Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

charcoal-sorbitol 25 g Oral Susp 120 mL [CQCH]

Facility

OP

$0.18

Service Code	NDC 66689020304
Hospital Charge Code	105916052
Hospital Revenue Code	251
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of AZ Commercial	$0.16
Rate for Payer: Aetna of AZ Medicare	$0.05
Rate for Payer: Allwell Medicare	$0.03
Rate for Payer: Amerigroup Medicare	$0.03
Rate for Payer: APIPA Medicare/Medicaid	$0.07
Rate for Payer: AZCH Complete Medicare	$0.03
Rate for Payer: Banner UC Health Medicare	$0.03
Rate for Payer: Bisbee Police All Plans	$0.05
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.12
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of AZ Commercial	$0.12
Rate for Payer: Copperpoint Commercial	$0.04
Rate for Payer: Health Net of AZ Commercial	$0.11
Rate for Payer: Health Net of AZ Medicare	$0.05
Rate for Payer: Humana of AZ Medicare	$0.03
Rate for Payer: Self Pay Self Pay	$0.14
Rate for Payer: TriWest Medicare	$0.03
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.10
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.03

charcoal-sorbitol 25 g Oral Susp 120 mL [CQCH]

Facility

IP

$0.18

Service Code	NDC 66689020304
Hospital Charge Code	105916052
Hospital Revenue Code	251
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of AZ Commercial	$0.16
Rate for Payer: Bisbee Police All Plans	$0.05
Rate for Payer: Cash Price	$0.14
Rate for Payer: Self Pay Self Pay	$0.14

CHECKMATE EXTENSION SET ANESTHESIA

Facility

IP

$63.00

Hospital Charge Code	22355567
Hospital Revenue Code	270
Min. Negotiated Rate	$16.38
Max. Negotiated Rate	$56.70
Rate for Payer: Aetna of AZ Commercial	$56.70
Rate for Payer: Bisbee Police All Plans	$16.38
Rate for Payer: Cash Price	$50.40
Rate for Payer: Self Pay Self Pay	$50.40

CHECKMATE EXTENSION SET ANESTHESIA

Facility

OP

$63.00

Hospital Charge Code	22355567
Hospital Revenue Code	270
Min. Negotiated Rate	$9.45
Max. Negotiated Rate	$56.70
Rate for Payer: Aetna of AZ Commercial	$56.70
Rate for Payer: Aetna of AZ Medicare	$17.64
Rate for Payer: Allwell Medicare	$9.45
Rate for Payer: Amerigroup Medicare	$9.45
Rate for Payer: APIPA Medicare/Medicaid	$23.53
Rate for Payer: AZCH Complete Medicare	$9.45
Rate for Payer: Banner UC Health Medicare	$9.45
Rate for Payer: Bisbee Police All Plans	$16.38
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$42.84
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna of AZ Commercial	$44.10
Rate for Payer: Copperpoint Commercial	$15.59
Rate for Payer: Health Net of AZ Commercial	$37.80
Rate for Payer: Health Net of AZ Medicare	$17.64
Rate for Payer: Humana of AZ Medicare	$9.45
Rate for Payer: Self Pay Self Pay	$50.40
Rate for Payer: TriWest Medicare	$9.45
Rate for Payer: UnitedHealth Group of AZ Commercial	$36.73
Rate for Payer: UnitedHealth Group of AZ Medicare	$11.34

Chemotherapy For Acute Leukemia

Facility

IP

$6,175.13

Service Code	APR-DRG 6952
Hospital Charge Code	APRDRG6952
Min. Negotiated Rate	$6,175.13
Max. Negotiated Rate	$6,175.13
Rate for Payer: AHCCCS Medicaid	$6,175.13
Rate for Payer: Allwell Medicaid	$6,175.13
Rate for Payer: AZCH Complete Medicaid	$6,175.13
Rate for Payer: Banner UC Health Medicaid	$6,175.13
Rate for Payer: Mercy Care Medicaid	$6,175.13

