Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Mini-Neb Subsequent

Facility

$169.79

Service Code	CPT 94640
Hospital Charge Code	1886942
Hospital Revenue Code	410
Min. Negotiated Rate	$26.89
Max. Negotiated Rate	$338.82
Rate for Payer: Aetna of AZ Commercial	$152.81
Rate for Payer: Arizona Complete Health Allwell	$27.17
Rate for Payer: Banner UC Health Medicare	$27.17
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$115.46
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.17
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.17
Rate for Payer: Cash Price	$135.83
Rate for Payer: Cash Price	$135.83
Rate for Payer: Cigna of AZ Commercial	$118.85
Rate for Payer: Devoted Health Medicare	$30.56
Rate for Payer: Humana of AZ Medicare	$27.17
Rate for Payer: Seven Corners Travel Insurance	$338.82
Rate for Payer: Southwest Service Administrators UFCW	$115.46
Rate for Payer: TriWest Medicare	$27.17
Rate for Payer: United Healthcare Commercial	$97.12
Rate for Payer: United Healthcare Medicare	$27.17
Rate for Payer: United Healthcare New Mexico Commercial	$32.26
Rate for Payer: Veterans Affairs TRICARE	$26.89

Mini-Neb Subsequent

Facility

$169.79

Service Code	CPT 94640
Hospital Charge Code	1886942
Hospital Revenue Code	410
Min. Negotiated Rate	$152.81
Max. Negotiated Rate	$152.81
Rate for Payer: Aetna of AZ Commercial	$152.81
Rate for Payer: Cash Price	$135.83

MINI QUICKANCHOR PLUS KIT

Facility

$2,069.00

Hospital Charge Code	27434247
Hospital Revenue Code	270
Min. Negotiated Rate	$327.73
Max. Negotiated Rate	$1,862.10
Rate for Payer: Aetna of AZ Commercial	$1,862.10
Rate for Payer: Arizona Complete Health Allwell	$331.04
Rate for Payer: Banner UC Health Medicare	$331.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,406.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$331.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$331.04
Rate for Payer: Cash Price	$1,655.20
Rate for Payer: Cigna of AZ Commercial	$1,448.30
Rate for Payer: Devoted Health Medicare	$372.42
Rate for Payer: Humana of AZ Medicare	$331.04
Rate for Payer: Southwest Service Administrators UFCW	$1,406.92
Rate for Payer: TriWest Medicare	$331.04
Rate for Payer: United Healthcare Commercial	$1,183.47
Rate for Payer: United Healthcare Medicare	$331.04
Rate for Payer: Veterans Affairs TRICARE	$327.73

MINI QUICKANCHOR PLUS KIT

Facility

$2,069.00

Hospital Charge Code	27434247
Hospital Revenue Code	270
Min. Negotiated Rate	$1,862.10
Max. Negotiated Rate	$1,862.10
Rate for Payer: Aetna of AZ Commercial	$1,862.10
Rate for Payer: Cash Price	$1,655.20

MINOR BLADDER PROCEDURES WITH CC

Facility

$19,647.28

Service Code	MSDRG 663
Min. Negotiated Rate	$19,647.28
Max. Negotiated Rate	$19,647.28
Rate for Payer: Seven Corners Travel Insurance	$19,647.28

MINOR BLADDER PROCEDURES WITH MCC

Facility

$39,567.25

Service Code	MSDRG 662
Min. Negotiated Rate	$39,567.25
Max. Negotiated Rate	$39,567.25
Rate for Payer: Seven Corners Travel Insurance	$39,567.25

MINOR BLADDER PROCEDURES WITHOUT CC/MCC

Facility

$13,620.91

Service Code	MSDRG 664
Min. Negotiated Rate	$13,620.91
Max. Negotiated Rate	$13,620.91
Rate for Payer: Seven Corners Travel Insurance	$13,620.91

