Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

12053 LR FACE MUC MEMB 5.1-7.5

Facility

$990.00

Service Code	CPT 12053
Hospital Charge Code	22282796
Hospital Revenue Code	450
Min. Negotiated Rate	$891.00
Max. Negotiated Rate	$891.00
Rate for Payer: Aetna of AZ Commercial	$891.00
Rate for Payer: Cash Price	$792.00

12053 LR FACE MUC MEMB 5.1-7.5

Facility

$990.00

Service Code	CPT 12053
Hospital Charge Code	22282796
Hospital Revenue Code	450
Min. Negotiated Rate	$156.63
Max. Negotiated Rate	$891.00
Rate for Payer: Aetna of AZ Commercial	$891.00
Rate for Payer: Arizona Complete Health Allwell	$158.40
Rate for Payer: Banner UC Health Medicare	$158.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$673.20
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$156.63
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$158.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$158.40
Rate for Payer: Cash Price	$792.00
Rate for Payer: Cash Price	$792.00
Rate for Payer: Cigna of AZ Commercial	$693.00
Rate for Payer: Devoted Health Medicare	$178.20
Rate for Payer: Humana of AZ Medicare	$158.40
Rate for Payer: Mercy Care Medicaid	$156.63
Rate for Payer: NaphCare Correctional Healthcare	$156.63
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$673.20
Rate for Payer: TriWest Medicare	$158.40
Rate for Payer: United Healthcare Commercial	$566.28
Rate for Payer: United Healthcare Medicare	$158.40
Rate for Payer: United Healthcare New Mexico Commercial	$188.10
Rate for Payer: Veterans Affairs TRICARE	$156.82

12054 LR FACE MUC MEB 7.6-12.5

Facility

$1,245.00

Service Code	CPT 12054
Hospital Charge Code	22282797
Hospital Revenue Code	450
Min. Negotiated Rate	$171.66
Max. Negotiated Rate	$1,120.50
Rate for Payer: Aetna of AZ Commercial	$1,120.50
Rate for Payer: Arizona Complete Health Allwell	$199.20
Rate for Payer: Banner UC Health Medicare	$199.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$846.60
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$171.66
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$199.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$199.20
Rate for Payer: Cash Price	$996.00
Rate for Payer: Cash Price	$996.00
Rate for Payer: Cigna of AZ Commercial	$871.50
Rate for Payer: Devoted Health Medicare	$224.10
Rate for Payer: Humana of AZ Medicare	$199.20
Rate for Payer: Mercy Care Medicaid	$171.66
Rate for Payer: NaphCare Correctional Healthcare	$171.66
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$846.60
Rate for Payer: TriWest Medicare	$199.20
Rate for Payer: United Healthcare Commercial	$712.14
Rate for Payer: United Healthcare Medicare	$199.20
Rate for Payer: United Healthcare New Mexico Commercial	$236.55
Rate for Payer: Veterans Affairs TRICARE	$197.21

12054 LR FACE MUC MEB 7.6-12.5

Facility

$1,245.00

Service Code	CPT 12054
Hospital Charge Code	22282797
Hospital Revenue Code	450
Min. Negotiated Rate	$1,120.50
Max. Negotiated Rate	$1,120.50
Rate for Payer: Aetna of AZ Commercial	$1,120.50
Rate for Payer: Cash Price	$996.00

12055 LR FACE MUC MEN 12.6-20

Facility

$1,599.00

Service Code	CPT 12055
Hospital Charge Code	22282798
Hospital Revenue Code	450
Min. Negotiated Rate	$1,439.10
Max. Negotiated Rate	$1,439.10
Rate for Payer: Aetna of AZ Commercial	$1,439.10
Rate for Payer: Cash Price	$1,279.20

