Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

16010 DSG/DBD WANES SMALL

Facility

$242.00

Service Code	CPT 16010
Hospital Charge Code	22282815
Hospital Revenue Code	450
Min. Negotiated Rate	$62.92
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of AZ Commercial	$217.80
Rate for Payer: Bisbee Police All Plans	$62.92
Rate for Payer: Cash Price	$193.60
Rate for Payer: Self Pay Self Pay	$193.60

16015 DSG/MJR DBRD W/ANES M/L

Facility

$816.00

Service Code	CPT 16015
Hospital Charge Code	22282816
Hospital Revenue Code	450
Min. Negotiated Rate	$212.16
Max. Negotiated Rate	$734.40
Rate for Payer: Aetna of AZ Commercial	$734.40
Rate for Payer: Bisbee Police All Plans	$212.16
Rate for Payer: Cash Price	$652.80
Rate for Payer: Self Pay Self Pay	$652.80

16015 DSG/MJR DBRD W/ANES M/L

Facility

$816.00

Service Code	CPT 16015
Hospital Charge Code	22282816
Hospital Revenue Code	450
Min. Negotiated Rate	$130.56
Max. Negotiated Rate	$734.40
Rate for Payer: Aetna of AZ Commercial	$734.40
Rate for Payer: Aetna of AZ Medicare	$228.48
Rate for Payer: Allwell Medicare	$130.56
Rate for Payer: Amerigroup Medicare	$130.56
Rate for Payer: APIPA Medicare/Medicaid	$304.78
Rate for Payer: AZCH Complete Medicare	$130.56
Rate for Payer: Banner UC Health Medicare	$130.56
Rate for Payer: Bisbee Police All Plans	$212.16
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$554.88
Rate for Payer: Cash Price	$652.80
Rate for Payer: Cigna of AZ Commercial	$571.20
Rate for Payer: Copperpoint Commercial	$201.96
Rate for Payer: Health Net of AZ Commercial	$489.60
Rate for Payer: Health Net of AZ Medicare	$228.48
Rate for Payer: Humana of AZ Medicare	$130.56
Rate for Payer: Self Pay Self Pay	$652.80
Rate for Payer: TriWest Medicare	$130.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$475.73
Rate for Payer: UnitedHealth Group of AZ Medicare	$146.88

16020 DSG/DBD W/O ANES SM

Facility

$290.00

Service Code	CPT 16020
Hospital Charge Code	22282817
Hospital Revenue Code	450
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

16020 DSG/DBD W/O ANES SM

Facility

$290.00

Service Code	CPT 16020
Hospital Charge Code	22282817
Hospital Revenue Code	450
Min. Negotiated Rate	$46.40
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$261.00
Rate for Payer: Aetna of AZ Medicare	$81.20
Rate for Payer: AHCCCS Medicaid	$130.17
Rate for Payer: Allwell Medicaid	$130.17
Rate for Payer: Allwell Medicare	$46.40
Rate for Payer: Amerigroup Medicare	$46.40
Rate for Payer: APIPA Medicare/Medicaid	$108.31
Rate for Payer: AZCH Complete Medicaid	$130.17
Rate for Payer: AZCH Complete Medicare	$46.40
Rate for Payer: Banner UC Health Medicaid	$130.17
Rate for Payer: Banner UC Health Medicare	$46.40
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: 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	$46.40
Rate for Payer: Mercy Care Medicaid	$130.17
Rate for Payer: Self Pay Self Pay	$232.00
Rate for Payer: TriWest Medicare	$46.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$52.20

