Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

mycophenolate 500 mg Tab UD [CQCH]

Facility

$0.62

Service Code	HCPCS J7517
Hospital Charge Code	108074965
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.56
Rate for Payer: Aetna of AZ Commercial	$0.56
Rate for Payer: Bisbee Police All Plans	$0.16
Rate for Payer: Cash Price	$0.50
Rate for Payer: Self Pay Self Pay	$0.50

Myoglobin, Serum LC

Facility

$301.00

Service Code	CPT 83874
Hospital Charge Code	2087628
Hospital Revenue Code	301
Min. Negotiated Rate	$78.26
Max. Negotiated Rate	$270.90
Rate for Payer: Aetna of AZ Commercial	$270.90
Rate for Payer: Bisbee Police All Plans	$78.26
Rate for Payer: Cash Price	$240.80
Rate for Payer: Self Pay Self Pay	$240.80

Myoglobin, Serum LC

Facility

$301.00

Service Code	CPT 83874
Hospital Charge Code	2087628
Hospital Revenue Code	301
Min. Negotiated Rate	$48.16
Max. Negotiated Rate	$270.90
Rate for Payer: Aetna of AZ Commercial	$270.90
Rate for Payer: Aetna of AZ Medicare	$84.28
Rate for Payer: Allwell Medicare	$48.16
Rate for Payer: Amerigroup Medicare	$48.16
Rate for Payer: APIPA Medicare/Medicaid	$112.42
Rate for Payer: AZCH Complete Medicare	$48.16
Rate for Payer: Banner UC Health Medicare	$48.16
Rate for Payer: Bisbee Police All Plans	$78.26
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$204.68
Rate for Payer: Cash Price	$240.80
Rate for Payer: Cigna of AZ Commercial	$195.65
Rate for Payer: Copperpoint Commercial	$74.50
Rate for Payer: Health Net of AZ Commercial	$180.60
Rate for Payer: Health Net of AZ Medicare	$84.28
Rate for Payer: Humana of AZ Medicare	$48.16
Rate for Payer: Self Pay Self Pay	$240.80
Rate for Payer: TriWest Medicare	$48.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$175.48
Rate for Payer: UnitedHealth Group of AZ Medicare	$54.18

Myoglobin, Urine LC

Facility

$308.00

Service Code	CPT 83874
Hospital Charge Code	2269443
Hospital Revenue Code	301
Min. Negotiated Rate	$49.28
Max. Negotiated Rate	$277.20
Rate for Payer: Aetna of AZ Commercial	$277.20
Rate for Payer: Aetna of AZ Medicare	$86.24
Rate for Payer: Allwell Medicare	$49.28
Rate for Payer: Amerigroup Medicare	$49.28
Rate for Payer: APIPA Medicare/Medicaid	$115.04
Rate for Payer: AZCH Complete Medicare	$49.28
Rate for Payer: Banner UC Health Medicare	$49.28
Rate for Payer: Bisbee Police All Plans	$80.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$209.44
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cigna of AZ Commercial	$200.20
Rate for Payer: Copperpoint Commercial	$76.23
Rate for Payer: Health Net of AZ Commercial	$184.80
Rate for Payer: Health Net of AZ Medicare	$86.24
Rate for Payer: Humana of AZ Medicare	$49.28
Rate for Payer: Self Pay Self Pay	$246.40
Rate for Payer: TriWest Medicare	$49.28
Rate for Payer: UnitedHealth Group of AZ Commercial	$179.56
Rate for Payer: UnitedHealth Group of AZ Medicare	$55.44

Myoglobin, Urine LC

Facility

$308.00

Service Code	CPT 83874
Hospital Charge Code	2269443
Hospital Revenue Code	301
Min. Negotiated Rate	$80.08
Max. Negotiated Rate	$277.20
Rate for Payer: Aetna of AZ Commercial	$277.20
Rate for Payer: Bisbee Police All Plans	$80.08
Rate for Payer: Cash Price	$246.40
Rate for Payer: Self Pay Self Pay	$246.40

