Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

INSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT

Facility

$346.75

Service Code	CPT 11981
Hospital Charge Code	22760242
Hospital Revenue Code	982
Min. Negotiated Rate	$312.07
Max. Negotiated Rate	$312.07
Rate for Payer: Aetna of AZ Commercial	$312.07
Rate for Payer: Cash Price	$277.40

INSERTION OF GUIDE WIRE THROUGH KIDNEY INTO URETER USING AN

Facility

$934.00

Service Code	CPT 52334
Hospital Charge Code	30512448
Hospital Revenue Code	360
Min. Negotiated Rate	$147.95
Max. Negotiated Rate	$5,454.10
Rate for Payer: Aetna of AZ Commercial	$840.60
Rate for Payer: Arizona Complete Health Allwell	$149.44
Rate for Payer: Banner UC Health Medicare	$1,171.31
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$635.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$149.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$149.44
Rate for Payer: Cash Price	$747.20
Rate for Payer: Cash Price	$747.20
Rate for Payer: Cash Price	$747.20
Rate for Payer: Cigna of AZ Commercial	$467.00
Rate for Payer: Devoted Health Medicare	$168.12
Rate for Payer: Humana of AZ Medicare	$149.44
Rate for Payer: NaphCare Correctional Healthcare	$1,171.31
Rate for Payer: Seven Corners Travel Insurance	$5,454.10
Rate for Payer: Southwest Service Administrators UFCW	$635.12
Rate for Payer: TriWest Medicare	$149.44
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$149.44
Rate for Payer: Veterans Affairs TRICARE	$147.95

INSERTION OF GUIDE WIRE THROUGH KIDNEY INTO URETER USING AN

Facility

$934.00

Service Code	CPT 52334
Hospital Charge Code	30512448
Hospital Revenue Code	360
Min. Negotiated Rate	$840.60
Max. Negotiated Rate	$840.60
Rate for Payer: Aetna of AZ Commercial	$840.60
Rate for Payer: Cash Price	$747.20

INSERTION OF INDWELLING TUBE FOR DRAINAGE OF LUNG FLUID Tech

Facility

$1,051.00

Service Code	CPT 32550
Hospital Charge Code	27927131
Hospital Revenue Code	360
Min. Negotiated Rate	$945.90
Max. Negotiated Rate	$945.90
Rate for Payer: Aetna of AZ Commercial	$945.90
Rate for Payer: Cash Price	$840.80

INSERTION OF INDWELLING TUBE FOR DRAINAGE OF LUNG FLUID Tech

Facility

$1,051.00

Service Code	CPT 32550
Hospital Charge Code	27927131
Hospital Revenue Code	360
Min. Negotiated Rate	$166.48
Max. Negotiated Rate	$5,539.84
Rate for Payer: Aetna of AZ Commercial	$945.90
Rate for Payer: Arizona Complete Health Allwell	$168.16
Rate for Payer: Banner UC Health Medicare	$1,509.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$714.68
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$550.89
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$168.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$168.16
Rate for Payer: Cash Price	$840.80
Rate for Payer: Cash Price	$840.80
Rate for Payer: Cash Price	$840.80
Rate for Payer: Cigna of AZ Commercial	$525.50
Rate for Payer: Devoted Health Medicare	$189.18
Rate for Payer: Humana of AZ Medicare	$168.16
Rate for Payer: Mercy Care Medicaid	$550.89
Rate for Payer: NaphCare Correctional Healthcare	$1,509.08
Rate for Payer: Seven Corners Travel Insurance	$5,539.84
Rate for Payer: Southwest Service Administrators UFCW	$714.68
Rate for Payer: TriWest Medicare	$168.16
Rate for Payer: United Healthcare Commercial	$4,838.00
Rate for Payer: United Healthcare Medicare	$168.16
Rate for Payer: Veterans Affairs TRICARE	$166.48

INSERTION OF INTRAUTERINE DEVICE (IUD)

