Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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

IgG, Subclasses(1-4) LC

Facility

$120.00

Service Code	CPT 82784
Hospital Charge Code	2029255
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

IgG, Subclasses(1-4) LC

Facility

$120.00

Service Code	CPT 82784
Hospital Charge Code	2029255
Hospital Revenue Code	301
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Cash Price	$96.00

IGP,Aptima HPV,CtNg Age Gdln LC

Facility

$174.00

Service Code	CPT 87624
Hospital Charge Code	22660591
Hospital Revenue Code	300
Min. Negotiated Rate	$27.56
Max. Negotiated Rate	$156.60
Rate for Payer: Aetna of AZ Commercial	$156.60
Rate for Payer: Arizona Complete Health Allwell	$27.84
Rate for Payer: Banner UC Health Medicare	$27.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$118.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.84
Rate for Payer: Cash Price	$139.20
Rate for Payer: Cash Price	$139.20
Rate for Payer: Cigna of AZ Commercial	$113.10
Rate for Payer: Devoted Health Medicare	$31.32
Rate for Payer: Humana of AZ Medicare	$27.84
Rate for Payer: Seven Corners Travel Insurance	$50.88
Rate for Payer: Southwest Service Administrators UFCW	$118.32
Rate for Payer: TriWest Medicare	$27.84
Rate for Payer: United Healthcare Commercial	$99.53
Rate for Payer: United Healthcare Medicare	$27.84
Rate for Payer: Veterans Affairs TRICARE	$27.56

IGP,Aptima HPV,CtNg Age Gdln LC

Facility

$174.00

Service Code	CPT 87624
Hospital Charge Code	22660591
Hospital Revenue Code	300
Min. Negotiated Rate	$156.60
Max. Negotiated Rate	$156.60
Rate for Payer: Aetna of AZ Commercial	$156.60
Rate for Payer: Cash Price	$139.20

IMAGING OF URINARY TRACT FOLLOWING INJECTION OF A CONTRAST A

Facility

$404.00

Service Code	CPT 74420
Hospital Charge Code	27797698
Hospital Revenue Code	360
Min. Negotiated Rate	$63.99
Max. Negotiated Rate	$3,373.00
Rate for Payer: Aetna of AZ Commercial	$363.60
Rate for Payer: Arizona Complete Health Allwell	$64.64
Rate for Payer: Banner UC Health Medicare	$134.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$274.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$64.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$64.64
Rate for Payer: Cash Price	$323.20
Rate for Payer: Cash Price	$323.20
Rate for Payer: Cash Price	$323.20
Rate for Payer: Cigna of AZ Commercial	$202.00
Rate for Payer: Devoted Health Medicare	$72.72
Rate for Payer: Humana of AZ Medicare	$64.64
Rate for Payer: NaphCare Correctional Healthcare	$134.76
Rate for Payer: Seven Corners Travel Insurance	$539.81
Rate for Payer: Southwest Service Administrators UFCW	$274.72
Rate for Payer: TriWest Medicare	$64.64
Rate for Payer: United Healthcare Commercial	$3,373.00
Rate for Payer: United Healthcare Medicare	$64.64
Rate for Payer: Veterans Affairs TRICARE	$63.99

IMAGING OF URINARY TRACT FOLLOWING INJECTION OF A CONTRAST A

Facility

$404.00

Service Code	CPT 74420
Hospital Charge Code	27797698
Hospital Revenue Code	360
Min. Negotiated Rate	$363.60
Max. Negotiated Rate	$363.60
Rate for Payer: Aetna of AZ Commercial	$363.60
Rate for Payer: Cash Price	$323.20

imipenem-cilastatin 500 mg Inj [CQCH]

Facility

$8.35

Service Code	HCPCS J0743
Hospital Charge Code	120268247
Hospital Revenue Code	250
Min. Negotiated Rate	$7.51
Max. Negotiated Rate	$7.51
Rate for Payer: Aetna of AZ Commercial	$7.51
Rate for Payer: Cash Price	$6.68

imipenem-cilastatin 500 mg Inj [CQCH]

