Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) INTRAVENOUS SOLUTION

Facility

$15.00

Service Code	HCPCS A9585
Hospital Charge Code	152499
Hospital Revenue Code	636
Min. Negotiated Rate	$9.45
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna Commercial	$12.75
Rate for Payer: Aetna New Business (MI Preferred)	$9.75
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cofinity Commercial	$10.50
Rate for Payer: Cofinity Commercial	$12.90
Rate for Payer: Cofinity Medicare Advantage	$10.50
Rate for Payer: Encore Health Key Benefits Commercial	$12.00
Rate for Payer: Healthscope Commercial	$13.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.75
Rate for Payer: PHP Commercial	$12.75
Rate for Payer: Priority Health Cigna Priority Health	$9.75
Rate for Payer: Priority Health SBD	$9.45

GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) INTRAVENOUS SOLUTION

Facility

$15.00

Service Code	HCPCS A9585
Hospital Charge Code	152499
Hospital Revenue Code	636
Min. Negotiated Rate	$6.00
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna Commercial	$12.75
Rate for Payer: Aetna Medicare	$7.50
Rate for Payer: Aetna New Business (MI Preferred)	$9.75
Rate for Payer: BCBS Complete	$6.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cofinity Commercial	$10.50
Rate for Payer: Cofinity Commercial	$12.90
Rate for Payer: Cofinity Medicare Advantage	$10.50
Rate for Payer: Encore Health Key Benefits Commercial	$12.00
Rate for Payer: Healthscope Commercial	$13.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.75
Rate for Payer: PHP Commercial	$12.75
Rate for Payer: Priority Health Cigna Priority Health	$9.75
Rate for Payer: Priority Health SBD	$9.45

GADOPENTETATE DIMEGLUMINE 10 MMOL/20 ML(469.01 MG/ML) INTRAVENOUS SOLN

Facility

$77.62

Service Code	HCPCS A9579
Hospital Charge Code	118272
Hospital Revenue Code	636
Min. Negotiated Rate	$31.05
Max. Negotiated Rate	$69.86
Rate for Payer: Aetna Commercial	$65.98
Rate for Payer: Aetna Medicare	$38.81
Rate for Payer: Aetna New Business (MI Preferred)	$50.45
Rate for Payer: BCBS Complete	$31.05
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cofinity Commercial	$54.33
Rate for Payer: Cofinity Commercial	$66.75
Rate for Payer: Cofinity Medicare Advantage	$54.33
Rate for Payer: Encore Health Key Benefits Commercial	$62.10
Rate for Payer: Healthscope Commercial	$69.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$65.98
Rate for Payer: PHP Commercial	$65.98
Rate for Payer: Priority Health Cigna Priority Health	$50.45
Rate for Payer: Priority Health SBD	$48.90

GADOPENTETATE DIMEGLUMINE 10 MMOL/20 ML(469.01 MG/ML) INTRAVENOUS SOLN

Facility

$77.62

Service Code	HCPCS A9579
Hospital Charge Code	118272
Hospital Revenue Code	636
Min. Negotiated Rate	$48.90
Max. Negotiated Rate	$69.86
Rate for Payer: Aetna Commercial	$65.98
Rate for Payer: Aetna New Business (MI Preferred)	$50.45
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cofinity Commercial	$54.33
Rate for Payer: Cofinity Commercial	$66.75
Rate for Payer: Cofinity Medicare Advantage	$54.33
Rate for Payer: Encore Health Key Benefits Commercial	$62.10
Rate for Payer: Healthscope Commercial	$69.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$65.98
Rate for Payer: PHP Commercial	$65.98
Rate for Payer: Priority Health Cigna Priority Health	$50.45
Rate for Payer: Priority Health SBD	$48.90

GADOPENTETATE DIMEGLUMINE 2.5 MMOL/5 ML(469.01 MG/ML) INTRAVENOUS SOLN

Facility

$21.62

Service Code	HCPCS A9579
Hospital Charge Code	118269
Hospital Revenue Code	636
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$19.46
Rate for Payer: Aetna Commercial	$18.38
Rate for Payer: Aetna Medicare	$10.81
Rate for Payer: Aetna New Business (MI Preferred)	$14.05
Rate for Payer: BCBS Complete	$8.65
Rate for Payer: Cash Price	$17.30
Rate for Payer: Cofinity Commercial	$15.13
Rate for Payer: Cofinity Commercial	$18.59
Rate for Payer: Cofinity Medicare Advantage	$15.13
Rate for Payer: Encore Health Key Benefits Commercial	$17.30
Rate for Payer: Healthscope Commercial	$19.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.38
Rate for Payer: PHP Commercial	$18.38
Rate for Payer: Priority Health Cigna Priority Health	$14.05
Rate for Payer: Priority Health SBD	$13.62

