Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

96374 - IV Injection, single/initial

Facility

$268.00

Service Code	CPT 96374
Hospital Charge Code	22283169
Hospital Revenue Code	450
Min. Negotiated Rate	$241.20
Max. Negotiated Rate	$241.20
Rate for Payer: Aetna of AZ Commercial	$241.20
Rate for Payer: Cash Price	$214.40

96374 - IV Injection, single/initial

Facility

$268.00

Service Code	CPT 96374
Hospital Charge Code	22283169
Hospital Revenue Code	450
Min. Negotiated Rate	$42.45
Max. Negotiated Rate	$329.11
Rate for Payer: Aetna of AZ Commercial	$241.20
Rate for Payer: Arizona Complete Health Allwell	$42.88
Rate for Payer: Banner UC Health Medicare	$42.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$182.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$42.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$42.88
Rate for Payer: Cash Price	$214.40
Rate for Payer: Cash Price	$214.40
Rate for Payer: Cigna of AZ Commercial	$187.60
Rate for Payer: Devoted Health Medicare	$48.24
Rate for Payer: Humana of AZ Medicare	$42.88
Rate for Payer: Seven Corners Travel Insurance	$329.11
Rate for Payer: Southwest Service Administrators UFCW	$182.24
Rate for Payer: TriWest Medicare	$42.88
Rate for Payer: United Healthcare Commercial	$153.30
Rate for Payer: United Healthcare Medicare	$42.88
Rate for Payer: United Healthcare New Mexico Commercial	$50.92
Rate for Payer: Veterans Affairs TRICARE	$42.45

96380 ADMIN RSV VACCINE INCLUDING COUNSELING

Facility

$48.00

Service Code	CPT 96380
Hospital Charge Code	28143534
Hospital Revenue Code	521
Min. Negotiated Rate	$7.60
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of AZ Commercial	$43.20
Rate for Payer: Arizona Complete Health Allwell	$7.68
Rate for Payer: Banner UC Health Medicare	$7.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$32.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.68
Rate for Payer: Cash Price	$38.40
Rate for Payer: Cigna of AZ Commercial	$33.60
Rate for Payer: Devoted Health Medicare	$8.64
Rate for Payer: Humana of AZ Medicare	$7.68
Rate for Payer: Southwest Service Administrators UFCW	$32.64
Rate for Payer: TriWest Medicare	$7.68
Rate for Payer: United Healthcare Commercial	$27.46
Rate for Payer: United Healthcare Medicare	$7.68
Rate for Payer: Veterans Affairs TRICARE	$7.60

96380 ADMIN RSV VACCINE INCLUDING COUNSELING

Facility

$48.00

Service Code	CPT 96380
Hospital Charge Code	28143534
Hospital Revenue Code	521
Min. Negotiated Rate	$43.20
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of AZ Commercial	$43.20
Rate for Payer: Cash Price	$38.40

96381 ADMIN RSV VACCINE WITHOUT COUNSELING

Facility

$40.00

Service Code	CPT 96381
Hospital Charge Code	28137940
Hospital Revenue Code	521
Min. Negotiated Rate	$6.34
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna of AZ Commercial	$36.00
Rate for Payer: Arizona Complete Health Allwell	$6.40
Rate for Payer: Banner UC Health Medicare	$6.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$27.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$6.40
Rate for Payer: Cash Price	$32.00
Rate for Payer: Cigna of AZ Commercial	$28.00
Rate for Payer: Devoted Health Medicare	$7.20
Rate for Payer: Humana of AZ Medicare	$6.40
Rate for Payer: Southwest Service Administrators UFCW	$27.20
Rate for Payer: TriWest Medicare	$6.40
Rate for Payer: United Healthcare Commercial	$22.88
Rate for Payer: United Healthcare Medicare	$6.40
Rate for Payer: Veterans Affairs TRICARE	$6.34

96381 ADMIN RSV VACCINE WITHOUT COUNSELING

Facility

$40.00

Service Code	CPT 96381
Hospital Charge Code	28137940
Hospital Revenue Code	521
Min. Negotiated Rate	$36.00
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna of AZ Commercial	$36.00
Rate for Payer: Cash Price	$32.00

