|
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12
|
Facility
|
OP
|
$16,386.90
|
|
|
Service Code
|
CPT 42820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$289.79 |
| Max. Negotiated Rate |
$16,386.90 |
| Rate for Payer: Aetna Medicare |
$5,413.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,506.78
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,506.78
|
| Rate for Payer: BCBS Complete |
$2,989.99
|
| Rate for Payer: BCBS MAPPO |
$5,205.42
|
| Rate for Payer: BCBS Trust/PPO |
$2,675.48
|
| Rate for Payer: BCN Medicare Advantage |
$5,205.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,205.42
|
| Rate for Payer: Mclaren Medicaid |
$2,847.36
|
| Rate for Payer: Mclaren Medicare |
$5,205.42
|
| Rate for Payer: Meridian Medicaid |
$2,989.99
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,465.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,986.23
|
| Rate for Payer: PACE Medicare |
$4,945.15
|
| Rate for Payer: PACE SWMI |
$5,205.42
|
| Rate for Payer: PHP Medicare Advantage |
$5,205.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,847.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,386.90
|
| Rate for Payer: Priority Health Medicare |
$5,205.42
|
| Rate for Payer: Priority Health Narrow Network |
$13,109.52
|
| Rate for Payer: Railroad Medicare Medicare |
$5,205.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$318.77
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,205.42
|
| Rate for Payer: UHC Exchange |
$289.79
|
| Rate for Payer: UHC Medicare Advantage |
$5,361.58
|
| Rate for Payer: VA VA |
$5,205.42
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER
|
Facility
|
OP
|
$9,009.23
|
|
|
Service Code
|
CPT 42826
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$254.75 |
| Max. Negotiated Rate |
$9,009.23 |
| Rate for Payer: Aetna Medicare |
$2,976.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,577.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,577.30
|
| Rate for Payer: BCBS Complete |
$1,643.84
|
| Rate for Payer: BCBS MAPPO |
$2,861.84
|
| Rate for Payer: BCBS Trust/PPO |
$2,623.30
|
| Rate for Payer: BCN Medicare Advantage |
$2,861.84
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2,861.84
|
| Rate for Payer: Mclaren Medicaid |
$1,565.43
|
| Rate for Payer: Mclaren Medicare |
$2,861.84
|
| Rate for Payer: Meridian Medicaid |
$1,643.84
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$3,004.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,291.12
|
| Rate for Payer: PACE Medicare |
$2,718.75
|
| Rate for Payer: PACE SWMI |
$2,861.84
|
| Rate for Payer: PHP Medicare Advantage |
$2,861.84
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,565.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$9,009.23
|
| Rate for Payer: Priority Health Medicare |
$2,861.84
|
| Rate for Payer: Priority Health Narrow Network |
$7,207.38
|
| Rate for Payer: Railroad Medicare Medicare |
$2,861.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$280.22
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$2,861.84
|
| Rate for Payer: UHC Exchange |
$254.75
|
| Rate for Payer: UHC Medicare Advantage |
$2,947.70
|
| Rate for Payer: VA VA |
$2,861.84
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12
|
Facility
|
OP
|
$16,386.90
|
|
|
Service Code
|
CPT 42825
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$267.52 |
| Max. Negotiated Rate |
$16,386.90 |
| Rate for Payer: Aetna Medicare |
$5,413.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6,506.78
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6,506.78
|
| Rate for Payer: BCBS Complete |
$2,989.99
|
| Rate for Payer: BCBS MAPPO |
$5,205.42
|
| Rate for Payer: BCBS Trust/PPO |
$2,783.78
|
| Rate for Payer: BCN Medicare Advantage |
$5,205.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,205.42
|
| Rate for Payer: Mclaren Medicaid |
$2,847.36
|
| Rate for Payer: Mclaren Medicare |
$5,205.42
|
| Rate for Payer: Meridian Medicaid |
$2,989.99
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$5,465.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5,986.23
|
| Rate for Payer: PACE Medicare |
$4,945.15
|
| Rate for Payer: PACE SWMI |
$5,205.42
|
| Rate for Payer: PHP Medicare Advantage |
$5,205.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$2,847.36
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16,386.90
|
| Rate for Payer: Priority Health Medicare |
$5,205.42
|
| Rate for Payer: Priority Health Narrow Network |
$13,109.52
|
| Rate for Payer: Railroad Medicare Medicare |
$5,205.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$294.27
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,205.42
|
| Rate for Payer: UHC Exchange |
$267.52
|
