Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

CLIENT IV-LACTATED RINGERS : 1000 ML

Facility

$30.00

Hospital Charge Code	22331338
Hospital Revenue Code	250
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Bisbee Police All Plans	$7.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Self Pay Self Pay	$24.00

CLIENT KNEE LIMITED RT

Facility

$538.00

Service Code	CPT 73560 RT
Hospital Charge Code	22331345
Hospital Revenue Code	320
Min. Negotiated Rate	$139.88
Max. Negotiated Rate	$484.20
Rate for Payer: Aetna of AZ Commercial	$484.20
Rate for Payer: Bisbee Police All Plans	$139.88
Rate for Payer: Cash Price	$430.40
Rate for Payer: Self Pay Self Pay	$430.40

CLIENT KNEE LIMITED RT

Facility

$538.00

Service Code	CPT 73560 RT
Hospital Charge Code	22331345
Hospital Revenue Code	320
Min. Negotiated Rate	$80.70
Max. Negotiated Rate	$484.20
Rate for Payer: Aetna of AZ Commercial	$484.20
Rate for Payer: Aetna of AZ Medicare	$150.64
Rate for Payer: Allwell Medicare	$80.70
Rate for Payer: Amerigroup Medicare	$80.70
Rate for Payer: APIPA Medicare/Medicaid	$200.94
Rate for Payer: AZCH Complete Medicare	$80.70
Rate for Payer: Banner UC Health Medicare	$80.70
Rate for Payer: Bisbee Police All Plans	$139.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$365.84
Rate for Payer: Cash Price	$430.40
Rate for Payer: Cigna of AZ Commercial	$349.70
Rate for Payer: Copperpoint Commercial	$133.16
Rate for Payer: Health Net of AZ Commercial	$322.80
Rate for Payer: Health Net of AZ Medicare	$150.64
Rate for Payer: Humana of AZ Medicare	$80.70
Rate for Payer: Self Pay Self Pay	$430.40
Rate for Payer: TriWest Medicare	$80.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$313.65
Rate for Payer: UnitedHealth Group of AZ Medicare	$96.84

CLIENT MMR VACCINE

Facility

$69.00

Hospital Charge Code	22331364
Hospital Revenue Code	636
Min. Negotiated Rate	$17.94
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Bisbee Police All Plans	$17.94
Rate for Payer: Cash Price	$55.20
Rate for Payer: Self Pay Self Pay	$55.20

CLIENT MMR VACCINE

Facility

$69.00

Hospital Charge Code	22331364
Hospital Revenue Code	636
Min. Negotiated Rate	$10.35
Max. Negotiated Rate	$62.10
Rate for Payer: Aetna of AZ Commercial	$62.10
Rate for Payer: Aetna of AZ Medicare	$19.32
Rate for Payer: Allwell Medicare	$10.35
Rate for Payer: Amerigroup Medicare	$10.35
Rate for Payer: APIPA Medicare/Medicaid	$25.77
Rate for Payer: AZCH Complete Medicare	$10.35
Rate for Payer: Banner UC Health Medicare	$10.35
Rate for Payer: Bisbee Police All Plans	$17.94
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$46.92
Rate for Payer: Cash Price	$55.20
Rate for Payer: Cigna of AZ Commercial	$48.30
Rate for Payer: Copperpoint Commercial	$17.08
Rate for Payer: Health Net of AZ Commercial	$41.40
Rate for Payer: Health Net of AZ Medicare	$19.32
Rate for Payer: Humana of AZ Medicare	$10.35
Rate for Payer: Self Pay Self Pay	$55.20
Rate for Payer: TriWest Medicare	$10.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$40.23
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.42

