Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

SIMPLE CHANGE OF BLADDER TUBE

Facility

$270.00

Service Code	CPT 51705
Hospital Charge Code	28070629
Hospital Revenue Code	360
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of AZ Commercial	$243.00
Rate for Payer: Bisbee Police All Plans	$70.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Self Pay Self Pay	$216.00

SIMPLE REMOVAL OF FOREIGN BODY, STONE, OR STENT IN URETHRA O

Facility

$781.00

Service Code	CPT 52310
Hospital Charge Code	27797697
Hospital Revenue Code	360
Min. Negotiated Rate	$203.06
Max. Negotiated Rate	$702.90
Rate for Payer: Aetna of AZ Commercial	$702.90
Rate for Payer: Bisbee Police All Plans	$203.06
Rate for Payer: Cash Price	$624.80
Rate for Payer: Self Pay Self Pay	$624.80

SIMPLE REMOVAL OF FOREIGN BODY, STONE, OR STENT IN URETHRA O

Facility

$781.00

Service Code	CPT 52310
Hospital Charge Code	27797697
Hospital Revenue Code	360
Min. Negotiated Rate	$124.96
Max. Negotiated Rate	$2,909.00
Rate for Payer: Aetna of AZ Commercial	$702.90
Rate for Payer: Aetna of AZ Medicare	$218.68
Rate for Payer: AHCCCS Medicaid	$1,299.92
Rate for Payer: Allwell Medicaid	$1,299.92
Rate for Payer: Allwell Medicare	$124.96
Rate for Payer: Amerigroup Medicare	$124.96
Rate for Payer: APIPA Medicare/Medicaid	$291.70
Rate for Payer: AZCH Complete Medicaid	$1,299.92
Rate for Payer: AZCH Complete Medicare	$124.96
Rate for Payer: Banner UC Health Medicaid	$1,299.92
Rate for Payer: Banner UC Health Medicare	$124.96
Rate for Payer: Bisbee Police All Plans	$203.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$531.08
Rate for Payer: Cash Price	$624.80
Rate for Payer: Cash Price	$624.80
Rate for Payer: Cigna of AZ Commercial	$390.50
Rate for Payer: Copperpoint Commercial	$193.30
Rate for Payer: Health Net of AZ Commercial	$468.60
Rate for Payer: Health Net of AZ Medicare	$218.68
Rate for Payer: Humana of AZ Medicare	$124.96
Rate for Payer: Mercy Care Medicaid	$1,299.92
Rate for Payer: Self Pay Self Pay	$624.80
Rate for Payer: TriWest Medicare	$124.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,909.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$140.58

SIMPLE TIMED ASSESSMENT OF BLADDER EMPTYING Tech

Facility

$72.00

Service Code	CPT 51736
Hospital Charge Code	27925076
Hospital Revenue Code	360
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

SIMPLE TIMED ASSESSMENT OF BLADDER EMPTYING Tech

Facility

$72.00

Service Code	CPT 51736
Hospital Charge Code	27925076
Hospital Revenue Code	360
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$2,161.00
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: Cash Price	$57.60
Rate for Payer: Cigna of AZ Commercial	$36.00
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	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.96

Simple vulvectomy complete

Facility

$3,420.00

Service Code	CPT 56625
Hospital Charge Code	27267830
Hospital Revenue Code	360
Min. Negotiated Rate	$889.20
Max. Negotiated Rate	$3,078.00
Rate for Payer: Aetna of AZ Commercial	$3,078.00
Rate for Payer: Bisbee Police All Plans	$889.20
Rate for Payer: Cash Price	$2,736.00
Rate for Payer: Self Pay Self Pay	$2,736.00

