|
TOPIRAMATE 100 MG TABLET
|
Facility
|
OP
|
$111.39
|
|
|
Service Code
|
NDC 68382014014
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.21 |
| Max. Negotiated Rate |
$100.25 |
| Rate for Payer: Aetna American Axle |
$72.40
|
| Rate for Payer: Aetna Commercial |
$94.68
|
| Rate for Payer: Aetna Medicare |
$55.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.40
|
| Rate for Payer: BCBS Complete |
$44.56
|
| Rate for Payer: Cash Price |
$89.11
|
| Rate for Payer: Cofinity Advantage |
$77.97
|
| Rate for Payer: Cofinity Commercial |
$95.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.11
|
| Rate for Payer: Healthscope Commercial |
$100.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$83.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$89.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$83.54
|
| Rate for Payer: PHP Commercial |
$94.68
|
| Rate for Payer: Priority Health SBD |
$70.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$72.40
|
| Rate for Payer: UHC Core |
$58.03
|
| Rate for Payer: UHC Exchange |
$43.78
|
| Rate for Payer: UMR Bronson Commercial |
$41.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$83.54
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
OP
|
$417.05
|
|
|
Service Code
|
NDC 68084034401
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.31 |
| Max. Negotiated Rate |
$375.35 |
| Rate for Payer: Aetna American Axle |
$271.08
|
| Rate for Payer: Aetna Commercial |
$354.49
|
| Rate for Payer: Aetna Medicare |
$208.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.08
|
| Rate for Payer: BCBS Complete |
$166.82
|
| Rate for Payer: Cash Price |
$333.64
|
| Rate for Payer: Cofinity Advantage |
$291.94
|
| Rate for Payer: Cofinity Commercial |
$358.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$333.64
|
| Rate for Payer: Healthscope Commercial |
$375.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$291.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$312.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$333.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$354.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$312.79
|
| Rate for Payer: PHP Commercial |
$354.49
|
| Rate for Payer: Priority Health SBD |
$262.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$271.08
|
| Rate for Payer: UHC Core |
$217.28
|
| Rate for Payer: UHC Exchange |
$163.90
|
| Rate for Payer: UMR Bronson Commercial |
$154.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$312.79
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
IP
|
$417.05
|
|
|
Service Code
|
NDC 68084034401
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.50 |
| Max. Negotiated Rate |
$375.35 |
| Rate for Payer: Aetna American Axle |
$271.08
|
| Rate for Payer: Aetna Commercial |
$354.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.08
|
| Rate for Payer: Cash Price |
$333.64
|
| Rate for Payer: Cofinity Advantage |
$291.94
|
| Rate for Payer: Cofinity Commercial |
$358.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$333.64
|
| Rate for Payer: Healthscope Commercial |
$375.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$291.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$312.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$354.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$312.79
|
| Rate for Payer: PHP Commercial |
$354.49
|
| Rate for Payer: Priority Health SBD |
$262.74
|
| Rate for Payer: UMR Bronson Commercial |
$183.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$312.79
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
OP
|
$379.05
|
|
|
Service Code
|
NDC 00904692961
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.25 |
| Max. Negotiated Rate |
$341.14 |
| Rate for Payer: Aetna American Axle |
$246.38
|
| Rate for Payer: Aetna Commercial |
$322.19
|
| Rate for Payer: Aetna Medicare |
$189.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.38
|
| Rate for Payer: BCBS Complete |
$151.62
|
| Rate for Payer: Cash Price |
$303.24
|
| Rate for Payer: Cofinity Advantage |
$265.33
|
| Rate for Payer: Cofinity Commercial |
$325.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$303.24
|
| Rate for Payer: Healthscope Commercial |
$341.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$265.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$284.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$303.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$322.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$284.29
|
| Rate for Payer: PHP Commercial |
$322.19
|
| Rate for Payer: Priority Health SBD |
$238.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$246.38
