Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

IPV Inactivated Poliovirus Vaccine POC

Facility

$108.00

Service Code	CPT 90713
Hospital Charge Code	667685
Hospital Revenue Code	521
Min. Negotiated Rate	$97.20
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of AZ Commercial	$97.20
Rate for Payer: Cash Price	$86.40

IPV Inactivated Poliovirus Vaccine POC

Facility

$108.00

Service Code	CPT 90713
Hospital Charge Code	667685
Hospital Revenue Code	521
Min. Negotiated Rate	$17.11
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of AZ Commercial	$97.20
Rate for Payer: Arizona Complete Health Allwell	$17.28
Rate for Payer: Banner UC Health Medicare	$17.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$73.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.28
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna of AZ Commercial	$75.60
Rate for Payer: Devoted Health Medicare	$19.44
Rate for Payer: Humana of AZ Medicare	$17.28
Rate for Payer: Southwest Service Administrators UFCW	$73.44
Rate for Payer: TriWest Medicare	$17.28
Rate for Payer: United Healthcare Commercial	$61.78
Rate for Payer: United Healthcare Medicare	$17.28
Rate for Payer: Veterans Affairs TRICARE	$17.11

Iron

Facility

$82.00

Service Code	CPT 83540
Hospital Charge Code	22631513
Hospital Revenue Code	301
Min. Negotiated Rate	$9.38
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Arizona Complete Health Allwell	$13.12
Rate for Payer: Banner UC Health Medicare	$13.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$55.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.12
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cigna of AZ Commercial	$53.30
Rate for Payer: Devoted Health Medicare	$14.76
Rate for Payer: Humana of AZ Medicare	$13.12
Rate for Payer: Seven Corners Travel Insurance	$9.38
Rate for Payer: Southwest Service Administrators UFCW	$55.76
Rate for Payer: TriWest Medicare	$13.12
Rate for Payer: United Healthcare Commercial	$46.90
Rate for Payer: United Healthcare Medicare	$13.12
Rate for Payer: Veterans Affairs TRICARE	$12.99

Iron

Facility

$82.00

Service Code	CPT 83540
Hospital Charge Code	22631513
Hospital Revenue Code	301
Min. Negotiated Rate	$73.80
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Cash Price	$65.60

Iron Binding Capacity

Facility

$447.00

Service Code	CPT 83550
Hospital Charge Code	22481487
Hospital Revenue Code	301
Min. Negotiated Rate	$402.30
Max. Negotiated Rate	$402.30
Rate for Payer: Aetna of AZ Commercial	$402.30
Rate for Payer: Cash Price	$357.60

Iron Binding Capacity

Facility

$447.00

Service Code	CPT 83550
Hospital Charge Code	22481487
Hospital Revenue Code	301
Min. Negotiated Rate	$12.67
Max. Negotiated Rate	$402.30
Rate for Payer: Aetna of AZ Commercial	$402.30
Rate for Payer: Arizona Complete Health Allwell	$71.52
Rate for Payer: Banner UC Health Medicare	$71.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$303.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$71.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$71.52
Rate for Payer: Cash Price	$357.60
Rate for Payer: Cash Price	$357.60
Rate for Payer: Cigna of AZ Commercial	$290.55
Rate for Payer: Devoted Health Medicare	$80.46
Rate for Payer: Humana of AZ Medicare	$71.52
Rate for Payer: Seven Corners Travel Insurance	$12.67
Rate for Payer: Southwest Service Administrators UFCW	$303.96
Rate for Payer: TriWest Medicare	$71.52
Rate for Payer: United Healthcare Commercial	$255.68
Rate for Payer: United Healthcare Medicare	$71.52
Rate for Payer: Veterans Affairs TRICARE	$70.80

iron dextran 50 mg/mL Sol[CQCH]

Facility

$15.54

Service Code	HCPCS J1750
Hospital Charge Code	216496522
Hospital Revenue Code	250
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$27.54
Rate for Payer: Aetna of AZ Commercial	$13.99
Rate for Payer: Arizona Complete Health Allwell	$2.49
Rate for Payer: Banner UC Health Medicare	$2.49
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$10.57
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.49
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.49
Rate for Payer: Cash Price	$12.43
Rate for Payer: Cash Price	$12.43
Rate for Payer: Cigna of AZ Commercial	$10.10
Rate for Payer: Devoted Health Medicare	$2.80
Rate for Payer: Humana of AZ Medicare	$2.49
Rate for Payer: Seven Corners Travel Insurance	$27.54
Rate for Payer: Southwest Service Administrators UFCW	$10.57
Rate for Payer: TriWest Medicare	$2.49
Rate for Payer: United Healthcare Commercial	$8.89
Rate for Payer: United Healthcare Medicare	$2.49
Rate for Payer: Veterans Affairs TRICARE	$2.46

iron dextran 50 mg/mL Sol[CQCH]

