|
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 20 MG TABLET
|
Facility
|
OP
|
$178.60
|
|
|
Service Code
|
NDC 63739064510
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.08 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna American Axle |
$116.09
|
| Rate for Payer: Aetna Commercial |
$151.81
|
| Rate for Payer: Aetna Medicare |
$89.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.09
|
| Rate for Payer: BCBS Complete |
$71.44
|
| Rate for Payer: Cash Price |
$142.88
|
| Rate for Payer: Cofinity Commercial |
$125.02
|
| Rate for Payer: Cofinity Commercial |
$153.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$125.02
|
| 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 Commercial |
$151.81
|
| Rate for Payer: PHP Commercial |
$151.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.09
|
| Rate for Payer: Priority Health SBD |
$112.52
|
| Rate for Payer: UMR Bronson Commercial |
$66.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.95
|
|
|
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
|
$112.80
|
|
|
Service Code
|
NDC 00172572860
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.74 |
| Max. Negotiated Rate |
$101.52 |
| Rate for Payer: Aetna American Axle |
$73.32
|
| Rate for Payer: Aetna Commercial |
$95.88
|
| Rate for Payer: Aetna Medicare |
$56.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$73.32
|
| Rate for Payer: BCBS Complete |
$45.12
|
| 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 |
$41.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$84.60
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$4.33
|
|
|
Service Code
|
NDC 60687059511
|
| 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: Cofinity Medicare Advantage |
$3.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.46
|
| Rate for Payer: Healthscope Commercial |
$3.90
|
| Rate for Payer: 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 Commercial |
$3.68
|
| Rate for Payer: PHP Commercial |
$3.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.81
|
| Rate for Payer: Priority Health SBD |
$2.73
|
| 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
|
$116.33
|
|
|
Service Code
|
NDC 00904578051
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.04 |
| Max. Negotiated Rate |
$104.70 |
| Rate for Payer: Aetna American Axle |
$75.61
|
| Rate for Payer: Aetna Commercial |
$98.88
|
| Rate for Payer: Aetna Medicare |
$58.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.61
|
| Rate for Payer: BCBS Complete |
$46.53
|
| Rate for Payer: Cash Price |
$93.06
|
| Rate for Payer: Cofinity Commercial |
$100.04
|
| Rate for Payer: Cofinity Commercial |
$81.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.06
|
| Rate for Payer: Healthscope Commercial |
$104.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.88
|
| Rate for Payer: PHP Commercial |
$98.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.61
|
| Rate for Payer: Priority Health SBD |
$73.29
|
| Rate for Payer: UMR Bronson Commercial |
$43.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.25
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$432.40
|
|
|
Service Code
|
NDC 60687059501
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$159.99 |
| Max. Negotiated Rate |
$389.16 |
| Rate for Payer: Aetna American Axle |
$281.06
|
| Rate for Payer: Aetna Commercial |
$367.54
|
| Rate for Payer: Aetna Medicare |
$216.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$281.06
|
| Rate for Payer: BCBS Complete |
$172.96
|
| Rate for Payer: Cash Price |
$345.92
|
| Rate for Payer: Cofinity Commercial |
$302.68
|
| Rate for Payer: Cofinity Commercial |
$371.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$302.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$345.92
|
| Rate for Payer: Healthscope Commercial |
$389.16
|
| Rate for Payer: 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 Commercial |
$367.54
|
| Rate for Payer: PHP Commercial |
$367.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$281.06
|
| Rate for Payer: Priority Health SBD |
$272.41
|
| Rate for Payer: UMR Bronson Commercial |
$159.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$324.30
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$2.21
|
|
|
Service Code
|
NDC 50268030311
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.82 |
| Max. Negotiated Rate |
$1.99 |
| Rate for Payer: Aetna American Axle |
$1.44
|
| Rate for Payer: Aetna Commercial |
$1.88
|
| Rate for Payer: Aetna Medicare |
$1.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.44
|
| Rate for Payer: BCBS Complete |
$0.88
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cofinity Commercial |
$1.55
|
| Rate for Payer: Cofinity Commercial |
$1.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.77
|
| Rate for Payer: Healthscope Commercial |
$1.99
|
| Rate for Payer: 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 |
$0.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.66
|
|
|
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
|
OP
|
$190.35
|
|
|
Service Code
|
NDC 00536129801
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.43 |
| Max. Negotiated Rate |
$171.32 |
| Rate for Payer: Aetna American Axle |
$123.73
|
| Rate for Payer: Aetna Commercial |
$161.80
|
| Rate for Payer: Aetna Medicare |
$95.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.73
|
| Rate for Payer: BCBS Complete |
$76.14
|
| Rate for Payer: Cash Price |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$133.24
|
| Rate for Payer: Cofinity Commercial |
$163.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$133.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.28
|
| Rate for Payer: Healthscope Commercial |
$171.32
|
| Rate for Payer: 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 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 |
$70.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.76
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$150.40
|
|
|
Service Code
|
NDC 61442012101
|
| 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 Medicare |
$75.20
|
| 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: Cofinity Medicare Advantage |
$105.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.32
|
| Rate for Payer: Healthscope Commercial |
$135.36
|
| Rate for Payer: 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 Commercial |
$127.84
|
| Rate for Payer: PHP Commercial |
$127.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.76
|
| Rate for Payer: Priority Health SBD |
$94.75
|
| Rate for Payer: UMR Bronson Commercial |
$55.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.80
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$110.45
|
|
|
Service Code
|
NDC 50268030315
|
| 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 Medicare |
