Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

CT Spine Lumbar w/ + w/o Contrast

Facility

$3,316.00

Service Code	CPT 72133
Hospital Charge Code	1005217
Hospital Revenue Code	352
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$2,984.40
Rate for Payer: Aetna of AZ Commercial	$2,984.40
Rate for Payer: Arizona Complete Health Allwell	$530.56
Rate for Payer: Banner UC Health Medicare	$530.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,254.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$530.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$530.56
Rate for Payer: Cash Price	$2,652.80
Rate for Payer: Cash Price	$2,652.80
Rate for Payer: Cigna of AZ Commercial	$2,155.40
Rate for Payer: Devoted Health Medicare	$596.88
Rate for Payer: Humana of AZ Medicare	$530.56
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$2,254.88
Rate for Payer: TriWest Medicare	$530.56
Rate for Payer: United Healthcare Commercial	$1,896.75
Rate for Payer: United Healthcare Medicare	$530.56
Rate for Payer: Veterans Affairs TRICARE	$525.25

CT Spine Lumbar w/ + w/o Contrast

Facility

$3,316.00

Service Code	CPT 72133
Hospital Charge Code	1005217
Hospital Revenue Code	352
Min. Negotiated Rate	$2,984.40
Max. Negotiated Rate	$2,984.40
Rate for Payer: Aetna of AZ Commercial	$2,984.40
Rate for Payer: Cash Price	$2,652.80

CT Spine Thoracic w/ Contrast

Facility

$2,399.00

Service Code	CPT 72129
Hospital Charge Code	1005223
Hospital Revenue Code	352
Min. Negotiated Rate	$2,159.10
Max. Negotiated Rate	$2,159.10
Rate for Payer: Aetna of AZ Commercial	$2,159.10
Rate for Payer: Cash Price	$1,919.20

CT Spine Thoracic w/ Contrast

Facility

$2,399.00

Service Code	CPT 72129
Hospital Charge Code	1005223
Hospital Revenue Code	352
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$2,159.10
Rate for Payer: Aetna of AZ Commercial	$2,159.10
Rate for Payer: Arizona Complete Health Allwell	$383.84
Rate for Payer: Banner UC Health Medicare	$383.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,631.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$383.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$383.84
Rate for Payer: Cash Price	$1,919.20
Rate for Payer: Cash Price	$1,919.20
Rate for Payer: Cigna of AZ Commercial	$1,559.35
Rate for Payer: Devoted Health Medicare	$431.82
Rate for Payer: Humana of AZ Medicare	$383.84
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$1,631.32
Rate for Payer: TriWest Medicare	$383.84
Rate for Payer: United Healthcare Commercial	$1,372.23
Rate for Payer: United Healthcare Medicare	$383.84
Rate for Payer: Veterans Affairs TRICARE	$380.00

CT Spine Thoracic w/o Contrast

Facility

$1,921.00

Service Code	CPT 72128
Hospital Charge Code	821376
Hospital Revenue Code	352
Min. Negotiated Rate	$1,728.90
Max. Negotiated Rate	$1,728.90
Rate for Payer: Aetna of AZ Commercial	$1,728.90
Rate for Payer: Cash Price	$1,536.80

CT Spine Thoracic w/o Contrast

Facility

$1,921.00

Service Code	CPT 72128
Hospital Charge Code	821376
Hospital Revenue Code	352
Min. Negotiated Rate	$161.76
Max. Negotiated Rate	$1,728.90
Rate for Payer: Aetna of AZ Commercial	$1,728.90
Rate for Payer: Arizona Complete Health Allwell	$307.36
Rate for Payer: Banner UC Health Medicare	$307.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,306.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$307.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$307.36
Rate for Payer: Cash Price	$1,536.80
Rate for Payer: Cash Price	$1,536.80
Rate for Payer: Cigna of AZ Commercial	$1,248.65
Rate for Payer: Devoted Health Medicare	$345.78
Rate for Payer: Humana of AZ Medicare	$307.36
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$1,306.28
Rate for Payer: TriWest Medicare	$307.36
Rate for Payer: United Healthcare Commercial	$1,098.81
Rate for Payer: United Healthcare Medicare	$307.36
Rate for Payer: Veterans Affairs TRICARE	$304.29

CT Spine Thoracic w/ + w/o Contrast

Facility

$3,078.00

Service Code	CPT 72130
Hospital Charge Code	1005221
Hospital Revenue Code	352
Min. Negotiated Rate	$2,770.20
Max. Negotiated Rate	$2,770.20
Rate for Payer: Aetna of AZ Commercial	$2,770.20
Rate for Payer: Cash Price	$2,462.40

