Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

97542 Wheelchair Management ea 15 Min

Facility

$181.00

Service Code	CPT 97542 GP
Hospital Charge Code	23818480
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

97606 NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED D

Facility

$137.00

Service Code	CPT 97606
Hospital Charge Code	24053047
Hospital Revenue Code	360
Min. Negotiated Rate	$35.62
Max. Negotiated Rate	$123.30
Rate for Payer: Aetna of AZ Commercial	$123.30
Rate for Payer: Bisbee Police All Plans	$35.62
Rate for Payer: Cash Price	$109.60
Rate for Payer: Self Pay Self Pay	$109.60

97606 NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED D

Facility

$137.00

Service Code	CPT 97606
Hospital Charge Code	24053047
Hospital Revenue Code	360
Min. Negotiated Rate	$21.92
Max. Negotiated Rate	$250.73
Rate for Payer: Aetna of AZ Commercial	$123.30
Rate for Payer: Aetna of AZ Medicare	$38.36
Rate for Payer: AHCCCS Medicaid	$250.73
Rate for Payer: Allwell Medicaid	$250.73
Rate for Payer: Allwell Medicare	$21.92
Rate for Payer: Amerigroup Medicare	$21.92
Rate for Payer: APIPA Medicare/Medicaid	$51.17
Rate for Payer: AZCH Complete Medicaid	$250.73
Rate for Payer: AZCH Complete Medicare	$21.92
Rate for Payer: Banner UC Health Medicaid	$250.73
Rate for Payer: Banner UC Health Medicare	$21.92
Rate for Payer: Bisbee Police All Plans	$35.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$93.16
Rate for Payer: Cash Price	$109.60
Rate for Payer: Cash Price	$109.60
Rate for Payer: Cigna of AZ Commercial	$68.50
Rate for Payer: Copperpoint Commercial	$33.91
Rate for Payer: Health Net of AZ Commercial	$82.20
Rate for Payer: Health Net of AZ Medicare	$38.36
Rate for Payer: Humana of AZ Medicare	$21.92
Rate for Payer: Mercy Care Medicaid	$250.73
Rate for Payer: Self Pay Self Pay	$109.60
Rate for Payer: TriWest Medicare	$21.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$79.87
Rate for Payer: UnitedHealth Group of AZ Medicare	$24.66

99144 ANES 1ST 0:30 CHARGE

Facility

$622.00

Hospital Charge Code	22406220
Hospital Revenue Code	370
Min. Negotiated Rate	$161.72
Max. Negotiated Rate	$559.80
Rate for Payer: Aetna of AZ Commercial	$559.80
Rate for Payer: Bisbee Police All Plans	$161.72
Rate for Payer: Cash Price	$497.60
Rate for Payer: Self Pay Self Pay	$497.60

99144 ANES 1ST 0:30 CHARGE

Facility

$622.00

Hospital Charge Code	22406220
Hospital Revenue Code	370
Min. Negotiated Rate	$99.52
Max. Negotiated Rate	$559.80
Rate for Payer: Aetna of AZ Commercial	$559.80
Rate for Payer: Aetna of AZ Medicare	$174.16
Rate for Payer: Allwell Medicare	$99.52
Rate for Payer: Amerigroup Medicare	$99.52
Rate for Payer: APIPA Medicare/Medicaid	$232.32
Rate for Payer: AZCH Complete Medicare	$99.52
Rate for Payer: Banner UC Health Medicare	$99.52
Rate for Payer: Bisbee Police All Plans	$161.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$422.96
Rate for Payer: Cash Price	$497.60
Rate for Payer: Cigna of AZ Commercial	$404.30
Rate for Payer: Copperpoint Commercial	$153.94
Rate for Payer: Health Net of AZ Commercial	$373.20
Rate for Payer: Health Net of AZ Medicare	$174.16
Rate for Payer: Humana of AZ Medicare	$99.52
Rate for Payer: Self Pay Self Pay	$497.60
Rate for Payer: TriWest Medicare	$99.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$362.63
Rate for Payer: UnitedHealth Group of AZ Medicare	$111.96

