Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

SURG PATH LVL 2 GROSS EXAM

Facility

$708.00

Service Code	CPT 88302
Hospital Charge Code	22545712
Hospital Revenue Code	310
Min. Negotiated Rate	$637.20
Max. Negotiated Rate	$637.20
Rate for Payer: Aetna of AZ Commercial	$637.20
Rate for Payer: Cash Price	$566.40

SURG PATH LVL 2 GROSS EXAM

Facility

$708.00

Service Code	CPT 88302
Hospital Charge Code	22545712
Hospital Revenue Code	310
Min. Negotiated Rate	$23.30
Max. Negotiated Rate	$637.20
Rate for Payer: Aetna of AZ Commercial	$637.20
Rate for Payer: Arizona Complete Health Allwell	$113.28
Rate for Payer: Banner UC Health Medicare	$113.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$481.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$113.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$23.30
Rate for Payer: Cash Price	$566.40
Rate for Payer: Cash Price	$566.40
Rate for Payer: Cigna of AZ Commercial	$460.20
Rate for Payer: Devoted Health Medicare	$127.44
Rate for Payer: Humana of AZ Medicare	$113.28
Rate for Payer: Seven Corners Travel Insurance	$57.80
Rate for Payer: Southwest Service Administrators UFCW	$481.44
Rate for Payer: TriWest Medicare	$113.28
Rate for Payer: United Healthcare Commercial	$404.98
Rate for Payer: United Healthcare Medicare	$113.28
Rate for Payer: Veterans Affairs TRICARE	$112.15

SURG PATH LVL 3 GROSS EXAM

Facility

$830.00

Service Code	CPT 88304
Hospital Charge Code	22545713
Hospital Revenue Code	310
Min. Negotiated Rate	$747.00
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of AZ Commercial	$747.00
Rate for Payer: Cash Price	$664.00

SURG PATH LVL 3 GROSS EXAM

Facility

$830.00

Service Code	CPT 88304
Hospital Charge Code	22545713
Hospital Revenue Code	310
Min. Negotiated Rate	$29.74
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of AZ Commercial	$747.00
Rate for Payer: Arizona Complete Health Allwell	$132.80
Rate for Payer: Banner UC Health Medicare	$132.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$564.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$132.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$29.74
Rate for Payer: Cash Price	$664.00
Rate for Payer: Cash Price	$664.00
Rate for Payer: Cigna of AZ Commercial	$539.50
Rate for Payer: Devoted Health Medicare	$149.40
Rate for Payer: Humana of AZ Medicare	$132.80
Rate for Payer: Seven Corners Travel Insurance	$80.63
Rate for Payer: Southwest Service Administrators UFCW	$564.40
Rate for Payer: TriWest Medicare	$132.80
Rate for Payer: United Healthcare Commercial	$474.76
Rate for Payer: United Healthcare Medicare	$132.80
Rate for Payer: Veterans Affairs TRICARE	$131.47

SURG PATH LVL 4 GROSS EXAM

Facility

$1,206.00

Service Code	CPT 88305
Hospital Charge Code	22545714
Hospital Revenue Code	310
Min. Negotiated Rate	$1,085.40
Max. Negotiated Rate	$1,085.40
Rate for Payer: Aetna of AZ Commercial	$1,085.40
Rate for Payer: Cash Price	$964.80

SURG PATH LVL 4 GROSS EXAM

Facility

$1,206.00

Service Code	CPT 88305
Hospital Charge Code	22545714
Hospital Revenue Code	310
Min. Negotiated Rate	$51.06
Max. Negotiated Rate	$1,085.40
Rate for Payer: Aetna of AZ Commercial	$1,085.40
Rate for Payer: Arizona Complete Health Allwell	$192.96
Rate for Payer: Banner UC Health Medicare	$192.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$820.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$192.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$51.06
Rate for Payer: Cash Price	$964.80
Rate for Payer: Cash Price	$964.80
Rate for Payer: Cigna of AZ Commercial	$783.90
Rate for Payer: Devoted Health Medicare	$217.08
Rate for Payer: Humana of AZ Medicare	$192.96
Rate for Payer: Seven Corners Travel Insurance	$80.63
Rate for Payer: Southwest Service Administrators UFCW	$820.08
Rate for Payer: TriWest Medicare	$192.96
Rate for Payer: United Healthcare Commercial	$689.83
Rate for Payer: United Healthcare Medicare	$192.96
Rate for Payer: Veterans Affairs TRICARE	$191.03

SURG PATH LVL 5 GROSS EXAM

Facility

$4,790.00

Service Code	CPT 88307
Hospital Charge Code	22545715
Hospital Revenue Code	310
Min. Negotiated Rate	$4,311.00
Max. Negotiated Rate	$4,311.00
Rate for Payer: Aetna of AZ Commercial	$4,311.00
Rate for Payer: Cash Price	$3,832.00

