Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBCUTANEOUS; LESS THAN 3 CM

Facility

$4,448.08

Service Code	CPT 27327
Hospital Revenue Code	360
Min. Negotiated Rate	$846.98
Max. Negotiated Rate	$4,448.08
Rate for Payer: Aetna Medicare	$1,643.40
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,975.24
Rate for Payer: Amish Plain Church Group Commercial	$1,975.24
Rate for Payer: BCBS Complete	$889.33
Rate for Payer: BCBS MAPPO	$1,580.19
Rate for Payer: BCN Medicare Advantage	$1,580.19
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,580.19
Rate for Payer: Mclaren Medicaid	$846.98
Rate for Payer: Mclaren Medicare	$1,580.19
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,659.20
Rate for Payer: Meridian Medicaid	$889.33
Rate for Payer: MI Amish Medical Board Commercial	$1,817.22
Rate for Payer: PACE Medicare	$1,501.18
Rate for Payer: PACE SWMI	$1,580.19
Rate for Payer: PHP Medicare Advantage	$1,580.19
Rate for Payer: Priority Health Choice Medicaid	$846.98
Rate for Payer: Priority Health Medicare	$1,580.19
Rate for Payer: Railroad Medicare Medicare	$1,580.19
Rate for Payer: UHC All Payor (Choice/PPO)	$4,448.08
Rate for Payer: UHC Dual Complete DSNP	$1,580.19
Rate for Payer: UHC Medicare Advantage	$1,580.19
Rate for Payer: UHCCP Medicaid	$889.65
Rate for Payer: VA VA	$1,580.19

EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER

Facility

$7,857.23

Service Code	CPT 27339
Hospital Revenue Code	360
Min. Negotiated Rate	$1,496.14
Max. Negotiated Rate	$7,857.23
Rate for Payer: Aetna Medicare	$2,902.95
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,489.12
Rate for Payer: Amish Plain Church Group Commercial	$3,489.12
Rate for Payer: BCBS Complete	$1,570.94
Rate for Payer: BCBS MAPPO	$2,791.30
Rate for Payer: BCN Medicare Advantage	$2,791.30
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,791.30
Rate for Payer: Mclaren Medicaid	$1,496.14
Rate for Payer: Mclaren Medicare	$2,791.30
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$2,930.86
Rate for Payer: Meridian Medicaid	$1,570.94
Rate for Payer: MI Amish Medical Board Commercial	$3,209.99
Rate for Payer: PACE Medicare	$2,651.74
Rate for Payer: PACE SWMI	$2,791.30
Rate for Payer: PHP Medicare Advantage	$2,791.30
Rate for Payer: Priority Health Choice Medicaid	$1,496.14
Rate for Payer: Priority Health Medicare	$2,791.30
Rate for Payer: Railroad Medicare Medicare	$2,791.30
Rate for Payer: UHC All Payor (Choice/PPO)	$7,857.23
Rate for Payer: UHC Dual Complete DSNP	$2,791.30
Rate for Payer: UHC Medicare Advantage	$2,791.30
Rate for Payer: UHCCP Medicaid	$1,571.50
Rate for Payer: VA VA	$2,791.30

