Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

DRSG MEPILEX BORDER 3X3

Facility

$16.00

Hospital Charge Code	22354828
Hospital Revenue Code	270
Min. Negotiated Rate	$2.56
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	$2.56
Rate for Payer: Amerigroup Medicare	$2.56
Rate for Payer: APIPA Medicare/Medicaid	$5.98
Rate for Payer: AZCH Complete Medicare	$2.56
Rate for Payer: Banner UC Health Medicare	$2.56
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	$2.56
Rate for Payer: Self Pay Self Pay	$12.80
Rate for Payer: TriWest Medicare	$2.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$9.33
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.88

DRSG MEPILEX BORDER 4X4

Facility

$19.00

Hospital Charge Code	27569980
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 MEPILEX BORDER 4X4

Facility

$19.00

Hospital Charge Code	27569980
Hospital Revenue Code	270
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

DRSG MEPILEX BORDER 4X4

Facility

$19.00

Hospital Charge Code	22354832
Hospital Revenue Code	270
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

DRSG MEPILEX BORDER 4X4

Facility

$19.00

Hospital Charge Code	22354832
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 MEPILEX BORDER 6X6

Facility

$32.00

Hospital Charge Code	27571814
Hospital Revenue Code	272
Min. Negotiated Rate	$5.12
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	$5.12
Rate for Payer: Amerigroup Medicare	$5.12
Rate for Payer: APIPA Medicare/Medicaid	$11.95
Rate for Payer: AZCH Complete Medicare	$5.12
Rate for Payer: Banner UC Health Medicare	$5.12
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	$5.12
Rate for Payer: Self Pay Self Pay	$25.60
Rate for Payer: TriWest Medicare	$5.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$18.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$5.76

DRSG MEPILEX BORDER 6X6

Facility

$32.00

Hospital Charge Code	27571814
Hospital Revenue Code	272
Min. Negotiated Rate	$8.32
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Bisbee Police All Plans	$8.32
Rate for Payer: Cash Price	$25.60
Rate for Payer: Self Pay Self Pay	$25.60

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 MICROFOAM 1-IN TAPE

Facility

$19.00

Hospital Charge Code	22355175
Hospital Revenue Code	270
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

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	$1.76
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	$1.76
Rate for Payer: Amerigroup Medicare	$1.76
Rate for Payer: APIPA Medicare/Medicaid	$4.11
Rate for Payer: AZCH Complete Medicare	$1.76
Rate for Payer: Banner UC Health Medicare	$1.76
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	$1.76
Rate for Payer: Self Pay Self Pay	$8.80
Rate for Payer: TriWest Medicare	$1.76
Rate for Payer: UnitedHealth Group of AZ Commercial	$6.41
Rate for Payer: UnitedHealth Group of AZ Medicare	$1.98

DRSG POLYMEM 3X3

Facility

$93.00

Hospital Charge Code	22355313
Hospital Revenue Code	270
Min. Negotiated Rate	$14.88
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	$14.88
Rate for Payer: Amerigroup Medicare	$14.88
Rate for Payer: APIPA Medicare/Medicaid	$34.74
Rate for Payer: AZCH Complete Medicare	$14.88
Rate for Payer: Banner UC Health Medicare	$14.88
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	$14.88
Rate for Payer: Self Pay Self Pay	$74.40
Rate for Payer: TriWest Medicare	$14.88
Rate for Payer: UnitedHealth Group of AZ Commercial	$54.22
Rate for Payer: UnitedHealth Group of AZ Medicare	$16.74

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 SILVER 4.25 X 4.25

Facility

$81.00

Hospital Charge Code	22355430
Hospital Revenue Code	270
Min. Negotiated Rate	$12.96
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	$12.96
Rate for Payer: Amerigroup Medicare	$12.96
Rate for Payer: APIPA Medicare/Medicaid	$30.25
Rate for Payer: AZCH Complete Medicare	$12.96
Rate for Payer: Banner UC Health Medicare	$12.96
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	$12.96
Rate for Payer: Self Pay Self Pay	$64.80
Rate for Payer: TriWest Medicare	$12.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$47.22
Rate for Payer: UnitedHealth Group of AZ Medicare	$14.58

