Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Progesterone LC

Facility

$544.00

Service Code	CPT 84144
Hospital Charge Code	1909537
Hospital Revenue Code	301
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$489.60
Rate for Payer: Aetna of AZ Commercial	$489.60
Rate for Payer: Cash Price	$435.20

Progesterone LC

Facility

$544.00

Service Code	CPT 84144
Hospital Charge Code	1909537
Hospital Revenue Code	301
Min. Negotiated Rate	$30.25
Max. Negotiated Rate	$489.60
Rate for Payer: Aetna of AZ Commercial	$489.60
Rate for Payer: Arizona Complete Health Allwell	$87.04
Rate for Payer: Banner UC Health Medicare	$87.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$369.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$87.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$87.04
Rate for Payer: Cash Price	$435.20
Rate for Payer: Cash Price	$435.20
Rate for Payer: Cigna of AZ Commercial	$353.60
Rate for Payer: Devoted Health Medicare	$97.92
Rate for Payer: Humana of AZ Medicare	$87.04
Rate for Payer: Seven Corners Travel Insurance	$30.25
Rate for Payer: Southwest Service Administrators UFCW	$369.92
Rate for Payer: TriWest Medicare	$87.04
Rate for Payer: United Healthcare Commercial	$311.17
Rate for Payer: United Healthcare Medicare	$87.04
Rate for Payer: Veterans Affairs TRICARE	$86.17

Programming State II

Facility

$210.00

Service Code	CPT 95972
Hospital Charge Code	27281906
Hospital Revenue Code	360
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Cash Price	$168.00

Programming State II

Facility

$210.00

Service Code	CPT 95972
Hospital Charge Code	27281906
Hospital Revenue Code	360
Min. Negotiated Rate	$17.78
Max. Negotiated Rate	$3,373.00
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Arizona Complete Health Allwell	$33.60
Rate for Payer: Banner UC Health Medicare	$33.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$142.80
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$17.78
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$33.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$33.60
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cigna of AZ Commercial	$105.00
Rate for Payer: Devoted Health Medicare	$37.80
Rate for Payer: Humana of AZ Medicare	$33.60
Rate for Payer: Mercy Care Medicaid	$17.78
Rate for Payer: NaphCare Correctional Healthcare	$17.78
Rate for Payer: Seven Corners Travel Insurance	$147.10
Rate for Payer: Southwest Service Administrators UFCW	$142.80
Rate for Payer: TriWest Medicare	$33.60
Rate for Payer: United Healthcare Commercial	$3,373.00
Rate for Payer: United Healthcare Medicare	$33.60
Rate for Payer: Veterans Affairs TRICARE	$33.26

PROINSULIN

Facility

$125.00

Service Code	CPT 84206
Hospital Charge Code	22576579
Hospital Revenue Code	301
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$112.50
Rate for Payer: Aetna of AZ Commercial	$112.50
Rate for Payer: Arizona Complete Health Allwell	$20.00
Rate for Payer: Banner UC Health Medicare	$20.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$85.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.00
Rate for Payer: Cash Price	$100.00
Rate for Payer: Cash Price	$100.00
Rate for Payer: Cigna of AZ Commercial	$81.25
Rate for Payer: Devoted Health Medicare	$22.50
Rate for Payer: Humana of AZ Medicare	$20.00
Rate for Payer: Seven Corners Travel Insurance	$38.70
Rate for Payer: Southwest Service Administrators UFCW	$85.00
Rate for Payer: TriWest Medicare	$20.00
Rate for Payer: United Healthcare Commercial	$71.50
Rate for Payer: United Healthcare Medicare	$20.00
Rate for Payer: Veterans Affairs TRICARE	$19.80

PROINSULIN

Facility

$125.00

Service Code	CPT 84206
Hospital Charge Code	22576579
Hospital Revenue Code	301
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Aetna of AZ Commercial	$112.50
Rate for Payer: Cash Price	$100.00

Prolactin LC

Facility

$240.00

Service Code	CPT 84146
Hospital Charge Code	1285574
Hospital Revenue Code	301
Min. Negotiated Rate	$28.10
Max. Negotiated Rate	$216.00
Rate for Payer: Aetna of AZ Commercial	$216.00
Rate for Payer: Arizona Complete Health Allwell	$38.40
Rate for Payer: Banner UC Health Medicare	$38.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$163.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.40
Rate for Payer: Cash Price	$192.00
Rate for Payer: Cash Price	$192.00
Rate for Payer: Cigna of AZ Commercial	$156.00
Rate for Payer: Devoted Health Medicare	$43.20
Rate for Payer: Humana of AZ Medicare	$38.40
Rate for Payer: Seven Corners Travel Insurance	$28.10
Rate for Payer: Southwest Service Administrators UFCW	$163.20
Rate for Payer: TriWest Medicare	$38.40
Rate for Payer: United Healthcare Commercial	$137.28
Rate for Payer: United Healthcare Medicare	$38.40
Rate for Payer: Veterans Affairs TRICARE	$38.02

