Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

CT Lower Extremity w/o Contrast Right

Facility

$2,019.00

Service Code	CPT 73700 RT
Hospital Charge Code	821344
Hospital Revenue Code	352
Min. Negotiated Rate	$524.94
Max. Negotiated Rate	$1,817.10
Rate for Payer: Aetna of AZ Commercial	$1,817.10
Rate for Payer: Bisbee Police All Plans	$524.94
Rate for Payer: Cash Price	$1,615.20
Rate for Payer: Self Pay Self Pay	$1,615.20

CT Lower Extremity w/o Contrast Right

Facility

$2,019.00

Service Code	CPT 73700 RT
Hospital Charge Code	821344
Hospital Revenue Code	352
Min. Negotiated Rate	$323.04
Max. Negotiated Rate	$1,817.10
Rate for Payer: Aetna of AZ Commercial	$1,817.10
Rate for Payer: Aetna of AZ Medicare	$565.32
Rate for Payer: Allwell Medicare	$323.04
Rate for Payer: Amerigroup Medicare	$323.04
Rate for Payer: APIPA Medicare/Medicaid	$754.10
Rate for Payer: AZCH Complete Medicare	$323.04
Rate for Payer: Banner UC Health Medicare	$323.04
Rate for Payer: Bisbee Police All Plans	$524.94
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,372.92
Rate for Payer: Cash Price	$1,615.20
Rate for Payer: Cigna of AZ Commercial	$1,312.35
Rate for Payer: Copperpoint Commercial	$499.70
Rate for Payer: Health Net of AZ Commercial	$1,211.40
Rate for Payer: Health Net of AZ Medicare	$565.32
Rate for Payer: Humana of AZ Medicare	$323.04
Rate for Payer: Self Pay Self Pay	$1,615.20
Rate for Payer: TriWest Medicare	$323.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,177.08
Rate for Payer: UnitedHealth Group of AZ Medicare	$363.42

CT Lower Extremity w/ + w/o Contrast Left

Facility

$2,521.00

Service Code	CPT 73702 LT
Hospital Charge Code	1101576
Hospital Revenue Code	352
Min. Negotiated Rate	$403.36
Max. Negotiated Rate	$2,268.90
Rate for Payer: Aetna of AZ Commercial	$2,268.90
Rate for Payer: Aetna of AZ Medicare	$705.88
Rate for Payer: Allwell Medicare	$403.36
Rate for Payer: Amerigroup Medicare	$403.36
Rate for Payer: APIPA Medicare/Medicaid	$941.59
Rate for Payer: AZCH Complete Medicare	$403.36
Rate for Payer: Banner UC Health Medicare	$403.36
Rate for Payer: Bisbee Police All Plans	$655.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,714.28
Rate for Payer: Cash Price	$2,016.80
Rate for Payer: Cigna of AZ Commercial	$1,638.65
Rate for Payer: Copperpoint Commercial	$623.95
Rate for Payer: Health Net of AZ Commercial	$1,512.60
Rate for Payer: Health Net of AZ Medicare	$705.88
Rate for Payer: Humana of AZ Medicare	$403.36
Rate for Payer: Self Pay Self Pay	$2,016.80
Rate for Payer: TriWest Medicare	$403.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,469.74
Rate for Payer: UnitedHealth Group of AZ Medicare	$453.78

CT Lower Extremity w/ + w/o Contrast Left

Facility

$2,521.00

Service Code	CPT 73702 LT
Hospital Charge Code	1101576
Hospital Revenue Code	352
Min. Negotiated Rate	$655.46
Max. Negotiated Rate	$2,268.90
Rate for Payer: Aetna of AZ Commercial	$2,268.90
Rate for Payer: Bisbee Police All Plans	$655.46
Rate for Payer: Cash Price	$2,016.80
Rate for Payer: Self Pay Self Pay	$2,016.80

