Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

OPTIFLOW PLUS CANNULA SIZE L

Facility

$97.00

Hospital Charge Code	24154232
Hospital Revenue Code	270
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

OPTIFLOW PLUS CANNULA SIZE M

Facility

$97.00

Hospital Charge Code	24154231
Hospital Revenue Code	270
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

OPTIFLOW PLUS CANNULA SIZE M

Facility

$97.00

Hospital Charge Code	24154231
Hospital Revenue Code	270
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

OPTIFLOW PULS CANNULA SIZE S

Facility

$97.00

Hospital Charge Code	24154230
Hospital Revenue Code	270
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

OPTIFLOW PULS CANNULA SIZE S

Facility

$97.00

Hospital Charge Code	24154230
Hospital Revenue Code	270
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

OPTIFOAM GENTLE AG SA BORDERED 6X6

Facility

$32.00

Hospital Charge Code	27569983
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

OPTIFOAM GENTLE AG SA BORDERED 6X6

Facility

$32.00

Hospital Charge Code	27569983
Hospital Revenue Code	272
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Cash Price	$25.60

Optilite Holmium Fiber 150 micron

Facility

$1,274.00

Hospital Charge Code	22926479
Hospital Revenue Code	272
Min. Negotiated Rate	$201.80
Max. Negotiated Rate	$1,146.60
Rate for Payer: Aetna of AZ Commercial	$1,146.60
Rate for Payer: Arizona Complete Health Allwell	$203.84
Rate for Payer: Banner UC Health Medicare	$203.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$866.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$203.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$203.84
Rate for Payer: Cash Price	$1,019.20
Rate for Payer: Cigna of AZ Commercial	$891.80
Rate for Payer: Devoted Health Medicare	$229.32
Rate for Payer: Humana of AZ Medicare	$203.84
Rate for Payer: Southwest Service Administrators UFCW	$866.32
Rate for Payer: TriWest Medicare	$203.84
Rate for Payer: United Healthcare Commercial	$728.73
Rate for Payer: United Healthcare Medicare	$203.84
Rate for Payer: Veterans Affairs TRICARE	$201.80

Optilite Holmium Fiber 150 micron

Facility

$1,274.00

Hospital Charge Code	22926479
Hospital Revenue Code	272
Min. Negotiated Rate	$1,146.60
Max. Negotiated Rate	$1,146.60
Rate for Payer: Aetna of AZ Commercial	$1,146.60
Rate for Payer: Cash Price	$1,019.20

ORBITAL PROCEDURES WITH CC/MCC

Facility

$30,385.97

Service Code	MSDRG 113
Min. Negotiated Rate	$30,385.97
Max. Negotiated Rate	$30,385.97
Rate for Payer: Seven Corners Travel Insurance	$30,385.97

ORBITAL PROCEDURES WITHOUT CC/MCC

Facility

$17,499.54

Service Code	MSDRG 114
Min. Negotiated Rate	$17,499.54
Max. Negotiated Rate	$17,499.54
Rate for Payer: Seven Corners Travel Insurance	$17,499.54

Orbit And Eye Procedures

Facility

$15,146.73

Service Code	APR-DRG 0733
Hospital Charge Code	APRDRG0732
Min. Negotiated Rate	$15,146.73
Max. Negotiated Rate	$15,146.73
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$15,146.73
Rate for Payer: Mercy Care Medicaid	$15,146.73
Rate for Payer: NaphCare Correctional Healthcare	$15,146.73

Orbit And Eye Procedures

Facility

$28,755.30

Service Code	APR-DRG 0734
Hospital Charge Code	APRDRG0732
Min. Negotiated Rate	$28,755.30
Max. Negotiated Rate	$28,755.30
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$28,755.30
Rate for Payer: Mercy Care Medicaid	$28,755.30
Rate for Payer: NaphCare Correctional Healthcare	$28,755.30

Orbit And Eye Procedures

Facility

$6,265.61

Service Code	APR-DRG 0731
Hospital Charge Code	APRDRG0733
Min. Negotiated Rate	$6,265.61
Max. Negotiated Rate	$6,265.61
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$6,265.61
Rate for Payer: Mercy Care Medicaid	$6,265.61
Rate for Payer: NaphCare Correctional Healthcare	$6,265.61

