Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Acute Measles Panel, IgM Antibody and PCR LC

Facility

$76.00

Service Code	CPT 86765
Hospital Charge Code	28059749
Hospital Revenue Code	302
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of AZ Commercial	$68.40
Rate for Payer: Arizona Complete Health Allwell	$12.16
Rate for Payer: Banner UC Health Medicare	$12.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$51.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.16
Rate for Payer: Cash Price	$60.80
Rate for Payer: Cash Price	$60.80
Rate for Payer: Cigna of AZ Commercial	$49.40
Rate for Payer: Devoted Health Medicare	$13.68
Rate for Payer: Humana of AZ Medicare	$12.16
Rate for Payer: Seven Corners Travel Insurance	$18.68
Rate for Payer: Southwest Service Administrators UFCW	$51.68
Rate for Payer: TriWest Medicare	$12.16
Rate for Payer: United Healthcare Commercial	$43.47
Rate for Payer: United Healthcare Medicare	$12.16
Rate for Payer: Veterans Affairs TRICARE	$12.04

Acute Myocardial Infarction

Facility

$11,936.43

Service Code	APR-DRG 1904
Hospital Charge Code	APRDRG1901
Min. Negotiated Rate	$11,936.43
Max. Negotiated Rate	$11,936.43
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$11,936.43
Rate for Payer: Mercy Care Medicaid	$11,936.43
Rate for Payer: NaphCare Correctional Healthcare	$11,936.43

Acute Myocardial Infarction

Facility

$5,750.78

Service Code	APR-DRG 1902
Hospital Charge Code	APRDRG1904
Min. Negotiated Rate	$5,750.78
Max. Negotiated Rate	$5,750.78
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,750.78
Rate for Payer: Mercy Care Medicaid	$5,750.78
Rate for Payer: NaphCare Correctional Healthcare	$5,750.78

Acute Myocardial Infarction

Facility

$5,099.18

Service Code	APR-DRG 1901
Hospital Charge Code	APRDRG1903
Min. Negotiated Rate	$5,099.18
Max. Negotiated Rate	$5,099.18
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,099.18
Rate for Payer: Mercy Care Medicaid	$5,099.18
Rate for Payer: NaphCare Correctional Healthcare	$5,099.18

Acute Myocardial Infarction

Facility

$7,646.66

Service Code	APR-DRG 1903
Hospital Charge Code	APRDRG1903
Min. Negotiated Rate	$7,646.66
Max. Negotiated Rate	$7,646.66
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$7,646.66
Rate for Payer: Mercy Care Medicaid	$7,646.66
Rate for Payer: NaphCare Correctional Healthcare	$7,646.66

Acute Myocardial Infarction

Facility

$11,936.43

Service Code	APR-DRG 1904
Hospital Charge Code	APRDRG1903
Min. Negotiated Rate	$11,936.43
Max. Negotiated Rate	$11,936.43
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$11,936.43
Rate for Payer: Mercy Care Medicaid	$11,936.43
Rate for Payer: NaphCare Correctional Healthcare	$11,936.43

Acute Myocardial Infarction

Facility

$7,646.66

Service Code	APR-DRG 1903
Hospital Charge Code	APRDRG1901
Min. Negotiated Rate	$7,646.66
Max. Negotiated Rate	$7,646.66
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$7,646.66
Rate for Payer: Mercy Care Medicaid	$7,646.66
Rate for Payer: NaphCare Correctional Healthcare	$7,646.66

Acute Myocardial Infarction

Facility

$7,646.66

Service Code	APR-DRG 1903
Hospital Charge Code	APRDRG1902
Min. Negotiated Rate	$7,646.66
Max. Negotiated Rate	$7,646.66
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$7,646.66
Rate for Payer: Mercy Care Medicaid	$7,646.66
Rate for Payer: NaphCare Correctional Healthcare	$7,646.66

Acute Myocardial Infarction

Facility

$7,646.66

Service Code	APR-DRG 1903
Hospital Charge Code	APRDRG1904
Min. Negotiated Rate	$7,646.66
Max. Negotiated Rate	$7,646.66
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$7,646.66
Rate for Payer: Mercy Care Medicaid	$7,646.66
Rate for Payer: NaphCare Correctional Healthcare	$7,646.66

Acute Myocardial Infarction

Facility

$5,750.78

Service Code	APR-DRG 1902
Hospital Charge Code	APRDRG1901
Min. Negotiated Rate	$5,750.78
Max. Negotiated Rate	$5,750.78
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,750.78
Rate for Payer: Mercy Care Medicaid	$5,750.78
Rate for Payer: NaphCare Correctional Healthcare	$5,750.78

Acute Myocardial Infarction

Facility

$5,750.78

Service Code	APR-DRG 1902
Hospital Charge Code	APRDRG1902
Min. Negotiated Rate	$5,750.78
Max. Negotiated Rate	$5,750.78
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,750.78
Rate for Payer: Mercy Care Medicaid	$5,750.78
Rate for Payer: NaphCare Correctional Healthcare	$5,750.78

