Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

KWIRE SMOOTH DOUBLE TROCAR 062INX9IN

Facility

$41.00

Hospital Charge Code	24100619
Hospital Revenue Code	270
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of AZ Commercial	$36.90
Rate for Payer: Cash Price	$32.80

KWIRE SMOOTH DOUBLE TROCAR 062INX9IN

Facility

$41.00

Hospital Charge Code	24100619
Hospital Revenue Code	270
Min. Negotiated Rate	$6.49
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of AZ Commercial	$36.90
Rate for Payer: Arizona Complete Health Allwell	$6.56
Rate for Payer: Banner UC Health Medicare	$6.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$27.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.56
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cigna of AZ Commercial	$28.70
Rate for Payer: Devoted Health Medicare	$7.38
Rate for Payer: Humana of AZ Medicare	$6.56
Rate for Payer: Southwest Service Administrators UFCW	$27.88
Rate for Payer: TriWest Medicare	$6.56
Rate for Payer: United Healthcare Commercial	$23.45
Rate for Payer: United Healthcare Medicare	$6.56
Rate for Payer: Veterans Affairs TRICARE	$6.49

KYLEENA IUD CQCH_AZ

Facility

$1,490.00

Service Code	HCPCS J7296
Hospital Charge Code	28228886
Hospital Revenue Code	272
Min. Negotiated Rate	$1,341.00
Max. Negotiated Rate	$1,341.00
Rate for Payer: Aetna of AZ Commercial	$1,341.00
Rate for Payer: Cash Price	$1,192.00

KYLEENA IUD CQCH_AZ

Facility

$1,490.00

Service Code	HCPCS J7296
Hospital Charge Code	28228886
Hospital Revenue Code	272
Min. Negotiated Rate	$236.02
Max. Negotiated Rate	$1,341.00
Rate for Payer: Aetna of AZ Commercial	$1,341.00
Rate for Payer: Arizona Complete Health Allwell	$238.40
Rate for Payer: Banner UC Health Medicare	$238.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,013.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$238.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$238.40
Rate for Payer: Cash Price	$1,192.00
Rate for Payer: Cigna of AZ Commercial	$1,043.00
Rate for Payer: Devoted Health Medicare	$268.20
Rate for Payer: Humana of AZ Medicare	$238.40
Rate for Payer: Southwest Service Administrators UFCW	$1,013.20
Rate for Payer: TriWest Medicare	$238.40
Rate for Payer: United Healthcare Commercial	$852.28
Rate for Payer: United Healthcare Medicare	$238.40
Rate for Payer: Veterans Affairs TRICARE	$236.02

L0120 Cervical Collar Only Clinic Charge

Facility

$9.00

Service Code	HCPCS L0120
Hospital Charge Code	10410970
Hospital Revenue Code	521
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Arizona Complete Health Allwell	$1.44
Rate for Payer: Banner UC Health Medicare	$1.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$6.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.44
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna of AZ Commercial	$6.30
Rate for Payer: Devoted Health Medicare	$1.62
Rate for Payer: Humana of AZ Medicare	$1.44
Rate for Payer: Southwest Service Administrators UFCW	$6.12
Rate for Payer: TriWest Medicare	$1.44
Rate for Payer: United Healthcare Commercial	$5.15
Rate for Payer: United Healthcare Medicare	$1.44
Rate for Payer: Veterans Affairs TRICARE	$1.43

L0120 Cervical Collar Only Clinic Charge

Facility

$9.00

Service Code	HCPCS L0120
Hospital Charge Code	10410970
Hospital Revenue Code	521
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Cash Price	$7.20

