Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

DILATION OF ESOPHAGUS TECH

Facility

$406.00

Service Code	CPT 43450
Hospital Charge Code	28224519
Hospital Revenue Code	750
Min. Negotiated Rate	$64.31
Max. Negotiated Rate	$3,596.00
Rate for Payer: Aetna of AZ Commercial	$365.40
Rate for Payer: Arizona Complete Health Allwell	$64.96
Rate for Payer: Banner UC Health Medicare	$343.75
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$276.08
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$109.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$64.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$64.96
Rate for Payer: Cash Price	$324.80
Rate for Payer: Cash Price	$324.80
Rate for Payer: Cash Price	$324.80
Rate for Payer: Cigna of AZ Commercial	$284.20
Rate for Payer: Devoted Health Medicare	$73.08
Rate for Payer: Humana of AZ Medicare	$64.96
Rate for Payer: Mercy Care Medicaid	$109.48
Rate for Payer: NaphCare Correctional Healthcare	$343.75
Rate for Payer: Seven Corners Travel Insurance	$1,403.35
Rate for Payer: Southwest Service Administrators UFCW	$276.08
Rate for Payer: TriWest Medicare	$64.96
Rate for Payer: United Healthcare Commercial	$3,596.00
Rate for Payer: United Healthcare Medicare	$64.96
Rate for Payer: United Healthcare New Mexico Commercial	$77.14
Rate for Payer: Veterans Affairs TRICARE	$64.31

DILATION OF URETHRA USING AN ENDOSCOPE Tech

Facility

$790.00

Service Code	CPT 52281
Hospital Charge Code	27927129
Hospital Revenue Code	360
Min. Negotiated Rate	$711.00
Max. Negotiated Rate	$711.00
Rate for Payer: Aetna of AZ Commercial	$711.00
Rate for Payer: Cash Price	$632.00

DILATION OF URETHRA USING AN ENDOSCOPE Tech

Facility

$790.00

Service Code	CPT 52281
Hospital Charge Code	27927129
Hospital Revenue Code	360
Min. Negotiated Rate	$125.14
Max. Negotiated Rate	$3,596.00
Rate for Payer: Aetna of AZ Commercial	$711.00
Rate for Payer: Arizona Complete Health Allwell	$126.40
Rate for Payer: Banner UC Health Medicare	$690.65
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$537.20
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$157.95
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$126.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$126.40
Rate for Payer: Cash Price	$632.00
Rate for Payer: Cash Price	$632.00
Rate for Payer: Cash Price	$632.00
Rate for Payer: Cigna of AZ Commercial	$395.00
Rate for Payer: Devoted Health Medicare	$142.20
Rate for Payer: Humana of AZ Medicare	$126.40
Rate for Payer: Mercy Care Medicaid	$157.95
Rate for Payer: NaphCare Correctional Healthcare	$690.65
Rate for Payer: Seven Corners Travel Insurance	$3,234.38
Rate for Payer: Southwest Service Administrators UFCW	$537.20
Rate for Payer: TriWest Medicare	$126.40
Rate for Payer: United Healthcare Commercial	$3,596.00
Rate for Payer: United Healthcare Medicare	$126.40
Rate for Payer: Veterans Affairs TRICARE	$125.14

DILATOR URETERAL 6X4 BALLOON

Facility

$802.00

Hospital Charge Code	22354207
Hospital Revenue Code	270
Min. Negotiated Rate	$721.80
Max. Negotiated Rate	$721.80
Rate for Payer: Aetna of AZ Commercial	$721.80
Rate for Payer: Cash Price	$641.60

DILATOR URETERAL 6X4 BALLOON

Facility

$802.00

Hospital Charge Code	22354207
Hospital Revenue Code	270
Min. Negotiated Rate	$127.04
Max. Negotiated Rate	$721.80
Rate for Payer: Aetna of AZ Commercial	$721.80
Rate for Payer: Arizona Complete Health Allwell	$128.32
Rate for Payer: Banner UC Health Medicare	$128.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$545.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$128.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$128.32
Rate for Payer: Cash Price	$641.60
Rate for Payer: Cigna of AZ Commercial	$561.40
Rate for Payer: Devoted Health Medicare	$144.36
Rate for Payer: Humana of AZ Medicare	$128.32
Rate for Payer: Southwest Service Administrators UFCW	$545.36
Rate for Payer: TriWest Medicare	$128.32
Rate for Payer: United Healthcare Commercial	$458.74
Rate for Payer: United Healthcare Medicare	$128.32
Rate for Payer: Veterans Affairs TRICARE	$127.04

dilTIAZem 100 mg IV Inj (ADD-Vantage) [CQCH]