16025 DSG/DBD W/O ANES MED

Facility

$490.00

Service Code	CPT 16025
Hospital Charge Code	22282818
Hospital Revenue Code	450
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$441.00
Rate for Payer: Aetna of AZ Medicare	$137.20
Rate for Payer: AHCCCS Medicaid	$130.17
Rate for Payer: Allwell Medicaid	$130.17
Rate for Payer: Allwell Medicare	$78.40
Rate for Payer: Amerigroup Medicare	$78.40
Rate for Payer: APIPA Medicare/Medicaid	$183.01
Rate for Payer: AZCH Complete Medicaid	$130.17
Rate for Payer: AZCH Complete Medicare	$78.40
Rate for Payer: Banner UC Health Medicaid	$130.17
Rate for Payer: Banner UC Health Medicare	$78.40
Rate for Payer: Bisbee Police All Plans	$127.40
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$333.20
Rate for Payer: Cash Price	$392.00
Rate for Payer: Cash Price	$392.00
Rate for Payer: Cigna of AZ Commercial	$343.00
Rate for Payer: Copperpoint Commercial	$121.28
Rate for Payer: Health Net of AZ Commercial	$294.00
Rate for Payer: Health Net of AZ Medicare	$137.20
Rate for Payer: Humana of AZ Medicare	$78.40
Rate for Payer: Mercy Care Medicaid	$130.17
Rate for Payer: Self Pay Self Pay	$392.00
Rate for Payer: TriWest Medicare	$78.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$88.20

16025 DSG/DBD W/O ANES MED

Facility

$490.00

Service Code	CPT 16025
Hospital Charge Code	22282818
Hospital Revenue Code	450
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$441.00
Rate for Payer: Aetna of AZ Commercial	$441.00
Rate for Payer: Bisbee Police All Plans	$127.40
Rate for Payer: Cash Price	$392.00
Rate for Payer: Self Pay Self Pay	$392.00

16030 DSG/DBD W/O ANES LG

Facility

$600.00

Service Code	CPT 16030
Hospital Charge Code	22282819
Hospital Revenue Code	450
Min. Negotiated Rate	$96.00
Max. Negotiated Rate	$2,161.00
Rate for Payer: Aetna of AZ Commercial	$540.00
Rate for Payer: Aetna of AZ Medicare	$168.00
Rate for Payer: AHCCCS Medicaid	$250.73
Rate for Payer: Allwell Medicaid	$250.73
Rate for Payer: Allwell Medicare	$96.00
Rate for Payer: Amerigroup Medicare	$96.00
Rate for Payer: APIPA Medicare/Medicaid	$224.10
Rate for Payer: AZCH Complete Medicaid	$250.73
Rate for Payer: AZCH Complete Medicare	$96.00
Rate for Payer: Banner UC Health Medicaid	$250.73
Rate for Payer: Banner UC Health Medicare	$96.00
Rate for Payer: Bisbee Police All Plans	$156.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$408.00
Rate for Payer: Cash Price	$480.00
Rate for Payer: Cash Price	$480.00
Rate for Payer: Cigna of AZ Commercial	$420.00
Rate for Payer: Copperpoint Commercial	$148.50
Rate for Payer: Health Net of AZ Commercial	$360.00
Rate for Payer: Health Net of AZ Medicare	$168.00
Rate for Payer: Humana of AZ Medicare	$96.00
Rate for Payer: Mercy Care Medicaid	$250.73
Rate for Payer: Self Pay Self Pay	$480.00
Rate for Payer: TriWest Medicare	$96.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,161.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$108.00

16030 DSG/DBD W/O ANES LG

Facility

$600.00

Service Code	CPT 16030
Hospital Charge Code	22282819
Hospital Revenue Code	450
Min. Negotiated Rate	$156.00
Max. Negotiated Rate	$540.00
Rate for Payer: Aetna of AZ Commercial	$540.00
Rate for Payer: Bisbee Police All Plans	$156.00
Rate for Payer: Cash Price	$480.00
Rate for Payer: Self Pay Self Pay	$480.00

165MM SUCTION SLEEVE

Facility

$190.00

Hospital Charge Code	27773154
Hospital Revenue Code	270
Min. Negotiated Rate	$49.40
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna of AZ Commercial	$171.00
Rate for Payer: Bisbee Police All Plans	$49.40
Rate for Payer: Cash Price	$152.00
Rate for Payer: Self Pay Self Pay	$152.00

