|
ISOSOURCE HN INTERMITTENT FEED
|
Facility
|
IP
|
$4.75
|
|
|
Service Code
|
NDC 43900018457
|
| Hospital Charge Code |
200074
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.09 |
| Max. Negotiated Rate |
$4.28 |
| Rate for Payer: Aetna Commercial |
$4.04
|
| Rate for Payer: BCBS Trust/PPO |
$3.88
|
| 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 Commercial |
$4.04
|
| Rate for Payer: Nomi Health Commercial |
$3.90
|
| Rate for Payer: PHP Commercial |
$4.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.09
|
| Rate for Payer: Priority Health HMO/PPO |
$4.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.18
|
| 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
|
|
|
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 |
$9.17 |
| 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 |
$15.45
|
| Rate for Payer: BCBS MAPPO |
$9.66
|
| Rate for Payer: BCBS Trust/PPO |
$31.76
|
| Rate for Payer: BCN Commercial |
$30.03
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.84
|
| Rate for Payer: Nomi Health Commercial |
$31.68
|
| 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 Cigna Priority Health |
$25.11
|
| Rate for Payer: Priority Health HMO/PPO |
$33.61
|
| Rate for Payer: Priority Health Medicare |
$9.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.88
|
| 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 Dual Complete DSNP |
$9.66
|
| Rate for Payer: UHC Exchange |
$9.66
|
| Rate for Payer: UHC Medicare Advantage |
$9.66
|
| Rate for Payer: VA VA |
$9.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.97
|
|
|
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 |
$25.11 |
| Max. Negotiated Rate |
$34.77 |
| Rate for Payer: Aetna Commercial |
$32.84
|
| Rate for Payer: BCBS Trust/PPO |
$31.53
|
| Rate for Payer: BCN Commercial |
$29.85
|
| 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: PHP Commercial |
$32.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.11
|
| Rate for Payer: Priority Health HMO/PPO |
$33.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.88
|
| 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
|
$38.65
|
|
|
Service Code
|
NDC 00409004005
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.18 |
| 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 |
$15.46
|
| Rate for Payer: BCBS MAPPO |
$9.66
|
| Rate for Payer: BCBS Trust/PPO |
$31.77
|
| Rate for Payer: BCN Commercial |
$30.05
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.85
|
| Rate for Payer: Nomi Health Commercial |
$31.69
|
| 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 Cigna Priority Health |
$25.12
|
| Rate for Payer: Priority Health HMO/PPO |
$33.63
|
| Rate for Payer: Priority Health Medicare |
$9.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.90
|
| 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 Dual Complete DSNP |
$9.66
|
| Rate for Payer: UHC Exchange |
$9.66
|
| Rate for Payer: UHC Medicare Advantage |
$9.66
|
| 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
|
OP
|
$38.63
|
|
|
Service Code
|
NDC 00409205115
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.17 |
| 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 |
$15.45
|
| Rate for Payer: BCBS MAPPO |
$9.66
|
| Rate for Payer: BCBS Trust/PPO |
$31.76
|
| Rate for Payer: BCN Commercial |
$30.03
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.84
|
| Rate for Payer: Nomi Health Commercial |
$31.68
|
| 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 Cigna Priority Health |
$25.11
|
| Rate for Payer: Priority Health HMO/PPO |
$33.61
|
| Rate for Payer: Priority Health Medicare |
$9.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.88
|
| 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 Dual Complete DSNP |
$9.66
|
| Rate for Payer: UHC Exchange |
$9.66
|
| Rate for Payer: UHC Medicare Advantage |
$9.66
|
| 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
|
IP
|
$38.65
|
|
|
Service Code
|
NDC 00409004010
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.12 |
| Max. Negotiated Rate |
$34.78 |
| Rate for Payer: Aetna Commercial |
$32.85
|
| Rate for Payer: BCBS Trust/PPO |
$31.55
|
| Rate for Payer: BCN Commercial |
$29.87
|
| 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: PHP Commercial |
$32.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.12
|
| Rate for Payer: Priority Health HMO/PPO |
$33.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.90
|
| 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
|
$38.63
|
|
|
Service Code
