Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

SEROTONIN

Facility

$124.00

Service Code	CPT 84260
Hospital Charge Code	28010054
Hospital Revenue Code	302
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	$44.92
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

sertraline 50 mg Tab [CQCH]

Facility

$0.21

Service Code	NDC 60687024201
Hospital Charge Code	105940109
Hospital Revenue Code	251
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of AZ Commercial	$0.19
Rate for Payer: Cash Price	$0.17

sertraline 50 mg Tab [CQCH]

Facility

$0.21

Service Code	NDC 60687024201
Hospital Charge Code	105940109
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of AZ Commercial	$0.19
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	$0.17
Rate for Payer: Cigna of AZ Commercial	$0.14
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	$0.12
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

Services performed by qualified Physical Therapist in the ho

Facility

$215.00

Service Code	HCPCS G0151
Hospital Charge Code	27342346
Hospital Revenue Code	420
Min. Negotiated Rate	$193.50
Max. Negotiated Rate	$193.50
Rate for Payer: Aetna of AZ Commercial	$193.50
Rate for Payer: Cash Price	$172.00

Services performed by qualified Physical Therapist in the ho

Facility

$215.00

Service Code	HCPCS G0151
Hospital Charge Code	27342346
Hospital Revenue Code	420
Min. Negotiated Rate	$34.06
Max. Negotiated Rate	$193.50
Rate for Payer: Aetna of AZ Commercial	$193.50
Rate for Payer: Arizona Complete Health Allwell	$34.40
Rate for Payer: Banner UC Health Medicare	$34.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$146.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$34.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$34.40
Rate for Payer: Cash Price	$172.00
Rate for Payer: Cigna of AZ Commercial	$150.50
Rate for Payer: Devoted Health Medicare	$38.70
Rate for Payer: Humana of AZ Medicare	$34.40
Rate for Payer: Southwest Service Administrators UFCW	$146.20
Rate for Payer: TriWest Medicare	$34.40
Rate for Payer: United Healthcare Commercial	$122.98
Rate for Payer: United Healthcare Medicare	$34.40
Rate for Payer: United Healthcare New Mexico Commercial	$40.85
Rate for Payer: Veterans Affairs TRICARE	$34.06

Services provided by Occupational therapist in the home or h

Facility

$205.00

Service Code	HCPCS G0152
Hospital Charge Code	27377828
Hospital Revenue Code	420
Min. Negotiated Rate	$184.50
Max. Negotiated Rate	$184.50
Rate for Payer: Aetna of AZ Commercial	$184.50
Rate for Payer: Cash Price	$164.00

Services provided by Occupational therapist in the home or h

Facility

$205.00

Service Code	HCPCS G0152
Hospital Charge Code	27377828
Hospital Revenue Code	420
Min. Negotiated Rate	$32.47
Max. Negotiated Rate	$184.50
Rate for Payer: Aetna of AZ Commercial	$184.50
Rate for Payer: Arizona Complete Health Allwell	$32.80
Rate for Payer: Banner UC Health Medicare	$32.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$139.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.80
Rate for Payer: Cash Price	$164.00
Rate for Payer: Cigna of AZ Commercial	$143.50
Rate for Payer: Devoted Health Medicare	$36.90
Rate for Payer: Humana of AZ Medicare	$32.80
Rate for Payer: Southwest Service Administrators UFCW	$139.40
Rate for Payer: TriWest Medicare	$32.80
Rate for Payer: United Healthcare Commercial	$117.26
Rate for Payer: United Healthcare Medicare	$32.80
Rate for Payer: United Healthcare New Mexico Commercial	$38.95
Rate for Payer: Veterans Affairs TRICARE	$32.47

SESAMOIDECTOMY FIRST TOE (SEPARATE PROCEDURE)

Facility

$1,590.00

Service Code	CPT 28315
Hospital Charge Code	24043328
Hospital Revenue Code	360
Min. Negotiated Rate	$148.18
Max. Negotiated Rate	$5,062.66
Rate for Payer: Aetna of AZ Commercial	$1,431.00
Rate for Payer: Arizona Complete Health Allwell	$254.40
Rate for Payer: Banner UC Health Medicare	$1,062.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,081.20
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$148.18
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$254.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$254.40
Rate for Payer: Cash Price	$1,272.00
Rate for Payer: Cash Price	$1,272.00
Rate for Payer: Cash Price	$1,272.00
Rate for Payer: Cigna of AZ Commercial	$795.00
Rate for Payer: Devoted Health Medicare	$286.20
Rate for Payer: Humana of AZ Medicare	$254.40
Rate for Payer: Mercy Care Medicaid	$148.18
Rate for Payer: NaphCare Correctional Healthcare	$1,062.88
Rate for Payer: Seven Corners Travel Insurance	$5,062.66
Rate for Payer: Southwest Service Administrators UFCW	$1,081.20
Rate for Payer: TriWest Medicare	$254.40
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$254.40
Rate for Payer: Veterans Affairs TRICARE	$251.86

