Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

EXTRACRANIAL PROCEDURES WITHOUT CC/MCC

Facility

$16,149.96

Service Code	MSDRG 039
Min. Negotiated Rate	$9,708.54
Max. Negotiated Rate	$16,149.96
Rate for Payer: Aetna Medicare	$10,219.52
Rate for Payer: Allen County Amish Medical Aid Commercial	$12,774.40
Rate for Payer: Amish Plain Church Group Commercial	$12,774.40
Rate for Payer: BCBS MAPPO	$10,219.52
Rate for Payer: BCN Medicare Advantage	$10,219.52
Rate for Payer: Health Alliance Plan Medicare Advantage	$10,219.52
Rate for Payer: Humana Choice PPO Medicare	$10,219.52
Rate for Payer: Mclaren Medicare	$10,219.52
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$10,730.50
Rate for Payer: MI Amish Medical Board Commercial	$11,752.45
Rate for Payer: Molina Medicare/Medicaid	$11,241.47
Rate for Payer: PACE Medicare	$9,708.54
Rate for Payer: PACE SWMI	$10,219.52
Rate for Payer: PHP Commercial	$11,241.47
Rate for Payer: PHP Medicare Advantage	$10,219.52
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$16,149.96
Rate for Payer: Priority Health Medicare	$10,219.52
Rate for Payer: Priority Health Narrow Network	$12,919.97
Rate for Payer: Railroad Medicare Medicare	$10,219.52
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$10,219.52
Rate for Payer: UHC Exchange	$15,840.26
Rate for Payer: UHCCP DNSP	$10,219.52
Rate for Payer: VA VA	$10,219.52

EXTRAOCULAR PROCEDURES EXCEPT ORBIT

Facility

$21,087.68

Service Code	MSDRG 115
Min. Negotiated Rate	$12,167.27
Max. Negotiated Rate	$21,087.68
Rate for Payer: Aetna Medicare	$12,807.65
Rate for Payer: Allen County Amish Medical Aid Commercial	$16,009.56
Rate for Payer: Amish Plain Church Group Commercial	$16,009.56
Rate for Payer: BCBS MAPPO	$12,807.65
Rate for Payer: BCN Medicare Advantage	$12,807.65
Rate for Payer: Health Alliance Plan Medicare Advantage	$12,807.65
Rate for Payer: Humana Choice PPO Medicare	$12,807.65
Rate for Payer: Mclaren Medicare	$12,807.65
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$13,448.03
Rate for Payer: MI Amish Medical Board Commercial	$14,728.80
Rate for Payer: Molina Medicare/Medicaid	$14,088.42
Rate for Payer: PACE Medicare	$12,167.27
Rate for Payer: PACE SWMI	$12,807.65
Rate for Payer: PHP Commercial	$14,088.42
Rate for Payer: PHP Medicare Advantage	$12,807.65
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$21,087.68
Rate for Payer: Priority Health Medicare	$12,807.65
Rate for Payer: Priority Health Narrow Network	$16,870.15
Rate for Payer: Railroad Medicare Medicare	$12,807.65
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$12,807.65
Rate for Payer: UHC Exchange	$19,851.86
Rate for Payer: UHCCP DNSP	$12,807.65
Rate for Payer: VA VA	$12,807.65

EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE

Facility

$117,455.75

Service Code	MSDRG 790
Min. Negotiated Rate	$42,327.30
Max. Negotiated Rate	$117,455.75
Rate for Payer: Aetna Medicare	$44,555.05
Rate for Payer: Allen County Amish Medical Aid Commercial	$55,693.81
Rate for Payer: Amish Plain Church Group Commercial	$55,693.81
Rate for Payer: BCBS MAPPO	$44,555.05
Rate for Payer: BCN Medicare Advantage	$44,555.05
Rate for Payer: Health Alliance Plan Medicare Advantage	$44,555.05
Rate for Payer: Humana Choice PPO Medicare	$44,555.05
Rate for Payer: Mclaren Medicare	$44,555.05
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$46,782.80
Rate for Payer: MI Amish Medical Board Commercial	$51,238.31
Rate for Payer: Molina Medicare/Medicaid	$49,010.56
Rate for Payer: PACE Medicare	$42,327.30
Rate for Payer: PACE SWMI	$44,555.05
Rate for Payer: PHP Commercial	$49,010.56
Rate for Payer: PHP Medicare Advantage	$44,555.05
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$117,455.75
Rate for Payer: Priority Health Medicare	$44,555.05
Rate for Payer: Priority Health Narrow Network	$93,964.60
Rate for Payer: Railroad Medicare Medicare	$44,555.05
Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage	$44,555.05
Rate for Payer: UHC Exchange	$69,060.33
Rate for Payer: UHCCP DNSP	$44,555.05
Rate for Payer: VA VA	$44,555.05

