Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

carbidopa-levodopa 25 mg-100 mg DIS Tablet [CQCH]

Facility

$0.84

Service Code	NDC 47335018788
Hospital Charge Code	126238058
Hospital Revenue Code	251
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.76
Rate for Payer: Aetna of AZ Commercial	$0.76
Rate for Payer: Bisbee Police All Plans	$0.22
Rate for Payer: Cash Price	$0.68
Rate for Payer: Self Pay Self Pay	$0.67

carbidopa-levodopa 25 mg-100 mg ER Tab [CQCH]

Facility

$0.22

Service Code	NDC 51079097820
Hospital Charge Code	105914520
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of AZ Commercial	$0.20
Rate for Payer: Aetna of AZ Medicare	$0.06
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 Medicare	$0.03
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	$0.18
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: 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

carbidopa-levodopa 25 mg-100 mg ER Tab [CQCH]

Facility

$0.22

Service Code	NDC 51079097820
Hospital Charge Code	105914520
Hospital Revenue Code	251
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	$0.18
Rate for Payer: Self Pay Self Pay	$0.18

carbidopa-levodopa 25 mg-100 mg Tab-IR[CQCH]

Facility

$0.19

Service Code	NDC 904725761
Hospital Charge Code	105914587
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of AZ Commercial	$0.17
Rate for Payer: Bisbee Police All Plans	$0.05
Rate for Payer: Cash Price	$0.15
Rate for Payer: Self Pay Self Pay	$0.15

carbidopa-levodopa 25 mg-100 mg Tab-IR[CQCH]

Facility

$0.19

Service Code	NDC 904725761
Hospital Charge Code	105914587
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of AZ Commercial	$0.17
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	$0.07
Rate for Payer: AZCH Complete Medicare	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Bisbee Police All Plans	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.13
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of AZ Commercial	$0.12
Rate for Payer: Copperpoint Commercial	$0.05
Rate for Payer: Health Net of AZ Commercial	$0.11
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	$0.15
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.11
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.03

carbidopa-levodopa 25 mg-250 mg IR Tab [CQCH]

Facility

$0.29

Service Code	NDC 60687083601
Hospital Charge Code	107994470
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of AZ Commercial	$0.26
Rate for Payer: Aetna of AZ Medicare	$0.08
Rate for Payer: Allwell Medicare	$0.04
Rate for Payer: Amerigroup Medicare	$0.04
Rate for Payer: APIPA Medicare/Medicaid	$0.11
Rate for Payer: AZCH Complete Medicare	$0.04
Rate for Payer: Banner UC Health Medicare	$0.04
Rate for Payer: Bisbee Police All Plans	$0.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.20
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of AZ Commercial	$0.19
Rate for Payer: Copperpoint Commercial	$0.07
Rate for Payer: Health Net of AZ Commercial	$0.17
Rate for Payer: Health Net of AZ Medicare	$0.08
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Self Pay Self Pay	$0.23
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.17
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.05

carbidopa-levodopa 25 mg-250 mg IR Tab [CQCH]

Facility

$0.29

Service Code	NDC 60687083601
Hospital Charge Code	107994470
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of AZ Commercial	$0.26
Rate for Payer: Bisbee Police All Plans	$0.08
Rate for Payer: Cash Price	$0.23
Rate for Payer: Self Pay Self Pay	$0.23

Carbohydrate Antigen 19-9 LC

Facility

$258.00

Service Code	CPT 86301
Hospital Charge Code	2269492
Hospital Revenue Code	302
Min. Negotiated Rate	$20.81
Max. Negotiated Rate	$232.20
Rate for Payer: Aetna of AZ Commercial	$232.20
Rate for Payer: Aetna of AZ Medicare	$72.24
Rate for Payer: AHCCCS Medicaid	$20.81
Rate for Payer: Allwell Medicaid	$20.81
Rate for Payer: Allwell Medicare	$38.70
Rate for Payer: Amerigroup Medicare	$38.70
Rate for Payer: APIPA Medicare/Medicaid	$96.36
Rate for Payer: AZCH Complete Medicaid	$20.81
Rate for Payer: AZCH Complete Medicare	$38.70
Rate for Payer: Banner UC Health Medicaid	$20.81
Rate for Payer: Banner UC Health Medicare	$38.70
Rate for Payer: Bisbee Police All Plans	$67.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$175.44
Rate for Payer: Cash Price	$206.40
Rate for Payer: Cash Price	$206.40
Rate for Payer: Cigna of AZ Commercial	$167.70
Rate for Payer: Copperpoint Commercial	$63.86
Rate for Payer: Health Net of AZ Commercial	$154.80
Rate for Payer: Health Net of AZ Medicare	$72.24
Rate for Payer: Humana of AZ Medicare	$38.70
Rate for Payer: Mercy Care Medicaid	$20.81
Rate for Payer: Self Pay Self Pay	$206.40
Rate for Payer: TriWest Medicare	$38.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$150.41
Rate for Payer: UnitedHealth Group of AZ Medicare	$46.44