EXCISION, TUMOR, SOFT TISSUE OF THIGH OR KNEE AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM

Facility

$7,857.23

Service Code	CPT 27328
Hospital Revenue Code	360
Min. Negotiated Rate	$1,496.14
Max. Negotiated Rate	$7,857.23
Rate for Payer: Aetna Medicare	$2,902.95
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,489.12
Rate for Payer: Amish Plain Church Group Commercial	$3,489.12
Rate for Payer: BCBS Complete	$1,570.94
Rate for Payer: BCBS MAPPO	$2,791.30
Rate for Payer: BCN Medicare Advantage	$2,791.30
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,791.30
Rate for Payer: Mclaren Medicaid	$1,496.14
Rate for Payer: Mclaren Medicare	$2,791.30
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$2,930.86
Rate for Payer: Meridian Medicaid	$1,570.94
Rate for Payer: MI Amish Medical Board Commercial	$3,209.99
Rate for Payer: PACE Medicare	$2,651.74
Rate for Payer: PACE SWMI	$2,791.30
Rate for Payer: PHP Medicare Advantage	$2,791.30
Rate for Payer: Priority Health Choice Medicaid	$1,496.14
Rate for Payer: Priority Health Medicare	$2,791.30
Rate for Payer: Railroad Medicare Medicare	$2,791.30
Rate for Payer: UHC All Payor (Choice/PPO)	$7,857.23
Rate for Payer: UHC Dual Complete DSNP	$2,791.30
Rate for Payer: UHC Medicare Advantage	$2,791.30
Rate for Payer: UHCCP Medicaid	$1,571.50
Rate for Payer: VA VA	$2,791.30

EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBCUTANEOUS; 3 CM OR GREATER

Facility

$7,857.23

Service Code	CPT 24071
Hospital Revenue Code	360
Min. Negotiated Rate	$1,496.14
Max. Negotiated Rate	$7,857.23
Rate for Payer: Aetna Medicare	$2,902.95
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,489.12
Rate for Payer: Amish Plain Church Group Commercial	$3,489.12
Rate for Payer: BCBS Complete	$1,570.94
Rate for Payer: BCBS MAPPO	$2,791.30
Rate for Payer: BCN Medicare Advantage	$2,791.30
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,791.30
Rate for Payer: Mclaren Medicaid	$1,496.14
Rate for Payer: Mclaren Medicare	$2,791.30
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$2,930.86
Rate for Payer: Meridian Medicaid	$1,570.94
Rate for Payer: MI Amish Medical Board Commercial	$3,209.99
Rate for Payer: PACE Medicare	$2,651.74
Rate for Payer: PACE SWMI	$2,791.30
Rate for Payer: PHP Medicare Advantage	$2,791.30
Rate for Payer: Priority Health Choice Medicaid	$1,496.14
Rate for Payer: Priority Health Medicare	$2,791.30
Rate for Payer: Railroad Medicare Medicare	$2,791.30
Rate for Payer: UHC All Payor (Choice/PPO)	$7,857.23
Rate for Payer: UHC Dual Complete DSNP	$2,791.30
Rate for Payer: UHC Medicare Advantage	$2,791.30
Rate for Payer: UHCCP Medicaid	$1,571.50
Rate for Payer: VA VA	$2,791.30

EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER

Facility

$7,857.23

Service Code	CPT 24073
Hospital Revenue Code	360
Min. Negotiated Rate	$1,496.14
Max. Negotiated Rate	$7,857.23
Rate for Payer: Aetna Medicare	$2,902.95
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,489.12
Rate for Payer: Amish Plain Church Group Commercial	$3,489.12
Rate for Payer: BCBS Complete	$1,570.94
Rate for Payer: BCBS MAPPO	$2,791.30
Rate for Payer: BCN Medicare Advantage	$2,791.30
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,791.30
Rate for Payer: Mclaren Medicaid	$1,496.14
Rate for Payer: Mclaren Medicare	$2,791.30
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$2,930.86
Rate for Payer: Meridian Medicaid	$1,570.94
Rate for Payer: MI Amish Medical Board Commercial	$3,209.99
Rate for Payer: PACE Medicare	$2,651.74
Rate for Payer: PACE SWMI	$2,791.30
Rate for Payer: PHP Medicare Advantage	$2,791.30
Rate for Payer: Priority Health Choice Medicaid	$1,496.14
Rate for Payer: Priority Health Medicare	$2,791.30
Rate for Payer: Railroad Medicare Medicare	$2,791.30
Rate for Payer: UHC All Payor (Choice/PPO)	$7,857.23
Rate for Payer: UHC Dual Complete DSNP	$2,791.30
Rate for Payer: UHC Medicare Advantage	$2,791.30
Rate for Payer: UHCCP Medicaid	$1,571.50
Rate for Payer: VA VA	$2,791.30

EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5 CM

Facility

$7,857.23

Service Code	CPT 24076
Hospital Revenue Code	360
Min. Negotiated Rate	$1,496.14
Max. Negotiated Rate	$7,857.23
Rate for Payer: Aetna Medicare	$2,902.95
Rate for Payer: Allen County Amish Medical Aid Commercial	$3,489.12
Rate for Payer: Amish Plain Church Group Commercial	$3,489.12
Rate for Payer: BCBS Complete	$1,570.94
Rate for Payer: BCBS MAPPO	$2,791.30
Rate for Payer: BCN Medicare Advantage	$2,791.30
Rate for Payer: Health Alliance Plan Medicare Advantage	$2,791.30
Rate for Payer: Mclaren Medicaid	$1,496.14
Rate for Payer: Mclaren Medicare	$2,791.30
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$2,930.86
Rate for Payer: Meridian Medicaid	$1,570.94
Rate for Payer: MI Amish Medical Board Commercial	$3,209.99
Rate for Payer: PACE Medicare	$2,651.74
Rate for Payer: PACE SWMI	$2,791.30
Rate for Payer: PHP Medicare Advantage	$2,791.30
Rate for Payer: Priority Health Choice Medicaid	$1,496.14
Rate for Payer: Priority Health Medicare	$2,791.30
Rate for Payer: Railroad Medicare Medicare	$2,791.30
Rate for Payer: UHC All Payor (Choice/PPO)	$7,857.23
Rate for Payer: UHC Dual Complete DSNP	$2,791.30
Rate for Payer: UHC Medicare Advantage	$2,791.30
Rate for Payer: UHCCP Medicaid	$1,571.50
Rate for Payer: VA VA	$2,791.30

EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); EXTREMITY

Facility

$4,448.08

Service Code	CPT 20103
Hospital Revenue Code	360
Min. Negotiated Rate	$846.98
Max. Negotiated Rate	$4,448.08
Rate for Payer: Aetna Medicare	$1,643.40
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,975.24
Rate for Payer: Amish Plain Church Group Commercial	$1,975.24
Rate for Payer: BCBS Complete	$889.33
Rate for Payer: BCBS MAPPO	$1,580.19
Rate for Payer: BCN Medicare Advantage	$1,580.19
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,580.19
Rate for Payer: Mclaren Medicaid	$846.98
Rate for Payer: Mclaren Medicare	$1,580.19
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,659.20
Rate for Payer: Meridian Medicaid	$889.33
Rate for Payer: MI Amish Medical Board Commercial	$1,817.22
Rate for Payer: PACE Medicare	$1,501.18
Rate for Payer: PACE SWMI	$1,580.19
Rate for Payer: PHP Medicare Advantage	$1,580.19
Rate for Payer: Priority Health Choice Medicaid	$846.98
Rate for Payer: Priority Health Medicare	$1,580.19
Rate for Payer: Railroad Medicare Medicare	$1,580.19
Rate for Payer: UHC All Payor (Choice/PPO)	$4,448.08
Rate for Payer: UHC Dual Complete DSNP	$1,580.19
Rate for Payer: UHC Medicare Advantage	$1,580.19
Rate for Payer: UHCCP Medicaid	$889.65
Rate for Payer: VA VA	$1,580.19

EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST

Facility

$4,393.64

Service Code	CPT 25248
Hospital Revenue Code	360
Min. Negotiated Rate	$836.62
Max. Negotiated Rate	$4,393.64
Rate for Payer: Aetna Medicare	$1,623.28
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,951.06
Rate for Payer: Amish Plain Church Group Commercial	$1,951.06
Rate for Payer: BCBS Complete	$878.45
Rate for Payer: BCBS MAPPO	$1,560.85
Rate for Payer: BCN Medicare Advantage	$1,560.85
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,560.85
Rate for Payer: Mclaren Medicaid	$836.62
Rate for Payer: Mclaren Medicare	$1,560.85
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$1,638.89
Rate for Payer: Meridian Medicaid	$878.45
Rate for Payer: MI Amish Medical Board Commercial	$1,794.98
Rate for Payer: PACE Medicare	$1,482.81
Rate for Payer: PACE SWMI	$1,560.85
Rate for Payer: PHP Medicare Advantage	$1,560.85
Rate for Payer: Priority Health Choice Medicaid	$836.62
Rate for Payer: Priority Health Medicare	$1,560.85
Rate for Payer: Railroad Medicare Medicare	$1,560.85
Rate for Payer: UHC All Payor (Choice/PPO)	$4,393.64
Rate for Payer: UHC Dual Complete DSNP	$1,560.85
Rate for Payer: UHC Medicare Advantage	$1,560.85
Rate for Payer: UHCCP Medicaid	$878.76
Rate for Payer: VA VA	$1,560.85

EYELASH TINTING

Professional

Both

$31.00

Service Code	HCPCS 00176
Hospital Revenue Code	960
Min. Negotiated Rate	$12.40
Max. Negotiated Rate	$20.15
Rate for Payer: Aetna Medicare	$15.50
Rate for Payer: BCBS Complete	$12.40
Rate for Payer: Cash Price	$24.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.15
Rate for Payer: Priority Health Cigna Priority Health	$20.15

EZETIMIBE 10 MG TABLET

Facility

$668.45

Service Code	NDC 60687037321
Hospital Charge Code	34153
Hospital Revenue Code	637
Min. Negotiated Rate	$267.38
Max. Negotiated Rate	$601.61
Rate for Payer: Aetna Commercial	$568.18
Rate for Payer: Aetna Medicare	$334.23
Rate for Payer: Aetna New Business (MI Preferred)	$434.49
Rate for Payer: BCBS Complete	$267.38
Rate for Payer: Cash Price	$534.76
Rate for Payer: Cofinity Commercial	$467.92
Rate for Payer: Cofinity Commercial	$574.87
Rate for Payer: Cofinity Medicare Advantage	$467.92
Rate for Payer: Encore Health Key Benefits Commercial	$534.76
Rate for Payer: Healthscope Commercial	$601.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$568.18
Rate for Payer: PHP Commercial	$568.18
Rate for Payer: Priority Health Cigna Priority Health	$434.49
Rate for Payer: Priority Health SBD	$421.12

EZETIMIBE 10 MG TABLET

Facility

$81.80

Service Code	NDC 67877049030
Hospital Charge Code	34153
Hospital Revenue Code	637
Min. Negotiated Rate	$32.72
Max. Negotiated Rate	$73.62
Rate for Payer: Aetna Commercial	$69.53
Rate for Payer: Aetna Medicare	$40.90
Rate for Payer: Aetna New Business (MI Preferred)	$53.17
Rate for Payer: BCBS Complete	$32.72
Rate for Payer: Cash Price	$65.44
Rate for Payer: Cofinity Commercial	$57.26
Rate for Payer: Cofinity Commercial	$70.35
Rate for Payer: Cofinity Medicare Advantage	$57.26
Rate for Payer: Encore Health Key Benefits Commercial	$65.44
Rate for Payer: Healthscope Commercial	$73.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$69.53
Rate for Payer: PHP Commercial	$69.53
Rate for Payer: Priority Health Cigna Priority Health	$53.17
Rate for Payer: Priority Health SBD	$51.53

EZETIMIBE 10 MG TABLET

Facility

$76.95

Service Code	NDC 00781569031
Hospital Charge Code	34153
Hospital Revenue Code	637
Min. Negotiated Rate	$48.48
Max. Negotiated Rate	$69.25
Rate for Payer: Aetna Commercial	$65.41
Rate for Payer: Aetna New Business (MI Preferred)	$50.02
Rate for Payer: Cash Price	$61.56
Rate for Payer: Cofinity Commercial	$53.87
Rate for Payer: Cofinity Commercial	$66.18
Rate for Payer: Cofinity Medicare Advantage	$53.87
Rate for Payer: Encore Health Key Benefits Commercial	$61.56
Rate for Payer: Healthscope Commercial	$69.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$65.41
Rate for Payer: PHP Commercial	$65.41
Rate for Payer: Priority Health Cigna Priority Health	$50.02
Rate for Payer: Priority Health SBD	$48.48

