Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC

Facility

$13,204.03

Service Code	MSDRG 815
Min. Negotiated Rate	$13,204.03
Max. Negotiated Rate	$13,204.03
Rate for Payer: Seven Corners Travel Insurance	$13,204.03

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC

Facility

$27,485.76

Service Code	MSDRG 814
Min. Negotiated Rate	$27,485.76
Max. Negotiated Rate	$27,485.76
Rate for Payer: Seven Corners Travel Insurance	$27,485.76

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC

Facility

$8,363.61

Service Code	MSDRG 816
Min. Negotiated Rate	$8,363.61
Max. Negotiated Rate	$8,363.61
Rate for Payer: Seven Corners Travel Insurance	$8,363.61

RETRACTOR BALLOON

Facility

$419.00

Hospital Charge Code	22354815
Hospital Revenue Code	270
Min. Negotiated Rate	$66.37
Max. Negotiated Rate	$377.10
Rate for Payer: Aetna of AZ Commercial	$377.10
Rate for Payer: Arizona Complete Health Allwell	$67.04
Rate for Payer: Banner UC Health Medicare	$67.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$284.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$67.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$67.04
Rate for Payer: Cash Price	$335.20
Rate for Payer: Cigna of AZ Commercial	$293.30
Rate for Payer: Devoted Health Medicare	$75.42
Rate for Payer: Humana of AZ Medicare	$67.04
Rate for Payer: Southwest Service Administrators UFCW	$284.92
Rate for Payer: TriWest Medicare	$67.04
Rate for Payer: United Healthcare Commercial	$239.67
Rate for Payer: United Healthcare Medicare	$67.04
Rate for Payer: Veterans Affairs TRICARE	$66.37

RETRACTOR BALLOON

Facility

$419.00

Hospital Charge Code	22354815
Hospital Revenue Code	270
Min. Negotiated Rate	$377.10
Max. Negotiated Rate	$377.10
Rate for Payer: Aetna of AZ Commercial	$377.10
Rate for Payer: Cash Price	$335.20

RETRACTOR RING 31.8X18.3CM DISP

Facility

$267.00

Hospital Charge Code	22354167
Hospital Revenue Code	270
Min. Negotiated Rate	$42.29
Max. Negotiated Rate	$240.30
Rate for Payer: Aetna of AZ Commercial	$240.30
Rate for Payer: Arizona Complete Health Allwell	$42.72
Rate for Payer: Banner UC Health Medicare	$42.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$181.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$42.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$42.72
Rate for Payer: Cash Price	$213.60
Rate for Payer: Cigna of AZ Commercial	$186.90
Rate for Payer: Devoted Health Medicare	$48.06
Rate for Payer: Humana of AZ Medicare	$42.72
Rate for Payer: Southwest Service Administrators UFCW	$181.56
Rate for Payer: TriWest Medicare	$42.72
Rate for Payer: United Healthcare Commercial	$152.72
Rate for Payer: United Healthcare Medicare	$42.72
Rate for Payer: Veterans Affairs TRICARE	$42.29

RETRACTOR RING 31.8X18.3CM DISP

Facility

$267.00

Hospital Charge Code	22354167
Hospital Revenue Code	270
Min. Negotiated Rate	$240.30
Max. Negotiated Rate	$240.30
Rate for Payer: Aetna of AZ Commercial	$240.30
Rate for Payer: Cash Price	$213.60

RETRIEVAL TISSUE SYSTEM ANCHOR

Facility

$368.00

Hospital Charge Code	22354821
Hospital Revenue Code	270
Min. Negotiated Rate	$58.29
Max. Negotiated Rate	$331.20
Rate for Payer: Aetna of AZ Commercial	$331.20
Rate for Payer: Arizona Complete Health Allwell	$58.88
Rate for Payer: Banner UC Health Medicare	$58.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$250.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$58.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$58.88
Rate for Payer: Cash Price	$294.40
Rate for Payer: Cigna of AZ Commercial	$257.60
Rate for Payer: Devoted Health Medicare	$66.24
Rate for Payer: Humana of AZ Medicare	$58.88
Rate for Payer: Southwest Service Administrators UFCW	$250.24
Rate for Payer: TriWest Medicare	$58.88
Rate for Payer: United Healthcare Commercial	$210.50
Rate for Payer: United Healthcare Medicare	$58.88
Rate for Payer: Veterans Affairs TRICARE	$58.29

RETRIEVAL TISSUE SYSTEM ANCHOR

Facility

$368.00

Hospital Charge Code	22354821
Hospital Revenue Code	270
Min. Negotiated Rate	$331.20
Max. Negotiated Rate	$331.20
Rate for Payer: Aetna of AZ Commercial	$331.20
Rate for Payer: Cash Price	$294.40

