|
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 |
$17.00 |
| Max. Negotiated Rate |
$34.77 |
| Rate for Payer: Aetna American Axle |
$25.11
|
| Rate for Payer: Aetna Commercial |
$32.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.11
|
| Rate for Payer: Cash Price |
$30.90
|
| Rate for Payer: Cofinity Commercial |
$27.04
|
| Rate for Payer: Cofinity Commercial |
$33.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.90
|
| Rate for Payer: Healthscope Commercial |
$34.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.84
|
| Rate for Payer: PHP Commercial |
$32.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.11
|
| Rate for Payer: Priority Health SBD |
$24.34
|
| Rate for Payer: UMR Bronson Commercial |
$17.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.97
|
|
|
KETAMINE 10 MG/1 ML ORAL SUSPENSION
|
Facility
|
IP
|
$0.67
|
|
|
Service Code
|
NDC 09900001981
|
| Hospital Charge Code |
301699
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna American Axle |
$0.44
|
| Rate for Payer: Aetna Commercial |
$0.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.44
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cofinity Commercial |
$0.47
|
| Rate for Payer: Cofinity Commercial |
$0.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.54
|
| Rate for Payer: Healthscope Commercial |
$0.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.57
|
| Rate for Payer: PHP Commercial |
$0.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.44
|
| Rate for Payer: Priority Health SBD |
$0.42
|
| Rate for Payer: UMR Bronson Commercial |
$0.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.50
|
|
|
KETAMINE 10 MG/1 ML ORAL SUSPENSION
|
Facility
|
OP
|
$0.67
|
|
|
Service Code
|
NDC 09900001981
|
| Hospital Charge Code |
301699
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Aetna American Axle |
$0.44
|
| Rate for Payer: Aetna Commercial |
$0.57
|
| Rate for Payer: Aetna Medicare |
$0.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.44
|
| Rate for Payer: BCBS Complete |
$0.27
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cofinity Commercial |
$0.47
|
| Rate for Payer: Cofinity Commercial |
$0.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.54
|
| Rate for Payer: Healthscope Commercial |
$0.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.57
|
| Rate for Payer: PHP Commercial |
$0.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.44
|
| Rate for Payer: Priority Health SBD |
$0.42
|
| Rate for Payer: UMR Bronson Commercial |
$0.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.50
|
|
|
KETAMINE 10 MG/ML INJECTION IV (CODE)
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
NDC 09900001925
|
| 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: Cofinity Medicare Advantage |
$67.20
|
| 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 Commercial |
$81.60
|
| Rate for Payer: PHP Commercial |
$81.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.40
|
| 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
|
IP
|
$96.00
|
|
|
Service Code
|
NDC 09900000869
|
| 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: Cofinity Medicare Advantage |
$67.20
|
| 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 Commercial |
$81.60
|
| Rate for Payer: PHP Commercial |
$81.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.40
|
| 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
|
OP
|
$96.00
|
|
|
Service Code
|
NDC 09900001925
|
| Hospital Charge Code |
163727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.52 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna American Axle |
$62.40
|
| Rate for Payer: Aetna Commercial |
$81.60
|
| Rate for Payer: Aetna Medicare |
$48.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.40
|
| Rate for Payer: BCBS Complete |
$38.40
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Cofinity Commercial |
$67.20
|
| Rate for Payer: Cofinity Commercial |
$82.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$67.20
|
| 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 Commercial |
$81.60
|
| Rate for Payer: PHP Commercial |
$81.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.40
|
| Rate for Payer: Priority Health SBD |
$60.48
|
| Rate for Payer: UMR Bronson Commercial |
$35.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.00
|
|
|
KETAMINE 10 MG/ML INJECTION IV (CODE)
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
NDC 09900000869
|
| Hospital Charge Code |
163727
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.52 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna American Axle |
$62.40
|
| Rate for Payer: Aetna Commercial |
$81.60
|
| Rate for Payer: Aetna Medicare |
$48.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.40
|
| Rate for Payer: BCBS Complete |
$38.40
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Cofinity Commercial |
$67.20
|
| Rate for Payer: Cofinity Commercial |
$82.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$67.20
|
| 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 Commercial |
$81.60
|
