Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

XR Spine Lumbosacral Bending Only

Facility

$923.00

Service Code	CPT 72120
Hospital Charge Code	1163883
Hospital Revenue Code	320
Min. Negotiated Rate	$239.98
Max. Negotiated Rate	$830.70
Rate for Payer: Aetna of AZ Commercial	$830.70
Rate for Payer: Bisbee Police All Plans	$239.98
Rate for Payer: Cash Price	$738.40
Rate for Payer: Self Pay Self Pay	$738.40

XR Spine Lumbosacral Bending Only

Facility

$923.00

Service Code	CPT 72120
Hospital Charge Code	1163883
Hospital Revenue Code	320
Min. Negotiated Rate	$147.68
Max. Negotiated Rate	$830.70
Rate for Payer: Aetna of AZ Commercial	$830.70
Rate for Payer: Aetna of AZ Medicare	$258.44
Rate for Payer: Allwell Medicare	$147.68
Rate for Payer: Amerigroup Medicare	$147.68
Rate for Payer: APIPA Medicare/Medicaid	$344.74
Rate for Payer: AZCH Complete Medicare	$147.68
Rate for Payer: Banner UC Health Medicare	$147.68
Rate for Payer: Bisbee Police All Plans	$239.98
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$627.64
Rate for Payer: Cash Price	$738.40
Rate for Payer: Cigna of AZ Commercial	$599.95
Rate for Payer: Copperpoint Commercial	$228.44
Rate for Payer: Health Net of AZ Commercial	$553.80
Rate for Payer: Health Net of AZ Medicare	$258.44
Rate for Payer: Humana of AZ Medicare	$147.68
Rate for Payer: Self Pay Self Pay	$738.40
Rate for Payer: TriWest Medicare	$147.68
Rate for Payer: UnitedHealth Group of AZ Commercial	$538.11
Rate for Payer: UnitedHealth Group of AZ Medicare	$166.14

XR Spine Lumbosacral Complete w/ Bending

Facility

$843.00

Service Code	CPT 72114
Hospital Charge Code	1008092
Hospital Revenue Code	320
Min. Negotiated Rate	$219.18
Max. Negotiated Rate	$758.70
Rate for Payer: Aetna of AZ Commercial	$758.70
Rate for Payer: Bisbee Police All Plans	$219.18
Rate for Payer: Cash Price	$674.40
Rate for Payer: Self Pay Self Pay	$674.40

XR Spine Lumbosacral Complete w/ Bending

Facility

$843.00

Service Code	CPT 72114
Hospital Charge Code	1008092
Hospital Revenue Code	320
Min. Negotiated Rate	$134.88
Max. Negotiated Rate	$758.70
Rate for Payer: Aetna of AZ Commercial	$758.70
Rate for Payer: Aetna of AZ Medicare	$236.04
Rate for Payer: Allwell Medicare	$134.88
Rate for Payer: Amerigroup Medicare	$134.88
Rate for Payer: APIPA Medicare/Medicaid	$314.86
Rate for Payer: AZCH Complete Medicare	$134.88
Rate for Payer: Banner UC Health Medicare	$134.88
Rate for Payer: Bisbee Police All Plans	$219.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$573.24
Rate for Payer: Cash Price	$674.40
Rate for Payer: Cigna of AZ Commercial	$547.95
Rate for Payer: Copperpoint Commercial	$208.64
Rate for Payer: Health Net of AZ Commercial	$505.80
Rate for Payer: Health Net of AZ Medicare	$236.04
Rate for Payer: Humana of AZ Medicare	$134.88
Rate for Payer: Self Pay Self Pay	$674.40
Rate for Payer: TriWest Medicare	$134.88
Rate for Payer: UnitedHealth Group of AZ Commercial	$491.47
Rate for Payer: UnitedHealth Group of AZ Medicare	$151.74

