Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Alteration In Consciousness

Facility

$4,026.04

Service Code	APR-DRG 0521
Hospital Charge Code	APRDRG0521
Min. Negotiated Rate	$4,026.04
Max. Negotiated Rate	$4,026.04
Rate for Payer: AHCCCS Medicaid	$4,026.04
Rate for Payer: Allwell Medicaid	$4,026.04
Rate for Payer: AZCH Complete Medicaid	$4,026.04
Rate for Payer: Banner UC Health Medicaid	$4,026.04
Rate for Payer: Mercy Care Medicaid	$4,026.04

Alteration In Consciousness

Facility

$13,677.30

Service Code	APR-DRG 0524
Hospital Charge Code	APRDRG0523
Min. Negotiated Rate	$13,677.30
Max. Negotiated Rate	$13,677.30
Rate for Payer: AHCCCS Medicaid	$13,677.30
Rate for Payer: Allwell Medicaid	$13,677.30
Rate for Payer: AZCH Complete Medicaid	$13,677.30
Rate for Payer: Banner UC Health Medicaid	$13,677.30
Rate for Payer: Mercy Care Medicaid	$13,677.30

Alteration In Consciousness

Facility

$4,524.03

Service Code	APR-DRG 0522
Hospital Charge Code	APRDRG0524
Min. Negotiated Rate	$4,524.03
Max. Negotiated Rate	$4,524.03
Rate for Payer: AHCCCS Medicaid	$4,524.03
Rate for Payer: Allwell Medicaid	$4,524.03
Rate for Payer: AZCH Complete Medicaid	$4,524.03
Rate for Payer: Banner UC Health Medicaid	$4,524.03
Rate for Payer: Mercy Care Medicaid	$4,524.03

Alteration In Consciousness

Facility

$13,677.30

Service Code	APR-DRG 0524
Hospital Charge Code	APRDRG0521
Min. Negotiated Rate	$13,677.30
Max. Negotiated Rate	$13,677.30
Rate for Payer: AHCCCS Medicaid	$13,677.30
Rate for Payer: Allwell Medicaid	$13,677.30
Rate for Payer: AZCH Complete Medicaid	$13,677.30
Rate for Payer: Banner UC Health Medicaid	$13,677.30
Rate for Payer: Mercy Care Medicaid	$13,677.30

Alteration In Consciousness

Facility

$5,836.35

Service Code	APR-DRG 0523
Hospital Charge Code	APRDRG0524
Min. Negotiated Rate	$5,836.35
Max. Negotiated Rate	$5,836.35
Rate for Payer: AHCCCS Medicaid	$5,836.35
Rate for Payer: Allwell Medicaid	$5,836.35
Rate for Payer: AZCH Complete Medicaid	$5,836.35
Rate for Payer: Banner UC Health Medicaid	$5,836.35
Rate for Payer: Mercy Care Medicaid	$5,836.35

ALTIS COLOPLAST SLING

Facility

$8,237.00

Hospital Charge Code	22729662
Hospital Revenue Code	272
Min. Negotiated Rate	$2,141.62
Max. Negotiated Rate	$7,413.30
Rate for Payer: Aetna of AZ Commercial	$7,413.30
Rate for Payer: Bisbee Police All Plans	$2,141.62
Rate for Payer: Cash Price	$6,589.60
Rate for Payer: Self Pay Self Pay	$6,589.60

ALTIS COLOPLAST SLING

Facility

$8,237.00

Hospital Charge Code	22729662
Hospital Revenue Code	272
Min. Negotiated Rate	$1,235.55
Max. Negotiated Rate	$7,413.30
Rate for Payer: Aetna of AZ Commercial	$7,413.30
Rate for Payer: Aetna of AZ Medicare	$2,306.36
Rate for Payer: Allwell Medicare	$1,235.55
Rate for Payer: Amerigroup Medicare	$1,235.55
Rate for Payer: APIPA Medicare/Medicaid	$3,076.52
Rate for Payer: AZCH Complete Medicare	$1,235.55
Rate for Payer: Banner UC Health Medicare	$1,235.55
Rate for Payer: Bisbee Police All Plans	$2,141.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$5,601.16
Rate for Payer: Cash Price	$6,589.60
Rate for Payer: Cigna of AZ Commercial	$5,765.90
Rate for Payer: Copperpoint Commercial	$2,038.66
Rate for Payer: Health Net of AZ Commercial	$4,942.20
Rate for Payer: Health Net of AZ Medicare	$2,306.36
Rate for Payer: Humana of AZ Medicare	$1,235.55
Rate for Payer: Self Pay Self Pay	$6,589.60
Rate for Payer: TriWest Medicare	$1,235.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$4,802.17
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,482.66

amantadine 100 mg Cap UD [CQCH]

