Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Cytopathology, cervical or vaginal (any reporting system), c

Facility

$126.00

Service Code	CPT 88175
Hospital Charge Code	22660588
Hospital Revenue Code	300
Min. Negotiated Rate	$19.96
Max. Negotiated Rate	$113.40
Rate for Payer: Aetna of AZ Commercial	$113.40
Rate for Payer: Arizona Complete Health Allwell	$20.16
Rate for Payer: Banner UC Health Medicare	$20.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$85.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.16
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna of AZ Commercial	$81.90
Rate for Payer: Devoted Health Medicare	$22.68
Rate for Payer: Humana of AZ Medicare	$20.16
Rate for Payer: Seven Corners Travel Insurance	$38.58
Rate for Payer: Southwest Service Administrators UFCW	$85.68
Rate for Payer: TriWest Medicare	$20.16
Rate for Payer: United Healthcare Commercial	$72.07
Rate for Payer: United Healthcare Medicare	$20.16
Rate for Payer: Veterans Affairs TRICARE	$19.96

Cytopathology, cervical or vaginal (any reporting system), c

Facility

$126.00

Service Code	CPT 88175
Hospital Charge Code	22660588
Hospital Revenue Code	300
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$113.40
Rate for Payer: Aetna of AZ Commercial	$113.40
Rate for Payer: Cash Price	$100.80

CYTOPATH SMEAR OTH SOURCE

Facility

$203.00

Service Code	CPT 88160
Hospital Charge Code	22545730
Hospital Revenue Code	310
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$182.70
Rate for Payer: Aetna of AZ Commercial	$182.70
Rate for Payer: Cash Price	$162.40

CYTOPATH SMEAR OTH SOURCE

Facility

$203.00

Service Code	CPT 88160
Hospital Charge Code	22545730
Hospital Revenue Code	310
Min. Negotiated Rate	$32.16
Max. Negotiated Rate	$182.70
Rate for Payer: Aetna of AZ Commercial	$182.70
Rate for Payer: Arizona Complete Health Allwell	$32.48
Rate for Payer: Banner UC Health Medicare	$32.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$138.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$58.99
Rate for Payer: Cash Price	$162.40
Rate for Payer: Cash Price	$162.40
Rate for Payer: Cigna of AZ Commercial	$131.95
Rate for Payer: Devoted Health Medicare	$36.54
Rate for Payer: Humana of AZ Medicare	$32.48
Rate for Payer: Seven Corners Travel Insurance	$44.75
Rate for Payer: Southwest Service Administrators UFCW	$138.04
Rate for Payer: TriWest Medicare	$32.48
Rate for Payer: United Healthcare Commercial	$116.12
Rate for Payer: United Healthcare Medicare	$32.48
Rate for Payer: Veterans Affairs TRICARE	$32.16

CYTOPATH SMEAR OTH SOURCE 2

Facility

$179.00

Service Code	CPT 88161
Hospital Charge Code	22545736
Hospital Revenue Code	310
Min. Negotiated Rate	$28.35
Max. Negotiated Rate	$161.10
Rate for Payer: Aetna of AZ Commercial	$161.10
Rate for Payer: Arizona Complete Health Allwell	$28.64
Rate for Payer: Banner UC Health Medicare	$28.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$121.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$59.73
Rate for Payer: Cash Price	$143.20
Rate for Payer: Cash Price	$143.20
Rate for Payer: Cigna of AZ Commercial	$116.35
Rate for Payer: Devoted Health Medicare	$32.22
Rate for Payer: Humana of AZ Medicare	$28.64
Rate for Payer: Seven Corners Travel Insurance	$44.75
Rate for Payer: Southwest Service Administrators UFCW	$121.72
Rate for Payer: TriWest Medicare	$28.64
Rate for Payer: United Healthcare Commercial	$102.39
Rate for Payer: United Healthcare Medicare	$28.64
Rate for Payer: Veterans Affairs TRICARE	$28.35

CYTOPATH SMEAR OTH SOURCE 2

Facility

$179.00

Service Code	CPT 88161
Hospital Charge Code	22545736
Hospital Revenue Code	310
Min. Negotiated Rate	$161.10
Max. Negotiated Rate	$161.10
Rate for Payer: Aetna of AZ Commercial	$161.10
Rate for Payer: Cash Price	$143.20

