Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Complete Blood Count/Hemogram Standard

Facility

$238.00

Service Code	CPT 85025
Hospital Charge Code	22141055
Hospital Revenue Code	305
Min. Negotiated Rate	$11.27
Max. Negotiated Rate	$214.20
Rate for Payer: Aetna of AZ Commercial	$214.20
Rate for Payer: Aetna of AZ Commercial	$153.00
Rate for Payer: Arizona Complete Health Allwell	$27.20
Rate for Payer: Arizona Complete Health Allwell	$38.08
Rate for Payer: Banner UC Health Medicare	$27.20
Rate for Payer: Banner UC Health Medicare	$38.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$161.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$115.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.08
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$136.00
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$136.00
Rate for Payer: Cigna of AZ Commercial	$154.70
Rate for Payer: Cigna of AZ Commercial	$110.50
Rate for Payer: Devoted Health Medicare	$42.84
Rate for Payer: Devoted Health Medicare	$30.60
Rate for Payer: Humana of AZ Medicare	$27.20
Rate for Payer: Humana of AZ Medicare	$38.08
Rate for Payer: Seven Corners Travel Insurance	$11.27
Rate for Payer: Seven Corners Travel Insurance	$11.27
Rate for Payer: Southwest Service Administrators UFCW	$115.60
Rate for Payer: Southwest Service Administrators UFCW	$161.84
Rate for Payer: TriWest Medicare	$27.20
Rate for Payer: TriWest Medicare	$38.08
Rate for Payer: United Healthcare Commercial	$136.14
Rate for Payer: United Healthcare Commercial	$97.24
Rate for Payer: United Healthcare Medicare	$27.20
Rate for Payer: United Healthcare Medicare	$38.08
Rate for Payer: Veterans Affairs TRICARE	$37.70
Rate for Payer: Veterans Affairs TRICARE	$26.93

COMPLETE LASER FRAGMENTATION OF PROSTATE INCLUDING CONTROL O

Facility

$4,322.00

Service Code	CPT 52649
Hospital Charge Code	27881571
Hospital Revenue Code	360
Min. Negotiated Rate	$684.60
Max. Negotiated Rate	$8,296.15
Rate for Payer: Aetna of AZ Commercial	$3,889.80
Rate for Payer: Arizona Complete Health Allwell	$691.52
Rate for Payer: Banner UC Health Medicare	$1,977.90
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,938.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$691.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$691.52
Rate for Payer: Cash Price	$3,457.60
Rate for Payer: Cash Price	$3,457.60
Rate for Payer: Cash Price	$3,457.60
Rate for Payer: Cigna of AZ Commercial	$2,161.00
Rate for Payer: Devoted Health Medicare	$777.96
Rate for Payer: Humana of AZ Medicare	$691.52
Rate for Payer: NaphCare Correctional Healthcare	$1,977.90
Rate for Payer: Seven Corners Travel Insurance	$8,296.15
Rate for Payer: Southwest Service Administrators UFCW	$2,938.96
Rate for Payer: TriWest Medicare	$691.52
Rate for Payer: United Healthcare Commercial	$5,611.00
Rate for Payer: United Healthcare Medicare	$691.52
Rate for Payer: Veterans Affairs TRICARE	$684.60

COMPLETE LASER FRAGMENTATION OF PROSTATE INCLUDING CONTROL O

Facility

$4,322.00

Service Code	CPT 52649
Hospital Charge Code	27881571
Hospital Revenue Code	360
Min. Negotiated Rate	$3,889.80
Max. Negotiated Rate	$3,889.80
Rate for Payer: Aetna of AZ Commercial	$3,889.80
Rate for Payer: Cash Price	$3,457.60

