Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

TUBE NG SALEM SUMP 12FR

Facility

$12.00

Hospital Charge Code	22355571
Hospital Revenue Code	270
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$10.80
Rate for Payer: Aetna of AZ Commercial	$10.80
Rate for Payer: Cash Price	$9.60

TUBE NG SALEM SUMP 14FR

Facility

$12.00

Hospital Charge Code	22355572
Hospital Revenue Code	270
Min. Negotiated Rate	$1.90
Max. Negotiated Rate	$10.80
Rate for Payer: Aetna of AZ Commercial	$10.80
Rate for Payer: Arizona Complete Health Allwell	$1.92
Rate for Payer: Banner UC Health Medicare	$1.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$8.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.92
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cigna of AZ Commercial	$8.40
Rate for Payer: Devoted Health Medicare	$2.16
Rate for Payer: Humana of AZ Medicare	$1.92
Rate for Payer: Southwest Service Administrators UFCW	$8.16
Rate for Payer: TriWest Medicare	$1.92
Rate for Payer: United Healthcare Commercial	$6.86
Rate for Payer: United Healthcare Medicare	$1.92
Rate for Payer: Veterans Affairs TRICARE	$1.90

TUBE NG SALEM SUMP 14FR

Facility

$12.00

Hospital Charge Code	22355572
Hospital Revenue Code	270
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$10.80
Rate for Payer: Aetna of AZ Commercial	$10.80
Rate for Payer: Cash Price	$9.60

TUBE NG SALEM SUMP 16FR

Facility

$13.00

Hospital Charge Code	22355585
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

TUBE NG SALEM SUMP 16FR

Facility

$13.00

Hospital Charge Code	22355585
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

TUBE NG SALEM SUMP 18FR

Facility

$13.00

Hospital Charge Code	22355586
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

TUBE NG SALEM SUMP 18FR

Facility

$13.00

Hospital Charge Code	22355586
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

TUBE NITRO GLYC IV

Facility

$70.00

Hospital Charge Code	22354259
Hospital Revenue Code	270
Min. Negotiated Rate	$11.09
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna of AZ Commercial	$63.00
Rate for Payer: Arizona Complete Health Allwell	$11.20
Rate for Payer: Banner UC Health Medicare	$11.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$47.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$11.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$11.20
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cigna of AZ Commercial	$49.00
Rate for Payer: Devoted Health Medicare	$12.60
Rate for Payer: Humana of AZ Medicare	$11.20
Rate for Payer: Southwest Service Administrators UFCW	$47.60
Rate for Payer: TriWest Medicare	$11.20
Rate for Payer: United Healthcare Commercial	$40.04
Rate for Payer: United Healthcare Medicare	$11.20
Rate for Payer: Veterans Affairs TRICARE	$11.09

TUBE NITRO GLYC IV

Facility

$70.00

Hospital Charge Code	22354259
Hospital Revenue Code	270
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna of AZ Commercial	$63.00
Rate for Payer: Cash Price	$56.00

tuberculin ppd 5 TU/0.1 mL ID Sol [CQCH]

Facility

$66.79

Service Code	NDC 49281075221
Hospital Charge Code	105944468
Hospital Revenue Code	251
Min. Negotiated Rate	$60.11
Max. Negotiated Rate	$60.11
Rate for Payer: Aetna of AZ Commercial	$60.11
Rate for Payer: Cash Price	$53.43

tuberculin ppd 5 TU/0.1 mL ID Sol [CQCH]

Facility

$66.79

Service Code	NDC 49281075221
Hospital Charge Code	105944468
Hospital Revenue Code	251
Min. Negotiated Rate	$10.58
Max. Negotiated Rate	$60.11
Rate for Payer: Aetna of AZ Commercial	$60.11
Rate for Payer: Arizona Complete Health Allwell	$10.69
Rate for Payer: Banner UC Health Medicare	$10.69
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$45.42
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.69
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.69
Rate for Payer: Cash Price	$53.43
Rate for Payer: Cigna of AZ Commercial	$43.41
Rate for Payer: Devoted Health Medicare	$12.02
Rate for Payer: Humana of AZ Medicare	$10.69
Rate for Payer: Southwest Service Administrators UFCW	$45.42
Rate for Payer: TriWest Medicare	$10.69
Rate for Payer: United Healthcare Commercial	$38.20
Rate for Payer: United Healthcare Medicare	$10.69
Rate for Payer: Veterans Affairs TRICARE	$10.58

TUBE SECONDARY IV

Facility

$9.00

Hospital Charge Code	22355541
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

TUBE SECONDARY IV

Facility

$9.00

Hospital Charge Code	22355541
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