| Rate for Payer: PHP Commercial |
$81.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.40
|
| Rate for Payer: Priority Health SBD |
$60.48
|
| Rate for Payer: UMR Bronson Commercial |
$35.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.00
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$96.00
|
|
|
Service Code
|
NDC 09900001925
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$35.52 |
| Max. Negotiated Rate |
$86.40 |
| Rate for Payer: Aetna American Axle |
$62.40
|
| Rate for Payer: Aetna Commercial |
$81.60
|
| Rate for Payer: Aetna Medicare |
$48.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.40
|
| Rate for Payer: BCBS Complete |
$38.40
|
| Rate for Payer: Cash Price |
$76.80
|
| Rate for Payer: Cofinity Commercial |
$67.20
|
| Rate for Payer: Cofinity Commercial |
$82.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$67.20
|
| 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 Commercial |
$81.60
|
| Rate for Payer: PHP Commercial |
$81.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.40
|
| Rate for Payer: Priority Health SBD |
$60.48
|
| Rate for Payer: UMR Bronson Commercial |
$35.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$72.00
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
NDC 69374030805
|
| 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: Cofinity Medicare Advantage |
$24.50
|
| 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 Commercial |
$29.75
|
| Rate for Payer: PHP Commercial |
$29.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.75
|
| 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
|
OP
|
$68.00
|
|
|
Service Code
|
NDC 67457018120
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.16 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Aetna American Axle |
$44.20
|
| Rate for Payer: Aetna Commercial |
$57.80
|
| Rate for Payer: Aetna Medicare |
$34.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.20
|
| Rate for Payer: BCBS Complete |
$27.20
|
| Rate for Payer: Cash Price |
$54.40
|
| Rate for Payer: Cofinity Commercial |
$47.60
|
| Rate for Payer: Cofinity Commercial |
$58.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.40
|
| Rate for Payer: Healthscope Commercial |
$61.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$47.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.80
|
| Rate for Payer: PHP Commercial |
$57.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.20
|
| Rate for Payer: Priority Health SBD |
$42.84
|
| Rate for Payer: UMR Bronson Commercial |
$25.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.00
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 69374098255
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.95 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna American Axle |
$22.75
|
| Rate for Payer: Aetna Commercial |
$29.75
|
| Rate for Payer: Aetna Medicare |
$17.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.75
|
| Rate for Payer: BCBS Complete |
$14.00
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: Cofinity Commercial |
$24.50
|
| Rate for Payer: Cofinity Commercial |
$30.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.50
|
| 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 Commercial |
$29.75
|
| Rate for Payer: PHP Commercial |
$29.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.75
|
| Rate for Payer: Priority Health SBD |
$22.05
|
| Rate for Payer: UMR Bronson Commercial |
$12.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.25
|
|
|
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 |
$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: Cofinity Medicare Advantage |
$24.50
|
| 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 Commercial |
$29.75
|
| Rate for Payer: PHP Commercial |
$29.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.75
|
| 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
|
IP
|
$67.70
|
|
|
Service Code
|
NDC 55150043810
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.79 |
| Max. Negotiated Rate |
$60.93 |
| Rate for Payer: Aetna American Axle |
$44.01
|
| Rate for Payer: Aetna Commercial |
$57.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.01
|
| Rate for Payer: Cash Price |
$54.16
|
| Rate for Payer: Cofinity Commercial |
$47.39
|
| Rate for Payer: Cofinity Commercial |
$58.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.39
|
| 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 |
$50.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.55
|
| Rate for Payer: PHP Commercial |
$57.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.01
|
| 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 |
$50.77
|
|
|
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 |
$24.55 |
| Max. Negotiated Rate |
$50.22 |
| Rate for Payer: Aetna American Axle |
$36.27
|
| Rate for Payer: Aetna Commercial |
$47.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.27
|
| Rate for Payer: Cash Price |
$44.64
|
| Rate for Payer: Cofinity Commercial |
$39.06
|
| Rate for Payer: Cofinity Commercial |
$47.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.64
|
