|
lisinopril 2.5 mg Tab [CQCH]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 68084076525
|
| Hospital Charge Code |
105929411
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of AZ Commercial |
$0.40
|
| Rate for Payer: Cash Price |
$0.35
|
|
|
lisinopril 2.5 mg Tab [CQCH]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 68084076525
|
| Hospital Charge Code |
105929411
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of AZ Commercial |
$0.40
|
| 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 |
$0.30
|
| 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 |
$0.35
|
| Rate for Payer: Cigna of AZ Commercial |
$0.29
|
| Rate for Payer: Devoted Health Medicare |
$0.08
|
| Rate for Payer: Humana of AZ Medicare |
$0.07
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.30
|
| 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
|
|
|
lisinopril 5 mg Tab [CQCH]
|
Facility
|
OP
|
$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: 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 |
$0.04
|
| 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 |
$0.03
|
| Rate for Payer: United Healthcare Medicare |
$0.01
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.01
|
|
|
lisinopril 5 mg Tab [CQCH]
|
Facility
|
IP
|
$0.05
|
|
|
Service Code
|
NDC 904679761
|
| Hospital Charge Code |
105929279
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.05 |
| Rate for Payer: Aetna of AZ Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$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: 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 |
$0.02
|
| 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 |
$0.02
|
| Rate for Payer: Cigna of AZ Commercial |
$0.02
|
| Rate for Payer: Devoted Health Medicare |
$0.01
|
| Rate for Payer: Humana of AZ Medicare |
$0.00
|
| Rate for Payer: Southwest Service Administrators UFCW |
$0.02
|
| Rate for Payer: TriWest Medicare |
$0.00
|
| Rate for Payer: United Healthcare Commercial |
$0.02
|
| Rate for Payer: United Healthcare Medicare |
$0.00
|
| Rate for Payer: Veterans Affairs TRICARE |
$0.00
|
|
|
lithium 300 mg Cap [CQCH]
|
Facility
|
IP
|
$0.03
|
|
|
Service Code
|
NDC 54252725
|
| Hospital Charge Code |
105929541
|
|
Hospital Revenue Code
|
251
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Aetna of AZ Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
|
|
Lithium (Eskalith), Serum LC
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
CPT 80178
|
| Hospital Charge Code |
1905523
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.58 |
| Max. Negotiated Rate |
$154.80 |
| Rate for Payer: Aetna of AZ Commercial |
$154.80
|
| Rate for Payer: Aetna of AZ Commercial |
$109.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$19.52
|
| Rate for Payer: Arizona Complete Health Allwell |
$27.52
|
| Rate for Payer: Banner UC Health Medicare |
$19.52
|
| Rate for Payer: Banner UC Health Medicare |
$27.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$116.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$82.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$19.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$27.52
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$19.52
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$27.52
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Cash Price |
$97.60
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Cash Price |
$97.60
|
| Rate for Payer: Cigna of AZ Commercial |
$111.80
|
| Rate for Payer: Cigna of AZ Commercial |
$79.30
|
| Rate for Payer: Devoted Health Medicare |
$30.96
|
| Rate for Payer: Devoted Health Medicare |
$21.96
|
| Rate for Payer: Humana of AZ Medicare |
$19.52
|
| Rate for Payer: Humana of AZ Medicare |
$27.52
|
| Rate for Payer: Seven Corners Travel Insurance |
$9.58
|
| Rate for Payer: Seven Corners Travel Insurance |
$9.58
|