GADOPENTETATE DIMEGLUMINE 2.5 MMOL/5 ML(469.01 MG/ML) INTRAVENOUS SOLN

Facility

$21.62

Service Code	HCPCS A9579
Hospital Charge Code	118269
Hospital Revenue Code	636
Min. Negotiated Rate	$13.62
Max. Negotiated Rate	$19.46
Rate for Payer: Aetna Commercial	$18.38
Rate for Payer: Aetna New Business (MI Preferred)	$14.05
Rate for Payer: Cash Price	$17.30
Rate for Payer: Cofinity Commercial	$15.13
Rate for Payer: Cofinity Commercial	$18.59
Rate for Payer: Cofinity Medicare Advantage	$15.13
Rate for Payer: Encore Health Key Benefits Commercial	$17.30
Rate for Payer: Healthscope Commercial	$19.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.38
Rate for Payer: PHP Commercial	$18.38
Rate for Payer: Priority Health Cigna Priority Health	$14.05
Rate for Payer: Priority Health SBD	$13.62

GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION

Facility

$631.68

Service Code	HCPCS A9581
Hospital Charge Code	93574
Hospital Revenue Code	636
Min. Negotiated Rate	$397.96
Max. Negotiated Rate	$568.51
Rate for Payer: Aetna Commercial	$536.93
Rate for Payer: Aetna New Business (MI Preferred)	$410.59
Rate for Payer: Cash Price	$505.34
Rate for Payer: Cofinity Commercial	$442.18
Rate for Payer: Cofinity Commercial	$543.24
Rate for Payer: Cofinity Medicare Advantage	$442.18
Rate for Payer: Encore Health Key Benefits Commercial	$505.34
Rate for Payer: Healthscope Commercial	$568.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$536.93
Rate for Payer: PHP Commercial	$536.93
Rate for Payer: Priority Health Cigna Priority Health	$410.59
Rate for Payer: Priority Health SBD	$397.96

GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION

Facility

$631.68

Service Code	HCPCS A9581
Hospital Charge Code	93574
Hospital Revenue Code	636
Min. Negotiated Rate	$252.67
Max. Negotiated Rate	$568.51
Rate for Payer: Aetna Commercial	$536.93
Rate for Payer: Aetna Medicare	$315.84
Rate for Payer: Aetna New Business (MI Preferred)	$410.59
Rate for Payer: BCBS Complete	$252.67
Rate for Payer: Cash Price	$505.34
Rate for Payer: Cofinity Commercial	$442.18
Rate for Payer: Cofinity Commercial	$543.24
Rate for Payer: Cofinity Medicare Advantage	$442.18
Rate for Payer: Encore Health Key Benefits Commercial	$505.34
Rate for Payer: Healthscope Commercial	$568.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$536.93
Rate for Payer: PHP Commercial	$536.93
Rate for Payer: Priority Health Cigna Priority Health	$410.59
Rate for Payer: Priority Health SBD	$397.96

GALANTAMINE 4 MG TABLET

Facility

$238.83

Service Code	NDC 70436000406
Hospital Charge Code	29806
Hospital Revenue Code	637
Min. Negotiated Rate	$150.46
Max. Negotiated Rate	$214.95
Rate for Payer: Aetna Commercial	$203.01
Rate for Payer: Aetna New Business (MI Preferred)	$155.24
Rate for Payer: Cash Price	$191.06
Rate for Payer: Cofinity Commercial	$167.18
Rate for Payer: Cofinity Commercial	$205.39
Rate for Payer: Cofinity Medicare Advantage	$167.18
Rate for Payer: Encore Health Key Benefits Commercial	$191.06
Rate for Payer: Healthscope Commercial	$214.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$203.01
Rate for Payer: PHP Commercial	$203.01
Rate for Payer: Priority Health Cigna Priority Health	$155.24
Rate for Payer: Priority Health SBD	$150.46