Myomectomy abdominal

Facility

$5,082.00

Service Code	CPT 58140
Hospital Charge Code	27281892
Hospital Revenue Code	360
Min. Negotiated Rate	$1,321.32
Max. Negotiated Rate	$4,573.80
Rate for Payer: Aetna of AZ Commercial	$4,573.80
Rate for Payer: Bisbee Police All Plans	$1,321.32
Rate for Payer: Cash Price	$4,065.60
Rate for Payer: Self Pay Self Pay	$4,065.60

Myomectomy abdominal

Facility

$5,082.00

Service Code	CPT 58140
Hospital Charge Code	27281892
Hospital Revenue Code	360
Min. Negotiated Rate	$813.12
Max. Negotiated Rate	$4,573.80
Rate for Payer: Aetna of AZ Commercial	$4,573.80
Rate for Payer: Aetna of AZ Medicare	$1,422.96
Rate for Payer: Allwell Medicare	$813.12
Rate for Payer: Amerigroup Medicare	$813.12
Rate for Payer: APIPA Medicare/Medicaid	$1,898.13
Rate for Payer: AZCH Complete Medicare	$813.12
Rate for Payer: Banner UC Health Medicare	$813.12
Rate for Payer: Bisbee Police All Plans	$1,321.32
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,455.76
Rate for Payer: Cash Price	$4,065.60
Rate for Payer: Cigna of AZ Commercial	$2,541.00
Rate for Payer: Copperpoint Commercial	$1,257.80
Rate for Payer: Health Net of AZ Commercial	$3,049.20
Rate for Payer: Health Net of AZ Medicare	$1,422.96
Rate for Payer: Humana of AZ Medicare	$813.12
Rate for Payer: Self Pay Self Pay	$4,065.60
Rate for Payer: TriWest Medicare	$813.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,962.81
Rate for Payer: UnitedHealth Group of AZ Medicare	$914.76

MYOSURE HYSTEROSCOPE TISSUE REMOVAL DEV

Facility

$3,713.00

Hospital Charge Code	22354782
Hospital Revenue Code	270
Min. Negotiated Rate	$965.38
Max. Negotiated Rate	$3,341.70
Rate for Payer: Aetna of AZ Commercial	$3,341.70
Rate for Payer: Bisbee Police All Plans	$965.38
Rate for Payer: Cash Price	$2,970.40
Rate for Payer: Self Pay Self Pay	$2,970.40

MYOSURE HYSTEROSCOPE TISSUE REMOVAL DEV

Facility

$3,713.00

Hospital Charge Code	22354782
Hospital Revenue Code	270
Min. Negotiated Rate	$594.08
Max. Negotiated Rate	$3,341.70
Rate for Payer: Aetna of AZ Commercial	$3,341.70
Rate for Payer: Aetna of AZ Medicare	$1,039.64
Rate for Payer: Allwell Medicare	$594.08
Rate for Payer: Amerigroup Medicare	$594.08
Rate for Payer: APIPA Medicare/Medicaid	$1,386.81
Rate for Payer: AZCH Complete Medicare	$594.08
Rate for Payer: Banner UC Health Medicare	$594.08
Rate for Payer: Bisbee Police All Plans	$965.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,524.84
Rate for Payer: Cash Price	$2,970.40
Rate for Payer: Cigna of AZ Commercial	$2,599.10
Rate for Payer: Copperpoint Commercial	$918.97
Rate for Payer: Health Net of AZ Commercial	$2,227.80
Rate for Payer: Health Net of AZ Medicare	$1,039.64
Rate for Payer: Humana of AZ Medicare	$594.08
Rate for Payer: Self Pay Self Pay	$2,970.40
Rate for Payer: TriWest Medicare	$594.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,164.68
Rate for Payer: UnitedHealth Group of AZ Medicare	$668.34

