Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

diclofenac topical 1% Gel[CQCH]

Facility

$0.17

Service Code	NDC 67815202
Hospital Charge Code	139707016
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	$0.13
Rate for Payer: Self Pay Self Pay	$0.14

dicyclomine 10 mg Cap [CQCH]

Facility

$0.48

Service Code	NDC 60687036901
Hospital Charge Code	105918834
Hospital Revenue Code	251
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of AZ Commercial	$0.43
Rate for Payer: Bisbee Police All Plans	$0.12
Rate for Payer: Cash Price	$0.38
Rate for Payer: Self Pay Self Pay	$0.38

dicyclomine 10 mg Cap [CQCH]

Facility

$0.48

Service Code	NDC 60687036901
Hospital Charge Code	105918834
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of AZ Commercial	$0.43
Rate for Payer: Aetna of AZ Medicare	$0.13
Rate for Payer: Allwell Medicare	$0.07
Rate for Payer: Amerigroup Medicare	$0.07
Rate for Payer: APIPA Medicare/Medicaid	$0.18
Rate for Payer: AZCH Complete Medicare	$0.07
Rate for Payer: Banner UC Health Medicare	$0.07
Rate for Payer: Bisbee Police All Plans	$0.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.33
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cigna of AZ Commercial	$0.31
Rate for Payer: Copperpoint Commercial	$0.12
Rate for Payer: Health Net of AZ Commercial	$0.29
Rate for Payer: Health Net of AZ Medicare	$0.13
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Self Pay Self Pay	$0.38
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.09

dicyclomine 20 mg Inj Sol [CQCH]

Facility

$34.46

Service Code	HCPCS J0500
Hospital Charge Code	105918763
Hospital Revenue Code	250
Min. Negotiated Rate	$8.96
Max. Negotiated Rate	$31.01
Rate for Payer: Aetna of AZ Commercial	$31.01
Rate for Payer: Bisbee Police All Plans	$8.96
Rate for Payer: Cash Price	$27.57
Rate for Payer: Self Pay Self Pay	$27.57

dicyclomine 20 mg Inj Sol [CQCH]

Facility

$34.46

Service Code	HCPCS J0500
Hospital Charge Code	105918763
Hospital Revenue Code	250
Min. Negotiated Rate	$5.17
Max. Negotiated Rate	$45.96
Rate for Payer: Aetna of AZ Commercial	$31.01
Rate for Payer: Aetna of AZ Medicare	$9.65
Rate for Payer: AHCCCS Medicaid	$45.96
Rate for Payer: Allwell Medicaid	$45.96
Rate for Payer: Allwell Medicare	$5.17
Rate for Payer: Amerigroup Medicare	$5.17
Rate for Payer: APIPA Medicare/Medicaid	$12.87
Rate for Payer: AZCH Complete Medicaid	$45.96
Rate for Payer: AZCH Complete Medicare	$5.17
Rate for Payer: Banner UC Health Medicaid	$45.96
Rate for Payer: Banner UC Health Medicare	$5.17
Rate for Payer: Bisbee Police All Plans	$8.96
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$23.43
Rate for Payer: Cash Price	$27.57
Rate for Payer: Cash Price	$27.57
Rate for Payer: Cigna of AZ Commercial	$22.40
Rate for Payer: Copperpoint Commercial	$8.53
Rate for Payer: Health Net of AZ Commercial	$20.68
Rate for Payer: Health Net of AZ Medicare	$9.65
Rate for Payer: Humana of AZ Medicare	$5.17
Rate for Payer: Mercy Care Medicaid	$45.96
Rate for Payer: Self Pay Self Pay	$27.57
Rate for Payer: TriWest Medicare	$5.17
Rate for Payer: UnitedHealth Group of AZ Commercial	$20.09
Rate for Payer: UnitedHealth Group of AZ Medicare	$6.20

Digestive Malignancy

Facility

$15,754.85

Service Code	APR-DRG 2404
Hospital Charge Code	APRDRG2402
Min. Negotiated Rate	$15,754.85
Max. Negotiated Rate	$15,754.85
Rate for Payer: AHCCCS Medicaid	$15,754.85
Rate for Payer: Allwell Medicaid	$15,754.85
Rate for Payer: AZCH Complete Medicaid	$15,754.85
Rate for Payer: Banner UC Health Medicaid	$15,754.85
Rate for Payer: Mercy Care Medicaid	$15,754.85

