Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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: Bisbee Police All Plans	$0.00
Rate for Payer: Self Pay Self Pay	$0.01

Sodium Chloride 0.9% Sol 500 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J7040
Hospital Charge Code	108127424
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: 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	$0.00
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 0.9% Sol 500 mL [CQCH]

Facility

$0.01

Service Code	HCPCS J7040
Hospital Charge Code	108127424
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: Cash Price	$0.01
Rate for Payer: Self Pay Self Pay	$0.01

sodium chloride 1000 mg tab [CQCH]

Facility

$0.06

Service Code	NDC 223176001
Hospital Charge Code	105941113
Hospital Revenue Code	251
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	$0.02
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	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.04
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of AZ Commercial	$0.04
Rate for Payer: Copperpoint Commercial	$0.01
Rate for Payer: Health Net of AZ Commercial	$0.04
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	$0.05
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 1000 mg tab [CQCH]

Facility

$0.06

Service Code	NDC 223176001
Hospital Charge Code	105941113
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of AZ Commercial	$0.05
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Cash Price	$0.05
Rate for Payer: Self Pay Self Pay	$0.05

sodium chloride 23.4% IV Sol 30 mL [CQCH]

Facility

$0.09

Service Code	HCPCS J7131
Hospital Charge Code	105941968
Hospital Revenue Code	251
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of AZ Commercial	$0.08
Rate for Payer: Aetna of AZ Medicare	$0.03
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	$0.06
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of AZ Commercial	$0.06
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	$0.03
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Self Pay Self Pay	$0.07
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	$0.02

sodium chloride 23.4% IV Sol 30 mL [CQCH]

Facility

$0.09

Service Code	HCPCS J7131
Hospital Charge Code	105941968
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of AZ Commercial	$0.08
Rate for Payer: Bisbee Police All Plans	$0.02
Rate for Payer: Cash Price	$0.07
Rate for Payer: Self Pay Self Pay	$0.07

Sodium Chloride 3% IV Sol (Hypertonic saline) 500 mL [CQCH]

Facility

$0.08

Service Code	NDC 63323053075
Hospital Charge Code	112802150
Hospital Revenue Code	250
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 3% IV Sol (Hypertonic saline) 500 mL [CQCH]

Facility

$0.08

Service Code	NDC 63323053075
Hospital Charge Code	112802150
Hospital Revenue Code	250
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 nasal 0.65% Gel [CQCH]

Facility

$2.39

Service Code	NDC 225052547
Hospital Charge Code	105942100
Hospital Revenue Code	251
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$2.15
Rate for Payer: Aetna of AZ Commercial	$2.15
Rate for Payer: Aetna of AZ Medicare	$0.67
Rate for Payer: Allwell Medicare	$0.38
Rate for Payer: Amerigroup Medicare	$0.38
Rate for Payer: APIPA Medicare/Medicaid	$0.89
Rate for Payer: AZCH Complete Medicare	$0.38
Rate for Payer: Banner UC Health Medicare	$0.38
Rate for Payer: Bisbee Police All Plans	$0.62
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1.63
Rate for Payer: Cash Price	$1.91
Rate for Payer: Cigna of AZ Commercial	$1.55
Rate for Payer: Copperpoint Commercial	$0.59
Rate for Payer: Health Net of AZ Commercial	$1.43
Rate for Payer: Health Net of AZ Medicare	$0.67
Rate for Payer: Humana of AZ Medicare	$0.38
Rate for Payer: Self Pay Self Pay	$1.91
Rate for Payer: TriWest Medicare	$0.38
Rate for Payer: UnitedHealth Group of AZ Commercial	$1.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.43

sodium chloride nasal 0.65% Gel [CQCH]

Facility

$2.39

Service Code	NDC 225052547
Hospital Charge Code	105942100
Hospital Revenue Code	251
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$2.15
Rate for Payer: Aetna of AZ Commercial	$2.15
Rate for Payer: Bisbee Police All Plans	$0.62
Rate for Payer: Cash Price	$1.91
Rate for Payer: Self Pay Self Pay	$1.91

Sodium Level

Facility

$66.00

Service Code	CPT 84295
Hospital Charge Code	633611
Hospital Revenue Code	301
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of AZ Commercial	$59.40
Rate for Payer: Aetna of AZ Medicare	$18.48
Rate for Payer: Allwell Medicare	$10.56
Rate for Payer: Amerigroup Medicare	$10.56
Rate for Payer: APIPA Medicare/Medicaid	$24.65
Rate for Payer: AZCH Complete Medicare	$10.56
Rate for Payer: Banner UC Health Medicare	$10.56
Rate for Payer: Bisbee Police All Plans	$17.16
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$44.88
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cigna of AZ Commercial	$42.90
Rate for Payer: Copperpoint Commercial	$16.34
Rate for Payer: Health Net of AZ Commercial	$39.60
Rate for Payer: Health Net of AZ Medicare	$18.48
Rate for Payer: Humana of AZ Medicare	$10.56
Rate for Payer: Self Pay Self Pay	$52.80
Rate for Payer: TriWest Medicare	$10.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$38.48
Rate for Payer: UnitedHealth Group of AZ Medicare	$11.88

