Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

promethazine 25 mg Supp [CQCH]

Facility

$3.03

Service Code	NDC 45802075930
Hospital Charge Code	105938401
Hospital Revenue Code	251
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$2.73
Rate for Payer: Aetna of AZ Commercial	$2.73
Rate for Payer: Bisbee Police All Plans	$0.79
Rate for Payer: Cash Price	$2.42
Rate for Payer: Self Pay Self Pay	$2.42

promethazine 25 mg Tab [CQCH]

Facility

$0.11

Service Code	HCPCS Q0169
Hospital Charge Code	105938332
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of AZ Commercial	$0.10
Rate for Payer: Aetna of AZ Medicare	$0.03
Rate for Payer: Allwell Medicare	$0.02
Rate for Payer: Amerigroup Medicare	$0.02
Rate for Payer: APIPA Medicare/Medicaid	$0.04
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	$0.07
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of AZ Commercial	$0.07
Rate for Payer: Copperpoint Commercial	$0.03
Rate for Payer: Health Net of AZ Commercial	$0.07
Rate for Payer: Health Net of AZ Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Self Pay Self Pay	$0.09
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.06
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.02

promethazine 25 mg Tab [CQCH]

Facility

$0.11

Service Code	HCPCS Q0169
Hospital Charge Code	105938332
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of AZ Commercial	$0.10
Rate for Payer: Bisbee Police All Plans	$0.03
Rate for Payer: Cash Price	$0.09
Rate for Payer: Self Pay Self Pay	$0.09

promethazine-dextromethorphan-6.25-15mg mg/5 mL Oral Syrup 118 mL [CQCH]

Facility

$0.06

Service Code	NDC 60432060416
Hospital Charge Code	105918225
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	$0.04
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

promethazine-dextromethorphan-6.25-15mg mg/5 mL Oral Syrup 118 mL [CQCH]

Facility

$0.06

Service Code	NDC 60432060416
Hospital Charge Code	105918225
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	$0.04
Rate for Payer: Self Pay Self Pay	$0.05

propafenone 150 mg Tab UD [CQCH]

Facility

$0.17

Service Code	NDC 603544821
Hospital Charge Code	109867534
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
Rate for Payer: Aetna of AZ Medicare	$0.05
Rate for Payer: Allwell Medicare	$0.03
Rate for Payer: Amerigroup Medicare	$0.03
Rate for Payer: APIPA Medicare/Medicaid	$0.06
Rate for Payer: AZCH Complete Medicare	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.12
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of AZ Commercial	$0.11
Rate for Payer: Copperpoint Commercial	$0.04
Rate for Payer: Health Net of AZ Commercial	$0.10
Rate for Payer: Health Net of AZ Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Self Pay Self Pay	$0.14
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.10
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.03

propafenone 150 mg Tab UD [CQCH]

Facility

$0.17

Service Code	NDC 603544821
Hospital Charge Code	109867534
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Cash Price	$0.14
Rate for Payer: Self Pay Self Pay	$0.14

proparacaine Ophth 0.5% Sol [CQCH]

Facility

$2.17

Service Code	NDC 24208073006
Hospital Charge Code	105938535
Hospital Revenue Code	251
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna of AZ Commercial	$1.95
Rate for Payer: Bisbee Police All Plans	$0.56
Rate for Payer: Cash Price	$1.74
Rate for Payer: Self Pay Self Pay	$1.74

proparacaine Ophth 0.5% Sol [CQCH]

