Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

12032 REPAIR INTMD WND 2.6CM TO 7.5CM

Facility

$1,929.00

Service Code	CPT 12032
Hospital Charge Code	22282783
Hospital Revenue Code	450
Min. Negotiated Rate	$1,736.10
Max. Negotiated Rate	$1,736.10
Rate for Payer: Aetna of AZ Commercial	$1,736.10
Rate for Payer: Cash Price	$1,543.20

12034 REPAIR INTMD WND 7.6CM TO 12.5CM

Facility

$1,453.00

Service Code	CPT 12034
Hospital Charge Code	22282784
Hospital Revenue Code	450
Min. Negotiated Rate	$136.61
Max. Negotiated Rate	$1,307.70
Rate for Payer: Aetna of AZ Commercial	$1,307.70
Rate for Payer: Arizona Complete Health Allwell	$232.48
Rate for Payer: Banner UC Health Medicare	$232.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$988.04
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$136.61
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$232.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$232.48
Rate for Payer: Cash Price	$1,162.40
Rate for Payer: Cash Price	$1,162.40
Rate for Payer: Cigna of AZ Commercial	$1,017.10
Rate for Payer: Devoted Health Medicare	$261.54
Rate for Payer: Humana of AZ Medicare	$232.48
Rate for Payer: Mercy Care Medicaid	$136.61
Rate for Payer: NaphCare Correctional Healthcare	$136.61
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$988.04
Rate for Payer: TriWest Medicare	$232.48
Rate for Payer: United Healthcare Commercial	$831.12
Rate for Payer: United Healthcare Medicare	$232.48
Rate for Payer: United Healthcare New Mexico Commercial	$276.07
Rate for Payer: Veterans Affairs TRICARE	$230.16

12034 REPAIR INTMD WND 7.6CM TO 12.5CM

Facility

$1,453.00

Service Code	CPT 12034
Hospital Charge Code	22282784
Hospital Revenue Code	450
Min. Negotiated Rate	$1,307.70
Max. Negotiated Rate	$1,307.70
Rate for Payer: Aetna of AZ Commercial	$1,307.70
Rate for Payer: Cash Price	$1,162.40

12035 LYR SPL 12.6CM-20.0CM

Facility

$1,100.00

Service Code	CPT 12035
Hospital Charge Code	22282785
Hospital Revenue Code	450
Min. Negotiated Rate	$990.00
Max. Negotiated Rate	$990.00
Rate for Payer: Aetna of AZ Commercial	$990.00
Rate for Payer: Cash Price	$880.00

12035 LYR SPL 12.6CM-20.0CM

Facility

$1,100.00

Service Code	CPT 12035
Hospital Charge Code	22282785
Hospital Revenue Code	450
Min. Negotiated Rate	$155.92
Max. Negotiated Rate	$990.00
Rate for Payer: Aetna of AZ Commercial	$990.00
Rate for Payer: Arizona Complete Health Allwell	$176.00
Rate for Payer: Banner UC Health Medicare	$176.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$748.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$155.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$176.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$176.00
Rate for Payer: Cash Price	$880.00
Rate for Payer: Cash Price	$880.00
Rate for Payer: Cigna of AZ Commercial	$770.00
Rate for Payer: Devoted Health Medicare	$198.00
Rate for Payer: Humana of AZ Medicare	$176.00
Rate for Payer: Mercy Care Medicaid	$155.92
Rate for Payer: NaphCare Correctional Healthcare	$155.92
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$748.00
Rate for Payer: TriWest Medicare	$176.00
Rate for Payer: United Healthcare Commercial	$629.20
Rate for Payer: United Healthcare Medicare	$176.00
Rate for Payer: United Healthcare New Mexico Commercial	$209.00
Rate for Payer: Veterans Affairs TRICARE	$174.24

12036 LYR S/P AXL TNK 20.1-30

Facility

$1,348.00

Service Code	CPT 12036
Hospital Charge Code	22282786
Hospital Revenue Code	450
Min. Negotiated Rate	$1,213.20
Max. Negotiated Rate	$1,213.20
Rate for Payer: Aetna of AZ Commercial	$1,213.20
Rate for Payer: Cash Price	$1,078.40

