Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

30901 TX EPISTAXIS ANT SIMPLE

Facility

$682.00

Service Code	CPT 30901
Hospital Charge Code	22282893
Hospital Revenue Code	450
Min. Negotiated Rate	$613.80
Max. Negotiated Rate	$613.80
Rate for Payer: Aetna of AZ Commercial	$613.80
Rate for Payer: Cash Price	$545.60

30903 TX EPISTAXIS ANT COMPLEX

Facility

$1,305.00

Service Code	CPT 30903
Hospital Charge Code	22282894
Hospital Revenue Code	450
Min. Negotiated Rate	$174.88
Max. Negotiated Rate	$1,174.50
Rate for Payer: Aetna of AZ Commercial	$1,174.50
Rate for Payer: Arizona Complete Health Allwell	$208.80
Rate for Payer: Banner UC Health Medicare	$208.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$887.40
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$174.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$208.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$208.80
Rate for Payer: Cash Price	$1,044.00
Rate for Payer: Cash Price	$1,044.00
Rate for Payer: Cigna of AZ Commercial	$913.50
Rate for Payer: Devoted Health Medicare	$234.90
Rate for Payer: Humana of AZ Medicare	$208.80
Rate for Payer: Mercy Care Medicaid	$174.88
Rate for Payer: NaphCare Correctional Healthcare	$174.88
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$887.40
Rate for Payer: TriWest Medicare	$208.80
Rate for Payer: United Healthcare Commercial	$746.46
Rate for Payer: United Healthcare Medicare	$208.80
Rate for Payer: United Healthcare New Mexico Commercial	$247.95
Rate for Payer: Veterans Affairs TRICARE	$206.71

30903 TX EPISTAXIS ANT COMPLEX

Facility

$1,305.00

Service Code	CPT 30903
Hospital Charge Code	22282894
Hospital Revenue Code	450
Min. Negotiated Rate	$1,174.50
Max. Negotiated Rate	$1,174.50
Rate for Payer: Aetna of AZ Commercial	$1,174.50
Rate for Payer: Cash Price	$1,044.00

30905 TX EPISTAXIS POST SIMPLE

Facility

$1,203.00

Service Code	CPT 30905
Hospital Charge Code	22282895
Hospital Revenue Code	450
Min. Negotiated Rate	$1,082.70
Max. Negotiated Rate	$1,082.70
Rate for Payer: Aetna of AZ Commercial	$1,082.70
Rate for Payer: Cash Price	$962.40

30905 TX EPISTAXIS POST SIMPLE

Facility

$1,203.00

Service Code	CPT 30905
Hospital Charge Code	22282895
Hospital Revenue Code	450
Min. Negotiated Rate	$190.56
Max. Negotiated Rate	$1,082.70
Rate for Payer: Aetna of AZ Commercial	$1,082.70
Rate for Payer: Arizona Complete Health Allwell	$192.48
Rate for Payer: Banner UC Health Medicare	$192.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$818.04
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$256.06
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$192.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$192.48
Rate for Payer: Cash Price	$962.40
Rate for Payer: Cash Price	$962.40
Rate for Payer: Cigna of AZ Commercial	$842.10
Rate for Payer: Devoted Health Medicare	$216.54
Rate for Payer: Humana of AZ Medicare	$192.48
Rate for Payer: Mercy Care Medicaid	$256.06
Rate for Payer: NaphCare Correctional Healthcare	$256.06
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$818.04
Rate for Payer: TriWest Medicare	$192.48
Rate for Payer: United Healthcare Commercial	$688.12
Rate for Payer: United Healthcare Medicare	$192.48
Rate for Payer: United Healthcare New Mexico Commercial	$228.57
Rate for Payer: Veterans Affairs TRICARE	$190.56

30906 TX EPISTAXIS POST COMPLEX

Facility

$1,341.00

Service Code	CPT 30906
Hospital Charge Code	22282896
Hospital Revenue Code	450
Min. Negotiated Rate	$1,206.90
Max. Negotiated Rate	$1,206.90
Rate for Payer: Aetna of AZ Commercial	$1,206.90
Rate for Payer: Cash Price	$1,072.80

