Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

glycopyrrolate 0.2 mg/mL Inj Sol [CQCH]

Facility

$2.72

Service Code	HCPCS J7642
Hospital Charge Code	105924820
Hospital Revenue Code	250
Min. Negotiated Rate	$2.45
Max. Negotiated Rate	$2.45
Rate for Payer: Aetna of AZ Commercial	$2.45
Rate for Payer: Cash Price	$2.17

glycopyrrolate 0.2 mg/mL Inj Sol [CQCH]

Facility

$2.72

Service Code	HCPCS J7642
Hospital Charge Code	105924820
Hospital Revenue Code	250
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$2.45
Rate for Payer: Aetna of AZ Commercial	$2.45
Rate for Payer: Arizona Complete Health Allwell	$0.44
Rate for Payer: Banner UC Health Medicare	$0.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.85
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.44
Rate for Payer: Cash Price	$2.17
Rate for Payer: Cigna of AZ Commercial	$1.77
Rate for Payer: Devoted Health Medicare	$0.49
Rate for Payer: Humana of AZ Medicare	$0.44
Rate for Payer: Southwest Service Administrators UFCW	$1.85
Rate for Payer: TriWest Medicare	$0.44
Rate for Payer: United Healthcare Commercial	$1.56
Rate for Payer: United Healthcare Medicare	$0.44
Rate for Payer: Veterans Affairs TRICARE	$0.43

golimumab 50 mg/4 mL Sol[CQCH]

Facility

$484.56

Service Code	HCPCS J1602
Hospital Charge Code	199590300
Hospital Revenue Code	250
Min. Negotiated Rate	$436.10
Max. Negotiated Rate	$436.10
Rate for Payer: Aetna of AZ Commercial	$436.10
Rate for Payer: Cash Price	$387.65

golimumab 50 mg/4 mL Sol[CQCH]

Facility

$484.56

Service Code	HCPCS J1602
Hospital Charge Code	199590300
Hospital Revenue Code	250
Min. Negotiated Rate	$16.01
Max. Negotiated Rate	$436.10
Rate for Payer: Aetna of AZ Commercial	$436.10
Rate for Payer: Arizona Complete Health Allwell	$77.53
Rate for Payer: Banner UC Health Medicare	$77.53
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$329.50
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$77.53
Rate for Payer: Care1st Health Plan Arizona Medicare	$77.53
Rate for Payer: Cash Price	$387.65
Rate for Payer: Cash Price	$387.65
Rate for Payer: Cigna of AZ Commercial	$314.96
Rate for Payer: Devoted Health Medicare	$87.22
Rate for Payer: Humana of AZ Medicare	$77.53
Rate for Payer: Seven Corners Travel Insurance	$16.01
Rate for Payer: Southwest Service Administrators UFCW	$329.50
Rate for Payer: TriWest Medicare	$77.53
Rate for Payer: United Healthcare Commercial	$277.17
Rate for Payer: United Healthcare Medicare	$77.53
Rate for Payer: Veterans Affairs TRICARE	$76.75

gramicidin/neomycin/polymyxin B Ophth Sol [CQCH]

Facility

$47.44

Service Code	NDC 24208079062
Hospital Charge Code	105924896
Hospital Revenue Code	251
Min. Negotiated Rate	$7.51
Max. Negotiated Rate	$42.70
Rate for Payer: Aetna of AZ Commercial	$42.70
Rate for Payer: Arizona Complete Health Allwell	$7.59
Rate for Payer: Banner UC Health Medicare	$7.59
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$32.26
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.59
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.59
Rate for Payer: Cash Price	$37.95
Rate for Payer: Cigna of AZ Commercial	$30.84
Rate for Payer: Devoted Health Medicare	$8.54
Rate for Payer: Humana of AZ Medicare	$7.59
Rate for Payer: Southwest Service Administrators UFCW	$32.26
Rate for Payer: TriWest Medicare	$7.59
Rate for Payer: United Healthcare Commercial	$27.14
Rate for Payer: United Healthcare Medicare	$7.59
Rate for Payer: Veterans Affairs TRICARE	$7.51

gramicidin/neomycin/polymyxin B Ophth Sol [CQCH]

Facility

$47.44

Service Code	NDC 24208079062
Hospital Charge Code	105924896
Hospital Revenue Code	251
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$42.70
Rate for Payer: Aetna of AZ Commercial	$42.70
Rate for Payer: Cash Price	$37.95

Gram Stain

Facility

$107.00

Service Code	CPT 87205
Hospital Charge Code	850753
Hospital Revenue Code	306
Min. Negotiated Rate	$96.30
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Cash Price	$85.60

Gram Stain

Facility

$107.00

Service Code	CPT 87205
Hospital Charge Code	3426222
Hospital Revenue Code	306
Min. Negotiated Rate	$96.30
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Cash Price	$85.60

