Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

TC 3.0/4.0 OVERDRILL

Facility

$945.00

Hospital Charge Code	24127774
Hospital Revenue Code	270
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$850.50
Rate for Payer: Aetna of AZ Commercial	$850.50
Rate for Payer: Aetna of AZ Medicare	$264.60
Rate for Payer: Allwell Medicare	$151.20
Rate for Payer: Amerigroup Medicare	$151.20
Rate for Payer: APIPA Medicare/Medicaid	$352.96
Rate for Payer: AZCH Complete Medicare	$151.20
Rate for Payer: Banner UC Health Medicare	$151.20
Rate for Payer: Bisbee Police All Plans	$245.70
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$642.60
Rate for Payer: Cash Price	$756.00
Rate for Payer: Cigna of AZ Commercial	$661.50
Rate for Payer: Copperpoint Commercial	$233.89
Rate for Payer: Health Net of AZ Commercial	$567.00
Rate for Payer: Health Net of AZ Medicare	$264.60
Rate for Payer: Humana of AZ Medicare	$151.20
Rate for Payer: Self Pay Self Pay	$756.00
Rate for Payer: TriWest Medicare	$151.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$550.93
Rate for Payer: UnitedHealth Group of AZ Medicare	$170.10

TCS SERIES CANN OVER DRILL 3.0/4.0MM SCREWS

Facility

$1,096.00

Hospital Charge Code	24209394
Hospital Revenue Code	270
Min. Negotiated Rate	$284.96
Max. Negotiated Rate	$986.40
Rate for Payer: Aetna of AZ Commercial	$986.40
Rate for Payer: Bisbee Police All Plans	$284.96
Rate for Payer: Cash Price	$876.80
Rate for Payer: Self Pay Self Pay	$876.80

TCS SERIES CANN OVER DRILL 3.0/4.0MM SCREWS

Facility

$1,096.00

Hospital Charge Code	24209394
Hospital Revenue Code	270
Min. Negotiated Rate	$175.36
Max. Negotiated Rate	$986.40
Rate for Payer: Aetna of AZ Commercial	$986.40
Rate for Payer: Aetna of AZ Medicare	$306.88
Rate for Payer: Allwell Medicare	$175.36
Rate for Payer: Amerigroup Medicare	$175.36
Rate for Payer: APIPA Medicare/Medicaid	$409.36
Rate for Payer: AZCH Complete Medicare	$175.36
Rate for Payer: Banner UC Health Medicare	$175.36
Rate for Payer: Bisbee Police All Plans	$284.96
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$745.28
Rate for Payer: Cash Price	$876.80
Rate for Payer: Cigna of AZ Commercial	$767.20
Rate for Payer: Copperpoint Commercial	$271.26
Rate for Payer: Health Net of AZ Commercial	$657.60
Rate for Payer: Health Net of AZ Medicare	$306.88
Rate for Payer: Humana of AZ Medicare	$175.36
Rate for Payer: Self Pay Self Pay	$876.80
Rate for Payer: TriWest Medicare	$175.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$638.97
Rate for Payer: UnitedHealth Group of AZ Medicare	$197.28

TEL 613-8S

Facility

$861.00

Hospital Charge Code	22354822
Hospital Revenue Code	270
Min. Negotiated Rate	$137.76
Max. Negotiated Rate	$774.90
Rate for Payer: Aetna of AZ Commercial	$774.90
Rate for Payer: Aetna of AZ Medicare	$241.08
Rate for Payer: Allwell Medicare	$137.76
Rate for Payer: Amerigroup Medicare	$137.76
Rate for Payer: APIPA Medicare/Medicaid	$321.58
Rate for Payer: AZCH Complete Medicare	$137.76
Rate for Payer: Banner UC Health Medicare	$137.76
Rate for Payer: Bisbee Police All Plans	$223.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$585.48
Rate for Payer: Cash Price	$688.80
Rate for Payer: Cigna of AZ Commercial	$602.70
Rate for Payer: Copperpoint Commercial	$213.10
Rate for Payer: Health Net of AZ Commercial	$516.60
Rate for Payer: Health Net of AZ Medicare	$241.08
Rate for Payer: Humana of AZ Medicare	$137.76
Rate for Payer: Self Pay Self Pay	$688.80
Rate for Payer: TriWest Medicare	$137.76
Rate for Payer: UnitedHealth Group of AZ Commercial	$501.96
Rate for Payer: UnitedHealth Group of AZ Medicare	$154.98

