Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

T4, Total

Facility

$116.00

Service Code	CPT 84436
Hospital Charge Code	1281223
Hospital Revenue Code	301
Min. Negotiated Rate	$9.96
Max. Negotiated Rate	$104.40
Rate for Payer: Aetna of AZ Commercial	$104.40
Rate for Payer: Arizona Complete Health Allwell	$18.56
Rate for Payer: Banner UC Health Medicare	$18.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$78.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$18.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$18.56
Rate for Payer: Cash Price	$92.80
Rate for Payer: Cash Price	$92.80
Rate for Payer: Cigna of AZ Commercial	$75.40
Rate for Payer: Devoted Health Medicare	$20.88
Rate for Payer: Humana of AZ Medicare	$18.56
Rate for Payer: Seven Corners Travel Insurance	$9.96
Rate for Payer: Southwest Service Administrators UFCW	$78.88
Rate for Payer: TriWest Medicare	$18.56
Rate for Payer: United Healthcare Commercial	$66.35
Rate for Payer: United Healthcare Medicare	$18.56
Rate for Payer: Veterans Affairs TRICARE	$18.37

Tacrolimus (FK506), Blood LC

Facility

$357.00

Service Code	CPT 80197
Hospital Charge Code	1902306
Hospital Revenue Code	301
Min. Negotiated Rate	$19.91
Max. Negotiated Rate	$321.30
Rate for Payer: Aetna of AZ Commercial	$321.30
Rate for Payer: Arizona Complete Health Allwell	$57.12
Rate for Payer: Banner UC Health Medicare	$57.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$242.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$57.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$57.12
Rate for Payer: Cash Price	$285.60
Rate for Payer: Cash Price	$285.60
Rate for Payer: Cigna of AZ Commercial	$232.05
Rate for Payer: Devoted Health Medicare	$64.26
Rate for Payer: Humana of AZ Medicare	$57.12
Rate for Payer: Seven Corners Travel Insurance	$19.91
Rate for Payer: Southwest Service Administrators UFCW	$242.76
Rate for Payer: TriWest Medicare	$57.12
Rate for Payer: United Healthcare Commercial	$204.20
Rate for Payer: United Healthcare Medicare	$57.12
Rate for Payer: Veterans Affairs TRICARE	$56.55

Tacrolimus (FK506), Blood LC

Facility

$357.00

Service Code	CPT 80197
Hospital Charge Code	1902306
Hospital Revenue Code	301
Min. Negotiated Rate	$321.30
Max. Negotiated Rate	$321.30
Rate for Payer: Aetna of AZ Commercial	$321.30
Rate for Payer: Cash Price	$285.60

TAH with Burch

Facility

$6,767.00

Service Code	CPT 58152
Hospital Charge Code	27291786
Hospital Revenue Code	360
Min. Negotiated Rate	$6,090.30
Max. Negotiated Rate	$6,090.30
Rate for Payer: Aetna of AZ Commercial	$6,090.30
Rate for Payer: Cash Price	$5,413.60

TAH with Burch

Facility

$6,767.00

Service Code	CPT 58152
Hospital Charge Code	27291786
Hospital Revenue Code	360
Min. Negotiated Rate	$1,071.89
Max. Negotiated Rate	$6,090.30
Rate for Payer: Aetna of AZ Commercial	$6,090.30
Rate for Payer: Arizona Complete Health Allwell	$1,082.72
Rate for Payer: Banner UC Health Medicare	$1,082.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$4,601.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1,082.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$1,082.72
Rate for Payer: Cash Price	$5,413.60
Rate for Payer: Cash Price	$5,413.60
Rate for Payer: Cigna of AZ Commercial	$3,383.50
Rate for Payer: Devoted Health Medicare	$1,218.06
Rate for Payer: Humana of AZ Medicare	$1,082.72
Rate for Payer: Southwest Service Administrators UFCW	$4,601.56
Rate for Payer: TriWest Medicare	$1,082.72
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$1,082.72
Rate for Payer: Veterans Affairs TRICARE	$1,071.89

tamsulosin 0.4 mg Oral Cap [CQCH]

