Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

rifaximin 200 mg Tab [CQCH]

Facility

$20.78

Service Code	NDC 65649030103
Hospital Charge Code	105939447
Hospital Revenue Code	251
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$18.70
Rate for Payer: Aetna of AZ Commercial	$18.70
Rate for Payer: Cash Price	$16.62

RIGID SINGLE USE STYLET MEDIUM

Facility

$57.00

Hospital Charge Code	27728098
Hospital Revenue Code	270
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna of AZ Commercial	$51.30
Rate for Payer: Cash Price	$45.60

RIGID SINGLE USE STYLET MEDIUM

Facility

$57.00

Hospital Charge Code	27728098
Hospital Revenue Code	270
Min. Negotiated Rate	$9.03
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna of AZ Commercial	$51.30
Rate for Payer: Arizona Complete Health Allwell	$9.12
Rate for Payer: Banner UC Health Medicare	$9.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$38.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.12
Rate for Payer: Cash Price	$45.60
Rate for Payer: Cigna of AZ Commercial	$39.90
Rate for Payer: Devoted Health Medicare	$10.26
Rate for Payer: Humana of AZ Medicare	$9.12
Rate for Payer: Southwest Service Administrators UFCW	$38.76
Rate for Payer: TriWest Medicare	$9.12
Rate for Payer: United Healthcare Commercial	$32.60
Rate for Payer: United Healthcare Medicare	$9.12
Rate for Payer: Veterans Affairs TRICARE	$9.03

RIGID SINGLE USE STYLET SMALL

Facility

$33.00

Hospital Charge Code	27728092
Hospital Revenue Code	270
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Cash Price	$26.40

RIGID SINGLE USE STYLET SMALL

Facility

$33.00

Hospital Charge Code	27728092
Hospital Revenue Code	270
Min. Negotiated Rate	$5.23
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Arizona Complete Health Allwell	$5.28
Rate for Payer: Banner UC Health Medicare	$5.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$22.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.28
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cigna of AZ Commercial	$23.10
Rate for Payer: Devoted Health Medicare	$5.94
Rate for Payer: Humana of AZ Medicare	$5.28
Rate for Payer: Southwest Service Administrators UFCW	$22.44
Rate for Payer: TriWest Medicare	$5.28
Rate for Payer: United Healthcare Commercial	$18.88
Rate for Payer: United Healthcare Medicare	$5.28
Rate for Payer: Veterans Affairs TRICARE	$5.23

Ringers Lactate Infusion, Up To 1000 Cc

Facility

$5.00

Service Code	HCPCS J7210
Hospital Charge Code	1413423
Hospital Revenue Code	521
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Arizona Complete Health Allwell	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.80
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of AZ Commercial	$3.50
Rate for Payer: Devoted Health Medicare	$0.90
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Seven Corners Travel Insurance	$2.35
Rate for Payer: Southwest Service Administrators UFCW	$3.40
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: United Healthcare Commercial	$2.86
Rate for Payer: United Healthcare Medicare	$0.80
Rate for Payer: Veterans Affairs TRICARE	$0.79

Ringers Lactate Infusion, Up To 1000 Cc

Facility

$5.00

Service Code	HCPCS J7210
Hospital Charge Code	1413423
Hospital Revenue Code	521
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Cash Price	$4.00

risankizumab rzaa 60 mg/mL Sol[CQCH]

Facility

$921.80

Service Code	HCPCS J2327
Hospital Charge Code	222641743
Hospital Revenue Code	250
Min. Negotiated Rate	$829.62
Max. Negotiated Rate	$829.62
Rate for Payer: Aetna of AZ Commercial	$829.62
Rate for Payer: Cash Price	$737.44

risankizumab rzaa 60 mg/mL Sol[CQCH]

Facility

$921.80

Service Code	HCPCS J2327
Hospital Charge Code	222641743
Hospital Revenue Code	250
Min. Negotiated Rate	$21.07
Max. Negotiated Rate	$829.62
Rate for Payer: Aetna of AZ Commercial	$829.62
Rate for Payer: Arizona Complete Health Allwell	$147.49
Rate for Payer: Banner UC Health Medicare	$147.49
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$626.82
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$147.49
Rate for Payer: Care1st Health Plan Arizona Medicare	$147.49
Rate for Payer: Cash Price	$737.44
Rate for Payer: Cash Price	$737.44
Rate for Payer: Cigna of AZ Commercial	$599.17
Rate for Payer: Devoted Health Medicare	$165.92
Rate for Payer: Humana of AZ Medicare	$147.49
Rate for Payer: Seven Corners Travel Insurance	$21.07
Rate for Payer: Southwest Service Administrators UFCW	$626.82
Rate for Payer: TriWest Medicare	$147.49
Rate for Payer: United Healthcare Commercial	$527.27
Rate for Payer: United Healthcare Medicare	$147.49
Rate for Payer: Veterans Affairs TRICARE	$146.01

risperiDONE 0.5 mg Tab [CQCH]

