Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

ertapenem 1 gm Inj [CQCH]

Facility

$74.41

Service Code	HCPCS J1335
Hospital Charge Code	105921355
Hospital Revenue Code	250
Min. Negotiated Rate	$66.97
Max. Negotiated Rate	$66.97
Rate for Payer: Aetna of AZ Commercial	$66.97
Rate for Payer: Cash Price	$59.53

erythromycin base 250 mg Tab [CQCH]

Facility

$6.98

Service Code	NDC 24338010213
Hospital Charge Code	105921514
Hospital Revenue Code	251
Min. Negotiated Rate	$6.28
Max. Negotiated Rate	$6.28
Rate for Payer: Aetna of AZ Commercial	$6.28
Rate for Payer: Cash Price	$5.58

erythromycin base 250 mg Tab [CQCH]

Facility

$6.98

Service Code	NDC 24338010213
Hospital Charge Code	105921514
Hospital Revenue Code	251
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$6.28
Rate for Payer: Aetna of AZ Commercial	$6.28
Rate for Payer: Arizona Complete Health Allwell	$1.12
Rate for Payer: Banner UC Health Medicare	$1.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$4.75
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.12
Rate for Payer: Cash Price	$5.58
Rate for Payer: Cigna of AZ Commercial	$4.54
Rate for Payer: Devoted Health Medicare	$1.26
Rate for Payer: Humana of AZ Medicare	$1.12
Rate for Payer: Southwest Service Administrators UFCW	$4.75
Rate for Payer: TriWest Medicare	$1.12
Rate for Payer: United Healthcare Commercial	$3.99
Rate for Payer: United Healthcare Medicare	$1.12
Rate for Payer: Veterans Affairs TRICARE	$1.11

erythromycin lactobionate 500 mg Inj [CQCH]

Facility

$41.00

Service Code	HCPCS J1364
Hospital Charge Code	105921428
Hospital Revenue Code	250
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of AZ Commercial	$36.90
Rate for Payer: Cash Price	$32.80

erythromycin lactobionate 500 mg Inj [CQCH]

Facility

$41.00

Service Code	HCPCS J1364
Hospital Charge Code	105921428
Hospital Revenue Code	250
Min. Negotiated Rate	$6.49
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of AZ Commercial	$36.90
Rate for Payer: Arizona Complete Health Allwell	$6.56
Rate for Payer: Banner UC Health Medicare	$6.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$27.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.56
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cigna of AZ Commercial	$26.65
Rate for Payer: Devoted Health Medicare	$7.38
Rate for Payer: Humana of AZ Medicare	$6.56
Rate for Payer: Southwest Service Administrators UFCW	$27.88
Rate for Payer: TriWest Medicare	$6.56
Rate for Payer: United Healthcare Commercial	$23.45
Rate for Payer: United Healthcare Medicare	$6.56
Rate for Payer: Veterans Affairs TRICARE	$6.49

erythromycin Ophth 0.5% Oint 1gm Ud [CQCH]

Facility

$7.82

Service Code	NDC 17478007031
Hospital Charge Code	105921579
Hospital Revenue Code	251
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$7.04
Rate for Payer: Aetna of AZ Commercial	$7.04
Rate for Payer: Arizona Complete Health Allwell	$1.25
Rate for Payer: Banner UC Health Medicare	$1.25
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.25
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.25
Rate for Payer: Cash Price	$6.26
Rate for Payer: Cigna of AZ Commercial	$5.08
Rate for Payer: Devoted Health Medicare	$1.41
Rate for Payer: Humana of AZ Medicare	$1.25
Rate for Payer: Southwest Service Administrators UFCW	$5.32
Rate for Payer: TriWest Medicare	$1.25
Rate for Payer: United Healthcare Commercial	$4.47
Rate for Payer: United Healthcare Medicare	$1.25
Rate for Payer: Veterans Affairs TRICARE	$1.24

erythromycin Ophth 0.5% Oint 1gm Ud [CQCH]

Facility

$7.82

Service Code	NDC 17478007031
Hospital Charge Code	105921579
Hospital Revenue Code	251
Min. Negotiated Rate	$7.04
Max. Negotiated Rate	$7.04
Rate for Payer: Aetna of AZ Commercial	$7.04
Rate for Payer: Cash Price	$6.26