Facility

$0.34

Service Code	NDC 904640161
Hospital Charge Code	105943045
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.31
Rate for Payer: Aetna of AZ Commercial	$0.31
Rate for Payer: Arizona Complete Health Allwell	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.23
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.05
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.05
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of AZ Commercial	$0.22
Rate for Payer: Devoted Health Medicare	$0.06
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Southwest Service Administrators UFCW	$0.23
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: United Healthcare Commercial	$0.19
Rate for Payer: United Healthcare Medicare	$0.05
Rate for Payer: Veterans Affairs TRICARE	$0.05

tamsulosin 0.4 mg Oral Cap [CQCH]

Facility

$0.34

Service Code	NDC 904640161
Hospital Charge Code	105943045
Hospital Revenue Code	251
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.31
Rate for Payer: Aetna of AZ Commercial	$0.31
Rate for Payer: Cash Price	$0.27

TAPER POST BOSS 10MM

Facility

$2,221.00

Hospital Charge Code	27745953
Hospital Revenue Code	270
Min. Negotiated Rate	$1,998.90
Max. Negotiated Rate	$1,998.90
Rate for Payer: Aetna of AZ Commercial	$1,998.90
Rate for Payer: Cash Price	$1,776.80

TAPER POST BOSS 10MM

Facility

$2,221.00

Hospital Charge Code	27745953
Hospital Revenue Code	270
Min. Negotiated Rate	$351.81
Max. Negotiated Rate	$1,998.90
Rate for Payer: Aetna of AZ Commercial	$1,998.90
Rate for Payer: Arizona Complete Health Allwell	$355.36
Rate for Payer: Banner UC Health Medicare	$355.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,510.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$355.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$355.36
Rate for Payer: Cash Price	$1,776.80
Rate for Payer: Cigna of AZ Commercial	$1,554.70
Rate for Payer: Devoted Health Medicare	$399.78
Rate for Payer: Humana of AZ Medicare	$355.36
Rate for Payer: Southwest Service Administrators UFCW	$1,510.28
Rate for Payer: TriWest Medicare	$355.36
Rate for Payer: United Healthcare Commercial	$1,270.41
Rate for Payer: United Healthcare Medicare	$355.36
Rate for Payer: Veterans Affairs TRICARE	$351.81

TB Skin Test POC

Facility

$45.00

Service Code	CPT 86580
Hospital Charge Code	2673222
Hospital Revenue Code	521
Min. Negotiated Rate	$7.13
Max. Negotiated Rate	$44.75
Rate for Payer: Aetna of AZ Commercial	$40.50
Rate for Payer: Arizona Complete Health Allwell	$7.20
Rate for Payer: Banner UC Health Medicare	$7.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$30.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.20
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna of AZ Commercial	$31.50
Rate for Payer: Devoted Health Medicare	$8.10
Rate for Payer: Humana of AZ Medicare	$7.20
Rate for Payer: Seven Corners Travel Insurance	$44.75
Rate for Payer: Southwest Service Administrators UFCW	$30.60
Rate for Payer: TriWest Medicare	$7.20
Rate for Payer: United Healthcare Commercial	$25.74
Rate for Payer: United Healthcare Medicare	$7.20
Rate for Payer: Veterans Affairs TRICARE	$7.13

TB Skin Test POC

Facility

$45.00

Service Code	CPT 86580
Hospital Charge Code	2673222
Hospital Revenue Code	521
Min. Negotiated Rate	$40.50
Max. Negotiated Rate	$40.50
Rate for Payer: Aetna of AZ Commercial	$40.50
Rate for Payer: Cash Price	$36.00

TC 3.0/4.0 OVERDRILL

Facility

$945.00

Hospital Charge Code	24127774
Hospital Revenue Code	270
Min. Negotiated Rate	$149.69
Max. Negotiated Rate	$850.50
Rate for Payer: Aetna of AZ Commercial	$850.50
Rate for Payer: Arizona Complete Health Allwell	$151.20
Rate for Payer: Banner UC Health Medicare	$151.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$642.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$151.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$151.20
Rate for Payer: Cash Price	$756.00
Rate for Payer: Cigna of AZ Commercial	$661.50
Rate for Payer: Devoted Health Medicare	$170.10
Rate for Payer: Humana of AZ Medicare	$151.20
Rate for Payer: Southwest Service Administrators UFCW	$642.60
Rate for Payer: TriWest Medicare	$151.20
Rate for Payer: United Healthcare Commercial	$540.54
Rate for Payer: United Healthcare Medicare	$151.20
Rate for Payer: Veterans Affairs TRICARE	$149.69

