Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

primidone 50 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 603537121
Hospital Charge Code	105938066
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Arizona Complete Health Allwell	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.01
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.01
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of AZ Commercial	$0.04
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.04
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.03
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

primidone 50 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 603537121
Hospital Charge Code	105938066
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Cash Price	$0.05

Primidone (Mysoline), Serum LC

Facility

$319.00

Service Code	CPT 80188
Hospital Charge Code	1285610
Hospital Revenue Code	301
Min. Negotiated Rate	$24.06
Max. Negotiated Rate	$287.10
Rate for Payer: Aetna of AZ Commercial	$287.10
Rate for Payer: Arizona Complete Health Allwell	$51.04
Rate for Payer: Banner UC Health Medicare	$51.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$216.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$51.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$51.04
Rate for Payer: Cash Price	$255.20
Rate for Payer: Cash Price	$255.20
Rate for Payer: Cigna of AZ Commercial	$207.35
Rate for Payer: Devoted Health Medicare	$57.42
Rate for Payer: Humana of AZ Medicare	$51.04
Rate for Payer: Seven Corners Travel Insurance	$24.06
Rate for Payer: Southwest Service Administrators UFCW	$216.92
Rate for Payer: TriWest Medicare	$51.04
Rate for Payer: United Healthcare Commercial	$182.47
Rate for Payer: United Healthcare Medicare	$51.04
Rate for Payer: Veterans Affairs TRICARE	$50.53

Primidone (Mysoline), Serum LC

Facility

$319.00

Service Code	CPT 80188
Hospital Charge Code	1285610
Hospital Revenue Code	301
Min. Negotiated Rate	$287.10
Max. Negotiated Rate	$287.10
Rate for Payer: Aetna of AZ Commercial	$287.10
Rate for Payer: Cash Price	$255.20

PROBE PULSE OX PED/ADULT NOVAMETRIX

Facility

$101.00

Hospital Charge Code	22355401
Hospital Revenue Code	270
Min. Negotiated Rate	$90.90
Max. Negotiated Rate	$90.90
Rate for Payer: Aetna of AZ Commercial	$90.90
Rate for Payer: Cash Price	$80.80

PROBE PULSE OX PED/ADULT NOVAMETRIX

Facility

$101.00

Hospital Charge Code	22355401
Hospital Revenue Code	270
Min. Negotiated Rate	$16.00
Max. Negotiated Rate	$90.90
Rate for Payer: Aetna of AZ Commercial	$90.90
Rate for Payer: Arizona Complete Health Allwell	$16.16
Rate for Payer: Banner UC Health Medicare	$16.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$68.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.16
Rate for Payer: Cash Price	$80.80
Rate for Payer: Cigna of AZ Commercial	$70.70
Rate for Payer: Devoted Health Medicare	$18.18
Rate for Payer: Humana of AZ Medicare	$16.16
Rate for Payer: Southwest Service Administrators UFCW	$68.68
Rate for Payer: TriWest Medicare	$16.16
Rate for Payer: United Healthcare Commercial	$57.77
Rate for Payer: United Healthcare Medicare	$16.16
Rate for Payer: Veterans Affairs TRICARE	$16.00

proBNP LC

Facility

$124.00

Service Code	CPT 83880
Hospital Charge Code	1285628
Hospital Revenue Code	301
Min. Negotiated Rate	$19.64
Max. Negotiated Rate	$111.60
Rate for Payer: Aetna of AZ Commercial	$111.60
Rate for Payer: Arizona Complete Health Allwell	$19.84
Rate for Payer: Banner UC Health Medicare	$19.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$84.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$19.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$19.84
Rate for Payer: Cash Price	$99.20
Rate for Payer: Cash Price	$99.20
Rate for Payer: Cigna of AZ Commercial	$80.60
Rate for Payer: Devoted Health Medicare	$22.32
Rate for Payer: Humana of AZ Medicare	$19.84
Rate for Payer: Seven Corners Travel Insurance	$56.93
Rate for Payer: Southwest Service Administrators UFCW	$84.32
Rate for Payer: TriWest Medicare	$19.84
Rate for Payer: United Healthcare Commercial	$70.93
Rate for Payer: United Healthcare Medicare	$19.84
Rate for Payer: Veterans Affairs TRICARE	$19.64

