Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

97130 THERAPY PROCEDURE FOR A RANGE OF MENTAL PROCESSES, EAC

Facility

$120.00

Service Code	CPT 97130 GN
Hospital Charge Code	27724314
Hospital Revenue Code	440
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna of AZ Commercial	$108.00
Rate for Payer: Cash Price	$96.00

97140 MANUAL THERAPY CHARGE

Facility

$181.00

Service Code	CPT 97140 GP
Hospital Charge Code	9299440
Hospital Revenue Code	420
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	$29.03
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

97140 MANUAL THERAPY CHARGE

Facility

$181.00

Service Code	CPT 97140 GP
Hospital Charge Code	9299440
Hospital Revenue Code	420
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

97150 THERAPEUTIC PROCEDURE(S), GROUP (2 OR MORE INDIVIDUALS

Facility

$122.00

Service Code	CPT 97150
Hospital Charge Code	23919282
Hospital Revenue Code	521
Min. Negotiated Rate	$109.80
Max. Negotiated Rate	$109.80
Rate for Payer: Aetna of AZ Commercial	$109.80
Rate for Payer: Cash Price	$97.60

97150 THERAPEUTIC PROCEDURE(S), GROUP (2 OR MORE INDIVIDUALS

Facility

$122.00

Service Code	CPT 97150
Hospital Charge Code	23919282
Hospital Revenue Code	521
Min. Negotiated Rate	$19.32
Max. Negotiated Rate	$109.80
Rate for Payer: Aetna of AZ Commercial	$109.80
Rate for Payer: Arizona Complete Health Allwell	$19.52
Rate for Payer: Banner UC Health Medicare	$19.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$82.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$19.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$19.52
Rate for Payer: Cash Price	$97.60
Rate for Payer: Cigna of AZ Commercial	$85.40
Rate for Payer: Devoted Health Medicare	$21.96
Rate for Payer: Humana of AZ Medicare	$19.52
Rate for Payer: Southwest Service Administrators UFCW	$82.96
Rate for Payer: TriWest Medicare	$19.52
Rate for Payer: United Healthcare Commercial	$69.78
Rate for Payer: United Healthcare Medicare	$19.52
Rate for Payer: Veterans Affairs TRICARE	$19.32

97530 THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CO

Facility

$267.00

Service Code	CPT 97530
Hospital Charge Code	23919283
Hospital Revenue Code	521
Min. Negotiated Rate	$42.29
Max. Negotiated Rate	$240.30
Rate for Payer: Aetna of AZ Commercial	$240.30
Rate for Payer: Arizona Complete Health Allwell	$42.72
Rate for Payer: Banner UC Health Medicare	$42.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$181.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$42.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$42.72
Rate for Payer: Cash Price	$213.60
Rate for Payer: Cigna of AZ Commercial	$186.90
Rate for Payer: Devoted Health Medicare	$48.06
Rate for Payer: Humana of AZ Medicare	$42.72
Rate for Payer: Southwest Service Administrators UFCW	$181.56
Rate for Payer: TriWest Medicare	$42.72
Rate for Payer: United Healthcare Commercial	$152.72
Rate for Payer: United Healthcare Medicare	$42.72
Rate for Payer: Veterans Affairs TRICARE	$42.29

97530 THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CO

Facility

$267.00

Service Code	CPT 97530
Hospital Charge Code	23919283
Hospital Revenue Code	521
Min. Negotiated Rate	$240.30
Max. Negotiated Rate	$240.30
Rate for Payer: Aetna of AZ Commercial	$240.30
Rate for Payer: Cash Price	$213.60

97530 THERAPEUTIC ACTIVITY (ea. 15 mins) CHARGE

Facility

$181.00

Service Code	CPT 97530 GO
Hospital Charge Code	15989382
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

97530 THERAPEUTIC ACTIVITY (ea. 15 mins) CHARGE

Facility

$181.00

Service Code	CPT 97530 GO
Hospital Charge Code	15989382
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

97535 PT Self-care mngment training (Timed per 15 mins)

Facility

$181.00

Service Code	CPT 97535 GP
Hospital Charge Code	23955343
Hospital Revenue Code	420
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

97535 PT Self-care mngment training (Timed per 15 mins)

Facility

$181.00

Service Code	CPT 97535 GP
Hospital Charge Code	23955343
Hospital Revenue Code	420
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

97535 SELF-CARE/HOME MANAGEMENT TRAINING (EG, ACTIVITIES OF

Facility

$229.00

Service Code	CPT 97535
Hospital Charge Code	23919284
Hospital Revenue Code	521
Min. Negotiated Rate	$206.10
Max. Negotiated Rate	$206.10
Rate for Payer: Aetna of AZ Commercial	$206.10
Rate for Payer: Cash Price	$183.20