165MM SUCTION SLEEVE

Facility

$190.00

Hospital Charge Code	27773154
Hospital Revenue Code	270
Min. Negotiated Rate	$30.40
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna of AZ Commercial	$171.00
Rate for Payer: Aetna of AZ Medicare	$53.20
Rate for Payer: Allwell Medicare	$30.40
Rate for Payer: Amerigroup Medicare	$30.40
Rate for Payer: APIPA Medicare/Medicaid	$70.97
Rate for Payer: AZCH Complete Medicare	$30.40
Rate for Payer: Banner UC Health Medicare	$30.40
Rate for Payer: Bisbee Police All Plans	$49.40
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$129.20
Rate for Payer: Cash Price	$152.00
Rate for Payer: Cigna of AZ Commercial	$133.00
Rate for Payer: Copperpoint Commercial	$47.02
Rate for Payer: Health Net of AZ Commercial	$114.00
Rate for Payer: Health Net of AZ Medicare	$53.20
Rate for Payer: Humana of AZ Medicare	$30.40
Rate for Payer: Self Pay Self Pay	$152.00
Rate for Payer: TriWest Medicare	$30.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$110.77
Rate for Payer: UnitedHealth Group of AZ Medicare	$34.20

1.6MM K WIRE

Facility

$69.00

Hospital Charge Code	22354195
Hospital Revenue Code	270
Min. Negotiated Rate	$17.94
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Bisbee Police All Plans	$17.94
Rate for Payer: Cash Price	$55.20
Rate for Payer: Self Pay Self Pay	$55.20

1.6MM K WIRE

Facility

$69.00

Hospital Charge Code	22354195
Hospital Revenue Code	270
Min. Negotiated Rate	$11.04
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Aetna of AZ Medicare	$19.32
Rate for Payer: Allwell Medicare	$11.04
Rate for Payer: Amerigroup Medicare	$11.04
Rate for Payer: APIPA Medicare/Medicaid	$25.77
Rate for Payer: AZCH Complete Medicare	$11.04
Rate for Payer: Banner UC Health Medicare	$11.04
Rate for Payer: Bisbee Police All Plans	$17.94
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$46.92
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cigna of AZ Commercial	$48.30
Rate for Payer: Copperpoint Commercial	$17.08
Rate for Payer: Health Net of AZ Commercial	$41.40
Rate for Payer: Health Net of AZ Medicare	$19.32
Rate for Payer: Humana of AZ Medicare	$11.04
Rate for Payer: Self Pay Self Pay	$55.20
Rate for Payer: TriWest Medicare	$11.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$40.23
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.42

1 6MM TAPER SIDE CUTTING CARBIDE BUR

Facility

$56.00

Hospital Charge Code	27433627
Hospital Revenue Code	270
Min. Negotiated Rate	$8.96
Max. Negotiated Rate	$50.40
Rate for Payer: Aetna of AZ Commercial	$50.40
Rate for Payer: Aetna of AZ Medicare	$15.68
Rate for Payer: Allwell Medicare	$8.96
Rate for Payer: Amerigroup Medicare	$8.96
Rate for Payer: APIPA Medicare/Medicaid	$20.92
Rate for Payer: AZCH Complete Medicare	$8.96
Rate for Payer: Banner UC Health Medicare	$8.96
Rate for Payer: Bisbee Police All Plans	$14.56
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$38.08
Rate for Payer: Cash Price	$44.80
Rate for Payer: Cigna of AZ Commercial	$39.20
Rate for Payer: Copperpoint Commercial	$13.86
Rate for Payer: Health Net of AZ Commercial	$33.60
Rate for Payer: Health Net of AZ Medicare	$15.68
Rate for Payer: Humana of AZ Medicare	$8.96
Rate for Payer: Self Pay Self Pay	$44.80
Rate for Payer: TriWest Medicare	$8.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$32.65
Rate for Payer: UnitedHealth Group of AZ Medicare	$10.08

