Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

J0456 Zithromax 500 mg IV

Facility

$92.00

Service Code	HCPCS J0456
Hospital Charge Code	22022612
Hospital Revenue Code	521
Min. Negotiated Rate	$14.57
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of AZ Commercial	$82.80
Rate for Payer: Arizona Complete Health Allwell	$14.72
Rate for Payer: Banner UC Health Medicare	$14.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$62.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.72
Rate for Payer: Cash Price	$73.60
Rate for Payer: Cigna of AZ Commercial	$64.40
Rate for Payer: Devoted Health Medicare	$16.56
Rate for Payer: Humana of AZ Medicare	$14.72
Rate for Payer: Southwest Service Administrators UFCW	$62.56
Rate for Payer: TriWest Medicare	$14.72
Rate for Payer: United Healthcare Commercial	$52.62
Rate for Payer: United Healthcare Medicare	$14.72
Rate for Payer: Veterans Affairs TRICARE	$14.57

J0456 Zithromax 500 mg IV

Facility

$92.00

Service Code	HCPCS J0456
Hospital Charge Code	22022612
Hospital Revenue Code	521
Min. Negotiated Rate	$82.80
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of AZ Commercial	$82.80
Rate for Payer: Cash Price	$73.60

J3120 Testosterone Enanthate Inj

Facility

$34.00

Service Code	HCPCS J3120
Hospital Charge Code	22245608
Hospital Revenue Code	521
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$30.60
Rate for Payer: Aetna of AZ Commercial	$30.60
Rate for Payer: Cash Price	$27.20

J3120 Testosterone Enanthate Inj

Facility

$34.00

Service Code	HCPCS J3120
Hospital Charge Code	22245608
Hospital Revenue Code	521
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$30.60
Rate for Payer: Aetna of AZ Commercial	$30.60
Rate for Payer: Arizona Complete Health Allwell	$5.44
Rate for Payer: Banner UC Health Medicare	$5.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$23.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.44
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cigna of AZ Commercial	$23.80
Rate for Payer: Devoted Health Medicare	$6.12
Rate for Payer: Humana of AZ Medicare	$5.44
Rate for Payer: Southwest Service Administrators UFCW	$23.12
Rate for Payer: TriWest Medicare	$5.44
Rate for Payer: United Healthcare Commercial	$19.45
Rate for Payer: United Healthcare Medicare	$5.44
Rate for Payer: Veterans Affairs TRICARE	$5.39

J7040 Infusion, normal saline solution, sterile (500 ml=1 unit)

Facility

$34.00

Service Code	HCPCS J7040
Hospital Charge Code	22051886
Hospital Revenue Code	521
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$30.60
Rate for Payer: Aetna of AZ Commercial	$30.60
Rate for Payer: Cash Price	$27.20

J7040 Infusion, normal saline solution, sterile (500 ml=1 unit)

Facility

$34.00

Service Code	HCPCS J7040
Hospital Charge Code	22051886
Hospital Revenue Code	521
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$30.60
Rate for Payer: Aetna of AZ Commercial	$30.60
Rate for Payer: Arizona Complete Health Allwell	$5.44
Rate for Payer: Banner UC Health Medicare	$5.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$23.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.44
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cigna of AZ Commercial	$23.80
Rate for Payer: Devoted Health Medicare	$6.12
Rate for Payer: Humana of AZ Medicare	$5.44
Rate for Payer: Southwest Service Administrators UFCW	$23.12
Rate for Payer: TriWest Medicare	$5.44
Rate for Payer: United Healthcare Commercial	$19.45
Rate for Payer: United Healthcare Medicare	$5.44
Rate for Payer: Veterans Affairs TRICARE	$5.39

