Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

EGD

Facility

$1,956.00

Service Code	CPT 43235
Hospital Charge Code	885915
Hospital Revenue Code	750
Min. Negotiated Rate	$166.32
Max. Negotiated Rate	$3,596.00
Rate for Payer: Aetna of AZ Commercial	$1,760.40
Rate for Payer: Arizona Complete Health Allwell	$312.96
Rate for Payer: Banner UC Health Medicare	$343.75
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,330.08
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$166.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$312.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$312.96
Rate for Payer: Cash Price	$1,564.80
Rate for Payer: Cash Price	$1,564.80
Rate for Payer: Cash Price	$1,564.80
Rate for Payer: Cigna of AZ Commercial	$1,369.20
Rate for Payer: Devoted Health Medicare	$352.08
Rate for Payer: Humana of AZ Medicare	$312.96
Rate for Payer: Mercy Care Medicaid	$166.32
Rate for Payer: NaphCare Correctional Healthcare	$343.75
Rate for Payer: Seven Corners Travel Insurance	$1,403.35
Rate for Payer: Southwest Service Administrators UFCW	$1,330.08
Rate for Payer: TriWest Medicare	$312.96
Rate for Payer: United Healthcare Commercial	$3,596.00
Rate for Payer: United Healthcare Medicare	$312.96
Rate for Payer: United Healthcare New Mexico Commercial	$371.64
Rate for Payer: Veterans Affairs TRICARE	$309.83

EGD

Facility

$2,340.00

Service Code	CPT 43235
Hospital Charge Code	22531756
Hospital Revenue Code	750
Min. Negotiated Rate	$166.32
Max. Negotiated Rate	$3,596.00
Rate for Payer: Aetna of AZ Commercial	$2,106.00
Rate for Payer: Arizona Complete Health Allwell	$374.40
Rate for Payer: Banner UC Health Medicare	$343.75
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,591.20
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$166.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$374.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$374.40
Rate for Payer: Cash Price	$1,872.00
Rate for Payer: Cash Price	$1,872.00
Rate for Payer: Cash Price	$1,872.00
Rate for Payer: Cigna of AZ Commercial	$1,638.00
Rate for Payer: Devoted Health Medicare	$421.20
Rate for Payer: Humana of AZ Medicare	$374.40
Rate for Payer: Mercy Care Medicaid	$166.32
Rate for Payer: NaphCare Correctional Healthcare	$343.75
Rate for Payer: Seven Corners Travel Insurance	$1,403.35
Rate for Payer: Southwest Service Administrators UFCW	$1,591.20
Rate for Payer: TriWest Medicare	$374.40
Rate for Payer: United Healthcare Commercial	$3,596.00
Rate for Payer: United Healthcare Medicare	$374.40
Rate for Payer: United Healthcare New Mexico Commercial	$444.60
Rate for Payer: Veterans Affairs TRICARE	$370.66

EGD

Facility

$1,956.00

Service Code	CPT 43235
Hospital Charge Code	885915
Hospital Revenue Code	750
Min. Negotiated Rate	$1,760.40
Max. Negotiated Rate	$1,760.40
Rate for Payer: Aetna of AZ Commercial	$1,760.40
Rate for Payer: Cash Price	$1,564.80

EGD DILATION

Facility

$6,347.00

Service Code	CPT 43249
Hospital Charge Code	23598980
Hospital Revenue Code	750
Min. Negotiated Rate	$617.94
Max. Negotiated Rate	$5,712.30
Rate for Payer: Aetna of AZ Commercial	$5,712.30
Rate for Payer: Arizona Complete Health Allwell	$1,015.52
Rate for Payer: Banner UC Health Medicare	$617.94
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$4,315.96
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$887.01
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,015.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,015.52
Rate for Payer: Cash Price	$5,077.60
Rate for Payer: Cash Price	$5,077.60
Rate for Payer: Cash Price	$5,077.60
Rate for Payer: Cigna of AZ Commercial	$4,442.90
Rate for Payer: Devoted Health Medicare	$1,142.46
Rate for Payer: Humana of AZ Medicare	$1,015.52
Rate for Payer: Mercy Care Medicaid	$887.01
Rate for Payer: NaphCare Correctional Healthcare	$617.94
Rate for Payer: Seven Corners Travel Insurance	$2,969.06
Rate for Payer: Southwest Service Administrators UFCW	$4,315.96
Rate for Payer: TriWest Medicare	$1,015.52
Rate for Payer: United Healthcare Commercial	$3,596.00
Rate for Payer: United Healthcare Medicare	$1,015.52
Rate for Payer: United Healthcare New Mexico Commercial	$1,205.93
Rate for Payer: Veterans Affairs TRICARE	$1,005.36

