Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

miconazole 100 mg Vag Supp [CQCH]

Facility

$0.42

Service Code	NDC 49348083361
Hospital Charge Code	105932229
Hospital Revenue Code	251
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of AZ Commercial	$0.38
Rate for Payer: Bisbee Police All Plans	$0.11
Rate for Payer: Cash Price	$0.34
Rate for Payer: Self Pay Self Pay	$0.34

miconazole 2% Vag Crm w/Appl [CQCH]

Facility

$0.07

Service Code	NDC 904773445
Hospital Charge Code	105932168
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of AZ Commercial	$0.06
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Cash Price	$0.06
Rate for Payer: Self Pay Self Pay	$0.06

miconazole 2% Vag Crm w/Appl [CQCH]

Facility

$0.07

Service Code	NDC 904773445
Hospital Charge Code	105932168
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of AZ Commercial	$0.06
Rate for Payer: Aetna of AZ Medicare	$0.02
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.03
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.05
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of AZ Commercial	$0.05
Rate for Payer: Copperpoint Commercial	$0.02
Rate for Payer: Health Net of AZ Commercial	$0.04
Rate for Payer: Health Net of AZ Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Self Pay Self Pay	$0.06
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.04
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

Microalb/Creat Ratio

Facility

$315.00

Service Code	CPT 82043
Hospital Charge Code	1657587
Hospital Revenue Code	301
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of AZ Commercial	$283.50
Rate for Payer: Aetna of AZ Medicare	$88.20
Rate for Payer: Allwell Medicare	$50.40
Rate for Payer: Amerigroup Medicare	$50.40
Rate for Payer: APIPA Medicare/Medicaid	$117.65
Rate for Payer: AZCH Complete Medicare	$50.40
Rate for Payer: Banner UC Health Medicare	$50.40
Rate for Payer: Bisbee Police All Plans	$81.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$214.20
Rate for Payer: Cash Price	$252.00
Rate for Payer: Cigna of AZ Commercial	$204.75
Rate for Payer: Copperpoint Commercial	$77.96
Rate for Payer: Health Net of AZ Commercial	$189.00
Rate for Payer: Health Net of AZ Medicare	$88.20
Rate for Payer: Humana of AZ Medicare	$50.40
Rate for Payer: Self Pay Self Pay	$252.00
Rate for Payer: TriWest Medicare	$50.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$183.65
Rate for Payer: UnitedHealth Group of AZ Medicare	$56.70

Microalb/Creat Ratio

Facility

$315.00

Service Code	CPT 82043
Hospital Charge Code	1657587
Hospital Revenue Code	301
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of AZ Commercial	$283.50
Rate for Payer: Bisbee Police All Plans	$81.90
Rate for Payer: Cash Price	$252.00
Rate for Payer: Self Pay Self Pay	$252.00

MICRODISSECTION MANUAL

Facility

$590.00

Service Code	CPT 88381
Hospital Charge Code	22545748
Hospital Revenue Code	310
Min. Negotiated Rate	$94.40
Max. Negotiated Rate	$531.00
Rate for Payer: Aetna of AZ Commercial	$531.00
Rate for Payer: Aetna of AZ Medicare	$165.20
Rate for Payer: Allwell Medicare	$94.40
Rate for Payer: Amerigroup Medicare	$94.40
Rate for Payer: APIPA Medicare/Medicaid	$220.37
Rate for Payer: AZCH Complete Medicare	$94.40
Rate for Payer: Banner UC Health Medicare	$94.40
Rate for Payer: Bisbee Police All Plans	$153.40
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$401.20
Rate for Payer: Cash Price	$472.00
Rate for Payer: Cigna of AZ Commercial	$383.50
Rate for Payer: Copperpoint Commercial	$146.03
Rate for Payer: Health Net of AZ Commercial	$354.00
Rate for Payer: Health Net of AZ Medicare	$165.20
Rate for Payer: Humana of AZ Medicare	$94.40
Rate for Payer: Self Pay Self Pay	$472.00
Rate for Payer: TriWest Medicare	$94.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$343.97
Rate for Payer: UnitedHealth Group of AZ Medicare	$106.20

MICRODISSECTION MANUAL

Facility

$590.00

Service Code	CPT 88381
Hospital Charge Code	22545748
Hospital Revenue Code	310
Min. Negotiated Rate	$153.40
Max. Negotiated Rate	$531.00
Rate for Payer: Aetna of AZ Commercial	$531.00
Rate for Payer: Bisbee Police All Plans	$153.40
Rate for Payer: Cash Price	$472.00
Rate for Payer: Self Pay Self Pay	$472.00

