Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Measles (Rubeola), PCR, Urine LC

Facility

$175.00

Service Code	CPT 87798
Hospital Charge Code	27539788
Hospital Revenue Code	306
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Cash Price	$140.00

Measles (Rubeola), PCR, Urine LC

Facility

$175.00

Service Code	CPT 87798
Hospital Charge Code	27539788
Hospital Revenue Code	306
Min. Negotiated Rate	$27.72
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Arizona Complete Health Allwell	$28.00
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 Medicare	$28.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cigna of AZ Commercial	$113.75
Rate for Payer: Devoted Health Medicare	$31.50
Rate for Payer: Humana of AZ Medicare	$28.00
Rate for Payer: Seven Corners Travel Insurance	$50.88
Rate for Payer: Southwest Service Administrators UFCW	$119.00
Rate for Payer: TriWest Medicare	$28.00
Rate for Payer: United Healthcare Commercial	$100.10
Rate for Payer: United Healthcare Medicare	$28.00
Rate for Payer: Veterans Affairs TRICARE	$27.72

MEASUREMENT OF TISSUE TRANSGLUTAMINASE

Facility

$58.00

Service Code	CPT 86364
Hospital Charge Code	28010048
Hospital Revenue Code	302
Min. Negotiated Rate	$9.19
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of AZ Commercial	$52.20
Rate for Payer: Arizona Complete Health Allwell	$9.28
Rate for Payer: Banner UC Health Medicare	$9.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$39.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.28
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cigna of AZ Commercial	$37.70
Rate for Payer: Devoted Health Medicare	$10.44
Rate for Payer: Humana of AZ Medicare	$9.28
Rate for Payer: Seven Corners Travel Insurance	$16.72
Rate for Payer: Southwest Service Administrators UFCW	$39.44
Rate for Payer: TriWest Medicare	$9.28
Rate for Payer: United Healthcare Commercial	$33.18
Rate for Payer: United Healthcare Medicare	$9.28
Rate for Payer: Veterans Affairs TRICARE	$9.19

MEASUREMENT OF TISSUE TRANSGLUTAMINASE

Facility

$58.00

Service Code	CPT 86364
Hospital Charge Code	28010048
Hospital Revenue Code	302
Min. Negotiated Rate	$52.20
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of AZ Commercial	$52.20
Rate for Payer: Cash Price	$46.40

meclizine 25 mg tab [CQCH]

Facility

$0.87

Service Code	NDC 68084049101
Hospital Charge Code	105954961
Hospital Revenue Code	251
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.78
Rate for Payer: Aetna of AZ Commercial	$0.78
Rate for Payer: Arizona Complete Health Allwell	$0.14
Rate for Payer: Banner UC Health Medicare	$0.14
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.59
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.14
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.14
Rate for Payer: Cash Price	$0.70
Rate for Payer: Cigna of AZ Commercial	$0.57
Rate for Payer: Devoted Health Medicare	$0.16
Rate for Payer: Humana of AZ Medicare	$0.14
Rate for Payer: Southwest Service Administrators UFCW	$0.59
Rate for Payer: TriWest Medicare	$0.14
Rate for Payer: United Healthcare Commercial	$0.50
Rate for Payer: United Healthcare Medicare	$0.14
Rate for Payer: Veterans Affairs TRICARE	$0.14

meclizine 25 mg tab [CQCH]

Facility

$0.87

Service Code	NDC 68084049101
Hospital Charge Code	105954961
Hospital Revenue Code	251
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$0.78
Rate for Payer: Aetna of AZ Commercial	$0.78
Rate for Payer: Cash Price	$0.70

MECONIUM ASPIRATIORS

Facility

$41.00

Hospital Charge Code	22355517
Hospital Revenue Code	270
Min. Negotiated Rate	$6.49
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of AZ Commercial	$36.90
Rate for Payer: Arizona Complete Health Allwell	$6.56
Rate for Payer: Banner UC Health Medicare	$6.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$27.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.56
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cigna of AZ Commercial	$28.70
Rate for Payer: Devoted Health Medicare	$7.38
Rate for Payer: Humana of AZ Medicare	$6.56
Rate for Payer: Southwest Service Administrators UFCW	$27.88
Rate for Payer: TriWest Medicare	$6.56
Rate for Payer: United Healthcare Commercial	$23.45
Rate for Payer: United Healthcare Medicare	$6.56
Rate for Payer: Veterans Affairs TRICARE	$6.49