EGD DILATION

Facility

$6,347.00

Service Code	CPT 43249
Hospital Charge Code	23598980
Hospital Revenue Code	750
Min. Negotiated Rate	$5,712.30
Max. Negotiated Rate	$5,712.30
Rate for Payer: Aetna of AZ Commercial	$5,712.30
Rate for Payer: Cash Price	$5,077.60

EGD Dilation Professional Fee

Facility

$2,056.00

Service Code	CPT 43249
Hospital Charge Code	23598974
Min. Negotiated Rate	$325.67
Max. Negotiated Rate	$2,969.06
Rate for Payer: Aetna of AZ Commercial	$1,850.40
Rate for Payer: Arizona Complete Health Allwell	$328.96
Rate for Payer: Banner UC Health Medicare	$328.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,398.08
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$887.01
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$328.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$328.96
Rate for Payer: Cash Price	$1,644.80
Rate for Payer: Cash Price	$1,644.80
Rate for Payer: Cigna of AZ Commercial	$1,439.20
Rate for Payer: Devoted Health Medicare	$370.08
Rate for Payer: Humana of AZ Medicare	$328.96
Rate for Payer: Mercy Care Medicaid	$887.01
Rate for Payer: NaphCare Correctional Healthcare	$887.01
Rate for Payer: Seven Corners Travel Insurance	$2,969.06
Rate for Payer: Southwest Service Administrators UFCW	$1,398.08
Rate for Payer: TriWest Medicare	$328.96
Rate for Payer: United Healthcare Commercial	$1,176.03
Rate for Payer: United Healthcare Medicare	$328.96
Rate for Payer: Veterans Affairs TRICARE	$325.67

EGD Dilation Professional Fee

Facility

$2,056.00

Service Code	CPT 43249
Hospital Charge Code	23598974
Min. Negotiated Rate	$1,850.40
Max. Negotiated Rate	$1,850.40
Rate for Payer: Aetna of AZ Commercial	$1,850.40
Rate for Payer: Cash Price	$1,644.80

EGD W/BIOPSY SGL/MULTI

Facility

$1,382.00

Service Code	CPT 43239
Hospital Charge Code	1251729
Hospital Revenue Code	984
Min. Negotiated Rate	$1,243.80
Max. Negotiated Rate	$1,243.80
Rate for Payer: Aetna of AZ Commercial	$1,243.80
Rate for Payer: Cash Price	$1,105.60

EGD W/BIOPSY SGL/MULTI

Facility

$1,382.00

Service Code	CPT 43239
Hospital Charge Code	1251729
Hospital Revenue Code	984
Min. Negotiated Rate	$218.91
Max. Negotiated Rate	$1,403.35
Rate for Payer: Aetna of AZ Commercial	$1,243.80
Rate for Payer: Arizona Complete Health Allwell	$221.12
Rate for Payer: Banner UC Health Medicare	$221.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$939.76
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$236.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$221.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$221.12
Rate for Payer: Cash Price	$1,105.60
Rate for Payer: Cash Price	$1,105.60
Rate for Payer: Cigna of AZ Commercial	$967.40
Rate for Payer: Devoted Health Medicare	$248.76
Rate for Payer: Humana of AZ Medicare	$221.12
Rate for Payer: Mercy Care Medicaid	$236.04
Rate for Payer: NaphCare Correctional Healthcare	$236.04
Rate for Payer: Seven Corners Travel Insurance	$1,403.35
Rate for Payer: Southwest Service Administrators UFCW	$939.76
Rate for Payer: TriWest Medicare	$221.12
Rate for Payer: United Healthcare Commercial	$790.50
Rate for Payer: United Healthcare Medicare	$221.12
Rate for Payer: United Healthcare New Mexico Commercial	$262.58
Rate for Payer: Veterans Affairs TRICARE	$218.91

