Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

SUTURE ETHILON 6-0 P-1

Facility

$50.00

Hospital Charge Code	22355128
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 ETHILON 6-0 P-3

Facility

$93.00

Hospital Charge Code	22355198
Hospital Revenue Code	270
Min. Negotiated Rate	$83.70
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Cash Price	$74.40

SUTURE ETHILON 6-0 P-3

Facility

$93.00

Hospital Charge Code	22355198
Hospital Revenue Code	270
Min. Negotiated Rate	$14.73
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of AZ Commercial	$83.70
Rate for Payer: Arizona Complete Health Allwell	$14.88
Rate for Payer: Banner UC Health Medicare	$14.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$63.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.88
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cigna of AZ Commercial	$65.10
Rate for Payer: Devoted Health Medicare	$16.74
Rate for Payer: Humana of AZ Medicare	$14.88
Rate for Payer: Southwest Service Administrators UFCW	$63.24
Rate for Payer: TriWest Medicare	$14.88
Rate for Payer: United Healthcare Commercial	$53.20
Rate for Payer: United Healthcare Medicare	$14.88
Rate for Payer: Veterans Affairs TRICARE	$14.73

SUTURE ETHILON MONO 2/0 BLK

Facility

$64.00

Hospital Charge Code	22754080
Hospital Revenue Code	272
Min. Negotiated Rate	$10.14
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of AZ Commercial	$57.60
Rate for Payer: Arizona Complete Health Allwell	$10.24
Rate for Payer: Banner UC Health Medicare	$10.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$43.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.24
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cigna of AZ Commercial	$44.80
Rate for Payer: Devoted Health Medicare	$11.52
Rate for Payer: Humana of AZ Medicare	$10.24
Rate for Payer: Southwest Service Administrators UFCW	$43.52
Rate for Payer: TriWest Medicare	$10.24
Rate for Payer: United Healthcare Commercial	$36.61
Rate for Payer: United Healthcare Medicare	$10.24
Rate for Payer: Veterans Affairs TRICARE	$10.14

SUTURE ETHILON MONO 2/0 BLK

Facility

$64.00

Hospital Charge Code	22754080
Hospital Revenue Code	272
Min. Negotiated Rate	$57.60
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of AZ Commercial	$57.60
Rate for Payer: Cash Price	$51.20

SUTURE MONOCRYL 4-0 PS-2

Facility

$32.00

Hospital Charge Code	23580266
Hospital Revenue Code	272
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Cash Price	$25.60

SUTURE MONOCRYL 4-0 PS-2

Facility

$32.00

Hospital Charge Code	23580266
Hospital Revenue Code	272
Min. Negotiated Rate	$5.07
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Arizona Complete Health Allwell	$5.12
Rate for Payer: Banner UC Health Medicare	$5.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$21.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.12
Rate for Payer: Cash Price	$25.60
Rate for Payer: Cigna of AZ Commercial	$22.40
Rate for Payer: Devoted Health Medicare	$5.76
Rate for Payer: Humana of AZ Medicare	$5.12
Rate for Payer: Southwest Service Administrators UFCW	$21.76
Rate for Payer: TriWest Medicare	$5.12
Rate for Payer: United Healthcare Commercial	$18.30
Rate for Payer: United Healthcare Medicare	$5.12
Rate for Payer: Veterans Affairs TRICARE	$5.07

SUTURE MONOCRYL 4-0 PS-2 Y496G

Facility

$35.00

Hospital Charge Code	22355197
Hospital Revenue Code	270
Min. Negotiated Rate	$5.54
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of AZ Commercial	$31.50
Rate for Payer: Arizona Complete Health Allwell	$5.60
Rate for Payer: Banner UC Health Medicare	$5.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$23.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.60
Rate for Payer: Cash Price	$28.00
Rate for Payer: Cigna of AZ Commercial	$24.50
Rate for Payer: Devoted Health Medicare	$6.30
Rate for Payer: Humana of AZ Medicare	$5.60
Rate for Payer: Southwest Service Administrators UFCW	$23.80
Rate for Payer: TriWest Medicare	$5.60
Rate for Payer: United Healthcare Commercial	$20.02
Rate for Payer: United Healthcare Medicare	$5.60
Rate for Payer: Veterans Affairs TRICARE	$5.54

SUTURE MONOCRYL 4-0 PS-2 Y496G

Facility

$35.00

Hospital Charge Code	22355197
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of AZ Commercial	$31.50
Rate for Payer: Cash Price	$28.00

