Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

MRI Chest w/o Contrast

Facility

$2,553.00

Service Code	CPT 71550
Hospital Charge Code	1005415
Hospital Revenue Code	610
Min. Negotiated Rate	$2,297.70
Max. Negotiated Rate	$2,297.70
Rate for Payer: Aetna of AZ Commercial	$2,297.70
Rate for Payer: Cash Price	$2,042.40

MRI Chest w/ + w/o Contrast

Facility

$2,363.00

Service Code	CPT 71552
Hospital Charge Code	821404
Hospital Revenue Code	610
Min. Negotiated Rate	$2,126.70
Max. Negotiated Rate	$2,126.70
Rate for Payer: Aetna of AZ Commercial	$2,126.70
Rate for Payer: Cash Price	$1,890.40

MRI Chest w/ + w/o Contrast

Facility

$2,363.00

Service Code	CPT 71552
Hospital Charge Code	821404
Hospital Revenue Code	610
Min. Negotiated Rate	$374.30
Max. Negotiated Rate	$2,126.70
Rate for Payer: Aetna of AZ Commercial	$2,126.70
Rate for Payer: Arizona Complete Health Allwell	$378.08
Rate for Payer: Banner UC Health Medicare	$378.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,606.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$378.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$378.08
Rate for Payer: Cash Price	$1,890.40
Rate for Payer: Cash Price	$1,890.40
Rate for Payer: Cigna of AZ Commercial	$1,654.10
Rate for Payer: Devoted Health Medicare	$425.34
Rate for Payer: Humana of AZ Medicare	$378.08
Rate for Payer: Seven Corners Travel Insurance	$539.81
Rate for Payer: Southwest Service Administrators UFCW	$1,606.84
Rate for Payer: TriWest Medicare	$378.08
Rate for Payer: United Healthcare Commercial	$1,351.64
Rate for Payer: United Healthcare Medicare	$378.08
Rate for Payer: United Healthcare New Mexico Commercial	$448.97
Rate for Payer: Veterans Affairs TRICARE	$374.30

MRI Face Neck Orbit w/ Contrast

Facility

$2,233.00

Service Code	CPT 70542
Hospital Charge Code	821408
Hospital Revenue Code	610
Min. Negotiated Rate	$2,009.70
Max. Negotiated Rate	$2,009.70
Rate for Payer: Aetna of AZ Commercial	$2,009.70
Rate for Payer: Cash Price	$1,786.40

MRI Face Neck Orbit w/ Contrast

Facility

$2,233.00

Service Code	CPT 70542
Hospital Charge Code	821408
Hospital Revenue Code	610
Min. Negotiated Rate	$353.71
Max. Negotiated Rate	$2,009.70
Rate for Payer: Aetna of AZ Commercial	$2,009.70
Rate for Payer: Arizona Complete Health Allwell	$357.28
Rate for Payer: Banner UC Health Medicare	$357.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,518.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$357.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$357.28
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: Devoted Health Medicare	$401.94
Rate for Payer: Humana of AZ Medicare	$357.28
Rate for Payer: Seven Corners Travel Insurance	$539.81
Rate for Payer: Southwest Service Administrators UFCW	$1,518.44
Rate for Payer: TriWest Medicare	$357.28
Rate for Payer: United Healthcare Commercial	$1,277.28
Rate for Payer: United Healthcare Medicare	$357.28
Rate for Payer: United Healthcare New Mexico Commercial	$424.27
Rate for Payer: Veterans Affairs TRICARE	$353.71

MRI Face Neck Orbit w/o Contrast

Facility

$3,533.00

Service Code	CPT 70540
Hospital Charge Code	1005420
Hospital Revenue Code	610
Min. Negotiated Rate	$3,179.70
Max. Negotiated Rate	$3,179.70
Rate for Payer: Aetna of AZ Commercial	$3,179.70
Rate for Payer: Cash Price	$2,826.40