MINOR SKIN DISORDERS WITH MCC

Facility

$19,556.82

Service Code	MSDRG 606
Min. Negotiated Rate	$19,556.82
Max. Negotiated Rate	$19,556.82
Rate for Payer: Seven Corners Travel Insurance	$19,556.82

MINOR SKIN DISORDERS WITHOUT MCC

Facility

$11,840.58

Service Code	MSDRG 607
Min. Negotiated Rate	$11,840.58
Max. Negotiated Rate	$11,840.58
Rate for Payer: Seven Corners Travel Insurance	$11,840.58

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC

Facility

$19,446.95

Service Code	MSDRG 345
Min. Negotiated Rate	$19,446.95
Max. Negotiated Rate	$19,446.95
Rate for Payer: Seven Corners Travel Insurance	$19,446.95

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC

Facility

$33,380.46

Service Code	MSDRG 344
Min. Negotiated Rate	$33,380.46
Max. Negotiated Rate	$33,380.46
Rate for Payer: Seven Corners Travel Insurance	$33,380.46

MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC

Facility

$15,386.01

Service Code	MSDRG 346
Min. Negotiated Rate	$15,386.01
Max. Negotiated Rate	$15,386.01
Rate for Payer: Seven Corners Travel Insurance	$15,386.01

Mirena IUD CQCH_AZ

Facility

$533.00

Service Code	HCPCS J7298
Hospital Charge Code	28219689
Hospital Revenue Code	272
Min. Negotiated Rate	$479.70
Max. Negotiated Rate	$479.70
Rate for Payer: Aetna of AZ Commercial	$479.70
Rate for Payer: Cash Price	$426.40

Mirena IUD CQCH_AZ

Facility

$533.00

Service Code	HCPCS J7298
Hospital Charge Code	28219689
Hospital Revenue Code	272
Min. Negotiated Rate	$84.43
Max. Negotiated Rate	$479.70
Rate for Payer: Aetna of AZ Commercial	$479.70
Rate for Payer: Arizona Complete Health Allwell	$85.28
Rate for Payer: Banner UC Health Medicare	$85.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$362.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$85.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$85.28
Rate for Payer: Cash Price	$426.40
Rate for Payer: Cigna of AZ Commercial	$373.10
Rate for Payer: Devoted Health Medicare	$95.94
Rate for Payer: Humana of AZ Medicare	$85.28
Rate for Payer: Southwest Service Administrators UFCW	$362.44
Rate for Payer: TriWest Medicare	$85.28
Rate for Payer: United Healthcare Commercial	$304.88
Rate for Payer: United Healthcare Medicare	$85.28
Rate for Payer: Veterans Affairs TRICARE	$84.43

mirtazapine 15 mg Tab [CQCH]

Facility

$0.13

Service Code	NDC 63739009810
Hospital Charge Code	105932503
Hospital Revenue Code	251
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Cash Price	$0.10

mirtazapine 15 mg Tab [CQCH]

Facility

$0.13

Service Code	NDC 63739009810
Hospital Charge Code	105932503
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Arizona Complete Health Allwell	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.09
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.02
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.02
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of AZ Commercial	$0.08
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.09
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.07
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC

Facility

$17,279.07

Service Code	MSDRG 640
Min. Negotiated Rate	$17,279.07
Max. Negotiated Rate	$17,279.07
Rate for Payer: Seven Corners Travel Insurance	$17,279.07

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC

Facility

$10,216.15

Service Code	MSDRG 641
Min. Negotiated Rate	$10,216.15
Max. Negotiated Rate	$10,216.15
Rate for Payer: Seven Corners Travel Insurance	$10,216.15

miSOPROStol 100 mcg Tab UD [CQCH]

Facility

$0.91

Service Code	NDC 68084004001
Hospital Charge Code	123200105
Hospital Revenue Code	251
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$0.82
Rate for Payer: Aetna of AZ Commercial	$0.82
Rate for Payer: Cash Price	$0.73

miSOPROStol 100 mcg Tab UD [CQCH]

