Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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	$2,268.90
Max. Negotiated Rate	$2,268.90
Rate for Payer: Aetna of AZ Commercial	$2,268.90
Rate for Payer: Cash Price	$2,016.80

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	$399.33
Max. Negotiated Rate	$2,268.90
Rate for Payer: Aetna of AZ Commercial	$2,268.90
Rate for Payer: Arizona Complete Health Allwell	$403.36
Rate for Payer: Banner UC Health Medicare	$403.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,714.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$403.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$403.36
Rate for Payer: Cash Price	$2,016.80
Rate for Payer: Cigna of AZ Commercial	$1,638.65
Rate for Payer: Devoted Health Medicare	$453.78
Rate for Payer: Humana of AZ Medicare	$403.36
Rate for Payer: Southwest Service Administrators UFCW	$1,714.28
Rate for Payer: TriWest Medicare	$403.36
Rate for Payer: United Healthcare Commercial	$1,442.01
Rate for Payer: United Healthcare Medicare	$403.36
Rate for Payer: Veterans Affairs TRICARE	$399.33

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	$2,646.90
Max. Negotiated Rate	$2,646.90
Rate for Payer: Aetna of AZ Commercial	$2,646.90
Rate for Payer: Cash Price	$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	$271.40
Max. Negotiated Rate	$2,646.90
Rate for Payer: Aetna of AZ Commercial	$2,646.90
Rate for Payer: Arizona Complete Health Allwell	$470.56
Rate for Payer: Banner UC Health Medicare	$470.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,999.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$470.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$470.56
Rate for Payer: Cash Price	$2,352.80
Rate for Payer: Cash Price	$2,352.80
Rate for Payer: Cigna of AZ Commercial	$1,911.65
Rate for Payer: Devoted Health Medicare	$529.38
Rate for Payer: Humana of AZ Medicare	$470.56
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$1,999.88
Rate for Payer: TriWest Medicare	$470.56
Rate for Payer: United Healthcare Commercial	$1,682.25
Rate for Payer: United Healthcare Medicare	$470.56
Rate for Payer: Veterans Affairs TRICARE	$465.85

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	$2,268.90
Max. Negotiated Rate	$2,268.90
Rate for Payer: Aetna of AZ Commercial	$2,268.90
Rate for Payer: Cash Price	$2,016.80

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	$399.33
Max. Negotiated Rate	$2,268.90
Rate for Payer: Aetna of AZ Commercial	$2,268.90
Rate for Payer: Arizona Complete Health Allwell	$403.36
Rate for Payer: Banner UC Health Medicare	$403.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,714.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$403.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$403.36
Rate for Payer: Cash Price	$2,016.80
Rate for Payer: Cigna of AZ Commercial	$1,638.65
Rate for Payer: Devoted Health Medicare	$453.78
Rate for Payer: Humana of AZ Medicare	$403.36
Rate for Payer: Southwest Service Administrators UFCW	$1,714.28
Rate for Payer: TriWest Medicare	$403.36
Rate for Payer: United Healthcare Commercial	$1,442.01
Rate for Payer: United Healthcare Medicare	$403.36
Rate for Payer: Veterans Affairs TRICARE	$399.33

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	$2,735.10
Max. Negotiated Rate	$2,735.10
Rate for Payer: Aetna of AZ Commercial	$2,735.10
Rate for Payer: Cash Price	$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	$271.40
Max. Negotiated Rate	$2,735.10
Rate for Payer: Aetna of AZ Commercial	$2,735.10
Rate for Payer: Arizona Complete Health Allwell	$486.24
Rate for Payer: Banner UC Health Medicare	$486.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,066.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$486.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$486.24
Rate for Payer: Cash Price	$2,431.20
Rate for Payer: Cash Price	$2,431.20
Rate for Payer: Cigna of AZ Commercial	$1,975.35
Rate for Payer: Devoted Health Medicare	$547.02
Rate for Payer: Humana of AZ Medicare	$486.24
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$2,066.52
Rate for Payer: TriWest Medicare	$486.24
Rate for Payer: United Healthcare Commercial	$1,738.31
Rate for Payer: United Healthcare Medicare	$486.24
Rate for Payer: Veterans Affairs TRICARE	$481.38

