Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Phosphorus Level

Facility

$116.00

Service Code	CPT 84100
Hospital Charge Code	633803
Hospital Revenue Code	301
Min. Negotiated Rate	$6.87
Max. Negotiated Rate	$104.40
Rate for Payer: Aetna of AZ Commercial	$104.40
Rate for Payer: Arizona Complete Health Allwell	$18.56
Rate for Payer: Banner UC Health Medicare	$18.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$78.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$18.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$18.56
Rate for Payer: Cash Price	$92.80
Rate for Payer: Cash Price	$92.80
Rate for Payer: Cigna of AZ Commercial	$75.40
Rate for Payer: Devoted Health Medicare	$20.88
Rate for Payer: Humana of AZ Medicare	$18.56
Rate for Payer: Seven Corners Travel Insurance	$6.87
Rate for Payer: Southwest Service Administrators UFCW	$78.88
Rate for Payer: TriWest Medicare	$18.56
Rate for Payer: United Healthcare Commercial	$66.35
Rate for Payer: United Healthcare Medicare	$18.56
Rate for Payer: Veterans Affairs TRICARE	$18.37

Phosphorus Level

Facility

$116.00

Service Code	CPT 84100
Hospital Charge Code	633803
Hospital Revenue Code	301
Min. Negotiated Rate	$104.40
Max. Negotiated Rate	$104.40
Rate for Payer: Aetna of AZ Commercial	$104.40
Rate for Payer: Cash Price	$92.80

Physical fitness testing

Facility

$46.00

Service Code	CPT 97799
Hospital Charge Code	27790993
Hospital Revenue Code	302
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of AZ Commercial	$41.40
Rate for Payer: Arizona Complete Health Allwell	$7.36
Rate for Payer: Banner UC Health Medicare	$7.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$31.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.36
Rate for Payer: Cash Price	$36.80
Rate for Payer: Cigna of AZ Commercial	$29.90
Rate for Payer: Devoted Health Medicare	$8.28
Rate for Payer: Humana of AZ Medicare	$7.36
Rate for Payer: Southwest Service Administrators UFCW	$31.28
Rate for Payer: TriWest Medicare	$7.36
Rate for Payer: United Healthcare Commercial	$26.31
Rate for Payer: United Healthcare Medicare	$7.36
Rate for Payer: Veterans Affairs TRICARE	$7.29

Physical fitness testing

Facility

$46.00

Service Code	CPT 97799
Hospital Charge Code	27790993
Hospital Revenue Code	302
Min. Negotiated Rate	$41.40
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of AZ Commercial	$41.40
Rate for Payer: Cash Price	$36.80

phytonadione 10 mg/ 1mL Inj Sol [CQCH]

Facility

$34.78

Service Code	HCPCS J3430
Hospital Charge Code	105936764
Hospital Revenue Code	250
Min. Negotiated Rate	$31.30
Max. Negotiated Rate	$31.30
Rate for Payer: Aetna of AZ Commercial	$31.30
Rate for Payer: Cash Price	$27.82

phytonadione 10 mg/ 1mL Inj Sol [CQCH]

Facility

$34.78

Service Code	HCPCS J3430
Hospital Charge Code	105936764
Hospital Revenue Code	250
Min. Negotiated Rate	$5.51
Max. Negotiated Rate	$31.30
Rate for Payer: Aetna of AZ Commercial	$31.30
Rate for Payer: Arizona Complete Health Allwell	$5.56
Rate for Payer: Banner UC Health Medicare	$5.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$23.65
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.56
Rate for Payer: Cash Price	$27.82
Rate for Payer: Cigna of AZ Commercial	$22.61
Rate for Payer: Devoted Health Medicare	$6.26
Rate for Payer: Humana of AZ Medicare	$5.56
Rate for Payer: Southwest Service Administrators UFCW	$23.65
Rate for Payer: TriWest Medicare	$5.56
Rate for Payer: United Healthcare Commercial	$19.89
Rate for Payer: United Healthcare Medicare	$5.56
Rate for Payer: Veterans Affairs TRICARE	$5.51

phytonadione 1 mg/0.5 mL PFS Inj [CQCH]

