Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

ISOSOURCE 1.5 INTERMITTENT FEED

Facility

$4.75

Service Code	NDC 43900018150
Hospital Charge Code	200080
Hospital Revenue Code	637
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: ASR ASR	$4.61
Rate for Payer: ASR Commercial	$4.61
Rate for Payer: BCBS Trust/PPO	$3.87
Rate for Payer: BCN Commercial	$3.68
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	$4.75
Rate for Payer: Healthscope Whirlpool	$4.61
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: Priority Health Cigna Priority Health	$3.09
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	$3.09
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: ASR ASR	$4.61
Rate for Payer: ASR Commercial	$4.61
Rate for Payer: BCBS Trust/PPO	$3.87
Rate for Payer: BCN Commercial	$3.68
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	$4.75
Rate for Payer: Healthscope Whirlpool	$4.61
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: Priority Health Cigna Priority Health	$3.09
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	$1.90
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: Aetna Medicare	$2.38
Rate for Payer: ASR ASR	$4.61
Rate for Payer: ASR Commercial	$4.61
Rate for Payer: BCBS Complete	$1.90
Rate for Payer: BCBS Trust/PPO	$3.89
Rate for Payer: BCN Commercial	$3.68
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	$4.75
Rate for Payer: Healthscope Whirlpool	$4.61
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: Priority Health Cigna Priority Health	$3.09
Rate for Payer: 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	$3.09
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: ASR ASR	$4.61
Rate for Payer: ASR Commercial	$4.61
Rate for Payer: BCBS Trust/PPO	$3.87
Rate for Payer: BCN Commercial	$3.68
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	$4.75
Rate for Payer: Healthscope Whirlpool	$4.61
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: Priority Health Cigna Priority Health	$3.09
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	$1.90
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: Aetna Medicare	$2.38
Rate for Payer: ASR ASR	$4.61
Rate for Payer: ASR Commercial	$4.61
Rate for Payer: BCBS Complete	$1.90
Rate for Payer: BCBS Trust/PPO	$3.89
Rate for Payer: BCN Commercial	$3.68
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	$4.75
Rate for Payer: Healthscope Whirlpool	$4.61
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: Priority Health Cigna Priority Health	$3.09
Rate for Payer: 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	$1.90
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: Aetna Medicare	$2.38
Rate for Payer: ASR ASR	$4.61
Rate for Payer: ASR Commercial	$4.61
Rate for Payer: BCBS Complete	$1.90
Rate for Payer: BCBS Trust/PPO	$3.89
Rate for Payer: BCN Commercial	$3.68
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	$4.75
Rate for Payer: Healthscope Whirlpool	$4.61
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: Priority Health Cigna Priority Health	$3.09
Rate for Payer: 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	$3.09
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: ASR ASR	$4.61
Rate for Payer: ASR Commercial	$4.61
Rate for Payer: BCBS Trust/PPO	$3.87
Rate for Payer: BCN Commercial	$3.68
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	$4.75
Rate for Payer: Healthscope Whirlpool	$4.61
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: Priority Health Cigna Priority Health	$3.09
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	$1.90
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: Aetna Medicare	$2.38
Rate for Payer: ASR ASR	$4.61
Rate for Payer: ASR Commercial	$4.61
Rate for Payer: BCBS Complete	$1.90
Rate for Payer: BCBS Trust/PPO	$3.89
Rate for Payer: BCN Commercial	$3.68
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	$4.75
Rate for Payer: Healthscope Whirlpool	$4.61
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: Priority Health Cigna Priority Health	$3.09
Rate for Payer: 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 INTERMITTENT FEED

Facility

$4.75

Service Code	NDC 43900018457
Hospital Charge Code	200074
Hospital Revenue Code	637
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$4.75
Rate for Payer: Aetna Commercial	$4.28
Rate for Payer: ASR ASR	$4.61
Rate for Payer: ASR Commercial	$4.61
Rate for Payer: BCBS Trust/PPO	$3.87
Rate for Payer: BCN Commercial	$3.68
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	$4.75
Rate for Payer: Healthscope Whirlpool	$4.61
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: Priority Health Cigna Priority Health	$3.09
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.18

