Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Dressings and/or debridement of partial-thickness burns, initial or subsequent;

Facility

$150.00

Service Code	CPT 16020
Hospital Charge Code	749804
Hospital Revenue Code	521
Min. Negotiated Rate	$135.00
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of AZ Commercial	$135.00
Rate for Payer: Cash Price	$120.00

Dressings and/or debridement of partial-thickness burns, initial or subsequent;

Facility

$150.00

Service Code	CPT 16020
Hospital Charge Code	749804
Hospital Revenue Code	521
Min. Negotiated Rate	$23.76
Max. Negotiated Rate	$310.43
Rate for Payer: Aetna of AZ Commercial	$135.00
Rate for Payer: Arizona Complete Health Allwell	$24.00
Rate for Payer: Banner UC Health Medicare	$24.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$102.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$30.33
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$24.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$24.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cigna of AZ Commercial	$105.00
Rate for Payer: Devoted Health Medicare	$27.00
Rate for Payer: Humana of AZ Medicare	$24.00
Rate for Payer: Mercy Care Medicaid	$30.33
Rate for Payer: NaphCare Correctional Healthcare	$30.33
Rate for Payer: Seven Corners Travel Insurance	$310.43
Rate for Payer: Southwest Service Administrators UFCW	$102.00
Rate for Payer: TriWest Medicare	$24.00
Rate for Payer: United Healthcare Commercial	$85.80
Rate for Payer: United Healthcare Medicare	$24.00
Rate for Payer: Veterans Affairs TRICARE	$23.76

DRESSING STRATASORB COMP 4X10

Facility

$10.00

Hospital Charge Code	27449661
Hospital Revenue Code	270
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna of AZ Commercial	$9.00
Rate for Payer: Arizona Complete Health Allwell	$1.60
Rate for Payer: Banner UC Health Medicare	$1.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$6.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.60
Rate for Payer: Cash Price	$8.00
Rate for Payer: Cigna of AZ Commercial	$7.00
Rate for Payer: Devoted Health Medicare	$1.80
Rate for Payer: Humana of AZ Medicare	$1.60
Rate for Payer: Southwest Service Administrators UFCW	$6.80
Rate for Payer: TriWest Medicare	$1.60
Rate for Payer: United Healthcare Commercial	$5.72
Rate for Payer: United Healthcare Medicare	$1.60
Rate for Payer: Veterans Affairs TRICARE	$1.58

DRESSING STRATASORB COMP 4X10

Facility

$10.00

Hospital Charge Code	27449661
Hospital Revenue Code	270
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna of AZ Commercial	$9.00
Rate for Payer: Cash Price	$8.00

DRILL 2 X 095

Facility

$960.00

Hospital Charge Code	28018262
Hospital Revenue Code	270
Min. Negotiated Rate	$864.00
Max. Negotiated Rate	$864.00
Rate for Payer: Aetna of AZ Commercial	$864.00
Rate for Payer: Cash Price	$768.00

DRILL 2 X 095

Facility

$960.00

Hospital Charge Code	28018262
Hospital Revenue Code	270
Min. Negotiated Rate	$152.06
Max. Negotiated Rate	$864.00
Rate for Payer: Aetna of AZ Commercial	$864.00
Rate for Payer: Arizona Complete Health Allwell	$153.60
Rate for Payer: Banner UC Health Medicare	$153.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$652.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$153.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$153.60
Rate for Payer: Cash Price	$768.00
Rate for Payer: Cigna of AZ Commercial	$672.00
Rate for Payer: Devoted Health Medicare	$172.80
Rate for Payer: Humana of AZ Medicare	$153.60
Rate for Payer: Southwest Service Administrators UFCW	$652.80
Rate for Payer: TriWest Medicare	$153.60
Rate for Payer: United Healthcare Commercial	$549.12
Rate for Payer: United Healthcare Medicare	$153.60
Rate for Payer: Veterans Affairs TRICARE	$152.06

DRSG ACTICOAT 7 4X5 IN.

