|
ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$292.60
|
|
|
Service Code
|
NDC 00904645061
|
| Hospital Charge Code |
24268
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.65 |
| Max. Negotiated Rate |
$263.34 |
| Rate for Payer: Aetna Commercial |
$248.71
|
| Rate for Payer: BCBS Trust/PPO |
$241.66
|
| Rate for Payer: BCN Commercial |
$241.66
|
| Rate for Payer: Cash Price |
$234.08
|
| Rate for Payer: Cofinity Commercial |
$251.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$234.08
|
| Rate for Payer: Healthscope Commercial |
$263.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$219.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$248.71
|
| Rate for Payer: Nomi Health Commercial |
$239.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$219.45
|
| Rate for Payer: PHP Commercial |
$248.71
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$254.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$203.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$257.49
|
| Rate for Payer: UHC Core |
$244.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$219.45
|
|
|
ISOSOURCE 1.5 BOLUS FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 43900018150
|
| Hospital Charge Code |
150768
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: BCBS Trust/PPO |
$3.92
|
| Rate for Payer: BCN Commercial |
$3.92
|
| 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 Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$4.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.31
|
| 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 BOLUS FEED
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 43900018150
|
| Hospital Charge Code |
150768
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: Aetna Medicare |
$1.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.48
|
| Rate for Payer: BCBS Complete |
$0.88
|
| Rate for Payer: BCBS MAPPO |
$1.19
|
| Rate for Payer: BCBS Trust/PPO |
$3.90
|
| Rate for Payer: BCN Commercial |
$3.90
|
| Rate for Payer: BCN Medicare Advantage |
$1.19
|
| 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: Health Alliance Plan Medicare Advantage |
$1.19
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.56
|
| Rate for Payer: Mclaren Medicaid |
$0.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.25
|
| Rate for Payer: Meridian Medicaid |
$0.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.37
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: PACE Senior Care Partners |
$1.13
|
| Rate for Payer: PACE SWMI |
$1.19
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: PHP Medicare Advantage |
$1.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$4.13
|
| Rate for Payer: Priority Health Medicare |
$1.20
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.31
|
| Rate for Payer: Railroad Medicare Medicare |
$1.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.18
|
| Rate for Payer: UHC Core |
$3.97
|
| Rate for Payer: UHC Exchange |
$1.19
|
| Rate for Payer: UHC Medicaid |
$0.84
|
| Rate for Payer: UHC Medicare Advantage |
$1.19
|
| Rate for Payer: UHCCP Medicaid |
$0.84
|
| Rate for Payer: VA VA |
$1.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.56
|
|
|
ISOSOURCE 1.5 CONTINUOUS FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 43900018150
|
| Hospital Charge Code |
168943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: BCBS Trust/PPO |
$3.92
|
| Rate for Payer: BCN Commercial |
$3.92
|
| 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 Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$4.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.31
|
| 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 CONTINUOUS FEED
|
Facility
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 43900018150
|
| Hospital Charge Code |
168943
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: Aetna Medicare |
$1.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.48
|
| Rate for Payer: BCBS Complete |
$0.88
|
| Rate for Payer: BCBS MAPPO |
$1.19
|
| Rate for Payer: BCBS Trust/PPO |
$3.90
|
| Rate for Payer: BCN Commercial |
$3.90
|
| Rate for Payer: BCN Medicare Advantage |
$1.19
|
| 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: Health Alliance Plan Medicare Advantage |
$1.19
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.56
|
| Rate for Payer: Mclaren Medicaid |
$0.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.25
|
| Rate for Payer: Meridian Medicaid |
$0.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.37
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: PACE Senior Care Partners |
$1.13
|
| Rate for Payer: PACE SWMI |
$1.19
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: PHP Medicare Advantage |
$1.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$4.13
|
| Rate for Payer: Priority Health Medicare |
$1.20
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.31
|
| Rate for Payer: Railroad Medicare Medicare |
$1.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.18
|
| Rate for Payer: UHC Core |
$3.97
|
| Rate for Payer: UHC Exchange |
$1.19
|
| Rate for Payer: UHC Medicaid |
$0.84
|
| Rate for Payer: UHC Medicare Advantage |
