Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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 WITH CC

Facility

$11,711.33

Service Code	MSDRG 638
Min. Negotiated Rate	$11,711.33
Max. Negotiated Rate	$11,711.33
Rate for Payer: Seven Corners Travel Insurance	$11,711.33

DIABETES WITH MCC

Facility

$18,568.12

Service Code	MSDRG 637
Min. Negotiated Rate	$18,568.12
Max. Negotiated Rate	$18,568.12
Rate for Payer: Seven Corners Travel Insurance	$18,568.12

DIABETES WITHOUT CC/MCC

Facility

$8,226.79

Service Code	MSDRG 639
Min. Negotiated Rate	$8,226.79
Max. Negotiated Rate	$8,226.79
Rate for Payer: Seven Corners Travel Insurance	$8,226.79

diazePAM 10mg Inj Sol [CQCH]

Facility

$11.07

Service Code	HCPCS J3360
Hospital Charge Code	105918623
Hospital Revenue Code	250
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$9.96
Rate for Payer: Aetna of AZ Commercial	$9.96
Rate for Payer: Arizona Complete Health Allwell	$1.77
Rate for Payer: Banner UC Health Medicare	$1.77
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$7.53
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.77
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.77
Rate for Payer: Cash Price	$8.85
Rate for Payer: Cigna of AZ Commercial	$7.20
Rate for Payer: Devoted Health Medicare	$1.99
Rate for Payer: Humana of AZ Medicare	$1.77
Rate for Payer: Southwest Service Administrators UFCW	$7.53
Rate for Payer: TriWest Medicare	$1.77
Rate for Payer: United Healthcare Commercial	$6.33
Rate for Payer: United Healthcare Medicare	$1.77
Rate for Payer: Veterans Affairs TRICARE	$1.75

diazePAM 10mg Inj Sol [CQCH]

Facility

$11.07

Service Code	HCPCS J3360
Hospital Charge Code	105918623
Hospital Revenue Code	250
Min. Negotiated Rate	$9.96
Max. Negotiated Rate	$9.96
Rate for Payer: Aetna of AZ Commercial	$9.96
Rate for Payer: Cash Price	$8.85

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	$14.45
Max. Negotiated Rate	$82.12
Rate for Payer: Aetna of AZ Commercial	$82.12
Rate for Payer: Arizona Complete Health Allwell	$14.60
Rate for Payer: Banner UC Health Medicare	$14.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$62.05
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.60
Rate for Payer: Cash Price	$73.00
Rate for Payer: Cigna of AZ Commercial	$59.31
Rate for Payer: Devoted Health Medicare	$16.43
Rate for Payer: Humana of AZ Medicare	$14.60
Rate for Payer: Southwest Service Administrators UFCW	$62.05
Rate for Payer: TriWest Medicare	$14.60
Rate for Payer: United Healthcare Commercial	$52.20
Rate for Payer: United Healthcare Medicare	$14.60
Rate for Payer: Veterans Affairs TRICARE	$14.45

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	$82.12
Max. Negotiated Rate	$82.12
Rate for Payer: Aetna of AZ Commercial	$82.12
Rate for Payer: Cash Price	$73.00

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: 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	$0.03
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	$0.03
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.03
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

diazePAM 5 mg Tab [CQCH]

Facility

$0.05

Service Code	NDC 51079028520
Hospital Charge Code	105918698
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

diclofenac topical 1% Gel[CQCH]

Facility

$0.17

Service Code	NDC 67815202
Hospital Charge Code	139707016
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	$0.13

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: 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	$0.13
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

dicyclomine 10 mg Cap [CQCH]

Facility

$0.48

Service Code	NDC 60687036901
Hospital Charge Code	105918834
Hospital Revenue Code	251
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of AZ Commercial	$0.43
Rate for Payer: Arizona Complete Health Allwell	$0.08
Rate for Payer: Banner UC Health Medicare	$0.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.33
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.08
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cigna of AZ Commercial	$0.31
Rate for Payer: Devoted Health Medicare	$0.09
Rate for Payer: Humana of AZ Medicare	$0.08
Rate for Payer: Southwest Service Administrators UFCW	$0.33
Rate for Payer: TriWest Medicare	$0.08
Rate for Payer: United Healthcare Commercial	$0.27
Rate for Payer: United Healthcare Medicare	$0.08
Rate for Payer: Veterans Affairs TRICARE	$0.08

dicyclomine 10 mg Cap [CQCH]

Facility

$0.48

Service Code	NDC 60687036901
Hospital Charge Code	105918834
Hospital Revenue Code	251
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of AZ Commercial	$0.43
Rate for Payer: Cash Price	$0.38

dicyclomine 20 mg Inj Sol [CQCH]

