Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

NOVASURE ADVANCE

Facility

$3,154.00

Hospital Charge Code	27448975
Hospital Revenue Code	272
Min. Negotiated Rate	$504.64
Max. Negotiated Rate	$2,838.60
Rate for Payer: Aetna of AZ Commercial	$2,838.60
Rate for Payer: Aetna of AZ Medicare	$883.12
Rate for Payer: Allwell Medicare	$504.64
Rate for Payer: Amerigroup Medicare	$504.64
Rate for Payer: APIPA Medicare/Medicaid	$1,178.02
Rate for Payer: AZCH Complete Medicare	$504.64
Rate for Payer: Banner UC Health Medicare	$504.64
Rate for Payer: Bisbee Police All Plans	$820.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,144.72
Rate for Payer: Cash Price	$2,523.20
Rate for Payer: Cigna of AZ Commercial	$2,207.80
Rate for Payer: Copperpoint Commercial	$780.62
Rate for Payer: Health Net of AZ Commercial	$1,892.40
Rate for Payer: Health Net of AZ Medicare	$883.12
Rate for Payer: Humana of AZ Medicare	$504.64
Rate for Payer: Self Pay Self Pay	$2,523.20
Rate for Payer: TriWest Medicare	$504.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,838.78
Rate for Payer: UnitedHealth Group of AZ Medicare	$567.72

NOVASURE ADVANCE

Facility

$3,154.00

Hospital Charge Code	27448975
Hospital Revenue Code	272
Min. Negotiated Rate	$820.04
Max. Negotiated Rate	$2,838.60
Rate for Payer: Aetna of AZ Commercial	$2,838.60
Rate for Payer: Bisbee Police All Plans	$820.04
Rate for Payer: Cash Price	$2,523.20
Rate for Payer: Self Pay Self Pay	$2,523.20

NOVASURE KIT, NS-2007

Facility

$3,820.00

Service Code	CPT 58563
Hospital Charge Code	22354784
Hospital Revenue Code	270
Min. Negotiated Rate	$611.20
Max. Negotiated Rate	$3,438.00
Rate for Payer: Aetna of AZ Commercial	$3,438.00
Rate for Payer: Aetna of AZ Medicare	$1,069.60
Rate for Payer: AHCCCS Medicaid	$3,196.92
Rate for Payer: Allwell Medicaid	$3,196.92
Rate for Payer: Allwell Medicare	$611.20
Rate for Payer: Amerigroup Medicare	$611.20
Rate for Payer: APIPA Medicare/Medicaid	$1,426.77
Rate for Payer: AZCH Complete Medicaid	$3,196.92
Rate for Payer: AZCH Complete Medicare	$611.20
Rate for Payer: Banner UC Health Medicaid	$3,196.92
Rate for Payer: Banner UC Health Medicare	$611.20
Rate for Payer: Bisbee Police All Plans	$993.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,597.60
Rate for Payer: Cash Price	$3,056.00
Rate for Payer: Cash Price	$3,056.00
Rate for Payer: Cigna of AZ Commercial	$2,674.00
Rate for Payer: Copperpoint Commercial	$945.45
Rate for Payer: Health Net of AZ Commercial	$2,292.00
Rate for Payer: Health Net of AZ Medicare	$1,069.60
Rate for Payer: Humana of AZ Medicare	$611.20
Rate for Payer: Mercy Care Medicaid	$3,196.92
Rate for Payer: Self Pay Self Pay	$3,056.00
Rate for Payer: TriWest Medicare	$611.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,227.06
Rate for Payer: UnitedHealth Group of AZ Medicare	$687.60

NOVASURE KIT, NS-2007

Facility

$3,820.00

Service Code	CPT 58563
Hospital Charge Code	22354784
Hospital Revenue Code	270
Min. Negotiated Rate	$993.20
Max. Negotiated Rate	$3,438.00
Rate for Payer: Aetna of AZ Commercial	$3,438.00
Rate for Payer: Bisbee Police All Plans	$993.20
Rate for Payer: Cash Price	$3,056.00
Rate for Payer: Self Pay Self Pay	$3,056.00

