Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

morphine 10 mg/mL preservative-free Sol[CQCH]

Facility

$1.94

Service Code	HCPCS J2274
Hospital Charge Code	169360742
Hospital Revenue Code	250
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$1.75
Rate for Payer: Aetna of AZ Commercial	$1.75
Rate for Payer: Cash Price	$1.55

morphine 15 mg ER Tab [CQCH]

Facility

$0.49

Service Code	NDC 406831562
Hospital Charge Code	105932700
Hospital Revenue Code	251
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.44
Rate for Payer: Aetna of AZ Commercial	$0.44
Rate for Payer: Cash Price	$0.39

morphine 15 mg ER Tab [CQCH]

Facility

$0.49

Service Code	NDC 406831562
Hospital Charge Code	105932700
Hospital Revenue Code	251
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.44
Rate for Payer: Aetna of AZ Commercial	$0.44
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	$0.33
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	$0.39
Rate for Payer: Cigna of AZ Commercial	$0.32
Rate for Payer: Devoted Health Medicare	$0.09
Rate for Payer: Humana of AZ Medicare	$0.08
Rate for Payer: Southwest Service Administrators UFCW	$0.33
Rate for Payer: TriWest Medicare	$0.08
Rate for Payer: United Healthcare Commercial	$0.28
Rate for Payer: United Healthcare Medicare	$0.08
Rate for Payer: Veterans Affairs TRICARE	$0.08

morphine 15 mg Tab-IR [CQCH]

Facility

$0.33

Service Code	NDC 832027311
Hospital Charge Code	145868627
Hospital Revenue Code	250
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of AZ Commercial	$0.30
Rate for Payer: Cash Price	$0.27

morphine 15 mg Tab-IR [CQCH]

Facility

$0.33

Service Code	NDC 832027311
Hospital Charge Code	145868627
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of AZ Commercial	$0.30
Rate for Payer: Arizona Complete Health Allwell	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.22
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.05
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.05
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of AZ Commercial	$0.21
Rate for Payer: Devoted Health Medicare	$0.06
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Southwest Service Administrators UFCW	$0.22
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: United Healthcare Commercial	$0.19
Rate for Payer: United Healthcare Medicare	$0.05
Rate for Payer: Veterans Affairs TRICARE	$0.05

morphine 2 mg/ 1 mL Inj Soln [CQCH]

Facility

$1.73

Service Code	HCPCS J2270
Hospital Charge Code	105932635
Hospital Revenue Code	250
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$1.56
Rate for Payer: Aetna of AZ Commercial	$1.56
Rate for Payer: Cash Price	$1.38

morphine 2 mg/ 1 mL Inj Soln [CQCH]

Facility

$1.73

Service Code	HCPCS J2270
Hospital Charge Code	105932635
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$1.56
Rate for Payer: Aetna of AZ Commercial	$1.56
Rate for Payer: Arizona Complete Health Allwell	$0.28
Rate for Payer: Banner UC Health Medicare	$0.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.18
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.28
Rate for Payer: Cash Price	$1.38
Rate for Payer: Cigna of AZ Commercial	$1.12
Rate for Payer: Devoted Health Medicare	$0.31
Rate for Payer: Humana of AZ Medicare	$0.28
Rate for Payer: Southwest Service Administrators UFCW	$1.18
Rate for Payer: TriWest Medicare	$0.28
Rate for Payer: United Healthcare Commercial	$0.99
Rate for Payer: United Healthcare Medicare	$0.28
Rate for Payer: Veterans Affairs TRICARE	$0.27

morphine 4 mg/ 1 mL Inj Sol [CQCH]

