Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

LEOS 3.5MM LOCKING SCREW 8MM

Facility

$2,595.00

Hospital Charge Code	27808545
Hospital Revenue Code	270
Min. Negotiated Rate	$411.05
Max. Negotiated Rate	$2,335.50
Rate for Payer: Aetna of AZ Commercial	$2,335.50
Rate for Payer: Arizona Complete Health Allwell	$415.20
Rate for Payer: Banner UC Health Medicare	$415.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,764.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$415.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$415.20
Rate for Payer: Cash Price	$2,076.00
Rate for Payer: Cigna of AZ Commercial	$1,816.50
Rate for Payer: Devoted Health Medicare	$467.10
Rate for Payer: Humana of AZ Medicare	$415.20
Rate for Payer: Southwest Service Administrators UFCW	$1,764.60
Rate for Payer: TriWest Medicare	$415.20
Rate for Payer: United Healthcare Commercial	$1,484.34
Rate for Payer: United Healthcare Medicare	$415.20
Rate for Payer: Veterans Affairs TRICARE	$411.05

LEOS MTP PLATE SM 5 DEGREE LT

Facility

$18,675.00

Hospital Charge Code	27810503
Hospital Revenue Code	270
Min. Negotiated Rate	$16,807.50
Max. Negotiated Rate	$16,807.50
Rate for Payer: Aetna of AZ Commercial	$16,807.50
Rate for Payer: Cash Price	$14,940.00

LEOS MTP PLATE SM 5 DEGREE LT

Facility

$18,675.00

Hospital Charge Code	27810503
Hospital Revenue Code	270
Min. Negotiated Rate	$2,958.12
Max. Negotiated Rate	$16,807.50
Rate for Payer: Aetna of AZ Commercial	$16,807.50
Rate for Payer: Arizona Complete Health Allwell	$2,988.00
Rate for Payer: Banner UC Health Medicare	$2,988.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$12,699.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2,988.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$2,988.00
Rate for Payer: Cash Price	$14,940.00
Rate for Payer: Cigna of AZ Commercial	$13,072.50
Rate for Payer: Devoted Health Medicare	$3,361.50
Rate for Payer: Humana of AZ Medicare	$2,988.00
Rate for Payer: Southwest Service Administrators UFCW	$12,699.00
Rate for Payer: TriWest Medicare	$2,988.00
Rate for Payer: United Healthcare Commercial	$10,682.10
Rate for Payer: United Healthcare Medicare	$2,988.00
Rate for Payer: Veterans Affairs TRICARE	$2,958.12

LEOS PLATE TACK 10MM

Facility

$1,260.00

Hospital Charge Code	27595626
Hospital Revenue Code	270
Min. Negotiated Rate	$199.58
Max. Negotiated Rate	$1,134.00
Rate for Payer: Aetna of AZ Commercial	$1,134.00
Rate for Payer: Arizona Complete Health Allwell	$201.60
Rate for Payer: Banner UC Health Medicare	$201.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$856.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$201.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$201.60
Rate for Payer: Cash Price	$1,008.00
Rate for Payer: Cigna of AZ Commercial	$882.00
Rate for Payer: Devoted Health Medicare	$226.80
Rate for Payer: Humana of AZ Medicare	$201.60
Rate for Payer: Southwest Service Administrators UFCW	$856.80
Rate for Payer: TriWest Medicare	$201.60
Rate for Payer: United Healthcare Commercial	$720.72
Rate for Payer: United Healthcare Medicare	$201.60
Rate for Payer: Veterans Affairs TRICARE	$199.58

LEOS PLATE TACK 10MM

Facility

$1,260.00

Hospital Charge Code	27595626
Hospital Revenue Code	270
Min. Negotiated Rate	$1,134.00
Max. Negotiated Rate	$1,134.00
Rate for Payer: Aetna of AZ Commercial	$1,134.00
Rate for Payer: Cash Price	$1,008.00

