Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

pilocarpine Ophth 2% Sol [CQCH]

Facility

$1.97

Service Code	NDC 61314020315
Hospital Charge Code	105936902
Hospital Revenue Code	251
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$1.77
Rate for Payer: Aetna of AZ Commercial	$1.77
Rate for Payer: Bisbee Police All Plans	$0.51
Rate for Payer: Cash Price	$1.58
Rate for Payer: Self Pay Self Pay	$1.58

pilocarpine Ophth 2% Sol [CQCH]

Facility

$1.97

Service Code	NDC 61314020315
Hospital Charge Code	105936902
Hospital Revenue Code	251
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$1.77
Rate for Payer: Aetna of AZ Commercial	$1.77
Rate for Payer: Aetna of AZ Medicare	$0.55
Rate for Payer: Allwell Medicare	$0.32
Rate for Payer: Amerigroup Medicare	$0.32
Rate for Payer: APIPA Medicare/Medicaid	$0.74
Rate for Payer: AZCH Complete Medicare	$0.32
Rate for Payer: Banner UC Health Medicare	$0.32
Rate for Payer: Bisbee Police All Plans	$0.51
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.34
Rate for Payer: Cash Price	$1.58
Rate for Payer: Cigna of AZ Commercial	$1.28
Rate for Payer: Copperpoint Commercial	$0.49
Rate for Payer: Health Net of AZ Commercial	$1.18
Rate for Payer: Health Net of AZ Medicare	$0.55
Rate for Payer: Humana of AZ Medicare	$0.32
Rate for Payer: Self Pay Self Pay	$1.58
Rate for Payer: TriWest Medicare	$0.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.15
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.35

Pinworm Prep

Facility

$88.00

Service Code	CPT 87172
Hospital Charge Code	633912
Hospital Revenue Code	306
Min. Negotiated Rate	$22.88
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of AZ Commercial	$79.20
Rate for Payer: Bisbee Police All Plans	$22.88
Rate for Payer: Cash Price	$70.40
Rate for Payer: Self Pay Self Pay	$70.40

Pinworm Prep

Facility

$92.00

Service Code	CPT 87172
Hospital Charge Code	1725569
Hospital Revenue Code	306
Min. Negotiated Rate	$23.92
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of AZ Commercial	$82.80
Rate for Payer: Bisbee Police All Plans	$23.92
Rate for Payer: Cash Price	$73.60
Rate for Payer: Self Pay Self Pay	$73.60

Pinworm Prep

Facility

$92.00

Service Code	CPT 87172
Hospital Charge Code	1725569
Hospital Revenue Code	306
Min. Negotiated Rate	$14.72
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of AZ Commercial	$82.80
Rate for Payer: Aetna of AZ Medicare	$25.76
Rate for Payer: Allwell Medicare	$14.72
Rate for Payer: Amerigroup Medicare	$14.72
Rate for Payer: APIPA Medicare/Medicaid	$34.36
Rate for Payer: AZCH Complete Medicare	$14.72
Rate for Payer: Banner UC Health Medicare	$14.72
Rate for Payer: Bisbee Police All Plans	$23.92
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$62.56
Rate for Payer: Cash Price	$73.60
Rate for Payer: Cigna of AZ Commercial	$59.80
Rate for Payer: Copperpoint Commercial	$22.77
Rate for Payer: Health Net of AZ Commercial	$55.20
Rate for Payer: Health Net of AZ Medicare	$25.76
Rate for Payer: Humana of AZ Medicare	$14.72
Rate for Payer: Self Pay Self Pay	$73.60
Rate for Payer: TriWest Medicare	$14.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$53.64
Rate for Payer: UnitedHealth Group of AZ Medicare	$16.56

Pinworm Prep

Facility

$88.00

Service Code	CPT 87172
Hospital Charge Code	633912
Hospital Revenue Code	306
Min. Negotiated Rate	$14.08
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of AZ Commercial	$79.20
Rate for Payer: Aetna of AZ Medicare	$24.64
Rate for Payer: Allwell Medicare	$14.08
Rate for Payer: Amerigroup Medicare	$14.08
Rate for Payer: APIPA Medicare/Medicaid	$32.87
Rate for Payer: AZCH Complete Medicare	$14.08
Rate for Payer: Banner UC Health Medicare	$14.08
Rate for Payer: Bisbee Police All Plans	$22.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$59.84
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cigna of AZ Commercial	$57.20
Rate for Payer: Copperpoint Commercial	$21.78
Rate for Payer: Health Net of AZ Commercial	$52.80
Rate for Payer: Health Net of AZ Medicare	$24.64
Rate for Payer: Humana of AZ Medicare	$14.08
Rate for Payer: Self Pay Self Pay	$70.40
Rate for Payer: TriWest Medicare	$14.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$51.30
Rate for Payer: UnitedHealth Group of AZ Medicare	$15.84

piperacillin-tazobactam 2.25 gm IV Inj [CQCH]