$1.19
|
| Rate for Payer: UHCCP Medicaid |
$0.84
|
| Rate for Payer: VA VA |
$1.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.56
|
|
|
ISOSOURCE 1.5 CYCLIC FEED
|
Facility
|
IP
|
$9.60
|
|
|
Service Code
|
NDC 43900018181
|
| Hospital Charge Code |
200081
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: BCBS Trust/PPO |
$7.93
|
| Rate for Payer: BCN Commercial |
$7.93
|
| 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 Commercial |
$8.16
|
| Rate for Payer: Nomi Health Commercial |
$7.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.20
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$8.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.68
|
| 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 CYCLIC FEED
|
Facility
|
OP
|
$9.60
|
|
|
Service Code
|
NDC 43900018181
|
| Hospital Charge Code |
200081
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Aetna Medicare |
$2.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.00
|
| Rate for Payer: BCBS Complete |
$1.78
|
| Rate for Payer: BCBS MAPPO |
$2.40
|
| Rate for Payer: BCBS Trust/PPO |
$7.89
|
| Rate for Payer: BCN Commercial |
$7.89
|
| Rate for Payer: BCN Medicare Advantage |
$2.40
|
| 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: Health Alliance Plan Medicare Advantage |
$2.40
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.20
|
| Rate for Payer: Mclaren Medicaid |
$1.69
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2.52
|
| Rate for Payer: Meridian Medicaid |
$1.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.76
|
| Rate for Payer: Molina Medicare/Medicaid |
$2.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.16
|
| Rate for Payer: Nomi Health Commercial |
$7.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.20
|
| Rate for Payer: PACE Senior Care Partners |
$2.28
|
| Rate for Payer: PACE SWMI |
$2.40
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: PHP Medicare Advantage |
$2.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$1.69
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$8.35
|
| Rate for Payer: Priority Health Medicare |
$2.42
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.68
|
| Rate for Payer: Railroad Medicare Medicare |
$2.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.45
|
| Rate for Payer: UHC Core |
$8.02
|
| Rate for Payer: UHC Exchange |
$2.40
|
| Rate for Payer: UHC Medicaid |
$1.69
|
| Rate for Payer: UHC Medicare Advantage |
$2.40
|
| Rate for Payer: UHCCP Medicaid |
$1.69
|
| Rate for Payer: VA VA |
$2.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.20
|
|
|
ISOSOURCE 1.5 INTERMITTENT FEED
|
Facility
|
OP
|
$9.60
|
|
|
Service Code
|
NDC 43900018181
|
| Hospital Charge Code |
200080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Aetna Medicare |
$2.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.00
|
| Rate for Payer: BCBS Complete |
$1.78
|
| Rate for Payer: BCBS MAPPO |
$2.40
|
| Rate for Payer: BCBS Trust/PPO |
$7.89
|
| Rate for Payer: BCN Commercial |
$7.89
|
| Rate for Payer: BCN Medicare Advantage |
$2.40
|
| 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: Health Alliance Plan Medicare Advantage |
$2.40
|
| Rate for Payer: Healthscope Commercial |
$8.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.20
|
| Rate for Payer: Mclaren Medicaid |
$1.69
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2.52
|
| Rate for Payer: Meridian Medicaid |
$1.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.76
|
| Rate for Payer: Molina Medicare/Medicaid |
$2.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.16
|
| Rate for Payer: Nomi Health Commercial |
$7.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.20
|
| Rate for Payer: PACE Senior Care Partners |
$2.28
|
| Rate for Payer: PACE SWMI |
$2.40
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: PHP Medicare Advantage |
$2.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$1.69
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$8.35
|
| Rate for Payer: Priority Health Medicare |
$2.42
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.68
|
| Rate for Payer: Railroad Medicare Medicare |
$2.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.45
|
| Rate for Payer: UHC Core |
$8.02
|
| Rate for Payer: UHC Exchange |
$2.40
|
| Rate for Payer: UHC Medicaid |
$1.69
|
| Rate for Payer: UHC Medicare Advantage |
$2.40
|
| Rate for Payer: UHCCP Medicaid |
$1.69
|
| Rate for Payer: VA VA |
$2.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.20
|
|
|
ISOSOURCE 1.5 INTERMITTENT FEED
|
Facility
|
IP
|
$9.60
|
|
|
Service Code
|
NDC 43900018181
|
| Hospital Charge Code |
200080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.68 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: BCBS Trust/PPO |
$7.93
|
| Rate for Payer: BCN Commercial |
$7.93
|
| 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 Commercial |
$8.16
|
| Rate for Payer: Nomi Health Commercial |
$7.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.20
|
| Rate for Payer: PHP Commercial |
$8.16
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$8.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.68
|
