Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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	$123.43
Max. Negotiated Rate	$5,129.91
Rate for Payer: Aetna of AZ Commercial	$706.50
Rate for Payer: Arizona Complete Health Allwell	$125.60
Rate for Payer: Banner UC Health Medicare	$125.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$533.80
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$123.43
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$125.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$125.60
Rate for Payer: Cash Price	$628.00
Rate for Payer: Cash Price	$628.00
Rate for Payer: Cigna of AZ Commercial	$549.50
Rate for Payer: Devoted Health Medicare	$141.30
Rate for Payer: Humana of AZ Medicare	$125.60
Rate for Payer: Mercy Care Medicaid	$123.43
Rate for Payer: NaphCare Correctional Healthcare	$123.43
Rate for Payer: Seven Corners Travel Insurance	$5,129.91
Rate for Payer: Southwest Service Administrators UFCW	$533.80
Rate for Payer: TriWest Medicare	$125.60
Rate for Payer: United Healthcare Commercial	$449.02
Rate for Payer: United Healthcare Medicare	$125.60
Rate for Payer: United Healthcare New Mexico Commercial	$149.15
Rate for Payer: Veterans Affairs TRICARE	$124.34

21800 CLSD TX RIB FX UNCOM @

Facility

$379.00

Service Code	CPT 21800
Hospital Charge Code	22282828
Hospital Revenue Code	450
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

21800 CLSD TX RIB FX UNCOM @

Facility

$379.00

Service Code	CPT 21800
Hospital Charge Code	22282828
Hospital Revenue Code	450
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	$60.64
Rate for Payer: Cash Price	$303.20
Rate for Payer: Cigna of AZ Commercial	$265.30
Rate for Payer: Devoted Health Medicare	$68.22
Rate for Payer: Humana of AZ Medicare	$60.64
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: United Healthcare New Mexico Commercial	$72.01
Rate for Payer: Veterans Affairs TRICARE	$60.03

21810 TX FLAI CHEST

Facility

$2,940.00

Service Code	CPT 21810
Hospital Charge Code	22282829
Hospital Revenue Code	450
Min. Negotiated Rate	$2,646.00
Max. Negotiated Rate	$2,646.00
Rate for Payer: Aetna of AZ Commercial	$2,646.00
Rate for Payer: Cash Price	$2,352.00

21810 TX FLAI CHEST

Facility

$2,940.00

Service Code	CPT 21810
Hospital Charge Code	22282829
Hospital Revenue Code	450
Min. Negotiated Rate	$465.70
Max. Negotiated Rate	$2,646.00
Rate for Payer: Aetna of AZ Commercial	$2,646.00
Rate for Payer: Arizona Complete Health Allwell	$470.40
Rate for Payer: Banner UC Health Medicare	$470.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,999.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$470.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$470.40
Rate for Payer: Cash Price	$2,352.00
Rate for Payer: Cigna of AZ Commercial	$2,058.00
Rate for Payer: Devoted Health Medicare	$529.20
Rate for Payer: Humana of AZ Medicare	$470.40
Rate for Payer: Southwest Service Administrators UFCW	$1,999.20
Rate for Payer: TriWest Medicare	$470.40
Rate for Payer: United Healthcare Commercial	$1,681.68
Rate for Payer: United Healthcare Medicare	$470.40
Rate for Payer: United Healthcare New Mexico Commercial	$558.60
Rate for Payer: Veterans Affairs TRICARE	$465.70

22305 CLSD TX FX VERT

Facility

$852.00

Hospital Charge Code	22282830
Hospital Revenue Code	450
Min. Negotiated Rate	$134.96
Max. Negotiated Rate	$766.80
Rate for Payer: Aetna of AZ Commercial	$766.80
Rate for Payer: Arizona Complete Health Allwell	$136.32
Rate for Payer: Banner UC Health Medicare	$136.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$579.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$136.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$136.32
Rate for Payer: Cash Price	$681.60
Rate for Payer: Cigna of AZ Commercial	$596.40
Rate for Payer: Devoted Health Medicare	$153.36
Rate for Payer: Humana of AZ Medicare	$136.32
Rate for Payer: Southwest Service Administrators UFCW	$579.36
Rate for Payer: TriWest Medicare	$136.32
Rate for Payer: United Healthcare Commercial	$487.34
Rate for Payer: United Healthcare Medicare	$136.32
Rate for Payer: United Healthcare New Mexico Commercial	$161.88
Rate for Payer: Veterans Affairs TRICARE	$134.96