TEL 613-8S

Facility

$861.00

Hospital Charge Code	22354822
Hospital Revenue Code	270
Min. Negotiated Rate	$223.86
Max. Negotiated Rate	$774.90
Rate for Payer: Aetna of AZ Commercial	$774.90
Rate for Payer: Bisbee Police All Plans	$223.86
Rate for Payer: Cash Price	$688.80
Rate for Payer: Self Pay Self Pay	$688.80

TELEHEALTH CARDIO SITE FACILITY FEE

Facility

$62.00

Service Code	CPT Q3014
Hospital Charge Code	22247983
Hospital Revenue Code	780
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Aetna of AZ Medicare	$17.36
Rate for Payer: Allwell Medicare	$9.92
Rate for Payer: Amerigroup Medicare	$9.92
Rate for Payer: APIPA Medicare/Medicaid	$23.16
Rate for Payer: AZCH Complete Medicare	$9.92
Rate for Payer: Banner UC Health Medicare	$9.92
Rate for Payer: Bisbee Police All Plans	$16.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$42.16
Rate for Payer: Cash Price	$49.60
Rate for Payer: Cigna of AZ Commercial	$43.40
Rate for Payer: Copperpoint Commercial	$15.35
Rate for Payer: Health Net of AZ Commercial	$37.20
Rate for Payer: Health Net of AZ Medicare	$17.36
Rate for Payer: Humana of AZ Medicare	$9.92
Rate for Payer: Self Pay Self Pay	$49.60
Rate for Payer: TriWest Medicare	$9.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$36.15
Rate for Payer: UnitedHealth Group of AZ Medicare	$11.16

TELEHEALTH CARDIO SITE FACILITY FEE

Facility

$62.00

Service Code	CPT Q3014
Hospital Charge Code	22247983
Hospital Revenue Code	780
Min. Negotiated Rate	$16.12
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Bisbee Police All Plans	$16.12
Rate for Payer: Cash Price	$49.60
Rate for Payer: Self Pay Self Pay	$49.60

TELEHEALTH CONSULTATION, EMERGENCY DEPT OR INPATIENT TYPICAL

Facility

$912.00

Service Code	CPT G0427
Hospital Charge Code	24270136
Hospital Revenue Code	780
Min. Negotiated Rate	$145.92
Max. Negotiated Rate	$820.80
Rate for Payer: Aetna of AZ Commercial	$820.80
Rate for Payer: Aetna of AZ Medicare	$255.36
Rate for Payer: Allwell Medicare	$145.92
Rate for Payer: Amerigroup Medicare	$145.92
Rate for Payer: APIPA Medicare/Medicaid	$340.63
Rate for Payer: AZCH Complete Medicare	$145.92
Rate for Payer: Banner UC Health Medicare	$145.92
Rate for Payer: Bisbee Police All Plans	$237.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$620.16
Rate for Payer: Cash Price	$729.60
Rate for Payer: Cigna of AZ Commercial	$638.40
Rate for Payer: Copperpoint Commercial	$225.72
Rate for Payer: Health Net of AZ Commercial	$547.20
Rate for Payer: Health Net of AZ Medicare	$255.36
Rate for Payer: Humana of AZ Medicare	$145.92
Rate for Payer: Self Pay Self Pay	$729.60
Rate for Payer: TriWest Medicare	$145.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$531.70
Rate for Payer: UnitedHealth Group of AZ Medicare	$164.16

