Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

PLUG FISTULA .7 COOK

Facility

$2,854.00

Hospital Charge Code	22955986
Hospital Revenue Code	272
Min. Negotiated Rate	$742.04
Max. Negotiated Rate	$2,568.60
Rate for Payer: Aetna of AZ Commercial	$2,568.60
Rate for Payer: Bisbee Police All Plans	$742.04
Rate for Payer: Cash Price	$2,283.20
Rate for Payer: Self Pay Self Pay	$2,283.20

PM AMPHETAMINE;1 OR 2

Facility

$239.00

Service Code	CPT 80324
Hospital Charge Code	23293444
Hospital Revenue Code	301
Min. Negotiated Rate	$62.14
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Bisbee Police All Plans	$62.14
Rate for Payer: Cash Price	$191.20
Rate for Payer: Self Pay Self Pay	$191.20

PM AMPHETAMINE;1 OR 2

Facility

$239.00

Service Code	CPT 80324
Hospital Charge Code	23293444
Hospital Revenue Code	301
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Aetna of AZ Medicare	$66.92
Rate for Payer: AHCCCS Medicaid	$0.13
Rate for Payer: Allwell Medicaid	$0.13
Rate for Payer: Allwell Medicare	$35.85
Rate for Payer: Amerigroup Medicare	$35.85
Rate for Payer: APIPA Medicare/Medicaid	$89.27
Rate for Payer: AZCH Complete Medicaid	$0.13
Rate for Payer: AZCH Complete Medicare	$35.85
Rate for Payer: Banner UC Health Medicaid	$0.13
Rate for Payer: Banner UC Health Medicare	$35.85
Rate for Payer: Bisbee Police All Plans	$62.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$162.52
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cigna of AZ Commercial	$155.35
Rate for Payer: Copperpoint Commercial	$59.15
Rate for Payer: Health Net of AZ Commercial	$143.40
Rate for Payer: Health Net of AZ Medicare	$66.92
Rate for Payer: Humana of AZ Medicare	$35.85
Rate for Payer: Mercy Care Medicaid	$0.13
Rate for Payer: Self Pay Self Pay	$191.20
Rate for Payer: TriWest Medicare	$35.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$139.34
Rate for Payer: UnitedHealth Group of AZ Medicare	$43.02

PM BARBITURATES

Facility

$296.00

Service Code	CPT 80307
Hospital Charge Code	23293446
Hospital Revenue Code	301
Min. Negotiated Rate	$76.96
Max. Negotiated Rate	$266.40
Rate for Payer: Aetna of AZ Commercial	$266.40
Rate for Payer: Bisbee Police All Plans	$76.96
Rate for Payer: Cash Price	$236.80
Rate for Payer: Self Pay Self Pay	$236.80

PM BARBITURATES

Facility

$296.00

Service Code	CPT 80307
Hospital Charge Code	23293446
Hospital Revenue Code	301
Min. Negotiated Rate	$44.40
Max. Negotiated Rate	$266.40
Rate for Payer: Aetna of AZ Commercial	$266.40
Rate for Payer: Aetna of AZ Medicare	$82.88
Rate for Payer: AHCCCS Medicaid	$62.14
Rate for Payer: Allwell Medicaid	$62.14
Rate for Payer: Allwell Medicare	$44.40
Rate for Payer: Amerigroup Medicare	$44.40
Rate for Payer: APIPA Medicare/Medicaid	$110.56
Rate for Payer: AZCH Complete Medicaid	$62.14
Rate for Payer: AZCH Complete Medicare	$44.40
Rate for Payer: Banner UC Health Medicaid	$62.14
Rate for Payer: Banner UC Health Medicare	$44.40
Rate for Payer: Bisbee Police All Plans	$76.96
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$201.28
Rate for Payer: Cash Price	$236.80
Rate for Payer: Cash Price	$236.80
Rate for Payer: Cigna of AZ Commercial	$192.40
Rate for Payer: Copperpoint Commercial	$73.26
Rate for Payer: Health Net of AZ Commercial	$177.60
Rate for Payer: Health Net of AZ Medicare	$82.88
Rate for Payer: Humana of AZ Medicare	$44.40
Rate for Payer: Mercy Care Medicaid	$62.14
Rate for Payer: Self Pay Self Pay	$236.80
Rate for Payer: TriWest Medicare	$44.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$172.57
Rate for Payer: UnitedHealth Group of AZ Medicare	$53.28

