Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

CLL FISH Panel LC

Facility

$205.00

Service Code	CPT 88271
Hospital Charge Code	2029268
Hospital Revenue Code	310
Min. Negotiated Rate	$53.30
Max. Negotiated Rate	$184.50
Rate for Payer: Aetna of AZ Commercial	$184.50
Rate for Payer: Bisbee Police All Plans	$53.30
Rate for Payer: Cash Price	$164.00
Rate for Payer: Self Pay Self Pay	$164.00

CLL FISH Panel LC

Facility

$205.00

Service Code	CPT 88271
Hospital Charge Code	2029268
Hospital Revenue Code	310
Min. Negotiated Rate	$32.80
Max. Negotiated Rate	$184.50
Rate for Payer: Aetna of AZ Commercial	$184.50
Rate for Payer: Aetna of AZ Medicare	$57.40
Rate for Payer: Allwell Medicare	$32.80
Rate for Payer: Amerigroup Medicare	$32.80
Rate for Payer: APIPA Medicare/Medicaid	$76.57
Rate for Payer: AZCH Complete Medicare	$32.80
Rate for Payer: Banner UC Health Medicare	$32.80
Rate for Payer: Bisbee Police All Plans	$53.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$139.40
Rate for Payer: Cash Price	$164.00
Rate for Payer: Cigna of AZ Commercial	$133.25
Rate for Payer: Copperpoint Commercial	$50.74
Rate for Payer: Health Net of AZ Commercial	$123.00
Rate for Payer: Health Net of AZ Medicare	$57.40
Rate for Payer: Humana of AZ Medicare	$32.80
Rate for Payer: Self Pay Self Pay	$164.00
Rate for Payer: TriWest Medicare	$32.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$119.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$36.90

clonazePAM 0.5 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 228300311
Hospital Charge Code	105916868
Hospital Revenue Code	251
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of AZ Commercial	$0.02
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.02
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

clonazePAM 0.5 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 228300311
Hospital Charge Code	105916868
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Self Pay Self Pay	$0.02

clonazePAM 1 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 51079088220
Hospital Charge Code	105916803
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Cash Price	$0.05
Rate for Payer: Self Pay Self Pay	$0.05

clonazePAM 1 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 51079088220
Hospital Charge Code	105916803
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: Aetna of AZ Medicare	$0.02
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.02
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.04
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of AZ Commercial	$0.04
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.04
Rate for Payer: Health Net of AZ Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Self Pay Self Pay	$0.05
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

cloNIDine 0.1 mg/24 hr Transderm Patch [CQCH]

Facility

$15.51

Service Code	NDC 378087199
Hospital Charge Code	105916933
Hospital Revenue Code	251
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$13.96
Rate for Payer: Aetna of AZ Commercial	$13.96
Rate for Payer: Bisbee Police All Plans	$4.03
Rate for Payer: Cash Price	$12.40
Rate for Payer: Self Pay Self Pay	$12.41

cloNIDine 0.1 mg/24 hr Transderm Patch [CQCH]

Facility

$15.51

Service Code	NDC 378087199
Hospital Charge Code	105916933
Hospital Revenue Code	251
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$13.96
Rate for Payer: Aetna of AZ Commercial	$13.96
Rate for Payer: Aetna of AZ Medicare	$4.34
Rate for Payer: Allwell Medicare	$2.48
Rate for Payer: Amerigroup Medicare	$2.48
Rate for Payer: APIPA Medicare/Medicaid	$5.79
Rate for Payer: AZCH Complete Medicare	$2.48
Rate for Payer: Banner UC Health Medicare	$2.48
Rate for Payer: Bisbee Police All Plans	$4.03
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$10.55
Rate for Payer: Cash Price	$12.40
Rate for Payer: Cigna of AZ Commercial	$10.08
Rate for Payer: Copperpoint Commercial	$3.84
Rate for Payer: Health Net of AZ Commercial	$9.31
Rate for Payer: Health Net of AZ Medicare	$4.34
Rate for Payer: Humana of AZ Medicare	$2.48
Rate for Payer: Self Pay Self Pay	$12.41
Rate for Payer: TriWest Medicare	$2.48
Rate for Payer: UnitedHealth Group of AZ Commercial	$9.04
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.79

cloNIDine 0.1 mg Tab [CQCH]

