Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Antithrombin Deficiency Profile LC

Facility

$444.00

Service Code	CPT 85300
Hospital Charge Code	22012108
Hospital Revenue Code	305
Min. Negotiated Rate	$115.44
Max. Negotiated Rate	$399.60
Rate for Payer: Aetna of AZ Commercial	$399.60
Rate for Payer: Bisbee Police All Plans	$115.44
Rate for Payer: Cash Price	$355.20
Rate for Payer: Self Pay Self Pay	$355.20

antivenin (Crotalidae) polyvalent - Anavip [CQCH]

Facility

$1,166.62

Service Code	HCPCS J0841
Hospital Charge Code	215305345
Hospital Revenue Code	636
Min. Negotiated Rate	$186.66
Max. Negotiated Rate	$1,049.96
Rate for Payer: Aetna of AZ Commercial	$1,049.96
Rate for Payer: Aetna of AZ Medicare	$326.65
Rate for Payer: Allwell Medicare	$186.66
Rate for Payer: Amerigroup Medicare	$186.66
Rate for Payer: APIPA Medicare/Medicaid	$435.73
Rate for Payer: AZCH Complete Medicare	$186.66
Rate for Payer: Banner UC Health Medicare	$186.66
Rate for Payer: Bisbee Police All Plans	$303.32
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$793.30
Rate for Payer: Cash Price	$933.30
Rate for Payer: Cigna of AZ Commercial	$816.63
Rate for Payer: Copperpoint Commercial	$288.74
Rate for Payer: Health Net of AZ Commercial	$699.97
Rate for Payer: Health Net of AZ Medicare	$326.65
Rate for Payer: Humana of AZ Medicare	$186.66
Rate for Payer: Self Pay Self Pay	$933.30
Rate for Payer: TriWest Medicare	$186.66
Rate for Payer: UnitedHealth Group of AZ Commercial	$680.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$209.99

antivenin (Crotalidae) polyvalent - Anavip [CQCH]

Facility

$1,166.62

Service Code	HCPCS J0841
Hospital Charge Code	215305345
Hospital Revenue Code	636
Min. Negotiated Rate	$303.32
Max. Negotiated Rate	$1,049.96
Rate for Payer: Aetna of AZ Commercial	$1,049.96
Rate for Payer: Bisbee Police All Plans	$303.32
Rate for Payer: Cash Price	$933.30
Rate for Payer: Self Pay Self Pay	$933.30

Aph FFP ACDA

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	857632
Hospital Revenue Code	390
Min. Negotiated Rate	$28.32
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Aetna of AZ Medicare	$49.56
Rate for Payer: Allwell Medicare	$28.32
Rate for Payer: Amerigroup Medicare	$28.32
Rate for Payer: APIPA Medicare/Medicaid	$66.11
Rate for Payer: AZCH Complete Medicare	$28.32
Rate for Payer: Banner UC Health Medicare	$28.32
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$120.36
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cigna of AZ Commercial	$115.05
Rate for Payer: Copperpoint Commercial	$43.81
Rate for Payer: Health Net of AZ Commercial	$106.20
Rate for Payer: Health Net of AZ Medicare	$49.56
Rate for Payer: Humana of AZ Medicare	$28.32
Rate for Payer: Self Pay Self Pay	$141.60
Rate for Payer: TriWest Medicare	$28.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$103.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$31.86

Aph FFP ACDA

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	857632
Hospital Revenue Code	390
Min. Negotiated Rate	$46.02
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Cash Price	$141.60
Rate for Payer: Self Pay Self Pay	$141.60

Aph FFP ACDA Thawed

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	1221767
Hospital Revenue Code	390
Min. Negotiated Rate	$46.02
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Cash Price	$141.60
Rate for Payer: Self Pay Self Pay	$141.60

Aph FFP ACDA Thawed

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	1221767
Hospital Revenue Code	390
Min. Negotiated Rate	$28.32
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Aetna of AZ Medicare	$49.56
Rate for Payer: Allwell Medicare	$28.32
Rate for Payer: Amerigroup Medicare	$28.32
Rate for Payer: APIPA Medicare/Medicaid	$66.11
Rate for Payer: AZCH Complete Medicare	$28.32
Rate for Payer: Banner UC Health Medicare	$28.32
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$120.36
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cigna of AZ Commercial	$115.05
Rate for Payer: Copperpoint Commercial	$43.81
Rate for Payer: Health Net of AZ Commercial	$106.20
Rate for Payer: Health Net of AZ Medicare	$49.56
Rate for Payer: Humana of AZ Medicare	$28.32
Rate for Payer: Self Pay Self Pay	$141.60
Rate for Payer: TriWest Medicare	$28.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$103.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$31.86

