Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINEN

Facility

$19,694.00

Service Code	CPT 51992
Hospital Charge Code	23093915
Hospital Revenue Code	360
Min. Negotiated Rate	$2,606.64
Max. Negotiated Rate	$17,724.60
Rate for Payer: Aetna of AZ Commercial	$17,724.60
Rate for Payer: Arizona Complete Health Allwell	$3,151.04
Rate for Payer: Banner UC Health Medicare	$2,606.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$13,391.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3,151.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$3,151.04
Rate for Payer: Cash Price	$15,755.20
Rate for Payer: Cash Price	$15,755.20
Rate for Payer: Cash Price	$15,755.20
Rate for Payer: Cigna of AZ Commercial	$9,847.00
Rate for Payer: Devoted Health Medicare	$3,544.92
Rate for Payer: Humana of AZ Medicare	$3,151.04
Rate for Payer: NaphCare Correctional Healthcare	$2,606.64
Rate for Payer: Seven Corners Travel Insurance	$9,354.07
Rate for Payer: Southwest Service Administrators UFCW	$13,391.92
Rate for Payer: TriWest Medicare	$3,151.04
Rate for Payer: United Healthcare Commercial	$6,508.00
Rate for Payer: United Healthcare Medicare	$3,151.04
Rate for Payer: Veterans Affairs TRICARE	$3,119.53

Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method

Facility

$9,354.07

Service Code	CPT 58662
Hospital Revenue Code	360
Min. Negotiated Rate	$1,984.28
Max. Negotiated Rate	$9,354.07
Rate for Payer: Banner UC Health Medicare	$1,984.28
Rate for Payer: NaphCare Correctional Healthcare	$1,984.28
Rate for Payer: Seven Corners Travel Insurance	$9,354.07
Rate for Payer: United Healthcare Commercial	$6,508.00

Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy)

Facility

$9,354.07

Service Code	CPT 58661
Hospital Revenue Code	360
Min. Negotiated Rate	$1,984.28
Max. Negotiated Rate	$9,354.07
Rate for Payer: Banner UC Health Medicare	$1,984.28
Rate for Payer: NaphCare Correctional Healthcare	$1,984.28
Rate for Payer: Seven Corners Travel Insurance	$9,354.07
Rate for Payer: United Healthcare Commercial	$6,508.00

LAPIPLASTY SPEEDPLATE QUAD 28X13X11

Facility

$31,427.00

Hospital Charge Code	27733676
Hospital Revenue Code	270
Min. Negotiated Rate	$28,284.30
Max. Negotiated Rate	$28,284.30
Rate for Payer: Aetna of AZ Commercial	$28,284.30
Rate for Payer: Cash Price	$25,141.60

LAPIPLASTY SPEEDPLATE QUAD 28X13X11

Facility

$31,427.00

Hospital Charge Code	27733676
Hospital Revenue Code	270
Min. Negotiated Rate	$4,978.04
Max. Negotiated Rate	$28,284.30
Rate for Payer: Aetna of AZ Commercial	$28,284.30
Rate for Payer: Arizona Complete Health Allwell	$5,028.32
Rate for Payer: Banner UC Health Medicare	$5,028.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$21,370.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5,028.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$5,028.32
Rate for Payer: Cash Price	$25,141.60
Rate for Payer: Cigna of AZ Commercial	$21,998.90
Rate for Payer: Devoted Health Medicare	$5,656.86
Rate for Payer: Humana of AZ Medicare	$5,028.32
Rate for Payer: Southwest Service Administrators UFCW	$21,370.36
Rate for Payer: TriWest Medicare	$5,028.32
Rate for Payer: United Healthcare Commercial	$17,976.24
Rate for Payer: United Healthcare Medicare	$5,028.32
Rate for Payer: Veterans Affairs TRICARE	$4,978.04

LAPIPLASTY SYSTEM 4

Facility

$33,448.00

Hospital Charge Code	27431788
Hospital Revenue Code	270
Min. Negotiated Rate	$5,298.16
Max. Negotiated Rate	$30,103.20
Rate for Payer: Aetna of AZ Commercial	$30,103.20
Rate for Payer: Arizona Complete Health Allwell	$5,351.68
Rate for Payer: Banner UC Health Medicare	$5,351.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$22,744.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5,351.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$5,351.68
Rate for Payer: Cash Price	$26,758.40
Rate for Payer: Cigna of AZ Commercial	$23,413.60
Rate for Payer: Devoted Health Medicare	$6,020.64
Rate for Payer: Humana of AZ Medicare	$5,351.68
Rate for Payer: Southwest Service Administrators UFCW	$22,744.64
Rate for Payer: TriWest Medicare	$5,351.68
Rate for Payer: United Healthcare Commercial	$19,132.26
Rate for Payer: United Healthcare Medicare	$5,351.68
Rate for Payer: Veterans Affairs TRICARE	$5,298.16

