Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

EPINEPHrine-lidocaine 1:200,000-0.5% Inj Sol 50 mL [CQCH]

Facility

$0.04

Service Code	NDC 63323048157
Hospital Charge Code	105921073
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
Rate for Payer: Cash Price	$0.03

EPINEPHrine-lidocaine 1:200,000-0.5% Inj Sol 50 mL [CQCH]

Facility

$0.04

Service Code	NDC 63323048157
Hospital Charge Code	105921073
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
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	$0.03
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	$0.02
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

EPINEPHRINE TO 1 ML

Facility

$34.00

Service Code	HCPCS J0170
Hospital Charge Code	1170039
Hospital Revenue Code	521
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$30.60
Rate for Payer: Aetna of AZ Commercial	$30.60
Rate for Payer: Cash Price	$27.20

EPINEPHRINE TO 1 ML

Facility

$34.00

Service Code	HCPCS J0170
Hospital Charge Code	1170039
Hospital Revenue Code	521
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$30.60
Rate for Payer: Aetna of AZ Commercial	$30.60
Rate for Payer: Arizona Complete Health Allwell	$5.44
Rate for Payer: Banner UC Health Medicare	$5.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$23.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.44
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cigna of AZ Commercial	$23.80
Rate for Payer: Devoted Health Medicare	$6.12
Rate for Payer: Humana of AZ Medicare	$5.44
Rate for Payer: Southwest Service Administrators UFCW	$23.12
Rate for Payer: TriWest Medicare	$5.44
Rate for Payer: United Healthcare Commercial	$19.45
Rate for Payer: United Healthcare Medicare	$5.44
Rate for Payer: Veterans Affairs TRICARE	$5.39

EPISTAXIS ANTERIOR/POSTERIOR

Facility

$159.00

Hospital Charge Code	22354927
Hospital Revenue Code	270
Min. Negotiated Rate	$143.10
Max. Negotiated Rate	$143.10
Rate for Payer: Aetna of AZ Commercial	$143.10
Rate for Payer: Cash Price	$127.20

EPISTAXIS ANTERIOR/POSTERIOR

Facility

$159.00

Hospital Charge Code	22354927
Hospital Revenue Code	270
Min. Negotiated Rate	$25.19
Max. Negotiated Rate	$143.10
Rate for Payer: Aetna of AZ Commercial	$143.10
Rate for Payer: Arizona Complete Health Allwell	$25.44
Rate for Payer: Banner UC Health Medicare	$25.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$108.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$25.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$25.44
Rate for Payer: Cash Price	$127.20
Rate for Payer: Cigna of AZ Commercial	$111.30
Rate for Payer: Devoted Health Medicare	$28.62
Rate for Payer: Humana of AZ Medicare	$25.44
Rate for Payer: Southwest Service Administrators UFCW	$108.12
Rate for Payer: TriWest Medicare	$25.44
Rate for Payer: United Healthcare Commercial	$90.95
Rate for Payer: United Healthcare Medicare	$25.44
Rate for Payer: Veterans Affairs TRICARE	$25.19

EPISTAXIS WITH MCC

Facility

$17,227.13

Service Code	MSDRG 150
Min. Negotiated Rate	$17,227.13
Max. Negotiated Rate	$17,227.13
Rate for Payer: Seven Corners Travel Insurance	$17,227.13

EPISTAXIS WITHOUT MCC

Facility

$9,656.09

Service Code	MSDRG 151
Min. Negotiated Rate	$9,656.09
Max. Negotiated Rate	$9,656.09
Rate for Payer: Seven Corners Travel Insurance	$9,656.09

EPIX GRASPERS 5MM X 35CM

Facility

$225.00

Hospital Charge Code	28004103
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

EPIX GRASPERS 5MM X 35CM

Facility

$225.00

Hospital Charge Code	28004103
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

EPIXPRESS 2X3

Facility

$14,000.00

Service Code	HCPCS Q4361
Hospital Charge Code	28156456
Hospital Revenue Code	636
Min. Negotiated Rate	$12,600.00
Max. Negotiated Rate	$12,600.00
Rate for Payer: Aetna of AZ Commercial	$12,600.00
Rate for Payer: Cash Price	$11,200.00

EPIXPRESS 2X3

Facility

$14,000.00

Service Code	HCPCS Q4361
Hospital Charge Code	28156456
Hospital Revenue Code	636
Min. Negotiated Rate	$192.55
Max. Negotiated Rate	$12,600.00
Rate for Payer: Aetna of AZ Commercial	$12,600.00
Rate for Payer: Arizona Complete Health Allwell	$2,240.00
Rate for Payer: Banner UC Health Medicare	$2,240.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$9,520.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2,240.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$2,240.00
Rate for Payer: Cash Price	$11,200.00
Rate for Payer: Cash Price	$11,200.00
Rate for Payer: Cigna of AZ Commercial	$9,800.00
Rate for Payer: Devoted Health Medicare	$2,520.00
Rate for Payer: Humana of AZ Medicare	$2,240.00
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$9,520.00
Rate for Payer: TriWest Medicare	$2,240.00
Rate for Payer: United Healthcare Commercial	$8,008.00
Rate for Payer: United Healthcare Medicare	$2,240.00
Rate for Payer: United Healthcare New Mexico Commercial	$2,660.00
Rate for Payer: Veterans Affairs TRICARE	$2,217.60

