Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

SUMAtriptan 50 mg Tab [CQCH]

Facility

$0.52

Service Code	NDC 62756052169
Hospital Charge Code	105942980
Hospital Revenue Code	251
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of AZ Commercial	$0.47
Rate for Payer: Aetna of AZ Medicare	$0.15
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	$0.14
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.35
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cigna of AZ Commercial	$0.34
Rate for Payer: Copperpoint Commercial	$0.13
Rate for Payer: Health Net of AZ Commercial	$0.31
Rate for Payer: Health Net of AZ Medicare	$0.15
Rate for Payer: Humana of AZ Medicare	$0.08
Rate for Payer: Self Pay Self Pay	$0.42
Rate for Payer: TriWest Medicare	$0.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.30
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.09

SUMAtriptan 50 mg Tab [CQCH]

Facility

$0.52

Service Code	NDC 62756052169
Hospital Charge Code	105942980
Hospital Revenue Code	251
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of AZ Commercial	$0.47
Rate for Payer: Bisbee Police All Plans	$0.14
Rate for Payer: Cash Price	$0.41
Rate for Payer: Self Pay Self Pay	$0.42

SUMAtriptan 6 mg SubQ Inj [CQCH]

Facility

$13.40

Service Code	HCPCS J3030
Hospital Charge Code	105942909
Hospital Revenue Code	250
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$907.88
Rate for Payer: Aetna of AZ Commercial	$12.06
Rate for Payer: Aetna of AZ Medicare	$3.75
Rate for Payer: AHCCCS Medicaid	$907.88
Rate for Payer: Allwell Medicaid	$907.88
Rate for Payer: Allwell Medicare	$2.01
Rate for Payer: Amerigroup Medicare	$2.01
Rate for Payer: APIPA Medicare/Medicaid	$5.00
Rate for Payer: AZCH Complete Medicaid	$907.88
Rate for Payer: AZCH Complete Medicare	$2.01
Rate for Payer: Banner UC Health Medicaid	$907.88
Rate for Payer: Banner UC Health Medicare	$2.01
Rate for Payer: Bisbee Police All Plans	$3.48
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$9.11
Rate for Payer: Cash Price	$10.72
Rate for Payer: Cash Price	$10.72
Rate for Payer: Cigna of AZ Commercial	$8.71
Rate for Payer: Copperpoint Commercial	$3.32
Rate for Payer: Health Net of AZ Commercial	$8.04
Rate for Payer: Health Net of AZ Medicare	$3.75
Rate for Payer: Humana of AZ Medicare	$2.01
Rate for Payer: Mercy Care Medicaid	$907.88
Rate for Payer: Self Pay Self Pay	$10.72
Rate for Payer: TriWest Medicare	$2.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$7.81
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.41

SUMAtriptan 6 mg SubQ Inj [CQCH]

Facility

$13.40

Service Code	HCPCS J3030
Hospital Charge Code	105942909
Hospital Revenue Code	250
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$12.06
Rate for Payer: Aetna of AZ Commercial	$12.06
Rate for Payer: Bisbee Police All Plans	$3.48
Rate for Payer: Cash Price	$10.72
Rate for Payer: Self Pay Self Pay	$10.72

SUPER STIFF 0.38 FIXED WIRE GUIDE

Facility

$163.00

Hospital Charge Code	27747584
Hospital Revenue Code	263
Min. Negotiated Rate	$42.38
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Bisbee Police All Plans	$42.38
Rate for Payer: Cash Price	$130.40
Rate for Payer: Self Pay Self Pay	$130.40

SUPER STIFF 0.38 FIXED WIRE GUIDE

Facility

$163.00

Hospital Charge Code	27747584
Hospital Revenue Code	263
Min. Negotiated Rate	$24.45
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of AZ Commercial	$146.70
Rate for Payer: Aetna of AZ Medicare	$45.64
Rate for Payer: Allwell Medicare	$24.45
Rate for Payer: Amerigroup Medicare	$24.45
Rate for Payer: APIPA Medicare/Medicaid	$60.88
Rate for Payer: AZCH Complete Medicare	$24.45
Rate for Payer: Banner UC Health Medicare	$24.45
Rate for Payer: Bisbee Police All Plans	$42.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$110.84
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cigna of AZ Commercial	$114.10
Rate for Payer: Copperpoint Commercial	$40.34
Rate for Payer: Health Net of AZ Commercial	$97.80
Rate for Payer: Health Net of AZ Medicare	$45.64
Rate for Payer: Humana of AZ Medicare	$24.45
Rate for Payer: Self Pay Self Pay	$130.40
Rate for Payer: TriWest Medicare	$24.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$95.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$29.34

