Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

bisacodyl 5 mg EC Tab [CQCH]

Facility

$0.03

Service Code	NDC 904640761
Hospital Charge Code	105913044
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Cash Price	$0.02

bisacodyl 5 mg EC Tab [CQCH]

Facility

$0.03

Service Code	NDC 904640761
Hospital Charge Code	105913044
Hospital Revenue Code	251
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Arizona Complete Health Allwell	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.00
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of AZ Commercial	$0.02
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Southwest Service Administrators UFCW	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: United Healthcare Commercial	$0.02
Rate for Payer: United Healthcare Medicare	$0.00
Rate for Payer: Veterans Affairs TRICARE	$0.00

BITE PROOF BITE BLOCK

Facility

$56.35

Hospital Charge Code	27542969
Hospital Revenue Code	270
Min. Negotiated Rate	$50.72
Max. Negotiated Rate	$50.72
Rate for Payer: Aetna of AZ Commercial	$50.72
Rate for Payer: Cash Price	$45.08

BITE PROOF BITE BLOCK

Facility

$56.35

Hospital Charge Code	27542969
Hospital Revenue Code	270
Min. Negotiated Rate	$8.93
Max. Negotiated Rate	$50.72
Rate for Payer: Aetna of AZ Commercial	$50.72
Rate for Payer: Arizona Complete Health Allwell	$9.02
Rate for Payer: Banner UC Health Medicare	$9.02
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$38.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.02
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.02
Rate for Payer: Cash Price	$45.08
Rate for Payer: Cigna of AZ Commercial	$39.45
Rate for Payer: Devoted Health Medicare	$10.14
Rate for Payer: Humana of AZ Medicare	$9.02
Rate for Payer: Southwest Service Administrators UFCW	$38.32
Rate for Payer: TriWest Medicare	$9.02
Rate for Payer: United Healthcare Commercial	$32.23
Rate for Payer: United Healthcare Medicare	$9.02
Rate for Payer: Veterans Affairs TRICARE	$8.93

BK Quant PCR (Plasma/Serum) LC

Facility

$532.00

Service Code	CPT 87799
Hospital Charge Code	2029177
Hospital Revenue Code	306
Min. Negotiated Rate	$62.12
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of AZ Commercial	$478.80
Rate for Payer: Arizona Complete Health Allwell	$85.12
Rate for Payer: Banner UC Health Medicare	$85.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$361.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$85.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$85.12
Rate for Payer: Cash Price	$425.60
Rate for Payer: Cash Price	$425.60
Rate for Payer: Cigna of AZ Commercial	$345.80
Rate for Payer: Devoted Health Medicare	$95.76
Rate for Payer: Humana of AZ Medicare	$85.12
Rate for Payer: Seven Corners Travel Insurance	$62.12
Rate for Payer: Southwest Service Administrators UFCW	$361.76
Rate for Payer: TriWest Medicare	$85.12
Rate for Payer: United Healthcare Commercial	$304.30
Rate for Payer: United Healthcare Medicare	$85.12
Rate for Payer: Veterans Affairs TRICARE	$84.27

BK Quant PCR (Plasma/Serum) LC

Facility

$532.00

Service Code	CPT 87799
Hospital Charge Code	2029177
Hospital Revenue Code	306
Min. Negotiated Rate	$478.80
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of AZ Commercial	$478.80
Rate for Payer: Cash Price	$425.60

Black Silicone Filiform ureteral stent

Facility

$1,159.00

Hospital Charge Code	22926477
Hospital Revenue Code	272
Min. Negotiated Rate	$183.59
Max. Negotiated Rate	$1,043.10
Rate for Payer: Aetna of AZ Commercial	$1,043.10
Rate for Payer: Arizona Complete Health Allwell	$185.44
Rate for Payer: Banner UC Health Medicare	$185.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$788.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$185.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$185.44
Rate for Payer: Cash Price	$927.20
Rate for Payer: Cigna of AZ Commercial	$811.30
Rate for Payer: Devoted Health Medicare	$208.62
Rate for Payer: Humana of AZ Medicare	$185.44
Rate for Payer: Southwest Service Administrators UFCW	$788.12
Rate for Payer: TriWest Medicare	$185.44
Rate for Payer: United Healthcare Commercial	$662.95
Rate for Payer: United Healthcare Medicare	$185.44
Rate for Payer: Veterans Affairs TRICARE	$183.59

Black Silicone Filiform ureteral stent

Facility

$1,159.00

Hospital Charge Code	22926477
Hospital Revenue Code	272
Min. Negotiated Rate	$1,043.10
Max. Negotiated Rate	$1,043.10
Rate for Payer: Aetna of AZ Commercial	$1,043.10
Rate for Payer: Cash Price	$927.20

BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION

Facility

$2,671.00

Service Code	CPT 51700
Hospital Revenue Code	750
Min. Negotiated Rate	$30.85
Max. Negotiated Rate	$2,671.00
Rate for Payer: Banner UC Health Medicare	$30.85
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$47.07
Rate for Payer: Mercy Care Medicaid	$47.07
Rate for Payer: NaphCare Correctional Healthcare	$30.85
Rate for Payer: Seven Corners Travel Insurance	$386.58
Rate for Payer: United Healthcare Commercial	$2,671.00

Bladder scan (PVR)

Facility

$53.00

Service Code	CPT 51798
Hospital Charge Code	27267788
Hospital Revenue Code	360
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$2,671.00
Rate for Payer: Aetna of AZ Commercial	$47.70
Rate for Payer: Arizona Complete Health Allwell	$8.48
Rate for Payer: Banner UC Health Medicare	$8.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$36.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.48
Rate for Payer: Cash Price	$42.40
Rate for Payer: Cash Price	$42.40
Rate for Payer: Cash Price	$42.40
Rate for Payer: Cigna of AZ Commercial	$26.50
Rate for Payer: Devoted Health Medicare	$9.54
Rate for Payer: Humana of AZ Medicare	$8.48
Rate for Payer: Seven Corners Travel Insurance	$91.28
Rate for Payer: Southwest Service Administrators UFCW	$36.04
Rate for Payer: TriWest Medicare	$8.48
Rate for Payer: United Healthcare Commercial	$2,671.00
Rate for Payer: United Healthcare Medicare	$8.48
Rate for Payer: Veterans Affairs TRICARE	$8.40

Bladder scan (PVR)

Facility

$53.00

Service Code	CPT 51798
Hospital Charge Code	27267788
Hospital Revenue Code	360
Min. Negotiated Rate	$47.70
Max. Negotiated Rate	$47.70
Rate for Payer: Aetna of AZ Commercial	$47.70
Rate for Payer: Cash Price	$42.40

BLADE CUDA 4.2MM

Facility

$213.00

Hospital Charge Code	22354870
Hospital Revenue Code	270
Min. Negotiated Rate	$191.70
Max. Negotiated Rate	$191.70
Rate for Payer: Aetna of AZ Commercial	$191.70
Rate for Payer: Cash Price	$170.40

BLADE CUDA 4.2MM

Facility

$213.00

Hospital Charge Code	22354870
Hospital Revenue Code	270
Min. Negotiated Rate	$33.74
Max. Negotiated Rate	$191.70
Rate for Payer: Aetna of AZ Commercial	$191.70
Rate for Payer: Arizona Complete Health Allwell	$34.08
Rate for Payer: Banner UC Health Medicare	$34.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$144.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$34.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$34.08
Rate for Payer: Cash Price	$170.40
Rate for Payer: Cigna of AZ Commercial	$149.10
Rate for Payer: Devoted Health Medicare	$38.34
Rate for Payer: Humana of AZ Medicare	$34.08
Rate for Payer: Southwest Service Administrators UFCW	$144.84
Rate for Payer: TriWest Medicare	$34.08
Rate for Payer: United Healthcare Commercial	$121.84
Rate for Payer: United Healthcare Medicare	$34.08
Rate for Payer: Veterans Affairs TRICARE	$33.74

BLADE GLIDESCOPE GVL 1

Facility

$109.00

Hospital Charge Code	22560418
Hospital Revenue Code	272
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Arizona Complete Health Allwell	$17.44
Rate for Payer: Banner UC Health Medicare	$17.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$74.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.44
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cigna of AZ Commercial	$76.30
Rate for Payer: Devoted Health Medicare	$19.62
Rate for Payer: Humana of AZ Medicare	$17.44
Rate for Payer: Southwest Service Administrators UFCW	$74.12
Rate for Payer: TriWest Medicare	$17.44
Rate for Payer: United Healthcare Commercial	$62.35
Rate for Payer: United Healthcare Medicare	$17.44
Rate for Payer: Veterans Affairs TRICARE	$17.27

BLADE GLIDESCOPE GVL 1

Facility

$109.00

Hospital Charge Code	22560418
Hospital Revenue Code	272
Min. Negotiated Rate	$98.10
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Cash Price	$87.20

BLADE GLIDESCOPE GVL 2

Facility

$109.00

Hospital Charge Code	22561231
Hospital Revenue Code	272
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Arizona Complete Health Allwell	$17.44
Rate for Payer: Banner UC Health Medicare	$17.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$74.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.44
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cigna of AZ Commercial	$76.30
Rate for Payer: Devoted Health Medicare	$19.62
Rate for Payer: Humana of AZ Medicare	$17.44
Rate for Payer: Southwest Service Administrators UFCW	$74.12
Rate for Payer: TriWest Medicare	$17.44
Rate for Payer: United Healthcare Commercial	$62.35
Rate for Payer: United Healthcare Medicare	$17.44
Rate for Payer: Veterans Affairs TRICARE	$17.27