Carbohydrate Antigen 19-9 LC

Facility

$258.00

Service Code	CPT 86301
Hospital Charge Code	2269492
Hospital Revenue Code	302
Min. Negotiated Rate	$67.08
Max. Negotiated Rate	$232.20
Rate for Payer: Aetna of AZ Commercial	$232.20
Rate for Payer: Bisbee Police All Plans	$67.08
Rate for Payer: Cash Price	$206.40
Rate for Payer: Self Pay Self Pay	$206.40

Carbon Dioxide Level

Facility

$113.00

Service Code	CPT 82374
Hospital Charge Code	633626
Hospital Revenue Code	301
Min. Negotiated Rate	$4.88
Max. Negotiated Rate	$101.70
Rate for Payer: Aetna of AZ Commercial	$101.70
Rate for Payer: Aetna of AZ Medicare	$31.64
Rate for Payer: AHCCCS Medicaid	$4.88
Rate for Payer: Allwell Medicaid	$4.88
Rate for Payer: Allwell Medicare	$16.95
Rate for Payer: Amerigroup Medicare	$16.95
Rate for Payer: APIPA Medicare/Medicaid	$42.21
Rate for Payer: AZCH Complete Medicaid	$4.88
Rate for Payer: AZCH Complete Medicare	$16.95
Rate for Payer: Banner UC Health Medicaid	$4.88
Rate for Payer: Banner UC Health Medicare	$16.95
Rate for Payer: Bisbee Police All Plans	$29.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$76.84
Rate for Payer: Cash Price	$90.40
Rate for Payer: Cash Price	$90.40
Rate for Payer: Cigna of AZ Commercial	$73.45
Rate for Payer: Copperpoint Commercial	$27.97
Rate for Payer: Health Net of AZ Commercial	$67.80
Rate for Payer: Health Net of AZ Medicare	$31.64
Rate for Payer: Humana of AZ Medicare	$16.95
Rate for Payer: Mercy Care Medicaid	$4.88
Rate for Payer: Self Pay Self Pay	$90.40
Rate for Payer: TriWest Medicare	$16.95
Rate for Payer: UnitedHealth Group of AZ Commercial	$65.88
Rate for Payer: UnitedHealth Group of AZ Medicare	$20.34

Carbon Dioxide Level

Facility

$113.00

Service Code	CPT 82374
Hospital Charge Code	633626
Hospital Revenue Code	301
Min. Negotiated Rate	$29.38
Max. Negotiated Rate	$101.70
Rate for Payer: Aetna of AZ Commercial	$101.70
Rate for Payer: Bisbee Police All Plans	$29.38
Rate for Payer: Cash Price	$90.40
Rate for Payer: Self Pay Self Pay	$90.40

