Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

amoxicillin 500 mg Cap [CQCH]

Facility

$0.09

Service Code	NDC 16714029903
Hospital Charge Code	105910767
Hospital Revenue Code	251
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of AZ Commercial	$0.08
Rate for Payer: Cash Price	$0.07

amoxicillin-clavulanate 500 mg-125 mg Tab [CQCH]

Facility

$0.25

Service Code	NDC 16714049401
Hospital Charge Code	105910897
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

amoxicillin-clavulanate 500 mg-125 mg Tab [CQCH]

Facility

$0.25

Service Code	NDC 16714049401
Hospital Charge Code	105910897
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

amoxicillin-clavulanate 600 mg/5 mL Oral Liq (75 mL after reconst.) [CQCH]

Facility

$3.12

Service Code	NDC 16714029401
Hospital Charge Code	105910962
Hospital Revenue Code	251
Min. Negotiated Rate	$2.81
Max. Negotiated Rate	$2.81
Rate for Payer: Aetna of AZ Commercial	$2.81
Rate for Payer: Cash Price	$2.50

amoxicillin-clavulanate 600 mg/5 mL Oral Liq (75 mL after reconst.) [CQCH]

Facility

$3.12

Service Code	NDC 16714029401
Hospital Charge Code	105910962
Hospital Revenue Code	251
Min. Negotiated Rate	$0.49
Max. Negotiated Rate	$2.81
Rate for Payer: Aetna of AZ Commercial	$2.81
Rate for Payer: Arizona Complete Health Allwell	$0.50
Rate for Payer: Banner UC Health Medicare	$0.50
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.50
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.50
Rate for Payer: Cash Price	$2.50
Rate for Payer: Cigna of AZ Commercial	$2.03
Rate for Payer: Devoted Health Medicare	$0.56
Rate for Payer: Humana of AZ Medicare	$0.50
Rate for Payer: Southwest Service Administrators UFCW	$2.12
Rate for Payer: TriWest Medicare	$0.50
Rate for Payer: United Healthcare Commercial	$1.78
Rate for Payer: United Healthcare Medicare	$0.50
Rate for Payer: Veterans Affairs TRICARE	$0.49

amoxicillin-clavulanate 875 mg-125 mg Tab [CQCH]

Facility

$0.68

Service Code	NDC 16714047801
Hospital Charge Code	105911029
Hospital Revenue Code	251
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.61
Rate for Payer: Aetna of AZ Commercial	$0.61
Rate for Payer: Cash Price	$0.55

amoxicillin-clavulanate 875 mg-125 mg Tab [CQCH]

Facility

$0.68

Service Code	NDC 16714047801
Hospital Charge Code	105911029
Hospital Revenue Code	251
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.61
Rate for Payer: Aetna of AZ Commercial	$0.61
Rate for Payer: Arizona Complete Health Allwell	$0.11
Rate for Payer: Banner UC Health Medicare	$0.11
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.46
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.11
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.11
Rate for Payer: Cash Price	$0.55
Rate for Payer: Cigna of AZ Commercial	$0.44
Rate for Payer: Devoted Health Medicare	$0.12
Rate for Payer: Humana of AZ Medicare	$0.11
Rate for Payer: Southwest Service Administrators UFCW	$0.46
Rate for Payer: TriWest Medicare	$0.11
Rate for Payer: United Healthcare Commercial	$0.39
Rate for Payer: United Healthcare Medicare	$0.11
Rate for Payer: Veterans Affairs TRICARE	$0.11

.Amphetamines, GC/MS Confirm LC

Facility

$194.00

Service Code	CPT 82145
Hospital Charge Code	22311130
Hospital Revenue Code	301
Min. Negotiated Rate	$174.60
Max. Negotiated Rate	$174.60
Rate for Payer: Aetna of AZ Commercial	$174.60
Rate for Payer: Cash Price	$155.20

