Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE

Facility

$5,207.85

Service Code	CPT 44364
Hospital Revenue Code	360
Min. Negotiated Rate	$991.65
Max. Negotiated Rate	$5,207.85
Rate for Payer: Aetna Medicare	$1,924.10
Rate for Payer: Allen County Amish Medical Aid Commercial	$2,312.62
Rate for Payer: Amish Plain Church Group Commercial	$2,312.62
Rate for Payer: BCBS Complete	$1,041.24
Rate for Payer: BCBS MAPPO	$1,850.10
Rate for Payer: BCN Medicare Advantage	$1,850.10
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,850.10
Rate for Payer: Mclaren Medicaid	$991.65
Rate for Payer: Mclaren Medicare	$1,850.10
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,942.61
Rate for Payer: Meridian Medicaid	$1,041.24
Rate for Payer: MI Amish Medical Board Commercial	$2,127.61
Rate for Payer: PACE Medicare	$1,757.60
Rate for Payer: PACE SWMI	$1,850.10
Rate for Payer: PHP Medicare Advantage	$1,850.10
Rate for Payer: Priority Health Choice Medicaid	$991.65
Rate for Payer: Priority Health Medicare	$1,850.10
Rate for Payer: Railroad Medicare Medicare	$1,850.10
Rate for Payer: UHC All Payor (Choice/PPO)	$5,207.85
Rate for Payer: UHC Dual Complete DSNP	$1,850.10
Rate for Payer: UHC Medicare Advantage	$1,850.10
Rate for Payer: UHCCP Medicaid	$1,041.61
Rate for Payer: VA VA	$1,850.10

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$21.61

Service Code	NDC 00409729973
Hospital Charge Code	7301
Hospital Revenue Code	250
Min. Negotiated Rate	$13.61
Max. Negotiated Rate	$19.45
Rate for Payer: Aetna Commercial	$18.37
Rate for Payer: Aetna New Business (MI Preferred)	$14.05
Rate for Payer: Cash Price	$17.29
Rate for Payer: Cofinity Commercial	$15.13
Rate for Payer: Cofinity Commercial	$18.58
Rate for Payer: Cofinity Medicare Advantage	$15.13
Rate for Payer: Encore Health Key Benefits Commercial	$17.29
Rate for Payer: Healthscope Commercial	$19.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.37
Rate for Payer: PHP Commercial	$18.37
Rate for Payer: Priority Health Cigna Priority Health	$14.05
Rate for Payer: Priority Health SBD	$13.61

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$21.61

Service Code	NDC 00409729973
Hospital Charge Code	7301
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$19.45
Rate for Payer: Aetna Commercial	$18.37
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: Aetna New Business (MI Preferred)	$14.05
Rate for Payer: BCBS Complete	$8.64
Rate for Payer: Cash Price	$17.29
Rate for Payer: Cofinity Commercial	$15.13
Rate for Payer: Cofinity Commercial	$18.58
Rate for Payer: Cofinity Medicare Advantage	$15.13
Rate for Payer: Encore Health Key Benefits Commercial	$17.29
Rate for Payer: Healthscope Commercial	$19.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.37
Rate for Payer: PHP Commercial	$18.37
Rate for Payer: Priority Health Cigna Priority Health	$14.05
Rate for Payer: Priority Health SBD	$13.61

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$21.61

Service Code	NDC 00409729983
Hospital Charge Code	7301
Hospital Revenue Code	250
Min. Negotiated Rate	$8.64
Max. Negotiated Rate	$19.45
Rate for Payer: Aetna Commercial	$18.37
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: Aetna New Business (MI Preferred)	$14.05
Rate for Payer: BCBS Complete	$8.64
Rate for Payer: Cash Price	$17.29
Rate for Payer: Cofinity Commercial	$15.13
Rate for Payer: Cofinity Commercial	$18.58
Rate for Payer: Cofinity Medicare Advantage	$15.13
Rate for Payer: Encore Health Key Benefits Commercial	$17.29
Rate for Payer: Healthscope Commercial	$19.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.37
Rate for Payer: PHP Commercial	$18.37
Rate for Payer: Priority Health Cigna Priority Health	$14.05
Rate for Payer: Priority Health SBD	$13.61

