Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Pinworm Prep

Facility

$88.00

Service Code	CPT 87172
Hospital Charge Code	633912
Hospital Revenue Code	306
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of AZ Commercial	$79.20
Rate for Payer: Arizona Complete Health Allwell	$14.08
Rate for Payer: Banner UC Health Medicare	$14.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$59.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.08
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cigna of AZ Commercial	$57.20
Rate for Payer: Devoted Health Medicare	$15.84
Rate for Payer: Humana of AZ Medicare	$14.08
Rate for Payer: Seven Corners Travel Insurance	$6.19
Rate for Payer: Southwest Service Administrators UFCW	$59.84
Rate for Payer: TriWest Medicare	$14.08
Rate for Payer: United Healthcare Commercial	$50.34
Rate for Payer: United Healthcare Medicare	$14.08
Rate for Payer: Veterans Affairs TRICARE	$13.94

Pinworm Prep

Facility

$92.00

Service Code	CPT 87172
Hospital Charge Code	1725569
Hospital Revenue Code	306
Min. Negotiated Rate	$82.80
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of AZ Commercial	$82.80
Rate for Payer: Cash Price	$73.60

Pinworm Prep

Facility

$92.00

Service Code	CPT 87172
Hospital Charge Code	1725569
Hospital Revenue Code	306
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of AZ Commercial	$82.80
Rate for Payer: Arizona Complete Health Allwell	$14.72
Rate for Payer: Banner UC Health Medicare	$14.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$62.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.72
Rate for Payer: Cash Price	$73.60
Rate for Payer: Cash Price	$73.60
Rate for Payer: Cigna of AZ Commercial	$59.80
Rate for Payer: Devoted Health Medicare	$16.56
Rate for Payer: Humana of AZ Medicare	$14.72
Rate for Payer: Seven Corners Travel Insurance	$6.19
Rate for Payer: Southwest Service Administrators UFCW	$62.56
Rate for Payer: TriWest Medicare	$14.72
Rate for Payer: United Healthcare Commercial	$52.62
Rate for Payer: United Healthcare Medicare	$14.72
Rate for Payer: Veterans Affairs TRICARE	$14.57

piperacillin-tazobactam 2.25 gm IV Inj [CQCH]

Facility

$3.90

Service Code	HCPCS J2543
Hospital Charge Code	105970066
Hospital Revenue Code	250
Min. Negotiated Rate	$3.51
Max. Negotiated Rate	$3.51
Rate for Payer: Aetna of AZ Commercial	$3.51
Rate for Payer: Cash Price	$3.12

piperacillin-tazobactam 2.25 gm IV Inj [CQCH]

Facility

$3.90

Service Code	HCPCS J2543
Hospital Charge Code	105970066
Hospital Revenue Code	250
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$3.51
Rate for Payer: Aetna of AZ Commercial	$3.51
Rate for Payer: Arizona Complete Health Allwell	$0.62
Rate for Payer: Banner UC Health Medicare	$0.62
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2.65
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.62
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.62
Rate for Payer: Cash Price	$3.12
Rate for Payer: Cigna of AZ Commercial	$2.54
Rate for Payer: Devoted Health Medicare	$0.70
Rate for Payer: Humana of AZ Medicare	$0.62
Rate for Payer: Southwest Service Administrators UFCW	$2.65
Rate for Payer: TriWest Medicare	$0.62
Rate for Payer: United Healthcare Commercial	$2.23
Rate for Payer: United Healthcare Medicare	$0.62
Rate for Payer: Veterans Affairs TRICARE	$0.62

piperacillin-tazobactam 3.375 gm IV Inj [CQCH]

Facility

$5.30

Service Code	HCPCS J2543
Hospital Charge Code	105970909
Hospital Revenue Code	250
Min. Negotiated Rate	$4.77
Max. Negotiated Rate	$4.77
Rate for Payer: Aetna of AZ Commercial	$4.77
Rate for Payer: Cash Price	$4.24

piperacillin-tazobactam 3.375 gm IV Inj [CQCH]

