Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY

Facility

$28,570.10

Service Code	MSDRG 934
Min. Negotiated Rate	$28,570.10
Max. Negotiated Rate	$28,570.10
Rate for Payer: Seven Corners Travel Insurance	$28,570.10

FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC

Facility

$92,700.98

Service Code	MSDRG 928
Min. Negotiated Rate	$92,700.98
Max. Negotiated Rate	$92,700.98
Rate for Payer: Seven Corners Travel Insurance	$92,700.98

FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC

Facility

$41,626.05

Service Code	MSDRG 929
Min. Negotiated Rate	$41,626.05
Max. Negotiated Rate	$41,626.05
Rate for Payer: Seven Corners Travel Insurance	$41,626.05

.Fungal Cult LC

Facility

$243.00

Service Code	CPT 87101
Hospital Charge Code	9228407
Hospital Revenue Code	301
Min. Negotiated Rate	$11.18
Max. Negotiated Rate	$218.70
Rate for Payer: Aetna of AZ Commercial	$218.70
Rate for Payer: Arizona Complete Health Allwell	$38.88
Rate for Payer: Banner UC Health Medicare	$38.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$165.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.88
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cigna of AZ Commercial	$157.95
Rate for Payer: Devoted Health Medicare	$43.74
Rate for Payer: Humana of AZ Medicare	$38.88
Rate for Payer: Seven Corners Travel Insurance	$11.18
Rate for Payer: Southwest Service Administrators UFCW	$165.24
Rate for Payer: TriWest Medicare	$38.88
Rate for Payer: United Healthcare Commercial	$139.00
Rate for Payer: United Healthcare Medicare	$38.88
Rate for Payer: Veterans Affairs TRICARE	$38.49

.Fungal Cult LC

Facility

$243.00

Service Code	CPT 87101
Hospital Charge Code	9228407
Hospital Revenue Code	301
Min. Negotiated Rate	$218.70
Max. Negotiated Rate	$218.70
Rate for Payer: Aetna of AZ Commercial	$218.70
Rate for Payer: Cash Price	$194.40

Fungus (Mycology) Culture LC

Facility

$323.00

Service Code	CPT 87101
Hospital Charge Code	1905615
Hospital Revenue Code	306
Min. Negotiated Rate	$290.70
Max. Negotiated Rate	$290.70
Rate for Payer: Aetna of AZ Commercial	$290.70
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Cash Price	$258.40
Rate for Payer: Cash Price	$193.60

Fungus (Mycology) Culture LC

Facility

$242.00

Service Code	CPT 87101
Hospital Charge Code	1905615
Hospital Revenue Code	306
Min. Negotiated Rate	$11.18
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Aetna of AZ Commercial	$290.70
Rate for Payer: Arizona Complete Health Allwell	$51.68
Rate for Payer: Arizona Complete Health Allwell	$38.72
Rate for Payer: Banner UC Health Medicare	$51.68
Rate for Payer: Banner UC Health Medicare	$38.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$164.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$219.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$51.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$51.68
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cash Price	$258.40
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cash Price	$258.40
Rate for Payer: Cigna of AZ Commercial	$209.95
Rate for Payer: Cigna of AZ Commercial	$157.30
Rate for Payer: Devoted Health Medicare	$58.14
Rate for Payer: Devoted Health Medicare	$43.56
Rate for Payer: Humana of AZ Medicare	$38.72
Rate for Payer: Humana of AZ Medicare	$51.68
Rate for Payer: Seven Corners Travel Insurance	$11.18
Rate for Payer: Seven Corners Travel Insurance	$11.18
Rate for Payer: Southwest Service Administrators UFCW	$219.64
Rate for Payer: Southwest Service Administrators UFCW	$164.56
Rate for Payer: TriWest Medicare	$38.72
Rate for Payer: TriWest Medicare	$51.68
Rate for Payer: United Healthcare Commercial	$138.42
Rate for Payer: United Healthcare Commercial	$184.76
Rate for Payer: United Healthcare Medicare	$38.72
Rate for Payer: United Healthcare Medicare	$51.68
Rate for Payer: Veterans Affairs TRICARE	$51.16
Rate for Payer: Veterans Affairs TRICARE	$38.33

furosemide 20 mg/2 mL Inj Sol [CQCH]

