Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Therapeutic Exercise Charges

Facility

$243.00

Service Code	CPT 97110 GO
Hospital Charge Code	23955327
Hospital Revenue Code	430
Min. Negotiated Rate	$30.45
Max. Negotiated Rate	$218.70
Rate for Payer: Aetna of AZ Commercial	$218.70
Rate for Payer: Arizona Complete Health Allwell	$38.88
Rate for Payer: Banner UC Health Medicare	$38.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$165.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$30.45
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cigna of AZ Commercial	$170.10
Rate for Payer: Devoted Health Medicare	$43.74
Rate for Payer: Humana of AZ Medicare	$38.88
Rate for Payer: Southwest Service Administrators UFCW	$165.24
Rate for Payer: TriWest Medicare	$38.88
Rate for Payer: United Healthcare Commercial	$139.00
Rate for Payer: United Healthcare Medicare	$38.88
Rate for Payer: United Healthcare New Mexico Commercial	$46.17
Rate for Payer: Veterans Affairs TRICARE	$38.49

Therapeutic Exercise Charges

Facility

$231.00

Service Code	CPT 97110 GO
Hospital Charge Code	8822780
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

Therapeutic Phlebotomy 6

Facility

$429.00

Service Code	CPT 99195
Hospital Charge Code	22309912
Hospital Revenue Code	300
Min. Negotiated Rate	$67.95
Max. Negotiated Rate	$386.10
Rate for Payer: Aetna of AZ Commercial	$386.10
Rate for Payer: Arizona Complete Health Allwell	$68.64
Rate for Payer: Banner UC Health Medicare	$68.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$291.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$68.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$70.39
Rate for Payer: Cash Price	$343.20
Rate for Payer: Cash Price	$343.20
Rate for Payer: Cigna of AZ Commercial	$278.85
Rate for Payer: Devoted Health Medicare	$77.22
Rate for Payer: Humana of AZ Medicare	$68.64
Rate for Payer: Seven Corners Travel Insurance	$205.86
Rate for Payer: Southwest Service Administrators UFCW	$291.72
Rate for Payer: TriWest Medicare	$68.64
Rate for Payer: United Healthcare Commercial	$245.39
Rate for Payer: United Healthcare Medicare	$68.64
Rate for Payer: Veterans Affairs TRICARE	$67.95

Therapeutic Phlebotomy 6

Facility

$429.00

Service Code	CPT 99195
Hospital Charge Code	22309912
Hospital Revenue Code	300
Min. Negotiated Rate	$386.10
Max. Negotiated Rate	$386.10
Rate for Payer: Aetna of AZ Commercial	$386.10
Rate for Payer: Cash Price	$343.20

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug

Facility

$3,373.00

Service Code	CPT 96374
Hospital Revenue Code	490
Min. Negotiated Rate	$329.11
Max. Negotiated Rate	$3,373.00
Rate for Payer: Seven Corners Travel Insurance	$329.11
Rate for Payer: United Healthcare Commercial	$3,373.00

THERAPEUTIC, PROPHYLACTIC, OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR

Facility

$3,373.00

Service Code	CPT 96372
Hospital Revenue Code	490
Min. Negotiated Rate	$111.40
Max. Negotiated Rate	$3,373.00
Rate for Payer: Seven Corners Travel Insurance	$111.40
Rate for Payer: United Healthcare Commercial	$3,373.00

thiamine 100 mg Tab [CQCH]

Facility

$0.02

Service Code	NDC 10006073020
Hospital Charge Code	105943723
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Cash Price	$0.02

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: Arizona Complete Health Allwell	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.00
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Devoted Health Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Southwest Service Administrators UFCW	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: United Healthcare Commercial	$0.01
Rate for Payer: United Healthcare Medicare	$0.00
Rate for Payer: Veterans Affairs TRICARE	$0.00

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	$2.35
Max. Negotiated Rate	$2.35
Rate for Payer: Aetna of AZ Commercial	$2.35
Rate for Payer: Cash Price	$2.08

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	$0.41
Max. Negotiated Rate	$2.35
Rate for Payer: Aetna of AZ Commercial	$2.35
Rate for Payer: Arizona Complete Health Allwell	$0.42
Rate for Payer: Banner UC Health Medicare	$0.42
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.77
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.42
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.42
Rate for Payer: Cash Price	$2.08
Rate for Payer: Cigna of AZ Commercial	$1.70
Rate for Payer: Devoted Health Medicare	$0.47
Rate for Payer: Humana of AZ Medicare	$0.42
Rate for Payer: Southwest Service Administrators UFCW	$1.77
Rate for Payer: TriWest Medicare	$0.42
Rate for Payer: United Healthcare Commercial	$1.49
Rate for Payer: United Healthcare Medicare	$0.42
Rate for Payer: Veterans Affairs TRICARE	$0.41

