Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

HSV Culture and Typing LC

Facility

$307.00

Service Code	CPT 87254
Hospital Charge Code	1906898
Hospital Revenue Code	306
Min. Negotiated Rate	$28.36
Max. Negotiated Rate	$276.30
Rate for Payer: Aetna of AZ Commercial	$276.30
Rate for Payer: Arizona Complete Health Allwell	$49.12
Rate for Payer: Banner UC Health Medicare	$49.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$208.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$49.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$49.12
Rate for Payer: Cash Price	$245.60
Rate for Payer: Cash Price	$245.60
Rate for Payer: Cigna of AZ Commercial	$199.55
Rate for Payer: Devoted Health Medicare	$55.26
Rate for Payer: Humana of AZ Medicare	$49.12
Rate for Payer: Seven Corners Travel Insurance	$28.36
Rate for Payer: Southwest Service Administrators UFCW	$208.76
Rate for Payer: TriWest Medicare	$49.12
Rate for Payer: United Healthcare Commercial	$175.60
Rate for Payer: United Healthcare Medicare	$49.12
Rate for Payer: Veterans Affairs TRICARE	$48.63

HSV Type 1-Specific Ab, IgG LC

Facility

$163.00

Service Code	CPT 86695
Hospital Charge Code	2087613
Hospital Revenue Code	302
Min. Negotiated Rate	$19.13
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Arizona Complete Health Allwell	$26.08
Rate for Payer: Banner UC Health Medicare	$26.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$110.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$26.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$26.08
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cigna of AZ Commercial	$105.95
Rate for Payer: Devoted Health Medicare	$29.34
Rate for Payer: Humana of AZ Medicare	$26.08
Rate for Payer: Seven Corners Travel Insurance	$19.13
Rate for Payer: Southwest Service Administrators UFCW	$110.84
Rate for Payer: TriWest Medicare	$26.08
Rate for Payer: United Healthcare Commercial	$93.24
Rate for Payer: United Healthcare Medicare	$26.08
Rate for Payer: Veterans Affairs TRICARE	$25.82

HSV Type 1-Specific Ab, IgG LC

Facility

$163.00

Service Code	CPT 86695
Hospital Charge Code	2087613
Hospital Revenue Code	302
Min. Negotiated Rate	$146.70
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Cash Price	$130.40

HSV Type 2-Specific Ab, IgG LC

Facility

$229.00

Service Code	CPT 86696
Hospital Charge Code	1906902
Hospital Revenue Code	302
Min. Negotiated Rate	$28.06
Max. Negotiated Rate	$206.10
Rate for Payer: Aetna of AZ Commercial	$206.10
Rate for Payer: Arizona Complete Health Allwell	$36.64
Rate for Payer: Banner UC Health Medicare	$36.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$155.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.64
Rate for Payer: Cash Price	$183.20
Rate for Payer: Cash Price	$183.20
Rate for Payer: Cigna of AZ Commercial	$148.85
Rate for Payer: Devoted Health Medicare	$41.22
Rate for Payer: Humana of AZ Medicare	$36.64
Rate for Payer: Seven Corners Travel Insurance	$28.06
Rate for Payer: Southwest Service Administrators UFCW	$155.72
Rate for Payer: TriWest Medicare	$36.64
Rate for Payer: United Healthcare Commercial	$130.99
Rate for Payer: United Healthcare Medicare	$36.64
Rate for Payer: Veterans Affairs TRICARE	$36.27

HSV Type 2-Specific Ab, IgG LC

Facility

$229.00

Service Code	CPT 86696
Hospital Charge Code	1906902
Hospital Revenue Code	302
Min. Negotiated Rate	$206.10
Max. Negotiated Rate	$206.10
Rate for Payer: Aetna of AZ Commercial	$206.10
Rate for Payer: Cash Price	$183.20