SUTURE PDSII 0 CT-1

Facility

$62.00

Hospital Charge Code	22355506
Hospital Revenue Code	270
Min. Negotiated Rate	$9.82
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Arizona Complete Health Allwell	$9.92
Rate for Payer: Banner UC Health Medicare	$9.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$42.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.92
Rate for Payer: Cash Price	$49.60
Rate for Payer: Cigna of AZ Commercial	$43.40
Rate for Payer: Devoted Health Medicare	$11.16
Rate for Payer: Humana of AZ Medicare	$9.92
Rate for Payer: Southwest Service Administrators UFCW	$42.16
Rate for Payer: TriWest Medicare	$9.92
Rate for Payer: United Healthcare Commercial	$35.46
Rate for Payer: United Healthcare Medicare	$9.92
Rate for Payer: Veterans Affairs TRICARE	$9.82

SUTURE PDSII 0 CT-1

Facility

$62.00

Hospital Charge Code	22355506
Hospital Revenue Code	270
Min. Negotiated Rate	$55.80
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Cash Price	$49.60

SUTURE PDSII 1-0 CT-1

Facility

$63.00

Hospital Charge Code	22355507
Hospital Revenue Code	270
Min. Negotiated Rate	$9.98
Max. Negotiated Rate	$56.70
Rate for Payer: Aetna of AZ Commercial	$56.70
Rate for Payer: Arizona Complete Health Allwell	$10.08
Rate for Payer: Banner UC Health Medicare	$10.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$42.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.08
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna of AZ Commercial	$44.10
Rate for Payer: Devoted Health Medicare	$11.34
Rate for Payer: Humana of AZ Medicare	$10.08
Rate for Payer: Southwest Service Administrators UFCW	$42.84
Rate for Payer: TriWest Medicare	$10.08
Rate for Payer: United Healthcare Commercial	$36.04
Rate for Payer: United Healthcare Medicare	$10.08
Rate for Payer: Veterans Affairs TRICARE	$9.98

SUTURE PDSII 1-0 CT-1

Facility

$63.00

Hospital Charge Code	22355507
Hospital Revenue Code	270
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$56.70
Rate for Payer: Aetna of AZ Commercial	$56.70
Rate for Payer: Cash Price	$50.40

SUTURE POLYSORB 3-0 GS-22

Facility

$43.00

Hospital Charge Code	22355450
Hospital Revenue Code	270
Min. Negotiated Rate	$6.81
Max. Negotiated Rate	$38.70
Rate for Payer: Aetna of AZ Commercial	$38.70
Rate for Payer: Arizona Complete Health Allwell	$6.88
Rate for Payer: Banner UC Health Medicare	$6.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$29.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.88
Rate for Payer: Cash Price	$34.40
Rate for Payer: Cigna of AZ Commercial	$30.10
Rate for Payer: Devoted Health Medicare	$7.74
Rate for Payer: Humana of AZ Medicare	$6.88
Rate for Payer: Southwest Service Administrators UFCW	$29.24
Rate for Payer: TriWest Medicare	$6.88
Rate for Payer: United Healthcare Commercial	$24.60
Rate for Payer: United Healthcare Medicare	$6.88
Rate for Payer: Veterans Affairs TRICARE	$6.81

SUTURE POLYSORB 3-0 GS-22

Facility

$43.00

Hospital Charge Code	22355450
Hospital Revenue Code	270
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$38.70
Rate for Payer: Aetna of AZ Commercial	$38.70
Rate for Payer: Cash Price	$34.40

SUTURE POLYSORB 5-0 C-13

Facility

$67.00

Hospital Charge Code	22354173
Hospital Revenue Code	270
Min. Negotiated Rate	$10.61
Max. Negotiated Rate	$60.30
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Arizona Complete Health Allwell	$10.72
Rate for Payer: Banner UC Health Medicare	$10.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$45.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.72
Rate for Payer: Cash Price	$53.60
Rate for Payer: Cigna of AZ Commercial	$46.90
Rate for Payer: Devoted Health Medicare	$12.06
Rate for Payer: Humana of AZ Medicare	$10.72
Rate for Payer: Southwest Service Administrators UFCW	$45.56
Rate for Payer: TriWest Medicare	$10.72
Rate for Payer: United Healthcare Commercial	$38.32
Rate for Payer: United Healthcare Medicare	$10.72
Rate for Payer: Veterans Affairs TRICARE	$10.61

SUTURE POLYSORB 5-0 C-13

Facility

$67.00

Hospital Charge Code	22354173
Hospital Revenue Code	270
Min. Negotiated Rate	$60.30
Max. Negotiated Rate	$60.30
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Cash Price	$53.60

