Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

DRYLINE WATER TRAP ADULT/PEDIATRIC

Facility

$156.00

Hospital Charge Code	24157851
Min. Negotiated Rate	$140.40
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of AZ Commercial	$140.40
Rate for Payer: Cash Price	$124.80

DTaP Diphtheria/Pertussis, acellular/Tetanus Vaccine DTaP Un

Facility

$100.00

Service Code	CPT 90700
Hospital Charge Code	667676
Hospital Revenue Code	521
Min. Negotiated Rate	$15.84
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of AZ Commercial	$90.00
Rate for Payer: Arizona Complete Health Allwell	$16.00
Rate for Payer: Banner UC Health Medicare	$16.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$68.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cigna of AZ Commercial	$70.00
Rate for Payer: Devoted Health Medicare	$18.00
Rate for Payer: Humana of AZ Medicare	$16.00
Rate for Payer: Southwest Service Administrators UFCW	$68.00
Rate for Payer: TriWest Medicare	$16.00
Rate for Payer: United Healthcare Commercial	$57.20
Rate for Payer: United Healthcare Medicare	$16.00
Rate for Payer: Veterans Affairs TRICARE	$15.84

DTaP Diphtheria/Pertussis, acellular/Tetanus Vaccine DTaP Un

Facility

$100.00

Service Code	CPT 90700
Hospital Charge Code	667676
Hospital Revenue Code	521
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of AZ Commercial	$90.00
Rate for Payer: Cash Price	$80.00

DULoxetine 30 mg DR capsule[CQCH]

Facility

$0.65

Service Code	NDC 904704461
Hospital Charge Code	223918420
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of AZ Commercial	$0.59
Rate for Payer: Arizona Complete Health Allwell	$0.10
Rate for Payer: Banner UC Health Medicare	$0.10
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.10
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.10
Rate for Payer: Cash Price	$0.52
Rate for Payer: Cigna of AZ Commercial	$0.42
Rate for Payer: Devoted Health Medicare	$0.12
Rate for Payer: Humana of AZ Medicare	$0.10
Rate for Payer: Southwest Service Administrators UFCW	$0.44
Rate for Payer: TriWest Medicare	$0.10
Rate for Payer: United Healthcare Commercial	$0.37
Rate for Payer: United Healthcare Medicare	$0.10
Rate for Payer: Veterans Affairs TRICARE	$0.10

DULoxetine 30 mg DR capsule[CQCH]

Facility

$0.65

Service Code	NDC 904704461
Hospital Charge Code	223918420
Hospital Revenue Code	250
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of AZ Commercial	$0.59
Rate for Payer: Cash Price	$0.52

DULoxetine 60 mg DR capsule [CQCH]

Facility

$1.20

Service Code	NDC 68084069201
Hospital Charge Code	111166027
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$1.08
Rate for Payer: Aetna of AZ Commercial	$1.08
Rate for Payer: Arizona Complete Health Allwell	$0.19
Rate for Payer: Banner UC Health Medicare	$0.19
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.82
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.19
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.19
Rate for Payer: Cash Price	$0.96
Rate for Payer: Cigna of AZ Commercial	$0.78
Rate for Payer: Devoted Health Medicare	$0.22
Rate for Payer: Humana of AZ Medicare	$0.19
Rate for Payer: Southwest Service Administrators UFCW	$0.82
Rate for Payer: TriWest Medicare	$0.19
Rate for Payer: United Healthcare Commercial	$0.69
Rate for Payer: United Healthcare Medicare	$0.19
Rate for Payer: Veterans Affairs TRICARE	$0.19

DULoxetine 60 mg DR capsule [CQCH]

Facility

$1.20

Service Code	NDC 68084069201
Hospital Charge Code	111166027
Hospital Revenue Code	250
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$1.08
Rate for Payer: Aetna of AZ Commercial	$1.08
Rate for Payer: Cash Price	$0.96

Du Test

Facility

$106.00

Service Code	CPT 86885
Hospital Charge Code	9229048
Hospital Revenue Code	302
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

Du Test

Facility

$106.00

Service Code	CPT 86885
Hospital Charge Code	9229048
Hospital Revenue Code	302
Min. Negotiated Rate	$8.29
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: Cash Price	$84.80
Rate for Payer: Cigna of AZ Commercial	$68.90
Rate for Payer: Devoted Health Medicare	$19.08
Rate for Payer: Humana of AZ Medicare	$16.96
Rate for Payer: Seven Corners Travel Insurance	$8.29
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

