Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

5-HIAA,Quant.,24 Hr Urine LC

Facility

$245.00

Service Code	CPT 83497
Hospital Charge Code	2084298
Hospital Revenue Code	301
Min. Negotiated Rate	$220.50
Max. Negotiated Rate	$220.50
Rate for Payer: Aetna of AZ Commercial	$220.50
Rate for Payer: Cash Price	$196.00

5-HIAA,Quant.,24 Hr Urine LC

Facility

$245.00

Service Code	CPT 83497
Hospital Charge Code	2084298
Hospital Revenue Code	301
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$220.50
Rate for Payer: Aetna of AZ Commercial	$220.50
Rate for Payer: Arizona Complete Health Allwell	$39.20
Rate for Payer: Banner UC Health Medicare	$39.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$166.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$39.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$39.20
Rate for Payer: Cash Price	$196.00
Rate for Payer: Cash Price	$196.00
Rate for Payer: Cigna of AZ Commercial	$159.25
Rate for Payer: Devoted Health Medicare	$44.10
Rate for Payer: Humana of AZ Medicare	$39.20
Rate for Payer: Seven Corners Travel Insurance	$18.70
Rate for Payer: Southwest Service Administrators UFCW	$166.60
Rate for Payer: TriWest Medicare	$39.20
Rate for Payer: United Healthcare Commercial	$140.14
Rate for Payer: United Healthcare Medicare	$39.20
Rate for Payer: Veterans Affairs TRICARE	$38.81

62270 LUMBAR SPINAL TAP

Facility

$700.00

Service Code	CPT 62270
Hospital Charge Code	22282923
Hospital Revenue Code	450
Min. Negotiated Rate	$83.33
Max. Negotiated Rate	$1,092.18
Rate for Payer: Aetna of AZ Commercial	$630.00
Rate for Payer: Arizona Complete Health Allwell	$112.00
Rate for Payer: Banner UC Health Medicare	$112.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$476.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$83.33
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$112.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$112.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Cigna of AZ Commercial	$490.00
Rate for Payer: Devoted Health Medicare	$126.00
Rate for Payer: Humana of AZ Medicare	$112.00
Rate for Payer: Mercy Care Medicaid	$83.33
Rate for Payer: NaphCare Correctional Healthcare	$83.33
Rate for Payer: Seven Corners Travel Insurance	$1,092.18
Rate for Payer: Southwest Service Administrators UFCW	$476.00
Rate for Payer: TriWest Medicare	$112.00
Rate for Payer: United Healthcare Commercial	$400.40
Rate for Payer: United Healthcare Medicare	$112.00
Rate for Payer: United Healthcare New Mexico Commercial	$133.00
Rate for Payer: Veterans Affairs TRICARE	$110.88

62270 LUMBAR SPINAL TAP

Facility

$700.00

Service Code	CPT 62270
Hospital Charge Code	22282923
Hospital Revenue Code	450
Min. Negotiated Rate	$630.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna of AZ Commercial	$630.00
Rate for Payer: Cash Price	$560.00

64405 Injection, Anesthetic agent; Facial Nerve

Facility

$549.00

Service Code	CPT 64405
Hospital Charge Code	22704948
Hospital Revenue Code	450
Min. Negotiated Rate	$494.10
Max. Negotiated Rate	$494.10
Rate for Payer: Aetna of AZ Commercial	$494.10
Rate for Payer: Cash Price	$439.20

