Bronson Methodist Hospital

All Charges

Charge

Type

Setting

Price

KATE FARMS BOLUS FEED VANILLA 1.4 0.06 GRAM-1.4 KCAL/ML ORAL LIQUID

Facility

$13.23

Service Code	NDC 1111203042
Hospital Charge Code	301450
Hospital Revenue Code	637
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$11.91
Rate for Payer: Aetna American Axle	$8.60
Rate for Payer: Aetna Commercial	$11.25
Rate for Payer: Aetna New Business (MI Preferred)	$8.60
Rate for Payer: Cash Price	$10.58
Rate for Payer: Cofinity Commercial	$11.38
Rate for Payer: Cofinity Commercial	$9.26
Rate for Payer: Encore Health Key Benefits Commercial	$10.58
Rate for Payer: Healthscope Commercial	$11.91
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$9.26
Rate for Payer: Lakeland Regional Health Systems Commercial	$9.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$11.25
Rate for Payer: PHP Commercial	$11.25
Rate for Payer: Priority Health Cigna Priority Health	$9.26
Rate for Payer: Priority Health SBD	$8.33
Rate for Payer: UMR Bronson Commercial	$5.82
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$9.92

KATE FARMS CONTINUOUS FEED VANILLA 1.4 0.06 GRAM-1.4 KCAL/ML ORAL LIQUID

Facility

$13.23

Service Code	NDC 1111203042
Hospital Charge Code	301451
Hospital Revenue Code	637
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$11.91
Rate for Payer: Aetna American Axle	$8.60
Rate for Payer: Aetna Commercial	$11.25
Rate for Payer: Aetna New Business (MI Preferred)	$8.60
Rate for Payer: Cash Price	$10.58
Rate for Payer: Cofinity Commercial	$11.38
Rate for Payer: Cofinity Commercial	$9.26
Rate for Payer: Encore Health Key Benefits Commercial	$10.58
Rate for Payer: Healthscope Commercial	$11.91
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$9.26
Rate for Payer: Lakeland Regional Health Systems Commercial	$9.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$11.25
Rate for Payer: PHP Commercial	$11.25
Rate for Payer: Priority Health Cigna Priority Health	$9.26
Rate for Payer: Priority Health SBD	$8.33
Rate for Payer: UMR Bronson Commercial	$5.82
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$9.92

KATE FARMS CYCLIC FEED VANILLA 1.4 0.06 GRAM-1.4 KCAL/ML ORAL LIQUID

Facility

$13.23

Service Code	NDC 1111203042
Hospital Charge Code	301452
Hospital Revenue Code	637
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$11.91
Rate for Payer: Aetna American Axle	$8.60
Rate for Payer: Aetna Commercial	$11.25
Rate for Payer: Aetna New Business (MI Preferred)	$8.60
Rate for Payer: Cash Price	$10.58
Rate for Payer: Cofinity Commercial	$11.38
Rate for Payer: Cofinity Commercial	$9.26
Rate for Payer: Encore Health Key Benefits Commercial	$10.58
Rate for Payer: Healthscope Commercial	$11.91
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$9.26
Rate for Payer: Lakeland Regional Health Systems Commercial	$9.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$11.25
Rate for Payer: PHP Commercial	$11.25
Rate for Payer: Priority Health Cigna Priority Health	$9.26
Rate for Payer: Priority Health SBD	$8.33
Rate for Payer: UMR Bronson Commercial	$5.82
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$9.92

