Copper Queen Community Hospital

All Charges

Charge

Type

Setting

Price

benzocaine top 20% 0.5mL oral anesthetic

Facility

$18.24

Service Code	NDC 283061043
Hospital Charge Code	112661648
Hospital Revenue Code	251
Min. Negotiated Rate	$16.42
Max. Negotiated Rate	$16.42
Rate for Payer: Aetna of AZ Commercial	$16.42
Rate for Payer: Cash Price	$14.59

benzocaine Top 20% mucous membrane spray [CQCH]

Facility

$0.04

Service Code	NDC 283067902
Hospital Charge Code	105912709
Hospital Revenue Code	251
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

benzocaine Top 20% mucous membrane spray [CQCH]

Facility

$0.04

Service Code	NDC 283067902
Hospital Charge Code	105912709
Hospital Revenue Code	251
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of AZ Commercial	$0.04
Rate for Payer: Cash Price	$0.03

Benzodiazepines

Facility

$104.00

Service Code	CPT 80347
Hospital Charge Code	23090938
Hospital Revenue Code	301
Min. Negotiated Rate	$93.60
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of AZ Commercial	$93.60
Rate for Payer: Cash Price	$83.20

Benzodiazepines

Facility

$104.00

Service Code	CPT 80347
Hospital Charge Code	23090938
Hospital Revenue Code	301
Min. Negotiated Rate	$16.47
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of AZ Commercial	$93.60
Rate for Payer: Arizona Complete Health Allwell	$16.64
Rate for Payer: Banner UC Health Medicare	$16.64
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$70.72
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$16.64
Rate for Payer: Care1st Health Plan Arizona Medicare	$16.64
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cigna of AZ Commercial	$67.60
Rate for Payer: Devoted Health Medicare	$18.72
Rate for Payer: Humana of AZ Medicare	$16.64
Rate for Payer: Southwest Service Administrators UFCW	$70.72
Rate for Payer: TriWest Medicare	$16.64
Rate for Payer: United Healthcare Commercial	$59.49
Rate for Payer: United Healthcare Medicare	$16.64
Rate for Payer: Veterans Affairs TRICARE	$16.47

benzonatate 100 mg Cap [CQCH]

Facility

$0.36

Service Code	NDC 904656461
Hospital Charge Code	105912774
Hospital Revenue Code	251
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of AZ Commercial	$0.32
Rate for Payer: Cash Price	$0.28

benzonatate 100 mg Cap [CQCH]

Facility

$0.36

Service Code	NDC 904656461
Hospital Charge Code	105912774
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of AZ Commercial	$0.32
Rate for Payer: Arizona Complete Health Allwell	$0.06
Rate for Payer: Banner UC Health Medicare	$0.06
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$0.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$0.06
Rate for Payer: Care1st Health Plan Arizona Medicare	$0.06
Rate for Payer: Cash Price	$0.28
Rate for Payer: Cigna of AZ Commercial	$0.23
Rate for Payer: Devoted Health Medicare	$0.06
Rate for Payer: Humana of AZ Medicare	$0.06
Rate for Payer: Southwest Service Administrators UFCW	$0.24
Rate for Payer: TriWest Medicare	$0.06
Rate for Payer: United Healthcare Commercial	$0.21
Rate for Payer: United Healthcare Medicare	$0.06
Rate for Payer: Veterans Affairs TRICARE	$0.06

benztropine 1 mg Tab [CQCH]

Facility

$0.41

Service Code	NDC 60687036801
Hospital Charge Code	105912839
Hospital Revenue Code	251
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of AZ Commercial	$0.37
Rate for Payer: Cash Price	$0.33

benztropine 1 mg Tab [CQCH]

