|
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 |
$44.00
|
| Rate for Payer: Aetna Commercial |
$57.54
|
| Rate for Payer: Aetna Medicare |
$33.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.00
|
| 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 |
$50.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.54
|
| Rate for Payer: PHP Commercial |
$57.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.00
|
| 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 |
$50.78
|
|
|
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 |
$44.00
|
| Rate for Payer: Aetna Commercial |
$57.54
|
| Rate for Payer: Aetna Medicare |
$33.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.00
|
| 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 |
$50.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.54
|
| Rate for Payer: PHP Commercial |
$57.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.00
|
| 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 |
$50.78
|
|
|
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 |
$30.28 |
| Rate for Payer: Cofinity Commercial |
$23.56
|
| Rate for Payer: Cofinity Commercial |
$28.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.56
|
| 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: Encore Health Key Benefits Commercial |
$26.92
|
| Rate for Payer: Healthscope Commercial |
$30.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.56
|
| 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) 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 |
$30.28 |
| 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 |
$23.56
|
| Rate for Payer: Cofinity Commercial |
$28.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.92
|
| Rate for Payer: Healthscope Commercial |
$30.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.56
|
| 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) 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 |
$32.24
|
| 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 |
$32.24
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IV SYRINGE
|
Facility
|
IP
|
$32.20
|
|
|
Service Code
|
NDC 70092111944
|
| Hospital Charge Code |
118700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.17 |
| Max. Negotiated Rate |
$28.98 |
| Rate for Payer: Aetna American Axle |
$20.93
|
| Rate for Payer: Aetna Commercial |
$27.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.93
|
| 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 |
$14.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.15
|
|
|
KETAMINE 50 MG/5 ML (10 MG/ML) IV SYRINGE
|
Facility
|
OP
|
$42.98
|
|
|
Service Code
|
NDC 70092911944
|
| Hospital Charge Code |
118700
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.90 |
| Max. Negotiated Rate |
$38.68 |
| Rate for Payer: Aetna American Axle |
$27.94
|
| Rate for Payer: Aetna Commercial |
$36.53
|
| Rate for Payer: Aetna Medicare |
$21.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$27.94
|
| Rate for Payer: BCBS Complete |
$17.19
|
| 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 |
$32.24
|
| 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 |
$15.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.24
|
|
|
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/ML INJECTION SOLUTION
|
Facility
|
OP
|
$39.06
|
|
|
Service Code
|
NDC 00143950810
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Aetna American Axle |
$25.39
|
| Rate for Payer: Aetna Commercial |
$33.20
|
| Rate for Payer: Aetna Medicare |
$19.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.39
|
| Rate for Payer: BCBS Complete |
$15.62
|
| Rate for Payer: Cash Price |
$31.25
|
| Rate for Payer: Cofinity Commercial |
$27.34
|
| Rate for Payer: Cofinity Commercial |
$33.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.25
|
| Rate for Payer: Healthscope Commercial |
$35.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.20
|
| Rate for Payer: PHP Commercial |
$33.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.39
|
| Rate for Payer: Priority Health SBD |
$24.61
|
| Rate for Payer: UMR Bronson Commercial |
$14.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.30
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$39.06
|
|
|
Service Code
|
NDC 00143950801
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Aetna American Axle |
$25.39
|
| Rate for Payer: Aetna Commercial |
$33.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.39
|
| Rate for Payer: Cash Price |
$31.25
|
| Rate for Payer: Cofinity Commercial |
$27.34
|
| Rate for Payer: Cofinity Commercial |
$33.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.25
|
| Rate for Payer: Healthscope Commercial |
$35.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.20
|
| Rate for Payer: PHP Commercial |
$33.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.39
|
| Rate for Payer: Priority Health SBD |
$24.61
|
| Rate for Payer: UMR Bronson Commercial |
