Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$23,569.75

Service Code	MSDRG 465
Min. Negotiated Rate	$23,569.75
Max. Negotiated Rate	$23,569.75
Rate for Payer: Seven Corners Travel Insurance	$23,569.75

WOUND DEBRIDEMENTS FOR INJURIES WITH CC

Facility

$24,743.28

Service Code	MSDRG 902
Min. Negotiated Rate	$24,743.28
Max. Negotiated Rate	$24,743.28
Rate for Payer: Seven Corners Travel Insurance	$24,743.28

WOUND DEBRIDEMENTS FOR INJURIES WITH MCC

Facility

$54,237.44

Service Code	MSDRG 901
Min. Negotiated Rate	$54,237.44
Max. Negotiated Rate	$54,237.44
Rate for Payer: Seven Corners Travel Insurance	$54,237.44

WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC

Facility

$15,175.64

Service Code	MSDRG 903
Min. Negotiated Rate	$15,175.64
Max. Negotiated Rate	$15,175.64
Rate for Payer: Seven Corners Travel Insurance	$15,175.64

Woven Ureteral Catheter Cone Tip 10Fr

Facility

$525.00

Hospital Charge Code	22926427
Hospital Revenue Code	272
Min. Negotiated Rate	$472.50
Max. Negotiated Rate	$472.50
Rate for Payer: Aetna of AZ Commercial	$472.50
Rate for Payer: Cash Price	$420.00

Woven Ureteral Catheter Cone Tip 10Fr

Facility

$525.00

Hospital Charge Code	22926427
Hospital Revenue Code	272
Min. Negotiated Rate	$83.16
Max. Negotiated Rate	$472.50
Rate for Payer: Aetna of AZ Commercial	$472.50
Rate for Payer: Arizona Complete Health Allwell	$84.00
Rate for Payer: Banner UC Health Medicare	$84.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$357.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$84.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$84.00
Rate for Payer: Cash Price	$420.00
Rate for Payer: Cigna of AZ Commercial	$367.50
Rate for Payer: Devoted Health Medicare	$94.50
Rate for Payer: Humana of AZ Medicare	$84.00
Rate for Payer: Southwest Service Administrators UFCW	$357.00
Rate for Payer: TriWest Medicare	$84.00
Rate for Payer: United Healthcare Commercial	$300.30
Rate for Payer: United Healthcare Medicare	$84.00
Rate for Payer: Veterans Affairs TRICARE	$83.16

Woven Ureteral Catheter Cone Tip 8Fr

Facility

$525.00

Hospital Charge Code	22926428
Hospital Revenue Code	272
Min. Negotiated Rate	$472.50
Max. Negotiated Rate	$472.50
Rate for Payer: Aetna of AZ Commercial	$472.50
Rate for Payer: Cash Price	$420.00

Woven Ureteral Catheter Cone Tip 8Fr

Facility

$525.00

Hospital Charge Code	22926428
Hospital Revenue Code	272
Min. Negotiated Rate	$83.16
Max. Negotiated Rate	$472.50
Rate for Payer: Aetna of AZ Commercial	$472.50
Rate for Payer: Arizona Complete Health Allwell	$84.00
Rate for Payer: Banner UC Health Medicare	$84.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$357.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$84.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$84.00
Rate for Payer: Cash Price	$420.00
Rate for Payer: Cigna of AZ Commercial	$367.50
Rate for Payer: Devoted Health Medicare	$94.50
Rate for Payer: Humana of AZ Medicare	$84.00
Rate for Payer: Southwest Service Administrators UFCW	$357.00
Rate for Payer: TriWest Medicare	$84.00
Rate for Payer: United Healthcare Commercial	$300.30
Rate for Payer: United Healthcare Medicare	$84.00
Rate for Payer: Veterans Affairs TRICARE	$83.16

