Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

CLIENT SLING ARM LARGE

Facility

$25.00

Hospital Charge Code	22331497
Hospital Revenue Code	270
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of AZ Commercial	$22.50
Rate for Payer: Cash Price	$20.00

CLIENT SLING ARM LARGE

Facility

$25.00

Hospital Charge Code	22331497
Hospital Revenue Code	270
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of AZ Commercial	$22.50
Rate for Payer: Arizona Complete Health Allwell	$4.00
Rate for Payer: Banner UC Health Medicare	$4.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$17.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cigna of AZ Commercial	$17.50
Rate for Payer: Devoted Health Medicare	$4.50
Rate for Payer: Humana of AZ Medicare	$4.00
Rate for Payer: Southwest Service Administrators UFCW	$17.00
Rate for Payer: TriWest Medicare	$4.00
Rate for Payer: United Healthcare Commercial	$14.30
Rate for Payer: United Healthcare Medicare	$4.00
Rate for Payer: Veterans Affairs TRICARE	$3.96

CLIENT TB SKIN TEST (0.1 ML)

Facility

$36.00

Hospital Charge Code	22331518
Hospital Revenue Code	250
Min. Negotiated Rate	$32.40
Max. Negotiated Rate	$32.40
Rate for Payer: Aetna of AZ Commercial	$32.40
Rate for Payer: Cash Price	$28.80

CLIENT TB SKIN TEST (0.1 ML)

Facility

$36.00

Hospital Charge Code	22331518
Hospital Revenue Code	250
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$32.40
Rate for Payer: Aetna of AZ Commercial	$32.40
Rate for Payer: Arizona Complete Health Allwell	$5.76
Rate for Payer: Banner UC Health Medicare	$5.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$24.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.76
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna of AZ Commercial	$23.40
Rate for Payer: Devoted Health Medicare	$6.48
Rate for Payer: Humana of AZ Medicare	$5.76
Rate for Payer: Southwest Service Administrators UFCW	$24.48
Rate for Payer: TriWest Medicare	$5.76
Rate for Payer: United Healthcare Commercial	$20.59
Rate for Payer: United Healthcare Medicare	$5.76
Rate for Payer: Veterans Affairs TRICARE	$5.70

CLIENT TDAP

Facility

$72.00

Hospital Charge Code	22331519
Hospital Revenue Code	636
Min. Negotiated Rate	$11.40
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Arizona Complete Health Allwell	$11.52
Rate for Payer: Banner UC Health Medicare	$11.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$48.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.52
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna of AZ Commercial	$50.40
Rate for Payer: Devoted Health Medicare	$12.96
Rate for Payer: Humana of AZ Medicare	$11.52
Rate for Payer: Southwest Service Administrators UFCW	$48.96
Rate for Payer: TriWest Medicare	$11.52
Rate for Payer: United Healthcare Commercial	$41.18
Rate for Payer: United Healthcare Medicare	$11.52
Rate for Payer: United Healthcare New Mexico Commercial	$13.68
Rate for Payer: Veterans Affairs TRICARE	$11.40

CLIENT TDAP

Facility

$72.00

Hospital Charge Code	22331519
Hospital Revenue Code	636
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Cash Price	$57.60

CLIENT TRAUMA LEVEL 4

Facility

$494.00

Hospital Charge Code	22331530
Hospital Revenue Code	684
Min. Negotiated Rate	$78.25
Max. Negotiated Rate	$444.60
Rate for Payer: Aetna of AZ Commercial	$444.60
Rate for Payer: Arizona Complete Health Allwell	$79.04
Rate for Payer: Banner UC Health Medicare	$79.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$335.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$79.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$79.04
Rate for Payer: Cash Price	$395.20
Rate for Payer: Cigna of AZ Commercial	$345.80
Rate for Payer: Devoted Health Medicare	$88.92
Rate for Payer: Humana of AZ Medicare	$79.04
Rate for Payer: Southwest Service Administrators UFCW	$335.92
Rate for Payer: TriWest Medicare	$79.04
Rate for Payer: United Healthcare Commercial	$282.57
Rate for Payer: United Healthcare Medicare	$79.04
Rate for Payer: United Healthcare New Mexico Commercial	$93.86
Rate for Payer: Veterans Affairs TRICARE	$78.25