Human Epididymis Protein 4 LC

Facility

$358.00

Service Code	CPT 86304
Hospital Charge Code	22201907
Hospital Revenue Code	301
Min. Negotiated Rate	$30.17
Max. Negotiated Rate	$322.20
Rate for Payer: Aetna of AZ Commercial	$322.20
Rate for Payer: Arizona Complete Health Allwell	$57.28
Rate for Payer: Banner UC Health Medicare	$57.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$243.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$57.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$57.28
Rate for Payer: Cash Price	$286.40
Rate for Payer: Cash Price	$286.40
Rate for Payer: Cigna of AZ Commercial	$232.70
Rate for Payer: Devoted Health Medicare	$64.44
Rate for Payer: Humana of AZ Medicare	$57.28
Rate for Payer: Seven Corners Travel Insurance	$30.17
Rate for Payer: Southwest Service Administrators UFCW	$243.44
Rate for Payer: TriWest Medicare	$57.28
Rate for Payer: United Healthcare Commercial	$204.78
Rate for Payer: United Healthcare Medicare	$57.28
Rate for Payer: Veterans Affairs TRICARE	$56.71

Human Epididymis Protein 4 LC

Facility

$358.00

Service Code	CPT 86304
Hospital Charge Code	22201907
Hospital Revenue Code	301
Min. Negotiated Rate	$322.20
Max. Negotiated Rate	$322.20
Rate for Payer: Aetna of AZ Commercial	$322.20
Rate for Payer: Cash Price	$286.40

Human Papilloma virus (HPV) Vaccine POC

Facility

$531.00

Service Code	HCPCS T1015
Hospital Charge Code	784548
Hospital Revenue Code	636
Min. Negotiated Rate	$477.90
Max. Negotiated Rate	$477.90
Rate for Payer: Aetna of AZ Commercial	$477.90
Rate for Payer: Cash Price	$424.80

Human Papilloma virus (HPV) Vaccine POC

Facility

$531.00

Service Code	HCPCS T1015
Hospital Charge Code	784548
Hospital Revenue Code	636
Min. Negotiated Rate	$84.11
Max. Negotiated Rate	$477.90
Rate for Payer: Aetna of AZ Commercial	$477.90
Rate for Payer: Arizona Complete Health Allwell	$84.96
Rate for Payer: Banner UC Health Medicare	$84.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$361.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$84.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$84.96
Rate for Payer: Cash Price	$424.80
Rate for Payer: Cigna of AZ Commercial	$371.70
Rate for Payer: Devoted Health Medicare	$95.58
Rate for Payer: Humana of AZ Medicare	$84.96
Rate for Payer: Southwest Service Administrators UFCW	$361.08
Rate for Payer: TriWest Medicare	$84.96
Rate for Payer: United Healthcare Commercial	$303.73
Rate for Payer: United Healthcare Medicare	$84.96
Rate for Payer: United Healthcare New Mexico Commercial	$100.89
Rate for Payer: Veterans Affairs TRICARE	$84.11

HUMIDIFIER REFILL 500 ML

Facility

$22.00

Hospital Charge Code	22355209
Hospital Revenue Code	270
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$19.80
Rate for Payer: Aetna of AZ Commercial	$19.80
Rate for Payer: Cash Price	$17.60

HUMIDIFIER REFILL 500 ML

Facility

$22.00

Hospital Charge Code	22355209
Hospital Revenue Code	270
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$19.80
Rate for Payer: Aetna of AZ Commercial	$19.80
Rate for Payer: Arizona Complete Health Allwell	$3.52
Rate for Payer: Banner UC Health Medicare	$3.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$14.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.52
Rate for Payer: Cash Price	$17.60
Rate for Payer: Cigna of AZ Commercial	$15.40
Rate for Payer: Devoted Health Medicare	$3.96
Rate for Payer: Humana of AZ Medicare	$3.52
Rate for Payer: Southwest Service Administrators UFCW	$14.96
Rate for Payer: TriWest Medicare	$3.52
Rate for Payer: United Healthcare Commercial	$12.58
Rate for Payer: United Healthcare Medicare	$3.52
Rate for Payer: Veterans Affairs TRICARE	$3.48

