Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Office/OP Established Visit Level 2 99212

Facility

$242.00

Service Code	CPT 99212
Hospital Charge Code	1264824
Hospital Revenue Code	521
Min. Negotiated Rate	$15.33
Max. Negotiated Rate	$367.62
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Arizona Complete Health Allwell	$38.72
Rate for Payer: Banner UC Health Medicare	$38.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$164.56
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$15.33
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.72
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cigna of AZ Commercial	$169.40
Rate for Payer: Devoted Health Medicare	$43.56
Rate for Payer: Humana of AZ Medicare	$38.72
Rate for Payer: Mercy Care Medicaid	$15.33
Rate for Payer: NaphCare Correctional Healthcare	$15.33
Rate for Payer: Southwest Service Administrators UFCW	$164.56
Rate for Payer: TriWest Medicare	$38.72
Rate for Payer: United Healthcare Commercial	$138.42
Rate for Payer: United Healthcare Community Plan	$367.62
Rate for Payer: United Healthcare Medicare	$38.72
Rate for Payer: Veterans Affairs TRICARE	$38.33

Office/OP Established Visit Level 2 99212

Facility

$242.00

Service Code	CPT 99212
Hospital Charge Code	1264824
Hospital Revenue Code	521
Min. Negotiated Rate	$217.80
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Cash Price	$193.60

Office/OP Established Visit Level 3 99213

Facility

$309.00

Service Code	CPT 99213
Hospital Charge Code	631674
Hospital Revenue Code	521
Min. Negotiated Rate	$278.10
Max. Negotiated Rate	$278.10
Rate for Payer: Aetna of AZ Commercial	$278.10
Rate for Payer: Cash Price	$247.20

Office/OP Established Visit Level 3 99213

Facility

$309.00

Service Code	CPT 99213
Hospital Charge Code	631674
Hospital Revenue Code	521
Min. Negotiated Rate	$17.97
Max. Negotiated Rate	$367.62
Rate for Payer: Aetna of AZ Commercial	$278.10
Rate for Payer: Arizona Complete Health Allwell	$49.44
Rate for Payer: Banner UC Health Medicare	$49.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$210.12
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$17.97
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$49.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$49.44
Rate for Payer: Cash Price	$247.20
Rate for Payer: Cash Price	$247.20
Rate for Payer: Cash Price	$247.20
Rate for Payer: Cigna of AZ Commercial	$216.30
Rate for Payer: Devoted Health Medicare	$55.62
Rate for Payer: Humana of AZ Medicare	$49.44
Rate for Payer: Mercy Care Medicaid	$17.97
Rate for Payer: NaphCare Correctional Healthcare	$17.97
Rate for Payer: Southwest Service Administrators UFCW	$210.12
Rate for Payer: TriWest Medicare	$49.44
Rate for Payer: United Healthcare Commercial	$176.75
Rate for Payer: United Healthcare Community Plan	$367.62
Rate for Payer: United Healthcare Medicare	$49.44
Rate for Payer: Veterans Affairs TRICARE	$48.95

Office/OP Established Visit Level 4 99214

Facility

$398.00

Service Code	CPT 99214
Hospital Charge Code	1264828
Hospital Revenue Code	521
Min. Negotiated Rate	$358.20
Max. Negotiated Rate	$358.20
Rate for Payer: Aetna of AZ Commercial	$358.20
Rate for Payer: Cash Price	$318.40

Office/OP Established Visit Level 4 99214

Facility

$398.00

Service Code	CPT 99214
Hospital Charge Code	1264828
Hospital Revenue Code	521
Min. Negotiated Rate	$22.28
Max. Negotiated Rate	$367.62
Rate for Payer: Aetna of AZ Commercial	$358.20
Rate for Payer: Arizona Complete Health Allwell	$63.68
Rate for Payer: Banner UC Health Medicare	$63.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$270.64
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$22.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$63.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$63.68
Rate for Payer: Cash Price	$318.40
Rate for Payer: Cash Price	$318.40
Rate for Payer: Cash Price	$318.40
Rate for Payer: Cigna of AZ Commercial	$278.60
Rate for Payer: Devoted Health Medicare	$71.64
Rate for Payer: Humana of AZ Medicare	$63.68
Rate for Payer: Mercy Care Medicaid	$22.28
Rate for Payer: NaphCare Correctional Healthcare	$22.28
Rate for Payer: Southwest Service Administrators UFCW	$270.64
Rate for Payer: TriWest Medicare	$63.68
Rate for Payer: United Healthcare Commercial	$227.66
Rate for Payer: United Healthcare Community Plan	$367.62
Rate for Payer: United Healthcare Medicare	$63.68
Rate for Payer: Veterans Affairs TRICARE	$63.04

