Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

SUTURE VICRYL 2-0 CT-2

Facility

$46.00

Hospital Charge Code	22355491
Hospital Revenue Code	270
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of AZ Commercial	$41.40
Rate for Payer: Arizona Complete Health Allwell	$7.36
Rate for Payer: Banner UC Health Medicare	$7.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$31.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.36
Rate for Payer: Cash Price	$36.80
Rate for Payer: Cigna of AZ Commercial	$32.20
Rate for Payer: Devoted Health Medicare	$8.28
Rate for Payer: Humana of AZ Medicare	$7.36
Rate for Payer: Southwest Service Administrators UFCW	$31.28
Rate for Payer: TriWest Medicare	$7.36
Rate for Payer: United Healthcare Commercial	$26.31
Rate for Payer: United Healthcare Medicare	$7.36
Rate for Payer: Veterans Affairs TRICARE	$7.29

SUTURE VICRYL 2-0 CT-3

Facility

$13.00

Hospital Charge Code	22355480
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-3

Facility

$13.00

Hospital Charge Code	22355480
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 SH

Facility

$44.00

Hospital Charge Code	22355455
Hospital Revenue Code	270
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$39.60
Rate for Payer: Aetna of AZ Commercial	$39.60
Rate for Payer: Cash Price	$35.20

SUTURE VICRYL 2-0 SH

Facility

$44.00

Hospital Charge Code	22355455
Hospital Revenue Code	270
Min. Negotiated Rate	$6.97
Max. Negotiated Rate	$39.60
Rate for Payer: Aetna of AZ Commercial	$39.60
Rate for Payer: Arizona Complete Health Allwell	$7.04
Rate for Payer: Banner UC Health Medicare	$7.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$29.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.04
Rate for Payer: Cash Price	$35.20
Rate for Payer: Cigna of AZ Commercial	$30.80
Rate for Payer: Devoted Health Medicare	$7.92
Rate for Payer: Humana of AZ Medicare	$7.04
Rate for Payer: Southwest Service Administrators UFCW	$29.92
Rate for Payer: TriWest Medicare	$7.04
Rate for Payer: United Healthcare Commercial	$25.17
Rate for Payer: United Healthcare Medicare	$7.04
Rate for Payer: Veterans Affairs TRICARE	$6.97

SUTURE VICRYL 2-0 SPAK TIES

Facility

$55.00

Hospital Charge Code	22355363
Hospital Revenue Code	270
Min. Negotiated Rate	$8.71
Max. Negotiated Rate	$49.50
Rate for Payer: Aetna of AZ Commercial	$49.50
Rate for Payer: Arizona Complete Health Allwell	$8.80
Rate for Payer: Banner UC Health Medicare	$8.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$37.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.80
Rate for Payer: Cash Price	$44.00
Rate for Payer: Cigna of AZ Commercial	$38.50
Rate for Payer: Devoted Health Medicare	$9.90
Rate for Payer: Humana of AZ Medicare	$8.80
Rate for Payer: Southwest Service Administrators UFCW	$37.40
Rate for Payer: TriWest Medicare	$8.80
Rate for Payer: United Healthcare Commercial	$31.46
Rate for Payer: United Healthcare Medicare	$8.80
Rate for Payer: Veterans Affairs TRICARE	$8.71

SUTURE VICRYL 2-0 SPAK TIES

Facility

$55.00

Hospital Charge Code	22355363
Hospital Revenue Code	270
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$49.50
Rate for Payer: Aetna of AZ Commercial	$49.50
Rate for Payer: Cash Price	$44.00

SUTURE VICRYL 3-0 12-18 SPAK TIES

Facility

$65.00

Hospital Charge Code	22355369
Hospital Revenue Code	270
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of AZ Commercial	$58.50
Rate for Payer: Arizona Complete Health Allwell	$10.40
Rate for Payer: Banner UC Health Medicare	$10.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$44.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.40
Rate for Payer: Cash Price	$52.00
Rate for Payer: Cigna of AZ Commercial	$45.50
Rate for Payer: Devoted Health Medicare	$11.70
Rate for Payer: Humana of AZ Medicare	$10.40
Rate for Payer: Southwest Service Administrators UFCW	$44.20
Rate for Payer: TriWest Medicare	$10.40
Rate for Payer: United Healthcare Commercial	$37.18
Rate for Payer: United Healthcare Medicare	$10.40
Rate for Payer: Veterans Affairs TRICARE	$10.30

