Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

PURAPLAY AM 3X4 FENESTRATED

Facility

$880.00

Service Code	CPT Q4196
Hospital Charge Code	24358090
Hospital Revenue Code	636
Min. Negotiated Rate	$140.80
Max. Negotiated Rate	$792.00
Rate for Payer: Aetna of AZ Commercial	$792.00
Rate for Payer: Aetna of AZ Medicare	$246.40
Rate for Payer: Allwell Medicare	$140.80
Rate for Payer: Amerigroup Medicare	$140.80
Rate for Payer: APIPA Medicare/Medicaid	$328.68
Rate for Payer: AZCH Complete Medicare	$140.80
Rate for Payer: Banner UC Health Medicare	$140.80
Rate for Payer: Bisbee Police All Plans	$228.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$598.40
Rate for Payer: Cash Price	$704.00
Rate for Payer: Cigna of AZ Commercial	$616.00
Rate for Payer: Copperpoint Commercial	$217.80
Rate for Payer: Health Net of AZ Commercial	$528.00
Rate for Payer: Health Net of AZ Medicare	$246.40
Rate for Payer: Humana of AZ Medicare	$140.80
Rate for Payer: Self Pay Self Pay	$704.00
Rate for Payer: TriWest Medicare	$140.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$513.04
Rate for Payer: UnitedHealth Group of AZ Medicare	$158.40

PURAPLYAM

Facility

$8,078.00

Service Code	CPT Q4196
Hospital Charge Code	24358088
Hospital Revenue Code	636
Min. Negotiated Rate	$1,292.48
Max. Negotiated Rate	$7,270.20
Rate for Payer: Aetna of AZ Commercial	$7,270.20
Rate for Payer: Aetna of AZ Medicare	$2,261.84
Rate for Payer: Allwell Medicare	$1,292.48
Rate for Payer: Amerigroup Medicare	$1,292.48
Rate for Payer: APIPA Medicare/Medicaid	$3,017.13
Rate for Payer: AZCH Complete Medicare	$1,292.48
Rate for Payer: Banner UC Health Medicare	$1,292.48
Rate for Payer: Bisbee Police All Plans	$2,100.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$5,493.04
Rate for Payer: Cash Price	$6,462.40
Rate for Payer: Cigna of AZ Commercial	$5,654.60
Rate for Payer: Copperpoint Commercial	$1,999.31
Rate for Payer: Health Net of AZ Commercial	$4,846.80
Rate for Payer: Health Net of AZ Medicare	$2,261.84
Rate for Payer: Humana of AZ Medicare	$1,292.48
Rate for Payer: Self Pay Self Pay	$6,462.40
Rate for Payer: TriWest Medicare	$1,292.48
Rate for Payer: UnitedHealth Group of AZ Commercial	$4,709.47
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,454.04

PURAPLYAM

Facility

$8,078.00

Service Code	CPT Q4196
Hospital Charge Code	24358088
Hospital Revenue Code	636
Min. Negotiated Rate	$2,100.28
Max. Negotiated Rate	$7,270.20
Rate for Payer: Aetna of AZ Commercial	$7,270.20
Rate for Payer: Bisbee Police All Plans	$2,100.28
Rate for Payer: Cash Price	$6,462.40
Rate for Payer: Self Pay Self Pay	$6,462.40

