Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

BAG PREM LEG DISPOSABLE

Facility

$15.00

Hospital Charge Code	22354156
Hospital Revenue Code	270
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of AZ Commercial	$13.50
Rate for Payer: Cash Price	$12.00

BAG URINARY LEG

Facility

$15.00

Service Code	HCPCS A5112
Hospital Charge Code	22355176
Hospital Revenue Code	270
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of AZ Commercial	$13.50
Rate for Payer: Cash Price	$12.00

BAG URINARY LEG

Facility

$15.00

Service Code	HCPCS A5112
Hospital Charge Code	22355176
Hospital Revenue Code	270
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of AZ Commercial	$13.50
Rate for Payer: Arizona Complete Health Allwell	$2.40
Rate for Payer: Banner UC Health Medicare	$2.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$10.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cigna of AZ Commercial	$10.50
Rate for Payer: Devoted Health Medicare	$2.70
Rate for Payer: Humana of AZ Medicare	$2.40
Rate for Payer: Southwest Service Administrators UFCW	$10.20
Rate for Payer: TriWest Medicare	$2.40
Rate for Payer: United Healthcare Commercial	$8.58
Rate for Payer: United Healthcare Medicare	$2.40
Rate for Payer: Veterans Affairs TRICARE	$2.38

BAIR HUGGER DISPOSABLE BLANKET

Facility

$148.00

Hospital Charge Code	22354968
Hospital Revenue Code	270
Min. Negotiated Rate	$133.20
Max. Negotiated Rate	$133.20
Rate for Payer: Aetna of AZ Commercial	$133.20
Rate for Payer: Cash Price	$118.40

BAIR HUGGER DISPOSABLE BLANKET

Facility

$148.00

Hospital Charge Code	22354968
Hospital Revenue Code	270
Min. Negotiated Rate	$23.44
Max. Negotiated Rate	$133.20
Rate for Payer: Aetna of AZ Commercial	$133.20
Rate for Payer: Arizona Complete Health Allwell	$23.68
Rate for Payer: Banner UC Health Medicare	$23.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$100.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$23.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$23.68
Rate for Payer: Cash Price	$118.40
Rate for Payer: Cigna of AZ Commercial	$103.60
Rate for Payer: Devoted Health Medicare	$26.64
Rate for Payer: Humana of AZ Medicare	$23.68
Rate for Payer: Southwest Service Administrators UFCW	$100.64
Rate for Payer: TriWest Medicare	$23.68
Rate for Payer: United Healthcare Commercial	$84.66
Rate for Payer: United Healthcare Medicare	$23.68
Rate for Payer: Veterans Affairs TRICARE	$23.44

BAKRI POSTPARTUM BALLOON

Facility

$1,275.06

Hospital Charge Code	30230653
Hospital Revenue Code	270
Min. Negotiated Rate	$1,147.55
Max. Negotiated Rate	$1,147.55
Rate for Payer: Aetna of AZ Commercial	$1,147.55
Rate for Payer: Cash Price	$1,020.05

BAKRI POSTPARTUM BALLOON

Facility

$1,275.06

Hospital Charge Code	30230653
Hospital Revenue Code	270
Min. Negotiated Rate	$201.97
Max. Negotiated Rate	$1,147.55
Rate for Payer: Aetna of AZ Commercial	$1,147.55
Rate for Payer: Arizona Complete Health Allwell	$204.01
Rate for Payer: Banner UC Health Medicare	$204.01
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$867.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$204.01
Rate for Payer: Care1st Health Plan Arizona Medicare	$204.01
Rate for Payer: Cash Price	$1,020.05
Rate for Payer: Cigna of AZ Commercial	$892.54
Rate for Payer: Devoted Health Medicare	$229.51
Rate for Payer: Humana of AZ Medicare	$204.01
Rate for Payer: Southwest Service Administrators UFCW	$867.04
Rate for Payer: TriWest Medicare	$204.01
Rate for Payer: United Healthcare Commercial	$729.33
Rate for Payer: United Healthcare Medicare	$204.01
Rate for Payer: Veterans Affairs TRICARE	$201.97

BALL ELECTRODE 5MM CONMED

Facility

$109.00

Hospital Charge Code	22554974
Hospital Revenue Code	272
Min. Negotiated Rate	$98.10
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Cash Price	$87.20

BALL ELECTRODE 5MM CONMED

Facility

$109.00

Hospital Charge Code	22554974
Hospital Revenue Code	272
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Arizona Complete Health Allwell	$17.44
Rate for Payer: Banner UC Health Medicare	$17.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$74.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.44
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cigna of AZ Commercial	$76.30
Rate for Payer: Devoted Health Medicare	$19.62
Rate for Payer: Humana of AZ Medicare	$17.44
Rate for Payer: Southwest Service Administrators UFCW	$74.12
Rate for Payer: TriWest Medicare	$17.44
Rate for Payer: United Healthcare Commercial	$62.35
Rate for Payer: United Healthcare Medicare	$17.44
Rate for Payer: Veterans Affairs TRICARE	$17.27

