Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

00944 ANESTHESIA FOR VAGINAL PROCEDURES (INCLUDING BIOPSY OF

Facility

$591.00

Service Code	CPT 00944
Hospital Charge Code	23597459
Hospital Revenue Code	370
Min. Negotiated Rate	$531.90
Max. Negotiated Rate	$531.90
Rate for Payer: Aetna of AZ Commercial	$531.90
Rate for Payer: Cash Price	$472.80

00944 ANESTHESIA FOR VAGINAL PROCEDURES (INCLUDING BIOPSY OF

Facility

$591.00

Service Code	CPT 00944
Hospital Charge Code	23597459
Hospital Revenue Code	370
Min. Negotiated Rate	$93.61
Max. Negotiated Rate	$531.90
Rate for Payer: Aetna of AZ Commercial	$531.90
Rate for Payer: Arizona Complete Health Allwell	$94.56
Rate for Payer: Banner UC Health Medicare	$94.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$401.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$94.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$94.56
Rate for Payer: Cash Price	$472.80
Rate for Payer: Cigna of AZ Commercial	$384.15
Rate for Payer: Devoted Health Medicare	$106.38
Rate for Payer: Humana of AZ Medicare	$94.56
Rate for Payer: Southwest Service Administrators UFCW	$401.88
Rate for Payer: TriWest Medicare	$94.56
Rate for Payer: United Healthcare Commercial	$338.05
Rate for Payer: United Healthcare Medicare	$94.56
Rate for Payer: Veterans Affairs TRICARE	$93.61

00944 ANESTHESIA FOR VAGINAL PROCEDURES (INCLUDING BIOPSY OF

Facility

$591.00

Service Code	CPT 00944
Hospital Charge Code	23597458
Hospital Revenue Code	370
Min. Negotiated Rate	$531.90
Max. Negotiated Rate	$531.90
Rate for Payer: Aetna of AZ Commercial	$531.90
Rate for Payer: Cash Price	$472.80

00944 ANESTHESIA FOR VAGINAL PROCEDURES (INCLUDING BIOPSY OF

Facility

$591.00

Service Code	CPT 00944
Hospital Charge Code	23597458
Hospital Revenue Code	370
Min. Negotiated Rate	$93.61
Max. Negotiated Rate	$531.90
Rate for Payer: Aetna of AZ Commercial	$531.90
Rate for Payer: Arizona Complete Health Allwell	$94.56
Rate for Payer: Banner UC Health Medicare	$94.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$401.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$94.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$94.56
Rate for Payer: Cash Price	$472.80
Rate for Payer: Cigna of AZ Commercial	$384.15
Rate for Payer: Devoted Health Medicare	$106.38
Rate for Payer: Humana of AZ Medicare	$94.56
Rate for Payer: Southwest Service Administrators UFCW	$401.88
Rate for Payer: TriWest Medicare	$94.56
Rate for Payer: United Healthcare Commercial	$338.05
Rate for Payer: United Healthcare Medicare	$94.56
Rate for Payer: Veterans Affairs TRICARE	$93.61

00952 ANES HYSTEROSCOPY ADDITIONAL MINUTES

Facility

$9.00

Service Code	CPT 00952
Hospital Charge Code	22406177
Hospital Revenue Code	370
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Arizona Complete Health Allwell	$1.44
Rate for Payer: Banner UC Health Medicare	$1.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$6.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.44
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna of AZ Commercial	$5.85
Rate for Payer: Devoted Health Medicare	$1.62
Rate for Payer: Humana of AZ Medicare	$1.44
Rate for Payer: Southwest Service Administrators UFCW	$6.12
Rate for Payer: TriWest Medicare	$1.44
Rate for Payer: United Healthcare Commercial	$5.15
Rate for Payer: United Healthcare Medicare	$1.44
Rate for Payer: Veterans Affairs TRICARE	$1.43

00952 ANES HYSTEROSCOPY ADDITIONAL MINUTES

Facility

$9.00

Service Code	CPT 00952
Hospital Charge Code	22406177
Hospital Revenue Code	370
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Cash Price	$7.20

00952 ANES HYSTEROSCOPY ADDTNL 0:30 CHARGE

Facility

$298.00

Service Code	CPT 00952
Hospital Charge Code	22406179
Hospital Revenue Code	370
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Cash Price	$238.40

