Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

PUREWICK FEMALE EXTERNAL CATHETER

Facility

$50.26

Hospital Charge Code	27437084
Hospital Revenue Code	270
Min. Negotiated Rate	$7.96
Max. Negotiated Rate	$45.23
Rate for Payer: Aetna of AZ Commercial	$45.23
Rate for Payer: Arizona Complete Health Allwell	$8.04
Rate for Payer: Banner UC Health Medicare	$8.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$34.18
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.04
Rate for Payer: Cash Price	$40.21
Rate for Payer: Cigna of AZ Commercial	$35.18
Rate for Payer: Devoted Health Medicare	$9.05
Rate for Payer: Humana of AZ Medicare	$8.04
Rate for Payer: Southwest Service Administrators UFCW	$34.18
Rate for Payer: TriWest Medicare	$8.04
Rate for Payer: United Healthcare Commercial	$28.75
Rate for Payer: United Healthcare Medicare	$8.04
Rate for Payer: Veterans Affairs TRICARE	$7.96

PUREWICK FEMALE EXTERNAL CATHETER

Facility

$50.26

Hospital Charge Code	27437084
Hospital Revenue Code	270
Min. Negotiated Rate	$45.23
Max. Negotiated Rate	$45.23
Rate for Payer: Aetna of AZ Commercial	$45.23
Rate for Payer: Cash Price	$40.21

PVC SUCTION TUBING

Facility

$128.46

Hospital Charge Code	27839758
Hospital Revenue Code	270
Min. Negotiated Rate	$115.61
Max. Negotiated Rate	$115.61
Rate for Payer: Aetna of AZ Commercial	$115.61
Rate for Payer: Cash Price	$102.77

PVC SUCTION TUBING

Facility

$128.46

Hospital Charge Code	27839758
Hospital Revenue Code	270
Min. Negotiated Rate	$20.35
Max. Negotiated Rate	$115.61
Rate for Payer: Aetna of AZ Commercial	$115.61
Rate for Payer: Arizona Complete Health Allwell	$20.55
Rate for Payer: Banner UC Health Medicare	$20.55
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$87.35
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$20.55
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.55
Rate for Payer: Cash Price	$102.77
Rate for Payer: Cigna of AZ Commercial	$89.92
Rate for Payer: Devoted Health Medicare	$23.12
Rate for Payer: Humana of AZ Medicare	$20.55
Rate for Payer: Southwest Service Administrators UFCW	$87.35
Rate for Payer: TriWest Medicare	$20.55
Rate for Payer: United Healthcare Commercial	$73.48
Rate for Payer: United Healthcare Medicare	$20.55
Rate for Payer: Veterans Affairs TRICARE	$20.35

Q0091 Medicare Pap Collection Clinic Charge

Facility

$199.00

Service Code	HCPCS Q0091
Hospital Charge Code	10411045
Hospital Revenue Code	521
Min. Negotiated Rate	$179.10
Max. Negotiated Rate	$179.10
Rate for Payer: Aetna of AZ Commercial	$179.10
Rate for Payer: Cash Price	$159.20

Q0091 Medicare Pap Collection Clinic Charge

Facility

$199.00

Service Code	HCPCS Q0091
Hospital Charge Code	10411045
Hospital Revenue Code	521
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$179.10
Rate for Payer: Aetna of AZ Commercial	$179.10
Rate for Payer: Arizona Complete Health Allwell	$31.84
Rate for Payer: Banner UC Health Medicare	$31.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$135.32
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$27.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$31.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.84
Rate for Payer: Cash Price	$159.20
Rate for Payer: Cash Price	$159.20
Rate for Payer: Cigna of AZ Commercial	$139.30
Rate for Payer: Devoted Health Medicare	$35.82
Rate for Payer: Humana of AZ Medicare	$31.84
Rate for Payer: Mercy Care Medicaid	$27.20
Rate for Payer: NaphCare Correctional Healthcare	$27.20
Rate for Payer: Seven Corners Travel Insurance	$44.75
Rate for Payer: Southwest Service Administrators UFCW	$135.32
Rate for Payer: TriWest Medicare	$31.84
Rate for Payer: United Healthcare Commercial	$113.83
Rate for Payer: United Healthcare Medicare	$31.84
Rate for Payer: Veterans Affairs TRICARE	$31.52

