Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

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

$37.40

Service Code	NDC 63323073809
Hospital Charge Code	10009
Hospital Revenue Code	250
Min. Negotiated Rate	$14.96
Max. Negotiated Rate	$33.66
Rate for Payer: Aetna Commercial	$31.79
Rate for Payer: Aetna Medicare	$18.70
Rate for Payer: Aetna New Business (MI Preferred)	$24.31
Rate for Payer: BCBS Complete	$14.96
Rate for Payer: Cash Price	$29.92
Rate for Payer: Cofinity Commercial	$26.18
Rate for Payer: Cofinity Commercial	$32.16
Rate for Payer: Cofinity Medicare Advantage	$26.18
Rate for Payer: Encore Health Key Benefits Commercial	$29.92
Rate for Payer: Healthscope Commercial	$33.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$31.79
Rate for Payer: PHP Commercial	$31.79
Rate for Payer: Priority Health Cigna Priority Health	$24.31
Rate for Payer: Priority Health SBD	$23.56

FAMOTIDINE 10 MG/ML IV (CODE)

Facility

$93.00

Service Code	NDC 00641602101
Hospital Charge Code	163732
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 IV (CODE)

Facility

$93.00

Service Code	NDC 00641602101
Hospital Charge Code	163732
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 20 MG TABLET

Facility

$98.80

Service Code	NDC 16837085525
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$39.52
Max. Negotiated Rate	$88.92
Rate for Payer: Aetna Commercial	$83.98
Rate for Payer: Aetna Medicare	$49.40
Rate for Payer: Aetna New Business (MI Preferred)	$64.22
Rate for Payer: BCBS Complete	$39.52
Rate for Payer: Cash Price	$79.04
Rate for Payer: Cofinity Commercial	$69.16
Rate for Payer: Cofinity Commercial	$84.97
Rate for Payer: Cofinity Medicare Advantage	$69.16
Rate for Payer: Encore Health Key Benefits Commercial	$79.04
Rate for Payer: Healthscope Commercial	$88.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$83.98
Rate for Payer: PHP Commercial	$83.98
Rate for Payer: Priority Health Cigna Priority Health	$64.22
Rate for Payer: Priority Health SBD	$62.24

FAMOTIDINE 20 MG TABLET

Facility

$265.55

Service Code	NDC 72606050902
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$106.22
Max. Negotiated Rate	$239.00
Rate for Payer: Aetna Commercial	$225.72
Rate for Payer: Aetna Medicare	$132.78
Rate for Payer: Aetna New Business (MI Preferred)	$172.61
Rate for Payer: BCBS Complete	$106.22
Rate for Payer: Cash Price	$212.44
Rate for Payer: Cofinity Commercial	$185.88
Rate for Payer: Cofinity Commercial	$228.37
Rate for Payer: Cofinity Medicare Advantage	$185.88
Rate for Payer: Encore Health Key Benefits Commercial	$212.44
Rate for Payer: Healthscope Commercial	$239.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$225.72
Rate for Payer: PHP Commercial	$225.72
Rate for Payer: Priority Health Cigna Priority Health	$172.61
Rate for Payer: Priority Health SBD	$167.30

FAMOTIDINE 20 MG TABLET

Facility

$148.05

Service Code	NDC 51079096620
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$93.27
Max. Negotiated Rate	$133.25
Rate for Payer: Aetna Commercial	$125.84
Rate for Payer: Aetna New Business (MI Preferred)	$96.23
Rate for Payer: Cash Price	$118.44
Rate for Payer: Cofinity Commercial	$103.64
Rate for Payer: Cofinity Commercial	$127.32
Rate for Payer: Cofinity Medicare Advantage	$103.64
Rate for Payer: Encore Health Key Benefits Commercial	$118.44
Rate for Payer: Healthscope Commercial	$133.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$125.84
Rate for Payer: PHP Commercial	$125.84
Rate for Payer: Priority Health Cigna Priority Health	$96.23
Rate for Payer: Priority Health SBD	$93.27

