Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

glucagon 1 mg Inj [CQCH]

Facility

$233.41

Service Code	HCPCS J1610
Hospital Charge Code	105924472
Hospital Revenue Code	250
Min. Negotiated Rate	$36.97
Max. Negotiated Rate	$210.07
Rate for Payer: Aetna of AZ Commercial	$210.07
Rate for Payer: Arizona Complete Health Allwell	$37.35
Rate for Payer: Banner UC Health Medicare	$37.35
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$158.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$37.35
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.35
Rate for Payer: Cash Price	$186.73
Rate for Payer: Cash Price	$186.73
Rate for Payer: Cigna of AZ Commercial	$151.72
Rate for Payer: Devoted Health Medicare	$42.01
Rate for Payer: Humana of AZ Medicare	$37.35
Rate for Payer: Seven Corners Travel Insurance	$170.13
Rate for Payer: Southwest Service Administrators UFCW	$158.72
Rate for Payer: TriWest Medicare	$37.35
Rate for Payer: United Healthcare Commercial	$133.51
Rate for Payer: United Healthcare Medicare	$37.35
Rate for Payer: Veterans Affairs TRICARE	$36.97

Glucose 2 Hour Post Prandial

Facility

$83.00

Service Code	CPT 82950
Hospital Charge Code	633598
Hospital Revenue Code	301
Min. Negotiated Rate	$6.89
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of AZ Commercial	$74.70
Rate for Payer: Arizona Complete Health Allwell	$13.28
Rate for Payer: Banner UC Health Medicare	$13.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$56.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.28
Rate for Payer: Cash Price	$66.40
Rate for Payer: Cash Price	$66.40
Rate for Payer: Cigna of AZ Commercial	$53.95
Rate for Payer: Devoted Health Medicare	$14.94
Rate for Payer: Humana of AZ Medicare	$13.28
Rate for Payer: Seven Corners Travel Insurance	$6.89
Rate for Payer: Southwest Service Administrators UFCW	$56.44
Rate for Payer: TriWest Medicare	$13.28
Rate for Payer: United Healthcare Commercial	$47.48
Rate for Payer: United Healthcare Medicare	$13.28
Rate for Payer: Veterans Affairs TRICARE	$13.15

Glucose 2 Hour Post Prandial

Facility

$83.00

Service Code	CPT 82950
Hospital Charge Code	633598
Hospital Revenue Code	301
Min. Negotiated Rate	$74.70
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of AZ Commercial	$74.70
Rate for Payer: Cash Price	$66.40

Glucose 2 HR PP

Facility

$83.00

Service Code	CPT 82950
Hospital Charge Code	22245891
Hospital Revenue Code	302
Min. Negotiated Rate	$6.89
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of AZ Commercial	$74.70
Rate for Payer: Arizona Complete Health Allwell	$13.28
Rate for Payer: Banner UC Health Medicare	$13.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$56.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.28
Rate for Payer: Cash Price	$66.40
Rate for Payer: Cash Price	$66.40
Rate for Payer: Cigna of AZ Commercial	$53.95
Rate for Payer: Devoted Health Medicare	$14.94
Rate for Payer: Humana of AZ Medicare	$13.28
Rate for Payer: Seven Corners Travel Insurance	$6.89
Rate for Payer: Southwest Service Administrators UFCW	$56.44
Rate for Payer: TriWest Medicare	$13.28
Rate for Payer: United Healthcare Commercial	$47.48
Rate for Payer: United Healthcare Medicare	$13.28
Rate for Payer: Veterans Affairs TRICARE	$13.15

Glucose 2 HR PP

Facility

$83.00

Service Code	CPT 82950
Hospital Charge Code	22245891
Hospital Revenue Code	302
Min. Negotiated Rate	$74.70
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of AZ Commercial	$74.70
Rate for Payer: Cash Price	$66.40

Glucose CSF

Facility

$79.00

Service Code	CPT 82945
Hospital Charge Code	633604
Hospital Revenue Code	301
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$71.10
Rate for Payer: Aetna of AZ Commercial	$71.10
Rate for Payer: Arizona Complete Health Allwell	$12.64
Rate for Payer: Banner UC Health Medicare	$12.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$53.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.64
Rate for Payer: Cash Price	$63.20
Rate for Payer: Cash Price	$63.20
Rate for Payer: Cigna of AZ Commercial	$51.35
Rate for Payer: Devoted Health Medicare	$14.22
Rate for Payer: Humana of AZ Medicare	$12.64
Rate for Payer: Seven Corners Travel Insurance	$5.70
Rate for Payer: Southwest Service Administrators UFCW	$53.72
Rate for Payer: TriWest Medicare	$12.64
Rate for Payer: United Healthcare Commercial	$45.19
Rate for Payer: United Healthcare Medicare	$12.64
Rate for Payer: Veterans Affairs TRICARE	$12.51

