Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

TEST TO MEASURE RATE OF AIRFLOW

Facility

$108.00

Service Code	CPT 94375
Hospital Charge Code	27880810
Hospital Revenue Code	521
Min. Negotiated Rate	$97.20
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of AZ Commercial	$97.20
Rate for Payer: Cash Price	$86.40

TEST TO MEASURE RATE OF AIRFLOW

Facility

$108.00

Service Code	CPT 94375
Hospital Charge Code	27880810
Hospital Revenue Code	521
Min. Negotiated Rate	$17.11
Max. Negotiated Rate	$334.09
Rate for Payer: Aetna of AZ Commercial	$97.20
Rate for Payer: Arizona Complete Health Allwell	$17.28
Rate for Payer: Banner UC Health Medicare	$17.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$73.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.28
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna of AZ Commercial	$75.60
Rate for Payer: Devoted Health Medicare	$19.44
Rate for Payer: Humana of AZ Medicare	$17.28
Rate for Payer: Seven Corners Travel Insurance	$334.09
Rate for Payer: Southwest Service Administrators UFCW	$73.44
Rate for Payer: TriWest Medicare	$17.28
Rate for Payer: United Healthcare Commercial	$61.78
Rate for Payer: United Healthcare Medicare	$17.28
Rate for Payer: Veterans Affairs TRICARE	$17.11

Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for use in indi

Facility

$85.00

Service Code	CPT 90714
Hospital Charge Code	749833
Hospital Revenue Code	636
Min. Negotiated Rate	$13.46
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of AZ Commercial	$76.50
Rate for Payer: Arizona Complete Health Allwell	$13.60
Rate for Payer: Banner UC Health Medicare	$13.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$57.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.60
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cigna of AZ Commercial	$59.50
Rate for Payer: Devoted Health Medicare	$15.30
Rate for Payer: Humana of AZ Medicare	$13.60
Rate for Payer: Southwest Service Administrators UFCW	$57.80
Rate for Payer: TriWest Medicare	$13.60
Rate for Payer: United Healthcare Commercial	$48.62
Rate for Payer: United Healthcare Medicare	$13.60
Rate for Payer: United Healthcare New Mexico Commercial	$16.15
Rate for Payer: Veterans Affairs TRICARE	$13.46

Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for use in indi

Facility

$85.00

Service Code	CPT 90714
Hospital Charge Code	749833
Hospital Revenue Code	636
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of AZ Commercial	$76.50
Rate for Payer: Cash Price	$68.00

Tetanus, diphtheria toxoids acellular pertussis vaccine (T

Facility

$135.00

Service Code	CPT 90715
Hospital Charge Code	755159
Hospital Revenue Code	636
Min. Negotiated Rate	$21.38
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of AZ Commercial	$121.50
Rate for Payer: Arizona Complete Health Allwell	$21.60
Rate for Payer: Banner UC Health Medicare	$21.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$91.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$21.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$21.60
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna of AZ Commercial	$94.50
Rate for Payer: Devoted Health Medicare	$24.30
Rate for Payer: Humana of AZ Medicare	$21.60
Rate for Payer: Southwest Service Administrators UFCW	$91.80
Rate for Payer: TriWest Medicare	$21.60
Rate for Payer: United Healthcare Commercial	$77.22
Rate for Payer: United Healthcare Medicare	$21.60
Rate for Payer: United Healthcare New Mexico Commercial	$25.65
Rate for Payer: Veterans Affairs TRICARE	$21.38

Tetanus, diphtheria toxoids acellular pertussis vaccine (T

Facility

$135.00

Service Code	CPT 90715
Hospital Charge Code	755159
Hospital Revenue Code	636
Min. Negotiated Rate	$121.50
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of AZ Commercial	$121.50
Rate for Payer: Cash Price	$108.00

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	$40.90
Max. Negotiated Rate	$40.90
Rate for Payer: Aetna of AZ Commercial	$40.90
Rate for Payer: Cash Price	$36.35

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	$7.20
Max. Negotiated Rate	$40.90
Rate for Payer: Aetna of AZ Commercial	$40.90
Rate for Payer: Arizona Complete Health Allwell	$7.27
Rate for Payer: Banner UC Health Medicare	$7.27
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$30.90
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.27
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.27
Rate for Payer: Cash Price	$36.35
Rate for Payer: Cigna of AZ Commercial	$29.54
Rate for Payer: Devoted Health Medicare	$8.18
Rate for Payer: Humana of AZ Medicare	$7.27
Rate for Payer: Southwest Service Administrators UFCW	$30.90
Rate for Payer: TriWest Medicare	$7.27
Rate for Payer: United Healthcare Commercial	$25.99
Rate for Payer: United Healthcare Medicare	$7.27
Rate for Payer: Veterans Affairs TRICARE	$7.20

