Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Poisoning Of Medicinal Agents

Facility

$2,564.32

Service Code	APR-DRG 8121
Hospital Charge Code	APRDRG8122
Min. Negotiated Rate	$2,564.32
Max. Negotiated Rate	$2,564.32
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,564.32
Rate for Payer: Mercy Care Medicaid	$2,564.32
Rate for Payer: NaphCare Correctional Healthcare	$2,564.32

Poisoning Of Medicinal Agents

Facility

$3,462.81

Service Code	APR-DRG 8122
Hospital Charge Code	APRDRG8122
Min. Negotiated Rate	$3,462.81
Max. Negotiated Rate	$3,462.81
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$3,462.81
Rate for Payer: Mercy Care Medicaid	$3,462.81
Rate for Payer: NaphCare Correctional Healthcare	$3,462.81

Poisoning Of Medicinal Agents

Facility

$9,939.54

Service Code	APR-DRG 8124
Hospital Charge Code	APRDRG8123
Min. Negotiated Rate	$9,939.54
Max. Negotiated Rate	$9,939.54
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$9,939.54
Rate for Payer: Mercy Care Medicaid	$9,939.54
Rate for Payer: NaphCare Correctional Healthcare	$9,939.54

Poisoning Of Medicinal Agents

Facility

$5,178.44

Service Code	APR-DRG 8123
Hospital Charge Code	APRDRG8121
Min. Negotiated Rate	$5,178.44
Max. Negotiated Rate	$5,178.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,178.44
Rate for Payer: Mercy Care Medicaid	$5,178.44
Rate for Payer: NaphCare Correctional Healthcare	$5,178.44

Poisoning Of Medicinal Agents

Facility

$3,462.81

Service Code	APR-DRG 8122
Hospital Charge Code	APRDRG8123
Min. Negotiated Rate	$3,462.81
Max. Negotiated Rate	$3,462.81
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$3,462.81
Rate for Payer: Mercy Care Medicaid	$3,462.81
Rate for Payer: NaphCare Correctional Healthcare	$3,462.81

Poisoning Of Medicinal Agents

Facility

$3,462.81

Service Code	APR-DRG 8122
Hospital Charge Code	APRDRG8121
Min. Negotiated Rate	$3,462.81
Max. Negotiated Rate	$3,462.81
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$3,462.81
Rate for Payer: Mercy Care Medicaid	$3,462.81
Rate for Payer: NaphCare Correctional Healthcare	$3,462.81

Poisoning Of Medicinal Agents

Facility

$2,564.32

Service Code	APR-DRG 8121
Hospital Charge Code	APRDRG8124
Min. Negotiated Rate	$2,564.32
Max. Negotiated Rate	$2,564.32
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,564.32
Rate for Payer: Mercy Care Medicaid	$2,564.32
Rate for Payer: NaphCare Correctional Healthcare	$2,564.32

Poisoning Of Medicinal Agents

Facility

$5,178.44

Service Code	APR-DRG 8123
Hospital Charge Code	APRDRG8123
Min. Negotiated Rate	$5,178.44
Max. Negotiated Rate	$5,178.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,178.44
Rate for Payer: Mercy Care Medicaid	$5,178.44
Rate for Payer: NaphCare Correctional Healthcare	$5,178.44

Poisoning Of Medicinal Agents

Facility

$5,178.44

Service Code	APR-DRG 8123
Hospital Charge Code	APRDRG8124
Min. Negotiated Rate	$5,178.44
Max. Negotiated Rate	$5,178.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,178.44
Rate for Payer: Mercy Care Medicaid	$5,178.44
Rate for Payer: NaphCare Correctional Healthcare	$5,178.44

Poisoning Of Medicinal Agents

Facility

$3,462.81

Service Code	APR-DRG 8122
Hospital Charge Code	APRDRG8124
Min. Negotiated Rate	$3,462.81
Max. Negotiated Rate	$3,462.81
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$3,462.81
Rate for Payer: Mercy Care Medicaid	$3,462.81
Rate for Payer: NaphCare Correctional Healthcare	$3,462.81

Poisoning Of Medicinal Agents

Facility

$9,939.54

Service Code	APR-DRG 8124
Hospital Charge Code	APRDRG8121
Min. Negotiated Rate	$9,939.54
Max. Negotiated Rate	$9,939.54
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$9,939.54
Rate for Payer: Mercy Care Medicaid	$9,939.54
Rate for Payer: NaphCare Correctional Healthcare	$9,939.54

Poisoning Of Medicinal Agents

Facility

$2,564.32

Service Code	APR-DRG 8121
Hospital Charge Code	APRDRG8121
Min. Negotiated Rate	$2,564.32
Max. Negotiated Rate	$2,564.32
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,564.32
Rate for Payer: Mercy Care Medicaid	$2,564.32
Rate for Payer: NaphCare Correctional Healthcare	$2,564.32

Poisoning Of Medicinal Agents

Facility

$9,939.54

Service Code	APR-DRG 8124
Hospital Charge Code	APRDRG8124
Min. Negotiated Rate	$9,939.54
Max. Negotiated Rate	$9,939.54
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$9,939.54
Rate for Payer: Mercy Care Medicaid	$9,939.54
Rate for Payer: NaphCare Correctional Healthcare	$9,939.54

