Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

16010 DSG/DBD WANES SMALL

Facility

$242.00

Service Code	CPT 16010
Hospital Charge Code	22282815
Hospital Revenue Code	450
Min. Negotiated Rate	$217.80
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Cash Price	$193.60

16010 DSG/DBD WANES SMALL

Facility

$242.00

Service Code	CPT 16010
Hospital Charge Code	22282815
Hospital Revenue Code	450
Min. Negotiated Rate	$38.33
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Arizona Complete Health Allwell	$38.72
Rate for Payer: Banner UC Health Medicare	$38.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$164.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.72
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cigna of AZ Commercial	$169.40
Rate for Payer: Devoted Health Medicare	$43.56
Rate for Payer: Humana of AZ Medicare	$38.72
Rate for Payer: Southwest Service Administrators UFCW	$164.56
Rate for Payer: TriWest Medicare	$38.72
Rate for Payer: United Healthcare Commercial	$138.42
Rate for Payer: United Healthcare Medicare	$38.72
Rate for Payer: United Healthcare New Mexico Commercial	$45.98
Rate for Payer: Veterans Affairs TRICARE	$38.33

16015 DSG/MJR DBRD W/ANES M/L

Facility

$816.00

Service Code	CPT 16015
Hospital Charge Code	22282816
Hospital Revenue Code	450
Min. Negotiated Rate	$734.40
Max. Negotiated Rate	$734.40
Rate for Payer: Aetna of AZ Commercial	$734.40
Rate for Payer: Cash Price	$652.80

16015 DSG/MJR DBRD W/ANES M/L

Facility

$816.00

Service Code	CPT 16015
Hospital Charge Code	22282816
Hospital Revenue Code	450
Min. Negotiated Rate	$129.25
Max. Negotiated Rate	$734.40
Rate for Payer: Aetna of AZ Commercial	$734.40
Rate for Payer: Arizona Complete Health Allwell	$130.56
Rate for Payer: Banner UC Health Medicare	$130.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$554.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$130.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$130.56
Rate for Payer: Cash Price	$652.80
Rate for Payer: Cigna of AZ Commercial	$571.20
Rate for Payer: Devoted Health Medicare	$146.88
Rate for Payer: Humana of AZ Medicare	$130.56
Rate for Payer: Southwest Service Administrators UFCW	$554.88
Rate for Payer: TriWest Medicare	$130.56
Rate for Payer: United Healthcare Commercial	$466.75
Rate for Payer: United Healthcare Medicare	$130.56
Rate for Payer: United Healthcare New Mexico Commercial	$155.04
Rate for Payer: Veterans Affairs TRICARE	$129.25

16020 DSG/DBD W/O ANES SM

Facility

$290.00

Service Code	CPT 16020
Hospital Charge Code	22282817
Hospital Revenue Code	450
Min. Negotiated Rate	$30.33
Max. Negotiated Rate	$310.43
Rate for Payer: Aetna of AZ Commercial	$261.00
Rate for Payer: Arizona Complete Health Allwell	$46.40
Rate for Payer: Banner UC Health Medicare	$46.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$197.20
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$30.33
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$46.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$46.40
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cigna of AZ Commercial	$203.00
Rate for Payer: Devoted Health Medicare	$52.20
Rate for Payer: Humana of AZ Medicare	$46.40
Rate for Payer: Mercy Care Medicaid	$30.33
Rate for Payer: NaphCare Correctional Healthcare	$30.33
Rate for Payer: Seven Corners Travel Insurance	$310.43
Rate for Payer: Southwest Service Administrators UFCW	$197.20
Rate for Payer: TriWest Medicare	$46.40
Rate for Payer: United Healthcare Commercial	$165.88
Rate for Payer: United Healthcare Medicare	$46.40
Rate for Payer: United Healthcare New Mexico Commercial	$55.10
Rate for Payer: Veterans Affairs TRICARE	$45.94

16020 DSG/DBD W/O ANES SM

Facility

$290.00

Service Code	CPT 16020
Hospital Charge Code	22282817
Hospital Revenue Code	450
Min. Negotiated Rate	$261.00
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna of AZ Commercial	$261.00
Rate for Payer: Cash Price	$232.00

