Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

gentamicin Ophth 0.3% Sol [CQCH]

Facility

$32.95

Service Code	NDC 61314063305
Hospital Charge Code	105924210
Hospital Revenue Code	251
Min. Negotiated Rate	$8.57
Max. Negotiated Rate	$29.66
Rate for Payer: Aetna of AZ Commercial	$29.66
Rate for Payer: Bisbee Police All Plans	$8.57
Rate for Payer: Cash Price	$26.36
Rate for Payer: Self Pay Self Pay	$26.36

Gentamicin Peak

Facility

$256.00

Service Code	CPT 80170
Hospital Charge Code	23122406
Hospital Revenue Code	301
Min. Negotiated Rate	$66.56
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna of AZ Commercial	$230.40
Rate for Payer: Bisbee Police All Plans	$66.56
Rate for Payer: Cash Price	$204.80
Rate for Payer: Self Pay Self Pay	$204.80

Gentamicin Peak

Facility

$256.00

Service Code	CPT 80170
Hospital Charge Code	23122406
Hospital Revenue Code	301
Min. Negotiated Rate	$40.96
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna of AZ Commercial	$230.40
Rate for Payer: Aetna of AZ Medicare	$71.68
Rate for Payer: Allwell Medicare	$40.96
Rate for Payer: Amerigroup Medicare	$40.96
Rate for Payer: APIPA Medicare/Medicaid	$95.62
Rate for Payer: AZCH Complete Medicare	$40.96
Rate for Payer: Banner UC Health Medicare	$40.96
Rate for Payer: Bisbee Police All Plans	$66.56
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$174.08
Rate for Payer: Cash Price	$204.80
Rate for Payer: Cigna of AZ Commercial	$166.40
Rate for Payer: Copperpoint Commercial	$63.36
Rate for Payer: Health Net of AZ Commercial	$153.60
Rate for Payer: Health Net of AZ Medicare	$71.68
Rate for Payer: Humana of AZ Medicare	$40.96
Rate for Payer: Self Pay Self Pay	$204.80
Rate for Payer: TriWest Medicare	$40.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$149.25
Rate for Payer: UnitedHealth Group of AZ Medicare	$46.08

gentamicin PF 20 mg/2 mL Inj Sol [CQCH]

Facility

$0.70

Service Code	HCPCS J1580
Hospital Charge Code	105924078
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.63
Rate for Payer: Aetna of AZ Commercial	$0.63
Rate for Payer: Aetna of AZ Medicare	$0.20
Rate for Payer: Allwell Medicare	$0.11
Rate for Payer: Amerigroup Medicare	$0.11
Rate for Payer: APIPA Medicare/Medicaid	$0.26
Rate for Payer: AZCH Complete Medicare	$0.11
Rate for Payer: Banner UC Health Medicare	$0.11
Rate for Payer: Bisbee Police All Plans	$0.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.48
Rate for Payer: Cash Price	$0.56
Rate for Payer: Cigna of AZ Commercial	$0.46
Rate for Payer: Copperpoint Commercial	$0.17
Rate for Payer: Health Net of AZ Commercial	$0.42
Rate for Payer: Health Net of AZ Medicare	$0.20
Rate for Payer: Humana of AZ Medicare	$0.11
Rate for Payer: Self Pay Self Pay	$0.56
Rate for Payer: TriWest Medicare	$0.11
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.41
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.13

gentamicin PF 20 mg/2 mL Inj Sol [CQCH]

Facility

$0.70

Service Code	HCPCS J1580
Hospital Charge Code	105924078
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.63
Rate for Payer: Aetna of AZ Commercial	$0.63
Rate for Payer: Bisbee Police All Plans	$0.18
Rate for Payer: Cash Price	$0.56
Rate for Payer: Self Pay Self Pay	$0.56

GENTAMICIN, RANDOM

Facility

$256.00

Service Code	CPT 80170
Hospital Charge Code	23122403
Hospital Revenue Code	301
Min. Negotiated Rate	$40.96
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna of AZ Commercial	$230.40
Rate for Payer: Aetna of AZ Medicare	$71.68
Rate for Payer: Allwell Medicare	$40.96
Rate for Payer: Amerigroup Medicare	$40.96
Rate for Payer: APIPA Medicare/Medicaid	$95.62
Rate for Payer: AZCH Complete Medicare	$40.96
Rate for Payer: Banner UC Health Medicare	$40.96
Rate for Payer: Bisbee Police All Plans	$66.56
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$174.08
Rate for Payer: Cash Price	$204.80
Rate for Payer: Cigna of AZ Commercial	$166.40
Rate for Payer: Copperpoint Commercial	$63.36
Rate for Payer: Health Net of AZ Commercial	$153.60
Rate for Payer: Health Net of AZ Medicare	$71.68
Rate for Payer: Humana of AZ Medicare	$40.96
Rate for Payer: Self Pay Self Pay	$204.80
Rate for Payer: TriWest Medicare	$40.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$149.25
Rate for Payer: UnitedHealth Group of AZ Medicare	$46.08