LAPIPLASTY SYSTEM 4

Facility

$33,448.00

Hospital Charge Code	27431788
Hospital Revenue Code	270
Min. Negotiated Rate	$30,103.20
Max. Negotiated Rate	$30,103.20
Rate for Payer: Aetna of AZ Commercial	$30,103.20
Rate for Payer: Cash Price	$26,758.40

LAP-KIT INSTRUMENT HOLDER ETHOX

Facility

$26.00

Hospital Charge Code	22561837
Hospital Revenue Code	272
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna of AZ Commercial	$23.40
Rate for Payer: Arizona Complete Health Allwell	$4.16
Rate for Payer: Banner UC Health Medicare	$4.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$17.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.16
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cigna of AZ Commercial	$18.20
Rate for Payer: Devoted Health Medicare	$4.68
Rate for Payer: Humana of AZ Medicare	$4.16
Rate for Payer: Southwest Service Administrators UFCW	$17.68
Rate for Payer: TriWest Medicare	$4.16
Rate for Payer: United Healthcare Commercial	$14.87
Rate for Payer: United Healthcare Medicare	$4.16
Rate for Payer: Veterans Affairs TRICARE	$4.12

LAP-KIT INSTRUMENT HOLDER ETHOX

Facility

$26.00

Hospital Charge Code	22561837
Hospital Revenue Code	272
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna of AZ Commercial	$23.40
Rate for Payer: Cash Price	$20.80

LAP KIT LAPAROSCOPIC INSTRUMENT HOLDER

Facility

$33.00

Hospital Charge Code	27372824
Hospital Revenue Code	270
Min. Negotiated Rate	$5.23
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Arizona Complete Health Allwell	$5.28
Rate for Payer: Banner UC Health Medicare	$5.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$22.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.28
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cigna of AZ Commercial	$23.10
Rate for Payer: Devoted Health Medicare	$5.94
Rate for Payer: Humana of AZ Medicare	$5.28
Rate for Payer: Southwest Service Administrators UFCW	$22.44
Rate for Payer: TriWest Medicare	$5.28
Rate for Payer: United Healthcare Commercial	$18.88
Rate for Payer: United Healthcare Medicare	$5.28
Rate for Payer: Veterans Affairs TRICARE	$5.23

LAP KIT LAPAROSCOPIC INSTRUMENT HOLDER

Facility

$33.00

Hospital Charge Code	27372824
Hospital Revenue Code	270
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Cash Price	$26.40

LAPLPLASTY

Facility

$32,550.00

Hospital Charge Code	24358101
Hospital Revenue Code	270
Min. Negotiated Rate	$29,295.00
Max. Negotiated Rate	$29,295.00
Rate for Payer: Aetna of AZ Commercial	$29,295.00
Rate for Payer: Cash Price	$26,040.00

LAPLPLASTY

Facility

$32,550.00

Hospital Charge Code	24358101
Hospital Revenue Code	270
Min. Negotiated Rate	$5,155.92
Max. Negotiated Rate	$29,295.00
Rate for Payer: Aetna of AZ Commercial	$29,295.00
Rate for Payer: Arizona Complete Health Allwell	$5,208.00
Rate for Payer: Banner UC Health Medicare	$5,208.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$22,134.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5,208.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$5,208.00
Rate for Payer: Cash Price	$26,040.00
Rate for Payer: Cigna of AZ Commercial	$22,785.00
Rate for Payer: Devoted Health Medicare	$5,859.00
Rate for Payer: Humana of AZ Medicare	$5,208.00
Rate for Payer: Southwest Service Administrators UFCW	$22,134.00
Rate for Payer: TriWest Medicare	$5,208.00
Rate for Payer: United Healthcare Commercial	$18,618.60
Rate for Payer: United Healthcare Medicare	$5,208.00
Rate for Payer: Veterans Affairs TRICARE	$5,155.92

