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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

polyethylene glycol 3350 Oral Pwdr (GaviLyte-C) for Sol 4000 mL [CQCH]

Facility

OP

$22.01

Service Code	NDC 43386006019
Hospital Charge Code	105937171
Hospital Revenue Code	251
Min. Negotiated Rate	$3.52
Max. Negotiated Rate	$19.81
Rate for Payer: Aetna of AZ Commercial	$19.81
Rate for Payer: Aetna of AZ Medicare	$6.16
Rate for Payer: Allwell Medicare	$3.52
Rate for Payer: Amerigroup Medicare	$3.52
Rate for Payer: APIPA Medicare/Medicaid	$8.22
Rate for Payer: AZCH Complete Medicare	$3.52
Rate for Payer: Banner UC Health Medicare	$3.52
Rate for Payer: Bisbee Police All Plans	$5.72
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$14.97
Rate for Payer: Cash Price	$17.61
Rate for Payer: Cigna of AZ Commercial	$14.31
Rate for Payer: Copperpoint Commercial	$5.45
Rate for Payer: Health Net of AZ Commercial	$13.21
Rate for Payer: Health Net of AZ Medicare	$6.16
Rate for Payer: Humana of AZ Medicare	$3.52
Rate for Payer: Self Pay Self Pay	$17.61
Rate for Payer: TriWest Medicare	$3.52
Rate for Payer: UnitedHealth Group of AZ Commercial	$12.83
Rate for Payer: UnitedHealth Group of AZ Medicare	$3.96

polyethylene glycol 3350 Oral Pwdr (GaviLyte-C) for Sol 4000 mL [CQCH]

Facility

IP

$22.01

Service Code	NDC 43386006019
Hospital Charge Code	105937171
Hospital Revenue Code	251
Min. Negotiated Rate	$5.72
Max. Negotiated Rate	$19.81
Rate for Payer: Aetna of AZ Commercial	$19.81
Rate for Payer: Bisbee Police All Plans	$5.72
Rate for Payer: Cash Price	$17.61
Rate for Payer: Self Pay Self Pay	$17.61

polyethylene glycol 3350 - REC[CQCH]

Facility

OP

$0.04

Service Code	NDC 11523723403
Hospital Charge Code	168068958
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: Aetna of AZ Medicare	$0.01
Rate for Payer: Allwell Medicare	$0.01
Rate for Payer: Amerigroup Medicare	$0.01
Rate for Payer: APIPA Medicare/Medicaid	$0.01
Rate for Payer: AZCH Complete Medicare	$0.01
Rate for Payer: Banner UC Health Medicare	$0.01
Rate for Payer: Bisbee Police All Plans	$0.01
Rate for Payer: Blue Cross Blue Shield of Arizona All Commercial	$0.03
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of AZ Commercial	$0.03
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	$0.01
Rate for Payer: Self Pay Self Pay	$0.03
Rate for Payer: TriWest Medicare	$0.01
Rate for Payer: UnitedHealth Group of AZ Commercial	$0.02
Rate for Payer: UnitedHealth Group of AZ Medicare	$0.01

polyethylene glycol 3350 - REC[CQCH]

Facility

IP

$0.04

Service Code	NDC 11523723403
Hospital Charge Code	168068958
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: Bisbee Police All Plans	$0.01
Rate for Payer: Cash Price	$0.03
Rate for Payer: Self Pay Self Pay	$0.03

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$33,120.81

Service Code	APR-DRG 7114
Hospital Charge Code	APRDRG7112
Min. Negotiated Rate	$33,120.81
Max. Negotiated Rate	$33,120.81
Rate for Payer: AHCCCS Medicaid	$33,120.81
Rate for Payer: Allwell Medicaid	$33,120.81
Rate for Payer: AZCH Complete Medicaid	$33,120.81
Rate for Payer: Banner UC Health Medicaid	$33,120.81
Rate for Payer: Mercy Care Medicaid	$33,120.81

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$7,152.88

Service Code	APR-DRG 7111
Hospital Charge Code	APRDRG7114
Min. Negotiated Rate	$7,152.88
Max. Negotiated Rate	$7,152.88
Rate for Payer: AHCCCS Medicaid	$7,152.88
Rate for Payer: Allwell Medicaid	$7,152.88
Rate for Payer: AZCH Complete Medicaid	$7,152.88
Rate for Payer: Banner UC Health Medicaid	$7,152.88
Rate for Payer: Mercy Care Medicaid	$7,152.88

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$9,573.41

Service Code	APR-DRG 7112
Hospital Charge Code	APRDRG7112
Min. Negotiated Rate	$9,573.41
Max. Negotiated Rate	$9,573.41
Rate for Payer: AHCCCS Medicaid	$9,573.41
Rate for Payer: Allwell Medicaid	$9,573.41
Rate for Payer: AZCH Complete Medicaid	$9,573.41
Rate for Payer: Banner UC Health Medicaid	$9,573.41
Rate for Payer: Mercy Care Medicaid	$9,573.41