PM Benzos:1-12

Facility

$228.00

Service Code	CPT 80346
Hospital Charge Code	23293443
Hospital Revenue Code	301
Min. Negotiated Rate	$59.28
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna of AZ Commercial	$205.20
Rate for Payer: Bisbee Police All Plans	$59.28
Rate for Payer: Cash Price	$182.40
Rate for Payer: Self Pay Self Pay	$182.40

PM Benzos:1-12

Facility

$228.00

Service Code	CPT 80346
Hospital Charge Code	23293443
Hospital Revenue Code	301
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna of AZ Commercial	$205.20
Rate for Payer: Aetna of AZ Medicare	$63.84
Rate for Payer: AHCCCS Medicaid	$0.13
Rate for Payer: Allwell Medicaid	$0.13
Rate for Payer: Allwell Medicare	$34.20
Rate for Payer: Amerigroup Medicare	$34.20
Rate for Payer: APIPA Medicare/Medicaid	$85.16
Rate for Payer: AZCH Complete Medicaid	$0.13
Rate for Payer: AZCH Complete Medicare	$34.20
Rate for Payer: Banner UC Health Medicaid	$0.13
Rate for Payer: Banner UC Health Medicare	$34.20
Rate for Payer: Bisbee Police All Plans	$59.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$155.04
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cigna of AZ Commercial	$148.20
Rate for Payer: Copperpoint Commercial	$56.43
Rate for Payer: Health Net of AZ Commercial	$136.80
Rate for Payer: Health Net of AZ Medicare	$63.84
Rate for Payer: Humana of AZ Medicare	$34.20
Rate for Payer: Mercy Care Medicaid	$0.13
Rate for Payer: Self Pay Self Pay	$182.40
Rate for Payer: TriWest Medicare	$34.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$132.92
Rate for Payer: UnitedHealth Group of AZ Medicare	$41.04

PM CANNABINOIDS

Facility

$239.00

Service Code	CPT 80349
Hospital Charge Code	23293447
Hospital Revenue Code	301
Min. Negotiated Rate	$62.14
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Bisbee Police All Plans	$62.14
Rate for Payer: Cash Price	$191.20
Rate for Payer: Self Pay Self Pay	$191.20

PM CANNABINOIDS

Facility

$239.00

Service Code	CPT 80349
Hospital Charge Code	23293447
Hospital Revenue Code	301
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Aetna of AZ Medicare	$66.92
Rate for Payer: AHCCCS Medicaid	$0.13
Rate for Payer: Allwell Medicaid	$0.13
Rate for Payer: Allwell Medicare	$35.85
Rate for Payer: Amerigroup Medicare	$35.85
Rate for Payer: APIPA Medicare/Medicaid	$89.27
Rate for Payer: AZCH Complete Medicaid	$0.13
Rate for Payer: AZCH Complete Medicare	$35.85
Rate for Payer: Banner UC Health Medicaid	$0.13
Rate for Payer: Banner UC Health Medicare	$35.85
Rate for Payer: Bisbee Police All Plans	$62.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$162.52
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cigna of AZ Commercial	$155.35
Rate for Payer: Copperpoint Commercial	$59.15
Rate for Payer: Health Net of AZ Commercial	$143.40
Rate for Payer: Health Net of AZ Medicare	$66.92
Rate for Payer: Humana of AZ Medicare	$35.85
Rate for Payer: Mercy Care Medicaid	$0.13
Rate for Payer: Self Pay Self Pay	$191.20
Rate for Payer: TriWest Medicare	$35.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$139.34
Rate for Payer: UnitedHealth Group of AZ Medicare	$43.02

PM COCAINE METABOLITE

Facility

$239.00

Service Code	CPT 80353
Hospital Charge Code	23293448
Hospital Revenue Code	301
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Aetna of AZ Medicare	$66.92
Rate for Payer: AHCCCS Medicaid	$0.13
Rate for Payer: Allwell Medicaid	$0.13
Rate for Payer: Allwell Medicare	$35.85
Rate for Payer: Amerigroup Medicare	$35.85
Rate for Payer: APIPA Medicare/Medicaid	$89.27
Rate for Payer: AZCH Complete Medicaid	$0.13
Rate for Payer: AZCH Complete Medicare	$35.85
Rate for Payer: Banner UC Health Medicaid	$0.13
Rate for Payer: Banner UC Health Medicare	$35.85
Rate for Payer: Bisbee Police All Plans	$62.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$162.52
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cigna of AZ Commercial	$155.35
Rate for Payer: Copperpoint Commercial	$59.15
Rate for Payer: Health Net of AZ Commercial	$143.40
Rate for Payer: Health Net of AZ Medicare	$66.92
Rate for Payer: Humana of AZ Medicare	$35.85
Rate for Payer: Mercy Care Medicaid	$0.13
Rate for Payer: Self Pay Self Pay	$191.20
Rate for Payer: TriWest Medicare	$35.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$139.34
Rate for Payer: UnitedHealth Group of AZ Medicare	$43.02