Facility

$34.46

Service Code	HCPCS J0500
Hospital Charge Code	105918763
Hospital Revenue Code	250
Min. Negotiated Rate	$31.01
Max. Negotiated Rate	$31.01
Rate for Payer: Aetna of AZ Commercial	$31.01
Rate for Payer: Cash Price	$27.57

dicyclomine 20 mg Inj Sol [CQCH]

Facility

$34.46

Service Code	HCPCS J0500
Hospital Charge Code	105918763
Hospital Revenue Code	250
Min. Negotiated Rate	$5.46
Max. Negotiated Rate	$31.01
Rate for Payer: Aetna of AZ Commercial	$31.01
Rate for Payer: Arizona Complete Health Allwell	$5.51
Rate for Payer: Banner UC Health Medicare	$5.51
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$23.43
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.51
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.51
Rate for Payer: Cash Price	$27.57
Rate for Payer: Cigna of AZ Commercial	$22.40
Rate for Payer: Devoted Health Medicare	$6.20
Rate for Payer: Humana of AZ Medicare	$5.51
Rate for Payer: Southwest Service Administrators UFCW	$23.43
Rate for Payer: TriWest Medicare	$5.51
Rate for Payer: United Healthcare Commercial	$19.71
Rate for Payer: United Healthcare Medicare	$5.51
Rate for Payer: Veterans Affairs TRICARE	$5.46

Digestive Malignancy

Facility

$5,198.78

Service Code	APR-DRG 2401
Hospital Charge Code	APRDRG2402
Min. Negotiated Rate	$5,198.78
Max. Negotiated Rate	$5,198.78
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,198.78
Rate for Payer: Mercy Care Medicaid	$5,198.78
Rate for Payer: NaphCare Correctional Healthcare	$5,198.78

Digestive Malignancy

Facility

$5,986.45

Service Code	APR-DRG 2402
Hospital Charge Code	APRDRG2404
Min. Negotiated Rate	$5,986.45
Max. Negotiated Rate	$5,986.45
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,986.45
Rate for Payer: Mercy Care Medicaid	$5,986.45
Rate for Payer: NaphCare Correctional Healthcare	$5,986.45

Digestive Malignancy

Facility

$8,453.27

Service Code	APR-DRG 2403
Hospital Charge Code	APRDRG2401
Min. Negotiated Rate	$8,453.27
Max. Negotiated Rate	$8,453.27
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8,453.27
Rate for Payer: Mercy Care Medicaid	$8,453.27
Rate for Payer: NaphCare Correctional Healthcare	$8,453.27

Digestive Malignancy

Facility

$15,754.85

Service Code	APR-DRG 2404
Hospital Charge Code	APRDRG2401
Min. Negotiated Rate	$15,754.85
Max. Negotiated Rate	$15,754.85
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$15,754.85
Rate for Payer: Mercy Care Medicaid	$15,754.85
Rate for Payer: NaphCare Correctional Healthcare	$15,754.85

Digestive Malignancy

Facility

$15,754.85

Service Code	APR-DRG 2404
Hospital Charge Code	APRDRG2402
Min. Negotiated Rate	$15,754.85
Max. Negotiated Rate	$15,754.85
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$15,754.85
Rate for Payer: Mercy Care Medicaid	$15,754.85
Rate for Payer: NaphCare Correctional Healthcare	$15,754.85

Digestive Malignancy

Facility

$15,754.85

Service Code	APR-DRG 2404
Hospital Charge Code	APRDRG2403
Min. Negotiated Rate	$15,754.85
Max. Negotiated Rate	$15,754.85
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$15,754.85
Rate for Payer: Mercy Care Medicaid	$15,754.85
Rate for Payer: NaphCare Correctional Healthcare	$15,754.85

Digestive Malignancy

Facility

$15,754.85

Service Code	APR-DRG 2404
Hospital Charge Code	APRDRG2404
Min. Negotiated Rate	$15,754.85
Max. Negotiated Rate	$15,754.85
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$15,754.85
Rate for Payer: Mercy Care Medicaid	$15,754.85
Rate for Payer: NaphCare Correctional Healthcare	$15,754.85

Digestive Malignancy

Facility

$8,453.27

Service Code	APR-DRG 2403
Hospital Charge Code	APRDRG2403
Min. Negotiated Rate	$8,453.27
Max. Negotiated Rate	$8,453.27
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8,453.27
Rate for Payer: Mercy Care Medicaid	$8,453.27
Rate for Payer: NaphCare Correctional Healthcare	$8,453.27

Digestive Malignancy

Facility

$5,986.45

Service Code	APR-DRG 2402
Hospital Charge Code	APRDRG2403
Min. Negotiated Rate	$5,986.45
Max. Negotiated Rate	$5,986.45
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,986.45
Rate for Payer: Mercy Care Medicaid	$5,986.45
Rate for Payer: NaphCare Correctional Healthcare	$5,986.45

Know your out-of-pocket cost for care.

All Charges