Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

90715 VFC Tdap Vaccine 7+years

Facility

$142.00

Service Code	CPT 90715 SL
Hospital Charge Code	22311078
Hospital Revenue Code	636
Min. Negotiated Rate	$22.49
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of AZ Commercial	$127.80
Rate for Payer: Arizona Complete Health Allwell	$22.72
Rate for Payer: Banner UC Health Medicare	$22.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$96.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$22.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$22.72
Rate for Payer: Cash Price	$113.60
Rate for Payer: Cigna of AZ Commercial	$99.40
Rate for Payer: Devoted Health Medicare	$25.56
Rate for Payer: Humana of AZ Medicare	$22.72
Rate for Payer: Southwest Service Administrators UFCW	$96.56
Rate for Payer: TriWest Medicare	$22.72
Rate for Payer: United Healthcare Commercial	$81.22
Rate for Payer: United Healthcare Medicare	$22.72
Rate for Payer: United Healthcare New Mexico Commercial	$26.98
Rate for Payer: Veterans Affairs TRICARE	$22.49

90723 Diphtheria, tetanus toxoids, acellular pertussis vac, hep B, inactivated p

Facility

$226.00

Service Code	CPT 90723
Hospital Charge Code	22051644
Hospital Revenue Code	521
Min. Negotiated Rate	$35.80
Max. Negotiated Rate	$203.40
Rate for Payer: Aetna of AZ Commercial	$203.40
Rate for Payer: Arizona Complete Health Allwell	$36.16
Rate for Payer: Banner UC Health Medicare	$36.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$153.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.16
Rate for Payer: Cash Price	$180.80
Rate for Payer: Cigna of AZ Commercial	$158.20
Rate for Payer: Devoted Health Medicare	$40.68
Rate for Payer: Humana of AZ Medicare	$36.16
Rate for Payer: Southwest Service Administrators UFCW	$153.68
Rate for Payer: TriWest Medicare	$36.16
Rate for Payer: United Healthcare Commercial	$129.27
Rate for Payer: United Healthcare Medicare	$36.16
Rate for Payer: Veterans Affairs TRICARE	$35.80

90723 Diphtheria, tetanus toxoids, acellular pertussis vac, hep B, inactivated p

Facility

$226.00

Service Code	CPT 90723
Hospital Charge Code	22051644
Hospital Revenue Code	521
Min. Negotiated Rate	$203.40
Max. Negotiated Rate	$203.40
Rate for Payer: Aetna of AZ Commercial	$203.40
Rate for Payer: Cash Price	$180.80

90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for in

Facility

$108.00

Service Code	CPT 90744
Hospital Charge Code	22051651
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

90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for in

Facility

$108.00

Service Code	CPT 90744
Hospital Charge Code	22051651
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

90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use

Facility

$285.00

Service Code	CPT 90746
Hospital Charge Code	22051652
Hospital Revenue Code	636
Min. Negotiated Rate	$256.50
Max. Negotiated Rate	$256.50
Rate for Payer: Aetna of AZ Commercial	$256.50
Rate for Payer: Cash Price	$228.00

90746 Hepatitis B vaccine, adult dosage (3 dose schedule), for intramuscular use

Facility

$285.00

Service Code	CPT 90746
Hospital Charge Code	22051652
Hospital Revenue Code	636
Min. Negotiated Rate	$45.14
Max. Negotiated Rate	$256.50
Rate for Payer: Aetna of AZ Commercial	$256.50
Rate for Payer: Arizona Complete Health Allwell	$45.60
Rate for Payer: Banner UC Health Medicare	$45.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$193.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$45.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$45.60
Rate for Payer: Cash Price	$228.00
Rate for Payer: Cigna of AZ Commercial	$199.50
Rate for Payer: Devoted Health Medicare	$51.30
Rate for Payer: Humana of AZ Medicare	$45.60
Rate for Payer: Southwest Service Administrators UFCW	$193.80
Rate for Payer: TriWest Medicare	$45.60
Rate for Payer: United Healthcare Commercial	$163.02
Rate for Payer: United Healthcare Medicare	$45.60
Rate for Payer: United Healthcare New Mexico Commercial	$54.15
Rate for Payer: Veterans Affairs TRICARE	$45.14

