Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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	$483.30
Max. Negotiated Rate	$483.30
Rate for Payer: Aetna of AZ Commercial	$483.30
Rate for Payer: Cash Price	$429.60

XR Knee Standing AP Bilateral

Facility

$494.00

Service Code	CPT 73565 50
Hospital Charge Code	1008002
Hospital Revenue Code	320
Min. Negotiated Rate	$37.66
Max. Negotiated Rate	$444.60
Rate for Payer: Aetna of AZ Commercial	$444.60
Rate for Payer: Arizona Complete Health Allwell	$79.04
Rate for Payer: Banner UC Health Medicare	$79.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$335.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$79.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.66
Rate for Payer: Cash Price	$395.20
Rate for Payer: Cash Price	$395.20
Rate for Payer: Cigna of AZ Commercial	$321.10
Rate for Payer: Devoted Health Medicare	$88.92
Rate for Payer: Humana of AZ Medicare	$79.04
Rate for Payer: Southwest Service Administrators UFCW	$335.92
Rate for Payer: TriWest Medicare	$79.04
Rate for Payer: United Healthcare Commercial	$282.57
Rate for Payer: United Healthcare Medicare	$79.04
Rate for Payer: Veterans Affairs TRICARE	$78.25

XR Knee Standing AP Bilateral

Facility

$494.00

Service Code	CPT 73565 50
Hospital Charge Code	1008002
Hospital Revenue Code	320
Min. Negotiated Rate	$444.60
Max. Negotiated Rate	$444.60
Rate for Payer: Aetna of AZ Commercial	$444.60
Rate for Payer: Cash Price	$395.20

XR Mandible Complete Minimum 4 Views

Facility

$854.00

Service Code	CPT 70110
Hospital Charge Code	823600
Hospital Revenue Code	320
Min. Negotiated Rate	$40.15
Max. Negotiated Rate	$768.60
Rate for Payer: Aetna of AZ Commercial	$768.60
Rate for Payer: Arizona Complete Health Allwell	$136.64
Rate for Payer: Banner UC Health Medicare	$136.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$580.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$136.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$40.15
Rate for Payer: Cash Price	$683.20
Rate for Payer: Cash Price	$683.20
Rate for Payer: Cigna of AZ Commercial	$555.10
Rate for Payer: Devoted Health Medicare	$153.72
Rate for Payer: Humana of AZ Medicare	$136.64
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$580.72
Rate for Payer: TriWest Medicare	$136.64
Rate for Payer: United Healthcare Commercial	$488.49
Rate for Payer: United Healthcare Medicare	$136.64
Rate for Payer: Veterans Affairs TRICARE	$135.27

XR Mandible Complete Minimum 4 Views

Facility

$854.00

Service Code	CPT 70110
Hospital Charge Code	823600
Hospital Revenue Code	320
Min. Negotiated Rate	$768.60
Max. Negotiated Rate	$768.60
Rate for Payer: Aetna of AZ Commercial	$768.60
Rate for Payer: Cash Price	$683.20

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	$421.20
Max. Negotiated Rate	$421.20
Rate for Payer: Aetna of AZ Commercial	$421.20
Rate for Payer: Cash Price	$374.40

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	$37.60
Max. Negotiated Rate	$421.20
Rate for Payer: Aetna of AZ Commercial	$421.20
Rate for Payer: Arizona Complete Health Allwell	$74.88
Rate for Payer: Banner UC Health Medicare	$74.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$318.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$74.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.60
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cigna of AZ Commercial	$304.20
Rate for Payer: Devoted Health Medicare	$84.24
Rate for Payer: Humana of AZ Medicare	$74.88
Rate for Payer: Seven Corners Travel Insurance	$134.65
Rate for Payer: Southwest Service Administrators UFCW	$318.24
Rate for Payer: TriWest Medicare	$74.88
Rate for Payer: United Healthcare Commercial	$267.70
Rate for Payer: United Healthcare Medicare	$74.88
Rate for Payer: Veterans Affairs TRICARE	$74.13

XR Mastoids < 3 Views Bilateral

Facility

$488.00

Service Code	CPT 70120 50
Hospital Charge Code	1008015
Hospital Revenue Code	320
Min. Negotiated Rate	$36.01
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Arizona Complete Health Allwell	$78.08
Rate for Payer: Banner UC Health Medicare	$78.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$331.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$78.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.01
Rate for Payer: Cash Price	$390.40
Rate for Payer: Cash Price	$390.40
Rate for Payer: Cigna of AZ Commercial	$317.20
Rate for Payer: Devoted Health Medicare	$87.84
Rate for Payer: Humana of AZ Medicare	$78.08
Rate for Payer: Southwest Service Administrators UFCW	$331.84
Rate for Payer: TriWest Medicare	$78.08
Rate for Payer: United Healthcare Commercial	$279.14
Rate for Payer: United Healthcare Medicare	$78.08
Rate for Payer: Veterans Affairs TRICARE	$77.30

XR Mastoids < 3 Views Bilateral

Facility

$488.00

Service Code	CPT 70120 50
Hospital Charge Code	1008015
Hospital Revenue Code	320
Min. Negotiated Rate	$439.20
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Cash Price	$390.40

