Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

0001A ADM SARSCOV2 VAC 30MCG/0.3ML IM 1ST PFIZER

Facility

$59.00

Service Code	CPT 0001A
Hospital Charge Code	24155432
Hospital Revenue Code	521
Min. Negotiated Rate	$53.10
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Cash Price	$47.20

0001A ADM SARSCOV2 VAC 30MCG/0.3ML IM 1ST PFIZER

Facility

$59.00

Service Code	CPT 0001A
Hospital Charge Code	24155432
Hospital Revenue Code	521
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Arizona Complete Health Allwell	$9.44
Rate for Payer: Banner UC Health Medicare	$9.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$40.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.44
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cigna of AZ Commercial	$41.30
Rate for Payer: Devoted Health Medicare	$10.62
Rate for Payer: Humana of AZ Medicare	$9.44
Rate for Payer: Southwest Service Administrators UFCW	$40.12
Rate for Payer: TriWest Medicare	$9.44
Rate for Payer: United Healthcare Commercial	$33.75
Rate for Payer: United Healthcare Medicare	$9.44
Rate for Payer: Veterans Affairs TRICARE	$9.35

0002A ADM SARSCOV2 VAC 30MCG/0.3ML IM 2ND PFIZER

Facility

$59.00

Service Code	CPT 0002A
Hospital Charge Code	24155433
Hospital Revenue Code	521
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Arizona Complete Health Allwell	$9.44
Rate for Payer: Banner UC Health Medicare	$9.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$40.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.44
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cigna of AZ Commercial	$41.30
Rate for Payer: Devoted Health Medicare	$10.62
Rate for Payer: Humana of AZ Medicare	$9.44
Rate for Payer: Southwest Service Administrators UFCW	$40.12
Rate for Payer: TriWest Medicare	$9.44
Rate for Payer: United Healthcare Commercial	$33.75
Rate for Payer: United Healthcare Medicare	$9.44
Rate for Payer: Veterans Affairs TRICARE	$9.35

0002A ADM SARSCOV2 VAC 30MCG/0.3ML IM 2ND PFIZER

Facility

$59.00

Service Code	CPT 0002A
Hospital Charge Code	24155433
Hospital Revenue Code	521
Min. Negotiated Rate	$53.10
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Cash Price	$47.20

0004A Pfizer Admin Booster

Facility

$55.00

Service Code	CPT 0004A
Hospital Charge Code	24409108
Hospital Revenue Code	521
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$49.50
Rate for Payer: Aetna of AZ Commercial	$49.50
Rate for Payer: Cash Price	$44.00

0004A Pfizer Admin Booster

Facility

$55.00

Service Code	CPT 0004A
Hospital Charge Code	24409108
Hospital Revenue Code	521
Min. Negotiated Rate	$8.71
Max. Negotiated Rate	$49.50
Rate for Payer: Aetna of AZ Commercial	$49.50
Rate for Payer: Arizona Complete Health Allwell	$8.80
Rate for Payer: Banner UC Health Medicare	$8.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$37.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.80
Rate for Payer: Cash Price	$44.00
Rate for Payer: Cigna of AZ Commercial	$38.50
Rate for Payer: Devoted Health Medicare	$9.90
Rate for Payer: Humana of AZ Medicare	$8.80
Rate for Payer: Southwest Service Administrators UFCW	$37.40
Rate for Payer: TriWest Medicare	$8.80
Rate for Payer: United Healthcare Commercial	$31.46
Rate for Payer: United Healthcare Medicare	$8.80
Rate for Payer: Veterans Affairs TRICARE	$8.71

0011A ADM SARSCOV2 VAC 100MCG/0.5ML IM 1ST MODERNA

Facility

$59.00

Service Code	CPT 0011A
Hospital Charge Code	24157096
Hospital Revenue Code	521
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Arizona Complete Health Allwell	$9.44
Rate for Payer: Banner UC Health Medicare	$9.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$40.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.44
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cigna of AZ Commercial	$41.30
Rate for Payer: Devoted Health Medicare	$10.62
Rate for Payer: Humana of AZ Medicare	$9.44
Rate for Payer: Southwest Service Administrators UFCW	$40.12
Rate for Payer: TriWest Medicare	$9.44
Rate for Payer: United Healthcare Commercial	$33.75
Rate for Payer: United Healthcare Medicare	$9.44
Rate for Payer: Veterans Affairs TRICARE	$9.35

0011A ADM SARSCOV2 VAC 100MCG/0.5ML IM 1ST MODERNA

Facility

$59.00

Service Code	CPT 0011A
Hospital Charge Code	24157096
Hospital Revenue Code	521
Min. Negotiated Rate	$53.10
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Cash Price	$47.20

