Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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	$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 Non Joint w/ Contrast Right

Facility

$2,233.00

Service Code	CPT 73719 RT
Hospital Charge Code	1005470
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 Non Joint w/ Contrast Right

Facility

$2,233.00

Service Code	CPT 73719 RT
Hospital Charge Code	1005470
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 Non Joint w/o Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73718 50
Hospital Charge Code	821428
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/o Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73718 50
Hospital Charge Code	821428
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/o Contrast Left

Facility

$3,345.00

Service Code	CPT 73718 LT
Hospital Charge Code	1005472
Hospital Revenue Code	610
Min. Negotiated Rate	$501.75
Max. Negotiated Rate	$3,010.50
Rate for Payer: Aetna of AZ Commercial	$3,010.50
Rate for Payer: Aetna of AZ Medicare	$936.60
Rate for Payer: Allwell Medicare	$501.75
Rate for Payer: Amerigroup Medicare	$501.75
Rate for Payer: APIPA Medicare/Medicaid	$1,249.36
Rate for Payer: AZCH Complete Medicare	$501.75
Rate for Payer: Banner UC Health Medicare	$501.75
Rate for Payer: Bisbee Police All Plans	$869.70
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,274.60
Rate for Payer: Cash Price	$2,676.00
Rate for Payer: Cigna of AZ Commercial	$2,341.50
Rate for Payer: Copperpoint Commercial	$827.89
Rate for Payer: Health Net of AZ Commercial	$2,007.00
Rate for Payer: Health Net of AZ Medicare	$936.60
Rate for Payer: Humana of AZ Medicare	$501.75
Rate for Payer: Self Pay Self Pay	$2,676.00
Rate for Payer: TriWest Medicare	$501.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,950.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$602.10

MRI LE Non Joint w/o Contrast Left

Facility

$3,345.00

Service Code	CPT 73718 LT
Hospital Charge Code	1005472
Hospital Revenue Code	610
Min. Negotiated Rate	$869.70
Max. Negotiated Rate	$3,010.50
Rate for Payer: Aetna of AZ Commercial	$3,010.50
Rate for Payer: Bisbee Police All Plans	$869.70
Rate for Payer: Cash Price	$2,676.00
Rate for Payer: Self Pay Self Pay	$2,676.00

MRI LE Non Joint w/o Contrast Right

Facility

$3,345.00

Service Code	CPT 73718 RT
Hospital Charge Code	1005474
Hospital Revenue Code	610
Min. Negotiated Rate	$501.75
Max. Negotiated Rate	$3,010.50
Rate for Payer: Aetna of AZ Commercial	$3,010.50
Rate for Payer: Aetna of AZ Medicare	$936.60
Rate for Payer: Allwell Medicare	$501.75
Rate for Payer: Amerigroup Medicare	$501.75
Rate for Payer: APIPA Medicare/Medicaid	$1,249.36
Rate for Payer: AZCH Complete Medicare	$501.75
Rate for Payer: Banner UC Health Medicare	$501.75
Rate for Payer: Bisbee Police All Plans	$869.70
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,274.60
Rate for Payer: Cash Price	$2,676.00
Rate for Payer: Cigna of AZ Commercial	$2,341.50
Rate for Payer: Copperpoint Commercial	$827.89
Rate for Payer: Health Net of AZ Commercial	$2,007.00
Rate for Payer: Health Net of AZ Medicare	$936.60
Rate for Payer: Humana of AZ Medicare	$501.75
Rate for Payer: Self Pay Self Pay	$2,676.00
Rate for Payer: TriWest Medicare	$501.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,950.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$602.10

MRI LE Non Joint w/o Contrast Right

Facility

$3,345.00

Service Code	CPT 73718 RT
Hospital Charge Code	1005474
Hospital Revenue Code	610
Min. Negotiated Rate	$869.70
Max. Negotiated Rate	$3,010.50
Rate for Payer: Aetna of AZ Commercial	$3,010.50
Rate for Payer: Bisbee Police All Plans	$869.70
Rate for Payer: Cash Price	$2,676.00
Rate for Payer: Self Pay Self Pay	$2,676.00

MRI LE Non Joint w/ + w/o Contrast Bilat

Facility

$2,481.00

Service Code	CPT 73720 50
Hospital Charge Code	821424
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/ + w/o Contrast Bilat

Facility

$2,481.00

Service Code	CPT 73720 50
Hospital Charge Code	821424
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/ + w/o Contrast Left

