Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Testosterone, Serum LC

Facility

$321.00

Service Code	CPT 84403
Hospital Charge Code	1285542
Hospital Revenue Code	301
Min. Negotiated Rate	$83.46
Max. Negotiated Rate	$288.90
Rate for Payer: Aetna of AZ Commercial	$288.90
Rate for Payer: Bisbee Police All Plans	$83.46
Rate for Payer: Cash Price	$256.80
Rate for Payer: Self Pay Self Pay	$256.80

tetanus-diphtheria toxoids (Td)adult IM [CQCH]

Facility

$45.44

Service Code	HCPCS 90714
Hospital Charge Code	105943587
Hospital Revenue Code	250
Min. Negotiated Rate	$7.27
Max. Negotiated Rate	$40.90
Rate for Payer: Aetna of AZ Commercial	$40.90
Rate for Payer: Aetna of AZ Medicare	$12.72
Rate for Payer: Allwell Medicare	$7.27
Rate for Payer: Amerigroup Medicare	$7.27
Rate for Payer: APIPA Medicare/Medicaid	$16.97
Rate for Payer: AZCH Complete Medicare	$7.27
Rate for Payer: Banner UC Health Medicare	$7.27
Rate for Payer: Bisbee Police All Plans	$11.81
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$30.90
Rate for Payer: Cash Price	$36.35
Rate for Payer: Cigna of AZ Commercial	$29.54
Rate for Payer: Copperpoint Commercial	$11.25
Rate for Payer: Health Net of AZ Commercial	$27.26
Rate for Payer: Health Net of AZ Medicare	$12.72
Rate for Payer: Humana of AZ Medicare	$7.27
Rate for Payer: Self Pay Self Pay	$36.35
Rate for Payer: TriWest Medicare	$7.27
Rate for Payer: UnitedHealth Group of AZ Commercial	$26.49
Rate for Payer: UnitedHealth Group of AZ Medicare	$8.18

tetanus-diphtheria toxoids (Td)adult IM [CQCH]

Facility

$45.44

Service Code	HCPCS 90714
Hospital Charge Code	105943587
Hospital Revenue Code	250
Min. Negotiated Rate	$11.81
Max. Negotiated Rate	$40.90
Rate for Payer: Aetna of AZ Commercial	$40.90
Rate for Payer: Bisbee Police All Plans	$11.81
Rate for Payer: Cash Price	$36.35
Rate for Payer: Self Pay Self Pay	$36.35

tetanus/diphth/pertuss (ADACEL-Tdap) adult/adol 5 units-2 units-15.5 mcg/0.5 mL Sus [CQCH]

Facility

$94.59

Service Code	NDC 49281040010
Hospital Charge Code	118000817
Hospital Revenue Code	250
Min. Negotiated Rate	$15.13
Max. Negotiated Rate	$85.13
Rate for Payer: Aetna of AZ Commercial	$85.13
Rate for Payer: Aetna of AZ Medicare	$26.49
Rate for Payer: Allwell Medicare	$15.13
Rate for Payer: Amerigroup Medicare	$15.13
Rate for Payer: APIPA Medicare/Medicaid	$35.33
Rate for Payer: AZCH Complete Medicare	$15.13
Rate for Payer: Banner UC Health Medicare	$15.13
Rate for Payer: Bisbee Police All Plans	$24.59
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$64.32
Rate for Payer: Cash Price	$75.67
Rate for Payer: Cigna of AZ Commercial	$61.48
Rate for Payer: Copperpoint Commercial	$23.41
Rate for Payer: Health Net of AZ Commercial	$56.75
Rate for Payer: Health Net of AZ Medicare	$26.49
Rate for Payer: Humana of AZ Medicare	$15.13
Rate for Payer: Self Pay Self Pay	$75.67
Rate for Payer: TriWest Medicare	$15.13
Rate for Payer: UnitedHealth Group of AZ Commercial	$55.15
Rate for Payer: UnitedHealth Group of AZ Medicare	$17.03

tetanus/diphth/pertuss (ADACEL-Tdap) adult/adol 5 units-2 units-15.5 mcg/0.5 mL Sus [CQCH]

Facility

$94.59

Service Code	NDC 49281040010
Hospital Charge Code	118000817
Hospital Revenue Code	250
Min. Negotiated Rate	$24.59
Max. Negotiated Rate	$85.13
Rate for Payer: Aetna of AZ Commercial	$85.13
Rate for Payer: Bisbee Police All Plans	$24.59
Rate for Payer: Cash Price	$75.67
Rate for Payer: Self Pay Self Pay	$75.67

tetanus immune globulin 250 units IM [CQCH]

