Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

SODIUM BICARBONATE 650 MG TABLET

Facility

$305.50

Service Code	NDC 64980052810
Hospital Charge Code	7312
Hospital Revenue Code	637
Min. Negotiated Rate	$120.06
Max. Negotiated Rate	$274.95
Rate for Payer: Aetna Commercial	$259.68
Rate for Payer: Aetna Medicare	$152.75
Rate for Payer: Aetna New Business (MI Preferred)	$198.57
Rate for Payer: BCBS Complete	$122.20
Rate for Payer: Cash Price	$244.40
Rate for Payer: Cofinity Advantage	$213.85
Rate for Payer: Cofinity Commercial	$262.73
Rate for Payer: Encore Health Key Benefits Commercial	$244.40
Rate for Payer: Healthscope Commercial	$274.95
Rate for Payer: MI Amish Medical Board Commercial	$244.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$259.68
Rate for Payer: Opus (Opus Packaging Group) HMA	$229.12
Rate for Payer: PHP Commercial	$259.68
Rate for Payer: Priority Health SBD	$192.47
Rate for Payer: UHC All Payor (Choice/PPO)	$198.57
Rate for Payer: UHC Core	$159.17
Rate for Payer: UHC Exchange	$120.06

SODIUM BICARBONATE 650 MG TABLET

Facility

$277.30

Service Code	NDC 77333083110
Hospital Charge Code	7312
Hospital Revenue Code	637
Min. Negotiated Rate	$108.98
Max. Negotiated Rate	$249.57
Rate for Payer: Aetna Commercial	$235.71
Rate for Payer: Aetna Medicare	$138.65
Rate for Payer: Aetna New Business (MI Preferred)	$180.25
Rate for Payer: BCBS Complete	$110.92
Rate for Payer: Cash Price	$221.84
Rate for Payer: Cofinity Advantage	$194.11
Rate for Payer: Cofinity Commercial	$238.48
Rate for Payer: Encore Health Key Benefits Commercial	$221.84
Rate for Payer: Healthscope Commercial	$249.57
Rate for Payer: MI Amish Medical Board Commercial	$221.84
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$235.71
Rate for Payer: Opus (Opus Packaging Group) HMA	$207.97
Rate for Payer: PHP Commercial	$235.71
Rate for Payer: Priority Health SBD	$174.70
Rate for Payer: UHC All Payor (Choice/PPO)	$180.25
Rate for Payer: UHC Core	$144.47
Rate for Payer: UHC Exchange	$108.98

SODIUM BICARBONATE 650 MG TABLET

Facility

$2.78

Service Code	NDC 77333083125
Hospital Charge Code	7312
Hospital Revenue Code	637
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna Commercial	$2.36
Rate for Payer: Aetna Medicare	$1.39
Rate for Payer: Aetna New Business (MI Preferred)	$1.81
Rate for Payer: BCBS Complete	$1.11
Rate for Payer: Cash Price	$2.22
Rate for Payer: Cofinity Advantage	$1.95
Rate for Payer: Cofinity Commercial	$2.39
Rate for Payer: Encore Health Key Benefits Commercial	$2.22
Rate for Payer: Healthscope Commercial	$2.50
Rate for Payer: MI Amish Medical Board Commercial	$2.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.36
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.08
Rate for Payer: PHP Commercial	$2.36
Rate for Payer: Priority Health SBD	$1.75
Rate for Payer: UHC All Payor (Choice/PPO)	$1.81
Rate for Payer: UHC Core	$1.45
Rate for Payer: UHC Exchange	$1.09

SODIUM BICARBONATE 650 MG TABLET

Facility

$277.30

Service Code	NDC 77333083110
Hospital Charge Code	7312
Hospital Revenue Code	637
Min. Negotiated Rate	$174.70
Max. Negotiated Rate	$249.57
Rate for Payer: Aetna Commercial	$235.71
Rate for Payer: Aetna New Business (MI Preferred)	$180.25
Rate for Payer: Cash Price	$221.84
Rate for Payer: Cofinity Advantage	$194.11
Rate for Payer: Cofinity Commercial	$238.48
Rate for Payer: Encore Health Key Benefits Commercial	$221.84
Rate for Payer: Healthscope Commercial	$249.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$235.71
Rate for Payer: Opus (Opus Packaging Group) HMA	$207.97
Rate for Payer: PHP Commercial	$235.71
Rate for Payer: Priority Health SBD	$174.70

