Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

ibuprofen 600 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 904585461
Hospital Charge Code	105926448
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Arizona Complete Health Allwell	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.01
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.01
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of AZ Commercial	$0.04
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.04
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.03
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

ibuprofen 600 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 904585461
Hospital Charge Code	105926448
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Cash Price	$0.05

ibuprofen 800 mg Tab [CQCH]

Facility

$0.08

Service Code	NDC 63739069110
Hospital Charge Code	105926383
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
Rate for Payer: Arizona Complete Health Allwell	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.01
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.01
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of AZ Commercial	$0.05
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.05
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.05
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

ibuprofen 800 mg Tab [CQCH]

Facility

$0.08

Service Code	NDC 63739069110
Hospital Charge Code	105926383
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
Rate for Payer: Cash Price	$0.07

IFE and PE, Random Urine LC

Facility

$903.00

Service Code	CPT 86335
Hospital Charge Code	1285723
Hospital Revenue Code	302
Min. Negotiated Rate	$42.56
Max. Negotiated Rate	$812.70
Rate for Payer: Aetna of AZ Commercial	$812.70
Rate for Payer: Arizona Complete Health Allwell	$144.48
Rate for Payer: Banner UC Health Medicare	$144.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$614.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$144.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$144.48
Rate for Payer: Cash Price	$722.40
Rate for Payer: Cash Price	$722.40
Rate for Payer: Cigna of AZ Commercial	$586.95
Rate for Payer: Devoted Health Medicare	$162.54
Rate for Payer: Humana of AZ Medicare	$144.48
Rate for Payer: Seven Corners Travel Insurance	$42.56
Rate for Payer: Southwest Service Administrators UFCW	$614.04
Rate for Payer: TriWest Medicare	$144.48
Rate for Payer: United Healthcare Commercial	$516.52
Rate for Payer: United Healthcare Medicare	$144.48
Rate for Payer: Veterans Affairs TRICARE	$143.04

IFE and PE, Random Urine LC

Facility

$903.00

Service Code	CPT 86335
Hospital Charge Code	1285723
Hospital Revenue Code	302
Min. Negotiated Rate	$812.70
Max. Negotiated Rate	$812.70
Rate for Payer: Aetna of AZ Commercial	$812.70
Rate for Payer: Cash Price	$722.40

IFE and PE, Serum LC

Facility

$681.00

Service Code	CPT 84165
Hospital Charge Code	1905770
Hospital Revenue Code	302
Min. Negotiated Rate	$612.90
Max. Negotiated Rate	$612.90
Rate for Payer: Aetna of AZ Commercial	$612.90
Rate for Payer: Cash Price	$544.80

IFE and PE, Serum LC

Facility

$681.00

Service Code	CPT 84165
Hospital Charge Code	1905770
Hospital Revenue Code	302
Min. Negotiated Rate	$15.57
Max. Negotiated Rate	$612.90
Rate for Payer: Aetna of AZ Commercial	$612.90
Rate for Payer: Arizona Complete Health Allwell	$108.96
Rate for Payer: Banner UC Health Medicare	$108.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$463.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$108.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$108.96
Rate for Payer: Cash Price	$544.80
Rate for Payer: Cash Price	$544.80
Rate for Payer: Cigna of AZ Commercial	$442.65
Rate for Payer: Devoted Health Medicare	$122.58
Rate for Payer: Humana of AZ Medicare	$108.96
Rate for Payer: Seven Corners Travel Insurance	$15.57
Rate for Payer: Southwest Service Administrators UFCW	$463.08
Rate for Payer: TriWest Medicare	$108.96
Rate for Payer: United Healthcare Commercial	$389.53
Rate for Payer: United Healthcare Medicare	$108.96
Rate for Payer: Veterans Affairs TRICARE	$107.87

IFE+Protein Electro, 24-Hr Ur LC

Facility

$903.00

Service Code	CPT 86335
Hospital Charge Code	1285722
Hospital Revenue Code	302
Min. Negotiated Rate	$812.70
Max. Negotiated Rate	$812.70
Rate for Payer: Aetna of AZ Commercial	$812.70
Rate for Payer: Cash Price	$722.40