Facility

$1.68

Service Code	HCPCS J2270
Hospital Charge Code	105932899
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$1.51
Rate for Payer: Aetna of AZ Commercial	$1.51
Rate for Payer: Arizona Complete Health Allwell	$0.27
Rate for Payer: Banner UC Health Medicare	$0.27
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.14
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.27
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.27
Rate for Payer: Cash Price	$1.34
Rate for Payer: Cigna of AZ Commercial	$1.09
Rate for Payer: Devoted Health Medicare	$0.30
Rate for Payer: Humana of AZ Medicare	$0.27
Rate for Payer: Southwest Service Administrators UFCW	$1.14
Rate for Payer: TriWest Medicare	$0.27
Rate for Payer: United Healthcare Commercial	$0.96
Rate for Payer: United Healthcare Medicare	$0.27
Rate for Payer: Veterans Affairs TRICARE	$0.27

morphine 4 mg/ 1 mL Inj Sol [CQCH]

Facility

$1.68

Service Code	HCPCS J2270
Hospital Charge Code	105932899
Hospital Revenue Code	250
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$1.51
Rate for Payer: Aetna of AZ Commercial	$1.51
Rate for Payer: Cash Price	$1.34

morphine 5 mg/ 1 mL Inj Sol PF [CQCH]

Facility

$1.84

Service Code	HCPCS J2270
Hospital Charge Code	108648889
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$1.66
Rate for Payer: Aetna of AZ Commercial	$1.66
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	$1.25
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	$1.47
Rate for Payer: Cigna of AZ Commercial	$1.20
Rate for Payer: Devoted Health Medicare	$0.33
Rate for Payer: Humana of AZ Medicare	$0.29
Rate for Payer: Southwest Service Administrators UFCW	$1.25
Rate for Payer: TriWest Medicare	$0.29
Rate for Payer: United Healthcare Commercial	$1.05
Rate for Payer: United Healthcare Medicare	$0.29
Rate for Payer: Veterans Affairs TRICARE	$0.29

morphine 5 mg/ 1 mL Inj Sol PF [CQCH]

Facility

$1.84

Service Code	HCPCS J2270
Hospital Charge Code	108648889
Hospital Revenue Code	250
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$1.66
Rate for Payer: Aetna of AZ Commercial	$1.66
Rate for Payer: Cash Price	$1.47

morphine 5 mg/mL Sol

Facility

$31.00

Service Code	HCPCS J2274
Hospital Charge Code	22282603
Hospital Revenue Code	250
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$27.90
Rate for Payer: Aetna of AZ Commercial	$27.90
Rate for Payer: Arizona Complete Health Allwell	$4.96
Rate for Payer: Banner UC Health Medicare	$4.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$21.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.96
Rate for Payer: Cash Price	$24.80
Rate for Payer: Cigna of AZ Commercial	$20.15
Rate for Payer: Devoted Health Medicare	$5.58
Rate for Payer: Humana of AZ Medicare	$4.96
Rate for Payer: Southwest Service Administrators UFCW	$21.08
Rate for Payer: TriWest Medicare	$4.96
Rate for Payer: United Healthcare Commercial	$17.73
Rate for Payer: United Healthcare Medicare	$4.96
Rate for Payer: Veterans Affairs TRICARE	$4.91

morphine 5 mg/mL Sol

Facility

$31.00

Service Code	HCPCS J2274
Hospital Charge Code	22282603
Hospital Revenue Code	250
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$27.90
Rate for Payer: Aetna of AZ Commercial	$27.90
Rate for Payer: Cash Price	$24.80

MORPHOMETRIC ANALYSIS

Facility

$551.00

Service Code	CPT 88361
Hospital Charge Code	22545726
Hospital Revenue Code	310
Min. Negotiated Rate	$83.03
Max. Negotiated Rate	$554.61
Rate for Payer: Aetna of AZ Commercial	$495.90
Rate for Payer: Arizona Complete Health Allwell	$88.16
Rate for Payer: Banner UC Health Medicare	$88.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$374.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$88.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$83.03
Rate for Payer: Cash Price	$440.80
Rate for Payer: Cash Price	$440.80
Rate for Payer: Cigna of AZ Commercial	$358.15
Rate for Payer: Devoted Health Medicare	$99.18
Rate for Payer: Humana of AZ Medicare	$88.16
Rate for Payer: Seven Corners Travel Insurance	$554.61
Rate for Payer: Southwest Service Administrators UFCW	$374.68
Rate for Payer: TriWest Medicare	$88.16
Rate for Payer: United Healthcare Commercial	$315.17
Rate for Payer: United Healthcare Medicare	$88.16
Rate for Payer: Veterans Affairs TRICARE	$87.28