| 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
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 43900018457
|
| Hospital Charge Code |
150769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: Aetna Medicare |
$1.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.48
|
| Rate for Payer: BCBS Complete |
$0.88
|
| Rate for Payer: BCBS MAPPO |
$1.19
|
| Rate for Payer: BCBS Trust/PPO |
$3.90
|
| Rate for Payer: BCN Commercial |
$3.90
|
| Rate for Payer: BCN Medicare Advantage |
$1.19
|
| 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: Health Alliance Plan Medicare Advantage |
$1.19
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.56
|
| Rate for Payer: Mclaren Medicaid |
$0.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.25
|
| Rate for Payer: Meridian Medicaid |
$0.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.37
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: PACE Senior Care Partners |
$1.13
|
| Rate for Payer: PACE SWMI |
$1.19
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: PHP Medicare Advantage |
$1.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$4.13
|
| Rate for Payer: Priority Health Medicare |
$1.20
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.31
|
| Rate for Payer: Railroad Medicare Medicare |
$1.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.18
|
| Rate for Payer: UHC Core |
$3.97
|
| Rate for Payer: UHC Exchange |
$1.19
|
| Rate for Payer: UHC Medicaid |
$0.84
|
| Rate for Payer: UHC Medicare Advantage |
$1.19
|
| Rate for Payer: UHCCP Medicaid |
$0.84
|
| Rate for Payer: VA VA |
$1.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.56
|
|
|
ISOSOURCE HN BOLUS FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 43900018457
|
| Hospital Charge Code |
150769
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: BCBS Trust/PPO |
$3.92
|
| Rate for Payer: BCN Commercial |
$3.92
|
| 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 Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$4.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.31
|
| 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 43900018457
|
| Hospital Charge Code |
200075
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: BCBS Trust/PPO |
$3.92
|
| Rate for Payer: BCN Commercial |
$3.92
|
| 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 Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$4.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.31
|
| 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
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 43900018457
|
| Hospital Charge Code |
200075
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: Aetna Medicare |
$1.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.48
|
| Rate for Payer: BCBS Complete |
$0.88
|
| Rate for Payer: BCBS MAPPO |
$1.19
|
| Rate for Payer: BCBS Trust/PPO |
$3.90
|
| Rate for Payer: BCN Commercial |
$3.90
|
| Rate for Payer: BCN Medicare Advantage |
$1.19
|
| 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: Health Alliance Plan Medicare Advantage |
$1.19
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.56
|
| Rate for Payer: Mclaren Medicaid |
$0.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.25
|
| Rate for Payer: Meridian Medicaid |
$0.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.37
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: PACE Senior Care Partners |
$1.13
|
| Rate for Payer: PACE SWMI |
$1.19
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: PHP Medicare Advantage |
$1.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$4.13
|
| Rate for Payer: Priority Health Medicare |
$1.20
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.31
|
| Rate for Payer: Railroad Medicare Medicare |
$1.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.18
|
| Rate for Payer: UHC Core |
$3.97
|
| Rate for Payer: UHC Exchange |
$1.19
|
| Rate for Payer: UHC Medicaid |
$0.84
|
| Rate for Payer: UHC Medicare Advantage |
$1.19
|
| Rate for Payer: UHCCP Medicaid |
$0.84
|
| Rate for Payer: VA VA |
$1.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.56
|
|
|
ISOSOURCE HN INTERMITTENT FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 43900018457
|
| Hospital Charge Code |
200074
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.31 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: BCBS Trust/PPO |
$3.92
|
| Rate for Payer: BCN Commercial |
$3.92
|
| 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 Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$4.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.31
|
| 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
|
OP
|
$4.75
|
|
|
Service Code
|
NDC 43900018457
|
| Hospital Charge Code |
200074
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: Aetna Medicare |
$1.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.48
|
| Rate for Payer: BCBS Complete |
$0.88
|
| Rate for Payer: BCBS MAPPO |
$1.19
|
| Rate for Payer: BCBS Trust/PPO |
$3.90
|
| Rate for Payer: BCN Commercial |
$3.90
|
| Rate for Payer: BCN Medicare Advantage |
$1.19
|
| 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: Health Alliance Plan Medicare Advantage |
