Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

PM CANNABINOIDS

Facility

$239.00

Service Code	CPT 80349
Hospital Charge Code	23293447
Hospital Revenue Code	301
Min. Negotiated Rate	$37.86
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Arizona Complete Health Allwell	$38.24
Rate for Payer: Banner UC Health Medicare	$38.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$162.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.24
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cigna of AZ Commercial	$155.35
Rate for Payer: Devoted Health Medicare	$43.02
Rate for Payer: Humana of AZ Medicare	$38.24
Rate for Payer: Southwest Service Administrators UFCW	$162.52
Rate for Payer: TriWest Medicare	$38.24
Rate for Payer: United Healthcare Commercial	$136.71
Rate for Payer: United Healthcare Medicare	$38.24
Rate for Payer: Veterans Affairs TRICARE	$37.86

PM COCAINE METABOLITE

Facility

$239.00

Service Code	CPT 80353
Hospital Charge Code	23293448
Hospital Revenue Code	301
Min. Negotiated Rate	$215.10
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Cash Price	$191.20

PM COCAINE METABOLITE

Facility

$239.00

Service Code	CPT 80353
Hospital Charge Code	23293448
Hospital Revenue Code	301
Min. Negotiated Rate	$37.86
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Arizona Complete Health Allwell	$38.24
Rate for Payer: Banner UC Health Medicare	$38.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$162.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.24
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cigna of AZ Commercial	$155.35
Rate for Payer: Devoted Health Medicare	$43.02
Rate for Payer: Humana of AZ Medicare	$38.24
Rate for Payer: Southwest Service Administrators UFCW	$162.52
Rate for Payer: TriWest Medicare	$38.24
Rate for Payer: United Healthcare Commercial	$136.71
Rate for Payer: United Healthcare Medicare	$38.24
Rate for Payer: Veterans Affairs TRICARE	$37.86

PM DOA Screen

Facility

$163.00

Service Code	CPT 80305 QW
Hospital Charge Code	23741289
Hospital Revenue Code	301
Min. Negotiated Rate	$146.70
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Cash Price	$130.40

PM DOA Screen

Facility

$163.00

Service Code	CPT 80305 QW
Hospital Charge Code	23741289
Hospital Revenue Code	301
Min. Negotiated Rate	$18.27
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Arizona Complete Health Allwell	$26.08
Rate for Payer: Banner UC Health Medicare	$26.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$110.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$26.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$26.08
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cigna of AZ Commercial	$105.95
Rate for Payer: Devoted Health Medicare	$29.34
Rate for Payer: Humana of AZ Medicare	$26.08
Rate for Payer: Seven Corners Travel Insurance	$18.27
Rate for Payer: Southwest Service Administrators UFCW	$110.84
Rate for Payer: TriWest Medicare	$26.08
Rate for Payer: United Healthcare Commercial	$93.24
Rate for Payer: United Healthcare Medicare	$26.08
Rate for Payer: Veterans Affairs TRICARE	$25.82

PM METHADONE

Facility

$228.00

Service Code	CPT 80358
Hospital Charge Code	23293445
Hospital Revenue Code	301
Min. Negotiated Rate	$36.12
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna of AZ Commercial	$205.20
Rate for Payer: Arizona Complete Health Allwell	$36.48
Rate for Payer: Banner UC Health Medicare	$36.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$155.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.48
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cigna of AZ Commercial	$148.20
Rate for Payer: Devoted Health Medicare	$41.04
Rate for Payer: Humana of AZ Medicare	$36.48
Rate for Payer: Southwest Service Administrators UFCW	$155.04
Rate for Payer: TriWest Medicare	$36.48
Rate for Payer: United Healthcare Commercial	$130.42
Rate for Payer: United Healthcare Medicare	$36.48
Rate for Payer: Veterans Affairs TRICARE	$36.12