CARBON MONOXIDE DIFFUSING CAPACITY

Facility

$645.00

Service Code	CPT 94729
Hospital Charge Code	1886870
Hospital Revenue Code	410
Min. Negotiated Rate	$96.75
Max. Negotiated Rate	$580.50
Rate for Payer: Aetna of AZ Commercial	$580.50
Rate for Payer: Aetna of AZ Medicare	$180.60
Rate for Payer: AHCCCS Medicaid	$121.26
Rate for Payer: Allwell Medicaid	$121.26
Rate for Payer: Allwell Medicare	$96.75
Rate for Payer: Amerigroup Medicare	$96.75
Rate for Payer: APIPA Medicare/Medicaid	$240.91
Rate for Payer: AZCH Complete Medicaid	$121.26
Rate for Payer: AZCH Complete Medicare	$96.75
Rate for Payer: Banner UC Health Medicaid	$121.26
Rate for Payer: Banner UC Health Medicare	$96.75
Rate for Payer: Bisbee Police All Plans	$167.70
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$438.60
Rate for Payer: Cash Price	$516.00
Rate for Payer: Cash Price	$516.00
Rate for Payer: Cigna of AZ Commercial	$451.50
Rate for Payer: Copperpoint Commercial	$159.64
Rate for Payer: Health Net of AZ Commercial	$387.00
Rate for Payer: Health Net of AZ Medicare	$180.60
Rate for Payer: Humana of AZ Medicare	$96.75
Rate for Payer: Mercy Care Medicaid	$121.26
Rate for Payer: Self Pay Self Pay	$516.00
Rate for Payer: TriWest Medicare	$96.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$376.04
Rate for Payer: UnitedHealth Group of AZ Medicare	$116.10

CARBON MONOXIDE DIFFUSING CAPACITY

Facility

$645.00

Service Code	CPT 94729
Hospital Charge Code	1886870
Hospital Revenue Code	410
Min. Negotiated Rate	$167.70
Max. Negotiated Rate	$580.50
Rate for Payer: Aetna of AZ Commercial	$580.50
Rate for Payer: Bisbee Police All Plans	$167.70
Rate for Payer: Cash Price	$516.00
Rate for Payer: Self Pay Self Pay	$516.00

Cardiac Arrest And Shock

Facility

$3,941.17

Service Code	APR-DRG 1962
Hospital Charge Code	APRDRG1962
Min. Negotiated Rate	$3,941.17
Max. Negotiated Rate	$3,941.17
Rate for Payer: AHCCCS Medicaid	$3,941.17
Rate for Payer: Allwell Medicaid	$3,941.17
Rate for Payer: AZCH Complete Medicaid	$3,941.17
Rate for Payer: Banner UC Health Medicaid	$3,941.17
Rate for Payer: Mercy Care Medicaid	$3,941.17

Cardiac Arrest And Shock

Facility

$2,874.34

Service Code	APR-DRG 1961
Hospital Charge Code	APRDRG1961
Min. Negotiated Rate	$2,874.34
Max. Negotiated Rate	$2,874.34
Rate for Payer: AHCCCS Medicaid	$2,874.34
Rate for Payer: Allwell Medicaid	$2,874.34
Rate for Payer: AZCH Complete Medicaid	$2,874.34
Rate for Payer: Banner UC Health Medicaid	$2,874.34
Rate for Payer: Mercy Care Medicaid	$2,874.34

Cardiac Arrest And Shock

Facility

$2,874.34

Service Code	APR-DRG 1961
Hospital Charge Code	APRDRG1964
Min. Negotiated Rate	$2,874.34
Max. Negotiated Rate	$2,874.34
Rate for Payer: AHCCCS Medicaid	$2,874.34
Rate for Payer: Allwell Medicaid	$2,874.34
Rate for Payer: AZCH Complete Medicaid	$2,874.34
Rate for Payer: Banner UC Health Medicaid	$2,874.34
Rate for Payer: Mercy Care Medicaid	$2,874.34

Cardiac Arrest And Shock

Facility

$11,544.34

Service Code	APR-DRG 1964
Hospital Charge Code	APRDRG1961
Min. Negotiated Rate	$11,544.34
Max. Negotiated Rate	$11,544.34
Rate for Payer: AHCCCS Medicaid	$11,544.34
Rate for Payer: Allwell Medicaid	$11,544.34
Rate for Payer: AZCH Complete Medicaid	$11,544.34
Rate for Payer: Banner UC Health Medicaid	$11,544.34
Rate for Payer: Mercy Care Medicaid	$11,544.34

Cardiac Arrest And Shock

Facility

$11,544.34

Service Code	APR-DRG 1964
Hospital Charge Code	APRDRG1963
Min. Negotiated Rate	$11,544.34
Max. Negotiated Rate	$11,544.34
Rate for Payer: AHCCCS Medicaid	$11,544.34
Rate for Payer: Allwell Medicaid	$11,544.34
Rate for Payer: AZCH Complete Medicaid	$11,544.34
Rate for Payer: Banner UC Health Medicaid	$11,544.34
Rate for Payer: Mercy Care Medicaid	$11,544.34