97032-Attended Estem

Facility

$181.00

Service Code	CPT 97032
Hospital Charge Code	27373775
Hospital Revenue Code	420
Min. Negotiated Rate	$162.90
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Cash Price	$144.80

97032-Attended Estem

Facility

$181.00

Service Code	CPT 97032
Hospital Charge Code	27373775
Hospital Revenue Code	420
Min. Negotiated Rate	$15.23
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Arizona Complete Health Allwell	$28.96
Rate for Payer: Banner UC Health Medicare	$28.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$123.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.23
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cigna of AZ Commercial	$126.70
Rate for Payer: Devoted Health Medicare	$32.58
Rate for Payer: Humana of AZ Medicare	$28.96
Rate for Payer: Southwest Service Administrators UFCW	$123.08
Rate for Payer: TriWest Medicare	$28.96
Rate for Payer: United Healthcare Commercial	$103.53
Rate for Payer: United Healthcare Medicare	$28.96
Rate for Payer: United Healthcare New Mexico Commercial	$34.39
Rate for Payer: Veterans Affairs TRICARE	$28.67

97033 IONTOPHORESIS CHARGE

Facility

$181.00

Service Code	CPT 97033 GP
Hospital Charge Code	15989377
Min. Negotiated Rate	$162.90
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Cash Price	$144.80

97033 IONTOPHORESIS CHARGE

Facility

$181.00

Service Code	CPT 97033 GP
Hospital Charge Code	15989377
Min. Negotiated Rate	$28.67
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Arizona Complete Health Allwell	$28.96
Rate for Payer: Banner UC Health Medicare	$28.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$123.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.96
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cigna of AZ Commercial	$126.70
Rate for Payer: Devoted Health Medicare	$32.58
Rate for Payer: Humana of AZ Medicare	$28.96
Rate for Payer: Southwest Service Administrators UFCW	$123.08
Rate for Payer: TriWest Medicare	$28.96
Rate for Payer: United Healthcare Commercial	$103.53
Rate for Payer: United Healthcare Medicare	$28.96
Rate for Payer: Veterans Affairs TRICARE	$28.67

97035 ULTRASOUND/15 MIN CHARGE

Facility

$181.00

Service Code	CPT 97035 GP
Hospital Charge Code	9299439
Min. Negotiated Rate	$28.67
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Arizona Complete Health Allwell	$28.96
Rate for Payer: Banner UC Health Medicare	$28.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$123.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.96
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cigna of AZ Commercial	$126.70
Rate for Payer: Devoted Health Medicare	$32.58
Rate for Payer: Humana of AZ Medicare	$28.96
Rate for Payer: Southwest Service Administrators UFCW	$123.08
Rate for Payer: TriWest Medicare	$28.96
Rate for Payer: United Healthcare Commercial	$103.53
Rate for Payer: United Healthcare Medicare	$28.96
Rate for Payer: Veterans Affairs TRICARE	$28.67

97035 ULTRASOUND/15 MIN CHARGE

Facility

$181.00

Service Code	CPT 97035 GP
Hospital Charge Code	9299439
Min. Negotiated Rate	$162.90
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Cash Price	$144.80

97110 Therapeutic Exercise Charges

Facility

$181.00

Service Code	CPT 97110 GP
Hospital Charge Code	24237124
Hospital Revenue Code	430
Min. Negotiated Rate	$28.67
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Arizona Complete Health Allwell	$28.96
Rate for Payer: Banner UC Health Medicare	$28.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$123.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$30.45
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cigna of AZ Commercial	$126.70
Rate for Payer: Devoted Health Medicare	$32.58
Rate for Payer: Humana of AZ Medicare	$28.96
Rate for Payer: Southwest Service Administrators UFCW	$123.08
Rate for Payer: TriWest Medicare	$28.96
Rate for Payer: United Healthcare Commercial	$103.53
Rate for Payer: United Healthcare Medicare	$28.96
Rate for Payer: United Healthcare New Mexico Commercial	$34.39
Rate for Payer: Veterans Affairs TRICARE	$28.67

