St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

TOPAZ EPF MICRODEBIDER

Facility

$700.00

Hospital Charge Code	40200964
Hospital Revenue Code	270
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$560.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$385.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$350.00
Rate for Payer: Aetna Government	$350.00
Rate for Payer: Brighton Health Commercial	$525.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$560.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$476.00
Rate for Payer: Group Health Inc Commercial	$350.00
Rate for Payer: Group Health Inc Medicare	$245.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$350.00
Rate for Payer: Hamaspik Choice Inc Medicare	$350.00

TOPICAL APPLICATION OF FLUORIDE E

Facility

$35.00

Service Code	HCPCS D1208
Hospital Charge Code	42300255
Hospital Revenue Code	361
Min. Negotiated Rate	$9.68
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$19.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$9.68
Rate for Payer: Aetna Government	$9.68
Rate for Payer: Brighton Health Commercial	$26.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Group Health Inc Commercial	$17.50
Rate for Payer: Group Health Inc Medicare	$12.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$17.50
Rate for Payer: Hamaspik Choice Inc Medicare	$17.50

TOPICAL FLUORIDE VARNISH

Facility

$75.00

Service Code	HCPCS D1206
Hospital Charge Code	42303419
Hospital Revenue Code	361
Min. Negotiated Rate	$16.51
Max. Negotiated Rate	$2,915.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$41.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.51
Rate for Payer: Aetna Government	$16.51
Rate for Payer: Brighton Health Commercial	$56.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2,915.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$2,477.75
Rate for Payer: Group Health Inc Commercial	$37.50
Rate for Payer: Group Health Inc Medicare	$26.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$37.50
Rate for Payer: Hamaspik Choice Inc Medicare	$37.50

TOPICAL FLUORIDE VARNISH

Facility

$20.00

Service Code	HCPCS D1206
Hospital Charge Code	30300087
Hospital Revenue Code	510
Min. Negotiated Rate	$10.00
Max. Negotiated Rate	$250.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.00
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$16.51
Rate for Payer: Aetna Government	$16.51
Rate for Payer: Brighton Health Commercial	$233.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$204.58
Rate for Payer: Cigna LocalPlus Benefit Plan	$173.89
Rate for Payer: Group Health Inc Commercial	$250.00
Rate for Payer: Group Health Inc Medicare	$250.00
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.00
Rate for Payer: Hamaspik Choice Inc Medicare	$10.00

TOPIRAMATE 100 MG PO TABS [18922]

Facility

$6.20

Service Code	NDC 68084034401
Hospital Charge Code	68084034401
Hospital Revenue Code	250
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$4.96
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.41
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.10
Rate for Payer: Aetna Government	$3.10
Rate for Payer: Brighton Health Commercial	$4.65
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$4.96
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.22
Rate for Payer: Group Health Inc Commercial	$3.10
Rate for Payer: Group Health Inc Medicare	$2.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.10
Rate for Payer: Hamaspik Choice Inc Medicare	$3.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.03

TOPIRAMATE 100 MG PO TABS [18922]

Facility

$6.96

Service Code	NDC 68382014014
Hospital Charge Code	68382014014
Hospital Revenue Code	250
Min. Negotiated Rate	$2.44
Max. Negotiated Rate	$5.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.83
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$3.48
Rate for Payer: Aetna Government	$3.48
Rate for Payer: Brighton Health Commercial	$5.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$5.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$4.73
Rate for Payer: Group Health Inc Commercial	$3.48
Rate for Payer: Group Health Inc Medicare	$2.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$3.48
Rate for Payer: Hamaspik Choice Inc Medicare	$3.48
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$4.53

TOPIRAMATE 100 MG PO TABS [18922]

Facility

$21.43

Service Code	NDC 50458064165
Hospital Charge Code	50458064165
Hospital Revenue Code	250
Min. Negotiated Rate	$7.50
Max. Negotiated Rate	$17.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$11.79
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$10.72
Rate for Payer: Aetna Government	$10.72
Rate for Payer: Brighton Health Commercial	$16.07
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$17.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$14.57
Rate for Payer: Group Health Inc Commercial	$10.72
Rate for Payer: Group Health Inc Medicare	$7.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$10.72
Rate for Payer: Hamaspik Choice Inc Medicare	$10.72
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$13.93

TOPIRAMATE 100 MG TAB

Facility

$0.39

Hospital Charge Code	41655129
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.20
Rate for Payer: Aetna Government	$0.20
Rate for Payer: Brighton Health Commercial	$0.29
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.31
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.27
Rate for Payer: Group Health Inc Commercial	$0.20
Rate for Payer: Group Health Inc Medicare	$0.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.20
Rate for Payer: Hamaspik Choice Inc Medicare	$0.20
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.25

TOPIRAMATE 100 MG TAB

Facility

$0.39

Hospital Charge Code	41645129
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.31
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.21
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.20
Rate for Payer: Aetna Government	$0.20
Rate for Payer: Brighton Health Commercial	$0.29
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.31
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.27
Rate for Payer: Group Health Inc Commercial	$0.20
Rate for Payer: Group Health Inc Medicare	$0.14
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.20
Rate for Payer: Hamaspik Choice Inc Medicare	$0.20
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.25

TOPIRAMATE 15MG CAP

Facility

$1.62

Hospital Charge Code	41645157
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$1.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.89
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Brighton Health Commercial	$1.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.10
Rate for Payer: Group Health Inc Commercial	$0.81
Rate for Payer: Group Health Inc Medicare	$0.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.81
Rate for Payer: Hamaspik Choice Inc Medicare	$0.81
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.05