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility

$14,700.57

Service Code	APR-DRG 0824
Min. Negotiated Rate	$13,291.08
Max. Negotiated Rate	$14,700.57
Rate for Payer: BCBS Complete	$14,700.57
Rate for Payer: Mclaren Medicaid	$14,000.54
Rate for Payer: Meridian Medicaid	$14,700.57
Rate for Payer: PHP Medicaid	$13,291.08
Rate for Payer: Priority Health Choice Medicaid	$14,000.54
Rate for Payer: UHC Medicaid	$14,000.54
Rate for Payer: UHCCP Medicaid	$14,000.54

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility

$9,691.39

Service Code	APR-DRG 0823
Min. Negotiated Rate	$8,762.18
Max. Negotiated Rate	$9,691.39
Rate for Payer: BCBS Complete	$9,691.39
Rate for Payer: Mclaren Medicaid	$9,229.90
Rate for Payer: Meridian Medicaid	$9,691.39
Rate for Payer: PHP Medicaid	$8,762.18
Rate for Payer: Priority Health Choice Medicaid	$9,229.90
Rate for Payer: UHC Medicaid	$9,229.90
Rate for Payer: UHCCP Medicaid	$9,229.90

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility

$5,255.50

Service Code	APR-DRG 0822
Min. Negotiated Rate	$4,751.60
Max. Negotiated Rate	$5,255.50
Rate for Payer: BCBS Complete	$5,255.50
Rate for Payer: Mclaren Medicaid	$5,005.24
Rate for Payer: Meridian Medicaid	$5,255.50
Rate for Payer: PHP Medicaid	$4,751.60
Rate for Payer: Priority Health Choice Medicaid	$5,005.24
Rate for Payer: UHC Medicaid	$5,005.24
Rate for Payer: UHCCP Medicaid	$5,005.24

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility

$3,193.41

Service Code	APR-DRG 0821
Min. Negotiated Rate	$2,887.22
Max. Negotiated Rate	$3,193.41
Rate for Payer: BCBS Complete	$3,193.41
Rate for Payer: Mclaren Medicaid	$3,041.34
Rate for Payer: Meridian Medicaid	$3,193.41
Rate for Payer: PHP Medicaid	$2,887.22
Rate for Payer: Priority Health Choice Medicaid	$3,041.34
Rate for Payer: UHC Medicaid	$3,041.34
Rate for Payer: UHCCP Medicaid	$3,041.34

EYELASH TINTING

Professional

Both

$32.00

Hospital Revenue Code	960
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$24.00
Rate for Payer: BCBS Complete	$12.80
Rate for Payer: Cash Price	$25.60
Rate for Payer: Opus (Opus Packaging Group) HMA	$24.00

EZETIMIBE 10 MG TABLET

Facility

$53.58

Service Code	NDC 50228037930
Hospital Charge Code	34153
Hospital Revenue Code	637
Min. Negotiated Rate	$19.82
Max. Negotiated Rate	$53.58
Rate for Payer: Aetna Commercial	$48.22
Rate for Payer: Aetna Medicare	$19.82
Rate for Payer: ASR ASR	$51.97
Rate for Payer: BCBS Complete	$21.43
Rate for Payer: BCBS Trust/PPO	$44.18
Rate for Payer: BCN Commercial	$44.18
Rate for Payer: Cash Price	$42.86
Rate for Payer: Cofinity Commercial	$50.37
Rate for Payer: Encore Health Key Benefits Commercial	$42.86
Rate for Payer: Healthscope Commercial	$51.97
Rate for Payer: Healthscope Whirlpool	$53.58
Rate for Payer: Mclaren Commercial	$48.22
Rate for Payer: MI Amish Medical Board Commercial	$42.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$45.54
Rate for Payer: Nomi Health Commercial	$43.94
Rate for Payer: Opus (Opus Packaging Group) HMA	$40.19
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$46.95
Rate for Payer: Priority Health Narrow Network	$37.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$47.15

