Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

MANIPULATION OF STONE IN URETER USING AN ENDOSCOPE Tech

Facility

$1,363.00

Service Code	CPT 52330
Hospital Charge Code	27883522
Hospital Revenue Code	360
Min. Negotiated Rate	$1,226.70
Max. Negotiated Rate	$1,226.70
Rate for Payer: Aetna of AZ Commercial	$1,226.70
Rate for Payer: Cash Price	$1,090.40

MANIPULATION OF STONE IN URETER USING AN ENDOSCOPE Tech

Facility

$1,363.00

Service Code	CPT 52330
Hospital Charge Code	27883522
Hospital Revenue Code	360
Min. Negotiated Rate	$215.90
Max. Negotiated Rate	$5,454.10
Rate for Payer: Aetna of AZ Commercial	$1,226.70
Rate for Payer: Arizona Complete Health Allwell	$218.08
Rate for Payer: Banner UC Health Medicare	$1,171.31
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$926.84
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$321.47
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$218.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$218.08
Rate for Payer: Cash Price	$1,090.40
Rate for Payer: Cash Price	$1,090.40
Rate for Payer: Cash Price	$1,090.40
Rate for Payer: Cigna of AZ Commercial	$681.50
Rate for Payer: Devoted Health Medicare	$245.34
Rate for Payer: Humana of AZ Medicare	$218.08
Rate for Payer: Mercy Care Medicaid	$321.47
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	$926.84
Rate for Payer: TriWest Medicare	$218.08
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$218.08
Rate for Payer: Veterans Affairs TRICARE	$215.90

Manual Differential

Facility

$47.00

Service Code	CPT 85007
Hospital Charge Code	22394401
Hospital Revenue Code	305
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Arizona Complete Health Allwell	$7.52
Rate for Payer: Banner UC Health Medicare	$7.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$31.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.52
Rate for Payer: Cash Price	$37.60
Rate for Payer: Cash Price	$37.60
Rate for Payer: Cigna of AZ Commercial	$30.55
Rate for Payer: Devoted Health Medicare	$8.46
Rate for Payer: Humana of AZ Medicare	$7.52
Rate for Payer: Seven Corners Travel Insurance	$5.51
Rate for Payer: Southwest Service Administrators UFCW	$31.96
Rate for Payer: TriWest Medicare	$7.52
Rate for Payer: United Healthcare Commercial	$26.88
Rate for Payer: United Healthcare Medicare	$7.52
Rate for Payer: Veterans Affairs TRICARE	$7.44

Manual Differential

Facility

$47.00

Service Code	CPT 85007
Hospital Charge Code	22394401
Hospital Revenue Code	305
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Cash Price	$37.60

Manual Differential Standard

Facility

$45.00

Service Code	CPT 85007
Hospital Charge Code	22242914
Hospital Revenue Code	305
Min. Negotiated Rate	$40.50
Max. Negotiated Rate	$40.50
Rate for Payer: Aetna of AZ Commercial	$40.50
Rate for Payer: Cash Price	$36.00

Manual Differential Standard

Facility

$45.00

Service Code	CPT 85007
Hospital Charge Code	22242914
Hospital Revenue Code	305
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$40.50
Rate for Payer: Aetna of AZ Commercial	$40.50
Rate for Payer: Arizona Complete Health Allwell	$7.20
Rate for Payer: Banner UC Health Medicare	$7.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$30.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna of AZ Commercial	$29.25
Rate for Payer: Devoted Health Medicare	$8.10
Rate for Payer: Humana of AZ Medicare	$7.20
Rate for Payer: Seven Corners Travel Insurance	$5.51
Rate for Payer: Southwest Service Administrators UFCW	$30.60
Rate for Payer: TriWest Medicare	$7.20
Rate for Payer: United Healthcare Commercial	$25.74
Rate for Payer: United Healthcare Medicare	$7.20
Rate for Payer: Veterans Affairs TRICARE	$7.13

Manual Therapy Charge Units

Facility

$181.00

Service Code	CPT 97140 GP
Hospital Charge Code	692252
Hospital Revenue Code	420
Min. Negotiated Rate	$162.90
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Cash Price	$144.80

Manual Therapy Charge Units

Facility

$181.00

Service Code	CPT 97140 GP
Hospital Charge Code	692252
Hospital Revenue Code	420
Min. Negotiated Rate	$28.67
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Arizona Complete Health Allwell	$28.96
Rate for Payer: Banner UC Health Medicare	$28.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$123.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$29.03
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cigna of AZ Commercial	$126.70
Rate for Payer: Devoted Health Medicare	$32.58
Rate for Payer: Humana of AZ Medicare	$28.96
Rate for Payer: Southwest Service Administrators UFCW	$123.08
Rate for Payer: TriWest Medicare	$28.96
Rate for Payer: United Healthcare Commercial	$103.53
Rate for Payer: United Healthcare Medicare	$28.96
Rate for Payer: United Healthcare New Mexico Commercial	$34.39
Rate for Payer: Veterans Affairs TRICARE	$28.67