SUTURE PROLENE 0 CT-1

Facility

$253.00

Hospital Charge Code	22355189
Hospital Revenue Code	270
Min. Negotiated Rate	$40.08
Max. Negotiated Rate	$227.70
Rate for Payer: Aetna of AZ Commercial	$227.70
Rate for Payer: Arizona Complete Health Allwell	$40.48
Rate for Payer: Banner UC Health Medicare	$40.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$172.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$40.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$40.48
Rate for Payer: Cash Price	$202.40
Rate for Payer: Cigna of AZ Commercial	$177.10
Rate for Payer: Devoted Health Medicare	$45.54
Rate for Payer: Humana of AZ Medicare	$40.48
Rate for Payer: Southwest Service Administrators UFCW	$172.04
Rate for Payer: TriWest Medicare	$40.48
Rate for Payer: United Healthcare Commercial	$144.72
Rate for Payer: United Healthcare Medicare	$40.48
Rate for Payer: Veterans Affairs TRICARE	$40.08

SUTURE PROLENE 0 CT-1

Facility

$253.00

Hospital Charge Code	22355189
Hospital Revenue Code	270
Min. Negotiated Rate	$227.70
Max. Negotiated Rate	$227.70
Rate for Payer: Aetna of AZ Commercial	$227.70
Rate for Payer: Cash Price	$202.40

SUTURE PROLENE 0 CT-2

Facility

$62.00

Hospital Charge Code	22355448
Hospital Revenue Code	270
Min. Negotiated Rate	$55.80
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Cash Price	$49.60

SUTURE PROLENE 0 CT-2

Facility

$62.00

Hospital Charge Code	22355448
Hospital Revenue Code	270
Min. Negotiated Rate	$9.82
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Arizona Complete Health Allwell	$9.92
Rate for Payer: Banner UC Health Medicare	$9.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$42.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.92
Rate for Payer: Cash Price	$49.60
Rate for Payer: Cigna of AZ Commercial	$43.40
Rate for Payer: Devoted Health Medicare	$11.16
Rate for Payer: Humana of AZ Medicare	$9.92
Rate for Payer: Southwest Service Administrators UFCW	$42.16
Rate for Payer: TriWest Medicare	$9.92
Rate for Payer: United Healthcare Commercial	$35.46
Rate for Payer: United Healthcare Medicare	$9.92
Rate for Payer: Veterans Affairs TRICARE	$9.82

SUTURE PROLENE 0 CT-2 SURGIPRO

Facility

$54.00

Hospital Charge Code	22355479
Hospital Revenue Code	270
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$48.60
Rate for Payer: Aetna of AZ Commercial	$48.60
Rate for Payer: Arizona Complete Health Allwell	$8.64
Rate for Payer: Banner UC Health Medicare	$8.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$36.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.64
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna of AZ Commercial	$37.80
Rate for Payer: Devoted Health Medicare	$9.72
Rate for Payer: Humana of AZ Medicare	$8.64
Rate for Payer: Southwest Service Administrators UFCW	$36.72
Rate for Payer: TriWest Medicare	$8.64
Rate for Payer: United Healthcare Commercial	$30.89
Rate for Payer: United Healthcare Medicare	$8.64
Rate for Payer: Veterans Affairs TRICARE	$8.55

SUTURE PROLENE 0 CT-2 SURGIPRO

Facility

$54.00

Hospital Charge Code	22355479
Hospital Revenue Code	270
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$48.60
Rate for Payer: Aetna of AZ Commercial	$48.60
Rate for Payer: Cash Price	$43.20

SUTURE PROLENE 1-0 CTX

Facility

$15.00

Hospital Charge Code	22355470
Hospital Revenue Code	270
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of AZ Commercial	$13.50
Rate for Payer: Arizona Complete Health Allwell	$2.40
Rate for Payer: Banner UC Health Medicare	$2.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$10.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.40
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cigna of AZ Commercial	$10.50
Rate for Payer: Devoted Health Medicare	$2.70
Rate for Payer: Humana of AZ Medicare	$2.40
Rate for Payer: Southwest Service Administrators UFCW	$10.20
Rate for Payer: TriWest Medicare	$2.40
Rate for Payer: United Healthcare Commercial	$8.58
Rate for Payer: United Healthcare Medicare	$2.40
Rate for Payer: Veterans Affairs TRICARE	$2.38

SUTURE PROLENE 1-0 CTX

Facility

$15.00

Hospital Charge Code	22355470
Hospital Revenue Code	270
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna of AZ Commercial	$13.50
Rate for Payer: Cash Price	$12.00

Know your out-of-pocket cost for care.

All Charges