Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

CT Abdomen/Pelvis w/ Contrast

Facility

$4,585.00

Service Code	CPT 74177
Hospital Charge Code	1005109
Hospital Revenue Code	350
Min. Negotiated Rate	$4,126.50
Max. Negotiated Rate	$4,126.50
Rate for Payer: Aetna of AZ Commercial	$4,126.50
Rate for Payer: Cash Price	$3,668.00

CT Abdomen/Pelvis w/ Contrast

Facility

$4,585.00

Service Code	CPT 74177
Hospital Charge Code	1005109
Hospital Revenue Code	350
Min. Negotiated Rate	$539.81
Max. Negotiated Rate	$4,126.50
Rate for Payer: Aetna of AZ Commercial	$4,126.50
Rate for Payer: Arizona Complete Health Allwell	$733.60
Rate for Payer: Banner UC Health Medicare	$733.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,117.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$733.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$733.60
Rate for Payer: Cash Price	$3,668.00
Rate for Payer: Cash Price	$3,668.00
Rate for Payer: Cigna of AZ Commercial	$2,980.25
Rate for Payer: Devoted Health Medicare	$825.30
Rate for Payer: Humana of AZ Medicare	$733.60
Rate for Payer: Seven Corners Travel Insurance	$539.81
Rate for Payer: Southwest Service Administrators UFCW	$3,117.80
Rate for Payer: TriWest Medicare	$733.60
Rate for Payer: United Healthcare Commercial	$2,622.62
Rate for Payer: United Healthcare Medicare	$733.60
Rate for Payer: Veterans Affairs TRICARE	$726.26

CT Abdomen/Pelvis w/o Contrast

Facility

$4,535.00

Service Code	CPT 74176
Hospital Charge Code	1005112
Hospital Revenue Code	350
Min. Negotiated Rate	$369.18
Max. Negotiated Rate	$4,081.50
Rate for Payer: Aetna of AZ Commercial	$4,081.50
Rate for Payer: Arizona Complete Health Allwell	$725.60
Rate for Payer: Banner UC Health Medicare	$725.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,083.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$725.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$725.60
Rate for Payer: Cash Price	$3,628.00
Rate for Payer: Cash Price	$3,628.00
Rate for Payer: Cigna of AZ Commercial	$2,947.75
Rate for Payer: Devoted Health Medicare	$816.30
Rate for Payer: Humana of AZ Medicare	$725.60
Rate for Payer: Seven Corners Travel Insurance	$369.18
Rate for Payer: Southwest Service Administrators UFCW	$3,083.80
Rate for Payer: TriWest Medicare	$725.60
Rate for Payer: United Healthcare Commercial	$2,594.02
Rate for Payer: United Healthcare Medicare	$725.60
Rate for Payer: Veterans Affairs TRICARE	$718.34

CT Abdomen/Pelvis w/o Contrast

Facility

$4,535.00

Service Code	CPT 74176
Hospital Charge Code	1005112
Hospital Revenue Code	350
Min. Negotiated Rate	$4,081.50
Max. Negotiated Rate	$4,081.50
Rate for Payer: Aetna of AZ Commercial	$4,081.50
Rate for Payer: Cash Price	$3,628.00

CT Abdomen/Pelvis w + w/o Contrast

Facility

$5,174.00

Service Code	CPT 74178
Hospital Charge Code	1005106
Hospital Revenue Code	350
Min. Negotiated Rate	$539.81
Max. Negotiated Rate	$4,656.60
Rate for Payer: Aetna of AZ Commercial	$4,656.60
Rate for Payer: Arizona Complete Health Allwell	$827.84
Rate for Payer: Banner UC Health Medicare	$827.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,518.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$827.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$827.84
Rate for Payer: Cash Price	$4,139.20
Rate for Payer: Cash Price	$4,139.20
Rate for Payer: Cigna of AZ Commercial	$3,363.10
Rate for Payer: Devoted Health Medicare	$931.32
Rate for Payer: Humana of AZ Medicare	$827.84
Rate for Payer: Seven Corners Travel Insurance	$539.81
Rate for Payer: Southwest Service Administrators UFCW	$3,518.32
Rate for Payer: TriWest Medicare	$827.84
Rate for Payer: United Healthcare Commercial	$2,959.53
Rate for Payer: United Healthcare Medicare	$827.84
Rate for Payer: Veterans Affairs TRICARE	$819.56

CT Abdomen/Pelvis w + w/o Contrast

Facility

$5,174.00

Service Code	CPT 74178
Hospital Charge Code	1005106
Hospital Revenue Code	350
Min. Negotiated Rate	$4,656.60
Max. Negotiated Rate	$4,656.60
Rate for Payer: Aetna of AZ Commercial	$4,656.60
Rate for Payer: Cash Price	$4,139.20

