Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

G0378 ER OBSERVATION

Facility

$133.00

Service Code	HCPCS G0378
Hospital Charge Code	22282939
Hospital Revenue Code	762
Min. Negotiated Rate	$21.07
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of AZ Commercial	$119.70
Rate for Payer: Arizona Complete Health Allwell	$21.28
Rate for Payer: Banner UC Health Medicare	$21.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$90.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$21.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$21.28
Rate for Payer: Cash Price	$106.40
Rate for Payer: Cigna of AZ Commercial	$93.10
Rate for Payer: Devoted Health Medicare	$23.94
Rate for Payer: Humana of AZ Medicare	$21.28
Rate for Payer: Southwest Service Administrators UFCW	$90.44
Rate for Payer: TriWest Medicare	$21.28
Rate for Payer: United Healthcare Commercial	$76.08
Rate for Payer: United Healthcare Medicare	$21.28
Rate for Payer: United Healthcare New Mexico Commercial	$25.27
Rate for Payer: Veterans Affairs TRICARE	$21.07

G0378 ER OBSERVATION

Facility

$133.00

Service Code	HCPCS G0378
Hospital Charge Code	22282939
Hospital Revenue Code	762
Min. Negotiated Rate	$119.70
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of AZ Commercial	$119.70
Rate for Payer: Cash Price	$106.40

G0379 DIRECT OBSERVATION

Facility

$167.00

Service Code	HCPCS G0379
Hospital Charge Code	22282941
Hospital Revenue Code	762
Min. Negotiated Rate	$150.30
Max. Negotiated Rate	$150.30
Rate for Payer: Aetna of AZ Commercial	$150.30
Rate for Payer: Cash Price	$133.60

G0379 DIRECT OBSERVATION

Facility

$167.00

Service Code	HCPCS G0379
Hospital Charge Code	22282941
Hospital Revenue Code	762
Min. Negotiated Rate	$26.45
Max. Negotiated Rate	$921.45
Rate for Payer: Aetna of AZ Commercial	$150.30
Rate for Payer: Arizona Complete Health Allwell	$26.72
Rate for Payer: Banner UC Health Medicare	$26.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$113.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$26.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$26.72
Rate for Payer: Cash Price	$133.60
Rate for Payer: Cash Price	$133.60
Rate for Payer: Cigna of AZ Commercial	$116.90
Rate for Payer: Devoted Health Medicare	$30.06
Rate for Payer: Humana of AZ Medicare	$26.72
Rate for Payer: Seven Corners Travel Insurance	$921.45
Rate for Payer: Southwest Service Administrators UFCW	$113.56
Rate for Payer: TriWest Medicare	$26.72
Rate for Payer: United Healthcare Commercial	$95.52
Rate for Payer: United Healthcare Medicare	$26.72
Rate for Payer: United Healthcare New Mexico Commercial	$31.73
Rate for Payer: Veterans Affairs TRICARE	$26.45

G0390 TRAUMA LEVEL 4

Facility

$1,634.00

Service Code	HCPCS G0390
Hospital Charge Code	22282942
Hospital Revenue Code	684
Min. Negotiated Rate	$258.83
Max. Negotiated Rate	$2,062.36
Rate for Payer: Aetna of AZ Commercial	$1,470.60
Rate for Payer: Arizona Complete Health Allwell	$261.44
Rate for Payer: Banner UC Health Medicare	$261.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,111.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$261.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$261.44
Rate for Payer: Cash Price	$1,307.20
Rate for Payer: Cash Price	$1,307.20
Rate for Payer: Cigna of AZ Commercial	$1,143.80
Rate for Payer: Devoted Health Medicare	$294.12
Rate for Payer: Humana of AZ Medicare	$261.44
Rate for Payer: Seven Corners Travel Insurance	$2,062.36
Rate for Payer: Southwest Service Administrators UFCW	$1,111.12
Rate for Payer: TriWest Medicare	$261.44
Rate for Payer: United Healthcare Commercial	$934.65
Rate for Payer: United Healthcare Medicare	$261.44
Rate for Payer: United Healthcare New Mexico Commercial	$310.46
Rate for Payer: Veterans Affairs TRICARE	$258.83

G0390 TRAUMA LEVEL 4

Facility

$1,634.00

Service Code	HCPCS G0390
Hospital Charge Code	22282942
Hospital Revenue Code	684
Min. Negotiated Rate	$1,470.60
Max. Negotiated Rate	$1,470.60
Rate for Payer: Aetna of AZ Commercial	$1,470.60
Rate for Payer: Cash Price	$1,307.20

G0447 FACE TO FACE BEHAVIORAL COUNSELING FOR OBSEITY 15 MINU

Facility

$30.00

Service Code	HCPCS G0447
Hospital Charge Code	28256448
Hospital Revenue Code	521
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Cash Price	$24.00