CT Maxillofacial w/ Contrast

Facility

$2,347.00

Service Code	CPT 70487
Hospital Charge Code	821346
Hospital Revenue Code	351
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$2,112.30
Rate for Payer: Aetna of AZ Commercial	$2,112.30
Rate for Payer: Arizona Complete Health Allwell	$375.52
Rate for Payer: Banner UC Health Medicare	$375.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,595.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$375.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$375.52
Rate for Payer: Cash Price	$1,877.60
Rate for Payer: Cash Price	$1,877.60
Rate for Payer: Cigna of AZ Commercial	$1,525.55
Rate for Payer: Devoted Health Medicare	$422.46
Rate for Payer: Humana of AZ Medicare	$375.52
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$1,595.96
Rate for Payer: TriWest Medicare	$375.52
Rate for Payer: United Healthcare Commercial	$1,342.48
Rate for Payer: United Healthcare Medicare	$375.52
Rate for Payer: Veterans Affairs TRICARE	$371.76

CT Maxillofacial w/ Contrast

Facility

$2,347.00

Service Code	CPT 70487
Hospital Charge Code	821346
Hospital Revenue Code	351
Min. Negotiated Rate	$2,112.30
Max. Negotiated Rate	$2,112.30
Rate for Payer: Aetna of AZ Commercial	$2,112.30
Rate for Payer: Cash Price	$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	$161.76
Max. Negotiated Rate	$1,859.40
Rate for Payer: Aetna of AZ Commercial	$1,859.40
Rate for Payer: Arizona Complete Health Allwell	$330.56
Rate for Payer: Banner UC Health Medicare	$330.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,404.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$330.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$330.56
Rate for Payer: Cash Price	$1,652.80
Rate for Payer: Cash Price	$1,652.80
Rate for Payer: Cigna of AZ Commercial	$1,342.90
Rate for Payer: Devoted Health Medicare	$371.88
Rate for Payer: Humana of AZ Medicare	$330.56
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$1,404.88
Rate for Payer: TriWest Medicare	$330.56
Rate for Payer: United Healthcare Commercial	$1,181.75
Rate for Payer: United Healthcare Medicare	$330.56
Rate for Payer: Veterans Affairs TRICARE	$327.25

CT Maxillofacial w/o Contrast

Facility

$2,066.00

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

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	$161.76
Max. Negotiated Rate	$1,766.70
Rate for Payer: Aetna of AZ Commercial	$1,766.70
Rate for Payer: Arizona Complete Health Allwell	$314.08
Rate for Payer: Banner UC Health Medicare	$314.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,334.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$314.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$314.08
Rate for Payer: Cash Price	$1,570.40
Rate for Payer: Cash Price	$1,570.40
Rate for Payer: Cigna of AZ Commercial	$1,275.95
Rate for Payer: Devoted Health Medicare	$353.34
Rate for Payer: Humana of AZ Medicare	$314.08
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$1,334.84
Rate for Payer: TriWest Medicare	$314.08
Rate for Payer: United Healthcare Commercial	$1,122.84
Rate for Payer: United Healthcare Medicare	$314.08
Rate for Payer: Veterans Affairs TRICARE	$310.94

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	$1,766.70
Max. Negotiated Rate	$1,766.70
Rate for Payer: Aetna of AZ Commercial	$1,766.70
Rate for Payer: Cash Price	$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	$3,187.80
Max. Negotiated Rate	$3,187.80
Rate for Payer: Aetna of AZ Commercial	$3,187.80
Rate for Payer: Cash Price	$2,833.60

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	$271.40
Max. Negotiated Rate	$3,187.80
Rate for Payer: Aetna of AZ Commercial	$3,187.80
Rate for Payer: Arizona Complete Health Allwell	$566.72
Rate for Payer: Banner UC Health Medicare	$566.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,408.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$566.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$566.72
Rate for Payer: Cash Price	$2,833.60
Rate for Payer: Cash Price	$2,833.60
Rate for Payer: Cigna of AZ Commercial	$2,302.30
Rate for Payer: Devoted Health Medicare	$637.56
Rate for Payer: Humana of AZ Medicare	$566.72
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$2,408.56
Rate for Payer: TriWest Medicare	$566.72
Rate for Payer: United Healthcare Commercial	$2,026.02
Rate for Payer: United Healthcare Medicare	$566.72
Rate for Payer: Veterans Affairs TRICARE	$561.05

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	$2,433.60
Max. Negotiated Rate	$2,433.60
Rate for Payer: Aetna of AZ Commercial	$2,433.60
Rate for Payer: Cash Price	$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	$271.40
Max. Negotiated Rate	$2,433.60
Rate for Payer: Aetna of AZ Commercial	$2,433.60
Rate for Payer: Arizona Complete Health Allwell	$432.64
Rate for Payer: Banner UC Health Medicare	$432.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,838.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$432.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$432.64
Rate for Payer: Cash Price	$2,163.20
Rate for Payer: Cash Price	$2,163.20
Rate for Payer: Cigna of AZ Commercial	$1,757.60
Rate for Payer: Devoted Health Medicare	$486.72
Rate for Payer: Humana of AZ Medicare	$432.64
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$1,838.72
Rate for Payer: TriWest Medicare	$432.64
Rate for Payer: United Healthcare Commercial	$1,546.69
Rate for Payer: United Healthcare Medicare	$432.64
Rate for Payer: Veterans Affairs TRICARE	$428.31

