Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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

LAMBDA FREE LT CHAIN QNT

Facility

$274.00

Service Code	CPT 83883
Hospital Charge Code	22481488
Hospital Revenue Code	301
Min. Negotiated Rate	$19.72
Max. Negotiated Rate	$246.60
Rate for Payer: Aetna of AZ Commercial	$246.60
Rate for Payer: Arizona Complete Health Allwell	$43.84
Rate for Payer: Banner UC Health Medicare	$43.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$186.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$43.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.84
Rate for Payer: Cash Price	$219.20
Rate for Payer: Cash Price	$219.20
Rate for Payer: Cigna of AZ Commercial	$178.10
Rate for Payer: Devoted Health Medicare	$49.32
Rate for Payer: Humana of AZ Medicare	$43.84
Rate for Payer: Seven Corners Travel Insurance	$19.72
Rate for Payer: Southwest Service Administrators UFCW	$186.32
Rate for Payer: TriWest Medicare	$43.84
Rate for Payer: United Healthcare Commercial	$156.73
Rate for Payer: United Healthcare Medicare	$43.84
Rate for Payer: Veterans Affairs TRICARE	$43.40

LAMBDA FREE LT CHAIN QNT

Facility

$274.00

Service Code	CPT 83883
Hospital Charge Code	22481488
Hospital Revenue Code	301
Min. Negotiated Rate	$246.60
Max. Negotiated Rate	$246.60
Rate for Payer: Aetna of AZ Commercial	$246.60
Rate for Payer: Cash Price	$219.20

lamoTRIgine 100 mg Tab [CQCH]

Facility

$0.13

Service Code	NDC 904700861
Hospital Charge Code	105950212
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
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	$0.09
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	$0.10
Rate for Payer: Cigna of AZ Commercial	$0.08
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.09
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.07
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

lamoTRIgine 100 mg Tab [CQCH]

Facility

$0.13

Service Code	NDC 904700861
Hospital Charge Code	105950212
Hospital Revenue Code	251
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Cash Price	$0.10

Lamotrigine (Lamictal), Serum LC

Facility

$321.00

Service Code	CPT 80299
Hospital Charge Code	1905811
Hospital Revenue Code	301
Min. Negotiated Rate	$288.90
Max. Negotiated Rate	$288.90
Rate for Payer: Aetna of AZ Commercial	$288.90
Rate for Payer: Cash Price	$256.80

Lamotrigine (Lamictal), Serum LC

Facility

$321.00

Service Code	CPT 80299
Hospital Charge Code	1905811
Hospital Revenue Code	301
Min. Negotiated Rate	$27.03
Max. Negotiated Rate	$288.90
Rate for Payer: Aetna of AZ Commercial	$288.90
Rate for Payer: Arizona Complete Health Allwell	$51.36
Rate for Payer: Banner UC Health Medicare	$51.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$218.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$51.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$51.36
Rate for Payer: Cash Price	$256.80
Rate for Payer: Cash Price	$256.80
Rate for Payer: Cigna of AZ Commercial	$208.65
Rate for Payer: Devoted Health Medicare	$57.78
Rate for Payer: Humana of AZ Medicare	$51.36
Rate for Payer: Seven Corners Travel Insurance	$27.03
Rate for Payer: Southwest Service Administrators UFCW	$218.28
Rate for Payer: TriWest Medicare	$51.36
Rate for Payer: United Healthcare Commercial	$183.61
Rate for Payer: United Healthcare Medicare	$51.36
Rate for Payer: Veterans Affairs TRICARE	$50.85

Laparoscopic burch

Facility

$4,037.00

Service Code	CPT 51990
Hospital Charge Code	27267839
Hospital Revenue Code	360
Min. Negotiated Rate	$639.46
Max. Negotiated Rate	$9,354.07
Rate for Payer: Aetna of AZ Commercial	$3,633.30
Rate for Payer: Arizona Complete Health Allwell	$645.92
Rate for Payer: Banner UC Health Medicare	$1,984.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,745.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$645.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$645.92
Rate for Payer: Cash Price	$3,229.60
Rate for Payer: Cash Price	$3,229.60
Rate for Payer: Cash Price	$3,229.60
Rate for Payer: Cigna of AZ Commercial	$2,018.50
Rate for Payer: Devoted Health Medicare	$726.66
Rate for Payer: Humana of AZ Medicare	$645.92
Rate for Payer: NaphCare Correctional Healthcare	$1,984.28
Rate for Payer: Seven Corners Travel Insurance	$9,354.07
Rate for Payer: Southwest Service Administrators UFCW	$2,745.16
Rate for Payer: TriWest Medicare	$645.92
Rate for Payer: United Healthcare Commercial	$6,508.00
Rate for Payer: United Healthcare Medicare	$645.92
Rate for Payer: Veterans Affairs TRICARE	$639.46

