Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

sodium bicarbonate 8.4% IV Sol (50 mL PFS) [CQCH]

Facility

$0.17

Service Code	NDC 409663734
Hospital Charge Code	105940871
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	$0.14
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

Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J3480
Hospital Charge Code	105941369
Hospital Revenue Code	258
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01

Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J3480
Hospital Charge Code	105941369
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

Sodium Chloride 0.9% 50 ML IV SOLN(CQCH)

Facility

$2.29

Service Code	HCPCS J7040
Hospital Charge Code	121934599
Hospital Revenue Code	250
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$2.06
Rate for Payer: Aetna of AZ Commercial	$2.06
Rate for Payer: Cash Price	$1.83

Sodium Chloride 0.9% 50 ML IV SOLN(CQCH)

Facility

$2.29

Service Code	HCPCS J7040
Hospital Charge Code	121934599
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$2.06
Rate for Payer: Aetna of AZ Commercial	$2.06
Rate for Payer: Arizona Complete Health Allwell	$0.37
Rate for Payer: Banner UC Health Medicare	$0.37
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.37
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.37
Rate for Payer: Cash Price	$1.83
Rate for Payer: Cigna of AZ Commercial	$1.49
Rate for Payer: Devoted Health Medicare	$0.41
Rate for Payer: Humana of AZ Medicare	$0.37
Rate for Payer: Southwest Service Administrators UFCW	$1.56
Rate for Payer: TriWest Medicare	$0.37
Rate for Payer: United Healthcare Commercial	$1.31
Rate for Payer: United Healthcare Medicare	$0.37
Rate for Payer: Veterans Affairs TRICARE	$0.36

sodium chloride 0.9% Inh Sol 3 mL [CQCH]

Facility

$0.03

Service Code	NDC 487930103
Hospital Charge Code	105941436
Hospital Revenue Code	251
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
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	$0.02
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: Cash Price	$0.03
Rate for Payer: Cigna of AZ Commercial	$0.02
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Southwest Service Administrators UFCW	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: United Healthcare Commercial	$0.02
Rate for Payer: United Healthcare Medicare	$0.00
Rate for Payer: Veterans Affairs TRICARE	$0.00

sodium chloride 0.9% Inh Sol 3 mL [CQCH]

Facility

$0.03

Service Code	NDC 487930103
Hospital Charge Code	105941436
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Cash Price	$0.03

sodium chloride 0.9% Inj Sol 10 mL [CQCH]

Facility

$0.08

Service Code	NDC 409488810
Hospital Charge Code	105941657
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
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	$0.05
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

sodium chloride 0.9% Inj Sol 10 mL [CQCH]

Facility

$0.08

Service Code	NDC 409488810
Hospital Charge Code	105941657
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
Rate for Payer: Cash Price	$0.06

Sodium Chloride 0.9% IV Sol 100 mL IVPB [CQCH]

Facility

$0.05

Service Code	HCPCS J7040
Hospital Charge Code	105953385
Hospital Revenue Code	258
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

Sodium Chloride 0.9% IV Sol 100 mL IVPB [CQCH]

Facility

$0.05

Service Code	HCPCS J7040
Hospital Charge Code	105953385
Hospital Revenue Code	258
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

Sodium Chloride 0.9% IV Sol 250 mL IVPB [CQCH]

Facility

$0.02

Service Code	HCPCS J7040
Hospital Charge Code	105953498
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Cash Price	$0.02

Sodium Chloride 0.9% IV Sol 250 mL IVPB [CQCH]

Facility

$0.02

Service Code	HCPCS J7040
Hospital Charge Code	105953498
Hospital Revenue Code	250
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
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: Cash Price	$0.02
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

Sodium Chloride 0.9% Sol 1000 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J7040
Hospital Charge Code	108127272
Hospital Revenue Code	258
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01

Sodium Chloride 0.9% Sol 1000 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J7040
Hospital Charge Code	108127272
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

Sodium Chloride 0.9% Sol 500 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J7040
Hospital Charge Code	108127424
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: Cash Price	$0.01
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

Sodium Chloride 0.9% Sol 500 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J7040
Hospital Charge Code	108127424
Hospital Revenue Code	258
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Cash Price	$0.01

sodium chloride 1000 mg tab [CQCH]

Facility

$0.06

Service Code	NDC 223176001
Hospital Charge Code	105941113
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	$0.04
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	$0.05
Rate for Payer: Cigna of AZ Commercial	$0.04
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.04
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

sodium chloride 1000 mg tab [CQCH]

Facility

$0.06

Service Code	NDC 223176001
Hospital Charge Code	105941113
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	$0.05

sodium chloride 23.4% IV Sol 30 mL [CQCH]

Facility

$0.09

Service Code	HCPCS J7131
Hospital Charge Code	105941968
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of AZ Commercial	$0.08
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	$0.06
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	$0.07
Rate for Payer: Cigna of AZ Commercial	$0.06
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.06
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.05
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

sodium chloride 23.4% IV Sol 30 mL [CQCH]

Facility

$0.09

Service Code	HCPCS J7131
Hospital Charge Code	105941968
Hospital Revenue Code	251
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of AZ Commercial	$0.08
Rate for Payer: Cash Price	$0.07

Sodium Chloride 3% IV Sol (Hypertonic saline) 500 mL [CQCH]

Facility

$0.08

Service Code	NDC 63323053075
Hospital Charge Code	112802150
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
Rate for Payer: Cash Price	$0.06

Sodium Chloride 3% IV Sol (Hypertonic saline) 500 mL [CQCH]

Facility

$0.08

Service Code	NDC 63323053075
Hospital Charge Code	112802150
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
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	$0.05
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

sodium chloride nasal 0.65% Gel [CQCH]

Facility

$2.39

Service Code	NDC 225052547
Hospital Charge Code	105942100
Hospital Revenue Code	251
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$2.15
Rate for Payer: Aetna of AZ Commercial	$2.15
Rate for Payer: Arizona Complete Health Allwell	$0.38
Rate for Payer: Banner UC Health Medicare	$0.38
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.63
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.38
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.38
Rate for Payer: Cash Price	$1.91
Rate for Payer: Cigna of AZ Commercial	$1.55
Rate for Payer: Devoted Health Medicare	$0.43
Rate for Payer: Humana of AZ Medicare	$0.38
Rate for Payer: Southwest Service Administrators UFCW	$1.63
Rate for Payer: TriWest Medicare	$0.38
Rate for Payer: United Healthcare Commercial	$1.37
Rate for Payer: United Healthcare Medicare	$0.38
Rate for Payer: Veterans Affairs TRICARE	$0.38

sodium chloride nasal 0.65% Gel [CQCH]

Facility

$2.39

Service Code	NDC 225052547
Hospital Charge Code	105942100
Hospital Revenue Code	251
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$2.15
Rate for Payer: Aetna of AZ Commercial	$2.15
Rate for Payer: Cash Price	$1.91

Know your out-of-pocket cost for care.

All Charges