90783 INTRA ARTERIAL

Facility

$98.00

Service Code	CPT 90783
Hospital Charge Code	22282929
Hospital Revenue Code	450
Min. Negotiated Rate	$15.52
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of AZ Commercial	$88.20
Rate for Payer: Arizona Complete Health Allwell	$15.68
Rate for Payer: Banner UC Health Medicare	$15.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$66.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$15.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.68
Rate for Payer: Cash Price	$78.40
Rate for Payer: Cigna of AZ Commercial	$68.60
Rate for Payer: Devoted Health Medicare	$17.64
Rate for Payer: Humana of AZ Medicare	$15.68
Rate for Payer: Southwest Service Administrators UFCW	$66.64
Rate for Payer: TriWest Medicare	$15.68
Rate for Payer: United Healthcare Commercial	$56.06
Rate for Payer: United Healthcare Medicare	$15.68
Rate for Payer: United Healthcare New Mexico Commercial	$18.62
Rate for Payer: Veterans Affairs TRICARE	$15.52

90783 INTRA ARTERIAL

Facility

$98.00

Service Code	CPT 90783
Hospital Charge Code	22282929
Hospital Revenue Code	450
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of AZ Commercial	$88.20
Rate for Payer: Cash Price	$78.40

90791 Intake Psychiatric diagnostic interview examination

Facility

$804.00

Service Code	CPT 90791
Hospital Charge Code	23919255
Hospital Revenue Code	521
Min. Negotiated Rate	$25.56
Max. Negotiated Rate	$723.60
Rate for Payer: Aetna of AZ Commercial	$723.60
Rate for Payer: Arizona Complete Health Allwell	$128.64
Rate for Payer: Banner UC Health Medicare	$128.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$546.72
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$25.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$128.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$128.64
Rate for Payer: Cash Price	$643.20
Rate for Payer: Cash Price	$643.20
Rate for Payer: Cigna of AZ Commercial	$562.80
Rate for Payer: Devoted Health Medicare	$144.72
Rate for Payer: Humana of AZ Medicare	$128.64
Rate for Payer: Mercy Care Medicaid	$25.56
Rate for Payer: NaphCare Correctional Healthcare	$25.56
Rate for Payer: Seven Corners Travel Insurance	$274.63
Rate for Payer: Southwest Service Administrators UFCW	$546.72
Rate for Payer: TriWest Medicare	$128.64
Rate for Payer: United Healthcare Commercial	$459.89
Rate for Payer: United Healthcare Medicare	$128.64
Rate for Payer: Veterans Affairs TRICARE	$127.35

90791 Intake Psychiatric diagnostic interview examination

Facility

$804.00

Service Code	CPT 90791
Hospital Charge Code	23919255
Hospital Revenue Code	521
Min. Negotiated Rate	$723.60
Max. Negotiated Rate	$723.60
Rate for Payer: Aetna of AZ Commercial	$723.60
Rate for Payer: Cash Price	$643.20

90792 Intake Psychiatric diagnostic interview examination

Facility

$949.00

Service Code	CPT 90792
Hospital Charge Code	23919267
Hospital Revenue Code	521
Min. Negotiated Rate	$25.92
Max. Negotiated Rate	$854.10
Rate for Payer: Aetna of AZ Commercial	$854.10
Rate for Payer: Arizona Complete Health Allwell	$151.84
Rate for Payer: Banner UC Health Medicare	$151.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$645.32
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$25.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$151.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$151.84
Rate for Payer: Cash Price	$759.20
Rate for Payer: Cash Price	$759.20
Rate for Payer: Cigna of AZ Commercial	$664.30
Rate for Payer: Devoted Health Medicare	$170.82
Rate for Payer: Humana of AZ Medicare	$151.84
Rate for Payer: Mercy Care Medicaid	$25.92
Rate for Payer: NaphCare Correctional Healthcare	$25.92
Rate for Payer: Seven Corners Travel Insurance	$274.63
Rate for Payer: Southwest Service Administrators UFCW	$645.32
Rate for Payer: TriWest Medicare	$151.84
Rate for Payer: United Healthcare Commercial	$542.83
Rate for Payer: United Healthcare Medicare	$151.84
Rate for Payer: Veterans Affairs TRICARE	$150.32

90792 Intake Psychiatric diagnostic interview examination

Facility

$949.00

Service Code	CPT 90792
Hospital Charge Code	23919267
Hospital Revenue Code	521
Min. Negotiated Rate	$854.10
Max. Negotiated Rate	$854.10
Rate for Payer: Aetna of AZ Commercial	$854.10
Rate for Payer: Cash Price	$759.20

