Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Shave (Epi)Dermal Lesion, Single, Scalp, Neck, Hands, Feet, Genital; Diam 0.5 cm

Facility

$171.00

Service Code	CPT 11305
Hospital Charge Code	713811
Hospital Revenue Code	521
Min. Negotiated Rate	$27.09
Max. Negotiated Rate	$310.43
Rate for Payer: Aetna of AZ Commercial	$153.90
Rate for Payer: Arizona Complete Health Allwell	$27.36
Rate for Payer: Banner UC Health Medicare	$27.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$116.28
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$71.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.36
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cigna of AZ Commercial	$119.70
Rate for Payer: Devoted Health Medicare	$30.78
Rate for Payer: Humana of AZ Medicare	$27.36
Rate for Payer: Mercy Care Medicaid	$71.52
Rate for Payer: NaphCare Correctional Healthcare	$71.52
Rate for Payer: Seven Corners Travel Insurance	$310.43
Rate for Payer: Southwest Service Administrators UFCW	$116.28
Rate for Payer: TriWest Medicare	$27.36
Rate for Payer: United Healthcare Commercial	$97.81
Rate for Payer: United Healthcare Medicare	$27.36
Rate for Payer: Veterans Affairs TRICARE	$27.09

Shave (Epi)Dermal Lesion, Single, Scalp, Neck, Hands, Feet, Genital; Diam 0.5 cm

Facility

$171.00

Service Code	CPT 11305
Hospital Charge Code	713811
Hospital Revenue Code	521
Min. Negotiated Rate	$153.90
Max. Negotiated Rate	$153.90
Rate for Payer: Aetna of AZ Commercial	$153.90
Rate for Payer: Cash Price	$136.80

Shave (Epi)Dermal Lesion, Single, Scalp, Neck, Hands, Feet, Genital; Diam 0.6 to

Facility

$260.00

Service Code	CPT 11306
Hospital Charge Code	713813
Hospital Revenue Code	521
Min. Negotiated Rate	$41.18
Max. Negotiated Rate	$310.43
Rate for Payer: Aetna of AZ Commercial	$234.00
Rate for Payer: Arizona Complete Health Allwell	$41.60
Rate for Payer: Banner UC Health Medicare	$41.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$176.80
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$77.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$41.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$41.60
Rate for Payer: Cash Price	$208.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Cigna of AZ Commercial	$182.00
Rate for Payer: Devoted Health Medicare	$46.80
Rate for Payer: Humana of AZ Medicare	$41.60
Rate for Payer: Mercy Care Medicaid	$77.60
Rate for Payer: NaphCare Correctional Healthcare	$77.60
Rate for Payer: Seven Corners Travel Insurance	$310.43
Rate for Payer: Southwest Service Administrators UFCW	$176.80
Rate for Payer: TriWest Medicare	$41.60
Rate for Payer: United Healthcare Commercial	$148.72
Rate for Payer: United Healthcare Medicare	$41.60
Rate for Payer: Veterans Affairs TRICARE	$41.18

Shave (Epi)Dermal Lesion, Single, Scalp, Neck, Hands, Feet, Genital; Diam 0.6 to

Facility

$260.00

Service Code	CPT 11306
Hospital Charge Code	713813
Hospital Revenue Code	521
Min. Negotiated Rate	$234.00
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna of AZ Commercial	$234.00
Rate for Payer: Cash Price	$208.00

Shave (Epi)Dermal Lesion, Single, Trunk, Arms or Legs; Diam 0.6 to 1.0 cm Charge

Facility

$263.00

Service Code	CPT 11301
Hospital Charge Code	713805
Hospital Revenue Code	521
Min. Negotiated Rate	$41.66
Max. Negotiated Rate	$310.43
Rate for Payer: Aetna of AZ Commercial	$236.70
Rate for Payer: Arizona Complete Health Allwell	$42.08
Rate for Payer: Banner UC Health Medicare	$42.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$178.84
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$74.39
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$42.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$42.08
Rate for Payer: Cash Price	$210.40
Rate for Payer: Cash Price	$210.40
Rate for Payer: Cigna of AZ Commercial	$184.10
Rate for Payer: Devoted Health Medicare	$47.34
Rate for Payer: Humana of AZ Medicare	$42.08
Rate for Payer: Mercy Care Medicaid	$74.39
Rate for Payer: NaphCare Correctional Healthcare	$74.39
Rate for Payer: Seven Corners Travel Insurance	$310.43
Rate for Payer: Southwest Service Administrators UFCW	$178.84
Rate for Payer: TriWest Medicare	$42.08
Rate for Payer: United Healthcare Commercial	$150.44
Rate for Payer: United Healthcare Medicare	$42.08
Rate for Payer: Veterans Affairs TRICARE	$41.66

