Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

SSA Urine

Facility

$55.00

Service Code	CPT 81099
Hospital Charge Code	1657596
Hospital Revenue Code	300
Min. Negotiated Rate	$8.71
Max. Negotiated Rate	$49.50
Rate for Payer: Aetna of AZ Commercial	$49.50
Rate for Payer: Arizona Complete Health Allwell	$8.80
Rate for Payer: Banner UC Health Medicare	$8.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$37.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.80
Rate for Payer: Cash Price	$44.00
Rate for Payer: Cigna of AZ Commercial	$35.75
Rate for Payer: Devoted Health Medicare	$9.90
Rate for Payer: Humana of AZ Medicare	$8.80
Rate for Payer: Southwest Service Administrators UFCW	$37.40
Rate for Payer: TriWest Medicare	$8.80
Rate for Payer: United Healthcare Commercial	$31.46
Rate for Payer: United Healthcare Medicare	$8.80
Rate for Payer: Veterans Affairs TRICARE	$8.71

STAPLER 35W

Facility

$109.00

Hospital Charge Code	22355362
Hospital Revenue Code	270
Min. Negotiated Rate	$98.10
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Cash Price	$87.20

STAPLER 35W

Facility

$109.00

Hospital Charge Code	22355362
Hospital Revenue Code	270
Min. Negotiated Rate	$17.27
Max. Negotiated Rate	$98.10
Rate for Payer: Aetna of AZ Commercial	$98.10
Rate for Payer: Arizona Complete Health Allwell	$17.44
Rate for Payer: Banner UC Health Medicare	$17.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$74.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.44
Rate for Payer: Cash Price	$87.20
Rate for Payer: Cigna of AZ Commercial	$76.30
Rate for Payer: Devoted Health Medicare	$19.62
Rate for Payer: Humana of AZ Medicare	$17.44
Rate for Payer: Southwest Service Administrators UFCW	$74.12
Rate for Payer: TriWest Medicare	$17.44
Rate for Payer: United Healthcare Commercial	$62.35
Rate for Payer: United Healthcare Medicare	$17.44
Rate for Payer: Veterans Affairs TRICARE	$17.27

STAPLER ENDOSHEARS 5MM STRL

Facility

$1,478.00

Hospital Charge Code	22354872
Hospital Revenue Code	270
Min. Negotiated Rate	$234.12
Max. Negotiated Rate	$1,330.20
Rate for Payer: Aetna of AZ Commercial	$1,330.20
Rate for Payer: Arizona Complete Health Allwell	$236.48
Rate for Payer: Banner UC Health Medicare	$236.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,005.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$236.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$236.48
Rate for Payer: Cash Price	$1,182.40
Rate for Payer: Cigna of AZ Commercial	$1,034.60
Rate for Payer: Devoted Health Medicare	$266.04
Rate for Payer: Humana of AZ Medicare	$236.48
Rate for Payer: Southwest Service Administrators UFCW	$1,005.04
Rate for Payer: TriWest Medicare	$236.48
Rate for Payer: United Healthcare Commercial	$845.42
Rate for Payer: United Healthcare Medicare	$236.48
Rate for Payer: Veterans Affairs TRICARE	$234.12

STAPLER ENDOSHEARS 5MM STRL

Facility

$1,478.00

Hospital Charge Code	22354872
Hospital Revenue Code	270
Min. Negotiated Rate	$1,330.20
Max. Negotiated Rate	$1,330.20
Rate for Payer: Aetna of AZ Commercial	$1,330.20
Rate for Payer: Cash Price	$1,182.40

STAPLER PREM 35 MF

Facility

$719.00

Hospital Charge Code	22354871
Hospital Revenue Code	270
Min. Negotiated Rate	$647.10
Max. Negotiated Rate	$647.10
Rate for Payer: Aetna of AZ Commercial	$647.10
Rate for Payer: Cash Price	$575.20

