Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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	$24.71
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of AZ Commercial	$140.40
Rate for Payer: Arizona Complete Health Allwell	$24.96
Rate for Payer: Banner UC Health Medicare	$24.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$106.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$24.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$24.96
Rate for Payer: Cash Price	$124.80
Rate for Payer: Cash Price	$124.80
Rate for Payer: Cigna of AZ Commercial	$109.20
Rate for Payer: Devoted Health Medicare	$28.08
Rate for Payer: Humana of AZ Medicare	$24.96
Rate for Payer: Seven Corners Travel Insurance	$72.46
Rate for Payer: Southwest Service Administrators UFCW	$106.08
Rate for Payer: TriWest Medicare	$24.96
Rate for Payer: United Healthcare Commercial	$89.23
Rate for Payer: United Healthcare Medicare	$24.96
Rate for Payer: Veterans Affairs TRICARE	$24.71

96366 IV DRUG ADDITIONAL HOUR

Facility

$234.00

Service Code	CPT 96366
Hospital Charge Code	22282935
Hospital Revenue Code	450
Min. Negotiated Rate	$37.07
Max. Negotiated Rate	$210.60
Rate for Payer: Aetna of AZ Commercial	$210.60
Rate for Payer: Arizona Complete Health Allwell	$37.44
Rate for Payer: Banner UC Health Medicare	$37.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$159.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$37.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.44
Rate for Payer: Cash Price	$187.20
Rate for Payer: Cash Price	$187.20
Rate for Payer: Cigna of AZ Commercial	$163.80
Rate for Payer: Devoted Health Medicare	$42.12
Rate for Payer: Humana of AZ Medicare	$37.44
Rate for Payer: Seven Corners Travel Insurance	$72.46
Rate for Payer: Southwest Service Administrators UFCW	$159.12
Rate for Payer: TriWest Medicare	$37.44
Rate for Payer: United Healthcare Commercial	$133.85
Rate for Payer: United Healthcare Medicare	$37.44
Rate for Payer: United Healthcare New Mexico Commercial	$44.46
Rate for Payer: Veterans Affairs TRICARE	$37.07

96366 IV DRUG ADDITIONAL HOUR

Facility

$234.00

Service Code	CPT 96366
Hospital Charge Code	22282935
Hospital Revenue Code	450
Min. Negotiated Rate	$210.60
Max. Negotiated Rate	$210.60
Rate for Payer: Aetna of AZ Commercial	$210.60
Rate for Payer: Cash Price	$187.20

96366 - IV tx, each additional hour

Facility

$173.00

Service Code	CPT 96366
Hospital Charge Code	22283164
Hospital Revenue Code	450
Min. Negotiated Rate	$155.70
Max. Negotiated Rate	$155.70
Rate for Payer: Aetna of AZ Commercial	$155.70
Rate for Payer: Cash Price	$138.40

96366 - IV tx, each additional hour

Facility

$173.00

Service Code	CPT 96366
Hospital Charge Code	22283164
Hospital Revenue Code	450
Min. Negotiated Rate	$27.40
Max. Negotiated Rate	$155.70
Rate for Payer: Aetna of AZ Commercial	$155.70
Rate for Payer: Arizona Complete Health Allwell	$27.68
Rate for Payer: Banner UC Health Medicare	$27.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$117.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.68
Rate for Payer: Cash Price	$138.40
Rate for Payer: Cash Price	$138.40
Rate for Payer: Cigna of AZ Commercial	$121.10
Rate for Payer: Devoted Health Medicare	$31.14
Rate for Payer: Humana of AZ Medicare	$27.68
Rate for Payer: Seven Corners Travel Insurance	$72.46
Rate for Payer: Southwest Service Administrators UFCW	$117.64
Rate for Payer: TriWest Medicare	$27.68
Rate for Payer: United Healthcare Commercial	$98.96
Rate for Payer: United Healthcare Medicare	$27.68
Rate for Payer: United Healthcare New Mexico Commercial	$32.87
Rate for Payer: Veterans Affairs TRICARE	$27.40