LEOS PLATE TACK 20MM

Facility

$1,245.00

Hospital Charge Code	27702569
Hospital Revenue Code	270
Min. Negotiated Rate	$197.21
Max. Negotiated Rate	$1,120.50
Rate for Payer: Aetna of AZ Commercial	$1,120.50
Rate for Payer: Arizona Complete Health Allwell	$199.20
Rate for Payer: Banner UC Health Medicare	$199.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$846.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$199.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$199.20
Rate for Payer: Cash Price	$996.00
Rate for Payer: Cigna of AZ Commercial	$871.50
Rate for Payer: Devoted Health Medicare	$224.10
Rate for Payer: Humana of AZ Medicare	$199.20
Rate for Payer: Southwest Service Administrators UFCW	$846.60
Rate for Payer: TriWest Medicare	$199.20
Rate for Payer: United Healthcare Commercial	$712.14
Rate for Payer: United Healthcare Medicare	$199.20
Rate for Payer: Veterans Affairs TRICARE	$197.21

LEOS PLATE TACK 20MM

Facility

$1,245.00

Hospital Charge Code	27702569
Hospital Revenue Code	270
Min. Negotiated Rate	$1,120.50
Max. Negotiated Rate	$1,120.50
Rate for Payer: Aetna of AZ Commercial	$1,120.50
Rate for Payer: Cash Price	$996.00

LETs Topical Gel[CQCH]

Facility

$3.93

Service Code	NDC 51552153601
Hospital Charge Code	138784370
Hospital Revenue Code	250
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$3.54
Rate for Payer: Aetna of AZ Commercial	$3.54
Rate for Payer: Arizona Complete Health Allwell	$0.63
Rate for Payer: Banner UC Health Medicare	$0.63
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2.67
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.63
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.63
Rate for Payer: Cash Price	$3.14
Rate for Payer: Cigna of AZ Commercial	$2.55
Rate for Payer: Devoted Health Medicare	$0.71
Rate for Payer: Humana of AZ Medicare	$0.63
Rate for Payer: Southwest Service Administrators UFCW	$2.67
Rate for Payer: TriWest Medicare	$0.63
Rate for Payer: United Healthcare Commercial	$2.25
Rate for Payer: United Healthcare Medicare	$0.63
Rate for Payer: Veterans Affairs TRICARE	$0.62

LETs Topical Gel[CQCH]

Facility

$3.93

Service Code	NDC 51552153601
Hospital Charge Code	138784370
Hospital Revenue Code	250
Min. Negotiated Rate	$3.54
Max. Negotiated Rate	$3.54
Rate for Payer: Aetna of AZ Commercial	$3.54
Rate for Payer: Cash Price	$3.14

levalbuterol 1.25 mg/0.5 mL Inh Sol UD [CQCH]

Facility

$1.51

Service Code	HCPCS J7614
Hospital Charge Code	105927907
Hospital Revenue Code	250
Min. Negotiated Rate	$1.36
Max. Negotiated Rate	$1.36
Rate for Payer: Aetna of AZ Commercial	$1.36
Rate for Payer: Cash Price	$1.21

levalbuterol 1.25 mg/0.5 mL Inh Sol UD [CQCH]

Facility

$1.51

Service Code	HCPCS J7614
Hospital Charge Code	105927907
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$1.36
Rate for Payer: Aetna of AZ Commercial	$1.36
Rate for Payer: Arizona Complete Health Allwell	$0.24
Rate for Payer: Banner UC Health Medicare	$0.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.03
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.24
Rate for Payer: Cash Price	$1.21
Rate for Payer: Cigna of AZ Commercial	$0.98
Rate for Payer: Devoted Health Medicare	$0.27
Rate for Payer: Humana of AZ Medicare	$0.24
Rate for Payer: Southwest Service Administrators UFCW	$1.03
Rate for Payer: TriWest Medicare	$0.24
Rate for Payer: United Healthcare Commercial	$0.86
Rate for Payer: United Healthcare Medicare	$0.24
Rate for Payer: Veterans Affairs TRICARE	$0.24

Levalbuterol comp unit

Facility

$8.00

Service Code	HCPCS J7615
Hospital Charge Code	1240995
Hospital Revenue Code	521
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Arizona Complete Health Allwell	$1.28
Rate for Payer: Banner UC Health Medicare	$1.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.28
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cigna of AZ Commercial	$5.60
Rate for Payer: Devoted Health Medicare	$1.44
Rate for Payer: Humana of AZ Medicare	$1.28
Rate for Payer: Southwest Service Administrators UFCW	$5.44
Rate for Payer: TriWest Medicare	$1.28
Rate for Payer: United Healthcare Commercial	$4.58
Rate for Payer: United Healthcare Medicare	$1.28
Rate for Payer: Veterans Affairs TRICARE	$1.27