16025 DSG/DBD W/O ANES MED

Facility

$490.00

Service Code	CPT 16025
Hospital Charge Code	22282818
Hospital Revenue Code	450
Min. Negotiated Rate	$46.37
Max. Negotiated Rate	$441.00
Rate for Payer: Aetna of AZ Commercial	$441.00
Rate for Payer: Arizona Complete Health Allwell	$78.40
Rate for Payer: Banner UC Health Medicare	$78.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$333.20
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$46.37
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$78.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$78.40
Rate for Payer: Cash Price	$392.00
Rate for Payer: Cash Price	$392.00
Rate for Payer: Cigna of AZ Commercial	$343.00
Rate for Payer: Devoted Health Medicare	$88.20
Rate for Payer: Humana of AZ Medicare	$78.40
Rate for Payer: Mercy Care Medicaid	$46.37
Rate for Payer: NaphCare Correctional Healthcare	$46.37
Rate for Payer: Seven Corners Travel Insurance	$310.43
Rate for Payer: Southwest Service Administrators UFCW	$333.20
Rate for Payer: TriWest Medicare	$78.40
Rate for Payer: United Healthcare Commercial	$280.28
Rate for Payer: United Healthcare Medicare	$78.40
Rate for Payer: United Healthcare New Mexico Commercial	$93.10
Rate for Payer: Veterans Affairs TRICARE	$77.62

16025 DSG/DBD W/O ANES MED

Facility

$490.00

Service Code	CPT 16025
Hospital Charge Code	22282818
Hospital Revenue Code	450
Min. Negotiated Rate	$441.00
Max. Negotiated Rate	$441.00
Rate for Payer: Aetna of AZ Commercial	$441.00
Rate for Payer: Cash Price	$392.00

16030 DSG/DBD W/O ANES LG

Facility

$600.00

Service Code	CPT 16030
Hospital Charge Code	22282819
Hospital Revenue Code	450
Min. Negotiated Rate	$540.00
Max. Negotiated Rate	$540.00
Rate for Payer: Aetna of AZ Commercial	$540.00
Rate for Payer: Cash Price	$480.00

16030 DSG/DBD W/O ANES LG

Facility

$600.00

Service Code	CPT 16030
Hospital Charge Code	22282819
Hospital Revenue Code	450
Min. Negotiated Rate	$67.64
Max. Negotiated Rate	$629.00
Rate for Payer: Aetna of AZ Commercial	$540.00
Rate for Payer: Arizona Complete Health Allwell	$96.00
Rate for Payer: Banner UC Health Medicare	$96.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$408.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$67.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$96.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$96.00
Rate for Payer: Cash Price	$480.00
Rate for Payer: Cash Price	$480.00
Rate for Payer: Cigna of AZ Commercial	$420.00
Rate for Payer: Devoted Health Medicare	$108.00
Rate for Payer: Humana of AZ Medicare	$96.00
Rate for Payer: Mercy Care Medicaid	$67.64
Rate for Payer: NaphCare Correctional Healthcare	$67.64
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$408.00
Rate for Payer: TriWest Medicare	$96.00
Rate for Payer: United Healthcare Commercial	$343.20
Rate for Payer: United Healthcare Medicare	$96.00
Rate for Payer: United Healthcare New Mexico Commercial	$114.00
Rate for Payer: Veterans Affairs TRICARE	$95.04

165MM SUCTION SLEEVE

Facility

$190.00

Hospital Charge Code	27773154
Hospital Revenue Code	270
Min. Negotiated Rate	$171.00
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna of AZ Commercial	$171.00
Rate for Payer: Cash Price	$152.00

165MM SUCTION SLEEVE

Facility

$190.00

Hospital Charge Code	27773154
Hospital Revenue Code	270
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna of AZ Commercial	$171.00
Rate for Payer: Arizona Complete Health Allwell	$30.40
Rate for Payer: Banner UC Health Medicare	$30.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$129.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$30.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$30.40
Rate for Payer: Cash Price	$152.00
Rate for Payer: Cigna of AZ Commercial	$133.00
Rate for Payer: Devoted Health Medicare	$34.20
Rate for Payer: Humana of AZ Medicare	$30.40
Rate for Payer: Southwest Service Administrators UFCW	$129.20
Rate for Payer: TriWest Medicare	$30.40
Rate for Payer: United Healthcare Commercial	$108.68
Rate for Payer: United Healthcare Medicare	$30.40
Rate for Payer: Veterans Affairs TRICARE	$30.10

