Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

90461 Immunization administration with counseling ea added

Facility

$39.00

Service Code	CPT 90461
Hospital Charge Code	15961929
Hospital Revenue Code	521
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Cash Price	$31.20

90461 Immunization administration with counseling ea added

Facility

$39.00

Service Code	CPT 90461
Hospital Charge Code	15961929
Hospital Revenue Code	521
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Arizona Complete Health Allwell	$6.24
Rate for Payer: Banner UC Health Medicare	$6.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$26.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.24
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cigna of AZ Commercial	$27.30
Rate for Payer: Devoted Health Medicare	$7.02
Rate for Payer: Humana of AZ Medicare	$6.24
Rate for Payer: Southwest Service Administrators UFCW	$26.52
Rate for Payer: TriWest Medicare	$6.24
Rate for Payer: United Healthcare Commercial	$22.31
Rate for Payer: United Healthcare Medicare	$6.24
Rate for Payer: Veterans Affairs TRICARE	$6.18

90472 Each additional vaccine

Facility

$39.00

Service Code	CPT 90472
Hospital Charge Code	1169531
Hospital Revenue Code	521
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Arizona Complete Health Allwell	$6.24
Rate for Payer: Banner UC Health Medicare	$6.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$26.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.24
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cigna of AZ Commercial	$27.30
Rate for Payer: Devoted Health Medicare	$7.02
Rate for Payer: Humana of AZ Medicare	$6.24
Rate for Payer: Southwest Service Administrators UFCW	$26.52
Rate for Payer: TriWest Medicare	$6.24
Rate for Payer: United Healthcare Commercial	$22.31
Rate for Payer: United Healthcare Medicare	$6.24
Rate for Payer: Veterans Affairs TRICARE	$6.18

90472 Each additional vaccine

Facility

$39.00

Service Code	CPT 90472
Hospital Charge Code	1169531
Hospital Revenue Code	521
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Cash Price	$31.20

90473 Immunizaiton administration oral

Facility

$34.00

Service Code	CPT 90473
Hospital Charge Code	13103368
Min. Negotiated Rate	$30.60
Max. Negotiated Rate	$30.60
Rate for Payer: Aetna of AZ Commercial	$30.60
Rate for Payer: Cash Price	$27.20

90473 Immunizaiton administration oral

Facility

$34.00

Service Code	CPT 90473
Hospital Charge Code	13103368
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$111.40
Rate for Payer: Aetna of AZ Commercial	$30.60
Rate for Payer: Arizona Complete Health Allwell	$5.44
Rate for Payer: Banner UC Health Medicare	$5.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$23.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$5.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$5.44
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cigna of AZ Commercial	$23.80
Rate for Payer: Devoted Health Medicare	$6.12
Rate for Payer: Humana of AZ Medicare	$5.44
Rate for Payer: Seven Corners Travel Insurance	$111.40
Rate for Payer: Southwest Service Administrators UFCW	$23.12
Rate for Payer: TriWest Medicare	$5.44
Rate for Payer: United Healthcare Commercial	$19.45
Rate for Payer: United Healthcare Medicare	$5.44
Rate for Payer: Veterans Affairs TRICARE	$5.39

90480 Covid Vaccine Admin Charge CQCH

Facility

$55.00

Service Code	CPT 90480
Hospital Charge Code	27617449
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

90480 Covid Vaccine Admin Charge CQCH

Facility

$55.00

Service Code	CPT 90480
Hospital Charge Code	27617449
Hospital Revenue Code	521
Min. Negotiated Rate	$8.71
Max. Negotiated Rate	$62.89
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: 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: Seven Corners Travel Insurance	$62.89
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

90648 Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), f

Facility

$108.00

Service Code	CPT 90648
Hospital Charge Code	22051469
Hospital Revenue Code	636
Min. Negotiated Rate	$17.11
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of AZ Commercial	$97.20
Rate for Payer: Arizona Complete Health Allwell	$17.28
Rate for Payer: Banner UC Health Medicare	$17.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$73.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$17.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$17.28
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna of AZ Commercial	$75.60
Rate for Payer: Devoted Health Medicare	$19.44
Rate for Payer: Humana of AZ Medicare	$17.28
Rate for Payer: Southwest Service Administrators UFCW	$73.44
Rate for Payer: TriWest Medicare	$17.28
Rate for Payer: United Healthcare Commercial	$61.78
Rate for Payer: United Healthcare Medicare	$17.28
Rate for Payer: United Healthcare New Mexico Commercial	$20.52
Rate for Payer: Veterans Affairs TRICARE	$17.11

