Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Thawed Plasma CPDA1 Irr

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316426
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 CPDA1 Irr

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316426
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 CPD Irr

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316431
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 CPD Irr

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316431
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 NaCitrate Irr <= 24h

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316429
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 NaCitrate Irr <= 24h

Facility

$177.00

Service Code	CPT P9017
Hospital Charge Code	22316429
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 Pooled Cryo

Facility

$480.00

Service Code	CPT P9044
Hospital Charge Code	22316447
Hospital Revenue Code	390
Min. Negotiated Rate	$76.80
Max. Negotiated Rate	$432.00
Rate for Payer: Aetna of AZ Commercial	$432.00
Rate for Payer: Aetna of AZ Medicare	$134.40
Rate for Payer: Allwell Medicare	$76.80
Rate for Payer: Amerigroup Medicare	$76.80
Rate for Payer: APIPA Medicare/Medicaid	$179.28
Rate for Payer: AZCH Complete Medicare	$76.80
Rate for Payer: Banner UC Health Medicare	$76.80
Rate for Payer: Bisbee Police All Plans	$124.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$326.40
Rate for Payer: Cash Price	$384.00
Rate for Payer: Cigna of AZ Commercial	$312.00
Rate for Payer: Copperpoint Commercial	$118.80
Rate for Payer: Health Net of AZ Commercial	$288.00
Rate for Payer: Health Net of AZ Medicare	$134.40
Rate for Payer: Humana of AZ Medicare	$76.80
Rate for Payer: Self Pay Self Pay	$384.00
Rate for Payer: TriWest Medicare	$76.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$279.84
Rate for Payer: UnitedHealth Group of AZ Medicare	$86.40

Thawed Pooled Cryo

Facility

$480.00

Service Code	CPT P9044
Hospital Charge Code	22316447
Hospital Revenue Code	390
Min. Negotiated Rate	$124.80
Max. Negotiated Rate	$432.00
Rate for Payer: Aetna of AZ Commercial	$432.00
Rate for Payer: Bisbee Police All Plans	$124.80
Rate for Payer: Cash Price	$384.00
Rate for Payer: Self Pay Self Pay	$384.00

THEOPHYLLINE

Facility

$165.00

Service Code	CPT 80198
Hospital Charge Code	23603248
Hospital Revenue Code	301
Min. Negotiated Rate	$42.90
Max. Negotiated Rate	$148.50
Rate for Payer: Aetna of AZ Commercial	$148.50
Rate for Payer: Bisbee Police All Plans	$42.90
Rate for Payer: Cash Price	$132.00
Rate for Payer: Self Pay Self Pay	$132.00

THEOPHYLLINE

Facility

$165.00

Service Code	CPT 80198
Hospital Charge Code	23603248
Hospital Revenue Code	301
Min. Negotiated Rate	$26.40
Max. Negotiated Rate	$148.50
Rate for Payer: Aetna of AZ Commercial	$148.50
Rate for Payer: Aetna of AZ Medicare	$46.20
Rate for Payer: Allwell Medicare	$26.40
Rate for Payer: Amerigroup Medicare	$26.40
Rate for Payer: APIPA Medicare/Medicaid	$61.63
Rate for Payer: AZCH Complete Medicare	$26.40
Rate for Payer: Banner UC Health Medicare	$26.40
Rate for Payer: Bisbee Police All Plans	$42.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$112.20
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cigna of AZ Commercial	$107.25
Rate for Payer: Copperpoint Commercial	$40.84
Rate for Payer: Health Net of AZ Commercial	$99.00
Rate for Payer: Health Net of AZ Medicare	$46.20
Rate for Payer: Humana of AZ Medicare	$26.40
Rate for Payer: Self Pay Self Pay	$132.00
Rate for Payer: TriWest Medicare	$26.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$96.19
Rate for Payer: UnitedHealth Group of AZ Medicare	$29.70

Theophylline, Serum LC

Facility

$173.00

Service Code	CPT 80198
Hospital Charge Code	1285596
Hospital Revenue Code	301
Min. Negotiated Rate	$27.68
Max. Negotiated Rate	$155.70
Rate for Payer: Aetna of AZ Commercial	$155.70
Rate for Payer: Aetna of AZ Medicare	$48.44
Rate for Payer: Allwell Medicare	$27.68
Rate for Payer: Amerigroup Medicare	$27.68
Rate for Payer: APIPA Medicare/Medicaid	$64.62
Rate for Payer: AZCH Complete Medicare	$27.68
Rate for Payer: Banner UC Health Medicare	$27.68
Rate for Payer: Bisbee Police All Plans	$44.98
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$117.64
Rate for Payer: Cash Price	$138.40
Rate for Payer: Cigna of AZ Commercial	$112.45
Rate for Payer: Copperpoint Commercial	$42.82
Rate for Payer: Health Net of AZ Commercial	$103.80
Rate for Payer: Health Net of AZ Medicare	$48.44
Rate for Payer: Humana of AZ Medicare	$27.68
Rate for Payer: Self Pay Self Pay	$138.40
Rate for Payer: TriWest Medicare	$27.68
Rate for Payer: UnitedHealth Group of AZ Commercial	$100.86
Rate for Payer: UnitedHealth Group of AZ Medicare	$31.14

