Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

TUMOR IMMUNOHISTOCHEM/MANUAL

Facility

$401.00

Service Code	CPT 88360
Hospital Charge Code	22545741
Hospital Revenue Code	310
Min. Negotiated Rate	$63.52
Max. Negotiated Rate	$360.90
Rate for Payer: Aetna of AZ Commercial	$360.90
Rate for Payer: Arizona Complete Health Allwell	$64.16
Rate for Payer: Banner UC Health Medicare	$64.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$272.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$64.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$87.00
Rate for Payer: Cash Price	$320.80
Rate for Payer: Cash Price	$320.80
Rate for Payer: Cigna of AZ Commercial	$260.65
Rate for Payer: Devoted Health Medicare	$72.18
Rate for Payer: Humana of AZ Medicare	$64.16
Rate for Payer: Seven Corners Travel Insurance	$263.61
Rate for Payer: Southwest Service Administrators UFCW	$272.68
Rate for Payer: TriWest Medicare	$64.16
Rate for Payer: United Healthcare Commercial	$229.37
Rate for Payer: United Healthcare Medicare	$64.16
Rate for Payer: Veterans Affairs TRICARE	$63.52

TVH/BSO

Facility

$5,056.00

Service Code	CPT 58262
Hospital Charge Code	27281886
Hospital Revenue Code	360
Min. Negotiated Rate	$800.87
Max. Negotiated Rate	$7,740.14
Rate for Payer: Aetna of AZ Commercial	$4,550.40
Rate for Payer: Arizona Complete Health Allwell	$808.96
Rate for Payer: Banner UC Health Medicare	$1,698.98
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,438.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$808.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$808.96
Rate for Payer: Cash Price	$4,044.80
Rate for Payer: Cash Price	$4,044.80
Rate for Payer: Cash Price	$4,044.80
Rate for Payer: Cigna of AZ Commercial	$2,528.00
Rate for Payer: Devoted Health Medicare	$910.08
Rate for Payer: Humana of AZ Medicare	$808.96
Rate for Payer: NaphCare Correctional Healthcare	$1,698.98
Rate for Payer: Seven Corners Travel Insurance	$7,740.14
Rate for Payer: Southwest Service Administrators UFCW	$3,438.08
Rate for Payer: TriWest Medicare	$808.96
Rate for Payer: United Healthcare Commercial	$4,838.00
Rate for Payer: United Healthcare Medicare	$808.96
Rate for Payer: Veterans Affairs TRICARE	$800.87

TVH/BSO

Facility

$5,056.00

Service Code	CPT 58262
Hospital Charge Code	27281886
Hospital Revenue Code	360
Min. Negotiated Rate	$4,550.40
Max. Negotiated Rate	$4,550.40
Rate for Payer: Aetna of AZ Commercial	$4,550.40
Rate for Payer: Cash Price	$4,044.80

TVH/BSO w/enterocele

Facility

$4,877.00

Service Code	CPT 58270
Hospital Charge Code	27281887
Hospital Revenue Code	360
Min. Negotiated Rate	$4,389.30
Max. Negotiated Rate	$4,389.30
Rate for Payer: Aetna of AZ Commercial	$4,389.30
Rate for Payer: Cash Price	$3,901.60

TVH/BSO w/enterocele

Facility

$4,877.00

Service Code	CPT 58270
Hospital Charge Code	27281887
Hospital Revenue Code	360
Min. Negotiated Rate	$772.52
Max. Negotiated Rate	$7,740.14
Rate for Payer: Aetna of AZ Commercial	$4,389.30
Rate for Payer: Arizona Complete Health Allwell	$780.32
Rate for Payer: Banner UC Health Medicare	$1,698.98
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,316.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$780.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$780.32
Rate for Payer: Cash Price	$3,901.60
Rate for Payer: Cash Price	$3,901.60
Rate for Payer: Cash Price	$3,901.60
Rate for Payer: Cigna of AZ Commercial	$2,438.50
Rate for Payer: Devoted Health Medicare	$877.86
Rate for Payer: Humana of AZ Medicare	$780.32
Rate for Payer: NaphCare Correctional Healthcare	$1,698.98
Rate for Payer: Seven Corners Travel Insurance	$7,740.14
Rate for Payer: Southwest Service Administrators UFCW	$3,316.36
Rate for Payer: TriWest Medicare	$780.32
Rate for Payer: United Healthcare Commercial	$4,838.00
Rate for Payer: United Healthcare Medicare	$780.32
Rate for Payer: Veterans Affairs TRICARE	$772.52

