|
FAMOTIDINE 10 MG/ML IV (CODE)
|
Facility
|
IP
|
$548.75
|
|
|
Service Code
|
NDC 55390-026-01
|
| Hospital Charge Code |
163732
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$241.45 |
| Max. Negotiated Rate |
$493.88 |
| Rate for Payer: Aetna American Axle |
$356.69
|
| Rate for Payer: Aetna Commercial |
$466.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$356.69
|
| Rate for Payer: Cash Price |
$439.00
|
| Rate for Payer: Cofinity Commercial |
$384.12
|
| Rate for Payer: Cofinity Commercial |
$471.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$439.00
|
| Rate for Payer: Healthscope Commercial |
$493.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$384.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$411.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$466.44
|
| Rate for Payer: PHP Commercial |
$466.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$384.12
|
| Rate for Payer: Priority Health SBD |
$345.71
|
| Rate for Payer: UMR Bronson Commercial |
$241.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$411.56
|
|
|
FAMOTIDINE 10 MG TABLET
|
Facility
|
IP
|
$198.81
|
|
|
Service Code
|
NDC 0363-0141-75
|
| Hospital Charge Code |
15065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.48 |
| Max. Negotiated Rate |
$178.93 |
| Rate for Payer: Aetna American Axle |
$129.23
|
| Rate for Payer: Aetna Commercial |
$168.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.23
|
| Rate for Payer: Cash Price |
$159.05
|
| Rate for Payer: Cofinity Commercial |
$139.17
|
| Rate for Payer: Cofinity Commercial |
$170.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.05
|
| Rate for Payer: Healthscope Commercial |
$178.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$139.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$149.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$168.99
|
| Rate for Payer: PHP Commercial |
$168.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$139.17
|
| Rate for Payer: Priority Health SBD |
$125.25
|
| Rate for Payer: UMR Bronson Commercial |
$87.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.11
|
|
|
FAMOTIDINE 10 MG TABLET
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 9900-0008-80
|
| Hospital Charge Code |
15065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.70 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna American Axle |
$1.04
|
| Rate for Payer: Aetna Commercial |
$1.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.04
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Cofinity Commercial |
$1.12
|
| Rate for Payer: Cofinity Commercial |
$1.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.28
|
| Rate for Payer: Healthscope Commercial |
$1.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.36
|
| Rate for Payer: PHP Commercial |
$1.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.12
|
| Rate for Payer: Priority Health SBD |
$1.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.20
|
|
|
FAMOTIDINE 10 MG TABLET
|
Facility
|
IP
|
$66.27
|
|
|
Service Code
|
NDC 96295-13963
|
| Hospital Charge Code |
15065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.16 |
| Max. Negotiated Rate |
$59.64 |
| Rate for Payer: Aetna American Axle |
$43.08
|
| Rate for Payer: Aetna Commercial |
$56.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.08
|
| Rate for Payer: Cash Price |
$53.02
|
| Rate for Payer: Cofinity Commercial |
$46.39
|
| Rate for Payer: Cofinity Commercial |
$56.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.02
|
| Rate for Payer: Healthscope Commercial |
$59.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$56.33
|
| Rate for Payer: PHP Commercial |
$56.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.39
|
| Rate for Payer: Priority Health SBD |
$41.75
|
| Rate for Payer: UMR Bronson Commercial |
$29.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.70
|
|
|
FAMOTIDINE 10 MG TABLET
|
Facility
|
IP
|
$59.93
|
|
|
Service Code
|
NDC 0904-5529-87
|
| Hospital Charge Code |
15065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.37 |
| Max. Negotiated Rate |
$53.94 |
| Rate for Payer: Aetna American Axle |
$38.95
|
| Rate for Payer: Aetna Commercial |
$50.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.95
|
| Rate for Payer: Cash Price |
$47.94
|
| Rate for Payer: Cofinity Commercial |
$41.95
|
| Rate for Payer: Cofinity Commercial |
$51.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.94
|
| Rate for Payer: Healthscope Commercial |
$53.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.94
|
| Rate for Payer: PHP Commercial |
$50.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.95
|
| Rate for Payer: Priority Health SBD |
$37.76
|
| Rate for Payer: UMR Bronson Commercial |
$26.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.95
|
|
|
FAMOTIDINE 10 MG TABLET
|
Facility
|
IP
|
$70.50
|
|
|
Service Code
|
NDC 70000-0048-1
|
| Hospital Charge Code |
15065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.02 |
| Max. Negotiated Rate |
$63.45 |
| Rate for Payer: Aetna American Axle |
$45.82
|
| Rate for Payer: Aetna Commercial |