J7321, Supartz FX 25 mg/2.5 mL, Hyaluronan or derivative, Hy

Facility

$226.00

Service Code	HCPCS J7321
Hospital Charge Code	23547327
Hospital Revenue Code	521
Min. Negotiated Rate	$35.80
Max. Negotiated Rate	$203.40
Rate for Payer: Aetna of AZ Commercial	$203.40
Rate for Payer: Arizona Complete Health Allwell	$36.16
Rate for Payer: Banner UC Health Medicare	$36.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$153.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.16
Rate for Payer: Cash Price	$180.80
Rate for Payer: Cigna of AZ Commercial	$158.20
Rate for Payer: Devoted Health Medicare	$40.68
Rate for Payer: Humana of AZ Medicare	$36.16
Rate for Payer: Southwest Service Administrators UFCW	$153.68
Rate for Payer: TriWest Medicare	$36.16
Rate for Payer: United Healthcare Commercial	$129.27
Rate for Payer: United Healthcare Medicare	$36.16
Rate for Payer: Veterans Affairs TRICARE	$35.80

J7321, Supartz FX 25 mg/2.5 mL, Hyaluronan or derivative, Hy

Facility

$226.00

Service Code	HCPCS J7321
Hospital Charge Code	23547327
Hospital Revenue Code	521
Min. Negotiated Rate	$203.40
Max. Negotiated Rate	$203.40
Rate for Payer: Aetna of AZ Commercial	$203.40
Rate for Payer: Cash Price	$180.80

J7610 Albuterol, inhalation solution, compounded product, co

Facility

$71.00

Service Code	HCPCS J7610
Hospital Charge Code	22429132
Hospital Revenue Code	521
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Cash Price	$56.80

J7610 Albuterol, inhalation solution, compounded product, co

Facility

$71.00

Service Code	HCPCS J7610
Hospital Charge Code	22429132
Hospital Revenue Code	521
Min. Negotiated Rate	$11.25
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Arizona Complete Health Allwell	$11.36
Rate for Payer: Banner UC Health Medicare	$11.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$48.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.36
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cigna of AZ Commercial	$49.70
Rate for Payer: Devoted Health Medicare	$12.78
Rate for Payer: Humana of AZ Medicare	$11.36
Rate for Payer: Southwest Service Administrators UFCW	$48.28
Rate for Payer: TriWest Medicare	$11.36
Rate for Payer: United Healthcare Commercial	$40.61
Rate for Payer: United Healthcare Medicare	$11.36
Rate for Payer: Veterans Affairs TRICARE	$11.25

JAK2 (JANUS KINASE 2) (EG, MYELOPROLIFERATIVE DISORDER) TARG

Facility

$925.00

Service Code	CPT 81279
Hospital Charge Code	28008410
Hospital Revenue Code	302
Min. Negotiated Rate	$832.50
Max. Negotiated Rate	$832.50
Rate for Payer: Aetna of AZ Commercial	$832.50
Rate for Payer: Cash Price	$740.00

JAK2 (JANUS KINASE 2) (EG, MYELOPROLIFERATIVE DISORDER) TARG

Facility

$925.00

Service Code	CPT 81279
Hospital Charge Code	28008410
Hospital Revenue Code	302
Min. Negotiated Rate	$146.52
Max. Negotiated Rate	$832.50
Rate for Payer: Aetna of AZ Commercial	$832.50
Rate for Payer: Arizona Complete Health Allwell	$148.00
Rate for Payer: Banner UC Health Medicare	$148.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$629.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$148.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$148.00
Rate for Payer: Cash Price	$740.00
Rate for Payer: Cash Price	$740.00
Rate for Payer: Cigna of AZ Commercial	$601.25
Rate for Payer: Devoted Health Medicare	$166.50
Rate for Payer: Humana of AZ Medicare	$148.00
Rate for Payer: Seven Corners Travel Insurance	$268.54
Rate for Payer: Southwest Service Administrators UFCW	$629.00
Rate for Payer: TriWest Medicare	$148.00
Rate for Payer: United Healthcare Commercial	$529.10
Rate for Payer: United Healthcare Medicare	$148.00
Rate for Payer: Veterans Affairs TRICARE	$146.52

JAK2 Mutation Analysis, Qual LC

Facility

$1,137.00

Service Code	CPT 81270
Hospital Charge Code	2029233
Hospital Revenue Code	301
Min. Negotiated Rate	$1,023.30
Max. Negotiated Rate	$1,023.30
Rate for Payer: Aetna of AZ Commercial	$1,023.30
Rate for Payer: Cash Price	$909.60

