Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

D16 LOW PROFILE 3MM X 30MM BONE SCREW

Facility

$1,915.00

Hospital Charge Code	27663809
Hospital Revenue Code	270
Min. Negotiated Rate	$306.40
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Aetna of AZ Medicare	$536.20
Rate for Payer: Allwell Medicare	$306.40
Rate for Payer: Amerigroup Medicare	$306.40
Rate for Payer: APIPA Medicare/Medicaid	$715.25
Rate for Payer: AZCH Complete Medicare	$306.40
Rate for Payer: Banner UC Health Medicare	$306.40
Rate for Payer: Bisbee Police All Plans	$497.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,302.20
Rate for Payer: Cash Price	$1,532.00
Rate for Payer: Cigna of AZ Commercial	$1,340.50
Rate for Payer: Copperpoint Commercial	$473.96
Rate for Payer: Health Net of AZ Commercial	$1,149.00
Rate for Payer: Health Net of AZ Medicare	$536.20
Rate for Payer: Humana of AZ Medicare	$306.40
Rate for Payer: Self Pay Self Pay	$1,532.00
Rate for Payer: TriWest Medicare	$306.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,116.44
Rate for Payer: UnitedHealth Group of AZ Medicare	$344.70

dantrolene 20 mg IV Inj [CQCH]

Facility

$64.25

Service Code	NDC 42023012306
Hospital Charge Code	105917797
Hospital Revenue Code	250
Min. Negotiated Rate	$16.70
Max. Negotiated Rate	$57.83
Rate for Payer: Aetna of AZ Commercial	$57.83
Rate for Payer: Bisbee Police All Plans	$16.70
Rate for Payer: Cash Price	$51.40
Rate for Payer: Self Pay Self Pay	$51.40

dantrolene 20 mg IV Inj [CQCH]

Facility

$64.25

Service Code	NDC 42023012306
Hospital Charge Code	105917797
Hospital Revenue Code	250
Min. Negotiated Rate	$10.28
Max. Negotiated Rate	$57.83
Rate for Payer: Aetna of AZ Commercial	$57.83
Rate for Payer: Aetna of AZ Medicare	$17.99
Rate for Payer: Allwell Medicare	$10.28
Rate for Payer: Amerigroup Medicare	$10.28
Rate for Payer: APIPA Medicare/Medicaid	$24.00
Rate for Payer: AZCH Complete Medicare	$10.28
Rate for Payer: Banner UC Health Medicare	$10.28
Rate for Payer: Bisbee Police All Plans	$16.70
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$43.69
Rate for Payer: Cash Price	$51.40
Rate for Payer: Cigna of AZ Commercial	$41.76
Rate for Payer: Copperpoint Commercial	$15.90
Rate for Payer: Health Net of AZ Commercial	$38.55
Rate for Payer: Health Net of AZ Medicare	$17.99
Rate for Payer: Humana of AZ Medicare	$10.28
Rate for Payer: Self Pay Self Pay	$51.40
Rate for Payer: TriWest Medicare	$10.28
Rate for Payer: UnitedHealth Group of AZ Commercial	$37.46
Rate for Payer: UnitedHealth Group of AZ Medicare	$11.56

dantrolene 250 mg vial [CQCH]

Facility

$2,791.83

Service Code	NDC 42367054032
Hospital Charge Code	118269942
Hospital Revenue Code	250
Min. Negotiated Rate	$446.69
Max. Negotiated Rate	$2,512.65
Rate for Payer: Aetna of AZ Commercial	$2,512.65
Rate for Payer: Aetna of AZ Medicare	$781.71
Rate for Payer: Allwell Medicare	$446.69
Rate for Payer: Amerigroup Medicare	$446.69
Rate for Payer: APIPA Medicare/Medicaid	$1,042.75
Rate for Payer: AZCH Complete Medicare	$446.69
Rate for Payer: Banner UC Health Medicare	$446.69
Rate for Payer: Bisbee Police All Plans	$725.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,898.44
Rate for Payer: Cash Price	$2,233.46
Rate for Payer: Cigna of AZ Commercial	$1,814.69
Rate for Payer: Copperpoint Commercial	$690.98
Rate for Payer: Health Net of AZ Commercial	$1,675.10
Rate for Payer: Health Net of AZ Medicare	$781.71
Rate for Payer: Humana of AZ Medicare	$446.69
Rate for Payer: Self Pay Self Pay	$2,233.46
Rate for Payer: TriWest Medicare	$446.69
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,627.64
Rate for Payer: UnitedHealth Group of AZ Medicare	$502.53

dantrolene 250 mg vial [CQCH]

