Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

INCISION OF URETHRA USING AN ENDOSCOPE

Facility

$1,344.00

Service Code	CPT 52276
Hospital Charge Code	28133134
Hospital Revenue Code	360
Min. Negotiated Rate	$212.89
Max. Negotiated Rate	$4,169.00
Rate for Payer: Aetna of AZ Commercial	$1,209.60
Rate for Payer: Arizona Complete Health Allwell	$215.04
Rate for Payer: Banner UC Health Medicare	$690.65
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$913.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$215.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$215.04
Rate for Payer: Cash Price	$1,075.20
Rate for Payer: Cash Price	$1,075.20
Rate for Payer: Cash Price	$1,075.20
Rate for Payer: Cigna of AZ Commercial	$672.00
Rate for Payer: Devoted Health Medicare	$241.92
Rate for Payer: Humana of AZ Medicare	$215.04
Rate for Payer: NaphCare Correctional Healthcare	$690.65
Rate for Payer: Seven Corners Travel Insurance	$3,234.38
Rate for Payer: Southwest Service Administrators UFCW	$913.92
Rate for Payer: TriWest Medicare	$215.04
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$215.04
Rate for Payer: Veterans Affairs TRICARE	$212.89

INCISION OF URETHRA USING AN ENDOSCOPE

Facility

$1,344.00

Service Code	CPT 52276
Hospital Charge Code	28133134
Hospital Revenue Code	360
Min. Negotiated Rate	$1,209.60
Max. Negotiated Rate	$1,209.60
Rate for Payer: Aetna of AZ Commercial	$1,209.60
Rate for Payer: Cash Price	$1,075.20

Incision Removal of Foreign Body, Subcutaneous Tissues; Complicated Charge

Facility

$627.00

Service Code	CPT 10121
Hospital Charge Code	729093
Hospital Revenue Code	521
Min. Negotiated Rate	$85.47
Max. Negotiated Rate	$2,555.47
Rate for Payer: Aetna of AZ Commercial	$564.30
Rate for Payer: Arizona Complete Health Allwell	$100.32
Rate for Payer: Banner UC Health Medicare	$100.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$426.36
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$85.47
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$100.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$100.32
Rate for Payer: Cash Price	$501.60
Rate for Payer: Cash Price	$501.60
Rate for Payer: Cigna of AZ Commercial	$438.90
Rate for Payer: Devoted Health Medicare	$112.86
Rate for Payer: Humana of AZ Medicare	$100.32
Rate for Payer: Mercy Care Medicaid	$85.47
Rate for Payer: NaphCare Correctional Healthcare	$85.47
Rate for Payer: Seven Corners Travel Insurance	$2,555.47
Rate for Payer: Southwest Service Administrators UFCW	$426.36
Rate for Payer: TriWest Medicare	$100.32
Rate for Payer: United Healthcare Commercial	$358.64
Rate for Payer: United Healthcare Medicare	$100.32
Rate for Payer: Veterans Affairs TRICARE	$99.32

Incision Removal of Foreign Body, Subcutaneous Tissues; Complicated Charge

Facility

$627.00

Service Code	CPT 10121
Hospital Charge Code	729093
Hospital Revenue Code	521
Min. Negotiated Rate	$564.30
Max. Negotiated Rate	$564.30
Rate for Payer: Aetna of AZ Commercial	$564.30
Rate for Payer: Cash Price	$501.60

Incision Removal of Foreign Body, Subcutaneous Tissues; Simple Charge

Facility

$385.00

Service Code	CPT 10120
Hospital Charge Code	729091
Hospital Revenue Code	521
Min. Negotiated Rate	$346.50
Max. Negotiated Rate	$346.50
Rate for Payer: Aetna of AZ Commercial	$346.50
Rate for Payer: Cash Price	$308.00

Incision Removal of Foreign Body, Subcutaneous Tissues; Simple Charge

Facility

$385.00

Service Code	CPT 10120
Hospital Charge Code	729091
Hospital Revenue Code	521
Min. Negotiated Rate	$48.99
Max. Negotiated Rate	$629.00
Rate for Payer: Aetna of AZ Commercial	$346.50
Rate for Payer: Arizona Complete Health Allwell	$61.60
Rate for Payer: Banner UC Health Medicare	$61.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$261.80
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$48.99
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$61.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$61.60
Rate for Payer: Cash Price	$308.00
Rate for Payer: Cash Price	$308.00
Rate for Payer: Cigna of AZ Commercial	$269.50
Rate for Payer: Devoted Health Medicare	$69.30
Rate for Payer: Humana of AZ Medicare	$61.60
Rate for Payer: Mercy Care Medicaid	$48.99
Rate for Payer: NaphCare Correctional Healthcare	$48.99
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$261.80
Rate for Payer: TriWest Medicare	$61.60
Rate for Payer: United Healthcare Commercial	$220.22
Rate for Payer: United Healthcare Medicare	$61.60
Rate for Payer: Veterans Affairs TRICARE	$60.98

inclisiran 284 mg/1.5 mL Sol[CQCH]

