Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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

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	$0.09
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	$0.09
Rate for Payer: Amerigroup Medicare	$0.09
Rate for Payer: APIPA Medicare/Medicaid	$0.21
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	$0.38
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	$0.09
Rate for Payer: Self Pay Self Pay	$0.45
Rate for Payer: TriWest Medicare	$0.09
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	$18.24
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	$18.24
Rate for Payer: Amerigroup Medicare	$18.24
Rate for Payer: APIPA Medicare/Medicaid	$42.58
Rate for Payer: AZCH Complete Medicare	$18.24
Rate for Payer: Banner UC Health Medicare	$18.24
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	$28.21
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	$18.24
Rate for Payer: Self Pay Self Pay	$91.20
Rate for Payer: TriWest Medicare	$18.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$66.46
Rate for Payer: UnitedHealth Group of AZ Medicare	$20.52

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

IV CATHETERIZATION

Facility

$97.00

Hospital Charge Code	22282948
Hospital Revenue Code	272
Min. Negotiated Rate	$15.52
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	$15.52
Rate for Payer: Amerigroup Medicare	$15.52
Rate for Payer: APIPA Medicare/Medicaid	$36.23
Rate for Payer: AZCH Complete Medicare	$15.52
Rate for Payer: Banner UC Health Medicare	$15.52
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	$15.52
Rate for Payer: Self Pay Self Pay	$77.60
Rate for Payer: TriWest Medicare	$15.52
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	$4.80
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	$4.80
Rate for Payer: Amerigroup Medicare	$4.80
Rate for Payer: APIPA Medicare/Medicaid	$11.21
Rate for Payer: AZCH Complete Medicare	$4.80
Rate for Payer: Banner UC Health Medicare	$4.80
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	$4.80
Rate for Payer: Self Pay Self Pay	$24.00
Rate for Payer: TriWest Medicare	$4.80
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	$32.00
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	$77.79
Rate for Payer: Allwell Medicaid	$77.79
Rate for Payer: Allwell Medicare	$32.00
Rate for Payer: Amerigroup Medicare	$32.00
Rate for Payer: APIPA Medicare/Medicaid	$74.70
Rate for Payer: AZCH Complete Medicaid	$77.79
Rate for Payer: AZCH Complete Medicare	$32.00
Rate for Payer: Banner UC Health Medicaid	$77.79
Rate for Payer: Banner UC Health Medicare	$32.00
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	$32.00
Rate for Payer: Mercy Care Medicaid	$77.79
Rate for Payer: Self Pay Self Pay	$160.00
Rate for Payer: TriWest Medicare	$32.00
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

IV PRIMARY TUBING HOSPIRA

Facility

$62.00

Hospital Charge Code	22355539
Hospital Revenue Code	270
Min. Negotiated Rate	$16.12
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Bisbee Police All Plans	$16.12
Rate for Payer: Cash Price	$49.60
Rate for Payer: Self Pay Self Pay	$49.60

IV PRIMARY TUBING HOSPIRA

Facility

$62.00

Hospital Charge Code	22355539
Hospital Revenue Code	270
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Aetna of AZ Medicare	$17.36
Rate for Payer: Allwell Medicare	$9.92
Rate for Payer: Amerigroup Medicare	$9.92
Rate for Payer: APIPA Medicare/Medicaid	$23.16
Rate for Payer: AZCH Complete Medicare	$9.92
Rate for Payer: Banner UC Health Medicare	$9.92
Rate for Payer: Bisbee Police All Plans	$16.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$42.16
Rate for Payer: Cash Price	$49.60
Rate for Payer: Cigna of AZ Commercial	$43.40
Rate for Payer: Copperpoint Commercial	$15.35
Rate for Payer: Health Net of AZ Commercial	$37.20
Rate for Payer: Health Net of AZ Medicare	$17.36
Rate for Payer: Humana of AZ Medicare	$9.92
Rate for Payer: Self Pay Self Pay	$49.60
Rate for Payer: TriWest Medicare	$9.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$36.15
Rate for Payer: UnitedHealth Group of AZ Medicare	$11.16