L300 Brace, Foot CQCH

Facility

$247.00

Service Code	HCPCS L3000
Hospital Charge Code	24317908
Hospital Revenue Code	521
Min. Negotiated Rate	$39.12
Max. Negotiated Rate	$222.30
Rate for Payer: Aetna of AZ Commercial	$222.30
Rate for Payer: Arizona Complete Health Allwell	$39.52
Rate for Payer: Banner UC Health Medicare	$39.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$167.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$39.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$39.52
Rate for Payer: Cash Price	$197.60
Rate for Payer: Cigna of AZ Commercial	$172.90
Rate for Payer: Devoted Health Medicare	$44.46
Rate for Payer: Humana of AZ Medicare	$39.52
Rate for Payer: Southwest Service Administrators UFCW	$167.96
Rate for Payer: TriWest Medicare	$39.52
Rate for Payer: United Healthcare Commercial	$141.28
Rate for Payer: United Healthcare Medicare	$39.52
Rate for Payer: Veterans Affairs TRICARE	$39.12

L300 Brace, Foot CQCH

Facility

$247.00

Service Code	HCPCS L3000
Hospital Charge Code	24317908
Hospital Revenue Code	521
Min. Negotiated Rate	$222.30
Max. Negotiated Rate	$222.30
Rate for Payer: Aetna of AZ Commercial	$222.30
Rate for Payer: Cash Price	$197.60

labetalol 100 mg Tab UD [CQCH]

Facility

$0.25

Service Code	NDC 51079092820
Hospital Charge Code	107742758
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of AZ Commercial	$0.23
Rate for Payer: Arizona Complete Health Allwell	$0.04
Rate for Payer: Banner UC Health Medicare	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.17
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.04
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna of AZ Commercial	$0.16
Rate for Payer: Devoted Health Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Southwest Service Administrators UFCW	$0.17
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: United Healthcare Commercial	$0.14
Rate for Payer: United Healthcare Medicare	$0.04
Rate for Payer: Veterans Affairs TRICARE	$0.04

labetalol 100 mg Tab UD [CQCH]

Facility

$0.25

Service Code	NDC 51079092820
Hospital Charge Code	107742758
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of AZ Commercial	$0.23
Rate for Payer: Cash Price	$0.20

labetalol 5 mg/mL IV Sol [CQCH]

Facility

$0.11

Service Code	NDC 143932001
Hospital Charge Code	105927646
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of AZ Commercial	$0.10
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	$0.07
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	$0.09
Rate for Payer: Cigna of AZ Commercial	$0.07
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.07
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.06
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

labetalol 5 mg/mL IV Sol [CQCH]

Facility

$0.11

Service Code	NDC 143932001
Hospital Charge Code	105927646
Hospital Revenue Code	251
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of AZ Commercial	$0.10
Rate for Payer: Cash Price	$0.09

Lacosamide LC

Facility

$1,264.00

Service Code	CPT 80339
Hospital Charge Code	2087619
Hospital Revenue Code	301
Min. Negotiated Rate	$1,137.60
Max. Negotiated Rate	$1,137.60
Rate for Payer: Aetna of AZ Commercial	$1,137.60
Rate for Payer: Aetna of AZ Commercial	$846.90
Rate for Payer: Cash Price	$1,011.20
Rate for Payer: Cash Price	$752.80

Lacosamide LC

Facility

$941.00

Service Code	CPT 80339
Hospital Charge Code	2087619
Hospital Revenue Code	301
Min. Negotiated Rate	$149.05
Max. Negotiated Rate	$846.90
Rate for Payer: Aetna of AZ Commercial	$846.90
Rate for Payer: Aetna of AZ Commercial	$1,137.60
Rate for Payer: Arizona Complete Health Allwell	$202.24
Rate for Payer: Arizona Complete Health Allwell	$150.56
Rate for Payer: Banner UC Health Medicare	$202.24
Rate for Payer: Banner UC Health Medicare	$150.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$859.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$639.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$150.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$202.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$150.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$202.24
Rate for Payer: Cash Price	$1,011.20
Rate for Payer: Cash Price	$752.80
Rate for Payer: Cigna of AZ Commercial	$821.60
Rate for Payer: Cigna of AZ Commercial	$611.65
Rate for Payer: Devoted Health Medicare	$169.38
Rate for Payer: Devoted Health Medicare	$227.52
Rate for Payer: Humana of AZ Medicare	$150.56
Rate for Payer: Humana of AZ Medicare	$202.24
Rate for Payer: Southwest Service Administrators UFCW	$639.88
Rate for Payer: Southwest Service Administrators UFCW	$859.52
Rate for Payer: TriWest Medicare	$202.24
Rate for Payer: TriWest Medicare	$150.56
Rate for Payer: United Healthcare Commercial	$538.25
Rate for Payer: United Healthcare Commercial	$723.01
Rate for Payer: United Healthcare Medicare	$202.24
Rate for Payer: United Healthcare Medicare	$150.56
Rate for Payer: Veterans Affairs TRICARE	$200.22
Rate for Payer: Veterans Affairs TRICARE	$149.05