CLIENT TRAUMA LEVEL 4

Facility

$494.00

Hospital Charge Code	22331530
Hospital Revenue Code	684
Min. Negotiated Rate	$444.60
Max. Negotiated Rate	$444.60
Rate for Payer: Aetna of AZ Commercial	$444.60
Rate for Payer: Cash Price	$395.20

CLIENT URINALYSIS (W/ MICRO)

Facility

$76.00

Service Code	CPT 81001
Hospital Charge Code	22331539
Hospital Revenue Code	307
Min. Negotiated Rate	$68.40
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of AZ Commercial	$68.40
Rate for Payer: Cash Price	$60.80

CLIENT URINALYSIS (W/ MICRO)

Facility

$76.00

Service Code	CPT 81001
Hospital Charge Code	22331539
Hospital Revenue Code	307
Min. Negotiated Rate	$4.60
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of AZ Commercial	$68.40
Rate for Payer: Arizona Complete Health Allwell	$12.16
Rate for Payer: Banner UC Health Medicare	$12.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$51.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.16
Rate for Payer: Cash Price	$60.80
Rate for Payer: Cash Price	$60.80
Rate for Payer: Cigna of AZ Commercial	$49.40
Rate for Payer: Devoted Health Medicare	$13.68
Rate for Payer: Humana of AZ Medicare	$12.16
Rate for Payer: Seven Corners Travel Insurance	$4.60
Rate for Payer: Southwest Service Administrators UFCW	$51.68
Rate for Payer: TriWest Medicare	$12.16
Rate for Payer: United Healthcare Commercial	$43.47
Rate for Payer: United Healthcare Medicare	$12.16
Rate for Payer: Veterans Affairs TRICARE	$12.04

CLIENT URINE COLLECTION (LC/SQ)

Facility

$21.00

Hospital Charge Code	22331541
Hospital Revenue Code	302
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Cash Price	$16.80

CLIENT URINE COLLECTION (LC/SQ)

Facility

$21.00

Hospital Charge Code	22331541
Hospital Revenue Code	302
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Arizona Complete Health Allwell	$3.36
Rate for Payer: Banner UC Health Medicare	$3.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$14.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.36
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna of AZ Commercial	$13.65
Rate for Payer: Devoted Health Medicare	$3.78
Rate for Payer: Humana of AZ Medicare	$3.36
Rate for Payer: Southwest Service Administrators UFCW	$14.28
Rate for Payer: TriWest Medicare	$3.36
Rate for Payer: United Healthcare Commercial	$12.01
Rate for Payer: United Healthcare Medicare	$3.36
Rate for Payer: Veterans Affairs TRICARE	$3.33

CLIENT URINE DIP

Facility

$7.00

Hospital Charge Code	22331542
Hospital Revenue Code	301
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$6.30
Rate for Payer: Aetna of AZ Commercial	$6.30
Rate for Payer: Cash Price	$5.60

CLIENT URINE DIP

Facility

$7.00

Hospital Charge Code	22331542
Hospital Revenue Code	301
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$6.30
Rate for Payer: Aetna of AZ Commercial	$6.30
Rate for Payer: Arizona Complete Health Allwell	$1.12
Rate for Payer: Banner UC Health Medicare	$1.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$4.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.12
Rate for Payer: Cash Price	$5.60
Rate for Payer: Cigna of AZ Commercial	$4.55
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Humana of AZ Medicare	$1.12
Rate for Payer: Southwest Service Administrators UFCW	$4.76
Rate for Payer: TriWest Medicare	$1.12
Rate for Payer: United Healthcare Commercial	$4.00
Rate for Payer: United Healthcare Medicare	$1.12
Rate for Payer: Veterans Affairs TRICARE	$1.11

CLIENT US DOPPLER COLOR

Facility

$1,946.00

Service Code	CPT 93975
Hospital Charge Code	22331547
Hospital Revenue Code	921
Min. Negotiated Rate	$308.25
Max. Negotiated Rate	$1,751.40
Rate for Payer: Aetna of AZ Commercial	$1,751.40
Rate for Payer: Arizona Complete Health Allwell	$311.36
Rate for Payer: Banner UC Health Medicare	$311.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,323.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$311.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$311.36
Rate for Payer: Cash Price	$1,556.80
Rate for Payer: Cash Price	$1,556.80
Rate for Payer: Cigna of AZ Commercial	$1,362.20
Rate for Payer: Devoted Health Medicare	$350.28
Rate for Payer: Humana of AZ Medicare	$311.36
Rate for Payer: Seven Corners Travel Insurance	$369.18
Rate for Payer: Southwest Service Administrators UFCW	$1,323.28
Rate for Payer: TriWest Medicare	$311.36
Rate for Payer: United Healthcare Commercial	$1,113.11
Rate for Payer: United Healthcare Medicare	$311.36
Rate for Payer: United Healthcare New Mexico Commercial	$369.74
Rate for Payer: Veterans Affairs TRICARE	$308.25