Sodium Level

Facility

$66.00

Service Code	CPT 84295
Hospital Charge Code	633611
Hospital Revenue Code	301
Min. Negotiated Rate	$17.16
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of AZ Commercial	$59.40
Rate for Payer: Bisbee Police All Plans	$17.16
Rate for Payer: Cash Price	$52.80
Rate for Payer: Self Pay Self Pay	$52.80

Sodium Level 24 Hour Urine

Facility

$84.00

Service Code	CPT 84300
Hospital Charge Code	633613
Hospital Revenue Code	301
Min. Negotiated Rate	$13.44
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Aetna of AZ Medicare	$23.52
Rate for Payer: Allwell Medicare	$13.44
Rate for Payer: Amerigroup Medicare	$13.44
Rate for Payer: APIPA Medicare/Medicaid	$31.37
Rate for Payer: AZCH Complete Medicare	$13.44
Rate for Payer: Banner UC Health Medicare	$13.44
Rate for Payer: Bisbee Police All Plans	$21.84
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$57.12
Rate for Payer: Cash Price	$67.20
Rate for Payer: Cigna of AZ Commercial	$54.60
Rate for Payer: Copperpoint Commercial	$20.79
Rate for Payer: Health Net of AZ Commercial	$50.40
Rate for Payer: Health Net of AZ Medicare	$23.52
Rate for Payer: Humana of AZ Medicare	$13.44
Rate for Payer: Self Pay Self Pay	$67.20
Rate for Payer: TriWest Medicare	$13.44
Rate for Payer: UnitedHealth Group of AZ Commercial	$48.97
Rate for Payer: UnitedHealth Group of AZ Medicare	$15.12

Sodium Level 24 Hour Urine

Facility

$84.00

Service Code	CPT 84300
Hospital Charge Code	633613
Hospital Revenue Code	301
Min. Negotiated Rate	$21.84
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of AZ Commercial	$75.60
Rate for Payer: Bisbee Police All Plans	$21.84
Rate for Payer: Cash Price	$67.20
Rate for Payer: Self Pay Self Pay	$67.20

Sodium Level Urine

Facility

$88.00

Service Code	CPT 84300
Hospital Charge Code	887730
Hospital Revenue Code	301
Min. Negotiated Rate	$22.88
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of AZ Commercial	$79.20
Rate for Payer: Bisbee Police All Plans	$22.88
Rate for Payer: Cash Price	$70.40
Rate for Payer: Self Pay Self Pay	$70.40

Sodium Level Urine

Facility

$88.00

Service Code	CPT 84300
Hospital Charge Code	887730
Hospital Revenue Code	301
Min. Negotiated Rate	$14.08
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of AZ Commercial	$79.20
Rate for Payer: Aetna of AZ Medicare	$24.64
Rate for Payer: Allwell Medicare	$14.08
Rate for Payer: Amerigroup Medicare	$14.08
Rate for Payer: APIPA Medicare/Medicaid	$32.87
Rate for Payer: AZCH Complete Medicare	$14.08
Rate for Payer: Banner UC Health Medicare	$14.08
Rate for Payer: Bisbee Police All Plans	$22.88
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$59.84
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cigna of AZ Commercial	$57.20
Rate for Payer: Copperpoint Commercial	$21.78
Rate for Payer: Health Net of AZ Commercial	$52.80
Rate for Payer: Health Net of AZ Medicare	$24.64
Rate for Payer: Humana of AZ Medicare	$14.08
Rate for Payer: Self Pay Self Pay	$70.40
Rate for Payer: TriWest Medicare	$14.08
Rate for Payer: UnitedHealth Group of AZ Commercial	$51.30
Rate for Payer: UnitedHealth Group of AZ Medicare	$15.84

sodium polystyrene sulfonate - Pow[CQCH]

Facility

$0.78

Service Code	NDC 11534016615
Hospital Charge Code	143761878
Hospital Revenue Code	251
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.70
Rate for Payer: Aetna of AZ Commercial	$0.70
Rate for Payer: Aetna of AZ Medicare	$0.22
Rate for Payer: Allwell Medicare	$0.12
Rate for Payer: Amerigroup Medicare	$0.12
Rate for Payer: APIPA Medicare/Medicaid	$0.29
Rate for Payer: AZCH Complete Medicare	$0.12
Rate for Payer: Banner UC Health Medicare	$0.12
Rate for Payer: Bisbee Police All Plans	$0.20
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.53
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna of AZ Commercial	$0.51
Rate for Payer: Copperpoint Commercial	$0.19
Rate for Payer: Health Net of AZ Commercial	$0.47
Rate for Payer: Health Net of AZ Medicare	$0.22
Rate for Payer: Humana of AZ Medicare	$0.12
Rate for Payer: Self Pay Self Pay	$0.62
Rate for Payer: TriWest Medicare	$0.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.45
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.14

sodium polystyrene sulfonate - Pow[CQCH]

