Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Mastectomy Procedures

Facility

$14,776.39

Service Code	APR-DRG 3623
Hospital Charge Code	APRDRG3621
Min. Negotiated Rate	$14,776.39
Max. Negotiated Rate	$14,776.39
Rate for Payer: AHCCCS Medicaid	$14,776.39
Rate for Payer: Allwell Medicaid	$14,776.39
Rate for Payer: AZCH Complete Medicaid	$14,776.39
Rate for Payer: Banner UC Health Medicaid	$14,776.39
Rate for Payer: Mercy Care Medicaid	$14,776.39

Mastectomy Procedures

Facility

$11,591.34

Service Code	APR-DRG 3622
Hospital Charge Code	APRDRG3621
Min. Negotiated Rate	$11,591.34
Max. Negotiated Rate	$11,591.34
Rate for Payer: AHCCCS Medicaid	$11,591.34
Rate for Payer: Allwell Medicaid	$11,591.34
Rate for Payer: AZCH Complete Medicaid	$11,591.34
Rate for Payer: Banner UC Health Medicaid	$11,591.34
Rate for Payer: Mercy Care Medicaid	$11,591.34

Mastectomy Procedures

Facility

$8,417.50

Service Code	APR-DRG 3621
Hospital Charge Code	APRDRG3623
Min. Negotiated Rate	$8,417.50
Max. Negotiated Rate	$8,417.50
Rate for Payer: AHCCCS Medicaid	$8,417.50
Rate for Payer: Allwell Medicaid	$8,417.50
Rate for Payer: AZCH Complete Medicaid	$8,417.50
Rate for Payer: Banner UC Health Medicaid	$8,417.50
Rate for Payer: Mercy Care Medicaid	$8,417.50

Mastectomy Procedures

Facility

$8,417.50

Service Code	APR-DRG 3621
Hospital Charge Code	APRDRG3622
Min. Negotiated Rate	$8,417.50
Max. Negotiated Rate	$8,417.50
Rate for Payer: AHCCCS Medicaid	$8,417.50
Rate for Payer: Allwell Medicaid	$8,417.50
Rate for Payer: AZCH Complete Medicaid	$8,417.50
Rate for Payer: Banner UC Health Medicaid	$8,417.50
Rate for Payer: Mercy Care Medicaid	$8,417.50

Mastectomy Procedures

Facility

$14,776.39

Service Code	APR-DRG 3623
Hospital Charge Code	APRDRG3624
Min. Negotiated Rate	$14,776.39
Max. Negotiated Rate	$14,776.39
Rate for Payer: AHCCCS Medicaid	$14,776.39
Rate for Payer: Allwell Medicaid	$14,776.39
Rate for Payer: AZCH Complete Medicaid	$14,776.39
Rate for Payer: Banner UC Health Medicaid	$14,776.39
Rate for Payer: Mercy Care Medicaid	$14,776.39

Mastectomy Procedures

Facility

$17,489.41

Service Code	APR-DRG 3624
Hospital Charge Code	APRDRG3621
Min. Negotiated Rate	$17,489.41
Max. Negotiated Rate	$17,489.41
Rate for Payer: AHCCCS Medicaid	$17,489.41
Rate for Payer: Allwell Medicaid	$17,489.41
Rate for Payer: AZCH Complete Medicaid	$17,489.41
Rate for Payer: Banner UC Health Medicaid	$17,489.41
Rate for Payer: Mercy Care Medicaid	$17,489.41

M D I INSTRUCT/INIT

Facility

$224.00

Service Code	CPT 94664
Hospital Charge Code	2158628
Hospital Revenue Code	460
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$272.42
Rate for Payer: Aetna of AZ Commercial	$201.60
Rate for Payer: Aetna of AZ Medicare	$62.72
Rate for Payer: AHCCCS Medicaid	$272.42
Rate for Payer: Allwell Medicaid	$272.42
Rate for Payer: Allwell Medicare	$33.60
Rate for Payer: Amerigroup Medicare	$33.60
Rate for Payer: APIPA Medicare/Medicaid	$83.66
Rate for Payer: AZCH Complete Medicaid	$272.42
Rate for Payer: AZCH Complete Medicare	$33.60
Rate for Payer: Banner UC Health Medicaid	$272.42
Rate for Payer: Banner UC Health Medicare	$33.60
Rate for Payer: Bisbee Police All Plans	$58.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$152.32
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cigna of AZ Commercial	$156.80
Rate for Payer: Copperpoint Commercial	$55.44
Rate for Payer: Health Net of AZ Commercial	$134.40
Rate for Payer: Health Net of AZ Medicare	$62.72
Rate for Payer: Humana of AZ Medicare	$33.60
Rate for Payer: Mercy Care Medicaid	$272.42
Rate for Payer: Self Pay Self Pay	$179.20
Rate for Payer: TriWest Medicare	$33.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$130.59
Rate for Payer: UnitedHealth Group of AZ Medicare	$40.32

