Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Sodium Level

Facility

$66.00

Service Code	CPT 84295
Hospital Charge Code	633611
Hospital Revenue Code	301
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of AZ Commercial	$59.40
Rate for Payer: Cash Price	$52.80

Sodium Level

Facility

$66.00

Service Code	CPT 84295
Hospital Charge Code	633611
Hospital Revenue Code	301
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of AZ Commercial	$59.40
Rate for Payer: Arizona Complete Health Allwell	$10.56
Rate for Payer: Banner UC Health Medicare	$10.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$44.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.56
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cigna of AZ Commercial	$42.90
Rate for Payer: Devoted Health Medicare	$11.88
Rate for Payer: Humana of AZ Medicare	$10.56
Rate for Payer: Seven Corners Travel Insurance	$6.97
Rate for Payer: Southwest Service Administrators UFCW	$44.88
Rate for Payer: TriWest Medicare	$10.56
Rate for Payer: United Healthcare Commercial	$37.75
Rate for Payer: United Healthcare Medicare	$10.56
Rate for Payer: Veterans Affairs TRICARE	$10.45

Sodium Level 24 Hour Urine

Facility

$84.00

Service Code	CPT 84300
Hospital Charge Code	633613
Hospital Revenue Code	301
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Cash Price	$67.20

Sodium Level 24 Hour Urine

Facility

$84.00

Service Code	CPT 84300
Hospital Charge Code	633613
Hospital Revenue Code	301
Min. Negotiated Rate	$7.34
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Arizona Complete Health Allwell	$13.44
Rate for Payer: Banner UC Health Medicare	$13.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$57.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.44
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cigna of AZ Commercial	$54.60
Rate for Payer: Devoted Health Medicare	$15.12
Rate for Payer: Humana of AZ Medicare	$13.44
Rate for Payer: Seven Corners Travel Insurance	$7.34
Rate for Payer: Southwest Service Administrators UFCW	$57.12
Rate for Payer: TriWest Medicare	$13.44
Rate for Payer: United Healthcare Commercial	$48.05
Rate for Payer: United Healthcare Medicare	$13.44
Rate for Payer: Veterans Affairs TRICARE	$13.31

Sodium Level Urine

Facility

$88.00

Service Code	CPT 84300
Hospital Charge Code	887730
Hospital Revenue Code	301
Min. Negotiated Rate	$7.34
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of AZ Commercial	$79.20
Rate for Payer: Arizona Complete Health Allwell	$14.08
Rate for Payer: Banner UC Health Medicare	$14.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$59.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.08
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cigna of AZ Commercial	$57.20
Rate for Payer: Devoted Health Medicare	$15.84
Rate for Payer: Humana of AZ Medicare	$14.08
Rate for Payer: Seven Corners Travel Insurance	$7.34
Rate for Payer: Southwest Service Administrators UFCW	$59.84
Rate for Payer: TriWest Medicare	$14.08
Rate for Payer: United Healthcare Commercial	$50.34
Rate for Payer: United Healthcare Medicare	$14.08
Rate for Payer: Veterans Affairs TRICARE	$13.94

Sodium Level Urine

Facility

$88.00

Service Code	CPT 84300
Hospital Charge Code	887730
Hospital Revenue Code	301
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of AZ Commercial	$79.20
Rate for Payer: Cash Price	$70.40

sodium polystyrene sulfonate - Pow[CQCH]

Facility

$0.78

Service Code	NDC 11534016615
Hospital Charge Code	143761878
Hospital Revenue Code	251
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$0.70
Rate for Payer: Aetna of AZ Commercial	$0.70
Rate for Payer: Cash Price	$0.62

sodium polystyrene sulfonate - Pow[CQCH]