Facility

$2,791.83

Service Code	NDC 42367054032
Hospital Charge Code	118269942
Hospital Revenue Code	250
Min. Negotiated Rate	$725.88
Max. Negotiated Rate	$2,512.65
Rate for Payer: Aetna of AZ Commercial	$2,512.65
Rate for Payer: Bisbee Police All Plans	$725.88
Rate for Payer: Cash Price	$2,233.46
Rate for Payer: Self Pay Self Pay	$2,233.46

dapsone 100 mg Tab[CQCH]

Facility

$0.69

Service Code	NDC 70954013620
Hospital Charge Code	146921850
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of AZ Commercial	$0.62
Rate for Payer: Bisbee Police All Plans	$0.18
Rate for Payer: Cash Price	$0.55
Rate for Payer: Self Pay Self Pay	$0.55

dapsone 100 mg Tab[CQCH]

Facility

$0.69

Service Code	NDC 70954013620
Hospital Charge Code	146921850
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.62
Rate for Payer: Aetna of AZ Commercial	$0.62
Rate for Payer: Aetna of AZ Medicare	$0.19
Rate for Payer: Allwell Medicare	$0.11
Rate for Payer: Amerigroup Medicare	$0.11
Rate for Payer: APIPA Medicare/Medicaid	$0.26
Rate for Payer: AZCH Complete Medicare	$0.11
Rate for Payer: Banner UC Health Medicare	$0.11
Rate for Payer: Bisbee Police All Plans	$0.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.47
Rate for Payer: Cash Price	$0.55
Rate for Payer: Cigna of AZ Commercial	$0.45
Rate for Payer: Copperpoint Commercial	$0.17
Rate for Payer: Health Net of AZ Commercial	$0.41
Rate for Payer: Health Net of AZ Medicare	$0.19
Rate for Payer: Humana of AZ Medicare	$0.11
Rate for Payer: Self Pay Self Pay	$0.55
Rate for Payer: TriWest Medicare	$0.11
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.40
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.12

DAT Complement

Facility

$74.00

Service Code	CPT 86880
Hospital Charge Code	22244675
Hospital Revenue Code	302
Min. Negotiated Rate	$19.24
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Bisbee Police All Plans	$19.24
Rate for Payer: Cash Price	$59.20
Rate for Payer: Self Pay Self Pay	$59.20

DAT Complement

Facility

$74.00

Service Code	CPT 86880
Hospital Charge Code	22244675
Hospital Revenue Code	302
Min. Negotiated Rate	$11.84
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Aetna of AZ Medicare	$20.72
Rate for Payer: Allwell Medicare	$11.84
Rate for Payer: Amerigroup Medicare	$11.84
Rate for Payer: APIPA Medicare/Medicaid	$27.64
Rate for Payer: AZCH Complete Medicare	$11.84
Rate for Payer: Banner UC Health Medicare	$11.84
Rate for Payer: Bisbee Police All Plans	$19.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$50.32
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cigna of AZ Commercial	$48.10
Rate for Payer: Copperpoint Commercial	$18.32
Rate for Payer: Health Net of AZ Commercial	$44.40
Rate for Payer: Health Net of AZ Medicare	$20.72
Rate for Payer: Humana of AZ Medicare	$11.84
Rate for Payer: Self Pay Self Pay	$59.20
Rate for Payer: TriWest Medicare	$11.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$43.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$13.32

DAT IgG

Facility

$74.00

Service Code	CPT 86880
Hospital Charge Code	14018312
Hospital Revenue Code	302
Min. Negotiated Rate	$19.24
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Bisbee Police All Plans	$19.24
Rate for Payer: Cash Price	$59.20
Rate for Payer: Self Pay Self Pay	$59.20

