Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Burns With Skin Graft Except Extensive Third Degree Burns

Facility

$71,693.60

Service Code	APR-DRG 8424
Hospital Charge Code	APRDRG8421
Min. Negotiated Rate	$71,693.60
Max. Negotiated Rate	$71,693.60
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$71,693.60
Rate for Payer: Mercy Care Medicaid	$71,693.60
Rate for Payer: NaphCare Correctional Healthcare	$71,693.60

busPIRone 5 mg Tab [CQCH]

Facility

$0.02

Service Code	NDC 64380074108
Hospital Charge Code	105913714
Hospital Revenue Code	251
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
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	$0.01
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	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Devoted Health Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Southwest Service Administrators UFCW	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: United Healthcare Commercial	$0.01
Rate for Payer: United Healthcare Medicare	$0.00
Rate for Payer: Veterans Affairs TRICARE	$0.00

busPIRone 5 mg Tab [CQCH]

Facility

$0.02

Service Code	NDC 64380074108
Hospital Charge Code	105913714
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Cash Price	$0.01

butorphanol 1 mg/mL Inj Sol [CQCH]

Facility

$3.53

Service Code	HCPCS J0595
Hospital Charge Code	105913781
Hospital Revenue Code	250
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$3.18
Rate for Payer: Aetna of AZ Commercial	$3.18
Rate for Payer: Arizona Complete Health Allwell	$0.56
Rate for Payer: Banner UC Health Medicare	$0.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.56
Rate for Payer: Cash Price	$2.82
Rate for Payer: Cigna of AZ Commercial	$2.29
Rate for Payer: Devoted Health Medicare	$0.64
Rate for Payer: Humana of AZ Medicare	$0.56
Rate for Payer: Southwest Service Administrators UFCW	$2.40
Rate for Payer: TriWest Medicare	$0.56
Rate for Payer: United Healthcare Commercial	$2.02
Rate for Payer: United Healthcare Medicare	$0.56
Rate for Payer: Veterans Affairs TRICARE	$0.56

butorphanol 1 mg/mL Inj Sol [CQCH]

Facility

$3.53

Service Code	HCPCS J0595
Hospital Charge Code	105913781
Hospital Revenue Code	250
Min. Negotiated Rate	$3.18
Max. Negotiated Rate	$3.18
Rate for Payer: Aetna of AZ Commercial	$3.18
Rate for Payer: Cash Price	$2.82

butorphanol 2 mg/mL Sol[CQCH]

Facility

$4.73

Service Code	HCPCS J0595
Hospital Charge Code	133556199
Hospital Revenue Code	250
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$4.26
Rate for Payer: Aetna of AZ Commercial	$4.26
Rate for Payer: Arizona Complete Health Allwell	$0.76
Rate for Payer: Banner UC Health Medicare	$0.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3.22
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.76
Rate for Payer: Cash Price	$3.78
Rate for Payer: Cigna of AZ Commercial	$3.07
Rate for Payer: Devoted Health Medicare	$0.85
Rate for Payer: Humana of AZ Medicare	$0.76
Rate for Payer: Southwest Service Administrators UFCW	$3.22
Rate for Payer: TriWest Medicare	$0.76
Rate for Payer: United Healthcare Commercial	$2.71
Rate for Payer: United Healthcare Medicare	$0.76
Rate for Payer: Veterans Affairs TRICARE	$0.75

butorphanol 2 mg/mL Sol[CQCH]

Facility

$4.73

Service Code	HCPCS J0595
Hospital Charge Code	133556199
Hospital Revenue Code	250
Min. Negotiated Rate	$4.26
Max. Negotiated Rate	$4.26
Rate for Payer: Aetna of AZ Commercial	$4.26
Rate for Payer: Cash Price	$3.78

BUTTON CAP SET

Facility

$38.00

Hospital Charge Code	23624660
Min. Negotiated Rate	$34.20
Max. Negotiated Rate	$34.20
Rate for Payer: Aetna of AZ Commercial	$34.20
Rate for Payer: Cash Price	$30.40