SESAMOIDECTOMY FIRST TOE (SEPARATE PROCEDURE)

Facility

$1,590.00

Service Code	CPT 28315
Hospital Charge Code	24043328
Hospital Revenue Code	360
Min. Negotiated Rate	$1,431.00
Max. Negotiated Rate	$1,431.00
Rate for Payer: Aetna of AZ Commercial	$1,431.00
Rate for Payer: Cash Price	$1,272.00

SET BLOOD Y-TYPE HOSPIRA LIFESHIELD

Facility

$101.00

Hospital Charge Code	22355308
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

SET BLOOD Y-TYPE HOSPIRA LIFESHIELD

Facility

$101.00

Hospital Charge Code	22355308
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

SET CATH RUTNER SUPRAPUBIC 16F COOK

Facility

$237.00

Hospital Charge Code	22354213
Hospital Revenue Code	270
Min. Negotiated Rate	$213.30
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Cash Price	$189.60

SET CATH RUTNER SUPRAPUBIC 16F COOK

Facility

$237.00

Hospital Charge Code	22354213
Hospital Revenue Code	270
Min. Negotiated Rate	$37.54
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Arizona Complete Health Allwell	$37.92
Rate for Payer: Banner UC Health Medicare	$37.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$161.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$37.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.92
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cigna of AZ Commercial	$165.90
Rate for Payer: Devoted Health Medicare	$42.66
Rate for Payer: Humana of AZ Medicare	$37.92
Rate for Payer: Southwest Service Administrators UFCW	$161.16
Rate for Payer: TriWest Medicare	$37.92
Rate for Payer: United Healthcare Commercial	$135.56
Rate for Payer: United Healthcare Medicare	$37.92
Rate for Payer: Veterans Affairs TRICARE	$37.54

SET CATH SUPRAPUBIC COOK

Facility

$272.00

Hospital Charge Code	22354225
Hospital Revenue Code	270
Min. Negotiated Rate	$43.08
Max. Negotiated Rate	$244.80
Rate for Payer: Aetna of AZ Commercial	$244.80
Rate for Payer: Arizona Complete Health Allwell	$43.52
Rate for Payer: Banner UC Health Medicare	$43.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$184.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$43.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.52
Rate for Payer: Cash Price	$217.60
Rate for Payer: Cigna of AZ Commercial	$190.40
Rate for Payer: Devoted Health Medicare	$48.96
Rate for Payer: Humana of AZ Medicare	$43.52
Rate for Payer: Southwest Service Administrators UFCW	$184.96
Rate for Payer: TriWest Medicare	$43.52
Rate for Payer: United Healthcare Commercial	$155.58
Rate for Payer: United Healthcare Medicare	$43.52
Rate for Payer: Veterans Affairs TRICARE	$43.08

SET CATH SUPRAPUBIC COOK

Facility

$272.00

Hospital Charge Code	22354225
Hospital Revenue Code	270
Min. Negotiated Rate	$244.80
Max. Negotiated Rate	$244.80
Rate for Payer: Aetna of AZ Commercial	$244.80
Rate for Payer: Cash Price	$217.60

SET CYSTO

Facility

$37.00

Hospital Charge Code	22355110
Hospital Revenue Code	270
Min. Negotiated Rate	$5.86
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Arizona Complete Health Allwell	$5.92
Rate for Payer: Banner UC Health Medicare	$5.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$25.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.92
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cigna of AZ Commercial	$25.90
Rate for Payer: Devoted Health Medicare	$6.66
Rate for Payer: Humana of AZ Medicare	$5.92
Rate for Payer: Southwest Service Administrators UFCW	$25.16
Rate for Payer: TriWest Medicare	$5.92
Rate for Payer: United Healthcare Commercial	$21.16
Rate for Payer: United Healthcare Medicare	$5.92
Rate for Payer: Veterans Affairs TRICARE	$5.86

SET CYSTO

Facility

$37.00

Hospital Charge Code	22355110
Hospital Revenue Code	270
Min. Negotiated Rate	$33.30
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Cash Price	$29.60

sevoflurane Inh (16 ml per 1/2 hour) [CQCH]

Facility

$0.26

Service Code	NDC 66794001525
Hospital Charge Code	105940176
Hospital Revenue Code	251
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of AZ Commercial	$0.23
Rate for Payer: Cash Price	$0.21

sevoflurane Inh (16 ml per 1/2 hour) [CQCH]

Facility

$0.26

Service Code	NDC 66794001525
Hospital Charge Code	105940176
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of AZ Commercial	$0.23
Rate for Payer: Arizona Complete Health Allwell	$0.04
Rate for Payer: Banner UC Health Medicare	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.18
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.04
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of AZ Commercial	$0.17
Rate for Payer: Devoted Health Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Southwest Service Administrators UFCW	$0.18
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: United Healthcare Commercial	$0.15
Rate for Payer: United Healthcare Medicare	$0.04
Rate for Payer: Veterans Affairs TRICARE	$0.04

