Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

91313 Moderna Bivalent vaccine for Adults

Facility

$0.13

Service Code	CPT 91313
Hospital Charge Code	27410202
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

91313 Moderna Bivalent vaccine for Adults

Facility

$0.13

Service Code	CPT 91313
Hospital Charge Code	27410202
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

91314 Moderna Bivalent vaccine for children

Facility

$0.13

Service Code	CPT 91314
Hospital Charge Code	27410203
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

91314 Moderna Bivalent vaccine for children

Facility

$0.13

Service Code	CPT 91314
Hospital Charge Code	27410203
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

91315 PFizer Bivalent vaccine under 12

Facility

$0.13

Service Code	CPT 91315
Hospital Charge Code	27407080
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

91315 PFizer Bivalent vaccine under 12

Facility

$0.13

Service Code	CPT 91315
Hospital Charge Code	27407080
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

91322 Spikevax Medication Charge

Facility

$284.00

Service Code	CPT 91322
Hospital Charge Code	27620085
Hospital Revenue Code	521
Min. Negotiated Rate	$44.99
Max. Negotiated Rate	$255.60
Rate for Payer: Aetna of AZ Commercial	$255.60
Rate for Payer: Arizona Complete Health Allwell	$45.44
Rate for Payer: Banner UC Health Medicare	$45.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$193.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$45.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$45.44
Rate for Payer: Cash Price	$227.20
Rate for Payer: Cigna of AZ Commercial	$198.80
Rate for Payer: Devoted Health Medicare	$51.12
Rate for Payer: Humana of AZ Medicare	$45.44
Rate for Payer: Southwest Service Administrators UFCW	$193.12
Rate for Payer: TriWest Medicare	$45.44
Rate for Payer: United Healthcare Commercial	$162.45
Rate for Payer: United Healthcare Medicare	$45.44
Rate for Payer: Veterans Affairs TRICARE	$44.99

91322 Spikevax Medication Charge

Facility

$284.00

Service Code	CPT 91322
Hospital Charge Code	27620085
Hospital Revenue Code	521
Min. Negotiated Rate	$255.60
Max. Negotiated Rate	$255.60
Rate for Payer: Aetna of AZ Commercial	$255.60
Rate for Payer: Cash Price	$227.20

92507 TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, A

Facility

$252.00

Service Code	CPT 92507 GN
Hospital Charge Code	27726434
Hospital Revenue Code	440
Min. Negotiated Rate	$39.92
Max. Negotiated Rate	$226.80
Rate for Payer: Aetna of AZ Commercial	$226.80
Rate for Payer: Arizona Complete Health Allwell	$40.32
Rate for Payer: Banner UC Health Medicare	$40.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$171.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$40.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$40.79
Rate for Payer: Cash Price	$201.60
Rate for Payer: Cash Price	$201.60
Rate for Payer: Cigna of AZ Commercial	$176.40
Rate for Payer: Devoted Health Medicare	$45.36
Rate for Payer: Humana of AZ Medicare	$40.32
Rate for Payer: Southwest Service Administrators UFCW	$171.36
Rate for Payer: TriWest Medicare	$40.32
Rate for Payer: United Healthcare Commercial	$144.14
Rate for Payer: United Healthcare Medicare	$40.32
Rate for Payer: United Healthcare New Mexico Commercial	$47.88
Rate for Payer: Veterans Affairs TRICARE	$39.92

92507 TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, A

Facility

$252.00

Service Code	CPT 92507 GN
Hospital Charge Code	27726434
Hospital Revenue Code	440
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$226.80
Rate for Payer: Aetna of AZ Commercial	$226.80
Rate for Payer: Cash Price	$201.60