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	$14.98
Max. Negotiated Rate	$85.13
Rate for Payer: Aetna of AZ Commercial	$85.13
Rate for Payer: Arizona Complete Health Allwell	$15.13
Rate for Payer: Banner UC Health Medicare	$15.13
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$64.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$15.13
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.13
Rate for Payer: Cash Price	$75.67
Rate for Payer: Cigna of AZ Commercial	$61.48
Rate for Payer: Devoted Health Medicare	$17.03
Rate for Payer: Humana of AZ Medicare	$15.13
Rate for Payer: Southwest Service Administrators UFCW	$64.32
Rate for Payer: TriWest Medicare	$15.13
Rate for Payer: United Healthcare Commercial	$54.11
Rate for Payer: United Healthcare Medicare	$15.13
Rate for Payer: Veterans Affairs TRICARE	$14.98

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	$85.13
Max. Negotiated Rate	$85.13
Rate for Payer: Aetna of AZ Commercial	$85.13
Rate for Payer: Cash Price	$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	$469.80
Max. Negotiated Rate	$469.80
Rate for Payer: Aetna of AZ Commercial	$469.80
Rate for Payer: Cash Price	$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	$82.68
Max. Negotiated Rate	$862.78
Rate for Payer: Aetna of AZ Commercial	$469.80
Rate for Payer: Arizona Complete Health Allwell	$83.52
Rate for Payer: Banner UC Health Medicare	$83.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$354.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$83.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$83.52
Rate for Payer: Cash Price	$417.60
Rate for Payer: Cash Price	$417.60
Rate for Payer: Cigna of AZ Commercial	$339.30
Rate for Payer: Devoted Health Medicare	$93.96
Rate for Payer: Humana of AZ Medicare	$83.52
Rate for Payer: Seven Corners Travel Insurance	$862.78
Rate for Payer: Southwest Service Administrators UFCW	$354.96
Rate for Payer: TriWest Medicare	$83.52
Rate for Payer: United Healthcare Commercial	$298.58
Rate for Payer: United Healthcare Medicare	$83.52
Rate for Payer: Veterans Affairs TRICARE	$82.68

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: Arizona Complete Health Allwell	$0.65
Rate for Payer: Banner UC Health Medicare	$0.65
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2.77
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.65
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.65
Rate for Payer: Cash Price	$3.26
Rate for Payer: Cigna of AZ Commercial	$2.65
Rate for Payer: Devoted Health Medicare	$0.73
Rate for Payer: Humana of AZ Medicare	$0.65
Rate for Payer: Southwest Service Administrators UFCW	$2.77
Rate for Payer: TriWest Medicare	$0.65
Rate for Payer: United Healthcare Commercial	$2.33
Rate for Payer: United Healthcare Medicare	$0.65
Rate for Payer: Veterans Affairs TRICARE	$0.65

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	$3.67
Max. Negotiated Rate	$3.67
Rate for Payer: Aetna of AZ Commercial	$3.67
Rate for Payer: Cash Price	$3.26

Thawed Aph FFP ACDA 200-400 ml

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316425
Hospital Revenue Code	390
Min. Negotiated Rate	$28.04
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Arizona Complete Health Allwell	$28.32
Rate for Payer: Banner UC Health Medicare	$28.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$120.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.32
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cigna of AZ Commercial	$115.05
Rate for Payer: Devoted Health Medicare	$31.86
Rate for Payer: Humana of AZ Medicare	$28.32
Rate for Payer: Seven Corners Travel Insurance	$130.21
Rate for Payer: Southwest Service Administrators UFCW	$120.36
Rate for Payer: TriWest Medicare	$28.32
Rate for Payer: United Healthcare Commercial	$101.24
Rate for Payer: United Healthcare Medicare	$28.32
Rate for Payer: Veterans Affairs TRICARE	$28.04

Thawed Aph FFP ACDA 200-400 ml

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316425
Hospital Revenue Code	390
Min. Negotiated Rate	$159.30
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Cash Price	$141.60

