Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Supplies

Facility

$1,904.00

Hospital Charge Code	22528813
Hospital Revenue Code	270
Min. Negotiated Rate	$1,713.60
Max. Negotiated Rate	$1,713.60
Rate for Payer: Aetna of AZ Commercial	$1,713.60
Rate for Payer: Cash Price	$1,523.20

Supplies

Facility

$1,533.00

Hospital Charge Code	22528807
Hospital Revenue Code	270
Min. Negotiated Rate	$242.83
Max. Negotiated Rate	$1,379.70
Rate for Payer: Aetna of AZ Commercial	$1,379.70
Rate for Payer: Arizona Complete Health Allwell	$245.28
Rate for Payer: Banner UC Health Medicare	$245.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,042.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$245.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$245.28
Rate for Payer: Cash Price	$1,226.40
Rate for Payer: Cigna of AZ Commercial	$1,073.10
Rate for Payer: Devoted Health Medicare	$275.94
Rate for Payer: Humana of AZ Medicare	$245.28
Rate for Payer: Southwest Service Administrators UFCW	$1,042.44
Rate for Payer: TriWest Medicare	$245.28
Rate for Payer: United Healthcare Commercial	$876.88
Rate for Payer: United Healthcare Medicare	$245.28
Rate for Payer: Veterans Affairs TRICARE	$242.83

Supplies

Facility

$1,029.00

Hospital Charge Code	22528829
Hospital Revenue Code	270
Min. Negotiated Rate	$926.10
Max. Negotiated Rate	$926.10
Rate for Payer: Aetna of AZ Commercial	$926.10
Rate for Payer: Cash Price	$823.20

Supplies

Facility

$1,904.00

Hospital Charge Code	22528813
Hospital Revenue Code	270
Min. Negotiated Rate	$301.59
Max. Negotiated Rate	$1,713.60
Rate for Payer: Aetna of AZ Commercial	$1,713.60
Rate for Payer: Arizona Complete Health Allwell	$304.64
Rate for Payer: Banner UC Health Medicare	$304.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,294.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$304.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$304.64
Rate for Payer: Cash Price	$1,523.20
Rate for Payer: Cigna of AZ Commercial	$1,332.80
Rate for Payer: Devoted Health Medicare	$342.72
Rate for Payer: Humana of AZ Medicare	$304.64
Rate for Payer: Southwest Service Administrators UFCW	$1,294.72
Rate for Payer: TriWest Medicare	$304.64
Rate for Payer: United Healthcare Commercial	$1,089.09
Rate for Payer: United Healthcare Medicare	$304.64
Rate for Payer: Veterans Affairs TRICARE	$301.59

Supplies

Facility

$3,066.00

Hospital Charge Code	22528815
Hospital Revenue Code	270
Min. Negotiated Rate	$2,759.40
Max. Negotiated Rate	$2,759.40
Rate for Payer: Aetna of AZ Commercial	$2,759.40
Rate for Payer: Cash Price	$2,452.80

Supplies

Facility

$3,066.00

Hospital Charge Code	22528815
Hospital Revenue Code	270
Min. Negotiated Rate	$485.65
Max. Negotiated Rate	$2,759.40
Rate for Payer: Aetna of AZ Commercial	$2,759.40
Rate for Payer: Arizona Complete Health Allwell	$490.56
Rate for Payer: Banner UC Health Medicare	$490.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,084.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$490.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$490.56
Rate for Payer: Cash Price	$2,452.80
Rate for Payer: Cigna of AZ Commercial	$2,146.20
Rate for Payer: Devoted Health Medicare	$551.88
Rate for Payer: Humana of AZ Medicare	$490.56
Rate for Payer: Southwest Service Administrators UFCW	$2,084.88
Rate for Payer: TriWest Medicare	$490.56
Rate for Payer: United Healthcare Commercial	$1,753.75
Rate for Payer: United Healthcare Medicare	$490.56
Rate for Payer: Veterans Affairs TRICARE	$485.65

Supplies

Facility

$4,891.00

Hospital Charge Code	22528817
Hospital Revenue Code	270
Min. Negotiated Rate	$4,401.90
Max. Negotiated Rate	$4,401.90
Rate for Payer: Aetna of AZ Commercial	$4,401.90
Rate for Payer: Cash Price	$3,912.80

Supplies

Facility

$2,750.00

Hospital Charge Code	22528811
Hospital Revenue Code	270
Min. Negotiated Rate	$2,475.00
Max. Negotiated Rate	$2,475.00
Rate for Payer: Aetna of AZ Commercial	$2,475.00
Rate for Payer: Cash Price	$2,200.00

