Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

SUTURE VICRYL 0 CT-1 CR8

Facility

$210.00

Hospital Charge Code	22355200
Hospital Revenue Code	270
Min. Negotiated Rate	$33.26
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Arizona Complete Health Allwell	$33.60
Rate for Payer: Banner UC Health Medicare	$33.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$142.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$33.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$33.60
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cigna of AZ Commercial	$147.00
Rate for Payer: Devoted Health Medicare	$37.80
Rate for Payer: Humana of AZ Medicare	$33.60
Rate for Payer: Southwest Service Administrators UFCW	$142.80
Rate for Payer: TriWest Medicare	$33.60
Rate for Payer: United Healthcare Commercial	$120.12
Rate for Payer: United Healthcare Medicare	$33.60
Rate for Payer: Veterans Affairs TRICARE	$33.26

SUTURE VICRYL 0 CT-1 CR8

Facility

$210.00

Hospital Charge Code	22355200
Hospital Revenue Code	270
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Cash Price	$168.00

SUTURE VICRYL 0 CT-1 J260H

Facility

$16.00

Hospital Charge Code	22355459
Hospital Revenue Code	270
Min. Negotiated Rate	$2.53
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Arizona Complete Health Allwell	$2.56
Rate for Payer: Banner UC Health Medicare	$2.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$10.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.56
Rate for Payer: Cash Price	$12.80
Rate for Payer: Cigna of AZ Commercial	$11.20
Rate for Payer: Devoted Health Medicare	$2.88
Rate for Payer: Humana of AZ Medicare	$2.56
Rate for Payer: Southwest Service Administrators UFCW	$10.88
Rate for Payer: TriWest Medicare	$2.56
Rate for Payer: United Healthcare Commercial	$9.15
Rate for Payer: United Healthcare Medicare	$2.56
Rate for Payer: Veterans Affairs TRICARE	$2.53

SUTURE VICRYL 0 CT-1 J260H

Facility

$16.00

Hospital Charge Code	22355459
Hospital Revenue Code	270
Min. Negotiated Rate	$14.40
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of AZ Commercial	$14.40
Rate for Payer: Cash Price	$12.80

SUTURE VICRYL 0 CT-2

Facility

$45.00

Hospital Charge Code	22355492
Hospital Revenue Code	270
Min. Negotiated Rate	$40.50
Max. Negotiated Rate	$40.50
Rate for Payer: Aetna of AZ Commercial	$40.50
Rate for Payer: Cash Price	$36.00

SUTURE VICRYL 0 CT-2

Facility

$45.00

Hospital Charge Code	22355492
Hospital Revenue Code	270
Min. Negotiated Rate	$7.13
Max. Negotiated Rate	$40.50
Rate for Payer: Aetna of AZ Commercial	$40.50
Rate for Payer: Arizona Complete Health Allwell	$7.20
Rate for Payer: Banner UC Health Medicare	$7.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$30.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna of AZ Commercial	$31.50
Rate for Payer: Devoted Health Medicare	$8.10
Rate for Payer: Humana of AZ Medicare	$7.20
Rate for Payer: Southwest Service Administrators UFCW	$30.60
Rate for Payer: TriWest Medicare	$7.20
Rate for Payer: United Healthcare Commercial	$25.74
Rate for Payer: United Healthcare Medicare	$7.20
Rate for Payer: Veterans Affairs TRICARE	$7.13

SUTURE VICRYL 0 ENDOLOOP

Facility

$268.00

Hospital Charge Code	22355191
Hospital Revenue Code	270
Min. Negotiated Rate	$42.45
Max. Negotiated Rate	$241.20
Rate for Payer: Aetna of AZ Commercial	$241.20
Rate for Payer: Arizona Complete Health Allwell	$42.88
Rate for Payer: Banner UC Health Medicare	$42.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$182.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$42.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$42.88
Rate for Payer: Cash Price	$214.40
Rate for Payer: Cigna of AZ Commercial	$187.60
Rate for Payer: Devoted Health Medicare	$48.24
Rate for Payer: Humana of AZ Medicare	$42.88
Rate for Payer: Southwest Service Administrators UFCW	$182.24
Rate for Payer: TriWest Medicare	$42.88
Rate for Payer: United Healthcare Commercial	$153.30
Rate for Payer: United Healthcare Medicare	$42.88
Rate for Payer: Veterans Affairs TRICARE	$42.45

SUTURE VICRYL 0 ENDOLOOP

Facility

$268.00

Hospital Charge Code	22355191
Hospital Revenue Code	270
Min. Negotiated Rate	$241.20
Max. Negotiated Rate	$241.20
Rate for Payer: Aetna of AZ Commercial	$241.20
Rate for Payer: Cash Price	$214.40

SUTURE VICRYL 0 OS-6

Facility

$19.00

Hospital Charge Code	22355483
Hospital Revenue Code	270
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$17.10
Rate for Payer: Aetna of AZ Commercial	$17.10
Rate for Payer: Arizona Complete Health Allwell	$3.04
Rate for Payer: Banner UC Health Medicare	$3.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$12.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.04
Rate for Payer: Cash Price	$15.20
Rate for Payer: Cigna of AZ Commercial	$13.30
Rate for Payer: Devoted Health Medicare	$3.42
Rate for Payer: Humana of AZ Medicare	$3.04
Rate for Payer: Southwest Service Administrators UFCW	$12.92
Rate for Payer: TriWest Medicare	$3.04
Rate for Payer: United Healthcare Commercial	$10.87
Rate for Payer: United Healthcare Medicare	$3.04
Rate for Payer: Veterans Affairs TRICARE	$3.01

