Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

OT PROSTH TRAIN EA 15 MIN

Facility

$181.00

Service Code	CPT 97761 GO
Hospital Charge Code	1238651
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	$42.14
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 RE-EVALUATION UPTO 30 MIN

Facility

$358.00

Service Code	CPT 97168 GO
Hospital Charge Code	22528986
Hospital Revenue Code	434
Min. Negotiated Rate	$56.71
Max. Negotiated Rate	$322.20
Rate for Payer: Aetna of AZ Commercial	$322.20
Rate for Payer: Arizona Complete Health Allwell	$57.28
Rate for Payer: Banner UC Health Medicare	$57.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$243.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$57.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$71.53
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: Devoted Health Medicare	$64.44
Rate for Payer: Humana of AZ Medicare	$57.28
Rate for Payer: Southwest Service Administrators UFCW	$243.44
Rate for Payer: TriWest Medicare	$57.28
Rate for Payer: United Healthcare Commercial	$204.78
Rate for Payer: United Healthcare Medicare	$57.28
Rate for Payer: United Healthcare New Mexico Commercial	$68.02
Rate for Payer: Veterans Affairs TRICARE	$56.71

OT RE-EVALUATION UPTO 30 MIN

Facility

$358.00

Service Code	CPT 97168 GO
Hospital Charge Code	22528986
Hospital Revenue Code	434
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

OT SELF-CARE HOME MANG @ 15 MIN

Facility

$181.00

Service Code	CPT 97535 GO
Hospital Charge Code	691327
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	$33.64
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 SELF-CARE HOME MANG @ 15 MIN

Facility

$181.00

Service Code	CPT 97535 GO
Hospital Charge Code	691327
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 TENS

Facility

$664.00

Service Code	CPT 64550 GO
Hospital Charge Code	2619695
Hospital Revenue Code	434
Min. Negotiated Rate	$597.60
Max. Negotiated Rate	$597.60
Rate for Payer: Aetna of AZ Commercial	$597.60
Rate for Payer: Cash Price	$531.20

OT TENS

Facility

$664.00

Service Code	CPT 64550 GO
Hospital Charge Code	2619695
Hospital Revenue Code	434
Min. Negotiated Rate	$105.18
Max. Negotiated Rate	$597.60
Rate for Payer: Aetna of AZ Commercial	$597.60
Rate for Payer: Arizona Complete Health Allwell	$106.24
Rate for Payer: Banner UC Health Medicare	$106.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$451.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$106.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$106.24
Rate for Payer: Cash Price	$531.20
Rate for Payer: Cigna of AZ Commercial	$464.80
Rate for Payer: Devoted Health Medicare	$119.52
Rate for Payer: Humana of AZ Medicare	$106.24
Rate for Payer: Southwest Service Administrators UFCW	$451.52
Rate for Payer: TriWest Medicare	$106.24
Rate for Payer: United Healthcare Commercial	$379.81
Rate for Payer: United Healthcare Medicare	$106.24
Rate for Payer: United Healthcare New Mexico Commercial	$126.16
Rate for Payer: Veterans Affairs TRICARE	$105.18

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	$162.90
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Cash Price	$144.80

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	$27.24
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	$36.47
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 THERAP ACTIV EA 15 MIN

Facility

$172.00

Service Code	CPT 97530 GO
Hospital Charge Code	691304
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 THERAP ACTIV EA 15 MIN

Facility

$181.00

Service Code	CPT 97530 GO
Hospital Charge Code	11473404
Hospital Revenue Code	430
Min. Negotiated Rate	$28.67
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	$36.47
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 ULTRASOUND- EACH 15

Facility

$181.00

Service Code	CPT 97035 GO
Hospital Charge Code	691311
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 ULTRASOUND- EACH 15

Facility

$181.00

Service Code	CPT 97035 GO
Hospital Charge Code	691311
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 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	$28.67
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	$32.22
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 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	$162.90
Max. Negotiated Rate	$162.90
Rate for Payer: Aetna of AZ Commercial	$162.90
Rate for Payer: Cash Price	$144.80

