Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

AUX WATER CHANNEL ADAPTER

Facility

$26.00

Hospital Charge Code	23640517
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna of AZ Commercial	$23.40
Rate for Payer: Cash Price	$20.80

Avulsion of Nail Plate, Partial or Complete, Simple; each Addtl Nail PlateCharge

Facility

$120.00

Service Code	CPT 11732
Hospital Charge Code	729131
Hospital Revenue Code	521
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Cash Price	$96.00

Avulsion of Nail Plate, Partial or Complete, Simple; each Addtl Nail PlateCharge

Facility

$120.00

Service Code	CPT 11732
Hospital Charge Code	729131
Hospital Revenue Code	521
Min. Negotiated Rate	$17.17
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Arizona Complete Health Allwell	$19.20
Rate for Payer: Banner UC Health Medicare	$19.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$81.60
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$17.17
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$19.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$19.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cigna of AZ Commercial	$84.00
Rate for Payer: Devoted Health Medicare	$21.60
Rate for Payer: Humana of AZ Medicare	$19.20
Rate for Payer: Mercy Care Medicaid	$17.17
Rate for Payer: NaphCare Correctional Healthcare	$17.17
Rate for Payer: Southwest Service Administrators UFCW	$81.60
Rate for Payer: TriWest Medicare	$19.20
Rate for Payer: United Healthcare Commercial	$68.64
Rate for Payer: United Healthcare Medicare	$19.20
Rate for Payer: Veterans Affairs TRICARE	$19.01

Avulsion of Nail Plate, Partial or Complete, Simple; Single Charge

Facility

$301.00

Service Code	CPT 11730
Hospital Charge Code	729129
Hospital Revenue Code	521
Min. Negotiated Rate	$47.68
Max. Negotiated Rate	$310.43
Rate for Payer: Aetna of AZ Commercial	$270.90
Rate for Payer: Arizona Complete Health Allwell	$48.16
Rate for Payer: Banner UC Health Medicare	$48.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$204.68
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$64.73
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$48.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$48.16
Rate for Payer: Cash Price	$240.80
Rate for Payer: Cash Price	$240.80
Rate for Payer: Cigna of AZ Commercial	$210.70
Rate for Payer: Devoted Health Medicare	$54.18
Rate for Payer: Humana of AZ Medicare	$48.16
Rate for Payer: Mercy Care Medicaid	$64.73
Rate for Payer: NaphCare Correctional Healthcare	$64.73
Rate for Payer: Seven Corners Travel Insurance	$310.43
Rate for Payer: Southwest Service Administrators UFCW	$204.68
Rate for Payer: TriWest Medicare	$48.16
Rate for Payer: United Healthcare Commercial	$172.17
Rate for Payer: United Healthcare Medicare	$48.16
Rate for Payer: Veterans Affairs TRICARE	$47.68

Avulsion of Nail Plate, Partial or Complete, Simple; Single Charge

Facility

$301.00

Service Code	CPT 11730
Hospital Charge Code	729129
Hospital Revenue Code	521
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$270.90
Rate for Payer: Aetna of AZ Commercial	$270.90
Rate for Payer: Cash Price	$240.80

AXIOFILL 500MG

Facility

$9,288.00

Hospital Charge Code	27469180
Hospital Revenue Code	270
Min. Negotiated Rate	$8,359.20
Max. Negotiated Rate	$8,359.20
Rate for Payer: Aetna of AZ Commercial	$8,359.20
Rate for Payer: Cash Price	$7,430.40

AXIOFILL 500MG

Facility

$9,288.00

Hospital Charge Code	27469180
Hospital Revenue Code	270
Min. Negotiated Rate	$1,471.22
Max. Negotiated Rate	$8,359.20
Rate for Payer: Aetna of AZ Commercial	$8,359.20
Rate for Payer: Arizona Complete Health Allwell	$1,486.08
Rate for Payer: Banner UC Health Medicare	$1,486.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$6,315.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,486.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,486.08
Rate for Payer: Cash Price	$7,430.40
Rate for Payer: Cigna of AZ Commercial	$6,501.60
Rate for Payer: Devoted Health Medicare	$1,671.84
Rate for Payer: Humana of AZ Medicare	$1,486.08
Rate for Payer: Southwest Service Administrators UFCW	$6,315.84
Rate for Payer: TriWest Medicare	$1,486.08
Rate for Payer: United Healthcare Commercial	$5,312.74
Rate for Payer: United Healthcare Medicare	$1,486.08
Rate for Payer: Veterans Affairs TRICARE	$1,471.22