SODIUM BICARBONATE 650 MG TABLET

Facility

$319.60

Service Code	NDC 77333082710
Hospital Charge Code	7312
Hospital Revenue Code	637
Min. Negotiated Rate	$125.60
Max. Negotiated Rate	$287.64
Rate for Payer: Aetna Commercial	$271.66
Rate for Payer: Aetna Medicare	$159.80
Rate for Payer: Aetna New Business (MI Preferred)	$207.74
Rate for Payer: BCBS Complete	$127.84
Rate for Payer: Cash Price	$255.68
Rate for Payer: Cofinity Advantage	$223.72
Rate for Payer: Cofinity Commercial	$274.86
Rate for Payer: Encore Health Key Benefits Commercial	$255.68
Rate for Payer: Healthscope Commercial	$287.64
Rate for Payer: MI Amish Medical Board Commercial	$255.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$271.66
Rate for Payer: Opus (Opus Packaging Group) HMA	$239.70
Rate for Payer: PHP Commercial	$271.66
Rate for Payer: Priority Health SBD	$201.35
Rate for Payer: UHC All Payor (Choice/PPO)	$207.74
Rate for Payer: UHC Core	$166.51
Rate for Payer: UHC Exchange	$125.60

SODIUM BICARBONATE 650 MG TABLET

Facility

$2.78

Service Code	NDC 77333083125
Hospital Charge Code	7312
Hospital Revenue Code	637
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna Commercial	$2.36
Rate for Payer: Aetna New Business (MI Preferred)	$1.81
Rate for Payer: Cash Price	$2.22
Rate for Payer: Cofinity Advantage	$1.95
Rate for Payer: Cofinity Commercial	$2.39
Rate for Payer: Encore Health Key Benefits Commercial	$2.22
Rate for Payer: Healthscope Commercial	$2.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.36
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.08
Rate for Payer: PHP Commercial	$2.36
Rate for Payer: Priority Health SBD	$1.75

SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYRINGE (CODE)

Facility

$73.21

Service Code	NDC 00409663724
Hospital Charge Code	163719
Hospital Revenue Code	250
Min. Negotiated Rate	$28.77
Max. Negotiated Rate	$65.89
Rate for Payer: Aetna Commercial	$62.23
Rate for Payer: Aetna Medicare	$36.60
Rate for Payer: Aetna New Business (MI Preferred)	$47.59
Rate for Payer: BCBS Complete	$29.28
Rate for Payer: Cash Price	$58.57
Rate for Payer: Cofinity Advantage	$51.25
Rate for Payer: Cofinity Commercial	$62.96
Rate for Payer: Encore Health Key Benefits Commercial	$58.57
Rate for Payer: Healthscope Commercial	$65.89
Rate for Payer: MI Amish Medical Board Commercial	$58.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$62.23
Rate for Payer: Opus (Opus Packaging Group) HMA	$54.91
Rate for Payer: PHP Commercial	$62.23
Rate for Payer: Priority Health SBD	$46.12
Rate for Payer: UHC All Payor (Choice/PPO)	$47.59
Rate for Payer: UHC Core	$38.14
Rate for Payer: UHC Exchange	$28.77

SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYRINGE (CODE)

Facility

$73.21

Service Code	NDC 00409663714
Hospital Charge Code	163719
Hospital Revenue Code	250
Min. Negotiated Rate	$28.77
Max. Negotiated Rate	$65.89
Rate for Payer: Aetna Commercial	$62.23
Rate for Payer: Aetna Medicare	$36.60
Rate for Payer: Aetna New Business (MI Preferred)	$47.59
Rate for Payer: BCBS Complete	$29.28
Rate for Payer: Cash Price	$58.57
Rate for Payer: Cofinity Advantage	$51.25
Rate for Payer: Cofinity Commercial	$62.96
Rate for Payer: Encore Health Key Benefits Commercial	$58.57
Rate for Payer: Healthscope Commercial	$65.89
Rate for Payer: MI Amish Medical Board Commercial	$58.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$62.23
Rate for Payer: Opus (Opus Packaging Group) HMA	$54.91
Rate for Payer: PHP Commercial	$62.23
Rate for Payer: Priority Health SBD	$46.12
Rate for Payer: UHC All Payor (Choice/PPO)	$47.59
Rate for Payer: UHC Core	$38.14
Rate for Payer: UHC Exchange	$28.77

SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYRINGE (CODE)

