Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

NONTRAUMATIC STUPOR AND COMA WITHOUT MCC

Facility

$11,703.73

Service Code	MSDRG 081
Min. Negotiated Rate	$11,703.73
Max. Negotiated Rate	$11,703.73
Rate for Payer: Seven Corners Travel Insurance	$11,703.73

norEPINEPHrine 4 mg/250 mL-D5% Sol[CQCH]

Facility

$0.07

Service Code	NDC 338011220
Hospital Charge Code	238057883
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of AZ Commercial	$0.06
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	$0.04
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

norEPINEPHrine 4 mg/250 mL-D5% Sol[CQCH]

Facility

$0.07

Service Code	NDC 338011220
Hospital Charge Code	238057883
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of AZ Commercial	$0.06
Rate for Payer: Cash Price	$0.06

norEPINEPHrine 4 mg/ 4 mL IV Sol [CQCH]

Facility

$1.55

Service Code	NDC 703115303
Hospital Charge Code	105934341
Hospital Revenue Code	251
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of AZ Commercial	$1.40
Rate for Payer: Arizona Complete Health Allwell	$0.25
Rate for Payer: Banner UC Health Medicare	$0.25
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.05
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.25
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.25
Rate for Payer: Cash Price	$1.24
Rate for Payer: Cigna of AZ Commercial	$1.01
Rate for Payer: Devoted Health Medicare	$0.28
Rate for Payer: Humana of AZ Medicare	$0.25
Rate for Payer: Southwest Service Administrators UFCW	$1.05
Rate for Payer: TriWest Medicare	$0.25
Rate for Payer: United Healthcare Commercial	$0.89
Rate for Payer: United Healthcare Medicare	$0.25
Rate for Payer: Veterans Affairs TRICARE	$0.25

norEPINEPHrine 4 mg/ 4 mL IV Sol [CQCH]

Facility

$1.55

Service Code	NDC 703115303
Hospital Charge Code	105934341
Hospital Revenue Code	251
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of AZ Commercial	$1.40
Rate for Payer: Cash Price	$1.24

NORMAL NEWBORN

Facility

$2,887.11

Service Code	MSDRG 795
Min. Negotiated Rate	$2,887.11
Max. Negotiated Rate	$2,887.11
Rate for Payer: Seven Corners Travel Insurance	$2,887.11

Normal saline solution infus

Facility

$43.00

Service Code	HCPCS J7030
Hospital Charge Code	1240732
Hospital Revenue Code	521
Min. Negotiated Rate	$6.81
Max. Negotiated Rate	$38.70
Rate for Payer: Aetna of AZ Commercial	$38.70
Rate for Payer: Arizona Complete Health Allwell	$6.88
Rate for Payer: Banner UC Health Medicare	$6.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$29.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.88
Rate for Payer: Cash Price	$34.40
Rate for Payer: Cigna of AZ Commercial	$30.10
Rate for Payer: Devoted Health Medicare	$7.74
Rate for Payer: Humana of AZ Medicare	$6.88
Rate for Payer: Southwest Service Administrators UFCW	$29.24
Rate for Payer: TriWest Medicare	$6.88
Rate for Payer: United Healthcare Commercial	$24.60
Rate for Payer: United Healthcare Medicare	$6.88
Rate for Payer: Veterans Affairs TRICARE	$6.81

Normal saline solution infus

Facility

$43.00

Service Code	HCPCS J7030
Hospital Charge Code	1240732
Hospital Revenue Code	521
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$38.70
Rate for Payer: Aetna of AZ Commercial	$38.70
Rate for Payer: Cash Price	$34.40

NOVACOR 1.5X2.75

Facility

$4,875.00

Hospital Charge Code	27690539
Hospital Revenue Code	270
Min. Negotiated Rate	$4,387.50
Max. Negotiated Rate	$4,387.50
Rate for Payer: Aetna of AZ Commercial	$4,387.50
Rate for Payer: Cash Price	$3,900.00