Facility

$0.20

Service Code	NDC 904635861
Hospital Charge Code	105939512
Hospital Revenue Code	251
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.18
Rate for Payer: Cash Price	$0.16

risperiDONE 0.5 mg Tab [CQCH]

Facility

$0.20

Service Code	NDC 904635861
Hospital Charge Code	105939512
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.18
Rate for Payer: Arizona Complete Health Allwell	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.14
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.03
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.03
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of AZ Commercial	$0.13
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Southwest Service Administrators UFCW	$0.14
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: United Healthcare Commercial	$0.11
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

rivaroxaban 10 mg Tab [CQCH]

Facility

$12.04

Service Code	NDC 50458058010
Hospital Charge Code	105939709
Hospital Revenue Code	251
Min. Negotiated Rate	$10.84
Max. Negotiated Rate	$10.84
Rate for Payer: Aetna of AZ Commercial	$10.84
Rate for Payer: Cash Price	$9.63

rivaroxaban 10 mg Tab [CQCH]

Facility

$12.04

Service Code	NDC 50458058010
Hospital Charge Code	105939709
Hospital Revenue Code	251
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$10.84
Rate for Payer: Aetna of AZ Commercial	$10.84
Rate for Payer: Arizona Complete Health Allwell	$1.93
Rate for Payer: Banner UC Health Medicare	$1.93
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$8.19
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.93
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.93
Rate for Payer: Cash Price	$9.63
Rate for Payer: Cigna of AZ Commercial	$7.83
Rate for Payer: Devoted Health Medicare	$2.17
Rate for Payer: Humana of AZ Medicare	$1.93
Rate for Payer: Southwest Service Administrators UFCW	$8.19
Rate for Payer: TriWest Medicare	$1.93
Rate for Payer: United Healthcare Commercial	$6.89
Rate for Payer: United Healthcare Medicare	$1.93
Rate for Payer: Veterans Affairs TRICARE	$1.91

rivaroxaban 15 mg Tab [CQCH]

Facility

$11.81

Service Code	NDC 50458057810
Hospital Charge Code	105939642
Hospital Revenue Code	251
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$10.63
Rate for Payer: Aetna of AZ Commercial	$10.63
Rate for Payer: Arizona Complete Health Allwell	$1.89
Rate for Payer: Banner UC Health Medicare	$1.89
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$8.03
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.89
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.89
Rate for Payer: Cash Price	$9.45
Rate for Payer: Cigna of AZ Commercial	$7.68
Rate for Payer: Devoted Health Medicare	$2.13
Rate for Payer: Humana of AZ Medicare	$1.89
Rate for Payer: Southwest Service Administrators UFCW	$8.03
Rate for Payer: TriWest Medicare	$1.89
Rate for Payer: United Healthcare Commercial	$6.76
Rate for Payer: United Healthcare Medicare	$1.89
Rate for Payer: Veterans Affairs TRICARE	$1.87

rivaroxaban 15 mg Tab [CQCH]

Facility

$11.81

Service Code	NDC 50458057810
Hospital Charge Code	105939642
Hospital Revenue Code	251
Min. Negotiated Rate	$10.63
Max. Negotiated Rate	$10.63
Rate for Payer: Aetna of AZ Commercial	$10.63
Rate for Payer: Cash Price	$9.45

.RMSF, IgG, IFA LC

Facility

$238.00

Service Code	CPT 86757
Hospital Charge Code	1285666
Hospital Revenue Code	302
Min. Negotiated Rate	$28.06
Max. Negotiated Rate	$214.20
Rate for Payer: Aetna of AZ Commercial	$214.20
Rate for Payer: Arizona Complete Health Allwell	$38.08
Rate for Payer: Banner UC Health Medicare	$38.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$161.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.08
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cash Price	$190.40
Rate for Payer: Cigna of AZ Commercial	$154.70
Rate for Payer: Devoted Health Medicare	$42.84
Rate for Payer: Humana of AZ Medicare	$38.08
Rate for Payer: Seven Corners Travel Insurance	$28.06
Rate for Payer: Southwest Service Administrators UFCW	$161.84
Rate for Payer: TriWest Medicare	$38.08
Rate for Payer: United Healthcare Commercial	$136.14
Rate for Payer: United Healthcare Medicare	$38.08
Rate for Payer: Veterans Affairs TRICARE	$37.70

.RMSF, IgG, IFA LC

Facility

$238.00

Service Code	CPT 86757
Hospital Charge Code	1285666
Hospital Revenue Code	302
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$214.20
Rate for Payer: Aetna of AZ Commercial	$214.20
Rate for Payer: Cash Price	$190.40

Rmve Drug implant

Facility

$681.00

Service Code	CPT 11976
Hospital Charge Code	24235385
Hospital Revenue Code	521
Min. Negotiated Rate	$55.79
Max. Negotiated Rate	$1,095.68
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 Health Choice	$55.79
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	$476.70
Rate for Payer: Devoted Health Medicare	$122.58
Rate for Payer: Humana of AZ Medicare	$108.96
Rate for Payer: Mercy Care Medicaid	$55.79
Rate for Payer: NaphCare Correctional Healthcare	$55.79
Rate for Payer: Seven Corners Travel Insurance	$1,095.68
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

