Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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

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

Facility

$544.00

Service Code	CPT 70482
Hospital Charge Code	22862168
Hospital Revenue Code	972
Min. Negotiated Rate	$489.60
Max. Negotiated Rate	$489.60
Rate for Payer: Aetna of AZ Commercial	$489.60
Rate for Payer: Cash Price	$435.20

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	$271.40
Max. Negotiated Rate	$2,877.30
Rate for Payer: Aetna of AZ Commercial	$2,877.30
Rate for Payer: Arizona Complete Health Allwell	$511.52
Rate for Payer: Banner UC Health Medicare	$511.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,173.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$511.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$511.52
Rate for Payer: Cash Price	$2,557.60
Rate for Payer: Cash Price	$2,557.60
Rate for Payer: Cigna of AZ Commercial	$2,078.05
Rate for Payer: Devoted Health Medicare	$575.46
Rate for Payer: Humana of AZ Medicare	$511.52
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$2,173.96
Rate for Payer: TriWest Medicare	$511.52
Rate for Payer: United Healthcare Commercial	$1,828.68
Rate for Payer: United Healthcare Medicare	$511.52
Rate for Payer: Veterans Affairs TRICARE	$506.40

CT Pelvis w/ Contrast

Facility

$3,655.00

Service Code	CPT 72193
Hospital Charge Code	821359
Hospital Revenue Code	352
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$3,289.50
Rate for Payer: Aetna of AZ Commercial	$3,289.50
Rate for Payer: Arizona Complete Health Allwell	$584.80
Rate for Payer: Banner UC Health Medicare	$584.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,485.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$584.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$584.80
Rate for Payer: Cash Price	$2,924.00
Rate for Payer: Cash Price	$2,924.00
Rate for Payer: Cigna of AZ Commercial	$2,375.75
Rate for Payer: Devoted Health Medicare	$657.90
Rate for Payer: Humana of AZ Medicare	$584.80
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$2,485.40
Rate for Payer: TriWest Medicare	$584.80
Rate for Payer: United Healthcare Commercial	$2,090.66
Rate for Payer: United Healthcare Medicare	$584.80
Rate for Payer: Veterans Affairs TRICARE	$578.95

CT Pelvis w/ Contrast

Facility

$3,655.00

Service Code	CPT 72193
Hospital Charge Code	821359
Hospital Revenue Code	352
Min. Negotiated Rate	$3,289.50
Max. Negotiated Rate	$3,289.50
Rate for Payer: Aetna of AZ Commercial	$3,289.50
Rate for Payer: Cash Price	$2,924.00

CT Pelvis w/o Contrast

Facility

$1,953.00

Service Code	CPT 72192
Hospital Charge Code	821361
Hospital Revenue Code	352
Min. Negotiated Rate	$161.76
Max. Negotiated Rate	$1,757.70
Rate for Payer: Aetna of AZ Commercial	$1,757.70
Rate for Payer: Arizona Complete Health Allwell	$312.48
Rate for Payer: Banner UC Health Medicare	$312.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,328.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$312.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$312.48
Rate for Payer: Cash Price	$1,562.40
Rate for Payer: Cash Price	$1,562.40
Rate for Payer: Cigna of AZ Commercial	$1,269.45
Rate for Payer: Devoted Health Medicare	$351.54
Rate for Payer: Humana of AZ Medicare	$312.48
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$1,328.04
Rate for Payer: TriWest Medicare	$312.48
Rate for Payer: United Healthcare Commercial	$1,117.12
Rate for Payer: United Healthcare Medicare	$312.48
Rate for Payer: Veterans Affairs TRICARE	$309.36

CT Pelvis w/o Contrast

Facility

$1,953.00

Service Code	CPT 72192
Hospital Charge Code	821361
Hospital Revenue Code	352
Min. Negotiated Rate	$1,757.70
Max. Negotiated Rate	$1,757.70
Rate for Payer: Aetna of AZ Commercial	$1,757.70
Rate for Payer: Cash Price	$1,562.40