Facility

$5,117.00

Service Code	CPT 73720 LT
Hospital Charge Code	1005464
Hospital Revenue Code	610
Min. Negotiated Rate	$767.55
Max. Negotiated Rate	$4,605.30
Rate for Payer: Aetna of AZ Commercial	$4,605.30
Rate for Payer: Aetna of AZ Medicare	$1,432.76
Rate for Payer: Allwell Medicare	$767.55
Rate for Payer: Amerigroup Medicare	$767.55
Rate for Payer: APIPA Medicare/Medicaid	$1,911.20
Rate for Payer: AZCH Complete Medicare	$767.55
Rate for Payer: Banner UC Health Medicare	$767.55
Rate for Payer: Bisbee Police All Plans	$1,330.42
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,479.56
Rate for Payer: Cash Price	$4,093.60
Rate for Payer: Cigna of AZ Commercial	$3,581.90
Rate for Payer: Copperpoint Commercial	$1,266.46
Rate for Payer: Health Net of AZ Commercial	$3,070.20
Rate for Payer: Health Net of AZ Medicare	$1,432.76
Rate for Payer: Humana of AZ Medicare	$767.55
Rate for Payer: Self Pay Self Pay	$4,093.60
Rate for Payer: TriWest Medicare	$767.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,983.21
Rate for Payer: UnitedHealth Group of AZ Medicare	$921.06

MRI LE Non Joint w/ + w/o Contrast Left

Facility

$5,117.00

Service Code	CPT 73720 LT
Hospital Charge Code	1005464
Hospital Revenue Code	610
Min. Negotiated Rate	$1,330.42
Max. Negotiated Rate	$4,605.30
Rate for Payer: Aetna of AZ Commercial	$4,605.30
Rate for Payer: Bisbee Police All Plans	$1,330.42
Rate for Payer: Cash Price	$4,093.60
Rate for Payer: Self Pay Self Pay	$4,093.60

MRI LE Non Joint w/ + w/o Contrast Right

Facility

$5,117.00

Service Code	CPT 73720 RT
Hospital Charge Code	1005466
Hospital Revenue Code	610
Min. Negotiated Rate	$767.55
Max. Negotiated Rate	$4,605.30
Rate for Payer: Aetna of AZ Commercial	$4,605.30
Rate for Payer: Aetna of AZ Medicare	$1,432.76
Rate for Payer: Allwell Medicare	$767.55
Rate for Payer: Amerigroup Medicare	$767.55
Rate for Payer: APIPA Medicare/Medicaid	$1,911.20
Rate for Payer: AZCH Complete Medicare	$767.55
Rate for Payer: Banner UC Health Medicare	$767.55
Rate for Payer: Bisbee Police All Plans	$1,330.42
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,479.56
Rate for Payer: Cash Price	$4,093.60
Rate for Payer: Cigna of AZ Commercial	$3,581.90
Rate for Payer: Copperpoint Commercial	$1,266.46
Rate for Payer: Health Net of AZ Commercial	$3,070.20
Rate for Payer: Health Net of AZ Medicare	$1,432.76
Rate for Payer: Humana of AZ Medicare	$767.55
Rate for Payer: Self Pay Self Pay	$4,093.60
Rate for Payer: TriWest Medicare	$767.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,983.21
Rate for Payer: UnitedHealth Group of AZ Medicare	$921.06

MRI LE Non Joint w/ + w/o Contrast Right

Facility

$5,117.00

Service Code	CPT 73720 RT
Hospital Charge Code	1005466
Hospital Revenue Code	610
Min. Negotiated Rate	$1,330.42
Max. Negotiated Rate	$4,605.30
Rate for Payer: Aetna of AZ Commercial	$4,605.30
Rate for Payer: Bisbee Police All Plans	$1,330.42
Rate for Payer: Cash Price	$4,093.60
Rate for Payer: Self Pay Self Pay	$4,093.60

MRI Pelvis w/ Contrast

Facility

$2,233.00

Service Code	CPT 72196
Hospital Charge Code	821432
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: AHCCCS Medicaid	$533.78
Rate for Payer: Allwell Medicaid	$533.78
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 Medicaid	$533.78
Rate for Payer: AZCH Complete Medicare	$334.95
Rate for Payer: Banner UC Health Medicaid	$533.78
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: 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: Mercy Care Medicaid	$533.78
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 Pelvis w/ Contrast

Facility

$2,233.00

Service Code	CPT 72196
Hospital Charge Code	821432
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 Pelvis w/o Contrast

