Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

XR Skull Complete

Facility

$1,108.00

Service Code	CPT 70260
Hospital Charge Code	1008072
Hospital Revenue Code	320
Min. Negotiated Rate	$40.79
Max. Negotiated Rate	$997.20
Rate for Payer: Aetna of AZ Commercial	$997.20
Rate for Payer: Arizona Complete Health Allwell	$177.28
Rate for Payer: Banner UC Health Medicare	$177.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$753.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$177.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$40.79
Rate for Payer: Cash Price	$886.40
Rate for Payer: Cash Price	$886.40
Rate for Payer: Cigna of AZ Commercial	$720.20
Rate for Payer: Devoted Health Medicare	$199.44
Rate for Payer: Humana of AZ Medicare	$177.28
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$753.44
Rate for Payer: TriWest Medicare	$177.28
Rate for Payer: United Healthcare Commercial	$633.78
Rate for Payer: United Healthcare Medicare	$177.28
Rate for Payer: Veterans Affairs TRICARE	$175.51

XR Skull Complete

Facility

$1,108.00

Service Code	CPT 70260
Hospital Charge Code	1008072
Hospital Revenue Code	320
Min. Negotiated Rate	$997.20
Max. Negotiated Rate	$997.20
Rate for Payer: Aetna of AZ Commercial	$997.20
Rate for Payer: Cash Price	$886.40

XR Spine Cervical 2 or 3 Views

Facility

$551.00

Service Code	CPT 72040
Hospital Charge Code	823635
Hospital Revenue Code	320
Min. Negotiated Rate	$37.33
Max. Negotiated Rate	$495.90
Rate for Payer: Aetna of AZ Commercial	$495.90
Rate for Payer: Arizona Complete Health Allwell	$88.16
Rate for Payer: Banner UC Health Medicare	$88.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$374.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$88.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.33
Rate for Payer: Cash Price	$440.80
Rate for Payer: Cash Price	$440.80
Rate for Payer: Cigna of AZ Commercial	$358.15
Rate for Payer: Devoted Health Medicare	$99.18
Rate for Payer: Humana of AZ Medicare	$88.16
Rate for Payer: Seven Corners Travel Insurance	$134.65
Rate for Payer: Southwest Service Administrators UFCW	$374.68
Rate for Payer: TriWest Medicare	$88.16
Rate for Payer: United Healthcare Commercial	$315.17
Rate for Payer: United Healthcare Medicare	$88.16
Rate for Payer: Veterans Affairs TRICARE	$87.28

XR Spine Cervical 2 or 3 Views

Facility

$551.00

Service Code	CPT 72040
Hospital Charge Code	823635
Hospital Revenue Code	320
Min. Negotiated Rate	$495.90
Max. Negotiated Rate	$495.90
Rate for Payer: Aetna of AZ Commercial	$495.90
Rate for Payer: Cash Price	$440.80

XR Spine Cervical 4 or 5 Views

Facility

$1,108.00

Service Code	CPT 72050
Hospital Charge Code	4694460
Hospital Revenue Code	320
Min. Negotiated Rate	$997.20
Max. Negotiated Rate	$997.20
Rate for Payer: Aetna of AZ Commercial	$997.20
Rate for Payer: Cash Price	$886.40

XR Spine Cervical 4 or 5 Views

Facility

$1,108.00

Service Code	CPT 72050
Hospital Charge Code	4694460
Hospital Revenue Code	320
Min. Negotiated Rate	$50.53
Max. Negotiated Rate	$997.20
Rate for Payer: Aetna of AZ Commercial	$997.20
Rate for Payer: Arizona Complete Health Allwell	$177.28
Rate for Payer: Banner UC Health Medicare	$177.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$753.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$177.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$50.53
Rate for Payer: Cash Price	$886.40
Rate for Payer: Cash Price	$886.40
Rate for Payer: Cigna of AZ Commercial	$720.20
Rate for Payer: Devoted Health Medicare	$199.44
Rate for Payer: Humana of AZ Medicare	$177.28
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$753.44
Rate for Payer: TriWest Medicare	$177.28
Rate for Payer: United Healthcare Commercial	$633.78
Rate for Payer: United Healthcare Medicare	$177.28
Rate for Payer: Veterans Affairs TRICARE	$175.51

