Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTIO

Facility

$355.00

Service Code	CPT 44361
Hospital Charge Code	22921046
Min. Negotiated Rate	$319.50
Max. Negotiated Rate	$319.50
Rate for Payer: Aetna of AZ Commercial	$319.50
Rate for Payer: Cash Price	$284.00

SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTIO

Facility

$355.00

Service Code	CPT 44361
Hospital Charge Code	22921046
Min. Negotiated Rate	$56.23
Max. Negotiated Rate	$2,969.06
Rate for Payer: Aetna of AZ Commercial	$319.50
Rate for Payer: Arizona Complete Health Allwell	$56.80
Rate for Payer: Banner UC Health Medicare	$56.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$241.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$56.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$56.80
Rate for Payer: Cash Price	$284.00
Rate for Payer: Cash Price	$284.00
Rate for Payer: Cigna of AZ Commercial	$248.50
Rate for Payer: Devoted Health Medicare	$63.90
Rate for Payer: Humana of AZ Medicare	$56.80
Rate for Payer: Seven Corners Travel Insurance	$2,969.06
Rate for Payer: Southwest Service Administrators UFCW	$241.40
Rate for Payer: TriWest Medicare	$56.80
Rate for Payer: United Healthcare Commercial	$203.06
Rate for Payer: United Healthcare Medicare	$56.80
Rate for Payer: Veterans Affairs TRICARE	$56.23

SMART TOE 2 IMPLANT 15MM

Facility

$11,965.00

Hospital Charge Code	27519891
Hospital Revenue Code	270
Min. Negotiated Rate	$10,768.50
Max. Negotiated Rate	$10,768.50
Rate for Payer: Aetna of AZ Commercial	$10,768.50
Rate for Payer: Cash Price	$9,572.00

SMART TOE 2 IMPLANT 15MM

Facility

$11,965.00

Hospital Charge Code	27519891
Hospital Revenue Code	270
Min. Negotiated Rate	$1,895.26
Max. Negotiated Rate	$10,768.50
Rate for Payer: Aetna of AZ Commercial	$10,768.50
Rate for Payer: Arizona Complete Health Allwell	$1,914.40
Rate for Payer: Banner UC Health Medicare	$1,914.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$8,136.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,914.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,914.40
Rate for Payer: Cash Price	$9,572.00
Rate for Payer: Cigna of AZ Commercial	$8,375.50
Rate for Payer: Devoted Health Medicare	$2,153.70
Rate for Payer: Humana of AZ Medicare	$1,914.40
Rate for Payer: Southwest Service Administrators UFCW	$8,136.20
Rate for Payer: TriWest Medicare	$1,914.40
Rate for Payer: United Healthcare Commercial	$6,843.98
Rate for Payer: United Healthcare Medicare	$1,914.40
Rate for Payer: Veterans Affairs TRICARE	$1,895.26

SMOKING CESSATION OVER 10 MIN

Facility

$54.00

Service Code	CPT 99406
Hospital Charge Code	853513
Hospital Revenue Code	942
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$57.97
Rate for Payer: Aetna of AZ Commercial	$48.60
Rate for Payer: Arizona Complete Health Allwell	$8.64
Rate for Payer: Banner UC Health Medicare	$8.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$36.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.64
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna of AZ Commercial	$37.80
Rate for Payer: Devoted Health Medicare	$9.72
Rate for Payer: Humana of AZ Medicare	$8.64
Rate for Payer: Seven Corners Travel Insurance	$57.97
Rate for Payer: Southwest Service Administrators UFCW	$36.72
Rate for Payer: TriWest Medicare	$8.64
Rate for Payer: United Healthcare Commercial	$30.89
Rate for Payer: United Healthcare Medicare	$8.64
Rate for Payer: United Healthcare New Mexico Commercial	$10.26
Rate for Payer: Veterans Affairs TRICARE	$8.55

SMOKING CESSATION OVER 10 MIN

Facility

$54.00

Service Code	CPT 99406
Hospital Charge Code	853513
Hospital Revenue Code	942
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$48.60
Rate for Payer: Aetna of AZ Commercial	$48.60
Rate for Payer: Cash Price	$43.20

SNAP CARTRIDGE 125 MM

Facility

$671.00

Hospital Charge Code	22355019
Hospital Revenue Code	270
Min. Negotiated Rate	$106.29
Max. Negotiated Rate	$603.90
Rate for Payer: Aetna of AZ Commercial	$603.90
Rate for Payer: Arizona Complete Health Allwell	$107.36
Rate for Payer: Banner UC Health Medicare	$107.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$456.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$107.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$107.36
Rate for Payer: Cash Price	$536.80
Rate for Payer: Cigna of AZ Commercial	$469.70
Rate for Payer: Devoted Health Medicare	$120.78
Rate for Payer: Humana of AZ Medicare	$107.36
Rate for Payer: Southwest Service Administrators UFCW	$456.28
Rate for Payer: TriWest Medicare	$107.36
Rate for Payer: United Healthcare Commercial	$383.81
Rate for Payer: United Healthcare Medicare	$107.36
Rate for Payer: Veterans Affairs TRICARE	$106.29