IFE+Protein Electro, 24-Hr Ur LC

Facility

$903.00

Service Code	CPT 86335
Hospital Charge Code	1285722
Hospital Revenue Code	302
Min. Negotiated Rate	$42.56
Max. Negotiated Rate	$812.70
Rate for Payer: Aetna of AZ Commercial	$812.70
Rate for Payer: Arizona Complete Health Allwell	$144.48
Rate for Payer: Banner UC Health Medicare	$144.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$614.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$144.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$144.48
Rate for Payer: Cash Price	$722.40
Rate for Payer: Cash Price	$722.40
Rate for Payer: Cigna of AZ Commercial	$586.95
Rate for Payer: Devoted Health Medicare	$162.54
Rate for Payer: Humana of AZ Medicare	$144.48
Rate for Payer: Seven Corners Travel Insurance	$42.56
Rate for Payer: Southwest Service Administrators UFCW	$614.04
Rate for Payer: TriWest Medicare	$144.48
Rate for Payer: United Healthcare Commercial	$516.52
Rate for Payer: United Healthcare Medicare	$144.48
Rate for Payer: Veterans Affairs TRICARE	$143.04

I-GEL 1

Facility

$60.00

Hospital Charge Code	22926453
Hospital Revenue Code	272
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Cash Price	$48.00

I-GEL 1

Facility

$60.00

Hospital Charge Code	22926453
Hospital Revenue Code	272
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Arizona Complete Health Allwell	$9.60
Rate for Payer: Banner UC Health Medicare	$9.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$40.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cigna of AZ Commercial	$42.00
Rate for Payer: Devoted Health Medicare	$10.80
Rate for Payer: Humana of AZ Medicare	$9.60
Rate for Payer: Southwest Service Administrators UFCW	$40.80
Rate for Payer: TriWest Medicare	$9.60
Rate for Payer: United Healthcare Commercial	$34.32
Rate for Payer: United Healthcare Medicare	$9.60
Rate for Payer: Veterans Affairs TRICARE	$9.50

I-GEL 2

Facility

$60.00

Hospital Charge Code	22926454
Hospital Revenue Code	272
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Arizona Complete Health Allwell	$9.60
Rate for Payer: Banner UC Health Medicare	$9.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$40.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cigna of AZ Commercial	$42.00
Rate for Payer: Devoted Health Medicare	$10.80
Rate for Payer: Humana of AZ Medicare	$9.60
Rate for Payer: Southwest Service Administrators UFCW	$40.80
Rate for Payer: TriWest Medicare	$9.60
Rate for Payer: United Healthcare Commercial	$34.32
Rate for Payer: United Healthcare Medicare	$9.60
Rate for Payer: Veterans Affairs TRICARE	$9.50

I-GEL 2

Facility

$60.00

Hospital Charge Code	22926454
Hospital Revenue Code	272
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Cash Price	$48.00

I-GEL 2.5

Facility

$60.00

Hospital Charge Code	22926455
Hospital Revenue Code	272
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Cash Price	$48.00

I-GEL 2.5

Facility

$60.00

Hospital Charge Code	22926455
Hospital Revenue Code	272
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Arizona Complete Health Allwell	$9.60
Rate for Payer: Banner UC Health Medicare	$9.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$40.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cigna of AZ Commercial	$42.00
Rate for Payer: Devoted Health Medicare	$10.80
Rate for Payer: Humana of AZ Medicare	$9.60
Rate for Payer: Southwest Service Administrators UFCW	$40.80
Rate for Payer: TriWest Medicare	$9.60
Rate for Payer: United Healthcare Commercial	$34.32
Rate for Payer: United Healthcare Medicare	$9.60
Rate for Payer: Veterans Affairs TRICARE	$9.50

I-GEL 3

Facility

$60.00

Hospital Charge Code	22926456
Hospital Revenue Code	272
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Arizona Complete Health Allwell	$9.60
Rate for Payer: Banner UC Health Medicare	$9.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$40.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cigna of AZ Commercial	$42.00
Rate for Payer: Devoted Health Medicare	$10.80
Rate for Payer: Humana of AZ Medicare	$9.60
Rate for Payer: Southwest Service Administrators UFCW	$40.80
Rate for Payer: TriWest Medicare	$9.60
Rate for Payer: United Healthcare Commercial	$34.32
Rate for Payer: United Healthcare Medicare	$9.60
Rate for Payer: Veterans Affairs TRICARE	$9.50

I-GEL 3

Facility

$60.00

Hospital Charge Code	22926456
Hospital Revenue Code	272
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Cash Price	$48.00