Facility

$0.41

Service Code	NDC 60687036801
Hospital Charge Code	105912839
Hospital Revenue Code	251
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of AZ Commercial	$0.37
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	$0.28
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	$0.33
Rate for Payer: Cigna of AZ Commercial	$0.27
Rate for Payer: Devoted Health Medicare	$0.07
Rate for Payer: Humana of AZ Medicare	$0.07
Rate for Payer: Southwest Service Administrators UFCW	$0.28
Rate for Payer: TriWest Medicare	$0.07
Rate for Payer: United Healthcare Commercial	$0.23
Rate for Payer: United Healthcare Medicare	$0.07
Rate for Payer: Veterans Affairs TRICARE	$0.06

.Beta-2 Glyco I Ab, IgA, Please Note LC

Facility

$302.00

Service Code	CPT 86146
Hospital Charge Code	22311136
Hospital Revenue Code	302
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of AZ Commercial	$271.80
Rate for Payer: Arizona Complete Health Allwell	$48.32
Rate for Payer: Banner UC Health Medicare	$48.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$205.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$48.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$48.32
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cigna of AZ Commercial	$196.30
Rate for Payer: Devoted Health Medicare	$54.36
Rate for Payer: Humana of AZ Medicare	$48.32
Rate for Payer: Seven Corners Travel Insurance	$36.90
Rate for Payer: Southwest Service Administrators UFCW	$205.36
Rate for Payer: TriWest Medicare	$48.32
Rate for Payer: United Healthcare Commercial	$172.74
Rate for Payer: United Healthcare Medicare	$48.32
Rate for Payer: Veterans Affairs TRICARE	$47.84

.Beta-2 Glyco I Ab, IgA, Please Note LC

Facility

$302.00

Service Code	CPT 86146
Hospital Charge Code	22311136
Hospital Revenue Code	302
Min. Negotiated Rate	$271.80
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of AZ Commercial	$271.80
Rate for Payer: Cash Price	$241.60

.Beta-2 Glyco I Ab, IgG, Please Note LC

Facility

$302.00

Service Code	CPT 86146
Hospital Charge Code	22311137
Hospital Revenue Code	302
Min. Negotiated Rate	$271.80
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of AZ Commercial	$271.80
Rate for Payer: Cash Price	$241.60

.Beta-2 Glyco I Ab, IgG, Please Note LC

Facility

$302.00

Service Code	CPT 86146
Hospital Charge Code	22311137
Hospital Revenue Code	302
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of AZ Commercial	$271.80
Rate for Payer: Arizona Complete Health Allwell	$48.32
Rate for Payer: Banner UC Health Medicare	$48.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$205.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$48.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$48.32
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cigna of AZ Commercial	$196.30
Rate for Payer: Devoted Health Medicare	$54.36
Rate for Payer: Humana of AZ Medicare	$48.32
Rate for Payer: Seven Corners Travel Insurance	$36.90
Rate for Payer: Southwest Service Administrators UFCW	$205.36
Rate for Payer: TriWest Medicare	$48.32
Rate for Payer: United Healthcare Commercial	$172.74
Rate for Payer: United Healthcare Medicare	$48.32
Rate for Payer: Veterans Affairs TRICARE	$47.84

.Beta-2 Glyco I Ab, IgM, Please Note LC

Facility

$317.00

Service Code	CPT 86146
Hospital Charge Code	22311138
Hospital Revenue Code	302
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$285.30
Rate for Payer: Aetna of AZ Commercial	$285.30
Rate for Payer: Arizona Complete Health Allwell	$50.72
Rate for Payer: Banner UC Health Medicare	$50.72
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$215.56
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$50.72
Rate for Payer: Care1st Health Plan Arizona Medicare	$50.72
Rate for Payer: Cash Price	$253.60
Rate for Payer: Cash Price	$253.60
Rate for Payer: Cigna of AZ Commercial	$206.05
Rate for Payer: Devoted Health Medicare	$57.06
Rate for Payer: Humana of AZ Medicare	$50.72
Rate for Payer: Seven Corners Travel Insurance	$36.90
Rate for Payer: Southwest Service Administrators UFCW	$215.56
Rate for Payer: TriWest Medicare	$50.72
Rate for Payer: United Healthcare Commercial	$181.32
Rate for Payer: United Healthcare Medicare	$50.72
Rate for Payer: Veterans Affairs TRICARE	$50.21

