Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

latanoprost Ophth 0.005% Sol [CQCH]

Facility

$2.20

Service Code	NDC 17478062512
Hospital Charge Code	105927842
Hospital Revenue Code	251
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$1.98
Rate for Payer: Aetna of AZ Commercial	$1.98
Rate for Payer: Aetna of AZ Medicare	$0.62
Rate for Payer: Allwell Medicare	$0.35
Rate for Payer: Amerigroup Medicare	$0.35
Rate for Payer: APIPA Medicare/Medicaid	$0.82
Rate for Payer: AZCH Complete Medicare	$0.35
Rate for Payer: Banner UC Health Medicare	$0.35
Rate for Payer: Bisbee Police All Plans	$0.57
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.50
Rate for Payer: Cash Price	$1.76
Rate for Payer: Cigna of AZ Commercial	$1.43
Rate for Payer: Copperpoint Commercial	$0.54
Rate for Payer: Health Net of AZ Commercial	$1.32
Rate for Payer: Health Net of AZ Medicare	$0.62
Rate for Payer: Humana of AZ Medicare	$0.35
Rate for Payer: Self Pay Self Pay	$1.76
Rate for Payer: TriWest Medicare	$0.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.40

LDL-C 100-129 mg/dL

Facility

$0.01

Service Code	CPT 3049F
Hospital Charge Code	21279304
Hospital Revenue Code	301
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.01

LDL-C 100-129 mg/dL

Facility

$0.01

Service Code	CPT 3049F
Hospital Charge Code	21279304
Hospital Revenue Code	301
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

LDL-C greater than or equal to 130 mg/dL

Facility

$0.01

Service Code	CPT 3050F
Hospital Charge Code	21279305
Hospital Revenue Code	301
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.01

LDL-C greater than or equal to 130 mg/dL

Facility

$0.01

Service Code	CPT 3050F
Hospital Charge Code	21279305
Hospital Revenue Code	301
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

LDL-C less than 100mg/dL

Facility

$0.01

Service Code	CPT 3048F
Hospital Charge Code	21279303
Hospital Revenue Code	301
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.01

LDL-C less than 100mg/dL

Facility

$0.01

Service Code	CPT 3048F
Hospital Charge Code	21279303
Hospital Revenue Code	301
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

.LDL Size Comment LC

Facility

$158.00

Service Code	CPT 83721
Hospital Charge Code	22311155
Hospital Revenue Code	301
Min. Negotiated Rate	$25.28
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of AZ Commercial	$142.20
Rate for Payer: Aetna of AZ Medicare	$44.24
Rate for Payer: Allwell Medicare	$25.28
Rate for Payer: Amerigroup Medicare	$25.28
Rate for Payer: APIPA Medicare/Medicaid	$59.01
Rate for Payer: AZCH Complete Medicare	$25.28
Rate for Payer: Banner UC Health Medicare	$25.28
Rate for Payer: Bisbee Police All Plans	$41.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$107.44
Rate for Payer: Cash Price	$126.40
Rate for Payer: Cigna of AZ Commercial	$102.70
Rate for Payer: Copperpoint Commercial	$39.10
Rate for Payer: Health Net of AZ Commercial	$94.80
Rate for Payer: Health Net of AZ Medicare	$44.24
Rate for Payer: Humana of AZ Medicare	$25.28
Rate for Payer: Self Pay Self Pay	$126.40
Rate for Payer: TriWest Medicare	$25.28
Rate for Payer: UnitedHealth Group of AZ Commercial	$92.11
Rate for Payer: UnitedHealth Group of AZ Medicare	$28.44

.LDL Size Comment LC

Facility

$158.00

Service Code	CPT 83721
Hospital Charge Code	22311155
Hospital Revenue Code	301
Min. Negotiated Rate	$41.08
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of AZ Commercial	$142.20
Rate for Payer: Bisbee Police All Plans	$41.08
Rate for Payer: Cash Price	$126.40
Rate for Payer: Self Pay Self Pay	$126.40

LEAD

Facility

$19,029.00

Service Code	CPT C1778
Hospital Charge Code	22354567
Hospital Revenue Code	270
Min. Negotiated Rate	$4,947.54
Max. Negotiated Rate	$17,126.10
Rate for Payer: Aetna of AZ Commercial	$17,126.10
Rate for Payer: Bisbee Police All Plans	$4,947.54
Rate for Payer: Cash Price	$15,223.20
Rate for Payer: Self Pay Self Pay	$15,223.20

