Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

XR Cystogram Non Voiding

Facility

$285.00

Service Code	CPT 74430
Hospital Charge Code	1319963
Hospital Revenue Code	320
Min. Negotiated Rate	$256.50
Max. Negotiated Rate	$256.50
Rate for Payer: Aetna of AZ Commercial	$256.50
Rate for Payer: Cash Price	$228.00

XR Cystogram Voiding

Facility

$308.00

Service Code	CPT 51600
Hospital Charge Code	1319966
Hospital Revenue Code	320
Min. Negotiated Rate	$35.05
Max. Negotiated Rate	$277.20
Rate for Payer: Aetna of AZ Commercial	$277.20
Rate for Payer: Arizona Complete Health Allwell	$49.28
Rate for Payer: Banner UC Health Medicare	$49.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$209.44
Rate for Payer: Blue Cross Blue Shield of Arizona Health Choice	$164.57
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$49.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$35.05
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cash Price	$246.40
Rate for Payer: Cigna of AZ Commercial	$200.20
Rate for Payer: Devoted Health Medicare	$55.44
Rate for Payer: Humana of AZ Medicare	$49.28
Rate for Payer: Mercy Care Medicaid	$164.57
Rate for Payer: NaphCare Correctional Healthcare	$164.57
Rate for Payer: Southwest Service Administrators UFCW	$209.44
Rate for Payer: TriWest Medicare	$49.28
Rate for Payer: United Healthcare Commercial	$176.18
Rate for Payer: United Healthcare Medicare	$49.28
Rate for Payer: Veterans Affairs TRICARE	$48.79

XR Cystogram Voiding

Facility

$308.00

Service Code	CPT 51600
Hospital Charge Code	1319966
Hospital Revenue Code	320
Min. Negotiated Rate	$277.20
Max. Negotiated Rate	$277.20
Rate for Payer: Aetna of AZ Commercial	$277.20
Rate for Payer: Cash Price	$246.40

XR Elbow 2 Views Left

Facility

$363.00

Service Code	CPT 73070 LT
Hospital Charge Code	823520
Hospital Revenue Code	320
Min. Negotiated Rate	$27.68
Max. Negotiated Rate	$326.70
Rate for Payer: Aetna of AZ Commercial	$326.70
Rate for Payer: Arizona Complete Health Allwell	$58.08
Rate for Payer: Banner UC Health Medicare	$58.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$246.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$58.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.68
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cigna of AZ Commercial	$235.95
Rate for Payer: Devoted Health Medicare	$65.34
Rate for Payer: Humana of AZ Medicare	$58.08
Rate for Payer: Southwest Service Administrators UFCW	$246.84
Rate for Payer: TriWest Medicare	$58.08
Rate for Payer: United Healthcare Commercial	$207.64
Rate for Payer: United Healthcare Medicare	$58.08
Rate for Payer: Veterans Affairs TRICARE	$57.50

XR Elbow 2 Views Left

Facility

$363.00

Service Code	CPT 73070 LT
Hospital Charge Code	823520
Hospital Revenue Code	320
Min. Negotiated Rate	$326.70
Max. Negotiated Rate	$326.70
Rate for Payer: Aetna of AZ Commercial	$326.70
Rate for Payer: Cash Price	$290.40

XR Elbow 2 Views Right

Facility

$363.00

Service Code	CPT 73070 RT
Hospital Charge Code	823522
Hospital Revenue Code	320
Min. Negotiated Rate	$326.70
Max. Negotiated Rate	$326.70
Rate for Payer: Aetna of AZ Commercial	$326.70
Rate for Payer: Cash Price	$290.40

XR Elbow 2 Views Right

Facility

$363.00

Service Code	CPT 73070 RT
Hospital Charge Code	823522
Hospital Revenue Code	320
Min. Negotiated Rate	$27.68
Max. Negotiated Rate	$326.70
Rate for Payer: Aetna of AZ Commercial	$326.70
Rate for Payer: Arizona Complete Health Allwell	$58.08
Rate for Payer: Banner UC Health Medicare	$58.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$246.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$58.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.68
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cigna of AZ Commercial	$235.95
Rate for Payer: Devoted Health Medicare	$65.34
Rate for Payer: Humana of AZ Medicare	$58.08
Rate for Payer: Southwest Service Administrators UFCW	$246.84
Rate for Payer: TriWest Medicare	$58.08
Rate for Payer: United Healthcare Commercial	$207.64
Rate for Payer: United Healthcare Medicare	$58.08
Rate for Payer: Veterans Affairs TRICARE	$57.50

