Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Acute Myocardial Infarction

Facility

$7,646.66

Service Code	APR-DRG 1903
Hospital Charge Code	APRDRG1904
Min. Negotiated Rate	$7,646.66
Max. Negotiated Rate	$7,646.66
Rate for Payer: AHCCCS Medicaid	$7,646.66
Rate for Payer: Allwell Medicaid	$7,646.66
Rate for Payer: AZCH Complete Medicaid	$7,646.66
Rate for Payer: Banner UC Health Medicaid	$7,646.66
Rate for Payer: Mercy Care Medicaid	$7,646.66

Acute Myocardial Infarction

Facility

$5,750.78

Service Code	APR-DRG 1902
Hospital Charge Code	APRDRG1901
Min. Negotiated Rate	$5,750.78
Max. Negotiated Rate	$5,750.78
Rate for Payer: AHCCCS Medicaid	$5,750.78
Rate for Payer: Allwell Medicaid	$5,750.78
Rate for Payer: AZCH Complete Medicaid	$5,750.78
Rate for Payer: Banner UC Health Medicaid	$5,750.78
Rate for Payer: Mercy Care Medicaid	$5,750.78

acyclovir 500 mg/10 mL Sol [CQCH]

Facility

$0.32

Service Code	HCPCS J0133
Hospital Charge Code	107616107
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of AZ Commercial	$0.29
Rate for Payer: Bisbee Police All Plans	$0.08
Rate for Payer: Cash Price	$0.26
Rate for Payer: Self Pay Self Pay	$0.26

acyclovir 500 mg/10 mL Sol [CQCH]

Facility

$0.32

Service Code	HCPCS J0133
Hospital Charge Code	107616107
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of AZ Commercial	$0.29
Rate for Payer: Aetna of AZ Medicare	$0.09
Rate for Payer: Allwell Medicare	$0.05
Rate for Payer: Amerigroup Medicare	$0.05
Rate for Payer: APIPA Medicare/Medicaid	$0.12
Rate for Payer: AZCH Complete Medicare	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
Rate for Payer: Bisbee Police All Plans	$0.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.22
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cigna of AZ Commercial	$0.21
Rate for Payer: Copperpoint Commercial	$0.08
Rate for Payer: Health Net of AZ Commercial	$0.19
Rate for Payer: Health Net of AZ Medicare	$0.09
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Self Pay Self Pay	$0.26
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.06

ADAPTER AIRWAY CO2 TIDALWAVE

Facility

$72.00

Hospital Charge Code	22354926
Hospital Revenue Code	270
Min. Negotiated Rate	$18.72
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Bisbee Police All Plans	$18.72
Rate for Payer: Cash Price	$57.60
Rate for Payer: Self Pay Self Pay	$57.60

ADAPTER AIRWAY CO2 TIDALWAVE

Facility

$72.00

Hospital Charge Code	22354926
Hospital Revenue Code	270
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Aetna of AZ Medicare	$20.16
Rate for Payer: Allwell Medicare	$11.52
Rate for Payer: Amerigroup Medicare	$11.52
Rate for Payer: APIPA Medicare/Medicaid	$26.89
Rate for Payer: AZCH Complete Medicare	$11.52
Rate for Payer: Banner UC Health Medicare	$11.52
Rate for Payer: Bisbee Police All Plans	$18.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$48.96
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna of AZ Commercial	$50.40
Rate for Payer: Copperpoint Commercial	$17.82
Rate for Payer: Health Net of AZ Commercial	$43.20
Rate for Payer: Health Net of AZ Medicare	$20.16
Rate for Payer: Humana of AZ Medicare	$11.52
Rate for Payer: Self Pay Self Pay	$57.60
Rate for Payer: TriWest Medicare	$11.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$41.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.96

ADAPTER ETT CO2 PED/ADULT (TIDAL WAVE)

