Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

bisacodyl 10 mg Supp [CQCH]

Facility

$0.08

Service Code	NDC 713010912
Hospital Charge Code	105913109
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

bisacodyl 10 mg Supp [CQCH]

Facility

$0.08

Service Code	NDC 713010912
Hospital Charge Code	105913109
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

bisacodyl 5 mg EC Tab [CQCH]

Facility

$0.03

Service Code	NDC 904640761
Hospital Charge Code	105913044
Hospital Revenue Code	251
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of AZ Commercial	$0.02
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.02
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

bisacodyl 5 mg EC Tab [CQCH]

Facility

$0.03

Service Code	NDC 904640761
Hospital Charge Code	105913044
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Self Pay Self Pay	$0.02

BITE PROOF BITE BLOCK

Facility

$56.35

Hospital Charge Code	27542969
Hospital Revenue Code	270
Min. Negotiated Rate	$14.65
Max. Negotiated Rate	$50.72
Rate for Payer: Aetna of AZ Commercial	$50.72
Rate for Payer: Bisbee Police All Plans	$14.65
Rate for Payer: Cash Price	$45.08
Rate for Payer: Self Pay Self Pay	$45.08

BITE PROOF BITE BLOCK

Facility

$56.35

Hospital Charge Code	27542969
Hospital Revenue Code	270
Min. Negotiated Rate	$8.45
Max. Negotiated Rate	$50.72
Rate for Payer: Aetna of AZ Commercial	$50.72
Rate for Payer: Aetna of AZ Medicare	$15.78
Rate for Payer: Allwell Medicare	$8.45
Rate for Payer: Amerigroup Medicare	$8.45
Rate for Payer: APIPA Medicare/Medicaid	$21.05
Rate for Payer: AZCH Complete Medicare	$8.45
Rate for Payer: Banner UC Health Medicare	$8.45
Rate for Payer: Bisbee Police All Plans	$14.65
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$38.32
Rate for Payer: Cash Price	$45.08
Rate for Payer: Cigna of AZ Commercial	$39.44
Rate for Payer: Copperpoint Commercial	$13.95
Rate for Payer: Health Net of AZ Commercial	$33.81
Rate for Payer: Health Net of AZ Medicare	$15.78
Rate for Payer: Humana of AZ Medicare	$8.45
Rate for Payer: Self Pay Self Pay	$45.08
Rate for Payer: TriWest Medicare	$8.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$32.85
Rate for Payer: UnitedHealth Group of AZ Medicare	$10.14

BK Quant PCR (Plasma/Serum) LC

Facility

$560.00

Service Code	CPT 87799
Hospital Charge Code	2029177
Hospital Revenue Code	306
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$504.00
Rate for Payer: Aetna of AZ Commercial	$504.00
Rate for Payer: Bisbee Police All Plans	$145.60
Rate for Payer: Cash Price	$448.00
Rate for Payer: Self Pay Self Pay	$448.00

BK Quant PCR (Plasma/Serum) LC

Facility

$560.00

Service Code	CPT 87799
Hospital Charge Code	2029177
Hospital Revenue Code	306
Min. Negotiated Rate	$42.84
Max. Negotiated Rate	$504.00
Rate for Payer: Aetna of AZ Commercial	$504.00
Rate for Payer: Aetna of AZ Medicare	$156.80
Rate for Payer: AHCCCS Medicaid	$42.84
Rate for Payer: Allwell Medicaid	$42.84
Rate for Payer: Allwell Medicare	$84.00
Rate for Payer: Amerigroup Medicare	$84.00
Rate for Payer: APIPA Medicare/Medicaid	$209.16
Rate for Payer: AZCH Complete Medicaid	$42.84
Rate for Payer: AZCH Complete Medicare	$84.00
Rate for Payer: Banner UC Health Medicaid	$42.84
Rate for Payer: Banner UC Health Medicare	$84.00
Rate for Payer: Bisbee Police All Plans	$145.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$380.80
Rate for Payer: Cash Price	$448.00
Rate for Payer: Cash Price	$448.00
Rate for Payer: Cigna of AZ Commercial	$364.00
Rate for Payer: Copperpoint Commercial	$138.60
Rate for Payer: Health Net of AZ Commercial	$336.00
Rate for Payer: Health Net of AZ Medicare	$156.80
Rate for Payer: Humana of AZ Medicare	$84.00
Rate for Payer: Mercy Care Medicaid	$42.84
Rate for Payer: Self Pay Self Pay	$448.00
Rate for Payer: TriWest Medicare	$84.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$326.48
Rate for Payer: UnitedHealth Group of AZ Medicare	$100.80

