Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Protein Level Urine

Facility

$95.00

Service Code	CPT 84156
Hospital Charge Code	12253376
Hospital Revenue Code	301
Min. Negotiated Rate	$85.50
Max. Negotiated Rate	$85.50
Rate for Payer: Aetna of AZ Commercial	$85.50
Rate for Payer: Cash Price	$76.00

Protein S-Functional LC

Facility

$180.00

Service Code	CPT 85306
Hospital Charge Code	2087641
Hospital Revenue Code	301
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of AZ Commercial	$162.00
Rate for Payer: Cash Price	$144.00

Protein S-Functional LC

Facility

$180.00

Service Code	CPT 85306
Hospital Charge Code	2087641
Hospital Revenue Code	301
Min. Negotiated Rate	$22.21
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of AZ Commercial	$162.00
Rate for Payer: Arizona Complete Health Allwell	$28.80
Rate for Payer: Banner UC Health Medicare	$28.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$122.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cigna of AZ Commercial	$117.00
Rate for Payer: Devoted Health Medicare	$32.40
Rate for Payer: Humana of AZ Medicare	$28.80
Rate for Payer: Seven Corners Travel Insurance	$22.21
Rate for Payer: Southwest Service Administrators UFCW	$122.40
Rate for Payer: TriWest Medicare	$28.80
Rate for Payer: United Healthcare Commercial	$102.96
Rate for Payer: United Healthcare Medicare	$28.80
Rate for Payer: Veterans Affairs TRICARE	$28.51

Protein S Panel LC

Facility

$1,073.00

Service Code	CPT 85306
Hospital Charge Code	2087640
Hospital Revenue Code	305
Min. Negotiated Rate	$965.70
Max. Negotiated Rate	$965.70
Rate for Payer: Aetna of AZ Commercial	$965.70
Rate for Payer: Cash Price	$858.40

Protein S Panel LC

Facility

$1,073.00

Service Code	CPT 85306
Hospital Charge Code	2087640
Hospital Revenue Code	305
Min. Negotiated Rate	$22.21
Max. Negotiated Rate	$965.70
Rate for Payer: Aetna of AZ Commercial	$965.70
Rate for Payer: Arizona Complete Health Allwell	$171.68
Rate for Payer: Banner UC Health Medicare	$171.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$729.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$171.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$171.68
Rate for Payer: Cash Price	$858.40
Rate for Payer: Cash Price	$858.40
Rate for Payer: Cigna of AZ Commercial	$697.45
Rate for Payer: Devoted Health Medicare	$193.14
Rate for Payer: Humana of AZ Medicare	$171.68
Rate for Payer: Seven Corners Travel Insurance	$22.21
Rate for Payer: Southwest Service Administrators UFCW	$729.64
Rate for Payer: TriWest Medicare	$171.68
Rate for Payer: United Healthcare Commercial	$613.76
Rate for Payer: United Healthcare Medicare	$171.68
Rate for Payer: Veterans Affairs TRICARE	$169.96

Protein Total

Facility

$79.00

Service Code	CPT 84155
Hospital Charge Code	633818
Hospital Revenue Code	301
Min. Negotiated Rate	$5.32
Max. Negotiated Rate	$71.10
Rate for Payer: Aetna of AZ Commercial	$71.10
Rate for Payer: Arizona Complete Health Allwell	$12.64
Rate for Payer: Banner UC Health Medicare	$12.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$53.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.64
Rate for Payer: Cash Price	$63.20
Rate for Payer: Cash Price	$63.20
Rate for Payer: Cigna of AZ Commercial	$51.35
Rate for Payer: Devoted Health Medicare	$14.22
Rate for Payer: Humana of AZ Medicare	$12.64
Rate for Payer: Seven Corners Travel Insurance	$5.32
Rate for Payer: Southwest Service Administrators UFCW	$53.72
Rate for Payer: TriWest Medicare	$12.64
Rate for Payer: United Healthcare Commercial	$45.19
Rate for Payer: United Healthcare Medicare	$12.64
Rate for Payer: Veterans Affairs TRICARE	$12.51