CT Pelvis w/ + w/o Contrast

Facility

$2,619.00

Service Code	CPT 72194
Hospital Charge Code	821357
Hospital Revenue Code	352
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$2,357.10
Rate for Payer: Aetna of AZ Commercial	$2,357.10
Rate for Payer: Arizona Complete Health Allwell	$419.04
Rate for Payer: Banner UC Health Medicare	$419.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,780.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$419.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$419.04
Rate for Payer: Cash Price	$2,095.20
Rate for Payer: Cash Price	$2,095.20
Rate for Payer: Cigna of AZ Commercial	$1,702.35
Rate for Payer: Devoted Health Medicare	$471.42
Rate for Payer: Humana of AZ Medicare	$419.04
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$1,780.92
Rate for Payer: TriWest Medicare	$419.04
Rate for Payer: United Healthcare Commercial	$1,498.07
Rate for Payer: United Healthcare Medicare	$419.04
Rate for Payer: Veterans Affairs TRICARE	$414.85

CT Pelvis w/ + w/o Contrast

Facility

$2,619.00

Service Code	CPT 72194
Hospital Charge Code	821357
Hospital Revenue Code	352
Min. Negotiated Rate	$2,357.10
Max. Negotiated Rate	$2,357.10
Rate for Payer: Aetna of AZ Commercial	$2,357.10
Rate for Payer: Cash Price	$2,095.20

CT Soft Tissue Neck w/ Contrast

Facility

$2,678.00

Service Code	CPT 70491
Hospital Charge Code	821368
Hospital Revenue Code	351
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$2,410.20
Rate for Payer: Aetna of AZ Commercial	$2,410.20
Rate for Payer: Arizona Complete Health Allwell	$428.48
Rate for Payer: Banner UC Health Medicare	$428.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,821.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$428.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$428.48
Rate for Payer: Cash Price	$2,142.40
Rate for Payer: Cash Price	$2,142.40
Rate for Payer: Cigna of AZ Commercial	$1,740.70
Rate for Payer: Devoted Health Medicare	$482.04
Rate for Payer: Humana of AZ Medicare	$428.48
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$1,821.04
Rate for Payer: TriWest Medicare	$428.48
Rate for Payer: United Healthcare Commercial	$1,531.82
Rate for Payer: United Healthcare Medicare	$428.48
Rate for Payer: Veterans Affairs TRICARE	$424.20

CT Soft Tissue Neck w/ Contrast

Facility

$2,678.00

Service Code	CPT 70491
Hospital Charge Code	821368
Hospital Revenue Code	351
Min. Negotiated Rate	$2,410.20
Max. Negotiated Rate	$2,410.20
Rate for Payer: Aetna of AZ Commercial	$2,410.20
Rate for Payer: Cash Price	$2,142.40

CT Soft Tissue Neck w/o Contrast

Facility

$2,352.00

Service Code	CPT 70490
Hospital Charge Code	821370
Hospital Revenue Code	351
Min. Negotiated Rate	$161.76
Max. Negotiated Rate	$2,116.80
Rate for Payer: Aetna of AZ Commercial	$2,116.80
Rate for Payer: Arizona Complete Health Allwell	$376.32
Rate for Payer: Banner UC Health Medicare	$376.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,599.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$376.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$376.32
Rate for Payer: Cash Price	$1,881.60
Rate for Payer: Cash Price	$1,881.60
Rate for Payer: Cigna of AZ Commercial	$1,528.80
Rate for Payer: Devoted Health Medicare	$423.36
Rate for Payer: Humana of AZ Medicare	$376.32
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$1,599.36
Rate for Payer: TriWest Medicare	$376.32
Rate for Payer: United Healthcare Commercial	$1,345.34
Rate for Payer: United Healthcare Medicare	$376.32
Rate for Payer: Veterans Affairs TRICARE	$372.56

CT Soft Tissue Neck w/o Contrast

Facility

$2,352.00

Service Code	CPT 70490
Hospital Charge Code	821370
Hospital Revenue Code	351
Min. Negotiated Rate	$2,116.80
Max. Negotiated Rate	$2,116.80
Rate for Payer: Aetna of AZ Commercial	$2,116.80
Rate for Payer: Cash Price	$1,881.60

CT Soft Tissue Neck w/ + w/o Contrast

Facility

$3,382.00

Service Code	CPT 70492
Hospital Charge Code	821366
Hospital Revenue Code	351
Min. Negotiated Rate	$3,043.80
Max. Negotiated Rate	$3,043.80
Rate for Payer: Aetna of AZ Commercial	$3,043.80
Rate for Payer: Cash Price	$2,705.60