92520 STUDY OF VOICE BOX FUNCTION

Facility

$219.00

Service Code	CPT 92520 GN
Hospital Charge Code	27728009
Hospital Revenue Code	440
Min. Negotiated Rate	$33.99
Max. Negotiated Rate	$197.10
Rate for Payer: Aetna of AZ Commercial	$197.10
Rate for Payer: Arizona Complete Health Allwell	$35.04
Rate for Payer: Banner UC Health Medicare	$35.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$148.92
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$51.26
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$35.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$33.99
Rate for Payer: Cash Price	$175.20
Rate for Payer: Cash Price	$175.20
Rate for Payer: Cigna of AZ Commercial	$153.30
Rate for Payer: Devoted Health Medicare	$39.42
Rate for Payer: Humana of AZ Medicare	$35.04
Rate for Payer: Mercy Care Medicaid	$51.26
Rate for Payer: NaphCare Correctional Healthcare	$51.26
Rate for Payer: Southwest Service Administrators UFCW	$148.92
Rate for Payer: TriWest Medicare	$35.04
Rate for Payer: United Healthcare Commercial	$125.27
Rate for Payer: United Healthcare Medicare	$35.04
Rate for Payer: United Healthcare New Mexico Commercial	$41.61
Rate for Payer: Veterans Affairs TRICARE	$34.69

92520 STUDY OF VOICE BOX FUNCTION

Facility

$219.00

Service Code	CPT 92520 GN
Hospital Charge Code	27728009
Hospital Revenue Code	440
Min. Negotiated Rate	$197.10
Max. Negotiated Rate	$197.10
Rate for Payer: Aetna of AZ Commercial	$197.10
Rate for Payer: Cash Price	$175.20

92521 EVALUATION OF SPEECH CONTINUITY, SMOOTHNESS, RATE, AND

Facility

$736.00

Service Code	CPT 92521 GN
Hospital Charge Code	27726435
Hospital Revenue Code	444
Min. Negotiated Rate	$116.58
Max. Negotiated Rate	$662.40
Rate for Payer: Aetna of AZ Commercial	$662.40
Rate for Payer: Arizona Complete Health Allwell	$117.76
Rate for Payer: Banner UC Health Medicare	$117.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$500.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$117.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$139.16
Rate for Payer: Cash Price	$588.80
Rate for Payer: Cash Price	$588.80
Rate for Payer: Cigna of AZ Commercial	$515.20
Rate for Payer: Devoted Health Medicare	$132.48
Rate for Payer: Humana of AZ Medicare	$117.76
Rate for Payer: Southwest Service Administrators UFCW	$500.48
Rate for Payer: TriWest Medicare	$117.76
Rate for Payer: United Healthcare Commercial	$420.99
Rate for Payer: United Healthcare Medicare	$117.76
Rate for Payer: United Healthcare New Mexico Commercial	$139.84
Rate for Payer: Veterans Affairs TRICARE	$116.58

92521 EVALUATION OF SPEECH CONTINUITY, SMOOTHNESS, RATE, AND

Facility

$736.00

Service Code	CPT 92521 GN
Hospital Charge Code	27726435
Hospital Revenue Code	444
Min. Negotiated Rate	$662.40
Max. Negotiated Rate	$662.40
Rate for Payer: Aetna of AZ Commercial	$662.40
Rate for Payer: Cash Price	$588.80

92522 EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATIO

Facility

$584.00

Service Code	CPT 92522 GN
Hospital Charge Code	27728007
Hospital Revenue Code	444
Min. Negotiated Rate	$525.60
Max. Negotiated Rate	$525.60
Rate for Payer: Aetna of AZ Commercial	$525.60
Rate for Payer: Cash Price	$467.20