Protein Total

Facility

$79.00

Service Code	CPT 84155
Hospital Charge Code	633818
Hospital Revenue Code	301
Min. Negotiated Rate	$71.10
Max. Negotiated Rate	$71.10
Rate for Payer: Aetna of AZ Commercial	$71.10
Rate for Payer: Cash Price	$63.20

Protein total CSF

Facility

$86.00

Service Code	CPT 84157
Hospital Charge Code	633813
Hospital Revenue Code	301
Min. Negotiated Rate	$77.40
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of AZ Commercial	$77.40
Rate for Payer: Cash Price	$68.80

Protein total CSF

Facility

$86.00

Service Code	CPT 84157
Hospital Charge Code	633813
Hospital Revenue Code	301
Min. Negotiated Rate	$5.80
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of AZ Commercial	$77.40
Rate for Payer: Arizona Complete Health Allwell	$13.76
Rate for Payer: Banner UC Health Medicare	$13.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$58.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.76
Rate for Payer: Cash Price	$68.80
Rate for Payer: Cash Price	$68.80
Rate for Payer: Cigna of AZ Commercial	$55.90
Rate for Payer: Devoted Health Medicare	$15.48
Rate for Payer: Humana of AZ Medicare	$13.76
Rate for Payer: Seven Corners Travel Insurance	$5.80
Rate for Payer: Southwest Service Administrators UFCW	$58.48
Rate for Payer: TriWest Medicare	$13.76
Rate for Payer: United Healthcare Commercial	$49.19
Rate for Payer: United Healthcare Medicare	$13.76
Rate for Payer: Veterans Affairs TRICARE	$13.62

PROT EL 24 HR

Facility

$808.00

Service Code	CPT 84166
Hospital Charge Code	22481495
Hospital Revenue Code	301
Min. Negotiated Rate	$727.20
Max. Negotiated Rate	$727.20
Rate for Payer: Aetna of AZ Commercial	$727.20
Rate for Payer: Cash Price	$646.40

PROT EL 24 HR

Facility

$808.00

Service Code	CPT 84166
Hospital Charge Code	22481495
Hospital Revenue Code	301
Min. Negotiated Rate	$25.85
Max. Negotiated Rate	$727.20
Rate for Payer: Aetna of AZ Commercial	$727.20
Rate for Payer: Arizona Complete Health Allwell	$129.28
Rate for Payer: Banner UC Health Medicare	$129.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$549.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$129.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$129.28
Rate for Payer: Cash Price	$646.40
Rate for Payer: Cash Price	$646.40
Rate for Payer: Cigna of AZ Commercial	$525.20
Rate for Payer: Devoted Health Medicare	$145.44
Rate for Payer: Humana of AZ Medicare	$129.28
Rate for Payer: Seven Corners Travel Insurance	$25.85
Rate for Payer: Southwest Service Administrators UFCW	$549.44
Rate for Payer: TriWest Medicare	$129.28
Rate for Payer: United Healthcare Commercial	$462.18
Rate for Payer: United Healthcare Medicare	$129.28
Rate for Payer: Veterans Affairs TRICARE	$127.99

PROT EL R UR

Facility

$808.00

Service Code	CPT 84166
Hospital Charge Code	22481496
Hospital Revenue Code	301
Min. Negotiated Rate	$727.20
Max. Negotiated Rate	$727.20
Rate for Payer: Aetna of AZ Commercial	$727.20
Rate for Payer: Cash Price	$646.40

PROT EL R UR

Facility

$808.00

Service Code	CPT 84166
Hospital Charge Code	22481496
Hospital Revenue Code	301
Min. Negotiated Rate	$25.85
Max. Negotiated Rate	$727.20
Rate for Payer: Aetna of AZ Commercial	$727.20
Rate for Payer: Arizona Complete Health Allwell	$129.28
Rate for Payer: Banner UC Health Medicare	$129.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$549.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$129.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$129.28
Rate for Payer: Cash Price	$646.40
Rate for Payer: Cash Price	$646.40
Rate for Payer: Cigna of AZ Commercial	$525.20
Rate for Payer: Devoted Health Medicare	$145.44
Rate for Payer: Humana of AZ Medicare	$129.28
Rate for Payer: Seven Corners Travel Insurance	$25.85
Rate for Payer: Southwest Service Administrators UFCW	$549.44
Rate for Payer: TriWest Medicare	$129.28
Rate for Payer: United Healthcare Commercial	$462.18
Rate for Payer: United Healthcare Medicare	$129.28
Rate for Payer: Veterans Affairs TRICARE	$127.99

prothrombin complex - REC[CQCH]