Facility

$522.00

Service Code	HCPCS J1670
Hospital Charge Code	105943449
Hospital Revenue Code	250
Min. Negotiated Rate	$135.72
Max. Negotiated Rate	$469.80
Rate for Payer: Aetna of AZ Commercial	$469.80
Rate for Payer: Bisbee Police All Plans	$135.72
Rate for Payer: Cash Price	$417.60
Rate for Payer: Self Pay Self Pay	$417.60

tetanus immune globulin 250 units IM [CQCH]

Facility

$522.00

Service Code	HCPCS J1670
Hospital Charge Code	105943449
Hospital Revenue Code	250
Min. Negotiated Rate	$83.52
Max. Negotiated Rate	$469.80
Rate for Payer: Aetna of AZ Commercial	$469.80
Rate for Payer: Aetna of AZ Medicare	$146.16
Rate for Payer: Allwell Medicare	$83.52
Rate for Payer: Amerigroup Medicare	$83.52
Rate for Payer: APIPA Medicare/Medicaid	$194.97
Rate for Payer: AZCH Complete Medicare	$83.52
Rate for Payer: Banner UC Health Medicare	$83.52
Rate for Payer: Bisbee Police All Plans	$135.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$354.96
Rate for Payer: Cash Price	$417.60
Rate for Payer: Cigna of AZ Commercial	$339.30
Rate for Payer: Copperpoint Commercial	$129.19
Rate for Payer: Health Net of AZ Commercial	$313.20
Rate for Payer: Health Net of AZ Medicare	$146.16
Rate for Payer: Humana of AZ Medicare	$83.52
Rate for Payer: Self Pay Self Pay	$417.60
Rate for Payer: TriWest Medicare	$83.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$304.33
Rate for Payer: UnitedHealth Group of AZ Medicare	$93.96

tetracaine ophth 0.5% Soln 15 mL [CQCH]

Facility

$4.08

Service Code	NDC 68682092064
Hospital Charge Code	111669704
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$3.67
Rate for Payer: Aetna of AZ Commercial	$3.67
Rate for Payer: Aetna of AZ Medicare	$1.14
Rate for Payer: Allwell Medicare	$0.65
Rate for Payer: Amerigroup Medicare	$0.65
Rate for Payer: APIPA Medicare/Medicaid	$1.52
Rate for Payer: AZCH Complete Medicare	$0.65
Rate for Payer: Banner UC Health Medicare	$0.65
Rate for Payer: Bisbee Police All Plans	$1.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2.77
Rate for Payer: Cash Price	$3.26
Rate for Payer: Cigna of AZ Commercial	$2.65
Rate for Payer: Copperpoint Commercial	$1.01
Rate for Payer: Health Net of AZ Commercial	$2.45
Rate for Payer: Health Net of AZ Medicare	$1.14
Rate for Payer: Humana of AZ Medicare	$0.65
Rate for Payer: Self Pay Self Pay	$3.26
Rate for Payer: TriWest Medicare	$0.65
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.73

tetracaine ophth 0.5% Soln 15 mL [CQCH]

Facility

$4.08

Service Code	NDC 68682092064
Hospital Charge Code	111669704
Hospital Revenue Code	250
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$3.67
Rate for Payer: Aetna of AZ Commercial	$3.67
Rate for Payer: Bisbee Police All Plans	$1.06
Rate for Payer: Cash Price	$3.26
Rate for Payer: Self Pay Self Pay	$3.26

Thawed Aph FFP ACDA 200-400 ml

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316425
Hospital Revenue Code	390
Min. Negotiated Rate	$46.02
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Cash Price	$141.60
Rate for Payer: Self Pay Self Pay	$141.60

Thawed Aph FFP ACDA 200-400 ml

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316425
Hospital Revenue Code	390
Min. Negotiated Rate	$28.32
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Aetna of AZ Medicare	$49.56
Rate for Payer: Allwell Medicare	$28.32
Rate for Payer: Amerigroup Medicare	$28.32
Rate for Payer: APIPA Medicare/Medicaid	$66.11
Rate for Payer: AZCH Complete Medicare	$28.32
Rate for Payer: Banner UC Health Medicare	$28.32
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$120.36
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cigna of AZ Commercial	$115.05
Rate for Payer: Copperpoint Commercial	$43.81
Rate for Payer: Health Net of AZ Commercial	$106.20
Rate for Payer: Health Net of AZ Medicare	$49.56
Rate for Payer: Humana of AZ Medicare	$28.32
Rate for Payer: Self Pay Self Pay	$141.60
Rate for Payer: TriWest Medicare	$28.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$103.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$31.86