Facility

$3,537.00

Service Code	CPT 72195
Hospital Charge Code	821434
Hospital Revenue Code	610
Min. Negotiated Rate	$333.68
Max. Negotiated Rate	$3,183.30
Rate for Payer: Aetna of AZ Commercial	$3,183.30
Rate for Payer: Aetna of AZ Medicare	$990.36
Rate for Payer: AHCCCS Medicaid	$333.68
Rate for Payer: Allwell Medicaid	$333.68
Rate for Payer: Allwell Medicare	$530.55
Rate for Payer: Amerigroup Medicare	$530.55
Rate for Payer: APIPA Medicare/Medicaid	$1,321.07
Rate for Payer: AZCH Complete Medicaid	$333.68
Rate for Payer: AZCH Complete Medicare	$530.55
Rate for Payer: Banner UC Health Medicaid	$333.68
Rate for Payer: Banner UC Health Medicare	$530.55
Rate for Payer: Bisbee Police All Plans	$919.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,405.16
Rate for Payer: Cash Price	$2,829.60
Rate for Payer: Cash Price	$2,829.60
Rate for Payer: Cigna of AZ Commercial	$2,475.90
Rate for Payer: Copperpoint Commercial	$875.41
Rate for Payer: Health Net of AZ Commercial	$2,122.20
Rate for Payer: Health Net of AZ Medicare	$990.36
Rate for Payer: Humana of AZ Medicare	$530.55
Rate for Payer: Mercy Care Medicaid	$333.68
Rate for Payer: Self Pay Self Pay	$2,829.60
Rate for Payer: TriWest Medicare	$530.55
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,062.07
Rate for Payer: UnitedHealth Group of AZ Medicare	$636.66

MRI Pelvis w/o Contrast

Facility

$3,537.00

Service Code	CPT 72195
Hospital Charge Code	821434
Hospital Revenue Code	610
Min. Negotiated Rate	$919.62
Max. Negotiated Rate	$3,183.30
Rate for Payer: Aetna of AZ Commercial	$3,183.30
Rate for Payer: Bisbee Police All Plans	$919.62
Rate for Payer: Cash Price	$2,829.60
Rate for Payer: Self Pay Self Pay	$2,829.60

MRI Pelvis w/ + w/o Contrast

Facility

$5,118.00

Service Code	CPT 72197
Hospital Charge Code	1005497
Hospital Revenue Code	610
Min. Negotiated Rate	$1,330.68
Max. Negotiated Rate	$4,606.20
Rate for Payer: Aetna of AZ Commercial	$4,606.20
Rate for Payer: Bisbee Police All Plans	$1,330.68
Rate for Payer: Cash Price	$4,094.40
Rate for Payer: Self Pay Self Pay	$4,094.40

MRI Pelvis w/ + w/o Contrast

Facility

$5,118.00

Service Code	CPT 72197
Hospital Charge Code	1005497
Hospital Revenue Code	610
Min. Negotiated Rate	$533.78
Max. Negotiated Rate	$4,606.20
Rate for Payer: Aetna of AZ Commercial	$4,606.20
Rate for Payer: Aetna of AZ Medicare	$1,433.04
Rate for Payer: AHCCCS Medicaid	$533.78
Rate for Payer: Allwell Medicaid	$533.78
Rate for Payer: Allwell Medicare	$767.70
Rate for Payer: Amerigroup Medicare	$767.70
Rate for Payer: APIPA Medicare/Medicaid	$1,911.57
Rate for Payer: AZCH Complete Medicaid	$533.78
Rate for Payer: AZCH Complete Medicare	$767.70
Rate for Payer: Banner UC Health Medicaid	$533.78
Rate for Payer: Banner UC Health Medicare	$767.70
Rate for Payer: Bisbee Police All Plans	$1,330.68
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,480.24
Rate for Payer: Cash Price	$4,094.40
Rate for Payer: Cash Price	$4,094.40
Rate for Payer: Cigna of AZ Commercial	$3,582.60
Rate for Payer: Copperpoint Commercial	$1,266.70
Rate for Payer: Health Net of AZ Commercial	$3,070.80
Rate for Payer: Health Net of AZ Medicare	$1,433.04
Rate for Payer: Humana of AZ Medicare	$767.70
Rate for Payer: Mercy Care Medicaid	$533.78
Rate for Payer: Self Pay Self Pay	$4,094.40
Rate for Payer: TriWest Medicare	$767.70
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,983.79
Rate for Payer: UnitedHealth Group of AZ Medicare	$921.24

