Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

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	$10.84
Rate for Payer: Aetna Commercial	$10.24
Rate for Payer: Aetna Medicare	$6.02
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	$10.84
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	$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

$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

$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

$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	$4.60
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

$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	$7.59
Max. Negotiated Rate	$10.84
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	$10.84
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

$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 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

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

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	$26.27
Max. Negotiated Rate	$3,874.09
Rate for Payer: Aetna Commercial	$3,658.86
Rate for Payer: Aetna Medicare	$50.97
Rate for Payer: Aetna New Business (MI Preferred)	$2,797.95
Rate for Payer: Allen County Amish Medical Aid Commercial	$61.26
Rate for Payer: Amish Plain Church Group Commercial	$61.26
Rate for Payer: BCBS Complete	$27.58
Rate for Payer: BCBS MAPPO	$49.01
Rate for Payer: BCBS Trust/PPO	$137.85
Rate for Payer: BCN Commercial	$137.85
Rate for Payer: BCN Medicare Advantage	$49.01
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	$49.01
Rate for Payer: Healthscope Commercial	$3,874.09
Rate for Payer: Mclaren Medicaid	$26.27
Rate for Payer: Mclaren Medicare	$49.01
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$51.46
Rate for Payer: Meridian Medicaid	$27.58
Rate for Payer: MI Amish Medical Board Commercial	$56.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,658.86
Rate for Payer: Nomi Health Commercial	$147.03
Rate for Payer: PACE Medicare	$46.56
Rate for Payer: PACE SWMI	$49.01
Rate for Payer: PHP Commercial	$3,658.86
Rate for Payer: PHP Medicare Advantage	$49.01
Rate for Payer: Priority Health Choice Medicaid	$26.27
Rate for Payer: Priority Health Cigna Priority Health	$2,797.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$140.45
Rate for Payer: Priority Health Medicare	$49.01
Rate for Payer: Priority Health Narrow Network	$112.36
Rate for Payer: Priority Health SBD	$2,711.86
Rate for Payer: Railroad Medicare Medicare	$49.01
Rate for Payer: UHC All Payor (Choice/PPO)	$137.96
Rate for Payer: UHC Dual Complete DSNP	$49.01
Rate for Payer: UHC Medicare Advantage	$49.01
Rate for Payer: UHCCP Medicaid	$27.59
Rate for Payer: VA VA	$49.01

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

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 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	$99.88
Rate for Payer: Aetna New Business (MI Preferred)	$129.85
Rate for Payer: BCBS Complete	$79.91
Rate for Payer: BCBS Trust/PPO	$102.83
Rate for Payer: BCN Commercial	$102.83
Rate for Payer: Cash Price	$159.82
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

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	$59.47
Max. Negotiated Rate	$133.81
Rate for Payer: Aetna Commercial	$126.38
Rate for Payer: Aetna Medicare	$74.34
Rate for Payer: Aetna New Business (MI Preferred)	$96.64
Rate for Payer: BCBS Complete	$59.47
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

GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE)

Facility

$9,991.56

Service Code	CPT 27687
Hospital Revenue Code	360
Min. Negotiated Rate	$482.66
Max. Negotiated Rate	$9,991.56
Rate for Payer: Aetna Medicare	$3,306.16
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,973.75
Rate for Payer: Amish Plain Church Group Commercial	$3,973.75
Rate for Payer: BCBS Complete	$1,789.14
Rate for Payer: BCBS MAPPO	$3,179.00
Rate for Payer: BCBS Trust/PPO	$1,271.09
Rate for Payer: BCN Commercial	$1,271.09
Rate for Payer: BCN Medicare Advantage	$3,179.00
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,179.00
Rate for Payer: Mclaren Medicaid	$1,703.94
Rate for Payer: Mclaren Medicare	$3,179.00
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,337.95
Rate for Payer: Meridian Medicaid	$1,789.14
Rate for Payer: MI Amish Medical Board Commercial	$3,655.85
Rate for Payer: Nomi Health Commercial	$6,675.90
Rate for Payer: PACE Medicare	$3,020.05
Rate for Payer: PACE SWMI	$3,179.00
Rate for Payer: PHP Medicare Advantage	$3,179.00
Rate for Payer: Priority Health Choice Medicaid	$1,703.94
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9,991.56
Rate for Payer: Priority Health Medicare	$3,179.00
Rate for Payer: Priority Health Narrow Network	$7,993.25
Rate for Payer: Railroad Medicare Medicare	$3,179.00
Rate for Payer: UHC All Payor (Choice/PPO)	$482.66
Rate for Payer: UHC Core	$5,427.00
Rate for Payer: UHC Dual Complete DSNP	$3,179.00
Rate for Payer: UHC Exchange	$5,811.00
Rate for Payer: UHC Medicare Advantage	$3,179.00
Rate for Payer: UHCCP Medicaid	$1,789.78
Rate for Payer: VA VA	$3,179.00