Thiopurine Methyltransferase LC

Facility

$673.00

Service Code	CPT 82542
Hospital Charge Code	2087652
Hospital Revenue Code	301
Min. Negotiated Rate	$605.70
Max. Negotiated Rate	$605.70
Rate for Payer: Aetna of AZ Commercial	$605.70
Rate for Payer: Cash Price	$538.40

Thiopurine Methyltransferase LC

Facility

$673.00

Service Code	CPT 82542
Hospital Charge Code	2087652
Hospital Revenue Code	301
Min. Negotiated Rate	$34.93
Max. Negotiated Rate	$605.70
Rate for Payer: Aetna of AZ Commercial	$605.70
Rate for Payer: Arizona Complete Health Allwell	$107.68
Rate for Payer: Banner UC Health Medicare	$107.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$457.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$107.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$107.68
Rate for Payer: Cash Price	$538.40
Rate for Payer: Cash Price	$538.40
Rate for Payer: Cigna of AZ Commercial	$437.45
Rate for Payer: Devoted Health Medicare	$121.14
Rate for Payer: Humana of AZ Medicare	$107.68
Rate for Payer: Seven Corners Travel Insurance	$34.93
Rate for Payer: Southwest Service Administrators UFCW	$457.64
Rate for Payer: TriWest Medicare	$107.68
Rate for Payer: United Healthcare Commercial	$384.96
Rate for Payer: United Healthcare Medicare	$107.68
Rate for Payer: Veterans Affairs TRICARE	$106.60

THORACENTESIS

Facility

$440.00

Hospital Charge Code	22282949
Hospital Revenue Code	302
Min. Negotiated Rate	$396.00
Max. Negotiated Rate	$396.00
Rate for Payer: Aetna of AZ Commercial	$396.00
Rate for Payer: Cash Price	$352.00

THORACENTESIS

Facility

$440.00

Hospital Charge Code	22282949
Hospital Revenue Code	302
Min. Negotiated Rate	$69.70
Max. Negotiated Rate	$396.00
Rate for Payer: Aetna of AZ Commercial	$396.00
Rate for Payer: Arizona Complete Health Allwell	$70.40
Rate for Payer: Banner UC Health Medicare	$70.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$299.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$70.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$70.40
Rate for Payer: Cash Price	$352.00
Rate for Payer: Cigna of AZ Commercial	$286.00
Rate for Payer: Devoted Health Medicare	$79.20
Rate for Payer: Humana of AZ Medicare	$70.40
Rate for Payer: Southwest Service Administrators UFCW	$299.20
Rate for Payer: TriWest Medicare	$70.40
Rate for Payer: United Healthcare Commercial	$251.68
Rate for Payer: United Healthcare Medicare	$70.40
Rate for Payer: Veterans Affairs TRICARE	$69.70

THP albuterol MDI-90 mcg/inh 8 gm [CQCH]

Facility

$35.00

Service Code	NDC 99999999968
Hospital Charge Code	110285600
Hospital Revenue Code	253
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of AZ Commercial	$31.50
Rate for Payer: Cash Price	$28.00

THP albuterol MDI-90 mcg/inh 8 gm [CQCH]

Facility

$35.00

Service Code	NDC 99999999968
Hospital Charge Code	110285600
Hospital Revenue Code	253
Min. Negotiated Rate	$5.54
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna of AZ Commercial	$31.50
Rate for Payer: Arizona Complete Health Allwell	$5.60
Rate for Payer: Banner UC Health Medicare	$5.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$23.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.60
Rate for Payer: Cash Price	$28.00
Rate for Payer: Cigna of AZ Commercial	$22.75
Rate for Payer: Devoted Health Medicare	$6.30
Rate for Payer: Humana of AZ Medicare	$5.60
Rate for Payer: Southwest Service Administrators UFCW	$23.80
Rate for Payer: TriWest Medicare	$5.60
Rate for Payer: United Healthcare Commercial	$20.02
Rate for Payer: United Healthcare Medicare	$5.60
Rate for Payer: Veterans Affairs TRICARE	$5.54

THP amoxicillin 250 mg/5 mL Oral susp (80 mL after reconst) [CQCH]

Facility

$3.24

Service Code	NDC 99999999970
Hospital Charge Code	110285383
Hospital Revenue Code	253
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$2.92
Rate for Payer: Aetna of AZ Commercial	$2.92
Rate for Payer: Arizona Complete Health Allwell	$0.52
Rate for Payer: Banner UC Health Medicare	$0.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.52
Rate for Payer: Cash Price	$2.59
Rate for Payer: Cigna of AZ Commercial	$2.11
Rate for Payer: Devoted Health Medicare	$0.58
Rate for Payer: Humana of AZ Medicare	$0.52
Rate for Payer: Southwest Service Administrators UFCW	$2.20
Rate for Payer: TriWest Medicare	$0.52
Rate for Payer: United Healthcare Commercial	$1.85
Rate for Payer: United Healthcare Medicare	$0.52
Rate for Payer: Veterans Affairs TRICARE	$0.51

