|
ISOSOURCE 1.5 CONTINUOUS FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 4390018150
|
| Hospital Charge Code |
168943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: BCBS Trust/PPO |
$3.67
|
| Rate for Payer: BCN Commercial |
$3.67
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.18
|
| Rate for Payer: UHC Core |
$3.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.56
|
|
|
ISOSOURCE 1.5 CYCLIC FEED
|
Facility
|
IP
|
$9.60
|
|
|
Service Code
|
NDC 4390018181
|
| Hospital Charge Code |
200081
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: BCBS Trust/PPO |
$7.42
|
| Rate for Payer: BCN Commercial |
$7.42
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cofinity Commercial |
$8.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.68
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.16
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.45
|
| Rate for Payer: UHC Core |
$8.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.20
|
|
|
ISOSOURCE 1.5 INTERMITTENT FEED
|
Facility
|
IP
|
$9.60
|
|
|
Service Code
|
NDC 4390018181
|
| Hospital Charge Code |
200080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.86 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: BCBS Trust/PPO |
$7.42
|
| Rate for Payer: BCN Commercial |
$7.42
|
| Rate for Payer: Cash Price |
$7.68
|
| Rate for Payer: Cofinity Commercial |
$8.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.68
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.16
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$8.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$5.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.45
|
| Rate for Payer: UHC Core |
$8.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.20
|
|
|
ISOSOURCE HN BOLUS FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 4390018457
|
| Hospital Charge Code |
150769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: BCBS Trust/PPO |
$3.67
|
| Rate for Payer: BCN Commercial |
$3.67
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.18
|
| Rate for Payer: UHC Core |
$3.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.56
|
|
|
ISOSOURCE HN CYCLIC FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 4390018457
|
| Hospital Charge Code |
200075
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: BCBS Trust/PPO |
$3.67
|
| Rate for Payer: BCN Commercial |
$3.67
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.18
|
| Rate for Payer: UHC Core |
$3.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.56
|
|
|
ISOSOURCE HN INTERMITTENT FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 4390018457
|
| Hospital Charge Code |
200074
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: BCBS Trust/PPO |
$3.67
|
| Rate for Payer: BCN Commercial |
$3.67
|
| Rate for Payer: Cash Price |
$3.80
|
| Rate for Payer: Cofinity Commercial |
$4.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.04
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.18
|
| Rate for Payer: UHC Core |
$3.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.56
|
|
|
ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION
|
Facility
|
IP
|
$3,157.22
|
|
|
Service Code
|
HCPCS Q9968
|
| Hospital Charge Code |
10358
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,925.59 |
| Max. Negotiated Rate |
$2,841.50 |
| Rate for Payer: Aetna Commercial |
$2,683.64
|
| Rate for Payer: BCBS Trust/PPO |
$2,439.90
|
| Rate for Payer: BCN Commercial |
$2,439.90
|
| Rate for Payer: Cash Price |
$2,525.78
|
| Rate for Payer: Cofinity Commercial |
$2,715.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,525.78
|
| Rate for Payer: Healthscope Commercial |
$2,841.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,367.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,683.64
|
| Rate for Payer: PHP Commercial |
$2,683.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,210.05
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2,746.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1,925.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,778.35
|
| Rate for Payer: UHC Core |
$2,636.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,367.92
|
|
|
KETAMINE 100 MG/ML INJECTION IM (CODE)
|
Facility
|
IP
|
$32.55
|
|
|
Service Code
|
NDC 0409-2051-05
|
| Hospital Charge Code |
163728
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.85 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna Commercial |
$27.67
|
| Rate for Payer: BCBS Trust/PPO |
$25.15
|
