Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

US OB Transvaginal < 14 Wks Single Gest

Facility

$1,036.00

Service Code	CPT 76801
Hospital Charge Code	2214215
Hospital Revenue Code	402
Min. Negotiated Rate	$932.40
Max. Negotiated Rate	$932.40
Rate for Payer: Aetna of AZ Commercial	$932.40
Rate for Payer: Cash Price	$828.80

US Pancreas

Facility

$525.00

Service Code	CPT 76700
Hospital Charge Code	1779918
Hospital Revenue Code	402
Min. Negotiated Rate	$472.50
Max. Negotiated Rate	$472.50
Rate for Payer: Aetna of AZ Commercial	$472.50
Rate for Payer: Cash Price	$420.00

US Pancreas

Facility

$525.00

Service Code	CPT 76700
Hospital Charge Code	1779918
Hospital Revenue Code	402
Min. Negotiated Rate	$83.16
Max. Negotiated Rate	$472.50
Rate for Payer: Aetna of AZ Commercial	$472.50
Rate for Payer: Arizona Complete Health Allwell	$84.00
Rate for Payer: Banner UC Health Medicare	$84.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$357.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$84.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$84.00
Rate for Payer: Cash Price	$420.00
Rate for Payer: Cash Price	$420.00
Rate for Payer: Cigna of AZ Commercial	$367.50
Rate for Payer: Devoted Health Medicare	$94.50
Rate for Payer: Humana of AZ Medicare	$84.00
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$357.00
Rate for Payer: TriWest Medicare	$84.00
Rate for Payer: United Healthcare Commercial	$300.30
Rate for Payer: United Healthcare Medicare	$84.00
Rate for Payer: United Healthcare New Mexico Commercial	$99.75
Rate for Payer: Veterans Affairs TRICARE	$83.16

US Pelvis Non-OB Complete

Facility

$1,291.00

Service Code	CPT 76856
Hospital Charge Code	823448
Hospital Revenue Code	402
Min. Negotiated Rate	$1,161.90
Max. Negotiated Rate	$1,161.90
Rate for Payer: Aetna of AZ Commercial	$1,161.90
Rate for Payer: Cash Price	$1,032.80

US Pelvis Non-OB Complete

Facility

$1,291.00

Service Code	CPT 76856
Hospital Charge Code	823448
Hospital Revenue Code	402
Min. Negotiated Rate	$161.76
Max. Negotiated Rate	$1,161.90
Rate for Payer: Aetna of AZ Commercial	$1,161.90
Rate for Payer: Arizona Complete Health Allwell	$206.56
Rate for Payer: Banner UC Health Medicare	$206.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$877.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$206.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$206.56
Rate for Payer: Cash Price	$1,032.80
Rate for Payer: Cash Price	$1,032.80
Rate for Payer: Cigna of AZ Commercial	$903.70
Rate for Payer: Devoted Health Medicare	$232.38
Rate for Payer: Humana of AZ Medicare	$206.56
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$877.88
Rate for Payer: TriWest Medicare	$206.56
Rate for Payer: United Healthcare Commercial	$738.45
Rate for Payer: United Healthcare Medicare	$206.56
Rate for Payer: United Healthcare New Mexico Commercial	$245.29
Rate for Payer: Veterans Affairs TRICARE	$204.49

US Pelvis Non-OB Limited

Facility

$393.00

Service Code	CPT 76857
Hospital Charge Code	823450
Hospital Revenue Code	402
Min. Negotiated Rate	$62.25
Max. Negotiated Rate	$353.70
Rate for Payer: Aetna of AZ Commercial	$353.70
Rate for Payer: Arizona Complete Health Allwell	$62.88
Rate for Payer: Banner UC Health Medicare	$62.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$267.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$62.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$62.88
Rate for Payer: Cash Price	$314.40
Rate for Payer: Cash Price	$314.40
Rate for Payer: Cigna of AZ Commercial	$275.10
Rate for Payer: Devoted Health Medicare	$70.74
Rate for Payer: Humana of AZ Medicare	$62.88
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$267.24
Rate for Payer: TriWest Medicare	$62.88
Rate for Payer: United Healthcare Commercial	$224.80
Rate for Payer: United Healthcare Medicare	$62.88
Rate for Payer: United Healthcare New Mexico Commercial	$74.67
Rate for Payer: Veterans Affairs TRICARE	$62.25