THP amoxicillin 250 mg/5 mL Oral susp (80 mL after reconst) [CQCH]

Facility

$3.24

Service Code	NDC 99999999970
Hospital Charge Code	110285383
Hospital Revenue Code	253
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$2.92
Rate for Payer: Aetna of AZ Commercial	$2.92
Rate for Payer: Cash Price	$2.59

THP amoxicillin 500 mg Cap [CQCH]

Facility

$0.28

Service Code	NDC 99999999972
Hospital Charge Code	110285149
Hospital Revenue Code	253
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of AZ Commercial	$0.25
Rate for Payer: Arizona Complete Health Allwell	$0.04
Rate for Payer: Banner UC Health Medicare	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.19
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.04
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna of AZ Commercial	$0.18
Rate for Payer: Devoted Health Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Southwest Service Administrators UFCW	$0.19
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: United Healthcare Commercial	$0.16
Rate for Payer: United Healthcare Medicare	$0.04
Rate for Payer: Veterans Affairs TRICARE	$0.04

THP amoxicillin 500 mg Cap [CQCH]

Facility

$0.28

Service Code	NDC 99999999972
Hospital Charge Code	110285149
Hospital Revenue Code	253
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.25
Rate for Payer: Aetna of AZ Commercial	$0.25
Rate for Payer: Cash Price	$0.22

THP amoxicillin-clavulanate 600 mg/5 mL Oral Liq (75 mL after reconst.) [CQCH]

Facility

$25.26

Service Code	NDC 99999999969
Hospital Charge Code	110285455
Hospital Revenue Code	253
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$22.73
Rate for Payer: Aetna of AZ Commercial	$22.73
Rate for Payer: Arizona Complete Health Allwell	$4.04
Rate for Payer: Banner UC Health Medicare	$4.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$17.18
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.04
Rate for Payer: Cash Price	$20.21
Rate for Payer: Cigna of AZ Commercial	$16.42
Rate for Payer: Devoted Health Medicare	$4.55
Rate for Payer: Humana of AZ Medicare	$4.04
Rate for Payer: Southwest Service Administrators UFCW	$17.18
Rate for Payer: TriWest Medicare	$4.04
Rate for Payer: United Healthcare Commercial	$14.45
Rate for Payer: United Healthcare Medicare	$4.04
Rate for Payer: Veterans Affairs TRICARE	$4.00

THP amoxicillin-clavulanate 600 mg/5 mL Oral Liq (75 mL after reconst.) [CQCH]

Facility

$25.26

Service Code	NDC 99999999969
Hospital Charge Code	110285455
Hospital Revenue Code	253
Min. Negotiated Rate	$22.73
Max. Negotiated Rate	$22.73
Rate for Payer: Aetna of AZ Commercial	$22.73
Rate for Payer: Cash Price	$20.21

THP azithromycin 200 mg/5 mL Oral Susp (22.5 mL after reconst) [CQCH]

Facility

$25.88

Service Code	NDC 99999999971
Hospital Charge Code	110285309
Hospital Revenue Code	253
Min. Negotiated Rate	$4.10
Max. Negotiated Rate	$23.29
Rate for Payer: Aetna of AZ Commercial	$23.29
Rate for Payer: Arizona Complete Health Allwell	$4.14
Rate for Payer: Banner UC Health Medicare	$4.14
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$17.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.14
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.14
Rate for Payer: Cash Price	$20.70
Rate for Payer: Cigna of AZ Commercial	$16.82
Rate for Payer: Devoted Health Medicare	$4.66
Rate for Payer: Humana of AZ Medicare	$4.14
Rate for Payer: Southwest Service Administrators UFCW	$17.60
Rate for Payer: TriWest Medicare	$4.14
Rate for Payer: United Healthcare Commercial	$14.80
Rate for Payer: United Healthcare Medicare	$4.14
Rate for Payer: Veterans Affairs TRICARE	$4.10

THP azithromycin 200 mg/5 mL Oral Susp (22.5 mL after reconst) [CQCH]

Facility

$25.88

Service Code	NDC 99999999971
Hospital Charge Code	110285309
Hospital Revenue Code	253
Min. Negotiated Rate	$23.29
Max. Negotiated Rate	$23.29
Rate for Payer: Aetna of AZ Commercial	$23.29
Rate for Payer: Cash Price	$20.70

THP cephalexin 500 mg Cap [CQCH]

Facility

$0.32

Service Code	NDC 99999999977
Hospital Charge Code	110283528
Hospital Revenue Code	253
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of AZ Commercial	$0.29
Rate for Payer: Cash Price	$0.26

Know your out-of-pocket cost for care.

All Charges