XR Spine Cervical Comp w/ Flex/Ext

Facility

$843.00

Service Code	CPT 72052
Hospital Charge Code	1008084
Hospital Revenue Code	320
Min. Negotiated Rate	$59.22
Max. Negotiated Rate	$758.70
Rate for Payer: Aetna of AZ Commercial	$758.70
Rate for Payer: Arizona Complete Health Allwell	$134.88
Rate for Payer: Banner UC Health Medicare	$134.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$573.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$134.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$59.22
Rate for Payer: Cash Price	$674.40
Rate for Payer: Cash Price	$674.40
Rate for Payer: Cigna of AZ Commercial	$547.95
Rate for Payer: Devoted Health Medicare	$151.74
Rate for Payer: Humana of AZ Medicare	$134.88
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$573.24
Rate for Payer: TriWest Medicare	$134.88
Rate for Payer: United Healthcare Commercial	$482.20
Rate for Payer: United Healthcare Medicare	$134.88
Rate for Payer: Veterans Affairs TRICARE	$133.53

XR Spine Cervical Comp w/ Flex/Ext

Facility

$843.00

Service Code	CPT 72052
Hospital Charge Code	1008084
Hospital Revenue Code	320
Min. Negotiated Rate	$758.70
Max. Negotiated Rate	$758.70
Rate for Payer: Aetna of AZ Commercial	$758.70
Rate for Payer: Cash Price	$674.40

XR Spine Entire 1 View

Facility

$743.00

Service Code	CPT 72081
Hospital Charge Code	22200642
Hospital Revenue Code	320
Min. Negotiated Rate	$40.23
Max. Negotiated Rate	$668.70
Rate for Payer: Aetna of AZ Commercial	$668.70
Rate for Payer: Arizona Complete Health Allwell	$118.88
Rate for Payer: Banner UC Health Medicare	$118.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$505.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$118.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$40.23
Rate for Payer: Cash Price	$594.40
Rate for Payer: Cash Price	$594.40
Rate for Payer: Cigna of AZ Commercial	$482.95
Rate for Payer: Devoted Health Medicare	$133.74
Rate for Payer: Humana of AZ Medicare	$118.88
Rate for Payer: Seven Corners Travel Insurance	$134.65
Rate for Payer: Southwest Service Administrators UFCW	$505.24
Rate for Payer: TriWest Medicare	$118.88
Rate for Payer: United Healthcare Commercial	$425.00
Rate for Payer: United Healthcare Medicare	$118.88
Rate for Payer: Veterans Affairs TRICARE	$117.69

XR Spine Entire 1 View

Facility

$743.00

Service Code	CPT 72081
Hospital Charge Code	22200642
Hospital Revenue Code	320
Min. Negotiated Rate	$668.70
Max. Negotiated Rate	$668.70
Rate for Payer: Aetna of AZ Commercial	$668.70
Rate for Payer: Cash Price	$594.40

XR Spine Lumbosacral 2 or 3 Views

Facility

$918.00

Service Code	CPT 72100
Hospital Charge Code	823641
Hospital Revenue Code	320
Min. Negotiated Rate	$37.66
Max. Negotiated Rate	$826.20
Rate for Payer: Aetna of AZ Commercial	$826.20
Rate for Payer: Arizona Complete Health Allwell	$146.88
Rate for Payer: Banner UC Health Medicare	$146.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$624.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$146.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.66
Rate for Payer: Cash Price	$734.40
Rate for Payer: Cash Price	$734.40
Rate for Payer: Cigna of AZ Commercial	$596.70
Rate for Payer: Devoted Health Medicare	$165.24
Rate for Payer: Humana of AZ Medicare	$146.88
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$624.24
Rate for Payer: TriWest Medicare	$146.88
Rate for Payer: United Healthcare Commercial	$525.10
Rate for Payer: United Healthcare Medicare	$146.88
Rate for Payer: Veterans Affairs TRICARE	$145.41

