Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

doxycycline 100 mg Tab UD [CQCH]

Facility

$1.09

Service Code	NDC 904043006
Hospital Charge Code	108072609
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of AZ Commercial	$0.98
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	$0.74
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	$0.87
Rate for Payer: Cigna of AZ Commercial	$0.71
Rate for Payer: Devoted Health Medicare	$0.20
Rate for Payer: Humana of AZ Medicare	$0.17
Rate for Payer: Southwest Service Administrators UFCW	$0.74
Rate for Payer: TriWest Medicare	$0.17
Rate for Payer: United Healthcare Commercial	$0.62
Rate for Payer: United Healthcare Medicare	$0.17
Rate for Payer: Veterans Affairs TRICARE	$0.17

doxycycline 100 mg Tab UD [CQCH]

Facility

$1.09

Service Code	NDC 904043006
Hospital Charge Code	108072609
Hospital Revenue Code	250
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of AZ Commercial	$0.98
Rate for Payer: Cash Price	$0.87

Drainage of Ovarian Cyst abd

Facility

$2,321.00

Service Code	CPT 58805
Hospital Charge Code	27281893
Hospital Revenue Code	360
Min. Negotiated Rate	$2,088.90
Max. Negotiated Rate	$2,088.90
Rate for Payer: Aetna of AZ Commercial	$2,088.90
Rate for Payer: Cash Price	$1,856.80

Drainage of Ovarian Cyst abd

Facility

$2,321.00

Service Code	CPT 58805
Hospital Charge Code	27281893
Hospital Revenue Code	360
Min. Negotiated Rate	$367.65
Max. Negotiated Rate	$5,008.71
Rate for Payer: Aetna of AZ Commercial	$2,088.90
Rate for Payer: Arizona Complete Health Allwell	$371.36
Rate for Payer: Banner UC Health Medicare	$1,051.19
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,578.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$371.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$371.36
Rate for Payer: Cash Price	$1,856.80
Rate for Payer: Cash Price	$1,856.80
Rate for Payer: Cash Price	$1,856.80
Rate for Payer: Cigna of AZ Commercial	$1,160.50
Rate for Payer: Devoted Health Medicare	$417.78
Rate for Payer: Humana of AZ Medicare	$371.36
Rate for Payer: NaphCare Correctional Healthcare	$1,051.19
Rate for Payer: Seven Corners Travel Insurance	$5,008.71
Rate for Payer: Southwest Service Administrators UFCW	$1,578.28
Rate for Payer: TriWest Medicare	$371.36
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$371.36
Rate for Payer: Veterans Affairs TRICARE	$367.65

Drainage of Ovariona Abscess abd

Facility

$3,896.00

Service Code	CPT 58822
Hospital Charge Code	27281894
Hospital Revenue Code	360
Min. Negotiated Rate	$617.13
Max. Negotiated Rate	$4,838.00
Rate for Payer: Aetna of AZ Commercial	$3,506.40
Rate for Payer: Arizona Complete Health Allwell	$623.36
Rate for Payer: Banner UC Health Medicare	$623.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,649.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$623.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$623.36
Rate for Payer: Cash Price	$3,116.80
Rate for Payer: Cash Price	$3,116.80
Rate for Payer: Cigna of AZ Commercial	$1,948.00
Rate for Payer: Devoted Health Medicare	$701.28
Rate for Payer: Humana of AZ Medicare	$623.36
Rate for Payer: Southwest Service Administrators UFCW	$2,649.28
Rate for Payer: TriWest Medicare	$623.36
Rate for Payer: United Healthcare Commercial	$4,838.00
Rate for Payer: United Healthcare Medicare	$623.36
Rate for Payer: Veterans Affairs TRICARE	$617.13

Drainage of Ovariona Abscess abd

Facility

$3,896.00

Service Code	CPT 58822
Hospital Charge Code	27281894
Hospital Revenue Code	360
Min. Negotiated Rate	$3,506.40
Max. Negotiated Rate	$3,506.40
Rate for Payer: Aetna of AZ Commercial	$3,506.40
Rate for Payer: Cash Price	$3,116.80