EPIXPRESS 3X5

Facility

$14,000.00

Service Code	HCPCS Q4361
Hospital Charge Code	28156457
Hospital Revenue Code	636
Min. Negotiated Rate	$12,600.00
Max. Negotiated Rate	$12,600.00
Rate for Payer: Aetna of AZ Commercial	$12,600.00
Rate for Payer: Cash Price	$11,200.00

EPIXPRESS 3X5

Facility

$14,000.00

Service Code	HCPCS Q4361
Hospital Charge Code	28156457
Hospital Revenue Code	636
Min. Negotiated Rate	$192.55
Max. Negotiated Rate	$12,600.00
Rate for Payer: Aetna of AZ Commercial	$12,600.00
Rate for Payer: Arizona Complete Health Allwell	$2,240.00
Rate for Payer: Banner UC Health Medicare	$2,240.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$9,520.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2,240.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$2,240.00
Rate for Payer: Cash Price	$11,200.00
Rate for Payer: Cash Price	$11,200.00
Rate for Payer: Cigna of AZ Commercial	$9,800.00
Rate for Payer: Devoted Health Medicare	$2,520.00
Rate for Payer: Humana of AZ Medicare	$2,240.00
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$9,520.00
Rate for Payer: TriWest Medicare	$2,240.00
Rate for Payer: United Healthcare Commercial	$8,008.00
Rate for Payer: United Healthcare Medicare	$2,240.00
Rate for Payer: United Healthcare New Mexico Commercial	$2,660.00
Rate for Payer: Veterans Affairs TRICARE	$2,217.60

EPIXPRESS 7X7

Facility

$14,000.00

Service Code	HCPCS Q4361
Hospital Charge Code	28143631
Hospital Revenue Code	636
Min. Negotiated Rate	$192.55
Max. Negotiated Rate	$12,600.00
Rate for Payer: Aetna of AZ Commercial	$12,600.00
Rate for Payer: Arizona Complete Health Allwell	$2,240.00
Rate for Payer: Banner UC Health Medicare	$2,240.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$9,520.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2,240.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$2,240.00
Rate for Payer: Cash Price	$11,200.00
Rate for Payer: Cash Price	$11,200.00
Rate for Payer: Cigna of AZ Commercial	$9,800.00
Rate for Payer: Devoted Health Medicare	$2,520.00
Rate for Payer: Humana of AZ Medicare	$2,240.00
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$9,520.00
Rate for Payer: TriWest Medicare	$2,240.00
Rate for Payer: United Healthcare Commercial	$8,008.00
Rate for Payer: United Healthcare Medicare	$2,240.00
Rate for Payer: United Healthcare New Mexico Commercial	$2,660.00
Rate for Payer: Veterans Affairs TRICARE	$2,217.60

EPIXPRESS 7X7

Facility

$14,000.00

Service Code	HCPCS Q4361
Hospital Charge Code	28143631
Hospital Revenue Code	636
Min. Negotiated Rate	$12,600.00
Max. Negotiated Rate	$12,600.00
Rate for Payer: Aetna of AZ Commercial	$12,600.00
Rate for Payer: Cash Price	$11,200.00

epoetin alfa 40,000 units/mL preservative-free Sol[CQCH]

Facility

$559.94

Service Code	HCPCS J0885
Hospital Charge Code	239902997
Hospital Revenue Code	250
Min. Negotiated Rate	$9.98
Max. Negotiated Rate	$503.95
Rate for Payer: Aetna of AZ Commercial	$503.95
Rate for Payer: Arizona Complete Health Allwell	$89.59
Rate for Payer: Banner UC Health Medicare	$89.59
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$380.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$89.59
Rate for Payer: Care1st Health Plan Arizona Medicare	$89.59
Rate for Payer: Cash Price	$447.95
Rate for Payer: Cash Price	$447.95
Rate for Payer: Cigna of AZ Commercial	$363.96
Rate for Payer: Devoted Health Medicare	$100.79
Rate for Payer: Humana of AZ Medicare	$89.59
Rate for Payer: Seven Corners Travel Insurance	$9.98
Rate for Payer: Southwest Service Administrators UFCW	$380.76
Rate for Payer: TriWest Medicare	$89.59
Rate for Payer: United Healthcare Commercial	$320.29
Rate for Payer: United Healthcare Medicare	$89.59
Rate for Payer: Veterans Affairs TRICARE	$88.69

epoetin alfa 40,000 units/mL preservative-free Sol[CQCH]

Facility

$559.94

Service Code	HCPCS J0885
Hospital Charge Code	239902997
Hospital Revenue Code	250
Min. Negotiated Rate	$503.95
Max. Negotiated Rate	$503.95
Rate for Payer: Aetna of AZ Commercial	$503.95
Rate for Payer: Cash Price	$447.95

eptifibatide 0.75 mg/mL IV Sol [CQCH]

