Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Inflammatory Bowel Disease

Facility

$13,758.66

Service Code	APR-DRG 2454
Hospital Charge Code	APRDRG2451
Min. Negotiated Rate	$13,758.66
Max. Negotiated Rate	$13,758.66
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13,758.66
Rate for Payer: Mercy Care Medicaid	$13,758.66
Rate for Payer: NaphCare Correctional Healthcare	$13,758.66

Inflammatory Bowel Disease

Facility

$7,278.43

Service Code	APR-DRG 2453
Hospital Charge Code	APRDRG2451
Min. Negotiated Rate	$7,278.43
Max. Negotiated Rate	$7,278.43
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$7,278.43
Rate for Payer: Mercy Care Medicaid	$7,278.43
Rate for Payer: NaphCare Correctional Healthcare	$7,278.43

Inflammatory Bowel Disease

Facility

$13,758.66

Service Code	APR-DRG 2454
Hospital Charge Code	APRDRG2453
Min. Negotiated Rate	$13,758.66
Max. Negotiated Rate	$13,758.66
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13,758.66
Rate for Payer: Mercy Care Medicaid	$13,758.66
Rate for Payer: NaphCare Correctional Healthcare	$13,758.66

Inflammatory Bowel Disease

Facility

$4,831.94

Service Code	APR-DRG 2452
Hospital Charge Code	APRDRG2451
Min. Negotiated Rate	$4,831.94
Max. Negotiated Rate	$4,831.94
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$4,831.94
Rate for Payer: Mercy Care Medicaid	$4,831.94
Rate for Payer: NaphCare Correctional Healthcare	$4,831.94

Inflammatory Bowel Disease

Facility

$3,807.20

Service Code	APR-DRG 2451
Hospital Charge Code	APRDRG2454
Min. Negotiated Rate	$3,807.20
Max. Negotiated Rate	$3,807.20
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$3,807.20
Rate for Payer: Mercy Care Medicaid	$3,807.20
Rate for Payer: NaphCare Correctional Healthcare	$3,807.20

INFLAMMATORY BOWEL DISEASE WITH CC

Facility

$12,726.30

Service Code	MSDRG 386
Min. Negotiated Rate	$12,726.30
Max. Negotiated Rate	$12,726.30
Rate for Payer: Seven Corners Travel Insurance	$12,726.30

INFLAMMATORY BOWEL DISEASE WITH MCC

Facility

$20,449.87

Service Code	MSDRG 385
Min. Negotiated Rate	$20,449.87
Max. Negotiated Rate	$20,449.87
Rate for Payer: Seven Corners Travel Insurance	$20,449.87

INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC

Facility

$8,988.33

Service Code	MSDRG 387
Min. Negotiated Rate	$8,988.33
Max. Negotiated Rate	$8,988.33
Rate for Payer: Seven Corners Travel Insurance	$8,988.33

inFLIXimab 100 mg REC[CQCH]

Facility

$460.52

Service Code	HCPCS J1745
Hospital Charge Code	199586827
Hospital Revenue Code	250
Min. Negotiated Rate	$414.47
Max. Negotiated Rate	$414.47
Rate for Payer: Aetna of AZ Commercial	$414.47
Rate for Payer: Cash Price	$368.42

inFLIXimab 100 mg REC[CQCH]

Facility

$460.52

Service Code	HCPCS J1745
Hospital Charge Code	199586827
Hospital Revenue Code	250
Min. Negotiated Rate	$45.65
Max. Negotiated Rate	$414.47
Rate for Payer: Aetna of AZ Commercial	$414.47
Rate for Payer: Arizona Complete Health Allwell	$73.68
Rate for Payer: Banner UC Health Medicare	$73.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$313.15
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$73.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$73.68
Rate for Payer: Cash Price	$368.42
Rate for Payer: Cash Price	$368.42
Rate for Payer: Cigna of AZ Commercial	$299.34
Rate for Payer: Devoted Health Medicare	$82.89
Rate for Payer: Humana of AZ Medicare	$73.68
Rate for Payer: Seven Corners Travel Insurance	$45.65
Rate for Payer: Southwest Service Administrators UFCW	$313.15
Rate for Payer: TriWest Medicare	$73.68
Rate for Payer: United Healthcare Commercial	$263.42
Rate for Payer: United Healthcare Medicare	$73.68
Rate for Payer: Veterans Affairs TRICARE	$72.95

inFLIXimab abda 100 mg REC[CQCH]