NOVACOR 1.5X2.75

Facility

$4,875.00

Hospital Charge Code	27690539
Hospital Revenue Code	270
Min. Negotiated Rate	$772.20
Max. Negotiated Rate	$4,387.50
Rate for Payer: Aetna of AZ Commercial	$4,387.50
Rate for Payer: Arizona Complete Health Allwell	$780.00
Rate for Payer: Banner UC Health Medicare	$780.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,315.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$780.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$780.00
Rate for Payer: Cash Price	$3,900.00
Rate for Payer: Cigna of AZ Commercial	$3,412.50
Rate for Payer: Devoted Health Medicare	$877.50
Rate for Payer: Humana of AZ Medicare	$780.00
Rate for Payer: Southwest Service Administrators UFCW	$3,315.00
Rate for Payer: TriWest Medicare	$780.00
Rate for Payer: United Healthcare Commercial	$2,788.50
Rate for Payer: United Healthcare Medicare	$780.00
Rate for Payer: Veterans Affairs TRICARE	$772.20

NOVASURE ADVANCE

Facility

$3,154.00

Hospital Charge Code	27448975
Hospital Revenue Code	272
Min. Negotiated Rate	$499.59
Max. Negotiated Rate	$2,838.60
Rate for Payer: Aetna of AZ Commercial	$2,838.60
Rate for Payer: Arizona Complete Health Allwell	$504.64
Rate for Payer: Banner UC Health Medicare	$504.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,144.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$504.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$504.64
Rate for Payer: Cash Price	$2,523.20
Rate for Payer: Cigna of AZ Commercial	$2,207.80
Rate for Payer: Devoted Health Medicare	$567.72
Rate for Payer: Humana of AZ Medicare	$504.64
Rate for Payer: Southwest Service Administrators UFCW	$2,144.72
Rate for Payer: TriWest Medicare	$504.64
Rate for Payer: United Healthcare Commercial	$1,804.09
Rate for Payer: United Healthcare Medicare	$504.64
Rate for Payer: Veterans Affairs TRICARE	$499.59

NOVASURE ADVANCE

Facility

$3,154.00

Hospital Charge Code	27448975
Hospital Revenue Code	272
Min. Negotiated Rate	$2,838.60
Max. Negotiated Rate	$2,838.60
Rate for Payer: Aetna of AZ Commercial	$2,838.60
Rate for Payer: Cash Price	$2,523.20

NOVASURE KIT, NS-2007

Facility

$3,820.00

Service Code	CPT 58563
Hospital Charge Code	22354784
Hospital Revenue Code	270
Min. Negotiated Rate	$605.09
Max. Negotiated Rate	$7,740.14
Rate for Payer: Aetna of AZ Commercial	$3,438.00
Rate for Payer: Arizona Complete Health Allwell	$611.20
Rate for Payer: Banner UC Health Medicare	$611.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,597.60
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$1,756.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$611.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$611.20
Rate for Payer: Cash Price	$3,056.00
Rate for Payer: Cash Price	$3,056.00
Rate for Payer: Cigna of AZ Commercial	$2,674.00
Rate for Payer: Devoted Health Medicare	$687.60
Rate for Payer: Humana of AZ Medicare	$611.20
Rate for Payer: Mercy Care Medicaid	$1,756.60
Rate for Payer: NaphCare Correctional Healthcare	$1,756.60
Rate for Payer: Seven Corners Travel Insurance	$7,740.14
Rate for Payer: Southwest Service Administrators UFCW	$2,597.60
Rate for Payer: TriWest Medicare	$611.20
Rate for Payer: United Healthcare Commercial	$2,185.04
Rate for Payer: United Healthcare Medicare	$611.20
Rate for Payer: Veterans Affairs TRICARE	$605.09

NOVASURE KIT, NS-2007

Facility

$3,820.00

Service Code	CPT 58563
Hospital Charge Code	22354784
Hospital Revenue Code	270
Min. Negotiated Rate	$3,438.00
Max. Negotiated Rate	$3,438.00
Rate for Payer: Aetna of AZ Commercial	$3,438.00
Rate for Payer: Cash Price	$3,056.00

