Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Mastectomy Procedures

Facility

$11,591.34

Service Code	APR-DRG 3622
Hospital Charge Code	APRDRG3622
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	APRDRG3624
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

$17,489.41

Service Code	APR-DRG 3624
Hospital Charge Code	APRDRG3622
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

Mastectomy Procedures

Facility

$8,417.50

Service Code	APR-DRG 3621
Hospital Charge Code	APRDRG3621
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	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

M D I INSTRUCT/INIT

Facility

$150.00

Service Code	CPT 94664
Hospital Charge Code	1886939
Hospital Revenue Code	460
Min. Negotiated Rate	$39.00
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of AZ Commercial	$135.00
Rate for Payer: Bisbee Police All Plans	$39.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Self Pay Self Pay	$120.00

M D I INSTRUCT/INIT

Facility

$224.00

Service Code	CPT 94664
Hospital Charge Code	2158628
Hospital Revenue Code	460
Min. Negotiated Rate	$35.84
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of AZ Commercial	$201.60
Rate for Payer: Aetna of AZ Medicare	$62.72
Rate for Payer: AHCCCS Medicaid	$136.21
Rate for Payer: Allwell Medicaid	$136.21
Rate for Payer: Allwell Medicare	$35.84
Rate for Payer: Amerigroup Medicare	$35.84
Rate for Payer: APIPA Medicare/Medicaid	$83.66
Rate for Payer: AZCH Complete Medicaid	$136.21
Rate for Payer: AZCH Complete Medicare	$35.84
Rate for Payer: Banner UC Health Medicaid	$136.21
Rate for Payer: Banner UC Health Medicare	$35.84
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	$35.84
Rate for Payer: Mercy Care Medicaid	$136.21
Rate for Payer: Self Pay Self Pay	$179.20
Rate for Payer: TriWest Medicare	$35.84
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

$150.00

Service Code	CPT 94664
Hospital Charge Code	1886939
Hospital Revenue Code	460
Min. Negotiated Rate	$24.00
Max. Negotiated Rate	$136.21
Rate for Payer: Aetna of AZ Commercial	$135.00
Rate for Payer: Aetna of AZ Medicare	$42.00
Rate for Payer: AHCCCS Medicaid	$136.21
Rate for Payer: Allwell Medicaid	$136.21
Rate for Payer: Allwell Medicare	$24.00
Rate for Payer: Amerigroup Medicare	$24.00
Rate for Payer: APIPA Medicare/Medicaid	$56.02
Rate for Payer: AZCH Complete Medicaid	$136.21
Rate for Payer: AZCH Complete Medicare	$24.00
Rate for Payer: Banner UC Health Medicaid	$136.21
Rate for Payer: Banner UC Health Medicare	$24.00
Rate for Payer: Bisbee Police All Plans	$39.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$102.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cigna of AZ Commercial	$105.00
Rate for Payer: Copperpoint Commercial	$37.12
Rate for Payer: Health Net of AZ Commercial	$90.00
Rate for Payer: Health Net of AZ Medicare	$42.00
Rate for Payer: Humana of AZ Medicare	$24.00
Rate for Payer: Mercy Care Medicaid	$136.21
Rate for Payer: Self Pay Self Pay	$120.00
Rate for Payer: TriWest Medicare	$24.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$87.45
Rate for Payer: UnitedHealth Group of AZ Medicare	$27.00

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

Measles/Mumps/Rubella Immunity LC

Facility

$165.00

Service Code	CPT 86735
Hospital Charge Code	2269429
Hospital Revenue Code	302
Min. Negotiated Rate	$26.40
Max. Negotiated Rate	$148.50
Rate for Payer: Aetna of AZ Commercial	$148.50
Rate for Payer: Aetna of AZ Medicare	$46.20
Rate for Payer: Allwell Medicare	$26.40
Rate for Payer: Amerigroup Medicare	$26.40
Rate for Payer: APIPA Medicare/Medicaid	$61.63
Rate for Payer: AZCH Complete Medicare	$26.40
Rate for Payer: Banner UC Health Medicare	$26.40
Rate for Payer: Bisbee Police All Plans	$42.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$112.20
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cigna of AZ Commercial	$107.25
Rate for Payer: Copperpoint Commercial	$40.84
Rate for Payer: Health Net of AZ Commercial	$99.00
Rate for Payer: Health Net of AZ Medicare	$46.20
Rate for Payer: Humana of AZ Medicare	$26.40
Rate for Payer: Self Pay Self Pay	$132.00
Rate for Payer: TriWest Medicare	$26.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$96.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$29.70

Measles/Mumps/Rubella Immunity LC

Facility

$165.00

Service Code	CPT 86735
Hospital Charge Code	2269429
Hospital Revenue Code	302
Min. Negotiated Rate	$42.90
Max. Negotiated Rate	$148.50
Rate for Payer: Aetna of AZ Commercial	$148.50
Rate for Payer: Bisbee Police All Plans	$42.90
Rate for Payer: Cash Price	$132.00
Rate for Payer: Self Pay Self Pay	$132.00

Measles (Rubeola), PCR, Swab LC

Facility

$175.00

Service Code	CPT 87798
Hospital Charge Code	27537339
Hospital Revenue Code	306
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Aetna of AZ Medicare	$49.00
Rate for Payer: Allwell Medicare	$28.00
Rate for Payer: Amerigroup Medicare	$28.00
Rate for Payer: APIPA Medicare/Medicaid	$65.36
Rate for Payer: AZCH Complete Medicare	$28.00
Rate for Payer: Banner UC Health Medicare	$28.00
Rate for Payer: Bisbee Police All Plans	$45.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$119.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cigna of AZ Commercial	$113.75
Rate for Payer: Copperpoint Commercial	$43.31
Rate for Payer: Health Net of AZ Commercial	$105.00
Rate for Payer: Health Net of AZ Medicare	$49.00
Rate for Payer: Humana of AZ Medicare	$28.00
Rate for Payer: Self Pay Self Pay	$140.00
Rate for Payer: TriWest Medicare	$28.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$102.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$31.50

