Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

dextrose (infant)25% IV Sol 10 mL [CQCH]

Facility

$0.65

Service Code	NDC 409177510
Hospital Charge Code	105924552
Hospital Revenue Code	251
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of AZ Commercial	$0.59
Rate for Payer: Aetna of AZ Medicare	$0.18
Rate for Payer: Allwell Medicare	$0.10
Rate for Payer: Amerigroup Medicare	$0.10
Rate for Payer: APIPA Medicare/Medicaid	$0.24
Rate for Payer: AZCH Complete Medicare	$0.10
Rate for Payer: Banner UC Health Medicare	$0.10
Rate for Payer: Bisbee Police All Plans	$0.17
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.44
Rate for Payer: Cash Price	$0.52
Rate for Payer: Cigna of AZ Commercial	$0.42
Rate for Payer: Copperpoint Commercial	$0.16
Rate for Payer: Health Net of AZ Commercial	$0.39
Rate for Payer: Health Net of AZ Medicare	$0.18
Rate for Payer: Humana of AZ Medicare	$0.10
Rate for Payer: Self Pay Self Pay	$0.52
Rate for Payer: TriWest Medicare	$0.10
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.12

dextrose (infant)25% IV Sol 10 mL [CQCH]

Facility

$0.65

Service Code	NDC 409177510
Hospital Charge Code	105924552
Hospital Revenue Code	251
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of AZ Commercial	$0.59
Rate for Payer: Bisbee Police All Plans	$0.17
Rate for Payer: Cash Price	$0.52
Rate for Payer: Self Pay Self Pay	$0.52

Diabetes

Facility

$5,568.41

Service Code	APR-DRG 4203
Hospital Charge Code	APRDRG4203
Min. Negotiated Rate	$5,568.41
Max. Negotiated Rate	$5,568.41
Rate for Payer: AHCCCS Medicaid	$5,568.41
Rate for Payer: Allwell Medicaid	$5,568.41
Rate for Payer: AZCH Complete Medicaid	$5,568.41
Rate for Payer: Banner UC Health Medicaid	$5,568.41
Rate for Payer: Mercy Care Medicaid	$5,568.41

Diabetes

Facility

$11,890.83

Service Code	APR-DRG 4204
Hospital Charge Code	APRDRG4202
Min. Negotiated Rate	$11,890.83
Max. Negotiated Rate	$11,890.83
Rate for Payer: AHCCCS Medicaid	$11,890.83
Rate for Payer: Allwell Medicaid	$11,890.83
Rate for Payer: AZCH Complete Medicaid	$11,890.83
Rate for Payer: Banner UC Health Medicaid	$11,890.83
Rate for Payer: Mercy Care Medicaid	$11,890.83

Diabetes

Facility

$11,890.83

Service Code	APR-DRG 4204
Hospital Charge Code	APRDRG4204
Min. Negotiated Rate	$11,890.83
Max. Negotiated Rate	$11,890.83
Rate for Payer: AHCCCS Medicaid	$11,890.83
Rate for Payer: Allwell Medicaid	$11,890.83
Rate for Payer: AZCH Complete Medicaid	$11,890.83
Rate for Payer: Banner UC Health Medicaid	$11,890.83
Rate for Payer: Mercy Care Medicaid	$11,890.83

Diabetes

Facility

$3,025.14

Service Code	APR-DRG 4201
Hospital Charge Code	APRDRG4201
Min. Negotiated Rate	$3,025.14
Max. Negotiated Rate	$3,025.14
Rate for Payer: AHCCCS Medicaid	$3,025.14
Rate for Payer: Allwell Medicaid	$3,025.14
Rate for Payer: AZCH Complete Medicaid	$3,025.14
Rate for Payer: Banner UC Health Medicaid	$3,025.14
Rate for Payer: Mercy Care Medicaid	$3,025.14