00952 ANES HYSTEROSCOPY ADDTNL 0:30 CHARGE

Facility

$298.00

Service Code	CPT 00952
Hospital Charge Code	22406179
Hospital Revenue Code	370
Min. Negotiated Rate	$47.20
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Arizona Complete Health Allwell	$47.68
Rate for Payer: Banner UC Health Medicare	$47.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$202.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$47.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$47.68
Rate for Payer: Cash Price	$238.40
Rate for Payer: Cigna of AZ Commercial	$193.70
Rate for Payer: Devoted Health Medicare	$53.64
Rate for Payer: Humana of AZ Medicare	$47.68
Rate for Payer: Southwest Service Administrators UFCW	$202.64
Rate for Payer: TriWest Medicare	$47.68
Rate for Payer: United Healthcare Commercial	$170.46
Rate for Payer: United Healthcare Medicare	$47.68
Rate for Payer: Veterans Affairs TRICARE	$47.20

00955 INTRATHECAL INJECTION

Facility

$1,384.00

Service Code	CPT 00955
Hospital Charge Code	23361647
Hospital Revenue Code	370
Min. Negotiated Rate	$219.23
Max. Negotiated Rate	$1,245.60
Rate for Payer: Aetna of AZ Commercial	$1,245.60
Rate for Payer: Arizona Complete Health Allwell	$221.44
Rate for Payer: Banner UC Health Medicare	$221.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$941.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$221.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$221.44
Rate for Payer: Cash Price	$1,107.20
Rate for Payer: Cigna of AZ Commercial	$899.60
Rate for Payer: Devoted Health Medicare	$249.12
Rate for Payer: Humana of AZ Medicare	$221.44
Rate for Payer: Southwest Service Administrators UFCW	$941.12
Rate for Payer: TriWest Medicare	$221.44
Rate for Payer: United Healthcare Commercial	$791.65
Rate for Payer: United Healthcare Medicare	$221.44
Rate for Payer: Veterans Affairs TRICARE	$219.23

00955 INTRATHECAL INJECTION

Facility

$1,384.00

Service Code	CPT 00955
Hospital Charge Code	23361647
Hospital Revenue Code	370
Min. Negotiated Rate	$1,245.60
Max. Negotiated Rate	$1,245.60
Rate for Payer: Aetna of AZ Commercial	$1,245.60
Rate for Payer: Cash Price	$1,107.20

0111A Moderna Pediatric Admin 6mth-5yrs 1st Dose Admin Charg

Facility

$55.00

Service Code	CPT 0111A
Hospital Charge Code	27407523
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

0111A Moderna Pediatric Admin 6mth-5yrs 1st Dose Admin Charg

Facility

$55.00

Service Code	CPT 0111A
Hospital Charge Code	27407523
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

0112A Moderna Pediatric Admin 6mth-5yrs 2nd Dose Admin Charg

Facility

$55.00

Service Code	CPT 0112A
Hospital Charge Code	27410758
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

0112A Moderna Pediatric Admin 6mth-5yrs 2nd Dose Admin Charg

Facility

$55.00

Service Code	CPT 0112A
Hospital Charge Code	27410758
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

0124APfizer Bivalent vaccine 12yrs and older administration

Facility

$55.00

Service Code	CPT 0124A
Hospital Charge Code	27407082
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

0124APfizer Bivalent vaccine 12yrs and older administration

Facility

$55.00

Service Code	CPT 0124A
Hospital Charge Code	27407082
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

0134A Moderna Bivalent vaccine for Adults Administration

Facility

$55.00

Service Code	CPT 0134A
Hospital Charge Code	27408331
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

0134A Moderna Bivalent vaccine for Adults Administration

Facility

$55.00

Service Code	CPT 0134A
Hospital Charge Code	27408331
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

