Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

OT PROSTH TRAIN EA 15 MIN

Facility

$181.00

Service Code	CPT 97761 GO
Hospital Charge Code	1238651
Hospital Revenue Code	430
Min. Negotiated Rate	$27.15
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	$27.15
Rate for Payer: Amerigroup Medicare	$27.15
Rate for Payer: APIPA Medicare/Medicaid	$67.60
Rate for Payer: AZCH Complete Medicare	$27.15
Rate for Payer: Banner UC Health Medicare	$27.15
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	$27.15
Rate for Payer: Self Pay Self Pay	$144.80
Rate for Payer: TriWest Medicare	$27.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$105.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$32.58

OT PROSTH TRAIN EA 15 MIN

Facility

$181.00

Service Code	CPT 97761 GO
Hospital Charge Code	1238651
Hospital Revenue Code	430
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

OT RE-EVALUATION UPTO 30 MIN

Facility

$358.00

Service Code	CPT 97168 GO
Hospital Charge Code	22528986
Hospital Revenue Code	434
Min. Negotiated Rate	$53.70
Max. Negotiated Rate	$322.20
Rate for Payer: Aetna of AZ Commercial	$322.20
Rate for Payer: Aetna of AZ Medicare	$100.24
Rate for Payer: Allwell Medicare	$53.70
Rate for Payer: Amerigroup Medicare	$53.70
Rate for Payer: APIPA Medicare/Medicaid	$133.71
Rate for Payer: AZCH Complete Medicare	$53.70
Rate for Payer: Banner UC Health Medicare	$53.70
Rate for Payer: Bisbee Police All Plans	$93.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$243.44
Rate for Payer: Cash Price	$286.40
Rate for Payer: Cigna of AZ Commercial	$250.60
Rate for Payer: Copperpoint Commercial	$88.60
Rate for Payer: Health Net of AZ Commercial	$214.80
Rate for Payer: Health Net of AZ Medicare	$100.24
Rate for Payer: Humana of AZ Medicare	$53.70
Rate for Payer: Self Pay Self Pay	$286.40
Rate for Payer: TriWest Medicare	$53.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$208.71
Rate for Payer: UnitedHealth Group of AZ Medicare	$64.44

OT RE-EVALUATION UPTO 30 MIN

Facility

$358.00

Service Code	CPT 97168 GO
Hospital Charge Code	22528986
Hospital Revenue Code	434
Min. Negotiated Rate	$93.08
Max. Negotiated Rate	$322.20
Rate for Payer: Aetna of AZ Commercial	$322.20
Rate for Payer: Bisbee Police All Plans	$93.08
Rate for Payer: Cash Price	$286.40
Rate for Payer: Self Pay Self Pay	$286.40

OT SELF-CARE HOME MANG @ 15 MIN

Facility

$181.00

Service Code	CPT 97535 GO
Hospital Charge Code	691327
Hospital Revenue Code	430
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

OT SELF-CARE HOME MANG @ 15 MIN

Facility

$181.00

Service Code	CPT 97535 GO
Hospital Charge Code	691327
Hospital Revenue Code	430
Min. Negotiated Rate	$27.15
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	$27.15
Rate for Payer: Amerigroup Medicare	$27.15
Rate for Payer: APIPA Medicare/Medicaid	$67.60
Rate for Payer: AZCH Complete Medicare	$27.15
Rate for Payer: Banner UC Health Medicare	$27.15
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	$27.15
Rate for Payer: Self Pay Self Pay	$144.80
Rate for Payer: TriWest Medicare	$27.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$105.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$32.58

OT TENS

Facility

$664.00

Service Code	CPT 64550 GO
Hospital Charge Code	2619695
Hospital Revenue Code	434
Min. Negotiated Rate	$99.60
Max. Negotiated Rate	$597.60
Rate for Payer: Aetna of AZ Commercial	$597.60
Rate for Payer: Aetna of AZ Medicare	$185.92
Rate for Payer: Allwell Medicare	$99.60
Rate for Payer: Amerigroup Medicare	$99.60
Rate for Payer: APIPA Medicare/Medicaid	$248.00
Rate for Payer: AZCH Complete Medicare	$99.60
Rate for Payer: Banner UC Health Medicare	$99.60
Rate for Payer: Bisbee Police All Plans	$172.64
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$451.52
Rate for Payer: Cash Price	$531.20
Rate for Payer: Cigna of AZ Commercial	$464.80
Rate for Payer: Copperpoint Commercial	$164.34
Rate for Payer: Health Net of AZ Commercial	$398.40
Rate for Payer: Health Net of AZ Medicare	$185.92
Rate for Payer: Humana of AZ Medicare	$99.60
Rate for Payer: Self Pay Self Pay	$531.20
Rate for Payer: TriWest Medicare	$99.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$387.11
Rate for Payer: UnitedHealth Group of AZ Medicare	$119.52

