Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

THYROXINE BINDING GLOBULIN (TBG)

Facility

$100.00

Service Code	CPT 84442
Hospital Charge Code	22949892
Hospital Revenue Code	301
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of AZ Commercial	$90.00
Rate for Payer: Cash Price	$80.00

.Thyroxine (T4) Free, Direct H LC

Facility

$374.00

Service Code	CPT 84439
Hospital Charge Code	22531068
Hospital Revenue Code	302
Min. Negotiated Rate	$336.60
Max. Negotiated Rate	$336.60
Rate for Payer: Aetna of AZ Commercial	$336.60
Rate for Payer: Cash Price	$299.20

.Thyroxine (T4) Free, Direct H LC

Facility

$374.00

Service Code	CPT 84439
Hospital Charge Code	22531068
Hospital Revenue Code	302
Min. Negotiated Rate	$13.08
Max. Negotiated Rate	$336.60
Rate for Payer: Aetna of AZ Commercial	$336.60
Rate for Payer: Arizona Complete Health Allwell	$59.84
Rate for Payer: Banner UC Health Medicare	$59.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$254.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$59.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$59.84
Rate for Payer: Cash Price	$299.20
Rate for Payer: Cash Price	$299.20
Rate for Payer: Cigna of AZ Commercial	$243.10
Rate for Payer: Devoted Health Medicare	$67.32
Rate for Payer: Humana of AZ Medicare	$59.84
Rate for Payer: Seven Corners Travel Insurance	$13.08
Rate for Payer: Southwest Service Administrators UFCW	$254.32
Rate for Payer: TriWest Medicare	$59.84
Rate for Payer: United Healthcare Commercial	$213.93
Rate for Payer: United Healthcare Medicare	$59.84
Rate for Payer: Veterans Affairs TRICARE	$59.24

Thyroxine (T4) Free, Direct, LC

Facility

$374.00

Service Code	CPT 84439
Hospital Charge Code	1285539
Hospital Revenue Code	301
Min. Negotiated Rate	$336.60
Max. Negotiated Rate	$336.60
Rate for Payer: Aetna of AZ Commercial	$336.60
Rate for Payer: Cash Price	$299.20

Thyroxine (T4) Free, Direct, LC

Facility

$374.00

Service Code	CPT 84439
Hospital Charge Code	1285539
Hospital Revenue Code	301
Min. Negotiated Rate	$13.08
Max. Negotiated Rate	$336.60
Rate for Payer: Aetna of AZ Commercial	$336.60
Rate for Payer: Arizona Complete Health Allwell	$59.84
Rate for Payer: Banner UC Health Medicare	$59.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$254.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$59.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$59.84
Rate for Payer: Cash Price	$299.20
Rate for Payer: Cash Price	$299.20
Rate for Payer: Cigna of AZ Commercial	$243.10
Rate for Payer: Devoted Health Medicare	$67.32
Rate for Payer: Humana of AZ Medicare	$59.84
Rate for Payer: Seven Corners Travel Insurance	$13.08
Rate for Payer: Southwest Service Administrators UFCW	$254.32
Rate for Payer: TriWest Medicare	$59.84
Rate for Payer: United Healthcare Commercial	$213.93
Rate for Payer: United Healthcare Medicare	$59.84
Rate for Payer: Veterans Affairs TRICARE	$59.24

TI6 DIGITAL SCREW 2.0 X 36MM

Facility

$1,591.00

Hospital Charge Code	24127797
Hospital Revenue Code	270
Min. Negotiated Rate	$1,431.90
Max. Negotiated Rate	$1,431.90
Rate for Payer: Aetna of AZ Commercial	$1,431.90
Rate for Payer: Cash Price	$1,272.80

TI6 DIGITAL SCREW 2.0 X 36MM

Facility

$1,591.00

Hospital Charge Code	24127797
Hospital Revenue Code	270
Min. Negotiated Rate	$252.01
Max. Negotiated Rate	$1,431.90
Rate for Payer: Aetna of AZ Commercial	$1,431.90
Rate for Payer: Arizona Complete Health Allwell	$254.56
Rate for Payer: Banner UC Health Medicare	$254.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,081.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$254.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$254.56
Rate for Payer: Cash Price	$1,272.80
Rate for Payer: Cigna of AZ Commercial	$1,113.70
Rate for Payer: Devoted Health Medicare	$286.38
Rate for Payer: Humana of AZ Medicare	$254.56
Rate for Payer: Southwest Service Administrators UFCW	$1,081.88
Rate for Payer: TriWest Medicare	$254.56
Rate for Payer: United Healthcare Commercial	$910.05
Rate for Payer: United Healthcare Medicare	$254.56
Rate for Payer: Veterans Affairs TRICARE	$252.01