CT Abdomen w/ Contrast

Facility

$3,627.00

Service Code	CPT 74160
Hospital Charge Code	821328
Hospital Revenue Code	352
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$3,264.30
Rate for Payer: Aetna of AZ Commercial	$3,264.30
Rate for Payer: Arizona Complete Health Allwell	$580.32
Rate for Payer: Banner UC Health Medicare	$580.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,466.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$580.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$580.32
Rate for Payer: Cash Price	$2,901.60
Rate for Payer: Cash Price	$2,901.60
Rate for Payer: Cigna of AZ Commercial	$2,357.55
Rate for Payer: Devoted Health Medicare	$652.86
Rate for Payer: Humana of AZ Medicare	$580.32
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$2,466.36
Rate for Payer: TriWest Medicare	$580.32
Rate for Payer: United Healthcare Commercial	$2,074.64
Rate for Payer: United Healthcare Medicare	$580.32
Rate for Payer: Veterans Affairs TRICARE	$574.52

CT Abdomen w/ Contrast

Facility

$3,627.00

Service Code	CPT 74160
Hospital Charge Code	821328
Hospital Revenue Code	352
Min. Negotiated Rate	$3,264.30
Max. Negotiated Rate	$3,264.30
Rate for Payer: Aetna of AZ Commercial	$3,264.30
Rate for Payer: Cash Price	$2,901.60

CT Abdomen w/o Contrast

Facility

$2,395.00

Service Code	CPT 74150
Hospital Charge Code	821330
Hospital Revenue Code	352
Min. Negotiated Rate	$161.76
Max. Negotiated Rate	$2,155.50
Rate for Payer: Aetna of AZ Commercial	$2,155.50
Rate for Payer: Arizona Complete Health Allwell	$383.20
Rate for Payer: Banner UC Health Medicare	$383.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,628.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$383.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$383.20
Rate for Payer: Cash Price	$1,916.00
Rate for Payer: Cash Price	$1,916.00
Rate for Payer: Cigna of AZ Commercial	$1,556.75
Rate for Payer: Devoted Health Medicare	$431.10
Rate for Payer: Humana of AZ Medicare	$383.20
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$1,628.60
Rate for Payer: TriWest Medicare	$383.20
Rate for Payer: United Healthcare Commercial	$1,369.94
Rate for Payer: United Healthcare Medicare	$383.20
Rate for Payer: Veterans Affairs TRICARE	$379.37

CT Abdomen w/o Contrast

Facility

$2,395.00

Service Code	CPT 74150
Hospital Charge Code	821330
Hospital Revenue Code	352
Min. Negotiated Rate	$2,155.50
Max. Negotiated Rate	$2,155.50
Rate for Payer: Aetna of AZ Commercial	$2,155.50
Rate for Payer: Cash Price	$1,916.00

CT Abdomen w/ + w/o Contrast

Facility

$4,113.00

Service Code	CPT 74170
Hospital Charge Code	821326
Hospital Revenue Code	352
Min. Negotiated Rate	$3,701.70
Max. Negotiated Rate	$3,701.70
Rate for Payer: Aetna of AZ Commercial	$3,701.70
Rate for Payer: Cash Price	$3,290.40

CT Abdomen w/ + w/o Contrast

Facility

$4,113.00

Service Code	CPT 74170
Hospital Charge Code	821326
Hospital Revenue Code	352
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$3,701.70
Rate for Payer: Aetna of AZ Commercial	$3,701.70
Rate for Payer: Arizona Complete Health Allwell	$658.08
Rate for Payer: Banner UC Health Medicare	$658.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,796.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$658.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$658.08
Rate for Payer: Cash Price	$3,290.40
Rate for Payer: Cash Price	$3,290.40
Rate for Payer: Cigna of AZ Commercial	$2,673.45
Rate for Payer: Devoted Health Medicare	$740.34
Rate for Payer: Humana of AZ Medicare	$658.08
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$2,796.84
Rate for Payer: TriWest Medicare	$658.08
Rate for Payer: United Healthcare Commercial	$2,352.64
Rate for Payer: United Healthcare Medicare	$658.08
Rate for Payer: Veterans Affairs TRICARE	$651.50

CTA EXTREMITY W/

Facility

$519.00

Service Code	CPT 73706
Hospital Charge Code	1185058
Hospital Revenue Code	351
Min. Negotiated Rate	$467.10
Max. Negotiated Rate	$467.10
Rate for Payer: Aetna of AZ Commercial	$467.10
Rate for Payer: Cash Price	$415.20

