Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

WARMER SCOPE BLUE HEAT SINGLE USE

Facility

$99.00

Hospital Charge Code	22354936
Hospital Revenue Code	270
Min. Negotiated Rate	$89.10
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of AZ Commercial	$89.10
Rate for Payer: Cash Price	$79.20

WATER STERILE 750 ML RESP THERAPY

Facility

$20.00

Hospital Charge Code	22355211
Hospital Revenue Code	270
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Cash Price	$16.00

WATER STERILE 750 ML RESP THERAPY

Facility

$20.00

Hospital Charge Code	22355211
Hospital Revenue Code	270
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Arizona Complete Health Allwell	$3.20
Rate for Payer: Banner UC Health Medicare	$3.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$13.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.20
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cigna of AZ Commercial	$14.00
Rate for Payer: Devoted Health Medicare	$3.60
Rate for Payer: Humana of AZ Medicare	$3.20
Rate for Payer: Southwest Service Administrators UFCW	$13.60
Rate for Payer: TriWest Medicare	$3.20
Rate for Payer: United Healthcare Commercial	$11.44
Rate for Payer: United Healthcare Medicare	$3.20
Rate for Payer: Veterans Affairs TRICARE	$3.17

West Nile Virus LC

Facility

$383.00

Service Code	CPT 86788
Hospital Charge Code	3508632
Hospital Revenue Code	302
Min. Negotiated Rate	$344.70
Max. Negotiated Rate	$344.70
Rate for Payer: Aetna of AZ Commercial	$344.70
Rate for Payer: Cash Price	$306.40

West Nile Virus LC

Facility

$383.00

Service Code	CPT 86788
Hospital Charge Code	3508632
Hospital Revenue Code	302
Min. Negotiated Rate	$24.43
Max. Negotiated Rate	$344.70
Rate for Payer: Aetna of AZ Commercial	$344.70
Rate for Payer: Arizona Complete Health Allwell	$61.28
Rate for Payer: Banner UC Health Medicare	$61.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$260.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$61.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$61.28
Rate for Payer: Cash Price	$306.40
Rate for Payer: Cash Price	$306.40
Rate for Payer: Cigna of AZ Commercial	$248.95
Rate for Payer: Devoted Health Medicare	$68.94
Rate for Payer: Humana of AZ Medicare	$61.28
Rate for Payer: Seven Corners Travel Insurance	$24.43
Rate for Payer: Southwest Service Administrators UFCW	$260.44
Rate for Payer: TriWest Medicare	$61.28
Rate for Payer: United Healthcare Commercial	$219.08
Rate for Payer: United Healthcare Medicare	$61.28
Rate for Payer: Veterans Affairs TRICARE	$60.67

Wet Prep

Facility

$132.00

Service Code	CPT 87210
Hospital Charge Code	1657611
Hospital Revenue Code	306
Min. Negotiated Rate	$8.44
Max. Negotiated Rate	$118.80
Rate for Payer: Aetna of AZ Commercial	$118.80
Rate for Payer: Arizona Complete Health Allwell	$21.12
Rate for Payer: Banner UC Health Medicare	$21.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$89.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$21.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$21.12
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cigna of AZ Commercial	$85.80
Rate for Payer: Devoted Health Medicare	$23.76
Rate for Payer: Humana of AZ Medicare	$21.12
Rate for Payer: Seven Corners Travel Insurance	$8.44
Rate for Payer: Southwest Service Administrators UFCW	$89.76
Rate for Payer: TriWest Medicare	$21.12
Rate for Payer: United Healthcare Commercial	$75.50
Rate for Payer: United Healthcare Medicare	$21.12
Rate for Payer: Veterans Affairs TRICARE	$20.91

Wet Prep

Facility

$132.00

Service Code	CPT 87210
Hospital Charge Code	1657611
Hospital Revenue Code	306
Min. Negotiated Rate	$118.80
Max. Negotiated Rate	$118.80
Rate for Payer: Aetna of AZ Commercial	$118.80
Rate for Payer: Cash Price	$105.60

