Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

PT RE-EVAL

Facility

$358.00

Service Code	CPT 97164 GP
Hospital Charge Code	22528957
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 RE-EVALUATION 31 TO 60 MIN

Facility

$697.00

Hospital Charge Code	22528958
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 RE-EVALUATION 31 TO 60 MIN

Facility

$697.00

Hospital Charge Code	22528958
Hospital Revenue Code	424
Min. Negotiated Rate	$111.52
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	$111.52
Rate for Payer: Amerigroup Medicare	$111.52
Rate for Payer: APIPA Medicare/Medicaid	$260.33
Rate for Payer: AZCH Complete Medicare	$111.52
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: 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: 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

PT Self-Care Current Status G-8987 CH 0% impaired

Facility

$5.00

Service Code	CPT G8987 GP
Hospital Charge Code	6035383
Hospital Revenue Code	420
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Aetna of AZ Medicare	$1.40
Rate for Payer: Allwell Medicare	$0.80
Rate for Payer: Amerigroup Medicare	$0.80
Rate for Payer: APIPA Medicare/Medicaid	$1.87
Rate for Payer: AZCH Complete Medicare	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Bisbee Police All Plans	$1.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3.40
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of AZ Commercial	$3.50
Rate for Payer: Copperpoint Commercial	$1.24
Rate for Payer: Health Net of AZ Commercial	$3.00
Rate for Payer: Health Net of AZ Medicare	$1.40
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Self Pay Self Pay	$4.00
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.92
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.90

PT Self-Care Current Status G-8987 CH 0% impaired

Facility

$5.00

Service Code	CPT G8987 GP
Hospital Charge Code	6035383
Hospital Revenue Code	420
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Bisbee Police All Plans	$1.30
Rate for Payer: Cash Price	$4.00
Rate for Payer: Self Pay Self Pay	$4.00

PT Self-Care Current Status G-8987 CI At least 1% but less than 20% impaired

Facility

$5.00

Service Code	CPT G8987 GP
Hospital Charge Code	6035382
Hospital Revenue Code	420
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Bisbee Police All Plans	$1.30
Rate for Payer: Cash Price	$4.00
Rate for Payer: Self Pay Self Pay	$4.00

PT Self-Care Current Status G-8987 CI At least 1% but less than 20% impaired

Facility

$5.00

Service Code	CPT G8987 GP
Hospital Charge Code	6035382
Hospital Revenue Code	420
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Aetna of AZ Medicare	$1.40
Rate for Payer: Allwell Medicare	$0.80
Rate for Payer: Amerigroup Medicare	$0.80
Rate for Payer: APIPA Medicare/Medicaid	$1.87
Rate for Payer: AZCH Complete Medicare	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Bisbee Police All Plans	$1.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3.40
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of AZ Commercial	$3.50
Rate for Payer: Copperpoint Commercial	$1.24
Rate for Payer: Health Net of AZ Commercial	$3.00
Rate for Payer: Health Net of AZ Medicare	$1.40
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Self Pay Self Pay	$4.00
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.92
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.90

PT Self-Care Current Status G-8987 CJ At least 20% but less than 40% impaired

Facility

$5.00

Service Code	CPT G8987 GP
Hospital Charge Code	6035381
Hospital Revenue Code	420
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Aetna of AZ Medicare	$1.40
Rate for Payer: Allwell Medicare	$0.80
Rate for Payer: Amerigroup Medicare	$0.80
Rate for Payer: APIPA Medicare/Medicaid	$1.87
Rate for Payer: AZCH Complete Medicare	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Bisbee Police All Plans	$1.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3.40
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of AZ Commercial	$3.50
Rate for Payer: Copperpoint Commercial	$1.24
Rate for Payer: Health Net of AZ Commercial	$3.00
Rate for Payer: Health Net of AZ Medicare	$1.40
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Self Pay Self Pay	$4.00
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.92
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.90

PT Self-Care Current Status G-8987 CJ At least 20% but less than 40% impaired

Facility

$5.00

Service Code	CPT G8987 GP
Hospital Charge Code	6035381
Hospital Revenue Code	420
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Bisbee Police All Plans	$1.30
Rate for Payer: Cash Price	$4.00
Rate for Payer: Self Pay Self Pay	$4.00

PT Self-Care Current Status G-8987 CK At least 40% but less than 60% impaired

Facility

$5.00

Service Code	CPT G8987 GP
Hospital Charge Code	6035380
Hospital Revenue Code	420
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Bisbee Police All Plans	$1.30
Rate for Payer: Cash Price	$4.00
Rate for Payer: Self Pay Self Pay	$4.00

PT Self-Care Current Status G-8987 CK At least 40% but less than 60% impaired

Facility

$5.00

Service Code	CPT G8987 GP
Hospital Charge Code	6035380
Hospital Revenue Code	420
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Aetna of AZ Medicare	$1.40
Rate for Payer: Allwell Medicare	$0.80
Rate for Payer: Amerigroup Medicare	$0.80
Rate for Payer: APIPA Medicare/Medicaid	$1.87
Rate for Payer: AZCH Complete Medicare	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Bisbee Police All Plans	$1.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3.40
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of AZ Commercial	$3.50
Rate for Payer: Copperpoint Commercial	$1.24
Rate for Payer: Health Net of AZ Commercial	$3.00
Rate for Payer: Health Net of AZ Medicare	$1.40
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Self Pay Self Pay	$4.00
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.92
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.90

