Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

EPIFIX 2X2

Facility

$1,725.50

Service Code	HCPCS Q4186
Hospital Charge Code	28244699
Hospital Revenue Code	636
Min. Negotiated Rate	$1,552.95
Max. Negotiated Rate	$1,552.95
Rate for Payer: Aetna of AZ Commercial	$1,552.95
Rate for Payer: Cash Price	$1,380.40

EPIFIX 4CMX4CM

Facility

$1,324.31

Service Code	HCPCS Q4186
Hospital Charge Code	28186426
Hospital Revenue Code	636
Min. Negotiated Rate	$192.55
Max. Negotiated Rate	$1,191.88
Rate for Payer: Aetna of AZ Commercial	$1,191.88
Rate for Payer: Arizona Complete Health Allwell	$211.89
Rate for Payer: Banner UC Health Medicare	$211.89
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$900.53
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$211.89
Rate for Payer: Care1st Health Plan Arizona Medicare	$211.89
Rate for Payer: Cash Price	$1,059.45
Rate for Payer: Cash Price	$1,059.45
Rate for Payer: Cigna of AZ Commercial	$927.02
Rate for Payer: Devoted Health Medicare	$238.38
Rate for Payer: Humana of AZ Medicare	$211.89
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$900.53
Rate for Payer: TriWest Medicare	$211.89
Rate for Payer: United Healthcare Commercial	$757.51
Rate for Payer: United Healthcare Medicare	$211.89
Rate for Payer: United Healthcare New Mexico Commercial	$251.62
Rate for Payer: Veterans Affairs TRICARE	$209.77

EPIFIX 4CMX4CM

Facility

$1,324.31

Service Code	HCPCS Q4186
Hospital Charge Code	28186426
Hospital Revenue Code	636
Min. Negotiated Rate	$1,191.88
Max. Negotiated Rate	$1,191.88
Rate for Payer: Aetna of AZ Commercial	$1,191.88
Rate for Payer: Cash Price	$1,059.45

EPIFIX 4 X 4.5CM

Facility

$877.55

Service Code	HCPCS Q4186
Hospital Charge Code	27592021
Hospital Revenue Code	636
Min. Negotiated Rate	$139.00
Max. Negotiated Rate	$789.79
Rate for Payer: Aetna of AZ Commercial	$789.79
Rate for Payer: Arizona Complete Health Allwell	$140.41
Rate for Payer: Banner UC Health Medicare	$140.41
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$596.73
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$140.41
Rate for Payer: Care1st Health Plan Arizona Medicare	$140.41
Rate for Payer: Cash Price	$702.04
Rate for Payer: Cash Price	$702.04
Rate for Payer: Cigna of AZ Commercial	$614.28
Rate for Payer: Devoted Health Medicare	$157.96
Rate for Payer: Humana of AZ Medicare	$140.41
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$596.73
Rate for Payer: TriWest Medicare	$140.41
Rate for Payer: United Healthcare Commercial	$501.96
Rate for Payer: United Healthcare Medicare	$140.41
Rate for Payer: United Healthcare New Mexico Commercial	$166.73
Rate for Payer: Veterans Affairs TRICARE	$139.00

EPIFIX 4 X 4.5CM

Facility

$877.55

Service Code	HCPCS Q4186
Hospital Charge Code	27592021
Hospital Revenue Code	636
Min. Negotiated Rate	$789.79
Max. Negotiated Rate	$789.79
Rate for Payer: Aetna of AZ Commercial	$789.79
Rate for Payer: Cash Price	$702.04

EPIFIX 4X6

Facility

$1,108.33

Service Code	HCPCS Q4186
Hospital Charge Code	28224715
Hospital Revenue Code	636
Min. Negotiated Rate	$175.56
Max. Negotiated Rate	$997.50
Rate for Payer: Aetna of AZ Commercial	$997.50
Rate for Payer: Arizona Complete Health Allwell	$177.33
Rate for Payer: Banner UC Health Medicare	$177.33
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$753.66
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$177.33
Rate for Payer: Care1st Health Plan Arizona Medicare	$177.33
Rate for Payer: Cash Price	$886.66
Rate for Payer: Cash Price	$886.66
Rate for Payer: Cigna of AZ Commercial	$775.83
Rate for Payer: Devoted Health Medicare	$199.50
Rate for Payer: Humana of AZ Medicare	$177.33
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$753.66
Rate for Payer: TriWest Medicare	$177.33
Rate for Payer: United Healthcare Commercial	$633.96
Rate for Payer: United Healthcare Medicare	$177.33
Rate for Payer: United Healthcare New Mexico Commercial	$210.58
Rate for Payer: Veterans Affairs TRICARE	$175.56

EPIFIX 4X6

Facility

$1,108.33

Service Code	HCPCS Q4186
Hospital Charge Code	28224715
Hospital Revenue Code	636
Min. Negotiated Rate	$997.50
Max. Negotiated Rate	$997.50
Rate for Payer: Aetna of AZ Commercial	$997.50
Rate for Payer: Cash Price	$886.66

