Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

BRONCHITIS AND ASTHMA WITHOUT CC/MCC

Facility

$8,845.12

Service Code	MSDRG 203
Min. Negotiated Rate	$8,845.12
Max. Negotiated Rate	$8,845.12
Rate for Payer: Seven Corners Travel Insurance	$8,845.12

budesonide 0.5 mg/2 mL Inh [CQCH]

Facility

$6.16

Service Code	HCPCS J7626
Hospital Charge Code	105913304
Hospital Revenue Code	250
Min. Negotiated Rate	$5.54
Max. Negotiated Rate	$5.54
Rate for Payer: Aetna of AZ Commercial	$5.54
Rate for Payer: Cash Price	$4.93

budesonide 0.5 mg/2 mL Inh [CQCH]

Facility

$6.16

Service Code	HCPCS J7626
Hospital Charge Code	105913304
Hospital Revenue Code	250
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$5.54
Rate for Payer: Aetna of AZ Commercial	$5.54
Rate for Payer: Arizona Complete Health Allwell	$0.99
Rate for Payer: Banner UC Health Medicare	$0.99
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$4.19
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.99
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.99
Rate for Payer: Cash Price	$4.93
Rate for Payer: Cigna of AZ Commercial	$4.00
Rate for Payer: Devoted Health Medicare	$1.11
Rate for Payer: Humana of AZ Medicare	$0.99
Rate for Payer: Southwest Service Administrators UFCW	$4.19
Rate for Payer: TriWest Medicare	$0.99
Rate for Payer: United Healthcare Commercial	$3.52
Rate for Payer: United Healthcare Medicare	$0.99
Rate for Payer: Veterans Affairs TRICARE	$0.98

BULB IRRIG W/TUBING PATH FINDER

Facility

$292.59

Hospital Charge Code	22354307
Hospital Revenue Code	270
Min. Negotiated Rate	$263.33
Max. Negotiated Rate	$263.33
Rate for Payer: Aetna of AZ Commercial	$263.33
Rate for Payer: Cash Price	$234.07

BULB IRRIG W/TUBING PATH FINDER

Facility

$292.59

Hospital Charge Code	22354307
Hospital Revenue Code	270
Min. Negotiated Rate	$46.35
Max. Negotiated Rate	$263.33
Rate for Payer: Aetna of AZ Commercial	$263.33
Rate for Payer: Arizona Complete Health Allwell	$46.81
Rate for Payer: Banner UC Health Medicare	$46.81
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$198.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$46.81
Rate for Payer: Care1st Health Plan Arizona Medicare	$46.81
Rate for Payer: Cash Price	$234.07
Rate for Payer: Cigna of AZ Commercial	$204.81
Rate for Payer: Devoted Health Medicare	$52.67
Rate for Payer: Humana of AZ Medicare	$46.81
Rate for Payer: Southwest Service Administrators UFCW	$198.96
Rate for Payer: TriWest Medicare	$46.81
Rate for Payer: United Healthcare Commercial	$167.36
Rate for Payer: United Healthcare Medicare	$46.81
Rate for Payer: Veterans Affairs TRICARE	$46.35

Bulkamid INJECTION OF IMPLANT MATERIAL BENEATH LINING OF BLA

Facility

$1,082.00

Service Code	CPT 51715
Hospital Charge Code	26811662
Hospital Revenue Code	360
Min. Negotiated Rate	$155.51
Max. Negotiated Rate	$5,454.10
Rate for Payer: Aetna of AZ Commercial	$973.80
Rate for Payer: Arizona Complete Health Allwell	$173.12
Rate for Payer: Banner UC Health Medicare	$1,529.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$735.76
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$155.51
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$173.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$173.12
Rate for Payer: Cash Price	$865.60
Rate for Payer: Cash Price	$865.60
Rate for Payer: Cash Price	$865.60
Rate for Payer: Cigna of AZ Commercial	$541.00
Rate for Payer: Devoted Health Medicare	$194.76
Rate for Payer: Humana of AZ Medicare	$173.12
Rate for Payer: Mercy Care Medicaid	$155.51
Rate for Payer: NaphCare Correctional Healthcare	$1,529.32
Rate for Payer: Seven Corners Travel Insurance	$5,454.10
Rate for Payer: Southwest Service Administrators UFCW	$735.76
Rate for Payer: TriWest Medicare	$173.12
Rate for Payer: United Healthcare Commercial	$4,838.00
Rate for Payer: United Healthcare Medicare	$173.12
Rate for Payer: Veterans Affairs TRICARE	$171.39

Bulkamid INJECTION OF IMPLANT MATERIAL BENEATH LINING OF BLA

Facility

$569.00

Service Code	CPT 51715
Hospital Charge Code	26811663
Hospital Revenue Code	521
Min. Negotiated Rate	$512.10
Max. Negotiated Rate	$512.10
Rate for Payer: Aetna of AZ Commercial	$512.10
Rate for Payer: Cash Price	$455.20

