Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

PT Other Primary Goal Status G-8991 CJ At least 20% but less than 40% impaired

Facility

$5.00

Service Code	HCPCS G8991 GP
Hospital Charge Code	6035356
Hospital Revenue Code	420
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Arizona Complete Health Allwell	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.80
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of AZ Commercial	$3.50
Rate for Payer: Devoted Health Medicare	$0.90
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Southwest Service Administrators UFCW	$3.40
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: United Healthcare Commercial	$2.86
Rate for Payer: United Healthcare Medicare	$0.80
Rate for Payer: United Healthcare New Mexico Commercial	$0.95
Rate for Payer: Veterans Affairs TRICARE	$0.79

PT Other Primary Goal Status G-8991 CK At least 40% but less than 60% impaired

Facility

$5.00

Service Code	HCPCS G8991 GP
Hospital Charge Code	6035355
Hospital Revenue Code	420
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Cash Price	$4.00

PT Other Primary Goal Status G-8991 CK At least 40% but less than 60% impaired

Facility

$5.00

Service Code	HCPCS G8991 GP
Hospital Charge Code	6035355
Hospital Revenue Code	420
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Arizona Complete Health Allwell	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.80
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of AZ Commercial	$3.50
Rate for Payer: Devoted Health Medicare	$0.90
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Southwest Service Administrators UFCW	$3.40
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: United Healthcare Commercial	$2.86
Rate for Payer: United Healthcare Medicare	$0.80
Rate for Payer: United Healthcare New Mexico Commercial	$0.95
Rate for Payer: Veterans Affairs TRICARE	$0.79

PT Other Primary Goal Status G-8991 CL At least 60% but less than 80% impaired

Facility

$5.00

Service Code	HCPCS G8991 GP
Hospital Charge Code	6035354
Hospital Revenue Code	420
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Arizona Complete Health Allwell	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.80
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of AZ Commercial	$3.50
Rate for Payer: Devoted Health Medicare	$0.90
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Southwest Service Administrators UFCW	$3.40
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: United Healthcare Commercial	$2.86
Rate for Payer: United Healthcare Medicare	$0.80
Rate for Payer: United Healthcare New Mexico Commercial	$0.95
Rate for Payer: Veterans Affairs TRICARE	$0.79

PT Other Primary Goal Status G-8991 CL At least 60% but less than 80% impaired

Facility

$5.00

Service Code	HCPCS G8991 GP
Hospital Charge Code	6035354
Hospital Revenue Code	420
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Cash Price	$4.00

PT Other Primary Goal Status G-8991 CM At least 80% but less than 100% impaired

Facility

$5.00

Service Code	HCPCS G8991 GP
Hospital Charge Code	6035353
Hospital Revenue Code	420
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Arizona Complete Health Allwell	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.80
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of AZ Commercial	$3.50
Rate for Payer: Devoted Health Medicare	$0.90
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Southwest Service Administrators UFCW	$3.40
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: United Healthcare Commercial	$2.86
Rate for Payer: United Healthcare Medicare	$0.80
Rate for Payer: United Healthcare New Mexico Commercial	$0.95
Rate for Payer: Veterans Affairs TRICARE	$0.79

PT Other Primary Goal Status G-8991 CM At least 80% but less than 100% impaired

Facility

$5.00

Service Code	HCPCS G8991 GP
Hospital Charge Code	6035353
Hospital Revenue Code	420
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Cash Price	$4.00

PT Other Primary Goal Status G-8991 CN 100% impaired

Facility

$5.00

Service Code	HCPCS G8991 GP
Hospital Charge Code	6035352
Hospital Revenue Code	420
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Cash Price	$4.00

PT Other Primary Goal Status G-8991 CN 100% impaired

Facility

$5.00

Service Code	HCPCS G8991 GP
Hospital Charge Code	6035352
Hospital Revenue Code	420
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Arizona Complete Health Allwell	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.80
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of AZ Commercial	$3.50
Rate for Payer: Devoted Health Medicare	$0.90
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Southwest Service Administrators UFCW	$3.40
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: United Healthcare Commercial	$2.86
Rate for Payer: United Healthcare Medicare	$0.80
Rate for Payer: United Healthcare New Mexico Commercial	$0.95
Rate for Payer: Veterans Affairs TRICARE	$0.79

