Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

99284 - ED Level 4

Facility

$2,318.00

Service Code	CPT 99284
Hospital Charge Code	22283178
Hospital Revenue Code	450
Min. Negotiated Rate	$602.68
Max. Negotiated Rate	$2,086.20
Rate for Payer: Aetna of AZ Commercial	$2,086.20
Rate for Payer: Bisbee Police All Plans	$602.68
Rate for Payer: Cash Price	$1,854.40
Rate for Payer: Self Pay Self Pay	$1,854.40

99284 - ED Level 4

Facility

$2,318.00

Service Code	CPT 99284
Hospital Charge Code	22283178
Hospital Revenue Code	450
Min. Negotiated Rate	$347.70
Max. Negotiated Rate	$2,086.20
Rate for Payer: Aetna of AZ Commercial	$2,086.20
Rate for Payer: Aetna of AZ Medicare	$649.04
Rate for Payer: AHCCCS Medicaid	$442.36
Rate for Payer: Allwell Medicaid	$442.36
Rate for Payer: Allwell Medicare	$347.70
Rate for Payer: Amerigroup Medicare	$347.70
Rate for Payer: APIPA Medicare/Medicaid	$865.77
Rate for Payer: AZCH Complete Medicaid	$442.36
Rate for Payer: AZCH Complete Medicare	$347.70
Rate for Payer: Banner UC Health Medicaid	$442.36
Rate for Payer: Banner UC Health Medicare	$347.70
Rate for Payer: Bisbee Police All Plans	$602.68
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,576.24
Rate for Payer: Cash Price	$1,854.40
Rate for Payer: Cash Price	$1,854.40
Rate for Payer: Cash Price	$1,854.40
Rate for Payer: Cigna of AZ Commercial	$1,622.60
Rate for Payer: Copperpoint Commercial	$573.70
Rate for Payer: Health Net of AZ Commercial	$1,390.80
Rate for Payer: Health Net of AZ Medicare	$649.04
Rate for Payer: Humana of AZ Medicare	$347.70
Rate for Payer: Mercy Care Medicaid	$442.36
Rate for Payer: Self Pay Self Pay	$1,854.40
Rate for Payer: TriWest Medicare	$347.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,190.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$417.24

99285 - ED Level 5

Facility

$3,448.00

Service Code	CPT 99285
Hospital Charge Code	22283179
Hospital Revenue Code	450
Min. Negotiated Rate	$517.20
Max. Negotiated Rate	$3,103.20
Rate for Payer: Aetna of AZ Commercial	$3,103.20
Rate for Payer: Aetna of AZ Medicare	$965.44
Rate for Payer: AHCCCS Medicaid	$664.80
Rate for Payer: Allwell Medicaid	$664.80
Rate for Payer: Allwell Medicare	$517.20
Rate for Payer: Amerigroup Medicare	$517.20
Rate for Payer: APIPA Medicare/Medicaid	$1,287.83
Rate for Payer: AZCH Complete Medicaid	$664.80
Rate for Payer: AZCH Complete Medicare	$517.20
Rate for Payer: Banner UC Health Medicaid	$664.80
Rate for Payer: Banner UC Health Medicare	$517.20
Rate for Payer: Bisbee Police All Plans	$896.48
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,344.64
Rate for Payer: Cash Price	$2,758.40
Rate for Payer: Cash Price	$2,758.40
Rate for Payer: Cash Price	$2,758.40
Rate for Payer: Cigna of AZ Commercial	$2,413.60
Rate for Payer: Copperpoint Commercial	$853.38
Rate for Payer: Health Net of AZ Commercial	$2,068.80
Rate for Payer: Health Net of AZ Medicare	$965.44
Rate for Payer: Humana of AZ Medicare	$517.20
Rate for Payer: Mercy Care Medicaid	$664.80
Rate for Payer: Self Pay Self Pay	$2,758.40
Rate for Payer: TriWest Medicare	$517.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,544.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$620.64