LEAD

Facility

$19,029.00

Service Code	CPT C1778
Hospital Charge Code	22354567
Hospital Revenue Code	270
Min. Negotiated Rate	$3,044.64
Max. Negotiated Rate	$17,126.10
Rate for Payer: Aetna of AZ Commercial	$17,126.10
Rate for Payer: Aetna of AZ Medicare	$5,328.12
Rate for Payer: Allwell Medicare	$3,044.64
Rate for Payer: Amerigroup Medicare	$3,044.64
Rate for Payer: APIPA Medicare/Medicaid	$7,107.33
Rate for Payer: AZCH Complete Medicare	$3,044.64
Rate for Payer: Banner UC Health Medicare	$3,044.64
Rate for Payer: Bisbee Police All Plans	$4,947.54
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$12,939.72
Rate for Payer: Cash Price	$15,223.20
Rate for Payer: Cigna of AZ Commercial	$13,320.30
Rate for Payer: Copperpoint Commercial	$4,709.68
Rate for Payer: Health Net of AZ Commercial	$11,417.40
Rate for Payer: Health Net of AZ Medicare	$5,328.12
Rate for Payer: Humana of AZ Medicare	$3,044.64
Rate for Payer: Self Pay Self Pay	$15,223.20
Rate for Payer: TriWest Medicare	$3,044.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$11,093.91
Rate for Payer: UnitedHealth Group of AZ Medicare	$3,425.22

LEAD ADULT

Facility

$296.00

Service Code	CPT 83655
Hospital Charge Code	22481489
Hospital Revenue Code	301
Min. Negotiated Rate	$47.36
Max. Negotiated Rate	$266.40
Rate for Payer: Aetna of AZ Commercial	$266.40
Rate for Payer: Aetna of AZ Medicare	$82.88
Rate for Payer: Allwell Medicare	$47.36
Rate for Payer: Amerigroup Medicare	$47.36
Rate for Payer: APIPA Medicare/Medicaid	$110.56
Rate for Payer: AZCH Complete Medicare	$47.36
Rate for Payer: Banner UC Health Medicare	$47.36
Rate for Payer: Bisbee Police All Plans	$76.96
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$201.28
Rate for Payer: Cash Price	$236.80
Rate for Payer: Cigna of AZ Commercial	$192.40
Rate for Payer: Copperpoint Commercial	$73.26
Rate for Payer: Health Net of AZ Commercial	$177.60
Rate for Payer: Health Net of AZ Medicare	$82.88
Rate for Payer: Humana of AZ Medicare	$47.36
Rate for Payer: Self Pay Self Pay	$236.80
Rate for Payer: TriWest Medicare	$47.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$172.57
Rate for Payer: UnitedHealth Group of AZ Medicare	$53.28

LEAD ADULT

Facility

$296.00

Service Code	CPT 83655
Hospital Charge Code	22481489
Hospital Revenue Code	301
Min. Negotiated Rate	$76.96
Max. Negotiated Rate	$266.40
Rate for Payer: Aetna of AZ Commercial	$266.40
Rate for Payer: Bisbee Police All Plans	$76.96
Rate for Payer: Cash Price	$236.80
Rate for Payer: Self Pay Self Pay	$236.80

Lead, Blood (Adult) LC

Facility

$270.00

Service Code	CPT 83655
Hospital Charge Code	1285614
Hospital Revenue Code	301
Min. Negotiated Rate	$43.20
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of AZ Commercial	$243.00
Rate for Payer: Aetna of AZ Medicare	$75.60
Rate for Payer: Allwell Medicare	$43.20
Rate for Payer: Amerigroup Medicare	$43.20
Rate for Payer: APIPA Medicare/Medicaid	$100.84
Rate for Payer: AZCH Complete Medicare	$43.20
Rate for Payer: Banner UC Health Medicare	$43.20
Rate for Payer: Bisbee Police All Plans	$70.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$183.60
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna of AZ Commercial	$175.50
Rate for Payer: Copperpoint Commercial	$66.83
Rate for Payer: Health Net of AZ Commercial	$162.00
Rate for Payer: Health Net of AZ Medicare	$75.60
Rate for Payer: Humana of AZ Medicare	$43.20
Rate for Payer: Self Pay Self Pay	$216.00
Rate for Payer: TriWest Medicare	$43.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$157.41
Rate for Payer: UnitedHealth Group of AZ Medicare	$48.60

