Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

phenytoin 100 mg ER Cap [CQCH]

Facility

$0.52

Service Code	NDC 68084037601
Hospital Charge Code	105936628
Hospital Revenue Code	251
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of AZ Commercial	$0.47
Rate for Payer: Aetna of AZ Medicare	$0.15
Rate for Payer: Allwell Medicare	$0.08
Rate for Payer: Amerigroup Medicare	$0.08
Rate for Payer: APIPA Medicare/Medicaid	$0.19
Rate for Payer: AZCH Complete Medicare	$0.08
Rate for Payer: Banner UC Health Medicare	$0.08
Rate for Payer: Bisbee Police All Plans	$0.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.35
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of AZ Commercial	$0.34
Rate for Payer: Copperpoint Commercial	$0.13
Rate for Payer: Health Net of AZ Commercial	$0.31
Rate for Payer: Health Net of AZ Medicare	$0.15
Rate for Payer: Humana of AZ Medicare	$0.08
Rate for Payer: Self Pay Self Pay	$0.42
Rate for Payer: TriWest Medicare	$0.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.30
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.09

Phenytoin, Free, Serum LC

Facility

$318.00

Service Code	CPT 80186
Hospital Charge Code	2087633
Hospital Revenue Code	301
Min. Negotiated Rate	$50.88
Max. Negotiated Rate	$286.20
Rate for Payer: Aetna of AZ Commercial	$286.20
Rate for Payer: Aetna of AZ Medicare	$89.04
Rate for Payer: Allwell Medicare	$50.88
Rate for Payer: Amerigroup Medicare	$50.88
Rate for Payer: APIPA Medicare/Medicaid	$118.77
Rate for Payer: AZCH Complete Medicare	$50.88
Rate for Payer: Banner UC Health Medicare	$50.88
Rate for Payer: Bisbee Police All Plans	$82.68
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$216.24
Rate for Payer: Cash Price	$254.40
Rate for Payer: Cigna of AZ Commercial	$206.70
Rate for Payer: Copperpoint Commercial	$78.70
Rate for Payer: Health Net of AZ Commercial	$190.80
Rate for Payer: Health Net of AZ Medicare	$89.04
Rate for Payer: Humana of AZ Medicare	$50.88
Rate for Payer: Self Pay Self Pay	$254.40
Rate for Payer: TriWest Medicare	$50.88
Rate for Payer: UnitedHealth Group of AZ Commercial	$185.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$57.24

Phenytoin, Free, Serum LC

Facility

$318.00

Service Code	CPT 80186
Hospital Charge Code	2087633
Hospital Revenue Code	301
Min. Negotiated Rate	$82.68
Max. Negotiated Rate	$286.20
Rate for Payer: Aetna of AZ Commercial	$286.20
Rate for Payer: Bisbee Police All Plans	$82.68
Rate for Payer: Cash Price	$254.40
Rate for Payer: Self Pay Self Pay	$254.40

Phenytoin Lvl

Facility

$201.00

Service Code	CPT 80185
Hospital Charge Code	858788
Hospital Revenue Code	301
Min. Negotiated Rate	$32.16
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of AZ Commercial	$180.90
Rate for Payer: Aetna of AZ Medicare	$56.28
Rate for Payer: Allwell Medicare	$32.16
Rate for Payer: Amerigroup Medicare	$32.16
Rate for Payer: APIPA Medicare/Medicaid	$75.07
Rate for Payer: AZCH Complete Medicare	$32.16
Rate for Payer: Banner UC Health Medicare	$32.16
Rate for Payer: Bisbee Police All Plans	$52.26
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$136.68
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cigna of AZ Commercial	$130.65
Rate for Payer: Copperpoint Commercial	$49.75
Rate for Payer: Health Net of AZ Commercial	$120.60
Rate for Payer: Health Net of AZ Medicare	$56.28
Rate for Payer: Humana of AZ Medicare	$32.16
Rate for Payer: Self Pay Self Pay	$160.80
Rate for Payer: TriWest Medicare	$32.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$117.18
Rate for Payer: UnitedHealth Group of AZ Medicare	$36.18

Phenytoin Lvl

Facility

$201.00

Service Code	CPT 80185
Hospital Charge Code	858788
Hospital Revenue Code	301
Min. Negotiated Rate	$52.26
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of AZ Commercial	$180.90
Rate for Payer: Bisbee Police All Plans	$52.26
Rate for Payer: Cash Price	$160.80
Rate for Payer: Self Pay Self Pay	$160.80