TUBE SUMP SALEM 8FR W/FUNNEL

Facility

$57.00

Hospital Charge Code	23371935
Hospital Revenue Code	272
Min. Negotiated Rate	$9.03
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna of AZ Commercial	$51.30
Rate for Payer: Arizona Complete Health Allwell	$9.12
Rate for Payer: Banner UC Health Medicare	$9.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$38.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.12
Rate for Payer: Cash Price	$45.60
Rate for Payer: Cigna of AZ Commercial	$39.90
Rate for Payer: Devoted Health Medicare	$10.26
Rate for Payer: Humana of AZ Medicare	$9.12
Rate for Payer: Southwest Service Administrators UFCW	$38.76
Rate for Payer: TriWest Medicare	$9.12
Rate for Payer: United Healthcare Commercial	$32.60
Rate for Payer: United Healthcare Medicare	$9.12
Rate for Payer: Veterans Affairs TRICARE	$9.03

TUBE SUMP SALEM 8FR W/FUNNEL

Facility

$57.00

Hospital Charge Code	23371935
Hospital Revenue Code	272
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna of AZ Commercial	$51.30
Rate for Payer: Cash Price	$45.60

TUBE TRACH CUFFED 5.0

Facility

$9.00

Hospital Charge Code	22354958
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

TUBE TRACH CUFFED 5.0

Facility

$9.00

Hospital Charge Code	22354958
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

TUBE TRACH CUFFED 5.5

Facility

$8.00

Hospital Charge Code	22354930
Hospital Revenue Code	270
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Cash Price	$6.40

TUBE TRACH CUFFED 5.5

Facility

$8.00

Hospital Charge Code	22354930
Hospital Revenue Code	270
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Arizona Complete Health Allwell	$1.28
Rate for Payer: Banner UC Health Medicare	$1.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.28
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cigna of AZ Commercial	$5.60
Rate for Payer: Devoted Health Medicare	$1.44
Rate for Payer: Humana of AZ Medicare	$1.28
Rate for Payer: Southwest Service Administrators UFCW	$5.44
Rate for Payer: TriWest Medicare	$1.28
Rate for Payer: United Healthcare Commercial	$4.58
Rate for Payer: United Healthcare Medicare	$1.28
Rate for Payer: Veterans Affairs TRICARE	$1.27

TUBE TRACH CUFFED 6.0

Facility

$250.00

Hospital Charge Code	22354834
Hospital Revenue Code	270
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna of AZ Commercial	$225.00
Rate for Payer: Cash Price	$200.00

TUBE TRACH CUFFED 6.0

Facility

$250.00

Hospital Charge Code	22354834
Hospital Revenue Code	270
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna of AZ Commercial	$225.00
Rate for Payer: Arizona Complete Health Allwell	$40.00
Rate for Payer: Banner UC Health Medicare	$40.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$170.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$40.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$40.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cigna of AZ Commercial	$175.00
Rate for Payer: Devoted Health Medicare	$45.00
Rate for Payer: Humana of AZ Medicare	$40.00
Rate for Payer: Southwest Service Administrators UFCW	$170.00
Rate for Payer: TriWest Medicare	$40.00
Rate for Payer: United Healthcare Commercial	$143.00
Rate for Payer: United Healthcare Medicare	$40.00
Rate for Payer: Veterans Affairs TRICARE	$39.60

TUBE TRACH CUFFED 6.5

Facility

$8.00

Hospital Charge Code	22354966
Hospital Revenue Code	270
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Cash Price	$6.40

TUBE TRACH CUFFED 6.5

Facility

$8.00

Hospital Charge Code	22354966
Hospital Revenue Code	270
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Arizona Complete Health Allwell	$1.28
Rate for Payer: Banner UC Health Medicare	$1.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.28
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cigna of AZ Commercial	$5.60
Rate for Payer: Devoted Health Medicare	$1.44
Rate for Payer: Humana of AZ Medicare	$1.28
Rate for Payer: Southwest Service Administrators UFCW	$5.44
Rate for Payer: TriWest Medicare	$1.28
Rate for Payer: United Healthcare Commercial	$4.58
Rate for Payer: United Healthcare Medicare	$1.28
Rate for Payer: Veterans Affairs TRICARE	$1.27

TUBE TRACH CUFFED 7.0

Facility

$8.00

Hospital Charge Code	22354928
Hospital Revenue Code	270
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Cash Price	$6.40

TUBE TRACH CUFFED 7.0

Facility

$8.00

Hospital Charge Code	22354928
Hospital Revenue Code	270
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of AZ Commercial	$7.20
Rate for Payer: Arizona Complete Health Allwell	$1.28
Rate for Payer: Banner UC Health Medicare	$1.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.28
Rate for Payer: Cash Price	$6.40
Rate for Payer: Cigna of AZ Commercial	$5.60
Rate for Payer: Devoted Health Medicare	$1.44
Rate for Payer: Humana of AZ Medicare	$1.28
Rate for Payer: Southwest Service Administrators UFCW	$5.44
Rate for Payer: TriWest Medicare	$1.28
Rate for Payer: United Healthcare Commercial	$4.58
Rate for Payer: United Healthcare Medicare	$1.28
Rate for Payer: Veterans Affairs TRICARE	$1.27

Know your out-of-pocket cost for care.

All Charges