ISOSOURCE HN ORAL LIQUID

Facility

$61.26

Service Code	NDC 70074056016
Hospital Charge Code	157366
Hospital Revenue Code	637
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$61.26
Rate for Payer: Aetna Commercial	$55.13
Rate for Payer: Aetna Medicare	$30.63
Rate for Payer: ASR ASR	$59.42
Rate for Payer: ASR Commercial	$59.42
Rate for Payer: BCBS Complete	$24.50
Rate for Payer: BCBS Trust/PPO	$50.17
Rate for Payer: BCN Commercial	$47.49
Rate for Payer: Cash Price	$49.01
Rate for Payer: Cofinity Commercial	$57.58
Rate for Payer: Encore Health Key Benefits Commercial	$49.01
Rate for Payer: Healthscope Commercial	$61.26
Rate for Payer: Healthscope Whirlpool	$59.42
Rate for Payer: Mclaren Commercial	$55.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$52.07
Rate for Payer: Nomi Health Commercial	$50.23
Rate for Payer: Priority Health Cigna Priority Health	$39.82
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$53.68
Rate for Payer: Priority Health Narrow Network	$42.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$53.91

ISOSOURCE HN ORAL LIQUID

Facility

$61.26

Service Code	NDC 70074056016
Hospital Charge Code	157366
Hospital Revenue Code	637
Min. Negotiated Rate	$39.82
Max. Negotiated Rate	$61.26
Rate for Payer: Aetna Commercial	$55.13
Rate for Payer: ASR ASR	$59.42
Rate for Payer: ASR Commercial	$59.42
Rate for Payer: BCBS Trust/PPO	$49.92
Rate for Payer: BCN Commercial	$47.49
Rate for Payer: Cash Price	$49.01
Rate for Payer: Cofinity Commercial	$57.58
Rate for Payer: Encore Health Key Benefits Commercial	$49.01
Rate for Payer: Healthscope Commercial	$61.26
Rate for Payer: Healthscope Whirlpool	$59.42
Rate for Payer: Mclaren Commercial	$55.13
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$52.07
Rate for Payer: Nomi Health Commercial	$50.23
Rate for Payer: Priority Health Cigna Priority Health	$39.82
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	$3.62
Max. Negotiated Rate	$5.57
Rate for Payer: Aetna Commercial	$5.01
Rate for Payer: ASR ASR	$5.40
Rate for Payer: ASR Commercial	$5.40
Rate for Payer: BCBS Trust/PPO	$4.54
Rate for Payer: BCN Commercial	$4.32
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	$5.57
Rate for Payer: Healthscope Whirlpool	$5.40
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: Priority Health Cigna Priority Health	$3.62
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	$2.23
Max. Negotiated Rate	$5.57
Rate for Payer: Aetna Commercial	$5.01
Rate for Payer: Aetna Medicare	$2.78
Rate for Payer: ASR ASR	$5.40
Rate for Payer: ASR Commercial	$5.40
Rate for Payer: BCBS Complete	$2.23
Rate for Payer: BCBS Trust/PPO	$4.56
Rate for Payer: BCN Commercial	$4.32
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	$5.57
Rate for Payer: Healthscope Whirlpool	$5.40
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: Priority Health Cigna Priority Health	$3.62
Rate for Payer: 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 IM (CODE)

Facility

$56.10

Service Code	NDC 67457010810
Hospital Charge Code	163728
Hospital Revenue Code	250
Min. Negotiated Rate	$22.44
Max. Negotiated Rate	$56.10
Rate for Payer: Aetna Commercial	$50.49
Rate for Payer: Aetna Medicare	$28.05
Rate for Payer: ASR ASR	$54.42
Rate for Payer: ASR Commercial	$54.42
Rate for Payer: BCBS Complete	$22.44
Rate for Payer: BCBS Trust/PPO	$45.94
Rate for Payer: BCN Commercial	$43.49
Rate for Payer: Cash Price	$44.88
Rate for Payer: Cofinity Commercial	$52.73
Rate for Payer: Encore Health Key Benefits Commercial	$44.88
Rate for Payer: Healthscope Commercial	$56.10
Rate for Payer: Healthscope Whirlpool	$54.42
Rate for Payer: Mclaren Commercial	$50.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$47.68
Rate for Payer: Nomi Health Commercial	$46.00
Rate for Payer: Priority Health Cigna Priority Health	$36.46
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$49.15
Rate for Payer: Priority Health Narrow Network	$39.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$49.37

