Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

SURESEAL

Facility

$76.00

Hospital Charge Code	27750226
Hospital Revenue Code	270
Min. Negotiated Rate	$12.16
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of AZ Commercial	$68.40
Rate for Payer: Aetna of AZ Medicare	$21.28
Rate for Payer: Allwell Medicare	$12.16
Rate for Payer: Amerigroup Medicare	$12.16
Rate for Payer: APIPA Medicare/Medicaid	$28.39
Rate for Payer: AZCH Complete Medicare	$12.16
Rate for Payer: Banner UC Health Medicare	$12.16
Rate for Payer: Bisbee Police All Plans	$19.76
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$51.68
Rate for Payer: Cash Price	$60.80
Rate for Payer: Cigna of AZ Commercial	$53.20
Rate for Payer: Copperpoint Commercial	$18.81
Rate for Payer: Health Net of AZ Commercial	$45.60
Rate for Payer: Health Net of AZ Medicare	$21.28
Rate for Payer: Humana of AZ Medicare	$12.16
Rate for Payer: Self Pay Self Pay	$60.80
Rate for Payer: TriWest Medicare	$12.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$44.31
Rate for Payer: UnitedHealth Group of AZ Medicare	$13.68

SURESEAL

Facility

$76.00

Hospital Charge Code	27750226
Hospital Revenue Code	270
Min. Negotiated Rate	$19.76
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of AZ Commercial	$68.40
Rate for Payer: Bisbee Police All Plans	$19.76
Rate for Payer: Cash Price	$60.80
Rate for Payer: Self Pay Self Pay	$60.80

SURE SEAL VALVE

Facility

$111.00

Hospital Charge Code	22354974
Hospital Revenue Code	270
Min. Negotiated Rate	$28.86
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of AZ Commercial	$99.90
Rate for Payer: Bisbee Police All Plans	$28.86
Rate for Payer: Cash Price	$88.80
Rate for Payer: Self Pay Self Pay	$88.80

SURE SEAL VALVE

Facility

$111.00

Hospital Charge Code	22354974
Hospital Revenue Code	270
Min. Negotiated Rate	$17.76
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of AZ Commercial	$99.90
Rate for Payer: Aetna of AZ Medicare	$31.08
Rate for Payer: Allwell Medicare	$17.76
Rate for Payer: Amerigroup Medicare	$17.76
Rate for Payer: APIPA Medicare/Medicaid	$41.46
Rate for Payer: AZCH Complete Medicare	$17.76
Rate for Payer: Banner UC Health Medicare	$17.76
Rate for Payer: Bisbee Police All Plans	$28.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$75.48
Rate for Payer: Cash Price	$88.80
Rate for Payer: Cigna of AZ Commercial	$77.70
Rate for Payer: Copperpoint Commercial	$27.47
Rate for Payer: Health Net of AZ Commercial	$66.60
Rate for Payer: Health Net of AZ Medicare	$31.08
Rate for Payer: Humana of AZ Medicare	$17.76
Rate for Payer: Self Pay Self Pay	$88.80
Rate for Payer: TriWest Medicare	$17.76
Rate for Payer: UnitedHealth Group of AZ Commercial	$64.71
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.98

SURGICAL GOWN LG

Facility

$17.00

Hospital Charge Code	22549514
Hospital Revenue Code	272
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$15.30
Rate for Payer: Aetna of AZ Commercial	$15.30
Rate for Payer: Bisbee Police All Plans	$4.42
Rate for Payer: Cash Price	$13.60
Rate for Payer: Self Pay Self Pay	$13.60

SURGICAL GOWN LG

Facility

$17.00

Hospital Charge Code	22549514
Hospital Revenue Code	272
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$15.30
Rate for Payer: Aetna of AZ Commercial	$15.30
Rate for Payer: Aetna of AZ Medicare	$4.76
Rate for Payer: Allwell Medicare	$2.72
Rate for Payer: Amerigroup Medicare	$2.72
Rate for Payer: APIPA Medicare/Medicaid	$6.35
Rate for Payer: AZCH Complete Medicare	$2.72
Rate for Payer: Banner UC Health Medicare	$2.72
Rate for Payer: Bisbee Police All Plans	$4.42
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$11.56
Rate for Payer: Cash Price	$13.60
Rate for Payer: Cigna of AZ Commercial	$11.90
Rate for Payer: Copperpoint Commercial	$4.21
Rate for Payer: Health Net of AZ Commercial	$10.20
Rate for Payer: Health Net of AZ Medicare	$4.76
Rate for Payer: Humana of AZ Medicare	$2.72
Rate for Payer: Self Pay Self Pay	$13.60
Rate for Payer: TriWest Medicare	$2.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$9.91
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.06

