Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

20600 ASP / INJECTIONS JOINT SMALL

Facility

$258.00

Service Code	CPT 20600
Hospital Charge Code	22282822
Hospital Revenue Code	450
Min. Negotiated Rate	$232.20
Max. Negotiated Rate	$232.20
Rate for Payer: Aetna of AZ Commercial	$232.20
Rate for Payer: Cash Price	$206.40

20600 ASP / INJECTIONS JOINT SMALL

Facility

$258.00

Service Code	CPT 20600
Hospital Charge Code	22282822
Hospital Revenue Code	450
Min. Negotiated Rate	$18.83
Max. Negotiated Rate	$474.93
Rate for Payer: Aetna of AZ Commercial	$232.20
Rate for Payer: Arizona Complete Health Allwell	$41.28
Rate for Payer: Banner UC Health Medicare	$41.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$175.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$18.83
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$41.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$41.28
Rate for Payer: Cash Price	$206.40
Rate for Payer: Cash Price	$206.40
Rate for Payer: Cigna of AZ Commercial	$180.60
Rate for Payer: Devoted Health Medicare	$46.44
Rate for Payer: Humana of AZ Medicare	$41.28
Rate for Payer: Mercy Care Medicaid	$18.83
Rate for Payer: NaphCare Correctional Healthcare	$18.83
Rate for Payer: Seven Corners Travel Insurance	$474.93
Rate for Payer: Southwest Service Administrators UFCW	$175.44
Rate for Payer: TriWest Medicare	$41.28
Rate for Payer: United Healthcare Commercial	$147.58
Rate for Payer: United Healthcare Medicare	$41.28
Rate for Payer: United Healthcare New Mexico Commercial	$49.02
Rate for Payer: Veterans Affairs TRICARE	$40.87

20605 Arthrocentesis, Asp, Inj - Intermediate

Facility

$242.00

Service Code	CPT 20605
Hospital Charge Code	9310237
Hospital Revenue Code	521
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

20605 Arthrocentesis, Asp, Inj - Intermediate

Facility

$242.00

Service Code	CPT 20605
Hospital Charge Code	9310237
Hospital Revenue Code	521
Min. Negotiated Rate	$18.82
Max. Negotiated Rate	$474.93
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 Health Choice	$18.82
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: 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: Mercy Care Medicaid	$18.82
Rate for Payer: NaphCare Correctional Healthcare	$18.82
Rate for Payer: Seven Corners Travel Insurance	$474.93
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: Veterans Affairs TRICARE	$38.33

20605 ASP / INJECTIONS JOINT INTERMEDIATE

Facility

$367.00

Service Code	CPT 20605
Hospital Charge Code	22282823
Hospital Revenue Code	450
Min. Negotiated Rate	$330.30
Max. Negotiated Rate	$330.30
Rate for Payer: Aetna of AZ Commercial	$330.30
Rate for Payer: Cash Price	$293.60

20605 ASP / INJECTIONS JOINT INTERMEDIATE

Facility

$367.00

Service Code	CPT 20605
Hospital Charge Code	22282823
Hospital Revenue Code	450
Min. Negotiated Rate	$18.82
Max. Negotiated Rate	$474.93
Rate for Payer: Aetna of AZ Commercial	$330.30
Rate for Payer: Arizona Complete Health Allwell	$58.72
Rate for Payer: Banner UC Health Medicare	$58.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$249.56
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$18.82
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$58.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$58.72
Rate for Payer: Cash Price	$293.60
Rate for Payer: Cash Price	$293.60
Rate for Payer: Cigna of AZ Commercial	$256.90
Rate for Payer: Devoted Health Medicare	$66.06
Rate for Payer: Humana of AZ Medicare	$58.72
Rate for Payer: Mercy Care Medicaid	$18.82
Rate for Payer: NaphCare Correctional Healthcare	$18.82
Rate for Payer: Seven Corners Travel Insurance	$474.93
Rate for Payer: Southwest Service Administrators UFCW	$249.56
Rate for Payer: TriWest Medicare	$58.72
Rate for Payer: United Healthcare Commercial	$209.92
Rate for Payer: United Healthcare Medicare	$58.72
Rate for Payer: United Healthcare New Mexico Commercial	$69.73
Rate for Payer: Veterans Affairs TRICARE	$58.13

