Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

folic acid 1 mg Tab [CQCH]

Facility

$0.13

Service Code	NDC 62584089701
Hospital Charge Code	105923258
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Aetna of AZ Medicare	$0.04
Rate for Payer: Allwell Medicare	$0.02
Rate for Payer: Amerigroup Medicare	$0.02
Rate for Payer: APIPA Medicare/Medicaid	$0.05
Rate for Payer: AZCH Complete Medicare	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Bisbee Police All Plans	$0.03
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.09
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of AZ Commercial	$0.08
Rate for Payer: Copperpoint Commercial	$0.03
Rate for Payer: Health Net of AZ Commercial	$0.08
Rate for Payer: Health Net of AZ Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Self Pay Self Pay	$0.10
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.08
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.02

folic acid 5 mg/mL Inj Sol [CQCH]

Facility

$2.04

Service Code	NDC 39822110001
Hospital Charge Code	105923323
Hospital Revenue Code	251
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$1.84
Rate for Payer: Aetna of AZ Commercial	$1.84
Rate for Payer: Bisbee Police All Plans	$0.53
Rate for Payer: Cash Price	$1.63
Rate for Payer: Self Pay Self Pay	$1.63

folic acid 5 mg/mL Inj Sol [CQCH]

Facility

$2.04

Service Code	NDC 39822110001
Hospital Charge Code	105923323
Hospital Revenue Code	251
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$1.84
Rate for Payer: Aetna of AZ Commercial	$1.84
Rate for Payer: Aetna of AZ Medicare	$0.57
Rate for Payer: Allwell Medicare	$0.33
Rate for Payer: Amerigroup Medicare	$0.33
Rate for Payer: APIPA Medicare/Medicaid	$0.76
Rate for Payer: AZCH Complete Medicare	$0.33
Rate for Payer: Banner UC Health Medicare	$0.33
Rate for Payer: Bisbee Police All Plans	$0.53
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.39
Rate for Payer: Cash Price	$1.63
Rate for Payer: Cigna of AZ Commercial	$1.33
Rate for Payer: Copperpoint Commercial	$0.50
Rate for Payer: Health Net of AZ Commercial	$1.22
Rate for Payer: Health Net of AZ Medicare	$0.57
Rate for Payer: Humana of AZ Medicare	$0.33
Rate for Payer: Self Pay Self Pay	$1.63
Rate for Payer: TriWest Medicare	$0.33
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.37

Folic Acid(FOLATE)

Facility

$181.00

Service Code	CPT 82746
Hospital Charge Code	22540594
Hospital Revenue Code	301
Min. Negotiated Rate	$28.96
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Aetna of AZ Medicare	$50.68
Rate for Payer: Allwell Medicare	$28.96
Rate for Payer: Amerigroup Medicare	$28.96
Rate for Payer: APIPA Medicare/Medicaid	$67.60
Rate for Payer: AZCH Complete Medicare	$28.96
Rate for Payer: Banner UC Health Medicare	$28.96
Rate for Payer: Bisbee Police All Plans	$47.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$123.08
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cigna of AZ Commercial	$117.65
Rate for Payer: Copperpoint Commercial	$44.80
Rate for Payer: Health Net of AZ Commercial	$108.60
Rate for Payer: Health Net of AZ Medicare	$50.68
Rate for Payer: Humana of AZ Medicare	$28.96
Rate for Payer: Self Pay Self Pay	$144.80
Rate for Payer: TriWest Medicare	$28.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$105.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$32.58

Folic Acid(FOLATE)

Facility

$181.00

Service Code	CPT 82746
Hospital Charge Code	22540594
Hospital Revenue Code	301
Min. Negotiated Rate	$47.06
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Bisbee Police All Plans	$47.06
Rate for Payer: Cash Price	$144.80
Rate for Payer: Self Pay Self Pay	$144.80

Food Allergy Profile LC

Facility

$1,062.00

Service Code	CPT 86003
Hospital Charge Code	22201915
Hospital Revenue Code	302
Min. Negotiated Rate	$276.12
Max. Negotiated Rate	$955.80
Rate for Payer: Aetna of AZ Commercial	$955.80
Rate for Payer: Bisbee Police All Plans	$276.12
Rate for Payer: Cash Price	$849.60
Rate for Payer: Self Pay Self Pay	$849.60