KATE FARMS INTERMITTENT FEED VANILLA 1.4 0.06 GRAM-1.4 KCAL/ML ORAL LIQUID

Facility

$13.23

Service Code	NDC 1111203042
Hospital Charge Code	301453
Hospital Revenue Code	637
Min. Negotiated Rate	$5.82
Max. Negotiated Rate	$11.91
Rate for Payer: Aetna American Axle	$8.60
Rate for Payer: Aetna Commercial	$11.25
Rate for Payer: Aetna New Business (MI Preferred)	$8.60
Rate for Payer: Cash Price	$10.58
Rate for Payer: Cofinity Commercial	$11.38
Rate for Payer: Cofinity Commercial	$9.26
Rate for Payer: Encore Health Key Benefits Commercial	$10.58
Rate for Payer: Healthscope Commercial	$11.91
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$9.26
Rate for Payer: Lakeland Regional Health Systems Commercial	$9.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$11.25
Rate for Payer: PHP Commercial	$11.25
Rate for Payer: Priority Health Cigna Priority Health	$9.26
Rate for Payer: Priority Health SBD	$8.33
Rate for Payer: UMR Bronson Commercial	$5.82
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$9.92

KATE FARMS PEDIATRIC PEPTIDE BOLUS FEED VANILLA 1.5 0.05 GRAM-1.5 KCAL LIQUID

Facility

$40.70

Service Code	NDC 1111203069
Hospital Charge Code	301447
Hospital Revenue Code	637
Min. Negotiated Rate	$17.91
Max. Negotiated Rate	$36.63
Rate for Payer: Aetna American Axle	$26.46
Rate for Payer: Aetna Commercial	$34.60
Rate for Payer: Aetna New Business (MI Preferred)	$26.46
Rate for Payer: Cash Price	$32.56
Rate for Payer: Cofinity Commercial	$28.49
Rate for Payer: Cofinity Commercial	$35.00
Rate for Payer: Encore Health Key Benefits Commercial	$32.56
Rate for Payer: Healthscope Commercial	$36.63
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$28.49
Rate for Payer: Lakeland Regional Health Systems Commercial	$30.52
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$34.60
Rate for Payer: PHP Commercial	$34.60
Rate for Payer: Priority Health Cigna Priority Health	$28.49
Rate for Payer: Priority Health SBD	$25.64
Rate for Payer: UMR Bronson Commercial	$17.91
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$30.52

KATE FARMS PEDIATRIC PEPTIDE CONTINUOUS FEED VANILLA 1.5 0.05 GRAM-1.5L

Facility

$40.70

Service Code	NDC 5182300687
Hospital Charge Code	301446
Hospital Revenue Code	637
Min. Negotiated Rate	$17.91
Max. Negotiated Rate	$36.63
Rate for Payer: Aetna American Axle	$26.46
Rate for Payer: Aetna Commercial	$34.60
Rate for Payer: Aetna New Business (MI Preferred)	$26.46
Rate for Payer: Cash Price	$32.56
Rate for Payer: Cofinity Commercial	$28.49
Rate for Payer: Cofinity Commercial	$35.00
Rate for Payer: Encore Health Key Benefits Commercial	$32.56
Rate for Payer: Healthscope Commercial	$36.63
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$28.49
Rate for Payer: Lakeland Regional Health Systems Commercial	$30.52
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$34.60
Rate for Payer: PHP Commercial	$34.60
Rate for Payer: Priority Health Cigna Priority Health	$28.49
Rate for Payer: Priority Health SBD	$25.64
Rate for Payer: UMR Bronson Commercial	$17.91
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$30.52

KATE FARMS PEDIATRIC PEPTIDE CONTINUOUS FEED VANILLA 1.5 0.05 GRAM-1.5L

Facility

$40.70

Service Code	NDC 1111203069
Hospital Charge Code	301446
Hospital Revenue Code	637
Min. Negotiated Rate	$17.91
Max. Negotiated Rate	$36.63
Rate for Payer: Aetna American Axle	$26.46
Rate for Payer: Aetna Commercial	$34.60
Rate for Payer: Aetna New Business (MI Preferred)	$26.46
Rate for Payer: Cash Price	$32.56
Rate for Payer: Cofinity Commercial	$28.49
Rate for Payer: Cofinity Commercial	$35.00
Rate for Payer: Encore Health Key Benefits Commercial	$32.56
Rate for Payer: Healthscope Commercial	$36.63
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$28.49
Rate for Payer: Lakeland Regional Health Systems Commercial	$30.52
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$34.60
Rate for Payer: PHP Commercial	$34.60
Rate for Payer: Priority Health Cigna Priority Health	$28.49
Rate for Payer: Priority Health SBD	$25.64
Rate for Payer: UMR Bronson Commercial	$17.91
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$30.52