Facility

$3.90

Service Code	HCPCS J2543
Hospital Charge Code	105970066
Hospital Revenue Code	250
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$3.51
Rate for Payer: Aetna of AZ Commercial	$3.51
Rate for Payer: Aetna of AZ Medicare	$1.09
Rate for Payer: Allwell Medicare	$0.62
Rate for Payer: Amerigroup Medicare	$0.62
Rate for Payer: APIPA Medicare/Medicaid	$1.46
Rate for Payer: AZCH Complete Medicare	$0.62
Rate for Payer: Banner UC Health Medicare	$0.62
Rate for Payer: Bisbee Police All Plans	$1.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2.65
Rate for Payer: Cash Price	$3.12
Rate for Payer: Cigna of AZ Commercial	$2.54
Rate for Payer: Copperpoint Commercial	$0.97
Rate for Payer: Health Net of AZ Commercial	$2.34
Rate for Payer: Health Net of AZ Medicare	$1.09
Rate for Payer: Humana of AZ Medicare	$0.62
Rate for Payer: Self Pay Self Pay	$3.12
Rate for Payer: TriWest Medicare	$0.62
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.27
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.70

piperacillin-tazobactam 2.25 gm IV Inj [CQCH]

Facility

$3.90

Service Code	HCPCS J2543
Hospital Charge Code	105970066
Hospital Revenue Code	250
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$3.51
Rate for Payer: Aetna of AZ Commercial	$3.51
Rate for Payer: Bisbee Police All Plans	$1.01
Rate for Payer: Cash Price	$3.12
Rate for Payer: Self Pay Self Pay	$3.12

piperacillin-tazobactam 3.375 gm IV Inj [CQCH]

Facility

$5.30

Service Code	HCPCS J2543
Hospital Charge Code	105970909
Hospital Revenue Code	250
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$4.77
Rate for Payer: Aetna of AZ Commercial	$4.77
Rate for Payer: Bisbee Police All Plans	$1.38
Rate for Payer: Cash Price	$4.24
Rate for Payer: Self Pay Self Pay	$4.24

piperacillin-tazobactam 3.375 gm IV Inj [CQCH]

Facility

$5.30

Service Code	HCPCS J2543
Hospital Charge Code	105970909
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$4.77
Rate for Payer: Aetna of AZ Commercial	$4.77
Rate for Payer: Aetna of AZ Medicare	$1.48
Rate for Payer: Allwell Medicare	$0.85
Rate for Payer: Amerigroup Medicare	$0.85
Rate for Payer: APIPA Medicare/Medicaid	$1.98
Rate for Payer: AZCH Complete Medicare	$0.85
Rate for Payer: Banner UC Health Medicare	$0.85
Rate for Payer: Bisbee Police All Plans	$1.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3.60
Rate for Payer: Cash Price	$4.24
Rate for Payer: Cigna of AZ Commercial	$3.44
Rate for Payer: Copperpoint Commercial	$1.31
Rate for Payer: Health Net of AZ Commercial	$3.18
Rate for Payer: Health Net of AZ Medicare	$1.48
Rate for Payer: Humana of AZ Medicare	$0.85
Rate for Payer: Self Pay Self Pay	$4.24
Rate for Payer: TriWest Medicare	$0.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$3.09
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.95

piperacillin-tazobactam 4.5 gm rec [CQCH]

