|
lisinopril 5 mg Tab [CQCH]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 904679761
|
| Hospital Charge Code |
105929279
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of AZ Commercial |
$0.05
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Self Pay Self Pay |
$0.04
|
|
|
lithium 300 mg Cap [CQCH]
|
Facility
|
OP
|
$0.03
|
|
|
Service Code
|
NDC 54252725
|
| Hospital Charge Code |
105929541
|
|
Hospital Revenue Code
|
251
|
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Aetna of AZ Medicare |
$0.01
|
| Rate for Payer: Allwell Medicare |
$0.00
|
| Rate for Payer: Amerigroup Medicare |
$0.00
|
| Rate for Payer: APIPA Medicare/Medicaid |
$0.01
|
| Rate for Payer: AZCH Complete Medicare |
$0.00
|
| Rate for Payer: Banner UC Health Medicare |
$0.00
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of AZ Commercial |
$0.02
|
| Rate for Payer: Copperpoint Commercial |
$0.01
|
| Rate for Payer: Health Net of AZ Commercial |
$0.02
|
| Rate for Payer: Health Net of AZ Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.00
|
| Rate for Payer: Self Pay Self Pay |
$0.02
|
| Rate for Payer: TriWest Medicare |
$0.00
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$0.02
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$0.01
|
|
|
lithium 300 mg Cap [CQCH]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 54252725
|
| Hospital Charge Code |
105929541
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Bisbee Police All Plans |
$0.01
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Self Pay Self Pay |
$0.02
|
|
|
Lithium (Eskalith), Serum LC
|
Facility
|
OP
|
$122.00
|
|
|
Service Code
|
CPT 80178
|
| Hospital Charge Code |
1905523
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.52 |
| Max. Negotiated Rate |
$109.80 |
| Rate for Payer: Aetna of AZ Commercial |
$109.80
|
| Rate for Payer: Aetna of AZ Medicare |
$34.16
|
| Rate for Payer: Allwell Medicare |
$19.52
|
| Rate for Payer: Amerigroup Medicare |
$19.52
|
| Rate for Payer: APIPA Medicare/Medicaid |
$45.57
|
| Rate for Payer: AZCH Complete Medicare |
$19.52
|
| Rate for Payer: Banner UC Health Medicare |
$19.52
|
| Rate for Payer: Bisbee Police All Plans |
$31.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$82.96
|
| Rate for Payer: Cash Price |
$97.60
|
| Rate for Payer: Cigna of AZ Commercial |
$79.30
|
| Rate for Payer: Copperpoint Commercial |
$30.20
|
| Rate for Payer: Health Net of AZ Commercial |
$73.20
|
| Rate for Payer: Health Net of AZ Medicare |
$34.16
|
| Rate for Payer: Humana of AZ Medicare |
$19.52
|
| Rate for Payer: Self Pay Self Pay |
$97.60
|
| Rate for Payer: TriWest Medicare |
$19.52
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$71.13
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$21.96
|
|
|
Lithium (Eskalith), Serum LC
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
CPT 80178
|
| Hospital Charge Code |
1905523
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$31.72 |
| Max. Negotiated Rate |
$109.80 |
| Rate for Payer: Aetna of AZ Commercial |
$109.80
|
| Rate for Payer: Bisbee Police All Plans |
$31.72
|
| Rate for Payer: Cash Price |
$97.60
|
| Rate for Payer: Self Pay Self Pay |
$97.60
|
|
|
Liver elastography
|
Facility
|
IP
|
$224.00
|
|
|
Service Code
|
CPT 91200
|
| Hospital Charge Code |
22282825
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$58.24 |
| Max. Negotiated Rate |
$201.60 |
| Rate for Payer: Aetna of AZ Commercial |
$201.60
|
| Rate for Payer: Bisbee Police All Plans |
$58.24
