Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

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	$0.14
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of AZ Commercial	$0.14
Rate for Payer: Cash Price	$0.12

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	$0.81
Max. Negotiated Rate	$0.81
Rate for Payer: Aetna of AZ Commercial	$0.81
Rate for Payer: Cash Price	$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: Arizona Complete Health Allwell	$0.14
Rate for Payer: Banner UC Health Medicare	$0.14
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.61
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.14
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.14
Rate for Payer: Cash Price	$0.72
Rate for Payer: Cigna of AZ Commercial	$0.59
Rate for Payer: Devoted Health Medicare	$0.16
Rate for Payer: Humana of AZ Medicare	$0.14
Rate for Payer: Southwest Service Administrators UFCW	$0.61
Rate for Payer: TriWest Medicare	$0.14
Rate for Payer: United Healthcare Commercial	$0.51
Rate for Payer: United Healthcare Medicare	$0.14
Rate for Payer: Veterans Affairs TRICARE	$0.14

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: Arizona Complete Health Allwell	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.03
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.03
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of AZ Commercial	$0.11
Rate for Payer: Devoted Health Medicare	$0.03
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Southwest Service Administrators UFCW	$0.12
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: United Healthcare Commercial	$0.10
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$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	$0.15
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of AZ Commercial	$0.15
Rate for Payer: Cash Price	$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	$0.26
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of AZ Commercial	$0.26
Rate for Payer: Cash Price	$0.23

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: Arizona Complete Health Allwell	$0.05
Rate for Payer: Banner UC Health Medicare	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.20
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.05
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.05
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of AZ Commercial	$0.19
Rate for Payer: Devoted Health Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.05
Rate for Payer: Southwest Service Administrators UFCW	$0.20
Rate for Payer: TriWest Medicare	$0.05
Rate for Payer: United Healthcare Commercial	$0.17
Rate for Payer: United Healthcare Medicare	$0.05
Rate for Payer: Veterans Affairs TRICARE	$0.05

SUMAtriptan 50 mg Tab [CQCH]

Facility

$0.52

Service Code	NDC 62756052169
Hospital Charge Code	105942980
Hospital Revenue Code	251
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of AZ Commercial	$0.47
Rate for Payer: Cash Price	$0.41

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: 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	$0.35
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	$0.41
Rate for Payer: Cigna of AZ Commercial	$0.34
Rate for Payer: Devoted Health Medicare	$0.09
Rate for Payer: Humana of AZ Medicare	$0.08
Rate for Payer: Southwest Service Administrators UFCW	$0.35
Rate for Payer: TriWest Medicare	$0.08
Rate for Payer: United Healthcare Commercial	$0.30
Rate for Payer: United Healthcare Medicare	$0.08
Rate for Payer: Veterans Affairs TRICARE	$0.08

SUMAtriptan 6 mg SubQ Inj [CQCH]

Facility

$13.40

Service Code	HCPCS J3030
Hospital Charge Code	105942909
Hospital Revenue Code	250
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$12.06
Rate for Payer: Aetna of AZ Commercial	$12.06
Rate for Payer: Arizona Complete Health Allwell	$2.14
Rate for Payer: Banner UC Health Medicare	$2.14
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$9.11
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$2.14
Rate for Payer: Care1st Health Plan Arizona Medicare	$2.14
Rate for Payer: Cash Price	$10.72
Rate for Payer: Cigna of AZ Commercial	$8.71
Rate for Payer: Devoted Health Medicare	$2.41
Rate for Payer: Humana of AZ Medicare	$2.14
Rate for Payer: Southwest Service Administrators UFCW	$9.11
Rate for Payer: TriWest Medicare	$2.14
Rate for Payer: United Healthcare Commercial	$7.66
Rate for Payer: United Healthcare Medicare	$2.14
Rate for Payer: Veterans Affairs TRICARE	$2.12

SUMAtriptan 6 mg SubQ Inj [CQCH]

Facility

$13.40

Service Code	HCPCS J3030
Hospital Charge Code	105942909
Hospital Revenue Code	250
Min. Negotiated Rate	$12.06
Max. Negotiated Rate	$12.06
Rate for Payer: Aetna of AZ Commercial	$12.06
Rate for Payer: Cash Price	$10.72

SUPER STIFF 0.38 FIXED WIRE GUIDE

Facility

$155.00

Hospital Charge Code	27747584
Hospital Revenue Code	263
Min. Negotiated Rate	$24.55
Max. Negotiated Rate	$139.50
Rate for Payer: Aetna of AZ Commercial	$139.50
Rate for Payer: Arizona Complete Health Allwell	$24.80
Rate for Payer: Banner UC Health Medicare	$24.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$105.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$24.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$24.80
Rate for Payer: Cash Price	$124.00
Rate for Payer: Cigna of AZ Commercial	$108.50
Rate for Payer: Devoted Health Medicare	$27.90
Rate for Payer: Humana of AZ Medicare	$24.80
Rate for Payer: Southwest Service Administrators UFCW	$105.40
Rate for Payer: TriWest Medicare	$24.80
Rate for Payer: United Healthcare Commercial	$88.66
Rate for Payer: United Healthcare Medicare	$24.80
Rate for Payer: Veterans Affairs TRICARE	$24.55