Chemotherapy For Acute Leukemia

Facility

IP

$6,175.13

Service Code	APR-DRG 6951
Hospital Charge Code	APRDRG6954
Min. Negotiated Rate	$6,175.13
Max. Negotiated Rate	$6,175.13
Rate for Payer: AHCCCS Medicaid	$6,175.13
Rate for Payer: Allwell Medicaid	$6,175.13
Rate for Payer: AZCH Complete Medicaid	$6,175.13
Rate for Payer: Banner UC Health Medicaid	$6,175.13
Rate for Payer: Mercy Care Medicaid	$6,175.13

Chemotherapy For Acute Leukemia

Facility

IP

$16,241.62

Service Code	APR-DRG 6953
Hospital Charge Code	APRDRG6954
Min. Negotiated Rate	$16,241.62
Max. Negotiated Rate	$16,241.62
Rate for Payer: AHCCCS Medicaid	$16,241.62
Rate for Payer: Allwell Medicaid	$16,241.62
Rate for Payer: AZCH Complete Medicaid	$16,241.62
Rate for Payer: Banner UC Health Medicaid	$16,241.62
Rate for Payer: Mercy Care Medicaid	$16,241.62

Chemotherapy For Acute Leukemia

Facility

IP

$44,263.25

Service Code	APR-DRG 6954
Hospital Charge Code	APRDRG6951
Min. Negotiated Rate	$44,263.25
Max. Negotiated Rate	$44,263.25
Rate for Payer: AHCCCS Medicaid	$44,263.25
Rate for Payer: Allwell Medicaid	$44,263.25
Rate for Payer: AZCH Complete Medicaid	$44,263.25
Rate for Payer: Banner UC Health Medicaid	$44,263.25
Rate for Payer: Mercy Care Medicaid	$44,263.25

Chemotherapy For Acute Leukemia

Facility

IP

$6,175.13

Service Code	APR-DRG 6951
Hospital Charge Code	APRDRG6953
Min. Negotiated Rate	$6,175.13
Max. Negotiated Rate	$6,175.13
Rate for Payer: AHCCCS Medicaid	$6,175.13
Rate for Payer: Allwell Medicaid	$6,175.13
Rate for Payer: AZCH Complete Medicaid	$6,175.13
Rate for Payer: Banner UC Health Medicaid	$6,175.13
Rate for Payer: Mercy Care Medicaid	$6,175.13

Chemotherapy For Acute Leukemia

Facility

IP

$16,241.62

Service Code	APR-DRG 6953
Hospital Charge Code	APRDRG6951
Min. Negotiated Rate	$16,241.62
Max. Negotiated Rate	$16,241.62
Rate for Payer: AHCCCS Medicaid	$16,241.62
Rate for Payer: Allwell Medicaid	$16,241.62
Rate for Payer: AZCH Complete Medicaid	$16,241.62
Rate for Payer: Banner UC Health Medicaid	$16,241.62
Rate for Payer: Mercy Care Medicaid	$16,241.62

Chemotherapy For Acute Leukemia

Facility

IP

$6,175.13

Service Code	APR-DRG 6951
Hospital Charge Code	APRDRG6952
Min. Negotiated Rate	$6,175.13
Max. Negotiated Rate	$6,175.13
Rate for Payer: AHCCCS Medicaid	$6,175.13
Rate for Payer: Allwell Medicaid	$6,175.13
Rate for Payer: AZCH Complete Medicaid	$6,175.13
Rate for Payer: Banner UC Health Medicaid	$6,175.13
Rate for Payer: Mercy Care Medicaid	$6,175.13

Chemotherapy For Acute Leukemia

Facility

IP

$6,175.13

Service Code	APR-DRG 6952
Hospital Charge Code	APRDRG6953
Min. Negotiated Rate	$6,175.13
Max. Negotiated Rate	$6,175.13
Rate for Payer: AHCCCS Medicaid	$6,175.13
Rate for Payer: Allwell Medicaid	$6,175.13
Rate for Payer: AZCH Complete Medicaid	$6,175.13
Rate for Payer: Banner UC Health Medicaid	$6,175.13
Rate for Payer: Mercy Care Medicaid	$6,175.13