US Pelvis Non-OB Limited

Facility

$393.00

Service Code	CPT 76857
Hospital Charge Code	823450
Hospital Revenue Code	402
Min. Negotiated Rate	$353.70
Max. Negotiated Rate	$353.70
Rate for Payer: Aetna of AZ Commercial	$353.70
Rate for Payer: Cash Price	$314.40

US Pregnancy Transvaginal

Facility

$716.00

Service Code	CPT 76817
Hospital Charge Code	823456
Hospital Revenue Code	402
Min. Negotiated Rate	$113.41
Max. Negotiated Rate	$644.40
Rate for Payer: Aetna of AZ Commercial	$644.40
Rate for Payer: Arizona Complete Health Allwell	$114.56
Rate for Payer: Banner UC Health Medicare	$114.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$486.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$114.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$114.56
Rate for Payer: Cash Price	$572.80
Rate for Payer: Cash Price	$572.80
Rate for Payer: Cigna of AZ Commercial	$501.20
Rate for Payer: Devoted Health Medicare	$128.88
Rate for Payer: Humana of AZ Medicare	$114.56
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$486.88
Rate for Payer: TriWest Medicare	$114.56
Rate for Payer: United Healthcare Commercial	$409.55
Rate for Payer: United Healthcare Medicare	$114.56
Rate for Payer: United Healthcare New Mexico Commercial	$136.04
Rate for Payer: Veterans Affairs TRICARE	$113.41

US Pregnancy Transvaginal

Facility

$716.00

Service Code	CPT 76817
Hospital Charge Code	823456
Hospital Revenue Code	402
Min. Negotiated Rate	$644.40
Max. Negotiated Rate	$644.40
Rate for Payer: Aetna of AZ Commercial	$644.40
Rate for Payer: Cash Price	$572.80

US Renal

Facility

$828.00

Service Code	CPT 76770
Hospital Charge Code	1007818
Hospital Revenue Code	402
Min. Negotiated Rate	$131.16
Max. Negotiated Rate	$745.20
Rate for Payer: Aetna of AZ Commercial	$745.20
Rate for Payer: Arizona Complete Health Allwell	$132.48
Rate for Payer: Banner UC Health Medicare	$132.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$563.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$132.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$132.48
Rate for Payer: Cash Price	$662.40
Rate for Payer: Cash Price	$662.40
Rate for Payer: Cigna of AZ Commercial	$579.60
Rate for Payer: Devoted Health Medicare	$149.04
Rate for Payer: Humana of AZ Medicare	$132.48
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$563.04
Rate for Payer: TriWest Medicare	$132.48
Rate for Payer: United Healthcare Commercial	$473.62
Rate for Payer: United Healthcare Medicare	$132.48
Rate for Payer: United Healthcare New Mexico Commercial	$157.32
Rate for Payer: Veterans Affairs TRICARE	$131.16

US Renal

Facility

$828.00

Service Code	CPT 76770
Hospital Charge Code	1007818
Hospital Revenue Code	402
Min. Negotiated Rate	$745.20
Max. Negotiated Rate	$745.20
Rate for Payer: Aetna of AZ Commercial	$745.20
Rate for Payer: Cash Price	$662.40

US Renal Arterial Duplex Sono Comp

Facility

$1,444.00

Service Code	CPT 93975
Hospital Charge Code	22269030
Hospital Revenue Code	921
Min. Negotiated Rate	$1,299.60
Max. Negotiated Rate	$1,299.60
Rate for Payer: Aetna of AZ Commercial	$1,299.60
Rate for Payer: Cash Price	$1,155.20

US Renal Arterial Duplex Sono Comp

Facility

$1,444.00

Service Code	CPT 93975
Hospital Charge Code	22269030
Hospital Revenue Code	921
Min. Negotiated Rate	$228.73
Max. Negotiated Rate	$1,299.60
Rate for Payer: Aetna of AZ Commercial	$1,299.60
Rate for Payer: Arizona Complete Health Allwell	$231.04
Rate for Payer: Banner UC Health Medicare	$231.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$981.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$231.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$231.04
Rate for Payer: Cash Price	$1,155.20
Rate for Payer: Cash Price	$1,155.20
Rate for Payer: Cigna of AZ Commercial	$1,010.80
Rate for Payer: Devoted Health Medicare	$259.92
Rate for Payer: Humana of AZ Medicare	$231.04
Rate for Payer: Seven Corners Travel Insurance	$369.18
Rate for Payer: Southwest Service Administrators UFCW	$981.92
Rate for Payer: TriWest Medicare	$231.04
Rate for Payer: United Healthcare Commercial	$825.97
Rate for Payer: United Healthcare Medicare	$231.04
Rate for Payer: United Healthcare New Mexico Commercial	$274.36
Rate for Payer: Veterans Affairs TRICARE	$228.73

