Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

.GTT 2Hr Post Prandial

Facility

$83.00

Service Code	CPT 82950
Hospital Charge Code	1165876
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

GTT 3-Hour

Facility

$284.00

Service Code	CPT 82951
Hospital Charge Code	10349371
Hospital Revenue Code	301
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 3-Hour

Facility

$284.00

Service Code	CPT 82951
Hospital Charge Code	10349371
Hospital Revenue Code	301
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-3 Hr

Facility

$283.00

Hospital Charge Code	1160800
Hospital Revenue Code	301
Min. Negotiated Rate	$44.83
Max. Negotiated Rate	$254.70
Rate for Payer: Aetna of AZ Commercial	$254.70
Rate for Payer: Arizona Complete Health Allwell	$45.28
Rate for Payer: Banner UC Health Medicare	$45.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$192.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$45.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$45.28
Rate for Payer: Cash Price	$226.40
Rate for Payer: Cigna of AZ Commercial	$183.95
Rate for Payer: Devoted Health Medicare	$50.94
Rate for Payer: Humana of AZ Medicare	$45.28
Rate for Payer: Southwest Service Administrators UFCW	$192.44
Rate for Payer: TriWest Medicare	$45.28
Rate for Payer: United Healthcare Commercial	$161.88
Rate for Payer: United Healthcare Medicare	$45.28
Rate for Payer: Veterans Affairs TRICARE	$44.83

.GTT-3 Hr

Facility

$283.00

Hospital Charge Code	1160800
Hospital Revenue Code	301
Min. Negotiated Rate	$254.70
Max. Negotiated Rate	$254.70
Rate for Payer: Aetna of AZ Commercial	$254.70
Rate for Payer: Cash Price	$226.40

GTT Each Add

Facility

$33.00

Service Code	CPT 82952
Hospital Charge Code	22525225
Hospital Revenue Code	301
Min. Negotiated Rate	$5.23
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Arizona Complete Health Allwell	$5.28
Rate for Payer: Banner UC Health Medicare	$5.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$22.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.28
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cigna of AZ Commercial	$21.45
Rate for Payer: Devoted Health Medicare	$5.94
Rate for Payer: Humana of AZ Medicare	$5.28
Rate for Payer: Seven Corners Travel Insurance	$5.68
Rate for Payer: Southwest Service Administrators UFCW	$22.44
Rate for Payer: TriWest Medicare	$5.28
Rate for Payer: United Healthcare Commercial	$18.88
Rate for Payer: United Healthcare Medicare	$5.28
Rate for Payer: Veterans Affairs TRICARE	$5.23

GTT Each Add

Facility

$33.00

Service Code	CPT 82952
Hospital Charge Code	22525225
Hospital Revenue Code	301
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Cash Price	$26.40

GTT OB 3 Hour

Facility

$298.00

Service Code	CPT 82951
Hospital Charge Code	22283156
Hospital Revenue Code	301
Min. Negotiated Rate	$18.66
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Arizona Complete Health Allwell	$47.68
Rate for Payer: Banner UC Health Medicare	$47.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$202.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$47.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$47.68
Rate for Payer: Cash Price	$238.40
Rate for Payer: Cash Price	$238.40
Rate for Payer: Cigna of AZ Commercial	$193.70
Rate for Payer: Devoted Health Medicare	$53.64
Rate for Payer: Humana of AZ Medicare	$47.68
Rate for Payer: Seven Corners Travel Insurance	$18.66
Rate for Payer: Southwest Service Administrators UFCW	$202.64
Rate for Payer: TriWest Medicare	$47.68
Rate for Payer: United Healthcare Commercial	$170.46
Rate for Payer: United Healthcare Medicare	$47.68
Rate for Payer: Veterans Affairs TRICARE	$47.20

GTT OB 3 Hour

Facility

$298.00

Service Code	CPT 82951
Hospital Charge Code	22283156
Hospital Revenue Code	301
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Cash Price	$238.40

guaiFENesin 100 mg/5 mL UD Oral Liq [CQCH]