Facility

$0.78

Service Code	NDC 11534016615
Hospital Charge Code	143761878
Hospital Revenue Code	251
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.70
Rate for Payer: Aetna of AZ Commercial	$0.70
Rate for Payer: Arizona Complete Health Allwell	$0.12
Rate for Payer: Banner UC Health Medicare	$0.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.53
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.12
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna of AZ Commercial	$0.51
Rate for Payer: Devoted Health Medicare	$0.14
Rate for Payer: Humana of AZ Medicare	$0.12
Rate for Payer: Southwest Service Administrators UFCW	$0.53
Rate for Payer: TriWest Medicare	$0.12
Rate for Payer: United Healthcare Commercial	$0.45
Rate for Payer: United Healthcare Medicare	$0.12
Rate for Payer: Veterans Affairs TRICARE	$0.12

SOFT TISSUE PROCEDURES WITH CC

Facility

$22,592.70

Service Code	MSDRG 501
Min. Negotiated Rate	$22,592.70
Max. Negotiated Rate	$22,592.70
Rate for Payer: Seven Corners Travel Insurance	$22,592.70

SOFT TISSUE PROCEDURES WITH MCC

Facility

$40,902.32

Service Code	MSDRG 500
Min. Negotiated Rate	$40,902.32
Max. Negotiated Rate	$40,902.32
Rate for Payer: Seven Corners Travel Insurance	$40,902.32

SOFT TISSUE PROCEDURES WITHOUT CC/MCC

Facility

$17,409.58

Service Code	MSDRG 502
Min. Negotiated Rate	$17,409.58
Max. Negotiated Rate	$17,409.58
Rate for Payer: Seven Corners Travel Insurance	$17,409.58

SOL IRRG D/W 500 BOTTLE

Facility

$30.00

Hospital Charge Code	22355366
Hospital Revenue Code	270
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Cash Price	$24.00

SOL IRRG D/W 500 BOTTLE

Facility

$30.00

Hospital Charge Code	22355366
Hospital Revenue Code	270
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Arizona Complete Health Allwell	$4.80
Rate for Payer: Banner UC Health Medicare	$4.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$20.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna of AZ Commercial	$21.00
Rate for Payer: Devoted Health Medicare	$5.40
Rate for Payer: Humana of AZ Medicare	$4.80
Rate for Payer: Southwest Service Administrators UFCW	$20.40
Rate for Payer: TriWest Medicare	$4.80
Rate for Payer: United Healthcare Commercial	$17.16
Rate for Payer: United Healthcare Medicare	$4.80
Rate for Payer: Veterans Affairs TRICARE	$4.75

SOL IRRIG 1000ML DW

Facility

$32.00

Hospital Charge Code	24154073
Hospital Revenue Code	270
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Cash Price	$25.60

SOL IRRIG 1000ML DW

Facility

$32.00

Hospital Charge Code	24154073
Hospital Revenue Code	270
Min. Negotiated Rate	$5.07
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Arizona Complete Health Allwell	$5.12
Rate for Payer: Banner UC Health Medicare	$5.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$21.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.12
Rate for Payer: Cash Price	$25.60
Rate for Payer: Cigna of AZ Commercial	$22.40
Rate for Payer: Devoted Health Medicare	$5.76
Rate for Payer: Humana of AZ Medicare	$5.12
Rate for Payer: Southwest Service Administrators UFCW	$21.76
Rate for Payer: TriWest Medicare	$5.12
Rate for Payer: United Healthcare Commercial	$18.30
Rate for Payer: United Healthcare Medicare	$5.12
Rate for Payer: Veterans Affairs TRICARE	$5.07

SOL IRRIG 3000ML DW

Facility

$72.00

Hospital Charge Code	24153497
Hospital Revenue Code	270
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

SOL IRRIG 3000ML DW

Facility

$72.00

Hospital Charge Code	24153497
Hospital Revenue Code	270
Min. Negotiated Rate	$11.40
Max. Negotiated Rate	$64.80
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: Cigna of AZ Commercial	$50.40
Rate for Payer: Devoted Health Medicare	$12.96
Rate for Payer: Humana of AZ Medicare	$11.52
Rate for Payer: Southwest Service Administrators UFCW	$48.96
Rate for Payer: TriWest Medicare	$11.52
Rate for Payer: United Healthcare Commercial	$41.18
Rate for Payer: United Healthcare Medicare	$11.52
Rate for Payer: Veterans Affairs TRICARE	$11.40