Facility

$0.91

Service Code	NDC 68084004001
Hospital Charge Code	123200105
Hospital Revenue Code	251
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.82
Rate for Payer: Aetna of AZ Commercial	$0.82
Rate for Payer: Arizona Complete Health Allwell	$0.15
Rate for Payer: Banner UC Health Medicare	$0.15
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.62
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.15
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.15
Rate for Payer: Cash Price	$0.73
Rate for Payer: Cigna of AZ Commercial	$0.59
Rate for Payer: Devoted Health Medicare	$0.16
Rate for Payer: Humana of AZ Medicare	$0.15
Rate for Payer: Southwest Service Administrators UFCW	$0.62
Rate for Payer: TriWest Medicare	$0.15
Rate for Payer: United Healthcare Commercial	$0.52
Rate for Payer: United Healthcare Medicare	$0.15
Rate for Payer: Veterans Affairs TRICARE	$0.14

Mitochondrial (M2) Antibody LC

Facility

$249.00

Service Code	CPT 86255
Hospital Charge Code	1285785
Hospital Revenue Code	302
Min. Negotiated Rate	$224.10
Max. Negotiated Rate	$224.10
Rate for Payer: Aetna of AZ Commercial	$224.10
Rate for Payer: Cash Price	$199.20

Mitochondrial (M2) Antibody LC

Facility

$249.00

Service Code	CPT 86255
Hospital Charge Code	1285785
Hospital Revenue Code	302
Min. Negotiated Rate	$17.47
Max. Negotiated Rate	$224.10
Rate for Payer: Aetna of AZ Commercial	$224.10
Rate for Payer: Arizona Complete Health Allwell	$39.84
Rate for Payer: Banner UC Health Medicare	$39.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$169.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$39.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$39.84
Rate for Payer: Cash Price	$199.20
Rate for Payer: Cash Price	$199.20
Rate for Payer: Cigna of AZ Commercial	$161.85
Rate for Payer: Devoted Health Medicare	$44.82
Rate for Payer: Humana of AZ Medicare	$39.84
Rate for Payer: Seven Corners Travel Insurance	$17.47
Rate for Payer: Southwest Service Administrators UFCW	$169.32
Rate for Payer: TriWest Medicare	$39.84
Rate for Payer: United Healthcare Commercial	$142.43
Rate for Payer: United Healthcare Medicare	$39.84
Rate for Payer: Veterans Affairs TRICARE	$39.44

MMR Measles/Mumps/Rubella Virus Vaccine POC

Facility

$210.00

Service Code	CPT 90707
Hospital Charge Code	667682
Hospital Revenue Code	636
Min. Negotiated Rate	$33.26
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Arizona Complete Health Allwell	$33.60
Rate for Payer: Banner UC Health Medicare	$33.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$142.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$33.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$33.60
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cigna of AZ Commercial	$147.00
Rate for Payer: Devoted Health Medicare	$37.80
Rate for Payer: Humana of AZ Medicare	$33.60
Rate for Payer: Southwest Service Administrators UFCW	$142.80
Rate for Payer: TriWest Medicare	$33.60
Rate for Payer: United Healthcare Commercial	$120.12
Rate for Payer: United Healthcare Medicare	$33.60
Rate for Payer: United Healthcare New Mexico Commercial	$39.90
Rate for Payer: Veterans Affairs TRICARE	$33.26

MMR Measles/Mumps/Rubella Virus Vaccine POC

Facility

$210.00

Service Code	CPT 90707
Hospital Charge Code	667682
Hospital Revenue Code	636
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Cash Price	$168.00

MOD COMPLEXITY OBSERVATION CHARGE

Facility

$445.00

Service Code	CPT 99219
Hospital Charge Code	22331365
Min. Negotiated Rate	$400.50
Max. Negotiated Rate	$400.50
Rate for Payer: Aetna of AZ Commercial	$400.50
Rate for Payer: Cash Price	$356.00

Know your out-of-pocket cost for care.

All Charges