| Rate for Payer: UHC Medicare Advantage |
$5,361.58
|
| Rate for Payer: VA VA |
$5,205.42
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
IP
|
$153.69
|
|
|
Service Code
|
NDC 68462-109-60
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.62 |
| Max. Negotiated Rate |
$138.32 |
| Rate for Payer: Aetna American Axle |
$99.90
|
| Rate for Payer: Aetna Commercial |
$130.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$99.90
|
| Rate for Payer: Cash Price |
$122.95
|
| Rate for Payer: Cofinity Commercial |
$107.58
|
| Rate for Payer: Cofinity Commercial |
$132.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$122.95
|
| Rate for Payer: Healthscope Commercial |
$138.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$107.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$115.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$130.64
|
| Rate for Payer: PHP Commercial |
$130.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.58
|
| Rate for Payer: Priority Health SBD |
$96.82
|
| Rate for Payer: UMR Bronson Commercial |
$67.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$115.27
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
IP
|
$383.80
|
|
|
Service Code
|
NDC 68084-344-11
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.87 |
| Max. Negotiated Rate |
$345.42 |
| Rate for Payer: Aetna American Axle |
$249.47
|
| Rate for Payer: Aetna Commercial |
$326.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$249.47
|
| Rate for Payer: Cash Price |
$307.04
|
| Rate for Payer: Cofinity Commercial |
$268.66
|
| Rate for Payer: Cofinity Commercial |
$330.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$307.04
|
| Rate for Payer: Healthscope Commercial |
$345.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$268.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$287.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$326.23
|
| Rate for Payer: PHP Commercial |
$326.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$268.66
|
| Rate for Payer: Priority Health SBD |
$241.79
|
| Rate for Payer: UMR Bronson Commercial |
$168.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$287.85
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
IP
|
$73.32
|
|
|
Service Code
|
NDC 68382-140-14
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.26 |
| Max. Negotiated Rate |
$65.99 |
| Rate for Payer: Aetna American Axle |
$47.66
|
| Rate for Payer: Aetna Commercial |
$62.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.66
|
| Rate for Payer: Cash Price |
$58.66
|
| Rate for Payer: Cofinity Commercial |
$51.32
|
| Rate for Payer: Cofinity Commercial |
$63.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.66
|
| Rate for Payer: Healthscope Commercial |
$65.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$62.32
|
| Rate for Payer: PHP Commercial |
$62.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.32
|
| Rate for Payer: Priority Health SBD |
$46.19
|
| Rate for Payer: UMR Bronson Commercial |
$32.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.99
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
IP
|
$383.80
|
|
|
Service Code
|
NDC 68084-344-01
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.87 |
| Max. Negotiated Rate |
$345.42 |
| Rate for Payer: Aetna American Axle |
$249.47
|
| Rate for Payer: Aetna Commercial |
$326.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$249.47
|
| Rate for Payer: Cash Price |
$307.04
|
| Rate for Payer: Cofinity Commercial |
$268.66
|
| Rate for Payer: Cofinity Commercial |
$330.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$307.04
|
| Rate for Payer: Healthscope Commercial |
$345.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$268.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$287.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$326.23
|
| Rate for Payer: PHP Commercial |
$326.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$268.66
|
| Rate for Payer: Priority Health SBD |
$241.79
|
| Rate for Payer: UMR Bronson Commercial |
$168.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$287.85
|
|
|
TOPIRAMATE 15 MG SPRINKLE CAPSULE
|
Facility
|
IP
|
$275.88
|
|
|
Service Code
|
NDC 68382-004-14
|
| Hospital Charge Code |
27641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.39 |
| Max. Negotiated Rate |
$248.29 |
| Rate for Payer: Aetna American Axle |
$179.32
|
| Rate for Payer: Aetna Commercial |
$234.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.32
|
| Rate for Payer: Cash Price |
$220.70
|
| Rate for Payer: Cofinity Commercial |
$193.12
|
| Rate for Payer: Cofinity Commercial |
$237.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.70
|
| Rate for Payer: Healthscope Commercial |
