Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

FSH and LH LC

Facility

$419.00

Service Code	CPT 83001
Hospital Charge Code	1285571
Hospital Revenue Code	301
Min. Negotiated Rate	$108.94
Max. Negotiated Rate	$377.10
Rate for Payer: Aetna of AZ Commercial	$377.10
Rate for Payer: Bisbee Police All Plans	$108.94
Rate for Payer: Cash Price	$335.20
Rate for Payer: Self Pay Self Pay	$335.20

FSH, Serum LC

Facility

$419.00

Service Code	CPT 83001
Hospital Charge Code	1285570
Hospital Revenue Code	301
Min. Negotiated Rate	$108.94
Max. Negotiated Rate	$377.10
Rate for Payer: Aetna of AZ Commercial	$377.10
Rate for Payer: Bisbee Police All Plans	$108.94
Rate for Payer: Cash Price	$335.20
Rate for Payer: Self Pay Self Pay	$335.20

FSH, Serum LC

Facility

$419.00

Service Code	CPT 83001
Hospital Charge Code	1285570
Hospital Revenue Code	301
Min. Negotiated Rate	$67.04
Max. Negotiated Rate	$377.10
Rate for Payer: Aetna of AZ Commercial	$377.10
Rate for Payer: Aetna of AZ Medicare	$117.32
Rate for Payer: Allwell Medicare	$67.04
Rate for Payer: Amerigroup Medicare	$67.04
Rate for Payer: APIPA Medicare/Medicaid	$156.50
Rate for Payer: AZCH Complete Medicare	$67.04
Rate for Payer: Banner UC Health Medicare	$67.04
Rate for Payer: Bisbee Police All Plans	$108.94
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$284.92
Rate for Payer: Cash Price	$335.20
Rate for Payer: Cigna of AZ Commercial	$272.35
Rate for Payer: Copperpoint Commercial	$103.70
Rate for Payer: Health Net of AZ Commercial	$251.40
Rate for Payer: Health Net of AZ Medicare	$117.32
Rate for Payer: Humana of AZ Medicare	$67.04
Rate for Payer: Self Pay Self Pay	$335.20
Rate for Payer: TriWest Medicare	$67.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$244.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$75.42

.Fungal Cult LC

Facility

$243.00

Service Code	CPT 87101
Hospital Charge Code	9228407
Hospital Revenue Code	301
Min. Negotiated Rate	$38.88
Max. Negotiated Rate	$218.70
Rate for Payer: Aetna of AZ Commercial	$218.70
Rate for Payer: Aetna of AZ Medicare	$68.04
Rate for Payer: Allwell Medicare	$38.88
Rate for Payer: Amerigroup Medicare	$38.88
Rate for Payer: APIPA Medicare/Medicaid	$90.76
Rate for Payer: AZCH Complete Medicare	$38.88
Rate for Payer: Banner UC Health Medicare	$38.88
Rate for Payer: Bisbee Police All Plans	$63.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$165.24
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cigna of AZ Commercial	$157.95
Rate for Payer: Copperpoint Commercial	$60.14
Rate for Payer: Health Net of AZ Commercial	$145.80
Rate for Payer: Health Net of AZ Medicare	$68.04
Rate for Payer: Humana of AZ Medicare	$38.88
Rate for Payer: Self Pay Self Pay	$194.40
Rate for Payer: TriWest Medicare	$38.88
Rate for Payer: UnitedHealth Group of AZ Commercial	$141.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$43.74

.Fungal Cult LC

Facility

$243.00

Service Code	CPT 87101
Hospital Charge Code	9228407
Hospital Revenue Code	301
Min. Negotiated Rate	$63.18
Max. Negotiated Rate	$218.70
Rate for Payer: Aetna of AZ Commercial	$218.70
Rate for Payer: Bisbee Police All Plans	$63.18
Rate for Payer: Cash Price	$194.40
Rate for Payer: Self Pay Self Pay	$194.40

Fungus (Mycology) Culture LC

Facility

$242.00

Service Code	CPT 87101
Hospital Charge Code	1905615
Hospital Revenue Code	306
Min. Negotiated Rate	$62.92
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Bisbee Police All Plans	$62.92
Rate for Payer: Cash Price	$193.60
Rate for Payer: Self Pay Self Pay	$193.60

