Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Manual Differential Standard

Facility

$45.00

Service Code	CPT 85007
Hospital Charge Code	22242914
Hospital Revenue Code	305
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$40.50
Rate for Payer: Aetna of AZ Commercial	$40.50
Rate for Payer: Bisbee Police All Plans	$11.70
Rate for Payer: Cash Price	$36.00
Rate for Payer: Self Pay Self Pay	$36.00

Manual Therapy Charge Units

Facility

$181.00

Service Code	CPT 97140 GP
Hospital Charge Code	692252
Hospital Revenue Code	420
Min. Negotiated Rate	$28.96
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Aetna of AZ Medicare	$50.68
Rate for Payer: Allwell Medicare	$28.96
Rate for Payer: Amerigroup Medicare	$28.96
Rate for Payer: APIPA Medicare/Medicaid	$67.60
Rate for Payer: AZCH Complete Medicare	$28.96
Rate for Payer: Banner UC Health Medicare	$28.96
Rate for Payer: Bisbee Police All Plans	$47.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$123.08
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cigna of AZ Commercial	$126.70
Rate for Payer: Copperpoint Commercial	$44.80
Rate for Payer: Health Net of AZ Commercial	$108.60
Rate for Payer: Health Net of AZ Medicare	$50.68
Rate for Payer: Humana of AZ Medicare	$28.96
Rate for Payer: Self Pay Self Pay	$144.80
Rate for Payer: TriWest Medicare	$28.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$105.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$32.58

Manual Therapy Charge Units

Facility

$181.00

Service Code	CPT 97140 GP
Hospital Charge Code	692252
Hospital Revenue Code	420
Min. Negotiated Rate	$47.06
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Bisbee Police All Plans	$47.06
Rate for Payer: Cash Price	$144.80
Rate for Payer: Self Pay Self Pay	$144.80

MASIMO INFANT SENSOR 18IN

Facility

$67.00

Hospital Charge Code	24316100
Hospital Revenue Code	270
Min. Negotiated Rate	$17.42
Max. Negotiated Rate	$60.30
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Bisbee Police All Plans	$17.42
Rate for Payer: Cash Price	$53.60
Rate for Payer: Self Pay Self Pay	$53.60

MASIMO INFANT SENSOR 18IN

Facility

$67.00

Hospital Charge Code	24316100
Hospital Revenue Code	270
Min. Negotiated Rate	$10.72
Max. Negotiated Rate	$60.30
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Aetna of AZ Medicare	$18.76
Rate for Payer: Allwell Medicare	$10.72
Rate for Payer: Amerigroup Medicare	$10.72
Rate for Payer: APIPA Medicare/Medicaid	$25.02
Rate for Payer: AZCH Complete Medicare	$10.72
Rate for Payer: Banner UC Health Medicare	$10.72
Rate for Payer: Bisbee Police All Plans	$17.42
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$45.56
Rate for Payer: Cash Price	$53.60
Rate for Payer: Cigna of AZ Commercial	$46.90
Rate for Payer: Copperpoint Commercial	$16.58
Rate for Payer: Health Net of AZ Commercial	$40.20
Rate for Payer: Health Net of AZ Medicare	$18.76
Rate for Payer: Humana of AZ Medicare	$10.72
Rate for Payer: Self Pay Self Pay	$53.60
Rate for Payer: TriWest Medicare	$10.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$39.06
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.06