| Rate for Payer: Southwest Service Administrators UFCW |
$82.96
|
| Rate for Payer: Southwest Service Administrators UFCW |
$116.96
|
| Rate for Payer: TriWest Medicare |
$19.52
|
| Rate for Payer: TriWest Medicare |
$27.52
|
| Rate for Payer: United Healthcare Commercial |
$98.38
|
| Rate for Payer: United Healthcare Commercial |
$69.78
|
| Rate for Payer: United Healthcare Medicare |
$19.52
|
| Rate for Payer: United Healthcare Medicare |
$27.52
|
| Rate for Payer: Veterans Affairs TRICARE |
$27.24
|
| Rate for Payer: Veterans Affairs TRICARE |
$19.32
|
|
|
Lithium (Eskalith), Serum LC
|
Facility
|
IP
|
$122.00
|
|
|
Service Code
|
CPT 80178
|
| Hospital Charge Code |
1905523
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$109.80 |
| Max. Negotiated Rate |
$109.80 |
| Rate for Payer: Aetna of AZ Commercial |
$109.80
|
| Rate for Payer: Aetna of AZ Commercial |
$154.80
|
| Rate for Payer: Cash Price |
$97.60
|
| Rate for Payer: Cash Price |
$137.60
|
|
|
Litholink 24-Hour Urine, KS LC
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
CPT 81050
|
| Hospital Charge Code |
28268570
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$42.30 |
| Max. Negotiated Rate |
$42.30 |
| Rate for Payer: Aetna of AZ Commercial |
$42.30
|
| Rate for Payer: Cash Price |
$37.60
|
|
|
Litholink 24-Hour Urine, KS LC
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
CPT 81050
|
| Hospital Charge Code |
28268570
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.28 |
| Max. Negotiated Rate |
$42.30 |
| Rate for Payer: Aetna of AZ Commercial |
$42.30
|
| Rate for Payer: Arizona Complete Health Allwell |
$7.52
|
| Rate for Payer: Banner UC Health Medicare |
$7.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$31.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$7.52
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$7.52
|
| Rate for Payer: Cash Price |
$37.60
|
| Rate for Payer: Cash Price |
$37.60
|
| Rate for Payer: Cigna of AZ Commercial |
$30.55
|
| Rate for Payer: Devoted Health Medicare |
$8.46
|
| Rate for Payer: Humana of AZ Medicare |
$7.52
|
| Rate for Payer: Seven Corners Travel Insurance |
$5.28
|
| Rate for Payer: Southwest Service Administrators UFCW |
$31.96
|
| Rate for Payer: TriWest Medicare |
$7.52
|
| Rate for Payer: United Healthcare Commercial |
$26.88
|
| Rate for Payer: United Healthcare Medicare |
$7.52
|
| Rate for Payer: Veterans Affairs TRICARE |
$7.44
|
|
|
Liver elastography
|
Facility
|
OP
|
$224.00
|
|
|
Service Code
|
CPT 91200
|
| Hospital Charge Code |
22282825
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$35.48 |
| Max. Negotiated Rate |
$201.60 |
| Rate for Payer: Aetna of AZ Commercial |
$201.60
|
| Rate for Payer: Arizona Complete Health Allwell |
$35.84
|
| Rate for Payer: Banner UC Health Medicare |
$35.84
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$152.32
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$35.84
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$35.84
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: Cigna of AZ Commercial |
$156.80
|
| Rate for Payer: Devoted Health Medicare |
$40.32
|
| Rate for Payer: Humana of AZ Medicare |
$35.84
|
| Rate for Payer: Seven Corners Travel Insurance |
$199.09
|
| Rate for Payer: Southwest Service Administrators UFCW |
$152.32
|
| Rate for Payer: TriWest Medicare |
$35.84
|
| Rate for Payer: United Healthcare Commercial |
$128.13
|
| Rate for Payer: United Healthcare Medicare |
$35.84
|
| Rate for Payer: Veterans Affairs TRICARE |
$35.48
|
|
|
Liver elastography
|
Facility
|
IP
|
$224.00
|
|
|
Service Code
|
CPT 91200
|
| Hospital Charge Code |
22282825
|
|
Hospital Revenue Code
|
400
|
| Min. Negotiated Rate |
$201.60 |
| Max. Negotiated Rate |
$201.60 |
| Rate for Payer: Aetna of AZ Commercial |
$201.60
|
| Rate for Payer: Cash Price |
$179.20
|
|
|