Theophylline, Serum LC

Facility

$173.00

Service Code	CPT 80198
Hospital Charge Code	1285596
Hospital Revenue Code	301
Min. Negotiated Rate	$44.98
Max. Negotiated Rate	$155.70
Rate for Payer: Aetna of AZ Commercial	$155.70
Rate for Payer: Bisbee Police All Plans	$44.98
Rate for Payer: Cash Price	$138.40
Rate for Payer: Self Pay Self Pay	$138.40

Therapeutic Activities Charges

Facility

$172.00

Service Code	CPT 97530 GP
Hospital Charge Code	692245
Hospital Revenue Code	420
Min. Negotiated Rate	$27.52
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Aetna of AZ Medicare	$48.16
Rate for Payer: Allwell Medicare	$27.52
Rate for Payer: Amerigroup Medicare	$27.52
Rate for Payer: APIPA Medicare/Medicaid	$64.24
Rate for Payer: AZCH Complete Medicare	$27.52
Rate for Payer: Banner UC Health Medicare	$27.52
Rate for Payer: Bisbee Police All Plans	$44.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$116.96
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cigna of AZ Commercial	$120.40
Rate for Payer: Copperpoint Commercial	$42.57
Rate for Payer: Health Net of AZ Commercial	$103.20
Rate for Payer: Health Net of AZ Medicare	$48.16
Rate for Payer: Humana of AZ Medicare	$27.52
Rate for Payer: Self Pay Self Pay	$137.60
Rate for Payer: TriWest Medicare	$27.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$100.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$30.96

Therapeutic Activities Charges

Facility

$172.00

Service Code	CPT 97530 GP
Hospital Charge Code	692245
Hospital Revenue Code	420
Min. Negotiated Rate	$44.72
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Bisbee Police All Plans	$44.72
Rate for Payer: Cash Price	$137.60
Rate for Payer: Self Pay Self Pay	$137.60

Therapeutic Exercise Charges

Facility

$231.00

Service Code	CPT 97110 GO
Hospital Charge Code	691306
Hospital Revenue Code	430
Min. Negotiated Rate	$36.96
Max. Negotiated Rate	$207.90
Rate for Payer: Aetna of AZ Commercial	$207.90
Rate for Payer: Aetna of AZ Medicare	$64.68
Rate for Payer: Allwell Medicare	$36.96
Rate for Payer: Amerigroup Medicare	$36.96
Rate for Payer: APIPA Medicare/Medicaid	$86.28
Rate for Payer: AZCH Complete Medicare	$36.96
Rate for Payer: Banner UC Health Medicare	$36.96
Rate for Payer: Bisbee Police All Plans	$60.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$157.08
Rate for Payer: Cash Price	$184.80
Rate for Payer: Cigna of AZ Commercial	$161.70
Rate for Payer: Copperpoint Commercial	$57.17
Rate for Payer: Health Net of AZ Commercial	$138.60
Rate for Payer: Health Net of AZ Medicare	$64.68
Rate for Payer: Humana of AZ Medicare	$36.96
Rate for Payer: Self Pay Self Pay	$184.80
Rate for Payer: TriWest Medicare	$36.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$134.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$41.58

Therapeutic Exercise Charges

Facility

$231.00

Service Code	CPT 97110 GO
Hospital Charge Code	691306
Hospital Revenue Code	430
Min. Negotiated Rate	$60.06
Max. Negotiated Rate	$207.90
Rate for Payer: Aetna of AZ Commercial	$207.90
Rate for Payer: Bisbee Police All Plans	$60.06
Rate for Payer: Cash Price	$184.80
Rate for Payer: Self Pay Self Pay	$184.80

Therapeutic Exercise Charges

Facility

$243.00

Service Code	CPT 97110 GO
Hospital Charge Code	23955327
Hospital Revenue Code	430
Min. Negotiated Rate	$38.88
Max. Negotiated Rate	$218.70
Rate for Payer: Aetna of AZ Commercial	$218.70
Rate for Payer: Aetna of AZ Medicare	$68.04
Rate for Payer: Allwell Medicare	$38.88
Rate for Payer: Amerigroup Medicare	$38.88
Rate for Payer: APIPA Medicare/Medicaid	$90.76
Rate for Payer: AZCH Complete Medicare	$38.88
Rate for Payer: Banner UC Health Medicare	$38.88
Rate for Payer: Bisbee Police All Plans	$63.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$165.24
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cigna of AZ Commercial	$170.10
Rate for Payer: Copperpoint Commercial	$60.14
Rate for Payer: Health Net of AZ Commercial	$145.80
Rate for Payer: Health Net of AZ Medicare	$68.04
Rate for Payer: Humana of AZ Medicare	$38.88
Rate for Payer: Self Pay Self Pay	$194.40
Rate for Payer: TriWest Medicare	$38.88
Rate for Payer: UnitedHealth Group of AZ Commercial	$141.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$43.74

