Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Rubeola Antibodies, IgG LC

Facility

$219.00

Service Code	CPT 86765
Hospital Charge Code	22201672
Hospital Revenue Code	302
Min. Negotiated Rate	$197.10
Max. Negotiated Rate	$197.10
Rate for Payer: Aetna of AZ Commercial	$197.10
Rate for Payer: Cash Price	$175.20

Rubeola Antibodies, IgG LC

Facility

$219.00

Service Code	CPT 86765
Hospital Charge Code	22201672
Hospital Revenue Code	302
Min. Negotiated Rate	$18.68
Max. Negotiated Rate	$197.10
Rate for Payer: Aetna of AZ Commercial	$197.10
Rate for Payer: Arizona Complete Health Allwell	$35.04
Rate for Payer: Banner UC Health Medicare	$35.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$148.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$35.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$35.04
Rate for Payer: Cash Price	$175.20
Rate for Payer: Cash Price	$175.20
Rate for Payer: Cigna of AZ Commercial	$142.35
Rate for Payer: Devoted Health Medicare	$39.42
Rate for Payer: Humana of AZ Medicare	$35.04
Rate for Payer: Seven Corners Travel Insurance	$18.68
Rate for Payer: Southwest Service Administrators UFCW	$148.92
Rate for Payer: TriWest Medicare	$35.04
Rate for Payer: United Healthcare Commercial	$125.27
Rate for Payer: United Healthcare Medicare	$35.04
Rate for Payer: Veterans Affairs TRICARE	$34.69

RUBEOLA IGG

Facility

$230.00

Service Code	CPT 86765
Hospital Charge Code	22481503
Hospital Revenue Code	302
Min. Negotiated Rate	$207.00
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna of AZ Commercial	$207.00
Rate for Payer: Cash Price	$184.00

RUBEOLA IGG

Facility

$230.00

Service Code	CPT 86765
Hospital Charge Code	22481503
Hospital Revenue Code	302
Min. Negotiated Rate	$18.68
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna of AZ Commercial	$207.00
Rate for Payer: Arizona Complete Health Allwell	$36.80
Rate for Payer: Banner UC Health Medicare	$36.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$156.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.80
Rate for Payer: Cash Price	$184.00
Rate for Payer: Cash Price	$184.00
Rate for Payer: Cigna of AZ Commercial	$149.50
Rate for Payer: Devoted Health Medicare	$41.40
Rate for Payer: Humana of AZ Medicare	$36.80
Rate for Payer: Seven Corners Travel Insurance	$18.68
Rate for Payer: Southwest Service Administrators UFCW	$156.40
Rate for Payer: TriWest Medicare	$36.80
Rate for Payer: United Healthcare Commercial	$131.56
Rate for Payer: United Healthcare Medicare	$36.80
Rate for Payer: Veterans Affairs TRICARE	$36.43

Rubeola IgM LC

Facility

$242.00

Service Code	CPT 86765
Hospital Charge Code	6780983
Hospital Revenue Code	302
Min. Negotiated Rate	$217.80
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Cash Price	$193.60

Rubeola IgM LC

Facility

$242.00

Service Code	CPT 86765
Hospital Charge Code	6780983
Hospital Revenue Code	302
Min. Negotiated Rate	$18.68
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Arizona Complete Health Allwell	$38.72
Rate for Payer: Banner UC Health Medicare	$38.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$164.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.72
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cigna of AZ Commercial	$157.30
Rate for Payer: Devoted Health Medicare	$43.56
Rate for Payer: Humana of AZ Medicare	$38.72
Rate for Payer: Seven Corners Travel Insurance	$18.68
Rate for Payer: Southwest Service Administrators UFCW	$164.56
Rate for Payer: TriWest Medicare	$38.72
Rate for Payer: United Healthcare Commercial	$138.42
Rate for Payer: United Healthcare Medicare	$38.72
Rate for Payer: Veterans Affairs TRICARE	$38.33

Sacrospinous ligament fixaton

Facility

$3,595.00

Service Code	CPT 57282
Hospital Charge Code	27267823
Hospital Revenue Code	360
Min. Negotiated Rate	$3,235.50
Max. Negotiated Rate	$3,235.50
Rate for Payer: Aetna of AZ Commercial	$3,235.50
Rate for Payer: Cash Price	$2,876.00