|
NDC 00409205115
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.11 |
| Max. Negotiated Rate |
$34.77 |
| Rate for Payer: Aetna Commercial |
$32.84
|
| Rate for Payer: BCBS Trust/PPO |
$31.53
|
| Rate for Payer: BCN Commercial |
$29.85
|
| 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: PHP Commercial |
$32.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.11
|
| Rate for Payer: Priority Health HMO/PPO |
$33.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.88
|
| 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
|
IP
|
$41.48
|
|
|
Service Code
|
NDC 00143950901
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.96 |
| Max. Negotiated Rate |
$37.33 |
| Rate for Payer: Aetna Commercial |
$35.26
|
| Rate for Payer: BCBS Trust/PPO |
$33.86
|
| Rate for Payer: BCN Commercial |
$32.06
|
| 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: PHP Commercial |
$35.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.96
|
| Rate for Payer: Priority Health HMO/PPO |
$36.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.79
|
| 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
|
OP
|
$41.48
|
|
|
Service Code
|
NDC 00143950910
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.85 |
| 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 |
$16.59
|
| Rate for Payer: BCBS MAPPO |
$10.37
|
| Rate for Payer: BCBS Trust/PPO |
$34.10
|
| Rate for Payer: BCN Commercial |
$32.25
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.26
|
| Rate for Payer: Nomi Health Commercial |
$34.01
|
| 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 Cigna Priority Health |
$26.96
|
| Rate for Payer: Priority Health HMO/PPO |
$36.09
|
| Rate for Payer: Priority Health Medicare |
$10.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.79
|
| 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 Dual Complete DSNP |
$10.37
|
| Rate for Payer: UHC Exchange |
$10.37
|
| Rate for Payer: UHC Medicare Advantage |
$10.37
|
| 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
|
$41.48
|
|
|
Service Code
|
NDC 00143950910
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.96 |
| Max. Negotiated Rate |
$37.33 |
| Rate for Payer: Aetna Commercial |
$35.26
|
| Rate for Payer: BCBS Trust/PPO |
$33.86
|
| Rate for Payer: BCN Commercial |
$32.06
|
| 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: PHP Commercial |
$35.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.96
|
| Rate for Payer: Priority Health HMO/PPO |
$36.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.79
|
| 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
|
OP
|
$41.48
|
|
|
Service Code
|
NDC 00143950901
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.85 |
| 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 |
$16.59
|
| Rate for Payer: BCBS MAPPO |
$10.37
|
| Rate for Payer: BCBS Trust/PPO |
$34.10
|
| Rate for Payer: BCN Commercial |
$32.25
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$35.26
|
| Rate for Payer: Nomi Health Commercial |
$34.01
|
| 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 Cigna Priority Health |
$26.96
|
| Rate for Payer: Priority Health HMO/PPO |
$36.09
|
| Rate for Payer: Priority Health Medicare |
$10.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.79
|
| 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 Dual Complete DSNP |
$10.37
|
| Rate for Payer: UHC Exchange |
$10.37
|
| Rate for Payer: UHC Medicare Advantage |
$10.37
|
| 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
|
OP
|
$38.65
|
|
|
Service Code
|
NDC 00409004010
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.18 |
| 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 |
$15.46
|
| Rate for Payer: BCBS MAPPO |
$9.66
|
| Rate for Payer: BCBS Trust/PPO |
$31.77
|
| Rate for Payer: BCN Commercial |
$30.05
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.85
|
| Rate for Payer: Nomi Health Commercial |
$31.69
|
| 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 Cigna Priority Health |
$25.12
|
| Rate for Payer: Priority Health HMO/PPO |
$33.63
|
| Rate for Payer: Priority Health Medicare |
$9.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.90
|
| 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 Dual Complete DSNP |
$9.66
|
| Rate for Payer: UHC Exchange |
$9.66
|
| Rate for Payer: UHC Medicare Advantage |
$9.66
|
| 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
|
OP
|
$38.63
|
|
|
Service Code
|
NDC 00409205105
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.17 |
