Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

warfarin 5 mg Tab [CQCH]

Facility

$0.38

Service Code	NDC 832121601
Hospital Charge Code	105945397
Hospital Revenue Code	251
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of AZ Commercial	$0.34
Rate for Payer: Bisbee Police All Plans	$0.10
Rate for Payer: Cash Price	$0.30
Rate for Payer: Self Pay Self Pay	$0.30

warfarin 5 mg Tab [CQCH]

Facility

$0.38

Service Code	NDC 832121601
Hospital Charge Code	105945397
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of AZ Commercial	$0.34
Rate for Payer: Aetna of AZ Medicare	$0.11
Rate for Payer: Allwell Medicare	$0.06
Rate for Payer: Amerigroup Medicare	$0.06
Rate for Payer: APIPA Medicare/Medicaid	$0.14
Rate for Payer: AZCH Complete Medicare	$0.06
Rate for Payer: Banner UC Health Medicare	$0.06
Rate for Payer: Bisbee Police All Plans	$0.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.26
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cigna of AZ Commercial	$0.25
Rate for Payer: Copperpoint Commercial	$0.09
Rate for Payer: Health Net of AZ Commercial	$0.23
Rate for Payer: Health Net of AZ Medicare	$0.11
Rate for Payer: Humana of AZ Medicare	$0.06
Rate for Payer: Self Pay Self Pay	$0.30
Rate for Payer: TriWest Medicare	$0.06
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.22
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.07

warfarin 7.5 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 56017375
Hospital Charge Code	105945332
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
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	$0.02
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	$0.04
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of AZ Commercial	$0.04
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.04
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	$0.05
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

warfarin 7.5 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 56017375
Hospital Charge Code	105945332
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Cash Price	$0.05
Rate for Payer: Self Pay Self Pay	$0.05

WARMER SCOPE BLUE HEAT SINGLE USE

Facility

$99.00

Hospital Charge Code	22354936
Hospital Revenue Code	270
Min. Negotiated Rate	$14.85
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of AZ Commercial	$89.10
Rate for Payer: Aetna of AZ Medicare	$27.72
Rate for Payer: Allwell Medicare	$14.85
Rate for Payer: Amerigroup Medicare	$14.85
Rate for Payer: APIPA Medicare/Medicaid	$36.98
Rate for Payer: AZCH Complete Medicare	$14.85
Rate for Payer: Banner UC Health Medicare	$14.85
Rate for Payer: Bisbee Police All Plans	$25.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$67.32
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna of AZ Commercial	$69.30
Rate for Payer: Copperpoint Commercial	$24.50
Rate for Payer: Health Net of AZ Commercial	$59.40
Rate for Payer: Health Net of AZ Medicare	$27.72
Rate for Payer: Humana of AZ Medicare	$14.85
Rate for Payer: Self Pay Self Pay	$79.20
Rate for Payer: TriWest Medicare	$14.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$57.72
Rate for Payer: UnitedHealth Group of AZ Medicare	$17.82

WARMER SCOPE BLUE HEAT SINGLE USE

Facility

$99.00

Hospital Charge Code	22354936
Hospital Revenue Code	270
Min. Negotiated Rate	$25.74
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of AZ Commercial	$89.10
Rate for Payer: Bisbee Police All Plans	$25.74
Rate for Payer: Cash Price	$79.20
Rate for Payer: Self Pay Self Pay	$79.20

WATER STERILE 750 ML RESP THERAPY

Facility

$20.00

Hospital Charge Code	22355211
Hospital Revenue Code	270
Min. Negotiated Rate	$5.20
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Bisbee Police All Plans	$5.20
Rate for Payer: Cash Price	$16.00
Rate for Payer: Self Pay Self Pay	$16.00

