Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

XR Orbits Complete Bilateral

Facility

$923.00

Service Code	CPT 70200 50
Hospital Charge Code	823606
Hospital Revenue Code	320
Min. Negotiated Rate	$43.34
Max. Negotiated Rate	$830.70
Rate for Payer: Aetna of AZ Commercial	$830.70
Rate for Payer: Arizona Complete Health Allwell	$147.68
Rate for Payer: Banner UC Health Medicare	$147.68
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$627.64
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$147.68
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.34
Rate for Payer: Cash Price	$738.40
Rate for Payer: Cash Price	$738.40
Rate for Payer: Cigna of AZ Commercial	$599.95
Rate for Payer: Devoted Health Medicare	$166.14
Rate for Payer: Humana of AZ Medicare	$147.68
Rate for Payer: Southwest Service Administrators UFCW	$627.64
Rate for Payer: TriWest Medicare	$147.68
Rate for Payer: United Healthcare Commercial	$527.96
Rate for Payer: United Healthcare Medicare	$147.68
Rate for Payer: Veterans Affairs TRICARE	$146.20

XR Orbits Complete Bilateral

Facility

$923.00

Service Code	CPT 70200 50
Hospital Charge Code	823606
Hospital Revenue Code	320
Min. Negotiated Rate	$830.70
Max. Negotiated Rate	$830.70
Rate for Payer: Aetna of AZ Commercial	$830.70
Rate for Payer: Cash Price	$738.40

XR Orbits Complete Left

Facility

$972.00

Service Code	CPT 70200 LT
Hospital Charge Code	1163868
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 Orbits Complete Left

Facility

$972.00

Service Code	CPT 70200 LT
Hospital Charge Code	1163868
Hospital Revenue Code	320
Min. Negotiated Rate	$43.34
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	$43.34
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 Orbits Complete Right

Facility

$972.00

Service Code	CPT 70200 RT
Hospital Charge Code	1163870
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 Orbits Complete Right

Facility

$972.00

Service Code	CPT 70200 RT
Hospital Charge Code	1163870
Hospital Revenue Code	320
Min. Negotiated Rate	$43.34
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	$43.34
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 Pelvis 1 View

Facility

$339.00

Service Code	CPT 72170
Hospital Charge Code	1319989
Hospital Revenue Code	320
Min. Negotiated Rate	$26.39
Max. Negotiated Rate	$305.10
Rate for Payer: Aetna of AZ Commercial	$305.10
Rate for Payer: Arizona Complete Health Allwell	$54.24
Rate for Payer: Banner UC Health Medicare	$54.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$230.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$54.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$26.39
Rate for Payer: Cash Price	$271.20
Rate for Payer: Cash Price	$271.20
Rate for Payer: Cigna of AZ Commercial	$220.35
Rate for Payer: Devoted Health Medicare	$61.02
Rate for Payer: Humana of AZ Medicare	$54.24
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$230.52
Rate for Payer: TriWest Medicare	$54.24
Rate for Payer: United Healthcare Commercial	$193.91
Rate for Payer: United Healthcare Medicare	$54.24
Rate for Payer: Veterans Affairs TRICARE	$53.70

XR Pelvis 1 View

Facility

$339.00

Service Code	CPT 72170
Hospital Charge Code	1319989
Hospital Revenue Code	320
Min. Negotiated Rate	$305.10
Max. Negotiated Rate	$305.10
Rate for Payer: Aetna of AZ Commercial	$305.10
Rate for Payer: Cash Price	$271.20

XR Pelvis Complete Minimum 3 Views

Facility

$555.00

Service Code	CPT 72190
Hospital Charge Code	1021656
Hospital Revenue Code	320
Min. Negotiated Rate	$39.91
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	$39.91
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	$161.76
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 Pelvis Complete Minimum 3 Views

Facility

$555.00

Service Code	CPT 72190
Hospital Charge Code	1021656
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 Radiological Specimen

Facility

$226.00

Service Code	CPT 76098
Hospital Charge Code	2214272
Hospital Revenue Code	320
Min. Negotiated Rate	$203.40
Max. Negotiated Rate	$203.40
Rate for Payer: Aetna of AZ Commercial	$203.40
Rate for Payer: Cash Price	$180.80

