Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

FAMOTIDINE IVPB 20MG/50ML ISO

Facility

OP

$31.36

Service Code	NDC 338519741
Hospital Charge Code	60629161
Hospital Revenue Code	250
Min. Negotiated Rate	$4.08
Max. Negotiated Rate	$15.68
Rate for Payer: Aetna Commercial	$9.41
Rate for Payer: Aetna Medicare Advantage	$9.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$8.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$8.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$8.00
Rate for Payer: Cigna Commercial	$15.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$4.08
Rate for Payer: Oxford Commercial	$15.68
Rate for Payer: Qualcare PPO/HMO/WC	$4.70
Rate for Payer: UnitedHealthcare Commercial	$15.68

FAMOTIDINE IVPB 20MG/50ML ISO

Facility

IP

$31.36

Service Code	NDC 338519741
Hospital Charge Code	60629161
Hospital Revenue Code	250
Min. Negotiated Rate	$4.70
Max. Negotiated Rate	$4.70
Rate for Payer: Qualcare PPO/HMO/WC	$4.70

FAMOTIDINE TAB 40MG***********

Facility

OP

$26.00

Hospital Charge Code	60629235
Hospital Revenue Code	250
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$7.80
Rate for Payer: Aetna Medicare Advantage	$7.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6.63
Rate for Payer: Cigna Commercial	$13.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.38
Rate for Payer: Oxford Commercial	$13.00
Rate for Payer: Qualcare PPO/HMO/WC	$3.90
Rate for Payer: UnitedHealthcare Commercial	$13.00

FAMOTIDINE TAB 40MG***********

Facility

IP

$26.00

Hospital Charge Code	60629235
Hospital Revenue Code	250
Min. Negotiated Rate	$3.90
Max. Negotiated Rate	$3.90
Rate for Payer: Qualcare PPO/HMO/WC	$3.90

FAM SES ADLT WO PT/30MIN MCAID

Facility

IP

$750.00

Service Code	HCPCS 90846
Hospital Charge Code	4511605
Hospital Revenue Code	914
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADLT WO PT/30MIN MCAID

Facility

IP

$750.00

Service Code	HCPCS 90846
Hospital Charge Code	4535605
Hospital Revenue Code	914
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADLT WO PT/30MIN MCAID

Facility

OP

$750.00

Service Code	HCPCS 90846
Hospital Charge Code	4818605
Hospital Revenue Code	914
Min. Negotiated Rate	$97.50
Max. Negotiated Rate	$422.69
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: Aetna Medicare Advantage	$225.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$170.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.25
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$97.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADLT WO PT/30MIN MCAID

Facility

IP

$750.00

Service Code	HCPCS 90846
Hospital Charge Code	4502605
Hospital Revenue Code	914
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADLT WO PT/30MIN MCAID

Facility

IP

$750.00

Service Code	HCPCS 90846
Hospital Charge Code	4832605
Hospital Revenue Code	914
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADLT WO PT/30MIN MCAID

Facility

OP

$750.00

Service Code	HCPCS 90846
Hospital Charge Code	4822605
Hospital Revenue Code	914
Min. Negotiated Rate	$97.50
Max. Negotiated Rate	$422.69
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: Aetna Medicare Advantage	$225.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$170.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.25
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$97.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADLT WO PT/30MIN MCAID

Facility

OP

$750.00

Service Code	HCPCS 90846
Hospital Charge Code	4502605
Hospital Revenue Code	914
Min. Negotiated Rate	$97.50
Max. Negotiated Rate	$422.69
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: Aetna Medicare Advantage	$225.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$170.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.25
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$97.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADLT WO PT/30MIN MCAID

Facility

OP

$750.00

Service Code	HCPCS 90846
Hospital Charge Code	4504605
Hospital Revenue Code	914
Min. Negotiated Rate	$97.50
Max. Negotiated Rate	$422.69
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: Aetna Medicare Advantage	$225.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$170.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.25
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$97.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADLT WO PT/30MIN MCAID

Facility

IP

$750.00

Service Code	HCPCS 90846
Hospital Charge Code	4822605
Hospital Revenue Code	914
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADLT WO PT/30MIN MCAID

Facility

IP

$750.00

Service Code	HCPCS 90846
Hospital Charge Code	4504605
Hospital Revenue Code	914
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADLT WO PT/30MIN MCAID

Facility

OP

$750.00

Service Code	HCPCS 90846
Hospital Charge Code	4535605
Hospital Revenue Code	914
Min. Negotiated Rate	$97.50
Max. Negotiated Rate	$422.69
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: Aetna Medicare Advantage	$225.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$170.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.25
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$97.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADLT WO PT/30MIN MCAID

Facility

OP

$750.00

Service Code	HCPCS 90846
Hospital Charge Code	4832605
Hospital Revenue Code	914
Min. Negotiated Rate	$97.50
Max. Negotiated Rate	$422.69
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: Aetna Medicare Advantage	$225.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$170.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.25
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$97.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADLT WO PT/30MIN MCAID

Facility

IP

$750.00

Service Code	HCPCS 90846
Hospital Charge Code	4818605
Hospital Revenue Code	914
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADLT WO PT/30MIN MCAID

Facility

OP

$750.00

Service Code	HCPCS 90846
Hospital Charge Code	4511605
Hospital Revenue Code	914
Min. Negotiated Rate	$97.50
Max. Negotiated Rate	$422.69
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: Aetna Medicare Advantage	$225.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$170.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.25
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$97.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADULT W PT/30MIN MCAID

Facility

IP

$750.00

Service Code	HCPCS 90847
Hospital Charge Code	4818606
Hospital Revenue Code	914
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADULT W PT/30MIN MCAID

Facility

IP

$750.00

Service Code	HCPCS 90847
Hospital Charge Code	4504606
Hospital Revenue Code	914
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADULT W PT/30MIN MCAID

Facility

OP

$750.00

Service Code	HCPCS 90847
Hospital Charge Code	4822606
Hospital Revenue Code	914
Min. Negotiated Rate	$97.50
Max. Negotiated Rate	$422.69
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: Aetna Medicare Advantage	$225.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$189.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.25
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$97.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$113.84

FAM SES ADULT W PT/30MIN MCAID

Facility

IP

$750.00

Service Code	HCPCS 90847
Hospital Charge Code	4832606
Hospital Revenue Code	914
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADULT W PT/30MIN MCAID

Facility

OP

$750.00

Service Code	HCPCS 90847
Hospital Charge Code	4535606
Hospital Revenue Code	914
Min. Negotiated Rate	$97.50
Max. Negotiated Rate	$422.69
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: Aetna Medicare Advantage	$225.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$189.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.25
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$97.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$113.84

FAM SES ADULT W PT/30MIN MCAID

Facility

IP

$750.00

Service Code	HCPCS 90847
Hospital Charge Code	4535606
Hospital Revenue Code	914
Min. Negotiated Rate	$112.50
Max. Negotiated Rate	$112.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50

FAM SES ADULT W PT/30MIN MCAID

Facility

OP

$750.00

Service Code	HCPCS 90847
Hospital Charge Code	4832606
Hospital Revenue Code	914
Min. Negotiated Rate	$97.50
Max. Negotiated Rate	$422.69
Rate for Payer: Aetna Commercial	$225.00
Rate for Payer: Aetna Medicare Advantage	$225.00
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$191.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$189.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$191.25
Rate for Payer: Cigna Commercial	$422.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$97.50
Rate for Payer: Qualcare PPO/HMO/WC	$112.50
Rate for Payer: Wellcare New Jersey Medicaid/Family Care	$113.84