SUPER STIFF 0.38 FIXED WIRE GUIDE

Facility

$155.00

Hospital Charge Code	27747584
Hospital Revenue Code	263
Min. Negotiated Rate	$139.50
Max. Negotiated Rate	$139.50
Rate for Payer: Aetna of AZ Commercial	$139.50
Rate for Payer: Cash Price	$124.00

Supplies

Facility

$805.00

Hospital Charge Code	22528823
Hospital Revenue Code	270
Min. Negotiated Rate	$127.51
Max. Negotiated Rate	$724.50
Rate for Payer: Aetna of AZ Commercial	$724.50
Rate for Payer: Arizona Complete Health Allwell	$128.80
Rate for Payer: Banner UC Health Medicare	$128.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$547.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$128.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$128.80
Rate for Payer: Cash Price	$644.00
Rate for Payer: Cigna of AZ Commercial	$563.50
Rate for Payer: Devoted Health Medicare	$144.90
Rate for Payer: Humana of AZ Medicare	$128.80
Rate for Payer: Southwest Service Administrators UFCW	$547.40
Rate for Payer: TriWest Medicare	$128.80
Rate for Payer: United Healthcare Commercial	$460.46
Rate for Payer: United Healthcare Medicare	$128.80
Rate for Payer: Veterans Affairs TRICARE	$127.51

Supplies

Facility

$810.00

Hospital Charge Code	22528825
Hospital Revenue Code	270
Min. Negotiated Rate	$729.00
Max. Negotiated Rate	$729.00
Rate for Payer: Aetna of AZ Commercial	$729.00
Rate for Payer: Cash Price	$648.00

Supplies

Facility

$1,904.00

Hospital Charge Code	22528813
Hospital Revenue Code	270
Min. Negotiated Rate	$1,713.60
Max. Negotiated Rate	$1,713.60
Rate for Payer: Aetna of AZ Commercial	$1,713.60
Rate for Payer: Cash Price	$1,523.20

Supplies

Facility

$805.00

Hospital Charge Code	22528823
Hospital Revenue Code	270
Min. Negotiated Rate	$724.50
Max. Negotiated Rate	$724.50
Rate for Payer: Aetna of AZ Commercial	$724.50
Rate for Payer: Cash Price	$644.00

Supplies

Facility

$2,099.00

Hospital Charge Code	22528809
Hospital Revenue Code	270
Min. Negotiated Rate	$332.48
Max. Negotiated Rate	$1,889.10
Rate for Payer: Aetna of AZ Commercial	$1,889.10
Rate for Payer: Arizona Complete Health Allwell	$335.84
Rate for Payer: Banner UC Health Medicare	$335.84
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,427.32
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$335.84
Rate for Payer: Care1st Health Plan Arizona Medicare	$335.84
Rate for Payer: Cash Price	$1,679.20
Rate for Payer: Cigna of AZ Commercial	$1,469.30
Rate for Payer: Devoted Health Medicare	$377.82
Rate for Payer: Humana of AZ Medicare	$335.84
Rate for Payer: Southwest Service Administrators UFCW	$1,427.32
Rate for Payer: TriWest Medicare	$335.84
Rate for Payer: United Healthcare Commercial	$1,200.63
Rate for Payer: United Healthcare Medicare	$335.84
Rate for Payer: Veterans Affairs TRICARE	$332.48

Supplies

Facility

$2,750.00

Hospital Charge Code	22528811
Hospital Revenue Code	270
Min. Negotiated Rate	$435.60
Max. Negotiated Rate	$2,475.00
Rate for Payer: Aetna of AZ Commercial	$2,475.00
Rate for Payer: Arizona Complete Health Allwell	$440.00
Rate for Payer: Banner UC Health Medicare	$440.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,870.00
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$440.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$440.00
Rate for Payer: Cash Price	$2,200.00
Rate for Payer: Cigna of AZ Commercial	$1,925.00
Rate for Payer: Devoted Health Medicare	$495.00
Rate for Payer: Humana of AZ Medicare	$440.00
Rate for Payer: Southwest Service Administrators UFCW	$1,870.00
Rate for Payer: TriWest Medicare	$440.00
Rate for Payer: United Healthcare Commercial	$1,573.00
Rate for Payer: United Healthcare Medicare	$440.00
Rate for Payer: Veterans Affairs TRICARE	$435.60