Erythropoietin (EPO), Serum LC

Facility

$360.00

Service Code	CPT 82668
Hospital Charge Code	1906839
Hospital Revenue Code	301
Min. Negotiated Rate	$27.25
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna of AZ Commercial	$324.00
Rate for Payer: Arizona Complete Health Allwell	$57.60
Rate for Payer: Banner UC Health Medicare	$57.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$244.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$57.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$57.60
Rate for Payer: Cash Price	$288.00
Rate for Payer: Cash Price	$288.00
Rate for Payer: Cigna of AZ Commercial	$234.00
Rate for Payer: Devoted Health Medicare	$64.80
Rate for Payer: Humana of AZ Medicare	$57.60
Rate for Payer: Seven Corners Travel Insurance	$27.25
Rate for Payer: Southwest Service Administrators UFCW	$244.80
Rate for Payer: TriWest Medicare	$57.60
Rate for Payer: United Healthcare Commercial	$205.92
Rate for Payer: United Healthcare Medicare	$57.60
Rate for Payer: Veterans Affairs TRICARE	$57.02

Erythropoietin (EPO), Serum LC

Facility

$360.00

Service Code	CPT 82668
Hospital Charge Code	1906839
Hospital Revenue Code	301
Min. Negotiated Rate	$324.00
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna of AZ Commercial	$324.00
Rate for Payer: Cash Price	$288.00

ESG PLASMALOOP LARGE 12

Facility

$2,664.00

Hospital Charge Code	27748824
Hospital Revenue Code	270
Min. Negotiated Rate	$2,397.60
Max. Negotiated Rate	$2,397.60
Rate for Payer: Aetna of AZ Commercial	$2,397.60
Rate for Payer: Cash Price	$2,131.20

ESG PLASMALOOP LARGE 12

Facility

$2,664.00

Hospital Charge Code	27748824
Hospital Revenue Code	270
Min. Negotiated Rate	$421.98
Max. Negotiated Rate	$2,397.60
Rate for Payer: Aetna of AZ Commercial	$2,397.60
Rate for Payer: Arizona Complete Health Allwell	$426.24
Rate for Payer: Banner UC Health Medicare	$426.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,811.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$426.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$426.24
Rate for Payer: Cash Price	$2,131.20
Rate for Payer: Cigna of AZ Commercial	$1,864.80
Rate for Payer: Devoted Health Medicare	$479.52
Rate for Payer: Humana of AZ Medicare	$426.24
Rate for Payer: Southwest Service Administrators UFCW	$1,811.52
Rate for Payer: TriWest Medicare	$426.24
Rate for Payer: United Healthcare Commercial	$1,523.81
Rate for Payer: United Healthcare Medicare	$426.24
Rate for Payer: Veterans Affairs TRICARE	$421.98

ESMARK 4''''

Facility

$11.00

Hospital Charge Code	22926421
Hospital Revenue Code	272
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of AZ Commercial	$9.90
Rate for Payer: Arizona Complete Health Allwell	$1.76
Rate for Payer: Banner UC Health Medicare	$1.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$7.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.76
Rate for Payer: Cash Price	$8.80
Rate for Payer: Cigna of AZ Commercial	$7.70
Rate for Payer: Devoted Health Medicare	$1.98
Rate for Payer: Humana of AZ Medicare	$1.76
Rate for Payer: Southwest Service Administrators UFCW	$7.48
Rate for Payer: TriWest Medicare	$1.76
Rate for Payer: United Healthcare Commercial	$6.29
Rate for Payer: United Healthcare Medicare	$1.76
Rate for Payer: Veterans Affairs TRICARE	$1.74

ESMARK 4''''

Facility

$11.00

Hospital Charge Code	22926421
Hospital Revenue Code	272
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of AZ Commercial	$9.90
Rate for Payer: Cash Price	$8.80

ESMARK 6''''

Facility

$23.33

Hospital Charge Code	22926422
Hospital Revenue Code	272
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna of AZ Commercial	$21.00
Rate for Payer: Cash Price	$18.66

ESMARK 6''''

Facility

$23.33

Hospital Charge Code	22926422
Hospital Revenue Code	272
Min. Negotiated Rate	$3.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna of AZ Commercial	$21.00
Rate for Payer: Arizona Complete Health Allwell	$3.73
Rate for Payer: Banner UC Health Medicare	$3.73
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$15.86
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.73
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.73
Rate for Payer: Cash Price	$18.66
Rate for Payer: Cigna of AZ Commercial	$16.33
Rate for Payer: Devoted Health Medicare	$4.20
Rate for Payer: Humana of AZ Medicare	$3.73
Rate for Payer: Southwest Service Administrators UFCW	$15.86
Rate for Payer: TriWest Medicare	$3.73
Rate for Payer: United Healthcare Commercial	$13.34
Rate for Payer: United Healthcare Medicare	$3.73
Rate for Payer: Veterans Affairs TRICARE	$3.70

esmolol 10 mg/mL Sol[CQCH]

Facility

$0.19

Service Code	HCPCS J1805
Hospital Charge Code	233028583
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of AZ Commercial	$0.17
Rate for Payer: Cash Price	$0.15

esmolol 10 mg/mL Sol[CQCH]

