Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

levoFLOXacin 250 mg/50 mL Premix IVPB [CQCH]

Facility

$0.03

Service Code	HCPCS J1956
Hospital Charge Code	105928254
Hospital Revenue Code	250
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of AZ Commercial	$0.02
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.02
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

levoFLOXacin 250 mg/50 mL Premix IVPB [CQCH]

Facility

$0.03

Service Code	HCPCS J1956
Hospital Charge Code	105928254
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Self Pay Self Pay	$0.02

levoFLOXacin 500 mg/100 mL premix IVPB [CQCH]

Facility

$0.04

Service Code	HCPCS J1956
Hospital Charge Code	105928179
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.03
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of AZ Commercial	$0.03
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.02
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Self Pay Self Pay	$0.03
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

levoFLOXacin 500 mg/100 mL premix IVPB [CQCH]

Facility

$0.04

Service Code	HCPCS J1956
Hospital Charge Code	105928179
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.03
Rate for Payer: Self Pay Self Pay	$0.03

levoFLOXacin 500 mg Tab [CQCH]

Facility

$0.24

Service Code	NDC 904635261
Hospital Charge Code	105928112
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of AZ Commercial	$0.22
Rate for Payer: Aetna of AZ Medicare	$0.07
Rate for Payer: Allwell Medicare	$0.04
Rate for Payer: Amerigroup Medicare	$0.04
Rate for Payer: APIPA Medicare/Medicaid	$0.09
Rate for Payer: AZCH Complete Medicare	$0.04
Rate for Payer: Banner UC Health Medicare	$0.04
Rate for Payer: Bisbee Police All Plans	$0.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.16
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of AZ Commercial	$0.16
Rate for Payer: Copperpoint Commercial	$0.06
Rate for Payer: Health Net of AZ Commercial	$0.14
Rate for Payer: Health Net of AZ Medicare	$0.07
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Self Pay Self Pay	$0.19
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.04

levoFLOXacin 500 mg Tab [CQCH]

Facility

$0.24

Service Code	NDC 904635261
Hospital Charge Code	105928112
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of AZ Commercial	$0.22
Rate for Payer: Bisbee Police All Plans	$0.06
Rate for Payer: Cash Price	$0.19
Rate for Payer: Self Pay Self Pay	$0.19

levoFLOXacin 750 mg/150 mL premix IVBP [CQCH]

Facility

$0.04

Service Code	HCPCS J1956
Hospital Charge Code	105951033
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.03
Rate for Payer: Self Pay Self Pay	$0.03

levoFLOXacin 750 mg/150 mL premix IVBP [CQCH]

Facility

$0.04

Service Code	HCPCS J1956
Hospital Charge Code	105951033
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.03
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of AZ Commercial	$0.03
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.02
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Self Pay Self Pay	$0.03
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

levonorgestrel 1.5 mg Tab [CQCH]

Facility

$32.01

Service Code	NDC 51285016288
Hospital Charge Code	105928328
Hospital Revenue Code	251
Min. Negotiated Rate	$5.12
Max. Negotiated Rate	$28.81
Rate for Payer: Aetna of AZ Commercial	$28.81
Rate for Payer: Aetna of AZ Medicare	$8.96
Rate for Payer: Allwell Medicare	$5.12
Rate for Payer: Amerigroup Medicare	$5.12
Rate for Payer: APIPA Medicare/Medicaid	$11.96
Rate for Payer: AZCH Complete Medicare	$5.12
Rate for Payer: Banner UC Health Medicare	$5.12
Rate for Payer: Bisbee Police All Plans	$8.32
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$21.77
Rate for Payer: Cash Price	$25.61
Rate for Payer: Cigna of AZ Commercial	$20.81
Rate for Payer: Copperpoint Commercial	$7.92
Rate for Payer: Health Net of AZ Commercial	$19.21
Rate for Payer: Health Net of AZ Medicare	$8.96
Rate for Payer: Humana of AZ Medicare	$5.12
Rate for Payer: Self Pay Self Pay	$25.61
Rate for Payer: TriWest Medicare	$5.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$18.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$5.76

levonorgestrel 1.5 mg Tab [CQCH]

Facility

$32.01

Service Code	NDC 51285016288
Hospital Charge Code	105928328
Hospital Revenue Code	251
Min. Negotiated Rate	$8.32
Max. Negotiated Rate	$28.81
Rate for Payer: Aetna of AZ Commercial	$28.81
Rate for Payer: Bisbee Police All Plans	$8.32
Rate for Payer: Cash Price	$25.61
Rate for Payer: Self Pay Self Pay	$25.61

levothyroxine 100 mcg Tab [CQCH]