Digestive Malignancy

Facility

$15,754.85

Service Code	APR-DRG 2404
Hospital Charge Code	APRDRG2401
Min. Negotiated Rate	$15,754.85
Max. Negotiated Rate	$15,754.85
Rate for Payer: AHCCCS Medicaid	$15,754.85
Rate for Payer: Allwell Medicaid	$15,754.85
Rate for Payer: AZCH Complete Medicaid	$15,754.85
Rate for Payer: Banner UC Health Medicaid	$15,754.85
Rate for Payer: Mercy Care Medicaid	$15,754.85

Digestive Malignancy

Facility

$15,754.85

Service Code	APR-DRG 2404
Hospital Charge Code	APRDRG2404
Min. Negotiated Rate	$15,754.85
Max. Negotiated Rate	$15,754.85
Rate for Payer: AHCCCS Medicaid	$15,754.85
Rate for Payer: Allwell Medicaid	$15,754.85
Rate for Payer: AZCH Complete Medicaid	$15,754.85
Rate for Payer: Banner UC Health Medicaid	$15,754.85
Rate for Payer: Mercy Care Medicaid	$15,754.85

Digestive Malignancy

Facility

$8,453.27

Service Code	APR-DRG 2403
Hospital Charge Code	APRDRG2403
Min. Negotiated Rate	$8,453.27
Max. Negotiated Rate	$8,453.27
Rate for Payer: AHCCCS Medicaid	$8,453.27
Rate for Payer: Allwell Medicaid	$8,453.27
Rate for Payer: AZCH Complete Medicaid	$8,453.27
Rate for Payer: Banner UC Health Medicaid	$8,453.27
Rate for Payer: Mercy Care Medicaid	$8,453.27

Digestive Malignancy

Facility

$15,754.85

Service Code	APR-DRG 2404
Hospital Charge Code	APRDRG2403
Min. Negotiated Rate	$15,754.85
Max. Negotiated Rate	$15,754.85
Rate for Payer: AHCCCS Medicaid	$15,754.85
Rate for Payer: Allwell Medicaid	$15,754.85
Rate for Payer: AZCH Complete Medicaid	$15,754.85
Rate for Payer: Banner UC Health Medicaid	$15,754.85
Rate for Payer: Mercy Care Medicaid	$15,754.85

Digestive Malignancy

Facility

$8,453.27

Service Code	APR-DRG 2403
Hospital Charge Code	APRDRG2402
Min. Negotiated Rate	$8,453.27
Max. Negotiated Rate	$8,453.27
Rate for Payer: AHCCCS Medicaid	$8,453.27
Rate for Payer: Allwell Medicaid	$8,453.27
Rate for Payer: AZCH Complete Medicaid	$8,453.27
Rate for Payer: Banner UC Health Medicaid	$8,453.27
Rate for Payer: Mercy Care Medicaid	$8,453.27

Digestive Malignancy

Facility

$5,986.45

Service Code	APR-DRG 2402
Hospital Charge Code	APRDRG2401
Min. Negotiated Rate	$5,986.45
Max. Negotiated Rate	$5,986.45
Rate for Payer: AHCCCS Medicaid	$5,986.45
Rate for Payer: Allwell Medicaid	$5,986.45
Rate for Payer: AZCH Complete Medicaid	$5,986.45
Rate for Payer: Banner UC Health Medicaid	$5,986.45
Rate for Payer: Mercy Care Medicaid	$5,986.45

Digestive Malignancy

Facility

$5,986.45

Service Code	APR-DRG 2402
Hospital Charge Code	APRDRG2404
Min. Negotiated Rate	$5,986.45
Max. Negotiated Rate	$5,986.45
Rate for Payer: AHCCCS Medicaid	$5,986.45
Rate for Payer: Allwell Medicaid	$5,986.45
Rate for Payer: AZCH Complete Medicaid	$5,986.45
Rate for Payer: Banner UC Health Medicaid	$5,986.45
Rate for Payer: Mercy Care Medicaid	$5,986.45