TC 3.0/4.0 OVERDRILL

Facility

$945.00

Hospital Charge Code	24127774
Hospital Revenue Code	270
Min. Negotiated Rate	$850.50
Max. Negotiated Rate	$850.50
Rate for Payer: Aetna of AZ Commercial	$850.50
Rate for Payer: Cash Price	$756.00

TCOC 7FA ABDOMINAL SENSOR CATHETER

Facility

$259.00

Hospital Charge Code	27750193
Hospital Revenue Code	270
Min. Negotiated Rate	$41.03
Max. Negotiated Rate	$233.10
Rate for Payer: Aetna of AZ Commercial	$233.10
Rate for Payer: Arizona Complete Health Allwell	$41.44
Rate for Payer: Banner UC Health Medicare	$41.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$176.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$41.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$41.44
Rate for Payer: Cash Price	$207.20
Rate for Payer: Cigna of AZ Commercial	$181.30
Rate for Payer: Devoted Health Medicare	$46.62
Rate for Payer: Humana of AZ Medicare	$41.44
Rate for Payer: Southwest Service Administrators UFCW	$176.12
Rate for Payer: TriWest Medicare	$41.44
Rate for Payer: United Healthcare Commercial	$148.15
Rate for Payer: United Healthcare Medicare	$41.44
Rate for Payer: Veterans Affairs TRICARE	$41.03

TCOC 7FA ABDOMINAL SENSOR CATHETER

Facility

$259.00

Hospital Charge Code	27750193
Hospital Revenue Code	270
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$233.10
Rate for Payer: Aetna of AZ Commercial	$233.10
Rate for Payer: Cash Price	$207.20

TCS SERIES CANN OVER DRILL 3.0/4.0MM SCREWS

Facility

$1,096.00

Hospital Charge Code	24209394
Hospital Revenue Code	270
Min. Negotiated Rate	$173.61
Max. Negotiated Rate	$986.40
Rate for Payer: Aetna of AZ Commercial	$986.40
Rate for Payer: Arizona Complete Health Allwell	$175.36
Rate for Payer: Banner UC Health Medicare	$175.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$745.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$175.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$175.36
Rate for Payer: Cash Price	$876.80
Rate for Payer: Cigna of AZ Commercial	$767.20
Rate for Payer: Devoted Health Medicare	$197.28
Rate for Payer: Humana of AZ Medicare	$175.36
Rate for Payer: Southwest Service Administrators UFCW	$745.28
Rate for Payer: TriWest Medicare	$175.36
Rate for Payer: United Healthcare Commercial	$626.91
Rate for Payer: United Healthcare Medicare	$175.36
Rate for Payer: Veterans Affairs TRICARE	$173.61

TCS SERIES CANN OVER DRILL 3.0/4.0MM SCREWS

Facility

$1,096.00

Hospital Charge Code	24209394
Hospital Revenue Code	270
Min. Negotiated Rate	$986.40
Max. Negotiated Rate	$986.40
Rate for Payer: Aetna of AZ Commercial	$986.40
Rate for Payer: Cash Price	$876.80

TDOC 7FD SENSOR 7FR

Facility

$551.00

Hospital Charge Code	28265124
Hospital Revenue Code	270
Min. Negotiated Rate	$87.28
Max. Negotiated Rate	$495.90
Rate for Payer: Aetna of AZ Commercial	$495.90
Rate for Payer: Arizona Complete Health Allwell	$88.16
Rate for Payer: Banner UC Health Medicare	$88.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$374.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$88.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$88.16
Rate for Payer: Cash Price	$440.80
Rate for Payer: Cigna of AZ Commercial	$385.70
Rate for Payer: Devoted Health Medicare	$99.18
Rate for Payer: Humana of AZ Medicare	$88.16
Rate for Payer: Southwest Service Administrators UFCW	$374.68
Rate for Payer: TriWest Medicare	$88.16
Rate for Payer: United Healthcare Commercial	$315.17
Rate for Payer: United Healthcare Medicare	$88.16
Rate for Payer: Veterans Affairs TRICARE	$87.28

