Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

betamethasone 30 mg/ 5 mL Inj [CQCH]

Facility

$7.57

Service Code	HCPCS J0702
Hospital Charge Code	105912906
Hospital Revenue Code	250
Min. Negotiated Rate	$6.81
Max. Negotiated Rate	$6.81
Rate for Payer: Aetna of AZ Commercial	$6.81
Rate for Payer: Cash Price	$6.05

betamethasone 30 mg/ 5 mL Inj [CQCH]

Facility

$7.57

Service Code	HCPCS J0702
Hospital Charge Code	105912906
Hospital Revenue Code	250
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$6.81
Rate for Payer: Aetna of AZ Commercial	$6.81
Rate for Payer: Arizona Complete Health Allwell	$1.21
Rate for Payer: Banner UC Health Medicare	$1.21
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5.15
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.21
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.21
Rate for Payer: Cash Price	$6.05
Rate for Payer: Cigna of AZ Commercial	$4.92
Rate for Payer: Devoted Health Medicare	$1.36
Rate for Payer: Humana of AZ Medicare	$1.21
Rate for Payer: Southwest Service Administrators UFCW	$5.15
Rate for Payer: TriWest Medicare	$1.21
Rate for Payer: United Healthcare Commercial	$4.33
Rate for Payer: United Healthcare Medicare	$1.21
Rate for Payer: Veterans Affairs TRICARE	$1.20

betamethasone-clotrimazole Top 0.05%-1% Crm [CQCH]

Facility

$11.20

Service Code	NDC 16714049602
Hospital Charge Code	105912979
Hospital Revenue Code	251
Min. Negotiated Rate	$10.08
Max. Negotiated Rate	$10.08
Rate for Payer: Aetna of AZ Commercial	$10.08
Rate for Payer: Cash Price	$8.96

betamethasone-clotrimazole Top 0.05%-1% Crm [CQCH]

Facility

$11.20

Service Code	NDC 16714049602
Hospital Charge Code	105912979
Hospital Revenue Code	251
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$10.08
Rate for Payer: Aetna of AZ Commercial	$10.08
Rate for Payer: Arizona Complete Health Allwell	$1.79
Rate for Payer: Banner UC Health Medicare	$1.79
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$7.62
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.79
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.79
Rate for Payer: Cash Price	$8.96
Rate for Payer: Cigna of AZ Commercial	$7.28
Rate for Payer: Devoted Health Medicare	$2.02
Rate for Payer: Humana of AZ Medicare	$1.79
Rate for Payer: Southwest Service Administrators UFCW	$7.62
Rate for Payer: TriWest Medicare	$1.79
Rate for Payer: United Healthcare Commercial	$6.41
Rate for Payer: United Healthcare Medicare	$1.79
Rate for Payer: Veterans Affairs TRICARE	$1.77

BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC

Facility

$71,380.02

Service Code	MSDRG 461
Min. Negotiated Rate	$71,380.02
Max. Negotiated Rate	$71,380.02
Rate for Payer: Seven Corners Travel Insurance	$71,380.02

BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC

Facility

$34,378.22

Service Code	MSDRG 462
Min. Negotiated Rate	$34,378.22
Max. Negotiated Rate	$34,378.22
Rate for Payer: Seven Corners Travel Insurance	$34,378.22

BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC

Facility

$28,139.74

Service Code	MSDRG 409
Min. Negotiated Rate	$28,139.74
Max. Negotiated Rate	$28,139.74
Rate for Payer: Seven Corners Travel Insurance	$28,139.74

BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC

Facility

$46,082.33

Service Code	MSDRG 408
Min. Negotiated Rate	$46,082.33
Max. Negotiated Rate	$46,082.33
Rate for Payer: Seven Corners Travel Insurance	$46,082.33

BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC

Facility

$20,519.67

Service Code	MSDRG 410
Min. Negotiated Rate	$20,519.67
Max. Negotiated Rate	$20,519.67
Rate for Payer: Seven Corners Travel Insurance	$20,519.67

Bilirubin Direct

Facility

$112.00

Service Code	CPT 82248
Hospital Charge Code	633670
Hospital Revenue Code	301
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of AZ Commercial	$100.80
Rate for Payer: Cash Price	$89.60

