Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

OSTEOPATHIC MANIPULATIVE TREATMENT, 7-8 BODY REGIONS

Facility

$160.00

Service Code	CPT 98928
Hospital Charge Code	27898314
Min. Negotiated Rate	$144.00
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna of AZ Commercial	$144.00
Rate for Payer: Cash Price	$128.00

OSTEOPATHIC MANIPULATIVE TREATMENT, 7-8 BODY REGIONS

Facility

$160.00

Service Code	CPT 98928
Hospital Charge Code	27898314
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna of AZ Commercial	$144.00
Rate for Payer: Arizona Complete Health Allwell	$25.60
Rate for Payer: Banner UC Health Medicare	$25.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$108.80
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$14.30
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$25.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$25.60
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cash Price	$128.00
Rate for Payer: Cigna of AZ Commercial	$112.00
Rate for Payer: Devoted Health Medicare	$28.80
Rate for Payer: Humana of AZ Medicare	$25.60
Rate for Payer: Mercy Care Medicaid	$14.30
Rate for Payer: NaphCare Correctional Healthcare	$14.30
Rate for Payer: Seven Corners Travel Insurance	$33.41
Rate for Payer: Southwest Service Administrators UFCW	$108.80
Rate for Payer: TriWest Medicare	$25.60
Rate for Payer: United Healthcare Commercial	$91.52
Rate for Payer: United Healthcare Medicare	$25.60
Rate for Payer: Veterans Affairs TRICARE	$25.34

OSTEOPATHIC MANIPULATIVE TREATMENT, 9-10 BODY REGIONS

Facility

$193.00

Service Code	CPT 98929
Hospital Charge Code	27898315
Min. Negotiated Rate	$15.69
Max. Negotiated Rate	$173.70
Rate for Payer: Aetna of AZ Commercial	$173.70
Rate for Payer: Arizona Complete Health Allwell	$30.88
Rate for Payer: Banner UC Health Medicare	$30.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$131.24
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$15.69
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$30.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$30.88
Rate for Payer: Cash Price	$154.40
Rate for Payer: Cash Price	$154.40
Rate for Payer: Cigna of AZ Commercial	$135.10
Rate for Payer: Devoted Health Medicare	$34.74
Rate for Payer: Humana of AZ Medicare	$30.88
Rate for Payer: Mercy Care Medicaid	$15.69
Rate for Payer: NaphCare Correctional Healthcare	$15.69
Rate for Payer: Seven Corners Travel Insurance	$33.41
Rate for Payer: Southwest Service Administrators UFCW	$131.24
Rate for Payer: TriWest Medicare	$30.88
Rate for Payer: United Healthcare Commercial	$110.40
Rate for Payer: United Healthcare Medicare	$30.88
Rate for Payer: Veterans Affairs TRICARE	$30.57

OSTEOPATHIC MANIPULATIVE TREATMENT, 9-10 BODY REGIONS

Facility

$193.00

Service Code	CPT 98929
Hospital Charge Code	27898315
Min. Negotiated Rate	$173.70
Max. Negotiated Rate	$173.70
Rate for Payer: Aetna of AZ Commercial	$173.70
Rate for Payer: Cash Price	$154.40

OSTEOSET RESORBABLE MINI BEAD FAST

Facility

$2,293.00

Hospital Charge Code	22354275
Hospital Revenue Code	270
Min. Negotiated Rate	$2,063.70
Max. Negotiated Rate	$2,063.70
Rate for Payer: Aetna of AZ Commercial	$2,063.70
Rate for Payer: Cash Price	$1,834.40

OSTEOSET RESORBABLE MINI BEAD FAST

Facility

$2,293.00

Hospital Charge Code	22354275
Hospital Revenue Code	270
Min. Negotiated Rate	$363.21
Max. Negotiated Rate	$2,063.70
Rate for Payer: Aetna of AZ Commercial	$2,063.70
Rate for Payer: Arizona Complete Health Allwell	$366.88
Rate for Payer: Banner UC Health Medicare	$366.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,559.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$366.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$366.88
Rate for Payer: Cash Price	$1,834.40
Rate for Payer: Cigna of AZ Commercial	$1,605.10
Rate for Payer: Devoted Health Medicare	$412.74
Rate for Payer: Humana of AZ Medicare	$366.88
Rate for Payer: Southwest Service Administrators UFCW	$1,559.24
Rate for Payer: TriWest Medicare	$366.88
Rate for Payer: United Healthcare Commercial	$1,311.60
Rate for Payer: United Healthcare Medicare	$366.88
Rate for Payer: Veterans Affairs TRICARE	$363.21

