|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$112.80
|
|
|
Service Code
|
NDC 00172572860
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.63 |
| Max. Negotiated Rate |
$101.52 |
| Rate for Payer: Aetna American Axle |
$73.32
|
| Rate for Payer: Aetna Commercial |
$95.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$73.32
|
| Rate for Payer: Cash Price |
$90.24
|
| Rate for Payer: Cofinity Commercial |
$78.96
|
| Rate for Payer: Cofinity Commercial |
$97.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$78.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$90.24
|
| Rate for Payer: Healthscope Commercial |
$101.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$78.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$84.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$95.88
|
| Rate for Payer: PHP Commercial |
$95.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$73.32
|
| Rate for Payer: Priority Health SBD |
$71.06
|
| Rate for Payer: UMR Bronson Commercial |
$49.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$84.60
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$2.21
|
|
|
Service Code
|
NDC 50268030311
|
| 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: 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: 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 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
|
| Rate for Payer: UMR Bronson Commercial |
$0.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.66
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$265.55
|
|
|
Service Code
|
NDC 72606050902
|
| 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 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: 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 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
|
| Rate for Payer: UMR Bronson Commercial |
$98.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$199.16
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 51079096620
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.14 |
| Max. Negotiated Rate |
$133.25 |
| 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: 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: 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 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
|
| 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
|
$190.35
|
|
|
Service Code
|
NDC 00536129801
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.75 |
| Max. Negotiated Rate |
$171.31 |
| 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 |
$133.25
|
| Rate for Payer: Cofinity Commercial |
$163.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$133.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.28
|
| Rate for Payer: Healthscope Commercial |
$171.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$133.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.76
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$83.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.76
|
|
|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION
|
Facility
|
IP
|
$441.84
|
|
|
Service Code
|
NDC 68180015001
|
| 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: Cofinity Medicare Advantage |
$309.29
|
| 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 Commercial |
$375.56
|
| Rate for Payer: PHP Commercial |
$375.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.20
|
| 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
|
$440.88
|
|
|
Service Code
|
NDC 68382044405
|
| Hospital Charge Code |
10010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$193.99 |
| Max. Negotiated Rate |
$396.79 |
| Rate for Payer: Aetna American Axle |
$286.57
|
| Rate for Payer: Aetna Commercial |
$374.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$286.57
|
| Rate for Payer: Cash Price |
$352.70
|
| Rate for Payer: Cofinity Commercial |
$308.62
|
| Rate for Payer: Cofinity Commercial |
$379.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$308.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$352.70
|
| Rate for Payer: Healthscope Commercial |
$396.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$308.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$330.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$374.75
|
| Rate for Payer: PHP Commercial |
$374.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.57
|
| Rate for Payer: Priority Health SBD |
$277.75
|
| Rate for Payer: UMR Bronson Commercial |
$193.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$330.66
|
|
|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION
|
Facility
|
OP
|
$441.84
|
|
|
Service Code
|
NDC 68180015001
|
| Hospital Charge Code |
10010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.48 |
| Max. Negotiated Rate |
$397.66 |
| Rate for Payer: Aetna American Axle |
$287.20
|
| Rate for Payer: Aetna Commercial |
$375.56
|
| Rate for Payer: Aetna Medicare |
$220.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.20
|
| Rate for Payer: BCBS Complete |
$176.74
|
| Rate for Payer: Cash Price |
$353.47
|
| Rate for Payer: Cofinity Commercial |
$309.29
|
| Rate for Payer: Cofinity Commercial |
$379.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$309.29
|
| 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 Commercial |
$375.56
|
| Rate for Payer: PHP Commercial |
$375.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.20
|
| Rate for Payer: Priority Health SBD |
$278.36
|
| Rate for Payer: UMR Bronson Commercial |
$163.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$331.38
|
|
|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION
|
Facility
|
IP
|
$224.20
|
|
|
Service Code
|
NDC 70954031610
|
| Hospital Charge Code |
10010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.65 |
| Max. Negotiated Rate |
$201.78 |
| Rate for Payer: Aetna American Axle |
$145.73
|
| Rate for Payer: Aetna Commercial |
$190.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.73
|
| Rate for Payer: Cash Price |
$179.36
|
| Rate for Payer: Cofinity Commercial |
$156.94
|
| Rate for Payer: Cofinity Commercial |
$192.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.36
|
