Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

PURAPLAY AM 3X4 FENESTRATED

Facility

$880.00

Service Code	HCPCS Q4196
Hospital Charge Code	24358090
Hospital Revenue Code	636
Min. Negotiated Rate	$792.00
Max. Negotiated Rate	$792.00
Rate for Payer: Aetna of AZ Commercial	$792.00
Rate for Payer: Cash Price	$704.00

PURAPLYAM

Facility

$8,078.00

Service Code	HCPCS Q4196
Hospital Charge Code	24358088
Hospital Revenue Code	636
Min. Negotiated Rate	$192.55
Max. Negotiated Rate	$7,270.20
Rate for Payer: Aetna of AZ Commercial	$7,270.20
Rate for Payer: Arizona Complete Health Allwell	$1,292.48
Rate for Payer: Banner UC Health Medicare	$1,292.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5,493.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,292.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,292.48
Rate for Payer: Cash Price	$6,462.40
Rate for Payer: Cash Price	$6,462.40
Rate for Payer: Cigna of AZ Commercial	$5,654.60
Rate for Payer: Devoted Health Medicare	$1,454.04
Rate for Payer: Humana of AZ Medicare	$1,292.48
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$5,493.04
Rate for Payer: TriWest Medicare	$1,292.48
Rate for Payer: United Healthcare Commercial	$4,620.62
Rate for Payer: United Healthcare Medicare	$1,292.48
Rate for Payer: United Healthcare New Mexico Commercial	$1,534.82
Rate for Payer: Veterans Affairs TRICARE	$1,279.56

PURAPLYAM

Facility

$8,078.00

Service Code	HCPCS Q4196
Hospital Charge Code	24358088
Hospital Revenue Code	636
Min. Negotiated Rate	$7,270.20
Max. Negotiated Rate	$7,270.20
Rate for Payer: Aetna of AZ Commercial	$7,270.20
Rate for Payer: Cash Price	$6,462.40

PURAPLYAM

Facility

$1,973.00

Service Code	HCPCS Q4196
Hospital Charge Code	24358083
Hospital Revenue Code	636
Min. Negotiated Rate	$1,775.70
Max. Negotiated Rate	$1,775.70
Rate for Payer: Aetna of AZ Commercial	$1,775.70
Rate for Payer: Cash Price	$1,578.40

PURAPLYAM

Facility

$1,973.00

Service Code	HCPCS Q4196
Hospital Charge Code	24358083
Hospital Revenue Code	636
Min. Negotiated Rate	$192.55
Max. Negotiated Rate	$1,775.70
Rate for Payer: Aetna of AZ Commercial	$1,775.70
Rate for Payer: Arizona Complete Health Allwell	$315.68
Rate for Payer: Banner UC Health Medicare	$315.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,341.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$315.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$315.68
Rate for Payer: Cash Price	$1,578.40
Rate for Payer: Cash Price	$1,578.40
Rate for Payer: Cigna of AZ Commercial	$1,381.10
Rate for Payer: Devoted Health Medicare	$355.14
Rate for Payer: Humana of AZ Medicare	$315.68
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$1,341.64
Rate for Payer: TriWest Medicare	$315.68
Rate for Payer: United Healthcare Commercial	$1,128.56
Rate for Payer: United Healthcare Medicare	$315.68
Rate for Payer: United Healthcare New Mexico Commercial	$374.87
Rate for Payer: Veterans Affairs TRICARE	$312.52

PURAPLY AM 3X4

Facility

$1,096.00

Service Code	HCPCS Q4196
Hospital Charge Code	24358089
Hospital Revenue Code	636
Min. Negotiated Rate	$173.61
Max. Negotiated Rate	$986.40
Rate for Payer: Aetna of AZ Commercial	$986.40
Rate for Payer: Arizona Complete Health Allwell	$175.36
Rate for Payer: Banner UC Health Medicare	$175.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$745.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$175.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$175.36
Rate for Payer: Cash Price	$876.80
Rate for Payer: Cash Price	$876.80
Rate for Payer: Cigna of AZ Commercial	$767.20
Rate for Payer: Devoted Health Medicare	$197.28
Rate for Payer: Humana of AZ Medicare	$175.36
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$745.28
Rate for Payer: TriWest Medicare	$175.36
Rate for Payer: United Healthcare Commercial	$626.91
Rate for Payer: United Healthcare Medicare	$175.36
Rate for Payer: United Healthcare New Mexico Commercial	$208.24
Rate for Payer: Veterans Affairs TRICARE	$173.61