EPIFIX 7X7

Facility

$1,373.43

Service Code	HCPCS Q4186
Hospital Charge Code	28160406
Hospital Revenue Code	636
Min. Negotiated Rate	$192.55
Max. Negotiated Rate	$1,236.09
Rate for Payer: Aetna of AZ Commercial	$1,236.09
Rate for Payer: Arizona Complete Health Allwell	$219.75
Rate for Payer: Banner UC Health Medicare	$219.75
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$933.93
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$219.75
Rate for Payer: Care1st Health Plan Arizona Medicare	$219.75
Rate for Payer: Cash Price	$1,098.74
Rate for Payer: Cash Price	$1,098.74
Rate for Payer: Cigna of AZ Commercial	$961.40
Rate for Payer: Devoted Health Medicare	$247.22
Rate for Payer: Humana of AZ Medicare	$219.75
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$933.93
Rate for Payer: TriWest Medicare	$219.75
Rate for Payer: United Healthcare Commercial	$785.60
Rate for Payer: United Healthcare Medicare	$219.75
Rate for Payer: United Healthcare New Mexico Commercial	$260.95
Rate for Payer: Veterans Affairs TRICARE	$217.55

EPIFIX 7X7

Facility

$1,373.43

Service Code	HCPCS Q4186
Hospital Charge Code	28160406
Hospital Revenue Code	636
Min. Negotiated Rate	$1,236.09
Max. Negotiated Rate	$1,236.09
Rate for Payer: Aetna of AZ Commercial	$1,236.09
Rate for Payer: Cash Price	$1,098.74

EPIFIX DISC 24MM

Facility

$1,085.00

Service Code	HCPCS Q4186
Hospital Charge Code	28215943
Hospital Revenue Code	636
Min. Negotiated Rate	$976.50
Max. Negotiated Rate	$976.50
Rate for Payer: Aetna of AZ Commercial	$976.50
Rate for Payer: Cash Price	$868.00

EPIFIX DISC 24MM

Facility

$1,085.00

Service Code	HCPCS Q4186
Hospital Charge Code	28215943
Hospital Revenue Code	636
Min. Negotiated Rate	$171.86
Max. Negotiated Rate	$976.50
Rate for Payer: Aetna of AZ Commercial	$976.50
Rate for Payer: Arizona Complete Health Allwell	$173.60
Rate for Payer: Banner UC Health Medicare	$173.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$737.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$173.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$173.60
Rate for Payer: Cash Price	$868.00
Rate for Payer: Cash Price	$868.00
Rate for Payer: Cigna of AZ Commercial	$759.50
Rate for Payer: Devoted Health Medicare	$195.30
Rate for Payer: Humana of AZ Medicare	$173.60
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$737.80
Rate for Payer: TriWest Medicare	$173.60
Rate for Payer: United Healthcare Commercial	$620.62
Rate for Payer: United Healthcare Medicare	$173.60
Rate for Payer: United Healthcare New Mexico Commercial	$206.15
Rate for Payer: Veterans Affairs TRICARE	$171.86

EPINEPHrine 0.1 mg/mL Inj PFS 10 mL [CQCH]

Facility

$0.44

Service Code	HCPCS J0170
Hospital Charge Code	105920789
Hospital Revenue Code	250
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of AZ Commercial	$0.40
Rate for Payer: Cash Price	$0.35

EPINEPHrine 0.1 mg/mL Inj PFS 10 mL [CQCH]

Facility

$0.44

Service Code	HCPCS J0170
Hospital Charge Code	105920789
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of AZ Commercial	$0.40
Rate for Payer: Arizona Complete Health Allwell	$0.07
Rate for Payer: Banner UC Health Medicare	$0.07
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.30
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.07
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.07
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cigna of AZ Commercial	$0.29
Rate for Payer: Devoted Health Medicare	$0.08
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Southwest Service Administrators UFCW	$0.30
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: United Healthcare Commercial	$0.25
Rate for Payer: United Healthcare Medicare	$0.07
Rate for Payer: Veterans Affairs TRICARE	$0.07

EPINEPHrine 1 mg/mL Inj Sol 1 mL [CQCH]

Facility

$12.87

Service Code	HCPCS J0171
Hospital Charge Code	105920860
Hospital Revenue Code	250
Min. Negotiated Rate	$11.58
Max. Negotiated Rate	$11.58
Rate for Payer: Aetna of AZ Commercial	$11.58
Rate for Payer: Cash Price	$10.30

EPINEPHrine 1 mg/mL Inj Sol 1 mL [CQCH]

Facility

$12.87

Service Code	HCPCS J0171
Hospital Charge Code	105920860
Hospital Revenue Code	250
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$11.58
Rate for Payer: Aetna of AZ Commercial	$11.58
Rate for Payer: Arizona Complete Health Allwell	$2.06
Rate for Payer: Banner UC Health Medicare	$2.06
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$8.75
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.06
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.06
Rate for Payer: Cash Price	$10.30
Rate for Payer: Cigna of AZ Commercial	$8.37
Rate for Payer: Devoted Health Medicare	$2.32
Rate for Payer: Humana of AZ Medicare	$2.06
Rate for Payer: Southwest Service Administrators UFCW	$8.75
Rate for Payer: TriWest Medicare	$2.06
Rate for Payer: United Healthcare Commercial	$7.36
Rate for Payer: United Healthcare Medicare	$2.06
Rate for Payer: Veterans Affairs TRICARE	$2.04

