Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Drain Skin Abscess, Simple/Single Charge

Facility

$405.00

Service Code	CPT 10060
Hospital Charge Code	713671
Hospital Revenue Code	521
Min. Negotiated Rate	$364.50
Max. Negotiated Rate	$364.50
Rate for Payer: Aetna of AZ Commercial	$364.50
Rate for Payer: Cash Price	$324.00

DRAPE BASIC PK V

Facility

$54.00

Hospital Charge Code	22354911
Hospital Revenue Code	270
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$48.60
Rate for Payer: Aetna of AZ Commercial	$48.60
Rate for Payer: Cash Price	$43.20

DRAPE BASIC PK V

Facility

$54.00

Hospital Charge Code	22354911
Hospital Revenue Code	270
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$48.60
Rate for Payer: Aetna of AZ Commercial	$48.60
Rate for Payer: Arizona Complete Health Allwell	$8.64
Rate for Payer: Banner UC Health Medicare	$8.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$36.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.64
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna of AZ Commercial	$37.80
Rate for Payer: Devoted Health Medicare	$9.72
Rate for Payer: Humana of AZ Medicare	$8.64
Rate for Payer: Southwest Service Administrators UFCW	$36.72
Rate for Payer: TriWest Medicare	$8.64
Rate for Payer: United Healthcare Commercial	$30.89
Rate for Payer: United Healthcare Medicare	$8.64
Rate for Payer: Veterans Affairs TRICARE	$8.55

DRAPE C ARM COVER

Facility

$81.00

Hospital Charge Code	22355316
Hospital Revenue Code	270
Min. Negotiated Rate	$72.90
Max. Negotiated Rate	$72.90
Rate for Payer: Aetna of AZ Commercial	$72.90
Rate for Payer: Cash Price	$64.80

DRAPE C ARM COVER

Facility

$81.00

Hospital Charge Code	22355316
Hospital Revenue Code	270
Min. Negotiated Rate	$12.83
Max. Negotiated Rate	$72.90
Rate for Payer: Aetna of AZ Commercial	$72.90
Rate for Payer: Arizona Complete Health Allwell	$12.96
Rate for Payer: Banner UC Health Medicare	$12.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$55.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.96
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna of AZ Commercial	$56.70
Rate for Payer: Devoted Health Medicare	$14.58
Rate for Payer: Humana of AZ Medicare	$12.96
Rate for Payer: Southwest Service Administrators UFCW	$55.08
Rate for Payer: TriWest Medicare	$12.96
Rate for Payer: United Healthcare Commercial	$46.33
Rate for Payer: United Healthcare Medicare	$12.96
Rate for Payer: Veterans Affairs TRICARE	$12.83

DRAPE CLEAR U-DRAPE

Facility

$26.00

Hospital Charge Code	22354921
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

DRAPE CLEAR U-DRAPE

Facility

$26.00

Hospital Charge Code	22354921
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

DRAPE, CLOSED CAMERA SYSTEM 9X96

Facility

$35.00

Hospital Charge Code	22926411
Hospital Revenue Code	272
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of AZ Commercial	$31.50
Rate for Payer: Cash Price	$28.00

DRAPE, CLOSED CAMERA SYSTEM 9X96

Facility

$35.00

Hospital Charge Code	22926411
Hospital Revenue Code	272
Min. Negotiated Rate	$5.54
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of AZ Commercial	$31.50
Rate for Payer: Arizona Complete Health Allwell	$5.60
Rate for Payer: Banner UC Health Medicare	$5.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$23.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.60
Rate for Payer: Cash Price	$28.00
Rate for Payer: Cigna of AZ Commercial	$24.50
Rate for Payer: Devoted Health Medicare	$6.30
Rate for Payer: Humana of AZ Medicare	$5.60
Rate for Payer: Southwest Service Administrators UFCW	$23.80
Rate for Payer: TriWest Medicare	$5.60
Rate for Payer: United Healthcare Commercial	$20.02
Rate for Payer: United Healthcare Medicare	$5.60
Rate for Payer: Veterans Affairs TRICARE	$5.54

DRAPE EXTREMITY

Facility

$33.00

Hospital Charge Code	22355294
Hospital Revenue Code	270
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Cash Price	$26.40