FAMOTIDINE 20 MG TABLET

Facility

$4,550.26

Service Code	NDC 00187442010
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$1,820.10
Max. Negotiated Rate	$4,095.23
Rate for Payer: Aetna Commercial	$3,867.72
Rate for Payer: Aetna Medicare	$2,275.13
Rate for Payer: Aetna New Business (MI Preferred)	$2,957.67
Rate for Payer: BCBS Complete	$1,820.10
Rate for Payer: Cash Price	$3,640.21
Rate for Payer: Cofinity Commercial	$3,185.18
Rate for Payer: Cofinity Commercial	$3,913.22
Rate for Payer: Cofinity Medicare Advantage	$3,185.18
Rate for Payer: Encore Health Key Benefits Commercial	$3,640.21
Rate for Payer: Healthscope Commercial	$4,095.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,867.72
Rate for Payer: PHP Commercial	$3,867.72
Rate for Payer: Priority Health Cigna Priority Health	$2,957.67
Rate for Payer: Priority Health SBD	$2,866.66

FAMOTIDINE 20 MG TABLET

Facility

$110.45

Service Code	NDC 50268030315
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$44.18
Max. Negotiated Rate	$99.41
Rate for Payer: Aetna Commercial	$93.88
Rate for Payer: Aetna Medicare	$55.23
Rate for Payer: Aetna New Business (MI Preferred)	$71.79
Rate for Payer: BCBS Complete	$44.18
Rate for Payer: Cash Price	$88.36
Rate for Payer: Cofinity Commercial	$77.31
Rate for Payer: Cofinity Commercial	$94.99
Rate for Payer: Cofinity Medicare Advantage	$77.31
Rate for Payer: Encore Health Key Benefits Commercial	$88.36
Rate for Payer: Healthscope Commercial	$99.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$93.88
Rate for Payer: PHP Commercial	$93.88
Rate for Payer: Priority Health Cigna Priority Health	$71.79
Rate for Payer: Priority Health SBD	$69.58

FAMOTIDINE 20 MG TABLET

Facility

$218.55

Service Code	NDC 62332000131
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$87.42
Max. Negotiated Rate	$196.69
Rate for Payer: Aetna Commercial	$185.77
Rate for Payer: Aetna Medicare	$109.28
Rate for Payer: Aetna New Business (MI Preferred)	$142.06
Rate for Payer: BCBS Complete	$87.42
Rate for Payer: Cash Price	$174.84
Rate for Payer: Cofinity Commercial	$152.99
Rate for Payer: Cofinity Commercial	$187.95
Rate for Payer: Cofinity Medicare Advantage	$152.99
Rate for Payer: Encore Health Key Benefits Commercial	$174.84
Rate for Payer: Healthscope Commercial	$196.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$185.77
Rate for Payer: PHP Commercial	$185.77
Rate for Payer: Priority Health Cigna Priority Health	$142.06
Rate for Payer: Priority Health SBD	$137.69

FAMOTIDINE 20 MG TABLET

Facility

$432.40

Service Code	NDC 60687059501
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$172.96
Max. Negotiated Rate	$389.16
Rate for Payer: Aetna Commercial	$367.54
Rate for Payer: Aetna Medicare	$216.20
Rate for Payer: Aetna New Business (MI Preferred)	$281.06
Rate for Payer: BCBS Complete	$172.96
Rate for Payer: Cash Price	$345.92
Rate for Payer: Cofinity Commercial	$302.68
Rate for Payer: Cofinity Commercial	$371.86
Rate for Payer: Cofinity Medicare Advantage	$302.68
Rate for Payer: Encore Health Key Benefits Commercial	$345.92
Rate for Payer: Healthscope Commercial	$389.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$367.54
Rate for Payer: PHP Commercial	$367.54
Rate for Payer: Priority Health Cigna Priority Health	$281.06
Rate for Payer: Priority Health SBD	$272.41

