Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Services provided by Occupational therapist in the home or h

Facility

$205.00

Service Code	CPT G0152
Hospital Charge Code	27377828
Hospital Revenue Code	420
Min. Negotiated Rate	$32.80
Max. Negotiated Rate	$184.50
Rate for Payer: Aetna of AZ Commercial	$184.50
Rate for Payer: Aetna of AZ Medicare	$57.40
Rate for Payer: Allwell Medicare	$32.80
Rate for Payer: Amerigroup Medicare	$32.80
Rate for Payer: APIPA Medicare/Medicaid	$76.57
Rate for Payer: AZCH Complete Medicare	$32.80
Rate for Payer: Banner UC Health Medicare	$32.80
Rate for Payer: Bisbee Police All Plans	$53.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$139.40
Rate for Payer: Cash Price	$164.00
Rate for Payer: Cigna of AZ Commercial	$143.50
Rate for Payer: Copperpoint Commercial	$50.74
Rate for Payer: Health Net of AZ Commercial	$123.00
Rate for Payer: Health Net of AZ Medicare	$57.40
Rate for Payer: Humana of AZ Medicare	$32.80
Rate for Payer: Self Pay Self Pay	$164.00
Rate for Payer: TriWest Medicare	$32.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$119.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$36.90

Services provided by Occupational therapist in the home or h

Facility

$205.00

Service Code	CPT G0152
Hospital Charge Code	27377828
Hospital Revenue Code	420
Min. Negotiated Rate	$53.30
Max. Negotiated Rate	$184.50
Rate for Payer: Aetna of AZ Commercial	$184.50
Rate for Payer: Bisbee Police All Plans	$53.30
Rate for Payer: Cash Price	$164.00
Rate for Payer: Self Pay Self Pay	$164.00

SESAMOIDECTOMY FIRST TOE (SEPARATE PROCEDURE)

Facility

$1,590.00

Service Code	CPT 28315
Hospital Charge Code	24043328
Hospital Revenue Code	360
Min. Negotiated Rate	$413.40
Max. Negotiated Rate	$1,431.00
Rate for Payer: Aetna of AZ Commercial	$1,431.00
Rate for Payer: Bisbee Police All Plans	$413.40
Rate for Payer: Cash Price	$1,272.00
Rate for Payer: Self Pay Self Pay	$1,272.00

SESAMOIDECTOMY FIRST TOE (SEPARATE PROCEDURE)

Facility

$1,590.00

Service Code	CPT 28315
Hospital Charge Code	24043328
Hospital Revenue Code	360
Min. Negotiated Rate	$254.40
Max. Negotiated Rate	$3,373.00
Rate for Payer: Aetna of AZ Commercial	$1,431.00
Rate for Payer: Aetna of AZ Medicare	$445.20
Rate for Payer: AHCCCS Medicaid	$2,052.04
Rate for Payer: Allwell Medicaid	$2,052.04
Rate for Payer: Allwell Medicare	$254.40
Rate for Payer: Amerigroup Medicare	$254.40
Rate for Payer: APIPA Medicare/Medicaid	$593.87
Rate for Payer: AZCH Complete Medicaid	$2,052.04
Rate for Payer: AZCH Complete Medicare	$254.40
Rate for Payer: Banner UC Health Medicaid	$2,052.04
Rate for Payer: Banner UC Health Medicare	$254.40
Rate for Payer: Bisbee Police All Plans	$413.40
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,081.20
Rate for Payer: Cash Price	$1,272.00
Rate for Payer: Cash Price	$1,272.00
Rate for Payer: Cigna of AZ Commercial	$795.00
Rate for Payer: Copperpoint Commercial	$393.52
Rate for Payer: Health Net of AZ Commercial	$954.00
Rate for Payer: Health Net of AZ Medicare	$445.20
Rate for Payer: Humana of AZ Medicare	$254.40
Rate for Payer: Mercy Care Medicaid	$2,052.04
Rate for Payer: Self Pay Self Pay	$1,272.00
Rate for Payer: TriWest Medicare	$254.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,373.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$286.20

