Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

sucralfate 1 g Tab [CQCH]

Facility

$0.24

Service Code	NDC 63739094310
Hospital Charge Code	105942580
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of AZ Commercial	$0.22
Rate for Payer: Aetna of AZ Medicare	$0.07
Rate for Payer: Allwell Medicare	$0.04
Rate for Payer: Amerigroup Medicare	$0.04
Rate for Payer: APIPA Medicare/Medicaid	$0.09
Rate for Payer: AZCH Complete Medicare	$0.04
Rate for Payer: Banner UC Health Medicare	$0.04
Rate for Payer: Bisbee Police All Plans	$0.06
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.16
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of AZ Commercial	$0.16
Rate for Payer: Copperpoint Commercial	$0.06
Rate for Payer: Health Net of AZ Commercial	$0.14
Rate for Payer: Health Net of AZ Medicare	$0.07
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Self Pay Self Pay	$0.19
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.14
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.04

Sucrose 24% oral soln [CQCH]

Facility

$0.50

Service Code	NDC 98980560340
Hospital Charge Code	113461007
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of AZ Commercial	$0.45
Rate for Payer: Aetna of AZ Medicare	$0.14
Rate for Payer: Allwell Medicare	$0.08
Rate for Payer: Amerigroup Medicare	$0.08
Rate for Payer: APIPA Medicare/Medicaid	$0.19
Rate for Payer: AZCH Complete Medicare	$0.08
Rate for Payer: Banner UC Health Medicare	$0.08
Rate for Payer: Bisbee Police All Plans	$0.13
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.34
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cigna of AZ Commercial	$0.33
Rate for Payer: Copperpoint Commercial	$0.12
Rate for Payer: Health Net of AZ Commercial	$0.30
Rate for Payer: Health Net of AZ Medicare	$0.14
Rate for Payer: Humana of AZ Medicare	$0.08
Rate for Payer: Self Pay Self Pay	$0.40
Rate for Payer: TriWest Medicare	$0.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.29
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.09

Sucrose 24% oral soln [CQCH]

Facility

$0.50

Service Code	NDC 98980560340
Hospital Charge Code	113461007
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of AZ Commercial	$0.45
Rate for Payer: Bisbee Police All Plans	$0.13
Rate for Payer: Cash Price	$0.40
Rate for Payer: Self Pay Self Pay	$0.40

SUCTION

Facility

$43.00

Service Code	CPT 94799
Hospital Charge Code	1886869
Hospital Revenue Code	410
Min. Negotiated Rate	$6.45
Max. Negotiated Rate	$202.34
Rate for Payer: Aetna of AZ Commercial	$38.70
Rate for Payer: Aetna of AZ Medicare	$12.04
Rate for Payer: AHCCCS Medicaid	$202.34
Rate for Payer: Allwell Medicaid	$202.34
Rate for Payer: Allwell Medicare	$6.45
Rate for Payer: Amerigroup Medicare	$6.45
Rate for Payer: APIPA Medicare/Medicaid	$16.06
Rate for Payer: AZCH Complete Medicaid	$202.34
Rate for Payer: AZCH Complete Medicare	$6.45
Rate for Payer: Banner UC Health Medicaid	$202.34
Rate for Payer: Banner UC Health Medicare	$6.45
Rate for Payer: Bisbee Police All Plans	$11.18
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$29.24
Rate for Payer: Cash Price	$34.40
Rate for Payer: Cash Price	$34.40
Rate for Payer: Cigna of AZ Commercial	$30.10
Rate for Payer: Copperpoint Commercial	$10.64
Rate for Payer: Health Net of AZ Commercial	$25.80
Rate for Payer: Health Net of AZ Medicare	$12.04
Rate for Payer: Humana of AZ Medicare	$6.45
Rate for Payer: Mercy Care Medicaid	$202.34
Rate for Payer: Self Pay Self Pay	$34.40
Rate for Payer: TriWest Medicare	$6.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$25.07
Rate for Payer: UnitedHealth Group of AZ Medicare	$7.74