SUTURE VICRYL 0 OS-6

Facility

$19.00

Hospital Charge Code	22355483
Hospital Revenue Code	270
Min. Negotiated Rate	$17.10
Max. Negotiated Rate	$17.10
Rate for Payer: Aetna of AZ Commercial	$17.10
Rate for Payer: Cash Price	$15.20

SUTURE VICRYL 0 SPAK TIES

Facility

$97.00

Hospital Charge Code	22355373
Hospital Revenue Code	270
Min. Negotiated Rate	$15.36
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna of AZ Commercial	$87.30
Rate for Payer: Arizona Complete Health Allwell	$15.52
Rate for Payer: Banner UC Health Medicare	$15.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$65.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$15.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.52
Rate for Payer: Cash Price	$77.60
Rate for Payer: Cigna of AZ Commercial	$67.90
Rate for Payer: Devoted Health Medicare	$17.46
Rate for Payer: Humana of AZ Medicare	$15.52
Rate for Payer: Southwest Service Administrators UFCW	$65.96
Rate for Payer: TriWest Medicare	$15.52
Rate for Payer: United Healthcare Commercial	$55.48
Rate for Payer: United Healthcare Medicare	$15.52
Rate for Payer: Veterans Affairs TRICARE	$15.36

SUTURE VICRYL 0 SPAK TIES

Facility

$97.00

Hospital Charge Code	22355373
Hospital Revenue Code	270
Min. Negotiated Rate	$87.30
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna of AZ Commercial	$87.30
Rate for Payer: Cash Price	$77.60

SUTURE VICRYL 0 UR-6

Facility

$15.00

Hospital Charge Code	22355496
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 VICRYL 0 UR-6

Facility

$15.00

Hospital Charge Code	22355496
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

SUTURE VICRYL 1-0 CT-1

Facility

$84.00

Hospital Charge Code	22355458
Hospital Revenue Code	270
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Cash Price	$67.20

SUTURE VICRYL 1-0 CT-1

Facility

$84.00

Hospital Charge Code	22355458
Hospital Revenue Code	270
Min. Negotiated Rate	$13.31
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Arizona Complete Health Allwell	$13.44
Rate for Payer: Banner UC Health Medicare	$13.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$57.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.44
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cigna of AZ Commercial	$58.80
Rate for Payer: Devoted Health Medicare	$15.12
Rate for Payer: Humana of AZ Medicare	$13.44
Rate for Payer: Southwest Service Administrators UFCW	$57.12
Rate for Payer: TriWest Medicare	$13.44
Rate for Payer: United Healthcare Commercial	$48.05
Rate for Payer: United Healthcare Medicare	$13.44
Rate for Payer: Veterans Affairs TRICARE	$13.31

SUTURE VICRYL 2-0 27-IN SH

Facility

$69.00

Hospital Charge Code	22355204
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 VICRYL 2-0 27-IN SH

Facility

$69.00

Hospital Charge Code	22355204
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 VICRYL 2-0 CP-1

Facility

$14.00

Hospital Charge Code	22355454
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 VICRYL 2-0 CP-1

Facility

$14.00

Hospital Charge Code	22355454
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 VICRYL 2-0 CT-1

Facility

$13.00

Hospital Charge Code	22355490
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 VICRYL 2-0 CT-1

Facility

$13.00

Hospital Charge Code	22355490
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 VICRYL 2-0 CT-1 CR8

Facility

$223.00

Hospital Charge Code	22355201
Hospital Revenue Code	270
Min. Negotiated Rate	$35.32
Max. Negotiated Rate	$200.70
Rate for Payer: Aetna of AZ Commercial	$200.70
Rate for Payer: Arizona Complete Health Allwell	$35.68
Rate for Payer: Banner UC Health Medicare	$35.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$151.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$35.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$35.68
Rate for Payer: Cash Price	$178.40
Rate for Payer: Cigna of AZ Commercial	$156.10
Rate for Payer: Devoted Health Medicare	$40.14
Rate for Payer: Humana of AZ Medicare	$35.68
Rate for Payer: Southwest Service Administrators UFCW	$151.64
Rate for Payer: TriWest Medicare	$35.68
Rate for Payer: United Healthcare Commercial	$127.56
Rate for Payer: United Healthcare Medicare	$35.68
Rate for Payer: Veterans Affairs TRICARE	$35.32

SUTURE VICRYL 2-0 CT-1 CR8

Facility

$223.00

Hospital Charge Code	22355201
Hospital Revenue Code	270
Min. Negotiated Rate	$200.70
Max. Negotiated Rate	$200.70
Rate for Payer: Aetna of AZ Commercial	$200.70
Rate for Payer: Cash Price	$178.40

SUTURE VICRYL 2-0 CT-2

Facility

$46.00

Hospital Charge Code	22355491
Hospital Revenue Code	270
Min. Negotiated Rate	$41.40
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of AZ Commercial	$41.40
Rate for Payer: Cash Price	$36.80

Know your out-of-pocket cost for care.

All Charges