Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

cystourethroscopic treatment of a benign prostatic obstructi

Facility

$1,200.00

Service Code	CPT 52443
Hospital Charge Code	28254332
Hospital Revenue Code	360
Min. Negotiated Rate	$190.08
Max. Negotiated Rate	$14,647.16
Rate for Payer: Aetna of AZ Commercial	$1,080.00
Rate for Payer: Arizona Complete Health Allwell	$192.00
Rate for Payer: Banner UC Health Medicare	$6,342.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$816.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,833.94
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$192.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$192.00
Rate for Payer: Cash Price	$960.00
Rate for Payer: Cash Price	$960.00
Rate for Payer: Cash Price	$960.00
Rate for Payer: Cigna of AZ Commercial	$600.00
Rate for Payer: Devoted Health Medicare	$216.00
Rate for Payer: Humana of AZ Medicare	$192.00
Rate for Payer: Mercy Care Medicaid	$5,833.94
Rate for Payer: NaphCare Correctional Healthcare	$6,342.56
Rate for Payer: Seven Corners Travel Insurance	$14,647.16
Rate for Payer: Southwest Service Administrators UFCW	$816.00
Rate for Payer: TriWest Medicare	$192.00
Rate for Payer: United Healthcare Commercial	$3,373.00
Rate for Payer: United Healthcare Medicare	$192.00
Rate for Payer: Veterans Affairs TRICARE	$190.08

cystourethroscopic treatment of a benign prostatic obstructi

Facility

$1,200.00

Service Code	CPT 52443
Hospital Charge Code	28254332
Hospital Revenue Code	360
Min. Negotiated Rate	$1,080.00
Max. Negotiated Rate	$1,080.00
Rate for Payer: Aetna of AZ Commercial	$1,080.00
Rate for Payer: Cash Price	$960.00

Cystourethroscopy (separate procedure)

Facility

$3,098.00

Service Code	CPT 52000
Hospital Revenue Code	360
Min. Negotiated Rate	$142.60
Max. Negotiated Rate	$3,098.00
Rate for Payer: Banner UC Health Medicare	$211.61
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$142.60
Rate for Payer: Mercy Care Medicaid	$142.60
Rate for Payer: NaphCare Correctional Healthcare	$211.61
Rate for Payer: Seven Corners Travel Insurance	$1,078.90
Rate for Payer: United Healthcare Commercial	$3,098.00

Cystourethroscopy (separate procedure)

Facility

$3,098.00

Service Code	CPT 52000
Hospital Revenue Code	490
Min. Negotiated Rate	$142.60
Max. Negotiated Rate	$3,098.00
Rate for Payer: Banner UC Health Medicare	$211.61
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$142.60
Rate for Payer: Mercy Care Medicaid	$142.60
Rate for Payer: NaphCare Correctional Healthcare	$211.61
Rate for Payer: Seven Corners Travel Insurance	$1,078.90
Rate for Payer: United Healthcare Commercial	$3,098.00

Cystourethroscopy, with biopsy(s)

Facility

$4,169.00

Service Code	CPT 52204
Hospital Revenue Code	750
Min. Negotiated Rate	$217.57
Max. Negotiated Rate	$4,169.00
Rate for Payer: Banner UC Health Medicare	$690.65
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$217.57
Rate for Payer: Mercy Care Medicaid	$217.57
Rate for Payer: NaphCare Correctional Healthcare	$690.65
Rate for Payer: Seven Corners Travel Insurance	$3,234.38
Rate for Payer: United Healthcare Commercial	$4,169.00

Cystourethroscopy, with biopsy(s)

Facility

$4,169.00

Service Code	CPT 52204
Hospital Revenue Code	490
Min. Negotiated Rate	$217.57
Max. Negotiated Rate	$4,169.00
Rate for Payer: Banner UC Health Medicare	$690.65
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$217.57
Rate for Payer: Mercy Care Medicaid	$217.57
Rate for Payer: NaphCare Correctional Healthcare	$690.65
Rate for Payer: Seven Corners Travel Insurance	$3,234.38
Rate for Payer: United Healthcare Commercial	$4,169.00

CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA

Facility

$3,596.00

Service Code	CPT 52260
Hospital Revenue Code	750
Min. Negotiated Rate	$690.65
Max. Negotiated Rate	$3,596.00
Rate for Payer: Banner UC Health Medicare	$690.65
Rate for Payer: NaphCare Correctional Healthcare	$690.65
Rate for Payer: Seven Corners Travel Insurance	$3,234.38
Rate for Payer: United Healthcare Commercial	$3,596.00

Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands

Facility

$5,454.10

Service Code	CPT 52214
Hospital Revenue Code	490
Min. Negotiated Rate	$544.27
Max. Negotiated Rate	$5,454.10
Rate for Payer: Banner UC Health Medicare	$1,171.31
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$544.27
Rate for Payer: Mercy Care Medicaid	$544.27
Rate for Payer: NaphCare Correctional Healthcare	$1,171.31
Rate for Payer: Seven Corners Travel Insurance	$5,454.10
Rate for Payer: United Healthcare Commercial	$4,169.00

Cystourethroscopy with irrigation and evacuation of multiple obstructing clots

Facility

$5,454.10

Service Code	CPT 52001
Hospital Revenue Code	490
Min. Negotiated Rate	$138.77
Max. Negotiated Rate	$5,454.10
Rate for Payer: Banner UC Health Medicare	$1,171.31
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$138.77
Rate for Payer: Mercy Care Medicaid	$138.77
Rate for Payer: NaphCare Correctional Healthcare	$1,171.31
Rate for Payer: Seven Corners Travel Insurance	$5,454.10
Rate for Payer: United Healthcare Commercial	$3,596.00

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; DIAGNOSTIC

Facility

$5,454.10

Service Code	CPT 52351
Hospital Revenue Code	360
Min. Negotiated Rate	$1,171.31
Max. Negotiated Rate	$5,454.10
Rate for Payer: Banner UC Health Medicare	$1,171.31
Rate for Payer: NaphCare Correctional Healthcare	$1,171.31
Rate for Payer: Seven Corners Travel Insurance	$5,454.10
Rate for Payer: United Healthcare Commercial	$4,169.00

Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral stent (e.g., Gibbons or double-J type)

Facility

$8,296.15

Service Code	CPT 52356
Hospital Revenue Code	360
Min. Negotiated Rate	$1,977.90
Max. Negotiated Rate	$8,296.15
Rate for Payer: Banner UC Health Medicare	$1,977.90
Rate for Payer: NaphCare Correctional Healthcare	$1,977.90
Rate for Payer: Seven Corners Travel Insurance	$8,296.15
Rate for Payer: United Healthcare Commercial	$5,611.00

Cytomegalovirus (CMV) Ab, IgG LC

Facility

$219.00

Service Code	CPT 86644
Hospital Charge Code	2029259
Hospital Revenue Code	302
Min. Negotiated Rate	$20.87
Max. Negotiated Rate	$197.10
Rate for Payer: Aetna of AZ Commercial	$197.10
Rate for Payer: Arizona Complete Health Allwell	$35.04
Rate for Payer: Banner UC Health Medicare	$35.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$148.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$35.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$35.04
Rate for Payer: Cash Price	$175.20
Rate for Payer: Cash Price	$175.20
Rate for Payer: Cigna of AZ Commercial	$142.35
Rate for Payer: Devoted Health Medicare	$39.42
Rate for Payer: Humana of AZ Medicare	$35.04
Rate for Payer: Seven Corners Travel Insurance	$20.87
Rate for Payer: Southwest Service Administrators UFCW	$148.92
Rate for Payer: TriWest Medicare	$35.04
Rate for Payer: United Healthcare Commercial	$125.27
Rate for Payer: United Healthcare Medicare	$35.04
Rate for Payer: Veterans Affairs TRICARE	$34.69

Cytomegalovirus (CMV) Ab, IgG LC

Facility

$219.00

Service Code	CPT 86644
Hospital Charge Code	2029259
Hospital Revenue Code	302
Min. Negotiated Rate	$197.10
Max. Negotiated Rate	$197.10
Rate for Payer: Aetna of AZ Commercial	$197.10
Rate for Payer: Cash Price	$175.20