Facility

$8.35

Service Code	HCPCS J0743
Hospital Charge Code	120268247
Hospital Revenue Code	250
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$7.51
Rate for Payer: Aetna of AZ Commercial	$7.51
Rate for Payer: Arizona Complete Health Allwell	$1.34
Rate for Payer: Banner UC Health Medicare	$1.34
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.34
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.34
Rate for Payer: Cash Price	$6.68
Rate for Payer: Cigna of AZ Commercial	$5.43
Rate for Payer: Devoted Health Medicare	$1.50
Rate for Payer: Humana of AZ Medicare	$1.34
Rate for Payer: Southwest Service Administrators UFCW	$5.68
Rate for Payer: TriWest Medicare	$1.34
Rate for Payer: United Healthcare Commercial	$4.78
Rate for Payer: United Healthcare Medicare	$1.34
Rate for Payer: Veterans Affairs TRICARE	$1.32

IMITREX 6 MG INJ

Facility

$174.00

Service Code	HCPCS J3030
Hospital Charge Code	1170079
Hospital Revenue Code	521
Min. Negotiated Rate	$156.60
Max. Negotiated Rate	$156.60
Rate for Payer: Aetna of AZ Commercial	$156.60
Rate for Payer: Cash Price	$139.20

IMITREX 6 MG INJ

Facility

$174.00

Service Code	HCPCS J3030
Hospital Charge Code	1170079
Hospital Revenue Code	521
Min. Negotiated Rate	$27.56
Max. Negotiated Rate	$156.60
Rate for Payer: Aetna of AZ Commercial	$156.60
Rate for Payer: Arizona Complete Health Allwell	$27.84
Rate for Payer: Banner UC Health Medicare	$27.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$118.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.84
Rate for Payer: Cash Price	$139.20
Rate for Payer: Cigna of AZ Commercial	$121.80
Rate for Payer: Devoted Health Medicare	$31.32
Rate for Payer: Humana of AZ Medicare	$27.84
Rate for Payer: Southwest Service Administrators UFCW	$118.32
Rate for Payer: TriWest Medicare	$27.84
Rate for Payer: United Healthcare Commercial	$99.53
Rate for Payer: United Healthcare Medicare	$27.84
Rate for Payer: Veterans Affairs TRICARE	$27.56

IMMNASSY FOR NONINFECT (CELIAC COMP)

Facility

$156.00

Service Code	CPT 83516
Hospital Charge Code	22481480
Hospital Revenue Code	301
Min. Negotiated Rate	$16.72
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of AZ Commercial	$140.40
Rate for Payer: Arizona Complete Health Allwell	$24.96
Rate for Payer: Banner UC Health Medicare	$24.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$106.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$24.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$24.96
Rate for Payer: Cash Price	$124.80
Rate for Payer: Cash Price	$124.80
Rate for Payer: Cigna of AZ Commercial	$101.40
Rate for Payer: Devoted Health Medicare	$28.08
Rate for Payer: Humana of AZ Medicare	$24.96
Rate for Payer: Seven Corners Travel Insurance	$16.72
Rate for Payer: Southwest Service Administrators UFCW	$106.08
Rate for Payer: TriWest Medicare	$24.96
Rate for Payer: United Healthcare Commercial	$89.23
Rate for Payer: United Healthcare Medicare	$24.96
Rate for Payer: Veterans Affairs TRICARE	$24.71

IMMNASSY FOR NONINFECT (CELIAC COMP)

Facility

$156.00

Service Code	CPT 83516
Hospital Charge Code	22481480
Hospital Revenue Code	301
Min. Negotiated Rate	$140.40
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of AZ Commercial	$140.40
Rate for Payer: Cash Price	$124.80