PM COCAINE METABOLITE

Facility

$239.00

Service Code	CPT 80353
Hospital Charge Code	23293448
Hospital Revenue Code	301
Min. Negotiated Rate	$62.14
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Bisbee Police All Plans	$62.14
Rate for Payer: Cash Price	$191.20
Rate for Payer: Self Pay Self Pay	$191.20

PM DOA Screen

Facility

$163.00

Service Code	CPT 80305 QW
Hospital Charge Code	23741289
Hospital Revenue Code	301
Min. Negotiated Rate	$42.38
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Bisbee Police All Plans	$42.38
Rate for Payer: Cash Price	$130.40
Rate for Payer: Self Pay Self Pay	$130.40

PM DOA Screen

Facility

$163.00

Service Code	CPT 80305 QW
Hospital Charge Code	23741289
Hospital Revenue Code	301
Min. Negotiated Rate	$24.45
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Aetna of AZ Medicare	$45.64
Rate for Payer: Allwell Medicare	$24.45
Rate for Payer: Amerigroup Medicare	$24.45
Rate for Payer: APIPA Medicare/Medicaid	$60.88
Rate for Payer: AZCH Complete Medicare	$24.45
Rate for Payer: Banner UC Health Medicare	$24.45
Rate for Payer: Bisbee Police All Plans	$42.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$110.84
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cigna of AZ Commercial	$105.95
Rate for Payer: Copperpoint Commercial	$40.34
Rate for Payer: Health Net of AZ Commercial	$97.80
Rate for Payer: Health Net of AZ Medicare	$45.64
Rate for Payer: Humana of AZ Medicare	$24.45
Rate for Payer: Self Pay Self Pay	$130.40
Rate for Payer: TriWest Medicare	$24.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$95.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$29.34

PM METHADONE

Facility

$228.00

Service Code	CPT 80358
Hospital Charge Code	23293445
Hospital Revenue Code	301
Min. Negotiated Rate	$59.28
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna of AZ Commercial	$205.20
Rate for Payer: Bisbee Police All Plans	$59.28
Rate for Payer: Cash Price	$182.40
Rate for Payer: Self Pay Self Pay	$182.40

PM METHADONE

Facility

$228.00

Service Code	CPT 80358
Hospital Charge Code	23293445
Hospital Revenue Code	301
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$205.20
Rate for Payer: Aetna of AZ Commercial	$205.20
Rate for Payer: Aetna of AZ Medicare	$63.84
Rate for Payer: AHCCCS Medicaid	$0.13
Rate for Payer: Allwell Medicaid	$0.13
Rate for Payer: Allwell Medicare	$34.20
Rate for Payer: Amerigroup Medicare	$34.20
Rate for Payer: APIPA Medicare/Medicaid	$85.16
Rate for Payer: AZCH Complete Medicaid	$0.13
Rate for Payer: AZCH Complete Medicare	$34.20
Rate for Payer: Banner UC Health Medicaid	$0.13
Rate for Payer: Banner UC Health Medicare	$34.20
Rate for Payer: Bisbee Police All Plans	$59.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$155.04
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cash Price	$182.40
Rate for Payer: Cigna of AZ Commercial	$148.20
Rate for Payer: Copperpoint Commercial	$56.43
Rate for Payer: Health Net of AZ Commercial	$136.80
Rate for Payer: Health Net of AZ Medicare	$63.84
Rate for Payer: Humana of AZ Medicare	$34.20
Rate for Payer: Mercy Care Medicaid	$0.13
Rate for Payer: Self Pay Self Pay	$182.40
Rate for Payer: TriWest Medicare	$34.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$132.92
Rate for Payer: UnitedHealth Group of AZ Medicare	$41.04

PM OPIATES

Facility

$239.00

Service Code	CPT 80361
Hospital Charge Code	23293439
Hospital Revenue Code	301
Min. Negotiated Rate	$62.14
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Bisbee Police All Plans	$62.14
Rate for Payer: Cash Price	$191.20
Rate for Payer: Self Pay Self Pay	$191.20