Facility

$34.00

Hospital Charge Code	22355405
Hospital Revenue Code	270
Min. Negotiated Rate	$5.44
Max. Negotiated Rate	$30.60
Rate for Payer: Aetna of AZ Commercial	$30.60
Rate for Payer: Aetna of AZ Medicare	$9.52
Rate for Payer: Allwell Medicare	$5.44
Rate for Payer: Amerigroup Medicare	$5.44
Rate for Payer: APIPA Medicare/Medicaid	$12.70
Rate for Payer: AZCH Complete Medicare	$5.44
Rate for Payer: Banner UC Health Medicare	$5.44
Rate for Payer: Bisbee Police All Plans	$8.84
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$23.12
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cigna of AZ Commercial	$23.80
Rate for Payer: Copperpoint Commercial	$8.41
Rate for Payer: Health Net of AZ Commercial	$20.40
Rate for Payer: Health Net of AZ Medicare	$9.52
Rate for Payer: Humana of AZ Medicare	$5.44
Rate for Payer: Self Pay Self Pay	$27.20
Rate for Payer: TriWest Medicare	$5.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$19.82
Rate for Payer: UnitedHealth Group of AZ Medicare	$6.12

ADAPTER ETT CO2 PED/ADULT (TIDAL WAVE)

Facility

$34.00

Hospital Charge Code	22355405
Hospital Revenue Code	270
Min. Negotiated Rate	$8.84
Max. Negotiated Rate	$30.60
Rate for Payer: Aetna of AZ Commercial	$30.60
Rate for Payer: Bisbee Police All Plans	$8.84
Rate for Payer: Cash Price	$27.20
Rate for Payer: Self Pay Self Pay	$27.20

ADAPTER SAMPLING NC CO2

Facility

$85.00

Hospital Charge Code	22354925
Hospital Revenue Code	270
Min. Negotiated Rate	$22.10
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of AZ Commercial	$76.50
Rate for Payer: Bisbee Police All Plans	$22.10
Rate for Payer: Cash Price	$68.00
Rate for Payer: Self Pay Self Pay	$68.00

ADAPTER SAMPLING NC CO2

Facility

$85.00

Hospital Charge Code	22354925
Hospital Revenue Code	270
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of AZ Commercial	$76.50
Rate for Payer: Aetna of AZ Medicare	$23.80
Rate for Payer: Allwell Medicare	$13.60
Rate for Payer: Amerigroup Medicare	$13.60
Rate for Payer: APIPA Medicare/Medicaid	$31.75
Rate for Payer: AZCH Complete Medicare	$13.60
Rate for Payer: Banner UC Health Medicare	$13.60
Rate for Payer: Bisbee Police All Plans	$22.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$57.80
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cigna of AZ Commercial	$59.50
Rate for Payer: Copperpoint Commercial	$21.04
Rate for Payer: Health Net of AZ Commercial	$51.00
Rate for Payer: Health Net of AZ Medicare	$23.80
Rate for Payer: Humana of AZ Medicare	$13.60
Rate for Payer: Self Pay Self Pay	$68.00
Rate for Payer: TriWest Medicare	$13.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$49.55
Rate for Payer: UnitedHealth Group of AZ Medicare	$15.30

ADAPTER SAMPLING SIDESTREAM CO2

Facility

$69.00

Hospital Charge Code	22354924
Hospital Revenue Code	270
Min. Negotiated Rate	$17.94
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Bisbee Police All Plans	$17.94
Rate for Payer: Cash Price	$55.20
Rate for Payer: Self Pay Self Pay	$55.20

