Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

lidocaine 1% Inj Sol 20 mL [CQCH]

Facility

$0.04

Service Code	HCPCS J2001
Hospital Charge Code	105928808
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
Rate for Payer: Arizona Complete Health Allwell	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.03
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.01
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.01
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of AZ Commercial	$0.03
Rate for Payer: Devoted Health Medicare	$0.01
Rate for Payer: Humana of AZ Medicare	$0.01
Rate for Payer: Southwest Service Administrators UFCW	$0.03
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: United Healthcare Commercial	$0.02
Rate for Payer: United Healthcare Medicare	$0.01
Rate for Payer: Veterans Affairs TRICARE	$0.01

lidocaine 1% preservative-free Sol[CQCH]

Facility

$0.43

Service Code	NDC 63323049227
Hospital Charge Code	200368509
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of AZ Commercial	$0.39
Rate for Payer: Cash Price	$0.34

lidocaine 1% preservative-free Sol[CQCH]

Facility

$0.43

Service Code	NDC 63323049227
Hospital Charge Code	200368509
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of AZ Commercial	$0.39
Rate for Payer: Arizona Complete Health Allwell	$0.07
Rate for Payer: Banner UC Health Medicare	$0.07
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.29
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.07
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.07
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cigna of AZ Commercial	$0.28
Rate for Payer: Devoted Health Medicare	$0.08
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Southwest Service Administrators UFCW	$0.29
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: United Healthcare Commercial	$0.25
Rate for Payer: United Healthcare Medicare	$0.07
Rate for Payer: Veterans Affairs TRICARE	$0.07

lidocaine 2% 50 ml Sol[CQCH]

Facility

$0.13

Service Code	NDC 63323048657
Hospital Charge Code	233160006
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
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	$0.09
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	$0.10
Rate for Payer: Cigna of AZ Commercial	$0.08
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.09
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.07
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

lidocaine 2% 50 ml Sol[CQCH]

Facility

$0.13

Service Code	NDC 63323048657
Hospital Charge Code	233160006
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Cash Price	$0.10

lidocaine 2% Inj Sol 20 mL [CQCH]

Facility

$0.20

Service Code	HCPCS J2001
Hospital Charge Code	105928879
Hospital Revenue Code	250
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.18
Rate for Payer: Cash Price	$0.16

lidocaine 2% Inj Sol 20 mL [CQCH]

Facility

$0.20

Service Code	HCPCS J2001
Hospital Charge Code	105928879
Hospital Revenue Code	250
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of AZ Commercial	$0.18
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	$0.14
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	$0.16
Rate for Payer: Cigna of AZ Commercial	$0.13
Rate for Payer: Devoted Health Medicare	$0.04
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Southwest Service Administrators UFCW	$0.14
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: United Healthcare Commercial	$0.11
Rate for Payer: United Healthcare Medicare	$0.03
Rate for Payer: Veterans Affairs TRICARE	$0.03

lidocaine drip 2 gm in 500 ml [CQCH]

Facility

$0.01

Service Code	HCPCS J2001
Hospital Charge Code	207791435
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Arizona Complete Health Allwell	$0.00
Rate for Payer: Banner UC Health Medicare	$0.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of AZ Commercial	$0.01
Rate for Payer: Devoted Health Medicare	$0.00
Rate for Payer: Humana of AZ Medicare	$0.00
Rate for Payer: Southwest Service Administrators UFCW	$0.01
Rate for Payer: TriWest Medicare	$0.00
Rate for Payer: United Healthcare Commercial	$0.01
Rate for Payer: United Healthcare Medicare	$0.00
Rate for Payer: Veterans Affairs TRICARE	$0.00

lidocaine drip 2 gm in 500 ml [CQCH]

Facility

$0.01

Service Code	HCPCS J2001
Hospital Charge Code	207791435
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna of AZ Commercial	$0.01
Rate for Payer: Cash Price	$0.01

lidocaine inj 100 mg pre-filled syringe [CQCH]

