Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

RED BLOOD CELL DISORDERS WITHOUT MCC

Facility

$11,990.11

Service Code	MSDRG 812
Min. Negotiated Rate	$11,990.11
Max. Negotiated Rate	$11,990.11
Rate for Payer: Seven Corners Travel Insurance	$11,990.11

REDUCTION OF TORSION OF TESTIS, SURGICAL, WITH OR WITHOUT FI

Facility

$2,343.00

Service Code	CPT 54600
Hospital Charge Code	28259372
Hospital Revenue Code	360
Min. Negotiated Rate	$371.13
Max. Negotiated Rate	$5,454.10
Rate for Payer: Aetna of AZ Commercial	$2,108.70
Rate for Payer: Arizona Complete Health Allwell	$374.88
Rate for Payer: Banner UC Health Medicare	$1,171.31
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,593.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$374.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$374.88
Rate for Payer: Cash Price	$1,874.40
Rate for Payer: Cash Price	$1,874.40
Rate for Payer: Cash Price	$1,874.40
Rate for Payer: Cigna of AZ Commercial	$1,171.50
Rate for Payer: Devoted Health Medicare	$421.74
Rate for Payer: Humana of AZ Medicare	$374.88
Rate for Payer: NaphCare Correctional Healthcare	$1,171.31
Rate for Payer: Seven Corners Travel Insurance	$5,454.10
Rate for Payer: Southwest Service Administrators UFCW	$1,593.24
Rate for Payer: TriWest Medicare	$374.88
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$374.88
Rate for Payer: Veterans Affairs TRICARE	$371.13

REDUCTION OF TORSION OF TESTIS, SURGICAL, WITH OR WITHOUT FI

Facility

$2,343.00

Service Code	CPT 54600
Hospital Charge Code	28259372
Hospital Revenue Code	360
Min. Negotiated Rate	$2,108.70
Max. Negotiated Rate	$2,108.70
Rate for Payer: Aetna of AZ Commercial	$2,108.70
Rate for Payer: Cash Price	$1,874.40

REF Ab Titer

Facility

$107.00

Service Code	CPT 86886
Hospital Charge Code	22248796
Hospital Revenue Code	302
Min. Negotiated Rate	$96.30
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Cash Price	$85.60

REF Ab Titer

Facility

$107.00

Service Code	CPT 86886
Hospital Charge Code	22248796
Hospital Revenue Code	302
Min. Negotiated Rate	$7.51
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Arizona Complete Health Allwell	$17.12
Rate for Payer: Banner UC Health Medicare	$17.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$72.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.12
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cigna of AZ Commercial	$69.55
Rate for Payer: Devoted Health Medicare	$19.26
Rate for Payer: Humana of AZ Medicare	$17.12
Rate for Payer: Seven Corners Travel Insurance	$7.51
Rate for Payer: Southwest Service Administrators UFCW	$72.76
Rate for Payer: TriWest Medicare	$17.12
Rate for Payer: United Healthcare Commercial	$61.20
Rate for Payer: United Healthcare Medicare	$17.12
Rate for Payer: Veterans Affairs TRICARE	$16.95

REF BB ANTIBODY ID ADDT'L AB

Facility

$249.00

Service Code	CPT 86870
Hospital Charge Code	22373731
Hospital Revenue Code	302
Min. Negotiated Rate	$224.10
Max. Negotiated Rate	$224.10
Rate for Payer: Aetna of AZ Commercial	$224.10
Rate for Payer: Cash Price	$199.20

REF BB ANTIBODY ID ADDT'L AB

Facility

$249.00

Service Code	CPT 86870
Hospital Charge Code	22373731
Hospital Revenue Code	302
Min. Negotiated Rate	$39.44
Max. Negotiated Rate	$554.61
Rate for Payer: Aetna of AZ Commercial	$224.10
Rate for Payer: Arizona Complete Health Allwell	$39.84
Rate for Payer: Banner UC Health Medicare	$39.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$169.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$39.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$39.84
Rate for Payer: Cash Price	$199.20
Rate for Payer: Cash Price	$199.20
Rate for Payer: Cigna of AZ Commercial	$161.85
Rate for Payer: Devoted Health Medicare	$44.82
Rate for Payer: Humana of AZ Medicare	$39.84
Rate for Payer: Seven Corners Travel Insurance	$554.61
Rate for Payer: Southwest Service Administrators UFCW	$169.32
Rate for Payer: TriWest Medicare	$39.84
Rate for Payer: United Healthcare Commercial	$142.43
Rate for Payer: United Healthcare Medicare	$39.84
Rate for Payer: Veterans Affairs TRICARE	$39.44

REF DAT

Facility

$237.00

Service Code	CPT 86880
Hospital Charge Code	5562972
Hospital Revenue Code	302
Min. Negotiated Rate	$213.30
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Cash Price	$189.60

