Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

94762 - Oximetry

Facility

$78.00

Service Code	CPT 94762
Hospital Charge Code	25741669
Min. Negotiated Rate	$12.36
Max. Negotiated Rate	$199.09
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: 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: Seven Corners Travel Insurance	$199.09
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

94762 - Oximetry

Facility

$78.00

Service Code	CPT 94762
Hospital Charge Code	25741669
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

95992 canalith reposition procedure

Facility

$203.00

Service Code	CPT 95992 GP
Hospital Charge Code	25261721
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$182.70
Rate for Payer: Aetna of AZ Commercial	$182.70
Rate for Payer: Arizona Complete Health Allwell	$32.48
Rate for Payer: Banner UC Health Medicare	$32.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$138.04
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$6.97
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.48
Rate for Payer: Cash Price	$162.40
Rate for Payer: Cash Price	$162.40
Rate for Payer: Cigna of AZ Commercial	$142.10
Rate for Payer: Devoted Health Medicare	$36.54
Rate for Payer: Humana of AZ Medicare	$32.48
Rate for Payer: Mercy Care Medicaid	$6.97
Rate for Payer: NaphCare Correctional Healthcare	$6.97
Rate for Payer: Southwest Service Administrators UFCW	$138.04
Rate for Payer: TriWest Medicare	$32.48
Rate for Payer: United Healthcare Commercial	$116.12
Rate for Payer: United Healthcare Medicare	$32.48
Rate for Payer: Veterans Affairs TRICARE	$32.16

95992 canalith reposition procedure

Facility

$203.00

Service Code	CPT 95992 GP
Hospital Charge Code	25261721
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$182.70
Rate for Payer: Aetna of AZ Commercial	$182.70
Rate for Payer: Cash Price	$162.40

96105 ASSESSMENT OF APHASIA WITH INTERPRETATION AND REPORT P

Facility

$513.00

Service Code	CPT 96105 GN
Hospital Charge Code	27728005
Hospital Revenue Code	440
Min. Negotiated Rate	$461.70
Max. Negotiated Rate	$461.70
Rate for Payer: Aetna of AZ Commercial	$461.70
Rate for Payer: Cash Price	$410.40

96105 ASSESSMENT OF APHASIA WITH INTERPRETATION AND REPORT P

Facility

$513.00

Service Code	CPT 96105 GN
Hospital Charge Code	27728005
Hospital Revenue Code	440
Min. Negotiated Rate	$81.26
Max. Negotiated Rate	$461.70
Rate for Payer: Aetna of AZ Commercial	$461.70
Rate for Payer: Arizona Complete Health Allwell	$82.08
Rate for Payer: Banner UC Health Medicare	$82.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$348.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$82.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$101.62
Rate for Payer: Cash Price	$410.40
Rate for Payer: Cash Price	$410.40
Rate for Payer: Cigna of AZ Commercial	$359.10
Rate for Payer: Devoted Health Medicare	$92.34
Rate for Payer: Humana of AZ Medicare	$82.08
Rate for Payer: Southwest Service Administrators UFCW	$348.84
Rate for Payer: TriWest Medicare	$82.08
Rate for Payer: United Healthcare Commercial	$293.44
Rate for Payer: United Healthcare Medicare	$82.08
Rate for Payer: United Healthcare New Mexico Commercial	$97.47
Rate for Payer: Veterans Affairs TRICARE	$81.26

96125 STANDARDIZED COGNITIVE PERFORMANCE TESTING PER HOUR

Facility

$538.00

Service Code	CPT 96125 GN
Hospital Charge Code	27728006
Hospital Revenue Code	440
Min. Negotiated Rate	$85.22
Max. Negotiated Rate	$484.20
Rate for Payer: Aetna of AZ Commercial	$484.20
Rate for Payer: Arizona Complete Health Allwell	$86.08
Rate for Payer: Banner UC Health Medicare	$86.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$365.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$86.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$107.29
Rate for Payer: Cash Price	$430.40
Rate for Payer: Cash Price	$430.40
Rate for Payer: Cigna of AZ Commercial	$376.60
Rate for Payer: Devoted Health Medicare	$96.84
Rate for Payer: Humana of AZ Medicare	$86.08
Rate for Payer: Southwest Service Administrators UFCW	$365.84
Rate for Payer: TriWest Medicare	$86.08
Rate for Payer: United Healthcare Commercial	$307.74
Rate for Payer: United Healthcare Medicare	$86.08
Rate for Payer: United Healthcare New Mexico Commercial	$102.22
Rate for Payer: Veterans Affairs TRICARE	$85.22

