Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

GENTAMICIN, RANDOM

Facility

$256.00

Service Code	CPT 80170
Hospital Charge Code	23122403
Hospital Revenue Code	301
Min. Negotiated Rate	$23.75
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna of AZ Commercial	$230.40
Rate for Payer: Arizona Complete Health Allwell	$40.96
Rate for Payer: Banner UC Health Medicare	$40.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$174.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$40.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$40.96
Rate for Payer: Cash Price	$204.80
Rate for Payer: Cash Price	$204.80
Rate for Payer: Cigna of AZ Commercial	$166.40
Rate for Payer: Devoted Health Medicare	$46.08
Rate for Payer: Humana of AZ Medicare	$40.96
Rate for Payer: Seven Corners Travel Insurance	$23.75
Rate for Payer: Southwest Service Administrators UFCW	$174.08
Rate for Payer: TriWest Medicare	$40.96
Rate for Payer: United Healthcare Commercial	$146.43
Rate for Payer: United Healthcare Medicare	$40.96
Rate for Payer: Veterans Affairs TRICARE	$40.55

GENTAMICIN, RANDOM

Facility

$256.00

Service Code	CPT 80170
Hospital Charge Code	23122403
Hospital Revenue Code	301
Min. Negotiated Rate	$230.40
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna of AZ Commercial	$230.40
Rate for Payer: Cash Price	$204.80

Gentamicin Trough

Facility

$256.00

Service Code	CPT 80170
Hospital Charge Code	23122404
Hospital Revenue Code	301
Min. Negotiated Rate	$230.40
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna of AZ Commercial	$230.40
Rate for Payer: Cash Price	$204.80

Gentamicin Trough

Facility

$256.00

Service Code	CPT 80170
Hospital Charge Code	23122404
Hospital Revenue Code	301
Min. Negotiated Rate	$23.75
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna of AZ Commercial	$230.40
Rate for Payer: Arizona Complete Health Allwell	$40.96
Rate for Payer: Banner UC Health Medicare	$40.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$174.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$40.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$40.96
Rate for Payer: Cash Price	$204.80
Rate for Payer: Cash Price	$204.80
Rate for Payer: Cigna of AZ Commercial	$166.40
Rate for Payer: Devoted Health Medicare	$46.08
Rate for Payer: Humana of AZ Medicare	$40.96
Rate for Payer: Seven Corners Travel Insurance	$23.75
Rate for Payer: Southwest Service Administrators UFCW	$174.08
Rate for Payer: TriWest Medicare	$40.96
Rate for Payer: United Healthcare Commercial	$146.43
Rate for Payer: United Healthcare Medicare	$40.96
Rate for Payer: Veterans Affairs TRICARE	$40.55

GGT LC

Facility

$166.00

Service Code	CPT 82977
Hospital Charge Code	1902205
Hospital Revenue Code	301
Min. Negotiated Rate	$10.44
Max. Negotiated Rate	$149.40
Rate for Payer: Aetna of AZ Commercial	$149.40
Rate for Payer: Arizona Complete Health Allwell	$26.56
Rate for Payer: Banner UC Health Medicare	$26.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$112.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$26.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$26.56
Rate for Payer: Cash Price	$132.80
Rate for Payer: Cash Price	$132.80
Rate for Payer: Cigna of AZ Commercial	$107.90
Rate for Payer: Devoted Health Medicare	$29.88
Rate for Payer: Humana of AZ Medicare	$26.56
Rate for Payer: Seven Corners Travel Insurance	$10.44
Rate for Payer: Southwest Service Administrators UFCW	$112.88
Rate for Payer: TriWest Medicare	$26.56
Rate for Payer: United Healthcare Commercial	$94.95
Rate for Payer: United Healthcare Medicare	$26.56
Rate for Payer: Veterans Affairs TRICARE	$26.29

GGT LC

Facility

$166.00

Service Code	CPT 82977
Hospital Charge Code	1902205
Hospital Revenue Code	301
Min. Negotiated Rate	$149.40
Max. Negotiated Rate	$149.40
Rate for Payer: Aetna of AZ Commercial	$149.40
Rate for Payer: Cash Price	$132.80

Giardia Lamblia Direct Detection EIA, LC

Facility

$217.00

Service Code	CPT 87329
Hospital Charge Code	3601506
Hospital Revenue Code	302
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$195.30
Rate for Payer: Aetna of AZ Commercial	$195.30
Rate for Payer: Cash Price	$173.60

