Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Nervous System Malignancy

Facility

$12,266.78

Service Code	APR-DRG 0414
Hospital Charge Code	APRDRG0412
Min. Negotiated Rate	$12,266.78
Max. Negotiated Rate	$12,266.78
Rate for Payer: AHCCCS Medicaid	$12,266.78
Rate for Payer: Allwell Medicaid	$12,266.78
Rate for Payer: AZCH Complete Medicaid	$12,266.78
Rate for Payer: Banner UC Health Medicaid	$12,266.78
Rate for Payer: Mercy Care Medicaid	$12,266.78

Nervous System Malignancy

Facility

$5,862.30

Service Code	APR-DRG 0412
Hospital Charge Code	APRDRG0414
Min. Negotiated Rate	$5,862.30
Max. Negotiated Rate	$5,862.30
Rate for Payer: AHCCCS Medicaid	$5,862.30
Rate for Payer: Allwell Medicaid	$5,862.30
Rate for Payer: AZCH Complete Medicaid	$5,862.30
Rate for Payer: Banner UC Health Medicaid	$5,862.30
Rate for Payer: Mercy Care Medicaid	$5,862.30

Nervous System Malignancy

Facility

$5,242.97

Service Code	APR-DRG 0411
Hospital Charge Code	APRDRG0411
Min. Negotiated Rate	$5,242.97
Max. Negotiated Rate	$5,242.97
Rate for Payer: AHCCCS Medicaid	$5,242.97
Rate for Payer: Allwell Medicaid	$5,242.97
Rate for Payer: AZCH Complete Medicaid	$5,242.97
Rate for Payer: Banner UC Health Medicaid	$5,242.97
Rate for Payer: Mercy Care Medicaid	$5,242.97

NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUN

Facility

$2,352.00

Service Code	CPT 64721
Hospital Charge Code	27371852
Hospital Revenue Code	360
Min. Negotiated Rate	$352.80
Max. Negotiated Rate	$3,373.00
Rate for Payer: Aetna of AZ Commercial	$2,116.80
Rate for Payer: Aetna of AZ Medicare	$658.56
Rate for Payer: AHCCCS Medicaid	$2,543.86
Rate for Payer: Allwell Medicaid	$2,543.86
Rate for Payer: Allwell Medicare	$352.80
Rate for Payer: Amerigroup Medicare	$352.80
Rate for Payer: APIPA Medicare/Medicaid	$878.47
Rate for Payer: AZCH Complete Medicaid	$2,543.86
Rate for Payer: AZCH Complete Medicare	$352.80
Rate for Payer: Banner UC Health Medicaid	$2,543.86
Rate for Payer: Banner UC Health Medicare	$352.80
Rate for Payer: Bisbee Police All Plans	$611.52
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,599.36
Rate for Payer: Cash Price	$1,881.60
Rate for Payer: Cash Price	$1,881.60
Rate for Payer: Cigna of AZ Commercial	$1,176.00
Rate for Payer: Copperpoint Commercial	$582.12
Rate for Payer: Health Net of AZ Commercial	$1,411.20
Rate for Payer: Health Net of AZ Medicare	$658.56
Rate for Payer: Humana of AZ Medicare	$352.80
Rate for Payer: Mercy Care Medicaid	$2,543.86
Rate for Payer: Self Pay Self Pay	$1,881.60
Rate for Payer: TriWest Medicare	$352.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,373.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$423.36

NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUN

Facility

$2,352.00

Service Code	CPT 64721
Hospital Charge Code	27371852
Hospital Revenue Code	360
Min. Negotiated Rate	$611.52
Max. Negotiated Rate	$2,116.80
Rate for Payer: Aetna of AZ Commercial	$2,116.80
Rate for Payer: Bisbee Police All Plans	$611.52
Rate for Payer: Cash Price	$1,881.60
Rate for Payer: Self Pay Self Pay	$1,881.60