Phosphorus, 24 hr Urine LC

Facility

$69.00

Service Code	CPT 84105
Hospital Charge Code	2029252
Hospital Revenue Code	301
Min. Negotiated Rate	$17.94
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Bisbee Police All Plans	$17.94
Rate for Payer: Cash Price	$55.20
Rate for Payer: Self Pay Self Pay	$55.20

Phosphorus, 24 hr Urine LC

Facility

$69.00

Service Code	CPT 84105
Hospital Charge Code	2029252
Hospital Revenue Code	301
Min. Negotiated Rate	$11.04
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Aetna of AZ Medicare	$19.32
Rate for Payer: Allwell Medicare	$11.04
Rate for Payer: Amerigroup Medicare	$11.04
Rate for Payer: APIPA Medicare/Medicaid	$25.77
Rate for Payer: AZCH Complete Medicare	$11.04
Rate for Payer: Banner UC Health Medicare	$11.04
Rate for Payer: Bisbee Police All Plans	$17.94
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$46.92
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cigna of AZ Commercial	$44.85
Rate for Payer: Copperpoint Commercial	$17.08
Rate for Payer: Health Net of AZ Commercial	$41.40
Rate for Payer: Health Net of AZ Medicare	$19.32
Rate for Payer: Humana of AZ Medicare	$11.04
Rate for Payer: Self Pay Self Pay	$55.20
Rate for Payer: TriWest Medicare	$11.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$40.23
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.42

Phosphorus Level

Facility

$116.00

Service Code	CPT 84100
Hospital Charge Code	633803
Hospital Revenue Code	301
Min. Negotiated Rate	$18.56
Max. Negotiated Rate	$104.40
Rate for Payer: Aetna of AZ Commercial	$104.40
Rate for Payer: Aetna of AZ Medicare	$32.48
Rate for Payer: Allwell Medicare	$18.56
Rate for Payer: Amerigroup Medicare	$18.56
Rate for Payer: APIPA Medicare/Medicaid	$43.33
Rate for Payer: AZCH Complete Medicare	$18.56
Rate for Payer: Banner UC Health Medicare	$18.56
Rate for Payer: Bisbee Police All Plans	$30.16
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$78.88
Rate for Payer: Cash Price	$92.80
Rate for Payer: Cigna of AZ Commercial	$75.40
Rate for Payer: Copperpoint Commercial	$28.71
Rate for Payer: Health Net of AZ Commercial	$69.60
Rate for Payer: Health Net of AZ Medicare	$32.48
Rate for Payer: Humana of AZ Medicare	$18.56
Rate for Payer: Self Pay Self Pay	$92.80
Rate for Payer: TriWest Medicare	$18.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$67.63
Rate for Payer: UnitedHealth Group of AZ Medicare	$20.88

Phosphorus Level

Facility

$116.00

Service Code	CPT 84100
Hospital Charge Code	633803
Hospital Revenue Code	301
Min. Negotiated Rate	$30.16
Max. Negotiated Rate	$104.40
Rate for Payer: Aetna of AZ Commercial	$104.40
Rate for Payer: Bisbee Police All Plans	$30.16
Rate for Payer: Cash Price	$92.80
Rate for Payer: Self Pay Self Pay	$92.80

Physical fitness testing

Facility

$46.00

Service Code	CPT 97799
Hospital Charge Code	27790993
Hospital Revenue Code	302
Min. Negotiated Rate	$7.36
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of AZ Commercial	$41.40
Rate for Payer: Aetna of AZ Medicare	$12.88
Rate for Payer: Allwell Medicare	$7.36
Rate for Payer: Amerigroup Medicare	$7.36
Rate for Payer: APIPA Medicare/Medicaid	$17.18
Rate for Payer: AZCH Complete Medicare	$7.36
Rate for Payer: Banner UC Health Medicare	$7.36
Rate for Payer: Bisbee Police All Plans	$11.96
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$31.28
Rate for Payer: Cash Price	$36.80
Rate for Payer: Cigna of AZ Commercial	$29.90
Rate for Payer: Copperpoint Commercial	$11.38
Rate for Payer: Health Net of AZ Commercial	$27.60
Rate for Payer: Health Net of AZ Medicare	$12.88
Rate for Payer: Humana of AZ Medicare	$7.36
Rate for Payer: Self Pay Self Pay	$36.80
Rate for Payer: TriWest Medicare	$7.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$26.82
Rate for Payer: UnitedHealth Group of AZ Medicare	$8.28