MICROVASIVE ROTATABLE SNARE 13MM MICRO O

Facility

$1,279.00

Hospital Charge Code	22354317
Hospital Revenue Code	270
Min. Negotiated Rate	$204.64
Max. Negotiated Rate	$1,151.10
Rate for Payer: Aetna of AZ Commercial	$1,151.10
Rate for Payer: Aetna of AZ Medicare	$358.12
Rate for Payer: Allwell Medicare	$204.64
Rate for Payer: Amerigroup Medicare	$204.64
Rate for Payer: APIPA Medicare/Medicaid	$477.71
Rate for Payer: AZCH Complete Medicare	$204.64
Rate for Payer: Banner UC Health Medicare	$204.64
Rate for Payer: Bisbee Police All Plans	$332.54
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$869.72
Rate for Payer: Cash Price	$1,023.20
Rate for Payer: Cigna of AZ Commercial	$895.30
Rate for Payer: Copperpoint Commercial	$316.55
Rate for Payer: Health Net of AZ Commercial	$767.40
Rate for Payer: Health Net of AZ Medicare	$358.12
Rate for Payer: Humana of AZ Medicare	$204.64
Rate for Payer: Self Pay Self Pay	$1,023.20
Rate for Payer: TriWest Medicare	$204.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$745.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$230.22

MICROVASIVE ROTATABLE SNARE 13MM MICRO O

Facility

$1,279.00

Hospital Charge Code	22354317
Hospital Revenue Code	270
Min. Negotiated Rate	$332.54
Max. Negotiated Rate	$1,151.10
Rate for Payer: Aetna of AZ Commercial	$1,151.10
Rate for Payer: Bisbee Police All Plans	$332.54
Rate for Payer: Cash Price	$1,023.20
Rate for Payer: Self Pay Self Pay	$1,023.20

MICU

Facility

$152.00

Service Code	CPT 87077
Hospital Charge Code	1161242
Hospital Revenue Code	306
Min. Negotiated Rate	$24.32
Max. Negotiated Rate	$136.80
Rate for Payer: Aetna of AZ Commercial	$136.80
Rate for Payer: Aetna of AZ Medicare	$42.56
Rate for Payer: Allwell Medicare	$24.32
Rate for Payer: Amerigroup Medicare	$24.32
Rate for Payer: APIPA Medicare/Medicaid	$56.77
Rate for Payer: AZCH Complete Medicare	$24.32
Rate for Payer: Banner UC Health Medicare	$24.32
Rate for Payer: Bisbee Police All Plans	$39.52
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$103.36
Rate for Payer: Cash Price	$121.60
Rate for Payer: Cigna of AZ Commercial	$98.80
Rate for Payer: Copperpoint Commercial	$37.62
Rate for Payer: Health Net of AZ Commercial	$91.20
Rate for Payer: Health Net of AZ Medicare	$42.56
Rate for Payer: Humana of AZ Medicare	$24.32
Rate for Payer: Self Pay Self Pay	$121.60
Rate for Payer: TriWest Medicare	$24.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$88.62
Rate for Payer: UnitedHealth Group of AZ Medicare	$27.36

MICU

Facility

$152.00

Service Code	CPT 87077
Hospital Charge Code	1161242
Hospital Revenue Code	306
Min. Negotiated Rate	$39.52
Max. Negotiated Rate	$136.80
Rate for Payer: Aetna of AZ Commercial	$136.80
Rate for Payer: Bisbee Police All Plans	$39.52
Rate for Payer: Cash Price	$121.60
Rate for Payer: Self Pay Self Pay	$121.60

midazolam 2 mg/ 2 mL Inj Sol [CQCH]

Facility

$0.16

Service Code	HCPCS J2250
Hospital Charge Code	105932290
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Cash Price	$0.13
Rate for Payer: Self Pay Self Pay	$0.13

midazolam 2 mg/ 2 mL Inj Sol [CQCH]

Facility

$0.16

Service Code	HCPCS J2250
Hospital Charge Code	105932290
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
Rate for Payer: Aetna of AZ Medicare	$0.04
Rate for Payer: Allwell Medicare	$0.03
Rate for Payer: Amerigroup Medicare	$0.03
Rate for Payer: APIPA Medicare/Medicaid	$0.06
Rate for Payer: AZCH Complete Medicare	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.11
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cigna of AZ Commercial	$0.10
Rate for Payer: Copperpoint Commercial	$0.04
Rate for Payer: Health Net of AZ Commercial	$0.10
Rate for Payer: Health Net of AZ Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Self Pay Self Pay	$0.13
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.09
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.03

midazolam 2 mg/2 mL preservative-free Sol[CQCH]