M D I INSTRUCT/INIT

Facility

$224.00

Service Code	CPT 94664
Hospital Charge Code	1886939
Hospital Revenue Code	460
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$272.42
Rate for Payer: Aetna of AZ Commercial	$201.60
Rate for Payer: Aetna of AZ Medicare	$62.72
Rate for Payer: AHCCCS Medicaid	$272.42
Rate for Payer: Allwell Medicaid	$272.42
Rate for Payer: Allwell Medicare	$33.60
Rate for Payer: Amerigroup Medicare	$33.60
Rate for Payer: APIPA Medicare/Medicaid	$83.66
Rate for Payer: AZCH Complete Medicaid	$272.42
Rate for Payer: AZCH Complete Medicare	$33.60
Rate for Payer: Banner UC Health Medicaid	$272.42
Rate for Payer: Banner UC Health Medicare	$33.60
Rate for Payer: Bisbee Police All Plans	$58.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$152.32
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cigna of AZ Commercial	$156.80
Rate for Payer: Copperpoint Commercial	$55.44
Rate for Payer: Health Net of AZ Commercial	$134.40
Rate for Payer: Health Net of AZ Medicare	$62.72
Rate for Payer: Humana of AZ Medicare	$33.60
Rate for Payer: Mercy Care Medicaid	$272.42
Rate for Payer: Self Pay Self Pay	$179.20
Rate for Payer: TriWest Medicare	$33.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$130.59
Rate for Payer: UnitedHealth Group of AZ Medicare	$40.32

M D I INSTRUCT/INIT

Facility

$224.00

Service Code	CPT 94664
Hospital Charge Code	2158628
Hospital Revenue Code	460
Min. Negotiated Rate	$58.24
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of AZ Commercial	$201.60
Rate for Payer: Bisbee Police All Plans	$58.24
Rate for Payer: Cash Price	$179.20
Rate for Payer: Self Pay Self Pay	$179.20

M D I INSTRUCT/INIT

Facility

$224.00

Service Code	CPT 94664
Hospital Charge Code	1886939
Hospital Revenue Code	460
Min. Negotiated Rate	$58.24
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of AZ Commercial	$201.60
Rate for Payer: Bisbee Police All Plans	$58.24
Rate for Payer: Cash Price	$179.20
Rate for Payer: Self Pay Self Pay	$179.20

Measles/Mumps/Rubella Immunity LC

Facility

$174.00

Service Code	CPT 86735
Hospital Charge Code	2269429
Hospital Revenue Code	302
Min. Negotiated Rate	$13.05
Max. Negotiated Rate	$156.60
Rate for Payer: Aetna of AZ Commercial	$156.60
Rate for Payer: Aetna of AZ Medicare	$48.72
Rate for Payer: AHCCCS Medicaid	$13.05
Rate for Payer: Allwell Medicaid	$13.05
Rate for Payer: Allwell Medicare	$26.10
Rate for Payer: Amerigroup Medicare	$26.10
Rate for Payer: APIPA Medicare/Medicaid	$64.99
Rate for Payer: AZCH Complete Medicaid	$13.05
Rate for Payer: AZCH Complete Medicare	$26.10
Rate for Payer: Banner UC Health Medicaid	$13.05
Rate for Payer: Banner UC Health Medicare	$26.10
Rate for Payer: Bisbee Police All Plans	$45.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$118.32
Rate for Payer: Cash Price	$139.20
Rate for Payer: Cash Price	$139.20
Rate for Payer: Cigna of AZ Commercial	$113.10
Rate for Payer: Copperpoint Commercial	$43.06
Rate for Payer: Health Net of AZ Commercial	$104.40
Rate for Payer: Health Net of AZ Medicare	$48.72
Rate for Payer: Humana of AZ Medicare	$26.10
Rate for Payer: Mercy Care Medicaid	$13.05
Rate for Payer: Self Pay Self Pay	$139.20
Rate for Payer: TriWest Medicare	$26.10
Rate for Payer: UnitedHealth Group of AZ Commercial	$101.44
Rate for Payer: UnitedHealth Group of AZ Medicare	$31.32

Measles/Mumps/Rubella Immunity LC

Facility

$174.00

Service Code	CPT 86735
Hospital Charge Code	2269429
Hospital Revenue Code	302
Min. Negotiated Rate	$45.24
Max. Negotiated Rate	$156.60
Rate for Payer: Aetna of AZ Commercial	$156.60
Rate for Payer: Bisbee Police All Plans	$45.24
Rate for Payer: Cash Price	$139.20
Rate for Payer: Self Pay Self Pay	$139.20

meclizine 25 mg tab [CQCH]

