Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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	$46.09
Max. Negotiated Rate	$629.00
Rate for Payer: Aetna of AZ Commercial	$261.90
Rate for Payer: Arizona Complete Health Allwell	$46.56
Rate for Payer: Banner UC Health Medicare	$46.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$197.88
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$117.30
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$46.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$46.56
Rate for Payer: Cash Price	$232.80
Rate for Payer: Cash Price	$232.80
Rate for Payer: Cigna of AZ Commercial	$203.70
Rate for Payer: Devoted Health Medicare	$52.38
Rate for Payer: Humana of AZ Medicare	$46.56
Rate for Payer: Mercy Care Medicaid	$117.30
Rate for Payer: NaphCare Correctional Healthcare	$117.30
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$197.88
Rate for Payer: TriWest Medicare	$46.56
Rate for Payer: United Healthcare Commercial	$166.45
Rate for Payer: United Healthcare Medicare	$46.56
Rate for Payer: Veterans Affairs TRICARE	$46.09

.LDL Size Comment LC

Facility

$158.00

Service Code	CPT 83721
Hospital Charge Code	22311155
Hospital Revenue Code	301
Min. Negotiated Rate	$142.20
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of AZ Commercial	$142.20
Rate for Payer: Cash Price	$126.40

.LDL Size Comment LC

Facility

$158.00

Service Code	CPT 83721
Hospital Charge Code	22311155
Hospital Revenue Code	301
Min. Negotiated Rate	$15.22
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of AZ Commercial	$142.20
Rate for Payer: Arizona Complete Health Allwell	$25.28
Rate for Payer: Banner UC Health Medicare	$25.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$107.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$25.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$25.28
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cigna of AZ Commercial	$102.70
Rate for Payer: Devoted Health Medicare	$28.44
Rate for Payer: Humana of AZ Medicare	$25.28
Rate for Payer: Seven Corners Travel Insurance	$15.22
Rate for Payer: Southwest Service Administrators UFCW	$107.44
Rate for Payer: TriWest Medicare	$25.28
Rate for Payer: United Healthcare Commercial	$90.38
Rate for Payer: United Healthcare Medicare	$25.28
Rate for Payer: Veterans Affairs TRICARE	$25.03

LEAD

Facility

$19,029.00

Service Code	HCPCS C1778
Hospital Charge Code	22354567
Hospital Revenue Code	270
Min. Negotiated Rate	$17,126.10
Max. Negotiated Rate	$17,126.10
Rate for Payer: Aetna of AZ Commercial	$17,126.10
Rate for Payer: Cash Price	$15,223.20

LEAD

Facility

$19,029.00

Service Code	HCPCS C1778
Hospital Charge Code	22354567
Hospital Revenue Code	270
Min. Negotiated Rate	$3,014.19
Max. Negotiated Rate	$17,126.10
Rate for Payer: Aetna of AZ Commercial	$17,126.10
Rate for Payer: Arizona Complete Health Allwell	$3,044.64
Rate for Payer: Banner UC Health Medicare	$3,044.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$12,939.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3,044.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$3,044.64
Rate for Payer: Cash Price	$15,223.20
Rate for Payer: Cigna of AZ Commercial	$13,320.30
Rate for Payer: Devoted Health Medicare	$3,425.22
Rate for Payer: Humana of AZ Medicare	$3,044.64
Rate for Payer: Southwest Service Administrators UFCW	$12,939.72
Rate for Payer: TriWest Medicare	$3,044.64
Rate for Payer: United Healthcare Commercial	$10,884.59
Rate for Payer: United Healthcare Medicare	$3,044.64
Rate for Payer: Veterans Affairs TRICARE	$3,014.19