GENTAMICIN, RANDOM

Facility

$256.00

Service Code	CPT 80170
Hospital Charge Code	23122403
Hospital Revenue Code	301
Min. Negotiated Rate	$66.56
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna of AZ Commercial	$230.40
Rate for Payer: Bisbee Police All Plans	$66.56
Rate for Payer: Cash Price	$204.80
Rate for Payer: Self Pay Self Pay	$204.80

Gentamicin Trough

Facility

$256.00

Service Code	CPT 80170
Hospital Charge Code	23122404
Hospital Revenue Code	301
Min. Negotiated Rate	$40.96
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna of AZ Commercial	$230.40
Rate for Payer: Aetna of AZ Medicare	$71.68
Rate for Payer: Allwell Medicare	$40.96
Rate for Payer: Amerigroup Medicare	$40.96
Rate for Payer: APIPA Medicare/Medicaid	$95.62
Rate for Payer: AZCH Complete Medicare	$40.96
Rate for Payer: Banner UC Health Medicare	$40.96
Rate for Payer: Bisbee Police All Plans	$66.56
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$174.08
Rate for Payer: Cash Price	$204.80
Rate for Payer: Cigna of AZ Commercial	$166.40
Rate for Payer: Copperpoint Commercial	$63.36
Rate for Payer: Health Net of AZ Commercial	$153.60
Rate for Payer: Health Net of AZ Medicare	$71.68
Rate for Payer: Humana of AZ Medicare	$40.96
Rate for Payer: Self Pay Self Pay	$204.80
Rate for Payer: TriWest Medicare	$40.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$149.25
Rate for Payer: UnitedHealth Group of AZ Medicare	$46.08

Gentamicin Trough

Facility

$256.00

Service Code	CPT 80170
Hospital Charge Code	23122404
Hospital Revenue Code	301
Min. Negotiated Rate	$66.56
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna of AZ Commercial	$230.40
Rate for Payer: Bisbee Police All Plans	$66.56
Rate for Payer: Cash Price	$204.80
Rate for Payer: Self Pay Self Pay	$204.80

GGT LC

Facility

$166.00

Service Code	CPT 82977
Hospital Charge Code	1902205
Hospital Revenue Code	301
Min. Negotiated Rate	$43.16
Max. Negotiated Rate	$149.40
Rate for Payer: Aetna of AZ Commercial	$149.40
Rate for Payer: Bisbee Police All Plans	$43.16
Rate for Payer: Cash Price	$132.80
Rate for Payer: Self Pay Self Pay	$132.80

GGT LC

Facility

$166.00

Service Code	CPT 82977
Hospital Charge Code	1902205
Hospital Revenue Code	301
Min. Negotiated Rate	$26.56
Max. Negotiated Rate	$149.40
Rate for Payer: Aetna of AZ Commercial	$149.40
Rate for Payer: Aetna of AZ Medicare	$46.48
Rate for Payer: Allwell Medicare	$26.56
Rate for Payer: Amerigroup Medicare	$26.56
Rate for Payer: APIPA Medicare/Medicaid	$62.00
Rate for Payer: AZCH Complete Medicare	$26.56
Rate for Payer: Banner UC Health Medicare	$26.56
Rate for Payer: Bisbee Police All Plans	$43.16
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$112.88
Rate for Payer: Cash Price	$132.80
Rate for Payer: Cigna of AZ Commercial	$107.90
Rate for Payer: Copperpoint Commercial	$41.09
Rate for Payer: Health Net of AZ Commercial	$99.60
Rate for Payer: Health Net of AZ Medicare	$46.48
Rate for Payer: Humana of AZ Medicare	$26.56
Rate for Payer: Self Pay Self Pay	$132.80
Rate for Payer: TriWest Medicare	$26.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$96.78
Rate for Payer: UnitedHealth Group of AZ Medicare	$29.88

Giardia Lamblia Direct Detection EIA, LC

Facility

$217.00

Service Code	CPT 87329
Hospital Charge Code	3601506
Hospital Revenue Code	302
Min. Negotiated Rate	$56.42
Max. Negotiated Rate	$195.30
Rate for Payer: Aetna of AZ Commercial	$195.30
Rate for Payer: Bisbee Police All Plans	$56.42
Rate for Payer: Cash Price	$173.60
Rate for Payer: Self Pay Self Pay	$173.60