CYTOPATH SMEAR OTH SOURCE 3

Facility

$297.00

Service Code	CPT 88162
Hospital Charge Code	22545737
Hospital Revenue Code	310
Min. Negotiated Rate	$47.04
Max. Negotiated Rate	$267.30
Rate for Payer: Aetna of AZ Commercial	$267.30
Rate for Payer: Arizona Complete Health Allwell	$47.52
Rate for Payer: Banner UC Health Medicare	$47.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$201.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$47.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$92.20
Rate for Payer: Cash Price	$237.60
Rate for Payer: Cash Price	$237.60
Rate for Payer: Cigna of AZ Commercial	$193.05
Rate for Payer: Devoted Health Medicare	$53.46
Rate for Payer: Humana of AZ Medicare	$47.52
Rate for Payer: Seven Corners Travel Insurance	$80.63
Rate for Payer: Southwest Service Administrators UFCW	$201.96
Rate for Payer: TriWest Medicare	$47.52
Rate for Payer: United Healthcare Commercial	$169.88
Rate for Payer: United Healthcare Medicare	$47.52
Rate for Payer: Veterans Affairs TRICARE	$47.04

CYTOPATH SMEAR OTH SOURCE 3

Facility

$297.00

Service Code	CPT 88162
Hospital Charge Code	22545737
Hospital Revenue Code	310
Min. Negotiated Rate	$267.30
Max. Negotiated Rate	$267.30
Rate for Payer: Aetna of AZ Commercial	$267.30
Rate for Payer: Cash Price	$237.60

CYTP DX EVAL FNA 1ST EA SITE

Facility

$93.00

Service Code	CPT 88172
Hospital Charge Code	22545708
Hospital Revenue Code	310
Min. Negotiated Rate	$83.70
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Cash Price	$74.40

CYTP DX EVAL FNA 1ST EA SITE

Facility

$93.00

Service Code	CPT 88172
Hospital Charge Code	22545708
Hospital Revenue Code	310
Min. Negotiated Rate	$14.73
Max. Negotiated Rate	$263.61
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Arizona Complete Health Allwell	$14.88
Rate for Payer: Banner UC Health Medicare	$14.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$63.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$39.41
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cigna of AZ Commercial	$60.45
Rate for Payer: Devoted Health Medicare	$16.74
Rate for Payer: Humana of AZ Medicare	$14.88
Rate for Payer: Seven Corners Travel Insurance	$263.61
Rate for Payer: Southwest Service Administrators UFCW	$63.24
Rate for Payer: TriWest Medicare	$14.88
Rate for Payer: United Healthcare Commercial	$53.20
Rate for Payer: United Healthcare Medicare	$14.88
Rate for Payer: Veterans Affairs TRICARE	$14.73

CYTP FNA EVAL EA ADDL

Facility

$42.00

Service Code	CPT 88177
Hospital Charge Code	22545738
Hospital Revenue Code	310
Min. Negotiated Rate	$6.65
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Arizona Complete Health Allwell	$6.72
Rate for Payer: Banner UC Health Medicare	$6.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$28.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$21.07
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cigna of AZ Commercial	$27.30
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Humana of AZ Medicare	$6.72
Rate for Payer: Southwest Service Administrators UFCW	$28.56
Rate for Payer: TriWest Medicare	$6.72
Rate for Payer: United Healthcare Commercial	$24.02
Rate for Payer: United Healthcare Medicare	$6.72
Rate for Payer: Veterans Affairs TRICARE	$6.65

CYTP FNA EVAL EA ADDL

Facility

$42.00

Service Code	CPT 88177
Hospital Charge Code	22545738
Hospital Revenue Code	310
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Cash Price	$33.60

D16 LOW PROFILE 3MM X 30MM BONE SCREW

Facility

$1,915.00

Hospital Charge Code	27663809
Hospital Revenue Code	270
Min. Negotiated Rate	$1,723.50
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Cash Price	$1,532.00

