Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

pseudoephedrine 30 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 904505359
Hospital Charge Code	105938744
Hospital Revenue Code	251
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of AZ Commercial	$0.02
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.02
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

psyllium 5.8 g oral pkt [CQCH]

Facility

$0.42

Service Code	NDC 37000002404
Hospital Charge Code	205060988
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of AZ Commercial	$0.38
Rate for Payer: Aetna of AZ Medicare	$0.12
Rate for Payer: Allwell Medicare	$0.06
Rate for Payer: Amerigroup Medicare	$0.06
Rate for Payer: APIPA Medicare/Medicaid	$0.16
Rate for Payer: AZCH Complete Medicare	$0.06
Rate for Payer: Banner UC Health Medicare	$0.06
Rate for Payer: Bisbee Police All Plans	$0.11
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.29
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cigna of AZ Commercial	$0.27
Rate for Payer: Copperpoint Commercial	$0.10
Rate for Payer: Health Net of AZ Commercial	$0.25
Rate for Payer: Health Net of AZ Medicare	$0.12
Rate for Payer: Humana of AZ Medicare	$0.06
Rate for Payer: Self Pay Self Pay	$0.34
Rate for Payer: TriWest Medicare	$0.06
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.24
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.08

psyllium 5.8 g oral pkt [CQCH]

Facility

$0.42

Service Code	NDC 37000002404
Hospital Charge Code	205060988
Hospital Revenue Code	251
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of AZ Commercial	$0.38
Rate for Payer: Bisbee Police All Plans	$0.11
Rate for Payer: Cash Price	$0.34
Rate for Payer: Self Pay Self Pay	$0.34

PT CANALITH REPOSITIONING

Facility

$203.00

Service Code	CPT 95992 GP
Hospital Charge Code	4836205
Hospital Revenue Code	424
Min. Negotiated Rate	$30.45
Max. Negotiated Rate	$182.70
Rate for Payer: Aetna of AZ Commercial	$182.70
Rate for Payer: Aetna of AZ Medicare	$56.84
Rate for Payer: Allwell Medicare	$30.45
Rate for Payer: Amerigroup Medicare	$30.45
Rate for Payer: APIPA Medicare/Medicaid	$75.82
Rate for Payer: AZCH Complete Medicare	$30.45
Rate for Payer: Banner UC Health Medicare	$30.45
Rate for Payer: Bisbee Police All Plans	$52.78
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$138.04
Rate for Payer: Cash Price	$162.40
Rate for Payer: Cigna of AZ Commercial	$142.10
Rate for Payer: Copperpoint Commercial	$50.24
Rate for Payer: Health Net of AZ Commercial	$121.80
Rate for Payer: Health Net of AZ Medicare	$56.84
Rate for Payer: Humana of AZ Medicare	$30.45
Rate for Payer: Self Pay Self Pay	$162.40
Rate for Payer: TriWest Medicare	$30.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$118.35
Rate for Payer: UnitedHealth Group of AZ Medicare	$36.54

PT CANALITH REPOSITIONING

Facility

$203.00

Service Code	CPT 95992 GP
Hospital Charge Code	4836205
Hospital Revenue Code	424
Min. Negotiated Rate	$52.78
Max. Negotiated Rate	$182.70
Rate for Payer: Aetna of AZ Commercial	$182.70
Rate for Payer: Bisbee Police All Plans	$52.78
Rate for Payer: Cash Price	$162.40
Rate for Payer: Self Pay Self Pay	$162.40

PT Community/Work Reintegration Charge

Facility

$181.00

Service Code	CPT 97537 GP
Hospital Charge Code	22408476
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

PT Community/Work Reintegration Charge

Facility

$181.00

Service Code	CPT 97537 GP
Hospital Charge Code	22408476
Hospital Revenue Code	420
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

PT CONTRAST BATH @ 15 MIN

Facility

$181.00

Service Code	CPT 97034 GP
Hospital Charge Code	8865467
Hospital Revenue Code	420
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

PT CONTRAST BATH @ 15 MIN

Facility

$181.00

Service Code	CPT 97034 GP
Hospital Charge Code	8865467
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

PT ELEC STIM MANUAL @ 15 MIN

Facility

$172.00

Service Code	CPT 97032 GP
Hospital Charge Code	692259
Hospital Revenue Code	420
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

