Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

simethicone 80 mg Chew Tab [CQCH]

Facility

$0.02

Service Code	NDC 904506860
Hospital Charge Code	105940475
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	$0.01
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

SIMPLE CHANGE OF BLADDER TUBE

Facility

$270.00

Service Code	CPT 51705
Hospital Charge Code	28070629
Hospital Revenue Code	360
Min. Negotiated Rate	$37.28
Max. Negotiated Rate	$2,671.00
Rate for Payer: Aetna of AZ Commercial	$243.00
Rate for Payer: Arizona Complete Health Allwell	$43.20
Rate for Payer: Banner UC Health Medicare	$37.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$183.60
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$46.02
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$43.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna of AZ Commercial	$135.00
Rate for Payer: Devoted Health Medicare	$48.60
Rate for Payer: Humana of AZ Medicare	$43.20
Rate for Payer: Mercy Care Medicaid	$46.02
Rate for Payer: NaphCare Correctional Healthcare	$37.28
Rate for Payer: Seven Corners Travel Insurance	$386.58
Rate for Payer: Southwest Service Administrators UFCW	$183.60
Rate for Payer: TriWest Medicare	$43.20
Rate for Payer: United Healthcare Commercial	$2,671.00
Rate for Payer: United Healthcare Medicare	$43.20
Rate for Payer: Veterans Affairs TRICARE	$42.77

SIMPLE CHANGE OF BLADDER TUBE

Facility

$270.00

Service Code	CPT 51705
Hospital Charge Code	28070629
Hospital Revenue Code	360
Min. Negotiated Rate	$243.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of AZ Commercial	$243.00
Rate for Payer: Cash Price	$216.00

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

$10,567.15

Service Code	MSDRG 194
Min. Negotiated Rate	$10,567.15
Max. Negotiated Rate	$10,567.15
Rate for Payer: Seven Corners Travel Insurance	$10,567.15

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

$17,010.43

Service Code	MSDRG 193
Min. Negotiated Rate	$17,010.43
Max. Negotiated Rate	$17,010.43
Rate for Payer: Seven Corners Travel Insurance	$17,010.43

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

$8,319.24

Service Code	MSDRG 195
Min. Negotiated Rate	$8,319.24
Max. Negotiated Rate	$8,319.24
Rate for Payer: Seven Corners Travel Insurance	$8,319.24

SIMPLE REMOVAL OF FOREIGN BODY, STONE, OR STENT IN URETHRA O

Facility

$781.00

Service Code	CPT 52310
Hospital Charge Code	27797697
Hospital Revenue Code	360
Min. Negotiated Rate	$123.71
Max. Negotiated Rate	$3,596.00
Rate for Payer: Aetna of AZ Commercial	$702.90
Rate for Payer: Arizona Complete Health Allwell	$124.96
Rate for Payer: Banner UC Health Medicare	$690.65
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$531.08
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$153.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$124.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$124.96
Rate for Payer: Cash Price	$624.80
Rate for Payer: Cash Price	$624.80
Rate for Payer: Cash Price	$624.80
Rate for Payer: Cigna of AZ Commercial	$390.50
Rate for Payer: Devoted Health Medicare	$140.58
Rate for Payer: Humana of AZ Medicare	$124.96
Rate for Payer: Mercy Care Medicaid	$153.76
Rate for Payer: NaphCare Correctional Healthcare	$690.65
Rate for Payer: Seven Corners Travel Insurance	$3,234.38
Rate for Payer: Southwest Service Administrators UFCW	$531.08
Rate for Payer: TriWest Medicare	$124.96
Rate for Payer: United Healthcare Commercial	$3,596.00
Rate for Payer: United Healthcare Medicare	$124.96
Rate for Payer: Veterans Affairs TRICARE	$123.71