64405 Injection, Anesthetic agent; Facial Nerve

Facility

$549.00

Service Code	CPT 64405
Hospital Charge Code	22704948
Hospital Revenue Code	450
Min. Negotiated Rate	$23.02
Max. Negotiated Rate	$494.10
Rate for Payer: Aetna of AZ Commercial	$494.10
Rate for Payer: Arizona Complete Health Allwell	$87.84
Rate for Payer: Banner UC Health Medicare	$87.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$373.32
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$23.02
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$87.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$87.84
Rate for Payer: Cash Price	$439.20
Rate for Payer: Cash Price	$439.20
Rate for Payer: Cigna of AZ Commercial	$384.30
Rate for Payer: Devoted Health Medicare	$98.82
Rate for Payer: Humana of AZ Medicare	$87.84
Rate for Payer: Mercy Care Medicaid	$23.02
Rate for Payer: NaphCare Correctional Healthcare	$23.02
Rate for Payer: Seven Corners Travel Insurance	$474.93
Rate for Payer: Southwest Service Administrators UFCW	$373.32
Rate for Payer: TriWest Medicare	$87.84
Rate for Payer: United Healthcare Commercial	$314.03
Rate for Payer: United Healthcare Medicare	$87.84
Rate for Payer: United Healthcare New Mexico Commercial	$104.31
Rate for Payer: Veterans Affairs TRICARE	$86.96

64430 INJECTION OF ANESTHETIC AGENT AND/OR STEROID INTO PUDE

Facility

$299.00

Service Code	CPT 64430
Hospital Charge Code	27410735
Hospital Revenue Code	360
Min. Negotiated Rate	$269.10
Max. Negotiated Rate	$269.10
Rate for Payer: Aetna of AZ Commercial	$269.10
Rate for Payer: Cash Price	$239.20

64430 INJECTION OF ANESTHETIC AGENT AND/OR STEROID INTO PUDE

Facility

$299.00

Service Code	CPT 64430
Hospital Charge Code	27410735
Hospital Revenue Code	360
Min. Negotiated Rate	$43.59
Max. Negotiated Rate	$3,098.00
Rate for Payer: Aetna of AZ Commercial	$269.10
Rate for Payer: Arizona Complete Health Allwell	$47.84
Rate for Payer: Banner UC Health Medicare	$293.41
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$203.32
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$43.59
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$47.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$47.84
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cigna of AZ Commercial	$149.50
Rate for Payer: Devoted Health Medicare	$53.82
Rate for Payer: Humana of AZ Medicare	$47.84
Rate for Payer: Mercy Care Medicaid	$43.59
Rate for Payer: NaphCare Correctional Healthcare	$293.41
Rate for Payer: Seven Corners Travel Insurance	$1,368.52
Rate for Payer: Southwest Service Administrators UFCW	$203.32
Rate for Payer: TriWest Medicare	$47.84
Rate for Payer: United Healthcare Commercial	$3,098.00
Rate for Payer: United Healthcare Medicare	$47.84
Rate for Payer: Veterans Affairs TRICARE	$47.36

64450 INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR

Facility

$287.00

Service Code	CPT 64450
Hospital Charge Code	24063188
Hospital Revenue Code	521
Min. Negotiated Rate	$33.12
Max. Negotiated Rate	$1,092.18
Rate for Payer: Aetna of AZ Commercial	$258.30
Rate for Payer: Arizona Complete Health Allwell	$45.92
Rate for Payer: Banner UC Health Medicare	$45.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$195.16
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$33.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$45.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$45.92
Rate for Payer: Cash Price	$229.60
Rate for Payer: Cash Price	$229.60
Rate for Payer: Cigna of AZ Commercial	$200.90
Rate for Payer: Devoted Health Medicare	$51.66
Rate for Payer: Humana of AZ Medicare	$45.92
Rate for Payer: Mercy Care Medicaid	$33.12
Rate for Payer: NaphCare Correctional Healthcare	$33.12
Rate for Payer: Seven Corners Travel Insurance	$1,092.18
Rate for Payer: Southwest Service Administrators UFCW	$195.16
Rate for Payer: TriWest Medicare	$45.92
Rate for Payer: United Healthcare Commercial	$164.16
Rate for Payer: United Healthcare Medicare	$45.92
Rate for Payer: Veterans Affairs TRICARE	$45.46

64450 INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR

Facility

$287.00

Service Code	CPT 64450
Hospital Charge Code	24063188
Hospital Revenue Code	521
Min. Negotiated Rate	$258.30
Max. Negotiated Rate	$258.30
Rate for Payer: Aetna of AZ Commercial	$258.30
Rate for Payer: Cash Price	$229.60