KETAMINE 100 MG/ML INJECTION IM (CODE)

Facility

$56.10

Service Code	NDC 67457010810
Hospital Charge Code	163728
Hospital Revenue Code	250
Min. Negotiated Rate	$36.46
Max. Negotiated Rate	$56.10
Rate for Payer: Aetna Commercial	$50.49
Rate for Payer: ASR ASR	$54.42
Rate for Payer: ASR Commercial	$54.42
Rate for Payer: BCBS Trust/PPO	$45.72
Rate for Payer: BCN Commercial	$43.49
Rate for Payer: Cash Price	$44.88
Rate for Payer: Cofinity Commercial	$52.73
Rate for Payer: Encore Health Key Benefits Commercial	$44.88
Rate for Payer: Healthscope Commercial	$56.10
Rate for Payer: Healthscope Whirlpool	$54.42
Rate for Payer: Mclaren Commercial	$50.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$47.68
Rate for Payer: Nomi Health Commercial	$46.00
Rate for Payer: Priority Health Cigna Priority Health	$36.46
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$49.37

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$42.31

Service Code	NDC 00143950901
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$42.31
Rate for Payer: Aetna Commercial	$38.08
Rate for Payer: ASR ASR	$41.04
Rate for Payer: ASR Commercial	$41.04
Rate for Payer: BCBS Trust/PPO	$34.48
Rate for Payer: BCN Commercial	$32.80
Rate for Payer: Cash Price	$33.85
Rate for Payer: Cofinity Commercial	$39.77
Rate for Payer: Encore Health Key Benefits Commercial	$33.85
Rate for Payer: Healthscope Commercial	$42.31
Rate for Payer: Healthscope Whirlpool	$41.04
Rate for Payer: Mclaren Commercial	$38.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.96
Rate for Payer: Nomi Health Commercial	$34.69
Rate for Payer: Priority Health Cigna Priority Health	$27.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$37.23

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$56.10

Service Code	NDC 67457010810
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$22.44
Max. Negotiated Rate	$56.10
Rate for Payer: Aetna Commercial	$50.49
Rate for Payer: Aetna Medicare	$28.05
Rate for Payer: ASR ASR	$54.42
Rate for Payer: ASR Commercial	$54.42
Rate for Payer: BCBS Complete	$22.44
Rate for Payer: BCBS Trust/PPO	$45.94
Rate for Payer: BCN Commercial	$43.49
Rate for Payer: Cash Price	$44.88
Rate for Payer: Cofinity Commercial	$52.73
Rate for Payer: Encore Health Key Benefits Commercial	$44.88
Rate for Payer: Healthscope Commercial	$56.10
Rate for Payer: Healthscope Whirlpool	$54.42
Rate for Payer: Mclaren Commercial	$50.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$47.68
Rate for Payer: Nomi Health Commercial	$46.00
Rate for Payer: Priority Health Cigna Priority Health	$36.46
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$49.15
Rate for Payer: Priority Health Narrow Network	$39.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$49.37

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$42.31

Service Code	NDC 00143950910
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$27.50
Max. Negotiated Rate	$42.31
Rate for Payer: Aetna Commercial	$38.08
Rate for Payer: ASR ASR	$41.04
Rate for Payer: ASR Commercial	$41.04
Rate for Payer: BCBS Trust/PPO	$34.48
Rate for Payer: BCN Commercial	$32.80
Rate for Payer: Cash Price	$33.85
Rate for Payer: Cofinity Commercial	$39.77
Rate for Payer: Encore Health Key Benefits Commercial	$33.85
Rate for Payer: Healthscope Commercial	$42.31
Rate for Payer: Healthscope Whirlpool	$41.04
Rate for Payer: Mclaren Commercial	$38.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.96
Rate for Payer: Nomi Health Commercial	$34.69
Rate for Payer: Priority Health Cigna Priority Health	$27.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$37.23

