|
FACTOR IX HUMAN (RECOMBINANT THR 148) 1,500 UNIT INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$3.24
|
|
|
Service Code
|
HCPCS J7213
|
| Hospital Charge Code |
168781
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$6.60 |
| Rate for Payer: Aetna American Axle |
$2.11
|
| Rate for Payer: Aetna Commercial |
$2.75
|
| Rate for Payer: Aetna Medicare |
$2.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.11
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2.75
|
| Rate for Payer: BCBS Complete |
$1.24
|
| Rate for Payer: BCBS MAPPO |
$2.20
|
| Rate for Payer: BCBS Trust/PPO |
$5.93
|
| Rate for Payer: BCN Commercial |
$5.93
|
| Rate for Payer: BCN Medicare Advantage |
$2.20
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Cofinity Commercial |
$2.79
|
| Rate for Payer: Cofinity Commercial |
$2.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.59
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2.20
|
| Rate for Payer: Healthscope Commercial |
$2.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.43
|
| Rate for Payer: Mclaren Medicaid |
$1.18
|
| Rate for Payer: Mclaren Medicare |
$2.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2.31
|
| Rate for Payer: Meridian Medicaid |
$1.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.75
|
| Rate for Payer: Nomi Health Commercial |
$6.60
|
| Rate for Payer: PACE Medicare |
$2.09
|
| Rate for Payer: PACE SWMI |
$2.20
|
| Rate for Payer: PHP Commercial |
$2.75
|
| Rate for Payer: PHP Medicare Advantage |
$2.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$1.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5.21
|
| Rate for Payer: Priority Health Medicare |
$2.20
|
| Rate for Payer: Priority Health Narrow Network |
$4.17
|
| Rate for Payer: Priority Health SBD |
$2.04
|
| Rate for Payer: Railroad Medicare Medicare |
$2.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.19
|
| Rate for Payer: UHC Dual Complete DSNP |
$2.20
|
| Rate for Payer: UHC Exchange |
$4.20
|
| Rate for Payer: UHC Medicare Advantage |
$2.20
|
| Rate for Payer: UHCCP Medicaid |
$1.18
|
| Rate for Payer: UMR Bronson Commercial |
$1.20
|
| Rate for Payer: VA VA |
$2.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.43
|
|
|
FACTOR IX HUMAN (RECOMBINANT THR 148) 1,500 UNIT INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$3.24
|
|
|
Service Code
|
HCPCS J7213
|
| Hospital Charge Code |
168781
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$2.92 |
| Rate for Payer: Aetna American Axle |
$2.11
|
| Rate for Payer: Aetna Commercial |
$2.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.11
|
| Rate for Payer: Cash Price |
$2.59
|
| Rate for Payer: Cofinity Commercial |
$2.27
|
| Rate for Payer: Cofinity Commercial |
$2.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.59
|
| Rate for Payer: Healthscope Commercial |
$2.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.75
|
| Rate for Payer: PHP Commercial |
$2.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.11
|
| Rate for Payer: Priority Health SBD |
$2.04
|
| Rate for Payer: UMR Bronson Commercial |
$1.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.43
|
|
|
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$548.75
|
|
|
Service Code
|
NDC 55390002601
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$203.04 |
| Max. Negotiated Rate |
$493.88 |
| Rate for Payer: Aetna American Axle |
$356.69
|
| Rate for Payer: Aetna Commercial |
$466.44
|
| Rate for Payer: Aetna Medicare |
$274.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$356.69
|
| Rate for Payer: BCBS Complete |
$219.50
|
| Rate for Payer: Cash Price |
$439.00
|
| Rate for Payer: Cofinity Commercial |
$384.12
|
| Rate for Payer: Cofinity Commercial |
$471.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$384.12
|
| 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 Commercial |
$466.44
|
| Rate for Payer: PHP Commercial |
$466.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$356.69
|
| Rate for Payer: Priority Health SBD |
$345.71
|
| Rate for Payer: UMR Bronson Commercial |
$203.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$411.56
|
|
|
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
NDC 55390002701
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$125.40 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Aetna American Axle |
$185.25
|
| Rate for Payer: Aetna Commercial |
$242.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.25
|
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Cofinity Commercial |
$199.50
|
| Rate for Payer: Cofinity Commercial |
$245.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$199.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.00
|
| Rate for Payer: Healthscope Commercial |
$256.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$242.25
|
| Rate for Payer: PHP Commercial |
$242.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.25
|
| Rate for Payer: Priority Health SBD |
$179.55
|
| Rate for Payer: UMR Bronson Commercial |
$125.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.75
|
|
|
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$90.50
|
|
|
Service Code
|
NDC 63323073820
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.48 |
| Max. Negotiated Rate |
$81.45 |
| Rate for Payer: Aetna American Axle |
$58.82
|
| Rate for Payer: Aetna Commercial |
$76.92
|
| Rate for Payer: Aetna Medicare |
