Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

MRI Face Neck Orbit w/o Contrast

Facility

$3,374.00

Service Code	CPT 70540
Hospital Charge Code	1005420
Hospital Revenue Code	610
Min. Negotiated Rate	$333.68
Max. Negotiated Rate	$3,036.60
Rate for Payer: Aetna of AZ Commercial	$3,036.60
Rate for Payer: Aetna of AZ Medicare	$944.72
Rate for Payer: AHCCCS Medicaid	$333.68
Rate for Payer: Allwell Medicaid	$333.68
Rate for Payer: Allwell Medicare	$506.10
Rate for Payer: Amerigroup Medicare	$506.10
Rate for Payer: APIPA Medicare/Medicaid	$1,260.19
Rate for Payer: AZCH Complete Medicaid	$333.68
Rate for Payer: AZCH Complete Medicare	$506.10
Rate for Payer: Banner UC Health Medicaid	$333.68
Rate for Payer: Banner UC Health Medicare	$506.10
Rate for Payer: Bisbee Police All Plans	$877.24
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,294.32
Rate for Payer: Cash Price	$2,699.20
Rate for Payer: Cash Price	$2,699.20
Rate for Payer: Cigna of AZ Commercial	$2,361.80
Rate for Payer: Copperpoint Commercial	$835.06
Rate for Payer: Health Net of AZ Commercial	$2,024.40
Rate for Payer: Health Net of AZ Medicare	$944.72
Rate for Payer: Humana of AZ Medicare	$506.10
Rate for Payer: Mercy Care Medicaid	$333.68
Rate for Payer: Self Pay Self Pay	$2,699.20
Rate for Payer: TriWest Medicare	$506.10
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,967.04
Rate for Payer: UnitedHealth Group of AZ Medicare	$607.32

MRI Face Neck Orbit w/o Contrast

Facility

$3,374.00

Service Code	CPT 70540
Hospital Charge Code	1005420
Hospital Revenue Code	610
Min. Negotiated Rate	$877.24
Max. Negotiated Rate	$3,036.60
Rate for Payer: Aetna of AZ Commercial	$3,036.60
Rate for Payer: Bisbee Police All Plans	$877.24
Rate for Payer: Cash Price	$2,699.20
Rate for Payer: Self Pay Self Pay	$2,699.20

MRI Face Neck Orbit w/ + w/o Contrast

Facility

$5,122.00

Service Code	CPT 70543
Hospital Charge Code	821406
Hospital Revenue Code	610
Min. Negotiated Rate	$1,331.72
Max. Negotiated Rate	$4,609.80
Rate for Payer: Aetna of AZ Commercial	$4,609.80
Rate for Payer: Bisbee Police All Plans	$1,331.72
Rate for Payer: Cash Price	$4,097.60
Rate for Payer: Self Pay Self Pay	$4,097.60

MRI Face Neck Orbit w/ + w/o Contrast

Facility

$5,122.00

Service Code	CPT 70543
Hospital Charge Code	821406
Hospital Revenue Code	610
Min. Negotiated Rate	$533.78
Max. Negotiated Rate	$4,609.80
Rate for Payer: Aetna of AZ Commercial	$4,609.80
Rate for Payer: Aetna of AZ Medicare	$1,434.16
Rate for Payer: AHCCCS Medicaid	$533.78
Rate for Payer: Allwell Medicaid	$533.78
Rate for Payer: Allwell Medicare	$768.30
Rate for Payer: Amerigroup Medicare	$768.30
Rate for Payer: APIPA Medicare/Medicaid	$1,913.07
Rate for Payer: AZCH Complete Medicaid	$533.78
Rate for Payer: AZCH Complete Medicare	$768.30
Rate for Payer: Banner UC Health Medicaid	$533.78
Rate for Payer: Banner UC Health Medicare	$768.30
Rate for Payer: Bisbee Police All Plans	$1,331.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,482.96
Rate for Payer: Cash Price	$4,097.60
Rate for Payer: Cash Price	$4,097.60
Rate for Payer: Cigna of AZ Commercial	$3,585.40
Rate for Payer: Copperpoint Commercial	$1,267.70
Rate for Payer: Health Net of AZ Commercial	$3,073.20
Rate for Payer: Health Net of AZ Medicare	$1,434.16
Rate for Payer: Humana of AZ Medicare	$768.30
Rate for Payer: Mercy Care Medicaid	$533.78
Rate for Payer: Self Pay Self Pay	$4,097.60
Rate for Payer: TriWest Medicare	$768.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,986.13
Rate for Payer: UnitedHealth Group of AZ Medicare	$921.96