Glucose CSF

Facility

$79.00

Service Code	CPT 82945
Hospital Charge Code	633604
Hospital Revenue Code	301
Min. Negotiated Rate	$71.10
Max. Negotiated Rate	$71.10
Rate for Payer: Aetna of AZ Commercial	$71.10
Rate for Payer: Cash Price	$63.20

Glucose Fasting

Facility

$78.00

Service Code	CPT 82947
Hospital Charge Code	633593
Hospital Revenue Code	301
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Arizona Complete Health Allwell	$12.48
Rate for Payer: Banner UC Health Medicare	$12.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$53.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.48
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cigna of AZ Commercial	$50.70
Rate for Payer: Devoted Health Medicare	$14.04
Rate for Payer: Humana of AZ Medicare	$12.48
Rate for Payer: Seven Corners Travel Insurance	$5.70
Rate for Payer: Southwest Service Administrators UFCW	$53.04
Rate for Payer: TriWest Medicare	$12.48
Rate for Payer: United Healthcare Commercial	$44.62
Rate for Payer: United Healthcare Medicare	$12.48
Rate for Payer: Veterans Affairs TRICARE	$12.36

Glucose Fasting

Facility

$78.00

Service Code	CPT 82947
Hospital Charge Code	633593
Hospital Revenue Code	301
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Cash Price	$62.40

Glucose Level

Facility

$82.00

Service Code	CPT 82947
Hospital Charge Code	633594
Hospital Revenue Code	301
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Arizona Complete Health Allwell	$13.12
Rate for Payer: Banner UC Health Medicare	$13.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$55.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.12
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cigna of AZ Commercial	$53.30
Rate for Payer: Devoted Health Medicare	$14.76
Rate for Payer: Humana of AZ Medicare	$13.12
Rate for Payer: Seven Corners Travel Insurance	$5.70
Rate for Payer: Southwest Service Administrators UFCW	$55.76
Rate for Payer: TriWest Medicare	$13.12
Rate for Payer: United Healthcare Commercial	$46.90
Rate for Payer: United Healthcare Medicare	$13.12
Rate for Payer: Veterans Affairs TRICARE	$12.99

Glucose Level

Facility

$82.00

Service Code	CPT 82947
Hospital Charge Code	633594
Hospital Revenue Code	301
Min. Negotiated Rate	$73.80
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Cash Price	$65.60

Glucose Level POCT

Facility

$82.00

Service Code	CPT 82948
Hospital Charge Code	23597236
Hospital Revenue Code	301
Min. Negotiated Rate	$7.31
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Arizona Complete Health Allwell	$13.12
Rate for Payer: Banner UC Health Medicare	$13.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$55.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.12
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cigna of AZ Commercial	$53.30
Rate for Payer: Devoted Health Medicare	$14.76
Rate for Payer: Humana of AZ Medicare	$13.12
Rate for Payer: Seven Corners Travel Insurance	$7.31
Rate for Payer: Southwest Service Administrators UFCW	$55.76
Rate for Payer: TriWest Medicare	$13.12
Rate for Payer: United Healthcare Commercial	$46.90
Rate for Payer: United Healthcare Medicare	$13.12
Rate for Payer: Veterans Affairs TRICARE	$12.99

Glucose Level POCT

Facility

$82.00

Service Code	CPT 82948
Hospital Charge Code	23597236
Hospital Revenue Code	301
Min. Negotiated Rate	$73.80
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Cash Price	$65.60

glucose oral Gel 15 gm dextrose in 37.5 gm [CQCH]

Facility

$0.21

Service Code	NDC 574006930
Hospital Charge Code	108473448
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of AZ Commercial	$0.19
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	$0.17
Rate for Payer: Cigna of AZ Commercial	$0.14
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	$0.12
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

glucose oral Gel 15 gm dextrose in 37.5 gm [CQCH]

Facility

$0.21

Service Code	NDC 574006930
Hospital Charge Code	108473448
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of AZ Commercial	$0.19
Rate for Payer: Cash Price	$0.17

Glucose POC (Lab)

Facility

$37.00

Service Code	CPT 82962
Hospital Charge Code	10456470
Hospital Revenue Code	301
Min. Negotiated Rate	$33.30
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Cash Price	$29.60

Glucose POC (Lab)