US Retroperitoneal Complete

Facility

$310.00

Service Code	CPT 76775
Hospital Charge Code	22862395
Hospital Revenue Code	972
Min. Negotiated Rate	$49.10
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of AZ Commercial	$279.00
Rate for Payer: Arizona Complete Health Allwell	$49.60
Rate for Payer: Banner UC Health Medicare	$49.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$210.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$49.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$49.60
Rate for Payer: Cash Price	$248.00
Rate for Payer: Cash Price	$248.00
Rate for Payer: Cigna of AZ Commercial	$217.00
Rate for Payer: Devoted Health Medicare	$55.80
Rate for Payer: Humana of AZ Medicare	$49.60
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$210.80
Rate for Payer: TriWest Medicare	$49.60
Rate for Payer: United Healthcare Commercial	$177.32
Rate for Payer: United Healthcare Medicare	$49.60
Rate for Payer: United Healthcare New Mexico Commercial	$58.90
Rate for Payer: Veterans Affairs TRICARE	$49.10

US Retroperitoneal Complete

Facility

$1,474.00

Service Code	CPT 76775
Hospital Charge Code	823461
Hospital Revenue Code	402
Min. Negotiated Rate	$161.76
Max. Negotiated Rate	$1,326.60
Rate for Payer: Aetna of AZ Commercial	$1,326.60
Rate for Payer: Arizona Complete Health Allwell	$235.84
Rate for Payer: Banner UC Health Medicare	$235.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,002.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$235.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$235.84
Rate for Payer: Cash Price	$1,179.20
Rate for Payer: Cash Price	$1,179.20
Rate for Payer: Cigna of AZ Commercial	$1,031.80
Rate for Payer: Devoted Health Medicare	$265.32
Rate for Payer: Humana of AZ Medicare	$235.84
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$1,002.32
Rate for Payer: TriWest Medicare	$235.84
Rate for Payer: United Healthcare Commercial	$843.13
Rate for Payer: United Healthcare Medicare	$235.84
Rate for Payer: United Healthcare New Mexico Commercial	$280.06
Rate for Payer: Veterans Affairs TRICARE	$233.48

US Retroperitoneal Complete

Facility

$310.00

Service Code	CPT 76775
Hospital Charge Code	22862395
Hospital Revenue Code	972
Min. Negotiated Rate	$279.00
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of AZ Commercial	$279.00
Rate for Payer: Cash Price	$248.00

US Retroperitoneal Complete

Facility

$1,474.00

Service Code	CPT 76775
Hospital Charge Code	823461
Hospital Revenue Code	402
Min. Negotiated Rate	$1,326.60
Max. Negotiated Rate	$1,326.60
Rate for Payer: Aetna of AZ Commercial	$1,326.60
Rate for Payer: Cash Price	$1,179.20

US Scrotum (Contents)

Facility

$1,011.00

Service Code	CPT 76870
Hospital Charge Code	823463
Hospital Revenue Code	402
Min. Negotiated Rate	$909.90
Max. Negotiated Rate	$909.90
Rate for Payer: Aetna of AZ Commercial	$909.90
Rate for Payer: Cash Price	$808.80

US Scrotum (Contents)

Facility

$1,011.00

Service Code	CPT 76870
Hospital Charge Code	823463
Hospital Revenue Code	402
Min. Negotiated Rate	$160.14
Max. Negotiated Rate	$909.90
Rate for Payer: Aetna of AZ Commercial	$909.90
Rate for Payer: Arizona Complete Health Allwell	$161.76
Rate for Payer: Banner UC Health Medicare	$161.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$687.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$161.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$161.76
Rate for Payer: Cash Price	$808.80
Rate for Payer: Cash Price	$808.80
Rate for Payer: Cigna of AZ Commercial	$707.70
Rate for Payer: Devoted Health Medicare	$181.98
Rate for Payer: Humana of AZ Medicare	$161.76
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$687.48
Rate for Payer: TriWest Medicare	$161.76
Rate for Payer: United Healthcare Commercial	$578.29
Rate for Payer: United Healthcare Medicare	$161.76
Rate for Payer: United Healthcare New Mexico Commercial	$192.09
Rate for Payer: Veterans Affairs TRICARE	$160.14