$45.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.82
|
| Rate for Payer: BCBS Complete |
$36.20
|
| Rate for Payer: Cash Price |
$72.40
|
| Rate for Payer: Cofinity Commercial |
$63.35
|
| Rate for Payer: Cofinity Commercial |
$77.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$63.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.40
|
| Rate for Payer: Healthscope Commercial |
$81.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$63.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$67.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.92
|
| Rate for Payer: PHP Commercial |
$76.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.82
|
| Rate for Payer: Priority Health SBD |
$57.02
|
| Rate for Payer: UMR Bronson Commercial |
$33.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$67.88
|
|
|
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$37.40
|
|
|
Service Code
|
NDC 63323073809
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.46 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Aetna American Axle |
$24.31
|
| Rate for Payer: Aetna Commercial |
$31.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.31
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$26.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.05
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$16.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.05
|
|
|
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$90.50
|
|
|
Service Code
|
NDC 63323073806
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.48 |
| Max. Negotiated Rate |
$81.45 |
| Rate for Payer: Aetna American Axle |
$58.82
|
| Rate for Payer: Aetna Commercial |
$76.92
|
| Rate for Payer: Aetna Medicare |
$45.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.82
|
| Rate for Payer: BCBS Complete |
$36.20
|
| Rate for Payer: Cash Price |
$72.40
|
| Rate for Payer: Cofinity Commercial |
$63.35
|
| Rate for Payer: Cofinity Commercial |
$77.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$63.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.40
|
| Rate for Payer: Healthscope Commercial |
$81.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$63.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$67.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.92
|
| Rate for Payer: PHP Commercial |
$76.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.82
|
| Rate for Payer: Priority Health SBD |
$57.02
|
| Rate for Payer: UMR Bronson Commercial |
$33.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$67.88
|
|
|
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
NDC 55390002701
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$105.45 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Aetna American Axle |
$185.25
|
| Rate for Payer: Aetna Commercial |
$242.25
|
| Rate for Payer: Aetna Medicare |
$142.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.25
|
| Rate for Payer: BCBS Complete |
$114.00
|
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Cofinity Commercial |
$199.50
|
| Rate for Payer: Cofinity Commercial |
$245.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$199.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.00
|
| Rate for Payer: Healthscope Commercial |
$256.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$242.25
|
| Rate for Payer: PHP Commercial |
$242.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.25
|
| Rate for Payer: Priority Health SBD |
$179.55
|
| Rate for Payer: UMR Bronson Commercial |
$105.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.75
|
|
|
FAMOTIDINE 10 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$548.75
|
|
|
Service Code
|
NDC 55390002601
|
| Hospital Charge Code |
10009
|
|
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: Cofinity Medicare Advantage |
$384.12
|
| 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 Commercial |
$466.44
|
| Rate for Payer: PHP Commercial |
$466.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$356.69
|
| 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/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$37.40
|
|
|
Service Code
|
NDC 63323073809
|
| Hospital Charge Code |
10009
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.84 |
| Max. Negotiated Rate |
$33.66 |
| Rate for Payer: Aetna American Axle |
$24.31
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$26.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.05
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$13.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.05
|
|
|
FAMOTIDINE 10 MG/ML IV (CODE)
|
Facility
|
IP
|
$39.10
|
|
|
Service Code
|
NDC 67457044843
|
| Hospital Charge Code |
163732
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$35.19 |
| Rate for Payer: Aetna American Axle |
$25.42
|
| Rate for Payer: Aetna Commercial |
$33.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.42
|
| Rate for Payer: Cash Price |
$31.28
|
| Rate for Payer: Cofinity Commercial |
$27.37
|
| Rate for Payer: Cofinity Commercial |
$33.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.28
|
| Rate for Payer: Healthscope Commercial |
$35.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.24
|
| Rate for Payer: PHP Commercial |
$33.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.42
|
| Rate for Payer: Priority Health SBD |
$24.63
|
| Rate for Payer: UMR Bronson Commercial |