Simple vulvectomy complete

Facility

$3,420.00

Service Code	CPT 56625
Hospital Charge Code	27267830
Hospital Revenue Code	360
Min. Negotiated Rate	$547.20
Max. Negotiated Rate	$3,373.00
Rate for Payer: Aetna of AZ Commercial	$3,078.00
Rate for Payer: Aetna of AZ Medicare	$957.60
Rate for Payer: AHCCCS Medicaid	$1,901.83
Rate for Payer: Allwell Medicaid	$1,901.83
Rate for Payer: Allwell Medicare	$547.20
Rate for Payer: Amerigroup Medicare	$547.20
Rate for Payer: APIPA Medicare/Medicaid	$1,277.37
Rate for Payer: AZCH Complete Medicaid	$1,901.83
Rate for Payer: AZCH Complete Medicare	$547.20
Rate for Payer: Banner UC Health Medicaid	$1,901.83
Rate for Payer: Banner UC Health Medicare	$547.20
Rate for Payer: Bisbee Police All Plans	$889.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,325.60
Rate for Payer: Cash Price	$2,736.00
Rate for Payer: Cash Price	$2,736.00
Rate for Payer: Cigna of AZ Commercial	$1,710.00
Rate for Payer: Copperpoint Commercial	$846.45
Rate for Payer: Health Net of AZ Commercial	$2,052.00
Rate for Payer: Health Net of AZ Medicare	$957.60
Rate for Payer: Humana of AZ Medicare	$547.20
Rate for Payer: Mercy Care Medicaid	$1,901.83
Rate for Payer: Self Pay Self Pay	$2,736.00
Rate for Payer: TriWest Medicare	$547.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,373.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$615.60

simvastatin 20 mg Tab [CQCH]

Facility

$0.24

Service Code	NDC 68084051201
Hospital Charge Code	105940605
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of AZ Commercial	$0.22
Rate for Payer: Bisbee Police All Plans	$0.06
Rate for Payer: Cash Price	$0.19
Rate for Payer: Self Pay Self Pay	$0.19

simvastatin 20 mg Tab [CQCH]

Facility

$0.24

Service Code	NDC 68084051201
Hospital Charge Code	105940605
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of AZ Commercial	$0.22
Rate for Payer: Aetna of AZ Medicare	$0.07
Rate for Payer: Allwell Medicare	$0.04
Rate for Payer: Amerigroup Medicare	$0.04
Rate for Payer: APIPA Medicare/Medicaid	$0.09
Rate for Payer: AZCH Complete Medicare	$0.04
Rate for Payer: Banner UC Health Medicare	$0.04
Rate for Payer: Bisbee Police All Plans	$0.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.16
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of AZ Commercial	$0.16
Rate for Payer: Copperpoint Commercial	$0.06
Rate for Payer: Health Net of AZ Commercial	$0.14
Rate for Payer: Health Net of AZ Medicare	$0.07
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Self Pay Self Pay	$0.19
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.04

SINGLE USE BITE BLOCK

Facility

$8.00

Hospital Charge Code	22355557
Hospital Revenue Code	270
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Aetna of AZ Medicare	$2.24
Rate for Payer: Allwell Medicare	$1.28
Rate for Payer: Amerigroup Medicare	$1.28
Rate for Payer: APIPA Medicare/Medicaid	$2.99
Rate for Payer: AZCH Complete Medicare	$1.28
Rate for Payer: Banner UC Health Medicare	$1.28
Rate for Payer: Bisbee Police All Plans	$2.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$5.44
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cigna of AZ Commercial	$5.60
Rate for Payer: Copperpoint Commercial	$1.98
Rate for Payer: Health Net of AZ Commercial	$4.80
Rate for Payer: Health Net of AZ Medicare	$2.24
Rate for Payer: Humana of AZ Medicare	$1.28
Rate for Payer: Self Pay Self Pay	$6.40
Rate for Payer: TriWest Medicare	$1.28
Rate for Payer: UnitedHealth Group of AZ Commercial	$4.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.44

SINGLE USE BITE BLOCK

Facility

$8.00

Hospital Charge Code	22355557
Hospital Revenue Code	270
Min. Negotiated Rate	$2.08
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Bisbee Police All Plans	$2.08
Rate for Payer: Cash Price	$6.40
Rate for Payer: Self Pay Self Pay	$6.40

SIROLIMUS (RAPAMUNE)