.Beta-2 Glyco I Ab, IgM, Please Note LC

Facility

$317.00

Service Code	CPT 86146
Hospital Charge Code	22311138
Hospital Revenue Code	302
Min. Negotiated Rate	$285.30
Max. Negotiated Rate	$285.30
Rate for Payer: Aetna of AZ Commercial	$285.30
Rate for Payer: Cash Price	$253.60

.BETA 2 GLYCOPROTEIN AB, IGA

Facility

$318.00

Service Code	CPT 86146
Hospital Charge Code	22481442
Hospital Revenue Code	302
Min. Negotiated Rate	$286.20
Max. Negotiated Rate	$286.20
Rate for Payer: Aetna of AZ Commercial	$286.20
Rate for Payer: Cash Price	$254.40

.BETA 2 GLYCOPROTEIN AB, IGA

Facility

$318.00

Service Code	CPT 86146
Hospital Charge Code	22481442
Hospital Revenue Code	302
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$286.20
Rate for Payer: Aetna of AZ Commercial	$286.20
Rate for Payer: Arizona Complete Health Allwell	$50.88
Rate for Payer: Banner UC Health Medicare	$50.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$216.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$50.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$50.88
Rate for Payer: Cash Price	$254.40
Rate for Payer: Cash Price	$254.40
Rate for Payer: Cigna of AZ Commercial	$206.70
Rate for Payer: Devoted Health Medicare	$57.24
Rate for Payer: Humana of AZ Medicare	$50.88
Rate for Payer: Seven Corners Travel Insurance	$36.90
Rate for Payer: Southwest Service Administrators UFCW	$216.24
Rate for Payer: TriWest Medicare	$50.88
Rate for Payer: United Healthcare Commercial	$181.90
Rate for Payer: United Healthcare Medicare	$50.88
Rate for Payer: Veterans Affairs TRICARE	$50.37

.BETA 2 GLYCOPROTEIN AB, IGG

Facility

$318.00

Service Code	CPT 86146
Hospital Charge Code	22481443
Hospital Revenue Code	302
Min. Negotiated Rate	$286.20
Max. Negotiated Rate	$286.20
Rate for Payer: Aetna of AZ Commercial	$286.20
Rate for Payer: Cash Price	$254.40

.BETA 2 GLYCOPROTEIN AB, IGG

Facility

$318.00

Service Code	CPT 86146
Hospital Charge Code	22481443
Hospital Revenue Code	302
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$286.20
Rate for Payer: Aetna of AZ Commercial	$286.20
Rate for Payer: Arizona Complete Health Allwell	$50.88
Rate for Payer: Banner UC Health Medicare	$50.88
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$216.24
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$50.88
Rate for Payer: Care1st Health Plan Arizona Medicare	$50.88
Rate for Payer: Cash Price	$254.40
Rate for Payer: Cash Price	$254.40
Rate for Payer: Cigna of AZ Commercial	$206.70
Rate for Payer: Devoted Health Medicare	$57.24
Rate for Payer: Humana of AZ Medicare	$50.88
Rate for Payer: Seven Corners Travel Insurance	$36.90
Rate for Payer: Southwest Service Administrators UFCW	$216.24
Rate for Payer: TriWest Medicare	$50.88
Rate for Payer: United Healthcare Commercial	$181.90
Rate for Payer: United Healthcare Medicare	$50.88
Rate for Payer: Veterans Affairs TRICARE	$50.37

