Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

CATH COUDE TIEMANN 16F

Facility

$26.00

Service Code	HCPCS A4340
Hospital Charge Code	22355163
Hospital Revenue Code	270
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna of AZ Commercial	$23.40
Rate for Payer: Cash Price	$20.80

CATH COUDE TIEMANN 16F

Facility

$26.00

Service Code	HCPCS A4340
Hospital Charge Code	22355163
Hospital Revenue Code	270
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna of AZ Commercial	$23.40
Rate for Payer: Arizona Complete Health Allwell	$4.16
Rate for Payer: Banner UC Health Medicare	$4.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$17.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.16
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cigna of AZ Commercial	$18.20
Rate for Payer: Devoted Health Medicare	$4.68
Rate for Payer: Humana of AZ Medicare	$4.16
Rate for Payer: Southwest Service Administrators UFCW	$17.68
Rate for Payer: TriWest Medicare	$4.16
Rate for Payer: United Healthcare Commercial	$14.87
Rate for Payer: United Healthcare Medicare	$4.16
Rate for Payer: Veterans Affairs TRICARE	$4.12

CATH COUDE TIEMANN 18F

Facility

$26.00

Service Code	HCPCS A4340
Hospital Charge Code	22355105
Hospital Revenue Code	270
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna of AZ Commercial	$23.40
Rate for Payer: Arizona Complete Health Allwell	$4.16
Rate for Payer: Banner UC Health Medicare	$4.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$17.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.16
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cigna of AZ Commercial	$18.20
Rate for Payer: Devoted Health Medicare	$4.68
Rate for Payer: Humana of AZ Medicare	$4.16
Rate for Payer: Southwest Service Administrators UFCW	$17.68
Rate for Payer: TriWest Medicare	$4.16
Rate for Payer: United Healthcare Commercial	$14.87
Rate for Payer: United Healthcare Medicare	$4.16
Rate for Payer: Veterans Affairs TRICARE	$4.12

CATH COUDE TIEMANN 18F

Facility

$26.00

Service Code	HCPCS A4340
Hospital Charge Code	22355105
Hospital Revenue Code	270
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna of AZ Commercial	$23.40
Rate for Payer: Cash Price	$20.80

CATH COUDE TIEMANN 20F

Facility

$180.00

Service Code	HCPCS A4340
Hospital Charge Code	22355135
Hospital Revenue Code	270
Min. Negotiated Rate	$28.51
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of AZ Commercial	$162.00
Rate for Payer: Arizona Complete Health Allwell	$28.80
Rate for Payer: Banner UC Health Medicare	$28.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$122.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cigna of AZ Commercial	$126.00
Rate for Payer: Devoted Health Medicare	$32.40
Rate for Payer: Humana of AZ Medicare	$28.80
Rate for Payer: Southwest Service Administrators UFCW	$122.40
Rate for Payer: TriWest Medicare	$28.80
Rate for Payer: United Healthcare Commercial	$102.96
Rate for Payer: United Healthcare Medicare	$28.80
Rate for Payer: Veterans Affairs TRICARE	$28.51

CATH COUDE TIEMANN 20F

Facility

$180.00

Service Code	HCPCS A4340
Hospital Charge Code	22355135
Hospital Revenue Code	270
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of AZ Commercial	$162.00
Rate for Payer: Cash Price	$144.00

CATHETER FOLEY COUDE 18FR 5ML 2 WAY

Facility

$86.00

Hospital Charge Code	23758407
Hospital Revenue Code	270
Min. Negotiated Rate	$13.62
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of AZ Commercial	$77.40
Rate for Payer: Arizona Complete Health Allwell	$13.76
Rate for Payer: Banner UC Health Medicare	$13.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$58.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.76
Rate for Payer: Cash Price	$68.80
Rate for Payer: Cigna of AZ Commercial	$60.20
Rate for Payer: Devoted Health Medicare	$15.48
Rate for Payer: Humana of AZ Medicare	$13.76
Rate for Payer: Southwest Service Administrators UFCW	$58.48
Rate for Payer: TriWest Medicare	$13.76
Rate for Payer: United Healthcare Commercial	$49.19
Rate for Payer: United Healthcare Medicare	$13.76
Rate for Payer: Veterans Affairs TRICARE	$13.62

CATHETER FOLEY COUDE 18FR 5ML 2 WAY

Facility

$86.00

Hospital Charge Code	23758407
Hospital Revenue Code	270
Min. Negotiated Rate	$77.40
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of AZ Commercial	$77.40
Rate for Payer: Cash Price	$68.80