OSTEOTOMY WITH OR WITHOUT LENGTHENING SHORTENING OR ANGULAR CORRECTION

Facility

$1,966.00

Service Code	CPT 28306
Hospital Charge Code	24043263
Hospital Revenue Code	360
Min. Negotiated Rate	$196.65
Max. Negotiated Rate	$11,227.32
Rate for Payer: Aetna of AZ Commercial	$1,769.40
Rate for Payer: Arizona Complete Health Allwell	$314.56
Rate for Payer: Banner UC Health Medicare	$3,026.13
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,336.88
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$196.65
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$314.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$314.56
Rate for Payer: Cash Price	$1,572.80
Rate for Payer: Cash Price	$1,572.80
Rate for Payer: Cash Price	$1,572.80
Rate for Payer: Cigna of AZ Commercial	$983.00
Rate for Payer: Devoted Health Medicare	$353.88
Rate for Payer: Humana of AZ Medicare	$314.56
Rate for Payer: Mercy Care Medicaid	$196.65
Rate for Payer: NaphCare Correctional Healthcare	$3,026.13
Rate for Payer: Seven Corners Travel Insurance	$11,227.32
Rate for Payer: Southwest Service Administrators UFCW	$1,336.88
Rate for Payer: TriWest Medicare	$314.56
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$314.56
Rate for Payer: Veterans Affairs TRICARE	$311.41

OSTEOTOMY WITH OR WITHOUT LENGTHENING SHORTENING OR ANGULAR CORRECTION

Facility

$1,966.00

Service Code	CPT 28306
Hospital Charge Code	24043263
Hospital Revenue Code	360
Min. Negotiated Rate	$1,769.40
Max. Negotiated Rate	$1,769.40
Rate for Payer: Aetna of AZ Commercial	$1,769.40
Rate for Payer: Cash Price	$1,572.80

OSTEOTOMY WITH OR WITHOUT LENGTHENING SHORTENING OR ANGULAR CORRECTION - 28308

Facility

$1,851.00

Service Code	CPT 28308
Hospital Charge Code	24043264
Hospital Revenue Code	360
Min. Negotiated Rate	$1,665.90
Max. Negotiated Rate	$1,665.90
Rate for Payer: Aetna of AZ Commercial	$1,665.90
Rate for Payer: Cash Price	$1,480.80

OSTEOTOMY WITH OR WITHOUT LENGTHENING SHORTENING OR ANGULAR CORRECTION - 28308

Facility

$1,851.00

Service Code	CPT 28308
Hospital Charge Code	24043264
Hospital Revenue Code	360
Min. Negotiated Rate	$177.82
Max. Negotiated Rate	$5,062.66
Rate for Payer: Aetna of AZ Commercial	$1,665.90
Rate for Payer: Arizona Complete Health Allwell	$296.16
Rate for Payer: Banner UC Health Medicare	$1,062.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,258.68
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$177.82
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$296.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$296.16
Rate for Payer: Cash Price	$1,480.80
Rate for Payer: Cash Price	$1,480.80
Rate for Payer: Cash Price	$1,480.80
Rate for Payer: Cigna of AZ Commercial	$925.50
Rate for Payer: Devoted Health Medicare	$333.18
Rate for Payer: Humana of AZ Medicare	$296.16
Rate for Payer: Mercy Care Medicaid	$177.82
Rate for Payer: NaphCare Correctional Healthcare	$1,062.88
Rate for Payer: Seven Corners Travel Insurance	$5,062.66
Rate for Payer: Southwest Service Administrators UFCW	$1,258.68
Rate for Payer: TriWest Medicare	$296.16
Rate for Payer: United Healthcare Commercial	$4,169.00
Rate for Payer: United Healthcare Medicare	$296.16
Rate for Payer: Veterans Affairs TRICARE	$293.20

OSTOMY BELT ADJUSTABLE

Facility

$67.00

Service Code	HCPCS A4367
Hospital Charge Code	22354246
Hospital Revenue Code	270
Min. Negotiated Rate	$10.61
Max. Negotiated Rate	$60.30
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Arizona Complete Health Allwell	$10.72
Rate for Payer: Banner UC Health Medicare	$10.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$45.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$10.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$10.72
Rate for Payer: Cash Price	$53.60
Rate for Payer: Cigna of AZ Commercial	$46.90
Rate for Payer: Devoted Health Medicare	$12.06
Rate for Payer: Humana of AZ Medicare	$10.72
Rate for Payer: Southwest Service Administrators UFCW	$45.56
Rate for Payer: TriWest Medicare	$10.72
Rate for Payer: United Healthcare Commercial	$38.32
Rate for Payer: United Healthcare Medicare	$10.72
Rate for Payer: Veterans Affairs TRICARE	$10.61