Nursing Care in home by LPN per hour

Facility

$121.00

Service Code	HCPCS S9124
Hospital Charge Code	27342347
Hospital Revenue Code	521
Min. Negotiated Rate	$108.90
Max. Negotiated Rate	$108.90
Rate for Payer: Aetna of AZ Commercial	$108.90
Rate for Payer: Cash Price	$96.80

Nursing Care in home by LPN per hour

Facility

$121.00

Service Code	HCPCS S9124
Hospital Charge Code	27342347
Hospital Revenue Code	521
Min. Negotiated Rate	$19.17
Max. Negotiated Rate	$108.90
Rate for Payer: Aetna of AZ Commercial	$108.90
Rate for Payer: Arizona Complete Health Allwell	$19.36
Rate for Payer: Banner UC Health Medicare	$19.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$82.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$19.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$19.36
Rate for Payer: Cash Price	$96.80
Rate for Payer: Cigna of AZ Commercial	$84.70
Rate for Payer: Devoted Health Medicare	$21.78
Rate for Payer: Humana of AZ Medicare	$19.36
Rate for Payer: Southwest Service Administrators UFCW	$82.28
Rate for Payer: TriWest Medicare	$19.36
Rate for Payer: United Healthcare Commercial	$69.21
Rate for Payer: United Healthcare Medicare	$19.36
Rate for Payer: Veterans Affairs TRICARE	$19.17

Nursing Care in home by RN per hour

Facility

$168.00

Service Code	HCPCS S9123
Hospital Charge Code	27342348
Hospital Revenue Code	521
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$151.20
Rate for Payer: Aetna of AZ Commercial	$151.20
Rate for Payer: Cash Price	$134.40

Nursing Care in home by RN per hour

Facility

$168.00

Service Code	HCPCS S9123
Hospital Charge Code	27342348
Hospital Revenue Code	521
Min. Negotiated Rate	$26.61
Max. Negotiated Rate	$151.20
Rate for Payer: Aetna of AZ Commercial	$151.20
Rate for Payer: Arizona Complete Health Allwell	$26.88
Rate for Payer: Banner UC Health Medicare	$26.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$114.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$26.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$26.88
Rate for Payer: Cash Price	$134.40
Rate for Payer: Cigna of AZ Commercial	$117.60
Rate for Payer: Devoted Health Medicare	$30.24
Rate for Payer: Humana of AZ Medicare	$26.88
Rate for Payer: Southwest Service Administrators UFCW	$114.24
Rate for Payer: TriWest Medicare	$26.88
Rate for Payer: United Healthcare Commercial	$96.10
Rate for Payer: United Healthcare Medicare	$26.88
Rate for Payer: Veterans Affairs TRICARE	$26.61

NUSHIELD

Facility

$1,394.00

Service Code	HCPCS Q4160
Hospital Charge Code	24358095
Hospital Revenue Code	636
Min. Negotiated Rate	$1,254.60
Max. Negotiated Rate	$1,254.60
Rate for Payer: Aetna of AZ Commercial	$1,254.60
Rate for Payer: Cash Price	$1,115.20

NUSHIELD

Facility

$916.67

Hospital Charge Code	24358097
Hospital Revenue Code	270
Min. Negotiated Rate	$145.20
Max. Negotiated Rate	$825.00
Rate for Payer: Aetna of AZ Commercial	$825.00
Rate for Payer: Arizona Complete Health Allwell	$146.67
Rate for Payer: Banner UC Health Medicare	$146.67
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$623.34
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$146.67
Rate for Payer: Care1st Health Plan Arizona Medicare	$146.67
Rate for Payer: Cash Price	$733.34
Rate for Payer: Cigna of AZ Commercial	$641.67
Rate for Payer: Devoted Health Medicare	$165.00
Rate for Payer: Humana of AZ Medicare	$146.67
Rate for Payer: Southwest Service Administrators UFCW	$623.34
Rate for Payer: TriWest Medicare	$146.67
Rate for Payer: United Healthcare Commercial	$524.34
Rate for Payer: United Healthcare Medicare	$146.67
Rate for Payer: Veterans Affairs TRICARE	$145.20

