Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

PNT 1209072 Aspergillus AB

Facility

$404.00

Service Code	CPT 86606
Hospital Charge Code	23090944
Hospital Revenue Code	301
Min. Negotiated Rate	$105.04
Max. Negotiated Rate	$363.60
Rate for Payer: Aetna of AZ Commercial	$363.60
Rate for Payer: Bisbee Police All Plans	$105.04
Rate for Payer: Cash Price	$323.20
Rate for Payer: Self Pay Self Pay	$323.20

PNT Coccidiodies Abs IGG/IGM

Facility

$135.00

Service Code	CPT 86635
Hospital Charge Code	23090943
Hospital Revenue Code	301
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of AZ Commercial	$121.50
Rate for Payer: Bisbee Police All Plans	$35.10
Rate for Payer: Cash Price	$108.00
Rate for Payer: Self Pay Self Pay	$108.00

PNT Coccidiodies Abs IGG/IGM

Facility

$135.00

Service Code	CPT 86635
Hospital Charge Code	23090943
Hospital Revenue Code	301
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of AZ Commercial	$121.50
Rate for Payer: Aetna of AZ Medicare	$37.80
Rate for Payer: Allwell Medicare	$21.60
Rate for Payer: Amerigroup Medicare	$21.60
Rate for Payer: APIPA Medicare/Medicaid	$50.42
Rate for Payer: AZCH Complete Medicare	$21.60
Rate for Payer: Banner UC Health Medicare	$21.60
Rate for Payer: Bisbee Police All Plans	$35.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$91.80
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna of AZ Commercial	$87.75
Rate for Payer: Copperpoint Commercial	$33.41
Rate for Payer: Health Net of AZ Commercial	$81.00
Rate for Payer: Health Net of AZ Medicare	$37.80
Rate for Payer: Humana of AZ Medicare	$21.60
Rate for Payer: Self Pay Self Pay	$108.00
Rate for Payer: TriWest Medicare	$21.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$78.70
Rate for Payer: UnitedHealth Group of AZ Medicare	$24.30

PNT Non-Severe Hemophilia

Facility

$236.00

Service Code	CPT 80500
Hospital Charge Code	23090939
Hospital Revenue Code	301
Min. Negotiated Rate	$37.76
Max. Negotiated Rate	$212.40
Rate for Payer: Aetna of AZ Commercial	$212.40
Rate for Payer: Aetna of AZ Medicare	$66.08
Rate for Payer: Allwell Medicare	$37.76
Rate for Payer: Amerigroup Medicare	$37.76
Rate for Payer: APIPA Medicare/Medicaid	$88.15
Rate for Payer: AZCH Complete Medicare	$37.76
Rate for Payer: Banner UC Health Medicare	$37.76
Rate for Payer: Bisbee Police All Plans	$61.36
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$160.48
Rate for Payer: Cash Price	$188.80
Rate for Payer: Cigna of AZ Commercial	$153.40
Rate for Payer: Copperpoint Commercial	$58.41
Rate for Payer: Health Net of AZ Commercial	$141.60
Rate for Payer: Health Net of AZ Medicare	$66.08
Rate for Payer: Humana of AZ Medicare	$37.76
Rate for Payer: Self Pay Self Pay	$188.80
Rate for Payer: TriWest Medicare	$37.76
Rate for Payer: UnitedHealth Group of AZ Commercial	$137.59
Rate for Payer: UnitedHealth Group of AZ Medicare	$42.48

PNT Non-Severe Hemophilia

Facility

$236.00

Service Code	CPT 80500
Hospital Charge Code	23090939
Hospital Revenue Code	301
Min. Negotiated Rate	$61.36
Max. Negotiated Rate	$212.40
Rate for Payer: Aetna of AZ Commercial	$212.40
Rate for Payer: Bisbee Police All Plans	$61.36
Rate for Payer: Cash Price	$188.80
Rate for Payer: Self Pay Self Pay	$188.80

PNUMOTHORAX 14FR 29CM CATH KIT

Facility

$753.00

Hospital Charge Code	27987620
Hospital Revenue Code	270
Min. Negotiated Rate	$195.78
Max. Negotiated Rate	$677.70
Rate for Payer: Aetna of AZ Commercial	$677.70
Rate for Payer: Bisbee Police All Plans	$195.78
Rate for Payer: Cash Price	$602.40
Rate for Payer: Self Pay Self Pay	$602.40