XR Radiological Specimen

Facility

$226.00

Service Code	CPT 76098
Hospital Charge Code	2214272
Hospital Revenue Code	320
Min. Negotiated Rate	$35.80
Max. Negotiated Rate	$845.45
Rate for Payer: Aetna of AZ Commercial	$203.40
Rate for Payer: Arizona Complete Health Allwell	$36.16
Rate for Payer: Banner UC Health Medicare	$36.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$153.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$36.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$40.15
Rate for Payer: Cash Price	$180.80
Rate for Payer: Cash Price	$180.80
Rate for Payer: Cigna of AZ Commercial	$146.90
Rate for Payer: Devoted Health Medicare	$40.68
Rate for Payer: Humana of AZ Medicare	$36.16
Rate for Payer: Seven Corners Travel Insurance	$845.45
Rate for Payer: Southwest Service Administrators UFCW	$153.68
Rate for Payer: TriWest Medicare	$36.16
Rate for Payer: United Healthcare Commercial	$129.27
Rate for Payer: United Healthcare Medicare	$36.16
Rate for Payer: Veterans Affairs TRICARE	$35.80

XR Ribs 3 Views Left

Facility

$464.00

Service Code	CPT 71100 LT
Hospital Charge Code	7003381
Hospital Revenue Code	324
Min. Negotiated Rate	$417.60
Max. Negotiated Rate	$417.60
Rate for Payer: Aetna of AZ Commercial	$417.60
Rate for Payer: Cash Price	$371.20

XR Ribs 3 Views Left

Facility

$464.00

Service Code	CPT 71100 LT
Hospital Charge Code	7003381
Hospital Revenue Code	324
Min. Negotiated Rate	$33.46
Max. Negotiated Rate	$417.60
Rate for Payer: Aetna of AZ Commercial	$417.60
Rate for Payer: Arizona Complete Health Allwell	$74.24
Rate for Payer: Banner UC Health Medicare	$74.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$315.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$74.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$33.46
Rate for Payer: Cash Price	$371.20
Rate for Payer: Cash Price	$371.20
Rate for Payer: Cigna of AZ Commercial	$301.60
Rate for Payer: Devoted Health Medicare	$83.52
Rate for Payer: Humana of AZ Medicare	$74.24
Rate for Payer: Southwest Service Administrators UFCW	$315.52
Rate for Payer: TriWest Medicare	$74.24
Rate for Payer: United Healthcare Commercial	$265.41
Rate for Payer: United Healthcare Medicare	$74.24
Rate for Payer: Veterans Affairs TRICARE	$73.50

XR Ribs 3 Views Right

Facility

$488.00

Service Code	CPT 71100 RT
Hospital Charge Code	7003384
Hospital Revenue Code	324
Min. Negotiated Rate	$33.46
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	$33.46
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 Ribs 3 Views Right

Facility

$488.00

Service Code	CPT 71100 RT
Hospital Charge Code	7003384
Hospital Revenue Code	324
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 Ribs Min 4 Views Bilateral

Facility

$618.00

Service Code	CPT 71110 50
Hospital Charge Code	2214281
Hospital Revenue Code	324
Min. Negotiated Rate	$39.83
Max. Negotiated Rate	$556.20
Rate for Payer: Aetna of AZ Commercial	$556.20
Rate for Payer: Arizona Complete Health Allwell	$98.88
Rate for Payer: Banner UC Health Medicare	$98.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$420.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$98.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$39.83
Rate for Payer: Cash Price	$494.40
Rate for Payer: Cash Price	$494.40
Rate for Payer: Cigna of AZ Commercial	$401.70
Rate for Payer: Devoted Health Medicare	$111.24
Rate for Payer: Humana of AZ Medicare	$98.88
Rate for Payer: Southwest Service Administrators UFCW	$420.24
Rate for Payer: TriWest Medicare	$98.88
Rate for Payer: United Healthcare Commercial	$353.50
Rate for Payer: United Healthcare Medicare	$98.88
Rate for Payer: Veterans Affairs TRICARE	$97.89

XR Ribs Min 4 Views Bilateral

Facility

$618.00

Service Code	CPT 71110 50
Hospital Charge Code	2214281
Hospital Revenue Code	324
Min. Negotiated Rate	$556.20
Max. Negotiated Rate	$556.20
Rate for Payer: Aetna of AZ Commercial	$556.20
Rate for Payer: Cash Price	$494.40

