Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

SPLINT COLLES SMALL LEFT HAND

Facility

$26.00

Hospital Charge Code	22354293
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

SPLINT COLLES SMALL RIGHT HAND

Facility

$26.00

Hospital Charge Code	22354297
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

SPLINT COLLES SMALL RIGHT HAND

Facility

$26.00

Hospital Charge Code	22354297
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

SPLINT COLLES X-SMALL LEFT HAND

Facility

$58.00

Hospital Charge Code	22354292
Hospital Revenue Code	270
Min. Negotiated Rate	$52.20
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of AZ Commercial	$52.20
Rate for Payer: Cash Price	$46.40

SPLINT COLLES X-SMALL LEFT HAND

Facility

$58.00

Hospital Charge Code	22354292
Hospital Revenue Code	270
Min. Negotiated Rate	$9.19
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of AZ Commercial	$52.20
Rate for Payer: Arizona Complete Health Allwell	$9.28
Rate for Payer: Banner UC Health Medicare	$9.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$39.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.28
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cigna of AZ Commercial	$40.60
Rate for Payer: Devoted Health Medicare	$10.44
Rate for Payer: Humana of AZ Medicare	$9.28
Rate for Payer: Southwest Service Administrators UFCW	$39.44
Rate for Payer: TriWest Medicare	$9.28
Rate for Payer: United Healthcare Commercial	$33.18
Rate for Payer: United Healthcare Medicare	$9.28
Rate for Payer: Veterans Affairs TRICARE	$9.19

SPLINT COLLES X-SMALL RIGHT HAND

Facility

$58.00

Hospital Charge Code	22354296
Hospital Revenue Code	270
Min. Negotiated Rate	$9.19
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of AZ Commercial	$52.20
Rate for Payer: Arizona Complete Health Allwell	$9.28
Rate for Payer: Banner UC Health Medicare	$9.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$39.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.28
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cigna of AZ Commercial	$40.60
Rate for Payer: Devoted Health Medicare	$10.44
Rate for Payer: Humana of AZ Medicare	$9.28
Rate for Payer: Southwest Service Administrators UFCW	$39.44
Rate for Payer: TriWest Medicare	$9.28
Rate for Payer: United Healthcare Commercial	$33.18
Rate for Payer: United Healthcare Medicare	$9.28
Rate for Payer: Veterans Affairs TRICARE	$9.19

SPLINT COLLES X-SMALL RIGHT HAND

Facility

$58.00

Hospital Charge Code	22354296
Hospital Revenue Code	270
Min. Negotiated Rate	$52.20
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of AZ Commercial	$52.20
Rate for Payer: Cash Price	$46.40

SPLINT LEG LARGE

Facility

$102.00

Hospital Charge Code	22354301
Hospital Revenue Code	270
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$91.80
Rate for Payer: Aetna of AZ Commercial	$91.80
Rate for Payer: Cash Price	$81.60

SPLINT LEG LARGE

Facility

$102.00

Hospital Charge Code	22354301
Hospital Revenue Code	270
Min. Negotiated Rate	$16.16
Max. Negotiated Rate	$91.80
Rate for Payer: Aetna of AZ Commercial	$91.80
Rate for Payer: Arizona Complete Health Allwell	$16.32
Rate for Payer: Banner UC Health Medicare	$16.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$69.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.32
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cigna of AZ Commercial	$71.40
Rate for Payer: Devoted Health Medicare	$18.36
Rate for Payer: Humana of AZ Medicare	$16.32
Rate for Payer: Southwest Service Administrators UFCW	$69.36
Rate for Payer: TriWest Medicare	$16.32
Rate for Payer: United Healthcare Commercial	$58.34
Rate for Payer: United Healthcare Medicare	$16.32
Rate for Payer: Veterans Affairs TRICARE	$16.16

SPLINT LEG MEDIUM

Facility

$102.00

Hospital Charge Code	22354300
Hospital Revenue Code	270
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$91.80
Rate for Payer: Aetna of AZ Commercial	$91.80
Rate for Payer: Cash Price	$81.60

SPLINT LEG MEDIUM

Facility

$102.00

Hospital Charge Code	22354300
Hospital Revenue Code	270
Min. Negotiated Rate	$16.16
Max. Negotiated Rate	$91.80
Rate for Payer: Aetna of AZ Commercial	$91.80
Rate for Payer: Arizona Complete Health Allwell	$16.32
Rate for Payer: Banner UC Health Medicare	$16.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$69.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.32
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cigna of AZ Commercial	$71.40
Rate for Payer: Devoted Health Medicare	$18.36
Rate for Payer: Humana of AZ Medicare	$16.32
Rate for Payer: Southwest Service Administrators UFCW	$69.36
Rate for Payer: TriWest Medicare	$16.32
Rate for Payer: United Healthcare Commercial	$58.34
Rate for Payer: United Healthcare Medicare	$16.32
Rate for Payer: Veterans Affairs TRICARE	$16.16

SPLINT LEG SMALL

Facility

$102.00

Hospital Charge Code	22354299
Hospital Revenue Code	270
Min. Negotiated Rate	$91.80
Max. Negotiated Rate	$91.80
Rate for Payer: Aetna of AZ Commercial	$91.80
Rate for Payer: Cash Price	$81.60