KATE FARMS PEDIATRIC STANDARD BOLUS FEED VANILLA 1.2 0.05 GRAM-1.2 KCAL

Facility

$15.73

Service Code	NDC 5182300690
Hospital Charge Code	301449
Hospital Revenue Code	637
Min. Negotiated Rate	$6.92
Max. Negotiated Rate	$14.16
Rate for Payer: Aetna American Axle	$10.22
Rate for Payer: Aetna Commercial	$13.37
Rate for Payer: Aetna New Business (MI Preferred)	$10.22
Rate for Payer: Cash Price	$12.58
Rate for Payer: Cofinity Commercial	$11.01
Rate for Payer: Cofinity Commercial	$13.53
Rate for Payer: Encore Health Key Benefits Commercial	$12.58
Rate for Payer: Healthscope Commercial	$14.16
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$11.01
Rate for Payer: Lakeland Regional Health Systems Commercial	$11.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$13.37
Rate for Payer: PHP Commercial	$13.37
Rate for Payer: Priority Health Cigna Priority Health	$11.01
Rate for Payer: Priority Health SBD	$9.91
Rate for Payer: UMR Bronson Commercial	$6.92
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$11.80

KATE FARMS PEDIATRIC STANDARD CONTINUOUS FEED VANILLA 1.2 0.05 GRAM-LIQUID

Facility

$15.73

Service Code	NDC 5182300690
Hospital Charge Code	301448
Hospital Revenue Code	637
Min. Negotiated Rate	$6.92
Max. Negotiated Rate	$14.16
Rate for Payer: Aetna American Axle	$10.22
Rate for Payer: Aetna Commercial	$13.37
Rate for Payer: Aetna New Business (MI Preferred)	$10.22
Rate for Payer: Cash Price	$12.58
Rate for Payer: Cofinity Commercial	$11.01
Rate for Payer: Cofinity Commercial	$13.53
Rate for Payer: Encore Health Key Benefits Commercial	$12.58
Rate for Payer: Healthscope Commercial	$14.16
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$11.01
Rate for Payer: Lakeland Regional Health Systems Commercial	$11.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$13.37
Rate for Payer: PHP Commercial	$13.37
Rate for Payer: Priority Health Cigna Priority Health	$11.01
Rate for Payer: Priority Health SBD	$9.91
Rate for Payer: UMR Bronson Commercial	$6.92
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$11.80

KETAMINE 100 MG/ML INJECTION IM (CODE)

Facility

$32.55

Service Code	NDC 0409-2051-05
Hospital Charge Code	163728
Hospital Revenue Code	250
Min. Negotiated Rate	$14.32
Max. Negotiated Rate	$29.30
Rate for Payer: Aetna American Axle	$21.16
Rate for Payer: Aetna Commercial	$27.67
Rate for Payer: Aetna New Business (MI Preferred)	$21.16
Rate for Payer: Cash Price	$26.04
Rate for Payer: Cofinity Commercial	$22.78
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: Kalamazoo County Sherrif's Dept Commercial	$22.78
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 SBD	$20.51
Rate for Payer: UMR Bronson Commercial	$14.32
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$24.41

KETAMINE 100 MG/ML INJECTION IM (CODE)