Facility

$0.04

Service Code	NDC 228212710
Hospital Charge Code	105916998
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: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.03
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of AZ Commercial	$0.03
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.02
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Self Pay Self Pay	$0.03
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

cloNIDine 0.1 mg Tab [CQCH]

Facility

$0.04

Service Code	NDC 228212710
Hospital Charge Code	105916998
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: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.03
Rate for Payer: Self Pay Self Pay	$0.03

clopidogrel 75 mg Tab [CQCH]

Facility

$0.17

Service Code	NDC 904629461
Hospital Charge Code	105917063
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Cash Price	$0.14
Rate for Payer: Self Pay Self Pay	$0.14

clopidogrel 75 mg Tab [CQCH]

Facility

$0.17

Service Code	NDC 904629461
Hospital Charge Code	105917063
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: Aetna of AZ Medicare	$0.05
Rate for Payer: Allwell Medicare	$0.03
Rate for Payer: Amerigroup Medicare	$0.03
Rate for Payer: APIPA Medicare/Medicaid	$0.06
Rate for Payer: AZCH Complete Medicare	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.12
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of AZ Commercial	$0.11
Rate for Payer: Copperpoint Commercial	$0.04
Rate for Payer: Health Net of AZ Commercial	$0.10
Rate for Payer: Health Net of AZ Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Self Pay Self Pay	$0.14
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.10
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.03

CLOSED TREATMENT OF LUNATE DISLOCATION, WITH MANIPULATION

Facility

$5,787.00

Service Code	CPT 25690
Hospital Charge Code	3634335
Hospital Revenue Code	450
Min. Negotiated Rate	$1,504.62
Max. Negotiated Rate	$5,208.30
Rate for Payer: Aetna of AZ Commercial	$5,208.30
Rate for Payer: Bisbee Police All Plans	$1,504.62
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Self Pay Self Pay	$4,629.60

CLOSED TREATMENT OF LUNATE DISLOCATION, WITH MANIPULATION

Facility

$5,787.00

Service Code	CPT 25690
Hospital Charge Code	3634335
Hospital Revenue Code	450
Min. Negotiated Rate	$925.92
Max. Negotiated Rate	$5,208.30
Rate for Payer: Aetna of AZ Commercial	$5,208.30
Rate for Payer: Aetna of AZ Medicare	$1,620.36
Rate for Payer: AHCCCS Medicaid	$1,009.45
Rate for Payer: Allwell Medicaid	$1,009.45
Rate for Payer: Allwell Medicare	$925.92
Rate for Payer: Amerigroup Medicare	$925.92
Rate for Payer: APIPA Medicare/Medicaid	$2,161.44
Rate for Payer: AZCH Complete Medicaid	$1,009.45
Rate for Payer: AZCH Complete Medicare	$925.92
Rate for Payer: Banner UC Health Medicaid	$1,009.45
Rate for Payer: Banner UC Health Medicare	$925.92
Rate for Payer: Bisbee Police All Plans	$1,504.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,935.16
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Cash Price	$4,629.60
Rate for Payer: Cigna of AZ Commercial	$4,050.90
Rate for Payer: Copperpoint Commercial	$1,432.28
Rate for Payer: Health Net of AZ Commercial	$3,472.20
Rate for Payer: Health Net of AZ Medicare	$1,620.36
Rate for Payer: Humana of AZ Medicare	$925.92
Rate for Payer: Mercy Care Medicaid	$1,009.45
Rate for Payer: Self Pay Self Pay	$4,629.60
Rate for Payer: TriWest Medicare	$925.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,909.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,041.66