COMPLETE REMOVAL OF REMAINING OR REGROWN PROSTATE TISSUE WIT

Facility

$2,113.00

Service Code	CPT 52630
Hospital Charge Code	27797699
Hospital Revenue Code	360
Min. Negotiated Rate	$334.70
Max. Negotiated Rate	$8,296.15
Rate for Payer: Aetna of AZ Commercial	$1,901.70
Rate for Payer: Arizona Complete Health Allwell	$338.08
Rate for Payer: Banner UC Health Medicare	$1,977.90
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,436.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$338.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$338.08
Rate for Payer: Cash Price	$1,690.40
Rate for Payer: Cash Price	$1,690.40
Rate for Payer: Cash Price	$1,690.40
Rate for Payer: Cigna of AZ Commercial	$1,056.50
Rate for Payer: Devoted Health Medicare	$380.34
Rate for Payer: Humana of AZ Medicare	$338.08
Rate for Payer: NaphCare Correctional Healthcare	$1,977.90
Rate for Payer: Seven Corners Travel Insurance	$8,296.15
Rate for Payer: Southwest Service Administrators UFCW	$1,436.84
Rate for Payer: TriWest Medicare	$338.08
Rate for Payer: United Healthcare Commercial	$5,611.00
Rate for Payer: United Healthcare Medicare	$338.08
Rate for Payer: Veterans Affairs TRICARE	$334.70

COMPLETE REMOVAL OF REMAINING OR REGROWN PROSTATE TISSUE WIT

Facility

$2,113.00

Service Code	CPT 52630
Hospital Charge Code	27803576
Hospital Revenue Code	982
Min. Negotiated Rate	$334.70
Max. Negotiated Rate	$8,296.15
Rate for Payer: Aetna of AZ Commercial	$1,901.70
Rate for Payer: Arizona Complete Health Allwell	$338.08
Rate for Payer: Banner UC Health Medicare	$338.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,436.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$338.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$338.08
Rate for Payer: Cash Price	$1,690.40
Rate for Payer: Cash Price	$1,690.40
Rate for Payer: Cigna of AZ Commercial	$1,479.10
Rate for Payer: Devoted Health Medicare	$380.34
Rate for Payer: Humana of AZ Medicare	$338.08
Rate for Payer: Seven Corners Travel Insurance	$8,296.15
Rate for Payer: Southwest Service Administrators UFCW	$1,436.84
Rate for Payer: TriWest Medicare	$338.08
Rate for Payer: United Healthcare Commercial	$1,208.64
Rate for Payer: United Healthcare Medicare	$338.08
Rate for Payer: United Healthcare New Mexico Commercial	$401.47
Rate for Payer: Veterans Affairs TRICARE	$334.70

COMPLETE REMOVAL OF REMAINING OR REGROWN PROSTATE TISSUE WIT

Facility

$2,113.00

Service Code	CPT 52630
Hospital Charge Code	27797699
Hospital Revenue Code	360
Min. Negotiated Rate	$1,901.70
Max. Negotiated Rate	$1,901.70
Rate for Payer: Aetna of AZ Commercial	$1,901.70
Rate for Payer: Cash Price	$1,690.40

COMPLETE REMOVAL OF REMAINING OR REGROWN PROSTATE TISSUE WIT

Facility

$2,113.00

Service Code	CPT 52630
Hospital Charge Code	27803576
Hospital Revenue Code	982
Min. Negotiated Rate	$1,901.70
Max. Negotiated Rate	$1,901.70
Rate for Payer: Aetna of AZ Commercial	$1,901.70
Rate for Payer: Cash Price	$1,690.40

COMPLETE ULTRASOUND STUDY OF ARM AND LEG ARTERIES

Facility

$661.00

Service Code	CPT 93923
Hospital Charge Code	28272953
Hospital Revenue Code	730
Min. Negotiated Rate	$594.90
Max. Negotiated Rate	$594.90
Rate for Payer: Aetna of AZ Commercial	$594.90
Rate for Payer: Cash Price	$528.80

