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$22.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$22.08
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cigna of AZ Commercial	$89.70
Rate for Payer: Devoted Health Medicare	$24.84
Rate for Payer: Humana of AZ Medicare	$22.08
Rate for Payer: Seven Corners Travel Insurance	$38.83
Rate for Payer: Southwest Service Administrators UFCW	$93.84
Rate for Payer: TriWest Medicare	$22.08
Rate for Payer: United Healthcare Commercial	$78.94
Rate for Payer: United Healthcare Medicare	$22.08
Rate for Payer: Veterans Affairs TRICARE	$21.86

Know your out-of-pocket cost for care.

All Charges