Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

SUTURE PROLENE 2-0 CT-2

Facility

$17.00

Hospital Charge Code	22355469
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 PROLENE 2-0 CT-2

Facility

$17.00

Hospital Charge Code	22355469
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 PROLENE 2-0 FS

Facility

$67.00

Hospital Charge Code	22355474
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 PROLENE 2-0 FS

Facility

$67.00

Hospital Charge Code	22355474
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 3-0 FS-2

Facility

$18.00

Hospital Charge Code	22355132
Hospital Revenue Code	270
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$16.20
Rate for Payer: Aetna of AZ Commercial	$16.20
Rate for Payer: Arizona Complete Health Allwell	$2.88
Rate for Payer: Banner UC Health Medicare	$2.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$12.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.88
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna of AZ Commercial	$12.60
Rate for Payer: Devoted Health Medicare	$3.24
Rate for Payer: Humana of AZ Medicare	$2.88
Rate for Payer: Southwest Service Administrators UFCW	$12.24
Rate for Payer: TriWest Medicare	$2.88
Rate for Payer: United Healthcare Commercial	$10.30
Rate for Payer: United Healthcare Medicare	$2.88
Rate for Payer: Veterans Affairs TRICARE	$2.85

SUTURE PROLENE 3-0 FS-2

Facility

$18.00

Hospital Charge Code	22355132
Hospital Revenue Code	270
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$16.20
Rate for Payer: Aetna of AZ Commercial	$16.20
Rate for Payer: Cash Price	$14.40

SUTURE PROLENE 3-0 RB-1

Facility

$71.00

Hospital Charge Code	22355475
Hospital Revenue Code	270
Min. Negotiated Rate	$11.25
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Arizona Complete Health Allwell	$11.36
Rate for Payer: Banner UC Health Medicare	$11.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$48.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.36
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cigna of AZ Commercial	$49.70
Rate for Payer: Devoted Health Medicare	$12.78
Rate for Payer: Humana of AZ Medicare	$11.36
Rate for Payer: Southwest Service Administrators UFCW	$48.28
Rate for Payer: TriWest Medicare	$11.36
Rate for Payer: United Healthcare Commercial	$40.61
Rate for Payer: United Healthcare Medicare	$11.36
Rate for Payer: Veterans Affairs TRICARE	$11.25

SUTURE PROLENE 3-0 RB-1

Facility

$71.00

Hospital Charge Code	22355475
Hospital Revenue Code	270
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Cash Price	$56.80

SUTURE PROLENE 3-0 SH

Facility

$69.00

Hospital Charge Code	22355449
Hospital Revenue Code	270
Min. Negotiated Rate	$62.10
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Cash Price	$55.20

SUTURE PROLENE 3-0 SH

Facility

$69.00

Hospital Charge Code	22355449
Hospital Revenue Code	270
Min. Negotiated Rate	$10.93
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Arizona Complete Health Allwell	$11.04
Rate for Payer: Banner UC Health Medicare	$11.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$46.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.04
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cigna of AZ Commercial	$48.30
Rate for Payer: Devoted Health Medicare	$12.42
Rate for Payer: Humana of AZ Medicare	$11.04
Rate for Payer: Southwest Service Administrators UFCW	$46.92
Rate for Payer: TriWest Medicare	$11.04
Rate for Payer: United Healthcare Commercial	$39.47
Rate for Payer: United Healthcare Medicare	$11.04
Rate for Payer: Veterans Affairs TRICARE	$10.93

SUTURE PROLENE 4-0 FS-1

Facility

$69.00

Hospital Charge Code	22355473
Hospital Revenue Code	270
Min. Negotiated Rate	$62.10
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Cash Price	$55.20

SUTURE PROLENE 4-0 FS-1

Facility

$69.00

Hospital Charge Code	22355473
Hospital Revenue Code	270
Min. Negotiated Rate	$10.93
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Arizona Complete Health Allwell	$11.04
Rate for Payer: Banner UC Health Medicare	$11.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$46.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.04
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cigna of AZ Commercial	$48.30
Rate for Payer: Devoted Health Medicare	$12.42
Rate for Payer: Humana of AZ Medicare	$11.04
Rate for Payer: Southwest Service Administrators UFCW	$46.92
Rate for Payer: TriWest Medicare	$11.04
Rate for Payer: United Healthcare Commercial	$39.47
Rate for Payer: United Healthcare Medicare	$11.04
Rate for Payer: Veterans Affairs TRICARE	$10.93

SUTURE PROLENE 4-0 FS-2

Facility

$18.00

Hospital Charge Code	22355133
Hospital Revenue Code	270
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$16.20
Rate for Payer: Aetna of AZ Commercial	$16.20
Rate for Payer: Arizona Complete Health Allwell	$2.88
Rate for Payer: Banner UC Health Medicare	$2.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$12.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.88
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna of AZ Commercial	$12.60
Rate for Payer: Devoted Health Medicare	$3.24
Rate for Payer: Humana of AZ Medicare	$2.88
Rate for Payer: Southwest Service Administrators UFCW	$12.24
Rate for Payer: TriWest Medicare	$2.88
Rate for Payer: United Healthcare Commercial	$10.30
Rate for Payer: United Healthcare Medicare	$2.88
Rate for Payer: Veterans Affairs TRICARE	$2.85

