Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

36550 THROMBOLYTIC AGENT

Facility

$91.00

Service Code	CPT 36550
Hospital Charge Code	22282912
Hospital Revenue Code	450
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$81.90
Rate for Payer: Aetna of AZ Commercial	$81.90
Rate for Payer: Cash Price	$72.80

36556 CENTRAL LINE INSERTION

Facility

$392.00

Service Code	CPT 36556
Hospital Charge Code	22282913
Hospital Revenue Code	760
Min. Negotiated Rate	$62.09
Max. Negotiated Rate	$4,885.47
Rate for Payer: Aetna of AZ Commercial	$352.80
Rate for Payer: Arizona Complete Health Allwell	$62.72
Rate for Payer: Banner UC Health Medicare	$62.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$266.56
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$126.91
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$62.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$62.72
Rate for Payer: Cash Price	$313.60
Rate for Payer: Cash Price	$313.60
Rate for Payer: Cigna of AZ Commercial	$274.40
Rate for Payer: Devoted Health Medicare	$70.56
Rate for Payer: Humana of AZ Medicare	$62.72
Rate for Payer: Mercy Care Medicaid	$126.91
Rate for Payer: NaphCare Correctional Healthcare	$126.91
Rate for Payer: Seven Corners Travel Insurance	$4,885.47
Rate for Payer: Southwest Service Administrators UFCW	$266.56
Rate for Payer: TriWest Medicare	$62.72
Rate for Payer: United Healthcare Commercial	$224.22
Rate for Payer: United Healthcare Medicare	$62.72
Rate for Payer: United Healthcare New Mexico Commercial	$74.48
Rate for Payer: Veterans Affairs TRICARE	$62.09

36556 CENTRAL LINE INSERTION

Facility

$392.00

Service Code	CPT 36556
Hospital Charge Code	22282913
Hospital Revenue Code	760
Min. Negotiated Rate	$352.80
Max. Negotiated Rate	$352.80
Rate for Payer: Aetna of AZ Commercial	$352.80
Rate for Payer: Cash Price	$313.60

36561 INSERTION OF PORTACATH

Facility

$1,863.00

Service Code	CPT 36561 26
Hospital Charge Code	22452991
Min. Negotiated Rate	$295.10
Max. Negotiated Rate	$1,676.70
Rate for Payer: Aetna of AZ Commercial	$1,676.70
Rate for Payer: Arizona Complete Health Allwell	$298.08
Rate for Payer: Banner UC Health Medicare	$298.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,266.84
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$611.22
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$298.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$298.08
Rate for Payer: Cash Price	$1,490.40
Rate for Payer: Cash Price	$1,490.40
Rate for Payer: Cigna of AZ Commercial	$1,304.10
Rate for Payer: Devoted Health Medicare	$335.34
Rate for Payer: Humana of AZ Medicare	$298.08
Rate for Payer: Mercy Care Medicaid	$611.22
Rate for Payer: NaphCare Correctional Healthcare	$611.22
Rate for Payer: Southwest Service Administrators UFCW	$1,266.84
Rate for Payer: TriWest Medicare	$298.08
Rate for Payer: United Healthcare Commercial	$1,065.64
Rate for Payer: United Healthcare Medicare	$298.08
Rate for Payer: Veterans Affairs TRICARE	$295.10

36561 INSERTION OF PORTACATH

Facility

$1,863.00

Service Code	CPT 36561 26
Hospital Charge Code	22452991
Min. Negotiated Rate	$1,676.70
Max. Negotiated Rate	$1,676.70
Rate for Payer: Aetna of AZ Commercial	$1,676.70
Rate for Payer: Cash Price	$1,490.40

36589 PROF REMOVAL TUNNEL CVC W/

Facility

$672.00

Service Code	CPT 36589 26
Hospital Charge Code	22389235
Min. Negotiated Rate	$604.80
Max. Negotiated Rate	$604.80
Rate for Payer: Aetna of AZ Commercial	$604.80
Rate for Payer: Cash Price	$537.60