Reverse T3 LC

Facility

$359.00

Service Code	CPT 84482
Hospital Charge Code	2087649
Hospital Revenue Code	301
Min. Negotiated Rate	$323.10
Max. Negotiated Rate	$323.10
Rate for Payer: Aetna of AZ Commercial	$323.10
Rate for Payer: Cash Price	$287.20

Reverse T3 LC

Facility

$359.00

Service Code	CPT 84482
Hospital Charge Code	2087649
Hospital Revenue Code	301
Min. Negotiated Rate	$22.85
Max. Negotiated Rate	$323.10
Rate for Payer: Aetna of AZ Commercial	$323.10
Rate for Payer: Arizona Complete Health Allwell	$57.44
Rate for Payer: Banner UC Health Medicare	$57.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$244.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$57.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$57.44
Rate for Payer: Cash Price	$287.20
Rate for Payer: Cash Price	$287.20
Rate for Payer: Cigna of AZ Commercial	$233.35
Rate for Payer: Devoted Health Medicare	$64.62
Rate for Payer: Humana of AZ Medicare	$57.44
Rate for Payer: Seven Corners Travel Insurance	$22.85
Rate for Payer: Southwest Service Administrators UFCW	$244.12
Rate for Payer: TriWest Medicare	$57.44
Rate for Payer: United Healthcare Commercial	$205.35
Rate for Payer: United Healthcare Medicare	$57.44
Rate for Payer: Veterans Affairs TRICARE	$56.87

REVISION OF HIP OR KNEE REPLACEMENT WITH CC

Facility

$45,578.27

Service Code	MSDRG 467
Min. Negotiated Rate	$45,578.27
Max. Negotiated Rate	$45,578.27
Rate for Payer: Seven Corners Travel Insurance	$45,578.27

REVISION OF HIP OR KNEE REPLACEMENT WITH MCC

Facility

$67,275.32

Service Code	MSDRG 466
Min. Negotiated Rate	$67,275.32
Max. Negotiated Rate	$67,275.32
Rate for Payer: Seven Corners Travel Insurance	$67,275.32

REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC

Facility

$35,515.53

Service Code	MSDRG 468
Min. Negotiated Rate	$35,515.53
Max. Negotiated Rate	$35,515.53
Rate for Payer: Seven Corners Travel Insurance	$35,515.53

RF Qualitative

Facility

$135.00

Service Code	CPT 86430
Hospital Charge Code	1051519
Hospital Revenue Code	302
Min. Negotiated Rate	$8.90
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of AZ Commercial	$121.50
Rate for Payer: Arizona Complete Health Allwell	$21.60
Rate for Payer: Banner UC Health Medicare	$21.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$21.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$21.60
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna of AZ Commercial	$87.75
Rate for Payer: Devoted Health Medicare	$24.30
Rate for Payer: Humana of AZ Medicare	$21.60
Rate for Payer: Seven Corners Travel Insurance	$8.90
Rate for Payer: Southwest Service Administrators UFCW	$91.80
Rate for Payer: TriWest Medicare	$21.60
Rate for Payer: United Healthcare Commercial	$77.22
Rate for Payer: United Healthcare Medicare	$21.60
Rate for Payer: Veterans Affairs TRICARE	$21.38

RF Qualitative

Facility

$135.00

Service Code	CPT 86430
Hospital Charge Code	1051519
Hospital Revenue Code	302
Min. Negotiated Rate	$121.50
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of AZ Commercial	$121.50
Rate for Payer: Cash Price	$108.00

Facility

$99.00

Service Code	CPT 86901
Hospital Charge Code	22308645
Hospital Revenue Code	302
Min. Negotiated Rate	$4.34
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of AZ Commercial	$89.10
Rate for Payer: Arizona Complete Health Allwell	$15.84
Rate for Payer: Banner UC Health Medicare	$15.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$67.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$15.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.84
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna of AZ Commercial	$64.35
Rate for Payer: Devoted Health Medicare	$17.82
Rate for Payer: Humana of AZ Medicare	$15.84
Rate for Payer: Seven Corners Travel Insurance	$4.34
Rate for Payer: Southwest Service Administrators UFCW	$67.32
Rate for Payer: TriWest Medicare	$15.84
Rate for Payer: United Healthcare Commercial	$56.63
Rate for Payer: United Healthcare Medicare	$15.84
Rate for Payer: Veterans Affairs TRICARE	$15.68