Food Allergy Profile LC

Facility

$1,062.00

Service Code	CPT 86003
Hospital Charge Code	22201915
Hospital Revenue Code	302
Min. Negotiated Rate	$169.92
Max. Negotiated Rate	$955.80
Rate for Payer: Aetna of AZ Commercial	$955.80
Rate for Payer: Aetna of AZ Medicare	$297.36
Rate for Payer: Allwell Medicare	$169.92
Rate for Payer: Amerigroup Medicare	$169.92
Rate for Payer: APIPA Medicare/Medicaid	$396.66
Rate for Payer: AZCH Complete Medicare	$169.92
Rate for Payer: Banner UC Health Medicare	$169.92
Rate for Payer: Bisbee Police All Plans	$276.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$722.16
Rate for Payer: Cash Price	$849.60
Rate for Payer: Cigna of AZ Commercial	$690.30
Rate for Payer: Copperpoint Commercial	$262.85
Rate for Payer: Health Net of AZ Commercial	$637.20
Rate for Payer: Health Net of AZ Medicare	$297.36
Rate for Payer: Humana of AZ Medicare	$169.92
Rate for Payer: Self Pay Self Pay	$849.60
Rate for Payer: TriWest Medicare	$169.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$619.15
Rate for Payer: UnitedHealth Group of AZ Medicare	$191.16

Foot And Toe Procedures

Facility

$7,268.61

Service Code	APR-DRG 3141
Hospital Charge Code	APRDRG3142
Min. Negotiated Rate	$7,268.61
Max. Negotiated Rate	$7,268.61
Rate for Payer: AHCCCS Medicaid	$7,268.61
Rate for Payer: Allwell Medicaid	$7,268.61
Rate for Payer: AZCH Complete Medicaid	$7,268.61
Rate for Payer: Banner UC Health Medicaid	$7,268.61
Rate for Payer: Mercy Care Medicaid	$7,268.61

Foot And Toe Procedures

Facility

$21,326.77

Service Code	APR-DRG 3144
Hospital Charge Code	APRDRG3144
Min. Negotiated Rate	$21,326.77
Max. Negotiated Rate	$21,326.77
Rate for Payer: AHCCCS Medicaid	$21,326.77
Rate for Payer: Allwell Medicaid	$21,326.77
Rate for Payer: AZCH Complete Medicaid	$21,326.77
Rate for Payer: Banner UC Health Medicaid	$21,326.77
Rate for Payer: Mercy Care Medicaid	$21,326.77

Foot And Toe Procedures

Facility

$11,056.87

Service Code	APR-DRG 3143
Hospital Charge Code	APRDRG3144
Min. Negotiated Rate	$11,056.87
Max. Negotiated Rate	$11,056.87
Rate for Payer: AHCCCS Medicaid	$11,056.87
Rate for Payer: Allwell Medicaid	$11,056.87
Rate for Payer: AZCH Complete Medicaid	$11,056.87
Rate for Payer: Banner UC Health Medicaid	$11,056.87
Rate for Payer: Mercy Care Medicaid	$11,056.87

Foot And Toe Procedures

Facility

$11,056.87

Service Code	APR-DRG 3143
Hospital Charge Code	APRDRG3142
Min. Negotiated Rate	$11,056.87
Max. Negotiated Rate	$11,056.87
Rate for Payer: AHCCCS Medicaid	$11,056.87
Rate for Payer: Allwell Medicaid	$11,056.87
Rate for Payer: AZCH Complete Medicaid	$11,056.87
Rate for Payer: Banner UC Health Medicaid	$11,056.87
Rate for Payer: Mercy Care Medicaid	$11,056.87

Foot And Toe Procedures

Facility

$7,850.07

Service Code	APR-DRG 3142
Hospital Charge Code	APRDRG3144
Min. Negotiated Rate	$7,850.07
Max. Negotiated Rate	$7,850.07
Rate for Payer: AHCCCS Medicaid	$7,850.07
Rate for Payer: Allwell Medicaid	$7,850.07
Rate for Payer: AZCH Complete Medicaid	$7,850.07
Rate for Payer: Banner UC Health Medicaid	$7,850.07
Rate for Payer: Mercy Care Medicaid	$7,850.07

