Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

Strep Confirmation

Facility

$173.00

Service Code	CPT 87081
Hospital Charge Code	853207
Hospital Revenue Code	306
Min. Negotiated Rate	$44.98
Max. Negotiated Rate	$155.70
Rate for Payer: Aetna of AZ Commercial	$155.70
Rate for Payer: Bisbee Police All Plans	$44.98
Rate for Payer: Cash Price	$138.40
Rate for Payer: Self Pay Self Pay	$138.40

Strep Test POC

Facility

$25.00

Service Code	CPT 87880 QW
Hospital Charge Code	23799747
Hospital Revenue Code	521
Min. Negotiated Rate	$6.50
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of AZ Commercial	$22.50
Rate for Payer: Bisbee Police All Plans	$6.50
Rate for Payer: Cash Price	$20.00
Rate for Payer: Self Pay Self Pay	$20.00

Strep Test POC

Facility

$25.00

Service Code	CPT 87880 QW
Hospital Charge Code	23799747
Hospital Revenue Code	521
Min. Negotiated Rate	$4.00
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of AZ Commercial	$22.50
Rate for Payer: Aetna of AZ Medicare	$4.00
Rate for Payer: Allwell Medicare	$4.00
Rate for Payer: Amerigroup Medicare	$4.00
Rate for Payer: APIPA Medicare/Medicaid	$9.34
Rate for Payer: AZCH Complete Medicare	$4.00
Rate for Payer: Banner UC Health Medicare	$4.00
Rate for Payer: Bisbee Police All Plans	$6.50
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$17.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cigna of AZ Commercial	$17.50
Rate for Payer: Copperpoint Commercial	$6.19
Rate for Payer: Health Net of AZ Commercial	$15.00
Rate for Payer: Health Net of AZ Medicare	$7.00
Rate for Payer: Humana of AZ Medicare	$4.00
Rate for Payer: Self Pay Self Pay	$20.00
Rate for Payer: TriWest Medicare	$4.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$14.57
Rate for Payer: UnitedHealth Group of AZ Medicare	$4.50

STRIP T'S STERILE ADHESIVE ORGANIZER

Facility

$50.00

Hospital Charge Code	22561786
Hospital Revenue Code	272
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna of AZ Commercial	$45.00
Rate for Payer: Bisbee Police All Plans	$13.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Self Pay Self Pay	$40.00

STRIP T'S STERILE ADHESIVE ORGANIZER

Facility

$50.00

Hospital Charge Code	22561786
Hospital Revenue Code	272
Min. Negotiated Rate	$8.00
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna of AZ Commercial	$45.00
Rate for Payer: Aetna of AZ Medicare	$14.00
Rate for Payer: Allwell Medicare	$8.00
Rate for Payer: Amerigroup Medicare	$8.00
Rate for Payer: APIPA Medicare/Medicaid	$18.68
Rate for Payer: AZCH Complete Medicare	$8.00
Rate for Payer: Banner UC Health Medicare	$8.00
Rate for Payer: Bisbee Police All Plans	$13.00
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$34.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cigna of AZ Commercial	$35.00
Rate for Payer: Copperpoint Commercial	$12.38
Rate for Payer: Health Net of AZ Commercial	$30.00
Rate for Payer: Health Net of AZ Medicare	$14.00
Rate for Payer: Humana of AZ Medicare	$8.00
Rate for Payer: Self Pay Self Pay	$40.00
Rate for Payer: TriWest Medicare	$8.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$29.15
Rate for Payer: UnitedHealth Group of AZ Medicare	$9.00

STYLETTE ET

Facility

$202.00

Hospital Charge Code	22560511
Hospital Revenue Code	272
Min. Negotiated Rate	$52.52
Max. Negotiated Rate	$181.80
Rate for Payer: Aetna of AZ Commercial	$181.80
Rate for Payer: Bisbee Police All Plans	$52.52
Rate for Payer: Cash Price	$161.60
Rate for Payer: Self Pay Self Pay	$161.60