Facility

$38.70

Service Code	HCPCS J3430
Hospital Charge Code	105936693
Hospital Revenue Code	250
Min. Negotiated Rate	$34.83
Max. Negotiated Rate	$34.83
Rate for Payer: Aetna of AZ Commercial	$34.83
Rate for Payer: Cash Price	$30.96

phytonadione 1 mg/0.5 mL PFS Inj [CQCH]

Facility

$38.70

Service Code	HCPCS J3430
Hospital Charge Code	105936693
Hospital Revenue Code	250
Min. Negotiated Rate	$6.13
Max. Negotiated Rate	$34.83
Rate for Payer: Aetna of AZ Commercial	$34.83
Rate for Payer: Arizona Complete Health Allwell	$6.19
Rate for Payer: Banner UC Health Medicare	$6.19
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$26.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.19
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.19
Rate for Payer: Cash Price	$30.96
Rate for Payer: Cigna of AZ Commercial	$25.16
Rate for Payer: Devoted Health Medicare	$6.97
Rate for Payer: Humana of AZ Medicare	$6.19
Rate for Payer: Southwest Service Administrators UFCW	$26.32
Rate for Payer: TriWest Medicare	$6.19
Rate for Payer: United Healthcare Commercial	$22.14
Rate for Payer: United Healthcare Medicare	$6.19
Rate for Payer: Veterans Affairs TRICARE	$6.13

PICC KIT 3FR SL

Facility

$1,209.00

Hospital Charge Code	23758900
Hospital Revenue Code	270
Min. Negotiated Rate	$1,088.10
Max. Negotiated Rate	$1,088.10
Rate for Payer: Aetna of AZ Commercial	$1,088.10
Rate for Payer: Cash Price	$967.20

PICC KIT 3FR SL

Facility

$1,209.00

Hospital Charge Code	23758900
Hospital Revenue Code	270
Min. Negotiated Rate	$191.51
Max. Negotiated Rate	$1,088.10
Rate for Payer: Aetna of AZ Commercial	$1,088.10
Rate for Payer: Arizona Complete Health Allwell	$193.44
Rate for Payer: Banner UC Health Medicare	$193.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$822.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$193.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$193.44
Rate for Payer: Cash Price	$967.20
Rate for Payer: Cigna of AZ Commercial	$846.30
Rate for Payer: Devoted Health Medicare	$217.62
Rate for Payer: Humana of AZ Medicare	$193.44
Rate for Payer: Southwest Service Administrators UFCW	$822.12
Rate for Payer: TriWest Medicare	$193.44
Rate for Payer: United Healthcare Commercial	$691.55
Rate for Payer: United Healthcare Medicare	$193.44
Rate for Payer: Veterans Affairs TRICARE	$191.51

PICC KIT 4FR DL

Facility

$1,255.00

Hospital Charge Code	23758902
Hospital Revenue Code	270
Min. Negotiated Rate	$198.79
Max. Negotiated Rate	$1,129.50
Rate for Payer: Aetna of AZ Commercial	$1,129.50
Rate for Payer: Arizona Complete Health Allwell	$200.80
Rate for Payer: Banner UC Health Medicare	$200.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$853.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$200.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$200.80
Rate for Payer: Cash Price	$1,004.00
Rate for Payer: Cigna of AZ Commercial	$878.50
Rate for Payer: Devoted Health Medicare	$225.90
Rate for Payer: Humana of AZ Medicare	$200.80
Rate for Payer: Southwest Service Administrators UFCW	$853.40
Rate for Payer: TriWest Medicare	$200.80
Rate for Payer: United Healthcare Commercial	$717.86
Rate for Payer: United Healthcare Medicare	$200.80
Rate for Payer: Veterans Affairs TRICARE	$198.79

PICC KIT 4FR DL

Facility

$1,255.00

Hospital Charge Code	23758902
Hospital Revenue Code	270
Min. Negotiated Rate	$1,129.50
Max. Negotiated Rate	$1,129.50
Rate for Payer: Aetna of AZ Commercial	$1,129.50
Rate for Payer: Cash Price	$1,004.00