Sacrospinous ligament fixaton

Facility

$3,595.00

Service Code	CPT 57282
Hospital Charge Code	27267823
Hospital Revenue Code	360
Min. Negotiated Rate	$569.45
Max. Negotiated Rate	$11,473.68
Rate for Payer: Aetna of AZ Commercial	$3,235.50
Rate for Payer: Arizona Complete Health Allwell	$575.20
Rate for Payer: Banner UC Health Medicare	$2,542.43
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,444.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$575.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$575.20
Rate for Payer: Cash Price	$2,876.00
Rate for Payer: Cash Price	$2,876.00
Rate for Payer: Cash Price	$2,876.00
Rate for Payer: Cigna of AZ Commercial	$1,797.50
Rate for Payer: Devoted Health Medicare	$647.10
Rate for Payer: Humana of AZ Medicare	$575.20
Rate for Payer: NaphCare Correctional Healthcare	$2,542.43
Rate for Payer: Seven Corners Travel Insurance	$11,473.68
Rate for Payer: Southwest Service Administrators UFCW	$2,444.60
Rate for Payer: TriWest Medicare	$575.20
Rate for Payer: United Healthcare Commercial	$5,611.00
Rate for Payer: United Healthcare Medicare	$575.20
Rate for Payer: Veterans Affairs TRICARE	$569.45

Salicylate Level

Facility

$180.00

Service Code	HCPCS G0480
Hospital Charge Code	633829
Hospital Revenue Code	301
Min. Negotiated Rate	$28.51
Max. Negotiated Rate	$165.92
Rate for Payer: Aetna of AZ Commercial	$162.00
Rate for Payer: Arizona Complete Health Allwell	$28.80
Rate for Payer: Banner UC Health Medicare	$28.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$122.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cigna of AZ Commercial	$117.00
Rate for Payer: Devoted Health Medicare	$32.40
Rate for Payer: Humana of AZ Medicare	$28.80
Rate for Payer: Seven Corners Travel Insurance	$165.92
Rate for Payer: Southwest Service Administrators UFCW	$122.40
Rate for Payer: TriWest Medicare	$28.80
Rate for Payer: United Healthcare Commercial	$102.96
Rate for Payer: United Healthcare Medicare	$28.80
Rate for Payer: Veterans Affairs TRICARE	$28.51

Salicylate Level

Facility

$180.00

Service Code	HCPCS G0480
Hospital Charge Code	633829
Hospital Revenue Code	301
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of AZ Commercial	$162.00
Rate for Payer: Cash Price	$144.00

SALINE FLUSH 10 ML

Facility

$4.00

Hospital Charge Code	22354289
Hospital Revenue Code	270
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of AZ Commercial	$3.60
Rate for Payer: Cash Price	$3.20

SALINE FLUSH 10 ML

Facility

$4.00

Hospital Charge Code	22354289
Hospital Revenue Code	270
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of AZ Commercial	$3.60
Rate for Payer: Arizona Complete Health Allwell	$0.64
Rate for Payer: Banner UC Health Medicare	$0.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.64
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cigna of AZ Commercial	$2.80
Rate for Payer: Devoted Health Medicare	$0.72
Rate for Payer: Humana of AZ Medicare	$0.64
Rate for Payer: Southwest Service Administrators UFCW	$2.72
Rate for Payer: TriWest Medicare	$0.64
Rate for Payer: United Healthcare Commercial	$2.29
Rate for Payer: United Healthcare Medicare	$0.64
Rate for Payer: Veterans Affairs TRICARE	$0.63

SALINE FLUSH 10 ML SYRINGE

Facility

$4.00

Hospital Charge Code	27569984
Hospital Revenue Code	270
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of AZ Commercial	$3.60
Rate for Payer: Arizona Complete Health Allwell	$0.64
Rate for Payer: Banner UC Health Medicare	$0.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.64
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cigna of AZ Commercial	$2.80
Rate for Payer: Devoted Health Medicare	$0.72
Rate for Payer: Humana of AZ Medicare	$0.64
Rate for Payer: Southwest Service Administrators UFCW	$2.72
Rate for Payer: TriWest Medicare	$0.64
Rate for Payer: United Healthcare Commercial	$2.29
Rate for Payer: United Healthcare Medicare	$0.64
Rate for Payer: Veterans Affairs TRICARE	$0.63

SALINE FLUSH 10 ML SYRINGE

Facility

$4.00

Hospital Charge Code	27569984
Hospital Revenue Code	270
Min. Negotiated Rate	$3.60
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of AZ Commercial	$3.60
Rate for Payer: Cash Price	$3.20

saline nasal moisturizing spray [CQCH]

Facility

$0.02

Service Code	NDC 49348035684
Hospital Charge Code	105942039
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Cash Price	$0.02

saline nasal moisturizing spray [CQCH]

Facility

$0.02

Service Code	NDC 49348035684
Hospital Charge Code	105942039
Hospital Revenue Code	251
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Arizona Complete Health Allwell	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.00
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Devoted Health Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Southwest Service Administrators UFCW	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: United Healthcare Commercial	$0.01
Rate for Payer: United Healthcare Medicare	$0.00
Rate for Payer: Veterans Affairs TRICARE	$0.00