Facility

$1,910.00

Service Code	HCPCS C9132
Hospital Charge Code	182934642
Hospital Revenue Code	250
Min. Negotiated Rate	$1,719.00
Max. Negotiated Rate	$1,719.00
Rate for Payer: Aetna of AZ Commercial	$1,719.00
Rate for Payer: Cash Price	$1,528.00

prothrombin complex - REC[CQCH]

Facility

$1,910.00

Service Code	HCPCS C9132
Hospital Charge Code	182934642
Hospital Revenue Code	250
Min. Negotiated Rate	$302.54
Max. Negotiated Rate	$1,719.00
Rate for Payer: Aetna of AZ Commercial	$1,719.00
Rate for Payer: Arizona Complete Health Allwell	$305.60
Rate for Payer: Banner UC Health Medicare	$305.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,298.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$305.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$305.60
Rate for Payer: Cash Price	$1,528.00
Rate for Payer: Cigna of AZ Commercial	$1,241.50
Rate for Payer: Devoted Health Medicare	$343.80
Rate for Payer: Humana of AZ Medicare	$305.60
Rate for Payer: Southwest Service Administrators UFCW	$1,298.80
Rate for Payer: TriWest Medicare	$305.60
Rate for Payer: United Healthcare Commercial	$1,092.52
Rate for Payer: United Healthcare Medicare	$305.60
Rate for Payer: Veterans Affairs TRICARE	$302.54

Prothrombin/INR POC

Facility

$71.00

Service Code	CPT 85610
Hospital Charge Code	714167
Hospital Revenue Code	305
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Cash Price	$56.80

Prothrombin/INR POC

Facility

$71.00

Service Code	CPT 85610
Hospital Charge Code	714167
Hospital Revenue Code	305
Min. Negotiated Rate	$6.22
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Arizona Complete Health Allwell	$11.36
Rate for Payer: Banner UC Health Medicare	$11.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$48.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.36
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cigna of AZ Commercial	$46.15
Rate for Payer: Devoted Health Medicare	$12.78
Rate for Payer: Humana of AZ Medicare	$11.36
Rate for Payer: Seven Corners Travel Insurance	$6.22
Rate for Payer: Southwest Service Administrators UFCW	$48.28
Rate for Payer: TriWest Medicare	$11.36
Rate for Payer: United Healthcare Commercial	$40.61
Rate for Payer: United Healthcare Medicare	$11.36
Rate for Payer: Veterans Affairs TRICARE	$11.25

Prothrombin Time

Facility

$95.00

Service Code	CPT 85610
Hospital Charge Code	633793
Hospital Revenue Code	305
Min. Negotiated Rate	$6.22
Max. Negotiated Rate	$85.50
Rate for Payer: Aetna of AZ Commercial	$85.50
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Arizona Complete Health Allwell	$10.72
Rate for Payer: Arizona Complete Health Allwell	$15.20
Rate for Payer: Banner UC Health Medicare	$10.72
Rate for Payer: Banner UC Health Medicare	$15.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$64.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$45.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$15.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.20
Rate for Payer: Cash Price	$76.00
Rate for Payer: Cash Price	$53.60
Rate for Payer: Cash Price	$76.00
Rate for Payer: Cash Price	$53.60
Rate for Payer: Cigna of AZ Commercial	$61.75
Rate for Payer: Cigna of AZ Commercial	$43.55
Rate for Payer: Devoted Health Medicare	$17.10
Rate for Payer: Devoted Health Medicare	$12.06
Rate for Payer: Humana of AZ Medicare	$10.72
Rate for Payer: Humana of AZ Medicare	$15.20
Rate for Payer: Seven Corners Travel Insurance	$6.22
Rate for Payer: Seven Corners Travel Insurance	$6.22
Rate for Payer: Southwest Service Administrators UFCW	$45.56
Rate for Payer: Southwest Service Administrators UFCW	$64.60
Rate for Payer: TriWest Medicare	$10.72
Rate for Payer: TriWest Medicare	$15.20
Rate for Payer: United Healthcare Commercial	$54.34
Rate for Payer: United Healthcare Commercial	$38.32
Rate for Payer: United Healthcare Medicare	$10.72
Rate for Payer: United Healthcare Medicare	$15.20
Rate for Payer: Veterans Affairs TRICARE	$15.05
Rate for Payer: Veterans Affairs TRICARE	$10.61