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: Self Pay Self Pay |
$179.20
|
|
|
Liver elastography
|
Facility
|
OP
|
$224.00
|
|
|
Service Code
|
CPT 91200
|
| Hospital Charge Code |
22282825
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$35.84 |
| Max. Negotiated Rate |
$201.60 |
| Rate for Payer: Aetna of AZ Commercial |
$201.60
|
| Rate for Payer: Aetna of AZ Medicare |
$62.72
|
| Rate for Payer: Allwell Medicare |
$35.84
|
| Rate for Payer: Amerigroup Medicare |
$35.84
|
| Rate for Payer: APIPA Medicare/Medicaid |
$83.66
|
| Rate for Payer: AZCH Complete Medicare |
$35.84
|
| Rate for Payer: Banner UC Health Medicare |
$35.84
|
| Rate for Payer: Bisbee Police All Plans |
$58.24
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$152.32
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: Cigna of AZ Commercial |
$156.80
|
| Rate for Payer: Copperpoint Commercial |
$55.44
|
| Rate for Payer: Health Net of AZ Commercial |
$134.40
|
| Rate for Payer: Health Net of AZ Medicare |
$62.72
|
| Rate for Payer: Humana of AZ Medicare |
$35.84
|
| Rate for Payer: Self Pay Self Pay |
$179.20
|
| Rate for Payer: TriWest Medicare |
$35.84
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$130.59
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$40.32
|
|
|
Liver-Kidney Microsomal Ab LC
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
CPT 86376
|
| Hospital Charge Code |
22011788
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$27.52 |
| Max. Negotiated Rate |
$154.80 |
| Rate for Payer: Aetna of AZ Commercial |
$154.80
|
| Rate for Payer: Aetna of AZ Medicare |
$48.16
|
| Rate for Payer: Allwell Medicare |
$27.52
|
| Rate for Payer: Amerigroup Medicare |
$27.52
|
| Rate for Payer: APIPA Medicare/Medicaid |
$64.24
|
| Rate for Payer: AZCH Complete Medicare |
$27.52
|
| Rate for Payer: Banner UC Health Medicare |
$27.52
|
| Rate for Payer: Bisbee Police All Plans |
$44.72
|
| Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial |
$116.96
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Cigna of AZ Commercial |
$111.80
|
| Rate for Payer: Copperpoint Commercial |
$42.57
|
| Rate for Payer: Health Net of AZ Commercial |
$103.20
|
| Rate for Payer: Health Net of AZ Medicare |
$48.16
|
| Rate for Payer: Humana of AZ Medicare |
$27.52
|
| Rate for Payer: Self Pay Self Pay |
$137.60
|
| Rate for Payer: TriWest Medicare |
$27.52
|
| Rate for Payer: UnitedHealth Group of AZ Commercial |
$100.28
|
| Rate for Payer: UnitedHealth Group of AZ Medicare |
$30.96
|
|
|
Liver-Kidney Microsomal Ab LC
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
CPT 86376
|
| Hospital Charge Code |
22011788
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$44.72 |
| Max. Negotiated Rate |
$154.80 |
| Rate for Payer: Aetna of AZ Commercial |
$154.80
|
| Rate for Payer: Bisbee Police All Plans |
$44.72
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Self Pay Self Pay |
$137.60
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$46,835.28
|
|
|
Service Code
|
APR-DRG 0011
|
| Hospital Charge Code |
APRDRG0014
|
| Min. Negotiated Rate |
$46,835.28 |
| Max. Negotiated Rate |
$46,835.28 |
| Rate for Payer: AHCCCS Medicaid |
$46,835.28
|
| Rate for Payer: Allwell Medicaid |
$46,835.28
|
| Rate for Payer: AZCH Complete Medicaid |
$46,835.28
|
| Rate for Payer: Banner UC Health Medicaid |
$46,835.28
|
| Rate for Payer: Mercy Care Medicaid |
$46,835.28
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$117,754.54
|
|
|
Service Code
|
APR-DRG 0014
|
| Hospital Charge Code |
APRDRG0013
|
| Min. Negotiated Rate |