XR Spine Lumbosacral Minimum 4 Views

Facility

$843.00

Service Code	CPT 72110
Hospital Charge Code	823643
Hospital Revenue Code	320
Min. Negotiated Rate	$134.88
Max. Negotiated Rate	$758.70
Rate for Payer: Aetna of AZ Commercial	$758.70
Rate for Payer: Aetna of AZ Medicare	$236.04
Rate for Payer: Allwell Medicare	$134.88
Rate for Payer: Amerigroup Medicare	$134.88
Rate for Payer: APIPA Medicare/Medicaid	$314.86
Rate for Payer: AZCH Complete Medicare	$134.88
Rate for Payer: Banner UC Health Medicare	$134.88
Rate for Payer: Bisbee Police All Plans	$219.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$573.24
Rate for Payer: Cash Price	$674.40
Rate for Payer: Cigna of AZ Commercial	$547.95
Rate for Payer: Copperpoint Commercial	$208.64
Rate for Payer: Health Net of AZ Commercial	$505.80
Rate for Payer: Health Net of AZ Medicare	$236.04
Rate for Payer: Humana of AZ Medicare	$134.88
Rate for Payer: Self Pay Self Pay	$674.40
Rate for Payer: TriWest Medicare	$134.88
Rate for Payer: UnitedHealth Group of AZ Commercial	$491.47
Rate for Payer: UnitedHealth Group of AZ Medicare	$151.74

XR Spine Lumbosacral Minimum 4 Views

Facility

$843.00

Service Code	CPT 72110
Hospital Charge Code	823643
Hospital Revenue Code	320
Min. Negotiated Rate	$219.18
Max. Negotiated Rate	$758.70
Rate for Payer: Aetna of AZ Commercial	$758.70
Rate for Payer: Bisbee Police All Plans	$219.18
Rate for Payer: Cash Price	$674.40
Rate for Payer: Self Pay Self Pay	$674.40

XR Spine Scoliosis Study Standing

Facility

$863.00

Service Code	CPT 72082
Hospital Charge Code	823645
Hospital Revenue Code	320
Min. Negotiated Rate	$224.38
Max. Negotiated Rate	$776.70
Rate for Payer: Aetna of AZ Commercial	$776.70
Rate for Payer: Bisbee Police All Plans	$224.38
Rate for Payer: Cash Price	$690.40
Rate for Payer: Self Pay Self Pay	$690.40

XR Spine Scoliosis Study Standing

Facility

$863.00

Service Code	CPT 72082
Hospital Charge Code	823645
Hospital Revenue Code	320
Min. Negotiated Rate	$138.08
Max. Negotiated Rate	$776.70
Rate for Payer: Aetna of AZ Commercial	$776.70
Rate for Payer: Aetna of AZ Medicare	$241.64
Rate for Payer: Allwell Medicare	$138.08
Rate for Payer: Amerigroup Medicare	$138.08
Rate for Payer: APIPA Medicare/Medicaid	$322.33
Rate for Payer: AZCH Complete Medicare	$138.08
Rate for Payer: Banner UC Health Medicare	$138.08
Rate for Payer: Bisbee Police All Plans	$224.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$586.84
Rate for Payer: Cash Price	$690.40
Rate for Payer: Cigna of AZ Commercial	$560.95
Rate for Payer: Copperpoint Commercial	$213.59
Rate for Payer: Health Net of AZ Commercial	$517.80
Rate for Payer: Health Net of AZ Medicare	$241.64
Rate for Payer: Humana of AZ Medicare	$138.08
Rate for Payer: Self Pay Self Pay	$690.40
Rate for Payer: TriWest Medicare	$138.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$503.13
Rate for Payer: UnitedHealth Group of AZ Medicare	$155.34

