Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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	$4,551.30
Max. Negotiated Rate	$4,551.30
Rate for Payer: Aetna of AZ Commercial	$4,551.30
Rate for Payer: Cash Price	$4,045.60

MRI Sacrum w/o Contrast

Facility

$2,680.00

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

MRI Sacrum w/o Contrast

Facility

$2,680.00

Service Code	CPT 72195
Hospital Charge Code	1397668
Hospital Revenue Code	610
Min. Negotiated Rate	$369.18
Max. Negotiated Rate	$2,412.00
Rate for Payer: Aetna of AZ Commercial	$2,412.00
Rate for Payer: Arizona Complete Health Allwell	$428.80
Rate for Payer: Banner UC Health Medicare	$428.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,822.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$428.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$428.80
Rate for Payer: Cash Price	$2,144.00
Rate for Payer: Cash Price	$2,144.00
Rate for Payer: Cigna of AZ Commercial	$1,876.00
Rate for Payer: Devoted Health Medicare	$482.40
Rate for Payer: Humana of AZ Medicare	$428.80
Rate for Payer: Seven Corners Travel Insurance	$369.18
Rate for Payer: Southwest Service Administrators UFCW	$1,822.40
Rate for Payer: TriWest Medicare	$428.80
Rate for Payer: United Healthcare Commercial	$1,532.96
Rate for Payer: United Healthcare Medicare	$428.80
Rate for Payer: United Healthcare New Mexico Commercial	$509.20
Rate for Payer: Veterans Affairs TRICARE	$424.51

MRI Sinus w/o Contrast

Facility

$1,985.00

Service Code	CPT 70540
Hospital Charge Code	1779815
Hospital Revenue Code	610
Min. Negotiated Rate	$1,786.50
Max. Negotiated Rate	$1,786.50
Rate for Payer: Aetna of AZ Commercial	$1,786.50
Rate for Payer: Cash Price	$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	$314.42
Max. Negotiated Rate	$1,786.50
Rate for Payer: Aetna of AZ Commercial	$1,786.50
Rate for Payer: Arizona Complete Health Allwell	$317.60
Rate for Payer: Banner UC Health Medicare	$317.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,349.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$317.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$317.60
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: Devoted Health Medicare	$357.30
Rate for Payer: Humana of AZ Medicare	$317.60
Rate for Payer: Seven Corners Travel Insurance	$369.18
Rate for Payer: Southwest Service Administrators UFCW	$1,349.80
Rate for Payer: TriWest Medicare	$317.60
Rate for Payer: United Healthcare Commercial	$1,135.42
Rate for Payer: United Healthcare Medicare	$317.60
Rate for Payer: United Healthcare New Mexico Commercial	$377.15
Rate for Payer: Veterans Affairs TRICARE	$314.42

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	$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: 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: Seven Corners Travel Insurance	$539.81
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 Sinus w/ + w/o Contrast

Facility

$2,481.00

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

Facility

$2,986.00

Service Code	CPT 72141
Hospital Charge Code	821441
Hospital Revenue Code	612
Min. Negotiated Rate	$369.18
Max. Negotiated Rate	$2,687.40
Rate for Payer: Aetna of AZ Commercial	$2,687.40
Rate for Payer: Arizona Complete Health Allwell	$477.76
Rate for Payer: Banner UC Health Medicare	$477.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,030.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$477.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$477.76
Rate for Payer: Cash Price	$2,388.80
Rate for Payer: Cash Price	$2,388.80
Rate for Payer: Cigna of AZ Commercial	$2,090.20
Rate for Payer: Devoted Health Medicare	$537.48
Rate for Payer: Humana of AZ Medicare	$477.76
Rate for Payer: Seven Corners Travel Insurance	$369.18
Rate for Payer: Southwest Service Administrators UFCW	$2,030.48
Rate for Payer: TriWest Medicare	$477.76
Rate for Payer: United Healthcare Commercial	$1,707.99
Rate for Payer: United Healthcare Medicare	$477.76
Rate for Payer: United Healthcare New Mexico Commercial	$567.34
Rate for Payer: Veterans Affairs TRICARE	$472.98

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	$2,687.40
Max. Negotiated Rate	$2,687.40
Rate for Payer: Aetna of AZ Commercial	$2,687.40
Rate for Payer: Cash Price	$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	$4,142.70
Max. Negotiated Rate	$4,142.70
Rate for Payer: Aetna of AZ Commercial	$4,142.70
Rate for Payer: Cash Price	$3,682.40