Aph Plt ACDA LR

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857738
Hospital Revenue Code	390
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Aetna of AZ Medicare	$455.00
Rate for Payer: Allwell Medicare	$260.00
Rate for Payer: Amerigroup Medicare	$260.00
Rate for Payer: APIPA Medicare/Medicaid	$606.94
Rate for Payer: AZCH Complete Medicare	$260.00
Rate for Payer: Banner UC Health Medicare	$260.00
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,105.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cigna of AZ Commercial	$1,056.25
Rate for Payer: Copperpoint Commercial	$402.19
Rate for Payer: Health Net of AZ Commercial	$975.00
Rate for Payer: Health Net of AZ Medicare	$455.00
Rate for Payer: Humana of AZ Medicare	$260.00
Rate for Payer: Self Pay Self Pay	$1,300.00
Rate for Payer: TriWest Medicare	$260.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$947.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$292.50

Aph Plt ACDA LR

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857738
Hospital Revenue Code	390
Min. Negotiated Rate	$422.50
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Self Pay Self Pay	$1,300.00

Aph Plt ACDA LR 1

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857739
Hospital Revenue Code	390
Min. Negotiated Rate	$422.50
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Self Pay Self Pay	$1,300.00

Aph Plt ACDA LR 1

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857739
Hospital Revenue Code	390
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Aetna of AZ Medicare	$455.00
Rate for Payer: Allwell Medicare	$260.00
Rate for Payer: Amerigroup Medicare	$260.00
Rate for Payer: APIPA Medicare/Medicaid	$606.94
Rate for Payer: AZCH Complete Medicare	$260.00
Rate for Payer: Banner UC Health Medicare	$260.00
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,105.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cigna of AZ Commercial	$1,056.25
Rate for Payer: Copperpoint Commercial	$402.19
Rate for Payer: Health Net of AZ Commercial	$975.00
Rate for Payer: Health Net of AZ Medicare	$455.00
Rate for Payer: Humana of AZ Medicare	$260.00
Rate for Payer: Self Pay Self Pay	$1,300.00
Rate for Payer: TriWest Medicare	$260.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$947.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$292.50

Aph Plt ACDA LR 2

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857740
Hospital Revenue Code	390
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Aetna of AZ Medicare	$455.00
Rate for Payer: Allwell Medicare	$260.00
Rate for Payer: Amerigroup Medicare	$260.00
Rate for Payer: APIPA Medicare/Medicaid	$606.94
Rate for Payer: AZCH Complete Medicare	$260.00
Rate for Payer: Banner UC Health Medicare	$260.00
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,105.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cigna of AZ Commercial	$1,056.25
Rate for Payer: Copperpoint Commercial	$402.19
Rate for Payer: Health Net of AZ Commercial	$975.00
Rate for Payer: Health Net of AZ Medicare	$455.00
Rate for Payer: Humana of AZ Medicare	$260.00
Rate for Payer: Self Pay Self Pay	$1,300.00
Rate for Payer: TriWest Medicare	$260.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$947.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$292.50

Aph Plt ACDA LR 2

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857740
Hospital Revenue Code	390
Min. Negotiated Rate	$422.50
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Self Pay Self Pay	$1,300.00

Aph Plt ACDA LR 3

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857741
Hospital Revenue Code	390
Min. Negotiated Rate	$422.50
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Self Pay Self Pay	$1,300.00

Aph Plt ACDA LR 3

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857741
Hospital Revenue Code	390
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Aetna of AZ Medicare	$455.00
Rate for Payer: Allwell Medicare	$260.00
Rate for Payer: Amerigroup Medicare	$260.00
Rate for Payer: APIPA Medicare/Medicaid	$606.94
Rate for Payer: AZCH Complete Medicare	$260.00
Rate for Payer: Banner UC Health Medicare	$260.00
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,105.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cigna of AZ Commercial	$1,056.25
Rate for Payer: Copperpoint Commercial	$402.19
Rate for Payer: Health Net of AZ Commercial	$975.00
Rate for Payer: Health Net of AZ Medicare	$455.00
Rate for Payer: Humana of AZ Medicare	$260.00
Rate for Payer: Self Pay Self Pay	$1,300.00
Rate for Payer: TriWest Medicare	$260.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$947.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$292.50

Aph Plt ACDA LR Irr

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857748
Hospital Revenue Code	390
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Aetna of AZ Medicare	$455.00
Rate for Payer: Allwell Medicare	$260.00
Rate for Payer: Amerigroup Medicare	$260.00
Rate for Payer: APIPA Medicare/Medicaid	$606.94
Rate for Payer: AZCH Complete Medicare	$260.00
Rate for Payer: Banner UC Health Medicare	$260.00
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,105.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cigna of AZ Commercial	$1,056.25
Rate for Payer: Copperpoint Commercial	$402.19
Rate for Payer: Health Net of AZ Commercial	$975.00
Rate for Payer: Health Net of AZ Medicare	$455.00
Rate for Payer: Humana of AZ Medicare	$260.00
Rate for Payer: Self Pay Self Pay	$1,300.00
Rate for Payer: TriWest Medicare	$260.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$947.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$292.50

