Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Pneumococcal IM (14 Serotype) LC

Facility

$73.00

Service Code	CPT 86317
Hospital Charge Code	22311203
Hospital Revenue Code	302
Min. Negotiated Rate	$11.56
Max. Negotiated Rate	$65.70
Rate for Payer: Aetna of AZ Commercial	$65.70
Rate for Payer: Arizona Complete Health Allwell	$11.68
Rate for Payer: Banner UC Health Medicare	$11.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$49.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.68
Rate for Payer: Cash Price	$58.40
Rate for Payer: Cash Price	$58.40
Rate for Payer: Cigna of AZ Commercial	$47.45
Rate for Payer: Devoted Health Medicare	$13.14
Rate for Payer: Humana of AZ Medicare	$11.68
Rate for Payer: Seven Corners Travel Insurance	$21.74
Rate for Payer: Southwest Service Administrators UFCW	$49.64
Rate for Payer: TriWest Medicare	$11.68
Rate for Payer: United Healthcare Commercial	$41.76
Rate for Payer: United Healthcare Medicare	$11.68
Rate for Payer: Veterans Affairs TRICARE	$11.56

Pneumococcal IM (14 Serotype) LC

Facility

$73.00

Service Code	CPT 86317
Hospital Charge Code	22311203
Hospital Revenue Code	302
Min. Negotiated Rate	$65.70
Max. Negotiated Rate	$65.70
Rate for Payer: Aetna of AZ Commercial	$65.70
Rate for Payer: Cash Price	$58.40

PNEUMOTHORAX 10FR 29CM CATH KIT

Facility

$821.70

Hospital Charge Code	27987619
Hospital Revenue Code	270
Min. Negotiated Rate	$130.16
Max. Negotiated Rate	$739.53
Rate for Payer: Aetna of AZ Commercial	$739.53
Rate for Payer: Arizona Complete Health Allwell	$131.47
Rate for Payer: Banner UC Health Medicare	$131.47
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$558.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$131.47
Rate for Payer: Care1st Health Plan Arizona Medicare	$131.47
Rate for Payer: Cash Price	$657.36
Rate for Payer: Cigna of AZ Commercial	$575.19
Rate for Payer: Devoted Health Medicare	$147.91
Rate for Payer: Humana of AZ Medicare	$131.47
Rate for Payer: Southwest Service Administrators UFCW	$558.76
Rate for Payer: TriWest Medicare	$131.47
Rate for Payer: United Healthcare Commercial	$470.01
Rate for Payer: United Healthcare Medicare	$131.47
Rate for Payer: Veterans Affairs TRICARE	$130.16

PNEUMOTHORAX 10FR 29CM CATH KIT

Facility

$821.70

Hospital Charge Code	27987619
Hospital Revenue Code	270
Min. Negotiated Rate	$739.53
Max. Negotiated Rate	$739.53
Rate for Payer: Aetna of AZ Commercial	$739.53
Rate for Payer: Cash Price	$657.36

PNEUMOTHORAX WITH CC

Facility

$14,284.88

Service Code	MSDRG 200
Min. Negotiated Rate	$14,284.88
Max. Negotiated Rate	$14,284.88
Rate for Payer: Seven Corners Travel Insurance	$14,284.88

PNEUMOTHORAX WITH MCC

Facility

$22,799.50

Service Code	MSDRG 199
Min. Negotiated Rate	$22,799.50
Max. Negotiated Rate	$22,799.50
Rate for Payer: Seven Corners Travel Insurance	$22,799.50

PNEUMOTHORAX WITHOUT CC/MCC

Facility

$9,416.60

Service Code	MSDRG 201
Min. Negotiated Rate	$9,416.60
Max. Negotiated Rate	$9,416.60
Rate for Payer: Seven Corners Travel Insurance	$9,416.60

PNT 1002836 Drug Screen 10 w/ confirmation

Facility

$282.00

Service Code	CPT 80307
Hospital Charge Code	23090932
Hospital Revenue Code	301
Min. Negotiated Rate	$44.67
Max. Negotiated Rate	$253.80
Rate for Payer: Aetna of AZ Commercial	$253.80
Rate for Payer: Arizona Complete Health Allwell	$45.12
Rate for Payer: Banner UC Health Medicare	$45.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$191.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$45.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$45.12
Rate for Payer: Cash Price	$225.60
Rate for Payer: Cash Price	$225.60
Rate for Payer: Cigna of AZ Commercial	$183.30
Rate for Payer: Devoted Health Medicare	$50.76
Rate for Payer: Humana of AZ Medicare	$45.12
Rate for Payer: Seven Corners Travel Insurance	$90.10
Rate for Payer: Southwest Service Administrators UFCW	$191.76
Rate for Payer: TriWest Medicare	$45.12
Rate for Payer: United Healthcare Commercial	$161.30
Rate for Payer: United Healthcare Medicare	$45.12
Rate for Payer: Veterans Affairs TRICARE	$44.67

