Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

92950 ER - CPR

Facility

$1,796.00

Service Code	CPT 92950
Hospital Charge Code	22282930
Hospital Revenue Code	450
Min. Negotiated Rate	$1,616.40
Max. Negotiated Rate	$1,616.40
Rate for Payer: Aetna of AZ Commercial	$1,616.40
Rate for Payer: Cash Price	$1,436.80

93010 EKG INTERP REPORT PRO FEE CHARGE

Facility

$128.00

Service Code	CPT 93010
Hospital Charge Code	22423578
Min. Negotiated Rate	$115.20
Max. Negotiated Rate	$115.20
Rate for Payer: Aetna of AZ Commercial	$115.20
Rate for Payer: Cash Price	$102.40

93010 EKG INTERP REPORT PRO FEE CHARGE

Facility

$128.00

Service Code	CPT 93010
Hospital Charge Code	22423578
Min. Negotiated Rate	$20.28
Max. Negotiated Rate	$115.20
Rate for Payer: Aetna of AZ Commercial	$115.20
Rate for Payer: Arizona Complete Health Allwell	$20.48
Rate for Payer: Banner UC Health Medicare	$20.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$87.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.48
Rate for Payer: Cash Price	$102.40
Rate for Payer: Cigna of AZ Commercial	$89.60
Rate for Payer: Devoted Health Medicare	$23.04
Rate for Payer: Humana of AZ Medicare	$20.48
Rate for Payer: Southwest Service Administrators UFCW	$87.04
Rate for Payer: TriWest Medicare	$20.48
Rate for Payer: United Healthcare Commercial	$73.22
Rate for Payer: United Healthcare Medicare	$20.48
Rate for Payer: Veterans Affairs TRICARE	$20.28

93225-Holter Monitor Hookup

Facility

$72.00

Service Code	CPT 93225
Hospital Charge Code	24384246
Hospital Revenue Code	731
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Cash Price	$57.60

93225-Holter Monitor Hookup

Facility

$72.00

Service Code	CPT 93225
Hospital Charge Code	24384246
Hospital Revenue Code	731
Min. Negotiated Rate	$11.40
Max. Negotiated Rate	$205.86
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Arizona Complete Health Allwell	$11.52
Rate for Payer: Banner UC Health Medicare	$11.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$48.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.52
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna of AZ Commercial	$50.40
Rate for Payer: Devoted Health Medicare	$12.96
Rate for Payer: Humana of AZ Medicare	$11.52
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$48.96
Rate for Payer: TriWest Medicare	$11.52
Rate for Payer: United Healthcare Commercial	$41.18
Rate for Payer: United Healthcare Medicare	$11.52
Rate for Payer: United Healthcare New Mexico Commercial	$13.68
Rate for Payer: Veterans Affairs TRICARE	$11.40

93227- Holter Monitor ProFee

Facility

$78.00

Service Code	CPT 93227
Hospital Charge Code	24384244
Hospital Revenue Code	521
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Cash Price	$62.40

93227- Holter Monitor ProFee

Facility

$78.00

Service Code	CPT 93227
Hospital Charge Code	24384244
Hospital Revenue Code	521
Min. Negotiated Rate	$12.36
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Arizona Complete Health Allwell	$12.48
Rate for Payer: Banner UC Health Medicare	$12.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$53.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.48
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cigna of AZ Commercial	$54.60
Rate for Payer: Devoted Health Medicare	$14.04
Rate for Payer: Humana of AZ Medicare	$12.48
Rate for Payer: Southwest Service Administrators UFCW	$53.04
Rate for Payer: TriWest Medicare	$12.48
Rate for Payer: United Healthcare Commercial	$44.62
Rate for Payer: United Healthcare Medicare	$12.48
Rate for Payer: Veterans Affairs TRICARE	$12.36

93228-MCOT ProFee

Facility

$78.00

Service Code	CPT 93228
Hospital Charge Code	24384242
Hospital Revenue Code	521
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Cash Price	$62.40