XR Spine Thoracic 3 Views

Facility

$460.00

Service Code	CPT 72072
Hospital Charge Code	823649
Hospital Revenue Code	320
Min. Negotiated Rate	$73.60
Max. Negotiated Rate	$414.00
Rate for Payer: Aetna of AZ Commercial	$414.00
Rate for Payer: Aetna of AZ Medicare	$128.80
Rate for Payer: Allwell Medicare	$73.60
Rate for Payer: Amerigroup Medicare	$73.60
Rate for Payer: APIPA Medicare/Medicaid	$171.81
Rate for Payer: AZCH Complete Medicare	$73.60
Rate for Payer: Banner UC Health Medicare	$73.60
Rate for Payer: Bisbee Police All Plans	$119.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$312.80
Rate for Payer: Cash Price	$368.00
Rate for Payer: Cigna of AZ Commercial	$299.00
Rate for Payer: Copperpoint Commercial	$113.85
Rate for Payer: Health Net of AZ Commercial	$276.00
Rate for Payer: Health Net of AZ Medicare	$128.80
Rate for Payer: Humana of AZ Medicare	$73.60
Rate for Payer: Self Pay Self Pay	$368.00
Rate for Payer: TriWest Medicare	$73.60
Rate for Payer: UnitedHealth Group of AZ Commercial	$268.18
Rate for Payer: UnitedHealth Group of AZ Medicare	$82.80

XR Spine Thoracic 3 Views

Facility

$460.00

Service Code	CPT 72072
Hospital Charge Code	823649
Hospital Revenue Code	320
Min. Negotiated Rate	$119.60
Max. Negotiated Rate	$414.00
Rate for Payer: Aetna of AZ Commercial	$414.00
Rate for Payer: Bisbee Police All Plans	$119.60
Rate for Payer: Cash Price	$368.00
Rate for Payer: Self Pay Self Pay	$368.00

XR Spine Thoracolumbar 2 Views

Facility

$464.00

Service Code	CPT 72080
Hospital Charge Code	1008101
Hospital Revenue Code	320
Min. Negotiated Rate	$120.64
Max. Negotiated Rate	$417.60
Rate for Payer: Aetna of AZ Commercial	$417.60
Rate for Payer: Bisbee Police All Plans	$120.64
Rate for Payer: Cash Price	$371.20
Rate for Payer: Self Pay Self Pay	$371.20

XR Spine Thoracolumbar 2 Views

Facility

$464.00

Service Code	CPT 72080
Hospital Charge Code	1008101
Hospital Revenue Code	320
Min. Negotiated Rate	$74.24
Max. Negotiated Rate	$417.60
Rate for Payer: Aetna of AZ Commercial	$417.60
Rate for Payer: Aetna of AZ Medicare	$129.92
Rate for Payer: Allwell Medicare	$74.24
Rate for Payer: Amerigroup Medicare	$74.24
Rate for Payer: APIPA Medicare/Medicaid	$173.30
Rate for Payer: AZCH Complete Medicare	$74.24
Rate for Payer: Banner UC Health Medicare	$74.24
Rate for Payer: Bisbee Police All Plans	$120.64
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$315.52
Rate for Payer: Cash Price	$371.20
Rate for Payer: Cigna of AZ Commercial	$301.60
Rate for Payer: Copperpoint Commercial	$114.84
Rate for Payer: Health Net of AZ Commercial	$278.40
Rate for Payer: Health Net of AZ Medicare	$129.92
Rate for Payer: Humana of AZ Medicare	$74.24
Rate for Payer: Self Pay Self Pay	$371.20
Rate for Payer: TriWest Medicare	$74.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$270.51
Rate for Payer: UnitedHealth Group of AZ Medicare	$83.52

XR Sternoclavicular Joint(s)

