Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

dexamethasone 10 mg/mL Inj Sol [CQCH]

Facility

$4.07

Service Code	HCPCS J1100
Hospital Charge Code	105918016
Hospital Revenue Code	250
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$3.66
Rate for Payer: Aetna of AZ Commercial	$3.66
Rate for Payer: Cash Price	$3.26

dexamethasone 1 mg Tab [CQCH]

Facility

$0.25

Service Code	HCPCS J8540
Hospital Charge Code	105918089
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

dexamethasone 1 mg Tab [CQCH]

Facility

$0.25

Service Code	HCPCS J8540
Hospital Charge Code	105918089
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

dexmedetomidine 100 mcg/mL Sol [CQCH]

Facility

$1.51

Service Code	NDC 143953225
Hospital Charge Code	145588585
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

dexmedetomidine 100 mcg/mL Sol [CQCH]

Facility

$1.51

Service Code	NDC 143953225
Hospital Charge Code	145588585
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

DEXTILE ANATOMICAL MESH LEFT

Facility

$880.05

Hospital Charge Code	27820406
Hospital Revenue Code	270
Min. Negotiated Rate	$792.04
Max. Negotiated Rate	$792.04
Rate for Payer: Aetna of AZ Commercial	$792.04
Rate for Payer: Cash Price	$704.04

DEXTILE ANATOMICAL MESH LEFT

Facility

$880.05

Hospital Charge Code	27820406
Hospital Revenue Code	270
Min. Negotiated Rate	$139.40
Max. Negotiated Rate	$792.04
Rate for Payer: Aetna of AZ Commercial	$792.04
Rate for Payer: Arizona Complete Health Allwell	$140.81
Rate for Payer: Banner UC Health Medicare	$140.81
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$598.43
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$140.81
Rate for Payer: Care1st Health Plan Arizona Medicare	$140.81
Rate for Payer: Cash Price	$704.04
Rate for Payer: Cigna of AZ Commercial	$616.03
Rate for Payer: Devoted Health Medicare	$158.41
Rate for Payer: Humana of AZ Medicare	$140.81
Rate for Payer: Southwest Service Administrators UFCW	$598.43
Rate for Payer: TriWest Medicare	$140.81
Rate for Payer: United Healthcare Commercial	$503.39
Rate for Payer: United Healthcare Medicare	$140.81
Rate for Payer: Veterans Affairs TRICARE	$139.40

DEXTILE ANATOMICAL MESH RIGHT

Facility

$880.05

Hospital Charge Code	27820407
Hospital Revenue Code	270
Min. Negotiated Rate	$139.40
Max. Negotiated Rate	$792.04
Rate for Payer: Aetna of AZ Commercial	$792.04
Rate for Payer: Arizona Complete Health Allwell	$140.81
Rate for Payer: Banner UC Health Medicare	$140.81
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$598.43
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$140.81
Rate for Payer: Care1st Health Plan Arizona Medicare	$140.81
Rate for Payer: Cash Price	$704.04
Rate for Payer: Cigna of AZ Commercial	$616.03
Rate for Payer: Devoted Health Medicare	$158.41
Rate for Payer: Humana of AZ Medicare	$140.81
Rate for Payer: Southwest Service Administrators UFCW	$598.43
Rate for Payer: TriWest Medicare	$140.81
Rate for Payer: United Healthcare Commercial	$503.39
Rate for Payer: United Healthcare Medicare	$140.81
Rate for Payer: Veterans Affairs TRICARE	$139.40

DEXTILE ANATOMICAL MESH RIGHT

Facility

$880.05

Hospital Charge Code	27820407
Hospital Revenue Code	270
Min. Negotiated Rate	$792.04
Max. Negotiated Rate	$792.04
Rate for Payer: Aetna of AZ Commercial	$792.04
Rate for Payer: Cash Price	$704.04

DEXTILE MESH MED LEFT

Facility

$839.30

Hospital Charge Code	28165982
Hospital Revenue Code	270
Min. Negotiated Rate	$755.37
Max. Negotiated Rate	$755.37
Rate for Payer: Aetna of AZ Commercial	$755.37
Rate for Payer: Cash Price	$671.44