EGD W/BIOPSY SGL/MULTI ADD ON CHARGE

Facility

$2,558.00

Service Code	CPT 43239
Hospital Charge Code	22331689
Hospital Revenue Code	750
Min. Negotiated Rate	$236.04
Max. Negotiated Rate	$3,596.00
Rate for Payer: Aetna of AZ Commercial	$2,302.20
Rate for Payer: Arizona Complete Health Allwell	$409.28
Rate for Payer: Banner UC Health Medicare	$343.75
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,739.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$236.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$409.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$409.28
Rate for Payer: Cash Price	$2,046.40
Rate for Payer: Cash Price	$2,046.40
Rate for Payer: Cash Price	$2,046.40
Rate for Payer: Cigna of AZ Commercial	$1,790.60
Rate for Payer: Devoted Health Medicare	$460.44
Rate for Payer: Humana of AZ Medicare	$409.28
Rate for Payer: Mercy Care Medicaid	$236.04
Rate for Payer: NaphCare Correctional Healthcare	$343.75
Rate for Payer: Seven Corners Travel Insurance	$1,403.35
Rate for Payer: Southwest Service Administrators UFCW	$1,739.44
Rate for Payer: TriWest Medicare	$409.28
Rate for Payer: United Healthcare Commercial	$3,596.00
Rate for Payer: United Healthcare Medicare	$409.28
Rate for Payer: United Healthcare New Mexico Commercial	$486.02
Rate for Payer: Veterans Affairs TRICARE	$405.19

EGD W/BIOPSY SGL/MULTI ADD ON CHARGE

Facility

$2,558.00

Service Code	CPT 43239
Hospital Charge Code	22331689
Hospital Revenue Code	750
Min. Negotiated Rate	$2,302.20
Max. Negotiated Rate	$2,302.20
Rate for Payer: Aetna of AZ Commercial	$2,302.20
Rate for Payer: Cash Price	$2,046.40

EGD With PEG

Facility

$1,485.00

Service Code	CPT 43235
Hospital Charge Code	23598984
Hospital Revenue Code	750
Min. Negotiated Rate	$166.32
Max. Negotiated Rate	$3,596.00
Rate for Payer: Aetna of AZ Commercial	$1,336.50
Rate for Payer: Arizona Complete Health Allwell	$237.60
Rate for Payer: Banner UC Health Medicare	$343.75
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,009.80
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$166.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$237.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$237.60
Rate for Payer: Cash Price	$1,188.00
Rate for Payer: Cash Price	$1,188.00
Rate for Payer: Cash Price	$1,188.00
Rate for Payer: Cigna of AZ Commercial	$1,039.50
Rate for Payer: Devoted Health Medicare	$267.30
Rate for Payer: Humana of AZ Medicare	$237.60
Rate for Payer: Mercy Care Medicaid	$166.32
Rate for Payer: NaphCare Correctional Healthcare	$343.75
Rate for Payer: Seven Corners Travel Insurance	$1,403.35
Rate for Payer: Southwest Service Administrators UFCW	$1,009.80
Rate for Payer: TriWest Medicare	$237.60
Rate for Payer: United Healthcare Commercial	$3,596.00
Rate for Payer: United Healthcare Medicare	$237.60
Rate for Payer: United Healthcare New Mexico Commercial	$282.15
Rate for Payer: Veterans Affairs TRICARE	$235.22

EGD With PEG

Facility

$1,485.00

Service Code	CPT 43235
Hospital Charge Code	23598984
Hospital Revenue Code	750
Min. Negotiated Rate	$1,336.50
Max. Negotiated Rate	$1,336.50
Rate for Payer: Aetna of AZ Commercial	$1,336.50
Rate for Payer: Cash Price	$1,188.00

EKG (12 LEAD)

Facility

$242.00

Service Code	CPT 93005
Hospital Charge Code	1886872
Hospital Revenue Code	730
Min. Negotiated Rate	$38.33
Max. Negotiated Rate	$217.80
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 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: Seven Corners Travel Insurance	$91.28
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: United Healthcare New Mexico Commercial	$45.98
Rate for Payer: Veterans Affairs TRICARE	$38.33

EKG (12 LEAD)

Facility

$242.00

Service Code	CPT 93005
Hospital Charge Code	1886872
Hospital Revenue Code	730
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

Elastic garment/cover

Facility

$107.00

Hospital Charge Code	1167832
Hospital Revenue Code	521
Min. Negotiated Rate	$96.30
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Cash Price	$85.60