22305 CLSD TX FX VERT

Facility

$852.00

Hospital Charge Code	22282830
Hospital Revenue Code	450
Min. Negotiated Rate	$766.80
Max. Negotiated Rate	$766.80
Rate for Payer: Aetna of AZ Commercial	$766.80
Rate for Payer: Cash Price	$681.60

23500 CLSD TXFX CLAR W/O MANIP

Facility

$837.00

Service Code	CPT 23500
Hospital Charge Code	22282831
Hospital Revenue Code	450
Min. Negotiated Rate	$132.58
Max. Negotiated Rate	$753.30
Rate for Payer: Aetna of AZ Commercial	$753.30
Rate for Payer: Arizona Complete Health Allwell	$133.92
Rate for Payer: Banner UC Health Medicare	$133.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$569.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$133.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$133.92
Rate for Payer: Cash Price	$669.60
Rate for Payer: Cash Price	$669.60
Rate for Payer: Cigna of AZ Commercial	$585.90
Rate for Payer: Devoted Health Medicare	$150.66
Rate for Payer: Humana of AZ Medicare	$133.92
Rate for Payer: Seven Corners Travel Insurance	$381.65
Rate for Payer: Southwest Service Administrators UFCW	$569.16
Rate for Payer: TriWest Medicare	$133.92
Rate for Payer: United Healthcare Commercial	$478.76
Rate for Payer: United Healthcare Medicare	$133.92
Rate for Payer: United Healthcare New Mexico Commercial	$159.03
Rate for Payer: Veterans Affairs TRICARE	$132.58

23500 CLSD TXFX CLAR W/O MANIP

Facility

$837.00

Service Code	CPT 23500
Hospital Charge Code	22282831
Hospital Revenue Code	450
Min. Negotiated Rate	$753.30
Max. Negotiated Rate	$753.30
Rate for Payer: Aetna of AZ Commercial	$753.30
Rate for Payer: Cash Price	$669.60

23505 CLSD TX FX CLAV W/MANIP

Facility

$1,400.00

Service Code	CPT 23505
Hospital Charge Code	22282832
Hospital Revenue Code	450
Min. Negotiated Rate	$27.89
Max. Negotiated Rate	$2,488.00
Rate for Payer: Aetna of AZ Commercial	$1,260.00
Rate for Payer: Arizona Complete Health Allwell	$224.00
Rate for Payer: Banner UC Health Medicare	$224.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$952.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$27.89
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$224.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$224.00
Rate for Payer: Cash Price	$1,120.00
Rate for Payer: Cash Price	$1,120.00
Rate for Payer: Cigna of AZ Commercial	$980.00
Rate for Payer: Devoted Health Medicare	$252.00
Rate for Payer: Humana of AZ Medicare	$224.00
Rate for Payer: Mercy Care Medicaid	$27.89
Rate for Payer: NaphCare Correctional Healthcare	$27.89
Rate for Payer: Seven Corners Travel Insurance	$2,488.00
Rate for Payer: Southwest Service Administrators UFCW	$952.00
Rate for Payer: TriWest Medicare	$224.00
Rate for Payer: United Healthcare Commercial	$800.80
Rate for Payer: United Healthcare Medicare	$224.00
Rate for Payer: United Healthcare New Mexico Commercial	$266.00
Rate for Payer: Veterans Affairs TRICARE	$221.76

23505 CLSD TX FX CLAV W/MANIP

Facility

$1,400.00

Service Code	CPT 23505
Hospital Charge Code	22282832
Hospital Revenue Code	450
Min. Negotiated Rate	$1,260.00
Max. Negotiated Rate	$1,260.00
Rate for Payer: Aetna of AZ Commercial	$1,260.00
Rate for Payer: Cash Price	$1,120.00

