Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

90913 Biofeedback additional 15 min

Facility

$167.00

Service Code	CPT 90913
Hospital Charge Code	23926325
Hospital Revenue Code	2105
Min. Negotiated Rate	$113.56
Max. Negotiated Rate	$1,700.00
Rate for Payer: Aetna of AZ Commercial	$150.30
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$113.56
Rate for Payer: Cash Price	$133.60
Rate for Payer: Cash Price	$133.60
Rate for Payer: Cigna of AZ Commercial	$1,700.00
Rate for Payer: Devoted Health Medicare	$1,434.00
Rate for Payer: Southwest Service Administrators UFCW	$113.56

91034 ESOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; WITH NASAL CA

Facility

$1,898.00

Service Code	CPT 91034
Hospital Charge Code	23599031
Hospital Revenue Code	750
Min. Negotiated Rate	$83.39
Max. Negotiated Rate	$2,671.00
Rate for Payer: Aetna of AZ Commercial	$1,708.20
Rate for Payer: Arizona Complete Health Allwell	$303.68
Rate for Payer: Banner UC Health Medicare	$83.39
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,290.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$303.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$303.68
Rate for Payer: Cash Price	$1,518.40
Rate for Payer: Cash Price	$1,518.40
Rate for Payer: Cash Price	$1,518.40
Rate for Payer: Cigna of AZ Commercial	$1,328.60
Rate for Payer: Devoted Health Medicare	$341.64
Rate for Payer: Humana of AZ Medicare	$303.68
Rate for Payer: NaphCare Correctional Healthcare	$83.39
Rate for Payer: Seven Corners Travel Insurance	$577.38
Rate for Payer: Southwest Service Administrators UFCW	$1,290.64
Rate for Payer: TriWest Medicare	$303.68
Rate for Payer: United Healthcare Commercial	$2,671.00
Rate for Payer: United Healthcare Medicare	$303.68
Rate for Payer: United Healthcare New Mexico Commercial	$360.62
Rate for Payer: Veterans Affairs TRICARE	$300.64

91034 ESOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; WITH NASAL CA

Facility

$1,898.00

Service Code	CPT 91034
Hospital Charge Code	23599031
Hospital Revenue Code	750
Min. Negotiated Rate	$1,708.20
Max. Negotiated Rate	$1,708.20
Rate for Payer: Aetna of AZ Commercial	$1,708.20
Rate for Payer: Cash Price	$1,518.40

91065 Breath Test

Facility

$193.00

Service Code	CPT 91065 26
Hospital Charge Code	23835642
Hospital Revenue Code	982
Min. Negotiated Rate	$173.70
Max. Negotiated Rate	$173.70
Rate for Payer: Aetna of AZ Commercial	$173.70
Rate for Payer: Cash Price	$154.40

91065 Breath Test

Facility

$193.00

Service Code	CPT 91065 26
Hospital Charge Code	23835642
Hospital Revenue Code	982
Min. Negotiated Rate	$30.57
Max. Negotiated Rate	$173.70
Rate for Payer: Aetna of AZ Commercial	$173.70
Rate for Payer: Arizona Complete Health Allwell	$30.88
Rate for Payer: Banner UC Health Medicare	$30.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$131.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$30.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$30.88
Rate for Payer: Cash Price	$154.40
Rate for Payer: Cigna of AZ Commercial	$135.10
Rate for Payer: Devoted Health Medicare	$34.74
Rate for Payer: Humana of AZ Medicare	$30.88
Rate for Payer: Southwest Service Administrators UFCW	$131.24
Rate for Payer: TriWest Medicare	$30.88
Rate for Payer: United Healthcare Commercial	$110.40
Rate for Payer: United Healthcare Medicare	$30.88
Rate for Payer: United Healthcare New Mexico Commercial	$36.67
Rate for Payer: Veterans Affairs TRICARE	$30.57

91110 Complete Capsule Endoscopy

Facility

$1,591.00

Service Code	CPT 91110 26
Hospital Charge Code	23835638
Hospital Revenue Code	982
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

91110 Complete Capsule Endoscopy

Facility

$1,591.00

Service Code	CPT 91110 26
Hospital Charge Code	23835638
Hospital Revenue Code	982
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: United Healthcare New Mexico Commercial	$302.29
Rate for Payer: Veterans Affairs TRICARE	$252.01

91111 Partial Capsule Endoscopy

Facility

$1,591.00

Service Code	CPT 91111 26
Hospital Charge Code	23835641
Hospital Revenue Code	521
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

91111 Partial Capsule Endoscopy

Facility

$1,591.00

Service Code	CPT 91111 26
Hospital Charge Code	23835641
Hospital Revenue Code	521
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

