Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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: 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	$0.16
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	$0.19
Rate for Payer: Cigna of AZ Commercial	$0.16
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Southwest Service Administrators UFCW	$0.16
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

levoFLOXacin 500 mg Tab [CQCH]

Facility

$0.24

Service Code	NDC 904635261
Hospital Charge Code	105928112
Hospital Revenue Code	251
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of AZ Commercial	$0.22
Rate for Payer: Cash Price	$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	$0.04
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
Rate for Payer: Cash Price	$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: 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

levonorgestrel 1.5 mg Tab [CQCH]

Facility

$32.01

Service Code	NDC 51285016288
Hospital Charge Code	105928328
Hospital Revenue Code	251
Min. Negotiated Rate	$5.07
Max. Negotiated Rate	$28.81
Rate for Payer: Aetna of AZ Commercial	$28.81
Rate for Payer: Arizona Complete Health Allwell	$5.12
Rate for Payer: Banner UC Health Medicare	$5.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$21.77
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.12
Rate for Payer: Cash Price	$25.61
Rate for Payer: Cigna of AZ Commercial	$20.81
Rate for Payer: Devoted Health Medicare	$5.76
Rate for Payer: Humana of AZ Medicare	$5.12
Rate for Payer: Southwest Service Administrators UFCW	$21.77
Rate for Payer: TriWest Medicare	$5.12
Rate for Payer: United Healthcare Commercial	$18.31
Rate for Payer: United Healthcare Medicare	$5.12
Rate for Payer: Veterans Affairs TRICARE	$5.07

levonorgestrel 1.5 mg Tab [CQCH]

Facility

$32.01

Service Code	NDC 51285016288
Hospital Charge Code	105928328
Hospital Revenue Code	251
Min. Negotiated Rate	$28.81
Max. Negotiated Rate	$28.81
Rate for Payer: Aetna of AZ Commercial	$28.81
Rate for Payer: Cash Price	$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	$0.14
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
Rate for Payer: Cash Price	$0.12

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: 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	$0.10
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	$0.12
Rate for Payer: Cigna of AZ Commercial	$0.10
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.10
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.09
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

levothyroxine 25 mcg Tab [CQCH]

Facility

$0.44

Service Code	NDC 51079044420
Hospital Charge Code	105928603
Hospital Revenue Code	251
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.40
Rate for Payer: Aetna of AZ Commercial	$0.40
Rate for Payer: Cash Price	$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: Arizona Complete Health Allwell	$0.07
Rate for Payer: Banner UC Health Medicare	$0.07
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.30
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.07
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.07
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cigna of AZ Commercial	$0.29
Rate for Payer: Devoted Health Medicare	$0.08
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Southwest Service Administrators UFCW	$0.30
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: United Healthcare Commercial	$0.25
Rate for Payer: United Healthcare Medicare	$0.07
Rate for Payer: Veterans Affairs TRICARE	$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	$0.06
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna of AZ Commercial	$0.33
Rate for Payer: Arizona Complete Health Allwell	$0.06
Rate for Payer: Banner UC Health Medicare	$0.06
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.25
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.06
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.06
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cigna of AZ Commercial	$0.24
Rate for Payer: Devoted Health Medicare	$0.07
Rate for Payer: Humana of AZ Medicare	$0.06
Rate for Payer: Southwest Service Administrators UFCW	$0.25
Rate for Payer: TriWest Medicare	$0.06
Rate for Payer: United Healthcare Commercial	$0.21
Rate for Payer: United Healthcare Medicare	$0.06
Rate for Payer: Veterans Affairs TRICARE	$0.06

levothyroxine 50 mcg Tab [CQCH]

Facility

$0.37

Service Code	NDC 51079044020
Hospital Charge Code	105928521
Hospital Revenue Code	251
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna of AZ Commercial	$0.33
Rate for Payer: Cash Price	$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	$0.06
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of AZ Commercial	$0.37
Rate for Payer: Arizona Complete Health Allwell	$0.07
Rate for Payer: Banner UC Health Medicare	$0.07
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.07
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.07
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna of AZ Commercial	$0.27
Rate for Payer: Devoted Health Medicare	$0.07
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Southwest Service Administrators UFCW	$0.28
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: United Healthcare Commercial	$0.23
Rate for Payer: United Healthcare Medicare	$0.07
Rate for Payer: Veterans Affairs TRICARE	$0.06

levothyroxine 75 mcg Tab [CQCH]

