Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

97762 Assessment, Prosthetic Mgt

Facility

$181.00

Service Code	CPT 97762 GP
Hospital Charge Code	22022872
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

97762 Assessment, Prosthetic Mgt

Facility

$181.00

Service Code	CPT 97762 GP
Hospital Charge Code	22022872
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

98966 TELEPHONE DISCUSSION PROVIDED TO AN ESTABLISHED PATIEN

Facility

$25.00

Service Code	CPT 98966
Hospital Charge Code	28256446
Hospital Revenue Code	521
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of AZ Commercial	$22.50
Rate for Payer: Cash Price	$20.00

98966 TELEPHONE DISCUSSION PROVIDED TO AN ESTABLISHED PATIEN

Facility

$25.00

Service Code	CPT 98966
Hospital Charge Code	28256446
Hospital Revenue Code	521
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of AZ Commercial	$22.50
Rate for Payer: Arizona Complete Health Allwell	$4.00
Rate for Payer: Banner UC Health Medicare	$4.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$17.00
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$1.79
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cigna of AZ Commercial	$17.50
Rate for Payer: Devoted Health Medicare	$4.50
Rate for Payer: Humana of AZ Medicare	$4.00
Rate for Payer: Mercy Care Medicaid	$1.79
Rate for Payer: NaphCare Correctional Healthcare	$1.79
Rate for Payer: Southwest Service Administrators UFCW	$17.00
Rate for Payer: TriWest Medicare	$4.00
Rate for Payer: United Healthcare Commercial	$14.30
Rate for Payer: United Healthcare Medicare	$4.00
Rate for Payer: Veterans Affairs TRICARE	$3.96

98968 TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED B

Facility

$255.00

Service Code	CPT 98968
Hospital Charge Code	23919286
Hospital Revenue Code	521
Min. Negotiated Rate	$229.50
Max. Negotiated Rate	$229.50
Rate for Payer: Aetna of AZ Commercial	$229.50
Rate for Payer: Cash Price	$204.00

98968 TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED B

Facility

$255.00

Service Code	CPT 98968
Hospital Charge Code	23919286
Hospital Revenue Code	521
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$229.50
Rate for Payer: Aetna of AZ Commercial	$229.50
Rate for Payer: Arizona Complete Health Allwell	$40.80
Rate for Payer: Banner UC Health Medicare	$40.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$173.40
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$2.51
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$40.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$40.80
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cash Price	$204.00
Rate for Payer: Cigna of AZ Commercial	$178.50
Rate for Payer: Devoted Health Medicare	$45.90
Rate for Payer: Humana of AZ Medicare	$40.80
Rate for Payer: Mercy Care Medicaid	$2.51
Rate for Payer: NaphCare Correctional Healthcare	$2.51
Rate for Payer: Southwest Service Administrators UFCW	$173.40
Rate for Payer: TriWest Medicare	$40.80
Rate for Payer: United Healthcare Commercial	$145.86
Rate for Payer: United Healthcare Medicare	$40.80
Rate for Payer: Veterans Affairs TRICARE	$40.39

99144 ANES 1ST 0:30 CHARGE

Facility

$622.00

Hospital Charge Code	22406220
Hospital Revenue Code	370
Min. Negotiated Rate	$98.52
Max. Negotiated Rate	$559.80
Rate for Payer: Aetna of AZ Commercial	$559.80
Rate for Payer: Arizona Complete Health Allwell	$99.52
Rate for Payer: Banner UC Health Medicare	$99.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$422.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$99.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$99.52
Rate for Payer: Cash Price	$497.60
Rate for Payer: Cigna of AZ Commercial	$404.30
Rate for Payer: Devoted Health Medicare	$111.96
Rate for Payer: Humana of AZ Medicare	$99.52
Rate for Payer: Southwest Service Administrators UFCW	$422.96
Rate for Payer: TriWest Medicare	$99.52
Rate for Payer: United Healthcare Commercial	$355.78
Rate for Payer: United Healthcare Medicare	$99.52
Rate for Payer: Veterans Affairs TRICARE	$98.52

99144 ANES 1ST 0:30 CHARGE

Facility

$622.00

Hospital Charge Code	22406220
Hospital Revenue Code	370
Min. Negotiated Rate	$559.80
Max. Negotiated Rate	$559.80
Rate for Payer: Aetna of AZ Commercial	$559.80
Rate for Payer: Cash Price	$497.60

99144 ANES ADDTNL 0:30 CHARGE

Facility

$622.00

Hospital Charge Code	22406221
Hospital Revenue Code	370
Min. Negotiated Rate	$559.80
Max. Negotiated Rate	$559.80
Rate for Payer: Aetna of AZ Commercial	$559.80
Rate for Payer: Cash Price	$497.60