Giardia Lamblia Direct Detection EIA, LC

Facility

$80.00

Service Code	CPT 87328
Hospital Charge Code	23173812
Hospital Revenue Code	301
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna of AZ Commercial	$72.00
Rate for Payer: Aetna of AZ Medicare	$22.40
Rate for Payer: Allwell Medicare	$12.80
Rate for Payer: Amerigroup Medicare	$12.80
Rate for Payer: APIPA Medicare/Medicaid	$29.88
Rate for Payer: AZCH Complete Medicare	$12.80
Rate for Payer: Banner UC Health Medicare	$12.80
Rate for Payer: Bisbee Police All Plans	$20.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$54.40
Rate for Payer: Cash Price	$64.00
Rate for Payer: Cigna of AZ Commercial	$52.00
Rate for Payer: Copperpoint Commercial	$19.80
Rate for Payer: Health Net of AZ Commercial	$48.00
Rate for Payer: Health Net of AZ Medicare	$22.40
Rate for Payer: Humana of AZ Medicare	$12.80
Rate for Payer: Self Pay Self Pay	$64.00
Rate for Payer: TriWest Medicare	$12.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$46.64
Rate for Payer: UnitedHealth Group of AZ Medicare	$14.40

Giardia Lamblia Direct Detection EIA, LC

Facility

$217.00

Service Code	CPT 87329
Hospital Charge Code	3601506
Hospital Revenue Code	302
Min. Negotiated Rate	$34.72
Max. Negotiated Rate	$195.30
Rate for Payer: Aetna of AZ Commercial	$195.30
Rate for Payer: Aetna of AZ Medicare	$60.76
Rate for Payer: Allwell Medicare	$34.72
Rate for Payer: Amerigroup Medicare	$34.72
Rate for Payer: APIPA Medicare/Medicaid	$81.05
Rate for Payer: AZCH Complete Medicare	$34.72
Rate for Payer: Banner UC Health Medicare	$34.72
Rate for Payer: Bisbee Police All Plans	$56.42
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$147.56
Rate for Payer: Cash Price	$173.60
Rate for Payer: Cigna of AZ Commercial	$141.05
Rate for Payer: Copperpoint Commercial	$53.71
Rate for Payer: Health Net of AZ Commercial	$130.20
Rate for Payer: Health Net of AZ Medicare	$60.76
Rate for Payer: Humana of AZ Medicare	$34.72
Rate for Payer: Self Pay Self Pay	$173.60
Rate for Payer: TriWest Medicare	$34.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$126.51
Rate for Payer: UnitedHealth Group of AZ Medicare	$39.06

Giardia Lamblia Direct Detection EIA, LC

Facility

$80.00

Service Code	CPT 87328
Hospital Charge Code	23173812
Hospital Revenue Code	301
Min. Negotiated Rate	$20.80
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna of AZ Commercial	$72.00
Rate for Payer: Bisbee Police All Plans	$20.80
Rate for Payer: Cash Price	$64.00
Rate for Payer: Self Pay Self Pay	$64.00

Giardia Lamblia Direct Detention EIA, LC

Facility

$228.00

Service Code	CPT 87329
Hospital Charge Code	23309229
Hospital Revenue Code	300
Min. Negotiated Rate	$59.28
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna of AZ Commercial	$205.20
Rate for Payer: Bisbee Police All Plans	$59.28
Rate for Payer: Cash Price	$182.40
Rate for Payer: Self Pay Self Pay	$182.40

Giardia Lamblia Direct Detention EIA, LC

Facility

$228.00

Service Code	CPT 87329
Hospital Charge Code	23309229
Hospital Revenue Code	300
Min. Negotiated Rate	$36.48
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna of AZ Commercial	$205.20
Rate for Payer: Aetna of AZ Medicare	$63.84
Rate for Payer: Allwell Medicare	$36.48
Rate for Payer: Amerigroup Medicare	$36.48
Rate for Payer: APIPA Medicare/Medicaid	$85.16
Rate for Payer: AZCH Complete Medicare	$36.48
Rate for Payer: Banner UC Health Medicare	$36.48
Rate for Payer: Bisbee Police All Plans	$59.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$155.04
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cigna of AZ Commercial	$148.20
Rate for Payer: Copperpoint Commercial	$56.43
Rate for Payer: Health Net of AZ Commercial	$136.80
Rate for Payer: Health Net of AZ Medicare	$63.84
Rate for Payer: Humana of AZ Medicare	$36.48
Rate for Payer: Self Pay Self Pay	$182.40
Rate for Payer: TriWest Medicare	$36.48
Rate for Payer: UnitedHealth Group of AZ Commercial	$132.92
Rate for Payer: UnitedHealth Group of AZ Medicare	$41.04

