Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Colonoscopy Flexible with Endoscopic Mucosal Resection

Facility

$1,415.00

Service Code	CPT 45390
Hospital Charge Code	23742111
Min. Negotiated Rate	$1,273.50
Max. Negotiated Rate	$1,273.50
Rate for Payer: Aetna of AZ Commercial	$1,273.50
Rate for Payer: Cash Price	$1,132.00

Colonoscopy Flexible with Endoscopic Mucosal Resection

Facility

$1,415.00

Service Code	CPT 45390
Hospital Charge Code	23742111
Min. Negotiated Rate	$224.14
Max. Negotiated Rate	$4,294.70
Rate for Payer: Aetna of AZ Commercial	$1,273.50
Rate for Payer: Arizona Complete Health Allwell	$226.40
Rate for Payer: Banner UC Health Medicare	$226.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$962.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$226.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$226.40
Rate for Payer: Cash Price	$1,132.00
Rate for Payer: Cash Price	$1,132.00
Rate for Payer: Cigna of AZ Commercial	$990.50
Rate for Payer: Devoted Health Medicare	$254.70
Rate for Payer: Humana of AZ Medicare	$226.40
Rate for Payer: Seven Corners Travel Insurance	$4,294.70
Rate for Payer: Southwest Service Administrators UFCW	$962.20
Rate for Payer: TriWest Medicare	$226.40
Rate for Payer: United Healthcare Commercial	$809.38
Rate for Payer: United Healthcare Medicare	$226.40
Rate for Payer: Veterans Affairs TRICARE	$224.14

Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

Facility

$3,596.00

Service Code	CPT 45385
Hospital Revenue Code	360
Min. Negotiated Rate	$202.23
Max. Negotiated Rate	$3,596.00
Rate for Payer: Banner UC Health Medicare	$383.41
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$202.23
Rate for Payer: Mercy Care Medicaid	$202.23
Rate for Payer: NaphCare Correctional Healthcare	$383.41
Rate for Payer: Seven Corners Travel Insurance	$1,851.53
Rate for Payer: United Healthcare Commercial	$3,596.00

Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

Facility

$3,596.00

Service Code	CPT 45385
Hospital Revenue Code	750
Min. Negotiated Rate	$202.23
Max. Negotiated Rate	$3,596.00
Rate for Payer: Banner UC Health Medicare	$383.41
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$202.23
Rate for Payer: Mercy Care Medicaid	$202.23
Rate for Payer: NaphCare Correctional Healthcare	$383.41
Rate for Payer: Seven Corners Travel Insurance	$1,851.53
Rate for Payer: United Healthcare Commercial	$3,596.00

Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

Facility

$3,596.00

Service Code	CPT 44388
Hospital Revenue Code	750
Min. Negotiated Rate	$162.83
Max. Negotiated Rate	$3,596.00
Rate for Payer: Banner UC Health Medicare	$297.60
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$162.83
Rate for Payer: Mercy Care Medicaid	$162.83
Rate for Payer: NaphCare Correctional Healthcare	$297.60
Rate for Payer: Seven Corners Travel Insurance	$1,438.89
Rate for Payer: United Healthcare Commercial	$3,596.00

Colonoscopy through stoma; with biopsy, single or multiple

Facility

$3,596.00

Service Code	CPT 44389
Hospital Revenue Code	750
Min. Negotiated Rate	$239.53
Max. Negotiated Rate	$3,596.00
Rate for Payer: Banner UC Health Medicare	$383.41
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$239.53
Rate for Payer: Mercy Care Medicaid	$239.53
Rate for Payer: NaphCare Correctional Healthcare	$383.41
Rate for Payer: Seven Corners Travel Insurance	$1,851.53
Rate for Payer: United Healthcare Commercial	$3,596.00

COLONOSCOPY WITH BANDING LITIGATION - TECH

Facility

$1,478.00

Service Code	CPT 45398
Hospital Charge Code	22043085
Hospital Revenue Code	750
Min. Negotiated Rate	$234.12
Max. Negotiated Rate	$3,596.00
Rate for Payer: Aetna of AZ Commercial	$1,330.20
Rate for Payer: Arizona Complete Health Allwell	$236.48
Rate for Payer: Banner UC Health Medicare	$383.41
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,005.04
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$570.43
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$236.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$236.48
Rate for Payer: Cash Price	$1,182.40
Rate for Payer: Cash Price	$1,182.40
Rate for Payer: Cash Price	$1,182.40
Rate for Payer: Cigna of AZ Commercial	$1,034.60
Rate for Payer: Devoted Health Medicare	$266.04
Rate for Payer: Humana of AZ Medicare	$236.48
Rate for Payer: Mercy Care Medicaid	$570.43
Rate for Payer: NaphCare Correctional Healthcare	$383.41
Rate for Payer: Seven Corners Travel Insurance	$1,851.53
Rate for Payer: Southwest Service Administrators UFCW	$1,005.04
Rate for Payer: TriWest Medicare	$236.48
Rate for Payer: United Healthcare Commercial	$3,596.00
Rate for Payer: United Healthcare Medicare	$236.48
Rate for Payer: United Healthcare New Mexico Commercial	$280.82
Rate for Payer: Veterans Affairs TRICARE	$234.12