BANDING OF HEMORRHOIDS USING A FLEXIBLE ENDOSCOPE (SIGMOIDOS

Facility

$527.00

Service Code	CPT 45350
Hospital Charge Code	28072245
Hospital Revenue Code	360
Min. Negotiated Rate	$474.30
Max. Negotiated Rate	$474.30
Rate for Payer: Aetna of AZ Commercial	$474.30
Rate for Payer: Cash Price	$421.60

BANDING OF HEMORRHOIDS USING A FLEXIBLE ENDOSCOPE (SIGMOIDOS

Facility

$527.00

Service Code	CPT 45350
Hospital Charge Code	28072245
Hospital Revenue Code	360
Min. Negotiated Rate	$83.48
Max. Negotiated Rate	$3,596.00
Rate for Payer: Aetna of AZ Commercial	$474.30
Rate for Payer: Arizona Complete Health Allwell	$84.32
Rate for Payer: Banner UC Health Medicare	$383.41
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$358.36
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$551.94
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$84.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$84.32
Rate for Payer: Cash Price	$421.60
Rate for Payer: Cash Price	$421.60
Rate for Payer: Cash Price	$421.60
Rate for Payer: Cigna of AZ Commercial	$263.50
Rate for Payer: Devoted Health Medicare	$94.86
Rate for Payer: Humana of AZ Medicare	$84.32
Rate for Payer: Mercy Care Medicaid	$551.94
Rate for Payer: NaphCare Correctional Healthcare	$383.41
Rate for Payer: Seven Corners Travel Insurance	$1,851.53
Rate for Payer: Southwest Service Administrators UFCW	$358.36
Rate for Payer: TriWest Medicare	$84.32
Rate for Payer: United Healthcare Commercial	$3,596.00
Rate for Payer: United Healthcare Medicare	$84.32
Rate for Payer: Veterans Affairs TRICARE	$83.48

baricitinib 2 mg Tab[CQCH]

Facility

$78.09

Service Code	NDC 2418230
Hospital Charge Code	188268943
Hospital Revenue Code	251
Min. Negotiated Rate	$12.37
Max. Negotiated Rate	$70.28
Rate for Payer: Aetna of AZ Commercial	$70.28
Rate for Payer: Arizona Complete Health Allwell	$12.49
Rate for Payer: Banner UC Health Medicare	$12.49
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$53.10
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.49
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.49
Rate for Payer: Cash Price	$62.47
Rate for Payer: Cigna of AZ Commercial	$50.76
Rate for Payer: Devoted Health Medicare	$14.06
Rate for Payer: Humana of AZ Medicare	$12.49
Rate for Payer: Southwest Service Administrators UFCW	$53.10
Rate for Payer: TriWest Medicare	$12.49
Rate for Payer: United Healthcare Commercial	$44.67
Rate for Payer: United Healthcare Medicare	$12.49
Rate for Payer: Veterans Affairs TRICARE	$12.37

baricitinib 2 mg Tab[CQCH]

Facility

$78.09

Service Code	NDC 2418230
Hospital Charge Code	188268943
Hospital Revenue Code	251
Min. Negotiated Rate	$70.28
Max. Negotiated Rate	$70.28
Rate for Payer: Aetna of AZ Commercial	$70.28
Rate for Payer: Cash Price	$62.47

BARRIER FILM SKINCARE CAVILON ADV 2.7ML

Facility

$67.00

Hospital Charge Code	23362063
Hospital Revenue Code	272
Min. Negotiated Rate	$60.30
Max. Negotiated Rate	$60.30
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Cash Price	$53.60

BARRIER FILM SKINCARE CAVILON ADV 2.7ML

Facility

$67.00

Hospital Charge Code	23362063
Hospital Revenue Code	272
Min. Negotiated Rate	$10.61
Max. Negotiated Rate	$60.30
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Arizona Complete Health Allwell	$10.72
Rate for Payer: Banner UC Health Medicare	$10.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$45.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.72
Rate for Payer: Cash Price	$53.60
Rate for Payer: Cigna of AZ Commercial	$46.90
Rate for Payer: Devoted Health Medicare	$12.06
Rate for Payer: Humana of AZ Medicare	$10.72
Rate for Payer: Southwest Service Administrators UFCW	$45.56
Rate for Payer: TriWest Medicare	$10.72
Rate for Payer: United Healthcare Commercial	$38.32
Rate for Payer: United Healthcare Medicare	$10.72
Rate for Payer: Veterans Affairs TRICARE	$10.61

BARRIER OINTMENT

Facility

$16.00

Hospital Charge Code	22355159
Hospital Revenue Code	270
Min. Negotiated Rate	$2.53
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Arizona Complete Health Allwell	$2.56
Rate for Payer: Banner UC Health Medicare	$2.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$10.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.56
Rate for Payer: Cash Price	$12.80
Rate for Payer: Cigna of AZ Commercial	$11.20
Rate for Payer: Devoted Health Medicare	$2.88
Rate for Payer: Humana of AZ Medicare	$2.56
Rate for Payer: Southwest Service Administrators UFCW	$10.88
Rate for Payer: TriWest Medicare	$2.56
Rate for Payer: United Healthcare Commercial	$9.15
Rate for Payer: United Healthcare Medicare	$2.56
Rate for Payer: Veterans Affairs TRICARE	$2.53