CT Lower Extremity w/+w/o Contrast Left

Facility

$2,941.00

Service Code	CPT 73702
Hospital Charge Code	1005179
Hospital Revenue Code	352
Min. Negotiated Rate	$764.66
Max. Negotiated Rate	$2,646.90
Rate for Payer: Aetna of AZ Commercial	$2,646.90
Rate for Payer: Bisbee Police All Plans	$764.66
Rate for Payer: Cash Price	$2,352.80
Rate for Payer: Self Pay Self Pay	$2,352.80

CT Lower Extremity w/+w/o Contrast Left

Facility

$2,941.00

Service Code	CPT 73702
Hospital Charge Code	1005179
Hospital Revenue Code	352
Min. Negotiated Rate	$470.56
Max. Negotiated Rate	$2,646.90
Rate for Payer: Aetna of AZ Commercial	$2,646.90
Rate for Payer: Aetna of AZ Medicare	$823.48
Rate for Payer: Allwell Medicare	$470.56
Rate for Payer: Amerigroup Medicare	$470.56
Rate for Payer: APIPA Medicare/Medicaid	$1,098.46
Rate for Payer: AZCH Complete Medicare	$470.56
Rate for Payer: Banner UC Health Medicare	$470.56
Rate for Payer: Bisbee Police All Plans	$764.66
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,999.88
Rate for Payer: Cash Price	$2,352.80
Rate for Payer: Cigna of AZ Commercial	$1,911.65
Rate for Payer: Copperpoint Commercial	$727.90
Rate for Payer: Health Net of AZ Commercial	$1,764.60
Rate for Payer: Health Net of AZ Medicare	$823.48
Rate for Payer: Humana of AZ Medicare	$470.56
Rate for Payer: Self Pay Self Pay	$2,352.80
Rate for Payer: TriWest Medicare	$470.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,714.60
Rate for Payer: UnitedHealth Group of AZ Medicare	$529.38

CT Lower Extremity w/ + w/o Contrast Right

Facility

$2,521.00

Service Code	CPT 73702 RT
Hospital Charge Code	1101579
Hospital Revenue Code	352
Min. Negotiated Rate	$403.36
Max. Negotiated Rate	$2,268.90
Rate for Payer: Aetna of AZ Commercial	$2,268.90
Rate for Payer: Aetna of AZ Medicare	$705.88
Rate for Payer: Allwell Medicare	$403.36
Rate for Payer: Amerigroup Medicare	$403.36
Rate for Payer: APIPA Medicare/Medicaid	$941.59
Rate for Payer: AZCH Complete Medicare	$403.36
Rate for Payer: Banner UC Health Medicare	$403.36
Rate for Payer: Bisbee Police All Plans	$655.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,714.28
Rate for Payer: Cash Price	$2,016.80
Rate for Payer: Cigna of AZ Commercial	$1,638.65
Rate for Payer: Copperpoint Commercial	$623.95
Rate for Payer: Health Net of AZ Commercial	$1,512.60
Rate for Payer: Health Net of AZ Medicare	$705.88
Rate for Payer: Humana of AZ Medicare	$403.36
Rate for Payer: Self Pay Self Pay	$2,016.80
Rate for Payer: TriWest Medicare	$403.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,469.74
Rate for Payer: UnitedHealth Group of AZ Medicare	$453.78

CT Lower Extremity w/ + w/o Contrast Right

Facility

$2,521.00

Service Code	CPT 73702 RT
Hospital Charge Code	1101579
Hospital Revenue Code	352
Min. Negotiated Rate	$655.46
Max. Negotiated Rate	$2,268.90
Rate for Payer: Aetna of AZ Commercial	$2,268.90
Rate for Payer: Bisbee Police All Plans	$655.46
Rate for Payer: Cash Price	$2,016.80
Rate for Payer: Self Pay Self Pay	$2,016.80