12055 LR FACE MUC MEN 12.6-20

Facility

$1,599.00

Service Code	CPT 12055
Hospital Charge Code	22282798
Hospital Revenue Code	450
Min. Negotiated Rate	$212.07
Max. Negotiated Rate	$1,439.10
Rate for Payer: Aetna of AZ Commercial	$1,439.10
Rate for Payer: Arizona Complete Health Allwell	$255.84
Rate for Payer: Banner UC Health Medicare	$255.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,087.32
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$212.07
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$255.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$255.84
Rate for Payer: Cash Price	$1,279.20
Rate for Payer: Cash Price	$1,279.20
Rate for Payer: Cigna of AZ Commercial	$1,119.30
Rate for Payer: Devoted Health Medicare	$287.82
Rate for Payer: Humana of AZ Medicare	$255.84
Rate for Payer: Mercy Care Medicaid	$212.07
Rate for Payer: NaphCare Correctional Healthcare	$212.07
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$1,087.32
Rate for Payer: TriWest Medicare	$255.84
Rate for Payer: United Healthcare Commercial	$914.63
Rate for Payer: United Healthcare Medicare	$255.84
Rate for Payer: United Healthcare New Mexico Commercial	$303.81
Rate for Payer: Veterans Affairs TRICARE	$253.28

12056 LR FACE MUC MEMB 20.1-30

Facility

$1,891.00

Service Code	CPT 12056
Hospital Charge Code	22282799
Hospital Revenue Code	450
Min. Negotiated Rate	$205.63
Max. Negotiated Rate	$1,701.90
Rate for Payer: Aetna of AZ Commercial	$1,701.90
Rate for Payer: Arizona Complete Health Allwell	$302.56
Rate for Payer: Banner UC Health Medicare	$302.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,285.88
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$205.63
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$302.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$302.56
Rate for Payer: Cash Price	$1,512.80
Rate for Payer: Cash Price	$1,512.80
Rate for Payer: Cigna of AZ Commercial	$1,323.70
Rate for Payer: Devoted Health Medicare	$340.38
Rate for Payer: Humana of AZ Medicare	$302.56
Rate for Payer: Mercy Care Medicaid	$205.63
Rate for Payer: NaphCare Correctional Healthcare	$205.63
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$1,285.88
Rate for Payer: TriWest Medicare	$302.56
Rate for Payer: United Healthcare Commercial	$1,081.65
Rate for Payer: United Healthcare Medicare	$302.56
Rate for Payer: United Healthcare New Mexico Commercial	$359.29
Rate for Payer: Veterans Affairs TRICARE	$299.53

12056 LR FACE MUC MEMB 20.1-30

Facility

$1,891.00

Service Code	CPT 12056
Hospital Charge Code	22282799
Hospital Revenue Code	450
Min. Negotiated Rate	$1,701.90
Max. Negotiated Rate	$1,701.90
Rate for Payer: Aetna of AZ Commercial	$1,701.90
Rate for Payer: Cash Price	$1,512.80

12057 LR FACE MUC MEM>30

Facility

$2,187.00

Service Code	CPT 12057
Hospital Charge Code	22282800
Hospital Revenue Code	450
Min. Negotiated Rate	$197.40
Max. Negotiated Rate	$1,968.30
Rate for Payer: Aetna of AZ Commercial	$1,968.30
Rate for Payer: Arizona Complete Health Allwell	$349.92
Rate for Payer: Banner UC Health Medicare	$349.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,487.16
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$197.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$349.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$349.92
Rate for Payer: Cash Price	$1,749.60
Rate for Payer: Cash Price	$1,749.60
Rate for Payer: Cigna of AZ Commercial	$1,530.90
Rate for Payer: Devoted Health Medicare	$393.66
Rate for Payer: Humana of AZ Medicare	$349.92
Rate for Payer: Mercy Care Medicaid	$197.40
Rate for Payer: NaphCare Correctional Healthcare	$197.40
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$1,487.16
Rate for Payer: TriWest Medicare	$349.92
Rate for Payer: United Healthcare Commercial	$1,250.96
Rate for Payer: United Healthcare Medicare	$349.92
Rate for Payer: United Healthcare New Mexico Commercial	$415.53
Rate for Payer: Veterans Affairs TRICARE	$346.42

12057 LR FACE MUC MEM>30

Facility

$2,187.00

Service Code	CPT 12057
Hospital Charge Code	22282800
Hospital Revenue Code	450
Min. Negotiated Rate	$1,968.30
Max. Negotiated Rate	$1,968.30
Rate for Payer: Aetna of AZ Commercial	$1,968.30
Rate for Payer: Cash Price	$1,749.60