Facility

$37.00

Service Code	CPT 82962
Hospital Charge Code	10456470
Hospital Revenue Code	301
Min. Negotiated Rate	$4.76
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Arizona Complete Health Allwell	$5.92
Rate for Payer: Banner UC Health Medicare	$5.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$25.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.92
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cigna of AZ Commercial	$24.05
Rate for Payer: Devoted Health Medicare	$6.66
Rate for Payer: Humana of AZ Medicare	$5.92
Rate for Payer: Seven Corners Travel Insurance	$4.76
Rate for Payer: Southwest Service Administrators UFCW	$25.16
Rate for Payer: TriWest Medicare	$5.92
Rate for Payer: United Healthcare Commercial	$21.16
Rate for Payer: United Healthcare Medicare	$5.92
Rate for Payer: Veterans Affairs TRICARE	$5.86

glyBURIDE 5 mg Tab [CQCH]

Facility

$0.33

Service Code	NDC 63739011910
Hospital Charge Code	105924688
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of AZ Commercial	$0.30
Rate for Payer: Arizona Complete Health Allwell	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.22
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.05
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.05
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna of AZ Commercial	$0.21
Rate for Payer: Devoted Health Medicare	$0.06
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Southwest Service Administrators UFCW	$0.22
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: United Healthcare Commercial	$0.19
Rate for Payer: United Healthcare Medicare	$0.05
Rate for Payer: Veterans Affairs TRICARE	$0.05

glyBURIDE 5 mg Tab [CQCH]

Facility

$0.33

Service Code	NDC 63739011910
Hospital Charge Code	105924688
Hospital Revenue Code	251
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of AZ Commercial	$0.30
Rate for Payer: Cash Price	$0.26

GLYCATED PROTEIN

Facility

$84.00

Service Code	CPT 82985
Hospital Charge Code	28010053
Hospital Revenue Code	302
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Cash Price	$67.20

GLYCATED PROTEIN

Facility

$84.00

Service Code	CPT 82985
Hospital Charge Code	28010053
Hospital Revenue Code	302
Min. Negotiated Rate	$13.31
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Arizona Complete Health Allwell	$13.44
Rate for Payer: Banner UC Health Medicare	$13.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$57.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.44
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cigna of AZ Commercial	$54.60
Rate for Payer: Devoted Health Medicare	$15.12
Rate for Payer: Humana of AZ Medicare	$13.44
Rate for Payer: Seven Corners Travel Insurance	$24.30
Rate for Payer: Southwest Service Administrators UFCW	$57.12
Rate for Payer: TriWest Medicare	$13.44
Rate for Payer: United Healthcare Commercial	$48.05
Rate for Payer: United Healthcare Medicare	$13.44
Rate for Payer: Veterans Affairs TRICARE	$13.31

glycerin pediatric Supp [CQCH]

Facility

$0.67

Service Code	NDC 713010209
Hospital Charge Code	105924755
Hospital Revenue Code	251
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of AZ Commercial	$0.60
Rate for Payer: Arizona Complete Health Allwell	$0.11
Rate for Payer: Banner UC Health Medicare	$0.11
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.46
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.11
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.11
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cigna of AZ Commercial	$0.44
Rate for Payer: Devoted Health Medicare	$0.12
Rate for Payer: Humana of AZ Medicare	$0.11
Rate for Payer: Southwest Service Administrators UFCW	$0.46
Rate for Payer: TriWest Medicare	$0.11
Rate for Payer: United Healthcare Commercial	$0.38
Rate for Payer: United Healthcare Medicare	$0.11
Rate for Payer: Veterans Affairs TRICARE	$0.11

glycerin pediatric Supp [CQCH]

Facility

$0.67

Service Code	NDC 713010209
Hospital Charge Code	105924755
Hospital Revenue Code	251
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of AZ Commercial	$0.60
Rate for Payer: Cash Price	$0.54

GlycoMark(R)(1,5 AG) LC

Facility

$78.00

Service Code	CPT 82945
Hospital Charge Code	2270019
Hospital Revenue Code	301
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Cash Price	$62.40

GlycoMark(R)(1,5 AG) LC

Facility

$78.00

Service Code	CPT 82945
Hospital Charge Code	2270019
Hospital Revenue Code	301
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Arizona Complete Health Allwell	$12.48
Rate for Payer: Banner UC Health Medicare	$12.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$53.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.48
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cigna of AZ Commercial	$50.70
Rate for Payer: Devoted Health Medicare	$14.04
Rate for Payer: Humana of AZ Medicare	$12.48
Rate for Payer: Seven Corners Travel Insurance	$5.70
Rate for Payer: Southwest Service Administrators UFCW	$53.04
Rate for Payer: TriWest Medicare	$12.48
Rate for Payer: United Healthcare Commercial	$44.62
Rate for Payer: United Healthcare Medicare	$12.48
Rate for Payer: Veterans Affairs TRICARE	$12.36

Know your out-of-pocket cost for care.

All Charges