$17.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.30
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$32.85
|
|
|
Service Code
|
NDC 67457000110
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.15 |
| Max. Negotiated Rate |
$29.56 |
| Rate for Payer: Aetna American Axle |
$21.35
|
| Rate for Payer: Aetna Commercial |
$27.92
|
| Rate for Payer: Aetna Medicare |
$16.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.35
|
| Rate for Payer: BCBS Complete |
$13.14
|
| Rate for Payer: Cash Price |
$26.28
|
| Rate for Payer: Cofinity Commercial |
$23.00
|
| Rate for Payer: Cofinity Commercial |
$28.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.28
|
| Rate for Payer: Healthscope Commercial |
$29.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.92
|
| Rate for Payer: PHP Commercial |
$27.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.35
|
| Rate for Payer: Priority Health SBD |
$20.70
|
| Rate for Payer: UMR Bronson Commercial |
$12.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.64
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$39.06
|
|
|
Service Code
|
NDC 00143950801
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Aetna American Axle |
$25.39
|
| Rate for Payer: Aetna Commercial |
$33.20
|
| Rate for Payer: Aetna Medicare |
$19.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.39
|
| Rate for Payer: BCBS Complete |
$15.62
|
| Rate for Payer: Cash Price |
$31.25
|
| Rate for Payer: Cofinity Commercial |
$27.34
|
| Rate for Payer: Cofinity Commercial |
$33.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.25
|
| Rate for Payer: Healthscope Commercial |
$35.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.20
|
| Rate for Payer: PHP Commercial |
$33.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.39
|
| Rate for Payer: Priority Health SBD |
$24.61
|
| Rate for Payer: UMR Bronson Commercial |
$14.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.30
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$32.65
|
|
|
Service Code
|
NDC 42023011410
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.08 |
| Max. Negotiated Rate |
$29.38 |
| Rate for Payer: Aetna American Axle |
$21.22
|
| Rate for Payer: Aetna Commercial |
$27.75
|
| Rate for Payer: Aetna Medicare |
$16.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.22
|
| Rate for Payer: BCBS Complete |
$13.06
|
| Rate for Payer: Cash Price |
$26.12
|
| Rate for Payer: Cofinity Commercial |
$22.86
|
| Rate for Payer: Cofinity Commercial |
$28.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.12
|
| Rate for Payer: Healthscope Commercial |
$29.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.75
|
| Rate for Payer: PHP Commercial |
$27.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.22
|
| Rate for Payer: Priority Health SBD |
$20.57
|
| Rate for Payer: UMR Bronson Commercial |
$12.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.49
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$23.10
|
|
|
Service Code
|
NDC 00409205310
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.55 |
| Max. Negotiated Rate |
$20.79 |
| Rate for Payer: Aetna American Axle |
$15.02
|
| Rate for Payer: Aetna Commercial |
$19.64
|
| Rate for Payer: Aetna Medicare |
$11.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.02
|
| Rate for Payer: BCBS Complete |
$9.24
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cofinity Commercial |
$16.17
|
| Rate for Payer: Cofinity Commercial |
$19.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.48
|
| Rate for Payer: Healthscope Commercial |
$20.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.64
|
| Rate for Payer: PHP Commercial |
$19.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.02
|
| Rate for Payer: Priority Health SBD |
$14.55
|
| Rate for Payer: UMR Bronson Commercial |
$8.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.32
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$32.65
|
|
|
Service Code
|
NDC 42023011410
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.37 |
| Max. Negotiated Rate |
$29.38 |
| Rate for Payer: Aetna American Axle |
$21.22
|
| Rate for Payer: Aetna Commercial |
$27.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.22
|
| Rate for Payer: Cash Price |
$26.12
|
| Rate for Payer: Cofinity Commercial |
$22.86
|
| Rate for Payer: Cofinity Commercial |
$28.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.12
|
| Rate for Payer: Healthscope Commercial |
$29.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.75
|
| Rate for Payer: PHP Commercial |
$27.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.22
|
| Rate for Payer: Priority Health SBD |
$20.57
|
| Rate for Payer: UMR Bronson Commercial |
$14.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.49
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$32.85
|
|
|
Service Code
|
NDC 67457000100
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$29.56 |
| Rate for Payer: Aetna American Axle |