NUSHIELD

Facility

$1,394.00

Service Code	CPT Q4160
Hospital Charge Code	24358095
Hospital Revenue Code	636
Min. Negotiated Rate	$362.44
Max. Negotiated Rate	$1,254.60
Rate for Payer: Aetna of AZ Commercial	$1,254.60
Rate for Payer: Bisbee Police All Plans	$362.44
Rate for Payer: Cash Price	$1,115.20
Rate for Payer: Self Pay Self Pay	$1,115.20

NUSHIELD

Facility

$1,394.00

Service Code	CPT Q4160
Hospital Charge Code	24358095
Hospital Revenue Code	636
Min. Negotiated Rate	$223.04
Max. Negotiated Rate	$1,254.60
Rate for Payer: Aetna of AZ Commercial	$1,254.60
Rate for Payer: Aetna of AZ Medicare	$390.32
Rate for Payer: Allwell Medicare	$223.04
Rate for Payer: Amerigroup Medicare	$223.04
Rate for Payer: APIPA Medicare/Medicaid	$520.66
Rate for Payer: AZCH Complete Medicare	$223.04
Rate for Payer: Banner UC Health Medicare	$223.04
Rate for Payer: Bisbee Police All Plans	$362.44
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$947.92
Rate for Payer: Cash Price	$1,115.20
Rate for Payer: Cigna of AZ Commercial	$975.80
Rate for Payer: Copperpoint Commercial	$345.01
Rate for Payer: Health Net of AZ Commercial	$836.40
Rate for Payer: Health Net of AZ Medicare	$390.32
Rate for Payer: Humana of AZ Medicare	$223.04
Rate for Payer: Self Pay Self Pay	$1,115.20
Rate for Payer: TriWest Medicare	$223.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$812.70
Rate for Payer: UnitedHealth Group of AZ Medicare	$250.92

NUSHIELD

Facility

$916.67

Hospital Charge Code	24358097
Hospital Revenue Code	270
Min. Negotiated Rate	$146.67
Max. Negotiated Rate	$825.00
Rate for Payer: Aetna of AZ Commercial	$825.00
Rate for Payer: Aetna of AZ Medicare	$256.67
Rate for Payer: Allwell Medicare	$146.67
Rate for Payer: Amerigroup Medicare	$146.67
Rate for Payer: APIPA Medicare/Medicaid	$342.38
Rate for Payer: AZCH Complete Medicare	$146.67
Rate for Payer: Banner UC Health Medicare	$146.67
Rate for Payer: Bisbee Police All Plans	$238.33
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$623.34
Rate for Payer: Cash Price	$733.34
Rate for Payer: Cigna of AZ Commercial	$641.67
Rate for Payer: Copperpoint Commercial	$226.88
Rate for Payer: Health Net of AZ Commercial	$550.00
Rate for Payer: Health Net of AZ Medicare	$256.67
Rate for Payer: Humana of AZ Medicare	$146.67
Rate for Payer: Self Pay Self Pay	$733.34
Rate for Payer: TriWest Medicare	$146.67
Rate for Payer: UnitedHealth Group of AZ Commercial	$534.42
Rate for Payer: UnitedHealth Group of AZ Medicare	$165.00

NUSHIELD

Facility

$916.67

Hospital Charge Code	24358097
Hospital Revenue Code	270
Min. Negotiated Rate	$238.33
Max. Negotiated Rate	$825.00
Rate for Payer: Aetna of AZ Commercial	$825.00
Rate for Payer: Bisbee Police All Plans	$238.33
Rate for Payer: Cash Price	$733.34
Rate for Payer: Self Pay Self Pay	$733.34

NUSHIELD 2X4

Facility

$950.00

Service Code	CPT Q4160
Hospital Charge Code	24358096
Hospital Revenue Code	636
Min. Negotiated Rate	$247.00
Max. Negotiated Rate	$855.00
Rate for Payer: Aetna of AZ Commercial	$855.00
Rate for Payer: Bisbee Police All Plans	$247.00
Rate for Payer: Cash Price	$760.00
Rate for Payer: Self Pay Self Pay	$760.00