Poisoning Of Medicinal Agents

Facility

$9,939.54

Service Code	APR-DRG 8124
Hospital Charge Code	APRDRG8122
Min. Negotiated Rate	$9,939.54
Max. Negotiated Rate	$9,939.54
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$9,939.54
Rate for Payer: Mercy Care Medicaid	$9,939.54
Rate for Payer: NaphCare Correctional Healthcare	$9,939.54

polyethylene glycol 3350 17 GmOral Pwdr [CQCH]

Facility

$0.87

Service Code	NDC 11523726803
Hospital Charge Code	105964541
Hospital Revenue Code	251
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$0.78
Rate for Payer: Aetna of AZ Commercial	$0.78
Rate for Payer: Cash Price	$0.70

polyethylene glycol 3350 17 GmOral Pwdr [CQCH]

Facility

$0.87

Service Code	NDC 11523726803
Hospital Charge Code	105964541
Hospital Revenue Code	251
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.78
Rate for Payer: Aetna of AZ Commercial	$0.78
Rate for Payer: Arizona Complete Health Allwell	$0.14
Rate for Payer: Banner UC Health Medicare	$0.14
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.59
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.14
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.14
Rate for Payer: Cash Price	$0.70
Rate for Payer: Cigna of AZ Commercial	$0.57
Rate for Payer: Devoted Health Medicare	$0.16
Rate for Payer: Humana of AZ Medicare	$0.14
Rate for Payer: Southwest Service Administrators UFCW	$0.59
Rate for Payer: TriWest Medicare	$0.14
Rate for Payer: United Healthcare Commercial	$0.50
Rate for Payer: United Healthcare Medicare	$0.14
Rate for Payer: Veterans Affairs TRICARE	$0.14

polyethylene glycol 3350 Oral Pwdr (GaviLyte-C) for Sol 4000 mL [CQCH]

Facility

$22.01

Service Code	NDC 43386006019
Hospital Charge Code	105937171
Hospital Revenue Code	251
Min. Negotiated Rate	$3.49
Max. Negotiated Rate	$19.81
Rate for Payer: Aetna of AZ Commercial	$19.81
Rate for Payer: Arizona Complete Health Allwell	$3.52
Rate for Payer: Banner UC Health Medicare	$3.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$14.97
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.52
Rate for Payer: Cash Price	$17.61
Rate for Payer: Cigna of AZ Commercial	$14.31
Rate for Payer: Devoted Health Medicare	$3.96
Rate for Payer: Humana of AZ Medicare	$3.52
Rate for Payer: Southwest Service Administrators UFCW	$14.97
Rate for Payer: TriWest Medicare	$3.52
Rate for Payer: United Healthcare Commercial	$12.59
Rate for Payer: United Healthcare Medicare	$3.52
Rate for Payer: Veterans Affairs TRICARE	$3.49

polyethylene glycol 3350 Oral Pwdr (GaviLyte-C) for Sol 4000 mL [CQCH]

Facility

$22.01

Service Code	NDC 43386006019
Hospital Charge Code	105937171
Hospital Revenue Code	251
Min. Negotiated Rate	$19.81
Max. Negotiated Rate	$19.81
Rate for Payer: Aetna of AZ Commercial	$19.81
Rate for Payer: Cash Price	$17.61

polyethylene glycol 3350 - REC[CQCH]

Facility

$0.04

Service Code	NDC 11523723403
Hospital Charge Code	168068958
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
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	$0.03
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	$0.02
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

polyethylene glycol 3350 - REC[CQCH]

Facility

$0.04

Service Code	NDC 11523723403
Hospital Charge Code	168068958
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
Rate for Payer: Cash Price	$0.03

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC

Facility

$23,569.75

Service Code	MSDRG 862
Min. Negotiated Rate	$23,569.75
Max. Negotiated Rate	$23,569.75
Rate for Payer: Seven Corners Travel Insurance	$23,569.75

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC

Facility

$12,999.99

Service Code	MSDRG 863
Min. Negotiated Rate	$12,999.99
Max. Negotiated Rate	$12,999.99
Rate for Payer: Seven Corners Travel Insurance	$12,999.99

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC

Facility

$27,677.05

Service Code	MSDRG 857
Min. Negotiated Rate	$27,677.05
Max. Negotiated Rate	$27,677.05
Rate for Payer: Seven Corners Travel Insurance	$27,677.05

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC

Facility

$58,788.05

Service Code	MSDRG 856
Min. Negotiated Rate	$58,788.05
Max. Negotiated Rate	$58,788.05
Rate for Payer: Seven Corners Travel Insurance	$58,788.05

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$18,005.13

Service Code	MSDRG 858
Min. Negotiated Rate	$18,005.13
Max. Negotiated Rate	$18,005.13
Rate for Payer: Seven Corners Travel Insurance	$18,005.13

Know your out-of-pocket cost for care.

All Charges