Facility

$15.54

Service Code	HCPCS J1750
Hospital Charge Code	216496522
Hospital Revenue Code	250
Min. Negotiated Rate	$13.99
Max. Negotiated Rate	$13.99
Rate for Payer: Aetna of AZ Commercial	$13.99
Rate for Payer: Cash Price	$12.43

Iron Level

Facility

$101.00

Service Code	CPT 83540
Hospital Charge Code	1137680
Hospital Revenue Code	301
Min. Negotiated Rate	$90.90
Max. Negotiated Rate	$90.90
Rate for Payer: Aetna of AZ Commercial	$90.90
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$80.80

Iron Level

Facility

$78.00

Service Code	CPT 83540
Hospital Charge Code	1137680
Hospital Revenue Code	301
Min. Negotiated Rate	$9.38
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Aetna of AZ Commercial	$90.90
Rate for Payer: Arizona Complete Health Allwell	$12.48
Rate for Payer: Arizona Complete Health Allwell	$16.16
Rate for Payer: Banner UC Health Medicare	$16.16
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 Commercial	$68.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.48
Rate for Payer: Cash Price	$80.80
Rate for Payer: Cash Price	$80.80
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cigna of AZ Commercial	$65.65
Rate for Payer: Cigna of AZ Commercial	$50.70
Rate for Payer: Devoted Health Medicare	$14.04
Rate for Payer: Devoted Health Medicare	$18.18
Rate for Payer: Humana of AZ Medicare	$16.16
Rate for Payer: Humana of AZ Medicare	$12.48
Rate for Payer: Seven Corners Travel Insurance	$9.38
Rate for Payer: Seven Corners Travel Insurance	$9.38
Rate for Payer: Southwest Service Administrators UFCW	$68.68
Rate for Payer: Southwest Service Administrators UFCW	$53.04
Rate for Payer: TriWest Medicare	$12.48
Rate for Payer: TriWest Medicare	$16.16
Rate for Payer: United Healthcare Commercial	$44.62
Rate for Payer: United Healthcare Commercial	$57.77
Rate for Payer: United Healthcare Medicare	$16.16
Rate for Payer: United Healthcare Medicare	$12.48
Rate for Payer: Veterans Affairs TRICARE	$12.36
Rate for Payer: Veterans Affairs TRICARE	$16.00

Iron Profile Standard

Facility

$110.00

Service Code	CPT 83540
Hospital Charge Code	22141050
Hospital Revenue Code	301
Min. Negotiated Rate	$9.38
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna of AZ Commercial	$99.00
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Arizona Complete Health Allwell	$12.48
Rate for Payer: Arizona Complete Health Allwell	$17.60
Rate for Payer: Banner UC Health Medicare	$12.48
Rate for Payer: Banner UC Health Medicare	$17.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$74.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$53.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.48
Rate for Payer: Cash Price	$88.00
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$88.00
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cigna of AZ Commercial	$50.70
Rate for Payer: Cigna of AZ Commercial	$71.50
Rate for Payer: Devoted Health Medicare	$14.04
Rate for Payer: Devoted Health Medicare	$19.80
Rate for Payer: Humana of AZ Medicare	$17.60
Rate for Payer: Humana of AZ Medicare	$12.48
Rate for Payer: Seven Corners Travel Insurance	$9.38
Rate for Payer: Seven Corners Travel Insurance	$9.38
Rate for Payer: Southwest Service Administrators UFCW	$53.04
Rate for Payer: Southwest Service Administrators UFCW	$74.80
Rate for Payer: TriWest Medicare	$17.60
Rate for Payer: TriWest Medicare	$12.48
Rate for Payer: United Healthcare Commercial	$62.92
Rate for Payer: United Healthcare Commercial	$44.62
Rate for Payer: United Healthcare Medicare	$17.60
Rate for Payer: United Healthcare Medicare	$12.48
Rate for Payer: Veterans Affairs TRICARE	$12.36
Rate for Payer: Veterans Affairs TRICARE	$17.42

Iron Profile Standard

Facility

$78.00

Service Code	CPT 83540
Hospital Charge Code	22141050
Hospital Revenue Code	301
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Aetna of AZ Commercial	$99.00
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$88.00

iron sucrose 100 mg/ 5 mL IV Sol [CQCH]

Facility

$5.95

Service Code	HCPCS J1756
Hospital Charge Code	105927079
Hospital Revenue Code	250
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$5.36
Rate for Payer: Aetna of AZ Commercial	$5.36
Rate for Payer: Arizona Complete Health Allwell	$0.95
Rate for Payer: Banner UC Health Medicare	$0.95
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$4.05
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.95
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.95
Rate for Payer: Cash Price	$4.76
Rate for Payer: Cigna of AZ Commercial	$3.87
Rate for Payer: Devoted Health Medicare	$1.07
Rate for Payer: Humana of AZ Medicare	$0.95
Rate for Payer: Southwest Service Administrators UFCW	$4.05
Rate for Payer: TriWest Medicare	$0.95
Rate for Payer: United Healthcare Commercial	$3.40
Rate for Payer: United Healthcare Medicare	$0.95
Rate for Payer: Veterans Affairs TRICARE	$0.94

iron sucrose 100 mg/ 5 mL IV Sol [CQCH]

