Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

metroNIDAZOLE 500 mg Tab [CQCH]

Facility

$0.18

Service Code	NDC 29300022701
Hospital Charge Code	105932030
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of AZ Commercial	$0.16
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	$0.14
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	$0.12
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

metroNIDAZOLE 500 mg Tab [CQCH]

Facility

$0.18

Service Code	NDC 29300022701
Hospital Charge Code	105932030
Hospital Revenue Code	251
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of AZ Commercial	$0.16
Rate for Payer: Cash Price	$0.14

miconazole 100 mg Vag Supp [CQCH]

Facility

$0.42

Service Code	NDC 49348083361
Hospital Charge Code	105932229
Hospital Revenue Code	251
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of AZ Commercial	$0.38
Rate for Payer: Cash Price	$0.34

miconazole 100 mg Vag Supp [CQCH]

Facility

$0.42

Service Code	NDC 49348083361
Hospital Charge Code	105932229
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of AZ Commercial	$0.38
Rate for Payer: Arizona Complete Health Allwell	$0.07
Rate for Payer: Banner UC Health Medicare	$0.07
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.29
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.07
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.07
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cigna of AZ Commercial	$0.27
Rate for Payer: Devoted Health Medicare	$0.08
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Southwest Service Administrators UFCW	$0.29
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: United Healthcare Commercial	$0.24
Rate for Payer: United Healthcare Medicare	$0.07
Rate for Payer: Veterans Affairs TRICARE	$0.07

miconazole 2% Vag Crm w/Appl [CQCH]

Facility

$0.07

Service Code	NDC 904773445
Hospital Charge Code	105932168
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of AZ Commercial	$0.06
Rate for Payer: Cash Price	$0.06

miconazole 2% Vag Crm w/Appl [CQCH]

Facility

$0.07

Service Code	NDC 904773445
Hospital Charge Code	105932168
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of AZ Commercial	$0.06
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	$0.05
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	$0.06
Rate for Payer: Cigna of AZ Commercial	$0.05
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.05
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.04
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

Microalb/Creat Ratio

Facility

$315.00

Service Code	CPT 82043
Hospital Charge Code	1657587
Hospital Revenue Code	301
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of AZ Commercial	$283.50
Rate for Payer: Cash Price	$252.00

Microalb/Creat Ratio

Facility

$315.00

Service Code	CPT 82043
Hospital Charge Code	1657587
Hospital Revenue Code	301
Min. Negotiated Rate	$8.38
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of AZ Commercial	$283.50
Rate for Payer: Arizona Complete Health Allwell	$50.40
Rate for Payer: Banner UC Health Medicare	$50.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$214.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$50.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$50.40
Rate for Payer: Cash Price	$252.00
Rate for Payer: Cash Price	$252.00
Rate for Payer: Cigna of AZ Commercial	$204.75
Rate for Payer: Devoted Health Medicare	$56.70
Rate for Payer: Humana of AZ Medicare	$50.40
Rate for Payer: Seven Corners Travel Insurance	$8.38
Rate for Payer: Southwest Service Administrators UFCW	$214.20
Rate for Payer: TriWest Medicare	$50.40
Rate for Payer: United Healthcare Commercial	$180.18
Rate for Payer: United Healthcare Medicare	$50.40
Rate for Payer: Veterans Affairs TRICARE	$49.90

MICRODISSECTION MANUAL

Facility

$590.00

Service Code	CPT 88381
Hospital Charge Code	22545748
Hospital Revenue Code	310
Min. Negotiated Rate	$531.00
Max. Negotiated Rate	$531.00
Rate for Payer: Aetna of AZ Commercial	$531.00
Rate for Payer: Cash Price	$472.00

MICRODISSECTION MANUAL

Facility

$590.00

Service Code	CPT 88381
Hospital Charge Code	22545748
Hospital Revenue Code	310
Min. Negotiated Rate	$93.46
Max. Negotiated Rate	$531.00
Rate for Payer: Aetna of AZ Commercial	$531.00
Rate for Payer: Arizona Complete Health Allwell	$94.40
Rate for Payer: Banner UC Health Medicare	$94.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$401.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$94.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$135.33
Rate for Payer: Cash Price	$472.00
Rate for Payer: Cash Price	$472.00
Rate for Payer: Cigna of AZ Commercial	$383.50
Rate for Payer: Devoted Health Medicare	$106.20
Rate for Payer: Humana of AZ Medicare	$94.40
Rate for Payer: Southwest Service Administrators UFCW	$401.20
Rate for Payer: TriWest Medicare	$94.40
Rate for Payer: United Healthcare Commercial	$337.48
Rate for Payer: United Healthcare Medicare	$94.40
Rate for Payer: Veterans Affairs TRICARE	$93.46

