Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

NUSHIELD 4X4

Facility

$712.50

Hospital Charge Code	24358098
Hospital Revenue Code	270
Min. Negotiated Rate	$641.25
Max. Negotiated Rate	$641.25
Rate for Payer: Aetna of AZ Commercial	$641.25
Rate for Payer: Cash Price	$570.00

NUSHIELD 4X6

Facility

$625.00

Hospital Charge Code	24358099
Hospital Revenue Code	270
Min. Negotiated Rate	$99.00
Max. Negotiated Rate	$562.50
Rate for Payer: Aetna of AZ Commercial	$562.50
Rate for Payer: Arizona Complete Health Allwell	$100.00
Rate for Payer: Banner UC Health Medicare	$100.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$425.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$100.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$100.00
Rate for Payer: Cash Price	$500.00
Rate for Payer: Cigna of AZ Commercial	$437.50
Rate for Payer: Devoted Health Medicare	$112.50
Rate for Payer: Humana of AZ Medicare	$100.00
Rate for Payer: Southwest Service Administrators UFCW	$425.00
Rate for Payer: TriWest Medicare	$100.00
Rate for Payer: United Healthcare Commercial	$357.50
Rate for Payer: United Healthcare Medicare	$100.00
Rate for Payer: Veterans Affairs TRICARE	$99.00

NUSHIELD 4X6

Facility

$625.00

Hospital Charge Code	24358099
Hospital Revenue Code	270
Min. Negotiated Rate	$562.50
Max. Negotiated Rate	$562.50
Rate for Payer: Aetna of AZ Commercial	$562.50
Rate for Payer: Cash Price	$500.00

NUSHIELD 6X6

Facility

$553.33

Hospital Charge Code	24358100
Hospital Revenue Code	270
Min. Negotiated Rate	$498.00
Max. Negotiated Rate	$498.00
Rate for Payer: Aetna of AZ Commercial	$498.00
Rate for Payer: Cash Price	$442.66

NUSHIELD 6X6

Facility

$553.33

Hospital Charge Code	24358100
Hospital Revenue Code	270
Min. Negotiated Rate	$87.65
Max. Negotiated Rate	$498.00
Rate for Payer: Aetna of AZ Commercial	$498.00
Rate for Payer: Arizona Complete Health Allwell	$88.53
Rate for Payer: Banner UC Health Medicare	$88.53
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$376.26
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$88.53
Rate for Payer: Care1st Health Plan Arizona Medicare	$88.53
Rate for Payer: Cash Price	$442.66
Rate for Payer: Cigna of AZ Commercial	$387.33
Rate for Payer: Devoted Health Medicare	$99.60
Rate for Payer: Humana of AZ Medicare	$88.53
Rate for Payer: Southwest Service Administrators UFCW	$376.26
Rate for Payer: TriWest Medicare	$88.53
Rate for Payer: United Healthcare Commercial	$316.50
Rate for Payer: United Healthcare Medicare	$88.53
Rate for Payer: Veterans Affairs TRICARE	$87.65

nystatin 500,000 units/ 5 mL UD Oral Susp [CQCH]

Facility

$0.20

Service Code	NDC 121478505
Hospital Charge Code	105934408
Hospital Revenue Code	251
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.18
Rate for Payer: Cash Price	$0.16

nystatin 500,000 units/ 5 mL UD Oral Susp [CQCH]

Facility

$0.20

Service Code	NDC 121478505
Hospital Charge Code	105934408
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.18
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	$0.16
Rate for Payer: Cigna of AZ Commercial	$0.13
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	$0.11
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

nystatin Top 100,000 units/g Pwdr [CQCH]

Facility

$0.62

Service Code	NDC 574200815
Hospital Charge Code	105934475
Hospital Revenue Code	251
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.56
Rate for Payer: Aetna of AZ Commercial	$0.56
Rate for Payer: Arizona Complete Health Allwell	$0.10
Rate for Payer: Banner UC Health Medicare	$0.10
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.42
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.10
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.10
Rate for Payer: Cash Price	$0.50
Rate for Payer: Cigna of AZ Commercial	$0.40
Rate for Payer: Devoted Health Medicare	$0.11
Rate for Payer: Humana of AZ Medicare	$0.10
Rate for Payer: Southwest Service Administrators UFCW	$0.42
Rate for Payer: TriWest Medicare	$0.10
Rate for Payer: United Healthcare Commercial	$0.35
Rate for Payer: United Healthcare Medicare	$0.10
Rate for Payer: Veterans Affairs TRICARE	$0.10

nystatin Top 100,000 units/g Pwdr [CQCH]

Facility

$0.62

Service Code	NDC 574200815
Hospital Charge Code	105934475
Hospital Revenue Code	251
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.56
Rate for Payer: Aetna of AZ Commercial	$0.56
Rate for Payer: Cash Price	$0.50

nystatin Top Cream 100,000 units/g [CQCH]