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE

Facility

$659.90

Service Code	NDC 63713001974
Hospital Charge Code	28025
Hospital Revenue Code	250
Min. Negotiated Rate	$415.74
Max. Negotiated Rate	$593.91
Rate for Payer: Aetna Commercial	$560.92
Rate for Payer: Aetna New Business (MI Preferred)	$428.94
Rate for Payer: Cash Price	$527.92
Rate for Payer: Cofinity Commercial	$461.93
Rate for Payer: Cofinity Commercial	$567.51
Rate for Payer: Cofinity Medicare Advantage	$461.93
Rate for Payer: Encore Health Key Benefits Commercial	$527.92
Rate for Payer: Healthscope Commercial	$593.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$560.92
Rate for Payer: PHP Commercial	$560.92
Rate for Payer: Priority Health Cigna Priority Health	$428.94
Rate for Payer: Priority Health SBD	$415.74

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE

Facility

$898.28

Service Code	NDC 00009034201
Hospital Charge Code	28025
Hospital Revenue Code	250
Min. Negotiated Rate	$359.31
Max. Negotiated Rate	$808.45
Rate for Payer: Aetna Commercial	$763.54
Rate for Payer: Aetna Medicare	$449.14
Rate for Payer: Aetna New Business (MI Preferred)	$583.88
Rate for Payer: BCBS Complete	$359.31
Rate for Payer: Cash Price	$718.62
Rate for Payer: Cofinity Commercial	$628.80
Rate for Payer: Cofinity Commercial	$772.52
Rate for Payer: Cofinity Medicare Advantage	$628.80
Rate for Payer: Encore Health Key Benefits Commercial	$718.62
Rate for Payer: Healthscope Commercial	$808.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$763.54
Rate for Payer: PHP Commercial	$763.54
Rate for Payer: Priority Health Cigna Priority Health	$583.88
Rate for Payer: Priority Health SBD	$565.92

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE

Facility

$898.28

Service Code	NDC 00009034201
Hospital Charge Code	28025
Hospital Revenue Code	250
Min. Negotiated Rate	$565.92
Max. Negotiated Rate	$808.45
Rate for Payer: Aetna Commercial	$763.54
Rate for Payer: Aetna New Business (MI Preferred)	$583.88
Rate for Payer: Cash Price	$718.62
Rate for Payer: Cofinity Commercial	$628.80
Rate for Payer: Cofinity Commercial	$772.52
Rate for Payer: Cofinity Medicare Advantage	$628.80
Rate for Payer: Encore Health Key Benefits Commercial	$718.62
Rate for Payer: Healthscope Commercial	$808.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$763.54
Rate for Payer: PHP Commercial	$763.54
Rate for Payer: Priority Health Cigna Priority Health	$583.88
Rate for Payer: Priority Health SBD	$565.92

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE

Facility

$659.90

Service Code	NDC 63713001974
Hospital Charge Code	28025
Hospital Revenue Code	250
Min. Negotiated Rate	$263.96
Max. Negotiated Rate	$593.91
Rate for Payer: Aetna Commercial	$560.92
Rate for Payer: Aetna Medicare	$329.95
Rate for Payer: Aetna New Business (MI Preferred)	$428.94
Rate for Payer: BCBS Complete	$263.96
Rate for Payer: Cash Price	$527.92
Rate for Payer: Cofinity Commercial	$461.93
Rate for Payer: Cofinity Commercial	$567.51
Rate for Payer: Cofinity Medicare Advantage	$461.93
Rate for Payer: Encore Health Key Benefits Commercial	$527.92
Rate for Payer: Healthscope Commercial	$593.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$560.92
Rate for Payer: PHP Commercial	$560.92
Rate for Payer: Priority Health Cigna Priority Health	$428.94
Rate for Payer: Priority Health SBD	$415.74

