Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

gabapentin 300 mg Cap [CQCH]

Facility

$0.20

Service Code	NDC 63739023610
Hospital Charge Code	105923804
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.18
Rate for Payer: Bisbee Police All Plans	$0.05
Rate for Payer: Cash Price	$0.16
Rate for Payer: Self Pay Self Pay	$0.16

gabapentin 300 mg Cap [CQCH]

Facility

$0.20

Service Code	NDC 63739023610
Hospital Charge Code	105923804
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.18
Rate for Payer: Aetna of AZ Medicare	$0.06
Rate for Payer: Allwell Medicare	$0.03
Rate for Payer: Amerigroup Medicare	$0.03
Rate for Payer: APIPA Medicare/Medicaid	$0.07
Rate for Payer: AZCH Complete Medicare	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Bisbee Police All Plans	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.14
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of AZ Commercial	$0.13
Rate for Payer: Copperpoint Commercial	$0.05
Rate for Payer: Health Net of AZ Commercial	$0.12
Rate for Payer: Health Net of AZ Medicare	$0.06
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Self Pay Self Pay	$0.16
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.12
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.04

gabapentin 400 mg Cap [CQCH]

Facility

$0.14

Service Code	NDC 68084077401
Hospital Charge Code	105923869
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of AZ Commercial	$0.13
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	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.10
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of AZ Commercial	$0.09
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	$0.11
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	$0.03

gabapentin 400 mg Cap [CQCH]

Facility

$0.14

Service Code	NDC 68084077401
Hospital Charge Code	105923869
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of AZ Commercial	$0.13
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Cash Price	$0.11
Rate for Payer: Self Pay Self Pay	$0.11

GAD-65 Autoab LC

Facility

$335.00

Service Code	CPT 83519
Hospital Charge Code	6780942
Hospital Revenue Code	301
Min. Negotiated Rate	$18.40
Max. Negotiated Rate	$301.50
Rate for Payer: Aetna of AZ Commercial	$301.50
Rate for Payer: Aetna of AZ Medicare	$93.80
Rate for Payer: AHCCCS Medicaid	$18.40
Rate for Payer: Allwell Medicaid	$18.40
Rate for Payer: Allwell Medicare	$50.25
Rate for Payer: Amerigroup Medicare	$50.25
Rate for Payer: APIPA Medicare/Medicaid	$125.12
Rate for Payer: AZCH Complete Medicaid	$18.40
Rate for Payer: AZCH Complete Medicare	$50.25
Rate for Payer: Banner UC Health Medicaid	$18.40
Rate for Payer: Banner UC Health Medicare	$50.25
Rate for Payer: Bisbee Police All Plans	$87.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$227.80
Rate for Payer: Cash Price	$268.00
Rate for Payer: Cash Price	$268.00
Rate for Payer: Cigna of AZ Commercial	$217.75
Rate for Payer: Copperpoint Commercial	$82.91
Rate for Payer: Health Net of AZ Commercial	$201.00
Rate for Payer: Health Net of AZ Medicare	$93.80
Rate for Payer: Humana of AZ Medicare	$50.25
Rate for Payer: Mercy Care Medicaid	$18.40
Rate for Payer: Self Pay Self Pay	$268.00
Rate for Payer: TriWest Medicare	$50.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$195.30
Rate for Payer: UnitedHealth Group of AZ Medicare	$60.30

GAD-65 Autoab LC

Facility

$335.00

Service Code	CPT 83519
Hospital Charge Code	6780942
Hospital Revenue Code	301
Min. Negotiated Rate	$87.10
Max. Negotiated Rate	$301.50
Rate for Payer: Aetna of AZ Commercial	$301.50
Rate for Payer: Bisbee Police All Plans	$87.10
Rate for Payer: Cash Price	$268.00
Rate for Payer: Self Pay Self Pay	$268.00