1 6MM TAPER SIDE CUTTING CARBIDE BUR

Facility

$56.00

Hospital Charge Code	27433627
Hospital Revenue Code	270
Min. Negotiated Rate	$14.56
Max. Negotiated Rate	$50.40
Rate for Payer: Aetna of AZ Commercial	$50.40
Rate for Payer: Bisbee Police All Plans	$14.56
Rate for Payer: Cash Price	$44.80
Rate for Payer: Self Pay Self Pay	$44.80

17-Hydroxypregnenolone MS LC

Facility

$270.00

Service Code	CPT 84143
Hospital Charge Code	6780894
Hospital Revenue Code	301
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of AZ Commercial	$243.00
Rate for Payer: Bisbee Police All Plans	$70.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Self Pay Self Pay	$216.00

17-Hydroxypregnenolone MS LC

Facility

$270.00

Service Code	CPT 84143
Hospital Charge Code	6780894
Hospital Revenue Code	301
Min. Negotiated Rate	$43.20
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of AZ Commercial	$243.00
Rate for Payer: Aetna of AZ Medicare	$75.60
Rate for Payer: Allwell Medicare	$43.20
Rate for Payer: Amerigroup Medicare	$43.20
Rate for Payer: APIPA Medicare/Medicaid	$100.84
Rate for Payer: AZCH Complete Medicare	$43.20
Rate for Payer: Banner UC Health Medicare	$43.20
Rate for Payer: Bisbee Police All Plans	$70.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$183.60
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna of AZ Commercial	$175.50
Rate for Payer: Copperpoint Commercial	$66.83
Rate for Payer: Health Net of AZ Commercial	$162.00
Rate for Payer: Health Net of AZ Medicare	$75.60
Rate for Payer: Humana of AZ Medicare	$43.20
Rate for Payer: Self Pay Self Pay	$216.00
Rate for Payer: TriWest Medicare	$43.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$157.41
Rate for Payer: UnitedHealth Group of AZ Medicare	$48.60

17-OH Progesterone LC

Facility

$441.00

Service Code	CPT 83498
Hospital Charge Code	6738679
Hospital Revenue Code	301
Min. Negotiated Rate	$70.56
Max. Negotiated Rate	$396.90
Rate for Payer: Aetna of AZ Commercial	$396.90
Rate for Payer: Aetna of AZ Medicare	$123.48
Rate for Payer: Allwell Medicare	$70.56
Rate for Payer: Amerigroup Medicare	$70.56
Rate for Payer: APIPA Medicare/Medicaid	$164.71
Rate for Payer: AZCH Complete Medicare	$70.56
Rate for Payer: Banner UC Health Medicare	$70.56
Rate for Payer: Bisbee Police All Plans	$114.66
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$299.88
Rate for Payer: Cash Price	$352.80
Rate for Payer: Cigna of AZ Commercial	$286.65
Rate for Payer: Copperpoint Commercial	$109.15
Rate for Payer: Health Net of AZ Commercial	$264.60
Rate for Payer: Health Net of AZ Medicare	$123.48
Rate for Payer: Humana of AZ Medicare	$70.56
Rate for Payer: Self Pay Self Pay	$352.80
Rate for Payer: TriWest Medicare	$70.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$257.10
Rate for Payer: UnitedHealth Group of AZ Medicare	$79.38

17-OH Progesterone LC

Facility

$441.00

Service Code	CPT 83498
Hospital Charge Code	6738679
Hospital Revenue Code	301
Min. Negotiated Rate	$114.66
Max. Negotiated Rate	$396.90
Rate for Payer: Aetna of AZ Commercial	$396.90
Rate for Payer: Bisbee Police All Plans	$114.66
Rate for Payer: Cash Price	$352.80
Rate for Payer: Self Pay Self Pay	$352.80

