Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

GlycoMark(R)(1,5 AG) LC

Facility

$78.00

Service Code	CPT 82945
Hospital Charge Code	2270019
Hospital Revenue Code	301
Min. Negotiated Rate	$12.48
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Aetna of AZ Medicare	$21.84
Rate for Payer: Allwell Medicare	$12.48
Rate for Payer: Amerigroup Medicare	$12.48
Rate for Payer: APIPA Medicare/Medicaid	$29.13
Rate for Payer: AZCH Complete Medicare	$12.48
Rate for Payer: Banner UC Health Medicare	$12.48
Rate for Payer: Bisbee Police All Plans	$20.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$53.04
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cigna of AZ Commercial	$50.70
Rate for Payer: Copperpoint Commercial	$19.30
Rate for Payer: Health Net of AZ Commercial	$46.80
Rate for Payer: Health Net of AZ Medicare	$21.84
Rate for Payer: Humana of AZ Medicare	$12.48
Rate for Payer: Self Pay Self Pay	$62.40
Rate for Payer: TriWest Medicare	$12.48
Rate for Payer: UnitedHealth Group of AZ Commercial	$45.47
Rate for Payer: UnitedHealth Group of AZ Medicare	$14.04

glycopyrrolate 0.2 mg/mL Inj Sol [CQCH]

Facility

$2.72

Service Code	HCPCS J7642
Hospital Charge Code	105924820
Hospital Revenue Code	250
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$2.45
Rate for Payer: Aetna of AZ Commercial	$2.45
Rate for Payer: Aetna of AZ Medicare	$0.76
Rate for Payer: Allwell Medicare	$0.44
Rate for Payer: Amerigroup Medicare	$0.44
Rate for Payer: APIPA Medicare/Medicaid	$1.02
Rate for Payer: AZCH Complete Medicare	$0.44
Rate for Payer: Banner UC Health Medicare	$0.44
Rate for Payer: Bisbee Police All Plans	$0.71
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.85
Rate for Payer: Cash Price	$2.17
Rate for Payer: Cigna of AZ Commercial	$1.77
Rate for Payer: Copperpoint Commercial	$0.67
Rate for Payer: Health Net of AZ Commercial	$1.63
Rate for Payer: Health Net of AZ Medicare	$0.76
Rate for Payer: Humana of AZ Medicare	$0.44
Rate for Payer: Self Pay Self Pay	$2.18
Rate for Payer: TriWest Medicare	$0.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.59
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.49

glycopyrrolate 0.2 mg/mL Inj Sol [CQCH]

Facility

$2.72

Service Code	HCPCS J7642
Hospital Charge Code	105924820
Hospital Revenue Code	250
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$2.45
Rate for Payer: Aetna of AZ Commercial	$2.45
Rate for Payer: Bisbee Police All Plans	$0.71
Rate for Payer: Cash Price	$2.17
Rate for Payer: Self Pay Self Pay	$2.18

golimumab 50 mg/4 mL Sol[CQCH]

Facility

$484.56

Service Code	HCPCS J1602
Hospital Charge Code	199590300
Hospital Revenue Code	250
Min. Negotiated Rate	$125.99
Max. Negotiated Rate	$436.10
Rate for Payer: Aetna of AZ Commercial	$436.10
Rate for Payer: Bisbee Police All Plans	$125.99
Rate for Payer: Cash Price	$387.65
Rate for Payer: Self Pay Self Pay	$387.65

golimumab 50 mg/4 mL Sol[CQCH]

Facility

$484.56

Service Code	HCPCS J1602
Hospital Charge Code	199590300
Hospital Revenue Code	250
Min. Negotiated Rate	$77.53
Max. Negotiated Rate	$436.10
Rate for Payer: Aetna of AZ Commercial	$436.10
Rate for Payer: Aetna of AZ Medicare	$135.68
Rate for Payer: Allwell Medicare	$77.53
Rate for Payer: Amerigroup Medicare	$77.53
Rate for Payer: APIPA Medicare/Medicaid	$180.98
Rate for Payer: AZCH Complete Medicare	$77.53
Rate for Payer: Banner UC Health Medicare	$77.53
Rate for Payer: Bisbee Police All Plans	$125.99
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$329.50
Rate for Payer: Cash Price	$387.65
Rate for Payer: Cigna of AZ Commercial	$314.96
Rate for Payer: Copperpoint Commercial	$119.93
Rate for Payer: Health Net of AZ Commercial	$290.74
Rate for Payer: Health Net of AZ Medicare	$135.68
Rate for Payer: Humana of AZ Medicare	$77.53
Rate for Payer: Self Pay Self Pay	$387.65
Rate for Payer: TriWest Medicare	$77.53
Rate for Payer: UnitedHealth Group of AZ Commercial	$282.50
Rate for Payer: UnitedHealth Group of AZ Medicare	$87.22

gramicidin/neomycin/polymyxin B Ophth Sol [CQCH]