PURAPLYAM

Facility

$1,973.00

Service Code	CPT Q4196
Hospital Charge Code	24358083
Hospital Revenue Code	636
Min. Negotiated Rate	$315.68
Max. Negotiated Rate	$1,775.70
Rate for Payer: Aetna of AZ Commercial	$1,775.70
Rate for Payer: Aetna of AZ Medicare	$552.44
Rate for Payer: Allwell Medicare	$315.68
Rate for Payer: Amerigroup Medicare	$315.68
Rate for Payer: APIPA Medicare/Medicaid	$736.92
Rate for Payer: AZCH Complete Medicare	$315.68
Rate for Payer: Banner UC Health Medicare	$315.68
Rate for Payer: Bisbee Police All Plans	$512.98
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,341.64
Rate for Payer: Cash Price	$1,578.40
Rate for Payer: Cigna of AZ Commercial	$1,381.10
Rate for Payer: Copperpoint Commercial	$488.32
Rate for Payer: Health Net of AZ Commercial	$1,183.80
Rate for Payer: Health Net of AZ Medicare	$552.44
Rate for Payer: Humana of AZ Medicare	$315.68
Rate for Payer: Self Pay Self Pay	$1,578.40
Rate for Payer: TriWest Medicare	$315.68
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,150.26
Rate for Payer: UnitedHealth Group of AZ Medicare	$355.14

PURAPLYAM

Facility

$1,973.00

Service Code	CPT Q4196
Hospital Charge Code	24358083
Hospital Revenue Code	636
Min. Negotiated Rate	$512.98
Max. Negotiated Rate	$1,775.70
Rate for Payer: Aetna of AZ Commercial	$1,775.70
Rate for Payer: Bisbee Police All Plans	$512.98
Rate for Payer: Cash Price	$1,578.40
Rate for Payer: Self Pay Self Pay	$1,578.40

PURAPLY AM 3X4

Facility

$1,096.00

Service Code	CPT Q4196
Hospital Charge Code	24358089
Hospital Revenue Code	636
Min. Negotiated Rate	$284.96
Max. Negotiated Rate	$986.40
Rate for Payer: Aetna of AZ Commercial	$986.40
Rate for Payer: Bisbee Police All Plans	$284.96
Rate for Payer: Cash Price	$876.80
Rate for Payer: Self Pay Self Pay	$876.80

PURAPLY AM 3X4

Facility

$1,096.00

Service Code	CPT Q4196
Hospital Charge Code	24358089
Hospital Revenue Code	636
Min. Negotiated Rate	$175.36
Max. Negotiated Rate	$986.40
Rate for Payer: Aetna of AZ Commercial	$986.40
Rate for Payer: Aetna of AZ Medicare	$306.88
Rate for Payer: Allwell Medicare	$175.36
Rate for Payer: Amerigroup Medicare	$175.36
Rate for Payer: APIPA Medicare/Medicaid	$409.36
Rate for Payer: AZCH Complete Medicare	$175.36
Rate for Payer: Banner UC Health Medicare	$175.36
Rate for Payer: Bisbee Police All Plans	$284.96
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$745.28
Rate for Payer: Cash Price	$876.80
Rate for Payer: Cigna of AZ Commercial	$767.20
Rate for Payer: Copperpoint Commercial	$271.26
Rate for Payer: Health Net of AZ Commercial	$657.60
Rate for Payer: Health Net of AZ Medicare	$306.88
Rate for Payer: Humana of AZ Medicare	$175.36
Rate for Payer: Self Pay Self Pay	$876.80
Rate for Payer: TriWest Medicare	$175.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$638.97
Rate for Payer: UnitedHealth Group of AZ Medicare	$197.28

PURAPLY AM 4X4

Facility

$864.00

Service Code	CPT Q4196
Hospital Charge Code	24358091
Hospital Revenue Code	636
Min. Negotiated Rate	$138.24
Max. Negotiated Rate	$777.60
Rate for Payer: Aetna of AZ Commercial	$777.60
Rate for Payer: Aetna of AZ Medicare	$241.92
Rate for Payer: Allwell Medicare	$138.24
Rate for Payer: Amerigroup Medicare	$138.24
Rate for Payer: APIPA Medicare/Medicaid	$322.70
Rate for Payer: AZCH Complete Medicare	$138.24
Rate for Payer: Banner UC Health Medicare	$138.24
Rate for Payer: Bisbee Police All Plans	$224.64
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$587.52
Rate for Payer: Cash Price	$691.20
Rate for Payer: Cigna of AZ Commercial	$604.80
Rate for Payer: Copperpoint Commercial	$213.84
Rate for Payer: Health Net of AZ Commercial	$518.40
Rate for Payer: Health Net of AZ Medicare	$241.92
Rate for Payer: Humana of AZ Medicare	$138.24
Rate for Payer: Self Pay Self Pay	$691.20
Rate for Payer: TriWest Medicare	$138.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$503.71
Rate for Payer: UnitedHealth Group of AZ Medicare	$155.52