MRI LE Joint w/ Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73722 50
Hospital Charge Code	1287203
Hospital Revenue Code	610
Min. Negotiated Rate	$645.06
Max. Negotiated Rate	$2,232.90
Rate for Payer: Aetna of AZ Commercial	$2,232.90
Rate for Payer: Bisbee Police All Plans	$645.06
Rate for Payer: Cash Price	$1,984.80
Rate for Payer: Self Pay Self Pay	$1,984.80

MRI LE Joint w/ Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73722 50
Hospital Charge Code	1287203
Hospital Revenue Code	610
Min. Negotiated Rate	$372.15
Max. Negotiated Rate	$2,232.90
Rate for Payer: Aetna of AZ Commercial	$2,232.90
Rate for Payer: Aetna of AZ Medicare	$694.68
Rate for Payer: Allwell Medicare	$372.15
Rate for Payer: Amerigroup Medicare	$372.15
Rate for Payer: APIPA Medicare/Medicaid	$926.65
Rate for Payer: AZCH Complete Medicare	$372.15
Rate for Payer: Banner UC Health Medicare	$372.15
Rate for Payer: Bisbee Police All Plans	$645.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,687.08
Rate for Payer: Cash Price	$1,984.80
Rate for Payer: Cigna of AZ Commercial	$1,736.70
Rate for Payer: Copperpoint Commercial	$614.05
Rate for Payer: Health Net of AZ Commercial	$1,488.60
Rate for Payer: Health Net of AZ Medicare	$694.68
Rate for Payer: Humana of AZ Medicare	$372.15
Rate for Payer: Self Pay Self Pay	$1,984.80
Rate for Payer: TriWest Medicare	$372.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,446.42
Rate for Payer: UnitedHealth Group of AZ Medicare	$446.58

MRI LE Joint w/ Contrast Left

Facility

$2,233.00

Service Code	CPT 73722 LT
Hospital Charge Code	1005460
Hospital Revenue Code	610
Min. Negotiated Rate	$334.95
Max. Negotiated Rate	$2,009.70
Rate for Payer: Aetna of AZ Commercial	$2,009.70
Rate for Payer: Aetna of AZ Medicare	$625.24
Rate for Payer: Allwell Medicare	$334.95
Rate for Payer: Amerigroup Medicare	$334.95
Rate for Payer: APIPA Medicare/Medicaid	$834.03
Rate for Payer: AZCH Complete Medicare	$334.95
Rate for Payer: Banner UC Health Medicare	$334.95
Rate for Payer: Bisbee Police All Plans	$580.58
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,518.44
Rate for Payer: Cash Price	$1,786.40
Rate for Payer: Cigna of AZ Commercial	$1,563.10
Rate for Payer: Copperpoint Commercial	$552.67
Rate for Payer: Health Net of AZ Commercial	$1,339.80
Rate for Payer: Health Net of AZ Medicare	$625.24
Rate for Payer: Humana of AZ Medicare	$334.95
Rate for Payer: Self Pay Self Pay	$1,786.40
Rate for Payer: TriWest Medicare	$334.95
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,301.84
Rate for Payer: UnitedHealth Group of AZ Medicare	$401.94