Bilirubin Direct

Facility

$112.00

Service Code	CPT 82248
Hospital Charge Code	633670
Hospital Revenue Code	301
Min. Negotiated Rate	$7.28
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of AZ Commercial	$100.80
Rate for Payer: Arizona Complete Health Allwell	$17.92
Rate for Payer: Banner UC Health Medicare	$17.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$76.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.92
Rate for Payer: Cash Price	$89.60
Rate for Payer: Cash Price	$89.60
Rate for Payer: Cigna of AZ Commercial	$72.80
Rate for Payer: Devoted Health Medicare	$20.16
Rate for Payer: Humana of AZ Medicare	$17.92
Rate for Payer: Seven Corners Travel Insurance	$7.28
Rate for Payer: Southwest Service Administrators UFCW	$76.16
Rate for Payer: TriWest Medicare	$17.92
Rate for Payer: United Healthcare Commercial	$64.06
Rate for Payer: United Healthcare Medicare	$17.92
Rate for Payer: Veterans Affairs TRICARE	$17.74

Bilirubin Total

Facility

$112.00

Service Code	CPT 82247
Hospital Charge Code	633672
Hospital Revenue Code	301
Min. Negotiated Rate	$7.28
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of AZ Commercial	$100.80
Rate for Payer: Arizona Complete Health Allwell	$17.92
Rate for Payer: Banner UC Health Medicare	$17.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$76.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.92
Rate for Payer: Cash Price	$89.60
Rate for Payer: Cash Price	$89.60
Rate for Payer: Cigna of AZ Commercial	$72.80
Rate for Payer: Devoted Health Medicare	$20.16
Rate for Payer: Humana of AZ Medicare	$17.92
Rate for Payer: Seven Corners Travel Insurance	$7.28
Rate for Payer: Southwest Service Administrators UFCW	$76.16
Rate for Payer: TriWest Medicare	$17.92
Rate for Payer: United Healthcare Commercial	$64.06
Rate for Payer: United Healthcare Medicare	$17.92
Rate for Payer: Veterans Affairs TRICARE	$17.74

Bilirubin Total

Facility

$112.00

Service Code	CPT 82247
Hospital Charge Code	633672
Hospital Revenue Code	301
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of AZ Commercial	$100.80
Rate for Payer: Cash Price	$89.60

Bill 602503 Johnson Grass

Facility

$39.00

Service Code	CPT 86003
Hospital Charge Code	23143910
Hospital Revenue Code	301
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Cash Price	$31.20

Bill 602503 Johnson Grass

Facility

$39.00

Service Code	CPT 86003
Hospital Charge Code	23143910
Hospital Revenue Code	301
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Arizona Complete Health Allwell	$6.24
Rate for Payer: Banner UC Health Medicare	$6.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$26.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.24
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cigna of AZ Commercial	$25.35
Rate for Payer: Devoted Health Medicare	$7.02
Rate for Payer: Humana of AZ Medicare	$6.24
Rate for Payer: Seven Corners Travel Insurance	$7.57
Rate for Payer: Southwest Service Administrators UFCW	$26.52
Rate for Payer: TriWest Medicare	$6.24
Rate for Payer: United Healthcare Commercial	$22.31
Rate for Payer: United Healthcare Medicare	$6.24
Rate for Payer: Veterans Affairs TRICARE	$6.18

Bill 602872 Rye Grass

Facility

$39.00

Service Code	CPT 86003
Hospital Charge Code	23143911
Hospital Revenue Code	301
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Arizona Complete Health Allwell	$6.24
Rate for Payer: Banner UC Health Medicare	$6.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$26.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.24
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cigna of AZ Commercial	$25.35
Rate for Payer: Devoted Health Medicare	$7.02
Rate for Payer: Humana of AZ Medicare	$6.24
Rate for Payer: Seven Corners Travel Insurance	$7.57
Rate for Payer: Southwest Service Administrators UFCW	$26.52
Rate for Payer: TriWest Medicare	$6.24
Rate for Payer: United Healthcare Commercial	$22.31
Rate for Payer: United Healthcare Medicare	$6.24
Rate for Payer: Veterans Affairs TRICARE	$6.18

Bill 602872 Rye Grass

Facility

$39.00

Service Code	CPT 86003
Hospital Charge Code	23143911
Hospital Revenue Code	301
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Cash Price	$31.20

Bill 602931 Mimosa/acacia

Facility

$39.00

Service Code	CPT 86003
Hospital Charge Code	23143912
Hospital Revenue Code	301
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Arizona Complete Health Allwell	$6.24
Rate for Payer: Banner UC Health Medicare	$6.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$26.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.24
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cigna of AZ Commercial	$25.35
Rate for Payer: Devoted Health Medicare	$7.02
Rate for Payer: Humana of AZ Medicare	$6.24
Rate for Payer: Seven Corners Travel Insurance	$7.57
Rate for Payer: Southwest Service Administrators UFCW	$26.52
Rate for Payer: TriWest Medicare	$6.24
Rate for Payer: United Healthcare Commercial	$22.31
Rate for Payer: United Healthcare Medicare	$6.24
Rate for Payer: Veterans Affairs TRICARE	$6.18