STYLETTE ET

Facility

$202.00

Hospital Charge Code	22560511
Hospital Revenue Code	272
Min. Negotiated Rate	$32.32
Max. Negotiated Rate	$181.80
Rate for Payer: Aetna of AZ Commercial	$181.80
Rate for Payer: Aetna of AZ Medicare	$56.56
Rate for Payer: Allwell Medicare	$32.32
Rate for Payer: Amerigroup Medicare	$32.32
Rate for Payer: APIPA Medicare/Medicaid	$75.45
Rate for Payer: AZCH Complete Medicare	$32.32
Rate for Payer: Banner UC Health Medicare	$32.32
Rate for Payer: Bisbee Police All Plans	$52.52
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$137.36
Rate for Payer: Cash Price	$161.60
Rate for Payer: Cigna of AZ Commercial	$141.40
Rate for Payer: Copperpoint Commercial	$49.99
Rate for Payer: Health Net of AZ Commercial	$121.20
Rate for Payer: Health Net of AZ Medicare	$56.56
Rate for Payer: Humana of AZ Medicare	$32.32
Rate for Payer: Self Pay Self Pay	$161.60
Rate for Payer: TriWest Medicare	$32.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$117.77
Rate for Payer: UnitedHealth Group of AZ Medicare	$36.36

succinylcholine 200 mg/ 10 mL Inj Sol [CQCH]

Facility

$0.81

Service Code	HCPCS J0330
Hospital Charge Code	105942505
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.73
Rate for Payer: Aetna of AZ Commercial	$0.73
Rate for Payer: Bisbee Police All Plans	$0.21
Rate for Payer: Cash Price	$0.65
Rate for Payer: Self Pay Self Pay	$0.65

succinylcholine 200 mg/ 10 mL Inj Sol [CQCH]

Facility

$0.81

Service Code	HCPCS J0330
Hospital Charge Code	105942505
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.73
Rate for Payer: Aetna of AZ Commercial	$0.73
Rate for Payer: Aetna of AZ Medicare	$0.23
Rate for Payer: Allwell Medicare	$0.13
Rate for Payer: Amerigroup Medicare	$0.13
Rate for Payer: APIPA Medicare/Medicaid	$0.30
Rate for Payer: AZCH Complete Medicare	$0.13
Rate for Payer: Banner UC Health Medicare	$0.13
Rate for Payer: Bisbee Police All Plans	$0.21
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.55
Rate for Payer: Cash Price	$0.65
Rate for Payer: Cigna of AZ Commercial	$0.53
Rate for Payer: Copperpoint Commercial	$0.20
Rate for Payer: Health Net of AZ Commercial	$0.49
Rate for Payer: Health Net of AZ Medicare	$0.23
Rate for Payer: Humana of AZ Medicare	$0.13
Rate for Payer: Self Pay Self Pay	$0.65
Rate for Payer: TriWest Medicare	$0.13
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.47
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.15

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

sucralfate 1 g Tab [CQCH]

Facility

$0.24

Service Code	NDC 63739094310
Hospital Charge Code	105942580
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of AZ Commercial	$0.22
Rate for Payer: Bisbee Police All Plans	$0.06
Rate for Payer: Cash Price	$0.19
Rate for Payer: Self Pay Self Pay	$0.19

