Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

STENT FILIFORM DOUBLE PIGTAIL 6.0FR/24CM

Facility

$543.00

Hospital Charge Code	22354214
Hospital Revenue Code	270
Min. Negotiated Rate	$141.18
Max. Negotiated Rate	$488.70
Rate for Payer: Aetna of AZ Commercial	$488.70
Rate for Payer: Bisbee Police All Plans	$141.18
Rate for Payer: Cash Price	$434.40
Rate for Payer: Self Pay Self Pay	$434.40

STENT FILIFORM DOUBLE PIGTAIL 6.0FR/26CM

Facility

$479.00

Hospital Charge Code	22354215
Hospital Revenue Code	270
Min. Negotiated Rate	$71.85
Max. Negotiated Rate	$431.10
Rate for Payer: Aetna of AZ Commercial	$431.10
Rate for Payer: Aetna of AZ Medicare	$134.12
Rate for Payer: Allwell Medicare	$71.85
Rate for Payer: Amerigroup Medicare	$71.85
Rate for Payer: APIPA Medicare/Medicaid	$178.91
Rate for Payer: AZCH Complete Medicare	$71.85
Rate for Payer: Banner UC Health Medicare	$71.85
Rate for Payer: Bisbee Police All Plans	$124.54
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$325.72
Rate for Payer: Cash Price	$383.20
Rate for Payer: Cigna of AZ Commercial	$335.30
Rate for Payer: Copperpoint Commercial	$118.55
Rate for Payer: Health Net of AZ Commercial	$287.40
Rate for Payer: Health Net of AZ Medicare	$134.12
Rate for Payer: Humana of AZ Medicare	$71.85
Rate for Payer: Self Pay Self Pay	$383.20
Rate for Payer: TriWest Medicare	$71.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$279.26
Rate for Payer: UnitedHealth Group of AZ Medicare	$86.22

STENT FILIFORM DOUBLE PIGTAIL 6.0FR/26CM

Facility

$479.00

Hospital Charge Code	22354215
Hospital Revenue Code	270
Min. Negotiated Rate	$124.54
Max. Negotiated Rate	$431.10
Rate for Payer: Aetna of AZ Commercial	$431.10
Rate for Payer: Bisbee Police All Plans	$124.54
Rate for Payer: Cash Price	$383.20
Rate for Payer: Self Pay Self Pay	$383.20

STENT OPTIMA 24F

Facility

$660.00

Hospital Charge Code	22354159
Hospital Revenue Code	270
Min. Negotiated Rate	$171.60
Max. Negotiated Rate	$594.00
Rate for Payer: Aetna of AZ Commercial	$594.00
Rate for Payer: Bisbee Police All Plans	$171.60
Rate for Payer: Cash Price	$528.00
Rate for Payer: Self Pay Self Pay	$528.00

STENT OPTIMA 24F

Facility

$660.00

Hospital Charge Code	22354159
Hospital Revenue Code	270
Min. Negotiated Rate	$99.00
Max. Negotiated Rate	$594.00
Rate for Payer: Aetna of AZ Commercial	$594.00
Rate for Payer: Aetna of AZ Medicare	$184.80
Rate for Payer: Allwell Medicare	$99.00
Rate for Payer: Amerigroup Medicare	$99.00
Rate for Payer: APIPA Medicare/Medicaid	$246.51
Rate for Payer: AZCH Complete Medicare	$99.00
Rate for Payer: Banner UC Health Medicare	$99.00
Rate for Payer: Bisbee Police All Plans	$171.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$448.80
Rate for Payer: Cash Price	$528.00
Rate for Payer: Cigna of AZ Commercial	$462.00
Rate for Payer: Copperpoint Commercial	$163.35
Rate for Payer: Health Net of AZ Commercial	$396.00
Rate for Payer: Health Net of AZ Medicare	$184.80
Rate for Payer: Humana of AZ Medicare	$99.00
Rate for Payer: Self Pay Self Pay	$528.00
Rate for Payer: TriWest Medicare	$99.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$384.78
Rate for Payer: UnitedHealth Group of AZ Medicare	$118.80

STENT OPTIMA 26F

Facility

$660.00

Hospital Charge Code	22354160
Hospital Revenue Code	270
Min. Negotiated Rate	$171.60
Max. Negotiated Rate	$594.00
Rate for Payer: Aetna of AZ Commercial	$594.00
Rate for Payer: Bisbee Police All Plans	$171.60
Rate for Payer: Cash Price	$528.00
Rate for Payer: Self Pay Self Pay	$528.00