Wet Prep 5

Facility

$132.00

Service Code	CPT 87210
Hospital Charge Code	10495297
Hospital Revenue Code	306
Min. Negotiated Rate	$118.80
Max. Negotiated Rate	$118.80
Rate for Payer: Aetna of AZ Commercial	$118.80
Rate for Payer: Cash Price	$105.60

Wet Prep 5

Facility

$132.00

Service Code	CPT 87210
Hospital Charge Code	10495297
Hospital Revenue Code	306
Min. Negotiated Rate	$8.44
Max. Negotiated Rate	$118.80
Rate for Payer: Aetna of AZ Commercial	$118.80
Rate for Payer: Arizona Complete Health Allwell	$21.12
Rate for Payer: Banner UC Health Medicare	$21.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$89.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$21.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$21.12
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cigna of AZ Commercial	$85.80
Rate for Payer: Devoted Health Medicare	$23.76
Rate for Payer: Humana of AZ Medicare	$21.12
Rate for Payer: Seven Corners Travel Insurance	$8.44
Rate for Payer: Southwest Service Administrators UFCW	$89.76
Rate for Payer: TriWest Medicare	$21.12
Rate for Payer: United Healthcare Commercial	$75.50
Rate for Payer: United Healthcare Medicare	$21.12
Rate for Payer: Veterans Affairs TRICARE	$20.91

WHISPER SWIVEL VALVE

Facility

$298.00

Hospital Charge Code	27733113
Hospital Revenue Code	270
Min. Negotiated Rate	$47.20
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Arizona Complete Health Allwell	$47.68
Rate for Payer: Banner UC Health Medicare	$47.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$202.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$47.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$47.68
Rate for Payer: Cash Price	$238.40
Rate for Payer: Cigna of AZ Commercial	$208.60
Rate for Payer: Devoted Health Medicare	$53.64
Rate for Payer: Humana of AZ Medicare	$47.68
Rate for Payer: Southwest Service Administrators UFCW	$202.64
Rate for Payer: TriWest Medicare	$47.68
Rate for Payer: United Healthcare Commercial	$170.46
Rate for Payer: United Healthcare Medicare	$47.68
Rate for Payer: Veterans Affairs TRICARE	$47.20

WHISPER SWIVEL VALVE

Facility

$298.00

Hospital Charge Code	27733113
Hospital Revenue Code	270
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Cash Price	$238.40

White Blood Cells (WBC), Stool LC

Facility

$21.00

Service Code	CPT 89055
Hospital Charge Code	1905875
Hospital Revenue Code	301
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Arizona Complete Health Allwell	$3.36
Rate for Payer: Banner UC Health Medicare	$3.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$14.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.36
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna of AZ Commercial	$13.65
Rate for Payer: Devoted Health Medicare	$3.78
Rate for Payer: Humana of AZ Medicare	$3.36
Rate for Payer: Seven Corners Travel Insurance	$6.19
Rate for Payer: Southwest Service Administrators UFCW	$14.28
Rate for Payer: TriWest Medicare	$3.36
Rate for Payer: United Healthcare Commercial	$12.01
Rate for Payer: United Healthcare Medicare	$3.36
Rate for Payer: Veterans Affairs TRICARE	$3.33

White Blood Cells (WBC), Stool LC

Facility

$21.00

Service Code	CPT 89055
Hospital Charge Code	1905875
Hospital Revenue Code	301
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Cash Price	$16.80

White Blood Count

Facility

$92.00

Service Code	CPT 85048
Hospital Charge Code	633873
Hospital Revenue Code	305
Min. Negotiated Rate	$3.68
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of AZ Commercial	$82.80
Rate for Payer: Arizona Complete Health Allwell	$14.72
Rate for Payer: Banner UC Health Medicare	$14.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$62.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.72
Rate for Payer: Cash Price	$73.60
Rate for Payer: Cash Price	$73.60
Rate for Payer: Cigna of AZ Commercial	$59.80
Rate for Payer: Devoted Health Medicare	$16.56
Rate for Payer: Humana of AZ Medicare	$14.72
Rate for Payer: Seven Corners Travel Insurance	$3.68
Rate for Payer: Southwest Service Administrators UFCW	$62.56
Rate for Payer: TriWest Medicare	$14.72
Rate for Payer: United Healthcare Commercial	$52.62
Rate for Payer: United Healthcare Medicare	$14.72
Rate for Payer: Veterans Affairs TRICARE	$14.57