PM OPIATES

Facility

$239.00

Service Code	CPT 80361
Hospital Charge Code	23293439
Hospital Revenue Code	301
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Aetna of AZ Medicare	$66.92
Rate for Payer: AHCCCS Medicaid	$0.13
Rate for Payer: Allwell Medicaid	$0.13
Rate for Payer: Allwell Medicare	$35.85
Rate for Payer: Amerigroup Medicare	$35.85
Rate for Payer: APIPA Medicare/Medicaid	$89.27
Rate for Payer: AZCH Complete Medicaid	$0.13
Rate for Payer: AZCH Complete Medicare	$35.85
Rate for Payer: Banner UC Health Medicaid	$0.13
Rate for Payer: Banner UC Health Medicare	$35.85
Rate for Payer: Bisbee Police All Plans	$62.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$162.52
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cigna of AZ Commercial	$155.35
Rate for Payer: Copperpoint Commercial	$59.15
Rate for Payer: Health Net of AZ Commercial	$143.40
Rate for Payer: Health Net of AZ Medicare	$66.92
Rate for Payer: Humana of AZ Medicare	$35.85
Rate for Payer: Mercy Care Medicaid	$0.13
Rate for Payer: Self Pay Self Pay	$191.20
Rate for Payer: TriWest Medicare	$35.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$139.34
Rate for Payer: UnitedHealth Group of AZ Medicare	$43.02

PM TRAMADOL

Facility

$239.00

Service Code	CPT 80373
Hospital Charge Code	23293441
Hospital Revenue Code	301
Min. Negotiated Rate	$62.14
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Bisbee Police All Plans	$62.14
Rate for Payer: Cash Price	$191.20
Rate for Payer: Self Pay Self Pay	$191.20

PM TRAMADOL

Facility

$239.00

Service Code	CPT 80373
Hospital Charge Code	23293441
Hospital Revenue Code	301
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of AZ Commercial	$215.10
Rate for Payer: Aetna of AZ Medicare	$66.92
Rate for Payer: AHCCCS Medicaid	$0.13
Rate for Payer: Allwell Medicaid	$0.13
Rate for Payer: Allwell Medicare	$35.85
Rate for Payer: Amerigroup Medicare	$35.85
Rate for Payer: APIPA Medicare/Medicaid	$89.27
Rate for Payer: AZCH Complete Medicaid	$0.13
Rate for Payer: AZCH Complete Medicare	$35.85
Rate for Payer: Banner UC Health Medicaid	$0.13
Rate for Payer: Banner UC Health Medicare	$35.85
Rate for Payer: Bisbee Police All Plans	$62.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$162.52
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cash Price	$191.20
Rate for Payer: Cigna of AZ Commercial	$155.35
Rate for Payer: Copperpoint Commercial	$59.15
Rate for Payer: Health Net of AZ Commercial	$143.40
Rate for Payer: Health Net of AZ Medicare	$66.92
Rate for Payer: Humana of AZ Medicare	$35.85
Rate for Payer: Mercy Care Medicaid	$0.13
Rate for Payer: Self Pay Self Pay	$191.20
Rate for Payer: TriWest Medicare	$35.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$139.34
Rate for Payer: UnitedHealth Group of AZ Medicare	$43.02

pneumococcal 13 vaccine Prevnar PFS [CQCH]

Facility

$770.66

Service Code	HCPCS 90670
Hospital Charge Code	105937029
Hospital Revenue Code	250
Min. Negotiated Rate	$115.60
Max. Negotiated Rate	$693.59
Rate for Payer: Aetna of AZ Commercial	$693.59
Rate for Payer: Aetna of AZ Medicare	$215.78
Rate for Payer: AHCCCS Medicaid	$490.18
Rate for Payer: Allwell Medicaid	$490.18
Rate for Payer: Allwell Medicare	$115.60
Rate for Payer: Amerigroup Medicare	$115.60
Rate for Payer: APIPA Medicare/Medicaid	$287.84
Rate for Payer: AZCH Complete Medicaid	$490.18
Rate for Payer: AZCH Complete Medicare	$115.60
Rate for Payer: Banner UC Health Medicaid	$490.18
Rate for Payer: Banner UC Health Medicare	$115.60
Rate for Payer: Bisbee Police All Plans	$200.37
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$524.05
Rate for Payer: Cash Price	$616.53
Rate for Payer: Cash Price	$616.53
Rate for Payer: Cigna of AZ Commercial	$500.93
Rate for Payer: Copperpoint Commercial	$190.74
Rate for Payer: Health Net of AZ Commercial	$462.40
Rate for Payer: Health Net of AZ Medicare	$215.78
Rate for Payer: Humana of AZ Medicare	$115.60
Rate for Payer: Mercy Care Medicaid	$490.18
Rate for Payer: Self Pay Self Pay	$616.53
Rate for Payer: TriWest Medicare	$115.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$449.29
Rate for Payer: UnitedHealth Group of AZ Medicare	$138.72

pneumococcal 13 vaccine Prevnar PFS [CQCH]

