Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

DRSG MEPILEX BORDER 6X6

Facility

$32.00

Hospital Charge Code	27571814
Hospital Revenue Code	272
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Aetna of AZ Medicare	$8.96
Rate for Payer: Allwell Medicare	$4.80
Rate for Payer: Amerigroup Medicare	$4.80
Rate for Payer: APIPA Medicare/Medicaid	$11.95
Rate for Payer: AZCH Complete Medicare	$4.80
Rate for Payer: Banner UC Health Medicare	$4.80
Rate for Payer: Bisbee Police All Plans	$8.32
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$21.76
Rate for Payer: Cash Price	$25.60
Rate for Payer: Cigna of AZ Commercial	$22.40
Rate for Payer: Copperpoint Commercial	$7.92
Rate for Payer: Health Net of AZ Commercial	$19.20
Rate for Payer: Health Net of AZ Medicare	$8.96
Rate for Payer: Humana of AZ Medicare	$4.80
Rate for Payer: Self Pay Self Pay	$25.60
Rate for Payer: TriWest Medicare	$4.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$18.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$5.76

DRSG MICROFOAM 1-IN TAPE

Facility

$19.00

Hospital Charge Code	22355175
Hospital Revenue Code	270
Min. Negotiated Rate	$2.85
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	$2.85
Rate for Payer: Amerigroup Medicare	$2.85
Rate for Payer: APIPA Medicare/Medicaid	$7.10
Rate for Payer: AZCH Complete Medicare	$2.85
Rate for Payer: Banner UC Health Medicare	$2.85
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	$2.85
Rate for Payer: Self Pay Self Pay	$15.20
Rate for Payer: TriWest Medicare	$2.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$11.08
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.42

DRSG MICROFOAM 1-IN TAPE

Facility

$19.00

Hospital Charge Code	22355175
Hospital Revenue Code	270
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

DRSG PACKING STRIP IODO 1/2

Facility

$11.00

Hospital Charge Code	27567553
Hospital Revenue Code	270
Min. Negotiated Rate	$2.86
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of AZ Commercial	$9.90
Rate for Payer: Bisbee Police All Plans	$2.86
Rate for Payer: Cash Price	$8.80
Rate for Payer: Self Pay Self Pay	$8.80

DRSG PACKING STRIP IODO 1/2

Facility

$11.00

Hospital Charge Code	27567553
Hospital Revenue Code	270
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of AZ Commercial	$9.90
Rate for Payer: Aetna of AZ Medicare	$3.08
Rate for Payer: Allwell Medicare	$1.65
Rate for Payer: Amerigroup Medicare	$1.65
Rate for Payer: APIPA Medicare/Medicaid	$4.11
Rate for Payer: AZCH Complete Medicare	$1.65
Rate for Payer: Banner UC Health Medicare	$1.65
Rate for Payer: Bisbee Police All Plans	$2.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$7.48
Rate for Payer: Cash Price	$8.80
Rate for Payer: Cigna of AZ Commercial	$7.70
Rate for Payer: Copperpoint Commercial	$2.72
Rate for Payer: Health Net of AZ Commercial	$6.60
Rate for Payer: Health Net of AZ Medicare	$3.08
Rate for Payer: Humana of AZ Medicare	$1.65
Rate for Payer: Self Pay Self Pay	$8.80
Rate for Payer: TriWest Medicare	$1.65
Rate for Payer: UnitedHealth Group of AZ Commercial	$6.41
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.98

DRSG PACKING STRIP IODO 1/2"

Facility

$11.00

Hospital Charge Code	22797908
Hospital Revenue Code	270
Min. Negotiated Rate	$2.86
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of AZ Commercial	$9.90
Rate for Payer: Bisbee Police All Plans	$2.86
Rate for Payer: Cash Price	$8.80
Rate for Payer: Self Pay Self Pay	$8.80

DRSG PACKING STRIP IODO 1/2"

Facility

$11.00

Hospital Charge Code	22797908
Hospital Revenue Code	270
Min. Negotiated Rate	$1.65
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of AZ Commercial	$9.90
Rate for Payer: Aetna of AZ Medicare	$3.08
Rate for Payer: Allwell Medicare	$1.65
Rate for Payer: Amerigroup Medicare	$1.65
Rate for Payer: APIPA Medicare/Medicaid	$4.11
Rate for Payer: AZCH Complete Medicare	$1.65
Rate for Payer: Banner UC Health Medicare	$1.65
Rate for Payer: Bisbee Police All Plans	$2.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$7.48
Rate for Payer: Cash Price	$8.80
Rate for Payer: Cigna of AZ Commercial	$7.70
Rate for Payer: Copperpoint Commercial	$2.72
Rate for Payer: Health Net of AZ Commercial	$6.60
Rate for Payer: Health Net of AZ Medicare	$3.08
Rate for Payer: Humana of AZ Medicare	$1.65
Rate for Payer: Self Pay Self Pay	$8.80
Rate for Payer: TriWest Medicare	$1.65
Rate for Payer: UnitedHealth Group of AZ Commercial	$6.41
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.98