99144 ANES ADDTNL 0:30 CHARGE

Facility

$622.00

Hospital Charge Code	22406221
Hospital Revenue Code	370
Min. Negotiated Rate	$98.52
Max. Negotiated Rate	$559.80
Rate for Payer: Aetna of AZ Commercial	$559.80
Rate for Payer: Arizona Complete Health Allwell	$99.52
Rate for Payer: Banner UC Health Medicare	$99.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$422.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$99.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$99.52
Rate for Payer: Cash Price	$497.60
Rate for Payer: Cigna of AZ Commercial	$404.30
Rate for Payer: Devoted Health Medicare	$111.96
Rate for Payer: Humana of AZ Medicare	$99.52
Rate for Payer: Southwest Service Administrators UFCW	$422.96
Rate for Payer: TriWest Medicare	$99.52
Rate for Payer: United Healthcare Commercial	$355.78
Rate for Payer: United Healthcare Medicare	$99.52
Rate for Payer: Veterans Affairs TRICARE	$98.52

99252 IN-PT EXPANDED INI. CONSULTATIONS

Facility

$198.00

Service Code	CPT 99252
Hospital Charge Code	22361549
Hospital Revenue Code	987
Min. Negotiated Rate	$178.20
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of AZ Commercial	$178.20
Rate for Payer: Cash Price	$158.40

99252 IN-PT EXPANDED INI. CONSULTATIONS

Facility

$198.00

Service Code	CPT 99252
Hospital Charge Code	22361549
Hospital Revenue Code	987
Min. Negotiated Rate	$31.36
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of AZ Commercial	$178.20
Rate for Payer: Arizona Complete Health Allwell	$31.68
Rate for Payer: Banner UC Health Medicare	$31.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$134.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$31.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.68
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cigna of AZ Commercial	$138.60
Rate for Payer: Devoted Health Medicare	$35.64
Rate for Payer: Humana of AZ Medicare	$31.68
Rate for Payer: Southwest Service Administrators UFCW	$134.64
Rate for Payer: TriWest Medicare	$31.68
Rate for Payer: United Healthcare Commercial	$113.26
Rate for Payer: United Healthcare Medicare	$31.68
Rate for Payer: United Healthcare New Mexico Commercial	$37.62
Rate for Payer: Veterans Affairs TRICARE	$31.36

99281 - ED Level 1

Facility

$394.00

Service Code	CPT 99281
Hospital Charge Code	22283175
Hospital Revenue Code	450
Min. Negotiated Rate	$32.72
Max. Negotiated Rate	$542.00
Rate for Payer: Aetna of AZ Commercial	$354.60
Rate for Payer: Arizona Complete Health Allwell	$63.04
Rate for Payer: Banner UC Health Medicare	$32.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$267.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$63.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$63.04
Rate for Payer: Cash Price	$315.20
Rate for Payer: Cash Price	$315.20
Rate for Payer: Cash Price	$315.20
Rate for Payer: Cigna of AZ Commercial	$275.80
Rate for Payer: Devoted Health Medicare	$70.92
Rate for Payer: Humana of AZ Medicare	$63.04
Rate for Payer: NaphCare Correctional Healthcare	$32.72
Rate for Payer: Seven Corners Travel Insurance	$130.47
Rate for Payer: Southwest Service Administrators UFCW	$267.92
Rate for Payer: TriWest Medicare	$63.04
Rate for Payer: United Healthcare Commercial	$542.00
Rate for Payer: United Healthcare Medicare	$63.04
Rate for Payer: United Healthcare New Mexico Commercial	$74.86
Rate for Payer: Veterans Affairs TRICARE	$62.41

99281 - ED Level 1

Facility

$394.00

Service Code	CPT 99281
Hospital Charge Code	22283175
Hospital Revenue Code	450
Min. Negotiated Rate	$354.60
Max. Negotiated Rate	$354.60
Rate for Payer: Aetna of AZ Commercial	$354.60
Rate for Payer: Cash Price	$315.20

99282 - ED Level 2

Facility

$781.00

Service Code	CPT 99282
Hospital Charge Code	22283176
Hospital Revenue Code	450
Min. Negotiated Rate	$702.90
Max. Negotiated Rate	$702.90
Rate for Payer: Aetna of AZ Commercial	$702.90
Rate for Payer: Cash Price	$624.80