18 GA Percutaneous Acce+B2:B102ss Needle

Facility

$292.00

Hospital Charge Code	22926475
Hospital Revenue Code	272
Min. Negotiated Rate	$75.92
Max. Negotiated Rate	$262.80
Rate for Payer: Aetna of AZ Commercial	$262.80
Rate for Payer: Bisbee Police All Plans	$75.92
Rate for Payer: Cash Price	$233.60
Rate for Payer: Self Pay Self Pay	$233.60

18 GA Percutaneous Acce+B2:B102ss Needle

Facility

$292.00

Hospital Charge Code	22926475
Hospital Revenue Code	272
Min. Negotiated Rate	$46.72
Max. Negotiated Rate	$262.80
Rate for Payer: Aetna of AZ Commercial	$262.80
Rate for Payer: Aetna of AZ Medicare	$81.76
Rate for Payer: Allwell Medicare	$46.72
Rate for Payer: Amerigroup Medicare	$46.72
Rate for Payer: APIPA Medicare/Medicaid	$109.06
Rate for Payer: AZCH Complete Medicare	$46.72
Rate for Payer: Banner UC Health Medicare	$46.72
Rate for Payer: Bisbee Police All Plans	$75.92
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$198.56
Rate for Payer: Cash Price	$233.60
Rate for Payer: Cigna of AZ Commercial	$204.40
Rate for Payer: Copperpoint Commercial	$72.27
Rate for Payer: Health Net of AZ Commercial	$175.20
Rate for Payer: Health Net of AZ Medicare	$81.76
Rate for Payer: Humana of AZ Medicare	$46.72
Rate for Payer: Self Pay Self Pay	$233.60
Rate for Payer: TriWest Medicare	$46.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$170.24
Rate for Payer: UnitedHealth Group of AZ Medicare	$52.56

1 Ethibond Excel CCS

Facility

$109.00

Hospital Charge Code	22926435
Hospital Revenue Code	272
Min. Negotiated Rate	$17.44
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	$17.44
Rate for Payer: Amerigroup Medicare	$17.44
Rate for Payer: APIPA Medicare/Medicaid	$40.71
Rate for Payer: AZCH Complete Medicare	$17.44
Rate for Payer: Banner UC Health Medicare	$17.44
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	$17.44
Rate for Payer: Self Pay Self Pay	$87.20
Rate for Payer: TriWest Medicare	$17.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$63.55
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.62

1 Ethibond Excel CCS

Facility

$109.00

Hospital Charge Code	22926435
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

1 Ethibond Excel OS-8

Facility

$19.00

Hospital Charge Code	22926437
Hospital Revenue Code	272
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$17.10
Rate for Payer: Aetna of AZ Commercial	$17.10
Rate for Payer: Aetna of AZ Medicare	$5.32
Rate for Payer: Allwell Medicare	$3.04
Rate for Payer: Amerigroup Medicare	$3.04
Rate for Payer: APIPA Medicare/Medicaid	$7.10
Rate for Payer: AZCH Complete Medicare	$3.04
Rate for Payer: Banner UC Health Medicare	$3.04
Rate for Payer: Bisbee Police All Plans	$4.94
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$12.92
Rate for Payer: Cash Price	$15.20
Rate for Payer: Cigna of AZ Commercial	$13.30
Rate for Payer: Copperpoint Commercial	$4.70
Rate for Payer: Health Net of AZ Commercial	$11.40
Rate for Payer: Health Net of AZ Medicare	$5.32
Rate for Payer: Humana of AZ Medicare	$3.04
Rate for Payer: Self Pay Self Pay	$15.20
Rate for Payer: TriWest Medicare	$3.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$11.08
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.42

1 Ethibond Excel OS-8

Facility

$19.00

Hospital Charge Code	22926437
Hospital Revenue Code	272
Min. Negotiated Rate	$4.94
Max. Negotiated Rate	$17.10
Rate for Payer: Aetna of AZ Commercial	$17.10
Rate for Payer: Bisbee Police All Plans	$4.94
Rate for Payer: Cash Price	$15.20
Rate for Payer: Self Pay Self Pay	$15.20

Know your out-of-pocket cost for care.

All Charges