Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

86357 NATURAL KILLER CELL SURFACE AG

Facility

$363.00

Service Code	CPT 86357
Hospital Charge Code	23568453
Hospital Revenue Code	301
Min. Negotiated Rate	$54.71
Max. Negotiated Rate	$326.70
Rate for Payer: Aetna of AZ Commercial	$326.70
Rate for Payer: Arizona Complete Health Allwell	$58.08
Rate for Payer: Banner UC Health Medicare	$58.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$246.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$58.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$58.08
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cigna of AZ Commercial	$235.95
Rate for Payer: Devoted Health Medicare	$65.34
Rate for Payer: Humana of AZ Medicare	$58.08
Rate for Payer: Seven Corners Travel Insurance	$54.71
Rate for Payer: Southwest Service Administrators UFCW	$246.84
Rate for Payer: TriWest Medicare	$58.08
Rate for Payer: United Healthcare Commercial	$207.64
Rate for Payer: United Healthcare Medicare	$58.08
Rate for Payer: Veterans Affairs TRICARE	$57.50

86357 NATURAL KILLER CELL SURFACE AG

Facility

$363.00

Service Code	CPT 86357
Hospital Charge Code	23568453
Hospital Revenue Code	301
Min. Negotiated Rate	$326.70
Max. Negotiated Rate	$326.70
Rate for Payer: Aetna of AZ Commercial	$326.70
Rate for Payer: Cash Price	$290.40

86359 T LYMPH CD3 CELLS

Facility

$331.00

Service Code	CPT 86359
Hospital Charge Code	23568454
Hospital Revenue Code	301
Min. Negotiated Rate	$297.90
Max. Negotiated Rate	$297.90
Rate for Payer: Aetna of AZ Commercial	$297.90
Rate for Payer: Cash Price	$264.80

86359 T LYMPH CD3 CELLS

Facility

$331.00

Service Code	CPT 86359
Hospital Charge Code	23568454
Hospital Revenue Code	301
Min. Negotiated Rate	$52.43
Max. Negotiated Rate	$297.90
Rate for Payer: Aetna of AZ Commercial	$297.90
Rate for Payer: Arizona Complete Health Allwell	$52.96
Rate for Payer: Banner UC Health Medicare	$52.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$225.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$52.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$52.96
Rate for Payer: Cash Price	$264.80
Rate for Payer: Cash Price	$264.80
Rate for Payer: Cigna of AZ Commercial	$215.15
Rate for Payer: Devoted Health Medicare	$59.58
Rate for Payer: Humana of AZ Medicare	$52.96
Rate for Payer: Seven Corners Travel Insurance	$54.71
Rate for Payer: Southwest Service Administrators UFCW	$225.08
Rate for Payer: TriWest Medicare	$52.96
Rate for Payer: United Healthcare Commercial	$189.33
Rate for Payer: United Healthcare Medicare	$52.96
Rate for Payer: Veterans Affairs TRICARE	$52.43

86628 CANDIDA AB

Facility

$255.00

Service Code	CPT 86628
Hospital Charge Code	23294423
Hospital Revenue Code	301
Min. Negotiated Rate	$229.50
Max. Negotiated Rate	$229.50
Rate for Payer: Aetna of AZ Commercial	$229.50
Rate for Payer: Cash Price	$204.00

86628 CANDIDA AB

Facility

$255.00

Service Code	CPT 86628
Hospital Charge Code	23294423
Hospital Revenue Code	301
Min. Negotiated Rate	$17.41
Max. Negotiated Rate	$229.50
Rate for Payer: Aetna of AZ Commercial	$229.50
Rate for Payer: Arizona Complete Health Allwell	$40.80
Rate for Payer: Banner UC Health Medicare	$40.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$173.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$40.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$40.80
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cigna of AZ Commercial	$165.75
Rate for Payer: Devoted Health Medicare	$45.90
Rate for Payer: Humana of AZ Medicare	$40.80
Rate for Payer: Seven Corners Travel Insurance	$17.41
Rate for Payer: Southwest Service Administrators UFCW	$173.40
Rate for Payer: TriWest Medicare	$40.80
Rate for Payer: United Healthcare Commercial	$145.86
Rate for Payer: United Healthcare Medicare	$40.80
Rate for Payer: Veterans Affairs TRICARE	$40.39