Facility

$478.00

Service Code	CPT 71130
Hospital Charge Code	823651
Hospital Revenue Code	320
Min. Negotiated Rate	$76.48
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Aetna of AZ Medicare	$133.84
Rate for Payer: Allwell Medicare	$76.48
Rate for Payer: Amerigroup Medicare	$76.48
Rate for Payer: APIPA Medicare/Medicaid	$178.53
Rate for Payer: AZCH Complete Medicare	$76.48
Rate for Payer: Banner UC Health Medicare	$76.48
Rate for Payer: Bisbee Police All Plans	$124.28
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$325.04
Rate for Payer: Cash Price	$382.40
Rate for Payer: Cigna of AZ Commercial	$310.70
Rate for Payer: Copperpoint Commercial	$118.31
Rate for Payer: Health Net of AZ Commercial	$286.80
Rate for Payer: Health Net of AZ Medicare	$133.84
Rate for Payer: Humana of AZ Medicare	$76.48
Rate for Payer: Self Pay Self Pay	$382.40
Rate for Payer: TriWest Medicare	$76.48
Rate for Payer: UnitedHealth Group of AZ Commercial	$278.67
Rate for Payer: UnitedHealth Group of AZ Medicare	$86.04

XR Sternoclavicular Joint(s)

Facility

$478.00

Service Code	CPT 71130
Hospital Charge Code	823651
Hospital Revenue Code	320
Min. Negotiated Rate	$124.28
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Bisbee Police All Plans	$124.28
Rate for Payer: Cash Price	$382.40
Rate for Payer: Self Pay Self Pay	$382.40

XR Sternum Minimum 2 Views

Facility

$646.00

Service Code	CPT 71120
Hospital Charge Code	823653
Hospital Revenue Code	320
Min. Negotiated Rate	$103.36
Max. Negotiated Rate	$581.40
Rate for Payer: Aetna of AZ Commercial	$581.40
Rate for Payer: Aetna of AZ Medicare	$180.88
Rate for Payer: Allwell Medicare	$103.36
Rate for Payer: Amerigroup Medicare	$103.36
Rate for Payer: APIPA Medicare/Medicaid	$241.28
Rate for Payer: AZCH Complete Medicare	$103.36
Rate for Payer: Banner UC Health Medicare	$103.36
Rate for Payer: Bisbee Police All Plans	$167.96
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$439.28
Rate for Payer: Cash Price	$516.80
Rate for Payer: Cigna of AZ Commercial	$419.90
Rate for Payer: Copperpoint Commercial	$159.88
Rate for Payer: Health Net of AZ Commercial	$387.60
Rate for Payer: Health Net of AZ Medicare	$180.88
Rate for Payer: Humana of AZ Medicare	$103.36
Rate for Payer: Self Pay Self Pay	$516.80
Rate for Payer: TriWest Medicare	$103.36
Rate for Payer: UnitedHealth Group of AZ Commercial	$376.62
Rate for Payer: UnitedHealth Group of AZ Medicare	$116.28

XR Sternum Minimum 2 Views

Facility

$646.00

Service Code	CPT 71120
Hospital Charge Code	823653
Hospital Revenue Code	320
Min. Negotiated Rate	$167.96
Max. Negotiated Rate	$581.40
Rate for Payer: Aetna of AZ Commercial	$581.40
Rate for Payer: Bisbee Police All Plans	$167.96
Rate for Payer: Cash Price	$516.80
Rate for Payer: Self Pay Self Pay	$516.80

XR Temporomandibular Joints

Facility

$739.00

Service Code	CPT 70330
Hospital Charge Code	1008107
Hospital Revenue Code	320
Min. Negotiated Rate	$118.24
Max. Negotiated Rate	$665.10
Rate for Payer: Aetna of AZ Commercial	$665.10
Rate for Payer: Aetna of AZ Medicare	$206.92
Rate for Payer: Allwell Medicare	$118.24
Rate for Payer: Amerigroup Medicare	$118.24
Rate for Payer: APIPA Medicare/Medicaid	$276.02
Rate for Payer: AZCH Complete Medicare	$118.24
Rate for Payer: Banner UC Health Medicare	$118.24
Rate for Payer: Bisbee Police All Plans	$192.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$502.52
Rate for Payer: Cash Price	$591.20
Rate for Payer: Cigna of AZ Commercial	$480.35
Rate for Payer: Copperpoint Commercial	$182.90
Rate for Payer: Health Net of AZ Commercial	$443.40
Rate for Payer: Health Net of AZ Medicare	$206.92
Rate for Payer: Humana of AZ Medicare	$118.24
Rate for Payer: Self Pay Self Pay	$591.20
Rate for Payer: TriWest Medicare	$118.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$430.84
Rate for Payer: UnitedHealth Group of AZ Medicare	$133.02