ADAPTER SAMPLING SIDESTREAM CO2

Facility

$69.00

Hospital Charge Code	22354924
Hospital Revenue Code	270
Min. Negotiated Rate	$11.04
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Aetna of AZ Medicare	$19.32
Rate for Payer: Allwell Medicare	$11.04
Rate for Payer: Amerigroup Medicare	$11.04
Rate for Payer: APIPA Medicare/Medicaid	$25.77
Rate for Payer: AZCH Complete Medicare	$11.04
Rate for Payer: Banner UC Health Medicare	$11.04
Rate for Payer: Bisbee Police All Plans	$17.94
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$46.92
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cigna of AZ Commercial	$48.30
Rate for Payer: Copperpoint Commercial	$17.08
Rate for Payer: Health Net of AZ Commercial	$41.40
Rate for Payer: Health Net of AZ Medicare	$19.32
Rate for Payer: Humana of AZ Medicare	$11.04
Rate for Payer: Self Pay Self Pay	$55.20
Rate for Payer: TriWest Medicare	$11.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$40.23
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.42

ADD IV PUSH NEW MED

Facility

$255.00

Service Code	CPT 96375
Hospital Charge Code	22283170
Hospital Revenue Code	450
Min. Negotiated Rate	$29.00
Max. Negotiated Rate	$229.50
Rate for Payer: Aetna of AZ Commercial	$229.50
Rate for Payer: Aetna of AZ Medicare	$71.40
Rate for Payer: AHCCCS Medicaid	$29.00
Rate for Payer: Allwell Medicaid	$29.00
Rate for Payer: Allwell Medicare	$40.80
Rate for Payer: Amerigroup Medicare	$40.80
Rate for Payer: APIPA Medicare/Medicaid	$95.24
Rate for Payer: AZCH Complete Medicaid	$29.00
Rate for Payer: AZCH Complete Medicare	$40.80
Rate for Payer: Banner UC Health Medicaid	$29.00
Rate for Payer: Banner UC Health Medicare	$40.80
Rate for Payer: Bisbee Police All Plans	$66.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$173.40
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cigna of AZ Commercial	$178.50
Rate for Payer: Copperpoint Commercial	$63.11
Rate for Payer: Health Net of AZ Commercial	$153.00
Rate for Payer: Health Net of AZ Medicare	$71.40
Rate for Payer: Humana of AZ Medicare	$40.80
Rate for Payer: Mercy Care Medicaid	$29.00
Rate for Payer: Self Pay Self Pay	$204.00
Rate for Payer: TriWest Medicare	$40.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$148.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$45.90

ADD IV PUSH NEW MED

Facility

$255.00

Service Code	CPT 96375
Hospital Charge Code	22283170
Hospital Revenue Code	450
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$229.50
Rate for Payer: Aetna of AZ Commercial	$229.50
Rate for Payer: Bisbee Police All Plans	$66.30
Rate for Payer: Cash Price	$204.00
Rate for Payer: Self Pay Self Pay	$204.00

ADD IV PUSH SAME MED

Facility

$255.00

Service Code	CPT 96376
Hospital Charge Code	22283171
Hospital Revenue Code	450
Min. Negotiated Rate	$66.30
Max. Negotiated Rate	$229.50
Rate for Payer: Aetna of AZ Commercial	$229.50
Rate for Payer: Bisbee Police All Plans	$66.30
Rate for Payer: Cash Price	$204.00
Rate for Payer: Self Pay Self Pay	$204.00

ADD IV PUSH SAME MED

Facility

$255.00

Service Code	CPT 96376
Hospital Charge Code	22283171
Hospital Revenue Code	450
Min. Negotiated Rate	$40.80
Max. Negotiated Rate	$229.50
Rate for Payer: Aetna of AZ Commercial	$229.50
Rate for Payer: Aetna of AZ Medicare	$71.40
Rate for Payer: Allwell Medicare	$40.80
Rate for Payer: Amerigroup Medicare	$40.80
Rate for Payer: APIPA Medicare/Medicaid	$95.24
Rate for Payer: AZCH Complete Medicare	$40.80
Rate for Payer: Banner UC Health Medicare	$40.80
Rate for Payer: Bisbee Police All Plans	$66.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$173.40
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cigna of AZ Commercial	$178.50
Rate for Payer: Copperpoint Commercial	$63.11
Rate for Payer: Health Net of AZ Commercial	$153.00
Rate for Payer: Health Net of AZ Medicare	$71.40
Rate for Payer: Humana of AZ Medicare	$40.80
Rate for Payer: Self Pay Self Pay	$204.00
Rate for Payer: TriWest Medicare	$40.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$148.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$45.90

adenosine 12 mg Inj PFS [CQCH]