Rmve Drug implant

Facility

$681.00

Service Code	CPT 11976
Hospital Charge Code	24235385
Hospital Revenue Code	521
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

RNA, PCR (NonGraph) rfx/Geno LC

Facility

$719.00

Service Code	CPT 87522
Hospital Charge Code	22311205
Hospital Revenue Code	306
Min. Negotiated Rate	$62.12
Max. Negotiated Rate	$647.10
Rate for Payer: Aetna of AZ Commercial	$647.10
Rate for Payer: Arizona Complete Health Allwell	$115.04
Rate for Payer: Banner UC Health Medicare	$115.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$488.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$115.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$115.04
Rate for Payer: Cash Price	$575.20
Rate for Payer: Cash Price	$575.20
Rate for Payer: Cigna of AZ Commercial	$467.35
Rate for Payer: Devoted Health Medicare	$129.42
Rate for Payer: Humana of AZ Medicare	$115.04
Rate for Payer: Seven Corners Travel Insurance	$62.12
Rate for Payer: Southwest Service Administrators UFCW	$488.92
Rate for Payer: TriWest Medicare	$115.04
Rate for Payer: United Healthcare Commercial	$411.27
Rate for Payer: United Healthcare Medicare	$115.04
Rate for Payer: Veterans Affairs TRICARE	$113.89

RNA, PCR (NonGraph) rfx/Geno LC

Facility

$719.00

Service Code	CPT 87522
Hospital Charge Code	22311205
Hospital Revenue Code	306
Min. Negotiated Rate	$647.10
Max. Negotiated Rate	$647.10
Rate for Payer: Aetna of AZ Commercial	$647.10
Rate for Payer: Cash Price	$575.20

RNA Real Time PCR (Non-Graph) LC

Facility

$1,058.00

Service Code	CPT 87536
Hospital Charge Code	6781926
Hospital Revenue Code	302
Min. Negotiated Rate	$123.39
Max. Negotiated Rate	$952.20
Rate for Payer: Aetna of AZ Commercial	$952.20
Rate for Payer: Arizona Complete Health Allwell	$169.28
Rate for Payer: Banner UC Health Medicare	$169.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$719.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$169.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$169.28
Rate for Payer: Cash Price	$846.40
Rate for Payer: Cash Price	$846.40
Rate for Payer: Cigna of AZ Commercial	$687.70
Rate for Payer: Devoted Health Medicare	$190.44
Rate for Payer: Humana of AZ Medicare	$169.28
Rate for Payer: Seven Corners Travel Insurance	$123.39
Rate for Payer: Southwest Service Administrators UFCW	$719.44
Rate for Payer: TriWest Medicare	$169.28
Rate for Payer: United Healthcare Commercial	$605.18
Rate for Payer: United Healthcare Medicare	$169.28
Rate for Payer: Veterans Affairs TRICARE	$167.59

RNA Real Time PCR (Non-Graph) LC

Facility

$1,058.00

Service Code	CPT 87536
Hospital Charge Code	6781926
Hospital Revenue Code	302
Min. Negotiated Rate	$952.20
Max. Negotiated Rate	$952.20
Rate for Payer: Aetna of AZ Commercial	$952.20
Rate for Payer: Cash Price	$846.40

Robotic colpopexy

Facility

$5,050.00

Service Code	CPT 57425
Hospital Charge Code	27281899
Hospital Revenue Code	360
Min. Negotiated Rate	$4,545.00
Max. Negotiated Rate	$4,545.00
Rate for Payer: Aetna of AZ Commercial	$4,545.00
Rate for Payer: Cash Price	$4,040.00

Robotic colpopexy

Facility

$5,050.00

Service Code	CPT 57425
Hospital Charge Code	27281899
Hospital Revenue Code	360
Min. Negotiated Rate	$799.92
Max. Negotiated Rate	$16,447.22
Rate for Payer: Aetna of AZ Commercial	$4,545.00
Rate for Payer: Arizona Complete Health Allwell	$808.00
Rate for Payer: Banner UC Health Medicare	$3,457.91
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,434.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$808.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$808.00
Rate for Payer: Cash Price	$4,040.00
Rate for Payer: Cash Price	$4,040.00
Rate for Payer: Cash Price	$4,040.00
Rate for Payer: Cigna of AZ Commercial	$2,525.00
Rate for Payer: Devoted Health Medicare	$909.00
Rate for Payer: Humana of AZ Medicare	$808.00
Rate for Payer: NaphCare Correctional Healthcare	$3,457.91
Rate for Payer: Seven Corners Travel Insurance	$16,447.22
Rate for Payer: Southwest Service Administrators UFCW	$3,434.00
Rate for Payer: TriWest Medicare	$808.00
Rate for Payer: United Healthcare Commercial	$6,508.00
Rate for Payer: United Healthcare Medicare	$808.00
Rate for Payer: Veterans Affairs TRICARE	$799.92

Know your out-of-pocket cost for care.

All Charges