Facility

$1.04

Service Code	NDC 904663061
Hospital Charge Code	107993868
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.94
Rate for Payer: Aetna of AZ Commercial	$0.94
Rate for Payer: Bisbee Police All Plans	$0.27
Rate for Payer: Cash Price	$0.84
Rate for Payer: Self Pay Self Pay	$0.83

amantadine 100 mg Cap UD [CQCH]

Facility

$1.04

Service Code	NDC 904663061
Hospital Charge Code	107993868
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.94
Rate for Payer: Aetna of AZ Commercial	$0.94
Rate for Payer: Aetna of AZ Medicare	$0.29
Rate for Payer: Allwell Medicare	$0.16
Rate for Payer: Amerigroup Medicare	$0.16
Rate for Payer: APIPA Medicare/Medicaid	$0.39
Rate for Payer: AZCH Complete Medicare	$0.16
Rate for Payer: Banner UC Health Medicare	$0.16
Rate for Payer: Bisbee Police All Plans	$0.27
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.71
Rate for Payer: Cash Price	$0.84
Rate for Payer: Cigna of AZ Commercial	$0.68
Rate for Payer: Copperpoint Commercial	$0.26
Rate for Payer: Health Net of AZ Commercial	$0.62
Rate for Payer: Health Net of AZ Medicare	$0.29
Rate for Payer: Humana of AZ Medicare	$0.16
Rate for Payer: Self Pay Self Pay	$0.83
Rate for Payer: TriWest Medicare	$0.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.61
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.19

amiodarone 150 mg/3 mL IV Sol [CQCH]

Facility

$1.05

Service Code	HCPCS J0282
Hospital Charge Code	105910495
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.95
Rate for Payer: Aetna of AZ Commercial	$0.95
Rate for Payer: Bisbee Police All Plans	$0.27
Rate for Payer: Cash Price	$0.84
Rate for Payer: Self Pay Self Pay	$0.84

amiodarone 150 mg/3 mL IV Sol [CQCH]

Facility

$1.05

Service Code	HCPCS J0282
Hospital Charge Code	105910495
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.95
Rate for Payer: Aetna of AZ Commercial	$0.95
Rate for Payer: Aetna of AZ Medicare	$0.29
Rate for Payer: AHCCCS Medicaid	$0.68
Rate for Payer: Allwell Medicaid	$0.68
Rate for Payer: Allwell Medicare	$0.16
Rate for Payer: Amerigroup Medicare	$0.16
Rate for Payer: APIPA Medicare/Medicaid	$0.39
Rate for Payer: AZCH Complete Medicaid	$0.68
Rate for Payer: AZCH Complete Medicare	$0.16
Rate for Payer: Banner UC Health Medicaid	$0.68
Rate for Payer: Banner UC Health Medicare	$0.16
Rate for Payer: Bisbee Police All Plans	$0.27
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.71
Rate for Payer: Cash Price	$0.84
Rate for Payer: Cash Price	$0.84
Rate for Payer: Cigna of AZ Commercial	$0.68
Rate for Payer: Copperpoint Commercial	$0.26
Rate for Payer: Health Net of AZ Commercial	$0.63
Rate for Payer: Health Net of AZ Medicare	$0.29
Rate for Payer: Humana of AZ Medicare	$0.16
Rate for Payer: Mercy Care Medicaid	$0.68
Rate for Payer: Self Pay Self Pay	$0.84
Rate for Payer: TriWest Medicare	$0.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.61
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.19

amiodarone 200 mg Tab [CQCH]

Facility

$0.24

Service Code	NDC 245014701
Hospital Charge Code	105910355
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	$0.20
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

amiodarone 200 mg Tab [CQCH]

Facility

$0.24

Service Code	NDC 245014701
Hospital Charge Code	105910355
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	$0.20
Rate for Payer: Self Pay Self Pay	$0.19

amiodarone 360 mg/200 mL-D5% Sol [CQCH]

Facility

$0.22

Service Code	HCPCS J0282
Hospital Charge Code	105910420
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of AZ Commercial	$0.20
Rate for Payer: Aetna of AZ Medicare	$0.06
Rate for Payer: AHCCCS Medicaid	$0.68
Rate for Payer: Allwell Medicaid	$0.68
Rate for Payer: Allwell Medicare	$0.03
Rate for Payer: Amerigroup Medicare	$0.03
Rate for Payer: APIPA Medicare/Medicaid	$0.08
Rate for Payer: AZCH Complete Medicaid	$0.68
Rate for Payer: AZCH Complete Medicare	$0.03
Rate for Payer: Banner UC Health Medicaid	$0.68
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Bisbee Police All Plans	$0.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.15
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of AZ Commercial	$0.14
Rate for Payer: Copperpoint Commercial	$0.05
Rate for Payer: Health Net of AZ Commercial	$0.13
Rate for Payer: Health Net of AZ Medicare	$0.06
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Mercy Care Medicaid	$0.68
Rate for Payer: Self Pay Self Pay	$0.18
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.13
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.04

amiodarone 360 mg/200 mL-D5% Sol [CQCH]