30906 TX EPISTAXIS POST COMPLEX

Facility

$1,341.00

Service Code	CPT 30906
Hospital Charge Code	22282896
Hospital Revenue Code	450
Min. Negotiated Rate	$212.41
Max. Negotiated Rate	$1,206.90
Rate for Payer: Aetna of AZ Commercial	$1,206.90
Rate for Payer: Arizona Complete Health Allwell	$214.56
Rate for Payer: Banner UC Health Medicare	$214.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$911.88
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$255.34
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$214.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$214.56
Rate for Payer: Cash Price	$1,072.80
Rate for Payer: Cash Price	$1,072.80
Rate for Payer: Cigna of AZ Commercial	$938.70
Rate for Payer: Devoted Health Medicare	$241.38
Rate for Payer: Humana of AZ Medicare	$214.56
Rate for Payer: Mercy Care Medicaid	$255.34
Rate for Payer: NaphCare Correctional Healthcare	$255.34
Rate for Payer: Seven Corners Travel Insurance	$366.47
Rate for Payer: Southwest Service Administrators UFCW	$911.88
Rate for Payer: TriWest Medicare	$214.56
Rate for Payer: United Healthcare Commercial	$767.05
Rate for Payer: United Healthcare Medicare	$214.56
Rate for Payer: United Healthcare New Mexico Commercial	$254.79
Rate for Payer: Veterans Affairs TRICARE	$212.41

3-0 Chromic Gut FS-1

Facility

$22.00

Hospital Charge Code	22926446
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

3-0 Chromic Gut FS-1

Facility

$22.00

Hospital Charge Code	22926446
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

3-0 Chromic Gut FS-2

Facility

$21.00

Hospital Charge Code	22926445
Hospital Revenue Code	272
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Cash Price	$16.80

3-0 Chromic Gut FS-2

Facility

$21.00

Hospital Charge Code	22926445
Hospital Revenue Code	272
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Arizona Complete Health Allwell	$3.36
Rate for Payer: Banner UC Health Medicare	$3.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$14.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.36
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna of AZ Commercial	$14.70
Rate for Payer: Devoted Health Medicare	$3.78
Rate for Payer: Humana of AZ Medicare	$3.36
Rate for Payer: Southwest Service Administrators UFCW	$14.28
Rate for Payer: TriWest Medicare	$3.36
Rate for Payer: United Healthcare Commercial	$12.01
Rate for Payer: United Healthcare Medicare	$3.36
Rate for Payer: Veterans Affairs TRICARE	$3.33

3-0 Prolene FS-1

Facility

$18.00

Hospital Charge Code	22926432
Hospital Revenue Code	272
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$16.20
Rate for Payer: Aetna of AZ Commercial	$16.20
Rate for Payer: Cash Price	$14.40

3-0 Prolene FS-1

Facility

$18.00

Hospital Charge Code	22926432
Hospital Revenue Code	272
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$16.20
Rate for Payer: Aetna of AZ Commercial	$16.20
Rate for Payer: Arizona Complete Health Allwell	$2.88
Rate for Payer: Banner UC Health Medicare	$2.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$12.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.88
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna of AZ Commercial	$12.60
Rate for Payer: Devoted Health Medicare	$3.24
Rate for Payer: Humana of AZ Medicare	$2.88
Rate for Payer: Southwest Service Administrators UFCW	$12.24
Rate for Payer: TriWest Medicare	$2.88
Rate for Payer: United Healthcare Commercial	$10.30
Rate for Payer: United Healthcare Medicare	$2.88
Rate for Payer: Veterans Affairs TRICARE	$2.85

3-0 Vicryl Plus MH Violet Braided

Facility

$13.00

Hospital Charge Code	22926429
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

3-0 Vicryl Plus MH Violet Braided

Facility

$13.00

Hospital Charge Code	22926429
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