Prolactin LC

Facility

$240.00

Service Code	CPT 84146
Hospital Charge Code	1285574
Hospital Revenue Code	301
Min. Negotiated Rate	$216.00
Max. Negotiated Rate	$216.00
Rate for Payer: Aetna of AZ Commercial	$216.00
Rate for Payer: Cash Price	$192.00

PROLENE 4 0 SH BLUE

Facility

$99.00

Hospital Charge Code	23770584
Hospital Revenue Code	270
Min. Negotiated Rate	$15.68
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of AZ Commercial	$89.10
Rate for Payer: Arizona Complete Health Allwell	$15.84
Rate for Payer: Banner UC Health Medicare	$15.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$67.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$15.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.84
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna of AZ Commercial	$69.30
Rate for Payer: Devoted Health Medicare	$17.82
Rate for Payer: Humana of AZ Medicare	$15.84
Rate for Payer: Southwest Service Administrators UFCW	$67.32
Rate for Payer: TriWest Medicare	$15.84
Rate for Payer: United Healthcare Commercial	$56.63
Rate for Payer: United Healthcare Medicare	$15.84
Rate for Payer: Veterans Affairs TRICARE	$15.68

PROLENE 4 0 SH BLUE

Facility

$99.00

Hospital Charge Code	23770584
Hospital Revenue Code	270
Min. Negotiated Rate	$89.10
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of AZ Commercial	$89.10
Rate for Payer: Cash Price	$79.20

Prolonged Physician Service Outpatient with Direct Patient Contact First Hour -

Facility

$79.00

Service Code	CPT 99354
Hospital Charge Code	621589
Hospital Revenue Code	521
Min. Negotiated Rate	$71.10
Max. Negotiated Rate	$71.10
Rate for Payer: Aetna of AZ Commercial	$71.10
Rate for Payer: Cash Price	$63.20

Prolonged Physician Service Outpatient with Direct Patient Contact First Hour -

Facility

$79.00

Service Code	CPT 99354
Hospital Charge Code	621589
Hospital Revenue Code	521
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$71.10
Rate for Payer: Aetna of AZ Commercial	$71.10
Rate for Payer: Arizona Complete Health Allwell	$12.64
Rate for Payer: Banner UC Health Medicare	$12.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$53.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.64
Rate for Payer: Cash Price	$63.20
Rate for Payer: Cigna of AZ Commercial	$55.30
Rate for Payer: Devoted Health Medicare	$14.22
Rate for Payer: Humana of AZ Medicare	$12.64
Rate for Payer: Southwest Service Administrators UFCW	$53.72
Rate for Payer: TriWest Medicare	$12.64
Rate for Payer: United Healthcare Commercial	$45.19
Rate for Payer: United Healthcare Medicare	$12.64
Rate for Payer: Veterans Affairs TRICARE	$12.51

promethazine 25 mg/ 1mL Inj Sol [CQCH]

Facility

$0.84

Service Code	HCPCS J2550
Hospital Charge Code	105938466
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$0.76
Rate for Payer: Aetna of AZ Commercial	$0.76
Rate for Payer: Cash Price	$0.67

promethazine 25 mg/ 1mL Inj Sol [CQCH]

Facility

$0.84

Service Code	HCPCS J2550
Hospital Charge Code	105938466
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.76
Rate for Payer: Aetna of AZ Commercial	$0.76
Rate for Payer: Arizona Complete Health Allwell	$0.13
Rate for Payer: Banner UC Health Medicare	$0.13
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.57
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.13
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.13
Rate for Payer: Cash Price	$0.67
Rate for Payer: Cigna of AZ Commercial	$0.55
Rate for Payer: Devoted Health Medicare	$0.15
Rate for Payer: Humana of AZ Medicare	$0.13
Rate for Payer: Southwest Service Administrators UFCW	$0.57
Rate for Payer: TriWest Medicare	$0.13
Rate for Payer: United Healthcare Commercial	$0.48
Rate for Payer: United Healthcare Medicare	$0.13
Rate for Payer: Veterans Affairs TRICARE	$0.13

promethazine 25 mg Supp [CQCH]