Facility

$0.87

Service Code	NDC 68084049101
Hospital Charge Code	105954961
Hospital Revenue Code	251
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.78
Rate for Payer: Aetna of AZ Commercial	$0.78
Rate for Payer: Bisbee Police All Plans	$0.23
Rate for Payer: Cash Price	$0.70
Rate for Payer: Self Pay Self Pay	$0.70

meclizine 25 mg tab [CQCH]

Facility

$0.87

Service Code	NDC 68084049101
Hospital Charge Code	105954961
Hospital Revenue Code	251
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.78
Rate for Payer: Aetna of AZ Commercial	$0.78
Rate for Payer: Aetna of AZ Medicare	$0.24
Rate for Payer: Allwell Medicare	$0.13
Rate for Payer: Amerigroup Medicare	$0.13
Rate for Payer: APIPA Medicare/Medicaid	$0.32
Rate for Payer: AZCH Complete Medicare	$0.13
Rate for Payer: Banner UC Health Medicare	$0.13
Rate for Payer: Bisbee Police All Plans	$0.23
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.59
Rate for Payer: Cash Price	$0.70
Rate for Payer: Cigna of AZ Commercial	$0.57
Rate for Payer: Copperpoint Commercial	$0.22
Rate for Payer: Health Net of AZ Commercial	$0.52
Rate for Payer: Health Net of AZ Medicare	$0.24
Rate for Payer: Humana of AZ Medicare	$0.13
Rate for Payer: Self Pay Self Pay	$0.70
Rate for Payer: TriWest Medicare	$0.13
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.51
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.16

MECONIUM ASPIRATIORS

Facility

$41.00

Hospital Charge Code	22355517
Hospital Revenue Code	270
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of AZ Commercial	$36.90
Rate for Payer: Bisbee Police All Plans	$10.66
Rate for Payer: Cash Price	$32.80
Rate for Payer: Self Pay Self Pay	$32.80

MECONIUM ASPIRATIORS

Facility

$41.00

Hospital Charge Code	22355517
Hospital Revenue Code	270
Min. Negotiated Rate	$6.15
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of AZ Commercial	$36.90
Rate for Payer: Aetna of AZ Medicare	$11.48
Rate for Payer: Allwell Medicare	$6.15
Rate for Payer: Amerigroup Medicare	$6.15
Rate for Payer: APIPA Medicare/Medicaid	$15.31
Rate for Payer: AZCH Complete Medicare	$6.15
Rate for Payer: Banner UC Health Medicare	$6.15
Rate for Payer: Bisbee Police All Plans	$10.66
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$27.88
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cigna of AZ Commercial	$28.70
Rate for Payer: Copperpoint Commercial	$10.15
Rate for Payer: Health Net of AZ Commercial	$24.60
Rate for Payer: Health Net of AZ Medicare	$11.48
Rate for Payer: Humana of AZ Medicare	$6.15
Rate for Payer: Self Pay Self Pay	$32.80
Rate for Payer: TriWest Medicare	$6.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$23.90
Rate for Payer: UnitedHealth Group of AZ Medicare	$7.38

MEDIHONEY 1.5 OZ

Facility

$71.00

Hospital Charge Code	27569982
Hospital Revenue Code	270
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Aetna of AZ Medicare	$19.88
Rate for Payer: Allwell Medicare	$10.65
Rate for Payer: Amerigroup Medicare	$10.65
Rate for Payer: APIPA Medicare/Medicaid	$26.52
Rate for Payer: AZCH Complete Medicare	$10.65
Rate for Payer: Banner UC Health Medicare	$10.65
Rate for Payer: Bisbee Police All Plans	$18.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$48.28
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cigna of AZ Commercial	$49.70
Rate for Payer: Copperpoint Commercial	$17.57
Rate for Payer: Health Net of AZ Commercial	$42.60
Rate for Payer: Health Net of AZ Medicare	$19.88
Rate for Payer: Humana of AZ Medicare	$10.65
Rate for Payer: Self Pay Self Pay	$56.80
Rate for Payer: TriWest Medicare	$10.65
Rate for Payer: UnitedHealth Group of AZ Commercial	$41.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.78

MEDIHONEY 1.5 OZ

Facility

$71.00

Hospital Charge Code	22354967
Hospital Revenue Code	270
Min. Negotiated Rate	$18.46
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Bisbee Police All Plans	$18.46
Rate for Payer: Cash Price	$56.80
Rate for Payer: Self Pay Self Pay	$56.80