CTA EXTREMITY W/

Facility

$519.00

Service Code	CPT 73706
Hospital Charge Code	1185058
Hospital Revenue Code	351
Min. Negotiated Rate	$82.21
Max. Negotiated Rate	$467.10
Rate for Payer: Aetna of AZ Commercial	$467.10
Rate for Payer: Arizona Complete Health Allwell	$83.04
Rate for Payer: Banner UC Health Medicare	$83.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$352.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$83.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$83.04
Rate for Payer: Cash Price	$415.20
Rate for Payer: Cash Price	$415.20
Rate for Payer: Cigna of AZ Commercial	$337.35
Rate for Payer: Devoted Health Medicare	$93.42
Rate for Payer: Humana of AZ Medicare	$83.04
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$352.92
Rate for Payer: TriWest Medicare	$83.04
Rate for Payer: United Healthcare Commercial	$296.87
Rate for Payer: United Healthcare Medicare	$83.04
Rate for Payer: Veterans Affairs TRICARE	$82.21

CTA LOWER EXTERMITY W/

Facility

$701.00

Service Code	CPT 75635
Hospital Charge Code	2213993
Hospital Revenue Code	351
Min. Negotiated Rate	$630.90
Max. Negotiated Rate	$630.90
Rate for Payer: Aetna of AZ Commercial	$630.90
Rate for Payer: Cash Price	$560.80

CTA LOWER EXTERMITY W/

Facility

$701.00

Service Code	CPT 75635
Hospital Charge Code	2213993
Hospital Revenue Code	351
Min. Negotiated Rate	$111.04
Max. Negotiated Rate	$630.90
Rate for Payer: Aetna of AZ Commercial	$630.90
Rate for Payer: Arizona Complete Health Allwell	$112.16
Rate for Payer: Banner UC Health Medicare	$112.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$476.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$112.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$112.16
Rate for Payer: Cash Price	$560.80
Rate for Payer: Cash Price	$560.80
Rate for Payer: Cigna of AZ Commercial	$455.65
Rate for Payer: Devoted Health Medicare	$126.18
Rate for Payer: Humana of AZ Medicare	$112.16
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$476.68
Rate for Payer: TriWest Medicare	$112.16
Rate for Payer: United Healthcare Commercial	$400.97
Rate for Payer: United Healthcare Medicare	$112.16
Rate for Payer: Veterans Affairs TRICARE	$111.04

CT Angiography Abdomen

Facility

$2,367.00

Service Code	CPT 74175
Hospital Charge Code	1005124
Hospital Revenue Code	352
Min. Negotiated Rate	$2,130.30
Max. Negotiated Rate	$2,130.30
Rate for Payer: Aetna of AZ Commercial	$2,130.30
Rate for Payer: Cash Price	$1,893.60

CT Angiography Abdomen

Facility

$2,367.00

Service Code	CPT 74175
Hospital Charge Code	1005124
Hospital Revenue Code	352
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$2,130.30
Rate for Payer: Aetna of AZ Commercial	$2,130.30
Rate for Payer: Arizona Complete Health Allwell	$378.72
Rate for Payer: Banner UC Health Medicare	$378.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,609.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$378.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$378.72
Rate for Payer: Cash Price	$1,893.60
Rate for Payer: Cash Price	$1,893.60
Rate for Payer: Cigna of AZ Commercial	$1,538.55
Rate for Payer: Devoted Health Medicare	$426.06
Rate for Payer: Humana of AZ Medicare	$378.72
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$1,609.56
Rate for Payer: TriWest Medicare	$378.72
Rate for Payer: United Healthcare Commercial	$1,353.92
Rate for Payer: United Healthcare Medicare	$378.72
Rate for Payer: Veterans Affairs TRICARE	$374.93

CT Angiography Abdomen/Pelvis

Facility

$5,874.00

Service Code	CPT 74174
Hospital Charge Code	4132928
Hospital Revenue Code	352
Min. Negotiated Rate	$539.81
Max. Negotiated Rate	$5,286.60
Rate for Payer: Aetna of AZ Commercial	$5,286.60
Rate for Payer: Arizona Complete Health Allwell	$939.84
Rate for Payer: Banner UC Health Medicare	$939.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,994.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$939.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$939.84
Rate for Payer: Cash Price	$4,699.20
Rate for Payer: Cash Price	$4,699.20
Rate for Payer: Cigna of AZ Commercial	$3,818.10
Rate for Payer: Devoted Health Medicare	$1,057.32
Rate for Payer: Humana of AZ Medicare	$939.84
Rate for Payer: Seven Corners Travel Insurance	$539.81
Rate for Payer: Southwest Service Administrators UFCW	$3,994.32
Rate for Payer: TriWest Medicare	$939.84
Rate for Payer: United Healthcare Commercial	$3,359.93
Rate for Payer: United Healthcare Medicare	$939.84
Rate for Payer: Veterans Affairs TRICARE	$930.44

