Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Orphenadrine injection

Facility

$78.00

Service Code	HCPCS J2360
Hospital Charge Code	1167748
Hospital Revenue Code	521
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Cash Price	$62.40

Orphenadrine injection

Facility

$78.00

Service Code	HCPCS J2360
Hospital Charge Code	1167748
Hospital Revenue Code	521
Min. Negotiated Rate	$12.36
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Arizona Complete Health Allwell	$12.48
Rate for Payer: Banner UC Health Medicare	$12.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$53.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.48
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cigna of AZ Commercial	$54.60
Rate for Payer: Devoted Health Medicare	$14.04
Rate for Payer: Humana of AZ Medicare	$12.48
Rate for Payer: Southwest Service Administrators UFCW	$53.04
Rate for Payer: TriWest Medicare	$12.48
Rate for Payer: United Healthcare Commercial	$44.62
Rate for Payer: United Healthcare Medicare	$12.48
Rate for Payer: Veterans Affairs TRICARE	$12.36

O.R. PROCEDURES FOR OBESITY WITH CC

Facility

$20,682.50

Service Code	MSDRG 620
Min. Negotiated Rate	$20,682.50
Max. Negotiated Rate	$20,682.50
Rate for Payer: Seven Corners Travel Insurance	$20,682.50

O.R. PROCEDURES FOR OBESITY WITH MCC

Facility

$37,317.17

Service Code	MSDRG 619
Min. Negotiated Rate	$37,317.17
Max. Negotiated Rate	$37,317.17
Rate for Payer: Seven Corners Travel Insurance	$37,317.17

O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC

Facility

$19,494.79

Service Code	MSDRG 621
Min. Negotiated Rate	$19,494.79
Max. Negotiated Rate	$19,494.79
Rate for Payer: Seven Corners Travel Insurance	$19,494.79

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC

Facility

$30,202.44

Service Code	MSDRG 940
Min. Negotiated Rate	$30,202.44
Max. Negotiated Rate	$30,202.44
Rate for Payer: Seven Corners Travel Insurance	$30,202.44

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC

Facility

$46,895.23

Service Code	MSDRG 939
Min. Negotiated Rate	$46,895.23
Max. Negotiated Rate	$46,895.23
Rate for Payer: Seven Corners Travel Insurance	$46,895.23

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC

Facility

$26,206.30

Service Code	MSDRG 941
Min. Negotiated Rate	$26,206.30
Max. Negotiated Rate	$26,206.30
Rate for Payer: Seven Corners Travel Insurance	$26,206.30

O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS

Facility

$49,950.51

Service Code	MSDRG 876
Min. Negotiated Rate	$49,950.51
Max. Negotiated Rate	$49,950.51
Rate for Payer: Seven Corners Travel Insurance	$49,950.51

oseltamivir 75 mg Cap [CQCH]

Facility

$1.73

Service Code	NDC 31722063231
Hospital Charge Code	105935149
Hospital Revenue Code	251
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	$1.39
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

oseltamivir 75 mg Cap [CQCH]

Facility

$1.73

Service Code	NDC 31722063231
Hospital Charge Code	105935149
Hospital Revenue Code	251
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$1.56
Rate for Payer: Aetna of AZ Commercial	$1.56
Rate for Payer: Cash Price	$1.39

oseltamivir oral susp 6 mg/mL -60mL [CQCH]

Facility

$148.46

Service Code	NDC 4082205
Hospital Charge Code	105935088
Hospital Revenue Code	251
Min. Negotiated Rate	$23.52
Max. Negotiated Rate	$133.61
Rate for Payer: Aetna of AZ Commercial	$133.61
Rate for Payer: Arizona Complete Health Allwell	$23.75
Rate for Payer: Banner UC Health Medicare	$23.75
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$100.95
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$23.75
Rate for Payer: Care1st Health Plan Arizona Medicare	$23.75
Rate for Payer: Cash Price	$118.77
Rate for Payer: Cigna of AZ Commercial	$96.50
Rate for Payer: Devoted Health Medicare	$26.72
Rate for Payer: Humana of AZ Medicare	$23.75
Rate for Payer: Southwest Service Administrators UFCW	$100.95
Rate for Payer: TriWest Medicare	$23.75
Rate for Payer: United Healthcare Commercial	$84.92
Rate for Payer: United Healthcare Medicare	$23.75
Rate for Payer: Veterans Affairs TRICARE	$23.52

oseltamivir oral susp 6 mg/mL -60mL [CQCH]

