Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

SNARE OVAL FLEX MEDIUM

Facility

$1,247.00

Hospital Charge Code	22354316
Hospital Revenue Code	270
Min. Negotiated Rate	$324.22
Max. Negotiated Rate	$1,122.30
Rate for Payer: Aetna of AZ Commercial	$1,122.30
Rate for Payer: Bisbee Police All Plans	$324.22
Rate for Payer: Cash Price	$997.60
Rate for Payer: Self Pay Self Pay	$997.60

SNARE OVAL FLEX MEDIUM

Facility

$1,247.00

Hospital Charge Code	22354316
Hospital Revenue Code	270
Min. Negotiated Rate	$199.52
Max. Negotiated Rate	$1,122.30
Rate for Payer: Aetna of AZ Commercial	$1,122.30
Rate for Payer: Aetna of AZ Medicare	$349.16
Rate for Payer: Allwell Medicare	$199.52
Rate for Payer: Amerigroup Medicare	$199.52
Rate for Payer: APIPA Medicare/Medicaid	$465.75
Rate for Payer: AZCH Complete Medicare	$199.52
Rate for Payer: Banner UC Health Medicare	$199.52
Rate for Payer: Bisbee Police All Plans	$324.22
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$847.96
Rate for Payer: Cash Price	$997.60
Rate for Payer: Cigna of AZ Commercial	$872.90
Rate for Payer: Copperpoint Commercial	$308.63
Rate for Payer: Health Net of AZ Commercial	$748.20
Rate for Payer: Health Net of AZ Medicare	$349.16
Rate for Payer: Humana of AZ Medicare	$199.52
Rate for Payer: Self Pay Self Pay	$997.60
Rate for Payer: TriWest Medicare	$199.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$727.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$224.46

SNARE POLYPECTOMY SML OVAL CONMED

Facility

$1,567.00

Hospital Charge Code	22354206
Hospital Revenue Code	270
Min. Negotiated Rate	$250.72
Max. Negotiated Rate	$1,410.30
Rate for Payer: Aetna of AZ Commercial	$1,410.30
Rate for Payer: Aetna of AZ Medicare	$438.76
Rate for Payer: Allwell Medicare	$250.72
Rate for Payer: Amerigroup Medicare	$250.72
Rate for Payer: APIPA Medicare/Medicaid	$585.27
Rate for Payer: AZCH Complete Medicare	$250.72
Rate for Payer: Banner UC Health Medicare	$250.72
Rate for Payer: Bisbee Police All Plans	$407.42
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,065.56
Rate for Payer: Cash Price	$1,253.60
Rate for Payer: Cigna of AZ Commercial	$1,096.90
Rate for Payer: Copperpoint Commercial	$387.83
Rate for Payer: Health Net of AZ Commercial	$940.20
Rate for Payer: Health Net of AZ Medicare	$438.76
Rate for Payer: Humana of AZ Medicare	$250.72
Rate for Payer: Self Pay Self Pay	$1,253.60
Rate for Payer: TriWest Medicare	$250.72
Rate for Payer: UnitedHealth Group of AZ Commercial	$913.56
Rate for Payer: UnitedHealth Group of AZ Medicare	$282.06

SNARE POLYPECTOMY SML OVAL CONMED

Facility

$1,567.00

Hospital Charge Code	22354206
Hospital Revenue Code	270
Min. Negotiated Rate	$407.42
Max. Negotiated Rate	$1,410.30
Rate for Payer: Aetna of AZ Commercial	$1,410.30
Rate for Payer: Bisbee Police All Plans	$407.42
Rate for Payer: Cash Price	$1,253.60
Rate for Payer: Self Pay Self Pay	$1,253.60

sodium bicarbonate 4.2% (infant PFS)IV 10 mL [CQCH]

Facility

$0.84

Service Code	NDC 409553434
Hospital Charge Code	105940804
Hospital Revenue Code	251
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.76
Rate for Payer: Aetna of AZ Commercial	$0.76
Rate for Payer: Bisbee Police All Plans	$0.22
Rate for Payer: Cash Price	$0.67
Rate for Payer: Self Pay Self Pay	$0.67

sodium bicarbonate 4.2% (infant PFS)IV 10 mL [CQCH]