SURGICEL 0.5X2-IN

Facility

$176.00

Hospital Charge Code	22355174
Hospital Revenue Code	270
Min. Negotiated Rate	$28.16
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of AZ Commercial	$158.40
Rate for Payer: Aetna of AZ Medicare	$49.28
Rate for Payer: Allwell Medicare	$28.16
Rate for Payer: Amerigroup Medicare	$28.16
Rate for Payer: APIPA Medicare/Medicaid	$65.74
Rate for Payer: AZCH Complete Medicare	$28.16
Rate for Payer: Banner UC Health Medicare	$28.16
Rate for Payer: Bisbee Police All Plans	$45.76
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$119.68
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cigna of AZ Commercial	$123.20
Rate for Payer: Copperpoint Commercial	$43.56
Rate for Payer: Health Net of AZ Commercial	$105.60
Rate for Payer: Health Net of AZ Medicare	$49.28
Rate for Payer: Humana of AZ Medicare	$28.16
Rate for Payer: Self Pay Self Pay	$140.80
Rate for Payer: TriWest Medicare	$28.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$102.61
Rate for Payer: UnitedHealth Group of AZ Medicare	$31.68

SURGICEL 0.5X2-IN

Facility

$176.00

Hospital Charge Code	22355174
Hospital Revenue Code	270
Min. Negotiated Rate	$45.76
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of AZ Commercial	$158.40
Rate for Payer: Bisbee Police All Plans	$45.76
Rate for Payer: Cash Price	$140.80
Rate for Payer: Self Pay Self Pay	$140.80

SURGI CLIP APPLIER 9IN

Facility

$2,173.60

Hospital Charge Code	28039306
Hospital Revenue Code	270
Min. Negotiated Rate	$347.78
Max. Negotiated Rate	$1,956.24
Rate for Payer: Aetna of AZ Commercial	$1,956.24
Rate for Payer: Aetna of AZ Medicare	$608.61
Rate for Payer: Allwell Medicare	$347.78
Rate for Payer: Amerigroup Medicare	$347.78
Rate for Payer: APIPA Medicare/Medicaid	$811.84
Rate for Payer: AZCH Complete Medicare	$347.78
Rate for Payer: Banner UC Health Medicare	$347.78
Rate for Payer: Bisbee Police All Plans	$565.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,478.05
Rate for Payer: Cash Price	$1,738.88
Rate for Payer: Cigna of AZ Commercial	$1,521.52
Rate for Payer: Copperpoint Commercial	$537.97
Rate for Payer: Health Net of AZ Commercial	$1,304.16
Rate for Payer: Health Net of AZ Medicare	$608.61
Rate for Payer: Humana of AZ Medicare	$347.78
Rate for Payer: Self Pay Self Pay	$1,738.88
Rate for Payer: TriWest Medicare	$347.78
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,267.21
Rate for Payer: UnitedHealth Group of AZ Medicare	$391.25

SURGI CLIP APPLIER 9IN

Facility

$2,173.60

Hospital Charge Code	28039306
Hospital Revenue Code	270
Min. Negotiated Rate	$565.14
Max. Negotiated Rate	$1,956.24
Rate for Payer: Aetna of AZ Commercial	$1,956.24
Rate for Payer: Bisbee Police All Plans	$565.14
Rate for Payer: Cash Price	$1,738.88
Rate for Payer: Self Pay Self Pay	$1,738.88

