Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

IRRG SOL GLYC 3000

Facility

$72.00

Hospital Charge Code	22354802
Hospital Revenue Code	270
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Aetna of AZ Medicare	$20.16
Rate for Payer: Allwell Medicare	$10.80
Rate for Payer: Amerigroup Medicare	$10.80
Rate for Payer: APIPA Medicare/Medicaid	$26.89
Rate for Payer: AZCH Complete Medicare	$10.80
Rate for Payer: Banner UC Health Medicare	$10.80
Rate for Payer: Bisbee Police All Plans	$18.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$48.96
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna of AZ Commercial	$50.40
Rate for Payer: Copperpoint Commercial	$17.82
Rate for Payer: Health Net of AZ Commercial	$43.20
Rate for Payer: Health Net of AZ Medicare	$20.16
Rate for Payer: Humana of AZ Medicare	$10.80
Rate for Payer: Self Pay Self Pay	$57.60
Rate for Payer: TriWest Medicare	$10.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$41.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.96

IRRG TUR SET 21-IN

Facility

$57.00

Hospital Charge Code	22355106
Hospital Revenue Code	270
Min. Negotiated Rate	$14.82
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna of AZ Commercial	$51.30
Rate for Payer: Bisbee Police All Plans	$14.82
Rate for Payer: Cash Price	$45.60
Rate for Payer: Self Pay Self Pay	$45.60

IRRG TUR SET 21-IN

Facility

$57.00

Hospital Charge Code	22355106
Hospital Revenue Code	270
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna of AZ Commercial	$51.30
Rate for Payer: Aetna of AZ Medicare	$15.96
Rate for Payer: Allwell Medicare	$8.55
Rate for Payer: Amerigroup Medicare	$8.55
Rate for Payer: APIPA Medicare/Medicaid	$21.29
Rate for Payer: AZCH Complete Medicare	$8.55
Rate for Payer: Banner UC Health Medicare	$8.55
Rate for Payer: Bisbee Police All Plans	$14.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$38.76
Rate for Payer: Cash Price	$45.60
Rate for Payer: Cigna of AZ Commercial	$39.90
Rate for Payer: Copperpoint Commercial	$14.11
Rate for Payer: Health Net of AZ Commercial	$34.20
Rate for Payer: Health Net of AZ Medicare	$15.96
Rate for Payer: Humana of AZ Medicare	$8.55
Rate for Payer: Self Pay Self Pay	$45.60
Rate for Payer: TriWest Medicare	$8.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$33.23
Rate for Payer: UnitedHealth Group of AZ Medicare	$10.26

IRRIG INSTR TRUMPIT

Facility

$269.00

Hospital Charge Code	22354940
Hospital Revenue Code	270
Min. Negotiated Rate	$40.35
Max. Negotiated Rate	$242.10
Rate for Payer: Aetna of AZ Commercial	$242.10
Rate for Payer: Aetna of AZ Medicare	$75.32
Rate for Payer: Allwell Medicare	$40.35
Rate for Payer: Amerigroup Medicare	$40.35
Rate for Payer: APIPA Medicare/Medicaid	$100.47
Rate for Payer: AZCH Complete Medicare	$40.35
Rate for Payer: Banner UC Health Medicare	$40.35
Rate for Payer: Bisbee Police All Plans	$69.94
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$182.92
Rate for Payer: Cash Price	$215.20
Rate for Payer: Cigna of AZ Commercial	$188.30
Rate for Payer: Copperpoint Commercial	$66.58
Rate for Payer: Health Net of AZ Commercial	$161.40
Rate for Payer: Health Net of AZ Medicare	$75.32
Rate for Payer: Humana of AZ Medicare	$40.35
Rate for Payer: Self Pay Self Pay	$215.20
Rate for Payer: TriWest Medicare	$40.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$156.83
Rate for Payer: UnitedHealth Group of AZ Medicare	$48.42