GALANTAMINE 4 MG TABLET

Facility

$12.05

Service Code	NDC 68084072911
Hospital Charge Code	29806
Hospital Revenue Code	637
Min. Negotiated Rate	$7.59
Max. Negotiated Rate	$10.85
Rate for Payer: Aetna Commercial	$10.24
Rate for Payer: Aetna New Business (MI Preferred)	$7.83
Rate for Payer: Cash Price	$9.64
Rate for Payer: Cofinity Commercial	$10.36
Rate for Payer: Cofinity Commercial	$8.44
Rate for Payer: Cofinity Medicare Advantage	$8.44
Rate for Payer: Encore Health Key Benefits Commercial	$9.64
Rate for Payer: Healthscope Commercial	$10.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.24
Rate for Payer: PHP Commercial	$10.24
Rate for Payer: Priority Health Cigna Priority Health	$7.83
Rate for Payer: Priority Health SBD	$7.59

GALANTAMINE 4 MG TABLET

Facility

$276.06

Service Code	NDC 51079085203
Hospital Charge Code	29806
Hospital Revenue Code	637
Min. Negotiated Rate	$110.42
Max. Negotiated Rate	$248.45
Rate for Payer: Aetna Commercial	$234.65
Rate for Payer: Aetna Medicare	$138.03
Rate for Payer: Aetna New Business (MI Preferred)	$179.44
Rate for Payer: BCBS Complete	$110.42
Rate for Payer: Cash Price	$220.85
Rate for Payer: Cofinity Commercial	$193.24
Rate for Payer: Cofinity Commercial	$237.41
Rate for Payer: Cofinity Medicare Advantage	$193.24
Rate for Payer: Encore Health Key Benefits Commercial	$220.85
Rate for Payer: Healthscope Commercial	$248.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$234.65
Rate for Payer: PHP Commercial	$234.65
Rate for Payer: Priority Health Cigna Priority Health	$179.44
Rate for Payer: Priority Health SBD	$173.92

GALANTAMINE 4 MG TABLET

Facility

$238.83

Service Code	NDC 70436000406
Hospital Charge Code	29806
Hospital Revenue Code	637
Min. Negotiated Rate	$95.53
Max. Negotiated Rate	$214.95
Rate for Payer: Aetna Commercial	$203.01
Rate for Payer: Aetna Medicare	$119.42
Rate for Payer: Aetna New Business (MI Preferred)	$155.24
Rate for Payer: BCBS Complete	$95.53
Rate for Payer: Cash Price	$191.06
Rate for Payer: Cofinity Commercial	$167.18
Rate for Payer: Cofinity Commercial	$205.39
Rate for Payer: Cofinity Medicare Advantage	$167.18
Rate for Payer: Encore Health Key Benefits Commercial	$191.06
Rate for Payer: Healthscope Commercial	$214.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$203.01
Rate for Payer: PHP Commercial	$203.01
Rate for Payer: Priority Health Cigna Priority Health	$155.24
Rate for Payer: Priority Health SBD	$150.46

GALANTAMINE 4 MG TABLET

Facility

$276.06

Service Code	NDC 51079085203
Hospital Charge Code	29806
Hospital Revenue Code	637
Min. Negotiated Rate	$173.92
Max. Negotiated Rate	$248.45
Rate for Payer: Aetna Commercial	$234.65
Rate for Payer: Aetna New Business (MI Preferred)	$179.44
Rate for Payer: Cash Price	$220.85
Rate for Payer: Cofinity Commercial	$193.24
Rate for Payer: Cofinity Commercial	$237.41
Rate for Payer: Cofinity Medicare Advantage	$193.24
Rate for Payer: Encore Health Key Benefits Commercial	$220.85
Rate for Payer: Healthscope Commercial	$248.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$234.65
Rate for Payer: PHP Commercial	$234.65
Rate for Payer: Priority Health Cigna Priority Health	$179.44
Rate for Payer: Priority Health SBD	$173.92