TI6 DIGITAL SCREW 2.0 X 46MM

Facility

$1,591.00

Hospital Charge Code	24127800
Hospital Revenue Code	270
Min. Negotiated Rate	$252.01
Max. Negotiated Rate	$1,431.90
Rate for Payer: Aetna of AZ Commercial	$1,431.90
Rate for Payer: Arizona Complete Health Allwell	$254.56
Rate for Payer: Banner UC Health Medicare	$254.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,081.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$254.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$254.56
Rate for Payer: Cash Price	$1,272.80
Rate for Payer: Cigna of AZ Commercial	$1,113.70
Rate for Payer: Devoted Health Medicare	$286.38
Rate for Payer: Humana of AZ Medicare	$254.56
Rate for Payer: Southwest Service Administrators UFCW	$1,081.88
Rate for Payer: TriWest Medicare	$254.56
Rate for Payer: United Healthcare Commercial	$910.05
Rate for Payer: United Healthcare Medicare	$254.56
Rate for Payer: Veterans Affairs TRICARE	$252.01

TI6 DIGITAL SCREW 2.0 X 46MM

Facility

$1,591.00

Hospital Charge Code	24127800
Hospital Revenue Code	270
Min. Negotiated Rate	$1,431.90
Max. Negotiated Rate	$1,431.90
Rate for Payer: Aetna of AZ Commercial	$1,431.90
Rate for Payer: Cash Price	$1,272.80

TI6 DIGITAL SCREW 2.0 X 48MM

Facility

$1,591.00

Hospital Charge Code	24127798
Hospital Revenue Code	270
Min. Negotiated Rate	$1,431.90
Max. Negotiated Rate	$1,431.90
Rate for Payer: Aetna of AZ Commercial	$1,431.90
Rate for Payer: Cash Price	$1,272.80

TI6 DIGITAL SCREW 2.0 X 48MM

Facility

$1,591.00

Hospital Charge Code	24127798
Hospital Revenue Code	270
Min. Negotiated Rate	$252.01
Max. Negotiated Rate	$1,431.90
Rate for Payer: Aetna of AZ Commercial	$1,431.90
Rate for Payer: Arizona Complete Health Allwell	$254.56
Rate for Payer: Banner UC Health Medicare	$254.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,081.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$254.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$254.56
Rate for Payer: Cash Price	$1,272.80
Rate for Payer: Cigna of AZ Commercial	$1,113.70
Rate for Payer: Devoted Health Medicare	$286.38
Rate for Payer: Humana of AZ Medicare	$254.56
Rate for Payer: Southwest Service Administrators UFCW	$1,081.88
Rate for Payer: TriWest Medicare	$254.56
Rate for Payer: United Healthcare Commercial	$910.05
Rate for Payer: United Healthcare Medicare	$254.56
Rate for Payer: Veterans Affairs TRICARE	$252.01

TI6 DIGITAL SCREW 2MMX38MM

Facility

$2,549.00

Hospital Charge Code	27567204
Hospital Revenue Code	270
Min. Negotiated Rate	$403.76
Max. Negotiated Rate	$2,294.10
Rate for Payer: Aetna of AZ Commercial	$2,294.10
Rate for Payer: Arizona Complete Health Allwell	$407.84
Rate for Payer: Banner UC Health Medicare	$407.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,733.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$407.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$407.84
Rate for Payer: Cash Price	$2,039.20
Rate for Payer: Cigna of AZ Commercial	$1,784.30
Rate for Payer: Devoted Health Medicare	$458.82
Rate for Payer: Humana of AZ Medicare	$407.84
Rate for Payer: Southwest Service Administrators UFCW	$1,733.32
Rate for Payer: TriWest Medicare	$407.84
Rate for Payer: United Healthcare Commercial	$1,458.03
Rate for Payer: United Healthcare Medicare	$407.84
Rate for Payer: Veterans Affairs TRICARE	$403.76

