Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Dextrose 5% in Water IV Sol 250 mL (DEHP-free) [CQCH]

Facility

$0.02

Service Code	HCPCS J7060
Hospital Charge Code	108156747
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Self Pay Self Pay	$0.02

Dextrose 5% in Water IV Sol 250 mL (DEHP-free) [CQCH]

Facility

$0.02

Service Code	HCPCS J7060
Hospital Charge Code	108156747
Hospital Revenue Code	250
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

Dextrose 5% in Water IV soln 100 ml[CQCH]

Facility

$0.02

Service Code	HCPCS J7060
Hospital Charge Code	152070800
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Self Pay Self Pay	$0.02

Dextrose 5% in Water IV soln 100 ml[CQCH]

Facility

$0.02

Service Code	HCPCS J7060
Hospital Charge Code	152070800
Hospital Revenue Code	250
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

Dextrose 5% in Water Sol 1,000 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J7060
Hospital Charge Code	107994985
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Self Pay Self Pay	$0.01

Dextrose 5% in Water Sol 1,000 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J7060
Hospital Charge Code	107994985
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

Dextrose 5% Water IV Sol 500 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J7060
Hospital Charge Code	108643402
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Self Pay Self Pay	$0.01

Dextrose 5% Water IV Sol 500 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J7060
Hospital Charge Code	108643402
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

Dextrose 5% with 0.45% NaCl and KCl 20 mEq/l IV Sol 1000 mL [CQCH]

Facility

$0.01

Service Code	NDC 409790209
Hospital Charge Code	105918456
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

Dextrose 5% with 0.45% NaCl and KCl 20 mEq/l IV Sol 1000 mL [CQCH]

Facility

$0.01

Service Code	NDC 409790209
Hospital Charge Code	105918456
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Self Pay Self Pay	$0.01

Dextrose 5% with 0.45% NaCl IV Sol 1000 mL [CQCH]

Facility

$0.01

Service Code	NDC 409792609
Hospital Charge Code	105918393
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Self Pay Self Pay	$0.01

Dextrose 5% with 0.45% NaCl IV Sol 1000 mL [CQCH]

Facility

$0.01

Service Code	NDC 409792609
Hospital Charge Code	105918393
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

Dextrose 5% with 0.9% NaCl and KCl 20 mEq/L IV Sol [CQCH]

Facility

$0.01

Service Code	NDC 409710709
Hospital Charge Code	107995125
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

Dextrose 5% with 0.9% NaCl and KCl 20 mEq/L IV Sol [CQCH]

Facility

$0.01

Service Code	NDC 409710709
Hospital Charge Code	107995125
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Self Pay Self Pay	$0.01

Dextrose 5% with 0.9% NaCl and KCl 40 mEq/L intravenous solution Dextrose 5% with 0.9% NaCl and KCl 40 mEq/L Sol 1000 mL [CQCH]

Facility

$0.01

Service Code	NDC 409710909
Hospital Charge Code	108342386
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Self Pay Self Pay	$0.01

Dextrose 5% with 0.9% NaCl and KCl 40 mEq/L intravenous solution Dextrose 5% with 0.9% NaCl and KCl 40 mEq/L Sol 1000 mL [CQCH]

Facility

$0.01

Service Code	NDC 409710909
Hospital Charge Code	108342386
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

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

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

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	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

$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

$3,647.98

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

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	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	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

Know your out-of-pocket cost for care.

All Charges