Gram Stain

Facility

$107.00

Service Code	CPT 87205
Hospital Charge Code	3426222
Hospital Revenue Code	306
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Arizona Complete Health Allwell	$17.12
Rate for Payer: Banner UC Health Medicare	$17.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$72.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.12
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cigna of AZ Commercial	$69.55
Rate for Payer: Devoted Health Medicare	$19.26
Rate for Payer: Humana of AZ Medicare	$17.12
Rate for Payer: Seven Corners Travel Insurance	$6.19
Rate for Payer: Southwest Service Administrators UFCW	$72.76
Rate for Payer: TriWest Medicare	$17.12
Rate for Payer: United Healthcare Commercial	$61.20
Rate for Payer: United Healthcare Medicare	$17.12
Rate for Payer: Veterans Affairs TRICARE	$16.95

Gram Stain

Facility

$107.00

Service Code	CPT 87205
Hospital Charge Code	850753
Hospital Revenue Code	306
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Arizona Complete Health Allwell	$17.12
Rate for Payer: Banner UC Health Medicare	$17.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$72.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.12
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cigna of AZ Commercial	$69.55
Rate for Payer: Devoted Health Medicare	$19.26
Rate for Payer: Humana of AZ Medicare	$17.12
Rate for Payer: Seven Corners Travel Insurance	$6.19
Rate for Payer: Southwest Service Administrators UFCW	$72.76
Rate for Payer: TriWest Medicare	$17.12
Rate for Payer: United Healthcare Commercial	$61.20
Rate for Payer: United Healthcare Medicare	$17.12
Rate for Payer: Veterans Affairs TRICARE	$16.95

GRAM STAIN

Facility

$112.00

Service Code	CPT 87205
Hospital Charge Code	22513017
Hospital Revenue Code	306
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of AZ Commercial	$100.80
Rate for Payer: Arizona Complete Health Allwell	$17.92
Rate for Payer: Banner UC Health Medicare	$17.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$76.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.92
Rate for Payer: Cash Price	$89.60
Rate for Payer: Cash Price	$89.60
Rate for Payer: Cigna of AZ Commercial	$72.80
Rate for Payer: Devoted Health Medicare	$20.16
Rate for Payer: Humana of AZ Medicare	$17.92
Rate for Payer: Seven Corners Travel Insurance	$6.19
Rate for Payer: Southwest Service Administrators UFCW	$76.16
Rate for Payer: TriWest Medicare	$17.92
Rate for Payer: United Healthcare Commercial	$64.06
Rate for Payer: United Healthcare Medicare	$17.92
Rate for Payer: Veterans Affairs TRICARE	$17.74

GRAM STAIN

Facility

$112.00

Service Code	CPT 87205
Hospital Charge Code	22513017
Hospital Revenue Code	306
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of AZ Commercial	$100.80
Rate for Payer: Cash Price	$89.60

Gram Stain Report

Facility

$102.00

Service Code	CPT 87205
Hospital Charge Code	634217
Hospital Revenue Code	306
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$91.80
Rate for Payer: Aetna of AZ Commercial	$91.80
Rate for Payer: Arizona Complete Health Allwell	$16.32
Rate for Payer: Banner UC Health Medicare	$16.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$69.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.32
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cigna of AZ Commercial	$66.30
Rate for Payer: Devoted Health Medicare	$18.36
Rate for Payer: Humana of AZ Medicare	$16.32
Rate for Payer: Seven Corners Travel Insurance	$6.19
Rate for Payer: Southwest Service Administrators UFCW	$69.36
Rate for Payer: TriWest Medicare	$16.32
Rate for Payer: United Healthcare Commercial	$58.34
Rate for Payer: United Healthcare Medicare	$16.32
Rate for Payer: Veterans Affairs TRICARE	$16.16

Gram Stain Report

Facility

$102.00

Service Code	CPT 87205
Hospital Charge Code	634217
Hospital Revenue Code	306
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$91.80
Rate for Payer: Aetna of AZ Commercial	$91.80
Rate for Payer: Cash Price	$81.60

GRASPING FORCEPS

Facility

$1,075.00

Hospital Charge Code	27750225
Hospital Revenue Code	270
Min. Negotiated Rate	$170.28
Max. Negotiated Rate	$967.50
Rate for Payer: Aetna of AZ Commercial	$967.50
Rate for Payer: Arizona Complete Health Allwell	$172.00
Rate for Payer: Banner UC Health Medicare	$172.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$731.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$172.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$172.00
Rate for Payer: Cash Price	$860.00
Rate for Payer: Cigna of AZ Commercial	$752.50
Rate for Payer: Devoted Health Medicare	$193.50
Rate for Payer: Humana of AZ Medicare	$172.00
Rate for Payer: Southwest Service Administrators UFCW	$731.00
Rate for Payer: TriWest Medicare	$172.00
Rate for Payer: United Healthcare Commercial	$614.90
Rate for Payer: United Healthcare Medicare	$172.00
Rate for Payer: Veterans Affairs TRICARE	$170.28

GRASPING FORCEPS

Facility

$1,075.00

Hospital Charge Code	27750225
Hospital Revenue Code	270
Min. Negotiated Rate	$967.50
Max. Negotiated Rate	$967.50
Rate for Payer: Aetna of AZ Commercial	$967.50
Rate for Payer: Cash Price	$860.00