Aph Plt ACDA LR Irr

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857748
Hospital Revenue Code	390
Min. Negotiated Rate	$422.50
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Self Pay Self Pay	$1,300.00

Aph Plt ACDA LR Irr 1

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857749
Hospital Revenue Code	390
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Aetna of AZ Medicare	$455.00
Rate for Payer: Allwell Medicare	$260.00
Rate for Payer: Amerigroup Medicare	$260.00
Rate for Payer: APIPA Medicare/Medicaid	$606.94
Rate for Payer: AZCH Complete Medicare	$260.00
Rate for Payer: Banner UC Health Medicare	$260.00
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,105.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cigna of AZ Commercial	$1,056.25
Rate for Payer: Copperpoint Commercial	$402.19
Rate for Payer: Health Net of AZ Commercial	$975.00
Rate for Payer: Health Net of AZ Medicare	$455.00
Rate for Payer: Humana of AZ Medicare	$260.00
Rate for Payer: Self Pay Self Pay	$1,300.00
Rate for Payer: TriWest Medicare	$260.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$947.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$292.50

Aph Plt ACDA LR Irr 1

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857749
Hospital Revenue Code	390
Min. Negotiated Rate	$422.50
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Self Pay Self Pay	$1,300.00

Aph Plt ACDA LR Irr 2

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857750
Hospital Revenue Code	390
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Aetna of AZ Medicare	$455.00
Rate for Payer: Allwell Medicare	$260.00
Rate for Payer: Amerigroup Medicare	$260.00
Rate for Payer: APIPA Medicare/Medicaid	$606.94
Rate for Payer: AZCH Complete Medicare	$260.00
Rate for Payer: Banner UC Health Medicare	$260.00
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,105.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cigna of AZ Commercial	$1,056.25
Rate for Payer: Copperpoint Commercial	$402.19
Rate for Payer: Health Net of AZ Commercial	$975.00
Rate for Payer: Health Net of AZ Medicare	$455.00
Rate for Payer: Humana of AZ Medicare	$260.00
Rate for Payer: Self Pay Self Pay	$1,300.00
Rate for Payer: TriWest Medicare	$260.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$947.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$292.50

Aph Plt ACDA LR Irr 2

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857750
Hospital Revenue Code	390
Min. Negotiated Rate	$422.50
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Self Pay Self Pay	$1,300.00

Aph Plt ACDA LR Irr 3

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857751
Hospital Revenue Code	390
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Aetna of AZ Medicare	$455.00
Rate for Payer: Allwell Medicare	$260.00
Rate for Payer: Amerigroup Medicare	$260.00
Rate for Payer: APIPA Medicare/Medicaid	$606.94
Rate for Payer: AZCH Complete Medicare	$260.00
Rate for Payer: Banner UC Health Medicare	$260.00
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,105.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cigna of AZ Commercial	$1,056.25
Rate for Payer: Copperpoint Commercial	$402.19
Rate for Payer: Health Net of AZ Commercial	$975.00
Rate for Payer: Health Net of AZ Medicare	$455.00
Rate for Payer: Humana of AZ Medicare	$260.00
Rate for Payer: Self Pay Self Pay	$1,300.00
Rate for Payer: TriWest Medicare	$260.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$947.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$292.50

Aph Plt ACDA LR Irr 3

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	857751
Hospital Revenue Code	390
Min. Negotiated Rate	$422.50
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Self Pay Self Pay	$1,300.00

Aph Plt ACDA LR Irr <3 X log 11 1

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	22316432
Hospital Revenue Code	390
Min. Negotiated Rate	$422.50
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Self Pay Self Pay	$1,300.00

Aph Plt ACDA LR Irr <3 X log 11 1

Facility

$1,625.00

Service Code	CPT P9034
Hospital Charge Code	22316432
Hospital Revenue Code	390
Min. Negotiated Rate	$260.00
Max. Negotiated Rate	$1,462.50
Rate for Payer: Aetna of AZ Commercial	$1,462.50
Rate for Payer: Aetna of AZ Medicare	$455.00
Rate for Payer: Allwell Medicare	$260.00
Rate for Payer: Amerigroup Medicare	$260.00
Rate for Payer: APIPA Medicare/Medicaid	$606.94
Rate for Payer: AZCH Complete Medicare	$260.00
Rate for Payer: Banner UC Health Medicare	$260.00
Rate for Payer: Bisbee Police All Plans	$422.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,105.00
Rate for Payer: Cash Price	$1,300.00
Rate for Payer: Cigna of AZ Commercial	$1,056.25
Rate for Payer: Copperpoint Commercial	$402.19
Rate for Payer: Health Net of AZ Commercial	$975.00
Rate for Payer: Health Net of AZ Medicare	$455.00
Rate for Payer: Humana of AZ Medicare	$260.00
Rate for Payer: Self Pay Self Pay	$1,300.00
Rate for Payer: TriWest Medicare	$260.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$947.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$292.50

Know your out-of-pocket cost for care.

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