Fungus (Mycology) Culture LC

Facility

$242.00

Service Code	CPT 87101
Hospital Charge Code	1905615
Hospital Revenue Code	306
Min. Negotiated Rate	$38.72
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Aetna of AZ Medicare	$67.76
Rate for Payer: Allwell Medicare	$38.72
Rate for Payer: Amerigroup Medicare	$38.72
Rate for Payer: APIPA Medicare/Medicaid	$90.39
Rate for Payer: AZCH Complete Medicare	$38.72
Rate for Payer: Banner UC Health Medicare	$38.72
Rate for Payer: Bisbee Police All Plans	$62.92
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$164.56
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cigna of AZ Commercial	$157.30
Rate for Payer: Copperpoint Commercial	$59.90
Rate for Payer: Health Net of AZ Commercial	$145.20
Rate for Payer: Health Net of AZ Medicare	$67.76
Rate for Payer: Humana of AZ Medicare	$38.72
Rate for Payer: Self Pay Self Pay	$193.60
Rate for Payer: TriWest Medicare	$38.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$141.09
Rate for Payer: UnitedHealth Group of AZ Medicare	$43.56

furosemide 20 mg/2 mL Inj Sol [CQCH]

Facility

$0.53

Service Code	HCPCS J1940
Hospital Charge Code	105923463
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of AZ Commercial	$0.48
Rate for Payer: Aetna of AZ Medicare	$0.15
Rate for Payer: Allwell Medicare	$0.08
Rate for Payer: Amerigroup Medicare	$0.08
Rate for Payer: APIPA Medicare/Medicaid	$0.20
Rate for Payer: AZCH Complete Medicare	$0.08
Rate for Payer: Banner UC Health Medicare	$0.08
Rate for Payer: Bisbee Police All Plans	$0.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.36
Rate for Payer: Cash Price	$0.42
Rate for Payer: Cigna of AZ Commercial	$0.34
Rate for Payer: Copperpoint Commercial	$0.13
Rate for Payer: Health Net of AZ Commercial	$0.32
Rate for Payer: Health Net of AZ Medicare	$0.15
Rate for Payer: Humana of AZ Medicare	$0.08
Rate for Payer: Self Pay Self Pay	$0.42
Rate for Payer: TriWest Medicare	$0.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.31
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.10

furosemide 20 mg/2 mL Inj Sol [CQCH]

Facility

$0.53

Service Code	HCPCS J1940
Hospital Charge Code	105923463
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of AZ Commercial	$0.48
Rate for Payer: Bisbee Police All Plans	$0.14
Rate for Payer: Cash Price	$0.42
Rate for Payer: Self Pay Self Pay	$0.42

furosemide 20 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 54829725
Hospital Charge Code	105923674
Hospital Revenue Code	251
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.02
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of AZ Commercial	$0.02
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.02
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

furosemide 20 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 54829725
Hospital Charge Code	105923674
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.03
Rate for Payer: Self Pay Self Pay	$0.02

furosemide 40 mg/ 4 mL Inj Sol [CQCH]

Facility

$0.45

Service Code	HCPCS J1940
Hospital Charge Code	105923534
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of AZ Commercial	$0.41
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	$0.17
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	$0.31
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of AZ Commercial	$0.29
Rate for Payer: Copperpoint Commercial	$0.11
Rate for Payer: Health Net of AZ Commercial	$0.27
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	$0.36
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.26
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.08

furosemide 40 mg/ 4 mL Inj Sol [CQCH]

Facility

$0.45

Service Code	HCPCS J1940
Hospital Charge Code	105923534
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of AZ Commercial	$0.41
Rate for Payer: Bisbee Police All Plans	$0.12
Rate for Payer: Cash Price	$0.36
Rate for Payer: Self Pay Self Pay	$0.36

furosemide 40 mg Tab [CQCH]

Facility

$0.04

Service Code	NDC 54829925
Hospital Charge Code	105923609
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.03
Rate for Payer: Self Pay Self Pay	$0.03

furosemide 40 mg Tab [CQCH]

Facility

$0.04

Service Code	NDC 54829925
Hospital Charge Code	105923609
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.03
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of AZ Commercial	$0.03
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.02
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Self Pay Self Pay	$0.03
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