MECONIUM ASPIRATIORS

Facility

$41.00

Hospital Charge Code	22355517
Hospital Revenue Code	270
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of AZ Commercial	$36.90
Rate for Payer: Cash Price	$32.80

MEDICAL BACK PROBLEMS WITH MCC

Facility

$21,662.16

Service Code	MSDRG 551
Min. Negotiated Rate	$21,662.16
Max. Negotiated Rate	$21,662.16
Rate for Payer: Seven Corners Travel Insurance	$21,662.16

MEDICAL BACK PROBLEMS WITHOUT MCC

Facility

$12,536.26

Service Code	MSDRG 552
Min. Negotiated Rate	$12,536.26
Max. Negotiated Rate	$12,536.26
Rate for Payer: Seven Corners Travel Insurance	$12,536.26

MEDIHONEY 1.5 OZ

Facility

$71.00

Hospital Charge Code	27569982
Hospital Revenue Code	270
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

MEDIHONEY 1.5 OZ

Facility

$71.00

Hospital Charge Code	27569982
Hospital Revenue Code	270
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

MEDIHONEY 1.5 OZ

Facility

$48.57

Hospital Charge Code	22354967
Hospital Revenue Code	270
Min. Negotiated Rate	$7.69
Max. Negotiated Rate	$43.71
Rate for Payer: Aetna of AZ Commercial	$43.71
Rate for Payer: Arizona Complete Health Allwell	$7.77
Rate for Payer: Banner UC Health Medicare	$7.77
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$33.03
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.77
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.77
Rate for Payer: Cash Price	$38.86
Rate for Payer: Cigna of AZ Commercial	$34.00
Rate for Payer: Devoted Health Medicare	$8.74
Rate for Payer: Humana of AZ Medicare	$7.77
Rate for Payer: Southwest Service Administrators UFCW	$33.03
Rate for Payer: TriWest Medicare	$7.77
Rate for Payer: United Healthcare Commercial	$27.78
Rate for Payer: United Healthcare Medicare	$7.77
Rate for Payer: Veterans Affairs TRICARE	$7.69

MEDIHONEY 1.5 OZ

Facility

$48.57

Hospital Charge Code	22354967
Hospital Revenue Code	270
Min. Negotiated Rate	$43.71
Max. Negotiated Rate	$43.71
Rate for Payer: Aetna of AZ Commercial	$43.71
Rate for Payer: Cash Price	$38.86

MEDIUM OVAL FLEXIBLE SHORT THROW

Facility

$47.00

Hospital Charge Code	23624450
Hospital Revenue Code	270
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Cash Price	$37.60

MEDIUM OVAL FLEXIBLE SHORT THROW

Facility

$47.00

Hospital Charge Code	23624450
Hospital Revenue Code	270
Min. Negotiated Rate	$7.44
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Arizona Complete Health Allwell	$7.52
Rate for Payer: Banner UC Health Medicare	$7.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$31.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.52
Rate for Payer: Cash Price	$37.60
Rate for Payer: Cigna of AZ Commercial	$32.90
Rate for Payer: Devoted Health Medicare	$8.46
Rate for Payer: Humana of AZ Medicare	$7.52
Rate for Payer: Southwest Service Administrators UFCW	$31.96
Rate for Payer: TriWest Medicare	$7.52
Rate for Payer: United Healthcare Commercial	$26.88
Rate for Payer: United Healthcare Medicare	$7.52
Rate for Payer: Veterans Affairs TRICARE	$7.44

MEDIUM OVAL FLEXIBLE SHORT THROW

Facility

$47.00

Hospital Charge Code	27497392
Hospital Revenue Code	270
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Cash Price	$37.60