MASK AEROSOL PED

Facility

$563.00

Hospital Charge Code	22354238
Hospital Revenue Code	270
Min. Negotiated Rate	$90.08
Max. Negotiated Rate	$506.70
Rate for Payer: Aetna of AZ Commercial	$506.70
Rate for Payer: Aetna of AZ Medicare	$157.64
Rate for Payer: Allwell Medicare	$90.08
Rate for Payer: Amerigroup Medicare	$90.08
Rate for Payer: APIPA Medicare/Medicaid	$210.28
Rate for Payer: AZCH Complete Medicare	$90.08
Rate for Payer: Banner UC Health Medicare	$90.08
Rate for Payer: Bisbee Police All Plans	$146.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$382.84
Rate for Payer: Cash Price	$450.40
Rate for Payer: Cigna of AZ Commercial	$394.10
Rate for Payer: Copperpoint Commercial	$139.34
Rate for Payer: Health Net of AZ Commercial	$337.80
Rate for Payer: Health Net of AZ Medicare	$157.64
Rate for Payer: Humana of AZ Medicare	$90.08
Rate for Payer: Self Pay Self Pay	$450.40
Rate for Payer: TriWest Medicare	$90.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$328.23
Rate for Payer: UnitedHealth Group of AZ Medicare	$101.34

MASK AEROSOL PED

Facility

$563.00

Hospital Charge Code	22354238
Hospital Revenue Code	270
Min. Negotiated Rate	$146.38
Max. Negotiated Rate	$506.70
Rate for Payer: Aetna of AZ Commercial	$506.70
Rate for Payer: Bisbee Police All Plans	$146.38
Rate for Payer: Cash Price	$450.40
Rate for Payer: Self Pay Self Pay	$450.40

MASK AMBU INFANT

Facility

$131.00

Hospital Charge Code	22355208
Hospital Revenue Code	270
Min. Negotiated Rate	$34.06
Max. Negotiated Rate	$117.90
Rate for Payer: Aetna of AZ Commercial	$117.90
Rate for Payer: Bisbee Police All Plans	$34.06
Rate for Payer: Cash Price	$104.80
Rate for Payer: Self Pay Self Pay	$104.80

MASK AMBU INFANT

Facility

$131.00

Hospital Charge Code	22355208
Hospital Revenue Code	270
Min. Negotiated Rate	$20.96
Max. Negotiated Rate	$117.90
Rate for Payer: Aetna of AZ Commercial	$117.90
Rate for Payer: Aetna of AZ Medicare	$36.68
Rate for Payer: Allwell Medicare	$20.96
Rate for Payer: Amerigroup Medicare	$20.96
Rate for Payer: APIPA Medicare/Medicaid	$48.93
Rate for Payer: AZCH Complete Medicare	$20.96
Rate for Payer: Banner UC Health Medicare	$20.96
Rate for Payer: Bisbee Police All Plans	$34.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$89.08
Rate for Payer: Cash Price	$104.80
Rate for Payer: Cigna of AZ Commercial	$91.70
Rate for Payer: Copperpoint Commercial	$32.42
Rate for Payer: Health Net of AZ Commercial	$78.60
Rate for Payer: Health Net of AZ Medicare	$36.68
Rate for Payer: Humana of AZ Medicare	$20.96
Rate for Payer: Self Pay Self Pay	$104.80
Rate for Payer: TriWest Medicare	$20.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$76.37
Rate for Payer: UnitedHealth Group of AZ Medicare	$23.58

MASK AMBU NEONATE

Facility

$149.00

Hospital Charge Code	22355207
Hospital Revenue Code	270
Min. Negotiated Rate	$38.74
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of AZ Commercial	$134.10
Rate for Payer: Bisbee Police All Plans	$38.74
Rate for Payer: Cash Price	$119.20
Rate for Payer: Self Pay Self Pay	$119.20