CLIENT US DOPPLER COLOR

Facility

$1,946.00

Service Code	CPT 93975
Hospital Charge Code	22331547
Hospital Revenue Code	921
Min. Negotiated Rate	$1,751.40
Max. Negotiated Rate	$1,751.40
Rate for Payer: Aetna of AZ Commercial	$1,751.40
Rate for Payer: Cash Price	$1,556.80

CLIENT VISION SCREEN

Facility

$16.00

Hospital Charge Code	22331566
Hospital Revenue Code	301
Min. Negotiated Rate	$2.53
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Arizona Complete Health Allwell	$2.56
Rate for Payer: Banner UC Health Medicare	$2.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$10.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.56
Rate for Payer: Cash Price	$12.80
Rate for Payer: Cigna of AZ Commercial	$10.40
Rate for Payer: Devoted Health Medicare	$2.88
Rate for Payer: Humana of AZ Medicare	$2.56
Rate for Payer: Southwest Service Administrators UFCW	$10.88
Rate for Payer: TriWest Medicare	$2.56
Rate for Payer: United Healthcare Commercial	$9.15
Rate for Payer: United Healthcare Medicare	$2.56
Rate for Payer: Veterans Affairs TRICARE	$2.53

CLIENT VISION SCREEN

Facility

$16.00

Hospital Charge Code	22331566
Hospital Revenue Code	301
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Cash Price	$12.80

clindamycin 150 mg Cap [CQCH]

Facility

$0.56

Service Code	NDC 63739005910
Hospital Charge Code	105916738
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

clindamycin 150 mg Cap [CQCH]

Facility

$0.56

Service Code	NDC 63739005910
Hospital Charge Code	105916738
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

clindamycin 150 mg/mL 2 mL Inj [CQCH]

Facility

$0.79

Service Code	NDC 9030225
Hospital Charge Code	105916669
Hospital Revenue Code	251
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.71
Rate for Payer: Aetna of AZ Commercial	$0.71
Rate for Payer: Arizona Complete Health Allwell	$0.13
Rate for Payer: Banner UC Health Medicare	$0.13
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.54
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.13
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.13
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cigna of AZ Commercial	$0.51
Rate for Payer: Devoted Health Medicare	$0.14
Rate for Payer: Humana of AZ Medicare	$0.13
Rate for Payer: Southwest Service Administrators UFCW	$0.54
Rate for Payer: TriWest Medicare	$0.13
Rate for Payer: United Healthcare Commercial	$0.45
Rate for Payer: United Healthcare Medicare	$0.13
Rate for Payer: Veterans Affairs TRICARE	$0.13

clindamycin 150 mg/mL 2 mL Inj [CQCH]

Facility

$0.79

Service Code	NDC 9030225
Hospital Charge Code	105916669
Hospital Revenue Code	251
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$0.71
Rate for Payer: Aetna of AZ Commercial	$0.71
Rate for Payer: Cash Price	$0.63

clindamycin 600 mg/50 mL D5W Soln[CQCH]

Facility

$0.08

Service Code	NDC 338361224
Hospital Charge Code	121230525
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
Rate for Payer: Cash Price	$0.07

clindamycin 600 mg/50 mL D5W Soln[CQCH]

Facility

$0.08

Service Code	NDC 338361224
Hospital Charge Code	121230525
Hospital Revenue Code	250
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	$0.07
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

clindamycin 900 mg/50 mL D5W Sol[CQCH]

Facility

$0.11

Service Code	NDC 338381424
Hospital Charge Code	125349014
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of AZ Commercial	$0.10
Rate for Payer: Arizona Complete Health Allwell	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.07
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.02
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.02
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of AZ Commercial	$0.07
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.07
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.06
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

Know your out-of-pocket cost for care.

All Charges