| 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 |
$15.45
|
| Rate for Payer: BCBS MAPPO |
$9.66
|
| Rate for Payer: BCBS Trust/PPO |
$31.76
|
| Rate for Payer: BCN Commercial |
$30.03
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.84
|
| Rate for Payer: Nomi Health Commercial |
$31.68
|
| 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 Cigna Priority Health |
$25.11
|
| Rate for Payer: Priority Health HMO/PPO |
$33.61
|
| Rate for Payer: Priority Health Medicare |
$9.75
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.88
|
| 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 Dual Complete DSNP |
$9.66
|
| Rate for Payer: UHC Exchange |
$9.66
|
| Rate for Payer: UHC Medicare Advantage |
$9.66
|
| 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
|
IP
|
$38.65
|
|
|
Service Code
|
NDC 00409004005
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.12 |
| Max. Negotiated Rate |
$34.78 |
| Rate for Payer: Aetna Commercial |
$32.85
|
| Rate for Payer: BCBS Trust/PPO |
$31.55
|
| Rate for Payer: BCN Commercial |
$29.87
|
| 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: PHP Commercial |
$32.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.12
|
| Rate for Payer: Priority Health HMO/PPO |
$33.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.90
|
| 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
|
$38.63
|
|
|
Service Code
|
NDC 00409205105
|
| Hospital Charge Code |
4237
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.11 |
| Max. Negotiated Rate |
$34.77 |
| Rate for Payer: Aetna Commercial |
$32.84
|
| Rate for Payer: BCBS Trust/PPO |
$31.53
|
| Rate for Payer: BCN Commercial |
$29.85
|
| 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: PHP Commercial |
$32.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.11
|
| Rate for Payer: Priority Health HMO/PPO |
$33.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.88
|
| 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 10 MG/ML INJECTION IV (CODE)
|
Facility
|
OP
|
$68.00
|
|
|
Service Code
|
NDC 67457018100
|
| Hospital Charge Code |
163727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.15 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Aetna Commercial |
$57.80
|
| Rate for Payer: Aetna Medicare |
$17.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.25
|
| Rate for Payer: BCBS Complete |
$27.20
|
| Rate for Payer: BCBS MAPPO |
$17.00
|
| Rate for Payer: BCBS Trust/PPO |
$55.90
|
| Rate for Payer: BCN Commercial |
$52.87
|
| Rate for Payer: BCN Medicare Advantage |
$17.00
|
| 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: Health Alliance Plan Medicare Advantage |
$17.00
|
| Rate for Payer: Healthscope Commercial |
$61.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.80
|
| Rate for Payer: Nomi Health Commercial |
$55.76
|
| Rate for Payer: PACE Senior Care Partners |
$16.15
|
| Rate for Payer: PACE SWMI |
$17.00
|
| Rate for Payer: PHP Commercial |
$57.80
|
| Rate for Payer: PHP Medicare Advantage |
$17.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.20
|
| Rate for Payer: Priority Health HMO/PPO |
$59.16
|
| Rate for Payer: Priority Health Medicare |
$17.17
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.56
|
| Rate for Payer: Railroad Medicare Medicare |
$17.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.84
|
| Rate for Payer: UHC Core |
$56.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$17.00
|
| Rate for Payer: UHC Exchange |
$17.00
|
| Rate for Payer: UHC Medicare Advantage |
$17.00
|
| Rate for Payer: VA VA |
$17.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.00
|
|
|
KETAMINE 10 MG/ML INJECTION IV (CODE)
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
NDC 67457018100
|
| Hospital Charge Code |
163727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.20 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Aetna Commercial |
$57.80
|
| Rate for Payer: BCBS Trust/PPO |
$55.51
|
| 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 Commercial |
$57.80
|
| Rate for Payer: Nomi Health Commercial |
$55.76
|
| Rate for Payer: PHP Commercial |
$57.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.20
|
| Rate for Payer: Priority Health HMO/PPO |
$59.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.56
|
| 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 09900000869
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.40 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna Commercial |
$81.60
|
| Rate for Payer: BCBS Trust/PPO |