Facility

$2.17

Service Code	NDC 24208073006
Hospital Charge Code	105938535
Hospital Revenue Code	251
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna of AZ Commercial	$1.95
Rate for Payer: Aetna of AZ Medicare	$0.61
Rate for Payer: Allwell Medicare	$0.35
Rate for Payer: Amerigroup Medicare	$0.35
Rate for Payer: APIPA Medicare/Medicaid	$0.81
Rate for Payer: AZCH Complete Medicare	$0.35
Rate for Payer: Banner UC Health Medicare	$0.35
Rate for Payer: Bisbee Police All Plans	$0.56
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.48
Rate for Payer: Cash Price	$1.74
Rate for Payer: Cigna of AZ Commercial	$1.41
Rate for Payer: Copperpoint Commercial	$0.54
Rate for Payer: Health Net of AZ Commercial	$1.30
Rate for Payer: Health Net of AZ Medicare	$0.61
Rate for Payer: Humana of AZ Medicare	$0.35
Rate for Payer: Self Pay Self Pay	$1.74
Rate for Payer: TriWest Medicare	$0.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.27
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.39

propofol 1000mg/100ml Emu (premix)(CQCH)

Facility

$0.08

Service Code	HCPCS J2704
Hospital Charge Code	121933170
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Cash Price	$0.07
Rate for Payer: Self Pay Self Pay	$0.06

propofol 1000mg/100ml Emu (premix)(CQCH)

Facility

$0.08

Service Code	HCPCS J2704
Hospital Charge Code	121933170
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
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	$0.07
Rate for Payer: Cigna of AZ Commercial	$0.05
Rate for Payer: Copperpoint Commercial	$0.02
Rate for Payer: Health Net of AZ Commercial	$0.05
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	$0.05
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

propofol 200 mg/20 mL IV Emul [CQCH]

Facility

$0.10

Service Code	HCPCS J2704
Hospital Charge Code	105938600
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of AZ Commercial	$0.09
Rate for Payer: Bisbee Police All Plans	$0.03
Rate for Payer: Cash Price	$0.08
Rate for Payer: Self Pay Self Pay	$0.08

propofol 200 mg/20 mL IV Emul [CQCH]

Facility

$0.10

Service Code	HCPCS J2704
Hospital Charge Code	105938600
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of AZ Commercial	$0.09
Rate for Payer: Aetna of AZ Medicare	$0.03
Rate for Payer: Allwell Medicare	$0.02
Rate for Payer: Amerigroup Medicare	$0.02
Rate for Payer: APIPA Medicare/Medicaid	$0.04
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	$0.07
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of AZ Commercial	$0.07
Rate for Payer: Copperpoint Commercial	$0.02
Rate for Payer: Health Net of AZ Commercial	$0.06
Rate for Payer: Health Net of AZ Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Self Pay Self Pay	$0.08
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.06
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.02

propranolol 20 mg Tab [CQCH]

Facility

$0.45

Service Code	NDC 60687059801
Hospital Charge Code	105953054
Hospital Revenue Code	251
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of AZ Commercial	$0.41
Rate for Payer: Bisbee Police All Plans	$0.12
Rate for Payer: Cash Price	$0.36
Rate for Payer: Self Pay Self Pay	$0.36

propranolol 20 mg Tab [CQCH]

Facility

$0.45

Service Code	NDC 60687059801
Hospital Charge Code	105953054
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of AZ Commercial	$0.41
Rate for Payer: Aetna of AZ Medicare	$0.13
Rate for Payer: Allwell Medicare	$0.07
Rate for Payer: Amerigroup Medicare	$0.07
Rate for Payer: APIPA Medicare/Medicaid	$0.17
Rate for Payer: AZCH Complete Medicare	$0.07
Rate for Payer: Banner UC Health Medicare	$0.07
Rate for Payer: Bisbee Police All Plans	$0.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.31
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of AZ Commercial	$0.29
Rate for Payer: Copperpoint Commercial	$0.11
Rate for Payer: Health Net of AZ Commercial	$0.27
Rate for Payer: Health Net of AZ Medicare	$0.13
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Self Pay Self Pay	$0.36
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.26
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.08

protamine 250 mg/25 mL Inj Sol [CQCH]