PT PARAFIN BATH

Facility

$172.00

Service Code	CPT 97018
Hospital Charge Code	1230143
Hospital Revenue Code	424
Min. Negotiated Rate	$6.37
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	$6.37
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

PT PARAFIN BATH

Facility

$172.00

Service Code	CPT 97018
Hospital Charge Code	1230143
Hospital Revenue Code	424
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

PT Prosthetic Management Train Units

Facility

$172.00

Service Code	CPT 97761 GP
Hospital Charge Code	8798869
Hospital Revenue Code	420
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	$42.14
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

PT Prosthetic Management Train Units

Facility

$172.00

Service Code	CPT 97761 GP
Hospital Charge Code	8798869
Hospital Revenue Code	420
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

PT PROSTHETIC TRN @15 MIN

Facility

$172.00

Service Code	CPT 97761 GP
Hospital Charge Code	692241
Hospital Revenue Code	420
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

PT PROSTHETIC TRN @15 MIN

Facility

$172.00

Service Code	CPT 97761 GP
Hospital Charge Code	692241
Hospital Revenue Code	420
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	$42.14
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

PT RE-EVAL

Facility

$358.00

Service Code	CPT 97164 GP
Hospital Charge Code	22528957
Hospital Revenue Code	424
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

PT RE-EVAL

Facility

$358.00

Service Code	CPT 97164 GP
Hospital Charge Code	22528957
Hospital Revenue Code	424
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	$70.46
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

PT RE-EVALUATION 31 TO 60 MIN

Facility

$697.00

Hospital Charge Code	22528958
Hospital Revenue Code	424
Min. Negotiated Rate	$110.40
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 Medicare	$111.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$111.52
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: 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

PT RE-EVALUATION 31 TO 60 MIN

Facility

$697.00

Hospital Charge Code	22528958
Hospital Revenue Code	424
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

PT Selective Debrid w/o Anes Great 20 cm Units

Facility

$697.00

Service Code	CPT 97598 GP
Hospital Charge Code	22725018
Hospital Revenue Code	420
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

PT Selective Debrid w/o Anes Great 20 cm Units

Facility

$697.00

Service Code	CPT 97598 GP
Hospital Charge Code	22725018
Hospital Revenue Code	420
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

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

Facility

$5.00

Service Code	HCPCS G8987 GP
Hospital Charge Code	6035383
Hospital Revenue Code	420
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Cash Price	$4.00

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

Facility

$5.00

Service Code	HCPCS G8987 GP
Hospital Charge Code	6035383
Hospital Revenue Code	420
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Arizona Complete Health Allwell	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.80
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of AZ Commercial	$3.50
Rate for Payer: Devoted Health Medicare	$0.90
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Southwest Service Administrators UFCW	$3.40
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: United Healthcare Commercial	$2.86
Rate for Payer: United Healthcare Medicare	$0.80
Rate for Payer: United Healthcare New Mexico Commercial	$0.95
Rate for Payer: Veterans Affairs TRICARE	$0.79

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

Facility

$5.00

Service Code	HCPCS G8987 GP
Hospital Charge Code	6035382
Hospital Revenue Code	420
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Arizona Complete Health Allwell	$0.80
Rate for Payer: Banner UC Health Medicare	$0.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.80
Rate for Payer: Cash Price	$4.00
Rate for Payer: Cigna of AZ Commercial	$3.50
Rate for Payer: Devoted Health Medicare	$0.90
Rate for Payer: Humana of AZ Medicare	$0.80
Rate for Payer: Southwest Service Administrators UFCW	$3.40
Rate for Payer: TriWest Medicare	$0.80
Rate for Payer: United Healthcare Commercial	$2.86
Rate for Payer: United Healthcare Medicare	$0.80
Rate for Payer: United Healthcare New Mexico Commercial	$0.95
Rate for Payer: Veterans Affairs TRICARE	$0.79

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

Facility

$5.00

Service Code	HCPCS G8987 GP
Hospital Charge Code	6035382
Hospital Revenue Code	420
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna of AZ Commercial	$4.50
Rate for Payer: Cash Price	$4.00

Know your out-of-pocket cost for care.

All Charges