|
| Rate for Payer: UHC Core |
$197.49
|
| Rate for Payer: UHC Exchange |
$148.97
|
| Rate for Payer: UMR Bronson Commercial |
$140.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$284.29
|
|
|
TOPIRAMATE 15 MG SPRINKLE CAPSULE
|
Facility
|
OP
|
$1,344.44
|
|
|
Service Code
|
NDC 50458064765
|
| Hospital Charge Code |
27641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$497.44 |
| Max. Negotiated Rate |
$1,210.00 |
| Rate for Payer: Aetna American Axle |
$873.89
|
| Rate for Payer: Aetna Commercial |
$1,142.77
|
| Rate for Payer: Aetna Medicare |
$672.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$873.89
|
| Rate for Payer: BCBS Complete |
$537.78
|
| Rate for Payer: Cash Price |
$1,075.55
|
| Rate for Payer: Cofinity Advantage |
$941.11
|
| Rate for Payer: Cofinity Commercial |
$1,156.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,075.55
|
| Rate for Payer: Healthscope Commercial |
$1,210.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$941.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,008.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,075.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,142.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,008.33
|
| Rate for Payer: PHP Commercial |
$1,142.77
|
| Rate for Payer: Priority Health SBD |
$847.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$873.89
|
| Rate for Payer: UHC Core |
$700.45
|
| Rate for Payer: UHC Exchange |
$528.36
|
| Rate for Payer: UMR Bronson Commercial |
$497.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,008.33
|
|
|
TOPIRAMATE 15 MG SPRINKLE CAPSULE
|
Facility
|
OP
|
$290.31
|
|
|
Service Code
|
NDC 68382000414
|
| Hospital Charge Code |
27641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.41 |
| Max. Negotiated Rate |
$261.28 |
| Rate for Payer: Aetna American Axle |
$188.70
|
| Rate for Payer: Aetna Commercial |
$246.76
|
| Rate for Payer: Aetna Medicare |
$145.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$188.70
|
| Rate for Payer: BCBS Complete |
$116.12
|
| Rate for Payer: Cash Price |
$232.25
|
| Rate for Payer: Cofinity Advantage |
$203.22
|
| Rate for Payer: Cofinity Commercial |
$249.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$232.25
|
| Rate for Payer: Healthscope Commercial |
$261.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$203.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$217.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$232.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$246.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$217.73
|
| Rate for Payer: PHP Commercial |
$246.76
|
| Rate for Payer: Priority Health SBD |
$182.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$188.70
|
| Rate for Payer: UHC Core |
$151.25
|
| Rate for Payer: UHC Exchange |
$114.09
|
| Rate for Payer: UMR Bronson Commercial |
$107.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$217.73
|
|
|
TOPIRAMATE 15 MG SPRINKLE CAPSULE
|
Facility
|
IP
|
$290.31
|
|
|
Service Code
|
NDC 68382000414
|
| Hospital Charge Code |
27641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.74 |
| Max. Negotiated Rate |
$261.28 |
| Rate for Payer: Aetna American Axle |
$188.70
|
| Rate for Payer: Aetna Commercial |
$246.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$188.70
|
| Rate for Payer: Cash Price |
$232.25
|
| Rate for Payer: Cofinity Advantage |
$203.22
|
| Rate for Payer: Cofinity Commercial |
$249.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$232.25
|
| Rate for Payer: Healthscope Commercial |
$261.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$203.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$217.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$246.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$217.73
|
| Rate for Payer: PHP Commercial |
$246.76
|
| Rate for Payer: Priority Health SBD |
$182.90
|
| Rate for Payer: UMR Bronson Commercial |
$127.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$217.73
|
|
|
TOPIRAMATE 15 MG SPRINKLE CAPSULE
|
Facility
|
IP
|
$1,344.44
|
|
|
Service Code
|
NDC 50458064765
|
| Hospital Charge Code |
27641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$591.55 |
| Max. Negotiated Rate |
$1,210.00 |
| Rate for Payer: Aetna American Axle |
$873.89
|
| Rate for Payer: Aetna Commercial |
$1,142.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$873.89
|
| Rate for Payer: Cash Price |
$1,075.55
|
| Rate for Payer: Cofinity Advantage |
$941.11
|
| Rate for Payer: Cofinity Commercial |
$1,156.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,075.55
|
| Rate for Payer: Healthscope Commercial |