0012A ADM SARSCOV2 VAC 100MCG/0.5ML IM 2ND MODERNA

Facility

$59.00

Service Code	CPT 0012A
Hospital Charge Code	24157097
Hospital Revenue Code	521
Min. Negotiated Rate	$9.35
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Arizona Complete Health Allwell	$9.44
Rate for Payer: Banner UC Health Medicare	$9.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$40.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$9.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$9.44
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cigna of AZ Commercial	$41.30
Rate for Payer: Devoted Health Medicare	$10.62
Rate for Payer: Humana of AZ Medicare	$9.44
Rate for Payer: Southwest Service Administrators UFCW	$40.12
Rate for Payer: TriWest Medicare	$9.44
Rate for Payer: United Healthcare Commercial	$33.75
Rate for Payer: United Healthcare Medicare	$9.44
Rate for Payer: Veterans Affairs TRICARE	$9.35

0012A ADM SARSCOV2 VAC 100MCG/0.5ML IM 2ND MODERNA

Facility

$59.00

Service Code	CPT 0012A
Hospital Charge Code	24157097
Hospital Revenue Code	521
Min. Negotiated Rate	$53.10
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Cash Price	$47.20

00140 ANES EYE PROCEDURE ADDITIONAL MINUTES

Facility

$9.00

Hospital Charge Code	22406078
Hospital Revenue Code	370
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Arizona Complete Health Allwell	$1.44
Rate for Payer: Banner UC Health Medicare	$1.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$6.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.44
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna of AZ Commercial	$5.85
Rate for Payer: Devoted Health Medicare	$1.62
Rate for Payer: Humana of AZ Medicare	$1.44
Rate for Payer: Southwest Service Administrators UFCW	$6.12
Rate for Payer: TriWest Medicare	$1.44
Rate for Payer: United Healthcare Commercial	$5.15
Rate for Payer: United Healthcare Medicare	$1.44
Rate for Payer: Veterans Affairs TRICARE	$1.43

00140 ANES EYE PROCEDURE ADDITIONAL MINUTES

Facility

$9.00

Hospital Charge Code	22406078
Hospital Revenue Code	370
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Cash Price	$7.20

00140 ANES EYE PROCEDURE ADDTNL 0:30 CHARGE

Facility

$298.00

Hospital Charge Code	22406079
Hospital Revenue Code	370
Min. Negotiated Rate	$47.20
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Arizona Complete Health Allwell	$47.68
Rate for Payer: Banner UC Health Medicare	$47.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$202.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$47.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$47.68
Rate for Payer: Cash Price	$238.40
Rate for Payer: Cigna of AZ Commercial	$193.70
Rate for Payer: Devoted Health Medicare	$53.64
Rate for Payer: Humana of AZ Medicare	$47.68
Rate for Payer: Southwest Service Administrators UFCW	$202.64
Rate for Payer: TriWest Medicare	$47.68
Rate for Payer: United Healthcare Commercial	$170.46
Rate for Payer: United Healthcare Medicare	$47.68
Rate for Payer: Veterans Affairs TRICARE	$47.20

00140 ANES EYE PROCEDURE ADDTNL 0:30 CHARGE

Facility

$298.00

Hospital Charge Code	22406079
Hospital Revenue Code	370
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Cash Price	$238.40

00164 ANES NOSE SINUS BIOPSY ADDITIONAL MINUTES

Facility

$9.00

Service Code	CPT 00164
Hospital Charge Code	22406081
Hospital Revenue Code	370
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Arizona Complete Health Allwell	$1.44
Rate for Payer: Banner UC Health Medicare	$1.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$6.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.44
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna of AZ Commercial	$5.85
Rate for Payer: Devoted Health Medicare	$1.62
Rate for Payer: Humana of AZ Medicare	$1.44
Rate for Payer: Southwest Service Administrators UFCW	$6.12
Rate for Payer: TriWest Medicare	$1.44
Rate for Payer: United Healthcare Commercial	$5.15
Rate for Payer: United Healthcare Medicare	$1.44
Rate for Payer: Veterans Affairs TRICARE	$1.43

00164 ANES NOSE SINUS BIOPSY ADDITIONAL MINUTES

Facility

$9.00

Service Code	CPT 00164
Hospital Charge Code	22406081
Hospital Revenue Code	370
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Cash Price	$7.20

00164 ANES NOSE SINUS BIOPSY ADDTNL 0:30 CHARGE

Facility

$298.00

Service Code	CPT 00164
Hospital Charge Code	22406082
Hospital Revenue Code	370
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Cash Price	$238.40