CT Spine Thoracic w/ + w/o Contrast

Facility

$3,078.00

Service Code	CPT 72130
Hospital Charge Code	1005221
Hospital Revenue Code	352
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$2,770.20
Rate for Payer: Aetna of AZ Commercial	$2,770.20
Rate for Payer: Arizona Complete Health Allwell	$492.48
Rate for Payer: Banner UC Health Medicare	$492.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,093.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$492.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$492.48
Rate for Payer: Cash Price	$2,462.40
Rate for Payer: Cash Price	$2,462.40
Rate for Payer: Cigna of AZ Commercial	$2,000.70
Rate for Payer: Devoted Health Medicare	$554.04
Rate for Payer: Humana of AZ Medicare	$492.48
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$2,093.04
Rate for Payer: TriWest Medicare	$492.48
Rate for Payer: United Healthcare Commercial	$1,760.62
Rate for Payer: United Healthcare Medicare	$492.48
Rate for Payer: Veterans Affairs TRICARE	$487.56

CT Upper Extremity w/ Contrast Left

Facility

$3,086.00

Service Code	CPT 73201 LT
Hospital Charge Code	821384
Hospital Revenue Code	352
Min. Negotiated Rate	$2,777.40
Max. Negotiated Rate	$2,777.40
Rate for Payer: Aetna of AZ Commercial	$2,777.40
Rate for Payer: Cash Price	$2,468.80

CT Upper Extremity w/ Contrast Left

Facility

$3,086.00

Service Code	CPT 73201 LT
Hospital Charge Code	821384
Hospital Revenue Code	352
Min. Negotiated Rate	$488.82
Max. Negotiated Rate	$2,777.40
Rate for Payer: Aetna of AZ Commercial	$2,777.40
Rate for Payer: Arizona Complete Health Allwell	$493.76
Rate for Payer: Banner UC Health Medicare	$493.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,098.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$493.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$493.76
Rate for Payer: Cash Price	$2,468.80
Rate for Payer: Cigna of AZ Commercial	$2,005.90
Rate for Payer: Devoted Health Medicare	$555.48
Rate for Payer: Humana of AZ Medicare	$493.76
Rate for Payer: Southwest Service Administrators UFCW	$2,098.48
Rate for Payer: TriWest Medicare	$493.76
Rate for Payer: United Healthcare Commercial	$1,765.19
Rate for Payer: United Healthcare Medicare	$493.76
Rate for Payer: Veterans Affairs TRICARE	$488.82

CT Upper Extremity w/ Contrast Right

Facility

$2,734.00

Service Code	CPT 73201 RT
Hospital Charge Code	821386
Hospital Revenue Code	352
Min. Negotiated Rate	$433.07
Max. Negotiated Rate	$2,460.60
Rate for Payer: Aetna of AZ Commercial	$2,460.60
Rate for Payer: Arizona Complete Health Allwell	$437.44
Rate for Payer: Banner UC Health Medicare	$437.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,859.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$437.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$437.44
Rate for Payer: Cash Price	$2,187.20
Rate for Payer: Cigna of AZ Commercial	$1,777.10
Rate for Payer: Devoted Health Medicare	$492.12
Rate for Payer: Humana of AZ Medicare	$437.44
Rate for Payer: Southwest Service Administrators UFCW	$1,859.12
Rate for Payer: TriWest Medicare	$437.44
Rate for Payer: United Healthcare Commercial	$1,563.85
Rate for Payer: United Healthcare Medicare	$437.44
Rate for Payer: Veterans Affairs TRICARE	$433.07

CT Upper Extremity w/ Contrast Right

Facility

$2,734.00

Service Code	CPT 73201 RT
Hospital Charge Code	821386
Hospital Revenue Code	352
Min. Negotiated Rate	$2,460.60
Max. Negotiated Rate	$2,460.60
Rate for Payer: Aetna of AZ Commercial	$2,460.60
Rate for Payer: Cash Price	$2,187.20

CT Upper Extremity w/o Contrast Left

Facility

$2,420.00

Service Code	CPT 73200 LT
Hospital Charge Code	821388
Hospital Revenue Code	352
Min. Negotiated Rate	$2,178.00
Max. Negotiated Rate	$2,178.00
Rate for Payer: Aetna of AZ Commercial	$2,178.00
Rate for Payer: Cash Price	$1,936.00

