Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Thawed Plasma ACDB Irr

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316437
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 CP2D Irr

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316450
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 CP2D Irr

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316450
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 CPDA1

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316428
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 CPDA1

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316428
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 CPDA1 Irr

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316426
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 CPDA1 Irr

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316426
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 CPD Irr

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316431
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 CPD Irr

Facility

$177.00

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

Facility

$177.00

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

Facility

$177.00

Service Code	HCPCS P9017
Hospital Charge Code	22316429
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 Pooled Cryo

Facility

$480.00

Service Code	HCPCS P9044
Hospital Charge Code	22316447
Hospital Revenue Code	390
Min. Negotiated Rate	$432.00
Max. Negotiated Rate	$432.00
Rate for Payer: Aetna of AZ Commercial	$432.00
Rate for Payer: Cash Price	$384.00

Thawed Pooled Cryo

Facility

$480.00

Service Code	HCPCS P9044
Hospital Charge Code	22316447
Hospital Revenue Code	390
Min. Negotiated Rate	$76.03
Max. Negotiated Rate	$432.00
Rate for Payer: Aetna of AZ Commercial	$432.00
Rate for Payer: Arizona Complete Health Allwell	$76.80
Rate for Payer: Banner UC Health Medicare	$76.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$326.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$76.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$76.80
Rate for Payer: Cash Price	$384.00
Rate for Payer: Cash Price	$384.00
Rate for Payer: Cigna of AZ Commercial	$312.00
Rate for Payer: Devoted Health Medicare	$86.40
Rate for Payer: Humana of AZ Medicare	$76.80
Rate for Payer: Seven Corners Travel Insurance	$199.98
Rate for Payer: Southwest Service Administrators UFCW	$326.40
Rate for Payer: TriWest Medicare	$76.80
Rate for Payer: United Healthcare Commercial	$274.56
Rate for Payer: United Healthcare Medicare	$76.80
Rate for Payer: Veterans Affairs TRICARE	$76.03

THEOPHYLLINE

Facility

$165.00

Service Code	CPT 80198
Hospital Charge Code	23603248
Hospital Revenue Code	301
Min. Negotiated Rate	$148.50
Max. Negotiated Rate	$148.50
Rate for Payer: Aetna of AZ Commercial	$148.50
Rate for Payer: Cash Price	$132.00

THEOPHYLLINE

Facility

$165.00

Service Code	CPT 80198
Hospital Charge Code	23603248
Hospital Revenue Code	301
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$148.50
Rate for Payer: Aetna of AZ Commercial	$148.50
Rate for Payer: Arizona Complete Health Allwell	$26.40
Rate for Payer: Banner UC Health Medicare	$26.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$112.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$26.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$26.40
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cigna of AZ Commercial	$107.25
Rate for Payer: Devoted Health Medicare	$29.70
Rate for Payer: Humana of AZ Medicare	$26.40
Rate for Payer: Seven Corners Travel Insurance	$20.50
Rate for Payer: Southwest Service Administrators UFCW	$112.20
Rate for Payer: TriWest Medicare	$26.40
Rate for Payer: United Healthcare Commercial	$94.38
Rate for Payer: United Healthcare Medicare	$26.40
Rate for Payer: Veterans Affairs TRICARE	$26.14

Theophylline, Serum LC

Facility

$173.00

Service Code	CPT 80198
Hospital Charge Code	1285596
Hospital Revenue Code	301
Min. Negotiated Rate	$20.50
Max. Negotiated Rate	$155.70
Rate for Payer: Aetna of AZ Commercial	$155.70
Rate for Payer: Arizona Complete Health Allwell	$27.68
Rate for Payer: Banner UC Health Medicare	$27.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$117.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.68
Rate for Payer: Cash Price	$138.40
Rate for Payer: Cash Price	$138.40
Rate for Payer: Cigna of AZ Commercial	$112.45
Rate for Payer: Devoted Health Medicare	$31.14
Rate for Payer: Humana of AZ Medicare	$27.68
Rate for Payer: Seven Corners Travel Insurance	$20.50
Rate for Payer: Southwest Service Administrators UFCW	$117.64
Rate for Payer: TriWest Medicare	$27.68
Rate for Payer: United Healthcare Commercial	$98.96
Rate for Payer: United Healthcare Medicare	$27.68
Rate for Payer: Veterans Affairs TRICARE	$27.40

Theophylline, Serum LC

Facility

$173.00

Service Code	CPT 80198
Hospital Charge Code	1285596
Hospital Revenue Code	301
Min. Negotiated Rate	$155.70
Max. Negotiated Rate	$155.70
Rate for Payer: Aetna of AZ Commercial	$155.70
Rate for Payer: Cash Price	$138.40