| Rate for Payer: Healthscope Commercial |
$201.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.57
|
| Rate for Payer: PHP Commercial |
$190.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.73
|
| Rate for Payer: Priority Health SBD |
$141.25
|
| Rate for Payer: UMR Bronson Commercial |
$98.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.15
|
|
|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION
|
Facility
|
OP
|
$440.88
|
|
|
Service Code
|
NDC 68382044405
|
| Hospital Charge Code |
10010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.13 |
| Max. Negotiated Rate |
$396.79 |
| Rate for Payer: Aetna American Axle |
$286.57
|
| Rate for Payer: Aetna Commercial |
$374.75
|
| Rate for Payer: Aetna Medicare |
$220.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$286.57
|
| Rate for Payer: BCBS Complete |
$176.35
|
| Rate for Payer: Cash Price |
$352.70
|
| Rate for Payer: Cofinity Commercial |
$308.62
|
| Rate for Payer: Cofinity Commercial |
$379.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$308.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$352.70
|
| Rate for Payer: Healthscope Commercial |
$396.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$308.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$330.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$374.75
|
| Rate for Payer: PHP Commercial |
$374.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.57
|
| Rate for Payer: Priority Health SBD |
$277.75
|
| Rate for Payer: UMR Bronson Commercial |
$163.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$330.66
|
|
|
FAMOTIDINE 40 MG/5 ML (8 MG/ML) ORAL SUSPENSION
|
Facility
|
OP
|
$224.20
|
|
|
Service Code
|
NDC 70954031610
|
| Hospital Charge Code |
10010
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.95 |
| Max. Negotiated Rate |
$201.78 |
| Rate for Payer: Aetna American Axle |
$145.73
|
| Rate for Payer: Aetna Commercial |
$190.57
|
| Rate for Payer: Aetna Medicare |
$112.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.73
|
| Rate for Payer: BCBS Complete |
$89.68
|
| Rate for Payer: Cash Price |
$179.36
|
| Rate for Payer: Cofinity Commercial |
$156.94
|
| Rate for Payer: Cofinity Commercial |
$192.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.36
|
| Rate for Payer: Healthscope Commercial |
$201.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.57
|
| Rate for Payer: PHP Commercial |
$190.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.73
|
| Rate for Payer: Priority Health SBD |
$141.25
|
| Rate for Payer: UMR Bronson Commercial |
$82.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.15
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$15.30
|
|
|
Service Code
|
NDC 70860075102
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$13.77 |
| Rate for Payer: Aetna American Axle |
$9.95
|
| Rate for Payer: Aetna Commercial |
$13.01
|
| Rate for Payer: Aetna Medicare |
$7.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.95
|
| Rate for Payer: BCBS Complete |
$6.12
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$10.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.01
|
| Rate for Payer: PHP Commercial |
$13.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.95
|
| Rate for Payer: Priority Health SBD |
$9.64
|
| Rate for Payer: UMR Bronson Commercial |
$5.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.47
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.95
|
|
|
Service Code
|
NDC 00641602225
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.79 |
| Max. Negotiated Rate |
$11.65 |
| Rate for Payer: Aetna American Axle |
$8.42
|
| Rate for Payer: Aetna Commercial |
$11.01
|
| Rate for Payer: Aetna Medicare |
$6.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.42
|
| Rate for Payer: BCBS Complete |
$5.18
|
| 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 |
$11.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.71
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$4.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.71
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.70
|
|
|
Service Code
|
NDC 09900000629
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$11.43 |
| Rate for Payer: Aetna American Axle |
$8.26
|
| Rate for Payer: Aetna Commercial |
$10.79
|
| Rate for Payer: Aetna Medicare |
$6.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.26
|
| Rate for Payer: BCBS Complete |
$5.08
|
| Rate for Payer: Cash Price |
$10.16
|
| Rate for Payer: Cofinity Commercial |
$10.92
|
| Rate for Payer: Cofinity Commercial |
$8.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.16
|
| Rate for Payer: Healthscope Commercial |
$11.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.79
|
| Rate for Payer: PHP Commercial |
$10.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.26
|
| Rate for Payer: Priority Health SBD |
$8.00
|
| Rate for Payer: UMR Bronson Commercial |
$4.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.53
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16.05
|
|
|
Service Code
|
NDC 63323073912
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$14.45 |
| Rate for Payer: Aetna American Axle |
$10.43
|
| Rate for Payer: Aetna Commercial |
$13.64
|
| Rate for Payer: Aetna Medicare |
$8.03
|
| 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 |
$11.23
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.84
|
| Rate for Payer: Healthscope Commercial |
$14.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.64
|
| Rate for Payer: PHP Commercial |
$13.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.43
|
| 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
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16.56
|
|
|
Service Code
|
NDC 55390002910
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.13 |
| Max. Negotiated Rate |
$14.90 |
| Rate for Payer: Aetna American Axle |
$10.76
|
| Rate for Payer: Aetna Commercial |
$14.08
|
| Rate for Payer: Aetna Medicare |
$8.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.76
|
| Rate for Payer: BCBS Complete |
$6.62
|
| Rate for Payer: Cash Price |
$13.25
|
| Rate for Payer: Cofinity Commercial |
$11.59
|
| Rate for Payer: Cofinity Commercial |