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$33,120.81

Service Code	APR-DRG 7114
Hospital Charge Code	APRDRG7113
Min. Negotiated Rate	$33,120.81
Max. Negotiated Rate	$33,120.81
Rate for Payer: AHCCCS Medicaid	$33,120.81
Rate for Payer: Allwell Medicaid	$33,120.81
Rate for Payer: AZCH Complete Medicaid	$33,120.81
Rate for Payer: Banner UC Health Medicaid	$33,120.81
Rate for Payer: Mercy Care Medicaid	$33,120.81

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$9,573.41

Service Code	APR-DRG 7112
Hospital Charge Code	APRDRG7114
Min. Negotiated Rate	$9,573.41
Max. Negotiated Rate	$9,573.41
Rate for Payer: AHCCCS Medicaid	$9,573.41
Rate for Payer: Allwell Medicaid	$9,573.41
Rate for Payer: AZCH Complete Medicaid	$9,573.41
Rate for Payer: Banner UC Health Medicaid	$9,573.41
Rate for Payer: Mercy Care Medicaid	$9,573.41

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$7,152.88

Service Code	APR-DRG 7111
Hospital Charge Code	APRDRG7112
Min. Negotiated Rate	$7,152.88
Max. Negotiated Rate	$7,152.88
Rate for Payer: AHCCCS Medicaid	$7,152.88
Rate for Payer: Allwell Medicaid	$7,152.88
Rate for Payer: AZCH Complete Medicaid	$7,152.88
Rate for Payer: Banner UC Health Medicaid	$7,152.88
Rate for Payer: Mercy Care Medicaid	$7,152.88

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$7,152.88

Service Code	APR-DRG 7111
Hospital Charge Code	APRDRG7111
Min. Negotiated Rate	$7,152.88
Max. Negotiated Rate	$7,152.88
Rate for Payer: AHCCCS Medicaid	$7,152.88
Rate for Payer: Allwell Medicaid	$7,152.88
Rate for Payer: AZCH Complete Medicaid	$7,152.88
Rate for Payer: Banner UC Health Medicaid	$7,152.88
Rate for Payer: Mercy Care Medicaid	$7,152.88

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$16,744.52

Service Code	APR-DRG 7113
Hospital Charge Code	APRDRG7114
Min. Negotiated Rate	$16,744.52
Max. Negotiated Rate	$16,744.52
Rate for Payer: AHCCCS Medicaid	$16,744.52
Rate for Payer: Allwell Medicaid	$16,744.52
Rate for Payer: AZCH Complete Medicaid	$16,744.52
Rate for Payer: Banner UC Health Medicaid	$16,744.52
Rate for Payer: Mercy Care Medicaid	$16,744.52

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$9,573.41

Service Code	APR-DRG 7112
Hospital Charge Code	APRDRG7113
Min. Negotiated Rate	$9,573.41
Max. Negotiated Rate	$9,573.41
Rate for Payer: AHCCCS Medicaid	$9,573.41
Rate for Payer: Allwell Medicaid	$9,573.41
Rate for Payer: AZCH Complete Medicaid	$9,573.41
Rate for Payer: Banner UC Health Medicaid	$9,573.41
Rate for Payer: Mercy Care Medicaid	$9,573.41

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$7,152.88

Service Code	APR-DRG 7111
Hospital Charge Code	APRDRG7113
Min. Negotiated Rate	$7,152.88
Max. Negotiated Rate	$7,152.88
Rate for Payer: AHCCCS Medicaid	$7,152.88
Rate for Payer: Allwell Medicaid	$7,152.88
Rate for Payer: AZCH Complete Medicaid	$7,152.88
Rate for Payer: Banner UC Health Medicaid	$7,152.88
Rate for Payer: Mercy Care Medicaid	$7,152.88

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$33,120.81

Service Code	APR-DRG 7114
Hospital Charge Code	APRDRG7114
Min. Negotiated Rate	$33,120.81
Max. Negotiated Rate	$33,120.81
Rate for Payer: AHCCCS Medicaid	$33,120.81
Rate for Payer: Allwell Medicaid	$33,120.81
Rate for Payer: AZCH Complete Medicaid	$33,120.81
Rate for Payer: Banner UC Health Medicaid	$33,120.81
Rate for Payer: Mercy Care Medicaid	$33,120.81

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$16,744.52

Service Code	APR-DRG 7113
Hospital Charge Code	APRDRG7111
Min. Negotiated Rate	$16,744.52
Max. Negotiated Rate	$16,744.52
Rate for Payer: AHCCCS Medicaid	$16,744.52
Rate for Payer: Allwell Medicaid	$16,744.52
Rate for Payer: AZCH Complete Medicaid	$16,744.52
Rate for Payer: Banner UC Health Medicaid	$16,744.52
Rate for Payer: Mercy Care Medicaid	$16,744.52