NUSHIELD 2X4

Facility

$950.00

Service Code	CPT Q4160
Hospital Charge Code	24358096
Hospital Revenue Code	636
Min. Negotiated Rate	$152.00
Max. Negotiated Rate	$855.00
Rate for Payer: Aetna of AZ Commercial	$855.00
Rate for Payer: Aetna of AZ Medicare	$266.00
Rate for Payer: Allwell Medicare	$152.00
Rate for Payer: Amerigroup Medicare	$152.00
Rate for Payer: APIPA Medicare/Medicaid	$354.82
Rate for Payer: AZCH Complete Medicare	$152.00
Rate for Payer: Banner UC Health Medicare	$152.00
Rate for Payer: Bisbee Police All Plans	$247.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$646.00
Rate for Payer: Cash Price	$760.00
Rate for Payer: Cigna of AZ Commercial	$665.00
Rate for Payer: Copperpoint Commercial	$235.12
Rate for Payer: Health Net of AZ Commercial	$570.00
Rate for Payer: Health Net of AZ Medicare	$266.00
Rate for Payer: Humana of AZ Medicare	$152.00
Rate for Payer: Self Pay Self Pay	$760.00
Rate for Payer: TriWest Medicare	$152.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$553.85
Rate for Payer: UnitedHealth Group of AZ Medicare	$171.00

NUSHIELD 4X4

Facility

$712.50

Hospital Charge Code	24358098
Hospital Revenue Code	270
Min. Negotiated Rate	$114.00
Max. Negotiated Rate	$641.25
Rate for Payer: Aetna of AZ Commercial	$641.25
Rate for Payer: Aetna of AZ Medicare	$199.50
Rate for Payer: Allwell Medicare	$114.00
Rate for Payer: Amerigroup Medicare	$114.00
Rate for Payer: APIPA Medicare/Medicaid	$266.12
Rate for Payer: AZCH Complete Medicare	$114.00
Rate for Payer: Banner UC Health Medicare	$114.00
Rate for Payer: Bisbee Police All Plans	$185.25
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$484.50
Rate for Payer: Cash Price	$570.00
Rate for Payer: Cigna of AZ Commercial	$498.75
Rate for Payer: Copperpoint Commercial	$176.34
Rate for Payer: Health Net of AZ Commercial	$427.50
Rate for Payer: Health Net of AZ Medicare	$199.50
Rate for Payer: Humana of AZ Medicare	$114.00
Rate for Payer: Self Pay Self Pay	$570.00
Rate for Payer: TriWest Medicare	$114.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$415.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$128.25

NUSHIELD 4X4

Facility

$712.50

Hospital Charge Code	24358098
Hospital Revenue Code	270
Min. Negotiated Rate	$185.25
Max. Negotiated Rate	$641.25
Rate for Payer: Aetna of AZ Commercial	$641.25
Rate for Payer: Bisbee Police All Plans	$185.25
Rate for Payer: Cash Price	$570.00
Rate for Payer: Self Pay Self Pay	$570.00

NUSHIELD 4X6

Facility

$625.00

Hospital Charge Code	24358099
Hospital Revenue Code	270
Min. Negotiated Rate	$162.50
Max. Negotiated Rate	$562.50
Rate for Payer: Aetna of AZ Commercial	$562.50
Rate for Payer: Bisbee Police All Plans	$162.50
Rate for Payer: Cash Price	$500.00
Rate for Payer: Self Pay Self Pay	$500.00

