Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

doxepin 25 mg Cap [CQCH]

Facility

$0.37

Service Code	NDC 51079043720
Hospital Charge Code	105920044
Hospital Revenue Code	251
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna of AZ Commercial	$0.33
Rate for Payer: Bisbee Police All Plans	$0.10
Rate for Payer: Cash Price	$0.30
Rate for Payer: Self Pay Self Pay	$0.30

doxepin 25 mg Cap [CQCH]

Facility

$0.37

Service Code	NDC 51079043720
Hospital Charge Code	105920044
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna of AZ Commercial	$0.33
Rate for Payer: Aetna of AZ Medicare	$0.10
Rate for Payer: Allwell Medicare	$0.06
Rate for Payer: Amerigroup Medicare	$0.06
Rate for Payer: APIPA Medicare/Medicaid	$0.14
Rate for Payer: AZCH Complete Medicare	$0.06
Rate for Payer: Banner UC Health Medicare	$0.06
Rate for Payer: Bisbee Police All Plans	$0.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.25
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cigna of AZ Commercial	$0.24
Rate for Payer: Copperpoint Commercial	$0.09
Rate for Payer: Health Net of AZ Commercial	$0.22
Rate for Payer: Health Net of AZ Medicare	$0.10
Rate for Payer: Humana of AZ Medicare	$0.06
Rate for Payer: Self Pay Self Pay	$0.30
Rate for Payer: TriWest Medicare	$0.06
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.22
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.07

doxycycline 100 mg IV Inj [CQCH]

Facility

$17.21

Service Code	NDC 63323013017
Hospital Charge Code	105920170
Hospital Revenue Code	251
Min. Negotiated Rate	$4.47
Max. Negotiated Rate	$15.49
Rate for Payer: Aetna of AZ Commercial	$15.49
Rate for Payer: Bisbee Police All Plans	$4.47
Rate for Payer: Cash Price	$13.77
Rate for Payer: Self Pay Self Pay	$13.77

doxycycline 100 mg IV Inj [CQCH]

Facility

$17.21

Service Code	NDC 63323013017
Hospital Charge Code	105920170
Hospital Revenue Code	251
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$15.49
Rate for Payer: Aetna of AZ Commercial	$15.49
Rate for Payer: Aetna of AZ Medicare	$4.82
Rate for Payer: Allwell Medicare	$2.75
Rate for Payer: Amerigroup Medicare	$2.75
Rate for Payer: APIPA Medicare/Medicaid	$6.43
Rate for Payer: AZCH Complete Medicare	$2.75
Rate for Payer: Banner UC Health Medicare	$2.75
Rate for Payer: Bisbee Police All Plans	$4.47
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$11.70
Rate for Payer: Cash Price	$13.77
Rate for Payer: Cigna of AZ Commercial	$11.19
Rate for Payer: Copperpoint Commercial	$4.26
Rate for Payer: Health Net of AZ Commercial	$10.33
Rate for Payer: Health Net of AZ Medicare	$4.82
Rate for Payer: Humana of AZ Medicare	$2.75
Rate for Payer: Self Pay Self Pay	$13.77
Rate for Payer: TriWest Medicare	$2.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$10.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.10

doxycycline 100 mg Tab UD [CQCH]

Facility

$1.09

Service Code	NDC 904043006
Hospital Charge Code	108072609
Hospital Revenue Code	250
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of AZ Commercial	$0.98
Rate for Payer: Bisbee Police All Plans	$0.28
Rate for Payer: Cash Price	$0.87
Rate for Payer: Self Pay Self Pay	$0.87

doxycycline 100 mg Tab UD [CQCH]