TVH w/vaginectomy (colpocleisis)

Facility

$5,402.00

Service Code	CPT 58275
Hospital Charge Code	27281888
Hospital Revenue Code	360
Min. Negotiated Rate	$855.68
Max. Negotiated Rate	$4,861.80
Rate for Payer: Aetna of AZ Commercial	$4,861.80
Rate for Payer: Arizona Complete Health Allwell	$864.32
Rate for Payer: Banner UC Health Medicare	$864.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,673.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$864.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$864.32
Rate for Payer: Cash Price	$4,321.60
Rate for Payer: Cash Price	$4,321.60
Rate for Payer: Cigna of AZ Commercial	$2,701.00
Rate for Payer: Devoted Health Medicare	$972.36
Rate for Payer: Humana of AZ Medicare	$864.32
Rate for Payer: Southwest Service Administrators UFCW	$3,673.36
Rate for Payer: TriWest Medicare	$864.32
Rate for Payer: United Healthcare Commercial	$4,838.00
Rate for Payer: United Healthcare Medicare	$864.32
Rate for Payer: Veterans Affairs TRICARE	$855.68

TVH w/vaginectomy (colpocleisis)

Facility

$5,402.00

Service Code	CPT 58275
Hospital Charge Code	27281888
Hospital Revenue Code	360
Min. Negotiated Rate	$4,861.80
Max. Negotiated Rate	$4,861.80
Rate for Payer: Aetna of AZ Commercial	$4,861.80
Rate for Payer: Cash Price	$4,321.60

TWIN CATH 18/20 MULT-LUMEN PERIPH CATH

Facility

$103.00

Hospital Charge Code	22355400
Hospital Revenue Code	270
Min. Negotiated Rate	$16.32
Max. Negotiated Rate	$92.70
Rate for Payer: Aetna of AZ Commercial	$92.70
Rate for Payer: Arizona Complete Health Allwell	$16.48
Rate for Payer: Banner UC Health Medicare	$16.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$70.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.48
Rate for Payer: Cash Price	$82.40
Rate for Payer: Cigna of AZ Commercial	$72.10
Rate for Payer: Devoted Health Medicare	$18.54
Rate for Payer: Humana of AZ Medicare	$16.48
Rate for Payer: Southwest Service Administrators UFCW	$70.04
Rate for Payer: TriWest Medicare	$16.48
Rate for Payer: United Healthcare Commercial	$58.92
Rate for Payer: United Healthcare Medicare	$16.48
Rate for Payer: Veterans Affairs TRICARE	$16.32

TWIN CATH 18/20 MULT-LUMEN PERIPH CATH

Facility

$103.00

Hospital Charge Code	22355400
Hospital Revenue Code	270
Min. Negotiated Rate	$92.70
Max. Negotiated Rate	$92.70
Rate for Payer: Aetna of AZ Commercial	$92.70
Rate for Payer: Cash Price	$82.40

TWIN-CATH 20/22 MULT-LUMEN PERIPH CATH

Facility

$104.00

Hospital Charge Code	22355399
Hospital Revenue Code	270
Min. Negotiated Rate	$93.60
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of AZ Commercial	$93.60
Rate for Payer: Cash Price	$83.20

TWIN-CATH 20/22 MULT-LUMEN PERIPH CATH

Facility

$104.00

Hospital Charge Code	22355399
Hospital Revenue Code	270
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of AZ Commercial	$93.60
Rate for Payer: Arizona Complete Health Allwell	$16.64
Rate for Payer: Banner UC Health Medicare	$16.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$70.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.64
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cigna of AZ Commercial	$72.80
Rate for Payer: Devoted Health Medicare	$18.72
Rate for Payer: Humana of AZ Medicare	$16.64
Rate for Payer: Southwest Service Administrators UFCW	$70.72
Rate for Payer: TriWest Medicare	$16.64
Rate for Payer: United Healthcare Commercial	$59.49
Rate for Payer: United Healthcare Medicare	$16.64
Rate for Payer: Veterans Affairs TRICARE	$16.47