proBNP LC

Facility

$124.00

Service Code	CPT 83880
Hospital Charge Code	1285628
Hospital Revenue Code	301
Min. Negotiated Rate	$111.60
Max. Negotiated Rate	$111.60
Rate for Payer: Aetna of AZ Commercial	$111.60
Rate for Payer: Cash Price	$99.20

procainamide 100 mg/mL Sol[CQCH]

Facility

$6.03

Service Code	HCPCS J2690
Hospital Charge Code	135202939
Hospital Revenue Code	250
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$428.27
Rate for Payer: Aetna of AZ Commercial	$5.43
Rate for Payer: Arizona Complete Health Allwell	$0.96
Rate for Payer: Banner UC Health Medicare	$0.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$4.10
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.96
Rate for Payer: Cash Price	$4.82
Rate for Payer: Cash Price	$4.82
Rate for Payer: Cigna of AZ Commercial	$3.92
Rate for Payer: Devoted Health Medicare	$1.09
Rate for Payer: Humana of AZ Medicare	$0.96
Rate for Payer: Seven Corners Travel Insurance	$428.27
Rate for Payer: Southwest Service Administrators UFCW	$4.10
Rate for Payer: TriWest Medicare	$0.96
Rate for Payer: United Healthcare Commercial	$3.45
Rate for Payer: United Healthcare Medicare	$0.96
Rate for Payer: Veterans Affairs TRICARE	$0.96

procainamide 100 mg/mL Sol[CQCH]

Facility

$6.03

Service Code	HCPCS J2690
Hospital Charge Code	135202939
Hospital Revenue Code	250
Min. Negotiated Rate	$5.43
Max. Negotiated Rate	$5.43
Rate for Payer: Aetna of AZ Commercial	$5.43
Rate for Payer: Cash Price	$4.82

Procedures For Obesity

Facility

$13,512.47

Service Code	APR-DRG 4033
Hospital Charge Code	APRDRG4034
Min. Negotiated Rate	$13,512.47
Max. Negotiated Rate	$13,512.47
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13,512.47
Rate for Payer: Mercy Care Medicaid	$13,512.47
Rate for Payer: NaphCare Correctional Healthcare	$13,512.47

Procedures For Obesity

Facility

$13,512.47

Service Code	APR-DRG 4033
Hospital Charge Code	APRDRG4031
Min. Negotiated Rate	$13,512.47
Max. Negotiated Rate	$13,512.47
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13,512.47
Rate for Payer: Mercy Care Medicaid	$13,512.47
Rate for Payer: NaphCare Correctional Healthcare	$13,512.47

Procedures For Obesity

Facility

$29,636.25

Service Code	APR-DRG 4034
Hospital Charge Code	APRDRG4034
Min. Negotiated Rate	$29,636.25
Max. Negotiated Rate	$29,636.25
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$29,636.25
Rate for Payer: Mercy Care Medicaid	$29,636.25
Rate for Payer: NaphCare Correctional Healthcare	$29,636.25

Procedures For Obesity

Facility

$8,425.22

Service Code	APR-DRG 4032
Hospital Charge Code	APRDRG4031
Min. Negotiated Rate	$8,425.22
Max. Negotiated Rate	$8,425.22
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8,425.22
Rate for Payer: Mercy Care Medicaid	$8,425.22
Rate for Payer: NaphCare Correctional Healthcare	$8,425.22

Procedures For Obesity

Facility

$7,285.44

Service Code	APR-DRG 4031
Hospital Charge Code	APRDRG4032
Min. Negotiated Rate	$7,285.44
Max. Negotiated Rate	$7,285.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$7,285.44
Rate for Payer: Mercy Care Medicaid	$7,285.44
Rate for Payer: NaphCare Correctional Healthcare	$7,285.44

