Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

MRI Pelvis w/o Contrast

Facility

$3,461.00

Service Code	CPT 72195
Hospital Charge Code	821434
Hospital Revenue Code	610
Min. Negotiated Rate	$553.76
Max. Negotiated Rate	$3,114.90
Rate for Payer: Aetna of AZ Commercial	$3,114.90
Rate for Payer: Aetna of AZ Medicare	$969.08
Rate for Payer: Allwell Medicare	$553.76
Rate for Payer: Amerigroup Medicare	$553.76
Rate for Payer: APIPA Medicare/Medicaid	$1,292.68
Rate for Payer: AZCH Complete Medicare	$553.76
Rate for Payer: Banner UC Health Medicare	$553.76
Rate for Payer: Bisbee Police All Plans	$899.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,353.48
Rate for Payer: Cash Price	$2,768.80
Rate for Payer: Cigna of AZ Commercial	$2,422.70
Rate for Payer: Copperpoint Commercial	$856.60
Rate for Payer: Health Net of AZ Commercial	$2,076.60
Rate for Payer: Health Net of AZ Medicare	$969.08
Rate for Payer: Humana of AZ Medicare	$553.76
Rate for Payer: Self Pay Self Pay	$2,768.80
Rate for Payer: TriWest Medicare	$553.76
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,017.76
Rate for Payer: UnitedHealth Group of AZ Medicare	$622.98

MRI Pelvis w/ + w/o Contrast

Facility

$5,057.00

Service Code	CPT 72197
Hospital Charge Code	1005497
Hospital Revenue Code	610
Min. Negotiated Rate	$1,314.82
Max. Negotiated Rate	$4,551.30
Rate for Payer: Aetna of AZ Commercial	$4,551.30
Rate for Payer: Bisbee Police All Plans	$1,314.82
Rate for Payer: Cash Price	$4,045.60
Rate for Payer: Self Pay Self Pay	$4,045.60

MRI Pelvis w/ + w/o Contrast

Facility

$5,057.00

Service Code	CPT 72197
Hospital Charge Code	1005497
Hospital Revenue Code	610
Min. Negotiated Rate	$809.12
Max. Negotiated Rate	$4,551.30
Rate for Payer: Aetna of AZ Commercial	$4,551.30
Rate for Payer: Aetna of AZ Medicare	$1,415.96
Rate for Payer: Allwell Medicare	$809.12
Rate for Payer: Amerigroup Medicare	$809.12
Rate for Payer: APIPA Medicare/Medicaid	$1,888.79
Rate for Payer: AZCH Complete Medicare	$809.12
Rate for Payer: Banner UC Health Medicare	$809.12
Rate for Payer: Bisbee Police All Plans	$1,314.82
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,438.76
Rate for Payer: Cash Price	$4,045.60
Rate for Payer: Cigna of AZ Commercial	$3,539.90
Rate for Payer: Copperpoint Commercial	$1,251.61
Rate for Payer: Health Net of AZ Commercial	$3,034.20
Rate for Payer: Health Net of AZ Medicare	$1,415.96
Rate for Payer: Humana of AZ Medicare	$809.12
Rate for Payer: Self Pay Self Pay	$4,045.60
Rate for Payer: TriWest Medicare	$809.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,948.23
Rate for Payer: UnitedHealth Group of AZ Medicare	$910.26

