Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Allogeneic Bone Marrow Transplant

Facility

$137,807.57

Service Code	APR-DRG 0074
Hospital Charge Code	APRDRG0073
Min. Negotiated Rate	$137,807.57
Max. Negotiated Rate	$137,807.57
Rate for Payer: AHCCCS Medicaid	$137,807.57
Rate for Payer: Allwell Medicaid	$137,807.57
Rate for Payer: AZCH Complete Medicaid	$137,807.57
Rate for Payer: Banner UC Health Medicaid	$137,807.57
Rate for Payer: Mercy Care Medicaid	$137,807.57

allopurinol 100 mg Tab [CQCH]

Facility

$0.26

Service Code	NDC 51079020520
Hospital Charge Code	105909905
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

allopurinol 100 mg Tab [CQCH]

Facility

$0.26

Service Code	NDC 51079020520
Hospital Charge Code	105909905
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

ALPHA-1-ANTITRYPSIN (PROTEIN) BLOOD TEST, PHENOTYPE

Facility

$72.25

Service Code	CPT 82104
Hospital Charge Code	28008412
Hospital Revenue Code	302
Min. Negotiated Rate	$11.56
Max. Negotiated Rate	$65.03
Rate for Payer: Aetna of AZ Commercial	$65.03
Rate for Payer: Aetna of AZ Medicare	$20.23
Rate for Payer: Allwell Medicare	$11.56
Rate for Payer: Amerigroup Medicare	$11.56
Rate for Payer: APIPA Medicare/Medicaid	$26.99
Rate for Payer: AZCH Complete Medicare	$11.56
Rate for Payer: Banner UC Health Medicare	$11.56
Rate for Payer: Bisbee Police All Plans	$18.79
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$49.13
Rate for Payer: Cash Price	$57.80
Rate for Payer: Cigna of AZ Commercial	$46.96
Rate for Payer: Copperpoint Commercial	$17.88
Rate for Payer: Health Net of AZ Commercial	$43.35
Rate for Payer: Health Net of AZ Medicare	$20.23
Rate for Payer: Humana of AZ Medicare	$11.56
Rate for Payer: Self Pay Self Pay	$57.80
Rate for Payer: TriWest Medicare	$11.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$42.12
Rate for Payer: UnitedHealth Group of AZ Medicare	$13.01

ALPHA-1-ANTITRYPSIN (PROTEIN) BLOOD TEST, PHENOTYPE

Facility

$72.25

Service Code	CPT 82104
Hospital Charge Code	28008412
Hospital Revenue Code	302
Min. Negotiated Rate	$18.79
Max. Negotiated Rate	$65.03
Rate for Payer: Aetna of AZ Commercial	$65.03
Rate for Payer: Bisbee Police All Plans	$18.79
Rate for Payer: Cash Price	$57.80
Rate for Payer: Self Pay Self Pay	$57.80

Alpha-1-Antitrypsin, Serum LC

Facility

$172.00

Service Code	CPT 82103
Hospital Charge Code	1905910
Hospital Revenue Code	301
Min. Negotiated Rate	$27.52
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Aetna of AZ Medicare	$48.16
Rate for Payer: Allwell Medicare	$27.52
Rate for Payer: Amerigroup Medicare	$27.52
Rate for Payer: APIPA Medicare/Medicaid	$64.24
Rate for Payer: AZCH Complete Medicare	$27.52
Rate for Payer: Banner UC Health Medicare	$27.52
Rate for Payer: Bisbee Police All Plans	$44.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$116.96
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cigna of AZ Commercial	$111.80
Rate for Payer: Copperpoint Commercial	$42.57
Rate for Payer: Health Net of AZ Commercial	$103.20
Rate for Payer: Health Net of AZ Medicare	$48.16
Rate for Payer: Humana of AZ Medicare	$27.52
Rate for Payer: Self Pay Self Pay	$137.60
Rate for Payer: TriWest Medicare	$27.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$100.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$30.96

Alpha-1-Antitrypsin, Serum LC

Facility

$172.00

Service Code	CPT 82103
Hospital Charge Code	1905910
Hospital Revenue Code	301
Min. Negotiated Rate	$44.72
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Bisbee Police All Plans	$44.72
Rate for Payer: Cash Price	$137.60
Rate for Payer: Self Pay Self Pay	$137.60