12GA ANGIOCATH

Facility

$156.10

Hospital Charge Code	28200937
Hospital Revenue Code	270
Min. Negotiated Rate	$140.49
Max. Negotiated Rate	$140.49
Rate for Payer: Aetna of AZ Commercial	$140.49
Rate for Payer: Cash Price	$124.88

12GA ANGIOCATH

Facility

$156.10

Hospital Charge Code	28200937
Hospital Revenue Code	270
Min. Negotiated Rate	$24.73
Max. Negotiated Rate	$140.49
Rate for Payer: Aetna of AZ Commercial	$140.49
Rate for Payer: Arizona Complete Health Allwell	$24.98
Rate for Payer: Banner UC Health Medicare	$24.98
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$106.15
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$24.98
Rate for Payer: Care1st Health Plan Arizona Medicare	$24.98
Rate for Payer: Cash Price	$124.88
Rate for Payer: Cigna of AZ Commercial	$109.27
Rate for Payer: Devoted Health Medicare	$28.10
Rate for Payer: Humana of AZ Medicare	$24.98
Rate for Payer: Southwest Service Administrators UFCW	$106.15
Rate for Payer: TriWest Medicare	$24.98
Rate for Payer: United Healthcare Commercial	$89.29
Rate for Payer: United Healthcare Medicare	$24.98
Rate for Payer: Veterans Affairs TRICARE	$24.73

13100 RPRELX TRUNK 1.1CM-2.5CM

Facility

$891.00

Service Code	CPT 13100
Hospital Charge Code	22282801
Hospital Revenue Code	450
Min. Negotiated Rate	$141.13
Max. Negotiated Rate	$1,143.54
Rate for Payer: Aetna of AZ Commercial	$801.90
Rate for Payer: Arizona Complete Health Allwell	$142.56
Rate for Payer: Banner UC Health Medicare	$142.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$605.88
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$148.06
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$142.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$142.56
Rate for Payer: Cash Price	$712.80
Rate for Payer: Cash Price	$712.80
Rate for Payer: Cigna of AZ Commercial	$623.70
Rate for Payer: Devoted Health Medicare	$160.38
Rate for Payer: Humana of AZ Medicare	$142.56
Rate for Payer: Mercy Care Medicaid	$148.06
Rate for Payer: NaphCare Correctional Healthcare	$148.06
Rate for Payer: Seven Corners Travel Insurance	$1,143.54
Rate for Payer: Southwest Service Administrators UFCW	$605.88
Rate for Payer: TriWest Medicare	$142.56
Rate for Payer: United Healthcare Commercial	$509.65
Rate for Payer: United Healthcare Medicare	$142.56
Rate for Payer: United Healthcare New Mexico Commercial	$169.29
Rate for Payer: Veterans Affairs TRICARE	$141.13

13100 RPRELX TRUNK 1.1CM-2.5CM

Facility

$891.00

Service Code	CPT 13100
Hospital Charge Code	22282801
Hospital Revenue Code	450
Min. Negotiated Rate	$801.90
Max. Negotiated Rate	$801.90
Rate for Payer: Aetna of AZ Commercial	$801.90
Rate for Payer: Cash Price	$712.80

13101 RPRELX TRUNK 2.6CM-7.5CM

Facility

$1,140.00

Service Code	CPT 13101
Hospital Charge Code	22282802
Hospital Revenue Code	450
Min. Negotiated Rate	$1,026.00
Max. Negotiated Rate	$1,026.00
Rate for Payer: Aetna of AZ Commercial	$1,026.00
Rate for Payer: Cash Price	$912.00