TELEHEALTH CONSULTATION, EMERGENCY DEPT OR INPATIENT TYPICAL

Facility

$473.00

Service Code	CPT G0425
Hospital Charge Code	24270131
Hospital Revenue Code	780
Min. Negotiated Rate	$122.98
Max. Negotiated Rate	$425.70
Rate for Payer: Aetna of AZ Commercial	$425.70
Rate for Payer: Bisbee Police All Plans	$122.98
Rate for Payer: Cash Price	$378.40
Rate for Payer: Self Pay Self Pay	$378.40

TELEHEALTH CONSULTATION, EMERGENCY DEPT OR INPATIENT TYPICAL

Facility

$912.00

Service Code	CPT G0427
Hospital Charge Code	24270136
Hospital Revenue Code	780
Min. Negotiated Rate	$237.12
Max. Negotiated Rate	$820.80
Rate for Payer: Aetna of AZ Commercial	$820.80
Rate for Payer: Bisbee Police All Plans	$237.12
Rate for Payer: Cash Price	$729.60
Rate for Payer: Self Pay Self Pay	$729.60

TELEHEALTH CONSULTATION, EMERGENCY DEPT OR INPATIENT TYPICAL

Facility

$473.00

Service Code	CPT G0425
Hospital Charge Code	24270131
Hospital Revenue Code	780
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$425.70
Rate for Payer: Aetna of AZ Commercial	$425.70
Rate for Payer: Aetna of AZ Medicare	$132.44
Rate for Payer: Allwell Medicare	$75.68
Rate for Payer: Amerigroup Medicare	$75.68
Rate for Payer: APIPA Medicare/Medicaid	$176.67
Rate for Payer: AZCH Complete Medicare	$75.68
Rate for Payer: Banner UC Health Medicare	$75.68
Rate for Payer: Bisbee Police All Plans	$122.98
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$321.64
Rate for Payer: Cash Price	$378.40
Rate for Payer: Cigna of AZ Commercial	$331.10
Rate for Payer: Copperpoint Commercial	$117.07
Rate for Payer: Health Net of AZ Commercial	$283.80
Rate for Payer: Health Net of AZ Medicare	$132.44
Rate for Payer: Humana of AZ Medicare	$75.68
Rate for Payer: Self Pay Self Pay	$378.40
Rate for Payer: TriWest Medicare	$75.68
Rate for Payer: UnitedHealth Group of AZ Commercial	$275.76
Rate for Payer: UnitedHealth Group of AZ Medicare	$85.14

TELEHEALTH CONSULTATION, EMERGENCY DEPT OR INPATIENT TYPICAL

Facility

$642.00

Service Code	CPT G0426
Hospital Charge Code	24270135
Hospital Revenue Code	780
Min. Negotiated Rate	$102.72
Max. Negotiated Rate	$577.80
Rate for Payer: Aetna of AZ Commercial	$577.80
Rate for Payer: Aetna of AZ Medicare	$179.76
Rate for Payer: Allwell Medicare	$102.72
Rate for Payer: Amerigroup Medicare	$102.72
Rate for Payer: APIPA Medicare/Medicaid	$239.79
Rate for Payer: AZCH Complete Medicare	$102.72
Rate for Payer: Banner UC Health Medicare	$102.72
Rate for Payer: Bisbee Police All Plans	$166.92
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$436.56
Rate for Payer: Cash Price	$513.60
Rate for Payer: Cigna of AZ Commercial	$449.40
Rate for Payer: Copperpoint Commercial	$158.90
Rate for Payer: Health Net of AZ Commercial	$385.20
Rate for Payer: Health Net of AZ Medicare	$179.76
Rate for Payer: Humana of AZ Medicare	$102.72
Rate for Payer: Self Pay Self Pay	$513.60
Rate for Payer: TriWest Medicare	$102.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$374.29
Rate for Payer: UnitedHealth Group of AZ Medicare	$115.56

