Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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	$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

OT THERAP ACTIV EA 15 MIN

Facility

$172.00

Service Code	CPT 97530 GO
Hospital Charge Code	691304
Hospital Revenue Code	430
Min. Negotiated Rate	$44.72
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Bisbee Police All Plans	$44.72
Rate for Payer: Cash Price	$137.60
Rate for Payer: Self Pay Self Pay	$137.60

OT THERAP ACTIV EA 15 MIN

Facility

$172.00

Service Code	CPT 97530 GO
Hospital Charge Code	691304
Hospital Revenue Code	430
Min. Negotiated Rate	$27.52
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Aetna of AZ Medicare	$48.16
Rate for Payer: Allwell Medicare	$27.52
Rate for Payer: Amerigroup Medicare	$27.52
Rate for Payer: APIPA Medicare/Medicaid	$64.24
Rate for Payer: AZCH Complete Medicare	$27.52
Rate for Payer: Banner UC Health Medicare	$27.52
Rate for Payer: Bisbee Police All Plans	$44.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$116.96
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cigna of AZ Commercial	$120.40
Rate for Payer: Copperpoint Commercial	$42.57
Rate for Payer: Health Net of AZ Commercial	$103.20
Rate for Payer: Health Net of AZ Medicare	$48.16
Rate for Payer: Humana of AZ Medicare	$27.52
Rate for Payer: Self Pay Self Pay	$137.60
Rate for Payer: TriWest Medicare	$27.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$100.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$30.96

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 ULTRASOUND- EACH 15

Facility

$181.00

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

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	$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	$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

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	$103.14
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: AHCCCS Medicaid	$103.14
Rate for Payer: Allwell Medicaid	$103.14
Rate for Payer: Allwell Medicare	$111.52
Rate for Payer: Amerigroup Medicare	$111.52
Rate for Payer: APIPA Medicare/Medicaid	$260.33
Rate for Payer: AZCH Complete Medicaid	$103.14
Rate for Payer: AZCH Complete Medicare	$111.52
Rate for Payer: Banner UC Health Medicaid	$103.14
Rate for Payer: Banner UC Health Medicare	$111.52
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: 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	$111.52
Rate for Payer: Mercy Care Medicaid	$103.14
Rate for Payer: Self Pay Self Pay	$557.60
Rate for Payer: TriWest Medicare	$111.52
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	$57.28
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: AHCCCS Medicaid	$130.17
Rate for Payer: Allwell Medicaid	$130.17
Rate for Payer: Allwell Medicare	$57.28
Rate for Payer: Amerigroup Medicare	$57.28
Rate for Payer: APIPA Medicare/Medicaid	$133.71
Rate for Payer: AZCH Complete Medicaid	$130.17
Rate for Payer: AZCH Complete Medicare	$57.28
Rate for Payer: Banner UC Health Medicaid	$130.17
Rate for Payer: Banner UC Health Medicare	$57.28
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: Cash Price	$286.40
Rate for Payer: Cigna of AZ Commercial	$250.60
Rate for Payer: Copperpoint Commercial	$88.61
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	$57.28
Rate for Payer: Mercy Care Medicaid	$130.17
Rate for Payer: Self Pay Self Pay	$286.40
Rate for Payer: TriWest Medicare	$57.28
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

$197.00

Service Code	CPT 87177
Hospital Charge Code	1285718
Hospital Revenue Code	300
Min. Negotiated Rate	$51.22
Max. Negotiated Rate	$177.30
Rate for Payer: Aetna of AZ Commercial	$177.30
Rate for Payer: Bisbee Police All Plans	$51.22
Rate for Payer: Cash Price	$157.60
Rate for Payer: Self Pay Self Pay	$157.60