IMMOBILIZER KNEE 20

Facility

$89.00

Hospital Charge Code	22354184
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

IMMOBILIZER KNEE 20

Facility

$89.00

Hospital Charge Code	22354184
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

IMMOBILIZER SHOULDER PED

Facility

$78.00

Hospital Charge Code	22354134
Hospital Revenue Code	270
Min. Negotiated Rate	$12.36
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: Cigna of AZ Commercial	$54.60
Rate for Payer: Devoted Health Medicare	$14.04
Rate for Payer: Humana of AZ Medicare	$12.48
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

IMMOBILIZER SHOULDER PED

Facility

$78.00

Hospital Charge Code	22354134
Hospital Revenue Code	270
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

Immunization Request:DTaP Diphtheria/Pertussis, acellular/Te

Facility

$100.00

Service Code	CPT 90700
Hospital Charge Code	752079
Hospital Revenue Code	521
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of AZ Commercial	$90.00
Rate for Payer: Cash Price	$80.00

Immunization Request:DTaP Diphtheria/Pertussis, acellular/Te

Facility

$100.00

Service Code	CPT 90700
Hospital Charge Code	752079
Hospital Revenue Code	521
Min. Negotiated Rate	$15.84
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of AZ Commercial	$90.00
Rate for Payer: Arizona Complete Health Allwell	$16.00
Rate for Payer: Banner UC Health Medicare	$16.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$68.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cigna of AZ Commercial	$70.00
Rate for Payer: Devoted Health Medicare	$18.00
Rate for Payer: Humana of AZ Medicare	$16.00
Rate for Payer: Southwest Service Administrators UFCW	$68.00
Rate for Payer: TriWest Medicare	$16.00
Rate for Payer: United Healthcare Commercial	$57.20
Rate for Payer: United Healthcare Medicare	$16.00
Rate for Payer: Veterans Affairs TRICARE	$15.84

Immunofixation (IFE) Urine LC

Facility

$903.00

Service Code	CPT 86335
Hospital Charge Code	3451611
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

Immunofixation (IFE) Urine LC

Facility

$903.00

Service Code	CPT 86335
Hospital Charge Code	3451611
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

Immunofixation, Serum LC

Facility

$821.00

Service Code	CPT 86334
Hospital Charge Code	2269421
Hospital Revenue Code	302
Min. Negotiated Rate	$32.39
Max. Negotiated Rate	$738.90
Rate for Payer: Aetna of AZ Commercial	$738.90
Rate for Payer: Arizona Complete Health Allwell	$131.36
Rate for Payer: Banner UC Health Medicare	$131.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$558.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$131.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$131.36
Rate for Payer: Cash Price	$656.80
Rate for Payer: Cash Price	$656.80
Rate for Payer: Cigna of AZ Commercial	$533.65
Rate for Payer: Devoted Health Medicare	$147.78
Rate for Payer: Humana of AZ Medicare	$131.36
Rate for Payer: Seven Corners Travel Insurance	$32.39
Rate for Payer: Southwest Service Administrators UFCW	$558.28
Rate for Payer: TriWest Medicare	$131.36
Rate for Payer: United Healthcare Commercial	$469.61
Rate for Payer: United Healthcare Medicare	$131.36
Rate for Payer: Veterans Affairs TRICARE	$130.05

Immunofixation, Serum LC

Facility

$821.00

Service Code	CPT 86334
Hospital Charge Code	2269421
Hospital Revenue Code	302
Min. Negotiated Rate	$738.90
Max. Negotiated Rate	$738.90
Rate for Payer: Aetna of AZ Commercial	$738.90
Rate for Payer: Cash Price	$656.80

IMMUNOGLOB A

Facility

$120.00

Service Code	CPT 82784
Hospital Charge Code	22481481
Hospital Revenue Code	301
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Cash Price	$96.00

IMMUNOGLOB A

Facility

$120.00

Service Code	CPT 82784
Hospital Charge Code	22481481
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