Facility

$0.84

Service Code	NDC 409553434
Hospital Charge Code	105940804
Hospital Revenue Code	251
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.76
Rate for Payer: Aetna of AZ Commercial	$0.76
Rate for Payer: Aetna of AZ Medicare	$0.24
Rate for Payer: Allwell Medicare	$0.13
Rate for Payer: Amerigroup Medicare	$0.13
Rate for Payer: APIPA Medicare/Medicaid	$0.31
Rate for Payer: AZCH Complete Medicare	$0.13
Rate for Payer: Banner UC Health Medicare	$0.13
Rate for Payer: Bisbee Police All Plans	$0.22
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.57
Rate for Payer: Cash Price	$0.67
Rate for Payer: Cigna of AZ Commercial	$0.55
Rate for Payer: Copperpoint Commercial	$0.21
Rate for Payer: Health Net of AZ Commercial	$0.50
Rate for Payer: Health Net of AZ Medicare	$0.24
Rate for Payer: Humana of AZ Medicare	$0.13
Rate for Payer: Self Pay Self Pay	$0.67
Rate for Payer: TriWest Medicare	$0.13
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.49
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.15

sodium bicarbonate 4% Soln 5 mL [CQCH]

Facility

$1.24

Service Code	NDC 409660902
Hospital Charge Code	111111011
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of AZ Commercial	$1.12
Rate for Payer: Aetna of AZ Medicare	$0.35
Rate for Payer: Allwell Medicare	$0.20
Rate for Payer: Amerigroup Medicare	$0.20
Rate for Payer: APIPA Medicare/Medicaid	$0.46
Rate for Payer: AZCH Complete Medicare	$0.20
Rate for Payer: Banner UC Health Medicare	$0.20
Rate for Payer: Bisbee Police All Plans	$0.32
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.84
Rate for Payer: Cash Price	$0.99
Rate for Payer: Cigna of AZ Commercial	$0.81
Rate for Payer: Copperpoint Commercial	$0.31
Rate for Payer: Health Net of AZ Commercial	$0.74
Rate for Payer: Health Net of AZ Medicare	$0.35
Rate for Payer: Humana of AZ Medicare	$0.20
Rate for Payer: Self Pay Self Pay	$0.99
Rate for Payer: TriWest Medicare	$0.20
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.72
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.22

sodium bicarbonate 4% Soln 5 mL [CQCH]

Facility

$1.24

Service Code	NDC 409660902
Hospital Charge Code	111111011
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of AZ Commercial	$1.12
Rate for Payer: Bisbee Police All Plans	$0.32
Rate for Payer: Cash Price	$0.99
Rate for Payer: Self Pay Self Pay	$0.99

sodium bicarbonate 650 mg Tab [CQCH]

Facility

$0.02

Service Code	NDC 536454410
Hospital Charge Code	105940670
Hospital Revenue Code	251
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

sodium bicarbonate 650 mg Tab [CQCH]

Facility

$0.02

Service Code	NDC 536454410
Hospital Charge Code	105940670
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.02

sodium bicarbonate 8.4% IV Sol (50 mL PFS) [CQCH]

Facility

$0.17

Service Code	NDC 409663734
Hospital Charge Code	105940871
Hospital Revenue Code	251
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

sodium bicarbonate 8.4% IV Sol (50 mL PFS) [CQCH]

Facility

$0.17

Service Code	NDC 409663734
Hospital Charge Code	105940871
Hospital Revenue Code	251
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

Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J3480
Hospital Charge Code	105941369
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J3480
Hospital Charge Code	105941369
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Self Pay Self Pay	$0.01

Sodium Chloride 0.9% 50 ML IV SOLN(CQCH)

Facility

$2.29

Service Code	HCPCS J7040
Hospital Charge Code	121934599
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$2.06
Rate for Payer: Aetna of AZ Commercial	$2.06
Rate for Payer: Bisbee Police All Plans	$0.60
Rate for Payer: Cash Price	$1.83
Rate for Payer: Self Pay Self Pay	$1.83

Sodium Chloride 0.9% 50 ML IV SOLN(CQCH)

