Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

HUMIDIFIER REFILL 500 ML

Facility

$22.00

Hospital Charge Code	22355209
Hospital Revenue Code	270
Min. Negotiated Rate	$5.72
Max. Negotiated Rate	$19.80
Rate for Payer: Aetna of AZ Commercial	$19.80
Rate for Payer: Bisbee Police All Plans	$5.72
Rate for Payer: Cash Price	$17.60
Rate for Payer: Self Pay Self Pay	$17.60

hydrALAZINE 20 mg/ 1 mL Sol [CQCH]

Facility

$3.15

Service Code	HCPCS J0360
Hospital Charge Code	122900854
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$2.83
Rate for Payer: Aetna of AZ Commercial	$2.83
Rate for Payer: Aetna of AZ Medicare	$0.88
Rate for Payer: Allwell Medicare	$0.50
Rate for Payer: Amerigroup Medicare	$0.50
Rate for Payer: APIPA Medicare/Medicaid	$1.18
Rate for Payer: AZCH Complete Medicare	$0.50
Rate for Payer: Banner UC Health Medicare	$0.50
Rate for Payer: Bisbee Police All Plans	$0.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2.14
Rate for Payer: Cash Price	$2.52
Rate for Payer: Cigna of AZ Commercial	$2.05
Rate for Payer: Copperpoint Commercial	$0.78
Rate for Payer: Health Net of AZ Commercial	$1.89
Rate for Payer: Health Net of AZ Medicare	$0.88
Rate for Payer: Humana of AZ Medicare	$0.50
Rate for Payer: Self Pay Self Pay	$2.52
Rate for Payer: TriWest Medicare	$0.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.84
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.57

hydrALAZINE 20 mg/ 1 mL Sol [CQCH]

Facility

$3.15

Service Code	HCPCS J0360
Hospital Charge Code	122900854
Hospital Revenue Code	250
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$2.83
Rate for Payer: Aetna of AZ Commercial	$2.83
Rate for Payer: Bisbee Police All Plans	$0.82
Rate for Payer: Cash Price	$2.52
Rate for Payer: Self Pay Self Pay	$2.52

hydrALAZINE 25 mg Tab [CQCH]

Facility

$0.10

Service Code	NDC 63739032710
Hospital Charge Code	105925507
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of AZ Commercial	$0.09
Rate for Payer: Bisbee Police All Plans	$0.03
Rate for Payer: Cash Price	$0.08
Rate for Payer: Self Pay Self Pay	$0.08

hydrALAZINE 25 mg Tab [CQCH]

Facility

$0.10

Service Code	NDC 63739032710
Hospital Charge Code	105925507
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of AZ Commercial	$0.09
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	$0.07
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of AZ Commercial	$0.07
Rate for Payer: Copperpoint Commercial	$0.02
Rate for Payer: Health Net of AZ Commercial	$0.06
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	$0.08
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.06
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.02

hydroCHLOROthiazide 25 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 63739012810
Hospital Charge Code	105925572
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	$0.02
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

hydroCHLOROthiazide 25 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 63739012810
Hospital Charge Code	105925572
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	$0.02
Rate for Payer: Self Pay Self Pay	$0.02

hydrocortisone 100 mg/2 mL Inj [CQCH]

Facility

$13.65

Service Code	HCPCS J1720
Hospital Charge Code	105925704
Hospital Revenue Code	250
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$12.29
Rate for Payer: Aetna of AZ Commercial	$12.29
Rate for Payer: Aetna of AZ Medicare	$3.82
Rate for Payer: Allwell Medicare	$2.18
Rate for Payer: Amerigroup Medicare	$2.18
Rate for Payer: APIPA Medicare/Medicaid	$5.10
Rate for Payer: AZCH Complete Medicare	$2.18
Rate for Payer: Banner UC Health Medicare	$2.18
Rate for Payer: Bisbee Police All Plans	$3.55
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$9.28
Rate for Payer: Cash Price	$10.92
Rate for Payer: Cigna of AZ Commercial	$8.87
Rate for Payer: Copperpoint Commercial	$3.38
Rate for Payer: Health Net of AZ Commercial	$8.19
Rate for Payer: Health Net of AZ Medicare	$3.82
Rate for Payer: Humana of AZ Medicare	$2.18
Rate for Payer: Self Pay Self Pay	$10.92
Rate for Payer: TriWest Medicare	$2.18
Rate for Payer: UnitedHealth Group of AZ Commercial	$7.96
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.46

hydrocortisone 100 mg/2 mL Inj [CQCH]

