Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

CT Spine Lumbar w/o Contrast

Facility

$1,981.00

Service Code	CPT 72131
Hospital Charge Code	821374
Hospital Revenue Code	352
Min. Negotiated Rate	$316.96
Max. Negotiated Rate	$1,782.90
Rate for Payer: Aetna of AZ Commercial	$1,782.90
Rate for Payer: Aetna of AZ Medicare	$554.68
Rate for Payer: Allwell Medicare	$316.96
Rate for Payer: Amerigroup Medicare	$316.96
Rate for Payer: APIPA Medicare/Medicaid	$739.90
Rate for Payer: AZCH Complete Medicare	$316.96
Rate for Payer: Banner UC Health Medicare	$316.96
Rate for Payer: Bisbee Police All Plans	$515.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,347.08
Rate for Payer: Cash Price	$1,584.80
Rate for Payer: Cigna of AZ Commercial	$1,287.65
Rate for Payer: Copperpoint Commercial	$490.30
Rate for Payer: Health Net of AZ Commercial	$1,188.60
Rate for Payer: Health Net of AZ Medicare	$554.68
Rate for Payer: Humana of AZ Medicare	$316.96
Rate for Payer: Self Pay Self Pay	$1,584.80
Rate for Payer: TriWest Medicare	$316.96
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,154.92
Rate for Payer: UnitedHealth Group of AZ Medicare	$356.58

CT Spine Lumbar w/o Contrast

Facility

$1,981.00

Service Code	CPT 72131
Hospital Charge Code	821374
Hospital Revenue Code	352
Min. Negotiated Rate	$515.06
Max. Negotiated Rate	$1,782.90
Rate for Payer: Aetna of AZ Commercial	$1,782.90
Rate for Payer: Bisbee Police All Plans	$515.06
Rate for Payer: Cash Price	$1,584.80
Rate for Payer: Self Pay Self Pay	$1,584.80

CT Spine Lumbar w/ + w/o Contrast

Facility

$3,316.00

Service Code	CPT 72133
Hospital Charge Code	1005217
Hospital Revenue Code	352
Min. Negotiated Rate	$530.56
Max. Negotiated Rate	$2,984.40
Rate for Payer: Aetna of AZ Commercial	$2,984.40
Rate for Payer: Aetna of AZ Medicare	$928.48
Rate for Payer: Allwell Medicare	$530.56
Rate for Payer: Amerigroup Medicare	$530.56
Rate for Payer: APIPA Medicare/Medicaid	$1,238.53
Rate for Payer: AZCH Complete Medicare	$530.56
Rate for Payer: Banner UC Health Medicare	$530.56
Rate for Payer: Bisbee Police All Plans	$862.16
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,254.88
Rate for Payer: Cash Price	$2,652.80
Rate for Payer: Cigna of AZ Commercial	$2,155.40
Rate for Payer: Copperpoint Commercial	$820.71
Rate for Payer: Health Net of AZ Commercial	$1,989.60
Rate for Payer: Health Net of AZ Medicare	$928.48
Rate for Payer: Humana of AZ Medicare	$530.56
Rate for Payer: Self Pay Self Pay	$2,652.80
Rate for Payer: TriWest Medicare	$530.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,933.23
Rate for Payer: UnitedHealth Group of AZ Medicare	$596.88

CT Spine Lumbar w/ + w/o Contrast

Facility

$3,316.00

Service Code	CPT 72133
Hospital Charge Code	1005217
Hospital Revenue Code	352
Min. Negotiated Rate	$862.16
Max. Negotiated Rate	$2,984.40
Rate for Payer: Aetna of AZ Commercial	$2,984.40
Rate for Payer: Bisbee Police All Plans	$862.16
Rate for Payer: Cash Price	$2,652.80
Rate for Payer: Self Pay Self Pay	$2,652.80