GROWTH HORMONE, HUMAN (HGH) (SOMATOTROPIN)

Facility

$83.00

Service Code	CPT 83003
Hospital Charge Code	28011459
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

GROWTH HORMONE, HUMAN (HGH) (SOMATOTROPIN)

Facility

$83.00

Service Code	CPT 83003
Hospital Charge Code	28011459
Hospital Revenue Code	302
Min. Negotiated Rate	$13.15
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	$24.17
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

GST GREEN RELOAD 45MM

Facility

$10,811.20

Hospital Charge Code	27770799
Hospital Revenue Code	270
Min. Negotiated Rate	$1,712.49
Max. Negotiated Rate	$9,730.08
Rate for Payer: Aetna of AZ Commercial	$9,730.08
Rate for Payer: Arizona Complete Health Allwell	$1,729.79
Rate for Payer: Banner UC Health Medicare	$1,729.79
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$7,351.62
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,729.79
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,729.79
Rate for Payer: Cash Price	$8,648.96
Rate for Payer: Cigna of AZ Commercial	$7,567.84
Rate for Payer: Devoted Health Medicare	$1,946.02
Rate for Payer: Humana of AZ Medicare	$1,729.79
Rate for Payer: Southwest Service Administrators UFCW	$7,351.62
Rate for Payer: TriWest Medicare	$1,729.79
Rate for Payer: United Healthcare Commercial	$6,184.01
Rate for Payer: United Healthcare Medicare	$1,729.79
Rate for Payer: Veterans Affairs TRICARE	$1,712.49

GST GREEN RELOAD 45MM

Facility

$10,811.20

Hospital Charge Code	27770799
Hospital Revenue Code	270
Min. Negotiated Rate	$9,730.08
Max. Negotiated Rate	$9,730.08
Rate for Payer: Aetna of AZ Commercial	$9,730.08
Rate for Payer: Cash Price	$8,648.96

.GTT-1 Hr

Facility

$244.00

Service Code	CPT 82952
Hospital Charge Code	1160798
Hospital Revenue Code	301
Min. Negotiated Rate	$219.60
Max. Negotiated Rate	$219.60
Rate for Payer: Aetna of AZ Commercial	$219.60
Rate for Payer: Cash Price	$195.20

.GTT-1 Hr

Facility

$244.00

Service Code	CPT 82952
Hospital Charge Code	1160798
Hospital Revenue Code	301
Min. Negotiated Rate	$5.68
Max. Negotiated Rate	$219.60
Rate for Payer: Aetna of AZ Commercial	$219.60
Rate for Payer: Arizona Complete Health Allwell	$39.04
Rate for Payer: Banner UC Health Medicare	$39.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$165.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$39.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$39.04
Rate for Payer: Cash Price	$195.20
Rate for Payer: Cash Price	$195.20
Rate for Payer: Cigna of AZ Commercial	$158.60
Rate for Payer: Devoted Health Medicare	$43.92
Rate for Payer: Humana of AZ Medicare	$39.04
Rate for Payer: Seven Corners Travel Insurance	$5.68
Rate for Payer: Southwest Service Administrators UFCW	$165.92
Rate for Payer: TriWest Medicare	$39.04
Rate for Payer: United Healthcare Commercial	$139.57
Rate for Payer: United Healthcare Medicare	$39.04
Rate for Payer: Veterans Affairs TRICARE	$38.65

.GTT-2 Hr

Facility

$284.00

Service Code	CPT 82951
Hospital Charge Code	1160799
Hospital Revenue Code	306
Min. Negotiated Rate	$18.66
Max. Negotiated Rate	$255.60
Rate for Payer: Aetna of AZ Commercial	$255.60
Rate for Payer: Arizona Complete Health Allwell	$45.44
Rate for Payer: Banner UC Health Medicare	$45.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$193.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$45.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$45.44
Rate for Payer: Cash Price	$227.20
Rate for Payer: Cash Price	$227.20
Rate for Payer: Cigna of AZ Commercial	$184.60
Rate for Payer: Devoted Health Medicare	$51.12
Rate for Payer: Humana of AZ Medicare	$45.44
Rate for Payer: Seven Corners Travel Insurance	$18.66
Rate for Payer: Southwest Service Administrators UFCW	$193.12
Rate for Payer: TriWest Medicare	$45.44
Rate for Payer: United Healthcare Commercial	$162.45
Rate for Payer: United Healthcare Medicare	$45.44
Rate for Payer: Veterans Affairs TRICARE	$44.99

.GTT-2 Hr

Facility

$284.00

Service Code	CPT 82951
Hospital Charge Code	1160799
Hospital Revenue Code	306
Min. Negotiated Rate	$255.60
Max. Negotiated Rate	$255.60
Rate for Payer: Aetna of AZ Commercial	$255.60
Rate for Payer: Cash Price	$227.20

.GTT 2Hr Post Prandial

Facility

$83.00

Service Code	CPT 82950
Hospital Charge Code	1165876
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

Know your out-of-pocket cost for care.

All Charges