Facility

$116.00

Hospital Charge Code	22354838
Hospital Revenue Code	270
Min. Negotiated Rate	$18.37
Max. Negotiated Rate	$104.40
Rate for Payer: Aetna of AZ Commercial	$104.40
Rate for Payer: Arizona Complete Health Allwell	$18.56
Rate for Payer: Banner UC Health Medicare	$18.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$78.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$18.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$18.56
Rate for Payer: Cash Price	$92.80
Rate for Payer: Cigna of AZ Commercial	$81.20
Rate for Payer: Devoted Health Medicare	$20.88
Rate for Payer: Humana of AZ Medicare	$18.56
Rate for Payer: Southwest Service Administrators UFCW	$78.88
Rate for Payer: TriWest Medicare	$18.56
Rate for Payer: United Healthcare Commercial	$66.35
Rate for Payer: United Healthcare Medicare	$18.56
Rate for Payer: Veterans Affairs TRICARE	$18.37

DRSG ACTICOAT 7 4X5 IN.

Facility

$116.00

Hospital Charge Code	22354838
Hospital Revenue Code	270
Min. Negotiated Rate	$104.40
Max. Negotiated Rate	$104.40
Rate for Payer: Aetna of AZ Commercial	$104.40
Rate for Payer: Cash Price	$92.80

DRSG ALGINATE AQUACEL 4X4.7

Facility

$53.00

Hospital Charge Code	22354975
Hospital Revenue Code	270
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

DRSG ALGINATE AQUACEL 4X4.7

Facility

$53.00

Hospital Charge Code	22354975
Hospital Revenue Code	270
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

DRSG COBAN 2 IN

Facility

$8.00

Hospital Charge Code	27571813
Hospital Revenue Code	270
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Arizona Complete Health Allwell	$1.28
Rate for Payer: Banner UC Health Medicare	$1.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.28
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cigna of AZ Commercial	$5.60
Rate for Payer: Devoted Health Medicare	$1.44
Rate for Payer: Humana of AZ Medicare	$1.28
Rate for Payer: Southwest Service Administrators UFCW	$5.44
Rate for Payer: TriWest Medicare	$1.28
Rate for Payer: United Healthcare Commercial	$4.58
Rate for Payer: United Healthcare Medicare	$1.28
Rate for Payer: Veterans Affairs TRICARE	$1.27

DRSG COBAN 2 IN

Facility

$8.00

Hospital Charge Code	22354290
Hospital Revenue Code	270
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Arizona Complete Health Allwell	$1.28
Rate for Payer: Banner UC Health Medicare	$1.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.28
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cigna of AZ Commercial	$5.60
Rate for Payer: Devoted Health Medicare	$1.44
Rate for Payer: Humana of AZ Medicare	$1.28
Rate for Payer: Southwest Service Administrators UFCW	$5.44
Rate for Payer: TriWest Medicare	$1.28
Rate for Payer: United Healthcare Commercial	$4.58
Rate for Payer: United Healthcare Medicare	$1.28
Rate for Payer: Veterans Affairs TRICARE	$1.27

DRSG COBAN 2 IN

Facility

$8.00

Hospital Charge Code	27571813
Hospital Revenue Code	270
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Cash Price	$6.40

DRSG COBAN 2 IN

Facility

$8.00

Hospital Charge Code	22354290
Hospital Revenue Code	270
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Cash Price	$6.40

DRSG COBAN 6 IN

Facility

$23.00

Service Code	HCPCS A4460
Hospital Charge Code	22355146
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

DRSG COBAN 6 IN

Facility

$23.00

Service Code	HCPCS A4460
Hospital Charge Code	22355146
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

DRSG DUODERM X THIN

Facility

$30.00

Hospital Charge Code	27567552
Hospital Revenue Code	270
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Cash Price	$24.00

DRSG DUODERM X THIN

Facility

$30.00

Hospital Charge Code	27567552
Hospital Revenue Code	270
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Arizona Complete Health Allwell	$4.80
Rate for Payer: Banner UC Health Medicare	$4.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$20.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna of AZ Commercial	$21.00
Rate for Payer: Devoted Health Medicare	$5.40
Rate for Payer: Humana of AZ Medicare	$4.80
Rate for Payer: Southwest Service Administrators UFCW	$20.40
Rate for Payer: TriWest Medicare	$4.80
Rate for Payer: United Healthcare Commercial	$17.16
Rate for Payer: United Healthcare Medicare	$4.80
Rate for Payer: Veterans Affairs TRICARE	$4.75