G0447 FACE TO FACE BEHAVIORAL COUNSELING FOR OBSEITY 15 MINU

Facility

$30.00

Service Code	HCPCS G0447
Hospital Charge Code	28256448
Hospital Revenue Code	521
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$157.18
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Arizona Complete Health Allwell	$4.80
Rate for Payer: Banner UC Health Medicare	$4.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$20.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna of AZ Commercial	$21.00
Rate for Payer: Devoted Health Medicare	$5.40
Rate for Payer: Humana of AZ Medicare	$4.80
Rate for Payer: Seven Corners Travel Insurance	$157.18
Rate for Payer: Southwest Service Administrators UFCW	$20.40
Rate for Payer: TriWest Medicare	$4.80
Rate for Payer: United Healthcare Commercial	$17.16
Rate for Payer: United Healthcare Medicare	$4.80
Rate for Payer: Veterans Affairs TRICARE	$4.75

G0506 Comp Asses

Facility

$195.00

Service Code	HCPCS G0506
Hospital Charge Code	23889554
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

G0506 Comp Asses

Facility

$195.00

Service Code	HCPCS G0506
Hospital Charge Code	23889554
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

G2025 Medicare Telehealth during PHE

Facility

$147.00

Service Code	HCPCS G2025
Hospital Charge Code	24025727
Hospital Revenue Code	521
Min. Negotiated Rate	$23.28
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of AZ Commercial	$132.30
Rate for Payer: Arizona Complete Health Allwell	$23.52
Rate for Payer: Banner UC Health Medicare	$23.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$99.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$23.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$23.52
Rate for Payer: Cash Price	$117.60
Rate for Payer: Cigna of AZ Commercial	$102.90
Rate for Payer: Devoted Health Medicare	$26.46
Rate for Payer: Humana of AZ Medicare	$23.52
Rate for Payer: Southwest Service Administrators UFCW	$99.96
Rate for Payer: TriWest Medicare	$23.52
Rate for Payer: United Healthcare Commercial	$84.08
Rate for Payer: United Healthcare Medicare	$23.52
Rate for Payer: Veterans Affairs TRICARE	$23.28

G2025 Medicare Telehealth during PHE

Facility

$147.00

Service Code	HCPCS G2025
Hospital Charge Code	24025727
Hospital Revenue Code	521
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of AZ Commercial	$132.30
Rate for Payer: Cash Price	$117.60

.G-6-PD Comment LC

Facility

$206.00

Service Code	CPT 82955
Hospital Charge Code	22311146
Hospital Revenue Code	301
Min. Negotiated Rate	$185.40
Max. Negotiated Rate	$185.40
Rate for Payer: Aetna of AZ Commercial	$185.40
Rate for Payer: Cash Price	$164.80

.G-6-PD Comment LC

Facility

$206.00

Service Code	CPT 82955
Hospital Charge Code	22311146
Hospital Revenue Code	301
Min. Negotiated Rate	$14.06
Max. Negotiated Rate	$185.40
Rate for Payer: Aetna of AZ Commercial	$185.40
Rate for Payer: Arizona Complete Health Allwell	$32.96
Rate for Payer: Banner UC Health Medicare	$32.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$140.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.96
Rate for Payer: Cash Price	$164.80
Rate for Payer: Cash Price	$164.80
Rate for Payer: Cigna of AZ Commercial	$133.90
Rate for Payer: Devoted Health Medicare	$37.08
Rate for Payer: Humana of AZ Medicare	$32.96
Rate for Payer: Seven Corners Travel Insurance	$14.06
Rate for Payer: Southwest Service Administrators UFCW	$140.08
Rate for Payer: TriWest Medicare	$32.96
Rate for Payer: United Healthcare Commercial	$117.83
Rate for Payer: United Healthcare Medicare	$32.96
Rate for Payer: Veterans Affairs TRICARE	$32.63

G6PDH Activity LC

Facility

$196.00

Service Code	CPT 82955
Hospital Charge Code	2769568
Hospital Revenue Code	301
Min. Negotiated Rate	$14.06
Max. Negotiated Rate	$176.40
Rate for Payer: Aetna of AZ Commercial	$176.40
Rate for Payer: Arizona Complete Health Allwell	$31.36
Rate for Payer: Banner UC Health Medicare	$31.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$133.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$31.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.36
Rate for Payer: Cash Price	$156.80
Rate for Payer: Cash Price	$156.80
Rate for Payer: Cigna of AZ Commercial	$127.40
Rate for Payer: Devoted Health Medicare	$35.28
Rate for Payer: Humana of AZ Medicare	$31.36
Rate for Payer: Seven Corners Travel Insurance	$14.06
Rate for Payer: Southwest Service Administrators UFCW	$133.28
Rate for Payer: TriWest Medicare	$31.36
Rate for Payer: United Healthcare Commercial	$112.11
Rate for Payer: United Healthcare Medicare	$31.36
Rate for Payer: Veterans Affairs TRICARE	$31.05