| Rate for Payer: BCN Commercial |
$25.15
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cofinity Commercial |
$27.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.04
|
| Rate for Payer: Healthscope Commercial |
$29.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.67
|
| Rate for Payer: PHP Commercial |
$27.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.64
|
| Rate for Payer: UHC Core |
$27.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.41
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$32.55
|
|
|
Service Code
|
NDC 0409-2051-15
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.85 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna Commercial |
$27.67
|
| Rate for Payer: BCBS Trust/PPO |
$25.15
|
| Rate for Payer: BCN Commercial |
$25.15
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cofinity Commercial |
$27.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.04
|
| Rate for Payer: Healthscope Commercial |
$29.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.67
|
| Rate for Payer: PHP Commercial |
$27.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.64
|
| Rate for Payer: UHC Core |
$27.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.41
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$59.03
|
|
|
Service Code
|
NDC 0143-9509-10
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$53.13 |
| Rate for Payer: Aetna Commercial |
$50.18
|
| Rate for Payer: BCBS Trust/PPO |
$45.62
|
| Rate for Payer: BCN Commercial |
$45.62
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Cofinity Commercial |
$50.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.22
|
| Rate for Payer: Healthscope Commercial |
$53.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.18
|
| Rate for Payer: PHP Commercial |
$50.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$51.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$36.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$51.95
|
| Rate for Payer: UHC Core |
$49.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.27
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$59.03
|
|
|
Service Code
|
NDC 0143-9509-01
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.00 |
| Max. Negotiated Rate |
$53.13 |
| Rate for Payer: Aetna Commercial |
$50.18
|
| Rate for Payer: BCBS Trust/PPO |
$45.62
|
| Rate for Payer: BCN Commercial |
$45.62
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Cofinity Commercial |
$50.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.22
|
| Rate for Payer: Healthscope Commercial |
$53.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.18
|
| Rate for Payer: PHP Commercial |
$50.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$51.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$36.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$51.95
|
| Rate for Payer: UHC Core |
$49.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.27
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$32.55
|
|
|
Service Code
|
NDC 0409-2051-05
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.85 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna Commercial |
$27.67
|
| Rate for Payer: BCBS Trust/PPO |
$25.15
|
| Rate for Payer: BCN Commercial |
$25.15
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cofinity Commercial |
$27.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.04
|
| Rate for Payer: Healthscope Commercial |
$29.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.67
|
| Rate for Payer: PHP Commercial |
$27.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.64
|
| Rate for Payer: UHC Core |
$27.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.41
|
|
|
KETAMINE 10 MG/ML INJECTION IV (CODE)
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
NDC 67457-181-00
|
| Hospital Charge Code |
163727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.47 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Aetna Commercial |
$57.80
|
| Rate for Payer: BCBS Trust/PPO |
$52.55
|
| Rate for Payer: BCN Commercial |
$52.55
|
| Rate for Payer: Cash Price |
$54.40
|
| Rate for Payer: Cofinity Commercial |
$58.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.40
|
| Rate for Payer: Healthscope Commercial |
$61.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.80
|
| Rate for Payer: PHP Commercial |
$57.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$59.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$41.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.84
|
