Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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

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

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	$0.05
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	$0.05
Rate for Payer: Amerigroup Medicare	$0.05
Rate for Payer: APIPA Medicare/Medicaid	$0.11
Rate for Payer: AZCH Complete Medicare	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
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	$0.05
Rate for Payer: Self Pay Self Pay	$0.23
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.17
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.05

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

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 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 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

SUMAtriptan 6 mg SubQ Inj [CQCH]

Facility

$13.40

Service Code	HCPCS J3030
Hospital Charge Code	105942909
Hospital Revenue Code	250
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$12.06
Rate for Payer: Aetna of AZ Commercial	$12.06
Rate for Payer: Aetna of AZ Medicare	$3.75
Rate for Payer: Allwell Medicare	$2.14
Rate for Payer: Amerigroup Medicare	$2.14
Rate for Payer: APIPA Medicare/Medicaid	$5.00
Rate for Payer: AZCH Complete Medicare	$2.14
Rate for Payer: Banner UC Health Medicare	$2.14
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: 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	$2.14
Rate for Payer: Self Pay Self Pay	$10.72
Rate for Payer: TriWest Medicare	$2.14
Rate for Payer: UnitedHealth Group of AZ Commercial	$7.81
Rate for Payer: UnitedHealth Group of AZ Medicare	$2.41

SUPER STIFF 0.38 FIXED WIRE GUIDE

Facility

$155.00

Hospital Charge Code	27747584
Hospital Revenue Code	263
Min. Negotiated Rate	$40.30
Max. Negotiated Rate	$139.50
Rate for Payer: Aetna of AZ Commercial	$139.50
Rate for Payer: Bisbee Police All Plans	$40.30
Rate for Payer: Cash Price	$124.00
Rate for Payer: Self Pay Self Pay	$124.00

SUPER STIFF 0.38 FIXED WIRE GUIDE

Facility

$155.00

Hospital Charge Code	27747584
Hospital Revenue Code	263
Min. Negotiated Rate	$24.80
Max. Negotiated Rate	$139.50
Rate for Payer: Aetna of AZ Commercial	$139.50
Rate for Payer: Aetna of AZ Medicare	$43.40
Rate for Payer: Allwell Medicare	$24.80
Rate for Payer: Amerigroup Medicare	$24.80
Rate for Payer: APIPA Medicare/Medicaid	$57.89
Rate for Payer: AZCH Complete Medicare	$24.80
Rate for Payer: Banner UC Health Medicare	$24.80
Rate for Payer: Bisbee Police All Plans	$40.30
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$105.40
Rate for Payer: Cash Price	$124.00
Rate for Payer: Cigna of AZ Commercial	$108.50
Rate for Payer: Copperpoint Commercial	$38.36
Rate for Payer: Health Net of AZ Commercial	$93.00
Rate for Payer: Health Net of AZ Medicare	$43.40
Rate for Payer: Humana of AZ Medicare	$24.80
Rate for Payer: Self Pay Self Pay	$124.00
Rate for Payer: TriWest Medicare	$24.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$90.36
Rate for Payer: UnitedHealth Group of AZ Medicare	$27.90

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

$4,891.00

Hospital Charge Code	22528817
Hospital Revenue Code	270
Min. Negotiated Rate	$782.56
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	$782.56
Rate for Payer: Amerigroup Medicare	$782.56
Rate for Payer: APIPA Medicare/Medicaid	$1,826.79
Rate for Payer: AZCH Complete Medicare	$782.56
Rate for Payer: Banner UC Health Medicare	$782.56
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	$782.56
Rate for Payer: Self Pay Self Pay	$3,912.80
Rate for Payer: TriWest Medicare	$782.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$2,851.45
Rate for Payer: UnitedHealth Group of AZ Medicare	$880.38