$55.22
|
| 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: Cofinity Medicare Advantage |
$77.32
|
| 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 Commercial |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| Rate for Payer: Priority Health SBD |
$69.58
|
| Rate for Payer: UMR Bronson Commercial |
$40.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
OP
|
$1.49
|
|
|
Service Code
|
NDC 51079096601
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.34 |
| Rate for Payer: Aetna American Axle |
$0.97
|
| Rate for Payer: Aetna Commercial |
$1.27
|
| Rate for Payer: Aetna Medicare |
$0.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.97
|
| Rate for Payer: BCBS Complete |
$0.60
|
| Rate for Payer: Cash Price |
$1.19
|
| Rate for Payer: Cofinity Commercial |
$1.04
|
| Rate for Payer: Cofinity Commercial |
$1.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.04
|
| 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 Commercial |
$1.27
|
| Rate for Payer: PHP Commercial |
$1.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.97
|
| Rate for Payer: Priority Health SBD |
$0.94
|
| Rate for Payer: UMR Bronson Commercial |
$0.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.12
|
|
|
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
|
$116.33
|
|
|
Service Code
|
NDC 00904578051
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.19 |
| Max. Negotiated Rate |
$104.70 |
| Rate for Payer: Aetna American Axle |
$75.61
|
| Rate for Payer: Aetna Commercial |
$98.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.61
|
| Rate for Payer: Cash Price |
$93.06
|
| Rate for Payer: Cofinity Commercial |
$100.04
|
| Rate for Payer: Cofinity Commercial |
$81.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$81.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.06
|
| Rate for Payer: Healthscope Commercial |
$104.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$98.88
|
| Rate for Payer: PHP Commercial |
$98.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.61
|
| Rate for Payer: Priority Health SBD |
$73.29
|
| Rate for Payer: UMR Bronson Commercial |
$51.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.25
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$178.60
|
|
|
Service Code
|
NDC 63739064510
|
| 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: Cofinity Medicare Advantage |
$125.02
|
| 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 Commercial |
$151.81
|
| Rate for Payer: PHP Commercial |
$151.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$116.09
|
| 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
|
$150.40
|
|
|
Service Code
|
NDC 61442012101
|
| 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: Cofinity Medicare Advantage |
$105.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.32
|
| Rate for Payer: Healthscope Commercial |
$135.36
|
| Rate for Payer: 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 Commercial |
$127.84
|
| Rate for Payer: PHP Commercial |
$127.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.76
|
| Rate for Payer: Priority Health SBD |
$94.75
|
| 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
|
$4.33
|
|
|
Service Code
|
NDC 60687059511
|
| Hospital Charge Code |
10011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Aetna American Axle |
$2.81
|
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Aetna Medicare |
$2.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.81
|
| Rate for Payer: BCBS Complete |
$1.73
|
| Rate for Payer: Cash Price |
$3.46
|
| Rate for Payer: Cofinity Commercial |
$3.03
|
| Rate for Payer: Cofinity Commercial |
$3.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.46
|
| Rate for Payer: Healthscope Commercial |
$3.90
|
| Rate for Payer: 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 Commercial |
$3.68
|
| Rate for Payer: PHP Commercial |
$3.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.81
|
| Rate for Payer: Priority Health SBD |
$2.73
|
| Rate for Payer: UMR Bronson Commercial |
$1.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.25
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$1.49
|
|
|
Service Code
|
NDC 51079096601
|
| 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: Cofinity Medicare Advantage |
$1.04
|
| 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 Commercial |
$1.27
|
| Rate for Payer: PHP Commercial |
$1.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.97
|
| 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
|
OP
|
$148.05
|
|
|
Service Code
|
NDC 51079096620
|
| 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 Medicare |
$74.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.23
|
| Rate for Payer: BCBS Complete |
$59.22
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$103.64
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$103.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.24
|
| 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 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 |
$54.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
FAMOTIDINE 20 MG TABLET
|
Facility
|
IP
|
$432.40
|
|
|
Service Code
|
NDC 60687059501
|
| 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: Cofinity Medicare Advantage |
$302.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$345.92
|
| Rate for Payer: Healthscope Commercial |
$389.16
|
| Rate for Payer: 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 Commercial |
$367.54
|
| Rate for Payer: PHP Commercial |
$367.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$281.06
|
| Rate for Payer: Priority Health SBD |
$272.41
|
| 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
|
$148.05
|
|
|
Service Code
|
NDC 51079096620
|
| 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: Cofinity Medicare Advantage |
$103.64
|
| 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 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
|
$110.45
|
|
|
Service Code
|
NDC 50268030315
|
| 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: Cofinity Medicare Advantage |
$77.32
|
| 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 Commercial |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| Rate for Payer: Priority Health SBD |
$69.58
|
| 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
|
$190.35
|
|
|
Service Code
|
NDC 00536129801
|
| 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: Cofinity Medicare Advantage |
$133.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.28
|
| Rate for Payer: Healthscope Commercial |
$171.32
|
| Rate for Payer: 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 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
|
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
|
|