CT Angiography Abdomen/Pelvis

Facility

$5,874.00

Service Code	CPT 74174
Hospital Charge Code	4132928
Hospital Revenue Code	352
Min. Negotiated Rate	$5,286.60
Max. Negotiated Rate	$5,286.60
Rate for Payer: Aetna of AZ Commercial	$5,286.60
Rate for Payer: Cash Price	$4,699.20

CT Angiography Chest w/ Contrast

Facility

$4,175.00

Service Code	CPT 71275
Hospital Charge Code	1165683
Hospital Revenue Code	350
Min. Negotiated Rate	$3,757.50
Max. Negotiated Rate	$3,757.50
Rate for Payer: Aetna of AZ Commercial	$3,757.50
Rate for Payer: Cash Price	$3,340.00

CT Angiography Chest w/ Contrast

Facility

$4,175.00

Service Code	CPT 71275
Hospital Charge Code	1165683
Hospital Revenue Code	350
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$3,757.50
Rate for Payer: Aetna of AZ Commercial	$3,757.50
Rate for Payer: Arizona Complete Health Allwell	$668.00
Rate for Payer: Banner UC Health Medicare	$668.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,839.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$668.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$668.00
Rate for Payer: Cash Price	$3,340.00
Rate for Payer: Cash Price	$3,340.00
Rate for Payer: Cigna of AZ Commercial	$2,713.75
Rate for Payer: Devoted Health Medicare	$751.50
Rate for Payer: Humana of AZ Medicare	$668.00
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$2,839.00
Rate for Payer: TriWest Medicare	$668.00
Rate for Payer: United Healthcare Commercial	$2,388.10
Rate for Payer: United Healthcare Medicare	$668.00
Rate for Payer: Veterans Affairs TRICARE	$661.32

CT Angiography Head w/ Contrast

Facility

$4,133.00

Service Code	CPT 70496
Hospital Charge Code	1477517
Hospital Revenue Code	351
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$3,719.70
Rate for Payer: Aetna of AZ Commercial	$3,719.70
Rate for Payer: Arizona Complete Health Allwell	$661.28
Rate for Payer: Banner UC Health Medicare	$661.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,810.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$661.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$661.28
Rate for Payer: Cash Price	$3,306.40
Rate for Payer: Cash Price	$3,306.40
Rate for Payer: Cigna of AZ Commercial	$2,686.45
Rate for Payer: Devoted Health Medicare	$743.94
Rate for Payer: Humana of AZ Medicare	$661.28
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$2,810.44
Rate for Payer: TriWest Medicare	$661.28
Rate for Payer: United Healthcare Commercial	$2,364.08
Rate for Payer: United Healthcare Medicare	$661.28
Rate for Payer: Veterans Affairs TRICARE	$654.67

CT Angiography Head w/ Contrast

Facility

$4,326.00

Service Code	CPT 70496
Hospital Charge Code	22035134
Hospital Revenue Code	350
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$3,893.40
Rate for Payer: Aetna of AZ Commercial	$3,893.40
Rate for Payer: Arizona Complete Health Allwell	$692.16
Rate for Payer: Banner UC Health Medicare	$692.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,941.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$692.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$692.16
Rate for Payer: Cash Price	$3,460.80
Rate for Payer: Cash Price	$3,460.80
Rate for Payer: Cigna of AZ Commercial	$2,811.90
Rate for Payer: Devoted Health Medicare	$778.68
Rate for Payer: Humana of AZ Medicare	$692.16
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$2,941.68
Rate for Payer: TriWest Medicare	$692.16
Rate for Payer: United Healthcare Commercial	$2,474.47
Rate for Payer: United Healthcare Medicare	$692.16
Rate for Payer: Veterans Affairs TRICARE	$685.24

CT Angiography Head w/ Contrast

Facility

$4,133.00

Service Code	CPT 70496
Hospital Charge Code	1477517
Hospital Revenue Code	351
Min. Negotiated Rate	$3,719.70
Max. Negotiated Rate	$3,719.70
Rate for Payer: Aetna of AZ Commercial	$3,719.70
Rate for Payer: Cash Price	$3,306.40

Know your out-of-pocket cost for care.

All Charges