STENT OPTIMA 26F

Facility

$660.00

Hospital Charge Code	22354160
Hospital Revenue Code	270
Min. Negotiated Rate	$99.00
Max. Negotiated Rate	$594.00
Rate for Payer: Aetna of AZ Commercial	$594.00
Rate for Payer: Aetna of AZ Medicare	$184.80
Rate for Payer: Allwell Medicare	$99.00
Rate for Payer: Amerigroup Medicare	$99.00
Rate for Payer: APIPA Medicare/Medicaid	$246.51
Rate for Payer: AZCH Complete Medicare	$99.00
Rate for Payer: Banner UC Health Medicare	$99.00
Rate for Payer: Bisbee Police All Plans	$171.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$448.80
Rate for Payer: Cash Price	$528.00
Rate for Payer: Cigna of AZ Commercial	$462.00
Rate for Payer: Copperpoint Commercial	$163.35
Rate for Payer: Health Net of AZ Commercial	$396.00
Rate for Payer: Health Net of AZ Medicare	$184.80
Rate for Payer: Humana of AZ Medicare	$99.00
Rate for Payer: Self Pay Self Pay	$528.00
Rate for Payer: TriWest Medicare	$99.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$384.78
Rate for Payer: UnitedHealth Group of AZ Medicare	$118.80

STENT SOFT URETERAL 24F UNIVERSA COOK

Facility

$478.00

Hospital Charge Code	22354230
Hospital Revenue Code	270
Min. Negotiated Rate	$124.28
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Bisbee Police All Plans	$124.28
Rate for Payer: Cash Price	$382.40
Rate for Payer: Self Pay Self Pay	$382.40

STENT SOFT URETERAL 24F UNIVERSA COOK

Facility

$478.00

Hospital Charge Code	22354230
Hospital Revenue Code	270
Min. Negotiated Rate	$71.70
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Aetna of AZ Medicare	$133.84
Rate for Payer: Allwell Medicare	$71.70
Rate for Payer: Amerigroup Medicare	$71.70
Rate for Payer: APIPA Medicare/Medicaid	$178.53
Rate for Payer: AZCH Complete Medicare	$71.70
Rate for Payer: Banner UC Health Medicare	$71.70
Rate for Payer: Bisbee Police All Plans	$124.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$325.04
Rate for Payer: Cash Price	$382.40
Rate for Payer: Cigna of AZ Commercial	$334.60
Rate for Payer: Copperpoint Commercial	$118.30
Rate for Payer: Health Net of AZ Commercial	$286.80
Rate for Payer: Health Net of AZ Medicare	$133.84
Rate for Payer: Humana of AZ Medicare	$71.70
Rate for Payer: Self Pay Self Pay	$382.40
Rate for Payer: TriWest Medicare	$71.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$278.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$86.04

STENT SOFT URETERAL 26F UNIVERSA COOK

Facility

$478.00

Hospital Charge Code	22354231
Hospital Revenue Code	270
Min. Negotiated Rate	$71.70
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Aetna of AZ Medicare	$133.84
Rate for Payer: Allwell Medicare	$71.70
Rate for Payer: Amerigroup Medicare	$71.70
Rate for Payer: APIPA Medicare/Medicaid	$178.53
Rate for Payer: AZCH Complete Medicare	$71.70
Rate for Payer: Banner UC Health Medicare	$71.70
Rate for Payer: Bisbee Police All Plans	$124.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$325.04
Rate for Payer: Cash Price	$382.40
Rate for Payer: Cigna of AZ Commercial	$334.60
Rate for Payer: Copperpoint Commercial	$118.30
Rate for Payer: Health Net of AZ Commercial	$286.80
Rate for Payer: Health Net of AZ Medicare	$133.84
Rate for Payer: Humana of AZ Medicare	$71.70
Rate for Payer: Self Pay Self Pay	$382.40
Rate for Payer: TriWest Medicare	$71.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$278.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$86.04

STENT SOFT URETERAL 26F UNIVERSA COOK

Facility

$478.00

Hospital Charge Code	22354231
Hospital Revenue Code	270
Min. Negotiated Rate	$124.28
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Bisbee Police All Plans	$124.28
Rate for Payer: Cash Price	$382.40
Rate for Payer: Self Pay Self Pay	$382.40