CT Lower Extremity w/+w/o Contrast Right

Facility

$3,039.00

Service Code	CPT 73702
Hospital Charge Code	1005181
Hospital Revenue Code	352
Min. Negotiated Rate	$790.14
Max. Negotiated Rate	$2,735.10
Rate for Payer: Aetna of AZ Commercial	$2,735.10
Rate for Payer: Bisbee Police All Plans	$790.14
Rate for Payer: Cash Price	$2,431.20
Rate for Payer: Self Pay Self Pay	$2,431.20

CT Lower Extremity w/+w/o Contrast Right

Facility

$3,039.00

Service Code	CPT 73702
Hospital Charge Code	1005181
Hospital Revenue Code	352
Min. Negotiated Rate	$486.24
Max. Negotiated Rate	$2,735.10
Rate for Payer: Aetna of AZ Commercial	$2,735.10
Rate for Payer: Aetna of AZ Medicare	$850.92
Rate for Payer: Allwell Medicare	$486.24
Rate for Payer: Amerigroup Medicare	$486.24
Rate for Payer: APIPA Medicare/Medicaid	$1,135.07
Rate for Payer: AZCH Complete Medicare	$486.24
Rate for Payer: Banner UC Health Medicare	$486.24
Rate for Payer: Bisbee Police All Plans	$790.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,066.52
Rate for Payer: Cash Price	$2,431.20
Rate for Payer: Cigna of AZ Commercial	$1,975.35
Rate for Payer: Copperpoint Commercial	$752.15
Rate for Payer: Health Net of AZ Commercial	$1,823.40
Rate for Payer: Health Net of AZ Medicare	$850.92
Rate for Payer: Humana of AZ Medicare	$486.24
Rate for Payer: Self Pay Self Pay	$2,431.20
Rate for Payer: TriWest Medicare	$486.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,771.74
Rate for Payer: UnitedHealth Group of AZ Medicare	$547.02

CT Maxillofacial w/ Contrast

Facility

$2,347.00

Service Code	CPT 70487
Hospital Charge Code	821346
Hospital Revenue Code	351
Min. Negotiated Rate	$375.52
Max. Negotiated Rate	$2,112.30
Rate for Payer: Aetna of AZ Commercial	$2,112.30
Rate for Payer: Aetna of AZ Medicare	$657.16
Rate for Payer: Allwell Medicare	$375.52
Rate for Payer: Amerigroup Medicare	$375.52
Rate for Payer: APIPA Medicare/Medicaid	$876.60
Rate for Payer: AZCH Complete Medicare	$375.52
Rate for Payer: Banner UC Health Medicare	$375.52
Rate for Payer: Bisbee Police All Plans	$610.22
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,595.96
Rate for Payer: Cash Price	$1,877.60
Rate for Payer: Cigna of AZ Commercial	$1,525.55
Rate for Payer: Copperpoint Commercial	$580.88
Rate for Payer: Health Net of AZ Commercial	$1,408.20
Rate for Payer: Health Net of AZ Medicare	$657.16
Rate for Payer: Humana of AZ Medicare	$375.52
Rate for Payer: Self Pay Self Pay	$1,877.60
Rate for Payer: TriWest Medicare	$375.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,368.30
Rate for Payer: UnitedHealth Group of AZ Medicare	$422.46

CT Maxillofacial w/ Contrast

Facility

$2,347.00

Service Code	CPT 70487
Hospital Charge Code	821346
Hospital Revenue Code	351
Min. Negotiated Rate	$610.22
Max. Negotiated Rate	$2,112.30
Rate for Payer: Aetna of AZ Commercial	$2,112.30
Rate for Payer: Bisbee Police All Plans	$610.22
Rate for Payer: Cash Price	$1,877.60
Rate for Payer: Self Pay Self Pay	$1,877.60