Facility

$0.21

Service Code	HCPCS J2250
Hospital Charge Code	169435887
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of AZ Commercial	$0.19
Rate for Payer: Bisbee Police All Plans	$0.05
Rate for Payer: Cash Price	$0.17
Rate for Payer: Self Pay Self Pay	$0.17

midazolam 2 mg/2 mL preservative-free Sol[CQCH]

Facility

$0.21

Service Code	HCPCS J2250
Hospital Charge Code	169435887
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of AZ Commercial	$0.19
Rate for Payer: Aetna of AZ Medicare	$0.06
Rate for Payer: Allwell Medicare	$0.03
Rate for Payer: Amerigroup Medicare	$0.03
Rate for Payer: APIPA Medicare/Medicaid	$0.08
Rate for Payer: AZCH Complete Medicare	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Bisbee Police All Plans	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.14
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of AZ Commercial	$0.14
Rate for Payer: Copperpoint Commercial	$0.05
Rate for Payer: Health Net of AZ Commercial	$0.13
Rate for Payer: Health Net of AZ Medicare	$0.06
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Self Pay Self Pay	$0.17
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.12
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.04

midazolam 5 mg/1 mL Inj Sol [CQCH]

Facility

$0.77

Service Code	HCPCS J2250
Hospital Charge Code	105932365
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.69
Rate for Payer: Aetna of AZ Commercial	$0.69
Rate for Payer: Bisbee Police All Plans	$0.20
Rate for Payer: Cash Price	$0.62
Rate for Payer: Self Pay Self Pay	$0.62

midazolam 5 mg/1 mL Inj Sol [CQCH]

Facility

$0.77

Service Code	HCPCS J2250
Hospital Charge Code	105932365
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.69
Rate for Payer: Aetna of AZ Commercial	$0.69
Rate for Payer: Aetna of AZ Medicare	$0.22
Rate for Payer: Allwell Medicare	$0.12
Rate for Payer: Amerigroup Medicare	$0.12
Rate for Payer: APIPA Medicare/Medicaid	$0.29
Rate for Payer: AZCH Complete Medicare	$0.12
Rate for Payer: Banner UC Health Medicare	$0.12
Rate for Payer: Bisbee Police All Plans	$0.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.52
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna of AZ Commercial	$0.50
Rate for Payer: Copperpoint Commercial	$0.19
Rate for Payer: Health Net of AZ Commercial	$0.46
Rate for Payer: Health Net of AZ Medicare	$0.22
Rate for Payer: Humana of AZ Medicare	$0.12
Rate for Payer: Self Pay Self Pay	$0.62
Rate for Payer: TriWest Medicare	$0.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.45
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.14

midazolam 5 mg/mL 10 ml Sol FOR DRIP [CQCH]

Facility

$1.55

Service Code	HCPCS J2250
Hospital Charge Code	176044314
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of AZ Commercial	$1.40
Rate for Payer: Aetna of AZ Medicare	$0.43
Rate for Payer: Allwell Medicare	$0.25
Rate for Payer: Amerigroup Medicare	$0.25
Rate for Payer: APIPA Medicare/Medicaid	$0.58
Rate for Payer: AZCH Complete Medicare	$0.25
Rate for Payer: Banner UC Health Medicare	$0.25
Rate for Payer: Bisbee Police All Plans	$0.40
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.05
Rate for Payer: Cash Price	$1.24
Rate for Payer: Cigna of AZ Commercial	$1.01
Rate for Payer: Copperpoint Commercial	$0.38
Rate for Payer: Health Net of AZ Commercial	$0.93
Rate for Payer: Health Net of AZ Medicare	$0.43
Rate for Payer: Humana of AZ Medicare	$0.25
Rate for Payer: Self Pay Self Pay	$1.24
Rate for Payer: TriWest Medicare	$0.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.90
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.28

midazolam 5 mg/mL 10 ml Sol FOR DRIP [CQCH]

Facility

$1.55

Service Code	HCPCS J2250
Hospital Charge Code	176044314
Hospital Revenue Code	250
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of AZ Commercial	$1.40
Rate for Payer: Bisbee Police All Plans	$0.40
Rate for Payer: Cash Price	$1.24
Rate for Payer: Self Pay Self Pay	$1.24