Q3014 TELEHEALTH BURN SITE FACILITY FEE

Facility

$65.00

Service Code	HCPCS Q3014
Hospital Charge Code	22282946
Hospital Revenue Code	780
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of AZ Commercial	$58.50
Rate for Payer: Arizona Complete Health Allwell	$10.40
Rate for Payer: Banner UC Health Medicare	$10.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$44.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.40
Rate for Payer: Cash Price	$52.00
Rate for Payer: Cigna of AZ Commercial	$45.50
Rate for Payer: Devoted Health Medicare	$11.70
Rate for Payer: Humana of AZ Medicare	$10.40
Rate for Payer: Southwest Service Administrators UFCW	$44.20
Rate for Payer: TriWest Medicare	$10.40
Rate for Payer: United Healthcare Commercial	$37.18
Rate for Payer: United Healthcare Medicare	$10.40
Rate for Payer: United Healthcare New Mexico Commercial	$12.35
Rate for Payer: Veterans Affairs TRICARE	$10.30

Q3014 TELEHEALTH BURN SITE FACILITY FEE

Facility

$65.00

Service Code	HCPCS Q3014
Hospital Charge Code	22282946
Hospital Revenue Code	780
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of AZ Commercial	$58.50
Rate for Payer: Cash Price	$52.00

Q3014 TELEHEALTH CARDIO SITE FACILITY FEE

Facility

$65.00

Service Code	HCPCS Q3014
Hospital Charge Code	22282944
Hospital Revenue Code	780
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of AZ Commercial	$58.50
Rate for Payer: Cash Price	$52.00

Q3014 TELEHEALTH CARDIO SITE FACILITY FEE

Facility

$65.00

Service Code	HCPCS Q3014
Hospital Charge Code	22282944
Hospital Revenue Code	780
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of AZ Commercial	$58.50
Rate for Payer: Arizona Complete Health Allwell	$10.40
Rate for Payer: Banner UC Health Medicare	$10.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$44.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.40
Rate for Payer: Cash Price	$52.00
Rate for Payer: Cigna of AZ Commercial	$45.50
Rate for Payer: Devoted Health Medicare	$11.70
Rate for Payer: Humana of AZ Medicare	$10.40
Rate for Payer: Southwest Service Administrators UFCW	$44.20
Rate for Payer: TriWest Medicare	$10.40
Rate for Payer: United Healthcare Commercial	$37.18
Rate for Payer: United Healthcare Medicare	$10.40
Rate for Payer: United Healthcare New Mexico Commercial	$12.35
Rate for Payer: Veterans Affairs TRICARE	$10.30

Q3014 TELEHEALTH NEURO SITE FACILITY FEE

Facility

$65.00

Service Code	HCPCS Q3014
Hospital Charge Code	22282943
Hospital Revenue Code	780
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of AZ Commercial	$58.50
Rate for Payer: Cash Price	$52.00

Q3014 TELEHEALTH NEURO SITE FACILITY FEE

Facility

$65.00

Service Code	HCPCS Q3014
Hospital Charge Code	22282943
Hospital Revenue Code	780
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of AZ Commercial	$58.50
Rate for Payer: Arizona Complete Health Allwell	$10.40
Rate for Payer: Banner UC Health Medicare	$10.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$44.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.40
Rate for Payer: Cash Price	$52.00
Rate for Payer: Cigna of AZ Commercial	$45.50
Rate for Payer: Devoted Health Medicare	$11.70
Rate for Payer: Humana of AZ Medicare	$10.40
Rate for Payer: Southwest Service Administrators UFCW	$44.20
Rate for Payer: TriWest Medicare	$10.40
Rate for Payer: United Healthcare Commercial	$37.18
Rate for Payer: United Healthcare Medicare	$10.40
Rate for Payer: United Healthcare New Mexico Commercial	$12.35
Rate for Payer: Veterans Affairs TRICARE	$10.30