NEURO STIMULATOR

Facility

$62,920.00

Service Code	CPT C1767
Hospital Charge Code	22354564
Hospital Revenue Code	270
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$56,628.00
Rate for Payer: Aetna of AZ Commercial	$56,628.00
Rate for Payer: Aetna of AZ Medicare	$17,617.60
Rate for Payer: AHCCCS Medicaid	$0.13
Rate for Payer: Allwell Medicaid	$0.13
Rate for Payer: Allwell Medicare	$9,438.00
Rate for Payer: Amerigroup Medicare	$9,438.00
Rate for Payer: APIPA Medicare/Medicaid	$23,500.62
Rate for Payer: AZCH Complete Medicaid	$0.13
Rate for Payer: AZCH Complete Medicare	$9,438.00
Rate for Payer: Banner UC Health Medicaid	$0.13
Rate for Payer: Banner UC Health Medicare	$9,438.00
Rate for Payer: Bisbee Police All Plans	$16,359.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$42,785.60
Rate for Payer: Cash Price	$50,336.00
Rate for Payer: Cash Price	$50,336.00
Rate for Payer: Cigna of AZ Commercial	$44,044.00
Rate for Payer: Copperpoint Commercial	$15,572.70
Rate for Payer: Health Net of AZ Commercial	$37,752.00
Rate for Payer: Health Net of AZ Medicare	$17,617.60
Rate for Payer: Humana of AZ Medicare	$9,438.00
Rate for Payer: Mercy Care Medicaid	$0.13
Rate for Payer: Self Pay Self Pay	$50,336.00
Rate for Payer: TriWest Medicare	$9,438.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$36,682.36
Rate for Payer: UnitedHealth Group of AZ Medicare	$11,325.60

NEURO STIMULATOR

Facility

$62,920.00

Service Code	CPT C1767
Hospital Charge Code	22354564
Hospital Revenue Code	270
Min. Negotiated Rate	$16,359.20
Max. Negotiated Rate	$56,628.00
Rate for Payer: Aetna of AZ Commercial	$56,628.00
Rate for Payer: Bisbee Police All Plans	$16,359.20
Rate for Payer: Cash Price	$50,336.00
Rate for Payer: Self Pay Self Pay	$50,336.00

NGAGE STONE EXTRACTOR 2.2 NITINOL

Facility

$1,322.30

Hospital Charge Code	22834568
Hospital Revenue Code	272
Min. Negotiated Rate	$198.34
Max. Negotiated Rate	$1,190.07
Rate for Payer: Aetna of AZ Commercial	$1,190.07
Rate for Payer: Aetna of AZ Medicare	$370.24
Rate for Payer: Allwell Medicare	$198.34
Rate for Payer: Amerigroup Medicare	$198.34
Rate for Payer: APIPA Medicare/Medicaid	$493.88
Rate for Payer: AZCH Complete Medicare	$198.34
Rate for Payer: Banner UC Health Medicare	$198.34
Rate for Payer: Bisbee Police All Plans	$343.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$899.16
Rate for Payer: Cash Price	$1,057.84
Rate for Payer: Cigna of AZ Commercial	$925.61
Rate for Payer: Copperpoint Commercial	$327.27
Rate for Payer: Health Net of AZ Commercial	$793.38
Rate for Payer: Health Net of AZ Medicare	$370.24
Rate for Payer: Humana of AZ Medicare	$198.34
Rate for Payer: Self Pay Self Pay	$1,057.84
Rate for Payer: TriWest Medicare	$198.34
Rate for Payer: UnitedHealth Group of AZ Commercial	$770.90
Rate for Payer: UnitedHealth Group of AZ Medicare	$238.01

NGAGE STONE EXTRACTOR 2.2 NITINOL

Facility

$1,322.30

Hospital Charge Code	22834568
Hospital Revenue Code	272
Min. Negotiated Rate	$343.80
Max. Negotiated Rate	$1,190.07
Rate for Payer: Aetna of AZ Commercial	$1,190.07
Rate for Payer: Bisbee Police All Plans	$343.80
Rate for Payer: Cash Price	$1,057.84
Rate for Payer: Self Pay Self Pay	$1,057.84

niCARdipine 20 mg/200 mL-NaCl Premix IV Sol[CQCH]