NUSHIELD 4X6

Facility

$625.00

Hospital Charge Code	24358099
Hospital Revenue Code	270
Min. Negotiated Rate	$100.00
Max. Negotiated Rate	$562.50
Rate for Payer: Aetna of AZ Commercial	$562.50
Rate for Payer: Aetna of AZ Medicare	$175.00
Rate for Payer: Allwell Medicare	$100.00
Rate for Payer: Amerigroup Medicare	$100.00
Rate for Payer: APIPA Medicare/Medicaid	$233.44
Rate for Payer: AZCH Complete Medicare	$100.00
Rate for Payer: Banner UC Health Medicare	$100.00
Rate for Payer: Bisbee Police All Plans	$162.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$425.00
Rate for Payer: Cash Price	$500.00
Rate for Payer: Cigna of AZ Commercial	$437.50
Rate for Payer: Copperpoint Commercial	$154.69
Rate for Payer: Health Net of AZ Commercial	$375.00
Rate for Payer: Health Net of AZ Medicare	$175.00
Rate for Payer: Humana of AZ Medicare	$100.00
Rate for Payer: Self Pay Self Pay	$500.00
Rate for Payer: TriWest Medicare	$100.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$364.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$112.50

NUSHIELD 6X6

Facility

$553.33

Hospital Charge Code	24358100
Hospital Revenue Code	270
Min. Negotiated Rate	$143.87
Max. Negotiated Rate	$498.00
Rate for Payer: Aetna of AZ Commercial	$498.00
Rate for Payer: Bisbee Police All Plans	$143.87
Rate for Payer: Cash Price	$442.66
Rate for Payer: Self Pay Self Pay	$442.66

NUSHIELD 6X6

Facility

$553.33

Hospital Charge Code	24358100
Hospital Revenue Code	270
Min. Negotiated Rate	$88.53
Max. Negotiated Rate	$498.00
Rate for Payer: Aetna of AZ Commercial	$498.00
Rate for Payer: Aetna of AZ Medicare	$154.93
Rate for Payer: Allwell Medicare	$88.53
Rate for Payer: Amerigroup Medicare	$88.53
Rate for Payer: APIPA Medicare/Medicaid	$206.67
Rate for Payer: AZCH Complete Medicare	$88.53
Rate for Payer: Banner UC Health Medicare	$88.53
Rate for Payer: Bisbee Police All Plans	$143.87
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$376.26
Rate for Payer: Cash Price	$442.66
Rate for Payer: Cigna of AZ Commercial	$387.33
Rate for Payer: Copperpoint Commercial	$136.95
Rate for Payer: Health Net of AZ Commercial	$332.00
Rate for Payer: Health Net of AZ Medicare	$154.93
Rate for Payer: Humana of AZ Medicare	$88.53
Rate for Payer: Self Pay Self Pay	$442.66
Rate for Payer: TriWest Medicare	$88.53
Rate for Payer: UnitedHealth Group of AZ Commercial	$322.59
Rate for Payer: UnitedHealth Group of AZ Medicare	$99.60

nystatin 500,000 units/ 5 mL UD Oral Susp [CQCH]

Facility

$0.20

Service Code	NDC 121478505
Hospital Charge Code	105934408
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.18
Rate for Payer: Bisbee Police All Plans	$0.05
Rate for Payer: Cash Price	$0.16
Rate for Payer: Self Pay Self Pay	$0.16

nystatin 500,000 units/ 5 mL UD Oral Susp [CQCH]

Facility

$0.20

Service Code	NDC 121478505
Hospital Charge Code	105934408
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.18
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	$0.07
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	$0.16
Rate for Payer: Cigna of AZ Commercial	$0.13
Rate for Payer: Copperpoint Commercial	$0.05
Rate for Payer: Health Net of AZ Commercial	$0.12
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	$0.16
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

nystatin Top 100,000 units/g Pwdr [CQCH]