$78.36
|
| 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 Commercial |
$81.60
|
| Rate for Payer: Nomi Health Commercial |
$78.72
|
| Rate for Payer: PHP Commercial |
$81.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.40
|
| Rate for Payer: Priority Health HMO/PPO |
$83.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$64.32
|
| 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
|
$67.70
|
|
|
Service Code
|
NDC 55150043801
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.01 |
| Max. Negotiated Rate |
$60.93 |
| Rate for Payer: Aetna Commercial |
$57.55
|
| Rate for Payer: BCBS Trust/PPO |
$55.26
|
| Rate for Payer: BCN Commercial |
$52.32
|
| Rate for Payer: Cash Price |
$54.16
|
| Rate for Payer: Cofinity Commercial |
$58.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.16
|
| Rate for Payer: Healthscope Commercial |
$60.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.55
|
| Rate for Payer: Nomi Health Commercial |
$55.51
|
| Rate for Payer: PHP Commercial |
$57.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.01
|
| Rate for Payer: Priority Health HMO/PPO |
$58.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.58
|
| Rate for Payer: UHC Core |
$56.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.77
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$67.70
|
|
|
Service Code
|
NDC 55150043801
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.08 |
| Max. Negotiated Rate |
$60.93 |
| Rate for Payer: Aetna Commercial |
$57.55
|
| Rate for Payer: Aetna Medicare |
$17.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.16
|
| Rate for Payer: BCBS Complete |
$27.08
|
| Rate for Payer: BCBS MAPPO |
$16.93
|
| Rate for Payer: BCBS Trust/PPO |
$55.66
|
| Rate for Payer: BCN Commercial |
$52.64
|
| Rate for Payer: BCN Medicare Advantage |
$16.93
|
| Rate for Payer: Cash Price |
$54.16
|
| Rate for Payer: Cofinity Commercial |
$58.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16.93
|
| Rate for Payer: Healthscope Commercial |
$60.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.77
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.55
|
| Rate for Payer: Nomi Health Commercial |
$55.51
|
| Rate for Payer: PACE Senior Care Partners |
$16.08
|
| Rate for Payer: PACE SWMI |
$16.93
|
| Rate for Payer: PHP Commercial |
$57.55
|
| Rate for Payer: PHP Medicare Advantage |
$16.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.01
|
| Rate for Payer: Priority Health HMO/PPO |
$58.90
|
| Rate for Payer: Priority Health Medicare |
$17.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.36
|
| Rate for Payer: Railroad Medicare Medicare |
$16.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.58
|
| Rate for Payer: UHC Core |
$56.53
|
| Rate for Payer: UHC Dual Complete DSNP |
$16.93
|
| Rate for Payer: UHC Exchange |
$16.93
|
| Rate for Payer: UHC Medicare Advantage |
$16.93
|
| Rate for Payer: VA VA |
$16.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.77
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$55.80
|
|
|
Service Code
|
NDC 25021068220
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$50.22 |
| Rate for Payer: Aetna Commercial |
$47.43
|
| Rate for Payer: Aetna Medicare |
$14.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17.44
|
| Rate for Payer: BCBS Complete |
$22.32
|
| Rate for Payer: BCBS MAPPO |
$13.95
|
| Rate for Payer: BCBS Trust/PPO |
$45.87
|
| Rate for Payer: BCN Commercial |
$43.38
|
| Rate for Payer: BCN Medicare Advantage |
$13.95
|
| Rate for Payer: Cash Price |
$44.64
|
| Rate for Payer: Cofinity Commercial |
$47.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13.95
|
| Rate for Payer: Healthscope Commercial |
$50.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.85
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$14.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.43
|
| Rate for Payer: Nomi Health Commercial |
$45.76
|
| Rate for Payer: PACE Senior Care Partners |
$13.25
|
| Rate for Payer: PACE SWMI |
$13.95
|
| Rate for Payer: PHP Commercial |
$47.43
|
| Rate for Payer: PHP Medicare Advantage |
$13.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.27
|
| Rate for Payer: Priority Health HMO/PPO |
$48.55
|
| Rate for Payer: Priority Health Medicare |
$14.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$37.39
|
| Rate for Payer: Railroad Medicare Medicare |
$13.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$49.10
|
| Rate for Payer: UHC Core |
$46.59
|