DYNAFLEX COMP KIT

Facility

$111.00

Hospital Charge Code	22354908
Hospital Revenue Code	270
Min. Negotiated Rate	$17.58
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of AZ Commercial	$99.90
Rate for Payer: Arizona Complete Health Allwell	$17.76
Rate for Payer: Banner UC Health Medicare	$17.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$75.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.76
Rate for Payer: Cash Price	$88.80
Rate for Payer: Cigna of AZ Commercial	$77.70
Rate for Payer: Devoted Health Medicare	$19.98
Rate for Payer: Humana of AZ Medicare	$17.76
Rate for Payer: Southwest Service Administrators UFCW	$75.48
Rate for Payer: TriWest Medicare	$17.76
Rate for Payer: United Healthcare Commercial	$63.49
Rate for Payer: United Healthcare Medicare	$17.76
Rate for Payer: Veterans Affairs TRICARE	$17.58

DYNAFLEX COMP KIT

Facility

$111.00

Hospital Charge Code	22354908
Hospital Revenue Code	270
Min. Negotiated Rate	$99.90
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of AZ Commercial	$99.90
Rate for Payer: Cash Price	$88.80

DYSEQUILIBRIUM

Facility

$9,879.10

Service Code	MSDRG 149
Min. Negotiated Rate	$9,879.10
Max. Negotiated Rate	$9,879.10
Rate for Payer: Seven Corners Travel Insurance	$9,879.10

E0112 Crutches underarm, wood, adjustable or fixed, pair, wi

Facility

$101.00

Service Code	HCPCS E0112
Hospital Charge Code	22281178
Hospital Revenue Code	521
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$90.90
Rate for Payer: Aetna of AZ Commercial	$90.90
Rate for Payer: Arizona Complete Health Allwell	$16.16
Rate for Payer: Banner UC Health Medicare	$16.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$68.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.16
Rate for Payer: Cash Price	$80.80
Rate for Payer: Cigna of AZ Commercial	$70.70
Rate for Payer: Devoted Health Medicare	$18.18
Rate for Payer: Humana of AZ Medicare	$16.16
Rate for Payer: Southwest Service Administrators UFCW	$68.68
Rate for Payer: TriWest Medicare	$16.16
Rate for Payer: United Healthcare Commercial	$57.77
Rate for Payer: United Healthcare Medicare	$16.16
Rate for Payer: Veterans Affairs TRICARE	$16.00

E0112 Crutches underarm, wood, adjustable or fixed, pair, wi

Facility

$101.00

Service Code	HCPCS E0112
Hospital Charge Code	22281178
Hospital Revenue Code	521
Min. Negotiated Rate	$90.90
Max. Negotiated Rate	$90.90
Rate for Payer: Aetna of AZ Commercial	$90.90
Rate for Payer: Cash Price	$80.80

EACH ADDITIONAL HOUR

Facility

$97.00

Service Code	CPT 96361
Hospital Charge Code	22247980
Hospital Revenue Code	260
Min. Negotiated Rate	$87.30
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna of AZ Commercial	$87.30
Rate for Payer: Cash Price	$77.60

EACH ADDITIONAL HOUR

Facility

$97.00

Service Code	CPT 96361
Hospital Charge Code	22247980
Hospital Revenue Code	260
Min. Negotiated Rate	$15.36
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna of AZ Commercial	$87.30
Rate for Payer: Arizona Complete Health Allwell	$15.52
Rate for Payer: Banner UC Health Medicare	$15.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$65.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$15.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.52
Rate for Payer: Cash Price	$77.60
Rate for Payer: Cash Price	$77.60
Rate for Payer: Cigna of AZ Commercial	$67.90
Rate for Payer: Devoted Health Medicare	$17.46
Rate for Payer: Humana of AZ Medicare	$15.52
Rate for Payer: Seven Corners Travel Insurance	$72.46
Rate for Payer: Southwest Service Administrators UFCW	$65.96
Rate for Payer: TriWest Medicare	$15.52
Rate for Payer: United Healthcare Commercial	$55.48
Rate for Payer: United Healthcare Medicare	$15.52
Rate for Payer: Veterans Affairs TRICARE	$15.36

Ear Irrigation POC

Facility

$235.00

Service Code	CPT 69210
Hospital Charge Code	10305383
Hospital Revenue Code	521
Min. Negotiated Rate	$211.50
Max. Negotiated Rate	$211.50
Rate for Payer: Aetna of AZ Commercial	$211.50
Rate for Payer: Cash Price	$188.00