PNUMOTHORAX 14FR 29CM CATH KIT

Facility

$753.00

Hospital Charge Code	27987620
Hospital Revenue Code	270
Min. Negotiated Rate	$120.48
Max. Negotiated Rate	$677.70
Rate for Payer: Aetna of AZ Commercial	$677.70
Rate for Payer: Aetna of AZ Medicare	$210.84
Rate for Payer: Allwell Medicare	$120.48
Rate for Payer: Amerigroup Medicare	$120.48
Rate for Payer: APIPA Medicare/Medicaid	$281.25
Rate for Payer: AZCH Complete Medicare	$120.48
Rate for Payer: Banner UC Health Medicare	$120.48
Rate for Payer: Bisbee Police All Plans	$195.78
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$512.04
Rate for Payer: Cash Price	$602.40
Rate for Payer: Cigna of AZ Commercial	$527.10
Rate for Payer: Copperpoint Commercial	$186.37
Rate for Payer: Health Net of AZ Commercial	$451.80
Rate for Payer: Health Net of AZ Medicare	$210.84
Rate for Payer: Humana of AZ Medicare	$120.48
Rate for Payer: Self Pay Self Pay	$602.40
Rate for Payer: TriWest Medicare	$120.48
Rate for Payer: UnitedHealth Group of AZ Commercial	$439.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$135.54

Poisoning Of Medicinal Agents

Facility

$9,939.54

Service Code	APR-DRG 8124
Hospital Charge Code	APRDRG8121
Min. Negotiated Rate	$9,939.54
Max. Negotiated Rate	$9,939.54
Rate for Payer: AHCCCS Medicaid	$9,939.54
Rate for Payer: Allwell Medicaid	$9,939.54
Rate for Payer: AZCH Complete Medicaid	$9,939.54
Rate for Payer: Banner UC Health Medicaid	$9,939.54
Rate for Payer: Mercy Care Medicaid	$9,939.54

Poisoning Of Medicinal Agents

Facility

$9,939.54

Service Code	APR-DRG 8124
Hospital Charge Code	APRDRG8123
Min. Negotiated Rate	$9,939.54
Max. Negotiated Rate	$9,939.54
Rate for Payer: AHCCCS Medicaid	$9,939.54
Rate for Payer: Allwell Medicaid	$9,939.54
Rate for Payer: AZCH Complete Medicaid	$9,939.54
Rate for Payer: Banner UC Health Medicaid	$9,939.54
Rate for Payer: Mercy Care Medicaid	$9,939.54

Poisoning Of Medicinal Agents

Facility

$3,462.81

Service Code	APR-DRG 8122
Hospital Charge Code	APRDRG8123
Min. Negotiated Rate	$3,462.81
Max. Negotiated Rate	$3,462.81
Rate for Payer: AHCCCS Medicaid	$3,462.81
Rate for Payer: Allwell Medicaid	$3,462.81
Rate for Payer: AZCH Complete Medicaid	$3,462.81
Rate for Payer: Banner UC Health Medicaid	$3,462.81
Rate for Payer: Mercy Care Medicaid	$3,462.81

Poisoning Of Medicinal Agents

Facility

$3,462.81

Service Code	APR-DRG 8122
Hospital Charge Code	APRDRG8121
Min. Negotiated Rate	$3,462.81
Max. Negotiated Rate	$3,462.81
Rate for Payer: AHCCCS Medicaid	$3,462.81
Rate for Payer: Allwell Medicaid	$3,462.81
Rate for Payer: AZCH Complete Medicaid	$3,462.81
Rate for Payer: Banner UC Health Medicaid	$3,462.81
Rate for Payer: Mercy Care Medicaid	$3,462.81

Poisoning Of Medicinal Agents

Facility

$5,178.44

Service Code	APR-DRG 8123
Hospital Charge Code	APRDRG8122
Min. Negotiated Rate	$5,178.44
Max. Negotiated Rate	$5,178.44
Rate for Payer: AHCCCS Medicaid	$5,178.44
Rate for Payer: Allwell Medicaid	$5,178.44
Rate for Payer: AZCH Complete Medicaid	$5,178.44
Rate for Payer: Banner UC Health Medicaid	$5,178.44
Rate for Payer: Mercy Care Medicaid	$5,178.44