93228-MCOT ProFee

Facility

$78.00

Service Code	CPT 93228
Hospital Charge Code	24384242
Hospital Revenue Code	521
Min. Negotiated Rate	$12.36
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Arizona Complete Health Allwell	$12.48
Rate for Payer: Banner UC Health Medicare	$12.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$53.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.48
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cigna of AZ Commercial	$54.60
Rate for Payer: Devoted Health Medicare	$14.04
Rate for Payer: Humana of AZ Medicare	$12.48
Rate for Payer: Southwest Service Administrators UFCW	$53.04
Rate for Payer: TriWest Medicare	$12.48
Rate for Payer: United Healthcare Commercial	$44.62
Rate for Payer: United Healthcare Medicare	$12.48
Rate for Payer: Veterans Affairs TRICARE	$12.36

93270- Event Monitor Hookup

Facility

$22.00

Service Code	CPT 93270
Hospital Charge Code	24384245
Hospital Revenue Code	732
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$57.75
Rate for Payer: Aetna of AZ Commercial	$19.80
Rate for Payer: Arizona Complete Health Allwell	$3.52
Rate for Payer: Banner UC Health Medicare	$3.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$14.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.52
Rate for Payer: Cash Price	$17.60
Rate for Payer: Cash Price	$17.60
Rate for Payer: Cigna of AZ Commercial	$15.40
Rate for Payer: Devoted Health Medicare	$3.96
Rate for Payer: Humana of AZ Medicare	$3.52
Rate for Payer: Seven Corners Travel Insurance	$57.75
Rate for Payer: Southwest Service Administrators UFCW	$14.96
Rate for Payer: TriWest Medicare	$3.52
Rate for Payer: United Healthcare Commercial	$12.58
Rate for Payer: United Healthcare Medicare	$3.52
Rate for Payer: United Healthcare New Mexico Commercial	$4.18
Rate for Payer: Veterans Affairs TRICARE	$3.48

93270- Event Monitor Hookup

Facility

$22.00

Service Code	CPT 93270
Hospital Charge Code	24384245
Hospital Revenue Code	732
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$19.80
Rate for Payer: Aetna of AZ Commercial	$19.80
Rate for Payer: Cash Price	$17.60

93272- Event Monitor ProFee

Facility

$63.00

Service Code	CPT 93272
Hospital Charge Code	24384243
Hospital Revenue Code	521
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$56.70
Rate for Payer: Aetna of AZ Commercial	$56.70
Rate for Payer: Cash Price	$50.40

93272- Event Monitor ProFee

Facility

$63.00

Service Code	CPT 93272
Hospital Charge Code	24384243
Hospital Revenue Code	521
Min. Negotiated Rate	$9.98
Max. Negotiated Rate	$56.70
Rate for Payer: Aetna of AZ Commercial	$56.70
Rate for Payer: Arizona Complete Health Allwell	$10.08
Rate for Payer: Banner UC Health Medicare	$10.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$42.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.08
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna of AZ Commercial	$44.10
Rate for Payer: Devoted Health Medicare	$11.34
Rate for Payer: Humana of AZ Medicare	$10.08
Rate for Payer: Southwest Service Administrators UFCW	$42.84
Rate for Payer: TriWest Medicare	$10.08
Rate for Payer: United Healthcare Commercial	$36.04
Rate for Payer: United Healthcare Medicare	$10.08
Rate for Payer: Veterans Affairs TRICARE	$9.98