CLIENT NON DOT CDC UDS COLLECTION

Facility

$21.00

Hospital Charge Code	22331418
Hospital Revenue Code	301
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Aetna of AZ Medicare	$5.88
Rate for Payer: Allwell Medicare	$3.15
Rate for Payer: Amerigroup Medicare	$3.15
Rate for Payer: APIPA Medicare/Medicaid	$7.84
Rate for Payer: AZCH Complete Medicare	$3.15
Rate for Payer: Banner UC Health Medicare	$3.15
Rate for Payer: Bisbee Police All Plans	$5.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$14.28
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna of AZ Commercial	$13.65
Rate for Payer: Copperpoint Commercial	$5.20
Rate for Payer: Health Net of AZ Commercial	$12.60
Rate for Payer: Health Net of AZ Medicare	$5.88
Rate for Payer: Humana of AZ Medicare	$3.15
Rate for Payer: Self Pay Self Pay	$16.80
Rate for Payer: TriWest Medicare	$3.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$12.24
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.78

CLIENT NON DOT CDC UDS COLLECTION

Facility

$21.00

Hospital Charge Code	22331418
Hospital Revenue Code	301
Min. Negotiated Rate	$5.46
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Bisbee Police All Plans	$5.46
Rate for Payer: Cash Price	$16.80
Rate for Payer: Self Pay Self Pay	$16.80

CLIENT PFT PRE/POST

Facility

$108.00

Service Code	CPT 94060
Hospital Charge Code	22331441
Hospital Revenue Code	460
Min. Negotiated Rate	$28.08
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of AZ Commercial	$97.20
Rate for Payer: Bisbee Police All Plans	$28.08
Rate for Payer: Cash Price	$86.40
Rate for Payer: Self Pay Self Pay	$86.40

CLIENT PFT PRE/POST

Facility

$108.00

Service Code	CPT 94060
Hospital Charge Code	22331441
Hospital Revenue Code	460
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$383.46
Rate for Payer: Aetna of AZ Commercial	$97.20
Rate for Payer: Aetna of AZ Medicare	$30.24
Rate for Payer: AHCCCS Medicaid	$383.46
Rate for Payer: Allwell Medicaid	$383.46
Rate for Payer: Allwell Medicare	$16.20
Rate for Payer: Amerigroup Medicare	$16.20
Rate for Payer: APIPA Medicare/Medicaid	$40.34
Rate for Payer: AZCH Complete Medicaid	$383.46
Rate for Payer: AZCH Complete Medicare	$16.20
Rate for Payer: Banner UC Health Medicaid	$383.46
Rate for Payer: Banner UC Health Medicare	$16.20
Rate for Payer: Bisbee Police All Plans	$28.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$73.44
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna of AZ Commercial	$75.60
Rate for Payer: Copperpoint Commercial	$26.73
Rate for Payer: Health Net of AZ Commercial	$64.80
Rate for Payer: Health Net of AZ Medicare	$30.24
Rate for Payer: Humana of AZ Medicare	$16.20
Rate for Payer: Mercy Care Medicaid	$383.46
Rate for Payer: Self Pay Self Pay	$86.40
Rate for Payer: TriWest Medicare	$16.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$62.96
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.44

CLIENT PHYSICAN EXAM FEMALE OVER 39

Facility

$132.00

Hospital Charge Code	22331443
Hospital Revenue Code	301
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$118.80
Rate for Payer: Aetna of AZ Commercial	$118.80
Rate for Payer: Aetna of AZ Medicare	$36.96
Rate for Payer: Allwell Medicare	$19.80
Rate for Payer: Amerigroup Medicare	$19.80
Rate for Payer: APIPA Medicare/Medicaid	$49.30
Rate for Payer: AZCH Complete Medicare	$19.80
Rate for Payer: Banner UC Health Medicare	$19.80
Rate for Payer: Bisbee Police All Plans	$34.32
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$89.76
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cigna of AZ Commercial	$85.80
Rate for Payer: Copperpoint Commercial	$32.67
Rate for Payer: Health Net of AZ Commercial	$79.20
Rate for Payer: Health Net of AZ Medicare	$36.96
Rate for Payer: Humana of AZ Medicare	$19.80
Rate for Payer: Self Pay Self Pay	$105.60
Rate for Payer: TriWest Medicare	$19.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$76.96
Rate for Payer: UnitedHealth Group of AZ Medicare	$23.76

