|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
IP
|
$0.59
|
|
|
Service Code
|
NDC 62756-712-86
|
| Hospital Charge Code |
1713140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.47 |
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
OP
|
$0.59
|
|
|
Service Code
|
NDC 62756-712-86
|
| Hospital Charge Code |
1713140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.35
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.32
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.44
|
|
|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 68382-141-14
|
| Hospital Charge Code |
1713140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 68462-110-60
|
| Hospital Charge Code |
1713140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 68084-345-21
|
| Hospital Charge Code |
1713140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.96
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.90
|
|
|
TOPIRAMATE 200 MG TABLET [18921]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 68084-345-11
|
| Hospital Charge Code |
1713140
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$0.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.72
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.72
|
| Rate for Payer: Cash Price |
$0.54
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.66
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.90
|
|
|
TOPIRAMATE 25 MG SPRINKLE CAPSULE [27642]
|
Facility
|
IP
|
$1.59
|
|
|
Service Code
|
NDC 68382-005-14
|
| Hospital Charge Code |
1711957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.19
|
|
|
TOPIRAMATE 25 MG SPRINKLE CAPSULE [27642]
|
Facility
|
OP
|
$1.59
|
|
|
Service Code
|
NDC 68382-005-14
|
| Hospital Charge Code |
1711957
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.87 |
| Max. Negotiated Rate |
$1.19 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.95
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.95
|
| Rate for Payer: Cash Price |
$0.72
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.19
|
|
|
TOPIRAMATE 50 MG TABLET [37616]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 68084-343-11
|
| Hospital Charge Code |
1712408
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
TOPIRAMATE 50 MG TABLET [37616]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 68382-139-14
|
| Hospital Charge Code |
1712408
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
TOPIRAMATE 50 MG TABLET [37616]
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 68084-343-01
|
| Hospital Charge Code |
1712408
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.40
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
TOPIRAMATE 50 MG TABLET [37616]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 68382-139-14
|
| Hospital Charge Code |
1712408
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
TOPIRAMATE 50 MG TABLET [37616]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 68462-153-60
|
| Hospital Charge Code |
1712408
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
TOPIRAMATE 50 MG TABLET [37616]
|
Facility
|
IP
|
$0.11
|
|
|
Service Code
|
NDC 68462-153-60
|
| Hospital Charge Code |
1712408
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.08
|
|
|
TOPIRAMATE 50 MG TABLET [37616]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 68084-343-01
|
| Hospital Charge Code |
1712408
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
TOPIRAMATE 50 MG TABLET [37616]
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 68084-343-11
|
| Hospital Charge Code |
1712408
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.38
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
|
IP
|
$0.18
|
|
|
Service Code
|
NDC 62756-707-86
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 68084-342-11
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.27
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
|
OP
|
$0.18
|
|
|
Service Code
|
NDC 62756-707-86
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.11
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.14
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 68084-342-01
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.27
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 68382-138-14
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.06
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 68084-342-11
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.29
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.27
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 68462-108-60
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.06
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 68462-108-60
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.06
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 68084-342-01
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.22
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.27
|
|