Facility

$2.29

Service Code	HCPCS J7040
Hospital Charge Code	121934599
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$2.06
Rate for Payer: Aetna of AZ Commercial	$2.06
Rate for Payer: Aetna of AZ Medicare	$0.64
Rate for Payer: Allwell Medicare	$0.37
Rate for Payer: Amerigroup Medicare	$0.37
Rate for Payer: APIPA Medicare/Medicaid	$0.86
Rate for Payer: AZCH Complete Medicare	$0.37
Rate for Payer: Banner UC Health Medicare	$0.37
Rate for Payer: Bisbee Police All Plans	$0.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.56
Rate for Payer: Cash Price	$1.83
Rate for Payer: Cigna of AZ Commercial	$1.49
Rate for Payer: Copperpoint Commercial	$0.57
Rate for Payer: Health Net of AZ Commercial	$1.37
Rate for Payer: Health Net of AZ Medicare	$0.64
Rate for Payer: Humana of AZ Medicare	$0.37
Rate for Payer: Self Pay Self Pay	$1.83
Rate for Payer: TriWest Medicare	$0.37
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.34
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.41

sodium chloride 0.9% Inh Sol 3 mL [CQCH]

Facility

$0.03

Service Code	NDC 487930103
Hospital Charge Code	105941436
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.03
Rate for Payer: Self Pay Self Pay	$0.02

sodium chloride 0.9% Inh Sol 3 mL [CQCH]

Facility

$0.03

Service Code	NDC 487930103
Hospital Charge Code	105941436
Hospital Revenue Code	251
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of AZ Commercial	$0.03
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.02
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of AZ Commercial	$0.02
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.02
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

sodium chloride 0.9% Inj Sol 10 mL [CQCH]

Facility

$0.08

Service Code	NDC 409488810
Hospital Charge Code	105941657
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Cash Price	$0.06
Rate for Payer: Self Pay Self Pay	$0.06

sodium chloride 0.9% Inj Sol 10 mL [CQCH]

Facility

$0.08

Service Code	NDC 409488810
Hospital Charge Code	105941657
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of AZ Commercial	$0.07
Rate for Payer: Aetna of AZ Medicare	$0.02
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.03
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.05
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of AZ Commercial	$0.05
Rate for Payer: Copperpoint Commercial	$0.02
Rate for Payer: Health Net of AZ Commercial	$0.05
Rate for Payer: Health Net of AZ Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Self Pay Self Pay	$0.06
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.05
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

Sodium Chloride 0.9% IV Sol 100 mL IVPB [CQCH]

Facility

$0.05

Service Code	HCPCS J7040
Hospital Charge Code	105953385
Hospital Revenue Code	258
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.02
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.03
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of AZ Commercial	$0.03
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.03
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Self Pay Self Pay	$0.04
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

Sodium Chloride 0.9% IV Sol 100 mL IVPB [CQCH]

Facility

$0.05

Service Code	HCPCS J7040
Hospital Charge Code	105953385
Hospital Revenue Code	258
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.04
Rate for Payer: Self Pay Self Pay	$0.04

Sodium Chloride 0.9% IV Sol 250 mL IVPB [CQCH]

Facility

$0.02

Service Code	HCPCS J7040
Hospital Charge Code	105953498
Hospital Revenue Code	250
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.02
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

Sodium Chloride 0.9% IV Sol 250 mL IVPB [CQCH]

Facility

$0.02

Service Code	HCPCS J7040
Hospital Charge Code	105953498
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of AZ Commercial	$0.02
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.02
Rate for Payer: Self Pay Self Pay	$0.02

Sodium Chloride 0.9% Sol 1000 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J7040
Hospital Charge Code	108127272
Hospital Revenue Code	258
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Aetna of AZ Medicare	$0.00
Rate for Payer: Allwell Medicare	$0.00
Rate for Payer: Amerigroup Medicare	$0.00
Rate for Payer: APIPA Medicare/Medicaid	$0.00
Rate for Payer: AZCH Complete Medicare	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Bisbee Police All Plans	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Copperpoint Commercial	$0.00
Rate for Payer: Health Net of AZ Commercial	$0.01
Rate for Payer: Health Net of AZ Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Self Pay Self Pay	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.01
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.00

Know your out-of-pocket cost for care.

All Charges