Elastic garment/cover

Facility

$107.00

Hospital Charge Code	1167832
Hospital Revenue Code	521
Min. Negotiated Rate	$16.95
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Arizona Complete Health Allwell	$17.12
Rate for Payer: Banner UC Health Medicare	$17.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$72.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.12
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cigna of AZ Commercial	$74.90
Rate for Payer: Devoted Health Medicare	$19.26
Rate for Payer: Humana of AZ Medicare	$17.12
Rate for Payer: Southwest Service Administrators UFCW	$72.76
Rate for Payer: TriWest Medicare	$17.12
Rate for Payer: United Healthcare Commercial	$61.20
Rate for Payer: United Healthcare Medicare	$17.12
Rate for Payer: Veterans Affairs TRICARE	$16.95

ELASTOPLAST 4''''

Facility

$32.00

Hospital Charge Code	22926420
Hospital Revenue Code	272
Min. Negotiated Rate	$5.07
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Arizona Complete Health Allwell	$5.12
Rate for Payer: Banner UC Health Medicare	$5.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$21.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.12
Rate for Payer: Cash Price	$25.60
Rate for Payer: Cigna of AZ Commercial	$22.40
Rate for Payer: Devoted Health Medicare	$5.76
Rate for Payer: Humana of AZ Medicare	$5.12
Rate for Payer: Southwest Service Administrators UFCW	$21.76
Rate for Payer: TriWest Medicare	$5.12
Rate for Payer: United Healthcare Commercial	$18.30
Rate for Payer: United Healthcare Medicare	$5.12
Rate for Payer: Veterans Affairs TRICARE	$5.07

ELASTOPLAST 4''''

Facility

$32.00

Hospital Charge Code	22926420
Hospital Revenue Code	272
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Cash Price	$25.60

ELECT ADULT QUIK-COMBO PK/2

Facility

$131.00

Service Code	HCPCS A4556
Hospital Charge Code	22354171
Hospital Revenue Code	270
Min. Negotiated Rate	$20.75
Max. Negotiated Rate	$117.90
Rate for Payer: Aetna of AZ Commercial	$117.90
Rate for Payer: Arizona Complete Health Allwell	$20.96
Rate for Payer: Banner UC Health Medicare	$20.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$89.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.96
Rate for Payer: Cash Price	$104.80
Rate for Payer: Cigna of AZ Commercial	$91.70
Rate for Payer: Devoted Health Medicare	$23.58
Rate for Payer: Humana of AZ Medicare	$20.96
Rate for Payer: Southwest Service Administrators UFCW	$89.08
Rate for Payer: TriWest Medicare	$20.96
Rate for Payer: United Healthcare Commercial	$74.93
Rate for Payer: United Healthcare Medicare	$20.96
Rate for Payer: Veterans Affairs TRICARE	$20.75

ELECT ADULT QUIK-COMBO PK/2

Facility

$131.00

Service Code	HCPCS A4556
Hospital Charge Code	22354171
Hospital Revenue Code	270
Min. Negotiated Rate	$117.90
Max. Negotiated Rate	$117.90
Rate for Payer: Aetna of AZ Commercial	$117.90
Rate for Payer: Cash Price	$104.80

Elective Hip Joint Replacement

Facility

$8,616.70

Service Code	APR-DRG 3241
Hospital Charge Code	APRDRG3244
Min. Negotiated Rate	$8,616.70
Max. Negotiated Rate	$8,616.70
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8,616.70
Rate for Payer: Mercy Care Medicaid	$8,616.70
Rate for Payer: NaphCare Correctional Healthcare	$8,616.70

Elective Hip Joint Replacement

Facility

$13,788.12

Service Code	APR-DRG 3243
Hospital Charge Code	APRDRG3242
Min. Negotiated Rate	$13,788.12
Max. Negotiated Rate	$13,788.12
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13,788.12
Rate for Payer: Mercy Care Medicaid	$13,788.12
Rate for Payer: NaphCare Correctional Healthcare	$13,788.12

Elective Hip Joint Replacement

Facility

$8,616.70

Service Code	APR-DRG 3241
Hospital Charge Code	APRDRG3242
Min. Negotiated Rate	$8,616.70
Max. Negotiated Rate	$8,616.70
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8,616.70
Rate for Payer: Mercy Care Medicaid	$8,616.70
Rate for Payer: NaphCare Correctional Healthcare	$8,616.70

Elective Hip Joint Replacement

Facility

$23,099.91

Service Code	APR-DRG 3244
Hospital Charge Code	APRDRG3241
Min. Negotiated Rate	$23,099.91
Max. Negotiated Rate	$23,099.91
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$23,099.91
Rate for Payer: Mercy Care Medicaid	$23,099.91
Rate for Payer: NaphCare Correctional Healthcare	$23,099.91

Know your out-of-pocket cost for care.

All Charges