PM METHADONE

Facility

$228.00

Service Code	CPT 80358
Hospital Charge Code	23293445
Hospital Revenue Code	301
Min. Negotiated Rate	$205.20
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna of AZ Commercial	$205.20
Rate for Payer: Cash Price	$182.40

PM OPIATES

Facility

$227.00

Service Code	CPT 80361
Hospital Charge Code	23293439
Hospital Revenue Code	301
Min. Negotiated Rate	$35.96
Max. Negotiated Rate	$204.30
Rate for Payer: Aetna of AZ Commercial	$204.30
Rate for Payer: Arizona Complete Health Allwell	$36.32
Rate for Payer: Banner UC Health Medicare	$36.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$154.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.32
Rate for Payer: Cash Price	$181.60
Rate for Payer: Cigna of AZ Commercial	$147.55
Rate for Payer: Devoted Health Medicare	$40.86
Rate for Payer: Humana of AZ Medicare	$36.32
Rate for Payer: Southwest Service Administrators UFCW	$154.36
Rate for Payer: TriWest Medicare	$36.32
Rate for Payer: United Healthcare Commercial	$129.84
Rate for Payer: United Healthcare Medicare	$36.32
Rate for Payer: Veterans Affairs TRICARE	$35.96

PM OPIATES

Facility

$227.00

Service Code	CPT 80361
Hospital Charge Code	23293439
Hospital Revenue Code	301
Min. Negotiated Rate	$204.30
Max. Negotiated Rate	$204.30
Rate for Payer: Aetna of AZ Commercial	$204.30
Rate for Payer: Cash Price	$181.60

PM TRAMADOL

Facility

$239.00

Service Code	CPT 80373
Hospital Charge Code	23293441
Hospital Revenue Code	301
Min. Negotiated Rate	$37.86
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Arizona Complete Health Allwell	$38.24
Rate for Payer: Banner UC Health Medicare	$38.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$162.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$38.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.24
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cigna of AZ Commercial	$155.35
Rate for Payer: Devoted Health Medicare	$43.02
Rate for Payer: Humana of AZ Medicare	$38.24
Rate for Payer: Southwest Service Administrators UFCW	$162.52
Rate for Payer: TriWest Medicare	$38.24
Rate for Payer: United Healthcare Commercial	$136.71
Rate for Payer: United Healthcare Medicare	$38.24
Rate for Payer: Veterans Affairs TRICARE	$37.86

PM TRAMADOL

Facility

$239.00

Service Code	CPT 80373
Hospital Charge Code	23293441
Hospital Revenue Code	301
Min. Negotiated Rate	$215.10
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Cash Price	$191.20

Pneumatic Ankle Control Splint, Prefabricated, Includes Fitting And Adjustment

Facility

$272.00

Service Code	HCPCS L4350
Hospital Charge Code	1413445
Hospital Revenue Code	521
Min. Negotiated Rate	$43.08
Max. Negotiated Rate	$244.80
Rate for Payer: Aetna of AZ Commercial	$244.80
Rate for Payer: Arizona Complete Health Allwell	$43.52
Rate for Payer: Banner UC Health Medicare	$43.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$184.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$43.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.52
Rate for Payer: Cash Price	$217.60
Rate for Payer: Cigna of AZ Commercial	$190.40
Rate for Payer: Devoted Health Medicare	$48.96
Rate for Payer: Humana of AZ Medicare	$43.52
Rate for Payer: Southwest Service Administrators UFCW	$184.96
Rate for Payer: TriWest Medicare	$43.52
Rate for Payer: United Healthcare Commercial	$155.58
Rate for Payer: United Healthcare Medicare	$43.52
Rate for Payer: Veterans Affairs TRICARE	$43.08

Pneumatic Ankle Control Splint, Prefabricated, Includes Fitting And Adjustment

Facility

$272.00

Service Code	HCPCS L4350
Hospital Charge Code	1413445
Hospital Revenue Code	521
Min. Negotiated Rate	$244.80
Max. Negotiated Rate	$244.80
Rate for Payer: Aetna of AZ Commercial	$244.80
Rate for Payer: Cash Price	$217.60

pneumococcal 13 vaccine Prevnar PFS [CQCH]

