Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

XR Internal Audio Meati Complete Left

Facility

$680.00

Service Code	CPT 70134 LT
Hospital Charge Code	22271685
Hospital Revenue Code	320
Min. Negotiated Rate	$108.80
Max. Negotiated Rate	$612.00
Rate for Payer: Aetna of AZ Commercial	$612.00
Rate for Payer: Aetna of AZ Medicare	$190.40
Rate for Payer: Allwell Medicare	$108.80
Rate for Payer: Amerigroup Medicare	$108.80
Rate for Payer: APIPA Medicare/Medicaid	$253.98
Rate for Payer: AZCH Complete Medicare	$108.80
Rate for Payer: Banner UC Health Medicare	$108.80
Rate for Payer: Bisbee Police All Plans	$176.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$462.40
Rate for Payer: Cash Price	$544.00
Rate for Payer: Cigna of AZ Commercial	$442.00
Rate for Payer: Copperpoint Commercial	$168.30
Rate for Payer: Health Net of AZ Commercial	$408.00
Rate for Payer: Health Net of AZ Medicare	$190.40
Rate for Payer: Humana of AZ Medicare	$108.80
Rate for Payer: Self Pay Self Pay	$544.00
Rate for Payer: TriWest Medicare	$108.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$396.44
Rate for Payer: UnitedHealth Group of AZ Medicare	$122.40

XR Internal Audio Meati Complete Left

Facility

$680.00

Service Code	CPT 70134 LT
Hospital Charge Code	22271685
Hospital Revenue Code	320
Min. Negotiated Rate	$176.80
Max. Negotiated Rate	$612.00
Rate for Payer: Aetna of AZ Commercial	$612.00
Rate for Payer: Bisbee Police All Plans	$176.80
Rate for Payer: Cash Price	$544.00
Rate for Payer: Self Pay Self Pay	$544.00

XR Internal Audio Meati Complete Right

Facility

$680.00

Service Code	CPT 70134 RT
Hospital Charge Code	22271687
Hospital Revenue Code	320
Min. Negotiated Rate	$108.80
Max. Negotiated Rate	$612.00
Rate for Payer: Aetna of AZ Commercial	$612.00
Rate for Payer: Aetna of AZ Medicare	$190.40
Rate for Payer: Allwell Medicare	$108.80
Rate for Payer: Amerigroup Medicare	$108.80
Rate for Payer: APIPA Medicare/Medicaid	$253.98
Rate for Payer: AZCH Complete Medicare	$108.80
Rate for Payer: Banner UC Health Medicare	$108.80
Rate for Payer: Bisbee Police All Plans	$176.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$462.40
Rate for Payer: Cash Price	$544.00
Rate for Payer: Cigna of AZ Commercial	$442.00
Rate for Payer: Copperpoint Commercial	$168.30
Rate for Payer: Health Net of AZ Commercial	$408.00
Rate for Payer: Health Net of AZ Medicare	$190.40
Rate for Payer: Humana of AZ Medicare	$108.80
Rate for Payer: Self Pay Self Pay	$544.00
Rate for Payer: TriWest Medicare	$108.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$396.44
Rate for Payer: UnitedHealth Group of AZ Medicare	$122.40

XR Internal Audio Meati Complete Right

Facility

$680.00

Service Code	CPT 70134 RT
Hospital Charge Code	22271687
Hospital Revenue Code	320
Min. Negotiated Rate	$176.80
Max. Negotiated Rate	$612.00
Rate for Payer: Aetna of AZ Commercial	$612.00
Rate for Payer: Bisbee Police All Plans	$176.80
Rate for Payer: Cash Price	$544.00
Rate for Payer: Self Pay Self Pay	$544.00

XR Knee Complete Left

Facility

$48.00

Service Code	CPT 73564 LT
Hospital Charge Code	22862304
Hospital Revenue Code	972
Min. Negotiated Rate	$12.48
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of AZ Commercial	$43.20
Rate for Payer: Bisbee Police All Plans	$12.48
Rate for Payer: Cash Price	$38.40
Rate for Payer: Self Pay Self Pay	$38.40

XR Knee Complete Left

Facility

$567.00

Service Code	CPT 73564 LT
Hospital Charge Code	1007996
Hospital Revenue Code	320
Min. Negotiated Rate	$147.42
Max. Negotiated Rate	$510.30
Rate for Payer: Aetna of AZ Commercial	$510.30
Rate for Payer: Bisbee Police All Plans	$147.42
Rate for Payer: Cash Price	$453.60
Rate for Payer: Self Pay Self Pay	$453.60