Facility

$0.03

Service Code	NDC 121174405
Hospital Charge Code	105925028
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

guaiFENesin 100 mg/5 mL UD Oral Liq [CQCH]

Facility

$0.03

Service Code	NDC 121174405
Hospital Charge Code	105925028
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

guaiFENesin 600 mg ER Tablet [CQCH]

Facility

$0.33

Service Code	NDC 63824000834
Hospital Charge Code	105924961
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

guaiFENesin 600 mg ER Tablet [CQCH]

Facility

$0.33

Service Code	NDC 63824000834
Hospital Charge Code	105924961
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

guaiFENesin-dextromethorphan 100 mg-10 mg/5 mL UD Oral Liq [CQCH]

Facility

$0.13

Service Code	NDC 121063805
Hospital Charge Code	105918158
Hospital Revenue Code	251
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Cash Price	$0.10

guaiFENesin-dextromethorphan 100 mg-10 mg/5 mL UD Oral Liq [CQCH]

Facility

$0.13

Service Code	NDC 121063805
Hospital Charge Code	105918158
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
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	$0.09
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	$0.10
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	$0.09
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

GUIDEWIRE HI WIRE NITINOL CORE

Facility

$153.00

Hospital Charge Code	22354824
Hospital Revenue Code	270
Min. Negotiated Rate	$137.70
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of AZ Commercial	$137.70
Rate for Payer: Cash Price	$122.40

GUIDEWIRE HI WIRE NITINOL CORE

Facility

$153.00

Hospital Charge Code	22354824
Hospital Revenue Code	270
Min. Negotiated Rate	$24.24
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of AZ Commercial	$137.70
Rate for Payer: Arizona Complete Health Allwell	$24.48
Rate for Payer: Banner UC Health Medicare	$24.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$104.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$24.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$24.48
Rate for Payer: Cash Price	$122.40
Rate for Payer: Cigna of AZ Commercial	$107.10
Rate for Payer: Devoted Health Medicare	$27.54
Rate for Payer: Humana of AZ Medicare	$24.48
Rate for Payer: Southwest Service Administrators UFCW	$104.04
Rate for Payer: TriWest Medicare	$24.48
Rate for Payer: United Healthcare Commercial	$87.52
Rate for Payer: United Healthcare Medicare	$24.48
Rate for Payer: Veterans Affairs TRICARE	$24.24

GUIDE WIRE SMOOTH .82 X 90MM DOUBLE POINT

Facility

$89.00

Hospital Charge Code	24127799
Hospital Revenue Code	270
Min. Negotiated Rate	$80.10
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of AZ Commercial	$80.10
Rate for Payer: Cash Price	$71.20

GUIDE WIRE SMOOTH .82 X 90MM DOUBLE POINT

Facility

$89.00

Hospital Charge Code	24127799
Hospital Revenue Code	270
Min. Negotiated Rate	$14.10
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of AZ Commercial	$80.10
Rate for Payer: Arizona Complete Health Allwell	$14.24
Rate for Payer: Banner UC Health Medicare	$14.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$60.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.24
Rate for Payer: Cash Price	$71.20
Rate for Payer: Cigna of AZ Commercial	$62.30
Rate for Payer: Devoted Health Medicare	$16.02
Rate for Payer: Humana of AZ Medicare	$14.24
Rate for Payer: Southwest Service Administrators UFCW	$60.52
Rate for Payer: TriWest Medicare	$14.24
Rate for Payer: United Healthcare Commercial	$50.91
Rate for Payer: United Healthcare Medicare	$14.24
Rate for Payer: Veterans Affairs TRICARE	$14.10

