Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Tonsil And Adenoid Procedures

Facility

$3,787.56

Service Code	APR-DRG 0971
Hospital Charge Code	APRDRG0971
Min. Negotiated Rate	$3,787.56
Max. Negotiated Rate	$3,787.56
Rate for Payer: AHCCCS Medicaid	$3,787.56
Rate for Payer: Allwell Medicaid	$3,787.56
Rate for Payer: AZCH Complete Medicaid	$3,787.56
Rate for Payer: Banner UC Health Medicaid	$3,787.56
Rate for Payer: Mercy Care Medicaid	$3,787.56

Tonsil And Adenoid Procedures

Facility

$9,659.68

Service Code	APR-DRG 0973
Hospital Charge Code	APRDRG0973
Min. Negotiated Rate	$9,659.68
Max. Negotiated Rate	$9,659.68
Rate for Payer: AHCCCS Medicaid	$9,659.68
Rate for Payer: Allwell Medicaid	$9,659.68
Rate for Payer: AZCH Complete Medicaid	$9,659.68
Rate for Payer: Banner UC Health Medicaid	$9,659.68
Rate for Payer: Mercy Care Medicaid	$9,659.68

Tonsil And Adenoid Procedures

Facility

$5,522.12

Service Code	APR-DRG 0972
Hospital Charge Code	APRDRG0974
Min. Negotiated Rate	$5,522.12
Max. Negotiated Rate	$5,522.12
Rate for Payer: AHCCCS Medicaid	$5,522.12
Rate for Payer: Allwell Medicaid	$5,522.12
Rate for Payer: AZCH Complete Medicaid	$5,522.12
Rate for Payer: Banner UC Health Medicaid	$5,522.12
Rate for Payer: Mercy Care Medicaid	$5,522.12

Tonsil And Adenoid Procedures

Facility

$17,184.30

Service Code	APR-DRG 0974
Hospital Charge Code	APRDRG0973
Min. Negotiated Rate	$17,184.30
Max. Negotiated Rate	$17,184.30
Rate for Payer: AHCCCS Medicaid	$17,184.30
Rate for Payer: Allwell Medicaid	$17,184.30
Rate for Payer: AZCH Complete Medicaid	$17,184.30
Rate for Payer: Banner UC Health Medicaid	$17,184.30
Rate for Payer: Mercy Care Medicaid	$17,184.30

Tonsil And Adenoid Procedures

Facility

$9,659.68

Service Code	APR-DRG 0973
Hospital Charge Code	APRDRG0974
Min. Negotiated Rate	$9,659.68
Max. Negotiated Rate	$9,659.68
Rate for Payer: AHCCCS Medicaid	$9,659.68
Rate for Payer: Allwell Medicaid	$9,659.68
Rate for Payer: AZCH Complete Medicaid	$9,659.68
Rate for Payer: Banner UC Health Medicaid	$9,659.68
Rate for Payer: Mercy Care Medicaid	$9,659.68

Tonsil And Adenoid Procedures

Facility

$17,184.30

Service Code	APR-DRG 0974
Hospital Charge Code	APRDRG0971
Min. Negotiated Rate	$17,184.30
Max. Negotiated Rate	$17,184.30
Rate for Payer: AHCCCS Medicaid	$17,184.30
Rate for Payer: Allwell Medicaid	$17,184.30
Rate for Payer: AZCH Complete Medicaid	$17,184.30
Rate for Payer: Banner UC Health Medicaid	$17,184.30
Rate for Payer: Mercy Care Medicaid	$17,184.30

Tonsil And Adenoid Procedures

Facility

$9,659.68

Service Code	APR-DRG 0973
Hospital Charge Code	APRDRG0972
Min. Negotiated Rate	$9,659.68
Max. Negotiated Rate	$9,659.68
Rate for Payer: AHCCCS Medicaid	$9,659.68
Rate for Payer: Allwell Medicaid	$9,659.68
Rate for Payer: AZCH Complete Medicaid	$9,659.68
Rate for Payer: Banner UC Health Medicaid	$9,659.68
Rate for Payer: Mercy Care Medicaid	$9,659.68

Tonsil And Adenoid Procedures

Facility

$17,184.30

Service Code	APR-DRG 0974
Hospital Charge Code	APRDRG0974
Min. Negotiated Rate	$17,184.30
Max. Negotiated Rate	$17,184.30
Rate for Payer: AHCCCS Medicaid	$17,184.30
Rate for Payer: Allwell Medicaid	$17,184.30
Rate for Payer: AZCH Complete Medicaid	$17,184.30
Rate for Payer: Banner UC Health Medicaid	$17,184.30
Rate for Payer: Mercy Care Medicaid	$17,184.30