Facility

$62.03

Service Code	NDC 42023-115-10
Hospital Charge Code	163728
Hospital Revenue Code	250
Min. Negotiated Rate	$27.29
Max. Negotiated Rate	$55.83
Rate for Payer: Aetna American Axle	$40.32
Rate for Payer: Aetna Commercial	$52.73
Rate for Payer: Aetna New Business (MI Preferred)	$40.32
Rate for Payer: Cash Price	$49.62
Rate for Payer: Cofinity Commercial	$43.42
Rate for Payer: Cofinity Commercial	$53.35
Rate for Payer: Encore Health Key Benefits Commercial	$49.62
Rate for Payer: Healthscope Commercial	$55.83
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$43.42
Rate for Payer: Lakeland Regional Health Systems Commercial	$46.52
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$52.73
Rate for Payer: PHP Commercial	$52.73
Rate for Payer: Priority Health Cigna Priority Health	$43.42
Rate for Payer: Priority Health SBD	$39.08
Rate for Payer: UMR Bronson Commercial	$27.29
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$46.52

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$53.50

Service Code	NDC 55150-440-10
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$23.54
Max. Negotiated Rate	$48.15
Rate for Payer: Aetna American Axle	$34.78
Rate for Payer: Aetna Commercial	$45.48
Rate for Payer: Aetna New Business (MI Preferred)	$34.78
Rate for Payer: Cash Price	$42.80
Rate for Payer: Cofinity Commercial	$37.45
Rate for Payer: Cofinity Commercial	$46.01
Rate for Payer: Encore Health Key Benefits Commercial	$42.80
Rate for Payer: Healthscope Commercial	$48.15
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$37.45
Rate for Payer: Lakeland Regional Health Systems Commercial	$40.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$45.48
Rate for Payer: PHP Commercial	$45.48
Rate for Payer: Priority Health Cigna Priority Health	$37.45
Rate for Payer: Priority Health SBD	$33.70
Rate for Payer: UMR Bronson Commercial	$23.54
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$40.12

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$32.55

Service Code	NDC 0409-2051-05
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$14.32
Max. Negotiated Rate	$29.30
Rate for Payer: Aetna American Axle	$21.16
Rate for Payer: Aetna Commercial	$27.67
Rate for Payer: Aetna New Business (MI Preferred)	$21.16
Rate for Payer: Cash Price	$26.04
Rate for Payer: Cofinity Commercial	$22.78
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: Kalamazoo County Sherrif's Dept Commercial	$22.78
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 SBD	$20.51
Rate for Payer: UMR Bronson Commercial	$14.32
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$24.41

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$45.75

Service Code	NDC 81483-0007-0
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$20.13
Max. Negotiated Rate	$41.18
Rate for Payer: Aetna American Axle	$29.74
Rate for Payer: Aetna Commercial	$38.89
Rate for Payer: Aetna New Business (MI Preferred)	$29.74
Rate for Payer: Cash Price	$36.60
Rate for Payer: Cofinity Commercial	$32.02
Rate for Payer: Cofinity Commercial	$39.34
Rate for Payer: Encore Health Key Benefits Commercial	$36.60
Rate for Payer: Healthscope Commercial	$41.18
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$32.02
Rate for Payer: Lakeland Regional Health Systems Commercial	$34.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$38.89
Rate for Payer: PHP Commercial	$38.89
Rate for Payer: Priority Health Cigna Priority Health	$32.02
Rate for Payer: Priority Health SBD	$28.82
Rate for Payer: UMR Bronson Commercial	$20.13
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$34.31

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$53.50

Service Code	NDC 55150-440-01
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$23.54
Max. Negotiated Rate	$48.15
Rate for Payer: Aetna American Axle	$34.78
Rate for Payer: Aetna Commercial	$45.48
Rate for Payer: Aetna New Business (MI Preferred)	$34.78
Rate for Payer: Cash Price	$42.80
Rate for Payer: Cofinity Commercial	$37.45
Rate for Payer: Cofinity Commercial	$46.01
Rate for Payer: Encore Health Key Benefits Commercial	$42.80
Rate for Payer: Healthscope Commercial	$48.15
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$37.45
Rate for Payer: Lakeland Regional Health Systems Commercial	$40.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$45.48
Rate for Payer: PHP Commercial	$45.48
Rate for Payer: Priority Health Cigna Priority Health	$37.45
Rate for Payer: Priority Health SBD	$33.70
Rate for Payer: UMR Bronson Commercial	$23.54
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$40.12