IRRIG INSTR TRUMPIT

Facility

$269.00

Hospital Charge Code	22354940
Hospital Revenue Code	270
Min. Negotiated Rate	$69.94
Max. Negotiated Rate	$242.10
Rate for Payer: Aetna of AZ Commercial	$242.10
Rate for Payer: Bisbee Police All Plans	$69.94
Rate for Payer: Cash Price	$215.20
Rate for Payer: Self Pay Self Pay	$215.20

IRRIG SOL D/W 1000 BOTTLE

Facility

$30.00

Hospital Charge Code	22355216
Hospital Revenue Code	272
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Bisbee Police All Plans	$7.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Self Pay Self Pay	$24.00

IRRIG SOL D/W 1000 BOTTLE

Facility

$30.00

Hospital Charge Code	22355216
Hospital Revenue Code	272
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Aetna of AZ Medicare	$8.40
Rate for Payer: Allwell Medicare	$4.50
Rate for Payer: Amerigroup Medicare	$4.50
Rate for Payer: APIPA Medicare/Medicaid	$11.20
Rate for Payer: AZCH Complete Medicare	$4.50
Rate for Payer: Banner UC Health Medicare	$4.50
Rate for Payer: Bisbee Police All Plans	$7.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$20.40
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna of AZ Commercial	$21.00
Rate for Payer: Copperpoint Commercial	$7.42
Rate for Payer: Health Net of AZ Commercial	$18.00
Rate for Payer: Health Net of AZ Medicare	$8.40
Rate for Payer: Humana of AZ Medicare	$4.50
Rate for Payer: Self Pay Self Pay	$24.00
Rate for Payer: TriWest Medicare	$4.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$17.49
Rate for Payer: UnitedHealth Group of AZ Medicare	$5.40

ISONEB FILTERED NEBULIZER SYSTEM

Facility

$29.00

Hospital Charge Code	23937347
Hospital Revenue Code	270
Min. Negotiated Rate	$7.54
Max. Negotiated Rate	$26.10
Rate for Payer: Aetna of AZ Commercial	$26.10
Rate for Payer: Bisbee Police All Plans	$7.54
Rate for Payer: Cash Price	$23.20
Rate for Payer: Self Pay Self Pay	$23.20

ISONEB FILTERED NEBULIZER SYSTEM

Facility

$29.00

Hospital Charge Code	23937347
Hospital Revenue Code	270
Min. Negotiated Rate	$4.35
Max. Negotiated Rate	$26.10
Rate for Payer: Aetna of AZ Commercial	$26.10
Rate for Payer: Aetna of AZ Medicare	$8.12
Rate for Payer: Allwell Medicare	$4.35
Rate for Payer: Amerigroup Medicare	$4.35
Rate for Payer: APIPA Medicare/Medicaid	$10.83
Rate for Payer: AZCH Complete Medicare	$4.35
Rate for Payer: Banner UC Health Medicare	$4.35
Rate for Payer: Bisbee Police All Plans	$7.54
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$19.72
Rate for Payer: Cash Price	$23.20
Rate for Payer: Cigna of AZ Commercial	$20.30
Rate for Payer: Copperpoint Commercial	$7.18
Rate for Payer: Health Net of AZ Commercial	$17.40
Rate for Payer: Health Net of AZ Medicare	$8.12
Rate for Payer: Humana of AZ Medicare	$4.35
Rate for Payer: Self Pay Self Pay	$23.20
Rate for Payer: TriWest Medicare	$4.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$16.91
Rate for Payer: UnitedHealth Group of AZ Medicare	$5.22

isosorbide dinitrate 10 mg Tab [CQCH]

Facility

$0.59

Service Code	NDC 68084008201
Hospital Charge Code	105927222
Hospital Revenue Code	251
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.53
Rate for Payer: Aetna of AZ Commercial	$0.53
Rate for Payer: Bisbee Police All Plans	$0.15
Rate for Payer: Cash Price	$0.47
Rate for Payer: Self Pay Self Pay	$0.47

isosorbide dinitrate 10 mg Tab [CQCH]