CATHETER FOLEY COUDE 20FR 5CC 2 WAY

Facility

$45.07

Hospital Charge Code	27742597
Hospital Revenue Code	270
Min. Negotiated Rate	$7.14
Max. Negotiated Rate	$40.56
Rate for Payer: Aetna of AZ Commercial	$40.56
Rate for Payer: Arizona Complete Health Allwell	$7.21
Rate for Payer: Banner UC Health Medicare	$7.21
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$30.65
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.21
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.21
Rate for Payer: Cash Price	$36.06
Rate for Payer: Cigna of AZ Commercial	$31.55
Rate for Payer: Devoted Health Medicare	$8.11
Rate for Payer: Humana of AZ Medicare	$7.21
Rate for Payer: Southwest Service Administrators UFCW	$30.65
Rate for Payer: TriWest Medicare	$7.21
Rate for Payer: United Healthcare Commercial	$25.78
Rate for Payer: United Healthcare Medicare	$7.21
Rate for Payer: Veterans Affairs TRICARE	$7.14

CATHETER FOLEY COUDE 20FR 5CC 2 WAY

Facility

$45.07

Hospital Charge Code	27742597
Hospital Revenue Code	270
Min. Negotiated Rate	$40.56
Max. Negotiated Rate	$40.56
Rate for Payer: Aetna of AZ Commercial	$40.56
Rate for Payer: Cash Price	$36.06

CATHETER, FOLEY, IC, LATEX, 3WAY,20FR,5CC

Facility

$74.00

Hospital Charge Code	23288845
Hospital Revenue Code	272
Min. Negotiated Rate	$11.72
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Arizona Complete Health Allwell	$11.84
Rate for Payer: Banner UC Health Medicare	$11.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$50.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.84
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cigna of AZ Commercial	$51.80
Rate for Payer: Devoted Health Medicare	$13.32
Rate for Payer: Humana of AZ Medicare	$11.84
Rate for Payer: Southwest Service Administrators UFCW	$50.32
Rate for Payer: TriWest Medicare	$11.84
Rate for Payer: United Healthcare Commercial	$42.33
Rate for Payer: United Healthcare Medicare	$11.84
Rate for Payer: Veterans Affairs TRICARE	$11.72

CATHETER, FOLEY, IC, LATEX, 3WAY,20FR,5CC

Facility

$74.00

Hospital Charge Code	23288845
Hospital Revenue Code	272
Min. Negotiated Rate	$66.60
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Cash Price	$59.20

CATHETER FOLEY LUBRICATH 24FR 5 ML

Facility

$20.00

Hospital Charge Code	23758406
Hospital Revenue Code	270
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Cash Price	$16.00

CATHETER FOLEY LUBRICATH 24FR 5 ML

Facility

$20.00

Hospital Charge Code	23758406
Hospital Revenue Code	270
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Arizona Complete Health Allwell	$3.20
Rate for Payer: Banner UC Health Medicare	$3.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$13.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.20
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cigna of AZ Commercial	$14.00
Rate for Payer: Devoted Health Medicare	$3.60
Rate for Payer: Humana of AZ Medicare	$3.20
Rate for Payer: Southwest Service Administrators UFCW	$13.60
Rate for Payer: TriWest Medicare	$3.20
Rate for Payer: United Healthcare Commercial	$11.44
Rate for Payer: United Healthcare Medicare	$3.20
Rate for Payer: Veterans Affairs TRICARE	$3.17

CATHETER, FOLEY, LUBRICATH, STRL, 14FR,5ML

Facility

$20.00

Hospital Charge Code	23288846
Hospital Revenue Code	272
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Cash Price	$16.00

CATHETER, FOLEY, LUBRICATH, STRL, 14FR,5ML

Facility

$20.00

Hospital Charge Code	23288846
Hospital Revenue Code	272
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna of AZ Commercial	$18.00
Rate for Payer: Arizona Complete Health Allwell	$3.20
Rate for Payer: Banner UC Health Medicare	$3.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$13.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.20
Rate for Payer: Cash Price	$16.00
Rate for Payer: Cigna of AZ Commercial	$14.00
Rate for Payer: Devoted Health Medicare	$3.60
Rate for Payer: Humana of AZ Medicare	$3.20
Rate for Payer: Southwest Service Administrators UFCW	$13.60
Rate for Payer: TriWest Medicare	$3.20
Rate for Payer: United Healthcare Commercial	$11.44
Rate for Payer: United Healthcare Medicare	$3.20
Rate for Payer: Veterans Affairs TRICARE	$3.17