01360 ANES OPEN PROC LOWER 1/3 FEMUR ADDITIONAL MINUTES

Facility

$9.00

Service Code	CPT 01360
Hospital Charge Code	22406182
Hospital Revenue Code	370
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Arizona Complete Health Allwell	$1.44
Rate for Payer: Banner UC Health Medicare	$1.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$6.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.44
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna of AZ Commercial	$5.85
Rate for Payer: Devoted Health Medicare	$1.62
Rate for Payer: Humana of AZ Medicare	$1.44
Rate for Payer: Southwest Service Administrators UFCW	$6.12
Rate for Payer: TriWest Medicare	$1.44
Rate for Payer: United Healthcare Commercial	$5.15
Rate for Payer: United Healthcare Medicare	$1.44
Rate for Payer: Veterans Affairs TRICARE	$1.43

01360 ANES OPEN PROC LOWER 1/3 FEMUR ADDITIONAL MINUTES

Facility

$9.00

Service Code	CPT 01360
Hospital Charge Code	22406182
Hospital Revenue Code	370
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$8.10
Rate for Payer: Aetna of AZ Commercial	$8.10
Rate for Payer: Cash Price	$7.20

01360 ANES OPEN PROC LOWER 1/3 FEMUR ADDNL 30 CHARGE

Facility

$298.00

Service Code	CPT 01360
Hospital Charge Code	22406183
Hospital Revenue Code	370
Min. Negotiated Rate	$47.20
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Arizona Complete Health Allwell	$47.68
Rate for Payer: Banner UC Health Medicare	$47.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$202.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$47.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$47.68
Rate for Payer: Cash Price	$238.40
Rate for Payer: Cigna of AZ Commercial	$193.70
Rate for Payer: Devoted Health Medicare	$53.64
Rate for Payer: Humana of AZ Medicare	$47.68
Rate for Payer: Southwest Service Administrators UFCW	$202.64
Rate for Payer: TriWest Medicare	$47.68
Rate for Payer: United Healthcare Commercial	$170.46
Rate for Payer: United Healthcare Medicare	$47.68
Rate for Payer: Veterans Affairs TRICARE	$47.20

01360 ANES OPEN PROC LOWER 1/3 FEMUR ADDNL 30 CHARGE

Facility

$298.00

Service Code	CPT 01360
Hospital Charge Code	22406183
Hospital Revenue Code	370
Min. Negotiated Rate	$268.20
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of AZ Commercial	$268.20
Rate for Payer: Cash Price	$238.40

01360 ANES OPEN PROC LOWER 1/3 FEMUR BASE CHARGE AND 1ST MIN

Facility

$894.00

Service Code	CPT 01360
Hospital Charge Code	22406180
Hospital Revenue Code	964
Min. Negotiated Rate	$804.60
Max. Negotiated Rate	$804.60
Rate for Payer: Aetna of AZ Commercial	$804.60
Rate for Payer: Cash Price	$715.20

01360 ANES OPEN PROC LOWER 1/3 FEMUR BASE CHARGE AND 1ST MIN

Facility

$894.00

Service Code	CPT 01360
Hospital Charge Code	22406180
Hospital Revenue Code	964
Min. Negotiated Rate	$141.61
Max. Negotiated Rate	$804.60
Rate for Payer: Aetna of AZ Commercial	$804.60
Rate for Payer: Arizona Complete Health Allwell	$143.04
Rate for Payer: Banner UC Health Medicare	$143.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$607.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$143.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$143.04
Rate for Payer: Cash Price	$715.20
Rate for Payer: Cigna of AZ Commercial	$625.80
Rate for Payer: Devoted Health Medicare	$160.92
Rate for Payer: Humana of AZ Medicare	$143.04
Rate for Payer: Southwest Service Administrators UFCW	$607.92
Rate for Payer: TriWest Medicare	$143.04
Rate for Payer: United Healthcare Commercial	$511.37
Rate for Payer: United Healthcare Medicare	$143.04
Rate for Payer: United Healthcare New Mexico Commercial	$169.86
Rate for Payer: Veterans Affairs TRICARE	$141.61

01382 ANES FOR DIAGNOSTIC ARTHROSCOPIC PROCEDURES OF KNEE JO

Facility

$591.00

Service Code	CPT 01382
Hospital Charge Code	22889347
Hospital Revenue Code	370
Min. Negotiated Rate	$531.90
Max. Negotiated Rate	$531.90
Rate for Payer: Aetna of AZ Commercial	$531.90
Rate for Payer: Cash Price	$472.80

Know your out-of-pocket cost for care.

All Charges