92522 EVALUATION OF SPEECH SOUND PRODUCTION (EG, ARTICULATIO

Facility

$584.00

Service Code	CPT 92522 GN
Hospital Charge Code	27728007
Hospital Revenue Code	444
Min. Negotiated Rate	$92.51
Max. Negotiated Rate	$525.60
Rate for Payer: Aetna of AZ Commercial	$525.60
Rate for Payer: Arizona Complete Health Allwell	$93.44
Rate for Payer: Banner UC Health Medicare	$93.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$397.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$93.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$116.85
Rate for Payer: Cash Price	$467.20
Rate for Payer: Cash Price	$467.20
Rate for Payer: Cigna of AZ Commercial	$408.80
Rate for Payer: Devoted Health Medicare	$105.12
Rate for Payer: Humana of AZ Medicare	$93.44
Rate for Payer: Southwest Service Administrators UFCW	$397.12
Rate for Payer: TriWest Medicare	$93.44
Rate for Payer: United Healthcare Commercial	$334.05
Rate for Payer: United Healthcare Medicare	$93.44
Rate for Payer: United Healthcare New Mexico Commercial	$110.96
Rate for Payer: Veterans Affairs TRICARE	$92.51

92523 EVALUATION OF SPEECH SOUND PRODUCTION WITH EVAL OF LAN

Facility

$1,199.00

Service Code	CPT 92523 GN
Hospital Charge Code	27728008
Hospital Revenue Code	444
Min. Negotiated Rate	$1,079.10
Max. Negotiated Rate	$1,079.10
Rate for Payer: Aetna of AZ Commercial	$1,079.10
Rate for Payer: Cash Price	$959.20

92523 EVALUATION OF SPEECH SOUND PRODUCTION WITH EVAL OF LAN

Facility

$1,199.00

Service Code	CPT 92523 GN
Hospital Charge Code	27728008
Hospital Revenue Code	444
Min. Negotiated Rate	$189.92
Max. Negotiated Rate	$1,079.10
Rate for Payer: Aetna of AZ Commercial	$1,079.10
Rate for Payer: Arizona Complete Health Allwell	$191.84
Rate for Payer: Banner UC Health Medicare	$191.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$815.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$191.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$236.88
Rate for Payer: Cash Price	$959.20
Rate for Payer: Cash Price	$959.20
Rate for Payer: Cigna of AZ Commercial	$839.30
Rate for Payer: Devoted Health Medicare	$215.82
Rate for Payer: Humana of AZ Medicare	$191.84
Rate for Payer: Southwest Service Administrators UFCW	$815.32
Rate for Payer: TriWest Medicare	$191.84
Rate for Payer: United Healthcare Commercial	$685.83
Rate for Payer: United Healthcare Medicare	$191.84
Rate for Payer: United Healthcare New Mexico Commercial	$227.81
Rate for Payer: Veterans Affairs TRICARE	$189.92

92524 ANALYSIS OF VOICE AND RESONANCE PRODUCTION

Facility

$608.00

Service Code	CPT 92524 GN
Hospital Charge Code	27724316
Hospital Revenue Code	440
Min. Negotiated Rate	$547.20
Max. Negotiated Rate	$547.20
Rate for Payer: Aetna of AZ Commercial	$547.20
Rate for Payer: Cash Price	$486.40

92524 ANALYSIS OF VOICE AND RESONANCE PRODUCTION

Facility

$608.00

Service Code	CPT 92524 GN
Hospital Charge Code	27724316
Hospital Revenue Code	440
Min. Negotiated Rate	$96.31
Max. Negotiated Rate	$547.20
Rate for Payer: Aetna of AZ Commercial	$547.20
Rate for Payer: Arizona Complete Health Allwell	$97.28
Rate for Payer: Banner UC Health Medicare	$97.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$413.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$97.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$114.37
Rate for Payer: Cash Price	$486.40
Rate for Payer: Cash Price	$486.40
Rate for Payer: Cigna of AZ Commercial	$425.60
Rate for Payer: Devoted Health Medicare	$109.44
Rate for Payer: Humana of AZ Medicare	$97.28
Rate for Payer: Southwest Service Administrators UFCW	$413.44
Rate for Payer: TriWest Medicare	$97.28
Rate for Payer: United Healthcare Commercial	$347.78
Rate for Payer: United Healthcare Medicare	$97.28
Rate for Payer: United Healthcare New Mexico Commercial	$115.52
Rate for Payer: Veterans Affairs TRICARE	$96.31