Q3014 TELEHEALTH PEDIATRICS SITE FACILITY FEE

Facility

$65.00

Service Code	HCPCS Q3014
Hospital Charge Code	22282947
Hospital Revenue Code	780
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of AZ Commercial	$58.50
Rate for Payer: Arizona Complete Health Allwell	$10.40
Rate for Payer: Banner UC Health Medicare	$10.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$44.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.40
Rate for Payer: Cash Price	$52.00
Rate for Payer: Cigna of AZ Commercial	$45.50
Rate for Payer: Devoted Health Medicare	$11.70
Rate for Payer: Humana of AZ Medicare	$10.40
Rate for Payer: Southwest Service Administrators UFCW	$44.20
Rate for Payer: TriWest Medicare	$10.40
Rate for Payer: United Healthcare Commercial	$37.18
Rate for Payer: United Healthcare Medicare	$10.40
Rate for Payer: United Healthcare New Mexico Commercial	$12.35
Rate for Payer: Veterans Affairs TRICARE	$10.30

Q3014 TELEHEALTH PEDIATRICS SITE FACILITY FEE

Facility

$65.00

Service Code	HCPCS Q3014
Hospital Charge Code	22282947
Hospital Revenue Code	780
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of AZ Commercial	$58.50
Rate for Payer: Cash Price	$52.00

Q3014 TELEHEALTH PULMON SITE FACILITY FEE

Facility

$62.00

Service Code	HCPCS Q3014
Hospital Charge Code	22282945
Hospital Revenue Code	780
Min. Negotiated Rate	$9.82
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Arizona Complete Health Allwell	$9.92
Rate for Payer: Banner UC Health Medicare	$9.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$42.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.92
Rate for Payer: Cash Price	$49.60
Rate for Payer: Cigna of AZ Commercial	$43.40
Rate for Payer: Devoted Health Medicare	$11.16
Rate for Payer: Humana of AZ Medicare	$9.92
Rate for Payer: Southwest Service Administrators UFCW	$42.16
Rate for Payer: TriWest Medicare	$9.92
Rate for Payer: United Healthcare Commercial	$35.46
Rate for Payer: United Healthcare Medicare	$9.92
Rate for Payer: United Healthcare New Mexico Commercial	$11.78
Rate for Payer: Veterans Affairs TRICARE	$9.82

Q3014 TELEHEALTH PULMON SITE FACILITY FEE

Facility

$62.00

Service Code	HCPCS Q3014
Hospital Charge Code	22282945
Hospital Revenue Code	780
Min. Negotiated Rate	$55.80
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Cash Price	$49.60

Q4186 EPIFIX 5CM X 6CM GRAPH

Facility

$367.00

Service Code	HCPCS Q4186
Hospital Charge Code	24076075
Hospital Revenue Code	521
Min. Negotiated Rate	$58.13
Max. Negotiated Rate	$330.30
Rate for Payer: Aetna of AZ Commercial	$330.30
Rate for Payer: Arizona Complete Health Allwell	$58.72
Rate for Payer: Banner UC Health Medicare	$58.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$249.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$58.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$58.72
Rate for Payer: Cash Price	$293.60
Rate for Payer: Cash Price	$293.60
Rate for Payer: Cigna of AZ Commercial	$256.90
Rate for Payer: Devoted Health Medicare	$66.06
Rate for Payer: Humana of AZ Medicare	$58.72
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$249.56
Rate for Payer: TriWest Medicare	$58.72
Rate for Payer: United Healthcare Commercial	$209.92
Rate for Payer: United Healthcare Medicare	$58.72
Rate for Payer: Veterans Affairs TRICARE	$58.13