REF DAT

Facility

$237.00

Service Code	CPT 86880
Hospital Charge Code	5562972
Hospital Revenue Code	302
Min. Negotiated Rate	$7.82
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Arizona Complete Health Allwell	$37.92
Rate for Payer: Banner UC Health Medicare	$37.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$161.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$37.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.92
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cigna of AZ Commercial	$154.05
Rate for Payer: Devoted Health Medicare	$42.66
Rate for Payer: Humana of AZ Medicare	$37.92
Rate for Payer: Seven Corners Travel Insurance	$7.82
Rate for Payer: Southwest Service Administrators UFCW	$161.16
Rate for Payer: TriWest Medicare	$37.92
Rate for Payer: United Healthcare Commercial	$135.56
Rate for Payer: United Healthcare Medicare	$37.92
Rate for Payer: Veterans Affairs TRICARE	$37.54

Reference ABID

Facility

$1,022.00

Service Code	CPT 86870
Hospital Charge Code	1165545
Hospital Revenue Code	302
Min. Negotiated Rate	$161.88
Max. Negotiated Rate	$919.80
Rate for Payer: Aetna of AZ Commercial	$919.80
Rate for Payer: Arizona Complete Health Allwell	$163.52
Rate for Payer: Banner UC Health Medicare	$163.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$694.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$163.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$163.52
Rate for Payer: Cash Price	$817.60
Rate for Payer: Cash Price	$817.60
Rate for Payer: Cigna of AZ Commercial	$664.30
Rate for Payer: Devoted Health Medicare	$183.96
Rate for Payer: Humana of AZ Medicare	$163.52
Rate for Payer: Seven Corners Travel Insurance	$554.61
Rate for Payer: Southwest Service Administrators UFCW	$694.96
Rate for Payer: TriWest Medicare	$163.52
Rate for Payer: United Healthcare Commercial	$584.58
Rate for Payer: United Healthcare Medicare	$163.52
Rate for Payer: Veterans Affairs TRICARE	$161.88

Reference ABID

Facility

$1,022.00

Service Code	CPT 86870
Hospital Charge Code	1165545
Hospital Revenue Code	302
Min. Negotiated Rate	$919.80
Max. Negotiated Rate	$919.80
Rate for Payer: Aetna of AZ Commercial	$919.80
Rate for Payer: Cash Price	$817.60

Reference Elution

Facility

$112.00

Service Code	CPT 86976
Hospital Charge Code	1165547
Hospital Revenue Code	302
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of AZ Commercial	$100.80
Rate for Payer: Cash Price	$89.60

Reference Elution

Facility

$112.00

Service Code	CPT 86976
Hospital Charge Code	1165547
Hospital Revenue Code	302
Min. Negotiated Rate	$17.74
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of AZ Commercial	$100.80
Rate for Payer: Arizona Complete Health Allwell	$17.92
Rate for Payer: Banner UC Health Medicare	$17.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$76.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.92
Rate for Payer: Cash Price	$89.60
Rate for Payer: Cash Price	$89.60
Rate for Payer: Cigna of AZ Commercial	$72.80
Rate for Payer: Devoted Health Medicare	$20.16
Rate for Payer: Humana of AZ Medicare	$17.92
Rate for Payer: Seven Corners Travel Insurance	$44.75
Rate for Payer: Southwest Service Administrators UFCW	$76.16
Rate for Payer: TriWest Medicare	$17.92
Rate for Payer: United Healthcare Commercial	$64.06
Rate for Payer: United Healthcare Medicare	$17.92
Rate for Payer: Veterans Affairs TRICARE	$17.74

Reference Elution

Facility

$107.00

Service Code	CPT 86976
Hospital Charge Code	2192233
Hospital Revenue Code	302
Min. Negotiated Rate	$16.95
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Arizona Complete Health Allwell	$17.12
Rate for Payer: Banner UC Health Medicare	$17.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$72.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.12
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cigna of AZ Commercial	$69.55
Rate for Payer: Devoted Health Medicare	$19.26
Rate for Payer: Humana of AZ Medicare	$17.12
Rate for Payer: Seven Corners Travel Insurance	$44.75
Rate for Payer: Southwest Service Administrators UFCW	$72.76
Rate for Payer: TriWest Medicare	$17.12
Rate for Payer: United Healthcare Commercial	$61.20
Rate for Payer: United Healthcare Medicare	$17.12
Rate for Payer: Veterans Affairs TRICARE	$16.95

Reference Elution

Facility

$107.00

Service Code	CPT 86976
Hospital Charge Code	2192233
Hospital Revenue Code	302
Min. Negotiated Rate	$96.30
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Cash Price	$85.60

.Reflex to GenoSure(R) MG LC

Facility

$1,502.00

Service Code	CPT 87901
Hospital Charge Code	22311165
Hospital Revenue Code	306
Min. Negotiated Rate	$1,351.80
Max. Negotiated Rate	$1,351.80
Rate for Payer: Aetna of AZ Commercial	$1,351.80
Rate for Payer: Cash Price	$1,201.60