Facility

$0.41

Service Code	NDC 45802005911
Hospital Charge Code	105934540
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of AZ Commercial	$0.37
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	$0.28
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	$0.33
Rate for Payer: Cigna of AZ Commercial	$0.27
Rate for Payer: Devoted Health Medicare	$0.07
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Southwest Service Administrators UFCW	$0.28
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: United Healthcare Commercial	$0.23
Rate for Payer: United Healthcare Medicare	$0.07
Rate for Payer: Veterans Affairs TRICARE	$0.06

nystatin Top Cream 100,000 units/g [CQCH]

Facility

$0.41

Service Code	NDC 45802005911
Hospital Charge Code	105934540
Hospital Revenue Code	251
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of AZ Commercial	$0.37
Rate for Payer: Cash Price	$0.33

O2 MASK SIMPLE

Facility

$8.00

Hospital Charge Code	22355406
Hospital Revenue Code	270
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Arizona Complete Health Allwell	$1.28
Rate for Payer: Banner UC Health Medicare	$1.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.28
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cigna of AZ Commercial	$5.60
Rate for Payer: Devoted Health Medicare	$1.44
Rate for Payer: Humana of AZ Medicare	$1.28
Rate for Payer: Southwest Service Administrators UFCW	$5.44
Rate for Payer: TriWest Medicare	$1.28
Rate for Payer: United Healthcare Commercial	$4.58
Rate for Payer: United Healthcare Medicare	$1.28
Rate for Payer: Veterans Affairs TRICARE	$1.27

O2 MASK SIMPLE

Facility

$8.00

Hospital Charge Code	22355406
Hospital Revenue Code	270
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Cash Price	$6.40

Occult Blood, Gastric

Facility

$126.00

Service Code	CPT 82271
Hospital Charge Code	22146128
Hospital Revenue Code	301
Min. Negotiated Rate	$7.71
Max. Negotiated Rate	$113.40
Rate for Payer: Aetna of AZ Commercial	$113.40
Rate for Payer: Arizona Complete Health Allwell	$20.16
Rate for Payer: Banner UC Health Medicare	$20.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$85.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.16
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna of AZ Commercial	$81.90
Rate for Payer: Devoted Health Medicare	$22.68
Rate for Payer: Humana of AZ Medicare	$20.16
Rate for Payer: Seven Corners Travel Insurance	$7.71
Rate for Payer: Southwest Service Administrators UFCW	$85.68
Rate for Payer: TriWest Medicare	$20.16
Rate for Payer: United Healthcare Commercial	$72.07
Rate for Payer: United Healthcare Medicare	$20.16
Rate for Payer: Veterans Affairs TRICARE	$19.96

Occult Blood, Gastric

Facility

$126.00

Service Code	CPT 82271
Hospital Charge Code	22146128
Hospital Revenue Code	301
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$113.40
Rate for Payer: Aetna of AZ Commercial	$113.40
Rate for Payer: Cash Price	$100.80

Occult Blood Stool 1-3

Facility

$89.00

Service Code	CPT 82270
Hospital Charge Code	22283360
Hospital Revenue Code	301
Min. Negotiated Rate	$80.10
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of AZ Commercial	$80.10
Rate for Payer: Cash Price	$71.20

Occult Blood Stool 1-3

Facility

$89.00

Service Code	CPT 82270
Hospital Charge Code	22283360
Hospital Revenue Code	301
Min. Negotiated Rate	$6.35
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of AZ Commercial	$80.10
Rate for Payer: Arizona Complete Health Allwell	$14.24
Rate for Payer: Banner UC Health Medicare	$14.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$60.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.24
Rate for Payer: Cash Price	$71.20
Rate for Payer: Cash Price	$71.20
Rate for Payer: Cigna of AZ Commercial	$57.85
Rate for Payer: Devoted Health Medicare	$16.02
Rate for Payer: Humana of AZ Medicare	$14.24
Rate for Payer: Seven Corners Travel Insurance	$6.35
Rate for Payer: Southwest Service Administrators UFCW	$60.52
Rate for Payer: TriWest Medicare	$14.24
Rate for Payer: United Healthcare Commercial	$50.91
Rate for Payer: United Healthcare Medicare	$14.24
Rate for Payer: Veterans Affairs TRICARE	$14.10

ocrelizumab 300 mg/10 mL Sol[CQCH]

Facility

$1,877.56

Service Code	HCPCS J2350
Hospital Charge Code	215329113
Hospital Revenue Code	250
Min. Negotiated Rate	$1,689.80
Max. Negotiated Rate	$1,689.80
Rate for Payer: Aetna of AZ Commercial	$1,689.80
Rate for Payer: Cash Price	$1,502.05

ocrelizumab 300 mg/10 mL Sol[CQCH]