Facility

$47.44

Service Code	NDC 24208079062
Hospital Charge Code	105924896
Hospital Revenue Code	251
Min. Negotiated Rate	$12.33
Max. Negotiated Rate	$42.70
Rate for Payer: Aetna of AZ Commercial	$42.70
Rate for Payer: Bisbee Police All Plans	$12.33
Rate for Payer: Cash Price	$37.95
Rate for Payer: Self Pay Self Pay	$37.95

gramicidin/neomycin/polymyxin B Ophth Sol [CQCH]

Facility

$47.44

Service Code	NDC 24208079062
Hospital Charge Code	105924896
Hospital Revenue Code	251
Min. Negotiated Rate	$7.59
Max. Negotiated Rate	$42.70
Rate for Payer: Aetna of AZ Commercial	$42.70
Rate for Payer: Aetna of AZ Medicare	$13.28
Rate for Payer: Allwell Medicare	$7.59
Rate for Payer: Amerigroup Medicare	$7.59
Rate for Payer: APIPA Medicare/Medicaid	$17.72
Rate for Payer: AZCH Complete Medicare	$7.59
Rate for Payer: Banner UC Health Medicare	$7.59
Rate for Payer: Bisbee Police All Plans	$12.33
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$32.26
Rate for Payer: Cash Price	$37.95
Rate for Payer: Cigna of AZ Commercial	$30.84
Rate for Payer: Copperpoint Commercial	$11.74
Rate for Payer: Health Net of AZ Commercial	$28.46
Rate for Payer: Health Net of AZ Medicare	$13.28
Rate for Payer: Humana of AZ Medicare	$7.59
Rate for Payer: Self Pay Self Pay	$37.95
Rate for Payer: TriWest Medicare	$7.59
Rate for Payer: UnitedHealth Group of AZ Commercial	$27.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$8.54

Gram Stain

Facility

$107.00

Service Code	CPT 87205
Hospital Charge Code	3426222
Hospital Revenue Code	306
Min. Negotiated Rate	$17.12
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Aetna of AZ Medicare	$29.96
Rate for Payer: Allwell Medicare	$17.12
Rate for Payer: Amerigroup Medicare	$17.12
Rate for Payer: APIPA Medicare/Medicaid	$39.96
Rate for Payer: AZCH Complete Medicare	$17.12
Rate for Payer: Banner UC Health Medicare	$17.12
Rate for Payer: Bisbee Police All Plans	$27.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$72.76
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cigna of AZ Commercial	$69.55
Rate for Payer: Copperpoint Commercial	$26.48
Rate for Payer: Health Net of AZ Commercial	$64.20
Rate for Payer: Health Net of AZ Medicare	$29.96
Rate for Payer: Humana of AZ Medicare	$17.12
Rate for Payer: Self Pay Self Pay	$85.60
Rate for Payer: TriWest Medicare	$17.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$62.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.26

Gram Stain

Facility

$107.00

Service Code	CPT 87205
Hospital Charge Code	3426222
Hospital Revenue Code	306
Min. Negotiated Rate	$27.82
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Bisbee Police All Plans	$27.82
Rate for Payer: Cash Price	$85.60
Rate for Payer: Self Pay Self Pay	$85.60

Gram Stain

Facility

$107.00

Service Code	CPT 87205
Hospital Charge Code	850753
Hospital Revenue Code	306
Min. Negotiated Rate	$17.12
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Aetna of AZ Medicare	$29.96
Rate for Payer: Allwell Medicare	$17.12
Rate for Payer: Amerigroup Medicare	$17.12
Rate for Payer: APIPA Medicare/Medicaid	$39.96
Rate for Payer: AZCH Complete Medicare	$17.12
Rate for Payer: Banner UC Health Medicare	$17.12
Rate for Payer: Bisbee Police All Plans	$27.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$72.76
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cigna of AZ Commercial	$69.55
Rate for Payer: Copperpoint Commercial	$26.48
Rate for Payer: Health Net of AZ Commercial	$64.20
Rate for Payer: Health Net of AZ Medicare	$29.96
Rate for Payer: Humana of AZ Medicare	$17.12
Rate for Payer: Self Pay Self Pay	$85.60
Rate for Payer: TriWest Medicare	$17.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$62.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.26