PURAPLY AM 4X4

Facility

$864.00

Service Code	CPT Q4196
Hospital Charge Code	24358091
Hospital Revenue Code	636
Min. Negotiated Rate	$224.64
Max. Negotiated Rate	$777.60
Rate for Payer: Aetna of AZ Commercial	$777.60
Rate for Payer: Bisbee Police All Plans	$224.64
Rate for Payer: Cash Price	$691.20
Rate for Payer: Self Pay Self Pay	$691.20

PURAPLY AM 4X4 FENESTRATED

Facility

$864.00

Hospital Charge Code	24358092
Hospital Revenue Code	636
Min. Negotiated Rate	$138.24
Max. Negotiated Rate	$777.60
Rate for Payer: Aetna of AZ Commercial	$777.60
Rate for Payer: Aetna of AZ Medicare	$241.92
Rate for Payer: Allwell Medicare	$138.24
Rate for Payer: Amerigroup Medicare	$138.24
Rate for Payer: APIPA Medicare/Medicaid	$322.70
Rate for Payer: AZCH Complete Medicare	$138.24
Rate for Payer: Banner UC Health Medicare	$138.24
Rate for Payer: Bisbee Police All Plans	$224.64
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$587.52
Rate for Payer: Cash Price	$691.20
Rate for Payer: Cigna of AZ Commercial	$604.80
Rate for Payer: Copperpoint Commercial	$213.84
Rate for Payer: Health Net of AZ Commercial	$518.40
Rate for Payer: Health Net of AZ Medicare	$241.92
Rate for Payer: Humana of AZ Medicare	$138.24
Rate for Payer: Self Pay Self Pay	$691.20
Rate for Payer: TriWest Medicare	$138.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$503.71
Rate for Payer: UnitedHealth Group of AZ Medicare	$155.52

PURAPLY AM 4X4 FENESTRATED

Facility

$864.00

Hospital Charge Code	24358092
Hospital Revenue Code	636
Min. Negotiated Rate	$224.64
Max. Negotiated Rate	$777.60
Rate for Payer: Aetna of AZ Commercial	$777.60
Rate for Payer: Bisbee Police All Plans	$224.64
Rate for Payer: Cash Price	$691.20
Rate for Payer: Self Pay Self Pay	$691.20

PURAPLY AM 5X5

Facility

$832.00

Service Code	CPT Q4196
Hospital Charge Code	24358093
Hospital Revenue Code	636
Min. Negotiated Rate	$216.32
Max. Negotiated Rate	$748.80
Rate for Payer: Aetna of AZ Commercial	$748.80
Rate for Payer: Bisbee Police All Plans	$216.32
Rate for Payer: Cash Price	$665.60
Rate for Payer: Self Pay Self Pay	$665.60