GALANTAMINE 4 MG TABLET

Facility

$12.05

Service Code	NDC 68084072911
Hospital Charge Code	29806
Hospital Revenue Code	637
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$10.85
Rate for Payer: Aetna Commercial	$10.24
Rate for Payer: Aetna Medicare	$6.03
Rate for Payer: Aetna New Business (MI Preferred)	$7.83
Rate for Payer: BCBS Complete	$4.82
Rate for Payer: Cash Price	$9.64
Rate for Payer: Cofinity Commercial	$10.36
Rate for Payer: Cofinity Commercial	$8.44
Rate for Payer: Cofinity Medicare Advantage	$8.44
Rate for Payer: Encore Health Key Benefits Commercial	$9.64
Rate for Payer: Healthscope Commercial	$10.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.24
Rate for Payer: PHP Commercial	$10.24
Rate for Payer: Priority Health Cigna Priority Health	$7.83
Rate for Payer: Priority Health SBD	$7.59

GALANTAMINE 4 MG TABLET

Facility

$361.31

Service Code	NDC 68084072921
Hospital Charge Code	29806
Hospital Revenue Code	637
Min. Negotiated Rate	$227.63
Max. Negotiated Rate	$325.18
Rate for Payer: Aetna Commercial	$307.11
Rate for Payer: Aetna New Business (MI Preferred)	$234.85
Rate for Payer: Cash Price	$289.05
Rate for Payer: Cofinity Commercial	$252.92
Rate for Payer: Cofinity Commercial	$310.73
Rate for Payer: Cofinity Medicare Advantage	$252.92
Rate for Payer: Encore Health Key Benefits Commercial	$289.05
Rate for Payer: Healthscope Commercial	$325.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$307.11
Rate for Payer: PHP Commercial	$307.11
Rate for Payer: Priority Health Cigna Priority Health	$234.85
Rate for Payer: Priority Health SBD	$227.63

GALANTAMINE 4 MG TABLET

Facility

$361.31

Service Code	NDC 68084072921
Hospital Charge Code	29806
Hospital Revenue Code	637
Min. Negotiated Rate	$144.52
Max. Negotiated Rate	$325.18
Rate for Payer: Aetna Commercial	$307.11
Rate for Payer: Aetna Medicare	$180.66
Rate for Payer: Aetna New Business (MI Preferred)	$234.85
Rate for Payer: BCBS Complete	$144.52
Rate for Payer: Cash Price	$289.05
Rate for Payer: Cofinity Commercial	$252.92
Rate for Payer: Cofinity Commercial	$310.73
Rate for Payer: Cofinity Medicare Advantage	$252.92
Rate for Payer: Encore Health Key Benefits Commercial	$289.05
Rate for Payer: Healthscope Commercial	$325.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$307.11
Rate for Payer: PHP Commercial	$307.11
Rate for Payer: Priority Health Cigna Priority Health	$234.85
Rate for Payer: Priority Health SBD	$227.63

GALANTAMINE 4 MG TABLET

Facility

$9.21

Service Code	NDC 51079085201
Hospital Charge Code	29806
Hospital Revenue Code	637
Min. Negotiated Rate	$3.68
Max. Negotiated Rate	$8.29
Rate for Payer: Aetna Commercial	$7.83
Rate for Payer: Aetna Medicare	$4.61
Rate for Payer: Aetna New Business (MI Preferred)	$5.99
Rate for Payer: BCBS Complete	$3.68
Rate for Payer: Cash Price	$7.37
Rate for Payer: Cofinity Commercial	$6.45
Rate for Payer: Cofinity Commercial	$7.92
Rate for Payer: Cofinity Medicare Advantage	$6.45
Rate for Payer: Encore Health Key Benefits Commercial	$7.37
Rate for Payer: Healthscope Commercial	$8.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.83
Rate for Payer: PHP Commercial	$7.83
Rate for Payer: Priority Health Cigna Priority Health	$5.99
Rate for Payer: Priority Health SBD	$5.80

GALANTAMINE 4 MG TABLET

Facility

$9.21

Service Code	NDC 51079085201
Hospital Charge Code	29806
Hospital Revenue Code	637
Min. Negotiated Rate	$5.80
Max. Negotiated Rate	$8.29
Rate for Payer: Aetna Commercial	$7.83
Rate for Payer: Aetna New Business (MI Preferred)	$5.99
Rate for Payer: Cash Price	$7.37
Rate for Payer: Cofinity Commercial	$6.45
Rate for Payer: Cofinity Commercial	$7.92
Rate for Payer: Cofinity Medicare Advantage	$6.45
Rate for Payer: Encore Health Key Benefits Commercial	$7.37
Rate for Payer: Healthscope Commercial	$8.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.83
Rate for Payer: PHP Commercial	$7.83
Rate for Payer: Priority Health Cigna Priority Health	$5.99
Rate for Payer: Priority Health SBD	$5.80