$17.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.32
|
|
|
FAMOTIDINE 10 MG/ML IV (CODE)
|
Facility
|
OP
|
$39.10
|
|
|
Service Code
|
NDC 67457044843
|
| Hospital Charge Code |
163732
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.47 |
| Max. Negotiated Rate |
$35.19 |
| Rate for Payer: Aetna American Axle |
$25.42
|
| Rate for Payer: Aetna Commercial |
$33.24
|
| Rate for Payer: Aetna Medicare |
$19.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.42
|
| Rate for Payer: BCBS Complete |
$15.64
|
| Rate for Payer: Cash Price |
$31.28
|
| Rate for Payer: Cofinity Commercial |
$27.37
|
| Rate for Payer: Cofinity Commercial |
$33.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$27.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.28
|
| Rate for Payer: Healthscope Commercial |
$35.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.24
|
| Rate for Payer: PHP Commercial |
$33.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.42
|
| Rate for Payer: Priority Health SBD |
$24.63
|
| Rate for Payer: UMR Bronson Commercial |
$14.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.32
|
|
|
FAMOTIDINE 10 MG/ML IV (CODE)
|
Facility
|
OP
|
$548.75
|
|
|
Service Code
|
NDC 55390002601
|
| Hospital Charge Code |
163732
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$203.04 |
| Max. Negotiated Rate |
$493.88 |
| Rate for Payer: Aetna American Axle |
$356.69
|
| Rate for Payer: Aetna Commercial |
$466.44
|
| Rate for Payer: Aetna Medicare |
$274.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$356.69
|
| Rate for Payer: BCBS Complete |
$219.50
|
| Rate for Payer: Cash Price |
$439.00
|
| Rate for Payer: Cofinity Commercial |
$384.12
|
| Rate for Payer: Cofinity Commercial |
$471.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$384.12
|
| 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 Commercial |
$466.44
|
| Rate for Payer: PHP Commercial |
$466.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$356.69
|
| Rate for Payer: Priority Health SBD |
$345.71
|
| Rate for Payer: UMR Bronson Commercial |
$203.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$411.56
|
|
|
FAMOTIDINE 10 MG/ML IV (CODE)
|
Facility
|
IP
|
$548.75
|
|
|
Service Code
|
NDC 55390002601
|
| 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: Cofinity Medicare Advantage |
$384.12
|
| 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 Commercial |
$466.44
|
| Rate for Payer: PHP Commercial |
$466.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$356.69
|
| 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/ML IV (CODE)
|
Facility
|
OP
|
$285.00
|
|
|
Service Code
|
NDC 55390002701
|
| Hospital Charge Code |
163732
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$105.45 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Aetna American Axle |
$185.25
|
| Rate for Payer: Aetna Commercial |
$242.25
|
| Rate for Payer: Aetna Medicare |
$142.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.25
|
| Rate for Payer: BCBS Complete |
$114.00
|
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Cofinity Commercial |
$199.50
|
| Rate for Payer: Cofinity Commercial |
$245.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$199.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.00
|
| Rate for Payer: Healthscope Commercial |
$256.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$242.25
|
| Rate for Payer: PHP Commercial |
$242.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.25
|
| Rate for Payer: Priority Health SBD |
$179.55
|
| Rate for Payer: UMR Bronson Commercial |
$105.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.75
|
|
|
FAMOTIDINE 10 MG/ML IV (CODE)
|
Facility
|
IP
|
$285.00
|
|
|
Service Code
|
NDC 55390002701
|
| Hospital Charge Code |
163732
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$125.40 |
| Max. Negotiated Rate |
$256.50 |
| Rate for Payer: Aetna American Axle |
$185.25
|
| Rate for Payer: Aetna Commercial |
$242.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$185.25
|
| Rate for Payer: Cash Price |
$228.00
|
| Rate for Payer: Cofinity Commercial |
$199.50
|
| Rate for Payer: Cofinity Commercial |
$245.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$199.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.00
|
| Rate for Payer: Healthscope Commercial |
$256.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$242.25
|
| Rate for Payer: PHP Commercial |
$242.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$185.25
|
| Rate for Payer: Priority Health SBD |
$179.55
|
| Rate for Payer: UMR Bronson Commercial |
$125.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.75
|
|
|
FAMOTIDINE 10 MG TABLET
|
Facility
|
OP
|
$70.50
|
|
|
Service Code
|
NDC 70000004801
|
| Hospital Charge Code |
15065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$63.45 |
| Rate for Payer: Aetna American Axle |
$45.82
|
| Rate for Payer: Aetna Commercial |
$59.92
|
| Rate for Payer: Aetna Medicare |
$35.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.82
|
| Rate for Payer: BCBS Complete |
$28.20
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Commercial |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.35
|
| 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 Commercial |
$59.92
|
| Rate for Payer: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.82
|
| Rate for Payer: Priority Health SBD |
$44.42
|
| Rate for Payer: UMR Bronson Commercial |