TELEHEALTH CONSULTATION, EMERGENCY DEPT OR INPATIENT TYPICAL

Facility

$642.00

Service Code	CPT G0426
Hospital Charge Code	24270135
Hospital Revenue Code	780
Min. Negotiated Rate	$166.92
Max. Negotiated Rate	$577.80
Rate for Payer: Aetna of AZ Commercial	$577.80
Rate for Payer: Bisbee Police All Plans	$166.92
Rate for Payer: Cash Price	$513.60
Rate for Payer: Self Pay Self Pay	$513.60

TELEHEALTH NEURO SITE FACILITY FEE

Facility

$59.00

Service Code	CPT Q3014
Hospital Charge Code	22247982
Hospital Revenue Code	780
Min. Negotiated Rate	$9.44
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Aetna of AZ Medicare	$16.52
Rate for Payer: Allwell Medicare	$9.44
Rate for Payer: Amerigroup Medicare	$9.44
Rate for Payer: APIPA Medicare/Medicaid	$22.04
Rate for Payer: AZCH Complete Medicare	$9.44
Rate for Payer: Banner UC Health Medicare	$9.44
Rate for Payer: Bisbee Police All Plans	$15.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$40.12
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cigna of AZ Commercial	$41.30
Rate for Payer: Copperpoint Commercial	$14.60
Rate for Payer: Health Net of AZ Commercial	$35.40
Rate for Payer: Health Net of AZ Medicare	$16.52
Rate for Payer: Humana of AZ Medicare	$9.44
Rate for Payer: Self Pay Self Pay	$47.20
Rate for Payer: TriWest Medicare	$9.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$34.40
Rate for Payer: UnitedHealth Group of AZ Medicare	$10.62

TELEHEALTH NEURO SITE FACILITY FEE

Facility

$59.00

Service Code	CPT Q3014
Hospital Charge Code	22247982
Hospital Revenue Code	780
Min. Negotiated Rate	$15.34
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Bisbee Police All Plans	$15.34
Rate for Payer: Cash Price	$47.20
Rate for Payer: Self Pay Self Pay	$47.20

TELEHEALTH PULMON SITE FACILITY FEE

Facility

$62.00

Service Code	CPT Q3014
Hospital Charge Code	22247984
Hospital Revenue Code	780
Min. Negotiated Rate	$16.12
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Bisbee Police All Plans	$16.12
Rate for Payer: Cash Price	$49.60
Rate for Payer: Self Pay Self Pay	$49.60

TELEHEALTH PULMON SITE FACILITY FEE

Facility

$62.00

Service Code	CPT Q3014
Hospital Charge Code	22247984
Hospital Revenue Code	780
Min. Negotiated Rate	$9.92
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Aetna of AZ Medicare	$17.36
Rate for Payer: Allwell Medicare	$9.92
Rate for Payer: Amerigroup Medicare	$9.92
Rate for Payer: APIPA Medicare/Medicaid	$23.16
Rate for Payer: AZCH Complete Medicare	$9.92
Rate for Payer: Banner UC Health Medicare	$9.92
Rate for Payer: Bisbee Police All Plans	$16.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$42.16
Rate for Payer: Cash Price	$49.60
Rate for Payer: Cigna of AZ Commercial	$43.40
Rate for Payer: Copperpoint Commercial	$15.35
Rate for Payer: Health Net of AZ Commercial	$37.20
Rate for Payer: Health Net of AZ Medicare	$17.36
Rate for Payer: Humana of AZ Medicare	$9.92
Rate for Payer: Self Pay Self Pay	$49.60
Rate for Payer: TriWest Medicare	$9.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$36.15
Rate for Payer: UnitedHealth Group of AZ Medicare	$11.16

temazepam 15 mg Cap [CQCH]

Facility

$0.08

Service Code	NDC 67877014601
Hospital Charge Code	105943112
Hospital Revenue Code	251
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

temazepam 15 mg Cap [CQCH]