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE

Facility

$270.31

Service Code	NDC 63713001972
Hospital Charge Code	28018
Hospital Revenue Code	250
Min. Negotiated Rate	$170.30
Max. Negotiated Rate	$243.28
Rate for Payer: Aetna Commercial	$229.76
Rate for Payer: Aetna New Business (MI Preferred)	$175.70
Rate for Payer: Cash Price	$216.25
Rate for Payer: Cofinity Commercial	$189.22
Rate for Payer: Cofinity Commercial	$232.47
Rate for Payer: Cofinity Medicare Advantage	$189.22
Rate for Payer: Encore Health Key Benefits Commercial	$216.25
Rate for Payer: Healthscope Commercial	$243.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$229.76
Rate for Payer: PHP Commercial	$229.76
Rate for Payer: Priority Health Cigna Priority Health	$175.70
Rate for Payer: Priority Health SBD	$170.30

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE

Facility

$270.31

Service Code	NDC 63713001972
Hospital Charge Code	28018
Hospital Revenue Code	250
Min. Negotiated Rate	$108.12
Max. Negotiated Rate	$243.28
Rate for Payer: Aetna Commercial	$229.76
Rate for Payer: Aetna Medicare	$135.16
Rate for Payer: Aetna New Business (MI Preferred)	$175.70
Rate for Payer: BCBS Complete	$108.12
Rate for Payer: Cash Price	$216.25
Rate for Payer: Cofinity Commercial	$189.22
Rate for Payer: Cofinity Commercial	$232.47
Rate for Payer: Cofinity Medicare Advantage	$189.22
Rate for Payer: Encore Health Key Benefits Commercial	$216.25
Rate for Payer: Healthscope Commercial	$243.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$229.76
Rate for Payer: PHP Commercial	$229.76
Rate for Payer: Priority Health Cigna Priority Health	$175.70
Rate for Payer: Priority Health SBD	$170.30

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE

Facility

$370.88

Service Code	NDC 00009031508
Hospital Charge Code	28018
Hospital Revenue Code	250
Min. Negotiated Rate	$233.65
Max. Negotiated Rate	$333.79
Rate for Payer: Aetna Commercial	$315.25
Rate for Payer: Aetna New Business (MI Preferred)	$241.07
Rate for Payer: Cash Price	$296.70
Rate for Payer: Cofinity Commercial	$259.62
Rate for Payer: Cofinity Commercial	$318.96
Rate for Payer: Cofinity Medicare Advantage	$259.62
Rate for Payer: Encore Health Key Benefits Commercial	$296.70
Rate for Payer: Healthscope Commercial	$333.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$315.25
Rate for Payer: PHP Commercial	$315.25
Rate for Payer: Priority Health Cigna Priority Health	$241.07
Rate for Payer: Priority Health SBD	$233.65

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE

Facility

$370.88

Service Code	NDC 00009031508
Hospital Charge Code	28018
Hospital Revenue Code	250
Min. Negotiated Rate	$148.35
Max. Negotiated Rate	$333.79
Rate for Payer: Aetna Commercial	$315.25
Rate for Payer: Aetna Medicare	$185.44
Rate for Payer: Aetna New Business (MI Preferred)	$241.07
Rate for Payer: BCBS Complete	$148.35
Rate for Payer: Cash Price	$296.70
Rate for Payer: Cofinity Commercial	$259.62
Rate for Payer: Cofinity Commercial	$318.96
Rate for Payer: Cofinity Medicare Advantage	$259.62
Rate for Payer: Encore Health Key Benefits Commercial	$296.70
Rate for Payer: Healthscope Commercial	$333.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$315.25
Rate for Payer: PHP Commercial	$315.25
Rate for Payer: Priority Health Cigna Priority Health	$241.07
Rate for Payer: Priority Health SBD	$233.65

Know your out-of-pocket cost for care.

All Charges