COMPLETE ULTRASOUND STUDY OF ARM AND LEG ARTERIES

Facility

$661.00

Service Code	CPT 93923
Hospital Charge Code	28272953
Hospital Revenue Code	730
Min. Negotiated Rate	$104.70
Max. Negotiated Rate	$594.90
Rate for Payer: Aetna of AZ Commercial	$594.90
Rate for Payer: Arizona Complete Health Allwell	$105.76
Rate for Payer: Banner UC Health Medicare	$105.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$449.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$105.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$105.76
Rate for Payer: Cash Price	$528.80
Rate for Payer: Cash Price	$528.80
Rate for Payer: Cigna of AZ Commercial	$462.70
Rate for Payer: Devoted Health Medicare	$118.98
Rate for Payer: Humana of AZ Medicare	$105.76
Rate for Payer: Seven Corners Travel Insurance	$334.09
Rate for Payer: Southwest Service Administrators UFCW	$449.48
Rate for Payer: TriWest Medicare	$105.76
Rate for Payer: United Healthcare Commercial	$378.09
Rate for Payer: United Healthcare Medicare	$105.76
Rate for Payer: United Healthcare New Mexico Commercial	$125.59
Rate for Payer: Veterans Affairs TRICARE	$104.70

COMPLEX AORTIC ARCH PROCEDURES

Facility

$146,285.79

Service Code	MSDRG 209
Min. Negotiated Rate	$146,285.79
Max. Negotiated Rate	$146,285.79
Rate for Payer: Seven Corners Travel Insurance	$146,285.79

Complex CCM Services 60 minute per month

Facility

$368.00

Service Code	CPT 99487
Hospital Charge Code	23790902
Hospital Revenue Code	521
Min. Negotiated Rate	$331.20
Max. Negotiated Rate	$331.20
Rate for Payer: Aetna of AZ Commercial	$331.20
Rate for Payer: Cash Price	$294.40

Complex CCM Services 60 minute per month

Facility

$142.00

Service Code	CPT 99487
Hospital Charge Code	22984410
Hospital Revenue Code	521
Min. Negotiated Rate	$22.49
Max. Negotiated Rate	$274.63
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Arizona Complete Health Allwell	$22.72
Rate for Payer: Banner UC Health Medicare	$22.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$96.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$22.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$22.72
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cigna of AZ Commercial	$99.40
Rate for Payer: Devoted Health Medicare	$25.56
Rate for Payer: Humana of AZ Medicare	$22.72
Rate for Payer: Seven Corners Travel Insurance	$274.63
Rate for Payer: Southwest Service Administrators UFCW	$96.56
Rate for Payer: TriWest Medicare	$22.72
Rate for Payer: United Healthcare Commercial	$81.22
Rate for Payer: United Healthcare Medicare	$22.72
Rate for Payer: Veterans Affairs TRICARE	$22.49

Complex CCM Services 60 minute per month

Facility

$142.00

Service Code	CPT 99487
Hospital Charge Code	22984410
Hospital Revenue Code	521
Min. Negotiated Rate	$127.80
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Cash Price	$113.60

Complex CCM Services 60 minute per month

Facility

$368.00

Service Code	CPT 99487
Hospital Charge Code	23790902
Hospital Revenue Code	521
Min. Negotiated Rate	$58.29
Max. Negotiated Rate	$331.20
Rate for Payer: Aetna of AZ Commercial	$331.20
Rate for Payer: Arizona Complete Health Allwell	$58.88
Rate for Payer: Banner UC Health Medicare	$58.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$250.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$58.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$58.88
Rate for Payer: Cash Price	$294.40
Rate for Payer: Cash Price	$294.40
Rate for Payer: Cigna of AZ Commercial	$257.60
Rate for Payer: Devoted Health Medicare	$66.24
Rate for Payer: Humana of AZ Medicare	$58.88
Rate for Payer: Seven Corners Travel Insurance	$274.63
Rate for Payer: Southwest Service Administrators UFCW	$250.24
Rate for Payer: TriWest Medicare	$58.88
Rate for Payer: United Healthcare Commercial	$210.50
Rate for Payer: United Healthcare Medicare	$58.88
Rate for Payer: Veterans Affairs TRICARE	$58.29

