Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

MRI LE Joint w/ + w/o Contrast Left

Facility

$6,115.00

Service Code	CPT 73723 LT
Hospital Charge Code	821414
Hospital Revenue Code	610
Min. Negotiated Rate	$978.40
Max. Negotiated Rate	$5,503.50
Rate for Payer: Aetna of AZ Commercial	$5,503.50
Rate for Payer: Aetna of AZ Medicare	$1,712.20
Rate for Payer: Allwell Medicare	$978.40
Rate for Payer: Amerigroup Medicare	$978.40
Rate for Payer: APIPA Medicare/Medicaid	$2,283.95
Rate for Payer: AZCH Complete Medicare	$978.40
Rate for Payer: Banner UC Health Medicare	$978.40
Rate for Payer: Bisbee Police All Plans	$1,589.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$4,158.20
Rate for Payer: Cash Price	$4,892.00
Rate for Payer: Cigna of AZ Commercial	$4,280.50
Rate for Payer: Copperpoint Commercial	$1,513.46
Rate for Payer: Health Net of AZ Commercial	$3,669.00
Rate for Payer: Health Net of AZ Medicare	$1,712.20
Rate for Payer: Humana of AZ Medicare	$978.40
Rate for Payer: Self Pay Self Pay	$4,892.00
Rate for Payer: TriWest Medicare	$978.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,565.05
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,100.70

MRI LE Joint w/ + w/o Contrast Left

Facility

$6,115.00

Service Code	CPT 73723 LT
Hospital Charge Code	821414
Hospital Revenue Code	610
Min. Negotiated Rate	$1,589.90
Max. Negotiated Rate	$5,503.50
Rate for Payer: Aetna of AZ Commercial	$5,503.50
Rate for Payer: Bisbee Police All Plans	$1,589.90
Rate for Payer: Cash Price	$4,892.00
Rate for Payer: Self Pay Self Pay	$4,892.00

MRI LE Joint w/ + w/o Contrast Right

Facility

$6,115.00

Service Code	CPT 73723 RT
Hospital Charge Code	821416
Hospital Revenue Code	610
Min. Negotiated Rate	$978.40
Max. Negotiated Rate	$5,503.50
Rate for Payer: Aetna of AZ Commercial	$5,503.50
Rate for Payer: Aetna of AZ Medicare	$1,712.20
Rate for Payer: Allwell Medicare	$978.40
Rate for Payer: Amerigroup Medicare	$978.40
Rate for Payer: APIPA Medicare/Medicaid	$2,283.95
Rate for Payer: AZCH Complete Medicare	$978.40
Rate for Payer: Banner UC Health Medicare	$978.40
Rate for Payer: Bisbee Police All Plans	$1,589.90
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$4,158.20
Rate for Payer: Cash Price	$4,892.00
Rate for Payer: Cigna of AZ Commercial	$4,280.50
Rate for Payer: Copperpoint Commercial	$1,513.46
Rate for Payer: Health Net of AZ Commercial	$3,669.00
Rate for Payer: Health Net of AZ Medicare	$1,712.20
Rate for Payer: Humana of AZ Medicare	$978.40
Rate for Payer: Self Pay Self Pay	$4,892.00
Rate for Payer: TriWest Medicare	$978.40
Rate for Payer: UnitedHealth Group of AZ Commercial	$3,565.05
Rate for Payer: UnitedHealth Group of AZ Medicare	$1,100.70

MRI LE Joint w/ + w/o Contrast Right

Facility

$6,115.00

Service Code	CPT 73723 RT
Hospital Charge Code	821416
Hospital Revenue Code	610
Min. Negotiated Rate	$1,589.90
Max. Negotiated Rate	$5,503.50
Rate for Payer: Aetna of AZ Commercial	$5,503.50
Rate for Payer: Bisbee Police All Plans	$1,589.90
Rate for Payer: Cash Price	$4,892.00
Rate for Payer: Self Pay Self Pay	$4,892.00

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	$396.96
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	$396.96
Rate for Payer: Amerigroup Medicare	$396.96
Rate for Payer: APIPA Medicare/Medicaid	$926.65
Rate for Payer: AZCH Complete Medicare	$396.96
Rate for Payer: Banner UC Health Medicare	$396.96
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	$396.96
Rate for Payer: Self Pay Self Pay	$1,984.80
Rate for Payer: TriWest Medicare	$396.96
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	$357.28
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	$357.28
Rate for Payer: Amerigroup Medicare	$357.28
Rate for Payer: APIPA Medicare/Medicaid	$834.03
Rate for Payer: AZCH Complete Medicare	$357.28
Rate for Payer: Banner UC Health Medicare	$357.28
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	$357.28
Rate for Payer: Self Pay Self Pay	$1,786.40
Rate for Payer: TriWest Medicare	$357.28
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 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