Office/OP Established Visit Level 5 99215

Facility

$658.00

Service Code	CPT 99215
Hospital Charge Code	1264830
Hospital Revenue Code	521
Min. Negotiated Rate	$592.20
Max. Negotiated Rate	$592.20
Rate for Payer: Aetna of AZ Commercial	$592.20
Rate for Payer: Cash Price	$526.40

Office/OP Established Visit Level 5 99215

Facility

$658.00

Service Code	CPT 99215
Hospital Charge Code	1264830
Hospital Revenue Code	521
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$592.20
Rate for Payer: Aetna of AZ Commercial	$592.20
Rate for Payer: Arizona Complete Health Allwell	$105.28
Rate for Payer: Banner UC Health Medicare	$105.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$447.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$26.35
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$105.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$105.28
Rate for Payer: Cash Price	$526.40
Rate for Payer: Cash Price	$526.40
Rate for Payer: Cash Price	$526.40
Rate for Payer: Cigna of AZ Commercial	$460.60
Rate for Payer: Devoted Health Medicare	$118.44
Rate for Payer: Humana of AZ Medicare	$105.28
Rate for Payer: Mercy Care Medicaid	$26.35
Rate for Payer: NaphCare Correctional Healthcare	$26.35
Rate for Payer: Southwest Service Administrators UFCW	$447.44
Rate for Payer: TriWest Medicare	$105.28
Rate for Payer: United Healthcare Commercial	$376.38
Rate for Payer: United Healthcare Community Plan	$367.62
Rate for Payer: United Healthcare Medicare	$105.28
Rate for Payer: Veterans Affairs TRICARE	$104.23

Office/OP New Visit Level 1 99201

Facility

$229.00

Service Code	CPT 99201
Hospital Charge Code	1264811
Hospital Revenue Code	521
Min. Negotiated Rate	$206.10
Max. Negotiated Rate	$206.10
Rate for Payer: Aetna of AZ Commercial	$206.10
Rate for Payer: Cash Price	$183.20

Office/OP New Visit Level 1 99201

Facility

$229.00

Service Code	CPT 99201
Hospital Charge Code	1264811
Hospital Revenue Code	521
Min. Negotiated Rate	$36.27
Max. Negotiated Rate	$367.62
Rate for Payer: Aetna of AZ Commercial	$206.10
Rate for Payer: Arizona Complete Health Allwell	$36.64
Rate for Payer: Banner UC Health Medicare	$36.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$155.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.64
Rate for Payer: Cash Price	$183.20
Rate for Payer: Cash Price	$183.20
Rate for Payer: Cigna of AZ Commercial	$160.30
Rate for Payer: Devoted Health Medicare	$41.22
Rate for Payer: Humana of AZ Medicare	$36.64
Rate for Payer: Southwest Service Administrators UFCW	$155.72
Rate for Payer: TriWest Medicare	$36.64
Rate for Payer: United Healthcare Commercial	$130.99
Rate for Payer: United Healthcare Community Plan	$367.62
Rate for Payer: United Healthcare Medicare	$36.64
Rate for Payer: Veterans Affairs TRICARE	$36.27

Office/OP New Visit Level 2 99202

Facility

$278.00

Service Code	CPT 99202
Hospital Charge Code	1264813
Hospital Revenue Code	521
Min. Negotiated Rate	$17.72
Max. Negotiated Rate	$367.62
Rate for Payer: Aetna of AZ Commercial	$250.20
Rate for Payer: Arizona Complete Health Allwell	$44.48
Rate for Payer: Banner UC Health Medicare	$44.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$189.04
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$17.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$44.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$44.48
Rate for Payer: Cash Price	$222.40
Rate for Payer: Cash Price	$222.40
Rate for Payer: Cash Price	$222.40
Rate for Payer: Cigna of AZ Commercial	$194.60
Rate for Payer: Devoted Health Medicare	$50.04
Rate for Payer: Humana of AZ Medicare	$44.48
Rate for Payer: Mercy Care Medicaid	$17.72
Rate for Payer: NaphCare Correctional Healthcare	$17.72
Rate for Payer: Southwest Service Administrators UFCW	$189.04
Rate for Payer: TriWest Medicare	$44.48
Rate for Payer: United Healthcare Commercial	$159.02
Rate for Payer: United Healthcare Community Plan	$367.62
Rate for Payer: United Healthcare Medicare	$44.48
Rate for Payer: Veterans Affairs TRICARE	$44.04

Office/OP New Visit Level 2 99202

Facility

$278.00

Service Code	CPT 99202
Hospital Charge Code	1264813
Hospital Revenue Code	521
Min. Negotiated Rate	$250.20
Max. Negotiated Rate	$250.20
Rate for Payer: Aetna of AZ Commercial	$250.20
Rate for Payer: Cash Price	$222.40