93308 Echocardiography, transthoracic, real-time w/image doc

Facility

$541.00

Service Code	CPT 93308
Hospital Charge Code	27410734
Hospital Revenue Code	483
Min. Negotiated Rate	$85.69
Max. Negotiated Rate	$486.90
Rate for Payer: Aetna of AZ Commercial	$486.90
Rate for Payer: Arizona Complete Health Allwell	$86.56
Rate for Payer: Banner UC Health Medicare	$86.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$367.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$86.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$86.56
Rate for Payer: Cash Price	$432.80
Rate for Payer: Cash Price	$432.80
Rate for Payer: Cigna of AZ Commercial	$378.70
Rate for Payer: Devoted Health Medicare	$97.38
Rate for Payer: Humana of AZ Medicare	$86.56
Rate for Payer: Seven Corners Travel Insurance	$369.18
Rate for Payer: Southwest Service Administrators UFCW	$367.88
Rate for Payer: TriWest Medicare	$86.56
Rate for Payer: United Healthcare Commercial	$309.45
Rate for Payer: United Healthcare Medicare	$86.56
Rate for Payer: United Healthcare New Mexico Commercial	$102.79
Rate for Payer: Veterans Affairs TRICARE	$85.69

93308 Echocardiography, transthoracic, real-time w/image doc

Facility

$541.00

Service Code	CPT 93308
Hospital Charge Code	27410734
Hospital Revenue Code	483
Min. Negotiated Rate	$486.90
Max. Negotiated Rate	$486.90
Rate for Payer: Aetna of AZ Commercial	$486.90
Rate for Payer: Cash Price	$432.80

94010 PFT

Facility

$898.00

Service Code	CPT 94010
Hospital Charge Code	23897245
Hospital Revenue Code	460
Min. Negotiated Rate	$808.20
Max. Negotiated Rate	$808.20
Rate for Payer: Aetna of AZ Commercial	$808.20
Rate for Payer: Cash Price	$718.40

94010 PFT

Facility

$898.00

Service Code	CPT 94010
Hospital Charge Code	23897245
Hospital Revenue Code	460
Min. Negotiated Rate	$142.24
Max. Negotiated Rate	$808.20
Rate for Payer: Aetna of AZ Commercial	$808.20
Rate for Payer: Arizona Complete Health Allwell	$143.68
Rate for Payer: Banner UC Health Medicare	$143.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$610.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$143.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$143.68
Rate for Payer: Cash Price	$718.40
Rate for Payer: Cash Price	$718.40
Rate for Payer: Cigna of AZ Commercial	$628.60
Rate for Payer: Devoted Health Medicare	$161.64
Rate for Payer: Humana of AZ Medicare	$143.68
Rate for Payer: Seven Corners Travel Insurance	$334.09
Rate for Payer: Southwest Service Administrators UFCW	$610.64
Rate for Payer: TriWest Medicare	$143.68
Rate for Payer: United Healthcare Commercial	$513.66
Rate for Payer: United Healthcare Medicare	$143.68
Rate for Payer: United Healthcare New Mexico Commercial	$170.62
Rate for Payer: Veterans Affairs TRICARE	$142.24

94060 PFT PRE/POST PRO FEE CHARGE

Facility

$30.00

Service Code	CPT 94060 26
Hospital Charge Code	22461116
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Cash Price	$24.00

94060 PFT PRE/POST PRO FEE CHARGE

Facility

$30.00

Service Code	CPT 94060 26
Hospital Charge Code	22461116
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Arizona Complete Health Allwell	$4.80
Rate for Payer: Banner UC Health Medicare	$4.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$20.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna of AZ Commercial	$21.00
Rate for Payer: Devoted Health Medicare	$5.40
Rate for Payer: Humana of AZ Medicare	$4.80
Rate for Payer: Southwest Service Administrators UFCW	$20.40
Rate for Payer: TriWest Medicare	$4.80
Rate for Payer: United Healthcare Commercial	$17.16
Rate for Payer: United Healthcare Medicare	$4.80
Rate for Payer: Veterans Affairs TRICARE	$4.75

94640 Airway inhalation treatment

Facility

$93.00

Service Code	CPT 94640
Hospital Charge Code	21453915
Hospital Revenue Code	521
Min. Negotiated Rate	$83.70
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Cash Price	$74.40