Gram Stain

Facility

$107.00

Service Code	CPT 87205
Hospital Charge Code	850753
Hospital Revenue Code	306
Min. Negotiated Rate	$27.82
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Bisbee Police All Plans	$27.82
Rate for Payer: Cash Price	$85.60
Rate for Payer: Self Pay Self Pay	$85.60

GRAM STAIN

Facility

$112.00

Service Code	CPT 87205
Hospital Charge Code	22513017
Hospital Revenue Code	306
Min. Negotiated Rate	$17.92
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of AZ Commercial	$100.80
Rate for Payer: Aetna of AZ Medicare	$31.36
Rate for Payer: Allwell Medicare	$17.92
Rate for Payer: Amerigroup Medicare	$17.92
Rate for Payer: APIPA Medicare/Medicaid	$41.83
Rate for Payer: AZCH Complete Medicare	$17.92
Rate for Payer: Banner UC Health Medicare	$17.92
Rate for Payer: Bisbee Police All Plans	$29.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$76.16
Rate for Payer: Cash Price	$89.60
Rate for Payer: Cigna of AZ Commercial	$72.80
Rate for Payer: Copperpoint Commercial	$27.72
Rate for Payer: Health Net of AZ Commercial	$67.20
Rate for Payer: Health Net of AZ Medicare	$31.36
Rate for Payer: Humana of AZ Medicare	$17.92
Rate for Payer: Self Pay Self Pay	$89.60
Rate for Payer: TriWest Medicare	$17.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$65.30
Rate for Payer: UnitedHealth Group of AZ Medicare	$20.16

GRAM STAIN

Facility

$112.00

Service Code	CPT 87205
Hospital Charge Code	22513017
Hospital Revenue Code	306
Min. Negotiated Rate	$29.12
Max. Negotiated Rate	$100.80
Rate for Payer: Aetna of AZ Commercial	$100.80
Rate for Payer: Bisbee Police All Plans	$29.12
Rate for Payer: Cash Price	$89.60
Rate for Payer: Self Pay Self Pay	$89.60

Gram Stain Report

Facility

$102.00

Service Code	CPT 87205
Hospital Charge Code	634217
Hospital Revenue Code	306
Min. Negotiated Rate	$26.52
Max. Negotiated Rate	$91.80
Rate for Payer: Aetna of AZ Commercial	$91.80
Rate for Payer: Bisbee Police All Plans	$26.52
Rate for Payer: Cash Price	$81.60
Rate for Payer: Self Pay Self Pay	$81.60

Gram Stain Report

Facility

$102.00

Service Code	CPT 87205
Hospital Charge Code	634217
Hospital Revenue Code	306
Min. Negotiated Rate	$16.32
Max. Negotiated Rate	$91.80
Rate for Payer: Aetna of AZ Commercial	$91.80
Rate for Payer: Aetna of AZ Medicare	$28.56
Rate for Payer: Allwell Medicare	$16.32
Rate for Payer: Amerigroup Medicare	$16.32
Rate for Payer: APIPA Medicare/Medicaid	$38.10
Rate for Payer: AZCH Complete Medicare	$16.32
Rate for Payer: Banner UC Health Medicare	$16.32
Rate for Payer: Bisbee Police All Plans	$26.52
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$69.36
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cigna of AZ Commercial	$66.30
Rate for Payer: Copperpoint Commercial	$25.25
Rate for Payer: Health Net of AZ Commercial	$61.20
Rate for Payer: Health Net of AZ Medicare	$28.56
Rate for Payer: Humana of AZ Medicare	$16.32
Rate for Payer: Self Pay Self Pay	$81.60
Rate for Payer: TriWest Medicare	$16.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$59.47
Rate for Payer: UnitedHealth Group of AZ Medicare	$18.36

