Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

SURECLIP 11MM REPOSITIONABLE

Facility

$718.00

Hospital Charge Code	23152396
Hospital Revenue Code	272
Min. Negotiated Rate	$113.73
Max. Negotiated Rate	$646.20
Rate for Payer: Aetna of AZ Commercial	$646.20
Rate for Payer: Arizona Complete Health Allwell	$114.88
Rate for Payer: Banner UC Health Medicare	$114.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$488.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$114.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$114.88
Rate for Payer: Cash Price	$574.40
Rate for Payer: Cigna of AZ Commercial	$502.60
Rate for Payer: Devoted Health Medicare	$129.24
Rate for Payer: Humana of AZ Medicare	$114.88
Rate for Payer: Southwest Service Administrators UFCW	$488.24
Rate for Payer: TriWest Medicare	$114.88
Rate for Payer: United Healthcare Commercial	$410.70
Rate for Payer: United Healthcare Medicare	$114.88
Rate for Payer: Veterans Affairs TRICARE	$113.73

SUREFIX TI SCREW CAP 18MM

Facility

$2,085.25

Hospital Charge Code	27595624
Hospital Revenue Code	270
Min. Negotiated Rate	$1,876.72
Max. Negotiated Rate	$1,876.72
Rate for Payer: Aetna of AZ Commercial	$1,876.72
Rate for Payer: Cash Price	$1,668.20

SUREFIX TI SCREW CAP 18MM

Facility

$2,085.25

Hospital Charge Code	27595624
Hospital Revenue Code	270
Min. Negotiated Rate	$330.30
Max. Negotiated Rate	$1,876.72
Rate for Payer: Aetna of AZ Commercial	$1,876.72
Rate for Payer: Arizona Complete Health Allwell	$333.64
Rate for Payer: Banner UC Health Medicare	$333.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,417.97
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$333.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$333.64
Rate for Payer: Cash Price	$1,668.20
Rate for Payer: Cigna of AZ Commercial	$1,459.67
Rate for Payer: Devoted Health Medicare	$375.35
Rate for Payer: Humana of AZ Medicare	$333.64
Rate for Payer: Southwest Service Administrators UFCW	$1,417.97
Rate for Payer: TriWest Medicare	$333.64
Rate for Payer: United Healthcare Commercial	$1,192.76
Rate for Payer: United Healthcare Medicare	$333.64
Rate for Payer: Veterans Affairs TRICARE	$330.30

SURESEAL

Facility

$76.00

Hospital Charge Code	27750226
Hospital Revenue Code	270
Min. Negotiated Rate	$12.04
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of AZ Commercial	$68.40
Rate for Payer: Arizona Complete Health Allwell	$12.16
Rate for Payer: Banner UC Health Medicare	$12.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$51.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.16
Rate for Payer: Cash Price	$60.80
Rate for Payer: Cigna of AZ Commercial	$53.20
Rate for Payer: Devoted Health Medicare	$13.68
Rate for Payer: Humana of AZ Medicare	$12.16
Rate for Payer: Southwest Service Administrators UFCW	$51.68
Rate for Payer: TriWest Medicare	$12.16
Rate for Payer: United Healthcare Commercial	$43.47
Rate for Payer: United Healthcare Medicare	$12.16
Rate for Payer: Veterans Affairs TRICARE	$12.04

SURESEAL

Facility

$76.00

Hospital Charge Code	27750226
Hospital Revenue Code	270
Min. Negotiated Rate	$68.40
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of AZ Commercial	$68.40
Rate for Payer: Cash Price	$60.80

SURE SEAL VALVE

Facility

$111.00

Hospital Charge Code	22354974
Hospital Revenue Code	270
Min. Negotiated Rate	$99.90
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of AZ Commercial	$99.90
Rate for Payer: Cash Price	$88.80

SURE SEAL VALVE

Facility

$111.00

Hospital Charge Code	22354974
Hospital Revenue Code	270
Min. Negotiated Rate	$17.58
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of AZ Commercial	$99.90
Rate for Payer: Arizona Complete Health Allwell	$17.76
Rate for Payer: Banner UC Health Medicare	$17.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$75.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.76
Rate for Payer: Cash Price	$88.80
Rate for Payer: Cigna of AZ Commercial	$77.70
Rate for Payer: Devoted Health Medicare	$19.98
Rate for Payer: Humana of AZ Medicare	$17.76
Rate for Payer: Southwest Service Administrators UFCW	$75.48
Rate for Payer: TriWest Medicare	$17.76
Rate for Payer: United Healthcare Commercial	$63.49
Rate for Payer: United Healthcare Medicare	$17.76
Rate for Payer: Veterans Affairs TRICARE	$17.58