Bulkamid INJECTION OF IMPLANT MATERIAL BENEATH LINING OF BLA

Facility

$569.00

Service Code	CPT 51715
Hospital Charge Code	26811663
Hospital Revenue Code	521
Min. Negotiated Rate	$90.13
Max. Negotiated Rate	$5,454.10
Rate for Payer: Aetna of AZ Commercial	$512.10
Rate for Payer: Arizona Complete Health Allwell	$91.04
Rate for Payer: Banner UC Health Medicare	$91.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$386.92
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$155.51
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$91.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$91.04
Rate for Payer: Cash Price	$455.20
Rate for Payer: Cash Price	$455.20
Rate for Payer: Cigna of AZ Commercial	$398.30
Rate for Payer: Devoted Health Medicare	$102.42
Rate for Payer: Humana of AZ Medicare	$91.04
Rate for Payer: Mercy Care Medicaid	$155.51
Rate for Payer: NaphCare Correctional Healthcare	$155.51
Rate for Payer: Seven Corners Travel Insurance	$5,454.10
Rate for Payer: Southwest Service Administrators UFCW	$386.92
Rate for Payer: TriWest Medicare	$91.04
Rate for Payer: United Healthcare Commercial	$325.47
Rate for Payer: United Healthcare Medicare	$91.04
Rate for Payer: Veterans Affairs TRICARE	$90.13

Bulkamid INJECTION OF IMPLANT MATERIAL BENEATH LINING OF BLA

Facility

$1,082.00

Service Code	CPT 51715
Hospital Charge Code	26811662
Hospital Revenue Code	360
Min. Negotiated Rate	$973.80
Max. Negotiated Rate	$973.80
Rate for Payer: Aetna of AZ Commercial	$973.80
Rate for Payer: Cash Price	$865.60

bumetanide 1 mg/ 4 mL Inj Sol [CQCH]

Facility

$0.68

Service Code	NDC 641600810
Hospital Charge Code	105913379
Hospital Revenue Code	251
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.61
Rate for Payer: Aetna of AZ Commercial	$0.61
Rate for Payer: Arizona Complete Health Allwell	$0.11
Rate for Payer: Banner UC Health Medicare	$0.11
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.46
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.11
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.11
Rate for Payer: Cash Price	$0.55
Rate for Payer: Cigna of AZ Commercial	$0.44
Rate for Payer: Devoted Health Medicare	$0.12
Rate for Payer: Humana of AZ Medicare	$0.11
Rate for Payer: Southwest Service Administrators UFCW	$0.46
Rate for Payer: TriWest Medicare	$0.11
Rate for Payer: United Healthcare Commercial	$0.39
Rate for Payer: United Healthcare Medicare	$0.11
Rate for Payer: Veterans Affairs TRICARE	$0.11

bumetanide 1 mg/ 4 mL Inj Sol [CQCH]

Facility

$0.68

Service Code	NDC 641600810
Hospital Charge Code	105913379
Hospital Revenue Code	251
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.61
Rate for Payer: Aetna of AZ Commercial	$0.61
Rate for Payer: Cash Price	$0.55

bumetanide 2.5 mg/10 mL Sol [CQCH]

Facility

$0.28

Service Code	NDC 641600710
Hospital Charge Code	154090077
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of AZ Commercial	$0.25
Rate for Payer: Arizona Complete Health Allwell	$0.04
Rate for Payer: Banner UC Health Medicare	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.19
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.04
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna of AZ Commercial	$0.18
Rate for Payer: Devoted Health Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Southwest Service Administrators UFCW	$0.19
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: United Healthcare Commercial	$0.16
Rate for Payer: United Healthcare Medicare	$0.04
Rate for Payer: Veterans Affairs TRICARE	$0.04

bumetanide 2.5 mg/10 mL Sol [CQCH]

Facility

$0.28

Service Code	NDC 641600710
Hospital Charge Code	154090077
Hospital Revenue Code	251
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of AZ Commercial	$0.25
Rate for Payer: Cash Price	$0.22

BUN+Creat(Dialysate) LC

Facility

$91.00

Hospital Charge Code	22311179
Hospital Revenue Code	301
Min. Negotiated Rate	$14.41
Max. Negotiated Rate	$81.90
Rate for Payer: Aetna of AZ Commercial	$81.90
Rate for Payer: Arizona Complete Health Allwell	$14.56
Rate for Payer: Banner UC Health Medicare	$14.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$61.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.56
Rate for Payer: Cash Price	$72.80
Rate for Payer: Cigna of AZ Commercial	$59.15
Rate for Payer: Devoted Health Medicare	$16.38
Rate for Payer: Humana of AZ Medicare	$14.56
Rate for Payer: Southwest Service Administrators UFCW	$61.88
Rate for Payer: TriWest Medicare	$14.56
Rate for Payer: United Healthcare Commercial	$52.05
Rate for Payer: United Healthcare Medicare	$14.56
Rate for Payer: Veterans Affairs TRICARE	$14.41