CT Maxillofacial w/o Contrast

Facility

$2,066.00

Service Code	CPT 70486
Hospital Charge Code	821348
Hospital Revenue Code	351
Min. Negotiated Rate	$537.16
Max. Negotiated Rate	$1,859.40
Rate for Payer: Aetna of AZ Commercial	$1,859.40
Rate for Payer: Bisbee Police All Plans	$537.16
Rate for Payer: Cash Price	$1,652.80
Rate for Payer: Self Pay Self Pay	$1,652.80

CT Maxillofacial w/o Contrast

Facility

$2,066.00

Service Code	CPT 70486
Hospital Charge Code	821348
Hospital Revenue Code	351
Min. Negotiated Rate	$330.56
Max. Negotiated Rate	$1,859.40
Rate for Payer: Aetna of AZ Commercial	$1,859.40
Rate for Payer: Aetna of AZ Medicare	$578.48
Rate for Payer: Allwell Medicare	$330.56
Rate for Payer: Amerigroup Medicare	$330.56
Rate for Payer: APIPA Medicare/Medicaid	$771.65
Rate for Payer: AZCH Complete Medicare	$330.56
Rate for Payer: Banner UC Health Medicare	$330.56
Rate for Payer: Bisbee Police All Plans	$537.16
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,404.88
Rate for Payer: Cash Price	$1,652.80
Rate for Payer: Cigna of AZ Commercial	$1,342.90
Rate for Payer: Copperpoint Commercial	$511.33
Rate for Payer: Health Net of AZ Commercial	$1,239.60
Rate for Payer: Health Net of AZ Medicare	$578.48
Rate for Payer: Humana of AZ Medicare	$330.56
Rate for Payer: Self Pay Self Pay	$1,652.80
Rate for Payer: TriWest Medicare	$330.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,204.48
Rate for Payer: UnitedHealth Group of AZ Medicare	$371.88

CT Maxillofacial w/o Contrast Read

Facility

$1,963.00

Service Code	CPT 70486
Hospital Charge Code	777181
Hospital Revenue Code	351
Min. Negotiated Rate	$314.08
Max. Negotiated Rate	$1,766.70
Rate for Payer: Aetna of AZ Commercial	$1,766.70
Rate for Payer: Aetna of AZ Medicare	$549.64
Rate for Payer: Allwell Medicare	$314.08
Rate for Payer: Amerigroup Medicare	$314.08
Rate for Payer: APIPA Medicare/Medicaid	$733.18
Rate for Payer: AZCH Complete Medicare	$314.08
Rate for Payer: Banner UC Health Medicare	$314.08
Rate for Payer: Bisbee Police All Plans	$510.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,334.84
Rate for Payer: Cash Price	$1,570.40
Rate for Payer: Cigna of AZ Commercial	$1,275.95
Rate for Payer: Copperpoint Commercial	$485.84
Rate for Payer: Health Net of AZ Commercial	$1,177.80
Rate for Payer: Health Net of AZ Medicare	$549.64
Rate for Payer: Humana of AZ Medicare	$314.08
Rate for Payer: Self Pay Self Pay	$1,570.40
Rate for Payer: TriWest Medicare	$314.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,144.43
Rate for Payer: UnitedHealth Group of AZ Medicare	$353.34

CT Maxillofacial w/o Contrast Read

Facility

$1,963.00

Service Code	CPT 70486
Hospital Charge Code	777181
Hospital Revenue Code	351
Min. Negotiated Rate	$510.38
Max. Negotiated Rate	$1,766.70
Rate for Payer: Aetna of AZ Commercial	$1,766.70
Rate for Payer: Bisbee Police All Plans	$510.38
Rate for Payer: Cash Price	$1,570.40
Rate for Payer: Self Pay Self Pay	$1,570.40