DEXTILE MESH MED LEFT

Facility

$839.30

Hospital Charge Code	28165982
Hospital Revenue Code	270
Min. Negotiated Rate	$132.95
Max. Negotiated Rate	$755.37
Rate for Payer: Aetna of AZ Commercial	$755.37
Rate for Payer: Arizona Complete Health Allwell	$134.29
Rate for Payer: Banner UC Health Medicare	$134.29
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$570.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$134.29
Rate for Payer: Care1st Health Plan Arizona Medicare	$134.29
Rate for Payer: Cash Price	$671.44
Rate for Payer: Cigna of AZ Commercial	$587.51
Rate for Payer: Devoted Health Medicare	$151.07
Rate for Payer: Humana of AZ Medicare	$134.29
Rate for Payer: Southwest Service Administrators UFCW	$570.72
Rate for Payer: TriWest Medicare	$134.29
Rate for Payer: United Healthcare Commercial	$480.08
Rate for Payer: United Healthcare Medicare	$134.29
Rate for Payer: Veterans Affairs TRICARE	$132.95

DEXTILE MESH MED RIGHT

Facility

$839.30

Hospital Charge Code	28165983
Hospital Revenue Code	270
Min. Negotiated Rate	$132.95
Max. Negotiated Rate	$755.37
Rate for Payer: Aetna of AZ Commercial	$755.37
Rate for Payer: Arizona Complete Health Allwell	$134.29
Rate for Payer: Banner UC Health Medicare	$134.29
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$570.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$134.29
Rate for Payer: Care1st Health Plan Arizona Medicare	$134.29
Rate for Payer: Cash Price	$671.44
Rate for Payer: Cigna of AZ Commercial	$587.51
Rate for Payer: Devoted Health Medicare	$151.07
Rate for Payer: Humana of AZ Medicare	$134.29
Rate for Payer: Southwest Service Administrators UFCW	$570.72
Rate for Payer: TriWest Medicare	$134.29
Rate for Payer: United Healthcare Commercial	$480.08
Rate for Payer: United Healthcare Medicare	$134.29
Rate for Payer: Veterans Affairs TRICARE	$132.95

DEXTILE MESH MED RIGHT

Facility

$839.30

Hospital Charge Code	28165983
Hospital Revenue Code	270
Min. Negotiated Rate	$755.37
Max. Negotiated Rate	$755.37
Rate for Payer: Aetna of AZ Commercial	$755.37
Rate for Payer: Cash Price	$671.44

Dextrose 10% in Water 500 mL IV soln [CQCH]

Facility

$0.01

Service Code	NDC 409793003
Hospital Charge Code	112006059
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: 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

Dextrose 10% in Water 500 mL IV soln [CQCH]

Facility

$0.01

Service Code	NDC 409793003
Hospital Charge Code	112006059
Hospital Revenue Code	258
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Cash Price	$0.01

dextrose 50% (25gm)IV Sol 50 mL [CQCH]

Facility

$0.16

Service Code	NDC 409751716
Hospital Charge Code	105924619
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	$0.13

dextrose 50% (25gm)IV Sol 50 mL [CQCH]

Facility

$0.16

Service Code	NDC 409751716
Hospital Charge Code	105924619
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
Rate for Payer: Arizona Complete Health Allwell	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.11
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.03
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.03
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cigna of AZ Commercial	$0.10
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Southwest Service Administrators UFCW	$0.11
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: United Healthcare Commercial	$0.09
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

Dextrose 5% in Water IV Sol 250 mL (DEHP-free) [CQCH]

Facility

$0.02

Service Code	HCPCS J7060
Hospital Charge Code	108156747
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Cash Price	$0.02

Dextrose 5% in Water IV Sol 250 mL (DEHP-free) [CQCH]

Facility

$0.02

Service Code	HCPCS J7060
Hospital Charge Code	108156747
Hospital Revenue Code	250
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
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	$0.02
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

Dextrose 5% in Water IV soln 100 ml[CQCH]

Facility

$0.02

Service Code	HCPCS J7060
Hospital Charge Code	152070800
Hospital Revenue Code	250
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
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	$0.02
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

Dextrose 5% in Water IV soln 100 ml[CQCH]

Facility

$0.02

Service Code	HCPCS J7060
Hospital Charge Code	152070800
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Cash Price	$0.02

Dextrose 5% in Water Sol 1,000 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J7060
Hospital Charge Code	107994985
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

Dextrose 5% in Water Sol 1,000 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J7060
Hospital Charge Code	107994985
Hospital Revenue Code	258
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01

Dextrose 5% Water IV Sol 500 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J7060
Hospital Charge Code	108643402
Hospital Revenue Code	258
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01

Dextrose 5% Water IV Sol 500 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J7060
Hospital Charge Code	108643402
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

Know your out-of-pocket cost for care.

All Charges