MARQUIS STOPCOCK

Facility

$18.96

Hospital Charge Code	28268892
Hospital Revenue Code	270
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$17.06
Rate for Payer: Aetna of AZ Commercial	$17.06
Rate for Payer: Arizona Complete Health Allwell	$3.03
Rate for Payer: Banner UC Health Medicare	$3.03
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$12.89
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.03
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.03
Rate for Payer: Cash Price	$15.17
Rate for Payer: Cigna of AZ Commercial	$13.27
Rate for Payer: Devoted Health Medicare	$3.41
Rate for Payer: Humana of AZ Medicare	$3.03
Rate for Payer: Southwest Service Administrators UFCW	$12.89
Rate for Payer: TriWest Medicare	$3.03
Rate for Payer: United Healthcare Commercial	$10.85
Rate for Payer: United Healthcare Medicare	$3.03
Rate for Payer: Veterans Affairs TRICARE	$3.00

MARQUIS STOPCOCK

Facility

$18.96

Hospital Charge Code	28268892
Hospital Revenue Code	270
Min. Negotiated Rate	$17.06
Max. Negotiated Rate	$17.06
Rate for Payer: Aetna of AZ Commercial	$17.06
Rate for Payer: Cash Price	$15.17

MASIMO INFANT SENSOR 18IN

Facility

$67.00

Hospital Charge Code	24316100
Hospital Revenue Code	270
Min. Negotiated Rate	$10.61
Max. Negotiated Rate	$60.30
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Arizona Complete Health Allwell	$10.72
Rate for Payer: Banner UC Health Medicare	$10.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$45.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.72
Rate for Payer: Cash Price	$53.60
Rate for Payer: Cigna of AZ Commercial	$46.90
Rate for Payer: Devoted Health Medicare	$12.06
Rate for Payer: Humana of AZ Medicare	$10.72
Rate for Payer: Southwest Service Administrators UFCW	$45.56
Rate for Payer: TriWest Medicare	$10.72
Rate for Payer: United Healthcare Commercial	$38.32
Rate for Payer: United Healthcare Medicare	$10.72
Rate for Payer: Veterans Affairs TRICARE	$10.61

MASIMO INFANT SENSOR 18IN

Facility

$67.00

Hospital Charge Code	24316100
Hospital Revenue Code	270
Min. Negotiated Rate	$60.30
Max. Negotiated Rate	$60.30
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Cash Price	$53.60

MASK AEROSOL PED

Facility

$563.00

Hospital Charge Code	22354238
Hospital Revenue Code	270
Min. Negotiated Rate	$89.18
Max. Negotiated Rate	$506.70
Rate for Payer: Aetna of AZ Commercial	$506.70
Rate for Payer: Arizona Complete Health Allwell	$90.08
Rate for Payer: Banner UC Health Medicare	$90.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$382.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$90.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$90.08
Rate for Payer: Cash Price	$450.40
Rate for Payer: Cigna of AZ Commercial	$394.10
Rate for Payer: Devoted Health Medicare	$101.34
Rate for Payer: Humana of AZ Medicare	$90.08
Rate for Payer: Southwest Service Administrators UFCW	$382.84
Rate for Payer: TriWest Medicare	$90.08
Rate for Payer: United Healthcare Commercial	$322.04
Rate for Payer: United Healthcare Medicare	$90.08
Rate for Payer: Veterans Affairs TRICARE	$89.18

MASK AEROSOL PED

Facility

$563.00

Hospital Charge Code	22354238
Hospital Revenue Code	270
Min. Negotiated Rate	$506.70
Max. Negotiated Rate	$506.70
Rate for Payer: Aetna of AZ Commercial	$506.70
Rate for Payer: Cash Price	$450.40

MASK AMBU INFANT

Facility

$131.00

Hospital Charge Code	22355208
Hospital Revenue Code	270
Min. Negotiated Rate	$117.90
Max. Negotiated Rate	$117.90
Rate for Payer: Aetna of AZ Commercial	$117.90
Rate for Payer: Cash Price	$104.80

MASK AMBU INFANT

Facility

$131.00

Hospital Charge Code	22355208
Hospital Revenue Code	270
Min. Negotiated Rate	$20.75
Max. Negotiated Rate	$117.90
Rate for Payer: Aetna of AZ Commercial	$117.90
Rate for Payer: Arizona Complete Health Allwell	$20.96
Rate for Payer: Banner UC Health Medicare	$20.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$89.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.96
Rate for Payer: Cash Price	$104.80
Rate for Payer: Cigna of AZ Commercial	$91.70
Rate for Payer: Devoted Health Medicare	$23.58
Rate for Payer: Humana of AZ Medicare	$20.96
Rate for Payer: Southwest Service Administrators UFCW	$89.08
Rate for Payer: TriWest Medicare	$20.96
Rate for Payer: United Healthcare Commercial	$74.93
Rate for Payer: United Healthcare Medicare	$20.96
Rate for Payer: Veterans Affairs TRICARE	$20.75