Facility

$3.03

Service Code	NDC 45802075930
Hospital Charge Code	105938401
Hospital Revenue Code	251
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$2.73
Rate for Payer: Aetna of AZ Commercial	$2.73
Rate for Payer: Arizona Complete Health Allwell	$0.48
Rate for Payer: Banner UC Health Medicare	$0.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2.06
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.48
Rate for Payer: Cash Price	$2.42
Rate for Payer: Cigna of AZ Commercial	$1.97
Rate for Payer: Devoted Health Medicare	$0.55
Rate for Payer: Humana of AZ Medicare	$0.48
Rate for Payer: Southwest Service Administrators UFCW	$2.06
Rate for Payer: TriWest Medicare	$0.48
Rate for Payer: United Healthcare Commercial	$1.73
Rate for Payer: United Healthcare Medicare	$0.48
Rate for Payer: Veterans Affairs TRICARE	$0.48

promethazine 25 mg Supp [CQCH]

Facility

$3.03

Service Code	NDC 45802075930
Hospital Charge Code	105938401
Hospital Revenue Code	251
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$2.73
Rate for Payer: Aetna of AZ Commercial	$2.73
Rate for Payer: Cash Price	$2.42

promethazine 25 mg Tab [CQCH]

Facility

$0.11

Service Code	HCPCS Q0169
Hospital Charge Code	105938332
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of AZ Commercial	$0.10
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	$0.07
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	$0.09
Rate for Payer: Cigna of AZ Commercial	$0.07
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.07
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.06
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

promethazine 25 mg Tab [CQCH]

Facility

$0.11

Service Code	HCPCS Q0169
Hospital Charge Code	105938332
Hospital Revenue Code	251
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of AZ Commercial	$0.10
Rate for Payer: Cash Price	$0.09

promethazine-dextromethorphan-6.25-15mg mg/5 mL Oral Syrup 118 mL [CQCH]

Facility

$0.06

Service Code	NDC 60432060416
Hospital Charge Code	105918225
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Cash Price	$0.04

promethazine-dextromethorphan-6.25-15mg mg/5 mL Oral Syrup 118 mL [CQCH]

Facility

$0.06

Service Code	NDC 60432060416
Hospital Charge Code	105918225
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Arizona Complete Health Allwell	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.01
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.01
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of AZ Commercial	$0.04
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.04
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.03
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

Promethazine hcl injection

Facility

$33.00

Service Code	HCPCS J2550
Hospital Charge Code	1235636
Hospital Revenue Code	521
Min. Negotiated Rate	$5.23
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Arizona Complete Health Allwell	$5.28
Rate for Payer: Banner UC Health Medicare	$5.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$22.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.28
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cigna of AZ Commercial	$23.10
Rate for Payer: Devoted Health Medicare	$5.94
Rate for Payer: Humana of AZ Medicare	$5.28
Rate for Payer: Southwest Service Administrators UFCW	$22.44
Rate for Payer: TriWest Medicare	$5.28
Rate for Payer: United Healthcare Commercial	$18.88
Rate for Payer: United Healthcare Medicare	$5.28
Rate for Payer: Veterans Affairs TRICARE	$5.23

Promethazine hcl injection

Facility

$33.00

Service Code	HCPCS J2550
Hospital Charge Code	1235636
Hospital Revenue Code	521
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Cash Price	$26.40

propafenone 150 mg Tab UD [CQCH]

Facility

$0.17

Service Code	NDC 603544821
Hospital Charge Code	109867534
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
Rate for Payer: Cash Price	$0.14

propafenone 150 mg Tab UD [CQCH]

Facility

$0.17

Service Code	NDC 603544821
Hospital Charge Code	109867534
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
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	$0.12
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	$0.14
Rate for Payer: Cigna of AZ Commercial	$0.11
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Southwest Service Administrators UFCW	$0.12
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: United Healthcare Commercial	$0.10
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

proparacaine Ophth 0.5% Sol [CQCH]

Facility

$2.17

Service Code	NDC 24208073006
Hospital Charge Code	105938535
Hospital Revenue Code	251
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna of AZ Commercial	$1.95
Rate for Payer: Arizona Complete Health Allwell	$0.35
Rate for Payer: Banner UC Health Medicare	$0.35
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.35
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.35
Rate for Payer: Cash Price	$1.74
Rate for Payer: Cigna of AZ Commercial	$1.41
Rate for Payer: Devoted Health Medicare	$0.39
Rate for Payer: Humana of AZ Medicare	$0.35
Rate for Payer: Southwest Service Administrators UFCW	$1.48
Rate for Payer: TriWest Medicare	$0.35
Rate for Payer: United Healthcare Commercial	$1.24
Rate for Payer: United Healthcare Medicare	$0.35
Rate for Payer: Veterans Affairs TRICARE	$0.34

Know your out-of-pocket cost for care.

All Charges