TI6 DIGITAL SCREW 2MMX38MM

Facility

$2,549.00

Hospital Charge Code	27567204
Hospital Revenue Code	270
Min. Negotiated Rate	$2,294.10
Max. Negotiated Rate	$2,294.10
Rate for Payer: Aetna of AZ Commercial	$2,294.10
Rate for Payer: Cash Price	$2,039.20

TI6 DIGITAL SCREW 2MMX40MM

Facility

$2,549.00

Hospital Charge Code	27567203
Hospital Revenue Code	270
Min. Negotiated Rate	$2,294.10
Max. Negotiated Rate	$2,294.10
Rate for Payer: Aetna of AZ Commercial	$2,294.10
Rate for Payer: Cash Price	$2,039.20

TI6 DIGITAL SCREW 2MMX40MM

Facility

$2,549.00

Hospital Charge Code	27567203
Hospital Revenue Code	270
Min. Negotiated Rate	$403.76
Max. Negotiated Rate	$2,294.10
Rate for Payer: Aetna of AZ Commercial	$2,294.10
Rate for Payer: Arizona Complete Health Allwell	$407.84
Rate for Payer: Banner UC Health Medicare	$407.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,733.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$407.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$407.84
Rate for Payer: Cash Price	$2,039.20
Rate for Payer: Cigna of AZ Commercial	$1,784.30
Rate for Payer: Devoted Health Medicare	$458.82
Rate for Payer: Humana of AZ Medicare	$407.84
Rate for Payer: Southwest Service Administrators UFCW	$1,733.32
Rate for Payer: TriWest Medicare	$407.84
Rate for Payer: United Healthcare Commercial	$1,458.03
Rate for Payer: United Healthcare Medicare	$407.84
Rate for Payer: Veterans Affairs TRICARE	$403.76

TI6 LOW PROFILE 3.0MMX22MM BONE SCREW

Facility

$1,915.00

Hospital Charge Code	27519878
Hospital Revenue Code	270
Min. Negotiated Rate	$303.34
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Arizona Complete Health Allwell	$306.40
Rate for Payer: Banner UC Health Medicare	$306.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,302.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$306.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$306.40
Rate for Payer: Cash Price	$1,532.00
Rate for Payer: Cigna of AZ Commercial	$1,340.50
Rate for Payer: Devoted Health Medicare	$344.70
Rate for Payer: Humana of AZ Medicare	$306.40
Rate for Payer: Southwest Service Administrators UFCW	$1,302.20
Rate for Payer: TriWest Medicare	$306.40
Rate for Payer: United Healthcare Commercial	$1,095.38
Rate for Payer: United Healthcare Medicare	$306.40
Rate for Payer: Veterans Affairs TRICARE	$303.34

TI6 LOW PROFILE 3.0MMX22MM BONE SCREW

Facility

$1,915.00

Hospital Charge Code	27519878
Hospital Revenue Code	270
Min. Negotiated Rate	$1,723.50
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Cash Price	$1,532.00

TI6 LOW PROFILE 3.0MM X 24MM BONE SCREW

Facility

$1,196.00

Hospital Charge Code	24127796
Hospital Revenue Code	270
Min. Negotiated Rate	$1,076.40
Max. Negotiated Rate	$1,076.40
Rate for Payer: Aetna of AZ Commercial	$1,076.40
Rate for Payer: Cash Price	$956.80

TI6 LOW PROFILE 3.0MM X 24MM BONE SCREW

Facility

$1,196.00

Hospital Charge Code	24127796
Hospital Revenue Code	270
Min. Negotiated Rate	$189.45
Max. Negotiated Rate	$1,076.40
Rate for Payer: Aetna of AZ Commercial	$1,076.40
Rate for Payer: Arizona Complete Health Allwell	$191.36
Rate for Payer: Banner UC Health Medicare	$191.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$813.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$191.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$191.36
Rate for Payer: Cash Price	$956.80
Rate for Payer: Cigna of AZ Commercial	$837.20
Rate for Payer: Devoted Health Medicare	$215.28
Rate for Payer: Humana of AZ Medicare	$191.36
Rate for Payer: Southwest Service Administrators UFCW	$813.28
Rate for Payer: TriWest Medicare	$191.36
Rate for Payer: United Healthcare Commercial	$684.11
Rate for Payer: United Healthcare Medicare	$191.36
Rate for Payer: Veterans Affairs TRICARE	$189.45