AXIS DERMIS 6CM X 12CM

Facility

$13,145.00

Hospital Charge Code	27540060
Hospital Revenue Code	270
Min. Negotiated Rate	$11,830.50
Max. Negotiated Rate	$11,830.50
Rate for Payer: Aetna of AZ Commercial	$11,830.50
Rate for Payer: Cash Price	$10,516.00

AXIS DERMIS 6CM X 12CM

Facility

$13,145.00

Hospital Charge Code	27540060
Hospital Revenue Code	270
Min. Negotiated Rate	$2,082.17
Max. Negotiated Rate	$11,830.50
Rate for Payer: Aetna of AZ Commercial	$11,830.50
Rate for Payer: Arizona Complete Health Allwell	$2,103.20
Rate for Payer: Banner UC Health Medicare	$2,103.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$8,938.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2,103.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$2,103.20
Rate for Payer: Cash Price	$10,516.00
Rate for Payer: Cigna of AZ Commercial	$9,201.50
Rate for Payer: Devoted Health Medicare	$2,366.10
Rate for Payer: Humana of AZ Medicare	$2,103.20
Rate for Payer: Southwest Service Administrators UFCW	$8,938.60
Rate for Payer: TriWest Medicare	$2,103.20
Rate for Payer: United Healthcare Commercial	$7,518.94
Rate for Payer: United Healthcare Medicare	$2,103.20
Rate for Payer: Veterans Affairs TRICARE	$2,082.17

azithromycin 200 mg/5 mL Oral Susp (22.5mL after reconst) [CQCH]

Facility

$1.15

Service Code	HCPCS Q0144
Hospital Charge Code	105947029
Hospital Revenue Code	251
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$1.03
Rate for Payer: Aetna of AZ Commercial	$1.03
Rate for Payer: Arizona Complete Health Allwell	$0.18
Rate for Payer: Banner UC Health Medicare	$0.18
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.78
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.18
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.18
Rate for Payer: Cash Price	$0.92
Rate for Payer: Cigna of AZ Commercial	$0.75
Rate for Payer: Devoted Health Medicare	$0.21
Rate for Payer: Humana of AZ Medicare	$0.18
Rate for Payer: Southwest Service Administrators UFCW	$0.78
Rate for Payer: TriWest Medicare	$0.18
Rate for Payer: United Healthcare Commercial	$0.66
Rate for Payer: United Healthcare Medicare	$0.18
Rate for Payer: Veterans Affairs TRICARE	$0.18

azithromycin 200 mg/5 mL Oral Susp (22.5mL after reconst) [CQCH]

Facility

$1.15

Service Code	HCPCS Q0144
Hospital Charge Code	105947029
Hospital Revenue Code	251
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.03
Rate for Payer: Aetna of AZ Commercial	$1.03
Rate for Payer: Cash Price	$0.92

azithromycin 250 mg Tab [CQCH]

Facility

$0.63

Service Code	NDC 904670806
Hospital Charge Code	105912444
Hospital Revenue Code	251
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.57
Rate for Payer: Aetna of AZ Commercial	$0.57
Rate for Payer: Cash Price	$0.51

azithromycin 250 mg Tab [CQCH]

Facility

$0.63

Service Code	NDC 904670806
Hospital Charge Code	105912444
Hospital Revenue Code	251
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.57
Rate for Payer: Aetna of AZ Commercial	$0.57
Rate for Payer: Arizona Complete Health Allwell	$0.10
Rate for Payer: Banner UC Health Medicare	$0.10
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.43
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.10
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.10
Rate for Payer: Cash Price	$0.51
Rate for Payer: Cigna of AZ Commercial	$0.41
Rate for Payer: Devoted Health Medicare	$0.11
Rate for Payer: Humana of AZ Medicare	$0.10
Rate for Payer: Southwest Service Administrators UFCW	$0.43
Rate for Payer: TriWest Medicare	$0.10
Rate for Payer: United Healthcare Commercial	$0.36
Rate for Payer: United Healthcare Medicare	$0.10
Rate for Payer: Veterans Affairs TRICARE	$0.10

azithromycin 500 mg IV Inj [CQCH]