GALANTAMINE ER 8 MG 24 HR CAPSULE,EXTENDED RELEASE

Facility

$130.04

Service Code	NDC 47335083583
Hospital Charge Code	41138
Hospital Revenue Code	637
Min. Negotiated Rate	$81.93
Max. Negotiated Rate	$117.04
Rate for Payer: Aetna Commercial	$110.53
Rate for Payer: Aetna New Business (MI Preferred)	$84.53
Rate for Payer: Cash Price	$104.03
Rate for Payer: Cofinity Commercial	$111.83
Rate for Payer: Cofinity Commercial	$91.03
Rate for Payer: Cofinity Medicare Advantage	$91.03
Rate for Payer: Encore Health Key Benefits Commercial	$104.03
Rate for Payer: Healthscope Commercial	$117.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$110.53
Rate for Payer: PHP Commercial	$110.53
Rate for Payer: Priority Health Cigna Priority Health	$84.53
Rate for Payer: Priority Health SBD	$81.93

GALANTAMINE ER 8 MG 24 HR CAPSULE,EXTENDED RELEASE

Facility

$130.04

Service Code	NDC 47335083583
Hospital Charge Code	41138
Hospital Revenue Code	637
Min. Negotiated Rate	$52.02
Max. Negotiated Rate	$117.04
Rate for Payer: Aetna Commercial	$110.53
Rate for Payer: Aetna Medicare	$65.02
Rate for Payer: Aetna New Business (MI Preferred)	$84.53
Rate for Payer: BCBS Complete	$52.02
Rate for Payer: Cash Price	$104.03
Rate for Payer: Cofinity Commercial	$111.83
Rate for Payer: Cofinity Commercial	$91.03
Rate for Payer: Cofinity Medicare Advantage	$91.03
Rate for Payer: Encore Health Key Benefits Commercial	$104.03
Rate for Payer: Healthscope Commercial	$117.04
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$110.53
Rate for Payer: PHP Commercial	$110.53
Rate for Payer: Priority Health Cigna Priority Health	$84.53
Rate for Payer: Priority Health SBD	$81.93

GAMUNEX-C 10 GRAM/100 ML (10 %) INJECTION SOLUTION

Facility

$4,304.54

Service Code	HCPCS J1561
Hospital Charge Code	107780
Hospital Revenue Code	636
Min. Negotiated Rate	$2,711.86
Max. Negotiated Rate	$3,874.09
Rate for Payer: Aetna Commercial	$3,658.86
Rate for Payer: Aetna New Business (MI Preferred)	$2,797.95
Rate for Payer: Cash Price	$3,443.63
Rate for Payer: Cofinity Commercial	$3,013.18
Rate for Payer: Cofinity Commercial	$3,701.90
Rate for Payer: Cofinity Medicare Advantage	$3,013.18
Rate for Payer: Encore Health Key Benefits Commercial	$3,443.63
Rate for Payer: Healthscope Commercial	$3,874.09
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,658.86
Rate for Payer: PHP Commercial	$3,658.86
Rate for Payer: Priority Health Cigna Priority Health	$2,797.95
Rate for Payer: Priority Health SBD	$2,711.86