DAT IgG

Facility

$74.00

Service Code	CPT 86880
Hospital Charge Code	14018312
Hospital Revenue Code	302
Min. Negotiated Rate	$11.84
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Aetna of AZ Medicare	$20.72
Rate for Payer: Allwell Medicare	$11.84
Rate for Payer: Amerigroup Medicare	$11.84
Rate for Payer: APIPA Medicare/Medicaid	$27.64
Rate for Payer: AZCH Complete Medicare	$11.84
Rate for Payer: Banner UC Health Medicare	$11.84
Rate for Payer: Bisbee Police All Plans	$19.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$50.32
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cigna of AZ Commercial	$48.10
Rate for Payer: Copperpoint Commercial	$18.32
Rate for Payer: Health Net of AZ Commercial	$44.40
Rate for Payer: Health Net of AZ Medicare	$20.72
Rate for Payer: Humana of AZ Medicare	$11.84
Rate for Payer: Self Pay Self Pay	$59.20
Rate for Payer: TriWest Medicare	$11.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$43.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$13.32

DAT Poly

Facility

$70.00

Service Code	CPT 86880
Hospital Charge Code	14018311
Hospital Revenue Code	302
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna of AZ Commercial	$63.00
Rate for Payer: Aetna of AZ Medicare	$19.60
Rate for Payer: Allwell Medicare	$11.20
Rate for Payer: Amerigroup Medicare	$11.20
Rate for Payer: APIPA Medicare/Medicaid	$26.14
Rate for Payer: AZCH Complete Medicare	$11.20
Rate for Payer: Banner UC Health Medicare	$11.20
Rate for Payer: Bisbee Police All Plans	$18.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$47.60
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cigna of AZ Commercial	$45.50
Rate for Payer: Copperpoint Commercial	$17.32
Rate for Payer: Health Net of AZ Commercial	$42.00
Rate for Payer: Health Net of AZ Medicare	$19.60
Rate for Payer: Humana of AZ Medicare	$11.20
Rate for Payer: Self Pay Self Pay	$56.00
Rate for Payer: TriWest Medicare	$11.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$40.81
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.60

DAT Poly

Facility

$70.00

Service Code	CPT 86880
Hospital Charge Code	14018311
Hospital Revenue Code	302
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna of AZ Commercial	$63.00
Rate for Payer: Bisbee Police All Plans	$18.20
Rate for Payer: Cash Price	$56.00
Rate for Payer: Self Pay Self Pay	$56.00

DCP

Facility

$334.00

Service Code	CPT 83951
Hospital Charge Code	23185839
Hospital Revenue Code	302
Min. Negotiated Rate	$53.44
Max. Negotiated Rate	$300.60
Rate for Payer: Aetna of AZ Commercial	$300.60
Rate for Payer: Aetna of AZ Medicare	$93.52
Rate for Payer: Allwell Medicare	$53.44
Rate for Payer: Amerigroup Medicare	$53.44
Rate for Payer: APIPA Medicare/Medicaid	$124.75
Rate for Payer: AZCH Complete Medicare	$53.44
Rate for Payer: Banner UC Health Medicare	$53.44
Rate for Payer: Bisbee Police All Plans	$86.84
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$227.12
Rate for Payer: Cash Price	$267.20
Rate for Payer: Cigna of AZ Commercial	$217.10
Rate for Payer: Copperpoint Commercial	$82.67
Rate for Payer: Health Net of AZ Commercial	$200.40
Rate for Payer: Health Net of AZ Medicare	$93.52
Rate for Payer: Humana of AZ Medicare	$53.44
Rate for Payer: Self Pay Self Pay	$267.20
Rate for Payer: TriWest Medicare	$53.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$194.72
Rate for Payer: UnitedHealth Group of AZ Medicare	$60.12