XR Mastoids < 3 Views Left

Facility

$488.00

Service Code	CPT 70120 LT
Hospital Charge Code	3381503
Hospital Revenue Code	320
Min. Negotiated Rate	$439.20
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Cash Price	$390.40

XR Mastoids < 3 Views Left

Facility

$488.00

Service Code	CPT 70120 LT
Hospital Charge Code	3381503
Hospital Revenue Code	320
Min. Negotiated Rate	$36.01
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Arizona Complete Health Allwell	$78.08
Rate for Payer: Banner UC Health Medicare	$78.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$331.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$78.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.01
Rate for Payer: Cash Price	$390.40
Rate for Payer: Cash Price	$390.40
Rate for Payer: Cigna of AZ Commercial	$317.20
Rate for Payer: Devoted Health Medicare	$87.84
Rate for Payer: Humana of AZ Medicare	$78.08
Rate for Payer: Southwest Service Administrators UFCW	$331.84
Rate for Payer: TriWest Medicare	$78.08
Rate for Payer: United Healthcare Commercial	$279.14
Rate for Payer: United Healthcare Medicare	$78.08
Rate for Payer: Veterans Affairs TRICARE	$77.30

XR Mastoids < 3 Views Right

Facility

$488.00

Service Code	CPT 70120 RT
Hospital Charge Code	3381505
Hospital Revenue Code	320
Min. Negotiated Rate	$36.01
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Arizona Complete Health Allwell	$78.08
Rate for Payer: Banner UC Health Medicare	$78.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$331.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$78.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$36.01
Rate for Payer: Cash Price	$390.40
Rate for Payer: Cash Price	$390.40
Rate for Payer: Cigna of AZ Commercial	$317.20
Rate for Payer: Devoted Health Medicare	$87.84
Rate for Payer: Humana of AZ Medicare	$78.08
Rate for Payer: Southwest Service Administrators UFCW	$331.84
Rate for Payer: TriWest Medicare	$78.08
Rate for Payer: United Healthcare Commercial	$279.14
Rate for Payer: United Healthcare Medicare	$78.08
Rate for Payer: Veterans Affairs TRICARE	$77.30

XR Mastoids < 3 Views Right

Facility

$488.00

Service Code	CPT 70120 RT
Hospital Charge Code	3381505
Hospital Revenue Code	320
Min. Negotiated Rate	$439.20
Max. Negotiated Rate	$439.20
Rate for Payer: Aetna of AZ Commercial	$439.20
Rate for Payer: Cash Price	$390.40

XR Mastoids Complete Bilateral

Facility

$972.00

Service Code	CPT 70130 50
Hospital Charge Code	1008017
Hospital Revenue Code	320
Min. Negotiated Rate	$874.80
Max. Negotiated Rate	$874.80
Rate for Payer: Aetna of AZ Commercial	$874.80
Rate for Payer: Cash Price	$777.60

XR Mastoids Complete Bilateral

Facility

$972.00

Service Code	CPT 70130 50
Hospital Charge Code	1008017
Hospital Revenue Code	320
Min. Negotiated Rate	$56.73
Max. Negotiated Rate	$874.80
Rate for Payer: Aetna of AZ Commercial	$874.80
Rate for Payer: Arizona Complete Health Allwell	$155.52
Rate for Payer: Banner UC Health Medicare	$155.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$660.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$155.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$56.73
Rate for Payer: Cash Price	$777.60
Rate for Payer: Cash Price	$777.60
Rate for Payer: Cigna of AZ Commercial	$631.80
Rate for Payer: Devoted Health Medicare	$174.96
Rate for Payer: Humana of AZ Medicare	$155.52
Rate for Payer: Southwest Service Administrators UFCW	$660.96
Rate for Payer: TriWest Medicare	$155.52
Rate for Payer: United Healthcare Commercial	$555.98
Rate for Payer: United Healthcare Medicare	$155.52
Rate for Payer: Veterans Affairs TRICARE	$153.96

XR Mastoids Complete Left

Facility

$972.00

Service Code	CPT 70130 LT
Hospital Charge Code	1021647
Hospital Revenue Code	320
Min. Negotiated Rate	$56.73
Max. Negotiated Rate	$874.80
Rate for Payer: Aetna of AZ Commercial	$874.80
Rate for Payer: Arizona Complete Health Allwell	$155.52
Rate for Payer: Banner UC Health Medicare	$155.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$660.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$155.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$56.73
Rate for Payer: Cash Price	$777.60
Rate for Payer: Cash Price	$777.60
Rate for Payer: Cigna of AZ Commercial	$631.80
Rate for Payer: Devoted Health Medicare	$174.96
Rate for Payer: Humana of AZ Medicare	$155.52
Rate for Payer: Southwest Service Administrators UFCW	$660.96
Rate for Payer: TriWest Medicare	$155.52
Rate for Payer: United Healthcare Commercial	$555.98
Rate for Payer: United Healthcare Medicare	$155.52
Rate for Payer: Veterans Affairs TRICARE	$153.96