Facility

$331.00

Service Code	CPT 80195
Hospital Charge Code	23603249
Hospital Revenue Code	301
Min. Negotiated Rate	$52.96
Max. Negotiated Rate	$297.90
Rate for Payer: Aetna of AZ Commercial	$297.90
Rate for Payer: Aetna of AZ Medicare	$92.68
Rate for Payer: Allwell Medicare	$52.96
Rate for Payer: Amerigroup Medicare	$52.96
Rate for Payer: APIPA Medicare/Medicaid	$123.63
Rate for Payer: AZCH Complete Medicare	$52.96
Rate for Payer: Banner UC Health Medicare	$52.96
Rate for Payer: Bisbee Police All Plans	$86.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$225.08
Rate for Payer: Cash Price	$264.80
Rate for Payer: Cigna of AZ Commercial	$215.15
Rate for Payer: Copperpoint Commercial	$81.92
Rate for Payer: Health Net of AZ Commercial	$198.60
Rate for Payer: Health Net of AZ Medicare	$92.68
Rate for Payer: Humana of AZ Medicare	$52.96
Rate for Payer: Self Pay Self Pay	$264.80
Rate for Payer: TriWest Medicare	$52.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$192.97
Rate for Payer: UnitedHealth Group of AZ Medicare	$59.58

SIROLIMUS (RAPAMUNE)

Facility

$331.00

Service Code	CPT 80195
Hospital Charge Code	23603249
Hospital Revenue Code	301
Min. Negotiated Rate	$86.06
Max. Negotiated Rate	$297.90
Rate for Payer: Aetna of AZ Commercial	$297.90
Rate for Payer: Bisbee Police All Plans	$86.06
Rate for Payer: Cash Price	$264.80
Rate for Payer: Self Pay Self Pay	$264.80

Sirolimus (Rapamune), Blood LC

Facility

$314.00

Service Code	CPT 80195
Hospital Charge Code	2029238
Hospital Revenue Code	301
Min. Negotiated Rate	$50.24
Max. Negotiated Rate	$282.60
Rate for Payer: Aetna of AZ Commercial	$282.60
Rate for Payer: Aetna of AZ Medicare	$87.92
Rate for Payer: Allwell Medicare	$50.24
Rate for Payer: Amerigroup Medicare	$50.24
Rate for Payer: APIPA Medicare/Medicaid	$117.28
Rate for Payer: AZCH Complete Medicare	$50.24
Rate for Payer: Banner UC Health Medicare	$50.24
Rate for Payer: Bisbee Police All Plans	$81.64
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$213.52
Rate for Payer: Cash Price	$251.20
Rate for Payer: Cigna of AZ Commercial	$204.10
Rate for Payer: Copperpoint Commercial	$77.72
Rate for Payer: Health Net of AZ Commercial	$188.40
Rate for Payer: Health Net of AZ Medicare	$87.92
Rate for Payer: Humana of AZ Medicare	$50.24
Rate for Payer: Self Pay Self Pay	$251.20
Rate for Payer: TriWest Medicare	$50.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$183.06
Rate for Payer: UnitedHealth Group of AZ Medicare	$56.52

Sirolimus (Rapamune), Blood LC

Facility

$314.00

Service Code	CPT 80195
Hospital Charge Code	2029238
Hospital Revenue Code	301
Min. Negotiated Rate	$81.64
Max. Negotiated Rate	$282.60
Rate for Payer: Aetna of AZ Commercial	$282.60
Rate for Payer: Bisbee Police All Plans	$81.64
Rate for Payer: Cash Price	$251.20
Rate for Payer: Self Pay Self Pay	$251.20