Foot And Toe Procedures

Facility

$21,326.77

Service Code	APR-DRG 3144
Hospital Charge Code	APRDRG3143
Min. Negotiated Rate	$21,326.77
Max. Negotiated Rate	$21,326.77
Rate for Payer: AHCCCS Medicaid	$21,326.77
Rate for Payer: Allwell Medicaid	$21,326.77
Rate for Payer: AZCH Complete Medicaid	$21,326.77
Rate for Payer: Banner UC Health Medicaid	$21,326.77
Rate for Payer: Mercy Care Medicaid	$21,326.77

Foot And Toe Procedures

Facility

$11,056.87

Service Code	APR-DRG 3143
Hospital Charge Code	APRDRG3141
Min. Negotiated Rate	$11,056.87
Max. Negotiated Rate	$11,056.87
Rate for Payer: AHCCCS Medicaid	$11,056.87
Rate for Payer: Allwell Medicaid	$11,056.87
Rate for Payer: AZCH Complete Medicaid	$11,056.87
Rate for Payer: Banner UC Health Medicaid	$11,056.87
Rate for Payer: Mercy Care Medicaid	$11,056.87

Foot And Toe Procedures

Facility

$7,850.07

Service Code	APR-DRG 3142
Hospital Charge Code	APRDRG3141
Min. Negotiated Rate	$7,850.07
Max. Negotiated Rate	$7,850.07
Rate for Payer: AHCCCS Medicaid	$7,850.07
Rate for Payer: Allwell Medicaid	$7,850.07
Rate for Payer: AZCH Complete Medicaid	$7,850.07
Rate for Payer: Banner UC Health Medicaid	$7,850.07
Rate for Payer: Mercy Care Medicaid	$7,850.07

Foot And Toe Procedures

Facility

$7,850.07

Service Code	APR-DRG 3142
Hospital Charge Code	APRDRG3143
Min. Negotiated Rate	$7,850.07
Max. Negotiated Rate	$7,850.07
Rate for Payer: AHCCCS Medicaid	$7,850.07
Rate for Payer: Allwell Medicaid	$7,850.07
Rate for Payer: AZCH Complete Medicaid	$7,850.07
Rate for Payer: Banner UC Health Medicaid	$7,850.07
Rate for Payer: Mercy Care Medicaid	$7,850.07

Foot And Toe Procedures

Facility

$7,850.07

Service Code	APR-DRG 3142
Hospital Charge Code	APRDRG3142
Min. Negotiated Rate	$7,850.07
Max. Negotiated Rate	$7,850.07
Rate for Payer: AHCCCS Medicaid	$7,850.07
Rate for Payer: Allwell Medicaid	$7,850.07
Rate for Payer: AZCH Complete Medicaid	$7,850.07
Rate for Payer: Banner UC Health Medicaid	$7,850.07
Rate for Payer: Mercy Care Medicaid	$7,850.07

Foot And Toe Procedures

Facility

$11,056.87

Service Code	APR-DRG 3143
Hospital Charge Code	APRDRG3143
Min. Negotiated Rate	$11,056.87
Max. Negotiated Rate	$11,056.87
Rate for Payer: AHCCCS Medicaid	$11,056.87
Rate for Payer: Allwell Medicaid	$11,056.87
Rate for Payer: AZCH Complete Medicaid	$11,056.87
Rate for Payer: Banner UC Health Medicaid	$11,056.87
Rate for Payer: Mercy Care Medicaid	$11,056.87

Foot And Toe Procedures

Facility

$7,268.61

Service Code	APR-DRG 3141
Hospital Charge Code	APRDRG3143
Min. Negotiated Rate	$7,268.61
Max. Negotiated Rate	$7,268.61
Rate for Payer: AHCCCS Medicaid	$7,268.61
Rate for Payer: Allwell Medicaid	$7,268.61
Rate for Payer: AZCH Complete Medicaid	$7,268.61
Rate for Payer: Banner UC Health Medicaid	$7,268.61
Rate for Payer: Mercy Care Medicaid	$7,268.61