Wrist Hand Orthosis, Wrist Ext. Control cock-up, non molded, prefab., incl. fitt

Facility

$180.00

Service Code	HCPCS L3908
Hospital Charge Code	755109
Hospital Revenue Code	521
Min. Negotiated Rate	$28.51
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of AZ Commercial	$162.00
Rate for Payer: Arizona Complete Health Allwell	$28.80
Rate for Payer: Banner UC Health Medicare	$28.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$122.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.80
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cigna of AZ Commercial	$126.00
Rate for Payer: Devoted Health Medicare	$32.40
Rate for Payer: Humana of AZ Medicare	$28.80
Rate for Payer: Southwest Service Administrators UFCW	$122.40
Rate for Payer: TriWest Medicare	$28.80
Rate for Payer: United Healthcare Commercial	$102.96
Rate for Payer: United Healthcare Medicare	$28.80
Rate for Payer: Veterans Affairs TRICARE	$28.51

Wrist Hand Orthosis, Wrist Ext. Control cock-up, non molded, prefab., incl. fitt

Facility

$180.00

Service Code	HCPCS L3908
Hospital Charge Code	755109
Hospital Revenue Code	521
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of AZ Commercial	$162.00
Rate for Payer: Cash Price	$144.00

WRIST SPLINT COCKUP

Facility

$34.00

Hospital Charge Code	22354262
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

WRIST SPLINT COCKUP

Facility

$34.00

Hospital Charge Code	22354262
Hospital Revenue Code	270
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$30.60
Rate for Payer: Aetna of AZ Commercial	$30.60
Rate for Payer: Arizona Complete Health Allwell	$5.44
Rate for Payer: Banner UC Health Medicare	$5.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$23.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.44
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cigna of AZ Commercial	$23.80
Rate for Payer: Devoted Health Medicare	$6.12
Rate for Payer: Humana of AZ Medicare	$5.44
Rate for Payer: Southwest Service Administrators UFCW	$23.12
Rate for Payer: TriWest Medicare	$5.44
Rate for Payer: United Healthcare Commercial	$19.45
Rate for Payer: United Healthcare Medicare	$5.44
Rate for Payer: Veterans Affairs TRICARE	$5.39

XCEL 11MM TROCAR ENDOPATH

Facility

$256.00

Hospital Charge Code	23152395
Hospital Revenue Code	270
Min. Negotiated Rate	$40.55
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna of AZ Commercial	$230.40
Rate for Payer: Arizona Complete Health Allwell	$40.96
Rate for Payer: Banner UC Health Medicare	$40.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$174.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$40.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$40.96
Rate for Payer: Cash Price	$204.80
Rate for Payer: Cigna of AZ Commercial	$179.20
Rate for Payer: Devoted Health Medicare	$46.08
Rate for Payer: Humana of AZ Medicare	$40.96
Rate for Payer: Southwest Service Administrators UFCW	$174.08
Rate for Payer: TriWest Medicare	$40.96
Rate for Payer: United Healthcare Commercial	$146.43
Rate for Payer: United Healthcare Medicare	$40.96
Rate for Payer: Veterans Affairs TRICARE	$40.55

XCEL 11MM TROCAR ENDOPATH

Facility

$256.00

Hospital Charge Code	23152395
Hospital Revenue Code	270
Min. Negotiated Rate	$230.40
Max. Negotiated Rate	$230.40
Rate for Payer: Aetna of AZ Commercial	$230.40
Rate for Payer: Cash Price	$204.80

XCEL 5MM TROCAR ENDOPATH

Facility

$200.00

Hospital Charge Code	23152394
Hospital Revenue Code	272
Min. Negotiated Rate	$31.68
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna of AZ Commercial	$180.00
Rate for Payer: Arizona Complete Health Allwell	$32.00
Rate for Payer: Banner UC Health Medicare	$32.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$136.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.00
Rate for Payer: Cash Price	$160.00
Rate for Payer: Cigna of AZ Commercial	$140.00
Rate for Payer: Devoted Health Medicare	$36.00
Rate for Payer: Humana of AZ Medicare	$32.00
Rate for Payer: Southwest Service Administrators UFCW	$136.00
Rate for Payer: TriWest Medicare	$32.00
Rate for Payer: United Healthcare Commercial	$114.40
Rate for Payer: United Healthcare Medicare	$32.00
Rate for Payer: Veterans Affairs TRICARE	$31.68