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

$144.00

Service Code	CPT 94799
Hospital Charge Code	1886869
Hospital Revenue Code	410
Min. Negotiated Rate	$23.04
Max. Negotiated Rate	$129.60
Rate for Payer: Aetna of AZ Commercial	$129.60
Rate for Payer: Aetna of AZ Medicare	$40.32
Rate for Payer: Allwell Medicare	$23.04
Rate for Payer: Amerigroup Medicare	$23.04
Rate for Payer: APIPA Medicare/Medicaid	$53.78
Rate for Payer: AZCH Complete Medicare	$23.04
Rate for Payer: Banner UC Health Medicare	$23.04
Rate for Payer: Bisbee Police All Plans	$37.44
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$97.92
Rate for Payer: Cash Price	$115.20
Rate for Payer: Cigna of AZ Commercial	$100.80
Rate for Payer: Copperpoint Commercial	$35.64
Rate for Payer: Health Net of AZ Commercial	$86.40
Rate for Payer: Health Net of AZ Medicare	$40.32
Rate for Payer: Humana of AZ Medicare	$23.04
Rate for Payer: Self Pay Self Pay	$115.20
Rate for Payer: TriWest Medicare	$23.04
Rate for Payer: UnitedHealth Group of AZ Commercial	$83.95
Rate for Payer: UnitedHealth Group of AZ Medicare	$25.92

SUCTION

Facility

$144.00

Service Code	CPT 94799
Hospital Charge Code	1886869
Hospital Revenue Code	410
Min. Negotiated Rate	$37.44
Max. Negotiated Rate	$129.60
Rate for Payer: Aetna of AZ Commercial	$129.60
Rate for Payer: Bisbee Police All Plans	$37.44
Rate for Payer: Cash Price	$115.20
Rate for Payer: Self Pay Self Pay	$115.20

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 1200

Facility

$27.00

Hospital Charge Code	22355544
Hospital Revenue Code	270
Min. Negotiated Rate	$4.32
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	$4.32
Rate for Payer: Amerigroup Medicare	$4.32
Rate for Payer: APIPA Medicare/Medicaid	$10.08
Rate for Payer: AZCH Complete Medicare	$4.32
Rate for Payer: Banner UC Health Medicare	$4.32
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	$4.32
Rate for Payer: Self Pay Self Pay	$21.60
Rate for Payer: TriWest Medicare	$4.32
Rate for Payer: UnitedHealth Group of AZ Commercial	$15.74
Rate for Payer: UnitedHealth Group of AZ Medicare	$4.86

SUCTION CANISTER 800

Facility

$12.00

Hospital Charge Code	22355704
Hospital Revenue Code	270
Min. Negotiated Rate	$1.92
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	$1.92
Rate for Payer: Amerigroup Medicare	$1.92
Rate for Payer: APIPA Medicare/Medicaid	$4.48
Rate for Payer: AZCH Complete Medicare	$1.92
Rate for Payer: Banner UC Health Medicare	$1.92
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	$1.92
Rate for Payer: Self Pay Self Pay	$9.60
Rate for Payer: TriWest Medicare	$1.92
Rate for Payer: UnitedHealth Group of AZ Commercial	$7.00
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.16

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 OMNI

Facility

$555.00

Hospital Charge Code	22354183
Hospital Revenue Code	270
Min. Negotiated Rate	$88.80
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	$88.80
Rate for Payer: Amerigroup Medicare	$88.80
Rate for Payer: APIPA Medicare/Medicaid	$207.29
Rate for Payer: AZCH Complete Medicare	$88.80
Rate for Payer: Banner UC Health Medicare	$88.80
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	$88.80
Rate for Payer: Self Pay Self Pay	$444.00
Rate for Payer: TriWest Medicare	$88.80
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

sugammadex 100 mg/mL Sol[CQCH]

Facility

$48.70

Service Code	NDC 6542312
Hospital Charge Code	139706665
Hospital Revenue Code	250
Min. Negotiated Rate	$7.79
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	$7.79
Rate for Payer: Amerigroup Medicare	$7.79
Rate for Payer: APIPA Medicare/Medicaid	$18.19
Rate for Payer: AZCH Complete Medicare	$7.79
Rate for Payer: Banner UC Health Medicare	$7.79
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	$7.79
Rate for Payer: Self Pay Self Pay	$38.96
Rate for Payer: TriWest Medicare	$7.79
Rate for Payer: UnitedHealth Group of AZ Commercial	$28.39
Rate for Payer: UnitedHealth Group of AZ Medicare	$8.77

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

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

Know your out-of-pocket cost for care.

All Charges