SNAP CARTRIDGE 125 MM

Facility

$671.00

Hospital Charge Code	22355019
Hospital Revenue Code	270
Min. Negotiated Rate	$603.90
Max. Negotiated Rate	$603.90
Rate for Payer: Aetna of AZ Commercial	$603.90
Rate for Payer: Cash Price	$536.80

SNAP DRESSING KIT W FOAM 10X10

Facility

$210.00

Hospital Charge Code	22355018
Hospital Revenue Code	270
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Cash Price	$168.00

SNAP DRESSING KIT W FOAM 10X10

Facility

$210.00

Hospital Charge Code	22355018
Hospital Revenue Code	270
Min. Negotiated Rate	$33.26
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Arizona Complete Health Allwell	$33.60
Rate for Payer: Banner UC Health Medicare	$33.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$142.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$33.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$33.60
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cigna of AZ Commercial	$147.00
Rate for Payer: Devoted Health Medicare	$37.80
Rate for Payer: Humana of AZ Medicare	$33.60
Rate for Payer: Southwest Service Administrators UFCW	$142.80
Rate for Payer: TriWest Medicare	$33.60
Rate for Payer: United Healthcare Commercial	$120.12
Rate for Payer: United Healthcare Medicare	$33.60
Rate for Payer: Veterans Affairs TRICARE	$33.26

SNARE MASTER PLUS 15MM

Facility

$78.75

Hospital Charge Code	28141426
Hospital Revenue Code	270
Min. Negotiated Rate	$70.88
Max. Negotiated Rate	$70.88
Rate for Payer: Aetna of AZ Commercial	$70.88
Rate for Payer: Cash Price	$63.00

SNARE MASTER PLUS 15MM

Facility

$78.75

Hospital Charge Code	28141426
Hospital Revenue Code	270
Min. Negotiated Rate	$12.47
Max. Negotiated Rate	$70.88
Rate for Payer: Aetna of AZ Commercial	$70.88
Rate for Payer: Arizona Complete Health Allwell	$12.60
Rate for Payer: Banner UC Health Medicare	$12.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$53.55
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.60
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna of AZ Commercial	$55.12
Rate for Payer: Devoted Health Medicare	$14.18
Rate for Payer: Humana of AZ Medicare	$12.60
Rate for Payer: Southwest Service Administrators UFCW	$53.55
Rate for Payer: TriWest Medicare	$12.60
Rate for Payer: United Healthcare Commercial	$45.05
Rate for Payer: United Healthcare Medicare	$12.60
Rate for Payer: Veterans Affairs TRICARE	$12.47

SNARE OVAL FLEXIBLE MEDIUM

Facility

$121.00

Hospital Charge Code	23589498
Hospital Revenue Code	272
Min. Negotiated Rate	$19.17
Max. Negotiated Rate	$108.90
Rate for Payer: Aetna of AZ Commercial	$108.90
Rate for Payer: Arizona Complete Health Allwell	$19.36
Rate for Payer: Banner UC Health Medicare	$19.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$82.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$19.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$19.36
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cigna of AZ Commercial	$84.70
Rate for Payer: Devoted Health Medicare	$21.78
Rate for Payer: Humana of AZ Medicare	$19.36
Rate for Payer: Southwest Service Administrators UFCW	$82.28
Rate for Payer: TriWest Medicare	$19.36
Rate for Payer: United Healthcare Commercial	$69.21
Rate for Payer: United Healthcare Medicare	$19.36
Rate for Payer: Veterans Affairs TRICARE	$19.17

SNARE OVAL FLEXIBLE MEDIUM

Facility

$121.00

Hospital Charge Code	23589498
Hospital Revenue Code	272
Min. Negotiated Rate	$108.90
Max. Negotiated Rate	$108.90
Rate for Payer: Aetna of AZ Commercial	$108.90
Rate for Payer: Cash Price	$96.80

SNARE OVAL FLEX MEDIUM

Facility

$1,247.00

Hospital Charge Code	22354316
Hospital Revenue Code	270
Min. Negotiated Rate	$197.52
Max. Negotiated Rate	$1,122.30
Rate for Payer: Aetna of AZ Commercial	$1,122.30
Rate for Payer: Arizona Complete Health Allwell	$199.52
Rate for Payer: Banner UC Health Medicare	$199.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$847.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$199.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$199.52
Rate for Payer: Cash Price	$997.60
Rate for Payer: Cigna of AZ Commercial	$872.90
Rate for Payer: Devoted Health Medicare	$224.46
Rate for Payer: Humana of AZ Medicare	$199.52
Rate for Payer: Southwest Service Administrators UFCW	$847.96
Rate for Payer: TriWest Medicare	$199.52
Rate for Payer: United Healthcare Commercial	$713.28
Rate for Payer: United Healthcare Medicare	$199.52
Rate for Payer: Veterans Affairs TRICARE	$197.52