Shave (Epi)Dermal Lesion, Single, Trunk, Arms or Legs; Diam 0.6 to 1.0 cm Charge

Facility

$263.00

Service Code	CPT 11301
Hospital Charge Code	713805
Hospital Revenue Code	521
Min. Negotiated Rate	$236.70
Max. Negotiated Rate	$236.70
Rate for Payer: Aetna of AZ Commercial	$236.70
Rate for Payer: Cash Price	$210.40

Shave (Epi)Dermal Lesion, Single, Trunk, Arms or Legs; Diam 1.1 to 2.0 cm Charge

Facility

$272.00

Service Code	CPT 11302
Hospital Charge Code	713807
Hospital Revenue Code	521
Min. Negotiated Rate	$244.80
Max. Negotiated Rate	$244.80
Rate for Payer: Aetna of AZ Commercial	$244.80
Rate for Payer: Cash Price	$217.60

Shave (Epi)Dermal Lesion, Single, Trunk, Arms or Legs; Diam 1.1 to 2.0 cm Charge

Facility

$272.00

Service Code	CPT 11302
Hospital Charge Code	713807
Hospital Revenue Code	521
Min. Negotiated Rate	$43.08
Max. Negotiated Rate	$310.43
Rate for Payer: Aetna of AZ Commercial	$244.80
Rate for Payer: Arizona Complete Health Allwell	$43.52
Rate for Payer: Banner UC Health Medicare	$43.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$184.96
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$81.89
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$43.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.52
Rate for Payer: Cash Price	$217.60
Rate for Payer: Cash Price	$217.60
Rate for Payer: Cigna of AZ Commercial	$190.40
Rate for Payer: Devoted Health Medicare	$48.96
Rate for Payer: Humana of AZ Medicare	$43.52
Rate for Payer: Mercy Care Medicaid	$81.89
Rate for Payer: NaphCare Correctional Healthcare	$81.89
Rate for Payer: Seven Corners Travel Insurance	$310.43
Rate for Payer: Southwest Service Administrators UFCW	$184.96
Rate for Payer: TriWest Medicare	$43.52
Rate for Payer: United Healthcare Commercial	$155.58
Rate for Payer: United Healthcare Medicare	$43.52
Rate for Payer: Veterans Affairs TRICARE	$43.08

SHEATH FLEXOR PARALLEL 35CM

Facility

$701.00

Hospital Charge Code	22354226
Hospital Revenue Code	270
Min. Negotiated Rate	$111.04
Max. Negotiated Rate	$630.90
Rate for Payer: Aetna of AZ Commercial	$630.90
Rate for Payer: Arizona Complete Health Allwell	$112.16
Rate for Payer: Banner UC Health Medicare	$112.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$476.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$112.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$112.16
Rate for Payer: Cash Price	$560.80
Rate for Payer: Cigna of AZ Commercial	$490.70
Rate for Payer: Devoted Health Medicare	$126.18
Rate for Payer: Humana of AZ Medicare	$112.16
Rate for Payer: Southwest Service Administrators UFCW	$476.68
Rate for Payer: TriWest Medicare	$112.16
Rate for Payer: United Healthcare Commercial	$400.97
Rate for Payer: United Healthcare Medicare	$112.16
Rate for Payer: Veterans Affairs TRICARE	$111.04

SHEATH FLEXOR PARALLEL 35CM

Facility

$701.00

Hospital Charge Code	22354226
Hospital Revenue Code	270
Min. Negotiated Rate	$630.90
Max. Negotiated Rate	$630.90
Rate for Payer: Aetna of AZ Commercial	$630.90
Rate for Payer: Cash Price	$560.80

SHEATH FLEXOR URETERAL ACCESS 35CM COOK

Facility

$776.00

Hospital Charge Code	22354221
Hospital Revenue Code	270
Min. Negotiated Rate	$698.40
Max. Negotiated Rate	$698.40
Rate for Payer: Aetna of AZ Commercial	$698.40
Rate for Payer: Cash Price	$620.80

SHEATH FLEXOR URETERAL ACCESS 35CM COOK

Facility

$776.00

Hospital Charge Code	22354221
Hospital Revenue Code	270
Min. Negotiated Rate	$122.92
Max. Negotiated Rate	$698.40
Rate for Payer: Aetna of AZ Commercial	$698.40
Rate for Payer: Arizona Complete Health Allwell	$124.16
Rate for Payer: Banner UC Health Medicare	$124.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$527.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$124.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$124.16
Rate for Payer: Cash Price	$620.80
Rate for Payer: Cigna of AZ Commercial	$543.20
Rate for Payer: Devoted Health Medicare	$139.68
Rate for Payer: Humana of AZ Medicare	$124.16
Rate for Payer: Southwest Service Administrators UFCW	$527.68
Rate for Payer: TriWest Medicare	$124.16
Rate for Payer: United Healthcare Commercial	$443.87
Rate for Payer: United Healthcare Medicare	$124.16
Rate for Payer: Veterans Affairs TRICARE	$122.92