DRAPE EXTREMITY

Facility

$33.00

Hospital Charge Code	22355294
Hospital Revenue Code	270
Min. Negotiated Rate	$5.23
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Arizona Complete Health Allwell	$5.28
Rate for Payer: Banner UC Health Medicare	$5.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$22.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.28
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cigna of AZ Commercial	$23.10
Rate for Payer: Devoted Health Medicare	$5.94
Rate for Payer: Humana of AZ Medicare	$5.28
Rate for Payer: Southwest Service Administrators UFCW	$22.44
Rate for Payer: TriWest Medicare	$5.28
Rate for Payer: United Healthcare Commercial	$18.88
Rate for Payer: United Healthcare Medicare	$5.28
Rate for Payer: Veterans Affairs TRICARE	$5.23

DRAPE INCISE IOBAN 13X13-IN (36CM)

Facility

$68.00

Hospital Charge Code	22354969
Hospital Revenue Code	270
Min. Negotiated Rate	$10.77
Max. Negotiated Rate	$61.20
Rate for Payer: Aetna of AZ Commercial	$61.20
Rate for Payer: Arizona Complete Health Allwell	$10.88
Rate for Payer: Banner UC Health Medicare	$10.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$46.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.88
Rate for Payer: Cash Price	$54.40
Rate for Payer: Cigna of AZ Commercial	$47.60
Rate for Payer: Devoted Health Medicare	$12.24
Rate for Payer: Humana of AZ Medicare	$10.88
Rate for Payer: Southwest Service Administrators UFCW	$46.24
Rate for Payer: TriWest Medicare	$10.88
Rate for Payer: United Healthcare Commercial	$38.90
Rate for Payer: United Healthcare Medicare	$10.88
Rate for Payer: Veterans Affairs TRICARE	$10.77

DRAPE INCISE IOBAN 13X13-IN (36CM)

Facility

$68.00

Hospital Charge Code	22354969
Hospital Revenue Code	270
Min. Negotiated Rate	$61.20
Max. Negotiated Rate	$61.20
Rate for Payer: Aetna of AZ Commercial	$61.20
Rate for Payer: Cash Price	$54.40

DRAPE LAPAROSCOPY PACK

Facility

$153.00

Hospital Charge Code	22354239
Hospital Revenue Code	270
Min. Negotiated Rate	$137.70
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of AZ Commercial	$137.70
Rate for Payer: Cash Price	$122.40

DRAPE LAPAROSCOPY PACK

Facility

$153.00

Hospital Charge Code	22354239
Hospital Revenue Code	270
Min. Negotiated Rate	$24.24
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of AZ Commercial	$137.70
Rate for Payer: Arizona Complete Health Allwell	$24.48
Rate for Payer: Banner UC Health Medicare	$24.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$104.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$24.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$24.48
Rate for Payer: Cash Price	$122.40
Rate for Payer: Cigna of AZ Commercial	$107.10
Rate for Payer: Devoted Health Medicare	$27.54
Rate for Payer: Humana of AZ Medicare	$24.48
Rate for Payer: Southwest Service Administrators UFCW	$104.04
Rate for Payer: TriWest Medicare	$24.48
Rate for Payer: United Healthcare Commercial	$87.52
Rate for Payer: United Healthcare Medicare	$24.48
Rate for Payer: Veterans Affairs TRICARE	$24.24

DRAPE PELVIC

Facility

$97.00

Hospital Charge Code	22926417
Hospital Revenue Code	272
Min. Negotiated Rate	$15.36
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna of AZ Commercial	$87.30
Rate for Payer: Arizona Complete Health Allwell	$15.52
Rate for Payer: Banner UC Health Medicare	$15.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$65.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$15.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.52
Rate for Payer: Cash Price	$77.60
Rate for Payer: Cigna of AZ Commercial	$67.90
Rate for Payer: Devoted Health Medicare	$17.46
Rate for Payer: Humana of AZ Medicare	$15.52
Rate for Payer: Southwest Service Administrators UFCW	$65.96
Rate for Payer: TriWest Medicare	$15.52
Rate for Payer: United Healthcare Commercial	$55.48
Rate for Payer: United Healthcare Medicare	$15.52
Rate for Payer: Veterans Affairs TRICARE	$15.36

DRAPE PELVIC

Facility

$97.00

Hospital Charge Code	22926417
Hospital Revenue Code	272
Min. Negotiated Rate	$87.30
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna of AZ Commercial	$87.30
Rate for Payer: Cash Price	$77.60

DRAPE UNDER BUTTOCK W/FLUID COLLECTION

Facility

$23.00

Hospital Charge Code	22355540
Hospital Revenue Code	270
Min. Negotiated Rate	$20.70
Max. Negotiated Rate	$20.70
Rate for Payer: Aetna of AZ Commercial	$20.70
Rate for Payer: Cash Price	$18.40