MYO SURE TISSURE REMOVEL DEVICE

Facility

$2,867.00

Hospital Charge Code	22354169
Hospital Revenue Code	270
Min. Negotiated Rate	$458.72
Max. Negotiated Rate	$2,580.30
Rate for Payer: Aetna of AZ Commercial	$2,580.30
Rate for Payer: Aetna of AZ Medicare	$802.76
Rate for Payer: Allwell Medicare	$458.72
Rate for Payer: Amerigroup Medicare	$458.72
Rate for Payer: APIPA Medicare/Medicaid	$1,070.82
Rate for Payer: AZCH Complete Medicare	$458.72
Rate for Payer: Banner UC Health Medicare	$458.72
Rate for Payer: Bisbee Police All Plans	$745.42
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,949.56
Rate for Payer: Cash Price	$2,293.60
Rate for Payer: Cigna of AZ Commercial	$2,006.90
Rate for Payer: Copperpoint Commercial	$709.58
Rate for Payer: Health Net of AZ Commercial	$1,720.20
Rate for Payer: Health Net of AZ Medicare	$802.76
Rate for Payer: Humana of AZ Medicare	$458.72
Rate for Payer: Self Pay Self Pay	$2,293.60
Rate for Payer: TriWest Medicare	$458.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,671.46
Rate for Payer: UnitedHealth Group of AZ Medicare	$516.06

MYO SURE TISSURE REMOVEL DEVICE

Facility

$2,867.00

Hospital Charge Code	22354169
Hospital Revenue Code	270
Min. Negotiated Rate	$745.42
Max. Negotiated Rate	$2,580.30
Rate for Payer: Aetna of AZ Commercial	$2,580.30
Rate for Payer: Bisbee Police All Plans	$745.42
Rate for Payer: Cash Price	$2,293.60
Rate for Payer: Self Pay Self Pay	$2,293.60

MYOSURE XL HYSTEROSCOPE TISSUE REMVL DEV

Facility

$3,673.00

Hospital Charge Code	22354783
Hospital Revenue Code	270
Min. Negotiated Rate	$587.68
Max. Negotiated Rate	$3,305.70
Rate for Payer: Aetna of AZ Commercial	$3,305.70
Rate for Payer: Aetna of AZ Medicare	$1,028.44
Rate for Payer: Allwell Medicare	$587.68
Rate for Payer: Amerigroup Medicare	$587.68
Rate for Payer: APIPA Medicare/Medicaid	$1,371.87
Rate for Payer: AZCH Complete Medicare	$587.68
Rate for Payer: Banner UC Health Medicare	$587.68
Rate for Payer: Bisbee Police All Plans	$954.98
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,497.64
Rate for Payer: Cash Price	$2,938.40
Rate for Payer: Cigna of AZ Commercial	$2,571.10
Rate for Payer: Copperpoint Commercial	$909.07
Rate for Payer: Health Net of AZ Commercial	$2,203.80
Rate for Payer: Health Net of AZ Medicare	$1,028.44
Rate for Payer: Humana of AZ Medicare	$587.68
Rate for Payer: Self Pay Self Pay	$2,938.40
Rate for Payer: TriWest Medicare	$587.68
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,141.36
Rate for Payer: UnitedHealth Group of AZ Medicare	$661.14

MYOSURE XL HYSTEROSCOPE TISSUE REMVL DEV

Facility

$3,673.00

Hospital Charge Code	22354783
Hospital Revenue Code	270
Min. Negotiated Rate	$954.98
Max. Negotiated Rate	$3,305.70
Rate for Payer: Aetna of AZ Commercial	$3,305.70
Rate for Payer: Bisbee Police All Plans	$954.98
Rate for Payer: Cash Price	$2,938.40
Rate for Payer: Self Pay Self Pay	$2,938.40

naloxone 0.4 mg/ 1 mL Inj Sol [CQCH]

Facility

$12.78

Service Code	HCPCS J2310
Hospital Charge Code	105933490
Hospital Revenue Code	250
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$11.50
Rate for Payer: Aetna of AZ Commercial	$11.50
Rate for Payer: Bisbee Police All Plans	$3.32
Rate for Payer: Cash Price	$10.22
Rate for Payer: Self Pay Self Pay	$10.22

naloxone 0.4 mg/ 1 mL Inj Sol [CQCH]