COLONOSCOPY WITH BANDING LITIGATION - TECH

Facility

$1,478.00

Service Code	CPT 45398
Hospital Charge Code	22043085
Hospital Revenue Code	750
Min. Negotiated Rate	$1,330.20
Max. Negotiated Rate	$1,330.20
Rate for Payer: Aetna of AZ Commercial	$1,330.20
Rate for Payer: Cash Price	$1,182.40

COLONOSCOPY W POLYPECT

Facility

$1,734.00

Hospital Charge Code	1296770
Hospital Revenue Code	750
Min. Negotiated Rate	$274.67
Max. Negotiated Rate	$3,373.00
Rate for Payer: Aetna of AZ Commercial	$1,560.60
Rate for Payer: Arizona Complete Health Allwell	$277.44
Rate for Payer: Banner UC Health Medicare	$277.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,179.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$277.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$277.44
Rate for Payer: Cash Price	$1,387.20
Rate for Payer: Cash Price	$1,387.20
Rate for Payer: Cigna of AZ Commercial	$1,213.80
Rate for Payer: Devoted Health Medicare	$312.12
Rate for Payer: Humana of AZ Medicare	$277.44
Rate for Payer: Southwest Service Administrators UFCW	$1,179.12
Rate for Payer: TriWest Medicare	$277.44
Rate for Payer: United Healthcare Commercial	$3,373.00
Rate for Payer: United Healthcare Medicare	$277.44
Rate for Payer: United Healthcare New Mexico Commercial	$329.46
Rate for Payer: Veterans Affairs TRICARE	$274.67

COLONOSCOPY W POLYPECT

Facility

$1,734.00

Hospital Charge Code	1296770
Hospital Revenue Code	750
Min. Negotiated Rate	$1,560.60
Max. Negotiated Rate	$1,560.60
Rate for Payer: Aetna of AZ Commercial	$1,560.60
Rate for Payer: Cash Price	$1,387.20

COLONOSCOPY W POLYPECT ADD ON CHARGE

Facility

$226.00

Hospital Charge Code	22331687
Hospital Revenue Code	750
Min. Negotiated Rate	$35.80
Max. Negotiated Rate	$3,373.00
Rate for Payer: Aetna of AZ Commercial	$203.40
Rate for Payer: Arizona Complete Health Allwell	$36.16
Rate for Payer: Banner UC Health Medicare	$36.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$153.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.16
Rate for Payer: Cash Price	$180.80
Rate for Payer: Cash Price	$180.80
Rate for Payer: Cigna of AZ Commercial	$158.20
Rate for Payer: Devoted Health Medicare	$40.68
Rate for Payer: Humana of AZ Medicare	$36.16
Rate for Payer: Southwest Service Administrators UFCW	$153.68
Rate for Payer: TriWest Medicare	$36.16
Rate for Payer: United Healthcare Commercial	$3,373.00
Rate for Payer: United Healthcare Medicare	$36.16
Rate for Payer: United Healthcare New Mexico Commercial	$42.94
Rate for Payer: Veterans Affairs TRICARE	$35.80

COLONOSCOPY W POLYPECT ADD ON CHARGE

Facility

$226.00

Hospital Charge Code	22331687
Hospital Revenue Code	750
Min. Negotiated Rate	$203.40
Max. Negotiated Rate	$203.40
Rate for Payer: Aetna of AZ Commercial	$203.40
Rate for Payer: Cash Price	$180.80

COLONSCOPY FLEXIBLE WITH BAND LIGATION

Facility

$600.00

Service Code	CPT 45298
Hospital Charge Code	28068479
Hospital Revenue Code	360
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