EZETIMIBE 10 MG TABLET

Facility

$81.80

Service Code	NDC 67877049030
Hospital Charge Code	34153
Hospital Revenue Code	637
Min. Negotiated Rate	$61.35
Max. Negotiated Rate	$81.80
Rate for Payer: Aetna Commercial	$73.62
Rate for Payer: ASR ASR	$79.34
Rate for Payer: BCBS Trust/PPO	$67.17
Rate for Payer: BCN Commercial	$67.17
Rate for Payer: Cash Price	$65.44
Rate for Payer: Cofinity Commercial	$76.89
Rate for Payer: Encore Health Key Benefits Commercial	$65.44
Rate for Payer: Healthscope Commercial	$79.34
Rate for Payer: Healthscope Whirlpool	$81.80
Rate for Payer: Mclaren Commercial	$73.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$69.53
Rate for Payer: Nomi Health Commercial	$67.07
Rate for Payer: Opus (Opus Packaging Group) HMA	$61.35
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$71.98

EZETIMIBE 10 MG TABLET

Facility

$81.80

Service Code	NDC 67877049030
Hospital Charge Code	34153
Hospital Revenue Code	637
Min. Negotiated Rate	$30.26
Max. Negotiated Rate	$81.80
Rate for Payer: Aetna Commercial	$73.62
Rate for Payer: Aetna Medicare	$30.26
Rate for Payer: ASR ASR	$79.34
Rate for Payer: BCBS Complete	$32.72
Rate for Payer: BCBS Trust/PPO	$67.44
Rate for Payer: BCN Commercial	$67.44
Rate for Payer: Cash Price	$65.44
Rate for Payer: Cofinity Commercial	$76.89
Rate for Payer: Encore Health Key Benefits Commercial	$65.44
Rate for Payer: Healthscope Commercial	$79.34
Rate for Payer: Healthscope Whirlpool	$81.80
Rate for Payer: Mclaren Commercial	$73.62
Rate for Payer: MI Amish Medical Board Commercial	$65.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$69.53
Rate for Payer: Nomi Health Commercial	$67.07
Rate for Payer: Opus (Opus Packaging Group) HMA	$61.35
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$71.67
Rate for Payer: Priority Health Narrow Network	$57.34
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$71.98

EZETIMIBE 10 MG TABLET

Facility

$272.39

Service Code	NDC 904710310
Hospital Charge Code	34153
Hospital Revenue Code	637
Min. Negotiated Rate	$204.30
Max. Negotiated Rate	$272.39
Rate for Payer: Aetna Commercial	$245.15
Rate for Payer: ASR ASR	$264.22
Rate for Payer: BCBS Trust/PPO	$223.69
Rate for Payer: BCN Commercial	$223.69
Rate for Payer: Cash Price	$217.92
Rate for Payer: Cofinity Commercial	$256.05
Rate for Payer: Encore Health Key Benefits Commercial	$217.92
Rate for Payer: Healthscope Commercial	$264.22
Rate for Payer: Healthscope Whirlpool	$272.39
Rate for Payer: Mclaren Commercial	$245.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$231.53
Rate for Payer: Nomi Health Commercial	$223.36
Rate for Payer: Opus (Opus Packaging Group) HMA	$204.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$239.71

EZETIMIBE 10 MG TABLET

Facility

$53.58

Service Code	NDC 50228037930
Hospital Charge Code	34153
Hospital Revenue Code	637
Min. Negotiated Rate	$40.19
Max. Negotiated Rate	$53.58
Rate for Payer: Aetna Commercial	$48.22
Rate for Payer: ASR ASR	$51.97
Rate for Payer: BCBS Trust/PPO	$44.00
Rate for Payer: BCN Commercial	$44.00
Rate for Payer: Cash Price	$42.86
Rate for Payer: Cofinity Commercial	$50.37
Rate for Payer: Encore Health Key Benefits Commercial	$42.86
Rate for Payer: Healthscope Commercial	$51.97
Rate for Payer: Healthscope Whirlpool	$53.58
Rate for Payer: Mclaren Commercial	$48.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$45.54
Rate for Payer: Nomi Health Commercial	$43.94
Rate for Payer: Opus (Opus Packaging Group) HMA	$40.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$47.15

EZETIMIBE 10 MG TABLET

Facility

$272.39

Service Code	NDC 904710310
Hospital Charge Code	34153
Hospital Revenue Code	637
Min. Negotiated Rate	$100.79
Max. Negotiated Rate	$272.39
Rate for Payer: Aetna Commercial	$245.15
Rate for Payer: Aetna Medicare	$100.79
Rate for Payer: ASR ASR	$264.22
Rate for Payer: BCBS Complete	$108.96
Rate for Payer: BCBS Trust/PPO	$224.59
Rate for Payer: BCN Commercial	$224.59
Rate for Payer: Cash Price	$217.92
Rate for Payer: Cofinity Commercial	$256.05
Rate for Payer: Encore Health Key Benefits Commercial	$217.92
Rate for Payer: Healthscope Commercial	$264.22
Rate for Payer: Healthscope Whirlpool	$272.39
Rate for Payer: Mclaren Commercial	$245.15
Rate for Payer: MI Amish Medical Board Commercial	$217.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$231.53
Rate for Payer: Nomi Health Commercial	$223.36
Rate for Payer: Opus (Opus Packaging Group) HMA	$204.30
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$238.67
Rate for Payer: Priority Health Narrow Network	$190.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$239.71

