Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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

CLIP APPLIER LARGE ORANGE

Facility

$900.55

Hospital Charge Code	28132115
Hospital Revenue Code	270
Min. Negotiated Rate	$810.50
Max. Negotiated Rate	$810.50
Rate for Payer: Aetna of AZ Commercial	$810.50
Rate for Payer: Cash Price	$720.44

CLIP APPLIER LARGE ORANGE

Facility

$900.55

Hospital Charge Code	28132115
Hospital Revenue Code	270
Min. Negotiated Rate	$142.65
Max. Negotiated Rate	$810.50
Rate for Payer: Aetna of AZ Commercial	$810.50
Rate for Payer: Arizona Complete Health Allwell	$144.09
Rate for Payer: Banner UC Health Medicare	$144.09
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$612.37
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$144.09
Rate for Payer: Care1st Health Plan Arizona Medicare	$144.09
Rate for Payer: Cash Price	$720.44
Rate for Payer: Cigna of AZ Commercial	$630.38
Rate for Payer: Devoted Health Medicare	$162.10
Rate for Payer: Humana of AZ Medicare	$144.09
Rate for Payer: Southwest Service Administrators UFCW	$612.37
Rate for Payer: TriWest Medicare	$144.09
Rate for Payer: United Healthcare Commercial	$515.11
Rate for Payer: United Healthcare Medicare	$144.09
Rate for Payer: Veterans Affairs TRICARE	$142.65

CLIP APPLIER MULTIPLE ENDOSCOPIC

Facility

$734.00

Hospital Charge Code	22354781
Hospital Revenue Code	270
Min. Negotiated Rate	$116.27
Max. Negotiated Rate	$660.60
Rate for Payer: Aetna of AZ Commercial	$660.60
Rate for Payer: Arizona Complete Health Allwell	$117.44
Rate for Payer: Banner UC Health Medicare	$117.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$499.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$117.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$117.44
Rate for Payer: Cash Price	$587.20
Rate for Payer: Cigna of AZ Commercial	$513.80
Rate for Payer: Devoted Health Medicare	$132.12
Rate for Payer: Humana of AZ Medicare	$117.44
Rate for Payer: Southwest Service Administrators UFCW	$499.12
Rate for Payer: TriWest Medicare	$117.44
Rate for Payer: United Healthcare Commercial	$419.85
Rate for Payer: United Healthcare Medicare	$117.44
Rate for Payer: Veterans Affairs TRICARE	$116.27

CLIP APPLIER MULTIPLE ENDOSCOPIC

Facility

$734.00

Hospital Charge Code	22354781
Hospital Revenue Code	270
Min. Negotiated Rate	$660.60
Max. Negotiated Rate	$660.60
Rate for Payer: Aetna of AZ Commercial	$660.60
Rate for Payer: Cash Price	$587.20

CLIP HEMO LARGE

Facility

$23.00

Hospital Charge Code	22926416
Hospital Revenue Code	272
Min. Negotiated Rate	$20.70
Max. Negotiated Rate	$20.70
Rate for Payer: Aetna of AZ Commercial	$20.70
Rate for Payer: Cash Price	$18.40

CLIP HEMO LARGE

Facility

$23.00

Hospital Charge Code	22926416
Hospital Revenue Code	272
Min. Negotiated Rate	$3.64
Max. Negotiated Rate	$20.70
Rate for Payer: Aetna of AZ Commercial	$20.70
Rate for Payer: Arizona Complete Health Allwell	$3.68
Rate for Payer: Banner UC Health Medicare	$3.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$15.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.68
Rate for Payer: Cash Price	$18.40
Rate for Payer: Cigna of AZ Commercial	$16.10
Rate for Payer: Devoted Health Medicare	$4.14
Rate for Payer: Humana of AZ Medicare	$3.68
Rate for Payer: Southwest Service Administrators UFCW	$15.64
Rate for Payer: TriWest Medicare	$3.68
Rate for Payer: United Healthcare Commercial	$13.16
Rate for Payer: United Healthcare Medicare	$3.68
Rate for Payer: Veterans Affairs TRICARE	$3.64

CLL FISH Panel LC

Facility

$205.00

Service Code	CPT 88271
Hospital Charge Code	2029268
Hospital Revenue Code	310
Min. Negotiated Rate	$184.50
Max. Negotiated Rate	$184.50
Rate for Payer: Aetna of AZ Commercial	$184.50
Rate for Payer: Cash Price	$164.00

