Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

PHENobarbital 130 mg/1 mL Inj Sol [CQCH]

Facility

$50.21

Service Code	HCPCS J2560
Hospital Charge Code	105936151
Hospital Revenue Code	250
Min. Negotiated Rate	$45.19
Max. Negotiated Rate	$45.19
Rate for Payer: Aetna of AZ Commercial	$45.19
Rate for Payer: Cash Price	$40.17

PHENobarbital 32.4 mg Tab [CQCH]

Facility

$0.27

Service Code	NDC 904657561
Hospital Charge Code	105936220
Hospital Revenue Code	251
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	$0.21
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

PHENobarbital 32.4 mg Tab [CQCH]

Facility

$0.27

Service Code	NDC 904657561
Hospital Charge Code	105936220
Hospital Revenue Code	251
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of AZ Commercial	$0.24
Rate for Payer: Cash Price	$0.21

PHENobarbital 65 mg/mL Sol[CQCH]

Facility

$19.35

Service Code	HCPCS J2560
Hospital Charge Code	121708919
Hospital Revenue Code	250
Min. Negotiated Rate	$17.41
Max. Negotiated Rate	$17.41
Rate for Payer: Aetna of AZ Commercial	$17.41
Rate for Payer: Cash Price	$15.48

PHENobarbital 65 mg/mL Sol[CQCH]

Facility

$19.35

Service Code	HCPCS J2560
Hospital Charge Code	121708919
Hospital Revenue Code	250
Min. Negotiated Rate	$3.07
Max. Negotiated Rate	$17.41
Rate for Payer: Aetna of AZ Commercial	$17.41
Rate for Payer: Arizona Complete Health Allwell	$3.10
Rate for Payer: Banner UC Health Medicare	$3.10
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$13.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.10
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.10
Rate for Payer: Cash Price	$15.48
Rate for Payer: Cigna of AZ Commercial	$12.58
Rate for Payer: Devoted Health Medicare	$3.48
Rate for Payer: Humana of AZ Medicare	$3.10
Rate for Payer: Southwest Service Administrators UFCW	$13.16
Rate for Payer: TriWest Medicare	$3.10
Rate for Payer: United Healthcare Commercial	$11.07
Rate for Payer: United Healthcare Medicare	$3.10
Rate for Payer: Veterans Affairs TRICARE	$3.07

Phenobarbital, Serum LC

Facility

$206.00

Service Code	CPT 80184
Hospital Charge Code	1285609
Hospital Revenue Code	301
Min. Negotiated Rate	$22.18
Max. Negotiated Rate	$185.40
Rate for Payer: Aetna of AZ Commercial	$185.40
Rate for Payer: Arizona Complete Health Allwell	$32.96
Rate for Payer: Banner UC Health Medicare	$32.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$140.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.96
Rate for Payer: Cash Price	$164.80
Rate for Payer: Cash Price	$164.80
Rate for Payer: Cigna of AZ Commercial	$133.90
Rate for Payer: Devoted Health Medicare	$37.08
Rate for Payer: Humana of AZ Medicare	$32.96
Rate for Payer: Seven Corners Travel Insurance	$22.18
Rate for Payer: Southwest Service Administrators UFCW	$140.08
Rate for Payer: TriWest Medicare	$32.96
Rate for Payer: United Healthcare Commercial	$117.83
Rate for Payer: United Healthcare Medicare	$32.96
Rate for Payer: Veterans Affairs TRICARE	$32.63

Phenobarbital, Serum LC

Facility

$206.00

Service Code	CPT 80184
Hospital Charge Code	1285609
Hospital Revenue Code	301
Min. Negotiated Rate	$185.40
Max. Negotiated Rate	$185.40
Rate for Payer: Aetna of AZ Commercial	$185.40
Rate for Payer: Cash Price	$164.80

phenylephrine 10 mg/ 1 mL Inj Sol [CQCH]

Facility

$3.68

Service Code	HCPCS J2370
Hospital Charge Code	105936354
Hospital Revenue Code	250
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$3.31
Rate for Payer: Aetna of AZ Commercial	$3.31
Rate for Payer: Arizona Complete Health Allwell	$0.59
Rate for Payer: Banner UC Health Medicare	$0.59
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2.50
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.59
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.59
Rate for Payer: Cash Price	$2.95
Rate for Payer: Cigna of AZ Commercial	$2.39
Rate for Payer: Devoted Health Medicare	$0.66
Rate for Payer: Humana of AZ Medicare	$0.59
Rate for Payer: Southwest Service Administrators UFCW	$2.50
Rate for Payer: TriWest Medicare	$0.59
Rate for Payer: United Healthcare Commercial	$2.10
Rate for Payer: United Healthcare Medicare	$0.59
Rate for Payer: Veterans Affairs TRICARE	$0.58

phenylephrine 10 mg/ 1 mL Inj Sol [CQCH]