1.6MM K WIRE

Facility

$69.00

Hospital Charge Code	22354195
Hospital Revenue Code	270
Min. Negotiated Rate	$10.93
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Arizona Complete Health Allwell	$11.04
Rate for Payer: Banner UC Health Medicare	$11.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$46.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.04
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cigna of AZ Commercial	$48.30
Rate for Payer: Devoted Health Medicare	$12.42
Rate for Payer: Humana of AZ Medicare	$11.04
Rate for Payer: Southwest Service Administrators UFCW	$46.92
Rate for Payer: TriWest Medicare	$11.04
Rate for Payer: United Healthcare Commercial	$39.47
Rate for Payer: United Healthcare Medicare	$11.04
Rate for Payer: Veterans Affairs TRICARE	$10.93

1.6MM K WIRE

Facility

$69.00

Hospital Charge Code	22354195
Hospital Revenue Code	270
Min. Negotiated Rate	$62.10
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Cash Price	$55.20

1 6MM TAPER SIDE CUTTING CARBIDE BUR

Facility

$56.00

Hospital Charge Code	27433627
Hospital Revenue Code	270
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$50.40
Rate for Payer: Aetna of AZ Commercial	$50.40
Rate for Payer: Cash Price	$44.80

1 6MM TAPER SIDE CUTTING CARBIDE BUR

Facility

$56.00

Hospital Charge Code	27433627
Hospital Revenue Code	270
Min. Negotiated Rate	$8.87
Max. Negotiated Rate	$50.40
Rate for Payer: Aetna of AZ Commercial	$50.40
Rate for Payer: Arizona Complete Health Allwell	$8.96
Rate for Payer: Banner UC Health Medicare	$8.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$38.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.96
Rate for Payer: Cash Price	$44.80
Rate for Payer: Cigna of AZ Commercial	$39.20
Rate for Payer: Devoted Health Medicare	$10.08
Rate for Payer: Humana of AZ Medicare	$8.96
Rate for Payer: Southwest Service Administrators UFCW	$38.08
Rate for Payer: TriWest Medicare	$8.96
Rate for Payer: United Healthcare Commercial	$32.03
Rate for Payer: United Healthcare Medicare	$8.96
Rate for Payer: Veterans Affairs TRICARE	$8.87

17003 DESTRUCT LES 2-14 EA ADL

Facility

$53.00

Service Code	CPT 17003
Hospital Charge Code	12047454
Hospital Revenue Code	521
Min. Negotiated Rate	$47.70
Max. Negotiated Rate	$47.70
Rate for Payer: Aetna of AZ Commercial	$47.70
Rate for Payer: Cash Price	$42.40

17003 DESTRUCT LES 2-14 EA ADL

Facility

$53.00

Service Code	CPT 17003
Hospital Charge Code	12047454
Hospital Revenue Code	521
Min. Negotiated Rate	$4.88
Max. Negotiated Rate	$47.70
Rate for Payer: Aetna of AZ Commercial	$47.70
Rate for Payer: Arizona Complete Health Allwell	$8.48
Rate for Payer: Banner UC Health Medicare	$8.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$36.04
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$4.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.48
Rate for Payer: Cash Price	$42.40
Rate for Payer: Cash Price	$42.40
Rate for Payer: Cigna of AZ Commercial	$37.10
Rate for Payer: Devoted Health Medicare	$9.54
Rate for Payer: Humana of AZ Medicare	$8.48
Rate for Payer: Mercy Care Medicaid	$4.88
Rate for Payer: NaphCare Correctional Healthcare	$4.88
Rate for Payer: Southwest Service Administrators UFCW	$36.04
Rate for Payer: TriWest Medicare	$8.48
Rate for Payer: United Healthcare Commercial	$30.32
Rate for Payer: United Healthcare Medicare	$8.48
Rate for Payer: Veterans Affairs TRICARE	$8.40