Cardiac Arrest And Shock

Facility

$2,874.34

Service Code	APR-DRG 1961
Hospital Charge Code	APRDRG1962
Min. Negotiated Rate	$2,874.34
Max. Negotiated Rate	$2,874.34
Rate for Payer: AHCCCS Medicaid	$2,874.34
Rate for Payer: Allwell Medicaid	$2,874.34
Rate for Payer: AZCH Complete Medicaid	$2,874.34
Rate for Payer: Banner UC Health Medicaid	$2,874.34
Rate for Payer: Mercy Care Medicaid	$2,874.34

Cardiac Arrest And Shock

Facility

$3,941.17

Service Code	APR-DRG 1962
Hospital Charge Code	APRDRG1963
Min. Negotiated Rate	$3,941.17
Max. Negotiated Rate	$3,941.17
Rate for Payer: AHCCCS Medicaid	$3,941.17
Rate for Payer: Allwell Medicaid	$3,941.17
Rate for Payer: AZCH Complete Medicaid	$3,941.17
Rate for Payer: Banner UC Health Medicaid	$3,941.17
Rate for Payer: Mercy Care Medicaid	$3,941.17

Cardiac Arrest And Shock

Facility

$5,661.00

Service Code	APR-DRG 1963
Hospital Charge Code	APRDRG1964
Min. Negotiated Rate	$5,661.00
Max. Negotiated Rate	$5,661.00
Rate for Payer: AHCCCS Medicaid	$5,661.00
Rate for Payer: Allwell Medicaid	$5,661.00
Rate for Payer: AZCH Complete Medicaid	$5,661.00
Rate for Payer: Banner UC Health Medicaid	$5,661.00
Rate for Payer: Mercy Care Medicaid	$5,661.00

Cardiac Arrest And Shock

Facility

$5,661.00

Service Code	APR-DRG 1963
Hospital Charge Code	APRDRG1961
Min. Negotiated Rate	$5,661.00
Max. Negotiated Rate	$5,661.00
Rate for Payer: AHCCCS Medicaid	$5,661.00
Rate for Payer: Allwell Medicaid	$5,661.00
Rate for Payer: AZCH Complete Medicaid	$5,661.00
Rate for Payer: Banner UC Health Medicaid	$5,661.00
Rate for Payer: Mercy Care Medicaid	$5,661.00

Cardiac Arrest And Shock

Facility

$5,661.00

Service Code	APR-DRG 1963
Hospital Charge Code	APRDRG1962
Min. Negotiated Rate	$5,661.00
Max. Negotiated Rate	$5,661.00
Rate for Payer: AHCCCS Medicaid	$5,661.00
Rate for Payer: Allwell Medicaid	$5,661.00
Rate for Payer: AZCH Complete Medicaid	$5,661.00
Rate for Payer: Banner UC Health Medicaid	$5,661.00
Rate for Payer: Mercy Care Medicaid	$5,661.00

Cardiac Arrest And Shock

Facility

$3,941.17

Service Code	APR-DRG 1962
Hospital Charge Code	APRDRG1964
Min. Negotiated Rate	$3,941.17
Max. Negotiated Rate	$3,941.17
Rate for Payer: AHCCCS Medicaid	$3,941.17
Rate for Payer: Allwell Medicaid	$3,941.17
Rate for Payer: AZCH Complete Medicaid	$3,941.17
Rate for Payer: Banner UC Health Medicaid	$3,941.17
Rate for Payer: Mercy Care Medicaid	$3,941.17

Cardiac Arrest And Shock

Facility

$11,544.34

Service Code	APR-DRG 1964
Hospital Charge Code	APRDRG1964
Min. Negotiated Rate	$11,544.34
Max. Negotiated Rate	$11,544.34
Rate for Payer: AHCCCS Medicaid	$11,544.34
Rate for Payer: Allwell Medicaid	$11,544.34
Rate for Payer: AZCH Complete Medicaid	$11,544.34
Rate for Payer: Banner UC Health Medicaid	$11,544.34
Rate for Payer: Mercy Care Medicaid	$11,544.34

Know your out-of-pocket cost for care.

All Charges