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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

sodium bicarbonate 650 mg Tab [HMC]

Facility

OP

$5.61

Service Code	NDC 77333083110
Hospital Charge Code	3800087
Hospital Revenue Code	250
Min. Negotiated Rate	$2.24
Max. Negotiated Rate	$5.33
Rate for Payer: Aetna Commercial	$5.05
Rate for Payer: Humana Medicare Advantage	$2.36
Rate for Payer: UnitedHealthcare Commercial	$5.33
Rate for Payer: UnitedHealthcare Medicaid	$2.24
Rate for Payer: WPPA Medicare Advantage	$3.37

sodium bicarbonate 650 mg Tab [HMC]

Facility

IP

$5.61

Service Code	NDC 77333082710
Hospital Charge Code	3800087
Hospital Revenue Code	250
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.05
Rate for Payer: UnitedHealthcare Commercial	$5.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium bicarbonate 650 mg Tab [HMC]

Facility

IP

$5.16

Service Code	NDC 00223172101
Hospital Charge Code	3800087
Hospital Revenue Code	250
Min. Negotiated Rate	$4.64
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$4.64
Rate for Payer: UnitedHealthcare Commercial	$4.90
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium bicarbonate 650 mg Tab [HMC]

Facility

IP

$5.61

Service Code	NDC 77333083110
Hospital Charge Code	3800087
Hospital Revenue Code	250
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.05
Rate for Payer: UnitedHealthcare Commercial	$5.33
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium bicarbonate 8.4% IV Sol 10 mL [HMC]

Facility

OP

$53.72

Service Code	NDC 00409490034
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$21.49
Max. Negotiated Rate	$51.03
Rate for Payer: Aetna Commercial	$48.35
Rate for Payer: Humana Medicare Advantage	$22.56
Rate for Payer: UnitedHealthcare Commercial	$51.03
Rate for Payer: UnitedHealthcare Medicaid	$21.49
Rate for Payer: WPPA Medicare Advantage	$32.23

sodium bicarbonate 8.4% IV Sol 10 mL [HMC]

Facility

IP

$53.72

Service Code	NDC 00409490034
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$48.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$48.35
Rate for Payer: UnitedHealthcare Commercial	$51.03
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium bicarbonate 8.4% IV Sol 50 mL [HMC]

Facility

OP

$25.75

Service Code	NDC 51754500104
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$24.46
Rate for Payer: Aetna Commercial	$23.18
Rate for Payer: Humana Medicare Advantage	$10.81
Rate for Payer: UnitedHealthcare Commercial	$24.46
Rate for Payer: UnitedHealthcare Medicaid	$10.30
Rate for Payer: WPPA Medicare Advantage	$15.45

sodium bicarbonate 8.4% IV Sol 50 mL [HMC]

Facility

IP

$25.75

Service Code	NDC 51754500104
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$23.18
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$23.18
Rate for Payer: UnitedHealthcare Commercial	$24.46
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium bicarbonate 8.4% IV Sol 50 mL [HMC]

Facility

OP

$41.07

Service Code	NDC 00409663714
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$16.43
Max. Negotiated Rate	$39.02
Rate for Payer: Aetna Commercial	$36.96
Rate for Payer: Humana Medicare Advantage	$17.25
Rate for Payer: UnitedHealthcare Commercial	$39.02
Rate for Payer: UnitedHealthcare Medicaid	$16.43
Rate for Payer: WPPA Medicare Advantage	$24.64

sodium bicarbonate 8.4% IV Sol 50 mL [HMC]

Facility

OP

$27.70

Service Code	NDC 00409662514
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$11.08
Max. Negotiated Rate	$26.32
Rate for Payer: Aetna Commercial	$24.93
Rate for Payer: Humana Medicare Advantage	$11.63
Rate for Payer: UnitedHealthcare Commercial	$26.32
Rate for Payer: UnitedHealthcare Medicaid	$11.08
Rate for Payer: WPPA Medicare Advantage	$16.62

sodium bicarbonate 8.4% IV Sol 50 mL [HMC]

Facility

OP

$50.24

Service Code	NDC 63323008950
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$20.10
Max. Negotiated Rate	$47.73
Rate for Payer: Aetna Commercial	$45.22
Rate for Payer: Humana Medicare Advantage	$21.10
Rate for Payer: UnitedHealthcare Commercial	$47.73
Rate for Payer: UnitedHealthcare Medicaid	$20.10
Rate for Payer: WPPA Medicare Advantage	$30.14

sodium bicarbonate 8.4% IV Sol 50 mL [HMC]

Facility

OP

$29.49

Service Code	NDC 00409663734
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$11.80
Max. Negotiated Rate	$28.02
Rate for Payer: Aetna Commercial	$26.54
Rate for Payer: Humana Medicare Advantage	$12.39
Rate for Payer: UnitedHealthcare Commercial	$28.02
Rate for Payer: UnitedHealthcare Medicaid	$11.80
Rate for Payer: WPPA Medicare Advantage	$17.69

sodium bicarbonate 8.4% IV Sol 50 mL [HMC]