Facility

$8.25

Service Code	HCPCS J2543
Hospital Charge Code	112390998
Hospital Revenue Code	250
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$7.42
Rate for Payer: Aetna of AZ Commercial	$7.42
Rate for Payer: Aetna of AZ Medicare	$2.31
Rate for Payer: Allwell Medicare	$1.32
Rate for Payer: Amerigroup Medicare	$1.32
Rate for Payer: APIPA Medicare/Medicaid	$3.08
Rate for Payer: AZCH Complete Medicare	$1.32
Rate for Payer: Banner UC Health Medicare	$1.32
Rate for Payer: Bisbee Police All Plans	$2.15
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$5.61
Rate for Payer: Cash Price	$6.60
Rate for Payer: Cigna of AZ Commercial	$5.36
Rate for Payer: Copperpoint Commercial	$2.04
Rate for Payer: Health Net of AZ Commercial	$4.95
Rate for Payer: Health Net of AZ Medicare	$2.31
Rate for Payer: Humana of AZ Medicare	$1.32
Rate for Payer: Self Pay Self Pay	$6.60
Rate for Payer: TriWest Medicare	$1.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$4.81
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.49

piperacillin-tazobactam 4.5 gm rec [CQCH]

Facility

$8.25

Service Code	HCPCS J2543
Hospital Charge Code	112390998
Hospital Revenue Code	250
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$7.42
Rate for Payer: Aetna of AZ Commercial	$7.42
Rate for Payer: Bisbee Police All Plans	$2.15
Rate for Payer: Cash Price	$6.60
Rate for Payer: Self Pay Self Pay	$6.60

PKS CUTTING FORCEP 5MM/33CM

Facility

$1,557.00

Hospital Charge Code	22562751
Hospital Revenue Code	272
Min. Negotiated Rate	$249.12
Max. Negotiated Rate	$1,401.30
Rate for Payer: Aetna of AZ Commercial	$1,401.30
Rate for Payer: Aetna of AZ Medicare	$435.96
Rate for Payer: Allwell Medicare	$249.12
Rate for Payer: Amerigroup Medicare	$249.12
Rate for Payer: APIPA Medicare/Medicaid	$581.54
Rate for Payer: AZCH Complete Medicare	$249.12
Rate for Payer: Banner UC Health Medicare	$249.12
Rate for Payer: Bisbee Police All Plans	$404.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,058.76
Rate for Payer: Cash Price	$1,245.60
Rate for Payer: Cigna of AZ Commercial	$1,089.90
Rate for Payer: Copperpoint Commercial	$385.36
Rate for Payer: Health Net of AZ Commercial	$934.20
Rate for Payer: Health Net of AZ Medicare	$435.96
Rate for Payer: Humana of AZ Medicare	$249.12
Rate for Payer: Self Pay Self Pay	$1,245.60
Rate for Payer: TriWest Medicare	$249.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$907.73
Rate for Payer: UnitedHealth Group of AZ Medicare	$280.26

PKS CUTTING FORCEP 5MM/33CM

Facility

$1,557.00

Hospital Charge Code	22562751
Hospital Revenue Code	272
Min. Negotiated Rate	$404.82
Max. Negotiated Rate	$1,401.30
Rate for Payer: Aetna of AZ Commercial	$1,401.30
Rate for Payer: Bisbee Police All Plans	$404.82
Rate for Payer: Cash Price	$1,245.60
Rate for Payer: Self Pay Self Pay	$1,245.60

PKU Newborn

Facility

$129.00

Service Code	CPT 84030
Hospital Charge Code	1206897
Hospital Revenue Code	301
Min. Negotiated Rate	$20.64
Max. Negotiated Rate	$116.10
Rate for Payer: Aetna of AZ Commercial	$116.10
Rate for Payer: Aetna of AZ Medicare	$36.12
Rate for Payer: Allwell Medicare	$20.64
Rate for Payer: Amerigroup Medicare	$20.64
Rate for Payer: APIPA Medicare/Medicaid	$48.18
Rate for Payer: AZCH Complete Medicare	$20.64
Rate for Payer: Banner UC Health Medicare	$20.64
Rate for Payer: Bisbee Police All Plans	$33.54
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$87.72
Rate for Payer: Cash Price	$103.20
Rate for Payer: Cigna of AZ Commercial	$83.85
Rate for Payer: Copperpoint Commercial	$31.93
Rate for Payer: Health Net of AZ Commercial	$77.40
Rate for Payer: Health Net of AZ Medicare	$36.12
Rate for Payer: Humana of AZ Medicare	$20.64
Rate for Payer: Self Pay Self Pay	$103.20
Rate for Payer: TriWest Medicare	$20.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$75.21
Rate for Payer: UnitedHealth Group of AZ Medicare	$23.22