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	$539.81
Max. Negotiated Rate	$4,142.70
Rate for Payer: Aetna of AZ Commercial	$4,142.70
Rate for Payer: Arizona Complete Health Allwell	$736.48
Rate for Payer: Banner UC Health Medicare	$736.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,130.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$736.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$736.48
Rate for Payer: Cash Price	$3,682.40
Rate for Payer: Cash Price	$3,682.40
Rate for Payer: Cigna of AZ Commercial	$3,222.10
Rate for Payer: Devoted Health Medicare	$828.54
Rate for Payer: Humana of AZ Medicare	$736.48
Rate for Payer: Seven Corners Travel Insurance	$539.81
Rate for Payer: Southwest Service Administrators UFCW	$3,130.04
Rate for Payer: TriWest Medicare	$736.48
Rate for Payer: United Healthcare Commercial	$2,632.92
Rate for Payer: United Healthcare Medicare	$736.48
Rate for Payer: United Healthcare New Mexico Commercial	$874.57
Rate for Payer: Veterans Affairs TRICARE	$729.12

MRI Spine Lumbar w/ Contrast

Facility

$2,233.00

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

Facility

$2,233.00

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

Facility

$3,198.23

Service Code	CPT 72148
Hospital Charge Code	821445
Hospital Revenue Code	612
Min. Negotiated Rate	$2,878.41
Max. Negotiated Rate	$2,878.41
Rate for Payer: Aetna of AZ Commercial	$2,878.41
Rate for Payer: Cash Price	$2,558.58

MRI Spine Lumbar w/o Contrast

Facility

$3,198.23

Service Code	CPT 72148
Hospital Charge Code	821445
Hospital Revenue Code	612
Min. Negotiated Rate	$369.18
Max. Negotiated Rate	$2,878.41
Rate for Payer: Aetna of AZ Commercial	$2,878.41
Rate for Payer: Arizona Complete Health Allwell	$511.72
Rate for Payer: Banner UC Health Medicare	$511.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,174.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$511.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$511.72
Rate for Payer: Cash Price	$2,558.58
Rate for Payer: Cash Price	$2,558.58
Rate for Payer: Cigna of AZ Commercial	$2,238.76
Rate for Payer: Devoted Health Medicare	$575.68
Rate for Payer: Humana of AZ Medicare	$511.72
Rate for Payer: Seven Corners Travel Insurance	$369.18
Rate for Payer: Southwest Service Administrators UFCW	$2,174.80
Rate for Payer: TriWest Medicare	$511.72
Rate for Payer: United Healthcare Commercial	$1,829.39
Rate for Payer: United Healthcare Medicare	$511.72
Rate for Payer: United Healthcare New Mexico Commercial	$607.66
Rate for Payer: Veterans Affairs TRICARE	$506.60

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	$539.81
Max. Negotiated Rate	$4,130.10
Rate for Payer: Aetna of AZ Commercial	$4,130.10
Rate for Payer: Arizona Complete Health Allwell	$734.24
Rate for Payer: Banner UC Health Medicare	$734.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,120.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$734.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$734.24
Rate for Payer: Cash Price	$3,671.20
Rate for Payer: Cash Price	$3,671.20
Rate for Payer: Cigna of AZ Commercial	$3,212.30
Rate for Payer: Devoted Health Medicare	$826.02
Rate for Payer: Humana of AZ Medicare	$734.24
Rate for Payer: Seven Corners Travel Insurance	$539.81
Rate for Payer: Southwest Service Administrators UFCW	$3,120.52
Rate for Payer: TriWest Medicare	$734.24
Rate for Payer: United Healthcare Commercial	$2,624.91
Rate for Payer: United Healthcare Medicare	$734.24
Rate for Payer: United Healthcare New Mexico Commercial	$871.91
Rate for Payer: Veterans Affairs TRICARE	$726.90

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	$4,130.10
Max. Negotiated Rate	$4,130.10
Rate for Payer: Aetna of AZ Commercial	$4,130.10
Rate for Payer: Cash Price	$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	$4,155.30
Max. Negotiated Rate	$4,155.30
Rate for Payer: Aetna of AZ Commercial	$4,155.30
Rate for Payer: Cash Price	$3,693.60

MRI Spine Thoracic w/ Contrast

Facility

$4,617.00

Service Code	CPT 72157
Hospital Charge Code	821447
Hospital Revenue Code	612
Min. Negotiated Rate	$539.81
Max. Negotiated Rate	$4,155.30
Rate for Payer: Aetna of AZ Commercial	$4,155.30
Rate for Payer: Arizona Complete Health Allwell	$738.72
Rate for Payer: Banner UC Health Medicare	$738.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,139.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$738.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$738.72
Rate for Payer: Cash Price	$3,693.60
Rate for Payer: Cash Price	$3,693.60
Rate for Payer: Cigna of AZ Commercial	$3,231.90
Rate for Payer: Devoted Health Medicare	$831.06
Rate for Payer: Humana of AZ Medicare	$738.72
Rate for Payer: Seven Corners Travel Insurance	$539.81
Rate for Payer: Southwest Service Administrators UFCW	$3,139.56
Rate for Payer: TriWest Medicare	$738.72
Rate for Payer: United Healthcare Commercial	$2,640.92
Rate for Payer: United Healthcare Medicare	$738.72
Rate for Payer: United Healthcare New Mexico Commercial	$877.23
Rate for Payer: Veterans Affairs TRICARE	$731.33