MASK AMBU NEONATE

Facility

$149.00

Hospital Charge Code	22355207
Hospital Revenue Code	270
Min. Negotiated Rate	$23.84
Max. Negotiated Rate	$134.10
Rate for Payer: Aetna of AZ Commercial	$134.10
Rate for Payer: Aetna of AZ Medicare	$41.72
Rate for Payer: Allwell Medicare	$23.84
Rate for Payer: Amerigroup Medicare	$23.84
Rate for Payer: APIPA Medicare/Medicaid	$55.65
Rate for Payer: AZCH Complete Medicare	$23.84
Rate for Payer: Banner UC Health Medicare	$23.84
Rate for Payer: Bisbee Police All Plans	$38.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$101.32
Rate for Payer: Cash Price	$119.20
Rate for Payer: Cigna of AZ Commercial	$104.30
Rate for Payer: Copperpoint Commercial	$36.88
Rate for Payer: Health Net of AZ Commercial	$89.40
Rate for Payer: Health Net of AZ Medicare	$41.72
Rate for Payer: Humana of AZ Medicare	$23.84
Rate for Payer: Self Pay Self Pay	$119.20
Rate for Payer: TriWest Medicare	$23.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$86.87
Rate for Payer: UnitedHealth Group of AZ Medicare	$26.82

MASK BIPAP FULL FACE LARGE

Facility

$120.00

Hospital Charge Code	22354321
Hospital Revenue Code	270
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Bisbee Police All Plans	$31.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Self Pay Self Pay	$96.00

MASK BIPAP FULL FACE LARGE

Facility

$120.00

Hospital Charge Code	22354321
Hospital Revenue Code	270
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Aetna of AZ Medicare	$33.60
Rate for Payer: Allwell Medicare	$19.20
Rate for Payer: Amerigroup Medicare	$19.20
Rate for Payer: APIPA Medicare/Medicaid	$44.82
Rate for Payer: AZCH Complete Medicare	$19.20
Rate for Payer: Banner UC Health Medicare	$19.20
Rate for Payer: Bisbee Police All Plans	$31.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$81.60
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cigna of AZ Commercial	$84.00
Rate for Payer: Copperpoint Commercial	$29.70
Rate for Payer: Health Net of AZ Commercial	$72.00
Rate for Payer: Health Net of AZ Medicare	$33.60
Rate for Payer: Humana of AZ Medicare	$19.20
Rate for Payer: Self Pay Self Pay	$96.00
Rate for Payer: TriWest Medicare	$19.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$69.96
Rate for Payer: UnitedHealth Group of AZ Medicare	$21.60

MASK BIPAP FULL FACE MED

Facility

$120.00

Hospital Charge Code	22354319
Hospital Revenue Code	270
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Bisbee Police All Plans	$31.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Self Pay Self Pay	$96.00

MASK BIPAP FULL FACE MED

Facility

$120.00

Hospital Charge Code	22354319
Hospital Revenue Code	270
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Aetna of AZ Medicare	$33.60
Rate for Payer: Allwell Medicare	$19.20
Rate for Payer: Amerigroup Medicare	$19.20
Rate for Payer: APIPA Medicare/Medicaid	$44.82
Rate for Payer: AZCH Complete Medicare	$19.20
Rate for Payer: Banner UC Health Medicare	$19.20
Rate for Payer: Bisbee Police All Plans	$31.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$81.60
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cigna of AZ Commercial	$84.00
Rate for Payer: Copperpoint Commercial	$29.70
Rate for Payer: Health Net of AZ Commercial	$72.00
Rate for Payer: Health Net of AZ Medicare	$33.60
Rate for Payer: Humana of AZ Medicare	$19.20
Rate for Payer: Self Pay Self Pay	$96.00
Rate for Payer: TriWest Medicare	$19.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$69.96
Rate for Payer: UnitedHealth Group of AZ Medicare	$21.60