XR Spine Lumbosacral 2 or 3 Views

Facility

$918.00

Service Code	CPT 72100
Hospital Charge Code	823641
Hospital Revenue Code	320
Min. Negotiated Rate	$826.20
Max. Negotiated Rate	$826.20
Rate for Payer: Aetna of AZ Commercial	$826.20
Rate for Payer: Cash Price	$734.40

XR Spine Lumbosacral Bending Only

Facility

$923.00

Service Code	CPT 72120
Hospital Charge Code	1163883
Hospital Revenue Code	320
Min. Negotiated Rate	$38.30
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	$38.30
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	$161.76
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 Spine Lumbosacral Bending Only

Facility

$923.00

Service Code	CPT 72120
Hospital Charge Code	1163883
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 Spine Lumbosacral Complete w/ Bending

Facility

$843.00

Service Code	CPT 72114
Hospital Charge Code	1008092
Hospital Revenue Code	320
Min. Negotiated Rate	$758.70
Max. Negotiated Rate	$758.70
Rate for Payer: Aetna of AZ Commercial	$758.70
Rate for Payer: Cash Price	$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	$57.93
Max. Negotiated Rate	$758.70
Rate for Payer: Aetna of AZ Commercial	$758.70
Rate for Payer: Arizona Complete Health Allwell	$134.88
Rate for Payer: Banner UC Health Medicare	$134.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$573.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$134.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$57.93
Rate for Payer: Cash Price	$674.40
Rate for Payer: Cash Price	$674.40
Rate for Payer: Cigna of AZ Commercial	$547.95
Rate for Payer: Devoted Health Medicare	$151.74
Rate for Payer: Humana of AZ Medicare	$134.88
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$573.24
Rate for Payer: TriWest Medicare	$134.88
Rate for Payer: United Healthcare Commercial	$482.20
Rate for Payer: United Healthcare Medicare	$134.88
Rate for Payer: Veterans Affairs TRICARE	$133.53

XR Spine Lumbosacral Minimum 4 Views

Facility

$843.00

Service Code	CPT 72110
Hospital Charge Code	823643
Hospital Revenue Code	320
Min. Negotiated Rate	$49.25
Max. Negotiated Rate	$758.70
Rate for Payer: Aetna of AZ Commercial	$758.70
Rate for Payer: Arizona Complete Health Allwell	$134.88
Rate for Payer: Banner UC Health Medicare	$134.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$573.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$134.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$49.25
Rate for Payer: Cash Price	$674.40
Rate for Payer: Cash Price	$674.40
Rate for Payer: Cigna of AZ Commercial	$547.95
Rate for Payer: Devoted Health Medicare	$151.74
Rate for Payer: Humana of AZ Medicare	$134.88
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$573.24
Rate for Payer: TriWest Medicare	$134.88
Rate for Payer: United Healthcare Commercial	$482.20
Rate for Payer: United Healthcare Medicare	$134.88
Rate for Payer: Veterans Affairs TRICARE	$133.53