Facility

$0.53

Service Code	HCPCS J1940
Hospital Charge Code	105923463
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of AZ Commercial	$0.48
Rate for Payer: Arizona Complete Health Allwell	$0.08
Rate for Payer: Banner UC Health Medicare	$0.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.08
Rate for Payer: Cash Price	$0.42
Rate for Payer: Cigna of AZ Commercial	$0.34
Rate for Payer: Devoted Health Medicare	$0.10
Rate for Payer: Humana of AZ Medicare	$0.08
Rate for Payer: Southwest Service Administrators UFCW	$0.36
Rate for Payer: TriWest Medicare	$0.08
Rate for Payer: United Healthcare Commercial	$0.30
Rate for Payer: United Healthcare Medicare	$0.08
Rate for Payer: Veterans Affairs TRICARE	$0.08

furosemide 20 mg/2 mL Inj Sol [CQCH]

Facility

$0.53

Service Code	HCPCS J1940
Hospital Charge Code	105923463
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of AZ Commercial	$0.48
Rate for Payer: Cash Price	$0.42

furosemide 20 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 54829725
Hospital Charge Code	105923674
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Cash Price	$0.03

furosemide 20 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 54829725
Hospital Charge Code	105923674
Hospital Revenue Code	251
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Arizona Complete Health Allwell	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.00
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of AZ Commercial	$0.02
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Southwest Service Administrators UFCW	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: United Healthcare Commercial	$0.02
Rate for Payer: United Healthcare Medicare	$0.00
Rate for Payer: Veterans Affairs TRICARE	$0.00

furosemide 40 mg/ 4 mL Inj Sol [CQCH]

Facility

$0.45

Service Code	HCPCS J1940
Hospital Charge Code	105923534
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of AZ Commercial	$0.41
Rate for Payer: Cash Price	$0.36

furosemide 40 mg/ 4 mL Inj Sol [CQCH]

Facility

$0.45

Service Code	HCPCS J1940
Hospital Charge Code	105923534
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of AZ Commercial	$0.41
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	$0.31
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	$0.36
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	$0.31
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: United Healthcare Commercial	$0.26
Rate for Payer: United Healthcare Medicare	$0.07
Rate for Payer: Veterans Affairs TRICARE	$0.07

furosemide 40 mg Tab [CQCH]

Facility

$0.04

Service Code	NDC 54829925
Hospital Charge Code	105923609
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

furosemide 40 mg Tab [CQCH]

Facility

$0.04

Service Code	NDC 54829925
Hospital Charge Code	105923609
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

G0008 Admin Influenza Virus Vaccine POC

Facility

$57.00

Service Code	HCPCS G0008
Hospital Charge Code	1713521
Hospital Revenue Code	521
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna of AZ Commercial	$51.30
Rate for Payer: Cash Price	$45.60

G0008 Admin Influenza Virus Vaccine POC

Facility

$57.00

Service Code	HCPCS G0008
Hospital Charge Code	1713521
Hospital Revenue Code	521
Min. Negotiated Rate	$9.03
Max. Negotiated Rate	$72.46
Rate for Payer: Aetna of AZ Commercial	$51.30
Rate for Payer: Arizona Complete Health Allwell	$9.12
Rate for Payer: Banner UC Health Medicare	$9.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$38.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.12
Rate for Payer: Cash Price	$45.60
Rate for Payer: Cash Price	$45.60
Rate for Payer: Cigna of AZ Commercial	$39.90
Rate for Payer: Devoted Health Medicare	$10.26
Rate for Payer: Humana of AZ Medicare	$9.12
Rate for Payer: Seven Corners Travel Insurance	$72.46
Rate for Payer: Southwest Service Administrators UFCW	$38.76
Rate for Payer: TriWest Medicare	$9.12
Rate for Payer: United Healthcare Commercial	$32.60
Rate for Payer: United Healthcare Medicare	$9.12
Rate for Payer: Veterans Affairs TRICARE	$9.03

G0101 Screening Pelvic/Breast Exam Clinic Charge

Facility

$118.00

Hospital Charge Code	10408563
Min. Negotiated Rate	$18.69
Max. Negotiated Rate	$106.20
Rate for Payer: Aetna of AZ Commercial	$106.20
Rate for Payer: Arizona Complete Health Allwell	$18.88
Rate for Payer: Banner UC Health Medicare	$18.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$80.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$18.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$18.88
Rate for Payer: Cash Price	$94.40
Rate for Payer: Cigna of AZ Commercial	$82.60
Rate for Payer: Devoted Health Medicare	$21.24
Rate for Payer: Humana of AZ Medicare	$18.88
Rate for Payer: Southwest Service Administrators UFCW	$80.24
Rate for Payer: TriWest Medicare	$18.88
Rate for Payer: United Healthcare Commercial	$67.50
Rate for Payer: United Healthcare Medicare	$18.88
Rate for Payer: Veterans Affairs TRICARE	$18.69