$248.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$193.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$206.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$234.50
|
| Rate for Payer: PHP Commercial |
$234.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$193.12
|
| Rate for Payer: Priority Health SBD |
$173.80
|
| Rate for Payer: UMR Bronson Commercial |
$121.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$206.91
|
|
|
TOPIRAMATE 15 MG SPRINKLE CAPSULE
|
Facility
|
IP
|
$1,279.83
|
|
|
Service Code
|
NDC 50458-647-65
|
| Hospital Charge Code |
27641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$563.13 |
| Max. Negotiated Rate |
$1,151.85 |
| Rate for Payer: Aetna American Axle |
$831.89
|
| Rate for Payer: Aetna Commercial |
$1,087.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$831.89
|
| Rate for Payer: Cash Price |
$1,023.86
|
| Rate for Payer: Cofinity Commercial |
$1,100.65
|
| Rate for Payer: Cofinity Commercial |
$895.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,023.86
|
| Rate for Payer: Healthscope Commercial |
$1,151.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$895.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$959.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,087.86
|
| Rate for Payer: PHP Commercial |
$1,087.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$895.88
|
| Rate for Payer: Priority Health SBD |
$806.29
|
| Rate for Payer: UMR Bronson Commercial |
$563.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$959.87
|
|
|
TOPIRAMATE 200 MG TABLET
|
Facility
|
IP
|
$95.88
|
|
|
Service Code
|
NDC 68382-141-14
|
| Hospital Charge Code |
18921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.19 |
| Max. Negotiated Rate |
$86.29 |
| Rate for Payer: Aetna American Axle |
$62.32
|
| Rate for Payer: Aetna Commercial |
$81.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.32
|
| Rate for Payer: Cash Price |
$76.70
|
| Rate for Payer: Cofinity Commercial |
$67.12
|
| Rate for Payer: Cofinity Commercial |
$82.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.70
|
| Rate for Payer: Healthscope Commercial |
$86.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$67.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$81.50
|
| Rate for Payer: PHP Commercial |
$81.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.12
|
| Rate for Payer: Priority Health SBD |
$60.40
|
| Rate for Payer: UMR Bronson Commercial |
$42.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.91
|
|
|
TOPIRAMATE 200 MG TABLET
|
Facility
|
IP
|
$87.99
|
|
|
Service Code
|
NDC 68084-345-11
|
| Hospital Charge Code |
18921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.72 |
| Max. Negotiated Rate |
$79.19 |
| Rate for Payer: Aetna American Axle |
$57.19
|
| Rate for Payer: Aetna Commercial |
$74.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.19
|
| Rate for Payer: Cash Price |
$70.39
|
| Rate for Payer: Cofinity Commercial |
$61.59
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.39
|
| Rate for Payer: Healthscope Commercial |
$79.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.79
|
| Rate for Payer: PHP Commercial |
$74.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.59
|
| Rate for Payer: Priority Health SBD |
$55.43
|
| Rate for Payer: UMR Bronson Commercial |
$38.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.99
|
|
|
TOPIRAMATE 200 MG TABLET
|
Facility
|
IP
|
$201.63
|
|
|
Service Code
|
NDC 68462-110-60
|
| Hospital Charge Code |
18921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.72 |
| Max. Negotiated Rate |
$181.47 |
| Rate for Payer: Aetna American Axle |
$131.06
|
| Rate for Payer: Aetna Commercial |
$171.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$131.06
|
| Rate for Payer: Cash Price |
$161.30
|
| Rate for Payer: Cofinity Commercial |
$141.14
|
| Rate for Payer: Cofinity Commercial |
$173.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$161.30
|
| Rate for Payer: Healthscope Commercial |
$181.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$141.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$151.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$171.39
|
| Rate for Payer: PHP Commercial |
$171.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.14
|
| Rate for Payer: Priority Health SBD |
$127.03
|
| Rate for Payer: UMR Bronson Commercial |
$88.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$151.22
|
|
|
TOPIRAMATE 200 MG TABLET
|
Facility
|
IP
|
$87.99
|
|
|
Service Code
|
NDC 68084-345-21
|
| Hospital Charge Code |
18921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.72 |
| Max. Negotiated Rate |
$79.19 |
| Rate for Payer: Aetna American Axle |