CT Soft Tissue Neck w/ + w/o Contrast

Facility

$3,382.00

Service Code	CPT 70492
Hospital Charge Code	821366
Hospital Revenue Code	351
Min. Negotiated Rate	$271.40
Max. Negotiated Rate	$3,043.80
Rate for Payer: Aetna of AZ Commercial	$3,043.80
Rate for Payer: Arizona Complete Health Allwell	$541.12
Rate for Payer: Banner UC Health Medicare	$541.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,299.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$541.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$541.12
Rate for Payer: Cash Price	$2,705.60
Rate for Payer: Cash Price	$2,705.60
Rate for Payer: Cigna of AZ Commercial	$2,198.30
Rate for Payer: Devoted Health Medicare	$608.76
Rate for Payer: Humana of AZ Medicare	$541.12
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$2,299.76
Rate for Payer: TriWest Medicare	$541.12
Rate for Payer: United Healthcare Commercial	$1,934.50
Rate for Payer: United Healthcare Medicare	$541.12
Rate for Payer: Veterans Affairs TRICARE	$535.71

CT Spine Cervical w/ Contrast

Facility

$2,579.00

Service Code	CPT 72126
Hospital Charge Code	1005215
Hospital Revenue Code	352
Min. Negotiated Rate	$2,321.10
Max. Negotiated Rate	$2,321.10
Rate for Payer: Aetna of AZ Commercial	$2,321.10
Rate for Payer: Cash Price	$2,063.20

CT Spine Cervical w/ Contrast

Facility

$2,579.00

Service Code	CPT 72126
Hospital Charge Code	1005215
Hospital Revenue Code	352
Min. Negotiated Rate	$408.51
Max. Negotiated Rate	$2,321.10
Rate for Payer: Aetna of AZ Commercial	$2,321.10
Rate for Payer: Arizona Complete Health Allwell	$412.64
Rate for Payer: Banner UC Health Medicare	$412.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,753.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$412.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$412.64
Rate for Payer: Cash Price	$2,063.20
Rate for Payer: Cash Price	$2,063.20
Rate for Payer: Cigna of AZ Commercial	$1,676.35
Rate for Payer: Devoted Health Medicare	$464.22
Rate for Payer: Humana of AZ Medicare	$412.64
Rate for Payer: Seven Corners Travel Insurance	$539.81
Rate for Payer: Southwest Service Administrators UFCW	$1,753.72
Rate for Payer: TriWest Medicare	$412.64
Rate for Payer: United Healthcare Commercial	$1,475.19
Rate for Payer: United Healthcare Medicare	$412.64
Rate for Payer: Veterans Affairs TRICARE	$408.51

CT Spine Cervical w/o Contrast

Facility

$2,949.00

Service Code	CPT 72125
Hospital Charge Code	821372
Hospital Revenue Code	352
Min. Negotiated Rate	$161.76
Max. Negotiated Rate	$2,654.10
Rate for Payer: Aetna of AZ Commercial	$2,654.10
Rate for Payer: Arizona Complete Health Allwell	$471.84
Rate for Payer: Banner UC Health Medicare	$471.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,005.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$471.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$471.84
Rate for Payer: Cash Price	$2,359.20
Rate for Payer: Cash Price	$2,359.20
Rate for Payer: Cigna of AZ Commercial	$1,916.85
Rate for Payer: Devoted Health Medicare	$530.82
Rate for Payer: Humana of AZ Medicare	$471.84
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$2,005.32
Rate for Payer: TriWest Medicare	$471.84
Rate for Payer: United Healthcare Commercial	$1,686.83
Rate for Payer: United Healthcare Medicare	$471.84
Rate for Payer: Veterans Affairs TRICARE	$467.12

CT Spine Cervical w/o Contrast

Facility

$2,949.00

Service Code	CPT 72125
Hospital Charge Code	821372
Hospital Revenue Code	352
Min. Negotiated Rate	$2,654.10
Max. Negotiated Rate	$2,654.10
Rate for Payer: Aetna of AZ Commercial	$2,654.10
Rate for Payer: Cash Price	$2,359.20