99285 - ED Level 5

Facility

$3,448.00

Service Code	CPT 99285
Hospital Charge Code	22283179
Hospital Revenue Code	450
Min. Negotiated Rate	$896.48
Max. Negotiated Rate	$3,103.20
Rate for Payer: Aetna of AZ Commercial	$3,103.20
Rate for Payer: Bisbee Police All Plans	$896.48
Rate for Payer: Cash Price	$2,758.40
Rate for Payer: Self Pay Self Pay	$2,758.40

99291 - ED Critical Care

Facility

$3,576.00

Service Code	CPT 99291
Hospital Charge Code	22283180
Hospital Revenue Code	450
Min. Negotiated Rate	$929.76
Max. Negotiated Rate	$3,218.40
Rate for Payer: Aetna of AZ Commercial	$3,218.40
Rate for Payer: Bisbee Police All Plans	$929.76
Rate for Payer: Cash Price	$2,860.80
Rate for Payer: Self Pay Self Pay	$2,860.80

99291 - ED Critical Care

Facility

$3,576.00

Service Code	CPT 99291
Hospital Charge Code	22283180
Hospital Revenue Code	450
Min. Negotiated Rate	$536.40
Max. Negotiated Rate	$3,218.40
Rate for Payer: Aetna of AZ Commercial	$3,218.40
Rate for Payer: Aetna of AZ Medicare	$1,001.28
Rate for Payer: AHCCCS Medicaid	$1,004.38
Rate for Payer: Allwell Medicaid	$1,004.38
Rate for Payer: Allwell Medicare	$536.40
Rate for Payer: Amerigroup Medicare	$536.40
Rate for Payer: APIPA Medicare/Medicaid	$1,335.64
Rate for Payer: AZCH Complete Medicaid	$1,004.38
Rate for Payer: AZCH Complete Medicare	$536.40
Rate for Payer: Banner UC Health Medicaid	$1,004.38
Rate for Payer: Banner UC Health Medicare	$536.40
Rate for Payer: Bisbee Police All Plans	$929.76
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,431.68
Rate for Payer: Cash Price	$2,860.80
Rate for Payer: Cash Price	$2,860.80
Rate for Payer: Cash Price	$2,860.80
Rate for Payer: Cigna of AZ Commercial	$2,503.20
Rate for Payer: Copperpoint Commercial	$885.06
Rate for Payer: Health Net of AZ Commercial	$2,145.60
Rate for Payer: Health Net of AZ Medicare	$1,001.28
Rate for Payer: Humana of AZ Medicare	$536.40
Rate for Payer: Mercy Care Medicaid	$1,004.38
Rate for Payer: Self Pay Self Pay	$2,860.80
Rate for Payer: TriWest Medicare	$536.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,249.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$643.68

99292 - ED Critical Care, each 30 min

Facility

$1,822.00

Service Code	CPT 99292
Hospital Charge Code	22283181
Hospital Revenue Code	450
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$1,639.80
Rate for Payer: Aetna of AZ Commercial	$1,639.80
Rate for Payer: Aetna of AZ Medicare	$510.16
Rate for Payer: AHCCCS Medicaid	$0.13
Rate for Payer: Allwell Medicaid	$0.13
Rate for Payer: Allwell Medicare	$273.30
Rate for Payer: Amerigroup Medicare	$273.30
Rate for Payer: APIPA Medicare/Medicaid	$680.52
Rate for Payer: AZCH Complete Medicaid	$0.13
Rate for Payer: AZCH Complete Medicare	$273.30
Rate for Payer: Banner UC Health Medicaid	$0.13
Rate for Payer: Banner UC Health Medicare	$273.30
Rate for Payer: Bisbee Police All Plans	$473.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,238.96
Rate for Payer: Cash Price	$1,457.60
Rate for Payer: Cash Price	$1,457.60
Rate for Payer: Cigna of AZ Commercial	$1,275.40
Rate for Payer: Copperpoint Commercial	$450.94
Rate for Payer: Health Net of AZ Commercial	$1,093.20
Rate for Payer: Health Net of AZ Medicare	$510.16
Rate for Payer: Humana of AZ Medicare	$273.30
Rate for Payer: Mercy Care Medicaid	$0.13
Rate for Payer: Self Pay Self Pay	$1,457.60
Rate for Payer: TriWest Medicare	$273.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,062.23
Rate for Payer: UnitedHealth Group of AZ Medicare	$327.96