PURAPLY AM 3X4

Facility

$1,096.00

Service Code	HCPCS Q4196
Hospital Charge Code	24358089
Hospital Revenue Code	636
Min. Negotiated Rate	$986.40
Max. Negotiated Rate	$986.40
Rate for Payer: Aetna of AZ Commercial	$986.40
Rate for Payer: Cash Price	$876.80

PURAPLY AM 4X4

Facility

$864.00

Service Code	HCPCS Q4196
Hospital Charge Code	24358091
Hospital Revenue Code	636
Min. Negotiated Rate	$777.60
Max. Negotiated Rate	$777.60
Rate for Payer: Aetna of AZ Commercial	$777.60
Rate for Payer: Cash Price	$691.20

PURAPLY AM 4X4

Facility

$864.00

Service Code	HCPCS Q4196
Hospital Charge Code	24358091
Hospital Revenue Code	636
Min. Negotiated Rate	$136.86
Max. Negotiated Rate	$777.60
Rate for Payer: Aetna of AZ Commercial	$777.60
Rate for Payer: Arizona Complete Health Allwell	$138.24
Rate for Payer: Banner UC Health Medicare	$138.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$587.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$138.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$138.24
Rate for Payer: Cash Price	$691.20
Rate for Payer: Cash Price	$691.20
Rate for Payer: Cigna of AZ Commercial	$604.80
Rate for Payer: Devoted Health Medicare	$155.52
Rate for Payer: Humana of AZ Medicare	$138.24
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$587.52
Rate for Payer: TriWest Medicare	$138.24
Rate for Payer: United Healthcare Commercial	$494.21
Rate for Payer: United Healthcare Medicare	$138.24
Rate for Payer: United Healthcare New Mexico Commercial	$164.16
Rate for Payer: Veterans Affairs TRICARE	$136.86

PURAPLY AM 4X4 FENESTRATED

Facility

$864.00

Hospital Charge Code	24358092
Hospital Revenue Code	636
Min. Negotiated Rate	$136.86
Max. Negotiated Rate	$777.60
Rate for Payer: Aetna of AZ Commercial	$777.60
Rate for Payer: Arizona Complete Health Allwell	$138.24
Rate for Payer: Banner UC Health Medicare	$138.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$587.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$138.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$138.24
Rate for Payer: Cash Price	$691.20
Rate for Payer: Cigna of AZ Commercial	$604.80
Rate for Payer: Devoted Health Medicare	$155.52
Rate for Payer: Humana of AZ Medicare	$138.24
Rate for Payer: Southwest Service Administrators UFCW	$587.52
Rate for Payer: TriWest Medicare	$138.24
Rate for Payer: United Healthcare Commercial	$494.21
Rate for Payer: United Healthcare Medicare	$138.24
Rate for Payer: United Healthcare New Mexico Commercial	$164.16
Rate for Payer: Veterans Affairs TRICARE	$136.86

PURAPLY AM 4X4 FENESTRATED

Facility

$864.00

Hospital Charge Code	24358092
Hospital Revenue Code	636
Min. Negotiated Rate	$777.60
Max. Negotiated Rate	$777.60
Rate for Payer: Aetna of AZ Commercial	$777.60
Rate for Payer: Cash Price	$691.20

PURAPLY AM 5X5

Facility

$832.00

Service Code	HCPCS Q4196
Hospital Charge Code	24358093
Hospital Revenue Code	636
Min. Negotiated Rate	$131.79
Max. Negotiated Rate	$748.80
Rate for Payer: Aetna of AZ Commercial	$748.80
Rate for Payer: Arizona Complete Health Allwell	$133.12
Rate for Payer: Banner UC Health Medicare	$133.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$565.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$133.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$133.12
Rate for Payer: Cash Price	$665.60
Rate for Payer: Cash Price	$665.60
Rate for Payer: Cigna of AZ Commercial	$582.40
Rate for Payer: Devoted Health Medicare	$149.76
Rate for Payer: Humana of AZ Medicare	$133.12
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$565.76
Rate for Payer: TriWest Medicare	$133.12
Rate for Payer: United Healthcare Commercial	$475.90
Rate for Payer: United Healthcare Medicare	$133.12
Rate for Payer: United Healthcare New Mexico Commercial	$158.08
Rate for Payer: Veterans Affairs TRICARE	$131.79

