Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Salicylate Level

Facility

$189.00

Service Code	CPT G0480
Hospital Charge Code	633829
Hospital Revenue Code	301
Min. Negotiated Rate	$28.35
Max. Negotiated Rate	$228.86
Rate for Payer: Aetna of AZ Commercial	$170.10
Rate for Payer: Aetna of AZ Medicare	$52.92
Rate for Payer: AHCCCS Medicaid	$228.86
Rate for Payer: Allwell Medicaid	$228.86
Rate for Payer: Allwell Medicare	$28.35
Rate for Payer: Amerigroup Medicare	$28.35
Rate for Payer: APIPA Medicare/Medicaid	$70.59
Rate for Payer: AZCH Complete Medicaid	$228.86
Rate for Payer: AZCH Complete Medicare	$28.35
Rate for Payer: Banner UC Health Medicaid	$228.86
Rate for Payer: Banner UC Health Medicare	$28.35
Rate for Payer: Bisbee Police All Plans	$49.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$128.52
Rate for Payer: Cash Price	$151.20
Rate for Payer: Cash Price	$151.20
Rate for Payer: Cigna of AZ Commercial	$122.85
Rate for Payer: Copperpoint Commercial	$46.78
Rate for Payer: Health Net of AZ Commercial	$113.40
Rate for Payer: Health Net of AZ Medicare	$52.92
Rate for Payer: Humana of AZ Medicare	$28.35
Rate for Payer: Mercy Care Medicaid	$228.86
Rate for Payer: Self Pay Self Pay	$151.20
Rate for Payer: TriWest Medicare	$28.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$110.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$34.02

SALINE FLUSH 10 ML

Facility

$4.00

Hospital Charge Code	22354289
Hospital Revenue Code	270
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of AZ Commercial	$3.60
Rate for Payer: Aetna of AZ Medicare	$1.12
Rate for Payer: Allwell Medicare	$0.60
Rate for Payer: Amerigroup Medicare	$0.60
Rate for Payer: APIPA Medicare/Medicaid	$1.49
Rate for Payer: AZCH Complete Medicare	$0.60
Rate for Payer: Banner UC Health Medicare	$0.60
Rate for Payer: Bisbee Police All Plans	$1.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2.72
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cigna of AZ Commercial	$2.80
Rate for Payer: Copperpoint Commercial	$0.99
Rate for Payer: Health Net of AZ Commercial	$2.40
Rate for Payer: Health Net of AZ Medicare	$1.12
Rate for Payer: Humana of AZ Medicare	$0.60
Rate for Payer: Self Pay Self Pay	$3.20
Rate for Payer: TriWest Medicare	$0.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.33
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.72

SALINE FLUSH 10 ML

Facility

$4.00

Hospital Charge Code	22354289
Hospital Revenue Code	270
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of AZ Commercial	$3.60
Rate for Payer: Bisbee Police All Plans	$1.04
Rate for Payer: Cash Price	$3.20
Rate for Payer: Self Pay Self Pay	$3.20

SALINE FLUSH 10 ML SYRINGE

Facility

$4.00

Hospital Charge Code	27569984
Hospital Revenue Code	270
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of AZ Commercial	$3.60
Rate for Payer: Aetna of AZ Medicare	$1.12
Rate for Payer: Allwell Medicare	$0.60
Rate for Payer: Amerigroup Medicare	$0.60
Rate for Payer: APIPA Medicare/Medicaid	$1.49
Rate for Payer: AZCH Complete Medicare	$0.60
Rate for Payer: Banner UC Health Medicare	$0.60
Rate for Payer: Bisbee Police All Plans	$1.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2.72
Rate for Payer: Cash Price	$3.20
Rate for Payer: Cigna of AZ Commercial	$2.80
Rate for Payer: Copperpoint Commercial	$0.99
Rate for Payer: Health Net of AZ Commercial	$2.40
Rate for Payer: Health Net of AZ Medicare	$1.12
Rate for Payer: Humana of AZ Medicare	$0.60
Rate for Payer: Self Pay Self Pay	$3.20
Rate for Payer: TriWest Medicare	$0.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.33
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.72

SALINE FLUSH 10 ML SYRINGE

Facility

$4.00

Hospital Charge Code	27569984
Hospital Revenue Code	270
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of AZ Commercial	$3.60
Rate for Payer: Bisbee Police All Plans	$1.04
Rate for Payer: Cash Price	$3.20
Rate for Payer: Self Pay Self Pay	$3.20

saline nasal moisturizing spray [CQCH]