.Amphetamines, GC/MS Confirm LC

Facility

$194.00

Service Code	CPT 82145
Hospital Charge Code	22311130
Hospital Revenue Code	301
Min. Negotiated Rate	$30.73
Max. Negotiated Rate	$174.60
Rate for Payer: Aetna of AZ Commercial	$174.60
Rate for Payer: Arizona Complete Health Allwell	$31.04
Rate for Payer: Banner UC Health Medicare	$31.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$131.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$31.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.04
Rate for Payer: Cash Price	$155.20
Rate for Payer: Cigna of AZ Commercial	$126.10
Rate for Payer: Devoted Health Medicare	$34.92
Rate for Payer: Humana of AZ Medicare	$31.04
Rate for Payer: Southwest Service Administrators UFCW	$131.92
Rate for Payer: TriWest Medicare	$31.04
Rate for Payer: United Healthcare Commercial	$110.97
Rate for Payer: United Healthcare Medicare	$31.04
Rate for Payer: Veterans Affairs TRICARE	$30.73

ampicillin 1 g Inj [CQCH]

Facility

$1.62

Service Code	HCPCS J0290
Hospital Charge Code	105911094
Hospital Revenue Code	250
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$1.46
Rate for Payer: Aetna of AZ Commercial	$1.46
Rate for Payer: Cash Price	$1.29

ampicillin 1 g Inj [CQCH]

Facility

$1.62

Service Code	HCPCS J0290
Hospital Charge Code	105911094
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$1.46
Rate for Payer: Aetna of AZ Commercial	$1.46
Rate for Payer: Arizona Complete Health Allwell	$0.26
Rate for Payer: Banner UC Health Medicare	$0.26
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.10
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.26
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.26
Rate for Payer: Cash Price	$1.29
Rate for Payer: Cigna of AZ Commercial	$1.05
Rate for Payer: Devoted Health Medicare	$0.29
Rate for Payer: Humana of AZ Medicare	$0.26
Rate for Payer: Southwest Service Administrators UFCW	$1.10
Rate for Payer: TriWest Medicare	$0.26
Rate for Payer: United Healthcare Commercial	$0.93
Rate for Payer: United Healthcare Medicare	$0.26
Rate for Payer: Veterans Affairs TRICARE	$0.26

ampicillin-sulbactam 1 .5 g Inj [CQCH]

Facility

$1.49

Service Code	HCPCS J0295
Hospital Charge Code	105911169
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of AZ Commercial	$1.34
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	$1.01
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	$1.19
Rate for Payer: Cigna of AZ Commercial	$0.97
Rate for Payer: Devoted Health Medicare	$0.27
Rate for Payer: Humana of AZ Medicare	$0.24
Rate for Payer: Southwest Service Administrators UFCW	$1.01
Rate for Payer: TriWest Medicare	$0.24
Rate for Payer: United Healthcare Commercial	$0.85
Rate for Payer: United Healthcare Medicare	$0.24
Rate for Payer: Veterans Affairs TRICARE	$0.24

ampicillin-sulbactam 1 .5 g Inj [CQCH]

Facility

$1.49

Service Code	HCPCS J0295
Hospital Charge Code	105911169
Hospital Revenue Code	250
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of AZ Commercial	$1.34
Rate for Payer: Cash Price	$1.19

ampicillin-sulbactam 3 g Inj [CQCH]

Facility

$5.20

Service Code	HCPCS J0295
Hospital Charge Code	105911242
Hospital Revenue Code	250
Min. Negotiated Rate	$4.68
Max. Negotiated Rate	$4.68
Rate for Payer: Aetna of AZ Commercial	$4.68
Rate for Payer: Cash Price	$4.16

ampicillin-sulbactam 3 g Inj [CQCH]

Facility

$5.20

Service Code	HCPCS J0295
Hospital Charge Code	105911242
Hospital Revenue Code	250
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$4.68
Rate for Payer: Aetna of AZ Commercial	$4.68
Rate for Payer: Arizona Complete Health Allwell	$0.83
Rate for Payer: Banner UC Health Medicare	$0.83
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3.54
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.83
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.83
Rate for Payer: Cash Price	$4.16
Rate for Payer: Cigna of AZ Commercial	$3.38
Rate for Payer: Devoted Health Medicare	$0.94
Rate for Payer: Humana of AZ Medicare	$0.83
Rate for Payer: Southwest Service Administrators UFCW	$3.54
Rate for Payer: TriWest Medicare	$0.83
Rate for Payer: United Healthcare Commercial	$2.97
Rate for Payer: United Healthcare Medicare	$0.83
Rate for Payer: Veterans Affairs TRICARE	$0.82

