Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

VFC - 90633 Hepatitis A vaccine, pedi/adolescent

Facility

$141.00

Service Code	CPT 90633 SL
Hospital Charge Code	22409580
Hospital Revenue Code	521
Min. Negotiated Rate	$126.90
Max. Negotiated Rate	$126.90
Rate for Payer: Aetna of AZ Commercial	$126.90
Rate for Payer: Cash Price	$112.80

VFC - 90633 Hepatitis A vaccine, pedi/adolescent

Facility

$141.00

Service Code	CPT 90633 SL
Hospital Charge Code	22409580
Hospital Revenue Code	521
Min. Negotiated Rate	$22.33
Max. Negotiated Rate	$126.90
Rate for Payer: Aetna of AZ Commercial	$126.90
Rate for Payer: Arizona Complete Health Allwell	$22.56
Rate for Payer: Banner UC Health Medicare	$22.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$95.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$22.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$22.56
Rate for Payer: Cash Price	$112.80
Rate for Payer: Cigna of AZ Commercial	$98.70
Rate for Payer: Devoted Health Medicare	$25.38
Rate for Payer: Humana of AZ Medicare	$22.56
Rate for Payer: Southwest Service Administrators UFCW	$95.88
Rate for Payer: TriWest Medicare	$22.56
Rate for Payer: United Healthcare Commercial	$80.65
Rate for Payer: United Healthcare Medicare	$22.56
Rate for Payer: Veterans Affairs TRICARE	$22.33

VFC - 90647 Hib-PRP-OMP Vaccine

Facility

$91.00

Service Code	CPT 90647 SL
Hospital Charge Code	22409603
Hospital Revenue Code	521
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$81.90
Rate for Payer: Aetna of AZ Commercial	$81.90
Rate for Payer: Cash Price	$72.80

VFC - 90647 Hib-PRP-OMP Vaccine

Facility

$91.00

Service Code	CPT 90647 SL
Hospital Charge Code	22409603
Hospital Revenue Code	521
Min. Negotiated Rate	$14.41
Max. Negotiated Rate	$81.90
Rate for Payer: Aetna of AZ Commercial	$81.90
Rate for Payer: Arizona Complete Health Allwell	$14.56
Rate for Payer: Banner UC Health Medicare	$14.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$61.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.56
Rate for Payer: Cash Price	$72.80
Rate for Payer: Cigna of AZ Commercial	$63.70
Rate for Payer: Devoted Health Medicare	$16.38
Rate for Payer: Humana of AZ Medicare	$14.56
Rate for Payer: Southwest Service Administrators UFCW	$61.88
Rate for Payer: TriWest Medicare	$14.56
Rate for Payer: United Healthcare Commercial	$52.05
Rate for Payer: United Healthcare Medicare	$14.56
Rate for Payer: Veterans Affairs TRICARE	$14.41

VFC - 90651 HPV9 Vaccine

Facility

$385.00

Service Code	CPT 90651 SL
Hospital Charge Code	22409616
Hospital Revenue Code	521
Min. Negotiated Rate	$60.98
Max. Negotiated Rate	$346.50
Rate for Payer: Aetna of AZ Commercial	$346.50
Rate for Payer: Arizona Complete Health Allwell	$61.60
Rate for Payer: Banner UC Health Medicare	$61.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$261.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$61.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$61.60
Rate for Payer: Cash Price	$308.00
Rate for Payer: Cigna of AZ Commercial	$269.50
Rate for Payer: Devoted Health Medicare	$69.30
Rate for Payer: Humana of AZ Medicare	$61.60
Rate for Payer: Southwest Service Administrators UFCW	$261.80
Rate for Payer: TriWest Medicare	$61.60
Rate for Payer: United Healthcare Commercial	$220.22
Rate for Payer: United Healthcare Medicare	$61.60
Rate for Payer: Veterans Affairs TRICARE	$60.98