GRASPING FORCEPS

Facility

$1,075.00

Hospital Charge Code	27750225
Hospital Revenue Code	270
Min. Negotiated Rate	$172.00
Max. Negotiated Rate	$967.50
Rate for Payer: Aetna of AZ Commercial	$967.50
Rate for Payer: Aetna of AZ Medicare	$301.00
Rate for Payer: Allwell Medicare	$172.00
Rate for Payer: Amerigroup Medicare	$172.00
Rate for Payer: APIPA Medicare/Medicaid	$401.51
Rate for Payer: AZCH Complete Medicare	$172.00
Rate for Payer: Banner UC Health Medicare	$172.00
Rate for Payer: Bisbee Police All Plans	$279.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$731.00
Rate for Payer: Cash Price	$860.00
Rate for Payer: Cigna of AZ Commercial	$752.50
Rate for Payer: Copperpoint Commercial	$266.06
Rate for Payer: Health Net of AZ Commercial	$645.00
Rate for Payer: Health Net of AZ Medicare	$301.00
Rate for Payer: Humana of AZ Medicare	$172.00
Rate for Payer: Self Pay Self Pay	$860.00
Rate for Payer: TriWest Medicare	$172.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$626.73
Rate for Payer: UnitedHealth Group of AZ Medicare	$193.50

GRASPING FORCEPS

Facility

$1,075.00

Hospital Charge Code	27750225
Hospital Revenue Code	270
Min. Negotiated Rate	$279.50
Max. Negotiated Rate	$967.50
Rate for Payer: Aetna of AZ Commercial	$967.50
Rate for Payer: Bisbee Police All Plans	$279.50
Rate for Payer: Cash Price	$860.00
Rate for Payer: Self Pay Self Pay	$860.00

GROWTH HORMONE, HUMAN (HGH) (SOMATOTROPIN)

Facility

$83.00

Service Code	CPT 83003
Hospital Charge Code	28011459
Hospital Revenue Code	302
Min. Negotiated Rate	$13.28
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of AZ Commercial	$74.70
Rate for Payer: Aetna of AZ Medicare	$23.24
Rate for Payer: Allwell Medicare	$13.28
Rate for Payer: Amerigroup Medicare	$13.28
Rate for Payer: APIPA Medicare/Medicaid	$31.00
Rate for Payer: AZCH Complete Medicare	$13.28
Rate for Payer: Banner UC Health Medicare	$13.28
Rate for Payer: Bisbee Police All Plans	$21.58
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$56.44
Rate for Payer: Cash Price	$66.40
Rate for Payer: Cigna of AZ Commercial	$53.95
Rate for Payer: Copperpoint Commercial	$20.54
Rate for Payer: Health Net of AZ Commercial	$49.80
Rate for Payer: Health Net of AZ Medicare	$23.24
Rate for Payer: Humana of AZ Medicare	$13.28
Rate for Payer: Self Pay Self Pay	$66.40
Rate for Payer: TriWest Medicare	$13.28
Rate for Payer: UnitedHealth Group of AZ Commercial	$48.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$14.94

GROWTH HORMONE, HUMAN (HGH) (SOMATOTROPIN)

Facility

$83.00

Service Code	CPT 83003
Hospital Charge Code	28011459
Hospital Revenue Code	302
Min. Negotiated Rate	$21.58
Max. Negotiated Rate	$74.70
Rate for Payer: Aetna of AZ Commercial	$74.70
Rate for Payer: Bisbee Police All Plans	$21.58
Rate for Payer: Cash Price	$66.40
Rate for Payer: Self Pay Self Pay	$66.40

GST GREEN RELOAD 45MM

Facility

$10,811.20

Hospital Charge Code	27770799
Hospital Revenue Code	270
Min. Negotiated Rate	$2,810.91
Max. Negotiated Rate	$9,730.08
Rate for Payer: Aetna of AZ Commercial	$9,730.08
Rate for Payer: Bisbee Police All Plans	$2,810.91
Rate for Payer: Cash Price	$8,648.96
Rate for Payer: Self Pay Self Pay	$8,648.96