XR Temporomandibular Joints

Facility

$739.00

Service Code	CPT 70330
Hospital Charge Code	1008107
Hospital Revenue Code	320
Min. Negotiated Rate	$192.14
Max. Negotiated Rate	$665.10
Rate for Payer: Aetna of AZ Commercial	$665.10
Rate for Payer: Bisbee Police All Plans	$192.14
Rate for Payer: Cash Price	$591.20
Rate for Payer: Self Pay Self Pay	$591.20

XR Tibia/Fibula 2 Views Left

Facility

$537.00

Service Code	CPT 73590 LT
Hospital Charge Code	2214290
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 Tibia/Fibula 2 Views Left

Facility

$537.00

Service Code	CPT 73590 LT
Hospital Charge Code	2214290
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 Tibia/Fibula 2 Views Right

Facility

$537.00

Service Code	CPT 73590 RT
Hospital Charge Code	2214293
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 Tibia/Fibula 2 Views Right

Facility

$537.00

Service Code	CPT 73590 RT
Hospital Charge Code	2214293
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 Toes 2nd Digit Left

Facility

$464.00

Service Code	CPT 73660 T1
Hospital Charge Code	823659
Hospital Revenue Code	320
Min. Negotiated Rate	$74.24
Max. Negotiated Rate	$417.60
Rate for Payer: Aetna of AZ Commercial	$417.60
Rate for Payer: Aetna of AZ Medicare	$129.92
Rate for Payer: Allwell Medicare	$74.24
Rate for Payer: Amerigroup Medicare	$74.24
Rate for Payer: APIPA Medicare/Medicaid	$173.30
Rate for Payer: AZCH Complete Medicare	$74.24
Rate for Payer: Banner UC Health Medicare	$74.24
Rate for Payer: Bisbee Police All Plans	$120.64
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$315.52
Rate for Payer: Cash Price	$371.20
Rate for Payer: Cigna of AZ Commercial	$301.60
Rate for Payer: Copperpoint Commercial	$114.84
Rate for Payer: Health Net of AZ Commercial	$278.40
Rate for Payer: Health Net of AZ Medicare	$129.92
Rate for Payer: Humana of AZ Medicare	$74.24
Rate for Payer: Self Pay Self Pay	$371.20
Rate for Payer: TriWest Medicare	$74.24
Rate for Payer: UnitedHealth Group of AZ Commercial	$270.51
Rate for Payer: UnitedHealth Group of AZ Medicare	$83.52

XR Toes 2nd Digit Left

Facility

$464.00

Service Code	CPT 73660 T1
Hospital Charge Code	823659
Hospital Revenue Code	320
Min. Negotiated Rate	$120.64
Max. Negotiated Rate	$417.60
Rate for Payer: Aetna of AZ Commercial	$417.60
Rate for Payer: Bisbee Police All Plans	$120.64
Rate for Payer: Cash Price	$371.20
Rate for Payer: Self Pay Self Pay	$371.20

XR Toes 2nd Digit Right

Facility

$464.00

Service Code	CPT 73660 T6
Hospital Charge Code	823661
Hospital Revenue Code	320
Min. Negotiated Rate	$120.64
Max. Negotiated Rate	$417.60
Rate for Payer: Aetna of AZ Commercial	$417.60
Rate for Payer: Bisbee Police All Plans	$120.64
Rate for Payer: Cash Price	$371.20
Rate for Payer: Self Pay Self Pay	$371.20

Know your out-of-pocket cost for care.

All Charges