99144 ANES ADDTNL 0:30 CHARGE

Facility

$622.00

Hospital Charge Code	22406221
Hospital Revenue Code	370
Min. Negotiated Rate	$99.52
Max. Negotiated Rate	$559.80
Rate for Payer: Aetna of AZ Commercial	$559.80
Rate for Payer: Aetna of AZ Medicare	$174.16
Rate for Payer: Allwell Medicare	$99.52
Rate for Payer: Amerigroup Medicare	$99.52
Rate for Payer: APIPA Medicare/Medicaid	$232.32
Rate for Payer: AZCH Complete Medicare	$99.52
Rate for Payer: Banner UC Health Medicare	$99.52
Rate for Payer: Bisbee Police All Plans	$161.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$422.96
Rate for Payer: Cash Price	$497.60
Rate for Payer: Cigna of AZ Commercial	$404.30
Rate for Payer: Copperpoint Commercial	$153.94
Rate for Payer: Health Net of AZ Commercial	$373.20
Rate for Payer: Health Net of AZ Medicare	$174.16
Rate for Payer: Humana of AZ Medicare	$99.52
Rate for Payer: Self Pay Self Pay	$497.60
Rate for Payer: TriWest Medicare	$99.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$362.63
Rate for Payer: UnitedHealth Group of AZ Medicare	$111.96

99144 ANES ADDTNL 0:30 CHARGE

Facility

$622.00

Hospital Charge Code	22406221
Hospital Revenue Code	370
Min. Negotiated Rate	$161.72
Max. Negotiated Rate	$559.80
Rate for Payer: Aetna of AZ Commercial	$559.80
Rate for Payer: Bisbee Police All Plans	$161.72
Rate for Payer: Cash Price	$497.60
Rate for Payer: Self Pay Self Pay	$497.60

99252 IN-PT EXPANDED INI. CONSULTATIONS

Facility

$198.00

Service Code	CPT 99252
Hospital Charge Code	22361549
Hospital Revenue Code	987
Min. Negotiated Rate	$51.48
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of AZ Commercial	$178.20
Rate for Payer: Bisbee Police All Plans	$51.48
Rate for Payer: Cash Price	$158.40
Rate for Payer: Self Pay Self Pay	$158.40

99252 IN-PT EXPANDED INI. CONSULTATIONS

Facility

$198.00

Service Code	CPT 99252
Hospital Charge Code	22361549
Hospital Revenue Code	987
Min. Negotiated Rate	$31.68
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of AZ Commercial	$178.20
Rate for Payer: Aetna of AZ Medicare	$55.44
Rate for Payer: Allwell Medicare	$31.68
Rate for Payer: Amerigroup Medicare	$31.68
Rate for Payer: APIPA Medicare/Medicaid	$73.95
Rate for Payer: AZCH Complete Medicare	$31.68
Rate for Payer: Banner UC Health Medicare	$31.68
Rate for Payer: Bisbee Police All Plans	$51.48
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$134.64
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cigna of AZ Commercial	$138.60
Rate for Payer: Copperpoint Commercial	$49.01
Rate for Payer: Health Net of AZ Commercial	$118.80
Rate for Payer: Health Net of AZ Medicare	$55.44
Rate for Payer: Humana of AZ Medicare	$31.68
Rate for Payer: Self Pay Self Pay	$158.40
Rate for Payer: TriWest Medicare	$31.68
Rate for Payer: UnitedHealth Group of AZ Commercial	$115.43
Rate for Payer: UnitedHealth Group of AZ Medicare	$35.64