PURAPLY AM 5X5

Facility

$832.00

Service Code	CPT Q4196
Hospital Charge Code	24358093
Hospital Revenue Code	636
Min. Negotiated Rate	$133.12
Max. Negotiated Rate	$748.80
Rate for Payer: Aetna of AZ Commercial	$748.80
Rate for Payer: Aetna of AZ Medicare	$232.96
Rate for Payer: Allwell Medicare	$133.12
Rate for Payer: Amerigroup Medicare	$133.12
Rate for Payer: APIPA Medicare/Medicaid	$310.75
Rate for Payer: AZCH Complete Medicare	$133.12
Rate for Payer: Banner UC Health Medicare	$133.12
Rate for Payer: Bisbee Police All Plans	$216.32
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$565.76
Rate for Payer: Cash Price	$665.60
Rate for Payer: Cigna of AZ Commercial	$582.40
Rate for Payer: Copperpoint Commercial	$205.92
Rate for Payer: Health Net of AZ Commercial	$499.20
Rate for Payer: Health Net of AZ Medicare	$232.96
Rate for Payer: Humana of AZ Medicare	$133.12
Rate for Payer: Self Pay Self Pay	$665.60
Rate for Payer: TriWest Medicare	$133.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$485.06
Rate for Payer: UnitedHealth Group of AZ Medicare	$149.76

PURAPLY AM 6X9

Facility

$760.00

Service Code	CPT Q4196
Hospital Charge Code	24358094
Hospital Revenue Code	636
Min. Negotiated Rate	$197.60
Max. Negotiated Rate	$684.00
Rate for Payer: Aetna of AZ Commercial	$684.00
Rate for Payer: Bisbee Police All Plans	$197.60
Rate for Payer: Cash Price	$608.00
Rate for Payer: Self Pay Self Pay	$608.00

PURAPLY AM 6X9

Facility

$760.00

Service Code	CPT Q4196
Hospital Charge Code	24358094
Hospital Revenue Code	636
Min. Negotiated Rate	$121.60
Max. Negotiated Rate	$684.00
Rate for Payer: Aetna of AZ Commercial	$684.00
Rate for Payer: Aetna of AZ Medicare	$212.80
Rate for Payer: Allwell Medicare	$121.60
Rate for Payer: Amerigroup Medicare	$121.60
Rate for Payer: APIPA Medicare/Medicaid	$283.86
Rate for Payer: AZCH Complete Medicare	$121.60
Rate for Payer: Banner UC Health Medicare	$121.60
Rate for Payer: Bisbee Police All Plans	$197.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$516.80
Rate for Payer: Cash Price	$608.00
Rate for Payer: Cigna of AZ Commercial	$532.00
Rate for Payer: Copperpoint Commercial	$188.10
Rate for Payer: Health Net of AZ Commercial	$456.00
Rate for Payer: Health Net of AZ Medicare	$212.80
Rate for Payer: Humana of AZ Medicare	$121.60
Rate for Payer: Self Pay Self Pay	$608.00
Rate for Payer: TriWest Medicare	$121.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$443.08
Rate for Payer: UnitedHealth Group of AZ Medicare	$136.80

PURAPLY AM XT EF 4.91 X4.91

Facility

$601.00

Hospital Charge Code	27690859
Hospital Revenue Code	270
Min. Negotiated Rate	$156.26
Max. Negotiated Rate	$540.90
Rate for Payer: Aetna of AZ Commercial	$540.90
Rate for Payer: Bisbee Police All Plans	$156.26
Rate for Payer: Cash Price	$480.80
Rate for Payer: Self Pay Self Pay	$480.80

PURAPLY AM XT EF 4.91 X4.91

Facility

$601.00

Hospital Charge Code	27690859
Hospital Revenue Code	270
Min. Negotiated Rate	$96.16
Max. Negotiated Rate	$540.90
Rate for Payer: Aetna of AZ Commercial	$540.90
Rate for Payer: Aetna of AZ Medicare	$168.28
Rate for Payer: Allwell Medicare	$96.16
Rate for Payer: Amerigroup Medicare	$96.16
Rate for Payer: APIPA Medicare/Medicaid	$224.47
Rate for Payer: AZCH Complete Medicare	$96.16
Rate for Payer: Banner UC Health Medicare	$96.16
Rate for Payer: Bisbee Police All Plans	$156.26
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$408.68
Rate for Payer: Cash Price	$480.80
Rate for Payer: Cigna of AZ Commercial	$420.70
Rate for Payer: Copperpoint Commercial	$148.75
Rate for Payer: Health Net of AZ Commercial	$360.60
Rate for Payer: Health Net of AZ Medicare	$168.28
Rate for Payer: Humana of AZ Medicare	$96.16
Rate for Payer: Self Pay Self Pay	$480.80
Rate for Payer: TriWest Medicare	$96.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$350.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$108.18