36589 PROF REMOVAL TUNNEL CVC W/

Facility

$672.00

Service Code	CPT 36589 26
Hospital Charge Code	22389235
Min. Negotiated Rate	$28.94
Max. Negotiated Rate	$604.80
Rate for Payer: Aetna of AZ Commercial	$604.80
Rate for Payer: Arizona Complete Health Allwell	$107.52
Rate for Payer: Banner UC Health Medicare	$107.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$456.96
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$28.94
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$107.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$107.52
Rate for Payer: Cash Price	$537.60
Rate for Payer: Cash Price	$537.60
Rate for Payer: Cigna of AZ Commercial	$470.40
Rate for Payer: Devoted Health Medicare	$120.96
Rate for Payer: Humana of AZ Medicare	$107.52
Rate for Payer: Mercy Care Medicaid	$28.94
Rate for Payer: NaphCare Correctional Healthcare	$28.94
Rate for Payer: Southwest Service Administrators UFCW	$456.96
Rate for Payer: TriWest Medicare	$107.52
Rate for Payer: United Healthcare Commercial	$384.38
Rate for Payer: United Healthcare Medicare	$107.52
Rate for Payer: Veterans Affairs TRICARE	$106.44

36600 ART PUNCTURE DIANOSTIC

Facility

$111.00

Service Code	CPT 36600
Hospital Charge Code	22282915
Hospital Revenue Code	450
Min. Negotiated Rate	$13.25
Max. Negotiated Rate	$205.86
Rate for Payer: Aetna of AZ Commercial	$99.90
Rate for Payer: Arizona Complete Health Allwell	$17.76
Rate for Payer: Banner UC Health Medicare	$17.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$75.48
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13.25
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.76
Rate for Payer: Cash Price	$88.80
Rate for Payer: Cash Price	$88.80
Rate for Payer: Cigna of AZ Commercial	$77.70
Rate for Payer: Devoted Health Medicare	$19.98
Rate for Payer: Humana of AZ Medicare	$17.76
Rate for Payer: Mercy Care Medicaid	$13.25
Rate for Payer: NaphCare Correctional Healthcare	$13.25
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$75.48
Rate for Payer: TriWest Medicare	$17.76
Rate for Payer: United Healthcare Commercial	$63.49
Rate for Payer: United Healthcare Medicare	$17.76
Rate for Payer: United Healthcare New Mexico Commercial	$21.09
Rate for Payer: Veterans Affairs TRICARE	$17.58

36600 ART PUNCTURE DIANOSTIC

Facility

$111.00

Service Code	CPT 36600
Hospital Charge Code	22282915
Hospital Revenue Code	450
Min. Negotiated Rate	$99.90
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of AZ Commercial	$99.90
Rate for Payer: Cash Price	$88.80

36620 ARTCANN/SAMPL MNT

Facility

$338.00

Service Code	CPT 36620
Hospital Charge Code	22282916
Hospital Revenue Code	450
Min. Negotiated Rate	$53.54
Max. Negotiated Rate	$304.20
Rate for Payer: Aetna of AZ Commercial	$304.20
Rate for Payer: Arizona Complete Health Allwell	$54.08
Rate for Payer: Banner UC Health Medicare	$54.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$229.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$54.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$54.08
Rate for Payer: Cash Price	$270.40
Rate for Payer: Cigna of AZ Commercial	$236.60
Rate for Payer: Devoted Health Medicare	$60.84
Rate for Payer: Humana of AZ Medicare	$54.08
Rate for Payer: Southwest Service Administrators UFCW	$229.84
Rate for Payer: TriWest Medicare	$54.08
Rate for Payer: United Healthcare Commercial	$193.34
Rate for Payer: United Healthcare Medicare	$54.08
Rate for Payer: United Healthcare New Mexico Commercial	$64.22
Rate for Payer: Veterans Affairs TRICARE	$53.54

36620 ARTCANN/SAMPL MNT

Facility

$338.00

Service Code	CPT 36620
Hospital Charge Code	22282916
Hospital Revenue Code	450
Min. Negotiated Rate	$304.20
Max. Negotiated Rate	$304.20
Rate for Payer: Aetna of AZ Commercial	$304.20
Rate for Payer: Cash Price	$270.40