96125 STANDARDIZED COGNITIVE PERFORMANCE TESTING PER HOUR

Facility

$538.00

Service Code	CPT 96125 GN
Hospital Charge Code	27728006
Hospital Revenue Code	440
Min. Negotiated Rate	$484.20
Max. Negotiated Rate	$484.20
Rate for Payer: Aetna of AZ Commercial	$484.20
Rate for Payer: Cash Price	$430.40

96360 - Hydration, first hour

Facility

$294.80

Service Code	CPT 96360
Hospital Charge Code	22283161
Hospital Revenue Code	450
Min. Negotiated Rate	$265.32
Max. Negotiated Rate	$265.32
Rate for Payer: Aetna of AZ Commercial	$265.32
Rate for Payer: Cash Price	$235.84

96360 - Hydration, first hour

Facility

$294.80

Service Code	CPT 96360
Hospital Charge Code	22283161
Hospital Revenue Code	450
Min. Negotiated Rate	$46.70
Max. Negotiated Rate	$329.11
Rate for Payer: Aetna of AZ Commercial	$265.32
Rate for Payer: Arizona Complete Health Allwell	$47.17
Rate for Payer: Banner UC Health Medicare	$47.17
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$200.46
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$47.17
Rate for Payer: Care1st Health Plan Arizona Medicare	$47.17
Rate for Payer: Cash Price	$235.84
Rate for Payer: Cash Price	$235.84
Rate for Payer: Cigna of AZ Commercial	$206.36
Rate for Payer: Devoted Health Medicare	$53.06
Rate for Payer: Humana of AZ Medicare	$47.17
Rate for Payer: Seven Corners Travel Insurance	$329.11
Rate for Payer: Southwest Service Administrators UFCW	$200.46
Rate for Payer: TriWest Medicare	$47.17
Rate for Payer: United Healthcare Commercial	$168.63
Rate for Payer: United Healthcare Medicare	$47.17
Rate for Payer: United Healthcare New Mexico Commercial	$56.01
Rate for Payer: Veterans Affairs TRICARE	$46.70

96360 IV FLUID HYDRATION INITAL HOUR

Facility

$362.00

Service Code	CPT 96360
Hospital Charge Code	22282932
Hospital Revenue Code	260
Min. Negotiated Rate	$325.80
Max. Negotiated Rate	$325.80
Rate for Payer: Aetna of AZ Commercial	$325.80
Rate for Payer: Cash Price	$289.60

96360 IV FLUID HYDRATION INITAL HOUR

Facility

$362.00

Service Code	CPT 96360
Hospital Charge Code	22282932
Hospital Revenue Code	260
Min. Negotiated Rate	$57.34
Max. Negotiated Rate	$329.11
Rate for Payer: Aetna of AZ Commercial	$325.80
Rate for Payer: Arizona Complete Health Allwell	$57.92
Rate for Payer: Banner UC Health Medicare	$57.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$246.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$57.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$57.92
Rate for Payer: Cash Price	$289.60
Rate for Payer: Cash Price	$289.60
Rate for Payer: Cigna of AZ Commercial	$253.40
Rate for Payer: Devoted Health Medicare	$65.16
Rate for Payer: Humana of AZ Medicare	$57.92
Rate for Payer: Seven Corners Travel Insurance	$329.11
Rate for Payer: Southwest Service Administrators UFCW	$246.16
Rate for Payer: TriWest Medicare	$57.92
Rate for Payer: United Healthcare Commercial	$207.06
Rate for Payer: United Healthcare Medicare	$57.92
Rate for Payer: Veterans Affairs TRICARE	$57.34

96361 - Hydration, each additional hour

Facility

$190.30

Service Code	CPT 96361
Hospital Charge Code	22283162
Hospital Revenue Code	450
Min. Negotiated Rate	$171.27
Max. Negotiated Rate	$171.27
Rate for Payer: Aetna of AZ Commercial	$171.27
Rate for Payer: Cash Price	$152.24