PURAPLY MZ 1000MG

Facility

$18,520.00

Hospital Charge Code	27570614
Hospital Revenue Code	270
Min. Negotiated Rate	$4,815.20
Max. Negotiated Rate	$16,668.00
Rate for Payer: Aetna of AZ Commercial	$16,668.00
Rate for Payer: Bisbee Police All Plans	$4,815.20
Rate for Payer: Cash Price	$14,816.00
Rate for Payer: Self Pay Self Pay	$14,816.00

PURAPLY MZ 1000MG

Facility

$18,520.00

Hospital Charge Code	27570614
Hospital Revenue Code	270
Min. Negotiated Rate	$2,963.20
Max. Negotiated Rate	$16,668.00
Rate for Payer: Aetna of AZ Commercial	$16,668.00
Rate for Payer: Aetna of AZ Medicare	$5,185.60
Rate for Payer: Allwell Medicare	$2,963.20
Rate for Payer: Amerigroup Medicare	$2,963.20
Rate for Payer: APIPA Medicare/Medicaid	$6,917.22
Rate for Payer: AZCH Complete Medicare	$2,963.20
Rate for Payer: Banner UC Health Medicare	$2,963.20
Rate for Payer: Bisbee Police All Plans	$4,815.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$12,593.60
Rate for Payer: Cash Price	$14,816.00
Rate for Payer: Cigna of AZ Commercial	$12,964.00
Rate for Payer: Copperpoint Commercial	$4,583.70
Rate for Payer: Health Net of AZ Commercial	$11,112.00
Rate for Payer: Health Net of AZ Medicare	$5,185.60
Rate for Payer: Humana of AZ Medicare	$2,963.20
Rate for Payer: Self Pay Self Pay	$14,816.00
Rate for Payer: TriWest Medicare	$2,963.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$10,797.16
Rate for Payer: UnitedHealth Group of AZ Medicare	$3,333.60

PURAPLY MZ 100MG

Facility

$2,040.00

Hospital Charge Code	27570615
Hospital Revenue Code	270
Min. Negotiated Rate	$530.40
Max. Negotiated Rate	$1,836.00
Rate for Payer: Aetna of AZ Commercial	$1,836.00
Rate for Payer: Bisbee Police All Plans	$530.40
Rate for Payer: Cash Price	$1,632.00
Rate for Payer: Self Pay Self Pay	$1,632.00

PURAPLY MZ 100MG

Facility

$2,040.00

Hospital Charge Code	27570615
Hospital Revenue Code	270
Min. Negotiated Rate	$326.40
Max. Negotiated Rate	$1,836.00
Rate for Payer: Aetna of AZ Commercial	$1,836.00
Rate for Payer: Aetna of AZ Medicare	$571.20
Rate for Payer: Allwell Medicare	$326.40
Rate for Payer: Amerigroup Medicare	$326.40
Rate for Payer: APIPA Medicare/Medicaid	$761.94
Rate for Payer: AZCH Complete Medicare	$326.40
Rate for Payer: Banner UC Health Medicare	$326.40
Rate for Payer: Bisbee Police All Plans	$530.40
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,387.20
Rate for Payer: Cash Price	$1,632.00
Rate for Payer: Cigna of AZ Commercial	$1,428.00
Rate for Payer: Copperpoint Commercial	$504.90
Rate for Payer: Health Net of AZ Commercial	$1,224.00
Rate for Payer: Health Net of AZ Medicare	$571.20
Rate for Payer: Humana of AZ Medicare	$326.40
Rate for Payer: Self Pay Self Pay	$1,632.00
Rate for Payer: TriWest Medicare	$326.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,189.32
Rate for Payer: UnitedHealth Group of AZ Medicare	$367.20