Facility

$4.24

Service Code	HCPCS J0153
Hospital Charge Code	105909256
Hospital Revenue Code	250
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$3.82
Rate for Payer: Aetna of AZ Commercial	$3.82
Rate for Payer: Bisbee Police All Plans	$1.10
Rate for Payer: Cash Price	$3.39
Rate for Payer: Self Pay Self Pay	$3.39

adenosine 12 mg Inj PFS [CQCH]

Facility

$4.24

Service Code	HCPCS J0153
Hospital Charge Code	105909256
Hospital Revenue Code	250
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$3.82
Rate for Payer: Aetna of AZ Commercial	$3.82
Rate for Payer: Aetna of AZ Medicare	$1.19
Rate for Payer: Allwell Medicare	$0.68
Rate for Payer: Amerigroup Medicare	$0.68
Rate for Payer: APIPA Medicare/Medicaid	$1.58
Rate for Payer: AZCH Complete Medicare	$0.68
Rate for Payer: Banner UC Health Medicare	$0.68
Rate for Payer: Bisbee Police All Plans	$1.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2.88
Rate for Payer: Cash Price	$3.39
Rate for Payer: Cigna of AZ Commercial	$2.76
Rate for Payer: Copperpoint Commercial	$1.05
Rate for Payer: Health Net of AZ Commercial	$2.54
Rate for Payer: Health Net of AZ Medicare	$1.19
Rate for Payer: Humana of AZ Medicare	$0.68
Rate for Payer: Self Pay Self Pay	$3.39
Rate for Payer: TriWest Medicare	$0.68
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.47
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.76

adenosine 6 mg Inj [CQCH]

Facility

$4.77

Service Code	HCPCS J0150
Hospital Charge Code	105909329
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$4.29
Rate for Payer: Aetna of AZ Commercial	$4.29
Rate for Payer: Aetna of AZ Medicare	$1.34
Rate for Payer: Allwell Medicare	$0.76
Rate for Payer: Amerigroup Medicare	$0.76
Rate for Payer: APIPA Medicare/Medicaid	$1.78
Rate for Payer: AZCH Complete Medicare	$0.76
Rate for Payer: Banner UC Health Medicare	$0.76
Rate for Payer: Bisbee Police All Plans	$1.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3.24
Rate for Payer: Cash Price	$3.81
Rate for Payer: Cigna of AZ Commercial	$3.10
Rate for Payer: Copperpoint Commercial	$1.18
Rate for Payer: Health Net of AZ Commercial	$2.86
Rate for Payer: Health Net of AZ Medicare	$1.34
Rate for Payer: Humana of AZ Medicare	$0.76
Rate for Payer: Self Pay Self Pay	$3.82
Rate for Payer: TriWest Medicare	$0.76
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.78
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.86

adenosine 6 mg Inj [CQCH]

Facility

$4.77

Service Code	HCPCS J0150
Hospital Charge Code	105909329
Hospital Revenue Code	250
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$4.29
Rate for Payer: Aetna of AZ Commercial	$4.29
Rate for Payer: Bisbee Police All Plans	$1.24
Rate for Payer: Cash Price	$3.81
Rate for Payer: Self Pay Self Pay	$3.82

ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA: DEFECT

Facility

$4,259.00

Service Code	CPT 14301
Hospital Charge Code	24049289
Hospital Revenue Code	360
Min. Negotiated Rate	$681.44
Max. Negotiated Rate	$3,914.00
Rate for Payer: Aetna of AZ Commercial	$3,833.10
Rate for Payer: Aetna of AZ Medicare	$1,192.52
Rate for Payer: AHCCCS Medicaid	$2,553.56
Rate for Payer: Allwell Medicaid	$2,553.56
Rate for Payer: Allwell Medicare	$681.44
Rate for Payer: Amerigroup Medicare	$681.44
Rate for Payer: APIPA Medicare/Medicaid	$1,590.74
Rate for Payer: AZCH Complete Medicaid	$2,553.56
Rate for Payer: AZCH Complete Medicare	$681.44
Rate for Payer: Banner UC Health Medicaid	$2,553.56
Rate for Payer: Banner UC Health Medicare	$681.44
Rate for Payer: Bisbee Police All Plans	$1,107.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,896.12
Rate for Payer: Cash Price	$3,407.20
Rate for Payer: Cash Price	$3,407.20
Rate for Payer: Cigna of AZ Commercial	$2,129.50
Rate for Payer: Copperpoint Commercial	$1,054.10
Rate for Payer: Health Net of AZ Commercial	$2,555.40
Rate for Payer: Health Net of AZ Medicare	$1,192.52
Rate for Payer: Humana of AZ Medicare	$681.44
Rate for Payer: Mercy Care Medicaid	$2,553.56
Rate for Payer: Self Pay Self Pay	$3,407.20
Rate for Payer: TriWest Medicare	$681.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,914.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$766.62

ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA: DEFECT

Facility

$4,259.00

Service Code	CPT 14301
Hospital Charge Code	24049289
Hospital Revenue Code	360
Min. Negotiated Rate	$1,107.34
Max. Negotiated Rate	$3,833.10
Rate for Payer: Aetna of AZ Commercial	$3,833.10
Rate for Payer: Bisbee Police All Plans	$1,107.34
Rate for Payer: Cash Price	$3,407.20
Rate for Payer: Self Pay Self Pay	$3,407.20

Adjustment Disorders And Neuroses Except Depressive Diagnoses

Facility

$12,163.68

Service Code	APR-DRG 7554
Hospital Charge Code	APRDRG7552
Min. Negotiated Rate	$12,163.68
Max. Negotiated Rate	$12,163.68
Rate for Payer: AHCCCS Medicaid	$12,163.68
Rate for Payer: Allwell Medicaid	$12,163.68
Rate for Payer: AZCH Complete Medicaid	$12,163.68
Rate for Payer: Banner UC Health Medicaid	$12,163.68
Rate for Payer: Mercy Care Medicaid	$12,163.68

Adjustment Disorders And Neuroses Except Depressive Diagnoses

Facility

$12,163.68

Service Code	APR-DRG 7554
Hospital Charge Code	APRDRG7553
Min. Negotiated Rate	$12,163.68
Max. Negotiated Rate	$12,163.68
Rate for Payer: AHCCCS Medicaid	$12,163.68
Rate for Payer: Allwell Medicaid	$12,163.68
Rate for Payer: AZCH Complete Medicaid	$12,163.68
Rate for Payer: Banner UC Health Medicaid	$12,163.68
Rate for Payer: Mercy Care Medicaid	$12,163.68

Adjustment Disorders And Neuroses Except Depressive Diagnoses

Facility

$1,892.38

Service Code	APR-DRG 7551
Hospital Charge Code	APRDRG7552
Min. Negotiated Rate	$1,892.38
Max. Negotiated Rate	$1,892.38
Rate for Payer: AHCCCS Medicaid	$1,892.38
Rate for Payer: Allwell Medicaid	$1,892.38
Rate for Payer: AZCH Complete Medicaid	$1,892.38
Rate for Payer: Banner UC Health Medicaid	$1,892.38
Rate for Payer: Mercy Care Medicaid	$1,892.38

Know your out-of-pocket cost for care.

All Charges