64455 INJECTIONS OF ANESTHETIC AND/OR STEROID DRUG INTO NERV

Facility

$308.00

Service Code	CPT 64632
Hospital Charge Code	24063186
Min. Negotiated Rate	$24.06
Max. Negotiated Rate	$474.93
Rate for Payer: Aetna of AZ Commercial	$277.20
Rate for Payer: Arizona Complete Health Allwell	$49.28
Rate for Payer: Banner UC Health Medicare	$49.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$209.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$24.06
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$49.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$49.28
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cigna of AZ Commercial	$215.60
Rate for Payer: Devoted Health Medicare	$55.44
Rate for Payer: Humana of AZ Medicare	$49.28
Rate for Payer: Mercy Care Medicaid	$24.06
Rate for Payer: NaphCare Correctional Healthcare	$24.06
Rate for Payer: Seven Corners Travel Insurance	$474.93
Rate for Payer: Southwest Service Administrators UFCW	$209.44
Rate for Payer: TriWest Medicare	$49.28
Rate for Payer: United Healthcare Commercial	$176.18
Rate for Payer: United Healthcare Medicare	$49.28
Rate for Payer: Veterans Affairs TRICARE	$48.79

64455 INJECTIONS OF ANESTHETIC AND/OR STEROID DRUG INTO NERV

Facility

$1,104.00

Service Code	CPT 64455
Hospital Charge Code	22986169
Hospital Revenue Code	450
Min. Negotiated Rate	$993.60
Max. Negotiated Rate	$993.60
Rate for Payer: Aetna of AZ Commercial	$993.60
Rate for Payer: Cash Price	$883.20

64455 INJECTIONS OF ANESTHETIC AND/OR STEROID DRUG INTO NERV

Facility

$308.00

Service Code	CPT 64632
Hospital Charge Code	24063186
Min. Negotiated Rate	$277.20
Max. Negotiated Rate	$277.20
Rate for Payer: Aetna of AZ Commercial	$277.20
Rate for Payer: Cash Price	$246.40

64455 INJECTIONS OF ANESTHETIC AND/OR STEROID DRUG INTO NERV

Facility

$1,104.00

Service Code	CPT 64455
Hospital Charge Code	22986169
Hospital Revenue Code	450
Min. Negotiated Rate	$17.08
Max. Negotiated Rate	$993.60
Rate for Payer: Aetna of AZ Commercial	$993.60
Rate for Payer: Arizona Complete Health Allwell	$176.64
Rate for Payer: Banner UC Health Medicare	$176.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$750.72
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$17.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$176.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$176.64
Rate for Payer: Cash Price	$883.20
Rate for Payer: Cash Price	$883.20
Rate for Payer: Cigna of AZ Commercial	$772.80
Rate for Payer: Devoted Health Medicare	$198.72
Rate for Payer: Humana of AZ Medicare	$176.64
Rate for Payer: Mercy Care Medicaid	$17.08
Rate for Payer: NaphCare Correctional Healthcare	$17.08
Rate for Payer: Seven Corners Travel Insurance	$474.93
Rate for Payer: Southwest Service Administrators UFCW	$750.72
Rate for Payer: TriWest Medicare	$176.64
Rate for Payer: United Healthcare Commercial	$631.49
Rate for Payer: United Healthcare Medicare	$176.64
Rate for Payer: United Healthcare New Mexico Commercial	$209.76
Rate for Payer: Veterans Affairs TRICARE	$174.87

64550 TENS APPLICATION CHARGE

Facility

$697.00

Service Code	CPT 64550 GP
Hospital Charge Code	9299389
Min. Negotiated Rate	$627.30
Max. Negotiated Rate	$627.30
Rate for Payer: Aetna of AZ Commercial	$627.30
Rate for Payer: Cash Price	$557.60