Gamma Glutamyl Transferase

Facility

$158.00

Service Code	CPT 82977
Hospital Charge Code	633733
Hospital Revenue Code	301
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of AZ Commercial	$142.20
Rate for Payer: Aetna of AZ Medicare	$44.24
Rate for Payer: AHCCCS Medicaid	$7.20
Rate for Payer: Allwell Medicaid	$7.20
Rate for Payer: Allwell Medicare	$23.70
Rate for Payer: Amerigroup Medicare	$23.70
Rate for Payer: APIPA Medicare/Medicaid	$59.01
Rate for Payer: AZCH Complete Medicaid	$7.20
Rate for Payer: AZCH Complete Medicare	$23.70
Rate for Payer: Banner UC Health Medicaid	$7.20
Rate for Payer: Banner UC Health Medicare	$23.70
Rate for Payer: Bisbee Police All Plans	$41.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$107.44
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cigna of AZ Commercial	$102.70
Rate for Payer: Copperpoint Commercial	$39.10
Rate for Payer: Health Net of AZ Commercial	$94.80
Rate for Payer: Health Net of AZ Medicare	$44.24
Rate for Payer: Humana of AZ Medicare	$23.70
Rate for Payer: Mercy Care Medicaid	$7.20
Rate for Payer: Self Pay Self Pay	$126.40
Rate for Payer: TriWest Medicare	$23.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$92.11
Rate for Payer: UnitedHealth Group of AZ Medicare	$28.44

Gamma Glutamyl Transferase

Facility

$158.00

Service Code	CPT 82977
Hospital Charge Code	633733
Hospital Revenue Code	301
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of AZ Commercial	$142.20
Rate for Payer: Bisbee Police All Plans	$41.08
Rate for Payer: Cash Price	$126.40
Rate for Payer: Self Pay Self Pay	$126.40

GAS SAMPLING LINE

Facility

$11.00

Hospital Charge Code	22355640
Hospital Revenue Code	272
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of AZ Commercial	$9.90
Rate for Payer: Aetna of AZ Medicare	$3.08
Rate for Payer: Allwell Medicare	$1.65
Rate for Payer: Amerigroup Medicare	$1.65
Rate for Payer: APIPA Medicare/Medicaid	$4.11
Rate for Payer: AZCH Complete Medicare	$1.65
Rate for Payer: Banner UC Health Medicare	$1.65
Rate for Payer: Bisbee Police All Plans	$2.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$7.48
Rate for Payer: Cash Price	$8.80
Rate for Payer: Cigna of AZ Commercial	$7.70
Rate for Payer: Copperpoint Commercial	$2.72
Rate for Payer: Health Net of AZ Commercial	$6.60
Rate for Payer: Health Net of AZ Medicare	$3.08
Rate for Payer: Humana of AZ Medicare	$1.65
Rate for Payer: Self Pay Self Pay	$8.80
Rate for Payer: TriWest Medicare	$1.65
Rate for Payer: UnitedHealth Group of AZ Commercial	$6.41
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.98

GAS SAMPLING LINE

Facility

$11.00

Hospital Charge Code	22355640
Hospital Revenue Code	272
Min. Negotiated Rate	$2.86
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of AZ Commercial	$9.90
Rate for Payer: Bisbee Police All Plans	$2.86
Rate for Payer: Cash Price	$8.80
Rate for Payer: Self Pay Self Pay	$8.80

GAS SAMPLING LINE CANNULA CO2

Facility

$21.00

Hospital Charge Code	22354273
Hospital Revenue Code	270
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Aetna of AZ Medicare	$5.88
Rate for Payer: Allwell Medicare	$3.15
Rate for Payer: Amerigroup Medicare	$3.15
Rate for Payer: APIPA Medicare/Medicaid	$7.84
Rate for Payer: AZCH Complete Medicare	$3.15
Rate for Payer: Banner UC Health Medicare	$3.15
Rate for Payer: Bisbee Police All Plans	$5.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$14.28
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna of AZ Commercial	$14.70
Rate for Payer: Copperpoint Commercial	$5.20
Rate for Payer: Health Net of AZ Commercial	$12.60
Rate for Payer: Health Net of AZ Medicare	$5.88
Rate for Payer: Humana of AZ Medicare	$3.15
Rate for Payer: Self Pay Self Pay	$16.80
Rate for Payer: TriWest Medicare	$3.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$12.24
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.78