DRAPE UNDER BUTTOCK W/FLUID COLLECTION

Facility

$23.00

Hospital Charge Code	22355540
Hospital Revenue Code	270
Min. Negotiated Rate	$3.64
Max. Negotiated Rate	$20.70
Rate for Payer: Aetna of AZ Commercial	$20.70
Rate for Payer: Arizona Complete Health Allwell	$3.68
Rate for Payer: Banner UC Health Medicare	$3.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$15.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.68
Rate for Payer: Cash Price	$18.40
Rate for Payer: Cigna of AZ Commercial	$16.10
Rate for Payer: Devoted Health Medicare	$4.14
Rate for Payer: Humana of AZ Medicare	$3.68
Rate for Payer: Southwest Service Administrators UFCW	$15.64
Rate for Payer: TriWest Medicare	$3.68
Rate for Payer: United Healthcare Commercial	$13.16
Rate for Payer: United Healthcare Medicare	$3.68
Rate for Payer: Veterans Affairs TRICARE	$3.64

DRESSING COLLAGEN PURACOL PLUS AG 4X4

Facility

$109.00

Hospital Charge Code	27571812
Hospital Revenue Code	272
Min. Negotiated Rate	$98.10
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Cash Price	$87.20

DRESSING COLLAGEN PURACOL PLUS AG 4X4

Facility

$109.00

Hospital Charge Code	27571812
Hospital Revenue Code	272
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Arizona Complete Health Allwell	$17.44
Rate for Payer: Banner UC Health Medicare	$17.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$74.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.44
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cigna of AZ Commercial	$76.30
Rate for Payer: Devoted Health Medicare	$19.62
Rate for Payer: Humana of AZ Medicare	$17.44
Rate for Payer: Southwest Service Administrators UFCW	$74.12
Rate for Payer: TriWest Medicare	$17.44
Rate for Payer: United Healthcare Commercial	$62.35
Rate for Payer: United Healthcare Medicare	$17.44
Rate for Payer: Veterans Affairs TRICARE	$17.27

DRESSING MEPITEL SILICONE 3X4

Facility

$29.00

Hospital Charge Code	27569974
Hospital Revenue Code	270
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$26.10
Rate for Payer: Aetna of AZ Commercial	$26.10
Rate for Payer: Arizona Complete Health Allwell	$4.64
Rate for Payer: Banner UC Health Medicare	$4.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$19.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.64
Rate for Payer: Cash Price	$23.20
Rate for Payer: Cigna of AZ Commercial	$20.30
Rate for Payer: Devoted Health Medicare	$5.22
Rate for Payer: Humana of AZ Medicare	$4.64
Rate for Payer: Southwest Service Administrators UFCW	$19.72
Rate for Payer: TriWest Medicare	$4.64
Rate for Payer: United Healthcare Commercial	$16.59
Rate for Payer: United Healthcare Medicare	$4.64
Rate for Payer: Veterans Affairs TRICARE	$4.59

DRESSING MEPITEL SILICONE 3X4

Facility

$29.00

Hospital Charge Code	23770583
Hospital Revenue Code	270
Min. Negotiated Rate	$4.59
Max. Negotiated Rate	$26.10
Rate for Payer: Aetna of AZ Commercial	$26.10
Rate for Payer: Arizona Complete Health Allwell	$4.64
Rate for Payer: Banner UC Health Medicare	$4.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$19.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.64
Rate for Payer: Cash Price	$23.20
Rate for Payer: Cigna of AZ Commercial	$20.30
Rate for Payer: Devoted Health Medicare	$5.22
Rate for Payer: Humana of AZ Medicare	$4.64
Rate for Payer: Southwest Service Administrators UFCW	$19.72
Rate for Payer: TriWest Medicare	$4.64
Rate for Payer: United Healthcare Commercial	$16.59
Rate for Payer: United Healthcare Medicare	$4.64
Rate for Payer: Veterans Affairs TRICARE	$4.59

DRESSING MEPITEL SILICONE 3X4

Facility

$29.00

Hospital Charge Code	23770583
Hospital Revenue Code	270
Min. Negotiated Rate	$26.10
Max. Negotiated Rate	$26.10
Rate for Payer: Aetna of AZ Commercial	$26.10
Rate for Payer: Cash Price	$23.20

DRESSING MEPITEL SILICONE 3X4

Facility

$29.00

Hospital Charge Code	27569974
Hospital Revenue Code	270
Min. Negotiated Rate	$26.10
Max. Negotiated Rate	$26.10
Rate for Payer: Aetna of AZ Commercial	$26.10
Rate for Payer: Cash Price	$23.20

Know your out-of-pocket cost for care.

All Charges