PNT 1002836 Drug Screen 10 w/ confirmation

Facility

$282.00

Service Code	CPT 80307
Hospital Charge Code	23090932
Hospital Revenue Code	301
Min. Negotiated Rate	$253.80
Max. Negotiated Rate	$253.80
Rate for Payer: Aetna of AZ Commercial	$253.80
Rate for Payer: Cash Price	$225.60

PNT 1007757 C Diff Toxin Gene NAA DPT

Facility

$270.00

Service Code	CPT 87493
Hospital Charge Code	23090942
Hospital Revenue Code	301
Min. Negotiated Rate	$42.77
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of AZ Commercial	$243.00
Rate for Payer: Arizona Complete Health Allwell	$43.20
Rate for Payer: Banner UC Health Medicare	$43.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$183.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$43.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna of AZ Commercial	$175.50
Rate for Payer: Devoted Health Medicare	$48.60
Rate for Payer: Humana of AZ Medicare	$43.20
Rate for Payer: Seven Corners Travel Insurance	$54.04
Rate for Payer: Southwest Service Administrators UFCW	$183.60
Rate for Payer: TriWest Medicare	$43.20
Rate for Payer: United Healthcare Commercial	$154.44
Rate for Payer: United Healthcare Medicare	$43.20
Rate for Payer: Veterans Affairs TRICARE	$42.77

PNT 1007757 C Diff Toxin Gene NAA DPT

Facility

$270.00

Service Code	CPT 87493
Hospital Charge Code	23090942
Hospital Revenue Code	301
Min. Negotiated Rate	$243.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of AZ Commercial	$243.00
Rate for Payer: Cash Price	$216.00

PNT 1011215 Chromium, Unirine

Facility

$299.00

Service Code	CPT 82495
Hospital Charge Code	23090945
Hospital Revenue Code	301
Min. Negotiated Rate	$29.41
Max. Negotiated Rate	$269.10
Rate for Payer: Aetna of AZ Commercial	$269.10
Rate for Payer: Arizona Complete Health Allwell	$47.84
Rate for Payer: Banner UC Health Medicare	$47.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$203.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$47.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$47.84
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cigna of AZ Commercial	$194.35
Rate for Payer: Devoted Health Medicare	$53.82
Rate for Payer: Humana of AZ Medicare	$47.84
Rate for Payer: Seven Corners Travel Insurance	$29.41
Rate for Payer: Southwest Service Administrators UFCW	$203.32
Rate for Payer: TriWest Medicare	$47.84
Rate for Payer: United Healthcare Commercial	$171.03
Rate for Payer: United Healthcare Medicare	$47.84
Rate for Payer: Veterans Affairs TRICARE	$47.36

PNT 1011215 Chromium, Unirine

Facility

$299.00

Service Code	CPT 82495
Hospital Charge Code	23090945
Hospital Revenue Code	301
Min. Negotiated Rate	$269.10
Max. Negotiated Rate	$269.10
Rate for Payer: Aetna of AZ Commercial	$269.10
Rate for Payer: Cash Price	$239.20

PNT 1209072 Aspergillus AB

Facility

$404.00

Service Code	CPT 86606
Hospital Charge Code	23090944
Hospital Revenue Code	301
Min. Negotiated Rate	$21.82
Max. Negotiated Rate	$363.60
Rate for Payer: Aetna of AZ Commercial	$363.60
Rate for Payer: Arizona Complete Health Allwell	$64.64
Rate for Payer: Banner UC Health Medicare	$64.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$274.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$64.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$64.64
Rate for Payer: Cash Price	$323.20
Rate for Payer: Cash Price	$323.20
Rate for Payer: Cigna of AZ Commercial	$262.60
Rate for Payer: Devoted Health Medicare	$72.72
Rate for Payer: Humana of AZ Medicare	$64.64
Rate for Payer: Seven Corners Travel Insurance	$21.82
Rate for Payer: Southwest Service Administrators UFCW	$274.72
Rate for Payer: TriWest Medicare	$64.64
Rate for Payer: United Healthcare Commercial	$231.09
Rate for Payer: United Healthcare Medicare	$64.64
Rate for Payer: Veterans Affairs TRICARE	$63.99

PNT 1209072 Aspergillus AB

Facility

$404.00

Service Code	CPT 86606
Hospital Charge Code	23090944
Hospital Revenue Code	301
Min. Negotiated Rate	$363.60
Max. Negotiated Rate	$363.60
Rate for Payer: Aetna of AZ Commercial	$363.60
Rate for Payer: Cash Price	$323.20