MRI Face Neck Orbit w/o Contrast

Facility

$3,533.00

Service Code	CPT 70540
Hospital Charge Code	1005420
Hospital Revenue Code	610
Min. Negotiated Rate	$369.18
Max. Negotiated Rate	$3,179.70
Rate for Payer: Aetna of AZ Commercial	$3,179.70
Rate for Payer: Arizona Complete Health Allwell	$565.28
Rate for Payer: Banner UC Health Medicare	$565.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,402.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$565.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$565.28
Rate for Payer: Cash Price	$2,826.40
Rate for Payer: Cash Price	$2,826.40
Rate for Payer: Cigna of AZ Commercial	$2,473.10
Rate for Payer: Devoted Health Medicare	$635.94
Rate for Payer: Humana of AZ Medicare	$565.28
Rate for Payer: Seven Corners Travel Insurance	$369.18
Rate for Payer: Southwest Service Administrators UFCW	$2,402.44
Rate for Payer: TriWest Medicare	$565.28
Rate for Payer: United Healthcare Commercial	$2,020.88
Rate for Payer: United Healthcare Medicare	$565.28
Rate for Payer: United Healthcare New Mexico Commercial	$671.27
Rate for Payer: Veterans Affairs TRICARE	$559.63

MRI Face Neck Orbit w/ + w/o Contrast

Facility

$5,157.00

Service Code	CPT 70543
Hospital Charge Code	821406
Hospital Revenue Code	610
Min. Negotiated Rate	$539.81
Max. Negotiated Rate	$4,641.30
Rate for Payer: Aetna of AZ Commercial	$4,641.30
Rate for Payer: Arizona Complete Health Allwell	$825.12
Rate for Payer: Banner UC Health Medicare	$825.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,506.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$825.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$825.12
Rate for Payer: Cash Price	$4,125.60
Rate for Payer: Cash Price	$4,125.60
Rate for Payer: Cigna of AZ Commercial	$3,609.90
Rate for Payer: Devoted Health Medicare	$928.26
Rate for Payer: Humana of AZ Medicare	$825.12
Rate for Payer: Seven Corners Travel Insurance	$539.81
Rate for Payer: Southwest Service Administrators UFCW	$3,506.76
Rate for Payer: TriWest Medicare	$825.12
Rate for Payer: United Healthcare Commercial	$2,949.80
Rate for Payer: United Healthcare Medicare	$825.12
Rate for Payer: United Healthcare New Mexico Commercial	$979.83
Rate for Payer: Veterans Affairs TRICARE	$816.87

MRI Face Neck Orbit w/ + w/o Contrast

Facility

$5,157.00

Service Code	CPT 70543
Hospital Charge Code	821406
Hospital Revenue Code	610
Min. Negotiated Rate	$4,641.30
Max. Negotiated Rate	$4,641.30
Rate for Payer: Aetna of AZ Commercial	$4,641.30
Rate for Payer: Cash Price	$4,125.60

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	$2,232.90
Max. Negotiated Rate	$2,232.90
Rate for Payer: Aetna of AZ Commercial	$2,232.90
Rate for Payer: Cash Price	$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	$392.99
Max. Negotiated Rate	$2,232.90
Rate for Payer: Aetna of AZ Commercial	$2,232.90
Rate for Payer: Arizona Complete Health Allwell	$396.96
Rate for Payer: Banner UC Health Medicare	$396.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,687.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$396.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$396.96
Rate for Payer: Cash Price	$1,984.80
Rate for Payer: Cigna of AZ Commercial	$1,736.70
Rate for Payer: Devoted Health Medicare	$446.58
Rate for Payer: Humana of AZ Medicare	$396.96
Rate for Payer: Southwest Service Administrators UFCW	$1,687.08
Rate for Payer: TriWest Medicare	$396.96
Rate for Payer: United Healthcare Commercial	$1,419.13
Rate for Payer: United Healthcare Medicare	$396.96
Rate for Payer: United Healthcare New Mexico Commercial	$471.39
Rate for Payer: Veterans Affairs TRICARE	$392.99