SET BLOOD Y-TYPE HOSPIRA LIFESHIELD

Facility

$101.00

Hospital Charge Code	22355308
Hospital Revenue Code	270
Min. Negotiated Rate	$16.16
Max. Negotiated Rate	$90.90
Rate for Payer: Aetna of AZ Commercial	$90.90
Rate for Payer: Aetna of AZ Medicare	$28.28
Rate for Payer: Allwell Medicare	$16.16
Rate for Payer: Amerigroup Medicare	$16.16
Rate for Payer: APIPA Medicare/Medicaid	$37.72
Rate for Payer: AZCH Complete Medicare	$16.16
Rate for Payer: Banner UC Health Medicare	$16.16
Rate for Payer: Bisbee Police All Plans	$26.26
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$68.68
Rate for Payer: Cash Price	$80.80
Rate for Payer: Cigna of AZ Commercial	$70.70
Rate for Payer: Copperpoint Commercial	$25.00
Rate for Payer: Health Net of AZ Commercial	$60.60
Rate for Payer: Health Net of AZ Medicare	$28.28
Rate for Payer: Humana of AZ Medicare	$16.16
Rate for Payer: Self Pay Self Pay	$80.80
Rate for Payer: TriWest Medicare	$16.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$58.88
Rate for Payer: UnitedHealth Group of AZ Medicare	$18.18

SET BLOOD Y-TYPE HOSPIRA LIFESHIELD

Facility

$101.00

Hospital Charge Code	22355308
Hospital Revenue Code	270
Min. Negotiated Rate	$26.26
Max. Negotiated Rate	$90.90
Rate for Payer: Aetna of AZ Commercial	$90.90
Rate for Payer: Bisbee Police All Plans	$26.26
Rate for Payer: Cash Price	$80.80
Rate for Payer: Self Pay Self Pay	$80.80

SET CATH RUTNER SUPRAPUBIC 16F COOK

Facility

$237.00

Hospital Charge Code	22354213
Hospital Revenue Code	270
Min. Negotiated Rate	$37.92
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Aetna of AZ Medicare	$66.36
Rate for Payer: Allwell Medicare	$37.92
Rate for Payer: Amerigroup Medicare	$37.92
Rate for Payer: APIPA Medicare/Medicaid	$88.52
Rate for Payer: AZCH Complete Medicare	$37.92
Rate for Payer: Banner UC Health Medicare	$37.92
Rate for Payer: Bisbee Police All Plans	$61.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$161.16
Rate for Payer: Cash Price	$189.60
Rate for Payer: Cigna of AZ Commercial	$165.90
Rate for Payer: Copperpoint Commercial	$58.66
Rate for Payer: Health Net of AZ Commercial	$142.20
Rate for Payer: Health Net of AZ Medicare	$66.36
Rate for Payer: Humana of AZ Medicare	$37.92
Rate for Payer: Self Pay Self Pay	$189.60
Rate for Payer: TriWest Medicare	$37.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$138.17
Rate for Payer: UnitedHealth Group of AZ Medicare	$42.66

SET CATH RUTNER SUPRAPUBIC 16F COOK

Facility

$237.00

Hospital Charge Code	22354213
Hospital Revenue Code	270
Min. Negotiated Rate	$61.62
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of AZ Commercial	$213.30
Rate for Payer: Bisbee Police All Plans	$61.62
Rate for Payer: Cash Price	$189.60
Rate for Payer: Self Pay Self Pay	$189.60