MASK BIPAP FULL FACE SMALL

Facility

$120.00

Hospital Charge Code	22354320
Hospital Revenue Code	270
Min. Negotiated Rate	$19.20
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Aetna of AZ Medicare	$33.60
Rate for Payer: Allwell Medicare	$19.20
Rate for Payer: Amerigroup Medicare	$19.20
Rate for Payer: APIPA Medicare/Medicaid	$44.82
Rate for Payer: AZCH Complete Medicare	$19.20
Rate for Payer: Banner UC Health Medicare	$19.20
Rate for Payer: Bisbee Police All Plans	$31.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$81.60
Rate for Payer: Cash Price	$96.00
Rate for Payer: Cigna of AZ Commercial	$84.00
Rate for Payer: Copperpoint Commercial	$29.70
Rate for Payer: Health Net of AZ Commercial	$72.00
Rate for Payer: Health Net of AZ Medicare	$33.60
Rate for Payer: Humana of AZ Medicare	$19.20
Rate for Payer: Self Pay Self Pay	$96.00
Rate for Payer: TriWest Medicare	$19.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$69.96
Rate for Payer: UnitedHealth Group of AZ Medicare	$21.60

MASK BIPAP FULL FACE SMALL

Facility

$120.00

Hospital Charge Code	22354320
Hospital Revenue Code	270
Min. Negotiated Rate	$31.20
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Bisbee Police All Plans	$31.20
Rate for Payer: Cash Price	$96.00
Rate for Payer: Self Pay Self Pay	$96.00

MASK LARYNGEAL #2 DISPOSABLE

Facility

$44.00

Hospital Charge Code	22570783
Hospital Revenue Code	272
Min. Negotiated Rate	$7.04
Max. Negotiated Rate	$39.60
Rate for Payer: Aetna of AZ Commercial	$39.60
Rate for Payer: Aetna of AZ Medicare	$12.32
Rate for Payer: Allwell Medicare	$7.04
Rate for Payer: Amerigroup Medicare	$7.04
Rate for Payer: APIPA Medicare/Medicaid	$16.43
Rate for Payer: AZCH Complete Medicare	$7.04
Rate for Payer: Banner UC Health Medicare	$7.04
Rate for Payer: Bisbee Police All Plans	$11.44
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$29.92
Rate for Payer: Cash Price	$35.20
Rate for Payer: Cigna of AZ Commercial	$30.80
Rate for Payer: Copperpoint Commercial	$10.89
Rate for Payer: Health Net of AZ Commercial	$26.40
Rate for Payer: Health Net of AZ Medicare	$12.32
Rate for Payer: Humana of AZ Medicare	$7.04
Rate for Payer: Self Pay Self Pay	$35.20
Rate for Payer: TriWest Medicare	$7.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$25.65
Rate for Payer: UnitedHealth Group of AZ Medicare	$7.92

MASK LARYNGEAL #2 DISPOSABLE

Facility

$44.00

Hospital Charge Code	22570783
Hospital Revenue Code	272
Min. Negotiated Rate	$11.44
Max. Negotiated Rate	$39.60
Rate for Payer: Aetna of AZ Commercial	$39.60
Rate for Payer: Bisbee Police All Plans	$11.44
Rate for Payer: Cash Price	$35.20
Rate for Payer: Self Pay Self Pay	$35.20

MASK LARYNGEAL NO. 1 DISPOSABLE

Facility

$41.00

Hospital Charge Code	22570781
Hospital Revenue Code	270
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of AZ Commercial	$36.90
Rate for Payer: Bisbee Police All Plans	$10.66
Rate for Payer: Cash Price	$32.80
Rate for Payer: Self Pay Self Pay	$32.80

MASK LARYNGEAL NO. 1 DISPOSABLE

Facility

$41.00

Hospital Charge Code	22570781
Hospital Revenue Code	270
Min. Negotiated Rate	$6.56
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of AZ Commercial	$36.90
Rate for Payer: Aetna of AZ Medicare	$11.48
Rate for Payer: Allwell Medicare	$6.56
Rate for Payer: Amerigroup Medicare	$6.56
Rate for Payer: APIPA Medicare/Medicaid	$15.31
Rate for Payer: AZCH Complete Medicare	$6.56
Rate for Payer: Banner UC Health Medicare	$6.56
Rate for Payer: Bisbee Police All Plans	$10.66
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$27.88
Rate for Payer: Cash Price	$32.80
Rate for Payer: Cigna of AZ Commercial	$28.70
Rate for Payer: Copperpoint Commercial	$10.15
Rate for Payer: Health Net of AZ Commercial	$24.60
Rate for Payer: Health Net of AZ Medicare	$11.48
Rate for Payer: Humana of AZ Medicare	$6.56
Rate for Payer: Self Pay Self Pay	$32.80
Rate for Payer: TriWest Medicare	$6.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$23.90
Rate for Payer: UnitedHealth Group of AZ Medicare	$7.38