Lactate

Facility

$243.00

Service Code	CPT 83605
Hospital Charge Code	9578903
Hospital Revenue Code	301
Min. Negotiated Rate	$16.78
Max. Negotiated Rate	$218.70
Rate for Payer: Aetna of AZ Commercial	$218.70
Rate for Payer: Arizona Complete Health Allwell	$38.88
Rate for Payer: Banner UC Health Medicare	$38.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$165.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.88
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cigna of AZ Commercial	$157.95
Rate for Payer: Devoted Health Medicare	$43.74
Rate for Payer: Humana of AZ Medicare	$38.88
Rate for Payer: Seven Corners Travel Insurance	$16.78
Rate for Payer: Southwest Service Administrators UFCW	$165.24
Rate for Payer: TriWest Medicare	$38.88
Rate for Payer: United Healthcare Commercial	$139.00
Rate for Payer: United Healthcare Medicare	$38.88
Rate for Payer: Veterans Affairs TRICARE	$38.49

Lactate

Facility

$243.00

Service Code	CPT 83605
Hospital Charge Code	9578903
Hospital Revenue Code	301
Min. Negotiated Rate	$218.70
Max. Negotiated Rate	$218.70
Rate for Payer: Aetna of AZ Commercial	$218.70
Rate for Payer: Cash Price	$194.40

Lactate Dehydrogenase

Facility

$69.00

Service Code	CPT 83615
Hospital Charge Code	633770
Hospital Revenue Code	301
Min. Negotiated Rate	$8.76
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Arizona Complete Health Allwell	$11.04
Rate for Payer: Banner UC Health Medicare	$11.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$46.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.04
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cigna of AZ Commercial	$44.85
Rate for Payer: Devoted Health Medicare	$12.42
Rate for Payer: Humana of AZ Medicare	$11.04
Rate for Payer: Seven Corners Travel Insurance	$8.76
Rate for Payer: Southwest Service Administrators UFCW	$46.92
Rate for Payer: TriWest Medicare	$11.04
Rate for Payer: United Healthcare Commercial	$39.47
Rate for Payer: United Healthcare Medicare	$11.04
Rate for Payer: Veterans Affairs TRICARE	$10.93

Lactate Dehydrogenase

Facility

$69.00

Service Code	CPT 83615
Hospital Charge Code	633770
Hospital Revenue Code	301
Min. Negotiated Rate	$62.10
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Cash Price	$55.20

Lactated Ringers IV Sol 1000 ml [CQCH]

Facility

$0.01

Service Code	HCPCS J7120
Hospital Charge Code	107734454
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Arizona Complete Health Allwell	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.00
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Devoted Health Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Southwest Service Administrators UFCW	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: United Healthcare Commercial	$0.01
Rate for Payer: United Healthcare Medicare	$0.00
Rate for Payer: Veterans Affairs TRICARE	$0.00

Lactated Ringers IV Sol 1000 ml [CQCH]

Facility

$0.01

Service Code	HCPCS J7120
Hospital Charge Code	107734454
Hospital Revenue Code	258
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01