96367 Additional sequential infusion of a new drug/substance

Facility

$163.00

Service Code	CPT 96367
Hospital Charge Code	11340910
Hospital Revenue Code	260
Min. Negotiated Rate	$146.70
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Cash Price	$130.40

96367 Additional sequential infusion of a new drug/substance

Facility

$163.00

Service Code	CPT 96367
Hospital Charge Code	11340910
Hospital Revenue Code	260
Min. Negotiated Rate	$25.82
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Arizona Complete Health Allwell	$26.08
Rate for Payer: Banner UC Health Medicare	$26.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$110.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$26.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$26.08
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cigna of AZ Commercial	$114.10
Rate for Payer: Devoted Health Medicare	$29.34
Rate for Payer: Humana of AZ Medicare	$26.08
Rate for Payer: Seven Corners Travel Insurance	$111.40
Rate for Payer: Southwest Service Administrators UFCW	$110.84
Rate for Payer: TriWest Medicare	$26.08
Rate for Payer: United Healthcare Commercial	$93.24
Rate for Payer: United Healthcare Medicare	$26.08
Rate for Payer: Veterans Affairs TRICARE	$25.82

96367 - IV tx, sequential infusion

Facility

$348.00

Service Code	CPT 96367
Hospital Charge Code	22283165
Hospital Revenue Code	450
Min. Negotiated Rate	$55.12
Max. Negotiated Rate	$313.20
Rate for Payer: Aetna of AZ Commercial	$313.20
Rate for Payer: Arizona Complete Health Allwell	$55.68
Rate for Payer: Banner UC Health Medicare	$55.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$236.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$55.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$55.68
Rate for Payer: Cash Price	$278.40
Rate for Payer: Cash Price	$278.40
Rate for Payer: Cigna of AZ Commercial	$243.60
Rate for Payer: Devoted Health Medicare	$62.64
Rate for Payer: Humana of AZ Medicare	$55.68
Rate for Payer: Seven Corners Travel Insurance	$111.40
Rate for Payer: Southwest Service Administrators UFCW	$236.64
Rate for Payer: TriWest Medicare	$55.68
Rate for Payer: United Healthcare Commercial	$199.06
Rate for Payer: United Healthcare Medicare	$55.68
Rate for Payer: United Healthcare New Mexico Commercial	$66.12
Rate for Payer: Veterans Affairs TRICARE	$55.12

96367 - IV tx, sequential infusion

Facility

$348.00

Service Code	CPT 96367
Hospital Charge Code	22283165
Hospital Revenue Code	450
Min. Negotiated Rate	$313.20
Max. Negotiated Rate	$313.20
Rate for Payer: Aetna of AZ Commercial	$313.20
Rate for Payer: Cash Price	$278.40

96368 Concurrent Infusion - CQCH

Facility

$149.00

Service Code	CPT 96368
Hospital Charge Code	24377526
Hospital Revenue Code	260
Min. Negotiated Rate	$23.60
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of AZ Commercial	$134.10
Rate for Payer: Arizona Complete Health Allwell	$23.84
Rate for Payer: Banner UC Health Medicare	$23.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$101.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$23.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$23.84
Rate for Payer: Cash Price	$119.20
Rate for Payer: Cigna of AZ Commercial	$104.30
Rate for Payer: Devoted Health Medicare	$26.82
Rate for Payer: Humana of AZ Medicare	$23.84
Rate for Payer: Southwest Service Administrators UFCW	$101.32
Rate for Payer: TriWest Medicare	$23.84
Rate for Payer: United Healthcare Commercial	$85.23
Rate for Payer: United Healthcare Medicare	$23.84
Rate for Payer: Veterans Affairs TRICARE	$23.60

96368 Concurrent Infusion - CQCH

Facility

$149.00

Service Code	CPT 96368
Hospital Charge Code	24377526
Hospital Revenue Code	260
Min. Negotiated Rate	$134.10
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of AZ Commercial	$134.10
Rate for Payer: Cash Price	$119.20

96368 - IV tx, concurrent infusion

Facility

$233.00

Service Code	CPT 96368
Hospital Charge Code	22283166
Hospital Revenue Code	450
Min. Negotiated Rate	$209.70
Max. Negotiated Rate	$209.70
Rate for Payer: Aetna of AZ Commercial	$209.70
Rate for Payer: Cash Price	$186.40