Facility

$2,254.28

Service Code	HCPCS J1306
Hospital Charge Code	242946825
Hospital Revenue Code	250
Min. Negotiated Rate	$18.72
Max. Negotiated Rate	$2,028.85
Rate for Payer: Aetna of AZ Commercial	$2,028.85
Rate for Payer: Arizona Complete Health Allwell	$360.68
Rate for Payer: Banner UC Health Medicare	$360.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,532.91
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$360.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$360.68
Rate for Payer: Cash Price	$1,803.42
Rate for Payer: Cash Price	$1,803.42
Rate for Payer: Cigna of AZ Commercial	$1,465.28
Rate for Payer: Devoted Health Medicare	$405.77
Rate for Payer: Humana of AZ Medicare	$360.68
Rate for Payer: Seven Corners Travel Insurance	$18.72
Rate for Payer: Southwest Service Administrators UFCW	$1,532.91
Rate for Payer: TriWest Medicare	$360.68
Rate for Payer: United Healthcare Commercial	$1,289.45
Rate for Payer: United Healthcare Medicare	$360.68
Rate for Payer: Veterans Affairs TRICARE	$357.08

inclisiran 284 mg/1.5 mL Sol[CQCH]

Facility

$2,254.28

Service Code	HCPCS J1306
Hospital Charge Code	242946825
Hospital Revenue Code	250
Min. Negotiated Rate	$2,028.85
Max. Negotiated Rate	$2,028.85
Rate for Payer: Aetna of AZ Commercial	$2,028.85
Rate for Payer: Cash Price	$1,803.42

indomethacin 25 mg Cap [CQCH]

Facility

$0.19

Service Code	NDC 31722054201
Hospital Charge Code	105926578
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of AZ Commercial	$0.17
Rate for Payer: Arizona Complete Health Allwell	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.13
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.03
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.03
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of AZ Commercial	$0.12
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Southwest Service Administrators UFCW	$0.13
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: United Healthcare Commercial	$0.11
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

indomethacin 25 mg Cap [CQCH]

Facility

$0.19

Service Code	NDC 31722054201
Hospital Charge Code	105926578
Hospital Revenue Code	251
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of AZ Commercial	$0.17
Rate for Payer: Cash Price	$0.15

INFANT NASAL PRNG 3MM TO 4MM

Facility

$42.00

Hospital Charge Code	27704483
Hospital Revenue Code	270
Min. Negotiated Rate	$6.65
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Arizona Complete Health Allwell	$6.72
Rate for Payer: Banner UC Health Medicare	$6.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$28.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.72
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cigna of AZ Commercial	$29.40
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Humana of AZ Medicare	$6.72
Rate for Payer: Southwest Service Administrators UFCW	$28.56
Rate for Payer: TriWest Medicare	$6.72
Rate for Payer: United Healthcare Commercial	$24.02
Rate for Payer: United Healthcare Medicare	$6.72
Rate for Payer: Veterans Affairs TRICARE	$6.65

INFANT NASAL PRNG 3MM TO 4MM

Facility

$42.00

Hospital Charge Code	27704483
Hospital Revenue Code	270
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Cash Price	$33.60

INFANT NASAL PRNG 5MM TO 4MM

Facility

$42.00

Hospital Charge Code	27704486
Hospital Revenue Code	270
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Cash Price	$33.60

INFANT NASAL PRNG 5MM TO 4MM

Facility

$42.00

Hospital Charge Code	27704486
Hospital Revenue Code	270
Min. Negotiated Rate	$6.65
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Arizona Complete Health Allwell	$6.72
Rate for Payer: Banner UC Health Medicare	$6.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$28.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.72
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cigna of AZ Commercial	$29.40
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Humana of AZ Medicare	$6.72
Rate for Payer: Southwest Service Administrators UFCW	$28.56
Rate for Payer: TriWest Medicare	$6.72
Rate for Payer: United Healthcare Commercial	$24.02
Rate for Payer: United Healthcare Medicare	$6.72
Rate for Payer: Veterans Affairs TRICARE	$6.65