90832 Psychotherapy 30 Mins

Facility

$419.00

Service Code	CPT 90832
Hospital Charge Code	23919268
Hospital Revenue Code	521
Min. Negotiated Rate	$10.65
Max. Negotiated Rate	$377.10
Rate for Payer: Aetna of AZ Commercial	$377.10
Rate for Payer: Arizona Complete Health Allwell	$67.04
Rate for Payer: Banner UC Health Medicare	$67.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$284.92
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$10.65
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$67.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$67.04
Rate for Payer: Cash Price	$335.20
Rate for Payer: Cash Price	$335.20
Rate for Payer: Cigna of AZ Commercial	$293.30
Rate for Payer: Devoted Health Medicare	$75.42
Rate for Payer: Humana of AZ Medicare	$67.04
Rate for Payer: Mercy Care Medicaid	$10.65
Rate for Payer: NaphCare Correctional Healthcare	$10.65
Rate for Payer: Seven Corners Travel Insurance	$274.63
Rate for Payer: Southwest Service Administrators UFCW	$284.92
Rate for Payer: TriWest Medicare	$67.04
Rate for Payer: United Healthcare Commercial	$239.67
Rate for Payer: United Healthcare Medicare	$67.04
Rate for Payer: Veterans Affairs TRICARE	$66.37

90832 Psychotherapy 30 Mins

Facility

$419.00

Service Code	CPT 90832
Hospital Charge Code	23919268
Hospital Revenue Code	521
Min. Negotiated Rate	$377.10
Max. Negotiated Rate	$377.10
Rate for Payer: Aetna of AZ Commercial	$377.10
Rate for Payer: Cash Price	$335.20

90833 Psychotherapy 30 Minutes CQCH

Facility

$446.00

Service Code	CPT 90833
Hospital Charge Code	24090001
Hospital Revenue Code	521
Min. Negotiated Rate	$9.23
Max. Negotiated Rate	$401.40
Rate for Payer: Aetna of AZ Commercial	$401.40
Rate for Payer: Arizona Complete Health Allwell	$71.36
Rate for Payer: Banner UC Health Medicare	$71.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$303.28
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$9.23
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$71.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$71.36
Rate for Payer: Cash Price	$356.80
Rate for Payer: Cash Price	$356.80
Rate for Payer: Cigna of AZ Commercial	$312.20
Rate for Payer: Devoted Health Medicare	$80.28
Rate for Payer: Humana of AZ Medicare	$71.36
Rate for Payer: Mercy Care Medicaid	$9.23
Rate for Payer: NaphCare Correctional Healthcare	$9.23
Rate for Payer: Southwest Service Administrators UFCW	$303.28
Rate for Payer: TriWest Medicare	$71.36
Rate for Payer: United Healthcare Commercial	$255.11
Rate for Payer: United Healthcare Medicare	$71.36
Rate for Payer: Veterans Affairs TRICARE	$70.65

90833 Psychotherapy 30 Minutes CQCH

Facility

$446.00

Service Code	CPT 90833
Hospital Charge Code	24090001
Hospital Revenue Code	521
Min. Negotiated Rate	$401.40
Max. Negotiated Rate	$401.40
Rate for Payer: Aetna of AZ Commercial	$401.40
Rate for Payer: Cash Price	$356.80

90834 Psychotherapy 45 Mins

Facility

$558.00

Service Code	CPT 90834
Hospital Charge Code	23919269
Hospital Revenue Code	521
Min. Negotiated Rate	$502.20
Max. Negotiated Rate	$502.20
Rate for Payer: Aetna of AZ Commercial	$502.20
Rate for Payer: Cash Price	$446.40

90834 Psychotherapy 45 Mins

Facility

$558.00

Service Code	CPT 90834
Hospital Charge Code	23919269
Hospital Revenue Code	521
Min. Negotiated Rate	$14.20
Max. Negotiated Rate	$502.20
Rate for Payer: Aetna of AZ Commercial	$502.20
Rate for Payer: Arizona Complete Health Allwell	$89.28
Rate for Payer: Banner UC Health Medicare	$89.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$379.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$14.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$89.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$89.28
Rate for Payer: Cash Price	$446.40
Rate for Payer: Cash Price	$446.40
Rate for Payer: Cigna of AZ Commercial	$390.60
Rate for Payer: Devoted Health Medicare	$100.44
Rate for Payer: Humana of AZ Medicare	$89.28
Rate for Payer: Mercy Care Medicaid	$14.20
Rate for Payer: NaphCare Correctional Healthcare	$14.20
Rate for Payer: Seven Corners Travel Insurance	$274.63
Rate for Payer: Southwest Service Administrators UFCW	$379.44
Rate for Payer: TriWest Medicare	$89.28
Rate for Payer: United Healthcare Commercial	$319.18
Rate for Payer: United Healthcare Medicare	$89.28
Rate for Payer: Veterans Affairs TRICARE	$88.39

90836 Psychotherapy 45 Minutes CQCH

Facility

$560.00

Service Code	CPT 90836
Hospital Charge Code	24090002
Hospital Revenue Code	521
Min. Negotiated Rate	$504.00
Max. Negotiated Rate	$504.00
Rate for Payer: Aetna of AZ Commercial	$504.00
Rate for Payer: Cash Price	$448.00

