Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

0031A Janssen Covid-19 Vaccine Administration

Facility

$59.00

Service Code	CPT 0031A
Hospital Charge Code	24231328
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

00400 ANES INTEGUMENTARY SYSTEM ADDITIONAL MINUTES

Facility

$9.00

Service Code	CPT 00400
Hospital Charge Code	22406084
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

00400 ANES INTEGUMENTARY SYSTEM ADDITIONAL MINUTES

Facility

$9.00

Service Code	CPT 00400
Hospital Charge Code	22406084
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

00400 ANES INTEGUMENTARY SYSTEM ADDTNL 0:30 CHARGE

Facility

$298.00

Service Code	CPT 00400
Hospital Charge Code	22406085
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

00400 ANES INTEGUMENTARY SYSTEM ADDTNL 0:30 CHARGE

Facility

$298.00

Service Code	CPT 00400
Hospital Charge Code	22406085
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

0041A Admin of Novavax COVID19 Vaccine 1st Dose

Facility

$55.00

Service Code	CPT 0041A
Hospital Charge Code	27410725
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

0041A Admin of Novavax COVID19 Vaccine 1st Dose

Facility

$55.00

Service Code	CPT 0041A
Hospital Charge Code	27410725
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

0042A Admin of Novavax COVID19 Vaccine 2nd Dose

Facility

$55.00

Service Code	CPT 0042A
Hospital Charge Code	27407489
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

0042A Admin of Novavax COVID19 Vaccine 2nd Dose

Facility

$55.00

Service Code	CPT 0042A
Hospital Charge Code	27407489
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

0051A Pfizer Pediatric First Dose

Facility

$55.00

Service Code	CPT 0051A
Hospital Charge Code	27357085
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

0051A Pfizer Pediatric First Dose

Facility

$55.00

Service Code	CPT 0051A
Hospital Charge Code	27357085
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

0052A Pfizer Pediatric Second Dose

Facility

$55.00

Service Code	CPT 0052A
Hospital Charge Code	27368657
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

0052A Pfizer Pediatric Second Dose

Facility

$55.00

Service Code	CPT 0052A
Hospital Charge Code	27368657
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

0053A Pfizer Pediatric Third Dose

Facility

$55.00

Service Code	CPT 0053A
Hospital Charge Code	27368658
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

0053A Pfizer Pediatric Third Dose

Facility

$55.00

Service Code	CPT 0053A
Hospital Charge Code	27368658
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

0054A Pfizer Pediatric Booster

Facility

$55.00

Service Code	CPT 0054A
Hospital Charge Code	27368659
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

0054A Pfizer Pediatric Booster

Facility

$55.00

Service Code	CPT 0054A
Hospital Charge Code	27368659
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

0064A Moderna Low Dose Booster Admin

Facility

$55.00

Service Code	CPT 0064A
Hospital Charge Code	24409110
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

0064A Moderna Low Dose Booster Admin

Facility

$55.00

Service Code	CPT 0064A
Hospital Charge Code	24409110
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

007012 Lacosamide

Facility

$1,041.00

Service Code	CPT 80339
Hospital Charge Code	23173817
Hospital Revenue Code	301
Min. Negotiated Rate	$164.89
Max. Negotiated Rate	$936.90
Rate for Payer: Aetna of AZ Commercial	$936.90
Rate for Payer: Arizona Complete Health Allwell	$166.56
Rate for Payer: Banner UC Health Medicare	$166.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$707.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$166.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$166.56
Rate for Payer: Cash Price	$832.80
Rate for Payer: Cigna of AZ Commercial	$676.65
Rate for Payer: Devoted Health Medicare	$187.38
Rate for Payer: Humana of AZ Medicare	$166.56
Rate for Payer: Southwest Service Administrators UFCW	$707.88
Rate for Payer: TriWest Medicare	$166.56
Rate for Payer: United Healthcare Commercial	$595.45
Rate for Payer: United Healthcare Medicare	$166.56
Rate for Payer: Veterans Affairs TRICARE	$164.89

007012 Lacosamide

Facility

$1,041.00

Service Code	CPT 80339
Hospital Charge Code	23173817
Hospital Revenue Code	301
Min. Negotiated Rate	$936.90
Max. Negotiated Rate	$936.90
Rate for Payer: Aetna of AZ Commercial	$936.90
Rate for Payer: Cash Price	$832.80

0072A Pfizer Pediatric Second Dose

Facility

$55.00

Service Code	CPT 0072A
Hospital Charge Code	24409114
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

0072A Pfizer Pediatric Second Dose

Facility

$55.00

Service Code	CPT 0072A
Hospital Charge Code	24409114
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

00731 ANES UPPER GASTRO ENDO ADDITIONAL MINUTES

Facility

$9.00

Service Code	CPT 00731
Hospital Charge Code	22406087
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

00731 ANES UPPER GASTRO ENDO ADDITIONAL MINUTES

Facility

$9.00

Service Code	CPT 00731
Hospital Charge Code	22406087
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

Know your out-of-pocket cost for care.

All Charges