Hyaluronan or derivative, Hyalgan or Dupartz for IntraArticu

Facility

$226.00

Service Code	HCPCS J7321
Hospital Charge Code	20533460
Hospital Revenue Code	521
Min. Negotiated Rate	$203.40
Max. Negotiated Rate	$203.40
Rate for Payer: Aetna of AZ Commercial	$203.40
Rate for Payer: Cash Price	$180.80

Hyaluronan or derivative, Hyalgan or Dupartz for IntraArticu

Facility

$226.00

Service Code	HCPCS J7321
Hospital Charge Code	20533460
Hospital Revenue Code	521
Min. Negotiated Rate	$35.80
Max. Negotiated Rate	$203.40
Rate for Payer: Aetna of AZ Commercial	$203.40
Rate for Payer: Arizona Complete Health Allwell	$36.16
Rate for Payer: Banner UC Health Medicare	$36.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$153.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.16
Rate for Payer: Cash Price	$180.80
Rate for Payer: Cigna of AZ Commercial	$158.20
Rate for Payer: Devoted Health Medicare	$40.68
Rate for Payer: Humana of AZ Medicare	$36.16
Rate for Payer: Southwest Service Administrators UFCW	$153.68
Rate for Payer: TriWest Medicare	$36.16
Rate for Payer: United Healthcare Commercial	$129.27
Rate for Payer: United Healthcare Medicare	$36.16
Rate for Payer: Veterans Affairs TRICARE	$35.80

HYDRA IRRIGATION TUBING

Facility

$45.00

Hospital Charge Code	23751226
Min. Negotiated Rate	$40.50
Max. Negotiated Rate	$40.50
Rate for Payer: Aetna of AZ Commercial	$40.50
Rate for Payer: Cash Price	$36.00

HYDRA IRRIGATION TUBING

Facility

$45.00

Hospital Charge Code	23751226
Min. Negotiated Rate	$7.13
Max. Negotiated Rate	$40.50
Rate for Payer: Aetna of AZ Commercial	$40.50
Rate for Payer: Arizona Complete Health Allwell	$7.20
Rate for Payer: Banner UC Health Medicare	$7.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$30.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna of AZ Commercial	$31.50
Rate for Payer: Devoted Health Medicare	$8.10
Rate for Payer: Humana of AZ Medicare	$7.20
Rate for Payer: Southwest Service Administrators UFCW	$30.60
Rate for Payer: TriWest Medicare	$7.20
Rate for Payer: United Healthcare Commercial	$25.74
Rate for Payer: United Healthcare Medicare	$7.20
Rate for Payer: Veterans Affairs TRICARE	$7.13

hydrALAZINE 20 mg/ 1 mL Sol [CQCH]

Facility

$3.15

Service Code	HCPCS J0360
Hospital Charge Code	122900854
Hospital Revenue Code	250
Min. Negotiated Rate	$2.83
Max. Negotiated Rate	$2.83
Rate for Payer: Aetna of AZ Commercial	$2.83
Rate for Payer: Cash Price	$2.52

hydrALAZINE 20 mg/ 1 mL Sol [CQCH]

Facility

$3.15

Service Code	HCPCS J0360
Hospital Charge Code	122900854
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$2.83
Rate for Payer: Aetna of AZ Commercial	$2.83
Rate for Payer: Arizona Complete Health Allwell	$0.50
Rate for Payer: Banner UC Health Medicare	$0.50
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2.14
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.50
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.50
Rate for Payer: Cash Price	$2.52
Rate for Payer: Cigna of AZ Commercial	$2.05
Rate for Payer: Devoted Health Medicare	$0.57
Rate for Payer: Humana of AZ Medicare	$0.50
Rate for Payer: Southwest Service Administrators UFCW	$2.14
Rate for Payer: TriWest Medicare	$0.50
Rate for Payer: United Healthcare Commercial	$1.80
Rate for Payer: United Healthcare Medicare	$0.50
Rate for Payer: Veterans Affairs TRICARE	$0.50

hydrALAZINE 25 mg Tab [CQCH]