Supplies

Facility

$2,141.00

Hospital Charge Code	22528803
Hospital Revenue Code	270
Min. Negotiated Rate	$342.56
Max. Negotiated Rate	$1,926.90
Rate for Payer: Aetna of AZ Commercial	$1,926.90
Rate for Payer: Aetna of AZ Medicare	$599.48
Rate for Payer: Allwell Medicare	$342.56
Rate for Payer: Amerigroup Medicare	$342.56
Rate for Payer: APIPA Medicare/Medicaid	$799.66
Rate for Payer: AZCH Complete Medicare	$342.56
Rate for Payer: Banner UC Health Medicare	$342.56
Rate for Payer: Bisbee Police All Plans	$556.66
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,455.88
Rate for Payer: Cash Price	$1,712.80
Rate for Payer: Cigna of AZ Commercial	$1,498.70
Rate for Payer: Copperpoint Commercial	$529.90
Rate for Payer: Health Net of AZ Commercial	$1,284.60
Rate for Payer: Health Net of AZ Medicare	$599.48
Rate for Payer: Humana of AZ Medicare	$342.56
Rate for Payer: Self Pay Self Pay	$1,712.80
Rate for Payer: TriWest Medicare	$342.56
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,248.20
Rate for Payer: UnitedHealth Group of AZ Medicare	$385.38

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

$4,891.00

Hospital Charge Code	22528817
Hospital Revenue Code	270
Min. Negotiated Rate	$1,271.66
Max. Negotiated Rate	$4,401.90
Rate for Payer: Aetna of AZ Commercial	$4,401.90
Rate for Payer: Bisbee Police All Plans	$1,271.66
Rate for Payer: Cash Price	$3,912.80
Rate for Payer: Self Pay Self Pay	$3,912.80

Supplies

Facility

$1,904.00

Hospital Charge Code	22528813
Hospital Revenue Code	270
Min. Negotiated Rate	$304.64
Max. Negotiated Rate	$1,713.60
Rate for Payer: Aetna of AZ Commercial	$1,713.60
Rate for Payer: Aetna of AZ Medicare	$533.12
Rate for Payer: Allwell Medicare	$304.64
Rate for Payer: Amerigroup Medicare	$304.64
Rate for Payer: APIPA Medicare/Medicaid	$711.14
Rate for Payer: AZCH Complete Medicare	$304.64
Rate for Payer: Banner UC Health Medicare	$304.64
Rate for Payer: Bisbee Police All Plans	$495.04
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$1,294.72
Rate for Payer: Cash Price	$1,523.20
Rate for Payer: Cigna of AZ Commercial	$1,332.80
Rate for Payer: Copperpoint Commercial	$471.24
Rate for Payer: Health Net of AZ Commercial	$1,142.40
Rate for Payer: Health Net of AZ Medicare	$533.12
Rate for Payer: Humana of AZ Medicare	$304.64
Rate for Payer: Self Pay Self Pay	$1,523.20
Rate for Payer: TriWest Medicare	$304.64
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,110.03
Rate for Payer: UnitedHealth Group of AZ Medicare	$342.72

Supplies

Facility

$2,750.00

Hospital Charge Code	22528811
Hospital Revenue Code	270
Min. Negotiated Rate	$440.00
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	$440.00
Rate for Payer: Amerigroup Medicare	$440.00
Rate for Payer: APIPA Medicare/Medicaid	$1,027.12
Rate for Payer: AZCH Complete Medicare	$440.00
Rate for Payer: Banner UC Health Medicare	$440.00
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	$440.00
Rate for Payer: Self Pay Self Pay	$2,200.00
Rate for Payer: TriWest Medicare	$440.00
Rate for Payer: UnitedHealth Group of AZ Commercial	$1,603.25
Rate for Payer: UnitedHealth Group of AZ Medicare	$495.00

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

$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

$805.00

Hospital Charge Code	22528827
Hospital Revenue Code	270
Min. Negotiated Rate	$128.80
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	$128.80
Rate for Payer: Amerigroup Medicare	$128.80
Rate for Payer: APIPA Medicare/Medicaid	$300.67
Rate for Payer: AZCH Complete Medicare	$128.80
Rate for Payer: Banner UC Health Medicare	$128.80
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	$128.80
Rate for Payer: Self Pay Self Pay	$644.00
Rate for Payer: TriWest Medicare	$128.80
Rate for Payer: UnitedHealth Group of AZ Commercial	$469.31
Rate for Payer: UnitedHealth Group of AZ Medicare	$144.90

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

$2,141.00

Hospital Charge Code	22528803
Hospital Revenue Code	270
Min. Negotiated Rate	$556.66
Max. Negotiated Rate	$1,926.90
Rate for Payer: Aetna of AZ Commercial	$1,926.90
Rate for Payer: Bisbee Police All Plans	$556.66
Rate for Payer: Cash Price	$1,712.80
Rate for Payer: Self Pay Self Pay	$1,712.80

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

Know your out-of-pocket cost for care.

All Charges