White Blood Count

Facility

$92.00

Service Code	CPT 85048
Hospital Charge Code	633873
Hospital Revenue Code	305
Min. Negotiated Rate	$82.80
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of AZ Commercial	$82.80
Rate for Payer: Cash Price	$73.60

WIRE DILATION BALLON FIXED 10MM TO 12MM

Facility

$1,370.90

Hospital Charge Code	28138357
Hospital Revenue Code	270
Min. Negotiated Rate	$217.15
Max. Negotiated Rate	$1,233.81
Rate for Payer: Aetna of AZ Commercial	$1,233.81
Rate for Payer: Arizona Complete Health Allwell	$219.34
Rate for Payer: Banner UC Health Medicare	$219.34
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$932.21
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$219.34
Rate for Payer: Care1st Health Plan Arizona Medicare	$219.34
Rate for Payer: Cash Price	$1,096.72
Rate for Payer: Cigna of AZ Commercial	$959.63
Rate for Payer: Devoted Health Medicare	$246.76
Rate for Payer: Humana of AZ Medicare	$219.34
Rate for Payer: Southwest Service Administrators UFCW	$932.21
Rate for Payer: TriWest Medicare	$219.34
Rate for Payer: United Healthcare Commercial	$784.15
Rate for Payer: United Healthcare Medicare	$219.34
Rate for Payer: Veterans Affairs TRICARE	$217.15

WIRE DILATION BALLON FIXED 10MM TO 12MM

Facility

$1,370.90

Hospital Charge Code	28138357
Hospital Revenue Code	270
Min. Negotiated Rate	$1,233.81
Max. Negotiated Rate	$1,233.81
Rate for Payer: Aetna of AZ Commercial	$1,233.81
Rate for Payer: Cash Price	$1,096.72

WIRE GUIDED ESOPHAGEAL DILATOR 8MM-10MM

Facility

$700.00

Hospital Charge Code	24240011
Min. Negotiated Rate	$630.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna of AZ Commercial	$630.00
Rate for Payer: Cash Price	$560.00

WIRE GUIDED ESOPHAGEAL DILATOR 8MM-10MM

Facility

$700.00

Hospital Charge Code	24240011
Min. Negotiated Rate	$110.88
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna of AZ Commercial	$630.00
Rate for Payer: Arizona Complete Health Allwell	$112.00
Rate for Payer: Banner UC Health Medicare	$112.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$476.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$112.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$112.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Cigna of AZ Commercial	$490.00
Rate for Payer: Devoted Health Medicare	$126.00
Rate for Payer: Humana of AZ Medicare	$112.00
Rate for Payer: Southwest Service Administrators UFCW	$476.00
Rate for Payer: TriWest Medicare	$112.00
Rate for Payer: United Healthcare Commercial	$400.40
Rate for Payer: United Healthcare Medicare	$112.00
Rate for Payer: Veterans Affairs TRICARE	$110.88

Work Related Or Medical Disability Exam or Sports Physical

Facility

$33.00

Service Code	CPT 99455
Hospital Charge Code	1303643
Hospital Revenue Code	983
Min. Negotiated Rate	$5.23
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Aetna of AZ Commercial	$104.40
Rate for Payer: Arizona Complete Health Allwell	$18.56
Rate for Payer: Arizona Complete Health Allwell	$5.28
Rate for Payer: Banner UC Health Medicare	$18.56
Rate for Payer: Banner UC Health Medicare	$5.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$78.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$22.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$18.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$18.56
Rate for Payer: Cash Price	$92.80
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cigna of AZ Commercial	$81.20
Rate for Payer: Cigna of AZ Commercial	$23.10
Rate for Payer: Devoted Health Medicare	$20.88
Rate for Payer: Devoted Health Medicare	$5.94
Rate for Payer: Humana of AZ Medicare	$18.56
Rate for Payer: Humana of AZ Medicare	$5.28
Rate for Payer: Southwest Service Administrators UFCW	$22.44
Rate for Payer: Southwest Service Administrators UFCW	$78.88
Rate for Payer: TriWest Medicare	$5.28
Rate for Payer: TriWest Medicare	$18.56
Rate for Payer: United Healthcare Commercial	$66.35
Rate for Payer: United Healthcare Commercial	$18.88
Rate for Payer: United Healthcare Medicare	$5.28
Rate for Payer: United Healthcare Medicare	$18.56
Rate for Payer: United Healthcare New Mexico Commercial	$22.04
Rate for Payer: United Healthcare New Mexico Commercial	$6.27
Rate for Payer: Veterans Affairs TRICARE	$18.37
Rate for Payer: Veterans Affairs TRICARE	$5.23

