Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

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

$98.80

Service Code	NDC 16837085525
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$62.24
Max. Negotiated Rate	$88.92
Rate for Payer: Aetna Commercial	$83.98
Rate for Payer: Aetna New Business (MI Preferred)	$64.22
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

$1,365.08

Service Code	NDC 00187442030
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$860.00
Max. Negotiated Rate	$1,228.57
Rate for Payer: Aetna Commercial	$1,160.32
Rate for Payer: Aetna New Business (MI Preferred)	$887.30
Rate for Payer: Cash Price	$1,092.06
Rate for Payer: Cofinity Commercial	$1,173.97
Rate for Payer: Cofinity Commercial	$955.56
Rate for Payer: Cofinity Medicare Advantage	$955.56
Rate for Payer: Encore Health Key Benefits Commercial	$1,092.06
Rate for Payer: Healthscope Commercial	$1,228.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,160.32
Rate for Payer: PHP Commercial	$1,160.32
Rate for Payer: Priority Health Cigna Priority Health	$887.30
Rate for Payer: Priority Health SBD	$860.00

FAMOTIDINE 20 MG TABLET

Facility

$190.35

Service Code	NDC 00536129801
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$119.92
Max. Negotiated Rate	$171.32
Rate for Payer: Aetna Commercial	$161.80
Rate for Payer: Aetna New Business (MI Preferred)	$123.73
Rate for Payer: Cash Price	$152.28
Rate for Payer: Cofinity Commercial	$133.24
Rate for Payer: Cofinity Commercial	$163.70
Rate for Payer: Cofinity Medicare Advantage	$133.24
Rate for Payer: Encore Health Key Benefits Commercial	$152.28
Rate for Payer: Healthscope Commercial	$171.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$161.80
Rate for Payer: PHP Commercial	$161.80
Rate for Payer: Priority Health Cigna Priority Health	$123.73
Rate for Payer: Priority Health SBD	$119.92

FAMOTIDINE 20 MG TABLET

Facility

$111.63

Service Code	NDC 00904719306
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$44.65
Max. Negotiated Rate	$100.47
Rate for Payer: Aetna Commercial	$94.89
Rate for Payer: Aetna Medicare	$55.82
Rate for Payer: Aetna New Business (MI Preferred)	$72.56
Rate for Payer: BCBS Complete	$44.65
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

$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

$4.33

Service Code	NDC 60687059511
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$3.90
Rate for Payer: Aetna Commercial	$3.68
Rate for Payer: Aetna Medicare	$2.16
Rate for Payer: Aetna New Business (MI Preferred)	$2.81
Rate for Payer: BCBS Complete	$1.73
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

$99.88

Service Code	NDC 00904578017
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$62.92
Max. Negotiated Rate	$89.89
Rate for Payer: Aetna Commercial	$84.90
Rate for Payer: Aetna New Business (MI Preferred)	$64.92
Rate for Payer: Cash Price	$79.90
Rate for Payer: Cofinity Commercial	$69.92
Rate for Payer: Cofinity Commercial	$85.90
Rate for Payer: Cofinity Medicare Advantage	$69.92
Rate for Payer: Encore Health Key Benefits Commercial	$79.90
Rate for Payer: Healthscope Commercial	$89.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$84.90
Rate for Payer: PHP Commercial	$84.90
Rate for Payer: Priority Health Cigna Priority Health	$64.92
Rate for Payer: Priority Health SBD	$62.92

FAMOTIDINE 40 MG TABLET

Facility

$272.60

Service Code	NDC 61442012201
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$171.74
Max. Negotiated Rate	$245.34
Rate for Payer: Aetna Commercial	$231.71
Rate for Payer: Aetna New Business (MI Preferred)	$177.19
Rate for Payer: Cash Price	$218.08
Rate for Payer: Cofinity Commercial	$190.82
Rate for Payer: Cofinity Commercial	$234.44
Rate for Payer: Cofinity Medicare Advantage	$190.82
Rate for Payer: Encore Health Key Benefits Commercial	$218.08
Rate for Payer: Healthscope Commercial	$245.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$231.71
Rate for Payer: PHP Commercial	$231.71
Rate for Payer: Priority Health Cigna Priority Health	$177.19
Rate for Payer: Priority Health SBD	$171.74