$57.19
|
| Rate for Payer: Aetna Commercial |
$74.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.19
|
| Rate for Payer: Cash Price |
$70.39
|
| Rate for Payer: Cofinity Commercial |
$61.59
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.39
|
| Rate for Payer: Healthscope Commercial |
$79.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.79
|
| Rate for Payer: PHP Commercial |
$74.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.59
|
| Rate for Payer: Priority Health SBD |
$55.43
|
| Rate for Payer: UMR Bronson Commercial |
$38.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.99
|
|
|
TOPIRAMATE 25 MG SPRINKLE CAPSULE
|
Facility
|
IP
|
$1,547.12
|
|
|
Service Code
|
NDC 50458-645-65
|
| Hospital Charge Code |
27642
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$680.73 |
| Max. Negotiated Rate |
$1,392.41 |
| Rate for Payer: Aetna American Axle |
$1,005.63
|
| Rate for Payer: Aetna Commercial |
$1,315.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,005.63
|
| Rate for Payer: Cash Price |
$1,237.70
|
| Rate for Payer: Cofinity Commercial |
$1,082.98
|
| Rate for Payer: Cofinity Commercial |
$1,330.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,237.70
|
| Rate for Payer: Healthscope Commercial |
$1,392.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,082.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,160.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,315.05
|
| Rate for Payer: PHP Commercial |
$1,315.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,082.98
|
| Rate for Payer: Priority Health SBD |
$974.69
|
| Rate for Payer: UMR Bronson Commercial |
$680.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,160.34
|
|
|
TOPIRAMATE 25 MG SPRINKLE CAPSULE
|
Facility
|
IP
|
$214.89
|
|
|
Service Code
|
NDC 68382-005-14
|
| Hospital Charge Code |
27642
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.55 |
| Max. Negotiated Rate |
$193.40 |
| Rate for Payer: Aetna American Axle |
$139.68
|
| Rate for Payer: Aetna Commercial |
$182.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$139.68
|
| Rate for Payer: Cash Price |
$171.91
|
| Rate for Payer: Cofinity Commercial |
$150.42
|
| Rate for Payer: Cofinity Commercial |
$184.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.91
|
| Rate for Payer: Healthscope Commercial |
$193.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$150.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$161.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$182.66
|
| Rate for Payer: PHP Commercial |
$182.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.42
|
| Rate for Payer: Priority Health SBD |
$135.38
|
| Rate for Payer: UMR Bronson Commercial |
$94.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$161.17
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
IP
|
$215.65
|
|
|
Service Code
|
NDC 68084-342-11
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.89 |
| Max. Negotiated Rate |
$194.08 |
| Rate for Payer: Aetna American Axle |
$140.17
|
| Rate for Payer: Aetna Commercial |
$183.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$140.17
|
| Rate for Payer: Cash Price |
$172.52
|
| Rate for Payer: Cofinity Commercial |
$150.96
|
| Rate for Payer: Cofinity Commercial |
$185.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$172.52
|
| Rate for Payer: Healthscope Commercial |
$194.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$150.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$161.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$183.30
|
| Rate for Payer: PHP Commercial |
$183.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.96
|
| Rate for Payer: Priority Health SBD |
$135.86
|
| Rate for Payer: UMR Bronson Commercial |
$94.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$161.74
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
IP
|
$50.76
|
|
|
Service Code
|
NDC 68382-138-14
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.33 |
| Max. Negotiated Rate |
$45.68 |
| Rate for Payer: Aetna American Axle |
$32.99
|
| Rate for Payer: Aetna Commercial |
$43.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.99
|
| Rate for Payer: Cash Price |
$40.61
|
| Rate for Payer: Cofinity Commercial |
$35.53
|
| Rate for Payer: Cofinity Commercial |
$43.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.61
|
| Rate for Payer: Healthscope Commercial |
$45.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$35.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.15
|
| Rate for Payer: PHP Commercial |
$43.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.53
|
| Rate for Payer: Priority Health SBD |
$31.98
|
| Rate for Payer: UMR Bronson Commercial |