SHEATH URETERAL ACCESS 24CM ACMI UROPASS

Facility

$530.00

Hospital Charge Code	22354818
Hospital Revenue Code	270
Min. Negotiated Rate	$477.00
Max. Negotiated Rate	$477.00
Rate for Payer: Aetna of AZ Commercial	$477.00
Rate for Payer: Cash Price	$424.00

SHEATH URETERAL ACCESS 24CM ACMI UROPASS

Facility

$530.00

Hospital Charge Code	22354818
Hospital Revenue Code	270
Min. Negotiated Rate	$83.95
Max. Negotiated Rate	$477.00
Rate for Payer: Aetna of AZ Commercial	$477.00
Rate for Payer: Arizona Complete Health Allwell	$84.80
Rate for Payer: Banner UC Health Medicare	$84.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$360.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$84.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$84.80
Rate for Payer: Cash Price	$424.00
Rate for Payer: Cigna of AZ Commercial	$371.00
Rate for Payer: Devoted Health Medicare	$95.40
Rate for Payer: Humana of AZ Medicare	$84.80
Rate for Payer: Southwest Service Administrators UFCW	$360.40
Rate for Payer: TriWest Medicare	$84.80
Rate for Payer: United Healthcare Commercial	$303.16
Rate for Payer: United Healthcare Medicare	$84.80
Rate for Payer: Veterans Affairs TRICARE	$83.95

SHEATH URETERAL ACCESS 38CM ACMI UROPASS

Facility

$530.00

Hospital Charge Code	22354819
Hospital Revenue Code	270
Min. Negotiated Rate	$477.00
Max. Negotiated Rate	$477.00
Rate for Payer: Aetna of AZ Commercial	$477.00
Rate for Payer: Cash Price	$424.00

SHEATH URETERAL ACCESS 38CM ACMI UROPASS

Facility

$530.00

Hospital Charge Code	22354819
Hospital Revenue Code	270
Min. Negotiated Rate	$83.95
Max. Negotiated Rate	$477.00
Rate for Payer: Aetna of AZ Commercial	$477.00
Rate for Payer: Arizona Complete Health Allwell	$84.80
Rate for Payer: Banner UC Health Medicare	$84.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$360.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$84.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$84.80
Rate for Payer: Cash Price	$424.00
Rate for Payer: Cigna of AZ Commercial	$371.00
Rate for Payer: Devoted Health Medicare	$95.40
Rate for Payer: Humana of AZ Medicare	$84.80
Rate for Payer: Southwest Service Administrators UFCW	$360.40
Rate for Payer: TriWest Medicare	$84.80
Rate for Payer: United Healthcare Commercial	$303.16
Rate for Payer: United Healthcare Medicare	$84.80
Rate for Payer: Veterans Affairs TRICARE	$83.95

SHEATH URETERAL ACCESS DBL LUMEN 12X35

Facility

$534.00

Hospital Charge Code	22354224
Hospital Revenue Code	270
Min. Negotiated Rate	$84.59
Max. Negotiated Rate	$480.60
Rate for Payer: Aetna of AZ Commercial	$480.60
Rate for Payer: Arizona Complete Health Allwell	$85.44
Rate for Payer: Banner UC Health Medicare	$85.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$363.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$85.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$85.44
Rate for Payer: Cash Price	$427.20
Rate for Payer: Cigna of AZ Commercial	$373.80
Rate for Payer: Devoted Health Medicare	$96.12
Rate for Payer: Humana of AZ Medicare	$85.44
Rate for Payer: Southwest Service Administrators UFCW	$363.12
Rate for Payer: TriWest Medicare	$85.44
Rate for Payer: United Healthcare Commercial	$305.45
Rate for Payer: United Healthcare Medicare	$85.44
Rate for Payer: Veterans Affairs TRICARE	$84.59

SHEATH URETERAL ACCESS DBL LUMEN 12X35

Facility

$534.00

Hospital Charge Code	22354224
Hospital Revenue Code	270
Min. Negotiated Rate	$480.60
Max. Negotiated Rate	$480.60
Rate for Payer: Aetna of AZ Commercial	$480.60
Rate for Payer: Cash Price	$427.20