CT Orbit Sella etc. w/ Contrast

Facility

$486.00

Service Code	CPT 70481
Hospital Charge Code	22862167
Hospital Revenue Code	972
Min. Negotiated Rate	$437.40
Max. Negotiated Rate	$437.40
Rate for Payer: Aetna of AZ Commercial	$437.40
Rate for Payer: Cash Price	$388.80

CT Orbit Sella etc. w/ Contrast

Facility

$486.00

Service Code	CPT 70481
Hospital Charge Code	22862167
Hospital Revenue Code	972
Min. Negotiated Rate	$76.98
Max. Negotiated Rate	$437.40
Rate for Payer: Aetna of AZ Commercial	$437.40
Rate for Payer: Arizona Complete Health Allwell	$77.76
Rate for Payer: Banner UC Health Medicare	$77.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$330.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$77.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$77.76
Rate for Payer: Cash Price	$388.80
Rate for Payer: Cash Price	$388.80
Rate for Payer: Cigna of AZ Commercial	$340.20
Rate for Payer: Devoted Health Medicare	$87.48
Rate for Payer: Humana of AZ Medicare	$77.76
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$330.48
Rate for Payer: TriWest Medicare	$77.76
Rate for Payer: United Healthcare Commercial	$277.99
Rate for Payer: United Healthcare Medicare	$77.76
Rate for Payer: United Healthcare New Mexico Commercial	$92.34
Rate for Payer: Veterans Affairs TRICARE	$76.98

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	$2,186.10
Max. Negotiated Rate	$2,186.10
Rate for Payer: Aetna of AZ Commercial	$2,186.10
Rate for Payer: Cash Price	$1,943.20

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	$373.50
Max. Negotiated Rate	$373.50
Rate for Payer: Aetna of AZ Commercial	$373.50
Rate for Payer: Cash Price	$332.00

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	$65.74
Max. Negotiated Rate	$373.50
Rate for Payer: Aetna of AZ Commercial	$373.50
Rate for Payer: Arizona Complete Health Allwell	$66.40
Rate for Payer: Banner UC Health Medicare	$66.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$282.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$66.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$66.40
Rate for Payer: Cash Price	$332.00
Rate for Payer: Cash Price	$332.00
Rate for Payer: Cigna of AZ Commercial	$290.50
Rate for Payer: Devoted Health Medicare	$74.70
Rate for Payer: Humana of AZ Medicare	$66.40
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$282.20
Rate for Payer: TriWest Medicare	$66.40
Rate for Payer: United Healthcare Commercial	$237.38
Rate for Payer: United Healthcare Medicare	$66.40
Rate for Payer: United Healthcare New Mexico Commercial	$78.85
Rate for Payer: Veterans Affairs TRICARE	$65.74

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	$161.76
Max. Negotiated Rate	$2,186.10
Rate for Payer: Aetna of AZ Commercial	$2,186.10
Rate for Payer: Arizona Complete Health Allwell	$388.64
Rate for Payer: Banner UC Health Medicare	$388.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,651.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$388.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$388.64
Rate for Payer: Cash Price	$1,943.20
Rate for Payer: Cash Price	$1,943.20
Rate for Payer: Cigna of AZ Commercial	$1,578.85
Rate for Payer: Devoted Health Medicare	$437.22
Rate for Payer: Humana of AZ Medicare	$388.64
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$1,651.72
Rate for Payer: TriWest Medicare	$388.64
Rate for Payer: United Healthcare Commercial	$1,389.39
Rate for Payer: United Healthcare Medicare	$388.64
Rate for Payer: Veterans Affairs TRICARE	$384.75

CT Orbit Sella etc. w/ + w/o Contrast

Facility

$3,197.00

Service Code	CPT 70482
Hospital Charge Code	1005187
Hospital Revenue Code	351
Min. Negotiated Rate	$2,877.30
Max. Negotiated Rate	$2,877.30
Rate for Payer: Aetna of AZ Commercial	$2,877.30
Rate for Payer: Cash Price	$2,557.60

Know your out-of-pocket cost for care.

All Charges