Facility

$0.59

Service Code	NDC 68084008201
Hospital Charge Code	105927222
Hospital Revenue Code	251
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.53
Rate for Payer: Aetna of AZ Commercial	$0.53
Rate for Payer: Aetna of AZ Medicare	$0.17
Rate for Payer: Allwell Medicare	$0.09
Rate for Payer: Amerigroup Medicare	$0.09
Rate for Payer: APIPA Medicare/Medicaid	$0.22
Rate for Payer: AZCH Complete Medicare	$0.09
Rate for Payer: Banner UC Health Medicare	$0.09
Rate for Payer: Bisbee Police All Plans	$0.15
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.40
Rate for Payer: Cash Price	$0.47
Rate for Payer: Cigna of AZ Commercial	$0.38
Rate for Payer: Copperpoint Commercial	$0.15
Rate for Payer: Health Net of AZ Commercial	$0.35
Rate for Payer: Health Net of AZ Medicare	$0.17
Rate for Payer: Humana of AZ Medicare	$0.09
Rate for Payer: Self Pay Self Pay	$0.47
Rate for Payer: TriWest Medicare	$0.09
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.34
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.11

isosorbide dinitrate 20 mg Tab [CQCH]

Facility

$0.56

Service Code	NDC 143177201
Hospital Charge Code	105927157
Hospital Revenue Code	251
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of AZ Commercial	$0.50
Rate for Payer: Bisbee Police All Plans	$0.15
Rate for Payer: Cash Price	$0.45
Rate for Payer: Self Pay Self Pay	$0.45

isosorbide dinitrate 20 mg Tab [CQCH]

Facility

$0.56

Service Code	NDC 143177201
Hospital Charge Code	105927157
Hospital Revenue Code	251
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of AZ Commercial	$0.50
Rate for Payer: Aetna of AZ Medicare	$0.16
Rate for Payer: Allwell Medicare	$0.08
Rate for Payer: Amerigroup Medicare	$0.08
Rate for Payer: APIPA Medicare/Medicaid	$0.21
Rate for Payer: AZCH Complete Medicare	$0.08
Rate for Payer: Banner UC Health Medicare	$0.08
Rate for Payer: Bisbee Police All Plans	$0.15
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.38
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cigna of AZ Commercial	$0.36
Rate for Payer: Copperpoint Commercial	$0.14
Rate for Payer: Health Net of AZ Commercial	$0.34
Rate for Payer: Health Net of AZ Medicare	$0.16
Rate for Payer: Humana of AZ Medicare	$0.08
Rate for Payer: Self Pay Self Pay	$0.45
Rate for Payer: TriWest Medicare	$0.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.33
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.10

isosorbide mononitrate 30 mg ER Tab [CQCH]

Facility

$0.50

Service Code	NDC 68084059101
Hospital Charge Code	105927291
Hospital Revenue Code	251
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of AZ Commercial	$0.45
Rate for Payer: Bisbee Police All Plans	$0.13
Rate for Payer: Cash Price	$0.40
Rate for Payer: Self Pay Self Pay	$0.40

isosorbide mononitrate 30 mg ER Tab [CQCH]

Facility

$0.50

Service Code	NDC 68084059101
Hospital Charge Code	105927291
Hospital Revenue Code	251
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of AZ Commercial	$0.45
Rate for Payer: Aetna of AZ Medicare	$0.14
Rate for Payer: Allwell Medicare	$0.08
Rate for Payer: Amerigroup Medicare	$0.08
Rate for Payer: APIPA Medicare/Medicaid	$0.19
Rate for Payer: AZCH Complete Medicare	$0.08
Rate for Payer: Banner UC Health Medicare	$0.08
Rate for Payer: Bisbee Police All Plans	$0.13
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.34
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cigna of AZ Commercial	$0.33
Rate for Payer: Copperpoint Commercial	$0.12
Rate for Payer: Health Net of AZ Commercial	$0.30
Rate for Payer: Health Net of AZ Medicare	$0.14
Rate for Payer: Humana of AZ Medicare	$0.08
Rate for Payer: Self Pay Self Pay	$0.40
Rate for Payer: TriWest Medicare	$0.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.29
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.09