97110 Therapeutic Exercise Charges

Facility

$181.00

Service Code	CPT 97110 GP
Hospital Charge Code	24237124
Hospital Revenue Code	430
Min. Negotiated Rate	$162.90
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Cash Price	$144.80

97110 THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINU

Facility

$208.00

Service Code	CPT 97110
Hospital Charge Code	23919279
Hospital Revenue Code	521
Min. Negotiated Rate	$187.20
Max. Negotiated Rate	$187.20
Rate for Payer: Aetna of AZ Commercial	$187.20
Rate for Payer: Cash Price	$166.40

97110 THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINU

Facility

$208.00

Service Code	CPT 97110
Hospital Charge Code	23919279
Hospital Revenue Code	521
Min. Negotiated Rate	$32.95
Max. Negotiated Rate	$187.20
Rate for Payer: Aetna of AZ Commercial	$187.20
Rate for Payer: Arizona Complete Health Allwell	$33.28
Rate for Payer: Banner UC Health Medicare	$33.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$141.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$33.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$33.28
Rate for Payer: Cash Price	$166.40
Rate for Payer: Cigna of AZ Commercial	$145.60
Rate for Payer: Devoted Health Medicare	$37.44
Rate for Payer: Humana of AZ Medicare	$33.28
Rate for Payer: Southwest Service Administrators UFCW	$141.44
Rate for Payer: TriWest Medicare	$33.28
Rate for Payer: United Healthcare Commercial	$118.98
Rate for Payer: United Healthcare Medicare	$33.28
Rate for Payer: Veterans Affairs TRICARE	$32.95

97112 PT Neuromuscular reeducation (Timed per 15 mins)

Facility

$181.00

Service Code	CPT 97112 GP
Hospital Charge Code	23955336
Hospital Revenue Code	420
Min. Negotiated Rate	$28.67
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Arizona Complete Health Allwell	$28.96
Rate for Payer: Banner UC Health Medicare	$28.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$123.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$33.99
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cigna of AZ Commercial	$126.70
Rate for Payer: Devoted Health Medicare	$32.58
Rate for Payer: Humana of AZ Medicare	$28.96
Rate for Payer: Southwest Service Administrators UFCW	$123.08
Rate for Payer: TriWest Medicare	$28.96
Rate for Payer: United Healthcare Commercial	$103.53
Rate for Payer: United Healthcare Medicare	$28.96
Rate for Payer: United Healthcare New Mexico Commercial	$34.39
Rate for Payer: Veterans Affairs TRICARE	$28.67

97112 PT Neuromuscular reeducation (Timed per 15 mins)

Facility

$181.00

Service Code	CPT 97112 GP
Hospital Charge Code	23955336
Hospital Revenue Code	420
Min. Negotiated Rate	$162.90
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Cash Price	$144.80

97112 THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINU

Facility

$233.00

Service Code	CPT 97112
Hospital Charge Code	23919280
Hospital Revenue Code	521
Min. Negotiated Rate	$36.91
Max. Negotiated Rate	$209.70
Rate for Payer: Aetna of AZ Commercial	$209.70
Rate for Payer: Arizona Complete Health Allwell	$37.28
Rate for Payer: Banner UC Health Medicare	$37.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$158.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$37.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.28
Rate for Payer: Cash Price	$186.40
Rate for Payer: Cigna of AZ Commercial	$163.10
Rate for Payer: Devoted Health Medicare	$41.94
Rate for Payer: Humana of AZ Medicare	$37.28
Rate for Payer: Southwest Service Administrators UFCW	$158.44
Rate for Payer: TriWest Medicare	$37.28
Rate for Payer: United Healthcare Commercial	$133.28
Rate for Payer: United Healthcare Medicare	$37.28
Rate for Payer: Veterans Affairs TRICARE	$36.91

97112 THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINU

Facility

$233.00

Service Code	CPT 97112
Hospital Charge Code	23919280
Hospital Revenue Code	521
Min. Negotiated Rate	$209.70
Max. Negotiated Rate	$209.70
Rate for Payer: Aetna of AZ Commercial	$209.70
Rate for Payer: Cash Price	$186.40