THE PINK PAD XL

Facility

$806.20

Hospital Charge Code	28132811
Hospital Revenue Code	270
Min. Negotiated Rate	$725.58
Max. Negotiated Rate	$725.58
Rate for Payer: Aetna of AZ Commercial	$725.58
Rate for Payer: Cash Price	$644.96

THE PINK PAD XL

Facility

$806.20

Hospital Charge Code	28132811
Hospital Revenue Code	270
Min. Negotiated Rate	$127.70
Max. Negotiated Rate	$725.58
Rate for Payer: Aetna of AZ Commercial	$725.58
Rate for Payer: Arizona Complete Health Allwell	$128.99
Rate for Payer: Banner UC Health Medicare	$128.99
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$548.22
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$128.99
Rate for Payer: Care1st Health Plan Arizona Medicare	$128.99
Rate for Payer: Cash Price	$644.96
Rate for Payer: Cigna of AZ Commercial	$564.34
Rate for Payer: Devoted Health Medicare	$145.12
Rate for Payer: Humana of AZ Medicare	$128.99
Rate for Payer: Southwest Service Administrators UFCW	$548.22
Rate for Payer: TriWest Medicare	$128.99
Rate for Payer: United Healthcare Commercial	$461.15
Rate for Payer: United Healthcare Medicare	$128.99
Rate for Payer: Veterans Affairs TRICARE	$127.70

Therapeutic Activities Charges

Facility

$172.00

Service Code	CPT 97530 GP
Hospital Charge Code	692245
Hospital Revenue Code	420
Min. Negotiated Rate	$27.24
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Arizona Complete Health Allwell	$27.52
Rate for Payer: Banner UC Health Medicare	$27.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$116.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.47
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cigna of AZ Commercial	$120.40
Rate for Payer: Devoted Health Medicare	$30.96
Rate for Payer: Humana of AZ Medicare	$27.52
Rate for Payer: Southwest Service Administrators UFCW	$116.96
Rate for Payer: TriWest Medicare	$27.52
Rate for Payer: United Healthcare Commercial	$98.38
Rate for Payer: United Healthcare Medicare	$27.52
Rate for Payer: United Healthcare New Mexico Commercial	$32.68
Rate for Payer: Veterans Affairs TRICARE	$27.24

Therapeutic Activities Charges

Facility

$172.00

Service Code	CPT 97530 GP
Hospital Charge Code	692245
Hospital Revenue Code	420
Min. Negotiated Rate	$154.80
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Cash Price	$137.60

Therapeutic Exercise Charges

Facility

$231.00

Service Code	CPT 97110 GO
Hospital Charge Code	8822780
Hospital Revenue Code	430
Min. Negotiated Rate	$207.90
Max. Negotiated Rate	$207.90
Rate for Payer: Aetna of AZ Commercial	$207.90
Rate for Payer: Cash Price	$184.80

Therapeutic Exercise Charges

Facility

$243.00

Service Code	CPT 97110 GO
Hospital Charge Code	23955327
Hospital Revenue Code	430
Min. Negotiated Rate	$218.70
Max. Negotiated Rate	$218.70
Rate for Payer: Aetna of AZ Commercial	$218.70
Rate for Payer: Cash Price	$194.40

Therapeutic Exercise Charges

Facility

$231.00

Service Code	CPT 97110 GO
Hospital Charge Code	691306
Hospital Revenue Code	430
Min. Negotiated Rate	$207.90
Max. Negotiated Rate	$207.90
Rate for Payer: Aetna of AZ Commercial	$207.90
Rate for Payer: Cash Price	$184.80

Therapeutic Exercise Charges

Facility

$231.00

Service Code	CPT 97110 GO
Hospital Charge Code	691306
Hospital Revenue Code	430
Min. Negotiated Rate	$30.45
Max. Negotiated Rate	$207.90
Rate for Payer: Aetna of AZ Commercial	$207.90
Rate for Payer: Arizona Complete Health Allwell	$36.96
Rate for Payer: Banner UC Health Medicare	$36.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$157.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$30.45
Rate for Payer: Cash Price	$184.80
Rate for Payer: Cash Price	$184.80
Rate for Payer: Cigna of AZ Commercial	$161.70
Rate for Payer: Devoted Health Medicare	$41.58
Rate for Payer: Humana of AZ Medicare	$36.96
Rate for Payer: Southwest Service Administrators UFCW	$157.08
Rate for Payer: TriWest Medicare	$36.96
Rate for Payer: United Healthcare Commercial	$132.13
Rate for Payer: United Healthcare Medicare	$36.96
Rate for Payer: United Healthcare New Mexico Commercial	$43.89
Rate for Payer: Veterans Affairs TRICARE	$36.59

Know your out-of-pocket cost for care.

All Charges