Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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	$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

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	$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 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	$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 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	$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 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	$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 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	$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 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	$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 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	$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 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	$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 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	$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 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	$3,108.60
Max. Negotiated Rate	$3,108.60
Rate for Payer: Aetna of AZ Commercial	$3,108.60
Rate for Payer: Cash Price	$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	$547.11
Max. Negotiated Rate	$3,108.60
Rate for Payer: Aetna of AZ Commercial	$3,108.60
Rate for Payer: Arizona Complete Health Allwell	$552.64
Rate for Payer: Banner UC Health Medicare	$552.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,348.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$552.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$552.64
Rate for Payer: Cash Price	$2,763.20
Rate for Payer: Cigna of AZ Commercial	$2,417.80
Rate for Payer: Devoted Health Medicare	$621.72
Rate for Payer: Humana of AZ Medicare	$552.64
Rate for Payer: Southwest Service Administrators UFCW	$2,348.72
Rate for Payer: TriWest Medicare	$552.64
Rate for Payer: United Healthcare Commercial	$1,975.69
Rate for Payer: United Healthcare Medicare	$552.64
Rate for Payer: United Healthcare New Mexico Commercial	$656.26
Rate for Payer: Veterans Affairs TRICARE	$547.11

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	$547.11
Max. Negotiated Rate	$3,108.60
Rate for Payer: Aetna of AZ Commercial	$3,108.60
Rate for Payer: Arizona Complete Health Allwell	$552.64
Rate for Payer: Banner UC Health Medicare	$552.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,348.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$552.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$552.64
Rate for Payer: Cash Price	$2,763.20
Rate for Payer: Cigna of AZ Commercial	$2,417.80
Rate for Payer: Devoted Health Medicare	$621.72
Rate for Payer: Humana of AZ Medicare	$552.64
Rate for Payer: Southwest Service Administrators UFCW	$2,348.72
Rate for Payer: TriWest Medicare	$552.64
Rate for Payer: United Healthcare Commercial	$1,975.69
Rate for Payer: United Healthcare Medicare	$552.64
Rate for Payer: United Healthcare New Mexico Commercial	$656.26
Rate for Payer: Veterans Affairs TRICARE	$547.11

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	$3,108.60
Max. Negotiated Rate	$3,108.60
Rate for Payer: Aetna of AZ Commercial	$3,108.60
Rate for Payer: Cash Price	$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	$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 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	$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 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	$808.95
Max. Negotiated Rate	$4,596.30
Rate for Payer: Aetna of AZ Commercial	$4,596.30
Rate for Payer: Arizona Complete Health Allwell	$817.12
Rate for Payer: Banner UC Health Medicare	$817.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,472.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$817.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$817.12
Rate for Payer: Cash Price	$4,085.60
Rate for Payer: Cigna of AZ Commercial	$3,574.90
Rate for Payer: Devoted Health Medicare	$919.26
Rate for Payer: Humana of AZ Medicare	$817.12
Rate for Payer: Southwest Service Administrators UFCW	$3,472.76
Rate for Payer: TriWest Medicare	$817.12
Rate for Payer: United Healthcare Commercial	$2,921.20
Rate for Payer: United Healthcare Medicare	$817.12
Rate for Payer: United Healthcare New Mexico Commercial	$970.33
Rate for Payer: Veterans Affairs TRICARE	$808.95

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	$4,596.30
Max. Negotiated Rate	$4,596.30
Rate for Payer: Aetna of AZ Commercial	$4,596.30
Rate for Payer: Cash Price	$4,085.60

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	$810.53
Max. Negotiated Rate	$4,605.30
Rate for Payer: Aetna of AZ Commercial	$4,605.30
Rate for Payer: Arizona Complete Health Allwell	$818.72
Rate for Payer: Banner UC Health Medicare	$818.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,479.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$818.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$818.72
Rate for Payer: Cash Price	$4,093.60
Rate for Payer: Cigna of AZ Commercial	$3,581.90
Rate for Payer: Devoted Health Medicare	$921.06
Rate for Payer: Humana of AZ Medicare	$818.72
Rate for Payer: Southwest Service Administrators UFCW	$3,479.56
Rate for Payer: TriWest Medicare	$818.72
Rate for Payer: United Healthcare Commercial	$2,926.92
Rate for Payer: United Healthcare Medicare	$818.72
Rate for Payer: United Healthcare New Mexico Commercial	$972.23
Rate for Payer: Veterans Affairs TRICARE	$810.53

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	$4,605.30
Max. Negotiated Rate	$4,605.30
Rate for Payer: Aetna of AZ Commercial	$4,605.30
Rate for Payer: Cash Price	$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	$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 Pelvis w/ Contrast

Facility

$2,233.00

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

Facility

$3,461.00

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

MRI Pelvis w/o Contrast

Facility

$3,461.00

Service Code	CPT 72195
Hospital Charge Code	821434
Hospital Revenue Code	610
Min. Negotiated Rate	$369.18
Max. Negotiated Rate	$3,114.90
Rate for Payer: Aetna of AZ Commercial	$3,114.90
Rate for Payer: Arizona Complete Health Allwell	$553.76
Rate for Payer: Banner UC Health Medicare	$553.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,353.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$553.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$553.76
Rate for Payer: Cash Price	$2,768.80
Rate for Payer: Cash Price	$2,768.80
Rate for Payer: Cigna of AZ Commercial	$2,422.70
Rate for Payer: Devoted Health Medicare	$622.98
Rate for Payer: Humana of AZ Medicare	$553.76
Rate for Payer: Seven Corners Travel Insurance	$369.18
Rate for Payer: Southwest Service Administrators UFCW	$2,353.48
Rate for Payer: TriWest Medicare	$553.76
Rate for Payer: United Healthcare Commercial	$1,979.69
Rate for Payer: United Healthcare Medicare	$553.76
Rate for Payer: United Healthcare New Mexico Commercial	$657.59
Rate for Payer: Veterans Affairs TRICARE	$548.22

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	$539.81
Max. Negotiated Rate	$4,551.30
Rate for Payer: Aetna of AZ Commercial	$4,551.30
Rate for Payer: Arizona Complete Health Allwell	$809.12
Rate for Payer: Banner UC Health Medicare	$809.12
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,438.76
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$809.12
Rate for Payer: Care1st Health Plan Arizona Medicare	$809.12
Rate for Payer: Cash Price	$4,045.60
Rate for Payer: Cash Price	$4,045.60
Rate for Payer: Cigna of AZ Commercial	$3,539.90
Rate for Payer: Devoted Health Medicare	$910.26
Rate for Payer: Humana of AZ Medicare	$809.12
Rate for Payer: Seven Corners Travel Insurance	$539.81
Rate for Payer: Southwest Service Administrators UFCW	$3,438.76
Rate for Payer: TriWest Medicare	$809.12
Rate for Payer: United Healthcare Commercial	$2,892.60
Rate for Payer: United Healthcare Medicare	$809.12
Rate for Payer: United Healthcare New Mexico Commercial	$960.83
Rate for Payer: Veterans Affairs TRICARE	$801.03

Know your out-of-pocket cost for care.

All Charges