CT Spine Thoracic w/ Contrast

Facility

$2,399.00

Service Code	CPT 72129
Hospital Charge Code	1005223
Hospital Revenue Code	352
Min. Negotiated Rate	$383.84
Max. Negotiated Rate	$2,159.10
Rate for Payer: Aetna of AZ Commercial	$2,159.10
Rate for Payer: Aetna of AZ Medicare	$671.72
Rate for Payer: Allwell Medicare	$383.84
Rate for Payer: Amerigroup Medicare	$383.84
Rate for Payer: APIPA Medicare/Medicaid	$896.03
Rate for Payer: AZCH Complete Medicare	$383.84
Rate for Payer: Banner UC Health Medicare	$383.84
Rate for Payer: Bisbee Police All Plans	$623.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,631.32
Rate for Payer: Cash Price	$1,919.20
Rate for Payer: Cigna of AZ Commercial	$1,559.35
Rate for Payer: Copperpoint Commercial	$593.75
Rate for Payer: Health Net of AZ Commercial	$1,439.40
Rate for Payer: Health Net of AZ Medicare	$671.72
Rate for Payer: Humana of AZ Medicare	$383.84
Rate for Payer: Self Pay Self Pay	$1,919.20
Rate for Payer: TriWest Medicare	$383.84
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,398.62
Rate for Payer: UnitedHealth Group of AZ Medicare	$431.82

CT Spine Thoracic w/ Contrast

Facility

$2,399.00

Service Code	CPT 72129
Hospital Charge Code	1005223
Hospital Revenue Code	352
Min. Negotiated Rate	$623.74
Max. Negotiated Rate	$2,159.10
Rate for Payer: Aetna of AZ Commercial	$2,159.10
Rate for Payer: Bisbee Police All Plans	$623.74
Rate for Payer: Cash Price	$1,919.20
Rate for Payer: Self Pay Self Pay	$1,919.20

CT Spine Thoracic w/o Contrast

Facility

$1,921.00

Service Code	CPT 72128
Hospital Charge Code	821376
Hospital Revenue Code	352
Min. Negotiated Rate	$499.46
Max. Negotiated Rate	$1,728.90
Rate for Payer: Aetna of AZ Commercial	$1,728.90
Rate for Payer: Bisbee Police All Plans	$499.46
Rate for Payer: Cash Price	$1,536.80
Rate for Payer: Self Pay Self Pay	$1,536.80

CT Spine Thoracic w/o Contrast

Facility

$1,921.00

Service Code	CPT 72128
Hospital Charge Code	821376
Hospital Revenue Code	352
Min. Negotiated Rate	$307.36
Max. Negotiated Rate	$1,728.90
Rate for Payer: Aetna of AZ Commercial	$1,728.90
Rate for Payer: Aetna of AZ Medicare	$537.88
Rate for Payer: Allwell Medicare	$307.36
Rate for Payer: Amerigroup Medicare	$307.36
Rate for Payer: APIPA Medicare/Medicaid	$717.49
Rate for Payer: AZCH Complete Medicare	$307.36
Rate for Payer: Banner UC Health Medicare	$307.36
Rate for Payer: Bisbee Police All Plans	$499.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,306.28
Rate for Payer: Cash Price	$1,536.80
Rate for Payer: Cigna of AZ Commercial	$1,248.65
Rate for Payer: Copperpoint Commercial	$475.45
Rate for Payer: Health Net of AZ Commercial	$1,152.60
Rate for Payer: Health Net of AZ Medicare	$537.88
Rate for Payer: Humana of AZ Medicare	$307.36
Rate for Payer: Self Pay Self Pay	$1,536.80
Rate for Payer: TriWest Medicare	$307.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,119.94
Rate for Payer: UnitedHealth Group of AZ Medicare	$345.78

CT Spine Thoracic w/ + w/o Contrast

Facility

$3,078.00

Service Code	CPT 72130
Hospital Charge Code	1005221
Hospital Revenue Code	352
Min. Negotiated Rate	$800.28
Max. Negotiated Rate	$2,770.20
Rate for Payer: Aetna of AZ Commercial	$2,770.20
Rate for Payer: Bisbee Police All Plans	$800.28
Rate for Payer: Cash Price	$2,462.40
Rate for Payer: Self Pay Self Pay	$2,462.40