Chemotherapy For Acute Leukemia

Facility

IP

$16,241.62

Service Code	APR-DRG 6953
Hospital Charge Code	APRDRG6953
Min. Negotiated Rate	$16,241.62
Max. Negotiated Rate	$16,241.62
Rate for Payer: AHCCCS Medicaid	$16,241.62
Rate for Payer: Allwell Medicaid	$16,241.62
Rate for Payer: AZCH Complete Medicaid	$16,241.62
Rate for Payer: Banner UC Health Medicaid	$16,241.62
Rate for Payer: Mercy Care Medicaid	$16,241.62

Chemotherapy For Acute Leukemia

Facility

IP

$6,175.13

Service Code	APR-DRG 6952
Hospital Charge Code	APRDRG6951
Min. Negotiated Rate	$6,175.13
Max. Negotiated Rate	$6,175.13
Rate for Payer: AHCCCS Medicaid	$6,175.13
Rate for Payer: Allwell Medicaid	$6,175.13
Rate for Payer: AZCH Complete Medicaid	$6,175.13
Rate for Payer: Banner UC Health Medicaid	$6,175.13
Rate for Payer: Mercy Care Medicaid	$6,175.13

Chemotherapy For Acute Leukemia

Facility

IP

$44,263.25

Service Code	APR-DRG 6954
Hospital Charge Code	APRDRG6953
Min. Negotiated Rate	$44,263.25
Max. Negotiated Rate	$44,263.25
Rate for Payer: AHCCCS Medicaid	$44,263.25
Rate for Payer: Allwell Medicaid	$44,263.25
Rate for Payer: AZCH Complete Medicaid	$44,263.25
Rate for Payer: Banner UC Health Medicaid	$44,263.25
Rate for Payer: Mercy Care Medicaid	$44,263.25

Chemotherapy For Acute Leukemia

Facility

IP

$44,263.25

Service Code	APR-DRG 6954
Hospital Charge Code	APRDRG6954
Min. Negotiated Rate	$44,263.25
Max. Negotiated Rate	$44,263.25
Rate for Payer: AHCCCS Medicaid	$44,263.25
Rate for Payer: Allwell Medicaid	$44,263.25
Rate for Payer: AZCH Complete Medicaid	$44,263.25
Rate for Payer: Banner UC Health Medicaid	$44,263.25
Rate for Payer: Mercy Care Medicaid	$44,263.25

Chemotherapy For Acute Leukemia

Facility

IP

$44,263.25

Service Code	APR-DRG 6954
Hospital Charge Code	APRDRG6952
Min. Negotiated Rate	$44,263.25
Max. Negotiated Rate	$44,263.25
Rate for Payer: AHCCCS Medicaid	$44,263.25
Rate for Payer: Allwell Medicaid	$44,263.25
Rate for Payer: AZCH Complete Medicaid	$44,263.25
Rate for Payer: Banner UC Health Medicaid	$44,263.25
Rate for Payer: Mercy Care Medicaid	$44,263.25

Chemotherapy For Acute Leukemia

Facility

IP

$6,175.13

Service Code	APR-DRG 6952
Hospital Charge Code	APRDRG6954
Min. Negotiated Rate	$6,175.13
Max. Negotiated Rate	$6,175.13
Rate for Payer: AHCCCS Medicaid	$6,175.13
Rate for Payer: Allwell Medicaid	$6,175.13
Rate for Payer: AZCH Complete Medicaid	$6,175.13
Rate for Payer: Banner UC Health Medicaid	$6,175.13
Rate for Payer: Mercy Care Medicaid	$6,175.13