OSTOMY BELT ADJUSTABLE

Facility

$67.00

Service Code	HCPCS A4367
Hospital Charge Code	22354246
Hospital Revenue Code	270
Min. Negotiated Rate	$60.30
Max. Negotiated Rate	$60.30
Rate for Payer: Aetna of AZ Commercial	$60.30
Rate for Payer: Cash Price	$53.60

OT COGNITIVE TRAIN @ 15 MIN

Facility

$181.00

Service Code	CPT 97532 GO
Hospital Charge Code	691289
Hospital Revenue Code	430
Min. Negotiated Rate	$162.90
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Cash Price	$144.80

OT COGNITIVE TRAIN @ 15 MIN

Facility

$181.00

Service Code	CPT 97532 GO
Hospital Charge Code	11473411
Hospital Revenue Code	430
Min. Negotiated Rate	$162.90
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Cash Price	$144.80

OT COGNITIVE TRAIN @ 15 MIN

Facility

$181.00

Service Code	CPT 97532 GO
Hospital Charge Code	11473411
Hospital Revenue Code	430
Min. Negotiated Rate	$28.67
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Arizona Complete Health Allwell	$28.96
Rate for Payer: Banner UC Health Medicare	$28.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$123.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.96
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cigna of AZ Commercial	$126.70
Rate for Payer: Devoted Health Medicare	$32.58
Rate for Payer: Humana of AZ Medicare	$28.96
Rate for Payer: Southwest Service Administrators UFCW	$123.08
Rate for Payer: TriWest Medicare	$28.96
Rate for Payer: United Healthcare Commercial	$103.53
Rate for Payer: United Healthcare Medicare	$28.96
Rate for Payer: United Healthcare New Mexico Commercial	$34.39
Rate for Payer: Veterans Affairs TRICARE	$28.67

OT COGNITIVE TRAIN @ 15 MIN

Facility

$181.00

Service Code	CPT 97532 GO
Hospital Charge Code	691289
Hospital Revenue Code	430
Min. Negotiated Rate	$28.67
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Arizona Complete Health Allwell	$28.96
Rate for Payer: Banner UC Health Medicare	$28.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$123.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.96
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cigna of AZ Commercial	$126.70
Rate for Payer: Devoted Health Medicare	$32.58
Rate for Payer: Humana of AZ Medicare	$28.96
Rate for Payer: Southwest Service Administrators UFCW	$123.08
Rate for Payer: TriWest Medicare	$28.96
Rate for Payer: United Healthcare Commercial	$103.53
Rate for Payer: United Healthcare Medicare	$28.96
Rate for Payer: United Healthcare New Mexico Commercial	$34.39
Rate for Payer: Veterans Affairs TRICARE	$28.67

OT COMMUNITY/WORK TRAIN @ 15 MIN

Facility

$172.00

Service Code	CPT 97537 GO
Hospital Charge Code	691287
Hospital Revenue Code	430
Min. Negotiated Rate	$27.24
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Arizona Complete Health Allwell	$27.52
Rate for Payer: Banner UC Health Medicare	$27.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$116.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$33.28
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cash Price	$137.60
Rate for Payer: Cigna of AZ Commercial	$120.40
Rate for Payer: Devoted Health Medicare	$30.96
Rate for Payer: Humana of AZ Medicare	$27.52
Rate for Payer: Southwest Service Administrators UFCW	$116.96
Rate for Payer: TriWest Medicare	$27.52
Rate for Payer: United Healthcare Commercial	$98.38
Rate for Payer: United Healthcare Medicare	$27.52
Rate for Payer: United Healthcare New Mexico Commercial	$32.68
Rate for Payer: Veterans Affairs TRICARE	$27.24

OT COMMUNITY/WORK TRAIN @ 15 MIN

Facility

$172.00

Service Code	CPT 97537 GO
Hospital Charge Code	691287
Hospital Revenue Code	430
Min. Negotiated Rate	$154.80
Max. Negotiated Rate	$154.80
Rate for Payer: Aetna of AZ Commercial	$154.80
Rate for Payer: Cash Price	$137.60