ISOVUE 300 10 X 100 ML VL

Facility

$114.00

Hospital Charge Code	22354939
Hospital Revenue Code	270
Min. Negotiated Rate	$29.64
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of AZ Commercial	$102.60
Rate for Payer: Bisbee Police All Plans	$29.64
Rate for Payer: Cash Price	$91.20
Rate for Payer: Self Pay Self Pay	$91.20

ISOVUE 300 10 X 100 ML VL

Facility

$114.00

Hospital Charge Code	22354939
Hospital Revenue Code	270
Min. Negotiated Rate	$17.10
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of AZ Commercial	$102.60
Rate for Payer: Aetna of AZ Medicare	$31.92
Rate for Payer: Allwell Medicare	$17.10
Rate for Payer: Amerigroup Medicare	$17.10
Rate for Payer: APIPA Medicare/Medicaid	$42.58
Rate for Payer: AZCH Complete Medicare	$17.10
Rate for Payer: Banner UC Health Medicare	$17.10
Rate for Payer: Bisbee Police All Plans	$29.64
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$77.52
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cigna of AZ Commercial	$79.80
Rate for Payer: Copperpoint Commercial	$28.22
Rate for Payer: Health Net of AZ Commercial	$68.40
Rate for Payer: Health Net of AZ Medicare	$31.92
Rate for Payer: Humana of AZ Medicare	$17.10
Rate for Payer: Self Pay Self Pay	$91.20
Rate for Payer: TriWest Medicare	$17.10
Rate for Payer: UnitedHealth Group of AZ Commercial	$66.46
Rate for Payer: UnitedHealth Group of AZ Medicare	$20.52

IV-1/2 NORMAL SALINE BAG : 1000 ML

Facility

$30.00

Hospital Charge Code	22355377
Hospital Revenue Code	250
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Bisbee Police All Plans	$7.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Self Pay Self Pay	$24.00

IV-1/2 NORMAL SALINE BAG : 1000 ML

Facility

$30.00

Hospital Charge Code	22355377
Hospital Revenue Code	250
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Aetna of AZ Medicare	$8.40
Rate for Payer: Allwell Medicare	$4.50
Rate for Payer: Amerigroup Medicare	$4.50
Rate for Payer: APIPA Medicare/Medicaid	$11.20
Rate for Payer: AZCH Complete Medicare	$4.50
Rate for Payer: Banner UC Health Medicare	$4.50
Rate for Payer: Bisbee Police All Plans	$7.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$20.40
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna of AZ Commercial	$19.50
Rate for Payer: Copperpoint Commercial	$7.42
Rate for Payer: Health Net of AZ Commercial	$18.00
Rate for Payer: Health Net of AZ Medicare	$8.40
Rate for Payer: Humana of AZ Medicare	$4.50
Rate for Payer: Self Pay Self Pay	$24.00
Rate for Payer: TriWest Medicare	$4.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$17.49
Rate for Payer: UnitedHealth Group of AZ Medicare	$5.40

IV CATHETERIZATION

Facility

$97.00

Hospital Charge Code	22282948
Hospital Revenue Code	272
Min. Negotiated Rate	$14.55
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna of AZ Commercial	$87.30
Rate for Payer: Aetna of AZ Medicare	$27.16
Rate for Payer: Allwell Medicare	$14.55
Rate for Payer: Amerigroup Medicare	$14.55
Rate for Payer: APIPA Medicare/Medicaid	$36.23
Rate for Payer: AZCH Complete Medicare	$14.55
Rate for Payer: Banner UC Health Medicare	$14.55
Rate for Payer: Bisbee Police All Plans	$25.22
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$65.96
Rate for Payer: Cash Price	$77.60
Rate for Payer: Cigna of AZ Commercial	$67.90
Rate for Payer: Copperpoint Commercial	$24.01
Rate for Payer: Health Net of AZ Commercial	$58.20
Rate for Payer: Health Net of AZ Medicare	$27.16
Rate for Payer: Humana of AZ Medicare	$14.55
Rate for Payer: Self Pay Self Pay	$77.60
Rate for Payer: TriWest Medicare	$14.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$56.55
Rate for Payer: UnitedHealth Group of AZ Medicare	$17.46

