Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Electromyography (patch)

Facility

$357.00

Service Code	CPT 51784
Hospital Charge Code	27267787
Hospital Revenue Code	360
Min. Negotiated Rate	$15.98
Max. Negotiated Rate	$2,671.00
Rate for Payer: Aetna of AZ Commercial	$321.30
Rate for Payer: Arizona Complete Health Allwell	$57.12
Rate for Payer: Banner UC Health Medicare	$15.98
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$242.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$57.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$57.12
Rate for Payer: Cash Price	$285.60
Rate for Payer: Cash Price	$285.60
Rate for Payer: Cash Price	$285.60
Rate for Payer: Cigna of AZ Commercial	$178.50
Rate for Payer: Devoted Health Medicare	$64.26
Rate for Payer: Humana of AZ Medicare	$57.12
Rate for Payer: NaphCare Correctional Healthcare	$15.98
Rate for Payer: Seven Corners Travel Insurance	$199.09
Rate for Payer: Southwest Service Administrators UFCW	$242.76
Rate for Payer: TriWest Medicare	$57.12
Rate for Payer: United Healthcare Commercial	$2,671.00
Rate for Payer: United Healthcare Medicare	$57.12
Rate for Payer: Veterans Affairs TRICARE	$56.55

Electromyography (patch)

Facility

$357.00

Service Code	CPT 51784
Hospital Charge Code	27267787
Hospital Revenue Code	360
Min. Negotiated Rate	$321.30
Max. Negotiated Rate	$321.30
Rate for Payer: Aetna of AZ Commercial	$321.30
Rate for Payer: Cash Price	$285.60

Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique

Facility

$2,671.00

Service Code	CPT 51784
Hospital Revenue Code	490
Min. Negotiated Rate	$15.98
Max. Negotiated Rate	$2,671.00
Rate for Payer: Banner UC Health Medicare	$15.98
Rate for Payer: NaphCare Correctional Healthcare	$15.98
Rate for Payer: Seven Corners Travel Insurance	$199.09
Rate for Payer: United Healthcare Commercial	$2,671.00

ELECTRO PEN CORD BOVIE

Facility

$21.00

Hospital Charge Code	22355516
Hospital Revenue Code	270
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	$14.70
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

ELECTRO PEN CORD BOVIE

Facility

$21.00

Hospital Charge Code	22355516
Hospital Revenue Code	270
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

EMERGE 2X2

Facility

$11,543.00

Service Code	HCPCS Q4297
Hospital Charge Code	28160407
Hospital Revenue Code	636
Min. Negotiated Rate	$10,388.70
Max. Negotiated Rate	$10,388.70
Rate for Payer: Aetna of AZ Commercial	$10,388.70
Rate for Payer: Cash Price	$9,234.40

EMERGE 2X2

Facility

$11,543.00

Service Code	HCPCS Q4297
Hospital Charge Code	28160407
Hospital Revenue Code	636
Min. Negotiated Rate	$192.55
Max. Negotiated Rate	$10,388.70
Rate for Payer: Aetna of AZ Commercial	$10,388.70
Rate for Payer: Arizona Complete Health Allwell	$1,846.88
Rate for Payer: Banner UC Health Medicare	$1,846.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$7,849.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,846.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,846.88
Rate for Payer: Cash Price	$9,234.40
Rate for Payer: Cash Price	$9,234.40
Rate for Payer: Cigna of AZ Commercial	$8,080.10
Rate for Payer: Devoted Health Medicare	$2,077.74
Rate for Payer: Humana of AZ Medicare	$1,846.88
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$7,849.24
Rate for Payer: TriWest Medicare	$1,846.88
Rate for Payer: United Healthcare Commercial	$6,602.60
Rate for Payer: United Healthcare Medicare	$1,846.88
Rate for Payer: United Healthcare New Mexico Commercial	$2,193.17
Rate for Payer: Veterans Affairs TRICARE	$1,828.41