Facility

$148.46

Service Code	NDC 4082205
Hospital Charge Code	105935088
Hospital Revenue Code	251
Min. Negotiated Rate	$133.61
Max. Negotiated Rate	$133.61
Rate for Payer: Aetna of AZ Commercial	$133.61
Rate for Payer: Cash Price	$118.77

Osmolality LC

Facility

$186.00

Service Code	CPT 83930
Hospital Charge Code	1287369
Hospital Revenue Code	301
Min. Negotiated Rate	$9.58
Max. Negotiated Rate	$167.40
Rate for Payer: Aetna of AZ Commercial	$167.40
Rate for Payer: Arizona Complete Health Allwell	$29.76
Rate for Payer: Banner UC Health Medicare	$29.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$126.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$29.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$29.76
Rate for Payer: Cash Price	$148.80
Rate for Payer: Cash Price	$148.80
Rate for Payer: Cigna of AZ Commercial	$120.90
Rate for Payer: Devoted Health Medicare	$33.48
Rate for Payer: Humana of AZ Medicare	$29.76
Rate for Payer: Seven Corners Travel Insurance	$9.58
Rate for Payer: Southwest Service Administrators UFCW	$126.48
Rate for Payer: TriWest Medicare	$29.76
Rate for Payer: United Healthcare Commercial	$106.39
Rate for Payer: United Healthcare Medicare	$29.76
Rate for Payer: Veterans Affairs TRICARE	$29.46

Osmolality LC

Facility

$186.00

Service Code	CPT 83930
Hospital Charge Code	1287369
Hospital Revenue Code	301
Min. Negotiated Rate	$167.40
Max. Negotiated Rate	$167.40
Rate for Payer: Aetna of AZ Commercial	$167.40
Rate for Payer: Cash Price	$148.80

Osmolality, Serum

Facility

$177.00

Service Code	CPT 83930
Hospital Charge Code	852898
Hospital Revenue Code	301
Min. Negotiated Rate	$9.58
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Arizona Complete Health Allwell	$28.32
Rate for Payer: Banner UC Health Medicare	$28.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$120.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.32
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cigna of AZ Commercial	$115.05
Rate for Payer: Devoted Health Medicare	$31.86
Rate for Payer: Humana of AZ Medicare	$28.32
Rate for Payer: Seven Corners Travel Insurance	$9.58
Rate for Payer: Southwest Service Administrators UFCW	$120.36
Rate for Payer: TriWest Medicare	$28.32
Rate for Payer: United Healthcare Commercial	$101.24
Rate for Payer: United Healthcare Medicare	$28.32
Rate for Payer: Veterans Affairs TRICARE	$28.04

Osmolality, Serum

Facility

$177.00

Service Code	CPT 83930
Hospital Charge Code	852898
Hospital Revenue Code	301
Min. Negotiated Rate	$159.30
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Cash Price	$141.60

Osmolality, Urine

Facility

$141.00

Service Code	CPT 83935
Hospital Charge Code	1281255
Hospital Revenue Code	301
Min. Negotiated Rate	$126.90
Max. Negotiated Rate	$126.90
Rate for Payer: Aetna of AZ Commercial	$126.90
Rate for Payer: Cash Price	$112.80

Osmolality, Urine

Facility

$141.00

Service Code	CPT 83935
Hospital Charge Code	1281255
Hospital Revenue Code	301
Min. Negotiated Rate	$9.89
Max. Negotiated Rate	$126.90
Rate for Payer: Aetna of AZ Commercial	$126.90
Rate for Payer: Arizona Complete Health Allwell	$22.56
Rate for Payer: Banner UC Health Medicare	$22.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$95.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$22.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$22.56
Rate for Payer: Cash Price	$112.80
Rate for Payer: Cash Price	$112.80
Rate for Payer: Cigna of AZ Commercial	$91.65
Rate for Payer: Devoted Health Medicare	$25.38
Rate for Payer: Humana of AZ Medicare	$22.56
Rate for Payer: Seven Corners Travel Insurance	$9.89
Rate for Payer: Southwest Service Administrators UFCW	$95.88
Rate for Payer: TriWest Medicare	$22.56
Rate for Payer: United Healthcare Commercial	$80.65
Rate for Payer: United Healthcare Medicare	$22.56
Rate for Payer: Veterans Affairs TRICARE	$22.33