INFANT NASAL PRNG 5MM TO 6MM

Facility

$42.00

Hospital Charge Code	27704484
Hospital Revenue Code	270
Min. Negotiated Rate	$6.65
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Arizona Complete Health Allwell	$6.72
Rate for Payer: Banner UC Health Medicare	$6.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$28.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.72
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cigna of AZ Commercial	$29.40
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Humana of AZ Medicare	$6.72
Rate for Payer: Southwest Service Administrators UFCW	$28.56
Rate for Payer: TriWest Medicare	$6.72
Rate for Payer: United Healthcare Commercial	$24.02
Rate for Payer: United Healthcare Medicare	$6.72
Rate for Payer: Veterans Affairs TRICARE	$6.65

INFANT NASAL PRNG 5MM TO 6MM

Facility

$42.00

Hospital Charge Code	27704484
Hospital Revenue Code	270
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Cash Price	$33.60

INFANT NASAL PRNG 6MM TO 7MM

Facility

$42.00

Hospital Charge Code	27704485
Hospital Revenue Code	270
Min. Negotiated Rate	$6.65
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Arizona Complete Health Allwell	$6.72
Rate for Payer: Banner UC Health Medicare	$6.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$28.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.72
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cigna of AZ Commercial	$29.40
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Humana of AZ Medicare	$6.72
Rate for Payer: Southwest Service Administrators UFCW	$28.56
Rate for Payer: TriWest Medicare	$6.72
Rate for Payer: United Healthcare Commercial	$24.02
Rate for Payer: United Healthcare Medicare	$6.72
Rate for Payer: Veterans Affairs TRICARE	$6.65

INFANT NASAL PRNG 6MM TO 7MM

Facility

$42.00

Hospital Charge Code	27704485
Hospital Revenue Code	270
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Cash Price	$33.60

INFANT NASAL PRONG 3MM NARE

Facility

$42.00

Hospital Charge Code	27704469
Hospital Revenue Code	270
Min. Negotiated Rate	$6.65
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Arizona Complete Health Allwell	$6.72
Rate for Payer: Banner UC Health Medicare	$6.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$28.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.72
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cigna of AZ Commercial	$29.40
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Humana of AZ Medicare	$6.72
Rate for Payer: Southwest Service Administrators UFCW	$28.56
Rate for Payer: TriWest Medicare	$6.72
Rate for Payer: United Healthcare Commercial	$24.02
Rate for Payer: United Healthcare Medicare	$6.72
Rate for Payer: Veterans Affairs TRICARE	$6.65

INFANT NASAL PRONG 3MM NARE

Facility

$42.00

Hospital Charge Code	27704469
Hospital Revenue Code	270
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Cash Price	$33.60

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC

Facility

$12,760.52

Service Code	MSDRG 758
Min. Negotiated Rate	$12,760.52
Max. Negotiated Rate	$12,760.52
Rate for Payer: Seven Corners Travel Insurance	$12,760.52

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$18,506.07

Service Code	MSDRG 757
Min. Negotiated Rate	$18,506.07
Max. Negotiated Rate	$18,506.07
Rate for Payer: Seven Corners Travel Insurance	$18,506.07

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC

Facility

$8,764.03

Service Code	MSDRG 759
Min. Negotiated Rate	$8,764.03
Max. Negotiated Rate	$8,764.03
Rate for Payer: Seven Corners Travel Insurance	$8,764.03

Infections Of Upper Respiratory Tract

Facility

$4,914.71

Service Code	APR-DRG 1133
Hospital Charge Code	APRDRG1134
Min. Negotiated Rate	$4,914.71
Max. Negotiated Rate	$4,914.71
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$4,914.71
Rate for Payer: Mercy Care Medicaid	$4,914.71
Rate for Payer: NaphCare Correctional Healthcare	$4,914.71

Infections Of Upper Respiratory Tract

Facility

$3,359.71

Service Code	APR-DRG 1132
Hospital Charge Code	APRDRG1133
Min. Negotiated Rate	$3,359.71
Max. Negotiated Rate	$3,359.71
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$3,359.71
Rate for Payer: Mercy Care Medicaid	$3,359.71
Rate for Payer: NaphCare Correctional Healthcare	$3,359.71

Know your out-of-pocket cost for care.

All Charges