SUCTION

Facility

$43.00

Service Code	CPT 94799
Hospital Charge Code	1886869
Hospital Revenue Code	410
Min. Negotiated Rate	$11.18
Max. Negotiated Rate	$38.70
Rate for Payer: Aetna of AZ Commercial	$38.70
Rate for Payer: Bisbee Police All Plans	$11.18
Rate for Payer: Cash Price	$34.40
Rate for Payer: Self Pay Self Pay	$34.40

SUCTION CANISTER 1200

Facility

$27.00

Hospital Charge Code	22355544
Hospital Revenue Code	270
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$24.30
Rate for Payer: Aetna of AZ Commercial	$24.30
Rate for Payer: Aetna of AZ Medicare	$7.56
Rate for Payer: Allwell Medicare	$4.05
Rate for Payer: Amerigroup Medicare	$4.05
Rate for Payer: APIPA Medicare/Medicaid	$10.08
Rate for Payer: AZCH Complete Medicare	$4.05
Rate for Payer: Banner UC Health Medicare	$4.05
Rate for Payer: Bisbee Police All Plans	$7.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$18.36
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna of AZ Commercial	$18.90
Rate for Payer: Copperpoint Commercial	$6.68
Rate for Payer: Health Net of AZ Commercial	$16.20
Rate for Payer: Health Net of AZ Medicare	$7.56
Rate for Payer: Humana of AZ Medicare	$4.05
Rate for Payer: Self Pay Self Pay	$21.60
Rate for Payer: TriWest Medicare	$4.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$15.74
Rate for Payer: UnitedHealth Group of AZ Medicare	$4.86

SUCTION CANISTER 1200

Facility

$27.00

Hospital Charge Code	22355544
Hospital Revenue Code	270
Min. Negotiated Rate	$7.02
Max. Negotiated Rate	$24.30
Rate for Payer: Aetna of AZ Commercial	$24.30
Rate for Payer: Bisbee Police All Plans	$7.02
Rate for Payer: Cash Price	$21.60
Rate for Payer: Self Pay Self Pay	$21.60

SUCTION CANISTER 2000

Facility

$21.00

Hospital Charge Code	22524008
Hospital Revenue Code	270
Min. Negotiated Rate	$5.46
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Bisbee Police All Plans	$5.46
Rate for Payer: Cash Price	$16.80
Rate for Payer: Self Pay Self Pay	$16.80

SUCTION CANISTER 2000

Facility

$21.00

Hospital Charge Code	22524008
Hospital Revenue Code	270
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$18.90
Rate for Payer: Aetna of AZ Commercial	$18.90
Rate for Payer: Aetna of AZ Medicare	$5.88
Rate for Payer: Allwell Medicare	$3.15
Rate for Payer: Amerigroup Medicare	$3.15
Rate for Payer: APIPA Medicare/Medicaid	$7.84
Rate for Payer: AZCH Complete Medicare	$3.15
Rate for Payer: Banner UC Health Medicare	$3.15
Rate for Payer: Bisbee Police All Plans	$5.46
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$14.28
Rate for Payer: Cash Price	$16.80
Rate for Payer: Cigna of AZ Commercial	$14.70
Rate for Payer: Copperpoint Commercial	$5.20
Rate for Payer: Health Net of AZ Commercial	$12.60
Rate for Payer: Health Net of AZ Medicare	$5.88
Rate for Payer: Humana of AZ Medicare	$3.15
Rate for Payer: Self Pay Self Pay	$16.80
Rate for Payer: TriWest Medicare	$3.15
Rate for Payer: UnitedHealth Group of AZ Commercial	$12.24
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.78

SUCTION CANISTER 800

Facility

$12.00

Hospital Charge Code	22355704
Hospital Revenue Code	270
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$10.80
Rate for Payer: Aetna of AZ Commercial	$10.80
Rate for Payer: Bisbee Police All Plans	$3.12
Rate for Payer: Cash Price	$9.60
Rate for Payer: Self Pay Self Pay	$9.60