Facility

$0.78

Service Code	NDC 11534016615
Hospital Charge Code	143761878
Hospital Revenue Code	251
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.70
Rate for Payer: Aetna of AZ Commercial	$0.70
Rate for Payer: Bisbee Police All Plans	$0.20
Rate for Payer: Cash Price	$0.62
Rate for Payer: Self Pay Self Pay	$0.62

SOL IRRG D/W 500 BOTTLE

Facility

$30.00

Hospital Charge Code	22355366
Hospital Revenue Code	270
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Aetna of AZ Medicare	$8.40
Rate for Payer: Allwell Medicare	$4.80
Rate for Payer: Amerigroup Medicare	$4.80
Rate for Payer: APIPA Medicare/Medicaid	$11.21
Rate for Payer: AZCH Complete Medicare	$4.80
Rate for Payer: Banner UC Health Medicare	$4.80
Rate for Payer: Bisbee Police All Plans	$7.80
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$20.40
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna of AZ Commercial	$21.00
Rate for Payer: Copperpoint Commercial	$7.42
Rate for Payer: Health Net of AZ Commercial	$18.00
Rate for Payer: Health Net of AZ Medicare	$8.40
Rate for Payer: Humana of AZ Medicare	$4.80
Rate for Payer: Self Pay Self Pay	$24.00
Rate for Payer: TriWest Medicare	$4.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$17.49
Rate for Payer: UnitedHealth Group of AZ Medicare	$5.40

SOL IRRG D/W 500 BOTTLE

Facility

$30.00

Hospital Charge Code	22355366
Hospital Revenue Code	270
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Bisbee Police All Plans	$7.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Self Pay Self Pay	$24.00

SOL IRRIG 1000ML DW

Facility

$32.00

Hospital Charge Code	24154073
Hospital Revenue Code	270
Min. Negotiated Rate	$5.12
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Aetna of AZ Medicare	$8.96
Rate for Payer: Allwell Medicare	$5.12
Rate for Payer: Amerigroup Medicare	$5.12
Rate for Payer: APIPA Medicare/Medicaid	$11.95
Rate for Payer: AZCH Complete Medicare	$5.12
Rate for Payer: Banner UC Health Medicare	$5.12
Rate for Payer: Bisbee Police All Plans	$8.32
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$21.76
Rate for Payer: Cash Price	$25.60
Rate for Payer: Cigna of AZ Commercial	$22.40
Rate for Payer: Copperpoint Commercial	$7.92
Rate for Payer: Health Net of AZ Commercial	$19.20
Rate for Payer: Health Net of AZ Medicare	$8.96
Rate for Payer: Humana of AZ Medicare	$5.12
Rate for Payer: Self Pay Self Pay	$25.60
Rate for Payer: TriWest Medicare	$5.12
Rate for Payer: UnitedHealth Group of AZ Commercial	$18.66
Rate for Payer: UnitedHealth Group of AZ Medicare	$5.76

SOL IRRIG 1000ML DW

Facility

$32.00

Hospital Charge Code	24154073
Hospital Revenue Code	270
Min. Negotiated Rate	$8.32
Max. Negotiated Rate	$28.80
Rate for Payer: Aetna of AZ Commercial	$28.80
Rate for Payer: Bisbee Police All Plans	$8.32
Rate for Payer: Cash Price	$25.60
Rate for Payer: Self Pay Self Pay	$25.60

SOL IRRIG 3000ML DW

Facility

$72.00

Hospital Charge Code	24153497
Hospital Revenue Code	270
Min. Negotiated Rate	$18.72
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Bisbee Police All Plans	$18.72
Rate for Payer: Cash Price	$57.60
Rate for Payer: Self Pay Self Pay	$57.60

SOL IRRIG 3000ML DW

Facility

$72.00

Hospital Charge Code	24153497
Hospital Revenue Code	270
Min. Negotiated Rate	$11.52
Max. Negotiated Rate	$64.80
Rate for Payer: Aetna of AZ Commercial	$64.80
Rate for Payer: Aetna of AZ Medicare	$20.16
Rate for Payer: Allwell Medicare	$11.52
Rate for Payer: Amerigroup Medicare	$11.52
Rate for Payer: APIPA Medicare/Medicaid	$26.89
Rate for Payer: AZCH Complete Medicare	$11.52
Rate for Payer: Banner UC Health Medicare	$11.52
Rate for Payer: Bisbee Police All Plans	$18.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$48.96
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna of AZ Commercial	$50.40
Rate for Payer: Copperpoint Commercial	$17.82
Rate for Payer: Health Net of AZ Commercial	$43.20
Rate for Payer: Health Net of AZ Medicare	$20.16
Rate for Payer: Humana of AZ Medicare	$11.52
Rate for Payer: Self Pay Self Pay	$57.60
Rate for Payer: TriWest Medicare	$11.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$41.98
Rate for Payer: UnitedHealth Group of AZ Medicare	$12.96

Know your out-of-pocket cost for care.

All Charges