96368 - IV tx, concurrent infusion

Facility

$233.00

Service Code	CPT 96368
Hospital Charge Code	22283166
Hospital Revenue Code	450
Min. Negotiated Rate	$36.91
Max. Negotiated Rate	$209.70
Rate for Payer: Aetna of AZ Commercial	$209.70
Rate for Payer: Arizona Complete Health Allwell	$37.28
Rate for Payer: Banner UC Health Medicare	$37.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$158.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$37.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.28
Rate for Payer: Cash Price	$186.40
Rate for Payer: Cigna of AZ Commercial	$163.10
Rate for Payer: Devoted Health Medicare	$41.94
Rate for Payer: Humana of AZ Medicare	$37.28
Rate for Payer: Southwest Service Administrators UFCW	$158.44
Rate for Payer: TriWest Medicare	$37.28
Rate for Payer: United Healthcare Commercial	$133.28
Rate for Payer: United Healthcare Medicare	$37.28
Rate for Payer: United Healthcare New Mexico Commercial	$44.27
Rate for Payer: Veterans Affairs TRICARE	$36.91

96369 Subcutaneous infusion for therapy of prophylaxis initi

Facility

$851.00

Service Code	CPT 96369
Hospital Charge Code	24377528
Hospital Revenue Code	260
Min. Negotiated Rate	$765.90
Max. Negotiated Rate	$765.90
Rate for Payer: Aetna of AZ Commercial	$765.90
Rate for Payer: Cash Price	$680.80

96369 Subcutaneous infusion for therapy of prophylaxis initi

Facility

$851.00

Service Code	CPT 96369
Hospital Charge Code	24377528
Hospital Revenue Code	260
Min. Negotiated Rate	$134.80
Max. Negotiated Rate	$765.90
Rate for Payer: Aetna of AZ Commercial	$765.90
Rate for Payer: Arizona Complete Health Allwell	$136.16
Rate for Payer: Banner UC Health Medicare	$136.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$578.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$136.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$136.16
Rate for Payer: Cash Price	$680.80
Rate for Payer: Cash Price	$680.80
Rate for Payer: Cigna of AZ Commercial	$595.70
Rate for Payer: Devoted Health Medicare	$153.18
Rate for Payer: Humana of AZ Medicare	$136.16
Rate for Payer: Seven Corners Travel Insurance	$329.11
Rate for Payer: Southwest Service Administrators UFCW	$578.68
Rate for Payer: TriWest Medicare	$136.16
Rate for Payer: United Healthcare Commercial	$486.77
Rate for Payer: United Healthcare Medicare	$136.16
Rate for Payer: Veterans Affairs TRICARE	$134.80

96372 IM INJ OF ANTIBIOTIC

Facility

$42.00

Service Code	CPT 96372
Hospital Charge Code	22282937
Hospital Revenue Code	450
Min. Negotiated Rate	$6.65
Max. Negotiated Rate	$111.40
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Arizona Complete Health Allwell	$6.72
Rate for Payer: Banner UC Health Medicare	$6.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$28.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.72
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cigna of AZ Commercial	$29.40
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Humana of AZ Medicare	$6.72
Rate for Payer: Seven Corners Travel Insurance	$111.40
Rate for Payer: Southwest Service Administrators UFCW	$28.56
Rate for Payer: TriWest Medicare	$6.72
Rate for Payer: United Healthcare Commercial	$24.02
Rate for Payer: United Healthcare Medicare	$6.72
Rate for Payer: United Healthcare New Mexico Commercial	$7.98
Rate for Payer: Veterans Affairs TRICARE	$6.65

96372 IM INJ OF ANTIBIOTIC

Facility

$42.00

Service Code	CPT 96372
Hospital Charge Code	22282937
Hospital Revenue Code	450
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Cash Price	$33.60

96372 - Subq/IM Injection

Facility

$258.00

Service Code	CPT 96372
Hospital Charge Code	22283167
Hospital Revenue Code	450
Min. Negotiated Rate	$40.87
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	$180.60
Rate for Payer: Devoted Health Medicare	$46.44
Rate for Payer: Humana of AZ Medicare	$41.28
Rate for Payer: Seven Corners Travel Insurance	$111.40
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: United Healthcare New Mexico Commercial	$49.02
Rate for Payer: Veterans Affairs TRICARE	$40.87