Thawed Cryo AHF

Facility

$504.00

Service Code	HCPCS P9044
Hospital Charge Code	22191131
Hospital Revenue Code	390
Min. Negotiated Rate	$453.60
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of AZ Commercial	$453.60
Rate for Payer: Cash Price	$403.20

Thawed Cryo AHF

Facility

$504.00

Service Code	HCPCS P9044
Hospital Charge Code	22191131
Hospital Revenue Code	390
Min. Negotiated Rate	$79.83
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of AZ Commercial	$453.60
Rate for Payer: Arizona Complete Health Allwell	$80.64
Rate for Payer: Banner UC Health Medicare	$80.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$342.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$80.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$80.64
Rate for Payer: Cash Price	$403.20
Rate for Payer: Cash Price	$403.20
Rate for Payer: Cigna of AZ Commercial	$327.60
Rate for Payer: Devoted Health Medicare	$90.72
Rate for Payer: Humana of AZ Medicare	$80.64
Rate for Payer: Seven Corners Travel Insurance	$199.98
Rate for Payer: Southwest Service Administrators UFCW	$342.72
Rate for Payer: TriWest Medicare	$80.64
Rate for Payer: United Healthcare Commercial	$288.29
Rate for Payer: United Healthcare Medicare	$80.64
Rate for Payer: Veterans Affairs TRICARE	$79.83

Thawed Plasma ACDA

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316439
Hospital Revenue Code	390
Min. Negotiated Rate	$159.30
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Cash Price	$141.60

Thawed Plasma ACDA

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316439
Hospital Revenue Code	390
Min. Negotiated Rate	$28.04
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Arizona Complete Health Allwell	$28.32
Rate for Payer: Banner UC Health Medicare	$28.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$120.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.32
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cigna of AZ Commercial	$115.05
Rate for Payer: Devoted Health Medicare	$31.86
Rate for Payer: Humana of AZ Medicare	$28.32
Rate for Payer: Seven Corners Travel Insurance	$130.21
Rate for Payer: Southwest Service Administrators UFCW	$120.36
Rate for Payer: TriWest Medicare	$28.32
Rate for Payer: United Healthcare Commercial	$101.24
Rate for Payer: United Healthcare Medicare	$28.32
Rate for Payer: Veterans Affairs TRICARE	$28.04

Thawed Plasma ACDA Irr

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316442
Hospital Revenue Code	390
Min. Negotiated Rate	$28.04
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Arizona Complete Health Allwell	$28.32
Rate for Payer: Banner UC Health Medicare	$28.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$120.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.32
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cigna of AZ Commercial	$115.05
Rate for Payer: Devoted Health Medicare	$31.86
Rate for Payer: Humana of AZ Medicare	$28.32
Rate for Payer: Seven Corners Travel Insurance	$130.21
Rate for Payer: Southwest Service Administrators UFCW	$120.36
Rate for Payer: TriWest Medicare	$28.32
Rate for Payer: United Healthcare Commercial	$101.24
Rate for Payer: United Healthcare Medicare	$28.32
Rate for Payer: Veterans Affairs TRICARE	$28.04

Thawed Plasma ACDA Irr

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316442
Hospital Revenue Code	390
Min. Negotiated Rate	$159.30
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Cash Price	$141.60

Thawed Plasma ACDB

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316434
Hospital Revenue Code	390
Min. Negotiated Rate	$28.04
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Arizona Complete Health Allwell	$28.32
Rate for Payer: Banner UC Health Medicare	$28.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$120.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.32
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cigna of AZ Commercial	$115.05
Rate for Payer: Devoted Health Medicare	$31.86
Rate for Payer: Humana of AZ Medicare	$28.32
Rate for Payer: Seven Corners Travel Insurance	$130.21
Rate for Payer: Southwest Service Administrators UFCW	$120.36
Rate for Payer: TriWest Medicare	$28.32
Rate for Payer: United Healthcare Commercial	$101.24
Rate for Payer: United Healthcare Medicare	$28.32
Rate for Payer: Veterans Affairs TRICARE	$28.04

Thawed Plasma ACDB

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316434
Hospital Revenue Code	390
Min. Negotiated Rate	$159.30
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Cash Price	$141.60

Thawed Plasma ACDB Irr

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316437
Hospital Revenue Code	390
Min. Negotiated Rate	$159.30
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of AZ Commercial	$159.30
Rate for Payer: Cash Price	$141.60

Know your out-of-pocket cost for care.

All Charges