$117,754.54 |
| Max. Negotiated Rate |
$117,754.54 |
| Rate for Payer: AHCCCS Medicaid |
$117,754.54
|
| Rate for Payer: Allwell Medicaid |
$117,754.54
|
| Rate for Payer: AZCH Complete Medicaid |
$117,754.54
|
| Rate for Payer: Banner UC Health Medicaid |
$117,754.54
|
| Rate for Payer: Mercy Care Medicaid |
$117,754.54
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$46,835.28
|
|
|
Service Code
|
APR-DRG 0012
|
| Hospital Charge Code |
APRDRG0012
|
| Min. Negotiated Rate |
$46,835.28 |
| Max. Negotiated Rate |
$46,835.28 |
| Rate for Payer: AHCCCS Medicaid |
$46,835.28
|
| Rate for Payer: Allwell Medicaid |
$46,835.28
|
| Rate for Payer: AZCH Complete Medicaid |
$46,835.28
|
| Rate for Payer: Banner UC Health Medicaid |
$46,835.28
|
| Rate for Payer: Mercy Care Medicaid |
$46,835.28
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$117,754.54
|
|
|
Service Code
|
APR-DRG 0014
|
| Hospital Charge Code |
APRDRG0014
|
| Min. Negotiated Rate |
$117,754.54 |
| Max. Negotiated Rate |
$117,754.54 |
| Rate for Payer: AHCCCS Medicaid |
$117,754.54
|
| Rate for Payer: Allwell Medicaid |
$117,754.54
|
| Rate for Payer: AZCH Complete Medicaid |
$117,754.54
|
| Rate for Payer: Banner UC Health Medicaid |
$117,754.54
|
| Rate for Payer: Mercy Care Medicaid |
$117,754.54
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$55,504.59
|
|
|
Service Code
|
APR-DRG 0013
|
| Hospital Charge Code |
APRDRG0014
|
| Min. Negotiated Rate |
$55,504.59 |
| Max. Negotiated Rate |
$55,504.59 |
| Rate for Payer: AHCCCS Medicaid |
$55,504.59
|
| Rate for Payer: Allwell Medicaid |
$55,504.59
|
| Rate for Payer: AZCH Complete Medicaid |
$55,504.59
|
| Rate for Payer: Banner UC Health Medicaid |
$55,504.59
|
| Rate for Payer: Mercy Care Medicaid |
$55,504.59
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$55,504.59
|
|
|
Service Code
|
APR-DRG 0013
|
| Hospital Charge Code |
APRDRG0012
|
| Min. Negotiated Rate |
$55,504.59 |
| Max. Negotiated Rate |
$55,504.59 |
| Rate for Payer: AHCCCS Medicaid |
$55,504.59
|
| Rate for Payer: Allwell Medicaid |
$55,504.59
|
| Rate for Payer: AZCH Complete Medicaid |
$55,504.59
|
| Rate for Payer: Banner UC Health Medicaid |
$55,504.59
|
| Rate for Payer: Mercy Care Medicaid |
$55,504.59
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$46,835.28
|
|
|
Service Code
|
APR-DRG 0011
|
| Hospital Charge Code |
APRDRG0013
|
| Min. Negotiated Rate |
$46,835.28 |
| Max. Negotiated Rate |
$46,835.28 |
| Rate for Payer: AHCCCS Medicaid |
$46,835.28
|
| Rate for Payer: Allwell Medicaid |
$46,835.28
|
| Rate for Payer: AZCH Complete Medicaid |
$46,835.28
|
| Rate for Payer: Banner UC Health Medicaid |
$46,835.28
|
| Rate for Payer: Mercy Care Medicaid |
$46,835.28
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$46,835.28
|
|
|
Service Code
|
APR-DRG 0012
|
| Hospital Charge Code |
APRDRG0013
|
| Min. Negotiated Rate |
$46,835.28 |
| Max. Negotiated Rate |
$46,835.28 |
| Rate for Payer: AHCCCS Medicaid |
$46,835.28
|
| Rate for Payer: Allwell Medicaid |
$46,835.28
|
| Rate for Payer: AZCH Complete Medicaid |
$46,835.28
|
| Rate for Payer: Banner UC Health Medicaid |
$46,835.28
|
| Rate for Payer: Mercy Care Medicaid |
$46,835.28
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$55,504.59
|
|
|
Service Code
|
APR-DRG 0013
|
| Hospital Charge Code |
APRDRG0011
|
| Min. Negotiated Rate |
$55,504.59 |
| Max. Negotiated Rate |
$55,504.59 |
| Rate for Payer: AHCCCS Medicaid |
$55,504.59
|
| Rate for Payer: Allwell Medicaid |
$55,504.59
|