Cytomegalovirus (CMV) Ab, IgM LC

Facility

$230.00

Service Code	CPT 86645
Hospital Charge Code	2029230
Hospital Revenue Code	302
Min. Negotiated Rate	$207.00
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna of AZ Commercial	$207.00
Rate for Payer: Cash Price	$184.00

Cytomegalovirus (CMV) Ab, IgM LC

Facility

$230.00

Service Code	CPT 86645
Hospital Charge Code	2029230
Hospital Revenue Code	302
Min. Negotiated Rate	$24.43
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna of AZ Commercial	$207.00
Rate for Payer: Arizona Complete Health Allwell	$36.80
Rate for Payer: Banner UC Health Medicare	$36.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$156.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.80
Rate for Payer: Cash Price	$184.00
Rate for Payer: Cash Price	$184.00
Rate for Payer: Cigna of AZ Commercial	$149.50
Rate for Payer: Devoted Health Medicare	$41.40
Rate for Payer: Humana of AZ Medicare	$36.80
Rate for Payer: Seven Corners Travel Insurance	$24.43
Rate for Payer: Southwest Service Administrators UFCW	$156.40
Rate for Payer: TriWest Medicare	$36.80
Rate for Payer: United Healthcare Commercial	$131.56
Rate for Payer: United Healthcare Medicare	$36.80
Rate for Payer: Veterans Affairs TRICARE	$36.43

CYTOPATH CELL ENHANCE TECH

Facility

$177.00

Service Code	CPT 88112
Hospital Charge Code	22545729
Hospital Revenue Code	310
Min. Negotiated Rate	$159.30
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Cash Price	$141.60

CYTOPATH CELL ENHANCE TECH

Facility

$177.00

Service Code	CPT 88112
Hospital Charge Code	22545729
Hospital Revenue Code	310
Min. Negotiated Rate	$28.04
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Arizona Complete Health Allwell	$28.32
Rate for Payer: Banner UC Health Medicare	$28.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$120.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$47.34
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cigna of AZ Commercial	$115.05
Rate for Payer: Devoted Health Medicare	$31.86
Rate for Payer: Humana of AZ Medicare	$28.32
Rate for Payer: Seven Corners Travel Insurance	$80.63
Rate for Payer: Southwest Service Administrators UFCW	$120.36
Rate for Payer: TriWest Medicare	$28.32
Rate for Payer: United Healthcare Commercial	$101.24
Rate for Payer: United Healthcare Medicare	$28.32
Rate for Payer: Veterans Affairs TRICARE	$28.04

CYTOPATH CONCENTRATE TECH

Facility

$282.00

Service Code	CPT 88108
Hospital Charge Code	22545551
Hospital Revenue Code	310
Min. Negotiated Rate	$44.67
Max. Negotiated Rate	$253.80
Rate for Payer: Aetna of AZ Commercial	$253.80
Rate for Payer: Arizona Complete Health Allwell	$45.12
Rate for Payer: Banner UC Health Medicare	$45.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$191.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$45.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$49.82
Rate for Payer: Cash Price	$225.60
Rate for Payer: Cash Price	$225.60
Rate for Payer: Cigna of AZ Commercial	$183.30
Rate for Payer: Devoted Health Medicare	$50.76
Rate for Payer: Humana of AZ Medicare	$45.12
Rate for Payer: Seven Corners Travel Insurance	$57.80
Rate for Payer: Southwest Service Administrators UFCW	$191.76
Rate for Payer: TriWest Medicare	$45.12
Rate for Payer: United Healthcare Commercial	$161.30
Rate for Payer: United Healthcare Medicare	$45.12
Rate for Payer: Veterans Affairs TRICARE	$44.67

CYTOPATH CONCENTRATE TECH

Facility

$282.00

Service Code	CPT 88108
Hospital Charge Code	22545551
Hospital Revenue Code	310
Min. Negotiated Rate	$253.80
Max. Negotiated Rate	$253.80
Rate for Payer: Aetna of AZ Commercial	$253.80
Rate for Payer: Cash Price	$225.60