Facility

$0.10

Service Code	NDC 63739032710
Hospital Charge Code	105925507
Hospital Revenue Code	251
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of AZ Commercial	$0.09
Rate for Payer: Cash Price	$0.08

hydrALAZINE 25 mg Tab [CQCH]

Facility

$0.10

Service Code	NDC 63739032710
Hospital Charge Code	105925507
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of AZ Commercial	$0.09
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	$0.07
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	$0.08
Rate for Payer: Cigna of AZ Commercial	$0.07
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.07
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.06
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

hydroCHLOROthiazide 25 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 63739012810
Hospital Charge Code	105925572
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	$0.02
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

hydroCHLOROthiazide 25 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 63739012810
Hospital Charge Code	105925572
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	$0.02

hydrocortisone 100 mg/2 mL Inj [CQCH]

Facility

$13.65

Service Code	HCPCS J1720
Hospital Charge Code	105925704
Hospital Revenue Code	250
Min. Negotiated Rate	$12.29
Max. Negotiated Rate	$12.29
Rate for Payer: Aetna of AZ Commercial	$12.29
Rate for Payer: Cash Price	$10.92

hydrocortisone 100 mg/2 mL Inj [CQCH]

Facility

$13.65

Service Code	HCPCS J1720
Hospital Charge Code	105925704
Hospital Revenue Code	250
Min. Negotiated Rate	$2.16
Max. Negotiated Rate	$12.29
Rate for Payer: Aetna of AZ Commercial	$12.29
Rate for Payer: Arizona Complete Health Allwell	$2.18
Rate for Payer: Banner UC Health Medicare	$2.18
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$9.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.18
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.18
Rate for Payer: Cash Price	$10.92
Rate for Payer: Cigna of AZ Commercial	$8.87
Rate for Payer: Devoted Health Medicare	$2.46
Rate for Payer: Humana of AZ Medicare	$2.18
Rate for Payer: Southwest Service Administrators UFCW	$9.28
Rate for Payer: TriWest Medicare	$2.18
Rate for Payer: United Healthcare Commercial	$7.81
Rate for Payer: United Healthcare Medicare	$2.18
Rate for Payer: Veterans Affairs TRICARE	$2.16

hydrocortisone 25 mg Supp [CQCH]

Facility

$1.69

Service Code	NDC 42494030112
Hospital Charge Code	105925771
Hospital Revenue Code	251
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$1.52
Rate for Payer: Aetna of AZ Commercial	$1.52
Rate for Payer: Cash Price	$1.35

hydrocortisone 25 mg Supp [CQCH]

Facility

$1.69

Service Code	NDC 42494030112
Hospital Charge Code	105925771
Hospital Revenue Code	251
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$1.52
Rate for Payer: Aetna of AZ Commercial	$1.52
Rate for Payer: Arizona Complete Health Allwell	$0.27
Rate for Payer: Banner UC Health Medicare	$0.27
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.15
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.27
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.27
Rate for Payer: Cash Price	$1.35
Rate for Payer: Cigna of AZ Commercial	$1.10
Rate for Payer: Devoted Health Medicare	$0.30
Rate for Payer: Humana of AZ Medicare	$0.27
Rate for Payer: Southwest Service Administrators UFCW	$1.15
Rate for Payer: TriWest Medicare	$0.27
Rate for Payer: United Healthcare Commercial	$0.97
Rate for Payer: United Healthcare Medicare	$0.27
Rate for Payer: Veterans Affairs TRICARE	$0.27

Know your out-of-pocket cost for care.

All Charges