| Rate for Payer: Healthscope Commercial |
$50.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.43
|
| Rate for Payer: PHP Commercial |
$47.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.27
|
| Rate for Payer: Priority Health SBD |
$35.15
|
| Rate for Payer: UMR Bronson Commercial |
$24.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.85
|
|
|
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 |
$20.65 |
| Max. Negotiated Rate |
$50.22 |
| Rate for Payer: Aetna American Axle |
$36.27
|
| Rate for Payer: Aetna Commercial |
$47.43
|
| Rate for Payer: Aetna Medicare |
$27.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.27
|
| Rate for Payer: BCBS Complete |
$22.32
|
| Rate for Payer: Cash Price |
$44.64
|
| Rate for Payer: Cofinity Commercial |
$39.06
|
| Rate for Payer: Cofinity Commercial |
$47.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.64
|
| Rate for Payer: Healthscope Commercial |
$50.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.43
|
| Rate for Payer: PHP Commercial |
$47.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.27
|
| Rate for Payer: Priority Health SBD |
$35.15
|
| Rate for Payer: UMR Bronson Commercial |
$20.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.85
|
|
|
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 |
$25.05 |
| Max. Negotiated Rate |
$60.93 |
| Rate for Payer: Aetna American Axle |
$44.01
|
| Rate for Payer: Aetna Commercial |
$57.55
|
| Rate for Payer: Aetna Medicare |
$33.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.01
|
| Rate for Payer: BCBS Complete |
$27.08
|
| Rate for Payer: Cash Price |
$54.16
|
| Rate for Payer: Cofinity Commercial |
$47.39
|
| Rate for Payer: Cofinity Commercial |
$58.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.39
|
| 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 |
$50.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.55
|
| Rate for Payer: PHP Commercial |
$57.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.01
|
| Rate for Payer: Priority Health SBD |
$42.65
|
| Rate for Payer: UMR Bronson Commercial |
$25.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.77
|
|
|
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 |
$25.05 |
| Max. Negotiated Rate |
$60.93 |
| Rate for Payer: Aetna American Axle |
$44.01
|
| Rate for Payer: Aetna Commercial |
$57.55
|
| Rate for Payer: Aetna Medicare |
$33.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.01
|
| Rate for Payer: BCBS Complete |
$27.08
|
| Rate for Payer: Cash Price |
$54.16
|
| Rate for Payer: Cofinity Commercial |
$47.39
|
| Rate for Payer: Cofinity Commercial |
$58.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.39
|
| 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 |
$50.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.55
|
| Rate for Payer: PHP Commercial |
$57.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.01
|
| Rate for Payer: Priority Health SBD |
$42.65
|
| Rate for Payer: UMR Bronson Commercial |
$25.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.77
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
NDC 69374030805
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.95 |
| Max. Negotiated Rate |
$31.50 |
| Rate for Payer: Aetna American Axle |
$22.75
|
| Rate for Payer: Aetna Commercial |
$29.75
|
| Rate for Payer: Aetna Medicare |
$17.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.75
|
| Rate for Payer: BCBS Complete |
$14.00
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: Cofinity Commercial |
$24.50
|
| Rate for Payer: Cofinity Commercial |
$30.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.50
|
| 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 Commercial |
$29.75
|
| Rate for Payer: PHP Commercial |
$29.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.75
|
| Rate for Payer: Priority Health SBD |
$22.05
|
| Rate for Payer: UMR Bronson Commercial |
$12.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.25
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$68.00
|
|
|
Service Code
|
NDC 67457018120
|
| Hospital Charge Code |
4236
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.92 |
| Max. Negotiated Rate |
$61.20 |
| Rate for Payer: Aetna American Axle |
$44.20
|
| Rate for Payer: Aetna Commercial |
$57.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.20
|
| Rate for Payer: Cash Price |
$54.40
|
| Rate for Payer: Cofinity Commercial |
$47.60
|
| Rate for Payer: Cofinity Commercial |
$58.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.40
|
| Rate for Payer: Healthscope Commercial |
$61.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$47.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.80
|
| Rate for Payer: PHP Commercial |
$57.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.20
|
| Rate for Payer: Priority Health SBD |
$42.84
|
| Rate for Payer: UMR Bronson Commercial |
$29.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.00
|
|
|
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 |
$29.79 |
| Max. Negotiated Rate |
$60.93 |
| Rate for Payer: Aetna American Axle |