CYTOPATH EVAL FNA REPORT

Facility

$379.00

Service Code	CPT 88173
Hospital Charge Code	22545710
Hospital Revenue Code	310
Min. Negotiated Rate	$60.03
Max. Negotiated Rate	$341.10
Rate for Payer: Aetna of AZ Commercial	$341.10
Rate for Payer: Arizona Complete Health Allwell	$60.64
Rate for Payer: Banner UC Health Medicare	$60.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$257.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$60.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$120.71
Rate for Payer: Cash Price	$303.20
Rate for Payer: Cash Price	$303.20
Rate for Payer: Cigna of AZ Commercial	$246.35
Rate for Payer: Devoted Health Medicare	$68.22
Rate for Payer: Humana of AZ Medicare	$60.64
Rate for Payer: Seven Corners Travel Insurance	$80.63
Rate for Payer: Southwest Service Administrators UFCW	$257.72
Rate for Payer: TriWest Medicare	$60.64
Rate for Payer: United Healthcare Commercial	$216.79
Rate for Payer: United Healthcare Medicare	$60.64
Rate for Payer: Veterans Affairs TRICARE	$60.03

CYTOPATH EVAL FNA REPORT

Facility

$379.00

Service Code	CPT 88173
Hospital Charge Code	22545710
Hospital Revenue Code	310
Min. Negotiated Rate	$341.10
Max. Negotiated Rate	$341.10
Rate for Payer: Aetna of AZ Commercial	$341.10
Rate for Payer: Cash Price	$303.20

CYTOPATH FL NON GYN FILTER

Facility

$343.00

Service Code	CPT 88106
Hospital Charge Code	22545728
Hospital Revenue Code	310
Min. Negotiated Rate	$44.75
Max. Negotiated Rate	$308.70
Rate for Payer: Aetna of AZ Commercial	$308.70
Rate for Payer: Arizona Complete Health Allwell	$54.88
Rate for Payer: Banner UC Health Medicare	$54.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$233.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$54.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$48.83
Rate for Payer: Cash Price	$274.40
Rate for Payer: Cash Price	$274.40
Rate for Payer: Cigna of AZ Commercial	$222.95
Rate for Payer: Devoted Health Medicare	$61.74
Rate for Payer: Humana of AZ Medicare	$54.88
Rate for Payer: Seven Corners Travel Insurance	$44.75
Rate for Payer: Southwest Service Administrators UFCW	$233.24
Rate for Payer: TriWest Medicare	$54.88
Rate for Payer: United Healthcare Commercial	$196.20
Rate for Payer: United Healthcare Medicare	$54.88
Rate for Payer: Veterans Affairs TRICARE	$54.33

CYTOPATH FL NON GYN FILTER

Facility

$343.00

Service Code	CPT 88106
Hospital Charge Code	22545728
Hospital Revenue Code	310
Min. Negotiated Rate	$308.70
Max. Negotiated Rate	$308.70
Rate for Payer: Aetna of AZ Commercial	$308.70
Rate for Payer: Cash Price	$274.40

CYTOPATH FL NON GYN SMEARS

Facility

$239.00

Service Code	CPT 88104
Hospital Charge Code	22545727
Hospital Revenue Code	310
Min. Negotiated Rate	$215.10
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Cash Price	$191.20

CYTOPATH FL NON GYN SMEARS

Facility

$239.00

Service Code	CPT 88104
Hospital Charge Code	22545727
Hospital Revenue Code	310
Min. Negotiated Rate	$37.86
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Arizona Complete Health Allwell	$38.24
Rate for Payer: Banner UC Health Medicare	$38.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$162.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$60.97
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cigna of AZ Commercial	$155.35
Rate for Payer: Devoted Health Medicare	$43.02
Rate for Payer: Humana of AZ Medicare	$38.24
Rate for Payer: Seven Corners Travel Insurance	$57.80
Rate for Payer: Southwest Service Administrators UFCW	$162.52
Rate for Payer: TriWest Medicare	$38.24
Rate for Payer: United Healthcare Commercial	$136.71
Rate for Payer: United Healthcare Medicare	$38.24
Rate for Payer: Veterans Affairs TRICARE	$37.86

Know your out-of-pocket cost for care.

All Charges