EZETIMIBE 10 MG TABLET

Facility

$668.45

Service Code	NDC 60687037321
Hospital Charge Code	34153
Hospital Revenue Code	637
Min. Negotiated Rate	$421.12
Max. Negotiated Rate	$601.61
Rate for Payer: Aetna Commercial	$568.18
Rate for Payer: Aetna New Business (MI Preferred)	$434.49
Rate for Payer: Cash Price	$534.76
Rate for Payer: Cofinity Commercial	$467.92
Rate for Payer: Cofinity Commercial	$574.87
Rate for Payer: Cofinity Medicare Advantage	$467.92
Rate for Payer: Encore Health Key Benefits Commercial	$534.76
Rate for Payer: Healthscope Commercial	$601.61
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$568.18
Rate for Payer: PHP Commercial	$568.18
Rate for Payer: Priority Health Cigna Priority Health	$434.49
Rate for Payer: Priority Health SBD	$421.12

EZETIMIBE 10 MG TABLET

Facility

$76.95

Service Code	NDC 00781569031
Hospital Charge Code	34153
Hospital Revenue Code	637
Min. Negotiated Rate	$30.78
Max. Negotiated Rate	$69.25
Rate for Payer: Aetna Commercial	$65.41
Rate for Payer: Aetna Medicare	$38.48
Rate for Payer: Aetna New Business (MI Preferred)	$50.02
Rate for Payer: BCBS Complete	$30.78
Rate for Payer: Cash Price	$61.56
Rate for Payer: Cofinity Commercial	$53.87
Rate for Payer: Cofinity Commercial	$66.18
Rate for Payer: Cofinity Medicare Advantage	$53.87
Rate for Payer: Encore Health Key Benefits Commercial	$61.56
Rate for Payer: Healthscope Commercial	$69.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$65.41
Rate for Payer: PHP Commercial	$65.41
Rate for Payer: Priority Health Cigna Priority Health	$50.02
Rate for Payer: Priority Health SBD	$48.48

EZETIMIBE 10 MG TABLET

Facility

$22.29

Service Code	NDC 60687037311
Hospital Charge Code	34153
Hospital Revenue Code	637
Min. Negotiated Rate	$14.04
Max. Negotiated Rate	$20.06
Rate for Payer: Aetna Commercial	$18.95
Rate for Payer: Aetna New Business (MI Preferred)	$14.49
Rate for Payer: Cash Price	$17.83
Rate for Payer: Cofinity Commercial	$15.60
Rate for Payer: Cofinity Commercial	$19.17
Rate for Payer: Cofinity Medicare Advantage	$15.60
Rate for Payer: Encore Health Key Benefits Commercial	$17.83
Rate for Payer: Healthscope Commercial	$20.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.95
Rate for Payer: PHP Commercial	$18.95
Rate for Payer: Priority Health Cigna Priority Health	$14.49
Rate for Payer: Priority Health SBD	$14.04

EZETIMIBE 10 MG TABLET

Facility

$81.80

Service Code	NDC 67877049030
Hospital Charge Code	34153
Hospital Revenue Code	637
Min. Negotiated Rate	$51.53
Max. Negotiated Rate	$73.62
Rate for Payer: Aetna Commercial	$69.53
Rate for Payer: Aetna New Business (MI Preferred)	$53.17
Rate for Payer: Cash Price	$65.44
Rate for Payer: Cofinity Commercial	$57.26
Rate for Payer: Cofinity Commercial	$70.35
Rate for Payer: Cofinity Medicare Advantage	$57.26
Rate for Payer: Encore Health Key Benefits Commercial	$65.44
Rate for Payer: Healthscope Commercial	$73.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$69.53
Rate for Payer: PHP Commercial	$69.53
Rate for Payer: Priority Health Cigna Priority Health	$53.17
Rate for Payer: Priority Health SBD	$51.53