Giardia Lamblia Direct Detection EIA, LC

Facility

$217.00

Service Code	CPT 87329
Hospital Charge Code	3601506
Hospital Revenue Code	302
Min. Negotiated Rate	$17.37
Max. Negotiated Rate	$195.30
Rate for Payer: Aetna of AZ Commercial	$195.30
Rate for Payer: Arizona Complete Health Allwell	$34.72
Rate for Payer: Banner UC Health Medicare	$34.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$147.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$34.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$34.72
Rate for Payer: Cash Price	$173.60
Rate for Payer: Cash Price	$173.60
Rate for Payer: Cigna of AZ Commercial	$141.05
Rate for Payer: Devoted Health Medicare	$39.06
Rate for Payer: Humana of AZ Medicare	$34.72
Rate for Payer: Seven Corners Travel Insurance	$17.37
Rate for Payer: Southwest Service Administrators UFCW	$147.56
Rate for Payer: TriWest Medicare	$34.72
Rate for Payer: United Healthcare Commercial	$124.12
Rate for Payer: United Healthcare Medicare	$34.72
Rate for Payer: Veterans Affairs TRICARE	$34.37

Giardia Lamblia Direct Detection EIA, LC

Facility

$80.00

Service Code	CPT 87328
Hospital Charge Code	23173812
Hospital Revenue Code	301
Min. Negotiated Rate	$72.00
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna of AZ Commercial	$72.00
Rate for Payer: Cash Price	$64.00

Giardia Lamblia Direct Detection EIA, LC

Facility

$80.00

Service Code	CPT 87328
Hospital Charge Code	23173812
Hospital Revenue Code	301
Min. Negotiated Rate	$12.67
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna of AZ Commercial	$72.00
Rate for Payer: Arizona Complete Health Allwell	$12.80
Rate for Payer: Banner UC Health Medicare	$12.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$54.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.80
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cigna of AZ Commercial	$52.00
Rate for Payer: Devoted Health Medicare	$14.40
Rate for Payer: Humana of AZ Medicare	$12.80
Rate for Payer: Seven Corners Travel Insurance	$20.04
Rate for Payer: Southwest Service Administrators UFCW	$54.40
Rate for Payer: TriWest Medicare	$12.80
Rate for Payer: United Healthcare Commercial	$45.76
Rate for Payer: United Healthcare Medicare	$12.80
Rate for Payer: Veterans Affairs TRICARE	$12.67

Giardia Lamblia Direct Detention EIA, LC

Facility

$228.00

Service Code	CPT 87329
Hospital Charge Code	23309229
Hospital Revenue Code	300
Min. Negotiated Rate	$17.37
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna of AZ Commercial	$205.20
Rate for Payer: Arizona Complete Health Allwell	$36.48
Rate for Payer: Banner UC Health Medicare	$36.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$155.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.48
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cigna of AZ Commercial	$148.20
Rate for Payer: Devoted Health Medicare	$41.04
Rate for Payer: Humana of AZ Medicare	$36.48
Rate for Payer: Seven Corners Travel Insurance	$17.37
Rate for Payer: Southwest Service Administrators UFCW	$155.04
Rate for Payer: TriWest Medicare	$36.48
Rate for Payer: United Healthcare Commercial	$130.42
Rate for Payer: United Healthcare Medicare	$36.48
Rate for Payer: Veterans Affairs TRICARE	$36.12

Giardia Lamblia Direct Detention EIA, LC

Facility

$228.00

Service Code	CPT 87329
Hospital Charge Code	23309229
Hospital Revenue Code	300
Min. Negotiated Rate	$205.20
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna of AZ Commercial	$205.20
Rate for Payer: Cash Price	$182.40

GI EASE DIGESTIVE SUPPLEMENT

Facility

$140.00

Hospital Charge Code	28127141
Hospital Revenue Code	270
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$126.00
Rate for Payer: Aetna of AZ Commercial	$126.00
Rate for Payer: Cash Price	$112.00

GI EASE DIGESTIVE SUPPLEMENT

Facility

$140.00

Hospital Charge Code	28127141
Hospital Revenue Code	270
Min. Negotiated Rate	$22.18
Max. Negotiated Rate	$126.00
Rate for Payer: Aetna of AZ Commercial	$126.00
Rate for Payer: Arizona Complete Health Allwell	$22.40
Rate for Payer: Banner UC Health Medicare	$22.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$95.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$22.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$22.40
Rate for Payer: Cash Price	$112.00
Rate for Payer: Cigna of AZ Commercial	$98.00
Rate for Payer: Devoted Health Medicare	$25.20
Rate for Payer: Humana of AZ Medicare	$22.40
Rate for Payer: Southwest Service Administrators UFCW	$95.20
Rate for Payer: TriWest Medicare	$22.40
Rate for Payer: United Healthcare Commercial	$80.08
Rate for Payer: United Healthcare Medicare	$22.40
Rate for Payer: Veterans Affairs TRICARE	$22.18

Gliadin IgG IgA Ab Prof LC

Facility

$1,490.00

Service Code	CPT 83516
Hospital Charge Code	6781775
Hospital Revenue Code	301
Min. Negotiated Rate	$1,341.00
Max. Negotiated Rate	$1,341.00
Rate for Payer: Aetna of AZ Commercial	$1,341.00
Rate for Payer: Aetna of AZ Commercial	$1,769.40
Rate for Payer: Cash Price	$1,192.00
Rate for Payer: Cash Price	$1,572.80