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$54.45

Service Code	NDC 67457-108-10
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$23.96
Max. Negotiated Rate	$49.00
Rate for Payer: Aetna American Axle	$35.39
Rate for Payer: Aetna Commercial	$46.28
Rate for Payer: Aetna New Business (MI Preferred)	$35.39
Rate for Payer: Cash Price	$43.56
Rate for Payer: Cofinity Commercial	$38.12
Rate for Payer: Cofinity Commercial	$46.83
Rate for Payer: Encore Health Key Benefits Commercial	$43.56
Rate for Payer: Healthscope Commercial	$49.00
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$38.12
Rate for Payer: Lakeland Regional Health Systems Commercial	$40.84
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$46.28
Rate for Payer: PHP Commercial	$46.28
Rate for Payer: Priority Health Cigna Priority Health	$38.12
Rate for Payer: Priority Health SBD	$34.30
Rate for Payer: UMR Bronson Commercial	$23.96
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$40.84

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$59.03

Service Code	NDC 0143-9509-01
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$25.97
Max. Negotiated Rate	$53.13
Rate for Payer: Aetna American Axle	$38.37
Rate for Payer: Aetna Commercial	$50.18
Rate for Payer: Aetna New Business (MI Preferred)	$38.37
Rate for Payer: Cash Price	$47.22
Rate for Payer: Cofinity Commercial	$41.32
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: Kalamazoo County Sherrif's Dept Commercial	$41.32
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 SBD	$37.19
Rate for Payer: UMR Bronson Commercial	$25.97
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$44.27

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$62.03

Service Code	NDC 42023-115-10
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$27.29
Max. Negotiated Rate	$55.83
Rate for Payer: Aetna American Axle	$40.32
Rate for Payer: Aetna Commercial	$52.73
Rate for Payer: Aetna New Business (MI Preferred)	$40.32
Rate for Payer: Cash Price	$49.62
Rate for Payer: Cofinity Commercial	$43.42
Rate for Payer: Cofinity Commercial	$53.35
Rate for Payer: Encore Health Key Benefits Commercial	$49.62
Rate for Payer: Healthscope Commercial	$55.83
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$43.42
Rate for Payer: Lakeland Regional Health Systems Commercial	$46.52
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$52.73
Rate for Payer: PHP Commercial	$52.73
Rate for Payer: Priority Health Cigna Priority Health	$43.42
Rate for Payer: Priority Health SBD	$39.08
Rate for Payer: UMR Bronson Commercial	$27.29
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$46.52

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$54.45

Service Code	NDC 67457-108-00
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$23.96
Max. Negotiated Rate	$49.00
Rate for Payer: Aetna American Axle	$35.39
Rate for Payer: Aetna Commercial	$46.28
Rate for Payer: Aetna New Business (MI Preferred)	$35.39
Rate for Payer: Cash Price	$43.56
Rate for Payer: Cofinity Commercial	$38.12
Rate for Payer: Cofinity Commercial	$46.83
Rate for Payer: Encore Health Key Benefits Commercial	$43.56
Rate for Payer: Healthscope Commercial	$49.00
Rate for Payer: Kalamazoo County Sherrif's Dept Commercial	$38.12
Rate for Payer: Lakeland Regional Health Systems Commercial	$40.84
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$46.28
Rate for Payer: PHP Commercial	$46.28
Rate for Payer: Priority Health Cigna Priority Health	$38.12
Rate for Payer: Priority Health SBD	$34.30
Rate for Payer: UMR Bronson Commercial	$23.96
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$40.84

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$59.03

Service Code	NDC 0143-9509-10
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$25.97
Max. Negotiated Rate	$53.13
Rate for Payer: Aetna American Axle	$38.37
Rate for Payer: Aetna Commercial	$50.18
Rate for Payer: Aetna New Business (MI Preferred)	$38.37
Rate for Payer: Cash Price	$47.22
Rate for Payer: Cofinity Commercial	$41.32
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: Kalamazoo County Sherrif's Dept Commercial	$41.32
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 SBD	$37.19
Rate for Payer: UMR Bronson Commercial	$25.97
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$44.27