MRI Sacrum w/o Contrast

Facility

$2,680.00

Service Code	CPT 72195
Hospital Charge Code	1397668
Hospital Revenue Code	610
Min. Negotiated Rate	$428.80
Max. Negotiated Rate	$2,412.00
Rate for Payer: Aetna of AZ Commercial	$2,412.00
Rate for Payer: Aetna of AZ Medicare	$750.40
Rate for Payer: Allwell Medicare	$428.80
Rate for Payer: Amerigroup Medicare	$428.80
Rate for Payer: APIPA Medicare/Medicaid	$1,000.98
Rate for Payer: AZCH Complete Medicare	$428.80
Rate for Payer: Banner UC Health Medicare	$428.80
Rate for Payer: Bisbee Police All Plans	$696.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,822.40
Rate for Payer: Cash Price	$2,144.00
Rate for Payer: Cigna of AZ Commercial	$1,876.00
Rate for Payer: Copperpoint Commercial	$663.30
Rate for Payer: Health Net of AZ Commercial	$1,608.00
Rate for Payer: Health Net of AZ Medicare	$750.40
Rate for Payer: Humana of AZ Medicare	$428.80
Rate for Payer: Self Pay Self Pay	$2,144.00
Rate for Payer: TriWest Medicare	$428.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,562.44
Rate for Payer: UnitedHealth Group of AZ Medicare	$482.40

MRI Sacrum w/o Contrast

Facility

$2,680.00

Service Code	CPT 72195
Hospital Charge Code	1397668
Hospital Revenue Code	610
Min. Negotiated Rate	$696.80
Max. Negotiated Rate	$2,412.00
Rate for Payer: Aetna of AZ Commercial	$2,412.00
Rate for Payer: Bisbee Police All Plans	$696.80
Rate for Payer: Cash Price	$2,144.00
Rate for Payer: Self Pay Self Pay	$2,144.00

MRI Sinus w/o Contrast

Facility

$1,985.00

Service Code	CPT 70540
Hospital Charge Code	1779815
Hospital Revenue Code	610
Min. Negotiated Rate	$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	$317.60
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: Allwell Medicare	$317.60
Rate for Payer: Amerigroup Medicare	$317.60
Rate for Payer: APIPA Medicare/Medicaid	$741.40
Rate for Payer: AZCH Complete Medicare	$317.60
Rate for Payer: Banner UC Health Medicare	$317.60
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: 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	$317.60
Rate for Payer: Self Pay Self Pay	$1,588.00
Rate for Payer: TriWest Medicare	$317.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,157.26
Rate for Payer: UnitedHealth Group of AZ Medicare	$357.30

MRI Sinus w/ + w/o Contrast

Facility

$2,481.00

Service Code	CPT 70543
Hospital Charge Code	1779809
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 Sinus w/ + w/o Contrast

Facility

$2,481.00

Service Code	CPT 70543
Hospital Charge Code	1779809
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 Spine Cervical w/o Contrast

Facility

$2,986.00

Service Code	CPT 72141
Hospital Charge Code	821441
Hospital Revenue Code	612
Min. Negotiated Rate	$477.76
Max. Negotiated Rate	$2,687.40
Rate for Payer: Aetna of AZ Commercial	$2,687.40
Rate for Payer: Aetna of AZ Medicare	$836.08
Rate for Payer: Allwell Medicare	$477.76
Rate for Payer: Amerigroup Medicare	$477.76
Rate for Payer: APIPA Medicare/Medicaid	$1,115.27
Rate for Payer: AZCH Complete Medicare	$477.76
Rate for Payer: Banner UC Health Medicare	$477.76
Rate for Payer: Bisbee Police All Plans	$776.36
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,030.48
Rate for Payer: Cash Price	$2,388.80
Rate for Payer: Cigna of AZ Commercial	$2,090.20
Rate for Payer: Copperpoint Commercial	$739.03
Rate for Payer: Health Net of AZ Commercial	$1,791.60
Rate for Payer: Health Net of AZ Medicare	$836.08
Rate for Payer: Humana of AZ Medicare	$477.76
Rate for Payer: Self Pay Self Pay	$2,388.80
Rate for Payer: TriWest Medicare	$477.76
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,740.84
Rate for Payer: UnitedHealth Group of AZ Medicare	$537.48

MRI Spine Cervical w/o Contrast

Facility

$2,986.00

Service Code	CPT 72141
Hospital Charge Code	821441
Hospital Revenue Code	612
Min. Negotiated Rate	$776.36
Max. Negotiated Rate	$2,687.40
Rate for Payer: Aetna of AZ Commercial	$2,687.40
Rate for Payer: Bisbee Police All Plans	$776.36
Rate for Payer: Cash Price	$2,388.80
Rate for Payer: Self Pay Self Pay	$2,388.80