STAPLER PREM 35 MF

Facility

$719.00

Hospital Charge Code	22354871
Hospital Revenue Code	270
Min. Negotiated Rate	$113.89
Max. Negotiated Rate	$647.10
Rate for Payer: Aetna of AZ Commercial	$647.10
Rate for Payer: Arizona Complete Health Allwell	$115.04
Rate for Payer: Banner UC Health Medicare	$115.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$488.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$115.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$115.04
Rate for Payer: Cash Price	$575.20
Rate for Payer: Cigna of AZ Commercial	$503.30
Rate for Payer: Devoted Health Medicare	$129.42
Rate for Payer: Humana of AZ Medicare	$115.04
Rate for Payer: Southwest Service Administrators UFCW	$488.92
Rate for Payer: TriWest Medicare	$115.04
Rate for Payer: United Healthcare Commercial	$411.27
Rate for Payer: United Healthcare Medicare	$115.04
Rate for Payer: Veterans Affairs TRICARE	$113.89

STAPLER SKIN PXW35

Facility

$44.00

Hospital Charge Code	22354873
Hospital Revenue Code	270
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$39.60
Rate for Payer: Aetna of AZ Commercial	$39.60
Rate for Payer: Arizona Complete Health Allwell	$7.04
Rate for Payer: Banner UC Health Medicare	$7.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$29.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.04
Rate for Payer: Cash Price	$35.20
Rate for Payer: Cigna of AZ Commercial	$30.80
Rate for Payer: Devoted Health Medicare	$7.92
Rate for Payer: Humana of AZ Medicare	$7.04
Rate for Payer: Southwest Service Administrators UFCW	$29.92
Rate for Payer: TriWest Medicare	$7.04
Rate for Payer: United Healthcare Commercial	$25.17
Rate for Payer: United Healthcare Medicare	$7.04
Rate for Payer: Veterans Affairs TRICARE	$6.97

STAPLER SKIN PXW35

Facility

$44.00

Hospital Charge Code	22354873
Hospital Revenue Code	270
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$39.60
Rate for Payer: Aetna of AZ Commercial	$39.60
Rate for Payer: Cash Price	$35.20

STATLOCK PICC PLUS STABILIZATION DEVICE

Facility

$21.00

Hospital Charge Code	24093278
Hospital Revenue Code	270
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Arizona Complete Health Allwell	$3.36
Rate for Payer: Banner UC Health Medicare	$3.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$14.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.36
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna of AZ Commercial	$14.70
Rate for Payer: Devoted Health Medicare	$3.78
Rate for Payer: Humana of AZ Medicare	$3.36
Rate for Payer: Southwest Service Administrators UFCW	$14.28
Rate for Payer: TriWest Medicare	$3.36
Rate for Payer: United Healthcare Commercial	$12.01
Rate for Payer: United Healthcare Medicare	$3.36
Rate for Payer: Veterans Affairs TRICARE	$3.33

STATLOCK PICC PLUS STABILIZATION DEVICE

Facility

$21.00

Hospital Charge Code	24093278
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Cash Price	$16.80

STATSEAL ADVANCED POWDER

Facility

$258.18

Hospital Charge Code	23780374
Hospital Revenue Code	270
Min. Negotiated Rate	$232.36
Max. Negotiated Rate	$232.36
Rate for Payer: Aetna of AZ Commercial	$232.36
Rate for Payer: Cash Price	$206.54

STATSEAL ADVANCED POWDER

Facility

$258.18

Hospital Charge Code	23780374
Hospital Revenue Code	270
Min. Negotiated Rate	$40.90
Max. Negotiated Rate	$232.36
Rate for Payer: Aetna of AZ Commercial	$232.36
Rate for Payer: Arizona Complete Health Allwell	$41.31
Rate for Payer: Banner UC Health Medicare	$41.31
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$175.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$41.31
Rate for Payer: Care1st Health Plan Arizona Medicare	$41.31
Rate for Payer: Cash Price	$206.54
Rate for Payer: Cigna of AZ Commercial	$180.73
Rate for Payer: Devoted Health Medicare	$46.47
Rate for Payer: Humana of AZ Medicare	$41.31
Rate for Payer: Southwest Service Administrators UFCW	$175.56
Rate for Payer: TriWest Medicare	$41.31
Rate for Payer: United Healthcare Commercial	$147.68
Rate for Payer: United Healthcare Medicare	$41.31
Rate for Payer: Veterans Affairs TRICARE	$40.90