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$9,573.41

Service Code	APR-DRG 7112
Hospital Charge Code	APRDRG7111
Min. Negotiated Rate	$9,573.41
Max. Negotiated Rate	$9,573.41
Rate for Payer: AHCCCS Medicaid	$9,573.41
Rate for Payer: Allwell Medicaid	$9,573.41
Rate for Payer: AZCH Complete Medicaid	$9,573.41
Rate for Payer: Banner UC Health Medicaid	$9,573.41
Rate for Payer: Mercy Care Medicaid	$9,573.41

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$33,120.81

Service Code	APR-DRG 7114
Hospital Charge Code	APRDRG7111
Min. Negotiated Rate	$33,120.81
Max. Negotiated Rate	$33,120.81
Rate for Payer: AHCCCS Medicaid	$33,120.81
Rate for Payer: Allwell Medicaid	$33,120.81
Rate for Payer: AZCH Complete Medicaid	$33,120.81
Rate for Payer: Banner UC Health Medicaid	$33,120.81
Rate for Payer: Mercy Care Medicaid	$33,120.81

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$16,744.52

Service Code	APR-DRG 7113
Hospital Charge Code	APRDRG7113
Min. Negotiated Rate	$16,744.52
Max. Negotiated Rate	$16,744.52
Rate for Payer: AHCCCS Medicaid	$16,744.52
Rate for Payer: Allwell Medicaid	$16,744.52
Rate for Payer: AZCH Complete Medicaid	$16,744.52
Rate for Payer: Banner UC Health Medicaid	$16,744.52
Rate for Payer: Mercy Care Medicaid	$16,744.52

Post-Operative, Post-Trauma, Other Device Infections With O.R. Procedure

Facility

IP

$16,744.52

Service Code	APR-DRG 7113
Hospital Charge Code	APRDRG7112
Min. Negotiated Rate	$16,744.52
Max. Negotiated Rate	$16,744.52
Rate for Payer: AHCCCS Medicaid	$16,744.52
Rate for Payer: Allwell Medicaid	$16,744.52
Rate for Payer: AZCH Complete Medicaid	$16,744.52
Rate for Payer: Banner UC Health Medicaid	$16,744.52
Rate for Payer: Mercy Care Medicaid	$16,744.52

Post-Operative, Post-Traumatic, Other Device Infections

Facility

IP

$4,019.02

Service Code	APR-DRG 7211
Hospital Charge Code	APRDRG7213
Min. Negotiated Rate	$4,019.02
Max. Negotiated Rate	$4,019.02
Rate for Payer: AHCCCS Medicaid	$4,019.02
Rate for Payer: Allwell Medicaid	$4,019.02
Rate for Payer: AZCH Complete Medicaid	$4,019.02
Rate for Payer: Banner UC Health Medicaid	$4,019.02
Rate for Payer: Mercy Care Medicaid	$4,019.02

Post-Operative, Post-Traumatic, Other Device Infections

Facility

IP

$4,019.02

Service Code	APR-DRG 7211
Hospital Charge Code	APRDRG7211
Min. Negotiated Rate	$4,019.02
Max. Negotiated Rate	$4,019.02
Rate for Payer: AHCCCS Medicaid	$4,019.02
Rate for Payer: Allwell Medicaid	$4,019.02
Rate for Payer: AZCH Complete Medicaid	$4,019.02
Rate for Payer: Banner UC Health Medicaid	$4,019.02
Rate for Payer: Mercy Care Medicaid	$4,019.02

Post-Operative, Post-Traumatic, Other Device Infections

Facility

IP

$5,287.85

Service Code	APR-DRG 7212
Hospital Charge Code	APRDRG7214
Min. Negotiated Rate	$5,287.85
Max. Negotiated Rate	$5,287.85
Rate for Payer: AHCCCS Medicaid	$5,287.85
Rate for Payer: Allwell Medicaid	$5,287.85
Rate for Payer: AZCH Complete Medicaid	$5,287.85
Rate for Payer: Banner UC Health Medicaid	$5,287.85
Rate for Payer: Mercy Care Medicaid	$5,287.85

Post-Operative, Post-Traumatic, Other Device Infections

Facility

IP

$8,592.85

Service Code	APR-DRG 7213
Hospital Charge Code	APRDRG7214
Min. Negotiated Rate	$8,592.85
Max. Negotiated Rate	$8,592.85
Rate for Payer: AHCCCS Medicaid	$8,592.85
Rate for Payer: Allwell Medicaid	$8,592.85
Rate for Payer: AZCH Complete Medicaid	$8,592.85
Rate for Payer: Banner UC Health Medicaid	$8,592.85
Rate for Payer: Mercy Care Medicaid	$8,592.85

Post-Operative, Post-Traumatic, Other Device Infections

Facility

IP

$5,287.85

Service Code	APR-DRG 7212
Hospital Charge Code	APRDRG7213
Min. Negotiated Rate	$5,287.85
Max. Negotiated Rate	$5,287.85
Rate for Payer: AHCCCS Medicaid	$5,287.85
Rate for Payer: Allwell Medicaid	$5,287.85
Rate for Payer: AZCH Complete Medicaid	$5,287.85
Rate for Payer: Banner UC Health Medicaid	$5,287.85
Rate for Payer: Mercy Care Medicaid	$5,287.85

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