Digestive Malignancy

Facility

$5,198.78

Service Code	APR-DRG 2401
Hospital Charge Code	APRDRG2403
Min. Negotiated Rate	$5,198.78
Max. Negotiated Rate	$5,198.78
Rate for Payer: AHCCCS Medicaid	$5,198.78
Rate for Payer: Allwell Medicaid	$5,198.78
Rate for Payer: AZCH Complete Medicaid	$5,198.78
Rate for Payer: Banner UC Health Medicaid	$5,198.78
Rate for Payer: Mercy Care Medicaid	$5,198.78

Digestive Malignancy

Facility

$5,198.78

Service Code	APR-DRG 2401
Hospital Charge Code	APRDRG2401
Min. Negotiated Rate	$5,198.78
Max. Negotiated Rate	$5,198.78
Rate for Payer: AHCCCS Medicaid	$5,198.78
Rate for Payer: Allwell Medicaid	$5,198.78
Rate for Payer: AZCH Complete Medicaid	$5,198.78
Rate for Payer: Banner UC Health Medicaid	$5,198.78
Rate for Payer: Mercy Care Medicaid	$5,198.78

Digestive Malignancy

Facility

$5,986.45

Service Code	APR-DRG 2402
Hospital Charge Code	APRDRG2403
Min. Negotiated Rate	$5,986.45
Max. Negotiated Rate	$5,986.45
Rate for Payer: AHCCCS Medicaid	$5,986.45
Rate for Payer: Allwell Medicaid	$5,986.45
Rate for Payer: AZCH Complete Medicaid	$5,986.45
Rate for Payer: Banner UC Health Medicaid	$5,986.45
Rate for Payer: Mercy Care Medicaid	$5,986.45

Digestive Malignancy

Facility

$8,453.27

Service Code	APR-DRG 2403
Hospital Charge Code	APRDRG2404
Min. Negotiated Rate	$8,453.27
Max. Negotiated Rate	$8,453.27
Rate for Payer: AHCCCS Medicaid	$8,453.27
Rate for Payer: Allwell Medicaid	$8,453.27
Rate for Payer: AZCH Complete Medicaid	$8,453.27
Rate for Payer: Banner UC Health Medicaid	$8,453.27
Rate for Payer: Mercy Care Medicaid	$8,453.27

Digestive Malignancy

Facility

$5,986.45

Service Code	APR-DRG 2402
Hospital Charge Code	APRDRG2402
Min. Negotiated Rate	$5,986.45
Max. Negotiated Rate	$5,986.45
Rate for Payer: AHCCCS Medicaid	$5,986.45
Rate for Payer: Allwell Medicaid	$5,986.45
Rate for Payer: AZCH Complete Medicaid	$5,986.45
Rate for Payer: Banner UC Health Medicaid	$5,986.45
Rate for Payer: Mercy Care Medicaid	$5,986.45

Digestive Malignancy

Facility

$8,453.27

Service Code	APR-DRG 2403
Hospital Charge Code	APRDRG2401
Min. Negotiated Rate	$8,453.27
Max. Negotiated Rate	$8,453.27
Rate for Payer: AHCCCS Medicaid	$8,453.27
Rate for Payer: Allwell Medicaid	$8,453.27
Rate for Payer: AZCH Complete Medicaid	$8,453.27
Rate for Payer: Banner UC Health Medicaid	$8,453.27
Rate for Payer: Mercy Care Medicaid	$8,453.27

Digestive Malignancy

Facility

$5,198.78

Service Code	APR-DRG 2401
Hospital Charge Code	APRDRG2404
Min. Negotiated Rate	$5,198.78
Max. Negotiated Rate	$5,198.78
Rate for Payer: AHCCCS Medicaid	$5,198.78
Rate for Payer: Allwell Medicaid	$5,198.78
Rate for Payer: AZCH Complete Medicaid	$5,198.78
Rate for Payer: Banner UC Health Medicaid	$5,198.78
Rate for Payer: Mercy Care Medicaid	$5,198.78