Black Silicone Filiform ureteral stent

Facility

$1,159.00

Hospital Charge Code	22926477
Hospital Revenue Code	272
Min. Negotiated Rate	$301.34
Max. Negotiated Rate	$1,043.10
Rate for Payer: Aetna of AZ Commercial	$1,043.10
Rate for Payer: Bisbee Police All Plans	$301.34
Rate for Payer: Cash Price	$927.20
Rate for Payer: Self Pay Self Pay	$927.20

Black Silicone Filiform ureteral stent

Facility

$1,159.00

Hospital Charge Code	22926477
Hospital Revenue Code	272
Min. Negotiated Rate	$173.85
Max. Negotiated Rate	$1,043.10
Rate for Payer: Aetna of AZ Commercial	$1,043.10
Rate for Payer: Aetna of AZ Medicare	$324.52
Rate for Payer: Allwell Medicare	$173.85
Rate for Payer: Amerigroup Medicare	$173.85
Rate for Payer: APIPA Medicare/Medicaid	$432.89
Rate for Payer: AZCH Complete Medicare	$173.85
Rate for Payer: Banner UC Health Medicare	$173.85
Rate for Payer: Bisbee Police All Plans	$301.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$788.12
Rate for Payer: Cash Price	$927.20
Rate for Payer: Cigna of AZ Commercial	$811.30
Rate for Payer: Copperpoint Commercial	$286.85
Rate for Payer: Health Net of AZ Commercial	$695.40
Rate for Payer: Health Net of AZ Medicare	$324.52
Rate for Payer: Humana of AZ Medicare	$173.85
Rate for Payer: Self Pay Self Pay	$927.20
Rate for Payer: TriWest Medicare	$173.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$675.70
Rate for Payer: UnitedHealth Group of AZ Medicare	$208.62

Bladder scan (PVR)

Facility

$53.00

Service Code	CPT 51798
Hospital Charge Code	27267788
Hospital Revenue Code	360
Min. Negotiated Rate	$13.78
Max. Negotiated Rate	$47.70
Rate for Payer: Aetna of AZ Commercial	$47.70
Rate for Payer: Bisbee Police All Plans	$13.78
Rate for Payer: Cash Price	$42.40
Rate for Payer: Self Pay Self Pay	$42.40

Bladder scan (PVR)

Facility

$53.00

Service Code	CPT 51798
Hospital Charge Code	27267788
Hospital Revenue Code	360
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$47.70
Rate for Payer: Aetna of AZ Medicare	$14.84
Rate for Payer: AHCCCS Medicaid	$80.70
Rate for Payer: Allwell Medicaid	$80.70
Rate for Payer: Allwell Medicare	$7.95
Rate for Payer: Amerigroup Medicare	$7.95
Rate for Payer: APIPA Medicare/Medicaid	$19.80
Rate for Payer: AZCH Complete Medicaid	$80.70
Rate for Payer: AZCH Complete Medicare	$7.95
Rate for Payer: Banner UC Health Medicaid	$80.70
Rate for Payer: Banner UC Health Medicare	$7.95
Rate for Payer: Bisbee Police All Plans	$13.78
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$36.04
Rate for Payer: Cash Price	$42.40
Rate for Payer: Cash Price	$42.40
Rate for Payer: Cigna of AZ Commercial	$26.50
Rate for Payer: Copperpoint Commercial	$13.12
Rate for Payer: Health Net of AZ Commercial	$31.80
Rate for Payer: Health Net of AZ Medicare	$14.84
Rate for Payer: Humana of AZ Medicare	$7.95
Rate for Payer: Mercy Care Medicaid	$80.70
Rate for Payer: Self Pay Self Pay	$42.40
Rate for Payer: TriWest Medicare	$7.95
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$9.54