Poisoning Of Medicinal Agents

Facility

$2,564.32

Service Code	APR-DRG 8121
Hospital Charge Code	APRDRG8121
Min. Negotiated Rate	$2,564.32
Max. Negotiated Rate	$2,564.32
Rate for Payer: AHCCCS Medicaid	$2,564.32
Rate for Payer: Allwell Medicaid	$2,564.32
Rate for Payer: AZCH Complete Medicaid	$2,564.32
Rate for Payer: Banner UC Health Medicaid	$2,564.32
Rate for Payer: Mercy Care Medicaid	$2,564.32

Poisoning Of Medicinal Agents

Facility

$9,939.54

Service Code	APR-DRG 8124
Hospital Charge Code	APRDRG8122
Min. Negotiated Rate	$9,939.54
Max. Negotiated Rate	$9,939.54
Rate for Payer: AHCCCS Medicaid	$9,939.54
Rate for Payer: Allwell Medicaid	$9,939.54
Rate for Payer: AZCH Complete Medicaid	$9,939.54
Rate for Payer: Banner UC Health Medicaid	$9,939.54
Rate for Payer: Mercy Care Medicaid	$9,939.54

Poisoning Of Medicinal Agents

Facility

$2,564.32

Service Code	APR-DRG 8121
Hospital Charge Code	APRDRG8124
Min. Negotiated Rate	$2,564.32
Max. Negotiated Rate	$2,564.32
Rate for Payer: AHCCCS Medicaid	$2,564.32
Rate for Payer: Allwell Medicaid	$2,564.32
Rate for Payer: AZCH Complete Medicaid	$2,564.32
Rate for Payer: Banner UC Health Medicaid	$2,564.32
Rate for Payer: Mercy Care Medicaid	$2,564.32

Poisoning Of Medicinal Agents

Facility

$2,564.32

Service Code	APR-DRG 8121
Hospital Charge Code	APRDRG8122
Min. Negotiated Rate	$2,564.32
Max. Negotiated Rate	$2,564.32
Rate for Payer: AHCCCS Medicaid	$2,564.32
Rate for Payer: Allwell Medicaid	$2,564.32
Rate for Payer: AZCH Complete Medicaid	$2,564.32
Rate for Payer: Banner UC Health Medicaid	$2,564.32
Rate for Payer: Mercy Care Medicaid	$2,564.32

Poisoning Of Medicinal Agents

Facility

$9,939.54

Service Code	APR-DRG 8124
Hospital Charge Code	APRDRG8124
Min. Negotiated Rate	$9,939.54
Max. Negotiated Rate	$9,939.54
Rate for Payer: AHCCCS Medicaid	$9,939.54
Rate for Payer: Allwell Medicaid	$9,939.54
Rate for Payer: AZCH Complete Medicaid	$9,939.54
Rate for Payer: Banner UC Health Medicaid	$9,939.54
Rate for Payer: Mercy Care Medicaid	$9,939.54

Poisoning Of Medicinal Agents

Facility

$5,178.44

Service Code	APR-DRG 8123
Hospital Charge Code	APRDRG8124
Min. Negotiated Rate	$5,178.44
Max. Negotiated Rate	$5,178.44
Rate for Payer: AHCCCS Medicaid	$5,178.44
Rate for Payer: Allwell Medicaid	$5,178.44
Rate for Payer: AZCH Complete Medicaid	$5,178.44
Rate for Payer: Banner UC Health Medicaid	$5,178.44
Rate for Payer: Mercy Care Medicaid	$5,178.44

Poisoning Of Medicinal Agents

Facility

$2,564.32

Service Code	APR-DRG 8121
Hospital Charge Code	APRDRG8123
Min. Negotiated Rate	$2,564.32
Max. Negotiated Rate	$2,564.32
Rate for Payer: AHCCCS Medicaid	$2,564.32
Rate for Payer: Allwell Medicaid	$2,564.32
Rate for Payer: AZCH Complete Medicaid	$2,564.32
Rate for Payer: Banner UC Health Medicaid	$2,564.32
Rate for Payer: Mercy Care Medicaid	$2,564.32