MRI LE Joint w/ Contrast Left

Facility

$2,233.00

Service Code	CPT 73722 LT
Hospital Charge Code	1005460
Hospital Revenue Code	610
Min. Negotiated Rate	$580.58
Max. Negotiated Rate	$2,009.70
Rate for Payer: Aetna of AZ Commercial	$2,009.70
Rate for Payer: Bisbee Police All Plans	$580.58
Rate for Payer: Cash Price	$1,786.40
Rate for Payer: Self Pay Self Pay	$1,786.40

MRI LE Joint w/ Contrast Right

Facility

$2,233.00

Service Code	CPT 73722 RT
Hospital Charge Code	1005462
Hospital Revenue Code	610
Min. Negotiated Rate	$334.95
Max. Negotiated Rate	$2,009.70
Rate for Payer: Aetna of AZ Commercial	$2,009.70
Rate for Payer: Aetna of AZ Medicare	$625.24
Rate for Payer: Allwell Medicare	$334.95
Rate for Payer: Amerigroup Medicare	$334.95
Rate for Payer: APIPA Medicare/Medicaid	$834.03
Rate for Payer: AZCH Complete Medicare	$334.95
Rate for Payer: Banner UC Health Medicare	$334.95
Rate for Payer: Bisbee Police All Plans	$580.58
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,518.44
Rate for Payer: Cash Price	$1,786.40
Rate for Payer: Cigna of AZ Commercial	$1,563.10
Rate for Payer: Copperpoint Commercial	$552.67
Rate for Payer: Health Net of AZ Commercial	$1,339.80
Rate for Payer: Health Net of AZ Medicare	$625.24
Rate for Payer: Humana of AZ Medicare	$334.95
Rate for Payer: Self Pay Self Pay	$1,786.40
Rate for Payer: TriWest Medicare	$334.95
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,301.84
Rate for Payer: UnitedHealth Group of AZ Medicare	$401.94

MRI LE Joint w/ Contrast Right

Facility

$2,233.00

Service Code	CPT 73722 RT
Hospital Charge Code	1005462
Hospital Revenue Code	610
Min. Negotiated Rate	$580.58
Max. Negotiated Rate	$2,009.70
Rate for Payer: Aetna of AZ Commercial	$2,009.70
Rate for Payer: Bisbee Police All Plans	$580.58
Rate for Payer: Cash Price	$1,786.40
Rate for Payer: Self Pay Self Pay	$1,786.40

MRI LE Joint w/o Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73721 50
Hospital Charge Code	821418
Hospital Revenue Code	610
Min. Negotiated Rate	$645.06
Max. Negotiated Rate	$2,232.90
Rate for Payer: Aetna of AZ Commercial	$2,232.90
Rate for Payer: Bisbee Police All Plans	$645.06
Rate for Payer: Cash Price	$1,984.80
Rate for Payer: Self Pay Self Pay	$1,984.80

MRI LE Joint w/o Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73721 50
Hospital Charge Code	821418
Hospital Revenue Code	610
Min. Negotiated Rate	$372.15
Max. Negotiated Rate	$2,232.90
Rate for Payer: Aetna of AZ Commercial	$2,232.90
Rate for Payer: Aetna of AZ Medicare	$694.68
Rate for Payer: Allwell Medicare	$372.15
Rate for Payer: Amerigroup Medicare	$372.15
Rate for Payer: APIPA Medicare/Medicaid	$926.65
Rate for Payer: AZCH Complete Medicare	$372.15
Rate for Payer: Banner UC Health Medicare	$372.15
Rate for Payer: Bisbee Police All Plans	$645.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,687.08
Rate for Payer: Cash Price	$1,984.80
Rate for Payer: Cigna of AZ Commercial	$1,736.70
Rate for Payer: Copperpoint Commercial	$614.05
Rate for Payer: Health Net of AZ Commercial	$1,488.60
Rate for Payer: Health Net of AZ Medicare	$694.68
Rate for Payer: Humana of AZ Medicare	$372.15
Rate for Payer: Self Pay Self Pay	$1,984.80
Rate for Payer: TriWest Medicare	$372.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,446.42
Rate for Payer: UnitedHealth Group of AZ Medicare	$446.58