Facility

$0.22

Service Code	HCPCS J0282
Hospital Charge Code	105910420
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of AZ Commercial	$0.20
Rate for Payer: Bisbee Police All Plans	$0.06
Rate for Payer: Cash Price	$0.17
Rate for Payer: Self Pay Self Pay	$0.18

amitriptyline 10 mg Tab [CQCH]

Facility

$0.26

Service Code	NDC 50268003715
Hospital Charge Code	105910570
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of AZ Commercial	$0.23
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	$0.10
Rate for Payer: AZCH Complete Medicare	$0.04
Rate for Payer: Banner UC Health Medicare	$0.04
Rate for Payer: Bisbee Police All Plans	$0.07
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.18
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of AZ Commercial	$0.17
Rate for Payer: Copperpoint Commercial	$0.06
Rate for Payer: Health Net of AZ Commercial	$0.16
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	$0.21
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.15
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.05

amitriptyline 10 mg Tab [CQCH]

Facility

$0.26

Service Code	NDC 50268003715
Hospital Charge Code	105910570
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of AZ Commercial	$0.23
Rate for Payer: Bisbee Police All Plans	$0.07
Rate for Payer: Cash Price	$0.21
Rate for Payer: Self Pay Self Pay	$0.21

amitriptyline 25 mg Tab [CQCH]

Facility

$0.24

Service Code	NDC 60687043301
Hospital Charge Code	105910637
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

amitriptyline 25 mg Tab [CQCH]

Facility

$0.24

Service Code	NDC 60687043301
Hospital Charge Code	105910637
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

amLODIPine 5 mg Tab [CQCH]

Facility

$0.08

Service Code	NDC 904637061
Hospital Charge Code	105910702
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	$0.06
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

amLODIPine 5 mg Tab [CQCH]

Facility

$0.08

Service Code	NDC 904637061
Hospital Charge Code	105910702
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	$0.06
Rate for Payer: Self Pay Self Pay	$0.06

AMMONIA

Facility

$190.00

Service Code	CPT 82140
Hospital Charge Code	22481458
Hospital Revenue Code	301
Min. Negotiated Rate	$14.57
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna of AZ Commercial	$171.00
Rate for Payer: Aetna of AZ Medicare	$53.20
Rate for Payer: AHCCCS Medicaid	$14.57
Rate for Payer: Allwell Medicaid	$14.57
Rate for Payer: Allwell Medicare	$28.50
Rate for Payer: Amerigroup Medicare	$28.50
Rate for Payer: APIPA Medicare/Medicaid	$70.96
Rate for Payer: AZCH Complete Medicaid	$14.57
Rate for Payer: AZCH Complete Medicare	$28.50
Rate for Payer: Banner UC Health Medicaid	$14.57
Rate for Payer: Banner UC Health Medicare	$28.50
Rate for Payer: Bisbee Police All Plans	$49.40
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$129.20
Rate for Payer: Cash Price	$152.00
Rate for Payer: Cash Price	$152.00
Rate for Payer: Cigna of AZ Commercial	$123.50
Rate for Payer: Copperpoint Commercial	$47.02
Rate for Payer: Health Net of AZ Commercial	$114.00
Rate for Payer: Health Net of AZ Medicare	$53.20
Rate for Payer: Humana of AZ Medicare	$28.50
Rate for Payer: Mercy Care Medicaid	$14.57
Rate for Payer: Self Pay Self Pay	$152.00
Rate for Payer: TriWest Medicare	$28.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$110.77
Rate for Payer: UnitedHealth Group of AZ Medicare	$34.20

AMMONIA

Facility

$190.00

Service Code	CPT 82140
Hospital Charge Code	22481458
Hospital Revenue Code	301
Min. Negotiated Rate	$49.40
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna of AZ Commercial	$171.00
Rate for Payer: Bisbee Police All Plans	$49.40
Rate for Payer: Cash Price	$152.00
Rate for Payer: Self Pay Self Pay	$152.00

ammonia inhalant [CQCH]

Facility

$0.17

Service Code	NDC 39822990002
Hospital Charge Code	105953831
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
Rate for Payer: Aetna of AZ Medicare	$0.05
Rate for Payer: Allwell Medicare	$0.03
Rate for Payer: Amerigroup Medicare	$0.03
Rate for Payer: APIPA Medicare/Medicaid	$0.06
Rate for Payer: AZCH Complete Medicare	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.12
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of AZ Commercial	$0.11
Rate for Payer: Copperpoint Commercial	$0.04
Rate for Payer: Health Net of AZ Commercial	$0.10
Rate for Payer: Health Net of AZ Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Self Pay Self Pay	$0.14
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.10
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.03

ammonia inhalant [CQCH]

Facility

$0.17

Service Code	NDC 39822990002
Hospital Charge Code	105953831
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Cash Price	$0.14
Rate for Payer: Self Pay Self Pay	$0.14

Know your out-of-pocket cost for care.

All Charges