Q4186 EPIFIX 5CM X 6CM GRAPH

Facility

$367.00

Service Code	HCPCS Q4186
Hospital Charge Code	24076075
Hospital Revenue Code	521
Min. Negotiated Rate	$330.30
Max. Negotiated Rate	$330.30
Rate for Payer: Aetna of AZ Commercial	$330.30
Rate for Payer: Cash Price	$293.60

Q4187 EPICORD 3X5CM UMBILICAL ALLOGRAFT

Facility

$367.00

Service Code	HCPCS Q4187
Hospital Charge Code	24076076
Hospital Revenue Code	521
Min. Negotiated Rate	$58.13
Max. Negotiated Rate	$330.30
Rate for Payer: Aetna of AZ Commercial	$330.30
Rate for Payer: Arizona Complete Health Allwell	$58.72
Rate for Payer: Banner UC Health Medicare	$58.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$249.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$58.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$58.72
Rate for Payer: Cash Price	$293.60
Rate for Payer: Cash Price	$293.60
Rate for Payer: Cigna of AZ Commercial	$256.90
Rate for Payer: Devoted Health Medicare	$66.06
Rate for Payer: Humana of AZ Medicare	$58.72
Rate for Payer: Seven Corners Travel Insurance	$192.55
Rate for Payer: Southwest Service Administrators UFCW	$249.56
Rate for Payer: TriWest Medicare	$58.72
Rate for Payer: United Healthcare Commercial	$209.92
Rate for Payer: United Healthcare Medicare	$58.72
Rate for Payer: Veterans Affairs TRICARE	$58.13

Q4187 EPICORD 3X5CM UMBILICAL ALLOGRAFT

Facility

$367.00

Service Code	HCPCS Q4187
Hospital Charge Code	24076076
Hospital Revenue Code	521
Min. Negotiated Rate	$330.30
Max. Negotiated Rate	$330.30
Rate for Payer: Aetna of AZ Commercial	$330.30
Rate for Payer: Cash Price	$293.60

Q LOOP MEDIUM BIPOLAR LOOP

Facility

$1,775.00

Hospital Charge Code	27881561
Hospital Revenue Code	270
Min. Negotiated Rate	$281.16
Max. Negotiated Rate	$1,597.50
Rate for Payer: Aetna of AZ Commercial	$1,597.50
Rate for Payer: Arizona Complete Health Allwell	$284.00
Rate for Payer: Banner UC Health Medicare	$284.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,207.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$284.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$284.00
Rate for Payer: Cash Price	$1,420.00
Rate for Payer: Cigna of AZ Commercial	$1,242.50
Rate for Payer: Devoted Health Medicare	$319.50
Rate for Payer: Humana of AZ Medicare	$284.00
Rate for Payer: Southwest Service Administrators UFCW	$1,207.00
Rate for Payer: TriWest Medicare	$284.00
Rate for Payer: United Healthcare Commercial	$1,015.30
Rate for Payer: United Healthcare Medicare	$284.00
Rate for Payer: Veterans Affairs TRICARE	$281.16

Q LOOP MEDIUM BIPOLAR LOOP

Facility

$1,775.00

Hospital Charge Code	27881561
Hospital Revenue Code	270
Min. Negotiated Rate	$1,597.50
Max. Negotiated Rate	$1,597.50
Rate for Payer: Aetna of AZ Commercial	$1,597.50
Rate for Payer: Cash Price	$1,420.00

Quadrivalent Preservative Free Influenza Vaccine +3 yrs

Facility

$54.00

Service Code	CPT 90686
Hospital Charge Code	17543380
Hospital Revenue Code	521
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

Quadrivalent Preservative Free Influenza Vaccine +3 yrs

Facility

$54.00

Service Code	CPT 90686
Hospital Charge Code	17543380
Hospital Revenue Code	521
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

Quadrivalent Preservative Free Influenza Vaccine 6-35mos

Facility

$49.00

Service Code	CPT 90685
Hospital Charge Code	17541377
Hospital Revenue Code	636
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$44.10
Rate for Payer: Aetna of AZ Commercial	$44.10
Rate for Payer: Cash Price	$39.20

Know your out-of-pocket cost for care.

All Charges