Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

SUTURE ETHIBOND EXCEL 1-0 OS-4

Facility

$25.00

Hospital Charge Code	22355504
Hospital Revenue Code	270
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of AZ Commercial	$22.50
Rate for Payer: Cash Price	$20.00

SUTURE ETHIBOND EXCEL 1-0 OS-4

Facility

$25.00

Hospital Charge Code	22355504
Hospital Revenue Code	270
Min. Negotiated Rate	$3.96
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of AZ Commercial	$22.50
Rate for Payer: Arizona Complete Health Allwell	$4.00
Rate for Payer: Banner UC Health Medicare	$4.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$17.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cigna of AZ Commercial	$17.50
Rate for Payer: Devoted Health Medicare	$4.50
Rate for Payer: Humana of AZ Medicare	$4.00
Rate for Payer: Southwest Service Administrators UFCW	$17.00
Rate for Payer: TriWest Medicare	$4.00
Rate for Payer: United Healthcare Commercial	$14.30
Rate for Payer: United Healthcare Medicare	$4.00
Rate for Payer: Veterans Affairs TRICARE	$3.96

SUTURE ETHIBOND EXCEL 1-0 OS-8

Facility

$74.00

Hospital Charge Code	22355505
Hospital Revenue Code	270
Min. Negotiated Rate	$11.72
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Arizona Complete Health Allwell	$11.84
Rate for Payer: Banner UC Health Medicare	$11.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$50.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.84
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cigna of AZ Commercial	$51.80
Rate for Payer: Devoted Health Medicare	$13.32
Rate for Payer: Humana of AZ Medicare	$11.84
Rate for Payer: Southwest Service Administrators UFCW	$50.32
Rate for Payer: TriWest Medicare	$11.84
Rate for Payer: United Healthcare Commercial	$42.33
Rate for Payer: United Healthcare Medicare	$11.84
Rate for Payer: Veterans Affairs TRICARE	$11.72

SUTURE ETHIBOND EXCEL 1-0 OS-8

Facility

$74.00

Hospital Charge Code	22355505
Hospital Revenue Code	270
Min. Negotiated Rate	$66.60
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Cash Price	$59.20

SUTURE ETHILON 2-0 FS

Facility

$48.00

Hospital Charge Code	22355465
Hospital Revenue Code	270
Min. Negotiated Rate	$43.20
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of AZ Commercial	$43.20
Rate for Payer: Cash Price	$38.40

SUTURE ETHILON 2-0 FS

Facility

$48.00

Hospital Charge Code	22355465
Hospital Revenue Code	270
Min. Negotiated Rate	$7.60
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of AZ Commercial	$43.20
Rate for Payer: Arizona Complete Health Allwell	$7.68
Rate for Payer: Banner UC Health Medicare	$7.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$32.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.68
Rate for Payer: Cash Price	$38.40
Rate for Payer: Cigna of AZ Commercial	$33.60
Rate for Payer: Devoted Health Medicare	$8.64
Rate for Payer: Humana of AZ Medicare	$7.68
Rate for Payer: Southwest Service Administrators UFCW	$32.64
Rate for Payer: TriWest Medicare	$7.68
Rate for Payer: United Healthcare Commercial	$27.46
Rate for Payer: United Healthcare Medicare	$7.68
Rate for Payer: Veterans Affairs TRICARE	$7.60

SUTURE ETHILON 2-0 FSL

Facility

$13.00

Hospital Charge Code	22355446
Hospital Revenue Code	270
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$11.70
Rate for Payer: Aetna of AZ Commercial	$11.70
Rate for Payer: Arizona Complete Health Allwell	$2.08
Rate for Payer: Banner UC Health Medicare	$2.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$8.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.08
Rate for Payer: Cash Price	$10.40
Rate for Payer: Cigna of AZ Commercial	$9.10
Rate for Payer: Devoted Health Medicare	$2.34
Rate for Payer: Humana of AZ Medicare	$2.08
Rate for Payer: Southwest Service Administrators UFCW	$8.84
Rate for Payer: TriWest Medicare	$2.08
Rate for Payer: United Healthcare Commercial	$7.44
Rate for Payer: United Healthcare Medicare	$2.08
Rate for Payer: Veterans Affairs TRICARE	$2.06