WATER STERILE 750 ML RESP THERAPY

Facility

$20.00

Hospital Charge Code	22355211
Hospital Revenue Code	270
Min. Negotiated Rate	$3.00
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Aetna of AZ Medicare	$5.60
Rate for Payer: Allwell Medicare	$3.00
Rate for Payer: Amerigroup Medicare	$3.00
Rate for Payer: APIPA Medicare/Medicaid	$7.47
Rate for Payer: AZCH Complete Medicare	$3.00
Rate for Payer: Banner UC Health Medicare	$3.00
Rate for Payer: Bisbee Police All Plans	$5.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$13.60
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cigna of AZ Commercial	$14.00
Rate for Payer: Copperpoint Commercial	$4.95
Rate for Payer: Health Net of AZ Commercial	$12.00
Rate for Payer: Health Net of AZ Medicare	$5.60
Rate for Payer: Humana of AZ Medicare	$3.00
Rate for Payer: Self Pay Self Pay	$16.00
Rate for Payer: TriWest Medicare	$3.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$11.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.60

West Nile Virus LC

Facility

$403.00

Service Code	CPT 86788
Hospital Charge Code	3508632
Hospital Revenue Code	302
Min. Negotiated Rate	$104.78
Max. Negotiated Rate	$362.70
Rate for Payer: Aetna of AZ Commercial	$362.70
Rate for Payer: Bisbee Police All Plans	$104.78
Rate for Payer: Cash Price	$322.40
Rate for Payer: Self Pay Self Pay	$322.40

West Nile Virus LC

Facility

$403.00

Service Code	CPT 86788
Hospital Charge Code	3508632
Hospital Revenue Code	302
Min. Negotiated Rate	$16.85
Max. Negotiated Rate	$362.70
Rate for Payer: Aetna of AZ Commercial	$362.70
Rate for Payer: Aetna of AZ Medicare	$112.84
Rate for Payer: AHCCCS Medicaid	$16.85
Rate for Payer: Allwell Medicaid	$16.85
Rate for Payer: Allwell Medicare	$60.45
Rate for Payer: Amerigroup Medicare	$60.45
Rate for Payer: APIPA Medicare/Medicaid	$150.52
Rate for Payer: AZCH Complete Medicaid	$16.85
Rate for Payer: AZCH Complete Medicare	$60.45
Rate for Payer: Banner UC Health Medicaid	$16.85
Rate for Payer: Banner UC Health Medicare	$60.45
Rate for Payer: Bisbee Police All Plans	$104.78
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$274.04
Rate for Payer: Cash Price	$322.40
Rate for Payer: Cash Price	$322.40
Rate for Payer: Cigna of AZ Commercial	$261.95
Rate for Payer: Copperpoint Commercial	$99.74
Rate for Payer: Health Net of AZ Commercial	$241.80
Rate for Payer: Health Net of AZ Medicare	$112.84
Rate for Payer: Humana of AZ Medicare	$60.45
Rate for Payer: Mercy Care Medicaid	$16.85
Rate for Payer: Self Pay Self Pay	$322.40
Rate for Payer: TriWest Medicare	$60.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$234.95
Rate for Payer: UnitedHealth Group of AZ Medicare	$72.54

Wet Prep

Facility

$139.00

Service Code	CPT 87210
Hospital Charge Code	1657611
Hospital Revenue Code	306
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of AZ Commercial	$125.10
Rate for Payer: Aetna of AZ Medicare	$38.92
Rate for Payer: AHCCCS Medicaid	$5.82
Rate for Payer: Allwell Medicaid	$5.82
Rate for Payer: Allwell Medicare	$20.85
Rate for Payer: Amerigroup Medicare	$20.85
Rate for Payer: APIPA Medicare/Medicaid	$51.92
Rate for Payer: AZCH Complete Medicaid	$5.82
Rate for Payer: AZCH Complete Medicare	$20.85
Rate for Payer: Banner UC Health Medicaid	$5.82
Rate for Payer: Banner UC Health Medicare	$20.85
Rate for Payer: Bisbee Police All Plans	$36.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$94.52
Rate for Payer: Cash Price	$111.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Cigna of AZ Commercial	$90.35
Rate for Payer: Copperpoint Commercial	$34.40
Rate for Payer: Health Net of AZ Commercial	$83.40
Rate for Payer: Health Net of AZ Medicare	$38.92
Rate for Payer: Humana of AZ Medicare	$20.85
Rate for Payer: Mercy Care Medicaid	$5.82
Rate for Payer: Self Pay Self Pay	$111.20
Rate for Payer: TriWest Medicare	$20.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$81.04
Rate for Payer: UnitedHealth Group of AZ Medicare	$25.02