XR Mastoids Complete Left

Facility

$972.00

Service Code	CPT 70130 LT
Hospital Charge Code	1021647
Hospital Revenue Code	320
Min. Negotiated Rate	$874.80
Max. Negotiated Rate	$874.80
Rate for Payer: Aetna of AZ Commercial	$874.80
Rate for Payer: Cash Price	$777.60

XR Mastoids Complete Right

Facility

$972.00

Service Code	CPT 70130 RT
Hospital Charge Code	1021649
Hospital Revenue Code	320
Min. Negotiated Rate	$56.73
Max. Negotiated Rate	$874.80
Rate for Payer: Aetna of AZ Commercial	$874.80
Rate for Payer: Arizona Complete Health Allwell	$155.52
Rate for Payer: Banner UC Health Medicare	$155.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$660.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$155.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$56.73
Rate for Payer: Cash Price	$777.60
Rate for Payer: Cash Price	$777.60
Rate for Payer: Cigna of AZ Commercial	$631.80
Rate for Payer: Devoted Health Medicare	$174.96
Rate for Payer: Humana of AZ Medicare	$155.52
Rate for Payer: Southwest Service Administrators UFCW	$660.96
Rate for Payer: TriWest Medicare	$155.52
Rate for Payer: United Healthcare Commercial	$555.98
Rate for Payer: United Healthcare Medicare	$155.52
Rate for Payer: Veterans Affairs TRICARE	$153.96

XR Mastoids Complete Right

Facility

$972.00

Service Code	CPT 70130 RT
Hospital Charge Code	1021649
Hospital Revenue Code	320
Min. Negotiated Rate	$874.80
Max. Negotiated Rate	$874.80
Rate for Payer: Aetna of AZ Commercial	$874.80
Rate for Payer: Cash Price	$777.60

XR Nasal Bones Minimum 3 Views

Facility

$555.00

Service Code	CPT 70160
Hospital Charge Code	823602
Hospital Revenue Code	320
Min. Negotiated Rate	$34.74
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	$34.74
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: Seven Corners Travel Insurance	$134.65
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 Nasal Bones Minimum 3 Views

Facility

$555.00

Service Code	CPT 70160
Hospital Charge Code	823602
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 Neck Soft Tissue

Facility

$170.00

Service Code	CPT 70360
Hospital Charge Code	823604
Hospital Revenue Code	320
Min. Negotiated Rate	$26.93
Max. Negotiated Rate	$153.00
Rate for Payer: Aetna of AZ Commercial	$153.00
Rate for Payer: Arizona Complete Health Allwell	$27.20
Rate for Payer: Banner UC Health Medicare	$27.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$115.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$27.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$28.68
Rate for Payer: Cash Price	$136.00
Rate for Payer: Cash Price	$136.00
Rate for Payer: Cigna of AZ Commercial	$110.50
Rate for Payer: Devoted Health Medicare	$30.60
Rate for Payer: Humana of AZ Medicare	$27.20
Rate for Payer: Seven Corners Travel Insurance	$134.65
Rate for Payer: Southwest Service Administrators UFCW	$115.60
Rate for Payer: TriWest Medicare	$27.20
Rate for Payer: United Healthcare Commercial	$97.24
Rate for Payer: United Healthcare Medicare	$27.20
Rate for Payer: Veterans Affairs TRICARE	$26.93

XR Neck Soft Tissue

Facility

$170.00

Service Code	CPT 70360
Hospital Charge Code	823604
Hospital Revenue Code	320
Min. Negotiated Rate	$153.00
Max. Negotiated Rate	$153.00
Rate for Payer: Aetna of AZ Commercial	$153.00
Rate for Payer: Cash Price	$136.00

XR Optic Foramina

Facility

$305.00

Service Code	CPT 70190
Hospital Charge Code	1008029
Hospital Revenue Code	320
Min. Negotiated Rate	$274.50
Max. Negotiated Rate	$274.50
Rate for Payer: Aetna of AZ Commercial	$274.50
Rate for Payer: Cash Price	$244.00

XR Optic Foramina

Facility

$305.00

Service Code	CPT 70190
Hospital Charge Code	1008029
Hospital Revenue Code	320
Min. Negotiated Rate	$34.10
Max. Negotiated Rate	$274.50
Rate for Payer: Aetna of AZ Commercial	$274.50
Rate for Payer: Arizona Complete Health Allwell	$48.80
Rate for Payer: Banner UC Health Medicare	$48.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$207.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$48.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$34.10
Rate for Payer: Cash Price	$244.00
Rate for Payer: Cash Price	$244.00
Rate for Payer: Cigna of AZ Commercial	$198.25
Rate for Payer: Devoted Health Medicare	$54.90
Rate for Payer: Humana of AZ Medicare	$48.80
Rate for Payer: Seven Corners Travel Insurance	$134.65
Rate for Payer: Southwest Service Administrators UFCW	$207.40
Rate for Payer: TriWest Medicare	$48.80
Rate for Payer: United Healthcare Commercial	$174.46
Rate for Payer: United Healthcare Medicare	$48.80
Rate for Payer: Veterans Affairs TRICARE	$48.31

Know your out-of-pocket cost for care.

All Charges