CLIENT PHYSICAN EXAM FEMALE OVER 39

Facility

$132.00

Hospital Charge Code	22331443
Hospital Revenue Code	301
Min. Negotiated Rate	$34.32
Max. Negotiated Rate	$118.80
Rate for Payer: Aetna of AZ Commercial	$118.80
Rate for Payer: Bisbee Police All Plans	$34.32
Rate for Payer: Cash Price	$105.60
Rate for Payer: Self Pay Self Pay	$105.60

CLIENT PHYSICAN EXAM FEMALE UNDER 39

Facility

$70.00

Hospital Charge Code	22331444
Hospital Revenue Code	301
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna of AZ Commercial	$63.00
Rate for Payer: Aetna of AZ Medicare	$19.60
Rate for Payer: Allwell Medicare	$10.50
Rate for Payer: Amerigroup Medicare	$10.50
Rate for Payer: APIPA Medicare/Medicaid	$26.14
Rate for Payer: AZCH Complete Medicare	$10.50
Rate for Payer: Banner UC Health Medicare	$10.50
Rate for Payer: Bisbee Police All Plans	$18.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$47.60
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cigna of AZ Commercial	$45.50
Rate for Payer: Copperpoint Commercial	$17.32
Rate for Payer: Health Net of AZ Commercial	$42.00
Rate for Payer: Health Net of AZ Medicare	$19.60
Rate for Payer: Humana of AZ Medicare	$10.50
Rate for Payer: Self Pay Self Pay	$56.00
Rate for Payer: TriWest Medicare	$10.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$40.81
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.60

CLIENT PHYSICAN EXAM FEMALE UNDER 39

Facility

$70.00

Hospital Charge Code	22331444
Hospital Revenue Code	301
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna of AZ Commercial	$63.00
Rate for Payer: Bisbee Police All Plans	$18.20
Rate for Payer: Cash Price	$56.00
Rate for Payer: Self Pay Self Pay	$56.00

CLIENT PHYSICAN EXAM MALE OVER 39

Facility

$111.00

Hospital Charge Code	22331445
Hospital Revenue Code	301
Min. Negotiated Rate	$28.86
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of AZ Commercial	$99.90
Rate for Payer: Bisbee Police All Plans	$28.86
Rate for Payer: Cash Price	$88.80
Rate for Payer: Self Pay Self Pay	$88.80

CLIENT PHYSICAN EXAM MALE OVER 39

Facility

$111.00

Hospital Charge Code	22331445
Hospital Revenue Code	301
Min. Negotiated Rate	$16.65
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of AZ Commercial	$99.90
Rate for Payer: Aetna of AZ Medicare	$31.08
Rate for Payer: Allwell Medicare	$16.65
Rate for Payer: Amerigroup Medicare	$16.65
Rate for Payer: APIPA Medicare/Medicaid	$41.46
Rate for Payer: AZCH Complete Medicare	$16.65
Rate for Payer: Banner UC Health Medicare	$16.65
Rate for Payer: Bisbee Police All Plans	$28.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$75.48
Rate for Payer: Cash Price	$88.80
Rate for Payer: Cigna of AZ Commercial	$72.15
Rate for Payer: Copperpoint Commercial	$27.47
Rate for Payer: Health Net of AZ Commercial	$66.60
Rate for Payer: Health Net of AZ Medicare	$31.08
Rate for Payer: Humana of AZ Medicare	$16.65
Rate for Payer: Self Pay Self Pay	$88.80
Rate for Payer: TriWest Medicare	$16.65
Rate for Payer: UnitedHealth Group of AZ Commercial	$64.71
Rate for Payer: UnitedHealth Group of AZ Medicare	$19.98