MRI Spine Cervical w/ + w/o Contrast

Facility

$4,603.00

Service Code	CPT 72156
Hospital Charge Code	1005501
Hospital Revenue Code	612
Min. Negotiated Rate	$736.48
Max. Negotiated Rate	$4,142.70
Rate for Payer: Aetna of AZ Commercial	$4,142.70
Rate for Payer: Aetna of AZ Medicare	$1,288.84
Rate for Payer: Allwell Medicare	$736.48
Rate for Payer: Amerigroup Medicare	$736.48
Rate for Payer: APIPA Medicare/Medicaid	$1,719.22
Rate for Payer: AZCH Complete Medicare	$736.48
Rate for Payer: Banner UC Health Medicare	$736.48
Rate for Payer: Bisbee Police All Plans	$1,196.78
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,130.04
Rate for Payer: Cash Price	$3,682.40
Rate for Payer: Cigna of AZ Commercial	$3,222.10
Rate for Payer: Copperpoint Commercial	$1,139.24
Rate for Payer: Health Net of AZ Commercial	$2,761.80
Rate for Payer: Health Net of AZ Medicare	$1,288.84
Rate for Payer: Humana of AZ Medicare	$736.48
Rate for Payer: Self Pay Self Pay	$3,682.40
Rate for Payer: TriWest Medicare	$736.48
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,683.55
Rate for Payer: UnitedHealth Group of AZ Medicare	$828.54

MRI Spine Cervical w/ + w/o Contrast

Facility

$4,603.00

Service Code	CPT 72156
Hospital Charge Code	1005501
Hospital Revenue Code	612
Min. Negotiated Rate	$1,196.78
Max. Negotiated Rate	$4,142.70
Rate for Payer: Aetna of AZ Commercial	$4,142.70
Rate for Payer: Bisbee Police All Plans	$1,196.78
Rate for Payer: Cash Price	$3,682.40
Rate for Payer: Self Pay Self Pay	$3,682.40

MRI Spine Lumbar w/ Contrast

Facility

$2,233.00

Service Code	CPT 72149
Hospital Charge Code	821443
Hospital Revenue Code	612
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 Spine Lumbar w/ Contrast

Facility

$2,233.00

Service Code	CPT 72149
Hospital Charge Code	821443
Hospital Revenue Code	612
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 Spine Lumbar w/o Contrast

Facility

$2,989.00

Service Code	CPT 72148
Hospital Charge Code	821445
Hospital Revenue Code	612
Min. Negotiated Rate	$478.24
Max. Negotiated Rate	$2,690.10
Rate for Payer: Aetna of AZ Commercial	$2,690.10
Rate for Payer: Aetna of AZ Medicare	$836.92
Rate for Payer: Allwell Medicare	$478.24
Rate for Payer: Amerigroup Medicare	$478.24
Rate for Payer: APIPA Medicare/Medicaid	$1,116.39
Rate for Payer: AZCH Complete Medicare	$478.24
Rate for Payer: Banner UC Health Medicare	$478.24
Rate for Payer: Bisbee Police All Plans	$777.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,032.52
Rate for Payer: Cash Price	$2,391.20
Rate for Payer: Cigna of AZ Commercial	$2,092.30
Rate for Payer: Copperpoint Commercial	$739.78
Rate for Payer: Health Net of AZ Commercial	$1,793.40
Rate for Payer: Health Net of AZ Medicare	$836.92
Rate for Payer: Humana of AZ Medicare	$478.24
Rate for Payer: Self Pay Self Pay	$2,391.20
Rate for Payer: TriWest Medicare	$478.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,742.59
Rate for Payer: UnitedHealth Group of AZ Medicare	$538.02