13101 RPRELX TRUNK 2.6CM-7.5CM

Facility

$1,140.00

Service Code	CPT 13101
Hospital Charge Code	22282802
Hospital Revenue Code	450
Min. Negotiated Rate	$158.78
Max. Negotiated Rate	$1,143.54
Rate for Payer: Aetna of AZ Commercial	$1,026.00
Rate for Payer: Arizona Complete Health Allwell	$182.40
Rate for Payer: Banner UC Health Medicare	$182.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$775.20
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$158.78
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$182.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$182.40
Rate for Payer: Cash Price	$912.00
Rate for Payer: Cash Price	$912.00
Rate for Payer: Cigna of AZ Commercial	$798.00
Rate for Payer: Devoted Health Medicare	$205.20
Rate for Payer: Humana of AZ Medicare	$182.40
Rate for Payer: Mercy Care Medicaid	$158.78
Rate for Payer: NaphCare Correctional Healthcare	$158.78
Rate for Payer: Seven Corners Travel Insurance	$1,143.54
Rate for Payer: Southwest Service Administrators UFCW	$775.20
Rate for Payer: TriWest Medicare	$182.40
Rate for Payer: United Healthcare Commercial	$652.08
Rate for Payer: United Healthcare Medicare	$182.40
Rate for Payer: United Healthcare New Mexico Commercial	$216.60
Rate for Payer: Veterans Affairs TRICARE	$180.58

13102 REPAIR WOUND COMPLEX 5CM OR LESS

Facility

$516.00

Service Code	CPT 13102
Hospital Charge Code	22282803
Hospital Revenue Code	450
Min. Negotiated Rate	$47.57
Max. Negotiated Rate	$464.40
Rate for Payer: Aetna of AZ Commercial	$464.40
Rate for Payer: Arizona Complete Health Allwell	$82.56
Rate for Payer: Banner UC Health Medicare	$82.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$350.88
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$47.57
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$82.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$82.56
Rate for Payer: Cash Price	$412.80
Rate for Payer: Cash Price	$412.80
Rate for Payer: Cigna of AZ Commercial	$361.20
Rate for Payer: Devoted Health Medicare	$92.88
Rate for Payer: Humana of AZ Medicare	$82.56
Rate for Payer: Mercy Care Medicaid	$47.57
Rate for Payer: NaphCare Correctional Healthcare	$47.57
Rate for Payer: Southwest Service Administrators UFCW	$350.88
Rate for Payer: TriWest Medicare	$82.56
Rate for Payer: United Healthcare Commercial	$295.15
Rate for Payer: United Healthcare Medicare	$82.56
Rate for Payer: United Healthcare New Mexico Commercial	$98.04
Rate for Payer: Veterans Affairs TRICARE	$81.73

13102 REPAIR WOUND COMPLEX 5CM OR LESS

Facility

$516.00

Service Code	CPT 13102
Hospital Charge Code	22282803
Hospital Revenue Code	450
Min. Negotiated Rate	$464.40
Max. Negotiated Rate	$464.40
Rate for Payer: Aetna of AZ Commercial	$464.40
Rate for Payer: Cash Price	$412.80

13120 REPAIR COMPLEX WND 1.1CM TO 2.5

Facility

$1,528.00

Service Code	CPT 13120
Hospital Charge Code	22282804
Hospital Revenue Code	450
Min. Negotiated Rate	$130.88
Max. Negotiated Rate	$1,375.20
Rate for Payer: Aetna of AZ Commercial	$1,375.20
Rate for Payer: Arizona Complete Health Allwell	$244.48
Rate for Payer: Banner UC Health Medicare	$244.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,039.04
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$130.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$244.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$244.48
Rate for Payer: Cash Price	$1,222.40
Rate for Payer: Cash Price	$1,222.40
Rate for Payer: Cigna of AZ Commercial	$1,069.60
Rate for Payer: Devoted Health Medicare	$275.04
Rate for Payer: Humana of AZ Medicare	$244.48
Rate for Payer: Mercy Care Medicaid	$130.88
Rate for Payer: NaphCare Correctional Healthcare	$130.88
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$1,039.04
Rate for Payer: TriWest Medicare	$244.48
Rate for Payer: United Healthcare Commercial	$874.02
Rate for Payer: United Healthcare Medicare	$244.48
Rate for Payer: United Healthcare New Mexico Commercial	$290.32
Rate for Payer: Veterans Affairs TRICARE	$242.04