SURGICLIP APPLIER AUTOMATIC MEDIUM

Facility

$3,576.65

Hospital Charge Code	28009628
Hospital Revenue Code	270
Min. Negotiated Rate	$572.26
Max. Negotiated Rate	$3,218.99
Rate for Payer: Aetna of AZ Commercial	$3,218.99
Rate for Payer: Aetna of AZ Medicare	$1,001.46
Rate for Payer: Allwell Medicare	$572.26
Rate for Payer: Amerigroup Medicare	$572.26
Rate for Payer: APIPA Medicare/Medicaid	$1,335.88
Rate for Payer: AZCH Complete Medicare	$572.26
Rate for Payer: Banner UC Health Medicare	$572.26
Rate for Payer: Bisbee Police All Plans	$929.93
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,432.12
Rate for Payer: Cash Price	$2,861.32
Rate for Payer: Cigna of AZ Commercial	$2,503.66
Rate for Payer: Copperpoint Commercial	$885.22
Rate for Payer: Health Net of AZ Commercial	$2,145.99
Rate for Payer: Health Net of AZ Medicare	$1,001.46
Rate for Payer: Humana of AZ Medicare	$572.26
Rate for Payer: Self Pay Self Pay	$2,861.32
Rate for Payer: TriWest Medicare	$572.26
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,085.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$643.80

SURGICLIP APPLIER AUTOMATIC MEDIUM

Facility

$3,576.65

Hospital Charge Code	28009628
Hospital Revenue Code	270
Min. Negotiated Rate	$929.93
Max. Negotiated Rate	$3,218.99
Rate for Payer: Aetna of AZ Commercial	$3,218.99
Rate for Payer: Bisbee Police All Plans	$929.93
Rate for Payer: Cash Price	$2,861.32
Rate for Payer: Self Pay Self Pay	$2,861.32

SURGIFOAM 2CMX6CMX7MM

Facility

$78.00

Hospital Charge Code	27569184
Hospital Revenue Code	270
Min. Negotiated Rate	$12.48
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Aetna of AZ Medicare	$21.84
Rate for Payer: Allwell Medicare	$12.48
Rate for Payer: Amerigroup Medicare	$12.48
Rate for Payer: APIPA Medicare/Medicaid	$29.13
Rate for Payer: AZCH Complete Medicare	$12.48
Rate for Payer: Banner UC Health Medicare	$12.48
Rate for Payer: Bisbee Police All Plans	$20.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$53.04
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cigna of AZ Commercial	$54.60
Rate for Payer: Copperpoint Commercial	$19.30
Rate for Payer: Health Net of AZ Commercial	$46.80
Rate for Payer: Health Net of AZ Medicare	$21.84
Rate for Payer: Humana of AZ Medicare	$12.48
Rate for Payer: Self Pay Self Pay	$62.40
Rate for Payer: TriWest Medicare	$12.48
Rate for Payer: UnitedHealth Group of AZ Commercial	$45.47
Rate for Payer: UnitedHealth Group of AZ Medicare	$14.04

SURGIFOAM 2CMX6CMX7MM

Facility

$78.00

Hospital Charge Code	27569184
Hospital Revenue Code	270
Min. Negotiated Rate	$20.28
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Bisbee Police All Plans	$20.28
Rate for Payer: Cash Price	$62.40
Rate for Payer: Self Pay Self Pay	$62.40

SURGIFOAM GELATIN SPONGE 8CMX12CMX10MM

Facility

$259.00

Hospital Charge Code	27569183
Hospital Revenue Code	270
Min. Negotiated Rate	$67.34
Max. Negotiated Rate	$233.10
Rate for Payer: Aetna of AZ Commercial	$233.10
Rate for Payer: Bisbee Police All Plans	$67.34
Rate for Payer: Cash Price	$207.20
Rate for Payer: Self Pay Self Pay	$207.20

SURGIFOAM GELATIN SPONGE 8CMX12CMX10MM

Facility

$259.00

Hospital Charge Code	27569183
Hospital Revenue Code	270
Min. Negotiated Rate	$41.44
Max. Negotiated Rate	$233.10
Rate for Payer: Aetna of AZ Commercial	$233.10
Rate for Payer: Aetna of AZ Medicare	$72.52
Rate for Payer: Allwell Medicare	$41.44
Rate for Payer: Amerigroup Medicare	$41.44
Rate for Payer: APIPA Medicare/Medicaid	$96.74
Rate for Payer: AZCH Complete Medicare	$41.44
Rate for Payer: Banner UC Health Medicare	$41.44
Rate for Payer: Bisbee Police All Plans	$67.34
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$176.12
Rate for Payer: Cash Price	$207.20
Rate for Payer: Cigna of AZ Commercial	$181.30
Rate for Payer: Copperpoint Commercial	$64.10
Rate for Payer: Health Net of AZ Commercial	$155.40
Rate for Payer: Health Net of AZ Medicare	$72.52
Rate for Payer: Humana of AZ Medicare	$41.44
Rate for Payer: Self Pay Self Pay	$207.20
Rate for Payer: TriWest Medicare	$41.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$151.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$46.62