Orbit And Eye Procedures

Facility

$15,146.73

Service Code	APR-DRG 0733
Hospital Charge Code	APRDRG0734
Min. Negotiated Rate	$15,146.73
Max. Negotiated Rate	$15,146.73
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$15,146.73
Rate for Payer: Mercy Care Medicaid	$15,146.73
Rate for Payer: NaphCare Correctional Healthcare	$15,146.73

Orbit And Eye Procedures

Facility

$6,265.61

Service Code	APR-DRG 0731
Hospital Charge Code	APRDRG0731
Min. Negotiated Rate	$6,265.61
Max. Negotiated Rate	$6,265.61
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$6,265.61
Rate for Payer: Mercy Care Medicaid	$6,265.61
Rate for Payer: NaphCare Correctional Healthcare	$6,265.61

Orbit And Eye Procedures

Facility

$8,902.17

Service Code	APR-DRG 0732
Hospital Charge Code	APRDRG0733
Min. Negotiated Rate	$8,902.17
Max. Negotiated Rate	$8,902.17
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8,902.17
Rate for Payer: Mercy Care Medicaid	$8,902.17
Rate for Payer: NaphCare Correctional Healthcare	$8,902.17

Orbit And Eye Procedures

Facility

$8,902.17

Service Code	APR-DRG 0732
Hospital Charge Code	APRDRG0734
Min. Negotiated Rate	$8,902.17
Max. Negotiated Rate	$8,902.17
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8,902.17
Rate for Payer: Mercy Care Medicaid	$8,902.17
Rate for Payer: NaphCare Correctional Healthcare	$8,902.17

Orbit And Eye Procedures

Facility

$28,755.30

Service Code	APR-DRG 0734
Hospital Charge Code	APRDRG0734
Min. Negotiated Rate	$28,755.30
Max. Negotiated Rate	$28,755.30
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$28,755.30
Rate for Payer: Mercy Care Medicaid	$28,755.30
Rate for Payer: NaphCare Correctional Healthcare	$28,755.30

Orbit And Eye Procedures

Facility

$8,902.17

Service Code	APR-DRG 0732
Hospital Charge Code	APRDRG0732
Min. Negotiated Rate	$8,902.17
Max. Negotiated Rate	$8,902.17
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8,902.17
Rate for Payer: Mercy Care Medicaid	$8,902.17
Rate for Payer: NaphCare Correctional Healthcare	$8,902.17

Orbit And Eye Procedures

Facility

$28,755.30

Service Code	APR-DRG 0734
Hospital Charge Code	APRDRG0733
Min. Negotiated Rate	$28,755.30
Max. Negotiated Rate	$28,755.30
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$28,755.30
Rate for Payer: Mercy Care Medicaid	$28,755.30
Rate for Payer: NaphCare Correctional Healthcare	$28,755.30

Orbit And Eye Procedures

Facility

$8,902.17

Service Code	APR-DRG 0732
Hospital Charge Code	APRDRG0731
Min. Negotiated Rate	$8,902.17
Max. Negotiated Rate	$8,902.17
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$8,902.17
Rate for Payer: Mercy Care Medicaid	$8,902.17
Rate for Payer: NaphCare Correctional Healthcare	$8,902.17

Orbit And Eye Procedures

Facility

$28,755.30

Service Code	APR-DRG 0734
Hospital Charge Code	APRDRG0731
Min. Negotiated Rate	$28,755.30
Max. Negotiated Rate	$28,755.30
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$28,755.30
Rate for Payer: Mercy Care Medicaid	$28,755.30
Rate for Payer: NaphCare Correctional Healthcare	$28,755.30

Orbit And Eye Procedures

Facility

$15,146.73

Service Code	APR-DRG 0733
Hospital Charge Code	APRDRG0731
Min. Negotiated Rate	$15,146.73
Max. Negotiated Rate	$15,146.73
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$15,146.73
Rate for Payer: Mercy Care Medicaid	$15,146.73
Rate for Payer: NaphCare Correctional Healthcare	$15,146.73

Orbit And Eye Procedures

Facility

$6,265.61

Service Code	APR-DRG 0731
Hospital Charge Code	APRDRG0734
Min. Negotiated Rate	$6,265.61
Max. Negotiated Rate	$6,265.61
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$6,265.61
Rate for Payer: Mercy Care Medicaid	$6,265.61
Rate for Payer: NaphCare Correctional Healthcare	$6,265.61

Know your out-of-pocket cost for care.

All Charges