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	$357.28
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	$357.28
Rate for Payer: Amerigroup Medicare	$357.28
Rate for Payer: APIPA Medicare/Medicaid	$834.03
Rate for Payer: AZCH Complete Medicare	$357.28
Rate for Payer: Banner UC Health Medicare	$357.28
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	$357.28
Rate for Payer: Self Pay Self Pay	$1,786.40
Rate for Payer: TriWest Medicare	$357.28
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	$396.96
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	$396.96
Rate for Payer: Amerigroup Medicare	$396.96
Rate for Payer: APIPA Medicare/Medicaid	$926.65
Rate for Payer: AZCH Complete Medicare	$396.96
Rate for Payer: Banner UC Health Medicare	$396.96
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	$396.96
Rate for Payer: Self Pay Self Pay	$1,984.80
Rate for Payer: TriWest Medicare	$396.96
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

$3,454.00

Service Code	CPT 73718 LT
Hospital Charge Code	1005472
Hospital Revenue Code	610
Min. Negotiated Rate	$898.04
Max. Negotiated Rate	$3,108.60
Rate for Payer: Aetna of AZ Commercial	$3,108.60
Rate for Payer: Bisbee Police All Plans	$898.04
Rate for Payer: Cash Price	$2,763.20
Rate for Payer: Self Pay Self Pay	$2,763.20

MRI LE Non Joint w/o Contrast Left

Facility

$3,454.00

Service Code	CPT 73718 LT
Hospital Charge Code	1005472
Hospital Revenue Code	610
Min. Negotiated Rate	$552.64
Max. Negotiated Rate	$3,108.60
Rate for Payer: Aetna of AZ Commercial	$3,108.60
Rate for Payer: Aetna of AZ Medicare	$967.12
Rate for Payer: Allwell Medicare	$552.64
Rate for Payer: Amerigroup Medicare	$552.64
Rate for Payer: APIPA Medicare/Medicaid	$1,290.07
Rate for Payer: AZCH Complete Medicare	$552.64
Rate for Payer: Banner UC Health Medicare	$552.64
Rate for Payer: Bisbee Police All Plans	$898.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,348.72
Rate for Payer: Cash Price	$2,763.20
Rate for Payer: Cigna of AZ Commercial	$2,417.80
Rate for Payer: Copperpoint Commercial	$854.87
Rate for Payer: Health Net of AZ Commercial	$2,072.40
Rate for Payer: Health Net of AZ Medicare	$967.12
Rate for Payer: Humana of AZ Medicare	$552.64
Rate for Payer: Self Pay Self Pay	$2,763.20
Rate for Payer: TriWest Medicare	$552.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,013.68
Rate for Payer: UnitedHealth Group of AZ Medicare	$621.72

MRI LE Non Joint w/o Contrast Right

Facility

$3,454.00

Service Code	CPT 73718 RT
Hospital Charge Code	1005474
Hospital Revenue Code	610
Min. Negotiated Rate	$552.64
Max. Negotiated Rate	$3,108.60
Rate for Payer: Aetna of AZ Commercial	$3,108.60
Rate for Payer: Aetna of AZ Medicare	$967.12
Rate for Payer: Allwell Medicare	$552.64
Rate for Payer: Amerigroup Medicare	$552.64
Rate for Payer: APIPA Medicare/Medicaid	$1,290.07
Rate for Payer: AZCH Complete Medicare	$552.64
Rate for Payer: Banner UC Health Medicare	$552.64
Rate for Payer: Bisbee Police All Plans	$898.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,348.72
Rate for Payer: Cash Price	$2,763.20
Rate for Payer: Cigna of AZ Commercial	$2,417.80
Rate for Payer: Copperpoint Commercial	$854.87
Rate for Payer: Health Net of AZ Commercial	$2,072.40
Rate for Payer: Health Net of AZ Medicare	$967.12
Rate for Payer: Humana of AZ Medicare	$552.64
Rate for Payer: Self Pay Self Pay	$2,763.20
Rate for Payer: TriWest Medicare	$552.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,013.68
Rate for Payer: UnitedHealth Group of AZ Medicare	$621.72

