Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

fluorescein-proparacaine ophthalmic 0.25%-0.5% Sol[CQCH]

Facility

$7.37

Service Code	NDC 54799050721
Hospital Charge Code	134270412
Hospital Revenue Code	251
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$6.63
Rate for Payer: Aetna of AZ Commercial	$6.63
Rate for Payer: Arizona Complete Health Allwell	$1.18
Rate for Payer: Banner UC Health Medicare	$1.18
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5.01
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.18
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.18
Rate for Payer: Cash Price	$5.90
Rate for Payer: Cigna of AZ Commercial	$4.79
Rate for Payer: Devoted Health Medicare	$1.33
Rate for Payer: Humana of AZ Medicare	$1.18
Rate for Payer: Southwest Service Administrators UFCW	$5.01
Rate for Payer: TriWest Medicare	$1.18
Rate for Payer: United Healthcare Commercial	$4.22
Rate for Payer: United Healthcare Medicare	$1.18
Rate for Payer: Veterans Affairs TRICARE	$1.17

.FLUOR FOR NONINFECT AB (CELIAC COMP)

Facility

$698.00

Service Code	CPT 86255
Hospital Charge Code	22481445
Hospital Revenue Code	301
Min. Negotiated Rate	$17.47
Max. Negotiated Rate	$628.20
Rate for Payer: Aetna of AZ Commercial	$628.20
Rate for Payer: Arizona Complete Health Allwell	$111.68
Rate for Payer: Banner UC Health Medicare	$111.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$474.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$111.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$111.68
Rate for Payer: Cash Price	$558.40
Rate for Payer: Cash Price	$558.40
Rate for Payer: Cigna of AZ Commercial	$453.70
Rate for Payer: Devoted Health Medicare	$125.64
Rate for Payer: Humana of AZ Medicare	$111.68
Rate for Payer: Seven Corners Travel Insurance	$17.47
Rate for Payer: Southwest Service Administrators UFCW	$474.64
Rate for Payer: TriWest Medicare	$111.68
Rate for Payer: United Healthcare Commercial	$399.26
Rate for Payer: United Healthcare Medicare	$111.68
Rate for Payer: Veterans Affairs TRICARE	$110.56

.FLUOR FOR NONINFECT AB (CELIAC COMP)

Facility

$698.00

Service Code	CPT 86255
Hospital Charge Code	22481445
Hospital Revenue Code	301
Min. Negotiated Rate	$628.20
Max. Negotiated Rate	$628.20
Rate for Payer: Aetna of AZ Commercial	$628.20
Rate for Payer: Cash Price	$558.40

FLUOR NONINFECT AGENT AB TITER

Facility

$733.00

Service Code	CPT 86256
Hospital Charge Code	22481474
Hospital Revenue Code	302
Min. Negotiated Rate	$17.47
Max. Negotiated Rate	$659.70
Rate for Payer: Aetna of AZ Commercial	$659.70
Rate for Payer: Arizona Complete Health Allwell	$117.28
Rate for Payer: Banner UC Health Medicare	$117.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$498.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$117.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$117.28
Rate for Payer: Cash Price	$586.40
Rate for Payer: Cash Price	$586.40
Rate for Payer: Cigna of AZ Commercial	$476.45
Rate for Payer: Devoted Health Medicare	$131.94
Rate for Payer: Humana of AZ Medicare	$117.28
Rate for Payer: Seven Corners Travel Insurance	$17.47
Rate for Payer: Southwest Service Administrators UFCW	$498.44
Rate for Payer: TriWest Medicare	$117.28
Rate for Payer: United Healthcare Commercial	$419.28
Rate for Payer: United Healthcare Medicare	$117.28
Rate for Payer: Veterans Affairs TRICARE	$116.11

FLUOR NONINFECT AGENT AB TITER

Facility

$733.00

Service Code	CPT 86256
Hospital Charge Code	22481474
Hospital Revenue Code	302
Min. Negotiated Rate	$659.70
Max. Negotiated Rate	$659.70
Rate for Payer: Aetna of AZ Commercial	$659.70
Rate for Payer: Cash Price	$586.40

Fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time

Facility

$3,373.00

Service Code	CPT 76000
Hospital Revenue Code	360
Min. Negotiated Rate	$15.61
Max. Negotiated Rate	$3,373.00
Rate for Payer: Banner UC Health Medicare	$15.61
Rate for Payer: NaphCare Correctional Healthcare	$15.61
Rate for Payer: Seven Corners Travel Insurance	$369.18
Rate for Payer: United Healthcare Commercial	$3,373.00

Fluoroscopy Stage I

Facility

$535.00

Service Code	CPT 77003
Hospital Charge Code	27267838
Hospital Revenue Code	360
Min. Negotiated Rate	$84.74
Max. Negotiated Rate	$3,373.00
Rate for Payer: Aetna of AZ Commercial	$481.50
Rate for Payer: Arizona Complete Health Allwell	$85.60
Rate for Payer: Banner UC Health Medicare	$85.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$363.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$85.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$85.60
Rate for Payer: Cash Price	$428.00
Rate for Payer: Cash Price	$428.00
Rate for Payer: Cigna of AZ Commercial	$267.50
Rate for Payer: Devoted Health Medicare	$96.30
Rate for Payer: Humana of AZ Medicare	$85.60
Rate for Payer: Southwest Service Administrators UFCW	$363.80
Rate for Payer: TriWest Medicare	$85.60
Rate for Payer: United Healthcare Commercial	$3,373.00
Rate for Payer: United Healthcare Medicare	$85.60
Rate for Payer: Veterans Affairs TRICARE	$84.74

Fluoroscopy Stage I

Facility

$535.00

Service Code	CPT 77003
Hospital Charge Code	27267838
Hospital Revenue Code	360
Min. Negotiated Rate	$481.50
Max. Negotiated Rate	$481.50
Rate for Payer: Aetna of AZ Commercial	$481.50
Rate for Payer: Cash Price	$428.00

FLUoxetine 20 mg Cap [CQCH]

Facility

$0.09

Service Code	NDC 904578561
Hospital Charge Code	105923130
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

FLUoxetine 20 mg Cap [CQCH]

Facility

$0.09

Service Code	NDC 904578561
Hospital Charge Code	105923130
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

fluticasone 110 mcg/inh Inh Aer w/adapter 12 gm [CQCH]

Facility

$223.16

Service Code	NDC 173071920
Hospital Charge Code	105923197
Hospital Revenue Code	251
Min. Negotiated Rate	$35.35
Max. Negotiated Rate	$200.84
Rate for Payer: Aetna of AZ Commercial	$200.84
Rate for Payer: Arizona Complete Health Allwell	$35.71
Rate for Payer: Banner UC Health Medicare	$35.71
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$151.75
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$35.71
Rate for Payer: Care1st Health Plan Arizona Medicare	$35.71
Rate for Payer: Cash Price	$178.53
Rate for Payer: Cigna of AZ Commercial	$145.05
Rate for Payer: Devoted Health Medicare	$40.17
Rate for Payer: Humana of AZ Medicare	$35.71
Rate for Payer: Southwest Service Administrators UFCW	$151.75
Rate for Payer: TriWest Medicare	$35.71
Rate for Payer: United Healthcare Commercial	$127.65
Rate for Payer: United Healthcare Medicare	$35.71
Rate for Payer: Veterans Affairs TRICARE	$35.35

fluticasone 110 mcg/inh Inh Aer w/adapter 12 gm [CQCH]

Facility

$223.16

Service Code	NDC 173071920
Hospital Charge Code	105923197
Hospital Revenue Code	251
Min. Negotiated Rate	$200.84
Max. Negotiated Rate	$200.84
Rate for Payer: Aetna of AZ Commercial	$200.84
Rate for Payer: Cash Price	$178.53

fluticasone Nasal 0.05 mg/inh Spray [CQCH]