MRI LE Joint w/o Contrast Left

Facility

$3,243.00

Service Code	CPT 73721 LT
Hospital Charge Code	821420
Hospital Revenue Code	610
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$2,918.70
Rate for Payer: Aetna of AZ Commercial	$2,918.70
Rate for Payer: Aetna of AZ Medicare	$908.04
Rate for Payer: Allwell Medicare	$486.45
Rate for Payer: Amerigroup Medicare	$486.45
Rate for Payer: APIPA Medicare/Medicaid	$1,211.26
Rate for Payer: AZCH Complete Medicare	$486.45
Rate for Payer: Banner UC Health Medicare	$486.45
Rate for Payer: Bisbee Police All Plans	$843.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,205.24
Rate for Payer: Cash Price	$2,594.40
Rate for Payer: Cigna of AZ Commercial	$2,270.10
Rate for Payer: Copperpoint Commercial	$802.64
Rate for Payer: Health Net of AZ Commercial	$1,945.80
Rate for Payer: Health Net of AZ Medicare	$908.04
Rate for Payer: Humana of AZ Medicare	$486.45
Rate for Payer: Self Pay Self Pay	$2,594.40
Rate for Payer: TriWest Medicare	$486.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,890.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$583.74

MRI LE Joint w/o Contrast Left

Facility

$3,243.00

Service Code	CPT 73721 LT
Hospital Charge Code	821420
Hospital Revenue Code	610
Min. Negotiated Rate	$843.18
Max. Negotiated Rate	$2,918.70
Rate for Payer: Aetna of AZ Commercial	$2,918.70
Rate for Payer: Bisbee Police All Plans	$843.18
Rate for Payer: Cash Price	$2,594.40
Rate for Payer: Self Pay Self Pay	$2,594.40

MRI LE Joint w/o Contrast Right

Facility

$3,243.00

Service Code	CPT 73721 RT
Hospital Charge Code	821422
Hospital Revenue Code	610
Min. Negotiated Rate	$486.45
Max. Negotiated Rate	$2,918.70
Rate for Payer: Aetna of AZ Commercial	$2,918.70
Rate for Payer: Aetna of AZ Medicare	$908.04
Rate for Payer: Allwell Medicare	$486.45
Rate for Payer: Amerigroup Medicare	$486.45
Rate for Payer: APIPA Medicare/Medicaid	$1,211.26
Rate for Payer: AZCH Complete Medicare	$486.45
Rate for Payer: Banner UC Health Medicare	$486.45
Rate for Payer: Bisbee Police All Plans	$843.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,205.24
Rate for Payer: Cash Price	$2,594.40
Rate for Payer: Cigna of AZ Commercial	$2,270.10
Rate for Payer: Copperpoint Commercial	$802.64
Rate for Payer: Health Net of AZ Commercial	$1,945.80
Rate for Payer: Health Net of AZ Medicare	$908.04
Rate for Payer: Humana of AZ Medicare	$486.45
Rate for Payer: Self Pay Self Pay	$2,594.40
Rate for Payer: TriWest Medicare	$486.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,890.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$583.74

MRI LE Joint w/o Contrast Right

Facility

$3,243.00

Service Code	CPT 73721 RT
Hospital Charge Code	821422
Hospital Revenue Code	610
Min. Negotiated Rate	$843.18
Max. Negotiated Rate	$2,918.70
Rate for Payer: Aetna of AZ Commercial	$2,918.70
Rate for Payer: Bisbee Police All Plans	$843.18
Rate for Payer: Cash Price	$2,594.40
Rate for Payer: Self Pay Self Pay	$2,594.40