XR Elbow Complete Left

Facility

$555.00

Service Code	CPT 73080 LT
Hospital Charge Code	1007932
Hospital Revenue Code	320
Min. Negotiated Rate	$31.22
Max. Negotiated Rate	$499.50
Rate for Payer: Aetna of AZ Commercial	$499.50
Rate for Payer: Arizona Complete Health Allwell	$88.80
Rate for Payer: Banner UC Health Medicare	$88.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$377.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$88.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.22
Rate for Payer: Cash Price	$444.00
Rate for Payer: Cash Price	$444.00
Rate for Payer: Cigna of AZ Commercial	$360.75
Rate for Payer: Devoted Health Medicare	$99.90
Rate for Payer: Humana of AZ Medicare	$88.80
Rate for Payer: Southwest Service Administrators UFCW	$377.40
Rate for Payer: TriWest Medicare	$88.80
Rate for Payer: United Healthcare Commercial	$317.46
Rate for Payer: United Healthcare Medicare	$88.80
Rate for Payer: Veterans Affairs TRICARE	$87.91

XR Elbow Complete Left

Facility

$555.00

Service Code	CPT 73080 LT
Hospital Charge Code	1007932
Hospital Revenue Code	320
Min. Negotiated Rate	$499.50
Max. Negotiated Rate	$499.50
Rate for Payer: Aetna of AZ Commercial	$499.50
Rate for Payer: Cash Price	$444.00

XR Elbow Complete Right

Facility

$555.00

Service Code	CPT 73080 RT
Hospital Charge Code	1007934
Hospital Revenue Code	320
Min. Negotiated Rate	$499.50
Max. Negotiated Rate	$499.50
Rate for Payer: Aetna of AZ Commercial	$499.50
Rate for Payer: Cash Price	$444.00

XR Elbow Complete Right

Facility

$555.00

Service Code	CPT 73080 RT
Hospital Charge Code	1007934
Hospital Revenue Code	320
Min. Negotiated Rate	$31.22
Max. Negotiated Rate	$499.50
Rate for Payer: Aetna of AZ Commercial	$499.50
Rate for Payer: Arizona Complete Health Allwell	$88.80
Rate for Payer: Banner UC Health Medicare	$88.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$377.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$88.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.22
Rate for Payer: Cash Price	$444.00
Rate for Payer: Cash Price	$444.00
Rate for Payer: Cigna of AZ Commercial	$360.75
Rate for Payer: Devoted Health Medicare	$99.90
Rate for Payer: Humana of AZ Medicare	$88.80
Rate for Payer: Southwest Service Administrators UFCW	$377.40
Rate for Payer: TriWest Medicare	$88.80
Rate for Payer: United Healthcare Commercial	$317.46
Rate for Payer: United Healthcare Medicare	$88.80
Rate for Payer: Veterans Affairs TRICARE	$87.91

XR Facial Bones < 3 Views

Facility

$426.00

Service Code	CPT 70140
Hospital Charge Code	823524
Hospital Revenue Code	320
Min. Negotiated Rate	$29.32
Max. Negotiated Rate	$383.40
Rate for Payer: Aetna of AZ Commercial	$383.40
Rate for Payer: Arizona Complete Health Allwell	$68.16
Rate for Payer: Banner UC Health Medicare	$68.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$289.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$68.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$29.32
Rate for Payer: Cash Price	$340.80
Rate for Payer: Cash Price	$340.80
Rate for Payer: Cigna of AZ Commercial	$276.90
Rate for Payer: Devoted Health Medicare	$76.68
Rate for Payer: Humana of AZ Medicare	$68.16
Rate for Payer: Seven Corners Travel Insurance	$134.65
Rate for Payer: Southwest Service Administrators UFCW	$289.68
Rate for Payer: TriWest Medicare	$68.16
Rate for Payer: United Healthcare Commercial	$243.67
Rate for Payer: United Healthcare Medicare	$68.16
Rate for Payer: Veterans Affairs TRICARE	$67.48