Thawed Cryo AHF

Facility

$504.00

Service Code	CPT P9044
Hospital Charge Code	22191131
Hospital Revenue Code	390
Min. Negotiated Rate	$80.64
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of AZ Commercial	$453.60
Rate for Payer: Aetna of AZ Medicare	$141.12
Rate for Payer: Allwell Medicare	$80.64
Rate for Payer: Amerigroup Medicare	$80.64
Rate for Payer: APIPA Medicare/Medicaid	$188.24
Rate for Payer: AZCH Complete Medicare	$80.64
Rate for Payer: Banner UC Health Medicare	$80.64
Rate for Payer: Bisbee Police All Plans	$131.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$342.72
Rate for Payer: Cash Price	$403.20
Rate for Payer: Cigna of AZ Commercial	$327.60
Rate for Payer: Copperpoint Commercial	$124.74
Rate for Payer: Health Net of AZ Commercial	$302.40
Rate for Payer: Health Net of AZ Medicare	$141.12
Rate for Payer: Humana of AZ Medicare	$80.64
Rate for Payer: Self Pay Self Pay	$403.20
Rate for Payer: TriWest Medicare	$80.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$293.83
Rate for Payer: UnitedHealth Group of AZ Medicare	$90.72

Thawed Cryo AHF

Facility

$504.00

Service Code	CPT P9044
Hospital Charge Code	22191131
Hospital Revenue Code	390
Min. Negotiated Rate	$131.04
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of AZ Commercial	$453.60
Rate for Payer: Bisbee Police All Plans	$131.04
Rate for Payer: Cash Price	$403.20
Rate for Payer: Self Pay Self Pay	$403.20

Thawed Plasma ACDA

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316439
Hospital Revenue Code	390
Min. Negotiated Rate	$46.02
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Cash Price	$141.60
Rate for Payer: Self Pay Self Pay	$141.60

Thawed Plasma ACDA

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316439
Hospital Revenue Code	390
Min. Negotiated Rate	$28.32
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Aetna of AZ Medicare	$49.56
Rate for Payer: Allwell Medicare	$28.32
Rate for Payer: Amerigroup Medicare	$28.32
Rate for Payer: APIPA Medicare/Medicaid	$66.11
Rate for Payer: AZCH Complete Medicare	$28.32
Rate for Payer: Banner UC Health Medicare	$28.32
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$120.36
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cigna of AZ Commercial	$115.05
Rate for Payer: Copperpoint Commercial	$43.81
Rate for Payer: Health Net of AZ Commercial	$106.20
Rate for Payer: Health Net of AZ Medicare	$49.56
Rate for Payer: Humana of AZ Medicare	$28.32
Rate for Payer: Self Pay Self Pay	$141.60
Rate for Payer: TriWest Medicare	$28.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$103.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$31.86

Thawed Plasma ACDA Irr

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316442
Hospital Revenue Code	390
Min. Negotiated Rate	$28.32
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Aetna of AZ Medicare	$49.56
Rate for Payer: Allwell Medicare	$28.32
Rate for Payer: Amerigroup Medicare	$28.32
Rate for Payer: APIPA Medicare/Medicaid	$66.11
Rate for Payer: AZCH Complete Medicare	$28.32
Rate for Payer: Banner UC Health Medicare	$28.32
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$120.36
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cigna of AZ Commercial	$115.05
Rate for Payer: Copperpoint Commercial	$43.81
Rate for Payer: Health Net of AZ Commercial	$106.20
Rate for Payer: Health Net of AZ Medicare	$49.56
Rate for Payer: Humana of AZ Medicare	$28.32
Rate for Payer: Self Pay Self Pay	$141.60
Rate for Payer: TriWest Medicare	$28.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$103.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$31.86

Thawed Plasma ACDA Irr

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316442
Hospital Revenue Code	390
Min. Negotiated Rate	$46.02
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Cash Price	$141.60
Rate for Payer: Self Pay Self Pay	$141.60

Thawed Plasma ACDB

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316434
Hospital Revenue Code	390
Min. Negotiated Rate	$46.02
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Cash Price	$141.60
Rate for Payer: Self Pay Self Pay	$141.60

