|
TOLVAPTAN 30 MG TABLET
|
Facility
|
IP
|
$19,966.80
|
|
|
Service Code
|
NDC 59148002150
|
| Hospital Charge Code |
97894
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8,785.39 |
| Max. Negotiated Rate |
$17,970.12 |
| Rate for Payer: Aetna American Axle |
$12,978.42
|
| Rate for Payer: Aetna Commercial |
$16,971.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,978.42
|
| Rate for Payer: Cash Price |
$15,973.44
|
| Rate for Payer: Cofinity Commercial |
$13,976.76
|
| Rate for Payer: Cofinity Commercial |
$17,171.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,976.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,973.44
|
| Rate for Payer: Healthscope Commercial |
$17,970.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,976.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,975.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,971.78
|
| Rate for Payer: PHP Commercial |
$16,971.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,978.42
|
| Rate for Payer: Priority Health SBD |
$12,579.08
|
| Rate for Payer: UMR Bronson Commercial |
$8,785.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,975.10
|
|
|
TOLVAPTAN 30 MG TABLET
|
Facility
|
OP
|
$4,439.97
|
|
|
Service Code
|
NDC 31722086903
|
| Hospital Charge Code |
97894
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,642.79 |
| Max. Negotiated Rate |
$3,995.97 |
| Rate for Payer: Aetna American Axle |
$2,885.98
|
| Rate for Payer: Aetna Commercial |
$3,773.97
|
| Rate for Payer: Aetna Medicare |
$2,219.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,885.98
|
| Rate for Payer: BCBS Complete |
$1,775.99
|
| Rate for Payer: Cash Price |
$3,551.98
|
| Rate for Payer: Cofinity Commercial |
$3,107.98
|
| Rate for Payer: Cofinity Commercial |
$3,818.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,107.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,551.98
|
| Rate for Payer: Healthscope Commercial |
$3,995.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,107.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,329.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,773.97
|
| Rate for Payer: PHP Commercial |
$3,773.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,885.98
|
| Rate for Payer: Priority Health SBD |
$2,797.18
|
| Rate for Payer: UMR Bronson Commercial |
$1,642.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,329.98
|
|
|
TOLVAPTAN 30 MG TABLET
|
Facility
|
OP
|
$19,966.80
|
|
|
Service Code
|
NDC 59148002150
|
| Hospital Charge Code |
97894
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7,387.72 |
| Max. Negotiated Rate |
$17,970.12 |
| Rate for Payer: Aetna American Axle |
$12,978.42
|
| Rate for Payer: Aetna Commercial |
$16,971.78
|
| Rate for Payer: Aetna Medicare |
$9,983.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,978.42
|
| Rate for Payer: BCBS Complete |
$7,986.72
|
| Rate for Payer: Cash Price |
$15,973.44
|
| Rate for Payer: Cofinity Commercial |
$13,976.76
|
| Rate for Payer: Cofinity Commercial |
$17,171.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,976.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,973.44
|
| Rate for Payer: Healthscope Commercial |
$17,970.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,976.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,975.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,971.78
|
| Rate for Payer: PHP Commercial |
$16,971.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,978.42
|
| Rate for Payer: Priority Health SBD |
$12,579.08
|
| Rate for Payer: UMR Bronson Commercial |
$7,387.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,975.10
|
|
|
TOLVAPTAN 30 MG TABLET
|
Facility
|
IP
|
$4,439.97
|
|
|
Service Code
|
NDC 31722086903
|
| Hospital Charge Code |
97894
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,953.59 |
| Max. Negotiated Rate |
$3,995.97 |
| Rate for Payer: Aetna American Axle |
$2,885.98
|
| Rate for Payer: Aetna Commercial |
$3,773.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,885.98
|
| Rate for Payer: Cash Price |
$3,551.98
|
| Rate for Payer: Cofinity Commercial |
$3,107.98
|
| Rate for Payer: Cofinity Commercial |
$3,818.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,107.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,551.98
|
| Rate for Payer: Healthscope Commercial |
$3,995.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,107.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,329.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,773.97
|
| Rate for Payer: PHP Commercial |
$3,773.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,885.98
|
| Rate for Payer: Priority Health SBD |
$2,797.18
|
| Rate for Payer: UMR Bronson Commercial |
$1,953.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,329.98
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER
|
Facility
|
OP
|
$8,903.25
|
|
|
Service Code
|
CPT 42821
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,695.31 |
| Max. Negotiated Rate |
$8,903.25 |
| Rate for Payer: Aetna Medicare |
$3,289.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,953.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,953.62
|
| Rate for Payer: BCBS Complete |