Facility

$0.19

Service Code	HCPCS J1805
Hospital Charge Code	233028583
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of AZ Commercial	$0.17
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	$0.13
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	$0.15
Rate for Payer: Cigna of AZ Commercial	$0.12
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Southwest Service Administrators UFCW	$0.13
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: United Healthcare Commercial	$0.11
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

ESOPHAGEAL VARICIES BANDING

Facility

$6,347.00

Service Code	CPT 43244
Hospital Charge Code	23598982
Hospital Revenue Code	750
Min. Negotiated Rate	$5,712.30
Max. Negotiated Rate	$5,712.30
Rate for Payer: Aetna of AZ Commercial	$5,712.30
Rate for Payer: Cash Price	$5,077.60

ESOPHAGEAL VARICIES BANDING

Facility

$6,347.00

Service Code	CPT 43244
Hospital Charge Code	23598982
Hospital Revenue Code	750
Min. Negotiated Rate	$617.94
Max. Negotiated Rate	$5,712.30
Rate for Payer: Aetna of AZ Commercial	$5,712.30
Rate for Payer: Arizona Complete Health Allwell	$1,015.52
Rate for Payer: Banner UC Health Medicare	$617.94
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$4,315.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,015.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,015.52
Rate for Payer: Cash Price	$5,077.60
Rate for Payer: Cash Price	$5,077.60
Rate for Payer: Cash Price	$5,077.60
Rate for Payer: Cigna of AZ Commercial	$4,442.90
Rate for Payer: Devoted Health Medicare	$1,142.46
Rate for Payer: Humana of AZ Medicare	$1,015.52
Rate for Payer: NaphCare Correctional Healthcare	$617.94
Rate for Payer: Seven Corners Travel Insurance	$2,969.06
Rate for Payer: Southwest Service Administrators UFCW	$4,315.96
Rate for Payer: TriWest Medicare	$1,015.52
Rate for Payer: United Healthcare Commercial	$3,596.00
Rate for Payer: United Healthcare Medicare	$1,015.52
Rate for Payer: United Healthcare New Mexico Commercial	$1,205.93
Rate for Payer: Veterans Affairs TRICARE	$1,005.36

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC

Facility

$16,426.31

Service Code	MSDRG 391
Min. Negotiated Rate	$16,426.31
Max. Negotiated Rate	$16,426.31
Rate for Payer: Seven Corners Travel Insurance	$16,426.31

ESOPHAGITIS, GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC

Facility

$10,233.90

Service Code	MSDRG 392
Min. Negotiated Rate	$10,233.90
Max. Negotiated Rate	$10,233.90
Rate for Payer: Seven Corners Travel Insurance	$10,233.90

Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple

Facility

$3,596.00

Service Code	CPT 43239
Hospital Revenue Code	360
Min. Negotiated Rate	$236.04
Max. Negotiated Rate	$3,596.00
Rate for Payer: Banner UC Health Medicare	$343.75
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$236.04
Rate for Payer: Mercy Care Medicaid	$236.04
Rate for Payer: NaphCare Correctional Healthcare	$343.75
Rate for Payer: Seven Corners Travel Insurance	$1,403.35
Rate for Payer: United Healthcare Commercial	$3,596.00

Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method

Facility

$3,596.00

Service Code	CPT 43255
Hospital Revenue Code	750
Min. Negotiated Rate	$415.26
Max. Negotiated Rate	$3,596.00
Rate for Payer: Banner UC Health Medicare	$617.94
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$415.26
Rate for Payer: Mercy Care Medicaid	$415.26
Rate for Payer: NaphCare Correctional Healthcare	$617.94
Rate for Payer: Seven Corners Travel Insurance	$2,969.06
Rate for Payer: United Healthcare Commercial	$3,596.00

Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance

Facility

$3,596.00

Service Code	CPT 43236
Hospital Revenue Code	750
Min. Negotiated Rate	$259.75
Max. Negotiated Rate	$3,596.00
Rate for Payer: Banner UC Health Medicare	$343.75
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$259.75
Rate for Payer: Mercy Care Medicaid	$259.75
Rate for Payer: NaphCare Correctional Healthcare	$343.75
Rate for Payer: Seven Corners Travel Insurance	$1,403.35
Rate for Payer: United Healthcare Commercial	$3,596.00

Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)

Facility

$3,596.00

Service Code	CPT 43249
Hospital Revenue Code	360
Min. Negotiated Rate	$617.94
Max. Negotiated Rate	$3,596.00
Rate for Payer: Banner UC Health Medicare	$617.94
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$887.01
Rate for Payer: Mercy Care Medicaid	$887.01
Rate for Payer: NaphCare Correctional Healthcare	$617.94
Rate for Payer: Seven Corners Travel Insurance	$2,969.06
Rate for Payer: United Healthcare Commercial	$3,596.00

Know your out-of-pocket cost for care.

All Charges