MEDIHONEY 1.5 OZ

Facility

$71.00

Hospital Charge Code	27569982
Hospital Revenue Code	270
Min. Negotiated Rate	$18.46
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Bisbee Police All Plans	$18.46
Rate for Payer: Cash Price	$56.80
Rate for Payer: Self Pay Self Pay	$56.80

MEDIHONEY 1.5 OZ

Facility

$71.00

Hospital Charge Code	22354967
Hospital Revenue Code	270
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Aetna of AZ Medicare	$19.88
Rate for Payer: Allwell Medicare	$10.65
Rate for Payer: Amerigroup Medicare	$10.65
Rate for Payer: APIPA Medicare/Medicaid	$26.52
Rate for Payer: AZCH Complete Medicare	$10.65
Rate for Payer: Banner UC Health Medicare	$10.65
Rate for Payer: Bisbee Police All Plans	$18.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$48.28
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cigna of AZ Commercial	$49.70
Rate for Payer: Copperpoint Commercial	$17.57
Rate for Payer: Health Net of AZ Commercial	$42.60
Rate for Payer: Health Net of AZ Medicare	$19.88
Rate for Payer: Humana of AZ Medicare	$10.65
Rate for Payer: Self Pay Self Pay	$56.80
Rate for Payer: TriWest Medicare	$10.65
Rate for Payer: UnitedHealth Group of AZ Commercial	$41.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.78

MEDIUM OVAL FLEXIBLE SHORT THROW

Facility

$47.00

Hospital Charge Code	23624450
Hospital Revenue Code	270
Min. Negotiated Rate	$12.22
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Bisbee Police All Plans	$12.22
Rate for Payer: Cash Price	$37.60
Rate for Payer: Self Pay Self Pay	$37.60

MEDIUM OVAL FLEXIBLE SHORT THROW

Facility

$47.00

Hospital Charge Code	27497392
Hospital Revenue Code	270
Min. Negotiated Rate	$7.05
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Aetna of AZ Medicare	$13.16
Rate for Payer: Allwell Medicare	$7.05
Rate for Payer: Amerigroup Medicare	$7.05
Rate for Payer: APIPA Medicare/Medicaid	$17.55
Rate for Payer: AZCH Complete Medicare	$7.05
Rate for Payer: Banner UC Health Medicare	$7.05
Rate for Payer: Bisbee Police All Plans	$12.22
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$31.96
Rate for Payer: Cash Price	$37.60
Rate for Payer: Cigna of AZ Commercial	$32.90
Rate for Payer: Copperpoint Commercial	$11.63
Rate for Payer: Health Net of AZ Commercial	$28.20
Rate for Payer: Health Net of AZ Medicare	$13.16
Rate for Payer: Humana of AZ Medicare	$7.05
Rate for Payer: Self Pay Self Pay	$37.60
Rate for Payer: TriWest Medicare	$7.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$27.40
Rate for Payer: UnitedHealth Group of AZ Medicare	$8.46

MEDIUM OVAL FLEXIBLE SHORT THROW

Facility

$47.00

Hospital Charge Code	23624450
Hospital Revenue Code	270
Min. Negotiated Rate	$7.05
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Aetna of AZ Medicare	$13.16
Rate for Payer: Allwell Medicare	$7.05
Rate for Payer: Amerigroup Medicare	$7.05
Rate for Payer: APIPA Medicare/Medicaid	$17.55
Rate for Payer: AZCH Complete Medicare	$7.05
Rate for Payer: Banner UC Health Medicare	$7.05
Rate for Payer: Bisbee Police All Plans	$12.22
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$31.96
Rate for Payer: Cash Price	$37.60
Rate for Payer: Cigna of AZ Commercial	$32.90
Rate for Payer: Copperpoint Commercial	$11.63
Rate for Payer: Health Net of AZ Commercial	$28.20
Rate for Payer: Health Net of AZ Medicare	$13.16
Rate for Payer: Humana of AZ Medicare	$7.05
Rate for Payer: Self Pay Self Pay	$37.60
Rate for Payer: TriWest Medicare	$7.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$27.40
Rate for Payer: UnitedHealth Group of AZ Medicare	$8.46

MEDIUM OVAL FLEXIBLE SHORT THROW

Facility

$47.00

Hospital Charge Code	27497392
Hospital Revenue Code	270
Min. Negotiated Rate	$12.22
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Bisbee Police All Plans	$12.22
Rate for Payer: Cash Price	$37.60
Rate for Payer: Self Pay Self Pay	$37.60

medroxyPROGESTERone 2.5 mg Tab [CQCH]

Facility

$0.05

Service Code	NDC 555087202
Hospital Charge Code	105930428
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

Know your out-of-pocket cost for care.

All Charges