Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

predniSONE 20 mg Tab [CQCH]

Facility

$0.13

Service Code	HCPCS J7510
Hospital Charge Code	105937930
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Aetna of AZ Medicare	$0.04
Rate for Payer: Allwell Medicare	$0.02
Rate for Payer: Amerigroup Medicare	$0.02
Rate for Payer: APIPA Medicare/Medicaid	$0.05
Rate for Payer: AZCH Complete Medicare	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Bisbee Police All Plans	$0.03
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.09
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of AZ Commercial	$0.08
Rate for Payer: Copperpoint Commercial	$0.03
Rate for Payer: Health Net of AZ Commercial	$0.08
Rate for Payer: Health Net of AZ Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Self Pay Self Pay	$0.10
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.08
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.02

predniSONE 20 mg Tab [CQCH]

Facility

$0.13

Service Code	HCPCS J7510
Hospital Charge Code	105937930
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Bisbee Police All Plans	$0.03
Rate for Payer: Cash Price	$0.10
Rate for Payer: Self Pay Self Pay	$0.10

predniSONE 5 mg Tab [CQCH]

Facility

$0.14

Service Code	HCPCS J7510
Hospital Charge Code	105937719
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of AZ Commercial	$0.13
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Cash Price	$0.11
Rate for Payer: Self Pay Self Pay	$0.11

predniSONE 5 mg Tab [CQCH]

Facility

$0.14

Service Code	HCPCS J7510
Hospital Charge Code	105937719
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of AZ Commercial	$0.13
Rate for Payer: Aetna of AZ Medicare	$0.04
Rate for Payer: Allwell Medicare	$0.02
Rate for Payer: Amerigroup Medicare	$0.02
Rate for Payer: APIPA Medicare/Medicaid	$0.05
Rate for Payer: AZCH Complete Medicare	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.10
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of AZ Commercial	$0.09
Rate for Payer: Copperpoint Commercial	$0.03
Rate for Payer: Health Net of AZ Commercial	$0.08
Rate for Payer: Health Net of AZ Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Self Pay Self Pay	$0.11
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.08
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.03

pregabalin 50 mg oral cap [CQCH]

Facility

$0.41

Service Code	NDC 904699261
Hospital Charge Code	105937999
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	$0.32
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

pregabalin 50 mg oral cap [CQCH]

Facility

$0.41

Service Code	NDC 904699261
Hospital Charge Code	105937999
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	$0.32
Rate for Payer: Self Pay Self Pay	$0.33

PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A)

Facility

$114.00

Service Code	CPT 84163
Hospital Charge Code	23296930
Hospital Revenue Code	301
Min. Negotiated Rate	$18.24
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of AZ Commercial	$102.60
Rate for Payer: Aetna of AZ Medicare	$31.92
Rate for Payer: Allwell Medicare	$18.24
Rate for Payer: Amerigroup Medicare	$18.24
Rate for Payer: APIPA Medicare/Medicaid	$42.58
Rate for Payer: AZCH Complete Medicare	$18.24
Rate for Payer: Banner UC Health Medicare	$18.24
Rate for Payer: Bisbee Police All Plans	$29.64
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$77.52
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cigna of AZ Commercial	$74.10
Rate for Payer: Copperpoint Commercial	$28.21
Rate for Payer: Health Net of AZ Commercial	$68.40
Rate for Payer: Health Net of AZ Medicare	$31.92
Rate for Payer: Humana of AZ Medicare	$18.24
Rate for Payer: Self Pay Self Pay	$91.20
Rate for Payer: TriWest Medicare	$18.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$66.46
Rate for Payer: UnitedHealth Group of AZ Medicare	$20.52

PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A)

Facility

$109.00

Service Code	CPT 84163
Hospital Charge Code	23294372
Hospital Revenue Code	301
Min. Negotiated Rate	$17.44
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Aetna of AZ Medicare	$30.52
Rate for Payer: Allwell Medicare	$17.44
Rate for Payer: Amerigroup Medicare	$17.44
Rate for Payer: APIPA Medicare/Medicaid	$40.71
Rate for Payer: AZCH Complete Medicare	$17.44
Rate for Payer: Banner UC Health Medicare	$17.44
Rate for Payer: Bisbee Police All Plans	$28.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$74.12
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cigna of AZ Commercial	$70.85
Rate for Payer: Copperpoint Commercial	$26.98
Rate for Payer: Health Net of AZ Commercial	$65.40
Rate for Payer: Health Net of AZ Medicare	$30.52
Rate for Payer: Humana of AZ Medicare	$17.44
Rate for Payer: Self Pay Self Pay	$87.20
Rate for Payer: TriWest Medicare	$17.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$63.55
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.62

PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A)

Facility

$114.00

Service Code	CPT 84163
Hospital Charge Code	23296930
Hospital Revenue Code	301
Min. Negotiated Rate	$29.64
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of AZ Commercial	$102.60
Rate for Payer: Bisbee Police All Plans	$29.64
Rate for Payer: Cash Price	$91.20
Rate for Payer: Self Pay Self Pay	$91.20

PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A)

Facility

$109.00

Service Code	CPT 84163
Hospital Charge Code	23294372
Hospital Revenue Code	301
Min. Negotiated Rate	$28.34
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Bisbee Police All Plans	$28.34
Rate for Payer: Cash Price	$87.20
Rate for Payer: Self Pay Self Pay	$87.20

Pregnancy Test Serum 1

Facility

$15.00

Service Code	CPT 84703
Hospital Charge Code	9579719
Hospital Revenue Code	301
Min. Negotiated Rate	$3.90
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of AZ Commercial	$13.50
Rate for Payer: Bisbee Police All Plans	$3.90
Rate for Payer: Cash Price	$12.00
Rate for Payer: Self Pay Self Pay	$12.00

Pregnancy Test Serum 1

Facility

$15.00

Service Code	CPT 84703
Hospital Charge Code	9579719
Hospital Revenue Code	301
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of AZ Commercial	$13.50
Rate for Payer: Aetna of AZ Medicare	$4.20
Rate for Payer: Allwell Medicare	$2.40
Rate for Payer: Amerigroup Medicare	$2.40
Rate for Payer: APIPA Medicare/Medicaid	$5.60
Rate for Payer: AZCH Complete Medicare	$2.40
Rate for Payer: Banner UC Health Medicare	$2.40
Rate for Payer: Bisbee Police All Plans	$3.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$10.20
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cigna of AZ Commercial	$9.75
Rate for Payer: Copperpoint Commercial	$3.71
Rate for Payer: Health Net of AZ Commercial	$9.00
Rate for Payer: Health Net of AZ Medicare	$4.20
Rate for Payer: Humana of AZ Medicare	$2.40
Rate for Payer: Self Pay Self Pay	$12.00
Rate for Payer: TriWest Medicare	$2.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$8.74
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.70

Pregnancy Test Urine 1

Facility

$151.00

Service Code	CPT 81025
Hospital Charge Code	9579720
Hospital Revenue Code	300
Min. Negotiated Rate	$24.16
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of AZ Commercial	$135.90
Rate for Payer: Aetna of AZ Medicare	$42.28
Rate for Payer: Allwell Medicare	$24.16
Rate for Payer: Amerigroup Medicare	$24.16
Rate for Payer: APIPA Medicare/Medicaid	$56.40
Rate for Payer: AZCH Complete Medicare	$24.16
Rate for Payer: Banner UC Health Medicare	$24.16
Rate for Payer: Bisbee Police All Plans	$39.26
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$102.68
Rate for Payer: Cash Price	$120.80
Rate for Payer: Cigna of AZ Commercial	$98.15
Rate for Payer: Copperpoint Commercial	$37.37
Rate for Payer: Health Net of AZ Commercial	$90.60
Rate for Payer: Health Net of AZ Medicare	$42.28
Rate for Payer: Humana of AZ Medicare	$24.16
Rate for Payer: Self Pay Self Pay	$120.80
Rate for Payer: TriWest Medicare	$24.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$88.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$27.18

Pregnancy Test Urine 1

Facility

$151.00

Service Code	CPT 81025
Hospital Charge Code	9579720
Hospital Revenue Code	300
Min. Negotiated Rate	$39.26
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of AZ Commercial	$135.90
Rate for Payer: Bisbee Police All Plans	$39.26
Rate for Payer: Cash Price	$120.80
Rate for Payer: Self Pay Self Pay	$120.80