STENT FILIFORM DOUBLE PIGTAIL 6.0FR/24CM

Facility

$543.00

Hospital Charge Code	22354214
Hospital Revenue Code	270
Min. Negotiated Rate	$86.01
Max. Negotiated Rate	$488.70
Rate for Payer: Aetna of AZ Commercial	$488.70
Rate for Payer: Arizona Complete Health Allwell	$86.88
Rate for Payer: Banner UC Health Medicare	$86.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$369.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$86.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$86.88
Rate for Payer: Cash Price	$434.40
Rate for Payer: Cigna of AZ Commercial	$380.10
Rate for Payer: Devoted Health Medicare	$97.74
Rate for Payer: Humana of AZ Medicare	$86.88
Rate for Payer: Southwest Service Administrators UFCW	$369.24
Rate for Payer: TriWest Medicare	$86.88
Rate for Payer: United Healthcare Commercial	$310.60
Rate for Payer: United Healthcare Medicare	$86.88
Rate for Payer: Veterans Affairs TRICARE	$86.01

STENT FILIFORM DOUBLE PIGTAIL 6.0FR/24CM

Facility

$543.00

Hospital Charge Code	22354214
Hospital Revenue Code	270
Min. Negotiated Rate	$488.70
Max. Negotiated Rate	$488.70
Rate for Payer: Aetna of AZ Commercial	$488.70
Rate for Payer: Cash Price	$434.40

STENT FILIFORM DOUBLE PIGTAIL 6.0FR/26CM

Facility

$479.00

Hospital Charge Code	22354215
Hospital Revenue Code	270
Min. Negotiated Rate	$75.87
Max. Negotiated Rate	$431.10
Rate for Payer: Aetna of AZ Commercial	$431.10
Rate for Payer: Arizona Complete Health Allwell	$76.64
Rate for Payer: Banner UC Health Medicare	$76.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$325.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$76.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$76.64
Rate for Payer: Cash Price	$383.20
Rate for Payer: Cigna of AZ Commercial	$335.30
Rate for Payer: Devoted Health Medicare	$86.22
Rate for Payer: Humana of AZ Medicare	$76.64
Rate for Payer: Southwest Service Administrators UFCW	$325.72
Rate for Payer: TriWest Medicare	$76.64
Rate for Payer: United Healthcare Commercial	$273.99
Rate for Payer: United Healthcare Medicare	$76.64
Rate for Payer: Veterans Affairs TRICARE	$75.87

STENT FILIFORM DOUBLE PIGTAIL 6.0FR/26CM

Facility

$479.00

Hospital Charge Code	22354215
Hospital Revenue Code	270
Min. Negotiated Rate	$431.10
Max. Negotiated Rate	$431.10
Rate for Payer: Aetna of AZ Commercial	$431.10
Rate for Payer: Cash Price	$383.20

STENT OPTIMA 24F

Facility

$660.00

Hospital Charge Code	22354159
Hospital Revenue Code	270
Min. Negotiated Rate	$594.00
Max. Negotiated Rate	$594.00
Rate for Payer: Aetna of AZ Commercial	$594.00
Rate for Payer: Cash Price	$528.00

STENT OPTIMA 24F

Facility

$660.00

Hospital Charge Code	22354159
Hospital Revenue Code	270
Min. Negotiated Rate	$104.54
Max. Negotiated Rate	$594.00
Rate for Payer: Aetna of AZ Commercial	$594.00
Rate for Payer: Arizona Complete Health Allwell	$105.60
Rate for Payer: Banner UC Health Medicare	$105.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$448.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$105.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$105.60
Rate for Payer: Cash Price	$528.00
Rate for Payer: Cigna of AZ Commercial	$462.00
Rate for Payer: Devoted Health Medicare	$118.80
Rate for Payer: Humana of AZ Medicare	$105.60
Rate for Payer: Southwest Service Administrators UFCW	$448.80
Rate for Payer: TriWest Medicare	$105.60
Rate for Payer: United Healthcare Commercial	$377.52
Rate for Payer: United Healthcare Medicare	$105.60
Rate for Payer: Veterans Affairs TRICARE	$104.54