MIDLINE KIT 3FR SINGLE LUMEN

Facility

$741.00

Hospital Charge Code	23751600
Hospital Revenue Code	270
Min. Negotiated Rate	$118.56
Max. Negotiated Rate	$666.90
Rate for Payer: Aetna of AZ Commercial	$666.90
Rate for Payer: Aetna of AZ Medicare	$207.48
Rate for Payer: Allwell Medicare	$118.56
Rate for Payer: Amerigroup Medicare	$118.56
Rate for Payer: APIPA Medicare/Medicaid	$276.76
Rate for Payer: AZCH Complete Medicare	$118.56
Rate for Payer: Banner UC Health Medicare	$118.56
Rate for Payer: Bisbee Police All Plans	$192.66
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$503.88
Rate for Payer: Cash Price	$592.80
Rate for Payer: Cigna of AZ Commercial	$518.70
Rate for Payer: Copperpoint Commercial	$183.40
Rate for Payer: Health Net of AZ Commercial	$444.60
Rate for Payer: Health Net of AZ Medicare	$207.48
Rate for Payer: Humana of AZ Medicare	$118.56
Rate for Payer: Self Pay Self Pay	$592.80
Rate for Payer: TriWest Medicare	$118.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$432.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$133.38

MIDLINE KIT 3FR SINGLE LUMEN

Facility

$741.00

Hospital Charge Code	23751600
Hospital Revenue Code	270
Min. Negotiated Rate	$192.66
Max. Negotiated Rate	$666.90
Rate for Payer: Aetna of AZ Commercial	$666.90
Rate for Payer: Bisbee Police All Plans	$192.66
Rate for Payer: Cash Price	$592.80
Rate for Payer: Self Pay Self Pay	$592.80

midodrine 5 mg Tab [CQCH]

Facility

$0.94

Service Code	NDC 51079045320
Hospital Charge Code	105932438
Hospital Revenue Code	251
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.85
Rate for Payer: Aetna of AZ Commercial	$0.85
Rate for Payer: Aetna of AZ Medicare	$0.26
Rate for Payer: Allwell Medicare	$0.15
Rate for Payer: Amerigroup Medicare	$0.15
Rate for Payer: APIPA Medicare/Medicaid	$0.35
Rate for Payer: AZCH Complete Medicare	$0.15
Rate for Payer: Banner UC Health Medicare	$0.15
Rate for Payer: Bisbee Police All Plans	$0.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.64
Rate for Payer: Cash Price	$0.75
Rate for Payer: Cigna of AZ Commercial	$0.61
Rate for Payer: Copperpoint Commercial	$0.23
Rate for Payer: Health Net of AZ Commercial	$0.56
Rate for Payer: Health Net of AZ Medicare	$0.26
Rate for Payer: Humana of AZ Medicare	$0.15
Rate for Payer: Self Pay Self Pay	$0.75
Rate for Payer: TriWest Medicare	$0.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.55
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.17

midodrine 5 mg Tab [CQCH]

Facility

$0.94

Service Code	NDC 51079045320
Hospital Charge Code	105932438
Hospital Revenue Code	251
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.85
Rate for Payer: Aetna of AZ Commercial	$0.85
Rate for Payer: Bisbee Police All Plans	$0.24
Rate for Payer: Cash Price	$0.75
Rate for Payer: Self Pay Self Pay	$0.75

Migraine And Other Headaches

Facility

$5,772.52

Service Code	APR-DRG 0543
Hospital Charge Code	APRDRG0544
Min. Negotiated Rate	$5,772.52
Max. Negotiated Rate	$5,772.52
Rate for Payer: AHCCCS Medicaid	$5,772.52
Rate for Payer: Allwell Medicaid	$5,772.52
Rate for Payer: AZCH Complete Medicaid	$5,772.52
Rate for Payer: Banner UC Health Medicaid	$5,772.52
Rate for Payer: Mercy Care Medicaid	$5,772.52

Migraine And Other Headaches

Facility

$4,679.74

Service Code	APR-DRG 0542
Hospital Charge Code	APRDRG0541
Min. Negotiated Rate	$4,679.74
Max. Negotiated Rate	$4,679.74
Rate for Payer: AHCCCS Medicaid	$4,679.74
Rate for Payer: Allwell Medicaid	$4,679.74
Rate for Payer: AZCH Complete Medicaid	$4,679.74
Rate for Payer: Banner UC Health Medicaid	$4,679.74
Rate for Payer: Mercy Care Medicaid	$4,679.74

Know your out-of-pocket cost for care.

All Charges