PT ELEC STIM MANUAL @ 15 MIN

Facility

$172.00

Service Code	CPT 97032 GP
Hospital Charge Code	692259
Hospital Revenue Code	420
Min. Negotiated Rate	$25.80
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	$25.80
Rate for Payer: Amerigroup Medicare	$25.80
Rate for Payer: APIPA Medicare/Medicaid	$64.24
Rate for Payer: AZCH Complete Medicare	$25.80
Rate for Payer: Banner UC Health Medicare	$25.80
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	$25.80
Rate for Payer: Self Pay Self Pay	$137.60
Rate for Payer: TriWest Medicare	$25.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$100.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$30.96

PT E-STIM UNATT 1 OR MORE

Facility

$155.00

Service Code	CPT 97014 GP
Hospital Charge Code	1230068
Hospital Revenue Code	420
Min. Negotiated Rate	$23.25
Max. Negotiated Rate	$139.50
Rate for Payer: Aetna of AZ Commercial	$139.50
Rate for Payer: Aetna of AZ Medicare	$43.40
Rate for Payer: Allwell Medicare	$23.25
Rate for Payer: Amerigroup Medicare	$23.25
Rate for Payer: APIPA Medicare/Medicaid	$57.89
Rate for Payer: AZCH Complete Medicare	$23.25
Rate for Payer: Banner UC Health Medicare	$23.25
Rate for Payer: Bisbee Police All Plans	$40.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$105.40
Rate for Payer: Cash Price	$124.00
Rate for Payer: Cigna of AZ Commercial	$108.50
Rate for Payer: Copperpoint Commercial	$38.36
Rate for Payer: Health Net of AZ Commercial	$93.00
Rate for Payer: Health Net of AZ Medicare	$43.40
Rate for Payer: Humana of AZ Medicare	$23.25
Rate for Payer: Self Pay Self Pay	$124.00
Rate for Payer: TriWest Medicare	$23.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$90.36
Rate for Payer: UnitedHealth Group of AZ Medicare	$27.90

PT E-STIM UNATT 1 OR MORE

Facility

$155.00

Service Code	CPT 97014 GP
Hospital Charge Code	1230068
Hospital Revenue Code	420
Min. Negotiated Rate	$40.30
Max. Negotiated Rate	$139.50
Rate for Payer: Aetna of AZ Commercial	$139.50
Rate for Payer: Bisbee Police All Plans	$40.30
Rate for Payer: Cash Price	$124.00
Rate for Payer: Self Pay Self Pay	$124.00

PT E-STIM W US EACH 15

Facility

$172.00

Service Code	CPT 97035 GP
Hospital Charge Code	2619719
Hospital Revenue Code	420
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

PT E-STIM W US EACH 15

Facility

$172.00

Service Code	CPT 97035 GP
Hospital Charge Code	2619719
Hospital Revenue Code	420
Min. Negotiated Rate	$25.80
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	$25.80
Rate for Payer: Amerigroup Medicare	$25.80
Rate for Payer: APIPA Medicare/Medicaid	$64.24
Rate for Payer: AZCH Complete Medicare	$25.80
Rate for Payer: Banner UC Health Medicare	$25.80
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	$25.80
Rate for Payer: Self Pay Self Pay	$137.60
Rate for Payer: TriWest Medicare	$25.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$100.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$30.96

PT EVAL 45 MIN

Facility

$537.00

Hospital Charge Code	1230396
Hospital Revenue Code	424
Min. Negotiated Rate	$80.55
Max. Negotiated Rate	$483.30
Rate for Payer: Aetna of AZ Commercial	$483.30
Rate for Payer: Aetna of AZ Medicare	$150.36
Rate for Payer: Allwell Medicare	$80.55
Rate for Payer: Amerigroup Medicare	$80.55
Rate for Payer: APIPA Medicare/Medicaid	$200.57
Rate for Payer: AZCH Complete Medicare	$80.55
Rate for Payer: Banner UC Health Medicare	$80.55
Rate for Payer: Bisbee Police All Plans	$139.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$365.16
Rate for Payer: Cash Price	$429.60
Rate for Payer: Cigna of AZ Commercial	$375.90
Rate for Payer: Copperpoint Commercial	$132.91
Rate for Payer: Health Net of AZ Commercial	$322.20
Rate for Payer: Health Net of AZ Medicare	$150.36
Rate for Payer: Humana of AZ Medicare	$80.55
Rate for Payer: Self Pay Self Pay	$429.60
Rate for Payer: TriWest Medicare	$80.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$313.07
Rate for Payer: UnitedHealth Group of AZ Medicare	$96.66