MRI LE Non Joint w/o Contrast Right

Facility

$3,454.00

Service Code	CPT 73718 RT
Hospital Charge Code	1005474
Hospital Revenue Code	610
Min. Negotiated Rate	$898.04
Max. Negotiated Rate	$3,108.60
Rate for Payer: Aetna of AZ Commercial	$3,108.60
Rate for Payer: Bisbee Police All Plans	$898.04
Rate for Payer: Cash Price	$2,763.20
Rate for Payer: Self Pay Self Pay	$2,763.20

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 Bilat

Facility

$2,481.00

Service Code	CPT 73720 50
Hospital Charge Code	821424
Hospital Revenue Code	610
Min. Negotiated Rate	$396.96
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	$396.96
Rate for Payer: Amerigroup Medicare	$396.96
Rate for Payer: APIPA Medicare/Medicaid	$926.65
Rate for Payer: AZCH Complete Medicare	$396.96
Rate for Payer: Banner UC Health Medicare	$396.96
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	$396.96
Rate for Payer: Self Pay Self Pay	$1,984.80
Rate for Payer: TriWest Medicare	$396.96
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 Left

Facility

$5,107.00

Service Code	CPT 73720 LT
Hospital Charge Code	1005464
Hospital Revenue Code	610
Min. Negotiated Rate	$1,327.82
Max. Negotiated Rate	$4,596.30
Rate for Payer: Aetna of AZ Commercial	$4,596.30
Rate for Payer: Bisbee Police All Plans	$1,327.82
Rate for Payer: Cash Price	$4,085.60
Rate for Payer: Self Pay Self Pay	$4,085.60

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

Facility

$5,107.00

Service Code	CPT 73720 LT
Hospital Charge Code	1005464
Hospital Revenue Code	610
Min. Negotiated Rate	$817.12
Max. Negotiated Rate	$4,596.30
Rate for Payer: Aetna of AZ Commercial	$4,596.30
Rate for Payer: Aetna of AZ Medicare	$1,429.96
Rate for Payer: Allwell Medicare	$817.12
Rate for Payer: Amerigroup Medicare	$817.12
Rate for Payer: APIPA Medicare/Medicaid	$1,907.46
Rate for Payer: AZCH Complete Medicare	$817.12
Rate for Payer: Banner UC Health Medicare	$817.12
Rate for Payer: Bisbee Police All Plans	$1,327.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,472.76
Rate for Payer: Cash Price	$4,085.60
Rate for Payer: Cigna of AZ Commercial	$3,574.90
Rate for Payer: Copperpoint Commercial	$1,263.98
Rate for Payer: Health Net of AZ Commercial	$3,064.20
Rate for Payer: Health Net of AZ Medicare	$1,429.96
Rate for Payer: Humana of AZ Medicare	$817.12
Rate for Payer: Self Pay Self Pay	$4,085.60
Rate for Payer: TriWest Medicare	$817.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,977.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$919.26

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 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	$818.72
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	$818.72
Rate for Payer: Amerigroup Medicare	$818.72
Rate for Payer: APIPA Medicare/Medicaid	$1,911.20
Rate for Payer: AZCH Complete Medicare	$818.72
Rate for Payer: Banner UC Health Medicare	$818.72
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	$818.72
Rate for Payer: Self Pay Self Pay	$4,093.60
Rate for Payer: TriWest Medicare	$818.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,983.21
Rate for Payer: UnitedHealth Group of AZ Medicare	$921.06

MRI Pelvis w/ Contrast

Facility

$2,233.00

Service Code	CPT 72196
Hospital Charge Code	821432
Hospital Revenue Code	610
Min. Negotiated Rate	$357.28
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	$357.28
Rate for Payer: Amerigroup Medicare	$357.28
Rate for Payer: APIPA Medicare/Medicaid	$834.03
Rate for Payer: AZCH Complete Medicare	$357.28
Rate for Payer: Banner UC Health Medicare	$357.28
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	$357.28
Rate for Payer: Self Pay Self Pay	$1,786.40
Rate for Payer: TriWest Medicare	$357.28
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

$3,461.00

Service Code	CPT 72195
Hospital Charge Code	821434
Hospital Revenue Code	610
Min. Negotiated Rate	$899.86
Max. Negotiated Rate	$3,114.90
Rate for Payer: Aetna of AZ Commercial	$3,114.90
Rate for Payer: Bisbee Police All Plans	$899.86
Rate for Payer: Cash Price	$2,768.80
Rate for Payer: Self Pay Self Pay	$2,768.80

Know your out-of-pocket cost for care.

All Charges