$1,780.08
|
| Rate for Payer: BCBS MAPPO |
$3,162.90
|
| Rate for Payer: BCN Medicare Advantage |
$3,162.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,162.90
|
| Rate for Payer: Mclaren Medicaid |
$1,695.31
|
| Rate for Payer: Mclaren Medicare |
$3,162.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,321.05
|
| Rate for Payer: Meridian Medicaid |
$1,780.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,637.34
|
| Rate for Payer: PACE Medicare |
$3,004.76
|
| Rate for Payer: PACE SWMI |
$3,162.90
|
| Rate for Payer: PHP Medicare Advantage |
$3,162.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,695.31
|
| Rate for Payer: Priority Health Medicare |
$3,162.90
|
| Rate for Payer: Railroad Medicare Medicare |
$3,162.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,903.25
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,162.90
|
| Rate for Payer: UHC Exchange |
$6,044.62
|
| Rate for Payer: UHC Medicare Advantage |
$3,162.90
|
| Rate for Payer: UHCCP Medicaid |
$1,695.31
|
| Rate for Payer: VA VA |
$3,162.90
|
|
|
TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12
|
Facility
|
OP
|
$16,240.34
|
|
|
Service Code
|
CPT 42820
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,092.41 |
| Max. Negotiated Rate |
$16,240.34 |
| Rate for Payer: Aetna Medicare |
$6,000.20
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,211.77
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,211.77
|
| Rate for Payer: BCBS Complete |
$3,247.03
|
| Rate for Payer: BCBS MAPPO |
$5,769.42
|
| Rate for Payer: BCN Medicare Advantage |
$5,769.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,769.42
|
| Rate for Payer: Mclaren Medicaid |
$3,092.41
|
| Rate for Payer: Mclaren Medicare |
$5,769.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,057.89
|
| Rate for Payer: Meridian Medicaid |
$3,247.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,634.83
|
| Rate for Payer: PACE Medicare |
$5,480.95
|
| Rate for Payer: PACE SWMI |
$5,769.42
|
| Rate for Payer: PHP Medicare Advantage |
$5,769.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,092.41
|
| Rate for Payer: Priority Health Medicare |
$5,769.42
|
| Rate for Payer: Railroad Medicare Medicare |
$5,769.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16,240.34
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,769.42
|
| Rate for Payer: UHC Exchange |
$11,025.94
|
| Rate for Payer: UHC Medicare Advantage |
$5,769.42
|
| Rate for Payer: UHCCP Medicaid |
$3,092.41
|
| Rate for Payer: VA VA |
$5,769.42
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER
|
Facility
|
OP
|
$8,903.25
|
|
|
Service Code
|
CPT 42826
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,695.31 |
| Max. Negotiated Rate |
$8,903.25 |
| Rate for Payer: Aetna Medicare |
$3,289.42
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,953.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,953.62
|
| Rate for Payer: BCBS Complete |
$1,780.08
|
| Rate for Payer: BCBS MAPPO |
$3,162.90
|
| Rate for Payer: BCN Medicare Advantage |
$3,162.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,162.90
|
| Rate for Payer: Mclaren Medicaid |
$1,695.31
|
| Rate for Payer: Mclaren Medicare |
$3,162.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,321.05
|
| Rate for Payer: Meridian Medicaid |
$1,780.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,637.34
|
| Rate for Payer: PACE Medicare |
$3,004.76
|
| Rate for Payer: PACE SWMI |
$3,162.90
|
| Rate for Payer: PHP Medicare Advantage |
$3,162.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,695.31
|
| Rate for Payer: Priority Health Medicare |
$3,162.90
|
| Rate for Payer: Railroad Medicare Medicare |
$3,162.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8,903.25
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,162.90
|
| Rate for Payer: UHC Exchange |
$6,044.62
|
| Rate for Payer: UHC Medicare Advantage |
$3,162.90
|
| Rate for Payer: UHCCP Medicaid |
$1,695.31
|
| Rate for Payer: VA VA |
$3,162.90
|
|
|
TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12
|
Facility
|
OP
|
$16,240.34
|
|
|
Service Code
|
CPT 42825
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$3,092.41 |
| Max. Negotiated Rate |
$16,240.34 |
| Rate for Payer: Aetna Medicare |
$6,000.20
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7,211.77
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7,211.77
|
| Rate for Payer: BCBS Complete |
$3,247.03
|
| Rate for Payer: BCBS MAPPO |
$5,769.42
|
| Rate for Payer: BCN Medicare Advantage |
$5,769.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5,769.42
|
| Rate for Payer: Mclaren Medicaid |
$3,092.41
|
| Rate for Payer: Mclaren Medicare |
$5,769.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6,057.89
|
| Rate for Payer: Meridian Medicaid |
$3,247.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6,634.83
|
| Rate for Payer: PACE Medicare |
$5,480.95
|
| Rate for Payer: PACE SWMI |
$5,769.42
|
| Rate for Payer: PHP Medicare Advantage |
$5,769.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$3,092.41
|
| Rate for Payer: Priority Health Medicare |
$5,769.42
|
| Rate for Payer: Railroad Medicare Medicare |