$1,210.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$941.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,008.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,142.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,008.33
|
| Rate for Payer: PHP Commercial |
$1,142.77
|
| Rate for Payer: Priority Health SBD |
$847.00
|
| Rate for Payer: UMR Bronson Commercial |
$591.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,008.33
|
|
|
TOPIRAMATE 200 MG TABLET
|
Facility
|
IP
|
$166.38
|
|
|
Service Code
|
NDC 68382014114
|
| Hospital Charge Code |
18921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.21 |
| Max. Negotiated Rate |
$149.74 |
| Rate for Payer: Aetna American Axle |
$108.15
|
| Rate for Payer: Aetna Commercial |
$141.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.15
|
| Rate for Payer: Cash Price |
$133.10
|
| Rate for Payer: Cofinity Advantage |
$116.47
|
| Rate for Payer: Cofinity Commercial |
$143.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.10
|
| Rate for Payer: Healthscope Commercial |
$149.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$116.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$124.78
|
| Rate for Payer: PHP Commercial |
$141.42
|
| Rate for Payer: Priority Health SBD |
$104.82
|
| Rate for Payer: UMR Bronson Commercial |
$73.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.78
|
|
|
TOPIRAMATE 200 MG TABLET
|
Facility
|
OP
|
$110.31
|
|
|
Service Code
|
NDC 68084034511
|
| Hospital Charge Code |
18921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.81 |
| Max. Negotiated Rate |
$99.28 |
| Rate for Payer: Aetna American Axle |
$71.70
|
| Rate for Payer: Aetna Commercial |
$93.76
|
| Rate for Payer: Aetna Medicare |
$55.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.70
|
| Rate for Payer: BCBS Complete |
$44.12
|
| Rate for Payer: Cash Price |
$88.25
|
| Rate for Payer: Cofinity Advantage |
$77.22
|
| Rate for Payer: Cofinity Commercial |
$94.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.25
|
| Rate for Payer: Healthscope Commercial |
$99.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$88.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.73
|
| Rate for Payer: PHP Commercial |
$93.76
|
| Rate for Payer: Priority Health SBD |
$69.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$71.70
|
| Rate for Payer: UHC Core |
$57.47
|
| Rate for Payer: UHC Exchange |
$43.35
|
| Rate for Payer: UMR Bronson Commercial |
$40.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.73
|
|
|
TOPIRAMATE 200 MG TABLET
|
Facility
|
OP
|
$110.31
|
|
|
Service Code
|
NDC 68084034521
|
| Hospital Charge Code |
18921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.81 |
| Max. Negotiated Rate |
$99.28 |
| Rate for Payer: Aetna American Axle |
$71.70
|
| Rate for Payer: Aetna Commercial |
$93.76
|
| Rate for Payer: Aetna Medicare |
$55.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.70
|
| Rate for Payer: BCBS Complete |
$44.12
|
| Rate for Payer: Cash Price |
$88.25
|
| Rate for Payer: Cofinity Advantage |
$77.22
|
| Rate for Payer: Cofinity Commercial |
$94.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.25
|
| Rate for Payer: Healthscope Commercial |
$99.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$88.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.73
|
| Rate for Payer: PHP Commercial |
$93.76
|
| Rate for Payer: Priority Health SBD |
$69.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$71.70
|
| Rate for Payer: UHC Core |
$57.47
|
| Rate for Payer: UHC Exchange |
$43.35
|
| Rate for Payer: UMR Bronson Commercial |
$40.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.73
|
|
|
TOPIRAMATE 200 MG TABLET
|
Facility
|
IP
|
$201.63
|
|
|
Service Code
|
NDC 68462011060
|
| 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 Advantage |
$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 Commercial |
$171.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$151.22
|
| Rate for Payer: PHP Commercial |
$171.39
|
| 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
|
OP
|
$201.63
|
|
|
Service Code
|
NDC 68462011060
|
| Hospital Charge Code |
18921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.60 |
| Max. Negotiated Rate |
$181.47 |
| Rate for Payer: Aetna American Axle |
$131.06
|
| Rate for Payer: Aetna Commercial |
$171.39
|
| Rate for Payer: Aetna Medicare |
$100.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$131.06
|
| Rate for Payer: BCBS Complete |
$80.65
|
| Rate for Payer: Cash Price |
$161.30
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$161.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$171.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$151.22