ALPRAZolam 0.25 mg Oral DIS Tab [CQCH]

Facility

$0.75

Service Code	NDC 49884011074
Hospital Charge Code	205191087
Hospital Revenue Code	251
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of AZ Commercial	$0.68
Rate for Payer: Bisbee Police All Plans	$0.20
Rate for Payer: Cash Price	$0.60
Rate for Payer: Self Pay Self Pay	$0.60

ALPRAZolam 0.25 mg Oral DIS Tab [CQCH]

Facility

$0.75

Service Code	NDC 49884011074
Hospital Charge Code	205191087
Hospital Revenue Code	251
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.68
Rate for Payer: Aetna of AZ Commercial	$0.68
Rate for Payer: Aetna of AZ Medicare	$0.21
Rate for Payer: Allwell Medicare	$0.12
Rate for Payer: Amerigroup Medicare	$0.12
Rate for Payer: APIPA Medicare/Medicaid	$0.28
Rate for Payer: AZCH Complete Medicare	$0.12
Rate for Payer: Banner UC Health Medicare	$0.12
Rate for Payer: Bisbee Police All Plans	$0.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.51
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cigna of AZ Commercial	$0.49
Rate for Payer: Copperpoint Commercial	$0.19
Rate for Payer: Health Net of AZ Commercial	$0.45
Rate for Payer: Health Net of AZ Medicare	$0.21
Rate for Payer: Humana of AZ Medicare	$0.12
Rate for Payer: Self Pay Self Pay	$0.60
Rate for Payer: TriWest Medicare	$0.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.44
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.14

ALPRAZolam 1 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 904586061
Hospital Charge Code	105910004
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

ALPRAZolam 1 mg Tab [CQCH]

Facility

$0.06

Service Code	NDC 904586061
Hospital Charge Code	105910004
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

alteplase 100 mg IV Inj [CQCH]

Facility

$9,069.76

Service Code	HCPCS J2997
Hospital Charge Code	105910209
Hospital Revenue Code	636
Min. Negotiated Rate	$1,451.16
Max. Negotiated Rate	$8,162.78
Rate for Payer: Aetna of AZ Commercial	$8,162.78
Rate for Payer: Aetna of AZ Medicare	$2,539.53
Rate for Payer: Allwell Medicare	$1,451.16
Rate for Payer: Amerigroup Medicare	$1,451.16
Rate for Payer: APIPA Medicare/Medicaid	$3,387.56
Rate for Payer: AZCH Complete Medicare	$1,451.16
Rate for Payer: Banner UC Health Medicare	$1,451.16
Rate for Payer: Bisbee Police All Plans	$2,358.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$6,167.44
Rate for Payer: Cash Price	$7,255.81
Rate for Payer: Cigna of AZ Commercial	$6,348.83
Rate for Payer: Copperpoint Commercial	$2,244.77
Rate for Payer: Health Net of AZ Commercial	$5,441.86
Rate for Payer: Health Net of AZ Medicare	$2,539.53
Rate for Payer: Humana of AZ Medicare	$1,451.16
Rate for Payer: Self Pay Self Pay	$7,255.81
Rate for Payer: TriWest Medicare	$1,451.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$5,287.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,632.56

alteplase 100 mg IV Inj [CQCH]

Facility

$9,069.76

Service Code	HCPCS J2997
Hospital Charge Code	105910209
Hospital Revenue Code	636
Min. Negotiated Rate	$2,358.14
Max. Negotiated Rate	$8,162.78
Rate for Payer: Aetna of AZ Commercial	$8,162.78
Rate for Payer: Bisbee Police All Plans	$2,358.14
Rate for Payer: Cash Price	$7,255.81
Rate for Payer: Self Pay Self Pay	$7,255.81

alteplase 2 mg IV Inj [CQCH]