$5,769.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16,240.34
|
| Rate for Payer: UHC Dual Complete DSNP |
$5,769.42
|
| Rate for Payer: UHC Exchange |
$11,025.94
|
| Rate for Payer: UHC Medicare Advantage |
$5,769.42
|
| Rate for Payer: UHCCP Medicaid |
$3,092.41
|
| Rate for Payer: VA VA |
$5,769.42
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
IP
|
$101.52
|
|
|
Service Code
|
NDC 68382014014
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.67 |
| Max. Negotiated Rate |
$91.37 |
| Rate for Payer: Aetna American Axle |
$65.99
|
| Rate for Payer: Aetna Commercial |
$86.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.99
|
| Rate for Payer: Cash Price |
$81.22
|
| Rate for Payer: Cofinity Commercial |
$71.06
|
| Rate for Payer: Cofinity Commercial |
$87.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$71.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.22
|
| Rate for Payer: Healthscope Commercial |
$91.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$71.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$76.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.29
|
| Rate for Payer: PHP Commercial |
$86.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.99
|
| Rate for Payer: Priority Health SBD |
$63.96
|
| Rate for Payer: UMR Bronson Commercial |
$44.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$76.14
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
IP
|
$153.69
|
|
|
Service Code
|
NDC 68462010960
|
| 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: Cofinity Medicare Advantage |
$107.58
|
| 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 Commercial |
$130.64
|
| Rate for Payer: PHP Commercial |
$130.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.90
|
| 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
|
OP
|
$101.52
|
|
|
Service Code
|
NDC 68382014014
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$91.37 |
| Rate for Payer: Aetna American Axle |
$65.99
|
| Rate for Payer: Aetna Commercial |
$86.29
|
| Rate for Payer: Aetna Medicare |
$50.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.99
|
| Rate for Payer: BCBS Complete |
$40.61
|
| Rate for Payer: Cash Price |
$81.22
|
| Rate for Payer: Cofinity Commercial |
$71.06
|
| Rate for Payer: Cofinity Commercial |
$87.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$71.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.22
|
| Rate for Payer: Healthscope Commercial |
$91.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$71.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$76.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.29
|
| Rate for Payer: PHP Commercial |
$86.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.99
|
| Rate for Payer: Priority Health SBD |
$63.96
|
| Rate for Payer: UMR Bronson Commercial |
$37.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$76.14
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
OP
|
$382.85
|
|
|
Service Code
|
NDC 68084034401
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.65 |
| Max. Negotiated Rate |
$344.56 |
| Rate for Payer: Aetna American Axle |
$248.85
|
| Rate for Payer: Aetna Commercial |
$325.42
|
| Rate for Payer: Aetna Medicare |
$191.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.85
|
| Rate for Payer: BCBS Complete |
$153.14
|
| Rate for Payer: Cash Price |
$306.28
|
| Rate for Payer: Cofinity Commercial |
$268.00
|
| Rate for Payer: Cofinity Commercial |
$329.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$268.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.28
|
| Rate for Payer: Healthscope Commercial |
$344.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$268.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$287.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.42
|
| Rate for Payer: PHP Commercial |
$325.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.85
|
| Rate for Payer: Priority Health SBD |
$241.20
|
| Rate for Payer: UMR Bronson Commercial |
$141.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$287.14
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
IP
|
$382.85
|
|
|
Service Code
|
NDC 68084034401
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.45 |
| Max. Negotiated Rate |
$344.56 |
| Rate for Payer: Aetna American Axle |
$248.85
|
| Rate for Payer: Aetna Commercial |
$325.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.85
|
| Rate for Payer: Cash Price |
$306.28
|
| Rate for Payer: Cofinity Commercial |
$268.00
|
| Rate for Payer: Cofinity Commercial |
$329.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$268.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.28
|
| Rate for Payer: Healthscope Commercial |
$344.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$268.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$287.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.42
|
| Rate for Payer: PHP Commercial |
$325.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.85
|
| Rate for Payer: Priority Health SBD |
$241.20
|
| Rate for Payer: UMR Bronson Commercial |
$168.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$287.14
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