D16 LOW PROFILE 3MM X 30MM BONE SCREW

Facility

$1,915.00

Hospital Charge Code	27663809
Hospital Revenue Code	270
Min. Negotiated Rate	$303.34
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Arizona Complete Health Allwell	$306.40
Rate for Payer: Banner UC Health Medicare	$306.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,302.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$306.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$306.40
Rate for Payer: Cash Price	$1,532.00
Rate for Payer: Cigna of AZ Commercial	$1,340.50
Rate for Payer: Devoted Health Medicare	$344.70
Rate for Payer: Humana of AZ Medicare	$306.40
Rate for Payer: Southwest Service Administrators UFCW	$1,302.20
Rate for Payer: TriWest Medicare	$306.40
Rate for Payer: United Healthcare Commercial	$1,095.38
Rate for Payer: United Healthcare Medicare	$306.40
Rate for Payer: Veterans Affairs TRICARE	$303.34

dantrolene 20 mg IV Inj [CQCH]

Facility

$64.25

Service Code	NDC 42023012306
Hospital Charge Code	105917797
Hospital Revenue Code	250
Min. Negotiated Rate	$10.18
Max. Negotiated Rate	$57.83
Rate for Payer: Aetna of AZ Commercial	$57.83
Rate for Payer: Arizona Complete Health Allwell	$10.28
Rate for Payer: Banner UC Health Medicare	$10.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$43.69
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.28
Rate for Payer: Cash Price	$51.40
Rate for Payer: Cigna of AZ Commercial	$41.76
Rate for Payer: Devoted Health Medicare	$11.56
Rate for Payer: Humana of AZ Medicare	$10.28
Rate for Payer: Southwest Service Administrators UFCW	$43.69
Rate for Payer: TriWest Medicare	$10.28
Rate for Payer: United Healthcare Commercial	$36.75
Rate for Payer: United Healthcare Medicare	$10.28
Rate for Payer: Veterans Affairs TRICARE	$10.18

dantrolene 20 mg IV Inj [CQCH]

Facility

$64.25

Service Code	NDC 42023012306
Hospital Charge Code	105917797
Hospital Revenue Code	250
Min. Negotiated Rate	$57.83
Max. Negotiated Rate	$57.83
Rate for Payer: Aetna of AZ Commercial	$57.83
Rate for Payer: Cash Price	$51.40

dantrolene 250 mg vial [CQCH]

Facility

$2,791.83

Service Code	NDC 42367054032
Hospital Charge Code	118269942
Hospital Revenue Code	250
Min. Negotiated Rate	$2,512.65
Max. Negotiated Rate	$2,512.65
Rate for Payer: Aetna of AZ Commercial	$2,512.65
Rate for Payer: Cash Price	$2,233.46

dantrolene 250 mg vial [CQCH]

Facility

$2,791.83

Service Code	NDC 42367054032
Hospital Charge Code	118269942
Hospital Revenue Code	250
Min. Negotiated Rate	$442.23
Max. Negotiated Rate	$2,512.65
Rate for Payer: Aetna of AZ Commercial	$2,512.65
Rate for Payer: Arizona Complete Health Allwell	$446.69
Rate for Payer: Banner UC Health Medicare	$446.69
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,898.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$446.69
Rate for Payer: Care1st Health Plan Arizona Medicare	$446.69
Rate for Payer: Cash Price	$2,233.46
Rate for Payer: Cigna of AZ Commercial	$1,814.69
Rate for Payer: Devoted Health Medicare	$502.53
Rate for Payer: Humana of AZ Medicare	$446.69
Rate for Payer: Southwest Service Administrators UFCW	$1,898.44
Rate for Payer: TriWest Medicare	$446.69
Rate for Payer: United Healthcare Commercial	$1,596.93
Rate for Payer: United Healthcare Medicare	$446.69
Rate for Payer: Veterans Affairs TRICARE	$442.23

dapsone 100 mg Tab[CQCH]

Facility

$0.69

Service Code	NDC 70954013620
Hospital Charge Code	146921850
Hospital Revenue Code	250
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of AZ Commercial	$0.62
Rate for Payer: Cash Price	$0.55

dapsone 100 mg Tab[CQCH]

Facility

$0.69

Service Code	NDC 70954013620
Hospital Charge Code	146921850
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of AZ Commercial	$0.62
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	$0.47
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	$0.45
Rate for Payer: Devoted Health Medicare	$0.12
Rate for Payer: Humana of AZ Medicare	$0.11
Rate for Payer: Southwest Service Administrators UFCW	$0.47
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