Acute Myocardial Infarction

Facility

$5,099.18

Service Code	APR-DRG 1901
Hospital Charge Code	APRDRG1904
Min. Negotiated Rate	$5,099.18
Max. Negotiated Rate	$5,099.18
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,099.18
Rate for Payer: Mercy Care Medicaid	$5,099.18
Rate for Payer: NaphCare Correctional Healthcare	$5,099.18

Acute Myocardial Infarction

Facility

$11,936.43

Service Code	APR-DRG 1904
Hospital Charge Code	APRDRG1902
Min. Negotiated Rate	$11,936.43
Max. Negotiated Rate	$11,936.43
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$11,936.43
Rate for Payer: Mercy Care Medicaid	$11,936.43
Rate for Payer: NaphCare Correctional Healthcare	$11,936.43

Acute Myocardial Infarction

Facility

$5,750.78

Service Code	APR-DRG 1902
Hospital Charge Code	APRDRG1903
Min. Negotiated Rate	$5,750.78
Max. Negotiated Rate	$5,750.78
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,750.78
Rate for Payer: Mercy Care Medicaid	$5,750.78
Rate for Payer: NaphCare Correctional Healthcare	$5,750.78

Acute Myocardial Infarction

Facility

$11,936.43

Service Code	APR-DRG 1904
Hospital Charge Code	APRDRG1904
Min. Negotiated Rate	$11,936.43
Max. Negotiated Rate	$11,936.43
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$11,936.43
Rate for Payer: Mercy Care Medicaid	$11,936.43
Rate for Payer: NaphCare Correctional Healthcare	$11,936.43

Acute Myocardial Infarction

Facility

$5,099.18

Service Code	APR-DRG 1901
Hospital Charge Code	APRDRG1902
Min. Negotiated Rate	$5,099.18
Max. Negotiated Rate	$5,099.18
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,099.18
Rate for Payer: Mercy Care Medicaid	$5,099.18
Rate for Payer: NaphCare Correctional Healthcare	$5,099.18

Acute Myocardial Infarction

Facility

$5,099.18

Service Code	APR-DRG 1901
Hospital Charge Code	APRDRG1901
Min. Negotiated Rate	$5,099.18
Max. Negotiated Rate	$5,099.18
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,099.18
Rate for Payer: Mercy Care Medicaid	$5,099.18
Rate for Payer: NaphCare Correctional Healthcare	$5,099.18

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC

Facility

$12,001.52

Service Code	MSDRG 281
Min. Negotiated Rate	$12,001.52
Max. Negotiated Rate	$12,001.52
Rate for Payer: Seven Corners Travel Insurance	$12,001.52

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC

Facility

$20,731.61

Service Code	MSDRG 280
Min. Negotiated Rate	$20,731.61
Max. Negotiated Rate	$20,731.61
Rate for Payer: Seven Corners Travel Insurance	$20,731.61

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC

Facility

$9,517.96

Service Code	MSDRG 282
Min. Negotiated Rate	$9,517.96
Max. Negotiated Rate	$9,517.96
Rate for Payer: Seven Corners Travel Insurance	$9,517.96

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC

Facility

$9,126.43

Service Code	MSDRG 284
Min. Negotiated Rate	$9,126.43
Max. Negotiated Rate	$9,126.43
Rate for Payer: Seven Corners Travel Insurance	$9,126.43

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC

Facility

$25,600.13

Service Code	MSDRG 283
Min. Negotiated Rate	$25,600.13
Max. Negotiated Rate	$25,600.13
Rate for Payer: Seven Corners Travel Insurance	$25,600.13

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC

Facility

$7,944.22

Service Code	MSDRG 285
Min. Negotiated Rate	$7,944.22
Max. Negotiated Rate	$7,944.22
Rate for Payer: Seven Corners Travel Insurance	$7,944.22

acyclovir 500 mg/10 mL Sol [CQCH]

Facility

$0.32

Service Code	HCPCS J0133
Hospital Charge Code	107616107
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of AZ Commercial	$0.29
Rate for Payer: Arizona Complete Health Allwell	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.22
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.05
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.05
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna of AZ Commercial	$0.21
Rate for Payer: Devoted Health Medicare	$0.06
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Southwest Service Administrators UFCW	$0.22
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: United Healthcare Commercial	$0.18
Rate for Payer: United Healthcare Medicare	$0.05
Rate for Payer: Veterans Affairs TRICARE	$0.05

acyclovir 500 mg/10 mL Sol [CQCH]

Facility

$0.32

Service Code	HCPCS J0133
Hospital Charge Code	107616107
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of AZ Commercial	$0.29
Rate for Payer: Cash Price	$0.26

Know your out-of-pocket cost for care.

All Charges