Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, T

Facility

$586.00

Service Code	CPT 15273
Hospital Charge Code	24049290
Hospital Revenue Code	760
Min. Negotiated Rate	$527.40
Max. Negotiated Rate	$527.40
Rate for Payer: Aetna of AZ Commercial	$527.40
Rate for Payer: Cash Price	$468.80

APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, T

Facility

$3,972.00

Service Code	CPT 15271
Hospital Charge Code	23634011
Min. Negotiated Rate	$70.43
Max. Negotiated Rate	$3,574.80
Rate for Payer: Aetna of AZ Commercial	$3,574.80
Rate for Payer: Arizona Complete Health Allwell	$635.52
Rate for Payer: Banner UC Health Medicare	$635.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,700.96
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$70.43
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$635.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$635.52
Rate for Payer: Cash Price	$3,177.60
Rate for Payer: Cash Price	$3,177.60
Rate for Payer: Cigna of AZ Commercial	$2,780.40
Rate for Payer: Devoted Health Medicare	$714.96
Rate for Payer: Humana of AZ Medicare	$635.52
Rate for Payer: Mercy Care Medicaid	$70.43
Rate for Payer: NaphCare Correctional Healthcare	$70.43
Rate for Payer: Seven Corners Travel Insurance	$1,143.54
Rate for Payer: Southwest Service Administrators UFCW	$2,700.96
Rate for Payer: TriWest Medicare	$635.52
Rate for Payer: United Healthcare Commercial	$2,271.98
Rate for Payer: United Healthcare Medicare	$635.52
Rate for Payer: Veterans Affairs TRICARE	$629.16

APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, T

Facility

$4,586.00

Service Code	CPT 15271
Hospital Charge Code	23922975
Hospital Revenue Code	761
Min. Negotiated Rate	$4,127.40
Max. Negotiated Rate	$4,127.40
Rate for Payer: Aetna of AZ Commercial	$4,127.40
Rate for Payer: Cash Price	$3,668.80

APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, T

Facility

$4,586.00

Service Code	CPT 15271
Hospital Charge Code	23922975
Hospital Revenue Code	761
Min. Negotiated Rate	$70.43
Max. Negotiated Rate	$4,127.40
Rate for Payer: Aetna of AZ Commercial	$4,127.40
Rate for Payer: Arizona Complete Health Allwell	$733.76
Rate for Payer: Banner UC Health Medicare	$733.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,118.48
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$70.43
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$733.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$733.76
Rate for Payer: Cash Price	$3,668.80
Rate for Payer: Cash Price	$3,668.80
Rate for Payer: Cigna of AZ Commercial	$3,210.20
Rate for Payer: Devoted Health Medicare	$825.48
Rate for Payer: Humana of AZ Medicare	$733.76
Rate for Payer: Mercy Care Medicaid	$70.43
Rate for Payer: NaphCare Correctional Healthcare	$70.43
Rate for Payer: Seven Corners Travel Insurance	$1,143.54
Rate for Payer: Southwest Service Administrators UFCW	$3,118.48
Rate for Payer: TriWest Medicare	$733.76
Rate for Payer: United Healthcare Commercial	$2,623.19
Rate for Payer: United Healthcare Medicare	$733.76
Rate for Payer: United Healthcare New Mexico Commercial	$871.34
Rate for Payer: Veterans Affairs TRICARE	$726.42

APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; EACH ADDITIONAL 25 SQ CM WOUND SURFACE AREA, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$2,671.00

Service Code	CPT 15272
Hospital Revenue Code	490
Min. Negotiated Rate	$8.02
Max. Negotiated Rate	$2,671.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8.02
Rate for Payer: Mercy Care Medicaid	$8.02
Rate for Payer: NaphCare Correctional Healthcare	$8.02
Rate for Payer: United Healthcare Commercial	$2,671.00

APPLICATION OF SKIN SUBSTITUTE GRAFT TO TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LESS WOUND SURFACE AREA

Facility

$3,596.00

Service Code	CPT 15271
Hospital Revenue Code	490
Min. Negotiated Rate	$70.43
Max. Negotiated Rate	$3,596.00
Rate for Payer: Banner UC Health Medicare	$223.62
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$70.43
Rate for Payer: Mercy Care Medicaid	$70.43
Rate for Payer: NaphCare Correctional Healthcare	$223.62
Rate for Payer: Seven Corners Travel Insurance	$1,143.54
Rate for Payer: United Healthcare Commercial	$3,596.00