SITZ BATH

Facility

$13.00

Hospital Charge Code	22355310
Hospital Revenue Code	270
Min. Negotiated Rate	$2.08
Max. Negotiated Rate	$11.70
Rate for Payer: Aetna of AZ Commercial	$11.70
Rate for Payer: Aetna of AZ Medicare	$3.64
Rate for Payer: Allwell Medicare	$2.08
Rate for Payer: Amerigroup Medicare	$2.08
Rate for Payer: APIPA Medicare/Medicaid	$4.86
Rate for Payer: AZCH Complete Medicare	$2.08
Rate for Payer: Banner UC Health Medicare	$2.08
Rate for Payer: Bisbee Police All Plans	$3.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$8.84
Rate for Payer: Cash Price	$10.40
Rate for Payer: Cigna of AZ Commercial	$9.10
Rate for Payer: Copperpoint Commercial	$3.22
Rate for Payer: Health Net of AZ Commercial	$7.80
Rate for Payer: Health Net of AZ Medicare	$3.64
Rate for Payer: Humana of AZ Medicare	$2.08
Rate for Payer: Self Pay Self Pay	$10.40
Rate for Payer: TriWest Medicare	$2.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$7.58
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.34

SITZ BATH

Facility

$13.00

Hospital Charge Code	22355310
Hospital Revenue Code	270
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$11.70
Rate for Payer: Aetna of AZ Commercial	$11.70
Rate for Payer: Bisbee Police All Plans	$3.38
Rate for Payer: Cash Price	$10.40
Rate for Payer: Self Pay Self Pay	$10.40

Sjogren's Ab, Anti-SS-A/-SS-B LC

Facility

$182.00

Service Code	CPT 86235
Hospital Charge Code	1285798
Hospital Revenue Code	302
Min. Negotiated Rate	$47.32
Max. Negotiated Rate	$163.80
Rate for Payer: Aetna of AZ Commercial	$163.80
Rate for Payer: Bisbee Police All Plans	$47.32
Rate for Payer: Cash Price	$145.60
Rate for Payer: Self Pay Self Pay	$145.60

Sjogren's Ab, Anti-SS-A/-SS-B LC

Facility

$182.00

Service Code	CPT 86235
Hospital Charge Code	1285798
Hospital Revenue Code	302
Min. Negotiated Rate	$29.12
Max. Negotiated Rate	$163.80
Rate for Payer: Aetna of AZ Commercial	$163.80
Rate for Payer: Aetna of AZ Medicare	$50.96
Rate for Payer: Allwell Medicare	$29.12
Rate for Payer: Amerigroup Medicare	$29.12
Rate for Payer: APIPA Medicare/Medicaid	$67.98
Rate for Payer: AZCH Complete Medicare	$29.12
Rate for Payer: Banner UC Health Medicare	$29.12
Rate for Payer: Bisbee Police All Plans	$47.32
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$123.76
Rate for Payer: Cash Price	$145.60
Rate for Payer: Cigna of AZ Commercial	$118.30
Rate for Payer: Copperpoint Commercial	$45.05
Rate for Payer: Health Net of AZ Commercial	$109.20
Rate for Payer: Health Net of AZ Medicare	$50.96
Rate for Payer: Humana of AZ Medicare	$29.12
Rate for Payer: Self Pay Self Pay	$145.60
Rate for Payer: TriWest Medicare	$29.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$106.11
Rate for Payer: UnitedHealth Group of AZ Medicare	$32.76

.Sjoren's SSA LC

Facility

$119.00

Service Code	CPT 86235
Hospital Charge Code	22531159
Hospital Revenue Code	301
Min. Negotiated Rate	$30.94
Max. Negotiated Rate	$107.10
Rate for Payer: Aetna of AZ Commercial	$107.10
Rate for Payer: Bisbee Police All Plans	$30.94
Rate for Payer: Cash Price	$95.20
Rate for Payer: Self Pay Self Pay	$95.20

.Sjoren's SSA LC

Facility

$119.00

Service Code	CPT 86235
Hospital Charge Code	22531159
Hospital Revenue Code	301
Min. Negotiated Rate	$19.04
Max. Negotiated Rate	$107.10
Rate for Payer: Aetna of AZ Commercial	$107.10
Rate for Payer: Aetna of AZ Medicare	$33.32
Rate for Payer: Allwell Medicare	$19.04
Rate for Payer: Amerigroup Medicare	$19.04
Rate for Payer: APIPA Medicare/Medicaid	$44.45
Rate for Payer: AZCH Complete Medicare	$19.04
Rate for Payer: Banner UC Health Medicare	$19.04
Rate for Payer: Bisbee Police All Plans	$30.94
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$80.92
Rate for Payer: Cash Price	$95.20
Rate for Payer: Cigna of AZ Commercial	$77.35
Rate for Payer: Copperpoint Commercial	$29.45
Rate for Payer: Health Net of AZ Commercial	$71.40
Rate for Payer: Health Net of AZ Medicare	$33.32
Rate for Payer: Humana of AZ Medicare	$19.04
Rate for Payer: Self Pay Self Pay	$95.20
Rate for Payer: TriWest Medicare	$19.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$69.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$21.42