XR Knee Complete Left

Facility

$48.00

Service Code	CPT 73564 LT
Hospital Charge Code	22862304
Hospital Revenue Code	972
Min. Negotiated Rate	$7.68
Max. Negotiated Rate	$43.20
Rate for Payer: Aetna of AZ Commercial	$43.20
Rate for Payer: Aetna of AZ Medicare	$13.44
Rate for Payer: Allwell Medicare	$7.68
Rate for Payer: Amerigroup Medicare	$7.68
Rate for Payer: APIPA Medicare/Medicaid	$17.93
Rate for Payer: AZCH Complete Medicare	$7.68
Rate for Payer: Banner UC Health Medicare	$7.68
Rate for Payer: Bisbee Police All Plans	$12.48
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$32.64
Rate for Payer: Cash Price	$38.40
Rate for Payer: Cigna of AZ Commercial	$33.60
Rate for Payer: Copperpoint Commercial	$11.88
Rate for Payer: Health Net of AZ Commercial	$28.80
Rate for Payer: Health Net of AZ Medicare	$13.44
Rate for Payer: Humana of AZ Medicare	$7.68
Rate for Payer: Self Pay Self Pay	$38.40
Rate for Payer: TriWest Medicare	$7.68
Rate for Payer: UnitedHealth Group of AZ Commercial	$27.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$8.64

XR Knee Complete Left

Facility

$567.00

Service Code	CPT 73564 LT
Hospital Charge Code	1007996
Hospital Revenue Code	320
Min. Negotiated Rate	$90.72
Max. Negotiated Rate	$510.30
Rate for Payer: Aetna of AZ Commercial	$510.30
Rate for Payer: Aetna of AZ Medicare	$158.76
Rate for Payer: Allwell Medicare	$90.72
Rate for Payer: Amerigroup Medicare	$90.72
Rate for Payer: APIPA Medicare/Medicaid	$211.77
Rate for Payer: AZCH Complete Medicare	$90.72
Rate for Payer: Banner UC Health Medicare	$90.72
Rate for Payer: Bisbee Police All Plans	$147.42
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$385.56
Rate for Payer: Cash Price	$453.60
Rate for Payer: Cigna of AZ Commercial	$368.55
Rate for Payer: Copperpoint Commercial	$140.33
Rate for Payer: Health Net of AZ Commercial	$340.20
Rate for Payer: Health Net of AZ Medicare	$158.76
Rate for Payer: Humana of AZ Medicare	$90.72
Rate for Payer: Self Pay Self Pay	$453.60
Rate for Payer: TriWest Medicare	$90.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$330.56
Rate for Payer: UnitedHealth Group of AZ Medicare	$102.06

XR Knee Complete Right

Facility

$567.00

Service Code	CPT 73564 RT
Hospital Charge Code	1007998
Hospital Revenue Code	320
Min. Negotiated Rate	$90.72
Max. Negotiated Rate	$510.30
Rate for Payer: Aetna of AZ Commercial	$510.30
Rate for Payer: Aetna of AZ Medicare	$158.76
Rate for Payer: Allwell Medicare	$90.72
Rate for Payer: Amerigroup Medicare	$90.72
Rate for Payer: APIPA Medicare/Medicaid	$211.77
Rate for Payer: AZCH Complete Medicare	$90.72
Rate for Payer: Banner UC Health Medicare	$90.72
Rate for Payer: Bisbee Police All Plans	$147.42
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$385.56
Rate for Payer: Cash Price	$453.60
Rate for Payer: Cigna of AZ Commercial	$368.55
Rate for Payer: Copperpoint Commercial	$140.33
Rate for Payer: Health Net of AZ Commercial	$340.20
Rate for Payer: Health Net of AZ Medicare	$158.76
Rate for Payer: Humana of AZ Medicare	$90.72
Rate for Payer: Self Pay Self Pay	$453.60
Rate for Payer: TriWest Medicare	$90.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$330.56
Rate for Payer: UnitedHealth Group of AZ Medicare	$102.06