OP
|
$382.85
|
|
|
Service Code
|
NDC 68084034411
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.65 |
| Max. Negotiated Rate |
$344.56 |
| Rate for Payer: Aetna American Axle |
$248.85
|
| Rate for Payer: Aetna Commercial |
$325.42
|
| Rate for Payer: Aetna Medicare |
$191.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.85
|
| Rate for Payer: BCBS Complete |
$153.14
|
| Rate for Payer: Cash Price |
$306.28
|
| Rate for Payer: Cofinity Commercial |
$268.00
|
| Rate for Payer: Cofinity Commercial |
$329.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$268.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.28
|
| Rate for Payer: Healthscope Commercial |
$344.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$268.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$287.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.42
|
| Rate for Payer: PHP Commercial |
$325.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.85
|
| Rate for Payer: Priority Health SBD |
$241.20
|
| Rate for Payer: UMR Bronson Commercial |
$141.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$287.14
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
IP
|
$382.85
|
|
|
Service Code
|
NDC 68084034411
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.45 |
| Max. Negotiated Rate |
$344.56 |
| Rate for Payer: Aetna American Axle |
$248.85
|
| Rate for Payer: Aetna Commercial |
$325.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$248.85
|
| Rate for Payer: Cash Price |
$306.28
|
| Rate for Payer: Cofinity Commercial |
$268.00
|
| Rate for Payer: Cofinity Commercial |
$329.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$268.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$306.28
|
| Rate for Payer: Healthscope Commercial |
$344.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$268.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$287.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$325.42
|
| Rate for Payer: PHP Commercial |
$325.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$248.85
|
| Rate for Payer: Priority Health SBD |
$241.20
|
| Rate for Payer: UMR Bronson Commercial |
$168.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$287.14
|
|
|
TOPIRAMATE 100 MG TABLET
|
Facility
|
OP
|
$153.69
|
|
|
Service Code
|
NDC 68462010960
|
| Hospital Charge Code |
18922
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.87 |
| Max. Negotiated Rate |
$138.32 |
| Rate for Payer: Aetna American Axle |
$99.90
|
| Rate for Payer: Aetna Commercial |
$130.64
|
| Rate for Payer: Aetna Medicare |
$76.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$99.90
|
| Rate for Payer: BCBS Complete |
$61.48
|
| Rate for Payer: Cash Price |
$122.95
|
| Rate for Payer: Cofinity Commercial |
$107.58
|
| Rate for Payer: Cofinity Commercial |
$132.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$107.58
|
| 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 Commercial |
$130.64
|
| Rate for Payer: PHP Commercial |
$130.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.90
|
| Rate for Payer: Priority Health SBD |
$96.82
|
| Rate for Payer: UMR Bronson Commercial |
$56.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$115.27
|
|
|
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 Commercial |
$203.22
|
| Rate for Payer: Cofinity Commercial |
$249.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.22
|
| 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: PHP Commercial |
$246.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.70
|
| Rate for Payer: Priority Health SBD |
$182.90
|
| 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 Commercial |
$203.22
|
| Rate for Payer: Cofinity Commercial |
$249.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.22
|
| 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: PHP Commercial |
$246.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.70
|
| 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
|
OP
|
$1,305.36
|
|
|
Service Code
|
NDC 50458064765
|
| Hospital Charge Code |
27641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$482.98 |
| Max. Negotiated Rate |
$1,174.82 |
| Rate for Payer: Aetna American Axle |
$848.48
|
| Rate for Payer: Aetna Commercial |
$1,109.56
|
| Rate for Payer: Aetna Medicare |
$652.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$848.48
|
| Rate for Payer: BCBS Complete |
$522.14
|
| Rate for Payer: Cash Price |
$1,044.29
|
| Rate for Payer: Cofinity Commercial |
$1,122.61
|
| Rate for Payer: Cofinity Commercial |
$913.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$913.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,044.29
|
| Rate for Payer: Healthscope Commercial |
$1,174.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$913.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$979.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,109.56
|
| Rate for Payer: PHP Commercial |
$1,109.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$848.48
|
| Rate for Payer: Priority Health SBD |
$822.38
|
| Rate for Payer: UMR Bronson Commercial |
$482.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$979.02
|
|
|