IV CATHETERIZATION

Facility

$97.00

Hospital Charge Code	22282948
Hospital Revenue Code	272
Min. Negotiated Rate	$25.22
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna of AZ Commercial	$87.30
Rate for Payer: Bisbee Police All Plans	$25.22
Rate for Payer: Cash Price	$77.60
Rate for Payer: Self Pay Self Pay	$77.60

IV-D5NS BAG : 1000 ML

Facility

$30.00

Hospital Charge Code	22551066
Hospital Revenue Code	250
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Bisbee Police All Plans	$7.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Self Pay Self Pay	$24.00

IV-D5NS BAG : 1000 ML

Facility

$30.00

Hospital Charge Code	22551066
Hospital Revenue Code	250
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Aetna of AZ Medicare	$8.40
Rate for Payer: Allwell Medicare	$4.50
Rate for Payer: Amerigroup Medicare	$4.50
Rate for Payer: APIPA Medicare/Medicaid	$11.20
Rate for Payer: AZCH Complete Medicare	$4.50
Rate for Payer: Banner UC Health Medicare	$4.50
Rate for Payer: Bisbee Police All Plans	$7.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$20.40
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna of AZ Commercial	$19.50
Rate for Payer: Copperpoint Commercial	$7.42
Rate for Payer: Health Net of AZ Commercial	$18.00
Rate for Payer: Health Net of AZ Medicare	$8.40
Rate for Payer: Humana of AZ Medicare	$4.50
Rate for Payer: Self Pay Self Pay	$24.00
Rate for Payer: TriWest Medicare	$4.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$17.49
Rate for Payer: UnitedHealth Group of AZ Medicare	$5.40

IV INFUSION FOR THERAPY

Facility

$200.00

Service Code	CPT 96360
Hospital Charge Code	22247981
Hospital Revenue Code	260
Min. Negotiated Rate	$30.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna of AZ Commercial	$180.00
Rate for Payer: Aetna of AZ Medicare	$56.00
Rate for Payer: AHCCCS Medicaid	$155.58
Rate for Payer: Allwell Medicaid	$155.58
Rate for Payer: Allwell Medicare	$30.00
Rate for Payer: Amerigroup Medicare	$30.00
Rate for Payer: APIPA Medicare/Medicaid	$74.70
Rate for Payer: AZCH Complete Medicaid	$155.58
Rate for Payer: AZCH Complete Medicare	$30.00
Rate for Payer: Banner UC Health Medicaid	$155.58
Rate for Payer: Banner UC Health Medicare	$30.00
Rate for Payer: Bisbee Police All Plans	$52.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$136.00
Rate for Payer: Cash Price	$160.00
Rate for Payer: Cash Price	$160.00
Rate for Payer: Cigna of AZ Commercial	$140.00
Rate for Payer: Copperpoint Commercial	$49.50
Rate for Payer: Health Net of AZ Commercial	$120.00
Rate for Payer: Health Net of AZ Medicare	$56.00
Rate for Payer: Humana of AZ Medicare	$30.00
Rate for Payer: Mercy Care Medicaid	$155.58
Rate for Payer: Self Pay Self Pay	$160.00
Rate for Payer: TriWest Medicare	$30.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$116.60
Rate for Payer: UnitedHealth Group of AZ Medicare	$36.00

IV INFUSION FOR THERAPY

Facility

$200.00

Service Code	CPT 96360
Hospital Charge Code	22247981
Hospital Revenue Code	260
Min. Negotiated Rate	$52.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna of AZ Commercial	$180.00
Rate for Payer: Bisbee Police All Plans	$52.00
Rate for Payer: Cash Price	$160.00
Rate for Payer: Self Pay Self Pay	$160.00

Know your out-of-pocket cost for care.

All Charges