COLONSCOPY FLEXIBLE WITH BAND LIGATION

Facility

$600.00

Service Code	CPT 45298
Hospital Charge Code	28068479
Hospital Revenue Code	360
Min. Negotiated Rate	$95.04
Max. Negotiated Rate	$3,373.00
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 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	$300.00
Rate for Payer: Devoted Health Medicare	$108.00
Rate for Payer: Humana of AZ Medicare	$96.00
Rate for Payer: Southwest Service Administrators UFCW	$408.00
Rate for Payer: TriWest Medicare	$96.00
Rate for Payer: United Healthcare Commercial	$3,373.00
Rate for Payer: United Healthcare Medicare	$96.00
Rate for Payer: Veterans Affairs TRICARE	$95.04

Colorectal cancer screening; colonoscopy on individual at high risk

Facility

$3,098.00

Service Code	CPT G0105
Hospital Revenue Code	750
Min. Negotiated Rate	$158.29
Max. Negotiated Rate	$3,098.00
Rate for Payer: Banner UC Health Medicare	$297.60
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$158.29
Rate for Payer: Mercy Care Medicaid	$158.29
Rate for Payer: NaphCare Correctional Healthcare	$297.60
Rate for Payer: Seven Corners Travel Insurance	$1,438.89
Rate for Payer: United Healthcare Commercial	$3,098.00

Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

Facility

$3,098.00

Service Code	CPT G0121
Hospital Revenue Code	750
Min. Negotiated Rate	$157.95
Max. Negotiated Rate	$3,098.00
Rate for Payer: Banner UC Health Medicare	$297.60
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$157.95
Rate for Payer: Mercy Care Medicaid	$157.95
Rate for Payer: NaphCare Correctional Healthcare	$297.60
Rate for Payer: Seven Corners Travel Insurance	$1,438.89
Rate for Payer: United Healthcare Commercial	$3,098.00

Colpoclesis

Facility

$2,877.00

Service Code	CPT 57120
Hospital Charge Code	27267824
Hospital Revenue Code	360
Min. Negotiated Rate	$2,589.30
Max. Negotiated Rate	$2,589.30
Rate for Payer: Aetna of AZ Commercial	$2,589.30
Rate for Payer: Cash Price	$2,301.60

Colpoclesis

Facility

$2,877.00

Service Code	CPT 57120
Hospital Charge Code	27267824
Hospital Revenue Code	360
Min. Negotiated Rate	$455.72
Max. Negotiated Rate	$7,740.14
Rate for Payer: Aetna of AZ Commercial	$2,589.30
Rate for Payer: Arizona Complete Health Allwell	$460.32
Rate for Payer: Banner UC Health Medicare	$1,698.98
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,956.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$460.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$460.32
Rate for Payer: Cash Price	$2,301.60
Rate for Payer: Cash Price	$2,301.60
Rate for Payer: Cash Price	$2,301.60
Rate for Payer: Cigna of AZ Commercial	$1,438.50
Rate for Payer: Devoted Health Medicare	$517.86
Rate for Payer: Humana of AZ Medicare	$460.32
Rate for Payer: NaphCare Correctional Healthcare	$1,698.98
Rate for Payer: Seven Corners Travel Insurance	$7,740.14
Rate for Payer: Southwest Service Administrators UFCW	$1,956.36
Rate for Payer: TriWest Medicare	$460.32
Rate for Payer: United Healthcare Commercial	$4,838.00
Rate for Payer: United Healthcare Medicare	$460.32
Rate for Payer: Veterans Affairs TRICARE	$455.72

Colpoperineorrhaphy

Facility

$2,126.00

Service Code	CPT 57210
Hospital Charge Code	27267808
Hospital Revenue Code	360
Min. Negotiated Rate	$1,913.40
Max. Negotiated Rate	$1,913.40
Rate for Payer: Aetna of AZ Commercial	$1,913.40
Rate for Payer: Cash Price	$1,700.80

Colpoperineorrhaphy

Facility

$2,126.00

Service Code	CPT 57210
Hospital Charge Code	27267808
Hospital Revenue Code	360
Min. Negotiated Rate	$336.76
Max. Negotiated Rate	$5,008.71
Rate for Payer: Aetna of AZ Commercial	$1,913.40
Rate for Payer: Arizona Complete Health Allwell	$340.16
Rate for Payer: Banner UC Health Medicare	$1,051.19
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,445.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$340.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$340.16
Rate for Payer: Cash Price	$1,700.80
Rate for Payer: Cash Price	$1,700.80
Rate for Payer: Cash Price	$1,700.80
Rate for Payer: Cigna of AZ Commercial	$1,063.00
Rate for Payer: Devoted Health Medicare	$382.68
Rate for Payer: Humana of AZ Medicare	$340.16
Rate for Payer: NaphCare Correctional Healthcare	$1,051.19
Rate for Payer: Seven Corners Travel Insurance	$5,008.71
Rate for Payer: Southwest Service Administrators UFCW	$1,445.68
Rate for Payer: TriWest Medicare	$340.16
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$340.16
Rate for Payer: Veterans Affairs TRICARE	$336.76