.Sjoren's SSB LC

Facility

$119.00

Service Code	CPT 86235
Hospital Charge Code	22531177
Hospital Revenue Code	306
Min. Negotiated Rate	$19.04
Max. Negotiated Rate	$107.10
Rate for Payer: Aetna of AZ Commercial	$107.10
Rate for Payer: Aetna of AZ Medicare	$33.32
Rate for Payer: Allwell Medicare	$19.04
Rate for Payer: Amerigroup Medicare	$19.04
Rate for Payer: APIPA Medicare/Medicaid	$44.45
Rate for Payer: AZCH Complete Medicare	$19.04
Rate for Payer: Banner UC Health Medicare	$19.04
Rate for Payer: Bisbee Police All Plans	$30.94
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$80.92
Rate for Payer: Cash Price	$95.20
Rate for Payer: Cigna of AZ Commercial	$77.35
Rate for Payer: Copperpoint Commercial	$29.45
Rate for Payer: Health Net of AZ Commercial	$71.40
Rate for Payer: Health Net of AZ Medicare	$33.32
Rate for Payer: Humana of AZ Medicare	$19.04
Rate for Payer: Self Pay Self Pay	$95.20
Rate for Payer: TriWest Medicare	$19.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$69.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$21.42

.Sjoren's SSB LC

Facility

$119.00

Service Code	CPT 86235
Hospital Charge Code	22531177
Hospital Revenue Code	306
Min. Negotiated Rate	$30.94
Max. Negotiated Rate	$107.10
Rate for Payer: Aetna of AZ Commercial	$107.10
Rate for Payer: Bisbee Police All Plans	$30.94
Rate for Payer: Cash Price	$95.20
Rate for Payer: Self Pay Self Pay	$95.20

Sjoren's SSB LC

Facility

$119.00

Service Code	CPT 86235
Hospital Charge Code	22531160
Hospital Revenue Code	302
Min. Negotiated Rate	$30.94
Max. Negotiated Rate	$107.10
Rate for Payer: Aetna of AZ Commercial	$107.10
Rate for Payer: Bisbee Police All Plans	$30.94
Rate for Payer: Cash Price	$95.20
Rate for Payer: Self Pay Self Pay	$95.20

Sjoren's SSB LC

Facility

$119.00

Service Code	CPT 86235
Hospital Charge Code	22531160
Hospital Revenue Code	302
Min. Negotiated Rate	$19.04
Max. Negotiated Rate	$107.10
Rate for Payer: Aetna of AZ Commercial	$107.10
Rate for Payer: Aetna of AZ Medicare	$33.32
Rate for Payer: Allwell Medicare	$19.04
Rate for Payer: Amerigroup Medicare	$19.04
Rate for Payer: APIPA Medicare/Medicaid	$44.45
Rate for Payer: AZCH Complete Medicare	$19.04
Rate for Payer: Banner UC Health Medicare	$19.04
Rate for Payer: Bisbee Police All Plans	$30.94
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$80.92
Rate for Payer: Cash Price	$95.20
Rate for Payer: Cigna of AZ Commercial	$77.35
Rate for Payer: Copperpoint Commercial	$29.45
Rate for Payer: Health Net of AZ Commercial	$71.40
Rate for Payer: Health Net of AZ Medicare	$33.32
Rate for Payer: Humana of AZ Medicare	$19.04
Rate for Payer: Self Pay Self Pay	$95.20
Rate for Payer: TriWest Medicare	$19.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$69.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$21.42

Know your out-of-pocket cost for care.

All Charges