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	$2,684.70
Max. Negotiated Rate	$2,684.70
Rate for Payer: Aetna of AZ Commercial	$2,684.70
Rate for Payer: Cash Price	$2,386.40

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	$369.18
Max. Negotiated Rate	$2,684.70
Rate for Payer: Aetna of AZ Commercial	$2,684.70
Rate for Payer: Arizona Complete Health Allwell	$477.28
Rate for Payer: Banner UC Health Medicare	$477.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,028.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$477.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$477.28
Rate for Payer: Cash Price	$2,386.40
Rate for Payer: Cash Price	$2,386.40
Rate for Payer: Cigna of AZ Commercial	$2,088.10
Rate for Payer: Devoted Health Medicare	$536.94
Rate for Payer: Humana of AZ Medicare	$477.28
Rate for Payer: Seven Corners Travel Insurance	$369.18
Rate for Payer: Southwest Service Administrators UFCW	$2,028.44
Rate for Payer: TriWest Medicare	$477.28
Rate for Payer: United Healthcare Commercial	$1,706.28
Rate for Payer: United Healthcare Medicare	$477.28
Rate for Payer: United Healthcare New Mexico Commercial	$566.77
Rate for Payer: Veterans Affairs TRICARE	$472.51

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	$539.81
Max. Negotiated Rate	$4,329.90
Rate for Payer: Aetna of AZ Commercial	$4,329.90
Rate for Payer: Arizona Complete Health Allwell	$769.76
Rate for Payer: Banner UC Health Medicare	$769.76
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,271.48
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$769.76
Rate for Payer: Care1st Health Plan Arizona Medicare	$769.76
Rate for Payer: Cash Price	$3,848.80
Rate for Payer: Cash Price	$3,848.80
Rate for Payer: Cigna of AZ Commercial	$3,367.70
Rate for Payer: Devoted Health Medicare	$865.98
Rate for Payer: Humana of AZ Medicare	$769.76
Rate for Payer: Seven Corners Travel Insurance	$539.81
Rate for Payer: Southwest Service Administrators UFCW	$3,271.48
Rate for Payer: TriWest Medicare	$769.76
Rate for Payer: United Healthcare Commercial	$2,751.89
Rate for Payer: United Healthcare Medicare	$769.76
Rate for Payer: United Healthcare New Mexico Commercial	$914.09
Rate for Payer: Veterans Affairs TRICARE	$762.06

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	$4,329.90
Max. Negotiated Rate	$4,329.90
Rate for Payer: Aetna of AZ Commercial	$4,329.90
Rate for Payer: Cash Price	$3,848.80

MRI TMJ

Facility

$1,985.00

Service Code	CPT 70336
Hospital Charge Code	1005507
Hospital Revenue Code	610
Min. Negotiated Rate	$314.42
Max. Negotiated Rate	$1,786.50
Rate for Payer: Aetna of AZ Commercial	$1,786.50
Rate for Payer: Arizona Complete Health Allwell	$317.60
Rate for Payer: Banner UC Health Medicare	$317.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,349.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$317.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$317.60
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: Devoted Health Medicare	$357.30
Rate for Payer: Humana of AZ Medicare	$317.60
Rate for Payer: Seven Corners Travel Insurance	$369.18
Rate for Payer: Southwest Service Administrators UFCW	$1,349.80
Rate for Payer: TriWest Medicare	$317.60
Rate for Payer: United Healthcare Commercial	$1,135.42
Rate for Payer: United Healthcare Medicare	$317.60
Rate for Payer: United Healthcare New Mexico Commercial	$377.15
Rate for Payer: Veterans Affairs TRICARE	$314.42

MRI TMJ

Facility

$1,985.00

Service Code	CPT 70336
Hospital Charge Code	1005507
Hospital Revenue Code	610
Min. Negotiated Rate	$1,786.50
Max. Negotiated Rate	$1,786.50
Rate for Payer: Aetna of AZ Commercial	$1,786.50
Rate for Payer: Cash Price	$1,588.00

Know your out-of-pocket cost for care.

All Charges