MEDIUM OVAL FLEXIBLE SHORT THROW

Facility

$47.00

Hospital Charge Code	27497392
Hospital Revenue Code	270
Min. Negotiated Rate	$7.44
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Arizona Complete Health Allwell	$7.52
Rate for Payer: Banner UC Health Medicare	$7.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$31.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.52
Rate for Payer: Cash Price	$37.60
Rate for Payer: Cigna of AZ Commercial	$32.90
Rate for Payer: Devoted Health Medicare	$8.46
Rate for Payer: Humana of AZ Medicare	$7.52
Rate for Payer: Southwest Service Administrators UFCW	$31.96
Rate for Payer: TriWest Medicare	$7.52
Rate for Payer: United Healthcare Commercial	$26.88
Rate for Payer: United Healthcare Medicare	$7.52
Rate for Payer: Veterans Affairs TRICARE	$7.44

medroxyPROGESTERone 2.5 mg Tab [CQCH]

Facility

$0.05

Service Code	NDC 555087202
Hospital Charge Code	105930428
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Cash Price	$0.04

medroxyPROGESTERone 2.5 mg Tab [CQCH]

Facility

$0.05

Service Code	NDC 555087202
Hospital Charge Code	105930428
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Arizona Complete Health Allwell	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.03
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.01
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.01
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of AZ Commercial	$0.03
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.03
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.03
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

MEDTRONIC CLERIFY VISUALIZATION SYSTEM

Facility

$715.00

Hospital Charge Code	27392763
Hospital Revenue Code	270
Min. Negotiated Rate	$643.50
Max. Negotiated Rate	$643.50
Rate for Payer: Aetna of AZ Commercial	$643.50
Rate for Payer: Cash Price	$572.00

MEDTRONIC CLERIFY VISUALIZATION SYSTEM

Facility

$715.00

Hospital Charge Code	27392763
Hospital Revenue Code	270
Min. Negotiated Rate	$113.26
Max. Negotiated Rate	$643.50
Rate for Payer: Aetna of AZ Commercial	$643.50
Rate for Payer: Arizona Complete Health Allwell	$114.40
Rate for Payer: Banner UC Health Medicare	$114.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$486.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$114.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$114.40
Rate for Payer: Cash Price	$572.00
Rate for Payer: Cigna of AZ Commercial	$500.50
Rate for Payer: Devoted Health Medicare	$128.70
Rate for Payer: Humana of AZ Medicare	$114.40
Rate for Payer: Southwest Service Administrators UFCW	$486.20
Rate for Payer: TriWest Medicare	$114.40
Rate for Payer: United Healthcare Commercial	$408.98
Rate for Payer: United Healthcare Medicare	$114.40
Rate for Payer: Veterans Affairs TRICARE	$113.26

megestrol 400 mg/10 mL Oral Susp UD [CQCH]

Facility

$0.50

Service Code	NDC 66689002001
Hospital Charge Code	105930493
Hospital Revenue Code	251
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of AZ Commercial	$0.45
Rate for Payer: Arizona Complete Health Allwell	$0.08
Rate for Payer: Banner UC Health Medicare	$0.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.34
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.08
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cigna of AZ Commercial	$0.33
Rate for Payer: Devoted Health Medicare	$0.09
Rate for Payer: Humana of AZ Medicare	$0.08
Rate for Payer: Southwest Service Administrators UFCW	$0.34
Rate for Payer: TriWest Medicare	$0.08
Rate for Payer: United Healthcare Commercial	$0.29
Rate for Payer: United Healthcare Medicare	$0.08
Rate for Payer: Veterans Affairs TRICARE	$0.08

megestrol 400 mg/10 mL Oral Susp UD [CQCH]

Facility

$0.50

Service Code	NDC 66689002001
Hospital Charge Code	105930493
Hospital Revenue Code	251
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of AZ Commercial	$0.45
Rate for Payer: Cash Price	$0.40

melatonin 3 mg Tab UD [CQCH]

Facility

$0.17

Service Code	NDC 50268052415
Hospital Charge Code	111571064
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
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	$0.12
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	$0.13
Rate for Payer: Cigna of AZ Commercial	$0.11
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Southwest Service Administrators UFCW	$0.12
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: United Healthcare Commercial	$0.10
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

Know your out-of-pocket cost for care.

All Charges