Levalbuterol comp unit

Facility

$8.00

Service Code	HCPCS J7615
Hospital Charge Code	1240995
Hospital Revenue Code	521
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Cash Price	$6.40

levETIRAcetam 500 mg/ 5 mL Oral Sol UD [CQCH]

Facility

$0.25

Service Code	NDC 603138458
Hospital Charge Code	105927980
Hospital Revenue Code	251
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

levETIRAcetam 500 mg/ 5 mL Oral Sol UD [CQCH]

Facility

$0.25

Service Code	NDC 603138458
Hospital Charge Code	105927980
Hospital Revenue Code	251
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

levETIRAcetam 500 mg Inj 5 mL [CQCH]

Facility

$0.29

Service Code	HCPCS J1953
Hospital Charge Code	108073828
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of AZ Commercial	$0.26
Rate for Payer: Cash Price	$0.23

levETIRAcetam 500 mg Inj 5 mL [CQCH]

Facility

$0.29

Service Code	HCPCS J1953
Hospital Charge Code	108073828
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of AZ Commercial	$0.26
Rate for Payer: Arizona Complete Health Allwell	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.05
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.05
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of AZ Commercial	$0.19
Rate for Payer: Devoted Health Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Southwest Service Administrators UFCW	$0.20
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: United Healthcare Commercial	$0.17
Rate for Payer: United Healthcare Medicare	$0.05
Rate for Payer: Veterans Affairs TRICARE	$0.05

levETIRAcetam 500 mg Tab [CQCH]

Facility

$0.31

Service Code	NDC 68180011316
Hospital Charge Code	105928045
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: Arizona Complete Health Allwell	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.21
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.05
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.05
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of AZ Commercial	$0.20
Rate for Payer: Devoted Health Medicare	$0.06
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Southwest Service Administrators UFCW	$0.21
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: United Healthcare Commercial	$0.18
Rate for Payer: United Healthcare Medicare	$0.05
Rate for Payer: Veterans Affairs TRICARE	$0.05

levETIRAcetam 500 mg Tab [CQCH]

Facility

$0.31

Service Code	NDC 68180011316
Hospital Charge Code	105928045
Hospital Revenue Code	251
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.28
Rate for Payer: Aetna of AZ Commercial	$0.28
Rate for Payer: Cash Price	$0.24

Levetiracetam (Keppra), S LC

Facility

$281.00

Service Code	CPT 80299
Hospital Charge Code	1906919
Hospital Revenue Code	301
Min. Negotiated Rate	$27.03
Max. Negotiated Rate	$252.90
Rate for Payer: Aetna of AZ Commercial	$252.90
Rate for Payer: Arizona Complete Health Allwell	$44.96
Rate for Payer: Banner UC Health Medicare	$44.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$191.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$44.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$44.96
Rate for Payer: Cash Price	$224.80
Rate for Payer: Cash Price	$224.80
Rate for Payer: Cigna of AZ Commercial	$182.65
Rate for Payer: Devoted Health Medicare	$50.58
Rate for Payer: Humana of AZ Medicare	$44.96
Rate for Payer: Seven Corners Travel Insurance	$27.03
Rate for Payer: Southwest Service Administrators UFCW	$191.08
Rate for Payer: TriWest Medicare	$44.96
Rate for Payer: United Healthcare Commercial	$160.73
Rate for Payer: United Healthcare Medicare	$44.96
Rate for Payer: Veterans Affairs TRICARE	$44.51

Levetiracetam (Keppra), S LC

Facility

$281.00

Service Code	CPT 80299
Hospital Charge Code	1906919
Hospital Revenue Code	301
Min. Negotiated Rate	$252.90
Max. Negotiated Rate	$252.90
Rate for Payer: Aetna of AZ Commercial	$252.90
Rate for Payer: Cash Price	$224.80

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	$0.03
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Cash Price	$0.02

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: 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	$0.02
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	$0.02
Rate for Payer: Cigna of AZ Commercial	$0.02
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Southwest Service Administrators UFCW	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: United Healthcare Commercial	$0.02
Rate for Payer: United Healthcare Medicare	$0.00
Rate for Payer: Veterans Affairs TRICARE	$0.00

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: Arizona Complete Health Allwell	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.03
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.01
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.01
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of AZ Commercial	$0.03
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.03
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.02
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$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	$0.04
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
Rate for Payer: Cash Price	$0.03

Know your out-of-pocket cost for care.

All Charges