XR Facial Bones < 3 Views

Facility

$426.00

Service Code	CPT 70140
Hospital Charge Code	823524
Hospital Revenue Code	320
Min. Negotiated Rate	$383.40
Max. Negotiated Rate	$383.40
Rate for Payer: Aetna of AZ Commercial	$383.40
Rate for Payer: Cash Price	$340.80

XR Facial Bones Minimum 3 Views

Facility

$850.00

Service Code	CPT 70150
Hospital Charge Code	823526
Hospital Revenue Code	320
Min. Negotiated Rate	$43.34
Max. Negotiated Rate	$765.00
Rate for Payer: Aetna of AZ Commercial	$765.00
Rate for Payer: Arizona Complete Health Allwell	$136.00
Rate for Payer: Banner UC Health Medicare	$136.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$578.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$136.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.34
Rate for Payer: Cash Price	$680.00
Rate for Payer: Cash Price	$680.00
Rate for Payer: Cigna of AZ Commercial	$552.50
Rate for Payer: Devoted Health Medicare	$153.00
Rate for Payer: Humana of AZ Medicare	$136.00
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$578.00
Rate for Payer: TriWest Medicare	$136.00
Rate for Payer: United Healthcare Commercial	$486.20
Rate for Payer: United Healthcare Medicare	$136.00
Rate for Payer: Veterans Affairs TRICARE	$134.64

XR Facial Bones Minimum 3 Views

Facility

$850.00

Service Code	CPT 70150
Hospital Charge Code	823526
Hospital Revenue Code	320
Min. Negotiated Rate	$765.00
Max. Negotiated Rate	$765.00
Rate for Payer: Aetna of AZ Commercial	$765.00
Rate for Payer: Cash Price	$680.00

XR Femur 1 View Left

Facility

$445.00

Service Code	CPT 73551 LT
Hospital Charge Code	2160505
Hospital Revenue Code	320
Min. Negotiated Rate	$400.50
Max. Negotiated Rate	$400.50
Rate for Payer: Aetna of AZ Commercial	$400.50
Rate for Payer: Cash Price	$356.00

XR Femur 1 View Left

Facility

$445.00

Service Code	CPT 73551 LT
Hospital Charge Code	2160505
Hospital Revenue Code	320
Min. Negotiated Rate	$27.68
Max. Negotiated Rate	$400.50
Rate for Payer: Aetna of AZ Commercial	$400.50
Rate for Payer: Arizona Complete Health Allwell	$71.20
Rate for Payer: Banner UC Health Medicare	$71.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$302.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$71.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.68
Rate for Payer: Cash Price	$356.00
Rate for Payer: Cash Price	$356.00
Rate for Payer: Cigna of AZ Commercial	$289.25
Rate for Payer: Devoted Health Medicare	$80.10
Rate for Payer: Humana of AZ Medicare	$71.20
Rate for Payer: Southwest Service Administrators UFCW	$302.60
Rate for Payer: TriWest Medicare	$71.20
Rate for Payer: United Healthcare Commercial	$254.54
Rate for Payer: United Healthcare Medicare	$71.20
Rate for Payer: Veterans Affairs TRICARE	$70.49

XR Femur 1 View Left

Facility

$30.00

Service Code	CPT 73551 LT
Hospital Charge Code	22862300
Hospital Revenue Code	972
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Arizona Complete Health Allwell	$4.80
Rate for Payer: Banner UC Health Medicare	$4.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$20.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna of AZ Commercial	$21.00
Rate for Payer: Devoted Health Medicare	$5.40
Rate for Payer: Humana of AZ Medicare	$4.80
Rate for Payer: Southwest Service Administrators UFCW	$20.40
Rate for Payer: TriWest Medicare	$4.80
Rate for Payer: United Healthcare Commercial	$17.16
Rate for Payer: United Healthcare Medicare	$4.80
Rate for Payer: United Healthcare New Mexico Commercial	$5.70
Rate for Payer: Veterans Affairs TRICARE	$4.75

XR Femur 1 View Left

Facility

$30.00

Service Code	CPT 73551 LT
Hospital Charge Code	22862300
Hospital Revenue Code	972
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Cash Price	$24.00