SNARE OVAL FLEX MEDIUM

Facility

$1,247.00

Hospital Charge Code	22354316
Hospital Revenue Code	270
Min. Negotiated Rate	$1,122.30
Max. Negotiated Rate	$1,122.30
Rate for Payer: Aetna of AZ Commercial	$1,122.30
Rate for Payer: Cash Price	$997.60

SNARE POLYPECTOMY SML OVAL CONMED

Facility

$1,567.00

Hospital Charge Code	22354206
Hospital Revenue Code	270
Min. Negotiated Rate	$1,410.30
Max. Negotiated Rate	$1,410.30
Rate for Payer: Aetna of AZ Commercial	$1,410.30
Rate for Payer: Cash Price	$1,253.60

SNARE POLYPECTOMY SML OVAL CONMED

Facility

$1,567.00

Hospital Charge Code	22354206
Hospital Revenue Code	270
Min. Negotiated Rate	$248.21
Max. Negotiated Rate	$1,410.30
Rate for Payer: Aetna of AZ Commercial	$1,410.30
Rate for Payer: Arizona Complete Health Allwell	$250.72
Rate for Payer: Banner UC Health Medicare	$250.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,065.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$250.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$250.72
Rate for Payer: Cash Price	$1,253.60
Rate for Payer: Cigna of AZ Commercial	$1,096.90
Rate for Payer: Devoted Health Medicare	$282.06
Rate for Payer: Humana of AZ Medicare	$250.72
Rate for Payer: Southwest Service Administrators UFCW	$1,065.56
Rate for Payer: TriWest Medicare	$250.72
Rate for Payer: United Healthcare Commercial	$896.32
Rate for Payer: United Healthcare Medicare	$250.72
Rate for Payer: Veterans Affairs TRICARE	$248.21

sodium bicarbonate 4.2% (infant PFS)IV 10 mL [CQCH]

Facility

$0.84

Service Code	NDC 409553434
Hospital Charge Code	105940804
Hospital Revenue Code	251
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.76
Rate for Payer: Aetna of AZ Commercial	$0.76
Rate for Payer: Arizona Complete Health Allwell	$0.13
Rate for Payer: Banner UC Health Medicare	$0.13
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.57
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.13
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.13
Rate for Payer: Cash Price	$0.67
Rate for Payer: Cigna of AZ Commercial	$0.55
Rate for Payer: Devoted Health Medicare	$0.15
Rate for Payer: Humana of AZ Medicare	$0.13
Rate for Payer: Southwest Service Administrators UFCW	$0.57
Rate for Payer: TriWest Medicare	$0.13
Rate for Payer: United Healthcare Commercial	$0.48
Rate for Payer: United Healthcare Medicare	$0.13
Rate for Payer: Veterans Affairs TRICARE	$0.13

sodium bicarbonate 4.2% (infant PFS)IV 10 mL [CQCH]

Facility

$0.84

Service Code	NDC 409553434
Hospital Charge Code	105940804
Hospital Revenue Code	251
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$0.76
Rate for Payer: Aetna of AZ Commercial	$0.76
Rate for Payer: Cash Price	$0.67

sodium bicarbonate 4% Soln 5 mL [CQCH]

Facility

$1.24

Service Code	NDC 409660902
Hospital Charge Code	111111011
Hospital Revenue Code	250
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of AZ Commercial	$1.12
Rate for Payer: Cash Price	$0.99

sodium bicarbonate 4% Soln 5 mL [CQCH]

Facility

$1.24

Service Code	NDC 409660902
Hospital Charge Code	111111011
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of AZ Commercial	$1.12
Rate for Payer: Arizona Complete Health Allwell	$0.20
Rate for Payer: Banner UC Health Medicare	$0.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.20
Rate for Payer: Cash Price	$0.99
Rate for Payer: Cigna of AZ Commercial	$0.81
Rate for Payer: Devoted Health Medicare	$0.22
Rate for Payer: Humana of AZ Medicare	$0.20
Rate for Payer: Southwest Service Administrators UFCW	$0.84
Rate for Payer: TriWest Medicare	$0.20
Rate for Payer: United Healthcare Commercial	$0.71
Rate for Payer: United Healthcare Medicare	$0.20
Rate for Payer: Veterans Affairs TRICARE	$0.20

sodium bicarbonate 650 mg Tab [CQCH]

Facility

$0.02

Service Code	NDC 536454410
Hospital Charge Code	105940670
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

sodium bicarbonate 650 mg Tab [CQCH]

Facility

$0.02

Service Code	NDC 536454410
Hospital Charge Code	105940670
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	$0.01

sodium bicarbonate 8.4% IV Sol (50 mL PFS) [CQCH]

Facility

$0.17

Service Code	NDC 409663734
Hospital Charge Code	105940871
Hospital Revenue Code	251
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
Rate for Payer: Cash Price	$0.14

Know your out-of-pocket cost for care.

All Charges