13120 REPAIR COMPLEX WND 1.1CM TO 2.5

Facility

$1,528.00

Service Code	CPT 13120
Hospital Charge Code	22282804
Hospital Revenue Code	450
Min. Negotiated Rate	$1,375.20
Max. Negotiated Rate	$1,375.20
Rate for Payer: Aetna of AZ Commercial	$1,375.20
Rate for Payer: Cash Price	$1,222.40

13121 REPAIR COMPLEX WND 2.6CM-7.5CM

Facility

$2,083.00

Service Code	CPT 13121
Hospital Charge Code	22282805
Hospital Revenue Code	450
Min. Negotiated Rate	$1,874.70
Max. Negotiated Rate	$1,874.70
Rate for Payer: Aetna of AZ Commercial	$1,874.70
Rate for Payer: Cash Price	$1,666.40

13121 REPAIR COMPLEX WND 2.6CM-7.5CM

Facility

$2,083.00

Service Code	CPT 13121
Hospital Charge Code	22282805
Hospital Revenue Code	450
Min. Negotiated Rate	$177.02
Max. Negotiated Rate	$1,874.70
Rate for Payer: Aetna of AZ Commercial	$1,874.70
Rate for Payer: Arizona Complete Health Allwell	$333.28
Rate for Payer: Banner UC Health Medicare	$333.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,416.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$177.02
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$333.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$333.28
Rate for Payer: Cash Price	$1,666.40
Rate for Payer: Cash Price	$1,666.40
Rate for Payer: Cigna of AZ Commercial	$1,458.10
Rate for Payer: Devoted Health Medicare	$374.94
Rate for Payer: Humana of AZ Medicare	$333.28
Rate for Payer: Mercy Care Medicaid	$177.02
Rate for Payer: NaphCare Correctional Healthcare	$177.02
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$1,416.44
Rate for Payer: TriWest Medicare	$333.28
Rate for Payer: United Healthcare Commercial	$1,191.48
Rate for Payer: United Healthcare Medicare	$333.28
Rate for Payer: United Healthcare New Mexico Commercial	$395.77
Rate for Payer: Veterans Affairs TRICARE	$329.95

13122 RPR WND EA ADDL 5CM

Facility

$432.00

Service Code	CPT 13122
Hospital Charge Code	22282806
Hospital Revenue Code	450
Min. Negotiated Rate	$388.80
Max. Negotiated Rate	$388.80
Rate for Payer: Aetna of AZ Commercial	$388.80
Rate for Payer: Cash Price	$345.60

13122 RPR WND EA ADDL 5CM

Facility

$432.00

Service Code	CPT 13122
Hospital Charge Code	22282806
Hospital Revenue Code	450
Min. Negotiated Rate	$46.85
Max. Negotiated Rate	$388.80
Rate for Payer: Aetna of AZ Commercial	$388.80
Rate for Payer: Arizona Complete Health Allwell	$69.12
Rate for Payer: Banner UC Health Medicare	$69.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$293.76
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$46.85
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$69.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$69.12
Rate for Payer: Cash Price	$345.60
Rate for Payer: Cash Price	$345.60
Rate for Payer: Cigna of AZ Commercial	$302.40
Rate for Payer: Devoted Health Medicare	$77.76
Rate for Payer: Humana of AZ Medicare	$69.12
Rate for Payer: Mercy Care Medicaid	$46.85
Rate for Payer: NaphCare Correctional Healthcare	$46.85
Rate for Payer: Southwest Service Administrators UFCW	$293.76
Rate for Payer: TriWest Medicare	$69.12
Rate for Payer: United Healthcare Commercial	$247.10
Rate for Payer: United Healthcare Medicare	$69.12
Rate for Payer: United Healthcare New Mexico Commercial	$82.08
Rate for Payer: Veterans Affairs TRICARE	$68.43

13131 RPCLX FRHD ETC 1.1-2.5CM

Facility

$1,109.00

Service Code	CPT 13131
Hospital Charge Code	22282807
Hospital Revenue Code	450
Min. Negotiated Rate	$998.10
Max. Negotiated Rate	$998.10
Rate for Payer: Aetna of AZ Commercial	$998.10
Rate for Payer: Cash Price	$887.20

Know your out-of-pocket cost for care.

All Charges