Facility

$5.30

Service Code	HCPCS J2543
Hospital Charge Code	105970909
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$4.77
Rate for Payer: Aetna of AZ Commercial	$4.77
Rate for Payer: Arizona Complete Health Allwell	$0.85
Rate for Payer: Banner UC Health Medicare	$0.85
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.85
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.85
Rate for Payer: Cash Price	$4.24
Rate for Payer: Cigna of AZ Commercial	$3.44
Rate for Payer: Devoted Health Medicare	$0.95
Rate for Payer: Humana of AZ Medicare	$0.85
Rate for Payer: Southwest Service Administrators UFCW	$3.60
Rate for Payer: TriWest Medicare	$0.85
Rate for Payer: United Healthcare Commercial	$3.03
Rate for Payer: United Healthcare Medicare	$0.85
Rate for Payer: Veterans Affairs TRICARE	$0.84

piperacillin-tazobactam 4.5 gm rec [CQCH]

Facility

$8.25

Service Code	HCPCS J2543
Hospital Charge Code	112390998
Hospital Revenue Code	250
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$7.42
Rate for Payer: Aetna of AZ Commercial	$7.42
Rate for Payer: Arizona Complete Health Allwell	$1.32
Rate for Payer: Banner UC Health Medicare	$1.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5.61
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.32
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cigna of AZ Commercial	$5.36
Rate for Payer: Devoted Health Medicare	$1.49
Rate for Payer: Humana of AZ Medicare	$1.32
Rate for Payer: Southwest Service Administrators UFCW	$5.61
Rate for Payer: TriWest Medicare	$1.32
Rate for Payer: United Healthcare Commercial	$4.72
Rate for Payer: United Healthcare Medicare	$1.32
Rate for Payer: Veterans Affairs TRICARE	$1.31

piperacillin-tazobactam 4.5 gm rec [CQCH]

Facility

$8.25

Service Code	HCPCS J2543
Hospital Charge Code	112390998
Hospital Revenue Code	250
Min. Negotiated Rate	$7.42
Max. Negotiated Rate	$7.42
Rate for Payer: Aetna of AZ Commercial	$7.42
Rate for Payer: Cash Price	$6.60

PKS CUTTING FORCEP 5MM/33CM

Facility

$1,557.00

Hospital Charge Code	22562751
Hospital Revenue Code	272
Min. Negotiated Rate	$1,401.30
Max. Negotiated Rate	$1,401.30
Rate for Payer: Aetna of AZ Commercial	$1,401.30
Rate for Payer: Cash Price	$1,245.60

PKS CUTTING FORCEP 5MM/33CM

Facility

$1,557.00

Hospital Charge Code	22562751
Hospital Revenue Code	272
Min. Negotiated Rate	$246.63
Max. Negotiated Rate	$1,401.30
Rate for Payer: Aetna of AZ Commercial	$1,401.30
Rate for Payer: Arizona Complete Health Allwell	$249.12
Rate for Payer: Banner UC Health Medicare	$249.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,058.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$249.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$249.12
Rate for Payer: Cash Price	$1,245.60
Rate for Payer: Cigna of AZ Commercial	$1,089.90
Rate for Payer: Devoted Health Medicare	$280.26
Rate for Payer: Humana of AZ Medicare	$249.12
Rate for Payer: Southwest Service Administrators UFCW	$1,058.76
Rate for Payer: TriWest Medicare	$249.12
Rate for Payer: United Healthcare Commercial	$890.60
Rate for Payer: United Healthcare Medicare	$249.12
Rate for Payer: Veterans Affairs TRICARE	$246.63

PKU Newborn

Facility

$129.00

Service Code	CPT 84030
Hospital Charge Code	1206897
Hospital Revenue Code	301
Min. Negotiated Rate	$116.10
Max. Negotiated Rate	$116.10
Rate for Payer: Aetna of AZ Commercial	$116.10
Rate for Payer: Cash Price	$103.20

PKU Newborn

Facility

$129.00

Service Code	CPT 84030
Hospital Charge Code	1206897
Hospital Revenue Code	301
Min. Negotiated Rate	$7.97
Max. Negotiated Rate	$116.10
Rate for Payer: Aetna of AZ Commercial	$116.10
Rate for Payer: Arizona Complete Health Allwell	$20.64
Rate for Payer: Banner UC Health Medicare	$20.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$87.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.64
Rate for Payer: Cash Price	$103.20
Rate for Payer: Cash Price	$103.20
Rate for Payer: Cigna of AZ Commercial	$83.85
Rate for Payer: Devoted Health Medicare	$23.22
Rate for Payer: Humana of AZ Medicare	$20.64
Rate for Payer: Seven Corners Travel Insurance	$7.97
Rate for Payer: Southwest Service Administrators UFCW	$87.72
Rate for Payer: TriWest Medicare	$20.64
Rate for Payer: United Healthcare Commercial	$73.79
Rate for Payer: United Healthcare Medicare	$20.64
Rate for Payer: Veterans Affairs TRICARE	$20.43