Facility

$3.68

Service Code	HCPCS J2370
Hospital Charge Code	105936354
Hospital Revenue Code	250
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$3.31
Rate for Payer: Aetna of AZ Commercial	$3.31
Rate for Payer: Cash Price	$2.95

phenylephrine nasal 0.25% Sol 15 mL [CQCH]

Facility

$0.21

Service Code	NDC 24134803
Hospital Charge Code	105936423
Hospital Revenue Code	251
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of AZ Commercial	$0.19
Rate for Payer: Cash Price	$0.17

phenylephrine nasal 0.25% Sol 15 mL [CQCH]

Facility

$0.21

Service Code	NDC 24134803
Hospital Charge Code	105936423
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of AZ Commercial	$0.19
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	$0.14
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	$0.17
Rate for Payer: Cigna of AZ Commercial	$0.14
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Southwest Service Administrators UFCW	$0.14
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: United Healthcare Commercial	$0.12
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

phenylephrine nasal 1% spray 15 mL [CQCH]

Facility

$0.23

Service Code	NDC 24135202
Hospital Charge Code	105936488
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of AZ Commercial	$0.21
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	$0.18
Rate for Payer: Cigna of AZ Commercial	$0.15
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	$0.13
Rate for Payer: United Healthcare Medicare	$0.04
Rate for Payer: Veterans Affairs TRICARE	$0.04

phenylephrine nasal 1% spray 15 mL [CQCH]

Facility

$0.23

Service Code	NDC 24135202
Hospital Charge Code	105936488
Hospital Revenue Code	251
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of AZ Commercial	$0.21
Rate for Payer: Cash Price	$0.18

phenytoin 100 mg ER Cap [CQCH]

Facility

$0.52

Service Code	NDC 68084037601
Hospital Charge Code	105936628
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	$0.41
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

phenytoin 100 mg ER Cap [CQCH]

Facility

$0.52

Service Code	NDC 68084037601
Hospital Charge Code	105936628
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	$0.41

Phenytoin, Free, Serum LC

Facility

$318.00

Service Code	CPT 80186
Hospital Charge Code	2087633
Hospital Revenue Code	301
Min. Negotiated Rate	$286.20
Max. Negotiated Rate	$286.20
Rate for Payer: Aetna of AZ Commercial	$286.20
Rate for Payer: Cash Price	$254.40

Phenytoin, Free, Serum LC

Facility

$318.00

Service Code	CPT 80186
Hospital Charge Code	2087633
Hospital Revenue Code	301
Min. Negotiated Rate	$19.95
Max. Negotiated Rate	$286.20
Rate for Payer: Aetna of AZ Commercial	$286.20
Rate for Payer: Arizona Complete Health Allwell	$50.88
Rate for Payer: Banner UC Health Medicare	$50.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$216.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$50.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$50.88
Rate for Payer: Cash Price	$254.40
Rate for Payer: Cash Price	$254.40
Rate for Payer: Cigna of AZ Commercial	$206.70
Rate for Payer: Devoted Health Medicare	$57.24
Rate for Payer: Humana of AZ Medicare	$50.88
Rate for Payer: Seven Corners Travel Insurance	$19.95
Rate for Payer: Southwest Service Administrators UFCW	$216.24
Rate for Payer: TriWest Medicare	$50.88
Rate for Payer: United Healthcare Commercial	$181.90
Rate for Payer: United Healthcare Medicare	$50.88
Rate for Payer: Veterans Affairs TRICARE	$50.37

Phenytoin Lvl

Facility

$201.00

Service Code	CPT 80185
Hospital Charge Code	858788
Hospital Revenue Code	301
Min. Negotiated Rate	$180.90
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of AZ Commercial	$180.90
Rate for Payer: Aetna of AZ Commercial	$263.70
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cash Price	$234.40