$1.19
|
| Rate for Payer: Healthscope Commercial |
$4.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.56
|
| Rate for Payer: Mclaren Medicaid |
$0.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.25
|
| Rate for Payer: Meridian Medicaid |
$0.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.37
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.56
|
| Rate for Payer: PACE Senior Care Partners |
$1.13
|
| Rate for Payer: PACE SWMI |
$1.19
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: PHP Medicare Advantage |
$1.19
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$4.13
|
| Rate for Payer: Priority Health Medicare |
$1.20
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.31
|
| Rate for Payer: Railroad Medicare Medicare |
$1.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.18
|
| Rate for Payer: UHC Core |
$3.97
|
| Rate for Payer: UHC Exchange |
$1.19
|
| Rate for Payer: UHC Medicaid |
$0.84
|
| Rate for Payer: UHC Medicare Advantage |
$1.19
|
| Rate for Payer: UHCCP Medicaid |
$0.84
|
| Rate for Payer: VA VA |
$1.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.56
|
|
|
KETAMINE 100 MG/ML INJECTION IM (CODE)
|
Facility
|
IP
|
$38.63
|
|
|
Service Code
|
NDC 00409205105
|
| Hospital Charge Code |
163728
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.89 |
| Max. Negotiated Rate |
$34.77 |
| Rate for Payer: Aetna Commercial |
$32.84
|
| Rate for Payer: BCBS Trust/PPO |
$31.90
|
| Rate for Payer: BCN Commercial |
$31.90
|
| Rate for Payer: Cash Price |
$30.90
|
| Rate for Payer: Cofinity Commercial |
$33.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.90
|
| Rate for Payer: Healthscope Commercial |
$34.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.84
|
| Rate for Payer: Nomi Health Commercial |
$31.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.97
|
| Rate for Payer: PHP Commercial |
$32.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$33.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$26.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.99
|
| Rate for Payer: UHC Core |
$32.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.97
|
|
|
KETAMINE 100 MG/ML INJECTION IM (CODE)
|
Facility
|
OP
|
$38.63
|
|
|
Service Code
|
NDC 00409205105
|
| Hospital Charge Code |
163728
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.81 |
| Max. Negotiated Rate |
$34.77 |
| Rate for Payer: Aetna Commercial |
$32.84
|
| Rate for Payer: Aetna Medicare |
$10.04
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12.07
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12.07
|
| Rate for Payer: BCBS Complete |
$7.15
|
| Rate for Payer: BCBS MAPPO |
$9.66
|
| Rate for Payer: BCBS Trust/PPO |
$31.76
|
| Rate for Payer: BCN Commercial |
$31.76
|
| Rate for Payer: BCN Medicare Advantage |
$9.66
|
| Rate for Payer: Cash Price |
$30.90
|
| Rate for Payer: Cofinity Commercial |
$33.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.66
|
| Rate for Payer: Healthscope Commercial |
$34.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.97
|
| Rate for Payer: Mclaren Medicaid |
$6.81
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.14
|
| Rate for Payer: Meridian Medicaid |
$7.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.11
|
| Rate for Payer: Molina Medicare/Medicaid |
$10.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.84
|
| Rate for Payer: Nomi Health Commercial |
$31.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.97
|
| Rate for Payer: PACE Senior Care Partners |
$9.17
|
| Rate for Payer: PACE SWMI |
$9.66
|
| Rate for Payer: PHP Commercial |
$32.84
|
| Rate for Payer: PHP Medicare Advantage |
$9.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$6.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$33.61
|
| Rate for Payer: Priority Health Medicare |
$9.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$26.89
|
| Rate for Payer: Railroad Medicare Medicare |
$9.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.99
|
| Rate for Payer: UHC Core |
$32.26
|
| Rate for Payer: UHC Exchange |
$9.66
|
| Rate for Payer: UHC Medicaid |
$6.81
|
| Rate for Payer: UHC Medicare Advantage |
$9.66
|
| Rate for Payer: UHCCP Medicaid |
$6.81
|
| Rate for Payer: VA VA |
$9.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.97
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$38.65
|
|
|
Service Code
|
NDC 00409004010
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.81 |
| Max. Negotiated Rate |
$34.78 |
| Rate for Payer: Aetna Commercial |
$32.85
|
| Rate for Payer: Aetna Medicare |
$10.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12.08
|
| Rate for Payer: BCBS Complete |
$7.15
|
| Rate for Payer: BCBS MAPPO |
$9.66
|
| Rate for Payer: BCBS Trust/PPO |
$31.77
|
| Rate for Payer: BCN Commercial |
$31.77
|
| Rate for Payer: BCN Medicare Advantage |
$9.66
|
| Rate for Payer: Cash Price |
$30.92
|
| Rate for Payer: Cofinity Commercial |
$33.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.66
|
| Rate for Payer: Healthscope Commercial |
$34.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.99
|
| Rate for Payer: Mclaren Medicaid |