PT Self-Care Current Status G-8987 CL At least 60% but less than 80% impaired

Facility

$5.00

Service Code	CPT G8987 GP
Hospital Charge Code	6035379
Hospital Revenue Code	420
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Bisbee Police All Plans	$1.30
Rate for Payer: Cash Price	$4.00
Rate for Payer: Self Pay Self Pay	$4.00

PT Self-Care Current Status G-8987 CL At least 60% but less than 80% impaired

Facility

$5.00

Service Code	CPT G8987 GP
Hospital Charge Code	6035379
Hospital Revenue Code	420
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Aetna of AZ Medicare	$1.40
Rate for Payer: Allwell Medicare	$0.80
Rate for Payer: Amerigroup Medicare	$0.80
Rate for Payer: APIPA Medicare/Medicaid	$1.87
Rate for Payer: AZCH Complete Medicare	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Bisbee Police All Plans	$1.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3.40
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of AZ Commercial	$3.50
Rate for Payer: Copperpoint Commercial	$1.24
Rate for Payer: Health Net of AZ Commercial	$3.00
Rate for Payer: Health Net of AZ Medicare	$1.40
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Self Pay Self Pay	$4.00
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.92
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.90

PT Self-Care Current Status G-8987 CM At least 80% but less than 100% impaired

Facility

$5.00

Service Code	CPT G8987 GP
Hospital Charge Code	6035378
Hospital Revenue Code	420
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Bisbee Police All Plans	$1.30
Rate for Payer: Cash Price	$4.00
Rate for Payer: Self Pay Self Pay	$4.00

PT Self-Care Current Status G-8987 CM At least 80% but less than 100% impaired

Facility

$5.00

Service Code	CPT G8987 GP
Hospital Charge Code	6035378
Hospital Revenue Code	420
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Aetna of AZ Medicare	$1.40
Rate for Payer: Allwell Medicare	$0.80
Rate for Payer: Amerigroup Medicare	$0.80
Rate for Payer: APIPA Medicare/Medicaid	$1.87
Rate for Payer: AZCH Complete Medicare	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Bisbee Police All Plans	$1.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3.40
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of AZ Commercial	$3.50
Rate for Payer: Copperpoint Commercial	$1.24
Rate for Payer: Health Net of AZ Commercial	$3.00
Rate for Payer: Health Net of AZ Medicare	$1.40
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Self Pay Self Pay	$4.00
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.92
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.90

PT Self-Care Current Status G-8987 CN 100% impaired

Facility

$5.00

Service Code	CPT G8987 GP
Hospital Charge Code	6035377
Hospital Revenue Code	420
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Bisbee Police All Plans	$1.30
Rate for Payer: Cash Price	$4.00
Rate for Payer: Self Pay Self Pay	$4.00

PT Self-Care Current Status G-8987 CN 100% impaired

Facility

$5.00

Service Code	CPT G8987 GP
Hospital Charge Code	6035377
Hospital Revenue Code	420
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Aetna of AZ Medicare	$1.40
Rate for Payer: Allwell Medicare	$0.80
Rate for Payer: Amerigroup Medicare	$0.80
Rate for Payer: APIPA Medicare/Medicaid	$1.87
Rate for Payer: AZCH Complete Medicare	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Bisbee Police All Plans	$1.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3.40
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of AZ Commercial	$3.50
Rate for Payer: Copperpoint Commercial	$1.24
Rate for Payer: Health Net of AZ Commercial	$3.00
Rate for Payer: Health Net of AZ Medicare	$1.40
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Self Pay Self Pay	$4.00
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$2.92
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.90

PT Self-Care Discharge Status G-8989 CH 0% impaired

Facility

$0.01

Service Code	CPT G8989 GP
Hospital Charge Code	6035390
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 Self-Care Discharge Status G-8989 CH 0% impaired

Facility

$0.01

Service Code	CPT G8989 GP
Hospital Charge Code	6035390
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 Self-Care Discharge Status G-8989 CI At least 1% but less than 20% impaired

Facility

$0.01

Service Code	CPT G8989 GP
Hospital Charge Code	6035389
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 Self-Care Discharge Status G-8989 CI At least 1% but less than 20% impaired

Facility

$0.01

Service Code	CPT G8989 GP
Hospital Charge Code	6035389
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 Self-Care Discharge Status G-8989 CJ At least 20% but less than 40% impaired

Facility

$0.01

Service Code	CPT G8989 GP
Hospital Charge Code	6035388
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 Self-Care Discharge Status G-8989 CJ At least 20% but less than 40% impaired

Facility

$0.01

Service Code	CPT G8989 GP
Hospital Charge Code	6035388
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 Self-Care Discharge Status G-8989 CK At least 40% but less than 60% impaired

Facility

$0.01

Service Code	CPT G8989 GP
Hospital Charge Code	6035387
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 Self-Care Discharge Status G-8989 CK At least 40% but less than 60% impaired

Facility

$0.01

Service Code	CPT G8989 GP
Hospital Charge Code	6035387
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