PRESS PATCH

Facility

$38.00

Hospital Charge Code	22355154
Hospital Revenue Code	270
Min. Negotiated Rate	$6.08
Max. Negotiated Rate	$34.20
Rate for Payer: Aetna of AZ Commercial	$34.20
Rate for Payer: Aetna of AZ Medicare	$10.64
Rate for Payer: Allwell Medicare	$6.08
Rate for Payer: Amerigroup Medicare	$6.08
Rate for Payer: APIPA Medicare/Medicaid	$14.19
Rate for Payer: AZCH Complete Medicare	$6.08
Rate for Payer: Banner UC Health Medicare	$6.08
Rate for Payer: Bisbee Police All Plans	$9.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$25.84
Rate for Payer: Cash Price	$30.40
Rate for Payer: Cigna of AZ Commercial	$26.60
Rate for Payer: Copperpoint Commercial	$9.40
Rate for Payer: Health Net of AZ Commercial	$22.80
Rate for Payer: Health Net of AZ Medicare	$10.64
Rate for Payer: Humana of AZ Medicare	$6.08
Rate for Payer: Self Pay Self Pay	$30.40
Rate for Payer: TriWest Medicare	$6.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$22.15
Rate for Payer: UnitedHealth Group of AZ Medicare	$6.84

PRESS PATCH

Facility

$38.00

Hospital Charge Code	22355154
Hospital Revenue Code	270
Min. Negotiated Rate	$9.88
Max. Negotiated Rate	$34.20
Rate for Payer: Aetna of AZ Commercial	$34.20
Rate for Payer: Bisbee Police All Plans	$9.88
Rate for Payer: Cash Price	$30.40
Rate for Payer: Self Pay Self Pay	$30.40

primidone 50 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 603537121
Hospital Charge Code	105938066
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
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	$0.02
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	$0.04
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of AZ Commercial	$0.04
Rate for Payer: Copperpoint Commercial	$0.01
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	$0.05
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

primidone 50 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 603537121
Hospital Charge Code	105938066
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Cash Price	$0.05
Rate for Payer: Self Pay Self Pay	$0.05

Primidone (Mysoline), Serum LC

Facility

$319.00

Service Code	CPT 80188
Hospital Charge Code	1285610
Hospital Revenue Code	301
Min. Negotiated Rate	$51.04
Max. Negotiated Rate	$287.10
Rate for Payer: Aetna of AZ Commercial	$287.10
Rate for Payer: Aetna of AZ Medicare	$89.32
Rate for Payer: Allwell Medicare	$51.04
Rate for Payer: Amerigroup Medicare	$51.04
Rate for Payer: APIPA Medicare/Medicaid	$119.15
Rate for Payer: AZCH Complete Medicare	$51.04
Rate for Payer: Banner UC Health Medicare	$51.04
Rate for Payer: Bisbee Police All Plans	$82.94
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$216.92
Rate for Payer: Cash Price	$255.20
Rate for Payer: Cigna of AZ Commercial	$207.35
Rate for Payer: Copperpoint Commercial	$78.95
Rate for Payer: Health Net of AZ Commercial	$191.40
Rate for Payer: Health Net of AZ Medicare	$89.32
Rate for Payer: Humana of AZ Medicare	$51.04
Rate for Payer: Self Pay Self Pay	$255.20
Rate for Payer: TriWest Medicare	$51.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$185.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$57.42

Primidone (Mysoline), Serum LC

Facility

$319.00

Service Code	CPT 80188
Hospital Charge Code	1285610
Hospital Revenue Code	301
Min. Negotiated Rate	$82.94
Max. Negotiated Rate	$287.10
Rate for Payer: Aetna of AZ Commercial	$287.10
Rate for Payer: Bisbee Police All Plans	$82.94
Rate for Payer: Cash Price	$255.20
Rate for Payer: Self Pay Self Pay	$255.20

PROBE PULSE OX PED/ADULT NOVAMETRIX

Facility

$101.00

Hospital Charge Code	22355401
Hospital Revenue Code	270
Min. Negotiated Rate	$26.26
Max. Negotiated Rate	$90.90
Rate for Payer: Aetna of AZ Commercial	$90.90
Rate for Payer: Bisbee Police All Plans	$26.26
Rate for Payer: Cash Price	$80.80
Rate for Payer: Self Pay Self Pay	$80.80