Colpopexy(abdominal sacral uterosacral)

Facility

$5,261.00

Service Code	CPT 57280
Hospital Charge Code	27291792
Hospital Revenue Code	360
Min. Negotiated Rate	$4,734.90
Max. Negotiated Rate	$4,734.90
Rate for Payer: Aetna of AZ Commercial	$4,734.90
Rate for Payer: Cash Price	$4,208.80

Colpopexy(abdominal sacral uterosacral)

Facility

$5,261.00

Service Code	CPT 57280
Hospital Charge Code	27291792
Hospital Revenue Code	360
Min. Negotiated Rate	$833.34
Max. Negotiated Rate	$4,734.90
Rate for Payer: Aetna of AZ Commercial	$4,734.90
Rate for Payer: Arizona Complete Health Allwell	$841.76
Rate for Payer: Banner UC Health Medicare	$841.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,577.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$841.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$841.76
Rate for Payer: Cash Price	$4,208.80
Rate for Payer: Cash Price	$4,208.80
Rate for Payer: Cigna of AZ Commercial	$2,630.50
Rate for Payer: Devoted Health Medicare	$946.98
Rate for Payer: Humana of AZ Medicare	$841.76
Rate for Payer: Southwest Service Administrators UFCW	$3,577.48
Rate for Payer: TriWest Medicare	$841.76
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$841.76
Rate for Payer: Veterans Affairs TRICARE	$833.34

Colporrhaphy(repair injury site)

Facility

$1,780.00

Service Code	CPT 57200
Hospital Charge Code	27267807
Hospital Revenue Code	360
Min. Negotiated Rate	$1,602.00
Max. Negotiated Rate	$1,602.00
Rate for Payer: Aetna of AZ Commercial	$1,602.00
Rate for Payer: Cash Price	$1,424.00

Colporrhaphy(repair injury site)

Facility

$1,780.00

Service Code	CPT 57200
Hospital Charge Code	27267807
Hospital Revenue Code	360
Min. Negotiated Rate	$281.95
Max. Negotiated Rate	$5,008.71
Rate for Payer: Aetna of AZ Commercial	$1,602.00
Rate for Payer: Arizona Complete Health Allwell	$284.80
Rate for Payer: Banner UC Health Medicare	$1,051.19
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,210.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$284.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$284.80
Rate for Payer: Cash Price	$1,424.00
Rate for Payer: Cash Price	$1,424.00
Rate for Payer: Cash Price	$1,424.00
Rate for Payer: Cigna of AZ Commercial	$890.00
Rate for Payer: Devoted Health Medicare	$320.40
Rate for Payer: Humana of AZ Medicare	$284.80
Rate for Payer: NaphCare Correctional Healthcare	$1,051.19
Rate for Payer: Seven Corners Travel Insurance	$5,008.71
Rate for Payer: Southwest Service Administrators UFCW	$1,210.40
Rate for Payer: TriWest Medicare	$284.80
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$284.80
Rate for Payer: Veterans Affairs TRICARE	$281.95

Colposcopy of the cervix incuding upper/adjacent vagina

Facility

$911.00

Service Code	CPT 57452
Hospital Charge Code	22664756
Hospital Revenue Code	360
Min. Negotiated Rate	$35.92
Max. Negotiated Rate	$2,671.00
Rate for Payer: Aetna of AZ Commercial	$819.90
Rate for Payer: Arizona Complete Health Allwell	$145.76
Rate for Payer: Banner UC Health Medicare	$37.47
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$619.48
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$35.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$145.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$145.76
Rate for Payer: Cash Price	$728.80
Rate for Payer: Cash Price	$728.80
Rate for Payer: Cash Price	$728.80
Rate for Payer: Cigna of AZ Commercial	$455.50
Rate for Payer: Devoted Health Medicare	$163.98
Rate for Payer: Humana of AZ Medicare	$145.76
Rate for Payer: Mercy Care Medicaid	$35.92
Rate for Payer: NaphCare Correctional Healthcare	$37.47
Rate for Payer: Seven Corners Travel Insurance	$312.81
Rate for Payer: Southwest Service Administrators UFCW	$619.48
Rate for Payer: TriWest Medicare	$145.76
Rate for Payer: United Healthcare Commercial	$2,671.00
Rate for Payer: United Healthcare Medicare	$145.76
Rate for Payer: Veterans Affairs TRICARE	$144.30

Know your out-of-pocket cost for care.

All Charges