Facility

$13.65

Service Code	HCPCS J1720
Hospital Charge Code	105925704
Hospital Revenue Code	250
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$12.29
Rate for Payer: Aetna of AZ Commercial	$12.29
Rate for Payer: Bisbee Police All Plans	$3.55
Rate for Payer: Cash Price	$10.92
Rate for Payer: Self Pay Self Pay	$10.92

hydrocortisone 25 mg Supp [CQCH]

Facility

$1.69

Service Code	NDC 42494030112
Hospital Charge Code	105925771
Hospital Revenue Code	251
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$1.52
Rate for Payer: Aetna of AZ Commercial	$1.52
Rate for Payer: Bisbee Police All Plans	$0.44
Rate for Payer: Cash Price	$1.35
Rate for Payer: Self Pay Self Pay	$1.35

hydrocortisone 25 mg Supp [CQCH]

Facility

$1.69

Service Code	NDC 42494030112
Hospital Charge Code	105925771
Hospital Revenue Code	251
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$1.52
Rate for Payer: Aetna of AZ Commercial	$1.52
Rate for Payer: Aetna of AZ Medicare	$0.47
Rate for Payer: Allwell Medicare	$0.27
Rate for Payer: Amerigroup Medicare	$0.27
Rate for Payer: APIPA Medicare/Medicaid	$0.63
Rate for Payer: AZCH Complete Medicare	$0.27
Rate for Payer: Banner UC Health Medicare	$0.27
Rate for Payer: Bisbee Police All Plans	$0.44
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.15
Rate for Payer: Cash Price	$1.35
Rate for Payer: Cigna of AZ Commercial	$1.10
Rate for Payer: Copperpoint Commercial	$0.42
Rate for Payer: Health Net of AZ Commercial	$1.01
Rate for Payer: Health Net of AZ Medicare	$0.47
Rate for Payer: Humana of AZ Medicare	$0.27
Rate for Payer: Self Pay Self Pay	$1.35
Rate for Payer: TriWest Medicare	$0.27
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.99
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.30

hydrocortisone/neomycin/polymyxin B Otic Susp [CQCH]

Facility

$8.26

Service Code	NDC 24208063110
Hospital Charge Code	105925901
Hospital Revenue Code	251
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$7.43
Rate for Payer: Aetna of AZ Commercial	$7.43
Rate for Payer: Aetna of AZ Medicare	$2.31
Rate for Payer: Allwell Medicare	$1.32
Rate for Payer: Amerigroup Medicare	$1.32
Rate for Payer: APIPA Medicare/Medicaid	$3.09
Rate for Payer: AZCH Complete Medicare	$1.32
Rate for Payer: Banner UC Health Medicare	$1.32
Rate for Payer: Bisbee Police All Plans	$2.15
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$5.62
Rate for Payer: Cash Price	$6.61
Rate for Payer: Cigna of AZ Commercial	$5.37
Rate for Payer: Copperpoint Commercial	$2.04
Rate for Payer: Health Net of AZ Commercial	$4.96
Rate for Payer: Health Net of AZ Medicare	$2.31
Rate for Payer: Humana of AZ Medicare	$1.32
Rate for Payer: Self Pay Self Pay	$6.61
Rate for Payer: TriWest Medicare	$1.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$4.82
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.49

hydrocortisone/neomycin/polymyxin B Otic Susp [CQCH]

Facility

$8.26

Service Code	NDC 24208063110
Hospital Charge Code	105925901
Hospital Revenue Code	251
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$7.43
Rate for Payer: Aetna of AZ Commercial	$7.43
Rate for Payer: Bisbee Police All Plans	$2.15
Rate for Payer: Cash Price	$6.61
Rate for Payer: Self Pay Self Pay	$6.61

hydrocortisone Top 1% Crm 28 gm [CQCH]

Facility

$0.03

Service Code	NDC 603053550
Hospital Charge Code	105925836
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	$0.02
Rate for Payer: Self Pay Self Pay	$0.02

hydrocortisone Top 1% Crm 28 gm [CQCH]