Facility

$73.43

Service Code	NDC 76329335201
Hospital Charge Code	163719
Hospital Revenue Code	250
Min. Negotiated Rate	$46.26
Max. Negotiated Rate	$66.09
Rate for Payer: Aetna Commercial	$62.42
Rate for Payer: Aetna New Business (MI Preferred)	$47.73
Rate for Payer: Cash Price	$58.74
Rate for Payer: Cofinity Advantage	$51.40
Rate for Payer: Cofinity Commercial	$63.15
Rate for Payer: Encore Health Key Benefits Commercial	$58.74
Rate for Payer: Healthscope Commercial	$66.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$62.42
Rate for Payer: Opus (Opus Packaging Group) HMA	$55.07
Rate for Payer: PHP Commercial	$62.42
Rate for Payer: Priority Health SBD	$46.26

SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYRINGE (CODE)

Facility

$73.21

Service Code	NDC 00409663724
Hospital Charge Code	163719
Hospital Revenue Code	250
Min. Negotiated Rate	$46.12
Max. Negotiated Rate	$65.89
Rate for Payer: Aetna Commercial	$62.23
Rate for Payer: Aetna New Business (MI Preferred)	$47.59
Rate for Payer: Cash Price	$58.57
Rate for Payer: Cofinity Advantage	$51.25
Rate for Payer: Cofinity Commercial	$62.96
Rate for Payer: Encore Health Key Benefits Commercial	$58.57
Rate for Payer: Healthscope Commercial	$65.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$62.23
Rate for Payer: Opus (Opus Packaging Group) HMA	$54.91
Rate for Payer: PHP Commercial	$62.23
Rate for Payer: Priority Health SBD	$46.12

SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYRINGE (CODE)

Facility

$73.21

Service Code	NDC 00409663714
Hospital Charge Code	163719
Hospital Revenue Code	250
Min. Negotiated Rate	$46.12
Max. Negotiated Rate	$65.89
Rate for Payer: Aetna Commercial	$62.23
Rate for Payer: Aetna New Business (MI Preferred)	$47.59
Rate for Payer: Cash Price	$58.57
Rate for Payer: Cofinity Advantage	$51.25
Rate for Payer: Cofinity Commercial	$62.96
Rate for Payer: Encore Health Key Benefits Commercial	$58.57
Rate for Payer: Healthscope Commercial	$65.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$62.23
Rate for Payer: Opus (Opus Packaging Group) HMA	$54.91
Rate for Payer: PHP Commercial	$62.23
Rate for Payer: Priority Health SBD	$46.12

SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYRINGE (CODE)

Facility

$73.43

Service Code	NDC 76329335201
Hospital Charge Code	163719
Hospital Revenue Code	250
Min. Negotiated Rate	$28.86
Max. Negotiated Rate	$66.09
Rate for Payer: Aetna Commercial	$62.42
Rate for Payer: Aetna Medicare	$36.72
Rate for Payer: Aetna New Business (MI Preferred)	$47.73
Rate for Payer: BCBS Complete	$29.37
Rate for Payer: Cash Price	$58.74
Rate for Payer: Cofinity Advantage	$51.40
Rate for Payer: Cofinity Commercial	$63.15
Rate for Payer: Encore Health Key Benefits Commercial	$58.74
Rate for Payer: Healthscope Commercial	$66.09
Rate for Payer: MI Amish Medical Board Commercial	$58.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$62.42
Rate for Payer: Opus (Opus Packaging Group) HMA	$55.07
Rate for Payer: PHP Commercial	$62.42
Rate for Payer: Priority Health SBD	$46.26
Rate for Payer: UHC All Payor (Choice/PPO)	$47.73
Rate for Payer: UHC Core	$38.26
Rate for Payer: UHC Exchange	$28.86

SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN

Facility

$48.15

Service Code	NDC 00536122497
Hospital Charge Code	165406
Hospital Revenue Code	637
Min. Negotiated Rate	$30.33
Max. Negotiated Rate	$43.34
Rate for Payer: Aetna Commercial	$40.93
Rate for Payer: Aetna New Business (MI Preferred)	$31.30
Rate for Payer: Cash Price	$38.52
Rate for Payer: Cofinity Advantage	$33.70
Rate for Payer: Cofinity Commercial	$41.41
Rate for Payer: Encore Health Key Benefits Commercial	$38.52
Rate for Payer: Healthscope Commercial	$43.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$40.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$36.11
Rate for Payer: PHP Commercial	$40.93
Rate for Payer: Priority Health SBD	$30.33

SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN

Facility

$48.15

Service Code	NDC 00536122497
Hospital Charge Code	165406
Hospital Revenue Code	637
Min. Negotiated Rate	$18.92
Max. Negotiated Rate	$43.34
Rate for Payer: Aetna Commercial	$40.93
Rate for Payer: Aetna Medicare	$24.07
Rate for Payer: Aetna New Business (MI Preferred)	$31.30
Rate for Payer: BCBS Complete	$19.26
Rate for Payer: Cash Price	$38.52
Rate for Payer: Cofinity Advantage	$33.70
Rate for Payer: Cofinity Commercial	$41.41
Rate for Payer: Encore Health Key Benefits Commercial	$38.52
Rate for Payer: Healthscope Commercial	$43.34
Rate for Payer: MI Amish Medical Board Commercial	$38.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$40.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$36.11
Rate for Payer: PHP Commercial	$40.93
Rate for Payer: Priority Health SBD	$30.33
Rate for Payer: UHC All Payor (Choice/PPO)	$31.30
Rate for Payer: UHC Core	$25.09
Rate for Payer: UHC Exchange	$18.92

SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION

Facility

$69.92

Service Code	NDC 00338004304
Hospital Charge Code	7318
Hospital Revenue Code	250
Min. Negotiated Rate	$27.48
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna Medicare	$34.96
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: BCBS Complete	$27.97
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: MI Amish Medical Board Commercial	$55.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05
Rate for Payer: UHC All Payor (Choice/PPO)	$45.45
Rate for Payer: UHC Core	$36.43
Rate for Payer: UHC Exchange	$27.48

SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION

Facility

$69.92

Service Code	NDC 00338004304
Hospital Charge Code	7318
Hospital Revenue Code	250
Min. Negotiated Rate	$44.05
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05

SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION

Facility

$69.92

Service Code	NDC 338004304
Hospital Charge Code	7318
Hospital Revenue Code	250
Min. Negotiated Rate	$27.48
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna Medicare	$34.96
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: BCBS Complete	$27.97
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: MI Amish Medical Board Commercial	$55.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05
Rate for Payer: UHC All Payor (Choice/PPO)	$45.45
Rate for Payer: UHC Core	$36.43
Rate for Payer: UHC Exchange	$27.48

SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION (DOSE, ADMIN OVER & INDICATION REQUIRED)

Facility

$69.92

Service Code	NDC 338004304
Hospital Charge Code	301088
Hospital Revenue Code	250
Min. Negotiated Rate	$27.48
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna Medicare	$34.96
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: BCBS Complete	$27.97
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: MI Amish Medical Board Commercial	$55.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05
Rate for Payer: UHC All Payor (Choice/PPO)	$45.45
Rate for Payer: UHC Core	$36.43
Rate for Payer: UHC Exchange	$27.48

SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL

Facility

$6.08

Service Code	NDC 00904386575
Hospital Charge Code	29676
Hospital Revenue Code	637
Min. Negotiated Rate	$2.39
Max. Negotiated Rate	$5.47
Rate for Payer: Aetna Commercial	$5.17
Rate for Payer: Aetna Medicare	$3.04
Rate for Payer: Aetna New Business (MI Preferred)	$3.95
Rate for Payer: BCBS Complete	$2.43
Rate for Payer: Cash Price	$4.86
Rate for Payer: Cofinity Advantage	$4.26
Rate for Payer: Cofinity Commercial	$5.23
Rate for Payer: Encore Health Key Benefits Commercial	$4.86
Rate for Payer: Healthscope Commercial	$5.47
Rate for Payer: MI Amish Medical Board Commercial	$4.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.17
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.56
Rate for Payer: PHP Commercial	$5.17
Rate for Payer: Priority Health SBD	$3.83
Rate for Payer: UHC All Payor (Choice/PPO)	$3.95
Rate for Payer: UHC Core	$3.17
Rate for Payer: UHC Exchange	$2.39

SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL

Facility

$6.08

Service Code	NDC 00904386575
Hospital Charge Code	29676
Hospital Revenue Code	637
Min. Negotiated Rate	$3.83
Max. Negotiated Rate	$5.47
Rate for Payer: Aetna Commercial	$5.17
Rate for Payer: Aetna New Business (MI Preferred)	$3.95
Rate for Payer: Cash Price	$4.86
Rate for Payer: Cofinity Advantage	$4.26
Rate for Payer: Cofinity Commercial	$5.23
Rate for Payer: Encore Health Key Benefits Commercial	$4.86
Rate for Payer: Healthscope Commercial	$5.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$5.17
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.56
Rate for Payer: PHP Commercial	$5.17
Rate for Payer: Priority Health SBD	$3.83

