Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

.GTT 2Hr Post Prandial

Facility

$83.00

Service Code	CPT 82950
Hospital Charge Code	1165876
Hospital Revenue Code	301
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

.GTT 2Hr Post Prandial

Facility

$83.00

Service Code	CPT 82950
Hospital Charge Code	1165876
Hospital Revenue Code	301
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

GTT 3-Hour

Facility

$284.00

Service Code	CPT 82951
Hospital Charge Code	10349371
Hospital Revenue Code	301
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 3-Hour

Facility

$284.00

Service Code	CPT 82951
Hospital Charge Code	10349371
Hospital Revenue Code	301
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

.GTT-3 Hr

Facility

$283.00

Hospital Charge Code	1160800
Hospital Revenue Code	301
Min. Negotiated Rate	$45.28
Max. Negotiated Rate	$254.70
Rate for Payer: Aetna of AZ Commercial	$254.70
Rate for Payer: Aetna of AZ Medicare	$79.24
Rate for Payer: Allwell Medicare	$45.28
Rate for Payer: Amerigroup Medicare	$45.28
Rate for Payer: APIPA Medicare/Medicaid	$105.70
Rate for Payer: AZCH Complete Medicare	$45.28
Rate for Payer: Banner UC Health Medicare	$45.28
Rate for Payer: Bisbee Police All Plans	$73.58
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$192.44
Rate for Payer: Cash Price	$226.40
Rate for Payer: Cigna of AZ Commercial	$183.95
Rate for Payer: Copperpoint Commercial	$70.04
Rate for Payer: Health Net of AZ Commercial	$169.80
Rate for Payer: Health Net of AZ Medicare	$79.24
Rate for Payer: Humana of AZ Medicare	$45.28
Rate for Payer: Self Pay Self Pay	$226.40
Rate for Payer: TriWest Medicare	$45.28
Rate for Payer: UnitedHealth Group of AZ Commercial	$164.99
Rate for Payer: UnitedHealth Group of AZ Medicare	$50.94

.GTT-3 Hr

Facility

$283.00

Hospital Charge Code	1160800
Hospital Revenue Code	301
Min. Negotiated Rate	$73.58
Max. Negotiated Rate	$254.70
Rate for Payer: Aetna of AZ Commercial	$254.70
Rate for Payer: Bisbee Police All Plans	$73.58
Rate for Payer: Cash Price	$226.40
Rate for Payer: Self Pay Self Pay	$226.40

GTT Each Add

Facility

$33.00

Service Code	CPT 82952
Hospital Charge Code	22525225
Hospital Revenue Code	301
Min. Negotiated Rate	$5.28
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Aetna of AZ Medicare	$9.24
Rate for Payer: Allwell Medicare	$5.28
Rate for Payer: Amerigroup Medicare	$5.28
Rate for Payer: APIPA Medicare/Medicaid	$12.33
Rate for Payer: AZCH Complete Medicare	$5.28
Rate for Payer: Banner UC Health Medicare	$5.28
Rate for Payer: Bisbee Police All Plans	$8.58
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$22.44
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cigna of AZ Commercial	$21.45
Rate for Payer: Copperpoint Commercial	$8.17
Rate for Payer: Health Net of AZ Commercial	$19.80
Rate for Payer: Health Net of AZ Medicare	$9.24
Rate for Payer: Humana of AZ Medicare	$5.28
Rate for Payer: Self Pay Self Pay	$26.40
Rate for Payer: TriWest Medicare	$5.28
Rate for Payer: UnitedHealth Group of AZ Commercial	$19.24
Rate for Payer: UnitedHealth Group of AZ Medicare	$5.94

GTT Each Add

Facility

$33.00

Service Code	CPT 82952
Hospital Charge Code	22525225
Hospital Revenue Code	301
Min. Negotiated Rate	$8.58
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Bisbee Police All Plans	$8.58
Rate for Payer: Cash Price	$26.40
Rate for Payer: Self Pay Self Pay	$26.40

GTT OB 3 Hour

Facility

$298.00

Service Code	CPT 82951
Hospital Charge Code	22283156
Hospital Revenue Code	301
Min. Negotiated Rate	$77.48
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Bisbee Police All Plans	$77.48
Rate for Payer: Cash Price	$238.40
Rate for Payer: Self Pay Self Pay	$238.40

GTT OB 3 Hour

Facility

$298.00

Service Code	CPT 82951
Hospital Charge Code	22283156
Hospital Revenue Code	301
Min. Negotiated Rate	$47.68
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Aetna of AZ Medicare	$83.44
Rate for Payer: Allwell Medicare	$47.68
Rate for Payer: Amerigroup Medicare	$47.68
Rate for Payer: APIPA Medicare/Medicaid	$111.30
Rate for Payer: AZCH Complete Medicare	$47.68
Rate for Payer: Banner UC Health Medicare	$47.68
Rate for Payer: Bisbee Police All Plans	$77.48
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$202.64
Rate for Payer: Cash Price	$238.40
Rate for Payer: Cigna of AZ Commercial	$193.70
Rate for Payer: Copperpoint Commercial	$73.75
Rate for Payer: Health Net of AZ Commercial	$178.80
Rate for Payer: Health Net of AZ Medicare	$83.44
Rate for Payer: Humana of AZ Medicare	$47.68
Rate for Payer: Self Pay Self Pay	$238.40
Rate for Payer: TriWest Medicare	$47.68
Rate for Payer: UnitedHealth Group of AZ Commercial	$173.73
Rate for Payer: UnitedHealth Group of AZ Medicare	$53.64

guaiFENesin 100 mg/5 mL UD Oral Liq [CQCH]