Physical fitness testing

Facility

$46.00

Service Code	CPT 97799
Hospital Charge Code	27790993
Hospital Revenue Code	302
Min. Negotiated Rate	$11.96
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of AZ Commercial	$41.40
Rate for Payer: Bisbee Police All Plans	$11.96
Rate for Payer: Cash Price	$36.80
Rate for Payer: Self Pay Self Pay	$36.80

phytonadione 10 mg/ 1mL Inj Sol [CQCH]

Facility

$34.78

Service Code	HCPCS J3430
Hospital Charge Code	105936764
Hospital Revenue Code	250
Min. Negotiated Rate	$5.56
Max. Negotiated Rate	$31.30
Rate for Payer: Aetna of AZ Commercial	$31.30
Rate for Payer: Aetna of AZ Medicare	$9.74
Rate for Payer: Allwell Medicare	$5.56
Rate for Payer: Amerigroup Medicare	$5.56
Rate for Payer: APIPA Medicare/Medicaid	$12.99
Rate for Payer: AZCH Complete Medicare	$5.56
Rate for Payer: Banner UC Health Medicare	$5.56
Rate for Payer: Bisbee Police All Plans	$9.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$23.65
Rate for Payer: Cash Price	$27.82
Rate for Payer: Cigna of AZ Commercial	$22.61
Rate for Payer: Copperpoint Commercial	$8.61
Rate for Payer: Health Net of AZ Commercial	$20.87
Rate for Payer: Health Net of AZ Medicare	$9.74
Rate for Payer: Humana of AZ Medicare	$5.56
Rate for Payer: Self Pay Self Pay	$27.82
Rate for Payer: TriWest Medicare	$5.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$20.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$6.26

phytonadione 10 mg/ 1mL Inj Sol [CQCH]

Facility

$34.78

Service Code	HCPCS J3430
Hospital Charge Code	105936764
Hospital Revenue Code	250
Min. Negotiated Rate	$9.04
Max. Negotiated Rate	$31.30
Rate for Payer: Aetna of AZ Commercial	$31.30
Rate for Payer: Bisbee Police All Plans	$9.04
Rate for Payer: Cash Price	$27.82
Rate for Payer: Self Pay Self Pay	$27.82

phytonadione 1 mg/0.5 mL PFS Inj [CQCH]

Facility

$38.70

Service Code	HCPCS J3430
Hospital Charge Code	105936693
Hospital Revenue Code	250
Min. Negotiated Rate	$10.06
Max. Negotiated Rate	$34.83
Rate for Payer: Aetna of AZ Commercial	$34.83
Rate for Payer: Bisbee Police All Plans	$10.06
Rate for Payer: Cash Price	$30.96
Rate for Payer: Self Pay Self Pay	$30.96

phytonadione 1 mg/0.5 mL PFS Inj [CQCH]

Facility

$38.70

Service Code	HCPCS J3430
Hospital Charge Code	105936693
Hospital Revenue Code	250
Min. Negotiated Rate	$6.19
Max. Negotiated Rate	$34.83
Rate for Payer: Aetna of AZ Commercial	$34.83
Rate for Payer: Aetna of AZ Medicare	$10.84
Rate for Payer: Allwell Medicare	$6.19
Rate for Payer: Amerigroup Medicare	$6.19
Rate for Payer: APIPA Medicare/Medicaid	$14.45
Rate for Payer: AZCH Complete Medicare	$6.19
Rate for Payer: Banner UC Health Medicare	$6.19
Rate for Payer: Bisbee Police All Plans	$10.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$26.32
Rate for Payer: Cash Price	$30.96
Rate for Payer: Cigna of AZ Commercial	$25.16
Rate for Payer: Copperpoint Commercial	$9.58
Rate for Payer: Health Net of AZ Commercial	$23.22
Rate for Payer: Health Net of AZ Medicare	$10.84
Rate for Payer: Humana of AZ Medicare	$6.19
Rate for Payer: Self Pay Self Pay	$30.96
Rate for Payer: TriWest Medicare	$6.19
Rate for Payer: UnitedHealth Group of AZ Commercial	$22.56
Rate for Payer: UnitedHealth Group of AZ Medicare	$6.97