Bill 602931 Mimosa/acacia

Facility

$39.00

Service Code	CPT 86003
Hospital Charge Code	23143912
Hospital Revenue Code	301
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Cash Price	$31.20

Bill ABID

Facility

$246.00

Service Code	CPT 86870
Hospital Charge Code	12537756
Hospital Revenue Code	302
Min. Negotiated Rate	$38.97
Max. Negotiated Rate	$554.61
Rate for Payer: Aetna of AZ Commercial	$221.40
Rate for Payer: Arizona Complete Health Allwell	$39.36
Rate for Payer: Banner UC Health Medicare	$39.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$167.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$39.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$39.36
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cash Price	$196.80
Rate for Payer: Cigna of AZ Commercial	$159.90
Rate for Payer: Devoted Health Medicare	$44.28
Rate for Payer: Humana of AZ Medicare	$39.36
Rate for Payer: Seven Corners Travel Insurance	$554.61
Rate for Payer: Southwest Service Administrators UFCW	$167.28
Rate for Payer: TriWest Medicare	$39.36
Rate for Payer: United Healthcare Commercial	$140.71
Rate for Payer: United Healthcare Medicare	$39.36
Rate for Payer: Veterans Affairs TRICARE	$38.97

Bill ABID

Facility

$246.00

Service Code	CPT 86870
Hospital Charge Code	12537756
Hospital Revenue Code	302
Min. Negotiated Rate	$221.40
Max. Negotiated Rate	$221.40
Rate for Payer: Aetna of AZ Commercial	$221.40
Rate for Payer: Cash Price	$196.80

Bill ABID/each panel media

Facility

$237.00

Service Code	CPT 86870
Hospital Charge Code	2465092
Hospital Revenue Code	300
Min. Negotiated Rate	$37.54
Max. Negotiated Rate	$554.61
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Arizona Complete Health Allwell	$37.92
Rate for Payer: Banner UC Health Medicare	$37.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$161.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$37.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.92
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cigna of AZ Commercial	$154.05
Rate for Payer: Devoted Health Medicare	$42.66
Rate for Payer: Humana of AZ Medicare	$37.92
Rate for Payer: Seven Corners Travel Insurance	$554.61
Rate for Payer: Southwest Service Administrators UFCW	$161.16
Rate for Payer: TriWest Medicare	$37.92
Rate for Payer: United Healthcare Commercial	$135.56
Rate for Payer: United Healthcare Medicare	$37.92
Rate for Payer: Veterans Affairs TRICARE	$37.54

Bill ABID/each panel media

Facility

$237.00

Service Code	CPT 86870
Hospital Charge Code	2465092
Hospital Revenue Code	300
Min. Negotiated Rate	$213.30
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Cash Price	$189.60

Bill Allergen Test

Facility

$145.00

Service Code	CPT 86003
Hospital Charge Code	23568451
Hospital Revenue Code	301
Min. Negotiated Rate	$130.50
Max. Negotiated Rate	$130.50
Rate for Payer: Aetna of AZ Commercial	$130.50
Rate for Payer: Cash Price	$116.00

Bill Allergen Test

Facility

$145.00

Service Code	CPT 86003
Hospital Charge Code	23568451
Hospital Revenue Code	301
Min. Negotiated Rate	$7.57
Max. Negotiated Rate	$130.50
Rate for Payer: Aetna of AZ Commercial	$130.50
Rate for Payer: Arizona Complete Health Allwell	$23.20
Rate for Payer: Banner UC Health Medicare	$23.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$98.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$23.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$23.20
Rate for Payer: Cash Price	$116.00
Rate for Payer: Cash Price	$116.00
Rate for Payer: Cigna of AZ Commercial	$94.25
Rate for Payer: Devoted Health Medicare	$26.10
Rate for Payer: Humana of AZ Medicare	$23.20
Rate for Payer: Seven Corners Travel Insurance	$7.57
Rate for Payer: Southwest Service Administrators UFCW	$98.60
Rate for Payer: TriWest Medicare	$23.20
Rate for Payer: United Healthcare Commercial	$82.94
Rate for Payer: United Healthcare Medicare	$23.20
Rate for Payer: Veterans Affairs TRICARE	$22.97

Know your out-of-pocket cost for care.

All Charges