Facility

$770.66

Service Code	HCPCS 90670
Hospital Charge Code	105937029
Hospital Revenue Code	250
Min. Negotiated Rate	$693.59
Max. Negotiated Rate	$693.59
Rate for Payer: Aetna of AZ Commercial	$693.59
Rate for Payer: Cash Price	$616.53

pneumococcal 13 vaccine Prevnar PFS [CQCH]

Facility

$770.66

Service Code	HCPCS 90670
Hospital Charge Code	105937029
Hospital Revenue Code	250
Min. Negotiated Rate	$122.07
Max. Negotiated Rate	$693.59
Rate for Payer: Aetna of AZ Commercial	$693.59
Rate for Payer: Arizona Complete Health Allwell	$123.31
Rate for Payer: Banner UC Health Medicare	$123.31
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$524.05
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$123.31
Rate for Payer: Care1st Health Plan Arizona Medicare	$123.31
Rate for Payer: Cash Price	$616.53
Rate for Payer: Cigna of AZ Commercial	$500.93
Rate for Payer: Devoted Health Medicare	$138.72
Rate for Payer: Humana of AZ Medicare	$123.31
Rate for Payer: Southwest Service Administrators UFCW	$524.05
Rate for Payer: TriWest Medicare	$123.31
Rate for Payer: United Healthcare Commercial	$440.82
Rate for Payer: United Healthcare Medicare	$123.31
Rate for Payer: Veterans Affairs TRICARE	$122.07

pneumococcal 20-valent conjugate vaccine

Facility

$310.00

Service Code	CPT 90677
Hospital Charge Code	25663806
Hospital Revenue Code	521
Min. Negotiated Rate	$49.10
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of AZ Commercial	$279.00
Rate for Payer: Arizona Complete Health Allwell	$49.60
Rate for Payer: Banner UC Health Medicare	$49.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$210.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$49.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$49.60
Rate for Payer: Cash Price	$248.00
Rate for Payer: Cigna of AZ Commercial	$217.00
Rate for Payer: Devoted Health Medicare	$55.80
Rate for Payer: Humana of AZ Medicare	$49.60
Rate for Payer: Southwest Service Administrators UFCW	$210.80
Rate for Payer: TriWest Medicare	$49.60
Rate for Payer: United Healthcare Commercial	$177.32
Rate for Payer: United Healthcare Medicare	$49.60
Rate for Payer: Veterans Affairs TRICARE	$49.10

pneumococcal 20-valent conjugate vaccine

Facility

$310.00

Service Code	CPT 90677
Hospital Charge Code	25663806
Hospital Revenue Code	521
Min. Negotiated Rate	$279.00
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of AZ Commercial	$279.00
Rate for Payer: Cash Price	$248.00

pneumococcal 23 vaccine Inj [CQCH]

Facility

$414.52

Service Code	HCPCS 90732
Hospital Charge Code	105937100
Hospital Revenue Code	250
Min. Negotiated Rate	$65.66
Max. Negotiated Rate	$373.07
Rate for Payer: Aetna of AZ Commercial	$373.07
Rate for Payer: Arizona Complete Health Allwell	$66.32
Rate for Payer: Banner UC Health Medicare	$66.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$281.87
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$66.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$66.32
Rate for Payer: Cash Price	$331.62
Rate for Payer: Cigna of AZ Commercial	$269.44
Rate for Payer: Devoted Health Medicare	$74.61
Rate for Payer: Humana of AZ Medicare	$66.32
Rate for Payer: Southwest Service Administrators UFCW	$281.87
Rate for Payer: TriWest Medicare	$66.32
Rate for Payer: United Healthcare Commercial	$237.11
Rate for Payer: United Healthcare Medicare	$66.32
Rate for Payer: Veterans Affairs TRICARE	$65.66

pneumococcal 23 vaccine Inj [CQCH]