Facility

$0.58

Service Code	HCPCS J1327
Hospital Charge Code	105921209
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$5.61
Rate for Payer: Aetna of AZ Commercial	$0.52
Rate for Payer: Arizona Complete Health Allwell	$0.09
Rate for Payer: Banner UC Health Medicare	$0.09
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.39
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.09
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.09
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of AZ Commercial	$0.38
Rate for Payer: Devoted Health Medicare	$0.10
Rate for Payer: Humana of AZ Medicare	$0.09
Rate for Payer: Seven Corners Travel Insurance	$5.61
Rate for Payer: Southwest Service Administrators UFCW	$0.39
Rate for Payer: TriWest Medicare	$0.09
Rate for Payer: United Healthcare Commercial	$0.33
Rate for Payer: United Healthcare Medicare	$0.09
Rate for Payer: Veterans Affairs TRICARE	$0.09

eptifibatide 0.75 mg/mL IV Sol [CQCH]

Facility

$0.58

Service Code	HCPCS J1327
Hospital Charge Code	105921209
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.52
Rate for Payer: Aetna of AZ Commercial	$0.52
Rate for Payer: Cash Price	$0.46

eptifibatide 2 mg/mL IV Sol [CQCH]

Facility

$1.93

Service Code	HCPCS J1327
Hospital Charge Code	105921282
Hospital Revenue Code	250
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$5.61
Rate for Payer: Aetna of AZ Commercial	$1.74
Rate for Payer: Arizona Complete Health Allwell	$0.31
Rate for Payer: Banner UC Health Medicare	$0.31
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.31
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.31
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.31
Rate for Payer: Cash Price	$1.55
Rate for Payer: Cash Price	$1.55
Rate for Payer: Cigna of AZ Commercial	$1.25
Rate for Payer: Devoted Health Medicare	$0.35
Rate for Payer: Humana of AZ Medicare	$0.31
Rate for Payer: Seven Corners Travel Insurance	$5.61
Rate for Payer: Southwest Service Administrators UFCW	$1.31
Rate for Payer: TriWest Medicare	$0.31
Rate for Payer: United Healthcare Commercial	$1.10
Rate for Payer: United Healthcare Medicare	$0.31
Rate for Payer: Veterans Affairs TRICARE	$0.31

eptifibatide 2 mg/mL IV Sol [CQCH]

Facility

$1.93

Service Code	HCPCS J1327
Hospital Charge Code	105921282
Hospital Revenue Code	250
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$1.74
Rate for Payer: Aetna of AZ Commercial	$1.74
Rate for Payer: Cash Price	$1.55

ERBE FIAPC PROBE REF#20132-218

Facility

$738.00

Hospital Charge Code	23152397
Hospital Revenue Code	272
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$664.20
Rate for Payer: Aetna of AZ Commercial	$664.20
Rate for Payer: Arizona Complete Health Allwell	$118.08
Rate for Payer: Banner UC Health Medicare	$118.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$501.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$118.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$118.08
Rate for Payer: Cash Price	$590.40
Rate for Payer: Cigna of AZ Commercial	$516.60
Rate for Payer: Devoted Health Medicare	$132.84
Rate for Payer: Humana of AZ Medicare	$118.08
Rate for Payer: Southwest Service Administrators UFCW	$501.84
Rate for Payer: TriWest Medicare	$118.08
Rate for Payer: United Healthcare Commercial	$422.14
Rate for Payer: United Healthcare Medicare	$118.08
Rate for Payer: Veterans Affairs TRICARE	$116.90

ERBE FIAPC PROBE REF#20132-218

Facility

$738.00

Hospital Charge Code	23152397
Hospital Revenue Code	272
Min. Negotiated Rate	$664.20
Max. Negotiated Rate	$664.20
Rate for Payer: Aetna of AZ Commercial	$664.20
Rate for Payer: Cash Price	$590.40

ertapenem 1 gm Inj [CQCH]

Facility

$74.41

Service Code	HCPCS J1335
Hospital Charge Code	105921355
Hospital Revenue Code	250
Min. Negotiated Rate	$11.79
Max. Negotiated Rate	$66.97
Rate for Payer: Aetna of AZ Commercial	$66.97
Rate for Payer: Arizona Complete Health Allwell	$11.91
Rate for Payer: Banner UC Health Medicare	$11.91
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$50.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.91
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.91
Rate for Payer: Cash Price	$59.53
Rate for Payer: Cigna of AZ Commercial	$48.37
Rate for Payer: Devoted Health Medicare	$13.39
Rate for Payer: Humana of AZ Medicare	$11.91
Rate for Payer: Southwest Service Administrators UFCW	$50.60
Rate for Payer: TriWest Medicare	$11.91
Rate for Payer: United Healthcare Commercial	$42.56
Rate for Payer: United Healthcare Medicare	$11.91
Rate for Payer: Veterans Affairs TRICARE	$11.79

Know your out-of-pocket cost for care.

All Charges