SUCTION CANISTER 800

Facility

$12.00

Hospital Charge Code	22355704
Hospital Revenue Code	270
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$10.80
Rate for Payer: Aetna of AZ Commercial	$10.80
Rate for Payer: Aetna of AZ Medicare	$3.36
Rate for Payer: Allwell Medicare	$1.80
Rate for Payer: Amerigroup Medicare	$1.80
Rate for Payer: APIPA Medicare/Medicaid	$4.48
Rate for Payer: AZCH Complete Medicare	$1.80
Rate for Payer: Banner UC Health Medicare	$1.80
Rate for Payer: Bisbee Police All Plans	$3.12
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$8.16
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cigna of AZ Commercial	$8.40
Rate for Payer: Copperpoint Commercial	$2.97
Rate for Payer: Health Net of AZ Commercial	$7.20
Rate for Payer: Health Net of AZ Medicare	$3.36
Rate for Payer: Humana of AZ Medicare	$1.80
Rate for Payer: Self Pay Self Pay	$9.60
Rate for Payer: TriWest Medicare	$1.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$7.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.16

SUCTION CANISTER OMNI

Facility

$555.00

Hospital Charge Code	22354183
Hospital Revenue Code	270
Min. Negotiated Rate	$83.25
Max. Negotiated Rate	$499.50
Rate for Payer: Aetna of AZ Commercial	$499.50
Rate for Payer: Aetna of AZ Medicare	$155.40
Rate for Payer: Allwell Medicare	$83.25
Rate for Payer: Amerigroup Medicare	$83.25
Rate for Payer: APIPA Medicare/Medicaid	$207.29
Rate for Payer: AZCH Complete Medicare	$83.25
Rate for Payer: Banner UC Health Medicare	$83.25
Rate for Payer: Bisbee Police All Plans	$144.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$377.40
Rate for Payer: Cash Price	$444.00
Rate for Payer: Cigna of AZ Commercial	$388.50
Rate for Payer: Copperpoint Commercial	$137.36
Rate for Payer: Health Net of AZ Commercial	$333.00
Rate for Payer: Health Net of AZ Medicare	$155.40
Rate for Payer: Humana of AZ Medicare	$83.25
Rate for Payer: Self Pay Self Pay	$444.00
Rate for Payer: TriWest Medicare	$83.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$323.56
Rate for Payer: UnitedHealth Group of AZ Medicare	$99.90

SUCTION CANISTER OMNI

Facility

$555.00

Hospital Charge Code	22354183
Hospital Revenue Code	270
Min. Negotiated Rate	$144.30
Max. Negotiated Rate	$499.50
Rate for Payer: Aetna of AZ Commercial	$499.50
Rate for Payer: Bisbee Police All Plans	$144.30
Rate for Payer: Cash Price	$444.00
Rate for Payer: Self Pay Self Pay	$444.00

SUCTION COAGULATORS HAND CONTROL

Facility

$95.00

Hospital Charge Code	22355421
Hospital Revenue Code	272
Min. Negotiated Rate	$14.25
Max. Negotiated Rate	$85.50
Rate for Payer: Aetna of AZ Commercial	$85.50
Rate for Payer: Aetna of AZ Medicare	$26.60
Rate for Payer: Allwell Medicare	$14.25
Rate for Payer: Amerigroup Medicare	$14.25
Rate for Payer: APIPA Medicare/Medicaid	$35.48
Rate for Payer: AZCH Complete Medicare	$14.25
Rate for Payer: Banner UC Health Medicare	$14.25
Rate for Payer: Bisbee Police All Plans	$24.70
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$64.60
Rate for Payer: Cash Price	$76.00
Rate for Payer: Cigna of AZ Commercial	$66.50
Rate for Payer: Copperpoint Commercial	$23.51
Rate for Payer: Health Net of AZ Commercial	$57.00
Rate for Payer: Health Net of AZ Medicare	$26.60
Rate for Payer: Humana of AZ Medicare	$14.25
Rate for Payer: Self Pay Self Pay	$76.00
Rate for Payer: TriWest Medicare	$14.25
Rate for Payer: UnitedHealth Group of AZ Commercial	$55.38
Rate for Payer: UnitedHealth Group of AZ Medicare	$17.10