STENT SOFT URETERAL 28F UNIVERSA COOK

Facility

$478.00

Hospital Charge Code	22354232
Hospital Revenue Code	270
Min. Negotiated Rate	$124.28
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Bisbee Police All Plans	$124.28
Rate for Payer: Cash Price	$382.40
Rate for Payer: Self Pay Self Pay	$382.40

STENT SOFT URETERAL 28F UNIVERSA COOK

Facility

$478.00

Hospital Charge Code	22354232
Hospital Revenue Code	270
Min. Negotiated Rate	$71.70
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Aetna of AZ Medicare	$133.84
Rate for Payer: Allwell Medicare	$71.70
Rate for Payer: Amerigroup Medicare	$71.70
Rate for Payer: APIPA Medicare/Medicaid	$178.53
Rate for Payer: AZCH Complete Medicare	$71.70
Rate for Payer: Banner UC Health Medicare	$71.70
Rate for Payer: Bisbee Police All Plans	$124.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$325.04
Rate for Payer: Cash Price	$382.40
Rate for Payer: Cigna of AZ Commercial	$334.60
Rate for Payer: Copperpoint Commercial	$118.30
Rate for Payer: Health Net of AZ Commercial	$286.80
Rate for Payer: Health Net of AZ Medicare	$133.84
Rate for Payer: Humana of AZ Medicare	$71.70
Rate for Payer: Self Pay Self Pay	$382.40
Rate for Payer: TriWest Medicare	$71.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$278.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$86.04

STENT SOFT URETERAL 7X26 UNIVERSA COOK

Facility

$327.00

Hospital Charge Code	22354234
Hospital Revenue Code	270
Min. Negotiated Rate	$49.05
Max. Negotiated Rate	$294.30
Rate for Payer: Aetna of AZ Commercial	$294.30
Rate for Payer: Aetna of AZ Medicare	$91.56
Rate for Payer: Allwell Medicare	$49.05
Rate for Payer: Amerigroup Medicare	$49.05
Rate for Payer: APIPA Medicare/Medicaid	$122.13
Rate for Payer: AZCH Complete Medicare	$49.05
Rate for Payer: Banner UC Health Medicare	$49.05
Rate for Payer: Bisbee Police All Plans	$85.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$222.36
Rate for Payer: Cash Price	$261.60
Rate for Payer: Cigna of AZ Commercial	$228.90
Rate for Payer: Copperpoint Commercial	$80.93
Rate for Payer: Health Net of AZ Commercial	$196.20
Rate for Payer: Health Net of AZ Medicare	$91.56
Rate for Payer: Humana of AZ Medicare	$49.05
Rate for Payer: Self Pay Self Pay	$261.60
Rate for Payer: TriWest Medicare	$49.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$190.64
Rate for Payer: UnitedHealth Group of AZ Medicare	$58.86

STENT SOFT URETERAL 7X26 UNIVERSA COOK

Facility

$327.00

Hospital Charge Code	22354234
Hospital Revenue Code	270
Min. Negotiated Rate	$85.02
Max. Negotiated Rate	$294.30
Rate for Payer: Aetna of AZ Commercial	$294.30
Rate for Payer: Bisbee Police All Plans	$85.02
Rate for Payer: Cash Price	$261.60
Rate for Payer: Self Pay Self Pay	$261.60

STENT SOFT URETERAL UNIVERSA 28F COOK

Facility

$478.00

Hospital Charge Code	22354233
Hospital Revenue Code	270
Min. Negotiated Rate	$124.28
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Bisbee Police All Plans	$124.28
Rate for Payer: Cash Price	$382.40
Rate for Payer: Self Pay Self Pay	$382.40

STENT SOFT URETERAL UNIVERSA 28F COOK

Facility

$478.00

Hospital Charge Code	22354233
Hospital Revenue Code	270
Min. Negotiated Rate	$71.70
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Aetna of AZ Medicare	$133.84
Rate for Payer: Allwell Medicare	$71.70
Rate for Payer: Amerigroup Medicare	$71.70
Rate for Payer: APIPA Medicare/Medicaid	$178.53
Rate for Payer: AZCH Complete Medicare	$71.70
Rate for Payer: Banner UC Health Medicare	$71.70
Rate for Payer: Bisbee Police All Plans	$124.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$325.04
Rate for Payer: Cash Price	$382.40
Rate for Payer: Cigna of AZ Commercial	$334.60
Rate for Payer: Copperpoint Commercial	$118.30
Rate for Payer: Health Net of AZ Commercial	$286.80
Rate for Payer: Health Net of AZ Medicare	$133.84
Rate for Payer: Humana of AZ Medicare	$71.70
Rate for Payer: Self Pay Self Pay	$382.40
Rate for Payer: TriWest Medicare	$71.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$278.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$86.04