| Rate for Payer: UHC Core |
$56.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.00
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
NDC 9900-0008-69
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$58.55 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna Commercial |
$81.60
|
| Rate for Payer: BCBS Trust/PPO |
$74.19
|
| Rate for Payer: BCN Commercial |
$74.19
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Cofinity Commercial |
$82.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.80
|
| Rate for Payer: Healthscope Commercial |
$86.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$72.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$81.60
|
| Rate for Payer: PHP Commercial |
$81.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$83.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$58.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$84.48
|
| Rate for Payer: UHC Core |
$80.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.00
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 69374-982-55
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.35 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna Commercial |
$29.75
|
| Rate for Payer: BCBS Trust/PPO |
$27.05
|
| Rate for Payer: BCN Commercial |
$27.05
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: Cofinity Commercial |
$30.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.00
|
| Rate for Payer: Healthscope Commercial |
$31.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.75
|
| Rate for Payer: PHP Commercial |
$29.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$30.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$21.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$30.80
|
| Rate for Payer: UHC Core |
$29.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.25
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$92.00
|
|
|
Service Code
|
NDC 42023-113-10
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$56.11 |
| Max. Negotiated Rate |
$82.80 |
| Rate for Payer: Aetna Commercial |
$78.20
|
| Rate for Payer: BCBS Trust/PPO |
$71.10
|
| Rate for Payer: BCN Commercial |
$71.10
|
| Rate for Payer: Cash Price |
$73.60
|
| Rate for Payer: Cofinity Commercial |
$79.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.60
|
| Rate for Payer: Healthscope Commercial |
$82.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$69.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$78.20
|
| Rate for Payer: PHP Commercial |
$78.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.40
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$80.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$56.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$80.96
|
| Rate for Payer: UHC Core |
$76.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$69.00
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IV SYRINGE
|
Facility
|
IP
|
$32.20
|
|
|
Service Code
|
NDC 70092-1119-44
|
| Hospital Charge Code |
118700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.64 |
| Max. Negotiated Rate |
$28.98 |
| Rate for Payer: Aetna Commercial |
$27.37
|
| Rate for Payer: BCBS Trust/PPO |
$24.88
|
| Rate for Payer: BCN Commercial |
$24.88
|
| Rate for Payer: Cash Price |
$25.76
|
| Rate for Payer: Cofinity Commercial |
$27.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.76
|
| Rate for Payer: Healthscope Commercial |
$28.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.37
|
| Rate for Payer: PHP Commercial |
$27.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$28.34
|
| Rate for Payer: UHC Core |
$26.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.15
|
|
|
KETOCONAZOLE 2 % TOPICAL CREAM
|
Facility
|
IP
|
$73.82
|
|
|
Service Code
|
NDC 51672-1298-1
|
| Hospital Charge Code |
10368
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.02 |
| Max. Negotiated Rate |
$66.44 |
| Rate for Payer: Aetna Commercial |
$62.75
|
| Rate for Payer: BCBS Trust/PPO |
$57.05
|
| Rate for Payer: BCN Commercial |
$57.05
|
| Rate for Payer: Cash Price |
$59.06
|
| Rate for Payer: Cofinity Commercial |
$63.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.06
|
| Rate for Payer: Healthscope Commercial |
$66.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$62.75
|
| Rate for Payer: PHP Commercial |
$62.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$64.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$64.96
|
| Rate for Payer: UHC Core |
$61.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.36