U24 Microalbumin/Creat

Facility

$137.00

Service Code	CPT 82043
Hospital Charge Code	1279989
Hospital Revenue Code	301
Min. Negotiated Rate	$8.38
Max. Negotiated Rate	$123.30
Rate for Payer: Aetna of AZ Commercial	$123.30
Rate for Payer: Arizona Complete Health Allwell	$21.92
Rate for Payer: Banner UC Health Medicare	$21.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$93.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$21.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$21.92
Rate for Payer: Cash Price	$109.60
Rate for Payer: Cash Price	$109.60
Rate for Payer: Cigna of AZ Commercial	$89.05
Rate for Payer: Devoted Health Medicare	$24.66
Rate for Payer: Humana of AZ Medicare	$21.92
Rate for Payer: Seven Corners Travel Insurance	$8.38
Rate for Payer: Southwest Service Administrators UFCW	$93.16
Rate for Payer: TriWest Medicare	$21.92
Rate for Payer: United Healthcare Commercial	$78.36
Rate for Payer: United Healthcare Medicare	$21.92
Rate for Payer: Veterans Affairs TRICARE	$21.70

U24 Microalbumin/Creat

Facility

$137.00

Service Code	CPT 82043
Hospital Charge Code	1279989
Hospital Revenue Code	301
Min. Negotiated Rate	$123.30
Max. Negotiated Rate	$123.30
Rate for Payer: Aetna of AZ Commercial	$123.30
Rate for Payer: Cash Price	$109.60

UA Micro Standard

Facility

$37.00

Service Code	CPT 81015
Hospital Charge Code	22207838
Hospital Revenue Code	307
Min. Negotiated Rate	$33.30
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cash Price	$25.60

UA Micro Standard

Facility

$32.00

Service Code	CPT 81015
Hospital Charge Code	22207838
Hospital Revenue Code	307
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Arizona Complete Health Allwell	$5.92
Rate for Payer: Arizona Complete Health Allwell	$5.12
Rate for Payer: Banner UC Health Medicare	$5.92
Rate for Payer: Banner UC Health Medicare	$5.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$21.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$25.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.92
Rate for Payer: Cash Price	$25.60
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cash Price	$25.60
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cigna of AZ Commercial	$24.05
Rate for Payer: Cigna of AZ Commercial	$20.80
Rate for Payer: Devoted Health Medicare	$6.66
Rate for Payer: Devoted Health Medicare	$5.76
Rate for Payer: Humana of AZ Medicare	$5.12
Rate for Payer: Humana of AZ Medicare	$5.92
Rate for Payer: Seven Corners Travel Insurance	$4.42
Rate for Payer: Seven Corners Travel Insurance	$4.42
Rate for Payer: Southwest Service Administrators UFCW	$25.16
Rate for Payer: Southwest Service Administrators UFCW	$21.76
Rate for Payer: TriWest Medicare	$5.12
Rate for Payer: TriWest Medicare	$5.92
Rate for Payer: United Healthcare Commercial	$18.30
Rate for Payer: United Healthcare Commercial	$21.16
Rate for Payer: United Healthcare Medicare	$5.12
Rate for Payer: United Healthcare Medicare	$5.92
Rate for Payer: Veterans Affairs TRICARE	$5.86
Rate for Payer: Veterans Affairs TRICARE	$5.07

UA/M w/rflx Culture, Routine LC

Facility

$84.00

Service Code	CPT 81001
Hospital Charge Code	22311208
Hospital Revenue Code	307
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Arizona Complete Health Allwell	$13.44
Rate for Payer: Banner UC Health Medicare	$13.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$57.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.44
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cigna of AZ Commercial	$54.60
Rate for Payer: Devoted Health Medicare	$15.12
Rate for Payer: Humana of AZ Medicare	$13.44
Rate for Payer: Seven Corners Travel Insurance	$4.60
Rate for Payer: Southwest Service Administrators UFCW	$57.12
Rate for Payer: TriWest Medicare	$13.44
Rate for Payer: United Healthcare Commercial	$48.05
Rate for Payer: United Healthcare Medicare	$13.44
Rate for Payer: Veterans Affairs TRICARE	$13.31

UA/M w/rflx Culture, Routine LC

Facility

$84.00

Service Code	CPT 81001
Hospital Charge Code	22311208
Hospital Revenue Code	307
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Cash Price	$67.20