LEAD ADULT

Facility

$296.00

Service Code	CPT 83655
Hospital Charge Code	22481489
Hospital Revenue Code	301
Min. Negotiated Rate	$17.56
Max. Negotiated Rate	$266.40
Rate for Payer: Aetna of AZ Commercial	$266.40
Rate for Payer: Arizona Complete Health Allwell	$47.36
Rate for Payer: Banner UC Health Medicare	$47.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$201.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$47.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$47.36
Rate for Payer: Cash Price	$236.80
Rate for Payer: Cash Price	$236.80
Rate for Payer: Cigna of AZ Commercial	$192.40
Rate for Payer: Devoted Health Medicare	$53.28
Rate for Payer: Humana of AZ Medicare	$47.36
Rate for Payer: Seven Corners Travel Insurance	$17.56
Rate for Payer: Southwest Service Administrators UFCW	$201.28
Rate for Payer: TriWest Medicare	$47.36
Rate for Payer: United Healthcare Commercial	$169.31
Rate for Payer: United Healthcare Medicare	$47.36
Rate for Payer: Veterans Affairs TRICARE	$46.89

LEAD ADULT

Facility

$296.00

Service Code	CPT 83655
Hospital Charge Code	22481489
Hospital Revenue Code	301
Min. Negotiated Rate	$266.40
Max. Negotiated Rate	$266.40
Rate for Payer: Aetna of AZ Commercial	$266.40
Rate for Payer: Cash Price	$236.80

Lead, Blood (Adult) LC

Facility

$270.00

Service Code	CPT 83655
Hospital Charge Code	1285614
Hospital Revenue Code	301
Min. Negotiated Rate	$243.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of AZ Commercial	$243.00
Rate for Payer: Cash Price	$216.00

Lead, Blood (Adult) LC

Facility

$270.00

Service Code	CPT 83655
Hospital Charge Code	1285614
Hospital Revenue Code	301
Min. Negotiated Rate	$17.56
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of AZ Commercial	$243.00
Rate for Payer: Arizona Complete Health Allwell	$43.20
Rate for Payer: Banner UC Health Medicare	$43.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$183.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$43.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna of AZ Commercial	$175.50
Rate for Payer: Devoted Health Medicare	$48.60
Rate for Payer: Humana of AZ Medicare	$43.20
Rate for Payer: Seven Corners Travel Insurance	$17.56
Rate for Payer: Southwest Service Administrators UFCW	$183.60
Rate for Payer: TriWest Medicare	$43.20
Rate for Payer: United Healthcare Commercial	$154.44
Rate for Payer: United Healthcare Medicare	$43.20
Rate for Payer: Veterans Affairs TRICARE	$42.77

Lead, Blood (Pediatric) LC

Facility

$268.00

Service Code	CPT 83655
Hospital Charge Code	1285615
Hospital Revenue Code	301
Min. Negotiated Rate	$17.56
Max. Negotiated Rate	$241.20
Rate for Payer: Aetna of AZ Commercial	$241.20
Rate for Payer: Arizona Complete Health Allwell	$42.88
Rate for Payer: Banner UC Health Medicare	$42.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$182.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$42.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$42.88
Rate for Payer: Cash Price	$214.40
Rate for Payer: Cash Price	$214.40
Rate for Payer: Cigna of AZ Commercial	$174.20
Rate for Payer: Devoted Health Medicare	$48.24
Rate for Payer: Humana of AZ Medicare	$42.88
Rate for Payer: Seven Corners Travel Insurance	$17.56
Rate for Payer: Southwest Service Administrators UFCW	$182.24
Rate for Payer: TriWest Medicare	$42.88
Rate for Payer: United Healthcare Commercial	$153.30
Rate for Payer: United Healthcare Medicare	$42.88
Rate for Payer: Veterans Affairs TRICARE	$42.45

Lead, Blood (Pediatric) LC

Facility

$268.00

Service Code	CPT 83655
Hospital Charge Code	1285615
Hospital Revenue Code	301
Min. Negotiated Rate	$241.20
Max. Negotiated Rate	$241.20
Rate for Payer: Aetna of AZ Commercial	$241.20
Rate for Payer: Cash Price	$214.40