Clostridium difficile by DNA Amplification

Facility

$148.00

Hospital Charge Code	2210298
Hospital Revenue Code	306
Min. Negotiated Rate	$23.68
Max. Negotiated Rate	$133.20
Rate for Payer: Aetna of AZ Commercial	$133.20
Rate for Payer: Aetna of AZ Medicare	$41.44
Rate for Payer: Allwell Medicare	$23.68
Rate for Payer: Amerigroup Medicare	$23.68
Rate for Payer: APIPA Medicare/Medicaid	$55.28
Rate for Payer: AZCH Complete Medicare	$23.68
Rate for Payer: Banner UC Health Medicare	$23.68
Rate for Payer: Bisbee Police All Plans	$38.48
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$100.64
Rate for Payer: Cash Price	$118.40
Rate for Payer: Cigna of AZ Commercial	$96.20
Rate for Payer: Copperpoint Commercial	$36.63
Rate for Payer: Health Net of AZ Commercial	$88.80
Rate for Payer: Health Net of AZ Medicare	$41.44
Rate for Payer: Humana of AZ Medicare	$23.68
Rate for Payer: Self Pay Self Pay	$118.40
Rate for Payer: TriWest Medicare	$23.68
Rate for Payer: UnitedHealth Group of AZ Commercial	$86.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$26.64

Clostridium difficile by DNA Amplification

Facility

$148.00

Hospital Charge Code	2210298
Hospital Revenue Code	306
Min. Negotiated Rate	$38.48
Max. Negotiated Rate	$133.20
Rate for Payer: Aetna of AZ Commercial	$133.20
Rate for Payer: Bisbee Police All Plans	$38.48
Rate for Payer: Cash Price	$118.40
Rate for Payer: Self Pay Self Pay	$118.40

clotrimazole Top 1% Crm [CQCH]

Facility

$3.48

Service Code	NDC 68462018117
Hospital Charge Code	105917130
Hospital Revenue Code	251
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$3.13
Rate for Payer: Aetna of AZ Commercial	$3.13
Rate for Payer: Aetna of AZ Medicare	$0.97
Rate for Payer: Allwell Medicare	$0.56
Rate for Payer: Amerigroup Medicare	$0.56
Rate for Payer: APIPA Medicare/Medicaid	$1.30
Rate for Payer: AZCH Complete Medicare	$0.56
Rate for Payer: Banner UC Health Medicare	$0.56
Rate for Payer: Bisbee Police All Plans	$0.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2.37
Rate for Payer: Cash Price	$2.78
Rate for Payer: Cigna of AZ Commercial	$2.26
Rate for Payer: Copperpoint Commercial	$0.86
Rate for Payer: Health Net of AZ Commercial	$2.09
Rate for Payer: Health Net of AZ Medicare	$0.97
Rate for Payer: Humana of AZ Medicare	$0.56
Rate for Payer: Self Pay Self Pay	$2.78
Rate for Payer: TriWest Medicare	$0.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.63

clotrimazole Top 1% Crm [CQCH]

Facility

$3.48

Service Code	NDC 68462018117
Hospital Charge Code	105917130
Hospital Revenue Code	251
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$3.13
Rate for Payer: Aetna of AZ Commercial	$3.13
Rate for Payer: Bisbee Police All Plans	$0.90
Rate for Payer: Cash Price	$2.78
Rate for Payer: Self Pay Self Pay	$2.78

CLOTTING; FACTOR VIII (AHG), ONE STAGE

Facility

$139.00

Service Code	CPT 85240
Hospital Charge Code	23090940
Hospital Revenue Code	301
Min. Negotiated Rate	$22.24
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of AZ Commercial	$125.10
Rate for Payer: Aetna of AZ Medicare	$38.92
Rate for Payer: Allwell Medicare	$22.24
Rate for Payer: Amerigroup Medicare	$22.24
Rate for Payer: APIPA Medicare/Medicaid	$51.92
Rate for Payer: AZCH Complete Medicare	$22.24
Rate for Payer: Banner UC Health Medicare	$22.24
Rate for Payer: Bisbee Police All Plans	$36.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$94.52
Rate for Payer: Cash Price	$111.20
Rate for Payer: Cigna of AZ Commercial	$90.35
Rate for Payer: Copperpoint Commercial	$34.40
Rate for Payer: Health Net of AZ Commercial	$83.40
Rate for Payer: Health Net of AZ Medicare	$38.92
Rate for Payer: Humana of AZ Medicare	$22.24
Rate for Payer: Self Pay Self Pay	$111.20
Rate for Payer: TriWest Medicare	$22.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$81.04
Rate for Payer: UnitedHealth Group of AZ Medicare	$25.02