Diabetes

Facility

$3,025.14

Service Code	APR-DRG 4201
Hospital Charge Code	APRDRG4203
Min. Negotiated Rate	$3,025.14
Max. Negotiated Rate	$3,025.14
Rate for Payer: AHCCCS Medicaid	$3,025.14
Rate for Payer: Allwell Medicaid	$3,025.14
Rate for Payer: AZCH Complete Medicaid	$3,025.14
Rate for Payer: Banner UC Health Medicaid	$3,025.14
Rate for Payer: Mercy Care Medicaid	$3,025.14

Diabetes

Facility

$3,025.14

Service Code	APR-DRG 4201
Hospital Charge Code	APRDRG4202
Min. Negotiated Rate	$3,025.14
Max. Negotiated Rate	$3,025.14
Rate for Payer: AHCCCS Medicaid	$3,025.14
Rate for Payer: Allwell Medicaid	$3,025.14
Rate for Payer: AZCH Complete Medicaid	$3,025.14
Rate for Payer: Banner UC Health Medicaid	$3,025.14
Rate for Payer: Mercy Care Medicaid	$3,025.14

Diabetes

Facility

$3,647.98

Service Code	APR-DRG 4202
Hospital Charge Code	APRDRG4201
Min. Negotiated Rate	$3,647.98
Max. Negotiated Rate	$3,647.98
Rate for Payer: AHCCCS Medicaid	$3,647.98
Rate for Payer: Allwell Medicaid	$3,647.98
Rate for Payer: AZCH Complete Medicaid	$3,647.98
Rate for Payer: Banner UC Health Medicaid	$3,647.98
Rate for Payer: Mercy Care Medicaid	$3,647.98

Diabetes

Facility

$3,025.14

Service Code	APR-DRG 4201
Hospital Charge Code	APRDRG4204
Min. Negotiated Rate	$3,025.14
Max. Negotiated Rate	$3,025.14
Rate for Payer: AHCCCS Medicaid	$3,025.14
Rate for Payer: Allwell Medicaid	$3,025.14
Rate for Payer: AZCH Complete Medicaid	$3,025.14
Rate for Payer: Banner UC Health Medicaid	$3,025.14
Rate for Payer: Mercy Care Medicaid	$3,025.14

Diabetes

Facility

$11,890.83

Service Code	APR-DRG 4204
Hospital Charge Code	APRDRG4201
Min. Negotiated Rate	$11,890.83
Max. Negotiated Rate	$11,890.83
Rate for Payer: AHCCCS Medicaid	$11,890.83
Rate for Payer: Allwell Medicaid	$11,890.83
Rate for Payer: AZCH Complete Medicaid	$11,890.83
Rate for Payer: Banner UC Health Medicaid	$11,890.83
Rate for Payer: Mercy Care Medicaid	$11,890.83

Diabetes

Facility

$3,647.98

Service Code	APR-DRG 4202
Hospital Charge Code	APRDRG4204
Min. Negotiated Rate	$3,647.98
Max. Negotiated Rate	$3,647.98
Rate for Payer: AHCCCS Medicaid	$3,647.98
Rate for Payer: Allwell Medicaid	$3,647.98
Rate for Payer: AZCH Complete Medicaid	$3,647.98
Rate for Payer: Banner UC Health Medicaid	$3,647.98
Rate for Payer: Mercy Care Medicaid	$3,647.98

Diabetes

Facility

$5,568.41

Service Code	APR-DRG 4203
Hospital Charge Code	APRDRG4204
Min. Negotiated Rate	$5,568.41
Max. Negotiated Rate	$5,568.41
Rate for Payer: AHCCCS Medicaid	$5,568.41
Rate for Payer: Allwell Medicaid	$5,568.41
Rate for Payer: AZCH Complete Medicaid	$5,568.41
Rate for Payer: Banner UC Health Medicaid	$5,568.41
Rate for Payer: Mercy Care Medicaid	$5,568.41