SUCTION COAGULATORS HAND CONTROL

Facility

$95.00

Hospital Charge Code	22355421
Hospital Revenue Code	272
Min. Negotiated Rate	$24.70
Max. Negotiated Rate	$85.50
Rate for Payer: Aetna of AZ Commercial	$85.50
Rate for Payer: Bisbee Police All Plans	$24.70
Rate for Payer: Cash Price	$76.00
Rate for Payer: Self Pay Self Pay	$76.00

sugammadex 100 mg/mL Sol[CQCH]

Facility

$48.70

Service Code	NDC 6542312
Hospital Charge Code	139706665
Hospital Revenue Code	250
Min. Negotiated Rate	$12.66
Max. Negotiated Rate	$43.83
Rate for Payer: Aetna of AZ Commercial	$43.83
Rate for Payer: Bisbee Police All Plans	$12.66
Rate for Payer: Cash Price	$38.96
Rate for Payer: Self Pay Self Pay	$38.96

sugammadex 100 mg/mL Sol[CQCH]

Facility

$48.70

Service Code	NDC 6542312
Hospital Charge Code	139706665
Hospital Revenue Code	250
Min. Negotiated Rate	$7.30
Max. Negotiated Rate	$43.83
Rate for Payer: Aetna of AZ Commercial	$43.83
Rate for Payer: Aetna of AZ Medicare	$13.64
Rate for Payer: Allwell Medicare	$7.30
Rate for Payer: Amerigroup Medicare	$7.30
Rate for Payer: APIPA Medicare/Medicaid	$18.19
Rate for Payer: AZCH Complete Medicare	$7.30
Rate for Payer: Banner UC Health Medicare	$7.30
Rate for Payer: Bisbee Police All Plans	$12.66
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$33.12
Rate for Payer: Cash Price	$38.96
Rate for Payer: Cigna of AZ Commercial	$31.66
Rate for Payer: Copperpoint Commercial	$12.05
Rate for Payer: Health Net of AZ Commercial	$29.22
Rate for Payer: Health Net of AZ Medicare	$13.64
Rate for Payer: Humana of AZ Medicare	$7.30
Rate for Payer: Self Pay Self Pay	$38.96
Rate for Payer: TriWest Medicare	$7.30
Rate for Payer: UnitedHealth Group of AZ Commercial	$28.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$8.77

sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [CQCH]

Facility

$0.15

Service Code	NDC 904272561
Hospital Charge Code	105942777
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Cash Price	$0.12
Rate for Payer: Self Pay Self Pay	$0.12

sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [CQCH]

Facility

$0.15

Service Code	NDC 904272561
Hospital Charge Code	105942777
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
Rate for Payer: Aetna of AZ Medicare	$0.04
Rate for Payer: Allwell Medicare	$0.02
Rate for Payer: Amerigroup Medicare	$0.02
Rate for Payer: APIPA Medicare/Medicaid	$0.06
Rate for Payer: AZCH Complete Medicare	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.10
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of AZ Commercial	$0.10
Rate for Payer: Copperpoint Commercial	$0.04
Rate for Payer: Health Net of AZ Commercial	$0.09
Rate for Payer: Health Net of AZ Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Self Pay Self Pay	$0.12
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.09
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.03

sulfamethoxazole-trimethoprim 80 mg-16 mg/mL IV Sol 10 mL [CQCH]

