Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

codeine-guaiFENesin 20 mg-200 mg/10 mL UD Oral Syrup

Facility

$0.03

Service Code	NDC 50383008712
Hospital Charge Code	105917195
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Cash Price	$0.02

colchicine 0.6 mg Cap UD [CQCH]

Facility

$5.18

Service Code	NDC 904673204
Hospital Charge Code	145650361
Hospital Revenue Code	251
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$4.66
Rate for Payer: Aetna of AZ Commercial	$4.66
Rate for Payer: Arizona Complete Health Allwell	$0.83
Rate for Payer: Banner UC Health Medicare	$0.83
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.83
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.83
Rate for Payer: Cash Price	$4.14
Rate for Payer: Cigna of AZ Commercial	$3.37
Rate for Payer: Devoted Health Medicare	$0.93
Rate for Payer: Humana of AZ Medicare	$0.83
Rate for Payer: Southwest Service Administrators UFCW	$3.52
Rate for Payer: TriWest Medicare	$0.83
Rate for Payer: United Healthcare Commercial	$2.96
Rate for Payer: United Healthcare Medicare	$0.83
Rate for Payer: Veterans Affairs TRICARE	$0.82

colchicine 0.6 mg Cap UD [CQCH]

Facility

$5.18

Service Code	NDC 904673204
Hospital Charge Code	145650361
Hospital Revenue Code	251
Min. Negotiated Rate	$4.66
Max. Negotiated Rate	$4.66
Rate for Payer: Aetna of AZ Commercial	$4.66
Rate for Payer: Cash Price	$4.14

collagenase Top 250 units/g Oint [CQCH]

Facility

$238.22

Service Code	NDC 50484001030
Hospital Charge Code	105917327
Hospital Revenue Code	251
Min. Negotiated Rate	$214.40
Max. Negotiated Rate	$214.40
Rate for Payer: Aetna of AZ Commercial	$214.40
Rate for Payer: Cash Price	$190.58

collagenase Top 250 units/g Oint [CQCH]

Facility

$238.22

Service Code	NDC 50484001030
Hospital Charge Code	105917327
Hospital Revenue Code	251
Min. Negotiated Rate	$37.73
Max. Negotiated Rate	$214.40
Rate for Payer: Aetna of AZ Commercial	$214.40
Rate for Payer: Arizona Complete Health Allwell	$38.12
Rate for Payer: Banner UC Health Medicare	$38.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$161.99
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.12
Rate for Payer: Cash Price	$190.58
Rate for Payer: Cigna of AZ Commercial	$154.84
Rate for Payer: Devoted Health Medicare	$42.88
Rate for Payer: Humana of AZ Medicare	$38.12
Rate for Payer: Southwest Service Administrators UFCW	$161.99
Rate for Payer: TriWest Medicare	$38.12
Rate for Payer: United Healthcare Commercial	$136.26
Rate for Payer: United Healthcare Medicare	$38.12
Rate for Payer: Veterans Affairs TRICARE	$37.73

Collagen injection

Facility

$1,030.00

Service Code	CPT 51715
Hospital Charge Code	27267841
Hospital Revenue Code	360
Min. Negotiated Rate	$155.51
Max. Negotiated Rate	$5,454.10
Rate for Payer: Aetna of AZ Commercial	$927.00
Rate for Payer: Arizona Complete Health Allwell	$164.80
Rate for Payer: Banner UC Health Medicare	$1,529.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$700.40
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$155.51
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$164.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$164.80
Rate for Payer: Cash Price	$824.00
Rate for Payer: Cash Price	$824.00
Rate for Payer: Cash Price	$824.00
Rate for Payer: Cigna of AZ Commercial	$515.00
Rate for Payer: Devoted Health Medicare	$185.40
Rate for Payer: Humana of AZ Medicare	$164.80
Rate for Payer: Mercy Care Medicaid	$155.51
Rate for Payer: NaphCare Correctional Healthcare	$1,529.32
Rate for Payer: Seven Corners Travel Insurance	$5,454.10
Rate for Payer: Southwest Service Administrators UFCW	$700.40
Rate for Payer: TriWest Medicare	$164.80
Rate for Payer: United Healthcare Commercial	$4,838.00
Rate for Payer: United Healthcare Medicare	$164.80
Rate for Payer: Veterans Affairs TRICARE	$163.15

Collagen injection

Facility

$1,030.00

Service Code	CPT 51715
Hospital Charge Code	27267841
Hospital Revenue Code	360
Min. Negotiated Rate	$927.00
Max. Negotiated Rate	$927.00
Rate for Payer: Aetna of AZ Commercial	$927.00
Rate for Payer: Cash Price	$824.00