64550 TENS APPLICATION CHARGE

Facility

$697.00

Service Code	CPT 64550 GP
Hospital Charge Code	9299389
Min. Negotiated Rate	$110.40
Max. Negotiated Rate	$627.30
Rate for Payer: Aetna of AZ Commercial	$627.30
Rate for Payer: Arizona Complete Health Allwell	$111.52
Rate for Payer: Banner UC Health Medicare	$111.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$473.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$111.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$111.52
Rate for Payer: Cash Price	$557.60
Rate for Payer: Cigna of AZ Commercial	$487.90
Rate for Payer: Devoted Health Medicare	$125.46
Rate for Payer: Humana of AZ Medicare	$111.52
Rate for Payer: Southwest Service Administrators UFCW	$473.96
Rate for Payer: TriWest Medicare	$111.52
Rate for Payer: United Healthcare Commercial	$398.68
Rate for Payer: United Healthcare Medicare	$111.52
Rate for Payer: Veterans Affairs TRICARE	$110.40

64561 INSERTION OF SACRAL NERVE NEUROSTIMULATOR ELECTRODES,

Facility

$865.00

Service Code	CPT 64561
Hospital Charge Code	26865656
Hospital Revenue Code	521
Min. Negotiated Rate	$778.50
Max. Negotiated Rate	$778.50
Rate for Payer: Aetna of AZ Commercial	$778.50
Rate for Payer: Cash Price	$692.00

64561 INSERTION OF SACRAL NERVE NEUROSTIMULATOR ELECTRODES,

Facility

$865.00

Service Code	CPT 64561
Hospital Charge Code	26865656
Hospital Revenue Code	521
Min. Negotiated Rate	$137.02
Max. Negotiated Rate	$9,860.74
Rate for Payer: Aetna of AZ Commercial	$778.50
Rate for Payer: Arizona Complete Health Allwell	$138.40
Rate for Payer: Banner UC Health Medicare	$138.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$588.20
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$418.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$138.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$138.40
Rate for Payer: Cash Price	$692.00
Rate for Payer: Cash Price	$692.00
Rate for Payer: Cigna of AZ Commercial	$605.50
Rate for Payer: Devoted Health Medicare	$155.70
Rate for Payer: Humana of AZ Medicare	$138.40
Rate for Payer: Mercy Care Medicaid	$418.76
Rate for Payer: NaphCare Correctional Healthcare	$418.76
Rate for Payer: Seven Corners Travel Insurance	$9,860.74
Rate for Payer: Southwest Service Administrators UFCW	$588.20
Rate for Payer: TriWest Medicare	$138.40
Rate for Payer: United Healthcare Commercial	$494.78
Rate for Payer: United Healthcare Medicare	$138.40
Rate for Payer: Veterans Affairs TRICARE	$137.02

64566 POSTERIOR TIBIAL NEUROSTIMULATION, PERCUTANEOUS NEEDLE

Facility

$168.00

Service Code	CPT 64566
Hospital Charge Code	27414132
Hospital Revenue Code	360
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$151.20
Rate for Payer: Aetna of AZ Commercial	$151.20
Rate for Payer: Cash Price	$134.40

64566 POSTERIOR TIBIAL NEUROSTIMULATION, PERCUTANEOUS NEEDLE

Facility

$168.00

Service Code	CPT 64566
Hospital Charge Code	27414132
Hospital Revenue Code	360
Min. Negotiated Rate	$26.61
Max. Negotiated Rate	$2,671.00
Rate for Payer: Aetna of AZ Commercial	$151.20
Rate for Payer: Arizona Complete Health Allwell	$26.88
Rate for Payer: Banner UC Health Medicare	$52.35
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$114.24
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$85.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$26.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$26.88
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cigna of AZ Commercial	$84.00
Rate for Payer: Devoted Health Medicare	$30.24
Rate for Payer: Humana of AZ Medicare	$26.88
Rate for Payer: Mercy Care Medicaid	$85.08
Rate for Payer: NaphCare Correctional Healthcare	$52.35
Rate for Payer: Seven Corners Travel Insurance	$474.93
Rate for Payer: Southwest Service Administrators UFCW	$114.24
Rate for Payer: TriWest Medicare	$26.88
Rate for Payer: United Healthcare Commercial	$2,671.00
Rate for Payer: United Healthcare Medicare	$26.88
Rate for Payer: Veterans Affairs TRICARE	$26.61