SET CATH SUPRAPUBIC COOK

Facility

$272.00

Hospital Charge Code	22354225
Hospital Revenue Code	270
Min. Negotiated Rate	$43.52
Max. Negotiated Rate	$244.80
Rate for Payer: Aetna of AZ Commercial	$244.80
Rate for Payer: Aetna of AZ Medicare	$76.16
Rate for Payer: Allwell Medicare	$43.52
Rate for Payer: Amerigroup Medicare	$43.52
Rate for Payer: APIPA Medicare/Medicaid	$101.59
Rate for Payer: AZCH Complete Medicare	$43.52
Rate for Payer: Banner UC Health Medicare	$43.52
Rate for Payer: Bisbee Police All Plans	$70.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$184.96
Rate for Payer: Cash Price	$217.60
Rate for Payer: Cigna of AZ Commercial	$190.40
Rate for Payer: Copperpoint Commercial	$67.32
Rate for Payer: Health Net of AZ Commercial	$163.20
Rate for Payer: Health Net of AZ Medicare	$76.16
Rate for Payer: Humana of AZ Medicare	$43.52
Rate for Payer: Self Pay Self Pay	$217.60
Rate for Payer: TriWest Medicare	$43.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$158.58
Rate for Payer: UnitedHealth Group of AZ Medicare	$48.96

SET CATH SUPRAPUBIC COOK

Facility

$272.00

Hospital Charge Code	22354225
Hospital Revenue Code	270
Min. Negotiated Rate	$70.72
Max. Negotiated Rate	$244.80
Rate for Payer: Aetna of AZ Commercial	$244.80
Rate for Payer: Bisbee Police All Plans	$70.72
Rate for Payer: Cash Price	$217.60
Rate for Payer: Self Pay Self Pay	$217.60

SET CYSTO

Facility

$37.00

Hospital Charge Code	22355110
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

SET CYSTO

Facility

$37.00

Hospital Charge Code	22355110
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

sevoflurane Inh (16 ml per 1/2 hour) [CQCH]

Facility

$0.26

Service Code	NDC 66794001525
Hospital Charge Code	105940176
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of AZ Commercial	$0.23
Rate for Payer: Bisbee Police All Plans	$0.07
Rate for Payer: Cash Price	$0.21
Rate for Payer: Self Pay Self Pay	$0.21

sevoflurane Inh (16 ml per 1/2 hour) [CQCH]

Facility

$0.26

Service Code	NDC 66794001525
Hospital Charge Code	105940176
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of AZ Commercial	$0.23
Rate for Payer: Aetna of AZ Medicare	$0.07
Rate for Payer: Allwell Medicare	$0.04
Rate for Payer: Amerigroup Medicare	$0.04
Rate for Payer: APIPA Medicare/Medicaid	$0.10
Rate for Payer: AZCH Complete Medicare	$0.04
Rate for Payer: Banner UC Health Medicare	$0.04
Rate for Payer: Bisbee Police All Plans	$0.07
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.18
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of AZ Commercial	$0.17
Rate for Payer: Copperpoint Commercial	$0.06
Rate for Payer: Health Net of AZ Commercial	$0.16
Rate for Payer: Health Net of AZ Medicare	$0.07
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Self Pay Self Pay	$0.21
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.15
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.05

Sex Hormone Binding Globulin LC

Facility

$271.00

Service Code	CPT 84270
Hospital Charge Code	2275527
Hospital Revenue Code	301
Min. Negotiated Rate	$43.36
Max. Negotiated Rate	$243.90
Rate for Payer: Aetna of AZ Commercial	$243.90
Rate for Payer: Aetna of AZ Medicare	$75.88
Rate for Payer: Allwell Medicare	$43.36
Rate for Payer: Amerigroup Medicare	$43.36
Rate for Payer: APIPA Medicare/Medicaid	$101.22
Rate for Payer: AZCH Complete Medicare	$43.36
Rate for Payer: Banner UC Health Medicare	$43.36
Rate for Payer: Bisbee Police All Plans	$70.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$184.28
Rate for Payer: Cash Price	$216.80
Rate for Payer: Cigna of AZ Commercial	$176.15
Rate for Payer: Copperpoint Commercial	$67.07
Rate for Payer: Health Net of AZ Commercial	$162.60
Rate for Payer: Health Net of AZ Medicare	$75.88
Rate for Payer: Humana of AZ Medicare	$43.36
Rate for Payer: Self Pay Self Pay	$216.80
Rate for Payer: TriWest Medicare	$43.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$157.99
Rate for Payer: UnitedHealth Group of AZ Medicare	$48.78