DCP

Facility

$334.00

Service Code	CPT 83951
Hospital Charge Code	23185839
Hospital Revenue Code	302
Min. Negotiated Rate	$86.84
Max. Negotiated Rate	$300.60
Rate for Payer: Aetna of AZ Commercial	$300.60
Rate for Payer: Bisbee Police All Plans	$86.84
Rate for Payer: Cash Price	$267.20
Rate for Payer: Self Pay Self Pay	$267.20

D-Dimer

Facility

$295.00

Service Code	CPT 85379
Hospital Charge Code	633718
Hospital Revenue Code	305
Min. Negotiated Rate	$76.70
Max. Negotiated Rate	$265.50
Rate for Payer: Aetna of AZ Commercial	$265.50
Rate for Payer: Bisbee Police All Plans	$76.70
Rate for Payer: Cash Price	$236.00
Rate for Payer: Self Pay Self Pay	$236.00

D-Dimer

Facility

$295.00

Service Code	CPT 85379
Hospital Charge Code	633718
Hospital Revenue Code	305
Min. Negotiated Rate	$47.20
Max. Negotiated Rate	$265.50
Rate for Payer: Aetna of AZ Commercial	$265.50
Rate for Payer: Aetna of AZ Medicare	$82.60
Rate for Payer: Allwell Medicare	$47.20
Rate for Payer: Amerigroup Medicare	$47.20
Rate for Payer: APIPA Medicare/Medicaid	$110.18
Rate for Payer: AZCH Complete Medicare	$47.20
Rate for Payer: Banner UC Health Medicare	$47.20
Rate for Payer: Bisbee Police All Plans	$76.70
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$200.60
Rate for Payer: Cash Price	$236.00
Rate for Payer: Cigna of AZ Commercial	$191.75
Rate for Payer: Copperpoint Commercial	$73.01
Rate for Payer: Health Net of AZ Commercial	$177.00
Rate for Payer: Health Net of AZ Medicare	$82.60
Rate for Payer: Humana of AZ Medicare	$47.20
Rate for Payer: Self Pay Self Pay	$236.00
Rate for Payer: TriWest Medicare	$47.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$171.99
Rate for Payer: UnitedHealth Group of AZ Medicare	$53.10

D-Dimer 2

Facility

$311.00

Service Code	CPT 85379
Hospital Charge Code	18323368
Hospital Revenue Code	305
Min. Negotiated Rate	$49.76
Max. Negotiated Rate	$279.90
Rate for Payer: Aetna of AZ Commercial	$279.90
Rate for Payer: Aetna of AZ Medicare	$87.08
Rate for Payer: Allwell Medicare	$49.76
Rate for Payer: Amerigroup Medicare	$49.76
Rate for Payer: APIPA Medicare/Medicaid	$116.16
Rate for Payer: AZCH Complete Medicare	$49.76
Rate for Payer: Banner UC Health Medicare	$49.76
Rate for Payer: Bisbee Police All Plans	$80.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$211.48
Rate for Payer: Cash Price	$248.80
Rate for Payer: Cigna of AZ Commercial	$202.15
Rate for Payer: Copperpoint Commercial	$76.97
Rate for Payer: Health Net of AZ Commercial	$186.60
Rate for Payer: Health Net of AZ Medicare	$87.08
Rate for Payer: Humana of AZ Medicare	$49.76
Rate for Payer: Self Pay Self Pay	$248.80
Rate for Payer: TriWest Medicare	$49.76
Rate for Payer: UnitedHealth Group of AZ Commercial	$181.31
Rate for Payer: UnitedHealth Group of AZ Medicare	$55.98

D-Dimer 2

Facility

$311.00

Service Code	CPT 85379
Hospital Charge Code	18323368
Hospital Revenue Code	305
Min. Negotiated Rate	$80.86
Max. Negotiated Rate	$279.90
Rate for Payer: Aetna of AZ Commercial	$279.90
Rate for Payer: Bisbee Police All Plans	$80.86
Rate for Payer: Cash Price	$248.80
Rate for Payer: Self Pay Self Pay	$248.80