17110 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSU

Facility

$439.00

Service Code	CPT 17110
Hospital Charge Code	24063183
Hospital Revenue Code	521
Min. Negotiated Rate	$395.10
Max. Negotiated Rate	$395.10
Rate for Payer: Aetna of AZ Commercial	$395.10
Rate for Payer: Cash Price	$351.20

17110 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSU

Facility

$439.00

Service Code	CPT 17110
Hospital Charge Code	24063183
Hospital Revenue Code	521
Min. Negotiated Rate	$47.20
Max. Negotiated Rate	$395.10
Rate for Payer: Aetna of AZ Commercial	$395.10
Rate for Payer: Arizona Complete Health Allwell	$70.24
Rate for Payer: Banner UC Health Medicare	$70.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$298.52
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$47.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$70.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$70.24
Rate for Payer: Cash Price	$351.20
Rate for Payer: Cash Price	$351.20
Rate for Payer: Cigna of AZ Commercial	$307.30
Rate for Payer: Devoted Health Medicare	$79.02
Rate for Payer: Humana of AZ Medicare	$70.24
Rate for Payer: Mercy Care Medicaid	$47.20
Rate for Payer: NaphCare Correctional Healthcare	$47.20
Rate for Payer: Seven Corners Travel Insurance	$310.43
Rate for Payer: Southwest Service Administrators UFCW	$298.52
Rate for Payer: TriWest Medicare	$70.24
Rate for Payer: United Healthcare Commercial	$251.11
Rate for Payer: United Healthcare Medicare	$70.24
Rate for Payer: Veterans Affairs TRICARE	$69.54

17111 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSU

Facility

$513.00

Service Code	CPT 17111
Hospital Charge Code	24063184
Hospital Revenue Code	521
Min. Negotiated Rate	$52.22
Max. Negotiated Rate	$461.70
Rate for Payer: Aetna of AZ Commercial	$461.70
Rate for Payer: Arizona Complete Health Allwell	$82.08
Rate for Payer: Banner UC Health Medicare	$82.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$348.84
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$52.22
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$82.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$82.08
Rate for Payer: Cash Price	$410.40
Rate for Payer: Cash Price	$410.40
Rate for Payer: Cigna of AZ Commercial	$359.10
Rate for Payer: Devoted Health Medicare	$92.34
Rate for Payer: Humana of AZ Medicare	$82.08
Rate for Payer: Mercy Care Medicaid	$52.22
Rate for Payer: NaphCare Correctional Healthcare	$52.22
Rate for Payer: Seven Corners Travel Insurance	$310.43
Rate for Payer: Southwest Service Administrators UFCW	$348.84
Rate for Payer: TriWest Medicare	$82.08
Rate for Payer: United Healthcare Commercial	$293.44
Rate for Payer: United Healthcare Medicare	$82.08
Rate for Payer: Veterans Affairs TRICARE	$81.26

17111 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSU

Facility

$513.00

Service Code	CPT 17111
Hospital Charge Code	24063184
Hospital Revenue Code	521
Min. Negotiated Rate	$461.70
Max. Negotiated Rate	$461.70
Rate for Payer: Aetna of AZ Commercial	$461.70
Rate for Payer: Cash Price	$410.40

17-Hydroxypregnenolone MS LC

Facility

$270.00

Service Code	CPT 84143
Hospital Charge Code	6780894
Hospital Revenue Code	301
Min. Negotiated Rate	$33.07
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	$33.07
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

17-Hydroxypregnenolone MS LC

Facility

$270.00

Service Code	CPT 84143
Hospital Charge Code	6780894
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

17-OH Progesterone LC

Facility

$441.00

Service Code	CPT 83498
Hospital Charge Code	6738679
Hospital Revenue Code	301
Min. Negotiated Rate	$396.90
Max. Negotiated Rate	$396.90
Rate for Payer: Aetna of AZ Commercial	$396.90
Rate for Payer: Cash Price	$352.80

Know your out-of-pocket cost for care.

All Charges