XCEL 5MM TROCAR ENDOPATH

Facility

$200.00

Hospital Charge Code	23152394
Hospital Revenue Code	272
Min. Negotiated Rate	$180.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna of AZ Commercial	$180.00
Rate for Payer: Cash Price	$160.00

XFORCE U30 BALLOON CATHETER 6FRX10CM

Facility

$1,893.00

Hospital Charge Code	27770320
Hospital Revenue Code	270
Min. Negotiated Rate	$1,703.70
Max. Negotiated Rate	$1,703.70
Rate for Payer: Aetna of AZ Commercial	$1,703.70
Rate for Payer: Cash Price	$1,514.40

XFORCE U30 BALLOON CATHETER 6FRX10CM

Facility

$1,893.00

Hospital Charge Code	27770320
Hospital Revenue Code	270
Min. Negotiated Rate	$299.85
Max. Negotiated Rate	$1,703.70
Rate for Payer: Aetna of AZ Commercial	$1,703.70
Rate for Payer: Arizona Complete Health Allwell	$302.88
Rate for Payer: Banner UC Health Medicare	$302.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,287.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$302.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$302.88
Rate for Payer: Cash Price	$1,514.40
Rate for Payer: Cigna of AZ Commercial	$1,325.10
Rate for Payer: Devoted Health Medicare	$340.74
Rate for Payer: Humana of AZ Medicare	$302.88
Rate for Payer: Southwest Service Administrators UFCW	$1,287.24
Rate for Payer: TriWest Medicare	$302.88
Rate for Payer: United Healthcare Commercial	$1,082.80
Rate for Payer: United Healthcare Medicare	$302.88
Rate for Payer: Veterans Affairs TRICARE	$299.85

XFORCE U30 BALLOON CATHETER 6FRX4CM

Facility

$1,893.00

Hospital Charge Code	27778599
Hospital Revenue Code	270
Min. Negotiated Rate	$299.85
Max. Negotiated Rate	$1,703.70
Rate for Payer: Aetna of AZ Commercial	$1,703.70
Rate for Payer: Arizona Complete Health Allwell	$302.88
Rate for Payer: Banner UC Health Medicare	$302.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,287.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$302.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$302.88
Rate for Payer: Cash Price	$1,514.40
Rate for Payer: Cigna of AZ Commercial	$1,325.10
Rate for Payer: Devoted Health Medicare	$340.74
Rate for Payer: Humana of AZ Medicare	$302.88
Rate for Payer: Southwest Service Administrators UFCW	$1,287.24
Rate for Payer: TriWest Medicare	$302.88
Rate for Payer: United Healthcare Commercial	$1,082.80
Rate for Payer: United Healthcare Medicare	$302.88
Rate for Payer: Veterans Affairs TRICARE	$299.85

XFORCE U30 BALLOON CATHETER 6FRX4CM

Facility

$1,893.00

Hospital Charge Code	27778599
Hospital Revenue Code	270
Min. Negotiated Rate	$1,703.70
Max. Negotiated Rate	$1,703.70
Rate for Payer: Aetna of AZ Commercial	$1,703.70
Rate for Payer: Cash Price	$1,514.40