GAS SAMPLING LINE CANNULA CO2

Facility

$21.00

Hospital Charge Code	22354273
Hospital Revenue Code	270
Min. Negotiated Rate	$5.46
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Bisbee Police All Plans	$5.46
Rate for Payer: Cash Price	$16.80
Rate for Payer: Self Pay Self Pay	$16.80

Gastric Fundoplication

Facility

$13,458.46

Service Code	APR-DRG 2323
Hospital Charge Code	APRDRG2321
Min. Negotiated Rate	$13,458.46
Max. Negotiated Rate	$13,458.46
Rate for Payer: AHCCCS Medicaid	$13,458.46
Rate for Payer: Allwell Medicaid	$13,458.46
Rate for Payer: AZCH Complete Medicaid	$13,458.46
Rate for Payer: Banner UC Health Medicaid	$13,458.46
Rate for Payer: Mercy Care Medicaid	$13,458.46

Gastric Fundoplication

Facility

$6,459.19

Service Code	APR-DRG 2321
Hospital Charge Code	APRDRG2321
Min. Negotiated Rate	$6,459.19
Max. Negotiated Rate	$6,459.19
Rate for Payer: AHCCCS Medicaid	$6,459.19
Rate for Payer: Allwell Medicaid	$6,459.19
Rate for Payer: AZCH Complete Medicaid	$6,459.19
Rate for Payer: Banner UC Health Medicaid	$6,459.19
Rate for Payer: Mercy Care Medicaid	$6,459.19

Gastric Fundoplication

Facility

$46,303.62

Service Code	APR-DRG 2324
Hospital Charge Code	APRDRG2321
Min. Negotiated Rate	$46,303.62
Max. Negotiated Rate	$46,303.62
Rate for Payer: AHCCCS Medicaid	$46,303.62
Rate for Payer: Allwell Medicaid	$46,303.62
Rate for Payer: AZCH Complete Medicaid	$46,303.62
Rate for Payer: Banner UC Health Medicaid	$46,303.62
Rate for Payer: Mercy Care Medicaid	$46,303.62

Gastric Fundoplication

Facility

$13,458.46

Service Code	APR-DRG 2323
Hospital Charge Code	APRDRG2323
Min. Negotiated Rate	$13,458.46
Max. Negotiated Rate	$13,458.46
Rate for Payer: AHCCCS Medicaid	$13,458.46
Rate for Payer: Allwell Medicaid	$13,458.46
Rate for Payer: AZCH Complete Medicaid	$13,458.46
Rate for Payer: Banner UC Health Medicaid	$13,458.46
Rate for Payer: Mercy Care Medicaid	$13,458.46

Gastric Fundoplication

Facility

$8,538.84

Service Code	APR-DRG 2322
Hospital Charge Code	APRDRG2324
Min. Negotiated Rate	$8,538.84
Max. Negotiated Rate	$8,538.84
Rate for Payer: AHCCCS Medicaid	$8,538.84
Rate for Payer: Allwell Medicaid	$8,538.84
Rate for Payer: AZCH Complete Medicaid	$8,538.84
Rate for Payer: Banner UC Health Medicaid	$8,538.84
Rate for Payer: Mercy Care Medicaid	$8,538.84

Gastric Fundoplication

Facility

$8,538.84

Service Code	APR-DRG 2322
Hospital Charge Code	APRDRG2321
Min. Negotiated Rate	$8,538.84
Max. Negotiated Rate	$8,538.84
Rate for Payer: AHCCCS Medicaid	$8,538.84
Rate for Payer: Allwell Medicaid	$8,538.84
Rate for Payer: AZCH Complete Medicaid	$8,538.84
Rate for Payer: Banner UC Health Medicaid	$8,538.84
Rate for Payer: Mercy Care Medicaid	$8,538.84