COLLAR CERVICAL CHILD/X-SMALL

Facility

$147.00

Service Code	HCPCS L0120
Hospital Charge Code	22354247
Hospital Revenue Code	270
Min. Negotiated Rate	$23.28
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of AZ Commercial	$132.30
Rate for Payer: Arizona Complete Health Allwell	$23.52
Rate for Payer: Banner UC Health Medicare	$23.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$99.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$23.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$23.52
Rate for Payer: Cash Price	$117.60
Rate for Payer: Cigna of AZ Commercial	$102.90
Rate for Payer: Devoted Health Medicare	$26.46
Rate for Payer: Humana of AZ Medicare	$23.52
Rate for Payer: Southwest Service Administrators UFCW	$99.96
Rate for Payer: TriWest Medicare	$23.52
Rate for Payer: United Healthcare Commercial	$84.08
Rate for Payer: United Healthcare Medicare	$23.52
Rate for Payer: Veterans Affairs TRICARE	$23.28

COLLAR CERVICAL CHILD/X-SMALL

Facility

$147.00

Service Code	HCPCS L0120
Hospital Charge Code	22354247
Hospital Revenue Code	270
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of AZ Commercial	$132.30
Rate for Payer: Cash Price	$117.60

COLLAR CERVICAL LARGE

Facility

$20.00

Service Code	HCPCS L0120
Hospital Charge Code	22354304
Hospital Revenue Code	270
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Cash Price	$16.00

COLLAR CERVICAL LARGE

Facility

$20.00

Service Code	HCPCS L0120
Hospital Charge Code	22354304
Hospital Revenue Code	270
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Arizona Complete Health Allwell	$3.20
Rate for Payer: Banner UC Health Medicare	$3.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$13.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.20
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cigna of AZ Commercial	$14.00
Rate for Payer: Devoted Health Medicare	$3.60
Rate for Payer: Humana of AZ Medicare	$3.20
Rate for Payer: Southwest Service Administrators UFCW	$13.60
Rate for Payer: TriWest Medicare	$3.20
Rate for Payer: United Healthcare Commercial	$11.44
Rate for Payer: United Healthcare Medicare	$3.20
Rate for Payer: Veterans Affairs TRICARE	$3.17

COLLAR CERVICAL MED

Facility

$20.00

Service Code	HCPCS L0120
Hospital Charge Code	22354303
Hospital Revenue Code	270
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Arizona Complete Health Allwell	$3.20
Rate for Payer: Banner UC Health Medicare	$3.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$13.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.20
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cigna of AZ Commercial	$14.00
Rate for Payer: Devoted Health Medicare	$3.60
Rate for Payer: Humana of AZ Medicare	$3.20
Rate for Payer: Southwest Service Administrators UFCW	$13.60
Rate for Payer: TriWest Medicare	$3.20
Rate for Payer: United Healthcare Commercial	$11.44
Rate for Payer: United Healthcare Medicare	$3.20
Rate for Payer: Veterans Affairs TRICARE	$3.17

COLLAR CERVICAL MED

Facility

$20.00

Service Code	HCPCS L0120
Hospital Charge Code	22354303
Hospital Revenue Code	270
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Cash Price	$16.00

COLLAR CERVICAL SMALL

Facility

$20.00

Service Code	HCPCS L0120
Hospital Charge Code	22354302
Hospital Revenue Code	270
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Arizona Complete Health Allwell	$3.20
Rate for Payer: Banner UC Health Medicare	$3.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$13.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.20
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cigna of AZ Commercial	$14.00
Rate for Payer: Devoted Health Medicare	$3.60
Rate for Payer: Humana of AZ Medicare	$3.20
Rate for Payer: Southwest Service Administrators UFCW	$13.60
Rate for Payer: TriWest Medicare	$3.20
Rate for Payer: United Healthcare Commercial	$11.44
Rate for Payer: United Healthcare Medicare	$3.20
Rate for Payer: Veterans Affairs TRICARE	$3.17

COLLAR CERVICAL SMALL

Facility

$20.00

Service Code	HCPCS L0120
Hospital Charge Code	22354302
Hospital Revenue Code	270
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Cash Price	$16.00

COLLAR STIFF NECK INFANT

Facility

$46.00

Service Code	HCPCS L0120
Hospital Charge Code	22354176
Hospital Revenue Code	270
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of AZ Commercial	$41.40
Rate for Payer: Arizona Complete Health Allwell	$7.36
Rate for Payer: Banner UC Health Medicare	$7.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$31.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.36
Rate for Payer: Cash Price	$36.80
Rate for Payer: Cigna of AZ Commercial	$32.20
Rate for Payer: Devoted Health Medicare	$8.28
Rate for Payer: Humana of AZ Medicare	$7.36
Rate for Payer: Southwest Service Administrators UFCW	$31.28
Rate for Payer: TriWest Medicare	$7.36
Rate for Payer: United Healthcare Commercial	$26.31
Rate for Payer: United Healthcare Medicare	$7.36
Rate for Payer: Veterans Affairs TRICARE	$7.29