Facility

$0.43

Service Code	NDC 10122031310
Hospital Charge Code	124700531
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of AZ Commercial	$0.39
Rate for Payer: Bisbee Police All Plans	$0.11
Rate for Payer: Cash Price	$0.35
Rate for Payer: Self Pay Self Pay	$0.34

niCARdipine 20 mg/200 mL-NaCl Premix IV Sol[CQCH]

Facility

$0.43

Service Code	NDC 10122031310
Hospital Charge Code	124700531
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of AZ Commercial	$0.39
Rate for Payer: Aetna of AZ Medicare	$0.12
Rate for Payer: Allwell Medicare	$0.06
Rate for Payer: Amerigroup Medicare	$0.06
Rate for Payer: APIPA Medicare/Medicaid	$0.16
Rate for Payer: AZCH Complete Medicare	$0.06
Rate for Payer: Banner UC Health Medicare	$0.06
Rate for Payer: Bisbee Police All Plans	$0.11
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.29
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cigna of AZ Commercial	$0.28
Rate for Payer: Copperpoint Commercial	$0.11
Rate for Payer: Health Net of AZ Commercial	$0.26
Rate for Payer: Health Net of AZ Medicare	$0.12
Rate for Payer: Humana of AZ Medicare	$0.06
Rate for Payer: Self Pay Self Pay	$0.34
Rate for Payer: TriWest Medicare	$0.06
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.25
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.08

nicotine 21 mg patch [CQCH]

Facility

$1.78

Service Code	NDC 67512614
Hospital Charge Code	105933829
Hospital Revenue Code	251
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of AZ Commercial	$1.60
Rate for Payer: Bisbee Police All Plans	$0.46
Rate for Payer: Cash Price	$1.42
Rate for Payer: Self Pay Self Pay	$1.42

nicotine 21 mg patch [CQCH]

Facility

$1.78

Service Code	NDC 67512614
Hospital Charge Code	105933829
Hospital Revenue Code	251
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of AZ Commercial	$1.60
Rate for Payer: Aetna of AZ Medicare	$0.50
Rate for Payer: Allwell Medicare	$0.27
Rate for Payer: Amerigroup Medicare	$0.27
Rate for Payer: APIPA Medicare/Medicaid	$0.66
Rate for Payer: AZCH Complete Medicare	$0.27
Rate for Payer: Banner UC Health Medicare	$0.27
Rate for Payer: Bisbee Police All Plans	$0.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.21
Rate for Payer: Cash Price	$1.42
Rate for Payer: Cigna of AZ Commercial	$1.16
Rate for Payer: Copperpoint Commercial	$0.44
Rate for Payer: Health Net of AZ Commercial	$1.07
Rate for Payer: Health Net of AZ Medicare	$0.50
Rate for Payer: Humana of AZ Medicare	$0.27
Rate for Payer: Self Pay Self Pay	$1.42
Rate for Payer: TriWest Medicare	$0.27
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.04
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.32

nicotine 2mg Lozenge[CQCH]

Facility

$0.33

Service Code	NDC 135050802
Hospital Charge Code	122695398
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of AZ Commercial	$0.30
Rate for Payer: Aetna of AZ Medicare	$0.09
Rate for Payer: Allwell Medicare	$0.05
Rate for Payer: Amerigroup Medicare	$0.05
Rate for Payer: APIPA Medicare/Medicaid	$0.12
Rate for Payer: AZCH Complete Medicare	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
Rate for Payer: Bisbee Police All Plans	$0.09
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.22
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna of AZ Commercial	$0.21
Rate for Payer: Copperpoint Commercial	$0.08
Rate for Payer: Health Net of AZ Commercial	$0.20
Rate for Payer: Health Net of AZ Medicare	$0.09
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Self Pay Self Pay	$0.26
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.06

nicotine 2mg Lozenge[CQCH]