CT Spine Cervical w/ + w/o Contrast

Facility

$1,643.00

Service Code	CPT 72127
Hospital Charge Code	1005213
Hospital Revenue Code	352
Min. Negotiated Rate	$260.25
Max. Negotiated Rate	$1,478.70
Rate for Payer: Aetna of AZ Commercial	$1,478.70
Rate for Payer: Arizona Complete Health Allwell	$262.88
Rate for Payer: Banner UC Health Medicare	$262.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,117.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$262.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$262.88
Rate for Payer: Cash Price	$1,314.40
Rate for Payer: Cash Price	$1,314.40
Rate for Payer: Cigna of AZ Commercial	$1,067.95
Rate for Payer: Devoted Health Medicare	$295.74
Rate for Payer: Humana of AZ Medicare	$262.88
Rate for Payer: Seven Corners Travel Insurance	$271.40
Rate for Payer: Southwest Service Administrators UFCW	$1,117.24
Rate for Payer: TriWest Medicare	$262.88
Rate for Payer: United Healthcare Commercial	$939.80
Rate for Payer: United Healthcare Medicare	$262.88
Rate for Payer: Veterans Affairs TRICARE	$260.25

CT Spine Cervical w/ + w/o Contrast

Facility

$1,643.00

Service Code	CPT 72127
Hospital Charge Code	1005213
Hospital Revenue Code	352
Min. Negotiated Rate	$1,478.70
Max. Negotiated Rate	$1,478.70
Rate for Payer: Aetna of AZ Commercial	$1,478.70
Rate for Payer: Cash Price	$1,314.40

CT Spine Lumbar w/ Contrast

Facility

$3,131.00

Service Code	CPT 72132
Hospital Charge Code	1005219
Hospital Revenue Code	352
Min. Negotiated Rate	$2,817.90
Max. Negotiated Rate	$2,817.90
Rate for Payer: Aetna of AZ Commercial	$2,817.90
Rate for Payer: Cash Price	$2,504.80

CT Spine Lumbar w/ Contrast

Facility

$3,131.00

Service Code	CPT 72132
Hospital Charge Code	1005219
Hospital Revenue Code	352
Min. Negotiated Rate	$495.95
Max. Negotiated Rate	$2,817.90
Rate for Payer: Aetna of AZ Commercial	$2,817.90
Rate for Payer: Arizona Complete Health Allwell	$500.96
Rate for Payer: Banner UC Health Medicare	$500.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,129.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$500.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$500.96
Rate for Payer: Cash Price	$2,504.80
Rate for Payer: Cash Price	$2,504.80
Rate for Payer: Cigna of AZ Commercial	$2,035.15
Rate for Payer: Devoted Health Medicare	$563.58
Rate for Payer: Humana of AZ Medicare	$500.96
Rate for Payer: Seven Corners Travel Insurance	$539.81
Rate for Payer: Southwest Service Administrators UFCW	$2,129.08
Rate for Payer: TriWest Medicare	$500.96
Rate for Payer: United Healthcare Commercial	$1,790.93
Rate for Payer: United Healthcare Medicare	$500.96
Rate for Payer: Veterans Affairs TRICARE	$495.95

CT Spine Lumbar w/o Contrast

Facility

$2,218.72

Service Code	CPT 72131
Hospital Charge Code	821374
Hospital Revenue Code	352
Min. Negotiated Rate	$1,996.85
Max. Negotiated Rate	$1,996.85
Rate for Payer: Aetna of AZ Commercial	$1,996.85
Rate for Payer: Cash Price	$1,774.98

CT Spine Lumbar w/o Contrast

Facility

$2,218.72

Service Code	CPT 72131
Hospital Charge Code	821374
Hospital Revenue Code	352
Min. Negotiated Rate	$161.76
Max. Negotiated Rate	$1,996.85
Rate for Payer: Aetna of AZ Commercial	$1,996.85
Rate for Payer: Arizona Complete Health Allwell	$355.00
Rate for Payer: Banner UC Health Medicare	$355.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,508.73
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$355.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$355.00
Rate for Payer: Cash Price	$1,774.98
Rate for Payer: Cash Price	$1,774.98
Rate for Payer: Cigna of AZ Commercial	$1,442.17
Rate for Payer: Devoted Health Medicare	$399.37
Rate for Payer: Humana of AZ Medicare	$355.00
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$1,508.73
Rate for Payer: TriWest Medicare	$355.00
Rate for Payer: United Healthcare Commercial	$1,269.11
Rate for Payer: United Healthcare Medicare	$355.00
Rate for Payer: Veterans Affairs TRICARE	$351.45

Know your out-of-pocket cost for care.

All Charges