Facility

$0.08

Service Code	NDC 67877014601
Hospital Charge Code	105943112
Hospital Revenue Code	251
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

Tendon, Muscle And Other Soft Tissue Procedures

Facility

$14,282.61

Service Code	APR-DRG 3173
Hospital Charge Code	APRDRG3173
Min. Negotiated Rate	$14,282.61
Max. Negotiated Rate	$14,282.61
Rate for Payer: AHCCCS Medicaid	$14,282.61
Rate for Payer: Allwell Medicaid	$14,282.61
Rate for Payer: AZCH Complete Medicaid	$14,282.61
Rate for Payer: Banner UC Health Medicaid	$14,282.61
Rate for Payer: Mercy Care Medicaid	$14,282.61

Tendon, Muscle And Other Soft Tissue Procedures

Facility

$6,375.02

Service Code	APR-DRG 3171
Hospital Charge Code	APRDRG3173
Min. Negotiated Rate	$6,375.02
Max. Negotiated Rate	$6,375.02
Rate for Payer: AHCCCS Medicaid	$6,375.02
Rate for Payer: Allwell Medicaid	$6,375.02
Rate for Payer: AZCH Complete Medicaid	$6,375.02
Rate for Payer: Banner UC Health Medicaid	$6,375.02
Rate for Payer: Mercy Care Medicaid	$6,375.02

Tendon, Muscle And Other Soft Tissue Procedures

Facility

$27,861.71

Service Code	APR-DRG 3174
Hospital Charge Code	APRDRG3172
Min. Negotiated Rate	$27,861.71
Max. Negotiated Rate	$27,861.71
Rate for Payer: AHCCCS Medicaid	$27,861.71
Rate for Payer: Allwell Medicaid	$27,861.71
Rate for Payer: AZCH Complete Medicaid	$27,861.71
Rate for Payer: Banner UC Health Medicaid	$27,861.71
Rate for Payer: Mercy Care Medicaid	$27,861.71

Tendon, Muscle And Other Soft Tissue Procedures

Facility

$27,861.71

Service Code	APR-DRG 3174
Hospital Charge Code	APRDRG3171
Min. Negotiated Rate	$27,861.71
Max. Negotiated Rate	$27,861.71
Rate for Payer: AHCCCS Medicaid	$27,861.71
Rate for Payer: Allwell Medicaid	$27,861.71
Rate for Payer: AZCH Complete Medicaid	$27,861.71
Rate for Payer: Banner UC Health Medicaid	$27,861.71
Rate for Payer: Mercy Care Medicaid	$27,861.71

Tendon, Muscle And Other Soft Tissue Procedures

Facility

$6,375.02

Service Code	APR-DRG 3171
Hospital Charge Code	APRDRG3174
Min. Negotiated Rate	$6,375.02
Max. Negotiated Rate	$6,375.02
Rate for Payer: AHCCCS Medicaid	$6,375.02
Rate for Payer: Allwell Medicaid	$6,375.02
Rate for Payer: AZCH Complete Medicaid	$6,375.02
Rate for Payer: Banner UC Health Medicaid	$6,375.02
Rate for Payer: Mercy Care Medicaid	$6,375.02

Tendon, Muscle And Other Soft Tissue Procedures

Facility

$14,282.61

Service Code	APR-DRG 3173
Hospital Charge Code	APRDRG3172
Min. Negotiated Rate	$14,282.61
Max. Negotiated Rate	$14,282.61
Rate for Payer: AHCCCS Medicaid	$14,282.61
Rate for Payer: Allwell Medicaid	$14,282.61
Rate for Payer: AZCH Complete Medicaid	$14,282.61
Rate for Payer: Banner UC Health Medicaid	$14,282.61
Rate for Payer: Mercy Care Medicaid	$14,282.61

Know your out-of-pocket cost for care.

All Charges