Work Related Or Medical Disability Exam or Sports Physical

Facility

$116.00

Service Code	CPT 99455
Hospital Charge Code	1303643
Hospital Revenue Code	983
Min. Negotiated Rate	$104.40
Max. Negotiated Rate	$104.40
Rate for Payer: Aetna of AZ Commercial	$104.40
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Cash Price	$92.80
Rate for Payer: Cash Price	$26.40

Wound Culture

Facility

$417.00

Service Code	CPT 87070
Hospital Charge Code	858007
Hospital Revenue Code	306
Min. Negotiated Rate	$12.50
Max. Negotiated Rate	$375.30
Rate for Payer: Aetna of AZ Commercial	$375.30
Rate for Payer: Aetna of AZ Commercial	$279.00
Rate for Payer: Arizona Complete Health Allwell	$49.60
Rate for Payer: Arizona Complete Health Allwell	$66.72
Rate for Payer: Banner UC Health Medicare	$49.60
Rate for Payer: Banner UC Health Medicare	$66.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$283.56
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: Blue Cross Blue Shield of Arizona Medicare	$66.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$49.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$66.72
Rate for Payer: Cash Price	$333.60
Rate for Payer: Cash Price	$248.00
Rate for Payer: Cash Price	$333.60
Rate for Payer: Cash Price	$248.00
Rate for Payer: Cigna of AZ Commercial	$271.05
Rate for Payer: Cigna of AZ Commercial	$201.50
Rate for Payer: Devoted Health Medicare	$75.06
Rate for Payer: Devoted Health Medicare	$55.80
Rate for Payer: Humana of AZ Medicare	$49.60
Rate for Payer: Humana of AZ Medicare	$66.72
Rate for Payer: Seven Corners Travel Insurance	$12.50
Rate for Payer: Seven Corners Travel Insurance	$12.50
Rate for Payer: Southwest Service Administrators UFCW	$210.80
Rate for Payer: Southwest Service Administrators UFCW	$283.56
Rate for Payer: TriWest Medicare	$49.60
Rate for Payer: TriWest Medicare	$66.72
Rate for Payer: United Healthcare Commercial	$238.52
Rate for Payer: United Healthcare Commercial	$177.32
Rate for Payer: United Healthcare Medicare	$49.60
Rate for Payer: United Healthcare Medicare	$66.72
Rate for Payer: Veterans Affairs TRICARE	$66.05
Rate for Payer: Veterans Affairs TRICARE	$49.10

Wound Culture

Facility

$310.00

Service Code	CPT 87070
Hospital Charge Code	858007
Hospital Revenue Code	306
Min. Negotiated Rate	$279.00
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of AZ Commercial	$279.00
Rate for Payer: Aetna of AZ Commercial	$375.30
Rate for Payer: Cash Price	$248.00
Rate for Payer: Cash Price	$333.60

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$40,254.83

Service Code	MSDRG 464
Min. Negotiated Rate	$40,254.83
Max. Negotiated Rate	$40,254.83
Rate for Payer: Seven Corners Travel Insurance	$40,254.83

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$73,661.15

Service Code	MSDRG 463
Min. Negotiated Rate	$73,661.15
Max. Negotiated Rate	$73,661.15
Rate for Payer: Seven Corners Travel Insurance	$73,661.15

Know your out-of-pocket cost for care.

All Charges