SUTURE PROLENE 4-0 FS-2

Facility

$18.00

Hospital Charge Code	22355133
Hospital Revenue Code	270
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$16.20
Rate for Payer: Aetna of AZ Commercial	$16.20
Rate for Payer: Cash Price	$14.40

SUTURE PROLENE 4-0 PC-3

Facility

$105.00

Hospital Charge Code	22355130
Hospital Revenue Code	270
Min. Negotiated Rate	$16.63
Max. Negotiated Rate	$94.50
Rate for Payer: Aetna of AZ Commercial	$94.50
Rate for Payer: Arizona Complete Health Allwell	$16.80
Rate for Payer: Banner UC Health Medicare	$16.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$71.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.80
Rate for Payer: Cash Price	$84.00
Rate for Payer: Cigna of AZ Commercial	$73.50
Rate for Payer: Devoted Health Medicare	$18.90
Rate for Payer: Humana of AZ Medicare	$16.80
Rate for Payer: Southwest Service Administrators UFCW	$71.40
Rate for Payer: TriWest Medicare	$16.80
Rate for Payer: United Healthcare Commercial	$60.06
Rate for Payer: United Healthcare Medicare	$16.80
Rate for Payer: Veterans Affairs TRICARE	$16.63

SUTURE PROLENE 4-0 PC-3

Facility

$105.00

Hospital Charge Code	22355130
Hospital Revenue Code	270
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$94.50
Rate for Payer: Aetna of AZ Commercial	$94.50
Rate for Payer: Cash Price	$84.00

SUTURE PROLENE 4-0 RB-1

Facility

$107.00

Hospital Charge Code	22355472
Hospital Revenue Code	270
Min. Negotiated Rate	$96.30
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Cash Price	$85.60

SUTURE PROLENE 4-0 RB-1

Facility

$107.00

Hospital Charge Code	22355472
Hospital Revenue Code	270
Min. Negotiated Rate	$16.95
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Arizona Complete Health Allwell	$17.12
Rate for Payer: Banner UC Health Medicare	$17.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$72.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.12
Rate for Payer: Cash Price	$85.60
Rate for Payer: Cigna of AZ Commercial	$74.90
Rate for Payer: Devoted Health Medicare	$19.26
Rate for Payer: Humana of AZ Medicare	$17.12
Rate for Payer: Southwest Service Administrators UFCW	$72.76
Rate for Payer: TriWest Medicare	$17.12
Rate for Payer: United Healthcare Commercial	$61.20
Rate for Payer: United Healthcare Medicare	$17.12
Rate for Payer: Veterans Affairs TRICARE	$16.95

SUTURE PROLENE 4-0 SH

Facility

$69.00

Hospital Charge Code	22355451
Hospital Revenue Code	270
Min. Negotiated Rate	$62.10
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Cash Price	$55.20

SUTURE PROLENE 4-0 SH

Facility

$69.00

Hospital Charge Code	22355451
Hospital Revenue Code	270
Min. Negotiated Rate	$10.93
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Arizona Complete Health Allwell	$11.04
Rate for Payer: Banner UC Health Medicare	$11.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$46.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.04
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cigna of AZ Commercial	$48.30
Rate for Payer: Devoted Health Medicare	$12.42
Rate for Payer: Humana of AZ Medicare	$11.04
Rate for Payer: Southwest Service Administrators UFCW	$46.92
Rate for Payer: TriWest Medicare	$11.04
Rate for Payer: United Healthcare Commercial	$39.47
Rate for Payer: United Healthcare Medicare	$11.04
Rate for Payer: Veterans Affairs TRICARE	$10.93

SUTURE PROLENE 5-0 C-13 SURGIPRO

Facility

$63.00

Hospital Charge Code	22355500
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 PROLENE 5-0 C-13 SURGIPRO

Facility

$63.00

Hospital Charge Code	22355500
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 PROLENE 5-0 P-3

Facility

$33.00

Hospital Charge Code	22355186
Hospital Revenue Code	270
Min. Negotiated Rate	$5.23
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Arizona Complete Health Allwell	$5.28
Rate for Payer: Banner UC Health Medicare	$5.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$22.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.28
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cigna of AZ Commercial	$23.10
Rate for Payer: Devoted Health Medicare	$5.94
Rate for Payer: Humana of AZ Medicare	$5.28
Rate for Payer: Southwest Service Administrators UFCW	$22.44
Rate for Payer: TriWest Medicare	$5.28
Rate for Payer: United Healthcare Commercial	$18.88
Rate for Payer: United Healthcare Medicare	$5.28
Rate for Payer: Veterans Affairs TRICARE	$5.23

SUTURE PROLENE 5-0 P-3

Facility

$33.00

Hospital Charge Code	22355186
Hospital Revenue Code	270
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$29.70
Rate for Payer: Aetna of AZ Commercial	$29.70
Rate for Payer: Cash Price	$26.40

SUTURE PROLENE 5-0 RB-1

Facility

$107.00

Hospital Charge Code	22355471
Hospital Revenue Code	270
Min. Negotiated Rate	$96.30
Max. Negotiated Rate	$96.30
Rate for Payer: Aetna of AZ Commercial	$96.30
Rate for Payer: Cash Price	$85.60

Know your out-of-pocket cost for care.

All Charges