FACIAL

Professional

Both

$68.00

Hospital Revenue Code	960
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$51.00
Rate for Payer: BCBS Complete	$27.20
Rate for Payer: Cash Price	$54.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$51.00

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$33,852.84

Service Code	APR-DRG 0924
Min. Negotiated Rate	$30,607.02
Max. Negotiated Rate	$33,852.84
Rate for Payer: BCBS Complete	$33,852.84
Rate for Payer: Mclaren Medicaid	$32,240.80
Rate for Payer: Meridian Medicaid	$33,852.84
Rate for Payer: PHP Medicaid	$30,607.02
Rate for Payer: Priority Health Choice Medicaid	$32,240.80
Rate for Payer: UHC Medicaid	$32,240.80
Rate for Payer: UHCCP Medicaid	$32,240.80

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$10,653.23

Service Code	APR-DRG 0921
Min. Negotiated Rate	$9,631.79
Max. Negotiated Rate	$10,653.23
Rate for Payer: BCBS Complete	$10,653.23
Rate for Payer: Mclaren Medicaid	$10,145.93
Rate for Payer: Meridian Medicaid	$10,653.23
Rate for Payer: PHP Medicaid	$9,631.79
Rate for Payer: Priority Health Choice Medicaid	$10,145.93
Rate for Payer: UHC Medicaid	$10,145.93
Rate for Payer: UHCCP Medicaid	$10,145.93

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$11,984.54

Service Code	APR-DRG 0922
Min. Negotiated Rate	$10,835.46
Max. Negotiated Rate	$11,984.54
Rate for Payer: BCBS Complete	$11,984.54
Rate for Payer: Mclaren Medicaid	$11,413.85
Rate for Payer: Meridian Medicaid	$11,984.54
Rate for Payer: PHP Medicaid	$10,835.46
Rate for Payer: Priority Health Choice Medicaid	$11,413.85
Rate for Payer: UHC Medicaid	$11,413.85
Rate for Payer: UHCCP Medicaid	$11,413.85

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility

$21,368.58

Service Code	APR-DRG 0923
Min. Negotiated Rate	$19,319.75
Max. Negotiated Rate	$21,368.58
Rate for Payer: BCBS Complete	$21,368.58
Rate for Payer: Mclaren Medicaid	$20,351.03
Rate for Payer: Meridian Medicaid	$21,368.58
Rate for Payer: PHP Medicaid	$19,319.75
Rate for Payer: Priority Health Choice Medicaid	$20,351.03
Rate for Payer: UHC Medicaid	$20,351.03
Rate for Payer: UHCCP Medicaid	$20,351.03

FAMOTIDINE 20 MG TABLET

Facility

$1.48

Service Code	NDC 51079096601
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$1.48
Rate for Payer: Aetna Commercial	$1.33
Rate for Payer: Aetna Medicare	$0.55
Rate for Payer: ASR ASR	$1.44
Rate for Payer: BCBS Complete	$0.59
Rate for Payer: BCBS Trust/PPO	$1.22
Rate for Payer: BCN Commercial	$1.22
Rate for Payer: Cash Price	$1.18
Rate for Payer: Cofinity Commercial	$1.39
Rate for Payer: Encore Health Key Benefits Commercial	$1.18
Rate for Payer: Healthscope Commercial	$1.44
Rate for Payer: Healthscope Whirlpool	$1.48
Rate for Payer: Mclaren Commercial	$1.33
Rate for Payer: MI Amish Medical Board Commercial	$1.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.26
Rate for Payer: Nomi Health Commercial	$1.21
Rate for Payer: Opus (Opus Packaging Group) HMA	$1.11
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$1.30
Rate for Payer: Priority Health Narrow Network	$1.04
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1.30

FAMOTIDINE 20 MG TABLET

Facility

$148.05

Service Code	NDC 51079096620
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$111.04
Max. Negotiated Rate	$148.05
Rate for Payer: Aetna Commercial	$133.25
Rate for Payer: ASR ASR	$143.61
Rate for Payer: BCBS Trust/PPO	$121.58
Rate for Payer: BCN Commercial	$121.58
Rate for Payer: Cash Price	$118.44
Rate for Payer: Cofinity Commercial	$139.17
Rate for Payer: Encore Health Key Benefits Commercial	$118.44
Rate for Payer: Healthscope Commercial	$143.61
Rate for Payer: Healthscope Whirlpool	$148.05
Rate for Payer: Mclaren Commercial	$133.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$125.84
Rate for Payer: Nomi Health Commercial	$121.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$111.04
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$130.28