Facility

$0.03

Service Code	NDC 121174405
Hospital Charge Code	105925028
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

guaiFENesin 100 mg/5 mL UD Oral Liq [CQCH]

Facility

$0.03

Service Code	NDC 121174405
Hospital Charge Code	105925028
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

guaiFENesin 600 mg ER Tablet [CQCH]

Facility

$0.33

Service Code	NDC 63824000834
Hospital Charge Code	105924961
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of AZ Commercial	$0.30
Rate for Payer: Aetna of AZ Medicare	$0.09
Rate for Payer: Allwell Medicare	$0.05
Rate for Payer: Amerigroup Medicare	$0.05
Rate for Payer: APIPA Medicare/Medicaid	$0.12
Rate for Payer: AZCH Complete Medicare	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
Rate for Payer: Bisbee Police All Plans	$0.09
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.22
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna of AZ Commercial	$0.21
Rate for Payer: Copperpoint Commercial	$0.08
Rate for Payer: Health Net of AZ Commercial	$0.20
Rate for Payer: Health Net of AZ Medicare	$0.09
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Self Pay Self Pay	$0.26
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.06

guaiFENesin 600 mg ER Tablet [CQCH]

Facility

$0.33

Service Code	NDC 63824000834
Hospital Charge Code	105924961
Hospital Revenue Code	251
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of AZ Commercial	$0.30
Rate for Payer: Bisbee Police All Plans	$0.09
Rate for Payer: Cash Price	$0.26
Rate for Payer: Self Pay Self Pay	$0.26

guaiFENesin-dextromethorphan 100 mg-10 mg/5 mL UD Oral Liq [CQCH]

Facility

$0.13

Service Code	NDC 121063805
Hospital Charge Code	105918158
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Bisbee Police All Plans	$0.03
Rate for Payer: Cash Price	$0.10
Rate for Payer: Self Pay Self Pay	$0.10

guaiFENesin-dextromethorphan 100 mg-10 mg/5 mL UD Oral Liq [CQCH]

Facility

$0.13

Service Code	NDC 121063805
Hospital Charge Code	105918158
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

GUIDEWIRE HI WIRE NITINOL CORE

Facility

$153.00

Hospital Charge Code	22354824
Hospital Revenue Code	270
Min. Negotiated Rate	$24.48
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of AZ Commercial	$137.70
Rate for Payer: Aetna of AZ Medicare	$42.84
Rate for Payer: Allwell Medicare	$24.48
Rate for Payer: Amerigroup Medicare	$24.48
Rate for Payer: APIPA Medicare/Medicaid	$57.15
Rate for Payer: AZCH Complete Medicare	$24.48
Rate for Payer: Banner UC Health Medicare	$24.48
Rate for Payer: Bisbee Police All Plans	$39.78
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$104.04
Rate for Payer: Cash Price	$122.40
Rate for Payer: Cigna of AZ Commercial	$107.10
Rate for Payer: Copperpoint Commercial	$37.87
Rate for Payer: Health Net of AZ Commercial	$91.80
Rate for Payer: Health Net of AZ Medicare	$42.84
Rate for Payer: Humana of AZ Medicare	$24.48
Rate for Payer: Self Pay Self Pay	$122.40
Rate for Payer: TriWest Medicare	$24.48
Rate for Payer: UnitedHealth Group of AZ Commercial	$89.20
Rate for Payer: UnitedHealth Group of AZ Medicare	$27.54

GUIDEWIRE HI WIRE NITINOL CORE

Facility

$153.00

Hospital Charge Code	22354824
Hospital Revenue Code	270
Min. Negotiated Rate	$39.78
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of AZ Commercial	$137.70
Rate for Payer: Bisbee Police All Plans	$39.78
Rate for Payer: Cash Price	$122.40
Rate for Payer: Self Pay Self Pay	$122.40

GUIDE WIRE SMOOTH .82 X 90MM DOUBLE POINT

Facility

$89.00

Hospital Charge Code	24127799
Hospital Revenue Code	270
Min. Negotiated Rate	$14.24
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of AZ Commercial	$80.10
Rate for Payer: Aetna of AZ Medicare	$24.92
Rate for Payer: Allwell Medicare	$14.24
Rate for Payer: Amerigroup Medicare	$14.24
Rate for Payer: APIPA Medicare/Medicaid	$33.24
Rate for Payer: AZCH Complete Medicare	$14.24
Rate for Payer: Banner UC Health Medicare	$14.24
Rate for Payer: Bisbee Police All Plans	$23.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$60.52
Rate for Payer: Cash Price	$71.20
Rate for Payer: Cigna of AZ Commercial	$62.30
Rate for Payer: Copperpoint Commercial	$22.03
Rate for Payer: Health Net of AZ Commercial	$53.40
Rate for Payer: Health Net of AZ Medicare	$24.92
Rate for Payer: Humana of AZ Medicare	$14.24
Rate for Payer: Self Pay Self Pay	$71.20
Rate for Payer: TriWest Medicare	$14.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$51.89
Rate for Payer: UnitedHealth Group of AZ Medicare	$16.02