Facility

$661.00

Service Code	CPT 58300
Hospital Charge Code	22760243
Hospital Revenue Code	360
Min. Negotiated Rate	$594.90
Max. Negotiated Rate	$594.90
Rate for Payer: Aetna of AZ Commercial	$594.90
Rate for Payer: Cash Price	$528.80

INSERTION OF INTRAUTERINE DEVICE (IUD)

Facility

$661.00

Service Code	CPT 58300
Hospital Charge Code	22760243
Hospital Revenue Code	360
Min. Negotiated Rate	$58.93
Max. Negotiated Rate	$2,671.00
Rate for Payer: Aetna of AZ Commercial	$594.90
Rate for Payer: Arizona Complete Health Allwell	$105.76
Rate for Payer: Banner UC Health Medicare	$105.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$449.48
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$58.93
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$105.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$105.76
Rate for Payer: Cash Price	$528.80
Rate for Payer: Cash Price	$528.80
Rate for Payer: Cash Price	$528.80
Rate for Payer: Cigna of AZ Commercial	$330.50
Rate for Payer: Devoted Health Medicare	$118.98
Rate for Payer: Humana of AZ Medicare	$105.76
Rate for Payer: Mercy Care Medicaid	$58.93
Rate for Payer: NaphCare Correctional Healthcare	$58.93
Rate for Payer: Southwest Service Administrators UFCW	$449.48
Rate for Payer: TriWest Medicare	$105.76
Rate for Payer: United Healthcare Commercial	$2,671.00
Rate for Payer: United Healthcare Medicare	$105.76
Rate for Payer: Veterans Affairs TRICARE	$104.70

INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION FOR RESIDUAL URINE)

Facility

$2,671.00

Service Code	CPT 51701
Hospital Revenue Code	490
Min. Negotiated Rate	$19.18
Max. Negotiated Rate	$2,671.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$19.18
Rate for Payer: Mercy Care Medicaid	$19.18
Rate for Payer: NaphCare Correctional Healthcare	$19.18
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: United Healthcare Commercial	$2,671.00

INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP, WITHOUT IMAGING GUIDANCE; AGE 5 YEARS OR OLDER

Facility

$3,098.00

Service Code	CPT 36569
Hospital Revenue Code	490
Min. Negotiated Rate	$518.28
Max. Negotiated Rate	$3,098.00
Rate for Payer: Banner UC Health Medicare	$518.28
Rate for Payer: NaphCare Correctional Healthcare	$518.28
Rate for Payer: Seven Corners Travel Insurance	$2,435.64
Rate for Payer: United Healthcare Commercial	$3,098.00

INSERTION OF PESSARY INTRAVAGINAL SUPPORT DEVICE

Facility

$379.00

Service Code	CPT 57160
Hospital Charge Code	22951058
Hospital Revenue Code	750
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

INSERTION OF PESSARY INTRAVAGINAL SUPPORT DEVICE

Facility

$379.00

Service Code	CPT 57160
Hospital Charge Code	22951058
Hospital Revenue Code	750
Min. Negotiated Rate	$20.02
Max. Negotiated Rate	$2,671.00
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	$20.02
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$257.72
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$28.94
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: Cash Price	$303.20
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: Mercy Care Medicaid	$28.94
Rate for Payer: NaphCare Correctional Healthcare	$20.02
Rate for Payer: Seven Corners Travel Insurance	$312.81
Rate for Payer: Southwest Service Administrators UFCW	$257.72
Rate for Payer: TriWest Medicare	$60.64
Rate for Payer: United Healthcare Commercial	$2,671.00
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