VFC - 90651 HPV9 Vaccine

Facility

$385.00

Service Code	CPT 90651 SL
Hospital Charge Code	22409616
Hospital Revenue Code	521
Min. Negotiated Rate	$346.50
Max. Negotiated Rate	$346.50
Rate for Payer: Aetna of AZ Commercial	$346.50
Rate for Payer: Cash Price	$308.00

VFC - 90657 Influenza 6-35 Months Vaccine

Facility

$34.00

Service Code	CPT 90657 SL
Hospital Charge Code	22409629
Hospital Revenue Code	521
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

VFC - 90657 Influenza 6-35 Months Vaccine

Facility

$34.00

Service Code	CPT 90657 SL
Hospital Charge Code	22409629
Hospital Revenue Code	521
Min. Negotiated Rate	$5.39
Max. Negotiated Rate	$30.60
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: 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: 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

VFC 90658 Influenza 3+ years Virus Vaccine

Facility

$54.00

Service Code	CPT 90658 SL
Hospital Charge Code	22372395
Hospital Revenue Code	521
Min. Negotiated Rate	$48.60
Max. Negotiated Rate	$48.60
Rate for Payer: Aetna of AZ Commercial	$48.60
Rate for Payer: Cash Price	$43.20

VFC 90658 Influenza 3+ years Virus Vaccine

Facility

$54.00

Service Code	CPT 90658 SL
Hospital Charge Code	22372395
Hospital Revenue Code	521
Min. Negotiated Rate	$8.55
Max. Negotiated Rate	$48.60
Rate for Payer: Aetna of AZ Commercial	$48.60
Rate for Payer: Arizona Complete Health Allwell	$8.64
Rate for Payer: Banner UC Health Medicare	$8.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$36.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.64
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna of AZ Commercial	$37.80
Rate for Payer: Devoted Health Medicare	$9.72
Rate for Payer: Humana of AZ Medicare	$8.64
Rate for Payer: Southwest Service Administrators UFCW	$36.72
Rate for Payer: TriWest Medicare	$8.64
Rate for Payer: United Healthcare Commercial	$30.89
Rate for Payer: United Healthcare Medicare	$8.64
Rate for Payer: Veterans Affairs TRICARE	$8.55

VFC 90681 Rotavirus vaccine, human, attenuated, 2 dose sched

Facility

$309.00

Service Code	CPT 90680
Hospital Charge Code	22499733
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

VFC 90681 Rotavirus vaccine, human, attenuated, 2 dose sched

Facility

$309.00

Service Code	CPT 90680
Hospital Charge Code	22499733
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

VFC 90696 Kinrix Vaccine

Facility

$203.00

Service Code	CPT 90696 SL
Hospital Charge Code	22372400
Hospital Revenue Code	636
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$182.70
Rate for Payer: Aetna of AZ Commercial	$182.70
Rate for Payer: Cash Price	$162.40

VFC 90696 Kinrix Vaccine

Facility

$203.00

Service Code	CPT 90696 SL
Hospital Charge Code	22372400
Hospital Revenue Code	636
Min. Negotiated Rate	$32.16
Max. Negotiated Rate	$182.70
Rate for Payer: Aetna of AZ Commercial	$182.70
Rate for Payer: Arizona Complete Health Allwell	$32.48
Rate for Payer: Banner UC Health Medicare	$32.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$138.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.48
Rate for Payer: Cash Price	$162.40
Rate for Payer: Cigna of AZ Commercial	$142.10
Rate for Payer: Devoted Health Medicare	$36.54
Rate for Payer: Humana of AZ Medicare	$32.48
Rate for Payer: Southwest Service Administrators UFCW	$138.04
Rate for Payer: TriWest Medicare	$32.48
Rate for Payer: United Healthcare Commercial	$116.12
Rate for Payer: United Healthcare Medicare	$32.48
Rate for Payer: United Healthcare New Mexico Commercial	$38.57
Rate for Payer: Veterans Affairs TRICARE	$32.16

