Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

TRAUMATIC INJURY WITH MCC

Facility

$21,125.80

Service Code	MSDRG 913
Min. Negotiated Rate	$21,125.80
Max. Negotiated Rate	$21,125.80
Rate for Payer: Seven Corners Travel Insurance	$21,125.80

TRAUMATIC INJURY WITHOUT MCC

Facility

$11,575.77

Service Code	MSDRG 914
Min. Negotiated Rate	$11,575.77
Max. Negotiated Rate	$11,575.77
Rate for Payer: Seven Corners Travel Insurance	$11,575.77

TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC

Facility

$16,862.17

Service Code	MSDRG 086
Min. Negotiated Rate	$16,862.17
Max. Negotiated Rate	$16,862.17
Rate for Payer: Seven Corners Travel Insurance	$16,862.17

TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC

Facility

$18,041.90

Service Code	MSDRG 083
Min. Negotiated Rate	$18,041.90
Max. Negotiated Rate	$18,041.90
Rate for Payer: Seven Corners Travel Insurance	$18,041.90

TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC

Facility

$29,362.34

Service Code	MSDRG 085
Min. Negotiated Rate	$29,362.34
Max. Negotiated Rate	$29,362.34
Rate for Payer: Seven Corners Travel Insurance	$29,362.34

TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC

Facility

$29,539.43

Service Code	MSDRG 082
Min. Negotiated Rate	$29,539.43
Max. Negotiated Rate	$29,539.43
Rate for Payer: Seven Corners Travel Insurance	$29,539.43

TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC

Facility

$11,945.78

Service Code	MSDRG 087
Min. Negotiated Rate	$11,945.78
Max. Negotiated Rate	$11,945.78
Rate for Payer: Seven Corners Travel Insurance	$11,945.78

TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC

Facility

$12,466.55

Service Code	MSDRG 084
Min. Negotiated Rate	$12,466.55
Max. Negotiated Rate	$12,466.55
Rate for Payer: Seven Corners Travel Insurance	$12,466.55

TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC

Facility

$19,025.61

Service Code	MSDRG 604
Min. Negotiated Rate	$19,025.61
Max. Negotiated Rate	$19,025.61
Rate for Payer: Seven Corners Travel Insurance	$19,025.61

TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC

Facility

$11,962.21

Service Code	MSDRG 605
Min. Negotiated Rate	$11,962.21
Max. Negotiated Rate	$11,962.21
Rate for Payer: Seven Corners Travel Insurance	$11,962.21

TRAY BASIC 30CC

Facility

$14.00

Hospital Charge Code	22355321
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

TRAY BASIC 30CC

Facility

$14.00

Hospital Charge Code	22355321
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

TRAY DRESSING CHANGE

Facility

$23.00

Hospital Charge Code	22531720
Hospital Revenue Code	272
Min. Negotiated Rate	$3.64
Max. Negotiated Rate	$20.70
Rate for Payer: Aetna of AZ Commercial	$20.70
Rate for Payer: Arizona Complete Health Allwell	$3.68
Rate for Payer: Banner UC Health Medicare	$3.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$15.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$3.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$3.68
Rate for Payer: Cash Price	$18.40
Rate for Payer: Cigna of AZ Commercial	$16.10
Rate for Payer: Devoted Health Medicare	$4.14
Rate for Payer: Humana of AZ Medicare	$3.68
Rate for Payer: Southwest Service Administrators UFCW	$15.64
Rate for Payer: TriWest Medicare	$3.68
Rate for Payer: United Healthcare Commercial	$13.16
Rate for Payer: United Healthcare Medicare	$3.68
Rate for Payer: Veterans Affairs TRICARE	$3.64

TRAY DRESSING CHANGE

Facility

$23.00

Hospital Charge Code	22531720
Hospital Revenue Code	272
Min. Negotiated Rate	$20.70
Max. Negotiated Rate	$20.70
Rate for Payer: Aetna of AZ Commercial	$20.70
Rate for Payer: Cash Price	$18.40

TRAY EZ PREP

Facility

$41.00

Hospital Charge Code	22355323
Hospital Revenue Code	270
Min. Negotiated Rate	$6.49
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of AZ Commercial	$36.90
Rate for Payer: Arizona Complete Health Allwell	$6.56
Rate for Payer: Banner UC Health Medicare	$6.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$27.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.56
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cigna of AZ Commercial	$28.70
Rate for Payer: Devoted Health Medicare	$7.38
Rate for Payer: Humana of AZ Medicare	$6.56
Rate for Payer: Southwest Service Administrators UFCW	$27.88
Rate for Payer: TriWest Medicare	$6.56
Rate for Payer: United Healthcare Commercial	$23.45
Rate for Payer: United Healthcare Medicare	$6.56
Rate for Payer: Veterans Affairs TRICARE	$6.49