FAMOTIDINE 20 MG TABLET

Facility

$432.40

Service Code	NDC 60687059501
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$272.41
Max. Negotiated Rate	$389.16
Rate for Payer: Aetna Commercial	$367.54
Rate for Payer: Aetna New Business (MI Preferred)	$281.06
Rate for Payer: Cash Price	$345.92
Rate for Payer: Cofinity Commercial	$302.68
Rate for Payer: Cofinity Commercial	$371.86
Rate for Payer: Cofinity Medicare Advantage	$302.68
Rate for Payer: Encore Health Key Benefits Commercial	$345.92
Rate for Payer: Healthscope Commercial	$389.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$367.54
Rate for Payer: PHP Commercial	$367.54
Rate for Payer: Priority Health Cigna Priority Health	$281.06
Rate for Payer: Priority Health SBD	$272.41

FAMOTIDINE 20 MG TABLET

Facility

$2.21

Service Code	NDC 50268030311
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.99
Rate for Payer: Aetna Commercial	$1.88
Rate for Payer: Aetna Medicare	$1.10
Rate for Payer: Aetna New Business (MI Preferred)	$1.44
Rate for Payer: BCBS Complete	$0.88
Rate for Payer: Cash Price	$1.77
Rate for Payer: Cofinity Commercial	$1.55
Rate for Payer: Cofinity Commercial	$1.90
Rate for Payer: Cofinity Medicare Advantage	$1.55
Rate for Payer: Encore Health Key Benefits Commercial	$1.77
Rate for Payer: Healthscope Commercial	$1.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.88
Rate for Payer: PHP Commercial	$1.88
Rate for Payer: Priority Health Cigna Priority Health	$1.44
Rate for Payer: Priority Health SBD	$1.39

FAMOTIDINE 20 MG TABLET

Facility

$1,386.50

Service Code	NDC 61442012110
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$554.60
Max. Negotiated Rate	$1,247.85
Rate for Payer: Aetna Commercial	$1,178.53
Rate for Payer: Aetna Medicare	$693.25
Rate for Payer: Aetna New Business (MI Preferred)	$901.23
Rate for Payer: BCBS Complete	$554.60
Rate for Payer: Cash Price	$1,109.20
Rate for Payer: Cofinity Commercial	$1,192.39
Rate for Payer: Cofinity Commercial	$970.55
Rate for Payer: Cofinity Medicare Advantage	$970.55
Rate for Payer: Encore Health Key Benefits Commercial	$1,109.20
Rate for Payer: Healthscope Commercial	$1,247.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,178.53
Rate for Payer: PHP Commercial	$1,178.53
Rate for Payer: Priority Health Cigna Priority Health	$901.23
Rate for Payer: Priority Health SBD	$873.50

FAMOTIDINE 20 MG TABLET

Facility

$218.55

Service Code	NDC 62332000131
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$137.69
Max. Negotiated Rate	$196.69
Rate for Payer: Aetna Commercial	$185.77
Rate for Payer: Aetna New Business (MI Preferred)	$142.06
Rate for Payer: Cash Price	$174.84
Rate for Payer: Cofinity Commercial	$152.99
Rate for Payer: Cofinity Commercial	$187.95
Rate for Payer: Cofinity Medicare Advantage	$152.99
Rate for Payer: Encore Health Key Benefits Commercial	$174.84
Rate for Payer: Healthscope Commercial	$196.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$185.77
Rate for Payer: PHP Commercial	$185.77
Rate for Payer: Priority Health Cigna Priority Health	$142.06
Rate for Payer: Priority Health SBD	$137.69

FAMOTIDINE 20 MG TABLET

Facility

$4.33

Service Code	NDC 60687059511
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$3.90
Rate for Payer: Aetna Commercial	$3.68
Rate for Payer: Aetna New Business (MI Preferred)	$2.81
Rate for Payer: Cash Price	$3.46
Rate for Payer: Cofinity Commercial	$3.03
Rate for Payer: Cofinity Commercial	$3.72
Rate for Payer: Cofinity Medicare Advantage	$3.03
Rate for Payer: Encore Health Key Benefits Commercial	$3.46
Rate for Payer: Healthscope Commercial	$3.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.68
Rate for Payer: PHP Commercial	$3.68
Rate for Payer: Priority Health Cigna Priority Health	$2.81
Rate for Payer: Priority Health SBD	$2.73