20610 Arthrocentesis, Asp, Inj - Large

Facility

$314.00

Service Code	CPT 20610
Hospital Charge Code	9310239
Hospital Revenue Code	521
Min. Negotiated Rate	$282.60
Max. Negotiated Rate	$282.60
Rate for Payer: Aetna of AZ Commercial	$282.60
Rate for Payer: Cash Price	$251.20

20610 Arthrocentesis, Asp, Inj - Large

Facility

$314.00

Service Code	CPT 20610
Hospital Charge Code	9310239
Hospital Revenue Code	521
Min. Negotiated Rate	$20.57
Max. Negotiated Rate	$474.93
Rate for Payer: Aetna of AZ Commercial	$282.60
Rate for Payer: Arizona Complete Health Allwell	$50.24
Rate for Payer: Banner UC Health Medicare	$50.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$213.52
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$20.57
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$50.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$50.24
Rate for Payer: Cash Price	$251.20
Rate for Payer: Cash Price	$251.20
Rate for Payer: Cigna of AZ Commercial	$219.80
Rate for Payer: Devoted Health Medicare	$56.52
Rate for Payer: Humana of AZ Medicare	$50.24
Rate for Payer: Mercy Care Medicaid	$20.57
Rate for Payer: NaphCare Correctional Healthcare	$20.57
Rate for Payer: Seven Corners Travel Insurance	$474.93
Rate for Payer: Southwest Service Administrators UFCW	$213.52
Rate for Payer: TriWest Medicare	$50.24
Rate for Payer: United Healthcare Commercial	$179.61
Rate for Payer: United Healthcare Medicare	$50.24
Rate for Payer: Veterans Affairs TRICARE	$49.74

20610 ASP / INJECTIONS JOINT MAJOR

Facility

$450.00

Service Code	CPT 20610
Hospital Charge Code	22282824
Hospital Revenue Code	450
Min. Negotiated Rate	$20.57
Max. Negotiated Rate	$474.93
Rate for Payer: Aetna of AZ Commercial	$405.00
Rate for Payer: Arizona Complete Health Allwell	$72.00
Rate for Payer: Banner UC Health Medicare	$72.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$306.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$20.57
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$72.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$72.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna of AZ Commercial	$315.00
Rate for Payer: Devoted Health Medicare	$81.00
Rate for Payer: Humana of AZ Medicare	$72.00
Rate for Payer: Mercy Care Medicaid	$20.57
Rate for Payer: NaphCare Correctional Healthcare	$20.57
Rate for Payer: Seven Corners Travel Insurance	$474.93
Rate for Payer: Southwest Service Administrators UFCW	$306.00
Rate for Payer: TriWest Medicare	$72.00
Rate for Payer: United Healthcare Commercial	$257.40
Rate for Payer: United Healthcare Medicare	$72.00
Rate for Payer: United Healthcare New Mexico Commercial	$85.50
Rate for Payer: Veterans Affairs TRICARE	$71.28

20610 ASP / INJECTIONS JOINT MAJOR

Facility

$450.00

Service Code	CPT 20610
Hospital Charge Code	22282824
Hospital Revenue Code	450
Min. Negotiated Rate	$405.00
Max. Negotiated Rate	$405.00
Rate for Payer: Aetna of AZ Commercial	$405.00
Rate for Payer: Cash Price	$360.00

20612 Aspiration/injection of ganglion

Facility

$267.00

Service Code	CPT 20612
Hospital Charge Code	24076872
Hospital Revenue Code	521
Min. Negotiated Rate	$25.10
Max. Negotiated Rate	$474.93
Rate for Payer: Aetna of AZ Commercial	$240.30
Rate for Payer: Arizona Complete Health Allwell	$42.72
Rate for Payer: Banner UC Health Medicare	$42.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$181.56
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$25.10
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$42.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$42.72
Rate for Payer: Cash Price	$213.60
Rate for Payer: Cash Price	$213.60
Rate for Payer: Cigna of AZ Commercial	$186.90
Rate for Payer: Devoted Health Medicare	$48.06
Rate for Payer: Humana of AZ Medicare	$42.72
Rate for Payer: Mercy Care Medicaid	$25.10
Rate for Payer: NaphCare Correctional Healthcare	$25.10
Rate for Payer: Seven Corners Travel Insurance	$474.93
Rate for Payer: Southwest Service Administrators UFCW	$181.56
Rate for Payer: TriWest Medicare	$42.72
Rate for Payer: United Healthcare Commercial	$152.72
Rate for Payer: United Healthcare Medicare	$42.72
Rate for Payer: Veterans Affairs TRICARE	$42.29