SALIVARY GLAND PROCEDURES

Facility

$16,013.21

Service Code	MSDRG 139
Min. Negotiated Rate	$16,013.21
Max. Negotiated Rate	$16,013.21
Rate for Payer: Seven Corners Travel Insurance	$16,013.21

Salpingectomy complete/partial

Facility

$4,120.00

Service Code	CPT 58700
Hospital Charge Code	27281891
Hospital Revenue Code	360
Min. Negotiated Rate	$652.61
Max. Negotiated Rate	$4,838.00
Rate for Payer: Aetna of AZ Commercial	$3,708.00
Rate for Payer: Arizona Complete Health Allwell	$659.20
Rate for Payer: Banner UC Health Medicare	$659.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,801.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$659.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$659.20
Rate for Payer: Cash Price	$3,296.00
Rate for Payer: Cash Price	$3,296.00
Rate for Payer: Cigna of AZ Commercial	$2,060.00
Rate for Payer: Devoted Health Medicare	$741.60
Rate for Payer: Humana of AZ Medicare	$659.20
Rate for Payer: Southwest Service Administrators UFCW	$2,801.60
Rate for Payer: TriWest Medicare	$659.20
Rate for Payer: United Healthcare Commercial	$4,838.00
Rate for Payer: United Healthcare Medicare	$659.20
Rate for Payer: Veterans Affairs TRICARE	$652.61

Salpingectomy complete/partial

Facility

$4,120.00

Service Code	CPT 58700
Hospital Charge Code	27281891
Hospital Revenue Code	360
Min. Negotiated Rate	$3,708.00
Max. Negotiated Rate	$3,708.00
Rate for Payer: Aetna of AZ Commercial	$3,708.00
Rate for Payer: Cash Price	$3,296.00

SARS-CoV-2 (COVID-19) Ag/ Flu A andB

Facility

$125.00

Service Code	CPT 87811
Hospital Charge Code	24511665
Hospital Revenue Code	306
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$112.50
Rate for Payer: Aetna of AZ Commercial	$112.50
Rate for Payer: Arizona Complete Health Allwell	$20.00
Rate for Payer: Banner UC Health Medicare	$20.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$85.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.00
Rate for Payer: Cash Price	$100.00
Rate for Payer: Cash Price	$100.00
Rate for Payer: Cigna of AZ Commercial	$81.25
Rate for Payer: Devoted Health Medicare	$22.50
Rate for Payer: Humana of AZ Medicare	$20.00
Rate for Payer: Seven Corners Travel Insurance	$60.00
Rate for Payer: Southwest Service Administrators UFCW	$85.00
Rate for Payer: TriWest Medicare	$20.00
Rate for Payer: United Healthcare Commercial	$71.50
Rate for Payer: United Healthcare Medicare	$20.00
Rate for Payer: Veterans Affairs TRICARE	$19.80

SARS-CoV-2 (COVID-19) Ag/ Flu A andB

Facility

$125.00

Service Code	CPT 87811
Hospital Charge Code	24511665
Hospital Revenue Code	306
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Aetna of AZ Commercial	$112.50
Rate for Payer: Cash Price	$100.00

Schizophrenia

Facility

$4,006.40

Service Code	APR-DRG 7501
Hospital Charge Code	APRDRG7504
Min. Negotiated Rate	$4,006.40
Max. Negotiated Rate	$4,006.40
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$4,006.40
Rate for Payer: Mercy Care Medicaid	$4,006.40
Rate for Payer: NaphCare Correctional Healthcare	$4,006.40

Schizophrenia

Facility

$8,111.69

Service Code	APR-DRG 7503
Hospital Charge Code	APRDRG7504
Min. Negotiated Rate	$8,111.69
Max. Negotiated Rate	$8,111.69
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8,111.69
Rate for Payer: Mercy Care Medicaid	$8,111.69
Rate for Payer: NaphCare Correctional Healthcare	$8,111.69

Schizophrenia

Facility

$4,857.20

Service Code	APR-DRG 7502
Hospital Charge Code	APRDRG7504
Min. Negotiated Rate	$4,857.20
Max. Negotiated Rate	$4,857.20
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$4,857.20
Rate for Payer: Mercy Care Medicaid	$4,857.20
Rate for Payer: NaphCare Correctional Healthcare	$4,857.20

Schizophrenia

Facility

$4,857.20

Service Code	APR-DRG 7502
Hospital Charge Code	APRDRG7502
Min. Negotiated Rate	$4,857.20
Max. Negotiated Rate	$4,857.20
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$4,857.20
Rate for Payer: Mercy Care Medicaid	$4,857.20
Rate for Payer: NaphCare Correctional Healthcare	$4,857.20

Know your out-of-pocket cost for care.

All Charges