Price and financial assistance policy
The chart below has been developed to give patients an estimate of care prices for our most common procedures.
Copa Care Self Pay Discount Policy for Uninsured/Underinsured (09004 S)Copa Care Sliding Fee Schedule
| Maricopa Medical Center - based on 2011 data | ||||
| [download Prices file in Excel] | ||||
| Prices for Key Procedures | ||||
| Revised 12/10/2012 | Copa Care Category 3 | Copa Care Category 2 | Copa Care Category 1 | |
| default to Medicare rates||>200% FPL | 101-200% FPL | 0-100% FPL | ||
| Code | Description | Price for Uninsured Patient | Price for Uninsured Patient | Price for Uninsured Patient |
| Inpatient APR-DRG | ||||
| 5601 & 6401 | Vaginal Delivery - DRG 775 | $3,850.00 | $3,850.00 | $3,850.00 |
| Normal Newborn - DRG 795 | incl w/delivery | incl w/delivery | incl w/delivery | |
| 5401 & 6401 | Cesarean Delivery - DRG 765 | $5,600.00 | $5,600.00 | $5,600.00 |
| Normal Newborn - DRG 795 | incl w/delivery | incl w/delivery | incl w/delivery | |
| 3022 | Knee Joint Replacement - Moderate - DRG 488 | $18,903.67 | $800.00 | $400.00 |
| 1392 | Pneumonia - Moderate - DRG 194 | $11,029.34 | $1,000.00 | $500.00 |
| 1943 | Heart Failure- Major- DRG 291 | $16,512.11 | $1,200.00 | $600.00 |
| 1403 | Chronic Obstructive Plumonary Disorder - DRG 192 | $7,789.62 | $600.00 | $300.00 |
| 4632 | Kidney/Urinary Tract Infection - Moderate - DRG 690 | $8,657.58 | $800.00 | $400.00 |
| 3012 | Hip Joint Replacement- Moderate -DRG 470 | $22,954.14 | $800.00 | $400.00 |
| 2632 | Lap Cholecystectomy- Moderate - DRG 418 | $18,601.15 | $1,000.00 | $500.00 |
| 2251 | Appendectomy- Minor - DRG 343 | $10,546.41 | $400.00 | $200.00 |
| MS-DRG | ||||
| 192 | 192 Chronic Obstructive Pulmonary Disease without CC/MCC | $7,789.62 | $600.00 | $300.00 |
| 194 | 194 Simple Pneumonia and Pleurisy with CC | $11,029.34 | $1,000.00 | $500.00 |
| 291 | 291 Heart Failure and Shock with MCC | $16,512.10 | $1,200.00 | $600.00 |
| 343 | 343 Appendectomy without Complicated Principal Diagnosis without CC/MCC | $10,546.41 | $400.00 | $200.00 |
| 418 | 418 Laparoscopic Cholecystectomy without C.D.E. with CC | $18,601.15 | $1,000.00 | $500.00 |
| 470 | 470 Major Joint Replacement or Reattachment of Lower Extremity without MCC | $22,954.14 | $800.00 | $400.00 |
| 488 | 488 Knee Procedures without Principal Diagnosis of Infection with CC/MCC | $18,903.67 | $800.00 | $400.00 |
| 690 | 690 Kidney and Urinary Tract Infections without MCC | $8,657.58 | $800.00 | $400.00 |
| 765 | 765 Cesarean Section with CC/MCC | $5,600.00 | $1,000.00 | $500.00 |
| 775 | 775 Vaginal Delivery without Complicating Diagnoses | $3,850.00 | $400.00 | $200.00 |
| 795 | 795 Normal Newborn | incl w/delivery | incl w/delivery | incl w/delivery |
| Outpatient CPT4 | ||||
| 99283 | Emergency Department Visit - Level 3 | $136.03 | $100.00 | $50.00 |
| 99203/99213 | Urgent Care Visit - Level 3 | $95.12 | $20.00 | $10.00 |
| 69421 | Ear Tubes (Myringotomy) HCPC 69420,69421 | $1,180.62 | $983.83 | $491.91 |
| 42825 | Tonsillectomy 12yrs under HCPC 42825 | $1,742.64 | $871.32 | $435.66 |
| 42826 | Tonsillectomy 12 and over HCPC 42826 | $1,742.64 | $871.32 | $435.66 |
| 93451 | Heart Catheter left HCPC 93452 Right HCPC 93451 | $2,718.42 | $1,359.21 | $679.61 |
| 45378 | Colonoscopy diagnostic HPCPC 45378 | $655.31 | $327.66 | $163.83 |
| 97001 | Physical Therapy Evaluation HCPC 97001 | $114.57 | $38.12 | $19.06 |
| 70460 | MRI- Head/Skull w/ contrst HCPC 70460 | $300.49 | $150.25 | $75.12 |
| 70450 | MRI- Head/Skull w/o Contrst 70450 | $191.89 | $95.95 | $47.97 |
| 70470 | MRI- Head/Skull w/o followed by with HCPC 70470 | $334.09 | $167.05 | $83.52 |
| 77080 | Bone Density Exam HCPC 77080 | $71.48 | $35.74 | $17.87 |
| 77057 | Mammogram (screening bilateral) HCPC 77057 | $94.81 | $38.66 | $19.33 |
| 66984/66982 | Cataract removal - Extracapsular with insertion of lens prothesis (1 stage) 66984/66982 complex | $1,670.41 | $835.21 | $417.60 |
| 47652 | Laporoscopic Cholecystectomy-Total 47562 | $3,358.35 | $1,679.18 | $839.60 |
| 64721 | Carpal Tunnel Release 64721 | $1,321.02 | $650.51 | $330.26 |
| MATERNITY PACKAGE-includes all physician fees | ||
| if PIF within 90d or prior to discharge** | *Discounted* | |
| Normal Vaginal Delivery | $3,850 | $2,888.00 |
| Normal Vaginal Delivery with Bilateral Tubal Ligation | $4,150 | $3,113 |
| Unplanned Emergency C-Section-additional fee | $1,750 | Not Applicable |
| Planned C-Section | $5,600 | $5,200 |
| Bilateral Tubal Ligation with C-Section | $50 | $50 |
| Twins-additional fee | $200 | $200 |