Facility

$347.81

Service Code	HCPCS Q5104
Hospital Charge Code	218718750
Hospital Revenue Code	250
Min. Negotiated Rate	$313.03
Max. Negotiated Rate	$313.03
Rate for Payer: Aetna of AZ Commercial	$313.03
Rate for Payer: Cash Price	$278.25

inFLIXimab abda 100 mg REC[CQCH]

Facility

$347.81

Service Code	HCPCS Q5104
Hospital Charge Code	218718750
Hospital Revenue Code	250
Min. Negotiated Rate	$38.60
Max. Negotiated Rate	$313.03
Rate for Payer: Aetna of AZ Commercial	$313.03
Rate for Payer: Arizona Complete Health Allwell	$55.65
Rate for Payer: Banner UC Health Medicare	$55.65
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$236.51
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$55.65
Rate for Payer: Care1st Health Plan Arizona Medicare	$55.65
Rate for Payer: Cash Price	$278.25
Rate for Payer: Cash Price	$278.25
Rate for Payer: Cigna of AZ Commercial	$226.08
Rate for Payer: Devoted Health Medicare	$62.61
Rate for Payer: Humana of AZ Medicare	$55.65
Rate for Payer: Seven Corners Travel Insurance	$38.60
Rate for Payer: Southwest Service Administrators UFCW	$236.51
Rate for Payer: TriWest Medicare	$55.65
Rate for Payer: United Healthcare Commercial	$198.95
Rate for Payer: United Healthcare Medicare	$55.65
Rate for Payer: Veterans Affairs TRICARE	$55.09

inFLIXimab axxq 100 mg REC[CQCH]

Facility

$454.48

Service Code	HCPCS Q5104
Hospital Charge Code	193373980
Hospital Revenue Code	250
Min. Negotiated Rate	$38.60
Max. Negotiated Rate	$409.03
Rate for Payer: Aetna of AZ Commercial	$409.03
Rate for Payer: Arizona Complete Health Allwell	$72.72
Rate for Payer: Banner UC Health Medicare	$72.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$309.05
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$72.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$72.72
Rate for Payer: Cash Price	$363.58
Rate for Payer: Cash Price	$363.58
Rate for Payer: Cigna of AZ Commercial	$295.41
Rate for Payer: Devoted Health Medicare	$81.81
Rate for Payer: Humana of AZ Medicare	$72.72
Rate for Payer: Seven Corners Travel Insurance	$38.60
Rate for Payer: Southwest Service Administrators UFCW	$309.05
Rate for Payer: TriWest Medicare	$72.72
Rate for Payer: United Healthcare Commercial	$259.96
Rate for Payer: United Healthcare Medicare	$72.72
Rate for Payer: Veterans Affairs TRICARE	$71.99

inFLIXimab axxq 100 mg REC[CQCH]

Facility

$454.48

Service Code	HCPCS Q5104
Hospital Charge Code	193373980
Hospital Revenue Code	250
Min. Negotiated Rate	$409.03
Max. Negotiated Rate	$409.03
Rate for Payer: Aetna of AZ Commercial	$409.03
Rate for Payer: Cash Price	$363.58

inFLIXimab dyyb 100 mg REC[CQCH]

Facility

$491.58

Service Code	HCPCS Q5103
Hospital Charge Code	218723016
Hospital Revenue Code	250
Min. Negotiated Rate	$442.42
Max. Negotiated Rate	$442.42
Rate for Payer: Aetna of AZ Commercial	$442.42
Rate for Payer: Cash Price	$393.26

inFLIXimab dyyb 100 mg REC[CQCH]