Chemotherapy For Acute Leukemia

Facility

IP

$16,241.62

Service Code	APR-DRG 6953
Hospital Charge Code	APRDRG6952
Min. Negotiated Rate	$16,241.62
Max. Negotiated Rate	$16,241.62
Rate for Payer: AHCCCS Medicaid	$16,241.62
Rate for Payer: Allwell Medicaid	$16,241.62
Rate for Payer: AZCH Complete Medicaid	$16,241.62
Rate for Payer: Banner UC Health Medicaid	$16,241.62
Rate for Payer: Mercy Care Medicaid	$16,241.62

Chemotherapy For Acute Leukemia

Facility

IP

$6,175.13

Service Code	APR-DRG 6951
Hospital Charge Code	APRDRG6951
Min. Negotiated Rate	$6,175.13
Max. Negotiated Rate	$6,175.13
Rate for Payer: AHCCCS Medicaid	$6,175.13
Rate for Payer: Allwell Medicaid	$6,175.13
Rate for Payer: AZCH Complete Medicaid	$6,175.13
Rate for Payer: Banner UC Health Medicaid	$6,175.13
Rate for Payer: Mercy Care Medicaid	$6,175.13

Chest Pain

Facility

IP

$5,097.07

Service Code	APR-DRG 2033
Hospital Charge Code	APRDRG2032
Min. Negotiated Rate	$5,097.07
Max. Negotiated Rate	$5,097.07
Rate for Payer: AHCCCS Medicaid	$5,097.07
Rate for Payer: Allwell Medicaid	$5,097.07
Rate for Payer: AZCH Complete Medicaid	$5,097.07
Rate for Payer: Banner UC Health Medicaid	$5,097.07
Rate for Payer: Mercy Care Medicaid	$5,097.07

Chest Pain

Facility

IP

$3,615.02

Service Code	APR-DRG 2031
Hospital Charge Code	APRDRG2034
Min. Negotiated Rate	$3,615.02
Max. Negotiated Rate	$3,615.02
Rate for Payer: AHCCCS Medicaid	$3,615.02
Rate for Payer: Allwell Medicaid	$3,615.02
Rate for Payer: AZCH Complete Medicaid	$3,615.02
Rate for Payer: Banner UC Health Medicaid	$3,615.02
Rate for Payer: Mercy Care Medicaid	$3,615.02

Chest Pain

Facility

IP

$7,157.09

Service Code	APR-DRG 2034
Hospital Charge Code	APRDRG2031
Min. Negotiated Rate	$7,157.09
Max. Negotiated Rate	$7,157.09
Rate for Payer: AHCCCS Medicaid	$7,157.09
Rate for Payer: Allwell Medicaid	$7,157.09
Rate for Payer: AZCH Complete Medicaid	$7,157.09
Rate for Payer: Banner UC Health Medicaid	$7,157.09
Rate for Payer: Mercy Care Medicaid	$7,157.09

Chest Pain

Facility

IP

$4,107.40

Service Code	APR-DRG 2032
Hospital Charge Code	APRDRG2034
Min. Negotiated Rate	$4,107.40
Max. Negotiated Rate	$4,107.40
Rate for Payer: AHCCCS Medicaid	$4,107.40
Rate for Payer: Allwell Medicaid	$4,107.40
Rate for Payer: AZCH Complete Medicaid	$4,107.40
Rate for Payer: Banner UC Health Medicaid	$4,107.40
Rate for Payer: Mercy Care Medicaid	$4,107.40

Chest Pain

Facility

IP

$5,097.07

Service Code	APR-DRG 2033
Hospital Charge Code	APRDRG2031
Min. Negotiated Rate	$5,097.07
Max. Negotiated Rate	$5,097.07
Rate for Payer: AHCCCS Medicaid	$5,097.07
Rate for Payer: Allwell Medicaid	$5,097.07
Rate for Payer: AZCH Complete Medicaid	$5,097.07
Rate for Payer: Banner UC Health Medicaid	$5,097.07
Rate for Payer: Mercy Care Medicaid	$5,097.07

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