CT Maxillofacial w/ + w/o Contrast

Facility

$3,542.00

Service Code	CPT 70488
Hospital Charge Code	1005185
Hospital Revenue Code	351
Min. Negotiated Rate	$566.72
Max. Negotiated Rate	$3,187.80
Rate for Payer: Aetna of AZ Commercial	$3,187.80
Rate for Payer: Aetna of AZ Medicare	$991.76
Rate for Payer: Allwell Medicare	$566.72
Rate for Payer: Amerigroup Medicare	$566.72
Rate for Payer: APIPA Medicare/Medicaid	$1,322.94
Rate for Payer: AZCH Complete Medicare	$566.72
Rate for Payer: Banner UC Health Medicare	$566.72
Rate for Payer: Bisbee Police All Plans	$920.92
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,408.56
Rate for Payer: Cash Price	$2,833.60
Rate for Payer: Cigna of AZ Commercial	$2,302.30
Rate for Payer: Copperpoint Commercial	$876.64
Rate for Payer: Health Net of AZ Commercial	$2,125.20
Rate for Payer: Health Net of AZ Medicare	$991.76
Rate for Payer: Humana of AZ Medicare	$566.72
Rate for Payer: Self Pay Self Pay	$2,833.60
Rate for Payer: TriWest Medicare	$566.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,064.99
Rate for Payer: UnitedHealth Group of AZ Medicare	$637.56

CT Maxillofacial w/ + w/o Contrast

Facility

$3,542.00

Service Code	CPT 70488
Hospital Charge Code	1005185
Hospital Revenue Code	351
Min. Negotiated Rate	$920.92
Max. Negotiated Rate	$3,187.80
Rate for Payer: Aetna of AZ Commercial	$3,187.80
Rate for Payer: Bisbee Police All Plans	$920.92
Rate for Payer: Cash Price	$2,833.60
Rate for Payer: Self Pay Self Pay	$2,833.60

CT Orbit Sella etc. w/ Contrast

Facility

$486.00

Service Code	CPT 70481
Hospital Charge Code	22862167
Hospital Revenue Code	972
Min. Negotiated Rate	$77.76
Max. Negotiated Rate	$437.40
Rate for Payer: Aetna of AZ Commercial	$437.40
Rate for Payer: Aetna of AZ Medicare	$136.08
Rate for Payer: Allwell Medicare	$77.76
Rate for Payer: Amerigroup Medicare	$77.76
Rate for Payer: APIPA Medicare/Medicaid	$181.52
Rate for Payer: AZCH Complete Medicare	$77.76
Rate for Payer: Banner UC Health Medicare	$77.76
Rate for Payer: Bisbee Police All Plans	$126.36
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$330.48
Rate for Payer: Cash Price	$388.80
Rate for Payer: Cigna of AZ Commercial	$340.20
Rate for Payer: Copperpoint Commercial	$120.28
Rate for Payer: Health Net of AZ Commercial	$291.60
Rate for Payer: Health Net of AZ Medicare	$136.08
Rate for Payer: Humana of AZ Medicare	$77.76
Rate for Payer: Self Pay Self Pay	$388.80
Rate for Payer: TriWest Medicare	$77.76
Rate for Payer: UnitedHealth Group of AZ Commercial	$283.34
Rate for Payer: UnitedHealth Group of AZ Medicare	$87.48

CT Orbit Sella etc. w/ Contrast

Facility

$2,704.00

Service Code	CPT 70481
Hospital Charge Code	821350
Hospital Revenue Code	351
Min. Negotiated Rate	$703.04
Max. Negotiated Rate	$2,433.60
Rate for Payer: Aetna of AZ Commercial	$2,433.60
Rate for Payer: Bisbee Police All Plans	$703.04
Rate for Payer: Cash Price	$2,163.20
Rate for Payer: Self Pay Self Pay	$2,163.20