VFC - 90710 MMRV Vaccine

Facility

$588.00

Service Code	CPT 90710
Hospital Charge Code	22531103
Hospital Revenue Code	521
Min. Negotiated Rate	$93.14
Max. Negotiated Rate	$529.20
Rate for Payer: Aetna of AZ Commercial	$529.20
Rate for Payer: Arizona Complete Health Allwell	$94.08
Rate for Payer: Banner UC Health Medicare	$94.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$399.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$94.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$94.08
Rate for Payer: Cash Price	$470.40
Rate for Payer: Cigna of AZ Commercial	$411.60
Rate for Payer: Devoted Health Medicare	$105.84
Rate for Payer: Humana of AZ Medicare	$94.08
Rate for Payer: Southwest Service Administrators UFCW	$399.84
Rate for Payer: TriWest Medicare	$94.08
Rate for Payer: United Healthcare Commercial	$336.34
Rate for Payer: United Healthcare Medicare	$94.08
Rate for Payer: Veterans Affairs TRICARE	$93.14

VFC - 90710 MMRV Vaccine

Facility

$588.00

Service Code	CPT 90710
Hospital Charge Code	22531103
Hospital Revenue Code	521
Min. Negotiated Rate	$529.20
Max. Negotiated Rate	$529.20
Rate for Payer: Aetna of AZ Commercial	$529.20
Rate for Payer: Cash Price	$470.40

VFC - 90713 IPV Poliovirus Vaccine

Facility

$108.00

Service Code	CPT 90713 SL
Hospital Charge Code	22409636
Hospital Revenue Code	521
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: Veterans Affairs TRICARE	$17.11

VFC - 90713 IPV Poliovirus Vaccine

Facility

$108.00

Service Code	CPT 90713 SL
Hospital Charge Code	22409636
Hospital Revenue Code	521
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

VFC 90716 Varicella Virus Vaccine (Varivax)

Facility

$362.00

Service Code	CPT 90716 SL
Hospital Charge Code	22372407
Hospital Revenue Code	521
Min. Negotiated Rate	$57.34
Max. Negotiated Rate	$325.80
Rate for Payer: Aetna of AZ Commercial	$325.80
Rate for Payer: Arizona Complete Health Allwell	$57.92
Rate for Payer: Banner UC Health Medicare	$57.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$246.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$57.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$57.92
Rate for Payer: Cash Price	$289.60
Rate for Payer: Cigna of AZ Commercial	$253.40
Rate for Payer: Devoted Health Medicare	$65.16
Rate for Payer: Humana of AZ Medicare	$57.92
Rate for Payer: Southwest Service Administrators UFCW	$246.16
Rate for Payer: TriWest Medicare	$57.92
Rate for Payer: United Healthcare Commercial	$207.06
Rate for Payer: United Healthcare Medicare	$57.92
Rate for Payer: Veterans Affairs TRICARE	$57.34

VFC 90716 Varicella Virus Vaccine (Varivax)

Facility

$362.00

Service Code	CPT 90716 SL
Hospital Charge Code	22372407
Hospital Revenue Code	521
Min. Negotiated Rate	$325.80
Max. Negotiated Rate	$325.80
Rate for Payer: Aetna of AZ Commercial	$325.80
Rate for Payer: Cash Price	$289.60

VFC - 90732 Pneumococcal PPSV Vaccine

Facility

$85.00

Service Code	CPT 90732 SL
Hospital Charge Code	22409656
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

VFC - 90732 Pneumococcal PPSV Vaccine

Facility

$85.00

Service Code	CPT 90732 SL
Hospital Charge Code	22409656
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

VFC 90744 Heb B Pediatric Vaccine

Facility

$108.00

Service Code	CPT 90744 SL
Hospital Charge Code	22372454
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

VFC 90744 Heb B Pediatric Vaccine

Facility

$108.00

Service Code	CPT 90744 SL
Hospital Charge Code	22372454
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

VFC - Each additional vaccine

Facility

$39.00

Service Code	CPT 90472 SL
Hospital Charge Code	3067556
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

Know your out-of-pocket cost for care.

All Charges