Facility

$0.41

Service Code	NDC 51079044120
Hospital Charge Code	105928456
Hospital Revenue Code	251
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of AZ Commercial	$0.37
Rate for Payer: Cash Price	$0.33

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: 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	$0.25
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

levothyroxine 88 mcg Tab [CQCH]

Facility

$0.31

Service Code	NDC 378180777
Hospital Charge Code	105928391
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	$0.25

LH (LUTEINIZING HORMONE)

Facility

$519.00

Service Code	CPT 83002
Hospital Charge Code	22481490
Hospital Revenue Code	301
Min. Negotiated Rate	$467.10
Max. Negotiated Rate	$467.10
Rate for Payer: Aetna of AZ Commercial	$467.10
Rate for Payer: Cash Price	$415.20

LH (LUTEINIZING HORMONE)

Facility

$519.00

Service Code	CPT 83002
Hospital Charge Code	22481490
Hospital Revenue Code	301
Min. Negotiated Rate	$26.85
Max. Negotiated Rate	$467.10
Rate for Payer: Aetna of AZ Commercial	$467.10
Rate for Payer: Arizona Complete Health Allwell	$83.04
Rate for Payer: Banner UC Health Medicare	$83.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$352.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$83.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$83.04
Rate for Payer: Cash Price	$415.20
Rate for Payer: Cash Price	$415.20
Rate for Payer: Cigna of AZ Commercial	$337.35
Rate for Payer: Devoted Health Medicare	$93.42
Rate for Payer: Humana of AZ Medicare	$83.04
Rate for Payer: Seven Corners Travel Insurance	$26.85
Rate for Payer: Southwest Service Administrators UFCW	$352.92
Rate for Payer: TriWest Medicare	$83.04
Rate for Payer: United Healthcare Commercial	$296.87
Rate for Payer: United Healthcare Medicare	$83.04
Rate for Payer: Veterans Affairs TRICARE	$82.21

L HOOK TIP

Facility

$117.00

Hospital Charge Code	22354823
Hospital Revenue Code	270
Min. Negotiated Rate	$18.53
Max. Negotiated Rate	$105.30
Rate for Payer: Aetna of AZ Commercial	$105.30
Rate for Payer: Arizona Complete Health Allwell	$18.72
Rate for Payer: Banner UC Health Medicare	$18.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$79.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$18.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$18.72
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cigna of AZ Commercial	$81.90
Rate for Payer: Devoted Health Medicare	$21.06
Rate for Payer: Humana of AZ Medicare	$18.72
Rate for Payer: Southwest Service Administrators UFCW	$79.56
Rate for Payer: TriWest Medicare	$18.72
Rate for Payer: United Healthcare Commercial	$66.92
Rate for Payer: United Healthcare Medicare	$18.72
Rate for Payer: Veterans Affairs TRICARE	$18.53

L HOOK TIP

Facility

$117.00

Hospital Charge Code	22354823
Hospital Revenue Code	270
Min. Negotiated Rate	$105.30
Max. Negotiated Rate	$105.30
Rate for Payer: Aetna of AZ Commercial	$105.30
Rate for Payer: Cash Price	$93.60

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: 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	$0.04
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	$0.03
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

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	$0.05
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Cash Price	$0.04

lidocaine 1% inj 5 mL [CQCH]

Facility

$0.27

Service Code	HCPCS J2001
Hospital Charge Code	108919279
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of AZ Commercial	$0.24
Rate for Payer: Cash Price	$0.22

lidocaine 1% inj 5 mL [CQCH]

Facility

$0.27

Service Code	HCPCS J2001
Hospital Charge Code	108919279
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of AZ Commercial	$0.24
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	$0.18
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	$0.22
Rate for Payer: Cigna of AZ Commercial	$0.18
Rate for Payer: Devoted Health Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Southwest Service Administrators UFCW	$0.18
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: United Healthcare Commercial	$0.15
Rate for Payer: United Healthcare Medicare	$0.04
Rate for Payer: Veterans Affairs TRICARE	$0.04

lidocaine 1% Inj Sol 20 mL [CQCH]

Facility

$0.04

Service Code	HCPCS J2001
Hospital Charge Code	105928808
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