OT TENS

Facility

$664.00

Service Code	CPT 64550 GO
Hospital Charge Code	2619695
Hospital Revenue Code	434
Min. Negotiated Rate	$172.64
Max. Negotiated Rate	$597.60
Rate for Payer: Aetna of AZ Commercial	$597.60
Rate for Payer: Bisbee Police All Plans	$172.64
Rate for Payer: Cash Price	$531.20
Rate for Payer: Self Pay Self Pay	$531.20

OT THERAP ACTIV EA 15 MIN

Facility

$181.00

Service Code	CPT 97530 GO
Hospital Charge Code	11473404
Hospital Revenue Code	430
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

OT THERAP ACTIV EA 15 MIN

Facility

$181.00

Service Code	CPT 97530 GO
Hospital Charge Code	691304
Hospital Revenue Code	430
Min. Negotiated Rate	$27.15
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	$27.15
Rate for Payer: Amerigroup Medicare	$27.15
Rate for Payer: APIPA Medicare/Medicaid	$67.60
Rate for Payer: AZCH Complete Medicare	$27.15
Rate for Payer: Banner UC Health Medicare	$27.15
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	$27.15
Rate for Payer: Self Pay Self Pay	$144.80
Rate for Payer: TriWest Medicare	$27.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$105.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$32.58

OT THERAP ACTIV EA 15 MIN

Facility

$181.00

Service Code	CPT 97530 GO
Hospital Charge Code	11473404
Hospital Revenue Code	430
Min. Negotiated Rate	$27.15
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	$27.15
Rate for Payer: Amerigroup Medicare	$27.15
Rate for Payer: APIPA Medicare/Medicaid	$67.60
Rate for Payer: AZCH Complete Medicare	$27.15
Rate for Payer: Banner UC Health Medicare	$27.15
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	$27.15
Rate for Payer: Self Pay Self Pay	$144.80
Rate for Payer: TriWest Medicare	$27.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$105.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$32.58

OT THERAP ACTIV EA 15 MIN

Facility

$181.00

Service Code	CPT 97530 GO
Hospital Charge Code	691304
Hospital Revenue Code	430
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

OT ULTRASOUND- EACH 15

Facility

$181.00

Service Code	CPT 97035 GO
Hospital Charge Code	691311
Hospital Revenue Code	430
Min. Negotiated Rate	$27.15
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	$27.15
Rate for Payer: Amerigroup Medicare	$27.15
Rate for Payer: APIPA Medicare/Medicaid	$67.60
Rate for Payer: AZCH Complete Medicare	$27.15
Rate for Payer: Banner UC Health Medicare	$27.15
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	$27.15
Rate for Payer: Self Pay Self Pay	$144.80
Rate for Payer: TriWest Medicare	$27.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$105.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$32.58

OT ULTRASOUND- EACH 15

Facility

$181.00

Service Code	CPT 97035 GO
Hospital Charge Code	691311
Hospital Revenue Code	430
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

OT WH/CH TRAIN EA 15 MIN

Facility

$181.00

Service Code	CPT 97542 GO
Hospital Charge Code	1238649
Hospital Revenue Code	430
Min. Negotiated Rate	$27.15
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	$27.15
Rate for Payer: Amerigroup Medicare	$27.15
Rate for Payer: APIPA Medicare/Medicaid	$67.60
Rate for Payer: AZCH Complete Medicare	$27.15
Rate for Payer: Banner UC Health Medicare	$27.15
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	$27.15
Rate for Payer: Self Pay Self Pay	$144.80
Rate for Payer: TriWest Medicare	$27.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$105.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$32.58

OT WH/CH TRAIN EA 15 MIN

Facility

$181.00

Service Code	CPT 97542 GO
Hospital Charge Code	1238649
Hospital Revenue Code	430
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