JAK2 Mutation Analysis, Qual LC

Facility

$1,137.00

Service Code	CPT 81270
Hospital Charge Code	2029233
Hospital Revenue Code	301
Min. Negotiated Rate	$132.91
Max. Negotiated Rate	$1,023.30
Rate for Payer: Aetna of AZ Commercial	$1,023.30
Rate for Payer: Arizona Complete Health Allwell	$181.92
Rate for Payer: Banner UC Health Medicare	$181.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$773.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$181.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$181.92
Rate for Payer: Cash Price	$909.60
Rate for Payer: Cash Price	$909.60
Rate for Payer: Cigna of AZ Commercial	$739.05
Rate for Payer: Devoted Health Medicare	$204.66
Rate for Payer: Humana of AZ Medicare	$181.92
Rate for Payer: Seven Corners Travel Insurance	$132.91
Rate for Payer: Southwest Service Administrators UFCW	$773.16
Rate for Payer: TriWest Medicare	$181.92
Rate for Payer: United Healthcare Commercial	$650.36
Rate for Payer: United Healthcare Medicare	$181.92
Rate for Payer: Veterans Affairs TRICARE	$180.10

KATZ FOREIGN BODY EXTRACTOR

Facility

$555.00

Hospital Charge Code	23760177
Hospital Revenue Code	270
Min. Negotiated Rate	$499.50
Max. Negotiated Rate	$499.50
Rate for Payer: Aetna of AZ Commercial	$499.50
Rate for Payer: Cash Price	$444.00

KATZ FOREIGN BODY EXTRACTOR

Facility

$555.00

Hospital Charge Code	23760177
Hospital Revenue Code	270
Min. Negotiated Rate	$87.91
Max. Negotiated Rate	$499.50
Rate for Payer: Aetna of AZ Commercial	$499.50
Rate for Payer: Arizona Complete Health Allwell	$88.80
Rate for Payer: Banner UC Health Medicare	$88.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$377.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$88.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$88.80
Rate for Payer: Cash Price	$444.00
Rate for Payer: Cigna of AZ Commercial	$388.50
Rate for Payer: Devoted Health Medicare	$99.90
Rate for Payer: Humana of AZ Medicare	$88.80
Rate for Payer: Southwest Service Administrators UFCW	$377.40
Rate for Payer: TriWest Medicare	$88.80
Rate for Payer: United Healthcare Commercial	$317.46
Rate for Payer: United Healthcare Medicare	$88.80
Rate for Payer: Veterans Affairs TRICARE	$87.91

Kelly plication

Facility

$1,775.00

Service Code	CPT 57220
Hospital Charge Code	27267789
Hospital Revenue Code	360
Min. Negotiated Rate	$281.16
Max. Negotiated Rate	$7,740.14
Rate for Payer: Aetna of AZ Commercial	$1,597.50
Rate for Payer: Arizona Complete Health Allwell	$284.00
Rate for Payer: Banner UC Health Medicare	$1,698.98
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,207.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$284.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$284.00
Rate for Payer: Cash Price	$1,420.00
Rate for Payer: Cash Price	$1,420.00
Rate for Payer: Cash Price	$1,420.00
Rate for Payer: Cigna of AZ Commercial	$887.50
Rate for Payer: Devoted Health Medicare	$319.50
Rate for Payer: Humana of AZ Medicare	$284.00
Rate for Payer: NaphCare Correctional Healthcare	$1,698.98
Rate for Payer: Seven Corners Travel Insurance	$7,740.14
Rate for Payer: Southwest Service Administrators UFCW	$1,207.00
Rate for Payer: TriWest Medicare	$284.00
Rate for Payer: United Healthcare Commercial	$5,611.00
Rate for Payer: United Healthcare Medicare	$284.00
Rate for Payer: Veterans Affairs TRICARE	$281.16

Kelly plication

Facility

$1,775.00

Service Code	CPT 57220
Hospital Charge Code	27267789
Hospital Revenue Code	360
Min. Negotiated Rate	$1,597.50
Max. Negotiated Rate	$1,597.50
Rate for Payer: Aetna of AZ Commercial	$1,597.50
Rate for Payer: Cash Price	$1,420.00

ketamine inj concentrate 500 mg/5 mL Sol [CQCH]