JAK2 (JANUS KINASE 2) (EG, MYELOPROLIFERATIVE DISORDER) TARG

Facility

$925.00

Service Code	CPT 81279
Hospital Charge Code	28008410
Hospital Revenue Code	302
Min. Negotiated Rate	$148.00
Max. Negotiated Rate	$832.50
Rate for Payer: Aetna of AZ Commercial	$832.50
Rate for Payer: Aetna of AZ Medicare	$259.00
Rate for Payer: Allwell Medicare	$148.00
Rate for Payer: Amerigroup Medicare	$148.00
Rate for Payer: APIPA Medicare/Medicaid	$345.49
Rate for Payer: AZCH Complete Medicare	$148.00
Rate for Payer: Banner UC Health Medicare	$148.00
Rate for Payer: Bisbee Police All Plans	$240.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$629.00
Rate for Payer: Cash Price	$740.00
Rate for Payer: Cigna of AZ Commercial	$601.25
Rate for Payer: Copperpoint Commercial	$228.94
Rate for Payer: Health Net of AZ Commercial	$555.00
Rate for Payer: Health Net of AZ Medicare	$259.00
Rate for Payer: Humana of AZ Medicare	$148.00
Rate for Payer: Self Pay Self Pay	$740.00
Rate for Payer: TriWest Medicare	$148.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$539.27
Rate for Payer: UnitedHealth Group of AZ Medicare	$166.50

JAK2 (JANUS KINASE 2) (EG, MYELOPROLIFERATIVE DISORDER) TARG

Facility

$925.00

Service Code	CPT 81279
Hospital Charge Code	28008410
Hospital Revenue Code	302
Min. Negotiated Rate	$240.50
Max. Negotiated Rate	$832.50
Rate for Payer: Aetna of AZ Commercial	$832.50
Rate for Payer: Bisbee Police All Plans	$240.50
Rate for Payer: Cash Price	$740.00
Rate for Payer: Self Pay Self Pay	$740.00

JAK2 Mutation Analysis, Qual LC

Facility

$1,137.00

Service Code	CPT 81270
Hospital Charge Code	2029233
Hospital Revenue Code	301
Min. Negotiated Rate	$181.92
Max. Negotiated Rate	$1,023.30
Rate for Payer: Aetna of AZ Commercial	$1,023.30
Rate for Payer: Aetna of AZ Medicare	$318.36
Rate for Payer: Allwell Medicare	$181.92
Rate for Payer: Amerigroup Medicare	$181.92
Rate for Payer: APIPA Medicare/Medicaid	$424.67
Rate for Payer: AZCH Complete Medicare	$181.92
Rate for Payer: Banner UC Health Medicare	$181.92
Rate for Payer: Bisbee Police All Plans	$295.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$773.16
Rate for Payer: Cash Price	$909.60
Rate for Payer: Cigna of AZ Commercial	$739.05
Rate for Payer: Copperpoint Commercial	$281.41
Rate for Payer: Health Net of AZ Commercial	$682.20
Rate for Payer: Health Net of AZ Medicare	$318.36
Rate for Payer: Humana of AZ Medicare	$181.92
Rate for Payer: Self Pay Self Pay	$909.60
Rate for Payer: TriWest Medicare	$181.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$662.87
Rate for Payer: UnitedHealth Group of AZ Medicare	$204.66

JAK2 Mutation Analysis, Qual LC

Facility

$1,137.00

Service Code	CPT 81270
Hospital Charge Code	2029233
Hospital Revenue Code	301
Min. Negotiated Rate	$295.62
Max. Negotiated Rate	$1,023.30
Rate for Payer: Aetna of AZ Commercial	$1,023.30
Rate for Payer: Bisbee Police All Plans	$295.62
Rate for Payer: Cash Price	$909.60
Rate for Payer: Self Pay Self Pay	$909.60