PICC KIT 3FR SL

Facility

$1,209.00

Hospital Charge Code	23758900
Hospital Revenue Code	270
Min. Negotiated Rate	$193.44
Max. Negotiated Rate	$1,088.10
Rate for Payer: Aetna of AZ Commercial	$1,088.10
Rate for Payer: Aetna of AZ Medicare	$338.52
Rate for Payer: Allwell Medicare	$193.44
Rate for Payer: Amerigroup Medicare	$193.44
Rate for Payer: APIPA Medicare/Medicaid	$451.56
Rate for Payer: AZCH Complete Medicare	$193.44
Rate for Payer: Banner UC Health Medicare	$193.44
Rate for Payer: Bisbee Police All Plans	$314.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$822.12
Rate for Payer: Cash Price	$967.20
Rate for Payer: Cigna of AZ Commercial	$846.30
Rate for Payer: Copperpoint Commercial	$299.23
Rate for Payer: Health Net of AZ Commercial	$725.40
Rate for Payer: Health Net of AZ Medicare	$338.52
Rate for Payer: Humana of AZ Medicare	$193.44
Rate for Payer: Self Pay Self Pay	$967.20
Rate for Payer: TriWest Medicare	$193.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$704.85
Rate for Payer: UnitedHealth Group of AZ Medicare	$217.62

PICC KIT 3FR SL

Facility

$1,209.00

Hospital Charge Code	23758900
Hospital Revenue Code	270
Min. Negotiated Rate	$314.34
Max. Negotiated Rate	$1,088.10
Rate for Payer: Aetna of AZ Commercial	$1,088.10
Rate for Payer: Bisbee Police All Plans	$314.34
Rate for Payer: Cash Price	$967.20
Rate for Payer: Self Pay Self Pay	$967.20

PICC KIT 4FR DL

Facility

$1,255.00

Hospital Charge Code	23758902
Hospital Revenue Code	270
Min. Negotiated Rate	$200.80
Max. Negotiated Rate	$1,129.50
Rate for Payer: Aetna of AZ Commercial	$1,129.50
Rate for Payer: Aetna of AZ Medicare	$351.40
Rate for Payer: Allwell Medicare	$200.80
Rate for Payer: Amerigroup Medicare	$200.80
Rate for Payer: APIPA Medicare/Medicaid	$468.74
Rate for Payer: AZCH Complete Medicare	$200.80
Rate for Payer: Banner UC Health Medicare	$200.80
Rate for Payer: Bisbee Police All Plans	$326.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$853.40
Rate for Payer: Cash Price	$1,004.00
Rate for Payer: Cigna of AZ Commercial	$878.50
Rate for Payer: Copperpoint Commercial	$310.61
Rate for Payer: Health Net of AZ Commercial	$753.00
Rate for Payer: Health Net of AZ Medicare	$351.40
Rate for Payer: Humana of AZ Medicare	$200.80
Rate for Payer: Self Pay Self Pay	$1,004.00
Rate for Payer: TriWest Medicare	$200.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$731.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$225.90

PICC KIT 4FR DL

Facility

$1,255.00

Hospital Charge Code	23758902
Hospital Revenue Code	270
Min. Negotiated Rate	$326.30
Max. Negotiated Rate	$1,129.50
Rate for Payer: Aetna of AZ Commercial	$1,129.50
Rate for Payer: Bisbee Police All Plans	$326.30
Rate for Payer: Cash Price	$1,004.00
Rate for Payer: Self Pay Self Pay	$1,004.00

PICC KIT 4FR SL

Facility

$1,157.00

Hospital Charge Code	23758901
Hospital Revenue Code	270
Min. Negotiated Rate	$185.12
Max. Negotiated Rate	$1,041.30
Rate for Payer: Aetna of AZ Commercial	$1,041.30
Rate for Payer: Aetna of AZ Medicare	$323.96
Rate for Payer: Allwell Medicare	$185.12
Rate for Payer: Amerigroup Medicare	$185.12
Rate for Payer: APIPA Medicare/Medicaid	$432.14
Rate for Payer: AZCH Complete Medicare	$185.12
Rate for Payer: Banner UC Health Medicare	$185.12
Rate for Payer: Bisbee Police All Plans	$300.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$786.76
Rate for Payer: Cash Price	$925.60
Rate for Payer: Cigna of AZ Commercial	$809.90
Rate for Payer: Copperpoint Commercial	$286.36
Rate for Payer: Health Net of AZ Commercial	$694.20
Rate for Payer: Health Net of AZ Medicare	$323.96
Rate for Payer: Humana of AZ Medicare	$185.12
Rate for Payer: Self Pay Self Pay	$925.60
Rate for Payer: TriWest Medicare	$185.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$674.53
Rate for Payer: UnitedHealth Group of AZ Medicare	$208.26