Drainage of Pelvic Abscess

Facility

$700.00

Service Code	CPT 10030
Hospital Charge Code	27267827
Hospital Revenue Code	360
Min. Negotiated Rate	$110.88
Max. Negotiated Rate	$3,098.00
Rate for Payer: Aetna of AZ Commercial	$630.00
Rate for Payer: Arizona Complete Health Allwell	$112.00
Rate for Payer: Banner UC Health Medicare	$248.66
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$476.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$495.46
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$112.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$112.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Cigna of AZ Commercial	$350.00
Rate for Payer: Devoted Health Medicare	$126.00
Rate for Payer: Humana of AZ Medicare	$112.00
Rate for Payer: Mercy Care Medicaid	$495.46
Rate for Payer: NaphCare Correctional Healthcare	$248.66
Rate for Payer: Seven Corners Travel Insurance	$1,095.68
Rate for Payer: Southwest Service Administrators UFCW	$476.00
Rate for Payer: TriWest Medicare	$112.00
Rate for Payer: United Healthcare Commercial	$3,098.00
Rate for Payer: United Healthcare Medicare	$112.00
Rate for Payer: Veterans Affairs TRICARE	$110.88

Drainage of Pelvic Abscess

Facility

$700.00

Service Code	CPT 10030
Hospital Charge Code	27267827
Hospital Revenue Code	360
Min. Negotiated Rate	$630.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna of AZ Commercial	$630.00
Rate for Payer: Cash Price	$560.00

DRAIN HEMO 1/4-INCH X-LARGE

Facility

$225.00

Hospital Charge Code	22354952
Hospital Revenue Code	270
Min. Negotiated Rate	$202.50
Max. Negotiated Rate	$202.50
Rate for Payer: Aetna of AZ Commercial	$202.50
Rate for Payer: Cash Price	$180.00

DRAIN HEMO 1/4-INCH X-LARGE

Facility

$225.00

Hospital Charge Code	22354952
Hospital Revenue Code	270
Min. Negotiated Rate	$35.64
Max. Negotiated Rate	$202.50
Rate for Payer: Aetna of AZ Commercial	$202.50
Rate for Payer: Arizona Complete Health Allwell	$36.00
Rate for Payer: Banner UC Health Medicare	$36.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$153.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cigna of AZ Commercial	$157.50
Rate for Payer: Devoted Health Medicare	$40.50
Rate for Payer: Humana of AZ Medicare	$36.00
Rate for Payer: Southwest Service Administrators UFCW	$153.00
Rate for Payer: TriWest Medicare	$36.00
Rate for Payer: United Healthcare Commercial	$128.70
Rate for Payer: United Healthcare Medicare	$36.00
Rate for Payer: Veterans Affairs TRICARE	$35.64

DRAIN HEMO 1/8-INCH MEDIUM

Facility

$66.00

Hospital Charge Code	22354963
Hospital Revenue Code	270
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of AZ Commercial	$59.40
Rate for Payer: Arizona Complete Health Allwell	$10.56
Rate for Payer: Banner UC Health Medicare	$10.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$44.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.56
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cigna of AZ Commercial	$46.20
Rate for Payer: Devoted Health Medicare	$11.88
Rate for Payer: Humana of AZ Medicare	$10.56
Rate for Payer: Southwest Service Administrators UFCW	$44.88
Rate for Payer: TriWest Medicare	$10.56
Rate for Payer: United Healthcare Commercial	$37.75
Rate for Payer: United Healthcare Medicare	$10.56
Rate for Payer: Veterans Affairs TRICARE	$10.45

DRAIN HEMO 1/8-INCH MEDIUM

Facility

$66.00

Hospital Charge Code	22354963
Hospital Revenue Code	270
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of AZ Commercial	$59.40
Rate for Payer: Cash Price	$52.80

DRAIN HEMO 3/16-INCH LARGE

Facility

$225.00

Hospital Charge Code	22354950
Hospital Revenue Code	270
Min. Negotiated Rate	$202.50
Max. Negotiated Rate	$202.50
Rate for Payer: Aetna of AZ Commercial	$202.50
Rate for Payer: Cash Price	$180.00