Applic of Long Arm Splint (Shoulder to Hand) Charge

Facility

$143.00

Service Code	CPT 29105
Hospital Charge Code	730451
Hospital Revenue Code	521
Min. Negotiated Rate	$22.65
Max. Negotiated Rate	$251.43
Rate for Payer: Aetna of AZ Commercial	$128.70
Rate for Payer: Arizona Complete Health Allwell	$22.88
Rate for Payer: Banner UC Health Medicare	$22.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$97.24
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$44.98
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$22.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$22.88
Rate for Payer: Cash Price	$114.40
Rate for Payer: Cash Price	$114.40
Rate for Payer: Cigna of AZ Commercial	$100.10
Rate for Payer: Devoted Health Medicare	$25.74
Rate for Payer: Humana of AZ Medicare	$22.88
Rate for Payer: Mercy Care Medicaid	$44.98
Rate for Payer: NaphCare Correctional Healthcare	$44.98
Rate for Payer: Seven Corners Travel Insurance	$251.43
Rate for Payer: Southwest Service Administrators UFCW	$97.24
Rate for Payer: TriWest Medicare	$22.88
Rate for Payer: United Healthcare Commercial	$81.80
Rate for Payer: United Healthcare Medicare	$22.88
Rate for Payer: Veterans Affairs TRICARE	$22.65

Applic of Long Arm Splint (Shoulder to Hand) Charge

Facility

$143.00

Service Code	CPT 29105
Hospital Charge Code	730451
Hospital Revenue Code	521
Min. Negotiated Rate	$128.70
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna of AZ Commercial	$128.70
Rate for Payer: Cash Price	$114.40

AP with culdoplasty

Facility

$4,525.00

Service Code	CPT 57265
Hospital Charge Code	27291785
Hospital Revenue Code	360
Min. Negotiated Rate	$4,072.50
Max. Negotiated Rate	$4,072.50
Rate for Payer: Aetna of AZ Commercial	$4,072.50
Rate for Payer: Cash Price	$3,620.00

AP with culdoplasty

Facility

$4,525.00

Service Code	CPT 57265
Hospital Charge Code	27291785
Hospital Revenue Code	360
Min. Negotiated Rate	$716.76
Max. Negotiated Rate	$7,740.14
Rate for Payer: Aetna of AZ Commercial	$4,072.50
Rate for Payer: Arizona Complete Health Allwell	$724.00
Rate for Payer: Banner UC Health Medicare	$1,698.98
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,077.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$724.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$724.00
Rate for Payer: Cash Price	$3,620.00
Rate for Payer: Cash Price	$3,620.00
Rate for Payer: Cash Price	$3,620.00
Rate for Payer: Cigna of AZ Commercial	$2,262.50
Rate for Payer: Devoted Health Medicare	$814.50
Rate for Payer: Humana of AZ Medicare	$724.00
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	$3,077.00
Rate for Payer: TriWest Medicare	$724.00
Rate for Payer: United Healthcare Commercial	$5,611.00
Rate for Payer: United Healthcare Medicare	$724.00
Rate for Payer: Veterans Affairs TRICARE	$716.76

ARM4 ANORECTAL CATHETER

Facility

$781.00

Hospital Charge Code	27773233
Hospital Revenue Code	270
Min. Negotiated Rate	$702.90
Max. Negotiated Rate	$702.90
Rate for Payer: Aetna of AZ Commercial	$702.90
Rate for Payer: Cash Price	$624.80

ARM4 ANORECTAL CATHETER

Facility

$781.00

Hospital Charge Code	27773233
Hospital Revenue Code	270
Min. Negotiated Rate	$123.71
Max. Negotiated Rate	$702.90
Rate for Payer: Aetna of AZ Commercial	$702.90
Rate for Payer: Arizona Complete Health Allwell	$124.96
Rate for Payer: Banner UC Health Medicare	$124.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$531.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$124.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$124.96
Rate for Payer: Cash Price	$624.80
Rate for Payer: Cigna of AZ Commercial	$546.70
Rate for Payer: Devoted Health Medicare	$140.58
Rate for Payer: Humana of AZ Medicare	$124.96
Rate for Payer: Southwest Service Administrators UFCW	$531.08
Rate for Payer: TriWest Medicare	$124.96
Rate for Payer: United Healthcare Commercial	$446.73
Rate for Payer: United Healthcare Medicare	$124.96
Rate for Payer: Veterans Affairs TRICARE	$123.71