|
| Rate for Payer: PHP Commercial |
$171.39
|
| Rate for Payer: Priority Health SBD |
$127.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$131.06
|
| Rate for Payer: UHC Core |
$105.05
|
| Rate for Payer: UHC Exchange |
$79.24
|
| Rate for Payer: UMR Bronson Commercial |
$74.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$151.22
|
|
|
TOPIRAMATE 200 MG TABLET
|
Facility
|
IP
|
$110.31
|
|
|
Service Code
|
NDC 68084034521
|
| Hospital Charge Code |
18921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.54 |
| Max. Negotiated Rate |
$99.28 |
| Rate for Payer: Aetna American Axle |
$71.70
|
| Rate for Payer: Aetna Commercial |
$93.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.70
|
| Rate for Payer: Cash Price |
$88.25
|
| Rate for Payer: Cofinity Advantage |
$77.22
|
| Rate for Payer: Cofinity Commercial |
$94.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.25
|
| Rate for Payer: Healthscope Commercial |
$99.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.73
|
| Rate for Payer: PHP Commercial |
$93.76
|
| Rate for Payer: Priority Health SBD |
$69.50
|
| Rate for Payer: UMR Bronson Commercial |
$48.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.73
|
|
|
TOPIRAMATE 200 MG TABLET
|
Facility
|
OP
|
$166.38
|
|
|
Service Code
|
NDC 68382014114
|
| Hospital Charge Code |
18921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.56 |
| Max. Negotiated Rate |
$149.74 |
| Rate for Payer: Aetna American Axle |
$108.15
|
| Rate for Payer: Aetna Commercial |
$141.42
|
| Rate for Payer: Aetna Medicare |
$83.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.15
|
| Rate for Payer: BCBS Complete |
$66.55
|
| Rate for Payer: Cash Price |
$133.10
|
| Rate for Payer: Cofinity Advantage |
$116.47
|
| Rate for Payer: Cofinity Commercial |
$143.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.10
|
| Rate for Payer: Healthscope Commercial |
$149.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$116.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$133.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$124.78
|
| Rate for Payer: PHP Commercial |
$141.42
|
| Rate for Payer: Priority Health SBD |
$104.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$108.15
|
| Rate for Payer: UHC Core |
$86.68
|
| Rate for Payer: UHC Exchange |
$65.39
|
| Rate for Payer: UMR Bronson Commercial |
$61.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.78
|
|
|
TOPIRAMATE 200 MG TABLET
|
Facility
|
IP
|
$110.31
|
|
|
Service Code
|
NDC 68084034511
|
| Hospital Charge Code |
18921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.54 |
| Max. Negotiated Rate |
$99.28 |
| Rate for Payer: Aetna American Axle |
$71.70
|
| Rate for Payer: Aetna Commercial |
$93.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.70
|
| Rate for Payer: Cash Price |
$88.25
|
| Rate for Payer: Cofinity Advantage |
$77.22
|
| Rate for Payer: Cofinity Commercial |
$94.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.25
|
| Rate for Payer: Healthscope Commercial |
$99.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.73
|
| Rate for Payer: PHP Commercial |
$93.76
|
| Rate for Payer: Priority Health SBD |
$69.50
|
| Rate for Payer: UMR Bronson Commercial |
$48.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.73
|
|
|
TOPIRAMATE 25 MG SPRINKLE CAPSULE
|
Facility
|
OP
|
$1,625.27
|
|
|
Service Code
|
NDC 50458064565
|
| Hospital Charge Code |
27642
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$601.35 |
| Max. Negotiated Rate |
$1,462.74 |
| Rate for Payer: Aetna American Axle |
$1,056.43
|
| Rate for Payer: Aetna Commercial |
$1,381.48
|
| Rate for Payer: Aetna Medicare |
$812.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,056.43
|
| Rate for Payer: BCBS Complete |
$650.11
|
| Rate for Payer: Cash Price |
$1,300.22
|
| Rate for Payer: Cofinity Advantage |
$1,137.69
|
| Rate for Payer: Cofinity Commercial |
$1,397.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,300.22
|
| Rate for Payer: Healthscope Commercial |
$1,462.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,137.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,218.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,300.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,381.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,218.95
|
| Rate for Payer: PHP Commercial |
$1,381.48
|
| Rate for Payer: Priority Health SBD |
$1,023.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,056.43
|
| Rate for Payer: UHC Core |
$846.77
|
| Rate for Payer: UHC Exchange |
$638.73