LAPLPLASTY SAW BLADE 40MMX11MM STRYKER

Facility

$788.00

Hospital Charge Code	24358103
Hospital Revenue Code	270
Min. Negotiated Rate	$709.20
Max. Negotiated Rate	$709.20
Rate for Payer: Aetna of AZ Commercial	$709.20
Rate for Payer: Cash Price	$630.40

LAPLPLASTY SAW BLADE 40MMX11MM STRYKER

Facility

$788.00

Hospital Charge Code	24358103
Hospital Revenue Code	270
Min. Negotiated Rate	$124.82
Max. Negotiated Rate	$709.20
Rate for Payer: Aetna of AZ Commercial	$709.20
Rate for Payer: Arizona Complete Health Allwell	$126.08
Rate for Payer: Banner UC Health Medicare	$126.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$535.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$126.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$126.08
Rate for Payer: Cash Price	$630.40
Rate for Payer: Cigna of AZ Commercial	$551.60
Rate for Payer: Devoted Health Medicare	$141.84
Rate for Payer: Humana of AZ Medicare	$126.08
Rate for Payer: Southwest Service Administrators UFCW	$535.84
Rate for Payer: TriWest Medicare	$126.08
Rate for Payer: United Healthcare Commercial	$450.74
Rate for Payer: United Healthcare Medicare	$126.08
Rate for Payer: Veterans Affairs TRICARE	$124.82

LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); DIAGNOSTIC

Facility

$698.00

Service Code	CPT 31505
Hospital Charge Code	22209502
Hospital Revenue Code	450
Min. Negotiated Rate	$628.20
Max. Negotiated Rate	$628.20
Rate for Payer: Aetna of AZ Commercial	$628.20
Rate for Payer: Cash Price	$558.40

LARYNGOSCOPY, INDIRECT (SEPARATE PROCEDURE); DIAGNOSTIC

Facility

$698.00

Service Code	CPT 31505
Hospital Charge Code	22209502
Hospital Revenue Code	450
Min. Negotiated Rate	$38.71
Max. Negotiated Rate	$628.20
Rate for Payer: Aetna of AZ Commercial	$628.20
Rate for Payer: Arizona Complete Health Allwell	$111.68
Rate for Payer: Banner UC Health Medicare	$111.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$474.64
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$38.71
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$111.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$111.68
Rate for Payer: Cash Price	$558.40
Rate for Payer: Cash Price	$558.40
Rate for Payer: Cigna of AZ Commercial	$488.60
Rate for Payer: Devoted Health Medicare	$125.64
Rate for Payer: Humana of AZ Medicare	$111.68
Rate for Payer: Mercy Care Medicaid	$38.71
Rate for Payer: NaphCare Correctional Healthcare	$38.71
Rate for Payer: Seven Corners Travel Insurance	$308.85
Rate for Payer: Southwest Service Administrators UFCW	$474.64
Rate for Payer: TriWest Medicare	$111.68
Rate for Payer: United Healthcare Commercial	$399.26
Rate for Payer: United Healthcare Medicare	$111.68
Rate for Payer: United Healthcare New Mexico Commercial	$132.62
Rate for Payer: Veterans Affairs TRICARE	$110.56

LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED)

Facility

$8,296.15

Service Code	CPT 52649
Hospital Revenue Code	490
Min. Negotiated Rate	$1,977.90
Max. Negotiated Rate	$8,296.15
Rate for Payer: Banner UC Health Medicare	$1,977.90
Rate for Payer: NaphCare Correctional Healthcare	$1,977.90
Rate for Payer: Seven Corners Travel Insurance	$8,296.15
Rate for Payer: United Healthcare Commercial	$5,611.00

latanoprost Ophth 0.005% Sol [CQCH]

Facility

$2.20

Service Code	NDC 17478062512
Hospital Charge Code	105927842
Hospital Revenue Code	251
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$1.98
Rate for Payer: Aetna of AZ Commercial	$1.98
Rate for Payer: Cash Price	$1.76

latanoprost Ophth 0.005% Sol [CQCH]