Ear Irrigation POC

Facility

$235.00

Service Code	CPT 69210
Hospital Charge Code	10305383
Hospital Revenue Code	521
Min. Negotiated Rate	$16.45
Max. Negotiated Rate	$211.50
Rate for Payer: Aetna of AZ Commercial	$211.50
Rate for Payer: Arizona Complete Health Allwell	$37.60
Rate for Payer: Banner UC Health Medicare	$37.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$159.80
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$16.45
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$37.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.60
Rate for Payer: Cash Price	$188.00
Rate for Payer: Cash Price	$188.00
Rate for Payer: Cigna of AZ Commercial	$164.50
Rate for Payer: Devoted Health Medicare	$42.30
Rate for Payer: Humana of AZ Medicare	$37.60
Rate for Payer: Mercy Care Medicaid	$16.45
Rate for Payer: NaphCare Correctional Healthcare	$16.45
Rate for Payer: Seven Corners Travel Insurance	$91.28
Rate for Payer: Southwest Service Administrators UFCW	$159.80
Rate for Payer: TriWest Medicare	$37.60
Rate for Payer: United Healthcare Commercial	$134.42
Rate for Payer: United Healthcare Medicare	$37.60
Rate for Payer: Veterans Affairs TRICARE	$37.22

Ear Irrigation w/ impaction

Facility

$95.00

Service Code	CPT 69209
Hospital Charge Code	22573645
Hospital Revenue Code	521
Min. Negotiated Rate	$15.05
Max. Negotiated Rate	$91.28
Rate for Payer: Aetna of AZ Commercial	$85.50
Rate for Payer: Arizona Complete Health Allwell	$15.20
Rate for Payer: Banner UC Health Medicare	$15.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$64.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$15.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.20
Rate for Payer: Cash Price	$76.00
Rate for Payer: Cash Price	$76.00
Rate for Payer: Cigna of AZ Commercial	$66.50
Rate for Payer: Devoted Health Medicare	$17.10
Rate for Payer: Humana of AZ Medicare	$15.20
Rate for Payer: Seven Corners Travel Insurance	$91.28
Rate for Payer: Southwest Service Administrators UFCW	$64.60
Rate for Payer: TriWest Medicare	$15.20
Rate for Payer: United Healthcare Commercial	$54.34
Rate for Payer: United Healthcare Medicare	$15.20
Rate for Payer: Veterans Affairs TRICARE	$15.05

Ear Irrigation w/ impaction

Facility

$95.00

Service Code	CPT 69209
Hospital Charge Code	22573645
Hospital Revenue Code	521
Min. Negotiated Rate	$85.50
Max. Negotiated Rate	$85.50
Rate for Payer: Aetna of AZ Commercial	$85.50
Rate for Payer: Cash Price	$76.00

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC

Facility

$16,466.85

Service Code	MSDRG 147
Min. Negotiated Rate	$16,466.85
Max. Negotiated Rate	$16,466.85
Rate for Payer: Seven Corners Travel Insurance	$16,466.85

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC

Facility

$27,365.56

Service Code	MSDRG 146
Min. Negotiated Rate	$27,365.56
Max. Negotiated Rate	$27,365.56
Rate for Payer: Seven Corners Travel Insurance	$27,365.56

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC

Facility

$10,455.62

Service Code	MSDRG 148
Min. Negotiated Rate	$10,455.62
Max. Negotiated Rate	$10,455.62
Rate for Payer: Seven Corners Travel Insurance	$10,455.62

Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies

Facility

$4,909.80

Service Code	APR-DRG 1101
Hospital Charge Code	APRDRG1102
Min. Negotiated Rate	$4,909.80
Max. Negotiated Rate	$4,909.80
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$4,909.80
Rate for Payer: Mercy Care Medicaid	$4,909.80
Rate for Payer: NaphCare Correctional Healthcare	$4,909.80

Ear, Nose, Mouth, Throat And Cranial Or Facial Malignancies

Facility

$5,968.21

Service Code	APR-DRG 1102
Hospital Charge Code	APRDRG1102
Min. Negotiated Rate	$5,968.21
Max. Negotiated Rate	$5,968.21
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,968.21
Rate for Payer: Mercy Care Medicaid	$5,968.21
Rate for Payer: NaphCare Correctional Healthcare	$5,968.21

Know your out-of-pocket cost for care.

All Charges