Facility

OP

$39.03

Service Code	NDC 76329335201
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$15.61
Max. Negotiated Rate	$37.08
Rate for Payer: Aetna Commercial	$35.13
Rate for Payer: Humana Medicare Advantage	$16.39
Rate for Payer: UnitedHealthcare Commercial	$37.08
Rate for Payer: UnitedHealthcare Medicaid	$15.61
Rate for Payer: WPPA Medicare Advantage	$23.42

sodium bicarbonate 8.4% IV Sol 50 mL [HMC]

Facility

IP

$50.24

Service Code	NDC 63323008950
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$45.22
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$45.22
Rate for Payer: UnitedHealthcare Commercial	$47.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium bicarbonate 8.4% IV Sol 50 mL [HMC]

Facility

IP

$39.03

Service Code	NDC 76329335201
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$35.13
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.13
Rate for Payer: UnitedHealthcare Commercial	$37.08
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium bicarbonate 8.4% IV Sol 50 mL [HMC]

Facility

IP

$41.07

Service Code	NDC 00409663714
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$36.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$36.96
Rate for Payer: UnitedHealthcare Commercial	$39.02
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium bicarbonate 8.4% IV Sol 50 mL [HMC]

Facility

IP

$29.49

Service Code	NDC 00409663734
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$26.54
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$26.54
Rate for Payer: UnitedHealthcare Commercial	$28.02
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium bicarbonate 8.4% IV Sol 50 mL [HMC]

Facility

IP

$27.70

Service Code	NDC 00409662514
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$24.93
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.93
Rate for Payer: UnitedHealthcare Commercial	$26.32
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium bicarbonate 8.4% Sol

Facility

IP

$45.30

Service Code	NDC 70095005003
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$40.77
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$40.77
Rate for Payer: UnitedHealthcare Commercial	$43.03
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium bicarbonate 8.4% Sol

Facility

OP

$45.30

Service Code	NDC 70095005003
Hospital Charge Code	3807183
Hospital Revenue Code	250
Min. Negotiated Rate	$18.12
Max. Negotiated Rate	$43.03
Rate for Payer: Aetna Commercial	$40.77
Rate for Payer: Humana Medicare Advantage	$19.03
Rate for Payer: UnitedHealthcare Commercial	$43.03
Rate for Payer: UnitedHealthcare Medicaid	$18.12
Rate for Payer: WPPA Medicare Advantage	$27.18

sodium biphosphate-sodium phosphate 19 g-7 g Rectal Enema 133 mL [HMC]

Facility

IP

$21.92

Service Code	NDC 00132020145
Hospital Charge Code	3250920
Hospital Revenue Code	250
Min. Negotiated Rate	$19.73
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$19.73
Rate for Payer: UnitedHealthcare Commercial	$20.82
Rate for Payer: WPPA Medicare Advantage	$1,200.00

sodium biphosphate-sodium phosphate 19 g-7 g Rectal Enema 133 mL [HMC]

Facility

OP

$21.92

Service Code	NDC 00132020145
Hospital Charge Code	3250920
Hospital Revenue Code	250
Min. Negotiated Rate	$8.77
Max. Negotiated Rate	$20.82
Rate for Payer: Aetna Commercial	$19.73
Rate for Payer: Humana Medicare Advantage	$9.21
Rate for Payer: UnitedHealthcare Commercial	$20.82
Rate for Payer: UnitedHealthcare Medicaid	$8.77
Rate for Payer: WPPA Medicare Advantage	$13.15

Sodium Chloride 0.45% IV Sol 1000 mL [HMC]

Facility

OP

$40.83

Service Code	NDC 00409798509
Hospital Charge Code	3254005
Hospital Revenue Code	250
Min. Negotiated Rate	$16.33
Max. Negotiated Rate	$38.79
Rate for Payer: Aetna Commercial	$36.75
Rate for Payer: Humana Medicare Advantage	$17.15
Rate for Payer: UnitedHealthcare Commercial	$38.79
Rate for Payer: UnitedHealthcare Medicaid	$16.33
Rate for Payer: WPPA Medicare Advantage	$24.50

Sodium Chloride 0.45% IV Sol 1000 mL [HMC]

Facility

OP

$39.68

Service Code	NDC 00990798509
Hospital Charge Code	3254005
Hospital Revenue Code	250
Min. Negotiated Rate	$15.87
Max. Negotiated Rate	$37.70
Rate for Payer: Aetna Commercial	$35.71
Rate for Payer: Humana Medicare Advantage	$16.67
Rate for Payer: UnitedHealthcare Commercial	$37.70
Rate for Payer: UnitedHealthcare Medicaid	$15.87
Rate for Payer: WPPA Medicare Advantage	$23.81

Sodium Chloride 0.45% IV Sol 1000 mL [HMC]

Facility

IP

$39.68

Service Code	NDC 00990798509
Hospital Charge Code	3254005
Hospital Revenue Code	250
Min. Negotiated Rate	$35.71
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$35.71
Rate for Payer: UnitedHealthcare Commercial	$37.70
Rate for Payer: WPPA Medicare Advantage	$1,200.00

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