CATHETER MELKER EMER 3.5 ID 3.8 CM

Facility

$1,399.00

Hospital Charge Code	23371937
Hospital Revenue Code	272
Min. Negotiated Rate	$221.60
Max. Negotiated Rate	$1,259.10
Rate for Payer: Aetna of AZ Commercial	$1,259.10
Rate for Payer: Arizona Complete Health Allwell	$223.84
Rate for Payer: Banner UC Health Medicare	$223.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$951.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$223.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$223.84
Rate for Payer: Cash Price	$1,119.20
Rate for Payer: Cigna of AZ Commercial	$979.30
Rate for Payer: Devoted Health Medicare	$251.82
Rate for Payer: Humana of AZ Medicare	$223.84
Rate for Payer: Southwest Service Administrators UFCW	$951.32
Rate for Payer: TriWest Medicare	$223.84
Rate for Payer: United Healthcare Commercial	$800.23
Rate for Payer: United Healthcare Medicare	$223.84
Rate for Payer: Veterans Affairs TRICARE	$221.60

CATHETER MELKER EMER 3.5 ID 3.8 CM

Facility

$1,399.00

Hospital Charge Code	23371937
Hospital Revenue Code	272
Min. Negotiated Rate	$1,259.10
Max. Negotiated Rate	$1,259.10
Rate for Payer: Aetna of AZ Commercial	$1,259.10
Rate for Payer: Cash Price	$1,119.20

CATHETER THORACIC 40FR

Facility

$53.00

Hospital Charge Code	23371936
Hospital Revenue Code	272
Min. Negotiated Rate	$47.70
Max. Negotiated Rate	$47.70
Rate for Payer: Aetna of AZ Commercial	$47.70
Rate for Payer: Cash Price	$42.40

CATHETER THORACIC 40FR

Facility

$53.00

Hospital Charge Code	23371936
Hospital Revenue Code	272
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$47.70
Rate for Payer: Aetna of AZ Commercial	$47.70
Rate for Payer: Arizona Complete Health Allwell	$8.48
Rate for Payer: Banner UC Health Medicare	$8.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$36.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.48
Rate for Payer: Cash Price	$42.40
Rate for Payer: Cigna of AZ Commercial	$37.10
Rate for Payer: Devoted Health Medicare	$9.54
Rate for Payer: Humana of AZ Medicare	$8.48
Rate for Payer: Southwest Service Administrators UFCW	$36.04
Rate for Payer: TriWest Medicare	$8.48
Rate for Payer: United Healthcare Commercial	$30.32
Rate for Payer: United Healthcare Medicare	$8.48
Rate for Payer: Veterans Affairs TRICARE	$8.40

CATH FEMALE

Facility

$11.00

Hospital Charge Code	22355404
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

CATH FEMALE

Facility

$11.00

Hospital Charge Code	22355404
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

CATH FOLEY 10FR 3CC 2-WAY ST

Facility

$67.00

Hospital Charge Code	22355172
Hospital Revenue Code	270
Min. Negotiated Rate	$60.30
Max. Negotiated Rate	$60.30
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Cash Price	$53.60

CATH FOLEY 10FR 3CC 2-WAY ST

Facility

$67.00

Hospital Charge Code	22355172
Hospital Revenue Code	270
Min. Negotiated Rate	$10.61
Max. Negotiated Rate	$60.30
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Arizona Complete Health Allwell	$10.72
Rate for Payer: Banner UC Health Medicare	$10.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$45.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.72
Rate for Payer: Cash Price	$53.60
Rate for Payer: Cigna of AZ Commercial	$46.90
Rate for Payer: Devoted Health Medicare	$12.06
Rate for Payer: Humana of AZ Medicare	$10.72
Rate for Payer: Southwest Service Administrators UFCW	$45.56
Rate for Payer: TriWest Medicare	$10.72
Rate for Payer: United Healthcare Commercial	$38.32
Rate for Payer: United Healthcare Medicare	$10.72
Rate for Payer: Veterans Affairs TRICARE	$10.61

CATH FOLEY 12FR 5CC 2-WAY ST

Facility

$106.00

Hospital Charge Code	22355144
Hospital Revenue Code	270
Min. Negotiated Rate	$16.79
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of AZ Commercial	$95.40
Rate for Payer: Arizona Complete Health Allwell	$16.96
Rate for Payer: Banner UC Health Medicare	$16.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$72.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.96
Rate for Payer: Cash Price	$84.80
Rate for Payer: Cigna of AZ Commercial	$74.20
Rate for Payer: Devoted Health Medicare	$19.08
Rate for Payer: Humana of AZ Medicare	$16.96
Rate for Payer: Southwest Service Administrators UFCW	$72.08
Rate for Payer: TriWest Medicare	$16.96
Rate for Payer: United Healthcare Commercial	$60.63
Rate for Payer: United Healthcare Medicare	$16.96
Rate for Payer: Veterans Affairs TRICARE	$16.79

Know your out-of-pocket cost for care.

All Charges