Facility

$10.71

Service Code	NDC 409435003
Hospital Charge Code	105919232
Hospital Revenue Code	251
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$9.64
Rate for Payer: Aetna of AZ Commercial	$9.64
Rate for Payer: Arizona Complete Health Allwell	$1.71
Rate for Payer: Banner UC Health Medicare	$1.71
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$7.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.71
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.71
Rate for Payer: Cash Price	$8.56
Rate for Payer: Cigna of AZ Commercial	$6.96
Rate for Payer: Devoted Health Medicare	$1.93
Rate for Payer: Humana of AZ Medicare	$1.71
Rate for Payer: Southwest Service Administrators UFCW	$7.28
Rate for Payer: TriWest Medicare	$1.71
Rate for Payer: United Healthcare Commercial	$6.13
Rate for Payer: United Healthcare Medicare	$1.71
Rate for Payer: Veterans Affairs TRICARE	$1.70

dilTIAZem 100 mg IV Inj (ADD-Vantage) [CQCH]

Facility

$10.71

Service Code	NDC 409435003
Hospital Charge Code	105919232
Hospital Revenue Code	251
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$9.64
Rate for Payer: Aetna of AZ Commercial	$9.64
Rate for Payer: Cash Price	$8.56

dilTIAZem 120 mg ER Cap [CQCH]

Facility

$0.28

Service Code	NDC 60687019501
Hospital Charge Code	105919102
Hospital Revenue Code	251
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of AZ Commercial	$0.25
Rate for Payer: Cash Price	$0.23

dilTIAZem 120 mg ER Cap [CQCH]

Facility

$0.28

Service Code	NDC 60687019501
Hospital Charge Code	105919102
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of AZ Commercial	$0.25
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	$0.19
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	$0.23
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	$0.19
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: United Healthcare Commercial	$0.16
Rate for Payer: United Healthcare Medicare	$0.04
Rate for Payer: Veterans Affairs TRICARE	$0.04

dilTIAZem 125 mg/ 25 ml Sol [CQCH]

Facility

$0.41

Service Code	NDC 17478093725
Hospital Charge Code	108382261
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of AZ Commercial	$0.37
Rate for Payer: Cash Price	$0.32

dilTIAZem 125 mg/ 25 ml Sol [CQCH]

Facility

$0.41

Service Code	NDC 17478093725
Hospital Charge Code	108382261
Hospital Revenue Code	250
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	$0.32
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

dilTIAZem 180 mg ER Cap [CQCH]

Facility

$0.29

Service Code	NDC 63739001510
Hospital Charge Code	105919167
Hospital Revenue Code	251
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of AZ Commercial	$0.26
Rate for Payer: Cash Price	$0.24

dilTIAZem 180 mg ER Cap [CQCH]

Facility

$0.29

Service Code	NDC 63739001510
Hospital Charge Code	105919167
Hospital Revenue Code	251
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	$0.24
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

dilTIAZem 25 mg IV Sol [CQCH]

Facility

$0.52

Service Code	NDC 17478093705
Hospital Charge Code	105966082
Hospital Revenue Code	251
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of AZ Commercial	$0.47
Rate for Payer: Arizona Complete Health Allwell	$0.08
Rate for Payer: Banner UC Health Medicare	$0.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.35
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.08
Rate for Payer: Cash Price	$0.42
Rate for Payer: Cigna of AZ Commercial	$0.34
Rate for Payer: Devoted Health Medicare	$0.09
Rate for Payer: Humana of AZ Medicare	$0.08
Rate for Payer: Southwest Service Administrators UFCW	$0.35
Rate for Payer: TriWest Medicare	$0.08
Rate for Payer: United Healthcare Commercial	$0.30
Rate for Payer: United Healthcare Medicare	$0.08
Rate for Payer: Veterans Affairs TRICARE	$0.08

dilTIAZem 25 mg IV Sol [CQCH]