PT EVAL 45 MIN

Facility

$537.00

Hospital Charge Code	1230396
Hospital Revenue Code	424
Min. Negotiated Rate	$139.62
Max. Negotiated Rate	$483.30
Rate for Payer: Aetna of AZ Commercial	$483.30
Rate for Payer: Bisbee Police All Plans	$139.62
Rate for Payer: Cash Price	$429.60
Rate for Payer: Self Pay Self Pay	$429.60

PT EVAL HIGH COMPLEX

Facility

$697.00

Service Code	CPT 97163 GP
Hospital Charge Code	22528750
Hospital Revenue Code	424
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

PT EVAL HIGH COMPLEX

Facility

$697.00

Service Code	CPT 97163 GP
Hospital Charge Code	22528750
Hospital Revenue Code	424
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

PT EVAL LOW COMPLEX

Facility

$358.00

Service Code	CPT 97161 GP
Hospital Charge Code	22528753
Hospital Revenue Code	424
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

PT EVAL LOW COMPLEX

Facility

$358.00

Service Code	CPT 97161 GP
Hospital Charge Code	22528753
Hospital Revenue Code	424
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

PT EVAL MOD COMPLEX

Facility

$537.00

Service Code	CPT 97162 GP
Hospital Charge Code	22528754
Hospital Revenue Code	424
Min. Negotiated Rate	$139.62
Max. Negotiated Rate	$483.30
Rate for Payer: Aetna of AZ Commercial	$483.30
Rate for Payer: Bisbee Police All Plans	$139.62
Rate for Payer: Cash Price	$429.60
Rate for Payer: Self Pay Self Pay	$429.60

PT EVAL MOD COMPLEX

Facility

$537.00

Service Code	CPT 97162 GP
Hospital Charge Code	22528754
Hospital Revenue Code	424
Min. Negotiated Rate	$80.55
Max. Negotiated Rate	$483.30
Rate for Payer: Aetna of AZ Commercial	$483.30
Rate for Payer: Aetna of AZ Medicare	$150.36
Rate for Payer: Allwell Medicare	$80.55
Rate for Payer: Amerigroup Medicare	$80.55
Rate for Payer: APIPA Medicare/Medicaid	$200.57
Rate for Payer: AZCH Complete Medicare	$80.55
Rate for Payer: Banner UC Health Medicare	$80.55
Rate for Payer: Bisbee Police All Plans	$139.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$365.16
Rate for Payer: Cash Price	$429.60
Rate for Payer: Cigna of AZ Commercial	$375.90
Rate for Payer: Copperpoint Commercial	$132.91
Rate for Payer: Health Net of AZ Commercial	$322.20
Rate for Payer: Health Net of AZ Medicare	$150.36
Rate for Payer: Humana of AZ Medicare	$80.55
Rate for Payer: Self Pay Self Pay	$429.60
Rate for Payer: TriWest Medicare	$80.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$313.07
Rate for Payer: UnitedHealth Group of AZ Medicare	$96.66

PT FUNCTIONAL ACTIVITIES 15 MIN

Facility

$172.00

Service Code	CPT 97530 GP
Hospital Charge Code	5543179
Hospital Revenue Code	420
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

PT FUNCTIONAL ACTIVITIES 15 MIN

Facility

$172.00

Service Code	CPT 97530 GP
Hospital Charge Code	5543179
Hospital Revenue Code	420
Min. Negotiated Rate	$25.80
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	$25.80
Rate for Payer: Amerigroup Medicare	$25.80
Rate for Payer: APIPA Medicare/Medicaid	$64.24
Rate for Payer: AZCH Complete Medicare	$25.80
Rate for Payer: Banner UC Health Medicare	$25.80
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	$25.80
Rate for Payer: Self Pay Self Pay	$137.60
Rate for Payer: TriWest Medicare	$25.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$100.28
Rate for Payer: UnitedHealth Group of AZ Medicare	$30.96

Know your out-of-pocket cost for care.

All Charges