PNT Coccidiodies Abs IGG/IGM

Facility

$135.00

Service Code	CPT 86635
Hospital Charge Code	23090943
Hospital Revenue Code	301
Min. Negotiated Rate	$16.63
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of AZ Commercial	$121.50
Rate for Payer: Arizona Complete Health Allwell	$21.60
Rate for Payer: Banner UC Health Medicare	$21.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$21.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$21.60
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna of AZ Commercial	$87.75
Rate for Payer: Devoted Health Medicare	$24.30
Rate for Payer: Humana of AZ Medicare	$21.60
Rate for Payer: Seven Corners Travel Insurance	$16.63
Rate for Payer: Southwest Service Administrators UFCW	$91.80
Rate for Payer: TriWest Medicare	$21.60
Rate for Payer: United Healthcare Commercial	$77.22
Rate for Payer: United Healthcare Medicare	$21.60
Rate for Payer: Veterans Affairs TRICARE	$21.38

PNT Coccidiodies Abs IGG/IGM

Facility

$135.00

Service Code	CPT 86635
Hospital Charge Code	23090943
Hospital Revenue Code	301
Min. Negotiated Rate	$121.50
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of AZ Commercial	$121.50
Rate for Payer: Cash Price	$108.00

PNT Non-Severe Hemophilia

Facility

$236.00

Service Code	CPT 80500
Hospital Charge Code	23090939
Hospital Revenue Code	301
Min. Negotiated Rate	$37.38
Max. Negotiated Rate	$212.40
Rate for Payer: Aetna of AZ Commercial	$212.40
Rate for Payer: Arizona Complete Health Allwell	$37.76
Rate for Payer: Banner UC Health Medicare	$37.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$160.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$37.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.76
Rate for Payer: Cash Price	$188.80
Rate for Payer: Cigna of AZ Commercial	$153.40
Rate for Payer: Devoted Health Medicare	$42.48
Rate for Payer: Humana of AZ Medicare	$37.76
Rate for Payer: Southwest Service Administrators UFCW	$160.48
Rate for Payer: TriWest Medicare	$37.76
Rate for Payer: United Healthcare Commercial	$134.99
Rate for Payer: United Healthcare Medicare	$37.76
Rate for Payer: Veterans Affairs TRICARE	$37.38

PNT Non-Severe Hemophilia

Facility

$236.00

Service Code	CPT 80500
Hospital Charge Code	23090939
Hospital Revenue Code	301
Min. Negotiated Rate	$212.40
Max. Negotiated Rate	$212.40
Rate for Payer: Aetna of AZ Commercial	$212.40
Rate for Payer: Cash Price	$188.80

PNUMOTHORAX 14FR 29CM CATH KIT

Facility

$753.00

Hospital Charge Code	27987620
Hospital Revenue Code	270
Min. Negotiated Rate	$119.28
Max. Negotiated Rate	$677.70
Rate for Payer: Aetna of AZ Commercial	$677.70
Rate for Payer: Arizona Complete Health Allwell	$120.48
Rate for Payer: Banner UC Health Medicare	$120.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$512.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$120.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$120.48
Rate for Payer: Cash Price	$602.40
Rate for Payer: Cigna of AZ Commercial	$527.10
Rate for Payer: Devoted Health Medicare	$135.54
Rate for Payer: Humana of AZ Medicare	$120.48
Rate for Payer: Southwest Service Administrators UFCW	$512.04
Rate for Payer: TriWest Medicare	$120.48
Rate for Payer: United Healthcare Commercial	$430.72
Rate for Payer: United Healthcare Medicare	$120.48
Rate for Payer: Veterans Affairs TRICARE	$119.28

PNUMOTHORAX 14FR 29CM CATH KIT

Facility

$753.00

Hospital Charge Code	27987620
Hospital Revenue Code	270
Min. Negotiated Rate	$677.70
Max. Negotiated Rate	$677.70
Rate for Payer: Aetna of AZ Commercial	$677.70
Rate for Payer: Cash Price	$602.40

POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC

Facility

$20,270.22

Service Code	MSDRG 917
Min. Negotiated Rate	$20,270.22
Max. Negotiated Rate	$20,270.22
Rate for Payer: Seven Corners Travel Insurance	$20,270.22

POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC

Facility

$11,215.92

Service Code	MSDRG 918
Min. Negotiated Rate	$11,215.92
Max. Negotiated Rate	$11,215.92
Rate for Payer: Seven Corners Travel Insurance	$11,215.92

Poisoning Of Medicinal Agents

Facility

$2,564.32

Service Code	APR-DRG 8121
Hospital Charge Code	APRDRG8123
Min. Negotiated Rate	$2,564.32
Max. Negotiated Rate	$2,564.32
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,564.32
Rate for Payer: Mercy Care Medicaid	$2,564.32
Rate for Payer: NaphCare Correctional Healthcare	$2,564.32

Poisoning Of Medicinal Agents

Facility

$5,178.44

Service Code	APR-DRG 8123
Hospital Charge Code	APRDRG8122
Min. Negotiated Rate	$5,178.44
Max. Negotiated Rate	$5,178.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,178.44
Rate for Payer: Mercy Care Medicaid	$5,178.44
Rate for Payer: NaphCare Correctional Healthcare	$5,178.44

Know your out-of-pocket cost for care.

All Charges