Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

proparacaine Ophth 0.5% Sol [CQCH]

Facility

$2.17

Service Code	NDC 24208073006
Hospital Charge Code	105938535
Hospital Revenue Code	251
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna of AZ Commercial	$1.95
Rate for Payer: Cash Price	$1.74

propofol 1000mg/100ml Emu (premix)(CQCH)

Facility

$0.08

Service Code	HCPCS J2704
Hospital Charge Code	121933170
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
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	$0.05
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	$0.07
Rate for Payer: Cigna of AZ Commercial	$0.05
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.05
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.05
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

propofol 1000mg/100ml Emu (premix)(CQCH)

Facility

$0.08

Service Code	HCPCS J2704
Hospital Charge Code	121933170
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
Rate for Payer: Cash Price	$0.07

propofol 200 mg/20 mL IV Emul [CQCH]

Facility

$0.10

Service Code	HCPCS J2704
Hospital Charge Code	105938600
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of AZ Commercial	$0.09
Rate for Payer: Cash Price	$0.08

propofol 200 mg/20 mL IV Emul [CQCH]

Facility

$0.10

Service Code	HCPCS J2704
Hospital Charge Code	105938600
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of AZ Commercial	$0.09
Rate for Payer: Arizona Complete Health Allwell	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.07
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.02
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.02
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of AZ Commercial	$0.07
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.07
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.06
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

propranolol 20 mg Tab [CQCH]

Facility

$0.45

Service Code	NDC 60687059801
Hospital Charge Code	105953054
Hospital Revenue Code	251
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of AZ Commercial	$0.41
Rate for Payer: Cash Price	$0.36

propranolol 20 mg Tab [CQCH]

Facility

$0.45

Service Code	NDC 60687059801
Hospital Charge Code	105953054
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of AZ Commercial	$0.41
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	$0.31
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	$0.36
Rate for Payer: Cigna of AZ Commercial	$0.29
Rate for Payer: Devoted Health Medicare	$0.08
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Southwest Service Administrators UFCW	$0.31
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: United Healthcare Commercial	$0.26
Rate for Payer: United Healthcare Medicare	$0.07
Rate for Payer: Veterans Affairs TRICARE	$0.07

PROSTATECTOMY WITH CC

Facility

$22,608.18

Service Code	MSDRG 666
Min. Negotiated Rate	$22,608.18
Max. Negotiated Rate	$22,608.18
Rate for Payer: Seven Corners Travel Insurance	$22,608.18

PROSTATECTOMY WITH MCC

Facility

$40,338.83

Service Code	MSDRG 665
Min. Negotiated Rate	$40,338.83
Max. Negotiated Rate	$40,338.83
Rate for Payer: Seven Corners Travel Insurance	$40,338.83

PROSTATECTOMY WITHOUT CC/MCC

Facility

$14,372.30

Service Code	MSDRG 667
Min. Negotiated Rate	$14,372.30
Max. Negotiated Rate	$14,372.30
Rate for Payer: Seven Corners Travel Insurance	$14,372.30

protamine 250 mg/25 mL Inj Sol [CQCH]

Facility

$1.32

Service Code	HCPCS J2720
Hospital Charge Code	105938671
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$1.19
Rate for Payer: Aetna of AZ Commercial	$1.19
Rate for Payer: Arizona Complete Health Allwell	$0.21
Rate for Payer: Banner UC Health Medicare	$0.21
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.90
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.21
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.21
Rate for Payer: Cash Price	$1.06
Rate for Payer: Cigna of AZ Commercial	$0.86
Rate for Payer: Devoted Health Medicare	$0.24
Rate for Payer: Humana of AZ Medicare	$0.21
Rate for Payer: Southwest Service Administrators UFCW	$0.90
Rate for Payer: TriWest Medicare	$0.21
Rate for Payer: United Healthcare Commercial	$0.76
Rate for Payer: United Healthcare Medicare	$0.21
Rate for Payer: Veterans Affairs TRICARE	$0.21

protamine 250 mg/25 mL Inj Sol [CQCH]

Facility

$1.32

Service Code	HCPCS J2720
Hospital Charge Code	105938671
Hospital Revenue Code	250
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$1.19
Rate for Payer: Aetna of AZ Commercial	$1.19
Rate for Payer: Cash Price	$1.06