XR Knee Complete Right

Facility

$567.00

Service Code	CPT 73564 RT
Hospital Charge Code	1007998
Hospital Revenue Code	320
Min. Negotiated Rate	$147.42
Max. Negotiated Rate	$510.30
Rate for Payer: Aetna of AZ Commercial	$510.30
Rate for Payer: Bisbee Police All Plans	$147.42
Rate for Payer: Cash Price	$453.60
Rate for Payer: Self Pay Self Pay	$453.60

XR Knee One or Two Views Left

Facility

$537.00

Service Code	CPT 73560 LT
Hospital Charge Code	823596
Hospital Revenue Code	320
Min. Negotiated Rate	$85.92
Max. Negotiated Rate	$483.30
Rate for Payer: Aetna of AZ Commercial	$483.30
Rate for Payer: Aetna of AZ Medicare	$150.36
Rate for Payer: Allwell Medicare	$85.92
Rate for Payer: Amerigroup Medicare	$85.92
Rate for Payer: APIPA Medicare/Medicaid	$200.57
Rate for Payer: AZCH Complete Medicare	$85.92
Rate for Payer: Banner UC Health Medicare	$85.92
Rate for Payer: Bisbee Police All Plans	$139.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$365.16
Rate for Payer: Cash Price	$429.60
Rate for Payer: Cigna of AZ Commercial	$349.05
Rate for Payer: Copperpoint Commercial	$132.91
Rate for Payer: Health Net of AZ Commercial	$322.20
Rate for Payer: Health Net of AZ Medicare	$150.36
Rate for Payer: Humana of AZ Medicare	$85.92
Rate for Payer: Self Pay Self Pay	$429.60
Rate for Payer: TriWest Medicare	$85.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$313.07
Rate for Payer: UnitedHealth Group of AZ Medicare	$96.66

XR Knee One or Two Views Left

Facility

$537.00

Service Code	CPT 73560 LT
Hospital Charge Code	823596
Hospital Revenue Code	320
Min. Negotiated Rate	$139.62
Max. Negotiated Rate	$483.30
Rate for Payer: Aetna of AZ Commercial	$483.30
Rate for Payer: Bisbee Police All Plans	$139.62
Rate for Payer: Cash Price	$429.60
Rate for Payer: Self Pay Self Pay	$429.60

XR Knee One or Two Views Right

Facility

$537.00

Service Code	CPT 73560 RT
Hospital Charge Code	823598
Hospital Revenue Code	320
Min. Negotiated Rate	$139.62
Max. Negotiated Rate	$483.30
Rate for Payer: Aetna of AZ Commercial	$483.30
Rate for Payer: Bisbee Police All Plans	$139.62
Rate for Payer: Cash Price	$429.60
Rate for Payer: Self Pay Self Pay	$429.60

XR Knee One or Two Views Right

Facility

$537.00

Service Code	CPT 73560 RT
Hospital Charge Code	823598
Hospital Revenue Code	320
Min. Negotiated Rate	$85.92
Max. Negotiated Rate	$483.30
Rate for Payer: Aetna of AZ Commercial	$483.30
Rate for Payer: Aetna of AZ Medicare	$150.36
Rate for Payer: Allwell Medicare	$85.92
Rate for Payer: Amerigroup Medicare	$85.92
Rate for Payer: APIPA Medicare/Medicaid	$200.57
Rate for Payer: AZCH Complete Medicare	$85.92
Rate for Payer: Banner UC Health Medicare	$85.92
Rate for Payer: Bisbee Police All Plans	$139.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$365.16
Rate for Payer: Cash Price	$429.60
Rate for Payer: Cigna of AZ Commercial	$349.05
Rate for Payer: Copperpoint Commercial	$132.91
Rate for Payer: Health Net of AZ Commercial	$322.20
Rate for Payer: Health Net of AZ Medicare	$150.36
Rate for Payer: Humana of AZ Medicare	$85.92
Rate for Payer: Self Pay Self Pay	$429.60
Rate for Payer: TriWest Medicare	$85.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$313.07
Rate for Payer: UnitedHealth Group of AZ Medicare	$96.66

XR Knee Standing AP Bilateral

Facility

$494.00

Service Code	CPT 73565 50
Hospital Charge Code	1008002
Hospital Revenue Code	320
Min. Negotiated Rate	$128.44
Max. Negotiated Rate	$444.60
Rate for Payer: Aetna of AZ Commercial	$444.60
Rate for Payer: Bisbee Police All Plans	$128.44
Rate for Payer: Cash Price	$395.20
Rate for Payer: Self Pay Self Pay	$395.20