GYRUS ACMI SOF CURL URETERAL STENT 6.X24

Facility

$720.00

Hospital Charge Code	22354135
Hospital Revenue Code	270
Min. Negotiated Rate	$114.05
Max. Negotiated Rate	$648.00
Rate for Payer: Aetna of AZ Commercial	$648.00
Rate for Payer: Arizona Complete Health Allwell	$115.20
Rate for Payer: Banner UC Health Medicare	$115.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$489.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$115.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$115.20
Rate for Payer: Cash Price	$576.00
Rate for Payer: Cigna of AZ Commercial	$504.00
Rate for Payer: Devoted Health Medicare	$129.60
Rate for Payer: Humana of AZ Medicare	$115.20
Rate for Payer: Southwest Service Administrators UFCW	$489.60
Rate for Payer: TriWest Medicare	$115.20
Rate for Payer: United Healthcare Commercial	$411.84
Rate for Payer: United Healthcare Medicare	$115.20
Rate for Payer: Veterans Affairs TRICARE	$114.05

GYRUS ACMI SOF CURL URETERAL STENT 6.X24

Facility

$720.00

Hospital Charge Code	22354135
Hospital Revenue Code	270
Min. Negotiated Rate	$648.00
Max. Negotiated Rate	$648.00
Rate for Payer: Aetna of AZ Commercial	$648.00
Rate for Payer: Cash Price	$576.00

GYRUS ACMI SOF CURL URETERAL STENT 6.X26

Facility

$720.00

Hospital Charge Code	22354136
Hospital Revenue Code	270
Min. Negotiated Rate	$114.05
Max. Negotiated Rate	$648.00
Rate for Payer: Aetna of AZ Commercial	$648.00
Rate for Payer: Arizona Complete Health Allwell	$115.20
Rate for Payer: Banner UC Health Medicare	$115.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$489.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$115.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$115.20
Rate for Payer: Cash Price	$576.00
Rate for Payer: Cigna of AZ Commercial	$504.00
Rate for Payer: Devoted Health Medicare	$129.60
Rate for Payer: Humana of AZ Medicare	$115.20
Rate for Payer: Southwest Service Administrators UFCW	$489.60
Rate for Payer: TriWest Medicare	$115.20
Rate for Payer: United Healthcare Commercial	$411.84
Rate for Payer: United Healthcare Medicare	$115.20
Rate for Payer: Veterans Affairs TRICARE	$114.05

GYRUS ACMI SOF CURL URETERAL STENT 6.X26

Facility

$720.00

Hospital Charge Code	22354136
Hospital Revenue Code	270
Min. Negotiated Rate	$648.00
Max. Negotiated Rate	$648.00
Rate for Payer: Aetna of AZ Commercial	$648.00
Rate for Payer: Cash Price	$576.00

GYRUS ACMI SUR CATCH NT BASKET 2.2FR

Facility

$823.00

Hospital Charge Code	22354137
Hospital Revenue Code	270
Min. Negotiated Rate	$740.70
Max. Negotiated Rate	$740.70
Rate for Payer: Aetna of AZ Commercial	$740.70
Rate for Payer: Cash Price	$658.40

GYRUS ACMI SUR CATCH NT BASKET 2.2FR

Facility

$823.00

Hospital Charge Code	22354137
Hospital Revenue Code	270
Min. Negotiated Rate	$130.36
Max. Negotiated Rate	$740.70
Rate for Payer: Aetna of AZ Commercial	$740.70
Rate for Payer: Arizona Complete Health Allwell	$131.68
Rate for Payer: Banner UC Health Medicare	$131.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$559.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$131.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$131.68
Rate for Payer: Cash Price	$658.40
Rate for Payer: Cigna of AZ Commercial	$576.10
Rate for Payer: Devoted Health Medicare	$148.14
Rate for Payer: Humana of AZ Medicare	$131.68
Rate for Payer: Southwest Service Administrators UFCW	$559.64
Rate for Payer: TriWest Medicare	$131.68
Rate for Payer: United Healthcare Commercial	$470.76
Rate for Payer: United Healthcare Medicare	$131.68
Rate for Payer: Veterans Affairs TRICARE	$130.36

Know your out-of-pocket cost for care.

All Charges