G0168 WOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLY

Facility

$527.00

Service Code	CPT G0168
Hospital Charge Code	24599672
Hospital Revenue Code	450
Min. Negotiated Rate	$84.32
Max. Negotiated Rate	$474.30
Rate for Payer: Aetna of AZ Commercial	$474.30
Rate for Payer: Aetna of AZ Medicare	$147.56
Rate for Payer: Allwell Medicare	$84.32
Rate for Payer: Amerigroup Medicare	$84.32
Rate for Payer: APIPA Medicare/Medicaid	$196.83
Rate for Payer: AZCH Complete Medicare	$84.32
Rate for Payer: Banner UC Health Medicare	$84.32
Rate for Payer: Bisbee Police All Plans	$137.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$358.36
Rate for Payer: Cash Price	$421.60
Rate for Payer: Cigna of AZ Commercial	$368.90
Rate for Payer: Copperpoint Commercial	$130.43
Rate for Payer: Health Net of AZ Commercial	$316.20
Rate for Payer: Health Net of AZ Medicare	$147.56
Rate for Payer: Humana of AZ Medicare	$84.32
Rate for Payer: Self Pay Self Pay	$421.60
Rate for Payer: TriWest Medicare	$84.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$307.24
Rate for Payer: UnitedHealth Group of AZ Medicare	$94.86

G0168 WOUND CLOSURE UTILIZING TISSUE ADHESIVE(S) ONLY

Facility

$527.00

Service Code	CPT G0168
Hospital Charge Code	24599672
Hospital Revenue Code	450
Min. Negotiated Rate	$137.02
Max. Negotiated Rate	$474.30
Rate for Payer: Aetna of AZ Commercial	$474.30
Rate for Payer: Bisbee Police All Plans	$137.02
Rate for Payer: Cash Price	$421.60
Rate for Payer: Self Pay Self Pay	$421.60

G0378 ER OBSERVATION

Facility

$133.00

Service Code	CPT G0378
Hospital Charge Code	22282939
Hospital Revenue Code	762
Min. Negotiated Rate	$34.58
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of AZ Commercial	$119.70
Rate for Payer: Bisbee Police All Plans	$34.58
Rate for Payer: Cash Price	$106.40
Rate for Payer: Self Pay Self Pay	$106.40

G0378 ER OBSERVATION

Facility

$133.00

Service Code	CPT G0378
Hospital Charge Code	22282939
Hospital Revenue Code	762
Min. Negotiated Rate	$21.28
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of AZ Commercial	$119.70
Rate for Payer: Aetna of AZ Medicare	$37.24
Rate for Payer: Allwell Medicare	$21.28
Rate for Payer: Amerigroup Medicare	$21.28
Rate for Payer: APIPA Medicare/Medicaid	$49.68
Rate for Payer: AZCH Complete Medicare	$21.28
Rate for Payer: Banner UC Health Medicare	$21.28
Rate for Payer: Bisbee Police All Plans	$34.58
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$90.44
Rate for Payer: Cash Price	$106.40
Rate for Payer: Cigna of AZ Commercial	$93.10
Rate for Payer: Copperpoint Commercial	$32.92
Rate for Payer: Health Net of AZ Commercial	$79.80
Rate for Payer: Health Net of AZ Medicare	$37.24
Rate for Payer: Humana of AZ Medicare	$21.28
Rate for Payer: Self Pay Self Pay	$106.40
Rate for Payer: TriWest Medicare	$21.28
Rate for Payer: UnitedHealth Group of AZ Commercial	$77.54
Rate for Payer: UnitedHealth Group of AZ Medicare	$23.94

G0379 DIRECT OBSERVATION

Facility

$167.00

Service Code	CPT G0379
Hospital Charge Code	22282941
Hospital Revenue Code	762
Min. Negotiated Rate	$43.42
Max. Negotiated Rate	$150.30
Rate for Payer: Aetna of AZ Commercial	$150.30
Rate for Payer: Bisbee Police All Plans	$43.42
Rate for Payer: Cash Price	$133.60
Rate for Payer: Self Pay Self Pay	$133.60