CLIENT PHYSICAN EXAM MALE UNDER 39

Facility

$74.00

Hospital Charge Code	22331451
Hospital Revenue Code	301
Min. Negotiated Rate	$11.10
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Aetna of AZ Medicare	$20.72
Rate for Payer: Allwell Medicare	$11.10
Rate for Payer: Amerigroup Medicare	$11.10
Rate for Payer: APIPA Medicare/Medicaid	$27.64
Rate for Payer: AZCH Complete Medicare	$11.10
Rate for Payer: Banner UC Health Medicare	$11.10
Rate for Payer: Bisbee Police All Plans	$19.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$50.32
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cigna of AZ Commercial	$48.10
Rate for Payer: Copperpoint Commercial	$18.32
Rate for Payer: Health Net of AZ Commercial	$44.40
Rate for Payer: Health Net of AZ Medicare	$20.72
Rate for Payer: Humana of AZ Medicare	$11.10
Rate for Payer: Self Pay Self Pay	$59.20
Rate for Payer: TriWest Medicare	$11.10
Rate for Payer: UnitedHealth Group of AZ Commercial	$43.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$13.32

CLIENT PHYSICAN EXAM MALE UNDER 39

Facility

$74.00

Hospital Charge Code	22331451
Hospital Revenue Code	301
Min. Negotiated Rate	$19.24
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of AZ Commercial	$66.60
Rate for Payer: Bisbee Police All Plans	$19.24
Rate for Payer: Cash Price	$59.20
Rate for Payer: Self Pay Self Pay	$59.20

CLIENT RABIES VACCINE INJ (IM)

Facility

$350.00

Service Code	CPT 90675
Hospital Charge Code	22331466
Hospital Revenue Code	252
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$568.34
Rate for Payer: Aetna of AZ Commercial	$315.00
Rate for Payer: Aetna of AZ Medicare	$98.00
Rate for Payer: AHCCCS Medicaid	$568.34
Rate for Payer: Allwell Medicaid	$568.34
Rate for Payer: Allwell Medicare	$52.50
Rate for Payer: Amerigroup Medicare	$52.50
Rate for Payer: APIPA Medicare/Medicaid	$130.72
Rate for Payer: AZCH Complete Medicaid	$568.34
Rate for Payer: AZCH Complete Medicare	$52.50
Rate for Payer: Banner UC Health Medicaid	$568.34
Rate for Payer: Banner UC Health Medicare	$52.50
Rate for Payer: Bisbee Police All Plans	$91.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$238.00
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cigna of AZ Commercial	$227.50
Rate for Payer: Copperpoint Commercial	$86.62
Rate for Payer: Health Net of AZ Commercial	$210.00
Rate for Payer: Health Net of AZ Medicare	$98.00
Rate for Payer: Humana of AZ Medicare	$52.50
Rate for Payer: Mercy Care Medicaid	$568.34
Rate for Payer: Self Pay Self Pay	$280.00
Rate for Payer: TriWest Medicare	$52.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$204.05
Rate for Payer: UnitedHealth Group of AZ Medicare	$63.00

CLIENT RABIES VACCINE INJ (IM)

Facility

$350.00

Service Code	CPT 90675
Hospital Charge Code	22331466
Hospital Revenue Code	252
Min. Negotiated Rate	$91.00
Max. Negotiated Rate	$315.00
Rate for Payer: Aetna of AZ Commercial	$315.00
Rate for Payer: Bisbee Police All Plans	$91.00
Rate for Payer: Cash Price	$280.00
Rate for Payer: Self Pay Self Pay	$280.00

CLIENT RESPIRATOR FIT TEST

Facility

$22.00

Hospital Charge Code	22331471
Hospital Revenue Code	301
Min. Negotiated Rate	$5.72
Max. Negotiated Rate	$19.80
Rate for Payer: Aetna of AZ Commercial	$19.80
Rate for Payer: Bisbee Police All Plans	$5.72
Rate for Payer: Cash Price	$17.60
Rate for Payer: Self Pay Self Pay	$17.60