.Reflex to GenoSure(R) MG LC

Facility

$1,502.00

Service Code	CPT 87901
Hospital Charge Code	22311165
Hospital Revenue Code	306
Min. Negotiated Rate	$237.92
Max. Negotiated Rate	$1,351.80
Rate for Payer: Aetna of AZ Commercial	$1,351.80
Rate for Payer: Arizona Complete Health Allwell	$240.32
Rate for Payer: Banner UC Health Medicare	$240.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,021.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$240.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$240.32
Rate for Payer: Cash Price	$1,201.60
Rate for Payer: Cash Price	$1,201.60
Rate for Payer: Cigna of AZ Commercial	$976.30
Rate for Payer: Devoted Health Medicare	$270.36
Rate for Payer: Humana of AZ Medicare	$240.32
Rate for Payer: Seven Corners Travel Insurance	$373.30
Rate for Payer: Southwest Service Administrators UFCW	$1,021.36
Rate for Payer: TriWest Medicare	$240.32
Rate for Payer: United Healthcare Commercial	$859.14
Rate for Payer: United Healthcare Medicare	$240.32
Rate for Payer: Veterans Affairs TRICARE	$237.92

REF RBC OTHER THAN ABO

Facility

$237.00

Service Code	CPT 86905
Hospital Charge Code	22373722
Hospital Revenue Code	302
Min. Negotiated Rate	$5.55
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Arizona Complete Health Allwell	$37.92
Rate for Payer: Banner UC Health Medicare	$37.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$161.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$37.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.92
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cigna of AZ Commercial	$154.05
Rate for Payer: Devoted Health Medicare	$42.66
Rate for Payer: Humana of AZ Medicare	$37.92
Rate for Payer: Seven Corners Travel Insurance	$5.55
Rate for Payer: Southwest Service Administrators UFCW	$161.16
Rate for Payer: TriWest Medicare	$37.92
Rate for Payer: United Healthcare Commercial	$135.56
Rate for Payer: United Healthcare Medicare	$37.92
Rate for Payer: Veterans Affairs TRICARE	$37.54

REF RBC OTHER THAN ABO

Facility

$237.00

Service Code	CPT 86905
Hospital Charge Code	22373722
Hospital Revenue Code	302
Min. Negotiated Rate	$213.30
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Cash Price	$189.60

REF RBC PHENOTYPING

Facility

$249.00

Service Code	CPT 86906
Hospital Charge Code	1676008
Hospital Revenue Code	302
Min. Negotiated Rate	$11.24
Max. Negotiated Rate	$224.10
Rate for Payer: Aetna of AZ Commercial	$224.10
Rate for Payer: Arizona Complete Health Allwell	$39.84
Rate for Payer: Banner UC Health Medicare	$39.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$169.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$39.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$39.84
Rate for Payer: Cash Price	$199.20
Rate for Payer: Cash Price	$199.20
Rate for Payer: Cigna of AZ Commercial	$161.85
Rate for Payer: Devoted Health Medicare	$44.82
Rate for Payer: Humana of AZ Medicare	$39.84
Rate for Payer: Seven Corners Travel Insurance	$11.24
Rate for Payer: Southwest Service Administrators UFCW	$169.32
Rate for Payer: TriWest Medicare	$39.84
Rate for Payer: United Healthcare Commercial	$142.43
Rate for Payer: United Healthcare Medicare	$39.84
Rate for Payer: Veterans Affairs TRICARE	$39.44

REF RBC PHENOTYPING

Facility

$249.00

Service Code	CPT 86906
Hospital Charge Code	1676008
Hospital Revenue Code	302
Min. Negotiated Rate	$224.10
Max. Negotiated Rate	$224.10
Rate for Payer: Aetna of AZ Commercial	$224.10
Rate for Payer: Cash Price	$199.20

Rehabilitation

Facility

$7,453.78

Service Code	APR-DRG 8601
Hospital Charge Code	APRDRG8602
Min. Negotiated Rate	$7,453.78
Max. Negotiated Rate	$7,453.78
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$7,453.78
Rate for Payer: Mercy Care Medicaid	$7,453.78
Rate for Payer: NaphCare Correctional Healthcare	$7,453.78

Rehabilitation

Facility

$9,792.25

Service Code	APR-DRG 8602
Hospital Charge Code	APRDRG8604
Min. Negotiated Rate	$9,792.25
Max. Negotiated Rate	$9,792.25
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$9,792.25
Rate for Payer: Mercy Care Medicaid	$9,792.25
Rate for Payer: NaphCare Correctional Healthcare	$9,792.25

Rehabilitation

Facility

$15,792.02

Service Code	APR-DRG 8604
Hospital Charge Code	APRDRG8603
Min. Negotiated Rate	$15,792.02
Max. Negotiated Rate	$15,792.02
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$15,792.02
Rate for Payer: Mercy Care Medicaid	$15,792.02
Rate for Payer: NaphCare Correctional Healthcare	$15,792.02

Rehabilitation

Facility

$12,529.81

Service Code	APR-DRG 8603
Hospital Charge Code	APRDRG8603
Min. Negotiated Rate	$12,529.81
Max. Negotiated Rate	$12,529.81
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$12,529.81
Rate for Payer: Mercy Care Medicaid	$12,529.81
Rate for Payer: NaphCare Correctional Healthcare	$12,529.81

Know your out-of-pocket cost for care.

All Charges