20612 Aspiration/injection of ganglion

Facility

$267.00

Service Code	CPT 20612
Hospital Charge Code	24076872
Hospital Revenue Code	521
Min. Negotiated Rate	$240.30
Max. Negotiated Rate	$240.30
Rate for Payer: Aetna of AZ Commercial	$240.30
Rate for Payer: Cash Price	$213.60

2-0 Ethibond Excel CT-1

Facility

$13.00

Hospital Charge Code	22926439
Hospital Revenue Code	272
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$11.70
Rate for Payer: Aetna of AZ Commercial	$11.70
Rate for Payer: Cash Price	$10.40

2-0 Ethibond Excel CT-1

Facility

$13.00

Hospital Charge Code	22926439
Hospital Revenue Code	272
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$11.70
Rate for Payer: Aetna of AZ Commercial	$11.70
Rate for Payer: Arizona Complete Health Allwell	$2.08
Rate for Payer: Banner UC Health Medicare	$2.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$8.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.08
Rate for Payer: Cash Price	$10.40
Rate for Payer: Cigna of AZ Commercial	$9.10
Rate for Payer: Devoted Health Medicare	$2.34
Rate for Payer: Humana of AZ Medicare	$2.08
Rate for Payer: Southwest Service Administrators UFCW	$8.84
Rate for Payer: TriWest Medicare	$2.08
Rate for Payer: United Healthcare Commercial	$7.44
Rate for Payer: United Healthcare Medicare	$2.08
Rate for Payer: Veterans Affairs TRICARE	$2.06

2-0 Ethibond Excel MO-7

Facility

$84.00

Hospital Charge Code	22926438
Hospital Revenue Code	272
Min. Negotiated Rate	$13.31
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Arizona Complete Health Allwell	$13.44
Rate for Payer: Banner UC Health Medicare	$13.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$57.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.44
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cigna of AZ Commercial	$58.80
Rate for Payer: Devoted Health Medicare	$15.12
Rate for Payer: Humana of AZ Medicare	$13.44
Rate for Payer: Southwest Service Administrators UFCW	$57.12
Rate for Payer: TriWest Medicare	$13.44
Rate for Payer: United Healthcare Commercial	$48.05
Rate for Payer: United Healthcare Medicare	$13.44
Rate for Payer: Veterans Affairs TRICARE	$13.31

2-0 Ethibond Excel MO-7

Facility

$84.00

Hospital Charge Code	22926438
Hospital Revenue Code	272
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Cash Price	$67.20

20G INTROCAN SAFETY STRAIGHT FEP IV CATH

Facility

$7.16

Hospital Charge Code	27527452
Hospital Revenue Code	270
Min. Negotiated Rate	$6.44
Max. Negotiated Rate	$6.44
Rate for Payer: Aetna of AZ Commercial	$6.44
Rate for Payer: Cash Price	$5.73

20G INTROCAN SAFETY STRAIGHT FEP IV CATH

Facility

$7.16

Hospital Charge Code	27527452
Hospital Revenue Code	270
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$6.44
Rate for Payer: Aetna of AZ Commercial	$6.44
Rate for Payer: Arizona Complete Health Allwell	$1.15
Rate for Payer: Banner UC Health Medicare	$1.15
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$4.87
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.15
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.15
Rate for Payer: Cash Price	$5.73
Rate for Payer: Cigna of AZ Commercial	$5.01
Rate for Payer: Devoted Health Medicare	$1.29
Rate for Payer: Humana of AZ Medicare	$1.15
Rate for Payer: Southwest Service Administrators UFCW	$4.87
Rate for Payer: TriWest Medicare	$1.15
Rate for Payer: United Healthcare Commercial	$4.10
Rate for Payer: United Healthcare Medicare	$1.15
Rate for Payer: Veterans Affairs TRICARE	$1.13