MORPHOMETRIC ANALYSIS

Facility

$551.00

Service Code	CPT 88361
Hospital Charge Code	22545726
Hospital Revenue Code	310
Min. Negotiated Rate	$495.90
Max. Negotiated Rate	$495.90
Rate for Payer: Aetna of AZ Commercial	$495.90
Rate for Payer: Cash Price	$440.80

MOTORIZED ABSORBABLE 30 TACK TRACKER

Facility

$2,948.10

Hospital Charge Code	28006934
Hospital Revenue Code	270
Min. Negotiated Rate	$2,653.29
Max. Negotiated Rate	$2,653.29
Rate for Payer: Aetna of AZ Commercial	$2,653.29
Rate for Payer: Cash Price	$2,358.48

MOTORIZED ABSORBABLE 30 TACK TRACKER

Facility

$2,948.10

Hospital Charge Code	28006934
Hospital Revenue Code	270
Min. Negotiated Rate	$466.98
Max. Negotiated Rate	$2,653.29
Rate for Payer: Aetna of AZ Commercial	$2,653.29
Rate for Payer: Arizona Complete Health Allwell	$471.70
Rate for Payer: Banner UC Health Medicare	$471.70
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,004.71
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$471.70
Rate for Payer: Care1st Health Plan Arizona Medicare	$471.70
Rate for Payer: Cash Price	$2,358.48
Rate for Payer: Cigna of AZ Commercial	$2,063.67
Rate for Payer: Devoted Health Medicare	$530.66
Rate for Payer: Humana of AZ Medicare	$471.70
Rate for Payer: Southwest Service Administrators UFCW	$2,004.71
Rate for Payer: TriWest Medicare	$471.70
Rate for Payer: United Healthcare Commercial	$1,686.31
Rate for Payer: United Healthcare Medicare	$471.70
Rate for Payer: Veterans Affairs TRICARE	$466.98

MOUTH PROCEDURES WITH CC/MCC

Facility

$19,298.34

Service Code	MSDRG 137
Min. Negotiated Rate	$19,298.34
Max. Negotiated Rate	$19,298.34
Rate for Payer: Seven Corners Travel Insurance	$19,298.34

MOUTH PROCEDURES WITHOUT CC/MCC

Facility

$11,584.63

Service Code	MSDRG 138
Min. Negotiated Rate	$11,584.63
Max. Negotiated Rate	$11,584.63
Rate for Payer: Seven Corners Travel Insurance	$11,584.63

MPL (MPL PROTO-ONCOGENE, THROMBOPOIETIN RECEPTOR) (EG, MYELO

Facility

$751.00

Service Code	CPT 81338
Hospital Charge Code	28010051
Hospital Revenue Code	302
Min. Negotiated Rate	$675.90
Max. Negotiated Rate	$675.90
Rate for Payer: Aetna of AZ Commercial	$675.90
Rate for Payer: Cash Price	$600.80

