Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

amiodarone 360 mg/200 mL-D5% Sol [CQCH]

Facility

$0.22

Service Code	HCPCS J0282
Hospital Charge Code	105910420
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of AZ Commercial	$0.20
Rate for Payer: Cash Price	$0.17

amiodarone 360 mg/200 mL-D5% Sol [CQCH]

Facility

$0.22

Service Code	HCPCS J0282
Hospital Charge Code	105910420
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of AZ Commercial	$0.20
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	$0.15
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	$0.17
Rate for Payer: Cigna of AZ Commercial	$0.14
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Southwest Service Administrators UFCW	$0.15
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	$0.03

amitriptyline 10 mg Tab [CQCH]

Facility

$0.26

Service Code	NDC 50268003715
Hospital Charge Code	105910570
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	$0.18
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	$0.17
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

amitriptyline 10 mg Tab [CQCH]

Facility

$0.26

Service Code	NDC 50268003715
Hospital Charge Code	105910570
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	$0.21

amitriptyline 25 mg Tab [CQCH]

Facility

$0.24

Service Code	NDC 60687043301
Hospital Charge Code	105910637
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of AZ Commercial	$0.22
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	$0.19
Rate for Payer: Cigna of AZ Commercial	$0.16
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	$0.14
Rate for Payer: United Healthcare Medicare	$0.04
Rate for Payer: Veterans Affairs TRICARE	$0.04

amitriptyline 25 mg Tab [CQCH]

Facility

$0.24

Service Code	NDC 60687043301
Hospital Charge Code	105910637
Hospital Revenue Code	251
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of AZ Commercial	$0.22
Rate for Payer: Cash Price	$0.19

amLODIPine 5 mg Tab [CQCH]

Facility

$0.08

Service Code	NDC 904637061
Hospital Charge Code	105910702
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
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	$0.05
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	$0.06
Rate for Payer: Cigna of AZ Commercial	$0.05
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.05
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.05
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

amLODIPine 5 mg Tab [CQCH]

Facility

$0.08

Service Code	NDC 904637061
Hospital Charge Code	105910702
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
Rate for Payer: Cash Price	$0.06

AMMONIA

Facility

$190.00

Service Code	CPT 82140
Hospital Charge Code	22481458
Hospital Revenue Code	301
Min. Negotiated Rate	$21.13
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna of AZ Commercial	$171.00
Rate for Payer: Arizona Complete Health Allwell	$30.40
Rate for Payer: Banner UC Health Medicare	$30.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$129.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$30.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$30.40
Rate for Payer: Cash Price	$152.00
Rate for Payer: Cash Price	$152.00
Rate for Payer: Cigna of AZ Commercial	$123.50
Rate for Payer: Devoted Health Medicare	$34.20
Rate for Payer: Humana of AZ Medicare	$30.40
Rate for Payer: Seven Corners Travel Insurance	$21.13
Rate for Payer: Southwest Service Administrators UFCW	$129.20
Rate for Payer: TriWest Medicare	$30.40
Rate for Payer: United Healthcare Commercial	$108.68
Rate for Payer: United Healthcare Medicare	$30.40
Rate for Payer: Veterans Affairs TRICARE	$30.10

AMMONIA

Facility

$190.00

Service Code	CPT 82140
Hospital Charge Code	22481458
Hospital Revenue Code	301
Min. Negotiated Rate	$171.00
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna of AZ Commercial	$171.00
Rate for Payer: Cash Price	$152.00

ammonia inhalant [CQCH]

Facility

$0.17

Service Code	NDC 39822990002
Hospital Charge Code	105953831
Hospital Revenue Code	251
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

ammonia inhalant [CQCH]

Facility

$0.17

Service Code	NDC 39822990002
Hospital Charge Code	105953831
Hospital Revenue Code	251
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

Ammonia Level

Facility

$171.00

Service Code	CPT 82140
Hospital Charge Code	633648
Hospital Revenue Code	301
Min. Negotiated Rate	$21.13
Max. Negotiated Rate	$153.90
Rate for Payer: Aetna of AZ Commercial	$153.90
Rate for Payer: Arizona Complete Health Allwell	$27.36
Rate for Payer: Banner UC Health Medicare	$27.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$116.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.36
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cigna of AZ Commercial	$111.15
Rate for Payer: Devoted Health Medicare	$30.78
Rate for Payer: Humana of AZ Medicare	$27.36
Rate for Payer: Seven Corners Travel Insurance	$21.13
Rate for Payer: Southwest Service Administrators UFCW	$116.28
Rate for Payer: TriWest Medicare	$27.36
Rate for Payer: United Healthcare Commercial	$97.81
Rate for Payer: United Healthcare Medicare	$27.36
Rate for Payer: Veterans Affairs TRICARE	$27.09

Ammonia Level

Facility

$171.00

Service Code	CPT 82140
Hospital Charge Code	633648
Hospital Revenue Code	301
Min. Negotiated Rate	$153.90
Max. Negotiated Rate	$153.90
Rate for Payer: Aetna of AZ Commercial	$153.90
Rate for Payer: Cash Price	$136.80

AMNIOCORD 2X3CM

Facility

$7,400.00

Hospital Charge Code	27491238
Hospital Revenue Code	270
Min. Negotiated Rate	$6,660.00
Max. Negotiated Rate	$6,660.00
Rate for Payer: Aetna of AZ Commercial	$6,660.00
Rate for Payer: Cash Price	$5,920.00