Gliadin IgG IgA Ab Prof LC

Facility

$1,490.00

Service Code	CPT 83516
Hospital Charge Code	6781775
Hospital Revenue Code	301
Min. Negotiated Rate	$387.40
Max. Negotiated Rate	$1,341.00
Rate for Payer: Aetna of AZ Commercial	$1,341.00
Rate for Payer: Bisbee Police All Plans	$387.40
Rate for Payer: Cash Price	$1,192.00
Rate for Payer: Self Pay Self Pay	$1,192.00

Gliadin IgG IgA Ab Prof LC

Facility

$1,490.00

Service Code	CPT 83516
Hospital Charge Code	6781775
Hospital Revenue Code	301
Min. Negotiated Rate	$238.40
Max. Negotiated Rate	$1,341.00
Rate for Payer: Aetna of AZ Commercial	$1,341.00
Rate for Payer: Aetna of AZ Medicare	$417.20
Rate for Payer: Allwell Medicare	$238.40
Rate for Payer: Amerigroup Medicare	$238.40
Rate for Payer: APIPA Medicare/Medicaid	$556.51
Rate for Payer: AZCH Complete Medicare	$238.40
Rate for Payer: Banner UC Health Medicare	$238.40
Rate for Payer: Bisbee Police All Plans	$387.40
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,013.20
Rate for Payer: Cash Price	$1,192.00
Rate for Payer: Cigna of AZ Commercial	$968.50
Rate for Payer: Copperpoint Commercial	$368.77
Rate for Payer: Health Net of AZ Commercial	$894.00
Rate for Payer: Health Net of AZ Medicare	$417.20
Rate for Payer: Humana of AZ Medicare	$238.40
Rate for Payer: Self Pay Self Pay	$1,192.00
Rate for Payer: TriWest Medicare	$238.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$868.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$268.20

glimepiride 2 mg Tab [CQCH]

Facility

$0.53

Service Code	NDC 68084032601
Hospital Charge Code	105924275
Hospital Revenue Code	251
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

glimepiride 2 mg Tab [CQCH]

Facility

$0.53

Service Code	NDC 68084032601
Hospital Charge Code	105924275
Hospital Revenue Code	251
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

glipiZIDE 5 mg Tab [CQCH]

Facility

$0.25

Service Code	NDC 904663761
Hospital Charge Code	105924407
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of AZ Commercial	$0.23
Rate for Payer: Bisbee Police All Plans	$0.07
Rate for Payer: Cash Price	$0.20
Rate for Payer: Self Pay Self Pay	$0.20

glipiZIDE 5 mg Tab [CQCH]

Facility

$0.25

Service Code	NDC 904663761
Hospital Charge Code	105924407
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of AZ Commercial	$0.23
Rate for Payer: Aetna of AZ Medicare	$0.07
Rate for Payer: Allwell Medicare	$0.04
Rate for Payer: Amerigroup Medicare	$0.04
Rate for Payer: APIPA Medicare/Medicaid	$0.09
Rate for Payer: AZCH Complete Medicare	$0.04
Rate for Payer: Banner UC Health Medicare	$0.04
Rate for Payer: Bisbee Police All Plans	$0.07
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.17
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna of AZ Commercial	$0.16
Rate for Payer: Copperpoint Commercial	$0.06
Rate for Payer: Health Net of AZ Commercial	$0.15
Rate for Payer: Health Net of AZ Medicare	$0.07
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Self Pay Self Pay	$0.20
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.15
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.05

glipiZIDE XL 5 mg ER Tab [CQCH]

Facility

$0.12

Service Code	NDC 64980028001
Hospital Charge Code	105924342
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of AZ Commercial	$0.11
Rate for Payer: Aetna of AZ Medicare	$0.03
Rate for Payer: Allwell Medicare	$0.02
Rate for Payer: Amerigroup Medicare	$0.02
Rate for Payer: APIPA Medicare/Medicaid	$0.04
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	$0.08
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of AZ Commercial	$0.08
Rate for Payer: Copperpoint Commercial	$0.03
Rate for Payer: Health Net of AZ Commercial	$0.07
Rate for Payer: Health Net of AZ Medicare	$0.03
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	$0.07
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.02

glipiZIDE XL 5 mg ER Tab [CQCH]

Facility

$0.12

Service Code	NDC 64980028001
Hospital Charge Code	105924342
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of AZ Commercial	$0.11
Rate for Payer: Bisbee Police All Plans	$0.03
Rate for Payer: Cash Price	$0.09
Rate for Payer: Self Pay Self Pay	$0.10

Know your out-of-pocket cost for care.

All Charges