BARRIER OINTMENT

Facility

$16.00

Hospital Charge Code	22355159
Hospital Revenue Code	270
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Cash Price	$12.80

Bartholins Gland Excision

Facility

$1,625.00

Service Code	CPT 56740
Hospital Charge Code	27291808
Hospital Revenue Code	360
Min. Negotiated Rate	$1,462.50
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Cash Price	$1,300.00

Bartholins Gland Excision

Facility

$1,625.00

Service Code	CPT 56740
Hospital Charge Code	27291808
Hospital Revenue Code	360
Min. Negotiated Rate	$257.40
Max. Negotiated Rate	$5,008.71
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Arizona Complete Health Allwell	$260.00
Rate for Payer: Banner UC Health Medicare	$1,051.19
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,105.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$260.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$260.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cigna of AZ Commercial	$812.50
Rate for Payer: Devoted Health Medicare	$292.50
Rate for Payer: Humana of AZ Medicare	$260.00
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	$1,105.00
Rate for Payer: TriWest Medicare	$260.00
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$260.00
Rate for Payer: Veterans Affairs TRICARE	$257.40

Bartonella AB

Facility

$78.00

Service Code	CPT 86611
Hospital Charge Code	22912236
Hospital Revenue Code	301
Min. Negotiated Rate	$12.36
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Arizona Complete Health Allwell	$12.48
Rate for Payer: Banner UC Health Medicare	$12.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$53.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.48
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cigna of AZ Commercial	$50.70
Rate for Payer: Devoted Health Medicare	$14.04
Rate for Payer: Humana of AZ Medicare	$12.48
Rate for Payer: Seven Corners Travel Insurance	$14.76
Rate for Payer: Southwest Service Administrators UFCW	$53.04
Rate for Payer: TriWest Medicare	$12.48
Rate for Payer: United Healthcare Commercial	$44.62
Rate for Payer: United Healthcare Medicare	$12.48
Rate for Payer: Veterans Affairs TRICARE	$12.36

Bartonella AB

Facility

$78.00

Service Code	CPT 86611
Hospital Charge Code	22912236
Hospital Revenue Code	301
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Cash Price	$62.40

Bartonella Antibody Panel LC

Facility

$119.00

Service Code	CPT 86611
Hospital Charge Code	2029236
Hospital Revenue Code	301
Min. Negotiated Rate	$14.76
Max. Negotiated Rate	$107.10
Rate for Payer: Aetna of AZ Commercial	$107.10
Rate for Payer: Arizona Complete Health Allwell	$19.04
Rate for Payer: Banner UC Health Medicare	$19.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$80.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$19.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$19.04
Rate for Payer: Cash Price	$95.20
Rate for Payer: Cash Price	$95.20
Rate for Payer: Cigna of AZ Commercial	$77.35
Rate for Payer: Devoted Health Medicare	$21.42
Rate for Payer: Humana of AZ Medicare	$19.04
Rate for Payer: Seven Corners Travel Insurance	$14.76
Rate for Payer: Southwest Service Administrators UFCW	$80.92
Rate for Payer: TriWest Medicare	$19.04
Rate for Payer: United Healthcare Commercial	$68.07
Rate for Payer: United Healthcare Medicare	$19.04
Rate for Payer: Veterans Affairs TRICARE	$18.85

Bartonella Antibody Panel LC

Facility

$119.00

Service Code	CPT 86611
Hospital Charge Code	2029236
Hospital Revenue Code	301
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$107.10
Rate for Payer: Aetna of AZ Commercial	$107.10
Rate for Payer: Cash Price	$95.20

BASIC CYSTOSCOPY TRAY

Facility

$129.00

Hospital Charge Code	27749972
Hospital Revenue Code	270
Min. Negotiated Rate	$20.43
Max. Negotiated Rate	$116.10
Rate for Payer: Aetna of AZ Commercial	$116.10
Rate for Payer: Arizona Complete Health Allwell	$20.64
Rate for Payer: Banner UC Health Medicare	$20.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$87.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.64
Rate for Payer: Cash Price	$103.20
Rate for Payer: Cigna of AZ Commercial	$90.30
Rate for Payer: Devoted Health Medicare	$23.22
Rate for Payer: Humana of AZ Medicare	$20.64
Rate for Payer: Southwest Service Administrators UFCW	$87.72
Rate for Payer: TriWest Medicare	$20.64
Rate for Payer: United Healthcare Commercial	$73.79
Rate for Payer: United Healthcare Medicare	$20.64
Rate for Payer: Veterans Affairs TRICARE	$20.43

BASIC CYSTOSCOPY TRAY

Facility

$129.00

Hospital Charge Code	27749972
Hospital Revenue Code	270
Min. Negotiated Rate	$116.10
Max. Negotiated Rate	$116.10
Rate for Payer: Aetna of AZ Commercial	$116.10
Rate for Payer: Cash Price	$103.20

Know your out-of-pocket cost for care.

All Charges