Sex Hormone Binding Globulin LC

Facility

$271.00

Service Code	CPT 84270
Hospital Charge Code	2275527
Hospital Revenue Code	301
Min. Negotiated Rate	$70.46
Max. Negotiated Rate	$243.90
Rate for Payer: Aetna of AZ Commercial	$243.90
Rate for Payer: Bisbee Police All Plans	$70.46
Rate for Payer: Cash Price	$216.80
Rate for Payer: Self Pay Self Pay	$216.80

SHEATH FLEXOR PARALLEL 35CM

Facility

$701.00

Hospital Charge Code	22354226
Hospital Revenue Code	270
Min. Negotiated Rate	$112.16
Max. Negotiated Rate	$630.90
Rate for Payer: Aetna of AZ Commercial	$630.90
Rate for Payer: Aetna of AZ Medicare	$196.28
Rate for Payer: Allwell Medicare	$112.16
Rate for Payer: Amerigroup Medicare	$112.16
Rate for Payer: APIPA Medicare/Medicaid	$261.82
Rate for Payer: AZCH Complete Medicare	$112.16
Rate for Payer: Banner UC Health Medicare	$112.16
Rate for Payer: Bisbee Police All Plans	$182.26
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$476.68
Rate for Payer: Cash Price	$560.80
Rate for Payer: Cigna of AZ Commercial	$490.70
Rate for Payer: Copperpoint Commercial	$173.50
Rate for Payer: Health Net of AZ Commercial	$420.60
Rate for Payer: Health Net of AZ Medicare	$196.28
Rate for Payer: Humana of AZ Medicare	$112.16
Rate for Payer: Self Pay Self Pay	$560.80
Rate for Payer: TriWest Medicare	$112.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$408.68
Rate for Payer: UnitedHealth Group of AZ Medicare	$126.18

SHEATH FLEXOR PARALLEL 35CM

Facility

$701.00

Hospital Charge Code	22354226
Hospital Revenue Code	270
Min. Negotiated Rate	$182.26
Max. Negotiated Rate	$630.90
Rate for Payer: Aetna of AZ Commercial	$630.90
Rate for Payer: Bisbee Police All Plans	$182.26
Rate for Payer: Cash Price	$560.80
Rate for Payer: Self Pay Self Pay	$560.80

SHEATH FLEXOR URETERAL ACCESS 35CM COOK

Facility

$776.00

Hospital Charge Code	22354221
Hospital Revenue Code	270
Min. Negotiated Rate	$124.16
Max. Negotiated Rate	$698.40
Rate for Payer: Aetna of AZ Commercial	$698.40
Rate for Payer: Aetna of AZ Medicare	$217.28
Rate for Payer: Allwell Medicare	$124.16
Rate for Payer: Amerigroup Medicare	$124.16
Rate for Payer: APIPA Medicare/Medicaid	$289.84
Rate for Payer: AZCH Complete Medicare	$124.16
Rate for Payer: Banner UC Health Medicare	$124.16
Rate for Payer: Bisbee Police All Plans	$201.76
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$527.68
Rate for Payer: Cash Price	$620.80
Rate for Payer: Cigna of AZ Commercial	$543.20
Rate for Payer: Copperpoint Commercial	$192.06
Rate for Payer: Health Net of AZ Commercial	$465.60
Rate for Payer: Health Net of AZ Medicare	$217.28
Rate for Payer: Humana of AZ Medicare	$124.16
Rate for Payer: Self Pay Self Pay	$620.80
Rate for Payer: TriWest Medicare	$124.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$452.41
Rate for Payer: UnitedHealth Group of AZ Medicare	$139.68

SHEATH FLEXOR URETERAL ACCESS 35CM COOK

Facility

$776.00

Hospital Charge Code	22354221
Hospital Revenue Code	270
Min. Negotiated Rate	$201.76
Max. Negotiated Rate	$698.40
Rate for Payer: Aetna of AZ Commercial	$698.40
Rate for Payer: Bisbee Police All Plans	$201.76
Rate for Payer: Cash Price	$620.80
Rate for Payer: Self Pay Self Pay	$620.80