CLL FISH Panel LC

Facility

$205.00

Service Code	CPT 88271
Hospital Charge Code	2029268
Hospital Revenue Code	310
Min. Negotiated Rate	$31.06
Max. Negotiated Rate	$184.50
Rate for Payer: Aetna of AZ Commercial	$184.50
Rate for Payer: Arizona Complete Health Allwell	$32.80
Rate for Payer: Banner UC Health Medicare	$32.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$139.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.80
Rate for Payer: Cash Price	$164.00
Rate for Payer: Cash Price	$164.00
Rate for Payer: Cigna of AZ Commercial	$133.25
Rate for Payer: Devoted Health Medicare	$36.90
Rate for Payer: Humana of AZ Medicare	$32.80
Rate for Payer: Seven Corners Travel Insurance	$31.06
Rate for Payer: Southwest Service Administrators UFCW	$139.40
Rate for Payer: TriWest Medicare	$32.80
Rate for Payer: United Healthcare Commercial	$117.26
Rate for Payer: United Healthcare Medicare	$32.80
Rate for Payer: Veterans Affairs TRICARE	$32.47

clonazePAM 0.5 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 228300311
Hospital Charge Code	105916868
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

clonazePAM 0.5 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 228300311
Hospital Charge Code	105916868
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

clonazePAM 1 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 51079088220
Hospital Charge Code	105916803
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

clonazePAM 1 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 51079088220
Hospital Charge Code	105916803
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

cloNIDine 0.1 mg/24 hr Transderm Patch [CQCH]

Facility

$15.51

Service Code	NDC 378087199
Hospital Charge Code	105916933
Hospital Revenue Code	251
Min. Negotiated Rate	$13.96
Max. Negotiated Rate	$13.96
Rate for Payer: Aetna of AZ Commercial	$13.96
Rate for Payer: Cash Price	$12.40

cloNIDine 0.1 mg/24 hr Transderm Patch [CQCH]

Facility

$15.51

Service Code	NDC 378087199
Hospital Charge Code	105916933
Hospital Revenue Code	251
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$13.96
Rate for Payer: Aetna of AZ Commercial	$13.96
Rate for Payer: Arizona Complete Health Allwell	$2.48
Rate for Payer: Banner UC Health Medicare	$2.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$10.55
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.48
Rate for Payer: Cash Price	$12.40
Rate for Payer: Cigna of AZ Commercial	$10.08
Rate for Payer: Devoted Health Medicare	$2.79
Rate for Payer: Humana of AZ Medicare	$2.48
Rate for Payer: Southwest Service Administrators UFCW	$10.55
Rate for Payer: TriWest Medicare	$2.48
Rate for Payer: United Healthcare Commercial	$8.87
Rate for Payer: United Healthcare Medicare	$2.48
Rate for Payer: Veterans Affairs TRICARE	$2.46

cloNIDine 0.1 mg Tab [CQCH]

Facility

$0.04

Service Code	NDC 228212710
Hospital Charge Code	105916998
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
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	$0.03
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	$0.03
Rate for Payer: Cigna of AZ Commercial	$0.03
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.03
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.02
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

cloNIDine 0.1 mg Tab [CQCH]

Facility

$0.04

Service Code	NDC 228212710
Hospital Charge Code	105916998
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
Rate for Payer: Cash Price	$0.03

clopidogrel 75 mg Tab [CQCH]

Facility

$0.17

Service Code	NDC 904629461
Hospital Charge Code	105917063
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
Rate for Payer: Arizona Complete Health Allwell	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.03
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.03
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of AZ Commercial	$0.11
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Southwest Service Administrators UFCW	$0.12
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: United Healthcare Commercial	$0.10
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

clopidogrel 75 mg Tab [CQCH]

Facility

$0.17

Service Code	NDC 904629461
Hospital Charge Code	105917063
Hospital Revenue Code	251
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
Rate for Payer: Cash Price	$0.14

CLOSED TREATMENT OF LUNATE DISLOCATION, WITH MANIPULATION

Facility

$5,787.00

Service Code	CPT 25690
Hospital Charge Code	3634335
Hospital Revenue Code	450
Min. Negotiated Rate	$5,208.30
Max. Negotiated Rate	$5,208.30
Rate for Payer: Aetna of AZ Commercial	$5,208.30
Rate for Payer: Cash Price	$4,629.60