XR Femur 1 View Right

Facility

$445.00

Service Code	CPT 73551 RT
Hospital Charge Code	2160508
Hospital Revenue Code	320
Min. Negotiated Rate	$400.50
Max. Negotiated Rate	$400.50
Rate for Payer: Aetna of AZ Commercial	$400.50
Rate for Payer: Cash Price	$356.00

XR Femur 1 View Right

Facility

$445.00

Service Code	CPT 73551 RT
Hospital Charge Code	2160508
Hospital Revenue Code	320
Min. Negotiated Rate	$27.68
Max. Negotiated Rate	$400.50
Rate for Payer: Aetna of AZ Commercial	$400.50
Rate for Payer: Arizona Complete Health Allwell	$71.20
Rate for Payer: Banner UC Health Medicare	$71.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$302.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$71.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$27.68
Rate for Payer: Cash Price	$356.00
Rate for Payer: Cash Price	$356.00
Rate for Payer: Cigna of AZ Commercial	$289.25
Rate for Payer: Devoted Health Medicare	$80.10
Rate for Payer: Humana of AZ Medicare	$71.20
Rate for Payer: Southwest Service Administrators UFCW	$302.60
Rate for Payer: TriWest Medicare	$71.20
Rate for Payer: United Healthcare Commercial	$254.54
Rate for Payer: United Healthcare Medicare	$71.20
Rate for Payer: Veterans Affairs TRICARE	$70.49

XR Femur 2 Views Left

Facility

$421.00

Service Code	CPT 73552
Hospital Charge Code	2214248
Hospital Revenue Code	320
Min. Negotiated Rate	$378.90
Max. Negotiated Rate	$378.90
Rate for Payer: Aetna of AZ Commercial	$378.90
Rate for Payer: Cash Price	$336.80

XR Femur 2 Views Left

Facility

$421.00

Service Code	CPT 73552
Hospital Charge Code	2214248
Hospital Revenue Code	320
Min. Negotiated Rate	$33.80
Max. Negotiated Rate	$378.90
Rate for Payer: Aetna of AZ Commercial	$378.90
Rate for Payer: Arizona Complete Health Allwell	$67.36
Rate for Payer: Banner UC Health Medicare	$67.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$286.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$67.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$33.80
Rate for Payer: Cash Price	$336.80
Rate for Payer: Cash Price	$336.80
Rate for Payer: Cigna of AZ Commercial	$273.65
Rate for Payer: Devoted Health Medicare	$75.78
Rate for Payer: Humana of AZ Medicare	$67.36
Rate for Payer: Seven Corners Travel Insurance	$134.65
Rate for Payer: Southwest Service Administrators UFCW	$286.28
Rate for Payer: TriWest Medicare	$67.36
Rate for Payer: United Healthcare Commercial	$240.81
Rate for Payer: United Healthcare Medicare	$67.36
Rate for Payer: Veterans Affairs TRICARE	$66.69

XR Femur 2 Views Right

Facility

$421.00

Service Code	CPT 73552
Hospital Charge Code	2214251
Hospital Revenue Code	320
Min. Negotiated Rate	$378.90
Max. Negotiated Rate	$378.90
Rate for Payer: Aetna of AZ Commercial	$378.90
Rate for Payer: Cash Price	$336.80

XR Femur 2 Views Right

Facility

$421.00

Service Code	CPT 73552
Hospital Charge Code	2214251
Hospital Revenue Code	320
Min. Negotiated Rate	$33.80
Max. Negotiated Rate	$378.90
Rate for Payer: Aetna of AZ Commercial	$378.90
Rate for Payer: Arizona Complete Health Allwell	$67.36
Rate for Payer: Banner UC Health Medicare	$67.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$286.28
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$67.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$33.80
Rate for Payer: Cash Price	$336.80
Rate for Payer: Cash Price	$336.80
Rate for Payer: Cigna of AZ Commercial	$273.65
Rate for Payer: Devoted Health Medicare	$75.78
Rate for Payer: Humana of AZ Medicare	$67.36
Rate for Payer: Seven Corners Travel Insurance	$134.65
Rate for Payer: Southwest Service Administrators UFCW	$286.28
Rate for Payer: TriWest Medicare	$67.36
Rate for Payer: United Healthcare Commercial	$240.81
Rate for Payer: United Healthcare Medicare	$67.36
Rate for Payer: Veterans Affairs TRICARE	$66.69

Know your out-of-pocket cost for care.

All Charges