Facility

$414.52

Service Code	HCPCS 90732
Hospital Charge Code	105937100
Hospital Revenue Code	250
Min. Negotiated Rate	$373.07
Max. Negotiated Rate	$373.07
Rate for Payer: Aetna of AZ Commercial	$373.07
Rate for Payer: Cash Price	$331.62

Pneumococcal 23-Valent Adult Vaccine POC

Facility

$85.00

Service Code	CPT 90732
Hospital Charge Code	667692
Hospital Revenue Code	636
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: United Healthcare New Mexico Commercial	$16.15
Rate for Payer: Veterans Affairs TRICARE	$13.46

Pneumococcal 23-Valent Adult Vaccine POC

Facility

$85.00

Service Code	CPT 90732
Hospital Charge Code	667692
Hospital Revenue Code	636
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

Pneumococcal conjugate vaccine, 13 valent, for IM use

Facility

$417.00

Service Code	CPT 90670
Hospital Charge Code	20532952
Hospital Revenue Code	521
Min. Negotiated Rate	$375.30
Max. Negotiated Rate	$375.30
Rate for Payer: Aetna of AZ Commercial	$375.30
Rate for Payer: Cash Price	$333.60

Pneumococcal conjugate vaccine, 13 valent, for IM use

Facility

$417.00

Service Code	CPT 90670
Hospital Charge Code	20532952
Hospital Revenue Code	521
Min. Negotiated Rate	$66.05
Max. Negotiated Rate	$375.30
Rate for Payer: Aetna of AZ Commercial	$375.30
Rate for Payer: Arizona Complete Health Allwell	$66.72
Rate for Payer: Banner UC Health Medicare	$66.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$283.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$66.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$66.72
Rate for Payer: Cash Price	$333.60
Rate for Payer: Cigna of AZ Commercial	$291.90
Rate for Payer: Devoted Health Medicare	$75.06
Rate for Payer: Humana of AZ Medicare	$66.72
Rate for Payer: Southwest Service Administrators UFCW	$283.56
Rate for Payer: TriWest Medicare	$66.72
Rate for Payer: United Healthcare Commercial	$238.52
Rate for Payer: United Healthcare Medicare	$66.72
Rate for Payer: Veterans Affairs TRICARE	$66.05

Pneumococcal conjugate vaccine, 13 valent, for intramuscular

Facility

$296.00

Service Code	CPT 90670
Hospital Charge Code	1165947
Hospital Revenue Code	636
Min. Negotiated Rate	$46.89
Max. Negotiated Rate	$266.40
Rate for Payer: Aetna of AZ Commercial	$266.40
Rate for Payer: Arizona Complete Health Allwell	$47.36
Rate for Payer: Banner UC Health Medicare	$47.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$201.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$47.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$47.36
Rate for Payer: Cash Price	$236.80
Rate for Payer: Cigna of AZ Commercial	$207.20
Rate for Payer: Devoted Health Medicare	$53.28
Rate for Payer: Humana of AZ Medicare	$47.36
Rate for Payer: Southwest Service Administrators UFCW	$201.28
Rate for Payer: TriWest Medicare	$47.36
Rate for Payer: United Healthcare Commercial	$169.31
Rate for Payer: United Healthcare Medicare	$47.36
Rate for Payer: United Healthcare New Mexico Commercial	$56.24
Rate for Payer: Veterans Affairs TRICARE	$46.89

Pneumococcal conjugate vaccine, 13 valent, for intramuscular

Facility

$296.00

Service Code	CPT 90670
Hospital Charge Code	1165947
Hospital Revenue Code	636
Min. Negotiated Rate	$266.40
Max. Negotiated Rate	$266.40
Rate for Payer: Aetna of AZ Commercial	$266.40
Rate for Payer: Cash Price	$236.80

Know your out-of-pocket cost for care.

All Charges