Gliadin IgG IgA Ab Prof LC

Facility

$1,966.00

Service Code	CPT 83516
Hospital Charge Code	6781775
Hospital Revenue Code	301
Min. Negotiated Rate	$16.72
Max. Negotiated Rate	$1,769.40
Rate for Payer: Aetna of AZ Commercial	$1,769.40
Rate for Payer: Aetna of AZ Commercial	$1,341.00
Rate for Payer: Arizona Complete Health Allwell	$238.40
Rate for Payer: Arizona Complete Health Allwell	$314.56
Rate for Payer: Banner UC Health Medicare	$238.40
Rate for Payer: Banner UC Health Medicare	$314.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,336.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,013.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$238.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$314.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$238.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$314.56
Rate for Payer: Cash Price	$1,572.80
Rate for Payer: Cash Price	$1,192.00
Rate for Payer: Cash Price	$1,572.80
Rate for Payer: Cash Price	$1,192.00
Rate for Payer: Cigna of AZ Commercial	$1,277.90
Rate for Payer: Cigna of AZ Commercial	$968.50
Rate for Payer: Devoted Health Medicare	$353.88
Rate for Payer: Devoted Health Medicare	$268.20
Rate for Payer: Humana of AZ Medicare	$238.40
Rate for Payer: Humana of AZ Medicare	$314.56
Rate for Payer: Seven Corners Travel Insurance	$16.72
Rate for Payer: Seven Corners Travel Insurance	$16.72
Rate for Payer: Southwest Service Administrators UFCW	$1,013.20
Rate for Payer: Southwest Service Administrators UFCW	$1,336.88
Rate for Payer: TriWest Medicare	$238.40
Rate for Payer: TriWest Medicare	$314.56
Rate for Payer: United Healthcare Commercial	$1,124.55
Rate for Payer: United Healthcare Commercial	$852.28
Rate for Payer: United Healthcare Medicare	$238.40
Rate for Payer: United Healthcare Medicare	$314.56
Rate for Payer: Veterans Affairs TRICARE	$311.41
Rate for Payer: Veterans Affairs TRICARE	$236.02

glimepiride 2 mg Tab [CQCH]

Facility

$0.53

Service Code	NDC 68084032601
Hospital Charge Code	105924275
Hospital Revenue Code	251
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

glimepiride 2 mg Tab [CQCH]

Facility

$0.53

Service Code	NDC 68084032601
Hospital Charge Code	105924275
Hospital Revenue Code	251
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

glipiZIDE 5 mg Tab [CQCH]

Facility

$0.25

Service Code	NDC 904663761
Hospital Charge Code	105924407
Hospital Revenue Code	251
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of AZ Commercial	$0.23
Rate for Payer: Cash Price	$0.20

glipiZIDE 5 mg Tab [CQCH]

Facility

$0.25

Service Code	NDC 904663761
Hospital Charge Code	105924407
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of AZ Commercial	$0.23
Rate for Payer: Arizona Complete Health Allwell	$0.04
Rate for Payer: Banner UC Health Medicare	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.17
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.04
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna of AZ Commercial	$0.16
Rate for Payer: Devoted Health Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Southwest Service Administrators UFCW	$0.17
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: United Healthcare Commercial	$0.14
Rate for Payer: United Healthcare Medicare	$0.04
Rate for Payer: Veterans Affairs TRICARE	$0.04

glipiZIDE XL 5 mg ER Tab [CQCH]

Facility

$0.12

Service Code	NDC 64980028001
Hospital Charge Code	105924342
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of AZ Commercial	$0.11
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	$0.08
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	$0.09
Rate for Payer: Cigna of AZ Commercial	$0.08
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.08
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.07
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

glipiZIDE XL 5 mg ER Tab [CQCH]

Facility

$0.12

Service Code	NDC 64980028001
Hospital Charge Code	105924342
Hospital Revenue Code	251
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of AZ Commercial	$0.11
Rate for Payer: Cash Price	$0.09

GLOVE BIOGEL 6.00

Facility

$11.00

Hospital Charge Code	22543188
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

GLOVE BIOGEL 6.00

Facility

$11.00

Hospital Charge Code	22543188
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

glucagon 1 mg Inj [CQCH]

Facility

$233.41

Service Code	HCPCS J1610
Hospital Charge Code	105924472
Hospital Revenue Code	250
Min. Negotiated Rate	$210.07
Max. Negotiated Rate	$210.07
Rate for Payer: Aetna of AZ Commercial	$210.07
Rate for Payer: Cash Price	$186.73

Know your out-of-pocket cost for care.

All Charges