Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

DRSG MEPILEX BORDER 15X15 (6X6)

Facility

$32.00

Hospital Charge Code	22354829
Hospital Revenue Code	272
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Cash Price	$25.60

DRSG MEPILEX BORDER 3X3

Facility

$16.00

Hospital Charge Code	22354828
Hospital Revenue Code	270
Min. Negotiated Rate	$2.53
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Arizona Complete Health Allwell	$2.56
Rate for Payer: Banner UC Health Medicare	$2.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$10.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.56
Rate for Payer: Cash Price	$12.80
Rate for Payer: Cigna of AZ Commercial	$11.20
Rate for Payer: Devoted Health Medicare	$2.88
Rate for Payer: Humana of AZ Medicare	$2.56
Rate for Payer: Southwest Service Administrators UFCW	$10.88
Rate for Payer: TriWest Medicare	$2.56
Rate for Payer: United Healthcare Commercial	$9.15
Rate for Payer: United Healthcare Medicare	$2.56
Rate for Payer: Veterans Affairs TRICARE	$2.53

DRSG MEPILEX BORDER 3X3

Facility

$16.00

Hospital Charge Code	22354828
Hospital Revenue Code	270
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Cash Price	$12.80

DRSG MEPILEX BORDER 4X4

Facility

$19.00

Hospital Charge Code	27569980
Hospital Revenue Code	270
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$17.10
Rate for Payer: Aetna of AZ Commercial	$17.10
Rate for Payer: Arizona Complete Health Allwell	$3.04
Rate for Payer: Banner UC Health Medicare	$3.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$12.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.04
Rate for Payer: Cash Price	$15.20
Rate for Payer: Cigna of AZ Commercial	$13.30
Rate for Payer: Devoted Health Medicare	$3.42
Rate for Payer: Humana of AZ Medicare	$3.04
Rate for Payer: Southwest Service Administrators UFCW	$12.92
Rate for Payer: TriWest Medicare	$3.04
Rate for Payer: United Healthcare Commercial	$10.87
Rate for Payer: United Healthcare Medicare	$3.04
Rate for Payer: Veterans Affairs TRICARE	$3.01

DRSG MEPILEX BORDER 4X4

Facility

$19.00

Hospital Charge Code	27569980
Hospital Revenue Code	270
Min. Negotiated Rate	$17.10
Max. Negotiated Rate	$17.10
Rate for Payer: Aetna of AZ Commercial	$17.10
Rate for Payer: Cash Price	$15.20

DRSG MEPILEX BORDER 4X4

Facility

$19.00

Hospital Charge Code	22354832
Hospital Revenue Code	270
Min. Negotiated Rate	$17.10
Max. Negotiated Rate	$17.10
Rate for Payer: Aetna of AZ Commercial	$17.10
Rate for Payer: Cash Price	$15.20

DRSG MEPILEX BORDER 4X4

Facility

$19.00

Hospital Charge Code	22354832
Hospital Revenue Code	270
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$17.10
Rate for Payer: Aetna of AZ Commercial	$17.10
Rate for Payer: Arizona Complete Health Allwell	$3.04
Rate for Payer: Banner UC Health Medicare	$3.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$12.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.04
Rate for Payer: Cash Price	$15.20
Rate for Payer: Cigna of AZ Commercial	$13.30
Rate for Payer: Devoted Health Medicare	$3.42
Rate for Payer: Humana of AZ Medicare	$3.04
Rate for Payer: Southwest Service Administrators UFCW	$12.92
Rate for Payer: TriWest Medicare	$3.04
Rate for Payer: United Healthcare Commercial	$10.87
Rate for Payer: United Healthcare Medicare	$3.04
Rate for Payer: Veterans Affairs TRICARE	$3.01

DRSG MEPILEX BORDER 6X6

Facility

$32.00

Hospital Charge Code	27571814
Hospital Revenue Code	272
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Cash Price	$25.60

DRSG MEPILEX BORDER 6X6

Facility

$32.00

Hospital Charge Code	27571814
Hospital Revenue Code	272
Min. Negotiated Rate	$5.07
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Arizona Complete Health Allwell	$5.12
Rate for Payer: Banner UC Health Medicare	$5.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$21.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.12
Rate for Payer: Cash Price	$25.60
Rate for Payer: Cigna of AZ Commercial	$22.40
Rate for Payer: Devoted Health Medicare	$5.76
Rate for Payer: Humana of AZ Medicare	$5.12
Rate for Payer: Southwest Service Administrators UFCW	$21.76
Rate for Payer: TriWest Medicare	$5.12
Rate for Payer: United Healthcare Commercial	$18.30
Rate for Payer: United Healthcare Medicare	$5.12
Rate for Payer: Veterans Affairs TRICARE	$5.07