Facility

$7.42

Service Code	NDC 54327099
Hospital Charge Code	105949746
Hospital Revenue Code	251
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$6.68
Rate for Payer: Aetna of AZ Commercial	$6.68
Rate for Payer: Arizona Complete Health Allwell	$1.19
Rate for Payer: Banner UC Health Medicare	$1.19
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5.05
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.19
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.19
Rate for Payer: Cash Price	$5.94
Rate for Payer: Cigna of AZ Commercial	$4.82
Rate for Payer: Devoted Health Medicare	$1.34
Rate for Payer: Humana of AZ Medicare	$1.19
Rate for Payer: Southwest Service Administrators UFCW	$5.05
Rate for Payer: TriWest Medicare	$1.19
Rate for Payer: United Healthcare Commercial	$4.24
Rate for Payer: United Healthcare Medicare	$1.19
Rate for Payer: Veterans Affairs TRICARE	$1.18

fluticasone Nasal 0.05 mg/inh Spray [CQCH]

Facility

$7.42

Service Code	NDC 54327099
Hospital Charge Code	105949746
Hospital Revenue Code	251
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$6.68
Rate for Payer: Aetna of AZ Commercial	$6.68
Rate for Payer: Cash Price	$5.94

Flu Vaccine Split 3 yrs and Above IM POC

Facility

$54.00

Service Code	CPT 90658
Hospital Charge Code	667670
Hospital Revenue Code	521
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$48.60
Rate for Payer: Aetna of AZ Commercial	$48.60
Rate for Payer: Cash Price	$43.20

Flu Vaccine Split 3 yrs and Above IM POC

Facility

$54.00

Service Code	CPT 90658
Hospital Charge Code	667670
Hospital Revenue Code	521
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$48.60
Rate for Payer: Aetna of AZ Commercial	$48.60
Rate for Payer: Arizona Complete Health Allwell	$8.64
Rate for Payer: Banner UC Health Medicare	$8.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$36.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.64
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna of AZ Commercial	$37.80
Rate for Payer: Devoted Health Medicare	$9.72
Rate for Payer: Humana of AZ Medicare	$8.64
Rate for Payer: Southwest Service Administrators UFCW	$36.72
Rate for Payer: TriWest Medicare	$8.64
Rate for Payer: United Healthcare Commercial	$30.89
Rate for Payer: United Healthcare Medicare	$8.64
Rate for Payer: Veterans Affairs TRICARE	$8.55

Flu Vaccine Split 6-35 Months IM POC

Facility

$33.00

Service Code	CPT 90657
Hospital Charge Code	667669
Hospital Revenue Code	521
Min. Negotiated Rate	$5.23
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Arizona Complete Health Allwell	$5.28
Rate for Payer: Banner UC Health Medicare	$5.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$22.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.28
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cigna of AZ Commercial	$23.10
Rate for Payer: Devoted Health Medicare	$5.94
Rate for Payer: Humana of AZ Medicare	$5.28
Rate for Payer: Southwest Service Administrators UFCW	$22.44
Rate for Payer: TriWest Medicare	$5.28
Rate for Payer: United Healthcare Commercial	$18.88
Rate for Payer: United Healthcare Medicare	$5.28
Rate for Payer: Veterans Affairs TRICARE	$5.23

Flu Vaccine Split 6-35 Months IM POC

Facility

$33.00

Service Code	CPT 90657
Hospital Charge Code	667669
Hospital Revenue Code	521
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Cash Price	$26.40

Folate Level

Facility

$172.00

Service Code	CPT 82746
Hospital Charge Code	633729
Hospital Revenue Code	301
Min. Negotiated Rate	$21.32
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Aetna of AZ Commercial	$214.20
Rate for Payer: Arizona Complete Health Allwell	$38.08
Rate for Payer: Arizona Complete Health Allwell	$27.52
Rate for Payer: Banner UC Health Medicare	$38.08
Rate for Payer: Banner UC Health Medicare	$27.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$116.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$161.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.08
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cigna of AZ Commercial	$154.70
Rate for Payer: Cigna of AZ Commercial	$111.80
Rate for Payer: Devoted Health Medicare	$42.84
Rate for Payer: Devoted Health Medicare	$30.96
Rate for Payer: Humana of AZ Medicare	$27.52
Rate for Payer: Humana of AZ Medicare	$38.08
Rate for Payer: Seven Corners Travel Insurance	$21.32
Rate for Payer: Seven Corners Travel Insurance	$21.32
Rate for Payer: Southwest Service Administrators UFCW	$161.84
Rate for Payer: Southwest Service Administrators UFCW	$116.96
Rate for Payer: TriWest Medicare	$27.52
Rate for Payer: TriWest Medicare	$38.08
Rate for Payer: United Healthcare Commercial	$98.38
Rate for Payer: United Healthcare Commercial	$136.14
Rate for Payer: United Healthcare Medicare	$27.52
Rate for Payer: United Healthcare Medicare	$38.08
Rate for Payer: Veterans Affairs TRICARE	$37.70
Rate for Payer: Veterans Affairs TRICARE	$27.24