FAMOTIDINE 20 MG TABLET

Facility

$148.05

Service Code	NDC 61442012101
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$111.04
Max. Negotiated Rate	$148.05
Rate for Payer: Aetna Commercial	$133.25
Rate for Payer: ASR ASR	$143.61
Rate for Payer: BCBS Trust/PPO	$121.58
Rate for Payer: BCN Commercial	$121.58
Rate for Payer: Cash Price	$118.44
Rate for Payer: Cofinity Commercial	$139.17
Rate for Payer: Encore Health Key Benefits Commercial	$118.44
Rate for Payer: Healthscope Commercial	$143.61
Rate for Payer: Healthscope Whirlpool	$148.05
Rate for Payer: Mclaren Commercial	$133.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$125.84
Rate for Payer: Nomi Health Commercial	$121.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$111.04
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$130.28

FAMOTIDINE 20 MG TABLET

Facility

$197.40

Service Code	NDC 904719361
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$73.04
Max. Negotiated Rate	$197.40
Rate for Payer: Aetna Commercial	$177.66
Rate for Payer: Aetna Medicare	$73.04
Rate for Payer: ASR ASR	$191.48
Rate for Payer: BCBS Complete	$78.96
Rate for Payer: BCBS Trust/PPO	$162.76
Rate for Payer: BCN Commercial	$162.76
Rate for Payer: Cash Price	$157.92
Rate for Payer: Cofinity Commercial	$185.56
Rate for Payer: Encore Health Key Benefits Commercial	$157.92
Rate for Payer: Healthscope Commercial	$191.48
Rate for Payer: Healthscope Whirlpool	$197.40
Rate for Payer: Mclaren Commercial	$177.66
Rate for Payer: MI Amish Medical Board Commercial	$157.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$167.79
Rate for Payer: Nomi Health Commercial	$161.87
Rate for Payer: Opus (Opus Packaging Group) HMA	$148.05
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$172.96
Rate for Payer: Priority Health Narrow Network	$138.38
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$173.71

FAMOTIDINE 20 MG TABLET

Facility

$148.05

Service Code	NDC 61442012101
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$54.78
Max. Negotiated Rate	$148.05
Rate for Payer: Aetna Commercial	$133.25
Rate for Payer: Aetna Medicare	$54.78
Rate for Payer: ASR ASR	$143.61
Rate for Payer: BCBS Complete	$59.22
Rate for Payer: BCBS Trust/PPO	$122.07
Rate for Payer: BCN Commercial	$122.07
Rate for Payer: Cash Price	$118.44
Rate for Payer: Cofinity Commercial	$139.17
Rate for Payer: Encore Health Key Benefits Commercial	$118.44
Rate for Payer: Healthscope Commercial	$143.61
Rate for Payer: Healthscope Whirlpool	$148.05
Rate for Payer: Mclaren Commercial	$133.25
Rate for Payer: MI Amish Medical Board Commercial	$118.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$125.84
Rate for Payer: Nomi Health Commercial	$121.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$111.04
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$129.72
Rate for Payer: Priority Health Narrow Network	$103.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$130.28

FAMOTIDINE 20 MG TABLET

Facility

$148.05

Service Code	NDC 51079096620
Hospital Charge Code	10011
Hospital Revenue Code	637
Min. Negotiated Rate	$54.78
Max. Negotiated Rate	$148.05
Rate for Payer: Aetna Commercial	$133.25
Rate for Payer: Aetna Medicare	$54.78
Rate for Payer: ASR ASR	$143.61
Rate for Payer: BCBS Complete	$59.22
Rate for Payer: BCBS Trust/PPO	$122.07
Rate for Payer: BCN Commercial	$122.07
Rate for Payer: Cash Price	$118.44
Rate for Payer: Cofinity Commercial	$139.17
Rate for Payer: Encore Health Key Benefits Commercial	$118.44
Rate for Payer: Healthscope Commercial	$143.61
Rate for Payer: Healthscope Whirlpool	$148.05
Rate for Payer: Mclaren Commercial	$133.25
Rate for Payer: MI Amish Medical Board Commercial	$118.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$125.84
Rate for Payer: Nomi Health Commercial	$121.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$111.04
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$129.72
Rate for Payer: Priority Health Narrow Network	$103.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$130.28

Know your out-of-pocket cost for care.

All Charges