Facility

$1.09

Service Code	NDC 904043006
Hospital Charge Code	108072609
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of AZ Commercial	$0.98
Rate for Payer: Aetna of AZ Medicare	$0.31
Rate for Payer: Allwell Medicare	$0.17
Rate for Payer: Amerigroup Medicare	$0.17
Rate for Payer: APIPA Medicare/Medicaid	$0.41
Rate for Payer: AZCH Complete Medicare	$0.17
Rate for Payer: Banner UC Health Medicare	$0.17
Rate for Payer: Bisbee Police All Plans	$0.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.74
Rate for Payer: Cash Price	$0.87
Rate for Payer: Cigna of AZ Commercial	$0.71
Rate for Payer: Copperpoint Commercial	$0.27
Rate for Payer: Health Net of AZ Commercial	$0.65
Rate for Payer: Health Net of AZ Medicare	$0.31
Rate for Payer: Humana of AZ Medicare	$0.17
Rate for Payer: Self Pay Self Pay	$0.87
Rate for Payer: TriWest Medicare	$0.17
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.64
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.20

Drainage of Ovarian Cyst abd

Facility

$2,321.00

Service Code	CPT 58805
Hospital Charge Code	27281893
Hospital Revenue Code	360
Min. Negotiated Rate	$603.46
Max. Negotiated Rate	$2,088.90
Rate for Payer: Aetna of AZ Commercial	$2,088.90
Rate for Payer: Bisbee Police All Plans	$603.46
Rate for Payer: Cash Price	$1,856.80
Rate for Payer: Self Pay Self Pay	$1,856.80

Drainage of Ovarian Cyst abd

Facility

$2,321.00

Service Code	CPT 58805
Hospital Charge Code	27281893
Hospital Revenue Code	360
Min. Negotiated Rate	$371.36
Max. Negotiated Rate	$3,373.00
Rate for Payer: Aetna of AZ Commercial	$2,088.90
Rate for Payer: Aetna of AZ Medicare	$649.88
Rate for Payer: AHCCCS Medicaid	$1,901.83
Rate for Payer: Allwell Medicaid	$1,901.83
Rate for Payer: Allwell Medicare	$371.36
Rate for Payer: Amerigroup Medicare	$371.36
Rate for Payer: APIPA Medicare/Medicaid	$866.89
Rate for Payer: AZCH Complete Medicaid	$1,901.83
Rate for Payer: AZCH Complete Medicare	$371.36
Rate for Payer: Banner UC Health Medicaid	$1,901.83
Rate for Payer: Banner UC Health Medicare	$371.36
Rate for Payer: Bisbee Police All Plans	$603.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,578.28
Rate for Payer: Cash Price	$1,856.80
Rate for Payer: Cash Price	$1,856.80
Rate for Payer: Cigna of AZ Commercial	$1,160.50
Rate for Payer: Copperpoint Commercial	$574.45
Rate for Payer: Health Net of AZ Commercial	$1,392.60
Rate for Payer: Health Net of AZ Medicare	$649.88
Rate for Payer: Humana of AZ Medicare	$371.36
Rate for Payer: Mercy Care Medicaid	$1,901.83
Rate for Payer: Self Pay Self Pay	$1,856.80
Rate for Payer: TriWest Medicare	$371.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,373.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$417.78

Drainage of Ovariona Abscess abd

Facility

$3,896.00

Service Code	CPT 58822
Hospital Charge Code	27281894
Hospital Revenue Code	360
Min. Negotiated Rate	$623.36
Max. Negotiated Rate	$3,506.40
Rate for Payer: Aetna of AZ Commercial	$3,506.40
Rate for Payer: Aetna of AZ Medicare	$1,090.88
Rate for Payer: Allwell Medicare	$623.36
Rate for Payer: Amerigroup Medicare	$623.36
Rate for Payer: APIPA Medicare/Medicaid	$1,455.16
Rate for Payer: AZCH Complete Medicare	$623.36
Rate for Payer: Banner UC Health Medicare	$623.36
Rate for Payer: Bisbee Police All Plans	$1,012.96
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,649.28
Rate for Payer: Cash Price	$3,116.80
Rate for Payer: Cigna of AZ Commercial	$1,948.00
Rate for Payer: Copperpoint Commercial	$964.26
Rate for Payer: Health Net of AZ Commercial	$2,337.60
Rate for Payer: Health Net of AZ Medicare	$1,090.88
Rate for Payer: Humana of AZ Medicare	$623.36
Rate for Payer: Self Pay Self Pay	$3,116.80
Rate for Payer: TriWest Medicare	$623.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,271.37
Rate for Payer: UnitedHealth Group of AZ Medicare	$701.28