$21.35
|
| Rate for Payer: Aetna Commercial |
$27.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.35
|
| Rate for Payer: Cash Price |
$26.28
|
| Rate for Payer: Cofinity Commercial |
$23.00
|
| Rate for Payer: Cofinity Commercial |
$28.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.28
|
| Rate for Payer: Healthscope Commercial |
$29.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.92
|
| Rate for Payer: PHP Commercial |
$27.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.35
|
| Rate for Payer: Priority Health SBD |
$20.70
|
| Rate for Payer: UMR Bronson Commercial |
$14.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.64
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$32.85
|
|
|
Service Code
|
NDC 67457000100
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.15 |
| Max. Negotiated Rate |
$29.56 |
| Rate for Payer: Aetna American Axle |
$21.35
|
| Rate for Payer: Aetna Commercial |
$27.92
|
| Rate for Payer: Aetna Medicare |
$16.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.35
|
| Rate for Payer: BCBS Complete |
$13.14
|
| Rate for Payer: Cash Price |
$26.28
|
| Rate for Payer: Cofinity Commercial |
$23.00
|
| Rate for Payer: Cofinity Commercial |
$28.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.28
|
| Rate for Payer: Healthscope Commercial |
$29.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.92
|
| Rate for Payer: PHP Commercial |
$27.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.35
|
| Rate for Payer: Priority Health SBD |
$20.70
|
| Rate for Payer: UMR Bronson Commercial |
$12.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.64
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$32.85
|
|
|
Service Code
|
NDC 67457000110
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.45 |
| Max. Negotiated Rate |
$29.56 |
| Rate for Payer: Aetna American Axle |
$21.35
|
| Rate for Payer: Aetna Commercial |
$27.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.35
|
| Rate for Payer: Cash Price |
$26.28
|
| Rate for Payer: Cofinity Commercial |
$23.00
|
| Rate for Payer: Cofinity Commercial |
$28.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.28
|
| Rate for Payer: Healthscope Commercial |
$29.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.92
|
| Rate for Payer: PHP Commercial |
$27.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.35
|
| Rate for Payer: Priority Health SBD |
$20.70
|
| Rate for Payer: UMR Bronson Commercial |
$14.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.64
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$23.10
|
|
|
Service Code
|
NDC 00409205310
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.16 |
| Max. Negotiated Rate |
$20.79 |
| Rate for Payer: Aetna American Axle |
$15.02
|
| Rate for Payer: Aetna Commercial |
$19.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.02
|
| Rate for Payer: Cash Price |
$18.48
|
| Rate for Payer: Cofinity Commercial |
$16.17
|
| Rate for Payer: Cofinity Commercial |
$19.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.48
|
| Rate for Payer: Healthscope Commercial |
$20.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.64
|
| Rate for Payer: PHP Commercial |
$19.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.02
|
| Rate for Payer: Priority Health SBD |
$14.55
|
| Rate for Payer: UMR Bronson Commercial |
$10.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.32
|
|
|
KETAMINE 50 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$39.06
|
|
|
Service Code
|
NDC 00143950810
|
| Hospital Charge Code |
4238
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.19 |
| Max. Negotiated Rate |
$35.15 |
| Rate for Payer: Aetna American Axle |
$25.39
|
| Rate for Payer: Aetna Commercial |
$33.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.39
|
| Rate for Payer: Cash Price |
$31.25
|
| Rate for Payer: Cofinity Commercial |
$27.34
|
| Rate for Payer: Cofinity Commercial |
$33.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.25
|
| Rate for Payer: Healthscope Commercial |
$35.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.20
|
| Rate for Payer: PHP Commercial |
$33.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.39
|
| Rate for Payer: Priority Health SBD |
$24.61
|
| Rate for Payer: UMR Bronson Commercial |
$17.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.30
|
|
|
KETAMINE (BULK) 100 % POWDER
|
Facility
|
IP
|
$221.91
|
|
|
Service Code
|
NDC 38779175404
|
| Hospital Charge Code |
23101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$97.64 |
| Max. Negotiated Rate |
$199.72 |
| Rate for Payer: Aetna American Axle |
$144.24
|
| Rate for Payer: Aetna Commercial |
$188.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.24
|
| Rate for Payer: Cash Price |
$177.53
|
| Rate for Payer: Cofinity Commercial |
$155.34
|
| Rate for Payer: Cofinity Commercial |
$190.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$155.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.53