Lead, Blood (Adult) LC

Facility

$270.00

Service Code	CPT 83655
Hospital Charge Code	1285614
Hospital Revenue Code	301
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of AZ Commercial	$243.00
Rate for Payer: Bisbee Police All Plans	$70.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Self Pay Self Pay	$216.00

Lead, Blood (Pediatric) LC

Facility

$268.00

Service Code	CPT 83655
Hospital Charge Code	1285615
Hospital Revenue Code	301
Min. Negotiated Rate	$69.68
Max. Negotiated Rate	$241.20
Rate for Payer: Aetna of AZ Commercial	$241.20
Rate for Payer: Bisbee Police All Plans	$69.68
Rate for Payer: Cash Price	$214.40
Rate for Payer: Self Pay Self Pay	$214.40

Lead, Blood (Pediatric) LC

Facility

$268.00

Service Code	CPT 83655
Hospital Charge Code	1285615
Hospital Revenue Code	301
Min. Negotiated Rate	$42.88
Max. Negotiated Rate	$241.20
Rate for Payer: Aetna of AZ Commercial	$241.20
Rate for Payer: Aetna of AZ Medicare	$75.04
Rate for Payer: Allwell Medicare	$42.88
Rate for Payer: Amerigroup Medicare	$42.88
Rate for Payer: APIPA Medicare/Medicaid	$100.10
Rate for Payer: AZCH Complete Medicare	$42.88
Rate for Payer: Banner UC Health Medicare	$42.88
Rate for Payer: Bisbee Police All Plans	$69.68
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$182.24
Rate for Payer: Cash Price	$214.40
Rate for Payer: Cigna of AZ Commercial	$174.20
Rate for Payer: Copperpoint Commercial	$66.33
Rate for Payer: Health Net of AZ Commercial	$160.80
Rate for Payer: Health Net of AZ Medicare	$75.04
Rate for Payer: Humana of AZ Medicare	$42.88
Rate for Payer: Self Pay Self Pay	$214.40
Rate for Payer: TriWest Medicare	$42.88
Rate for Payer: UnitedHealth Group of AZ Commercial	$156.24
Rate for Payer: UnitedHealth Group of AZ Medicare	$48.24

LEAD INTRODUCER

Facility

$1,605.00

Service Code	CPT C1894
Hospital Charge Code	22354566
Hospital Revenue Code	270
Min. Negotiated Rate	$417.30
Max. Negotiated Rate	$1,444.50
Rate for Payer: Aetna of AZ Commercial	$1,444.50
Rate for Payer: Bisbee Police All Plans	$417.30
Rate for Payer: Cash Price	$1,284.00
Rate for Payer: Self Pay Self Pay	$1,284.00

LEAD INTRODUCER

Facility

$1,605.00

Service Code	CPT C1894
Hospital Charge Code	22354566
Hospital Revenue Code	270
Min. Negotiated Rate	$256.80
Max. Negotiated Rate	$1,444.50
Rate for Payer: Aetna of AZ Commercial	$1,444.50
Rate for Payer: Aetna of AZ Medicare	$449.40
Rate for Payer: Allwell Medicare	$256.80
Rate for Payer: Amerigroup Medicare	$256.80
Rate for Payer: APIPA Medicare/Medicaid	$599.47
Rate for Payer: AZCH Complete Medicare	$256.80
Rate for Payer: Banner UC Health Medicare	$256.80
Rate for Payer: Bisbee Police All Plans	$417.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,091.40
Rate for Payer: Cash Price	$1,284.00
Rate for Payer: Cigna of AZ Commercial	$1,123.50
Rate for Payer: Copperpoint Commercial	$397.24
Rate for Payer: Health Net of AZ Commercial	$963.00
Rate for Payer: Health Net of AZ Medicare	$449.40
Rate for Payer: Humana of AZ Medicare	$256.80
Rate for Payer: Self Pay Self Pay	$1,284.00
Rate for Payer: TriWest Medicare	$256.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$935.72
Rate for Payer: UnitedHealth Group of AZ Medicare	$288.90