65205 REMOVE FB EXT EYE SUPERT

Facility

$202.00

Service Code	CPT 65205
Hospital Charge Code	22282924
Hospital Revenue Code	450
Min. Negotiated Rate	$181.80
Max. Negotiated Rate	$181.80
Rate for Payer: Aetna of AZ Commercial	$181.80
Rate for Payer: Cash Price	$161.60

65205 REMOVE FB EXT EYE SUPERT

Facility

$202.00

Service Code	CPT 65205
Hospital Charge Code	22282924
Hospital Revenue Code	450
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$205.86
Rate for Payer: Aetna of AZ Commercial	$181.80
Rate for Payer: Arizona Complete Health Allwell	$32.32
Rate for Payer: Banner UC Health Medicare	$32.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$137.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.32
Rate for Payer: Cash Price	$161.60
Rate for Payer: Cash Price	$161.60
Rate for Payer: Cigna of AZ Commercial	$141.40
Rate for Payer: Devoted Health Medicare	$36.36
Rate for Payer: Humana of AZ Medicare	$32.32
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$137.36
Rate for Payer: TriWest Medicare	$32.32
Rate for Payer: United Healthcare Commercial	$115.54
Rate for Payer: United Healthcare Medicare	$32.32
Rate for Payer: United Healthcare New Mexico Commercial	$38.38
Rate for Payer: Veterans Affairs TRICARE	$32.00

65205 RMVL FB EXT EYE CONJ SUP

Facility

$168.00

Service Code	CPT 65205
Hospital Charge Code	12047486
Hospital Revenue Code	521
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$151.20
Rate for Payer: Aetna of AZ Commercial	$151.20
Rate for Payer: Cash Price	$134.40

65205 RMVL FB EXT EYE CONJ SUP

Facility

$168.00

Service Code	CPT 65205
Hospital Charge Code	12047486
Hospital Revenue Code	521
Min. Negotiated Rate	$26.61
Max. Negotiated Rate	$205.86
Rate for Payer: Aetna of AZ Commercial	$151.20
Rate for Payer: Arizona Complete Health Allwell	$26.88
Rate for Payer: Banner UC Health Medicare	$26.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$114.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$26.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$26.88
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cigna of AZ Commercial	$117.60
Rate for Payer: Devoted Health Medicare	$30.24
Rate for Payer: Humana of AZ Medicare	$26.88
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$114.24
Rate for Payer: TriWest Medicare	$26.88
Rate for Payer: United Healthcare Commercial	$96.10
Rate for Payer: United Healthcare Medicare	$26.88
Rate for Payer: Veterans Affairs TRICARE	$26.61

65210 REMOVE FB EXT EYE ENBEDD

Facility

$233.00

Service Code	CPT 65210
Hospital Charge Code	22282925
Hospital Revenue Code	450
Min. Negotiated Rate	$2.44
Max. Negotiated Rate	$691.20
Rate for Payer: Aetna of AZ Commercial	$209.70
Rate for Payer: Arizona Complete Health Allwell	$37.28
Rate for Payer: Banner UC Health Medicare	$37.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$158.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$37.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.28
Rate for Payer: Cash Price	$186.40
Rate for Payer: Cash Price	$186.40
Rate for Payer: Cigna of AZ Commercial	$163.10
Rate for Payer: Devoted Health Medicare	$41.94
Rate for Payer: Humana of AZ Medicare	$37.28
Rate for Payer: Mercy Care Medicaid	$2.44
Rate for Payer: NaphCare Correctional Healthcare	$2.44
Rate for Payer: Seven Corners Travel Insurance	$691.20
Rate for Payer: Southwest Service Administrators UFCW	$158.44
Rate for Payer: TriWest Medicare	$37.28
Rate for Payer: United Healthcare Commercial	$133.28
Rate for Payer: United Healthcare Medicare	$37.28
Rate for Payer: United Healthcare New Mexico Commercial	$44.27
Rate for Payer: Veterans Affairs TRICARE	$36.91

Know your out-of-pocket cost for care.

All Charges