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	$627.30
Max. Negotiated Rate	$627.30
Rate for Payer: Aetna of AZ Commercial	$627.30
Rate for Payer: Cash Price	$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	$20.92
Max. Negotiated Rate	$627.30
Rate for Payer: Aetna of AZ Commercial	$627.30
Rate for Payer: Arizona Complete Health Allwell	$111.52
Rate for Payer: Banner UC Health Medicare	$111.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$473.96
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$20.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$111.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$22.66
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: Devoted Health Medicare	$125.46
Rate for Payer: Humana of AZ Medicare	$111.52
Rate for Payer: Mercy Care Medicaid	$20.92
Rate for Payer: NaphCare Correctional Healthcare	$20.92
Rate for Payer: Southwest Service Administrators UFCW	$473.96
Rate for Payer: TriWest Medicare	$111.52
Rate for Payer: United Healthcare Commercial	$398.68
Rate for Payer: United Healthcare Medicare	$111.52
Rate for Payer: United Healthcare New Mexico Commercial	$132.43
Rate for Payer: Veterans Affairs TRICARE	$110.40

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	$32.58
Max. Negotiated Rate	$322.20
Rate for Payer: Aetna of AZ Commercial	$322.20
Rate for Payer: Arizona Complete Health Allwell	$57.28
Rate for Payer: Banner UC Health Medicare	$57.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$243.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$65.90
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$57.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.58
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: Devoted Health Medicare	$64.44
Rate for Payer: Humana of AZ Medicare	$57.28
Rate for Payer: Mercy Care Medicaid	$65.90
Rate for Payer: NaphCare Correctional Healthcare	$65.90
Rate for Payer: Southwest Service Administrators UFCW	$243.44
Rate for Payer: TriWest Medicare	$57.28
Rate for Payer: United Healthcare Commercial	$204.78
Rate for Payer: United Healthcare Medicare	$57.28
Rate for Payer: United Healthcare New Mexico Commercial	$68.02
Rate for Payer: Veterans Affairs TRICARE	$56.71

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	$322.20
Max. Negotiated Rate	$322.20
Rate for Payer: Aetna of AZ Commercial	$322.20
Rate for Payer: Cash Price	$286.40

Ova + Parasite Exam LC

Facility

$271.00

Service Code	CPT 87177
Hospital Charge Code	1285718
Hospital Revenue Code	300
Min. Negotiated Rate	$243.90
Max. Negotiated Rate	$243.90
Rate for Payer: Aetna of AZ Commercial	$243.90
Rate for Payer: Aetna of AZ Commercial	$177.30
Rate for Payer: Cash Price	$216.80
Rate for Payer: Cash Price	$157.60

Ova + Parasite Exam LC

Facility

$197.00

Service Code	CPT 87177
Hospital Charge Code	1285718
Hospital Revenue Code	300
Min. Negotiated Rate	$12.90
Max. Negotiated Rate	$177.30
Rate for Payer: Aetna of AZ Commercial	$177.30
Rate for Payer: Aetna of AZ Commercial	$243.90
Rate for Payer: Arizona Complete Health Allwell	$43.36
Rate for Payer: Arizona Complete Health Allwell	$31.52
Rate for Payer: Banner UC Health Medicare	$43.36
Rate for Payer: Banner UC Health Medicare	$31.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$133.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$184.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$31.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$43.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.36
Rate for Payer: Cash Price	$157.60
Rate for Payer: Cash Price	$216.80
Rate for Payer: Cash Price	$157.60
Rate for Payer: Cash Price	$216.80
Rate for Payer: Cigna of AZ Commercial	$176.15
Rate for Payer: Cigna of AZ Commercial	$128.05
Rate for Payer: Devoted Health Medicare	$48.78
Rate for Payer: Devoted Health Medicare	$35.46
Rate for Payer: Humana of AZ Medicare	$31.52
Rate for Payer: Humana of AZ Medicare	$43.36
Rate for Payer: Seven Corners Travel Insurance	$12.90
Rate for Payer: Seven Corners Travel Insurance	$12.90
Rate for Payer: Southwest Service Administrators UFCW	$184.28
Rate for Payer: Southwest Service Administrators UFCW	$133.96
Rate for Payer: TriWest Medicare	$31.52
Rate for Payer: TriWest Medicare	$43.36
Rate for Payer: United Healthcare Commercial	$112.68
Rate for Payer: United Healthcare Commercial	$155.01
Rate for Payer: United Healthcare Medicare	$31.52
Rate for Payer: United Healthcare Medicare	$43.36
Rate for Payer: Veterans Affairs TRICARE	$42.93
Rate for Payer: Veterans Affairs TRICARE	$31.20

