Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

STRIP T'S STERILE ADHESIVE ORGANIZER

Facility

$50.00

Hospital Charge Code	22561786
Hospital Revenue Code	272
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna of AZ Commercial	$45.00
Rate for Payer: Arizona Complete Health Allwell	$8.00
Rate for Payer: Banner UC Health Medicare	$8.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$34.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$8.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$8.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Cigna of AZ Commercial	$35.00
Rate for Payer: Devoted Health Medicare	$9.00
Rate for Payer: Humana of AZ Medicare	$8.00
Rate for Payer: Southwest Service Administrators UFCW	$34.00
Rate for Payer: TriWest Medicare	$8.00
Rate for Payer: United Healthcare Commercial	$28.60
Rate for Payer: United Healthcare Medicare	$8.00
Rate for Payer: Veterans Affairs TRICARE	$7.92

STRIP T'S STERILE ADHESIVE ORGANIZER

Facility

$50.00

Hospital Charge Code	22561786
Hospital Revenue Code	272
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna of AZ Commercial	$45.00
Rate for Payer: Cash Price	$40.00

STUDY OF RECTUM SENSITIVITY AND FUNCTION

Facility

$1,776.00

Service Code	CPT 91125
Hospital Charge Code	30283553
Hospital Revenue Code	360
Min. Negotiated Rate	$113.16
Max. Negotiated Rate	$3,373.00
Rate for Payer: Aetna of AZ Commercial	$1,598.40
Rate for Payer: Arizona Complete Health Allwell	$284.16
Rate for Payer: Banner UC Health Medicare	$113.16
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,207.68
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$284.16
Rate for Payer: Care1st Health Plan Arizona Medicare	$284.16
Rate for Payer: Cash Price	$1,420.80
Rate for Payer: Cash Price	$1,420.80
Rate for Payer: Cash Price	$1,420.80
Rate for Payer: Cigna of AZ Commercial	$888.00
Rate for Payer: Devoted Health Medicare	$319.68
Rate for Payer: Humana of AZ Medicare	$284.16
Rate for Payer: NaphCare Correctional Healthcare	$113.16
Rate for Payer: Seven Corners Travel Insurance	$577.38
Rate for Payer: Southwest Service Administrators UFCW	$1,207.68
Rate for Payer: TriWest Medicare	$284.16
Rate for Payer: United Healthcare Commercial	$3,373.00
Rate for Payer: United Healthcare Medicare	$284.16
Rate for Payer: Veterans Affairs TRICARE	$281.32

STUDY OF RECTUM SENSITIVITY AND FUNCTION

Facility

$1,776.00

Service Code	CPT 91125
Hospital Charge Code	30283553
Hospital Revenue Code	360
Min. Negotiated Rate	$1,598.40
Max. Negotiated Rate	$1,598.40
Rate for Payer: Aetna of AZ Commercial	$1,598.40
Rate for Payer: Cash Price	$1,420.80

STYLETTE ET

Facility

$202.00

Hospital Charge Code	22560511
Hospital Revenue Code	272
Min. Negotiated Rate	$32.00
Max. Negotiated Rate	$181.80
Rate for Payer: Aetna of AZ Commercial	$181.80
Rate for Payer: Arizona Complete Health Allwell	$32.32
Rate for Payer: Banner UC Health Medicare	$32.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$137.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$32.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$32.32
Rate for Payer: Cash Price	$161.60
Rate for Payer: Cigna of AZ Commercial	$141.40
Rate for Payer: Devoted Health Medicare	$36.36
Rate for Payer: Humana of AZ Medicare	$32.32
Rate for Payer: Southwest Service Administrators UFCW	$137.36
Rate for Payer: TriWest Medicare	$32.32
Rate for Payer: United Healthcare Commercial	$115.54
Rate for Payer: United Healthcare Medicare	$32.32
Rate for Payer: Veterans Affairs TRICARE	$32.00

STYLETTE ET

Facility

$202.00

Hospital Charge Code	22560511
Hospital Revenue Code	272
Min. Negotiated Rate	$181.80
Max. Negotiated Rate	$181.80
Rate for Payer: Aetna of AZ Commercial	$181.80
Rate for Payer: Cash Price	$161.60

SUBSEQUENT PROB FOCUSED VISIT

Facility

$147.00

Service Code	CPT 99231
Hospital Charge Code	22331512
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of AZ Commercial	$132.30
Rate for Payer: Cash Price	$117.60