$14.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.25
|
| Rate for Payer: Healthscope Commercial |
$14.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.08
|
| Rate for Payer: PHP Commercial |
$14.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.76
|
| Rate for Payer: Priority Health SBD |
$10.43
|
| Rate for Payer: UMR Bronson Commercial |
$6.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.42
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$16.05
|
|
|
Service Code
|
NDC 63323073912
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$14.45 |
| 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: Cash Price |
$12.84
|
| Rate for Payer: Cofinity Commercial |
$11.23
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.84
|
| Rate for Payer: Healthscope Commercial |
$14.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.64
|
| Rate for Payer: PHP Commercial |
$13.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.43
|
| Rate for Payer: Priority Health SBD |
$10.11
|
| Rate for Payer: UMR Bronson Commercial |
$7.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.04
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.05
|
|
|
Service Code
|
NDC 67457043322
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.46 |
| Max. Negotiated Rate |
$10.85 |
| Rate for Payer: Aetna American Axle |
$7.83
|
| Rate for Payer: Aetna Commercial |
$10.24
|
| Rate for Payer: Aetna Medicare |
$6.03
|
| 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 |
$10.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.04
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$4.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.04
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.95
|
|
|
Service Code
|
NDC 00641602201
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.79 |
| Max. Negotiated Rate |
$11.65 |
| Rate for Payer: Aetna American Axle |
$8.42
|
| Rate for Payer: Aetna Commercial |
$11.01
|
| Rate for Payer: Aetna Medicare |
$6.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.42
|
| Rate for Payer: BCBS Complete |
$5.18
|
| 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 |
$11.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.71
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$4.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.71
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.95
|
|
|
Service Code
|
NDC 00641602201
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.70 |
| Max. Negotiated Rate |
$11.65 |
| Rate for Payer: Aetna American Axle |
$8.42
|
| 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 |
$11.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.71
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$5.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.71
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$15.30
|
|
|
Service Code
|
NDC 70860075141
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$13.77 |
| Rate for Payer: Aetna American Axle |
$9.95
|
| Rate for Payer: Aetna Commercial |
$13.01
|
| Rate for Payer: Aetna Medicare |
$7.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.95
|
| Rate for Payer: BCBS Complete |
$6.12
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$10.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.01
|
| Rate for Payer: PHP Commercial |
$13.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.95
|
| Rate for Payer: Priority Health SBD |
$9.64
|
| Rate for Payer: UMR Bronson Commercial |
$5.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.47
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$16.05
|
|
|
Service Code
|
NDC 63323073911
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$14.45 |
| Rate for Payer: Aetna American Axle |
$10.43
|
| Rate for Payer: Aetna Commercial |
$13.64
|
| Rate for Payer: Aetna Medicare |
$8.03
|
| 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 |
$11.23
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.84
|
| Rate for Payer: Healthscope Commercial |
$14.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.64
|
| Rate for Payer: PHP Commercial |
$13.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.43
|
| 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
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$16.56
|
|
|
Service Code
|
NDC 55390002910
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.29 |
| Max. Negotiated Rate |
$14.90 |
| Rate for Payer: Aetna American Axle |
$10.76
|
| Rate for Payer: Aetna Commercial |
$14.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.76
|
| Rate for Payer: Cash Price |
$13.25
|
| Rate for Payer: Cofinity Commercial |
$11.59
|
| Rate for Payer: Cofinity Commercial |
$14.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.25
|
| Rate for Payer: Healthscope Commercial |
$14.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.08
|
| Rate for Payer: PHP Commercial |
$14.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.76
|
| Rate for Payer: Priority Health SBD |
$10.43
|
| Rate for Payer: UMR Bronson Commercial |
$7.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.42
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$12.05
|
|
|
Service Code
|
NDC 67457043300
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.46 |
| Max. Negotiated Rate |
$10.85 |
| Rate for Payer: Aetna American Axle |
$7.83
|
| Rate for Payer: Aetna Commercial |
$10.24
|
| Rate for Payer: Aetna Medicare |
$6.03
|
| 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 |
$10.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.04
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$4.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.04
|
|
|
FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$12.95
|
|
|
Service Code
|
NDC 00641602225
|
| Hospital Charge Code |
117801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.70 |
| Max. Negotiated Rate |
$11.65 |
| Rate for Payer: Aetna American Axle |
$8.42
|
| 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 |
$11.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.71
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$5.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.71
|
|