MRI LE Joint w/ + w/o Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73723 50
Hospital Charge Code	1005458
Hospital Revenue Code	610
Min. Negotiated Rate	$372.15
Max. Negotiated Rate	$2,232.90
Rate for Payer: Aetna of AZ Commercial	$2,232.90
Rate for Payer: Aetna of AZ Medicare	$694.68
Rate for Payer: Allwell Medicare	$372.15
Rate for Payer: Amerigroup Medicare	$372.15
Rate for Payer: APIPA Medicare/Medicaid	$926.65
Rate for Payer: AZCH Complete Medicare	$372.15
Rate for Payer: Banner UC Health Medicare	$372.15
Rate for Payer: Bisbee Police All Plans	$645.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,687.08
Rate for Payer: Cash Price	$1,984.80
Rate for Payer: Cigna of AZ Commercial	$1,736.70
Rate for Payer: Copperpoint Commercial	$614.05
Rate for Payer: Health Net of AZ Commercial	$1,488.60
Rate for Payer: Health Net of AZ Medicare	$694.68
Rate for Payer: Humana of AZ Medicare	$372.15
Rate for Payer: Self Pay Self Pay	$1,984.80
Rate for Payer: TriWest Medicare	$372.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,446.42
Rate for Payer: UnitedHealth Group of AZ Medicare	$446.58

MRI LE Joint w/ + w/o Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73723 50
Hospital Charge Code	1005458
Hospital Revenue Code	610
Min. Negotiated Rate	$645.06
Max. Negotiated Rate	$2,232.90
Rate for Payer: Aetna of AZ Commercial	$2,232.90
Rate for Payer: Bisbee Police All Plans	$645.06
Rate for Payer: Cash Price	$1,984.80
Rate for Payer: Self Pay Self Pay	$1,984.80

MRI LE Joint w/ + w/o Contrast Left

Facility

$5,621.00

Service Code	CPT 73723 LT
Hospital Charge Code	821414
Hospital Revenue Code	610
Min. Negotiated Rate	$1,461.46
Max. Negotiated Rate	$5,058.90
Rate for Payer: Aetna of AZ Commercial	$5,058.90
Rate for Payer: Bisbee Police All Plans	$1,461.46
Rate for Payer: Cash Price	$4,496.80
Rate for Payer: Self Pay Self Pay	$4,496.80

MRI LE Joint w/ + w/o Contrast Left

Facility

$5,621.00

Service Code	CPT 73723 LT
Hospital Charge Code	821414
Hospital Revenue Code	610
Min. Negotiated Rate	$843.15
Max. Negotiated Rate	$5,058.90
Rate for Payer: Aetna of AZ Commercial	$5,058.90
Rate for Payer: Aetna of AZ Medicare	$1,573.88
Rate for Payer: Allwell Medicare	$843.15
Rate for Payer: Amerigroup Medicare	$843.15
Rate for Payer: APIPA Medicare/Medicaid	$2,099.44
Rate for Payer: AZCH Complete Medicare	$843.15
Rate for Payer: Banner UC Health Medicare	$843.15
Rate for Payer: Bisbee Police All Plans	$1,461.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,822.28
Rate for Payer: Cash Price	$4,496.80
Rate for Payer: Cigna of AZ Commercial	$3,934.70
Rate for Payer: Copperpoint Commercial	$1,391.20
Rate for Payer: Health Net of AZ Commercial	$3,372.60
Rate for Payer: Health Net of AZ Medicare	$1,573.88
Rate for Payer: Humana of AZ Medicare	$843.15
Rate for Payer: Self Pay Self Pay	$4,496.80
Rate for Payer: TriWest Medicare	$843.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,277.04
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,011.78