94640 Airway inhalation treatment

Facility

$93.00

Service Code	CPT 94640
Hospital Charge Code	21453915
Hospital Revenue Code	521
Min. Negotiated Rate	$14.73
Max. Negotiated Rate	$338.82
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Arizona Complete Health Allwell	$14.88
Rate for Payer: Banner UC Health Medicare	$14.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$63.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.88
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cigna of AZ Commercial	$65.10
Rate for Payer: Devoted Health Medicare	$16.74
Rate for Payer: Humana of AZ Medicare	$14.88
Rate for Payer: Seven Corners Travel Insurance	$338.82
Rate for Payer: Southwest Service Administrators UFCW	$63.24
Rate for Payer: TriWest Medicare	$14.88
Rate for Payer: United Healthcare Commercial	$53.20
Rate for Payer: United Healthcare Medicare	$14.88
Rate for Payer: Veterans Affairs TRICARE	$14.73

94667 INITIAL THERAPY SERVICE TO FACILITATE LUNG FUNCTION

Facility

$129.00

Service Code	CPT 94667
Hospital Charge Code	28223715
Hospital Revenue Code	982
Min. Negotiated Rate	$116.10
Max. Negotiated Rate	$116.10
Rate for Payer: Aetna of AZ Commercial	$116.10
Rate for Payer: Cash Price	$103.20

94667 INITIAL THERAPY SERVICE TO FACILITATE LUNG FUNCTION

Facility

$129.00

Service Code	CPT 94667
Hospital Charge Code	28223715
Hospital Revenue Code	982
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$205.86
Rate for Payer: Aetna of AZ Commercial	$116.10
Rate for Payer: Arizona Complete Health Allwell	$20.64
Rate for Payer: Banner UC Health Medicare	$20.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$87.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.64
Rate for Payer: Cash Price	$103.20
Rate for Payer: Cash Price	$103.20
Rate for Payer: Cigna of AZ Commercial	$90.30
Rate for Payer: Devoted Health Medicare	$23.22
Rate for Payer: Humana of AZ Medicare	$20.64
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$87.72
Rate for Payer: TriWest Medicare	$20.64
Rate for Payer: United Healthcare Commercial	$73.79
Rate for Payer: United Healthcare Medicare	$20.64
Rate for Payer: United Healthcare New Mexico Commercial	$24.51
Rate for Payer: Veterans Affairs TRICARE	$20.43

94668 FOLLOW-UP THERAPY SERVICE TO FACILITATE LUNG FUNCTION

Facility

$197.00

Service Code	CPT 94668
Hospital Charge Code	28228618
Hospital Revenue Code	982
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$205.86
Rate for Payer: Aetna of AZ Commercial	$177.30
Rate for Payer: Arizona Complete Health Allwell	$31.52
Rate for Payer: Banner UC Health Medicare	$31.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$133.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$31.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.52
Rate for Payer: Cash Price	$157.60
Rate for Payer: Cash Price	$157.60
Rate for Payer: Cigna of AZ Commercial	$137.90
Rate for Payer: Devoted Health Medicare	$35.46
Rate for Payer: Humana of AZ Medicare	$31.52
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$133.96
Rate for Payer: TriWest Medicare	$31.52
Rate for Payer: United Healthcare Commercial	$112.68
Rate for Payer: United Healthcare Medicare	$31.52
Rate for Payer: United Healthcare New Mexico Commercial	$37.43
Rate for Payer: Veterans Affairs TRICARE	$31.20

94668 FOLLOW-UP THERAPY SERVICE TO FACILITATE LUNG FUNCTION

Facility

$197.00

Service Code	CPT 94668
Hospital Charge Code	28228618
Hospital Revenue Code	982
Min. Negotiated Rate	$177.30
Max. Negotiated Rate	$177.30
Rate for Payer: Aetna of AZ Commercial	$177.30
Rate for Payer: Cash Price	$157.60

Know your out-of-pocket cost for care.

All Charges