COLLAR STIFF NECK INFANT

Facility

$46.00

Service Code	HCPCS L0120
Hospital Charge Code	22354176
Hospital Revenue Code	270
Min. Negotiated Rate	$41.40
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of AZ Commercial	$41.40
Rate for Payer: Cash Price	$36.80

COLLAR STIFF NECK PED

Facility

$59.00

Service Code	HCPCS L0120
Hospital Charge Code	22354178
Hospital Revenue Code	270
Min. Negotiated Rate	$53.10
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Cash Price	$47.20

COLLAR STIFF NECK PED

Facility

$59.00

Service Code	HCPCS L0120
Hospital Charge Code	22354178
Hospital Revenue Code	270
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Arizona Complete Health Allwell	$9.44
Rate for Payer: Banner UC Health Medicare	$9.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$40.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.44
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cigna of AZ Commercial	$41.30
Rate for Payer: Devoted Health Medicare	$10.62
Rate for Payer: Humana of AZ Medicare	$9.44
Rate for Payer: Southwest Service Administrators UFCW	$40.12
Rate for Payer: TriWest Medicare	$9.44
Rate for Payer: United Healthcare Commercial	$33.75
Rate for Payer: United Healthcare Medicare	$9.44
Rate for Payer: Veterans Affairs TRICARE	$9.35

COLLAR STIFF NECK REGULAR

Facility

$97.00

Service Code	HCPCS L0120
Hospital Charge Code	22354179
Hospital Revenue Code	270
Min. Negotiated Rate	$87.30
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna of AZ Commercial	$87.30
Rate for Payer: Cash Price	$77.60

COLLAR STIFF NECK REGULAR

Facility

$97.00

Service Code	HCPCS L0120
Hospital Charge Code	22354179
Hospital Revenue Code	270
Min. Negotiated Rate	$15.36
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna of AZ Commercial	$87.30
Rate for Payer: Arizona Complete Health Allwell	$15.52
Rate for Payer: Banner UC Health Medicare	$15.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$65.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$15.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.52
Rate for Payer: Cash Price	$77.60
Rate for Payer: Cigna of AZ Commercial	$67.90
Rate for Payer: Devoted Health Medicare	$17.46
Rate for Payer: Humana of AZ Medicare	$15.52
Rate for Payer: Southwest Service Administrators UFCW	$65.96
Rate for Payer: TriWest Medicare	$15.52
Rate for Payer: United Healthcare Commercial	$55.48
Rate for Payer: United Healthcare Medicare	$15.52
Rate for Payer: Veterans Affairs TRICARE	$15.36

COLLAR STIFF NECK SHORT

Facility

$59.00

Service Code	HCPCS L0120
Hospital Charge Code	22354180
Hospital Revenue Code	270
Min. Negotiated Rate	$53.10
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Cash Price	$47.20

COLLAR STIFF NECK SHORT

Facility

$59.00

Service Code	HCPCS L0120
Hospital Charge Code	22354180
Hospital Revenue Code	270
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Arizona Complete Health Allwell	$9.44
Rate for Payer: Banner UC Health Medicare	$9.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$40.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.44
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cigna of AZ Commercial	$41.30
Rate for Payer: Devoted Health Medicare	$10.62
Rate for Payer: Humana of AZ Medicare	$9.44
Rate for Payer: Southwest Service Administrators UFCW	$40.12
Rate for Payer: TriWest Medicare	$9.44
Rate for Payer: United Healthcare Commercial	$33.75
Rate for Payer: United Healthcare Medicare	$9.44
Rate for Payer: Veterans Affairs TRICARE	$9.35

COLLAR STIFF NECK TALL

Facility

$56.00

Service Code	HCPCS L0120
Hospital Charge Code	22354181
Hospital Revenue Code	270
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$50.40
Rate for Payer: Aetna of AZ Commercial	$50.40
Rate for Payer: Cash Price	$44.80

COLLAR STIFF NECK TALL

Facility

$56.00

Service Code	HCPCS L0120
Hospital Charge Code	22354181
Hospital Revenue Code	270
Min. Negotiated Rate	$8.87
Max. Negotiated Rate	$50.40
Rate for Payer: Aetna of AZ Commercial	$50.40
Rate for Payer: Arizona Complete Health Allwell	$8.96
Rate for Payer: Banner UC Health Medicare	$8.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$38.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.96
Rate for Payer: Cash Price	$44.80
Rate for Payer: Cigna of AZ Commercial	$39.20
Rate for Payer: Devoted Health Medicare	$10.08
Rate for Payer: Humana of AZ Medicare	$8.96
Rate for Payer: Southwest Service Administrators UFCW	$38.08
Rate for Payer: TriWest Medicare	$8.96
Rate for Payer: United Healthcare Commercial	$32.03
Rate for Payer: United Healthcare Medicare	$8.96
Rate for Payer: Veterans Affairs TRICARE	$8.87

Know your out-of-pocket cost for care.

All Charges