PKU- Newborn

Facility

$142.00

Service Code	CPT 84030
Hospital Charge Code	22350384
Hospital Revenue Code	301
Min. Negotiated Rate	$127.80
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Cash Price	$113.60

PKU- Newborn

Facility

$142.00

Service Code	CPT 84030
Hospital Charge Code	22350384
Hospital Revenue Code	301
Min. Negotiated Rate	$7.97
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Arizona Complete Health Allwell	$22.72
Rate for Payer: Banner UC Health Medicare	$22.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$96.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$22.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$22.72
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cigna of AZ Commercial	$92.30
Rate for Payer: Devoted Health Medicare	$25.56
Rate for Payer: Humana of AZ Medicare	$22.72
Rate for Payer: Seven Corners Travel Insurance	$7.97
Rate for Payer: Southwest Service Administrators UFCW	$96.56
Rate for Payer: TriWest Medicare	$22.72
Rate for Payer: United Healthcare Commercial	$81.22
Rate for Payer: United Healthcare Medicare	$22.72
Rate for Payer: Veterans Affairs TRICARE	$22.49

Placement of generator stage II

Facility

$872.00

Service Code	CPT 64590
Hospital Charge Code	27281905
Hospital Revenue Code	360
Min. Negotiated Rate	$120.99
Max. Negotiated Rate	$30,017.20
Rate for Payer: Aetna of AZ Commercial	$784.80
Rate for Payer: Arizona Complete Health Allwell	$139.52
Rate for Payer: Banner UC Health Medicare	$16,154.90
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$592.96
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$120.99
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$139.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$139.52
Rate for Payer: Cash Price	$697.60
Rate for Payer: Cash Price	$697.60
Rate for Payer: Cash Price	$697.60
Rate for Payer: Cigna of AZ Commercial	$436.00
Rate for Payer: Devoted Health Medicare	$156.96
Rate for Payer: Humana of AZ Medicare	$139.52
Rate for Payer: Mercy Care Medicaid	$120.99
Rate for Payer: NaphCare Correctional Healthcare	$16,154.90
Rate for Payer: Seven Corners Travel Insurance	$30,017.20
Rate for Payer: Southwest Service Administrators UFCW	$592.96
Rate for Payer: TriWest Medicare	$139.52
Rate for Payer: United Healthcare Commercial	$10,160.00
Rate for Payer: United Healthcare Medicare	$139.52
Rate for Payer: Veterans Affairs TRICARE	$138.12

Placement of generator stage II

Facility

$872.00

Service Code	CPT 64590
Hospital Charge Code	27281905
Hospital Revenue Code	360
Min. Negotiated Rate	$784.80
Max. Negotiated Rate	$784.80
Rate for Payer: Aetna of AZ Commercial	$784.80
Rate for Payer: Cash Price	$697.60

Placement of lead Stage I

Facility

$3,581.00

Service Code	CPT 64581
Hospital Charge Code	27291810
Hospital Revenue Code	360
Min. Negotiated Rate	$3,222.90
Max. Negotiated Rate	$3,222.90
Rate for Payer: Aetna of AZ Commercial	$3,222.90
Rate for Payer: Cash Price	$2,864.80

Placement of lead Stage I

Facility

$3,581.00

Service Code	CPT 64581
Hospital Charge Code	27291810
Hospital Revenue Code	360
Min. Negotiated Rate	$567.23
Max. Negotiated Rate	$9,860.74
Rate for Payer: Aetna of AZ Commercial	$3,222.90
Rate for Payer: Arizona Complete Health Allwell	$572.96
Rate for Payer: Banner UC Health Medicare	$4,461.65
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,435.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$572.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$572.96
Rate for Payer: Cash Price	$2,864.80
Rate for Payer: Cash Price	$2,864.80
Rate for Payer: Cash Price	$2,864.80
Rate for Payer: Cigna of AZ Commercial	$1,790.50
Rate for Payer: Devoted Health Medicare	$644.58
Rate for Payer: Humana of AZ Medicare	$572.96
Rate for Payer: NaphCare Correctional Healthcare	$4,461.65
Rate for Payer: Seven Corners Travel Insurance	$9,860.74
Rate for Payer: Southwest Service Administrators UFCW	$2,435.08
Rate for Payer: TriWest Medicare	$572.96
Rate for Payer: United Healthcare Commercial	$7,552.00
Rate for Payer: United Healthcare Medicare	$572.96
Rate for Payer: Veterans Affairs TRICARE	$567.23