Facility

$0.47

Service Code	HCPCS J2001
Hospital Charge Code	112812649
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of AZ Commercial	$0.42
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	$0.32
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	$0.38
Rate for Payer: Cigna of AZ Commercial	$0.31
Rate for Payer: Devoted Health Medicare	$0.08
Rate for Payer: Humana of AZ Medicare	$0.08
Rate for Payer: Southwest Service Administrators UFCW	$0.32
Rate for Payer: TriWest Medicare	$0.08
Rate for Payer: United Healthcare Commercial	$0.27
Rate for Payer: United Healthcare Medicare	$0.08
Rate for Payer: Veterans Affairs TRICARE	$0.07

lidocaine inj 100 mg pre-filled syringe [CQCH]

Facility

$0.47

Service Code	HCPCS J2001
Hospital Charge Code	112812649
Hospital Revenue Code	250
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of AZ Commercial	$0.42
Rate for Payer: Cash Price	$0.38

Lidocaine injection

Facility

$30.00

Service Code	HCPCS J2001
Hospital Charge Code	1240718
Hospital Revenue Code	521
Min. Negotiated Rate	$4.75
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Arizona Complete Health Allwell	$4.80
Rate for Payer: Banner UC Health Medicare	$4.80
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$20.40
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$4.80
Rate for Payer: Care1st Health Plan Arizona Medicare	$4.80
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cigna of AZ Commercial	$21.00
Rate for Payer: Devoted Health Medicare	$5.40
Rate for Payer: Humana of AZ Medicare	$4.80
Rate for Payer: Southwest Service Administrators UFCW	$20.40
Rate for Payer: TriWest Medicare	$4.80
Rate for Payer: United Healthcare Commercial	$17.16
Rate for Payer: United Healthcare Medicare	$4.80
Rate for Payer: Veterans Affairs TRICARE	$4.75

Lidocaine injection

Facility

$30.00

Service Code	HCPCS J2001
Hospital Charge Code	1240718
Hospital Revenue Code	521
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of AZ Commercial	$27.00
Rate for Payer: Cash Price	$24.00

lidocaine jelly 2% top 5 mL [CQCH]

Facility

$0.43

Service Code	NDC 17478084005
Hospital Charge Code	105928950
Hospital Revenue Code	251
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of AZ Commercial	$0.39
Rate for Payer: Arizona Complete Health Allwell	$0.07
Rate for Payer: Banner UC Health Medicare	$0.07
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.29
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.07
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.07
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cigna of AZ Commercial	$0.28
Rate for Payer: Devoted Health Medicare	$0.08
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Southwest Service Administrators UFCW	$0.29
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: United Healthcare Commercial	$0.25
Rate for Payer: United Healthcare Medicare	$0.07
Rate for Payer: Veterans Affairs TRICARE	$0.07

lidocaine jelly 2% top 5 mL [CQCH]

Facility

$0.43

Service Code	NDC 17478084005
Hospital Charge Code	105928950
Hospital Revenue Code	251
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of AZ Commercial	$0.39
Rate for Payer: Cash Price	$0.34

lidocaine jelly (Uro-Jet) 2% Gel w/Appl [CQCH]

Facility

$6.28

Service Code	HCPCS J2001
Hospital Charge Code	105929013
Hospital Revenue Code	250
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$5.65
Rate for Payer: Aetna of AZ Commercial	$5.65
Rate for Payer: Arizona Complete Health Allwell	$1.00
Rate for Payer: Banner UC Health Medicare	$1.00
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$4.27
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$1.00
Rate for Payer: Care1st Health Plan Arizona Medicare	$1.00
Rate for Payer: Cash Price	$5.02
Rate for Payer: Cigna of AZ Commercial	$4.08
Rate for Payer: Devoted Health Medicare	$1.13
Rate for Payer: Humana of AZ Medicare	$1.00
Rate for Payer: Southwest Service Administrators UFCW	$4.27
Rate for Payer: TriWest Medicare	$1.00
Rate for Payer: United Healthcare Commercial	$3.59
Rate for Payer: United Healthcare Medicare	$1.00
Rate for Payer: Veterans Affairs TRICARE	$0.99

lidocaine jelly (Uro-Jet) 2% Gel w/Appl [CQCH]

Facility

$6.28

Service Code	HCPCS J2001
Hospital Charge Code	105929013
Hospital Revenue Code	250
Min. Negotiated Rate	$5.65
Max. Negotiated Rate	$5.65
Rate for Payer: Aetna of AZ Commercial	$5.65
Rate for Payer: Cash Price	$5.02

lidocaine-prilocaine Top 2.5%-2.5% Crm [CQCH]