TI6 LOW PROFILE 3.0MM X 28MM BONE SCREW

Facility

$1,196.00

Hospital Charge Code	24127794
Hospital Revenue Code	270
Min. Negotiated Rate	$1,076.40
Max. Negotiated Rate	$1,076.40
Rate for Payer: Aetna of AZ Commercial	$1,076.40
Rate for Payer: Cash Price	$956.80

TI6 LOW PROFILE 3.0MM X 28MM BONE SCREW

Facility

$1,196.00

Hospital Charge Code	24127794
Hospital Revenue Code	270
Min. Negotiated Rate	$189.45
Max. Negotiated Rate	$1,076.40
Rate for Payer: Aetna of AZ Commercial	$1,076.40
Rate for Payer: Arizona Complete Health Allwell	$191.36
Rate for Payer: Banner UC Health Medicare	$191.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$813.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$191.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$191.36
Rate for Payer: Cash Price	$956.80
Rate for Payer: Cigna of AZ Commercial	$837.20
Rate for Payer: Devoted Health Medicare	$215.28
Rate for Payer: Humana of AZ Medicare	$191.36
Rate for Payer: Southwest Service Administrators UFCW	$813.28
Rate for Payer: TriWest Medicare	$191.36
Rate for Payer: United Healthcare Commercial	$684.11
Rate for Payer: United Healthcare Medicare	$191.36
Rate for Payer: Veterans Affairs TRICARE	$189.45

TI6 LOW PROFILE 3.99MMX18MM BONE SCREW

Facility

$1,196.00

Hospital Charge Code	24127772
Hospital Revenue Code	270
Min. Negotiated Rate	$1,076.40
Max. Negotiated Rate	$1,076.40
Rate for Payer: Aetna of AZ Commercial	$1,076.40
Rate for Payer: Cash Price	$956.80

TI6 LOW PROFILE 3.99MMX18MM BONE SCREW

Facility

$1,196.00

Hospital Charge Code	24127772
Hospital Revenue Code	270
Min. Negotiated Rate	$189.45
Max. Negotiated Rate	$1,076.40
Rate for Payer: Aetna of AZ Commercial	$1,076.40
Rate for Payer: Arizona Complete Health Allwell	$191.36
Rate for Payer: Banner UC Health Medicare	$191.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$813.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$191.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$191.36
Rate for Payer: Cash Price	$956.80
Rate for Payer: Cigna of AZ Commercial	$837.20
Rate for Payer: Devoted Health Medicare	$215.28
Rate for Payer: Humana of AZ Medicare	$191.36
Rate for Payer: Southwest Service Administrators UFCW	$813.28
Rate for Payer: TriWest Medicare	$191.36
Rate for Payer: United Healthcare Commercial	$684.11
Rate for Payer: United Healthcare Medicare	$191.36
Rate for Payer: Veterans Affairs TRICARE	$189.45

TI6 LOW PROFILE 3MMX16MM BONE SCREW

Facility

$1,915.00

Hospital Charge Code	24358104
Hospital Revenue Code	270
Min. Negotiated Rate	$303.34
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Arizona Complete Health Allwell	$306.40
Rate for Payer: Banner UC Health Medicare	$306.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,302.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$306.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$306.40
Rate for Payer: Cash Price	$1,532.00
Rate for Payer: Cigna of AZ Commercial	$1,340.50
Rate for Payer: Devoted Health Medicare	$344.70
Rate for Payer: Humana of AZ Medicare	$306.40
Rate for Payer: Southwest Service Administrators UFCW	$1,302.20
Rate for Payer: TriWest Medicare	$306.40
Rate for Payer: United Healthcare Commercial	$1,095.38
Rate for Payer: United Healthcare Medicare	$306.40
Rate for Payer: Veterans Affairs TRICARE	$303.34

TI6 LOW PROFILE 3MMX16MM BONE SCREW

Facility

$1,915.00

Hospital Charge Code	24358104
Hospital Revenue Code	270
Min. Negotiated Rate	$1,723.50
Max. Negotiated Rate	$1,723.50
Rate for Payer: Aetna of AZ Commercial	$1,723.50
Rate for Payer: Cash Price	$1,532.00

Know your out-of-pocket cost for care.

All Charges