Foot And Toe Procedures

Facility

$7,268.61

Service Code	APR-DRG 3141
Hospital Charge Code	APRDRG3141
Min. Negotiated Rate	$7,268.61
Max. Negotiated Rate	$7,268.61
Rate for Payer: AHCCCS Medicaid	$7,268.61
Rate for Payer: Allwell Medicaid	$7,268.61
Rate for Payer: AZCH Complete Medicaid	$7,268.61
Rate for Payer: Banner UC Health Medicaid	$7,268.61
Rate for Payer: Mercy Care Medicaid	$7,268.61

Foot And Toe Procedures

Facility

$21,326.77

Service Code	APR-DRG 3144
Hospital Charge Code	APRDRG3142
Min. Negotiated Rate	$21,326.77
Max. Negotiated Rate	$21,326.77
Rate for Payer: AHCCCS Medicaid	$21,326.77
Rate for Payer: Allwell Medicaid	$21,326.77
Rate for Payer: AZCH Complete Medicaid	$21,326.77
Rate for Payer: Banner UC Health Medicaid	$21,326.77
Rate for Payer: Mercy Care Medicaid	$21,326.77

Foot And Toe Procedures

Facility

$7,268.61

Service Code	APR-DRG 3141
Hospital Charge Code	APRDRG3144
Min. Negotiated Rate	$7,268.61
Max. Negotiated Rate	$7,268.61
Rate for Payer: AHCCCS Medicaid	$7,268.61
Rate for Payer: Allwell Medicaid	$7,268.61
Rate for Payer: AZCH Complete Medicaid	$7,268.61
Rate for Payer: Banner UC Health Medicaid	$7,268.61
Rate for Payer: Mercy Care Medicaid	$7,268.61

Foot And Toe Procedures

Facility

$21,326.77

Service Code	APR-DRG 3144
Hospital Charge Code	APRDRG3141
Min. Negotiated Rate	$21,326.77
Max. Negotiated Rate	$21,326.77
Rate for Payer: AHCCCS Medicaid	$21,326.77
Rate for Payer: Allwell Medicaid	$21,326.77
Rate for Payer: AZCH Complete Medicaid	$21,326.77
Rate for Payer: Banner UC Health Medicaid	$21,326.77
Rate for Payer: Mercy Care Medicaid	$21,326.77

FORCEP BIOPSY RADIAL JAW 4 W/INDL 2.8MM STANDARD

Facility

$35.18

Hospital Charge Code	23589473
Hospital Revenue Code	272
Min. Negotiated Rate	$9.15
Max. Negotiated Rate	$31.66
Rate for Payer: Aetna of AZ Commercial	$31.66
Rate for Payer: Bisbee Police All Plans	$9.15
Rate for Payer: Cash Price	$28.14
Rate for Payer: Self Pay Self Pay	$28.14

FORCEP BIOPSY RADIAL JAW 4 W/INDL 2.8MM STANDARD

Facility

$35.18

Hospital Charge Code	23589473
Hospital Revenue Code	272
Min. Negotiated Rate	$5.63
Max. Negotiated Rate	$31.66
Rate for Payer: Aetna of AZ Commercial	$31.66
Rate for Payer: Aetna of AZ Medicare	$9.85
Rate for Payer: Allwell Medicare	$5.63
Rate for Payer: Amerigroup Medicare	$5.63
Rate for Payer: APIPA Medicare/Medicaid	$13.14
Rate for Payer: AZCH Complete Medicare	$5.63
Rate for Payer: Banner UC Health Medicare	$5.63
Rate for Payer: Bisbee Police All Plans	$9.15
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$23.92
Rate for Payer: Cash Price	$28.14
Rate for Payer: Cigna of AZ Commercial	$24.63
Rate for Payer: Copperpoint Commercial	$8.71
Rate for Payer: Health Net of AZ Commercial	$21.11
Rate for Payer: Health Net of AZ Medicare	$9.85
Rate for Payer: Humana of AZ Medicare	$5.63
Rate for Payer: Self Pay Self Pay	$28.14
Rate for Payer: TriWest Medicare	$5.63
Rate for Payer: UnitedHealth Group of AZ Commercial	$20.51
Rate for Payer: UnitedHealth Group of AZ Medicare	$6.33

Know your out-of-pocket cost for care.

All Charges