DRSG PACKING STRIP PLAIN 2-IN

Facility

$15.00

Hospital Charge Code	22592655
Hospital Revenue Code	272
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of AZ Commercial	$13.50
Rate for Payer: Aetna of AZ Medicare	$4.20
Rate for Payer: Allwell Medicare	$2.25
Rate for Payer: Amerigroup Medicare	$2.25
Rate for Payer: APIPA Medicare/Medicaid	$5.60
Rate for Payer: AZCH Complete Medicare	$2.25
Rate for Payer: Banner UC Health Medicare	$2.25
Rate for Payer: Bisbee Police All Plans	$3.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$10.20
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cigna of AZ Commercial	$10.50
Rate for Payer: Copperpoint Commercial	$3.71
Rate for Payer: Health Net of AZ Commercial	$9.00
Rate for Payer: Health Net of AZ Medicare	$4.20
Rate for Payer: Humana of AZ Medicare	$2.25
Rate for Payer: Self Pay Self Pay	$12.00
Rate for Payer: TriWest Medicare	$2.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$8.74
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.70

DRSG PACKING STRIP PLAIN 2-IN

Facility

$15.00

Hospital Charge Code	22592655
Hospital Revenue Code	272
Min. Negotiated Rate	$3.90
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of AZ Commercial	$13.50
Rate for Payer: Bisbee Police All Plans	$3.90
Rate for Payer: Cash Price	$12.00
Rate for Payer: Self Pay Self Pay	$12.00

DRSG POLYMEM 3X3

Facility

$93.00

Hospital Charge Code	22355313
Hospital Revenue Code	270
Min. Negotiated Rate	$24.18
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Bisbee Police All Plans	$24.18
Rate for Payer: Cash Price	$74.40
Rate for Payer: Self Pay Self Pay	$74.40

DRSG POLYMEM 3X3

Facility

$93.00

Hospital Charge Code	22355313
Hospital Revenue Code	270
Min. Negotiated Rate	$13.95
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Aetna of AZ Medicare	$26.04
Rate for Payer: Allwell Medicare	$13.95
Rate for Payer: Amerigroup Medicare	$13.95
Rate for Payer: APIPA Medicare/Medicaid	$34.74
Rate for Payer: AZCH Complete Medicare	$13.95
Rate for Payer: Banner UC Health Medicare	$13.95
Rate for Payer: Bisbee Police All Plans	$24.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$63.24
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cigna of AZ Commercial	$65.10
Rate for Payer: Copperpoint Commercial	$23.02
Rate for Payer: Health Net of AZ Commercial	$55.80
Rate for Payer: Health Net of AZ Medicare	$26.04
Rate for Payer: Humana of AZ Medicare	$13.95
Rate for Payer: Self Pay Self Pay	$74.40
Rate for Payer: TriWest Medicare	$13.95
Rate for Payer: UnitedHealth Group of AZ Commercial	$54.22
Rate for Payer: UnitedHealth Group of AZ Medicare	$16.74

DRSG POLYMEM SILVER 4.25 X 4.25

Facility

$81.00

Hospital Charge Code	22355430
Hospital Revenue Code	270
Min. Negotiated Rate	$21.06
Max. Negotiated Rate	$72.90
Rate for Payer: Aetna of AZ Commercial	$72.90
Rate for Payer: Bisbee Police All Plans	$21.06
Rate for Payer: Cash Price	$64.80
Rate for Payer: Self Pay Self Pay	$64.80