BLADE CLIPPER 9600 3M

Facility

$16.00

Hospital Charge Code	22355634
Hospital Revenue Code	272
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Aetna of AZ Medicare	$4.48
Rate for Payer: Allwell Medicare	$2.40
Rate for Payer: Amerigroup Medicare	$2.40
Rate for Payer: APIPA Medicare/Medicaid	$5.98
Rate for Payer: AZCH Complete Medicare	$2.40
Rate for Payer: Banner UC Health Medicare	$2.40
Rate for Payer: Bisbee Police All Plans	$4.16
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$10.88
Rate for Payer: Cash Price	$12.80
Rate for Payer: Cigna of AZ Commercial	$11.20
Rate for Payer: Copperpoint Commercial	$3.96
Rate for Payer: Health Net of AZ Commercial	$9.60
Rate for Payer: Health Net of AZ Medicare	$4.48
Rate for Payer: Humana of AZ Medicare	$2.40
Rate for Payer: Self Pay Self Pay	$12.80
Rate for Payer: TriWest Medicare	$2.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$9.33
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.88

BLADE CLIPPER 9600 3M

Facility

$16.00

Hospital Charge Code	22355634
Hospital Revenue Code	272
Min. Negotiated Rate	$4.16
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Bisbee Police All Plans	$4.16
Rate for Payer: Cash Price	$12.80
Rate for Payer: Self Pay Self Pay	$12.80

BLADE CUDA 4.2MM

Facility

$213.00

Hospital Charge Code	22354870
Hospital Revenue Code	270
Min. Negotiated Rate	$55.38
Max. Negotiated Rate	$191.70
Rate for Payer: Aetna of AZ Commercial	$191.70
Rate for Payer: Bisbee Police All Plans	$55.38
Rate for Payer: Cash Price	$170.40
Rate for Payer: Self Pay Self Pay	$170.40

BLADE CUDA 4.2MM

Facility

$213.00

Hospital Charge Code	22354870
Hospital Revenue Code	270
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$191.70
Rate for Payer: Aetna of AZ Commercial	$191.70
Rate for Payer: Aetna of AZ Medicare	$59.64
Rate for Payer: Allwell Medicare	$31.95
Rate for Payer: Amerigroup Medicare	$31.95
Rate for Payer: APIPA Medicare/Medicaid	$79.56
Rate for Payer: AZCH Complete Medicare	$31.95
Rate for Payer: Banner UC Health Medicare	$31.95
Rate for Payer: Bisbee Police All Plans	$55.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$144.84
Rate for Payer: Cash Price	$170.40
Rate for Payer: Cigna of AZ Commercial	$149.10
Rate for Payer: Copperpoint Commercial	$52.72
Rate for Payer: Health Net of AZ Commercial	$127.80
Rate for Payer: Health Net of AZ Medicare	$59.64
Rate for Payer: Humana of AZ Medicare	$31.95
Rate for Payer: Self Pay Self Pay	$170.40
Rate for Payer: TriWest Medicare	$31.95
Rate for Payer: UnitedHealth Group of AZ Commercial	$124.18
Rate for Payer: UnitedHealth Group of AZ Medicare	$38.34

BLADE GLIDESCOPE GVL 1

Facility

$109.00

Hospital Charge Code	22560418
Hospital Revenue Code	272
Min. Negotiated Rate	$16.35
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Aetna of AZ Medicare	$30.52
Rate for Payer: Allwell Medicare	$16.35
Rate for Payer: Amerigroup Medicare	$16.35
Rate for Payer: APIPA Medicare/Medicaid	$40.71
Rate for Payer: AZCH Complete Medicare	$16.35
Rate for Payer: Banner UC Health Medicare	$16.35
Rate for Payer: Bisbee Police All Plans	$28.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$74.12
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cigna of AZ Commercial	$76.30
Rate for Payer: Copperpoint Commercial	$26.98
Rate for Payer: Health Net of AZ Commercial	$65.40
Rate for Payer: Health Net of AZ Medicare	$30.52
Rate for Payer: Humana of AZ Medicare	$16.35
Rate for Payer: Self Pay Self Pay	$87.20
Rate for Payer: TriWest Medicare	$16.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$63.55
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.62

BLADE GLIDESCOPE GVL 1

Facility

$109.00

Hospital Charge Code	22560418
Hospital Revenue Code	272
Min. Negotiated Rate	$28.34
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Bisbee Police All Plans	$28.34
Rate for Payer: Cash Price	$87.20
Rate for Payer: Self Pay Self Pay	$87.20

BLADE GLIDESCOPE GVL 2

Facility

$109.00

Hospital Charge Code	22561231
Hospital Revenue Code	272
Min. Negotiated Rate	$28.34
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Bisbee Police All Plans	$28.34
Rate for Payer: Cash Price	$87.20
Rate for Payer: Self Pay Self Pay	$87.20