Measles (Rubeola), PCR, Swab LC

Facility

$175.00

Service Code	CPT 87798
Hospital Charge Code	27537339
Hospital Revenue Code	306
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Bisbee Police All Plans	$45.50
Rate for Payer: Cash Price	$140.00
Rate for Payer: Self Pay Self Pay	$140.00

Measles (Rubeola), PCR, Urine LC

Facility

$175.00

Service Code	CPT 87798
Hospital Charge Code	27539788
Hospital Revenue Code	306
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Aetna of AZ Medicare	$49.00
Rate for Payer: Allwell Medicare	$28.00
Rate for Payer: Amerigroup Medicare	$28.00
Rate for Payer: APIPA Medicare/Medicaid	$65.36
Rate for Payer: AZCH Complete Medicare	$28.00
Rate for Payer: Banner UC Health Medicare	$28.00
Rate for Payer: Bisbee Police All Plans	$45.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$119.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cigna of AZ Commercial	$113.75
Rate for Payer: Copperpoint Commercial	$43.31
Rate for Payer: Health Net of AZ Commercial	$105.00
Rate for Payer: Health Net of AZ Medicare	$49.00
Rate for Payer: Humana of AZ Medicare	$28.00
Rate for Payer: Self Pay Self Pay	$140.00
Rate for Payer: TriWest Medicare	$28.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$102.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$31.50

Measles (Rubeola), PCR, Urine LC

Facility

$175.00

Service Code	CPT 87798
Hospital Charge Code	27539788
Hospital Revenue Code	306
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of AZ Commercial	$157.50
Rate for Payer: Bisbee Police All Plans	$45.50
Rate for Payer: Cash Price	$140.00
Rate for Payer: Self Pay Self Pay	$140.00

MEASUREMENT OF TISSUE TRANSGLUTAMINASE

Facility

$58.00

Service Code	CPT 86364
Hospital Charge Code	28010048
Hospital Revenue Code	302
Min. Negotiated Rate	$15.08
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of AZ Commercial	$52.20
Rate for Payer: Bisbee Police All Plans	$15.08
Rate for Payer: Cash Price	$46.40
Rate for Payer: Self Pay Self Pay	$46.40

MEASUREMENT OF TISSUE TRANSGLUTAMINASE

Facility

$58.00

Service Code	CPT 86364
Hospital Charge Code	28010048
Hospital Revenue Code	302
Min. Negotiated Rate	$9.28
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of AZ Commercial	$52.20
Rate for Payer: Aetna of AZ Medicare	$16.24
Rate for Payer: Allwell Medicare	$9.28
Rate for Payer: Amerigroup Medicare	$9.28
Rate for Payer: APIPA Medicare/Medicaid	$21.66
Rate for Payer: AZCH Complete Medicare	$9.28
Rate for Payer: Banner UC Health Medicare	$9.28
Rate for Payer: Bisbee Police All Plans	$15.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$39.44
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cigna of AZ Commercial	$37.70
Rate for Payer: Copperpoint Commercial	$14.36
Rate for Payer: Health Net of AZ Commercial	$34.80
Rate for Payer: Health Net of AZ Medicare	$16.24
Rate for Payer: Humana of AZ Medicare	$9.28
Rate for Payer: Self Pay Self Pay	$46.40
Rate for Payer: TriWest Medicare	$9.28
Rate for Payer: UnitedHealth Group of AZ Commercial	$33.81
Rate for Payer: UnitedHealth Group of AZ Medicare	$10.44

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	$0.14
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	$0.14
Rate for Payer: Amerigroup Medicare	$0.14
Rate for Payer: APIPA Medicare/Medicaid	$0.32
Rate for Payer: AZCH Complete Medicare	$0.14
Rate for Payer: Banner UC Health Medicare	$0.14
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	$0.14
Rate for Payer: Self Pay Self Pay	$0.70
Rate for Payer: TriWest Medicare	$0.14
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	$6.56
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	$6.56
Rate for Payer: Amerigroup Medicare	$6.56
Rate for Payer: APIPA Medicare/Medicaid	$15.31
Rate for Payer: AZCH Complete Medicare	$6.56
Rate for Payer: Banner UC Health Medicare	$6.56
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	$6.56
Rate for Payer: Self Pay Self Pay	$32.80
Rate for Payer: TriWest Medicare	$6.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$23.90
Rate for Payer: UnitedHealth Group of AZ Medicare	$7.38

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

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	27569982
Hospital Revenue Code	270
Min. Negotiated Rate	$11.36
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	$11.36
Rate for Payer: Amerigroup Medicare	$11.36
Rate for Payer: APIPA Medicare/Medicaid	$26.52
Rate for Payer: AZCH Complete Medicare	$11.36
Rate for Payer: Banner UC Health Medicare	$11.36
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	$11.36
Rate for Payer: Self Pay Self Pay	$56.80
Rate for Payer: TriWest Medicare	$11.36
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	$11.36
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	$11.36
Rate for Payer: Amerigroup Medicare	$11.36
Rate for Payer: APIPA Medicare/Medicaid	$26.52
Rate for Payer: AZCH Complete Medicare	$11.36
Rate for Payer: Banner UC Health Medicare	$11.36
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	$11.36
Rate for Payer: Self Pay Self Pay	$56.80
Rate for Payer: TriWest Medicare	$11.36
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

Know your out-of-pocket cost for care.

All Charges