DRAIN HEMO 3/16-INCH LARGE

Facility

$225.00

Hospital Charge Code	22354950
Hospital Revenue Code	270
Min. Negotiated Rate	$35.64
Max. Negotiated Rate	$202.50
Rate for Payer: Aetna of AZ Commercial	$202.50
Rate for Payer: Arizona Complete Health Allwell	$36.00
Rate for Payer: Banner UC Health Medicare	$36.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$153.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cigna of AZ Commercial	$157.50
Rate for Payer: Devoted Health Medicare	$40.50
Rate for Payer: Humana of AZ Medicare	$36.00
Rate for Payer: Southwest Service Administrators UFCW	$153.00
Rate for Payer: TriWest Medicare	$36.00
Rate for Payer: United Healthcare Commercial	$128.70
Rate for Payer: United Healthcare Medicare	$36.00
Rate for Payer: Veterans Affairs TRICARE	$35.64

DRAIN HEMO 3/32-INCH SMALL

Facility

$70.00

Hospital Charge Code	22354949
Hospital Revenue Code	270
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna of AZ Commercial	$63.00
Rate for Payer: Cash Price	$56.00

DRAIN HEMO 3/32-INCH SMALL

Facility

$70.00

Hospital Charge Code	22354949
Hospital Revenue Code	270
Min. Negotiated Rate	$11.09
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna of AZ Commercial	$63.00
Rate for Payer: Arizona Complete Health Allwell	$11.20
Rate for Payer: Banner UC Health Medicare	$11.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$47.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.20
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cigna of AZ Commercial	$49.00
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Humana of AZ Medicare	$11.20
Rate for Payer: Southwest Service Administrators UFCW	$47.60
Rate for Payer: TriWest Medicare	$11.20
Rate for Payer: United Healthcare Commercial	$40.04
Rate for Payer: United Healthcare Medicare	$11.20
Rate for Payer: Veterans Affairs TRICARE	$11.09

DRAIN JP FLAT SUCT 10MM

Facility

$106.00

Hospital Charge Code	22354938
Hospital Revenue Code	270
Min. Negotiated Rate	$16.79
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of AZ Commercial	$95.40
Rate for Payer: Arizona Complete Health Allwell	$16.96
Rate for Payer: Banner UC Health Medicare	$16.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$72.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.96
Rate for Payer: Cash Price	$84.80
Rate for Payer: Cigna of AZ Commercial	$74.20
Rate for Payer: Devoted Health Medicare	$19.08
Rate for Payer: Humana of AZ Medicare	$16.96
Rate for Payer: Southwest Service Administrators UFCW	$72.08
Rate for Payer: TriWest Medicare	$16.96
Rate for Payer: United Healthcare Commercial	$60.63
Rate for Payer: United Healthcare Medicare	$16.96
Rate for Payer: Veterans Affairs TRICARE	$16.79

DRAIN JP FLAT SUCT 10MM

Facility

$106.00

Hospital Charge Code	22354938
Hospital Revenue Code	270
Min. Negotiated Rate	$95.40
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of AZ Commercial	$95.40
Rate for Payer: Cash Price	$84.80

DRAIN JP FLAT SUCT 7MM

Facility

$106.00

Hospital Charge Code	22354937
Hospital Revenue Code	270
Min. Negotiated Rate	$16.79
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of AZ Commercial	$95.40
Rate for Payer: Arizona Complete Health Allwell	$16.96
Rate for Payer: Banner UC Health Medicare	$16.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$72.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.96
Rate for Payer: Cash Price	$84.80
Rate for Payer: Cigna of AZ Commercial	$74.20
Rate for Payer: Devoted Health Medicare	$19.08
Rate for Payer: Humana of AZ Medicare	$16.96
Rate for Payer: Southwest Service Administrators UFCW	$72.08
Rate for Payer: TriWest Medicare	$16.96
Rate for Payer: United Healthcare Commercial	$60.63
Rate for Payer: United Healthcare Medicare	$16.96
Rate for Payer: Veterans Affairs TRICARE	$16.79

DRAIN JP FLAT SUCT 7MM

Facility

$106.00

Hospital Charge Code	22354937
Hospital Revenue Code	270
Min. Negotiated Rate	$95.40
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of AZ Commercial	$95.40
Rate for Payer: Cash Price	$84.80