SIMPLE REMOVAL OF FOREIGN BODY, STONE, OR STENT IN URETHRA O

Facility

$781.00

Service Code	CPT 52310
Hospital Charge Code	27797697
Hospital Revenue Code	360
Min. Negotiated Rate	$702.90
Max. Negotiated Rate	$702.90
Rate for Payer: Aetna of AZ Commercial	$702.90
Rate for Payer: Cash Price	$624.80

SIMPLE TIMED ASSESSMENT OF BLADDER EMPTYING Tech

Facility

$72.00

Service Code	CPT 51736
Hospital Charge Code	27925076
Hospital Revenue Code	360
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Cash Price	$57.60

SIMPLE TIMED ASSESSMENT OF BLADDER EMPTYING Tech

Facility

$72.00

Service Code	CPT 51736
Hospital Charge Code	27925076
Hospital Revenue Code	360
Min. Negotiated Rate	$11.40
Max. Negotiated Rate	$2,671.00
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Arizona Complete Health Allwell	$11.52
Rate for Payer: Banner UC Health Medicare	$11.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$48.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.52
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna of AZ Commercial	$36.00
Rate for Payer: Devoted Health Medicare	$12.96
Rate for Payer: Humana of AZ Medicare	$11.52
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$48.96
Rate for Payer: TriWest Medicare	$11.52
Rate for Payer: United Healthcare Commercial	$2,671.00
Rate for Payer: United Healthcare Medicare	$11.52
Rate for Payer: Veterans Affairs TRICARE	$11.40

Simple vulvectomy complete

Facility

$3,420.00

Service Code	CPT 56625
Hospital Charge Code	27267830
Hospital Revenue Code	360
Min. Negotiated Rate	$541.73
Max. Negotiated Rate	$5,008.71
Rate for Payer: Aetna of AZ Commercial	$3,078.00
Rate for Payer: Arizona Complete Health Allwell	$547.20
Rate for Payer: Banner UC Health Medicare	$1,051.19
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,325.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$547.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$547.20
Rate for Payer: Cash Price	$2,736.00
Rate for Payer: Cash Price	$2,736.00
Rate for Payer: Cash Price	$2,736.00
Rate for Payer: Cigna of AZ Commercial	$1,710.00
Rate for Payer: Devoted Health Medicare	$615.60
Rate for Payer: Humana of AZ Medicare	$547.20
Rate for Payer: NaphCare Correctional Healthcare	$1,051.19
Rate for Payer: Seven Corners Travel Insurance	$5,008.71
Rate for Payer: Southwest Service Administrators UFCW	$2,325.60
Rate for Payer: TriWest Medicare	$547.20
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$547.20
Rate for Payer: Veterans Affairs TRICARE	$541.73

Simple vulvectomy complete

Facility

$3,420.00

Service Code	CPT 56625
Hospital Charge Code	27267830
Hospital Revenue Code	360
Min. Negotiated Rate	$3,078.00
Max. Negotiated Rate	$3,078.00
Rate for Payer: Aetna of AZ Commercial	$3,078.00
Rate for Payer: Cash Price	$2,736.00

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT

Facility

$72,434.63

Service Code	MSDRG 008
Min. Negotiated Rate	$72,434.63
Max. Negotiated Rate	$72,434.63
Rate for Payer: Seven Corners Travel Insurance	$72,434.63

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS

Facility

$92,208.57

Service Code	MSDRG 019
Min. Negotiated Rate	$92,208.57
Max. Negotiated Rate	$92,208.57
Rate for Payer: Seven Corners Travel Insurance	$92,208.57

simvastatin 20 mg Tab [CQCH]

Facility

$0.24

Service Code	NDC 68084051201
Hospital Charge Code	105940605
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of AZ Commercial	$0.22
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	$0.16
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	$0.19
Rate for Payer: Cigna of AZ Commercial	$0.16
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Southwest Service Administrators UFCW	$0.16
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: United Healthcare Commercial	$0.14
Rate for Payer: United Healthcare Medicare	$0.04
Rate for Payer: Veterans Affairs TRICARE	$0.04

simvastatin 20 mg Tab [CQCH]