GUIDE WIRE SMOOTH .82 X 90MM DOUBLE POINT

Facility

$89.00

Hospital Charge Code	24127799
Hospital Revenue Code	270
Min. Negotiated Rate	$23.14
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of AZ Commercial	$80.10
Rate for Payer: Bisbee Police All Plans	$23.14
Rate for Payer: Cash Price	$71.20
Rate for Payer: Self Pay Self Pay	$71.20

GYRUS ACMI SOF CURL URETERAL STENT 6.X24

Facility

$720.00

Hospital Charge Code	22354135
Hospital Revenue Code	270
Min. Negotiated Rate	$115.20
Max. Negotiated Rate	$648.00
Rate for Payer: Aetna of AZ Commercial	$648.00
Rate for Payer: Aetna of AZ Medicare	$201.60
Rate for Payer: Allwell Medicare	$115.20
Rate for Payer: Amerigroup Medicare	$115.20
Rate for Payer: APIPA Medicare/Medicaid	$268.92
Rate for Payer: AZCH Complete Medicare	$115.20
Rate for Payer: Banner UC Health Medicare	$115.20
Rate for Payer: Bisbee Police All Plans	$187.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$489.60
Rate for Payer: Cash Price	$576.00
Rate for Payer: Cigna of AZ Commercial	$504.00
Rate for Payer: Copperpoint Commercial	$178.20
Rate for Payer: Health Net of AZ Commercial	$432.00
Rate for Payer: Health Net of AZ Medicare	$201.60
Rate for Payer: Humana of AZ Medicare	$115.20
Rate for Payer: Self Pay Self Pay	$576.00
Rate for Payer: TriWest Medicare	$115.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$419.76
Rate for Payer: UnitedHealth Group of AZ Medicare	$129.60

GYRUS ACMI SOF CURL URETERAL STENT 6.X24

Facility

$720.00

Hospital Charge Code	22354135
Hospital Revenue Code	270
Min. Negotiated Rate	$187.20
Max. Negotiated Rate	$648.00
Rate for Payer: Aetna of AZ Commercial	$648.00
Rate for Payer: Bisbee Police All Plans	$187.20
Rate for Payer: Cash Price	$576.00
Rate for Payer: Self Pay Self Pay	$576.00

GYRUS ACMI SOF CURL URETERAL STENT 6.X26

Facility

$720.00

Hospital Charge Code	22354136
Hospital Revenue Code	270
Min. Negotiated Rate	$187.20
Max. Negotiated Rate	$648.00
Rate for Payer: Aetna of AZ Commercial	$648.00
Rate for Payer: Bisbee Police All Plans	$187.20
Rate for Payer: Cash Price	$576.00
Rate for Payer: Self Pay Self Pay	$576.00

GYRUS ACMI SOF CURL URETERAL STENT 6.X26

Facility

$720.00

Hospital Charge Code	22354136
Hospital Revenue Code	270
Min. Negotiated Rate	$115.20
Max. Negotiated Rate	$648.00
Rate for Payer: Aetna of AZ Commercial	$648.00
Rate for Payer: Aetna of AZ Medicare	$201.60
Rate for Payer: Allwell Medicare	$115.20
Rate for Payer: Amerigroup Medicare	$115.20
Rate for Payer: APIPA Medicare/Medicaid	$268.92
Rate for Payer: AZCH Complete Medicare	$115.20
Rate for Payer: Banner UC Health Medicare	$115.20
Rate for Payer: Bisbee Police All Plans	$187.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$489.60
Rate for Payer: Cash Price	$576.00
Rate for Payer: Cigna of AZ Commercial	$504.00
Rate for Payer: Copperpoint Commercial	$178.20
Rate for Payer: Health Net of AZ Commercial	$432.00
Rate for Payer: Health Net of AZ Medicare	$201.60
Rate for Payer: Humana of AZ Medicare	$115.20
Rate for Payer: Self Pay Self Pay	$576.00
Rate for Payer: TriWest Medicare	$115.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$419.76
Rate for Payer: UnitedHealth Group of AZ Medicare	$129.60

GYRUS ACMI SUR CATCH NT BASKET 2.2FR

Facility

$823.00

Hospital Charge Code	22354137
Hospital Revenue Code	270
Min. Negotiated Rate	$213.98
Max. Negotiated Rate	$740.70
Rate for Payer: Aetna of AZ Commercial	$740.70
Rate for Payer: Bisbee Police All Plans	$213.98
Rate for Payer: Cash Price	$658.40
Rate for Payer: Self Pay Self Pay	$658.40

Know your out-of-pocket cost for care.

All Charges