97535 SELF-CARE/HOME MANAGEMENT TRAINING (EG, ACTIVITIES OF

Facility

$229.00

Service Code	CPT 97535
Hospital Charge Code	23919284
Hospital Revenue Code	521
Min. Negotiated Rate	$36.27
Max. Negotiated Rate	$206.10
Rate for Payer: Aetna of AZ Commercial	$206.10
Rate for Payer: Arizona Complete Health Allwell	$36.64
Rate for Payer: Banner UC Health Medicare	$36.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$155.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.64
Rate for Payer: Cash Price	$183.20
Rate for Payer: Cigna of AZ Commercial	$160.30
Rate for Payer: Devoted Health Medicare	$41.22
Rate for Payer: Humana of AZ Medicare	$36.64
Rate for Payer: Southwest Service Administrators UFCW	$155.72
Rate for Payer: TriWest Medicare	$36.64
Rate for Payer: United Healthcare Commercial	$130.99
Rate for Payer: United Healthcare Medicare	$36.64
Rate for Payer: Veterans Affairs TRICARE	$36.27

97537 COMMUNITY/WORK REINTEGRATION TRAINING CHARGE

Facility

$181.00

Service Code	CPT 97537 GP
Hospital Charge Code	22856918
Hospital Revenue Code	420
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	$33.28
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

97537 COMMUNITY/WORK REINTEGRATION TRAINING CHARGE

Facility

$181.00

Service Code	CPT 97537 GP
Hospital Charge Code	22856918
Hospital Revenue Code	420
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

97542 Wheelchair Management ea 15 Min

Facility

$181.00

Service Code	CPT 97542 GP
Hospital Charge Code	23818480
Hospital Revenue Code	420
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

97542 Wheelchair Management ea 15 Min

Facility

$181.00

Service Code	CPT 97542 GP
Hospital Charge Code	23818480
Hospital Revenue Code	420
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

97597 Debridement, total wound(s) surface area; first 20 sq cm or less

Facility

$200.00

Service Code	CPT 97597
Hospital Charge Code	22051643
Hospital Revenue Code	521
Min. Negotiated Rate	$31.68
Max. Negotiated Rate	$310.43
Rate for Payer: Aetna of AZ Commercial	$180.00
Rate for Payer: Arizona Complete Health Allwell	$32.00
Rate for Payer: Banner UC Health Medicare	$32.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$136.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$65.90
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.00
Rate for Payer: Cash Price	$160.00
Rate for Payer: Cash Price	$160.00
Rate for Payer: Cigna of AZ Commercial	$140.00
Rate for Payer: Devoted Health Medicare	$36.00
Rate for Payer: Humana of AZ Medicare	$32.00
Rate for Payer: Mercy Care Medicaid	$65.90
Rate for Payer: NaphCare Correctional Healthcare	$65.90
Rate for Payer: Seven Corners Travel Insurance	$310.43
Rate for Payer: Southwest Service Administrators UFCW	$136.00
Rate for Payer: TriWest Medicare	$32.00
Rate for Payer: United Healthcare Commercial	$114.40
Rate for Payer: United Healthcare Medicare	$32.00
Rate for Payer: Veterans Affairs TRICARE	$31.68

97597 Debridement, total wound(s) surface area; first 20 sq cm or less

Facility

$200.00

Service Code	CPT 97597
Hospital Charge Code	22051643
Hospital Revenue Code	521
Min. Negotiated Rate	$180.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna of AZ Commercial	$180.00
Rate for Payer: Cash Price	$160.00

97606 NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED D

Facility

$137.00

Service Code	CPT 97606
Hospital Charge Code	24053047
Hospital Revenue Code	360
Min. Negotiated Rate	$123.30
Max. Negotiated Rate	$123.30
Rate for Payer: Aetna of AZ Commercial	$123.30
Rate for Payer: Cash Price	$109.60

97606 NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED D

Facility

$137.00

Service Code	CPT 97606
Hospital Charge Code	24053047
Hospital Revenue Code	360
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$3,373.00
Rate for Payer: Aetna of AZ Commercial	$123.30
Rate for Payer: Arizona Complete Health Allwell	$21.92
Rate for Payer: Banner UC Health Medicare	$21.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$93.16
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$26.15
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$21.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$21.92
Rate for Payer: Cash Price	$109.60
Rate for Payer: Cash Price	$109.60
Rate for Payer: Cash Price	$109.60
Rate for Payer: Cigna of AZ Commercial	$68.50
Rate for Payer: Devoted Health Medicare	$24.66
Rate for Payer: Humana of AZ Medicare	$21.92
Rate for Payer: Mercy Care Medicaid	$26.15
Rate for Payer: NaphCare Correctional Healthcare	$26.15
Rate for Payer: Seven Corners Travel Insurance	$629.00
Rate for Payer: Southwest Service Administrators UFCW	$93.16
Rate for Payer: TriWest Medicare	$21.92
Rate for Payer: United Healthcare Commercial	$3,373.00
Rate for Payer: United Healthcare Medicare	$21.92
Rate for Payer: Veterans Affairs TRICARE	$21.70

97760 PT Orthotic management and training 1st en

Facility

$181.00

Service Code	CPT 97760 GP
Hospital Charge Code	23955344
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: Veterans Affairs TRICARE	$28.67

97760 PT Orthotic management and training 1st en

Facility

$181.00

Service Code	CPT 97760 GP
Hospital Charge Code	23955344
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

97761 PT Prosthetic training 1st enc

Facility

$181.00

Service Code	CPT 97761 GP
Hospital Charge Code	23955345
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: Veterans Affairs TRICARE	$28.67

97761 PT Prosthetic training 1st enc

Facility

$181.00

Service Code	CPT 97761 GP
Hospital Charge Code	23955345
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

Know your out-of-pocket cost for care.

All Charges