SPLINT LEG SMALL

Facility

$102.00

Hospital Charge Code	22354299
Hospital Revenue Code	270
Min. Negotiated Rate	$16.16
Max. Negotiated Rate	$91.80
Rate for Payer: Aetna of AZ Commercial	$91.80
Rate for Payer: Arizona Complete Health Allwell	$16.32
Rate for Payer: Banner UC Health Medicare	$16.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$69.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.32
Rate for Payer: Cash Price	$81.60
Rate for Payer: Cigna of AZ Commercial	$71.40
Rate for Payer: Devoted Health Medicare	$18.36
Rate for Payer: Humana of AZ Medicare	$16.32
Rate for Payer: Southwest Service Administrators UFCW	$69.36
Rate for Payer: TriWest Medicare	$16.32
Rate for Payer: United Healthcare Commercial	$58.34
Rate for Payer: United Healthcare Medicare	$16.32
Rate for Payer: Veterans Affairs TRICARE	$16.16

Splint Roll 2'' Ortho Glass Per Inch

Facility

$134.00

Service Code	HCPCS A4590
Hospital Charge Code	1459522
Hospital Revenue Code	521
Min. Negotiated Rate	$21.23
Max. Negotiated Rate	$120.60
Rate for Payer: Aetna of AZ Commercial	$120.60
Rate for Payer: Arizona Complete Health Allwell	$21.44
Rate for Payer: Banner UC Health Medicare	$21.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$91.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$21.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$21.44
Rate for Payer: Cash Price	$107.20
Rate for Payer: Cigna of AZ Commercial	$93.80
Rate for Payer: Devoted Health Medicare	$24.12
Rate for Payer: Humana of AZ Medicare	$21.44
Rate for Payer: Southwest Service Administrators UFCW	$91.12
Rate for Payer: TriWest Medicare	$21.44
Rate for Payer: United Healthcare Commercial	$76.65
Rate for Payer: United Healthcare Medicare	$21.44
Rate for Payer: Veterans Affairs TRICARE	$21.23

Splint Roll 2'' Ortho Glass Per Inch

Facility

$134.00

Service Code	HCPCS A4590
Hospital Charge Code	1459522
Hospital Revenue Code	521
Min. Negotiated Rate	$120.60
Max. Negotiated Rate	$120.60
Rate for Payer: Aetna of AZ Commercial	$120.60
Rate for Payer: Cash Price	$107.20

SPLINT WRIST/FA LG LEFT HAND

Facility

$93.00

Hospital Charge Code	22354270
Hospital Revenue Code	270
Min. Negotiated Rate	$14.73
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Arizona Complete Health Allwell	$14.88
Rate for Payer: Banner UC Health Medicare	$14.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$63.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.88
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cigna of AZ Commercial	$65.10
Rate for Payer: Devoted Health Medicare	$16.74
Rate for Payer: Humana of AZ Medicare	$14.88
Rate for Payer: Southwest Service Administrators UFCW	$63.24
Rate for Payer: TriWest Medicare	$14.88
Rate for Payer: United Healthcare Commercial	$53.20
Rate for Payer: United Healthcare Medicare	$14.88
Rate for Payer: Veterans Affairs TRICARE	$14.73

SPLINT WRIST/FA LG LEFT HAND

Facility

$93.00

Hospital Charge Code	22354270
Hospital Revenue Code	270
Min. Negotiated Rate	$83.70
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Cash Price	$74.40

SPLINT WRIST/FA LG RIGHT HAND

Facility

$93.00

Hospital Charge Code	22354269
Hospital Revenue Code	270
Min. Negotiated Rate	$14.73
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Arizona Complete Health Allwell	$14.88
Rate for Payer: Banner UC Health Medicare	$14.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$63.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.88
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cigna of AZ Commercial	$65.10
Rate for Payer: Devoted Health Medicare	$16.74
Rate for Payer: Humana of AZ Medicare	$14.88
Rate for Payer: Southwest Service Administrators UFCW	$63.24
Rate for Payer: TriWest Medicare	$14.88
Rate for Payer: United Healthcare Commercial	$53.20
Rate for Payer: United Healthcare Medicare	$14.88
Rate for Payer: Veterans Affairs TRICARE	$14.73

SPLINT WRIST/FA LG RIGHT HAND

Facility

$93.00

Hospital Charge Code	22354269
Hospital Revenue Code	270
Min. Negotiated Rate	$83.70
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Cash Price	$74.40

SPLINT WRIST/FA MED LEFT HAND

Facility

$116.00

Hospital Charge Code	22354248
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

SPLINT WRIST/FA MED LEFT HAND

Facility

$116.00

Hospital Charge Code	22354248
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

SPLINT WRIST/FA MED RIGHT HAND

Facility

$116.00

Hospital Charge Code	22354249
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

SPLINT WRIST/FA MED RIGHT HAND

Facility

$116.00

Hospital Charge Code	22354249
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

SPLINT WRIST/FA SM LEFT HAND

Facility

$116.00

Hospital Charge Code	22354266
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

SPLINT WRIST/FA SM LEFT HAND

Facility

$116.00

Hospital Charge Code	22354266
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

Know your out-of-pocket cost for care.

All Charges