|
| Rate for Payer: UMR Bronson Commercial |
$601.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,218.95
|
|
|
TOPIRAMATE 25 MG SPRINKLE CAPSULE
|
Facility
|
IP
|
$148.32
|
|
|
Service Code
|
NDC 24979021104
|
| Hospital Charge Code |
27642
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.26 |
| Max. Negotiated Rate |
$133.49 |
| Rate for Payer: Aetna American Axle |
$96.41
|
| Rate for Payer: Aetna Commercial |
$126.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.41
|
| Rate for Payer: Cash Price |
$118.66
|
| Rate for Payer: Cofinity Advantage |
$103.82
|
| Rate for Payer: Cofinity Commercial |
$127.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.66
|
| Rate for Payer: Healthscope Commercial |
$133.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$111.24
|
| Rate for Payer: PHP Commercial |
$126.07
|
| Rate for Payer: Priority Health SBD |
$93.44
|
| Rate for Payer: UMR Bronson Commercial |
$65.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.24
|
|
|
TOPIRAMATE 25 MG SPRINKLE CAPSULE
|
Facility
|
OP
|
$148.32
|
|
|
Service Code
|
NDC 24979021104
|
| Hospital Charge Code |
27642
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.88 |
| Max. Negotiated Rate |
$133.49 |
| Rate for Payer: Aetna American Axle |
$96.41
|
| Rate for Payer: Aetna Commercial |
$126.07
|
| Rate for Payer: Aetna Medicare |
$74.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.41
|
| Rate for Payer: BCBS Complete |
$59.33
|
| Rate for Payer: Cash Price |
$118.66
|
| Rate for Payer: Cofinity Advantage |
$103.82
|
| Rate for Payer: Cofinity Commercial |
$127.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.66
|
| Rate for Payer: Healthscope Commercial |
$133.49
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$118.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$126.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$111.24
|
| Rate for Payer: PHP Commercial |
$126.07
|
| Rate for Payer: Priority Health SBD |
$93.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$96.41
|
| Rate for Payer: UHC Core |
$77.27
|
| Rate for Payer: UHC Exchange |
$58.29
|
| Rate for Payer: UMR Bronson Commercial |
$54.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.24
|
|
|
TOPIRAMATE 25 MG SPRINKLE CAPSULE
|
Facility
|
IP
|
$1,625.27
|
|
|
Service Code
|
NDC 50458064565
|
| Hospital Charge Code |
27642
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$715.12 |
| Max. Negotiated Rate |
$1,462.74 |
| Rate for Payer: Aetna American Axle |
$1,056.43
|
| Rate for Payer: Aetna Commercial |
$1,381.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,056.43
|
| Rate for Payer: Cash Price |
$1,300.22
|
| Rate for Payer: Cofinity Advantage |
$1,137.69
|
| Rate for Payer: Cofinity Commercial |
$1,397.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,300.22
|
| Rate for Payer: Healthscope Commercial |
$1,462.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,137.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,218.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,381.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,218.95
|
| Rate for Payer: PHP Commercial |
$1,381.48
|
| Rate for Payer: Priority Health SBD |
$1,023.92
|
| Rate for Payer: UMR Bronson Commercial |
$715.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,218.95
|
|
|
TOPIRAMATE 25 MG SPRINKLE CAPSULE
|
Facility
|
IP
|
$354.82
|
|
|
Service Code
|
NDC 68382000514
|
| Hospital Charge Code |
27642
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.12 |
| Max. Negotiated Rate |
$319.34 |
| Rate for Payer: Aetna American Axle |
$230.63
|
| Rate for Payer: Aetna Commercial |
$301.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$230.63
|
| Rate for Payer: Cash Price |
$283.86
|
| Rate for Payer: Cofinity Advantage |
$248.37
|
| Rate for Payer: Cofinity Commercial |
$305.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$283.86
|
| Rate for Payer: Healthscope Commercial |
$319.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$248.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$266.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$301.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$266.12
|
| Rate for Payer: PHP Commercial |
$301.60
|
| Rate for Payer: Priority Health SBD |
$223.54
|
| Rate for Payer: UMR Bronson Commercial |
$156.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$266.12
|
|
|
TOPIRAMATE 25 MG SPRINKLE CAPSULE
|
Facility
|
OP
|
$354.82
|
|
|
Service Code
|
NDC 68382000514
|
| Hospital Charge Code |
27642
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.28 |
| Max. Negotiated Rate |
$319.34 |