FAMOTIDINE 40 MG TABLET

Facility

$8,794.90

Service Code	NDC 00187444010
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$5,540.79
Max. Negotiated Rate	$7,915.41
Rate for Payer: Aetna Commercial	$7,475.66
Rate for Payer: Aetna New Business (MI Preferred)	$5,716.68
Rate for Payer: Cash Price	$7,035.92
Rate for Payer: Cofinity Commercial	$6,156.43
Rate for Payer: Cofinity Commercial	$7,563.61
Rate for Payer: Cofinity Medicare Advantage	$6,156.43
Rate for Payer: Encore Health Key Benefits Commercial	$7,035.92
Rate for Payer: Healthscope Commercial	$7,915.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7,475.66
Rate for Payer: PHP Commercial	$7,475.66
Rate for Payer: Priority Health Cigna Priority Health	$5,716.68
Rate for Payer: Priority Health SBD	$5,540.79

FAMOTIDINE 40 MG TABLET

Facility

$893.00

Service Code	NDC 00172572970
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$357.20
Max. Negotiated Rate	$803.70
Rate for Payer: Aetna Commercial	$759.05
Rate for Payer: Aetna Medicare	$446.50
Rate for Payer: Aetna New Business (MI Preferred)	$580.45
Rate for Payer: BCBS Complete	$357.20
Rate for Payer: Cash Price	$714.40
Rate for Payer: Cofinity Commercial	$625.10
Rate for Payer: Cofinity Commercial	$767.98
Rate for Payer: Cofinity Medicare Advantage	$625.10
Rate for Payer: Encore Health Key Benefits Commercial	$714.40
Rate for Payer: Healthscope Commercial	$803.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$759.05
Rate for Payer: PHP Commercial	$759.05
Rate for Payer: Priority Health Cigna Priority Health	$580.45
Rate for Payer: Priority Health SBD	$562.59

FAMOTIDINE 40 MG TABLET

Facility

$272.60

Service Code	NDC 61442012201
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$109.04
Max. Negotiated Rate	$245.34
Rate for Payer: Aetna Commercial	$231.71
Rate for Payer: Aetna Medicare	$136.30
Rate for Payer: Aetna New Business (MI Preferred)	$177.19
Rate for Payer: BCBS Complete	$109.04
Rate for Payer: Cash Price	$218.08
Rate for Payer: Cofinity Commercial	$190.82
Rate for Payer: Cofinity Commercial	$234.44
Rate for Payer: Cofinity Medicare Advantage	$190.82
Rate for Payer: Encore Health Key Benefits Commercial	$218.08
Rate for Payer: Healthscope Commercial	$245.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$231.71
Rate for Payer: PHP Commercial	$231.71
Rate for Payer: Priority Health Cigna Priority Health	$177.19
Rate for Payer: Priority Health SBD	$171.74

FAMOTIDINE 40 MG TABLET

Facility

$2.38

Service Code	NDC 50268030411
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$2.14
Rate for Payer: Aetna Commercial	$2.02
Rate for Payer: Aetna Medicare	$1.19
Rate for Payer: Aetna New Business (MI Preferred)	$1.55
Rate for Payer: BCBS Complete	$0.95
Rate for Payer: Cash Price	$1.90
Rate for Payer: Cofinity Commercial	$1.67
Rate for Payer: Cofinity Commercial	$2.05
Rate for Payer: Cofinity Medicare Advantage	$1.67
Rate for Payer: Encore Health Key Benefits Commercial	$1.90
Rate for Payer: Healthscope Commercial	$2.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.02
Rate for Payer: PHP Commercial	$2.02
Rate for Payer: Priority Health Cigna Priority Health	$1.55
Rate for Payer: Priority Health SBD	$1.50

FAMOTIDINE 40 MG TABLET

Facility

$8,794.90

Service Code	NDC 00187444010
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$3,517.96
Max. Negotiated Rate	$7,915.41
Rate for Payer: Aetna Commercial	$7,475.66
Rate for Payer: Aetna Medicare	$4,397.45
Rate for Payer: Aetna New Business (MI Preferred)	$5,716.68
Rate for Payer: BCBS Complete	$3,517.96
Rate for Payer: Cash Price	$7,035.92
Rate for Payer: Cofinity Commercial	$6,156.43
Rate for Payer: Cofinity Commercial	$7,563.61
Rate for Payer: Cofinity Medicare Advantage	$6,156.43
Rate for Payer: Encore Health Key Benefits Commercial	$7,035.92
Rate for Payer: Healthscope Commercial	$7,915.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7,475.66
Rate for Payer: PHP Commercial	$7,475.66
Rate for Payer: Priority Health Cigna Priority Health	$5,716.68
Rate for Payer: Priority Health SBD	$5,540.79