| Rate for Payer: UHC Dual Complete DSNP |
$13.95
|
| Rate for Payer: UHC Exchange |
$13.95
|
| Rate for Payer: UHC Medicare Advantage |
$13.95
|
| Rate for Payer: VA VA |
$13.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.85
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$55.80
|
|
|
Service Code
|
NDC 25021068220
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.27 |
| Max. Negotiated Rate |
$50.22 |
| Rate for Payer: Aetna Commercial |
$47.43
|
| Rate for Payer: BCBS Trust/PPO |
$45.55
|
| Rate for Payer: BCN Commercial |
$43.12
|
| Rate for Payer: Cash Price |
$44.64
|
| Rate for Payer: Cofinity Commercial |
$47.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.64
|
| Rate for Payer: Healthscope Commercial |
$50.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.43
|
| Rate for Payer: Nomi Health Commercial |
$45.76
|
| Rate for Payer: PHP Commercial |
$47.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.27
|
| Rate for Payer: Priority Health HMO/PPO |
$48.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$37.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$49.10
|
| Rate for Payer: UHC Core |
$46.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.85
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 69374098255
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna Commercial |
$29.75
|
| Rate for Payer: BCBS Trust/PPO |
$28.57
|
| 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 Commercial |
$29.75
|
| Rate for Payer: Nomi Health Commercial |
$28.70
|
| Rate for Payer: PHP Commercial |
$29.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.75
|
| Rate for Payer: Priority Health HMO/PPO |
$30.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$23.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$30.80
|
| Rate for Payer: UHC Core |
$29.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.25
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$67.70
|
|
|
Service Code
|
NDC 55150043810
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.08 |
| Max. Negotiated Rate |
$60.93 |
| Rate for Payer: Aetna Commercial |
$57.55
|
| Rate for Payer: Aetna Medicare |
$17.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.16
|
| Rate for Payer: BCBS Complete |
$27.08
|
| Rate for Payer: BCBS MAPPO |
$16.93
|
| Rate for Payer: BCBS Trust/PPO |
$55.66
|
| Rate for Payer: BCN Commercial |
$52.64
|
| Rate for Payer: BCN Medicare Advantage |
$16.93
|
| Rate for Payer: Cash Price |
$54.16
|
| Rate for Payer: Cofinity Commercial |
$58.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16.93
|
| Rate for Payer: Healthscope Commercial |
$60.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.77
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.55
|
| Rate for Payer: Nomi Health Commercial |
$55.51
|
| Rate for Payer: PACE Senior Care Partners |
$16.08
|
| Rate for Payer: PACE SWMI |
$16.93
|
| Rate for Payer: PHP Commercial |
$57.55
|
| Rate for Payer: PHP Medicare Advantage |
$16.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.01
|
| Rate for Payer: Priority Health HMO/PPO |
$58.90
|
| Rate for Payer: Priority Health Medicare |
$17.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.36
|
| Rate for Payer: Railroad Medicare Medicare |
$16.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.58
|
| Rate for Payer: UHC Core |
$56.53
|
| Rate for Payer: UHC Dual Complete DSNP |
$16.93
|
| Rate for Payer: UHC Exchange |
$16.93
|
| Rate for Payer: UHC Medicare Advantage |
$16.93
|
| Rate for Payer: VA VA |
$16.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.77
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$67.70
|
|
|
Service Code
|
NDC 55150043810
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.01 |
| Max. Negotiated Rate |
$60.93 |
| Rate for Payer: Aetna Commercial |
$57.55
|
| Rate for Payer: BCBS Trust/PPO |
$55.26
|
| Rate for Payer: BCN Commercial |
$52.32
|
| Rate for Payer: Cash Price |
$54.16
|
| Rate for Payer: Cofinity Commercial |
$58.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.16
|
| Rate for Payer: Healthscope Commercial |
$60.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.55
|
| Rate for Payer: Nomi Health Commercial |
$55.51
|
| Rate for Payer: PHP Commercial |
$57.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.01
|
| Rate for Payer: Priority Health HMO/PPO |
$58.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.58
|
| Rate for Payer: UHC Core |
$56.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.77
|
|