| Rate for Payer: Aetna American Axle |
$230.63
|
| Rate for Payer: Aetna Commercial |
$301.60
|
| Rate for Payer: Aetna Medicare |
$177.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$230.63
|
| Rate for Payer: BCBS Complete |
$141.93
|
| Rate for Payer: Cash Price |
$283.86
|
| Rate for Payer: Cofinity Advantage |
$248.37
|
| Rate for Payer: Cofinity Commercial |
$305.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$283.86
|
| Rate for Payer: Healthscope Commercial |
$319.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$248.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$266.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$283.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$301.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$266.12
|
| Rate for Payer: PHP Commercial |
$301.60
|
| Rate for Payer: Priority Health SBD |
$223.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$230.63
|
| Rate for Payer: UHC Core |
$184.86
|
| Rate for Payer: UHC Exchange |
$139.44
|
| Rate for Payer: UMR Bronson Commercial |
$131.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$266.12
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
IP
|
$1,421.47
|
|
|
Service Code
|
NDC 50458063965
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$625.45 |
| Max. Negotiated Rate |
$1,279.32 |
| Rate for Payer: Aetna American Axle |
$923.96
|
| Rate for Payer: Aetna Commercial |
$1,208.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$923.96
|
| Rate for Payer: Cash Price |
$1,137.18
|
| Rate for Payer: Cofinity Advantage |
$995.03
|
| Rate for Payer: Cofinity Commercial |
$1,222.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,137.18
|
| Rate for Payer: Healthscope Commercial |
$1,279.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$995.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,066.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,208.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,066.10
|
| Rate for Payer: PHP Commercial |
$1,208.25
|
| Rate for Payer: Priority Health SBD |
$895.53
|
| Rate for Payer: UMR Bronson Commercial |
$625.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,066.10
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
OP
|
$232.75
|
|
|
Service Code
|
NDC 68084034201
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.12 |
| Max. Negotiated Rate |
$209.47 |
| Rate for Payer: Aetna American Axle |
$151.29
|
| Rate for Payer: Aetna Commercial |
$197.84
|
| Rate for Payer: Aetna Medicare |
$116.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.29
|
| Rate for Payer: BCBS Complete |
$93.10
|
| Rate for Payer: Cash Price |
$186.20
|
| Rate for Payer: Cofinity Advantage |
$162.93
|
| Rate for Payer: Cofinity Commercial |
$200.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$186.20
|
| Rate for Payer: Healthscope Commercial |
$209.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$174.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$186.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$174.56
|
| Rate for Payer: PHP Commercial |
$197.84
|
| Rate for Payer: Priority Health SBD |
$146.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$151.29
|
| Rate for Payer: UHC Core |
$121.26
|
| Rate for Payer: UHC Exchange |
$91.47
|
| Rate for Payer: UMR Bronson Commercial |
$86.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$174.56
|
|
|
TOPIRAMATE 25 MG TABLET
|
Facility
|
OP
|
$53.58
|
|
|
Service Code
|
NDC 68382013814
|
| Hospital Charge Code |
18920
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.82 |
| Max. Negotiated Rate |
$48.22 |
| Rate for Payer: Aetna American Axle |
$34.83
|
| Rate for Payer: Aetna Commercial |
$45.54
|
| Rate for Payer: Aetna Medicare |
$26.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$34.83
|
| Rate for Payer: BCBS Complete |
$21.43
|
| Rate for Payer: Cash Price |
$42.86
|
| Rate for Payer: Cofinity Advantage |
$37.51
|
| Rate for Payer: Cofinity Commercial |
$46.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.86
|
| Rate for Payer: Healthscope Commercial |
$48.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$37.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$40.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$42.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$40.19
|
| Rate for Payer: PHP Commercial |
$45.54
|
| Rate for Payer: Priority Health SBD |
$33.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34.83
|
| Rate for Payer: UHC Core |
$27.92
|
| Rate for Payer: UHC Exchange |
$21.06
|
| Rate for Payer: UMR Bronson Commercial |
$19.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$40.19
|
|