2-0 Plain Gut FN-2

Facility

$22.00

Hospital Charge Code	22926444
Hospital Revenue Code	272
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$19.80
Rate for Payer: Aetna of AZ Commercial	$19.80
Rate for Payer: Cash Price	$17.60

2-0 Plain Gut FN-2

Facility

$22.00

Hospital Charge Code	22926444
Hospital Revenue Code	272
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$19.80
Rate for Payer: Aetna of AZ Commercial	$19.80
Rate for Payer: Arizona Complete Health Allwell	$3.52
Rate for Payer: Banner UC Health Medicare	$3.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$14.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.52
Rate for Payer: Cash Price	$17.60
Rate for Payer: Cigna of AZ Commercial	$15.40
Rate for Payer: Devoted Health Medicare	$3.96
Rate for Payer: Humana of AZ Medicare	$3.52
Rate for Payer: Southwest Service Administrators UFCW	$14.96
Rate for Payer: TriWest Medicare	$3.52
Rate for Payer: United Healthcare Commercial	$12.58
Rate for Payer: United Healthcare Medicare	$3.52
Rate for Payer: Veterans Affairs TRICARE	$3.48

2-0 Surgical Steel FSLX

Facility

$14.00

Hospital Charge Code	22926440
Hospital Revenue Code	272
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of AZ Commercial	$12.60
Rate for Payer: Arizona Complete Health Allwell	$2.24
Rate for Payer: Banner UC Health Medicare	$2.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$9.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.24
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cigna of AZ Commercial	$9.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Humana of AZ Medicare	$2.24
Rate for Payer: Southwest Service Administrators UFCW	$9.52
Rate for Payer: TriWest Medicare	$2.24
Rate for Payer: United Healthcare Commercial	$8.01
Rate for Payer: United Healthcare Medicare	$2.24
Rate for Payer: Veterans Affairs TRICARE	$2.22

2-0 Surgical Steel FSLX

Facility

$14.00

Hospital Charge Code	22926440
Hospital Revenue Code	272
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of AZ Commercial	$12.60
Rate for Payer: Cash Price	$11.20

21315 CLSD TX NOSEFX W/O STABL

Facility

$822.00

Service Code	CPT 21315
Hospital Charge Code	22282826
Hospital Revenue Code	450
Min. Negotiated Rate	$97.99
Max. Negotiated Rate	$2,400.72
Rate for Payer: Aetna of AZ Commercial	$739.80
Rate for Payer: Arizona Complete Health Allwell	$131.52
Rate for Payer: Banner UC Health Medicare	$131.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$558.96
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$97.99
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$131.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$131.52
Rate for Payer: Cash Price	$657.60
Rate for Payer: Cash Price	$657.60
Rate for Payer: Cigna of AZ Commercial	$575.40
Rate for Payer: Devoted Health Medicare	$147.96
Rate for Payer: Humana of AZ Medicare	$131.52
Rate for Payer: Mercy Care Medicaid	$97.99
Rate for Payer: NaphCare Correctional Healthcare	$97.99
Rate for Payer: Seven Corners Travel Insurance	$2,400.72
Rate for Payer: Southwest Service Administrators UFCW	$558.96
Rate for Payer: TriWest Medicare	$131.52
Rate for Payer: United Healthcare Commercial	$470.18
Rate for Payer: United Healthcare Medicare	$131.52
Rate for Payer: United Healthcare New Mexico Commercial	$156.18
Rate for Payer: Veterans Affairs TRICARE	$130.20

21315 CLSD TX NOSEFX W/O STABL

Facility

$822.00

Service Code	CPT 21315
Hospital Charge Code	22282826
Hospital Revenue Code	450
Min. Negotiated Rate	$739.80
Max. Negotiated Rate	$739.80
Rate for Payer: Aetna of AZ Commercial	$739.80
Rate for Payer: Cash Price	$657.60

21320 CLSD TX NOSE FX W/STABL

Facility

$785.00

Service Code	CPT 21320
Hospital Charge Code	22282827
Hospital Revenue Code	450
Min. Negotiated Rate	$706.50
Max. Negotiated Rate	$706.50
Rate for Payer: Aetna of AZ Commercial	$706.50
Rate for Payer: Cash Price	$628.00

Know your out-of-pocket cost for care.

All Charges