Protein 24 Hour Urine

Facility

$71.00

Service Code	CPT 84133
Hospital Charge Code	633811
Hospital Revenue Code	301
Min. Negotiated Rate	$6.86
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Arizona Complete Health Allwell	$11.36
Rate for Payer: Banner UC Health Medicare	$11.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$48.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.36
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cigna of AZ Commercial	$46.15
Rate for Payer: Devoted Health Medicare	$12.78
Rate for Payer: Humana of AZ Medicare	$11.36
Rate for Payer: Seven Corners Travel Insurance	$6.86
Rate for Payer: Southwest Service Administrators UFCW	$48.28
Rate for Payer: TriWest Medicare	$11.36
Rate for Payer: United Healthcare Commercial	$40.61
Rate for Payer: United Healthcare Medicare	$11.36
Rate for Payer: Veterans Affairs TRICARE	$11.25

Protein 24 Hour Urine

Facility

$71.00

Service Code	CPT 84133
Hospital Charge Code	633811
Hospital Revenue Code	301
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Cash Price	$56.80

Protein C Activity (Chrom) LC

Facility

$163.00

Service Code	CPT 85303
Hospital Charge Code	6781142
Hospital Revenue Code	301
Min. Negotiated Rate	$146.70
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Cash Price	$130.40

Protein C Activity (Chrom) LC

Facility

$163.00

Service Code	CPT 85303
Hospital Charge Code	6781142
Hospital Revenue Code	301
Min. Negotiated Rate	$20.07
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Arizona Complete Health Allwell	$26.08
Rate for Payer: Banner UC Health Medicare	$26.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$110.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$26.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$26.08
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cigna of AZ Commercial	$105.95
Rate for Payer: Devoted Health Medicare	$29.34
Rate for Payer: Humana of AZ Medicare	$26.08
Rate for Payer: Seven Corners Travel Insurance	$20.07
Rate for Payer: Southwest Service Administrators UFCW	$110.84
Rate for Payer: TriWest Medicare	$26.08
Rate for Payer: United Healthcare Commercial	$93.24
Rate for Payer: United Healthcare Medicare	$26.08
Rate for Payer: Veterans Affairs TRICARE	$25.82

Protein C Deficiency Profile LC

Facility

$406.00

Service Code	CPT 85302
Hospital Charge Code	2087638
Hospital Revenue Code	305
Min. Negotiated Rate	$17.41
Max. Negotiated Rate	$365.40
Rate for Payer: Aetna of AZ Commercial	$365.40
Rate for Payer: Arizona Complete Health Allwell	$64.96
Rate for Payer: Banner UC Health Medicare	$64.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$276.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$64.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$64.96
Rate for Payer: Cash Price	$324.80
Rate for Payer: Cash Price	$324.80
Rate for Payer: Cigna of AZ Commercial	$263.90
Rate for Payer: Devoted Health Medicare	$73.08
Rate for Payer: Humana of AZ Medicare	$64.96
Rate for Payer: Seven Corners Travel Insurance	$17.41
Rate for Payer: Southwest Service Administrators UFCW	$276.08
Rate for Payer: TriWest Medicare	$64.96
Rate for Payer: United Healthcare Commercial	$232.23
Rate for Payer: United Healthcare Medicare	$64.96
Rate for Payer: Veterans Affairs TRICARE	$64.31

Protein C Deficiency Profile LC

Facility

$406.00

Service Code	CPT 85302
Hospital Charge Code	2087638
Hospital Revenue Code	305
Min. Negotiated Rate	$365.40
Max. Negotiated Rate	$365.40
Rate for Payer: Aetna of AZ Commercial	$365.40
Rate for Payer: Cash Price	$324.80

Protein Electro, 24-Hour Urine LC

Facility

$768.00

Service Code	CPT 84166
Hospital Charge Code	1285721
Hospital Revenue Code	301
Min. Negotiated Rate	$25.85
Max. Negotiated Rate	$691.20
Rate for Payer: Aetna of AZ Commercial	$691.20
Rate for Payer: Arizona Complete Health Allwell	$122.88
Rate for Payer: Banner UC Health Medicare	$122.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$522.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$122.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$122.88
Rate for Payer: Cash Price	$614.40
Rate for Payer: Cash Price	$614.40
Rate for Payer: Cigna of AZ Commercial	$499.20
Rate for Payer: Devoted Health Medicare	$138.24
Rate for Payer: Humana of AZ Medicare	$122.88
Rate for Payer: Seven Corners Travel Insurance	$25.85
Rate for Payer: Southwest Service Administrators UFCW	$522.24
Rate for Payer: TriWest Medicare	$122.88
Rate for Payer: United Healthcare Commercial	$439.30
Rate for Payer: United Healthcare Medicare	$122.88
Rate for Payer: Veterans Affairs TRICARE	$121.65