G0379 DIRECT OBSERVATION

Facility

$167.00

Service Code	CPT G0379
Hospital Charge Code	22282941
Hospital Revenue Code	762
Min. Negotiated Rate	$26.72
Max. Negotiated Rate	$150.30
Rate for Payer: Aetna of AZ Commercial	$150.30
Rate for Payer: Aetna of AZ Medicare	$46.76
Rate for Payer: Allwell Medicare	$26.72
Rate for Payer: Amerigroup Medicare	$26.72
Rate for Payer: APIPA Medicare/Medicaid	$62.37
Rate for Payer: AZCH Complete Medicare	$26.72
Rate for Payer: Banner UC Health Medicare	$26.72
Rate for Payer: Bisbee Police All Plans	$43.42
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$113.56
Rate for Payer: Cash Price	$133.60
Rate for Payer: Cigna of AZ Commercial	$116.90
Rate for Payer: Copperpoint Commercial	$41.33
Rate for Payer: Health Net of AZ Commercial	$100.20
Rate for Payer: Health Net of AZ Medicare	$46.76
Rate for Payer: Humana of AZ Medicare	$26.72
Rate for Payer: Self Pay Self Pay	$133.60
Rate for Payer: TriWest Medicare	$26.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$97.36
Rate for Payer: UnitedHealth Group of AZ Medicare	$30.06

G0390 TRAUMA LEVEL 4

Facility

$1,634.00

Service Code	CPT G0390
Hospital Charge Code	22282942
Hospital Revenue Code	684
Min. Negotiated Rate	$424.84
Max. Negotiated Rate	$1,470.60
Rate for Payer: Aetna of AZ Commercial	$1,470.60
Rate for Payer: Bisbee Police All Plans	$424.84
Rate for Payer: Cash Price	$1,307.20
Rate for Payer: Self Pay Self Pay	$1,307.20

G0390 TRAUMA LEVEL 4

Facility

$1,634.00

Service Code	CPT G0390
Hospital Charge Code	22282942
Hospital Revenue Code	684
Min. Negotiated Rate	$261.44
Max. Negotiated Rate	$1,470.60
Rate for Payer: Aetna of AZ Commercial	$1,470.60
Rate for Payer: Aetna of AZ Medicare	$457.52
Rate for Payer: Allwell Medicare	$261.44
Rate for Payer: Amerigroup Medicare	$261.44
Rate for Payer: APIPA Medicare/Medicaid	$610.30
Rate for Payer: AZCH Complete Medicare	$261.44
Rate for Payer: Banner UC Health Medicare	$261.44
Rate for Payer: Bisbee Police All Plans	$424.84
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,111.12
Rate for Payer: Cash Price	$1,307.20
Rate for Payer: Cigna of AZ Commercial	$1,143.80
Rate for Payer: Copperpoint Commercial	$404.42
Rate for Payer: Health Net of AZ Commercial	$980.40
Rate for Payer: Health Net of AZ Medicare	$457.52
Rate for Payer: Humana of AZ Medicare	$261.44
Rate for Payer: Self Pay Self Pay	$1,307.20
Rate for Payer: TriWest Medicare	$261.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$952.62
Rate for Payer: UnitedHealth Group of AZ Medicare	$294.12

.G-6-PD Comment LC

Facility

$206.00

Service Code	CPT 82955
Hospital Charge Code	22311146
Hospital Revenue Code	301
Min. Negotiated Rate	$32.96
Max. Negotiated Rate	$185.40
Rate for Payer: Aetna of AZ Commercial	$185.40
Rate for Payer: Aetna of AZ Medicare	$57.68
Rate for Payer: Allwell Medicare	$32.96
Rate for Payer: Amerigroup Medicare	$32.96
Rate for Payer: APIPA Medicare/Medicaid	$76.94
Rate for Payer: AZCH Complete Medicare	$32.96
Rate for Payer: Banner UC Health Medicare	$32.96
Rate for Payer: Bisbee Police All Plans	$53.56
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$140.08
Rate for Payer: Cash Price	$164.80
Rate for Payer: Cigna of AZ Commercial	$133.90
Rate for Payer: Copperpoint Commercial	$50.98
Rate for Payer: Health Net of AZ Commercial	$123.60
Rate for Payer: Health Net of AZ Medicare	$57.68
Rate for Payer: Humana of AZ Medicare	$32.96
Rate for Payer: Self Pay Self Pay	$164.80
Rate for Payer: TriWest Medicare	$32.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$120.10
Rate for Payer: UnitedHealth Group of AZ Medicare	$37.08

.G-6-PD Comment LC

Facility

$206.00

Service Code	CPT 82955
Hospital Charge Code	22311146
Hospital Revenue Code	301
Min. Negotiated Rate	$53.56
Max. Negotiated Rate	$185.40
Rate for Payer: Aetna of AZ Commercial	$185.40
Rate for Payer: Bisbee Police All Plans	$53.56
Rate for Payer: Cash Price	$164.80
Rate for Payer: Self Pay Self Pay	$164.80

Know your out-of-pocket cost for care.

All Charges