Therapeutic Exercise Charges

Facility

$243.00

Service Code	CPT 97110 GO
Hospital Charge Code	23955327
Hospital Revenue Code	430
Min. Negotiated Rate	$63.18
Max. Negotiated Rate	$218.70
Rate for Payer: Aetna of AZ Commercial	$218.70
Rate for Payer: Bisbee Police All Plans	$63.18
Rate for Payer: Cash Price	$194.40
Rate for Payer: Self Pay Self Pay	$194.40

Therapeutic Phlebotomy 6

Facility

$429.00

Service Code	CPT 99195
Hospital Charge Code	22309912
Hospital Revenue Code	300
Min. Negotiated Rate	$68.64
Max. Negotiated Rate	$386.10
Rate for Payer: Aetna of AZ Commercial	$386.10
Rate for Payer: Aetna of AZ Medicare	$120.12
Rate for Payer: Allwell Medicare	$68.64
Rate for Payer: Amerigroup Medicare	$68.64
Rate for Payer: APIPA Medicare/Medicaid	$160.23
Rate for Payer: AZCH Complete Medicare	$68.64
Rate for Payer: Banner UC Health Medicare	$68.64
Rate for Payer: Bisbee Police All Plans	$111.54
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$291.72
Rate for Payer: Cash Price	$343.20
Rate for Payer: Cigna of AZ Commercial	$278.85
Rate for Payer: Copperpoint Commercial	$106.18
Rate for Payer: Health Net of AZ Commercial	$257.40
Rate for Payer: Health Net of AZ Medicare	$120.12
Rate for Payer: Humana of AZ Medicare	$68.64
Rate for Payer: Self Pay Self Pay	$343.20
Rate for Payer: TriWest Medicare	$68.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$250.11
Rate for Payer: UnitedHealth Group of AZ Medicare	$77.22

Therapeutic Phlebotomy 6

Facility

$429.00

Service Code	CPT 99195
Hospital Charge Code	22309912
Hospital Revenue Code	300
Min. Negotiated Rate	$111.54
Max. Negotiated Rate	$386.10
Rate for Payer: Aetna of AZ Commercial	$386.10
Rate for Payer: Bisbee Police All Plans	$111.54
Rate for Payer: Cash Price	$343.20
Rate for Payer: Self Pay Self Pay	$343.20

thiamine 100 mg Tab [CQCH]

Facility

$0.02

Service Code	NDC 10006073020
Hospital Charge Code	105943723
Hospital Revenue Code	251
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

thiamine 100 mg Tab [CQCH]

Facility

$0.02

Service Code	NDC 10006073020
Hospital Charge Code	105943723
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Self Pay Self Pay	$0.02

thiamine 200 mg/ 2 mL Inj Sol [CQCH]

Facility

$2.61

Service Code	HCPCS J3411
Hospital Charge Code	105943788
Hospital Revenue Code	250
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$2.35
Rate for Payer: Aetna of AZ Commercial	$2.35
Rate for Payer: Aetna of AZ Medicare	$0.73
Rate for Payer: Allwell Medicare	$0.42
Rate for Payer: Amerigroup Medicare	$0.42
Rate for Payer: APIPA Medicare/Medicaid	$0.97
Rate for Payer: AZCH Complete Medicare	$0.42
Rate for Payer: Banner UC Health Medicare	$0.42
Rate for Payer: Bisbee Police All Plans	$0.68
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.77
Rate for Payer: Cash Price	$2.08
Rate for Payer: Cigna of AZ Commercial	$1.70
Rate for Payer: Copperpoint Commercial	$0.65
Rate for Payer: Health Net of AZ Commercial	$1.57
Rate for Payer: Health Net of AZ Medicare	$0.73
Rate for Payer: Humana of AZ Medicare	$0.42
Rate for Payer: Self Pay Self Pay	$2.09
Rate for Payer: TriWest Medicare	$0.42
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.47

thiamine 200 mg/ 2 mL Inj Sol [CQCH]

Facility

$2.61

Service Code	HCPCS J3411
Hospital Charge Code	105943788
Hospital Revenue Code	250
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$2.35
Rate for Payer: Aetna of AZ Commercial	$2.35
Rate for Payer: Bisbee Police All Plans	$0.68
Rate for Payer: Cash Price	$2.08
Rate for Payer: Self Pay Self Pay	$2.09

Thiopurine Methyltransferase LC

Facility

$673.00

Service Code	CPT 82542
Hospital Charge Code	2087652
Hospital Revenue Code	301
Min. Negotiated Rate	$174.98
Max. Negotiated Rate	$605.70
Rate for Payer: Aetna of AZ Commercial	$605.70
Rate for Payer: Bisbee Police All Plans	$174.98
Rate for Payer: Cash Price	$538.40
Rate for Payer: Self Pay Self Pay	$538.40

Know your out-of-pocket cost for care.

All Charges