31500 INTUB ET

Facility

$1,547.00

Service Code	CPT 31500
Hospital Charge Code	22282897
Hospital Revenue Code	450
Min. Negotiated Rate	$245.04
Max. Negotiated Rate	$1,392.30
Rate for Payer: Aetna of AZ Commercial	$1,392.30
Rate for Payer: Arizona Complete Health Allwell	$247.52
Rate for Payer: Banner UC Health Medicare	$247.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,051.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$247.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$247.52
Rate for Payer: Cash Price	$1,237.60
Rate for Payer: Cash Price	$1,237.60
Rate for Payer: Cigna of AZ Commercial	$1,082.90
Rate for Payer: Devoted Health Medicare	$278.46
Rate for Payer: Humana of AZ Medicare	$247.52
Rate for Payer: Seven Corners Travel Insurance	$366.47
Rate for Payer: Southwest Service Administrators UFCW	$1,051.96
Rate for Payer: TriWest Medicare	$247.52
Rate for Payer: United Healthcare Commercial	$884.88
Rate for Payer: United Healthcare Medicare	$247.52
Rate for Payer: United Healthcare New Mexico Commercial	$293.93
Rate for Payer: Veterans Affairs TRICARE	$245.04

31500 INTUB ET

Facility

$1,547.00

Service Code	CPT 31500
Hospital Charge Code	22282897
Hospital Revenue Code	450
Min. Negotiated Rate	$1,392.30
Max. Negotiated Rate	$1,392.30
Rate for Payer: Aetna of AZ Commercial	$1,392.30
Rate for Payer: Cash Price	$1,237.60

31502 TRACH TUBE CHANGE

Facility

$215.00

Service Code	CPT 31502
Hospital Charge Code	22282898
Hospital Revenue Code	450
Min. Negotiated Rate	$34.06
Max. Negotiated Rate	$366.47
Rate for Payer: Aetna of AZ Commercial	$193.50
Rate for Payer: Arizona Complete Health Allwell	$34.40
Rate for Payer: Banner UC Health Medicare	$34.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$146.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$34.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$34.40
Rate for Payer: Cash Price	$172.00
Rate for Payer: Cash Price	$172.00
Rate for Payer: Cigna of AZ Commercial	$150.50
Rate for Payer: Devoted Health Medicare	$38.70
Rate for Payer: Humana of AZ Medicare	$34.40
Rate for Payer: Seven Corners Travel Insurance	$366.47
Rate for Payer: Southwest Service Administrators UFCW	$146.20
Rate for Payer: TriWest Medicare	$34.40
Rate for Payer: United Healthcare Commercial	$122.98
Rate for Payer: United Healthcare Medicare	$34.40
Rate for Payer: United Healthcare New Mexico Commercial	$40.85
Rate for Payer: Veterans Affairs TRICARE	$34.06

31502 TRACH TUBE CHANGE

Facility

$215.00

Service Code	CPT 31502
Hospital Charge Code	22282898
Hospital Revenue Code	450
Min. Negotiated Rate	$193.50
Max. Negotiated Rate	$193.50
Rate for Payer: Aetna of AZ Commercial	$193.50
Rate for Payer: Cash Price	$172.00

31579 EXAM TO ASSESS MOVEMENT OF VOCAL CORD FLAPS USING AN E

Facility

$657.00

Service Code	CPT 31579 GN
Hospital Charge Code	27724317
Hospital Revenue Code	440
Min. Negotiated Rate	$591.30
Max. Negotiated Rate	$591.30
Rate for Payer: Aetna of AZ Commercial	$591.30
Rate for Payer: Cash Price	$525.60