12036 LYR S/P AXL TNK 20.1-30

Facility

$1,348.00

Service Code	CPT 12036
Hospital Charge Code	22282786
Hospital Revenue Code	450
Min. Negotiated Rate	$159.50
Max. Negotiated Rate	$1,213.20
Rate for Payer: Aetna of AZ Commercial	$1,213.20
Rate for Payer: Arizona Complete Health Allwell	$215.68
Rate for Payer: Banner UC Health Medicare	$215.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$916.64
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$159.50
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$215.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$215.68
Rate for Payer: Cash Price	$1,078.40
Rate for Payer: Cash Price	$1,078.40
Rate for Payer: Cigna of AZ Commercial	$943.60
Rate for Payer: Devoted Health Medicare	$242.64
Rate for Payer: Humana of AZ Medicare	$215.68
Rate for Payer: Mercy Care Medicaid	$159.50
Rate for Payer: NaphCare Correctional Healthcare	$159.50
Rate for Payer: Seven Corners Travel Insurance	$1,143.54
Rate for Payer: Southwest Service Administrators UFCW	$916.64
Rate for Payer: TriWest Medicare	$215.68
Rate for Payer: United Healthcare Commercial	$771.06
Rate for Payer: United Healthcare Medicare	$215.68
Rate for Payer: United Healthcare New Mexico Commercial	$256.12
Rate for Payer: Veterans Affairs TRICARE	$213.52

12037 LYR S/P AXL TNK>30

Facility

$1,600.00

Service Code	CPT 12037
Hospital Charge Code	22282787
Hospital Revenue Code	450
Min. Negotiated Rate	$1,440.00
Max. Negotiated Rate	$1,440.00
Rate for Payer: Aetna of AZ Commercial	$1,440.00
Rate for Payer: Cash Price	$1,280.00

12037 LYR S/P AXL TNK>30

Facility

$1,600.00

Service Code	CPT 12037
Hospital Charge Code	22282787
Hospital Revenue Code	450
Min. Negotiated Rate	$168.08
Max. Negotiated Rate	$3,192.45
Rate for Payer: Aetna of AZ Commercial	$1,440.00
Rate for Payer: Arizona Complete Health Allwell	$256.00
Rate for Payer: Banner UC Health Medicare	$256.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,088.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$168.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$256.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$256.00
Rate for Payer: Cash Price	$1,280.00
Rate for Payer: Cash Price	$1,280.00
Rate for Payer: Cigna of AZ Commercial	$1,120.00
Rate for Payer: Devoted Health Medicare	$288.00
Rate for Payer: Humana of AZ Medicare	$256.00
Rate for Payer: Mercy Care Medicaid	$168.08
Rate for Payer: NaphCare Correctional Healthcare	$168.08
Rate for Payer: Seven Corners Travel Insurance	$3,192.45
Rate for Payer: Southwest Service Administrators UFCW	$1,088.00
Rate for Payer: TriWest Medicare	$256.00
Rate for Payer: United Healthcare Commercial	$915.20
Rate for Payer: United Healthcare Medicare	$256.00
Rate for Payer: United Healthcare New Mexico Commercial	$304.00
Rate for Payer: Veterans Affairs TRICARE	$253.44

12041 LYR NK HND FT EXGEN 2.5

Facility

$896.00

Service Code	CPT 12041
Hospital Charge Code	22282788
Hospital Revenue Code	450
Min. Negotiated Rate	$124.81
Max. Negotiated Rate	$806.40
Rate for Payer: Aetna of AZ Commercial	$806.40
Rate for Payer: Arizona Complete Health Allwell	$143.36
Rate for Payer: Banner UC Health Medicare	$143.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$609.28
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$124.81
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$143.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$143.36
Rate for Payer: Cash Price	$716.80
Rate for Payer: Cash Price	$716.80
Rate for Payer: Cigna of AZ Commercial	$627.20
Rate for Payer: Devoted Health Medicare	$161.28
Rate for Payer: Humana of AZ Medicare	$143.36
Rate for Payer: Mercy Care Medicaid	$124.81
Rate for Payer: NaphCare Correctional Healthcare	$124.81
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$609.28
Rate for Payer: TriWest Medicare	$143.36
Rate for Payer: United Healthcare Commercial	$512.51
Rate for Payer: United Healthcare Medicare	$143.36
Rate for Payer: United Healthcare New Mexico Commercial	$170.24
Rate for Payer: Veterans Affairs TRICARE	$141.93