$6.81
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.15
|
| Rate for Payer: Meridian Medicaid |
$7.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.11
|
| Rate for Payer: Molina Medicare/Medicaid |
$10.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.85
|
| Rate for Payer: Nomi Health Commercial |
$31.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.99
|
| Rate for Payer: PACE Senior Care Partners |
$9.18
|
| Rate for Payer: PACE SWMI |
$9.66
|
| Rate for Payer: PHP Commercial |
$32.85
|
| Rate for Payer: PHP Medicare Advantage |
$9.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$6.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$33.63
|
| Rate for Payer: Priority Health Medicare |
$9.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$26.90
|
| Rate for Payer: Railroad Medicare Medicare |
$9.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34.01
|
| Rate for Payer: UHC Core |
$32.27
|
| Rate for Payer: UHC Exchange |
$9.66
|
| Rate for Payer: UHC Medicaid |
$6.81
|
| Rate for Payer: UHC Medicare Advantage |
$9.66
|
| Rate for Payer: UHCCP Medicaid |
$6.81
|
| Rate for Payer: VA VA |
$9.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.99
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$41.48
|
|
|
Service Code
|
NDC 00143950910
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.87 |
| Max. Negotiated Rate |
$37.33 |
| Rate for Payer: Aetna Commercial |
$35.26
|
| Rate for Payer: BCBS Trust/PPO |
$34.26
|
| Rate for Payer: BCN Commercial |
$34.26
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cofinity Commercial |
$35.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.18
|
| Rate for Payer: Healthscope Commercial |
$37.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.26
|
| Rate for Payer: Nomi Health Commercial |
$34.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.11
|
| Rate for Payer: PHP Commercial |
$35.26
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$36.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$28.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.50
|
| Rate for Payer: UHC Core |
$34.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.11
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$38.65
|
|
|
Service Code
|
NDC 00409004010
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.90 |
| Max. Negotiated Rate |
$34.78 |
| Rate for Payer: Aetna Commercial |
$32.85
|
| Rate for Payer: BCBS Trust/PPO |
$31.92
|
| Rate for Payer: BCN Commercial |
$31.92
|
| Rate for Payer: Cash Price |
$30.92
|
| Rate for Payer: Cofinity Commercial |
$33.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.92
|
| Rate for Payer: Healthscope Commercial |
$34.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.85
|
| Rate for Payer: Nomi Health Commercial |
$31.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.99
|
| Rate for Payer: PHP Commercial |
$32.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$33.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$26.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34.01
|
| Rate for Payer: UHC Core |
$32.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.99
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$40.95
|
|
|
Service Code
|
NDC 25021068405
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.50 |
| Max. Negotiated Rate |
$36.85 |
| Rate for Payer: Aetna Commercial |
$34.81
|
| Rate for Payer: BCBS Trust/PPO |
$33.82
|
| Rate for Payer: BCN Commercial |
$33.82
|
| Rate for Payer: Cash Price |
$32.76
|
| Rate for Payer: Cofinity Commercial |
$35.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.76
|
| Rate for Payer: Healthscope Commercial |
$36.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$30.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$34.81
|
| Rate for Payer: Nomi Health Commercial |
$33.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$30.71
|
| Rate for Payer: PHP Commercial |
$34.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$35.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$28.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.04
|
| Rate for Payer: UHC Core |
$34.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$30.71
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$38.65
|
|
|
Service Code
|
NDC 00409004005
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.81 |
| Max. Negotiated Rate |
$34.78 |
| Rate for Payer: Aetna Commercial |
$32.85
|
| Rate for Payer: Aetna Medicare |
$10.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12.08
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12.08
|
| Rate for Payer: BCBS Complete |
$7.15
|
| Rate for Payer: BCBS MAPPO |
$9.66
|
| Rate for Payer: BCBS Trust/PPO |
$31.77
|
| Rate for Payer: BCN Commercial |
$31.77
|
| Rate for Payer: BCN Medicare Advantage |
$9.66
|
| Rate for Payer: Cash Price |
$30.92
|
| Rate for Payer: Cofinity Commercial |
$33.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.66
|
| Rate for Payer: Healthscope Commercial |
$34.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.99
|
| Rate for Payer: Mclaren Medicaid |
$6.81
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.15