MICROVASIVE ROTATABLE SNARE 13MM MICRO O

Facility

$1,279.00

Hospital Charge Code	22354317
Hospital Revenue Code	270
Min. Negotiated Rate	$202.59
Max. Negotiated Rate	$1,151.10
Rate for Payer: Aetna of AZ Commercial	$1,151.10
Rate for Payer: Arizona Complete Health Allwell	$204.64
Rate for Payer: Banner UC Health Medicare	$204.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$869.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$204.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$204.64
Rate for Payer: Cash Price	$1,023.20
Rate for Payer: Cigna of AZ Commercial	$895.30
Rate for Payer: Devoted Health Medicare	$230.22
Rate for Payer: Humana of AZ Medicare	$204.64
Rate for Payer: Southwest Service Administrators UFCW	$869.72
Rate for Payer: TriWest Medicare	$204.64
Rate for Payer: United Healthcare Commercial	$731.59
Rate for Payer: United Healthcare Medicare	$204.64
Rate for Payer: Veterans Affairs TRICARE	$202.59

MICROVASIVE ROTATABLE SNARE 13MM MICRO O

Facility

$1,279.00

Hospital Charge Code	22354317
Hospital Revenue Code	270
Min. Negotiated Rate	$1,151.10
Max. Negotiated Rate	$1,151.10
Rate for Payer: Aetna of AZ Commercial	$1,151.10
Rate for Payer: Cash Price	$1,023.20

MICU

Facility

$152.00

Service Code	CPT 87077
Hospital Charge Code	1161242
Hospital Revenue Code	306
Min. Negotiated Rate	$11.72
Max. Negotiated Rate	$136.80
Rate for Payer: Aetna of AZ Commercial	$136.80
Rate for Payer: Arizona Complete Health Allwell	$24.32
Rate for Payer: Banner UC Health Medicare	$24.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$103.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$24.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$24.32
Rate for Payer: Cash Price	$121.60
Rate for Payer: Cash Price	$121.60
Rate for Payer: Cigna of AZ Commercial	$98.80
Rate for Payer: Devoted Health Medicare	$27.36
Rate for Payer: Humana of AZ Medicare	$24.32
Rate for Payer: Seven Corners Travel Insurance	$11.72
Rate for Payer: Southwest Service Administrators UFCW	$103.36
Rate for Payer: TriWest Medicare	$24.32
Rate for Payer: United Healthcare Commercial	$86.94
Rate for Payer: United Healthcare Medicare	$24.32
Rate for Payer: Veterans Affairs TRICARE	$24.08

MICU

Facility

$152.00

Service Code	CPT 87077
Hospital Charge Code	1161242
Hospital Revenue Code	306
Min. Negotiated Rate	$136.80
Max. Negotiated Rate	$136.80
Rate for Payer: Aetna of AZ Commercial	$136.80
Rate for Payer: Cash Price	$121.60

midazolam 2 mg/ 2 mL Inj Sol [CQCH]

Facility

$0.16

Service Code	HCPCS J2250
Hospital Charge Code	105932290
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
Rate for Payer: Cash Price	$0.13

midazolam 2 mg/ 2 mL Inj Sol [CQCH]

Facility

$0.16

Service Code	HCPCS J2250
Hospital Charge Code	105932290
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
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	$0.11
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	$0.10
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Southwest Service Administrators UFCW	$0.11
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: United Healthcare Commercial	$0.09
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

midazolam 2 mg/2 mL preservative-free Sol[CQCH]

Facility

$0.21

Service Code	HCPCS J2250
Hospital Charge Code	169435887
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of AZ Commercial	$0.19
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	$0.14
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	$0.17
Rate for Payer: Cigna of AZ Commercial	$0.14
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Southwest Service Administrators UFCW	$0.14
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: United Healthcare Commercial	$0.12
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

midazolam 2 mg/2 mL preservative-free Sol[CQCH]