Osmolality, Urine LC

Facility

$148.00

Service Code	CPT 83935
Hospital Charge Code	1905826
Hospital Revenue Code	301
Min. Negotiated Rate	$133.20
Max. Negotiated Rate	$133.20
Rate for Payer: Aetna of AZ Commercial	$133.20
Rate for Payer: Cash Price	$118.40

Osmolality, Urine LC

Facility

$148.00

Service Code	CPT 83935
Hospital Charge Code	1905826
Hospital Revenue Code	301
Min. Negotiated Rate	$9.89
Max. Negotiated Rate	$133.20
Rate for Payer: Aetna of AZ Commercial	$133.20
Rate for Payer: Arizona Complete Health Allwell	$23.68
Rate for Payer: Banner UC Health Medicare	$23.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$100.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$23.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$23.68
Rate for Payer: Cash Price	$118.40
Rate for Payer: Cash Price	$118.40
Rate for Payer: Cigna of AZ Commercial	$96.20
Rate for Payer: Devoted Health Medicare	$26.64
Rate for Payer: Humana of AZ Medicare	$23.68
Rate for Payer: Seven Corners Travel Insurance	$9.89
Rate for Payer: Southwest Service Administrators UFCW	$100.64
Rate for Payer: TriWest Medicare	$23.68
Rate for Payer: United Healthcare Commercial	$84.66
Rate for Payer: United Healthcare Medicare	$23.68
Rate for Payer: Veterans Affairs TRICARE	$23.44

OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD

Facility

$5,062.66

Service Code	CPT 28113
Hospital Revenue Code	360
Min. Negotiated Rate	$152.37
Max. Negotiated Rate	$5,062.66
Rate for Payer: Banner UC Health Medicare	$1,062.88
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$152.37
Rate for Payer: Mercy Care Medicaid	$152.37
Rate for Payer: NaphCare Correctional Healthcare	$1,062.88
Rate for Payer: Seven Corners Travel Insurance	$5,062.66
Rate for Payer: United Healthcare Commercial	$4,169.00

OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD

Facility

$5,062.66

Service Code	CPT 28111
Hospital Revenue Code	360
Min. Negotiated Rate	$151.33
Max. Negotiated Rate	$5,062.66
Rate for Payer: Banner UC Health Medicare	$1,062.88
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$151.33
Rate for Payer: Mercy Care Medicaid	$151.33
Rate for Payer: NaphCare Correctional Healthcare	$1,062.88
Rate for Payer: Seven Corners Travel Insurance	$5,062.66
Rate for Payer: United Healthcare Commercial	$4,169.00

OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL

Facility

$2,272.00

Service Code	CPT 28288
Hospital Charge Code	28254331
Hospital Revenue Code	360
Min. Negotiated Rate	$2,044.80
Max. Negotiated Rate	$2,044.80
Rate for Payer: Aetna of AZ Commercial	$2,044.80
Rate for Payer: Cash Price	$1,817.60

OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL

Facility

$2,272.00

Service Code	CPT 28288
Hospital Charge Code	28254331
Hospital Revenue Code	360
Min. Negotiated Rate	$161.43
Max. Negotiated Rate	$5,062.66
Rate for Payer: Aetna of AZ Commercial	$2,044.80
Rate for Payer: Arizona Complete Health Allwell	$363.52
Rate for Payer: Banner UC Health Medicare	$1,062.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,544.96
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$161.43
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$363.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$363.52
Rate for Payer: Cash Price	$1,817.60
Rate for Payer: Cash Price	$1,817.60
Rate for Payer: Cash Price	$1,817.60
Rate for Payer: Cigna of AZ Commercial	$1,136.00
Rate for Payer: Devoted Health Medicare	$408.96
Rate for Payer: Humana of AZ Medicare	$363.52
Rate for Payer: Mercy Care Medicaid	$161.43
Rate for Payer: NaphCare Correctional Healthcare	$1,062.88
Rate for Payer: Seven Corners Travel Insurance	$5,062.66
Rate for Payer: Southwest Service Administrators UFCW	$1,544.96
Rate for Payer: TriWest Medicare	$363.52
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$363.52
Rate for Payer: Veterans Affairs TRICARE	$359.88

Know your out-of-pocket cost for care.

All Charges