SUBSEQUENT PROB FOCUSED VISIT

Facility

$147.00

Service Code	CPT 99231
Hospital Charge Code	22331512
Min. Negotiated Rate	$23.28
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of AZ Commercial	$132.30
Rate for Payer: Arizona Complete Health Allwell	$23.52
Rate for Payer: Banner UC Health Medicare	$23.52
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$99.96
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$23.52
Rate for Payer: Care1st Health Plan Arizona Medicare	$23.52
Rate for Payer: Cash Price	$117.60
Rate for Payer: Cigna of AZ Commercial	$102.90
Rate for Payer: Devoted Health Medicare	$26.46
Rate for Payer: Humana of AZ Medicare	$23.52
Rate for Payer: Southwest Service Administrators UFCW	$99.96
Rate for Payer: TriWest Medicare	$23.52
Rate for Payer: United Healthcare Commercial	$84.08
Rate for Payer: United Healthcare Medicare	$23.52
Rate for Payer: Veterans Affairs TRICARE	$23.28

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: Arizona Complete Health Allwell	$0.13
Rate for Payer: Banner UC Health Medicare	$0.13
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.55
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.13
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.13
Rate for Payer: Cash Price	$0.65
Rate for Payer: Cigna of AZ Commercial	$0.53
Rate for Payer: Devoted Health Medicare	$0.15
Rate for Payer: Humana of AZ Medicare	$0.13
Rate for Payer: Southwest Service Administrators UFCW	$0.55
Rate for Payer: TriWest Medicare	$0.13
Rate for Payer: United Healthcare Commercial	$0.46
Rate for Payer: United Healthcare Medicare	$0.13
Rate for Payer: Veterans Affairs TRICARE	$0.13

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	$0.73
Max. Negotiated Rate	$0.73
Rate for Payer: Aetna of AZ Commercial	$0.73
Rate for Payer: Cash Price	$0.65

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: Arizona Complete Health Allwell	$0.04
Rate for Payer: Banner UC Health Medicare	$0.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.04
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of AZ Commercial	$0.16
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.04
Rate for Payer: Southwest Service Administrators UFCW	$0.16
Rate for Payer: TriWest Medicare	$0.04
Rate for Payer: United Healthcare Commercial	$0.14
Rate for Payer: United Healthcare Medicare	$0.04
Rate for Payer: Veterans Affairs TRICARE	$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	$0.22
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of AZ Commercial	$0.22
Rate for Payer: Cash Price	$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: Arizona Complete Health Allwell	$0.08
Rate for Payer: Banner UC Health Medicare	$0.08
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.34
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.08
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.08
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cigna of AZ Commercial	$0.33
Rate for Payer: Devoted Health Medicare	$0.09
Rate for Payer: Humana of AZ Medicare	$0.08
Rate for Payer: Southwest Service Administrators UFCW	$0.34
Rate for Payer: TriWest Medicare	$0.08
Rate for Payer: United Healthcare Commercial	$0.29
Rate for Payer: United Healthcare Medicare	$0.08
Rate for Payer: Veterans Affairs TRICARE	$0.08

Sucrose 24% oral soln [CQCH]

Facility

$0.50

Service Code	NDC 98980560340
Hospital Charge Code	113461007
Hospital Revenue Code	250
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.45
Rate for Payer: Aetna of AZ Commercial	$0.45
Rate for Payer: Cash Price	$0.40

SUCTION

Facility

$144.00

Service Code	CPT 94799
Hospital Charge Code	1886869
Hospital Revenue Code	410
Min. Negotiated Rate	$22.81
Max. Negotiated Rate	$199.09
Rate for Payer: Aetna of AZ Commercial	$129.60
Rate for Payer: Arizona Complete Health Allwell	$23.04
Rate for Payer: Banner UC Health Medicare	$23.04
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$97.92
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$23.04
Rate for Payer: Care1st Health Plan Arizona Medicare	$23.04
Rate for Payer: Cash Price	$115.20
Rate for Payer: Cash Price	$115.20
Rate for Payer: Cigna of AZ Commercial	$100.80
Rate for Payer: Devoted Health Medicare	$25.92
Rate for Payer: Humana of AZ Medicare	$23.04
Rate for Payer: Seven Corners Travel Insurance	$199.09
Rate for Payer: Southwest Service Administrators UFCW	$97.92
Rate for Payer: TriWest Medicare	$23.04
Rate for Payer: United Healthcare Commercial	$82.37
Rate for Payer: United Healthcare Medicare	$23.04
Rate for Payer: United Healthcare New Mexico Commercial	$27.36
Rate for Payer: Veterans Affairs TRICARE	$22.81

SUCTION

Facility

$144.00

Service Code	CPT 94799
Hospital Charge Code	1886869
Hospital Revenue Code	410
Min. Negotiated Rate	$129.60
Max. Negotiated Rate	$129.60
Rate for Payer: Aetna of AZ Commercial	$129.60
Rate for Payer: Cash Price	$115.20

SUCTION CANISTER 1200

Facility

$27.00

Hospital Charge Code	22355544
Hospital Revenue Code	270
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$24.30
Rate for Payer: Aetna of AZ Commercial	$24.30
Rate for Payer: Cash Price	$21.60