Facility

$99.00

Service Code	CPT 86901
Hospital Charge Code	22308645
Hospital Revenue Code	302
Min. Negotiated Rate	$89.10
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of AZ Commercial	$89.10
Rate for Payer: Cash Price	$79.20

Rheumatoid Arthritis Factor LC

Facility

$142.00

Service Code	CPT 86430
Hospital Charge Code	1285583
Hospital Revenue Code	302
Min. Negotiated Rate	$8.90
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	$8.90
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

Rheumatoid Arthritis Factor LC

Facility

$142.00

Service Code	CPT 86430
Hospital Charge Code	1285583
Hospital Revenue Code	302
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

RHo (D) immune globulin 300 mcg Sol[CQCH]

Facility

$126.14

Service Code	HCPCS J2790
Hospital Charge Code	132649818
Hospital Revenue Code	250
Min. Negotiated Rate	$19.98
Max. Negotiated Rate	$113.53
Rate for Payer: Aetna of AZ Commercial	$113.53
Rate for Payer: Arizona Complete Health Allwell	$20.18
Rate for Payer: Banner UC Health Medicare	$20.18
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$85.78
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.18
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.18
Rate for Payer: Cash Price	$100.91
Rate for Payer: Cigna of AZ Commercial	$81.99
Rate for Payer: Devoted Health Medicare	$22.71
Rate for Payer: Humana of AZ Medicare	$20.18
Rate for Payer: Southwest Service Administrators UFCW	$85.78
Rate for Payer: TriWest Medicare	$20.18
Rate for Payer: United Healthcare Commercial	$72.15
Rate for Payer: United Healthcare Medicare	$20.18
Rate for Payer: Veterans Affairs TRICARE	$19.98

RHo (D) immune globulin 300 mcg Sol[CQCH]

Facility

$126.14

Service Code	HCPCS J2790
Hospital Charge Code	132649818
Hospital Revenue Code	250
Min. Negotiated Rate	$113.53
Max. Negotiated Rate	$113.53
Rate for Payer: Aetna of AZ Commercial	$113.53
Rate for Payer: Cash Price	$100.91

rifAMPin 600 mg REC[CQCH]

Facility

$73.42

Service Code	NDC 68059701
Hospital Charge Code	127193752
Hospital Revenue Code	250
Min. Negotiated Rate	$66.08
Max. Negotiated Rate	$66.08
Rate for Payer: Aetna of AZ Commercial	$66.08
Rate for Payer: Cash Price	$58.74

rifAMPin 600 mg REC[CQCH]

Facility

$73.42

Service Code	NDC 68059701
Hospital Charge Code	127193752
Hospital Revenue Code	250
Min. Negotiated Rate	$11.63
Max. Negotiated Rate	$66.08
Rate for Payer: Aetna of AZ Commercial	$66.08
Rate for Payer: Arizona Complete Health Allwell	$11.75
Rate for Payer: Banner UC Health Medicare	$11.75
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$49.93
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.75
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.75
Rate for Payer: Cash Price	$58.74
Rate for Payer: Cigna of AZ Commercial	$47.72
Rate for Payer: Devoted Health Medicare	$13.22
Rate for Payer: Humana of AZ Medicare	$11.75
Rate for Payer: Southwest Service Administrators UFCW	$49.93
Rate for Payer: TriWest Medicare	$11.75
Rate for Payer: United Healthcare Commercial	$42.00
Rate for Payer: United Healthcare Medicare	$11.75
Rate for Payer: Veterans Affairs TRICARE	$11.63

rifaximin 200 mg Tab [CQCH]

Facility

$20.78

Service Code	NDC 65649030103
Hospital Charge Code	105939447
Hospital Revenue Code	251
Min. Negotiated Rate	$3.29
Max. Negotiated Rate	$18.70
Rate for Payer: Aetna of AZ Commercial	$18.70
Rate for Payer: Arizona Complete Health Allwell	$3.32
Rate for Payer: Banner UC Health Medicare	$3.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$14.13
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.32
Rate for Payer: Cash Price	$16.62
Rate for Payer: Cigna of AZ Commercial	$13.51
Rate for Payer: Devoted Health Medicare	$3.74
Rate for Payer: Humana of AZ Medicare	$3.32
Rate for Payer: Southwest Service Administrators UFCW	$14.13
Rate for Payer: TriWest Medicare	$3.32
Rate for Payer: United Healthcare Commercial	$11.89
Rate for Payer: United Healthcare Medicare	$3.32
Rate for Payer: Veterans Affairs TRICARE	$3.29

Know your out-of-pocket cost for care.

All Charges