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$42.31

Service Code	NDC 00143950910
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$16.92
Max. Negotiated Rate	$42.31
Rate for Payer: Aetna Commercial	$38.08
Rate for Payer: Aetna Medicare	$21.16
Rate for Payer: ASR ASR	$41.04
Rate for Payer: ASR Commercial	$41.04
Rate for Payer: BCBS Complete	$16.92
Rate for Payer: BCBS Trust/PPO	$34.65
Rate for Payer: BCN Commercial	$32.80
Rate for Payer: Cash Price	$33.85
Rate for Payer: Cofinity Commercial	$39.77
Rate for Payer: Encore Health Key Benefits Commercial	$33.85
Rate for Payer: Healthscope Commercial	$42.31
Rate for Payer: Healthscope Whirlpool	$41.04
Rate for Payer: Mclaren Commercial	$38.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.96
Rate for Payer: Nomi Health Commercial	$34.69
Rate for Payer: Priority Health Cigna Priority Health	$27.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$37.07
Rate for Payer: Priority Health Narrow Network	$29.66
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$37.23

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$42.31

Service Code	NDC 00143950901
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$16.92
Max. Negotiated Rate	$42.31
Rate for Payer: Aetna Commercial	$38.08
Rate for Payer: Aetna Medicare	$21.16
Rate for Payer: ASR ASR	$41.04
Rate for Payer: ASR Commercial	$41.04
Rate for Payer: BCBS Complete	$16.92
Rate for Payer: BCBS Trust/PPO	$34.65
Rate for Payer: BCN Commercial	$32.80
Rate for Payer: Cash Price	$33.85
Rate for Payer: Cofinity Commercial	$39.77
Rate for Payer: Encore Health Key Benefits Commercial	$33.85
Rate for Payer: Healthscope Commercial	$42.31
Rate for Payer: Healthscope Whirlpool	$41.04
Rate for Payer: Mclaren Commercial	$38.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$35.96
Rate for Payer: Nomi Health Commercial	$34.69
Rate for Payer: Priority Health Cigna Priority Health	$27.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$37.07
Rate for Payer: Priority Health Narrow Network	$29.66
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$37.23

KETAMINE 100 MG/ML INJECTION SOLUTION

Facility

$56.10

Service Code	NDC 67457010810
Hospital Charge Code	4237
Hospital Revenue Code	250
Min. Negotiated Rate	$36.46
Max. Negotiated Rate	$56.10
Rate for Payer: Aetna Commercial	$50.49
Rate for Payer: ASR ASR	$54.42
Rate for Payer: ASR Commercial	$54.42
Rate for Payer: BCBS Trust/PPO	$45.72
Rate for Payer: BCN Commercial	$43.49
Rate for Payer: Cash Price	$44.88
Rate for Payer: Cofinity Commercial	$52.73
Rate for Payer: Encore Health Key Benefits Commercial	$44.88
Rate for Payer: Healthscope Commercial	$56.10
Rate for Payer: Healthscope Whirlpool	$54.42
Rate for Payer: Mclaren Commercial	$50.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$47.68
Rate for Payer: Nomi Health Commercial	$46.00
Rate for Payer: Priority Health Cigna Priority Health	$36.46
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$49.37

KETAMINE 10 MG/ML INJECTION IV (CODE)