$59.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.82
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Commercial |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.40
|
| Rate for Payer: Healthscope Commercial |
$63.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.92
|
| Rate for Payer: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.35
|
| Rate for Payer: Priority Health SBD |
$44.42
|
| Rate for Payer: UMR Bronson Commercial |
$31.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.88
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$432.40
|
|
|
Service Code
|
NDC 60687-595-01
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$190.26 |
| Max. Negotiated Rate |
$389.16 |
| Rate for Payer: Aetna American Axle |
$281.06
|
| 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: Encore Health Key Benefits Commercial |
$345.92
|
| Rate for Payer: Healthscope Commercial |
$389.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$302.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$324.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$367.54
|
| Rate for Payer: PHP Commercial |
$367.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$302.68
|
| Rate for Payer: Priority Health SBD |
$272.41
|
| Rate for Payer: UMR Bronson Commercial |
$190.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$324.30
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$4.33
|
|
|
Service Code
|
NDC 60687-595-11
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.91 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Aetna American Axle |
$2.81
|
| 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: Encore Health Key Benefits Commercial |
$3.46
|
| Rate for Payer: Healthscope Commercial |
$3.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.68
|
| Rate for Payer: PHP Commercial |
$3.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.03
|
| Rate for Payer: Priority Health SBD |
$2.73
|
| Rate for Payer: UMR Bronson Commercial |
$1.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.25
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$110.45
|
|
|
Service Code
|
NDC 0172-5728-60
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.87 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna American Axle |
$71.79
|
| Rate for Payer: Aetna Commercial |
$93.88
|
| 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 |
$77.32
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.32
|
| Rate for Payer: Priority Health SBD |
$69.58
|
| Rate for Payer: UMR Bronson Commercial |
$40.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$1.49
|
|
|
Service Code
|
NDC 51079-966-01
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna American Axle |
$0.97
|
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.97
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cofinity Commercial |
$1.04
|
| Rate for Payer: Cofinity Commercial |
$1.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.19
|
| Rate for Payer: Healthscope Commercial |
$1.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.27
|
| Rate for Payer: PHP Commercial |
$1.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.04
|
| Rate for Payer: Priority Health SBD |
$0.94
|
| Rate for Payer: UMR Bronson Commercial |
$0.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.12
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$178.60
|
|
|
Service Code
|
NDC 0904-5780-51
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.58 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna American Axle |
$116.09
|
| Rate for Payer: Aetna Commercial |
$151.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.09
|
| Rate for Payer: Cash Price |
$142.88
|
| Rate for Payer: Cofinity Commercial |
$125.02
|
| Rate for Payer: Cofinity Commercial |
$153.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.88
|
| Rate for Payer: Healthscope Commercial |
$160.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$125.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$151.81
|
| Rate for Payer: PHP Commercial |
$151.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.02
|
| Rate for Payer: Priority Health SBD |
$112.52
|
| Rate for Payer: UMR Bronson Commercial |
$78.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.95
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$190.35
|
|
|
Service Code
|
NDC 0536-1298-01
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.75 |
| Max. Negotiated Rate |
$171.32 |
| Rate for Payer: Aetna American Axle |
$123.73
|
| 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: Encore Health Key Benefits Commercial |
$152.28
|
| Rate for Payer: Healthscope Commercial |
$171.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$133.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$161.80
|
| Rate for Payer: PHP Commercial |
$161.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.24
|
| Rate for Payer: Priority Health SBD |
$119.92
|
| Rate for Payer: UMR Bronson Commercial |
$83.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.76
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$265.55
|
|
|
Service Code
|