90836 Psychotherapy 45 Minutes CQCH

Facility

$560.00

Service Code	CPT 90836
Hospital Charge Code	24090002
Hospital Revenue Code	521
Min. Negotiated Rate	$11.36
Max. Negotiated Rate	$504.00
Rate for Payer: Aetna of AZ Commercial	$504.00
Rate for Payer: Arizona Complete Health Allwell	$89.60
Rate for Payer: Banner UC Health Medicare	$89.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$380.80
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$11.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$89.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$89.60
Rate for Payer: Cash Price	$448.00
Rate for Payer: Cash Price	$448.00
Rate for Payer: Cigna of AZ Commercial	$392.00
Rate for Payer: Devoted Health Medicare	$100.80
Rate for Payer: Humana of AZ Medicare	$89.60
Rate for Payer: Mercy Care Medicaid	$11.36
Rate for Payer: NaphCare Correctional Healthcare	$11.36
Rate for Payer: Southwest Service Administrators UFCW	$380.80
Rate for Payer: TriWest Medicare	$89.60
Rate for Payer: United Healthcare Commercial	$320.32
Rate for Payer: United Healthcare Medicare	$89.60
Rate for Payer: Veterans Affairs TRICARE	$88.70

90837 Psychotherapy 60 Mins

Facility

$838.00

Service Code	CPT 90837
Hospital Charge Code	23919270
Hospital Revenue Code	521
Min. Negotiated Rate	$754.20
Max. Negotiated Rate	$754.20
Rate for Payer: Aetna of AZ Commercial	$754.20
Rate for Payer: Cash Price	$670.40

90837 Psychotherapy 60 Mins

Facility

$838.00

Service Code	CPT 90837
Hospital Charge Code	23919270
Hospital Revenue Code	521
Min. Negotiated Rate	$20.95
Max. Negotiated Rate	$754.20
Rate for Payer: Aetna of AZ Commercial	$754.20
Rate for Payer: Arizona Complete Health Allwell	$134.08
Rate for Payer: Banner UC Health Medicare	$134.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$569.84
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$20.95
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$134.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$134.08
Rate for Payer: Cash Price	$670.40
Rate for Payer: Cash Price	$670.40
Rate for Payer: Cigna of AZ Commercial	$586.60
Rate for Payer: Devoted Health Medicare	$150.84
Rate for Payer: Humana of AZ Medicare	$134.08
Rate for Payer: Mercy Care Medicaid	$20.95
Rate for Payer: NaphCare Correctional Healthcare	$20.95
Rate for Payer: Seven Corners Travel Insurance	$274.63
Rate for Payer: Southwest Service Administrators UFCW	$569.84
Rate for Payer: TriWest Medicare	$134.08
Rate for Payer: United Healthcare Commercial	$479.34
Rate for Payer: United Healthcare Medicare	$134.08
Rate for Payer: Veterans Affairs TRICARE	$132.74

90838 Psychotherapy 60 minutes CQCH

Facility

$747.00

Service Code	CPT 90838
Hospital Charge Code	24090003
Hospital Revenue Code	521
Min. Negotiated Rate	$14.55
Max. Negotiated Rate	$672.30
Rate for Payer: Aetna of AZ Commercial	$672.30
Rate for Payer: Arizona Complete Health Allwell	$119.52
Rate for Payer: Banner UC Health Medicare	$119.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$507.96
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$14.55
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$119.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$119.52
Rate for Payer: Cash Price	$597.60
Rate for Payer: Cash Price	$597.60
Rate for Payer: Cigna of AZ Commercial	$522.90
Rate for Payer: Devoted Health Medicare	$134.46
Rate for Payer: Humana of AZ Medicare	$119.52
Rate for Payer: Mercy Care Medicaid	$14.55
Rate for Payer: NaphCare Correctional Healthcare	$14.55
Rate for Payer: Southwest Service Administrators UFCW	$507.96
Rate for Payer: TriWest Medicare	$119.52
Rate for Payer: United Healthcare Commercial	$427.28
Rate for Payer: United Healthcare Medicare	$119.52
Rate for Payer: Veterans Affairs TRICARE	$118.32

90838 Psychotherapy 60 minutes CQCH

Facility

$747.00

Service Code	CPT 90838
Hospital Charge Code	24090003
Hospital Revenue Code	521
Min. Negotiated Rate	$672.30
Max. Negotiated Rate	$672.30
Rate for Payer: Aetna of AZ Commercial	$672.30
Rate for Payer: Cash Price	$597.60

Know your out-of-pocket cost for care.

All Charges