99282 - ED Level 2

Facility

$781.00

Service Code	CPT 99282
Hospital Charge Code	22283176
Hospital Revenue Code	450
Min. Negotiated Rate	$71.10
Max. Negotiated Rate	$744.00
Rate for Payer: Aetna of AZ Commercial	$702.90
Rate for Payer: Arizona Complete Health Allwell	$124.96
Rate for Payer: Banner UC Health Medicare	$71.10
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$531.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$124.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$124.96
Rate for Payer: Cash Price	$624.80
Rate for Payer: Cash Price	$624.80
Rate for Payer: Cash Price	$624.80
Rate for Payer: Cigna of AZ Commercial	$546.70
Rate for Payer: Devoted Health Medicare	$140.58
Rate for Payer: Humana of AZ Medicare	$124.96
Rate for Payer: NaphCare Correctional Healthcare	$71.10
Rate for Payer: Seven Corners Travel Insurance	$237.57
Rate for Payer: Southwest Service Administrators UFCW	$531.08
Rate for Payer: TriWest Medicare	$124.96
Rate for Payer: United Healthcare Commercial	$744.00
Rate for Payer: United Healthcare Medicare	$124.96
Rate for Payer: United Healthcare New Mexico Commercial	$148.39
Rate for Payer: Veterans Affairs TRICARE	$123.71

99283 - ED Level 3

Facility

$1,387.00

Service Code	CPT 99283
Hospital Charge Code	22283177
Hospital Revenue Code	450
Min. Negotiated Rate	$125.32
Max. Negotiated Rate	$1,248.30
Rate for Payer: Aetna of AZ Commercial	$1,248.30
Rate for Payer: Arizona Complete Health Allwell	$221.92
Rate for Payer: Banner UC Health Medicare	$125.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$943.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$221.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$221.92
Rate for Payer: Cash Price	$1,109.60
Rate for Payer: Cash Price	$1,109.60
Rate for Payer: Cash Price	$1,109.60
Rate for Payer: Cigna of AZ Commercial	$970.90
Rate for Payer: Devoted Health Medicare	$249.66
Rate for Payer: Humana of AZ Medicare	$221.92
Rate for Payer: NaphCare Correctional Healthcare	$125.32
Rate for Payer: Seven Corners Travel Insurance	$422.37
Rate for Payer: Southwest Service Administrators UFCW	$943.16
Rate for Payer: TriWest Medicare	$221.92
Rate for Payer: United Healthcare Commercial	$1,067.00
Rate for Payer: United Healthcare Medicare	$221.92
Rate for Payer: United Healthcare New Mexico Commercial	$263.53
Rate for Payer: Veterans Affairs TRICARE	$219.70

99283 - ED Level 3

Facility

$1,387.00

Service Code	CPT 99283
Hospital Charge Code	22283177
Hospital Revenue Code	450
Min. Negotiated Rate	$1,248.30
Max. Negotiated Rate	$1,248.30
Rate for Payer: Aetna of AZ Commercial	$1,248.30
Rate for Payer: Cash Price	$1,109.60

99283 EMERGENCY RM- LEVEL 3 ED CHARGE- PROFESSIONAL FEE BCE

Facility

$1,049.00

Service Code	CPT 99283
Hospital Charge Code	22033859
Hospital Revenue Code	981
Min. Negotiated Rate	$166.16
Max. Negotiated Rate	$1,067.00
Rate for Payer: Aetna of AZ Commercial	$944.10
Rate for Payer: Arizona Complete Health Allwell	$167.84
Rate for Payer: Banner UC Health Medicare	$167.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$713.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$167.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$167.84
Rate for Payer: Cash Price	$839.20
Rate for Payer: Cash Price	$839.20
Rate for Payer: Cash Price	$839.20
Rate for Payer: Cigna of AZ Commercial	$734.30
Rate for Payer: Devoted Health Medicare	$188.82
Rate for Payer: Humana of AZ Medicare	$167.84
Rate for Payer: Seven Corners Travel Insurance	$422.37
Rate for Payer: Southwest Service Administrators UFCW	$713.32
Rate for Payer: TriWest Medicare	$167.84
Rate for Payer: United Healthcare Commercial	$1,067.00
Rate for Payer: United Healthcare Medicare	$167.84
Rate for Payer: United Healthcare New Mexico Commercial	$199.31
Rate for Payer: Veterans Affairs TRICARE	$166.16

99283 EMERGENCY RM- LEVEL 3 ED CHARGE- PROFESSIONAL FEE BCE

Facility

$1,049.00

Service Code	CPT 99283
Hospital Charge Code	22033859
Hospital Revenue Code	981
Min. Negotiated Rate	$944.10
Max. Negotiated Rate	$944.10
Rate for Payer: Aetna of AZ Commercial	$944.10
Rate for Payer: Cash Price	$839.20