EMERGE 2X4

Facility

$11,543.00

Service Code	HCPCS Q4297
Hospital Charge Code	28160411
Hospital Revenue Code	636
Min. Negotiated Rate	$192.55
Max. Negotiated Rate	$10,388.70
Rate for Payer: Aetna of AZ Commercial	$10,388.70
Rate for Payer: Arizona Complete Health Allwell	$1,846.88
Rate for Payer: Banner UC Health Medicare	$1,846.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$7,849.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,846.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,846.88
Rate for Payer: Cash Price	$9,234.40
Rate for Payer: Cash Price	$9,234.40
Rate for Payer: Cigna of AZ Commercial	$8,080.10
Rate for Payer: Devoted Health Medicare	$2,077.74
Rate for Payer: Humana of AZ Medicare	$1,846.88
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$7,849.24
Rate for Payer: TriWest Medicare	$1,846.88
Rate for Payer: United Healthcare Commercial	$6,602.60
Rate for Payer: United Healthcare Medicare	$1,846.88
Rate for Payer: United Healthcare New Mexico Commercial	$2,193.17
Rate for Payer: Veterans Affairs TRICARE	$1,828.41

EMERGE 2X4

Facility

$11,543.00

Service Code	HCPCS Q4297
Hospital Charge Code	28160411
Hospital Revenue Code	636
Min. Negotiated Rate	$10,388.70
Max. Negotiated Rate	$10,388.70
Rate for Payer: Aetna of AZ Commercial	$10,388.70
Rate for Payer: Cash Price	$9,234.40

EMERGE 4X4

Facility

$11,543.44

Service Code	HCPCS Q4297
Hospital Charge Code	28058743
Hospital Revenue Code	636
Min. Negotiated Rate	$192.55
Max. Negotiated Rate	$10,389.10
Rate for Payer: Aetna of AZ Commercial	$10,389.10
Rate for Payer: Arizona Complete Health Allwell	$1,846.95
Rate for Payer: Banner UC Health Medicare	$1,846.95
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$7,849.54
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,846.95
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,846.95
Rate for Payer: Cash Price	$9,234.75
Rate for Payer: Cash Price	$9,234.75
Rate for Payer: Cigna of AZ Commercial	$8,080.41
Rate for Payer: Devoted Health Medicare	$2,077.82
Rate for Payer: Humana of AZ Medicare	$1,846.95
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$7,849.54
Rate for Payer: TriWest Medicare	$1,846.95
Rate for Payer: United Healthcare Commercial	$6,602.85
Rate for Payer: United Healthcare Medicare	$1,846.95
Rate for Payer: United Healthcare New Mexico Commercial	$2,193.25
Rate for Payer: Veterans Affairs TRICARE	$1,828.48

EMERGE 4X4

Facility

$11,543.44

Service Code	HCPCS Q4297
Hospital Charge Code	28058743
Hospital Revenue Code	636
Min. Negotiated Rate	$10,389.10
Max. Negotiated Rate	$10,389.10
Rate for Payer: Aetna of AZ Commercial	$10,389.10
Rate for Payer: Cash Price	$9,234.75

EMERGE 4X6

Facility

$11,543.29

Service Code	HCPCS Q4297
Hospital Charge Code	28184317
Hospital Revenue Code	636
Min. Negotiated Rate	$192.55
Max. Negotiated Rate	$10,388.96
Rate for Payer: Aetna of AZ Commercial	$10,388.96
Rate for Payer: Arizona Complete Health Allwell	$1,846.93
Rate for Payer: Banner UC Health Medicare	$1,846.93
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$7,849.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,846.93
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,846.93
Rate for Payer: Cash Price	$9,234.63
Rate for Payer: Cash Price	$9,234.63
Rate for Payer: Cigna of AZ Commercial	$8,080.30
Rate for Payer: Devoted Health Medicare	$2,077.79
Rate for Payer: Humana of AZ Medicare	$1,846.93
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$7,849.44
Rate for Payer: TriWest Medicare	$1,846.93
Rate for Payer: United Healthcare Commercial	$6,602.76
Rate for Payer: United Healthcare Medicare	$1,846.93
Rate for Payer: United Healthcare New Mexico Commercial	$2,193.23
Rate for Payer: Veterans Affairs TRICARE	$1,828.46

EMERGE 4X6

Facility

$11,543.29

Service Code	HCPCS Q4297
Hospital Charge Code	28184317
Hospital Revenue Code	636
Min. Negotiated Rate	$10,388.96
Max. Negotiated Rate	$10,388.96
Rate for Payer: Aetna of AZ Commercial	$10,388.96
Rate for Payer: Cash Price	$9,234.63