Facility

$0.02

Service Code	NDC 49348035684
Hospital Charge Code	105942039
Hospital Revenue Code	251
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

saline nasal moisturizing spray [CQCH]

Facility

$0.02

Service Code	NDC 49348035684
Hospital Charge Code	105942039
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Self Pay Self Pay	$0.02

Salpingectomy complete/partial

Facility

$4,120.00

Service Code	CPT 58700
Hospital Charge Code	27281891
Hospital Revenue Code	360
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$3,914.00
Rate for Payer: Aetna of AZ Commercial	$3,708.00
Rate for Payer: Aetna of AZ Medicare	$1,153.60
Rate for Payer: AHCCCS Medicaid	$0.13
Rate for Payer: Allwell Medicaid	$0.13
Rate for Payer: Allwell Medicare	$618.00
Rate for Payer: Amerigroup Medicare	$618.00
Rate for Payer: APIPA Medicare/Medicaid	$1,538.82
Rate for Payer: AZCH Complete Medicaid	$0.13
Rate for Payer: AZCH Complete Medicare	$618.00
Rate for Payer: Banner UC Health Medicaid	$0.13
Rate for Payer: Banner UC Health Medicare	$618.00
Rate for Payer: Bisbee Police All Plans	$1,071.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,801.60
Rate for Payer: Cash Price	$3,296.00
Rate for Payer: Cash Price	$3,296.00
Rate for Payer: Cigna of AZ Commercial	$2,060.00
Rate for Payer: Copperpoint Commercial	$1,019.70
Rate for Payer: Health Net of AZ Commercial	$2,472.00
Rate for Payer: Health Net of AZ Medicare	$1,153.60
Rate for Payer: Humana of AZ Medicare	$618.00
Rate for Payer: Mercy Care Medicaid	$0.13
Rate for Payer: Self Pay Self Pay	$3,296.00
Rate for Payer: TriWest Medicare	$618.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,914.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$741.60

Salpingectomy complete/partial

Facility

$4,120.00

Service Code	CPT 58700
Hospital Charge Code	27281891
Hospital Revenue Code	360
Min. Negotiated Rate	$1,071.20
Max. Negotiated Rate	$3,708.00
Rate for Payer: Aetna of AZ Commercial	$3,708.00
Rate for Payer: Bisbee Police All Plans	$1,071.20
Rate for Payer: Cash Price	$3,296.00
Rate for Payer: Self Pay Self Pay	$3,296.00

SARS-CoV-2 (COVID-19) Antibody, IgG LC

Facility

$551.00

Service Code	CPT 86769
Hospital Charge Code	23968344
Hospital Revenue Code	300
Min. Negotiated Rate	$143.26
Max. Negotiated Rate	$495.90
Rate for Payer: Aetna of AZ Commercial	$495.90
Rate for Payer: Bisbee Police All Plans	$143.26
Rate for Payer: Cash Price	$440.80
Rate for Payer: Self Pay Self Pay	$440.80

SARS-CoV-2 (COVID-19) Antibody, IgG LC

Facility

$551.00

Service Code	CPT 86769
Hospital Charge Code	23968344
Hospital Revenue Code	300
Min. Negotiated Rate	$42.13
Max. Negotiated Rate	$495.90
Rate for Payer: Aetna of AZ Commercial	$495.90
Rate for Payer: Aetna of AZ Medicare	$154.28
Rate for Payer: AHCCCS Medicaid	$42.13
Rate for Payer: Allwell Medicaid	$42.13
Rate for Payer: Allwell Medicare	$82.65
Rate for Payer: Amerigroup Medicare	$82.65
Rate for Payer: APIPA Medicare/Medicaid	$205.80
Rate for Payer: AZCH Complete Medicaid	$42.13
Rate for Payer: AZCH Complete Medicare	$82.65
Rate for Payer: Banner UC Health Medicaid	$42.13
Rate for Payer: Banner UC Health Medicare	$82.65
Rate for Payer: Bisbee Police All Plans	$143.26
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$374.68
Rate for Payer: Cash Price	$440.80
Rate for Payer: Cash Price	$440.80
Rate for Payer: Cigna of AZ Commercial	$358.15
Rate for Payer: Copperpoint Commercial	$136.37
Rate for Payer: Health Net of AZ Commercial	$330.60
Rate for Payer: Health Net of AZ Medicare	$154.28
Rate for Payer: Humana of AZ Medicare	$82.65
Rate for Payer: Mercy Care Medicaid	$42.13
Rate for Payer: Self Pay Self Pay	$440.80
Rate for Payer: TriWest Medicare	$82.65
Rate for Payer: UnitedHealth Group of AZ Commercial	$321.23
Rate for Payer: UnitedHealth Group of AZ Medicare	$99.18