MRI Spine Lumbar w/o Contrast

Facility

$2,989.00

Service Code	CPT 72148
Hospital Charge Code	821445
Hospital Revenue Code	612
Min. Negotiated Rate	$777.14
Max. Negotiated Rate	$2,690.10
Rate for Payer: Aetna of AZ Commercial	$2,690.10
Rate for Payer: Bisbee Police All Plans	$777.14
Rate for Payer: Cash Price	$2,391.20
Rate for Payer: Self Pay Self Pay	$2,391.20

MRI Spine Lumbar w/ + w/o Contrast

Facility

$4,589.00

Service Code	CPT 72158
Hospital Charge Code	1005503
Hospital Revenue Code	612
Min. Negotiated Rate	$734.24
Max. Negotiated Rate	$4,130.10
Rate for Payer: Aetna of AZ Commercial	$4,130.10
Rate for Payer: Aetna of AZ Medicare	$1,284.92
Rate for Payer: Allwell Medicare	$734.24
Rate for Payer: Amerigroup Medicare	$734.24
Rate for Payer: APIPA Medicare/Medicaid	$1,713.99
Rate for Payer: AZCH Complete Medicare	$734.24
Rate for Payer: Banner UC Health Medicare	$734.24
Rate for Payer: Bisbee Police All Plans	$1,193.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,120.52
Rate for Payer: Cash Price	$3,671.20
Rate for Payer: Cigna of AZ Commercial	$3,212.30
Rate for Payer: Copperpoint Commercial	$1,135.78
Rate for Payer: Health Net of AZ Commercial	$2,753.40
Rate for Payer: Health Net of AZ Medicare	$1,284.92
Rate for Payer: Humana of AZ Medicare	$734.24
Rate for Payer: Self Pay Self Pay	$3,671.20
Rate for Payer: TriWest Medicare	$734.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,675.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$826.02

MRI Spine Lumbar w/ + w/o Contrast

Facility

$4,589.00

Service Code	CPT 72158
Hospital Charge Code	1005503
Hospital Revenue Code	612
Min. Negotiated Rate	$1,193.14
Max. Negotiated Rate	$4,130.10
Rate for Payer: Aetna of AZ Commercial	$4,130.10
Rate for Payer: Bisbee Police All Plans	$1,193.14
Rate for Payer: Cash Price	$3,671.20
Rate for Payer: Self Pay Self Pay	$3,671.20

MRI Spine Thoracic w/ Contrast

Facility

$4,617.00

Service Code	CPT 72157
Hospital Charge Code	821447
Hospital Revenue Code	612
Min. Negotiated Rate	$738.72
Max. Negotiated Rate	$4,155.30
Rate for Payer: Aetna of AZ Commercial	$4,155.30
Rate for Payer: Aetna of AZ Medicare	$1,292.76
Rate for Payer: Allwell Medicare	$738.72
Rate for Payer: Amerigroup Medicare	$738.72
Rate for Payer: APIPA Medicare/Medicaid	$1,724.45
Rate for Payer: AZCH Complete Medicare	$738.72
Rate for Payer: Banner UC Health Medicare	$738.72
Rate for Payer: Bisbee Police All Plans	$1,200.42
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,139.56
Rate for Payer: Cash Price	$3,693.60
Rate for Payer: Cigna of AZ Commercial	$3,231.90
Rate for Payer: Copperpoint Commercial	$1,142.71
Rate for Payer: Health Net of AZ Commercial	$2,770.20
Rate for Payer: Health Net of AZ Medicare	$1,292.76
Rate for Payer: Humana of AZ Medicare	$738.72
Rate for Payer: Self Pay Self Pay	$3,693.60
Rate for Payer: TriWest Medicare	$738.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,691.71
Rate for Payer: UnitedHealth Group of AZ Medicare	$831.06

MRI Spine Thoracic w/ Contrast

Facility

$4,617.00

Service Code	CPT 72157
Hospital Charge Code	821447
Hospital Revenue Code	612
Min. Negotiated Rate	$1,200.42
Max. Negotiated Rate	$4,155.30
Rate for Payer: Aetna of AZ Commercial	$4,155.30
Rate for Payer: Bisbee Police All Plans	$1,200.42
Rate for Payer: Cash Price	$3,693.60
Rate for Payer: Self Pay Self Pay	$3,693.60