CLOTTING; FACTOR VIII (AHG), ONE STAGE

Facility

$139.00

Service Code	CPT 85240
Hospital Charge Code	23090940
Hospital Revenue Code	301
Min. Negotiated Rate	$36.14
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of AZ Commercial	$125.10
Rate for Payer: Bisbee Police All Plans	$36.14
Rate for Payer: Cash Price	$111.20
Rate for Payer: Self Pay Self Pay	$111.20

Clozapine LC

Facility

$259.00

Service Code	CPT 80159
Hospital Charge Code	2669527
Hospital Revenue Code	301
Min. Negotiated Rate	$67.34
Max. Negotiated Rate	$233.10
Rate for Payer: Aetna of AZ Commercial	$233.10
Rate for Payer: Bisbee Police All Plans	$67.34
Rate for Payer: Cash Price	$207.20
Rate for Payer: Self Pay Self Pay	$207.20

Clozapine LC

Facility

$259.00

Service Code	CPT 80159
Hospital Charge Code	2669527
Hospital Revenue Code	301
Min. Negotiated Rate	$41.44
Max. Negotiated Rate	$233.10
Rate for Payer: Aetna of AZ Commercial	$233.10
Rate for Payer: Aetna of AZ Medicare	$72.52
Rate for Payer: Allwell Medicare	$41.44
Rate for Payer: Amerigroup Medicare	$41.44
Rate for Payer: APIPA Medicare/Medicaid	$96.74
Rate for Payer: AZCH Complete Medicare	$41.44
Rate for Payer: Banner UC Health Medicare	$41.44
Rate for Payer: Bisbee Police All Plans	$67.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$176.12
Rate for Payer: Cash Price	$207.20
Rate for Payer: Cigna of AZ Commercial	$168.35
Rate for Payer: Copperpoint Commercial	$64.10
Rate for Payer: Health Net of AZ Commercial	$155.40
Rate for Payer: Health Net of AZ Medicare	$72.52
Rate for Payer: Humana of AZ Medicare	$41.44
Rate for Payer: Self Pay Self Pay	$207.20
Rate for Payer: TriWest Medicare	$41.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$151.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$46.62

CMV PCR LC

Facility

$699.00

Service Code	CPT 87496
Hospital Charge Code	2087573
Hospital Revenue Code	301
Min. Negotiated Rate	$181.74
Max. Negotiated Rate	$629.10
Rate for Payer: Aetna of AZ Commercial	$629.10
Rate for Payer: Bisbee Police All Plans	$181.74
Rate for Payer: Cash Price	$559.20
Rate for Payer: Self Pay Self Pay	$559.20

CMV PCR LC

Facility

$699.00

Service Code	CPT 87496
Hospital Charge Code	2087573
Hospital Revenue Code	301
Min. Negotiated Rate	$111.84
Max. Negotiated Rate	$629.10
Rate for Payer: Aetna of AZ Commercial	$629.10
Rate for Payer: Aetna of AZ Medicare	$195.72
Rate for Payer: Allwell Medicare	$111.84
Rate for Payer: Amerigroup Medicare	$111.84
Rate for Payer: APIPA Medicare/Medicaid	$261.08
Rate for Payer: AZCH Complete Medicare	$111.84
Rate for Payer: Banner UC Health Medicare	$111.84
Rate for Payer: Bisbee Police All Plans	$181.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$475.32
Rate for Payer: Cash Price	$559.20
Rate for Payer: Cigna of AZ Commercial	$454.35
Rate for Payer: Copperpoint Commercial	$173.00
Rate for Payer: Health Net of AZ Commercial	$419.40
Rate for Payer: Health Net of AZ Medicare	$195.72
Rate for Payer: Humana of AZ Medicare	$111.84
Rate for Payer: Self Pay Self Pay	$559.20
Rate for Payer: TriWest Medicare	$111.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$407.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$125.82

CMV Quant DNA PCR (Plasma) LC

Facility

$319.00

Service Code	CPT 87497
Hospital Charge Code	2029097
Hospital Revenue Code	300
Min. Negotiated Rate	$82.94
Max. Negotiated Rate	$287.10
Rate for Payer: Aetna of AZ Commercial	$287.10
Rate for Payer: Bisbee Police All Plans	$82.94
Rate for Payer: Cash Price	$255.20
Rate for Payer: Self Pay Self Pay	$255.20

Know your out-of-pocket cost for care.

All Charges