G0101 Screening Pelvic/Breast Exam Clinic Charge

Facility

$118.00

Hospital Charge Code	10408563
Min. Negotiated Rate	$106.20
Max. Negotiated Rate	$106.20
Rate for Payer: Aetna of AZ Commercial	$106.20
Rate for Payer: Cash Price	$94.40

G0168 WOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLY

Facility

$527.00

Service Code	HCPCS G0168
Hospital Charge Code	24599672
Hospital Revenue Code	450
Min. Negotiated Rate	$474.30
Max. Negotiated Rate	$474.30
Rate for Payer: Aetna of AZ Commercial	$474.30
Rate for Payer: Cash Price	$421.60

G0168 WOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLY

Facility

$527.00

Service Code	HCPCS G0168
Hospital Charge Code	24599672
Hospital Revenue Code	450
Min. Negotiated Rate	$83.48
Max. Negotiated Rate	$474.30
Rate for Payer: Aetna of AZ Commercial	$474.30
Rate for Payer: Arizona Complete Health Allwell	$84.32
Rate for Payer: Banner UC Health Medicare	$84.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$358.36
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$86.13
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$84.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$84.32
Rate for Payer: Cash Price	$421.60
Rate for Payer: Cash Price	$421.60
Rate for Payer: Cigna of AZ Commercial	$368.90
Rate for Payer: Devoted Health Medicare	$94.86
Rate for Payer: Humana of AZ Medicare	$84.32
Rate for Payer: Mercy Care Medicaid	$86.13
Rate for Payer: NaphCare Correctional Healthcare	$86.13
Rate for Payer: Southwest Service Administrators UFCW	$358.36
Rate for Payer: TriWest Medicare	$84.32
Rate for Payer: United Healthcare Commercial	$301.44
Rate for Payer: United Healthcare Medicare	$84.32
Rate for Payer: United Healthcare New Mexico Commercial	$100.13
Rate for Payer: Veterans Affairs TRICARE	$83.48

G0179 Home Health Recertification Clinic Charge

Facility

$142.00

Service Code	HCPCS G0179
Hospital Charge Code	10408565
Hospital Revenue Code	521
Min. Negotiated Rate	$127.80
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Cash Price	$113.60

G0179 Home Health Recertification Clinic Charge

Facility

$142.00

Service Code	HCPCS G0179
Hospital Charge Code	10408565
Hospital Revenue Code	521
Min. Negotiated Rate	$22.49
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Arizona Complete Health Allwell	$22.72
Rate for Payer: Banner UC Health Medicare	$22.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$96.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$22.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$22.72
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cigna of AZ Commercial	$99.40
Rate for Payer: Devoted Health Medicare	$25.56
Rate for Payer: Humana of AZ Medicare	$22.72
Rate for Payer: Southwest Service Administrators UFCW	$96.56
Rate for Payer: TriWest Medicare	$22.72
Rate for Payer: United Healthcare Commercial	$81.22
Rate for Payer: United Healthcare Medicare	$22.72
Rate for Payer: Veterans Affairs TRICARE	$22.49

G0180 Home Health Certification

Facility

$195.00

Service Code	HCPCS G0180
Hospital Charge Code	22198991
Hospital Revenue Code	521
Min. Negotiated Rate	$30.89
Max. Negotiated Rate	$175.50
Rate for Payer: Aetna of AZ Commercial	$175.50
Rate for Payer: Arizona Complete Health Allwell	$31.20
Rate for Payer: Banner UC Health Medicare	$31.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$132.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$31.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.20
Rate for Payer: Cash Price	$156.00
Rate for Payer: Cigna of AZ Commercial	$136.50
Rate for Payer: Devoted Health Medicare	$35.10
Rate for Payer: Humana of AZ Medicare	$31.20
Rate for Payer: Southwest Service Administrators UFCW	$132.60
Rate for Payer: TriWest Medicare	$31.20
Rate for Payer: United Healthcare Commercial	$111.54
Rate for Payer: United Healthcare Medicare	$31.20
Rate for Payer: Veterans Affairs TRICARE	$30.89

G0180 Home Health Certification

Facility

$195.00

Service Code	HCPCS G0180
Hospital Charge Code	22198991
Hospital Revenue Code	521
Min. Negotiated Rate	$175.50
Max. Negotiated Rate	$175.50
Rate for Payer: Aetna of AZ Commercial	$175.50
Rate for Payer: Cash Price	$156.00

Know your out-of-pocket cost for care.

All Charges