LIVER ELASTOGRAPHY, MECHANICALLY INDUCED SHEAR WAVE (EG, VIBRATION), WITHOUT IMAGING, WITH INTERPRETATION AND REPORT
|
Facility
|
OP
|
$3,373.00
|
|
|
Service Code
|
CPT 91200
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$199.09 |
| Max. Negotiated Rate |
$3,373.00 |
| Rate for Payer: Seven Corners Travel Insurance |
$199.09
|
| Rate for Payer: United Healthcare Commercial |
$3,373.00
|
|
|
Liver-Kidney Microsomal Ab LC
|
Facility
|
OP
|
$172.00
|
|
|
Service Code
|
CPT 86376
|
| Hospital Charge Code |
22011788
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$21.10 |
| Max. Negotiated Rate |
$154.80 |
| Rate for Payer: Aetna of AZ Commercial |
$154.80
|
| Rate for Payer: Arizona Complete Health Allwell |
$27.52
|
| Rate for Payer: Banner UC Health Medicare |
$27.52
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Commercial |
$116.96
|
| Rate for Payer: Blue Cross Blue Shield of Arizona Medicare |
$27.52
|
| Rate for Payer: Care1st Health Plan Arizona Medicare |
$27.52
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Cash Price |
$137.60
|
| Rate for Payer: Cigna of AZ Commercial |
$111.80
|
| Rate for Payer: Devoted Health Medicare |
$30.96
|
| Rate for Payer: Humana of AZ Medicare |
$27.52
|
| Rate for Payer: Seven Corners Travel Insurance |
$21.10
|
| Rate for Payer: Southwest Service Administrators UFCW |
$116.96
|
| Rate for Payer: TriWest Medicare |
$27.52
|
| Rate for Payer: United Healthcare Commercial |
$98.38
|
| Rate for Payer: United Healthcare Medicare |
$27.52
|
| Rate for Payer: Veterans Affairs TRICARE |
$27.24
|
|
|
Liver-Kidney Microsomal Ab LC
|
Facility
|
IP
|
$172.00
|
|
|
Service Code
|
CPT 86376
|
| Hospital Charge Code |
22011788
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$154.80 |
| Max. Negotiated Rate |
$154.80 |
| Rate for Payer: Aetna of AZ Commercial |
$154.80
|
| Rate for Payer: Cash Price |
$137.60
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$117,754.54
|
| Rate for Payer: Mercy Care Medicaid |
$117,754.54
|
| Rate for Payer: NaphCare Correctional Healthcare |
$117,754.54
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$46,835.28
|
| Rate for Payer: Mercy Care Medicaid |
$46,835.28
|
| Rate for Payer: NaphCare Correctional Healthcare |
$46,835.28
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$117,754.54
|
| Rate for Payer: Mercy Care Medicaid |
$117,754.54
|
| Rate for Payer: NaphCare Correctional Healthcare |
$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: Blue Cross Blue Shield of Arizona Health Choice |
$46,835.28
|
| Rate for Payer: Mercy Care Medicaid |
$46,835.28
|
| Rate for Payer: NaphCare Correctional Healthcare |
$46,835.28
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$55,504.59
|
| Rate for Payer: Mercy Care Medicaid |
$55,504.59
|
| Rate for Payer: NaphCare Correctional Healthcare |
$55,504.59
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$117,754.54
|
| Rate for Payer: Mercy Care Medicaid |
$117,754.54
|
| Rate for Payer: NaphCare Correctional Healthcare |
$117,754.54
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$46,835.28
|
| Rate for Payer: Mercy Care Medicaid |
$46,835.28
|
| Rate for Payer: NaphCare Correctional Healthcare |
$46,835.28
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$46,835.28
|
| Rate for Payer: Mercy Care Medicaid |
$46,835.28
|
| Rate for Payer: NaphCare Correctional Healthcare |
$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: Blue Cross Blue Shield of Arizona Health Choice |
$55,504.59
|
| Rate for Payer: Mercy Care Medicaid |
$55,504.59
|
| Rate for Payer: NaphCare Correctional Healthcare |
$55,504.59
|
|
|
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: Blue Cross Blue Shield of Arizona Health Choice |
$46,835.28
|
| Rate for Payer: Mercy Care Medicaid |
$46,835.28
|
| Rate for Payer: NaphCare Correctional Healthcare |
$46,835.28
|
|