DECALCIFICATION PROCEDURE

Facility

$611.00

Service Code	CPT 88311
Hospital Charge Code	22545717
Hospital Revenue Code	310
Min. Negotiated Rate	$158.86
Max. Negotiated Rate	$549.90
Rate for Payer: Aetna of AZ Commercial	$549.90
Rate for Payer: Bisbee Police All Plans	$158.86
Rate for Payer: Cash Price	$488.80
Rate for Payer: Self Pay Self Pay	$488.80

DECALCIFICATION PROCEDURE

Facility

$611.00

Service Code	CPT 88311
Hospital Charge Code	22545717
Hospital Revenue Code	310
Min. Negotiated Rate	$97.76
Max. Negotiated Rate	$549.90
Rate for Payer: Aetna of AZ Commercial	$549.90
Rate for Payer: Aetna of AZ Medicare	$171.08
Rate for Payer: Allwell Medicare	$97.76
Rate for Payer: Amerigroup Medicare	$97.76
Rate for Payer: APIPA Medicare/Medicaid	$228.21
Rate for Payer: AZCH Complete Medicare	$97.76
Rate for Payer: Banner UC Health Medicare	$97.76
Rate for Payer: Bisbee Police All Plans	$158.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$415.48
Rate for Payer: Cash Price	$488.80
Rate for Payer: Cigna of AZ Commercial	$397.15
Rate for Payer: Copperpoint Commercial	$151.22
Rate for Payer: Health Net of AZ Commercial	$366.60
Rate for Payer: Health Net of AZ Medicare	$171.08
Rate for Payer: Humana of AZ Medicare	$97.76
Rate for Payer: Self Pay Self Pay	$488.80
Rate for Payer: TriWest Medicare	$97.76
Rate for Payer: UnitedHealth Group of AZ Commercial	$356.21
Rate for Payer: UnitedHealth Group of AZ Medicare	$109.98

Defibrillator Implants

Facility

$23,301.21

Service Code	APR-DRG 1791
Hospital Charge Code	APRDRG1793
Min. Negotiated Rate	$23,301.21
Max. Negotiated Rate	$23,301.21
Rate for Payer: AHCCCS Medicaid	$23,301.21
Rate for Payer: Allwell Medicaid	$23,301.21
Rate for Payer: AZCH Complete Medicaid	$23,301.21
Rate for Payer: Banner UC Health Medicaid	$23,301.21
Rate for Payer: Mercy Care Medicaid	$23,301.21

Defibrillator Implants

Facility

$32,110.79

Service Code	APR-DRG 1793
Hospital Charge Code	APRDRG1792
Min. Negotiated Rate	$32,110.79
Max. Negotiated Rate	$32,110.79
Rate for Payer: AHCCCS Medicaid	$32,110.79
Rate for Payer: Allwell Medicaid	$32,110.79
Rate for Payer: AZCH Complete Medicaid	$32,110.79
Rate for Payer: Banner UC Health Medicaid	$32,110.79
Rate for Payer: Mercy Care Medicaid	$32,110.79

Defibrillator Implants

Facility

$26,401.40

Service Code	APR-DRG 1792
Hospital Charge Code	APRDRG1793
Min. Negotiated Rate	$26,401.40
Max. Negotiated Rate	$26,401.40
Rate for Payer: AHCCCS Medicaid	$26,401.40
Rate for Payer: Allwell Medicaid	$26,401.40
Rate for Payer: AZCH Complete Medicaid	$26,401.40
Rate for Payer: Banner UC Health Medicaid	$26,401.40
Rate for Payer: Mercy Care Medicaid	$26,401.40

Defibrillator Implants

Facility

$32,110.79

Service Code	APR-DRG 1793
Hospital Charge Code	APRDRG1793
Min. Negotiated Rate	$32,110.79
Max. Negotiated Rate	$32,110.79
Rate for Payer: AHCCCS Medicaid	$32,110.79
Rate for Payer: Allwell Medicaid	$32,110.79
Rate for Payer: AZCH Complete Medicaid	$32,110.79
Rate for Payer: Banner UC Health Medicaid	$32,110.79
Rate for Payer: Mercy Care Medicaid	$32,110.79

Know your out-of-pocket cost for care.

All Charges