Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

MYOSURE XL HYSTEROSCOPE TISSUE REMVL DEV

Facility

$3,673.00

Hospital Charge Code	22354783
Hospital Revenue Code	270
Min. Negotiated Rate	$3,305.70
Max. Negotiated Rate	$3,305.70
Rate for Payer: Aetna of AZ Commercial	$3,305.70
Rate for Payer: Cash Price	$2,938.40

naloxone 0.4 mg/ 1 mL Inj Sol [CQCH]

Facility

$12.78

Service Code	HCPCS J2310
Hospital Charge Code	105933490
Hospital Revenue Code	250
Min. Negotiated Rate	$11.50
Max. Negotiated Rate	$11.50
Rate for Payer: Aetna of AZ Commercial	$11.50
Rate for Payer: Cash Price	$10.22

naloxone 0.4 mg/ 1 mL Inj Sol [CQCH]

Facility

$12.78

Service Code	HCPCS J2310
Hospital Charge Code	105933490
Hospital Revenue Code	250
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$11.50
Rate for Payer: Aetna of AZ Commercial	$11.50
Rate for Payer: Arizona Complete Health Allwell	$2.04
Rate for Payer: Banner UC Health Medicare	$2.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$8.69
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.04
Rate for Payer: Cash Price	$10.22
Rate for Payer: Cigna of AZ Commercial	$8.31
Rate for Payer: Devoted Health Medicare	$2.30
Rate for Payer: Humana of AZ Medicare	$2.04
Rate for Payer: Southwest Service Administrators UFCW	$8.69
Rate for Payer: TriWest Medicare	$2.04
Rate for Payer: United Healthcare Commercial	$7.31
Rate for Payer: United Healthcare Medicare	$2.04
Rate for Payer: Veterans Affairs TRICARE	$2.02

naloxone 2 mg PFS [CQCH]

Facility

$24.89

Service Code	HCPCS J2310
Hospital Charge Code	105933415
Hospital Revenue Code	250
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$22.40
Rate for Payer: Aetna of AZ Commercial	$22.40
Rate for Payer: Arizona Complete Health Allwell	$3.98
Rate for Payer: Banner UC Health Medicare	$3.98
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$16.93
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.98
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.98
Rate for Payer: Cash Price	$19.91
Rate for Payer: Cigna of AZ Commercial	$16.18
Rate for Payer: Devoted Health Medicare	$4.48
Rate for Payer: Humana of AZ Medicare	$3.98
Rate for Payer: Southwest Service Administrators UFCW	$16.93
Rate for Payer: TriWest Medicare	$3.98
Rate for Payer: United Healthcare Commercial	$14.24
Rate for Payer: United Healthcare Medicare	$3.98
Rate for Payer: Veterans Affairs TRICARE	$3.94

naloxone 2 mg PFS [CQCH]

Facility

$24.89

Service Code	HCPCS J2310
Hospital Charge Code	105933415
Hospital Revenue Code	250
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$22.40
Rate for Payer: Aetna of AZ Commercial	$22.40
Rate for Payer: Cash Price	$19.91

naproxen 500 mg Tab [CQCH]

Facility

$0.15

Service Code	NDC 68084012701
Hospital Charge Code	105933620
Hospital Revenue Code	251
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
Rate for Payer: Cash Price	$0.12

naproxen 500 mg Tab [CQCH]

Facility

$0.15

Service Code	NDC 68084012701
Hospital Charge Code	105933620
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
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	$0.10
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	$0.12
Rate for Payer: Cigna of AZ Commercial	$0.10
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.10
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.09
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

NASAL AND ORAL CO2 CANNULA PED WITH O2

Facility

$74.00

Hospital Charge Code	27410392
Hospital Revenue Code	270
Min. Negotiated Rate	$66.60
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Cash Price	$59.20

NASAL AND ORAL CO2 CANNULA PED WITH O2

Facility

$74.00

Hospital Charge Code	27410392
Hospital Revenue Code	270
Min. Negotiated Rate	$11.72
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Arizona Complete Health Allwell	$11.84
Rate for Payer: Banner UC Health Medicare	$11.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$50.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.84
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cigna of AZ Commercial	$51.80
Rate for Payer: Devoted Health Medicare	$13.32
Rate for Payer: Humana of AZ Medicare	$11.84
Rate for Payer: Southwest Service Administrators UFCW	$50.32
Rate for Payer: TriWest Medicare	$11.84
Rate for Payer: United Healthcare Commercial	$42.33
Rate for Payer: United Healthcare Medicare	$11.84
Rate for Payer: Veterans Affairs TRICARE	$11.72

NASAL CATH EPISTAT II

Facility

$242.00

Hospital Charge Code	22354310
Hospital Revenue Code	270
Min. Negotiated Rate	$217.80
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Cash Price	$193.60