23540 CLSD TX A/C DISW/O MANIP

Facility

$857.00

Service Code	CPT 23540
Hospital Charge Code	22282833
Hospital Revenue Code	450
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$771.30
Rate for Payer: Aetna of AZ Commercial	$771.30
Rate for Payer: Arizona Complete Health Allwell	$137.12
Rate for Payer: Banner UC Health Medicare	$137.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$582.76
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$1.74
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$137.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$137.12
Rate for Payer: Cash Price	$685.60
Rate for Payer: Cash Price	$685.60
Rate for Payer: Cigna of AZ Commercial	$599.90
Rate for Payer: Devoted Health Medicare	$154.26
Rate for Payer: Humana of AZ Medicare	$137.12
Rate for Payer: Mercy Care Medicaid	$1.74
Rate for Payer: NaphCare Correctional Healthcare	$1.74
Rate for Payer: Seven Corners Travel Insurance	$381.65
Rate for Payer: Southwest Service Administrators UFCW	$582.76
Rate for Payer: TriWest Medicare	$137.12
Rate for Payer: United Healthcare Commercial	$490.20
Rate for Payer: United Healthcare Medicare	$137.12
Rate for Payer: United Healthcare New Mexico Commercial	$162.83
Rate for Payer: Veterans Affairs TRICARE	$135.75

23540 CLSD TX A/C DISW/O MANIP

Facility

$857.00

Service Code	CPT 23540
Hospital Charge Code	22282833
Hospital Revenue Code	450
Min. Negotiated Rate	$771.30
Max. Negotiated Rate	$771.30
Rate for Payer: Aetna of AZ Commercial	$771.30
Rate for Payer: Cash Price	$685.60

23545 CLSD TX FX A/C DISLW/MAN

Facility

$1,212.00

Service Code	CPT 23545
Hospital Charge Code	22282834
Hospital Revenue Code	450
Min. Negotiated Rate	$40.45
Max. Negotiated Rate	$1,090.80
Rate for Payer: Aetna of AZ Commercial	$1,090.80
Rate for Payer: Arizona Complete Health Allwell	$193.92
Rate for Payer: Banner UC Health Medicare	$193.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$824.16
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$40.45
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$193.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$193.92
Rate for Payer: Cash Price	$969.60
Rate for Payer: Cash Price	$969.60
Rate for Payer: Cigna of AZ Commercial	$848.40
Rate for Payer: Devoted Health Medicare	$218.16
Rate for Payer: Humana of AZ Medicare	$193.92
Rate for Payer: Mercy Care Medicaid	$40.45
Rate for Payer: NaphCare Correctional Healthcare	$40.45
Rate for Payer: Seven Corners Travel Insurance	$381.65
Rate for Payer: Southwest Service Administrators UFCW	$824.16
Rate for Payer: TriWest Medicare	$193.92
Rate for Payer: United Healthcare Commercial	$693.26
Rate for Payer: United Healthcare Medicare	$193.92
Rate for Payer: United Healthcare New Mexico Commercial	$230.28
Rate for Payer: Veterans Affairs TRICARE	$191.98

23545 CLSD TX FX A/C DISLW/MAN

Facility

$1,212.00

Service Code	CPT 23545
Hospital Charge Code	22282834
Hospital Revenue Code	450
Min. Negotiated Rate	$1,090.80
Max. Negotiated Rate	$1,090.80
Rate for Payer: Aetna of AZ Commercial	$1,090.80
Rate for Payer: Cash Price	$969.60