Supplies

Facility

$2,750.00

Hospital Charge Code	22528811
Hospital Revenue Code	270
Min. Negotiated Rate	$412.50
Max. Negotiated Rate	$2,475.00
Rate for Payer: Aetna of AZ Commercial	$2,475.00
Rate for Payer: Aetna of AZ Medicare	$770.00
Rate for Payer: Allwell Medicare	$412.50
Rate for Payer: Amerigroup Medicare	$412.50
Rate for Payer: APIPA Medicare/Medicaid	$1,027.12
Rate for Payer: AZCH Complete Medicare	$412.50
Rate for Payer: Banner UC Health Medicare	$412.50
Rate for Payer: Bisbee Police All Plans	$715.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,870.00
Rate for Payer: Cash Price	$2,200.00
Rate for Payer: Cigna of AZ Commercial	$1,925.00
Rate for Payer: Copperpoint Commercial	$680.62
Rate for Payer: Health Net of AZ Commercial	$1,650.00
Rate for Payer: Health Net of AZ Medicare	$770.00
Rate for Payer: Humana of AZ Medicare	$412.50
Rate for Payer: Self Pay Self Pay	$2,200.00
Rate for Payer: TriWest Medicare	$412.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,603.25
Rate for Payer: UnitedHealth Group of AZ Medicare	$495.00

Supplies

Facility

$805.00

Hospital Charge Code	22528827
Hospital Revenue Code	270
Min. Negotiated Rate	$209.30
Max. Negotiated Rate	$724.50
Rate for Payer: Aetna of AZ Commercial	$724.50
Rate for Payer: Bisbee Police All Plans	$209.30
Rate for Payer: Cash Price	$644.00
Rate for Payer: Self Pay Self Pay	$644.00

Supplies

Facility

$2,099.00

Hospital Charge Code	22528809
Hospital Revenue Code	270
Min. Negotiated Rate	$545.74
Max. Negotiated Rate	$1,889.10
Rate for Payer: Aetna of AZ Commercial	$1,889.10
Rate for Payer: Bisbee Police All Plans	$545.74
Rate for Payer: Cash Price	$1,679.20
Rate for Payer: Self Pay Self Pay	$1,679.20

Supplies

Facility

$1,029.00

Hospital Charge Code	22528829
Hospital Revenue Code	270
Min. Negotiated Rate	$267.54
Max. Negotiated Rate	$926.10
Rate for Payer: Aetna of AZ Commercial	$926.10
Rate for Payer: Bisbee Police All Plans	$267.54
Rate for Payer: Cash Price	$823.20
Rate for Payer: Self Pay Self Pay	$823.20

Supplies

Facility

$3,066.00

Hospital Charge Code	22528815
Hospital Revenue Code	270
Min. Negotiated Rate	$797.16
Max. Negotiated Rate	$2,759.40
Rate for Payer: Aetna of AZ Commercial	$2,759.40
Rate for Payer: Bisbee Police All Plans	$797.16
Rate for Payer: Cash Price	$2,452.80
Rate for Payer: Self Pay Self Pay	$2,452.80

Supplies

Facility

$810.00

Hospital Charge Code	22528821
Hospital Revenue Code	270
Min. Negotiated Rate	$210.60
Max. Negotiated Rate	$729.00
Rate for Payer: Aetna of AZ Commercial	$729.00
Rate for Payer: Bisbee Police All Plans	$210.60
Rate for Payer: Cash Price	$648.00
Rate for Payer: Self Pay Self Pay	$648.00