$22.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.07
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
IP
|
$1,353.09
|
|
|
Service Code
|
NDC 50458-639-65
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$595.36 |
| Max. Negotiated Rate |
$1,217.78 |
| Rate for Payer: Aetna American Axle |
$879.51
|
| Rate for Payer: Aetna Commercial |
$1,150.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$879.51
|
| Rate for Payer: Cash Price |
$1,082.47
|
| Rate for Payer: Cofinity Commercial |
$1,163.66
|
| Rate for Payer: Cofinity Commercial |
$947.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,082.47
|
| Rate for Payer: Healthscope Commercial |
$1,217.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$947.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,014.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,150.13
|
| Rate for Payer: PHP Commercial |
$1,150.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$947.16
|
| Rate for Payer: Priority Health SBD |
$852.45
|
| Rate for Payer: UMR Bronson Commercial |
$595.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,014.82
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
IP
|
$215.65
|
|
|
Service Code
|
NDC 68084-342-01
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.89 |
| Max. Negotiated Rate |
$194.08 |
| Rate for Payer: Aetna American Axle |
$140.17
|
| Rate for Payer: Aetna Commercial |
$183.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$140.17
|
| Rate for Payer: Cash Price |
$172.52
|
| Rate for Payer: Cofinity Commercial |
$150.96
|
| Rate for Payer: Cofinity Commercial |
$185.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$172.52
|
| Rate for Payer: Healthscope Commercial |
$194.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$150.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$161.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$183.30
|
| Rate for Payer: PHP Commercial |
$183.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.96
|
| Rate for Payer: Priority Health SBD |
$135.86
|
| Rate for Payer: UMR Bronson Commercial |
$94.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$161.74
|
|
|
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$452.06
|
|
|
Service Code
|
HCPCS J9351
|
| Hospital Charge Code |
152057
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$406.85 |
| Rate for Payer: Aetna American Axle |
$293.84
|
| Rate for Payer: Aetna American Axle |
$68.82
|
| Rate for Payer: Aetna Commercial |
$384.25
|
| Rate for Payer: Aetna Commercial |
$90.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.84
|
| Rate for Payer: BCBS Complete |
$42.35
|
| Rate for Payer: BCBS Complete |
$180.82
|
| Rate for Payer: BCBS Trust/PPO |
$2.51
|
| Rate for Payer: BCBS Trust/PPO |
$2.51
|
| Rate for Payer: Cash Price |
$361.65
|
| Rate for Payer: Cash Price |
$84.70
|
| Rate for Payer: Cash Price |
$361.65
|
| Rate for Payer: Cash Price |
$84.70
|
| Rate for Payer: Cofinity Commercial |
$74.12
|
| Rate for Payer: Cofinity Commercial |
$388.77
|
| Rate for Payer: Cofinity Commercial |
$316.44
|
| Rate for Payer: Cofinity Commercial |
$91.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$361.65
|
| Rate for Payer: Healthscope Commercial |
$95.29
|
| Rate for Payer: Healthscope Commercial |
$406.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$316.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$339.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$384.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$90.00
|
| Rate for Payer: PHP Commercial |
$384.25
|
| Rate for Payer: PHP Commercial |
$90.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$74.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$316.44
|
| Rate for Payer: Priority Health SBD |
$66.70
|
| Rate for Payer: Priority Health SBD |
$284.80
|
| Rate for Payer: UMR Bronson Commercial |
$167.26
|
| Rate for Payer: UMR Bronson Commercial |
$39.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$339.04
|
|
|
TOPOTECAN 4 MG INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$458.18
|
|
|
Service Code
|
HCPCS J9351
|
| Hospital Charge Code |
17285
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$412.36 |
| Rate for Payer: Aetna American Axle |
$297.82
|
| Rate for Payer: Aetna Commercial |
$389.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$297.82
|
| Rate for Payer: BCBS Complete |
$183.27
|
| Rate for Payer: BCBS Trust/PPO |
$2.51
|
| Rate for Payer: Cash Price |
$366.54
|
| Rate for Payer: Cash Price |
$366.54
|
| Rate for Payer: Cofinity Commercial |
$320.73
|
| Rate for Payer: Cofinity Commercial |
$394.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$366.54
|