CT Spine Thoracic w/ + w/o Contrast

Facility

$3,078.00

Service Code	CPT 72130
Hospital Charge Code	1005221
Hospital Revenue Code	352
Min. Negotiated Rate	$492.48
Max. Negotiated Rate	$2,770.20
Rate for Payer: Aetna of AZ Commercial	$2,770.20
Rate for Payer: Aetna of AZ Medicare	$861.84
Rate for Payer: Allwell Medicare	$492.48
Rate for Payer: Amerigroup Medicare	$492.48
Rate for Payer: APIPA Medicare/Medicaid	$1,149.63
Rate for Payer: AZCH Complete Medicare	$492.48
Rate for Payer: Banner UC Health Medicare	$492.48
Rate for Payer: Bisbee Police All Plans	$800.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,093.04
Rate for Payer: Cash Price	$2,462.40
Rate for Payer: Cigna of AZ Commercial	$2,000.70
Rate for Payer: Copperpoint Commercial	$761.80
Rate for Payer: Health Net of AZ Commercial	$1,846.80
Rate for Payer: Health Net of AZ Medicare	$861.84
Rate for Payer: Humana of AZ Medicare	$492.48
Rate for Payer: Self Pay Self Pay	$2,462.40
Rate for Payer: TriWest Medicare	$492.48
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,794.47
Rate for Payer: UnitedHealth Group of AZ Medicare	$554.04

CT Upper Extremity w/ Contrast Left

Facility

$3,086.00

Service Code	CPT 73201 LT
Hospital Charge Code	821384
Hospital Revenue Code	352
Min. Negotiated Rate	$802.36
Max. Negotiated Rate	$2,777.40
Rate for Payer: Aetna of AZ Commercial	$2,777.40
Rate for Payer: Bisbee Police All Plans	$802.36
Rate for Payer: Cash Price	$2,468.80
Rate for Payer: Self Pay Self Pay	$2,468.80

CT Upper Extremity w/ Contrast Left

Facility

$3,086.00

Service Code	CPT 73201 LT
Hospital Charge Code	821384
Hospital Revenue Code	352
Min. Negotiated Rate	$493.76
Max. Negotiated Rate	$2,777.40
Rate for Payer: Aetna of AZ Commercial	$2,777.40
Rate for Payer: Aetna of AZ Medicare	$864.08
Rate for Payer: Allwell Medicare	$493.76
Rate for Payer: Amerigroup Medicare	$493.76
Rate for Payer: APIPA Medicare/Medicaid	$1,152.62
Rate for Payer: AZCH Complete Medicare	$493.76
Rate for Payer: Banner UC Health Medicare	$493.76
Rate for Payer: Bisbee Police All Plans	$802.36
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,098.48
Rate for Payer: Cash Price	$2,468.80
Rate for Payer: Cigna of AZ Commercial	$2,005.90
Rate for Payer: Copperpoint Commercial	$763.78
Rate for Payer: Health Net of AZ Commercial	$1,851.60
Rate for Payer: Health Net of AZ Medicare	$864.08
Rate for Payer: Humana of AZ Medicare	$493.76
Rate for Payer: Self Pay Self Pay	$2,468.80
Rate for Payer: TriWest Medicare	$493.76
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,799.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$555.48

CT Upper Extremity w/ Contrast Right

Facility

$2,734.00

Service Code	CPT 73201 RT
Hospital Charge Code	821386
Hospital Revenue Code	352
Min. Negotiated Rate	$710.84
Max. Negotiated Rate	$2,460.60
Rate for Payer: Aetna of AZ Commercial	$2,460.60
Rate for Payer: Bisbee Police All Plans	$710.84
Rate for Payer: Cash Price	$2,187.20
Rate for Payer: Self Pay Self Pay	$2,187.20

CT Upper Extremity w/ Contrast Right

Facility

$2,734.00

Service Code	CPT 73201 RT
Hospital Charge Code	821386
Hospital Revenue Code	352
Min. Negotiated Rate	$437.44
Max. Negotiated Rate	$2,460.60
Rate for Payer: Aetna of AZ Commercial	$2,460.60
Rate for Payer: Aetna of AZ Medicare	$765.52
Rate for Payer: Allwell Medicare	$437.44
Rate for Payer: Amerigroup Medicare	$437.44
Rate for Payer: APIPA Medicare/Medicaid	$1,021.15
Rate for Payer: AZCH Complete Medicare	$437.44
Rate for Payer: Banner UC Health Medicare	$437.44
Rate for Payer: Bisbee Police All Plans	$710.84
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,859.12
Rate for Payer: Cash Price	$2,187.20
Rate for Payer: Cigna of AZ Commercial	$1,777.10
Rate for Payer: Copperpoint Commercial	$676.66
Rate for Payer: Health Net of AZ Commercial	$1,640.40
Rate for Payer: Health Net of AZ Medicare	$765.52
Rate for Payer: Humana of AZ Medicare	$437.44
Rate for Payer: Self Pay Self Pay	$2,187.20
Rate for Payer: TriWest Medicare	$437.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,593.92
Rate for Payer: UnitedHealth Group of AZ Medicare	$492.12

