Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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	$355.50
Max. Negotiated Rate	$355.50
Rate for Payer: Aetna of AZ Commercial	$355.50
Rate for Payer: Cash Price	$316.00

XR Sacroiliac Joints Minimum 3 Views

Facility

$464.00

Service Code	CPT 72202
Hospital Charge Code	1021658
Hospital Revenue Code	320
Min. Negotiated Rate	$37.02
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	$37.02
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: Seven Corners Travel Insurance	$161.76
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 Sacroiliac Joints Minimum 3 Views

Facility

$464.00

Service Code	CPT 72202
Hospital Charge Code	1021658
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 Sacrum and Coccyx

Facility

$464.00

Service Code	CPT 72220
Hospital Charge Code	1163877
Hospital Revenue Code	320
Min. Negotiated Rate	$30.90
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	$30.90
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: Seven Corners Travel Insurance	$134.65
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 Sacrum and Coccyx

Facility

$464.00

Service Code	CPT 72220
Hospital Charge Code	1163877
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 Scapula Left

Facility

$464.00

Service Code	CPT 73010 LT
Hospital Charge Code	823619
Hospital Revenue Code	320
Min. Negotiated Rate	$22.53
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	$22.53
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 Scapula Left

Facility

$464.00

Service Code	CPT 73010 LT
Hospital Charge Code	823619
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 Scapula Right

Facility

$464.00

Service Code	CPT 73010 RT
Hospital Charge Code	823621
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 Scapula Right

Facility

$464.00

Service Code	CPT 73010 RT
Hospital Charge Code	823621
Hospital Revenue Code	320
Min. Negotiated Rate	$22.53
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	$22.53
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 Sella Turcica

Facility

$352.00

Service Code	CPT 70240
Hospital Charge Code	1008063
Hospital Revenue Code	320
Min. Negotiated Rate	$29.64
Max. Negotiated Rate	$316.80
Rate for Payer: Aetna of AZ Commercial	$316.80
Rate for Payer: Arizona Complete Health Allwell	$56.32
Rate for Payer: Banner UC Health Medicare	$56.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$239.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$56.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$29.64
Rate for Payer: Cash Price	$281.60
Rate for Payer: Cash Price	$281.60
Rate for Payer: Cigna of AZ Commercial	$228.80
Rate for Payer: Devoted Health Medicare	$63.36
Rate for Payer: Humana of AZ Medicare	$56.32
Rate for Payer: Seven Corners Travel Insurance	$134.65
Rate for Payer: Southwest Service Administrators UFCW	$239.36
Rate for Payer: TriWest Medicare	$56.32
Rate for Payer: United Healthcare Commercial	$201.34
Rate for Payer: United Healthcare Medicare	$56.32
Rate for Payer: Veterans Affairs TRICARE	$55.76

XR Sella Turcica

Facility

$352.00

Service Code	CPT 70240
Hospital Charge Code	1008063
Hospital Revenue Code	320
Min. Negotiated Rate	$316.80
Max. Negotiated Rate	$316.80
Rate for Payer: Aetna of AZ Commercial	$316.80
Rate for Payer: Cash Price	$281.60

XR Shoulder 2 Views Left

Facility

$445.00

Service Code	CPT 73020 LT
Hospital Charge Code	1284694
Hospital Revenue Code	320
Min. Negotiated Rate	$20.60
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	$20.60
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 Shoulder 2 Views Left

Facility

$445.00

Service Code	CPT 73020 LT
Hospital Charge Code	1284694
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 Shoulder 2 Views Right

Facility

$445.00

Service Code	CPT 73020 RT
Hospital Charge Code	1284697
Hospital Revenue Code	320
Min. Negotiated Rate	$20.60
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	$20.60
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 Shoulder 2 Views Right

Facility

$445.00

Service Code	CPT 73020 RT
Hospital Charge Code	1284697
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 Shoulder Complete Left

Facility

$555.00

Service Code	CPT 73030 LT
Hospital Charge Code	823627
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 Shoulder Complete Left

Facility

$555.00

Service Code	CPT 73030 LT
Hospital Charge Code	823627
Hospital Revenue Code	320
Min. Negotiated Rate	$33.15
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	$33.15
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 Shoulder Complete Right

Facility

$555.00

Service Code	CPT 73030 RT
Hospital Charge Code	823629
Hospital Revenue Code	320
Min. Negotiated Rate	$33.15
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	$33.15
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 Shoulder Complete Right

Facility

$555.00

Service Code	CPT 73030 RT
Hospital Charge Code	823629
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 Sinuses Paranasal < 3 Views

Facility

$465.00

Service Code	CPT 70210
Hospital Charge Code	1008070
Hospital Revenue Code	320
Min. Negotiated Rate	$29.95
Max. Negotiated Rate	$418.50
Rate for Payer: Aetna of AZ Commercial	$418.50
Rate for Payer: Arizona Complete Health Allwell	$74.40
Rate for Payer: Banner UC Health Medicare	$74.40
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$316.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$74.40
Rate for Payer: Care1st Health Plan Arizona Medicare	$29.95
Rate for Payer: Cash Price	$372.00
Rate for Payer: Cash Price	$372.00
Rate for Payer: Cigna of AZ Commercial	$302.25
Rate for Payer: Devoted Health Medicare	$83.70
Rate for Payer: Humana of AZ Medicare	$74.40
Rate for Payer: Seven Corners Travel Insurance	$134.65
Rate for Payer: Southwest Service Administrators UFCW	$316.20
Rate for Payer: TriWest Medicare	$74.40
Rate for Payer: United Healthcare Commercial	$265.98
Rate for Payer: United Healthcare Medicare	$74.40
Rate for Payer: Veterans Affairs TRICARE	$73.66

XR Sinuses Paranasal < 3 Views

Facility

$465.00

Service Code	CPT 70210
Hospital Charge Code	1008070
Hospital Revenue Code	320
Min. Negotiated Rate	$418.50
Max. Negotiated Rate	$418.50
Rate for Payer: Aetna of AZ Commercial	$418.50
Rate for Payer: Cash Price	$372.00

XR Sinuses Paranasal Complete

Facility

$923.00

Service Code	CPT 70220
Hospital Charge Code	823631
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 Sinuses Paranasal Complete

Facility

$923.00

Service Code	CPT 70220
Hospital Charge Code	823631
Hospital Revenue Code	320
Min. Negotiated Rate	$35.05
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	$35.05
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: Seven Corners Travel Insurance	$134.65
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 Skull < 4 Views

Facility

$464.00

Service Code	CPT 70250
Hospital Charge Code	823633
Hospital Revenue Code	320
Min. Negotiated Rate	$33.14
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	$33.14
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: Seven Corners Travel Insurance	$161.76
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 Skull < 4 Views

Facility

$464.00

Service Code	CPT 70250
Hospital Charge Code	823633
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

Know your out-of-pocket cost for care.

All Charges