ULTRASOUND2104

Facility

$60.24

Hospital Charge Code	27685138
Hospital Revenue Code	270
Min. Negotiated Rate	$54.22
Max. Negotiated Rate	$54.22
Rate for Payer: Aetna of AZ Commercial	$54.22
Rate for Payer: Cash Price	$48.19

ULTRASOUND2104

Facility

$60.24

Hospital Charge Code	27685138
Hospital Revenue Code	270
Min. Negotiated Rate	$9.54
Max. Negotiated Rate	$54.22
Rate for Payer: Aetna of AZ Commercial	$54.22
Rate for Payer: Arizona Complete Health Allwell	$9.64
Rate for Payer: Banner UC Health Medicare	$9.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$40.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.64
Rate for Payer: Cash Price	$48.19
Rate for Payer: Cigna of AZ Commercial	$42.17
Rate for Payer: Devoted Health Medicare	$10.84
Rate for Payer: Humana of AZ Medicare	$9.64
Rate for Payer: Southwest Service Administrators UFCW	$40.96
Rate for Payer: TriWest Medicare	$9.64
Rate for Payer: United Healthcare Commercial	$34.46
Rate for Payer: United Healthcare Medicare	$9.64
Rate for Payer: Veterans Affairs TRICARE	$9.54

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC

Facility

$71,938.37

Service Code	MSDRG 278
Min. Negotiated Rate	$71,938.37
Max. Negotiated Rate	$71,938.37
Rate for Payer: Seven Corners Travel Insurance	$71,938.37

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC

Facility

$46,609.61

Service Code	MSDRG 279
Min. Negotiated Rate	$46,609.61
Max. Negotiated Rate	$46,609.61
Rate for Payer: Seven Corners Travel Insurance	$46,609.61

ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM

Facility

$38,467.41

Service Code	MSDRG 173
Min. Negotiated Rate	$38,467.41
Max. Negotiated Rate	$38,467.41
Rate for Payer: Seven Corners Travel Insurance	$38,467.41

ULTRASOUND NEEDLE 21G X 3 IN

Facility

$58.00

Hospital Charge Code	27554884
Hospital Revenue Code	270
Min. Negotiated Rate	$52.20
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of AZ Commercial	$52.20
Rate for Payer: Cash Price	$46.40

ULTRASOUND NEEDLE 21G X 3 IN

Facility

$58.00

Hospital Charge Code	27554884
Hospital Revenue Code	270
Min. Negotiated Rate	$9.19
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of AZ Commercial	$52.20
Rate for Payer: Arizona Complete Health Allwell	$9.28
Rate for Payer: Banner UC Health Medicare	$9.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$39.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.28
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cigna of AZ Commercial	$40.60
Rate for Payer: Devoted Health Medicare	$10.44
Rate for Payer: Humana of AZ Medicare	$9.28
Rate for Payer: Southwest Service Administrators UFCW	$39.44
Rate for Payer: TriWest Medicare	$9.28
Rate for Payer: United Healthcare Commercial	$33.18
Rate for Payer: United Healthcare Medicare	$9.28
Rate for Payer: Veterans Affairs TRICARE	$9.19

ULTRASOUND OF LEG ARTERIES AT REST AND AFTER EXERCISE

Facility

$811.00

Service Code	CPT 93924
Hospital Charge Code	28277679
Hospital Revenue Code	730
Min. Negotiated Rate	$128.46
Max. Negotiated Rate	$729.90
Rate for Payer: Aetna of AZ Commercial	$729.90
Rate for Payer: Arizona Complete Health Allwell	$129.76
Rate for Payer: Banner UC Health Medicare	$129.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$551.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$129.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$129.76
Rate for Payer: Cash Price	$648.80
Rate for Payer: Cash Price	$648.80
Rate for Payer: Cigna of AZ Commercial	$567.70
Rate for Payer: Devoted Health Medicare	$145.98
Rate for Payer: Humana of AZ Medicare	$129.76
Rate for Payer: Seven Corners Travel Insurance	$334.09
Rate for Payer: Southwest Service Administrators UFCW	$551.48
Rate for Payer: TriWest Medicare	$129.76
Rate for Payer: United Healthcare Commercial	$463.89
Rate for Payer: United Healthcare Medicare	$129.76
Rate for Payer: United Healthcare New Mexico Commercial	$154.09
Rate for Payer: Veterans Affairs TRICARE	$128.46

Know your out-of-pocket cost for care.

All Charges