PKU Newborn

Facility

$129.00

Service Code	CPT 84030
Hospital Charge Code	1206897
Hospital Revenue Code	301
Min. Negotiated Rate	$33.54
Max. Negotiated Rate	$116.10
Rate for Payer: Aetna of AZ Commercial	$116.10
Rate for Payer: Bisbee Police All Plans	$33.54
Rate for Payer: Cash Price	$103.20
Rate for Payer: Self Pay Self Pay	$103.20

PKU- Newborn

Facility

$142.00

Service Code	CPT 84030
Hospital Charge Code	22350384
Hospital Revenue Code	301
Min. Negotiated Rate	$36.92
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Bisbee Police All Plans	$36.92
Rate for Payer: Cash Price	$113.60
Rate for Payer: Self Pay Self Pay	$113.60

PKU- Newborn

Facility

$142.00

Service Code	CPT 84030
Hospital Charge Code	22350384
Hospital Revenue Code	301
Min. Negotiated Rate	$22.72
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Aetna of AZ Medicare	$39.76
Rate for Payer: Allwell Medicare	$22.72
Rate for Payer: Amerigroup Medicare	$22.72
Rate for Payer: APIPA Medicare/Medicaid	$53.04
Rate for Payer: AZCH Complete Medicare	$22.72
Rate for Payer: Banner UC Health Medicare	$22.72
Rate for Payer: Bisbee Police All Plans	$36.92
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$96.56
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cigna of AZ Commercial	$92.30
Rate for Payer: Copperpoint Commercial	$35.15
Rate for Payer: Health Net of AZ Commercial	$85.20
Rate for Payer: Health Net of AZ Medicare	$39.76
Rate for Payer: Humana of AZ Medicare	$22.72
Rate for Payer: Self Pay Self Pay	$113.60
Rate for Payer: TriWest Medicare	$22.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$82.79
Rate for Payer: UnitedHealth Group of AZ Medicare	$25.56

Placement of generator stage II

Facility

$872.00

Service Code	CPT 64590
Hospital Charge Code	27281905
Hospital Revenue Code	360
Min. Negotiated Rate	$226.72
Max. Negotiated Rate	$784.80
Rate for Payer: Aetna of AZ Commercial	$784.80
Rate for Payer: Bisbee Police All Plans	$226.72
Rate for Payer: Cash Price	$697.60
Rate for Payer: Self Pay Self Pay	$697.60

Placement of generator stage II

Facility

$872.00

Service Code	CPT 64590
Hospital Charge Code	27281905
Hospital Revenue Code	360
Min. Negotiated Rate	$139.52
Max. Negotiated Rate	$14,847.84
Rate for Payer: Aetna of AZ Commercial	$784.80
Rate for Payer: Aetna of AZ Medicare	$244.16
Rate for Payer: AHCCCS Medicaid	$14,847.84
Rate for Payer: Allwell Medicaid	$14,847.84
Rate for Payer: Allwell Medicare	$139.52
Rate for Payer: Amerigroup Medicare	$139.52
Rate for Payer: APIPA Medicare/Medicaid	$325.69
Rate for Payer: AZCH Complete Medicaid	$14,847.84
Rate for Payer: AZCH Complete Medicare	$139.52
Rate for Payer: Banner UC Health Medicaid	$14,847.84
Rate for Payer: Banner UC Health Medicare	$139.52
Rate for Payer: Bisbee Police All Plans	$226.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$592.96
Rate for Payer: Cash Price	$697.60
Rate for Payer: Cash Price	$697.60
Rate for Payer: Cigna of AZ Commercial	$436.00
Rate for Payer: Copperpoint Commercial	$215.82
Rate for Payer: Health Net of AZ Commercial	$523.20
Rate for Payer: Health Net of AZ Medicare	$244.16
Rate for Payer: Humana of AZ Medicare	$139.52
Rate for Payer: Mercy Care Medicaid	$14,847.84
Rate for Payer: Self Pay Self Pay	$697.60
Rate for Payer: TriWest Medicare	$139.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$508.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$156.96