CLIENT RESPIRATOR FIT TEST

Facility

$22.00

Hospital Charge Code	22331471
Hospital Revenue Code	301
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$19.80
Rate for Payer: Aetna of AZ Commercial	$19.80
Rate for Payer: Aetna of AZ Medicare	$6.16
Rate for Payer: Allwell Medicare	$3.30
Rate for Payer: Amerigroup Medicare	$3.30
Rate for Payer: APIPA Medicare/Medicaid	$8.22
Rate for Payer: AZCH Complete Medicare	$3.30
Rate for Payer: Banner UC Health Medicare	$3.30
Rate for Payer: Bisbee Police All Plans	$5.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$14.96
Rate for Payer: Cash Price	$17.60
Rate for Payer: Cigna of AZ Commercial	$14.30
Rate for Payer: Copperpoint Commercial	$5.44
Rate for Payer: Health Net of AZ Commercial	$13.20
Rate for Payer: Health Net of AZ Medicare	$6.16
Rate for Payer: Humana of AZ Medicare	$3.30
Rate for Payer: Self Pay Self Pay	$17.60
Rate for Payer: TriWest Medicare	$3.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$12.83
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.96

CLIENT SLING ARM LARGE

Facility

$25.00

Hospital Charge Code	22331497
Hospital Revenue Code	270
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of AZ Commercial	$22.50
Rate for Payer: Bisbee Police All Plans	$6.50
Rate for Payer: Cash Price	$20.00
Rate for Payer: Self Pay Self Pay	$20.00

CLIENT SLING ARM LARGE

Facility

$25.00

Hospital Charge Code	22331497
Hospital Revenue Code	270
Min. Negotiated Rate	$3.75
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of AZ Commercial	$22.50
Rate for Payer: Aetna of AZ Medicare	$7.00
Rate for Payer: Allwell Medicare	$3.75
Rate for Payer: Amerigroup Medicare	$3.75
Rate for Payer: APIPA Medicare/Medicaid	$9.34
Rate for Payer: AZCH Complete Medicare	$3.75
Rate for Payer: Banner UC Health Medicare	$3.75
Rate for Payer: Bisbee Police All Plans	$6.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$17.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cigna of AZ Commercial	$17.50
Rate for Payer: Copperpoint Commercial	$6.19
Rate for Payer: Health Net of AZ Commercial	$15.00
Rate for Payer: Health Net of AZ Medicare	$7.00
Rate for Payer: Humana of AZ Medicare	$3.75
Rate for Payer: Self Pay Self Pay	$20.00
Rate for Payer: TriWest Medicare	$3.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$14.58
Rate for Payer: UnitedHealth Group of AZ Medicare	$4.50

CLIENT TB SKIN TEST (0.1 ML)

Facility

$36.00

Hospital Charge Code	22331518
Hospital Revenue Code	250
Min. Negotiated Rate	$5.40
Max. Negotiated Rate	$32.40
Rate for Payer: Aetna of AZ Commercial	$32.40
Rate for Payer: Aetna of AZ Medicare	$10.08
Rate for Payer: Allwell Medicare	$5.40
Rate for Payer: Amerigroup Medicare	$5.40
Rate for Payer: APIPA Medicare/Medicaid	$13.45
Rate for Payer: AZCH Complete Medicare	$5.40
Rate for Payer: Banner UC Health Medicare	$5.40
Rate for Payer: Bisbee Police All Plans	$9.36
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$24.48
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna of AZ Commercial	$23.40
Rate for Payer: Copperpoint Commercial	$8.91
Rate for Payer: Health Net of AZ Commercial	$21.60
Rate for Payer: Health Net of AZ Medicare	$10.08
Rate for Payer: Humana of AZ Medicare	$5.40
Rate for Payer: Self Pay Self Pay	$28.80
Rate for Payer: TriWest Medicare	$5.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$20.99
Rate for Payer: UnitedHealth Group of AZ Medicare	$6.48

CLIENT TB SKIN TEST (0.1 ML)

Facility

$36.00

Hospital Charge Code	22331518
Hospital Revenue Code	250
Min. Negotiated Rate	$9.36
Max. Negotiated Rate	$32.40
Rate for Payer: Aetna of AZ Commercial	$32.40
Rate for Payer: Bisbee Police All Plans	$9.36
Rate for Payer: Cash Price	$28.80
Rate for Payer: Self Pay Self Pay	$28.80

Know your out-of-pocket cost for care.

All Charges