NASAL CATH EPISTAT II

Facility

$242.00

Hospital Charge Code	22354310
Hospital Revenue Code	270
Min. Negotiated Rate	$38.33
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Arizona Complete Health Allwell	$38.72
Rate for Payer: Banner UC Health Medicare	$38.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$164.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.72
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cigna of AZ Commercial	$169.40
Rate for Payer: Devoted Health Medicare	$43.56
Rate for Payer: Humana of AZ Medicare	$38.72
Rate for Payer: Southwest Service Administrators UFCW	$164.56
Rate for Payer: TriWest Medicare	$38.72
Rate for Payer: United Healthcare Commercial	$138.42
Rate for Payer: United Healthcare Medicare	$38.72
Rate for Payer: Veterans Affairs TRICARE	$38.33

NCIRCLE HELICAL TIPLESS STONE EXTRACTOR

Facility

$1,388.00

Hospital Charge Code	22354220
Hospital Revenue Code	270
Min. Negotiated Rate	$1,249.20
Max. Negotiated Rate	$1,249.20
Rate for Payer: Aetna of AZ Commercial	$1,249.20
Rate for Payer: Cash Price	$1,110.40

NCIRCLE HELICAL TIPLESS STONE EXTRACTOR

Facility

$1,388.00

Hospital Charge Code	22354220
Hospital Revenue Code	270
Min. Negotiated Rate	$219.86
Max. Negotiated Rate	$1,249.20
Rate for Payer: Aetna of AZ Commercial	$1,249.20
Rate for Payer: Arizona Complete Health Allwell	$222.08
Rate for Payer: Banner UC Health Medicare	$222.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$943.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$222.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$222.08
Rate for Payer: Cash Price	$1,110.40
Rate for Payer: Cigna of AZ Commercial	$971.60
Rate for Payer: Devoted Health Medicare	$249.84
Rate for Payer: Humana of AZ Medicare	$222.08
Rate for Payer: Southwest Service Administrators UFCW	$943.84
Rate for Payer: TriWest Medicare	$222.08
Rate for Payer: United Healthcare Commercial	$793.94
Rate for Payer: United Healthcare Medicare	$222.08
Rate for Payer: Veterans Affairs TRICARE	$219.86

NCIRCLE TIPLESS STONE EXTRACTOR 1.5

Facility

$1,388.00

Hospital Charge Code	27748908
Hospital Revenue Code	270
Min. Negotiated Rate	$219.86
Max. Negotiated Rate	$1,249.20
Rate for Payer: Aetna of AZ Commercial	$1,249.20
Rate for Payer: Arizona Complete Health Allwell	$222.08
Rate for Payer: Banner UC Health Medicare	$222.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$943.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$222.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$222.08
Rate for Payer: Cash Price	$1,110.40
Rate for Payer: Cigna of AZ Commercial	$971.60
Rate for Payer: Devoted Health Medicare	$249.84
Rate for Payer: Humana of AZ Medicare	$222.08
Rate for Payer: Southwest Service Administrators UFCW	$943.84
Rate for Payer: TriWest Medicare	$222.08
Rate for Payer: United Healthcare Commercial	$793.94
Rate for Payer: United Healthcare Medicare	$222.08
Rate for Payer: Veterans Affairs TRICARE	$219.86

NCIRCLE TIPLESS STONE EXTRACTOR 1.5

Facility

$1,388.00

Hospital Charge Code	27748908
Hospital Revenue Code	270
Min. Negotiated Rate	$1,249.20
Max. Negotiated Rate	$1,249.20
Rate for Payer: Aetna of AZ Commercial	$1,249.20
Rate for Payer: Cash Price	$1,110.40

NDL SPINAL 20GX3.5

Facility

$26.00

Hospital Charge Code	22355398
Hospital Revenue Code	270
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna of AZ Commercial	$23.40
Rate for Payer: Arizona Complete Health Allwell	$4.16
Rate for Payer: Banner UC Health Medicare	$4.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$17.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.16
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cigna of AZ Commercial	$18.20
Rate for Payer: Devoted Health Medicare	$4.68
Rate for Payer: Humana of AZ Medicare	$4.16
Rate for Payer: Southwest Service Administrators UFCW	$17.68
Rate for Payer: TriWest Medicare	$4.16
Rate for Payer: United Healthcare Commercial	$14.87
Rate for Payer: United Healthcare Medicare	$4.16
Rate for Payer: Veterans Affairs TRICARE	$4.12

NDL SPINAL 20GX3.5

Facility

$26.00

Hospital Charge Code	22355398
Hospital Revenue Code	270
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna of AZ Commercial	$23.40
Rate for Payer: Cash Price	$20.80

