Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR

Facility

$292.60

Service Code	NDC 904645061
Hospital Charge Code	24268
Hospital Revenue Code	637
Min. Negotiated Rate	$219.45
Max. Negotiated Rate	$292.60
Rate for Payer: Aetna Commercial	$263.34
Rate for Payer: ASR ASR	$283.82
Rate for Payer: BCBS Trust/PPO	$240.28
Rate for Payer: BCN Commercial	$240.28
Rate for Payer: Cash Price	$234.08
Rate for Payer: Cofinity Commercial	$275.04
Rate for Payer: Encore Health Key Benefits Commercial	$234.08
Rate for Payer: Healthscope Commercial	$283.82
Rate for Payer: Healthscope Whirlpool	$292.60
Rate for Payer: Mclaren Commercial	$263.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$248.71
Rate for Payer: Nomi Health Commercial	$239.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$219.45
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$257.49

ISOSOURCE 1.5 BOLUS FEED

Facility

$4.75

Service Code	NDC 43900018150
Hospital Charge Code	150768
Hospital Revenue Code	637
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Trust/PPO	$3.90
Rate for Payer: BCN Commercial	$3.90
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE 1.5 BOLUS FEED

Facility

$4.75

Service Code	NDC 43900018150
Hospital Charge Code	150768
Hospital Revenue Code	637
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: Aetna Medicare	$1.76
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Complete	$1.90
Rate for Payer: BCBS Trust/PPO	$3.92
Rate for Payer: BCN Commercial	$3.92
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: MI Amish Medical Board Commercial	$3.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$4.16
Rate for Payer: Priority Health Narrow Network	$3.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE 1.5 CONTINUOUS FEED

Facility

$4.75

Service Code	NDC 43900018150
Hospital Charge Code	168943
Hospital Revenue Code	637
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: Aetna Medicare	$1.76
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Complete	$1.90
Rate for Payer: BCBS Trust/PPO	$3.92
Rate for Payer: BCN Commercial	$3.92
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: MI Amish Medical Board Commercial	$3.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$4.16
Rate for Payer: Priority Health Narrow Network	$3.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE 1.5 CONTINUOUS FEED

Facility

$4.75

Service Code	NDC 43900018150
Hospital Charge Code	168943
Hospital Revenue Code	637
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Trust/PPO	$3.90
Rate for Payer: BCN Commercial	$3.90
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE 1.5 CONTINUOUS FEED

Facility

$9.60

Service Code	NDC 43900018181
Hospital Charge Code	168943
Hospital Revenue Code	637
Min. Negotiated Rate	$3.55
Max. Negotiated Rate	$9.60
Rate for Payer: Aetna Commercial	$8.64
Rate for Payer: Aetna Medicare	$3.55
Rate for Payer: ASR ASR	$9.31
Rate for Payer: BCBS Complete	$3.84
Rate for Payer: BCBS Trust/PPO	$7.92
Rate for Payer: BCN Commercial	$7.92
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Commercial	$9.02
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$9.31
Rate for Payer: Healthscope Whirlpool	$9.60
Rate for Payer: Mclaren Commercial	$8.64
Rate for Payer: MI Amish Medical Board Commercial	$7.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Nomi Health Commercial	$7.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$8.41
Rate for Payer: Priority Health Narrow Network	$6.73
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$8.45

ISOSOURCE 1.5 CONTINUOUS FEED

Facility

$9.60

Service Code	NDC 43900018181
Hospital Charge Code	168943
Hospital Revenue Code	637
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$9.60
Rate for Payer: Aetna Commercial	$8.64
Rate for Payer: ASR ASR	$9.31
Rate for Payer: BCBS Trust/PPO	$7.88
Rate for Payer: BCN Commercial	$7.88
Rate for Payer: Cash Price	$7.68
Rate for Payer: Cofinity Commercial	$9.02
Rate for Payer: Encore Health Key Benefits Commercial	$7.68
Rate for Payer: Healthscope Commercial	$9.31
Rate for Payer: Healthscope Whirlpool	$9.60
Rate for Payer: Mclaren Commercial	$8.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.16
Rate for Payer: Nomi Health Commercial	$7.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$7.20
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$8.45

ISOSOURCE 1.5 CYCLIC FEED

Facility

$4.75

Service Code	NDC 43900018150
Hospital Charge Code	200081
Hospital Revenue Code	637
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Trust/PPO	$3.90
Rate for Payer: BCN Commercial	$3.90
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE 1.5 CYCLIC FEED

Facility

$4.75

Service Code	NDC 43900018150
Hospital Charge Code	200081
Hospital Revenue Code	637
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: Aetna Medicare	$1.76
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Complete	$1.90
Rate for Payer: BCBS Trust/PPO	$3.92
Rate for Payer: BCN Commercial	$3.92
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: MI Amish Medical Board Commercial	$3.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$4.16
Rate for Payer: Priority Health Narrow Network	$3.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE 1.5 INTERMITTENT FEED

