|
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 |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$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 |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.34
|
| Rate for Payer: Heritage Provider Network Senior |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$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 |
$0.09 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Adventist Health Commercial |
$0.10
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.38
|
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.29
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: Dignity Health Senior |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.31
|
| Rate for Payer: Heritage Provider Network Senior |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
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 |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
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 |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 68382-138-14
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 62756-707-86
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 68382-138-14
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 62756-707-86
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$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 |
$0.07 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 68084-342-11
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
OP
|
$0.36
|
|
|
Service Code
|
NDC 68084-342-01
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
IP
|
$0.36
|
|
|
Service Code
|
NDC 68084-342-11
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
OP
|
$0.08
|
|
|
Service Code
|
NDC 68462-108-60
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
TOPIRAMATE CRUSHED TABLET 25 MG/ML [40820386]
|
Facility
IP
|
$0.08
|
|
|
Service Code
|
NDC 68462-108-60
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
TOPIRAMATE ORAL SOLUTION COMPOUND 6 MG/ML [4080352]
|
Facility
IP
|
$6.04
|
|
|
Service Code
|
NDC 9994-0803-52
|
| Hospital Charge Code |
1715211
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$4.53 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.15
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$4.09
|
| Rate for Payer: Heritage Provider Network Senior |
$4.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$4.53
|
|
|
TOPIRAMATE ORAL SOLUTION COMPOUND 6 MG/ML [4080352]
|
Facility
OP
|
$6.04
|
|
|
Service Code
|
NDC 9994-0803-52
|
| Hospital Charge Code |
1715211
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$5.13 |
| Rate for Payer: Adventist Health Commercial |
$1.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$3.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$4.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$5.13
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.32
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.53
|
| Rate for Payer: Blue Shield of California Commercial |
$3.75
|
| Rate for Payer: Blue Shield of California EPN |
$3.55
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.93
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$5.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$5.13
|
| Rate for Payer: Dignity Health Senior |
$5.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.74
|
| Rate for Payer: Heritage Provider Network Senior |
$3.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.51
|
| Rate for Payer: Multiplan Commercial |
$4.53
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$5.13
|
| Rate for Payer: Vantage Medical Group Senior |
$5.13
|
|
|
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION [108590]
|
Facility
OP
|
$45.00
|
|
|
Service Code
|
CPT J9351
|
| Hospital Charge Code |
NDG108590
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$59.98 |
| Rate for Payer: Adventist Health Commercial |
$9.00
|
| Rate for Payer: Adventist Health Commercial |
$4.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.54
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.92
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$38.25
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$17.66
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$24.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$33.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$15.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$59.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$59.98
|
| Rate for Payer: Blue Shield of California Commercial |
$3.53
|
| Rate for Payer: Blue Shield of California Commercial |
$3.53
|
| Rate for Payer: Blue Shield of California EPN |
$3.53
|
| Rate for Payer: Blue Shield of California EPN |
$3.53
|
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Cash Price |
$9.35
|
| Rate for Payer: Cash Price |
$9.35
|
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.25
|
| Rate for Payer: Dignity Health Senior |
$38.25
|
| Rate for Payer: Dignity Health Senior |
$17.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$28.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.84
|
| Rate for Payer: Heritage Provider Network Senior |
$9.62
|
| Rate for Payer: Heritage Provider Network Senior |
$20.84
|
| Rate for Payer: IEHP Medi-Cal |
$8.17
|
| Rate for Payer: IEHP Medi-Cal |
$8.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$21.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Multiplan Commercial |
$15.58
|
| Rate for Payer: Multiplan Commercial |
$33.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.25
|
| Rate for Payer: Vantage Medical Group Senior |
$17.66
|
| Rate for Payer: Vantage Medical Group Senior |
$38.25
|
|
|
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION [108590]
|
Facility
IP
|
$45.00
|
|
|
Service Code
|
CPT J9351
|
| Hospital Charge Code |
NDG108590
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$33.75 |
| Rate for Payer: Adventist Health Commercial |
$9.00
|
| Rate for Payer: Adventist Health Commercial |
$4.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.92
|
| Rate for Payer: Cash Price |
$9.35
|
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.46
|
| Rate for Payer: Heritage Provider Network Senior |
$14.07
|
| Rate for Payer: Heritage Provider Network Senior |
$30.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Multiplan Commercial |
$33.75
|
| Rate for Payer: Multiplan Commercial |
$15.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.58
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.41
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$6.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.03
|
|
|
TOPOTECAN 4 MG INTRAVENOUS SOLUTION [17285]
|
Facility
IP
|
$282.00
|
|
|
Service Code
|
NDC 63323-762-17
|
| Hospital Charge Code |
1755756
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.04 |
| Max. Negotiated Rate |
$211.50 |
| Rate for Payer: Adventist Health Commercial |
$56.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$193.73
|
| Rate for Payer: Cash Price |
$126.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$129.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$190.91
|
| Rate for Payer: Heritage Provider Network Senior |
$190.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.50
|
| Rate for Payer: Multiplan Commercial |
$211.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$102.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$94.22
|
|
|
TOPOTECAN 4 MG INTRAVENOUS SOLUTION [17285]
|
Facility
IP
|
$282.00
|
|
|
Service Code
|
NDC 63323-762-10
|
| Hospital Charge Code |
1755756
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.04 |
| Max. Negotiated Rate |
$211.50 |
| Rate for Payer: Adventist Health Commercial |
$56.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$193.73
|
| Rate for Payer: Cash Price |
$126.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$129.72
|
| Rate for Payer: EPIC Health Plan Commercial |
$152.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$190.91
|
| Rate for Payer: Heritage Provider Network Senior |
$190.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.50
|
| Rate for Payer: Multiplan Commercial |
$211.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$102.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$94.22
|
|
|
TOPOTECAN 4 MG INTRAVENOUS SOLUTION [17285]
|
Facility
OP
|
$282.00
|
|
|
Service Code
|
NDC 63323-762-10
|
| Hospital Charge Code |
1755756
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.04 |
| Max. Negotiated Rate |
$239.70 |
| Rate for Payer: Adventist Health Commercial |
$56.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$150.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$193.73
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$239.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$155.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$211.50
|
| Rate for Payer: Blue Shield of California Commercial |
$175.12
|
| Rate for Payer: Blue Shield of California EPN |
$165.53
|
| Rate for Payer: Cash Price |
$126.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$129.72
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$239.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$239.70
|
| Rate for Payer: Dignity Health Senior |
$239.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$180.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$130.57
|
| Rate for Payer: Heritage Provider Network Senior |
$130.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$135.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$51.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$70.50
|
| Rate for Payer: Multiplan Commercial |
$211.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$102.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$94.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$239.70
|
| Rate for Payer: Vantage Medical Group Senior |
$239.70
|
|