Facility

$5.95

Service Code	HCPCS J1756
Hospital Charge Code	105927079
Hospital Revenue Code	250
Min. Negotiated Rate	$5.36
Max. Negotiated Rate	$5.36
Rate for Payer: Aetna of AZ Commercial	$5.36
Rate for Payer: Cash Price	$4.76

IRRG SOL GLYC 3000

Facility

$72.00

Hospital Charge Code	22354802
Hospital Revenue Code	270
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Cash Price	$57.60

IRRG SOL GLYC 3000

Facility

$72.00

Hospital Charge Code	22354802
Hospital Revenue Code	270
Min. Negotiated Rate	$11.40
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Arizona Complete Health Allwell	$11.52
Rate for Payer: Banner UC Health Medicare	$11.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$48.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.52
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna of AZ Commercial	$50.40
Rate for Payer: Devoted Health Medicare	$12.96
Rate for Payer: Humana of AZ Medicare	$11.52
Rate for Payer: Southwest Service Administrators UFCW	$48.96
Rate for Payer: TriWest Medicare	$11.52
Rate for Payer: United Healthcare Commercial	$41.18
Rate for Payer: United Healthcare Medicare	$11.52
Rate for Payer: Veterans Affairs TRICARE	$11.40

IRRG TUR SET 21-IN

Facility

$57.00

Hospital Charge Code	22355106
Hospital Revenue Code	270
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

IRRG TUR SET 21-IN

Facility

$57.00

Hospital Charge Code	22355106
Hospital Revenue Code	270
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

Irrigation of implanted venous access device for drug delivery systems

Facility

$3,373.00

Service Code	CPT 96523
Hospital Revenue Code	490
Min. Negotiated Rate	$91.28
Max. Negotiated Rate	$3,373.00
Rate for Payer: Seven Corners Travel Insurance	$91.28
Rate for Payer: United Healthcare Commercial	$3,373.00

Irrig drug delivery device

Facility

$4.00

Service Code	CPT 96523
Hospital Charge Code	1413446
Hospital Revenue Code	521
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of AZ Commercial	$3.60
Rate for Payer: Cash Price	$3.20

Irrig drug delivery device

Facility

$4.00

Service Code	CPT 96523
Hospital Charge Code	1413446
Hospital Revenue Code	521
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$91.28
Rate for Payer: Aetna of AZ Commercial	$3.60
Rate for Payer: Arizona Complete Health Allwell	$0.64
Rate for Payer: Banner UC Health Medicare	$0.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.64
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cigna of AZ Commercial	$2.80
Rate for Payer: Devoted Health Medicare	$0.72
Rate for Payer: Humana of AZ Medicare	$0.64
Rate for Payer: Seven Corners Travel Insurance	$91.28
Rate for Payer: Southwest Service Administrators UFCW	$2.72
Rate for Payer: TriWest Medicare	$0.64
Rate for Payer: United Healthcare Commercial	$2.29
Rate for Payer: United Healthcare Medicare	$0.64
Rate for Payer: Veterans Affairs TRICARE	$0.63

IRRIG INSTR TRUMPIT

Facility

$269.00

Hospital Charge Code	22354940
Hospital Revenue Code	270
Min. Negotiated Rate	$42.61
Max. Negotiated Rate	$242.10
Rate for Payer: Aetna of AZ Commercial	$242.10
Rate for Payer: Arizona Complete Health Allwell	$43.04
Rate for Payer: Banner UC Health Medicare	$43.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$182.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$43.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.04
Rate for Payer: Cash Price	$215.20
Rate for Payer: Cigna of AZ Commercial	$188.30
Rate for Payer: Devoted Health Medicare	$48.42
Rate for Payer: Humana of AZ Medicare	$43.04
Rate for Payer: Southwest Service Administrators UFCW	$182.92
Rate for Payer: TriWest Medicare	$43.04
Rate for Payer: United Healthcare Commercial	$153.87
Rate for Payer: United Healthcare Medicare	$43.04
Rate for Payer: Veterans Affairs TRICARE	$42.61

IRRIG INSTR TRUMPIT

Facility

$269.00

Hospital Charge Code	22354940
Hospital Revenue Code	270
Min. Negotiated Rate	$242.10
Max. Negotiated Rate	$242.10
Rate for Payer: Aetna of AZ Commercial	$242.10
Rate for Payer: Cash Price	$215.20

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC

Facility

$22,710.31

Service Code	MSDRG 062
Min. Negotiated Rate	$22,710.31
Max. Negotiated Rate	$22,710.31
Rate for Payer: Seven Corners Travel Insurance	$22,710.31

ISCHEMIC STROKE, PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC

Facility

$35,633.14

Service Code	MSDRG 061
Min. Negotiated Rate	$35,633.14
Max. Negotiated Rate	$35,633.14
Rate for Payer: Seven Corners Travel Insurance	$35,633.14

Know your out-of-pocket cost for care.

All Charges