Protein Electro, 24-Hour Urine LC

Facility

$768.00

Service Code	CPT 84166
Hospital Charge Code	1285721
Hospital Revenue Code	301
Min. Negotiated Rate	$691.20
Max. Negotiated Rate	$691.20
Rate for Payer: Aetna of AZ Commercial	$691.20
Rate for Payer: Cash Price	$614.40

Protein Electro, Random Urine LC

Facility

$768.00

Service Code	CPT 84166
Hospital Charge Code	2087639
Hospital Revenue Code	301
Min. Negotiated Rate	$691.20
Max. Negotiated Rate	$691.20
Rate for Payer: Aetna of AZ Commercial	$691.20
Rate for Payer: Cash Price	$614.40

Protein Electro, Random Urine LC

Facility

$768.00

Service Code	CPT 84166
Hospital Charge Code	2087639
Hospital Revenue Code	301
Min. Negotiated Rate	$25.85
Max. Negotiated Rate	$691.20
Rate for Payer: Aetna of AZ Commercial	$691.20
Rate for Payer: Arizona Complete Health Allwell	$122.88
Rate for Payer: Banner UC Health Medicare	$122.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$522.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$122.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$122.88
Rate for Payer: Cash Price	$614.40
Rate for Payer: Cash Price	$614.40
Rate for Payer: Cigna of AZ Commercial	$499.20
Rate for Payer: Devoted Health Medicare	$138.24
Rate for Payer: Humana of AZ Medicare	$122.88
Rate for Payer: Seven Corners Travel Insurance	$25.85
Rate for Payer: Southwest Service Administrators UFCW	$522.24
Rate for Payer: TriWest Medicare	$122.88
Rate for Payer: United Healthcare Commercial	$439.30
Rate for Payer: United Healthcare Medicare	$122.88
Rate for Payer: Veterans Affairs TRICARE	$121.65

Protein Electro Serum LC

Facility

$681.00

Service Code	CPT 84165
Hospital Charge Code	1285802
Hospital Revenue Code	301
Min. Negotiated Rate	$15.57
Max. Negotiated Rate	$612.90
Rate for Payer: Aetna of AZ Commercial	$612.90
Rate for Payer: Arizona Complete Health Allwell	$108.96
Rate for Payer: Banner UC Health Medicare	$108.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$463.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$108.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$108.96
Rate for Payer: Cash Price	$544.80
Rate for Payer: Cash Price	$544.80
Rate for Payer: Cigna of AZ Commercial	$442.65
Rate for Payer: Devoted Health Medicare	$122.58
Rate for Payer: Humana of AZ Medicare	$108.96
Rate for Payer: Seven Corners Travel Insurance	$15.57
Rate for Payer: Southwest Service Administrators UFCW	$463.08
Rate for Payer: TriWest Medicare	$108.96
Rate for Payer: United Healthcare Commercial	$389.53
Rate for Payer: United Healthcare Medicare	$108.96
Rate for Payer: Veterans Affairs TRICARE	$107.87

Protein Electro Serum LC

Facility

$681.00

Service Code	CPT 84165
Hospital Charge Code	1285802
Hospital Revenue Code	301
Min. Negotiated Rate	$612.90
Max. Negotiated Rate	$612.90
Rate for Payer: Aetna of AZ Commercial	$612.90
Rate for Payer: Cash Price	$544.80

Protein Level Urine

Facility

$95.00

Service Code	CPT 84156
Hospital Charge Code	12253376
Hospital Revenue Code	301
Min. Negotiated Rate	$5.32
Max. Negotiated Rate	$85.50
Rate for Payer: Aetna of AZ Commercial	$85.50
Rate for Payer: Arizona Complete Health Allwell	$15.20
Rate for Payer: Banner UC Health Medicare	$15.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$64.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$15.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.20
Rate for Payer: Cash Price	$76.00
Rate for Payer: Cash Price	$76.00
Rate for Payer: Cigna of AZ Commercial	$61.75
Rate for Payer: Devoted Health Medicare	$17.10
Rate for Payer: Humana of AZ Medicare	$15.20
Rate for Payer: Seven Corners Travel Insurance	$5.32
Rate for Payer: Southwest Service Administrators UFCW	$64.60
Rate for Payer: TriWest Medicare	$15.20
Rate for Payer: United Healthcare Commercial	$54.34
Rate for Payer: United Healthcare Medicare	$15.20
Rate for Payer: Veterans Affairs TRICARE	$15.05

Know your out-of-pocket cost for care.

All Charges