Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

PROTIME

Facility

$71.00

Service Code	CPT 85610
Hospital Charge Code	22481498
Hospital Revenue Code	305
Min. Negotiated Rate	$18.46
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Bisbee Police All Plans	$18.46
Rate for Payer: Cash Price	$56.80
Rate for Payer: Self Pay Self Pay	$56.80

Protime/PTT

Facility

$71.00

Service Code	CPT 85610
Hospital Charge Code	898512
Hospital Revenue Code	305
Min. Negotiated Rate	$11.36
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Aetna of AZ Medicare	$19.88
Rate for Payer: Allwell Medicare	$11.36
Rate for Payer: Amerigroup Medicare	$11.36
Rate for Payer: APIPA Medicare/Medicaid	$26.52
Rate for Payer: AZCH Complete Medicare	$11.36
Rate for Payer: Banner UC Health Medicare	$11.36
Rate for Payer: Bisbee Police All Plans	$18.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$48.28
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cigna of AZ Commercial	$46.15
Rate for Payer: Copperpoint Commercial	$17.57
Rate for Payer: Health Net of AZ Commercial	$42.60
Rate for Payer: Health Net of AZ Medicare	$19.88
Rate for Payer: Humana of AZ Medicare	$11.36
Rate for Payer: Self Pay Self Pay	$56.80
Rate for Payer: TriWest Medicare	$11.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$41.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.78

Protime/PTT

Facility

$71.00

Service Code	CPT 85610
Hospital Charge Code	898512
Hospital Revenue Code	305
Min. Negotiated Rate	$18.46
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of AZ Commercial	$63.90
Rate for Payer: Bisbee Police All Plans	$18.46
Rate for Payer: Cash Price	$56.80
Rate for Payer: Self Pay Self Pay	$56.80

PSA Diagnostic.

Facility

$224.00

Service Code	CPT 84153
Hospital Charge Code	13095387
Hospital Revenue Code	301
Min. Negotiated Rate	$58.24
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of AZ Commercial	$201.60
Rate for Payer: Bisbee Police All Plans	$58.24
Rate for Payer: Cash Price	$179.20
Rate for Payer: Self Pay Self Pay	$179.20

PSA Diagnostic.

Facility

$224.00

Service Code	CPT 84153
Hospital Charge Code	13095387
Hospital Revenue Code	301
Min. Negotiated Rate	$35.84
Max. Negotiated Rate	$201.60
Rate for Payer: Aetna of AZ Commercial	$201.60
Rate for Payer: Aetna of AZ Medicare	$62.72
Rate for Payer: Allwell Medicare	$35.84
Rate for Payer: Amerigroup Medicare	$35.84
Rate for Payer: APIPA Medicare/Medicaid	$83.66
Rate for Payer: AZCH Complete Medicare	$35.84
Rate for Payer: Banner UC Health Medicare	$35.84
Rate for Payer: Bisbee Police All Plans	$58.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$152.32
Rate for Payer: Cash Price	$179.20
Rate for Payer: Cigna of AZ Commercial	$145.60
Rate for Payer: Copperpoint Commercial	$55.44
Rate for Payer: Health Net of AZ Commercial	$134.40
Rate for Payer: Health Net of AZ Medicare	$62.72
Rate for Payer: Humana of AZ Medicare	$35.84
Rate for Payer: Self Pay Self Pay	$179.20
Rate for Payer: TriWest Medicare	$35.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$130.59
Rate for Payer: UnitedHealth Group of AZ Medicare	$40.32

PSA Screen

Facility

$223.00

Hospital Charge Code	1019535
Hospital Revenue Code	301
Min. Negotiated Rate	$57.98
Max. Negotiated Rate	$200.70
Rate for Payer: Aetna of AZ Commercial	$200.70
Rate for Payer: Bisbee Police All Plans	$57.98
Rate for Payer: Cash Price	$178.40
Rate for Payer: Self Pay Self Pay	$178.40

PSA Screen

Facility

$223.00

Hospital Charge Code	1019535
Hospital Revenue Code	301
Min. Negotiated Rate	$35.68
Max. Negotiated Rate	$200.70
Rate for Payer: Aetna of AZ Commercial	$200.70
Rate for Payer: Aetna of AZ Medicare	$62.44
Rate for Payer: Allwell Medicare	$35.68
Rate for Payer: Amerigroup Medicare	$35.68
Rate for Payer: APIPA Medicare/Medicaid	$83.29
Rate for Payer: AZCH Complete Medicare	$35.68
Rate for Payer: Banner UC Health Medicare	$35.68
Rate for Payer: Bisbee Police All Plans	$57.98
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$151.64
Rate for Payer: Cash Price	$178.40
Rate for Payer: Cigna of AZ Commercial	$144.95
Rate for Payer: Copperpoint Commercial	$55.19
Rate for Payer: Health Net of AZ Commercial	$133.80
Rate for Payer: Health Net of AZ Medicare	$62.44
Rate for Payer: Humana of AZ Medicare	$35.68
Rate for Payer: Self Pay Self Pay	$178.40
Rate for Payer: TriWest Medicare	$35.68
Rate for Payer: UnitedHealth Group of AZ Commercial	$130.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$40.14

PSA Total+% Free (Serial) LC

Facility

$257.00

Service Code	CPT 84154
Hospital Charge Code	1909550
Hospital Revenue Code	301
Min. Negotiated Rate	$66.82
Max. Negotiated Rate	$231.30
Rate for Payer: Aetna of AZ Commercial	$231.30
Rate for Payer: Bisbee Police All Plans	$66.82
Rate for Payer: Cash Price	$205.60
Rate for Payer: Self Pay Self Pay	$205.60