Wet Prep

Facility

$139.00

Service Code	CPT 87210
Hospital Charge Code	1657611
Hospital Revenue Code	306
Min. Negotiated Rate	$36.14
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of AZ Commercial	$125.10
Rate for Payer: Bisbee Police All Plans	$36.14
Rate for Payer: Cash Price	$111.20
Rate for Payer: Self Pay Self Pay	$111.20

Wet Prep 5

Facility

$132.00

Service Code	CPT 87210
Hospital Charge Code	10495297
Hospital Revenue Code	306
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$118.80
Rate for Payer: Aetna of AZ Commercial	$118.80
Rate for Payer: Aetna of AZ Medicare	$36.96
Rate for Payer: AHCCCS Medicaid	$5.82
Rate for Payer: Allwell Medicaid	$5.82
Rate for Payer: Allwell Medicare	$19.80
Rate for Payer: Amerigroup Medicare	$19.80
Rate for Payer: APIPA Medicare/Medicaid	$49.30
Rate for Payer: AZCH Complete Medicaid	$5.82
Rate for Payer: AZCH Complete Medicare	$19.80
Rate for Payer: Banner UC Health Medicaid	$5.82
Rate for Payer: Banner UC Health Medicare	$19.80
Rate for Payer: Bisbee Police All Plans	$34.32
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$89.76
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cigna of AZ Commercial	$85.80
Rate for Payer: Copperpoint Commercial	$32.67
Rate for Payer: Health Net of AZ Commercial	$79.20
Rate for Payer: Health Net of AZ Medicare	$36.96
Rate for Payer: Humana of AZ Medicare	$19.80
Rate for Payer: Mercy Care Medicaid	$5.82
Rate for Payer: Self Pay Self Pay	$105.60
Rate for Payer: TriWest Medicare	$19.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$76.96
Rate for Payer: UnitedHealth Group of AZ Medicare	$23.76

Wet Prep 5

Facility

$132.00

Service Code	CPT 87210
Hospital Charge Code	10495297
Hospital Revenue Code	306
Min. Negotiated Rate	$34.32
Max. Negotiated Rate	$118.80
Rate for Payer: Aetna of AZ Commercial	$118.80
Rate for Payer: Bisbee Police All Plans	$34.32
Rate for Payer: Cash Price	$105.60
Rate for Payer: Self Pay Self Pay	$105.60

WHISPER SWIVEL VALVE

Facility

$298.00

Hospital Charge Code	27733113
Hospital Revenue Code	270
Min. Negotiated Rate	$77.48
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Bisbee Police All Plans	$77.48
Rate for Payer: Cash Price	$238.40
Rate for Payer: Self Pay Self Pay	$238.40

WHISPER SWIVEL VALVE

Facility

$298.00

Hospital Charge Code	27733113
Hospital Revenue Code	270
Min. Negotiated Rate	$44.70
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Aetna of AZ Medicare	$83.44
Rate for Payer: Allwell Medicare	$44.70
Rate for Payer: Amerigroup Medicare	$44.70
Rate for Payer: APIPA Medicare/Medicaid	$111.30
Rate for Payer: AZCH Complete Medicare	$44.70
Rate for Payer: Banner UC Health Medicare	$44.70
Rate for Payer: Bisbee Police All Plans	$77.48
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$202.64
Rate for Payer: Cash Price	$238.40
Rate for Payer: Cigna of AZ Commercial	$208.60
Rate for Payer: Copperpoint Commercial	$73.76
Rate for Payer: Health Net of AZ Commercial	$178.80
Rate for Payer: Health Net of AZ Medicare	$83.44
Rate for Payer: Humana of AZ Medicare	$44.70
Rate for Payer: Self Pay Self Pay	$238.40
Rate for Payer: TriWest Medicare	$44.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$173.73
Rate for Payer: UnitedHealth Group of AZ Medicare	$53.64