96372 - Subq/IM Injection

Facility

$258.00

Service Code	CPT 96372
Hospital Charge Code	22283167
Hospital Revenue Code	450
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

96372 THERAPTIC PROPHALACTIC I

Facility

$245.00

Service Code	CPT 96372
Hospital Charge Code	22282936
Hospital Revenue Code	450
Min. Negotiated Rate	$38.81
Max. Negotiated Rate	$220.50
Rate for Payer: Aetna of AZ Commercial	$220.50
Rate for Payer: Arizona Complete Health Allwell	$39.20
Rate for Payer: Banner UC Health Medicare	$39.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$166.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$39.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$39.20
Rate for Payer: Cash Price	$196.00
Rate for Payer: Cash Price	$196.00
Rate for Payer: Cigna of AZ Commercial	$171.50
Rate for Payer: Devoted Health Medicare	$44.10
Rate for Payer: Humana of AZ Medicare	$39.20
Rate for Payer: Seven Corners Travel Insurance	$111.40
Rate for Payer: Southwest Service Administrators UFCW	$166.60
Rate for Payer: TriWest Medicare	$39.20
Rate for Payer: United Healthcare Commercial	$140.14
Rate for Payer: United Healthcare Medicare	$39.20
Rate for Payer: United Healthcare New Mexico Commercial	$46.55
Rate for Payer: Veterans Affairs TRICARE	$38.81

96372 THERAPTIC PROPHALACTIC I

Facility

$245.00

Service Code	CPT 96372
Hospital Charge Code	22282936
Hospital Revenue Code	450
Min. Negotiated Rate	$220.50
Max. Negotiated Rate	$220.50
Rate for Payer: Aetna of AZ Commercial	$220.50
Rate for Payer: Cash Price	$196.00

96373 - Intra-Arterial injection

Facility

$268.00

Service Code	CPT 96373
Hospital Charge Code	22283168
Hospital Revenue Code	450
Min. Negotiated Rate	$241.20
Max. Negotiated Rate	$241.20
Rate for Payer: Aetna of AZ Commercial	$241.20
Rate for Payer: Cash Price	$214.40

96373 - Intra-Arterial injection

Facility

$268.00

Service Code	CPT 96373
Hospital Charge Code	22283168
Hospital Revenue Code	450
Min. Negotiated Rate	$42.45
Max. Negotiated Rate	$329.11
Rate for Payer: Aetna of AZ Commercial	$241.20
Rate for Payer: Arizona Complete Health Allwell	$42.88
Rate for Payer: Banner UC Health Medicare	$42.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$182.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$42.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$42.88
Rate for Payer: Cash Price	$214.40
Rate for Payer: Cash Price	$214.40
Rate for Payer: Cigna of AZ Commercial	$187.60
Rate for Payer: Devoted Health Medicare	$48.24
Rate for Payer: Humana of AZ Medicare	$42.88
Rate for Payer: Seven Corners Travel Insurance	$329.11
Rate for Payer: Southwest Service Administrators UFCW	$182.24
Rate for Payer: TriWest Medicare	$42.88
Rate for Payer: United Healthcare Commercial	$153.30
Rate for Payer: United Healthcare Medicare	$42.88
Rate for Payer: United Healthcare New Mexico Commercial	$50.92
Rate for Payer: Veterans Affairs TRICARE	$42.45

96374 INTRAVENOUS PUSH ADMINISTRATI

Facility

$362.00

Service Code	CPT 96374
Hospital Charge Code	22282938
Hospital Revenue Code	450
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: United Healthcare New Mexico Commercial	$68.78
Rate for Payer: Veterans Affairs TRICARE	$57.34

96374 INTRAVENOUS PUSH ADMINISTRATI

Facility

$362.00

Service Code	CPT 96374
Hospital Charge Code	22282938
Hospital Revenue Code	450
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

Know your out-of-pocket cost for care.

All Charges