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	$353.71
Max. Negotiated Rate	$2,009.70
Rate for Payer: Aetna of AZ Commercial	$2,009.70
Rate for Payer: Arizona Complete Health Allwell	$357.28
Rate for Payer: Banner UC Health Medicare	$357.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,518.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$357.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$357.28
Rate for Payer: Cash Price	$1,786.40
Rate for Payer: Cigna of AZ Commercial	$1,563.10
Rate for Payer: Devoted Health Medicare	$401.94
Rate for Payer: Humana of AZ Medicare	$357.28
Rate for Payer: Southwest Service Administrators UFCW	$1,518.44
Rate for Payer: TriWest Medicare	$357.28
Rate for Payer: United Healthcare Commercial	$1,277.28
Rate for Payer: United Healthcare Medicare	$357.28
Rate for Payer: United Healthcare New Mexico Commercial	$424.27
Rate for Payer: Veterans Affairs TRICARE	$353.71

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	$2,009.70
Max. Negotiated Rate	$2,009.70
Rate for Payer: Aetna of AZ Commercial	$2,009.70
Rate for Payer: Cash Price	$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	$2,009.70
Max. Negotiated Rate	$2,009.70
Rate for Payer: Aetna of AZ Commercial	$2,009.70
Rate for Payer: Cash Price	$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	$353.71
Max. Negotiated Rate	$2,009.70
Rate for Payer: Aetna of AZ Commercial	$2,009.70
Rate for Payer: Arizona Complete Health Allwell	$357.28
Rate for Payer: Banner UC Health Medicare	$357.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,518.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$357.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$357.28
Rate for Payer: Cash Price	$1,786.40
Rate for Payer: Cigna of AZ Commercial	$1,563.10
Rate for Payer: Devoted Health Medicare	$401.94
Rate for Payer: Humana of AZ Medicare	$357.28
Rate for Payer: Southwest Service Administrators UFCW	$1,518.44
Rate for Payer: TriWest Medicare	$357.28
Rate for Payer: United Healthcare Commercial	$1,277.28
Rate for Payer: United Healthcare Medicare	$357.28
Rate for Payer: United Healthcare New Mexico Commercial	$424.27
Rate for Payer: Veterans Affairs TRICARE	$353.71

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	$2,232.90
Max. Negotiated Rate	$2,232.90
Rate for Payer: Aetna of AZ Commercial	$2,232.90
Rate for Payer: Cash Price	$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	$392.99
Max. Negotiated Rate	$2,232.90
Rate for Payer: Aetna of AZ Commercial	$2,232.90
Rate for Payer: Arizona Complete Health Allwell	$396.96
Rate for Payer: Banner UC Health Medicare	$396.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,687.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$396.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$396.96
Rate for Payer: Cash Price	$1,984.80
Rate for Payer: Cigna of AZ Commercial	$1,736.70
Rate for Payer: Devoted Health Medicare	$446.58
Rate for Payer: Humana of AZ Medicare	$396.96
Rate for Payer: Southwest Service Administrators UFCW	$1,687.08
Rate for Payer: TriWest Medicare	$396.96
Rate for Payer: United Healthcare Commercial	$1,419.13
Rate for Payer: United Healthcare Medicare	$396.96
Rate for Payer: United Healthcare New Mexico Commercial	$471.39
Rate for Payer: Veterans Affairs TRICARE	$392.99

MRI LE Joint w/o Contrast Left

Facility

$3,081.00

Service Code	CPT 73721 LT
Hospital Charge Code	821420
Hospital Revenue Code	610
Min. Negotiated Rate	$488.03
Max. Negotiated Rate	$2,772.90
Rate for Payer: Aetna of AZ Commercial	$2,772.90
Rate for Payer: Arizona Complete Health Allwell	$492.96
Rate for Payer: Banner UC Health Medicare	$492.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,095.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$492.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$492.96
Rate for Payer: Cash Price	$2,464.80
Rate for Payer: Cigna of AZ Commercial	$2,156.70
Rate for Payer: Devoted Health Medicare	$554.58
Rate for Payer: Humana of AZ Medicare	$492.96
Rate for Payer: Southwest Service Administrators UFCW	$2,095.08
Rate for Payer: TriWest Medicare	$492.96
Rate for Payer: United Healthcare Commercial	$1,762.33
Rate for Payer: United Healthcare Medicare	$492.96
Rate for Payer: United Healthcare New Mexico Commercial	$585.39
Rate for Payer: Veterans Affairs TRICARE	$488.03