Prothrombin Time

Facility

$67.00

Service Code	CPT 85610
Hospital Charge Code	633793
Hospital Revenue Code	305
Min. Negotiated Rate	$60.30
Max. Negotiated Rate	$60.30
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Aetna of AZ Commercial	$85.50
Rate for Payer: Cash Price	$53.60
Rate for Payer: Cash Price	$76.00

PROTIME

Facility

$71.00

Service Code	CPT 85610
Hospital Charge Code	22481498
Hospital Revenue Code	305
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Cash Price	$56.80

PROTIME

Facility

$71.00

Service Code	CPT 85610
Hospital Charge Code	22481498
Hospital Revenue Code	305
Min. Negotiated Rate	$6.22
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Arizona Complete Health Allwell	$11.36
Rate for Payer: Banner UC Health Medicare	$11.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$48.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.36
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cigna of AZ Commercial	$46.15
Rate for Payer: Devoted Health Medicare	$12.78
Rate for Payer: Humana of AZ Medicare	$11.36
Rate for Payer: Seven Corners Travel Insurance	$6.22
Rate for Payer: Southwest Service Administrators UFCW	$48.28
Rate for Payer: TriWest Medicare	$11.36
Rate for Payer: United Healthcare Commercial	$40.61
Rate for Payer: United Healthcare Medicare	$11.36
Rate for Payer: Veterans Affairs TRICARE	$11.25

Protime/PTT

Facility

$71.00

Service Code	CPT 85610
Hospital Charge Code	898512
Hospital Revenue Code	305
Min. Negotiated Rate	$6.22
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Arizona Complete Health Allwell	$11.36
Rate for Payer: Banner UC Health Medicare	$11.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$48.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.36
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cigna of AZ Commercial	$46.15
Rate for Payer: Devoted Health Medicare	$12.78
Rate for Payer: Humana of AZ Medicare	$11.36
Rate for Payer: Seven Corners Travel Insurance	$6.22
Rate for Payer: Southwest Service Administrators UFCW	$48.28
Rate for Payer: TriWest Medicare	$11.36
Rate for Payer: United Healthcare Commercial	$40.61
Rate for Payer: United Healthcare Medicare	$11.36
Rate for Payer: Veterans Affairs TRICARE	$11.25

Protime/PTT

Facility

$71.00

Service Code	CPT 85610
Hospital Charge Code	898512
Hospital Revenue Code	305
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Cash Price	$56.80

PSA Diagnostic.

Facility

$224.00

Service Code	CPT 84153
Hospital Charge Code	13095387
Hospital Revenue Code	301
Min. Negotiated Rate	$201.60
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of AZ Commercial	$201.60
Rate for Payer: Cash Price	$179.20

PSA Diagnostic.

Facility

$224.00

Service Code	CPT 84153
Hospital Charge Code	13095387
Hospital Revenue Code	301
Min. Negotiated Rate	$26.67
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of AZ Commercial	$201.60
Rate for Payer: Arizona Complete Health Allwell	$35.84
Rate for Payer: Banner UC Health Medicare	$35.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$152.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$35.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$35.84
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cigna of AZ Commercial	$145.60
Rate for Payer: Devoted Health Medicare	$40.32
Rate for Payer: Humana of AZ Medicare	$35.84
Rate for Payer: Seven Corners Travel Insurance	$26.67
Rate for Payer: Southwest Service Administrators UFCW	$152.32
Rate for Payer: TriWest Medicare	$35.84
Rate for Payer: United Healthcare Commercial	$128.13
Rate for Payer: United Healthcare Medicare	$35.84
Rate for Payer: Veterans Affairs TRICARE	$35.48

Know your out-of-pocket cost for care.

All Charges