DRSG DUODERM X THIN

Facility

$30.00

Hospital Charge Code	22354979
Hospital Revenue Code	270
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Cash Price	$24.00

DRSG DUODERM X THIN

Facility

$30.00

Hospital Charge Code	22354979
Hospital Revenue Code	270
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Arizona Complete Health Allwell	$4.80
Rate for Payer: Banner UC Health Medicare	$4.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$20.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna of AZ Commercial	$21.00
Rate for Payer: Devoted Health Medicare	$5.40
Rate for Payer: Humana of AZ Medicare	$4.80
Rate for Payer: Southwest Service Administrators UFCW	$20.40
Rate for Payer: TriWest Medicare	$4.80
Rate for Payer: United Healthcare Commercial	$17.16
Rate for Payer: United Healthcare Medicare	$4.80
Rate for Payer: Veterans Affairs TRICARE	$4.75

DRSG MEPILEX AG 4X4

Facility

$47.00

Hospital Charge Code	27569979
Hospital Revenue Code	272
Min. Negotiated Rate	$7.44
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Arizona Complete Health Allwell	$7.52
Rate for Payer: Banner UC Health Medicare	$7.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$31.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.52
Rate for Payer: Cash Price	$37.60
Rate for Payer: Cigna of AZ Commercial	$32.90
Rate for Payer: Devoted Health Medicare	$8.46
Rate for Payer: Humana of AZ Medicare	$7.52
Rate for Payer: Southwest Service Administrators UFCW	$31.96
Rate for Payer: TriWest Medicare	$7.52
Rate for Payer: United Healthcare Commercial	$26.88
Rate for Payer: United Healthcare Medicare	$7.52
Rate for Payer: Veterans Affairs TRICARE	$7.44

DRSG MEPILEX AG 4X4

Facility

$47.00

Hospital Charge Code	22355695
Hospital Revenue Code	272
Min. Negotiated Rate	$7.44
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Arizona Complete Health Allwell	$7.52
Rate for Payer: Banner UC Health Medicare	$7.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$31.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.52
Rate for Payer: Cash Price	$37.60
Rate for Payer: Cigna of AZ Commercial	$32.90
Rate for Payer: Devoted Health Medicare	$8.46
Rate for Payer: Humana of AZ Medicare	$7.52
Rate for Payer: Southwest Service Administrators UFCW	$31.96
Rate for Payer: TriWest Medicare	$7.52
Rate for Payer: United Healthcare Commercial	$26.88
Rate for Payer: United Healthcare Medicare	$7.52
Rate for Payer: Veterans Affairs TRICARE	$7.44

DRSG MEPILEX AG 4X4

Facility

$47.00

Hospital Charge Code	22355695
Hospital Revenue Code	272
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Cash Price	$37.60

DRSG MEPILEX AG 4X4

Facility

$47.00

Hospital Charge Code	27569979
Hospital Revenue Code	272
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of AZ Commercial	$42.30
Rate for Payer: Cash Price	$37.60

DRSG MEPILEX BORDER 15X15 (6X6)

Facility

$32.00

Hospital Charge Code	22354829
Hospital Revenue Code	272
Min. Negotiated Rate	$5.07
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Arizona Complete Health Allwell	$5.12
Rate for Payer: Banner UC Health Medicare	$5.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$21.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.12
Rate for Payer: Cash Price	$25.60
Rate for Payer: Cigna of AZ Commercial	$22.40
Rate for Payer: Devoted Health Medicare	$5.76
Rate for Payer: Humana of AZ Medicare	$5.12
Rate for Payer: Southwest Service Administrators UFCW	$21.76
Rate for Payer: TriWest Medicare	$5.12
Rate for Payer: United Healthcare Commercial	$18.30
Rate for Payer: United Healthcare Medicare	$5.12
Rate for Payer: Veterans Affairs TRICARE	$5.07

Know your out-of-pocket cost for care.

All Charges