Facility

$2.20

Service Code	NDC 17478062512
Hospital Charge Code	105927842
Hospital Revenue Code	251
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$1.98
Rate for Payer: Aetna of AZ Commercial	$1.98
Rate for Payer: Arizona Complete Health Allwell	$0.35
Rate for Payer: Banner UC Health Medicare	$0.35
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.50
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.35
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.35
Rate for Payer: Cash Price	$1.76
Rate for Payer: Cigna of AZ Commercial	$1.43
Rate for Payer: Devoted Health Medicare	$0.40
Rate for Payer: Humana of AZ Medicare	$0.35
Rate for Payer: Southwest Service Administrators UFCW	$1.50
Rate for Payer: TriWest Medicare	$0.35
Rate for Payer: United Healthcare Commercial	$1.26
Rate for Payer: United Healthcare Medicare	$0.35
Rate for Payer: Veterans Affairs TRICARE	$0.35

Layer Closure of Wounds of Face, Ear, Eyelid, Nose, Lip, Mucous Membrane 2.5 cm

Facility

$387.00

Service Code	CPT 12051
Hospital Charge Code	881170
Hospital Revenue Code	521
Min. Negotiated Rate	$348.30
Max. Negotiated Rate	$348.30
Rate for Payer: Aetna of AZ Commercial	$348.30
Rate for Payer: Cash Price	$309.60

Layer Closure of Wounds of Face, Ear, Eyelid, Nose, Lip, Mucous Membrane 2.5 cm

Facility

$387.00

Service Code	CPT 12051
Hospital Charge Code	881170
Hospital Revenue Code	521
Min. Negotiated Rate	$61.30
Max. Negotiated Rate	$629.00
Rate for Payer: Aetna of AZ Commercial	$348.30
Rate for Payer: Arizona Complete Health Allwell	$61.92
Rate for Payer: Banner UC Health Medicare	$61.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$263.16
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$120.51
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$61.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$61.92
Rate for Payer: Cash Price	$309.60
Rate for Payer: Cash Price	$309.60
Rate for Payer: Cigna of AZ Commercial	$270.90
Rate for Payer: Devoted Health Medicare	$69.66
Rate for Payer: Humana of AZ Medicare	$61.92
Rate for Payer: Mercy Care Medicaid	$120.51
Rate for Payer: NaphCare Correctional Healthcare	$120.51
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$263.16
Rate for Payer: TriWest Medicare	$61.92
Rate for Payer: United Healthcare Commercial	$221.36
Rate for Payer: United Healthcare Medicare	$61.92
Rate for Payer: Veterans Affairs TRICARE	$61.30

Layer Closure of Wounds of Neck, Hands, Feet and/or Ext Genitalia; 2.5 cm or Les

Facility

$363.00

Service Code	CPT 12041
Hospital Charge Code	1731849
Hospital Revenue Code	521
Min. Negotiated Rate	$326.70
Max. Negotiated Rate	$326.70
Rate for Payer: Aetna of AZ Commercial	$326.70
Rate for Payer: Cash Price	$290.40

Layer Closure of Wounds of Neck, Hands, Feet and/or Ext Genitalia; 2.5 cm or Les

Facility

$363.00

Service Code	CPT 12041
Hospital Charge Code	1731849
Hospital Revenue Code	521
Min. Negotiated Rate	$57.50
Max. Negotiated Rate	$629.00
Rate for Payer: Aetna of AZ Commercial	$326.70
Rate for Payer: Arizona Complete Health Allwell	$58.08
Rate for Payer: Banner UC Health Medicare	$58.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$246.84
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$124.81
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$58.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$58.08
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cigna of AZ Commercial	$254.10
Rate for Payer: Devoted Health Medicare	$65.34
Rate for Payer: Humana of AZ Medicare	$58.08
Rate for Payer: Mercy Care Medicaid	$124.81
Rate for Payer: NaphCare Correctional Healthcare	$124.81
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$246.84
Rate for Payer: TriWest Medicare	$58.08
Rate for Payer: United Healthcare Commercial	$207.64
Rate for Payer: United Healthcare Medicare	$58.08
Rate for Payer: Veterans Affairs TRICARE	$57.50

Layer Closure of Wounds of Scalp, Axillae, Trunk, Extremities(Exclude Hands and

Facility

$291.00

Service Code	CPT 12031
Hospital Charge Code	881121
Hospital Revenue Code	521
Min. Negotiated Rate	$261.90
Max. Negotiated Rate	$261.90
Rate for Payer: Aetna of AZ Commercial	$261.90
Rate for Payer: Cash Price	$232.80

Know your out-of-pocket cost for care.

All Charges