LEAD INTRODUCER

Facility

$1,605.00

Service Code	HCPCS C1894
Hospital Charge Code	22354566
Hospital Revenue Code	270
Min. Negotiated Rate	$1,444.50
Max. Negotiated Rate	$1,444.50
Rate for Payer: Aetna of AZ Commercial	$1,444.50
Rate for Payer: Cash Price	$1,284.00

LEAD INTRODUCER

Facility

$1,605.00

Service Code	HCPCS C1894
Hospital Charge Code	22354566
Hospital Revenue Code	270
Min. Negotiated Rate	$254.23
Max. Negotiated Rate	$1,444.50
Rate for Payer: Aetna of AZ Commercial	$1,444.50
Rate for Payer: Arizona Complete Health Allwell	$256.80
Rate for Payer: Banner UC Health Medicare	$256.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,091.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$256.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$256.80
Rate for Payer: Cash Price	$1,284.00
Rate for Payer: Cigna of AZ Commercial	$1,123.50
Rate for Payer: Devoted Health Medicare	$288.90
Rate for Payer: Humana of AZ Medicare	$256.80
Rate for Payer: Southwest Service Administrators UFCW	$1,091.40
Rate for Payer: TriWest Medicare	$256.80
Rate for Payer: United Healthcare Commercial	$918.06
Rate for Payer: United Healthcare Medicare	$256.80
Rate for Payer: Veterans Affairs TRICARE	$254.23

Legal Draw Fee

Facility

$48.00

Hospital Charge Code	2240047
Hospital Revenue Code	300
Min. Negotiated Rate	$43.20
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of AZ Commercial	$43.20
Rate for Payer: Cash Price	$38.40

Legal Draw Fee

Facility

$48.00

Hospital Charge Code	2240047
Hospital Revenue Code	300
Min. Negotiated Rate	$7.60
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of AZ Commercial	$43.20
Rate for Payer: Arizona Complete Health Allwell	$7.68
Rate for Payer: Banner UC Health Medicare	$7.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$32.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.68
Rate for Payer: Cash Price	$38.40
Rate for Payer: Cigna of AZ Commercial	$31.20
Rate for Payer: Devoted Health Medicare	$8.64
Rate for Payer: Humana of AZ Medicare	$7.68
Rate for Payer: Southwest Service Administrators UFCW	$32.64
Rate for Payer: TriWest Medicare	$7.68
Rate for Payer: United Healthcare Commercial	$27.46
Rate for Payer: United Healthcare Medicare	$7.68
Rate for Payer: Veterans Affairs TRICARE	$7.60

Legionella pneumophila Abs. LC

Facility

$86.00

Service Code	CPT 86713
Hospital Charge Code	22201718
Hospital Revenue Code	302
Min. Negotiated Rate	$13.62
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of AZ Commercial	$77.40
Rate for Payer: Arizona Complete Health Allwell	$13.76
Rate for Payer: Banner UC Health Medicare	$13.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$58.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.76
Rate for Payer: Cash Price	$68.80
Rate for Payer: Cash Price	$68.80
Rate for Payer: Cigna of AZ Commercial	$55.90
Rate for Payer: Devoted Health Medicare	$15.48
Rate for Payer: Humana of AZ Medicare	$13.76
Rate for Payer: Seven Corners Travel Insurance	$22.18
Rate for Payer: Southwest Service Administrators UFCW	$58.48
Rate for Payer: TriWest Medicare	$13.76
Rate for Payer: United Healthcare Commercial	$49.19
Rate for Payer: United Healthcare Medicare	$13.76
Rate for Payer: Veterans Affairs TRICARE	$13.62

Legionella pneumophila Abs. LC

Facility

$86.00

Service Code	CPT 86713
Hospital Charge Code	22201718
Hospital Revenue Code	302
Min. Negotiated Rate	$77.40
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of AZ Commercial	$77.40
Rate for Payer: Cash Price	$68.80