SURGICAL GOWN LG

Facility

$17.00

Hospital Charge Code	22549514
Hospital Revenue Code	272
Min. Negotiated Rate	$2.69
Max. Negotiated Rate	$15.30
Rate for Payer: Aetna of AZ Commercial	$15.30
Rate for Payer: Arizona Complete Health Allwell	$2.72
Rate for Payer: Banner UC Health Medicare	$2.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$11.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.72
Rate for Payer: Cash Price	$13.60
Rate for Payer: Cigna of AZ Commercial	$11.90
Rate for Payer: Devoted Health Medicare	$3.06
Rate for Payer: Humana of AZ Medicare	$2.72
Rate for Payer: Southwest Service Administrators UFCW	$11.56
Rate for Payer: TriWest Medicare	$2.72
Rate for Payer: United Healthcare Commercial	$9.72
Rate for Payer: United Healthcare Medicare	$2.72
Rate for Payer: Veterans Affairs TRICARE	$2.69

SURGICAL GOWN LG

Facility

$17.00

Hospital Charge Code	22549514
Hospital Revenue Code	272
Min. Negotiated Rate	$15.30
Max. Negotiated Rate	$15.30
Rate for Payer: Aetna of AZ Commercial	$15.30
Rate for Payer: Cash Price	$13.60

SURGICAL INSERTION OF MULTI COMPONENT INFLATABLE PENILE PROS

Facility

$863.00

Service Code	CPT 54405
Hospital Charge Code	28131050
Hospital Revenue Code	360
Min. Negotiated Rate	$136.70
Max. Negotiated Rate	$32,068.90
Rate for Payer: Aetna of AZ Commercial	$776.70
Rate for Payer: Arizona Complete Health Allwell	$138.08
Rate for Payer: Banner UC Health Medicare	$138.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$586.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$138.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$138.08
Rate for Payer: Cash Price	$690.40
Rate for Payer: Cash Price	$690.40
Rate for Payer: Cash Price	$690.40
Rate for Payer: Cigna of AZ Commercial	$431.50
Rate for Payer: Devoted Health Medicare	$155.34
Rate for Payer: Humana of AZ Medicare	$138.08
Rate for Payer: Seven Corners Travel Insurance	$32,068.90
Rate for Payer: Southwest Service Administrators UFCW	$586.84
Rate for Payer: TriWest Medicare	$138.08
Rate for Payer: United Healthcare Commercial	$8,758.00
Rate for Payer: United Healthcare Medicare	$138.08
Rate for Payer: Veterans Affairs TRICARE	$136.70

SURGICAL INSERTION OF MULTI COMPONENT INFLATABLE PENILE PROS

Facility

$863.00

Service Code	CPT 54405
Hospital Charge Code	28131050
Hospital Revenue Code	360
Min. Negotiated Rate	$776.70
Max. Negotiated Rate	$776.70
Rate for Payer: Aetna of AZ Commercial	$776.70
Rate for Payer: Cash Price	$690.40

SURGICAL PATHOLOGHY GROSS AND MICROSCOPIC EXAMINATION FOR P

Facility

$368.00

Service Code	HCPCS G0416
Hospital Charge Code	28260811
Hospital Revenue Code	310
Min. Negotiated Rate	$58.29
Max. Negotiated Rate	$554.61
Rate for Payer: Aetna of AZ Commercial	$331.20
Rate for Payer: Arizona Complete Health Allwell	$58.88
Rate for Payer: Banner UC Health Medicare	$58.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$250.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$58.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$58.88
Rate for Payer: Cash Price	$294.40
Rate for Payer: Cash Price	$294.40
Rate for Payer: Cigna of AZ Commercial	$239.20
Rate for Payer: Devoted Health Medicare	$66.24
Rate for Payer: Humana of AZ Medicare	$58.88
Rate for Payer: Seven Corners Travel Insurance	$554.61
Rate for Payer: Southwest Service Administrators UFCW	$250.24
Rate for Payer: TriWest Medicare	$58.88
Rate for Payer: United Healthcare Commercial	$210.50
Rate for Payer: United Healthcare Medicare	$58.88
Rate for Payer: Veterans Affairs TRICARE	$58.29