FAMOTIDINE 20 MG TABLET

Facility

$148.05

Service Code	NDC 51079096620
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$59.22
Max. Negotiated Rate	$133.25
Rate for Payer: Aetna Commercial	$125.84
Rate for Payer: Aetna Medicare	$74.03
Rate for Payer: Aetna New Business (MI Preferred)	$96.23
Rate for Payer: BCBS Complete	$59.22
Rate for Payer: Cash Price	$118.44
Rate for Payer: Cofinity Commercial	$103.64
Rate for Payer: Cofinity Commercial	$127.32
Rate for Payer: Cofinity Medicare Advantage	$103.64
Rate for Payer: Encore Health Key Benefits Commercial	$118.44
Rate for Payer: Healthscope Commercial	$133.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$125.84
Rate for Payer: PHP Commercial	$125.84
Rate for Payer: Priority Health Cigna Priority Health	$96.23
Rate for Payer: Priority Health SBD	$93.27

FAMOTIDINE 20 MG TABLET

Facility

$111.63

Service Code	NDC 00904719306
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$70.33
Max. Negotiated Rate	$100.47
Rate for Payer: Aetna Commercial	$94.89
Rate for Payer: Aetna New Business (MI Preferred)	$72.56
Rate for Payer: Cash Price	$89.30
Rate for Payer: Cofinity Commercial	$78.14
Rate for Payer: Cofinity Commercial	$96.00
Rate for Payer: Cofinity Medicare Advantage	$78.14
Rate for Payer: Encore Health Key Benefits Commercial	$89.30
Rate for Payer: Healthscope Commercial	$100.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$94.89
Rate for Payer: PHP Commercial	$94.89
Rate for Payer: Priority Health Cigna Priority Health	$72.56
Rate for Payer: Priority Health SBD	$70.33

FAMOTIDINE 20 MG TABLET

Facility

$218.55

Service Code	NDC 65862085901
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$87.42
Max. Negotiated Rate	$196.69
Rate for Payer: Aetna Commercial	$185.77
Rate for Payer: Aetna Medicare	$109.28
Rate for Payer: Aetna New Business (MI Preferred)	$142.06
Rate for Payer: BCBS Complete	$87.42
Rate for Payer: Cash Price	$174.84
Rate for Payer: Cofinity Commercial	$152.99
Rate for Payer: Cofinity Commercial	$187.95
Rate for Payer: Cofinity Medicare Advantage	$152.99
Rate for Payer: Encore Health Key Benefits Commercial	$174.84
Rate for Payer: Healthscope Commercial	$196.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$185.77
Rate for Payer: PHP Commercial	$185.77
Rate for Payer: Priority Health Cigna Priority Health	$142.06
Rate for Payer: Priority Health SBD	$137.69

FAMOTIDINE 20 MG TABLET

Facility

$150.40

Service Code	NDC 61442012101
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$94.75
Max. Negotiated Rate	$135.36
Rate for Payer: Aetna Commercial	$127.84
Rate for Payer: Aetna New Business (MI Preferred)	$97.76
Rate for Payer: Cash Price	$120.32
Rate for Payer: Cofinity Commercial	$105.28
Rate for Payer: Cofinity Commercial	$129.34
Rate for Payer: Cofinity Medicare Advantage	$105.28
Rate for Payer: Encore Health Key Benefits Commercial	$120.32
Rate for Payer: Healthscope Commercial	$135.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$127.84
Rate for Payer: PHP Commercial	$127.84
Rate for Payer: Priority Health Cigna Priority Health	$97.76
Rate for Payer: Priority Health SBD	$94.75