99292 - ED Critical Care, each 30 min

Facility

$1,822.00

Service Code	CPT 99292
Hospital Charge Code	22283181
Hospital Revenue Code	450
Min. Negotiated Rate	$473.72
Max. Negotiated Rate	$1,639.80
Rate for Payer: Aetna of AZ Commercial	$1,639.80
Rate for Payer: Bisbee Police All Plans	$473.72
Rate for Payer: Cash Price	$1,457.60
Rate for Payer: Self Pay Self Pay	$1,457.60

abatacept 250 mg REC [CQCH]

Facility

$1,338.50

Service Code	HCPCS J0129
Hospital Charge Code	220821185
Hospital Revenue Code	250
Min. Negotiated Rate	$348.01
Max. Negotiated Rate	$1,204.65
Rate for Payer: Aetna of AZ Commercial	$1,204.65
Rate for Payer: Bisbee Police All Plans	$348.01
Rate for Payer: Cash Price	$1,070.80
Rate for Payer: Self Pay Self Pay	$1,070.80

abatacept 250 mg REC [CQCH]

Facility

$1,338.50

Service Code	HCPCS J0129
Hospital Charge Code	220821185
Hospital Revenue Code	250
Min. Negotiated Rate	$69.60
Max. Negotiated Rate	$1,204.65
Rate for Payer: Aetna of AZ Commercial	$1,204.65
Rate for Payer: Aetna of AZ Medicare	$374.78
Rate for Payer: AHCCCS Medicaid	$69.60
Rate for Payer: Allwell Medicaid	$69.60
Rate for Payer: Allwell Medicare	$200.78
Rate for Payer: Amerigroup Medicare	$200.78
Rate for Payer: APIPA Medicare/Medicaid	$499.93
Rate for Payer: AZCH Complete Medicaid	$69.60
Rate for Payer: AZCH Complete Medicare	$200.78
Rate for Payer: Banner UC Health Medicaid	$69.60
Rate for Payer: Banner UC Health Medicare	$200.78
Rate for Payer: Bisbee Police All Plans	$348.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$910.18
Rate for Payer: Cash Price	$1,070.80
Rate for Payer: Cash Price	$1,070.80
Rate for Payer: Cigna of AZ Commercial	$870.02
Rate for Payer: Copperpoint Commercial	$331.28
Rate for Payer: Health Net of AZ Commercial	$803.10
Rate for Payer: Health Net of AZ Medicare	$374.78
Rate for Payer: Humana of AZ Medicare	$200.78
Rate for Payer: Mercy Care Medicaid	$69.60
Rate for Payer: Self Pay Self Pay	$1,070.80
Rate for Payer: TriWest Medicare	$200.78
Rate for Payer: UnitedHealth Group of AZ Commercial	$780.35
Rate for Payer: UnitedHealth Group of AZ Medicare	$240.93

Abdominal Pain

Facility

$3,504.19

Service Code	APR-DRG 2511
Hospital Charge Code	APRDRG2514
Min. Negotiated Rate	$3,504.19
Max. Negotiated Rate	$3,504.19
Rate for Payer: AHCCCS Medicaid	$3,504.19
Rate for Payer: Allwell Medicaid	$3,504.19
Rate for Payer: AZCH Complete Medicaid	$3,504.19
Rate for Payer: Banner UC Health Medicaid	$3,504.19
Rate for Payer: Mercy Care Medicaid	$3,504.19