SCALPEL BLADE #11

Facility

$2.33

Hospital Charge Code	22355080
Hospital Revenue Code	270
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$2.10
Rate for Payer: Aetna of AZ Commercial	$2.10
Rate for Payer: Bisbee Police All Plans	$0.61
Rate for Payer: Cash Price	$1.86
Rate for Payer: Self Pay Self Pay	$1.86

SCALPEL BLADE #11

Facility

$2.33

Hospital Charge Code	22355080
Hospital Revenue Code	270
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$2.10
Rate for Payer: Aetna of AZ Commercial	$2.10
Rate for Payer: Aetna of AZ Medicare	$0.65
Rate for Payer: Allwell Medicare	$0.35
Rate for Payer: Amerigroup Medicare	$0.35
Rate for Payer: APIPA Medicare/Medicaid	$0.87
Rate for Payer: AZCH Complete Medicare	$0.35
Rate for Payer: Banner UC Health Medicare	$0.35
Rate for Payer: Bisbee Police All Plans	$0.61
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.58
Rate for Payer: Cash Price	$1.86
Rate for Payer: Cigna of AZ Commercial	$1.63
Rate for Payer: Copperpoint Commercial	$0.58
Rate for Payer: Health Net of AZ Commercial	$1.40
Rate for Payer: Health Net of AZ Medicare	$0.65
Rate for Payer: Humana of AZ Medicare	$0.35
Rate for Payer: Self Pay Self Pay	$1.86
Rate for Payer: TriWest Medicare	$0.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.36
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.42

SCALPEL W/HANDLE #15 DISPOSABLE

Facility

$4.55

Hospital Charge Code	22355086
Hospital Revenue Code	270
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$4.10
Rate for Payer: Aetna of AZ Commercial	$4.10
Rate for Payer: Aetna of AZ Medicare	$1.27
Rate for Payer: Allwell Medicare	$0.68
Rate for Payer: Amerigroup Medicare	$0.68
Rate for Payer: APIPA Medicare/Medicaid	$1.70
Rate for Payer: AZCH Complete Medicare	$0.68
Rate for Payer: Banner UC Health Medicare	$0.68
Rate for Payer: Bisbee Police All Plans	$1.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3.09
Rate for Payer: Cash Price	$3.64
Rate for Payer: Cigna of AZ Commercial	$3.18
Rate for Payer: Copperpoint Commercial	$1.13
Rate for Payer: Health Net of AZ Commercial	$2.73
Rate for Payer: Health Net of AZ Medicare	$1.27
Rate for Payer: Humana of AZ Medicare	$0.68
Rate for Payer: Self Pay Self Pay	$3.64
Rate for Payer: TriWest Medicare	$0.68
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.65
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.82

SCALPEL W/HANDLE #15 DISPOSABLE

Facility

$4.55

Hospital Charge Code	22355086
Hospital Revenue Code	270
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$4.10
Rate for Payer: Aetna of AZ Commercial	$4.10
Rate for Payer: Bisbee Police All Plans	$1.18
Rate for Payer: Cash Price	$3.64
Rate for Payer: Self Pay Self Pay	$3.64

Schizophrenia

Facility

$17,732.79

Service Code	APR-DRG 7504
Hospital Charge Code	APRDRG7504
Min. Negotiated Rate	$17,732.79
Max. Negotiated Rate	$17,732.79
Rate for Payer: AHCCCS Medicaid	$17,732.79
Rate for Payer: Allwell Medicaid	$17,732.79
Rate for Payer: AZCH Complete Medicaid	$17,732.79
Rate for Payer: Banner UC Health Medicaid	$17,732.79
Rate for Payer: Mercy Care Medicaid	$17,732.79

Schizophrenia

Facility

$4,857.20

Service Code	APR-DRG 7502
Hospital Charge Code	APRDRG7504
Min. Negotiated Rate	$4,857.20
Max. Negotiated Rate	$4,857.20
Rate for Payer: AHCCCS Medicaid	$4,857.20
Rate for Payer: Allwell Medicaid	$4,857.20
Rate for Payer: AZCH Complete Medicaid	$4,857.20
Rate for Payer: Banner UC Health Medicaid	$4,857.20
Rate for Payer: Mercy Care Medicaid	$4,857.20