96361 - Hydration, each additional hour

Facility

$190.30

Service Code	CPT 96361
Hospital Charge Code	22283162
Hospital Revenue Code	450
Min. Negotiated Rate	$30.14
Max. Negotiated Rate	$171.27
Rate for Payer: Aetna of AZ Commercial	$171.27
Rate for Payer: Arizona Complete Health Allwell	$30.45
Rate for Payer: Banner UC Health Medicare	$30.45
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$129.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$30.45
Rate for Payer: Care1st Health Plan Arizona Medicare	$30.45
Rate for Payer: Cash Price	$152.24
Rate for Payer: Cash Price	$152.24
Rate for Payer: Cigna of AZ Commercial	$133.21
Rate for Payer: Devoted Health Medicare	$34.25
Rate for Payer: Humana of AZ Medicare	$30.45
Rate for Payer: Seven Corners Travel Insurance	$72.46
Rate for Payer: Southwest Service Administrators UFCW	$129.40
Rate for Payer: TriWest Medicare	$30.45
Rate for Payer: United Healthcare Commercial	$108.85
Rate for Payer: United Healthcare Medicare	$30.45
Rate for Payer: United Healthcare New Mexico Commercial	$36.16
Rate for Payer: Veterans Affairs TRICARE	$30.14

96361 IV HYDRATION EACH ADDITIONAL HOUR

Facility

$171.00

Service Code	CPT 96361
Hospital Charge Code	22282933
Hospital Revenue Code	450
Min. Negotiated Rate	$27.09
Max. Negotiated Rate	$153.90
Rate for Payer: Aetna of AZ Commercial	$153.90
Rate for Payer: Arizona Complete Health Allwell	$27.36
Rate for Payer: Banner UC Health Medicare	$27.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$116.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.36
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cigna of AZ Commercial	$119.70
Rate for Payer: Devoted Health Medicare	$30.78
Rate for Payer: Humana of AZ Medicare	$27.36
Rate for Payer: Seven Corners Travel Insurance	$72.46
Rate for Payer: Southwest Service Administrators UFCW	$116.28
Rate for Payer: TriWest Medicare	$27.36
Rate for Payer: United Healthcare Commercial	$97.81
Rate for Payer: United Healthcare Medicare	$27.36
Rate for Payer: United Healthcare New Mexico Commercial	$32.49
Rate for Payer: Veterans Affairs TRICARE	$27.09

96361 IV HYDRATION EACH ADDITIONAL HOUR

Facility

$171.00

Service Code	CPT 96361
Hospital Charge Code	22282933
Hospital Revenue Code	450
Min. Negotiated Rate	$153.90
Max. Negotiated Rate	$153.90
Rate for Payer: Aetna of AZ Commercial	$153.90
Rate for Payer: Cash Price	$136.80

96365 INFUSION INTO A VEIN FOR THERAPY, PREVENTION, OR DIAGN

Facility

$381.00

Service Code	CPT 96365
Hospital Charge Code	24377522
Hospital Revenue Code	260
Min. Negotiated Rate	$60.35
Max. Negotiated Rate	$342.90
Rate for Payer: Aetna of AZ Commercial	$342.90
Rate for Payer: Arizona Complete Health Allwell	$60.96
Rate for Payer: Banner UC Health Medicare	$60.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$259.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$60.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$60.96
Rate for Payer: Cash Price	$304.80
Rate for Payer: Cash Price	$304.80
Rate for Payer: Cigna of AZ Commercial	$266.70
Rate for Payer: Devoted Health Medicare	$68.58
Rate for Payer: Humana of AZ Medicare	$60.96
Rate for Payer: Seven Corners Travel Insurance	$329.11
Rate for Payer: Southwest Service Administrators UFCW	$259.08
Rate for Payer: TriWest Medicare	$60.96
Rate for Payer: United Healthcare Commercial	$217.93
Rate for Payer: United Healthcare Medicare	$60.96
Rate for Payer: Veterans Affairs TRICARE	$60.35

96365 INFUSION INTO A VEIN FOR THERAPY, PREVENTION, OR DIAGN

Facility

$381.00

Service Code	CPT 96365
Hospital Charge Code	24377522
Hospital Revenue Code	260
Min. Negotiated Rate	$342.90
Max. Negotiated Rate	$342.90
Rate for Payer: Aetna of AZ Commercial	$342.90
Rate for Payer: Cash Price	$304.80