MASK AMBU NEONATE

Facility

$149.00

Hospital Charge Code	22355207
Hospital Revenue Code	270
Min. Negotiated Rate	$23.60
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of AZ Commercial	$134.10
Rate for Payer: Arizona Complete Health Allwell	$23.84
Rate for Payer: Banner UC Health Medicare	$23.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$101.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$23.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$23.84
Rate for Payer: Cash Price	$119.20
Rate for Payer: Cigna of AZ Commercial	$104.30
Rate for Payer: Devoted Health Medicare	$26.82
Rate for Payer: Humana of AZ Medicare	$23.84
Rate for Payer: Southwest Service Administrators UFCW	$101.32
Rate for Payer: TriWest Medicare	$23.84
Rate for Payer: United Healthcare Commercial	$85.23
Rate for Payer: United Healthcare Medicare	$23.84
Rate for Payer: Veterans Affairs TRICARE	$23.60

MASK AMBU NEONATE

Facility

$149.00

Hospital Charge Code	22355207
Hospital Revenue Code	270
Min. Negotiated Rate	$134.10
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of AZ Commercial	$134.10
Rate for Payer: Cash Price	$119.20

MASK BIPAP FULL FACE LARGE

Facility

$120.00

Hospital Charge Code	22354321
Hospital Revenue Code	270
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Cash Price	$96.00

MASK BIPAP FULL FACE LARGE

Facility

$120.00

Hospital Charge Code	22354321
Hospital Revenue Code	270
Min. Negotiated Rate	$19.01
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Arizona Complete Health Allwell	$19.20
Rate for Payer: Banner UC Health Medicare	$19.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$81.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$19.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$19.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cigna of AZ Commercial	$84.00
Rate for Payer: Devoted Health Medicare	$21.60
Rate for Payer: Humana of AZ Medicare	$19.20
Rate for Payer: Southwest Service Administrators UFCW	$81.60
Rate for Payer: TriWest Medicare	$19.20
Rate for Payer: United Healthcare Commercial	$68.64
Rate for Payer: United Healthcare Medicare	$19.20
Rate for Payer: Veterans Affairs TRICARE	$19.01

MASK BIPAP FULL FACE MED

Facility

$120.00

Hospital Charge Code	22354319
Hospital Revenue Code	270
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Cash Price	$96.00

MASK BIPAP FULL FACE MED

Facility

$120.00

Hospital Charge Code	22354319
Hospital Revenue Code	270
Min. Negotiated Rate	$19.01
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Arizona Complete Health Allwell	$19.20
Rate for Payer: Banner UC Health Medicare	$19.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$81.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$19.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$19.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cigna of AZ Commercial	$84.00
Rate for Payer: Devoted Health Medicare	$21.60
Rate for Payer: Humana of AZ Medicare	$19.20
Rate for Payer: Southwest Service Administrators UFCW	$81.60
Rate for Payer: TriWest Medicare	$19.20
Rate for Payer: United Healthcare Commercial	$68.64
Rate for Payer: United Healthcare Medicare	$19.20
Rate for Payer: Veterans Affairs TRICARE	$19.01

MASK BIPAP FULL FACE SMALL

Facility

$120.00

Hospital Charge Code	22354320
Hospital Revenue Code	270
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Cash Price	$96.00

MASK BIPAP FULL FACE SMALL

Facility

$120.00

Hospital Charge Code	22354320
Hospital Revenue Code	270
Min. Negotiated Rate	$19.01
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Arizona Complete Health Allwell	$19.20
Rate for Payer: Banner UC Health Medicare	$19.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$81.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$19.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$19.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cigna of AZ Commercial	$84.00
Rate for Payer: Devoted Health Medicare	$21.60
Rate for Payer: Humana of AZ Medicare	$19.20
Rate for Payer: Southwest Service Administrators UFCW	$81.60
Rate for Payer: TriWest Medicare	$19.20
Rate for Payer: United Healthcare Commercial	$68.64
Rate for Payer: United Healthcare Medicare	$19.20
Rate for Payer: Veterans Affairs TRICARE	$19.01

MASK LARYNGEAL #2 DISPOSABLE

Facility

$44.00

Hospital Charge Code	22570783
Hospital Revenue Code	272
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$39.60
Rate for Payer: Aetna of AZ Commercial	$39.60
Rate for Payer: Cash Price	$35.20

Know your out-of-pocket cost for care.

All Charges