US Spleen

Facility

$870.00

Service Code	CPT 76700
Hospital Charge Code	2214236
Hospital Revenue Code	402
Min. Negotiated Rate	$783.00
Max. Negotiated Rate	$783.00
Rate for Payer: Aetna of AZ Commercial	$783.00
Rate for Payer: Cash Price	$696.00

US Spleen

Facility

$870.00

Service Code	CPT 76700
Hospital Charge Code	2214236
Hospital Revenue Code	402
Min. Negotiated Rate	$137.81
Max. Negotiated Rate	$783.00
Rate for Payer: Aetna of AZ Commercial	$783.00
Rate for Payer: Arizona Complete Health Allwell	$139.20
Rate for Payer: Banner UC Health Medicare	$139.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$591.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$139.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$139.20
Rate for Payer: Cash Price	$696.00
Rate for Payer: Cash Price	$696.00
Rate for Payer: Cigna of AZ Commercial	$609.00
Rate for Payer: Devoted Health Medicare	$156.60
Rate for Payer: Humana of AZ Medicare	$139.20
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$591.60
Rate for Payer: TriWest Medicare	$139.20
Rate for Payer: United Healthcare Commercial	$497.64
Rate for Payer: United Healthcare Medicare	$139.20
Rate for Payer: United Healthcare New Mexico Commercial	$165.30
Rate for Payer: Veterans Affairs TRICARE	$137.81

US Superficial Mass

Facility

$740.00

Service Code	CPT 76881
Hospital Charge Code	1319948
Hospital Revenue Code	402
Min. Negotiated Rate	$117.22
Max. Negotiated Rate	$666.00
Rate for Payer: Aetna of AZ Commercial	$666.00
Rate for Payer: Arizona Complete Health Allwell	$118.40
Rate for Payer: Banner UC Health Medicare	$118.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$503.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$118.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$118.40
Rate for Payer: Cash Price	$592.00
Rate for Payer: Cash Price	$592.00
Rate for Payer: Cigna of AZ Commercial	$518.00
Rate for Payer: Devoted Health Medicare	$133.20
Rate for Payer: Humana of AZ Medicare	$118.40
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$503.20
Rate for Payer: TriWest Medicare	$118.40
Rate for Payer: United Healthcare Commercial	$423.28
Rate for Payer: United Healthcare Medicare	$118.40
Rate for Payer: United Healthcare New Mexico Commercial	$140.60
Rate for Payer: Veterans Affairs TRICARE	$117.22

US Superficial Mass

Facility

$740.00

Service Code	CPT 76881
Hospital Charge Code	1319948
Hospital Revenue Code	402
Min. Negotiated Rate	$666.00
Max. Negotiated Rate	$666.00
Rate for Payer: Aetna of AZ Commercial	$666.00
Rate for Payer: Cash Price	$592.00

US Thyroid

Facility

$1,291.00

Service Code	CPT 76536
Hospital Charge Code	1007837
Hospital Revenue Code	402
Min. Negotiated Rate	$1,161.90
Max. Negotiated Rate	$1,161.90
Rate for Payer: Aetna of AZ Commercial	$1,161.90
Rate for Payer: Cash Price	$1,032.80

US Thyroid

Facility

$1,291.00

Service Code	CPT 76536
Hospital Charge Code	1007837
Hospital Revenue Code	402
Min. Negotiated Rate	$161.76
Max. Negotiated Rate	$1,161.90
Rate for Payer: Aetna of AZ Commercial	$1,161.90
Rate for Payer: Arizona Complete Health Allwell	$206.56
Rate for Payer: Banner UC Health Medicare	$206.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$877.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$206.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$206.56
Rate for Payer: Cash Price	$1,032.80
Rate for Payer: Cash Price	$1,032.80
Rate for Payer: Cigna of AZ Commercial	$903.70
Rate for Payer: Devoted Health Medicare	$232.38
Rate for Payer: Humana of AZ Medicare	$206.56
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$877.88
Rate for Payer: TriWest Medicare	$206.56
Rate for Payer: United Healthcare Commercial	$738.45
Rate for Payer: United Healthcare Medicare	$206.56
Rate for Payer: United Healthcare New Mexico Commercial	$245.29
Rate for Payer: Veterans Affairs TRICARE	$204.49

Know your out-of-pocket cost for care.

All Charges