BUTTON CAP SET

Facility

$38.00

Hospital Charge Code	23624660
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$34.20
Rate for Payer: Aetna of AZ Commercial	$34.20
Rate for Payer: Arizona Complete Health Allwell	$6.08
Rate for Payer: Banner UC Health Medicare	$6.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$25.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.08
Rate for Payer: Cash Price	$30.40
Rate for Payer: Cigna of AZ Commercial	$26.60
Rate for Payer: Devoted Health Medicare	$6.84
Rate for Payer: Humana of AZ Medicare	$6.08
Rate for Payer: Southwest Service Administrators UFCW	$25.84
Rate for Payer: TriWest Medicare	$6.08
Rate for Payer: United Healthcare Commercial	$21.74
Rate for Payer: United Healthcare Medicare	$6.08
Rate for Payer: Veterans Affairs TRICARE	$6.02

CA 15-3 (Serial Monitor) LC

Facility

$250.00

Service Code	CPT 86300
Hospital Charge Code	22311180
Hospital Revenue Code	302
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna of AZ Commercial	$225.00
Rate for Payer: Cash Price	$200.00

CA 15-3 (Serial Monitor) LC

Facility

$250.00

Service Code	CPT 86300
Hospital Charge Code	22311180
Hospital Revenue Code	302
Min. Negotiated Rate	$30.17
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna of AZ Commercial	$225.00
Rate for Payer: Arizona Complete Health Allwell	$40.00
Rate for Payer: Banner UC Health Medicare	$40.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$170.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$40.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$40.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cigna of AZ Commercial	$162.50
Rate for Payer: Devoted Health Medicare	$45.00
Rate for Payer: Humana of AZ Medicare	$40.00
Rate for Payer: Seven Corners Travel Insurance	$30.17
Rate for Payer: Southwest Service Administrators UFCW	$170.00
Rate for Payer: TriWest Medicare	$40.00
Rate for Payer: United Healthcare Commercial	$143.00
Rate for Payer: United Healthcare Medicare	$40.00
Rate for Payer: Veterans Affairs TRICARE	$39.60

CA 27.29 LC

Facility

$276.00

Service Code	CPT 86300
Hospital Charge Code	2270021
Hospital Revenue Code	302
Min. Negotiated Rate	$248.40
Max. Negotiated Rate	$248.40
Rate for Payer: Aetna of AZ Commercial	$248.40
Rate for Payer: Cash Price	$220.80

CA 27.29 LC

Facility

$276.00

Service Code	CPT 86300
Hospital Charge Code	2270021
Hospital Revenue Code	302
Min. Negotiated Rate	$30.17
Max. Negotiated Rate	$248.40
Rate for Payer: Aetna of AZ Commercial	$248.40
Rate for Payer: Arizona Complete Health Allwell	$44.16
Rate for Payer: Banner UC Health Medicare	$44.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$187.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$44.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$44.16
Rate for Payer: Cash Price	$220.80
Rate for Payer: Cash Price	$220.80
Rate for Payer: Cigna of AZ Commercial	$179.40
Rate for Payer: Devoted Health Medicare	$49.68
Rate for Payer: Humana of AZ Medicare	$44.16
Rate for Payer: Seven Corners Travel Insurance	$30.17
Rate for Payer: Southwest Service Administrators UFCW	$187.68
Rate for Payer: TriWest Medicare	$44.16
Rate for Payer: United Healthcare Commercial	$157.87
Rate for Payer: United Healthcare Medicare	$44.16
Rate for Payer: Veterans Affairs TRICARE	$43.72

calcitonin 200 intl units/inh Nasal Spry [CQCH]