BUN+Creat(Dialysate) LC

Facility

$91.00

Hospital Charge Code	22311179
Hospital Revenue Code	301
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$81.90
Rate for Payer: Aetna of AZ Commercial	$81.90
Rate for Payer: Cash Price	$72.80

BUN/Creat Ratio

Facility

$64.00

Service Code	CPT 84520
Hospital Charge Code	22146068
Hospital Revenue Code	301
Min. Negotiated Rate	$57.60
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of AZ Commercial	$57.60
Rate for Payer: Cash Price	$51.20

BUN/Creat Ratio

Facility

$64.00

Service Code	CPT 84520
Hospital Charge Code	22146068
Hospital Revenue Code	301
Min. Negotiated Rate	$5.73
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of AZ Commercial	$57.60
Rate for Payer: Arizona Complete Health Allwell	$10.24
Rate for Payer: Banner UC Health Medicare	$10.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$43.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.24
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cigna of AZ Commercial	$41.60
Rate for Payer: Devoted Health Medicare	$11.52
Rate for Payer: Humana of AZ Medicare	$10.24
Rate for Payer: Seven Corners Travel Insurance	$5.73
Rate for Payer: Southwest Service Administrators UFCW	$43.52
Rate for Payer: TriWest Medicare	$10.24
Rate for Payer: United Healthcare Commercial	$36.61
Rate for Payer: United Healthcare Medicare	$10.24
Rate for Payer: Veterans Affairs TRICARE	$10.14

bupivacaine 0.5% PF Inj Sol 30 mL [CQCH]

Facility

$0.06

Service Code	NDC 409116202
Hospital Charge Code	105913448
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Cash Price	$0.05

bupivacaine 0.5% PF Inj Sol 30 mL [CQCH]

Facility

$0.06

Service Code	NDC 409116202
Hospital Charge Code	105913448
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Arizona Complete Health Allwell	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.01
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.01
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of AZ Commercial	$0.04
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.04
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.03
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

bupivacaine-EPINEPHrine 0.5%-1:200,000 PF Inj Sol 50 mL [CQCH]

Facility

$0.08

Service Code	NDC 63323046357
Hospital Charge Code	105913586
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
Rate for Payer: Cash Price	$0.06

bupivacaine-EPINEPHrine 0.5%-1:200,000 PF Inj Sol 50 mL [CQCH]

Facility

$0.08

Service Code	NDC 63323046357
Hospital Charge Code	105913586
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
Rate for Payer: Arizona Complete Health Allwell	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.01
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.01
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of AZ Commercial	$0.05
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.05
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.05
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

bupivacaine-epinephrine 0.5%-1:200,000 preservative-free Sol[CQCH]

Facility

$0.35

Service Code	NDC 63323046217
Hospital Charge Code	156706442
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of AZ Commercial	$0.32
Rate for Payer: Arizona Complete Health Allwell	$0.06
Rate for Payer: Banner UC Health Medicare	$0.06
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.06
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.06
Rate for Payer: Cash Price	$0.28
Rate for Payer: Cigna of AZ Commercial	$0.23
Rate for Payer: Devoted Health Medicare	$0.06
Rate for Payer: Humana of AZ Medicare	$0.06
Rate for Payer: Southwest Service Administrators UFCW	$0.24
Rate for Payer: TriWest Medicare	$0.06
Rate for Payer: United Healthcare Commercial	$0.20
Rate for Payer: United Healthcare Medicare	$0.06
Rate for Payer: Veterans Affairs TRICARE	$0.06

bupivacaine-epinephrine 0.5%-1:200,000 preservative-free Sol[CQCH]

Facility

$0.35

Service Code	NDC 63323046217
Hospital Charge Code	156706442
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of AZ Commercial	$0.32
Rate for Payer: Cash Price	$0.28

Bupivacaine injection

Facility

$33.00

Service Code	HCPCS C9290
Hospital Charge Code	5830976
Hospital Revenue Code	521
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Cash Price	$26.40

Bupivacaine injection

Facility

$33.00

Service Code	HCPCS C9290
Hospital Charge Code	5830976
Hospital Revenue Code	521
Min. Negotiated Rate	$5.23
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Arizona Complete Health Allwell	$5.28
Rate for Payer: Banner UC Health Medicare	$5.28
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: Care1st Health Plan Arizona Medicare	$5.28
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cigna of AZ Commercial	$23.10
Rate for Payer: Devoted Health Medicare	$5.94
Rate for Payer: Humana of AZ Medicare	$5.28
Rate for Payer: Southwest Service Administrators UFCW	$22.44
Rate for Payer: TriWest Medicare	$5.28
Rate for Payer: United Healthcare Commercial	$18.88
Rate for Payer: United Healthcare Medicare	$5.28
Rate for Payer: Veterans Affairs TRICARE	$5.23

Know your out-of-pocket cost for care.

All Charges