MRI Spine Thoracic w/o Contrast

Facility

$2,983.00

Service Code	CPT 72146
Hospital Charge Code	821449
Hospital Revenue Code	612
Min. Negotiated Rate	$477.28
Max. Negotiated Rate	$2,684.70
Rate for Payer: Aetna of AZ Commercial	$2,684.70
Rate for Payer: Aetna of AZ Medicare	$835.24
Rate for Payer: Allwell Medicare	$477.28
Rate for Payer: Amerigroup Medicare	$477.28
Rate for Payer: APIPA Medicare/Medicaid	$1,114.15
Rate for Payer: AZCH Complete Medicare	$477.28
Rate for Payer: Banner UC Health Medicare	$477.28
Rate for Payer: Bisbee Police All Plans	$775.58
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,028.44
Rate for Payer: Cash Price	$2,386.40
Rate for Payer: Cigna of AZ Commercial	$2,088.10
Rate for Payer: Copperpoint Commercial	$738.29
Rate for Payer: Health Net of AZ Commercial	$1,789.80
Rate for Payer: Health Net of AZ Medicare	$835.24
Rate for Payer: Humana of AZ Medicare	$477.28
Rate for Payer: Self Pay Self Pay	$2,386.40
Rate for Payer: TriWest Medicare	$477.28
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,739.09
Rate for Payer: UnitedHealth Group of AZ Medicare	$536.94

MRI Spine Thoracic w/o Contrast

Facility

$2,983.00

Service Code	CPT 72146
Hospital Charge Code	821449
Hospital Revenue Code	612
Min. Negotiated Rate	$775.58
Max. Negotiated Rate	$2,684.70
Rate for Payer: Aetna of AZ Commercial	$2,684.70
Rate for Payer: Bisbee Police All Plans	$775.58
Rate for Payer: Cash Price	$2,386.40
Rate for Payer: Self Pay Self Pay	$2,386.40

MRI Spine Thoracic w/ + w/o Contrast

Facility

$4,811.00

Service Code	CPT 72157
Hospital Charge Code	1005505
Hospital Revenue Code	612
Min. Negotiated Rate	$769.76
Max. Negotiated Rate	$4,329.90
Rate for Payer: Aetna of AZ Commercial	$4,329.90
Rate for Payer: Aetna of AZ Medicare	$1,347.08
Rate for Payer: Allwell Medicare	$769.76
Rate for Payer: Amerigroup Medicare	$769.76
Rate for Payer: APIPA Medicare/Medicaid	$1,796.91
Rate for Payer: AZCH Complete Medicare	$769.76
Rate for Payer: Banner UC Health Medicare	$769.76
Rate for Payer: Bisbee Police All Plans	$1,250.86
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,271.48
Rate for Payer: Cash Price	$3,848.80
Rate for Payer: Cigna of AZ Commercial	$3,367.70
Rate for Payer: Copperpoint Commercial	$1,190.72
Rate for Payer: Health Net of AZ Commercial	$2,886.60
Rate for Payer: Health Net of AZ Medicare	$1,347.08
Rate for Payer: Humana of AZ Medicare	$769.76
Rate for Payer: Self Pay Self Pay	$3,848.80
Rate for Payer: TriWest Medicare	$769.76
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,804.81
Rate for Payer: UnitedHealth Group of AZ Medicare	$865.98

MRI Spine Thoracic w/ + w/o Contrast

Facility

$4,811.00

Service Code	CPT 72157
Hospital Charge Code	1005505
Hospital Revenue Code	612
Min. Negotiated Rate	$1,250.86
Max. Negotiated Rate	$4,329.90
Rate for Payer: Aetna of AZ Commercial	$4,329.90
Rate for Payer: Bisbee Police All Plans	$1,250.86
Rate for Payer: Cash Price	$3,848.80
Rate for Payer: Self Pay Self Pay	$3,848.80

Know your out-of-pocket cost for care.

All Charges