Facility

$0.33

Service Code	NDC 135050802
Hospital Charge Code	122695398
Hospital Revenue Code	251
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of AZ Commercial	$0.30
Rate for Payer: Bisbee Police All Plans	$0.09
Rate for Payer: Cash Price	$0.26
Rate for Payer: Self Pay Self Pay	$0.26

nicotine 7 mg patch [CQCH]

Facility

$1.76

Service Code	NDC 49348014646
Hospital Charge Code	108075360
Hospital Revenue Code	251
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna of AZ Commercial	$1.58
Rate for Payer: Bisbee Police All Plans	$0.46
Rate for Payer: Cash Price	$1.41
Rate for Payer: Self Pay Self Pay	$1.41

nicotine 7 mg patch [CQCH]

Facility

$1.76

Service Code	NDC 49348014646
Hospital Charge Code	108075360
Hospital Revenue Code	251
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna of AZ Commercial	$1.58
Rate for Payer: Aetna of AZ Medicare	$0.49
Rate for Payer: Allwell Medicare	$0.26
Rate for Payer: Amerigroup Medicare	$0.26
Rate for Payer: APIPA Medicare/Medicaid	$0.66
Rate for Payer: AZCH Complete Medicare	$0.26
Rate for Payer: Banner UC Health Medicare	$0.26
Rate for Payer: Bisbee Police All Plans	$0.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.20
Rate for Payer: Cash Price	$1.41
Rate for Payer: Cigna of AZ Commercial	$1.14
Rate for Payer: Copperpoint Commercial	$0.44
Rate for Payer: Health Net of AZ Commercial	$1.06
Rate for Payer: Health Net of AZ Medicare	$0.49
Rate for Payer: Humana of AZ Medicare	$0.26
Rate for Payer: Self Pay Self Pay	$1.41
Rate for Payer: TriWest Medicare	$0.26
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.32

nitrofurantoin macrocrystals 100 mg Cap UD[CQCH]

Facility

$2.06

Service Code	NDC 60687048301
Hospital Charge Code	181685120
Hospital Revenue Code	251
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$1.85
Rate for Payer: Aetna of AZ Commercial	$1.85
Rate for Payer: Aetna of AZ Medicare	$0.58
Rate for Payer: Allwell Medicare	$0.31
Rate for Payer: Amerigroup Medicare	$0.31
Rate for Payer: APIPA Medicare/Medicaid	$0.77
Rate for Payer: AZCH Complete Medicare	$0.31
Rate for Payer: Banner UC Health Medicare	$0.31
Rate for Payer: Bisbee Police All Plans	$0.54
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.40
Rate for Payer: Cash Price	$1.65
Rate for Payer: Cigna of AZ Commercial	$1.34
Rate for Payer: Copperpoint Commercial	$0.51
Rate for Payer: Health Net of AZ Commercial	$1.24
Rate for Payer: Health Net of AZ Medicare	$0.58
Rate for Payer: Humana of AZ Medicare	$0.31
Rate for Payer: Self Pay Self Pay	$1.65
Rate for Payer: TriWest Medicare	$0.31
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.20
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.37

nitrofurantoin macrocrystals 100 mg Cap UD[CQCH]

Facility

$2.06

Service Code	NDC 60687048301
Hospital Charge Code	181685120
Hospital Revenue Code	251
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$1.85
Rate for Payer: Aetna of AZ Commercial	$1.85
Rate for Payer: Bisbee Police All Plans	$0.54
Rate for Payer: Cash Price	$1.65
Rate for Payer: Self Pay Self Pay	$1.65

nitroglycerin 0.2 mg/hr patch [CQCH]

Facility

$0.46

Service Code	NDC 47781029703
Hospital Charge Code	105934020
Hospital Revenue Code	251
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of AZ Commercial	$0.41
Rate for Payer: Bisbee Police All Plans	$0.12
Rate for Payer: Cash Price	$0.37
Rate for Payer: Self Pay Self Pay	$0.37

nitroglycerin 0.2 mg/hr patch [CQCH]