Thawed Plasma ACDB

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316434
Hospital Revenue Code	390
Min. Negotiated Rate	$28.32
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Aetna of AZ Medicare	$49.56
Rate for Payer: Allwell Medicare	$28.32
Rate for Payer: Amerigroup Medicare	$28.32
Rate for Payer: APIPA Medicare/Medicaid	$66.11
Rate for Payer: AZCH Complete Medicare	$28.32
Rate for Payer: Banner UC Health Medicare	$28.32
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$120.36
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cigna of AZ Commercial	$115.05
Rate for Payer: Copperpoint Commercial	$43.81
Rate for Payer: Health Net of AZ Commercial	$106.20
Rate for Payer: Health Net of AZ Medicare	$49.56
Rate for Payer: Humana of AZ Medicare	$28.32
Rate for Payer: Self Pay Self Pay	$141.60
Rate for Payer: TriWest Medicare	$28.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$103.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$31.86

Thawed Plasma ACDB Irr

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316437
Hospital Revenue Code	390
Min. Negotiated Rate	$28.32
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Aetna of AZ Medicare	$49.56
Rate for Payer: Allwell Medicare	$28.32
Rate for Payer: Amerigroup Medicare	$28.32
Rate for Payer: APIPA Medicare/Medicaid	$66.11
Rate for Payer: AZCH Complete Medicare	$28.32
Rate for Payer: Banner UC Health Medicare	$28.32
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$120.36
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cigna of AZ Commercial	$115.05
Rate for Payer: Copperpoint Commercial	$43.81
Rate for Payer: Health Net of AZ Commercial	$106.20
Rate for Payer: Health Net of AZ Medicare	$49.56
Rate for Payer: Humana of AZ Medicare	$28.32
Rate for Payer: Self Pay Self Pay	$141.60
Rate for Payer: TriWest Medicare	$28.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$103.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$31.86

Thawed Plasma ACDB Irr

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316437
Hospital Revenue Code	390
Min. Negotiated Rate	$46.02
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Cash Price	$141.60
Rate for Payer: Self Pay Self Pay	$141.60

Thawed Plasma CP2D Irr

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316450
Hospital Revenue Code	390
Min. Negotiated Rate	$28.32
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Aetna of AZ Medicare	$49.56
Rate for Payer: Allwell Medicare	$28.32
Rate for Payer: Amerigroup Medicare	$28.32
Rate for Payer: APIPA Medicare/Medicaid	$66.11
Rate for Payer: AZCH Complete Medicare	$28.32
Rate for Payer: Banner UC Health Medicare	$28.32
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$120.36
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cigna of AZ Commercial	$115.05
Rate for Payer: Copperpoint Commercial	$43.81
Rate for Payer: Health Net of AZ Commercial	$106.20
Rate for Payer: Health Net of AZ Medicare	$49.56
Rate for Payer: Humana of AZ Medicare	$28.32
Rate for Payer: Self Pay Self Pay	$141.60
Rate for Payer: TriWest Medicare	$28.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$103.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$31.86

Thawed Plasma CP2D Irr

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316450
Hospital Revenue Code	390
Min. Negotiated Rate	$46.02
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Cash Price	$141.60
Rate for Payer: Self Pay Self Pay	$141.60

Thawed Plasma CPDA1

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316428
Hospital Revenue Code	390
Min. Negotiated Rate	$46.02
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Cash Price	$141.60
Rate for Payer: Self Pay Self Pay	$141.60

Thawed Plasma CPDA1

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316428
Hospital Revenue Code	390
Min. Negotiated Rate	$28.32
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Aetna of AZ Medicare	$49.56
Rate for Payer: Allwell Medicare	$28.32
Rate for Payer: Amerigroup Medicare	$28.32
Rate for Payer: APIPA Medicare/Medicaid	$66.11
Rate for Payer: AZCH Complete Medicare	$28.32
Rate for Payer: Banner UC Health Medicare	$28.32
Rate for Payer: Bisbee Police All Plans	$46.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$120.36
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cigna of AZ Commercial	$115.05
Rate for Payer: Copperpoint Commercial	$43.81
Rate for Payer: Health Net of AZ Commercial	$106.20
Rate for Payer: Health Net of AZ Medicare	$49.56
Rate for Payer: Humana of AZ Medicare	$28.32
Rate for Payer: Self Pay Self Pay	$141.60
Rate for Payer: TriWest Medicare	$28.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$103.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$31.86

Know your out-of-pocket cost for care.

All Charges