STENT URETERAL SOFT 22F UNIVERSA COOK

Facility

$478.00

Hospital Charge Code	22354229
Hospital Revenue Code	270
Min. Negotiated Rate	$124.28
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Bisbee Police All Plans	$124.28
Rate for Payer: Cash Price	$382.40
Rate for Payer: Self Pay Self Pay	$382.40

STENT URETERAL SOFT 22F UNIVERSA COOK

Facility

$478.00

Hospital Charge Code	22354229
Hospital Revenue Code	270
Min. Negotiated Rate	$71.70
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Aetna of AZ Medicare	$133.84
Rate for Payer: Allwell Medicare	$71.70
Rate for Payer: Amerigroup Medicare	$71.70
Rate for Payer: APIPA Medicare/Medicaid	$178.53
Rate for Payer: AZCH Complete Medicare	$71.70
Rate for Payer: Banner UC Health Medicare	$71.70
Rate for Payer: Bisbee Police All Plans	$124.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$325.04
Rate for Payer: Cash Price	$382.40
Rate for Payer: Cigna of AZ Commercial	$334.60
Rate for Payer: Copperpoint Commercial	$118.30
Rate for Payer: Health Net of AZ Commercial	$286.80
Rate for Payer: Health Net of AZ Medicare	$133.84
Rate for Payer: Humana of AZ Medicare	$71.70
Rate for Payer: Self Pay Self Pay	$382.40
Rate for Payer: TriWest Medicare	$71.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$278.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$86.04

Sterile Water 100 mL [CQCH]

Facility

$0.03

Service Code	HCPCS A4217
Hospital Charge Code	108476148
Hospital Revenue Code	252
Max. Negotiated Rate	$5.66
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: AHCCCS Medicaid	$5.66
Rate for Payer: Allwell Medicaid	$5.66
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicaid	$5.66
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicaid	$5.66
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.02
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of AZ Commercial	$0.02
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.02
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Mercy Care Medicaid	$5.66
Rate for Payer: Self Pay Self Pay	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

Sterile Water 100 mL [CQCH]

Facility

$0.03

Service Code	HCPCS A4217
Hospital Charge Code	108476148
Hospital Revenue Code	252
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.03
Rate for Payer: Self Pay Self Pay	$0.02

sterile water 10 ml Sol[CQCH]

Facility

$0.07

Service Code	HCPCS A4217
Hospital Charge Code	233117851
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of AZ Commercial	$0.06
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Cash Price	$0.06
Rate for Payer: Self Pay Self Pay	$0.06

sterile water 10 ml Sol[CQCH]

Facility

$0.07

Service Code	HCPCS A4217
Hospital Charge Code	233117851
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$5.66
Rate for Payer: Aetna of AZ Commercial	$0.06
Rate for Payer: Aetna of AZ Medicare	$0.02
Rate for Payer: AHCCCS Medicaid	$5.66
Rate for Payer: Allwell Medicaid	$5.66
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.03
Rate for Payer: AZCH Complete Medicaid	$5.66
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicaid	$5.66
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.05
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of AZ Commercial	$0.05
Rate for Payer: Copperpoint Commercial	$0.02
Rate for Payer: Health Net of AZ Commercial	$0.04
Rate for Payer: Health Net of AZ Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Mercy Care Medicaid	$5.66
Rate for Payer: Self Pay Self Pay	$0.06
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.04
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

STERIS PAPER ROLL

Facility

$16.00

Hospital Charge Code	27456000
Hospital Revenue Code	270
Min. Negotiated Rate	$4.16
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Bisbee Police All Plans	$4.16
Rate for Payer: Cash Price	$12.80
Rate for Payer: Self Pay Self Pay	$12.80

STERIS PAPER ROLL

Facility

$16.00

Hospital Charge Code	27456000
Hospital Revenue Code	270
Min. Negotiated Rate	$2.40
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	$2.40
Rate for Payer: Amerigroup Medicare	$2.40
Rate for Payer: APIPA Medicare/Medicaid	$5.98
Rate for Payer: AZCH Complete Medicare	$2.40
Rate for Payer: Banner UC Health Medicare	$2.40
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	$2.40
Rate for Payer: Self Pay Self Pay	$12.80
Rate for Payer: TriWest Medicare	$2.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$9.33
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.88

Know your out-of-pocket cost for care.

All Charges