Facility

$20.46

Service Code	NDC 09900001060
Hospital Charge Code	163727
Hospital Revenue Code	250
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$20.46
Rate for Payer: Aetna Commercial	$18.41
Rate for Payer: ASR ASR	$19.85
Rate for Payer: ASR Commercial	$19.85
Rate for Payer: BCBS Trust/PPO	$16.67
Rate for Payer: BCN Commercial	$15.86
Rate for Payer: Cash Price	$16.37
Rate for Payer: Cofinity Commercial	$19.23
Rate for Payer: Encore Health Key Benefits Commercial	$16.37
Rate for Payer: Healthscope Commercial	$20.46
Rate for Payer: Healthscope Whirlpool	$19.85
Rate for Payer: Mclaren Commercial	$18.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.39
Rate for Payer: Nomi Health Commercial	$16.78
Rate for Payer: Priority Health Cigna Priority Health	$13.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$18.00

KETAMINE 10 MG/ML INJECTION IV (CODE)

Facility

$53.50

Service Code	NDC 42023011310
Hospital Charge Code	163727
Hospital Revenue Code	250
Min. Negotiated Rate	$34.78
Max. Negotiated Rate	$53.50
Rate for Payer: Aetna Commercial	$48.15
Rate for Payer: ASR ASR	$51.90
Rate for Payer: ASR Commercial	$51.90
Rate for Payer: BCBS Trust/PPO	$43.60
Rate for Payer: BCN Commercial	$41.48
Rate for Payer: Cash Price	$42.80
Rate for Payer: Cofinity Commercial	$50.29
Rate for Payer: Encore Health Key Benefits Commercial	$42.80
Rate for Payer: Healthscope Commercial	$53.50
Rate for Payer: Healthscope Whirlpool	$51.90
Rate for Payer: Mclaren Commercial	$48.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$45.48
Rate for Payer: Nomi Health Commercial	$43.87
Rate for Payer: Priority Health Cigna Priority Health	$34.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$47.08

KETAMINE 10 MG/ML INJECTION IV (CODE)

Facility

$53.50

Service Code	NDC 42023011310
Hospital Charge Code	163727
Hospital Revenue Code	250
Min. Negotiated Rate	$21.40
Max. Negotiated Rate	$53.50
Rate for Payer: Aetna Commercial	$48.15
Rate for Payer: Aetna Medicare	$26.75
Rate for Payer: ASR ASR	$51.90
Rate for Payer: ASR Commercial	$51.90
Rate for Payer: BCBS Complete	$21.40
Rate for Payer: BCBS Trust/PPO	$43.81
Rate for Payer: BCN Commercial	$41.48
Rate for Payer: Cash Price	$42.80
Rate for Payer: Cofinity Commercial	$50.29
Rate for Payer: Encore Health Key Benefits Commercial	$42.80
Rate for Payer: Healthscope Commercial	$53.50
Rate for Payer: Healthscope Whirlpool	$51.90
Rate for Payer: Mclaren Commercial	$48.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$45.48
Rate for Payer: Nomi Health Commercial	$43.87
Rate for Payer: Priority Health Cigna Priority Health	$34.78
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$46.88
Rate for Payer: Priority Health Narrow Network	$37.50
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$47.08

KETAMINE 10 MG/ML INJECTION IV (CODE)

Facility

$20.46

Service Code	NDC 09900001060
Hospital Charge Code	163727
Hospital Revenue Code	250
Min. Negotiated Rate	$8.18
Max. Negotiated Rate	$20.46
Rate for Payer: Aetna Commercial	$18.41
Rate for Payer: Aetna Medicare	$10.23
Rate for Payer: ASR ASR	$19.85
Rate for Payer: ASR Commercial	$19.85
Rate for Payer: BCBS Complete	$8.18
Rate for Payer: BCBS Trust/PPO	$16.75
Rate for Payer: BCN Commercial	$15.86
Rate for Payer: Cash Price	$16.37
Rate for Payer: Cofinity Commercial	$19.23
Rate for Payer: Encore Health Key Benefits Commercial	$16.37
Rate for Payer: Healthscope Commercial	$20.46
Rate for Payer: Healthscope Whirlpool	$19.85
Rate for Payer: Mclaren Commercial	$18.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.39
Rate for Payer: Nomi Health Commercial	$16.78
Rate for Payer: Priority Health Cigna Priority Health	$13.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$17.93
Rate for Payer: Priority Health Narrow Network	$14.34
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$18.00

Know your out-of-pocket cost for care.

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