DRSG POLYMEM SILVER 4.25 X 4.25

Facility

$81.00

Hospital Charge Code	22355430
Hospital Revenue Code	270
Min. Negotiated Rate	$12.15
Max. Negotiated Rate	$72.90
Rate for Payer: Aetna of AZ Commercial	$72.90
Rate for Payer: Aetna of AZ Medicare	$22.68
Rate for Payer: Allwell Medicare	$12.15
Rate for Payer: Amerigroup Medicare	$12.15
Rate for Payer: APIPA Medicare/Medicaid	$30.25
Rate for Payer: AZCH Complete Medicare	$12.15
Rate for Payer: Banner UC Health Medicare	$12.15
Rate for Payer: Bisbee Police All Plans	$21.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$55.08
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna of AZ Commercial	$56.70
Rate for Payer: Copperpoint Commercial	$20.05
Rate for Payer: Health Net of AZ Commercial	$48.60
Rate for Payer: Health Net of AZ Medicare	$22.68
Rate for Payer: Humana of AZ Medicare	$12.15
Rate for Payer: Self Pay Self Pay	$64.80
Rate for Payer: TriWest Medicare	$12.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$47.22
Rate for Payer: UnitedHealth Group of AZ Medicare	$14.58

DRSG SURGICEL 4x8

Facility

$422.00

Hospital Charge Code	22355193
Hospital Revenue Code	270
Min. Negotiated Rate	$63.30
Max. Negotiated Rate	$379.80
Rate for Payer: Aetna of AZ Commercial	$379.80
Rate for Payer: Aetna of AZ Medicare	$118.16
Rate for Payer: Allwell Medicare	$63.30
Rate for Payer: Amerigroup Medicare	$63.30
Rate for Payer: APIPA Medicare/Medicaid	$157.62
Rate for Payer: AZCH Complete Medicare	$63.30
Rate for Payer: Banner UC Health Medicare	$63.30
Rate for Payer: Bisbee Police All Plans	$109.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$286.96
Rate for Payer: Cash Price	$337.60
Rate for Payer: Cigna of AZ Commercial	$295.40
Rate for Payer: Copperpoint Commercial	$104.44
Rate for Payer: Health Net of AZ Commercial	$253.20
Rate for Payer: Health Net of AZ Medicare	$118.16
Rate for Payer: Humana of AZ Medicare	$63.30
Rate for Payer: Self Pay Self Pay	$337.60
Rate for Payer: TriWest Medicare	$63.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$246.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$75.96

DRSG SURGICEL 4x8

Facility

$422.00

Hospital Charge Code	22355193
Hospital Revenue Code	270
Min. Negotiated Rate	$109.72
Max. Negotiated Rate	$379.80
Rate for Payer: Aetna of AZ Commercial	$379.80
Rate for Payer: Bisbee Police All Plans	$109.72
Rate for Payer: Cash Price	$337.60
Rate for Payer: Self Pay Self Pay	$337.60

DRSG WOUNDRESS 3OZ TUBE

Facility

$37.00

Hospital Charge Code	27571815
Hospital Revenue Code	270
Min. Negotiated Rate	$5.55
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Aetna of AZ Medicare	$10.36
Rate for Payer: Allwell Medicare	$5.55
Rate for Payer: Amerigroup Medicare	$5.55
Rate for Payer: APIPA Medicare/Medicaid	$13.82
Rate for Payer: AZCH Complete Medicare	$5.55
Rate for Payer: Banner UC Health Medicare	$5.55
Rate for Payer: Bisbee Police All Plans	$9.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$25.16
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cigna of AZ Commercial	$25.90
Rate for Payer: Copperpoint Commercial	$9.16
Rate for Payer: Health Net of AZ Commercial	$22.20
Rate for Payer: Health Net of AZ Medicare	$10.36
Rate for Payer: Humana of AZ Medicare	$5.55
Rate for Payer: Self Pay Self Pay	$29.60
Rate for Payer: TriWest Medicare	$5.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$21.57
Rate for Payer: UnitedHealth Group of AZ Medicare	$6.66

DRSG WOUNDRESS 3OZ TUBE

Facility

$37.00

Hospital Charge Code	27571815
Hospital Revenue Code	270
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Bisbee Police All Plans	$9.62
Rate for Payer: Cash Price	$29.60
Rate for Payer: Self Pay Self Pay	$29.60

DRSG WOUNDRESS 3OZ TUBE

Facility

$37.00

Hospital Charge Code	22355145
Hospital Revenue Code	270
Min. Negotiated Rate	$9.62
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Bisbee Police All Plans	$9.62
Rate for Payer: Cash Price	$29.60
Rate for Payer: Self Pay Self Pay	$29.60