SURG PATH LVL 1 GROSS EXAM

Facility

$86.00

Service Code	CPT 88300
Hospital Charge Code	22545711
Hospital Revenue Code	310
Min. Negotiated Rate	$13.76
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of AZ Commercial	$77.40
Rate for Payer: Aetna of AZ Medicare	$24.08
Rate for Payer: Allwell Medicare	$13.76
Rate for Payer: Amerigroup Medicare	$13.76
Rate for Payer: APIPA Medicare/Medicaid	$32.12
Rate for Payer: AZCH Complete Medicare	$13.76
Rate for Payer: Banner UC Health Medicare	$13.76
Rate for Payer: Bisbee Police All Plans	$22.36
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$58.48
Rate for Payer: Cash Price	$68.80
Rate for Payer: Cigna of AZ Commercial	$55.90
Rate for Payer: Copperpoint Commercial	$21.29
Rate for Payer: Health Net of AZ Commercial	$51.60
Rate for Payer: Health Net of AZ Medicare	$24.08
Rate for Payer: Humana of AZ Medicare	$13.76
Rate for Payer: Self Pay Self Pay	$68.80
Rate for Payer: TriWest Medicare	$13.76
Rate for Payer: UnitedHealth Group of AZ Commercial	$50.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$15.48

SURG PATH LVL 1 GROSS EXAM

Facility

$86.00

Service Code	CPT 88300
Hospital Charge Code	22545711
Hospital Revenue Code	310
Min. Negotiated Rate	$22.36
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of AZ Commercial	$77.40
Rate for Payer: Bisbee Police All Plans	$22.36
Rate for Payer: Cash Price	$68.80
Rate for Payer: Self Pay Self Pay	$68.80

SURG PATH LVL 2 GROSS EXAM

Facility

$708.00

Service Code	CPT 88302
Hospital Charge Code	22545712
Hospital Revenue Code	310
Min. Negotiated Rate	$184.08
Max. Negotiated Rate	$637.20
Rate for Payer: Aetna of AZ Commercial	$637.20
Rate for Payer: Bisbee Police All Plans	$184.08
Rate for Payer: Cash Price	$566.40
Rate for Payer: Self Pay Self Pay	$566.40

SURG PATH LVL 2 GROSS EXAM

Facility

$708.00

Service Code	CPT 88302
Hospital Charge Code	22545712
Hospital Revenue Code	310
Min. Negotiated Rate	$113.28
Max. Negotiated Rate	$637.20
Rate for Payer: Aetna of AZ Commercial	$637.20
Rate for Payer: Aetna of AZ Medicare	$198.24
Rate for Payer: Allwell Medicare	$113.28
Rate for Payer: Amerigroup Medicare	$113.28
Rate for Payer: APIPA Medicare/Medicaid	$264.44
Rate for Payer: AZCH Complete Medicare	$113.28
Rate for Payer: Banner UC Health Medicare	$113.28
Rate for Payer: Bisbee Police All Plans	$184.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$481.44
Rate for Payer: Cash Price	$566.40
Rate for Payer: Cigna of AZ Commercial	$460.20
Rate for Payer: Copperpoint Commercial	$175.23
Rate for Payer: Health Net of AZ Commercial	$424.80
Rate for Payer: Health Net of AZ Medicare	$198.24
Rate for Payer: Humana of AZ Medicare	$113.28
Rate for Payer: Self Pay Self Pay	$566.40
Rate for Payer: TriWest Medicare	$113.28
Rate for Payer: UnitedHealth Group of AZ Commercial	$412.76
Rate for Payer: UnitedHealth Group of AZ Medicare	$127.44

SURG PATH LVL 3 GROSS EXAM

Facility

$830.00

Service Code	CPT 88304
Hospital Charge Code	22545713
Hospital Revenue Code	310
Min. Negotiated Rate	$215.80
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of AZ Commercial	$747.00
Rate for Payer: Bisbee Police All Plans	$215.80
Rate for Payer: Cash Price	$664.00
Rate for Payer: Self Pay Self Pay	$664.00