NDC 72606-509-02
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.25 |
| Max. Negotiated Rate |
$239.00 |
| Rate for Payer: Aetna American Axle |
$172.61
|
| Rate for Payer: Aetna Commercial |
$225.72
|
| 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: Encore Health Key Benefits Commercial |
$212.44
|
| Rate for Payer: Healthscope Commercial |
$239.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$185.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$199.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$225.72
|
| Rate for Payer: PHP Commercial |
$225.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.88
|
| Rate for Payer: Priority Health SBD |
$167.30
|
| Rate for Payer: UMR Bronson Commercial |
$98.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$199.16
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$150.40
|
|
|
Service Code
|
NDC 61442-121-01
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.65 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna American Axle |
$97.76
|
| Rate for Payer: Aetna Commercial |
$127.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.76
|
| Rate for Payer: BCBS Complete |
$60.16
|
| Rate for Payer: Cash Price |
$120.32
|
| Rate for Payer: Cofinity Commercial |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$129.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.32
|
| Rate for Payer: Healthscope Commercial |
$135.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$105.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$127.84
|
| Rate for Payer: PHP Commercial |
$127.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.28
|
| Rate for Payer: Priority Health SBD |
$94.75
|
| Rate for Payer: UMR Bronson Commercial |
$55.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.80
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$150.40
|
|
|
Service Code
|
NDC 61442-121-01
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.18 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna American Axle |
$97.76
|
| 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: Encore Health Key Benefits Commercial |
$120.32
|
| Rate for Payer: Healthscope Commercial |
$135.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$105.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$127.84
|
| Rate for Payer: PHP Commercial |
$127.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.28
|
| Rate for Payer: Priority Health SBD |
$94.75
|
| Rate for Payer: UMR Bronson Commercial |
$66.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.80
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$148.05
|
|
|
Service Code
|
NDC 51079-966-20
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.78 |
| Max. Negotiated Rate |
$133.24 |
| Rate for Payer: Aetna American Axle |
$96.23
|
| Rate for Payer: Aetna Commercial |
$125.84
|
| 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: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$125.84
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.64
|
| Rate for Payer: Priority Health SBD |
$93.27
|
| Rate for Payer: UMR Bronson Commercial |
$54.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 51079-966-20
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.14 |
| Max. Negotiated Rate |
$133.24 |
| Rate for Payer: Aetna American Axle |
$96.23
|
| 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: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$125.84
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.64
|
| Rate for Payer: Priority Health SBD |
$93.27
|
| Rate for Payer: UMR Bronson Commercial |
$65.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$2.21
|
|
|
Service Code
|
NDC 50268-303-11
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Aetna American Axle |
$1.44
|
| 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: Encore Health Key Benefits Commercial |
$1.77
|
| Rate for Payer: Healthscope Commercial |
$1.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.88
|
| Rate for Payer: PHP Commercial |
$1.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.55
|
| Rate for Payer: Priority Health SBD |
$1.39
|
| Rate for Payer: UMR Bronson Commercial |
$0.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.66
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$110.45
|
|
|
Service Code
|
NDC 50268-303-15
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.60 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna American Axle |
$71.79
|
| 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 |
$77.32
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.32
|
| Rate for Payer: Priority Health SBD |
$69.58
|
| Rate for Payer: UMR Bronson Commercial |
$48.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$110.45
|
|
|
Service Code
|
NDC 0172-5728-60
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.60 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna American Axle |
$71.79
|
| 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 |
$77.32
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.32
|
| Rate for Payer: Priority Health SBD |
$69.58
|