Facility

$770.66

Service Code	HCPCS 90670
Hospital Charge Code	105937029
Hospital Revenue Code	250
Min. Negotiated Rate	$200.37
Max. Negotiated Rate	$693.59
Rate for Payer: Aetna of AZ Commercial	$693.59
Rate for Payer: Bisbee Police All Plans	$200.37
Rate for Payer: Cash Price	$616.53
Rate for Payer: Self Pay Self Pay	$616.53

pneumococcal 20-valent conjugate vaccine - Sus [CQCH]

Facility

$865.62

Service Code	NDC 5200010
Hospital Charge Code	206261087
Min. Negotiated Rate	$129.84
Max. Negotiated Rate	$779.06
Rate for Payer: Aetna of AZ Commercial	$779.06
Rate for Payer: Aetna of AZ Medicare	$242.37
Rate for Payer: Allwell Medicare	$129.84
Rate for Payer: Amerigroup Medicare	$129.84
Rate for Payer: APIPA Medicare/Medicaid	$323.31
Rate for Payer: AZCH Complete Medicare	$129.84
Rate for Payer: Banner UC Health Medicare	$129.84
Rate for Payer: Bisbee Police All Plans	$225.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$588.62
Rate for Payer: Cash Price	$692.50
Rate for Payer: Cigna of AZ Commercial	$605.93
Rate for Payer: Copperpoint Commercial	$214.24
Rate for Payer: Health Net of AZ Commercial	$519.37
Rate for Payer: Health Net of AZ Medicare	$242.37
Rate for Payer: Humana of AZ Medicare	$129.84
Rate for Payer: Self Pay Self Pay	$692.50
Rate for Payer: TriWest Medicare	$129.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$504.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$155.81

pneumococcal 20-valent conjugate vaccine - Sus [CQCH]

Facility

$865.62

Service Code	NDC 5200010
Hospital Charge Code	206261087
Min. Negotiated Rate	$225.06
Max. Negotiated Rate	$779.06
Rate for Payer: Aetna of AZ Commercial	$779.06
Rate for Payer: Bisbee Police All Plans	$225.06
Rate for Payer: Cash Price	$692.50
Rate for Payer: Self Pay Self Pay	$692.50

pneumococcal 23 vaccine Inj [CQCH]

Facility

$414.52

Service Code	HCPCS 90732
Hospital Charge Code	105937100
Hospital Revenue Code	250
Min. Negotiated Rate	$107.78
Max. Negotiated Rate	$373.07
Rate for Payer: Aetna of AZ Commercial	$373.07
Rate for Payer: Bisbee Police All Plans	$107.78
Rate for Payer: Cash Price	$331.62
Rate for Payer: Self Pay Self Pay	$331.62

pneumococcal 23 vaccine Inj [CQCH]

Facility

$414.52

Service Code	HCPCS 90732
Hospital Charge Code	105937100
Hospital Revenue Code	250
Min. Negotiated Rate	$62.18
Max. Negotiated Rate	$373.07
Rate for Payer: Aetna of AZ Commercial	$373.07
Rate for Payer: Aetna of AZ Medicare	$116.07
Rate for Payer: AHCCCS Medicaid	$253.60
Rate for Payer: Allwell Medicaid	$253.60
Rate for Payer: Allwell Medicare	$62.18
Rate for Payer: Amerigroup Medicare	$62.18
Rate for Payer: APIPA Medicare/Medicaid	$154.82
Rate for Payer: AZCH Complete Medicaid	$253.60
Rate for Payer: AZCH Complete Medicare	$62.18
Rate for Payer: Banner UC Health Medicaid	$253.60
Rate for Payer: Banner UC Health Medicare	$62.18
Rate for Payer: Bisbee Police All Plans	$107.78
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$281.87
Rate for Payer: Cash Price	$331.62
Rate for Payer: Cash Price	$331.62
Rate for Payer: Cigna of AZ Commercial	$269.44
Rate for Payer: Copperpoint Commercial	$102.59
Rate for Payer: Health Net of AZ Commercial	$248.71
Rate for Payer: Health Net of AZ Medicare	$116.07
Rate for Payer: Humana of AZ Medicare	$62.18
Rate for Payer: Mercy Care Medicaid	$253.60
Rate for Payer: Self Pay Self Pay	$331.62
Rate for Payer: TriWest Medicare	$62.18
Rate for Payer: UnitedHealth Group of AZ Commercial	$241.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$74.61

Know your out-of-pocket cost for care.

All Charges