23570 CLSD TX FX SCAP W/O MANI

Facility

$883.00

Service Code	CPT 23570
Hospital Charge Code	22282835
Hospital Revenue Code	450
Min. Negotiated Rate	$139.87
Max. Negotiated Rate	$794.70
Rate for Payer: Aetna of AZ Commercial	$794.70
Rate for Payer: Arizona Complete Health Allwell	$141.28
Rate for Payer: Banner UC Health Medicare	$141.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$600.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$141.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$141.28
Rate for Payer: Cash Price	$706.40
Rate for Payer: Cash Price	$706.40
Rate for Payer: Cigna of AZ Commercial	$618.10
Rate for Payer: Devoted Health Medicare	$158.94
Rate for Payer: Humana of AZ Medicare	$141.28
Rate for Payer: Seven Corners Travel Insurance	$381.65
Rate for Payer: Southwest Service Administrators UFCW	$600.44
Rate for Payer: TriWest Medicare	$141.28
Rate for Payer: United Healthcare Commercial	$505.08
Rate for Payer: United Healthcare Medicare	$141.28
Rate for Payer: United Healthcare New Mexico Commercial	$167.77
Rate for Payer: Veterans Affairs TRICARE	$139.87

23570 CLSD TX FX SCAP W/O MANI

Facility

$883.00

Service Code	CPT 23570
Hospital Charge Code	22282835
Hospital Revenue Code	450
Min. Negotiated Rate	$794.70
Max. Negotiated Rate	$794.70
Rate for Payer: Aetna of AZ Commercial	$794.70
Rate for Payer: Cash Price	$706.40

23575 CLSD TX FX SCAP W/MANIP

Facility

$1,537.00

Service Code	CPT 23575
Hospital Charge Code	22282836
Hospital Revenue Code	450
Min. Negotiated Rate	$1,383.30
Max. Negotiated Rate	$1,383.30
Rate for Payer: Aetna of AZ Commercial	$1,383.30
Rate for Payer: Cash Price	$1,229.60

23575 CLSD TX FX SCAP W/MANIP

Facility

$1,537.00

Service Code	CPT 23575
Hospital Charge Code	22282836
Hospital Revenue Code	450
Min. Negotiated Rate	$34.69
Max. Negotiated Rate	$2,488.00
Rate for Payer: Aetna of AZ Commercial	$1,383.30
Rate for Payer: Arizona Complete Health Allwell	$245.92
Rate for Payer: Banner UC Health Medicare	$245.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,045.16
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$34.69
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$245.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$245.92
Rate for Payer: Cash Price	$1,229.60
Rate for Payer: Cash Price	$1,229.60
Rate for Payer: Cigna of AZ Commercial	$1,075.90
Rate for Payer: Devoted Health Medicare	$276.66
Rate for Payer: Humana of AZ Medicare	$245.92
Rate for Payer: Mercy Care Medicaid	$34.69
Rate for Payer: NaphCare Correctional Healthcare	$34.69
Rate for Payer: Seven Corners Travel Insurance	$2,488.00
Rate for Payer: Southwest Service Administrators UFCW	$1,045.16
Rate for Payer: TriWest Medicare	$245.92
Rate for Payer: United Healthcare Commercial	$879.16
Rate for Payer: United Healthcare Medicare	$245.92
Rate for Payer: United Healthcare New Mexico Commercial	$292.03
Rate for Payer: Veterans Affairs TRICARE	$243.46

23650 CLD TX SHLDR WMANIP N/AN

Facility

$2,799.00

Service Code	CPT 23650
Hospital Charge Code	22282837
Hospital Revenue Code	450
Min. Negotiated Rate	$35.76
Max. Negotiated Rate	$2,519.10
Rate for Payer: Aetna of AZ Commercial	$2,519.10
Rate for Payer: Arizona Complete Health Allwell	$447.84
Rate for Payer: Banner UC Health Medicare	$447.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,903.32
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$35.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$447.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$447.84
Rate for Payer: Cash Price	$2,239.20
Rate for Payer: Cash Price	$2,239.20
Rate for Payer: Cigna of AZ Commercial	$1,959.30
Rate for Payer: Devoted Health Medicare	$503.82
Rate for Payer: Humana of AZ Medicare	$447.84
Rate for Payer: Mercy Care Medicaid	$35.76
Rate for Payer: NaphCare Correctional Healthcare	$35.76
Rate for Payer: Seven Corners Travel Insurance	$381.65
Rate for Payer: Southwest Service Administrators UFCW	$1,903.32
Rate for Payer: TriWest Medicare	$447.84
Rate for Payer: United Healthcare Commercial	$1,601.03
Rate for Payer: United Healthcare Medicare	$447.84
Rate for Payer: United Healthcare New Mexico Commercial	$531.81
Rate for Payer: Veterans Affairs TRICARE	$443.36