Laparoscopic burch

Facility

$4,037.00

Service Code	CPT 51990
Hospital Charge Code	27267839
Hospital Revenue Code	360
Min. Negotiated Rate	$3,633.30
Max. Negotiated Rate	$3,633.30
Rate for Payer: Aetna of AZ Commercial	$3,633.30
Rate for Payer: Cash Price	$3,229.60

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC

Facility

$21,862.48

Service Code	MSDRG 418
Min. Negotiated Rate	$21,862.48
Max. Negotiated Rate	$21,862.48
Rate for Payer: Seven Corners Travel Insurance	$21,862.48

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC

Facility

$30,842.17

Service Code	MSDRG 417
Min. Negotiated Rate	$30,842.17
Max. Negotiated Rate	$30,842.17
Rate for Payer: Seven Corners Travel Insurance	$30,842.17

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC

Facility

$17,661.72

Service Code	MSDRG 419
Min. Negotiated Rate	$17,661.72
Max. Negotiated Rate	$17,661.72
Rate for Payer: Seven Corners Travel Insurance	$17,661.72

Laparoscopic myomectomy

Facility

$5,082.00

Service Code	CPT 58140
Hospital Charge Code	27281908
Hospital Revenue Code	360
Min. Negotiated Rate	$4,573.80
Max. Negotiated Rate	$4,573.80
Rate for Payer: Aetna of AZ Commercial	$4,573.80
Rate for Payer: Cash Price	$4,065.60

Laparoscopic myomectomy

Facility

$5,082.00

Service Code	CPT 58140
Hospital Charge Code	27281908
Hospital Revenue Code	360
Min. Negotiated Rate	$804.99
Max. Negotiated Rate	$4,838.00
Rate for Payer: Aetna of AZ Commercial	$4,573.80
Rate for Payer: Arizona Complete Health Allwell	$813.12
Rate for Payer: Banner UC Health Medicare	$813.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,455.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$813.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$813.12
Rate for Payer: Cash Price	$4,065.60
Rate for Payer: Cash Price	$4,065.60
Rate for Payer: Cigna of AZ Commercial	$2,541.00
Rate for Payer: Devoted Health Medicare	$914.76
Rate for Payer: Humana of AZ Medicare	$813.12
Rate for Payer: Southwest Service Administrators UFCW	$3,455.76
Rate for Payer: TriWest Medicare	$813.12
Rate for Payer: United Healthcare Commercial	$4,838.00
Rate for Payer: United Healthcare Medicare	$813.12
Rate for Payer: Veterans Affairs TRICARE	$804.99

LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)

Facility

$9,354.07

Service Code	CPT 49320
Hospital Revenue Code	360
Min. Negotiated Rate	$1,984.28
Max. Negotiated Rate	$9,354.07
Rate for Payer: Banner UC Health Medicare	$1,984.28
Rate for Payer: NaphCare Correctional Healthcare	$1,984.28
Rate for Payer: Seven Corners Travel Insurance	$9,354.07
Rate for Payer: United Healthcare Commercial	$5,611.00

Laparoscopy lysis of adhesiions

Facility

$1,352.00

Service Code	CPT 58660
Hospital Charge Code	27281902
Hospital Revenue Code	360
Min. Negotiated Rate	$214.16
Max. Negotiated Rate	$9,354.07
Rate for Payer: Aetna of AZ Commercial	$1,216.80
Rate for Payer: Arizona Complete Health Allwell	$216.32
Rate for Payer: Banner UC Health Medicare	$1,984.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$919.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$216.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$216.32
Rate for Payer: Cash Price	$1,081.60
Rate for Payer: Cash Price	$1,081.60
Rate for Payer: Cash Price	$1,081.60
Rate for Payer: Cigna of AZ Commercial	$676.00
Rate for Payer: Devoted Health Medicare	$243.36
Rate for Payer: Humana of AZ Medicare	$216.32
Rate for Payer: NaphCare Correctional Healthcare	$1,984.28
Rate for Payer: Seven Corners Travel Insurance	$9,354.07
Rate for Payer: Southwest Service Administrators UFCW	$919.36
Rate for Payer: TriWest Medicare	$216.32
Rate for Payer: United Healthcare Commercial	$6,508.00
Rate for Payer: United Healthcare Medicare	$216.32
Rate for Payer: Veterans Affairs TRICARE	$214.16