White Blood Count

Facility

$92.00

Service Code	CPT 85048
Hospital Charge Code	633873
Hospital Revenue Code	305
Min. Negotiated Rate	$2.54
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of AZ Commercial	$82.80
Rate for Payer: Aetna of AZ Medicare	$25.76
Rate for Payer: AHCCCS Medicaid	$2.54
Rate for Payer: Allwell Medicaid	$2.54
Rate for Payer: Allwell Medicare	$13.80
Rate for Payer: Amerigroup Medicare	$13.80
Rate for Payer: APIPA Medicare/Medicaid	$34.36
Rate for Payer: AZCH Complete Medicaid	$2.54
Rate for Payer: AZCH Complete Medicare	$13.80
Rate for Payer: Banner UC Health Medicaid	$2.54
Rate for Payer: Banner UC Health Medicare	$13.80
Rate for Payer: Bisbee Police All Plans	$23.92
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$62.56
Rate for Payer: Cash Price	$73.60
Rate for Payer: Cash Price	$73.60
Rate for Payer: Cigna of AZ Commercial	$59.80
Rate for Payer: Copperpoint Commercial	$22.77
Rate for Payer: Health Net of AZ Commercial	$55.20
Rate for Payer: Health Net of AZ Medicare	$25.76
Rate for Payer: Humana of AZ Medicare	$13.80
Rate for Payer: Mercy Care Medicaid	$2.54
Rate for Payer: Self Pay Self Pay	$73.60
Rate for Payer: TriWest Medicare	$13.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$53.64
Rate for Payer: UnitedHealth Group of AZ Medicare	$16.56

White Blood Count

Facility

$92.00

Service Code	CPT 85048
Hospital Charge Code	633873
Hospital Revenue Code	305
Min. Negotiated Rate	$23.92
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of AZ Commercial	$82.80
Rate for Payer: Bisbee Police All Plans	$23.92
Rate for Payer: Cash Price	$73.60
Rate for Payer: Self Pay Self Pay	$73.60

WHITE INTRAOSSEOUS MODULE PEDS

Facility

$362.00

Hospital Charge Code	23175127
Hospital Revenue Code	272
Min. Negotiated Rate	$94.12
Max. Negotiated Rate	$325.80
Rate for Payer: Aetna of AZ Commercial	$325.80
Rate for Payer: Bisbee Police All Plans	$94.12
Rate for Payer: Cash Price	$289.60
Rate for Payer: Self Pay Self Pay	$289.60

WHITE INTRAOSSEOUS MODULE PEDS

Facility

$362.00

Hospital Charge Code	23175127
Hospital Revenue Code	272
Min. Negotiated Rate	$54.30
Max. Negotiated Rate	$325.80
Rate for Payer: Aetna of AZ Commercial	$325.80
Rate for Payer: Aetna of AZ Medicare	$101.36
Rate for Payer: Allwell Medicare	$54.30
Rate for Payer: Amerigroup Medicare	$54.30
Rate for Payer: APIPA Medicare/Medicaid	$135.21
Rate for Payer: AZCH Complete Medicare	$54.30
Rate for Payer: Banner UC Health Medicare	$54.30
Rate for Payer: Bisbee Police All Plans	$94.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$246.16
Rate for Payer: Cash Price	$289.60
Rate for Payer: Cigna of AZ Commercial	$253.40
Rate for Payer: Copperpoint Commercial	$89.60
Rate for Payer: Health Net of AZ Commercial	$217.20
Rate for Payer: Health Net of AZ Medicare	$101.36
Rate for Payer: Humana of AZ Medicare	$54.30
Rate for Payer: Self Pay Self Pay	$289.60
Rate for Payer: TriWest Medicare	$54.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$211.05
Rate for Payer: UnitedHealth Group of AZ Medicare	$65.16