Placement of lead Stage I

Facility

$3,581.00

Service Code	CPT 64581
Hospital Charge Code	27291810
Hospital Revenue Code	360
Min. Negotiated Rate	$572.96
Max. Negotiated Rate	$4,466.49
Rate for Payer: Aetna of AZ Commercial	$3,222.90
Rate for Payer: Aetna of AZ Medicare	$1,002.68
Rate for Payer: AHCCCS Medicaid	$4,466.49
Rate for Payer: Allwell Medicaid	$4,466.49
Rate for Payer: Allwell Medicare	$572.96
Rate for Payer: Amerigroup Medicare	$572.96
Rate for Payer: APIPA Medicare/Medicaid	$1,337.50
Rate for Payer: AZCH Complete Medicaid	$4,466.49
Rate for Payer: AZCH Complete Medicare	$572.96
Rate for Payer: Banner UC Health Medicaid	$4,466.49
Rate for Payer: Banner UC Health Medicare	$572.96
Rate for Payer: Bisbee Police All Plans	$931.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,435.08
Rate for Payer: Cash Price	$2,864.80
Rate for Payer: Cash Price	$2,864.80
Rate for Payer: Cigna of AZ Commercial	$1,790.50
Rate for Payer: Copperpoint Commercial	$886.30
Rate for Payer: Health Net of AZ Commercial	$2,148.60
Rate for Payer: Health Net of AZ Medicare	$1,002.68
Rate for Payer: Humana of AZ Medicare	$572.96
Rate for Payer: Mercy Care Medicaid	$4,466.49
Rate for Payer: Self Pay Self Pay	$2,864.80
Rate for Payer: TriWest Medicare	$572.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,087.72
Rate for Payer: UnitedHealth Group of AZ Medicare	$644.58

Placement of lead Stage I

Facility

$3,581.00

Service Code	CPT 64581
Hospital Charge Code	27291810
Hospital Revenue Code	360
Min. Negotiated Rate	$931.06
Max. Negotiated Rate	$3,222.90
Rate for Payer: Aetna of AZ Commercial	$3,222.90
Rate for Payer: Bisbee Police All Plans	$931.06
Rate for Payer: Cash Price	$2,864.80
Rate for Payer: Self Pay Self Pay	$2,864.80

PLANTAR PYTHON 2 PLATE LEFT

Facility

$8,663.00

Hospital Charge Code	24358102
Hospital Revenue Code	270
Min. Negotiated Rate	$2,252.38
Max. Negotiated Rate	$7,796.70
Rate for Payer: Aetna of AZ Commercial	$7,796.70
Rate for Payer: Bisbee Police All Plans	$2,252.38
Rate for Payer: Cash Price	$6,930.40
Rate for Payer: Self Pay Self Pay	$6,930.40

PLANTAR PYTHON 2 PLATE LEFT

Facility

$8,663.00

Hospital Charge Code	24358102
Hospital Revenue Code	270
Min. Negotiated Rate	$1,386.08
Max. Negotiated Rate	$7,796.70
Rate for Payer: Aetna of AZ Commercial	$7,796.70
Rate for Payer: Aetna of AZ Medicare	$2,425.64
Rate for Payer: Allwell Medicare	$1,386.08
Rate for Payer: Amerigroup Medicare	$1,386.08
Rate for Payer: APIPA Medicare/Medicaid	$3,235.63
Rate for Payer: AZCH Complete Medicare	$1,386.08
Rate for Payer: Banner UC Health Medicare	$1,386.08
Rate for Payer: Bisbee Police All Plans	$2,252.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$5,890.84
Rate for Payer: Cash Price	$6,930.40
Rate for Payer: Cigna of AZ Commercial	$6,064.10
Rate for Payer: Copperpoint Commercial	$2,144.09
Rate for Payer: Health Net of AZ Commercial	$5,197.80
Rate for Payer: Health Net of AZ Medicare	$2,425.64
Rate for Payer: Humana of AZ Medicare	$1,386.08
Rate for Payer: Self Pay Self Pay	$6,930.40
Rate for Payer: TriWest Medicare	$1,386.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$5,050.53
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,559.34

Plasma CPD Cryo Red

Facility

$504.00

Service Code	CPT P9044
Hospital Charge Code	1221760
Hospital Revenue Code	390
Min. Negotiated Rate	$131.04
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of AZ Commercial	$453.60
Rate for Payer: Bisbee Police All Plans	$131.04
Rate for Payer: Cash Price	$403.20
Rate for Payer: Self Pay Self Pay	$403.20

Know your out-of-pocket cost for care.

All Charges