Facility

$2.26

Service Code	HCPCS J0456
Hospital Charge Code	105948837
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$2.03
Rate for Payer: Aetna of AZ Commercial	$2.03
Rate for Payer: Arizona Complete Health Allwell	$0.36
Rate for Payer: Banner UC Health Medicare	$0.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.54
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.36
Rate for Payer: Cash Price	$1.81
Rate for Payer: Cigna of AZ Commercial	$1.47
Rate for Payer: Devoted Health Medicare	$0.41
Rate for Payer: Humana of AZ Medicare	$0.36
Rate for Payer: Southwest Service Administrators UFCW	$1.54
Rate for Payer: TriWest Medicare	$0.36
Rate for Payer: United Healthcare Commercial	$1.29
Rate for Payer: United Healthcare Medicare	$0.36
Rate for Payer: Veterans Affairs TRICARE	$0.36

azithromycin 500 mg IV Inj [CQCH]

Facility

$2.26

Service Code	HCPCS J0456
Hospital Charge Code	105948837
Hospital Revenue Code	250
Min. Negotiated Rate	$2.03
Max. Negotiated Rate	$2.03
Rate for Payer: Aetna of AZ Commercial	$2.03
Rate for Payer: Cash Price	$1.81

bacitracin/neomycin/polymyxin B Top Oint [CQCH]

Facility

$0.14

Service Code	NDC 45802014370
Hospital Charge Code	105912512
Hospital Revenue Code	251
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of AZ Commercial	$0.13
Rate for Payer: Cash Price	$0.11

bacitracin/neomycin/polymyxin B Top Oint [CQCH]

Facility

$0.14

Service Code	NDC 45802014370
Hospital Charge Code	105912512
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of AZ Commercial	$0.13
Rate for Payer: Arizona Complete Health Allwell	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.10
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.02
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.02
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of AZ Commercial	$0.09
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.10
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.08
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

bacitracin topical 500 units/g Oin[CQCH]

Facility

$0.20

Service Code	NDC 713028031
Hospital Charge Code	168975217
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.18
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	$0.16
Rate for Payer: Cigna of AZ Commercial	$0.13
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	$0.11
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

bacitracin topical 500 units/g Oin[CQCH]

Facility

$0.20

Service Code	NDC 713028031
Hospital Charge Code	168975217
Hospital Revenue Code	251
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.18
Rate for Payer: Cash Price	$0.16

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC

Facility

$25,850.88

Service Code	MSDRG 519
Min. Negotiated Rate	$25,850.88
Max. Negotiated Rate	$25,850.88
Rate for Payer: Seven Corners Travel Insurance	$25,850.88

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR

Facility

$48,301.39

Service Code	MSDRG 518
Min. Negotiated Rate	$48,301.39
Max. Negotiated Rate	$48,301.39
Rate for Payer: Seven Corners Travel Insurance	$48,301.39

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC

Facility

$19,307.36

Service Code	MSDRG 520
Min. Negotiated Rate	$19,307.36
Max. Negotiated Rate	$19,307.36
Rate for Payer: Seven Corners Travel Insurance	$19,307.36

baclofen 10 mg Tab [CQCH]

Facility

$0.33

Service Code	NDC 63739047910
Hospital Charge Code	105965598
Hospital Revenue Code	251
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of AZ Commercial	$0.30
Rate for Payer: Cash Price	$0.26

baclofen 10 mg Tab [CQCH]

Facility

$0.33

Service Code	NDC 63739047910
Hospital Charge Code	105965598
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of AZ Commercial	$0.30
Rate for Payer: Arizona Complete Health Allwell	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.22
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.05
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.05
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna of AZ Commercial	$0.21
Rate for Payer: Devoted Health Medicare	$0.06
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Southwest Service Administrators UFCW	$0.22
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: United Healthcare Commercial	$0.19
Rate for Payer: United Healthcare Medicare	$0.05
Rate for Payer: Veterans Affairs TRICARE	$0.05

Bacterial And Tuberculous Infections Of Nervous System

Facility

$16,798.53

Service Code	APR-DRG 0493
Hospital Charge Code	APRDRG0493
Min. Negotiated Rate	$16,798.53
Max. Negotiated Rate	$16,798.53
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$16,798.53
Rate for Payer: Mercy Care Medicaid	$16,798.53
Rate for Payer: NaphCare Correctional Healthcare	$16,798.53

Know your out-of-pocket cost for care.

All Charges