Supplies

Facility

$1,029.00

Hospital Charge Code	22528829
Hospital Revenue Code	270
Min. Negotiated Rate	$162.99
Max. Negotiated Rate	$926.10
Rate for Payer: Aetna of AZ Commercial	$926.10
Rate for Payer: Arizona Complete Health Allwell	$164.64
Rate for Payer: Banner UC Health Medicare	$164.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$699.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$164.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$164.64
Rate for Payer: Cash Price	$823.20
Rate for Payer: Cigna of AZ Commercial	$720.30
Rate for Payer: Devoted Health Medicare	$185.22
Rate for Payer: Humana of AZ Medicare	$164.64
Rate for Payer: Southwest Service Administrators UFCW	$699.72
Rate for Payer: TriWest Medicare	$164.64
Rate for Payer: United Healthcare Commercial	$588.59
Rate for Payer: United Healthcare Medicare	$164.64
Rate for Payer: Veterans Affairs TRICARE	$162.99

Supplies

Facility

$810.00

Hospital Charge Code	22528825
Hospital Revenue Code	270
Min. Negotiated Rate	$128.30
Max. Negotiated Rate	$729.00
Rate for Payer: Aetna of AZ Commercial	$729.00
Rate for Payer: Arizona Complete Health Allwell	$129.60
Rate for Payer: Banner UC Health Medicare	$129.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$550.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$129.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$129.60
Rate for Payer: Cash Price	$648.00
Rate for Payer: Cigna of AZ Commercial	$567.00
Rate for Payer: Devoted Health Medicare	$145.80
Rate for Payer: Humana of AZ Medicare	$129.60
Rate for Payer: Southwest Service Administrators UFCW	$550.80
Rate for Payer: TriWest Medicare	$129.60
Rate for Payer: United Healthcare Commercial	$463.32
Rate for Payer: United Healthcare Medicare	$129.60
Rate for Payer: Veterans Affairs TRICARE	$128.30

Supplies

Facility

$805.00

Hospital Charge Code	22528827
Hospital Revenue Code	270
Min. Negotiated Rate	$724.50
Max. Negotiated Rate	$724.50
Rate for Payer: Aetna of AZ Commercial	$724.50
Rate for Payer: Cash Price	$644.00

Supplies

Facility

$810.00

Hospital Charge Code	22528821
Hospital Revenue Code	270
Min. Negotiated Rate	$729.00
Max. Negotiated Rate	$729.00
Rate for Payer: Aetna of AZ Commercial	$729.00
Rate for Payer: Cash Price	$648.00

Supplies Materials(List Drugs, Trays, Supplies, or Materials Provided) Charge

Facility

$763.00

Service Code	CPT 99070
Hospital Charge Code	731293
Hospital Revenue Code	521
Min. Negotiated Rate	$686.70
Max. Negotiated Rate	$686.70
Rate for Payer: Aetna of AZ Commercial	$686.70
Rate for Payer: Cash Price	$610.40

Supplies Materials(List Drugs, Trays, Supplies, or Materials Provided) Charge

Facility

$763.00

Service Code	CPT 99070
Hospital Charge Code	731293
Hospital Revenue Code	521
Min. Negotiated Rate	$120.86
Max. Negotiated Rate	$686.70
Rate for Payer: Aetna of AZ Commercial	$686.70
Rate for Payer: Arizona Complete Health Allwell	$122.08
Rate for Payer: Banner UC Health Medicare	$122.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$518.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$122.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$122.08
Rate for Payer: Cash Price	$610.40
Rate for Payer: Cigna of AZ Commercial	$534.10
Rate for Payer: Devoted Health Medicare	$137.34
Rate for Payer: Humana of AZ Medicare	$122.08
Rate for Payer: Southwest Service Administrators UFCW	$518.84
Rate for Payer: TriWest Medicare	$122.08
Rate for Payer: United Healthcare Commercial	$436.44
Rate for Payer: United Healthcare Medicare	$122.08
Rate for Payer: Veterans Affairs TRICARE	$120.86

Supplies SLING DESARA

Facility

$3,297.00

Hospital Charge Code	22528819
Hospital Revenue Code	270
Min. Negotiated Rate	$2,967.30
Max. Negotiated Rate	$2,967.30
Rate for Payer: Aetna of AZ Commercial	$2,967.30
Rate for Payer: Cash Price	$2,637.60