BETA 2 GLYCOPROTEIN AB, IGM

Facility

$334.00

Service Code	CPT 86146
Hospital Charge Code	22481464
Hospital Revenue Code	302
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$300.60
Rate for Payer: Aetna of AZ Commercial	$300.60
Rate for Payer: Arizona Complete Health Allwell	$53.44
Rate for Payer: Banner UC Health Medicare	$53.44
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$227.12
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$53.44
Rate for Payer: Care1st Health Plan Arizona Medicare	$53.44
Rate for Payer: Cash Price	$267.20
Rate for Payer: Cash Price	$267.20
Rate for Payer: Cigna of AZ Commercial	$217.10
Rate for Payer: Devoted Health Medicare	$60.12
Rate for Payer: Humana of AZ Medicare	$53.44
Rate for Payer: Seven Corners Travel Insurance	$36.90
Rate for Payer: Southwest Service Administrators UFCW	$227.12
Rate for Payer: TriWest Medicare	$53.44
Rate for Payer: United Healthcare Commercial	$191.05
Rate for Payer: United Healthcare Medicare	$53.44
Rate for Payer: Veterans Affairs TRICARE	$52.91

BETA 2 GLYCOPROTEIN AB, IGM

Facility

$334.00

Service Code	CPT 86146
Hospital Charge Code	22481464
Hospital Revenue Code	302
Min. Negotiated Rate	$300.60
Max. Negotiated Rate	$300.60
Rate for Payer: Aetna of AZ Commercial	$300.60
Rate for Payer: Cash Price	$267.20

Beta-2 Glycoprotein I Ab,G,A,M LC

Facility

$302.00

Service Code	CPT 86146
Hospital Charge Code	2029264
Hospital Revenue Code	302
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of AZ Commercial	$271.80
Rate for Payer: Arizona Complete Health Allwell	$48.32
Rate for Payer: Banner UC Health Medicare	$48.32
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$205.36
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$48.32
Rate for Payer: Care1st Health Plan Arizona Medicare	$48.32
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cigna of AZ Commercial	$196.30
Rate for Payer: Devoted Health Medicare	$54.36
Rate for Payer: Humana of AZ Medicare	$48.32
Rate for Payer: Seven Corners Travel Insurance	$36.90
Rate for Payer: Southwest Service Administrators UFCW	$205.36
Rate for Payer: TriWest Medicare	$48.32
Rate for Payer: United Healthcare Commercial	$172.74
Rate for Payer: United Healthcare Medicare	$48.32
Rate for Payer: Veterans Affairs TRICARE	$47.84

Beta-2 Glycoprotein I Ab,G,A,M LC

Facility

$302.00

Service Code	CPT 86146
Hospital Charge Code	2029264
Hospital Revenue Code	302
Min. Negotiated Rate	$271.80
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of AZ Commercial	$271.80
Rate for Payer: Cash Price	$241.60

Beta-2 Microglobulin, Serum LC

Facility

$270.00

Service Code	CPT 82232
Hospital Charge Code	2029101
Hospital Revenue Code	301
Min. Negotiated Rate	$23.46
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of AZ Commercial	$243.00
Rate for Payer: Arizona Complete Health Allwell	$43.20
Rate for Payer: Banner UC Health Medicare	$43.20
Rate for Payer: Blue Cross Blue Shield of Arizona Commercial	$183.60
Rate for Payer: Blue Cross Blue Shield of Arizona Medicare	$43.20
Rate for Payer: Care1st Health Plan Arizona Medicare	$43.20
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna of AZ Commercial	$175.50
Rate for Payer: Devoted Health Medicare	$48.60
Rate for Payer: Humana of AZ Medicare	$43.20
Rate for Payer: Seven Corners Travel Insurance	$23.46
Rate for Payer: Southwest Service Administrators UFCW	$183.60
Rate for Payer: TriWest Medicare	$43.20
Rate for Payer: United Healthcare Commercial	$154.44
Rate for Payer: United Healthcare Medicare	$43.20
Rate for Payer: Veterans Affairs TRICARE	$42.77

Beta-2 Microglobulin, Serum LC

Facility

$270.00

Service Code	CPT 82232
Hospital Charge Code	2029101
Hospital Revenue Code	301
Min. Negotiated Rate	$243.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of AZ Commercial	$243.00
Rate for Payer: Cash Price	$216.00

Know your out-of-pocket cost for care.

All Charges