Diabetes

Facility

$3,647.98

Service Code	APR-DRG 4202
Hospital Charge Code	APRDRG4202
Min. Negotiated Rate	$3,647.98
Max. Negotiated Rate	$3,647.98
Rate for Payer: AHCCCS Medicaid	$3,647.98
Rate for Payer: Allwell Medicaid	$3,647.98
Rate for Payer: AZCH Complete Medicaid	$3,647.98
Rate for Payer: Banner UC Health Medicaid	$3,647.98
Rate for Payer: Mercy Care Medicaid	$3,647.98

Diabetes

Facility

$5,568.41

Service Code	APR-DRG 4203
Hospital Charge Code	APRDRG4201
Min. Negotiated Rate	$5,568.41
Max. Negotiated Rate	$5,568.41
Rate for Payer: AHCCCS Medicaid	$5,568.41
Rate for Payer: Allwell Medicaid	$5,568.41
Rate for Payer: AZCH Complete Medicaid	$5,568.41
Rate for Payer: Banner UC Health Medicaid	$5,568.41
Rate for Payer: Mercy Care Medicaid	$5,568.41

Diabetes

Facility

$11,890.83

Service Code	APR-DRG 4204
Hospital Charge Code	APRDRG4203
Min. Negotiated Rate	$11,890.83
Max. Negotiated Rate	$11,890.83
Rate for Payer: AHCCCS Medicaid	$11,890.83
Rate for Payer: Allwell Medicaid	$11,890.83
Rate for Payer: AZCH Complete Medicaid	$11,890.83
Rate for Payer: Banner UC Health Medicaid	$11,890.83
Rate for Payer: Mercy Care Medicaid	$11,890.83

Diabetes

Facility

$5,568.41

Service Code	APR-DRG 4203
Hospital Charge Code	APRDRG4202
Min. Negotiated Rate	$5,568.41
Max. Negotiated Rate	$5,568.41
Rate for Payer: AHCCCS Medicaid	$5,568.41
Rate for Payer: Allwell Medicaid	$5,568.41
Rate for Payer: AZCH Complete Medicaid	$5,568.41
Rate for Payer: Banner UC Health Medicaid	$5,568.41
Rate for Payer: Mercy Care Medicaid	$5,568.41

Diabetes

Facility

$3,647.98

Service Code	APR-DRG 4202
Hospital Charge Code	APRDRG4203
Min. Negotiated Rate	$3,647.98
Max. Negotiated Rate	$3,647.98
Rate for Payer: AHCCCS Medicaid	$3,647.98
Rate for Payer: Allwell Medicaid	$3,647.98
Rate for Payer: AZCH Complete Medicaid	$3,647.98
Rate for Payer: Banner UC Health Medicaid	$3,647.98
Rate for Payer: Mercy Care Medicaid	$3,647.98

diazePAM 10mg Inj Sol [CQCH]

Facility

$11.07

Service Code	HCPCS J3360
Hospital Charge Code	105918623
Hospital Revenue Code	250
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$9.96
Rate for Payer: Aetna of AZ Commercial	$9.96
Rate for Payer: Bisbee Police All Plans	$2.88
Rate for Payer: Cash Price	$8.85
Rate for Payer: Self Pay Self Pay	$8.86

diazePAM 10mg Inj Sol [CQCH]

Facility

$11.07

Service Code	HCPCS J3360
Hospital Charge Code	105918623
Hospital Revenue Code	250
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$16.24
Rate for Payer: Aetna of AZ Commercial	$9.96
Rate for Payer: Aetna of AZ Medicare	$3.10
Rate for Payer: AHCCCS Medicaid	$16.24
Rate for Payer: Allwell Medicaid	$16.24
Rate for Payer: Allwell Medicare	$1.66
Rate for Payer: Amerigroup Medicare	$1.66
Rate for Payer: APIPA Medicare/Medicaid	$4.13
Rate for Payer: AZCH Complete Medicaid	$16.24
Rate for Payer: AZCH Complete Medicare	$1.66
Rate for Payer: Banner UC Health Medicaid	$16.24
Rate for Payer: Banner UC Health Medicare	$1.66
Rate for Payer: Bisbee Police All Plans	$2.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$7.53
Rate for Payer: Cash Price	$8.85
Rate for Payer: Cash Price	$8.85
Rate for Payer: Cigna of AZ Commercial	$7.20
Rate for Payer: Copperpoint Commercial	$2.74
Rate for Payer: Health Net of AZ Commercial	$6.64
Rate for Payer: Health Net of AZ Medicare	$3.10
Rate for Payer: Humana of AZ Medicare	$1.66
Rate for Payer: Mercy Care Medicaid	$16.24
Rate for Payer: Self Pay Self Pay	$8.86
Rate for Payer: TriWest Medicare	$1.66
Rate for Payer: UnitedHealth Group of AZ Commercial	$6.45
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.99