91304 Novavax COVID19 Vaccine

Facility

$191.91

Service Code	CPT 91304
Hospital Charge Code	27414119
Hospital Revenue Code	521
Min. Negotiated Rate	$30.40
Max. Negotiated Rate	$172.72
Rate for Payer: Aetna of AZ Commercial	$172.72
Rate for Payer: Arizona Complete Health Allwell	$30.71
Rate for Payer: Banner UC Health Medicare	$30.71
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$130.50
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$30.71
Rate for Payer: Care1st Health Plan Arizona Medicare	$30.71
Rate for Payer: Cash Price	$153.53
Rate for Payer: Cigna of AZ Commercial	$134.34
Rate for Payer: Devoted Health Medicare	$34.54
Rate for Payer: Humana of AZ Medicare	$30.71
Rate for Payer: Southwest Service Administrators UFCW	$130.50
Rate for Payer: TriWest Medicare	$30.71
Rate for Payer: United Healthcare Commercial	$109.77
Rate for Payer: United Healthcare Medicare	$30.71
Rate for Payer: Veterans Affairs TRICARE	$30.40

91304 Novavax COVID19 Vaccine

Facility

$191.91

Service Code	CPT 91304
Hospital Charge Code	27414119
Hospital Revenue Code	521
Min. Negotiated Rate	$172.72
Max. Negotiated Rate	$172.72
Rate for Payer: Aetna of AZ Commercial	$172.72
Rate for Payer: Cash Price	$153.53

91305 Pfizer Pediatric Admin

Facility

$0.13

Service Code	CPT 91305
Hospital Charge Code	27371842
Hospital Revenue Code	521
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Arizona Complete Health Allwell	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.09
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.02
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.02
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of AZ Commercial	$0.09
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.09
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.07
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

91305 Pfizer Pediatric Admin

Facility

$0.13

Service Code	CPT 91305
Hospital Charge Code	27371842
Hospital Revenue Code	521
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Cash Price	$0.10

91306 Modern Low Dose Booster

Facility

$0.13

Service Code	CPT 91306
Hospital Charge Code	24409109
Hospital Revenue Code	521
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Cash Price	$0.10

91306 Modern Low Dose Booster

Facility

$0.13

Service Code	CPT 91306
Hospital Charge Code	24409109
Hospital Revenue Code	521
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Arizona Complete Health Allwell	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.09
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.02
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.02
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of AZ Commercial	$0.09
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.09
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.07
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

91307 Pfizer Pediatric vaccine

Facility

$0.13

Service Code	CPT 91307
Hospital Charge Code	24409111
Hospital Revenue Code	521
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Cash Price	$0.10

91307 Pfizer Pediatric vaccine

Facility

$0.13

Service Code	CPT 91307
Hospital Charge Code	24409111
Hospital Revenue Code	521
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Arizona Complete Health Allwell	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.09
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.02
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.02
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of AZ Commercial	$0.09
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.09
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.07
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

91308 Pfizer Pediatric 6mth-4yr Med Charge

Facility

$0.13

Service Code	CPT 91308
Hospital Charge Code	27407520
Hospital Revenue Code	521
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Cash Price	$0.10

91308 Pfizer Pediatric 6mth-4yr Med Charge

Facility

$0.13

Service Code	CPT 91308
Hospital Charge Code	27407520
Hospital Revenue Code	521
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Arizona Complete Health Allwell	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.09
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.02
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.02
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of AZ Commercial	$0.09
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.09
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.07
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

91309 Moderna 6-11 yrs Admin Charge CQCH

Facility

$0.13

Service Code	CPT 91309
Hospital Charge Code	27408320
Hospital Revenue Code	521
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Cash Price	$0.10

91309 Moderna 6-11 yrs Admin Charge CQCH

Facility

$0.13

Service Code	CPT 91309
Hospital Charge Code	27408320
Hospital Revenue Code	521
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Arizona Complete Health Allwell	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.09
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.02
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.02
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of AZ Commercial	$0.09
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.09
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.07
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

91311 Moderna Pediatric Admin 6mth-5yrs Med Charge

Facility

$55.00

Service Code	CPT 91311
Hospital Charge Code	27414161
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

91311 Moderna Pediatric Admin 6mth-5yrs Med Charge

Facility

$55.00

Service Code	CPT 91311
Hospital Charge Code	27414161
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

91312 Pfizer Bivalent vaccine for 12yrs and older

Facility

$0.13

Service Code	CPT 91312
Hospital Charge Code	27410225
Hospital Revenue Code	521
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Arizona Complete Health Allwell	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.09
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.02
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.02
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of AZ Commercial	$0.09
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.09
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.07
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

91312 Pfizer Bivalent vaccine for 12yrs and older

Facility

$0.13

Service Code	CPT 91312
Hospital Charge Code	27410225
Hospital Revenue Code	521
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Cash Price	$0.10

Know your out-of-pocket cost for care.

All Charges