23650 CLD TX SHLDR WMANIP N/AN

Facility

$2,799.00

Service Code	CPT 23650
Hospital Charge Code	22282837
Hospital Revenue Code	450
Min. Negotiated Rate	$2,519.10
Max. Negotiated Rate	$2,519.10
Rate for Payer: Aetna of AZ Commercial	$2,519.10
Rate for Payer: Cash Price	$2,239.20

23655 CLD TX SHLDR DS WMANIP A

Facility

$2,599.00

Service Code	CPT 23655
Hospital Charge Code	22282838
Hospital Revenue Code	450
Min. Negotiated Rate	$2,339.10
Max. Negotiated Rate	$2,339.10
Rate for Payer: Aetna of AZ Commercial	$2,339.10
Rate for Payer: Cash Price	$2,079.20

23655 CLD TX SHLDR DS WMANIP A

Facility

$2,599.00

Service Code	CPT 23655
Hospital Charge Code	22282838
Hospital Revenue Code	450
Min. Negotiated Rate	$411.68
Max. Negotiated Rate	$2,488.00
Rate for Payer: Aetna of AZ Commercial	$2,339.10
Rate for Payer: Arizona Complete Health Allwell	$415.84
Rate for Payer: Banner UC Health Medicare	$415.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,767.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$415.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$415.84
Rate for Payer: Cash Price	$2,079.20
Rate for Payer: Cash Price	$2,079.20
Rate for Payer: Cigna of AZ Commercial	$1,819.30
Rate for Payer: Devoted Health Medicare	$467.82
Rate for Payer: Humana of AZ Medicare	$415.84
Rate for Payer: Seven Corners Travel Insurance	$2,488.00
Rate for Payer: Southwest Service Administrators UFCW	$1,767.32
Rate for Payer: TriWest Medicare	$415.84
Rate for Payer: United Healthcare Commercial	$1,486.63
Rate for Payer: United Healthcare Medicare	$415.84
Rate for Payer: United Healthcare New Mexico Commercial	$493.81
Rate for Payer: Veterans Affairs TRICARE	$411.68

24500 CLD TX HUM FX W/O MANIP

Facility

$1,248.00

Service Code	CPT 24500
Hospital Charge Code	22282839
Hospital Revenue Code	450
Min. Negotiated Rate	$31.03
Max. Negotiated Rate	$1,123.20
Rate for Payer: Aetna of AZ Commercial	$1,123.20
Rate for Payer: Arizona Complete Health Allwell	$199.68
Rate for Payer: Banner UC Health Medicare	$199.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$848.64
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$31.03
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$199.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$199.68
Rate for Payer: Cash Price	$998.40
Rate for Payer: Cash Price	$998.40
Rate for Payer: Cigna of AZ Commercial	$873.60
Rate for Payer: Devoted Health Medicare	$224.64
Rate for Payer: Humana of AZ Medicare	$199.68
Rate for Payer: Mercy Care Medicaid	$31.03
Rate for Payer: NaphCare Correctional Healthcare	$31.03
Rate for Payer: Seven Corners Travel Insurance	$381.65
Rate for Payer: Southwest Service Administrators UFCW	$848.64
Rate for Payer: TriWest Medicare	$199.68
Rate for Payer: United Healthcare Commercial	$713.86
Rate for Payer: United Healthcare Medicare	$199.68
Rate for Payer: United Healthcare New Mexico Commercial	$237.12
Rate for Payer: Veterans Affairs TRICARE	$197.68

24500 CLD TX HUM FX W/O MANIP

Facility

$1,248.00

Service Code	CPT 24500
Hospital Charge Code	22282839
Hospital Revenue Code	450
Min. Negotiated Rate	$1,123.20
Max. Negotiated Rate	$1,123.20
Rate for Payer: Aetna of AZ Commercial	$1,123.20
Rate for Payer: Cash Price	$998.40

Know your out-of-pocket cost for care.

All Charges