Supplies

Facility

$4,891.00

Hospital Charge Code	22528817
Hospital Revenue Code	270
Min. Negotiated Rate	$733.65
Max. Negotiated Rate	$4,401.90
Rate for Payer: Aetna of AZ Commercial	$4,401.90
Rate for Payer: Aetna of AZ Medicare	$1,369.48
Rate for Payer: Allwell Medicare	$733.65
Rate for Payer: Amerigroup Medicare	$733.65
Rate for Payer: APIPA Medicare/Medicaid	$1,826.79
Rate for Payer: AZCH Complete Medicare	$733.65
Rate for Payer: Banner UC Health Medicare	$733.65
Rate for Payer: Bisbee Police All Plans	$1,271.66
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$3,325.88
Rate for Payer: Cash Price	$3,912.80
Rate for Payer: Cigna of AZ Commercial	$3,423.70
Rate for Payer: Copperpoint Commercial	$1,210.52
Rate for Payer: Health Net of AZ Commercial	$2,934.60
Rate for Payer: Health Net of AZ Medicare	$1,369.48
Rate for Payer: Humana of AZ Medicare	$733.65
Rate for Payer: Self Pay Self Pay	$3,912.80
Rate for Payer: TriWest Medicare	$733.65
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,851.45
Rate for Payer: UnitedHealth Group of AZ Medicare	$880.38

Supplies

Facility

$810.00

Hospital Charge Code	22528821
Hospital Revenue Code	270
Min. Negotiated Rate	$121.50
Max. Negotiated Rate	$729.00
Rate for Payer: Aetna of AZ Commercial	$729.00
Rate for Payer: Aetna of AZ Medicare	$226.80
Rate for Payer: Allwell Medicare	$121.50
Rate for Payer: Amerigroup Medicare	$121.50
Rate for Payer: APIPA Medicare/Medicaid	$302.54
Rate for Payer: AZCH Complete Medicare	$121.50
Rate for Payer: Banner UC Health Medicare	$121.50
Rate for Payer: Bisbee Police All Plans	$210.60
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$550.80
Rate for Payer: Cash Price	$648.00
Rate for Payer: Cigna of AZ Commercial	$567.00
Rate for Payer: Copperpoint Commercial	$200.48
Rate for Payer: Health Net of AZ Commercial	$486.00
Rate for Payer: Health Net of AZ Medicare	$226.80
Rate for Payer: Humana of AZ Medicare	$121.50
Rate for Payer: Self Pay Self Pay	$648.00
Rate for Payer: TriWest Medicare	$121.50
Rate for Payer: UnitedHealth Group of AZ Commercial	$472.23
Rate for Payer: UnitedHealth Group of AZ Medicare	$145.80

Supplies

Facility

$810.00

Hospital Charge Code	22528825
Hospital Revenue Code	270
Min. Negotiated Rate	$210.60
Max. Negotiated Rate	$729.00
Rate for Payer: Aetna of AZ Commercial	$729.00
Rate for Payer: Bisbee Police All Plans	$210.60
Rate for Payer: Cash Price	$648.00
Rate for Payer: Self Pay Self Pay	$648.00

Supplies

Facility

$805.00

Hospital Charge Code	22528823
Hospital Revenue Code	270
Min. Negotiated Rate	$120.75
Max. Negotiated Rate	$724.50
Rate for Payer: Aetna of AZ Commercial	$724.50
Rate for Payer: Aetna of AZ Medicare	$225.40
Rate for Payer: Allwell Medicare	$120.75
Rate for Payer: Amerigroup Medicare	$120.75
Rate for Payer: APIPA Medicare/Medicaid	$300.67
Rate for Payer: AZCH Complete Medicare	$120.75
Rate for Payer: Banner UC Health Medicare	$120.75
Rate for Payer: Bisbee Police All Plans	$209.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$547.40
Rate for Payer: Cash Price	$644.00
Rate for Payer: Cigna of AZ Commercial	$563.50
Rate for Payer: Copperpoint Commercial	$199.24
Rate for Payer: Health Net of AZ Commercial	$483.00
Rate for Payer: Health Net of AZ Medicare	$225.40
Rate for Payer: Humana of AZ Medicare	$120.75
Rate for Payer: Self Pay Self Pay	$644.00
Rate for Payer: TriWest Medicare	$120.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$469.32
Rate for Payer: UnitedHealth Group of AZ Medicare	$144.90

