Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

hydrocortisone/neomycin/polymyxin B Otic Susp [CQCH]

Facility

$8.26

Service Code	NDC 24208063110
Hospital Charge Code	105925901
Hospital Revenue Code	251
Min. Negotiated Rate	$7.43
Max. Negotiated Rate	$7.43
Rate for Payer: Aetna of AZ Commercial	$7.43
Rate for Payer: Cash Price	$6.61

hydrocortisone/neomycin/polymyxin B Otic Susp [CQCH]

Facility

$8.26

Service Code	NDC 24208063110
Hospital Charge Code	105925901
Hospital Revenue Code	251
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$7.43
Rate for Payer: Aetna of AZ Commercial	$7.43
Rate for Payer: Arizona Complete Health Allwell	$1.32
Rate for Payer: Banner UC Health Medicare	$1.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5.62
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.32
Rate for Payer: Cash Price	$6.61
Rate for Payer: Cigna of AZ Commercial	$5.37
Rate for Payer: Devoted Health Medicare	$1.49
Rate for Payer: Humana of AZ Medicare	$1.32
Rate for Payer: Southwest Service Administrators UFCW	$5.62
Rate for Payer: TriWest Medicare	$1.32
Rate for Payer: United Healthcare Commercial	$4.72
Rate for Payer: United Healthcare Medicare	$1.32
Rate for Payer: Veterans Affairs TRICARE	$1.31

hydrocortisone Top 1% Crm 28 gm [CQCH]

Facility

$0.03

Service Code	NDC 603053550
Hospital Charge Code	105925836
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

hydrocortisone Top 1% Crm 28 gm [CQCH]

Facility

$0.03

Service Code	NDC 603053550
Hospital Charge Code	105925836
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

HYDROFERA BLUE CLASSIC 2X2 DRESSING

Facility

$24.00

Hospital Charge Code	27709652
Hospital Revenue Code	270
Min. Negotiated Rate	$3.80
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna of AZ Commercial	$21.60
Rate for Payer: Arizona Complete Health Allwell	$3.84
Rate for Payer: Banner UC Health Medicare	$3.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$16.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.84
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cigna of AZ Commercial	$16.80
Rate for Payer: Devoted Health Medicare	$4.32
Rate for Payer: Humana of AZ Medicare	$3.84
Rate for Payer: Southwest Service Administrators UFCW	$16.32
Rate for Payer: TriWest Medicare	$3.84
Rate for Payer: United Healthcare Commercial	$13.73
Rate for Payer: United Healthcare Medicare	$3.84
Rate for Payer: Veterans Affairs TRICARE	$3.80

HYDROFERA BLUE CLASSIC 2X2 DRESSING

Facility

$24.00

Hospital Charge Code	27709652
Hospital Revenue Code	270
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna of AZ Commercial	$21.60
Rate for Payer: Cash Price	$19.20

HYDROFERA BLUE CLASSIC 4X4 DRESSING

Facility

$36.00

Hospital Charge Code	27709653
Hospital Revenue Code	270
Min. Negotiated Rate	$32.40
Max. Negotiated Rate	$32.40
Rate for Payer: Aetna of AZ Commercial	$32.40
Rate for Payer: Cash Price	$28.80

HYDROFERA BLUE CLASSIC 4X4 DRESSING

Facility

$36.00

Hospital Charge Code	27709653
Hospital Revenue Code	270
Min. Negotiated Rate	$5.70
Max. Negotiated Rate	$32.40
Rate for Payer: Aetna of AZ Commercial	$32.40
Rate for Payer: Arizona Complete Health Allwell	$5.76
Rate for Payer: Banner UC Health Medicare	$5.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$24.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.76
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna of AZ Commercial	$25.20
Rate for Payer: Devoted Health Medicare	$6.48
Rate for Payer: Humana of AZ Medicare	$5.76
Rate for Payer: Southwest Service Administrators UFCW	$24.48
Rate for Payer: TriWest Medicare	$5.76
Rate for Payer: United Healthcare Commercial	$20.59
Rate for Payer: United Healthcare Medicare	$5.76
Rate for Payer: Veterans Affairs TRICARE	$5.70

HYDROmorphone 0.5 mg/0.5 mL Sol[CQCH]