90648 Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), f

Facility

$108.00

Service Code	CPT 90648
Hospital Charge Code	22051469
Hospital Revenue Code	636
Min. Negotiated Rate	$97.20
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of AZ Commercial	$97.20
Rate for Payer: Cash Price	$86.40

90672 FLUMIST INFLUENZA VACCINE

Facility

$66.00

Service Code	CPT 90672
Hospital Charge Code	22043667
Hospital Revenue Code	521
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of AZ Commercial	$59.40
Rate for Payer: Arizona Complete Health Allwell	$10.56
Rate for Payer: Banner UC Health Medicare	$10.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$44.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.56
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cigna of AZ Commercial	$46.20
Rate for Payer: Devoted Health Medicare	$11.88
Rate for Payer: Humana of AZ Medicare	$10.56
Rate for Payer: Southwest Service Administrators UFCW	$44.88
Rate for Payer: TriWest Medicare	$10.56
Rate for Payer: United Healthcare Commercial	$37.75
Rate for Payer: United Healthcare Medicare	$10.56
Rate for Payer: Veterans Affairs TRICARE	$10.45

90672 FLUMIST INFLUENZA VACCINE

Facility

$66.00

Service Code	CPT 90672
Hospital Charge Code	22043667
Hospital Revenue Code	521
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of AZ Commercial	$59.40
Rate for Payer: Cash Price	$52.80

90673 Flu Vaccine RIV3 NO PRESERV

Facility

$84.00

Service Code	CPT 90673
Hospital Charge Code	22245601
Hospital Revenue Code	521
Min. Negotiated Rate	$13.31
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Arizona Complete Health Allwell	$13.44
Rate for Payer: Banner UC Health Medicare	$13.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$57.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.44
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cigna of AZ Commercial	$58.80
Rate for Payer: Devoted Health Medicare	$15.12
Rate for Payer: Humana of AZ Medicare	$13.44
Rate for Payer: Southwest Service Administrators UFCW	$57.12
Rate for Payer: TriWest Medicare	$13.44
Rate for Payer: United Healthcare Commercial	$48.05
Rate for Payer: United Healthcare Medicare	$13.44
Rate for Payer: Veterans Affairs TRICARE	$13.31

90673 Flu Vaccine RIV3 NO PRESERV

Facility

$84.00

Service Code	CPT 90673
Hospital Charge Code	22245601
Hospital Revenue Code	521
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Cash Price	$67.20

90680 Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use

Facility

$309.00

Service Code	CPT 90680
Hospital Charge Code	22051476
Hospital Revenue Code	521
Min. Negotiated Rate	$48.95
Max. Negotiated Rate	$278.10
Rate for Payer: Aetna of AZ Commercial	$278.10
Rate for Payer: Arizona Complete Health Allwell	$49.44
Rate for Payer: Banner UC Health Medicare	$49.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$210.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$49.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$49.44
Rate for Payer: Cash Price	$247.20
Rate for Payer: Cigna of AZ Commercial	$216.30
Rate for Payer: Devoted Health Medicare	$55.62
Rate for Payer: Humana of AZ Medicare	$49.44
Rate for Payer: Southwest Service Administrators UFCW	$210.12
Rate for Payer: TriWest Medicare	$49.44
Rate for Payer: United Healthcare Commercial	$176.75
Rate for Payer: United Healthcare Medicare	$49.44
Rate for Payer: Veterans Affairs TRICARE	$48.95

90680 Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use

Facility

$309.00

Service Code	CPT 90680
Hospital Charge Code	22051476
Hospital Revenue Code	521
Min. Negotiated Rate	$278.10
Max. Negotiated Rate	$278.10
Rate for Payer: Aetna of AZ Commercial	$278.10
Rate for Payer: Cash Price	$247.20

90697 Vax

Facility

$75.00

Service Code	CPT 90697
Hospital Charge Code	28136995
Hospital Revenue Code	636
Min. Negotiated Rate	$11.88
Max. Negotiated Rate	$67.50
Rate for Payer: Aetna of AZ Commercial	$67.50
Rate for Payer: Arizona Complete Health Allwell	$12.00
Rate for Payer: Banner UC Health Medicare	$12.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$51.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$12.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Cigna of AZ Commercial	$52.50
Rate for Payer: Devoted Health Medicare	$13.50
Rate for Payer: Humana of AZ Medicare	$12.00
Rate for Payer: Southwest Service Administrators UFCW	$51.00
Rate for Payer: TriWest Medicare	$12.00
Rate for Payer: United Healthcare Commercial	$42.90
Rate for Payer: United Healthcare Medicare	$12.00
Rate for Payer: United Healthcare New Mexico Commercial	$14.25
Rate for Payer: Veterans Affairs TRICARE	$11.88