Legal Draw Fee

Facility

$48.00

Hospital Charge Code	2240047
Hospital Revenue Code	300
Min. Negotiated Rate	$7.68
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of AZ Commercial	$43.20
Rate for Payer: Aetna of AZ Medicare	$13.44
Rate for Payer: Allwell Medicare	$7.68
Rate for Payer: Amerigroup Medicare	$7.68
Rate for Payer: APIPA Medicare/Medicaid	$17.93
Rate for Payer: AZCH Complete Medicare	$7.68
Rate for Payer: Banner UC Health Medicare	$7.68
Rate for Payer: Bisbee Police All Plans	$12.48
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$32.64
Rate for Payer: Cash Price	$38.40
Rate for Payer: Cigna of AZ Commercial	$31.20
Rate for Payer: Copperpoint Commercial	$11.88
Rate for Payer: Health Net of AZ Commercial	$28.80
Rate for Payer: Health Net of AZ Medicare	$13.44
Rate for Payer: Humana of AZ Medicare	$7.68
Rate for Payer: Self Pay Self Pay	$38.40
Rate for Payer: TriWest Medicare	$7.68
Rate for Payer: UnitedHealth Group of AZ Commercial	$27.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$8.64

Legal Draw Fee

Facility

$48.00

Hospital Charge Code	2240047
Hospital Revenue Code	300
Min. Negotiated Rate	$12.48
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of AZ Commercial	$43.20
Rate for Payer: Bisbee Police All Plans	$12.48
Rate for Payer: Cash Price	$38.40
Rate for Payer: Self Pay Self Pay	$38.40

Legionella pneumophila Abs. LC

Facility

$86.00

Service Code	CPT 86713
Hospital Charge Code	22201718
Hospital Revenue Code	302
Min. Negotiated Rate	$13.76
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of AZ Commercial	$77.40
Rate for Payer: Aetna of AZ Medicare	$24.08
Rate for Payer: Allwell Medicare	$13.76
Rate for Payer: Amerigroup Medicare	$13.76
Rate for Payer: APIPA Medicare/Medicaid	$32.12
Rate for Payer: AZCH Complete Medicare	$13.76
Rate for Payer: Banner UC Health Medicare	$13.76
Rate for Payer: Bisbee Police All Plans	$22.36
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$58.48
Rate for Payer: Cash Price	$68.80
Rate for Payer: Cigna of AZ Commercial	$55.90
Rate for Payer: Copperpoint Commercial	$21.29
Rate for Payer: Health Net of AZ Commercial	$51.60
Rate for Payer: Health Net of AZ Medicare	$24.08
Rate for Payer: Humana of AZ Medicare	$13.76
Rate for Payer: Self Pay Self Pay	$68.80
Rate for Payer: TriWest Medicare	$13.76
Rate for Payer: UnitedHealth Group of AZ Commercial	$50.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$15.48

Legionella pneumophila Abs. LC

Facility

$86.00

Service Code	CPT 86713
Hospital Charge Code	22201718
Hospital Revenue Code	302
Min. Negotiated Rate	$22.36
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of AZ Commercial	$77.40
Rate for Payer: Bisbee Police All Plans	$22.36
Rate for Payer: Cash Price	$68.80
Rate for Payer: Self Pay Self Pay	$68.80

LEOS 01.6MM SMOOTH K WIRE

Facility

$630.00

Hospital Charge Code	27595625
Hospital Revenue Code	270
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$567.00
Rate for Payer: Aetna of AZ Commercial	$567.00
Rate for Payer: Aetna of AZ Medicare	$176.40
Rate for Payer: Allwell Medicare	$100.80
Rate for Payer: Amerigroup Medicare	$100.80
Rate for Payer: APIPA Medicare/Medicaid	$235.31
Rate for Payer: AZCH Complete Medicare	$100.80
Rate for Payer: Banner UC Health Medicare	$100.80
Rate for Payer: Bisbee Police All Plans	$163.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$428.40
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cigna of AZ Commercial	$441.00
Rate for Payer: Copperpoint Commercial	$155.93
Rate for Payer: Health Net of AZ Commercial	$378.00
Rate for Payer: Health Net of AZ Medicare	$176.40
Rate for Payer: Humana of AZ Medicare	$100.80
Rate for Payer: Self Pay Self Pay	$504.00
Rate for Payer: TriWest Medicare	$100.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$367.29
Rate for Payer: UnitedHealth Group of AZ Medicare	$113.40

LEOS 01.6MM SMOOTH K WIRE

Facility

$630.00

Hospital Charge Code	27595625
Hospital Revenue Code	270
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$567.00
Rate for Payer: Aetna of AZ Commercial	$567.00
Rate for Payer: Bisbee Police All Plans	$163.80
Rate for Payer: Cash Price	$504.00
Rate for Payer: Self Pay Self Pay	$504.00

Know your out-of-pocket cost for care.

All Charges