Gastric Fundoplication

Facility

$8,538.84

Service Code	APR-DRG 2322
Hospital Charge Code	APRDRG2323
Min. Negotiated Rate	$8,538.84
Max. Negotiated Rate	$8,538.84
Rate for Payer: AHCCCS Medicaid	$8,538.84
Rate for Payer: Allwell Medicaid	$8,538.84
Rate for Payer: AZCH Complete Medicaid	$8,538.84
Rate for Payer: Banner UC Health Medicaid	$8,538.84
Rate for Payer: Mercy Care Medicaid	$8,538.84

Gastric Fundoplication

Facility

$6,459.19

Service Code	APR-DRG 2321
Hospital Charge Code	APRDRG2323
Min. Negotiated Rate	$6,459.19
Max. Negotiated Rate	$6,459.19
Rate for Payer: AHCCCS Medicaid	$6,459.19
Rate for Payer: Allwell Medicaid	$6,459.19
Rate for Payer: AZCH Complete Medicaid	$6,459.19
Rate for Payer: Banner UC Health Medicaid	$6,459.19
Rate for Payer: Mercy Care Medicaid	$6,459.19

Gastric Fundoplication

Facility

$46,303.62

Service Code	APR-DRG 2324
Hospital Charge Code	APRDRG2322
Min. Negotiated Rate	$46,303.62
Max. Negotiated Rate	$46,303.62
Rate for Payer: AHCCCS Medicaid	$46,303.62
Rate for Payer: Allwell Medicaid	$46,303.62
Rate for Payer: AZCH Complete Medicaid	$46,303.62
Rate for Payer: Banner UC Health Medicaid	$46,303.62
Rate for Payer: Mercy Care Medicaid	$46,303.62

Gastric Fundoplication

Facility

$6,459.19

Service Code	APR-DRG 2321
Hospital Charge Code	APRDRG2324
Min. Negotiated Rate	$6,459.19
Max. Negotiated Rate	$6,459.19
Rate for Payer: AHCCCS Medicaid	$6,459.19
Rate for Payer: Allwell Medicaid	$6,459.19
Rate for Payer: AZCH Complete Medicaid	$6,459.19
Rate for Payer: Banner UC Health Medicaid	$6,459.19
Rate for Payer: Mercy Care Medicaid	$6,459.19

Gastric Fundoplication

Facility

$6,459.19

Service Code	APR-DRG 2321
Hospital Charge Code	APRDRG2322
Min. Negotiated Rate	$6,459.19
Max. Negotiated Rate	$6,459.19
Rate for Payer: AHCCCS Medicaid	$6,459.19
Rate for Payer: Allwell Medicaid	$6,459.19
Rate for Payer: AZCH Complete Medicaid	$6,459.19
Rate for Payer: Banner UC Health Medicaid	$6,459.19
Rate for Payer: Mercy Care Medicaid	$6,459.19

Gastric Fundoplication

Facility

$46,303.62

Service Code	APR-DRG 2324
Hospital Charge Code	APRDRG2323
Min. Negotiated Rate	$46,303.62
Max. Negotiated Rate	$46,303.62
Rate for Payer: AHCCCS Medicaid	$46,303.62
Rate for Payer: Allwell Medicaid	$46,303.62
Rate for Payer: AZCH Complete Medicaid	$46,303.62
Rate for Payer: Banner UC Health Medicaid	$46,303.62
Rate for Payer: Mercy Care Medicaid	$46,303.62

Gastric Fundoplication

Facility

$13,458.46

Service Code	APR-DRG 2323
Hospital Charge Code	APRDRG2324
Min. Negotiated Rate	$13,458.46
Max. Negotiated Rate	$13,458.46
Rate for Payer: AHCCCS Medicaid	$13,458.46
Rate for Payer: Allwell Medicaid	$13,458.46
Rate for Payer: AZCH Complete Medicaid	$13,458.46
Rate for Payer: Banner UC Health Medicaid	$13,458.46
Rate for Payer: Mercy Care Medicaid	$13,458.46

Know your out-of-pocket cost for care.

All Charges