ARMBOARD INFANT NEONATAL

Facility

$42.00

Hospital Charge Code	22543301
Hospital Revenue Code	270
Min. Negotiated Rate	$6.65
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Arizona Complete Health Allwell	$6.72
Rate for Payer: Banner UC Health Medicare	$6.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$28.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.72
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cigna of AZ Commercial	$29.40
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Humana of AZ Medicare	$6.72
Rate for Payer: Southwest Service Administrators UFCW	$28.56
Rate for Payer: TriWest Medicare	$6.72
Rate for Payer: United Healthcare Commercial	$24.02
Rate for Payer: United Healthcare Medicare	$6.72
Rate for Payer: Veterans Affairs TRICARE	$6.65

ARMBOARD INFANT NEONATAL

Facility

$42.00

Hospital Charge Code	22543301
Hospital Revenue Code	270
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Cash Price	$33.60

ARSENIC BLOOD

Facility

$314.00

Service Code	CPT 82175
Hospital Charge Code	22481463
Hospital Revenue Code	301
Min. Negotiated Rate	$27.51
Max. Negotiated Rate	$282.60
Rate for Payer: Aetna of AZ Commercial	$282.60
Rate for Payer: Arizona Complete Health Allwell	$50.24
Rate for Payer: Banner UC Health Medicare	$50.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$213.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$50.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$50.24
Rate for Payer: Cash Price	$251.20
Rate for Payer: Cash Price	$251.20
Rate for Payer: Cigna of AZ Commercial	$204.10
Rate for Payer: Devoted Health Medicare	$56.52
Rate for Payer: Humana of AZ Medicare	$50.24
Rate for Payer: Seven Corners Travel Insurance	$27.51
Rate for Payer: Southwest Service Administrators UFCW	$213.52
Rate for Payer: TriWest Medicare	$50.24
Rate for Payer: United Healthcare Commercial	$179.61
Rate for Payer: United Healthcare Medicare	$50.24
Rate for Payer: Veterans Affairs TRICARE	$49.74

ARSENIC BLOOD

Facility

$314.00

Service Code	CPT 82175
Hospital Charge Code	22481463
Hospital Revenue Code	301
Min. Negotiated Rate	$282.60
Max. Negotiated Rate	$282.60
Rate for Payer: Aetna of AZ Commercial	$282.60
Rate for Payer: Cash Price	$251.20

Arsenic, Blood LC

Facility

$290.00

Service Code	CPT 82175
Hospital Charge Code	1285590
Hospital Revenue Code	301
Min. Negotiated Rate	$261.00
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna of AZ Commercial	$261.00
Rate for Payer: Cash Price	$232.00

Arsenic, Blood LC

Facility

$290.00

Service Code	CPT 82175
Hospital Charge Code	1285590
Hospital Revenue Code	301
Min. Negotiated Rate	$27.51
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna of AZ Commercial	$261.00
Rate for Payer: Arizona Complete Health Allwell	$46.40
Rate for Payer: Banner UC Health Medicare	$46.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$197.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$46.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$46.40
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cigna of AZ Commercial	$188.50
Rate for Payer: Devoted Health Medicare	$52.20
Rate for Payer: Humana of AZ Medicare	$46.40
Rate for Payer: Seven Corners Travel Insurance	$27.51
Rate for Payer: Southwest Service Administrators UFCW	$197.20
Rate for Payer: TriWest Medicare	$46.40
Rate for Payer: United Healthcare Commercial	$165.88
Rate for Payer: United Healthcare Medicare	$46.40
Rate for Payer: Veterans Affairs TRICARE	$45.94

.Arsenic, Comment LC

Facility

$299.00

Service Code	CPT 82175
Hospital Charge Code	22311133
Hospital Revenue Code	301
Min. Negotiated Rate	$269.10
Max. Negotiated Rate	$269.10
Rate for Payer: Aetna of AZ Commercial	$269.10
Rate for Payer: Cash Price	$239.20