Drainage of Ovariona Abscess abd

Facility

$3,896.00

Service Code	CPT 58822
Hospital Charge Code	27281894
Hospital Revenue Code	360
Min. Negotiated Rate	$1,012.96
Max. Negotiated Rate	$3,506.40
Rate for Payer: Aetna of AZ Commercial	$3,506.40
Rate for Payer: Bisbee Police All Plans	$1,012.96
Rate for Payer: Cash Price	$3,116.80
Rate for Payer: Self Pay Self Pay	$3,116.80

Drainage of Pelvic Abscess

Facility

$700.00

Service Code	CPT 10030
Hospital Charge Code	27267827
Hospital Revenue Code	360
Min. Negotiated Rate	$112.00
Max. Negotiated Rate	$2,507.00
Rate for Payer: Aetna of AZ Commercial	$630.00
Rate for Payer: Aetna of AZ Medicare	$196.00
Rate for Payer: AHCCCS Medicaid	$450.93
Rate for Payer: Allwell Medicaid	$450.93
Rate for Payer: Allwell Medicare	$112.00
Rate for Payer: Amerigroup Medicare	$112.00
Rate for Payer: APIPA Medicare/Medicaid	$261.45
Rate for Payer: AZCH Complete Medicaid	$450.93
Rate for Payer: AZCH Complete Medicare	$112.00
Rate for Payer: Banner UC Health Medicaid	$450.93
Rate for Payer: Banner UC Health Medicare	$112.00
Rate for Payer: Bisbee Police All Plans	$182.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$476.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Cigna of AZ Commercial	$350.00
Rate for Payer: Copperpoint Commercial	$173.25
Rate for Payer: Health Net of AZ Commercial	$420.00
Rate for Payer: Health Net of AZ Medicare	$196.00
Rate for Payer: Humana of AZ Medicare	$112.00
Rate for Payer: Mercy Care Medicaid	$450.93
Rate for Payer: Self Pay Self Pay	$560.00
Rate for Payer: TriWest Medicare	$112.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,507.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$126.00

Drainage of Pelvic Abscess

Facility

$700.00

Service Code	CPT 10030
Hospital Charge Code	27267827
Hospital Revenue Code	360
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna of AZ Commercial	$630.00
Rate for Payer: Bisbee Police All Plans	$182.00
Rate for Payer: Cash Price	$560.00
Rate for Payer: Self Pay Self Pay	$560.00

DRAIN HEMO 1/4-INCH X-LARGE

Facility

$225.00

Hospital Charge Code	22354952
Hospital Revenue Code	270
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$202.50
Rate for Payer: Aetna of AZ Commercial	$202.50
Rate for Payer: Bisbee Police All Plans	$58.50
Rate for Payer: Cash Price	$180.00
Rate for Payer: Self Pay Self Pay	$180.00