PURAPLY AM 5X5

Facility

$832.00

Service Code	HCPCS Q4196
Hospital Charge Code	24358093
Hospital Revenue Code	636
Min. Negotiated Rate	$748.80
Max. Negotiated Rate	$748.80
Rate for Payer: Aetna of AZ Commercial	$748.80
Rate for Payer: Cash Price	$665.60

PURAPLY AM 6X9

Facility

$760.00

Service Code	HCPCS Q4196
Hospital Charge Code	24358094
Hospital Revenue Code	636
Min. Negotiated Rate	$120.38
Max. Negotiated Rate	$684.00
Rate for Payer: Aetna of AZ Commercial	$684.00
Rate for Payer: Arizona Complete Health Allwell	$121.60
Rate for Payer: Banner UC Health Medicare	$121.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$516.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$121.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$121.60
Rate for Payer: Cash Price	$608.00
Rate for Payer: Cash Price	$608.00
Rate for Payer: Cigna of AZ Commercial	$532.00
Rate for Payer: Devoted Health Medicare	$136.80
Rate for Payer: Humana of AZ Medicare	$121.60
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$516.80
Rate for Payer: TriWest Medicare	$121.60
Rate for Payer: United Healthcare Commercial	$434.72
Rate for Payer: United Healthcare Medicare	$121.60
Rate for Payer: United Healthcare New Mexico Commercial	$144.40
Rate for Payer: Veterans Affairs TRICARE	$120.38

PURAPLY AM 6X9

Facility

$760.00

Service Code	HCPCS Q4196
Hospital Charge Code	24358094
Hospital Revenue Code	636
Min. Negotiated Rate	$684.00
Max. Negotiated Rate	$684.00
Rate for Payer: Aetna of AZ Commercial	$684.00
Rate for Payer: Cash Price	$608.00

PURAPLY AM XT EF 4.91 X4.91

Facility

$601.00

Hospital Charge Code	27690859
Hospital Revenue Code	270
Min. Negotiated Rate	$540.90
Max. Negotiated Rate	$540.90
Rate for Payer: Aetna of AZ Commercial	$540.90
Rate for Payer: Cash Price	$480.80

PURAPLY AM XT EF 4.91 X4.91

Facility

$601.00

Hospital Charge Code	27690859
Hospital Revenue Code	270
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$540.90
Rate for Payer: Aetna of AZ Commercial	$540.90
Rate for Payer: Arizona Complete Health Allwell	$96.16
Rate for Payer: Banner UC Health Medicare	$96.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$408.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$96.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$96.16
Rate for Payer: Cash Price	$480.80
Rate for Payer: Cigna of AZ Commercial	$420.70
Rate for Payer: Devoted Health Medicare	$108.18
Rate for Payer: Humana of AZ Medicare	$96.16
Rate for Payer: Southwest Service Administrators UFCW	$408.68
Rate for Payer: TriWest Medicare	$96.16
Rate for Payer: United Healthcare Commercial	$343.77
Rate for Payer: United Healthcare Medicare	$96.16
Rate for Payer: Veterans Affairs TRICARE	$95.20

PURAPLY MZ 1000MG

Facility

$18,520.00

Hospital Charge Code	27570614
Hospital Revenue Code	270
Min. Negotiated Rate	$2,933.57
Max. Negotiated Rate	$16,668.00
Rate for Payer: Aetna of AZ Commercial	$16,668.00
Rate for Payer: Arizona Complete Health Allwell	$2,963.20
Rate for Payer: Banner UC Health Medicare	$2,963.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$12,593.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2,963.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$2,963.20
Rate for Payer: Cash Price	$14,816.00
Rate for Payer: Cigna of AZ Commercial	$12,964.00
Rate for Payer: Devoted Health Medicare	$3,333.60
Rate for Payer: Humana of AZ Medicare	$2,963.20
Rate for Payer: Southwest Service Administrators UFCW	$12,593.60
Rate for Payer: TriWest Medicare	$2,963.20
Rate for Payer: United Healthcare Commercial	$10,593.44
Rate for Payer: United Healthcare Medicare	$2,963.20
Rate for Payer: Veterans Affairs TRICARE	$2,933.57

PURAPLY MZ 1000MG

Facility

$18,520.00

Hospital Charge Code	27570614
Hospital Revenue Code	270
Min. Negotiated Rate	$16,668.00
Max. Negotiated Rate	$16,668.00
Rate for Payer: Aetna of AZ Commercial	$16,668.00
Rate for Payer: Cash Price	$14,816.00