SODIUM CHLORIDE 0.9 % FLUSH SOLUTION 100 ML BAG

Facility

$62.71

Service Code	HCPCS J7040
Hospital Charge Code	300165
Hospital Revenue Code	636
Min. Negotiated Rate	$2.13
Max. Negotiated Rate	$56.44
Rate for Payer: Aetna Commercial	$53.30
Rate for Payer: Aetna Medicare	$31.36
Rate for Payer: Aetna New Business (MI Preferred)	$40.76
Rate for Payer: BCBS Complete	$25.08
Rate for Payer: BCBS Trust/PPO	$3.23
Rate for Payer: BCN Commercial	$3.23
Rate for Payer: Cash Price	$50.17
Rate for Payer: Cash Price	$50.17
Rate for Payer: Cofinity Advantage	$43.90
Rate for Payer: Cofinity Commercial	$53.93
Rate for Payer: Encore Health Key Benefits Commercial	$50.17
Rate for Payer: Healthscope Commercial	$56.44
Rate for Payer: MI Amish Medical Board Commercial	$50.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.30
Rate for Payer: Opus (Opus Packaging Group) HMA	$47.03
Rate for Payer: PHP Commercial	$53.30
Rate for Payer: Priority Health SBD	$39.51
Rate for Payer: UHC All Payor (Choice/PPO)	$2.13
Rate for Payer: UHC Core	$2.13
Rate for Payer: UHC Exchange	$2.13

SODIUM CHLORIDE 0.9 % FLUSH SOLUTION 100 ML BAG

Facility

$62.71

Service Code	HCPCS J7040
Hospital Charge Code	300165
Hospital Revenue Code	636
Min. Negotiated Rate	$39.51
Max. Negotiated Rate	$56.44
Rate for Payer: Aetna Commercial	$53.30
Rate for Payer: Aetna New Business (MI Preferred)	$40.76
Rate for Payer: Cash Price	$50.17
Rate for Payer: Cofinity Advantage	$43.90
Rate for Payer: Cofinity Commercial	$53.93
Rate for Payer: Encore Health Key Benefits Commercial	$50.17
Rate for Payer: Healthscope Commercial	$56.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.30
Rate for Payer: Opus (Opus Packaging Group) HMA	$47.03
Rate for Payer: PHP Commercial	$53.30
Rate for Payer: Priority Health SBD	$39.51

SODIUM CHLORIDE 0.9 % FOR AMNIOINFUSION (OB)

Facility

$69.92

Service Code	HCPCS J7030
Hospital Charge Code	158683
Hospital Revenue Code	636
Min. Negotiated Rate	$44.05
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05

SODIUM CHLORIDE 0.9 % FOR AMNIOINFUSION (OB)

Facility

$69.92

Service Code	HCPCS J7030
Hospital Charge Code	158683
Hospital Revenue Code	636
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$62.93
Rate for Payer: Aetna Commercial	$59.43
Rate for Payer: Aetna Medicare	$34.96
Rate for Payer: Aetna New Business (MI Preferred)	$45.45
Rate for Payer: BCBS Complete	$27.97
Rate for Payer: BCBS Trust/PPO	$4.97
Rate for Payer: BCN Commercial	$4.97
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cash Price	$55.94
Rate for Payer: Cofinity Advantage	$48.94
Rate for Payer: Cofinity Commercial	$60.13
Rate for Payer: Encore Health Key Benefits Commercial	$55.94
Rate for Payer: Healthscope Commercial	$62.93
Rate for Payer: MI Amish Medical Board Commercial	$55.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$59.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$52.44
Rate for Payer: PHP Commercial	$59.43
Rate for Payer: Priority Health SBD	$44.05
Rate for Payer: UHC All Payor (Choice/PPO)	$3.28
Rate for Payer: UHC Core	$3.28
Rate for Payer: UHC Exchange	$3.28

SODIUM CHLORIDE 0.9 % FOR NEBULIZATION

Facility

$3.14

Service Code	NDC 00378698501
Hospital Charge Code	7325
Hospital Revenue Code	250
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$2.83
Rate for Payer: Aetna Commercial	$2.67
Rate for Payer: Aetna Medicare	$1.57
Rate for Payer: Aetna New Business (MI Preferred)	$2.04
Rate for Payer: BCBS Complete	$1.26
Rate for Payer: Cash Price	$2.51
Rate for Payer: Cofinity Advantage	$2.20
Rate for Payer: Cofinity Commercial	$2.70
Rate for Payer: Encore Health Key Benefits Commercial	$2.51
Rate for Payer: Healthscope Commercial	$2.83
Rate for Payer: MI Amish Medical Board Commercial	$2.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.67
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.35
Rate for Payer: PHP Commercial	$2.67
Rate for Payer: Priority Health SBD	$1.98
Rate for Payer: UHC All Payor (Choice/PPO)	$2.04
Rate for Payer: UHC Core	$1.64
Rate for Payer: UHC Exchange	$1.23

Know your out-of-pocket cost for care.

All Charges