SURG PATH LVL 3 GROSS EXAM

Facility

$830.00

Service Code	CPT 88304
Hospital Charge Code	22545713
Hospital Revenue Code	310
Min. Negotiated Rate	$132.80
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of AZ Commercial	$747.00
Rate for Payer: Aetna of AZ Medicare	$232.40
Rate for Payer: Allwell Medicare	$132.80
Rate for Payer: Amerigroup Medicare	$132.80
Rate for Payer: APIPA Medicare/Medicaid	$310.00
Rate for Payer: AZCH Complete Medicare	$132.80
Rate for Payer: Banner UC Health Medicare	$132.80
Rate for Payer: Bisbee Police All Plans	$215.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$564.40
Rate for Payer: Cash Price	$664.00
Rate for Payer: Cigna of AZ Commercial	$539.50
Rate for Payer: Copperpoint Commercial	$205.43
Rate for Payer: Health Net of AZ Commercial	$498.00
Rate for Payer: Health Net of AZ Medicare	$232.40
Rate for Payer: Humana of AZ Medicare	$132.80
Rate for Payer: Self Pay Self Pay	$664.00
Rate for Payer: TriWest Medicare	$132.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$483.89
Rate for Payer: UnitedHealth Group of AZ Medicare	$149.40

SURG PATH LVL 4 GROSS EXAM

Facility

$1,206.00

Service Code	CPT 88305
Hospital Charge Code	22545714
Hospital Revenue Code	310
Min. Negotiated Rate	$313.56
Max. Negotiated Rate	$1,085.40
Rate for Payer: Aetna of AZ Commercial	$1,085.40
Rate for Payer: Bisbee Police All Plans	$313.56
Rate for Payer: Cash Price	$964.80
Rate for Payer: Self Pay Self Pay	$964.80

SURG PATH LVL 4 GROSS EXAM

Facility

$1,206.00

Service Code	CPT 88305
Hospital Charge Code	22545714
Hospital Revenue Code	310
Min. Negotiated Rate	$192.96
Max. Negotiated Rate	$1,085.40
Rate for Payer: Aetna of AZ Commercial	$1,085.40
Rate for Payer: Aetna of AZ Medicare	$337.68
Rate for Payer: Allwell Medicare	$192.96
Rate for Payer: Amerigroup Medicare	$192.96
Rate for Payer: APIPA Medicare/Medicaid	$450.44
Rate for Payer: AZCH Complete Medicare	$192.96
Rate for Payer: Banner UC Health Medicare	$192.96
Rate for Payer: Bisbee Police All Plans	$313.56
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$820.08
Rate for Payer: Cash Price	$964.80
Rate for Payer: Cigna of AZ Commercial	$783.90
Rate for Payer: Copperpoint Commercial	$298.49
Rate for Payer: Health Net of AZ Commercial	$723.60
Rate for Payer: Health Net of AZ Medicare	$337.68
Rate for Payer: Humana of AZ Medicare	$192.96
Rate for Payer: Self Pay Self Pay	$964.80
Rate for Payer: TriWest Medicare	$192.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$703.10
Rate for Payer: UnitedHealth Group of AZ Medicare	$217.08

SURG PATH LVL 5 GROSS EXAM

Facility

$4,790.00

Service Code	CPT 88307
Hospital Charge Code	22545715
Hospital Revenue Code	310
Min. Negotiated Rate	$766.40
Max. Negotiated Rate	$4,311.00
Rate for Payer: Aetna of AZ Commercial	$4,311.00
Rate for Payer: Aetna of AZ Medicare	$1,341.20
Rate for Payer: Allwell Medicare	$766.40
Rate for Payer: Amerigroup Medicare	$766.40
Rate for Payer: APIPA Medicare/Medicaid	$1,789.07
Rate for Payer: AZCH Complete Medicare	$766.40
Rate for Payer: Banner UC Health Medicare	$766.40
Rate for Payer: Bisbee Police All Plans	$1,245.40
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,257.20
Rate for Payer: Cash Price	$3,832.00
Rate for Payer: Cigna of AZ Commercial	$3,113.50
Rate for Payer: Copperpoint Commercial	$1,185.53
Rate for Payer: Health Net of AZ Commercial	$2,874.00
Rate for Payer: Health Net of AZ Medicare	$1,341.20
Rate for Payer: Humana of AZ Medicare	$766.40
Rate for Payer: Self Pay Self Pay	$3,832.00
Rate for Payer: TriWest Medicare	$766.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,792.57
Rate for Payer: UnitedHealth Group of AZ Medicare	$862.20

Know your out-of-pocket cost for care.

All Charges