Facility

$0.15

Service Code	NDC 74662411
Hospital Charge Code	105928668
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
Rate for Payer: Aetna of AZ Medicare	$0.04
Rate for Payer: Allwell Medicare	$0.02
Rate for Payer: Amerigroup Medicare	$0.02
Rate for Payer: APIPA Medicare/Medicaid	$0.06
Rate for Payer: AZCH Complete Medicare	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.10
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of AZ Commercial	$0.10
Rate for Payer: Copperpoint Commercial	$0.04
Rate for Payer: Health Net of AZ Commercial	$0.09
Rate for Payer: Health Net of AZ Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Self Pay Self Pay	$0.12
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.09
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.03

levothyroxine 100 mcg Tab [CQCH]

Facility

$0.15

Service Code	NDC 74662411
Hospital Charge Code	105928668
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Cash Price	$0.12
Rate for Payer: Self Pay Self Pay	$0.12

levothyroxine 25 mcg Tab [CQCH]

Facility

$0.44

Service Code	NDC 51079044420
Hospital Charge Code	105928603
Hospital Revenue Code	251
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of AZ Commercial	$0.40
Rate for Payer: Bisbee Police All Plans	$0.11
Rate for Payer: Cash Price	$0.35
Rate for Payer: Self Pay Self Pay	$0.35

levothyroxine 25 mcg Tab [CQCH]

Facility

$0.44

Service Code	NDC 51079044420
Hospital Charge Code	105928603
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of AZ Commercial	$0.40
Rate for Payer: Aetna of AZ Medicare	$0.12
Rate for Payer: Allwell Medicare	$0.07
Rate for Payer: Amerigroup Medicare	$0.07
Rate for Payer: APIPA Medicare/Medicaid	$0.16
Rate for Payer: AZCH Complete Medicare	$0.07
Rate for Payer: Banner UC Health Medicare	$0.07
Rate for Payer: Bisbee Police All Plans	$0.11
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.30
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cigna of AZ Commercial	$0.29
Rate for Payer: Copperpoint Commercial	$0.11
Rate for Payer: Health Net of AZ Commercial	$0.26
Rate for Payer: Health Net of AZ Medicare	$0.12
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Self Pay Self Pay	$0.35
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.26
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.08

levothyroxine 50 mcg Tab [CQCH]

Facility

$0.37

Service Code	NDC 51079044020
Hospital Charge Code	105928521
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna of AZ Commercial	$0.33
Rate for Payer: Aetna of AZ Medicare	$0.10
Rate for Payer: Allwell Medicare	$0.06
Rate for Payer: Amerigroup Medicare	$0.06
Rate for Payer: APIPA Medicare/Medicaid	$0.14
Rate for Payer: AZCH Complete Medicare	$0.06
Rate for Payer: Banner UC Health Medicare	$0.06
Rate for Payer: Bisbee Police All Plans	$0.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.25
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cigna of AZ Commercial	$0.24
Rate for Payer: Copperpoint Commercial	$0.09
Rate for Payer: Health Net of AZ Commercial	$0.22
Rate for Payer: Health Net of AZ Medicare	$0.10
Rate for Payer: Humana of AZ Medicare	$0.06
Rate for Payer: Self Pay Self Pay	$0.30
Rate for Payer: TriWest Medicare	$0.06
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.22
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.07

levothyroxine 50 mcg Tab [CQCH]

Facility

$0.37

Service Code	NDC 51079044020
Hospital Charge Code	105928521
Hospital Revenue Code	251
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna of AZ Commercial	$0.33
Rate for Payer: Bisbee Police All Plans	$0.10
Rate for Payer: Cash Price	$0.30
Rate for Payer: Self Pay Self Pay	$0.30

levothyroxine 75 mcg Tab [CQCH]

Facility

$0.41

Service Code	NDC 51079044120
Hospital Charge Code	105928456
Hospital Revenue Code	251
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of AZ Commercial	$0.37
Rate for Payer: Bisbee Police All Plans	$0.11
Rate for Payer: Cash Price	$0.33
Rate for Payer: Self Pay Self Pay	$0.33

levothyroxine 75 mcg Tab [CQCH]

Facility

$0.41

Service Code	NDC 51079044120
Hospital Charge Code	105928456
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of AZ Commercial	$0.37
Rate for Payer: Aetna of AZ Medicare	$0.11
Rate for Payer: Allwell Medicare	$0.07
Rate for Payer: Amerigroup Medicare	$0.07
Rate for Payer: APIPA Medicare/Medicaid	$0.15
Rate for Payer: AZCH Complete Medicare	$0.07
Rate for Payer: Banner UC Health Medicare	$0.07
Rate for Payer: Bisbee Police All Plans	$0.11
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.28
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna of AZ Commercial	$0.27
Rate for Payer: Copperpoint Commercial	$0.10
Rate for Payer: Health Net of AZ Commercial	$0.25
Rate for Payer: Health Net of AZ Medicare	$0.11
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Self Pay Self Pay	$0.33
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.24
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.07

levothyroxine 88 mcg Tab [CQCH]