86628 LC#LC

Facility

$255.00

Service Code	CPT 86628
Hospital Charge Code	23173802
Hospital Revenue Code	302
Min. Negotiated Rate	$229.50
Max. Negotiated Rate	$229.50
Rate for Payer: Aetna of AZ Commercial	$229.50
Rate for Payer: Cash Price	$204.00

86628 LC#LC

Facility

$255.00

Service Code	CPT 86628
Hospital Charge Code	23173802
Hospital Revenue Code	302
Min. Negotiated Rate	$17.41
Max. Negotiated Rate	$229.50
Rate for Payer: Aetna of AZ Commercial	$229.50
Rate for Payer: Arizona Complete Health Allwell	$40.80
Rate for Payer: Banner UC Health Medicare	$40.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$173.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$40.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$40.80
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cigna of AZ Commercial	$165.75
Rate for Payer: Devoted Health Medicare	$45.90
Rate for Payer: Humana of AZ Medicare	$40.80
Rate for Payer: Seven Corners Travel Insurance	$17.41
Rate for Payer: Southwest Service Administrators UFCW	$173.40
Rate for Payer: TriWest Medicare	$40.80
Rate for Payer: United Healthcare Commercial	$145.86
Rate for Payer: United Healthcare Medicare	$40.80
Rate for Payer: Veterans Affairs TRICARE	$40.39

87206 - Acid Fast Smear + Culture LC

Facility

$27.00

Service Code	CPT 87206
Hospital Charge Code	28268592
Hospital Revenue Code	306
Min. Negotiated Rate	$4.28
Max. Negotiated Rate	$24.30
Rate for Payer: Aetna of AZ Commercial	$24.30
Rate for Payer: Arizona Complete Health Allwell	$4.32
Rate for Payer: Banner UC Health Medicare	$4.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$18.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.32
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna of AZ Commercial	$17.55
Rate for Payer: Devoted Health Medicare	$4.86
Rate for Payer: Humana of AZ Medicare	$4.32
Rate for Payer: Seven Corners Travel Insurance	$7.82
Rate for Payer: Southwest Service Administrators UFCW	$18.36
Rate for Payer: TriWest Medicare	$4.32
Rate for Payer: United Healthcare Commercial	$15.44
Rate for Payer: United Healthcare Medicare	$4.32
Rate for Payer: Veterans Affairs TRICARE	$4.28

87206 - Acid Fast Smear + Culture LC

Facility

$27.00

Service Code	CPT 87206
Hospital Charge Code	28268592
Hospital Revenue Code	306
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$24.30
Rate for Payer: Aetna of AZ Commercial	$24.30
Rate for Payer: Cash Price	$21.60

87328 Giardia lamblia

Facility

$258.00

Service Code	CPT 87328
Hospital Charge Code	23173791
Hospital Revenue Code	302
Min. Negotiated Rate	$232.20
Max. Negotiated Rate	$232.20
Rate for Payer: Aetna of AZ Commercial	$232.20
Rate for Payer: Cash Price	$206.40

87328 Giardia lamblia

Facility

$258.00

Service Code	CPT 87328
Hospital Charge Code	23173791
Hospital Revenue Code	302
Min. Negotiated Rate	$20.04
Max. Negotiated Rate	$232.20
Rate for Payer: Aetna of AZ Commercial	$232.20
Rate for Payer: Arizona Complete Health Allwell	$41.28
Rate for Payer: Banner UC Health Medicare	$41.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$175.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$41.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$41.28
Rate for Payer: Cash Price	$206.40
Rate for Payer: Cash Price	$206.40
Rate for Payer: Cigna of AZ Commercial	$167.70
Rate for Payer: Devoted Health Medicare	$46.44
Rate for Payer: Humana of AZ Medicare	$41.28
Rate for Payer: Seven Corners Travel Insurance	$20.04
Rate for Payer: Southwest Service Administrators UFCW	$175.44
Rate for Payer: TriWest Medicare	$41.28
Rate for Payer: United Healthcare Commercial	$147.58
Rate for Payer: United Healthcare Medicare	$41.28
Rate for Payer: Veterans Affairs TRICARE	$40.87

