Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIU

Facility

$1,247.00

Service Code	CPT 58558
Hospital Charge Code	22892680
Hospital Revenue Code	982
Min. Negotiated Rate	$199.52
Max. Negotiated Rate	$3,373.00
Rate for Payer: Aetna of AZ Commercial	$1,122.30
Rate for Payer: Aetna of AZ Medicare	$349.16
Rate for Payer: AHCCCS Medicaid	$1,901.83
Rate for Payer: Allwell Medicaid	$1,901.83
Rate for Payer: Allwell Medicare	$199.52
Rate for Payer: Amerigroup Medicare	$199.52
Rate for Payer: APIPA Medicare/Medicaid	$465.75
Rate for Payer: AZCH Complete Medicaid	$1,901.83
Rate for Payer: AZCH Complete Medicare	$199.52
Rate for Payer: Banner UC Health Medicaid	$1,901.83
Rate for Payer: Banner UC Health Medicare	$199.52
Rate for Payer: Bisbee Police All Plans	$324.22
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$847.96
Rate for Payer: Cash Price	$997.60
Rate for Payer: Cash Price	$997.60
Rate for Payer: Cigna of AZ Commercial	$872.90
Rate for Payer: Copperpoint Commercial	$308.63
Rate for Payer: Health Net of AZ Commercial	$748.20
Rate for Payer: Health Net of AZ Medicare	$349.16
Rate for Payer: Humana of AZ Medicare	$199.52
Rate for Payer: Mercy Care Medicaid	$1,901.83
Rate for Payer: Self Pay Self Pay	$997.60
Rate for Payer: TriWest Medicare	$199.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,373.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$224.46

HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIU

Facility

$1,247.00

Service Code	CPT 58558
Hospital Charge Code	22892680
Hospital Revenue Code	982
Min. Negotiated Rate	$324.22
Max. Negotiated Rate	$1,122.30
Rate for Payer: Aetna of AZ Commercial	$1,122.30
Rate for Payer: Bisbee Police All Plans	$324.22
Rate for Payer: Cash Price	$997.60
Rate for Payer: Self Pay Self Pay	$997.60

ibuprofen 100 mg/5 mL Oral Susp [CQCH]

Facility

$0.12

Service Code	NDC 50383058407
Hospital Charge Code	105926316
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

ibuprofen 100 mg/5 mL Oral Susp [CQCH]

Facility

$0.12

Service Code	NDC 50383058407
Hospital Charge Code	105926316
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

ibuprofen 400 mg Tab [CQCH]

Facility

$0.05

Service Code	NDC 63739067210
Hospital Charge Code	105926513
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
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	$0.02
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	$0.04
Rate for Payer: Cigna of AZ Commercial	$0.03
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.03
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	$0.04
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

ibuprofen 400 mg Tab [CQCH]

Facility

$0.05

Service Code	NDC 63739067210
Hospital Charge Code	105926513
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.04
Rate for Payer: Self Pay Self Pay	$0.04

ibuprofen 600 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 904585461
Hospital Charge Code	105926448
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Aetna of AZ Medicare	$0.02
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.02
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.04
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of AZ Commercial	$0.04
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.04
Rate for Payer: Health Net of AZ Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Self Pay Self Pay	$0.05
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

ibuprofen 600 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 904585461
Hospital Charge Code	105926448
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Cash Price	$0.05
Rate for Payer: Self Pay Self Pay	$0.05

ibuprofen 800 mg Tab [CQCH]

Facility

$0.08

Service Code	NDC 63739069110
Hospital Charge Code	105926383
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Cash Price	$0.07
Rate for Payer: Self Pay Self Pay	$0.06

ibuprofen 800 mg Tab [CQCH]

Facility

$0.08

Service Code	NDC 63739069110
Hospital Charge Code	105926383
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
Rate for Payer: Aetna of AZ Medicare	$0.02
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.03
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.05
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of AZ Commercial	$0.05
Rate for Payer: Copperpoint Commercial	$0.02
Rate for Payer: Health Net of AZ Commercial	$0.05
Rate for Payer: Health Net of AZ Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Self Pay Self Pay	$0.06
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.05
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