SUTURE VICRYL 3-0 12-18 SPAK TIES

Facility

$65.00

Hospital Charge Code	22355369
Hospital Revenue Code	270
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of AZ Commercial	$58.50
Rate for Payer: Cash Price	$52.00

SUTURE VICRYL 3-0 27-IN SH

Facility

$69.00

Hospital Charge Code	22355203
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 3-0 27-IN SH

Facility

$69.00

Hospital Charge Code	22355203
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 3-0 36-IN CT-1

Facility

$74.00

Hospital Charge Code	22355205
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 VICRYL 3-0 36-IN CT-1

Facility

$74.00

Hospital Charge Code	22355205
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 VICRYL 3-0 CT-1

Facility

$46.00

Hospital Charge Code	22355452
Hospital Revenue Code	270
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of AZ Commercial	$41.40
Rate for Payer: Arizona Complete Health Allwell	$7.36
Rate for Payer: Banner UC Health Medicare	$7.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$31.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.36
Rate for Payer: Cash Price	$36.80
Rate for Payer: Cigna of AZ Commercial	$32.20
Rate for Payer: Devoted Health Medicare	$8.28
Rate for Payer: Humana of AZ Medicare	$7.36
Rate for Payer: Southwest Service Administrators UFCW	$31.28
Rate for Payer: TriWest Medicare	$7.36
Rate for Payer: United Healthcare Commercial	$26.31
Rate for Payer: United Healthcare Medicare	$7.36
Rate for Payer: Veterans Affairs TRICARE	$7.29

SUTURE VICRYL 3-0 CT-1

Facility

$46.00

Hospital Charge Code	22355452
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

SUTURE VICRYL 3-0 CT-2

Facility

$45.00

Hospital Charge Code	22355489
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 3-0 CT-2

Facility

$45.00

Hospital Charge Code	22355489
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 3-0 FS-1

Facility

$17.00

Hospital Charge Code	22355494
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 VICRYL 3-0 FS-1

Facility

$17.00

Hospital Charge Code	22355494
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 VICRYL 3-0 PS-2

Facility

$77.00

Hospital Charge Code	22355178
Hospital Revenue Code	270
Min. Negotiated Rate	$12.20
Max. Negotiated Rate	$69.30
Rate for Payer: Aetna of AZ Commercial	$69.30
Rate for Payer: Arizona Complete Health Allwell	$12.32
Rate for Payer: Banner UC Health Medicare	$12.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$52.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.32
Rate for Payer: Cash Price	$61.60
Rate for Payer: Cigna of AZ Commercial	$53.90
Rate for Payer: Devoted Health Medicare	$13.86
Rate for Payer: Humana of AZ Medicare	$12.32
Rate for Payer: Southwest Service Administrators UFCW	$52.36
Rate for Payer: TriWest Medicare	$12.32
Rate for Payer: United Healthcare Commercial	$44.04
Rate for Payer: United Healthcare Medicare	$12.32
Rate for Payer: Veterans Affairs TRICARE	$12.20

SUTURE VICRYL 3-0 PS-2

Facility

$77.00

Hospital Charge Code	22355178
Hospital Revenue Code	270
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$69.30
Rate for Payer: Aetna of AZ Commercial	$69.30
Rate for Payer: Cash Price	$61.60

SUTURE VICRYL 3-0 SH

Facility

$45.00

Hospital Charge Code	22355482
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 3-0 SH

Facility

$45.00

Hospital Charge Code	22355482
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 3-0 SPAK TIES

Facility

$160.00

Hospital Charge Code	22355374
Hospital Revenue Code	270
Min. Negotiated Rate	$144.00
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna of AZ Commercial	$144.00
Rate for Payer: Cash Price	$128.00

SUTURE VICRYL 3-0 SPAK TIES

Facility

$160.00

Hospital Charge Code	22355374
Hospital Revenue Code	270
Min. Negotiated Rate	$25.34
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna of AZ Commercial	$144.00
Rate for Payer: Arizona Complete Health Allwell	$25.60
Rate for Payer: Banner UC Health Medicare	$25.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$108.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$25.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$25.60
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cigna of AZ Commercial	$112.00
Rate for Payer: Devoted Health Medicare	$28.80
Rate for Payer: Humana of AZ Medicare	$25.60
Rate for Payer: Southwest Service Administrators UFCW	$108.80
Rate for Payer: TriWest Medicare	$25.60
Rate for Payer: United Healthcare Commercial	$91.52
Rate for Payer: United Healthcare Medicare	$25.60
Rate for Payer: Veterans Affairs TRICARE	$25.34

Know your out-of-pocket cost for care.

All Charges