DRAIN JP SUCT RESRV

Facility

$116.00

Hospital Charge Code	22355431
Hospital Revenue Code	270
Min. Negotiated Rate	$18.37
Max. Negotiated Rate	$104.40
Rate for Payer: Aetna of AZ Commercial	$104.40
Rate for Payer: Arizona Complete Health Allwell	$18.56
Rate for Payer: Banner UC Health Medicare	$18.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$78.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$18.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$18.56
Rate for Payer: Cash Price	$92.80
Rate for Payer: Cigna of AZ Commercial	$81.20
Rate for Payer: Devoted Health Medicare	$20.88
Rate for Payer: Humana of AZ Medicare	$18.56
Rate for Payer: Southwest Service Administrators UFCW	$78.88
Rate for Payer: TriWest Medicare	$18.56
Rate for Payer: United Healthcare Commercial	$66.35
Rate for Payer: United Healthcare Medicare	$18.56
Rate for Payer: Veterans Affairs TRICARE	$18.37

DRAIN JP SUCT RESRV

Facility

$116.00

Hospital Charge Code	22355431
Hospital Revenue Code	270
Min. Negotiated Rate	$104.40
Max. Negotiated Rate	$104.40
Rate for Payer: Aetna of AZ Commercial	$104.40
Rate for Payer: Cash Price	$92.80

Drain Skin Abscess, Complex/Multiple Charge

Facility

$513.00

Service Code	CPT 10061
Hospital Charge Code	713673
Hospital Revenue Code	521
Min. Negotiated Rate	$461.70
Max. Negotiated Rate	$461.70
Rate for Payer: Aetna of AZ Commercial	$461.70
Rate for Payer: Cash Price	$410.40

Drain Skin Abscess, Complex/Multiple Charge

Facility

$513.00

Service Code	CPT 10061
Hospital Charge Code	713673
Hospital Revenue Code	521
Min. Negotiated Rate	$31.83
Max. Negotiated Rate	$629.00
Rate for Payer: Aetna of AZ Commercial	$461.70
Rate for Payer: Arizona Complete Health Allwell	$82.08
Rate for Payer: Banner UC Health Medicare	$82.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$348.84
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$31.83
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$82.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$82.08
Rate for Payer: Cash Price	$410.40
Rate for Payer: Cash Price	$410.40
Rate for Payer: Cigna of AZ Commercial	$359.10
Rate for Payer: Devoted Health Medicare	$92.34
Rate for Payer: Humana of AZ Medicare	$82.08
Rate for Payer: Mercy Care Medicaid	$31.83
Rate for Payer: NaphCare Correctional Healthcare	$31.83
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$348.84
Rate for Payer: TriWest Medicare	$82.08
Rate for Payer: United Healthcare Commercial	$293.44
Rate for Payer: United Healthcare Medicare	$82.08
Rate for Payer: Veterans Affairs TRICARE	$81.26

Drain Skin Abscess, Simple/Single Charge

Facility

$405.00

Service Code	CPT 10060
Hospital Charge Code	713671
Hospital Revenue Code	521
Min. Negotiated Rate	$21.46
Max. Negotiated Rate	$364.50
Rate for Payer: Aetna of AZ Commercial	$364.50
Rate for Payer: Arizona Complete Health Allwell	$64.80
Rate for Payer: Banner UC Health Medicare	$64.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$275.40
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$21.46
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$64.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$64.80
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cigna of AZ Commercial	$283.50
Rate for Payer: Devoted Health Medicare	$72.90
Rate for Payer: Humana of AZ Medicare	$64.80
Rate for Payer: Mercy Care Medicaid	$21.46
Rate for Payer: NaphCare Correctional Healthcare	$21.46
Rate for Payer: Seven Corners Travel Insurance	$310.43
Rate for Payer: Southwest Service Administrators UFCW	$275.40
Rate for Payer: TriWest Medicare	$64.80
Rate for Payer: United Healthcare Commercial	$231.66
Rate for Payer: United Healthcare Medicare	$64.80
Rate for Payer: Veterans Affairs TRICARE	$64.15

Know your out-of-pocket cost for care.

All Charges