Insertion of Portacath additional minutes

Facility

$9.00

Service Code	CPT 00532
Hospital Charge Code	23968401
Hospital Revenue Code	370
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Arizona Complete Health Allwell	$1.44
Rate for Payer: Banner UC Health Medicare	$1.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$6.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.44
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna of AZ Commercial	$5.85
Rate for Payer: Devoted Health Medicare	$1.62
Rate for Payer: Humana of AZ Medicare	$1.44
Rate for Payer: Southwest Service Administrators UFCW	$6.12
Rate for Payer: TriWest Medicare	$1.44
Rate for Payer: United Healthcare Commercial	$5.15
Rate for Payer: United Healthcare Medicare	$1.44
Rate for Payer: Veterans Affairs TRICARE	$1.43

Insertion of Portacath additional minutes

Facility

$9.00

Service Code	CPT 00532
Hospital Charge Code	23968401
Hospital Revenue Code	370
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Cash Price	$7.20

INSERTION OF SACRAL NERVE NEUROSTIMULATOR ELECTRODE ARRAY

Facility

$1,588.00

Service Code	CPT 64561
Hospital Charge Code	28068478
Hospital Revenue Code	360
Min. Negotiated Rate	$251.54
Max. Negotiated Rate	$9,860.74
Rate for Payer: Aetna of AZ Commercial	$1,429.20
Rate for Payer: Arizona Complete Health Allwell	$254.08
Rate for Payer: Banner UC Health Medicare	$4,282.94
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,079.84
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$418.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$254.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$254.08
Rate for Payer: Cash Price	$1,270.40
Rate for Payer: Cash Price	$1,270.40
Rate for Payer: Cash Price	$1,270.40
Rate for Payer: Cigna of AZ Commercial	$794.00
Rate for Payer: Devoted Health Medicare	$285.84
Rate for Payer: Humana of AZ Medicare	$254.08
Rate for Payer: Mercy Care Medicaid	$418.76
Rate for Payer: NaphCare Correctional Healthcare	$4,282.94
Rate for Payer: Seven Corners Travel Insurance	$9,860.74
Rate for Payer: Southwest Service Administrators UFCW	$1,079.84
Rate for Payer: TriWest Medicare	$254.08
Rate for Payer: United Healthcare Commercial	$6,508.00
Rate for Payer: United Healthcare Medicare	$254.08
Rate for Payer: Veterans Affairs TRICARE	$251.54

INSERTION OF SACRAL NERVE NEUROSTIMULATOR ELECTRODE ARRAY

Facility

$1,588.00

Service Code	CPT 64561
Hospital Charge Code	28068478
Hospital Revenue Code	360
Min. Negotiated Rate	$1,429.20
Max. Negotiated Rate	$1,429.20
Rate for Payer: Aetna of AZ Commercial	$1,429.20
Rate for Payer: Cash Price	$1,270.40

INSERTION OF SPINAL NEUROSTIMULATOR ELECTRODE ARRAY USING FL

Facility

$1,702.00

Service Code	CPT 63661
Hospital Charge Code	28254330
Hospital Revenue Code	360
Min. Negotiated Rate	$1,531.80
Max. Negotiated Rate	$1,531.80
Rate for Payer: Aetna of AZ Commercial	$1,531.80
Rate for Payer: Cash Price	$1,361.60

INSERTION OF SPINAL NEUROSTIMULATOR ELECTRODE ARRAY USING FL

Facility

$1,702.00

Service Code	CPT 63661
Hospital Charge Code	28254330
Hospital Revenue Code	360
Min. Negotiated Rate	$269.60
Max. Negotiated Rate	$4,169.00
Rate for Payer: Aetna of AZ Commercial	$1,531.80
Rate for Payer: Arizona Complete Health Allwell	$272.32
Rate for Payer: Banner UC Health Medicare	$556.61
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,157.36
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$351.46
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$272.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$272.32
Rate for Payer: Cash Price	$1,361.60
Rate for Payer: Cash Price	$1,361.60
Rate for Payer: Cash Price	$1,361.60
Rate for Payer: Cigna of AZ Commercial	$851.00
Rate for Payer: Devoted Health Medicare	$306.36
Rate for Payer: Humana of AZ Medicare	$272.32
Rate for Payer: Mercy Care Medicaid	$351.46
Rate for Payer: NaphCare Correctional Healthcare	$556.61
Rate for Payer: Seven Corners Travel Insurance	$3,021.39
Rate for Payer: Southwest Service Administrators UFCW	$1,157.36
Rate for Payer: TriWest Medicare	$272.32
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$272.32
Rate for Payer: Veterans Affairs TRICARE	$269.60