90697 Vax

Facility

$75.00

Service Code	CPT 90697
Hospital Charge Code	28136995
Hospital Revenue Code	636
Min. Negotiated Rate	$67.50
Max. Negotiated Rate	$67.50
Rate for Payer: Aetna of AZ Commercial	$67.50
Rate for Payer: Cash Price	$60.00

90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), young

Facility

$100.00

Service Code	CPT 90700
Hospital Charge Code	22051479
Hospital Revenue Code	521
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

90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), young

Facility

$100.00

Service Code	CPT 90700
Hospital Charge Code	22051479
Hospital Revenue Code	521
Min. Negotiated Rate	$15.84
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of AZ Commercial	$90.00
Rate for Payer: Arizona Complete Health Allwell	$16.00
Rate for Payer: Banner UC Health Medicare	$16.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$68.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cigna of AZ Commercial	$70.00
Rate for Payer: Devoted Health Medicare	$18.00
Rate for Payer: Humana of AZ Medicare	$16.00
Rate for Payer: Southwest Service Administrators UFCW	$68.00
Rate for Payer: TriWest Medicare	$16.00
Rate for Payer: United Healthcare Commercial	$57.20
Rate for Payer: United Healthcare Medicare	$16.00
Rate for Payer: Veterans Affairs TRICARE	$15.84

90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use

Facility

$210.00

Service Code	CPT 90707
Hospital Charge Code	22051489
Hospital Revenue Code	636
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Cash Price	$168.00

90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use

Facility

$210.00

Service Code	CPT 90707
Hospital Charge Code	22051489
Hospital Revenue Code	636
Min. Negotiated Rate	$33.26
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Arizona Complete Health Allwell	$33.60
Rate for Payer: Banner UC Health Medicare	$33.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$142.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$33.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$33.60
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cigna of AZ Commercial	$147.00
Rate for Payer: Devoted Health Medicare	$37.80
Rate for Payer: Humana of AZ Medicare	$33.60
Rate for Payer: Southwest Service Administrators UFCW	$142.80
Rate for Payer: TriWest Medicare	$33.60
Rate for Payer: United Healthcare Commercial	$120.12
Rate for Payer: United Healthcare Medicare	$33.60
Rate for Payer: United Healthcare New Mexico Commercial	$39.90
Rate for Payer: Veterans Affairs TRICARE	$33.26

90714 Td - TENIVAC (7 yrs older)

Facility

$85.00

Service Code	CPT 90714
Hospital Charge Code	22328774
Hospital Revenue Code	521
Min. Negotiated Rate	$13.46
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of AZ Commercial	$76.50
Rate for Payer: Arizona Complete Health Allwell	$13.60
Rate for Payer: Banner UC Health Medicare	$13.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$57.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$13.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$13.60
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cigna of AZ Commercial	$59.50
Rate for Payer: Devoted Health Medicare	$15.30
Rate for Payer: Humana of AZ Medicare	$13.60
Rate for Payer: Southwest Service Administrators UFCW	$57.80
Rate for Payer: TriWest Medicare	$13.60
Rate for Payer: United Healthcare Commercial	$48.62
Rate for Payer: United Healthcare Medicare	$13.60
Rate for Payer: Veterans Affairs TRICARE	$13.46

90714 Td - TENIVAC (7 yrs older)

Facility

$85.00

Service Code	CPT 90714
Hospital Charge Code	22328774
Hospital Revenue Code	521
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of AZ Commercial	$76.50
Rate for Payer: Cash Price	$68.00

90715 VFC Tdap Vaccine 7+years

Facility

$142.00

Service Code	CPT 90715 SL
Hospital Charge Code	22311078
Hospital Revenue Code	636
Min. Negotiated Rate	$22.49
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Arizona Complete Health Allwell	$22.72
Rate for Payer: Banner UC Health Medicare	$22.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$96.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$22.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$22.72
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cigna of AZ Commercial	$99.40
Rate for Payer: Devoted Health Medicare	$25.56
Rate for Payer: Humana of AZ Medicare	$22.72
Rate for Payer: Southwest Service Administrators UFCW	$96.56
Rate for Payer: TriWest Medicare	$22.72
Rate for Payer: United Healthcare Commercial	$81.22
Rate for Payer: United Healthcare Medicare	$22.72
Rate for Payer: United Healthcare New Mexico Commercial	$26.98
Rate for Payer: Veterans Affairs TRICARE	$22.49

Know your out-of-pocket cost for care.

All Charges