BLADE GLIDESCOPE GVL 2

Facility

$109.00

Hospital Charge Code	22561231
Hospital Revenue Code	272
Min. Negotiated Rate	$16.35
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Aetna of AZ Medicare	$30.52
Rate for Payer: Allwell Medicare	$16.35
Rate for Payer: Amerigroup Medicare	$16.35
Rate for Payer: APIPA Medicare/Medicaid	$40.71
Rate for Payer: AZCH Complete Medicare	$16.35
Rate for Payer: Banner UC Health Medicare	$16.35
Rate for Payer: Bisbee Police All Plans	$28.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$74.12
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cigna of AZ Commercial	$76.30
Rate for Payer: Copperpoint Commercial	$26.98
Rate for Payer: Health Net of AZ Commercial	$65.40
Rate for Payer: Health Net of AZ Medicare	$30.52
Rate for Payer: Humana of AZ Medicare	$16.35
Rate for Payer: Self Pay Self Pay	$87.20
Rate for Payer: TriWest Medicare	$16.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$63.55
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.62

BLADE GLIDESCOPE GVL 3

Facility

$109.00

Hospital Charge Code	22561233
Hospital Revenue Code	272
Min. Negotiated Rate	$28.34
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Bisbee Police All Plans	$28.34
Rate for Payer: Cash Price	$87.20
Rate for Payer: Self Pay Self Pay	$87.20

BLADE GLIDESCOPE GVL 3

Facility

$109.00

Hospital Charge Code	22561233
Hospital Revenue Code	272
Min. Negotiated Rate	$16.35
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Aetna of AZ Medicare	$30.52
Rate for Payer: Allwell Medicare	$16.35
Rate for Payer: Amerigroup Medicare	$16.35
Rate for Payer: APIPA Medicare/Medicaid	$40.71
Rate for Payer: AZCH Complete Medicare	$16.35
Rate for Payer: Banner UC Health Medicare	$16.35
Rate for Payer: Bisbee Police All Plans	$28.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$74.12
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cigna of AZ Commercial	$76.30
Rate for Payer: Copperpoint Commercial	$26.98
Rate for Payer: Health Net of AZ Commercial	$65.40
Rate for Payer: Health Net of AZ Medicare	$30.52
Rate for Payer: Humana of AZ Medicare	$16.35
Rate for Payer: Self Pay Self Pay	$87.20
Rate for Payer: TriWest Medicare	$16.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$63.55
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.62

BLADE GLIDESCOPE GVL 4

Facility

$109.00

Hospital Charge Code	22561235
Hospital Revenue Code	272
Min. Negotiated Rate	$28.34
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Bisbee Police All Plans	$28.34
Rate for Payer: Cash Price	$87.20
Rate for Payer: Self Pay Self Pay	$87.20

BLADE GLIDESCOPE GVL 4

Facility

$109.00

Hospital Charge Code	22561235
Hospital Revenue Code	272
Min. Negotiated Rate	$16.35
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Aetna of AZ Medicare	$30.52
Rate for Payer: Allwell Medicare	$16.35
Rate for Payer: Amerigroup Medicare	$16.35
Rate for Payer: APIPA Medicare/Medicaid	$40.71
Rate for Payer: AZCH Complete Medicare	$16.35
Rate for Payer: Banner UC Health Medicare	$16.35
Rate for Payer: Bisbee Police All Plans	$28.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$74.12
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cigna of AZ Commercial	$76.30
Rate for Payer: Copperpoint Commercial	$26.98
Rate for Payer: Health Net of AZ Commercial	$65.40
Rate for Payer: Health Net of AZ Medicare	$30.52
Rate for Payer: Humana of AZ Medicare	$16.35
Rate for Payer: Self Pay Self Pay	$87.20
Rate for Payer: TriWest Medicare	$16.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$63.55
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.62

BLADE GLIDESCOPE SML

Facility

$109.00

Hospital Charge Code	22354971
Hospital Revenue Code	270
Min. Negotiated Rate	$28.34
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Bisbee Police All Plans	$28.34
Rate for Payer: Cash Price	$87.20
Rate for Payer: Self Pay Self Pay	$87.20

Know your out-of-pocket cost for care.

All Charges