BLADE GLIDESCOPE GVL 2

Facility

$109.00

Hospital Charge Code	22561231
Hospital Revenue Code	272
Min. Negotiated Rate	$98.10
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Cash Price	$87.20

BLADE GLIDESCOPE GVL 3

Facility

$109.00

Hospital Charge Code	22561233
Hospital Revenue Code	272
Min. Negotiated Rate	$98.10
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Cash Price	$87.20

BLADE GLIDESCOPE GVL 3

Facility

$109.00

Hospital Charge Code	22561233
Hospital Revenue Code	272
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Arizona Complete Health Allwell	$17.44
Rate for Payer: Banner UC Health Medicare	$17.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$74.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.44
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cigna of AZ Commercial	$76.30
Rate for Payer: Devoted Health Medicare	$19.62
Rate for Payer: Humana of AZ Medicare	$17.44
Rate for Payer: Southwest Service Administrators UFCW	$74.12
Rate for Payer: TriWest Medicare	$17.44
Rate for Payer: United Healthcare Commercial	$62.35
Rate for Payer: United Healthcare Medicare	$17.44
Rate for Payer: Veterans Affairs TRICARE	$17.27

BLADE GLIDESCOPE GVL 4

Facility

$109.00

Hospital Charge Code	22561235
Hospital Revenue Code	272
Min. Negotiated Rate	$98.10
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Cash Price	$87.20

BLADE GLIDESCOPE GVL 4

Facility

$109.00

Hospital Charge Code	22561235
Hospital Revenue Code	272
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Arizona Complete Health Allwell	$17.44
Rate for Payer: Banner UC Health Medicare	$17.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$74.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.44
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cigna of AZ Commercial	$76.30
Rate for Payer: Devoted Health Medicare	$19.62
Rate for Payer: Humana of AZ Medicare	$17.44
Rate for Payer: Southwest Service Administrators UFCW	$74.12
Rate for Payer: TriWest Medicare	$17.44
Rate for Payer: United Healthcare Commercial	$62.35
Rate for Payer: United Healthcare Medicare	$17.44
Rate for Payer: Veterans Affairs TRICARE	$17.27

BLADE GLIDESCOPE SML

Facility

$109.00

Hospital Charge Code	22354971
Hospital Revenue Code	270
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Arizona Complete Health Allwell	$17.44
Rate for Payer: Banner UC Health Medicare	$17.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$74.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.44
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cigna of AZ Commercial	$76.30
Rate for Payer: Devoted Health Medicare	$19.62
Rate for Payer: Humana of AZ Medicare	$17.44
Rate for Payer: Southwest Service Administrators UFCW	$74.12
Rate for Payer: TriWest Medicare	$17.44
Rate for Payer: United Healthcare Commercial	$62.35
Rate for Payer: United Healthcare Medicare	$17.44
Rate for Payer: Veterans Affairs TRICARE	$17.27

BLADE GLIDESCOPE SML

Facility

$109.00

Hospital Charge Code	22354971
Hospital Revenue Code	270
Min. Negotiated Rate	$98.10
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Cash Price	$87.20

BLADE LARYNGASCOPE #3

Facility

$222.00

Hospital Charge Code	22354256
Hospital Revenue Code	270
Min. Negotiated Rate	$199.80
Max. Negotiated Rate	$199.80
Rate for Payer: Aetna of AZ Commercial	$199.80
Rate for Payer: Cash Price	$177.60

BLADE LARYNGASCOPE #3

Facility

$222.00

Hospital Charge Code	22354256
Hospital Revenue Code	270
Min. Negotiated Rate	$35.16
Max. Negotiated Rate	$199.80
Rate for Payer: Aetna of AZ Commercial	$199.80
Rate for Payer: Arizona Complete Health Allwell	$35.52
Rate for Payer: Banner UC Health Medicare	$35.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$150.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$35.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$35.52
Rate for Payer: Cash Price	$177.60
Rate for Payer: Cigna of AZ Commercial	$155.40
Rate for Payer: Devoted Health Medicare	$39.96
Rate for Payer: Humana of AZ Medicare	$35.52
Rate for Payer: Southwest Service Administrators UFCW	$150.96
Rate for Payer: TriWest Medicare	$35.52
Rate for Payer: United Healthcare Commercial	$126.98
Rate for Payer: United Healthcare Medicare	$35.52
Rate for Payer: Veterans Affairs TRICARE	$35.16

Know your out-of-pocket cost for care.

All Charges