Procedures For Obesity

Facility

$8,425.22

Service Code	APR-DRG 4032
Hospital Charge Code	APRDRG4034
Min. Negotiated Rate	$8,425.22
Max. Negotiated Rate	$8,425.22
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8,425.22
Rate for Payer: Mercy Care Medicaid	$8,425.22
Rate for Payer: NaphCare Correctional Healthcare	$8,425.22

Procedures For Obesity

Facility

$29,636.25

Service Code	APR-DRG 4034
Hospital Charge Code	APRDRG4031
Min. Negotiated Rate	$29,636.25
Max. Negotiated Rate	$29,636.25
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$29,636.25
Rate for Payer: Mercy Care Medicaid	$29,636.25
Rate for Payer: NaphCare Correctional Healthcare	$29,636.25

Procedures For Obesity

Facility

$29,636.25

Service Code	APR-DRG 4034
Hospital Charge Code	APRDRG4032
Min. Negotiated Rate	$29,636.25
Max. Negotiated Rate	$29,636.25
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$29,636.25
Rate for Payer: Mercy Care Medicaid	$29,636.25
Rate for Payer: NaphCare Correctional Healthcare	$29,636.25

Procedures For Obesity

Facility

$8,425.22

Service Code	APR-DRG 4032
Hospital Charge Code	APRDRG4033
Min. Negotiated Rate	$8,425.22
Max. Negotiated Rate	$8,425.22
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8,425.22
Rate for Payer: Mercy Care Medicaid	$8,425.22
Rate for Payer: NaphCare Correctional Healthcare	$8,425.22

Procedures For Obesity

Facility

$7,285.44

Service Code	APR-DRG 4031
Hospital Charge Code	APRDRG4033
Min. Negotiated Rate	$7,285.44
Max. Negotiated Rate	$7,285.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$7,285.44
Rate for Payer: Mercy Care Medicaid	$7,285.44
Rate for Payer: NaphCare Correctional Healthcare	$7,285.44

Procedures For Obesity

Facility

$13,512.47

Service Code	APR-DRG 4033
Hospital Charge Code	APRDRG4033
Min. Negotiated Rate	$13,512.47
Max. Negotiated Rate	$13,512.47
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13,512.47
Rate for Payer: Mercy Care Medicaid	$13,512.47
Rate for Payer: NaphCare Correctional Healthcare	$13,512.47

Procedures For Obesity

Facility

$13,512.47

Service Code	APR-DRG 4033
Hospital Charge Code	APRDRG4032
Min. Negotiated Rate	$13,512.47
Max. Negotiated Rate	$13,512.47
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13,512.47
Rate for Payer: Mercy Care Medicaid	$13,512.47
Rate for Payer: NaphCare Correctional Healthcare	$13,512.47

Procedures For Obesity

Facility

$7,285.44

Service Code	APR-DRG 4031
Hospital Charge Code	APRDRG4031
Min. Negotiated Rate	$7,285.44
Max. Negotiated Rate	$7,285.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$7,285.44
Rate for Payer: Mercy Care Medicaid	$7,285.44
Rate for Payer: NaphCare Correctional Healthcare	$7,285.44

Procedures For Obesity

Facility

$8,425.22

Service Code	APR-DRG 4032
Hospital Charge Code	APRDRG4032
Min. Negotiated Rate	$8,425.22
Max. Negotiated Rate	$8,425.22
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8,425.22
Rate for Payer: Mercy Care Medicaid	$8,425.22
Rate for Payer: NaphCare Correctional Healthcare	$8,425.22

Procedures For Obesity

Facility

$29,636.25

Service Code	APR-DRG 4034
Hospital Charge Code	APRDRG4033
Min. Negotiated Rate	$29,636.25
Max. Negotiated Rate	$29,636.25
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$29,636.25
Rate for Payer: Mercy Care Medicaid	$29,636.25
Rate for Payer: NaphCare Correctional Healthcare	$29,636.25

Know your out-of-pocket cost for care.

All Charges