MRI LE Joint w/o Contrast Left

Facility

$3,081.00

Service Code	CPT 73721 LT
Hospital Charge Code	821420
Hospital Revenue Code	610
Min. Negotiated Rate	$2,772.90
Max. Negotiated Rate	$2,772.90
Rate for Payer: Aetna of AZ Commercial	$2,772.90
Rate for Payer: Cash Price	$2,464.80

MRI LE Joint w/o Contrast Right

Facility

$3,081.00

Service Code	CPT 73721 RT
Hospital Charge Code	821422
Hospital Revenue Code	610
Min. Negotiated Rate	$488.03
Max. Negotiated Rate	$2,772.90
Rate for Payer: Aetna of AZ Commercial	$2,772.90
Rate for Payer: Arizona Complete Health Allwell	$492.96
Rate for Payer: Banner UC Health Medicare	$492.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,095.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$492.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$492.96
Rate for Payer: Cash Price	$2,464.80
Rate for Payer: Cigna of AZ Commercial	$2,156.70
Rate for Payer: Devoted Health Medicare	$554.58
Rate for Payer: Humana of AZ Medicare	$492.96
Rate for Payer: Southwest Service Administrators UFCW	$2,095.08
Rate for Payer: TriWest Medicare	$492.96
Rate for Payer: United Healthcare Commercial	$1,762.33
Rate for Payer: United Healthcare Medicare	$492.96
Rate for Payer: United Healthcare New Mexico Commercial	$585.39
Rate for Payer: Veterans Affairs TRICARE	$488.03

MRI LE Joint w/o Contrast Right

Facility

$3,081.00

Service Code	CPT 73721 RT
Hospital Charge Code	821422
Hospital Revenue Code	610
Min. Negotiated Rate	$2,772.90
Max. Negotiated Rate	$2,772.90
Rate for Payer: Aetna of AZ Commercial	$2,772.90
Rate for Payer: Cash Price	$2,464.80

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	$2,232.90
Max. Negotiated Rate	$2,232.90
Rate for Payer: Aetna of AZ Commercial	$2,232.90
Rate for Payer: Cash Price	$1,984.80

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	$392.99
Max. Negotiated Rate	$2,232.90
Rate for Payer: Aetna of AZ Commercial	$2,232.90
Rate for Payer: Arizona Complete Health Allwell	$396.96
Rate for Payer: Banner UC Health Medicare	$396.96
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,687.08
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$396.96
Rate for Payer: Care1st Health Plan Arizona Medicare	$396.96
Rate for Payer: Cash Price	$1,984.80
Rate for Payer: Cigna of AZ Commercial	$1,736.70
Rate for Payer: Devoted Health Medicare	$446.58
Rate for Payer: Humana of AZ Medicare	$396.96
Rate for Payer: Southwest Service Administrators UFCW	$1,687.08
Rate for Payer: TriWest Medicare	$396.96
Rate for Payer: United Healthcare Commercial	$1,419.13
Rate for Payer: United Healthcare Medicare	$396.96
Rate for Payer: United Healthcare New Mexico Commercial	$471.39
Rate for Payer: Veterans Affairs TRICARE	$392.99

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	$968.62
Max. Negotiated Rate	$5,503.50
Rate for Payer: Aetna of AZ Commercial	$5,503.50
Rate for Payer: Arizona Complete Health Allwell	$978.40
Rate for Payer: Banner UC Health Medicare	$978.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$4,158.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$978.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$978.40
Rate for Payer: Cash Price	$4,892.00
Rate for Payer: Cigna of AZ Commercial	$4,280.50
Rate for Payer: Devoted Health Medicare	$1,100.70
Rate for Payer: Humana of AZ Medicare	$978.40
Rate for Payer: Southwest Service Administrators UFCW	$4,158.20
Rate for Payer: TriWest Medicare	$978.40
Rate for Payer: United Healthcare Commercial	$3,497.78
Rate for Payer: United Healthcare Medicare	$978.40
Rate for Payer: United Healthcare New Mexico Commercial	$1,161.85
Rate for Payer: Veterans Affairs TRICARE	$968.62

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	$5,503.50
Max. Negotiated Rate	$5,503.50
Rate for Payer: Aetna of AZ Commercial	$5,503.50
Rate for Payer: Cash Price	$4,892.00

Know your out-of-pocket cost for care.

All Charges