PICC KIT 4FR SL

Facility

$1,157.00

Hospital Charge Code	23758901
Hospital Revenue Code	270
Min. Negotiated Rate	$183.27
Max. Negotiated Rate	$1,041.30
Rate for Payer: Aetna of AZ Commercial	$1,041.30
Rate for Payer: Arizona Complete Health Allwell	$185.12
Rate for Payer: Banner UC Health Medicare	$185.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$786.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$185.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$185.12
Rate for Payer: Cash Price	$925.60
Rate for Payer: Cigna of AZ Commercial	$809.90
Rate for Payer: Devoted Health Medicare	$208.26
Rate for Payer: Humana of AZ Medicare	$185.12
Rate for Payer: Southwest Service Administrators UFCW	$786.76
Rate for Payer: TriWest Medicare	$185.12
Rate for Payer: United Healthcare Commercial	$661.80
Rate for Payer: United Healthcare Medicare	$185.12
Rate for Payer: Veterans Affairs TRICARE	$183.27

PICC KIT 4FR SL

Facility

$1,157.00

Hospital Charge Code	23758901
Hospital Revenue Code	270
Min. Negotiated Rate	$1,041.30
Max. Negotiated Rate	$1,041.30
Rate for Payer: Aetna of AZ Commercial	$1,041.30
Rate for Payer: Cash Price	$925.60

PICO 7 DISPOSABLE WOUND THERAPY SYSTEM

Facility

$1,659.00

Hospital Charge Code	24010984
Hospital Revenue Code	270
Min. Negotiated Rate	$1,493.10
Max. Negotiated Rate	$1,493.10
Rate for Payer: Aetna of AZ Commercial	$1,493.10
Rate for Payer: Cash Price	$1,327.20

PICO 7 DISPOSABLE WOUND THERAPY SYSTEM

Facility

$1,659.00

Hospital Charge Code	24010984
Hospital Revenue Code	270
Min. Negotiated Rate	$262.79
Max. Negotiated Rate	$1,493.10
Rate for Payer: Aetna of AZ Commercial	$1,493.10
Rate for Payer: Arizona Complete Health Allwell	$265.44
Rate for Payer: Banner UC Health Medicare	$265.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,128.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$265.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$265.44
Rate for Payer: Cash Price	$1,327.20
Rate for Payer: Cigna of AZ Commercial	$1,161.30
Rate for Payer: Devoted Health Medicare	$298.62
Rate for Payer: Humana of AZ Medicare	$265.44
Rate for Payer: Southwest Service Administrators UFCW	$1,128.12
Rate for Payer: TriWest Medicare	$265.44
Rate for Payer: United Healthcare Commercial	$948.95
Rate for Payer: United Healthcare Medicare	$265.44
Rate for Payer: Veterans Affairs TRICARE	$262.79

PILL SPLITTER

Facility

$23.71

Hospital Charge Code	28126254
Hospital Revenue Code	270
Min. Negotiated Rate	$3.76
Max. Negotiated Rate	$21.34
Rate for Payer: Aetna of AZ Commercial	$21.34
Rate for Payer: Arizona Complete Health Allwell	$3.79
Rate for Payer: Banner UC Health Medicare	$3.79
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$16.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.79
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.79
Rate for Payer: Cash Price	$18.97
Rate for Payer: Cigna of AZ Commercial	$16.60
Rate for Payer: Devoted Health Medicare	$4.27
Rate for Payer: Humana of AZ Medicare	$3.79
Rate for Payer: Southwest Service Administrators UFCW	$16.12
Rate for Payer: TriWest Medicare	$3.79
Rate for Payer: United Healthcare Commercial	$13.56
Rate for Payer: United Healthcare Medicare	$3.79
Rate for Payer: Veterans Affairs TRICARE	$3.76

PILL SPLITTER

Facility

$23.71

Hospital Charge Code	28126254
Hospital Revenue Code	270
Min. Negotiated Rate	$21.34
Max. Negotiated Rate	$21.34
Rate for Payer: Aetna of AZ Commercial	$21.34
Rate for Payer: Cash Price	$18.97

pilocarpine 5 mg Tab [CQCH]