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 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 SURGICEL 4x8

Facility

$422.00

Hospital Charge Code	22355193
Hospital Revenue Code	270
Min. Negotiated Rate	$67.52
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	$67.52
Rate for Payer: Amerigroup Medicare	$67.52
Rate for Payer: APIPA Medicare/Medicaid	$157.62
Rate for Payer: AZCH Complete Medicare	$67.52
Rate for Payer: Banner UC Health Medicare	$67.52
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	$67.52
Rate for Payer: Self Pay Self Pay	$337.60
Rate for Payer: TriWest Medicare	$67.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$246.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$75.96

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	$5.92
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	$5.92
Rate for Payer: Amerigroup Medicare	$5.92
Rate for Payer: APIPA Medicare/Medicaid	$13.82
Rate for Payer: AZCH Complete Medicare	$5.92
Rate for Payer: Banner UC Health Medicare	$5.92
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	$5.92
Rate for Payer: Self Pay Self Pay	$29.60
Rate for Payer: TriWest Medicare	$5.92
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	$5.92
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	$5.92
Rate for Payer: Amerigroup Medicare	$5.92
Rate for Payer: APIPA Medicare/Medicaid	$13.82
Rate for Payer: AZCH Complete Medicare	$5.92
Rate for Payer: Banner UC Health Medicare	$5.92
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	$5.92
Rate for Payer: Self Pay Self Pay	$29.60
Rate for Payer: TriWest Medicare	$5.92
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	$7.52
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	$7.52
Rate for Payer: Amerigroup Medicare	$7.52
Rate for Payer: APIPA Medicare/Medicaid	$17.55
Rate for Payer: AZCH Complete Medicare	$7.52
Rate for Payer: Banner UC Health Medicare	$7.52
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	$7.52
Rate for Payer: Self Pay Self Pay	$37.60
Rate for Payer: TriWest Medicare	$7.52
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 Analysis Profile, Comprehensive, Urine LC

Facility

$281.00

Service Code	CPT 80307
Hospital Charge Code	28073685
Hospital Revenue Code	301
Min. Negotiated Rate	$73.06
Max. Negotiated Rate	$252.90
Rate for Payer: Aetna of AZ Commercial	$252.90
Rate for Payer: Bisbee Police All Plans	$73.06
Rate for Payer: Cash Price	$224.80
Rate for Payer: Self Pay Self Pay	$224.80

Drug Analysis Profile, Comprehensive, Urine LC

Facility

$281.00

Service Code	CPT 80307
Hospital Charge Code	28073685
Hospital Revenue Code	301
Min. Negotiated Rate	$44.96
Max. Negotiated Rate	$252.90
Rate for Payer: Aetna of AZ Commercial	$252.90
Rate for Payer: Aetna of AZ Medicare	$78.68
Rate for Payer: Allwell Medicare	$44.96
Rate for Payer: Amerigroup Medicare	$44.96
Rate for Payer: APIPA Medicare/Medicaid	$104.95
Rate for Payer: AZCH Complete Medicare	$44.96
Rate for Payer: Banner UC Health Medicare	$44.96
Rate for Payer: Bisbee Police All Plans	$73.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$191.08
Rate for Payer: Cash Price	$224.80
Rate for Payer: Cigna of AZ Commercial	$182.65
Rate for Payer: Copperpoint Commercial	$69.55
Rate for Payer: Health Net of AZ Commercial	$168.60
Rate for Payer: Health Net of AZ Medicare	$78.68
Rate for Payer: Humana of AZ Medicare	$44.96
Rate for Payer: Self Pay Self Pay	$224.80
Rate for Payer: TriWest Medicare	$44.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$163.82
Rate for Payer: UnitedHealth Group of AZ Medicare	$50.58

Know your out-of-pocket cost for care.

All Charges