DRSG MICROFOAM 1-IN TAPE

Facility

$19.00

Hospital Charge Code	22355175
Hospital Revenue Code	270
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$17.10
Rate for Payer: Aetna of AZ Commercial	$17.10
Rate for Payer: Arizona Complete Health Allwell	$3.04
Rate for Payer: Banner UC Health Medicare	$3.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$12.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.04
Rate for Payer: Cash Price	$15.20
Rate for Payer: Cigna of AZ Commercial	$13.30
Rate for Payer: Devoted Health Medicare	$3.42
Rate for Payer: Humana of AZ Medicare	$3.04
Rate for Payer: Southwest Service Administrators UFCW	$12.92
Rate for Payer: TriWest Medicare	$3.04
Rate for Payer: United Healthcare Commercial	$10.87
Rate for Payer: United Healthcare Medicare	$3.04
Rate for Payer: Veterans Affairs TRICARE	$3.01

DRSG MICROFOAM 1-IN TAPE

Facility

$19.00

Hospital Charge Code	22355175
Hospital Revenue Code	270
Min. Negotiated Rate	$17.10
Max. Negotiated Rate	$17.10
Rate for Payer: Aetna of AZ Commercial	$17.10
Rate for Payer: Cash Price	$15.20

DRSG PACKING STRIP IODO 1/2

Facility

$11.00

Hospital Charge Code	27567553
Hospital Revenue Code	270
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of AZ Commercial	$9.90
Rate for Payer: Arizona Complete Health Allwell	$1.76
Rate for Payer: Banner UC Health Medicare	$1.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$7.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.76
Rate for Payer: Cash Price	$8.80
Rate for Payer: Cigna of AZ Commercial	$7.70
Rate for Payer: Devoted Health Medicare	$1.98
Rate for Payer: Humana of AZ Medicare	$1.76
Rate for Payer: Southwest Service Administrators UFCW	$7.48
Rate for Payer: TriWest Medicare	$1.76
Rate for Payer: United Healthcare Commercial	$6.29
Rate for Payer: United Healthcare Medicare	$1.76
Rate for Payer: Veterans Affairs TRICARE	$1.74

DRSG PACKING STRIP IODO 1/2

Facility

$11.00

Hospital Charge Code	27567553
Hospital Revenue Code	270
Min. Negotiated Rate	$9.90
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of AZ Commercial	$9.90
Rate for Payer: Cash Price	$8.80

DRSG POLYMEM 3X3

Facility

$93.00

Hospital Charge Code	22355313
Hospital Revenue Code	270
Min. Negotiated Rate	$83.70
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Cash Price	$74.40

DRSG POLYMEM 3X3

Facility

$93.00

Hospital Charge Code	22355313
Hospital Revenue Code	270
Min. Negotiated Rate	$14.73
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Arizona Complete Health Allwell	$14.88
Rate for Payer: Banner UC Health Medicare	$14.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$63.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.88
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cigna of AZ Commercial	$65.10
Rate for Payer: Devoted Health Medicare	$16.74
Rate for Payer: Humana of AZ Medicare	$14.88
Rate for Payer: Southwest Service Administrators UFCW	$63.24
Rate for Payer: TriWest Medicare	$14.88
Rate for Payer: United Healthcare Commercial	$53.20
Rate for Payer: United Healthcare Medicare	$14.88
Rate for Payer: Veterans Affairs TRICARE	$14.73

DRSG POLYMEM SILVER 4.25 X 4.25

Facility

$81.00

Hospital Charge Code	22355430
Hospital Revenue Code	270
Min. Negotiated Rate	$12.83
Max. Negotiated Rate	$72.90
Rate for Payer: Aetna of AZ Commercial	$72.90
Rate for Payer: Arizona Complete Health Allwell	$12.96
Rate for Payer: Banner UC Health Medicare	$12.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$55.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.96
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna of AZ Commercial	$56.70
Rate for Payer: Devoted Health Medicare	$14.58
Rate for Payer: Humana of AZ Medicare	$12.96
Rate for Payer: Southwest Service Administrators UFCW	$55.08
Rate for Payer: TriWest Medicare	$12.96
Rate for Payer: United Healthcare Commercial	$46.33
Rate for Payer: United Healthcare Medicare	$12.96
Rate for Payer: Veterans Affairs TRICARE	$12.83

DRSG POLYMEM SILVER 4.25 X 4.25

Facility

$81.00

Hospital Charge Code	22355430
Hospital Revenue Code	270
Min. Negotiated Rate	$72.90
Max. Negotiated Rate	$72.90
Rate for Payer: Aetna of AZ Commercial	$72.90
Rate for Payer: Cash Price	$64.80