CT Upper Extremity w/o Contrast Left

Facility

$2,420.00

Service Code	CPT 73200 LT
Hospital Charge Code	821388
Hospital Revenue Code	352
Min. Negotiated Rate	$387.20
Max. Negotiated Rate	$2,178.00
Rate for Payer: Aetna of AZ Commercial	$2,178.00
Rate for Payer: Aetna of AZ Medicare	$677.60
Rate for Payer: Allwell Medicare	$387.20
Rate for Payer: Amerigroup Medicare	$387.20
Rate for Payer: APIPA Medicare/Medicaid	$903.87
Rate for Payer: AZCH Complete Medicare	$387.20
Rate for Payer: Banner UC Health Medicare	$387.20
Rate for Payer: Bisbee Police All Plans	$629.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,645.60
Rate for Payer: Cash Price	$1,936.00
Rate for Payer: Cigna of AZ Commercial	$1,573.00
Rate for Payer: Copperpoint Commercial	$598.95
Rate for Payer: Health Net of AZ Commercial	$1,452.00
Rate for Payer: Health Net of AZ Medicare	$677.60
Rate for Payer: Humana of AZ Medicare	$387.20
Rate for Payer: Self Pay Self Pay	$1,936.00
Rate for Payer: TriWest Medicare	$387.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,410.86
Rate for Payer: UnitedHealth Group of AZ Medicare	$435.60

CT Upper Extremity w/o Contrast Left

Facility

$2,420.00

Service Code	CPT 73200 LT
Hospital Charge Code	821388
Hospital Revenue Code	352
Min. Negotiated Rate	$629.20
Max. Negotiated Rate	$2,178.00
Rate for Payer: Aetna of AZ Commercial	$2,178.00
Rate for Payer: Bisbee Police All Plans	$629.20
Rate for Payer: Cash Price	$1,936.00
Rate for Payer: Self Pay Self Pay	$1,936.00

CT Upper Extremity w/o Contrast Right

Facility

$2,352.00

Service Code	CPT 73200 RT
Hospital Charge Code	821390
Hospital Revenue Code	352
Min. Negotiated Rate	$611.52
Max. Negotiated Rate	$2,116.80
Rate for Payer: Aetna of AZ Commercial	$2,116.80
Rate for Payer: Bisbee Police All Plans	$611.52
Rate for Payer: Cash Price	$1,881.60
Rate for Payer: Self Pay Self Pay	$1,881.60

CT Upper Extremity w/o Contrast Right

Facility

$2,352.00

Service Code	CPT 73200 RT
Hospital Charge Code	821390
Hospital Revenue Code	352
Min. Negotiated Rate	$376.32
Max. Negotiated Rate	$2,116.80
Rate for Payer: Aetna of AZ Commercial	$2,116.80
Rate for Payer: Aetna of AZ Medicare	$658.56
Rate for Payer: Allwell Medicare	$376.32
Rate for Payer: Amerigroup Medicare	$376.32
Rate for Payer: APIPA Medicare/Medicaid	$878.47
Rate for Payer: AZCH Complete Medicare	$376.32
Rate for Payer: Banner UC Health Medicare	$376.32
Rate for Payer: Bisbee Police All Plans	$611.52
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,599.36
Rate for Payer: Cash Price	$1,881.60
Rate for Payer: Cigna of AZ Commercial	$1,528.80
Rate for Payer: Copperpoint Commercial	$582.12
Rate for Payer: Health Net of AZ Commercial	$1,411.20
Rate for Payer: Health Net of AZ Medicare	$658.56
Rate for Payer: Humana of AZ Medicare	$376.32
Rate for Payer: Self Pay Self Pay	$1,881.60
Rate for Payer: TriWest Medicare	$376.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,371.22
Rate for Payer: UnitedHealth Group of AZ Medicare	$423.36

CT Upper Extremity w/ + w/o Contrast Left

Facility

$3,603.00

Service Code	CPT 73202 LT
Hospital Charge Code	1005229
Hospital Revenue Code	352
Min. Negotiated Rate	$936.78
Max. Negotiated Rate	$3,242.70
Rate for Payer: Aetna of AZ Commercial	$3,242.70
Rate for Payer: Bisbee Police All Plans	$936.78
Rate for Payer: Cash Price	$2,882.40
Rate for Payer: Self Pay Self Pay	$2,882.40