Facility

$1,877.56

Service Code	HCPCS J2350
Hospital Charge Code	215329113
Hospital Revenue Code	250
Min. Negotiated Rate	$88.41
Max. Negotiated Rate	$1,689.80
Rate for Payer: Aetna of AZ Commercial	$1,689.80
Rate for Payer: Arizona Complete Health Allwell	$300.41
Rate for Payer: Banner UC Health Medicare	$300.41
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,276.74
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$300.41
Rate for Payer: Care1st Health Plan Arizona Medicare	$300.41
Rate for Payer: Cash Price	$1,502.05
Rate for Payer: Cash Price	$1,502.05
Rate for Payer: Cigna of AZ Commercial	$1,220.41
Rate for Payer: Devoted Health Medicare	$337.96
Rate for Payer: Humana of AZ Medicare	$300.41
Rate for Payer: Seven Corners Travel Insurance	$88.41
Rate for Payer: Southwest Service Administrators UFCW	$1,276.74
Rate for Payer: TriWest Medicare	$300.41
Rate for Payer: United Healthcare Commercial	$1,073.96
Rate for Payer: United Healthcare Medicare	$300.41
Rate for Payer: Veterans Affairs TRICARE	$297.41

octreotide 100 mcg/mL Inj Sol [CQCH]

Facility

$2.75

Service Code	HCPCS J2354
Hospital Charge Code	105934605
Hospital Revenue Code	250
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$2.48
Rate for Payer: Aetna of AZ Commercial	$2.48
Rate for Payer: Cash Price	$2.20

octreotide 100 mcg/mL Inj Sol [CQCH]

Facility

$2.75

Service Code	HCPCS J2354
Hospital Charge Code	105934605
Hospital Revenue Code	250
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$2.48
Rate for Payer: Aetna of AZ Commercial	$2.48
Rate for Payer: Arizona Complete Health Allwell	$0.44
Rate for Payer: Banner UC Health Medicare	$0.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.87
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.44
Rate for Payer: Cash Price	$2.20
Rate for Payer: Cigna of AZ Commercial	$1.79
Rate for Payer: Devoted Health Medicare	$0.50
Rate for Payer: Humana of AZ Medicare	$0.44
Rate for Payer: Southwest Service Administrators UFCW	$1.87
Rate for Payer: TriWest Medicare	$0.44
Rate for Payer: United Healthcare Commercial	$1.57
Rate for Payer: United Healthcare Medicare	$0.44
Rate for Payer: Veterans Affairs TRICARE	$0.44

octreotide 200 mcg/mL Sol [CQCH]

Facility

$4.41

Service Code	HCPCS J2354
Hospital Charge Code	206194616
Hospital Revenue Code	250
Min. Negotiated Rate	$3.97
Max. Negotiated Rate	$3.97
Rate for Payer: Aetna of AZ Commercial	$3.97
Rate for Payer: Cash Price	$3.53

octreotide 200 mcg/mL Sol [CQCH]

Facility

$4.41

Service Code	HCPCS J2354
Hospital Charge Code	206194616
Hospital Revenue Code	250
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$3.97
Rate for Payer: Aetna of AZ Commercial	$3.97
Rate for Payer: Arizona Complete Health Allwell	$0.71
Rate for Payer: Banner UC Health Medicare	$0.71
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.71
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.71
Rate for Payer: Cash Price	$3.53
Rate for Payer: Cigna of AZ Commercial	$2.87
Rate for Payer: Devoted Health Medicare	$0.79
Rate for Payer: Humana of AZ Medicare	$0.71
Rate for Payer: Southwest Service Administrators UFCW	$3.00
Rate for Payer: TriWest Medicare	$0.71
Rate for Payer: United Healthcare Commercial	$2.52
Rate for Payer: United Healthcare Medicare	$0.71
Rate for Payer: Veterans Affairs TRICARE	$0.70

Office/OP Established Visit Level 1 99211

Facility

$199.00

Service Code	CPT 99211
Hospital Charge Code	631670
Hospital Revenue Code	521
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$367.62
Rate for Payer: Aetna of AZ Commercial	$179.10
Rate for Payer: Arizona Complete Health Allwell	$31.84
Rate for Payer: Banner UC Health Medicare	$31.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$135.32
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$10.30
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$31.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.84
Rate for Payer: Cash Price	$159.20
Rate for Payer: Cash Price	$159.20
Rate for Payer: Cash Price	$159.20
Rate for Payer: Cigna of AZ Commercial	$139.30
Rate for Payer: Devoted Health Medicare	$35.82
Rate for Payer: Humana of AZ Medicare	$31.84
Rate for Payer: Mercy Care Medicaid	$10.30
Rate for Payer: NaphCare Correctional Healthcare	$10.30
Rate for Payer: Southwest Service Administrators UFCW	$135.32
Rate for Payer: TriWest Medicare	$31.84
Rate for Payer: United Healthcare Commercial	$113.83
Rate for Payer: United Healthcare Community Plan	$367.62
Rate for Payer: United Healthcare Medicare	$31.84
Rate for Payer: Veterans Affairs TRICARE	$31.52

Office/OP Established Visit Level 1 99211

Facility

$199.00

Service Code	CPT 99211
Hospital Charge Code	631670
Hospital Revenue Code	521
Min. Negotiated Rate	$179.10
Max. Negotiated Rate	$179.10
Rate for Payer: Aetna of AZ Commercial	$179.10
Rate for Payer: Cash Price	$159.20

Know your out-of-pocket cost for care.

All Charges