Supplies

Facility

$3,066.00

Hospital Charge Code	22528815
Hospital Revenue Code	270
Min. Negotiated Rate	$459.90
Max. Negotiated Rate	$2,759.40
Rate for Payer: Aetna of AZ Commercial	$2,759.40
Rate for Payer: Aetna of AZ Medicare	$858.48
Rate for Payer: Allwell Medicare	$459.90
Rate for Payer: Amerigroup Medicare	$459.90
Rate for Payer: APIPA Medicare/Medicaid	$1,145.15
Rate for Payer: AZCH Complete Medicare	$459.90
Rate for Payer: Banner UC Health Medicare	$459.90
Rate for Payer: Bisbee Police All Plans	$797.16
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$2,084.88
Rate for Payer: Cash Price	$2,452.80
Rate for Payer: Cigna of AZ Commercial	$2,146.20
Rate for Payer: Copperpoint Commercial	$758.84
Rate for Payer: Health Net of AZ Commercial	$1,839.60
Rate for Payer: Health Net of AZ Medicare	$858.48
Rate for Payer: Humana of AZ Medicare	$459.90
Rate for Payer: Self Pay Self Pay	$2,452.80
Rate for Payer: TriWest Medicare	$459.90
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,787.48
Rate for Payer: UnitedHealth Group of AZ Medicare	$551.88

Supplies

Facility

$1,533.00

Hospital Charge Code	22528807
Hospital Revenue Code	270
Min. Negotiated Rate	$398.58
Max. Negotiated Rate	$1,379.70
Rate for Payer: Aetna of AZ Commercial	$1,379.70
Rate for Payer: Bisbee Police All Plans	$398.58
Rate for Payer: Cash Price	$1,226.40
Rate for Payer: Self Pay Self Pay	$1,226.40

Supplies

Facility

$1,904.00

Hospital Charge Code	22528813
Hospital Revenue Code	270
Min. Negotiated Rate	$495.04
Max. Negotiated Rate	$1,713.60
Rate for Payer: Aetna of AZ Commercial	$1,713.60
Rate for Payer: Bisbee Police All Plans	$495.04
Rate for Payer: Cash Price	$1,523.20
Rate for Payer: Self Pay Self Pay	$1,523.20

Supplies

Facility

$1,029.00

Hospital Charge Code	22528829
Hospital Revenue Code	270
Min. Negotiated Rate	$154.35
Max. Negotiated Rate	$926.10
Rate for Payer: Aetna of AZ Commercial	$926.10
Rate for Payer: Aetna of AZ Medicare	$288.12
Rate for Payer: Allwell Medicare	$154.35
Rate for Payer: Amerigroup Medicare	$154.35
Rate for Payer: APIPA Medicare/Medicaid	$384.33
Rate for Payer: AZCH Complete Medicare	$154.35
Rate for Payer: Banner UC Health Medicare	$154.35
Rate for Payer: Bisbee Police All Plans	$267.54
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$699.72
Rate for Payer: Cash Price	$823.20
Rate for Payer: Cigna of AZ Commercial	$720.30
Rate for Payer: Copperpoint Commercial	$254.68
Rate for Payer: Health Net of AZ Commercial	$617.40
Rate for Payer: Health Net of AZ Medicare	$288.12
Rate for Payer: Humana of AZ Medicare	$154.35
Rate for Payer: Self Pay Self Pay	$823.20
Rate for Payer: TriWest Medicare	$154.35
Rate for Payer: UnitedHealth Group of AZ Commercial	$599.91
Rate for Payer: UnitedHealth Group of AZ Medicare	$185.22

Supplies

Facility

$2,099.00

Hospital Charge Code	22528809
Hospital Revenue Code	270
Min. Negotiated Rate	$314.85
Max. Negotiated Rate	$1,889.10
Rate for Payer: Aetna of AZ Commercial	$1,889.10
Rate for Payer: Aetna of AZ Medicare	$587.72
Rate for Payer: Allwell Medicare	$314.85
Rate for Payer: Amerigroup Medicare	$314.85
Rate for Payer: APIPA Medicare/Medicaid	$783.98
Rate for Payer: AZCH Complete Medicare	$314.85
Rate for Payer: Banner UC Health Medicare	$314.85
Rate for Payer: Bisbee Police All Plans	$545.74
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,427.32
Rate for Payer: Cash Price	$1,679.20
Rate for Payer: Cigna of AZ Commercial	$1,469.30
Rate for Payer: Copperpoint Commercial	$519.50
Rate for Payer: Health Net of AZ Commercial	$1,259.40
Rate for Payer: Health Net of AZ Medicare	$587.72
Rate for Payer: Humana of AZ Medicare	$314.85
Rate for Payer: Self Pay Self Pay	$1,679.20
Rate for Payer: TriWest Medicare	$314.85
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,223.72
Rate for Payer: UnitedHealth Group of AZ Medicare	$377.82