SOL IRRIG N/S 1000 BOTTLE

Facility

$30.00

Hospital Charge Code	22355109
Hospital Revenue Code	270
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Cash Price	$24.00

SOL IRRIG N/S 1000 BOTTLE

Facility

$30.00

Hospital Charge Code	27571817
Hospital Revenue Code	270
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Cash Price	$24.00

SOL IRRIG N/S 1000 BOTTLE

Facility

$30.00

Hospital Charge Code	22355109
Hospital Revenue Code	270
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Arizona Complete Health Allwell	$4.80
Rate for Payer: Banner UC Health Medicare	$4.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$20.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna of AZ Commercial	$21.00
Rate for Payer: Devoted Health Medicare	$5.40
Rate for Payer: Humana of AZ Medicare	$4.80
Rate for Payer: Southwest Service Administrators UFCW	$20.40
Rate for Payer: TriWest Medicare	$4.80
Rate for Payer: United Healthcare Commercial	$17.16
Rate for Payer: United Healthcare Medicare	$4.80
Rate for Payer: Veterans Affairs TRICARE	$4.75

SOL IRRIG N/S 1000 BOTTLE

Facility

$30.00

Hospital Charge Code	27571817
Hospital Revenue Code	270
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Arizona Complete Health Allwell	$4.80
Rate for Payer: Banner UC Health Medicare	$4.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$20.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna of AZ Commercial	$21.00
Rate for Payer: Devoted Health Medicare	$5.40
Rate for Payer: Humana of AZ Medicare	$4.80
Rate for Payer: Southwest Service Administrators UFCW	$20.40
Rate for Payer: TriWest Medicare	$4.80
Rate for Payer: United Healthcare Commercial	$17.16
Rate for Payer: United Healthcare Medicare	$4.80
Rate for Payer: Veterans Affairs TRICARE	$4.75

SOL IRRIG N/S 500 BOTTLE

Facility

$30.00

Hospital Charge Code	22355365
Hospital Revenue Code	270
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Arizona Complete Health Allwell	$4.80
Rate for Payer: Banner UC Health Medicare	$4.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$20.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna of AZ Commercial	$21.00
Rate for Payer: Devoted Health Medicare	$5.40
Rate for Payer: Humana of AZ Medicare	$4.80
Rate for Payer: Southwest Service Administrators UFCW	$20.40
Rate for Payer: TriWest Medicare	$4.80
Rate for Payer: United Healthcare Commercial	$17.16
Rate for Payer: United Healthcare Medicare	$4.80
Rate for Payer: Veterans Affairs TRICARE	$4.75

SOL IRRIG N/S 500 BOTTLE

Facility

$30.00

Hospital Charge Code	22355365
Hospital Revenue Code	270
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Cash Price	$24.00

SONESTA SEAT COVER

Facility

$29.28

Hospital Charge Code	27747577
Hospital Revenue Code	270
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$26.35
Rate for Payer: Aetna of AZ Commercial	$26.35
Rate for Payer: Cash Price	$23.42

SONESTA SEAT COVER

Facility

$29.28

Hospital Charge Code	27747577
Hospital Revenue Code	270
Min. Negotiated Rate	$4.64
Max. Negotiated Rate	$26.35
Rate for Payer: Aetna of AZ Commercial	$26.35
Rate for Payer: Arizona Complete Health Allwell	$4.68
Rate for Payer: Banner UC Health Medicare	$4.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$19.91
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.68
Rate for Payer: Cash Price	$23.42
Rate for Payer: Cigna of AZ Commercial	$20.50
Rate for Payer: Devoted Health Medicare	$5.27
Rate for Payer: Humana of AZ Medicare	$4.68
Rate for Payer: Southwest Service Administrators UFCW	$19.91
Rate for Payer: TriWest Medicare	$4.68
Rate for Payer: United Healthcare Commercial	$16.75
Rate for Payer: United Healthcare Medicare	$4.68
Rate for Payer: Veterans Affairs TRICARE	$4.64

Know your out-of-pocket cost for care.

All Charges