Facility

$0.31

Service Code	NDC 378180777
Hospital Charge Code	105928391
Hospital Revenue Code	251
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.28
Rate for Payer: Aetna of AZ Commercial	$0.28
Rate for Payer: Bisbee Police All Plans	$0.08
Rate for Payer: Cash Price	$0.25
Rate for Payer: Self Pay Self Pay	$0.25

levothyroxine 88 mcg Tab [CQCH]

Facility

$0.31

Service Code	NDC 378180777
Hospital Charge Code	105928391
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.28
Rate for Payer: Aetna of AZ Commercial	$0.28
Rate for Payer: Aetna of AZ Medicare	$0.09
Rate for Payer: Allwell Medicare	$0.05
Rate for Payer: Amerigroup Medicare	$0.05
Rate for Payer: APIPA Medicare/Medicaid	$0.12
Rate for Payer: AZCH Complete Medicare	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
Rate for Payer: Bisbee Police All Plans	$0.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.21
Rate for Payer: Cash Price	$0.25
Rate for Payer: Cigna of AZ Commercial	$0.20
Rate for Payer: Copperpoint Commercial	$0.08
Rate for Payer: Health Net of AZ Commercial	$0.19
Rate for Payer: Health Net of AZ Medicare	$0.09
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Self Pay Self Pay	$0.25
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.18
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.06

LH (LUTEINIZING HORMONE)

Facility

$519.00

Service Code	CPT 83002
Hospital Charge Code	22481490
Hospital Revenue Code	301
Min. Negotiated Rate	$134.94
Max. Negotiated Rate	$467.10
Rate for Payer: Aetna of AZ Commercial	$467.10
Rate for Payer: Bisbee Police All Plans	$134.94
Rate for Payer: Cash Price	$415.20
Rate for Payer: Self Pay Self Pay	$415.20

LH (LUTEINIZING HORMONE)

Facility

$519.00

Service Code	CPT 83002
Hospital Charge Code	22481490
Hospital Revenue Code	301
Min. Negotiated Rate	$83.04
Max. Negotiated Rate	$467.10
Rate for Payer: Aetna of AZ Commercial	$467.10
Rate for Payer: Aetna of AZ Medicare	$145.32
Rate for Payer: Allwell Medicare	$83.04
Rate for Payer: Amerigroup Medicare	$83.04
Rate for Payer: APIPA Medicare/Medicaid	$193.85
Rate for Payer: AZCH Complete Medicare	$83.04
Rate for Payer: Banner UC Health Medicare	$83.04
Rate for Payer: Bisbee Police All Plans	$134.94
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$352.92
Rate for Payer: Cash Price	$415.20
Rate for Payer: Cigna of AZ Commercial	$337.35
Rate for Payer: Copperpoint Commercial	$128.45
Rate for Payer: Health Net of AZ Commercial	$311.40
Rate for Payer: Health Net of AZ Medicare	$145.32
Rate for Payer: Humana of AZ Medicare	$83.04
Rate for Payer: Self Pay Self Pay	$415.20
Rate for Payer: TriWest Medicare	$83.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$302.58
Rate for Payer: UnitedHealth Group of AZ Medicare	$93.42

L HOOK TIP

Facility

$117.00

Hospital Charge Code	22354823
Hospital Revenue Code	270
Min. Negotiated Rate	$30.42
Max. Negotiated Rate	$105.30
Rate for Payer: Aetna of AZ Commercial	$105.30
Rate for Payer: Bisbee Police All Plans	$30.42
Rate for Payer: Cash Price	$93.60
Rate for Payer: Self Pay Self Pay	$93.60

L HOOK TIP

Facility

$117.00

Hospital Charge Code	22354823
Hospital Revenue Code	270
Min. Negotiated Rate	$18.72
Max. Negotiated Rate	$105.30
Rate for Payer: Aetna of AZ Commercial	$105.30
Rate for Payer: Aetna of AZ Medicare	$32.76
Rate for Payer: Allwell Medicare	$18.72
Rate for Payer: Amerigroup Medicare	$18.72
Rate for Payer: APIPA Medicare/Medicaid	$43.70
Rate for Payer: AZCH Complete Medicare	$18.72
Rate for Payer: Banner UC Health Medicare	$18.72
Rate for Payer: Bisbee Police All Plans	$30.42
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$79.56
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cigna of AZ Commercial	$81.90
Rate for Payer: Copperpoint Commercial	$28.96
Rate for Payer: Health Net of AZ Commercial	$70.20
Rate for Payer: Health Net of AZ Medicare	$32.76
Rate for Payer: Humana of AZ Medicare	$18.72
Rate for Payer: Self Pay Self Pay	$93.60
Rate for Payer: TriWest Medicare	$18.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$68.21
Rate for Payer: UnitedHealth Group of AZ Medicare	$21.06

lidocaine 0.5% Inj Sol 50 mL [CQCH]

Facility

$0.05

Service Code	HCPCS J2001
Hospital Charge Code	105928737
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.04
Rate for Payer: Self Pay Self Pay	$0.04

Know your out-of-pocket cost for care.

All Charges