Poisoning Of Medicinal Agents

Facility

$3,462.81

Service Code	APR-DRG 8122
Hospital Charge Code	APRDRG8124
Min. Negotiated Rate	$3,462.81
Max. Negotiated Rate	$3,462.81
Rate for Payer: AHCCCS Medicaid	$3,462.81
Rate for Payer: Allwell Medicaid	$3,462.81
Rate for Payer: AZCH Complete Medicaid	$3,462.81
Rate for Payer: Banner UC Health Medicaid	$3,462.81
Rate for Payer: Mercy Care Medicaid	$3,462.81

Poisoning Of Medicinal Agents

Facility

$3,462.81

Service Code	APR-DRG 8122
Hospital Charge Code	APRDRG8122
Min. Negotiated Rate	$3,462.81
Max. Negotiated Rate	$3,462.81
Rate for Payer: AHCCCS Medicaid	$3,462.81
Rate for Payer: Allwell Medicaid	$3,462.81
Rate for Payer: AZCH Complete Medicaid	$3,462.81
Rate for Payer: Banner UC Health Medicaid	$3,462.81
Rate for Payer: Mercy Care Medicaid	$3,462.81

Poisoning Of Medicinal Agents

Facility

$5,178.44

Service Code	APR-DRG 8123
Hospital Charge Code	APRDRG8121
Min. Negotiated Rate	$5,178.44
Max. Negotiated Rate	$5,178.44
Rate for Payer: AHCCCS Medicaid	$5,178.44
Rate for Payer: Allwell Medicaid	$5,178.44
Rate for Payer: AZCH Complete Medicaid	$5,178.44
Rate for Payer: Banner UC Health Medicaid	$5,178.44
Rate for Payer: Mercy Care Medicaid	$5,178.44

Poisoning Of Medicinal Agents

Facility

$5,178.44

Service Code	APR-DRG 8123
Hospital Charge Code	APRDRG8123
Min. Negotiated Rate	$5,178.44
Max. Negotiated Rate	$5,178.44
Rate for Payer: AHCCCS Medicaid	$5,178.44
Rate for Payer: Allwell Medicaid	$5,178.44
Rate for Payer: AZCH Complete Medicaid	$5,178.44
Rate for Payer: Banner UC Health Medicaid	$5,178.44
Rate for Payer: Mercy Care Medicaid	$5,178.44

polyethylene glycol 3350 17 GmOral Pwdr [CQCH]

Facility

$0.87

Service Code	NDC 11523726803
Hospital Charge Code	105964541
Hospital Revenue Code	251
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.78
Rate for Payer: Aetna of AZ Commercial	$0.78
Rate for Payer: Aetna of AZ Medicare	$0.24
Rate for Payer: Allwell Medicare	$0.14
Rate for Payer: Amerigroup Medicare	$0.14
Rate for Payer: APIPA Medicare/Medicaid	$0.32
Rate for Payer: AZCH Complete Medicare	$0.14
Rate for Payer: Banner UC Health Medicare	$0.14
Rate for Payer: Bisbee Police All Plans	$0.23
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.59
Rate for Payer: Cash Price	$0.70
Rate for Payer: Cigna of AZ Commercial	$0.57
Rate for Payer: Copperpoint Commercial	$0.22
Rate for Payer: Health Net of AZ Commercial	$0.52
Rate for Payer: Health Net of AZ Medicare	$0.24
Rate for Payer: Humana of AZ Medicare	$0.14
Rate for Payer: Self Pay Self Pay	$0.70
Rate for Payer: TriWest Medicare	$0.14
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.51
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.16

polyethylene glycol 3350 17 GmOral Pwdr [CQCH]

Facility

$0.87

Service Code	NDC 11523726803
Hospital Charge Code	105964541
Hospital Revenue Code	251
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.78
Rate for Payer: Aetna of AZ Commercial	$0.78
Rate for Payer: Bisbee Police All Plans	$0.23
Rate for Payer: Cash Price	$0.70
Rate for Payer: Self Pay Self Pay	$0.70

Know your out-of-pocket cost for care.

All Charges