Facility

$9.43

Service Code	NDC 60505082306
Hospital Charge Code	105913923
Hospital Revenue Code	251
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$8.49
Rate for Payer: Aetna of AZ Commercial	$8.49
Rate for Payer: Arizona Complete Health Allwell	$1.51
Rate for Payer: Banner UC Health Medicare	$1.51
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$6.41
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.51
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.51
Rate for Payer: Cash Price	$7.54
Rate for Payer: Cigna of AZ Commercial	$6.13
Rate for Payer: Devoted Health Medicare	$1.70
Rate for Payer: Humana of AZ Medicare	$1.51
Rate for Payer: Southwest Service Administrators UFCW	$6.41
Rate for Payer: TriWest Medicare	$1.51
Rate for Payer: United Healthcare Commercial	$5.39
Rate for Payer: United Healthcare Medicare	$1.51
Rate for Payer: Veterans Affairs TRICARE	$1.49

calcitonin 200 intl units/inh Nasal Spry [CQCH]

Facility

$9.43

Service Code	NDC 60505082306
Hospital Charge Code	105913923
Hospital Revenue Code	251
Min. Negotiated Rate	$8.49
Max. Negotiated Rate	$8.49
Rate for Payer: Aetna of AZ Commercial	$8.49
Rate for Payer: Cash Price	$7.54

calcitonin 200 intl units/mL Inj Sol [CQCH]

Facility

$480.12

Service Code	HCPCS J0630
Hospital Charge Code	105913850
Hospital Revenue Code	250
Min. Negotiated Rate	$432.11
Max. Negotiated Rate	$432.11
Rate for Payer: Aetna of AZ Commercial	$432.11
Rate for Payer: Cash Price	$384.09

calcitonin 200 intl units/mL Inj Sol [CQCH]

Facility

$480.12

Service Code	HCPCS J0630
Hospital Charge Code	105913850
Hospital Revenue Code	250
Min. Negotiated Rate	$76.05
Max. Negotiated Rate	$432.11
Rate for Payer: Aetna of AZ Commercial	$432.11
Rate for Payer: Arizona Complete Health Allwell	$76.82
Rate for Payer: Banner UC Health Medicare	$76.82
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$326.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$76.82
Rate for Payer: Care1st Health Plan Arizona Medicare	$76.82
Rate for Payer: Cash Price	$384.09
Rate for Payer: Cigna of AZ Commercial	$312.08
Rate for Payer: Devoted Health Medicare	$86.42
Rate for Payer: Humana of AZ Medicare	$76.82
Rate for Payer: Southwest Service Administrators UFCW	$326.48
Rate for Payer: TriWest Medicare	$76.82
Rate for Payer: United Healthcare Commercial	$274.63
Rate for Payer: United Healthcare Medicare	$76.82
Rate for Payer: Veterans Affairs TRICARE	$76.05

calcitriol 0.25 mcg Oral Cap [CQCH]

Facility

$0.56

Service Code	NDC 60687034501
Hospital Charge Code	105913988
Hospital Revenue Code	251
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of AZ Commercial	$0.50
Rate for Payer: Arizona Complete Health Allwell	$0.09
Rate for Payer: Banner UC Health Medicare	$0.09
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.38
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.09
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.09
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cigna of AZ Commercial	$0.36
Rate for Payer: Devoted Health Medicare	$0.10
Rate for Payer: Humana of AZ Medicare	$0.09
Rate for Payer: Southwest Service Administrators UFCW	$0.38
Rate for Payer: TriWest Medicare	$0.09
Rate for Payer: United Healthcare Commercial	$0.32
Rate for Payer: United Healthcare Medicare	$0.09
Rate for Payer: Veterans Affairs TRICARE	$0.09

calcitriol 0.25 mcg Oral Cap [CQCH]

Facility

$0.56

Service Code	NDC 60687034501
Hospital Charge Code	105913988
Hospital Revenue Code	251
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of AZ Commercial	$0.50
Rate for Payer: Cash Price	$0.45