Facility

$10.16

Service Code	HCPCS J1170
Hospital Charge Code	128562285
Hospital Revenue Code	250
Min. Negotiated Rate	$1.61
Max. Negotiated Rate	$9.14
Rate for Payer: Aetna of AZ Commercial	$9.14
Rate for Payer: Arizona Complete Health Allwell	$1.63
Rate for Payer: Banner UC Health Medicare	$1.63
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$6.91
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.63
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.63
Rate for Payer: Cash Price	$8.13
Rate for Payer: Cigna of AZ Commercial	$6.60
Rate for Payer: Devoted Health Medicare	$1.83
Rate for Payer: Humana of AZ Medicare	$1.63
Rate for Payer: Southwest Service Administrators UFCW	$6.91
Rate for Payer: TriWest Medicare	$1.63
Rate for Payer: United Healthcare Commercial	$5.81
Rate for Payer: United Healthcare Medicare	$1.63
Rate for Payer: Veterans Affairs TRICARE	$1.61

HYDROmorphone 0.5 mg/0.5 mL Sol[CQCH]

Facility

$10.16

Service Code	HCPCS J1170
Hospital Charge Code	128562285
Hospital Revenue Code	250
Min. Negotiated Rate	$9.14
Max. Negotiated Rate	$9.14
Rate for Payer: Aetna of AZ Commercial	$9.14
Rate for Payer: Cash Price	$8.13

HYDROmorphone 1 mg/mL Inj Sol [CQCH]

Facility

$2.02

Service Code	HCPCS J1170
Hospital Charge Code	105925966
Hospital Revenue Code	250
Min. Negotiated Rate	$1.82
Max. Negotiated Rate	$1.82
Rate for Payer: Aetna of AZ Commercial	$1.82
Rate for Payer: Cash Price	$1.61

HYDROmorphone 1 mg/mL Inj Sol [CQCH]

Facility

$2.02

Service Code	HCPCS J1170
Hospital Charge Code	105925966
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$1.82
Rate for Payer: Aetna of AZ Commercial	$1.82
Rate for Payer: Arizona Complete Health Allwell	$0.32
Rate for Payer: Banner UC Health Medicare	$0.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.37
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.32
Rate for Payer: Cash Price	$1.61
Rate for Payer: Cigna of AZ Commercial	$1.31
Rate for Payer: Devoted Health Medicare	$0.36
Rate for Payer: Humana of AZ Medicare	$0.32
Rate for Payer: Southwest Service Administrators UFCW	$1.37
Rate for Payer: TriWest Medicare	$0.32
Rate for Payer: United Healthcare Commercial	$1.16
Rate for Payer: United Healthcare Medicare	$0.32
Rate for Payer: Veterans Affairs TRICARE	$0.32

HYDROmorphone 2 mg/mL Sol[CQCH]

Facility

$1.15

Service Code	HCPCS J1170
Hospital Charge Code	128843622
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$1.03
Rate for Payer: Aetna of AZ Commercial	$1.03
Rate for Payer: Arizona Complete Health Allwell	$0.18
Rate for Payer: Banner UC Health Medicare	$0.18
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.78
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.18
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.18
Rate for Payer: Cash Price	$0.92
Rate for Payer: Cigna of AZ Commercial	$0.75
Rate for Payer: Devoted Health Medicare	$0.21
Rate for Payer: Humana of AZ Medicare	$0.18
Rate for Payer: Southwest Service Administrators UFCW	$0.78
Rate for Payer: TriWest Medicare	$0.18
Rate for Payer: United Healthcare Commercial	$0.66
Rate for Payer: United Healthcare Medicare	$0.18
Rate for Payer: Veterans Affairs TRICARE	$0.18

HYDROmorphone 2 mg/mL Sol[CQCH]

Facility

$1.15

Service Code	HCPCS J1170
Hospital Charge Code	128843622
Hospital Revenue Code	250
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.03
Rate for Payer: Aetna of AZ Commercial	$1.03
Rate for Payer: Cash Price	$0.92

HYDROmorphone 2 mg Tab UD [CQCH]

Facility

$0.16

Service Code	NDC 42858030125
Hospital Charge Code	205505588
Hospital Revenue Code	250
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

HYDROmorphone 2 mg Tab UD [CQCH]

Facility

$0.16

Service Code	NDC 42858030125
Hospital Charge Code	205505588
Hospital Revenue Code	250
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

hydroxocobalamin 5 g REC [CQCH]

Facility

$750.00

Service Code	NDC 11704037001
Hospital Charge Code	105926041
Hospital Revenue Code	251
Min. Negotiated Rate	$118.80
Max. Negotiated Rate	$675.00
Rate for Payer: Aetna of AZ Commercial	$675.00
Rate for Payer: Arizona Complete Health Allwell	$120.00
Rate for Payer: Banner UC Health Medicare	$120.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$510.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$120.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$120.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Cigna of AZ Commercial	$487.50
Rate for Payer: Devoted Health Medicare	$135.00
Rate for Payer: Humana of AZ Medicare	$120.00
Rate for Payer: Southwest Service Administrators UFCW	$510.00
Rate for Payer: TriWest Medicare	$120.00
Rate for Payer: United Healthcare Commercial	$429.00
Rate for Payer: United Healthcare Medicare	$120.00
Rate for Payer: Veterans Affairs TRICARE	$118.80

hydroxocobalamin 5 g REC [CQCH]