FAMOTIDINE 20 MG TABLET

Facility

$116.33

Service Code	NDC 00904578051
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$46.53
Max. Negotiated Rate	$104.70
Rate for Payer: Aetna Commercial	$98.88
Rate for Payer: Aetna Medicare	$58.16
Rate for Payer: Aetna New Business (MI Preferred)	$75.61
Rate for Payer: BCBS Complete	$46.53
Rate for Payer: Cash Price	$93.06
Rate for Payer: Cofinity Commercial	$100.04
Rate for Payer: Cofinity Commercial	$81.43
Rate for Payer: Cofinity Medicare Advantage	$81.43
Rate for Payer: Encore Health Key Benefits Commercial	$93.06
Rate for Payer: Healthscope Commercial	$104.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$98.88
Rate for Payer: PHP Commercial	$98.88
Rate for Payer: Priority Health Cigna Priority Health	$75.61
Rate for Payer: Priority Health SBD	$73.29

FAMOTIDINE 20 MG TABLET

Facility

$2.21

Service Code	NDC 50268030311
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$1.99
Rate for Payer: Aetna Commercial	$1.88
Rate for Payer: Aetna New Business (MI Preferred)	$1.44
Rate for Payer: Cash Price	$1.77
Rate for Payer: Cofinity Commercial	$1.55
Rate for Payer: Cofinity Commercial	$1.90
Rate for Payer: Cofinity Medicare Advantage	$1.55
Rate for Payer: Encore Health Key Benefits Commercial	$1.77
Rate for Payer: Healthscope Commercial	$1.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.88
Rate for Payer: PHP Commercial	$1.88
Rate for Payer: Priority Health Cigna Priority Health	$1.44
Rate for Payer: Priority Health SBD	$1.39

FAMOTIDINE 20 MG TABLET

Facility

$110.45

Service Code	NDC 50268030315
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$69.58
Max. Negotiated Rate	$99.41
Rate for Payer: Aetna Commercial	$93.88
Rate for Payer: Aetna New Business (MI Preferred)	$71.79
Rate for Payer: Cash Price	$88.36
Rate for Payer: Cofinity Commercial	$77.31
Rate for Payer: Cofinity Commercial	$94.99
Rate for Payer: Cofinity Medicare Advantage	$77.31
Rate for Payer: Encore Health Key Benefits Commercial	$88.36
Rate for Payer: Healthscope Commercial	$99.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$93.88
Rate for Payer: PHP Commercial	$93.88
Rate for Payer: Priority Health Cigna Priority Health	$71.79
Rate for Payer: Priority Health SBD	$69.58

FAMOTIDINE 20 MG TABLET

Facility

$116.33

Service Code	NDC 00904578051
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$73.29
Max. Negotiated Rate	$104.70
Rate for Payer: Aetna Commercial	$98.88
Rate for Payer: Aetna New Business (MI Preferred)	$75.61
Rate for Payer: Cash Price	$93.06
Rate for Payer: Cofinity Commercial	$100.04
Rate for Payer: Cofinity Commercial	$81.43
Rate for Payer: Cofinity Medicare Advantage	$81.43
Rate for Payer: Encore Health Key Benefits Commercial	$93.06
Rate for Payer: Healthscope Commercial	$104.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$98.88
Rate for Payer: PHP Commercial	$98.88
Rate for Payer: Priority Health Cigna Priority Health	$75.61
Rate for Payer: Priority Health SBD	$73.29

FAMOTIDINE 20 MG TABLET

Facility

$4,550.26

Service Code	NDC 00187442010
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$2,866.66
Max. Negotiated Rate	$4,095.23
Rate for Payer: Aetna Commercial	$3,867.72
Rate for Payer: Aetna New Business (MI Preferred)	$2,957.67
Rate for Payer: Cash Price	$3,640.21
Rate for Payer: Cofinity Commercial	$3,185.18
Rate for Payer: Cofinity Commercial	$3,913.22
Rate for Payer: Cofinity Medicare Advantage	$3,185.18
Rate for Payer: Encore Health Key Benefits Commercial	$3,640.21
Rate for Payer: Healthscope Commercial	$4,095.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,867.72
Rate for Payer: PHP Commercial	$3,867.72
Rate for Payer: Priority Health Cigna Priority Health	$2,957.67
Rate for Payer: Priority Health SBD	$2,866.66

Know your out-of-pocket cost for care.

All Charges