00164 ANES NOSE SINUS BIOPSY ADDTNL 0:30 CHARGE

Facility

$298.00

Service Code	CPT 00164
Hospital Charge Code	22406082
Hospital Revenue Code	370
Min. Negotiated Rate	$47.20
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Arizona Complete Health Allwell	$47.68
Rate for Payer: Banner UC Health Medicare	$47.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$202.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$47.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$47.68
Rate for Payer: Cash Price	$238.40
Rate for Payer: Cigna of AZ Commercial	$193.70
Rate for Payer: Devoted Health Medicare	$53.64
Rate for Payer: Humana of AZ Medicare	$47.68
Rate for Payer: Southwest Service Administrators UFCW	$202.64
Rate for Payer: TriWest Medicare	$47.68
Rate for Payer: United Healthcare Commercial	$170.46
Rate for Payer: United Healthcare Medicare	$47.68
Rate for Payer: Veterans Affairs TRICARE	$47.20

00300 ANES HEAD NECK POSTERIOR PROC ADDITIONAL MINUTES

Facility

$9.00

Service Code	CPT 00300
Hospital Charge Code	22406217
Hospital Revenue Code	370
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Arizona Complete Health Allwell	$1.44
Rate for Payer: Banner UC Health Medicare	$1.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$6.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.44
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna of AZ Commercial	$5.85
Rate for Payer: Devoted Health Medicare	$1.62
Rate for Payer: Humana of AZ Medicare	$1.44
Rate for Payer: Southwest Service Administrators UFCW	$6.12
Rate for Payer: TriWest Medicare	$1.44
Rate for Payer: United Healthcare Commercial	$5.15
Rate for Payer: United Healthcare Medicare	$1.44
Rate for Payer: Veterans Affairs TRICARE	$1.43

00300 ANES HEAD NECK POSTERIOR PROC ADDITIONAL MINUTES

Facility

$9.00

Service Code	CPT 00300
Hospital Charge Code	22406217
Hospital Revenue Code	370
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Cash Price	$7.20

00300 ANES HEAD NECK POSTERIOR PROC ADDNL 30 CHARGE

Facility

$298.00

Service Code	CPT 00300
Hospital Charge Code	22406218
Hospital Revenue Code	370
Min. Negotiated Rate	$47.20
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Arizona Complete Health Allwell	$47.68
Rate for Payer: Banner UC Health Medicare	$47.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$202.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$47.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$47.68
Rate for Payer: Cash Price	$238.40
Rate for Payer: Cigna of AZ Commercial	$193.70
Rate for Payer: Devoted Health Medicare	$53.64
Rate for Payer: Humana of AZ Medicare	$47.68
Rate for Payer: Southwest Service Administrators UFCW	$202.64
Rate for Payer: TriWest Medicare	$47.68
Rate for Payer: United Healthcare Commercial	$170.46
Rate for Payer: United Healthcare Medicare	$47.68
Rate for Payer: Veterans Affairs TRICARE	$47.20

00300 ANES HEAD NECK POSTERIOR PROC ADDNL 30 CHARGE

Facility

$298.00

Service Code	CPT 00300
Hospital Charge Code	22406218
Hospital Revenue Code	370
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Cash Price	$238.40

00300 ANES HEAD NECK POSTERIOR PROCEDURE BASE CHG AND 1ST MI

Facility

$490.00

Service Code	CPT 00300
Hospital Charge Code	22406215
Hospital Revenue Code	964
Min. Negotiated Rate	$77.62
Max. Negotiated Rate	$441.00
Rate for Payer: Aetna of AZ Commercial	$441.00
Rate for Payer: Arizona Complete Health Allwell	$78.40
Rate for Payer: Banner UC Health Medicare	$78.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$333.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$78.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$78.40
Rate for Payer: Cash Price	$392.00
Rate for Payer: Cigna of AZ Commercial	$343.00
Rate for Payer: Devoted Health Medicare	$88.20
Rate for Payer: Humana of AZ Medicare	$78.40
Rate for Payer: Southwest Service Administrators UFCW	$333.20
Rate for Payer: TriWest Medicare	$78.40
Rate for Payer: United Healthcare Commercial	$280.28
Rate for Payer: United Healthcare Medicare	$78.40
Rate for Payer: United Healthcare New Mexico Commercial	$93.10
Rate for Payer: Veterans Affairs TRICARE	$77.62

00300 ANES HEAD NECK POSTERIOR PROCEDURE BASE CHG AND 1ST MI

Facility

$490.00

Service Code	CPT 00300
Hospital Charge Code	22406215
Hospital Revenue Code	964
Min. Negotiated Rate	$441.00
Max. Negotiated Rate	$441.00
Rate for Payer: Aetna of AZ Commercial	$441.00
Rate for Payer: Cash Price	$392.00

0031A Janssen Covid-19 Vaccine Administration

Facility

$59.00

Service Code	CPT 0031A
Hospital Charge Code	24231328
Hospital Revenue Code	521
Min. Negotiated Rate	$53.10
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of AZ Commercial	$53.10
Rate for Payer: Cash Price	$47.20

Know your out-of-pocket cost for care.

All Charges