Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

PT ULTRASOUND EACH 15 MIN

Facility

$181.00

Service Code	CPT 97035 GP
Hospital Charge Code	692237
Hospital Revenue Code	420
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

PT ULTRASOUND EACH 15 MIN

Facility

$181.00

Service Code	CPT 97035 GP
Hospital Charge Code	692237
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

PT Ultrasound Units

Facility

$181.00

Service Code	CPT 97035 GP
Hospital Charge Code	8798836
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

PT Ultrasound Units

Facility

$181.00

Service Code	CPT 97035 GP
Hospital Charge Code	8798836
Hospital Revenue Code	420
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

PT UNLISTED THER PROCDUR

Facility

$39.00

Service Code	CPT 97139 GP
Hospital Charge Code	20731357
Hospital Revenue Code	420
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Arizona Complete Health Allwell	$6.24
Rate for Payer: Banner UC Health Medicare	$6.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$26.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$6.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$14.81
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cash Price	$31.20
Rate for Payer: Cigna of AZ Commercial	$27.30
Rate for Payer: Devoted Health Medicare	$7.02
Rate for Payer: Humana of AZ Medicare	$6.24
Rate for Payer: Southwest Service Administrators UFCW	$26.52
Rate for Payer: TriWest Medicare	$6.24
Rate for Payer: United Healthcare Commercial	$22.31
Rate for Payer: United Healthcare Medicare	$6.24
Rate for Payer: United Healthcare New Mexico Commercial	$7.41
Rate for Payer: Veterans Affairs TRICARE	$6.18

PT UNLISTED THER PROCDUR

Facility

$39.00

Service Code	CPT 97139 GP
Hospital Charge Code	20731357
Hospital Revenue Code	420
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna of AZ Commercial	$35.10
Rate for Payer: Cash Price	$31.20

PT VASOPNEUMATIC DEVICE

Facility

$104.00

Service Code	CPT 97016
Hospital Charge Code	8798800
Hospital Revenue Code	420
Min. Negotiated Rate	$12.39
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of AZ Commercial	$93.60
Rate for Payer: Arizona Complete Health Allwell	$16.64
Rate for Payer: Banner UC Health Medicare	$16.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$70.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.39
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cigna of AZ Commercial	$72.80
Rate for Payer: Devoted Health Medicare	$18.72
Rate for Payer: Humana of AZ Medicare	$16.64
Rate for Payer: Southwest Service Administrators UFCW	$70.72
Rate for Payer: TriWest Medicare	$16.64
Rate for Payer: United Healthcare Commercial	$59.49
Rate for Payer: United Healthcare Medicare	$16.64
Rate for Payer: United Healthcare New Mexico Commercial	$19.76
Rate for Payer: Veterans Affairs TRICARE	$16.47

PT VASOPNEUMATIC DEVICE

Facility

$104.00

Service Code	CPT 97016
Hospital Charge Code	8798800
Hospital Revenue Code	420
Min. Negotiated Rate	$93.60
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of AZ Commercial	$93.60
Rate for Payer: Cash Price	$83.20

PT VASOPNEUMATIC DEVICE

Facility

$104.00

Service Code	CPT 97016
Hospital Charge Code	11428383
Hospital Revenue Code	420
Min. Negotiated Rate	$93.60
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of AZ Commercial	$93.60
Rate for Payer: Cash Price	$83.20

PT VASOPNEUMATIC DEVICE

Facility

$104.00

Service Code	CPT 97016
Hospital Charge Code	11428383
Hospital Revenue Code	420
Min. Negotiated Rate	$12.39
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of AZ Commercial	$93.60
Rate for Payer: Arizona Complete Health Allwell	$16.64
Rate for Payer: Banner UC Health Medicare	$16.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$70.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$12.39
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cigna of AZ Commercial	$72.80
Rate for Payer: Devoted Health Medicare	$18.72
Rate for Payer: Humana of AZ Medicare	$16.64
Rate for Payer: Southwest Service Administrators UFCW	$70.72
Rate for Payer: TriWest Medicare	$16.64
Rate for Payer: United Healthcare Commercial	$59.49
Rate for Payer: United Healthcare Medicare	$16.64
Rate for Payer: United Healthcare New Mexico Commercial	$19.76
Rate for Payer: Veterans Affairs TRICARE	$16.47