Facility

$1.49

Service Code	NDC 409205105
Hospital Charge Code	113868946
Hospital Revenue Code	250
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of AZ Commercial	$1.34
Rate for Payer: Cash Price	$1.19

ketamine inj concentrate 500 mg/5 mL Sol [CQCH]

Facility

$1.49

Service Code	NDC 409205105
Hospital Charge Code	113868946
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of AZ Commercial	$1.34
Rate for Payer: Arizona Complete Health Allwell	$0.24
Rate for Payer: Banner UC Health Medicare	$0.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.01
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.24
Rate for Payer: Cash Price	$1.19
Rate for Payer: Cigna of AZ Commercial	$0.97
Rate for Payer: Devoted Health Medicare	$0.27
Rate for Payer: Humana of AZ Medicare	$0.24
Rate for Payer: Southwest Service Administrators UFCW	$1.01
Rate for Payer: TriWest Medicare	$0.24
Rate for Payer: United Healthcare Commercial	$0.85
Rate for Payer: United Healthcare Medicare	$0.24
Rate for Payer: Veterans Affairs TRICARE	$0.24

Ketone Serum

Facility

$169.00

Service Code	CPT 82009
Hospital Charge Code	887702
Hospital Revenue Code	302
Min. Negotiated Rate	$152.10
Max. Negotiated Rate	$152.10
Rate for Payer: Aetna of AZ Commercial	$152.10
Rate for Payer: Cash Price	$135.20

Ketone Serum

Facility

$169.00

Service Code	CPT 82009
Hospital Charge Code	887702
Hospital Revenue Code	302
Min. Negotiated Rate	$6.55
Max. Negotiated Rate	$152.10
Rate for Payer: Aetna of AZ Commercial	$152.10
Rate for Payer: Arizona Complete Health Allwell	$27.04
Rate for Payer: Banner UC Health Medicare	$27.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$114.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.04
Rate for Payer: Cash Price	$135.20
Rate for Payer: Cash Price	$135.20
Rate for Payer: Cigna of AZ Commercial	$109.85
Rate for Payer: Devoted Health Medicare	$30.42
Rate for Payer: Humana of AZ Medicare	$27.04
Rate for Payer: Seven Corners Travel Insurance	$6.55
Rate for Payer: Southwest Service Administrators UFCW	$114.92
Rate for Payer: TriWest Medicare	$27.04
Rate for Payer: United Healthcare Commercial	$96.67
Rate for Payer: United Healthcare Medicare	$27.04
Rate for Payer: Veterans Affairs TRICARE	$26.77

ketorolac 15 mg Inj Sol [CQCH]

Facility

$1.80

Service Code	HCPCS J1885
Hospital Charge Code	105927425
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$1.62
Rate for Payer: Aetna of AZ Commercial	$1.62
Rate for Payer: Arizona Complete Health Allwell	$0.29
Rate for Payer: Banner UC Health Medicare	$0.29
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.22
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.29
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.29
Rate for Payer: Cash Price	$1.44
Rate for Payer: Cash Price	$1.44
Rate for Payer: Cigna of AZ Commercial	$1.17
Rate for Payer: Devoted Health Medicare	$0.32
Rate for Payer: Humana of AZ Medicare	$0.29
Rate for Payer: Seven Corners Travel Insurance	$0.44
Rate for Payer: Southwest Service Administrators UFCW	$1.22
Rate for Payer: TriWest Medicare	$0.29
Rate for Payer: United Healthcare Commercial	$1.03
Rate for Payer: United Healthcare Medicare	$0.29
Rate for Payer: Veterans Affairs TRICARE	$0.29

ketorolac 15 mg Inj Sol [CQCH]

Facility

$1.80

Service Code	HCPCS J1885
Hospital Charge Code	105927425
Hospital Revenue Code	250
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$1.62
Rate for Payer: Aetna of AZ Commercial	$1.62
Rate for Payer: Cash Price	$1.44

ketorolac 30 mg Inj Sol [CQCH]

Facility

$0.88

Service Code	HCPCS J1885
Hospital Charge Code	105927498
Hospital Revenue Code	250
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$0.79
Rate for Payer: Aetna of AZ Commercial	$0.79
Rate for Payer: Cash Price	$0.70

Know your out-of-pocket cost for care.

All Charges