| Rate for Payer: UMR Bronson Commercial |
$48.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$188.00
|
|
|
Service Code
|
NDC 63739-645-10
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.72 |
| Max. Negotiated Rate |
$169.20 |
| Rate for Payer: Aetna American Axle |
$122.20
|
| Rate for Payer: Aetna Commercial |
$159.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.20
|
| Rate for Payer: Cash Price |
$150.40
|
| Rate for Payer: Cofinity Commercial |
$131.60
|
| Rate for Payer: Cofinity Commercial |
$161.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.40
|
| Rate for Payer: Healthscope Commercial |
$169.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$131.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$141.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$159.80
|
| Rate for Payer: PHP Commercial |
$159.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$131.60
|
| Rate for Payer: Priority Health SBD |
$118.44
|
| Rate for Payer: UMR Bronson Commercial |
$82.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.00
|
|
|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION
|
Facility
|
IP
|
$113.05
|
|
|
Service Code
|
NDC 68382-444-05
|
| Hospital Charge Code |
10010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.74 |
| Max. Negotiated Rate |
$101.74 |
| Rate for Payer: Aetna American Axle |
$73.48
|
| Rate for Payer: Aetna Commercial |
$96.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$73.48
|
| Rate for Payer: Cash Price |
$90.44
|
| Rate for Payer: Cofinity Commercial |
$79.14
|
| Rate for Payer: Cofinity Commercial |
$97.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$90.44
|
| Rate for Payer: Healthscope Commercial |
$101.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$79.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$84.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$96.09
|
| Rate for Payer: PHP Commercial |
$96.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$79.14
|
| Rate for Payer: Priority Health SBD |
$71.22
|
| Rate for Payer: UMR Bronson Commercial |
$49.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$84.79
|
|
|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION
|
Facility
|
IP
|
$441.84
|
|
|
Service Code
|
NDC 68180-150-01
|
| Hospital Charge Code |
10010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.41 |
| Max. Negotiated Rate |
$397.66 |
| Rate for Payer: Aetna American Axle |
$287.20
|
| Rate for Payer: Aetna Commercial |
$375.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.20
|
| Rate for Payer: Cash Price |
$353.47
|
| Rate for Payer: Cofinity Commercial |
$309.29
|
| Rate for Payer: Cofinity Commercial |
$379.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$353.47
|
| Rate for Payer: Healthscope Commercial |
$397.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$309.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$331.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$375.56
|
| Rate for Payer: PHP Commercial |
$375.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$309.29
|
| Rate for Payer: Priority Health SBD |
$278.36
|
| Rate for Payer: UMR Bronson Commercial |
$194.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$331.38
|
|
|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION
|
Facility
|
IP
|
$219.93
|
|
|
Service Code
|
NDC 70954-316-10
|
| Hospital Charge Code |
10010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.77 |
| Max. Negotiated Rate |
$197.94 |
| Rate for Payer: Aetna American Axle |
$142.95
|
| Rate for Payer: Aetna Commercial |
$186.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.95
|
| Rate for Payer: Cash Price |
$175.94
|
| Rate for Payer: Cofinity Commercial |
$153.95
|
| Rate for Payer: Cofinity Commercial |
$189.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.94
|
| Rate for Payer: Healthscope Commercial |
$197.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$153.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$164.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$186.94
|
| Rate for Payer: PHP Commercial |
$186.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.95
|
| Rate for Payer: Priority Health SBD |
$138.56
|
| Rate for Payer: UMR Bronson Commercial |
$96.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$164.95
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16.05
|
|
|
Service Code
|
NDC 63323-739-11
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Aetna American Axle |
$10.43
|
| Rate for Payer: Aetna Commercial |
$13.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.43
|
| Rate for Payer: BCBS Complete |
$6.42
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Cofinity Commercial |
$11.24
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.84
|
| Rate for Payer: Healthscope Commercial |
$14.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.64
|
| Rate for Payer: PHP Commercial |
$13.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.24
|
| Rate for Payer: Priority Health SBD |
$10.11
|
| Rate for Payer: UMR Bronson Commercial |
$5.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.04
|
|