FAMOTIDINE 40 MG TABLET

Facility

$2.38

Service Code	NDC 50268030411
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.14
Rate for Payer: Aetna Commercial	$2.02
Rate for Payer: Aetna New Business (MI Preferred)	$1.55
Rate for Payer: Cash Price	$1.90
Rate for Payer: Cofinity Commercial	$1.67
Rate for Payer: Cofinity Commercial	$2.05
Rate for Payer: Cofinity Medicare Advantage	$1.67
Rate for Payer: Encore Health Key Benefits Commercial	$1.90
Rate for Payer: Healthscope Commercial	$2.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.02
Rate for Payer: PHP Commercial	$2.02
Rate for Payer: Priority Health Cigna Priority Health	$1.55
Rate for Payer: Priority Health SBD	$1.50

FAMOTIDINE 40 MG TABLET

Facility

$206.80

Service Code	NDC 00172572960
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$82.72
Max. Negotiated Rate	$186.12
Rate for Payer: Aetna Commercial	$175.78
Rate for Payer: Aetna Medicare	$103.40
Rate for Payer: Aetna New Business (MI Preferred)	$134.42
Rate for Payer: BCBS Complete	$82.72
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cofinity Commercial	$144.76
Rate for Payer: Cofinity Commercial	$177.85
Rate for Payer: Cofinity Medicare Advantage	$144.76
Rate for Payer: Encore Health Key Benefits Commercial	$165.44
Rate for Payer: Healthscope Commercial	$186.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$175.78
Rate for Payer: PHP Commercial	$175.78
Rate for Payer: Priority Health Cigna Priority Health	$134.42
Rate for Payer: Priority Health SBD	$130.28

FAMOTIDINE 40 MG TABLET

Facility

$118.75

Service Code	NDC 50268030415
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$74.81
Max. Negotiated Rate	$106.88
Rate for Payer: Aetna Commercial	$100.94
Rate for Payer: Aetna New Business (MI Preferred)	$77.19
Rate for Payer: Cash Price	$95.00
Rate for Payer: Cofinity Commercial	$102.12
Rate for Payer: Cofinity Commercial	$83.12
Rate for Payer: Cofinity Medicare Advantage	$83.12
Rate for Payer: Encore Health Key Benefits Commercial	$95.00
Rate for Payer: Healthscope Commercial	$106.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$100.94
Rate for Payer: PHP Commercial	$100.94
Rate for Payer: Priority Health Cigna Priority Health	$77.19
Rate for Payer: Priority Health SBD	$74.81

FAMOTIDINE 40 MG TABLET

Facility

$893.00

Service Code	NDC 00172572970
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$562.59
Max. Negotiated Rate	$803.70
Rate for Payer: Aetna Commercial	$759.05
Rate for Payer: Aetna New Business (MI Preferred)	$580.45
Rate for Payer: Cash Price	$714.40
Rate for Payer: Cofinity Commercial	$625.10
Rate for Payer: Cofinity Commercial	$767.98
Rate for Payer: Cofinity Medicare Advantage	$625.10
Rate for Payer: Encore Health Key Benefits Commercial	$714.40
Rate for Payer: Healthscope Commercial	$803.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$759.05
Rate for Payer: PHP Commercial	$759.05
Rate for Payer: Priority Health Cigna Priority Health	$580.45
Rate for Payer: Priority Health SBD	$562.59

FAMOTIDINE 40 MG TABLET

Facility

$206.80

Service Code	NDC 00172572960
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$130.28
Max. Negotiated Rate	$186.12
Rate for Payer: Aetna Commercial	$175.78
Rate for Payer: Aetna New Business (MI Preferred)	$134.42
Rate for Payer: Cash Price	$165.44
Rate for Payer: Cofinity Commercial	$144.76
Rate for Payer: Cofinity Commercial	$177.85
Rate for Payer: Cofinity Medicare Advantage	$144.76
Rate for Payer: Encore Health Key Benefits Commercial	$165.44
Rate for Payer: Healthscope Commercial	$186.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$175.78
Rate for Payer: PHP Commercial	$175.78
Rate for Payer: Priority Health Cigna Priority Health	$134.42
Rate for Payer: Priority Health SBD	$130.28

FAMOTIDINE 40 MG TABLET

Facility

$118.75

Service Code	NDC 50268030415
Hospital Charge Code	10012
Hospital Revenue Code	637
Min. Negotiated Rate	$47.50
Max. Negotiated Rate	$106.88
Rate for Payer: Aetna Commercial	$100.94
Rate for Payer: Aetna Medicare	$59.38
Rate for Payer: Aetna New Business (MI Preferred)	$77.19
Rate for Payer: BCBS Complete	$47.50
Rate for Payer: Cash Price	$95.00
Rate for Payer: Cofinity Commercial	$102.12
Rate for Payer: Cofinity Commercial	$83.12
Rate for Payer: Cofinity Medicare Advantage	$83.12
Rate for Payer: Encore Health Key Benefits Commercial	$95.00
Rate for Payer: Healthscope Commercial	$106.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$100.94
Rate for Payer: PHP Commercial	$100.94
Rate for Payer: Priority Health Cigna Priority Health	$77.19
Rate for Payer: Priority Health SBD	$74.81