Facility

$491.58

Service Code	HCPCS Q5103
Hospital Charge Code	218723016
Hospital Revenue Code	250
Min. Negotiated Rate	$40.18
Max. Negotiated Rate	$442.42
Rate for Payer: Aetna of AZ Commercial	$442.42
Rate for Payer: Arizona Complete Health Allwell	$78.65
Rate for Payer: Banner UC Health Medicare	$78.65
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$334.27
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$78.65
Rate for Payer: Care1st Health Plan Arizona Medicare	$78.65
Rate for Payer: Cash Price	$393.26
Rate for Payer: Cash Price	$393.26
Rate for Payer: Cigna of AZ Commercial	$319.53
Rate for Payer: Devoted Health Medicare	$88.48
Rate for Payer: Humana of AZ Medicare	$78.65
Rate for Payer: Seven Corners Travel Insurance	$40.18
Rate for Payer: Southwest Service Administrators UFCW	$334.27
Rate for Payer: TriWest Medicare	$78.65
Rate for Payer: United Healthcare Commercial	$281.18
Rate for Payer: United Healthcare Medicare	$78.65
Rate for Payer: Veterans Affairs TRICARE	$77.87

INFLOW PUMP TUBING

Facility

$242.50

Hospital Charge Code	25519689
Hospital Revenue Code	270
Min. Negotiated Rate	$38.41
Max. Negotiated Rate	$218.25
Rate for Payer: Aetna of AZ Commercial	$218.25
Rate for Payer: Arizona Complete Health Allwell	$38.80
Rate for Payer: Banner UC Health Medicare	$38.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$164.90
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.80
Rate for Payer: Cash Price	$194.00
Rate for Payer: Cigna of AZ Commercial	$169.75
Rate for Payer: Devoted Health Medicare	$43.65
Rate for Payer: Humana of AZ Medicare	$38.80
Rate for Payer: Southwest Service Administrators UFCW	$164.90
Rate for Payer: TriWest Medicare	$38.80
Rate for Payer: United Healthcare Commercial	$138.71
Rate for Payer: United Healthcare Medicare	$38.80
Rate for Payer: Veterans Affairs TRICARE	$38.41

INFLOW PUMP TUBING

Facility

$242.50

Hospital Charge Code	25519689
Hospital Revenue Code	270
Min. Negotiated Rate	$218.25
Max. Negotiated Rate	$218.25
Rate for Payer: Aetna of AZ Commercial	$218.25
Rate for Payer: Cash Price	$194.00

INFLU B SCN

Facility

$205.00

Service Code	CPT 87804
Hospital Charge Code	22481485
Hospital Revenue Code	306
Min. Negotiated Rate	$184.50
Max. Negotiated Rate	$184.50
Rate for Payer: Aetna of AZ Commercial	$184.50
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Cash Price	$164.00
Rate for Payer: Cash Price	$140.00

INFLU B SCN

Facility

$175.00

Service Code	CPT 87804
Hospital Charge Code	22481485
Hospital Revenue Code	306
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Aetna of AZ Commercial	$184.50
Rate for Payer: Arizona Complete Health Allwell	$32.80
Rate for Payer: Arizona Complete Health Allwell	$28.00
Rate for Payer: Banner UC Health Medicare	$32.80
Rate for Payer: Banner UC Health Medicare	$28.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$119.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$139.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.80
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cash Price	$164.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cash Price	$164.00
Rate for Payer: Cigna of AZ Commercial	$133.25
Rate for Payer: Cigna of AZ Commercial	$113.75
Rate for Payer: Devoted Health Medicare	$36.90
Rate for Payer: Devoted Health Medicare	$31.50
Rate for Payer: Humana of AZ Medicare	$28.00
Rate for Payer: Humana of AZ Medicare	$32.80
Rate for Payer: Seven Corners Travel Insurance	$24.00
Rate for Payer: Seven Corners Travel Insurance	$24.00
Rate for Payer: Southwest Service Administrators UFCW	$139.40
Rate for Payer: Southwest Service Administrators UFCW	$119.00
Rate for Payer: TriWest Medicare	$28.00
Rate for Payer: TriWest Medicare	$32.80
Rate for Payer: United Healthcare Commercial	$100.10
Rate for Payer: United Healthcare Commercial	$117.26
Rate for Payer: United Healthcare Medicare	$28.00
Rate for Payer: United Healthcare Medicare	$32.80
Rate for Payer: Veterans Affairs TRICARE	$32.47
Rate for Payer: Veterans Affairs TRICARE	$27.72