NUSHIELD

Facility

$916.67

Hospital Charge Code	24358097
Hospital Revenue Code	270
Min. Negotiated Rate	$825.00
Max. Negotiated Rate	$825.00
Rate for Payer: Aetna of AZ Commercial	$825.00
Rate for Payer: Cash Price	$733.34

NUSHIELD

Facility

$1,394.00

Service Code	HCPCS Q4160
Hospital Charge Code	24358095
Hospital Revenue Code	636
Min. Negotiated Rate	$192.55
Max. Negotiated Rate	$1,254.60
Rate for Payer: Aetna of AZ Commercial	$1,254.60
Rate for Payer: Arizona Complete Health Allwell	$223.04
Rate for Payer: Banner UC Health Medicare	$223.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$947.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$223.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$223.04
Rate for Payer: Cash Price	$1,115.20
Rate for Payer: Cash Price	$1,115.20
Rate for Payer: Cigna of AZ Commercial	$975.80
Rate for Payer: Devoted Health Medicare	$250.92
Rate for Payer: Humana of AZ Medicare	$223.04
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$947.92
Rate for Payer: TriWest Medicare	$223.04
Rate for Payer: United Healthcare Commercial	$797.37
Rate for Payer: United Healthcare Medicare	$223.04
Rate for Payer: United Healthcare New Mexico Commercial	$264.86
Rate for Payer: Veterans Affairs TRICARE	$220.81

NUSHIELD 2X4

Facility

$950.00

Service Code	HCPCS Q4160
Hospital Charge Code	24358096
Hospital Revenue Code	636
Min. Negotiated Rate	$150.48
Max. Negotiated Rate	$855.00
Rate for Payer: Aetna of AZ Commercial	$855.00
Rate for Payer: Arizona Complete Health Allwell	$152.00
Rate for Payer: Banner UC Health Medicare	$152.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$646.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$152.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$152.00
Rate for Payer: Cash Price	$760.00
Rate for Payer: Cash Price	$760.00
Rate for Payer: Cigna of AZ Commercial	$665.00
Rate for Payer: Devoted Health Medicare	$171.00
Rate for Payer: Humana of AZ Medicare	$152.00
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$646.00
Rate for Payer: TriWest Medicare	$152.00
Rate for Payer: United Healthcare Commercial	$543.40
Rate for Payer: United Healthcare Medicare	$152.00
Rate for Payer: United Healthcare New Mexico Commercial	$180.50
Rate for Payer: Veterans Affairs TRICARE	$150.48

NUSHIELD 2X4

Facility

$950.00

Service Code	HCPCS Q4160
Hospital Charge Code	24358096
Hospital Revenue Code	636
Min. Negotiated Rate	$855.00
Max. Negotiated Rate	$855.00
Rate for Payer: Aetna of AZ Commercial	$855.00
Rate for Payer: Cash Price	$760.00

NUSHIELD 4X4

Facility

$712.50

Hospital Charge Code	24358098
Hospital Revenue Code	270
Min. Negotiated Rate	$112.86
Max. Negotiated Rate	$641.25
Rate for Payer: Aetna of AZ Commercial	$641.25
Rate for Payer: Arizona Complete Health Allwell	$114.00
Rate for Payer: Banner UC Health Medicare	$114.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$484.50
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$114.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$114.00
Rate for Payer: Cash Price	$570.00
Rate for Payer: Cigna of AZ Commercial	$498.75
Rate for Payer: Devoted Health Medicare	$128.25
Rate for Payer: Humana of AZ Medicare	$114.00
Rate for Payer: Southwest Service Administrators UFCW	$484.50
Rate for Payer: TriWest Medicare	$114.00
Rate for Payer: United Healthcare Commercial	$407.55
Rate for Payer: United Healthcare Medicare	$114.00
Rate for Payer: Veterans Affairs TRICARE	$112.86

Know your out-of-pocket cost for care.

All Charges