Complex CCM Services each add 30 min per month

Facility

$272.00

Service Code	CPT 99489
Hospital Charge Code	22758640
Hospital Revenue Code	521
Min. Negotiated Rate	$244.80
Max. Negotiated Rate	$244.80
Rate for Payer: Aetna of AZ Commercial	$244.80
Rate for Payer: Cash Price	$217.60

Complex CCM Services each add 30 min per month

Facility

$272.00

Service Code	CPT 99489
Hospital Charge Code	22758640
Hospital Revenue Code	521
Min. Negotiated Rate	$43.08
Max. Negotiated Rate	$244.80
Rate for Payer: Aetna of AZ Commercial	$244.80
Rate for Payer: Arizona Complete Health Allwell	$43.52
Rate for Payer: Banner UC Health Medicare	$43.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$184.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$43.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.52
Rate for Payer: Cash Price	$217.60
Rate for Payer: Cigna of AZ Commercial	$190.40
Rate for Payer: Devoted Health Medicare	$48.96
Rate for Payer: Humana of AZ Medicare	$43.52
Rate for Payer: Southwest Service Administrators UFCW	$184.96
Rate for Payer: TriWest Medicare	$43.52
Rate for Payer: United Healthcare Commercial	$155.58
Rate for Payer: United Healthcare Medicare	$43.52
Rate for Payer: Veterans Affairs TRICARE	$43.08

Complex CCM Services Each Add 30 min per month

Facility

$259.00

Service Code	CPT 99489
Hospital Charge Code	23790903
Hospital Revenue Code	521
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$233.10
Rate for Payer: Aetna of AZ Commercial	$233.10
Rate for Payer: Cash Price	$207.20

Complex CCM Services Each Add 30 min per month

Facility

$259.00

Service Code	CPT 99489
Hospital Charge Code	23790903
Hospital Revenue Code	521
Min. Negotiated Rate	$41.03
Max. Negotiated Rate	$233.10
Rate for Payer: Aetna of AZ Commercial	$233.10
Rate for Payer: Arizona Complete Health Allwell	$41.44
Rate for Payer: Banner UC Health Medicare	$41.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$176.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$41.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$41.44
Rate for Payer: Cash Price	$207.20
Rate for Payer: Cigna of AZ Commercial	$181.30
Rate for Payer: Devoted Health Medicare	$46.62
Rate for Payer: Humana of AZ Medicare	$41.44
Rate for Payer: Southwest Service Administrators UFCW	$176.12
Rate for Payer: TriWest Medicare	$41.44
Rate for Payer: United Healthcare Commercial	$148.15
Rate for Payer: United Healthcare Medicare	$41.44
Rate for Payer: Veterans Affairs TRICARE	$41.03

Complex cystometrogram (ie, calibrated electronic equipment)

Facility

$2,081.00

Service Code	CPT 51729
Hospital Charge Code	27802895
Hospital Revenue Code	360
Min. Negotiated Rate	$1,872.90
Max. Negotiated Rate	$1,872.90
Rate for Payer: Aetna of AZ Commercial	$1,872.90
Rate for Payer: Cash Price	$1,664.80

Complex cystometrogram (ie, calibrated electronic equipment)