Facility

$4.75

Service Code	NDC 43900018150
Hospital Charge Code	200080
Hospital Revenue Code	637
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: Aetna Medicare	$1.76
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Complete	$1.90
Rate for Payer: BCBS Trust/PPO	$3.92
Rate for Payer: BCN Commercial	$3.92
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: MI Amish Medical Board Commercial	$3.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$4.16
Rate for Payer: Priority Health Narrow Network	$3.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE 1.5 INTERMITTENT FEED

Facility

$4.75

Service Code	NDC 43900018150
Hospital Charge Code	200080
Hospital Revenue Code	637
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Trust/PPO	$3.90
Rate for Payer: BCN Commercial	$3.90
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE HN BOLUS FEED

Facility

$4.75

Service Code	NDC 43900018457
Hospital Charge Code	150769
Hospital Revenue Code	637
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Trust/PPO	$3.90
Rate for Payer: BCN Commercial	$3.90
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE HN BOLUS FEED

Facility

$4.75

Service Code	NDC 43900018457
Hospital Charge Code	150769
Hospital Revenue Code	637
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: Aetna Medicare	$1.76
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Complete	$1.90
Rate for Payer: BCBS Trust/PPO	$3.92
Rate for Payer: BCN Commercial	$3.92
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: MI Amish Medical Board Commercial	$3.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$4.16
Rate for Payer: Priority Health Narrow Network	$3.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE HN CONTINUOUS FEED

Facility

$4.75

Service Code	NDC 43900018457
Hospital Charge Code	168942
Hospital Revenue Code	637
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Trust/PPO	$3.90
Rate for Payer: BCN Commercial	$3.90
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE HN CONTINUOUS FEED

Facility

$4.75

Service Code	NDC 43900018457
Hospital Charge Code	168942
Hospital Revenue Code	637
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: Aetna Medicare	$1.76
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Complete	$1.90
Rate for Payer: BCBS Trust/PPO	$3.92
Rate for Payer: BCN Commercial	$3.92
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: MI Amish Medical Board Commercial	$3.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$4.16
Rate for Payer: Priority Health Narrow Network	$3.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE HN CYCLIC FEED

Facility

$4.75

Service Code	NDC 43900018457
Hospital Charge Code	200075
Hospital Revenue Code	637
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: Aetna Medicare	$1.76
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Complete	$1.90
Rate for Payer: BCBS Trust/PPO	$3.92
Rate for Payer: BCN Commercial	$3.92
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: MI Amish Medical Board Commercial	$3.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$4.16
Rate for Payer: Priority Health Narrow Network	$3.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE HN CYCLIC FEED

Facility

$4.75

Service Code	NDC 43900018457
Hospital Charge Code	200075
Hospital Revenue Code	637
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Trust/PPO	$3.90
Rate for Payer: BCN Commercial	$3.90
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE HN INTERMITTENT FEED

Facility

$4.75

Service Code	NDC 43900018457
Hospital Charge Code	200074
Hospital Revenue Code	637
Min. Negotiated Rate	$3.56
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Trust/PPO	$3.90
Rate for Payer: BCN Commercial	$3.90
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE HN INTERMITTENT FEED

Facility

$4.75

Service Code	NDC 43900018457
Hospital Charge Code	200074
Hospital Revenue Code	637
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: Aetna Medicare	$1.76
Rate for Payer: ASR ASR	$4.61
Rate for Payer: BCBS Complete	$1.90
Rate for Payer: BCBS Trust/PPO	$3.92
Rate for Payer: BCN Commercial	$3.92
Rate for Payer: Cash Price	$3.80
Rate for Payer: Cofinity Commercial	$4.46
Rate for Payer: Encore Health Key Benefits Commercial	$3.80
Rate for Payer: Healthscope Commercial	$4.61
Rate for Payer: Healthscope Whirlpool	$4.75
Rate for Payer: Mclaren Commercial	$4.28
Rate for Payer: MI Amish Medical Board Commercial	$3.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.04
Rate for Payer: Nomi Health Commercial	$3.90
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.56
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$4.16
Rate for Payer: Priority Health Narrow Network	$3.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE HN ORAL LIQUID

Facility

$61.27

Service Code	NDC 70074056016
Hospital Charge Code	157366
Hospital Revenue Code	637
Min. Negotiated Rate	$45.95
Max. Negotiated Rate	$61.27
Rate for Payer: Aetna Commercial	$55.14
Rate for Payer: ASR ASR	$59.43
Rate for Payer: BCBS Trust/PPO	$50.31
Rate for Payer: BCN Commercial	$50.31
Rate for Payer: Cash Price	$49.01
Rate for Payer: Cofinity Commercial	$57.59
Rate for Payer: Encore Health Key Benefits Commercial	$49.01
Rate for Payer: Healthscope Commercial	$59.43
Rate for Payer: Healthscope Whirlpool	$61.27
Rate for Payer: Mclaren Commercial	$55.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$52.08
Rate for Payer: Nomi Health Commercial	$50.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$45.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$53.91