SUTURE ETHILON 2-0 FSL

Facility

$13.00

Hospital Charge Code	22355446
Hospital Revenue Code	270
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$11.70
Rate for Payer: Aetna of AZ Commercial	$11.70
Rate for Payer: Cash Price	$10.40

SUTURE ETHILON 3-0 FSL

Facility

$14.00

Hospital Charge Code	22355445
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of AZ Commercial	$12.60
Rate for Payer: Cash Price	$11.20

SUTURE ETHILON 3-0 FSL

Facility

$14.00

Hospital Charge Code	22355445
Hospital Revenue Code	270
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of AZ Commercial	$12.60
Rate for Payer: Arizona Complete Health Allwell	$2.24
Rate for Payer: Banner UC Health Medicare	$2.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$9.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.24
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cigna of AZ Commercial	$9.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Humana of AZ Medicare	$2.24
Rate for Payer: Southwest Service Administrators UFCW	$9.52
Rate for Payer: TriWest Medicare	$2.24
Rate for Payer: United Healthcare Commercial	$8.01
Rate for Payer: United Healthcare Medicare	$2.24
Rate for Payer: Veterans Affairs TRICARE	$2.22

SUTURE ETHILON 4-0 C-14

Facility

$40.00

Hospital Charge Code	22355499
Hospital Revenue Code	270
Min. Negotiated Rate	$6.34
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna of AZ Commercial	$36.00
Rate for Payer: Arizona Complete Health Allwell	$6.40
Rate for Payer: Banner UC Health Medicare	$6.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$27.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.40
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cigna of AZ Commercial	$28.00
Rate for Payer: Devoted Health Medicare	$7.20
Rate for Payer: Humana of AZ Medicare	$6.40
Rate for Payer: Southwest Service Administrators UFCW	$27.20
Rate for Payer: TriWest Medicare	$6.40
Rate for Payer: United Healthcare Commercial	$22.88
Rate for Payer: United Healthcare Medicare	$6.40
Rate for Payer: Veterans Affairs TRICARE	$6.34

SUTURE ETHILON 4-0 C-14

Facility

$40.00

Hospital Charge Code	22355499
Hospital Revenue Code	270
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna of AZ Commercial	$36.00
Rate for Payer: Cash Price	$32.00

SUTURE ETHILON 4-0 FS-1

Facility

$14.00

Hospital Charge Code	22355444
Hospital Revenue Code	270
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of AZ Commercial	$12.60
Rate for Payer: Arizona Complete Health Allwell	$2.24
Rate for Payer: Banner UC Health Medicare	$2.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$9.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.24
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cigna of AZ Commercial	$9.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Humana of AZ Medicare	$2.24
Rate for Payer: Southwest Service Administrators UFCW	$9.52
Rate for Payer: TriWest Medicare	$2.24
Rate for Payer: United Healthcare Commercial	$8.01
Rate for Payer: United Healthcare Medicare	$2.24
Rate for Payer: Veterans Affairs TRICARE	$2.22

SUTURE ETHILON 4-0 FS-1

Facility

$14.00

Hospital Charge Code	22355444
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of AZ Commercial	$12.60
Rate for Payer: Cash Price	$11.20

SUTURE ETHILON 4-0 FS-2

Facility

$17.00

Hospital Charge Code	22355127
Hospital Revenue Code	270
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

SUTURE ETHILON 4-0 FS-2

Facility

$17.00

Hospital Charge Code	22355127
Hospital Revenue Code	270
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

SUTURE ETHILON 4-0 PS-2

Facility

$24.00

Hospital Charge Code	22355461
Hospital Revenue Code	270
Min. Negotiated Rate	$3.80
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna of AZ Commercial	$21.60
Rate for Payer: Arizona Complete Health Allwell	$3.84
Rate for Payer: Banner UC Health Medicare	$3.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$16.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.84
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cigna of AZ Commercial	$16.80
Rate for Payer: Devoted Health Medicare	$4.32
Rate for Payer: Humana of AZ Medicare	$3.84
Rate for Payer: Southwest Service Administrators UFCW	$16.32
Rate for Payer: TriWest Medicare	$3.84
Rate for Payer: United Healthcare Commercial	$13.73
Rate for Payer: United Healthcare Medicare	$3.84
Rate for Payer: Veterans Affairs TRICARE	$3.80