Lactoferrin

Facility

$236.00

Service Code	CPT 83630
Hospital Charge Code	1853551
Hospital Revenue Code	301
Min. Negotiated Rate	$212.40
Max. Negotiated Rate	$212.40
Rate for Payer: Aetna of AZ Commercial	$212.40
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Cash Price	$188.80
Rate for Payer: Cash Price	$140.00

Lactoferrin

Facility

$175.00

Service Code	CPT 83630
Hospital Charge Code	1853551
Hospital Revenue Code	301
Min. Negotiated Rate	$27.72
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Aetna of AZ Commercial	$212.40
Rate for Payer: Arizona Complete Health Allwell	$37.76
Rate for Payer: Arizona Complete Health Allwell	$28.00
Rate for Payer: Banner UC Health Medicare	$37.76
Rate for Payer: Banner UC Health Medicare	$28.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$119.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$160.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$37.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.76
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cash Price	$188.80
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cash Price	$188.80
Rate for Payer: Cigna of AZ Commercial	$153.40
Rate for Payer: Cigna of AZ Commercial	$113.75
Rate for Payer: Devoted Health Medicare	$42.48
Rate for Payer: Devoted Health Medicare	$31.50
Rate for Payer: Humana of AZ Medicare	$28.00
Rate for Payer: Humana of AZ Medicare	$37.76
Rate for Payer: Seven Corners Travel Insurance	$28.57
Rate for Payer: Seven Corners Travel Insurance	$28.57
Rate for Payer: Southwest Service Administrators UFCW	$160.48
Rate for Payer: Southwest Service Administrators UFCW	$119.00
Rate for Payer: TriWest Medicare	$28.00
Rate for Payer: TriWest Medicare	$37.76
Rate for Payer: United Healthcare Commercial	$100.10
Rate for Payer: United Healthcare Commercial	$134.99
Rate for Payer: United Healthcare Medicare	$28.00
Rate for Payer: United Healthcare Medicare	$37.76
Rate for Payer: Veterans Affairs TRICARE	$37.38
Rate for Payer: Veterans Affairs TRICARE	$27.72

Lactoferrin, Fecal, Quant. LC

Facility

$233.00

Service Code	CPT 83631
Hospital Charge Code	22311197
Hospital Revenue Code	301
Min. Negotiated Rate	$209.70
Max. Negotiated Rate	$209.70
Rate for Payer: Aetna of AZ Commercial	$209.70
Rate for Payer: Cash Price	$186.40

Lactoferrin, Fecal, Quant. LC

Facility

$233.00

Service Code	CPT 83631
Hospital Charge Code	22311197
Hospital Revenue Code	301
Min. Negotiated Rate	$28.46
Max. Negotiated Rate	$209.70
Rate for Payer: Aetna of AZ Commercial	$209.70
Rate for Payer: Arizona Complete Health Allwell	$37.28
Rate for Payer: Banner UC Health Medicare	$37.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$158.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$37.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.28
Rate for Payer: Cash Price	$186.40
Rate for Payer: Cash Price	$186.40
Rate for Payer: Cigna of AZ Commercial	$151.45
Rate for Payer: Devoted Health Medicare	$41.94
Rate for Payer: Humana of AZ Medicare	$37.28
Rate for Payer: Seven Corners Travel Insurance	$28.46
Rate for Payer: Southwest Service Administrators UFCW	$158.44
Rate for Payer: TriWest Medicare	$37.28
Rate for Payer: United Healthcare Commercial	$133.28
Rate for Payer: United Healthcare Medicare	$37.28
Rate for Payer: Veterans Affairs TRICARE	$36.91

lactulose 20 gm/30 mL Oral Syrup UD [CQCH]

Facility

$0.01

Service Code	NDC 121457730
Hospital Charge Code	105927775
Hospital Revenue Code	251
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Arizona Complete Health Allwell	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Devoted Health Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Southwest Service Administrators UFCW	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: United Healthcare Commercial	$0.01
Rate for Payer: United Healthcare Medicare	$0.00
Rate for Payer: Veterans Affairs TRICARE	$0.00

Know your out-of-pocket cost for care.

All Charges