IFE and PE, Random Urine LC

Facility

$903.00

Service Code	CPT 86335
Hospital Charge Code	1285723
Hospital Revenue Code	302
Min. Negotiated Rate	$144.48
Max. Negotiated Rate	$812.70
Rate for Payer: Aetna of AZ Commercial	$812.70
Rate for Payer: Aetna of AZ Medicare	$252.84
Rate for Payer: Allwell Medicare	$144.48
Rate for Payer: Amerigroup Medicare	$144.48
Rate for Payer: APIPA Medicare/Medicaid	$337.27
Rate for Payer: AZCH Complete Medicare	$144.48
Rate for Payer: Banner UC Health Medicare	$144.48
Rate for Payer: Bisbee Police All Plans	$234.78
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$614.04
Rate for Payer: Cash Price	$722.40
Rate for Payer: Cigna of AZ Commercial	$586.95
Rate for Payer: Copperpoint Commercial	$223.49
Rate for Payer: Health Net of AZ Commercial	$541.80
Rate for Payer: Health Net of AZ Medicare	$252.84
Rate for Payer: Humana of AZ Medicare	$144.48
Rate for Payer: Self Pay Self Pay	$722.40
Rate for Payer: TriWest Medicare	$144.48
Rate for Payer: UnitedHealth Group of AZ Commercial	$526.45
Rate for Payer: UnitedHealth Group of AZ Medicare	$162.54

IFE and PE, Random Urine LC

Facility

$903.00

Service Code	CPT 86335
Hospital Charge Code	1285723
Hospital Revenue Code	302
Min. Negotiated Rate	$234.78
Max. Negotiated Rate	$812.70
Rate for Payer: Aetna of AZ Commercial	$812.70
Rate for Payer: Bisbee Police All Plans	$234.78
Rate for Payer: Cash Price	$722.40
Rate for Payer: Self Pay Self Pay	$722.40

IFE and PE, Serum LC

Facility

$681.00

Service Code	CPT 84165
Hospital Charge Code	1905770
Hospital Revenue Code	302
Min. Negotiated Rate	$177.06
Max. Negotiated Rate	$612.90
Rate for Payer: Aetna of AZ Commercial	$612.90
Rate for Payer: Bisbee Police All Plans	$177.06
Rate for Payer: Cash Price	$544.80
Rate for Payer: Self Pay Self Pay	$544.80

IFE and PE, Serum LC

Facility

$681.00

Service Code	CPT 84165
Hospital Charge Code	1905770
Hospital Revenue Code	302
Min. Negotiated Rate	$108.96
Max. Negotiated Rate	$612.90
Rate for Payer: Aetna of AZ Commercial	$612.90
Rate for Payer: Aetna of AZ Medicare	$190.68
Rate for Payer: Allwell Medicare	$108.96
Rate for Payer: Amerigroup Medicare	$108.96
Rate for Payer: APIPA Medicare/Medicaid	$254.35
Rate for Payer: AZCH Complete Medicare	$108.96
Rate for Payer: Banner UC Health Medicare	$108.96
Rate for Payer: Bisbee Police All Plans	$177.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$463.08
Rate for Payer: Cash Price	$544.80
Rate for Payer: Cigna of AZ Commercial	$442.65
Rate for Payer: Copperpoint Commercial	$168.55
Rate for Payer: Health Net of AZ Commercial	$408.60
Rate for Payer: Health Net of AZ Medicare	$190.68
Rate for Payer: Humana of AZ Medicare	$108.96
Rate for Payer: Self Pay Self Pay	$544.80
Rate for Payer: TriWest Medicare	$108.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$397.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$122.58