Laparoscopy lysis of adhesiions

Facility

$1,352.00

Service Code	CPT 58660
Hospital Charge Code	27281902
Hospital Revenue Code	360
Min. Negotiated Rate	$1,216.80
Max. Negotiated Rate	$1,216.80
Rate for Payer: Aetna of AZ Commercial	$1,216.80
Rate for Payer: Cash Price	$1,081.60

Laparoscopy, surgical, appendectomy

Facility

$9,354.07

Service Code	CPT 44970
Hospital Revenue Code	360
Min. Negotiated Rate	$1,984.28
Max. Negotiated Rate	$9,354.07
Rate for Payer: Banner UC Health Medicare	$1,984.28
Rate for Payer: NaphCare Correctional Healthcare	$1,984.28
Rate for Payer: Seven Corners Travel Insurance	$9,354.07
Rate for Payer: United Healthcare Commercial	$6,508.00

Laparoscopy, surgical; cholecystectomy

Facility

$9,354.07

Service Code	CPT 47562
Hospital Revenue Code	490
Min. Negotiated Rate	$1,984.28
Max. Negotiated Rate	$9,354.07
Rate for Payer: Banner UC Health Medicare	$1,984.28
Rate for Payer: NaphCare Correctional Healthcare	$1,984.28
Rate for Payer: Seven Corners Travel Insurance	$9,354.07
Rate for Payer: United Healthcare Commercial	$6,508.00

Laparoscopy, surgical; cholecystectomy

Facility

$9,354.07

Service Code	CPT 47562
Hospital Revenue Code	360
Min. Negotiated Rate	$1,984.28
Max. Negotiated Rate	$9,354.07
Rate for Payer: Banner UC Health Medicare	$1,984.28
Rate for Payer: NaphCare Correctional Healthcare	$1,984.28
Rate for Payer: Seven Corners Travel Insurance	$9,354.07
Rate for Payer: United Healthcare Commercial	$6,508.00

Laparoscopy, surgical; cholecystectomy with cholangiography

Facility

$9,354.07

Service Code	CPT 47563
Hospital Revenue Code	360
Min. Negotiated Rate	$1,984.28
Max. Negotiated Rate	$9,354.07
Rate for Payer: Banner UC Health Medicare	$1,984.28
Rate for Payer: NaphCare Correctional Healthcare	$1,984.28
Rate for Payer: Seven Corners Travel Insurance	$9,354.07
Rate for Payer: United Healthcare Commercial	$6,508.00

Laparoscopy, surgical; repair initial inguinal hernia

Facility

$9,354.07

Service Code	CPT 49650
Hospital Revenue Code	360
Min. Negotiated Rate	$1,984.28
Max. Negotiated Rate	$9,354.07
Rate for Payer: Banner UC Health Medicare	$1,984.28
Rate for Payer: NaphCare Correctional Healthcare	$1,984.28
Rate for Payer: Seven Corners Travel Insurance	$9,354.07
Rate for Payer: United Healthcare Commercial	$6,508.00

LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA

Facility

$2,938.00

Service Code	CPT 49650
Hospital Charge Code	2612672
Min. Negotiated Rate	$2,644.20
Max. Negotiated Rate	$2,644.20
Rate for Payer: Aetna of AZ Commercial	$2,644.20
Rate for Payer: Cash Price	$2,350.40

LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA

Facility

$2,938.00

Service Code	CPT 49650
Hospital Charge Code	2612672
Min. Negotiated Rate	$465.38
Max. Negotiated Rate	$9,354.07
Rate for Payer: Aetna of AZ Commercial	$2,644.20
Rate for Payer: Arizona Complete Health Allwell	$470.08
Rate for Payer: Banner UC Health Medicare	$470.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,997.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$470.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$470.08
Rate for Payer: Cash Price	$2,350.40
Rate for Payer: Cash Price	$2,350.40
Rate for Payer: Cigna of AZ Commercial	$2,056.60
Rate for Payer: Devoted Health Medicare	$528.84
Rate for Payer: Humana of AZ Medicare	$470.08
Rate for Payer: Seven Corners Travel Insurance	$9,354.07
Rate for Payer: Southwest Service Administrators UFCW	$1,997.84
Rate for Payer: TriWest Medicare	$470.08
Rate for Payer: United Healthcare Commercial	$1,680.54
Rate for Payer: United Healthcare Medicare	$470.08
Rate for Payer: Veterans Affairs TRICARE	$465.38

LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINEN

Facility

$19,694.00

Service Code	CPT 51992
Hospital Charge Code	23093915
Hospital Revenue Code	360
Min. Negotiated Rate	$17,724.60
Max. Negotiated Rate	$17,724.60
Rate for Payer: Aetna of AZ Commercial	$17,724.60
Rate for Payer: Cash Price	$15,755.20

Know your out-of-pocket cost for care.

All Charges