Office/OP New Visit Level 3 99203

Facility

$355.00

Service Code	CPT 99203
Hospital Charge Code	1264815
Hospital Revenue Code	521
Min. Negotiated Rate	$319.50
Max. Negotiated Rate	$319.50
Rate for Payer: Aetna of AZ Commercial	$319.50
Rate for Payer: Cash Price	$284.00

Office/OP New Visit Level 3 99203

Facility

$355.00

Service Code	CPT 99203
Hospital Charge Code	1264815
Hospital Revenue Code	521
Min. Negotiated Rate	$21.32
Max. Negotiated Rate	$367.62
Rate for Payer: Aetna of AZ Commercial	$319.50
Rate for Payer: Arizona Complete Health Allwell	$56.80
Rate for Payer: Banner UC Health Medicare	$56.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$241.40
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$21.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$56.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$56.80
Rate for Payer: Cash Price	$284.00
Rate for Payer: Cash Price	$284.00
Rate for Payer: Cash Price	$284.00
Rate for Payer: Cigna of AZ Commercial	$248.50
Rate for Payer: Devoted Health Medicare	$63.90
Rate for Payer: Humana of AZ Medicare	$56.80
Rate for Payer: Mercy Care Medicaid	$21.32
Rate for Payer: NaphCare Correctional Healthcare	$21.32
Rate for Payer: Southwest Service Administrators UFCW	$241.40
Rate for Payer: TriWest Medicare	$56.80
Rate for Payer: United Healthcare Commercial	$203.06
Rate for Payer: United Healthcare Community Plan	$367.62
Rate for Payer: United Healthcare Medicare	$56.80
Rate for Payer: Veterans Affairs TRICARE	$56.23

Office/OP New Visit Level 4 99204

Facility

$459.00

Service Code	CPT 99204
Hospital Charge Code	1264817
Hospital Revenue Code	521
Min. Negotiated Rate	$413.10
Max. Negotiated Rate	$413.10
Rate for Payer: Aetna of AZ Commercial	$413.10
Rate for Payer: Cash Price	$367.20

Office/OP New Visit Level 4 99204

Facility

$459.00

Service Code	CPT 99204
Hospital Charge Code	1264817
Hospital Revenue Code	521
Min. Negotiated Rate	$24.43
Max. Negotiated Rate	$413.10
Rate for Payer: Aetna of AZ Commercial	$413.10
Rate for Payer: Arizona Complete Health Allwell	$73.44
Rate for Payer: Banner UC Health Medicare	$73.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$312.12
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$24.43
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$73.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$73.44
Rate for Payer: Cash Price	$367.20
Rate for Payer: Cash Price	$367.20
Rate for Payer: Cash Price	$367.20
Rate for Payer: Cigna of AZ Commercial	$321.30
Rate for Payer: Devoted Health Medicare	$82.62
Rate for Payer: Humana of AZ Medicare	$73.44
Rate for Payer: Mercy Care Medicaid	$24.43
Rate for Payer: NaphCare Correctional Healthcare	$24.43
Rate for Payer: Southwest Service Administrators UFCW	$312.12
Rate for Payer: TriWest Medicare	$73.44
Rate for Payer: United Healthcare Commercial	$262.55
Rate for Payer: United Healthcare Community Plan	$367.62
Rate for Payer: United Healthcare Medicare	$73.44
Rate for Payer: Veterans Affairs TRICARE	$72.71

Office/OP New Visit Level 5 99205

Facility

$757.00

Service Code	CPT 99205
Hospital Charge Code	1264819
Hospital Revenue Code	521
Min. Negotiated Rate	$681.30
Max. Negotiated Rate	$681.30
Rate for Payer: Aetna of AZ Commercial	$681.30
Rate for Payer: Cash Price	$605.60

Office/OP New Visit Level 5 99205

Facility

$757.00

Service Code	CPT 99205
Hospital Charge Code	1264819
Hospital Revenue Code	521
Min. Negotiated Rate	$28.50
Max. Negotiated Rate	$681.30
Rate for Payer: Aetna of AZ Commercial	$681.30
Rate for Payer: Arizona Complete Health Allwell	$121.12
Rate for Payer: Banner UC Health Medicare	$121.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$514.76
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$28.50
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$121.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$121.12
Rate for Payer: Cash Price	$605.60
Rate for Payer: Cash Price	$605.60
Rate for Payer: Cash Price	$605.60
Rate for Payer: Cigna of AZ Commercial	$529.90
Rate for Payer: Devoted Health Medicare	$136.26
Rate for Payer: Humana of AZ Medicare	$121.12
Rate for Payer: Mercy Care Medicaid	$28.50
Rate for Payer: NaphCare Correctional Healthcare	$28.50
Rate for Payer: Southwest Service Administrators UFCW	$514.76
Rate for Payer: TriWest Medicare	$121.12
Rate for Payer: United Healthcare Commercial	$433.00
Rate for Payer: United Healthcare Community Plan	$367.62
Rate for Payer: United Healthcare Medicare	$121.12
Rate for Payer: Veterans Affairs TRICARE	$119.91

Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.