Abdominal Pain

Facility

$4,198.58

Service Code	APR-DRG 2512
Hospital Charge Code	APRDRG2512
Min. Negotiated Rate	$4,198.58
Max. Negotiated Rate	$4,198.58
Rate for Payer: AHCCCS Medicaid	$4,198.58
Rate for Payer: Allwell Medicaid	$4,198.58
Rate for Payer: AZCH Complete Medicaid	$4,198.58
Rate for Payer: Banner UC Health Medicaid	$4,198.58
Rate for Payer: Mercy Care Medicaid	$4,198.58

Abdominal Pain

Facility

$5,578.94

Service Code	APR-DRG 2513
Hospital Charge Code	APRDRG2512
Min. Negotiated Rate	$5,578.94
Max. Negotiated Rate	$5,578.94
Rate for Payer: AHCCCS Medicaid	$5,578.94
Rate for Payer: Allwell Medicaid	$5,578.94
Rate for Payer: AZCH Complete Medicaid	$5,578.94
Rate for Payer: Banner UC Health Medicaid	$5,578.94
Rate for Payer: Mercy Care Medicaid	$5,578.94

Abdominal Pain

Facility

$10,527.31

Service Code	APR-DRG 2514
Hospital Charge Code	APRDRG2513
Min. Negotiated Rate	$10,527.31
Max. Negotiated Rate	$10,527.31
Rate for Payer: AHCCCS Medicaid	$10,527.31
Rate for Payer: Allwell Medicaid	$10,527.31
Rate for Payer: AZCH Complete Medicaid	$10,527.31
Rate for Payer: Banner UC Health Medicaid	$10,527.31
Rate for Payer: Mercy Care Medicaid	$10,527.31

Abdominal Pain

Facility

$10,527.31

Service Code	APR-DRG 2514
Hospital Charge Code	APRDRG2514
Min. Negotiated Rate	$10,527.31
Max. Negotiated Rate	$10,527.31
Rate for Payer: AHCCCS Medicaid	$10,527.31
Rate for Payer: Allwell Medicaid	$10,527.31
Rate for Payer: AZCH Complete Medicaid	$10,527.31
Rate for Payer: Banner UC Health Medicaid	$10,527.31
Rate for Payer: Mercy Care Medicaid	$10,527.31

Abdominal Pain

Facility

$10,527.31

Service Code	APR-DRG 2514
Hospital Charge Code	APRDRG2511
Min. Negotiated Rate	$10,527.31
Max. Negotiated Rate	$10,527.31
Rate for Payer: AHCCCS Medicaid	$10,527.31
Rate for Payer: Allwell Medicaid	$10,527.31
Rate for Payer: AZCH Complete Medicaid	$10,527.31
Rate for Payer: Banner UC Health Medicaid	$10,527.31
Rate for Payer: Mercy Care Medicaid	$10,527.31

Abdominal Pain

Facility

$5,578.94

Service Code	APR-DRG 2513
Hospital Charge Code	APRDRG2514
Min. Negotiated Rate	$5,578.94
Max. Negotiated Rate	$5,578.94
Rate for Payer: AHCCCS Medicaid	$5,578.94
Rate for Payer: Allwell Medicaid	$5,578.94
Rate for Payer: AZCH Complete Medicaid	$5,578.94
Rate for Payer: Banner UC Health Medicaid	$5,578.94
Rate for Payer: Mercy Care Medicaid	$5,578.94

Abdominal Pain

Facility

$5,578.94

Service Code	APR-DRG 2513
Hospital Charge Code	APRDRG2513
Min. Negotiated Rate	$5,578.94
Max. Negotiated Rate	$5,578.94
Rate for Payer: AHCCCS Medicaid	$5,578.94
Rate for Payer: Allwell Medicaid	$5,578.94
Rate for Payer: AZCH Complete Medicaid	$5,578.94
Rate for Payer: Banner UC Health Medicaid	$5,578.94
Rate for Payer: Mercy Care Medicaid	$5,578.94