99281 - ED Level 1

Facility

$394.00

Service Code	CPT 99281
Hospital Charge Code	22283175
Hospital Revenue Code	450
Min. Negotiated Rate	$63.04
Max. Negotiated Rate	$439.00
Rate for Payer: Aetna of AZ Commercial	$354.60
Rate for Payer: Aetna of AZ Medicare	$110.32
Rate for Payer: Allwell Medicare	$63.04
Rate for Payer: Amerigroup Medicare	$63.04
Rate for Payer: APIPA Medicare/Medicaid	$147.16
Rate for Payer: AZCH Complete Medicare	$63.04
Rate for Payer: Banner UC Health Medicare	$63.04
Rate for Payer: Bisbee Police All Plans	$102.44
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$267.92
Rate for Payer: Cash Price	$315.20
Rate for Payer: Cash Price	$315.20
Rate for Payer: Cigna of AZ Commercial	$275.80
Rate for Payer: Copperpoint Commercial	$97.52
Rate for Payer: Health Net of AZ Commercial	$236.40
Rate for Payer: Health Net of AZ Medicare	$110.32
Rate for Payer: Humana of AZ Medicare	$63.04
Rate for Payer: Self Pay Self Pay	$315.20
Rate for Payer: TriWest Medicare	$63.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$439.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$70.92

99281 - ED Level 1

Facility

$394.00

Service Code	CPT 99281
Hospital Charge Code	22283175
Hospital Revenue Code	450
Min. Negotiated Rate	$102.44
Max. Negotiated Rate	$354.60
Rate for Payer: Aetna of AZ Commercial	$354.60
Rate for Payer: Bisbee Police All Plans	$102.44
Rate for Payer: Cash Price	$315.20
Rate for Payer: Self Pay Self Pay	$315.20

99282 - ED Level 2

Facility

$781.00

Service Code	CPT 99282
Hospital Charge Code	22283176
Hospital Revenue Code	450
Min. Negotiated Rate	$124.96
Max. Negotiated Rate	$702.90
Rate for Payer: Aetna of AZ Commercial	$702.90
Rate for Payer: Aetna of AZ Medicare	$218.68
Rate for Payer: Allwell Medicare	$124.96
Rate for Payer: Amerigroup Medicare	$124.96
Rate for Payer: APIPA Medicare/Medicaid	$291.70
Rate for Payer: AZCH Complete Medicare	$124.96
Rate for Payer: Banner UC Health Medicare	$124.96
Rate for Payer: Bisbee Police All Plans	$203.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$531.08
Rate for Payer: Cash Price	$624.80
Rate for Payer: Cash Price	$624.80
Rate for Payer: Cigna of AZ Commercial	$546.70
Rate for Payer: Copperpoint Commercial	$193.30
Rate for Payer: Health Net of AZ Commercial	$468.60
Rate for Payer: Health Net of AZ Medicare	$218.68
Rate for Payer: Humana of AZ Medicare	$124.96
Rate for Payer: Self Pay Self Pay	$624.80
Rate for Payer: TriWest Medicare	$124.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$602.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$140.58

99282 - ED Level 2

Facility

$781.00

Service Code	CPT 99282
Hospital Charge Code	22283176
Hospital Revenue Code	450
Min. Negotiated Rate	$203.06
Max. Negotiated Rate	$702.90
Rate for Payer: Aetna of AZ Commercial	$702.90
Rate for Payer: Bisbee Police All Plans	$203.06
Rate for Payer: Cash Price	$624.80
Rate for Payer: Self Pay Self Pay	$624.80

99283 - ED Level 3

Facility

$1,387.00

Service Code	CPT 99283
Hospital Charge Code	22283177
Hospital Revenue Code	450
Min. Negotiated Rate	$360.62
Max. Negotiated Rate	$1,248.30
Rate for Payer: Aetna of AZ Commercial	$1,248.30
Rate for Payer: Bisbee Police All Plans	$360.62
Rate for Payer: Cash Price	$1,109.60
Rate for Payer: Self Pay Self Pay	$1,109.60

99283 - ED Level 3

Facility

$1,387.00

Service Code	CPT 99283
Hospital Charge Code	22283177
Hospital Revenue Code	450
Min. Negotiated Rate	$221.92
Max. Negotiated Rate	$1,248.30
Rate for Payer: Aetna of AZ Commercial	$1,248.30
Rate for Payer: Aetna of AZ Medicare	$388.36
Rate for Payer: Allwell Medicare	$221.92
Rate for Payer: Amerigroup Medicare	$221.92
Rate for Payer: APIPA Medicare/Medicaid	$518.04
Rate for Payer: AZCH Complete Medicare	$221.92
Rate for Payer: Banner UC Health Medicare	$221.92
Rate for Payer: Bisbee Police All Plans	$360.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$943.16
Rate for Payer: Cash Price	$1,109.60
Rate for Payer: Cash Price	$1,109.60
Rate for Payer: Cigna of AZ Commercial	$970.90
Rate for Payer: Copperpoint Commercial	$343.28
Rate for Payer: Health Net of AZ Commercial	$832.20
Rate for Payer: Health Net of AZ Medicare	$388.36
Rate for Payer: Humana of AZ Medicare	$221.92
Rate for Payer: Self Pay Self Pay	$1,109.60
Rate for Payer: TriWest Medicare	$221.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$863.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$249.66