STENT OPTIMA 26F

Facility

$660.00

Hospital Charge Code	22354160
Hospital Revenue Code	270
Min. Negotiated Rate	$104.54
Max. Negotiated Rate	$594.00
Rate for Payer: Aetna of AZ Commercial	$594.00
Rate for Payer: Arizona Complete Health Allwell	$105.60
Rate for Payer: Banner UC Health Medicare	$105.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$448.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$105.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$105.60
Rate for Payer: Cash Price	$528.00
Rate for Payer: Cigna of AZ Commercial	$462.00
Rate for Payer: Devoted Health Medicare	$118.80
Rate for Payer: Humana of AZ Medicare	$105.60
Rate for Payer: Southwest Service Administrators UFCW	$448.80
Rate for Payer: TriWest Medicare	$105.60
Rate for Payer: United Healthcare Commercial	$377.52
Rate for Payer: United Healthcare Medicare	$105.60
Rate for Payer: Veterans Affairs TRICARE	$104.54

STENT OPTIMA 26F

Facility

$660.00

Hospital Charge Code	22354160
Hospital Revenue Code	270
Min. Negotiated Rate	$594.00
Max. Negotiated Rate	$594.00
Rate for Payer: Aetna of AZ Commercial	$594.00
Rate for Payer: Cash Price	$528.00

STENT SOFT URETERAL 24F UNIVERSA COOK

Facility

$478.00

Hospital Charge Code	22354230
Hospital Revenue Code	270
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Cash Price	$382.40

STENT SOFT URETERAL 24F UNIVERSA COOK

Facility

$478.00

Hospital Charge Code	22354230
Hospital Revenue Code	270
Min. Negotiated Rate	$75.72
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Arizona Complete Health Allwell	$76.48
Rate for Payer: Banner UC Health Medicare	$76.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$325.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$76.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$76.48
Rate for Payer: Cash Price	$382.40
Rate for Payer: Cigna of AZ Commercial	$334.60
Rate for Payer: Devoted Health Medicare	$86.04
Rate for Payer: Humana of AZ Medicare	$76.48
Rate for Payer: Southwest Service Administrators UFCW	$325.04
Rate for Payer: TriWest Medicare	$76.48
Rate for Payer: United Healthcare Commercial	$273.42
Rate for Payer: United Healthcare Medicare	$76.48
Rate for Payer: Veterans Affairs TRICARE	$75.72

STENT SOFT URETERAL 26F UNIVERSA COOK

Facility

$478.00

Hospital Charge Code	22354231
Hospital Revenue Code	270
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Cash Price	$382.40

STENT SOFT URETERAL 26F UNIVERSA COOK

Facility

$478.00

Hospital Charge Code	22354231
Hospital Revenue Code	270
Min. Negotiated Rate	$75.72
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Arizona Complete Health Allwell	$76.48
Rate for Payer: Banner UC Health Medicare	$76.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$325.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$76.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$76.48
Rate for Payer: Cash Price	$382.40
Rate for Payer: Cigna of AZ Commercial	$334.60
Rate for Payer: Devoted Health Medicare	$86.04
Rate for Payer: Humana of AZ Medicare	$76.48
Rate for Payer: Southwest Service Administrators UFCW	$325.04
Rate for Payer: TriWest Medicare	$76.48
Rate for Payer: United Healthcare Commercial	$273.42
Rate for Payer: United Healthcare Medicare	$76.48
Rate for Payer: Veterans Affairs TRICARE	$75.72

Know your out-of-pocket cost for care.

All Charges