XR Spine Lumbosacral Minimum 4 Views

Facility

$843.00

Service Code	CPT 72110
Hospital Charge Code	823643
Hospital Revenue Code	320
Min. Negotiated Rate	$758.70
Max. Negotiated Rate	$758.70
Rate for Payer: Aetna of AZ Commercial	$758.70
Rate for Payer: Cash Price	$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	$776.70
Max. Negotiated Rate	$776.70
Rate for Payer: Aetna of AZ Commercial	$776.70
Rate for Payer: Cash Price	$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	$66.30
Max. Negotiated Rate	$776.70
Rate for Payer: Aetna of AZ Commercial	$776.70
Rate for Payer: Arizona Complete Health Allwell	$138.08
Rate for Payer: Banner UC Health Medicare	$138.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$586.84
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$138.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$66.30
Rate for Payer: Cash Price	$690.40
Rate for Payer: Cash Price	$690.40
Rate for Payer: Cigna of AZ Commercial	$560.95
Rate for Payer: Devoted Health Medicare	$155.34
Rate for Payer: Humana of AZ Medicare	$138.08
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$586.84
Rate for Payer: TriWest Medicare	$138.08
Rate for Payer: United Healthcare Commercial	$493.64
Rate for Payer: United Healthcare Medicare	$138.08
Rate for Payer: Veterans Affairs TRICARE	$136.70

XR Spine Thoracic 3 Views

Facility

$460.00

Service Code	CPT 72072
Hospital Charge Code	823649
Hospital Revenue Code	320
Min. Negotiated Rate	$414.00
Max. Negotiated Rate	$414.00
Rate for Payer: Aetna of AZ Commercial	$414.00
Rate for Payer: Cash Price	$368.00

XR Spine Thoracic 3 Views

Facility

$460.00

Service Code	CPT 72072
Hospital Charge Code	823649
Hospital Revenue Code	320
Min. Negotiated Rate	$37.33
Max. Negotiated Rate	$414.00
Rate for Payer: Aetna of AZ Commercial	$414.00
Rate for Payer: Arizona Complete Health Allwell	$73.60
Rate for Payer: Banner UC Health Medicare	$73.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$312.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$73.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$37.33
Rate for Payer: Cash Price	$368.00
Rate for Payer: Cash Price	$368.00
Rate for Payer: Cigna of AZ Commercial	$299.00
Rate for Payer: Devoted Health Medicare	$82.80
Rate for Payer: Humana of AZ Medicare	$73.60
Rate for Payer: Seven Corners Travel Insurance	$161.76
Rate for Payer: Southwest Service Administrators UFCW	$312.80
Rate for Payer: TriWest Medicare	$73.60
Rate for Payer: United Healthcare Commercial	$263.12
Rate for Payer: United Healthcare Medicare	$73.60
Rate for Payer: Veterans Affairs TRICARE	$72.86

XR Spine Thoracolumbar 2 Views

Facility

$464.00

Service Code	CPT 72080
Hospital Charge Code	1008101
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 Spine Thoracolumbar 2 Views

Facility

$464.00

Service Code	CPT 72080
Hospital Charge Code	1008101
Hospital Revenue Code	320
Min. Negotiated Rate	$32.83
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	$32.83
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 Sternoclavicular Joint(s)

Facility

$478.00

Service Code	CPT 71130
Hospital Charge Code	823651
Hospital Revenue Code	320
Min. Negotiated Rate	$38.56
Max. Negotiated Rate	$430.20
Rate for Payer: Aetna of AZ Commercial	$430.20
Rate for Payer: Arizona Complete Health Allwell	$76.48
Rate for Payer: Banner UC Health Medicare	$76.48
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$325.04
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$76.48
Rate for Payer: Care1st Health Plan Arizona Medicare	$38.56
Rate for Payer: Cash Price	$382.40
Rate for Payer: Cash Price	$382.40
Rate for Payer: Cigna of AZ Commercial	$310.70
Rate for Payer: Devoted Health Medicare	$86.04
Rate for Payer: Humana of AZ Medicare	$76.48
Rate for Payer: Seven Corners Travel Insurance	$134.65
Rate for Payer: Southwest Service Administrators UFCW	$325.04
Rate for Payer: TriWest Medicare	$76.48
Rate for Payer: United Healthcare Commercial	$273.42
Rate for Payer: United Healthcare Medicare	$76.48
Rate for Payer: Veterans Affairs TRICARE	$75.72

Know your out-of-pocket cost for care.

All Charges