MRI Sacrum w/o Contrast

Facility

$1,985.00

Service Code	CPT 72195
Hospital Charge Code	1397668
Hospital Revenue Code	610
Min. Negotiated Rate	$516.10
Max. Negotiated Rate	$1,786.50
Rate for Payer: Aetna of AZ Commercial	$1,786.50
Rate for Payer: Bisbee Police All Plans	$516.10
Rate for Payer: Cash Price	$1,588.00
Rate for Payer: Self Pay Self Pay	$1,588.00

MRI Sacrum w/o Contrast

Facility

$1,985.00

Service Code	CPT 72195
Hospital Charge Code	1397668
Hospital Revenue Code	610
Min. Negotiated Rate	$297.75
Max. Negotiated Rate	$1,786.50
Rate for Payer: Aetna of AZ Commercial	$1,786.50
Rate for Payer: Aetna of AZ Medicare	$555.80
Rate for Payer: AHCCCS Medicaid	$333.68
Rate for Payer: Allwell Medicaid	$333.68
Rate for Payer: Allwell Medicare	$297.75
Rate for Payer: Amerigroup Medicare	$297.75
Rate for Payer: APIPA Medicare/Medicaid	$741.40
Rate for Payer: AZCH Complete Medicaid	$333.68
Rate for Payer: AZCH Complete Medicare	$297.75
Rate for Payer: Banner UC Health Medicaid	$333.68
Rate for Payer: Banner UC Health Medicare	$297.75
Rate for Payer: Bisbee Police All Plans	$516.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,349.80
Rate for Payer: Cash Price	$1,588.00
Rate for Payer: Cash Price	$1,588.00
Rate for Payer: Cigna of AZ Commercial	$1,389.50
Rate for Payer: Copperpoint Commercial	$491.29
Rate for Payer: Health Net of AZ Commercial	$1,191.00
Rate for Payer: Health Net of AZ Medicare	$555.80
Rate for Payer: Humana of AZ Medicare	$297.75
Rate for Payer: Mercy Care Medicaid	$333.68
Rate for Payer: Self Pay Self Pay	$1,588.00
Rate for Payer: TriWest Medicare	$297.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,157.26
Rate for Payer: UnitedHealth Group of AZ Medicare	$357.30

MRI Sinus w/o Contrast

Facility

$1,985.00

Service Code	CPT 70540
Hospital Charge Code	1779815
Hospital Revenue Code	610
Min. Negotiated Rate	$516.10
Max. Negotiated Rate	$1,786.50
Rate for Payer: Aetna of AZ Commercial	$1,786.50
Rate for Payer: Bisbee Police All Plans	$516.10
Rate for Payer: Cash Price	$1,588.00
Rate for Payer: Self Pay Self Pay	$1,588.00

MRI Sinus w/o Contrast

Facility

$1,985.00

Service Code	CPT 70540
Hospital Charge Code	1779815
Hospital Revenue Code	610
Min. Negotiated Rate	$297.75
Max. Negotiated Rate	$1,786.50
Rate for Payer: Aetna of AZ Commercial	$1,786.50
Rate for Payer: Aetna of AZ Medicare	$555.80
Rate for Payer: AHCCCS Medicaid	$333.68
Rate for Payer: Allwell Medicaid	$333.68
Rate for Payer: Allwell Medicare	$297.75
Rate for Payer: Amerigroup Medicare	$297.75
Rate for Payer: APIPA Medicare/Medicaid	$741.40
Rate for Payer: AZCH Complete Medicaid	$333.68
Rate for Payer: AZCH Complete Medicare	$297.75
Rate for Payer: Banner UC Health Medicaid	$333.68
Rate for Payer: Banner UC Health Medicare	$297.75
Rate for Payer: Bisbee Police All Plans	$516.10
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,349.80
Rate for Payer: Cash Price	$1,588.00
Rate for Payer: Cash Price	$1,588.00
Rate for Payer: Cigna of AZ Commercial	$1,389.50
Rate for Payer: Copperpoint Commercial	$491.29
Rate for Payer: Health Net of AZ Commercial	$1,191.00
Rate for Payer: Health Net of AZ Medicare	$555.80
Rate for Payer: Humana of AZ Medicare	$297.75
Rate for Payer: Mercy Care Medicaid	$333.68
Rate for Payer: Self Pay Self Pay	$1,588.00
Rate for Payer: TriWest Medicare	$297.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,157.26
Rate for Payer: UnitedHealth Group of AZ Medicare	$357.30

Know your out-of-pocket cost for care.

All Charges