$44.01
|
| Rate for Payer: Aetna Commercial |
$57.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.01
|
| Rate for Payer: Cash Price |
$54.16
|
| Rate for Payer: Cofinity Commercial |
$47.39
|
| Rate for Payer: Cofinity Commercial |
$58.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.39
|
| 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 |
$50.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.55
|
| Rate for Payer: PHP Commercial |
$57.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.01
|
| 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 |
$50.77
|
|
|
KETAMINE 10 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$96.00
|
|
|
Service Code
|
NDC 09900001925
|
| Hospital Charge Code |
4236
|
|
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: Cofinity Medicare Advantage |
$67.20
|
| 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 Commercial |
$81.60
|
| Rate for Payer: PHP Commercial |
$81.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.40
|
| 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 50 MG/5 ML (10 MG/ML) IN SODIUM CHLOR,ISO-OSMOTIC IV SYRINGE
|
Facility
|
OP
|
$33.65
|
|
|
Service Code
|
NDC 73177015602
|
| Hospital Charge Code |
201243
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$30.29 |
| Rate for Payer: Aetna American Axle |
$21.87
|
| Rate for Payer: Aetna Commercial |
$28.60
|
| Rate for Payer: Aetna Medicare |
$16.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.87
|
| Rate for Payer: BCBS Complete |
$13.46
|
| Rate for Payer: Cash Price |
$26.92
|
| Rate for Payer: Cofinity Commercial |
$23.55
|
| Rate for Payer: Cofinity Commercial |
$28.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.92
|
| Rate for Payer: Healthscope Commercial |
$30.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.60
|
| Rate for Payer: PHP Commercial |
$28.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.87
|
| Rate for Payer: Priority Health SBD |
$21.20
|
| Rate for Payer: UMR Bronson Commercial |
$12.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.24
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IN SODIUM CHLOR,ISO-OSMOTIC IV SYRINGE
|
Facility
|
IP
|
$33.65
|
|
|
Service Code
|
NDC 73177015602
|
| Hospital Charge Code |
201243
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.81 |
| Max. Negotiated Rate |
$30.29 |
| Rate for Payer: Aetna American Axle |
$21.87
|
| Rate for Payer: Aetna Commercial |
$28.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.87
|
| Rate for Payer: Cash Price |
$26.92
|
| Rate for Payer: Cofinity Commercial |
$23.55
|
| Rate for Payer: Cofinity Commercial |
$28.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.92
|
| Rate for Payer: Healthscope Commercial |
$30.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.60
|
| Rate for Payer: PHP Commercial |
$28.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.87
|
| Rate for Payer: Priority Health SBD |
$21.20
|
| Rate for Payer: UMR Bronson Commercial |
$14.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.24
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IV SYRINGE
|
Facility
|
OP
|
$32.20
|
|
|
Service Code
|
NDC 70092111944
|
| Hospital Charge Code |
118700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.91 |
| Max. Negotiated Rate |
$28.98 |
| Rate for Payer: Aetna American Axle |
$20.93
|
| Rate for Payer: Aetna Commercial |
$27.37
|
| Rate for Payer: Aetna Medicare |
$16.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.93
|
| Rate for Payer: BCBS Complete |
$12.88
|
| Rate for Payer: Cash Price |
$25.76
|
| Rate for Payer: Cofinity Commercial |
$22.54
|
| Rate for Payer: Cofinity Commercial |
$27.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.76
|
| Rate for Payer: Healthscope Commercial |
$28.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.37
|
| Rate for Payer: PHP Commercial |
$27.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.93
|
| Rate for Payer: Priority Health SBD |
$20.29
|
| Rate for Payer: UMR Bronson Commercial |
$11.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.15
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IV SYRINGE
|
Facility
|
IP
|
$42.98
|
|
|
Service Code
|
NDC 70092911944
|
| Hospital Charge Code |
118700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.91 |
| Max. Negotiated Rate |
$38.68 |
| Rate for Payer: Aetna American Axle |
$27.94
|
| Rate for Payer: Aetna Commercial |
$36.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.94
|
| Rate for Payer: Cash Price |
$34.38
|
| Rate for Payer: Cofinity Commercial |
$30.09
|
| Rate for Payer: Cofinity Commercial |
$36.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$30.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.38
|
| Rate for Payer: Healthscope Commercial |
$38.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.53
|
| Rate for Payer: PHP Commercial |
$36.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.94
|
| Rate for Payer: Priority Health SBD |
$27.08
|
| Rate for Payer: UMR Bronson Commercial |
$18.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.23
|
|