PICC KIT 4FR SL

Facility

$1,157.00

Hospital Charge Code	23758901
Hospital Revenue Code	270
Min. Negotiated Rate	$300.82
Max. Negotiated Rate	$1,041.30
Rate for Payer: Aetna of AZ Commercial	$1,041.30
Rate for Payer: Bisbee Police All Plans	$300.82
Rate for Payer: Cash Price	$925.60
Rate for Payer: Self Pay Self Pay	$925.60

PICO 7 DISPOSABLE WOUND THERAPY SYSTEM

Facility

$1,659.00

Hospital Charge Code	24010984
Hospital Revenue Code	270
Min. Negotiated Rate	$431.34
Max. Negotiated Rate	$1,493.10
Rate for Payer: Aetna of AZ Commercial	$1,493.10
Rate for Payer: Bisbee Police All Plans	$431.34
Rate for Payer: Cash Price	$1,327.20
Rate for Payer: Self Pay Self Pay	$1,327.20

PICO 7 DISPOSABLE WOUND THERAPY SYSTEM

Facility

$1,659.00

Hospital Charge Code	24010984
Hospital Revenue Code	270
Min. Negotiated Rate	$265.44
Max. Negotiated Rate	$1,493.10
Rate for Payer: Aetna of AZ Commercial	$1,493.10
Rate for Payer: Aetna of AZ Medicare	$464.52
Rate for Payer: Allwell Medicare	$265.44
Rate for Payer: Amerigroup Medicare	$265.44
Rate for Payer: APIPA Medicare/Medicaid	$619.64
Rate for Payer: AZCH Complete Medicare	$265.44
Rate for Payer: Banner UC Health Medicare	$265.44
Rate for Payer: Bisbee Police All Plans	$431.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,128.12
Rate for Payer: Cash Price	$1,327.20
Rate for Payer: Cigna of AZ Commercial	$1,161.30
Rate for Payer: Copperpoint Commercial	$410.60
Rate for Payer: Health Net of AZ Commercial	$995.40
Rate for Payer: Health Net of AZ Medicare	$464.52
Rate for Payer: Humana of AZ Medicare	$265.44
Rate for Payer: Self Pay Self Pay	$1,327.20
Rate for Payer: TriWest Medicare	$265.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$967.20
Rate for Payer: UnitedHealth Group of AZ Medicare	$298.62

pilocarpine 5 mg Tab [CQCH]

Facility

$1.26

Service Code	NDC 62856070510
Hospital Charge Code	105936837
Hospital Revenue Code	251
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$1.13
Rate for Payer: Aetna of AZ Commercial	$1.13
Rate for Payer: Aetna of AZ Medicare	$0.35
Rate for Payer: Allwell Medicare	$0.20
Rate for Payer: Amerigroup Medicare	$0.20
Rate for Payer: APIPA Medicare/Medicaid	$0.47
Rate for Payer: AZCH Complete Medicare	$0.20
Rate for Payer: Banner UC Health Medicare	$0.20
Rate for Payer: Bisbee Police All Plans	$0.33
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.86
Rate for Payer: Cash Price	$1.01
Rate for Payer: Cigna of AZ Commercial	$0.82
Rate for Payer: Copperpoint Commercial	$0.31
Rate for Payer: Health Net of AZ Commercial	$0.76
Rate for Payer: Health Net of AZ Medicare	$0.35
Rate for Payer: Humana of AZ Medicare	$0.20
Rate for Payer: Self Pay Self Pay	$1.01
Rate for Payer: TriWest Medicare	$0.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.73
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.23

pilocarpine 5 mg Tab [CQCH]

Facility

$1.26

Service Code	NDC 62856070510
Hospital Charge Code	105936837
Hospital Revenue Code	251
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$1.13
Rate for Payer: Aetna of AZ Commercial	$1.13
Rate for Payer: Bisbee Police All Plans	$0.33
Rate for Payer: Cash Price	$1.01
Rate for Payer: Self Pay Self Pay	$1.01

Know your out-of-pocket cost for care.

All Charges