MRI LE Joint w/ + w/o Contrast Right

Facility

$5,621.00

Service Code	CPT 73723 RT
Hospital Charge Code	821416
Hospital Revenue Code	610
Min. Negotiated Rate	$843.15
Max. Negotiated Rate	$5,058.90
Rate for Payer: Aetna of AZ Commercial	$5,058.90
Rate for Payer: Aetna of AZ Medicare	$1,573.88
Rate for Payer: Allwell Medicare	$843.15
Rate for Payer: Amerigroup Medicare	$843.15
Rate for Payer: APIPA Medicare/Medicaid	$2,099.44
Rate for Payer: AZCH Complete Medicare	$843.15
Rate for Payer: Banner UC Health Medicare	$843.15
Rate for Payer: Bisbee Police All Plans	$1,461.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,822.28
Rate for Payer: Cash Price	$4,496.80
Rate for Payer: Cigna of AZ Commercial	$3,934.70
Rate for Payer: Copperpoint Commercial	$1,391.20
Rate for Payer: Health Net of AZ Commercial	$3,372.60
Rate for Payer: Health Net of AZ Medicare	$1,573.88
Rate for Payer: Humana of AZ Medicare	$843.15
Rate for Payer: Self Pay Self Pay	$4,496.80
Rate for Payer: TriWest Medicare	$843.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,277.04
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,011.78

MRI LE Joint w/ + w/o Contrast Right

Facility

$5,621.00

Service Code	CPT 73723 RT
Hospital Charge Code	821416
Hospital Revenue Code	610
Min. Negotiated Rate	$1,461.46
Max. Negotiated Rate	$5,058.90
Rate for Payer: Aetna of AZ Commercial	$5,058.90
Rate for Payer: Bisbee Police All Plans	$1,461.46
Rate for Payer: Cash Price	$4,496.80
Rate for Payer: Self Pay Self Pay	$4,496.80

MRI LE Non Joint w/ Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73719 50
Hospital Charge Code	821426
Hospital Revenue Code	610
Min. Negotiated Rate	$645.06
Max. Negotiated Rate	$2,232.90
Rate for Payer: Aetna of AZ Commercial	$2,232.90
Rate for Payer: Bisbee Police All Plans	$645.06
Rate for Payer: Cash Price	$1,984.80
Rate for Payer: Self Pay Self Pay	$1,984.80

MRI LE Non Joint w/ Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73719 50
Hospital Charge Code	821426
Hospital Revenue Code	610
Min. Negotiated Rate	$372.15
Max. Negotiated Rate	$2,232.90
Rate for Payer: Aetna of AZ Commercial	$2,232.90
Rate for Payer: Aetna of AZ Medicare	$694.68
Rate for Payer: Allwell Medicare	$372.15
Rate for Payer: Amerigroup Medicare	$372.15
Rate for Payer: APIPA Medicare/Medicaid	$926.65
Rate for Payer: AZCH Complete Medicare	$372.15
Rate for Payer: Banner UC Health Medicare	$372.15
Rate for Payer: Bisbee Police All Plans	$645.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,687.08
Rate for Payer: Cash Price	$1,984.80
Rate for Payer: Cigna of AZ Commercial	$1,736.70
Rate for Payer: Copperpoint Commercial	$614.05
Rate for Payer: Health Net of AZ Commercial	$1,488.60
Rate for Payer: Health Net of AZ Medicare	$694.68
Rate for Payer: Humana of AZ Medicare	$372.15
Rate for Payer: Self Pay Self Pay	$1,984.80
Rate for Payer: TriWest Medicare	$372.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,446.42
Rate for Payer: UnitedHealth Group of AZ Medicare	$446.58

MRI LE Non Joint w/ Contrast Left

Facility

$2,233.00

Service Code	CPT 73719 LT
Hospital Charge Code	1005468
Hospital Revenue Code	610
Min. Negotiated Rate	$580.58
Max. Negotiated Rate	$2,009.70
Rate for Payer: Aetna of AZ Commercial	$2,009.70
Rate for Payer: Bisbee Police All Plans	$580.58
Rate for Payer: Cash Price	$1,786.40
Rate for Payer: Self Pay Self Pay	$1,786.40

Know your out-of-pocket cost for care.

All Charges