St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

FAMOTIDINE 20 MG PO TABS [10011]

Facility

$2.42

Service Code	NDC 00172572860
Hospital Charge Code	00172572860
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.94
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.21
Rate for Payer: Aetna Government	$1.21
Rate for Payer: Brighton Health Commercial	$1.82
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.94
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.65
Rate for Payer: Group Health Inc Commercial	$1.21
Rate for Payer: Group Health Inc Medicare	$0.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.21
Rate for Payer: Hamaspik Choice Inc Medicare	$1.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.57

FAMOTIDINE 20 MG PO TABS [10011]

Facility

$0.12

Service Code	NDC 00536129801
Hospital Charge Code	00536129801
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Brighton Health Commercial	$0.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.08
Rate for Payer: Group Health Inc Commercial	$0.06
Rate for Payer: Group Health Inc Medicare	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.06
Rate for Payer: Hamaspik Choice Inc Medicare	$0.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.08

FAMOTIDINE 20 MG PO TABS [10011]

Facility

$0.15

Service Code	NDC 00904578051
Hospital Charge Code	00904578051
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Brighton Health Commercial	$0.11
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.10
Rate for Payer: Group Health Inc Commercial	$0.08
Rate for Payer: Group Health Inc Medicare	$0.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.08
Rate for Payer: Hamaspik Choice Inc Medicare	$0.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.10

FAMOTIDINE 20 MG PO TABS [10011]

Facility

$0.24

Service Code	NDC 60687059501
Hospital Charge Code	60687059501
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.19
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$0.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.16
Rate for Payer: Group Health Inc Commercial	$0.12
Rate for Payer: Group Health Inc Medicare	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.12
Rate for Payer: Hamaspik Choice Inc Medicare	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.16

FAMOTIDINE 20 MG PO TABS [10011]

Facility

$2.08

Service Code	NDC 61442012110
Hospital Charge Code	61442012110
Hospital Revenue Code	250
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.04
Rate for Payer: Aetna Government	$1.04
Rate for Payer: Brighton Health Commercial	$1.56
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.41
Rate for Payer: Group Health Inc Commercial	$1.04
Rate for Payer: Group Health Inc Medicare	$0.73
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.04
Rate for Payer: Hamaspik Choice Inc Medicare	$1.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.35

FAMOTIDINE 20 MG PO TABS [10011]

Facility

$2.42

Service Code	NDC 00172572870
Hospital Charge Code	00172572870
Hospital Revenue Code	250
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.94
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.21
Rate for Payer: Aetna Government	$1.21
Rate for Payer: Brighton Health Commercial	$1.82
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.94
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.65
Rate for Payer: Group Health Inc Commercial	$1.21
Rate for Payer: Group Health Inc Medicare	$0.85
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.21
Rate for Payer: Hamaspik Choice Inc Medicare	$1.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.57

FAMOTIDINE 20 MG PO TABS [10011]

Facility

$0.10

Service Code	NDC 63739064510
Hospital Charge Code	63739064510
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.08
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.06
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.05
Rate for Payer: Aetna Government	$0.05
Rate for Payer: Brighton Health Commercial	$0.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.08
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.07
Rate for Payer: Group Health Inc Commercial	$0.05
Rate for Payer: Group Health Inc Medicare	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.05
Rate for Payer: Hamaspik Choice Inc Medicare	$0.05
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.07

FAMOTIDINE 20MG TAB

Facility

$1.00

Service Code	HCPCS S0028
Hospital Charge Code	41658033
Hospital Revenue Code	636
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.74
Rate for Payer: Aetna Government	$0.74
Rate for Payer: Brighton Health Commercial	$0.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.58
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

FAMOTIDINE 20MG TAB

Facility

$1.00

Service Code	HCPCS S0028
Hospital Charge Code	41648033
Hospital Revenue Code	636
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.74
Rate for Payer: Aetna Government	$0.74
Rate for Payer: Brighton Health Commercial	$0.60
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.58
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

FAMOTIDINE 20MG TAB

Facility

$1.00

Service Code	HCPCS S0028
Hospital Charge Code	41648033
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50

FAMOTIDINE 20MG TAB

Facility

$1.00

Service Code	HCPCS S0028
Hospital Charge Code	41658033
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50

FAMOTIDINE (PF) 20 MG/2ML IV SOLN [183771]

Facility

$0.52

Service Code	NDC 70860075102
Hospital Charge Code	70860075102
Hospital Revenue Code	278
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26
Rate for Payer: Hamaspik Choice Inc Medicare	$0.26

FAMOTIDINE (PF) 20 MG/2ML IV SOLN [183771]

Facility

$0.53

Service Code	NDC 67457043300
Hospital Charge Code	67457043300
Hospital Revenue Code	278
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.29
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.27
Rate for Payer: Aetna Government	$0.27
Rate for Payer: Brighton Health Commercial	$0.32
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.27
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.31
Rate for Payer: EmblemHealth Commercial	$0.27
Rate for Payer: Fidelis Medicare Advantage	$0.56
Rate for Payer: Group Health Inc Commercial	$0.27
Rate for Payer: Group Health Inc Medicare	$0.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.27
Rate for Payer: Hamaspik Choice Inc Medicare	$0.27
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.35

FAMOTIDINE (PF) 20 MG/2ML IV SOLN [183771]