87328 Giardia Lamblia

Facility

$272.00

Service Code	CPT 87328
Hospital Charge Code	23309228
Hospital Revenue Code	300
Min. Negotiated Rate	$244.80
Max. Negotiated Rate	$244.80
Rate for Payer: Aetna of AZ Commercial	$244.80
Rate for Payer: Cash Price	$217.60

87328 Giardia Lamblia

Facility

$272.00

Service Code	CPT 87328
Hospital Charge Code	23309228
Hospital Revenue Code	300
Min. Negotiated Rate	$20.04
Max. Negotiated Rate	$244.80
Rate for Payer: Aetna of AZ Commercial	$244.80
Rate for Payer: Arizona Complete Health Allwell	$43.52
Rate for Payer: Banner UC Health Medicare	$43.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$184.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$43.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.52
Rate for Payer: Cash Price	$217.60
Rate for Payer: Cash Price	$217.60
Rate for Payer: Cigna of AZ Commercial	$176.80
Rate for Payer: Devoted Health Medicare	$48.96
Rate for Payer: Humana of AZ Medicare	$43.52
Rate for Payer: Seven Corners Travel Insurance	$20.04
Rate for Payer: Southwest Service Administrators UFCW	$184.96
Rate for Payer: TriWest Medicare	$43.52
Rate for Payer: United Healthcare Commercial	$155.58
Rate for Payer: United Healthcare Medicare	$43.52
Rate for Payer: Veterans Affairs TRICARE	$43.08

87329 Giardia lamblia

Facility

$228.00

Service Code	CPT 87329
Hospital Charge Code	23173792
Hospital Revenue Code	302
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

87329 Giardia lamblia

Facility

$228.00

Service Code	CPT 87329
Hospital Charge Code	23173792
Hospital Revenue Code	302
Min. Negotiated Rate	$17.37
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: 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: Seven Corners Travel Insurance	$17.37
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

87798 Acute Measles Panel, IgM Antibody and PCR LC

Facility

$76.00

Service Code	CPT 87798
Hospital Charge Code	28061914
Hospital Revenue Code	302
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of AZ Commercial	$68.40
Rate for Payer: Arizona Complete Health Allwell	$12.16
Rate for Payer: Banner UC Health Medicare	$12.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$51.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.16
Rate for Payer: Cash Price	$60.80
Rate for Payer: Cash Price	$60.80
Rate for Payer: Cigna of AZ Commercial	$49.40
Rate for Payer: Devoted Health Medicare	$13.68
Rate for Payer: Humana of AZ Medicare	$12.16
Rate for Payer: Seven Corners Travel Insurance	$50.88
Rate for Payer: Southwest Service Administrators UFCW	$51.68
Rate for Payer: TriWest Medicare	$12.16
Rate for Payer: United Healthcare Commercial	$43.47
Rate for Payer: United Healthcare Medicare	$12.16
Rate for Payer: Veterans Affairs TRICARE	$12.04

87798 Acute Measles Panel, IgM Antibody and PCR LC

Facility

$76.00

Service Code	CPT 87798
Hospital Charge Code	28061914
Hospital Revenue Code	302
Min. Negotiated Rate	$68.40
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of AZ Commercial	$68.40
Rate for Payer: Cash Price	$60.80

87804 SARS-CoV-2 (COVID-19) Ag/ Flu A andB (Influenza A)

Facility

$195.00

Service Code	CPT 87804
Hospital Charge Code	28169317
Hospital Revenue Code	306
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$175.50
Rate for Payer: Aetna of AZ Commercial	$175.50
Rate for Payer: Arizona Complete Health Allwell	$31.20
Rate for Payer: Banner UC Health Medicare	$31.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$132.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$31.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Cash Price	$156.00
Rate for Payer: Cigna of AZ Commercial	$126.75
Rate for Payer: Devoted Health Medicare	$35.10
Rate for Payer: Humana of AZ Medicare	$31.20
Rate for Payer: Seven Corners Travel Insurance	$24.00
Rate for Payer: Southwest Service Administrators UFCW	$132.60
Rate for Payer: TriWest Medicare	$31.20
Rate for Payer: United Healthcare Commercial	$111.54
Rate for Payer: United Healthcare Medicare	$31.20
Rate for Payer: Veterans Affairs TRICARE	$30.89