Facility

$0.46

Service Code	NDC 47781029703
Hospital Charge Code	105934020
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of AZ Commercial	$0.41
Rate for Payer: Aetna of AZ Medicare	$0.13
Rate for Payer: Allwell Medicare	$0.07
Rate for Payer: Amerigroup Medicare	$0.07
Rate for Payer: APIPA Medicare/Medicaid	$0.17
Rate for Payer: AZCH Complete Medicare	$0.07
Rate for Payer: Banner UC Health Medicare	$0.07
Rate for Payer: Bisbee Police All Plans	$0.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.31
Rate for Payer: Cash Price	$0.37
Rate for Payer: Cigna of AZ Commercial	$0.30
Rate for Payer: Copperpoint Commercial	$0.11
Rate for Payer: Health Net of AZ Commercial	$0.28
Rate for Payer: Health Net of AZ Medicare	$0.13
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Self Pay Self Pay	$0.37
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.27
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.08

nitroglycerin 0.4 mg/hr Patch [CQCH]

Facility

$0.49

Service Code	NDC 47781029803
Hospital Charge Code	105933959
Hospital Revenue Code	251
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.44
Rate for Payer: Aetna of AZ Commercial	$0.44
Rate for Payer: Bisbee Police All Plans	$0.13
Rate for Payer: Cash Price	$0.39
Rate for Payer: Self Pay Self Pay	$0.39

nitroglycerin 0.4 mg/hr Patch [CQCH]

Facility

$0.49

Service Code	NDC 47781029803
Hospital Charge Code	105933959
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.44
Rate for Payer: Aetna of AZ Commercial	$0.44
Rate for Payer: Aetna of AZ Medicare	$0.14
Rate for Payer: Allwell Medicare	$0.07
Rate for Payer: Amerigroup Medicare	$0.07
Rate for Payer: APIPA Medicare/Medicaid	$0.18
Rate for Payer: AZCH Complete Medicare	$0.07
Rate for Payer: Banner UC Health Medicare	$0.07
Rate for Payer: Bisbee Police All Plans	$0.13
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.33
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of AZ Commercial	$0.32
Rate for Payer: Copperpoint Commercial	$0.12
Rate for Payer: Health Net of AZ Commercial	$0.29
Rate for Payer: Health Net of AZ Medicare	$0.14
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Self Pay Self Pay	$0.39
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.29
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.09

nitroglycerin 0.4 mg sublingual Tab [CQCH]

Facility

$0.57

Service Code	NDC 68462063945
Hospital Charge Code	105934081
Hospital Revenue Code	251
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.51
Rate for Payer: Aetna of AZ Commercial	$0.51
Rate for Payer: Bisbee Police All Plans	$0.15
Rate for Payer: Cash Price	$0.45
Rate for Payer: Self Pay Self Pay	$0.46

nitroglycerin 0.4 mg sublingual Tab [CQCH]

Facility

$0.57

Service Code	NDC 68462063945
Hospital Charge Code	105934081
Hospital Revenue Code	251
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.51
Rate for Payer: Aetna of AZ Commercial	$0.51
Rate for Payer: Aetna of AZ Medicare	$0.16
Rate for Payer: Allwell Medicare	$0.09
Rate for Payer: Amerigroup Medicare	$0.09
Rate for Payer: APIPA Medicare/Medicaid	$0.21
Rate for Payer: AZCH Complete Medicare	$0.09
Rate for Payer: Banner UC Health Medicare	$0.09
Rate for Payer: Bisbee Police All Plans	$0.15
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.39
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cigna of AZ Commercial	$0.37
Rate for Payer: Copperpoint Commercial	$0.14
Rate for Payer: Health Net of AZ Commercial	$0.34
Rate for Payer: Health Net of AZ Medicare	$0.16
Rate for Payer: Humana of AZ Medicare	$0.09
Rate for Payer: Self Pay Self Pay	$0.46
Rate for Payer: TriWest Medicare	$0.09
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.33
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.10

Know your out-of-pocket cost for care.

All Charges