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$26.26

Service Code	NDC 00409329906
Hospital Charge Code	7301
Hospital Revenue Code	250
Min. Negotiated Rate	$16.54
Max. Negotiated Rate	$23.63
Rate for Payer: Aetna Commercial	$22.32
Rate for Payer: Aetna New Business (MI Preferred)	$17.07
Rate for Payer: Cash Price	$21.01
Rate for Payer: Cofinity Commercial	$18.38
Rate for Payer: Cofinity Commercial	$22.58
Rate for Payer: Cofinity Medicare Advantage	$18.38
Rate for Payer: Encore Health Key Benefits Commercial	$21.01
Rate for Payer: Healthscope Commercial	$23.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.32
Rate for Payer: PHP Commercial	$22.32
Rate for Payer: Priority Health Cigna Priority Health	$17.07
Rate for Payer: Priority Health SBD	$16.54

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$19.14

Service Code	NDC 00409329915
Hospital Charge Code	7301
Hospital Revenue Code	250
Min. Negotiated Rate	$7.66
Max. Negotiated Rate	$17.23
Rate for Payer: Aetna Commercial	$16.27
Rate for Payer: Aetna Medicare	$9.57
Rate for Payer: Aetna New Business (MI Preferred)	$12.44
Rate for Payer: BCBS Complete	$7.66
Rate for Payer: Cash Price	$15.31
Rate for Payer: Cofinity Commercial	$13.40
Rate for Payer: Cofinity Commercial	$16.46
Rate for Payer: Cofinity Medicare Advantage	$13.40
Rate for Payer: Encore Health Key Benefits Commercial	$15.31
Rate for Payer: Healthscope Commercial	$17.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.27
Rate for Payer: PHP Commercial	$16.27
Rate for Payer: Priority Health Cigna Priority Health	$12.44
Rate for Payer: Priority Health SBD	$12.06

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$19.14

Service Code	NDC 00409329915
Hospital Charge Code	7301
Hospital Revenue Code	250
Min. Negotiated Rate	$12.06
Max. Negotiated Rate	$17.23
Rate for Payer: Aetna Commercial	$16.27
Rate for Payer: Aetna New Business (MI Preferred)	$12.44
Rate for Payer: Cash Price	$15.31
Rate for Payer: Cofinity Commercial	$13.40
Rate for Payer: Cofinity Commercial	$16.46
Rate for Payer: Cofinity Medicare Advantage	$13.40
Rate for Payer: Encore Health Key Benefits Commercial	$15.31
Rate for Payer: Healthscope Commercial	$17.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.27
Rate for Payer: PHP Commercial	$16.27
Rate for Payer: Priority Health Cigna Priority Health	$12.44
Rate for Payer: Priority Health SBD	$12.06

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$26.26

Service Code	NDC 00409329906
Hospital Charge Code	7301
Hospital Revenue Code	250
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$23.63
Rate for Payer: Aetna Commercial	$22.32
Rate for Payer: Aetna Medicare	$13.13
Rate for Payer: Aetna New Business (MI Preferred)	$17.07
Rate for Payer: BCBS Complete	$10.50
Rate for Payer: Cash Price	$21.01
Rate for Payer: Cofinity Commercial	$18.38
Rate for Payer: Cofinity Commercial	$22.58
Rate for Payer: Cofinity Medicare Advantage	$18.38
Rate for Payer: Encore Health Key Benefits Commercial	$21.01
Rate for Payer: Healthscope Commercial	$23.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.32
Rate for Payer: PHP Commercial	$22.32
Rate for Payer: Priority Health Cigna Priority Health	$17.07
Rate for Payer: Priority Health SBD	$16.54