Facility

$1.26

Service Code	NDC 62856070510
Hospital Charge Code	105936837
Hospital Revenue Code	251
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.13
Rate for Payer: Aetna of AZ Commercial	$1.13
Rate for Payer: Cash Price	$1.01

pilocarpine 5 mg Tab [CQCH]

Facility

$1.26

Service Code	NDC 62856070510
Hospital Charge Code	105936837
Hospital Revenue Code	251
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$1.13
Rate for Payer: Aetna of AZ Commercial	$1.13
Rate for Payer: Arizona Complete Health Allwell	$0.20
Rate for Payer: Banner UC Health Medicare	$0.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.86
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.20
Rate for Payer: Cash Price	$1.01
Rate for Payer: Cigna of AZ Commercial	$0.82
Rate for Payer: Devoted Health Medicare	$0.23
Rate for Payer: Humana of AZ Medicare	$0.20
Rate for Payer: Southwest Service Administrators UFCW	$0.86
Rate for Payer: TriWest Medicare	$0.20
Rate for Payer: United Healthcare Commercial	$0.72
Rate for Payer: United Healthcare Medicare	$0.20
Rate for Payer: Veterans Affairs TRICARE	$0.20

pilocarpine Ophth 2% Sol [CQCH]

Facility

$1.97

Service Code	NDC 61314020315
Hospital Charge Code	105936902
Hospital Revenue Code	251
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$1.77
Rate for Payer: Aetna of AZ Commercial	$1.77
Rate for Payer: Arizona Complete Health Allwell	$0.32
Rate for Payer: Banner UC Health Medicare	$0.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.34
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.32
Rate for Payer: Cash Price	$1.58
Rate for Payer: Cigna of AZ Commercial	$1.28
Rate for Payer: Devoted Health Medicare	$0.35
Rate for Payer: Humana of AZ Medicare	$0.32
Rate for Payer: Southwest Service Administrators UFCW	$1.34
Rate for Payer: TriWest Medicare	$0.32
Rate for Payer: United Healthcare Commercial	$1.13
Rate for Payer: United Healthcare Medicare	$0.32
Rate for Payer: Veterans Affairs TRICARE	$0.31

pilocarpine Ophth 2% Sol [CQCH]

Facility

$1.97

Service Code	NDC 61314020315
Hospital Charge Code	105936902
Hospital Revenue Code	251
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$1.77
Rate for Payer: Aetna of AZ Commercial	$1.77
Rate for Payer: Cash Price	$1.58

PINK FOOT PAD 20X12X2

Facility

$155.05

Hospital Charge Code	28132810
Hospital Revenue Code	270
Min. Negotiated Rate	$24.56
Max. Negotiated Rate	$139.54
Rate for Payer: Aetna of AZ Commercial	$139.54
Rate for Payer: Arizona Complete Health Allwell	$24.81
Rate for Payer: Banner UC Health Medicare	$24.81
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$105.43
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$24.81
Rate for Payer: Care1st Health Plan Arizona Medicare	$24.81
Rate for Payer: Cash Price	$124.04
Rate for Payer: Cigna of AZ Commercial	$108.53
Rate for Payer: Devoted Health Medicare	$27.91
Rate for Payer: Humana of AZ Medicare	$24.81
Rate for Payer: Southwest Service Administrators UFCW	$105.43
Rate for Payer: TriWest Medicare	$24.81
Rate for Payer: United Healthcare Commercial	$88.69
Rate for Payer: United Healthcare Medicare	$24.81
Rate for Payer: Veterans Affairs TRICARE	$24.56

PINK FOOT PAD 20X12X2

Facility

$155.05

Hospital Charge Code	28132810
Hospital Revenue Code	270
Min. Negotiated Rate	$139.54
Max. Negotiated Rate	$139.54
Rate for Payer: Aetna of AZ Commercial	$139.54
Rate for Payer: Cash Price	$124.04

Pinworm Prep

Facility

$88.00

Service Code	CPT 87172
Hospital Charge Code	633912
Hospital Revenue Code	306
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of AZ Commercial	$79.20
Rate for Payer: Cash Price	$70.40

Know your out-of-pocket cost for care.

All Charges