Facility

$0.53

Service Code	NDC 67457043322
Hospital Charge Code	67457043322
Hospital Revenue Code	278
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.27
Rate for Payer: Hamaspik Choice Inc Medicare	$0.27

FAMOTIDINE (PF) 20 MG/2ML IV SOLN [183771]

Facility

$0.54

Service Code	NDC 63323073912
Hospital Charge Code	63323073912
Hospital Revenue Code	278
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.27
Rate for Payer: Aetna Government	$0.27
Rate for Payer: Brighton Health Commercial	$0.32
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.27
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.31
Rate for Payer: EmblemHealth Commercial	$0.27
Rate for Payer: Fidelis Medicare Advantage	$0.57
Rate for Payer: Group Health Inc Commercial	$0.27
Rate for Payer: Group Health Inc Medicare	$0.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.27
Rate for Payer: Hamaspik Choice Inc Medicare	$0.27
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.35

FAMOTIDINE (PF) 20 MG/2ML IV SOLN [183771]

Facility

$0.52

Service Code	NDC 70860075102
Hospital Charge Code	70860075102
Hospital Revenue Code	278
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.28
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.26
Rate for Payer: Aetna Government	$0.26
Rate for Payer: Brighton Health Commercial	$0.31
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.30
Rate for Payer: EmblemHealth Commercial	$0.26
Rate for Payer: Fidelis Medicare Advantage	$0.54
Rate for Payer: Group Health Inc Commercial	$0.26
Rate for Payer: Group Health Inc Medicare	$0.18
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.26
Rate for Payer: Hamaspik Choice Inc Medicare	$0.26
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.34

FAMOTIDINE (PF) 20 MG/2ML IV SOLN [183771]

Facility

$0.54

Service Code	NDC 63323073912
Hospital Charge Code	63323073912
Hospital Revenue Code	278
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.27
Rate for Payer: Hamaspik Choice Inc Medicare	$0.27

FAMOTIDINE (PF) 20 MG/2ML IV SOLN [183771]

Facility

$0.53

Service Code	NDC 67457043322
Hospital Charge Code	67457043322
Hospital Revenue Code	278
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.29
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.27
Rate for Payer: Aetna Government	$0.27
Rate for Payer: Brighton Health Commercial	$0.32
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.27
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.31
Rate for Payer: EmblemHealth Commercial	$0.27
Rate for Payer: Fidelis Medicare Advantage	$0.56
Rate for Payer: Group Health Inc Commercial	$0.27
Rate for Payer: Group Health Inc Medicare	$0.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.27
Rate for Payer: Hamaspik Choice Inc Medicare	$0.27
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.35

FAMOTIDINE (PF) 20 MG/2ML IV SOLN [183771]

Facility

$0.53

Service Code	NDC 67457043300
Hospital Charge Code	67457043300
Hospital Revenue Code	278
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.27
Rate for Payer: Hamaspik Choice Inc Medicare	$0.27

FAMOTIDINE PREMIXED 20-0.9 MG/50ML-% IV SOLN [30450]

Facility

$0.13

Service Code	NDC 00338519741
Hospital Charge Code	00338519741
Hospital Revenue Code	278
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.07
Rate for Payer: Aetna Government	$0.07
Rate for Payer: Brighton Health Commercial	$0.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.08
Rate for Payer: EmblemHealth Commercial	$0.07
Rate for Payer: Fidelis Medicare Advantage	$0.14
Rate for Payer: Group Health Inc Commercial	$0.07
Rate for Payer: Group Health Inc Medicare	$0.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.07
Rate for Payer: Hamaspik Choice Inc Medicare	$0.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.09

FAMOTIDINE PREMIXED 20-0.9 MG/50ML-% IV SOLN [30450]

Facility

$0.13

Service Code	NDC 00338519741
Hospital Charge Code	00338519741
Hospital Revenue Code	278
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.07
Rate for Payer: Hamaspik Choice Inc Medicare	$0.07

FAMOTIDINE (PRESERVE FREE)20MG2ML

Facility

$2.00

Service Code	HCPCS J3490
Hospital Charge Code	41648001
Hospital Revenue Code	636
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.00
Rate for Payer: Aetna Government	$1.00
Rate for Payer: Brighton Health Commercial	$1.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.15
Rate for Payer: Group Health Inc Commercial	$1.00
Rate for Payer: Group Health Inc Medicare	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30

FAMOTIDINE (PRESERVE FREE)20MG2ML

Facility

$2.00

Service Code	HCPCS J3490
Hospital Charge Code	41658001
Hospital Revenue Code	636
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00

FAMOTIDINE (PRESERVE FREE)20MG2ML

Facility

$2.00

Service Code	HCPCS J3490
Hospital Charge Code	41648001
Hospital Revenue Code	636
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00

FAMOTIDINE (PRESERVE FREE)20MG2ML

Facility

$2.00

Service Code	HCPCS J3490
Hospital Charge Code	41658001
Hospital Revenue Code	636
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.00
Rate for Payer: Aetna Government	$1.00
Rate for Payer: Brighton Health Commercial	$1.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.15
Rate for Payer: Group Health Inc Commercial	$1.00
Rate for Payer: Group Health Inc Medicare	$0.70
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.00
Rate for Payer: Hamaspik Choice Inc Medicare	$1.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.30

Know your out-of-pocket cost for care.

All Charges