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC

Facility

$36,840.27

Service Code	MSDRG 240
Min. Negotiated Rate	$36,840.27
Max. Negotiated Rate	$36,840.27
Rate for Payer: Seven Corners Travel Insurance	$36,840.27

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC

Facility

$63,608.73

Service Code	MSDRG 239
Min. Negotiated Rate	$63,608.73
Max. Negotiated Rate	$63,608.73
Rate for Payer: Seven Corners Travel Insurance	$63,608.73

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC

Facility

$17,897.42

Service Code	MSDRG 241
Min. Negotiated Rate	$17,897.42
Max. Negotiated Rate	$17,897.42
Rate for Payer: Seven Corners Travel Insurance	$17,897.42

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$29,411.45

Service Code	MSDRG 475
Min. Negotiated Rate	$29,411.45
Max. Negotiated Rate	$29,411.45
Rate for Payer: Seven Corners Travel Insurance	$29,411.45

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$55,482.05

Service Code	MSDRG 474
Min. Negotiated Rate	$55,482.05
Max. Negotiated Rate	$55,482.05
Rate for Payer: Seven Corners Travel Insurance	$55,482.05

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$15,309.97

Service Code	MSDRG 476
Min. Negotiated Rate	$15,309.97
Max. Negotiated Rate	$15,309.97
Rate for Payer: Seven Corners Travel Insurance	$15,309.97

AMPUTATION METATARSAL WITH TOE SINGLE

Facility

$2,086.00

Service Code	CPT 28810
Hospital Charge Code	24043301
Hospital Revenue Code	360
Min. Negotiated Rate	$330.42
Max. Negotiated Rate	$5,062.66
Rate for Payer: Aetna of AZ Commercial	$1,877.40
Rate for Payer: Arizona Complete Health Allwell	$333.76
Rate for Payer: Banner UC Health Medicare	$1,062.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,418.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$333.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$333.76
Rate for Payer: Cash Price	$1,668.80
Rate for Payer: Cash Price	$1,668.80
Rate for Payer: Cash Price	$1,668.80
Rate for Payer: Cigna of AZ Commercial	$1,043.00
Rate for Payer: Devoted Health Medicare	$375.48
Rate for Payer: Humana of AZ Medicare	$333.76
Rate for Payer: NaphCare Correctional Healthcare	$1,062.88
Rate for Payer: Seven Corners Travel Insurance	$5,062.66
Rate for Payer: Southwest Service Administrators UFCW	$1,418.48
Rate for Payer: TriWest Medicare	$333.76
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$333.76
Rate for Payer: Veterans Affairs TRICARE	$330.42

AMPUTATION METATARSAL WITH TOE SINGLE

Facility

$2,086.00

Service Code	CPT 28810
Hospital Charge Code	24043301
Hospital Revenue Code	360
Min. Negotiated Rate	$1,877.40
Max. Negotiated Rate	$1,877.40
Rate for Payer: Aetna of AZ Commercial	$1,877.40
Rate for Payer: Cash Price	$1,668.80

Amputation Of Lower Limb Except Toes

Facility

$14,950.34

Service Code	APR-DRG 3053
Hospital Charge Code	APRDRG3053
Min. Negotiated Rate	$14,950.34
Max. Negotiated Rate	$14,950.34
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$14,950.34
Rate for Payer: Mercy Care Medicaid	$14,950.34
Rate for Payer: NaphCare Correctional Healthcare	$14,950.34

Amputation Of Lower Limb Except Toes

Facility

$9,240.95

Service Code	APR-DRG 3052
Hospital Charge Code	APRDRG3052
Min. Negotiated Rate	$9,240.95
Max. Negotiated Rate	$9,240.95
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$9,240.95
Rate for Payer: Mercy Care Medicaid	$9,240.95
Rate for Payer: NaphCare Correctional Healthcare	$9,240.95

Know your out-of-pocket cost for care.

All Charges