EZETIMIBE 10 MG TABLET

Facility

$22.29

Service Code	NDC 60687037311
Hospital Charge Code	34153
Hospital Revenue Code	637
Min. Negotiated Rate	$8.92
Max. Negotiated Rate	$20.06
Rate for Payer: Aetna Commercial	$18.95
Rate for Payer: Aetna Medicare	$11.14
Rate for Payer: Aetna New Business (MI Preferred)	$14.49
Rate for Payer: BCBS Complete	$8.92
Rate for Payer: Cash Price	$17.83
Rate for Payer: Cofinity Commercial	$15.60
Rate for Payer: Cofinity Commercial	$19.17
Rate for Payer: Cofinity Medicare Advantage	$15.60
Rate for Payer: Encore Health Key Benefits Commercial	$17.83
Rate for Payer: Healthscope Commercial	$20.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.95
Rate for Payer: PHP Commercial	$18.95
Rate for Payer: Priority Health Cigna Priority Health	$14.49
Rate for Payer: Priority Health SBD	$14.04

FACIAL

Professional

Both

$66.00

Service Code	HCPCS 00174
Hospital Revenue Code	960
Min. Negotiated Rate	$26.40
Max. Negotiated Rate	$42.90
Rate for Payer: Aetna Medicare	$33.00
Rate for Payer: BCBS Complete	$26.40
Rate for Payer: Cash Price	$52.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$42.90
Rate for Payer: Priority Health Cigna Priority Health	$42.90

FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION

Facility

$93.00

Service Code	NDC 00641602101
Hospital Charge Code	10009
Hospital Revenue Code	250
Min. Negotiated Rate	$37.20
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna Commercial	$79.05
Rate for Payer: Aetna Medicare	$46.50
Rate for Payer: Aetna New Business (MI Preferred)	$60.45
Rate for Payer: BCBS Complete	$37.20
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cofinity Commercial	$65.10
Rate for Payer: Cofinity Commercial	$79.98
Rate for Payer: Cofinity Medicare Advantage	$65.10
Rate for Payer: Encore Health Key Benefits Commercial	$74.40
Rate for Payer: Healthscope Commercial	$83.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$79.05
Rate for Payer: PHP Commercial	$79.05
Rate for Payer: Priority Health Cigna Priority Health	$60.45
Rate for Payer: Priority Health SBD	$58.59

FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION

Facility

$204.50

Service Code	NDC 67457045700
Hospital Charge Code	10009
Hospital Revenue Code	250
Min. Negotiated Rate	$128.84
Max. Negotiated Rate	$184.05
Rate for Payer: Aetna Commercial	$173.82
Rate for Payer: Aetna New Business (MI Preferred)	$132.93
Rate for Payer: Cash Price	$163.60
Rate for Payer: Cofinity Commercial	$143.15
Rate for Payer: Cofinity Commercial	$175.87
Rate for Payer: Cofinity Medicare Advantage	$143.15
Rate for Payer: Encore Health Key Benefits Commercial	$163.60
Rate for Payer: Healthscope Commercial	$184.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$173.82
Rate for Payer: PHP Commercial	$173.82
Rate for Payer: Priority Health Cigna Priority Health	$132.93
Rate for Payer: Priority Health SBD	$128.84

FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION

Facility

$204.50

Service Code	NDC 67457045720
Hospital Charge Code	10009
Hospital Revenue Code	250
Min. Negotiated Rate	$81.80
Max. Negotiated Rate	$184.05
Rate for Payer: Aetna Commercial	$173.82
Rate for Payer: Aetna Medicare	$102.25
Rate for Payer: Aetna New Business (MI Preferred)	$132.93
Rate for Payer: BCBS Complete	$81.80
Rate for Payer: Cash Price	$163.60
Rate for Payer: Cofinity Commercial	$143.15
Rate for Payer: Cofinity Commercial	$175.87
Rate for Payer: Cofinity Medicare Advantage	$143.15
Rate for Payer: Encore Health Key Benefits Commercial	$163.60
Rate for Payer: Healthscope Commercial	$184.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$173.82
Rate for Payer: PHP Commercial	$173.82
Rate for Payer: Priority Health Cigna Priority Health	$132.93
Rate for Payer: Priority Health SBD	$128.84

FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION

Facility

$204.50

Service Code	NDC 67457045720
Hospital Charge Code	10009
Hospital Revenue Code	250
Min. Negotiated Rate	$128.84
Max. Negotiated Rate	$184.05
Rate for Payer: Aetna Commercial	$173.82
Rate for Payer: Aetna New Business (MI Preferred)	$132.93
Rate for Payer: Cash Price	$163.60
Rate for Payer: Cofinity Commercial	$143.15
Rate for Payer: Cofinity Commercial	$175.87
Rate for Payer: Cofinity Medicare Advantage	$143.15
Rate for Payer: Encore Health Key Benefits Commercial	$163.60
Rate for Payer: Healthscope Commercial	$184.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$173.82
Rate for Payer: PHP Commercial	$173.82
Rate for Payer: Priority Health Cigna Priority Health	$132.93
Rate for Payer: Priority Health SBD	$128.84

FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION

Facility

$93.00

Service Code	NDC 00641602101
Hospital Charge Code	10009
Hospital Revenue Code	250
Min. Negotiated Rate	$58.59
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna Commercial	$79.05
Rate for Payer: Aetna New Business (MI Preferred)	$60.45
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cofinity Commercial	$65.10
Rate for Payer: Cofinity Commercial	$79.98
Rate for Payer: Cofinity Medicare Advantage	$65.10
Rate for Payer: Encore Health Key Benefits Commercial	$74.40
Rate for Payer: Healthscope Commercial	$83.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$79.05
Rate for Payer: PHP Commercial	$79.05
Rate for Payer: Priority Health Cigna Priority Health	$60.45
Rate for Payer: Priority Health SBD	$58.59

FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION

Facility

$93.00

Service Code	NDC 00641602110
Hospital Charge Code	10009
Hospital Revenue Code	250
Min. Negotiated Rate	$37.20
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna Commercial	$79.05
Rate for Payer: Aetna Medicare	$46.50
Rate for Payer: Aetna New Business (MI Preferred)	$60.45
Rate for Payer: BCBS Complete	$37.20
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cofinity Commercial	$65.10
Rate for Payer: Cofinity Commercial	$79.98
Rate for Payer: Cofinity Medicare Advantage	$65.10
Rate for Payer: Encore Health Key Benefits Commercial	$74.40
Rate for Payer: Healthscope Commercial	$83.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$79.05
Rate for Payer: PHP Commercial	$79.05
Rate for Payer: Priority Health Cigna Priority Health	$60.45
Rate for Payer: Priority Health SBD	$58.59

FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION

Facility

$204.50

Service Code	NDC 67457045700
Hospital Charge Code	10009
Hospital Revenue Code	250
Min. Negotiated Rate	$81.80
Max. Negotiated Rate	$184.05
Rate for Payer: Aetna Commercial	$173.82
Rate for Payer: Aetna Medicare	$102.25
Rate for Payer: Aetna New Business (MI Preferred)	$132.93
Rate for Payer: BCBS Complete	$81.80
Rate for Payer: Cash Price	$163.60
Rate for Payer: Cofinity Commercial	$143.15
Rate for Payer: Cofinity Commercial	$175.87
Rate for Payer: Cofinity Medicare Advantage	$143.15
Rate for Payer: Encore Health Key Benefits Commercial	$163.60
Rate for Payer: Healthscope Commercial	$184.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$173.82
Rate for Payer: PHP Commercial	$173.82
Rate for Payer: Priority Health Cigna Priority Health	$132.93
Rate for Payer: Priority Health SBD	$128.84

Know your out-of-pocket cost for care.

All Charges