TOPIRAMATE 15 MG SPRINKLE CAPSULE
|
Facility
|
IP
|
$1,305.36
|
|
|
Service Code
|
NDC 50458064765
|
| Hospital Charge Code |
27641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$574.36 |
| Max. Negotiated Rate |
$1,174.82 |
| Rate for Payer: Aetna American Axle |
$848.48
|
| Rate for Payer: Aetna Commercial |
$1,109.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$848.48
|
| Rate for Payer: Cash Price |
$1,044.29
|
| Rate for Payer: Cofinity Commercial |
$1,122.61
|
| Rate for Payer: Cofinity Commercial |
$913.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$913.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,044.29
|
| Rate for Payer: Healthscope Commercial |
$1,174.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$913.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$979.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,109.56
|
| Rate for Payer: PHP Commercial |
$1,109.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$848.48
|
| Rate for Payer: Priority Health SBD |
$822.38
|
| Rate for Payer: UMR Bronson Commercial |
$574.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$979.02
|
|
|
TOPIRAMATE 200 MG TABLET
|
Facility
|
IP
|
$142.41
|
|
|
Service Code
|
NDC 68382014114
|
| Hospital Charge Code |
18921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.66 |
| Max. Negotiated Rate |
$128.17 |
| Rate for Payer: Aetna American Axle |
$92.57
|
| Rate for Payer: Aetna Commercial |
$121.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.57
|
| Rate for Payer: Cash Price |
$113.93
|
| Rate for Payer: Cofinity Commercial |
$122.47
|
| Rate for Payer: Cofinity Commercial |
$99.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$99.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.93
|
| Rate for Payer: Healthscope Commercial |
$128.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.05
|
| Rate for Payer: PHP Commercial |
$121.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.57
|
| Rate for Payer: Priority Health SBD |
$89.72
|
| Rate for Payer: UMR Bronson Commercial |
$62.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.81
|
|
|
TOPIRAMATE 200 MG TABLET
|
Facility
|
OP
|
$90.29
|
|
|
Service Code
|
NDC 68084034521
|
| Hospital Charge Code |
18921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.41 |
| Max. Negotiated Rate |
$81.26 |
| Rate for Payer: Aetna American Axle |
$58.69
|
| Rate for Payer: Aetna Commercial |
$76.75
|
| Rate for Payer: Aetna Medicare |
$45.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.69
|
| Rate for Payer: BCBS Complete |
$36.12
|
| Rate for Payer: Cash Price |
$72.23
|
| Rate for Payer: Cofinity Commercial |
$63.20
|
| Rate for Payer: Cofinity Commercial |
$77.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$63.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.23
|
| Rate for Payer: Healthscope Commercial |
$81.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$63.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$67.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.75
|
| Rate for Payer: PHP Commercial |
$76.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.69
|
| Rate for Payer: Priority Health SBD |
$56.88
|
| Rate for Payer: UMR Bronson Commercial |
$33.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$67.72
|
|
|
TOPIRAMATE 200 MG TABLET
|
Facility
|
OP
|
$142.41
|
|
|
Service Code
|
NDC 68382014114
|
| Hospital Charge Code |
18921
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.69 |
| Max. Negotiated Rate |
$128.17 |
| Rate for Payer: Aetna American Axle |
$92.57
|
| Rate for Payer: Aetna Commercial |
$121.05
|
| Rate for Payer: Aetna Medicare |
$71.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.57
|
| Rate for Payer: BCBS Complete |
$56.96
|
| Rate for Payer: Cash Price |
$113.93
|
| Rate for Payer: Cofinity Commercial |
$122.47
|
| Rate for Payer: Cofinity Commercial |
$99.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$99.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.93
|
| Rate for Payer: Healthscope Commercial |
$128.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.05
|
| Rate for Payer: PHP Commercial |
$121.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.57
|
| Rate for Payer: Priority Health SBD |
$89.72
|
| Rate for Payer: UMR Bronson Commercial |
$52.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.81
|
|
|
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 Commercial |
$141.14
|
| Rate for Payer: Cofinity Commercial |
$173.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$141.14
|
| 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: PHP Commercial |
$171.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$131.06
|
| Rate for Payer: Priority Health SBD |
$127.03
|
| 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
|
$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 Commercial |
$141.14
|
| Rate for Payer: Cofinity Commercial |
$173.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$141.14
|
| 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: PHP Commercial |
$171.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$131.06
|
| 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
|
|