GST GREEN RELOAD 45MM

Facility

$10,811.20

Hospital Charge Code	27770799
Hospital Revenue Code	270
Min. Negotiated Rate	$1,729.79
Max. Negotiated Rate	$9,730.08
Rate for Payer: Aetna of AZ Commercial	$9,730.08
Rate for Payer: Aetna of AZ Medicare	$3,027.14
Rate for Payer: Allwell Medicare	$1,729.79
Rate for Payer: Amerigroup Medicare	$1,729.79
Rate for Payer: APIPA Medicare/Medicaid	$4,037.98
Rate for Payer: AZCH Complete Medicare	$1,729.79
Rate for Payer: Banner UC Health Medicare	$1,729.79
Rate for Payer: Bisbee Police All Plans	$2,810.91
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$7,351.62
Rate for Payer: Cash Price	$8,648.96
Rate for Payer: Cigna of AZ Commercial	$7,567.84
Rate for Payer: Copperpoint Commercial	$2,675.77
Rate for Payer: Health Net of AZ Commercial	$6,486.72
Rate for Payer: Health Net of AZ Medicare	$3,027.14
Rate for Payer: Humana of AZ Medicare	$1,729.79
Rate for Payer: Self Pay Self Pay	$8,648.96
Rate for Payer: TriWest Medicare	$1,729.79
Rate for Payer: UnitedHealth Group of AZ Commercial	$6,302.93
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,946.02

.GTT-1 Hr

Facility

$244.00

Service Code	CPT 82952
Hospital Charge Code	1160798
Hospital Revenue Code	301
Min. Negotiated Rate	$63.44
Max. Negotiated Rate	$219.60
Rate for Payer: Aetna of AZ Commercial	$219.60
Rate for Payer: Bisbee Police All Plans	$63.44
Rate for Payer: Cash Price	$195.20
Rate for Payer: Self Pay Self Pay	$195.20

.GTT-1 Hr

Facility

$244.00

Service Code	CPT 82952
Hospital Charge Code	1160798
Hospital Revenue Code	301
Min. Negotiated Rate	$39.04
Max. Negotiated Rate	$219.60
Rate for Payer: Aetna of AZ Commercial	$219.60
Rate for Payer: Aetna of AZ Medicare	$68.32
Rate for Payer: Allwell Medicare	$39.04
Rate for Payer: Amerigroup Medicare	$39.04
Rate for Payer: APIPA Medicare/Medicaid	$91.13
Rate for Payer: AZCH Complete Medicare	$39.04
Rate for Payer: Banner UC Health Medicare	$39.04
Rate for Payer: Bisbee Police All Plans	$63.44
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$165.92
Rate for Payer: Cash Price	$195.20
Rate for Payer: Cigna of AZ Commercial	$158.60
Rate for Payer: Copperpoint Commercial	$60.39
Rate for Payer: Health Net of AZ Commercial	$146.40
Rate for Payer: Health Net of AZ Medicare	$68.32
Rate for Payer: Humana of AZ Medicare	$39.04
Rate for Payer: Self Pay Self Pay	$195.20
Rate for Payer: TriWest Medicare	$39.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$142.25
Rate for Payer: UnitedHealth Group of AZ Medicare	$43.92

.GTT-2 Hr

Facility

$284.00

Service Code	CPT 82951
Hospital Charge Code	1160799
Hospital Revenue Code	306
Min. Negotiated Rate	$45.44
Max. Negotiated Rate	$255.60
Rate for Payer: Aetna of AZ Commercial	$255.60
Rate for Payer: Aetna of AZ Medicare	$79.52
Rate for Payer: Allwell Medicare	$45.44
Rate for Payer: Amerigroup Medicare	$45.44
Rate for Payer: APIPA Medicare/Medicaid	$106.07
Rate for Payer: AZCH Complete Medicare	$45.44
Rate for Payer: Banner UC Health Medicare	$45.44
Rate for Payer: Bisbee Police All Plans	$73.84
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$193.12
Rate for Payer: Cash Price	$227.20
Rate for Payer: Cigna of AZ Commercial	$184.60
Rate for Payer: Copperpoint Commercial	$70.29
Rate for Payer: Health Net of AZ Commercial	$170.40
Rate for Payer: Health Net of AZ Medicare	$79.52
Rate for Payer: Humana of AZ Medicare	$45.44
Rate for Payer: Self Pay Self Pay	$227.20
Rate for Payer: TriWest Medicare	$45.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$165.57
Rate for Payer: UnitedHealth Group of AZ Medicare	$51.12

.GTT-2 Hr

Facility

$284.00

Service Code	CPT 82951
Hospital Charge Code	1160799
Hospital Revenue Code	306
Min. Negotiated Rate	$73.84
Max. Negotiated Rate	$255.60
Rate for Payer: Aetna of AZ Commercial	$255.60
Rate for Payer: Bisbee Police All Plans	$73.84
Rate for Payer: Cash Price	$227.20
Rate for Payer: Self Pay Self Pay	$227.20

Know your out-of-pocket cost for care.

All Charges