CT Upper Extremity w/ + w/o Contrast Left

Facility

$3,603.00

Service Code	CPT 73202 LT
Hospital Charge Code	1005229
Hospital Revenue Code	352
Min. Negotiated Rate	$576.48
Max. Negotiated Rate	$3,242.70
Rate for Payer: Aetna of AZ Commercial	$3,242.70
Rate for Payer: Aetna of AZ Medicare	$1,008.84
Rate for Payer: Allwell Medicare	$576.48
Rate for Payer: Amerigroup Medicare	$576.48
Rate for Payer: APIPA Medicare/Medicaid	$1,345.72
Rate for Payer: AZCH Complete Medicare	$576.48
Rate for Payer: Banner UC Health Medicare	$576.48
Rate for Payer: Bisbee Police All Plans	$936.78
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,450.04
Rate for Payer: Cash Price	$2,882.40
Rate for Payer: Cigna of AZ Commercial	$2,341.95
Rate for Payer: Copperpoint Commercial	$891.74
Rate for Payer: Health Net of AZ Commercial	$2,161.80
Rate for Payer: Health Net of AZ Medicare	$1,008.84
Rate for Payer: Humana of AZ Medicare	$576.48
Rate for Payer: Self Pay Self Pay	$2,882.40
Rate for Payer: TriWest Medicare	$576.48
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,100.55
Rate for Payer: UnitedHealth Group of AZ Medicare	$648.54

CT Upper Extremity w/ + w/o Contrast Right

Facility

$2,521.00

Service Code	CPT 73202 RT
Hospital Charge Code	1005231
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 Upper Extremity w/ + w/o Contrast Right

Facility

$2,521.00

Service Code	CPT 73202 RT
Hospital Charge Code	1005231
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

CUFF CONNECTION TUBE 100CM

Facility

$395.55

Hospital Charge Code	28013864
Hospital Revenue Code	270
Min. Negotiated Rate	$102.84
Max. Negotiated Rate	$356.00
Rate for Payer: Aetna of AZ Commercial	$356.00
Rate for Payer: Bisbee Police All Plans	$102.84
Rate for Payer: Cash Price	$316.44
Rate for Payer: Self Pay Self Pay	$316.44

CUFF CONNECTION TUBE 100CM

Facility

$395.55

Hospital Charge Code	28013864
Hospital Revenue Code	270
Min. Negotiated Rate	$63.29
Max. Negotiated Rate	$356.00
Rate for Payer: Aetna of AZ Commercial	$356.00
Rate for Payer: Aetna of AZ Medicare	$110.75
Rate for Payer: Allwell Medicare	$63.29
Rate for Payer: Amerigroup Medicare	$63.29
Rate for Payer: APIPA Medicare/Medicaid	$147.74
Rate for Payer: AZCH Complete Medicare	$63.29
Rate for Payer: Banner UC Health Medicare	$63.29
Rate for Payer: Bisbee Police All Plans	$102.84
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$268.97
Rate for Payer: Cash Price	$316.44
Rate for Payer: Cigna of AZ Commercial	$276.88
Rate for Payer: Copperpoint Commercial	$97.90
Rate for Payer: Health Net of AZ Commercial	$237.33
Rate for Payer: Health Net of AZ Medicare	$110.75
Rate for Payer: Humana of AZ Medicare	$63.29
Rate for Payer: Self Pay Self Pay	$316.44
Rate for Payer: TriWest Medicare	$63.29
Rate for Payer: UnitedHealth Group of AZ Commercial	$230.61
Rate for Payer: UnitedHealth Group of AZ Medicare	$71.20

Culdoplasty Enterocele Repair abdominal

Facility

$4,215.00

Service Code	CPT 57270
Hospital Charge Code	27267814
Hospital Revenue Code	360
Min. Negotiated Rate	$1,095.90
Max. Negotiated Rate	$3,793.50
Rate for Payer: Aetna of AZ Commercial	$3,793.50
Rate for Payer: Bisbee Police All Plans	$1,095.90
Rate for Payer: Cash Price	$3,372.00
Rate for Payer: Self Pay Self Pay	$3,372.00

Know your out-of-pocket cost for care.

All Charges