PROBE PULSE OX PED/ADULT NOVAMETRIX

Facility

$101.00

Hospital Charge Code	22355401
Hospital Revenue Code	270
Min. Negotiated Rate	$16.16
Max. Negotiated Rate	$90.90
Rate for Payer: Aetna of AZ Commercial	$90.90
Rate for Payer: Aetna of AZ Medicare	$28.28
Rate for Payer: Allwell Medicare	$16.16
Rate for Payer: Amerigroup Medicare	$16.16
Rate for Payer: APIPA Medicare/Medicaid	$37.72
Rate for Payer: AZCH Complete Medicare	$16.16
Rate for Payer: Banner UC Health Medicare	$16.16
Rate for Payer: Bisbee Police All Plans	$26.26
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$68.68
Rate for Payer: Cash Price	$80.80
Rate for Payer: Cigna of AZ Commercial	$70.70
Rate for Payer: Copperpoint Commercial	$25.00
Rate for Payer: Health Net of AZ Commercial	$60.60
Rate for Payer: Health Net of AZ Medicare	$28.28
Rate for Payer: Humana of AZ Medicare	$16.16
Rate for Payer: Self Pay Self Pay	$80.80
Rate for Payer: TriWest Medicare	$16.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$58.88
Rate for Payer: UnitedHealth Group of AZ Medicare	$18.18

proBNP LC

Facility

$124.00

Service Code	CPT 83880
Hospital Charge Code	1285628
Hospital Revenue Code	301
Min. Negotiated Rate	$19.84
Max. Negotiated Rate	$111.60
Rate for Payer: Aetna of AZ Commercial	$111.60
Rate for Payer: Aetna of AZ Medicare	$34.72
Rate for Payer: Allwell Medicare	$19.84
Rate for Payer: Amerigroup Medicare	$19.84
Rate for Payer: APIPA Medicare/Medicaid	$46.31
Rate for Payer: AZCH Complete Medicare	$19.84
Rate for Payer: Banner UC Health Medicare	$19.84
Rate for Payer: Bisbee Police All Plans	$32.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$84.32
Rate for Payer: Cash Price	$99.20
Rate for Payer: Cigna of AZ Commercial	$80.60
Rate for Payer: Copperpoint Commercial	$30.69
Rate for Payer: Health Net of AZ Commercial	$74.40
Rate for Payer: Health Net of AZ Medicare	$34.72
Rate for Payer: Humana of AZ Medicare	$19.84
Rate for Payer: Self Pay Self Pay	$99.20
Rate for Payer: TriWest Medicare	$19.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$72.29
Rate for Payer: UnitedHealth Group of AZ Medicare	$22.32

proBNP LC

Facility

$124.00

Service Code	CPT 83880
Hospital Charge Code	1285628
Hospital Revenue Code	301
Min. Negotiated Rate	$32.24
Max. Negotiated Rate	$111.60
Rate for Payer: Aetna of AZ Commercial	$111.60
Rate for Payer: Bisbee Police All Plans	$32.24
Rate for Payer: Cash Price	$99.20
Rate for Payer: Self Pay Self Pay	$99.20

procainamide 100 mg/mL Sol[CQCH]

Facility

$6.03

Service Code	HCPCS J2690
Hospital Charge Code	135202939
Hospital Revenue Code	250
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$5.43
Rate for Payer: Aetna of AZ Commercial	$5.43
Rate for Payer: Aetna of AZ Medicare	$1.69
Rate for Payer: Allwell Medicare	$0.96
Rate for Payer: Amerigroup Medicare	$0.96
Rate for Payer: APIPA Medicare/Medicaid	$2.25
Rate for Payer: AZCH Complete Medicare	$0.96
Rate for Payer: Banner UC Health Medicare	$0.96
Rate for Payer: Bisbee Police All Plans	$1.57
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$4.10
Rate for Payer: Cash Price	$4.82
Rate for Payer: Cigna of AZ Commercial	$3.92
Rate for Payer: Copperpoint Commercial	$1.49
Rate for Payer: Health Net of AZ Commercial	$3.62
Rate for Payer: Health Net of AZ Medicare	$1.69
Rate for Payer: Humana of AZ Medicare	$0.96
Rate for Payer: Self Pay Self Pay	$4.82
Rate for Payer: TriWest Medicare	$0.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$3.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.09

Know your out-of-pocket cost for care.

All Charges