DRSG WOUNDRESS 3OZ TUBE

Facility

$37.00

Hospital Charge Code	22355145
Hospital Revenue Code	270
Min. Negotiated Rate	$5.55
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Aetna of AZ Medicare	$10.36
Rate for Payer: Allwell Medicare	$5.55
Rate for Payer: Amerigroup Medicare	$5.55
Rate for Payer: APIPA Medicare/Medicaid	$13.82
Rate for Payer: AZCH Complete Medicare	$5.55
Rate for Payer: Banner UC Health Medicare	$5.55
Rate for Payer: Bisbee Police All Plans	$9.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$25.16
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cigna of AZ Commercial	$25.90
Rate for Payer: Copperpoint Commercial	$9.16
Rate for Payer: Health Net of AZ Commercial	$22.20
Rate for Payer: Health Net of AZ Medicare	$10.36
Rate for Payer: Humana of AZ Medicare	$5.55
Rate for Payer: Self Pay Self Pay	$29.60
Rate for Payer: TriWest Medicare	$5.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$21.57
Rate for Payer: UnitedHealth Group of AZ Medicare	$6.66

DRSG XEROFORM 5X9

Facility

$47.00

Hospital Charge Code	27571816
Hospital Revenue Code	270
Min. Negotiated Rate	$7.05
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Aetna of AZ Medicare	$13.16
Rate for Payer: Allwell Medicare	$7.05
Rate for Payer: Amerigroup Medicare	$7.05
Rate for Payer: APIPA Medicare/Medicaid	$17.55
Rate for Payer: AZCH Complete Medicare	$7.05
Rate for Payer: Banner UC Health Medicare	$7.05
Rate for Payer: Bisbee Police All Plans	$12.22
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$31.96
Rate for Payer: Cash Price	$37.60
Rate for Payer: Cigna of AZ Commercial	$32.90
Rate for Payer: Copperpoint Commercial	$11.63
Rate for Payer: Health Net of AZ Commercial	$28.20
Rate for Payer: Health Net of AZ Medicare	$13.16
Rate for Payer: Humana of AZ Medicare	$7.05
Rate for Payer: Self Pay Self Pay	$37.60
Rate for Payer: TriWest Medicare	$7.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$27.40
Rate for Payer: UnitedHealth Group of AZ Medicare	$8.46

DRSG XEROFORM 5X9

Facility

$47.00

Hospital Charge Code	27571816
Hospital Revenue Code	270
Min. Negotiated Rate	$12.22
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Bisbee Police All Plans	$12.22
Rate for Payer: Cash Price	$37.60
Rate for Payer: Self Pay Self Pay	$37.60

Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice

Facility

$2,506.80

Service Code	APR-DRG 7702
Hospital Charge Code	APRDRG7702
Min. Negotiated Rate	$2,506.80
Max. Negotiated Rate	$2,506.80
Rate for Payer: AHCCCS Medicaid	$2,506.80
Rate for Payer: Allwell Medicaid	$2,506.80
Rate for Payer: AZCH Complete Medicaid	$2,506.80
Rate for Payer: Banner UC Health Medicaid	$2,506.80
Rate for Payer: Mercy Care Medicaid	$2,506.80

Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice

Facility

$9,774.71

Service Code	APR-DRG 7704
Hospital Charge Code	APRDRG7702
Min. Negotiated Rate	$9,774.71
Max. Negotiated Rate	$9,774.71
Rate for Payer: AHCCCS Medicaid	$9,774.71
Rate for Payer: Allwell Medicaid	$9,774.71
Rate for Payer: AZCH Complete Medicaid	$9,774.71
Rate for Payer: Banner UC Health Medicaid	$9,774.71
Rate for Payer: Mercy Care Medicaid	$9,774.71

Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice

Facility

$9,774.71

Service Code	APR-DRG 7704
Hospital Charge Code	APRDRG7703
Min. Negotiated Rate	$9,774.71
Max. Negotiated Rate	$9,774.71
Rate for Payer: AHCCCS Medicaid	$9,774.71
Rate for Payer: Allwell Medicaid	$9,774.71
Rate for Payer: AZCH Complete Medicaid	$9,774.71
Rate for Payer: Banner UC Health Medicaid	$9,774.71
Rate for Payer: Mercy Care Medicaid	$9,774.71

Drug And Alcohol Abuse Or Dependence, Left Against Medical Advice

Facility

$1,604.10

Service Code	APR-DRG 7701
Hospital Charge Code	APRDRG7703
Min. Negotiated Rate	$1,604.10
Max. Negotiated Rate	$1,604.10
Rate for Payer: AHCCCS Medicaid	$1,604.10
Rate for Payer: Allwell Medicaid	$1,604.10
Rate for Payer: AZCH Complete Medicaid	$1,604.10
Rate for Payer: Banner UC Health Medicaid	$1,604.10
Rate for Payer: Mercy Care Medicaid	$1,604.10

Know your out-of-pocket cost for care.

All Charges