Supplies

Facility

$805.00

Hospital Charge Code	22528823
Hospital Revenue Code	270
Min. Negotiated Rate	$209.30
Max. Negotiated Rate	$724.50
Rate for Payer: Aetna of AZ Commercial	$724.50
Rate for Payer: Bisbee Police All Plans	$209.30
Rate for Payer: Cash Price	$644.00
Rate for Payer: Self Pay Self Pay	$644.00

Supplies

Facility

$2,750.00

Hospital Charge Code	22528811
Hospital Revenue Code	270
Min. Negotiated Rate	$715.00
Max. Negotiated Rate	$2,475.00
Rate for Payer: Aetna of AZ Commercial	$2,475.00
Rate for Payer: Bisbee Police All Plans	$715.00
Rate for Payer: Cash Price	$2,200.00
Rate for Payer: Self Pay Self Pay	$2,200.00

Supplies

Facility

$805.00

Hospital Charge Code	22528827
Hospital Revenue Code	270
Min. Negotiated Rate	$120.75
Max. Negotiated Rate	$724.50
Rate for Payer: Aetna of AZ Commercial	$724.50
Rate for Payer: Aetna of AZ Medicare	$225.40
Rate for Payer: Allwell Medicare	$120.75
Rate for Payer: Amerigroup Medicare	$120.75
Rate for Payer: APIPA Medicare/Medicaid	$300.67
Rate for Payer: AZCH Complete Medicare	$120.75
Rate for Payer: Banner UC Health Medicare	$120.75
Rate for Payer: Bisbee Police All Plans	$209.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$547.40
Rate for Payer: Cash Price	$644.00
Rate for Payer: Cigna of AZ Commercial	$563.50
Rate for Payer: Copperpoint Commercial	$199.24
Rate for Payer: Health Net of AZ Commercial	$483.00
Rate for Payer: Health Net of AZ Medicare	$225.40
Rate for Payer: Humana of AZ Medicare	$120.75
Rate for Payer: Self Pay Self Pay	$644.00
Rate for Payer: TriWest Medicare	$120.75
Rate for Payer: UnitedHealth Group of AZ Commercial	$469.32
Rate for Payer: UnitedHealth Group of AZ Medicare	$144.90

Supplies

Facility

$1,533.00

Hospital Charge Code	22528807
Hospital Revenue Code	270
Min. Negotiated Rate	$229.95
Max. Negotiated Rate	$1,379.70
Rate for Payer: Aetna of AZ Commercial	$1,379.70
Rate for Payer: Aetna of AZ Medicare	$429.24
Rate for Payer: Allwell Medicare	$229.95
Rate for Payer: Amerigroup Medicare	$229.95
Rate for Payer: APIPA Medicare/Medicaid	$572.58
Rate for Payer: AZCH Complete Medicare	$229.95
Rate for Payer: Banner UC Health Medicare	$229.95
Rate for Payer: Bisbee Police All Plans	$398.58
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,042.44
Rate for Payer: Cash Price	$1,226.40
Rate for Payer: Cigna of AZ Commercial	$1,073.10
Rate for Payer: Copperpoint Commercial	$379.42
Rate for Payer: Health Net of AZ Commercial	$919.80
Rate for Payer: Health Net of AZ Medicare	$429.24
Rate for Payer: Humana of AZ Medicare	$229.95
Rate for Payer: Self Pay Self Pay	$1,226.40
Rate for Payer: TriWest Medicare	$229.95
Rate for Payer: UnitedHealth Group of AZ Commercial	$893.74
Rate for Payer: UnitedHealth Group of AZ Medicare	$275.94

Know your out-of-pocket cost for care.

All Charges