|
|
|
KETOCONAZOLE 2 % TOPICAL CREAM
|
Facility
|
IP
|
$23.79
|
|
|
Service Code
|
NDC 0168-0099-15
|
| Hospital Charge Code |
10368
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.51 |
| Max. Negotiated Rate |
$21.41 |
| Rate for Payer: Aetna Commercial |
$20.22
|
| Rate for Payer: BCBS Trust/PPO |
$18.38
|
| Rate for Payer: BCN Commercial |
$18.38
|
| Rate for Payer: Cash Price |
$19.03
|
| Rate for Payer: Cofinity Commercial |
$20.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.03
|
| Rate for Payer: Healthscope Commercial |
$21.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.22
|
| Rate for Payer: PHP Commercial |
$20.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.70
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20.94
|
| Rate for Payer: UHC Core |
$19.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.84
|
|
|
KETOROLAC 15 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$15.35
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
22472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.36 |
| Max. Negotiated Rate |
$13.82 |
| Rate for Payer: Aetna Commercial |
$13.05
|
| Rate for Payer: Aetna Commercial |
$12.04
|
| Rate for Payer: Aetna Commercial |
$17.60
|
| Rate for Payer: Aetna Commercial |
$20.64
|
| Rate for Payer: BCBS Trust/PPO |
$16.00
|
| Rate for Payer: BCBS Trust/PPO |
$10.94
|
| Rate for Payer: BCBS Trust/PPO |
$18.76
|
| Rate for Payer: BCBS Trust/PPO |
$11.86
|
| Rate for Payer: BCN Commercial |
$18.76
|
| Rate for Payer: BCN Commercial |
$11.86
|
| Rate for Payer: BCN Commercial |
$10.94
|
| Rate for Payer: BCN Commercial |
$16.00
|
| Rate for Payer: Cash Price |
$19.42
|
| Rate for Payer: Cash Price |
$12.28
|
| Rate for Payer: Cash Price |
$16.56
|
| Rate for Payer: Cash Price |
$11.33
|
| Rate for Payer: Cofinity Commercial |
$12.18
|
| Rate for Payer: Cofinity Commercial |
$20.88
|
| Rate for Payer: Cofinity Commercial |
$13.20
|
| Rate for Payer: Cofinity Commercial |
$17.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.56
|
| Rate for Payer: Healthscope Commercial |
$21.85
|
| Rate for Payer: Healthscope Commercial |
$18.63
|
| Rate for Payer: Healthscope Commercial |
$12.74
|
| Rate for Payer: Healthscope Commercial |
$13.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.60
|
| Rate for Payer: PHP Commercial |
$12.04
|
| Rate for Payer: PHP Commercial |
$13.05
|
| Rate for Payer: PHP Commercial |
$20.64
|
| Rate for Payer: PHP Commercial |
$17.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$18.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21.12
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.46
|
| Rate for Payer: UHC Core |
$11.82
|
| Rate for Payer: UHC Core |
$17.28
|
| Rate for Payer: UHC Core |
$12.82
|
| Rate for Payer: UHC Core |
$20.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.21
|
|
|
KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION
|
Facility
|
IP
|
$22.23
|
|
|
Service Code
|
HCPCS J1885
|
| Hospital Charge Code |
22473
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.56 |
| Max. Negotiated Rate |
$20.01 |
| Rate for Payer: Aetna Commercial |
$18.90
|
| Rate for Payer: Aetna Commercial |
$13.43
|
| Rate for Payer: Aetna Commercial |
$22.97
|
| Rate for Payer: Aetna Commercial |
$10.73
|
| Rate for Payer: Aetna Commercial |
$12.87
|
| Rate for Payer: BCBS Trust/PPO |
$11.70
|
| Rate for Payer: BCBS Trust/PPO |
$9.75
|
| Rate for Payer: BCBS Trust/PPO |
$12.21
|
| Rate for Payer: BCBS Trust/PPO |
$20.88
|
| Rate for Payer: BCBS Trust/PPO |
$17.18
|
| Rate for Payer: BCN Commercial |
$12.21
|
| Rate for Payer: BCN Commercial |
$9.75
|
| Rate for Payer: BCN Commercial |
$17.18
|
| Rate for Payer: BCN Commercial |
$11.70
|
| Rate for Payer: BCN Commercial |
$20.88
|
| Rate for Payer: Cash Price |
$21.62
|
| Rate for Payer: Cash Price |
$10.10
|
| Rate for Payer: Cash Price |
$12.11
|
| Rate for Payer: Cash Price |
$17.78
|
| Rate for Payer: Cash Price |
$12.64
|
| Rate for Payer: Cofinity Commercial |
$13.02
|
| Rate for Payer: Cofinity Commercial |
$19.12
|
| Rate for Payer: Cofinity Commercial |
$23.24
|
| Rate for Payer: Cofinity Commercial |
$10.85
|
| Rate for Payer: Cofinity Commercial |
$13.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.78
|
| Rate for Payer: Healthscope Commercial |
$20.01
|
| Rate for Payer: Healthscope Commercial |
$13.63
|
| Rate for Payer: Healthscope Commercial |
$24.32
|
| Rate for Payer: Healthscope Commercial |
$11.36
|
| Rate for Payer: Healthscope Commercial |