PURAPLY MZ 500MG

Facility

$9,280.00

Hospital Charge Code	27570616
Hospital Revenue Code	270
Min. Negotiated Rate	$2,412.80
Max. Negotiated Rate	$8,352.00
Rate for Payer: Aetna of AZ Commercial	$8,352.00
Rate for Payer: Bisbee Police All Plans	$2,412.80
Rate for Payer: Cash Price	$7,424.00
Rate for Payer: Self Pay Self Pay	$7,424.00

PURAPLY MZ 500MG

Facility

$9,280.00

Hospital Charge Code	27570616
Hospital Revenue Code	270
Min. Negotiated Rate	$1,484.80
Max. Negotiated Rate	$8,352.00
Rate for Payer: Aetna of AZ Commercial	$8,352.00
Rate for Payer: Aetna of AZ Medicare	$2,598.40
Rate for Payer: Allwell Medicare	$1,484.80
Rate for Payer: Amerigroup Medicare	$1,484.80
Rate for Payer: APIPA Medicare/Medicaid	$3,466.08
Rate for Payer: AZCH Complete Medicare	$1,484.80
Rate for Payer: Banner UC Health Medicare	$1,484.80
Rate for Payer: Bisbee Police All Plans	$2,412.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$6,310.40
Rate for Payer: Cash Price	$7,424.00
Rate for Payer: Cigna of AZ Commercial	$6,496.00
Rate for Payer: Copperpoint Commercial	$2,296.80
Rate for Payer: Health Net of AZ Commercial	$5,568.00
Rate for Payer: Health Net of AZ Medicare	$2,598.40
Rate for Payer: Humana of AZ Medicare	$1,484.80
Rate for Payer: Self Pay Self Pay	$7,424.00
Rate for Payer: TriWest Medicare	$1,484.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$5,410.24
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,670.40

PuraPly XT

Facility

$15,509.00

Service Code	CPT Q4197
Hospital Charge Code	24363414
Hospital Revenue Code	636
Min. Negotiated Rate	$2,481.44
Max. Negotiated Rate	$13,958.10
Rate for Payer: Aetna of AZ Commercial	$13,958.10
Rate for Payer: Aetna of AZ Medicare	$4,342.52
Rate for Payer: Allwell Medicare	$2,481.44
Rate for Payer: Amerigroup Medicare	$2,481.44
Rate for Payer: APIPA Medicare/Medicaid	$5,792.61
Rate for Payer: AZCH Complete Medicare	$2,481.44
Rate for Payer: Banner UC Health Medicare	$2,481.44
Rate for Payer: Bisbee Police All Plans	$4,032.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$10,546.12
Rate for Payer: Cash Price	$12,407.20
Rate for Payer: Cigna of AZ Commercial	$10,856.30
Rate for Payer: Copperpoint Commercial	$3,838.48
Rate for Payer: Health Net of AZ Commercial	$9,305.40
Rate for Payer: Health Net of AZ Medicare	$4,342.52
Rate for Payer: Humana of AZ Medicare	$2,481.44
Rate for Payer: Self Pay Self Pay	$12,407.20
Rate for Payer: TriWest Medicare	$2,481.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$9,041.75
Rate for Payer: UnitedHealth Group of AZ Medicare	$2,791.62

PuraPly XT

Facility

$15,509.00

Service Code	CPT Q4197
Hospital Charge Code	24363414
Hospital Revenue Code	636
Min. Negotiated Rate	$4,032.34
Max. Negotiated Rate	$13,958.10
Rate for Payer: Aetna of AZ Commercial	$13,958.10
Rate for Payer: Bisbee Police All Plans	$4,032.34
Rate for Payer: Cash Price	$12,407.20
Rate for Payer: Self Pay Self Pay	$12,407.20

Know your out-of-pocket cost for care.

All Charges