OT WOUND CARE GREATER THAN 20 CM

Facility

$697.00

Service Code	CPT 97598 GO
Hospital Charge Code	2575289
Hospital Revenue Code	430
Min. Negotiated Rate	$181.22
Max. Negotiated Rate	$627.30
Rate for Payer: Aetna of AZ Commercial	$627.30
Rate for Payer: Bisbee Police All Plans	$181.22
Rate for Payer: Cash Price	$557.60
Rate for Payer: Self Pay Self Pay	$557.60

OT WOUND CARE GREATER THAN 20 CM

Facility

$697.00

Service Code	CPT 97598 GO
Hospital Charge Code	2575289
Hospital Revenue Code	430
Min. Negotiated Rate	$104.55
Max. Negotiated Rate	$627.30
Rate for Payer: Aetna of AZ Commercial	$627.30
Rate for Payer: Aetna of AZ Medicare	$195.16
Rate for Payer: Allwell Medicare	$104.55
Rate for Payer: Amerigroup Medicare	$104.55
Rate for Payer: APIPA Medicare/Medicaid	$260.33
Rate for Payer: AZCH Complete Medicare	$104.55
Rate for Payer: Banner UC Health Medicare	$104.55
Rate for Payer: Bisbee Police All Plans	$181.22
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$473.96
Rate for Payer: Cash Price	$557.60
Rate for Payer: Cigna of AZ Commercial	$487.90
Rate for Payer: Copperpoint Commercial	$172.51
Rate for Payer: Health Net of AZ Commercial	$418.20
Rate for Payer: Health Net of AZ Medicare	$195.16
Rate for Payer: Humana of AZ Medicare	$104.55
Rate for Payer: Self Pay Self Pay	$557.60
Rate for Payer: TriWest Medicare	$104.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$406.35
Rate for Payer: UnitedHealth Group of AZ Medicare	$125.46

OT WOUND CARE LESS THAN 20 CM

Facility

$358.00

Service Code	CPT 97597 GO
Hospital Charge Code	3938232
Hospital Revenue Code	430
Min. Negotiated Rate	$93.08
Max. Negotiated Rate	$322.20
Rate for Payer: Aetna of AZ Commercial	$322.20
Rate for Payer: Bisbee Police All Plans	$93.08
Rate for Payer: Cash Price	$286.40
Rate for Payer: Self Pay Self Pay	$286.40

OT WOUND CARE LESS THAN 20 CM

Facility

$358.00

Service Code	CPT 97597 GO
Hospital Charge Code	3938232
Hospital Revenue Code	430
Min. Negotiated Rate	$53.70
Max. Negotiated Rate	$322.20
Rate for Payer: Aetna of AZ Commercial	$322.20
Rate for Payer: Aetna of AZ Medicare	$100.24
Rate for Payer: Allwell Medicare	$53.70
Rate for Payer: Amerigroup Medicare	$53.70
Rate for Payer: APIPA Medicare/Medicaid	$133.71
Rate for Payer: AZCH Complete Medicare	$53.70
Rate for Payer: Banner UC Health Medicare	$53.70
Rate for Payer: Bisbee Police All Plans	$93.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$243.44
Rate for Payer: Cash Price	$286.40
Rate for Payer: Cigna of AZ Commercial	$250.60
Rate for Payer: Copperpoint Commercial	$88.60
Rate for Payer: Health Net of AZ Commercial	$214.80
Rate for Payer: Health Net of AZ Medicare	$100.24
Rate for Payer: Humana of AZ Medicare	$53.70
Rate for Payer: Self Pay Self Pay	$286.40
Rate for Payer: TriWest Medicare	$53.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$208.71
Rate for Payer: UnitedHealth Group of AZ Medicare	$64.44