MPL (MPL PROTO-ONCOGENE, THROMBOPOIETIN RECEPTOR) (EG, MYELO

Facility

$751.00

Service Code	CPT 81338
Hospital Charge Code	28010051
Hospital Revenue Code	302
Min. Negotiated Rate	$118.96
Max. Negotiated Rate	$675.90
Rate for Payer: Aetna of AZ Commercial	$675.90
Rate for Payer: Arizona Complete Health Allwell	$120.16
Rate for Payer: Banner UC Health Medicare	$120.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$510.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$120.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$120.16
Rate for Payer: Cash Price	$600.80
Rate for Payer: Cash Price	$600.80
Rate for Payer: Cigna of AZ Commercial	$488.15
Rate for Payer: Devoted Health Medicare	$135.18
Rate for Payer: Humana of AZ Medicare	$120.16
Rate for Payer: Seven Corners Travel Insurance	$217.98
Rate for Payer: Southwest Service Administrators UFCW	$510.68
Rate for Payer: TriWest Medicare	$120.16
Rate for Payer: United Healthcare Commercial	$429.57
Rate for Payer: United Healthcare Medicare	$120.16
Rate for Payer: Veterans Affairs TRICARE	$118.96

MRA Abdomen w/ Contrast

Facility

$2,233.00

Service Code	CPT 74185
Hospital Charge Code	2214011
Hospital Revenue Code	610
Min. Negotiated Rate	$2,009.70
Max. Negotiated Rate	$2,009.70
Rate for Payer: Aetna of AZ Commercial	$2,009.70
Rate for Payer: Cash Price	$1,786.40

MRA Abdomen w/ Contrast

Facility

$2,233.00

Service Code	CPT 74185
Hospital Charge Code	2214011
Hospital Revenue Code	610
Min. Negotiated Rate	$353.71
Max. Negotiated Rate	$2,009.70
Rate for Payer: Aetna of AZ Commercial	$2,009.70
Rate for Payer: Arizona Complete Health Allwell	$357.28
Rate for Payer: Banner UC Health Medicare	$357.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,518.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$357.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$357.28
Rate for Payer: Cash Price	$1,786.40
Rate for Payer: Cigna of AZ Commercial	$1,563.10
Rate for Payer: Devoted Health Medicare	$401.94
Rate for Payer: Humana of AZ Medicare	$357.28
Rate for Payer: Southwest Service Administrators UFCW	$1,518.44
Rate for Payer: TriWest Medicare	$357.28
Rate for Payer: United Healthcare Commercial	$1,277.28
Rate for Payer: United Healthcare Medicare	$357.28
Rate for Payer: United Healthcare New Mexico Commercial	$424.27
Rate for Payer: Veterans Affairs TRICARE	$353.71

MRA Abdomen w/o Contrast

Facility

$1,985.00

Service Code	CPT 74185
Hospital Charge Code	2214014
Hospital Revenue Code	610
Min. Negotiated Rate	$314.42
Max. Negotiated Rate	$1,786.50
Rate for Payer: Aetna of AZ Commercial	$1,786.50
Rate for Payer: Arizona Complete Health Allwell	$317.60
Rate for Payer: Banner UC Health Medicare	$317.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,349.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$317.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$317.60
Rate for Payer: Cash Price	$1,588.00
Rate for Payer: Cigna of AZ Commercial	$1,389.50
Rate for Payer: Devoted Health Medicare	$357.30
Rate for Payer: Humana of AZ Medicare	$317.60
Rate for Payer: Southwest Service Administrators UFCW	$1,349.80
Rate for Payer: TriWest Medicare	$317.60
Rate for Payer: United Healthcare Commercial	$1,135.42
Rate for Payer: United Healthcare Medicare	$317.60
Rate for Payer: United Healthcare New Mexico Commercial	$377.15
Rate for Payer: Veterans Affairs TRICARE	$314.42

MRA Abdomen w/o Contrast

Facility

$1,985.00

Service Code	CPT 74185
Hospital Charge Code	2214014
Hospital Revenue Code	610
Min. Negotiated Rate	$1,786.50
Max. Negotiated Rate	$1,786.50
Rate for Payer: Aetna of AZ Commercial	$1,786.50
Rate for Payer: Cash Price	$1,588.00

Know your out-of-pocket cost for care.

All Charges