Facility

$2,081.00

Service Code	CPT 51729
Hospital Charge Code	27802895
Hospital Revenue Code	360
Min. Negotiated Rate	$124.89
Max. Negotiated Rate	$3,098.00
Rate for Payer: Aetna of AZ Commercial	$1,872.90
Rate for Payer: Arizona Complete Health Allwell	$332.96
Rate for Payer: Banner UC Health Medicare	$124.89
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,415.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$332.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$332.96
Rate for Payer: Cash Price	$1,664.80
Rate for Payer: Cash Price	$1,664.80
Rate for Payer: Cash Price	$1,664.80
Rate for Payer: Cigna of AZ Commercial	$1,040.50
Rate for Payer: Devoted Health Medicare	$374.58
Rate for Payer: Humana of AZ Medicare	$332.96
Rate for Payer: NaphCare Correctional Healthcare	$124.89
Rate for Payer: Seven Corners Travel Insurance	$1,078.90
Rate for Payer: Southwest Service Administrators UFCW	$1,415.08
Rate for Payer: TriWest Medicare	$332.96
Rate for Payer: United Healthcare Commercial	$3,098.00
Rate for Payer: United Healthcare Medicare	$332.96
Rate for Payer: Veterans Affairs TRICARE	$329.63

Complex cystometrogram (i.e., calibrated electronic equipment); with voiding pressure studies (i.e., bladder voiding pressure), any technique

Facility

$3,098.00

Service Code	CPT 51728
Hospital Revenue Code	490
Min. Negotiated Rate	$127.64
Max. Negotiated Rate	$3,098.00
Rate for Payer: Banner UC Health Medicare	$127.64
Rate for Payer: NaphCare Correctional Healthcare	$127.64
Rate for Payer: Seven Corners Travel Insurance	$1,078.90
Rate for Payer: United Healthcare Commercial	$3,098.00

COMPLICATED INSERTION OF BLADDER TUBE

Facility

$389.00

Service Code	CPT 51703
Hospital Charge Code	28133135
Hospital Revenue Code	360
Min. Negotiated Rate	$41.01
Max. Negotiated Rate	$2,671.00
Rate for Payer: Aetna of AZ Commercial	$350.10
Rate for Payer: Arizona Complete Health Allwell	$62.24
Rate for Payer: Banner UC Health Medicare	$41.01
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$264.52
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$73.57
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$62.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$62.24
Rate for Payer: Cash Price	$311.20
Rate for Payer: Cash Price	$311.20
Rate for Payer: Cash Price	$311.20
Rate for Payer: Cigna of AZ Commercial	$194.50
Rate for Payer: Devoted Health Medicare	$70.02
Rate for Payer: Humana of AZ Medicare	$62.24
Rate for Payer: Mercy Care Medicaid	$73.57
Rate for Payer: NaphCare Correctional Healthcare	$41.01
Rate for Payer: Seven Corners Travel Insurance	$199.09
Rate for Payer: Southwest Service Administrators UFCW	$264.52
Rate for Payer: TriWest Medicare	$62.24
Rate for Payer: United Healthcare Commercial	$2,671.00
Rate for Payer: United Healthcare Medicare	$62.24
Rate for Payer: Veterans Affairs TRICARE	$61.62

COMPLICATED INSERTION OF BLADDER TUBE

Facility

$389.00

Service Code	CPT 51703
Hospital Charge Code	28133135
Hospital Revenue Code	360
Min. Negotiated Rate	$350.10
Max. Negotiated Rate	$350.10
Rate for Payer: Aetna of AZ Commercial	$350.10
Rate for Payer: Cash Price	$311.20

COMPLICATED PEPTIC ULCER WITH CC

Facility

$14,084.65

Service Code	MSDRG 381
Min. Negotiated Rate	$14,084.65
Max. Negotiated Rate	$14,084.65
Rate for Payer: Seven Corners Travel Insurance	$14,084.65

COMPLICATED PEPTIC ULCER WITH MCC

Facility

$25,359.73

Service Code	MSDRG 380
Min. Negotiated Rate	$25,359.73
Max. Negotiated Rate	$25,359.73
Rate for Payer: Seven Corners Travel Insurance	$25,359.73

Know your out-of-pocket cost for care.

All Charges