EPINEPHrine 1 mg/mL Inj Sol 30 mL [CQCH]

Facility

$5.27

Service Code	HCPCS J0171
Hospital Charge Code	105920929
Hospital Revenue Code	250
Min. Negotiated Rate	$4.74
Max. Negotiated Rate	$4.74
Rate for Payer: Aetna of AZ Commercial	$4.74
Rate for Payer: Cash Price	$4.22

EPINEPHrine 1 mg/mL Inj Sol 30 mL [CQCH]

Facility

$5.27

Service Code	HCPCS J0171
Hospital Charge Code	105920929
Hospital Revenue Code	250
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$4.74
Rate for Payer: Aetna of AZ Commercial	$4.74
Rate for Payer: Arizona Complete Health Allwell	$0.84
Rate for Payer: Banner UC Health Medicare	$0.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3.58
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.84
Rate for Payer: Cash Price	$4.22
Rate for Payer: Cigna of AZ Commercial	$3.43
Rate for Payer: Devoted Health Medicare	$0.95
Rate for Payer: Humana of AZ Medicare	$0.84
Rate for Payer: Southwest Service Administrators UFCW	$3.58
Rate for Payer: TriWest Medicare	$0.84
Rate for Payer: United Healthcare Commercial	$3.01
Rate for Payer: United Healthcare Medicare	$0.84
Rate for Payer: Veterans Affairs TRICARE	$0.83

EPINEPHrine-lidocaine 1:100000-1% 10 ml Sol [CQCH]

Facility

$0.16

Service Code	NDC 63323048217
Hospital Charge Code	205015963
Hospital Revenue Code	251
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
Rate for Payer: Cash Price	$0.13

EPINEPHrine-lidocaine 1:100000-1% 10 ml Sol [CQCH]

Facility

$0.16

Service Code	NDC 63323048217
Hospital Charge Code	205015963
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
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	$0.11
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	$0.13
Rate for Payer: Cigna of AZ Commercial	$0.10
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Southwest Service Administrators UFCW	$0.11
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: United Healthcare Commercial	$0.09
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

EPINEPHrine-lidocaine 1:100,000-1% Inj Sol 20 mL [CQCH]

Facility

$0.09

Service Code	NDC 409317801
Hospital Charge Code	105920998
Hospital Revenue Code	251
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of AZ Commercial	$0.08
Rate for Payer: Cash Price	$0.07

EPINEPHrine-lidocaine 1:100,000-1% Inj Sol 20 mL [CQCH]

Facility

$0.09

Service Code	NDC 409317801
Hospital Charge Code	105920998
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of AZ Commercial	$0.08
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	$0.06
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	$0.07
Rate for Payer: Cigna of AZ Commercial	$0.06
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.06
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.05
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

EPINEPHrine-lidocaine 1:100000-1% Sol 50 ml [CQCH]

Facility

$135.12

Service Code	NDC 63323048257
Hospital Charge Code	205010803
Hospital Revenue Code	250
Min. Negotiated Rate	$21.40
Max. Negotiated Rate	$121.61
Rate for Payer: Aetna of AZ Commercial	$121.61
Rate for Payer: Arizona Complete Health Allwell	$21.62
Rate for Payer: Banner UC Health Medicare	$21.62
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$91.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$21.62
Rate for Payer: Care1st Health Plan Arizona Medicare	$21.62
Rate for Payer: Cash Price	$108.10
Rate for Payer: Cigna of AZ Commercial	$87.83
Rate for Payer: Devoted Health Medicare	$24.32
Rate for Payer: Humana of AZ Medicare	$21.62
Rate for Payer: Southwest Service Administrators UFCW	$91.88
Rate for Payer: TriWest Medicare	$21.62
Rate for Payer: United Healthcare Commercial	$77.29
Rate for Payer: United Healthcare Medicare	$21.62
Rate for Payer: Veterans Affairs TRICARE	$21.40

EPINEPHrine-lidocaine 1:100000-1% Sol 50 ml [CQCH]

Facility

$135.12

Service Code	NDC 63323048257
Hospital Charge Code	205010803
Hospital Revenue Code	250
Min. Negotiated Rate	$121.61
Max. Negotiated Rate	$121.61
Rate for Payer: Aetna of AZ Commercial	$121.61
Rate for Payer: Cash Price	$108.10

EPINEPHrine-lidocaine 1:100000-2% Sol 20 mL [CQCH]

Facility

$0.05

Service Code	HCPCS J2001
Hospital Charge Code	108918758
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Cash Price	$0.04

EPINEPHrine-lidocaine 1:100000-2% Sol 20 mL [CQCH]

Facility

$0.05

Service Code	HCPCS J2001
Hospital Charge Code	108918758
Hospital Revenue Code	250
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	$0.03
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	$0.04
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	$0.03
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

Know your out-of-pocket cost for care.

All Charges