Ova + Parasite Exam LC

Facility

$197.00

Service Code	CPT 87177
Hospital Charge Code	1285718
Hospital Revenue Code	300
Min. Negotiated Rate	$31.52
Max. Negotiated Rate	$177.30
Rate for Payer: Aetna of AZ Commercial	$177.30
Rate for Payer: Aetna of AZ Medicare	$55.16
Rate for Payer: Allwell Medicare	$31.52
Rate for Payer: Amerigroup Medicare	$31.52
Rate for Payer: APIPA Medicare/Medicaid	$73.58
Rate for Payer: AZCH Complete Medicare	$31.52
Rate for Payer: Banner UC Health Medicare	$31.52
Rate for Payer: Bisbee Police All Plans	$51.22
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$133.96
Rate for Payer: Cash Price	$157.60
Rate for Payer: Cigna of AZ Commercial	$128.05
Rate for Payer: Copperpoint Commercial	$48.76
Rate for Payer: Health Net of AZ Commercial	$118.20
Rate for Payer: Health Net of AZ Medicare	$55.16
Rate for Payer: Humana of AZ Medicare	$31.52
Rate for Payer: Self Pay Self Pay	$157.60
Rate for Payer: TriWest Medicare	$31.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$114.85
Rate for Payer: UnitedHealth Group of AZ Medicare	$35.46

.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	$32.32
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: Allwell Medicare	$32.32
Rate for Payer: Amerigroup Medicare	$32.32
Rate for Payer: APIPA Medicare/Medicaid	$75.45
Rate for Payer: AZCH Complete Medicare	$32.32
Rate for Payer: Banner UC Health Medicare	$32.32
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: Cigna of AZ Commercial	$131.30
Rate for Payer: Copperpoint Commercial	$49.99
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	$32.32
Rate for Payer: Self Pay Self Pay	$161.60
Rate for Payer: TriWest Medicare	$32.32
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	$633.60
Max. Negotiated Rate	$3,564.00
Rate for Payer: Aetna of AZ Commercial	$3,564.00
Rate for Payer: Aetna of AZ Medicare	$1,108.80
Rate for Payer: AHCCCS Medicaid	$3,196.92
Rate for Payer: Allwell Medicaid	$3,196.92
Rate for Payer: Allwell Medicare	$633.60
Rate for Payer: Amerigroup Medicare	$633.60
Rate for Payer: APIPA Medicare/Medicaid	$1,479.06
Rate for Payer: AZCH Complete Medicaid	$3,196.92
Rate for Payer: AZCH Complete Medicare	$633.60
Rate for Payer: Banner UC Health Medicaid	$3,196.92
Rate for Payer: Banner UC Health Medicare	$633.60
Rate for Payer: Bisbee Police All Plans	$1,029.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,692.80
Rate for Payer: Cash Price	$3,168.00
Rate for Payer: Cash Price	$3,168.00
Rate for Payer: Cigna of AZ Commercial	$1,980.00
Rate for Payer: Copperpoint Commercial	$980.10
Rate for Payer: Health Net of AZ Commercial	$2,376.00
Rate for Payer: Health Net of AZ Medicare	$1,108.80
Rate for Payer: Humana of AZ Medicare	$633.60
Rate for Payer: Mercy Care Medicaid	$3,196.92
Rate for Payer: Self Pay Self Pay	$3,168.00
Rate for Payer: TriWest Medicare	$633.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,308.68
Rate for Payer: UnitedHealth Group of AZ Medicare	$712.80

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

OVERFLOW PROTECTION BACTERIAL FILTER

Facility

$85.06

Hospital Charge Code	27839757
Hospital Revenue Code	270
Min. Negotiated Rate	$13.61
Max. Negotiated Rate	$76.55
Rate for Payer: Aetna of AZ Commercial	$76.55
Rate for Payer: Aetna of AZ Medicare	$23.82
Rate for Payer: Allwell Medicare	$13.61
Rate for Payer: Amerigroup Medicare	$13.61
Rate for Payer: APIPA Medicare/Medicaid	$31.77
Rate for Payer: AZCH Complete Medicare	$13.61
Rate for Payer: Banner UC Health Medicare	$13.61
Rate for Payer: Bisbee Police All Plans	$22.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$57.84
Rate for Payer: Cash Price	$68.05
Rate for Payer: Cigna of AZ Commercial	$59.54
Rate for Payer: Copperpoint Commercial	$21.05
Rate for Payer: Health Net of AZ Commercial	$51.04
Rate for Payer: Health Net of AZ Medicare	$23.82
Rate for Payer: Humana of AZ Medicare	$13.61
Rate for Payer: Self Pay Self Pay	$68.05
Rate for Payer: TriWest Medicare	$13.61
Rate for Payer: UnitedHealth Group of AZ Commercial	$49.59
Rate for Payer: UnitedHealth Group of AZ Medicare	$15.31