PT Wheelchair Management Units

Facility

$172.00

Service Code	CPT 97542 GP
Hospital Charge Code	8798859
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	$32.22
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 Wheelchair Management Units

Facility

$172.00

Service Code	CPT 97542 GP
Hospital Charge Code	8798859
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 WHEELCHAIR MGT/PROP EACH 15

Facility

$172.00

Service Code	CPT 97542 GP
Hospital Charge Code	692240
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 WHEELCHAIR MGT/PROP EACH 15

Facility

$172.00

Service Code	CPT 97542 GP
Hospital Charge Code	692240
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	$32.22
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 WOUND CARE GREATER THAN 20 CM

Facility

$697.00

Service Code	CPT 97598 GP
Hospital Charge Code	2619686
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 WOUND CARE GREATER THAN 20 CM

Facility

$697.00

Service Code	CPT 97598 GP
Hospital Charge Code	2619686
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 WOUND CARE LESS THAN 20 CM

Facility

$358.00

Service Code	CPT 97597 GP
Hospital Charge Code	2734847
Hospital Revenue Code	420
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 WOUND CARE LESS THAN 20 CM

Facility

$358.00

Service Code	CPT 97597 GP
Hospital Charge Code	2734847
Hospital Revenue Code	420
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

PULMONARY EDEMA AND RESPIRATORY FAILURE

Facility

$16,009.44

Service Code	MSDRG 189
Min. Negotiated Rate	$16,009.44
Max. Negotiated Rate	$16,009.44
Rate for Payer: Seven Corners Travel Insurance	$16,009.44

Pulmonary Embolism

Facility

$3,769.32

Service Code	APR-DRG 1341
Hospital Charge Code	APRDRG1343
Min. Negotiated Rate	$3,769.32
Max. Negotiated Rate	$3,769.32
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$3,769.32
Rate for Payer: Mercy Care Medicaid	$3,769.32
Rate for Payer: NaphCare Correctional Healthcare	$3,769.32

Pulmonary Embolism

Facility

$7,455.18

Service Code	APR-DRG 1343
Hospital Charge Code	APRDRG1342
Min. Negotiated Rate	$7,455.18
Max. Negotiated Rate	$7,455.18
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$7,455.18
Rate for Payer: Mercy Care Medicaid	$7,455.18
Rate for Payer: NaphCare Correctional Healthcare	$7,455.18

Pulmonary Embolism

Facility

$11,397.75

Service Code	APR-DRG 1344
Hospital Charge Code	APRDRG1342
Min. Negotiated Rate	$11,397.75
Max. Negotiated Rate	$11,397.75
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$11,397.75
Rate for Payer: Mercy Care Medicaid	$11,397.75
Rate for Payer: NaphCare Correctional Healthcare	$11,397.75

Pulmonary Embolism

Facility

$11,397.75

Service Code	APR-DRG 1344
Hospital Charge Code	APRDRG1343
Min. Negotiated Rate	$11,397.75
Max. Negotiated Rate	$11,397.75
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$11,397.75
Rate for Payer: Mercy Care Medicaid	$11,397.75
Rate for Payer: NaphCare Correctional Healthcare	$11,397.75

Pulmonary Embolism

Facility

$5,001.68

Service Code	APR-DRG 1342
Hospital Charge Code	APRDRG1343
Min. Negotiated Rate	$5,001.68
Max. Negotiated Rate	$5,001.68
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,001.68
Rate for Payer: Mercy Care Medicaid	$5,001.68
Rate for Payer: NaphCare Correctional Healthcare	$5,001.68

Pulmonary Embolism

Facility

$5,001.68

Service Code	APR-DRG 1342
Hospital Charge Code	APRDRG1344
Min. Negotiated Rate	$5,001.68
Max. Negotiated Rate	$5,001.68
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$5,001.68
Rate for Payer: Mercy Care Medicaid	$5,001.68
Rate for Payer: NaphCare Correctional Healthcare	$5,001.68

Know your out-of-pocket cost for care.

All Charges