CLOSED TREATMENT OF LUNATE DISLOCATION, WITH MANIPULATION

Facility

$5,787.00

Service Code	CPT 25690
Hospital Charge Code	3634335
Hospital Revenue Code	450
Min. Negotiated Rate	$916.66
Max. Negotiated Rate	$5,208.30
Rate for Payer: Aetna of AZ Commercial	$5,208.30
Rate for Payer: Arizona Complete Health Allwell	$925.92
Rate for Payer: Banner UC Health Medicare	$925.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,935.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$925.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$925.92
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Cigna of AZ Commercial	$4,050.90
Rate for Payer: Devoted Health Medicare	$1,041.66
Rate for Payer: Humana of AZ Medicare	$925.92
Rate for Payer: Seven Corners Travel Insurance	$2,488.00
Rate for Payer: Southwest Service Administrators UFCW	$3,935.16
Rate for Payer: TriWest Medicare	$925.92
Rate for Payer: United Healthcare Commercial	$3,310.16
Rate for Payer: United Healthcare Medicare	$925.92
Rate for Payer: United Healthcare New Mexico Commercial	$1,099.53
Rate for Payer: Veterans Affairs TRICARE	$916.66

CLOSED TREATMENT OF MIDDLE PART OF BROKEN SHIN BONE WITH MAN

Facility

$2,584.00

Service Code	CPT 27752
Hospital Charge Code	28259373
Hospital Revenue Code	360
Min. Negotiated Rate	$49.51
Max. Negotiated Rate	$3,596.00
Rate for Payer: Aetna of AZ Commercial	$2,325.60
Rate for Payer: Arizona Complete Health Allwell	$413.44
Rate for Payer: Banner UC Health Medicare	$504.49
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,757.12
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$49.51
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$413.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$413.44
Rate for Payer: Cash Price	$2,067.20
Rate for Payer: Cash Price	$2,067.20
Rate for Payer: Cash Price	$2,067.20
Rate for Payer: Cigna of AZ Commercial	$1,292.00
Rate for Payer: Devoted Health Medicare	$465.12
Rate for Payer: Humana of AZ Medicare	$413.44
Rate for Payer: Mercy Care Medicaid	$49.51
Rate for Payer: NaphCare Correctional Healthcare	$504.49
Rate for Payer: Seven Corners Travel Insurance	$2,488.00
Rate for Payer: Southwest Service Administrators UFCW	$1,757.12
Rate for Payer: TriWest Medicare	$413.44
Rate for Payer: United Healthcare Commercial	$3,596.00
Rate for Payer: United Healthcare Medicare	$413.44
Rate for Payer: Veterans Affairs TRICARE	$409.31

CLOSED TREATMENT OF MIDDLE PART OF BROKEN SHIN BONE WITH MAN

Facility

$2,584.00

Service Code	CPT 27752
Hospital Charge Code	28259373
Hospital Revenue Code	360
Min. Negotiated Rate	$2,325.60
Max. Negotiated Rate	$2,325.60
Rate for Payer: Aetna of AZ Commercial	$2,325.60
Rate for Payer: Cash Price	$2,067.20

Closed treatment of nasal bone fracture with manipulation; without stabilization

Facility

$3,596.00

Service Code	CPT 21315
Hospital Revenue Code	750
Min. Negotiated Rate	$97.99
Max. Negotiated Rate	$3,596.00
Rate for Payer: Banner UC Health Medicare	$396.13
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$97.99
Rate for Payer: Mercy Care Medicaid	$97.99
Rate for Payer: NaphCare Correctional Healthcare	$396.13
Rate for Payer: Seven Corners Travel Insurance	$2,400.72
Rate for Payer: United Healthcare Commercial	$3,596.00

Closed Trtmt of Radial Head Subluxation In Child, Nursemaid Elbow, w/Manipulatio

Facility

$258.00

Service Code	CPT 24640
Hospital Charge Code	1735551
Hospital Revenue Code	521
Min. Negotiated Rate	$232.20
Max. Negotiated Rate	$232.20
Rate for Payer: Aetna of AZ Commercial	$232.20
Rate for Payer: Cash Price	$206.40

Know your out-of-pocket cost for care.

All Charges