INSERTION OF STENT IN URETER USING AN ENDOSCOPE

Facility

$802.00

Service Code	CPT 52332
Hospital Charge Code	27807900
Hospital Revenue Code	360
Min. Negotiated Rate	$127.04
Max. Negotiated Rate	$5,454.10
Rate for Payer: Aetna of AZ Commercial	$721.80
Rate for Payer: Arizona Complete Health Allwell	$128.32
Rate for Payer: Banner UC Health Medicare	$1,171.31
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$545.36
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$223.50
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$128.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$128.32
Rate for Payer: Cash Price	$641.60
Rate for Payer: Cash Price	$641.60
Rate for Payer: Cash Price	$641.60
Rate for Payer: Cigna of AZ Commercial	$401.00
Rate for Payer: Devoted Health Medicare	$144.36
Rate for Payer: Humana of AZ Medicare	$128.32
Rate for Payer: Mercy Care Medicaid	$223.50
Rate for Payer: NaphCare Correctional Healthcare	$1,171.31
Rate for Payer: Seven Corners Travel Insurance	$5,454.10
Rate for Payer: Southwest Service Administrators UFCW	$545.36
Rate for Payer: TriWest Medicare	$128.32
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$128.32
Rate for Payer: Veterans Affairs TRICARE	$127.04

INSERTION OF STENT IN URETER USING AN ENDOSCOPE

Facility

$802.00

Service Code	CPT 52332
Hospital Charge Code	27807900
Hospital Revenue Code	360
Min. Negotiated Rate	$721.80
Max. Negotiated Rate	$721.80
Rate for Payer: Aetna of AZ Commercial	$721.80
Rate for Payer: Cash Price	$641.60

INSERTION OF STOMACH TUBE USING AN EDOCS

Facility

$6,347.00

Service Code	CPT 43246
Hospital Charge Code	23599034
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 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: 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

INSERTION OF STOMACH TUBE USING AN EDOCS

Facility

$6,347.00

Service Code	CPT 43246
Hospital Charge Code	23599034
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

INSERTION OF STOMACH TUBE USING AN ENDOSCOPE

Facility

$6,347.00

Service Code	CPT 43246
Hospital Charge Code	23598981
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 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: 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

INSERTION OF STOMACH TUBE USING AN ENDOSCOPE

Facility

$6,347.00

Service Code	CPT 43246
Hospital Charge Code	23598981
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

Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older

Facility

$4,885.47

Service Code	CPT 36561
Hospital Revenue Code	360
Min. Negotiated Rate	$611.22
Max. Negotiated Rate	$4,885.47
Rate for Payer: Banner UC Health Medicare	$1,188.60
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$611.22
Rate for Payer: Mercy Care Medicaid	$611.22
Rate for Payer: NaphCare Correctional Healthcare	$1,188.60
Rate for Payer: Seven Corners Travel Insurance	$4,885.47
Rate for Payer: United Healthcare Commercial	$4,838.00

Insertion, Revision And Replacements Of Pacemaker And Other Cardiac Devices

Facility

$36,653.06

Service Code	APR-DRG 1764
Hospital Charge Code	APRDRG1763
Min. Negotiated Rate	$36,653.06
Max. Negotiated Rate	$36,653.06
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$36,653.06
Rate for Payer: Mercy Care Medicaid	$36,653.06
Rate for Payer: NaphCare Correctional Healthcare	$36,653.06

Know your out-of-pocket cost for care.

All Charges