CT Orbit Sella etc. w/ Contrast

Facility

$2,704.00

Service Code	CPT 70481
Hospital Charge Code	821350
Hospital Revenue Code	351
Min. Negotiated Rate	$432.64
Max. Negotiated Rate	$2,433.60
Rate for Payer: Aetna of AZ Commercial	$2,433.60
Rate for Payer: Aetna of AZ Medicare	$757.12
Rate for Payer: Allwell Medicare	$432.64
Rate for Payer: Amerigroup Medicare	$432.64
Rate for Payer: APIPA Medicare/Medicaid	$1,009.94
Rate for Payer: AZCH Complete Medicare	$432.64
Rate for Payer: Banner UC Health Medicare	$432.64
Rate for Payer: Bisbee Police All Plans	$703.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,838.72
Rate for Payer: Cash Price	$2,163.20
Rate for Payer: Cigna of AZ Commercial	$1,757.60
Rate for Payer: Copperpoint Commercial	$669.24
Rate for Payer: Health Net of AZ Commercial	$1,622.40
Rate for Payer: Health Net of AZ Medicare	$757.12
Rate for Payer: Humana of AZ Medicare	$432.64
Rate for Payer: Self Pay Self Pay	$2,163.20
Rate for Payer: TriWest Medicare	$432.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,576.43
Rate for Payer: UnitedHealth Group of AZ Medicare	$486.72

CT Orbit Sella etc. w/ Contrast

Facility

$486.00

Service Code	CPT 70481
Hospital Charge Code	22862167
Hospital Revenue Code	972
Min. Negotiated Rate	$126.36
Max. Negotiated Rate	$437.40
Rate for Payer: Aetna of AZ Commercial	$437.40
Rate for Payer: Bisbee Police All Plans	$126.36
Rate for Payer: Cash Price	$388.80
Rate for Payer: Self Pay Self Pay	$388.80

CT Orbit Sella etc. w/o Contrast

Facility

$2,429.00

Service Code	CPT 70480
Hospital Charge Code	821352
Hospital Revenue Code	351
Min. Negotiated Rate	$631.54
Max. Negotiated Rate	$2,186.10
Rate for Payer: Aetna of AZ Commercial	$2,186.10
Rate for Payer: Bisbee Police All Plans	$631.54
Rate for Payer: Cash Price	$1,943.20
Rate for Payer: Self Pay Self Pay	$1,943.20

CT Orbit Sella etc. w/o Contrast

Facility

$2,429.00

Service Code	CPT 70480
Hospital Charge Code	821352
Hospital Revenue Code	351
Min. Negotiated Rate	$388.64
Max. Negotiated Rate	$2,186.10
Rate for Payer: Aetna of AZ Commercial	$2,186.10
Rate for Payer: Aetna of AZ Medicare	$680.12
Rate for Payer: Allwell Medicare	$388.64
Rate for Payer: Amerigroup Medicare	$388.64
Rate for Payer: APIPA Medicare/Medicaid	$907.23
Rate for Payer: AZCH Complete Medicare	$388.64
Rate for Payer: Banner UC Health Medicare	$388.64
Rate for Payer: Bisbee Police All Plans	$631.54
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,651.72
Rate for Payer: Cash Price	$1,943.20
Rate for Payer: Cigna of AZ Commercial	$1,578.85
Rate for Payer: Copperpoint Commercial	$601.18
Rate for Payer: Health Net of AZ Commercial	$1,457.40
Rate for Payer: Health Net of AZ Medicare	$680.12
Rate for Payer: Humana of AZ Medicare	$388.64
Rate for Payer: Self Pay Self Pay	$1,943.20
Rate for Payer: TriWest Medicare	$388.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,416.11
Rate for Payer: UnitedHealth Group of AZ Medicare	$437.22

CT Orbit Sella etc. w/o Contrast

Facility

$415.00

Service Code	CPT 70480
Hospital Charge Code	22862166
Hospital Revenue Code	972
Min. Negotiated Rate	$107.90
Max. Negotiated Rate	$373.50
Rate for Payer: Aetna of AZ Commercial	$373.50
Rate for Payer: Bisbee Police All Plans	$107.90
Rate for Payer: Cash Price	$332.00
Rate for Payer: Self Pay Self Pay	$332.00

Know your out-of-pocket cost for care.

All Charges