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$12.05

Service Code	NDC 67457043300
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$7.59
Max. Negotiated Rate	$10.84
Rate for Payer: Aetna Commercial	$10.24
Rate for Payer: Aetna New Business (MI Preferred)	$7.83
Rate for Payer: Cash Price	$9.64
Rate for Payer: Cofinity Commercial	$10.36
Rate for Payer: Cofinity Commercial	$8.44
Rate for Payer: Cofinity Medicare Advantage	$8.44
Rate for Payer: Encore Health Key Benefits Commercial	$9.64
Rate for Payer: Healthscope Commercial	$10.84
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.24
Rate for Payer: PHP Commercial	$10.24
Rate for Payer: Priority Health Cigna Priority Health	$7.83
Rate for Payer: Priority Health SBD	$7.59

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$12.05

Service Code	NDC 67457043300
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$4.82
Max. Negotiated Rate	$10.84
Rate for Payer: Aetna Commercial	$10.24
Rate for Payer: Aetna Medicare	$6.02
Rate for Payer: Aetna New Business (MI Preferred)	$7.83
Rate for Payer: BCBS Complete	$4.82
Rate for Payer: Cash Price	$9.64
Rate for Payer: Cofinity Commercial	$10.36
Rate for Payer: Cofinity Commercial	$8.44
Rate for Payer: Cofinity Medicare Advantage	$8.44
Rate for Payer: Encore Health Key Benefits Commercial	$9.64
Rate for Payer: Healthscope Commercial	$10.84
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.24
Rate for Payer: PHP Commercial	$10.24
Rate for Payer: Priority Health Cigna Priority Health	$7.83
Rate for Payer: Priority Health SBD	$7.59

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$12.95

Service Code	NDC 00641602201
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$11.66
Rate for Payer: Aetna Commercial	$11.01
Rate for Payer: Aetna New Business (MI Preferred)	$8.42
Rate for Payer: Cash Price	$10.36
Rate for Payer: Cofinity Commercial	$11.14
Rate for Payer: Cofinity Commercial	$9.06
Rate for Payer: Cofinity Medicare Advantage	$9.06
Rate for Payer: Encore Health Key Benefits Commercial	$10.36
Rate for Payer: Healthscope Commercial	$11.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.01
Rate for Payer: PHP Commercial	$11.01
Rate for Payer: Priority Health Cigna Priority Health	$8.42
Rate for Payer: Priority Health SBD	$8.16

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$12.95

Service Code	NDC 00641602225
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$8.16
Max. Negotiated Rate	$11.66
Rate for Payer: Aetna Commercial	$11.01
Rate for Payer: Aetna New Business (MI Preferred)	$8.42
Rate for Payer: Cash Price	$10.36
Rate for Payer: Cofinity Commercial	$11.14
Rate for Payer: Cofinity Commercial	$9.06
Rate for Payer: Cofinity Medicare Advantage	$9.06
Rate for Payer: Encore Health Key Benefits Commercial	$10.36
Rate for Payer: Healthscope Commercial	$11.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$11.01
Rate for Payer: PHP Commercial	$11.01
Rate for Payer: Priority Health Cigna Priority Health	$8.42
Rate for Payer: Priority Health SBD	$8.16

FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION

Facility

$15.30

Service Code	NDC 70860075141
Hospital Charge Code	117801
Hospital Revenue Code	250
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$13.77
Rate for Payer: Aetna Commercial	$13.00
Rate for Payer: Aetna New Business (MI Preferred)	$9.94
Rate for Payer: Cash Price	$12.24
Rate for Payer: Cofinity Commercial	$10.71
Rate for Payer: Cofinity Commercial	$13.16
Rate for Payer: Cofinity Medicare Advantage	$10.71
Rate for Payer: Encore Health Key Benefits Commercial	$12.24
Rate for Payer: Healthscope Commercial	$13.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.00
Rate for Payer: PHP Commercial	$13.00
Rate for Payer: Priority Health Cigna Priority Health	$9.94
Rate for Payer: Priority Health SBD	$9.64

Know your out-of-pocket cost for care.

All Charges