Facility

$3,373.00

Service Code	CPT 99215
Hospital Revenue Code	360
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$3,373.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$26.35
Rate for Payer: Mercy Care Medicaid	$26.35
Rate for Payer: NaphCare Correctional Healthcare	$26.35
Rate for Payer: United Healthcare Commercial	$3,373.00

OLANZapine 10 mg Injection[CQCH]

Facility

$20.93

Service Code	NDC 781910572
Hospital Charge Code	168103443
Hospital Revenue Code	250
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$18.84
Rate for Payer: Aetna of AZ Commercial	$18.84
Rate for Payer: Arizona Complete Health Allwell	$3.35
Rate for Payer: Banner UC Health Medicare	$3.35
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$14.23
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.35
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.35
Rate for Payer: Cash Price	$16.74
Rate for Payer: Cigna of AZ Commercial	$13.60
Rate for Payer: Devoted Health Medicare	$3.77
Rate for Payer: Humana of AZ Medicare	$3.35
Rate for Payer: Southwest Service Administrators UFCW	$14.23
Rate for Payer: TriWest Medicare	$3.35
Rate for Payer: United Healthcare Commercial	$11.97
Rate for Payer: United Healthcare Medicare	$3.35
Rate for Payer: Veterans Affairs TRICARE	$3.32

OLANZapine 10 mg Injection[CQCH]

Facility

$20.93

Service Code	NDC 781910572
Hospital Charge Code	168103443
Hospital Revenue Code	250
Min. Negotiated Rate	$18.84
Max. Negotiated Rate	$18.84
Rate for Payer: Aetna of AZ Commercial	$18.84
Rate for Payer: Cash Price	$16.74

OLANZapine 5 mg Tab [CQCH]

Facility

$0.36

Service Code	NDC 60505311100
Hospital Charge Code	105969103
Hospital Revenue Code	251
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of AZ Commercial	$0.32
Rate for Payer: Cash Price	$0.29

OLANZapine 5 mg Tab [CQCH]

Facility

$0.36

Service Code	NDC 60505311100
Hospital Charge Code	105969103
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of AZ Commercial	$0.32
Rate for Payer: Arizona Complete Health Allwell	$0.06
Rate for Payer: Banner UC Health Medicare	$0.06
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.06
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.06
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of AZ Commercial	$0.23
Rate for Payer: Devoted Health Medicare	$0.06
Rate for Payer: Humana of AZ Medicare	$0.06
Rate for Payer: Southwest Service Administrators UFCW	$0.24
Rate for Payer: TriWest Medicare	$0.06
Rate for Payer: United Healthcare Commercial	$0.21
Rate for Payer: United Healthcare Medicare	$0.06
Rate for Payer: Veterans Affairs TRICARE	$0.06

OLYMPUS SHOCKPULSE PROBE

Facility

$1,988.00

Hospital Charge Code	22619416
Hospital Revenue Code	272
Min. Negotiated Rate	$314.90
Max. Negotiated Rate	$1,789.20
Rate for Payer: Aetna of AZ Commercial	$1,789.20
Rate for Payer: Arizona Complete Health Allwell	$318.08
Rate for Payer: Banner UC Health Medicare	$318.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,351.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$318.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$318.08
Rate for Payer: Cash Price	$1,590.40
Rate for Payer: Cigna of AZ Commercial	$1,391.60
Rate for Payer: Devoted Health Medicare	$357.84
Rate for Payer: Humana of AZ Medicare	$318.08
Rate for Payer: Southwest Service Administrators UFCW	$1,351.84
Rate for Payer: TriWest Medicare	$318.08
Rate for Payer: United Healthcare Commercial	$1,137.14
Rate for Payer: United Healthcare Medicare	$318.08
Rate for Payer: Veterans Affairs TRICARE	$314.90

OLYMPUS SHOCKPULSE PROBE

Facility

$1,988.00

Hospital Charge Code	22619416
Hospital Revenue Code	272
Min. Negotiated Rate	$1,789.20
Max. Negotiated Rate	$1,789.20
Rate for Payer: Aetna of AZ Commercial	$1,789.20
Rate for Payer: Cash Price	$1,590.40

Know your out-of-pocket cost for care.

All Charges