TDOC 7FD SENSOR 7FR

Facility

$551.00

Hospital Charge Code	28265124
Hospital Revenue Code	270
Min. Negotiated Rate	$495.90
Max. Negotiated Rate	$495.90
Rate for Payer: Aetna of AZ Commercial	$495.90
Rate for Payer: Cash Price	$440.80

TDOC 7FX SINGLE CATHETER

Facility

$303.80

Hospital Charge Code	27750192
Hospital Revenue Code	270
Min. Negotiated Rate	$48.12
Max. Negotiated Rate	$273.42
Rate for Payer: Aetna of AZ Commercial	$273.42
Rate for Payer: Arizona Complete Health Allwell	$48.61
Rate for Payer: Banner UC Health Medicare	$48.61
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$206.58
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$48.61
Rate for Payer: Care1st Health Plan Arizona Medicare	$48.61
Rate for Payer: Cash Price	$243.04
Rate for Payer: Cigna of AZ Commercial	$212.66
Rate for Payer: Devoted Health Medicare	$54.68
Rate for Payer: Humana of AZ Medicare	$48.61
Rate for Payer: Southwest Service Administrators UFCW	$206.58
Rate for Payer: TriWest Medicare	$48.61
Rate for Payer: United Healthcare Commercial	$173.77
Rate for Payer: United Healthcare Medicare	$48.61
Rate for Payer: Veterans Affairs TRICARE	$48.12

TDOC 7FX SINGLE CATHETER

Facility

$303.80

Hospital Charge Code	27750192
Hospital Revenue Code	270
Min. Negotiated Rate	$273.42
Max. Negotiated Rate	$273.42
Rate for Payer: Aetna of AZ Commercial	$273.42
Rate for Payer: Cash Price	$243.04

TEL 613-8S

Facility

$861.00

Hospital Charge Code	22354822
Hospital Revenue Code	270
Min. Negotiated Rate	$774.90
Max. Negotiated Rate	$774.90
Rate for Payer: Aetna of AZ Commercial	$774.90
Rate for Payer: Cash Price	$688.80

TEL 613-8S

Facility

$861.00

Hospital Charge Code	22354822
Hospital Revenue Code	270
Min. Negotiated Rate	$136.38
Max. Negotiated Rate	$774.90
Rate for Payer: Aetna of AZ Commercial	$774.90
Rate for Payer: Arizona Complete Health Allwell	$137.76
Rate for Payer: Banner UC Health Medicare	$137.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$585.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$137.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$137.76
Rate for Payer: Cash Price	$688.80
Rate for Payer: Cigna of AZ Commercial	$602.70
Rate for Payer: Devoted Health Medicare	$154.98
Rate for Payer: Humana of AZ Medicare	$137.76
Rate for Payer: Southwest Service Administrators UFCW	$585.48
Rate for Payer: TriWest Medicare	$137.76
Rate for Payer: United Healthcare Commercial	$492.49
Rate for Payer: United Healthcare Medicare	$137.76
Rate for Payer: Veterans Affairs TRICARE	$136.38

TELEHEALTH CARDIO SITE FACILITY FEE

Facility

$62.00

Service Code	HCPCS Q3014
Hospital Charge Code	22247983
Hospital Revenue Code	780
Min. Negotiated Rate	$55.80
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Cash Price	$49.60

TELEHEALTH CARDIO SITE FACILITY FEE

Facility

$62.00

Service Code	HCPCS Q3014
Hospital Charge Code	22247983
Hospital Revenue Code	780
Min. Negotiated Rate	$9.82
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of AZ Commercial	$55.80
Rate for Payer: Arizona Complete Health Allwell	$9.92
Rate for Payer: Banner UC Health Medicare	$9.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$42.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.92
Rate for Payer: Cash Price	$49.60
Rate for Payer: Cigna of AZ Commercial	$43.40
Rate for Payer: Devoted Health Medicare	$11.16
Rate for Payer: Humana of AZ Medicare	$9.92
Rate for Payer: Southwest Service Administrators UFCW	$42.16
Rate for Payer: TriWest Medicare	$9.92
Rate for Payer: United Healthcare Commercial	$35.46
Rate for Payer: United Healthcare Medicare	$9.92
Rate for Payer: United Healthcare New Mexico Commercial	$11.78
Rate for Payer: Veterans Affairs TRICARE	$9.82

Know your out-of-pocket cost for care.

All Charges