92526 TREATMENT OF SWALLOWING AND FEEDING DISORDER

Facility

$469.00

Service Code	CPT 92526 GN
Hospital Charge Code	27724313
Hospital Revenue Code	440
Min. Negotiated Rate	$74.29
Max. Negotiated Rate	$422.10
Rate for Payer: Aetna of AZ Commercial	$422.10
Rate for Payer: Arizona Complete Health Allwell	$75.04
Rate for Payer: Banner UC Health Medicare	$75.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$318.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$75.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$87.81
Rate for Payer: Cash Price	$375.20
Rate for Payer: Cash Price	$375.20
Rate for Payer: Cigna of AZ Commercial	$328.30
Rate for Payer: Devoted Health Medicare	$84.42
Rate for Payer: Humana of AZ Medicare	$75.04
Rate for Payer: Southwest Service Administrators UFCW	$318.92
Rate for Payer: TriWest Medicare	$75.04
Rate for Payer: United Healthcare Commercial	$268.27
Rate for Payer: United Healthcare Medicare	$75.04
Rate for Payer: United Healthcare New Mexico Commercial	$89.11
Rate for Payer: Veterans Affairs TRICARE	$74.29

92526 TREATMENT OF SWALLOWING AND FEEDING DISORDER

Facility

$469.00

Service Code	CPT 92526 GN
Hospital Charge Code	27724313
Hospital Revenue Code	440
Min. Negotiated Rate	$422.10
Max. Negotiated Rate	$422.10
Rate for Payer: Aetna of AZ Commercial	$422.10
Rate for Payer: Cash Price	$375.20

92610 EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION.

Facility

$370.00

Service Code	CPT 92610 GN
Hospital Charge Code	27724315
Hospital Revenue Code	444
Min. Negotiated Rate	$333.00
Max. Negotiated Rate	$333.00
Rate for Payer: Aetna of AZ Commercial	$333.00
Rate for Payer: Cash Price	$296.00

92610 EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION.

Facility

$370.00

Service Code	CPT 92610 GN
Hospital Charge Code	27724315
Hospital Revenue Code	444
Min. Negotiated Rate	$15.34
Max. Negotiated Rate	$333.00
Rate for Payer: Aetna of AZ Commercial	$333.00
Rate for Payer: Arizona Complete Health Allwell	$59.20
Rate for Payer: Banner UC Health Medicare	$59.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$251.60
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$15.34
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$59.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$60.90
Rate for Payer: Cash Price	$296.00
Rate for Payer: Cash Price	$296.00
Rate for Payer: Cigna of AZ Commercial	$259.00
Rate for Payer: Devoted Health Medicare	$66.60
Rate for Payer: Humana of AZ Medicare	$59.20
Rate for Payer: Mercy Care Medicaid	$15.34
Rate for Payer: NaphCare Correctional Healthcare	$15.34
Rate for Payer: Southwest Service Administrators UFCW	$251.60
Rate for Payer: TriWest Medicare	$59.20
Rate for Payer: United Healthcare Commercial	$211.64
Rate for Payer: United Healthcare Medicare	$59.20
Rate for Payer: United Healthcare New Mexico Commercial	$70.30
Rate for Payer: Veterans Affairs TRICARE	$58.61

92950 ER - CPR

Facility

$1,796.00

Service Code	CPT 92950
Hospital Charge Code	22282930
Hospital Revenue Code	450
Min. Negotiated Rate	$1,616.40
Max. Negotiated Rate	$1,616.40
Rate for Payer: Aetna of AZ Commercial	$1,616.40
Rate for Payer: Cash Price	$1,436.80

Know your out-of-pocket cost for care.

All Charges