Facility

$1.19

Service Code	NDC 115146860
Hospital Charge Code	105929212
Hospital Revenue Code	251
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$1.07
Rate for Payer: Aetna of AZ Commercial	$1.07
Rate for Payer: Cash Price	$0.95

lidocaine-prilocaine Top 2.5%-2.5% Crm [CQCH]

Facility

$1.19

Service Code	NDC 115146860
Hospital Charge Code	105929212
Hospital Revenue Code	251
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$1.07
Rate for Payer: Aetna of AZ Commercial	$1.07
Rate for Payer: Arizona Complete Health Allwell	$0.19
Rate for Payer: Banner UC Health Medicare	$0.19
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.81
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.19
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.19
Rate for Payer: Cash Price	$0.95
Rate for Payer: Cigna of AZ Commercial	$0.77
Rate for Payer: Devoted Health Medicare	$0.21
Rate for Payer: Humana of AZ Medicare	$0.19
Rate for Payer: Southwest Service Administrators UFCW	$0.81
Rate for Payer: TriWest Medicare	$0.19
Rate for Payer: United Healthcare Commercial	$0.68
Rate for Payer: United Healthcare Medicare	$0.19
Rate for Payer: Veterans Affairs TRICARE	$0.19

lidocaine Top 4% Sol 50 mL [CQCH]

Facility

$0.13

Service Code	NDC 54350547
Hospital Charge Code	105929084
Hospital Revenue Code	251
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
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	$0.09
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	$0.10
Rate for Payer: Cigna of AZ Commercial	$0.08
Rate for Payer: Devoted Health Medicare	$0.02
Rate for Payer: Humana of AZ Medicare	$0.02
Rate for Payer: Southwest Service Administrators UFCW	$0.09
Rate for Payer: TriWest Medicare	$0.02
Rate for Payer: United Healthcare Commercial	$0.07
Rate for Payer: United Healthcare Medicare	$0.02
Rate for Payer: Veterans Affairs TRICARE	$0.02

lidocaine Top 4% Sol 50 mL [CQCH]

Facility

$0.13

Service Code	NDC 54350547
Hospital Charge Code	105929084
Hospital Revenue Code	251
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of AZ Commercial	$0.12
Rate for Payer: Cash Price	$0.10

lidocaine viscous 2% Sol 15 mL UD [CQCH]

Facility

$0.30

Service Code	NDC 50383077517
Hospital Charge Code	105955400
Hospital Revenue Code	251
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of AZ Commercial	$0.27
Rate for Payer: Cash Price	$0.24

lidocaine viscous 2% Sol 15 mL UD [CQCH]

Facility

$0.30

Service Code	NDC 50383077517
Hospital Charge Code	105955400
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of AZ Commercial	$0.27
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	$0.24
Rate for Payer: Cigna of AZ Commercial	$0.20
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

lidoderm patch (5% lidocaine) [CQCH]

Facility

$2.23

Service Code	NDC 42858011830
Hospital Charge Code	105929145
Hospital Revenue Code	251
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$2.01
Rate for Payer: Aetna of AZ Commercial	$2.01
Rate for Payer: Cash Price	$1.79

lidoderm patch (5% lidocaine) [CQCH]

Facility

$2.23

Service Code	NDC 42858011830
Hospital Charge Code	105929145
Hospital Revenue Code	251
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$2.01
Rate for Payer: Aetna of AZ Commercial	$2.01
Rate for Payer: Arizona Complete Health Allwell	$0.36
Rate for Payer: Banner UC Health Medicare	$0.36
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$1.52
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.36
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.36
Rate for Payer: Cash Price	$1.79
Rate for Payer: Cigna of AZ Commercial	$1.45
Rate for Payer: Devoted Health Medicare	$0.40
Rate for Payer: Humana of AZ Medicare	$0.36
Rate for Payer: Southwest Service Administrators UFCW	$1.52
Rate for Payer: TriWest Medicare	$0.36
Rate for Payer: United Healthcare Commercial	$1.28
Rate for Payer: United Healthcare Medicare	$0.36
Rate for Payer: Veterans Affairs TRICARE	$0.35

Know your out-of-pocket cost for care.

All Charges