Schizophrenia

Facility

$17,732.79

Service Code	APR-DRG 7504
Hospital Charge Code	APRDRG7503
Min. Negotiated Rate	$17,732.79
Max. Negotiated Rate	$17,732.79
Rate for Payer: AHCCCS Medicaid	$17,732.79
Rate for Payer: Allwell Medicaid	$17,732.79
Rate for Payer: AZCH Complete Medicaid	$17,732.79
Rate for Payer: Banner UC Health Medicaid	$17,732.79
Rate for Payer: Mercy Care Medicaid	$17,732.79

Schizophrenia

Facility

$4,857.20

Service Code	APR-DRG 7502
Hospital Charge Code	APRDRG7501
Min. Negotiated Rate	$4,857.20
Max. Negotiated Rate	$4,857.20
Rate for Payer: AHCCCS Medicaid	$4,857.20
Rate for Payer: Allwell Medicaid	$4,857.20
Rate for Payer: AZCH Complete Medicaid	$4,857.20
Rate for Payer: Banner UC Health Medicaid	$4,857.20
Rate for Payer: Mercy Care Medicaid	$4,857.20

Schizophrenia

Facility

$17,732.79

Service Code	APR-DRG 7504
Hospital Charge Code	APRDRG7501
Min. Negotiated Rate	$17,732.79
Max. Negotiated Rate	$17,732.79
Rate for Payer: AHCCCS Medicaid	$17,732.79
Rate for Payer: Allwell Medicaid	$17,732.79
Rate for Payer: AZCH Complete Medicaid	$17,732.79
Rate for Payer: Banner UC Health Medicaid	$17,732.79
Rate for Payer: Mercy Care Medicaid	$17,732.79

Schizophrenia

Facility

$8,111.69

Service Code	APR-DRG 7503
Hospital Charge Code	APRDRG7501
Min. Negotiated Rate	$8,111.69
Max. Negotiated Rate	$8,111.69
Rate for Payer: AHCCCS Medicaid	$8,111.69
Rate for Payer: Allwell Medicaid	$8,111.69
Rate for Payer: AZCH Complete Medicaid	$8,111.69
Rate for Payer: Banner UC Health Medicaid	$8,111.69
Rate for Payer: Mercy Care Medicaid	$8,111.69

Schizophrenia

Facility

$4,857.20

Service Code	APR-DRG 7502
Hospital Charge Code	APRDRG7502
Min. Negotiated Rate	$4,857.20
Max. Negotiated Rate	$4,857.20
Rate for Payer: AHCCCS Medicaid	$4,857.20
Rate for Payer: Allwell Medicaid	$4,857.20
Rate for Payer: AZCH Complete Medicaid	$4,857.20
Rate for Payer: Banner UC Health Medicaid	$4,857.20
Rate for Payer: Mercy Care Medicaid	$4,857.20

Schizophrenia

Facility

$8,111.69

Service Code	APR-DRG 7503
Hospital Charge Code	APRDRG7502
Min. Negotiated Rate	$8,111.69
Max. Negotiated Rate	$8,111.69
Rate for Payer: AHCCCS Medicaid	$8,111.69
Rate for Payer: Allwell Medicaid	$8,111.69
Rate for Payer: AZCH Complete Medicaid	$8,111.69
Rate for Payer: Banner UC Health Medicaid	$8,111.69
Rate for Payer: Mercy Care Medicaid	$8,111.69

Schizophrenia

Facility

$8,111.69

Service Code	APR-DRG 7503
Hospital Charge Code	APRDRG7504
Min. Negotiated Rate	$8,111.69
Max. Negotiated Rate	$8,111.69
Rate for Payer: AHCCCS Medicaid	$8,111.69
Rate for Payer: Allwell Medicaid	$8,111.69
Rate for Payer: AZCH Complete Medicaid	$8,111.69
Rate for Payer: Banner UC Health Medicaid	$8,111.69
Rate for Payer: Mercy Care Medicaid	$8,111.69

Schizophrenia

Facility

$17,732.79

Service Code	APR-DRG 7504
Hospital Charge Code	APRDRG7502
Min. Negotiated Rate	$17,732.79
Max. Negotiated Rate	$17,732.79
Rate for Payer: AHCCCS Medicaid	$17,732.79
Rate for Payer: Allwell Medicaid	$17,732.79
Rate for Payer: AZCH Complete Medicaid	$17,732.79
Rate for Payer: Banner UC Health Medicaid	$17,732.79
Rate for Payer: Mercy Care Medicaid	$17,732.79

Know your out-of-pocket cost for care.

All Charges