Kelly plication

Facility

$1,775.00

Service Code	CPT 57220
Hospital Charge Code	27267789
Hospital Revenue Code	360
Min. Negotiated Rate	$461.50
Max. Negotiated Rate	$1,597.50
Rate for Payer: Aetna of AZ Commercial	$1,597.50
Rate for Payer: Bisbee Police All Plans	$461.50
Rate for Payer: Cash Price	$1,420.00
Rate for Payer: Self Pay Self Pay	$1,420.00

Kelly plication

Facility

$1,775.00

Service Code	CPT 57220
Hospital Charge Code	27267789
Hospital Revenue Code	360
Min. Negotiated Rate	$284.00
Max. Negotiated Rate	$3,196.92
Rate for Payer: Aetna of AZ Commercial	$1,597.50
Rate for Payer: Aetna of AZ Medicare	$497.00
Rate for Payer: AHCCCS Medicaid	$3,196.92
Rate for Payer: Allwell Medicaid	$3,196.92
Rate for Payer: Allwell Medicare	$284.00
Rate for Payer: Amerigroup Medicare	$284.00
Rate for Payer: APIPA Medicare/Medicaid	$662.96
Rate for Payer: AZCH Complete Medicaid	$3,196.92
Rate for Payer: AZCH Complete Medicare	$284.00
Rate for Payer: Banner UC Health Medicaid	$3,196.92
Rate for Payer: Banner UC Health Medicare	$284.00
Rate for Payer: Bisbee Police All Plans	$461.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,207.00
Rate for Payer: Cash Price	$1,420.00
Rate for Payer: Cash Price	$1,420.00
Rate for Payer: Cigna of AZ Commercial	$887.50
Rate for Payer: Copperpoint Commercial	$439.31
Rate for Payer: Health Net of AZ Commercial	$1,065.00
Rate for Payer: Health Net of AZ Medicare	$497.00
Rate for Payer: Humana of AZ Medicare	$284.00
Rate for Payer: Mercy Care Medicaid	$3,196.92
Rate for Payer: Self Pay Self Pay	$1,420.00
Rate for Payer: TriWest Medicare	$284.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,034.83
Rate for Payer: UnitedHealth Group of AZ Medicare	$319.50

ketamine inj concentrate 500 mg/5 mL Sol [CQCH]

Facility

$1.49

Service Code	NDC 409205105
Hospital Charge Code	113868946
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of AZ Commercial	$1.34
Rate for Payer: Bisbee Police All Plans	$0.39
Rate for Payer: Cash Price	$1.19
Rate for Payer: Self Pay Self Pay	$1.19

ketamine inj concentrate 500 mg/5 mL Sol [CQCH]

Facility

$1.49

Service Code	NDC 409205105
Hospital Charge Code	113868946
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of AZ Commercial	$1.34
Rate for Payer: Aetna of AZ Medicare	$0.42
Rate for Payer: Allwell Medicare	$0.24
Rate for Payer: Amerigroup Medicare	$0.24
Rate for Payer: APIPA Medicare/Medicaid	$0.56
Rate for Payer: AZCH Complete Medicare	$0.24
Rate for Payer: Banner UC Health Medicare	$0.24
Rate for Payer: Bisbee Police All Plans	$0.39
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.01
Rate for Payer: Cash Price	$1.19
Rate for Payer: Cigna of AZ Commercial	$0.97
Rate for Payer: Copperpoint Commercial	$0.37
Rate for Payer: Health Net of AZ Commercial	$0.89
Rate for Payer: Health Net of AZ Medicare	$0.42
Rate for Payer: Humana of AZ Medicare	$0.24
Rate for Payer: Self Pay Self Pay	$1.19
Rate for Payer: TriWest Medicare	$0.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.87
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.27

Know your out-of-pocket cost for care.

All Charges