DRAIN HEMO 1/4-INCH X-LARGE

Facility

$225.00

Hospital Charge Code	22354952
Hospital Revenue Code	270
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$202.50
Rate for Payer: Aetna of AZ Commercial	$202.50
Rate for Payer: Aetna of AZ Medicare	$63.00
Rate for Payer: Allwell Medicare	$36.00
Rate for Payer: Amerigroup Medicare	$36.00
Rate for Payer: APIPA Medicare/Medicaid	$84.04
Rate for Payer: AZCH Complete Medicare	$36.00
Rate for Payer: Banner UC Health Medicare	$36.00
Rate for Payer: Bisbee Police All Plans	$58.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$153.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cigna of AZ Commercial	$157.50
Rate for Payer: Copperpoint Commercial	$55.69
Rate for Payer: Health Net of AZ Commercial	$135.00
Rate for Payer: Health Net of AZ Medicare	$63.00
Rate for Payer: Humana of AZ Medicare	$36.00
Rate for Payer: Self Pay Self Pay	$180.00
Rate for Payer: TriWest Medicare	$36.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$131.18
Rate for Payer: UnitedHealth Group of AZ Medicare	$40.50

DRAIN HEMO 1/8-INCH MEDIUM

Facility

$66.00

Hospital Charge Code	22354963
Hospital Revenue Code	270
Min. Negotiated Rate	$17.16
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of AZ Commercial	$59.40
Rate for Payer: Bisbee Police All Plans	$17.16
Rate for Payer: Cash Price	$52.80
Rate for Payer: Self Pay Self Pay	$52.80

DRAIN HEMO 1/8-INCH MEDIUM

Facility

$66.00

Hospital Charge Code	22354963
Hospital Revenue Code	270
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of AZ Commercial	$59.40
Rate for Payer: Aetna of AZ Medicare	$18.48
Rate for Payer: Allwell Medicare	$10.56
Rate for Payer: Amerigroup Medicare	$10.56
Rate for Payer: APIPA Medicare/Medicaid	$24.65
Rate for Payer: AZCH Complete Medicare	$10.56
Rate for Payer: Banner UC Health Medicare	$10.56
Rate for Payer: Bisbee Police All Plans	$17.16
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$44.88
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cigna of AZ Commercial	$46.20
Rate for Payer: Copperpoint Commercial	$16.34
Rate for Payer: Health Net of AZ Commercial	$39.60
Rate for Payer: Health Net of AZ Medicare	$18.48
Rate for Payer: Humana of AZ Medicare	$10.56
Rate for Payer: Self Pay Self Pay	$52.80
Rate for Payer: TriWest Medicare	$10.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$38.48
Rate for Payer: UnitedHealth Group of AZ Medicare	$11.88

DRAIN HEMO 3/16-INCH LARGE

Facility

$225.00

Hospital Charge Code	22354950
Hospital Revenue Code	270
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$202.50
Rate for Payer: Aetna of AZ Commercial	$202.50
Rate for Payer: Bisbee Police All Plans	$58.50
Rate for Payer: Cash Price	$180.00
Rate for Payer: Self Pay Self Pay	$180.00

DRAIN HEMO 3/16-INCH LARGE

Facility

$225.00

Hospital Charge Code	22354950
Hospital Revenue Code	270
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$202.50
Rate for Payer: Aetna of AZ Commercial	$202.50
Rate for Payer: Aetna of AZ Medicare	$63.00
Rate for Payer: Allwell Medicare	$36.00
Rate for Payer: Amerigroup Medicare	$36.00
Rate for Payer: APIPA Medicare/Medicaid	$84.04
Rate for Payer: AZCH Complete Medicare	$36.00
Rate for Payer: Banner UC Health Medicare	$36.00
Rate for Payer: Bisbee Police All Plans	$58.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$153.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cigna of AZ Commercial	$157.50
Rate for Payer: Copperpoint Commercial	$55.69
Rate for Payer: Health Net of AZ Commercial	$135.00
Rate for Payer: Health Net of AZ Medicare	$63.00
Rate for Payer: Humana of AZ Medicare	$36.00
Rate for Payer: Self Pay Self Pay	$180.00
Rate for Payer: TriWest Medicare	$36.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$131.18
Rate for Payer: UnitedHealth Group of AZ Medicare	$40.50

DRAIN HEMO 3/32-INCH SMALL

Facility

$70.00

Hospital Charge Code	22354949
Hospital Revenue Code	270
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	$49.00
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