99283 EMERGENCY RM- LEVEL 3 ED CHARGE- PROFESSIONAL FEE BCE

Facility

$1,049.00

Service Code	CPT 99283
Hospital Charge Code	22033859
Hospital Revenue Code	981
Min. Negotiated Rate	$167.84
Max. Negotiated Rate	$944.10
Rate for Payer: Aetna of AZ Commercial	$944.10
Rate for Payer: Aetna of AZ Medicare	$293.72
Rate for Payer: Allwell Medicare	$167.84
Rate for Payer: Amerigroup Medicare	$167.84
Rate for Payer: APIPA Medicare/Medicaid	$391.80
Rate for Payer: AZCH Complete Medicare	$167.84
Rate for Payer: Banner UC Health Medicare	$167.84
Rate for Payer: Bisbee Police All Plans	$272.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$713.32
Rate for Payer: Cash Price	$839.20
Rate for Payer: Cash Price	$839.20
Rate for Payer: Cigna of AZ Commercial	$734.30
Rate for Payer: Copperpoint Commercial	$259.63
Rate for Payer: Health Net of AZ Commercial	$629.40
Rate for Payer: Health Net of AZ Medicare	$293.72
Rate for Payer: Humana of AZ Medicare	$167.84
Rate for Payer: Self Pay Self Pay	$839.20
Rate for Payer: TriWest Medicare	$167.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$863.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$188.82

99283 EMERGENCY RM- LEVEL 3 ED CHARGE- PROFESSIONAL FEE BCE

Facility

$1,049.00

Service Code	CPT 99283
Hospital Charge Code	22033859
Hospital Revenue Code	981
Min. Negotiated Rate	$272.74
Max. Negotiated Rate	$944.10
Rate for Payer: Aetna of AZ Commercial	$944.10
Rate for Payer: Bisbee Police All Plans	$272.74
Rate for Payer: Cash Price	$839.20
Rate for Payer: Self Pay Self Pay	$839.20

99284 - ED Level 4

Facility

$2,202.00

Service Code	CPT 99284
Hospital Charge Code	22283178
Hospital Revenue Code	450
Min. Negotiated Rate	$572.52
Max. Negotiated Rate	$1,981.80
Rate for Payer: Aetna of AZ Commercial	$1,981.80
Rate for Payer: Bisbee Police All Plans	$572.52
Rate for Payer: Cash Price	$1,761.60
Rate for Payer: Self Pay Self Pay	$1,761.60

99284 - ED Level 4

Facility

$2,202.00

Service Code	CPT 99284
Hospital Charge Code	22283178
Hospital Revenue Code	450
Min. Negotiated Rate	$352.32
Max. Negotiated Rate	$1,981.80
Rate for Payer: Aetna of AZ Commercial	$1,981.80
Rate for Payer: Aetna of AZ Medicare	$616.56
Rate for Payer: Allwell Medicare	$352.32
Rate for Payer: Amerigroup Medicare	$352.32
Rate for Payer: APIPA Medicare/Medicaid	$822.45
Rate for Payer: AZCH Complete Medicare	$352.32
Rate for Payer: Banner UC Health Medicare	$352.32
Rate for Payer: Bisbee Police All Plans	$572.52
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,497.36
Rate for Payer: Cash Price	$1,761.60
Rate for Payer: Cash Price	$1,761.60
Rate for Payer: Cigna of AZ Commercial	$1,541.40
Rate for Payer: Copperpoint Commercial	$545.00
Rate for Payer: Health Net of AZ Commercial	$1,321.20
Rate for Payer: Health Net of AZ Medicare	$616.56
Rate for Payer: Humana of AZ Medicare	$352.32
Rate for Payer: Self Pay Self Pay	$1,761.60
Rate for Payer: TriWest Medicare	$352.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,190.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$396.36