36680 INTRAOSSEOUS CNNULA PLCM

Facility

$471.00

Service Code	CPT 36680
Hospital Charge Code	22282917
Hospital Revenue Code	450
Min. Negotiated Rate	$74.61
Max. Negotiated Rate	$691.20
Rate for Payer: Aetna of AZ Commercial	$423.90
Rate for Payer: Arizona Complete Health Allwell	$75.36
Rate for Payer: Banner UC Health Medicare	$75.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$320.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$75.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$75.36
Rate for Payer: Cash Price	$376.80
Rate for Payer: Cash Price	$376.80
Rate for Payer: Cigna of AZ Commercial	$329.70
Rate for Payer: Devoted Health Medicare	$84.78
Rate for Payer: Humana of AZ Medicare	$75.36
Rate for Payer: Seven Corners Travel Insurance	$691.20
Rate for Payer: Southwest Service Administrators UFCW	$320.28
Rate for Payer: TriWest Medicare	$75.36
Rate for Payer: United Healthcare Commercial	$269.41
Rate for Payer: United Healthcare Medicare	$75.36
Rate for Payer: United Healthcare New Mexico Commercial	$89.49
Rate for Payer: Veterans Affairs TRICARE	$74.61

36680 INTRAOSSEOUS CNNULA PLCM

Facility

$471.00

Service Code	CPT 36680
Hospital Charge Code	22282917
Hospital Revenue Code	450
Min. Negotiated Rate	$423.90
Max. Negotiated Rate	$423.90
Rate for Payer: Aetna of AZ Commercial	$423.90
Rate for Payer: Cash Price	$376.80

4-0 Ethilon KS

Facility

$13.00

Hospital Charge Code	22926442
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

4-0 Ethilon KS

Facility

$13.00

Hospital Charge Code	22926442
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

4-0 Surgigut

Facility

$51.00

Hospital Charge Code	22926447
Hospital Revenue Code	272
Min. Negotiated Rate	$8.08
Max. Negotiated Rate	$45.90
Rate for Payer: Aetna of AZ Commercial	$45.90
Rate for Payer: Arizona Complete Health Allwell	$8.16
Rate for Payer: Banner UC Health Medicare	$8.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$34.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.16
Rate for Payer: Cash Price	$40.80
Rate for Payer: Cigna of AZ Commercial	$35.70
Rate for Payer: Devoted Health Medicare	$9.18
Rate for Payer: Humana of AZ Medicare	$8.16
Rate for Payer: Southwest Service Administrators UFCW	$34.68
Rate for Payer: TriWest Medicare	$8.16
Rate for Payer: United Healthcare Commercial	$29.17
Rate for Payer: United Healthcare Medicare	$8.16
Rate for Payer: Veterans Affairs TRICARE	$8.08

4-0 Surgigut

Facility

$51.00

Hospital Charge Code	22926447
Hospital Revenue Code	272
Min. Negotiated Rate	$45.90
Max. Negotiated Rate	$45.90
Rate for Payer: Aetna of AZ Commercial	$45.90
Rate for Payer: Cash Price	$40.80

4.0 x 28MM POLY SCREW

Facility

$1,865.00

Service Code	HCPCS C1778
Hospital Charge Code	22354175
Hospital Revenue Code	270
Min. Negotiated Rate	$295.42
Max. Negotiated Rate	$1,678.50
Rate for Payer: Aetna of AZ Commercial	$1,678.50
Rate for Payer: Arizona Complete Health Allwell	$298.40
Rate for Payer: Banner UC Health Medicare	$298.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,268.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$298.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$298.40
Rate for Payer: Cash Price	$1,492.00
Rate for Payer: Cigna of AZ Commercial	$1,305.50
Rate for Payer: Devoted Health Medicare	$335.70
Rate for Payer: Humana of AZ Medicare	$298.40
Rate for Payer: Southwest Service Administrators UFCW	$1,268.20
Rate for Payer: TriWest Medicare	$298.40
Rate for Payer: United Healthcare Commercial	$1,066.78
Rate for Payer: United Healthcare Medicare	$298.40
Rate for Payer: Veterans Affairs TRICARE	$295.42

4.0 x 28MM POLY SCREW

Facility

$1,865.00

Service Code	HCPCS C1778
Hospital Charge Code	22354175
Hospital Revenue Code	270
Min. Negotiated Rate	$1,678.50
Max. Negotiated Rate	$1,678.50
Rate for Payer: Aetna of AZ Commercial	$1,678.50
Rate for Payer: Cash Price	$1,492.00

4.0 X 32MM POLY CANN SCREW

Facility

$1,976.00

Service Code	HCPCS C1778
Hospital Charge Code	22354198
Hospital Revenue Code	270
Min. Negotiated Rate	$1,778.40
Max. Negotiated Rate	$1,778.40
Rate for Payer: Aetna of AZ Commercial	$1,778.40
Rate for Payer: Cash Price	$1,580.80