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$32.55

Service Code	NDC 0409-2051-15
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$14.32
Max. Negotiated Rate	$29.30
Rate for Payer: Aetna American Axle	$21.16
Rate for Payer: Aetna Commercial	$27.67
Rate for Payer: Aetna New Business (MI Preferred)	$21.16
Rate for Payer: Cash Price	$26.04
Rate for Payer: Cofinity Commercial	$22.78
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: Kalamazoo County Sherrif's Dept Commercial	$22.78
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 SBD	$20.51
Rate for Payer: UMR Bronson Commercial	$14.32
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$24.41

KETAMINE 10 MG/ML INJECTION IV (CODE)

Facility

$96.00

Service Code	NDC 9900-0019-25
Hospital Charge Code	163727
Hospital Revenue Code	250
Min. Negotiated Rate	$42.24
Max. Negotiated Rate	$86.40
Rate for Payer: Aetna American Axle	$62.40
Rate for Payer: Aetna Commercial	$81.60
Rate for Payer: Aetna New Business (MI Preferred)	$62.40
Rate for Payer: Cash Price	$76.80
Rate for Payer: Cofinity Commercial	$67.20
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: Kalamazoo County Sherrif's Dept Commercial	$67.20
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 SBD	$60.48
Rate for Payer: UMR Bronson Commercial	$42.24
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$72.00

KETAMINE 10 MG/ML INJECTION IV (CODE)

Facility

$96.00

Service Code	NDC 9900-0008-69
Hospital Charge Code	163727
Hospital Revenue Code	250
Min. Negotiated Rate	$42.24
Max. Negotiated Rate	$86.40
Rate for Payer: Aetna American Axle	$62.40
Rate for Payer: Aetna Commercial	$81.60
Rate for Payer: Aetna New Business (MI Preferred)	$62.40
Rate for Payer: Cash Price	$76.80
Rate for Payer: Cofinity Commercial	$67.20
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: Kalamazoo County Sherrif's Dept Commercial	$67.20
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 SBD	$60.48
Rate for Payer: UMR Bronson Commercial	$42.24
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$72.00

KETAMINE 10 MG/ML INJECTION SOLUTION

Facility

$35.00

Service Code	NDC 69374-308-05
Hospital Charge Code	4236
Hospital Revenue Code	250
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$31.50
Rate for Payer: Aetna American Axle	$22.75
Rate for Payer: Aetna Commercial	$29.75
Rate for Payer: Aetna New Business (MI Preferred)	$22.75
Rate for Payer: Cash Price	$28.00
Rate for Payer: Cofinity Commercial	$24.50
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: Kalamazoo County Sherrif's Dept Commercial	$24.50
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 SBD	$22.05
Rate for Payer: UMR Bronson Commercial	$15.40
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$26.25

KETAMINE 10 MG/ML INJECTION SOLUTION

Facility

$67.70

Service Code	NDC 55150-438-10
Hospital Charge Code	4236
Hospital Revenue Code	250
Min. Negotiated Rate	$29.79
Max. Negotiated Rate	$60.93
Rate for Payer: Aetna American Axle	$44.00
Rate for Payer: Aetna Commercial	$57.54
Rate for Payer: Aetna New Business (MI Preferred)	$44.00
Rate for Payer: Cash Price	$54.16
Rate for Payer: Cofinity Commercial	$47.39
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: Kalamazoo County Sherrif's Dept Commercial	$47.39
Rate for Payer: Lakeland Regional Health Systems Commercial	$50.78
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$57.54
Rate for Payer: PHP Commercial	$57.54
Rate for Payer: Priority Health Cigna Priority Health	$47.39
Rate for Payer: Priority Health SBD	$42.65
Rate for Payer: UMR Bronson Commercial	$29.79
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$50.78

Know your out-of-pocket cost for care.

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