CT Upper Extremity w/o Contrast Left

Facility

$2,420.00

Service Code	CPT 73200 LT
Hospital Charge Code	821388
Hospital Revenue Code	352
Min. Negotiated Rate	$383.33
Max. Negotiated Rate	$2,178.00
Rate for Payer: Aetna of AZ Commercial	$2,178.00
Rate for Payer: Arizona Complete Health Allwell	$387.20
Rate for Payer: Banner UC Health Medicare	$387.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,645.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$387.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$387.20
Rate for Payer: Cash Price	$1,936.00
Rate for Payer: Cigna of AZ Commercial	$1,573.00
Rate for Payer: Devoted Health Medicare	$435.60
Rate for Payer: Humana of AZ Medicare	$387.20
Rate for Payer: Southwest Service Administrators UFCW	$1,645.60
Rate for Payer: TriWest Medicare	$387.20
Rate for Payer: United Healthcare Commercial	$1,384.24
Rate for Payer: United Healthcare Medicare	$387.20
Rate for Payer: Veterans Affairs TRICARE	$383.33

CT Upper Extremity w/o Contrast Right

Facility

$2,352.00

Service Code	CPT 73200 RT
Hospital Charge Code	821390
Hospital Revenue Code	352
Min. Negotiated Rate	$2,116.80
Max. Negotiated Rate	$2,116.80
Rate for Payer: Aetna of AZ Commercial	$2,116.80
Rate for Payer: Cash Price	$1,881.60

CT Upper Extremity w/o Contrast Right

Facility

$2,352.00

Service Code	CPT 73200 RT
Hospital Charge Code	821390
Hospital Revenue Code	352
Min. Negotiated Rate	$372.56
Max. Negotiated Rate	$2,116.80
Rate for Payer: Aetna of AZ Commercial	$2,116.80
Rate for Payer: Arizona Complete Health Allwell	$376.32
Rate for Payer: Banner UC Health Medicare	$376.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,599.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$376.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$376.32
Rate for Payer: Cash Price	$1,881.60
Rate for Payer: Cigna of AZ Commercial	$1,528.80
Rate for Payer: Devoted Health Medicare	$423.36
Rate for Payer: Humana of AZ Medicare	$376.32
Rate for Payer: Southwest Service Administrators UFCW	$1,599.36
Rate for Payer: TriWest Medicare	$376.32
Rate for Payer: United Healthcare Commercial	$1,345.34
Rate for Payer: United Healthcare Medicare	$376.32
Rate for Payer: Veterans Affairs TRICARE	$372.56

CT Upper Extremity w/ + w/o Contrast Left

Facility

$3,603.00

Service Code	CPT 73202 LT
Hospital Charge Code	1005229
Hospital Revenue Code	352
Min. Negotiated Rate	$3,242.70
Max. Negotiated Rate	$3,242.70
Rate for Payer: Aetna of AZ Commercial	$3,242.70
Rate for Payer: Cash Price	$2,882.40

CT Upper Extremity w/ + w/o Contrast Left

Facility

$3,603.00

Service Code	CPT 73202 LT
Hospital Charge Code	1005229
Hospital Revenue Code	352
Min. Negotiated Rate	$570.72
Max. Negotiated Rate	$3,242.70
Rate for Payer: Aetna of AZ Commercial	$3,242.70
Rate for Payer: Arizona Complete Health Allwell	$576.48
Rate for Payer: Banner UC Health Medicare	$576.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,450.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$576.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$576.48
Rate for Payer: Cash Price	$2,882.40
Rate for Payer: Cigna of AZ Commercial	$2,341.95
Rate for Payer: Devoted Health Medicare	$648.54
Rate for Payer: Humana of AZ Medicare	$576.48
Rate for Payer: Southwest Service Administrators UFCW	$2,450.04
Rate for Payer: TriWest Medicare	$576.48
Rate for Payer: United Healthcare Commercial	$2,060.92
Rate for Payer: United Healthcare Medicare	$576.48
Rate for Payer: Veterans Affairs TRICARE	$570.72