Facility

$149.62

Service Code	HCPCS J2997
Hospital Charge Code	105910142
Hospital Revenue Code	250
Min. Negotiated Rate	$23.94
Max. Negotiated Rate	$134.66
Rate for Payer: Aetna of AZ Commercial	$134.66
Rate for Payer: Aetna of AZ Medicare	$41.89
Rate for Payer: Allwell Medicare	$23.94
Rate for Payer: Amerigroup Medicare	$23.94
Rate for Payer: APIPA Medicare/Medicaid	$55.88
Rate for Payer: AZCH Complete Medicare	$23.94
Rate for Payer: Banner UC Health Medicare	$23.94
Rate for Payer: Bisbee Police All Plans	$38.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$101.74
Rate for Payer: Cash Price	$119.70
Rate for Payer: Cigna of AZ Commercial	$97.25
Rate for Payer: Copperpoint Commercial	$37.03
Rate for Payer: Health Net of AZ Commercial	$89.77
Rate for Payer: Health Net of AZ Medicare	$41.89
Rate for Payer: Humana of AZ Medicare	$23.94
Rate for Payer: Self Pay Self Pay	$119.70
Rate for Payer: TriWest Medicare	$23.94
Rate for Payer: UnitedHealth Group of AZ Commercial	$87.23
Rate for Payer: UnitedHealth Group of AZ Medicare	$26.93

alteplase 2 mg IV Inj [CQCH]

Facility

$149.62

Service Code	HCPCS J2997
Hospital Charge Code	105910142
Hospital Revenue Code	250
Min. Negotiated Rate	$38.90
Max. Negotiated Rate	$134.66
Rate for Payer: Aetna of AZ Commercial	$134.66
Rate for Payer: Bisbee Police All Plans	$38.90
Rate for Payer: Cash Price	$119.70
Rate for Payer: Self Pay Self Pay	$119.70

alteplase 50 mg REC[CQCH]

Facility

$4,026.16

Service Code	HCPCS J2997
Hospital Charge Code	193296755
Hospital Revenue Code	636
Min. Negotiated Rate	$644.19
Max. Negotiated Rate	$3,623.54
Rate for Payer: Aetna of AZ Commercial	$3,623.54
Rate for Payer: Aetna of AZ Medicare	$1,127.32
Rate for Payer: Allwell Medicare	$644.19
Rate for Payer: Amerigroup Medicare	$644.19
Rate for Payer: APIPA Medicare/Medicaid	$1,503.77
Rate for Payer: AZCH Complete Medicare	$644.19
Rate for Payer: Banner UC Health Medicare	$644.19
Rate for Payer: Bisbee Police All Plans	$1,046.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,737.79
Rate for Payer: Cash Price	$3,220.93
Rate for Payer: Cigna of AZ Commercial	$2,818.31
Rate for Payer: Copperpoint Commercial	$996.47
Rate for Payer: Health Net of AZ Commercial	$2,415.70
Rate for Payer: Health Net of AZ Medicare	$1,127.32
Rate for Payer: Humana of AZ Medicare	$644.19
Rate for Payer: Self Pay Self Pay	$3,220.93
Rate for Payer: TriWest Medicare	$644.19
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,347.25
Rate for Payer: UnitedHealth Group of AZ Medicare	$724.71

alteplase 50 mg REC[CQCH]

Facility

$4,026.16

Service Code	HCPCS J2997
Hospital Charge Code	193296755
Hospital Revenue Code	636
Min. Negotiated Rate	$1,046.80
Max. Negotiated Rate	$3,623.54
Rate for Payer: Aetna of AZ Commercial	$3,623.54
Rate for Payer: Bisbee Police All Plans	$1,046.80
Rate for Payer: Cash Price	$3,220.93
Rate for Payer: Self Pay Self Pay	$3,220.93

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

$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

Alteration In Consciousness

Facility

$5,836.35

Service Code	APR-DRG 0523
Hospital Charge Code	APRDRG0523
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

Alteration In Consciousness

Facility

$5,836.35

Service Code	APR-DRG 0523
Hospital Charge Code	APRDRG0522
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

Alteration In Consciousness

Facility

$13,677.30

Service Code	APR-DRG 0524
Hospital Charge Code	APRDRG0524
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

$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

$4,524.03

Service Code	APR-DRG 0522
Hospital Charge Code	APRDRG0523
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	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

Know your out-of-pocket cost for care.

All Charges