4.0 X 32MM POLY CANN SCREW

Facility

$1,976.00

Service Code	HCPCS C1778
Hospital Charge Code	22354198
Hospital Revenue Code	270
Min. Negotiated Rate	$313.00
Max. Negotiated Rate	$1,778.40
Rate for Payer: Aetna of AZ Commercial	$1,778.40
Rate for Payer: Arizona Complete Health Allwell	$316.16
Rate for Payer: Banner UC Health Medicare	$316.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,343.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$316.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$316.16
Rate for Payer: Cash Price	$1,580.80
Rate for Payer: Cigna of AZ Commercial	$1,383.20
Rate for Payer: Devoted Health Medicare	$355.68
Rate for Payer: Humana of AZ Medicare	$316.16
Rate for Payer: Southwest Service Administrators UFCW	$1,343.68
Rate for Payer: TriWest Medicare	$316.16
Rate for Payer: United Healthcare Commercial	$1,130.27
Rate for Payer: United Healthcare Medicare	$316.16
Rate for Payer: Veterans Affairs TRICARE	$313.00

43235 EGD PRO FEE

Facility

$532.00

Service Code	CPT 43235
Hospital Charge Code	22546985
Min. Negotiated Rate	$478.80
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of AZ Commercial	$478.80
Rate for Payer: Cash Price	$425.60

43235 EGD PRO FEE

Facility

$532.00

Service Code	CPT 43235
Hospital Charge Code	22546985
Min. Negotiated Rate	$84.27
Max. Negotiated Rate	$1,403.35
Rate for Payer: Aetna of AZ Commercial	$478.80
Rate for Payer: Arizona Complete Health Allwell	$85.12
Rate for Payer: Banner UC Health Medicare	$85.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$361.76
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$166.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$85.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$85.12
Rate for Payer: Cash Price	$425.60
Rate for Payer: Cash Price	$425.60
Rate for Payer: Cigna of AZ Commercial	$372.40
Rate for Payer: Devoted Health Medicare	$95.76
Rate for Payer: Humana of AZ Medicare	$85.12
Rate for Payer: Mercy Care Medicaid	$166.32
Rate for Payer: NaphCare Correctional Healthcare	$166.32
Rate for Payer: Seven Corners Travel Insurance	$1,403.35
Rate for Payer: Southwest Service Administrators UFCW	$361.76
Rate for Payer: TriWest Medicare	$85.12
Rate for Payer: United Healthcare Commercial	$304.30
Rate for Payer: United Healthcare Medicare	$85.12
Rate for Payer: Veterans Affairs TRICARE	$84.27

43239 BIOPSY OF THE ESOPHAGUS, STOMACH, AND/OR UPPER SMALL B

Facility

$3,325.00

Service Code	CPT 43239
Hospital Charge Code	23599032
Hospital Revenue Code	750
Min. Negotiated Rate	$236.04
Max. Negotiated Rate	$3,596.00
Rate for Payer: Aetna of AZ Commercial	$2,992.50
Rate for Payer: Arizona Complete Health Allwell	$532.00
Rate for Payer: Banner UC Health Medicare	$343.75
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,261.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$236.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$532.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$532.00
Rate for Payer: Cash Price	$2,660.00
Rate for Payer: Cash Price	$2,660.00
Rate for Payer: Cash Price	$2,660.00
Rate for Payer: Cigna of AZ Commercial	$2,327.50
Rate for Payer: Devoted Health Medicare	$598.50
Rate for Payer: Humana of AZ Medicare	$532.00
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	$2,261.00
Rate for Payer: TriWest Medicare	$532.00
Rate for Payer: United Healthcare Commercial	$3,596.00
Rate for Payer: United Healthcare Medicare	$532.00
Rate for Payer: United Healthcare New Mexico Commercial	$631.75
Rate for Payer: Veterans Affairs TRICARE	$526.68

43239 BIOPSY OF THE ESOPHAGUS, STOMACH, AND/OR UPPER SMALL B

Facility

$3,325.00

Service Code	CPT 43239
Hospital Charge Code	23599032
Hospital Revenue Code	750
Min. Negotiated Rate	$2,992.50
Max. Negotiated Rate	$2,992.50
Rate for Payer: Aetna of AZ Commercial	$2,992.50
Rate for Payer: Cash Price	$2,660.00

Know your out-of-pocket cost for care.

All Charges