96365 IV DRUG FIRST HOUR

Facility

$847.00

Service Code	CPT 96365
Hospital Charge Code	22282934
Hospital Revenue Code	450
Min. Negotiated Rate	$134.16
Max. Negotiated Rate	$762.30
Rate for Payer: Aetna of AZ Commercial	$762.30
Rate for Payer: Arizona Complete Health Allwell	$135.52
Rate for Payer: Banner UC Health Medicare	$135.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$575.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$135.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$135.52
Rate for Payer: Cash Price	$677.60
Rate for Payer: Cash Price	$677.60
Rate for Payer: Cigna of AZ Commercial	$592.90
Rate for Payer: Devoted Health Medicare	$152.46
Rate for Payer: Humana of AZ Medicare	$135.52
Rate for Payer: Seven Corners Travel Insurance	$329.11
Rate for Payer: Southwest Service Administrators UFCW	$575.96
Rate for Payer: TriWest Medicare	$135.52
Rate for Payer: United Healthcare Commercial	$484.48
Rate for Payer: United Healthcare Medicare	$135.52
Rate for Payer: United Healthcare New Mexico Commercial	$160.93
Rate for Payer: Veterans Affairs TRICARE	$134.16

96365 IV DRUG FIRST HOUR

Facility

$847.00

Service Code	CPT 96365
Hospital Charge Code	22282934
Hospital Revenue Code	450
Min. Negotiated Rate	$762.30
Max. Negotiated Rate	$762.30
Rate for Payer: Aetna of AZ Commercial	$762.30
Rate for Payer: Cash Price	$677.60

96365 IV INFUSION 1ST HR Charge

Facility

$216.00

Service Code	CPT 96365
Hospital Charge Code	11021376
Hospital Revenue Code	521
Min. Negotiated Rate	$34.21
Max. Negotiated Rate	$329.11
Rate for Payer: Aetna of AZ Commercial	$194.40
Rate for Payer: Arizona Complete Health Allwell	$34.56
Rate for Payer: Banner UC Health Medicare	$34.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$146.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$34.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$34.56
Rate for Payer: Cash Price	$172.80
Rate for Payer: Cash Price	$172.80
Rate for Payer: Cigna of AZ Commercial	$151.20
Rate for Payer: Devoted Health Medicare	$38.88
Rate for Payer: Humana of AZ Medicare	$34.56
Rate for Payer: Seven Corners Travel Insurance	$329.11
Rate for Payer: Southwest Service Administrators UFCW	$146.88
Rate for Payer: TriWest Medicare	$34.56
Rate for Payer: United Healthcare Commercial	$123.55
Rate for Payer: United Healthcare Medicare	$34.56
Rate for Payer: Veterans Affairs TRICARE	$34.21

96365 IV INFUSION 1ST HR Charge

Facility

$216.00

Service Code	CPT 96365
Hospital Charge Code	11021376
Hospital Revenue Code	521
Min. Negotiated Rate	$194.40
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of AZ Commercial	$194.40
Rate for Payer: Cash Price	$172.80

96365 - IV tx, first hour

Facility

$856.00

Service Code	CPT 96365
Hospital Charge Code	22283163
Hospital Revenue Code	450
Min. Negotiated Rate	$770.40
Max. Negotiated Rate	$770.40
Rate for Payer: Aetna of AZ Commercial	$770.40
Rate for Payer: Cash Price	$684.80

96365 - IV tx, first hour

Facility

$856.00

Service Code	CPT 96365
Hospital Charge Code	22283163
Hospital Revenue Code	450
Min. Negotiated Rate	$135.59
Max. Negotiated Rate	$770.40
Rate for Payer: Aetna of AZ Commercial	$770.40
Rate for Payer: Arizona Complete Health Allwell	$136.96
Rate for Payer: Banner UC Health Medicare	$136.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$582.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$136.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$136.96
Rate for Payer: Cash Price	$684.80
Rate for Payer: Cash Price	$684.80
Rate for Payer: Cigna of AZ Commercial	$599.20
Rate for Payer: Devoted Health Medicare	$154.08
Rate for Payer: Humana of AZ Medicare	$136.96
Rate for Payer: Seven Corners Travel Insurance	$329.11
Rate for Payer: Southwest Service Administrators UFCW	$582.08
Rate for Payer: TriWest Medicare	$136.96
Rate for Payer: United Healthcare Commercial	$489.63
Rate for Payer: United Healthcare Medicare	$136.96
Rate for Payer: United Healthcare New Mexico Commercial	$162.64
Rate for Payer: Veterans Affairs TRICARE	$135.59

96366 INFUSION INTO A VEIN FOR THERAPY, PREVENTION, OR DIAGN

Facility

$156.00

Service Code	CPT 96366
Hospital Charge Code	24377525
Hospital Revenue Code	260
Min. Negotiated Rate	$140.40
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of AZ Commercial	$140.40
Rate for Payer: Cash Price	$124.80

Know your out-of-pocket cost for care.

All Charges