Facility

$0.03

Service Code	NDC 603053550
Hospital Charge Code	105925836
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	$0.02
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

HYDROFERA BLUE CLASSIC 2X2 DRESSING

Facility

$24.00

Hospital Charge Code	27709652
Hospital Revenue Code	270
Min. Negotiated Rate	$3.84
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna of AZ Commercial	$21.60
Rate for Payer: Aetna of AZ Medicare	$6.72
Rate for Payer: Allwell Medicare	$3.84
Rate for Payer: Amerigroup Medicare	$3.84
Rate for Payer: APIPA Medicare/Medicaid	$8.96
Rate for Payer: AZCH Complete Medicare	$3.84
Rate for Payer: Banner UC Health Medicare	$3.84
Rate for Payer: Bisbee Police All Plans	$6.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$16.32
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cigna of AZ Commercial	$16.80
Rate for Payer: Copperpoint Commercial	$5.94
Rate for Payer: Health Net of AZ Commercial	$14.40
Rate for Payer: Health Net of AZ Medicare	$6.72
Rate for Payer: Humana of AZ Medicare	$3.84
Rate for Payer: Self Pay Self Pay	$19.20
Rate for Payer: TriWest Medicare	$3.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$13.99
Rate for Payer: UnitedHealth Group of AZ Medicare	$4.32

HYDROFERA BLUE CLASSIC 2X2 DRESSING

Facility

$24.00

Hospital Charge Code	27709652
Hospital Revenue Code	270
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna of AZ Commercial	$21.60
Rate for Payer: Bisbee Police All Plans	$6.24
Rate for Payer: Cash Price	$19.20
Rate for Payer: Self Pay Self Pay	$19.20

HYDROFERA BLUE CLASSIC 4X4 DRESSING

Facility

$36.00

Hospital Charge Code	27709653
Hospital Revenue Code	270
Min. Negotiated Rate	$9.36
Max. Negotiated Rate	$32.40
Rate for Payer: Aetna of AZ Commercial	$32.40
Rate for Payer: Bisbee Police All Plans	$9.36
Rate for Payer: Cash Price	$28.80
Rate for Payer: Self Pay Self Pay	$28.80

HYDROFERA BLUE CLASSIC 4X4 DRESSING

Facility

$36.00

Hospital Charge Code	27709653
Hospital Revenue Code	270
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$32.40
Rate for Payer: Aetna of AZ Commercial	$32.40
Rate for Payer: Aetna of AZ Medicare	$10.08
Rate for Payer: Allwell Medicare	$5.76
Rate for Payer: Amerigroup Medicare	$5.76
Rate for Payer: APIPA Medicare/Medicaid	$13.45
Rate for Payer: AZCH Complete Medicare	$5.76
Rate for Payer: Banner UC Health Medicare	$5.76
Rate for Payer: Bisbee Police All Plans	$9.36
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$24.48
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna of AZ Commercial	$25.20
Rate for Payer: Copperpoint Commercial	$8.91
Rate for Payer: Health Net of AZ Commercial	$21.60
Rate for Payer: Health Net of AZ Medicare	$10.08
Rate for Payer: Humana of AZ Medicare	$5.76
Rate for Payer: Self Pay Self Pay	$28.80
Rate for Payer: TriWest Medicare	$5.76
Rate for Payer: UnitedHealth Group of AZ Commercial	$20.99
Rate for Payer: UnitedHealth Group of AZ Medicare	$6.48

HYDROmorphone 0.5 mg/0.5 mL Sol[CQCH]

Facility

$10.16

Service Code	HCPCS J1170
Hospital Charge Code	128562285
Hospital Revenue Code	250
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$9.14
Rate for Payer: Aetna of AZ Commercial	$9.14
Rate for Payer: Bisbee Police All Plans	$2.64
Rate for Payer: Cash Price	$8.13
Rate for Payer: Self Pay Self Pay	$8.13

HYDROmorphone 0.5 mg/0.5 mL Sol[CQCH]