XR Ribs w/ PA Chest Bilateral

Facility

$591.00

Service Code	CPT 71111 50
Hospital Charge Code	1008048
Hospital Revenue Code	320
Min. Negotiated Rate	$531.90
Max. Negotiated Rate	$531.90
Rate for Payer: Aetna of AZ Commercial	$531.90
Rate for Payer: Cash Price	$472.80

XR Ribs w/ PA Chest Bilateral

Facility

$591.00

Service Code	CPT 71111 50
Hospital Charge Code	1008048
Hospital Revenue Code	320
Min. Negotiated Rate	$47.80
Max. Negotiated Rate	$531.90
Rate for Payer: Aetna of AZ Commercial	$531.90
Rate for Payer: Arizona Complete Health Allwell	$94.56
Rate for Payer: Banner UC Health Medicare	$94.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$401.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$94.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$47.80
Rate for Payer: Cash Price	$472.80
Rate for Payer: Cash Price	$472.80
Rate for Payer: Cigna of AZ Commercial	$384.15
Rate for Payer: Devoted Health Medicare	$106.38
Rate for Payer: Humana of AZ Medicare	$94.56
Rate for Payer: Southwest Service Administrators UFCW	$401.88
Rate for Payer: TriWest Medicare	$94.56
Rate for Payer: United Healthcare Commercial	$338.05
Rate for Payer: United Healthcare Medicare	$94.56
Rate for Payer: Veterans Affairs TRICARE	$93.61

XR Ribs w/ PA Chest Left

Facility

$464.00

Service Code	CPT 71101 LT
Hospital Charge Code	1008050
Hospital Revenue Code	320
Min. Negotiated Rate	$417.60
Max. Negotiated Rate	$417.60
Rate for Payer: Aetna of AZ Commercial	$417.60
Rate for Payer: Cash Price	$371.20

XR Ribs w/ PA Chest Left

Facility

$464.00

Service Code	CPT 71101 LT
Hospital Charge Code	1008050
Hospital Revenue Code	320
Min. Negotiated Rate	$38.88
Max. Negotiated Rate	$417.60
Rate for Payer: Aetna of AZ Commercial	$417.60
Rate for Payer: Arizona Complete Health Allwell	$74.24
Rate for Payer: Banner UC Health Medicare	$74.24
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$315.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$74.24
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.88
Rate for Payer: Cash Price	$371.20
Rate for Payer: Cash Price	$371.20
Rate for Payer: Cigna of AZ Commercial	$301.60
Rate for Payer: Devoted Health Medicare	$83.52
Rate for Payer: Humana of AZ Medicare	$74.24
Rate for Payer: Southwest Service Administrators UFCW	$315.52
Rate for Payer: TriWest Medicare	$74.24
Rate for Payer: United Healthcare Commercial	$265.41
Rate for Payer: United Healthcare Medicare	$74.24
Rate for Payer: Veterans Affairs TRICARE	$73.50

XR Ribs w/ PA Chest Right

Facility

$488.00

Service Code	CPT 71101 RT
Hospital Charge Code	1008052
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 Ribs w/ PA Chest Right

Facility

$488.00

Service Code	CPT 71101 RT
Hospital Charge Code	1008052
Hospital Revenue Code	320
Min. Negotiated Rate	$38.88
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	$38.88
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 Sacroiliac Joints 1 or 2 Views

Facility

$395.00

Service Code	CPT 72200
Hospital Charge Code	1008054
Hospital Revenue Code	320
Min. Negotiated Rate	$31.55
Max. Negotiated Rate	$355.50
Rate for Payer: Aetna of AZ Commercial	$355.50
Rate for Payer: Arizona Complete Health Allwell	$63.20
Rate for Payer: Banner UC Health Medicare	$63.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$268.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$63.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$31.55
Rate for Payer: Cash Price	$316.00
Rate for Payer: Cash Price	$316.00
Rate for Payer: Cigna of AZ Commercial	$256.75
Rate for Payer: Devoted Health Medicare	$71.10
Rate for Payer: Humana of AZ Medicare	$63.20
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$268.60
Rate for Payer: TriWest Medicare	$63.20
Rate for Payer: United Healthcare Commercial	$225.94
Rate for Payer: United Healthcare Medicare	$63.20
Rate for Payer: Veterans Affairs TRICARE	$62.57

Know your out-of-pocket cost for care.

All Charges