Ova + Parasite Exam LC

Facility

$212.00

Service Code	CPT 87177
Hospital Charge Code	1285718
Hospital Revenue Code	300
Min. Negotiated Rate	$8.90
Max. Negotiated Rate	$190.80
Rate for Payer: Aetna of AZ Commercial	$190.80
Rate for Payer: Aetna of AZ Medicare	$59.36
Rate for Payer: AHCCCS Medicaid	$8.90
Rate for Payer: Allwell Medicaid	$8.90
Rate for Payer: Allwell Medicare	$31.80
Rate for Payer: Amerigroup Medicare	$31.80
Rate for Payer: APIPA Medicare/Medicaid	$79.18
Rate for Payer: AZCH Complete Medicaid	$8.90
Rate for Payer: AZCH Complete Medicare	$31.80
Rate for Payer: Banner UC Health Medicaid	$8.90
Rate for Payer: Banner UC Health Medicare	$31.80
Rate for Payer: Bisbee Police All Plans	$55.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$144.16
Rate for Payer: Cash Price	$169.60
Rate for Payer: Cash Price	$169.60
Rate for Payer: Cigna of AZ Commercial	$137.80
Rate for Payer: Copperpoint Commercial	$52.47
Rate for Payer: Health Net of AZ Commercial	$127.20
Rate for Payer: Health Net of AZ Medicare	$59.36
Rate for Payer: Humana of AZ Medicare	$31.80
Rate for Payer: Mercy Care Medicaid	$8.90
Rate for Payer: Self Pay Self Pay	$169.60
Rate for Payer: TriWest Medicare	$31.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$123.60
Rate for Payer: UnitedHealth Group of AZ Medicare	$38.16

Ova + Parasite Exam LC

Facility

$212.00

Service Code	CPT 87177
Hospital Charge Code	1285718
Hospital Revenue Code	300
Min. Negotiated Rate	$55.12
Max. Negotiated Rate	$190.80
Rate for Payer: Aetna of AZ Commercial	$190.80
Rate for Payer: Bisbee Police All Plans	$55.12
Rate for Payer: Cash Price	$169.60
Rate for Payer: Self Pay Self Pay	$169.60

.Ova + Parasite Exam Result

Facility

$202.00

Service Code	CPT 87177
Hospital Charge Code	1294971
Hospital Revenue Code	300
Min. Negotiated Rate	$52.52
Max. Negotiated Rate	$181.80
Rate for Payer: Aetna of AZ Commercial	$181.80
Rate for Payer: Bisbee Police All Plans	$52.52
Rate for Payer: Cash Price	$161.60
Rate for Payer: Self Pay Self Pay	$161.60

.Ova + Parasite Exam Result

Facility

$202.00

Service Code	CPT 87177
Hospital Charge Code	1294971
Hospital Revenue Code	300
Min. Negotiated Rate	$8.90
Max. Negotiated Rate	$181.80
Rate for Payer: Aetna of AZ Commercial	$181.80
Rate for Payer: Aetna of AZ Medicare	$56.56
Rate for Payer: AHCCCS Medicaid	$8.90
Rate for Payer: Allwell Medicaid	$8.90
Rate for Payer: Allwell Medicare	$30.30
Rate for Payer: Amerigroup Medicare	$30.30
Rate for Payer: APIPA Medicare/Medicaid	$75.45
Rate for Payer: AZCH Complete Medicaid	$8.90
Rate for Payer: AZCH Complete Medicare	$30.30
Rate for Payer: Banner UC Health Medicaid	$8.90
Rate for Payer: Banner UC Health Medicare	$30.30
Rate for Payer: Bisbee Police All Plans	$52.52
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$137.36
Rate for Payer: Cash Price	$161.60
Rate for Payer: Cash Price	$161.60
Rate for Payer: Cigna of AZ Commercial	$131.30
Rate for Payer: Copperpoint Commercial	$50.00
Rate for Payer: Health Net of AZ Commercial	$121.20
Rate for Payer: Health Net of AZ Medicare	$56.56
Rate for Payer: Humana of AZ Medicare	$30.30
Rate for Payer: Mercy Care Medicaid	$8.90
Rate for Payer: Self Pay Self Pay	$161.60
Rate for Payer: TriWest Medicare	$30.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$117.77
Rate for Payer: UnitedHealth Group of AZ Medicare	$36.36

Ovary cystectomy

Facility

$3,960.00

Service Code	CPT 58925
Hospital Charge Code	27267812
Hospital Revenue Code	360
Min. Negotiated Rate	$1,029.60
Max. Negotiated Rate	$3,564.00
Rate for Payer: Aetna of AZ Commercial	$3,564.00
Rate for Payer: Bisbee Police All Plans	$1,029.60
Rate for Payer: Cash Price	$3,168.00
Rate for Payer: Self Pay Self Pay	$3,168.00

Know your out-of-pocket cost for care.

All Charges