Tonsil And Adenoid Procedures

Facility

$3,787.56

Service Code	APR-DRG 0971
Hospital Charge Code	APRDRG0974
Min. Negotiated Rate	$3,787.56
Max. Negotiated Rate	$3,787.56
Rate for Payer: AHCCCS Medicaid	$3,787.56
Rate for Payer: Allwell Medicaid	$3,787.56
Rate for Payer: AZCH Complete Medicaid	$3,787.56
Rate for Payer: Banner UC Health Medicaid	$3,787.56
Rate for Payer: Mercy Care Medicaid	$3,787.56

Tonsil And Adenoid Procedures

Facility

$17,184.30

Service Code	APR-DRG 0974
Hospital Charge Code	APRDRG0972
Min. Negotiated Rate	$17,184.30
Max. Negotiated Rate	$17,184.30
Rate for Payer: AHCCCS Medicaid	$17,184.30
Rate for Payer: Allwell Medicaid	$17,184.30
Rate for Payer: AZCH Complete Medicaid	$17,184.30
Rate for Payer: Banner UC Health Medicaid	$17,184.30
Rate for Payer: Mercy Care Medicaid	$17,184.30

Tonsil And Adenoid Procedures

Facility

$5,522.12

Service Code	APR-DRG 0972
Hospital Charge Code	APRDRG0973
Min. Negotiated Rate	$5,522.12
Max. Negotiated Rate	$5,522.12
Rate for Payer: AHCCCS Medicaid	$5,522.12
Rate for Payer: Allwell Medicaid	$5,522.12
Rate for Payer: AZCH Complete Medicaid	$5,522.12
Rate for Payer: Banner UC Health Medicaid	$5,522.12
Rate for Payer: Mercy Care Medicaid	$5,522.12

Tonsil And Adenoid Procedures

Facility

$3,787.56

Service Code	APR-DRG 0971
Hospital Charge Code	APRDRG0972
Min. Negotiated Rate	$3,787.56
Max. Negotiated Rate	$3,787.56
Rate for Payer: AHCCCS Medicaid	$3,787.56
Rate for Payer: Allwell Medicaid	$3,787.56
Rate for Payer: AZCH Complete Medicaid	$3,787.56
Rate for Payer: Banner UC Health Medicaid	$3,787.56
Rate for Payer: Mercy Care Medicaid	$3,787.56

Tonsil And Adenoid Procedures

Facility

$9,659.68

Service Code	APR-DRG 0973
Hospital Charge Code	APRDRG0971
Min. Negotiated Rate	$9,659.68
Max. Negotiated Rate	$9,659.68
Rate for Payer: AHCCCS Medicaid	$9,659.68
Rate for Payer: Allwell Medicaid	$9,659.68
Rate for Payer: AZCH Complete Medicaid	$9,659.68
Rate for Payer: Banner UC Health Medicaid	$9,659.68
Rate for Payer: Mercy Care Medicaid	$9,659.68

Tonsil And Adenoid Procedures

Facility

$3,787.56

Service Code	APR-DRG 0971
Hospital Charge Code	APRDRG0973
Min. Negotiated Rate	$3,787.56
Max. Negotiated Rate	$3,787.56
Rate for Payer: AHCCCS Medicaid	$3,787.56
Rate for Payer: Allwell Medicaid	$3,787.56
Rate for Payer: AZCH Complete Medicaid	$3,787.56
Rate for Payer: Banner UC Health Medicaid	$3,787.56
Rate for Payer: Mercy Care Medicaid	$3,787.56

Tonsil And Adenoid Procedures

Facility

$5,522.12

Service Code	APR-DRG 0972
Hospital Charge Code	APRDRG0971
Min. Negotiated Rate	$5,522.12
Max. Negotiated Rate	$5,522.12
Rate for Payer: AHCCCS Medicaid	$5,522.12
Rate for Payer: Allwell Medicaid	$5,522.12
Rate for Payer: AZCH Complete Medicaid	$5,522.12
Rate for Payer: Banner UC Health Medicaid	$5,522.12
Rate for Payer: Mercy Care Medicaid	$5,522.12

TONSIL DAVIS NEEDLES

Facility

$22.03

Hospital Charge Code	27485971
Hospital Revenue Code	270
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$19.83
Rate for Payer: Aetna of AZ Commercial	$19.83
Rate for Payer: Aetna of AZ Medicare	$6.17
Rate for Payer: Allwell Medicare	$3.30
Rate for Payer: Amerigroup Medicare	$3.30
Rate for Payer: APIPA Medicare/Medicaid	$8.23
Rate for Payer: AZCH Complete Medicare	$3.30
Rate for Payer: Banner UC Health Medicare	$3.30
Rate for Payer: Bisbee Police All Plans	$5.73
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$14.98
Rate for Payer: Cash Price	$17.62
Rate for Payer: Cigna of AZ Commercial	$15.42
Rate for Payer: Copperpoint Commercial	$5.45
Rate for Payer: Health Net of AZ Commercial	$13.22
Rate for Payer: Health Net of AZ Medicare	$6.17
Rate for Payer: Humana of AZ Medicare	$3.30
Rate for Payer: Self Pay Self Pay	$17.62
Rate for Payer: TriWest Medicare	$3.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$12.84
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.97