SHIGA-TOXIN 1 AG

Facility

$83.00

Service Code	CPT 87899
Hospital Charge Code	22272337
Hospital Revenue Code	306
Min. Negotiated Rate	$74.70
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of AZ Commercial	$74.70
Rate for Payer: Cash Price	$66.40

SHIGA-TOXIN 1 AG

Facility

$83.00

Service Code	CPT 87899
Hospital Charge Code	22272337
Hospital Revenue Code	306
Min. Negotiated Rate	$13.15
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of AZ Commercial	$74.70
Rate for Payer: Arizona Complete Health Allwell	$13.28
Rate for Payer: Banner UC Health Medicare	$13.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$56.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.28
Rate for Payer: Cash Price	$66.40
Rate for Payer: Cash Price	$66.40
Rate for Payer: Cigna of AZ Commercial	$53.95
Rate for Payer: Devoted Health Medicare	$14.94
Rate for Payer: Humana of AZ Medicare	$13.28
Rate for Payer: Seven Corners Travel Insurance	$23.30
Rate for Payer: Southwest Service Administrators UFCW	$56.44
Rate for Payer: TriWest Medicare	$13.28
Rate for Payer: United Healthcare Commercial	$47.48
Rate for Payer: United Healthcare Medicare	$13.28
Rate for Payer: Veterans Affairs TRICARE	$13.15

SHIGA-TOXIN 2 AG

Facility

$87.00

Service Code	CPT 87899
Hospital Charge Code	22272338
Hospital Revenue Code	306
Min. Negotiated Rate	$78.30
Max. Negotiated Rate	$78.30
Rate for Payer: Aetna of AZ Commercial	$78.30
Rate for Payer: Cash Price	$69.60

SHIGA-TOXIN 2 AG

Facility

$87.00

Service Code	CPT 87899
Hospital Charge Code	22272338
Hospital Revenue Code	306
Min. Negotiated Rate	$13.78
Max. Negotiated Rate	$78.30
Rate for Payer: Aetna of AZ Commercial	$78.30
Rate for Payer: Arizona Complete Health Allwell	$13.92
Rate for Payer: Banner UC Health Medicare	$13.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$59.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.92
Rate for Payer: Cash Price	$69.60
Rate for Payer: Cash Price	$69.60
Rate for Payer: Cigna of AZ Commercial	$56.55
Rate for Payer: Devoted Health Medicare	$15.66
Rate for Payer: Humana of AZ Medicare	$13.92
Rate for Payer: Seven Corners Travel Insurance	$23.30
Rate for Payer: Southwest Service Administrators UFCW	$59.16
Rate for Payer: TriWest Medicare	$13.92
Rate for Payer: United Healthcare Commercial	$49.76
Rate for Payer: United Healthcare Medicare	$13.92
Rate for Payer: Veterans Affairs TRICARE	$13.78

Shockwave Therapy

Facility

$117.00

Service Code	CPT 0101T
Hospital Charge Code	27741439
Hospital Revenue Code	429
Min. Negotiated Rate	$18.53
Max. Negotiated Rate	$381.65
Rate for Payer: Aetna of AZ Commercial	$105.30
Rate for Payer: Arizona Complete Health Allwell	$18.72
Rate for Payer: Banner UC Health Medicare	$18.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$79.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$18.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$18.72
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cigna of AZ Commercial	$81.90
Rate for Payer: Devoted Health Medicare	$21.06
Rate for Payer: Humana of AZ Medicare	$18.72
Rate for Payer: Seven Corners Travel Insurance	$381.65
Rate for Payer: Southwest Service Administrators UFCW	$79.56
Rate for Payer: TriWest Medicare	$18.72
Rate for Payer: United Healthcare Commercial	$66.92
Rate for Payer: United Healthcare Medicare	$18.72
Rate for Payer: United Healthcare New Mexico Commercial	$22.23
Rate for Payer: Veterans Affairs TRICARE	$18.53

Shockwave Therapy

Facility

$117.00

Service Code	CPT 0101T
Hospital Charge Code	27741439
Hospital Revenue Code	429
Min. Negotiated Rate	$105.30
Max. Negotiated Rate	$105.30
Rate for Payer: Aetna of AZ Commercial	$105.30
Rate for Payer: Cash Price	$93.60

SHOE POST-OP FEMALE LARGE

Facility

$87.00

Service Code	HCPCS L3260
Hospital Charge Code	22354284
Hospital Revenue Code	270
Min. Negotiated Rate	$78.30
Max. Negotiated Rate	$78.30
Rate for Payer: Aetna of AZ Commercial	$78.30
Rate for Payer: Cash Price	$69.60

Know your out-of-pocket cost for care.

All Charges