Facility

$0.62

Service Code	NDC 574200815
Hospital Charge Code	105934475
Hospital Revenue Code	251
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.56
Rate for Payer: Aetna of AZ Commercial	$0.56
Rate for Payer: Aetna of AZ Medicare	$0.17
Rate for Payer: Allwell Medicare	$0.10
Rate for Payer: Amerigroup Medicare	$0.10
Rate for Payer: APIPA Medicare/Medicaid	$0.23
Rate for Payer: AZCH Complete Medicare	$0.10
Rate for Payer: Banner UC Health Medicare	$0.10
Rate for Payer: Bisbee Police All Plans	$0.16
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.42
Rate for Payer: Cash Price	$0.50
Rate for Payer: Cigna of AZ Commercial	$0.40
Rate for Payer: Copperpoint Commercial	$0.15
Rate for Payer: Health Net of AZ Commercial	$0.37
Rate for Payer: Health Net of AZ Medicare	$0.17
Rate for Payer: Humana of AZ Medicare	$0.10
Rate for Payer: Self Pay Self Pay	$0.50
Rate for Payer: TriWest Medicare	$0.10
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.36
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.11

nystatin Top 100,000 units/g Pwdr [CQCH]

Facility

$0.62

Service Code	NDC 574200815
Hospital Charge Code	105934475
Hospital Revenue Code	251
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

nystatin Top Cream 100,000 units/g [CQCH]

Facility

$0.41

Service Code	NDC 45802005911
Hospital Charge Code	105934540
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of AZ Commercial	$0.37
Rate for Payer: Aetna of AZ Medicare	$0.11
Rate for Payer: Allwell Medicare	$0.07
Rate for Payer: Amerigroup Medicare	$0.07
Rate for Payer: APIPA Medicare/Medicaid	$0.15
Rate for Payer: AZCH Complete Medicare	$0.07
Rate for Payer: Banner UC Health Medicare	$0.07
Rate for Payer: Bisbee Police All Plans	$0.11
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.28
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna of AZ Commercial	$0.27
Rate for Payer: Copperpoint Commercial	$0.10
Rate for Payer: Health Net of AZ Commercial	$0.25
Rate for Payer: Health Net of AZ Medicare	$0.11
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Self Pay Self Pay	$0.33
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.24
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.07

nystatin Top Cream 100,000 units/g [CQCH]

Facility

$0.41

Service Code	NDC 45802005911
Hospital Charge Code	105934540
Hospital Revenue Code	251
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of AZ Commercial	$0.37
Rate for Payer: Bisbee Police All Plans	$0.11
Rate for Payer: Cash Price	$0.33
Rate for Payer: Self Pay Self Pay	$0.33

O2 MASK SIMPLE

Facility

$8.00

Hospital Charge Code	22355406
Hospital Revenue Code	270
Min. Negotiated Rate	$2.08
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Bisbee Police All Plans	$2.08
Rate for Payer: Cash Price	$6.40
Rate for Payer: Self Pay Self Pay	$6.40

O2 MASK SIMPLE

Facility

$8.00

Hospital Charge Code	22355406
Hospital Revenue Code	270
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Aetna of AZ Medicare	$2.24
Rate for Payer: Allwell Medicare	$1.28
Rate for Payer: Amerigroup Medicare	$1.28
Rate for Payer: APIPA Medicare/Medicaid	$2.99
Rate for Payer: AZCH Complete Medicare	$1.28
Rate for Payer: Banner UC Health Medicare	$1.28
Rate for Payer: Bisbee Police All Plans	$2.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$5.44
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cigna of AZ Commercial	$5.60
Rate for Payer: Copperpoint Commercial	$1.98
Rate for Payer: Health Net of AZ Commercial	$4.80
Rate for Payer: Health Net of AZ Medicare	$2.24
Rate for Payer: Humana of AZ Medicare	$1.28
Rate for Payer: Self Pay Self Pay	$6.40
Rate for Payer: TriWest Medicare	$1.28
Rate for Payer: UnitedHealth Group of AZ Commercial	$4.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.44

Occult Blood, Gastric

Facility

$126.00

Service Code	CPT 82271
Hospital Charge Code	22146128
Hospital Revenue Code	301
Min. Negotiated Rate	$32.76
Max. Negotiated Rate	$113.40
Rate for Payer: Aetna of AZ Commercial	$113.40
Rate for Payer: Bisbee Police All Plans	$32.76
Rate for Payer: Cash Price	$100.80
Rate for Payer: Self Pay Self Pay	$100.80

Know your out-of-pocket cost for care.

All Charges