PURAPLY MZ 100MG

Facility

$2,040.00

Hospital Charge Code	27570615
Hospital Revenue Code	270
Min. Negotiated Rate	$1,836.00
Max. Negotiated Rate	$1,836.00
Rate for Payer: Aetna of AZ Commercial	$1,836.00
Rate for Payer: Cash Price	$1,632.00

PURAPLY MZ 100MG

Facility

$2,040.00

Hospital Charge Code	27570615
Hospital Revenue Code	270
Min. Negotiated Rate	$323.14
Max. Negotiated Rate	$1,836.00
Rate for Payer: Aetna of AZ Commercial	$1,836.00
Rate for Payer: Arizona Complete Health Allwell	$326.40
Rate for Payer: Banner UC Health Medicare	$326.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,387.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$326.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$326.40
Rate for Payer: Cash Price	$1,632.00
Rate for Payer: Cigna of AZ Commercial	$1,428.00
Rate for Payer: Devoted Health Medicare	$367.20
Rate for Payer: Humana of AZ Medicare	$326.40
Rate for Payer: Southwest Service Administrators UFCW	$1,387.20
Rate for Payer: TriWest Medicare	$326.40
Rate for Payer: United Healthcare Commercial	$1,166.88
Rate for Payer: United Healthcare Medicare	$326.40
Rate for Payer: Veterans Affairs TRICARE	$323.14

PURAPLY MZ 500MG

Facility

$9,280.00

Hospital Charge Code	27570616
Hospital Revenue Code	270
Min. Negotiated Rate	$1,469.95
Max. Negotiated Rate	$8,352.00
Rate for Payer: Aetna of AZ Commercial	$8,352.00
Rate for Payer: Arizona Complete Health Allwell	$1,484.80
Rate for Payer: Banner UC Health Medicare	$1,484.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$6,310.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,484.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,484.80
Rate for Payer: Cash Price	$7,424.00
Rate for Payer: Cigna of AZ Commercial	$6,496.00
Rate for Payer: Devoted Health Medicare	$1,670.40
Rate for Payer: Humana of AZ Medicare	$1,484.80
Rate for Payer: Southwest Service Administrators UFCW	$6,310.40
Rate for Payer: TriWest Medicare	$1,484.80
Rate for Payer: United Healthcare Commercial	$5,308.16
Rate for Payer: United Healthcare Medicare	$1,484.80
Rate for Payer: Veterans Affairs TRICARE	$1,469.95

PURAPLY MZ 500MG

Facility

$9,280.00

Hospital Charge Code	27570616
Hospital Revenue Code	270
Min. Negotiated Rate	$8,352.00
Max. Negotiated Rate	$8,352.00
Rate for Payer: Aetna of AZ Commercial	$8,352.00
Rate for Payer: Cash Price	$7,424.00

PuraPly XT

Facility

$15,509.00

Service Code	HCPCS Q4197
Hospital Charge Code	24363414
Hospital Revenue Code	636
Min. Negotiated Rate	$13,958.10
Max. Negotiated Rate	$13,958.10
Rate for Payer: Aetna of AZ Commercial	$13,958.10
Rate for Payer: Cash Price	$12,407.20

PuraPly XT

Facility

$15,509.00

Service Code	HCPCS Q4197
Hospital Charge Code	24363414
Hospital Revenue Code	636
Min. Negotiated Rate	$192.55
Max. Negotiated Rate	$13,958.10
Rate for Payer: Aetna of AZ Commercial	$13,958.10
Rate for Payer: Arizona Complete Health Allwell	$2,481.44
Rate for Payer: Banner UC Health Medicare	$2,481.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$10,546.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2,481.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$2,481.44
Rate for Payer: Cash Price	$12,407.20
Rate for Payer: Cash Price	$12,407.20
Rate for Payer: Cigna of AZ Commercial	$10,856.30
Rate for Payer: Devoted Health Medicare	$2,791.62
Rate for Payer: Humana of AZ Medicare	$2,481.44
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$10,546.12
Rate for Payer: TriWest Medicare	$2,481.44
Rate for Payer: United Healthcare Commercial	$8,871.15
Rate for Payer: United Healthcare Medicare	$2,481.44
Rate for Payer: United Healthcare New Mexico Commercial	$2,946.71
Rate for Payer: Veterans Affairs TRICARE	$2,456.63

Know your out-of-pocket cost for care.

All Charges