| Rate for Payer: AZCH Complete Medicaid |
$55,504.59
|
| Rate for Payer: Banner UC Health Medicaid |
$55,504.59
|
| Rate for Payer: Mercy Care Medicaid |
$55,504.59
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$117,754.54
|
|
|
Service Code
|
APR-DRG 0014
|
| Hospital Charge Code |
APRDRG0011
|
| Min. Negotiated Rate |
$117,754.54 |
| Max. Negotiated Rate |
$117,754.54 |
| Rate for Payer: AHCCCS Medicaid |
$117,754.54
|
| Rate for Payer: Allwell Medicaid |
$117,754.54
|
| Rate for Payer: AZCH Complete Medicaid |
$117,754.54
|
| Rate for Payer: Banner UC Health Medicaid |
$117,754.54
|
| Rate for Payer: Mercy Care Medicaid |
$117,754.54
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$46,835.28
|
|
|
Service Code
|
APR-DRG 0012
|
| Hospital Charge Code |
APRDRG0014
|
| Min. Negotiated Rate |
$46,835.28 |
| Max. Negotiated Rate |
$46,835.28 |
| Rate for Payer: AHCCCS Medicaid |
$46,835.28
|
| Rate for Payer: Allwell Medicaid |
$46,835.28
|
| Rate for Payer: AZCH Complete Medicaid |
$46,835.28
|
| Rate for Payer: Banner UC Health Medicaid |
$46,835.28
|
| Rate for Payer: Mercy Care Medicaid |
$46,835.28
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$46,835.28
|
|
|
Service Code
|
APR-DRG 0011
|
| Hospital Charge Code |
APRDRG0012
|
| Min. Negotiated Rate |
$46,835.28 |
| Max. Negotiated Rate |
$46,835.28 |
| Rate for Payer: AHCCCS Medicaid |
$46,835.28
|
| Rate for Payer: Allwell Medicaid |
$46,835.28
|
| Rate for Payer: AZCH Complete Medicaid |
$46,835.28
|
| Rate for Payer: Banner UC Health Medicaid |
$46,835.28
|
| Rate for Payer: Mercy Care Medicaid |
$46,835.28
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$117,754.54
|
|
|
Service Code
|
APR-DRG 0014
|
| Hospital Charge Code |
APRDRG0012
|
| Min. Negotiated Rate |
$117,754.54 |
| Max. Negotiated Rate |
$117,754.54 |
| Rate for Payer: AHCCCS Medicaid |
$117,754.54
|
| Rate for Payer: Allwell Medicaid |
$117,754.54
|
| Rate for Payer: AZCH Complete Medicaid |
$117,754.54
|
| Rate for Payer: Banner UC Health Medicaid |
$117,754.54
|
| Rate for Payer: Mercy Care Medicaid |
$117,754.54
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$46,835.28
|
|
|
Service Code
|
APR-DRG 0011
|
| Hospital Charge Code |
APRDRG0011
|
| Min. Negotiated Rate |
$46,835.28 |
| Max. Negotiated Rate |
$46,835.28 |
| Rate for Payer: AHCCCS Medicaid |
$46,835.28
|
| Rate for Payer: Allwell Medicaid |
$46,835.28
|
| Rate for Payer: AZCH Complete Medicaid |
$46,835.28
|
| Rate for Payer: Banner UC Health Medicaid |
$46,835.28
|
| Rate for Payer: Mercy Care Medicaid |
$46,835.28
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$46,835.28
|
|
|
Service Code
|
APR-DRG 0012
|
| Hospital Charge Code |
APRDRG0011
|
| Min. Negotiated Rate |
$46,835.28 |
| Max. Negotiated Rate |
$46,835.28 |
| Rate for Payer: AHCCCS Medicaid |
$46,835.28
|
| Rate for Payer: Allwell Medicaid |
$46,835.28
|
| Rate for Payer: AZCH Complete Medicaid |
$46,835.28
|
| Rate for Payer: Banner UC Health Medicaid |
$46,835.28
|
| Rate for Payer: Mercy Care Medicaid |
$46,835.28
|
|
|
Liver Transplant And/Or Intestinal Transplant
|
Facility
|
IP
|
$55,504.59
|
|
|
Service Code
|
APR-DRG 0013
|
| Hospital Charge Code |
APRDRG0013
|
| Min. Negotiated Rate |
$55,504.59 |
| Max. Negotiated Rate |
$55,504.59 |
| Rate for Payer: AHCCCS Medicaid |
$55,504.59
|
| Rate for Payer: Allwell Medicaid |
$55,504.59
|
| Rate for Payer: AZCH Complete Medicaid |
$55,504.59
|
| Rate for Payer: Banner UC Health Medicaid |
$55,504.59
|
| Rate for Payer: Mercy Care Medicaid |
$55,504.59
|
|