AMNIOCORD 2X3CM

Facility

$7,400.00

Hospital Charge Code	27491238
Hospital Revenue Code	270
Min. Negotiated Rate	$1,172.16
Max. Negotiated Rate	$6,660.00
Rate for Payer: Aetna of AZ Commercial	$6,660.00
Rate for Payer: Arizona Complete Health Allwell	$1,184.00
Rate for Payer: Banner UC Health Medicare	$1,184.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5,032.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,184.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,184.00
Rate for Payer: Cash Price	$5,920.00
Rate for Payer: Cigna of AZ Commercial	$5,180.00
Rate for Payer: Devoted Health Medicare	$1,332.00
Rate for Payer: Humana of AZ Medicare	$1,184.00
Rate for Payer: Southwest Service Administrators UFCW	$5,032.00
Rate for Payer: TriWest Medicare	$1,184.00
Rate for Payer: United Healthcare Commercial	$4,232.80
Rate for Payer: United Healthcare Medicare	$1,184.00
Rate for Payer: Veterans Affairs TRICARE	$1,172.16

AMNIOFIX 4X6 CM

Facility

$14,404.00

Hospital Charge Code	27520626
Hospital Revenue Code	270
Min. Negotiated Rate	$2,281.59
Max. Negotiated Rate	$12,963.60
Rate for Payer: Aetna of AZ Commercial	$12,963.60
Rate for Payer: Arizona Complete Health Allwell	$2,304.64
Rate for Payer: Banner UC Health Medicare	$2,304.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$9,794.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2,304.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$2,304.64
Rate for Payer: Cash Price	$11,523.20
Rate for Payer: Cigna of AZ Commercial	$10,082.80
Rate for Payer: Devoted Health Medicare	$2,592.72
Rate for Payer: Humana of AZ Medicare	$2,304.64
Rate for Payer: Southwest Service Administrators UFCW	$9,794.72
Rate for Payer: TriWest Medicare	$2,304.64
Rate for Payer: United Healthcare Commercial	$8,239.09
Rate for Payer: United Healthcare Medicare	$2,304.64
Rate for Payer: Veterans Affairs TRICARE	$2,281.59

AMNIOFIX 4X6 CM

Facility

$14,404.00

Hospital Charge Code	27520626
Hospital Revenue Code	270
Min. Negotiated Rate	$12,963.60
Max. Negotiated Rate	$12,963.60
Rate for Payer: Aetna of AZ Commercial	$12,963.60
Rate for Payer: Cash Price	$11,523.20

amoxicillin 250 mg/5 mL Oral Susp (80 mL after reconst.) [CQCH]

Facility

$1.38

Service Code	NDC 93415579
Hospital Charge Code	105910832
Hospital Revenue Code	251
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$1.24
Rate for Payer: Aetna of AZ Commercial	$1.24
Rate for Payer: Cash Price	$1.10

amoxicillin 250 mg/5 mL Oral Susp (80 mL after reconst.) [CQCH]

Facility

$1.38

Service Code	NDC 93415579
Hospital Charge Code	105910832
Hospital Revenue Code	251
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$1.24
Rate for Payer: Aetna of AZ Commercial	$1.24
Rate for Payer: Arizona Complete Health Allwell	$0.22
Rate for Payer: Banner UC Health Medicare	$0.22
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.94
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.22
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.22
Rate for Payer: Cash Price	$1.10
Rate for Payer: Cigna of AZ Commercial	$0.90
Rate for Payer: Devoted Health Medicare	$0.25
Rate for Payer: Humana of AZ Medicare	$0.22
Rate for Payer: Southwest Service Administrators UFCW	$0.94
Rate for Payer: TriWest Medicare	$0.22
Rate for Payer: United Healthcare Commercial	$0.79
Rate for Payer: United Healthcare Medicare	$0.22
Rate for Payer: Veterans Affairs TRICARE	$0.22

amoxicillin 250 mg/5 mL Susp (100 mls after reconstitution)[CQCH]

Facility

$0.02

Service Code	NDC 65862070701
Hospital Charge Code	210809148
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Cash Price	$0.01

amoxicillin 250 mg/5 mL Susp (100 mls after reconstitution)[CQCH]

Facility

$0.02

Service Code	NDC 65862070701
Hospital Charge Code	210809148
Hospital Revenue Code	251
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	$0.01
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

amoxicillin 250 mg/5 mL Susp (150 ml after reconstitution)

Facility

$0.10

Service Code	NDC 143988915
Hospital Charge Code	209124903
Hospital Revenue Code	231
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of AZ Commercial	$0.09
Rate for Payer: Cash Price	$0.08

amoxicillin 250 mg/5 mL Susp (150 ml after reconstitution)

Facility

$0.10

Service Code	NDC 143988915
Hospital Charge Code	209124903
Hospital Revenue Code	231
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of AZ Commercial	$0.09
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	$0.08
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

amoxicillin 500 mg Cap [CQCH]

Facility

$0.09

Service Code	NDC 16714029903
Hospital Charge Code	105910767
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of AZ Commercial	$0.08
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	$0.06
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	$0.07
Rate for Payer: Cigna of AZ Commercial	$0.06
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.06
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.05
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

Know your out-of-pocket cost for care.

All Charges