Facility

$0.52

Service Code	NDC 17478093705
Hospital Charge Code	105966082
Hospital Revenue Code	251
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of AZ Commercial	$0.47
Rate for Payer: Cash Price	$0.42

dilTIAZem 30 mg Tab [CQCH]

Facility

$0.43

Service Code	NDC 60687071701
Hospital Charge Code	105919041
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of AZ Commercial	$0.39
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	$0.29
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	$0.34
Rate for Payer: Cigna of AZ Commercial	$0.28
Rate for Payer: Devoted Health Medicare	$0.08
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Southwest Service Administrators UFCW	$0.29
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

dilTIAZem 30 mg Tab [CQCH]

Facility

$0.43

Service Code	NDC 60687071701
Hospital Charge Code	105919041
Hospital Revenue Code	251
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of AZ Commercial	$0.39
Rate for Payer: Cash Price	$0.34

diphenhydrAMINE 12.5 mg/5 mL Liq UD[CQCH]

Facility

$0.32

Service Code	HCPCS Q0163
Hospital Charge Code	127935116
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of AZ Commercial	$0.29
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	$0.22
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	$0.26
Rate for Payer: Cigna of AZ Commercial	$0.21
Rate for Payer: Devoted Health Medicare	$0.06
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Southwest Service Administrators UFCW	$0.22
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

diphenhydrAMINE 12.5 mg/5 mL Liq UD[CQCH]

Facility

$0.32

Service Code	HCPCS Q0163
Hospital Charge Code	127935116
Hospital Revenue Code	251
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of AZ Commercial	$0.29
Rate for Payer: Cash Price	$0.26

diphenhydrAMINE 25 mg/10 mL Oral Liq [CQCH]

Facility

$0.14

Service Code	HCPCS Q0163
Hospital Charge Code	105919435
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of AZ Commercial	$0.13
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	$0.11
Rate for Payer: Cigna of AZ Commercial	$0.09
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	$0.08
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

diphenhydrAMINE 25 mg/10 mL Oral Liq [CQCH]

Facility

$0.14

Service Code	HCPCS Q0163
Hospital Charge Code	105919435
Hospital Revenue Code	251
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of AZ Commercial	$0.13
Rate for Payer: Cash Price	$0.11

diphenhydrAMINE 25 mg Cap [CQCH]

Facility

$0.03

Service Code	HCPCS Q0163
Hospital Charge Code	105919293
Hospital Revenue Code	251
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

diphenhydrAMINE 25 mg Cap [CQCH]

Facility

$0.03

Service Code	HCPCS Q0163
Hospital Charge Code	105919293
Hospital Revenue Code	251
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

DIPHENHYDRAMINE/50MG

Facility

$34.00

Service Code	HCPCS J1200
Hospital Charge Code	1170060
Hospital Revenue Code	521
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$30.60
Rate for Payer: Aetna of AZ Commercial	$30.60
Rate for Payer: Arizona Complete Health Allwell	$5.44
Rate for Payer: Banner UC Health Medicare	$5.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$23.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.44
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cigna of AZ Commercial	$23.80
Rate for Payer: Devoted Health Medicare	$6.12
Rate for Payer: Humana of AZ Medicare	$5.44
Rate for Payer: Southwest Service Administrators UFCW	$23.12
Rate for Payer: TriWest Medicare	$5.44
Rate for Payer: United Healthcare Commercial	$19.45
Rate for Payer: United Healthcare Medicare	$5.44
Rate for Payer: Veterans Affairs TRICARE	$5.39

DIPHENHYDRAMINE/50MG

Facility

$34.00

Service Code	HCPCS J1200
Hospital Charge Code	1170060
Hospital Revenue Code	521
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$30.60
Rate for Payer: Aetna of AZ Commercial	$30.60
Rate for Payer: Cash Price	$27.20

Know your out-of-pocket cost for care.

All Charges