31579 EXAM TO ASSESS MOVEMENT OF VOCAL CORD FLAPS USING AN E

Facility

$657.00

Service Code	CPT 31579 GN
Hospital Charge Code	27724317
Hospital Revenue Code	440
Min. Negotiated Rate	$77.40
Max. Negotiated Rate	$591.30
Rate for Payer: Aetna of AZ Commercial	$591.30
Rate for Payer: Arizona Complete Health Allwell	$105.12
Rate for Payer: Banner UC Health Medicare	$105.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$446.76
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$77.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$105.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$107.64
Rate for Payer: Cash Price	$525.60
Rate for Payer: Cash Price	$525.60
Rate for Payer: Cigna of AZ Commercial	$459.90
Rate for Payer: Devoted Health Medicare	$118.26
Rate for Payer: Humana of AZ Medicare	$105.12
Rate for Payer: Mercy Care Medicaid	$77.40
Rate for Payer: NaphCare Correctional Healthcare	$77.40
Rate for Payer: Southwest Service Administrators UFCW	$446.76
Rate for Payer: TriWest Medicare	$105.12
Rate for Payer: United Healthcare Commercial	$375.80
Rate for Payer: United Healthcare Medicare	$105.12
Rate for Payer: United Healthcare New Mexico Commercial	$124.83
Rate for Payer: Veterans Affairs TRICARE	$104.07

32036 THORACOSTOMY W/O PENDING

Facility

$4,019.00

Service Code	CPT 32036
Hospital Charge Code	22282899
Hospital Revenue Code	450
Min. Negotiated Rate	$636.61
Max. Negotiated Rate	$3,617.10
Rate for Payer: Aetna of AZ Commercial	$3,617.10
Rate for Payer: Arizona Complete Health Allwell	$643.04
Rate for Payer: Banner UC Health Medicare	$643.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,732.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$643.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$643.04
Rate for Payer: Cash Price	$3,215.20
Rate for Payer: Cigna of AZ Commercial	$2,813.30
Rate for Payer: Devoted Health Medicare	$723.42
Rate for Payer: Humana of AZ Medicare	$643.04
Rate for Payer: Southwest Service Administrators UFCW	$2,732.92
Rate for Payer: TriWest Medicare	$643.04
Rate for Payer: United Healthcare Commercial	$2,298.87
Rate for Payer: United Healthcare Medicare	$643.04
Rate for Payer: United Healthcare New Mexico Commercial	$763.61
Rate for Payer: Veterans Affairs TRICARE	$636.61

32036 THORACOSTOMY W/O PENDING

Facility

$4,019.00

Service Code	CPT 32036
Hospital Charge Code	22282899
Hospital Revenue Code	450
Min. Negotiated Rate	$3,617.10
Max. Negotiated Rate	$3,617.10
Rate for Payer: Aetna of AZ Commercial	$3,617.10
Rate for Payer: Cash Price	$3,215.20

32095 THORACOSTOMY LIMITED

Facility

$3,747.00

Service Code	CPT 32095
Hospital Charge Code	22282900
Hospital Revenue Code	450
Min. Negotiated Rate	$593.52
Max. Negotiated Rate	$3,372.30
Rate for Payer: Aetna of AZ Commercial	$3,372.30
Rate for Payer: Arizona Complete Health Allwell	$599.52
Rate for Payer: Banner UC Health Medicare	$599.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,547.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$599.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$599.52
Rate for Payer: Cash Price	$2,997.60
Rate for Payer: Cigna of AZ Commercial	$2,622.90
Rate for Payer: Devoted Health Medicare	$674.46
Rate for Payer: Humana of AZ Medicare	$599.52
Rate for Payer: Southwest Service Administrators UFCW	$2,547.96
Rate for Payer: TriWest Medicare	$599.52
Rate for Payer: United Healthcare Commercial	$2,143.28
Rate for Payer: United Healthcare Medicare	$599.52
Rate for Payer: United Healthcare New Mexico Commercial	$711.93
Rate for Payer: Veterans Affairs TRICARE	$593.52

32095 THORACOSTOMY LIMITED

Facility

$3,747.00

Service Code	CPT 32095
Hospital Charge Code	22282900
Hospital Revenue Code	450
Min. Negotiated Rate	$3,372.30
Max. Negotiated Rate	$3,372.30
Rate for Payer: Aetna of AZ Commercial	$3,372.30
Rate for Payer: Cash Price	$2,997.60

Know your out-of-pocket cost for care.

All Charges