LEOS 01.6MM SMOOTH K WIRE

Facility

$630.00

Hospital Charge Code	27595625
Hospital Revenue Code	270
Min. Negotiated Rate	$99.79
Max. Negotiated Rate	$567.00
Rate for Payer: Aetna of AZ Commercial	$567.00
Rate for Payer: Arizona Complete Health Allwell	$100.80
Rate for Payer: Banner UC Health Medicare	$100.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$428.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$100.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$100.80
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cigna of AZ Commercial	$441.00
Rate for Payer: Devoted Health Medicare	$113.40
Rate for Payer: Humana of AZ Medicare	$100.80
Rate for Payer: Southwest Service Administrators UFCW	$428.40
Rate for Payer: TriWest Medicare	$100.80
Rate for Payer: United Healthcare Commercial	$360.36
Rate for Payer: United Healthcare Medicare	$100.80
Rate for Payer: Veterans Affairs TRICARE	$99.79

LEOS 01.6MM SMOOTH K WIRE

Facility

$630.00

Hospital Charge Code	27595625
Hospital Revenue Code	270
Min. Negotiated Rate	$567.00
Max. Negotiated Rate	$567.00
Rate for Payer: Aetna of AZ Commercial	$567.00
Rate for Payer: Cash Price	$504.00

LEOS 1.6MM THREADED K WIRE

Facility

$656.00

Hospital Charge Code	27663811
Hospital Revenue Code	270
Min. Negotiated Rate	$590.40
Max. Negotiated Rate	$590.40
Rate for Payer: Aetna of AZ Commercial	$590.40
Rate for Payer: Cash Price	$524.80

LEOS 1.6MM THREADED K WIRE

Facility

$656.00

Hospital Charge Code	27663811
Hospital Revenue Code	270
Min. Negotiated Rate	$103.91
Max. Negotiated Rate	$590.40
Rate for Payer: Aetna of AZ Commercial	$590.40
Rate for Payer: Arizona Complete Health Allwell	$104.96
Rate for Payer: Banner UC Health Medicare	$104.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$446.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$104.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$104.96
Rate for Payer: Cash Price	$524.80
Rate for Payer: Cigna of AZ Commercial	$459.20
Rate for Payer: Devoted Health Medicare	$118.08
Rate for Payer: Humana of AZ Medicare	$104.96
Rate for Payer: Southwest Service Administrators UFCW	$446.08
Rate for Payer: TriWest Medicare	$104.96
Rate for Payer: United Healthcare Commercial	$375.23
Rate for Payer: United Healthcare Medicare	$104.96
Rate for Payer: Veterans Affairs TRICARE	$103.91

LEOS 2.0MM K WIRE

Facility

$788.00

Hospital Charge Code	27595620
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

LEOS 2.0MM K WIRE

Facility

$788.00

Hospital Charge Code	27595620
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

LEOS 2.4 DRILL

Facility

$2,130.00

Hospital Charge Code	27808546
Hospital Revenue Code	270
Min. Negotiated Rate	$337.39
Max. Negotiated Rate	$1,917.00
Rate for Payer: Aetna of AZ Commercial	$1,917.00
Rate for Payer: Arizona Complete Health Allwell	$340.80
Rate for Payer: Banner UC Health Medicare	$340.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,448.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$340.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$340.80
Rate for Payer: Cash Price	$1,704.00
Rate for Payer: Cigna of AZ Commercial	$1,491.00
Rate for Payer: Devoted Health Medicare	$383.40
Rate for Payer: Humana of AZ Medicare	$340.80
Rate for Payer: Southwest Service Administrators UFCW	$1,448.40
Rate for Payer: TriWest Medicare	$340.80
Rate for Payer: United Healthcare Commercial	$1,218.36
Rate for Payer: United Healthcare Medicare	$340.80
Rate for Payer: Veterans Affairs TRICARE	$337.39

LEOS 2.4 DRILL

Facility

$2,130.00

Hospital Charge Code	27808546
Hospital Revenue Code	270
Min. Negotiated Rate	$1,917.00
Max. Negotiated Rate	$1,917.00
Rate for Payer: Aetna of AZ Commercial	$1,917.00
Rate for Payer: Cash Price	$1,704.00

Know your out-of-pocket cost for care.

All Charges