12041 LYR NK HND FT EXGEN 2.5

Facility

$896.00

Service Code	CPT 12041
Hospital Charge Code	22282788
Hospital Revenue Code	450
Min. Negotiated Rate	$806.40
Max. Negotiated Rate	$806.40
Rate for Payer: Aetna of AZ Commercial	$806.40
Rate for Payer: Cash Price	$716.80

12042 LR NK HD FT XGEN 2.6-7.5

Facility

$771.00

Service Code	CPT 12042
Hospital Charge Code	22282789
Hospital Revenue Code	450
Min. Negotiated Rate	$121.23
Max. Negotiated Rate	$693.90
Rate for Payer: Aetna of AZ Commercial	$693.90
Rate for Payer: Arizona Complete Health Allwell	$123.36
Rate for Payer: Banner UC Health Medicare	$123.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$524.28
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$121.23
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$123.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$123.36
Rate for Payer: Cash Price	$616.80
Rate for Payer: Cash Price	$616.80
Rate for Payer: Cigna of AZ Commercial	$539.70
Rate for Payer: Devoted Health Medicare	$138.78
Rate for Payer: Humana of AZ Medicare	$123.36
Rate for Payer: Mercy Care Medicaid	$121.23
Rate for Payer: NaphCare Correctional Healthcare	$121.23
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$524.28
Rate for Payer: TriWest Medicare	$123.36
Rate for Payer: United Healthcare Commercial	$441.01
Rate for Payer: United Healthcare Medicare	$123.36
Rate for Payer: United Healthcare New Mexico Commercial	$146.49
Rate for Payer: Veterans Affairs TRICARE	$122.13

12042 LR NK HD FT XGEN 2.6-7.5

Facility

$771.00

Service Code	CPT 12042
Hospital Charge Code	22282789
Hospital Revenue Code	450
Min. Negotiated Rate	$693.90
Max. Negotiated Rate	$693.90
Rate for Payer: Aetna of AZ Commercial	$693.90
Rate for Payer: Cash Price	$616.80

12044 LR NK HD FT XGN 7.5-12.5

Facility

$991.00

Service Code	CPT 12044
Hospital Charge Code	22282790
Hospital Revenue Code	450
Min. Negotiated Rate	$156.97
Max. Negotiated Rate	$1,143.54
Rate for Payer: Aetna of AZ Commercial	$891.90
Rate for Payer: Arizona Complete Health Allwell	$158.56
Rate for Payer: Banner UC Health Medicare	$158.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$673.88
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$177.74
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$158.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$158.56
Rate for Payer: Cash Price	$792.80
Rate for Payer: Cash Price	$792.80
Rate for Payer: Cigna of AZ Commercial	$693.70
Rate for Payer: Devoted Health Medicare	$178.38
Rate for Payer: Humana of AZ Medicare	$158.56
Rate for Payer: Mercy Care Medicaid	$177.74
Rate for Payer: NaphCare Correctional Healthcare	$177.74
Rate for Payer: Seven Corners Travel Insurance	$1,143.54
Rate for Payer: Southwest Service Administrators UFCW	$673.88
Rate for Payer: TriWest Medicare	$158.56
Rate for Payer: United Healthcare Commercial	$566.85
Rate for Payer: United Healthcare Medicare	$158.56
Rate for Payer: United Healthcare New Mexico Commercial	$188.29
Rate for Payer: Veterans Affairs TRICARE	$156.97

12044 LR NK HD FT XGN 7.5-12.5

Facility

$991.00

Service Code	CPT 12044
Hospital Charge Code	22282790
Hospital Revenue Code	450
Min. Negotiated Rate	$891.90
Max. Negotiated Rate	$891.90
Rate for Payer: Aetna of AZ Commercial	$891.90
Rate for Payer: Cash Price	$792.80