TONSIL DAVIS NEEDLES

Facility

$22.03

Hospital Charge Code	27485971
Hospital Revenue Code	270
Min. Negotiated Rate	$5.73
Max. Negotiated Rate	$19.83
Rate for Payer: Aetna of AZ Commercial	$19.83
Rate for Payer: Bisbee Police All Plans	$5.73
Rate for Payer: Cash Price	$17.62
Rate for Payer: Self Pay Self Pay	$17.62

topiramate 200 mg Tab [CQCH]

Facility

$0.48

Service Code	NDC 68084034521
Hospital Charge Code	105944129
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of AZ Commercial	$0.43
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	$0.18
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	$0.33
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cigna of AZ Commercial	$0.31
Rate for Payer: Copperpoint Commercial	$0.12
Rate for Payer: Health Net of AZ Commercial	$0.29
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	$0.38
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.09

topiramate 200 mg Tab [CQCH]

Facility

$0.48

Service Code	NDC 68084034521
Hospital Charge Code	105944129
Hospital Revenue Code	251
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of AZ Commercial	$0.43
Rate for Payer: Bisbee Police All Plans	$0.12
Rate for Payer: Cash Price	$0.38
Rate for Payer: Self Pay Self Pay	$0.38

topiramate 25 mg Tab [CQCH]

Facility

$0.11

Service Code	NDC 68084034201
Hospital Charge Code	105944064
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

topiramate 25 mg Tab [CQCH]

Facility

$0.11

Service Code	NDC 68084034201
Hospital Charge Code	105944064
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

Topiramate (Topamax), Serum LC

Facility

$319.00

Service Code	CPT 80201
Hospital Charge Code	2029223
Hospital Revenue Code	301
Min. Negotiated Rate	$11.92
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: AHCCCS Medicaid	$11.92
Rate for Payer: Allwell Medicaid	$11.92
Rate for Payer: Allwell Medicare	$47.85
Rate for Payer: Amerigroup Medicare	$47.85
Rate for Payer: APIPA Medicare/Medicaid	$119.15
Rate for Payer: AZCH Complete Medicaid	$11.92
Rate for Payer: AZCH Complete Medicare	$47.85
Rate for Payer: Banner UC Health Medicaid	$11.92
Rate for Payer: Banner UC Health Medicare	$47.85
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: 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	$47.85
Rate for Payer: Mercy Care Medicaid	$11.92
Rate for Payer: Self Pay Self Pay	$255.20
Rate for Payer: TriWest Medicare	$47.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$185.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$57.42

Topiramate (Topamax), Serum LC

Facility

$319.00

Service Code	CPT 80201
Hospital Charge Code	2029223
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

TOTAL PROTEIN 24HR URINE

Facility

$100.00

Service Code	CPT 84156
Hospital Charge Code	22664814
Hospital Revenue Code	301
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of AZ Commercial	$90.00
Rate for Payer: Aetna of AZ Medicare	$28.00
Rate for Payer: AHCCCS Medicaid	$3.67
Rate for Payer: Allwell Medicaid	$3.67
Rate for Payer: Allwell Medicare	$15.00
Rate for Payer: Amerigroup Medicare	$15.00
Rate for Payer: APIPA Medicare/Medicaid	$37.35
Rate for Payer: AZCH Complete Medicaid	$3.67
Rate for Payer: AZCH Complete Medicare	$15.00
Rate for Payer: Banner UC Health Medicaid	$3.67
Rate for Payer: Banner UC Health Medicare	$15.00
Rate for Payer: Bisbee Police All Plans	$26.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$68.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cigna of AZ Commercial	$65.00
Rate for Payer: Copperpoint Commercial	$24.75
Rate for Payer: Health Net of AZ Commercial	$60.00
Rate for Payer: Health Net of AZ Medicare	$28.00
Rate for Payer: Humana of AZ Medicare	$15.00
Rate for Payer: Mercy Care Medicaid	$3.67
Rate for Payer: Self Pay Self Pay	$80.00
Rate for Payer: TriWest Medicare	$15.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$58.30
Rate for Payer: UnitedHealth Group of AZ Medicare	$18.00

TOTAL PROTEIN 24HR URINE

Facility

$100.00

Service Code	CPT 84156
Hospital Charge Code	22664814
Hospital Revenue Code	301
Min. Negotiated Rate	$26.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of AZ Commercial	$90.00
Rate for Payer: Bisbee Police All Plans	$26.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Self Pay Self Pay	$80.00

Know your out-of-pocket cost for care.

All Charges