Facility

$1.32

Service Code	HCPCS J2720
Hospital Charge Code	105938671
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$1.19
Rate for Payer: Aetna of AZ Commercial	$1.19
Rate for Payer: Aetna of AZ Medicare	$0.37
Rate for Payer: Allwell Medicare	$0.21
Rate for Payer: Amerigroup Medicare	$0.21
Rate for Payer: APIPA Medicare/Medicaid	$0.49
Rate for Payer: AZCH Complete Medicare	$0.21
Rate for Payer: Banner UC Health Medicare	$0.21
Rate for Payer: Bisbee Police All Plans	$0.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.90
Rate for Payer: Cash Price	$1.06
Rate for Payer: Cigna of AZ Commercial	$0.86
Rate for Payer: Copperpoint Commercial	$0.33
Rate for Payer: Health Net of AZ Commercial	$0.79
Rate for Payer: Health Net of AZ Medicare	$0.37
Rate for Payer: Humana of AZ Medicare	$0.21
Rate for Payer: Self Pay Self Pay	$1.06
Rate for Payer: TriWest Medicare	$0.21
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.77
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.24

protamine 250 mg/25 mL Inj Sol [CQCH]

Facility

$1.32

Service Code	HCPCS J2720
Hospital Charge Code	105938671
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$1.19
Rate for Payer: Aetna of AZ Commercial	$1.19
Rate for Payer: Bisbee Police All Plans	$0.34
Rate for Payer: Cash Price	$1.06
Rate for Payer: Self Pay Self Pay	$1.06

Protein 24 Hour Urine

Facility

$71.00

Service Code	CPT 84133
Hospital Charge Code	633811
Hospital Revenue Code	301
Min. Negotiated Rate	$18.46
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Bisbee Police All Plans	$18.46
Rate for Payer: Cash Price	$56.80
Rate for Payer: Self Pay Self Pay	$56.80

Protein 24 Hour Urine

Facility

$71.00

Service Code	CPT 84133
Hospital Charge Code	633811
Hospital Revenue Code	301
Min. Negotiated Rate	$11.36
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Aetna of AZ Medicare	$19.88
Rate for Payer: Allwell Medicare	$11.36
Rate for Payer: Amerigroup Medicare	$11.36
Rate for Payer: APIPA Medicare/Medicaid	$26.52
Rate for Payer: AZCH Complete Medicare	$11.36
Rate for Payer: Banner UC Health Medicare	$11.36
Rate for Payer: Bisbee Police All Plans	$18.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$48.28
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cigna of AZ Commercial	$46.15
Rate for Payer: Copperpoint Commercial	$17.57
Rate for Payer: Health Net of AZ Commercial	$42.60
Rate for Payer: Health Net of AZ Medicare	$19.88
Rate for Payer: Humana of AZ Medicare	$11.36
Rate for Payer: Self Pay Self Pay	$56.80
Rate for Payer: TriWest Medicare	$11.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$41.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.78

Protein C Activity (Chrom) LC

Facility

$163.00

Service Code	CPT 85303
Hospital Charge Code	6781142
Hospital Revenue Code	301
Min. Negotiated Rate	$26.08
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Aetna of AZ Medicare	$45.64
Rate for Payer: Allwell Medicare	$26.08
Rate for Payer: Amerigroup Medicare	$26.08
Rate for Payer: APIPA Medicare/Medicaid	$60.88
Rate for Payer: AZCH Complete Medicare	$26.08
Rate for Payer: Banner UC Health Medicare	$26.08
Rate for Payer: Bisbee Police All Plans	$42.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$110.84
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cigna of AZ Commercial	$105.95
Rate for Payer: Copperpoint Commercial	$40.34
Rate for Payer: Health Net of AZ Commercial	$97.80
Rate for Payer: Health Net of AZ Medicare	$45.64
Rate for Payer: Humana of AZ Medicare	$26.08
Rate for Payer: Self Pay Self Pay	$130.40
Rate for Payer: TriWest Medicare	$26.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$95.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$29.34

Protein C Activity (Chrom) LC

Facility

$163.00

Service Code	CPT 85303
Hospital Charge Code	6781142
Hospital Revenue Code	301
Min. Negotiated Rate	$42.38
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Bisbee Police All Plans	$42.38
Rate for Payer: Cash Price	$130.40
Rate for Payer: Self Pay Self Pay	$130.40