G6PDH Activity LC

Facility

$196.00

Service Code	CPT 82955
Hospital Charge Code	2769568
Hospital Revenue Code	301
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$176.40
Rate for Payer: Aetna of AZ Commercial	$176.40
Rate for Payer: Cash Price	$156.80

gabapentin 100 mg Cap [CQCH]

Facility

$0.08

Service Code	NDC 904666561
Hospital Charge Code	105923739
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
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	$0.05
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	$0.06
Rate for Payer: Cigna of AZ Commercial	$0.05
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.05
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

gabapentin 100 mg Cap [CQCH]

Facility

$0.08

Service Code	NDC 904666561
Hospital Charge Code	105923739
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
Rate for Payer: Cash Price	$0.06

gabapentin 300 mg Cap [CQCH]

Facility

$0.20

Service Code	NDC 63739023610
Hospital Charge Code	105923804
Hospital Revenue Code	251
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.18
Rate for Payer: Cash Price	$0.16

gabapentin 300 mg Cap [CQCH]

Facility

$0.20

Service Code	NDC 63739023610
Hospital Charge Code	105923804
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.18
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	$0.14
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	$0.16
Rate for Payer: Cigna of AZ Commercial	$0.13
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Southwest Service Administrators UFCW	$0.14
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

gabapentin 400 mg Cap [CQCH]

Facility

$0.14

Service Code	NDC 68084077401
Hospital Charge Code	105923869
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of AZ Commercial	$0.13
Rate for Payer: Arizona Complete Health Allwell	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.10
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.02
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.02
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of AZ Commercial	$0.09
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.10
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.08
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

gabapentin 400 mg Cap [CQCH]

Facility

$0.14

Service Code	NDC 68084077401
Hospital Charge Code	105923869
Hospital Revenue Code	251
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of AZ Commercial	$0.13
Rate for Payer: Cash Price	$0.11

GAD-65 Autoab LC

Facility

$318.00

Service Code	CPT 83519
Hospital Charge Code	6780942
Hospital Revenue Code	301
Min. Negotiated Rate	$26.68
Max. Negotiated Rate	$286.20
Rate for Payer: Aetna of AZ Commercial	$286.20
Rate for Payer: Arizona Complete Health Allwell	$50.88
Rate for Payer: Banner UC Health Medicare	$50.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$216.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$50.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$50.88
Rate for Payer: Cash Price	$254.40
Rate for Payer: Cash Price	$254.40
Rate for Payer: Cigna of AZ Commercial	$206.70
Rate for Payer: Devoted Health Medicare	$57.24
Rate for Payer: Humana of AZ Medicare	$50.88
Rate for Payer: Seven Corners Travel Insurance	$26.68
Rate for Payer: Southwest Service Administrators UFCW	$216.24
Rate for Payer: TriWest Medicare	$50.88
Rate for Payer: United Healthcare Commercial	$181.90
Rate for Payer: United Healthcare Medicare	$50.88
Rate for Payer: Veterans Affairs TRICARE	$50.37

GAD-65 Autoab LC

Facility

$318.00

Service Code	CPT 83519
Hospital Charge Code	6780942
Hospital Revenue Code	301
Min. Negotiated Rate	$286.20
Max. Negotiated Rate	$286.20
Rate for Payer: Aetna of AZ Commercial	$286.20
Rate for Payer: Cash Price	$254.40

Gamma Glutamyl Transferase

Facility

$158.00

Service Code	CPT 82977
Hospital Charge Code	633733
Hospital Revenue Code	301
Min. Negotiated Rate	$10.44
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of AZ Commercial	$142.20
Rate for Payer: Arizona Complete Health Allwell	$25.28
Rate for Payer: Banner UC Health Medicare	$25.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$107.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$25.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$25.28
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cigna of AZ Commercial	$102.70
Rate for Payer: Devoted Health Medicare	$28.44
Rate for Payer: Humana of AZ Medicare	$25.28
Rate for Payer: Seven Corners Travel Insurance	$10.44
Rate for Payer: Southwest Service Administrators UFCW	$107.44
Rate for Payer: TriWest Medicare	$25.28
Rate for Payer: United Healthcare Commercial	$90.38
Rate for Payer: United Healthcare Medicare	$25.28
Rate for Payer: Veterans Affairs TRICARE	$25.03

Know your out-of-pocket cost for care.

All Charges