Facility

$0.21

Service Code	HCPCS J2250
Hospital Charge Code	169435887
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of AZ Commercial	$0.19
Rate for Payer: Cash Price	$0.17

midazolam 5 mg/1 mL Inj Sol [CQCH]

Facility

$0.77

Service Code	HCPCS J2250
Hospital Charge Code	105932365
Hospital Revenue Code	250
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$0.69
Rate for Payer: Aetna of AZ Commercial	$0.69
Rate for Payer: Cash Price	$0.62

midazolam 5 mg/1 mL Inj Sol [CQCH]

Facility

$0.77

Service Code	HCPCS J2250
Hospital Charge Code	105932365
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.69
Rate for Payer: Aetna of AZ Commercial	$0.69
Rate for Payer: Arizona Complete Health Allwell	$0.12
Rate for Payer: Banner UC Health Medicare	$0.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.12
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna of AZ Commercial	$0.50
Rate for Payer: Devoted Health Medicare	$0.14
Rate for Payer: Humana of AZ Medicare	$0.12
Rate for Payer: Southwest Service Administrators UFCW	$0.52
Rate for Payer: TriWest Medicare	$0.12
Rate for Payer: United Healthcare Commercial	$0.44
Rate for Payer: United Healthcare Medicare	$0.12
Rate for Payer: Veterans Affairs TRICARE	$0.12

midazolam 5 mg/mL 10 ml Sol FOR DRIP [CQCH]

Facility

$1.55

Service Code	HCPCS J2250
Hospital Charge Code	176044314
Hospital Revenue Code	250
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of AZ Commercial	$1.40
Rate for Payer: Cash Price	$1.24

midazolam 5 mg/mL 10 ml Sol FOR DRIP [CQCH]

Facility

$1.55

Service Code	HCPCS J2250
Hospital Charge Code	176044314
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of AZ Commercial	$1.40
Rate for Payer: Arizona Complete Health Allwell	$0.25
Rate for Payer: Banner UC Health Medicare	$0.25
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.05
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.25
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.25
Rate for Payer: Cash Price	$1.24
Rate for Payer: Cigna of AZ Commercial	$1.01
Rate for Payer: Devoted Health Medicare	$0.28
Rate for Payer: Humana of AZ Medicare	$0.25
Rate for Payer: Southwest Service Administrators UFCW	$1.05
Rate for Payer: TriWest Medicare	$0.25
Rate for Payer: United Healthcare Commercial	$0.89
Rate for Payer: United Healthcare Medicare	$0.25
Rate for Payer: Veterans Affairs TRICARE	$0.25

MIDLINE KIT 3FR SINGLE LUMEN

Facility

$741.00

Hospital Charge Code	23751600
Hospital Revenue Code	270
Min. Negotiated Rate	$666.90
Max. Negotiated Rate	$666.90
Rate for Payer: Aetna of AZ Commercial	$666.90
Rate for Payer: Cash Price	$592.80

MIDLINE KIT 3FR SINGLE LUMEN

Facility

$741.00

Hospital Charge Code	23751600
Hospital Revenue Code	270
Min. Negotiated Rate	$117.37
Max. Negotiated Rate	$666.90
Rate for Payer: Aetna of AZ Commercial	$666.90
Rate for Payer: Arizona Complete Health Allwell	$118.56
Rate for Payer: Banner UC Health Medicare	$118.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$503.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$118.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$118.56
Rate for Payer: Cash Price	$592.80
Rate for Payer: Cigna of AZ Commercial	$518.70
Rate for Payer: Devoted Health Medicare	$133.38
Rate for Payer: Humana of AZ Medicare	$118.56
Rate for Payer: Southwest Service Administrators UFCW	$503.88
Rate for Payer: TriWest Medicare	$118.56
Rate for Payer: United Healthcare Commercial	$423.85
Rate for Payer: United Healthcare Medicare	$118.56
Rate for Payer: Veterans Affairs TRICARE	$117.37

midodrine 5 mg Tab [CQCH]

Facility

$0.94

Service Code	NDC 51079045320
Hospital Charge Code	105932438
Hospital Revenue Code	251
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$0.85
Rate for Payer: Aetna of AZ Commercial	$0.85
Rate for Payer: Cash Price	$0.75

Know your out-of-pocket cost for care.

All Charges