97116 THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINU

Facility

$204.00

Service Code	CPT 97116
Hospital Charge Code	23919281
Hospital Revenue Code	521
Min. Negotiated Rate	$183.60
Max. Negotiated Rate	$183.60
Rate for Payer: Aetna of AZ Commercial	$183.60
Rate for Payer: Cash Price	$163.20

97116 THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINU

Facility

$204.00

Service Code	CPT 97116
Hospital Charge Code	23919281
Hospital Revenue Code	521
Min. Negotiated Rate	$32.31
Max. Negotiated Rate	$183.60
Rate for Payer: Aetna of AZ Commercial	$183.60
Rate for Payer: Arizona Complete Health Allwell	$32.64
Rate for Payer: Banner UC Health Medicare	$32.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$138.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.64
Rate for Payer: Cash Price	$163.20
Rate for Payer: Cigna of AZ Commercial	$142.80
Rate for Payer: Devoted Health Medicare	$36.72
Rate for Payer: Humana of AZ Medicare	$32.64
Rate for Payer: Southwest Service Administrators UFCW	$138.72
Rate for Payer: TriWest Medicare	$32.64
Rate for Payer: United Healthcare Commercial	$116.69
Rate for Payer: United Healthcare Medicare	$32.64
Rate for Payer: Veterans Affairs TRICARE	$32.31

97129 THERAPY PROCEDURE FOR A RANGE OF MENTAL PROCESSES, INI

Facility

$123.00

Service Code	CPT 97129 GN
Hospital Charge Code	27728004
Hospital Revenue Code	440
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$110.70
Rate for Payer: Aetna of AZ Commercial	$110.70
Rate for Payer: Arizona Complete Health Allwell	$19.68
Rate for Payer: Banner UC Health Medicare	$19.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$83.64
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$0.35
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$19.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$20.89
Rate for Payer: Cash Price	$98.40
Rate for Payer: Cash Price	$98.40
Rate for Payer: Cigna of AZ Commercial	$86.10
Rate for Payer: Devoted Health Medicare	$22.14
Rate for Payer: Humana of AZ Medicare	$19.68
Rate for Payer: Mercy Care Medicaid	$0.35
Rate for Payer: NaphCare Correctional Healthcare	$0.35
Rate for Payer: Southwest Service Administrators UFCW	$83.64
Rate for Payer: TriWest Medicare	$19.68
Rate for Payer: United Healthcare Commercial	$70.36
Rate for Payer: United Healthcare Medicare	$19.68
Rate for Payer: United Healthcare New Mexico Commercial	$23.37
Rate for Payer: Veterans Affairs TRICARE	$19.48

97129 THERAPY PROCEDURE FOR A RANGE OF MENTAL PROCESSES, INI

Facility

$123.00

Service Code	CPT 97129 GN
Hospital Charge Code	27728004
Hospital Revenue Code	440
Min. Negotiated Rate	$110.70
Max. Negotiated Rate	$110.70
Rate for Payer: Aetna of AZ Commercial	$110.70
Rate for Payer: Cash Price	$98.40

97130 THERAPY PROCEDURE FOR A RANGE OF MENTAL PROCESSES, EAC

Facility

$120.00

Service Code	CPT 97130 GN
Hospital Charge Code	27724314
Hospital Revenue Code	440
Min. Negotiated Rate	$19.01
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Arizona Complete Health Allwell	$19.20
Rate for Payer: Banner UC Health Medicare	$19.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$81.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$19.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$19.47
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cigna of AZ Commercial	$84.00
Rate for Payer: Devoted Health Medicare	$21.60
Rate for Payer: Humana of AZ Medicare	$19.20
Rate for Payer: Southwest Service Administrators UFCW	$81.60
Rate for Payer: TriWest Medicare	$19.20
Rate for Payer: United Healthcare Commercial	$68.64
Rate for Payer: United Healthcare Medicare	$19.20
Rate for Payer: United Healthcare New Mexico Commercial	$22.80
Rate for Payer: Veterans Affairs TRICARE	$19.01

Know your out-of-pocket cost for care.

All Charges