12045 LR NK HD FT XGN 12.5-20.

Facility

$1,179.00

Service Code	CPT 12045
Hospital Charge Code	22282791
Hospital Revenue Code	450
Min. Negotiated Rate	$147.34
Max. Negotiated Rate	$1,143.54
Rate for Payer: Aetna of AZ Commercial	$1,061.10
Rate for Payer: Arizona Complete Health Allwell	$188.64
Rate for Payer: Banner UC Health Medicare	$188.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$801.72
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$147.34
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$188.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$188.64
Rate for Payer: Cash Price	$943.20
Rate for Payer: Cash Price	$943.20
Rate for Payer: Cigna of AZ Commercial	$825.30
Rate for Payer: Devoted Health Medicare	$212.22
Rate for Payer: Humana of AZ Medicare	$188.64
Rate for Payer: Mercy Care Medicaid	$147.34
Rate for Payer: NaphCare Correctional Healthcare	$147.34
Rate for Payer: Seven Corners Travel Insurance	$1,143.54
Rate for Payer: Southwest Service Administrators UFCW	$801.72
Rate for Payer: TriWest Medicare	$188.64
Rate for Payer: United Healthcare Commercial	$674.39
Rate for Payer: United Healthcare Medicare	$188.64
Rate for Payer: United Healthcare New Mexico Commercial	$224.01
Rate for Payer: Veterans Affairs TRICARE	$186.75

12045 LR NK HD FT XGN 12.5-20.

Facility

$1,179.00

Service Code	CPT 12045
Hospital Charge Code	22282791
Hospital Revenue Code	450
Min. Negotiated Rate	$1,061.10
Max. Negotiated Rate	$1,061.10
Rate for Payer: Aetna of AZ Commercial	$1,061.10
Rate for Payer: Cash Price	$943.20

12046 LR NK HD FT XGN 20.-30.

Facility

$1,541.00

Service Code	CPT 12046
Hospital Charge Code	22282792
Hospital Revenue Code	450
Min. Negotiated Rate	$191.68
Max. Negotiated Rate	$1,386.90
Rate for Payer: Aetna of AZ Commercial	$1,386.90
Rate for Payer: Arizona Complete Health Allwell	$246.56
Rate for Payer: Banner UC Health Medicare	$246.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,047.88
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$191.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$246.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$246.56
Rate for Payer: Cash Price	$1,232.80
Rate for Payer: Cash Price	$1,232.80
Rate for Payer: Cigna of AZ Commercial	$1,078.70
Rate for Payer: Devoted Health Medicare	$277.38
Rate for Payer: Humana of AZ Medicare	$246.56
Rate for Payer: Mercy Care Medicaid	$191.68
Rate for Payer: NaphCare Correctional Healthcare	$191.68
Rate for Payer: Seven Corners Travel Insurance	$1,143.54
Rate for Payer: Southwest Service Administrators UFCW	$1,047.88
Rate for Payer: TriWest Medicare	$246.56
Rate for Payer: United Healthcare Commercial	$881.45
Rate for Payer: United Healthcare Medicare	$246.56
Rate for Payer: United Healthcare New Mexico Commercial	$292.79
Rate for Payer: Veterans Affairs TRICARE	$244.09

12046 LR NK HD FT XGN 20.-30.

Facility

$1,541.00

Service Code	CPT 12046
Hospital Charge Code	22282792
Hospital Revenue Code	450
Min. Negotiated Rate	$1,386.90
Max. Negotiated Rate	$1,386.90
Rate for Payer: Aetna of AZ Commercial	$1,386.90
Rate for Payer: Cash Price	$1,232.80

12047 LR NK HD FT XGN >30

Facility

$1,815.00

Service Code	CPT 12047
Hospital Charge Code	22282793
Hospital Revenue Code	450
Min. Negotiated Rate	$205.27
Max. Negotiated Rate	$3,192.45
Rate for Payer: Aetna of AZ Commercial	$1,633.50
Rate for Payer: Arizona Complete Health Allwell	$290.40
Rate for Payer: Banner UC Health Medicare	$290.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,234.20
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$205.27
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$290.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$290.40
Rate for Payer: Cash Price	$1,452.00
Rate for Payer: Cash Price	$1,452.00
Rate for Payer: Cigna of AZ Commercial	$1,270.50
Rate for Payer: Devoted Health Medicare	$326.70
Rate for Payer: Humana of AZ Medicare	$290.40
Rate for Payer: Mercy Care Medicaid	$205.27
Rate for Payer: NaphCare Correctional Healthcare	$205.27
Rate for Payer: Seven Corners Travel Insurance	$3,192.45
Rate for Payer: Southwest Service Administrators UFCW	$1,234.20
Rate for Payer: TriWest Medicare	$290.40
Rate for Payer: United Healthcare Commercial	$1,038.18
Rate for Payer: United Healthcare Medicare	$290.40
Rate for Payer: United Healthcare New Mexico Commercial	$344.85
Rate for Payer: Veterans Affairs TRICARE	$287.50

