Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

MRI UE Joint w/ Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73222 50
Hospital Charge Code	1007513
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 UE Joint w/ Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73222 50
Hospital Charge Code	1007513
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 UE Joint w/ Contrast Left

Facility

$2,233.00

Service Code	CPT 73222 LT
Hospital Charge Code	1007515
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 UE Joint w/ Contrast Left

Facility

$2,233.00

Service Code	CPT 73222 LT
Hospital Charge Code	1007515
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 UE Joint w/ Contrast Right

Facility

$2,233.00

Service Code	CPT 73222 RT
Hospital Charge Code	1007517
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 UE Joint w/ Contrast Right

Facility

$2,233.00

Service Code	CPT 73222 RT
Hospital Charge Code	1007517
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 UE Joint w/o Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73221 50
Hospital Charge Code	821453
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 UE Joint w/o Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73221 50
Hospital Charge Code	821453
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 UE Joint w/o Contrast Left

Facility

$3,085.00

Service Code	CPT 73221 LT
Hospital Charge Code	821455
Hospital Revenue Code	610
Min. Negotiated Rate	$488.66
Max. Negotiated Rate	$2,776.50
Rate for Payer: Aetna of AZ Commercial	$2,776.50
Rate for Payer: Arizona Complete Health Allwell	$493.60
Rate for Payer: Banner UC Health Medicare	$493.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,097.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$493.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$493.60
Rate for Payer: Cash Price	$2,468.00
Rate for Payer: Cigna of AZ Commercial	$2,159.50
Rate for Payer: Devoted Health Medicare	$555.30
Rate for Payer: Humana of AZ Medicare	$493.60
Rate for Payer: Southwest Service Administrators UFCW	$2,097.80
Rate for Payer: TriWest Medicare	$493.60
Rate for Payer: United Healthcare Commercial	$1,764.62
Rate for Payer: United Healthcare Medicare	$493.60
Rate for Payer: United Healthcare New Mexico Commercial	$586.15
Rate for Payer: Veterans Affairs TRICARE	$488.66

MRI UE Joint w/o Contrast Left

Facility

$3,085.00

Service Code	CPT 73221 LT
Hospital Charge Code	821455
Hospital Revenue Code	610
Min. Negotiated Rate	$2,776.50
Max. Negotiated Rate	$2,776.50
Rate for Payer: Aetna of AZ Commercial	$2,776.50
Rate for Payer: Cash Price	$2,468.00

MRI UE Joint w/o Contrast Right

Facility

$3,085.00

Service Code	CPT 73221 RT
Hospital Charge Code	821457
Hospital Revenue Code	610
Min. Negotiated Rate	$2,776.50
Max. Negotiated Rate	$2,776.50
Rate for Payer: Aetna of AZ Commercial	$2,776.50
Rate for Payer: Cash Price	$2,468.00

MRI UE Joint w/o Contrast Right

Facility

$3,085.00

Service Code	CPT 73221 RT
Hospital Charge Code	821457
Hospital Revenue Code	610
Min. Negotiated Rate	$488.66
Max. Negotiated Rate	$2,776.50
Rate for Payer: Aetna of AZ Commercial	$2,776.50
Rate for Payer: Arizona Complete Health Allwell	$493.60
Rate for Payer: Banner UC Health Medicare	$493.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,097.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$493.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$493.60
Rate for Payer: Cash Price	$2,468.00
Rate for Payer: Cigna of AZ Commercial	$2,159.50
Rate for Payer: Devoted Health Medicare	$555.30
Rate for Payer: Humana of AZ Medicare	$493.60
Rate for Payer: Southwest Service Administrators UFCW	$2,097.80
Rate for Payer: TriWest Medicare	$493.60
Rate for Payer: United Healthcare Commercial	$1,764.62
Rate for Payer: United Healthcare Medicare	$493.60
Rate for Payer: United Healthcare New Mexico Commercial	$586.15
Rate for Payer: Veterans Affairs TRICARE	$488.66

MRI UE Joint w/ + w/o Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73221 50
Hospital Charge Code	821451
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 UE Joint w/ + w/o Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73221 50
Hospital Charge Code	821451
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 UE Joint w/ + w/o Contrast Left

Facility

$3,349.00

Service Code	CPT 73223 LT
Hospital Charge Code	1005509
Hospital Revenue Code	610
Min. Negotiated Rate	$3,014.10
Max. Negotiated Rate	$3,014.10
Rate for Payer: Aetna of AZ Commercial	$3,014.10
Rate for Payer: Cash Price	$2,679.20