Facility

$12.78

Service Code	HCPCS J2310
Hospital Charge Code	105933490
Hospital Revenue Code	250
Min. Negotiated Rate	$2.04
Max. Negotiated Rate	$11.50
Rate for Payer: Aetna of AZ Commercial	$11.50
Rate for Payer: Aetna of AZ Medicare	$3.58
Rate for Payer: Allwell Medicare	$2.04
Rate for Payer: Amerigroup Medicare	$2.04
Rate for Payer: APIPA Medicare/Medicaid	$4.77
Rate for Payer: AZCH Complete Medicare	$2.04
Rate for Payer: Banner UC Health Medicare	$2.04
Rate for Payer: Bisbee Police All Plans	$3.32
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$8.69
Rate for Payer: Cash Price	$10.22
Rate for Payer: Cigna of AZ Commercial	$8.31
Rate for Payer: Copperpoint Commercial	$3.16
Rate for Payer: Health Net of AZ Commercial	$7.67
Rate for Payer: Health Net of AZ Medicare	$3.58
Rate for Payer: Humana of AZ Medicare	$2.04
Rate for Payer: Self Pay Self Pay	$10.22
Rate for Payer: TriWest Medicare	$2.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$7.45
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.30

naloxone 2 mg PFS [CQCH]

Facility

$24.89

Service Code	HCPCS J2310
Hospital Charge Code	105933415
Hospital Revenue Code	250
Min. Negotiated Rate	$6.47
Max. Negotiated Rate	$22.40
Rate for Payer: Aetna of AZ Commercial	$22.40
Rate for Payer: Bisbee Police All Plans	$6.47
Rate for Payer: Cash Price	$19.91
Rate for Payer: Self Pay Self Pay	$19.91

naloxone 2 mg PFS [CQCH]

Facility

$24.89

Service Code	HCPCS J2310
Hospital Charge Code	105933415
Hospital Revenue Code	250
Min. Negotiated Rate	$3.98
Max. Negotiated Rate	$22.40
Rate for Payer: Aetna of AZ Commercial	$22.40
Rate for Payer: Aetna of AZ Medicare	$6.97
Rate for Payer: Allwell Medicare	$3.98
Rate for Payer: Amerigroup Medicare	$3.98
Rate for Payer: APIPA Medicare/Medicaid	$9.30
Rate for Payer: AZCH Complete Medicare	$3.98
Rate for Payer: Banner UC Health Medicare	$3.98
Rate for Payer: Bisbee Police All Plans	$6.47
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$16.93
Rate for Payer: Cash Price	$19.91
Rate for Payer: Cigna of AZ Commercial	$16.18
Rate for Payer: Copperpoint Commercial	$6.16
Rate for Payer: Health Net of AZ Commercial	$14.93
Rate for Payer: Health Net of AZ Medicare	$6.97
Rate for Payer: Humana of AZ Medicare	$3.98
Rate for Payer: Self Pay Self Pay	$19.91
Rate for Payer: TriWest Medicare	$3.98
Rate for Payer: UnitedHealth Group of AZ Commercial	$14.51
Rate for Payer: UnitedHealth Group of AZ Medicare	$4.48

naproxen 500 mg Tab [CQCH]

Facility

$0.15

Service Code	NDC 68084012701
Hospital Charge Code	105933620
Hospital Revenue Code	251
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	$0.12
Rate for Payer: Self Pay Self Pay	$0.12

naproxen 500 mg Tab [CQCH]

Facility

$0.15

Service Code	NDC 68084012701
Hospital Charge Code	105933620
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
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	$0.02
Rate for Payer: Amerigroup Medicare	$0.02
Rate for Payer: APIPA Medicare/Medicaid	$0.06
Rate for Payer: AZCH Complete Medicare	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.10
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of AZ Commercial	$0.10
Rate for Payer: Copperpoint Commercial	$0.04
Rate for Payer: Health Net of AZ Commercial	$0.09
Rate for Payer: Health Net of AZ Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Self Pay Self Pay	$0.12
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.09
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.03

NASAL AND ORAL CO2 CANNULA PED WITH O2

Facility

$74.00

Hospital Charge Code	27410392
Hospital Revenue Code	270
Min. Negotiated Rate	$19.24
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Bisbee Police All Plans	$19.24
Rate for Payer: Cash Price	$59.20
Rate for Payer: Self Pay Self Pay	$59.20