Facility

$0.90

Service Code	NDC 703951403
Hospital Charge Code	105942710
Hospital Revenue Code	251
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.81
Rate for Payer: Aetna of AZ Commercial	$0.81
Rate for Payer: Aetna of AZ Medicare	$0.25
Rate for Payer: Allwell Medicare	$0.14
Rate for Payer: Amerigroup Medicare	$0.14
Rate for Payer: APIPA Medicare/Medicaid	$0.34
Rate for Payer: AZCH Complete Medicare	$0.14
Rate for Payer: Banner UC Health Medicare	$0.14
Rate for Payer: Bisbee Police All Plans	$0.23
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.61
Rate for Payer: Cash Price	$0.72
Rate for Payer: Cigna of AZ Commercial	$0.59
Rate for Payer: Copperpoint Commercial	$0.22
Rate for Payer: Health Net of AZ Commercial	$0.54
Rate for Payer: Health Net of AZ Medicare	$0.25
Rate for Payer: Humana of AZ Medicare	$0.14
Rate for Payer: Self Pay Self Pay	$0.72
Rate for Payer: TriWest Medicare	$0.14
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.52
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.16

sulfamethoxazole-trimethoprim 80 mg-16 mg/mL IV Sol 10 mL [CQCH]

Facility

$0.90

Service Code	NDC 703951403
Hospital Charge Code	105942710
Hospital Revenue Code	251
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.81
Rate for Payer: Aetna of AZ Commercial	$0.81
Rate for Payer: Bisbee Police All Plans	$0.23
Rate for Payer: Cash Price	$0.72
Rate for Payer: Self Pay Self Pay	$0.72

sulfamethox.-trimeth.800 mg-160 mg/20 mL oral Susp UD [CQCH]

Facility

$0.17

Service Code	NDC 50383082421
Hospital Charge Code	111213652
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
Rate for Payer: Aetna of AZ Medicare	$0.05
Rate for Payer: Allwell Medicare	$0.03
Rate for Payer: Amerigroup Medicare	$0.03
Rate for Payer: APIPA Medicare/Medicaid	$0.06
Rate for Payer: AZCH Complete Medicare	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.12
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of AZ Commercial	$0.11
Rate for Payer: Copperpoint Commercial	$0.04
Rate for Payer: Health Net of AZ Commercial	$0.10
Rate for Payer: Health Net of AZ Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Self Pay Self Pay	$0.14
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.10
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.03

sulfamethox.-trimeth.800 mg-160 mg/20 mL oral Susp UD [CQCH]

Facility

$0.17

Service Code	NDC 50383082421
Hospital Charge Code	111213652
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
Rate for Payer: Bisbee Police All Plans	$0.04
Rate for Payer: Cash Price	$0.14
Rate for Payer: Self Pay Self Pay	$0.14

sulfaSALAzine 500 mg Tab [CQCH]

Facility

$0.29

Service Code	NDC 50268073015
Hospital Charge Code	105942842
Hospital Revenue Code	251
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of AZ Commercial	$0.26
Rate for Payer: Bisbee Police All Plans	$0.08
Rate for Payer: Cash Price	$0.23
Rate for Payer: Self Pay Self Pay	$0.23

sulfaSALAzine 500 mg Tab [CQCH]

Facility

$0.29

Service Code	NDC 50268073015
Hospital Charge Code	105942842
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of AZ Commercial	$0.26
Rate for Payer: Aetna of AZ Medicare	$0.08
Rate for Payer: Allwell Medicare	$0.04
Rate for Payer: Amerigroup Medicare	$0.04
Rate for Payer: APIPA Medicare/Medicaid	$0.11
Rate for Payer: AZCH Complete Medicare	$0.04
Rate for Payer: Banner UC Health Medicare	$0.04
Rate for Payer: Bisbee Police All Plans	$0.08
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.20
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of AZ Commercial	$0.19
Rate for Payer: Copperpoint Commercial	$0.07
Rate for Payer: Health Net of AZ Commercial	$0.17
Rate for Payer: Health Net of AZ Medicare	$0.08
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Self Pay Self Pay	$0.23
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.17
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.05

Know your out-of-pocket cost for care.

All Charges