IFE+Protein Electro, 24-Hr Ur LC

Facility

$903.00

Service Code	CPT 86335
Hospital Charge Code	1285722
Hospital Revenue Code	302
Min. Negotiated Rate	$234.78
Max. Negotiated Rate	$812.70
Rate for Payer: Aetna of AZ Commercial	$812.70
Rate for Payer: Bisbee Police All Plans	$234.78
Rate for Payer: Cash Price	$722.40
Rate for Payer: Self Pay Self Pay	$722.40

IFE+Protein Electro, 24-Hr Ur LC

Facility

$903.00

Service Code	CPT 86335
Hospital Charge Code	1285722
Hospital Revenue Code	302
Min. Negotiated Rate	$144.48
Max. Negotiated Rate	$812.70
Rate for Payer: Aetna of AZ Commercial	$812.70
Rate for Payer: Aetna of AZ Medicare	$252.84
Rate for Payer: Allwell Medicare	$144.48
Rate for Payer: Amerigroup Medicare	$144.48
Rate for Payer: APIPA Medicare/Medicaid	$337.27
Rate for Payer: AZCH Complete Medicare	$144.48
Rate for Payer: Banner UC Health Medicare	$144.48
Rate for Payer: Bisbee Police All Plans	$234.78
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$614.04
Rate for Payer: Cash Price	$722.40
Rate for Payer: Cigna of AZ Commercial	$586.95
Rate for Payer: Copperpoint Commercial	$223.49
Rate for Payer: Health Net of AZ Commercial	$541.80
Rate for Payer: Health Net of AZ Medicare	$252.84
Rate for Payer: Humana of AZ Medicare	$144.48
Rate for Payer: Self Pay Self Pay	$722.40
Rate for Payer: TriWest Medicare	$144.48
Rate for Payer: UnitedHealth Group of AZ Commercial	$526.45
Rate for Payer: UnitedHealth Group of AZ Medicare	$162.54

I-GEL 1

Facility

$60.00

Hospital Charge Code	22926453
Hospital Revenue Code	272
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Bisbee Police All Plans	$15.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Self Pay Self Pay	$48.00

I-GEL 1

Facility

$60.00

Hospital Charge Code	22926453
Hospital Revenue Code	272
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Aetna of AZ Medicare	$16.80
Rate for Payer: Allwell Medicare	$9.60
Rate for Payer: Amerigroup Medicare	$9.60
Rate for Payer: APIPA Medicare/Medicaid	$22.41
Rate for Payer: AZCH Complete Medicare	$9.60
Rate for Payer: Banner UC Health Medicare	$9.60
Rate for Payer: Bisbee Police All Plans	$15.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$40.80
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cigna of AZ Commercial	$42.00
Rate for Payer: Copperpoint Commercial	$14.85
Rate for Payer: Health Net of AZ Commercial	$36.00
Rate for Payer: Health Net of AZ Medicare	$16.80
Rate for Payer: Humana of AZ Medicare	$9.60
Rate for Payer: Self Pay Self Pay	$48.00
Rate for Payer: TriWest Medicare	$9.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$34.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$10.80

I-GEL 2

Facility

$60.00

Hospital Charge Code	22926454
Hospital Revenue Code	272
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Aetna of AZ Medicare	$16.80
Rate for Payer: Allwell Medicare	$9.60
Rate for Payer: Amerigroup Medicare	$9.60
Rate for Payer: APIPA Medicare/Medicaid	$22.41
Rate for Payer: AZCH Complete Medicare	$9.60
Rate for Payer: Banner UC Health Medicare	$9.60
Rate for Payer: Bisbee Police All Plans	$15.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$40.80
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cigna of AZ Commercial	$42.00
Rate for Payer: Copperpoint Commercial	$14.85
Rate for Payer: Health Net of AZ Commercial	$36.00
Rate for Payer: Health Net of AZ Medicare	$16.80
Rate for Payer: Humana of AZ Medicare	$9.60
Rate for Payer: Self Pay Self Pay	$48.00
Rate for Payer: TriWest Medicare	$9.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$34.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$10.80