XPEEDA DSL DUAL WAVELENGHT FIBER

Facility

$8,242.95

Hospital Charge Code	27844712
Hospital Revenue Code	270
Min. Negotiated Rate	$1,305.68
Max. Negotiated Rate	$7,418.65
Rate for Payer: Aetna of AZ Commercial	$7,418.65
Rate for Payer: Arizona Complete Health Allwell	$1,318.87
Rate for Payer: Banner UC Health Medicare	$1,318.87
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$5,605.21
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,318.87
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,318.87
Rate for Payer: Cash Price	$6,594.36
Rate for Payer: Cigna of AZ Commercial	$5,770.06
Rate for Payer: Devoted Health Medicare	$1,483.73
Rate for Payer: Humana of AZ Medicare	$1,318.87
Rate for Payer: Southwest Service Administrators UFCW	$5,605.21
Rate for Payer: TriWest Medicare	$1,318.87
Rate for Payer: United Healthcare Commercial	$4,714.97
Rate for Payer: United Healthcare Medicare	$1,318.87
Rate for Payer: Veterans Affairs TRICARE	$1,305.68

XPEEDA DSL DUAL WAVELENGHT FIBER

Facility

$8,242.95

Hospital Charge Code	27844712
Hospital Revenue Code	270
Min. Negotiated Rate	$7,418.65
Max. Negotiated Rate	$7,418.65
Rate for Payer: Aetna of AZ Commercial	$7,418.65
Rate for Payer: Cash Price	$6,594.36

XR Abdomen 1 View

Facility

$353.00

Service Code	CPT 74018
Hospital Charge Code	823483
Hospital Revenue Code	320
Min. Negotiated Rate	$317.70
Max. Negotiated Rate	$317.70
Rate for Payer: Aetna of AZ Commercial	$317.70
Rate for Payer: Cash Price	$282.40

XR Abdomen 1 View

Facility

$353.00

Service Code	CPT 74018
Hospital Charge Code	823483
Hospital Revenue Code	320
Min. Negotiated Rate	$28.65
Max. Negotiated Rate	$317.70
Rate for Payer: Aetna of AZ Commercial	$317.70
Rate for Payer: Arizona Complete Health Allwell	$56.48
Rate for Payer: Banner UC Health Medicare	$56.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$240.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$56.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.65
Rate for Payer: Cash Price	$282.40
Rate for Payer: Cash Price	$282.40
Rate for Payer: Cigna of AZ Commercial	$229.45
Rate for Payer: Devoted Health Medicare	$63.54
Rate for Payer: Humana of AZ Medicare	$56.48
Rate for Payer: Seven Corners Travel Insurance	$134.65
Rate for Payer: Southwest Service Administrators UFCW	$240.04
Rate for Payer: TriWest Medicare	$56.48
Rate for Payer: United Healthcare Commercial	$201.92
Rate for Payer: United Healthcare Medicare	$56.48
Rate for Payer: Veterans Affairs TRICARE	$55.92

XR Abdomen 1 View w/Decub

Facility

$445.00

Service Code	CPT 74018
Hospital Charge Code	11849879
Hospital Revenue Code	320
Min. Negotiated Rate	$28.65
Max. Negotiated Rate	$400.50
Rate for Payer: Aetna of AZ Commercial	$400.50
Rate for Payer: Arizona Complete Health Allwell	$71.20
Rate for Payer: Banner UC Health Medicare	$71.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$302.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$71.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.65
Rate for Payer: Cash Price	$356.00
Rate for Payer: Cash Price	$356.00
Rate for Payer: Cigna of AZ Commercial	$289.25
Rate for Payer: Devoted Health Medicare	$80.10
Rate for Payer: Humana of AZ Medicare	$71.20
Rate for Payer: Seven Corners Travel Insurance	$134.65
Rate for Payer: Southwest Service Administrators UFCW	$302.60
Rate for Payer: TriWest Medicare	$71.20
Rate for Payer: United Healthcare Commercial	$254.54
Rate for Payer: United Healthcare Medicare	$71.20
Rate for Payer: Veterans Affairs TRICARE	$70.49

Know your out-of-pocket cost for care.

All Charges