SURGICAL PATHOLOGHY GROSS AND MICROSCOPIC EXAMINATION FOR P

Facility

$368.00

Service Code	HCPCS G0416
Hospital Charge Code	28260811
Hospital Revenue Code	310
Min. Negotiated Rate	$331.20
Max. Negotiated Rate	$331.20
Rate for Payer: Aetna of AZ Commercial	$331.20
Rate for Payer: Cash Price	$294.40

SURGICEL 0.5X2-IN

Facility

$176.00

Hospital Charge Code	22355174
Hospital Revenue Code	270
Min. Negotiated Rate	$27.88
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of AZ Commercial	$158.40
Rate for Payer: Arizona Complete Health Allwell	$28.16
Rate for Payer: Banner UC Health Medicare	$28.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$119.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.16
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cigna of AZ Commercial	$123.20
Rate for Payer: Devoted Health Medicare	$31.68
Rate for Payer: Humana of AZ Medicare	$28.16
Rate for Payer: Southwest Service Administrators UFCW	$119.68
Rate for Payer: TriWest Medicare	$28.16
Rate for Payer: United Healthcare Commercial	$100.67
Rate for Payer: United Healthcare Medicare	$28.16
Rate for Payer: Veterans Affairs TRICARE	$27.88

SURGICEL 0.5X2-IN

Facility

$176.00

Hospital Charge Code	22355174
Hospital Revenue Code	270
Min. Negotiated Rate	$158.40
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of AZ Commercial	$158.40
Rate for Payer: Cash Price	$140.80

SURGI CLIP APPLIER 9IN

Facility

$2,173.60

Hospital Charge Code	28039306
Hospital Revenue Code	270
Min. Negotiated Rate	$1,956.24
Max. Negotiated Rate	$1,956.24
Rate for Payer: Aetna of AZ Commercial	$1,956.24
Rate for Payer: Cash Price	$1,738.88

SURGI CLIP APPLIER 9IN

Facility

$2,173.60

Hospital Charge Code	28039306
Hospital Revenue Code	270
Min. Negotiated Rate	$344.30
Max. Negotiated Rate	$1,956.24
Rate for Payer: Aetna of AZ Commercial	$1,956.24
Rate for Payer: Arizona Complete Health Allwell	$347.78
Rate for Payer: Banner UC Health Medicare	$347.78
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,478.05
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$347.78
Rate for Payer: Care1st Health Plan Arizona Medicare	$347.78
Rate for Payer: Cash Price	$1,738.88
Rate for Payer: Cigna of AZ Commercial	$1,521.52
Rate for Payer: Devoted Health Medicare	$391.25
Rate for Payer: Humana of AZ Medicare	$347.78
Rate for Payer: Southwest Service Administrators UFCW	$1,478.05
Rate for Payer: TriWest Medicare	$347.78
Rate for Payer: United Healthcare Commercial	$1,243.30
Rate for Payer: United Healthcare Medicare	$347.78
Rate for Payer: Veterans Affairs TRICARE	$344.30

SURGICLIP APPLIER AUTOMATIC MEDIUM

Facility

$3,576.65

Hospital Charge Code	28009628
Hospital Revenue Code	270
Min. Negotiated Rate	$3,218.99
Max. Negotiated Rate	$3,218.99
Rate for Payer: Aetna of AZ Commercial	$3,218.99
Rate for Payer: Cash Price	$2,861.32

SURGICLIP APPLIER AUTOMATIC MEDIUM

Facility

$3,576.65

Hospital Charge Code	28009628
Hospital Revenue Code	270
Min. Negotiated Rate	$566.54
Max. Negotiated Rate	$3,218.99
Rate for Payer: Aetna of AZ Commercial	$3,218.99
Rate for Payer: Arizona Complete Health Allwell	$572.26
Rate for Payer: Banner UC Health Medicare	$572.26
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,432.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$572.26
Rate for Payer: Care1st Health Plan Arizona Medicare	$572.26
Rate for Payer: Cash Price	$2,861.32
Rate for Payer: Cigna of AZ Commercial	$2,503.66
Rate for Payer: Devoted Health Medicare	$643.80
Rate for Payer: Humana of AZ Medicare	$572.26
Rate for Payer: Southwest Service Administrators UFCW	$2,432.12
Rate for Payer: TriWest Medicare	$572.26
Rate for Payer: United Healthcare Commercial	$2,045.84
Rate for Payer: United Healthcare Medicare	$572.26
Rate for Payer: Veterans Affairs TRICARE	$566.54