SUTURE ETHILON 4-0 PS-2

Facility

$24.00

Hospital Charge Code	22355461
Hospital Revenue Code	270
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna of AZ Commercial	$21.60
Rate for Payer: Cash Price	$19.20

SUTURE ETHILON 5-0 C-2

Facility

$49.00

Hospital Charge Code	22355184
Hospital Revenue Code	270
Min. Negotiated Rate	$7.76
Max. Negotiated Rate	$44.10
Rate for Payer: Aetna of AZ Commercial	$44.10
Rate for Payer: Arizona Complete Health Allwell	$7.84
Rate for Payer: Banner UC Health Medicare	$7.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$33.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.84
Rate for Payer: Cash Price	$39.20
Rate for Payer: Cigna of AZ Commercial	$34.30
Rate for Payer: Devoted Health Medicare	$8.82
Rate for Payer: Humana of AZ Medicare	$7.84
Rate for Payer: Southwest Service Administrators UFCW	$33.32
Rate for Payer: TriWest Medicare	$7.84
Rate for Payer: United Healthcare Commercial	$28.03
Rate for Payer: United Healthcare Medicare	$7.84
Rate for Payer: Veterans Affairs TRICARE	$7.76

SUTURE ETHILON 5-0 C-2

Facility

$49.00

Hospital Charge Code	22355184
Hospital Revenue Code	270
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$44.10
Rate for Payer: Aetna of AZ Commercial	$44.10
Rate for Payer: Cash Price	$39.20

SUTURE ETHILON 5-0 FS-2

Facility

$14.00

Hospital Charge Code	22355447
Hospital Revenue Code	270
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of AZ Commercial	$12.60
Rate for Payer: Arizona Complete Health Allwell	$2.24
Rate for Payer: Banner UC Health Medicare	$2.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$9.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.24
Rate for Payer: Cash Price	$11.20
Rate for Payer: Cigna of AZ Commercial	$9.80
Rate for Payer: Devoted Health Medicare	$2.52
Rate for Payer: Humana of AZ Medicare	$2.24
Rate for Payer: Southwest Service Administrators UFCW	$9.52
Rate for Payer: TriWest Medicare	$2.24
Rate for Payer: United Healthcare Commercial	$8.01
Rate for Payer: United Healthcare Medicare	$2.24
Rate for Payer: Veterans Affairs TRICARE	$2.22

SUTURE ETHILON 5-0 FS-2

Facility

$14.00

Hospital Charge Code	22355447
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of AZ Commercial	$12.60
Rate for Payer: Cash Price	$11.20

SUTURE ETHILON 5-0 P-3

Facility

$24.00

Hospital Charge Code	22355129
Hospital Revenue Code	270
Min. Negotiated Rate	$3.80
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna of AZ Commercial	$21.60
Rate for Payer: Arizona Complete Health Allwell	$3.84
Rate for Payer: Banner UC Health Medicare	$3.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$16.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.84
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cigna of AZ Commercial	$16.80
Rate for Payer: Devoted Health Medicare	$4.32
Rate for Payer: Humana of AZ Medicare	$3.84
Rate for Payer: Southwest Service Administrators UFCW	$16.32
Rate for Payer: TriWest Medicare	$3.84
Rate for Payer: United Healthcare Commercial	$13.73
Rate for Payer: United Healthcare Medicare	$3.84
Rate for Payer: Veterans Affairs TRICARE	$3.80

SUTURE ETHILON 5-0 P-3

Facility

$24.00

Hospital Charge Code	22355129
Hospital Revenue Code	270
Min. Negotiated Rate	$21.60
Max. Negotiated Rate	$21.60
Rate for Payer: Aetna of AZ Commercial	$21.60
Rate for Payer: Cash Price	$19.20

SUTURE ETHILON 6-0 P-1

Facility

$50.00

Hospital Charge Code	22355128
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

Know your out-of-pocket cost for care.

All Charges