Facility

$750.00

Service Code	NDC 11704037001
Hospital Charge Code	105926041
Hospital Revenue Code	251
Min. Negotiated Rate	$675.00
Max. Negotiated Rate	$675.00
Rate for Payer: Aetna of AZ Commercial	$675.00
Rate for Payer: Cash Price	$600.00

hydroxychloroquine 200 mg Tab [CQCH]

Facility

$1.26

Service Code	NDC 16714075301
Hospital Charge Code	105926121
Hospital Revenue Code	251
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.13
Rate for Payer: Aetna of AZ Commercial	$1.13
Rate for Payer: Cash Price	$1.00

hydroxychloroquine 200 mg Tab [CQCH]

Facility

$1.26

Service Code	NDC 16714075301
Hospital Charge Code	105926121
Hospital Revenue Code	251
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$1.13
Rate for Payer: Aetna of AZ Commercial	$1.13
Rate for Payer: Arizona Complete Health Allwell	$0.20
Rate for Payer: Banner UC Health Medicare	$0.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.86
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.20
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cigna of AZ Commercial	$0.82
Rate for Payer: Devoted Health Medicare	$0.23
Rate for Payer: Humana of AZ Medicare	$0.20
Rate for Payer: Southwest Service Administrators UFCW	$0.86
Rate for Payer: TriWest Medicare	$0.20
Rate for Payer: United Healthcare Commercial	$0.72
Rate for Payer: United Healthcare Medicare	$0.20
Rate for Payer: Veterans Affairs TRICARE	$0.20

hydrOXYzine HCL 25 mg inj Sol [CQCH]

Facility

$3.21

Service Code	HCPCS J3410
Hospital Charge Code	108073338
Hospital Revenue Code	250
Min. Negotiated Rate	$2.89
Max. Negotiated Rate	$2.89
Rate for Payer: Aetna of AZ Commercial	$2.89
Rate for Payer: Cash Price	$2.57

hydrOXYzine HCL 25 mg inj Sol [CQCH]

Facility

$3.21

Service Code	HCPCS J3410
Hospital Charge Code	108073338
Hospital Revenue Code	250
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$2.89
Rate for Payer: Aetna of AZ Commercial	$2.89
Rate for Payer: Arizona Complete Health Allwell	$0.51
Rate for Payer: Banner UC Health Medicare	$0.51
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2.18
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.51
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.51
Rate for Payer: Cash Price	$2.57
Rate for Payer: Cigna of AZ Commercial	$2.09
Rate for Payer: Devoted Health Medicare	$0.58
Rate for Payer: Humana of AZ Medicare	$0.51
Rate for Payer: Southwest Service Administrators UFCW	$2.18
Rate for Payer: TriWest Medicare	$0.51
Rate for Payer: United Healthcare Commercial	$1.84
Rate for Payer: United Healthcare Medicare	$0.51
Rate for Payer: Veterans Affairs TRICARE	$0.51

hydrOXYzine pamoate 25 mg Cap UD [CQCH]

Facility

$0.38

Service Code	HCPCS Q0177
Hospital Charge Code	176182687
Hospital Revenue Code	251
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of AZ Commercial	$0.34
Rate for Payer: Cash Price	$0.30

hydrOXYzine pamoate 25 mg Cap UD [CQCH]

Facility

$0.38

Service Code	HCPCS Q0177
Hospital Charge Code	176182687
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of AZ Commercial	$0.34
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	$0.26
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	$0.25
Rate for Payer: Devoted Health Medicare	$0.07
Rate for Payer: Humana of AZ Medicare	$0.06
Rate for Payer: Southwest Service Administrators UFCW	$0.26
Rate for Payer: TriWest Medicare	$0.06
Rate for Payer: United Healthcare Commercial	$0.22
Rate for Payer: United Healthcare Medicare	$0.06
Rate for Payer: Veterans Affairs TRICARE	$0.06

hyoscyamine 0.125 mg Dis tab [CQCH}

Facility

$0.20

Service Code	NDC 42192033801
Hospital Charge Code	112802907
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.18
Rate for Payer: Cash Price	$0.16

Know your out-of-pocket cost for care.

All Charges