Supplies

Facility

$1,533.00

Hospital Charge Code	22528807
Hospital Revenue Code	270
Min. Negotiated Rate	$242.83
Max. Negotiated Rate	$1,379.70
Rate for Payer: Aetna of AZ Commercial	$1,379.70
Rate for Payer: Arizona Complete Health Allwell	$245.28
Rate for Payer: Banner UC Health Medicare	$245.28
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1,042.44
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$245.28
Rate for Payer: Care1st Health Plan Arizona Medicare	$245.28
Rate for Payer: Cash Price	$1,226.40
Rate for Payer: Cigna of AZ Commercial	$1,073.10
Rate for Payer: Devoted Health Medicare	$275.94
Rate for Payer: Humana of AZ Medicare	$245.28
Rate for Payer: Southwest Service Administrators UFCW	$1,042.44
Rate for Payer: TriWest Medicare	$245.28
Rate for Payer: United Healthcare Commercial	$876.88
Rate for Payer: United Healthcare Medicare	$245.28
Rate for Payer: Veterans Affairs TRICARE	$242.83

Supplies

Facility

$1,029.00

Hospital Charge Code	22528829
Hospital Revenue Code	270
Min. Negotiated Rate	$926.10
Max. Negotiated Rate	$926.10
Rate for Payer: Aetna of AZ Commercial	$926.10
Rate for Payer: Cash Price	$823.20

Supplies

Facility

$805.00

Hospital Charge Code	22528827
Hospital Revenue Code	270
Min. Negotiated Rate	$127.51
Max. Negotiated Rate	$724.50
Rate for Payer: Aetna of AZ Commercial	$724.50
Rate for Payer: Arizona Complete Health Allwell	$128.80
Rate for Payer: Banner UC Health Medicare	$128.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$547.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$128.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$128.80
Rate for Payer: Cash Price	$644.00
Rate for Payer: Cigna of AZ Commercial	$563.50
Rate for Payer: Devoted Health Medicare	$144.90
Rate for Payer: Humana of AZ Medicare	$128.80
Rate for Payer: Southwest Service Administrators UFCW	$547.40
Rate for Payer: TriWest Medicare	$128.80
Rate for Payer: United Healthcare Commercial	$460.46
Rate for Payer: United Healthcare Medicare	$128.80
Rate for Payer: Veterans Affairs TRICARE	$127.51

Supplies

Facility

$4,891.00

Hospital Charge Code	22528817
Hospital Revenue Code	270
Min. Negotiated Rate	$774.73
Max. Negotiated Rate	$4,401.90
Rate for Payer: Aetna of AZ Commercial	$4,401.90
Rate for Payer: Arizona Complete Health Allwell	$782.56
Rate for Payer: Banner UC Health Medicare	$782.56
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$3,325.88
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$782.56
Rate for Payer: Care1st Health Plan Arizona Medicare	$782.56
Rate for Payer: Cash Price	$3,912.80
Rate for Payer: Cigna of AZ Commercial	$3,423.70
Rate for Payer: Devoted Health Medicare	$880.38
Rate for Payer: Humana of AZ Medicare	$782.56
Rate for Payer: Southwest Service Administrators UFCW	$3,325.88
Rate for Payer: TriWest Medicare	$782.56
Rate for Payer: United Healthcare Commercial	$2,797.65
Rate for Payer: United Healthcare Medicare	$782.56
Rate for Payer: Veterans Affairs TRICARE	$774.73

Supplies

Facility

$810.00

Hospital Charge Code	22528825
Hospital Revenue Code	270
Min. Negotiated Rate	$128.30
Max. Negotiated Rate	$729.00
Rate for Payer: Aetna of AZ Commercial	$729.00
Rate for Payer: Arizona Complete Health Allwell	$129.60
Rate for Payer: Banner UC Health Medicare	$129.60
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$550.80
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$129.60
Rate for Payer: Care1st Health Plan Arizona Medicare	$129.60
Rate for Payer: Cash Price	$648.00
Rate for Payer: Cigna of AZ Commercial	$567.00
Rate for Payer: Devoted Health Medicare	$145.80
Rate for Payer: Humana of AZ Medicare	$129.60
Rate for Payer: Southwest Service Administrators UFCW	$550.80
Rate for Payer: TriWest Medicare	$129.60
Rate for Payer: United Healthcare Commercial	$463.32
Rate for Payer: United Healthcare Medicare	$129.60
Rate for Payer: Veterans Affairs TRICARE	$128.30

Supplies

Facility

$805.00

Hospital Charge Code	22528827
Hospital Revenue Code	270
Min. Negotiated Rate	$724.50
Max. Negotiated Rate	$724.50
Rate for Payer: Aetna of AZ Commercial	$724.50
Rate for Payer: Cash Price	$644.00

Know your out-of-pocket cost for care.

All Charges