Digestive Malignancy

Facility

$5,198.78

Service Code	APR-DRG 2401
Hospital Charge Code	APRDRG2402
Min. Negotiated Rate	$5,198.78
Max. Negotiated Rate	$5,198.78
Rate for Payer: AHCCCS Medicaid	$5,198.78
Rate for Payer: Allwell Medicaid	$5,198.78
Rate for Payer: AZCH Complete Medicaid	$5,198.78
Rate for Payer: Banner UC Health Medicaid	$5,198.78
Rate for Payer: Mercy Care Medicaid	$5,198.78

DIGIFUSE GUIDE WIRE SMOOTH .80 X 70MM

Facility

$89.00

Hospital Charge Code	24127791
Hospital Revenue Code	270
Min. Negotiated Rate	$13.35
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of AZ Commercial	$80.10
Rate for Payer: Aetna of AZ Medicare	$24.92
Rate for Payer: Allwell Medicare	$13.35
Rate for Payer: Amerigroup Medicare	$13.35
Rate for Payer: APIPA Medicare/Medicaid	$33.24
Rate for Payer: AZCH Complete Medicare	$13.35
Rate for Payer: Banner UC Health Medicare	$13.35
Rate for Payer: Bisbee Police All Plans	$23.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$60.52
Rate for Payer: Cash Price	$71.20
Rate for Payer: Cigna of AZ Commercial	$62.30
Rate for Payer: Copperpoint Commercial	$22.03
Rate for Payer: Health Net of AZ Commercial	$53.40
Rate for Payer: Health Net of AZ Medicare	$24.92
Rate for Payer: Humana of AZ Medicare	$13.35
Rate for Payer: Self Pay Self Pay	$71.20
Rate for Payer: TriWest Medicare	$13.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$51.89
Rate for Payer: UnitedHealth Group of AZ Medicare	$16.02

DIGIFUSE GUIDE WIRE SMOOTH .80 X 70MM

Facility

$89.00

Hospital Charge Code	24127791
Hospital Revenue Code	270
Min. Negotiated Rate	$23.14
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of AZ Commercial	$80.10
Rate for Payer: Bisbee Police All Plans	$23.14
Rate for Payer: Cash Price	$71.20
Rate for Payer: Self Pay Self Pay	$71.20

DIGIFUSE IMPLANT 2.0MM 0 DEGREE ANGLE

Facility

$5,757.00

Hospital Charge Code	24127789
Hospital Revenue Code	270
Min. Negotiated Rate	$1,496.82
Max. Negotiated Rate	$5,181.30
Rate for Payer: Aetna of AZ Commercial	$5,181.30
Rate for Payer: Bisbee Police All Plans	$1,496.82
Rate for Payer: Cash Price	$4,605.60
Rate for Payer: Self Pay Self Pay	$4,605.60

DIGIFUSE IMPLANT 2.0MM 0 DEGREE ANGLE

Facility

$5,757.00

Hospital Charge Code	24127789
Hospital Revenue Code	270
Min. Negotiated Rate	$863.55
Max. Negotiated Rate	$5,181.30
Rate for Payer: Aetna of AZ Commercial	$5,181.30
Rate for Payer: Aetna of AZ Medicare	$1,611.96
Rate for Payer: Allwell Medicare	$863.55
Rate for Payer: Amerigroup Medicare	$863.55
Rate for Payer: APIPA Medicare/Medicaid	$2,150.24
Rate for Payer: AZCH Complete Medicare	$863.55
Rate for Payer: Banner UC Health Medicare	$863.55
Rate for Payer: Bisbee Police All Plans	$1,496.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,914.76
Rate for Payer: Cash Price	$4,605.60
Rate for Payer: Cigna of AZ Commercial	$4,029.90
Rate for Payer: Copperpoint Commercial	$1,424.86
Rate for Payer: Health Net of AZ Commercial	$3,454.20
Rate for Payer: Health Net of AZ Medicare	$1,611.96
Rate for Payer: Humana of AZ Medicare	$863.55
Rate for Payer: Self Pay Self Pay	$4,605.60
Rate for Payer: TriWest Medicare	$863.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,356.33
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,036.26

Know your out-of-pocket cost for care.

All Charges