$26.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.88
|
|
|
FAMOTIDINE 10 MG TABLET
|
Facility
|
OP
|
$1.60
|
|
|
Service Code
|
NDC 09900000880
|
| Hospital Charge Code |
15065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Aetna American Axle |
$1.04
|
| Rate for Payer: Aetna Commercial |
$1.36
|
| Rate for Payer: Aetna Medicare |
$0.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.04
|
| Rate for Payer: BCBS Complete |
$0.64
|
| Rate for Payer: Cash Price |
$1.28
|
| Rate for Payer: Cofinity Commercial |
$1.12
|
| Rate for Payer: Cofinity Commercial |
$1.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.12
|
| 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 Commercial |
$1.36
|
| Rate for Payer: PHP Commercial |
$1.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.04
|
| Rate for Payer: Priority Health SBD |
$1.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.20
|
|
|
FAMOTIDINE 10 MG TABLET
|
Facility
|
IP
|
$1.60
|
|
|
Service Code
|
NDC 09900000880
|
| 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: Cofinity Medicare Advantage |
$1.12
|
| 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 Commercial |
$1.36
|
| Rate for Payer: PHP Commercial |
$1.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.04
|
| 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
|
$70.50
|
|
|
Service Code
|
NDC 70000004801
|
| 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: Cofinity Medicare Advantage |
$49.35
|
| 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 Commercial |
$59.92
|
| Rate for Payer: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.82
|
| 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 10 MG TABLET
|
Facility
|
IP
|
$59.93
|
|
|
Service Code
|
NDC 00904552987
|
| 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: Cofinity Medicare Advantage |
$41.95
|
| 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 Commercial |
$50.94
|
| Rate for Payer: PHP Commercial |
$50.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.95
|
| 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
|
OP
|
$66.27
|
|
|
Service Code
|
NDC 96295013963
|
| Hospital Charge Code |
15065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.52 |
| Max. Negotiated Rate |
$59.64 |
| Rate for Payer: Aetna American Axle |
$43.08
|
| Rate for Payer: Aetna Commercial |
$56.33
|
| Rate for Payer: Aetna Medicare |
$33.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.08
|
| Rate for Payer: BCBS Complete |
$26.51
|
| Rate for Payer: Cash Price |
$53.02
|
| Rate for Payer: Cofinity Commercial |
$46.39
|
| Rate for Payer: Cofinity Commercial |
$56.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.39
|
| 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 Commercial |
$56.33
|
| Rate for Payer: PHP Commercial |
$56.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.08
|
| Rate for Payer: Priority Health SBD |
$41.75
|
| Rate for Payer: UMR Bronson Commercial |
$24.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.70
|
|
|
FAMOTIDINE 10 MG TABLET
|
Facility
|
OP
|
$59.93
|
|
|
Service Code
|
NDC 00904552987
|
| Hospital Charge Code |
15065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.17 |
| Max. Negotiated Rate |
$53.94 |
| Rate for Payer: Aetna American Axle |
$38.95
|
| Rate for Payer: Aetna Commercial |
$50.94
|
| Rate for Payer: Aetna Medicare |
$29.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.95
|
| Rate for Payer: BCBS Complete |
$23.97
|
| Rate for Payer: Cash Price |
$47.94
|
| Rate for Payer: Cofinity Commercial |
$41.95
|
| Rate for Payer: Cofinity Commercial |
$51.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.95
|
| 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 Commercial |
$50.94
|
| Rate for Payer: PHP Commercial |
$50.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.95
|
| Rate for Payer: Priority Health SBD |
$37.76
|
| Rate for Payer: UMR Bronson Commercial |
$22.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.95
|
|
|
FAMOTIDINE 10 MG TABLET
|
Facility
|
OP
|
$198.81
|
|
|
Service Code
|
NDC 00363014175
|
| Hospital Charge Code |
15065
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.56 |
| Max. Negotiated Rate |
$178.93 |
| Rate for Payer: Aetna American Axle |
$129.23
|
| Rate for Payer: Aetna Commercial |
$168.99
|
| Rate for Payer: Aetna Medicare |
$99.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.23
|
| Rate for Payer: BCBS Complete |
$79.52
|
| Rate for Payer: Cash Price |
$159.05
|
| Rate for Payer: Cofinity Commercial |
$139.17
|
| Rate for Payer: Cofinity Commercial |
$170.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$139.17
|
| 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 Commercial |
$168.99
|
| Rate for Payer: PHP Commercial |
$168.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.23
|
| Rate for Payer: Priority Health SBD |
$125.25
|
| Rate for Payer: UMR Bronson Commercial |
$73.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.11
|
|
|
FAMOTIDINE 10 MG TABLET
|
Facility
|
IP
|
$198.81
|
|
|
Service Code
|
NDC 00363014175
|
| 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: Cofinity Medicare Advantage |
$139.17
|
| 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 Commercial |
$168.99
|
| Rate for Payer: PHP Commercial |
$168.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$129.23
|
| 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
|
|