|
| Rate for Payer: Meridian Medicaid |
$7.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.11
|
| Rate for Payer: Molina Medicare/Medicaid |
$10.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.85
|
| Rate for Payer: Nomi Health Commercial |
$31.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.99
|
| Rate for Payer: PACE Senior Care Partners |
$9.18
|
| Rate for Payer: PACE SWMI |
$9.66
|
| Rate for Payer: PHP Commercial |
$32.85
|
| Rate for Payer: PHP Medicare Advantage |
$9.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$6.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$33.63
|
| Rate for Payer: Priority Health Medicare |
$9.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$26.90
|
| Rate for Payer: Railroad Medicare Medicare |
$9.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34.01
|
| Rate for Payer: UHC Core |
$32.27
|
| Rate for Payer: UHC Exchange |
$9.66
|
| Rate for Payer: UHC Medicaid |
$6.81
|
| Rate for Payer: UHC Medicare Advantage |
$9.66
|
| Rate for Payer: UHCCP Medicaid |
$6.81
|
| Rate for Payer: VA VA |
$9.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.99
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$38.63
|
|
|
Service Code
|
NDC 00409205105
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.89 |
| Max. Negotiated Rate |
$34.77 |
| Rate for Payer: Aetna Commercial |
$32.84
|
| Rate for Payer: BCBS Trust/PPO |
$31.90
|
| Rate for Payer: BCN Commercial |
$31.90
|
| Rate for Payer: Cash Price |
$30.90
|
| Rate for Payer: Cofinity Commercial |
$33.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.90
|
| Rate for Payer: Healthscope Commercial |
$34.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.84
|
| Rate for Payer: Nomi Health Commercial |
$31.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.97
|
| Rate for Payer: PHP Commercial |
$32.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$33.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$26.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.99
|
| Rate for Payer: UHC Core |
$32.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.97
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$41.48
|
|
|
Service Code
|
NDC 00143950901
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$37.33 |
| Rate for Payer: Aetna Commercial |
$35.26
|
| Rate for Payer: Aetna Medicare |
$10.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12.96
|
| Rate for Payer: BCBS Complete |
$7.68
|
| Rate for Payer: BCBS MAPPO |
$10.37
|
| Rate for Payer: BCBS Trust/PPO |
$34.10
|
| Rate for Payer: BCN Commercial |
$34.10
|
| Rate for Payer: BCN Medicare Advantage |
$10.37
|
| Rate for Payer: Cash Price |
$33.18
|
| Rate for Payer: Cofinity Commercial |
$35.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$10.37
|
| Rate for Payer: Healthscope Commercial |
$37.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.11
|
| Rate for Payer: Mclaren Medicaid |
$7.31
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.89
|
| Rate for Payer: Meridian Medicaid |
$7.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.93
|
| Rate for Payer: Molina Medicare/Medicaid |
$11.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.26
|
| Rate for Payer: Nomi Health Commercial |
$34.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$31.11
|
| Rate for Payer: PACE Senior Care Partners |
$9.85
|
| Rate for Payer: PACE SWMI |
$10.37
|
| Rate for Payer: PHP Commercial |
$35.26
|
| Rate for Payer: PHP Medicare Advantage |
$10.37
|
| Rate for Payer: Priority Health Choice Medicaid |
$7.31
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$36.09
|
| Rate for Payer: Priority Health Medicare |
$10.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$28.87
|
| Rate for Payer: Railroad Medicare Medicare |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.50
|
| Rate for Payer: UHC Core |
$34.64
|
| Rate for Payer: UHC Exchange |
$10.37
|
| Rate for Payer: UHC Medicaid |
$7.31
|
| Rate for Payer: UHC Medicare Advantage |
$10.37
|
| Rate for Payer: UHCCP Medicaid |
$7.31
|
| Rate for Payer: VA VA |
$10.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.11
|
|
|
KETAMINE 100 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$35.21
|
|
|
Service Code
|
NDC 65219018605
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.51 |
| Max. Negotiated Rate |
$31.69 |
| Rate for Payer: Aetna Commercial |
$29.93
|
| Rate for Payer: BCBS Trust/PPO |
$29.08
|
| Rate for Payer: BCN Commercial |
$29.08
|
| Rate for Payer: Cash Price |
$28.17
|
| Rate for Payer: Cofinity Commercial |
$30.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.17
|
| Rate for Payer: Healthscope Commercial |
$31.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.93
|
| Rate for Payer: Nomi Health Commercial |
$28.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$26.41
|
| Rate for Payer: PHP Commercial |
$29.93
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$30.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$24.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$30.98
|
| Rate for Payer: UHC Core |
$29.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.41
|
|