DRAIN HEMO 3/32-INCH SMALL

Facility

$70.00

Hospital Charge Code	22354949
Hospital Revenue Code	270
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

DRAIN JP FLAT SUCT 10MM

Facility

$106.00

Hospital Charge Code	22354938
Hospital Revenue Code	270
Min. Negotiated Rate	$27.56
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of AZ Commercial	$95.40
Rate for Payer: Bisbee Police All Plans	$27.56
Rate for Payer: Cash Price	$84.80
Rate for Payer: Self Pay Self Pay	$84.80

DRAIN JP FLAT SUCT 10MM

Facility

$106.00

Hospital Charge Code	22354938
Hospital Revenue Code	270
Min. Negotiated Rate	$16.96
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of AZ Commercial	$95.40
Rate for Payer: Aetna of AZ Medicare	$29.68
Rate for Payer: Allwell Medicare	$16.96
Rate for Payer: Amerigroup Medicare	$16.96
Rate for Payer: APIPA Medicare/Medicaid	$39.59
Rate for Payer: AZCH Complete Medicare	$16.96
Rate for Payer: Banner UC Health Medicare	$16.96
Rate for Payer: Bisbee Police All Plans	$27.56
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$72.08
Rate for Payer: Cash Price	$84.80
Rate for Payer: Cigna of AZ Commercial	$74.20
Rate for Payer: Copperpoint Commercial	$26.23
Rate for Payer: Health Net of AZ Commercial	$63.60
Rate for Payer: Health Net of AZ Medicare	$29.68
Rate for Payer: Humana of AZ Medicare	$16.96
Rate for Payer: Self Pay Self Pay	$84.80
Rate for Payer: TriWest Medicare	$16.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$61.80
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.08

DRAIN JP FLAT SUCT 7MM

Facility

$106.00

Hospital Charge Code	22354937
Hospital Revenue Code	270
Min. Negotiated Rate	$27.56
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of AZ Commercial	$95.40
Rate for Payer: Bisbee Police All Plans	$27.56
Rate for Payer: Cash Price	$84.80
Rate for Payer: Self Pay Self Pay	$84.80

DRAIN JP FLAT SUCT 7MM

Facility

$106.00

Hospital Charge Code	22354937
Hospital Revenue Code	270
Min. Negotiated Rate	$16.96
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of AZ Commercial	$95.40
Rate for Payer: Aetna of AZ Medicare	$29.68
Rate for Payer: Allwell Medicare	$16.96
Rate for Payer: Amerigroup Medicare	$16.96
Rate for Payer: APIPA Medicare/Medicaid	$39.59
Rate for Payer: AZCH Complete Medicare	$16.96
Rate for Payer: Banner UC Health Medicare	$16.96
Rate for Payer: Bisbee Police All Plans	$27.56
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$72.08
Rate for Payer: Cash Price	$84.80
Rate for Payer: Cigna of AZ Commercial	$74.20
Rate for Payer: Copperpoint Commercial	$26.23
Rate for Payer: Health Net of AZ Commercial	$63.60
Rate for Payer: Health Net of AZ Medicare	$29.68
Rate for Payer: Humana of AZ Medicare	$16.96
Rate for Payer: Self Pay Self Pay	$84.80
Rate for Payer: TriWest Medicare	$16.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$61.80
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.08

DRAIN JP SUCT RESRV

Facility

$116.00

Hospital Charge Code	22355431
Hospital Revenue Code	270
Min. Negotiated Rate	$30.16
Max. Negotiated Rate	$104.40
Rate for Payer: Aetna of AZ Commercial	$104.40
Rate for Payer: Bisbee Police All Plans	$30.16
Rate for Payer: Cash Price	$92.80
Rate for Payer: Self Pay Self Pay	$92.80

Know your out-of-pocket cost for care.

All Charges