TRAY EZ PREP

Facility

$41.00

Hospital Charge Code	22355323
Hospital Revenue Code	270
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of AZ Commercial	$36.90
Rate for Payer: Cash Price	$32.80

TRAY FOLEY 10CC W/O BAG

Facility

$155.00

Hospital Charge Code	22355307
Hospital Revenue Code	270
Min. Negotiated Rate	$139.50
Max. Negotiated Rate	$139.50
Rate for Payer: Aetna of AZ Commercial	$139.50
Rate for Payer: Cash Price	$124.00

TRAY FOLEY 10CC W/O BAG

Facility

$155.00

Hospital Charge Code	22355307
Hospital Revenue Code	270
Min. Negotiated Rate	$24.55
Max. Negotiated Rate	$139.50
Rate for Payer: Aetna of AZ Commercial	$139.50
Rate for Payer: Arizona Complete Health Allwell	$24.80
Rate for Payer: Banner UC Health Medicare	$24.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$105.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$24.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$24.80
Rate for Payer: Cash Price	$124.00
Rate for Payer: Cigna of AZ Commercial	$108.50
Rate for Payer: Devoted Health Medicare	$27.90
Rate for Payer: Humana of AZ Medicare	$24.80
Rate for Payer: Southwest Service Administrators UFCW	$105.40
Rate for Payer: TriWest Medicare	$24.80
Rate for Payer: United Healthcare Commercial	$88.66
Rate for Payer: United Healthcare Medicare	$24.80
Rate for Payer: Veterans Affairs TRICARE	$24.55

TRAY FOLEY 18F AUTO

Facility

$43.00

Service Code	HCPCS A4314
Hospital Charge Code	22354964
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

TRAY FOLEY 18F AUTO

Facility

$43.00

Service Code	HCPCS A4314
Hospital Charge Code	22354964
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

TRAY GASTROSTOMY 20F

Facility

$1,332.00

Hospital Charge Code	22354768
Hospital Revenue Code	270
Min. Negotiated Rate	$210.99
Max. Negotiated Rate	$1,198.80
Rate for Payer: Aetna of AZ Commercial	$1,198.80
Rate for Payer: Arizona Complete Health Allwell	$213.12
Rate for Payer: Banner UC Health Medicare	$213.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$905.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$213.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$213.12
Rate for Payer: Cash Price	$1,065.60
Rate for Payer: Cigna of AZ Commercial	$932.40
Rate for Payer: Devoted Health Medicare	$239.76
Rate for Payer: Humana of AZ Medicare	$213.12
Rate for Payer: Southwest Service Administrators UFCW	$905.76
Rate for Payer: TriWest Medicare	$213.12
Rate for Payer: United Healthcare Commercial	$761.90
Rate for Payer: United Healthcare Medicare	$213.12
Rate for Payer: Veterans Affairs TRICARE	$210.99

TRAY GASTROSTOMY 20F

Facility

$1,332.00

Hospital Charge Code	22354768
Hospital Revenue Code	270
Min. Negotiated Rate	$1,198.80
Max. Negotiated Rate	$1,198.80
Rate for Payer: Aetna of AZ Commercial	$1,198.80
Rate for Payer: Cash Price	$1,065.60

TRAY IRRIG PISTON SYRINGE 70CC

Facility

$9.00

Hospital Charge Code	22355319
Hospital Revenue Code	270
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Cash Price	$7.20

TRAY IRRIG PISTON SYRINGE 70CC

Facility

$9.00

Hospital Charge Code	22355319
Hospital Revenue Code	270
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Arizona Complete Health Allwell	$1.44
Rate for Payer: Banner UC Health Medicare	$1.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$6.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.44
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna of AZ Commercial	$6.30
Rate for Payer: Devoted Health Medicare	$1.62
Rate for Payer: Humana of AZ Medicare	$1.44
Rate for Payer: Southwest Service Administrators UFCW	$6.12
Rate for Payer: TriWest Medicare	$1.44
Rate for Payer: United Healthcare Commercial	$5.15
Rate for Payer: United Healthcare Medicare	$1.44
Rate for Payer: Veterans Affairs TRICARE	$1.43

TRAY LACERATION STR ER

Facility

$34.00

Hospital Charge Code	22355311
Hospital Revenue Code	270
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$30.60
Rate for Payer: Aetna of AZ Commercial	$30.60
Rate for Payer: Cash Price	$27.20

Know your out-of-pocket cost for care.

All Charges