Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01

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: 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: 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

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: 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: 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

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
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01

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
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01

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: 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: 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

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
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$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: 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: 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

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	$0.59
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of AZ Commercial	$0.59
Rate for Payer: Cash Price	$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: Arizona Complete Health Allwell	$0.10
Rate for Payer: Banner UC Health Medicare	$0.10
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.10
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.10
Rate for Payer: Cash Price	$0.52
Rate for Payer: Cigna of AZ Commercial	$0.42
Rate for Payer: Devoted Health Medicare	$0.12
Rate for Payer: Humana of AZ Medicare	$0.10
Rate for Payer: Southwest Service Administrators UFCW	$0.44
Rate for Payer: TriWest Medicare	$0.10
Rate for Payer: United Healthcare Commercial	$0.37
Rate for Payer: United Healthcare Medicare	$0.10
Rate for Payer: Veterans Affairs TRICARE	$0.10

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: Blue Cross Blue Shield of Arizona Health Choice	$3,647.98
Rate for Payer: Mercy Care Medicaid	$3,647.98
Rate for Payer: NaphCare Correctional Healthcare	$3,647.98

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: Blue Cross Blue Shield of Arizona Health Choice	$11,890.83
Rate for Payer: Mercy Care Medicaid	$11,890.83
Rate for Payer: NaphCare Correctional Healthcare	$11,890.83

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: Blue Cross Blue Shield of Arizona Health Choice	$3,647.98
Rate for Payer: Mercy Care Medicaid	$3,647.98
Rate for Payer: NaphCare Correctional Healthcare	$3,647.98

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: Blue Cross Blue Shield of Arizona Health Choice	$5,568.41
Rate for Payer: Mercy Care Medicaid	$5,568.41
Rate for Payer: NaphCare Correctional Healthcare	$5,568.41

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: Blue Cross Blue Shield of Arizona Health Choice	$11,890.83
Rate for Payer: Mercy Care Medicaid	$11,890.83
Rate for Payer: NaphCare Correctional Healthcare	$11,890.83

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: Blue Cross Blue Shield of Arizona Health Choice	$5,568.41
Rate for Payer: Mercy Care Medicaid	$5,568.41
Rate for Payer: NaphCare Correctional Healthcare	$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: Blue Cross Blue Shield of Arizona Health Choice	$3,647.98
Rate for Payer: Mercy Care Medicaid	$3,647.98
Rate for Payer: NaphCare Correctional Healthcare	$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: Blue Cross Blue Shield of Arizona Health Choice	$5,568.41
Rate for Payer: Mercy Care Medicaid	$5,568.41
Rate for Payer: NaphCare Correctional Healthcare	$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: Blue Cross Blue Shield of Arizona Health Choice	$3,647.98
Rate for Payer: Mercy Care Medicaid	$3,647.98
Rate for Payer: NaphCare Correctional Healthcare	$3,647.98

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: Blue Cross Blue Shield of Arizona Health Choice	$3,025.14
Rate for Payer: Mercy Care Medicaid	$3,025.14
Rate for Payer: NaphCare Correctional Healthcare	$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: Blue Cross Blue Shield of Arizona Health Choice	$3,025.14
Rate for Payer: Mercy Care Medicaid	$3,025.14
Rate for Payer: NaphCare Correctional Healthcare	$3,025.14

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: Blue Cross Blue Shield of Arizona Health Choice	$5,568.41
Rate for Payer: Mercy Care Medicaid	$5,568.41
Rate for Payer: NaphCare Correctional Healthcare	$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: Blue Cross Blue Shield of Arizona Health Choice	$11,890.83
Rate for Payer: Mercy Care Medicaid	$11,890.83
Rate for Payer: NaphCare Correctional Healthcare	$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: Blue Cross Blue Shield of Arizona Health Choice	$3,025.14
Rate for Payer: Mercy Care Medicaid	$3,025.14
Rate for Payer: NaphCare Correctional Healthcare	$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: Blue Cross Blue Shield of Arizona Health Choice	$11,890.83
Rate for Payer: Mercy Care Medicaid	$11,890.83
Rate for Payer: NaphCare Correctional Healthcare	$11,890.83

Know your out-of-pocket cost for care.

All Charges