diazePAM 2.5 mg Rectal Gel Kit[CQCH]

Facility

$91.25

Service Code	NDC 66490065020
Hospital Charge Code	136170892
Hospital Revenue Code	251
Min. Negotiated Rate	$23.72
Max. Negotiated Rate	$82.12
Rate for Payer: Aetna of AZ Commercial	$82.12
Rate for Payer: Bisbee Police All Plans	$23.72
Rate for Payer: Cash Price	$73.00
Rate for Payer: Self Pay Self Pay	$73.00

diazePAM 2.5 mg Rectal Gel Kit[CQCH]

Facility

$91.25

Service Code	NDC 66490065020
Hospital Charge Code	136170892
Hospital Revenue Code	251
Min. Negotiated Rate	$13.69
Max. Negotiated Rate	$82.12
Rate for Payer: Aetna of AZ Commercial	$82.12
Rate for Payer: Aetna of AZ Medicare	$25.55
Rate for Payer: Allwell Medicare	$13.69
Rate for Payer: Amerigroup Medicare	$13.69
Rate for Payer: APIPA Medicare/Medicaid	$34.08
Rate for Payer: AZCH Complete Medicare	$13.69
Rate for Payer: Banner UC Health Medicare	$13.69
Rate for Payer: Bisbee Police All Plans	$23.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$62.05
Rate for Payer: Cash Price	$73.00
Rate for Payer: Cigna of AZ Commercial	$59.31
Rate for Payer: Copperpoint Commercial	$22.58
Rate for Payer: Health Net of AZ Commercial	$54.75
Rate for Payer: Health Net of AZ Medicare	$25.55
Rate for Payer: Humana of AZ Medicare	$13.69
Rate for Payer: Self Pay Self Pay	$73.00
Rate for Payer: TriWest Medicare	$13.69
Rate for Payer: UnitedHealth Group of AZ Commercial	$53.20
Rate for Payer: UnitedHealth Group of AZ Medicare	$16.42

diazePAM 5 mg Tab [CQCH]

Facility

$0.05

Service Code	NDC 51079028520
Hospital Charge Code	105918698
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: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.02
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.03
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of AZ Commercial	$0.03
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.03
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Self Pay Self Pay	$0.04
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

diazePAM 5 mg Tab [CQCH]

Facility

$0.05

Service Code	NDC 51079028520
Hospital Charge Code	105918698
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: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.04
Rate for Payer: Self Pay Self Pay	$0.04

diclofenac topical 1% Gel[CQCH]

Facility

$0.17

Service Code	NDC 67815202
Hospital Charge Code	139707016
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: Aetna of AZ Medicare	$0.05
Rate for Payer: Allwell Medicare	$0.03
Rate for Payer: Amerigroup Medicare	$0.03
Rate for Payer: APIPA Medicare/Medicaid	$0.06
Rate for Payer: AZCH Complete Medicare	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.12
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cigna of AZ Commercial	$0.11
Rate for Payer: Copperpoint Commercial	$0.04
Rate for Payer: Health Net of AZ Commercial	$0.10
Rate for Payer: Health Net of AZ Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Self Pay Self Pay	$0.14
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.10
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.03

Know your out-of-pocket cost for care.

All Charges