ISOSOURCE HN ORAL LIQUID

Facility

$61.27

Service Code	NDC 70074056016
Hospital Charge Code	157366
Hospital Revenue Code	637
Min. Negotiated Rate	$22.67
Max. Negotiated Rate	$61.27
Rate for Payer: Aetna Commercial	$55.14
Rate for Payer: Aetna Medicare	$22.67
Rate for Payer: ASR ASR	$59.43
Rate for Payer: BCBS Complete	$24.51
Rate for Payer: BCBS Trust/PPO	$50.51
Rate for Payer: BCN Commercial	$50.51
Rate for Payer: Cash Price	$49.01
Rate for Payer: Cofinity Commercial	$57.59
Rate for Payer: Encore Health Key Benefits Commercial	$49.01
Rate for Payer: Healthscope Commercial	$59.43
Rate for Payer: Healthscope Whirlpool	$61.27
Rate for Payer: Mclaren Commercial	$55.14
Rate for Payer: MI Amish Medical Board Commercial	$49.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$52.08
Rate for Payer: Nomi Health Commercial	$50.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$45.95
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$53.68
Rate for Payer: Priority Health Narrow Network	$42.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$53.91

JEVITY PLUS 1.2 CAL ORAL LIQUID CUSTOM

Facility

$5.57

Service Code	NDC 70074053119
Hospital Charge Code	150865
Hospital Revenue Code	637
Min. Negotiated Rate	$4.18
Max. Negotiated Rate	$5.57
Rate for Payer: Aetna Commercial	$5.01
Rate for Payer: ASR ASR	$5.40
Rate for Payer: BCBS Trust/PPO	$4.57
Rate for Payer: BCN Commercial	$4.57
Rate for Payer: Cash Price	$4.46
Rate for Payer: Cofinity Commercial	$5.24
Rate for Payer: Encore Health Key Benefits Commercial	$4.46
Rate for Payer: Healthscope Commercial	$5.40
Rate for Payer: Healthscope Whirlpool	$5.57
Rate for Payer: Mclaren Commercial	$5.01
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.73
Rate for Payer: Nomi Health Commercial	$4.57
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.90

JEVITY PLUS 1.2 CAL ORAL LIQUID CUSTOM

Facility

$5.57

Service Code	NDC 70074053119
Hospital Charge Code	150865
Hospital Revenue Code	637
Min. Negotiated Rate	$2.06
Max. Negotiated Rate	$5.57
Rate for Payer: Aetna Commercial	$5.01
Rate for Payer: Aetna Medicare	$2.06
Rate for Payer: ASR ASR	$5.40
Rate for Payer: BCBS Complete	$2.23
Rate for Payer: BCBS Trust/PPO	$4.59
Rate for Payer: BCN Commercial	$4.59
Rate for Payer: Cash Price	$4.46
Rate for Payer: Cofinity Commercial	$5.24
Rate for Payer: Encore Health Key Benefits Commercial	$4.46
Rate for Payer: Healthscope Commercial	$5.40
Rate for Payer: Healthscope Whirlpool	$5.57
Rate for Payer: Mclaren Commercial	$5.01
Rate for Payer: MI Amish Medical Board Commercial	$4.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$4.73
Rate for Payer: Nomi Health Commercial	$4.57
Rate for Payer: Opus (Opus Packaging Group) HMA	$4.18
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$4.88
Rate for Payer: Priority Health Narrow Network	$3.90
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.90

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$35.21

Service Code	NDC 65219018605
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$13.03
Max. Negotiated Rate	$35.21
Rate for Payer: Aetna Commercial	$31.69
Rate for Payer: Aetna Medicare	$13.03
Rate for Payer: ASR ASR	$34.15
Rate for Payer: BCBS Complete	$14.08
Rate for Payer: BCBS Trust/PPO	$29.03
Rate for Payer: BCN Commercial	$29.03
Rate for Payer: Cash Price	$28.17
Rate for Payer: Cofinity Commercial	$33.10
Rate for Payer: Encore Health Key Benefits Commercial	$28.17
Rate for Payer: Healthscope Commercial	$34.15
Rate for Payer: Healthscope Whirlpool	$35.21
Rate for Payer: Mclaren Commercial	$31.69
Rate for Payer: MI Amish Medical Board Commercial	$28.17
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$29.93
Rate for Payer: Nomi Health Commercial	$28.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$26.41
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$30.85
Rate for Payer: Priority Health Narrow Network	$24.68
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$30.98

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$35.21

Service Code	NDC 65219018605
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$26.41
Max. Negotiated Rate	$35.21
Rate for Payer: Aetna Commercial	$31.69
Rate for Payer: ASR ASR	$34.15
Rate for Payer: BCBS Trust/PPO	$28.91
Rate for Payer: BCN Commercial	$28.91
Rate for Payer: Cash Price	$28.17
Rate for Payer: Cofinity Commercial	$33.10
Rate for Payer: Encore Health Key Benefits Commercial	$28.17
Rate for Payer: Healthscope Commercial	$34.15
Rate for Payer: Healthscope Whirlpool	$35.21
Rate for Payer: Mclaren Commercial	$31.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$29.93
Rate for Payer: Nomi Health Commercial	$28.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$26.41
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$30.98

Know your out-of-pocket cost for care.

All Charges