Folate Level

Facility

$238.00

Service Code	CPT 82746
Hospital Charge Code	633729
Hospital Revenue Code	301
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$214.20
Rate for Payer: Aetna of AZ Commercial	$214.20
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$137.60

.Folate Note LC

Facility

$259.00

Service Code	CPT 82747
Hospital Charge Code	22311145
Hospital Revenue Code	306
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$233.10
Rate for Payer: Aetna of AZ Commercial	$233.10
Rate for Payer: Cash Price	$207.20

.Folate Note LC

Facility

$259.00

Service Code	CPT 82747
Hospital Charge Code	22311145
Hospital Revenue Code	306
Min. Negotiated Rate	$25.59
Max. Negotiated Rate	$233.10
Rate for Payer: Aetna of AZ Commercial	$233.10
Rate for Payer: Arizona Complete Health Allwell	$41.44
Rate for Payer: Banner UC Health Medicare	$41.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$176.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$41.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$41.44
Rate for Payer: Cash Price	$207.20
Rate for Payer: Cash Price	$207.20
Rate for Payer: Cigna of AZ Commercial	$168.35
Rate for Payer: Devoted Health Medicare	$46.62
Rate for Payer: Humana of AZ Medicare	$41.44
Rate for Payer: Seven Corners Travel Insurance	$25.59
Rate for Payer: Southwest Service Administrators UFCW	$176.12
Rate for Payer: TriWest Medicare	$41.44
Rate for Payer: United Healthcare Commercial	$148.15
Rate for Payer: United Healthcare Medicare	$41.44
Rate for Payer: Veterans Affairs TRICARE	$41.03

Folate, RBC LC

Facility

$246.00

Service Code	CPT 82747
Hospital Charge Code	1906862
Hospital Revenue Code	301
Min. Negotiated Rate	$221.40
Max. Negotiated Rate	$221.40
Rate for Payer: Aetna of AZ Commercial	$221.40
Rate for Payer: Cash Price	$196.80

Folate, RBC LC

Facility

$246.00

Service Code	CPT 82747
Hospital Charge Code	1906862
Hospital Revenue Code	301
Min. Negotiated Rate	$25.59
Max. Negotiated Rate	$221.40
Rate for Payer: Aetna of AZ Commercial	$221.40
Rate for Payer: Arizona Complete Health Allwell	$39.36
Rate for Payer: Banner UC Health Medicare	$39.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$167.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$39.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$39.36
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cigna of AZ Commercial	$159.90
Rate for Payer: Devoted Health Medicare	$44.28
Rate for Payer: Humana of AZ Medicare	$39.36
Rate for Payer: Seven Corners Travel Insurance	$25.59
Rate for Payer: Southwest Service Administrators UFCW	$167.28
Rate for Payer: TriWest Medicare	$39.36
Rate for Payer: United Healthcare Commercial	$140.71
Rate for Payer: United Healthcare Medicare	$39.36
Rate for Payer: Veterans Affairs TRICARE	$38.97

FOLEY CATH 30CC 20FR 3 WAY

Facility

$95.95

Hospital Charge Code	27796435
Hospital Revenue Code	270
Min. Negotiated Rate	$86.36
Max. Negotiated Rate	$86.36
Rate for Payer: Aetna of AZ Commercial	$86.36
Rate for Payer: Cash Price	$76.76

Know your out-of-pocket cost for care.

All Charges