I-GEL 4

Facility

$60.00

Hospital Charge Code	22926457
Hospital Revenue Code	272
Min. Negotiated Rate	$9.50
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Arizona Complete Health Allwell	$9.60
Rate for Payer: Banner UC Health Medicare	$9.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$40.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cigna of AZ Commercial	$42.00
Rate for Payer: Devoted Health Medicare	$10.80
Rate for Payer: Humana of AZ Medicare	$9.60
Rate for Payer: Southwest Service Administrators UFCW	$40.80
Rate for Payer: TriWest Medicare	$9.60
Rate for Payer: United Healthcare Commercial	$34.32
Rate for Payer: United Healthcare Medicare	$9.60
Rate for Payer: Veterans Affairs TRICARE	$9.50

I-GEL 4

Facility

$60.00

Hospital Charge Code	22926457
Hospital Revenue Code	272
Min. Negotiated Rate	$54.00
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Cash Price	$48.00

I-GEL 5

Facility

$57.00

Hospital Charge Code	22926458
Hospital Revenue Code	272
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna of AZ Commercial	$51.30
Rate for Payer: Cash Price	$45.60

I-GEL 5

Facility

$57.00

Hospital Charge Code	22926458
Hospital Revenue Code	272
Min. Negotiated Rate	$9.03
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna of AZ Commercial	$51.30
Rate for Payer: Arizona Complete Health Allwell	$9.12
Rate for Payer: Banner UC Health Medicare	$9.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$38.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.12
Rate for Payer: Cash Price	$45.60
Rate for Payer: Cigna of AZ Commercial	$39.90
Rate for Payer: Devoted Health Medicare	$10.26
Rate for Payer: Humana of AZ Medicare	$9.12
Rate for Payer: Southwest Service Administrators UFCW	$38.76
Rate for Payer: TriWest Medicare	$9.12
Rate for Payer: United Healthcare Commercial	$32.60
Rate for Payer: United Healthcare Medicare	$9.12
Rate for Payer: Veterans Affairs TRICARE	$9.03

IGF-1 LC

Facility

$480.00

Service Code	CPT 84305
Hospital Charge Code	1906904
Hospital Revenue Code	301
Min. Negotiated Rate	$432.00
Max. Negotiated Rate	$432.00
Rate for Payer: Aetna of AZ Commercial	$432.00
Rate for Payer: Cash Price	$384.00

IGF-1 LC

Facility

$480.00

Service Code	CPT 84305
Hospital Charge Code	1906904
Hospital Revenue Code	301
Min. Negotiated Rate	$30.83
Max. Negotiated Rate	$432.00
Rate for Payer: Aetna of AZ Commercial	$432.00
Rate for Payer: Arizona Complete Health Allwell	$76.80
Rate for Payer: Banner UC Health Medicare	$76.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$326.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$76.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$76.80
Rate for Payer: Cash Price	$384.00
Rate for Payer: Cash Price	$384.00
Rate for Payer: Cigna of AZ Commercial	$312.00
Rate for Payer: Devoted Health Medicare	$86.40
Rate for Payer: Humana of AZ Medicare	$76.80
Rate for Payer: Seven Corners Travel Insurance	$30.83
Rate for Payer: Southwest Service Administrators UFCW	$326.40
Rate for Payer: TriWest Medicare	$76.80
Rate for Payer: United Healthcare Commercial	$274.56
Rate for Payer: United Healthcare Medicare	$76.80
Rate for Payer: Veterans Affairs TRICARE	$76.03

IgG Subclasses 1-4 LC

Facility

$120.00

Service Code	CPT 82784
Hospital Charge Code	6781836
Hospital Revenue Code	301
Min. Negotiated Rate	$13.48
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Arizona Complete Health Allwell	$19.20
Rate for Payer: Banner UC Health Medicare	$19.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$81.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$19.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$19.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cigna of AZ Commercial	$78.00
Rate for Payer: Devoted Health Medicare	$21.60
Rate for Payer: Humana of AZ Medicare	$19.20
Rate for Payer: Seven Corners Travel Insurance	$13.48
Rate for Payer: Southwest Service Administrators UFCW	$81.60
Rate for Payer: TriWest Medicare	$19.20
Rate for Payer: United Healthcare Commercial	$68.64
Rate for Payer: United Healthcare Medicare	$19.20
Rate for Payer: Veterans Affairs TRICARE	$19.01

Know your out-of-pocket cost for care.

All Charges