.Arsenic, Comment LC

Facility

$299.00

Service Code	CPT 82175
Hospital Charge Code	22311133
Hospital Revenue Code	301
Min. Negotiated Rate	$27.51
Max. Negotiated Rate	$269.10
Rate for Payer: Aetna of AZ Commercial	$269.10
Rate for Payer: Arizona Complete Health Allwell	$47.84
Rate for Payer: Banner UC Health Medicare	$47.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$203.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$47.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$47.84
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cash Price	$239.20
Rate for Payer: Cigna of AZ Commercial	$194.35
Rate for Payer: Devoted Health Medicare	$53.82
Rate for Payer: Humana of AZ Medicare	$47.84
Rate for Payer: Seven Corners Travel Insurance	$27.51
Rate for Payer: Southwest Service Administrators UFCW	$203.32
Rate for Payer: TriWest Medicare	$47.84
Rate for Payer: United Healthcare Commercial	$171.03
Rate for Payer: United Healthcare Medicare	$47.84
Rate for Payer: Veterans Affairs TRICARE	$47.36

Arterial Blood Gas

Facility

$322.00

Service Code	CPT 82803
Hospital Charge Code	22521717
Hospital Revenue Code	301
Min. Negotiated Rate	$289.80
Max. Negotiated Rate	$289.80
Rate for Payer: Aetna of AZ Commercial	$289.80
Rate for Payer: Cash Price	$257.60

Arterial Blood Gas

Facility

$322.00

Service Code	CPT 82803
Hospital Charge Code	22521717
Hospital Revenue Code	301
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$289.80
Rate for Payer: Aetna of AZ Commercial	$289.80
Rate for Payer: Arizona Complete Health Allwell	$51.52
Rate for Payer: Banner UC Health Medicare	$51.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$218.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$51.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$51.52
Rate for Payer: Cash Price	$257.60
Rate for Payer: Cash Price	$257.60
Rate for Payer: Cigna of AZ Commercial	$209.30
Rate for Payer: Devoted Health Medicare	$57.96
Rate for Payer: Humana of AZ Medicare	$51.52
Rate for Payer: Seven Corners Travel Insurance	$37.80
Rate for Payer: Southwest Service Administrators UFCW	$218.96
Rate for Payer: TriWest Medicare	$51.52
Rate for Payer: United Healthcare Commercial	$184.18
Rate for Payer: United Healthcare Medicare	$51.52
Rate for Payer: Veterans Affairs TRICARE	$51.00

Arterial Blood Gas Standard

Facility

$306.00

Service Code	CPT 82803
Hospital Charge Code	22146116
Hospital Revenue Code	301
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$275.40
Rate for Payer: Aetna of AZ Commercial	$275.40
Rate for Payer: Arizona Complete Health Allwell	$48.96
Rate for Payer: Banner UC Health Medicare	$48.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$208.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$48.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$48.96
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cigna of AZ Commercial	$198.90
Rate for Payer: Devoted Health Medicare	$55.08
Rate for Payer: Humana of AZ Medicare	$48.96
Rate for Payer: Seven Corners Travel Insurance	$37.80
Rate for Payer: Southwest Service Administrators UFCW	$208.08
Rate for Payer: TriWest Medicare	$48.96
Rate for Payer: United Healthcare Commercial	$175.03
Rate for Payer: United Healthcare Medicare	$48.96
Rate for Payer: Veterans Affairs TRICARE	$48.47

Arterial Blood Gas Standard

Facility

$306.00

Service Code	CPT 82803
Hospital Charge Code	22146116
Hospital Revenue Code	301
Min. Negotiated Rate	$275.40
Max. Negotiated Rate	$275.40
Rate for Payer: Aetna of AZ Commercial	$275.40
Rate for Payer: Cash Price	$244.80

Arthrocentesis, Aspirtn and/or Inj; Small Joint or Bursa (eg, Fingers, toes) Cha

Facility

$239.00

Service Code	CPT 20600
Hospital Charge Code	729203
Hospital Revenue Code	521
Min. Negotiated Rate	$18.83
Max. Negotiated Rate	$474.93
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Arizona Complete Health Allwell	$38.24
Rate for Payer: Banner UC Health Medicare	$38.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$162.52
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$18.83
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.24
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cigna of AZ Commercial	$167.30
Rate for Payer: Devoted Health Medicare	$43.02
Rate for Payer: Humana of AZ Medicare	$38.24
Rate for Payer: Mercy Care Medicaid	$18.83
Rate for Payer: NaphCare Correctional Healthcare	$18.83
Rate for Payer: Seven Corners Travel Insurance	$474.93
Rate for Payer: Southwest Service Administrators UFCW	$162.52
Rate for Payer: TriWest Medicare	$38.24
Rate for Payer: United Healthcare Commercial	$136.71
Rate for Payer: United Healthcare Medicare	$38.24
Rate for Payer: Veterans Affairs TRICARE	$37.86

Know your out-of-pocket cost for care.

All Charges