SHEATH URETERAL ACCESS 24CM ACMI UROPASS

Facility

$530.00

Hospital Charge Code	22354818
Hospital Revenue Code	270
Min. Negotiated Rate	$84.80
Max. Negotiated Rate	$477.00
Rate for Payer: Aetna of AZ Commercial	$477.00
Rate for Payer: Aetna of AZ Medicare	$148.40
Rate for Payer: Allwell Medicare	$84.80
Rate for Payer: Amerigroup Medicare	$84.80
Rate for Payer: APIPA Medicare/Medicaid	$197.96
Rate for Payer: AZCH Complete Medicare	$84.80
Rate for Payer: Banner UC Health Medicare	$84.80
Rate for Payer: Bisbee Police All Plans	$137.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$360.40
Rate for Payer: Cash Price	$424.00
Rate for Payer: Cigna of AZ Commercial	$371.00
Rate for Payer: Copperpoint Commercial	$131.18
Rate for Payer: Health Net of AZ Commercial	$318.00
Rate for Payer: Health Net of AZ Medicare	$148.40
Rate for Payer: Humana of AZ Medicare	$84.80
Rate for Payer: Self Pay Self Pay	$424.00
Rate for Payer: TriWest Medicare	$84.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$308.99
Rate for Payer: UnitedHealth Group of AZ Medicare	$95.40

SHEATH URETERAL ACCESS 24CM ACMI UROPASS

Facility

$530.00

Hospital Charge Code	22354818
Hospital Revenue Code	270
Min. Negotiated Rate	$137.80
Max. Negotiated Rate	$477.00
Rate for Payer: Aetna of AZ Commercial	$477.00
Rate for Payer: Bisbee Police All Plans	$137.80
Rate for Payer: Cash Price	$424.00
Rate for Payer: Self Pay Self Pay	$424.00

SHEATH URETERAL ACCESS 38CM ACMI UROPASS

Facility

$530.00

Hospital Charge Code	22354819
Hospital Revenue Code	270
Min. Negotiated Rate	$84.80
Max. Negotiated Rate	$477.00
Rate for Payer: Aetna of AZ Commercial	$477.00
Rate for Payer: Aetna of AZ Medicare	$148.40
Rate for Payer: Allwell Medicare	$84.80
Rate for Payer: Amerigroup Medicare	$84.80
Rate for Payer: APIPA Medicare/Medicaid	$197.96
Rate for Payer: AZCH Complete Medicare	$84.80
Rate for Payer: Banner UC Health Medicare	$84.80
Rate for Payer: Bisbee Police All Plans	$137.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$360.40
Rate for Payer: Cash Price	$424.00
Rate for Payer: Cigna of AZ Commercial	$371.00
Rate for Payer: Copperpoint Commercial	$131.18
Rate for Payer: Health Net of AZ Commercial	$318.00
Rate for Payer: Health Net of AZ Medicare	$148.40
Rate for Payer: Humana of AZ Medicare	$84.80
Rate for Payer: Self Pay Self Pay	$424.00
Rate for Payer: TriWest Medicare	$84.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$308.99
Rate for Payer: UnitedHealth Group of AZ Medicare	$95.40

SHEATH URETERAL ACCESS 38CM ACMI UROPASS

Facility

$530.00

Hospital Charge Code	22354819
Hospital Revenue Code	270
Min. Negotiated Rate	$137.80
Max. Negotiated Rate	$477.00
Rate for Payer: Aetna of AZ Commercial	$477.00
Rate for Payer: Bisbee Police All Plans	$137.80
Rate for Payer: Cash Price	$424.00
Rate for Payer: Self Pay Self Pay	$424.00

SHEATH URETERAL ACCESS DBL LUMEN 12X35

Facility

$534.00

Hospital Charge Code	22354224
Hospital Revenue Code	270
Min. Negotiated Rate	$138.84
Max. Negotiated Rate	$480.60
Rate for Payer: Aetna of AZ Commercial	$480.60
Rate for Payer: Bisbee Police All Plans	$138.84
Rate for Payer: Cash Price	$427.20
Rate for Payer: Self Pay Self Pay	$427.20

Know your out-of-pocket cost for care.

All Charges