SURG PATH LVL 5 GROSS EXAM

Facility

$4,790.00

Service Code	CPT 88307
Hospital Charge Code	22545715
Hospital Revenue Code	310
Min. Negotiated Rate	$200.77
Max. Negotiated Rate	$4,311.00
Rate for Payer: Aetna of AZ Commercial	$4,311.00
Rate for Payer: Arizona Complete Health Allwell	$766.40
Rate for Payer: Banner UC Health Medicare	$766.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,257.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$766.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$200.77
Rate for Payer: Cash Price	$3,832.00
Rate for Payer: Cash Price	$3,832.00
Rate for Payer: Cigna of AZ Commercial	$3,113.50
Rate for Payer: Devoted Health Medicare	$862.20
Rate for Payer: Humana of AZ Medicare	$766.40
Rate for Payer: Seven Corners Travel Insurance	$554.61
Rate for Payer: Southwest Service Administrators UFCW	$3,257.20
Rate for Payer: TriWest Medicare	$766.40
Rate for Payer: United Healthcare Commercial	$2,739.88
Rate for Payer: United Healthcare Medicare	$766.40
Rate for Payer: Veterans Affairs TRICARE	$758.74

SURG PATH LVL 6 GROSS EXAM

Facility

$7,500.00

Service Code	CPT 88309
Hospital Charge Code	22545716
Hospital Revenue Code	310
Min. Negotiated Rate	$6,750.00
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna of AZ Commercial	$6,750.00
Rate for Payer: Cash Price	$6,000.00

SURG PATH LVL 6 GROSS EXAM

Facility

$7,500.00

Service Code	CPT 88309
Hospital Charge Code	22545716
Hospital Revenue Code	310
Min. Negotiated Rate	$299.17
Max. Negotiated Rate	$6,750.00
Rate for Payer: Aetna of AZ Commercial	$6,750.00
Rate for Payer: Arizona Complete Health Allwell	$1,200.00
Rate for Payer: Banner UC Health Medicare	$1,200.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5,100.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,200.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$299.17
Rate for Payer: Cash Price	$6,000.00
Rate for Payer: Cash Price	$6,000.00
Rate for Payer: Cigna of AZ Commercial	$4,875.00
Rate for Payer: Devoted Health Medicare	$1,350.00
Rate for Payer: Humana of AZ Medicare	$1,200.00
Rate for Payer: Seven Corners Travel Insurance	$1,246.61
Rate for Payer: Southwest Service Administrators UFCW	$5,100.00
Rate for Payer: TriWest Medicare	$1,200.00
Rate for Payer: United Healthcare Commercial	$4,290.00
Rate for Payer: United Healthcare Medicare	$1,200.00
Rate for Payer: Veterans Affairs TRICARE	$1,188.00

SUSPENSORY MALE LG

Facility

$82.00

Hospital Charge Code	22355538
Hospital Revenue Code	270
Min. Negotiated Rate	$73.80
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Cash Price	$65.60

SUSPENSORY MALE LG

Facility

$82.00

Hospital Charge Code	22355538
Hospital Revenue Code	270
Min. Negotiated Rate	$12.99
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Arizona Complete Health Allwell	$13.12
Rate for Payer: Banner UC Health Medicare	$13.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$55.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.12
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cigna of AZ Commercial	$57.40
Rate for Payer: Devoted Health Medicare	$14.76
Rate for Payer: Humana of AZ Medicare	$13.12
Rate for Payer: Southwest Service Administrators UFCW	$55.76
Rate for Payer: TriWest Medicare	$13.12
Rate for Payer: United Healthcare Commercial	$46.90
Rate for Payer: United Healthcare Medicare	$13.12
Rate for Payer: Veterans Affairs TRICARE	$12.99

SUSPENSORY MALE MED

Facility

$82.00

Hospital Charge Code	22354142
Hospital Revenue Code	270
Min. Negotiated Rate	$73.80
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Cash Price	$65.60

SUSPENSORY MALE MED

Facility

$82.00

Hospital Charge Code	22354142
Hospital Revenue Code	270
Min. Negotiated Rate	$12.99
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Arizona Complete Health Allwell	$13.12
Rate for Payer: Banner UC Health Medicare	$13.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$55.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.12
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cigna of AZ Commercial	$57.40
Rate for Payer: Devoted Health Medicare	$14.76
Rate for Payer: Humana of AZ Medicare	$13.12
Rate for Payer: Southwest Service Administrators UFCW	$55.76
Rate for Payer: TriWest Medicare	$13.12
Rate for Payer: United Healthcare Commercial	$46.90
Rate for Payer: United Healthcare Medicare	$13.12
Rate for Payer: Veterans Affairs TRICARE	$12.99

SUSPENSORY MALE SMALL

Facility

$82.00

Hospital Charge Code	22354141
Hospital Revenue Code	270
Min. Negotiated Rate	$73.80
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Cash Price	$65.60

SUSPENSORY MALE SMALL

Facility

$82.00

Hospital Charge Code	22354141
Hospital Revenue Code	270
Min. Negotiated Rate	$12.99
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of AZ Commercial	$73.80
Rate for Payer: Arizona Complete Health Allwell	$13.12
Rate for Payer: Banner UC Health Medicare	$13.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$55.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.12
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cigna of AZ Commercial	$57.40
Rate for Payer: Devoted Health Medicare	$14.76
Rate for Payer: Humana of AZ Medicare	$13.12
Rate for Payer: Southwest Service Administrators UFCW	$55.76
Rate for Payer: TriWest Medicare	$13.12
Rate for Payer: United Healthcare Commercial	$46.90
Rate for Payer: United Healthcare Medicare	$13.12
Rate for Payer: Veterans Affairs TRICARE	$12.99