.Ova + Parasite Exam Result

Facility

$202.00

Service Code	CPT 87177
Hospital Charge Code	1294971
Hospital Revenue Code	300
Min. Negotiated Rate	$181.80
Max. Negotiated Rate	$181.80
Rate for Payer: Aetna of AZ Commercial	$181.80
Rate for Payer: Cash Price	$161.60

.Ova + Parasite Exam Result

Facility

$202.00

Service Code	CPT 87177
Hospital Charge Code	1294971
Hospital Revenue Code	300
Min. Negotiated Rate	$12.90
Max. Negotiated Rate	$181.80
Rate for Payer: Aetna of AZ Commercial	$181.80
Rate for Payer: Arizona Complete Health Allwell	$32.32
Rate for Payer: Banner UC Health Medicare	$32.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$137.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.32
Rate for Payer: Cash Price	$161.60
Rate for Payer: Cash Price	$161.60
Rate for Payer: Cigna of AZ Commercial	$131.30
Rate for Payer: Devoted Health Medicare	$36.36
Rate for Payer: Humana of AZ Medicare	$32.32
Rate for Payer: Seven Corners Travel Insurance	$12.90
Rate for Payer: Southwest Service Administrators UFCW	$137.36
Rate for Payer: TriWest Medicare	$32.32
Rate for Payer: United Healthcare Commercial	$115.54
Rate for Payer: United Healthcare Medicare	$32.32
Rate for Payer: Veterans Affairs TRICARE	$32.00

Ovary cystectomy

Facility

$3,960.00

Service Code	CPT 58925
Hospital Charge Code	27267812
Hospital Revenue Code	360
Min. Negotiated Rate	$627.26
Max. Negotiated Rate	$7,740.14
Rate for Payer: Aetna of AZ Commercial	$3,564.00
Rate for Payer: Arizona Complete Health Allwell	$633.60
Rate for Payer: Banner UC Health Medicare	$1,698.98
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,692.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$633.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$633.60
Rate for Payer: Cash Price	$3,168.00
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: Devoted Health Medicare	$712.80
Rate for Payer: Humana of AZ Medicare	$633.60
Rate for Payer: NaphCare Correctional Healthcare	$1,698.98
Rate for Payer: Seven Corners Travel Insurance	$7,740.14
Rate for Payer: Southwest Service Administrators UFCW	$2,692.80
Rate for Payer: TriWest Medicare	$633.60
Rate for Payer: United Healthcare Commercial	$4,838.00
Rate for Payer: United Healthcare Medicare	$633.60
Rate for Payer: Veterans Affairs TRICARE	$627.26

Ovary cystectomy

Facility

$3,960.00

Service Code	CPT 58925
Hospital Charge Code	27267812
Hospital Revenue Code	360
Min. Negotiated Rate	$3,564.00
Max. Negotiated Rate	$3,564.00
Rate for Payer: Aetna of AZ Commercial	$3,564.00
Rate for Payer: Cash Price	$3,168.00

Know your out-of-pocket cost for care.

All Charges