Facility

$0.24

Service Code	NDC 68084051201
Hospital Charge Code	105940605
Hospital Revenue Code	251
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of AZ Commercial	$0.22
Rate for Payer: Cash Price	$0.19

SINGLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL

Facility

$51,961.49

Service Code	MSDRG 402
Min. Negotiated Rate	$51,961.49
Max. Negotiated Rate	$51,961.49
Rate for Payer: Seven Corners Travel Insurance	$51,961.49

SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$68,880.51

Service Code	MSDRG 450
Min. Negotiated Rate	$68,880.51
Max. Negotiated Rate	$68,880.51
Rate for Payer: Seven Corners Travel Insurance	$68,880.51

SINGLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$41,750.15

Service Code	MSDRG 451
Min. Negotiated Rate	$41,750.15
Max. Negotiated Rate	$41,750.15
Rate for Payer: Seven Corners Travel Insurance	$41,750.15

SINGLE USE BITE BLOCK

Facility

$8.00

Hospital Charge Code	22355557
Hospital Revenue Code	270
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Cash Price	$6.40

SINGLE USE BITE BLOCK

Facility

$8.00

Hospital Charge Code	22355557
Hospital Revenue Code	270
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Arizona Complete Health Allwell	$1.28
Rate for Payer: Banner UC Health Medicare	$1.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.28
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cigna of AZ Commercial	$5.60
Rate for Payer: Devoted Health Medicare	$1.44
Rate for Payer: Humana of AZ Medicare	$1.28
Rate for Payer: Southwest Service Administrators UFCW	$5.44
Rate for Payer: TriWest Medicare	$1.28
Rate for Payer: United Healthcare Commercial	$4.58
Rate for Payer: United Healthcare Medicare	$1.28
Rate for Payer: Veterans Affairs TRICARE	$1.27

SINUS AND MASTOID PROCEDURES WITH CC/MCC

Facility

$28,045.39

Service Code	MSDRG 135
Min. Negotiated Rate	$28,045.39
Max. Negotiated Rate	$28,045.39
Rate for Payer: Seven Corners Travel Insurance	$28,045.39

SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC

Facility

$13,220.49

Service Code	MSDRG 136
Min. Negotiated Rate	$13,220.49
Max. Negotiated Rate	$13,220.49
Rate for Payer: Seven Corners Travel Insurance	$13,220.49

SIROLIMUS (RAPAMUNE)

Facility

$331.00

Service Code	CPT 80195
Hospital Charge Code	23603249
Hospital Revenue Code	301
Min. Negotiated Rate	$297.90
Max. Negotiated Rate	$297.90
Rate for Payer: Aetna of AZ Commercial	$297.90
Rate for Payer: Cash Price	$264.80

SIROLIMUS (RAPAMUNE)

Facility

$331.00

Service Code	CPT 80195
Hospital Charge Code	23603249
Hospital Revenue Code	301
Min. Negotiated Rate	$19.91
Max. Negotiated Rate	$297.90
Rate for Payer: Aetna of AZ Commercial	$297.90
Rate for Payer: Arizona Complete Health Allwell	$52.96
Rate for Payer: Banner UC Health Medicare	$52.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$225.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$52.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$52.96
Rate for Payer: Cash Price	$264.80
Rate for Payer: Cash Price	$264.80
Rate for Payer: Cigna of AZ Commercial	$215.15
Rate for Payer: Devoted Health Medicare	$59.58
Rate for Payer: Humana of AZ Medicare	$52.96
Rate for Payer: Seven Corners Travel Insurance	$19.91
Rate for Payer: Southwest Service Administrators UFCW	$225.08
Rate for Payer: TriWest Medicare	$52.96
Rate for Payer: United Healthcare Commercial	$189.33
Rate for Payer: United Healthcare Medicare	$52.96
Rate for Payer: Veterans Affairs TRICARE	$52.43

Know your out-of-pocket cost for care.

All Charges