MRI UE Joint w/ + w/o Contrast Left

Facility

$3,349.00

Service Code	CPT 73223 LT
Hospital Charge Code	1005509
Hospital Revenue Code	610
Min. Negotiated Rate	$530.48
Max. Negotiated Rate	$3,014.10
Rate for Payer: Aetna of AZ Commercial	$3,014.10
Rate for Payer: Arizona Complete Health Allwell	$535.84
Rate for Payer: Banner UC Health Medicare	$535.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,277.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$535.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$535.84
Rate for Payer: Cash Price	$2,679.20
Rate for Payer: Cigna of AZ Commercial	$2,344.30
Rate for Payer: Devoted Health Medicare	$602.82
Rate for Payer: Humana of AZ Medicare	$535.84
Rate for Payer: Southwest Service Administrators UFCW	$2,277.32
Rate for Payer: TriWest Medicare	$535.84
Rate for Payer: United Healthcare Commercial	$1,915.63
Rate for Payer: United Healthcare Medicare	$535.84
Rate for Payer: United Healthcare New Mexico Commercial	$636.31
Rate for Payer: Veterans Affairs TRICARE	$530.48

MRI UE Joint w/ + w/o Contrast Right

Facility

$3,349.00

Service Code	CPT 73223 RT
Hospital Charge Code	1005511
Hospital Revenue Code	610
Min. Negotiated Rate	$530.48
Max. Negotiated Rate	$3,014.10
Rate for Payer: Aetna of AZ Commercial	$3,014.10
Rate for Payer: Arizona Complete Health Allwell	$535.84
Rate for Payer: Banner UC Health Medicare	$535.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$2,277.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$535.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$535.84
Rate for Payer: Cash Price	$2,679.20
Rate for Payer: Cigna of AZ Commercial	$2,344.30
Rate for Payer: Devoted Health Medicare	$602.82
Rate for Payer: Humana of AZ Medicare	$535.84
Rate for Payer: Southwest Service Administrators UFCW	$2,277.32
Rate for Payer: TriWest Medicare	$535.84
Rate for Payer: United Healthcare Commercial	$1,915.63
Rate for Payer: United Healthcare Medicare	$535.84
Rate for Payer: United Healthcare New Mexico Commercial	$636.31
Rate for Payer: Veterans Affairs TRICARE	$530.48

MRI UE Joint w/ + w/o Contrast Right

Facility

$3,349.00

Service Code	CPT 73223 RT
Hospital Charge Code	1005511
Hospital Revenue Code	610
Min. Negotiated Rate	$3,014.10
Max. Negotiated Rate	$3,014.10
Rate for Payer: Aetna of AZ Commercial	$3,014.10
Rate for Payer: Cash Price	$2,679.20

MRI UE Non Joint w/o Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73218 50
Hospital Charge Code	1007535
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 UE Non Joint w/o Contrast Bilateral

Facility

$2,481.00

Service Code	CPT 73218 50
Hospital Charge Code	1007535
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 UE Non Joint w/o Contrast Left

Facility

$2,680.00

Service Code	CPT 73218 LT
Hospital Charge Code	1007537
Hospital Revenue Code	610
Min. Negotiated Rate	$424.51
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: 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: 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 UE Non Joint w/o Contrast Left

Facility

$2,680.00

Service Code	CPT 73218 LT
Hospital Charge Code	1007537
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 UE Non Joint w/o Contrast Right

Facility

$5,143.00

Service Code	CPT 73218 RT
Hospital Charge Code	1007539
Hospital Revenue Code	610
Min. Negotiated Rate	$4,628.70
Max. Negotiated Rate	$4,628.70
Rate for Payer: Aetna of AZ Commercial	$4,628.70
Rate for Payer: Cash Price	$4,114.40

MRI UE Non Joint w/o Contrast Right

Facility

$5,143.00

Service Code	CPT 73218 RT
Hospital Charge Code	1007539
Hospital Revenue Code	610
Min. Negotiated Rate	$814.65
Max. Negotiated Rate	$4,628.70
Rate for Payer: Aetna of AZ Commercial	$4,628.70
Rate for Payer: Arizona Complete Health Allwell	$822.88
Rate for Payer: Banner UC Health Medicare	$822.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,497.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$822.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$822.88
Rate for Payer: Cash Price	$4,114.40
Rate for Payer: Cigna of AZ Commercial	$3,600.10
Rate for Payer: Devoted Health Medicare	$925.74
Rate for Payer: Humana of AZ Medicare	$822.88
Rate for Payer: Southwest Service Administrators UFCW	$3,497.24
Rate for Payer: TriWest Medicare	$822.88
Rate for Payer: United Healthcare Commercial	$2,941.80
Rate for Payer: United Healthcare Medicare	$822.88
Rate for Payer: United Healthcare New Mexico Commercial	$977.17
Rate for Payer: Veterans Affairs TRICARE	$814.65

MRI UE Non Joint w/ + w/o Contrast Bilat

Facility

$2,481.00

Service Code	CPT 73220 50
Hospital Charge Code	1007522
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

Know your out-of-pocket cost for care.

All Charges