GAMUNEX-C 10 GRAM/100 ML (10 %) INJECTION SOLUTION

Facility

$4,304.54

Service Code	HCPCS J1561
Hospital Charge Code	107780
Hospital Revenue Code	636
Min. Negotiated Rate	$26.24
Max. Negotiated Rate	$3,874.09
Rate for Payer: Aetna Commercial	$3,658.86
Rate for Payer: Aetna Medicare	$50.92
Rate for Payer: Aetna New Business (MI Preferred)	$2,797.95
Rate for Payer: Allen County Amish Medical Aid Commercial	$61.20
Rate for Payer: Amish Plain Church Group Commercial	$61.20
Rate for Payer: BCBS Complete	$27.55
Rate for Payer: BCBS MAPPO	$48.96
Rate for Payer: BCN Medicare Advantage	$48.96
Rate for Payer: Cash Price	$3,443.63
Rate for Payer: Cash Price	$3,443.63
Rate for Payer: Cofinity Commercial	$3,701.90
Rate for Payer: Cofinity Commercial	$3,013.18
Rate for Payer: Cofinity Medicare Advantage	$3,013.18
Rate for Payer: Encore Health Key Benefits Commercial	$3,443.63
Rate for Payer: Health Alliance Plan Medicare Advantage	$48.96
Rate for Payer: Healthscope Commercial	$3,874.09
Rate for Payer: Mclaren Medicaid	$26.24
Rate for Payer: Mclaren Medicare	$48.96
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$51.41
Rate for Payer: Meridian Medicaid	$27.55
Rate for Payer: MI Amish Medical Board Commercial	$56.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,658.86
Rate for Payer: PACE Medicare	$46.51
Rate for Payer: PACE SWMI	$48.96
Rate for Payer: PHP Commercial	$3,658.86
Rate for Payer: PHP Medicare Advantage	$48.96
Rate for Payer: Priority Health Choice Medicaid	$26.24
Rate for Payer: Priority Health Cigna Priority Health	$2,797.95
Rate for Payer: Priority Health Medicare	$48.96
Rate for Payer: Priority Health SBD	$2,711.86
Rate for Payer: Railroad Medicare Medicare	$48.96
Rate for Payer: UHC All Payor (Choice/PPO)	$137.82
Rate for Payer: UHC Dual Complete DSNP	$48.96
Rate for Payer: UHC Medicare Advantage	$48.96
Rate for Payer: UHCCP Medicaid	$27.56
Rate for Payer: VA VA	$48.96

GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION

Facility

$199.77

Service Code	HCPCS J1570
Hospital Charge Code	10101
Hospital Revenue Code	636
Min. Negotiated Rate	$79.91
Max. Negotiated Rate	$179.79
Rate for Payer: Aetna Commercial	$169.80
Rate for Payer: Aetna Medicare	$99.89
Rate for Payer: Aetna New Business (MI Preferred)	$129.85
Rate for Payer: BCBS Complete	$79.91
Rate for Payer: Cash Price	$159.82
Rate for Payer: Cofinity Commercial	$139.84
Rate for Payer: Cofinity Commercial	$171.80
Rate for Payer: Cofinity Medicare Advantage	$139.84
Rate for Payer: Encore Health Key Benefits Commercial	$159.82
Rate for Payer: Healthscope Commercial	$179.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$169.80
Rate for Payer: PHP Commercial	$169.80
Rate for Payer: Priority Health Cigna Priority Health	$129.85
Rate for Payer: Priority Health SBD	$125.86

GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION

Facility

$199.77

Service Code	HCPCS J1570
Hospital Charge Code	10101
Hospital Revenue Code	636
Min. Negotiated Rate	$125.86
Max. Negotiated Rate	$179.79
Rate for Payer: Aetna Commercial	$169.80
Rate for Payer: Aetna New Business (MI Preferred)	$129.85
Rate for Payer: Cash Price	$159.82
Rate for Payer: Cofinity Commercial	$139.84
Rate for Payer: Cofinity Commercial	$171.80
Rate for Payer: Cofinity Medicare Advantage	$139.84
Rate for Payer: Encore Health Key Benefits Commercial	$159.82
Rate for Payer: Healthscope Commercial	$179.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$169.80
Rate for Payer: PHP Commercial	$169.80
Rate for Payer: Priority Health Cigna Priority Health	$129.85
Rate for Payer: Priority Health SBD	$125.86

GANCICLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION

Facility

$148.68

Service Code	NDC 25021018510
Hospital Charge Code	186410
Hospital Revenue Code	250
Min. Negotiated Rate	$93.67
Max. Negotiated Rate	$133.81
Rate for Payer: Aetna Commercial	$126.38
Rate for Payer: Aetna New Business (MI Preferred)	$96.64
Rate for Payer: Cash Price	$118.94
Rate for Payer: Cofinity Commercial	$104.08
Rate for Payer: Cofinity Commercial	$127.86
Rate for Payer: Cofinity Medicare Advantage	$104.08
Rate for Payer: Encore Health Key Benefits Commercial	$118.94
Rate for Payer: Healthscope Commercial	$133.81
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$126.38
Rate for Payer: PHP Commercial	$126.38
Rate for Payer: Priority Health Cigna Priority Health	$96.64
Rate for Payer: Priority Health SBD	$93.67

Know your out-of-pocket cost for care.

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