XR Knee Standing AP Bilateral

Facility

$494.00

Service Code	CPT 73565 50
Hospital Charge Code	1008002
Hospital Revenue Code	320
Min. Negotiated Rate	$79.04
Max. Negotiated Rate	$444.60
Rate for Payer: Aetna of AZ Commercial	$444.60
Rate for Payer: Aetna of AZ Medicare	$138.32
Rate for Payer: Allwell Medicare	$79.04
Rate for Payer: Amerigroup Medicare	$79.04
Rate for Payer: APIPA Medicare/Medicaid	$184.51
Rate for Payer: AZCH Complete Medicare	$79.04
Rate for Payer: Banner UC Health Medicare	$79.04
Rate for Payer: Bisbee Police All Plans	$128.44
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$335.92
Rate for Payer: Cash Price	$395.20
Rate for Payer: Cigna of AZ Commercial	$321.10
Rate for Payer: Copperpoint Commercial	$122.27
Rate for Payer: Health Net of AZ Commercial	$296.40
Rate for Payer: Health Net of AZ Medicare	$138.32
Rate for Payer: Humana of AZ Medicare	$79.04
Rate for Payer: Self Pay Self Pay	$395.20
Rate for Payer: TriWest Medicare	$79.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$288.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$88.92

XR Mandible Complete Minimum 4 Views

Facility

$854.00

Service Code	CPT 70110
Hospital Charge Code	823600
Hospital Revenue Code	320
Min. Negotiated Rate	$222.04
Max. Negotiated Rate	$768.60
Rate for Payer: Aetna of AZ Commercial	$768.60
Rate for Payer: Bisbee Police All Plans	$222.04
Rate for Payer: Cash Price	$683.20
Rate for Payer: Self Pay Self Pay	$683.20

XR Mandible Complete Minimum 4 Views

Facility

$854.00

Service Code	CPT 70110
Hospital Charge Code	823600
Hospital Revenue Code	320
Min. Negotiated Rate	$136.64
Max. Negotiated Rate	$768.60
Rate for Payer: Aetna of AZ Commercial	$768.60
Rate for Payer: Aetna of AZ Medicare	$239.12
Rate for Payer: Allwell Medicare	$136.64
Rate for Payer: Amerigroup Medicare	$136.64
Rate for Payer: APIPA Medicare/Medicaid	$318.97
Rate for Payer: AZCH Complete Medicare	$136.64
Rate for Payer: Banner UC Health Medicare	$136.64
Rate for Payer: Bisbee Police All Plans	$222.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$580.72
Rate for Payer: Cash Price	$683.20
Rate for Payer: Cigna of AZ Commercial	$555.10
Rate for Payer: Copperpoint Commercial	$211.37
Rate for Payer: Health Net of AZ Commercial	$512.40
Rate for Payer: Health Net of AZ Medicare	$239.12
Rate for Payer: Humana of AZ Medicare	$136.64
Rate for Payer: Self Pay Self Pay	$683.20
Rate for Payer: TriWest Medicare	$136.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$497.88
Rate for Payer: UnitedHealth Group of AZ Medicare	$153.72

XR Mandible Partial Less Than 4 Views

Facility

$468.00

Service Code	CPT 70100
Hospital Charge Code	1008013
Hospital Revenue Code	320
Min. Negotiated Rate	$74.88
Max. Negotiated Rate	$421.20
Rate for Payer: Aetna of AZ Commercial	$421.20
Rate for Payer: Aetna of AZ Medicare	$131.04
Rate for Payer: Allwell Medicare	$74.88
Rate for Payer: Amerigroup Medicare	$74.88
Rate for Payer: APIPA Medicare/Medicaid	$174.80
Rate for Payer: AZCH Complete Medicare	$74.88
Rate for Payer: Banner UC Health Medicare	$74.88
Rate for Payer: Bisbee Police All Plans	$121.68
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$318.24
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cigna of AZ Commercial	$304.20
Rate for Payer: Copperpoint Commercial	$115.83
Rate for Payer: Health Net of AZ Commercial	$280.80
Rate for Payer: Health Net of AZ Medicare	$131.04
Rate for Payer: Humana of AZ Medicare	$74.88
Rate for Payer: Self Pay Self Pay	$374.40
Rate for Payer: TriWest Medicare	$74.88
Rate for Payer: UnitedHealth Group of AZ Commercial	$272.84
Rate for Payer: UnitedHealth Group of AZ Medicare	$84.24