Sex Hormone Binding Globulin LC

Facility

$271.00

Service Code	CPT 84270
Hospital Charge Code	2275527
Hospital Revenue Code	301
Min. Negotiated Rate	$31.51
Max. Negotiated Rate	$243.90
Rate for Payer: Aetna of AZ Commercial	$243.90
Rate for Payer: Arizona Complete Health Allwell	$43.36
Rate for Payer: Banner UC Health Medicare	$43.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$184.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$43.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.36
Rate for Payer: Cash Price	$216.80
Rate for Payer: Cash Price	$216.80
Rate for Payer: Cigna of AZ Commercial	$176.15
Rate for Payer: Devoted Health Medicare	$48.78
Rate for Payer: Humana of AZ Medicare	$43.36
Rate for Payer: Seven Corners Travel Insurance	$31.51
Rate for Payer: Southwest Service Administrators UFCW	$184.28
Rate for Payer: TriWest Medicare	$43.36
Rate for Payer: United Healthcare Commercial	$155.01
Rate for Payer: United Healthcare Medicare	$43.36
Rate for Payer: Veterans Affairs TRICARE	$42.93

Sex Hormone Binding Globulin LC

Facility

$271.00

Service Code	CPT 84270
Hospital Charge Code	2275527
Hospital Revenue Code	301
Min. Negotiated Rate	$243.90
Max. Negotiated Rate	$243.90
Rate for Payer: Aetna of AZ Commercial	$243.90
Rate for Payer: Cash Price	$216.80

Shave (Epi)Dermal Lesion, Single, Face/Ears/Eyelids/Nose/Lips/Mucous Memb; Diam

Facility

$274.00

Service Code	CPT 11311
Hospital Charge Code	713821
Hospital Revenue Code	521
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$310.43
Rate for Payer: Aetna of AZ Commercial	$246.60
Rate for Payer: Arizona Complete Health Allwell	$43.84
Rate for Payer: Banner UC Health Medicare	$43.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$186.32
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$78.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$43.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.84
Rate for Payer: Cash Price	$219.20
Rate for Payer: Cash Price	$219.20
Rate for Payer: Cigna of AZ Commercial	$191.80
Rate for Payer: Devoted Health Medicare	$49.32
Rate for Payer: Humana of AZ Medicare	$43.84
Rate for Payer: Mercy Care Medicaid	$78.32
Rate for Payer: NaphCare Correctional Healthcare	$78.32
Rate for Payer: Seven Corners Travel Insurance	$310.43
Rate for Payer: Southwest Service Administrators UFCW	$186.32
Rate for Payer: TriWest Medicare	$43.84
Rate for Payer: United Healthcare Commercial	$156.73
Rate for Payer: United Healthcare Medicare	$43.84
Rate for Payer: Veterans Affairs TRICARE	$43.40

Shave (Epi)Dermal Lesion, Single, Face/Ears/Eyelids/Nose/Lips/Mucous Memb; Diam

Facility

$274.00

Service Code	CPT 11311
Hospital Charge Code	713821
Hospital Revenue Code	521
Min. Negotiated Rate	$246.60
Max. Negotiated Rate	$246.60
Rate for Payer: Aetna of AZ Commercial	$246.60
Rate for Payer: Cash Price	$219.20

Shave (Epi)Dermal Lesion, Single, Face/Ears/Eyelids/Nose/Lips/Mucous Membrane; D

Facility

$224.00

Service Code	CPT 11310
Hospital Charge Code	713819
Hospital Revenue Code	521
Min. Negotiated Rate	$35.48
Max. Negotiated Rate	$310.43
Rate for Payer: Aetna of AZ Commercial	$201.60
Rate for Payer: Arizona Complete Health Allwell	$35.84
Rate for Payer: Banner UC Health Medicare	$35.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$152.32
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$74.03
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$35.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$35.84
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cigna of AZ Commercial	$156.80
Rate for Payer: Devoted Health Medicare	$40.32
Rate for Payer: Humana of AZ Medicare	$35.84
Rate for Payer: Mercy Care Medicaid	$74.03
Rate for Payer: NaphCare Correctional Healthcare	$74.03
Rate for Payer: Seven Corners Travel Insurance	$310.43
Rate for Payer: Southwest Service Administrators UFCW	$152.32
Rate for Payer: TriWest Medicare	$35.84
Rate for Payer: United Healthcare Commercial	$128.13
Rate for Payer: United Healthcare Medicare	$35.84
Rate for Payer: Veterans Affairs TRICARE	$35.48

Shave (Epi)Dermal Lesion, Single, Face/Ears/Eyelids/Nose/Lips/Mucous Membrane; D

Facility

$224.00

Service Code	CPT 11310
Hospital Charge Code	713819
Hospital Revenue Code	521
Min. Negotiated Rate	$201.60
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of AZ Commercial	$201.60
Rate for Payer: Cash Price	$179.20

Know your out-of-pocket cost for care.

All Charges