WHITE INTUBATION MODULE PEDS

Facility

$302.00

Hospital Charge Code	23175715
Hospital Revenue Code	272
Min. Negotiated Rate	$45.30
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of AZ Commercial	$271.80
Rate for Payer: Aetna of AZ Medicare	$84.56
Rate for Payer: Allwell Medicare	$45.30
Rate for Payer: Amerigroup Medicare	$45.30
Rate for Payer: APIPA Medicare/Medicaid	$112.80
Rate for Payer: AZCH Complete Medicare	$45.30
Rate for Payer: Banner UC Health Medicare	$45.30
Rate for Payer: Bisbee Police All Plans	$78.52
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$205.36
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cigna of AZ Commercial	$211.40
Rate for Payer: Copperpoint Commercial	$74.74
Rate for Payer: Health Net of AZ Commercial	$181.20
Rate for Payer: Health Net of AZ Medicare	$84.56
Rate for Payer: Humana of AZ Medicare	$45.30
Rate for Payer: Self Pay Self Pay	$241.60
Rate for Payer: TriWest Medicare	$45.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$176.07
Rate for Payer: UnitedHealth Group of AZ Medicare	$54.36

WHITE INTUBATION MODULE PEDS

Facility

$302.00

Hospital Charge Code	23175715
Hospital Revenue Code	272
Min. Negotiated Rate	$78.52
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of AZ Commercial	$271.80
Rate for Payer: Bisbee Police All Plans	$78.52
Rate for Payer: Cash Price	$241.60
Rate for Payer: Self Pay Self Pay	$241.60

WHITE IV DELIVERY MODULE PEDS

Facility

$290.00

Hospital Charge Code	23175708
Hospital Revenue Code	272
Min. Negotiated Rate	$75.40
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna of AZ Commercial	$261.00
Rate for Payer: Bisbee Police All Plans	$75.40
Rate for Payer: Cash Price	$232.00
Rate for Payer: Self Pay Self Pay	$232.00

WHITE IV DELIVERY MODULE PEDS

Facility

$290.00

Hospital Charge Code	23175708
Hospital Revenue Code	272
Min. Negotiated Rate	$43.50
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna of AZ Commercial	$261.00
Rate for Payer: Aetna of AZ Medicare	$81.20
Rate for Payer: Allwell Medicare	$43.50
Rate for Payer: Amerigroup Medicare	$43.50
Rate for Payer: APIPA Medicare/Medicaid	$108.32
Rate for Payer: AZCH Complete Medicare	$43.50
Rate for Payer: Banner UC Health Medicare	$43.50
Rate for Payer: Bisbee Police All Plans	$75.40
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$197.20
Rate for Payer: Cash Price	$232.00
Rate for Payer: Cigna of AZ Commercial	$203.00
Rate for Payer: Copperpoint Commercial	$71.78
Rate for Payer: Health Net of AZ Commercial	$174.00
Rate for Payer: Health Net of AZ Medicare	$81.20
Rate for Payer: Humana of AZ Medicare	$43.50
Rate for Payer: Self Pay Self Pay	$232.00
Rate for Payer: TriWest Medicare	$43.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$169.07
Rate for Payer: UnitedHealth Group of AZ Medicare	$52.20

WHITE OXYGEN DELIVERY MODULEM PEDS

Facility

$121.00

Hospital Charge Code	23175701
Hospital Revenue Code	272
Min. Negotiated Rate	$31.46
Max. Negotiated Rate	$108.90
Rate for Payer: Aetna of AZ Commercial	$108.90
Rate for Payer: Bisbee Police All Plans	$31.46
Rate for Payer: Cash Price	$96.80
Rate for Payer: Self Pay Self Pay	$96.80

Know your out-of-pocket cost for care.

All Charges