XR Mandible Partial Less Than 4 Views

Facility

$468.00

Service Code	CPT 70100
Hospital Charge Code	1008013
Hospital Revenue Code	320
Min. Negotiated Rate	$121.68
Max. Negotiated Rate	$421.20
Rate for Payer: Aetna of AZ Commercial	$421.20
Rate for Payer: Bisbee Police All Plans	$121.68
Rate for Payer: Cash Price	$374.40
Rate for Payer: Self Pay Self Pay	$374.40

XR Mastoids < 3 Views Bilateral

Facility

$488.00

Service Code	CPT 70120 50
Hospital Charge Code	1008015
Hospital Revenue Code	320
Min. Negotiated Rate	$126.88
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Bisbee Police All Plans	$126.88
Rate for Payer: Cash Price	$390.40
Rate for Payer: Self Pay Self Pay	$390.40

XR Mastoids < 3 Views Bilateral

Facility

$488.00

Service Code	CPT 70120 50
Hospital Charge Code	1008015
Hospital Revenue Code	320
Min. Negotiated Rate	$78.08
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Aetna of AZ Medicare	$136.64
Rate for Payer: Allwell Medicare	$78.08
Rate for Payer: Amerigroup Medicare	$78.08
Rate for Payer: APIPA Medicare/Medicaid	$182.27
Rate for Payer: AZCH Complete Medicare	$78.08
Rate for Payer: Banner UC Health Medicare	$78.08
Rate for Payer: Bisbee Police All Plans	$126.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$331.84
Rate for Payer: Cash Price	$390.40
Rate for Payer: Cigna of AZ Commercial	$317.20
Rate for Payer: Copperpoint Commercial	$120.78
Rate for Payer: Health Net of AZ Commercial	$292.80
Rate for Payer: Health Net of AZ Medicare	$136.64
Rate for Payer: Humana of AZ Medicare	$78.08
Rate for Payer: Self Pay Self Pay	$390.40
Rate for Payer: TriWest Medicare	$78.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$284.50
Rate for Payer: UnitedHealth Group of AZ Medicare	$87.84

XR Mastoids < 3 Views Left

Facility

$488.00

Service Code	CPT 70120 LT
Hospital Charge Code	3381503
Hospital Revenue Code	320
Min. Negotiated Rate	$78.08
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Aetna of AZ Medicare	$136.64
Rate for Payer: Allwell Medicare	$78.08
Rate for Payer: Amerigroup Medicare	$78.08
Rate for Payer: APIPA Medicare/Medicaid	$182.27
Rate for Payer: AZCH Complete Medicare	$78.08
Rate for Payer: Banner UC Health Medicare	$78.08
Rate for Payer: Bisbee Police All Plans	$126.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$331.84
Rate for Payer: Cash Price	$390.40
Rate for Payer: Cigna of AZ Commercial	$317.20
Rate for Payer: Copperpoint Commercial	$120.78
Rate for Payer: Health Net of AZ Commercial	$292.80
Rate for Payer: Health Net of AZ Medicare	$136.64
Rate for Payer: Humana of AZ Medicare	$78.08
Rate for Payer: Self Pay Self Pay	$390.40
Rate for Payer: TriWest Medicare	$78.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$284.50
Rate for Payer: UnitedHealth Group of AZ Medicare	$87.84

XR Mastoids < 3 Views Left

Facility

$488.00

Service Code	CPT 70120 LT
Hospital Charge Code	3381503
Hospital Revenue Code	320
Min. Negotiated Rate	$126.88
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Bisbee Police All Plans	$126.88
Rate for Payer: Cash Price	$390.40
Rate for Payer: Self Pay Self Pay	$390.40

XR Mastoids < 3 Views Right

Facility

$488.00

Service Code	CPT 70120 RT
Hospital Charge Code	3381505
Hospital Revenue Code	320
Min. Negotiated Rate	$126.88
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Bisbee Police All Plans	$126.88
Rate for Payer: Cash Price	$390.40
Rate for Payer: Self Pay Self Pay	$390.40

Know your out-of-pocket cost for care.

All Charges