Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Nonspecific Cva And Precerebral Occlusion Without Infarction

Facility

$7,488.15

Service Code	APR-DRG 0463
Hospital Charge Code	APRDRG0464
Min. Negotiated Rate	$7,488.15
Max. Negotiated Rate	$7,488.15
Rate for Payer: AHCCCS Medicaid	$7,488.15
Rate for Payer: Allwell Medicaid	$7,488.15
Rate for Payer: AZCH Complete Medicaid	$7,488.15
Rate for Payer: Banner UC Health Medicaid	$7,488.15
Rate for Payer: Mercy Care Medicaid	$7,488.15

norEPINEPHrine 4 mg/250 mL-D5% Sol[CQCH]

Facility

$0.07

Service Code	NDC 338011220
Hospital Charge Code	238057883
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

norEPINEPHrine 4 mg/250 mL-D5% Sol[CQCH]

Facility

$0.07

Service Code	NDC 338011220
Hospital Charge Code	238057883
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

norEPINEPHrine 4 mg/ 4 mL IV Sol [CQCH]

Facility

$1.55

Service Code	NDC 703115303
Hospital Charge Code	105934341
Hospital Revenue Code	251
Min. Negotiated Rate	$0.23
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	$0.23
Rate for Payer: Amerigroup Medicare	$0.23
Rate for Payer: APIPA Medicare/Medicaid	$0.58
Rate for Payer: AZCH Complete Medicare	$0.23
Rate for Payer: Banner UC Health Medicare	$0.23
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	$0.23
Rate for Payer: Self Pay Self Pay	$1.24
Rate for Payer: TriWest Medicare	$0.23
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.90
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.28

norEPINEPHrine 4 mg/ 4 mL IV Sol [CQCH]

Facility

$1.55

Service Code	NDC 703115303
Hospital Charge Code	105934341
Hospital Revenue Code	251
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

NOVASURE ADVANCE

Facility

$3,154.00

Hospital Charge Code	27448975
Hospital Revenue Code	272
Min. Negotiated Rate	$473.10
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	$473.10
Rate for Payer: Amerigroup Medicare	$473.10
Rate for Payer: APIPA Medicare/Medicaid	$1,178.02
Rate for Payer: AZCH Complete Medicare	$473.10
Rate for Payer: Banner UC Health Medicare	$473.10
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	$473.10
Rate for Payer: Self Pay Self Pay	$2,523.20
Rate for Payer: TriWest Medicare	$473.10
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	$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

NOVASURE KIT, NS-2007

Facility

$3,820.00

Service Code	CPT 58563
Hospital Charge Code	22354784
Hospital Revenue Code	270
Min. Negotiated Rate	$573.00
Max. Negotiated Rate	$6,393.84
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	$6,393.84
Rate for Payer: Allwell Medicaid	$6,393.84
Rate for Payer: Allwell Medicare	$573.00
Rate for Payer: Amerigroup Medicare	$573.00
Rate for Payer: APIPA Medicare/Medicaid	$1,426.77
Rate for Payer: AZCH Complete Medicaid	$6,393.84
Rate for Payer: AZCH Complete Medicare	$573.00
Rate for Payer: Banner UC Health Medicaid	$6,393.84
Rate for Payer: Banner UC Health Medicare	$573.00
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	$573.00
Rate for Payer: Mercy Care Medicaid	$6,393.84
Rate for Payer: Self Pay Self Pay	$3,056.00
Rate for Payer: TriWest Medicare	$573.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,914.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$687.60

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

Facility

$1,060.00

Service Code	CPT Q4160
Hospital Charge Code	24358095
Hospital Revenue Code	636
Min. Negotiated Rate	$275.60
Max. Negotiated Rate	$954.00
Rate for Payer: Aetna of AZ Commercial	$954.00
Rate for Payer: Bisbee Police All Plans	$275.60
Rate for Payer: Cash Price	$848.00
Rate for Payer: Self Pay Self Pay	$848.00

NUSHIELD

Facility

$916.67

Hospital Charge Code	24358097
Hospital Revenue Code	270
Min. Negotiated Rate	$137.50
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	$137.50
Rate for Payer: Amerigroup Medicare	$137.50
Rate for Payer: APIPA Medicare/Medicaid	$342.38
Rate for Payer: AZCH Complete Medicare	$137.50
Rate for Payer: Banner UC Health Medicare	$137.50
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	$137.50
Rate for Payer: Self Pay Self Pay	$733.34
Rate for Payer: TriWest Medicare	$137.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$534.42
Rate for Payer: UnitedHealth Group of AZ Medicare	$165.00