MASK LARYNGEAL NO.3 DISPOSABLE

Facility

$65.00

Hospital Charge Code	22354933
Hospital Revenue Code	270
Min. Negotiated Rate	$16.90
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of AZ Commercial	$58.50
Rate for Payer: Bisbee Police All Plans	$16.90
Rate for Payer: Cash Price	$52.00
Rate for Payer: Self Pay Self Pay	$52.00

MASK LARYNGEAL NO.3 DISPOSABLE

Facility

$65.00

Hospital Charge Code	22354933
Hospital Revenue Code	270
Min. Negotiated Rate	$10.40
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of AZ Commercial	$58.50
Rate for Payer: Aetna of AZ Medicare	$18.20
Rate for Payer: Allwell Medicare	$10.40
Rate for Payer: Amerigroup Medicare	$10.40
Rate for Payer: APIPA Medicare/Medicaid	$24.28
Rate for Payer: AZCH Complete Medicare	$10.40
Rate for Payer: Banner UC Health Medicare	$10.40
Rate for Payer: Bisbee Police All Plans	$16.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$44.20
Rate for Payer: Cash Price	$52.00
Rate for Payer: Cigna of AZ Commercial	$45.50
Rate for Payer: Copperpoint Commercial	$16.09
Rate for Payer: Health Net of AZ Commercial	$39.00
Rate for Payer: Health Net of AZ Medicare	$18.20
Rate for Payer: Humana of AZ Medicare	$10.40
Rate for Payer: Self Pay Self Pay	$52.00
Rate for Payer: TriWest Medicare	$10.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$37.90
Rate for Payer: UnitedHealth Group of AZ Medicare	$11.70

MASK LARYNGEAL NO.4 DISPOSABLE

Facility

$76.00

Hospital Charge Code	22354934
Hospital Revenue Code	270
Min. Negotiated Rate	$19.76
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of AZ Commercial	$68.40
Rate for Payer: Bisbee Police All Plans	$19.76
Rate for Payer: Cash Price	$60.80
Rate for Payer: Self Pay Self Pay	$60.80

MASK LARYNGEAL NO.4 DISPOSABLE

Facility

$76.00

Hospital Charge Code	22354934
Hospital Revenue Code	270
Min. Negotiated Rate	$12.16
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of AZ Commercial	$68.40
Rate for Payer: Aetna of AZ Medicare	$21.28
Rate for Payer: Allwell Medicare	$12.16
Rate for Payer: Amerigroup Medicare	$12.16
Rate for Payer: APIPA Medicare/Medicaid	$28.39
Rate for Payer: AZCH Complete Medicare	$12.16
Rate for Payer: Banner UC Health Medicare	$12.16
Rate for Payer: Bisbee Police All Plans	$19.76
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$51.68
Rate for Payer: Cash Price	$60.80
Rate for Payer: Cigna of AZ Commercial	$53.20
Rate for Payer: Copperpoint Commercial	$18.81
Rate for Payer: Health Net of AZ Commercial	$45.60
Rate for Payer: Health Net of AZ Medicare	$21.28
Rate for Payer: Humana of AZ Medicare	$12.16
Rate for Payer: Self Pay Self Pay	$60.80
Rate for Payer: TriWest Medicare	$12.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$44.31
Rate for Payer: UnitedHealth Group of AZ Medicare	$13.68

Know your out-of-pocket cost for care.

All Charges