SUCTION CANISTER 1200

Facility

$27.00

Hospital Charge Code	22355544
Hospital Revenue Code	270
Min. Negotiated Rate	$4.28
Max. Negotiated Rate	$24.30
Rate for Payer: Aetna of AZ Commercial	$24.30
Rate for Payer: Arizona Complete Health Allwell	$4.32
Rate for Payer: Banner UC Health Medicare	$4.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$18.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.32
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna of AZ Commercial	$18.90
Rate for Payer: Devoted Health Medicare	$4.86
Rate for Payer: Humana of AZ Medicare	$4.32
Rate for Payer: Southwest Service Administrators UFCW	$18.36
Rate for Payer: TriWest Medicare	$4.32
Rate for Payer: United Healthcare Commercial	$15.44
Rate for Payer: United Healthcare Medicare	$4.32
Rate for Payer: Veterans Affairs TRICARE	$4.28

SUCTION CANISTER 800

Facility

$12.00

Hospital Charge Code	22355704
Hospital Revenue Code	270
Min. Negotiated Rate	$10.80
Max. Negotiated Rate	$10.80
Rate for Payer: Aetna of AZ Commercial	$10.80
Rate for Payer: Cash Price	$9.60

SUCTION CANISTER 800

Facility

$12.00

Hospital Charge Code	22355704
Hospital Revenue Code	270
Min. Negotiated Rate	$1.90
Max. Negotiated Rate	$10.80
Rate for Payer: Aetna of AZ Commercial	$10.80
Rate for Payer: Arizona Complete Health Allwell	$1.92
Rate for Payer: Banner UC Health Medicare	$1.92
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$8.16
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.92
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.92
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cigna of AZ Commercial	$8.40
Rate for Payer: Devoted Health Medicare	$2.16
Rate for Payer: Humana of AZ Medicare	$1.92
Rate for Payer: Southwest Service Administrators UFCW	$8.16
Rate for Payer: TriWest Medicare	$1.92
Rate for Payer: United Healthcare Commercial	$6.86
Rate for Payer: United Healthcare Medicare	$1.92
Rate for Payer: Veterans Affairs TRICARE	$1.90

SUCTION CANISTER OMNI

Facility

$555.00

Hospital Charge Code	22354183
Hospital Revenue Code	270
Min. Negotiated Rate	$87.91
Max. Negotiated Rate	$499.50
Rate for Payer: Aetna of AZ Commercial	$499.50
Rate for Payer: Arizona Complete Health Allwell	$88.80
Rate for Payer: Banner UC Health Medicare	$88.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$377.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$88.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$88.80
Rate for Payer: Cash Price	$444.00
Rate for Payer: Cigna of AZ Commercial	$388.50
Rate for Payer: Devoted Health Medicare	$99.90
Rate for Payer: Humana of AZ Medicare	$88.80
Rate for Payer: Southwest Service Administrators UFCW	$377.40
Rate for Payer: TriWest Medicare	$88.80
Rate for Payer: United Healthcare Commercial	$317.46
Rate for Payer: United Healthcare Medicare	$88.80
Rate for Payer: Veterans Affairs TRICARE	$87.91

SUCTION CANISTER OMNI

Facility

$555.00

Hospital Charge Code	22354183
Hospital Revenue Code	270
Min. Negotiated Rate	$499.50
Max. Negotiated Rate	$499.50
Rate for Payer: Aetna of AZ Commercial	$499.50
Rate for Payer: Cash Price	$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	$7.71
Max. Negotiated Rate	$43.83
Rate for Payer: Aetna of AZ Commercial	$43.83
Rate for Payer: Arizona Complete Health Allwell	$7.79
Rate for Payer: Banner UC Health Medicare	$7.79
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$33.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$7.79
Rate for Payer: Care1st Health Plan Arizona Medicare	$7.79
Rate for Payer: Cash Price	$38.96
Rate for Payer: Cigna of AZ Commercial	$31.66
Rate for Payer: Devoted Health Medicare	$8.77
Rate for Payer: Humana of AZ Medicare	$7.79
Rate for Payer: Southwest Service Administrators UFCW	$33.12
Rate for Payer: TriWest Medicare	$7.79
Rate for Payer: United Healthcare Commercial	$27.86
Rate for Payer: United Healthcare Medicare	$7.79
Rate for Payer: Veterans Affairs TRICARE	$7.71

sugammadex 100 mg/mL Sol[CQCH]

Facility

$48.70

Service Code	NDC 6542312
Hospital Charge Code	139706665
Hospital Revenue Code	250
Min. Negotiated Rate	$43.83
Max. Negotiated Rate	$43.83
Rate for Payer: Aetna of AZ Commercial	$43.83
Rate for Payer: Cash Price	$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	$0.02
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
Rate for Payer: Arizona Complete Health Allwell	$0.02
Rate for Payer: Banner UC Health Medicare	$0.02
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.10
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.02
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.02
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of AZ Commercial	$0.10
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.10
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.09
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

Know your out-of-pocket cost for care.

All Charges