99285 - ED Level 5

Facility

$3,275.00

Service Code	CPT 99285
Hospital Charge Code	22283179
Hospital Revenue Code	450
Min. Negotiated Rate	$851.50
Max. Negotiated Rate	$2,947.50
Rate for Payer: Aetna of AZ Commercial	$2,947.50
Rate for Payer: Bisbee Police All Plans	$851.50
Rate for Payer: Cash Price	$2,620.00
Rate for Payer: Self Pay Self Pay	$2,620.00

99285 - ED Level 5

Facility

$3,275.00

Service Code	CPT 99285
Hospital Charge Code	22283179
Hospital Revenue Code	450
Min. Negotiated Rate	$524.00
Max. Negotiated Rate	$2,947.50
Rate for Payer: Aetna of AZ Commercial	$2,947.50
Rate for Payer: Aetna of AZ Medicare	$917.00
Rate for Payer: Allwell Medicare	$524.00
Rate for Payer: Amerigroup Medicare	$524.00
Rate for Payer: APIPA Medicare/Medicaid	$1,223.21
Rate for Payer: AZCH Complete Medicare	$524.00
Rate for Payer: Banner UC Health Medicare	$524.00
Rate for Payer: Bisbee Police All Plans	$851.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,227.00
Rate for Payer: Cash Price	$2,620.00
Rate for Payer: Cash Price	$2,620.00
Rate for Payer: Cigna of AZ Commercial	$2,292.50
Rate for Payer: Copperpoint Commercial	$810.56
Rate for Payer: Health Net of AZ Commercial	$1,965.00
Rate for Payer: Health Net of AZ Medicare	$917.00
Rate for Payer: Humana of AZ Medicare	$524.00
Rate for Payer: Self Pay Self Pay	$2,620.00
Rate for Payer: TriWest Medicare	$524.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,544.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$589.50

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	$572.16
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: Allwell Medicare	$572.16
Rate for Payer: Amerigroup Medicare	$572.16
Rate for Payer: APIPA Medicare/Medicaid	$1,335.64
Rate for Payer: AZCH Complete Medicare	$572.16
Rate for Payer: Banner UC Health Medicare	$572.16
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: 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	$572.16
Rate for Payer: Self Pay Self Pay	$2,860.80
Rate for Payer: TriWest Medicare	$572.16
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,249.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$643.68

99292 Critical care, evaluation and management of the critic

Facility

$210.00

Service Code	CPT 99292
Hospital Charge Code	24767656
Hospital Revenue Code	982
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Aetna of AZ Medicare	$58.80
Rate for Payer: Allwell Medicare	$33.60
Rate for Payer: Amerigroup Medicare	$33.60
Rate for Payer: APIPA Medicare/Medicaid	$78.44
Rate for Payer: AZCH Complete Medicare	$33.60
Rate for Payer: Banner UC Health Medicare	$33.60
Rate for Payer: Bisbee Police All Plans	$54.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$142.80
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cigna of AZ Commercial	$147.00
Rate for Payer: Copperpoint Commercial	$51.98
Rate for Payer: Health Net of AZ Commercial	$126.00
Rate for Payer: Health Net of AZ Medicare	$58.80
Rate for Payer: Humana of AZ Medicare	$33.60
Rate for Payer: Self Pay Self Pay	$168.00
Rate for Payer: TriWest Medicare	$33.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$122.43
Rate for Payer: UnitedHealth Group of AZ Medicare	$37.80

99292 Critical care, evaluation and management of the critic

Facility

$210.00

Service Code	CPT 99292
Hospital Charge Code	24767656
Hospital Revenue Code	982
Min. Negotiated Rate	$54.60
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna of AZ Commercial	$189.00
Rate for Payer: Bisbee Police All Plans	$54.60
Rate for Payer: Cash Price	$168.00
Rate for Payer: Self Pay Self Pay	$168.00

Know your out-of-pocket cost for care.

All Charges