CT Upper Extremity w/ + w/o Contrast Right

Facility

$2,521.00

Service Code	CPT 73202 RT
Hospital Charge Code	1005231
Hospital Revenue Code	352
Min. Negotiated Rate	$399.33
Max. Negotiated Rate	$2,268.90
Rate for Payer: Aetna of AZ Commercial	$2,268.90
Rate for Payer: Arizona Complete Health Allwell	$403.36
Rate for Payer: Banner UC Health Medicare	$403.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,714.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$403.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$403.36
Rate for Payer: Cash Price	$2,016.80
Rate for Payer: Cigna of AZ Commercial	$1,638.65
Rate for Payer: Devoted Health Medicare	$453.78
Rate for Payer: Humana of AZ Medicare	$403.36
Rate for Payer: Southwest Service Administrators UFCW	$1,714.28
Rate for Payer: TriWest Medicare	$403.36
Rate for Payer: United Healthcare Commercial	$1,442.01
Rate for Payer: United Healthcare Medicare	$403.36
Rate for Payer: Veterans Affairs TRICARE	$399.33

CT Upper Extremity w/ + w/o Contrast Right

Facility

$2,521.00

Service Code	CPT 73202 RT
Hospital Charge Code	1005231
Hospital Revenue Code	352
Min. Negotiated Rate	$2,268.90
Max. Negotiated Rate	$2,268.90
Rate for Payer: Aetna of AZ Commercial	$2,268.90
Rate for Payer: Cash Price	$2,016.80

CUFF CONNECTION TUBE 100CM

Facility

$395.55

Hospital Charge Code	28013864
Hospital Revenue Code	270
Min. Negotiated Rate	$62.66
Max. Negotiated Rate	$356.00
Rate for Payer: Aetna of AZ Commercial	$356.00
Rate for Payer: Arizona Complete Health Allwell	$63.29
Rate for Payer: Banner UC Health Medicare	$63.29
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$268.97
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$63.29
Rate for Payer: Care1st Health Plan Arizona Medicare	$63.29
Rate for Payer: Cash Price	$316.44
Rate for Payer: Cigna of AZ Commercial	$276.88
Rate for Payer: Devoted Health Medicare	$71.20
Rate for Payer: Humana of AZ Medicare	$63.29
Rate for Payer: Southwest Service Administrators UFCW	$268.97
Rate for Payer: TriWest Medicare	$63.29
Rate for Payer: United Healthcare Commercial	$226.25
Rate for Payer: United Healthcare Medicare	$63.29
Rate for Payer: Veterans Affairs TRICARE	$62.66

CUFF CONNECTION TUBE 100CM

Facility

$395.55

Hospital Charge Code	28013864
Hospital Revenue Code	270
Min. Negotiated Rate	$356.00
Max. Negotiated Rate	$356.00
Rate for Payer: Aetna of AZ Commercial	$356.00
Rate for Payer: Cash Price	$316.44

Culdoplasty Enterocele Repair abdominal

Facility

$4,215.00

Service Code	CPT 57270
Hospital Charge Code	27267814
Hospital Revenue Code	360
Min. Negotiated Rate	$667.66
Max. Negotiated Rate	$4,169.00
Rate for Payer: Aetna of AZ Commercial	$3,793.50
Rate for Payer: Arizona Complete Health Allwell	$674.40
Rate for Payer: Banner UC Health Medicare	$674.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,866.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$674.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$674.40
Rate for Payer: Cash Price	$3,372.00
Rate for Payer: Cash Price	$3,372.00
Rate for Payer: Cigna of AZ Commercial	$2,107.50
Rate for Payer: Devoted Health Medicare	$758.70
Rate for Payer: Humana of AZ Medicare	$674.40
Rate for Payer: Southwest Service Administrators UFCW	$2,866.20
Rate for Payer: TriWest Medicare	$674.40
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$674.40
Rate for Payer: Veterans Affairs TRICARE	$667.66

Culdoplasty Enterocele Repair abdominal

Facility

$4,215.00

Service Code	CPT 57270
Hospital Charge Code	27267814
Hospital Revenue Code	360
Min. Negotiated Rate	$3,793.50
Max. Negotiated Rate	$3,793.50
Rate for Payer: Aetna of AZ Commercial	$3,793.50
Rate for Payer: Cash Price	$3,372.00

Cva And Precerebral Occlusion With Infarction

Facility

$16,038.21

Service Code	APR-DRG 0454
Hospital Charge Code	APRDRG0451
Min. Negotiated Rate	$16,038.21
Max. Negotiated Rate	$16,038.21
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$16,038.21
Rate for Payer: Mercy Care Medicaid	$16,038.21
Rate for Payer: NaphCare Correctional Healthcare	$16,038.21

Know your out-of-pocket cost for care.

All Charges