NUSHIELD

Facility

$1,060.00

Service Code	CPT Q4160
Hospital Charge Code	24358095
Hospital Revenue Code	636
Min. Negotiated Rate	$159.00
Max. Negotiated Rate	$954.00
Rate for Payer: Aetna of AZ Commercial	$954.00
Rate for Payer: Aetna of AZ Medicare	$296.80
Rate for Payer: AHCCCS Medicaid	$178.72
Rate for Payer: Allwell Medicaid	$178.72
Rate for Payer: Allwell Medicare	$159.00
Rate for Payer: Amerigroup Medicare	$159.00
Rate for Payer: APIPA Medicare/Medicaid	$395.91
Rate for Payer: AZCH Complete Medicaid	$178.72
Rate for Payer: AZCH Complete Medicare	$159.00
Rate for Payer: Banner UC Health Medicaid	$178.72
Rate for Payer: Banner UC Health Medicare	$159.00
Rate for Payer: Bisbee Police All Plans	$275.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$720.80
Rate for Payer: Cash Price	$848.00
Rate for Payer: Cash Price	$848.00
Rate for Payer: Cigna of AZ Commercial	$742.00
Rate for Payer: Copperpoint Commercial	$262.35
Rate for Payer: Health Net of AZ Commercial	$636.00
Rate for Payer: Health Net of AZ Medicare	$296.80
Rate for Payer: Humana of AZ Medicare	$159.00
Rate for Payer: Mercy Care Medicaid	$178.72
Rate for Payer: Self Pay Self Pay	$848.00
Rate for Payer: TriWest Medicare	$159.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$617.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$190.80

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	$142.50
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: AHCCCS Medicaid	$178.72
Rate for Payer: Allwell Medicaid	$178.72
Rate for Payer: Allwell Medicare	$142.50
Rate for Payer: Amerigroup Medicare	$142.50
Rate for Payer: APIPA Medicare/Medicaid	$354.82
Rate for Payer: AZCH Complete Medicaid	$178.72
Rate for Payer: AZCH Complete Medicare	$142.50
Rate for Payer: Banner UC Health Medicaid	$178.72
Rate for Payer: Banner UC Health Medicare	$142.50
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: 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	$142.50
Rate for Payer: Mercy Care Medicaid	$178.72
Rate for Payer: Self Pay Self Pay	$760.00
Rate for Payer: TriWest Medicare	$142.50
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	$106.88
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	$106.88
Rate for Payer: Amerigroup Medicare	$106.88
Rate for Payer: APIPA Medicare/Medicaid	$266.12
Rate for Payer: AZCH Complete Medicare	$106.88
Rate for Payer: Banner UC Health Medicare	$106.88
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	$106.88
Rate for Payer: Self Pay Self Pay	$570.00
Rate for Payer: TriWest Medicare	$106.88
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	$93.75
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	$93.75
Rate for Payer: Amerigroup Medicare	$93.75
Rate for Payer: APIPA Medicare/Medicaid	$233.44
Rate for Payer: AZCH Complete Medicare	$93.75
Rate for Payer: Banner UC Health Medicare	$93.75
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	$93.75
Rate for Payer: Self Pay Self Pay	$500.00
Rate for Payer: TriWest Medicare	$93.75
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	$83.00
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	$83.00
Rate for Payer: Amerigroup Medicare	$83.00
Rate for Payer: APIPA Medicare/Medicaid	$206.67
Rate for Payer: AZCH Complete Medicare	$83.00
Rate for Payer: Banner UC Health Medicare	$83.00
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	$83.00
Rate for Payer: Self Pay Self Pay	$442.66
Rate for Payer: TriWest Medicare	$83.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$322.59
Rate for Payer: UnitedHealth Group of AZ Medicare	$99.60

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

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	$0.16
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 100,000 units/g Pwdr [CQCH]

Facility

$0.62

Service Code	NDC 574200815
Hospital Charge Code	105934475
Hospital Revenue Code	251
Min. Negotiated Rate	$0.09
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	$0.09
Rate for Payer: Amerigroup Medicare	$0.09
Rate for Payer: APIPA Medicare/Medicaid	$0.23
Rate for Payer: AZCH Complete Medicare	$0.09
Rate for Payer: Banner UC Health Medicare	$0.09
Rate for Payer: Bisbee Police All Plans	$0.16
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	$0.09
Rate for Payer: Self Pay Self Pay	$0.50
Rate for Payer: TriWest Medicare	$0.09
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.36
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.11

Know your out-of-pocket cost for care.

All Charges