Supplies SLING DESARA

Facility

$3,297.00

Hospital Charge Code	22528819
Hospital Revenue Code	270
Min. Negotiated Rate	$522.24
Max. Negotiated Rate	$2,967.30
Rate for Payer: Aetna of AZ Commercial	$2,967.30
Rate for Payer: Arizona Complete Health Allwell	$527.52
Rate for Payer: Banner UC Health Medicare	$527.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,241.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$527.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$527.52
Rate for Payer: Cash Price	$2,637.60
Rate for Payer: Cigna of AZ Commercial	$2,307.90
Rate for Payer: Devoted Health Medicare	$593.46
Rate for Payer: Humana of AZ Medicare	$527.52
Rate for Payer: Southwest Service Administrators UFCW	$2,241.96
Rate for Payer: TriWest Medicare	$527.52
Rate for Payer: United Healthcare Commercial	$1,885.88
Rate for Payer: United Healthcare Medicare	$527.52
Rate for Payer: Veterans Affairs TRICARE	$522.24

SUPPORTER ADULT LG

Facility

$88.00

Hospital Charge Code	22354192
Hospital Revenue Code	270
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of AZ Commercial	$79.20
Rate for Payer: Arizona Complete Health Allwell	$14.08
Rate for Payer: Banner UC Health Medicare	$14.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$59.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.08
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cigna of AZ Commercial	$61.60
Rate for Payer: Devoted Health Medicare	$15.84
Rate for Payer: Humana of AZ Medicare	$14.08
Rate for Payer: Southwest Service Administrators UFCW	$59.84
Rate for Payer: TriWest Medicare	$14.08
Rate for Payer: United Healthcare Commercial	$50.34
Rate for Payer: United Healthcare Medicare	$14.08
Rate for Payer: Veterans Affairs TRICARE	$13.94

SUPPORTER ADULT LG

Facility

$88.00

Hospital Charge Code	22354192
Hospital Revenue Code	270
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of AZ Commercial	$79.20
Rate for Payer: Cash Price	$70.40

SUPPORTER ADULT MED

Facility

$26.00

Hospital Charge Code	22354191
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

SUPPORTER ADULT MED

Facility

$26.00

Hospital Charge Code	22354191
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

SUPPORTER ADULT SMALL

Facility

$88.00

Hospital Charge Code	22354190
Hospital Revenue Code	270
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of AZ Commercial	$79.20
Rate for Payer: Cash Price	$70.40

SUPPORTER ADULT SMALL

Facility

$88.00

Hospital Charge Code	22354190
Hospital Revenue Code	270
Min. Negotiated Rate	$13.94
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of AZ Commercial	$79.20
Rate for Payer: Arizona Complete Health Allwell	$14.08
Rate for Payer: Banner UC Health Medicare	$14.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$59.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.08
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cigna of AZ Commercial	$61.60
Rate for Payer: Devoted Health Medicare	$15.84
Rate for Payer: Humana of AZ Medicare	$14.08
Rate for Payer: Southwest Service Administrators UFCW	$59.84
Rate for Payer: TriWest Medicare	$14.08
Rate for Payer: United Healthcare Commercial	$50.34
Rate for Payer: United Healthcare Medicare	$14.08
Rate for Payer: Veterans Affairs TRICARE	$13.94

SUPPORTER ADULT XL

Facility

$42.00

Hospital Charge Code	22354193
Hospital Revenue Code	270
Min. Negotiated Rate	$6.65
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Arizona Complete Health Allwell	$6.72
Rate for Payer: Banner UC Health Medicare	$6.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$28.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.72
Rate for Payer: Cash Price	$33.60
Rate for Payer: Cigna of AZ Commercial	$29.40
Rate for Payer: Devoted Health Medicare	$7.56
Rate for Payer: Humana of AZ Medicare	$6.72
Rate for Payer: Southwest Service Administrators UFCW	$28.56
Rate for Payer: TriWest Medicare	$6.72
Rate for Payer: United Healthcare Commercial	$24.02
Rate for Payer: United Healthcare Medicare	$6.72
Rate for Payer: Veterans Affairs TRICARE	$6.65

SUPPORTER ADULT XL

Facility

$42.00

Hospital Charge Code	22354193
Hospital Revenue Code	270
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$37.80
Rate for Payer: Aetna of AZ Commercial	$37.80
Rate for Payer: Cash Price	$33.60

SURECLIP 11MM REPOSITIONABLE

Facility

$718.00

Hospital Charge Code	23152396
Hospital Revenue Code	272
Min. Negotiated Rate	$646.20
Max. Negotiated Rate	$646.20
Rate for Payer: Aetna of AZ Commercial	$646.20
Rate for Payer: Cash Price	$574.40

Know your out-of-pocket cost for care.

All Charges