Abdominal Pain

Facility

$4,198.58

Service Code	APR-DRG 2512
Hospital Charge Code	APRDRG2514
Min. Negotiated Rate	$4,198.58
Max. Negotiated Rate	$4,198.58
Rate for Payer: AHCCCS Medicaid	$4,198.58
Rate for Payer: Allwell Medicaid	$4,198.58
Rate for Payer: AZCH Complete Medicaid	$4,198.58
Rate for Payer: Banner UC Health Medicaid	$4,198.58
Rate for Payer: Mercy Care Medicaid	$4,198.58

Abdominal Pain

Facility

$3,504.19

Service Code	APR-DRG 2511
Hospital Charge Code	APRDRG2513
Min. Negotiated Rate	$3,504.19
Max. Negotiated Rate	$3,504.19
Rate for Payer: AHCCCS Medicaid	$3,504.19
Rate for Payer: Allwell Medicaid	$3,504.19
Rate for Payer: AZCH Complete Medicaid	$3,504.19
Rate for Payer: Banner UC Health Medicaid	$3,504.19
Rate for Payer: Mercy Care Medicaid	$3,504.19

Abdominal Pain

Facility

$10,527.31

Service Code	APR-DRG 2514
Hospital Charge Code	APRDRG2512
Min. Negotiated Rate	$10,527.31
Max. Negotiated Rate	$10,527.31
Rate for Payer: AHCCCS Medicaid	$10,527.31
Rate for Payer: Allwell Medicaid	$10,527.31
Rate for Payer: AZCH Complete Medicaid	$10,527.31
Rate for Payer: Banner UC Health Medicaid	$10,527.31
Rate for Payer: Mercy Care Medicaid	$10,527.31

Abdominal Pain

Facility

$5,578.94

Service Code	APR-DRG 2513
Hospital Charge Code	APRDRG2511
Min. Negotiated Rate	$5,578.94
Max. Negotiated Rate	$5,578.94
Rate for Payer: AHCCCS Medicaid	$5,578.94
Rate for Payer: Allwell Medicaid	$5,578.94
Rate for Payer: AZCH Complete Medicaid	$5,578.94
Rate for Payer: Banner UC Health Medicaid	$5,578.94
Rate for Payer: Mercy Care Medicaid	$5,578.94

Abdominal Pain

Facility

$3,504.19

Service Code	APR-DRG 2511
Hospital Charge Code	APRDRG2511
Min. Negotiated Rate	$3,504.19
Max. Negotiated Rate	$3,504.19
Rate for Payer: AHCCCS Medicaid	$3,504.19
Rate for Payer: Allwell Medicaid	$3,504.19
Rate for Payer: AZCH Complete Medicaid	$3,504.19
Rate for Payer: Banner UC Health Medicaid	$3,504.19
Rate for Payer: Mercy Care Medicaid	$3,504.19

Abdominal Pain

Facility

$4,198.58

Service Code	APR-DRG 2512
Hospital Charge Code	APRDRG2513
Min. Negotiated Rate	$4,198.58
Max. Negotiated Rate	$4,198.58
Rate for Payer: AHCCCS Medicaid	$4,198.58
Rate for Payer: Allwell Medicaid	$4,198.58
Rate for Payer: AZCH Complete Medicaid	$4,198.58
Rate for Payer: Banner UC Health Medicaid	$4,198.58
Rate for Payer: Mercy Care Medicaid	$4,198.58

Abdominal Pain

Facility

$4,198.58

Service Code	APR-DRG 2512
Hospital Charge Code	APRDRG2511
Min. Negotiated Rate	$4,198.58
Max. Negotiated Rate	$4,198.58
Rate for Payer: AHCCCS Medicaid	$4,198.58
Rate for Payer: Allwell Medicaid	$4,198.58
Rate for Payer: AZCH Complete Medicaid	$4,198.58
Rate for Payer: Banner UC Health Medicaid	$4,198.58
Rate for Payer: Mercy Care Medicaid	$4,198.58

Know your out-of-pocket cost for care.

All Charges