99284 - ED Level 4

Facility

$2,202.00

Service Code	CPT 99284
Hospital Charge Code	22283178
Hospital Revenue Code	450
Min. Negotiated Rate	$221.43
Max. Negotiated Rate	$1,981.80
Rate for Payer: Aetna of AZ Commercial	$1,981.80
Rate for Payer: Arizona Complete Health Allwell	$352.32
Rate for Payer: Banner UC Health Medicare	$221.43
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,497.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$352.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$352.32
Rate for Payer: Cash Price	$1,761.60
Rate for Payer: Cash Price	$1,761.60
Rate for Payer: Cash Price	$1,761.60
Rate for Payer: Cigna of AZ Commercial	$1,541.40
Rate for Payer: Devoted Health Medicare	$396.36
Rate for Payer: Humana of AZ Medicare	$352.32
Rate for Payer: NaphCare Correctional Healthcare	$221.43
Rate for Payer: Seven Corners Travel Insurance	$645.61
Rate for Payer: Southwest Service Administrators UFCW	$1,497.36
Rate for Payer: TriWest Medicare	$352.32
Rate for Payer: United Healthcare Commercial	$1,471.00
Rate for Payer: United Healthcare Medicare	$352.32
Rate for Payer: United Healthcare New Mexico Commercial	$418.38
Rate for Payer: Veterans Affairs TRICARE	$348.80

99284 - ED Level 4

Facility

$2,202.00

Service Code	CPT 99284
Hospital Charge Code	22283178
Hospital Revenue Code	450
Min. Negotiated Rate	$1,981.80
Max. Negotiated Rate	$1,981.80
Rate for Payer: Aetna of AZ Commercial	$1,981.80
Rate for Payer: Cash Price	$1,761.60

99285 - ED Level 5

Facility

$3,275.00

Service Code	CPT 99285
Hospital Charge Code	22283179
Hospital Revenue Code	450
Min. Negotiated Rate	$2,947.50
Max. Negotiated Rate	$2,947.50
Rate for Payer: Aetna of AZ Commercial	$2,947.50
Rate for Payer: Cash Price	$2,620.00

99285 - ED Level 5

Facility

$3,275.00

Service Code	CPT 99285
Hospital Charge Code	22283179
Hospital Revenue Code	450
Min. Negotiated Rate	$332.40
Max. Negotiated Rate	$2,947.50
Rate for Payer: Aetna of AZ Commercial	$2,947.50
Rate for Payer: Arizona Complete Health Allwell	$524.00
Rate for Payer: Banner UC Health Medicare	$332.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,227.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$524.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$524.00
Rate for Payer: Cash Price	$2,620.00
Rate for Payer: Cash Price	$2,620.00
Rate for Payer: Cash Price	$2,620.00
Rate for Payer: Cigna of AZ Commercial	$2,292.50
Rate for Payer: Devoted Health Medicare	$589.50
Rate for Payer: Humana of AZ Medicare	$524.00
Rate for Payer: NaphCare Correctional Healthcare	$332.40
Rate for Payer: Seven Corners Travel Insurance	$921.45
Rate for Payer: Southwest Service Administrators UFCW	$2,227.00
Rate for Payer: TriWest Medicare	$524.00
Rate for Payer: United Healthcare Commercial	$1,909.00
Rate for Payer: United Healthcare Medicare	$524.00
Rate for Payer: United Healthcare New Mexico Commercial	$622.25
Rate for Payer: Veterans Affairs TRICARE	$518.76

99285 Visit Level 5 ED PRO FEE

Facility

$1,896.00

Service Code	CPT 99285
Hospital Charge Code	5175397
Min. Negotiated Rate	$300.33
Max. Negotiated Rate	$1,909.00
Rate for Payer: Aetna of AZ Commercial	$1,706.40
Rate for Payer: Arizona Complete Health Allwell	$303.36
Rate for Payer: Banner UC Health Medicare	$303.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,289.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$303.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$303.36
Rate for Payer: Cash Price	$1,516.80
Rate for Payer: Cash Price	$1,516.80
Rate for Payer: Cash Price	$1,516.80
Rate for Payer: Cigna of AZ Commercial	$1,327.20
Rate for Payer: Devoted Health Medicare	$341.28
Rate for Payer: Humana of AZ Medicare	$303.36
Rate for Payer: Seven Corners Travel Insurance	$921.45
Rate for Payer: Southwest Service Administrators UFCW	$1,289.28
Rate for Payer: TriWest Medicare	$303.36
Rate for Payer: United Healthcare Commercial	$1,909.00
Rate for Payer: United Healthcare Medicare	$303.36
Rate for Payer: Veterans Affairs TRICARE	$300.33

Know your out-of-pocket cost for care.

All Charges