87804 SARS-CoV-2 (COVID-19) Ag/ Flu A andB (Influenza A)

Facility

$195.00

Service Code	CPT 87804
Hospital Charge Code	28169317
Hospital Revenue Code	306
Min. Negotiated Rate	$175.50
Max. Negotiated Rate	$175.50
Rate for Payer: Aetna of AZ Commercial	$175.50
Rate for Payer: Cash Price	$156.00

87804 SARS-CoV-2 (COVID-19) Ag/ Flu A andB (Influenza B)

Facility

$205.00

Service Code	CPT 87804
Hospital Charge Code	28169318
Hospital Revenue Code	306
Min. Negotiated Rate	$184.50
Max. Negotiated Rate	$184.50
Rate for Payer: Aetna of AZ Commercial	$184.50
Rate for Payer: Cash Price	$164.00

87804 SARS-CoV-2 (COVID-19) Ag/ Flu A andB (Influenza B)

Facility

$205.00

Service Code	CPT 87804
Hospital Charge Code	28169318
Hospital Revenue Code	306
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$184.50
Rate for Payer: Aetna of AZ Commercial	$184.50
Rate for Payer: Arizona Complete Health Allwell	$32.80
Rate for Payer: Banner UC Health Medicare	$32.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$139.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.80
Rate for Payer: Cash Price	$164.00
Rate for Payer: Cash Price	$164.00
Rate for Payer: Cigna of AZ Commercial	$133.25
Rate for Payer: Devoted Health Medicare	$36.90
Rate for Payer: Humana of AZ Medicare	$32.80
Rate for Payer: Seven Corners Travel Insurance	$24.00
Rate for Payer: Southwest Service Administrators UFCW	$139.40
Rate for Payer: TriWest Medicare	$32.80
Rate for Payer: United Healthcare Commercial	$117.26
Rate for Payer: United Healthcare Medicare	$32.80
Rate for Payer: Veterans Affairs TRICARE	$32.47

87900 HIV-1 Genosure Archive

Facility

$999.00

Service Code	CPT 87901
Hospital Charge Code	23173795
Hospital Revenue Code	306
Min. Negotiated Rate	$899.10
Max. Negotiated Rate	$899.10
Rate for Payer: Aetna of AZ Commercial	$899.10
Rate for Payer: Cash Price	$799.20

87900 HIV-1 Genosure Archive

Facility

$999.00

Service Code	CPT 87901
Hospital Charge Code	23173795
Hospital Revenue Code	306
Min. Negotiated Rate	$158.24
Max. Negotiated Rate	$899.10
Rate for Payer: Aetna of AZ Commercial	$899.10
Rate for Payer: Arizona Complete Health Allwell	$159.84
Rate for Payer: Banner UC Health Medicare	$159.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$679.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$159.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$159.84
Rate for Payer: Cash Price	$799.20
Rate for Payer: Cash Price	$799.20
Rate for Payer: Cigna of AZ Commercial	$649.35
Rate for Payer: Devoted Health Medicare	$179.82
Rate for Payer: Humana of AZ Medicare	$159.84
Rate for Payer: Seven Corners Travel Insurance	$373.30
Rate for Payer: Southwest Service Administrators UFCW	$679.32
Rate for Payer: TriWest Medicare	$159.84
Rate for Payer: United Healthcare Commercial	$571.43
Rate for Payer: United Healthcare Medicare	$159.84
Rate for Payer: Veterans Affairs TRICARE	$158.24

87900 HIV-1 Quant PCR

Facility

$999.00

Service Code	CPT 87900
Hospital Charge Code	23173798
Hospital Revenue Code	306
Min. Negotiated Rate	$899.10
Max. Negotiated Rate	$899.10
Rate for Payer: Aetna of AZ Commercial	$899.10
Rate for Payer: Cash Price	$799.20

Know your out-of-pocket cost for care.

All Charges