I-GEL 2

Facility

$60.00

Hospital Charge Code	22926454
Hospital Revenue Code	272
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Bisbee Police All Plans	$15.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Self Pay Self Pay	$48.00

I-GEL 2.5

Facility

$60.00

Hospital Charge Code	22926455
Hospital Revenue Code	272
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Bisbee Police All Plans	$15.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Self Pay Self Pay	$48.00

I-GEL 2.5

Facility

$60.00

Hospital Charge Code	22926455
Hospital Revenue Code	272
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Aetna of AZ Medicare	$16.80
Rate for Payer: Allwell Medicare	$9.60
Rate for Payer: Amerigroup Medicare	$9.60
Rate for Payer: APIPA Medicare/Medicaid	$22.41
Rate for Payer: AZCH Complete Medicare	$9.60
Rate for Payer: Banner UC Health Medicare	$9.60
Rate for Payer: Bisbee Police All Plans	$15.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$40.80
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cigna of AZ Commercial	$42.00
Rate for Payer: Copperpoint Commercial	$14.85
Rate for Payer: Health Net of AZ Commercial	$36.00
Rate for Payer: Health Net of AZ Medicare	$16.80
Rate for Payer: Humana of AZ Medicare	$9.60
Rate for Payer: Self Pay Self Pay	$48.00
Rate for Payer: TriWest Medicare	$9.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$34.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$10.80

I-GEL 3

Facility

$60.00

Hospital Charge Code	22926456
Hospital Revenue Code	272
Min. Negotiated Rate	$15.60
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Bisbee Police All Plans	$15.60
Rate for Payer: Cash Price	$48.00
Rate for Payer: Self Pay Self Pay	$48.00

I-GEL 3

Facility

$60.00

Hospital Charge Code	22926456
Hospital Revenue Code	272
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Aetna of AZ Medicare	$16.80
Rate for Payer: Allwell Medicare	$9.60
Rate for Payer: Amerigroup Medicare	$9.60
Rate for Payer: APIPA Medicare/Medicaid	$22.41
Rate for Payer: AZCH Complete Medicare	$9.60
Rate for Payer: Banner UC Health Medicare	$9.60
Rate for Payer: Bisbee Police All Plans	$15.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$40.80
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cigna of AZ Commercial	$42.00
Rate for Payer: Copperpoint Commercial	$14.85
Rate for Payer: Health Net of AZ Commercial	$36.00
Rate for Payer: Health Net of AZ Medicare	$16.80
Rate for Payer: Humana of AZ Medicare	$9.60
Rate for Payer: Self Pay Self Pay	$48.00
Rate for Payer: TriWest Medicare	$9.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$34.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$10.80

I-GEL 4

Facility

$60.00

Hospital Charge Code	22926457
Hospital Revenue Code	272
Min. Negotiated Rate	$9.60
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of AZ Commercial	$54.00
Rate for Payer: Aetna of AZ Medicare	$16.80
Rate for Payer: Allwell Medicare	$9.60
Rate for Payer: Amerigroup Medicare	$9.60
Rate for Payer: APIPA Medicare/Medicaid	$22.41
Rate for Payer: AZCH Complete Medicare	$9.60
Rate for Payer: Banner UC Health Medicare	$9.60
Rate for Payer: Bisbee Police All Plans	$15.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$40.80
Rate for Payer: Cash Price	$48.00
Rate for Payer: Cigna of AZ Commercial	$42.00
Rate for Payer: Copperpoint Commercial	$14.85
Rate for Payer: Health Net of AZ Commercial	$36.00
Rate for Payer: Health Net of AZ Medicare	$16.80
Rate for Payer: Humana of AZ Medicare	$9.60
Rate for Payer: Self Pay Self Pay	$48.00
Rate for Payer: TriWest Medicare	$9.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$34.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$10.80

Know your out-of-pocket cost for care.

All Charges