Facility

$10.16

Service Code	HCPCS J1170
Hospital Charge Code	128562285
Hospital Revenue Code	250
Min. Negotiated Rate	$1.63
Max. Negotiated Rate	$9.14
Rate for Payer: Aetna of AZ Commercial	$9.14
Rate for Payer: Aetna of AZ Medicare	$2.84
Rate for Payer: Allwell Medicare	$1.63
Rate for Payer: Amerigroup Medicare	$1.63
Rate for Payer: APIPA Medicare/Medicaid	$3.79
Rate for Payer: AZCH Complete Medicare	$1.63
Rate for Payer: Banner UC Health Medicare	$1.63
Rate for Payer: Bisbee Police All Plans	$2.64
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$6.91
Rate for Payer: Cash Price	$8.13
Rate for Payer: Cigna of AZ Commercial	$6.60
Rate for Payer: Copperpoint Commercial	$2.51
Rate for Payer: Health Net of AZ Commercial	$6.10
Rate for Payer: Health Net of AZ Medicare	$2.84
Rate for Payer: Humana of AZ Medicare	$1.63
Rate for Payer: Self Pay Self Pay	$8.13
Rate for Payer: TriWest Medicare	$1.63
Rate for Payer: UnitedHealth Group of AZ Commercial	$5.92
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.83

HYDROmorphone 1 mg/mL Inj Sol [CQCH]

Facility

$2.02

Service Code	HCPCS J1170
Hospital Charge Code	105925966
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$1.82
Rate for Payer: Aetna of AZ Commercial	$1.82
Rate for Payer: Aetna of AZ Medicare	$0.57
Rate for Payer: Allwell Medicare	$0.32
Rate for Payer: Amerigroup Medicare	$0.32
Rate for Payer: APIPA Medicare/Medicaid	$0.75
Rate for Payer: AZCH Complete Medicare	$0.32
Rate for Payer: Banner UC Health Medicare	$0.32
Rate for Payer: Bisbee Police All Plans	$0.53
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.37
Rate for Payer: Cash Price	$1.61
Rate for Payer: Cigna of AZ Commercial	$1.31
Rate for Payer: Copperpoint Commercial	$0.50
Rate for Payer: Health Net of AZ Commercial	$1.21
Rate for Payer: Health Net of AZ Medicare	$0.57
Rate for Payer: Humana of AZ Medicare	$0.32
Rate for Payer: Self Pay Self Pay	$1.62
Rate for Payer: TriWest Medicare	$0.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.18
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.36

HYDROmorphone 1 mg/mL Inj Sol [CQCH]

Facility

$2.02

Service Code	HCPCS J1170
Hospital Charge Code	105925966
Hospital Revenue Code	250
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$1.82
Rate for Payer: Aetna of AZ Commercial	$1.82
Rate for Payer: Bisbee Police All Plans	$0.53
Rate for Payer: Cash Price	$1.61
Rate for Payer: Self Pay Self Pay	$1.62

HYDROmorphone 2 mg/mL Sol[CQCH]

Facility

$1.15

Service Code	HCPCS J1170
Hospital Charge Code	128843622
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$1.03
Rate for Payer: Aetna of AZ Commercial	$1.03
Rate for Payer: Aetna of AZ Medicare	$0.32
Rate for Payer: Allwell Medicare	$0.18
Rate for Payer: Amerigroup Medicare	$0.18
Rate for Payer: APIPA Medicare/Medicaid	$0.43
Rate for Payer: AZCH Complete Medicare	$0.18
Rate for Payer: Banner UC Health Medicare	$0.18
Rate for Payer: Bisbee Police All Plans	$0.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.78
Rate for Payer: Cash Price	$0.92
Rate for Payer: Cigna of AZ Commercial	$0.75
Rate for Payer: Copperpoint Commercial	$0.28
Rate for Payer: Health Net of AZ Commercial	$0.69
Rate for Payer: Health Net of AZ Medicare	$0.32
Rate for Payer: Humana of AZ Medicare	$0.18
Rate for Payer: Self Pay Self Pay	$0.92
Rate for Payer: TriWest Medicare	$0.18
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.21

HYDROmorphone 2 mg/mL Sol[CQCH]

Facility

$1.15

Service Code	HCPCS J1170
Hospital Charge Code	128843622
Hospital Revenue Code	250
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$1.03
Rate for Payer: Aetna of AZ Commercial	$1.03
Rate for Payer: Bisbee Police All Plans	$0.30
Rate for Payer: Cash Price	$0.92
Rate for Payer: Self Pay Self Pay	$0.92

Know your out-of-pocket cost for care.

All Charges