Calcitriol(1,25 di-OH Vit D) LC

Facility

$540.00

Service Code	CPT 82652
Hospital Charge Code	1905607
Hospital Revenue Code	301
Min. Negotiated Rate	$486.00
Max. Negotiated Rate	$486.00
Rate for Payer: Aetna of AZ Commercial	$486.00
Rate for Payer: Cash Price	$432.00

Calcitriol(1,25 di-OH Vit D) LC

Facility

$540.00

Service Code	CPT 82652
Hospital Charge Code	1905607
Hospital Revenue Code	301
Min. Negotiated Rate	$55.83
Max. Negotiated Rate	$486.00
Rate for Payer: Aetna of AZ Commercial	$486.00
Rate for Payer: Arizona Complete Health Allwell	$86.40
Rate for Payer: Banner UC Health Medicare	$86.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$367.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$86.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$86.40
Rate for Payer: Cash Price	$432.00
Rate for Payer: Cash Price	$432.00
Rate for Payer: Cigna of AZ Commercial	$351.00
Rate for Payer: Devoted Health Medicare	$97.20
Rate for Payer: Humana of AZ Medicare	$86.40
Rate for Payer: Seven Corners Travel Insurance	$55.83
Rate for Payer: Southwest Service Administrators UFCW	$367.20
Rate for Payer: TriWest Medicare	$86.40
Rate for Payer: United Healthcare Commercial	$308.88
Rate for Payer: United Healthcare Medicare	$86.40
Rate for Payer: Veterans Affairs TRICARE	$85.54

Calcium, 24Hr Urine LC

Facility

$74.00

Service Code	CPT 82340
Hospital Charge Code	1285720
Hospital Revenue Code	301
Min. Negotiated Rate	$8.74
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Arizona Complete Health Allwell	$11.84
Rate for Payer: Banner UC Health Medicare	$11.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$50.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.84
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cigna of AZ Commercial	$48.10
Rate for Payer: Devoted Health Medicare	$13.32
Rate for Payer: Humana of AZ Medicare	$11.84
Rate for Payer: Seven Corners Travel Insurance	$8.74
Rate for Payer: Southwest Service Administrators UFCW	$50.32
Rate for Payer: TriWest Medicare	$11.84
Rate for Payer: United Healthcare Commercial	$42.33
Rate for Payer: United Healthcare Medicare	$11.84
Rate for Payer: Veterans Affairs TRICARE	$11.72

Calcium, 24Hr Urine LC

Facility

$74.00

Service Code	CPT 82340
Hospital Charge Code	1285720
Hospital Revenue Code	301
Min. Negotiated Rate	$66.60
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Cash Price	$59.20

calcium acetate 667 mg Cap UD [CQCH]

Facility

$1.04

Service Code	NDC 68084047901
Hospital Charge Code	107994427
Hospital Revenue Code	250
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$0.94
Rate for Payer: Aetna of AZ Commercial	$0.94
Rate for Payer: Cash Price	$0.83

calcium acetate 667 mg Cap UD [CQCH]

Facility

$1.04

Service Code	NDC 68084047901
Hospital Charge Code	107994427
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.94
Rate for Payer: Aetna of AZ Commercial	$0.94
Rate for Payer: Arizona Complete Health Allwell	$0.17
Rate for Payer: Banner UC Health Medicare	$0.17
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.71
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.17
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.17
Rate for Payer: Cash Price	$0.83
Rate for Payer: Cigna of AZ Commercial	$0.68
Rate for Payer: Devoted Health Medicare	$0.19
Rate for Payer: Humana of AZ Medicare	$0.17
Rate for Payer: Southwest Service Administrators UFCW	$0.71
Rate for Payer: TriWest Medicare	$0.17
Rate for Payer: United Healthcare Commercial	$0.59
Rate for Payer: United Healthcare Medicare	$0.17
Rate for Payer: Veterans Affairs TRICARE	$0.16

Know your out-of-pocket cost for care.

All Charges