NASAL AND ORAL CO2 CANNULA PED WITH O2

Facility

$74.00

Hospital Charge Code	27410392
Hospital Revenue Code	270
Min. Negotiated Rate	$11.84
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Aetna of AZ Medicare	$20.72
Rate for Payer: Allwell Medicare	$11.84
Rate for Payer: Amerigroup Medicare	$11.84
Rate for Payer: APIPA Medicare/Medicaid	$27.64
Rate for Payer: AZCH Complete Medicare	$11.84
Rate for Payer: Banner UC Health Medicare	$11.84
Rate for Payer: Bisbee Police All Plans	$19.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$50.32
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cigna of AZ Commercial	$51.80
Rate for Payer: Copperpoint Commercial	$18.32
Rate for Payer: Health Net of AZ Commercial	$44.40
Rate for Payer: Health Net of AZ Medicare	$20.72
Rate for Payer: Humana of AZ Medicare	$11.84
Rate for Payer: Self Pay Self Pay	$59.20
Rate for Payer: TriWest Medicare	$11.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$43.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$13.32

NASAL CATH EPISTAT II

Facility

$242.00

Hospital Charge Code	22354310
Hospital Revenue Code	270
Min. Negotiated Rate	$38.72
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Aetna of AZ Medicare	$67.76
Rate for Payer: Allwell Medicare	$38.72
Rate for Payer: Amerigroup Medicare	$38.72
Rate for Payer: APIPA Medicare/Medicaid	$90.39
Rate for Payer: AZCH Complete Medicare	$38.72
Rate for Payer: Banner UC Health Medicare	$38.72
Rate for Payer: Bisbee Police All Plans	$62.92
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$164.56
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cigna of AZ Commercial	$169.40
Rate for Payer: Copperpoint Commercial	$59.90
Rate for Payer: Health Net of AZ Commercial	$145.20
Rate for Payer: Health Net of AZ Medicare	$67.76
Rate for Payer: Humana of AZ Medicare	$38.72
Rate for Payer: Self Pay Self Pay	$193.60
Rate for Payer: TriWest Medicare	$38.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$141.09
Rate for Payer: UnitedHealth Group of AZ Medicare	$43.56

NASAL CATH EPISTAT II

Facility

$242.00

Hospital Charge Code	22354310
Hospital Revenue Code	270
Min. Negotiated Rate	$62.92
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Bisbee Police All Plans	$62.92
Rate for Payer: Cash Price	$193.60
Rate for Payer: Self Pay Self Pay	$193.60

NCIRCLE HELICAL TIPLESS STONE EXTRACTOR

Facility

$1,388.00

Hospital Charge Code	22354220
Hospital Revenue Code	270
Min. Negotiated Rate	$222.08
Max. Negotiated Rate	$1,249.20
Rate for Payer: Aetna of AZ Commercial	$1,249.20
Rate for Payer: Aetna of AZ Medicare	$388.64
Rate for Payer: Allwell Medicare	$222.08
Rate for Payer: Amerigroup Medicare	$222.08
Rate for Payer: APIPA Medicare/Medicaid	$518.42
Rate for Payer: AZCH Complete Medicare	$222.08
Rate for Payer: Banner UC Health Medicare	$222.08
Rate for Payer: Bisbee Police All Plans	$360.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$943.84
Rate for Payer: Cash Price	$1,110.40
Rate for Payer: Cigna of AZ Commercial	$971.60
Rate for Payer: Copperpoint Commercial	$343.53
Rate for Payer: Health Net of AZ Commercial	$832.80
Rate for Payer: Health Net of AZ Medicare	$388.64
Rate for Payer: Humana of AZ Medicare	$222.08
Rate for Payer: Self Pay Self Pay	$1,110.40
Rate for Payer: TriWest Medicare	$222.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$809.20
Rate for Payer: UnitedHealth Group of AZ Medicare	$249.84

NCIRCLE HELICAL TIPLESS STONE EXTRACTOR

Facility

$1,388.00

Hospital Charge Code	22354220
Hospital Revenue Code	270
Min. Negotiated Rate	$360.88
Max. Negotiated Rate	$1,249.20
Rate for Payer: Aetna of AZ Commercial	$1,249.20
Rate for Payer: Bisbee Police All Plans	$360.88
Rate for Payer: Cash Price	$1,110.40
Rate for Payer: Self Pay Self Pay	$1,110.40

Know your out-of-pocket cost for care.

All Charges