12047 LR NK HD FT XGN >30

Facility

$1,815.00

Service Code	CPT 12047
Hospital Charge Code	22282793
Hospital Revenue Code	450
Min. Negotiated Rate	$1,633.50
Max. Negotiated Rate	$1,633.50
Rate for Payer: Aetna of AZ Commercial	$1,633.50
Rate for Payer: Cash Price	$1,452.00

12051 LR FACE MUC MEMB 2.5

Facility

$707.00

Service Code	CPT 12051
Hospital Charge Code	22282794
Hospital Revenue Code	450
Min. Negotiated Rate	$636.30
Max. Negotiated Rate	$636.30
Rate for Payer: Aetna of AZ Commercial	$636.30
Rate for Payer: Cash Price	$565.60

12051 LR FACE MUC MEMB 2.5

Facility

$707.00

Service Code	CPT 12051
Hospital Charge Code	22282794
Hospital Revenue Code	450
Min. Negotiated Rate	$111.99
Max. Negotiated Rate	$636.30
Rate for Payer: Aetna of AZ Commercial	$636.30
Rate for Payer: Arizona Complete Health Allwell	$113.12
Rate for Payer: Banner UC Health Medicare	$113.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$480.76
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$120.51
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$113.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$113.12
Rate for Payer: Cash Price	$565.60
Rate for Payer: Cash Price	$565.60
Rate for Payer: Cigna of AZ Commercial	$494.90
Rate for Payer: Devoted Health Medicare	$127.26
Rate for Payer: Humana of AZ Medicare	$113.12
Rate for Payer: Mercy Care Medicaid	$120.51
Rate for Payer: NaphCare Correctional Healthcare	$120.51
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$480.76
Rate for Payer: TriWest Medicare	$113.12
Rate for Payer: United Healthcare Commercial	$404.40
Rate for Payer: United Healthcare Medicare	$113.12
Rate for Payer: United Healthcare New Mexico Commercial	$134.33
Rate for Payer: Veterans Affairs TRICARE	$111.99

12052 LR FACE MUC MEMB 2.6-5.0

Facility

$997.00

Service Code	CPT 12052
Hospital Charge Code	22282795
Hospital Revenue Code	450
Min. Negotiated Rate	$122.66
Max. Negotiated Rate	$897.30
Rate for Payer: Aetna of AZ Commercial	$897.30
Rate for Payer: Arizona Complete Health Allwell	$159.52
Rate for Payer: Banner UC Health Medicare	$159.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$677.96
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$122.66
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$159.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$159.52
Rate for Payer: Cash Price	$797.60
Rate for Payer: Cash Price	$797.60
Rate for Payer: Cigna of AZ Commercial	$697.90
Rate for Payer: Devoted Health Medicare	$179.46
Rate for Payer: Humana of AZ Medicare	$159.52
Rate for Payer: Mercy Care Medicaid	$122.66
Rate for Payer: NaphCare Correctional Healthcare	$122.66
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$677.96
Rate for Payer: TriWest Medicare	$159.52
Rate for Payer: United Healthcare Commercial	$570.28
Rate for Payer: United Healthcare Medicare	$159.52
Rate for Payer: United Healthcare New Mexico Commercial	$189.43
Rate for Payer: Veterans Affairs TRICARE	$157.92

12052 LR FACE MUC MEMB 2.6-5.0

Facility

$997.00

Service Code	CPT 12052
Hospital Charge Code	22282795
Hospital Revenue Code	450
Min. Negotiated Rate	$897.30
Max. Negotiated Rate	$897.30
Rate for Payer: Aetna of AZ Commercial	$897.30
Rate for Payer: Cash Price	$797.60

Know your out-of-pocket cost for care.

All Charges