Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

VFC - Each additional vaccine

Facility

$39.00

Service Code	CPT 90472 SL
Hospital Charge Code	3067556
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

VICRYL PLUS 3 0 FS 1

Facility

$90.00

Hospital Charge Code	23770609
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna of AZ Commercial	$81.00
Rate for Payer: Cash Price	$72.00

VICRYL PLUS 3 0 FS 1

Facility

$90.00

Hospital Charge Code	23770609
Min. Negotiated Rate	$14.26
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna of AZ Commercial	$81.00
Rate for Payer: Arizona Complete Health Allwell	$14.40
Rate for Payer: Banner UC Health Medicare	$14.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$61.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$14.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.40
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna of AZ Commercial	$63.00
Rate for Payer: Devoted Health Medicare	$16.20
Rate for Payer: Humana of AZ Medicare	$14.40
Rate for Payer: Southwest Service Administrators UFCW	$61.20
Rate for Payer: TriWest Medicare	$14.40
Rate for Payer: United Healthcare Commercial	$51.48
Rate for Payer: United Healthcare Medicare	$14.40
Rate for Payer: Veterans Affairs TRICARE	$14.26

Viral Culture, General LC

Facility

$447.00

Service Code	CPT 87252
Hospital Charge Code	2029221
Hospital Revenue Code	306
Min. Negotiated Rate	$402.30
Max. Negotiated Rate	$402.30
Rate for Payer: Aetna of AZ Commercial	$402.30
Rate for Payer: Cash Price	$357.60

Viral Culture, General LC

Facility

$447.00

Service Code	CPT 87252
Hospital Charge Code	2029221
Hospital Revenue Code	306
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$402.30
Rate for Payer: Aetna of AZ Commercial	$402.30
Rate for Payer: Arizona Complete Health Allwell	$71.52
Rate for Payer: Banner UC Health Medicare	$71.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$303.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$71.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$71.52
Rate for Payer: Cash Price	$357.60
Rate for Payer: Cash Price	$357.60
Rate for Payer: Cigna of AZ Commercial	$290.55
Rate for Payer: Devoted Health Medicare	$80.46
Rate for Payer: Humana of AZ Medicare	$71.52
Rate for Payer: Seven Corners Travel Insurance	$37.80
Rate for Payer: Southwest Service Administrators UFCW	$303.96
Rate for Payer: TriWest Medicare	$71.52
Rate for Payer: United Healthcare Commercial	$255.68
Rate for Payer: United Healthcare Medicare	$71.52
Rate for Payer: Veterans Affairs TRICARE	$70.80

Viral Illness

Facility

$2,594.48

Service Code	APR-DRG 7231
Hospital Charge Code	APRDRG7233
Min. Negotiated Rate	$2,594.48
Max. Negotiated Rate	$2,594.48
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,594.48
Rate for Payer: Mercy Care Medicaid	$2,594.48
Rate for Payer: NaphCare Correctional Healthcare	$2,594.48

Viral Illness

Facility

$5,933.14

Service Code	APR-DRG 7233
Hospital Charge Code	APRDRG7233
Min. Negotiated Rate	$5,933.14
Max. Negotiated Rate	$5,933.14
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,933.14
Rate for Payer: Mercy Care Medicaid	$5,933.14
Rate for Payer: NaphCare Correctional Healthcare	$5,933.14

Viral Illness

Facility

$13,657.66

Service Code	APR-DRG 7234
Hospital Charge Code	APRDRG7234
Min. Negotiated Rate	$13,657.66
Max. Negotiated Rate	$13,657.66
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13,657.66
Rate for Payer: Mercy Care Medicaid	$13,657.66
Rate for Payer: NaphCare Correctional Healthcare	$13,657.66

Viral Illness

Facility

$13,657.66

Service Code	APR-DRG 7234
Hospital Charge Code	APRDRG7233
Min. Negotiated Rate	$13,657.66
Max. Negotiated Rate	$13,657.66
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13,657.66
Rate for Payer: Mercy Care Medicaid	$13,657.66
Rate for Payer: NaphCare Correctional Healthcare	$13,657.66

Viral Illness

Facility

$2,594.48

Service Code	APR-DRG 7231
Hospital Charge Code	APRDRG7232
Min. Negotiated Rate	$2,594.48
Max. Negotiated Rate	$2,594.48
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,594.48
Rate for Payer: Mercy Care Medicaid	$2,594.48
Rate for Payer: NaphCare Correctional Healthcare	$2,594.48

Viral Illness

Facility

$3,679.54

Service Code	APR-DRG 7232
Hospital Charge Code	APRDRG7234
Min. Negotiated Rate	$3,679.54
Max. Negotiated Rate	$3,679.54
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$3,679.54
Rate for Payer: Mercy Care Medicaid	$3,679.54
Rate for Payer: NaphCare Correctional Healthcare	$3,679.54