OVERFLOW PROTECTION BACTERIAL FILTER

Facility

$85.06

Hospital Charge Code	27839757
Hospital Revenue Code	270
Min. Negotiated Rate	$22.12
Max. Negotiated Rate	$76.55
Rate for Payer: Aetna of AZ Commercial	$76.55
Rate for Payer: Bisbee Police All Plans	$22.12
Rate for Payer: Cash Price	$68.05
Rate for Payer: Self Pay Self Pay	$68.05

Oxalate, Quant, 24-Hour Urine LC

Facility

$172.00

Service Code	CPT 83945
Hospital Charge Code	2029209
Hospital Revenue Code	301
Min. Negotiated Rate	$44.72
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Bisbee Police All Plans	$44.72
Rate for Payer: Cash Price	$137.60
Rate for Payer: Self Pay Self Pay	$137.60

Oxalate, Quant, 24-Hour Urine LC

Facility

$172.00

Service Code	CPT 83945
Hospital Charge Code	2029209
Hospital Revenue Code	301
Min. Negotiated Rate	$27.52
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Aetna of AZ Medicare	$48.16
Rate for Payer: Allwell Medicare	$27.52
Rate for Payer: Amerigroup Medicare	$27.52
Rate for Payer: APIPA Medicare/Medicaid	$64.24
Rate for Payer: AZCH Complete Medicare	$27.52
Rate for Payer: Banner UC Health Medicare	$27.52
Rate for Payer: Bisbee Police All Plans	$44.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$116.96
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cigna of AZ Commercial	$111.80
Rate for Payer: Copperpoint Commercial	$42.57
Rate for Payer: Health Net of AZ Commercial	$103.20
Rate for Payer: Health Net of AZ Medicare	$48.16
Rate for Payer: Humana of AZ Medicare	$27.52
Rate for Payer: Self Pay Self Pay	$137.60
Rate for Payer: TriWest Medicare	$27.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$100.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$30.96

OXcarbazepine 600 mg Tab [CQCH]

Facility

$0.94

Service Code	NDC 50268068115
Hospital Charge Code	110527678
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.85
Rate for Payer: Aetna of AZ Commercial	$0.85
Rate for Payer: Bisbee Police All Plans	$0.24
Rate for Payer: Cash Price	$0.75
Rate for Payer: Self Pay Self Pay	$0.75

OXcarbazepine 600 mg Tab [CQCH]

Facility

$0.94

Service Code	NDC 50268068115
Hospital Charge Code	110527678
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.85
Rate for Payer: Aetna of AZ Commercial	$0.85
Rate for Payer: Aetna of AZ Medicare	$0.26
Rate for Payer: Allwell Medicare	$0.15
Rate for Payer: Amerigroup Medicare	$0.15
Rate for Payer: APIPA Medicare/Medicaid	$0.35
Rate for Payer: AZCH Complete Medicare	$0.15
Rate for Payer: Banner UC Health Medicare	$0.15
Rate for Payer: Bisbee Police All Plans	$0.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.64
Rate for Payer: Cash Price	$0.75
Rate for Payer: Cigna of AZ Commercial	$0.61
Rate for Payer: Copperpoint Commercial	$0.23
Rate for Payer: Health Net of AZ Commercial	$0.56
Rate for Payer: Health Net of AZ Medicare	$0.26
Rate for Payer: Humana of AZ Medicare	$0.15
Rate for Payer: Self Pay Self Pay	$0.75
Rate for Payer: TriWest Medicare	$0.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.55
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.17

Oxcarbazepine (Trileptal), LC

Facility

$234.00

Service Code	CPT 80299
Hospital Charge Code	1285602
Hospital Revenue Code	301
Min. Negotiated Rate	$60.84
Max. Negotiated Rate	$210.60
Rate for Payer: Aetna of AZ Commercial	$210.60
Rate for Payer: Bisbee Police All Plans	$60.84
Rate for Payer: Cash Price	$187.20
Rate for Payer: Self Pay Self Pay	$187.20

Know your out-of-pocket cost for care.

All Charges