DRSG SURGICEL 4x8

Facility

$422.00

Hospital Charge Code	22355193
Hospital Revenue Code	270
Min. Negotiated Rate	$379.80
Max. Negotiated Rate	$379.80
Rate for Payer: Aetna of AZ Commercial	$379.80
Rate for Payer: Cash Price	$337.60

DRSG SURGICEL 4x8

Facility

$422.00

Hospital Charge Code	22355193
Hospital Revenue Code	270
Min. Negotiated Rate	$66.84
Max. Negotiated Rate	$379.80
Rate for Payer: Aetna of AZ Commercial	$379.80
Rate for Payer: Arizona Complete Health Allwell	$67.52
Rate for Payer: Banner UC Health Medicare	$67.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$286.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$67.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$67.52
Rate for Payer: Cash Price	$337.60
Rate for Payer: Cigna of AZ Commercial	$295.40
Rate for Payer: Devoted Health Medicare	$75.96
Rate for Payer: Humana of AZ Medicare	$67.52
Rate for Payer: Southwest Service Administrators UFCW	$286.96
Rate for Payer: TriWest Medicare	$67.52
Rate for Payer: United Healthcare Commercial	$241.38
Rate for Payer: United Healthcare Medicare	$67.52
Rate for Payer: Veterans Affairs TRICARE	$66.84

DRSG WOUNDRESS 3OZ TUBE

Facility

$37.00

Hospital Charge Code	27571815
Hospital Revenue Code	270
Min. Negotiated Rate	$5.86
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Arizona Complete Health Allwell	$5.92
Rate for Payer: Banner UC Health Medicare	$5.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$25.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.92
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cigna of AZ Commercial	$25.90
Rate for Payer: Devoted Health Medicare	$6.66
Rate for Payer: Humana of AZ Medicare	$5.92
Rate for Payer: Southwest Service Administrators UFCW	$25.16
Rate for Payer: TriWest Medicare	$5.92
Rate for Payer: United Healthcare Commercial	$21.16
Rate for Payer: United Healthcare Medicare	$5.92
Rate for Payer: Veterans Affairs TRICARE	$5.86

DRSG WOUNDRESS 3OZ TUBE

Facility

$37.00

Hospital Charge Code	27571815
Hospital Revenue Code	270
Min. Negotiated Rate	$33.30
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Cash Price	$29.60

DRSG WOUNDRESS 3OZ TUBE

Facility

$37.00

Hospital Charge Code	22355145
Hospital Revenue Code	270
Min. Negotiated Rate	$33.30
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Cash Price	$29.60

DRSG WOUNDRESS 3OZ TUBE

Facility

$37.00

Hospital Charge Code	22355145
Hospital Revenue Code	270
Min. Negotiated Rate	$5.86
Max. Negotiated Rate	$33.30
Rate for Payer: Aetna of AZ Commercial	$33.30
Rate for Payer: Arizona Complete Health Allwell	$5.92
Rate for Payer: Banner UC Health Medicare	$5.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$25.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.92
Rate for Payer: Cash Price	$29.60
Rate for Payer: Cigna of AZ Commercial	$25.90
Rate for Payer: Devoted Health Medicare	$6.66
Rate for Payer: Humana of AZ Medicare	$5.92
Rate for Payer: Southwest Service Administrators UFCW	$25.16
Rate for Payer: TriWest Medicare	$5.92
Rate for Payer: United Healthcare Commercial	$21.16
Rate for Payer: United Healthcare Medicare	$5.92
Rate for Payer: Veterans Affairs TRICARE	$5.86

DRSG XEROFORM 5X9

Facility

$47.00

Hospital Charge Code	27571816
Hospital Revenue Code	270
Min. Negotiated Rate	$7.44
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Arizona Complete Health Allwell	$7.52
Rate for Payer: Banner UC Health Medicare	$7.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$31.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.52
Rate for Payer: Cash Price	$37.60
Rate for Payer: Cigna of AZ Commercial	$32.90
Rate for Payer: Devoted Health Medicare	$8.46
Rate for Payer: Humana of AZ Medicare	$7.52
Rate for Payer: Southwest Service Administrators UFCW	$31.96
Rate for Payer: TriWest Medicare	$7.52
Rate for Payer: United Healthcare Commercial	$26.88
Rate for Payer: United Healthcare Medicare	$7.52
Rate for Payer: Veterans Affairs TRICARE	$7.44

DRSG XEROFORM 5X9

Facility

$47.00

Hospital Charge Code	27571816
Hospital Revenue Code	270
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Cash Price	$37.60

Know your out-of-pocket cost for care.

All Charges