EMERGE 4X8

Facility

$11,543.44

Service Code	HCPCS Q4297
Hospital Charge Code	28186424
Hospital Revenue Code	636
Min. Negotiated Rate	$192.55
Max. Negotiated Rate	$10,389.10
Rate for Payer: Aetna of AZ Commercial	$10,389.10
Rate for Payer: Arizona Complete Health Allwell	$1,846.95
Rate for Payer: Banner UC Health Medicare	$1,846.95
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$7,849.54
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,846.95
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,846.95
Rate for Payer: Cash Price	$9,234.75
Rate for Payer: Cash Price	$9,234.75
Rate for Payer: Cigna of AZ Commercial	$8,080.41
Rate for Payer: Devoted Health Medicare	$2,077.82
Rate for Payer: Humana of AZ Medicare	$1,846.95
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$7,849.54
Rate for Payer: TriWest Medicare	$1,846.95
Rate for Payer: United Healthcare Commercial	$6,602.85
Rate for Payer: United Healthcare Medicare	$1,846.95
Rate for Payer: United Healthcare New Mexico Commercial	$2,193.25
Rate for Payer: Veterans Affairs TRICARE	$1,828.48

EMERGE 4X8

Facility

$11,543.44

Service Code	HCPCS Q4297
Hospital Charge Code	28186424
Hospital Revenue Code	636
Min. Negotiated Rate	$10,389.10
Max. Negotiated Rate	$10,389.10
Rate for Payer: Aetna of AZ Commercial	$10,389.10
Rate for Payer: Cash Price	$9,234.75

emtricitabine-tenofovir 200 mg-300 mg Tab [CQCH]

Facility

$48.62

Service Code	NDC 61958070101
Hospital Charge Code	105920292
Hospital Revenue Code	250
Min. Negotiated Rate	$43.76
Max. Negotiated Rate	$43.76
Rate for Payer: Aetna of AZ Commercial	$43.76
Rate for Payer: Cash Price	$38.90

emtricitabine-tenofovir 200 mg-300 mg Tab [CQCH]

Facility

$48.62

Service Code	NDC 61958070101
Hospital Charge Code	105920292
Hospital Revenue Code	250
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$43.76
Rate for Payer: Aetna of AZ Commercial	$43.76
Rate for Payer: Arizona Complete Health Allwell	$7.78
Rate for Payer: Banner UC Health Medicare	$7.78
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$33.06
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.78
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.78
Rate for Payer: Cash Price	$38.90
Rate for Payer: Cigna of AZ Commercial	$31.60
Rate for Payer: Devoted Health Medicare	$8.75
Rate for Payer: Humana of AZ Medicare	$7.78
Rate for Payer: Southwest Service Administrators UFCW	$33.06
Rate for Payer: TriWest Medicare	$7.78
Rate for Payer: United Healthcare Commercial	$27.81
Rate for Payer: United Healthcare Medicare	$7.78
Rate for Payer: Veterans Affairs TRICARE	$7.70

.ENA+DNA/DS+Sjorgen's LC

Facility

$224.00

Service Code	CPT 86235
Hospital Charge Code	1285801
Hospital Revenue Code	301
Min. Negotiated Rate	$26.00
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of AZ Commercial	$201.60
Rate for Payer: Arizona Complete Health Allwell	$35.84
Rate for Payer: Banner UC Health Medicare	$35.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$152.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$35.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$35.84
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cigna of AZ Commercial	$145.60
Rate for Payer: Devoted Health Medicare	$40.32
Rate for Payer: Humana of AZ Medicare	$35.84
Rate for Payer: Seven Corners Travel Insurance	$26.00
Rate for Payer: Southwest Service Administrators UFCW	$152.32
Rate for Payer: TriWest Medicare	$35.84
Rate for Payer: United Healthcare Commercial	$128.13
Rate for Payer: United Healthcare Medicare	$35.84
Rate for Payer: Veterans Affairs TRICARE	$35.48

.ENA+DNA/DS+Sjorgen's LC

Facility

$224.00

Service Code	CPT 86235
Hospital Charge Code	1285801
Hospital Revenue Code	301
Min. Negotiated Rate	$201.60
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of AZ Commercial	$201.60
Rate for Payer: Cash Price	$179.20

enalaprilat 1.25 mg inj Sol [CQCH]