|
| Rate for Payer: Healthscope Commercial |
$199.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$155.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$166.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.62
|
| Rate for Payer: PHP Commercial |
$188.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.24
|
| Rate for Payer: Priority Health SBD |
$139.80
|
| Rate for Payer: UMR Bronson Commercial |
$97.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$166.43
|
|
|
KETAMINE (BULK) 100 % POWDER
|
Facility
|
OP
|
$221.91
|
|
|
Service Code
|
NDC 38779175404
|
| Hospital Charge Code |
23101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.11 |
| Max. Negotiated Rate |
$199.72 |
| Rate for Payer: Aetna Medicare |
$110.96
|
| Rate for Payer: Aetna American Axle |
$144.24
|
| Rate for Payer: Aetna Commercial |
$188.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$144.24
|
| Rate for Payer: BCBS Complete |
$88.76
|
| Rate for Payer: Cash Price |
$177.53
|
| Rate for Payer: Cofinity Commercial |
$155.34
|
| Rate for Payer: Cofinity Commercial |
$190.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$155.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.53
|
| Rate for Payer: Healthscope Commercial |
$199.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$155.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$166.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.62
|
| Rate for Payer: PHP Commercial |
$188.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.24
|
| Rate for Payer: Priority Health SBD |
$139.80
|
| Rate for Payer: UMR Bronson Commercial |
$82.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$166.43
|
|
|
KETOCONAZOLE 200 MG TABLET
|
Facility
|
OP
|
$385.92
|
|
|
Service Code
|
NDC 35573043302
|
| Hospital Charge Code |
10369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.79 |
| Max. Negotiated Rate |
$347.33 |
| Rate for Payer: Aetna American Axle |
$250.85
|
| Rate for Payer: Aetna Commercial |
$328.03
|
| Rate for Payer: Aetna Medicare |
$192.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.85
|
| Rate for Payer: BCBS Complete |
$154.37
|
| Rate for Payer: Cash Price |
$308.74
|
| Rate for Payer: Cofinity Commercial |
$270.14
|
| Rate for Payer: Cofinity Commercial |
$331.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$270.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.74
|
| Rate for Payer: Healthscope Commercial |
$347.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$270.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.03
|
| Rate for Payer: PHP Commercial |
$328.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.85
|
| Rate for Payer: Priority Health SBD |
$243.13
|
| Rate for Payer: UMR Bronson Commercial |
$142.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.44
|
|
|
KETOCONAZOLE 200 MG TABLET
|
Facility
|
IP
|
$385.92
|
|
|
Service Code
|
NDC 35573043302
|
| Hospital Charge Code |
10369
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.80 |
| Max. Negotiated Rate |
$347.33 |
| Rate for Payer: Aetna American Axle |
$250.85
|
| Rate for Payer: Aetna Commercial |
$328.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.85
|
| Rate for Payer: Cash Price |
$308.74
|
| Rate for Payer: Cofinity Commercial |
$270.14
|
| Rate for Payer: Cofinity Commercial |
$331.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$270.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.74
|
| Rate for Payer: Healthscope Commercial |
$347.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$270.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.03
|
| Rate for Payer: PHP Commercial |
$328.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$250.85
|
| Rate for Payer: Priority Health SBD |
$243.13
|
| Rate for Payer: UMR Bronson Commercial |
$169.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.44
|
|
|
KETOCONAZOLE 2 % TOPICAL CREAM
|
Facility
|
OP
|
$48.83
|
|
|
Service Code
|
NDC 21922002504
|
| Hospital Charge Code |
10368
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.07 |
| Max. Negotiated Rate |
$43.95 |
| Rate for Payer: Aetna American Axle |
$31.74
|
| Rate for Payer: Aetna Commercial |
$41.51
|
| Rate for Payer: Aetna Medicare |
$24.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.74
|
| Rate for Payer: BCBS Complete |
$19.53
|
| Rate for Payer: Cash Price |
$39.06
|
| Rate for Payer: Cofinity Commercial |
$34.18
|
| Rate for Payer: Cofinity Commercial |
$41.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$34.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.06
|
| Rate for Payer: Healthscope Commercial |
$43.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.51
|
| Rate for Payer: PHP Commercial |
$41.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.74
|
| Rate for Payer: Priority Health SBD |
$30.76
|
| Rate for Payer: UMR Bronson Commercial |
$18.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.62
|
|