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$21.61

Service Code	NDC 00409729983
Hospital Charge Code	7301
Hospital Revenue Code	250
Min. Negotiated Rate	$13.61
Max. Negotiated Rate	$19.45
Rate for Payer: Aetna Commercial	$18.37
Rate for Payer: Aetna New Business (MI Preferred)	$14.05
Rate for Payer: Cash Price	$17.29
Rate for Payer: Cofinity Commercial	$15.13
Rate for Payer: Cofinity Commercial	$18.58
Rate for Payer: Cofinity Medicare Advantage	$15.13
Rate for Payer: Encore Health Key Benefits Commercial	$17.29
Rate for Payer: Healthscope Commercial	$19.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.37
Rate for Payer: PHP Commercial	$18.37
Rate for Payer: Priority Health Cigna Priority Health	$14.05
Rate for Payer: Priority Health SBD	$13.61

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$19.14

Service Code	NDC 00409329905
Hospital Charge Code	7301
Hospital Revenue Code	250
Min. Negotiated Rate	$7.66
Max. Negotiated Rate	$17.23
Rate for Payer: Aetna Commercial	$16.27
Rate for Payer: Aetna Medicare	$9.57
Rate for Payer: Aetna New Business (MI Preferred)	$12.44
Rate for Payer: BCBS Complete	$7.66
Rate for Payer: Cash Price	$15.31
Rate for Payer: Cofinity Commercial	$13.40
Rate for Payer: Cofinity Commercial	$16.46
Rate for Payer: Cofinity Medicare Advantage	$13.40
Rate for Payer: Encore Health Key Benefits Commercial	$15.31
Rate for Payer: Healthscope Commercial	$17.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.27
Rate for Payer: PHP Commercial	$16.27
Rate for Payer: Priority Health Cigna Priority Health	$12.44
Rate for Payer: Priority Health SBD	$12.06

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION

Facility

$19.14

Service Code	NDC 00409329905
Hospital Charge Code	7301
Hospital Revenue Code	250
Min. Negotiated Rate	$12.06
Max. Negotiated Rate	$17.23
Rate for Payer: Aetna Commercial	$16.27
Rate for Payer: Aetna New Business (MI Preferred)	$12.44
Rate for Payer: Cash Price	$15.31
Rate for Payer: Cofinity Commercial	$13.40
Rate for Payer: Cofinity Commercial	$16.46
Rate for Payer: Cofinity Medicare Advantage	$13.40
Rate for Payer: Encore Health Key Benefits Commercial	$15.31
Rate for Payer: Healthscope Commercial	$17.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.27
Rate for Payer: PHP Commercial	$16.27
Rate for Payer: Priority Health Cigna Priority Health	$12.44
Rate for Payer: Priority Health SBD	$12.06

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION (TPN COMPONENT)

Facility

$64.97

Service Code	NDC 09900001916
Hospital Charge Code	300441
Hospital Revenue Code	250
Min. Negotiated Rate	$40.93
Max. Negotiated Rate	$58.47
Rate for Payer: Aetna Commercial	$55.22
Rate for Payer: Aetna New Business (MI Preferred)	$42.23
Rate for Payer: Cash Price	$51.98
Rate for Payer: Cofinity Commercial	$45.48
Rate for Payer: Cofinity Commercial	$55.87
Rate for Payer: Cofinity Medicare Advantage	$45.48
Rate for Payer: Encore Health Key Benefits Commercial	$51.98
Rate for Payer: Healthscope Commercial	$58.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$55.22
Rate for Payer: PHP Commercial	$55.22
Rate for Payer: Priority Health Cigna Priority Health	$42.23
Rate for Payer: Priority Health SBD	$40.93

SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION (TPN COMPONENT)

Facility

$64.97

Service Code	NDC 09900001916
Hospital Charge Code	300441
Hospital Revenue Code	250
Min. Negotiated Rate	$25.99
Max. Negotiated Rate	$58.47
Rate for Payer: Aetna Commercial	$55.22
Rate for Payer: Aetna Medicare	$32.48
Rate for Payer: Aetna New Business (MI Preferred)	$42.23
Rate for Payer: BCBS Complete	$25.99
Rate for Payer: Cash Price	$51.98
Rate for Payer: Cofinity Commercial	$45.48
Rate for Payer: Cofinity Commercial	$55.87
Rate for Payer: Cofinity Medicare Advantage	$45.48
Rate for Payer: Encore Health Key Benefits Commercial	$51.98
Rate for Payer: Healthscope Commercial	$58.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$55.22
Rate for Payer: PHP Commercial	$55.22
Rate for Payer: Priority Health Cigna Priority Health	$42.23
Rate for Payer: Priority Health SBD	$40.93

SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION

Facility

$102.80

Service Code	NDC 63323008950
Hospital Charge Code	108819
Hospital Revenue Code	250
Min. Negotiated Rate	$41.12
Max. Negotiated Rate	$92.52
Rate for Payer: Aetna Commercial	$87.38
Rate for Payer: Aetna Medicare	$51.40
Rate for Payer: Aetna New Business (MI Preferred)	$66.82
Rate for Payer: BCBS Complete	$41.12
Rate for Payer: Cash Price	$82.24
Rate for Payer: Cofinity Commercial	$71.96
Rate for Payer: Cofinity Commercial	$88.41
Rate for Payer: Cofinity Medicare Advantage	$71.96
Rate for Payer: Encore Health Key Benefits Commercial	$82.24
Rate for Payer: Healthscope Commercial	$92.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$87.38
Rate for Payer: PHP Commercial	$87.38
Rate for Payer: Priority Health Cigna Priority Health	$66.82
Rate for Payer: Priority Health SBD	$64.76

SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION

Facility

$22.70

Service Code	NDC 51754500101
Hospital Charge Code	108819
Hospital Revenue Code	250
Min. Negotiated Rate	$14.30
Max. Negotiated Rate	$20.43
Rate for Payer: Aetna Commercial	$19.30
Rate for Payer: Aetna New Business (MI Preferred)	$14.76
Rate for Payer: Cash Price	$18.16
Rate for Payer: Cofinity Commercial	$15.89
Rate for Payer: Cofinity Commercial	$19.52
Rate for Payer: Cofinity Medicare Advantage	$15.89
Rate for Payer: Encore Health Key Benefits Commercial	$18.16
Rate for Payer: Healthscope Commercial	$20.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.30
Rate for Payer: PHP Commercial	$19.30
Rate for Payer: Priority Health Cigna Priority Health	$14.76
Rate for Payer: Priority Health SBD	$14.30

SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION

Facility

$35.60

Service Code	NDC 00409662514
Hospital Charge Code	108819
Hospital Revenue Code	250
Min. Negotiated Rate	$22.43
Max. Negotiated Rate	$32.04
Rate for Payer: Aetna Commercial	$30.26
Rate for Payer: Aetna New Business (MI Preferred)	$23.14
Rate for Payer: Cash Price	$28.48
Rate for Payer: Cofinity Commercial	$24.92
Rate for Payer: Cofinity Commercial	$30.62
Rate for Payer: Cofinity Medicare Advantage	$24.92
Rate for Payer: Encore Health Key Benefits Commercial	$28.48
Rate for Payer: Healthscope Commercial	$32.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$30.26
Rate for Payer: PHP Commercial	$30.26
Rate for Payer: Priority Health Cigna Priority Health	$23.14
Rate for Payer: Priority Health SBD	$22.43

SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION

Facility

$23.81

Service Code	NDC 51754500105
Hospital Charge Code	108819
Hospital Revenue Code	250
Min. Negotiated Rate	$9.52
Max. Negotiated Rate	$21.43
Rate for Payer: Aetna Commercial	$20.24
Rate for Payer: Aetna Medicare	$11.90
Rate for Payer: Aetna New Business (MI Preferred)	$15.48
Rate for Payer: BCBS Complete	$9.52
Rate for Payer: Cash Price	$19.05
Rate for Payer: Cofinity Commercial	$16.67
Rate for Payer: Cofinity Commercial	$20.48
Rate for Payer: Cofinity Medicare Advantage	$16.67
Rate for Payer: Encore Health Key Benefits Commercial	$19.05
Rate for Payer: Healthscope Commercial	$21.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.24
Rate for Payer: PHP Commercial	$20.24
Rate for Payer: Priority Health Cigna Priority Health	$15.48
Rate for Payer: Priority Health SBD	$15.00

SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION

Facility

$102.80

Service Code	NDC 63323008950
Hospital Charge Code	108819
Hospital Revenue Code	250
Min. Negotiated Rate	$64.76
Max. Negotiated Rate	$92.52
Rate for Payer: Aetna Commercial	$87.38
Rate for Payer: Aetna New Business (MI Preferred)	$66.82
Rate for Payer: Cash Price	$82.24
Rate for Payer: Cofinity Commercial	$71.96
Rate for Payer: Cofinity Commercial	$88.41
Rate for Payer: Cofinity Medicare Advantage	$71.96
Rate for Payer: Encore Health Key Benefits Commercial	$82.24
Rate for Payer: Healthscope Commercial	$92.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$87.38
Rate for Payer: PHP Commercial	$87.38
Rate for Payer: Priority Health Cigna Priority Health	$66.82
Rate for Payer: Priority Health SBD	$64.76

SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION

Facility

$23.81

Service Code	NDC 51754500105
Hospital Charge Code	108819
Hospital Revenue Code	250
Min. Negotiated Rate	$15.00
Max. Negotiated Rate	$21.43
Rate for Payer: Aetna Commercial	$20.24
Rate for Payer: Aetna New Business (MI Preferred)	$15.48
Rate for Payer: Cash Price	$19.05
Rate for Payer: Cofinity Commercial	$16.67
Rate for Payer: Cofinity Commercial	$20.48
Rate for Payer: Cofinity Medicare Advantage	$16.67
Rate for Payer: Encore Health Key Benefits Commercial	$19.05
Rate for Payer: Healthscope Commercial	$21.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.24
Rate for Payer: PHP Commercial	$20.24
Rate for Payer: Priority Health Cigna Priority Health	$15.48
Rate for Payer: Priority Health SBD	$15.00

SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION

Facility

$35.60

Service Code	NDC 00409662522
Hospital Charge Code	108819
Hospital Revenue Code	250
Min. Negotiated Rate	$14.24
Max. Negotiated Rate	$32.04
Rate for Payer: Aetna Commercial	$30.26
Rate for Payer: Aetna Medicare	$17.80
Rate for Payer: Aetna New Business (MI Preferred)	$23.14
Rate for Payer: BCBS Complete	$14.24
Rate for Payer: Cash Price	$28.48
Rate for Payer: Cofinity Commercial	$24.92
Rate for Payer: Cofinity Commercial	$30.62
Rate for Payer: Cofinity Medicare Advantage	$24.92
Rate for Payer: Encore Health Key Benefits Commercial	$28.48
Rate for Payer: Healthscope Commercial	$32.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$30.26
Rate for Payer: PHP Commercial	$30.26
Rate for Payer: Priority Health Cigna Priority Health	$23.14
Rate for Payer: Priority Health SBD	$22.43

SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION

Facility

$35.60

Service Code	NDC 00409662514
Hospital Charge Code	108819
Hospital Revenue Code	250
Min. Negotiated Rate	$14.24
Max. Negotiated Rate	$32.04
Rate for Payer: Aetna Commercial	$30.26
Rate for Payer: Aetna Medicare	$17.80
Rate for Payer: Aetna New Business (MI Preferred)	$23.14
Rate for Payer: BCBS Complete	$14.24
Rate for Payer: Cash Price	$28.48
Rate for Payer: Cofinity Commercial	$24.92
Rate for Payer: Cofinity Commercial	$30.62
Rate for Payer: Cofinity Medicare Advantage	$24.92
Rate for Payer: Encore Health Key Benefits Commercial	$28.48
Rate for Payer: Healthscope Commercial	$32.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$30.26
Rate for Payer: PHP Commercial	$30.26
Rate for Payer: Priority Health Cigna Priority Health	$23.14
Rate for Payer: Priority Health SBD	$22.43

SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION

Facility

$35.60

Service Code	NDC 00409662522
Hospital Charge Code	108819
Hospital Revenue Code	250
Min. Negotiated Rate	$22.43
Max. Negotiated Rate	$32.04
Rate for Payer: Aetna Commercial	$30.26
Rate for Payer: Aetna New Business (MI Preferred)	$23.14
Rate for Payer: Cash Price	$28.48
Rate for Payer: Cofinity Commercial	$24.92
Rate for Payer: Cofinity Commercial	$30.62
Rate for Payer: Cofinity Medicare Advantage	$24.92
Rate for Payer: Encore Health Key Benefits Commercial	$28.48
Rate for Payer: Healthscope Commercial	$32.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$30.26
Rate for Payer: PHP Commercial	$30.26
Rate for Payer: Priority Health Cigna Priority Health	$23.14
Rate for Payer: Priority Health SBD	$22.43

SODIUM BICARBONATE 1 MEQ/ML (8.4 %) INTRAVENOUS SOLUTION

Facility

$22.70

Service Code	NDC 51754500101
Hospital Charge Code	108819
Hospital Revenue Code	250
Min. Negotiated Rate	$9.08
Max. Negotiated Rate	$20.43
Rate for Payer: Aetna Commercial	$19.30
Rate for Payer: Aetna Medicare	$11.35
Rate for Payer: Aetna New Business (MI Preferred)	$14.76
Rate for Payer: BCBS Complete	$9.08
Rate for Payer: Cash Price	$18.16
Rate for Payer: Cofinity Commercial	$15.89
Rate for Payer: Cofinity Commercial	$19.52
Rate for Payer: Cofinity Medicare Advantage	$15.89
Rate for Payer: Encore Health Key Benefits Commercial	$18.16
Rate for Payer: Healthscope Commercial	$20.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.30
Rate for Payer: PHP Commercial	$19.30
Rate for Payer: Priority Health Cigna Priority Health	$14.76
Rate for Payer: Priority Health SBD	$14.30

SODIUM BICARBONATE 2485 MG-CITRIC ACID 1949 MG (PICOT) POWDER PACKET

Facility

$4.40

Service Code	NDC 64613004562
Hospital Charge Code	301795
Hospital Revenue Code	637
Min. Negotiated Rate	$2.77
Max. Negotiated Rate	$3.96
Rate for Payer: Aetna Commercial	$3.74
Rate for Payer: Aetna New Business (MI Preferred)	$2.86
Rate for Payer: Cash Price	$3.52
Rate for Payer: Cofinity Commercial	$3.08
Rate for Payer: Cofinity Commercial	$3.78
Rate for Payer: Cofinity Medicare Advantage	$3.08
Rate for Payer: Encore Health Key Benefits Commercial	$3.52
Rate for Payer: Healthscope Commercial	$3.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.74
Rate for Payer: PHP Commercial	$3.74
Rate for Payer: Priority Health Cigna Priority Health	$2.86
Rate for Payer: Priority Health SBD	$2.77

SODIUM BICARBONATE 2485 MG-CITRIC ACID 1949 MG (PICOT) POWDER PACKET

Facility

$4.40

Service Code	NDC 64613004562
Hospital Charge Code	301795
Hospital Revenue Code	637
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$3.96
Rate for Payer: Aetna Commercial	$3.74
Rate for Payer: Aetna Medicare	$2.20
Rate for Payer: Aetna New Business (MI Preferred)	$2.86
Rate for Payer: BCBS Complete	$1.76
Rate for Payer: Cash Price	$3.52
Rate for Payer: Cofinity Commercial	$3.08
Rate for Payer: Cofinity Commercial	$3.78
Rate for Payer: Cofinity Medicare Advantage	$3.08
Rate for Payer: Encore Health Key Benefits Commercial	$3.52
Rate for Payer: Healthscope Commercial	$3.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.74
Rate for Payer: PHP Commercial	$3.74
Rate for Payer: Priority Health Cigna Priority Health	$2.86
Rate for Payer: Priority Health SBD	$2.77

Know your out-of-pocket cost for care.

All Charges