NDL SPINAL 25GX3.5

Facility

$26.00

Hospital Charge Code	22355397
Hospital Revenue Code	270
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna of AZ Commercial	$23.40
Rate for Payer: Arizona Complete Health Allwell	$4.16
Rate for Payer: Banner UC Health Medicare	$4.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$17.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.16
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cigna of AZ Commercial	$18.20
Rate for Payer: Devoted Health Medicare	$4.68
Rate for Payer: Humana of AZ Medicare	$4.16
Rate for Payer: Southwest Service Administrators UFCW	$17.68
Rate for Payer: TriWest Medicare	$4.16
Rate for Payer: United Healthcare Commercial	$14.87
Rate for Payer: United Healthcare Medicare	$4.16
Rate for Payer: Veterans Affairs TRICARE	$4.12

NDL SPINAL 25GX3.5

Facility

$26.00

Hospital Charge Code	22355397
Hospital Revenue Code	270
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna of AZ Commercial	$23.40
Rate for Payer: Cash Price	$20.80

NDL SPNL 20GX3.5 QUINCKE

Facility

$99.00

Hospital Charge Code	22354972
Hospital Revenue Code	270
Min. Negotiated Rate	$15.68
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of AZ Commercial	$89.10
Rate for Payer: Arizona Complete Health Allwell	$15.84
Rate for Payer: Banner UC Health Medicare	$15.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$67.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$15.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.84
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna of AZ Commercial	$69.30
Rate for Payer: Devoted Health Medicare	$17.82
Rate for Payer: Humana of AZ Medicare	$15.84
Rate for Payer: Southwest Service Administrators UFCW	$67.32
Rate for Payer: TriWest Medicare	$15.84
Rate for Payer: United Healthcare Commercial	$56.63
Rate for Payer: United Healthcare Medicare	$15.84
Rate for Payer: Veterans Affairs TRICARE	$15.68

NDL SPNL 20GX3.5 QUINCKE

Facility

$99.00

Hospital Charge Code	22354972
Hospital Revenue Code	270
Min. Negotiated Rate	$89.10
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of AZ Commercial	$89.10
Rate for Payer: Cash Price	$79.20

NEB HANDHELD

Facility

$11.00

Hospital Charge Code	22355590
Hospital Revenue Code	270
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of AZ Commercial	$9.90
Rate for Payer: Arizona Complete Health Allwell	$1.76
Rate for Payer: Banner UC Health Medicare	$1.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$7.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.76
Rate for Payer: Cash Price	$8.80
Rate for Payer: Cigna of AZ Commercial	$7.70
Rate for Payer: Devoted Health Medicare	$1.98
Rate for Payer: Humana of AZ Medicare	$1.76
Rate for Payer: Southwest Service Administrators UFCW	$7.48
Rate for Payer: TriWest Medicare	$1.76
Rate for Payer: United Healthcare Commercial	$6.29
Rate for Payer: United Healthcare Medicare	$1.76
Rate for Payer: Veterans Affairs TRICARE	$1.74

NEB HANDHELD

Facility

$11.00

Hospital Charge Code	22355590
Hospital Revenue Code	270
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of AZ Commercial	$9.90
Rate for Payer: Cash Price	$8.80

NEB HAND INITIAL SETUP

Facility

$258.00

Service Code	CPT 94664
Hospital Charge Code	3230233
Hospital Revenue Code	410
Min. Negotiated Rate	$40.87
Max. Negotiated Rate	$338.82
Rate for Payer: Aetna of AZ Commercial	$232.20
Rate for Payer: Arizona Complete Health Allwell	$41.28
Rate for Payer: Banner UC Health Medicare	$41.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$175.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$41.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$41.28
Rate for Payer: Cash Price	$206.40
Rate for Payer: Cash Price	$206.40
Rate for Payer: Cigna of AZ Commercial	$180.60
Rate for Payer: Devoted Health Medicare	$46.44
Rate for Payer: Humana of AZ Medicare	$41.28
Rate for Payer: Seven Corners Travel Insurance	$338.82
Rate for Payer: Southwest Service Administrators UFCW	$175.44
Rate for Payer: TriWest Medicare	$41.28
Rate for Payer: United Healthcare Commercial	$147.58
Rate for Payer: United Healthcare Medicare	$41.28
Rate for Payer: United Healthcare New Mexico Commercial	$49.02
Rate for Payer: Veterans Affairs TRICARE	$40.87

NEB HAND INITIAL SETUP

Facility

$258.00

Service Code	CPT 94664
Hospital Charge Code	3230233
Hospital Revenue Code	410
Min. Negotiated Rate	$232.20
Max. Negotiated Rate	$232.20
Rate for Payer: Aetna of AZ Commercial	$232.20
Rate for Payer: Cash Price	$206.40

Know your out-of-pocket cost for care.

All Charges