Phenytoin Lvl

Facility

$293.00

Service Code	CPT 80185
Hospital Charge Code	858788
Hospital Revenue Code	301
Min. Negotiated Rate	$19.21
Max. Negotiated Rate	$263.70
Rate for Payer: Aetna of AZ Commercial	$263.70
Rate for Payer: Aetna of AZ Commercial	$180.90
Rate for Payer: Arizona Complete Health Allwell	$32.16
Rate for Payer: Arizona Complete Health Allwell	$46.88
Rate for Payer: Banner UC Health Medicare	$32.16
Rate for Payer: Banner UC Health Medicare	$46.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$199.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$136.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$46.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$46.88
Rate for Payer: Cash Price	$234.40
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cash Price	$234.40
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cigna of AZ Commercial	$190.45
Rate for Payer: Cigna of AZ Commercial	$130.65
Rate for Payer: Devoted Health Medicare	$52.74
Rate for Payer: Devoted Health Medicare	$36.18
Rate for Payer: Humana of AZ Medicare	$32.16
Rate for Payer: Humana of AZ Medicare	$46.88
Rate for Payer: Seven Corners Travel Insurance	$19.21
Rate for Payer: Seven Corners Travel Insurance	$19.21
Rate for Payer: Southwest Service Administrators UFCW	$136.68
Rate for Payer: Southwest Service Administrators UFCW	$199.24
Rate for Payer: TriWest Medicare	$32.16
Rate for Payer: TriWest Medicare	$46.88
Rate for Payer: United Healthcare Commercial	$167.60
Rate for Payer: United Healthcare Commercial	$114.97
Rate for Payer: United Healthcare Medicare	$32.16
Rate for Payer: United Healthcare Medicare	$46.88
Rate for Payer: Veterans Affairs TRICARE	$46.41
Rate for Payer: Veterans Affairs TRICARE	$31.84

Phone EM by Physician 11 to 20 minutes of medical discussio

Facility

$288.00

Service Code	CPT 99442
Hospital Charge Code	1303895
Hospital Revenue Code	521
Min. Negotiated Rate	$259.20
Max. Negotiated Rate	$259.20
Rate for Payer: Aetna of AZ Commercial	$259.20
Rate for Payer: Cash Price	$230.40

Phone EM by Physician 11 to 20 minutes of medical discussio

Facility

$288.00

Service Code	CPT 99442
Hospital Charge Code	1303895
Hospital Revenue Code	521
Min. Negotiated Rate	$45.62
Max. Negotiated Rate	$259.20
Rate for Payer: Aetna of AZ Commercial	$259.20
Rate for Payer: Arizona Complete Health Allwell	$46.08
Rate for Payer: Banner UC Health Medicare	$46.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$195.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$46.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$46.08
Rate for Payer: Cash Price	$230.40
Rate for Payer: Cigna of AZ Commercial	$201.60
Rate for Payer: Devoted Health Medicare	$51.84
Rate for Payer: Humana of AZ Medicare	$46.08
Rate for Payer: Southwest Service Administrators UFCW	$195.84
Rate for Payer: TriWest Medicare	$46.08
Rate for Payer: United Healthcare Commercial	$164.74
Rate for Payer: United Healthcare Medicare	$46.08
Rate for Payer: Veterans Affairs TRICARE	$45.62

Phone EM by Physician 5 to 10 minutes of medical discussion

Facility

$150.00

Service Code	CPT 99441
Hospital Charge Code	1303892
Hospital Revenue Code	521
Min. Negotiated Rate	$135.00
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of AZ Commercial	$135.00
Rate for Payer: Cash Price	$120.00

Phone EM by Physician 5 to 10 minutes of medical discussion

Facility

$150.00

Service Code	CPT 99441
Hospital Charge Code	1303892
Hospital Revenue Code	521
Min. Negotiated Rate	$23.76
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of AZ Commercial	$135.00
Rate for Payer: Arizona Complete Health Allwell	$24.00
Rate for Payer: Banner UC Health Medicare	$24.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$102.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$24.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$24.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cigna of AZ Commercial	$105.00
Rate for Payer: Devoted Health Medicare	$27.00
Rate for Payer: Humana of AZ Medicare	$24.00
Rate for Payer: Southwest Service Administrators UFCW	$102.00
Rate for Payer: TriWest Medicare	$24.00
Rate for Payer: United Healthcare Commercial	$85.80
Rate for Payer: United Healthcare Medicare	$24.00
Rate for Payer: Veterans Affairs TRICARE	$23.76

Phosphorus, 24 hr Urine LC

Facility

$69.00

Service Code	CPT 84105
Hospital Charge Code	2029252
Hospital Revenue Code	301
Min. Negotiated Rate	$8.38
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Arizona Complete Health Allwell	$11.04
Rate for Payer: Banner UC Health Medicare	$11.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$46.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.04
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cigna of AZ Commercial	$44.85
Rate for Payer: Devoted Health Medicare	$12.42
Rate for Payer: Humana of AZ Medicare	$11.04
Rate for Payer: Seven Corners Travel Insurance	$8.38
Rate for Payer: Southwest Service Administrators UFCW	$46.92
Rate for Payer: TriWest Medicare	$11.04
Rate for Payer: United Healthcare Commercial	$39.47
Rate for Payer: United Healthcare Medicare	$11.04
Rate for Payer: Veterans Affairs TRICARE	$10.93

Phosphorus, 24 hr Urine LC

Facility

$69.00

Service Code	CPT 84105
Hospital Charge Code	2029252
Hospital Revenue Code	301
Min. Negotiated Rate	$62.10
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Cash Price	$55.20

Know your out-of-pocket cost for care.

All Charges