PLANTAR PYTHON 2 PLATE LEFT

Facility

$8,663.00

Hospital Charge Code	24358102
Hospital Revenue Code	270
Min. Negotiated Rate	$7,796.70
Max. Negotiated Rate	$7,796.70
Rate for Payer: Aetna of AZ Commercial	$7,796.70
Rate for Payer: Cash Price	$6,930.40

PLANTAR PYTHON 2 PLATE LEFT

Facility

$8,663.00

Hospital Charge Code	24358102
Hospital Revenue Code	270
Min. Negotiated Rate	$1,372.22
Max. Negotiated Rate	$7,796.70
Rate for Payer: Aetna of AZ Commercial	$7,796.70
Rate for Payer: Arizona Complete Health Allwell	$1,386.08
Rate for Payer: Banner UC Health Medicare	$1,386.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5,890.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,386.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,386.08
Rate for Payer: Cash Price	$6,930.40
Rate for Payer: Cigna of AZ Commercial	$6,064.10
Rate for Payer: Devoted Health Medicare	$1,559.34
Rate for Payer: Humana of AZ Medicare	$1,386.08
Rate for Payer: Southwest Service Administrators UFCW	$5,890.84
Rate for Payer: TriWest Medicare	$1,386.08
Rate for Payer: United Healthcare Commercial	$4,955.24
Rate for Payer: United Healthcare Medicare	$1,386.08
Rate for Payer: Veterans Affairs TRICARE	$1,372.22

Plasma CPD Cryo Red

Facility

$504.00

Service Code	HCPCS P9044
Hospital Charge Code	1221760
Hospital Revenue Code	390
Min. Negotiated Rate	$79.83
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of AZ Commercial	$453.60
Rate for Payer: Arizona Complete Health Allwell	$80.64
Rate for Payer: Banner UC Health Medicare	$80.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$342.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$80.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$80.64
Rate for Payer: Cash Price	$403.20
Rate for Payer: Cash Price	$403.20
Rate for Payer: Cigna of AZ Commercial	$327.60
Rate for Payer: Devoted Health Medicare	$90.72
Rate for Payer: Humana of AZ Medicare	$80.64
Rate for Payer: Seven Corners Travel Insurance	$199.98
Rate for Payer: Southwest Service Administrators UFCW	$342.72
Rate for Payer: TriWest Medicare	$80.64
Rate for Payer: United Healthcare Commercial	$288.29
Rate for Payer: United Healthcare Medicare	$80.64
Rate for Payer: Veterans Affairs TRICARE	$79.83

Plasma CPD Cryo Red

Facility

$504.00

Service Code	HCPCS P9044
Hospital Charge Code	1221760
Hospital Revenue Code	390
Min. Negotiated Rate	$453.60
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of AZ Commercial	$453.60
Rate for Payer: Cash Price	$403.20

Plasma CPD Cryo Red Thawed

Facility

$504.00

Service Code	HCPCS P9044
Hospital Charge Code	1221768
Hospital Revenue Code	390
Min. Negotiated Rate	$453.60
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of AZ Commercial	$453.60
Rate for Payer: Cash Price	$403.20

Plasma CPD Cryo Red Thawed

Facility

$504.00

Service Code	HCPCS P9044
Hospital Charge Code	1221768
Hospital Revenue Code	390
Min. Negotiated Rate	$79.83
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of AZ Commercial	$453.60
Rate for Payer: Arizona Complete Health Allwell	$80.64
Rate for Payer: Banner UC Health Medicare	$80.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$342.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$80.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$80.64
Rate for Payer: Cash Price	$403.20
Rate for Payer: Cash Price	$403.20
Rate for Payer: Cigna of AZ Commercial	$327.60
Rate for Payer: Devoted Health Medicare	$90.72
Rate for Payer: Humana of AZ Medicare	$80.64
Rate for Payer: Seven Corners Travel Insurance	$199.98
Rate for Payer: Southwest Service Administrators UFCW	$342.72
Rate for Payer: TriWest Medicare	$80.64
Rate for Payer: United Healthcare Commercial	$288.29
Rate for Payer: United Healthcare Medicare	$80.64
Rate for Payer: Veterans Affairs TRICARE	$79.83

Know your out-of-pocket cost for care.

All Charges