Facility

$3.68

Service Code	NDC 143978710
Hospital Charge Code	108072662
Hospital Revenue Code	251
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$3.31
Rate for Payer: Aetna of AZ Commercial	$3.31
Rate for Payer: Arizona Complete Health Allwell	$0.59
Rate for Payer: Banner UC Health Medicare	$0.59
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2.50
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.59
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.59
Rate for Payer: Cash Price	$2.94
Rate for Payer: Cigna of AZ Commercial	$2.39
Rate for Payer: Devoted Health Medicare	$0.66
Rate for Payer: Humana of AZ Medicare	$0.59
Rate for Payer: Southwest Service Administrators UFCW	$2.50
Rate for Payer: TriWest Medicare	$0.59
Rate for Payer: United Healthcare Commercial	$2.10
Rate for Payer: United Healthcare Medicare	$0.59
Rate for Payer: Veterans Affairs TRICARE	$0.58

enalaprilat 1.25 mg inj Sol [CQCH]

Facility

$3.68

Service Code	NDC 143978710
Hospital Charge Code	108072662
Hospital Revenue Code	251
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$3.31
Rate for Payer: Aetna of AZ Commercial	$3.31
Rate for Payer: Cash Price	$2.94

Endocervical Curettage (alone)

Facility

$578.00

Service Code	CPT 57505
Hospital Charge Code	27281903
Hospital Revenue Code	360
Min. Negotiated Rate	$43.93
Max. Negotiated Rate	$3,098.00
Rate for Payer: Aetna of AZ Commercial	$520.20
Rate for Payer: Arizona Complete Health Allwell	$92.48
Rate for Payer: Banner UC Health Medicare	$56.75
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$393.04
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$43.93
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$92.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$92.48
Rate for Payer: Cash Price	$462.40
Rate for Payer: Cash Price	$462.40
Rate for Payer: Cash Price	$462.40
Rate for Payer: Cigna of AZ Commercial	$289.00
Rate for Payer: Devoted Health Medicare	$104.04
Rate for Payer: Humana of AZ Medicare	$92.48
Rate for Payer: Mercy Care Medicaid	$43.93
Rate for Payer: NaphCare Correctional Healthcare	$56.75
Rate for Payer: Seven Corners Travel Insurance	$1,425.12
Rate for Payer: Southwest Service Administrators UFCW	$393.04
Rate for Payer: TriWest Medicare	$92.48
Rate for Payer: United Healthcare Commercial	$3,098.00
Rate for Payer: United Healthcare Medicare	$92.48
Rate for Payer: Veterans Affairs TRICARE	$91.56

Endocervical Curettage (alone)

Facility

$578.00

Service Code	CPT 57505
Hospital Charge Code	27281903
Hospital Revenue Code	360
Min. Negotiated Rate	$520.20
Max. Negotiated Rate	$520.20
Rate for Payer: Aetna of AZ Commercial	$520.20
Rate for Payer: Cash Price	$462.40

ENDO CLIP

Facility

$290.00

Hospital Charge Code	22354200
Hospital Revenue Code	270
Min. Negotiated Rate	$261.00
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna of AZ Commercial	$261.00
Rate for Payer: Cash Price	$232.00

ENDO CLIP

Facility

$290.00

Hospital Charge Code	22354200
Hospital Revenue Code	270
Min. Negotiated Rate	$45.94
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna of AZ Commercial	$261.00
Rate for Payer: Arizona Complete Health Allwell	$46.40
Rate for Payer: Banner UC Health Medicare	$46.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$197.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$46.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$46.40
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cigna of AZ Commercial	$203.00
Rate for Payer: Devoted Health Medicare	$52.20
Rate for Payer: Humana of AZ Medicare	$46.40
Rate for Payer: Southwest Service Administrators UFCW	$197.20
Rate for Payer: TriWest Medicare	$46.40
Rate for Payer: United Healthcare Commercial	$165.88
Rate for Payer: United Healthcare Medicare	$46.40
Rate for Payer: Veterans Affairs TRICARE	$45.94

Know your out-of-pocket cost for care.

All Charges