$14.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.87
|
| Rate for Payer: PHP Commercial |
$22.97
|
| Rate for Payer: PHP Commercial |
$10.73
|
| Rate for Payer: PHP Commercial |
$12.87
|
| Rate for Payer: PHP Commercial |
$13.43
|
| Rate for Payer: PHP Commercial |
$18.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$23.51
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$7.70
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.32
|
| Rate for Payer: UHC Core |
$13.19
|
| Rate for Payer: UHC Core |
$12.64
|
| Rate for Payer: UHC Core |
$18.56
|
| Rate for Payer: UHC Core |
$10.54
|
| Rate for Payer: UHC Core |
$22.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.46
|
|
|
LABETALOL 100 MG TABLET
|
Facility
|
IP
|
$270.75
|
|
|
Service Code
|
NDC 60687-439-01
|
| Hospital Charge Code |
10373
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.13 |
| Max. Negotiated Rate |
$243.68 |
| Rate for Payer: Aetna Commercial |
$230.14
|
| Rate for Payer: BCBS Trust/PPO |
$209.24
|
| Rate for Payer: BCN Commercial |
$209.24
|
| Rate for Payer: Cash Price |
$216.60
|
| Rate for Payer: Cofinity Commercial |
$232.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.60
|
| Rate for Payer: Healthscope Commercial |
$243.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$203.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$230.14
|
| Rate for Payer: PHP Commercial |
$230.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$235.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$165.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$238.26
|
| Rate for Payer: UHC Core |
$226.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.06
|
|
|
LABETALOL 100 MG TABLET
|
Facility
|
IP
|
$216.60
|
|
|
Service Code
|
NDC 0904-7109-61
|
| Hospital Charge Code |
10373
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.10 |
| Max. Negotiated Rate |
$194.94 |
| Rate for Payer: Aetna Commercial |
$184.11
|
| Rate for Payer: BCBS Trust/PPO |
$167.39
|
| Rate for Payer: BCN Commercial |
$167.39
|
| Rate for Payer: Cash Price |
$173.28
|
| Rate for Payer: Cofinity Commercial |
$186.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$173.28
|
| Rate for Payer: Healthscope Commercial |
$194.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$162.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$184.11
|
| Rate for Payer: PHP Commercial |
$184.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$151.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$188.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$132.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$190.61
|
| Rate for Payer: UHC Core |
$180.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$162.45
|
|
|
LABETALOL 100 MG TABLET
|
Facility
|
IP
|
$439.45
|
|
|
Service Code
|
NDC 68382-798-01
|
| Hospital Charge Code |
10373
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$268.02 |
| Max. Negotiated Rate |
$395.50 |
| Rate for Payer: Aetna Commercial |
$373.53
|
| Rate for Payer: BCBS Trust/PPO |
$339.61
|
| Rate for Payer: BCN Commercial |
$339.61
|
| Rate for Payer: Cash Price |
$351.56
|
| Rate for Payer: Cofinity Commercial |
$377.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$351.56
|
| Rate for Payer: Healthscope Commercial |
$395.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$329.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$373.53
|
| Rate for Payer: PHP Commercial |
$373.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$307.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$382.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$268.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$386.72
|
| Rate for Payer: UHC Core |
$366.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$329.59
|
|
|
LABETALOL 100 MG TABLET
|
Facility
|
IP
|
$2.71
|
|
|
Service Code
|
NDC 60687-439-11
|
| Hospital Charge Code |
10373
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.44 |
| Rate for Payer: Aetna Commercial |
$2.30
|
| Rate for Payer: BCBS Trust/PPO |
$2.09
|
| Rate for Payer: BCN Commercial |
$2.09
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cofinity Commercial |
$2.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.17
|
| Rate for Payer: Healthscope Commercial |
$2.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.30
|
| Rate for Payer: PHP Commercial |
$2.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.38
|
| Rate for Payer: UHC Core |
$2.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.03
|
|