Viral Illness

Facility

$5,933.14

Service Code	APR-DRG 7233
Hospital Charge Code	APRDRG7231
Min. Negotiated Rate	$5,933.14
Max. Negotiated Rate	$5,933.14
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,933.14
Rate for Payer: Mercy Care Medicaid	$5,933.14
Rate for Payer: NaphCare Correctional Healthcare	$5,933.14

Viral Illness

Facility

$13,657.66

Service Code	APR-DRG 7234
Hospital Charge Code	APRDRG7232
Min. Negotiated Rate	$13,657.66
Max. Negotiated Rate	$13,657.66
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13,657.66
Rate for Payer: Mercy Care Medicaid	$13,657.66
Rate for Payer: NaphCare Correctional Healthcare	$13,657.66

Viral Illness

Facility

$3,679.54

Service Code	APR-DRG 7232
Hospital Charge Code	APRDRG7231
Min. Negotiated Rate	$3,679.54
Max. Negotiated Rate	$3,679.54
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$3,679.54
Rate for Payer: Mercy Care Medicaid	$3,679.54
Rate for Payer: NaphCare Correctional Healthcare	$3,679.54

Viral Illness

Facility

$5,933.14

Service Code	APR-DRG 7233
Hospital Charge Code	APRDRG7232
Min. Negotiated Rate	$5,933.14
Max. Negotiated Rate	$5,933.14
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,933.14
Rate for Payer: Mercy Care Medicaid	$5,933.14
Rate for Payer: NaphCare Correctional Healthcare	$5,933.14

Viral Illness

Facility

$13,657.66

Service Code	APR-DRG 7234
Hospital Charge Code	APRDRG7231
Min. Negotiated Rate	$13,657.66
Max. Negotiated Rate	$13,657.66
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$13,657.66
Rate for Payer: Mercy Care Medicaid	$13,657.66
Rate for Payer: NaphCare Correctional Healthcare	$13,657.66

Viral Illness

Facility

$5,933.14

Service Code	APR-DRG 7233
Hospital Charge Code	APRDRG7234
Min. Negotiated Rate	$5,933.14
Max. Negotiated Rate	$5,933.14
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,933.14
Rate for Payer: Mercy Care Medicaid	$5,933.14
Rate for Payer: NaphCare Correctional Healthcare	$5,933.14

Viral Illness

Facility

$2,594.48

Service Code	APR-DRG 7231
Hospital Charge Code	APRDRG7231
Min. Negotiated Rate	$2,594.48
Max. Negotiated Rate	$2,594.48
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,594.48
Rate for Payer: Mercy Care Medicaid	$2,594.48
Rate for Payer: NaphCare Correctional Healthcare	$2,594.48

Viral Illness

Facility

$2,594.48

Service Code	APR-DRG 7231
Hospital Charge Code	APRDRG7234
Min. Negotiated Rate	$2,594.48
Max. Negotiated Rate	$2,594.48
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2,594.48
Rate for Payer: Mercy Care Medicaid	$2,594.48
Rate for Payer: NaphCare Correctional Healthcare	$2,594.48

Viral Illness

Facility

$3,679.54

Service Code	APR-DRG 7232
Hospital Charge Code	APRDRG7232
Min. Negotiated Rate	$3,679.54
Max. Negotiated Rate	$3,679.54
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$3,679.54
Rate for Payer: Mercy Care Medicaid	$3,679.54
Rate for Payer: NaphCare Correctional Healthcare	$3,679.54

Viral Illness

Facility

$3,679.54

Service Code	APR-DRG 7232
Hospital Charge Code	APRDRG7233
Min. Negotiated Rate	$3,679.54
Max. Negotiated Rate	$3,679.54
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$3,679.54
Rate for Payer: Mercy Care Medicaid	$3,679.54
Rate for Payer: NaphCare Correctional Healthcare	$3,679.54

VIRAL ILLNESS WITH MCC

Facility

$19,364.23

Service Code	MSDRG 865
Min. Negotiated Rate	$19,364.23
Max. Negotiated Rate	$19,364.23
Rate for Payer: Seven Corners Travel Insurance	$19,364.23

VIRAL ILLNESS WITHOUT MCC

Facility

$11,374.29

Service Code	MSDRG 866
Min. Negotiated Rate	$11,374.29
Max. Negotiated Rate	$11,374.29
Rate for Payer: Seven Corners Travel Insurance	$11,374.29

Viral Meningitis

Facility

$15,529.00

Service Code	APR-DRG 0514
Hospital Charge Code	APRDRG0512
Min. Negotiated Rate	$15,529.00
Max. Negotiated Rate	$15,529.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$15,529.00
Rate for Payer: Mercy Care Medicaid	$15,529.00
Rate for Payer: NaphCare Correctional Healthcare	$15,529.00

Viral Meningitis

Facility

$15,529.00

Service Code	APR-DRG 0514
Hospital Charge Code	APRDRG0513
Min. Negotiated Rate	$15,529.00
Max. Negotiated Rate	$15,529.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$15,529.00
Rate for Payer: Mercy Care Medicaid	$15,529.00
Rate for Payer: NaphCare Correctional Healthcare	$15,529.00

Know your out-of-pocket cost for care.

All Charges