SUTURE, 1 36 CTD VIC UND BR CT-1

Facility

$59.00

Hospital Charge Code	23293575
Hospital Revenue Code	272
Min. Negotiated Rate	$53.10
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Cash Price	$47.20

SUTURE, 1 36 CTD VIC UND BR CT-1

Facility

$59.00

Hospital Charge Code	23293575
Hospital Revenue Code	272
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Arizona Complete Health Allwell	$9.44
Rate for Payer: Banner UC Health Medicare	$9.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$40.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.44
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cigna of AZ Commercial	$41.30
Rate for Payer: Devoted Health Medicare	$10.62
Rate for Payer: Humana of AZ Medicare	$9.44
Rate for Payer: Southwest Service Administrators UFCW	$40.12
Rate for Payer: TriWest Medicare	$9.44
Rate for Payer: United Healthcare Commercial	$33.75
Rate for Payer: United Healthcare Medicare	$9.44
Rate for Payer: Veterans Affairs TRICARE	$9.35

SUTURE CHROMIC 0 CT-1

Facility

$85.00

Hospital Charge Code	22355467
Hospital Revenue Code	270
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of AZ Commercial	$76.50
Rate for Payer: Cash Price	$68.00

SUTURE CHROMIC 0 CT-1

Facility

$85.00

Hospital Charge Code	22355467
Hospital Revenue Code	270
Min. Negotiated Rate	$13.46
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of AZ Commercial	$76.50
Rate for Payer: Arizona Complete Health Allwell	$13.60
Rate for Payer: Banner UC Health Medicare	$13.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$57.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.60
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cigna of AZ Commercial	$59.50
Rate for Payer: Devoted Health Medicare	$15.30
Rate for Payer: Humana of AZ Medicare	$13.60
Rate for Payer: Southwest Service Administrators UFCW	$57.80
Rate for Payer: TriWest Medicare	$13.60
Rate for Payer: United Healthcare Commercial	$48.62
Rate for Payer: United Healthcare Medicare	$13.60
Rate for Payer: Veterans Affairs TRICARE	$13.46

SUTURE CHROMIC 1-0 CT-1

Facility

$50.00

Hospital Charge Code	22355468
Hospital Revenue Code	270
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna of AZ Commercial	$45.00
Rate for Payer: Cash Price	$40.00

SUTURE CHROMIC 1-0 CT-1

Facility

$50.00

Hospital Charge Code	22355468
Hospital Revenue Code	270
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna of AZ Commercial	$45.00
Rate for Payer: Arizona Complete Health Allwell	$8.00
Rate for Payer: Banner UC Health Medicare	$8.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$34.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cigna of AZ Commercial	$35.00
Rate for Payer: Devoted Health Medicare	$9.00
Rate for Payer: Humana of AZ Medicare	$8.00
Rate for Payer: Southwest Service Administrators UFCW	$34.00
Rate for Payer: TriWest Medicare	$8.00
Rate for Payer: United Healthcare Commercial	$28.60
Rate for Payer: United Healthcare Medicare	$8.00
Rate for Payer: Veterans Affairs TRICARE	$7.92

SUTURE CHROMIC 1-0 CT-1 8 PK

Facility

$275.00

Hospital Charge Code	22355190
Hospital Revenue Code	270
Min. Negotiated Rate	$43.56
Max. Negotiated Rate	$247.50
Rate for Payer: Aetna of AZ Commercial	$247.50
Rate for Payer: Arizona Complete Health Allwell	$44.00
Rate for Payer: Banner UC Health Medicare	$44.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$187.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$44.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$44.00
Rate for Payer: Cash Price	$220.00
Rate for Payer: Cigna of AZ Commercial	$192.50
Rate for Payer: Devoted Health Medicare	$49.50
Rate for Payer: Humana of AZ Medicare	$44.00
Rate for Payer: Southwest Service Administrators UFCW	$187.00
Rate for Payer: TriWest Medicare	$44.00
Rate for Payer: United Healthcare Commercial	$157.30
Rate for Payer: United Healthcare Medicare	$44.00
Rate for Payer: Veterans Affairs TRICARE	$43.56

SUTURE CHROMIC 1-0 CT-1 8 PK

Facility

$275.00

Hospital Charge Code	22355190
Hospital Revenue Code	270
Min. Negotiated Rate	$247.50
Max. Negotiated Rate	$247.50
Rate for Payer: Aetna of AZ Commercial	$247.50
Rate for Payer: Cash Price	$220.00

SUTURE CHROMIC 2-0 FS-1

Facility

$90.00

Hospital Charge Code	22355464
Hospital Revenue Code	270
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna of AZ Commercial	$81.00
Rate for Payer: Cash Price	$72.00

Know your out-of-pocket cost for care.

All Charges