| Rate for Payer: Healthscope Commercial |
$412.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$320.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$343.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$389.45
|
| Rate for Payer: PHP Commercial |
$389.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$320.73
|
| Rate for Payer: Priority Health SBD |
$288.65
|
| Rate for Payer: UMR Bronson Commercial |
$169.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$343.64
|
|
|
TOPOTECAN 4 MG INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$5,568.91
|
|
|
Service Code
|
HCPCS J9351
|
| Hospital Charge Code |
17285
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,450.32 |
| Max. Negotiated Rate |
$5,012.02 |
| Rate for Payer: Aetna American Axle |
$3,619.79
|
| Rate for Payer: Aetna Commercial |
$4,733.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,619.79
|
| Rate for Payer: Cash Price |
$4,455.13
|
| Rate for Payer: Cofinity Commercial |
$3,898.24
|
| Rate for Payer: Cofinity Commercial |
$4,789.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,455.13
|
| Rate for Payer: Healthscope Commercial |
$5,012.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,898.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,176.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4,733.57
|
| Rate for Payer: PHP Commercial |
$4,733.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,898.24
|
| Rate for Payer: Priority Health SBD |
$3,508.41
|
| Rate for Payer: UMR Bronson Commercial |
$2,450.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,176.68
|
|
|
TORSEMIDE 100 MG TABLET
|
Facility
|
IP
|
$148.68
|
|
|
Service Code
|
NDC 50268-757-15
|
| Hospital Charge Code |
18294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.42 |
| Max. Negotiated Rate |
$133.81 |
| Rate for Payer: Aetna American Axle |
$96.64
|
| Rate for Payer: Aetna Commercial |
$126.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.64
|
| Rate for Payer: Cash Price |
$118.94
|
| Rate for Payer: Cofinity Commercial |
$104.08
|
| Rate for Payer: Cofinity Commercial |
$127.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.94
|
| Rate for Payer: Healthscope Commercial |
$133.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$104.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$126.38
|
| Rate for Payer: PHP Commercial |
$126.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$104.08
|
| Rate for Payer: Priority Health SBD |
$93.67
|
| Rate for Payer: UMR Bronson Commercial |
$65.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.51
|
|
|
TORSEMIDE 100 MG TABLET
|
Facility
|
IP
|
$868.32
|
|
|
Service Code
|
NDC 50111-918-01
|
| Hospital Charge Code |
18294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$382.06 |
| Max. Negotiated Rate |
$781.49 |
| Rate for Payer: Aetna American Axle |
$564.41
|
| Rate for Payer: Aetna Commercial |
$738.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$564.41
|
| Rate for Payer: Cash Price |
$694.66
|
| Rate for Payer: Cofinity Commercial |
$607.82
|
| Rate for Payer: Cofinity Commercial |
$746.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$694.66
|
| Rate for Payer: Healthscope Commercial |
$781.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$607.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$651.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$738.07
|
| Rate for Payer: PHP Commercial |
$738.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$607.82
|
| Rate for Payer: Priority Health SBD |
$547.04
|
| Rate for Payer: UMR Bronson Commercial |
$382.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$651.24
|
|
|
TORSEMIDE 100 MG TABLET
|
Facility
|
IP
|
$343.10
|
|
|
Service Code
|
NDC 31722-532-01
|
| Hospital Charge Code |
18294
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.96 |
| Max. Negotiated Rate |
$308.79 |
| Rate for Payer: Aetna American Axle |
$223.02
|
| Rate for Payer: Aetna Commercial |
$291.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$223.02
|
| Rate for Payer: Cash Price |
$274.48
|
| Rate for Payer: Cofinity Commercial |
$240.17
|
| Rate for Payer: Cofinity Commercial |
$295.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$274.48
|
| Rate for Payer: Healthscope Commercial |
$308.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$240.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$257.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$291.64
|
| Rate for Payer: PHP Commercial |
$291.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$240.17
|
| Rate for Payer: Priority Health SBD |
$216.15
|
| Rate for Payer: UMR Bronson Commercial |
$150.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$257.32
|
|