Protein C Deficiency Profile LC

Facility

$406.00

Service Code	CPT 85302
Hospital Charge Code	2087638
Hospital Revenue Code	305
Min. Negotiated Rate	$105.56
Max. Negotiated Rate	$365.40
Rate for Payer: Aetna of AZ Commercial	$365.40
Rate for Payer: Bisbee Police All Plans	$105.56
Rate for Payer: Cash Price	$324.80
Rate for Payer: Self Pay Self Pay	$324.80

Protein C Deficiency Profile LC

Facility

$406.00

Service Code	CPT 85302
Hospital Charge Code	2087638
Hospital Revenue Code	305
Min. Negotiated Rate	$64.96
Max. Negotiated Rate	$365.40
Rate for Payer: Aetna of AZ Commercial	$365.40
Rate for Payer: Aetna of AZ Medicare	$113.68
Rate for Payer: Allwell Medicare	$64.96
Rate for Payer: Amerigroup Medicare	$64.96
Rate for Payer: APIPA Medicare/Medicaid	$151.64
Rate for Payer: AZCH Complete Medicare	$64.96
Rate for Payer: Banner UC Health Medicare	$64.96
Rate for Payer: Bisbee Police All Plans	$105.56
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$276.08
Rate for Payer: Cash Price	$324.80
Rate for Payer: Cigna of AZ Commercial	$263.90
Rate for Payer: Copperpoint Commercial	$100.48
Rate for Payer: Health Net of AZ Commercial	$243.60
Rate for Payer: Health Net of AZ Medicare	$113.68
Rate for Payer: Humana of AZ Medicare	$64.96
Rate for Payer: Self Pay Self Pay	$324.80
Rate for Payer: TriWest Medicare	$64.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$236.70
Rate for Payer: UnitedHealth Group of AZ Medicare	$73.08

Protein Electro, 24-Hour Urine LC

Facility

$768.00

Service Code	CPT 84166
Hospital Charge Code	1285721
Hospital Revenue Code	301
Min. Negotiated Rate	$199.68
Max. Negotiated Rate	$691.20
Rate for Payer: Aetna of AZ Commercial	$691.20
Rate for Payer: Bisbee Police All Plans	$199.68
Rate for Payer: Cash Price	$614.40
Rate for Payer: Self Pay Self Pay	$614.40

Protein Electro, 24-Hour Urine LC

Facility

$768.00

Service Code	CPT 84166
Hospital Charge Code	1285721
Hospital Revenue Code	301
Min. Negotiated Rate	$122.88
Max. Negotiated Rate	$691.20
Rate for Payer: Aetna of AZ Commercial	$691.20
Rate for Payer: Aetna of AZ Medicare	$215.04
Rate for Payer: Allwell Medicare	$122.88
Rate for Payer: Amerigroup Medicare	$122.88
Rate for Payer: APIPA Medicare/Medicaid	$286.85
Rate for Payer: AZCH Complete Medicare	$122.88
Rate for Payer: Banner UC Health Medicare	$122.88
Rate for Payer: Bisbee Police All Plans	$199.68
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$522.24
Rate for Payer: Cash Price	$614.40
Rate for Payer: Cigna of AZ Commercial	$499.20
Rate for Payer: Copperpoint Commercial	$190.08
Rate for Payer: Health Net of AZ Commercial	$460.80
Rate for Payer: Health Net of AZ Medicare	$215.04
Rate for Payer: Humana of AZ Medicare	$122.88
Rate for Payer: Self Pay Self Pay	$614.40
Rate for Payer: TriWest Medicare	$122.88
Rate for Payer: UnitedHealth Group of AZ Commercial	$447.74
Rate for Payer: UnitedHealth Group of AZ Medicare	$138.24

Know your out-of-pocket cost for care.

All Charges