Influenza A/B POC

Facility

$130.00

Service Code	CPT 87804 QW
Hospital Charge Code	13407374
Hospital Revenue Code	306
Min. Negotiated Rate	$20.59
Max. Negotiated Rate	$117.00
Rate for Payer: Aetna of AZ Commercial	$117.00
Rate for Payer: Arizona Complete Health Allwell	$20.80
Rate for Payer: Banner UC Health Medicare	$20.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$88.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.80
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cash Price	$104.00
Rate for Payer: Cigna of AZ Commercial	$84.50
Rate for Payer: Devoted Health Medicare	$23.40
Rate for Payer: Humana of AZ Medicare	$20.80
Rate for Payer: Seven Corners Travel Insurance	$24.00
Rate for Payer: Southwest Service Administrators UFCW	$88.40
Rate for Payer: TriWest Medicare	$20.80
Rate for Payer: United Healthcare Commercial	$74.36
Rate for Payer: United Healthcare Medicare	$20.80
Rate for Payer: Veterans Affairs TRICARE	$20.59

Influenza A/B POC

Facility

$130.00

Service Code	CPT 87804 QW
Hospital Charge Code	13407374
Hospital Revenue Code	306
Min. Negotiated Rate	$117.00
Max. Negotiated Rate	$117.00
Rate for Payer: Aetna of AZ Commercial	$117.00
Rate for Payer: Cash Price	$104.00

Influenza AB Rapid

Facility

$175.00

Service Code	CPT 87804
Hospital Charge Code	5696971
Hospital Revenue Code	306
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Aetna of AZ Commercial	$175.50
Rate for Payer: Arizona Complete Health Allwell	$31.20
Rate for Payer: Arizona Complete Health Allwell	$28.00
Rate for Payer: Banner UC Health Medicare	$31.20
Rate for Payer: Banner UC Health Medicare	$28.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$119.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$132.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$31.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.20
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cash Price	$156.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cash Price	$156.00
Rate for Payer: Cigna of AZ Commercial	$126.75
Rate for Payer: Cigna of AZ Commercial	$113.75
Rate for Payer: Devoted Health Medicare	$35.10
Rate for Payer: Devoted Health Medicare	$31.50
Rate for Payer: Humana of AZ Medicare	$28.00
Rate for Payer: Humana of AZ Medicare	$31.20
Rate for Payer: Seven Corners Travel Insurance	$24.00
Rate for Payer: Seven Corners Travel Insurance	$24.00
Rate for Payer: Southwest Service Administrators UFCW	$132.60
Rate for Payer: Southwest Service Administrators UFCW	$119.00
Rate for Payer: TriWest Medicare	$28.00
Rate for Payer: TriWest Medicare	$31.20
Rate for Payer: United Healthcare Commercial	$100.10
Rate for Payer: United Healthcare Commercial	$111.54
Rate for Payer: United Healthcare Medicare	$28.00
Rate for Payer: United Healthcare Medicare	$31.20
Rate for Payer: Veterans Affairs TRICARE	$30.89
Rate for Payer: Veterans Affairs TRICARE	$27.72

Influenza AB Rapid

Facility

$195.00

Service Code	CPT 87804
Hospital Charge Code	5696971
Hospital Revenue Code	306
Min. Negotiated Rate	$175.50
Max. Negotiated Rate	$175.50
Rate for Payer: Aetna of AZ Commercial	$175.50
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Cash Price	$156.00
Rate for Payer: Cash Price	$140.00

influenza virus vaccine 2024-2025, inactivated preservative-free trivalent Sus UD[CQCH]

Facility

$14.80

Service Code	NDC 19515081052
Hospital Charge Code	242320050
Hospital Revenue Code	250
Min. Negotiated Rate	$13.32
Max. Negotiated Rate	$13.32
Rate for Payer: Aetna of AZ Commercial	$13.32
Rate for Payer: Cash Price	$11.84

Know your out-of-pocket cost for care.

All Charges