DART FIRE EDGE CANNULATED SCREW CHORT .3MMX18MM

Facility

$2,777.05

Hospital Charge Code	29620505
Hospital Revenue Code	270
Min. Negotiated Rate	$439.88
Max. Negotiated Rate	$2,499.34
Rate for Payer: Aetna of AZ Commercial	$2,499.34
Rate for Payer: Arizona Complete Health Allwell	$444.33
Rate for Payer: Banner UC Health Medicare	$444.33
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,888.39
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$444.33
Rate for Payer: Care1st Health Plan Arizona Medicare	$444.33
Rate for Payer: Cash Price	$2,221.64
Rate for Payer: Cigna of AZ Commercial	$1,943.93
Rate for Payer: Devoted Health Medicare	$499.87
Rate for Payer: Humana of AZ Medicare	$444.33
Rate for Payer: Southwest Service Administrators UFCW	$1,888.39
Rate for Payer: TriWest Medicare	$444.33
Rate for Payer: United Healthcare Commercial	$1,588.47
Rate for Payer: United Healthcare Medicare	$444.33
Rate for Payer: Veterans Affairs TRICARE	$439.88

DART FIRE EDGE CANNULATED SCREW CHORT .3MMX18MM

Facility

$2,777.05

Hospital Charge Code	29620505
Hospital Revenue Code	270
Min. Negotiated Rate	$2,499.34
Max. Negotiated Rate	$2,499.34
Rate for Payer: Aetna of AZ Commercial	$2,499.34
Rate for Payer: Cash Price	$2,221.64

DARTFIRE EDGE COMP SCREW

Facility

$2,777.05

Hospital Charge Code	28194570
Hospital Revenue Code	270
Min. Negotiated Rate	$439.88
Max. Negotiated Rate	$2,499.34
Rate for Payer: Aetna of AZ Commercial	$2,499.34
Rate for Payer: Arizona Complete Health Allwell	$444.33
Rate for Payer: Banner UC Health Medicare	$444.33
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,888.39
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$444.33
Rate for Payer: Care1st Health Plan Arizona Medicare	$444.33
Rate for Payer: Cash Price	$2,221.64
Rate for Payer: Cigna of AZ Commercial	$1,943.93
Rate for Payer: Devoted Health Medicare	$499.87
Rate for Payer: Humana of AZ Medicare	$444.33
Rate for Payer: Southwest Service Administrators UFCW	$1,888.39
Rate for Payer: TriWest Medicare	$444.33
Rate for Payer: United Healthcare Commercial	$1,588.47
Rate for Payer: United Healthcare Medicare	$444.33
Rate for Payer: Veterans Affairs TRICARE	$439.88

DARTFIRE EDGE COMP SCREW

Facility

$2,777.05

Hospital Charge Code	28194570
Hospital Revenue Code	270
Min. Negotiated Rate	$2,499.34
Max. Negotiated Rate	$2,499.34
Rate for Payer: Aetna of AZ Commercial	$2,499.34
Rate for Payer: Cash Price	$2,221.64

DARTFIRE EDGE COMP SCREW D1130014

Facility

$2,777.05

Hospital Charge Code	28265122
Hospital Revenue Code	270
Min. Negotiated Rate	$439.88
Max. Negotiated Rate	$2,499.34
Rate for Payer: Aetna of AZ Commercial	$2,499.34
Rate for Payer: Arizona Complete Health Allwell	$444.33
Rate for Payer: Banner UC Health Medicare	$444.33
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,888.39
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$444.33
Rate for Payer: Care1st Health Plan Arizona Medicare	$444.33
Rate for Payer: Cash Price	$2,221.64
Rate for Payer: Cigna of AZ Commercial	$1,943.93
Rate for Payer: Devoted Health Medicare	$499.87
Rate for Payer: Humana of AZ Medicare	$444.33
Rate for Payer: Southwest Service Administrators UFCW	$1,888.39
Rate for Payer: TriWest Medicare	$444.33
Rate for Payer: United Healthcare Commercial	$1,588.47
Rate for Payer: United Healthcare Medicare	$444.33
Rate for Payer: Veterans Affairs TRICARE	$439.88

Know your out-of-pocket cost for care.

All Charges