PSA Total+% Free (Serial) LC

Facility

$257.00

Service Code	CPT 84154
Hospital Charge Code	1909550
Hospital Revenue Code	301
Min. Negotiated Rate	$41.12
Max. Negotiated Rate	$231.30
Rate for Payer: Aetna of AZ Commercial	$231.30
Rate for Payer: Aetna of AZ Medicare	$71.96
Rate for Payer: Allwell Medicare	$41.12
Rate for Payer: Amerigroup Medicare	$41.12
Rate for Payer: APIPA Medicare/Medicaid	$95.99
Rate for Payer: AZCH Complete Medicare	$41.12
Rate for Payer: Banner UC Health Medicare	$41.12
Rate for Payer: Bisbee Police All Plans	$66.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$174.76
Rate for Payer: Cash Price	$205.60
Rate for Payer: Cigna of AZ Commercial	$167.05
Rate for Payer: Copperpoint Commercial	$63.61
Rate for Payer: Health Net of AZ Commercial	$154.20
Rate for Payer: Health Net of AZ Medicare	$71.96
Rate for Payer: Humana of AZ Medicare	$41.12
Rate for Payer: Self Pay Self Pay	$205.60
Rate for Payer: TriWest Medicare	$41.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$149.83
Rate for Payer: UnitedHealth Group of AZ Medicare	$46.26

PSA Ultra. W/Serial Monitor LC

Facility

$250.00

Service Code	CPT 84153
Hospital Charge Code	22311204
Hospital Revenue Code	301
Min. Negotiated Rate	$40.00
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna of AZ Commercial	$225.00
Rate for Payer: Aetna of AZ Medicare	$70.00
Rate for Payer: Allwell Medicare	$40.00
Rate for Payer: Amerigroup Medicare	$40.00
Rate for Payer: APIPA Medicare/Medicaid	$93.38
Rate for Payer: AZCH Complete Medicare	$40.00
Rate for Payer: Banner UC Health Medicare	$40.00
Rate for Payer: Bisbee Police All Plans	$65.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$170.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Cigna of AZ Commercial	$162.50
Rate for Payer: Copperpoint Commercial	$61.88
Rate for Payer: Health Net of AZ Commercial	$150.00
Rate for Payer: Health Net of AZ Medicare	$70.00
Rate for Payer: Humana of AZ Medicare	$40.00
Rate for Payer: Self Pay Self Pay	$200.00
Rate for Payer: TriWest Medicare	$40.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$145.75
Rate for Payer: UnitedHealth Group of AZ Medicare	$45.00

PSA Ultra. W/Serial Monitor LC

Facility

$250.00

Service Code	CPT 84153
Hospital Charge Code	22311204
Hospital Revenue Code	301
Min. Negotiated Rate	$65.00
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna of AZ Commercial	$225.00
Rate for Payer: Bisbee Police All Plans	$65.00
Rate for Payer: Cash Price	$200.00
Rate for Payer: Self Pay Self Pay	$200.00

pseudoephedrine 30 mg Tab [CQCH]

Facility

$0.03

Service Code	NDC 904505359
Hospital Charge Code	105938744
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Self Pay Self Pay	$0.02

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	$0.11
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

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	$0.07
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	$0.07
Rate for Payer: Amerigroup Medicare	$0.07
Rate for Payer: APIPA Medicare/Medicaid	$0.16
Rate for Payer: AZCH Complete Medicare	$0.07
Rate for Payer: Banner UC Health Medicare	$0.07
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	$0.07
Rate for Payer: Self Pay Self Pay	$0.34
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.24
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.08

PT Body Position Current Status G-8981 CH 0% impaired

Facility

$0.01

Service Code	CPT G8981 GP
Hospital Charge Code	6035272
Hospital Revenue Code	420
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.01

PT Body Position Current Status G-8981 CH 0% impaired

Facility

$0.01

Service Code	CPT G8981 GP
Hospital Charge Code	6035272
Hospital Revenue Code	420
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

PT Body Position Current Status G-8981 CI At least 1% but less than 20% impaired

Facility

$0.01

Service Code	CPT G8981 GP
Hospital Charge Code	6035271
Hospital Revenue Code	420
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.01

PT Body Position Current Status G-8981 CI At least 1% but less than 20% impaired

Facility

$0.01

Service Code	CPT G8981 GP
Hospital Charge Code	6035271
Hospital Revenue Code	420
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

PT Body Position Current Status G-8981 CJ At least 20% but less than 40% impaire

Facility

$0.01

Service Code	CPT G8981 GP
Hospital Charge Code	6035270
Hospital Revenue Code	420
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.01

PT Body Position Current Status G-8981 CJ At least 20% but less than 40% impaire

Facility

$0.01

Service Code	CPT G8981 GP
Hospital Charge Code	6035270
Hospital Revenue Code	420
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

PT Body Position Current Status G-8981 CK At least 40% but less than 60% impaire

Facility

$0.01

Service Code	CPT G8981 GP
Hospital Charge Code	6035269
Hospital Revenue Code	420
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

PT Body Position Current Status G-8981 CK At least 40% but less than 60% impaire

Facility

$0.01

Service Code	CPT G8981 GP
Hospital Charge Code	6035269
Hospital Revenue Code	420
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.01

PT Body Position Current Status G-8981 CL At least 60% but less than 80% impaire

Facility

$0.01

Service Code	CPT G8981 GP
Hospital Charge Code	6035268
Hospital Revenue Code	420
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

PT Body Position Current Status G-8981 CL At least 60% but less than 80% impaire

Facility

$0.01

Service Code	CPT G8981 GP
Hospital Charge Code	6035268
Hospital Revenue Code	420
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.01

Know your out-of-pocket cost for care.

All Charges