SURGIFOAM 2CMX6CMX7MM

Facility

$78.00

Hospital Charge Code	27569184
Hospital Revenue Code	270
Min. Negotiated Rate	$12.36
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Arizona Complete Health Allwell	$12.48
Rate for Payer: Banner UC Health Medicare	$12.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$53.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.48
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cigna of AZ Commercial	$54.60
Rate for Payer: Devoted Health Medicare	$14.04
Rate for Payer: Humana of AZ Medicare	$12.48
Rate for Payer: Southwest Service Administrators UFCW	$53.04
Rate for Payer: TriWest Medicare	$12.48
Rate for Payer: United Healthcare Commercial	$44.62
Rate for Payer: United Healthcare Medicare	$12.48
Rate for Payer: Veterans Affairs TRICARE	$12.36

SURGIFOAM 2CMX6CMX7MM

Facility

$78.00

Hospital Charge Code	27569184
Hospital Revenue Code	270
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of AZ Commercial	$70.20
Rate for Payer: Cash Price	$62.40

SURGIFOAM GELATIN SPONGE 8CMX12CMX10MM

Facility

$259.00

Hospital Charge Code	27569183
Hospital Revenue Code	270
Min. Negotiated Rate	$41.03
Max. Negotiated Rate	$233.10
Rate for Payer: Aetna of AZ Commercial	$233.10
Rate for Payer: Arizona Complete Health Allwell	$41.44
Rate for Payer: Banner UC Health Medicare	$41.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$176.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$41.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$41.44
Rate for Payer: Cash Price	$207.20
Rate for Payer: Cigna of AZ Commercial	$181.30
Rate for Payer: Devoted Health Medicare	$46.62
Rate for Payer: Humana of AZ Medicare	$41.44
Rate for Payer: Southwest Service Administrators UFCW	$176.12
Rate for Payer: TriWest Medicare	$41.44
Rate for Payer: United Healthcare Commercial	$148.15
Rate for Payer: United Healthcare Medicare	$41.44
Rate for Payer: Veterans Affairs TRICARE	$41.03

SURGIFOAM GELATIN SPONGE 8CMX12CMX10MM

Facility

$259.00

Hospital Charge Code	27569183
Hospital Revenue Code	270
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$233.10
Rate for Payer: Aetna of AZ Commercial	$233.10
Rate for Payer: Cash Price	$207.20

SURG PATH LVL 1 GROSS EXAM

Facility

$86.00

Service Code	CPT 88300
Hospital Charge Code	22545711
Hospital Revenue Code	310
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of AZ Commercial	$77.40
Rate for Payer: Arizona Complete Health Allwell	$13.76
Rate for Payer: Banner UC Health Medicare	$13.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$58.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.90
Rate for Payer: Cash Price	$68.80
Rate for Payer: Cash Price	$68.80
Rate for Payer: Cigna of AZ Commercial	$55.90
Rate for Payer: Devoted Health Medicare	$15.48
Rate for Payer: Humana of AZ Medicare	$13.76
Rate for Payer: Seven Corners Travel Insurance	$44.75
Rate for Payer: Southwest Service Administrators UFCW	$58.48
Rate for Payer: TriWest Medicare	$13.76
Rate for Payer: United Healthcare Commercial	$49.19
Rate for Payer: United Healthcare Medicare	$13.76
Rate for Payer: Veterans Affairs TRICARE	$13.62

SURG PATH LVL 1 GROSS EXAM

Facility

$86.00

Service Code	CPT 88300
Hospital Charge Code	22545711
Hospital Revenue Code	310
Min. Negotiated Rate	$77.40
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of AZ Commercial	$77.40
Rate for Payer: Cash Price	$68.80

Know your out-of-pocket cost for care.

All Charges