OT COMMUNITY/WORK TRAIN @ 15 MIN

Facility

$184.00

Service Code	CPT 97537 GO
Hospital Charge Code	11473418
Hospital Revenue Code	430
Min. Negotiated Rate	$165.60
Max. Negotiated Rate	$165.60
Rate for Payer: Aetna of AZ Commercial	$165.60
Rate for Payer: Cash Price	$147.20

OT COMMUNITY/WORK TRAIN @ 15 MIN

Facility

$184.00

Service Code	CPT 97537 GO
Hospital Charge Code	11473418
Hospital Revenue Code	430
Min. Negotiated Rate	$29.15
Max. Negotiated Rate	$165.60
Rate for Payer: Aetna of AZ Commercial	$165.60
Rate for Payer: Arizona Complete Health Allwell	$29.44
Rate for Payer: Banner UC Health Medicare	$29.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$125.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$29.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$33.28
Rate for Payer: Cash Price	$147.20
Rate for Payer: Cash Price	$147.20
Rate for Payer: Cigna of AZ Commercial	$128.80
Rate for Payer: Devoted Health Medicare	$33.12
Rate for Payer: Humana of AZ Medicare	$29.44
Rate for Payer: Southwest Service Administrators UFCW	$125.12
Rate for Payer: TriWest Medicare	$29.44
Rate for Payer: United Healthcare Commercial	$105.25
Rate for Payer: United Healthcare Medicare	$29.44
Rate for Payer: United Healthcare New Mexico Commercial	$34.96
Rate for Payer: Veterans Affairs TRICARE	$29.15

OT ELECT STIM MANUAL @ 15 MIN

Facility

$181.00

Service Code	CPT 97032 GO
Hospital Charge Code	691324
Hospital Revenue Code	430
Min. Negotiated Rate	$15.23
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Arizona Complete Health Allwell	$28.96
Rate for Payer: Banner UC Health Medicare	$28.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$123.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$15.23
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cigna of AZ Commercial	$126.70
Rate for Payer: Devoted Health Medicare	$32.58
Rate for Payer: Humana of AZ Medicare	$28.96
Rate for Payer: Southwest Service Administrators UFCW	$123.08
Rate for Payer: TriWest Medicare	$28.96
Rate for Payer: United Healthcare Commercial	$103.53
Rate for Payer: United Healthcare Medicare	$28.96
Rate for Payer: United Healthcare New Mexico Commercial	$34.39
Rate for Payer: Veterans Affairs TRICARE	$28.67

OT ELECT STIM MANUAL @ 15 MIN

Facility

$181.00

Service Code	CPT 97032 GO
Hospital Charge Code	691324
Hospital Revenue Code	430
Min. Negotiated Rate	$162.90
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Cash Price	$144.80

OT E-STIM W US - EACH 15

Facility

$181.00

Service Code	CPT 97035 GO
Hospital Charge Code	8865394
Hospital Revenue Code	430
Min. Negotiated Rate	$162.90
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Cash Price	$144.80

OT E-STIM W US - EACH 15

Facility

$181.00

Service Code	CPT 97035 GO
Hospital Charge Code	8865394
Hospital Revenue Code	430
Min. Negotiated Rate	$14.87
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Arizona Complete Health Allwell	$28.96
Rate for Payer: Banner UC Health Medicare	$28.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$123.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$28.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.87
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cash Price	$144.80
Rate for Payer: Cigna of AZ Commercial	$126.70
Rate for Payer: Devoted Health Medicare	$32.58
Rate for Payer: Humana of AZ Medicare	$28.96
Rate for Payer: Southwest Service Administrators UFCW	$123.08
Rate for Payer: TriWest Medicare	$28.96
Rate for Payer: United Healthcare Commercial	$103.53
Rate for Payer: United Healthcare Medicare	$28.96
Rate for Payer: United Healthcare New Mexico Commercial	$34.39
Rate for Payer: Veterans Affairs TRICARE	$28.67

OT EVAL 30 MIN

Facility

$358.00

Service Code	CPT 97165 GO
Hospital Charge Code	22528841
Hospital Revenue Code	430
Min. Negotiated Rate	$322.20
Max. Negotiated Rate	$322.20
Rate for Payer: Aetna of AZ Commercial	$322.20
Rate for Payer: Cash Price	$286.40

Know your out-of-pocket cost for care.

All Charges