TOPIRAMATE 15MG CAP

Facility

$1.62

Hospital Charge Code	41655157
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$1.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.89
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.81
Rate for Payer: Aetna Government	$0.81
Rate for Payer: Brighton Health Commercial	$1.22
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.10
Rate for Payer: Group Health Inc Commercial	$0.81
Rate for Payer: Group Health Inc Medicare	$0.57
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.81
Rate for Payer: Hamaspik Choice Inc Medicare	$0.81
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.05

TOPIRAMATE 200 MG PO TABS [18921]

Facility

$1.12

Service Code	NDC 68084034521
Hospital Charge Code	68084034521
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.56
Rate for Payer: Aetna Government	$0.56
Rate for Payer: Brighton Health Commercial	$0.84
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.90
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.76
Rate for Payer: Group Health Inc Commercial	$0.56
Rate for Payer: Group Health Inc Medicare	$0.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.56
Rate for Payer: Hamaspik Choice Inc Medicare	$0.56
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.73

TOPIRAMATE 200 MG PO TABS [18921]

Facility

$1.12

Service Code	NDC 68084034511
Hospital Charge Code	68084034511
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.90
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.56
Rate for Payer: Aetna Government	$0.56
Rate for Payer: Brighton Health Commercial	$0.84
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.90
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.76
Rate for Payer: Group Health Inc Commercial	$0.56
Rate for Payer: Group Health Inc Medicare	$0.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.56
Rate for Payer: Hamaspik Choice Inc Medicare	$0.56
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.73

TOPIRAMATE 200 MG TAB

Facility

$0.83

Hospital Charge Code	41645130
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.42
Rate for Payer: Aetna Government	$0.42
Rate for Payer: Brighton Health Commercial	$0.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.56
Rate for Payer: Group Health Inc Commercial	$0.42
Rate for Payer: Group Health Inc Medicare	$0.29
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.42
Rate for Payer: Hamaspik Choice Inc Medicare	$0.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.54

TOPIRAMATE 200 MG TAB

Facility

$0.83

Hospital Charge Code	41655130
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.46
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.42
Rate for Payer: Aetna Government	$0.42
Rate for Payer: Brighton Health Commercial	$0.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.56
Rate for Payer: Group Health Inc Commercial	$0.42
Rate for Payer: Group Health Inc Medicare	$0.29
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.42
Rate for Payer: Hamaspik Choice Inc Medicare	$0.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.54

TOPIRAMATE 25 MG PO TABS [18920]

Facility

$2.55

Service Code	NDC 47335070786
Hospital Charge Code	47335070786
Hospital Revenue Code	250
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$2.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.40
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.28
Rate for Payer: Aetna Government	$1.28
Rate for Payer: Brighton Health Commercial	$1.92
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.74
Rate for Payer: Group Health Inc Commercial	$1.28
Rate for Payer: Group Health Inc Medicare	$0.89
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.28
Rate for Payer: Hamaspik Choice Inc Medicare	$1.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.66

TOPIRAMATE 25 MG PO TABS [18920]

Facility

$0.33

Service Code	NDC 00904692861
Hospital Charge Code	00904692861
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.26
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.18
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.17
Rate for Payer: Aetna Government	$0.17
Rate for Payer: Brighton Health Commercial	$0.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.22
Rate for Payer: Group Health Inc Commercial	$0.17
Rate for Payer: Group Health Inc Medicare	$0.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.17
Rate for Payer: Hamaspik Choice Inc Medicare	$0.17
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.21

TOPIRAMATE 25 MG PO TABS [18920]

Facility

$2.56

Service Code	NDC 68382013814
Hospital Charge Code	68382013814
Hospital Revenue Code	250
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$2.04
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.41
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.28
Rate for Payer: Aetna Government	$1.28
Rate for Payer: Brighton Health Commercial	$1.92
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.74
Rate for Payer: Group Health Inc Commercial	$1.28
Rate for Payer: Group Health Inc Medicare	$0.89
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.28
Rate for Payer: Hamaspik Choice Inc Medicare	$1.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.66

TOPIRAMATE 25 MG TAB

Facility

$0.22

Hospital Charge Code	41655127
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.18
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.11
Rate for Payer: Aetna Government	$0.11
Rate for Payer: Brighton Health Commercial	$0.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.15
Rate for Payer: Group Health Inc Commercial	$0.11
Rate for Payer: Group Health Inc Medicare	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.11
Rate for Payer: Hamaspik Choice Inc Medicare	$0.11
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.14

TOPIRAMATE 25 MG TAB

Facility

$0.22

Hospital Charge Code	41645127
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.18
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.12
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.11
Rate for Payer: Aetna Government	$0.11
Rate for Payer: Brighton Health Commercial	$0.17
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.18
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.15
Rate for Payer: Group Health Inc Commercial	$0.11
Rate for Payer: Group Health Inc Medicare	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.11
Rate for Payer: Hamaspik Choice Inc Medicare	$0.11
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.14

TOPIRAMATE 50 MG PO TABS [37616]

Facility

$0.50

Service Code	NDC 68084034311
Hospital Charge Code	68084034311
Hospital Revenue Code	250
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.40
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.27
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.25
Rate for Payer: Aetna Government	$0.25
Rate for Payer: Brighton Health Commercial	$0.37
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.40
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.34
Rate for Payer: Group Health Inc Commercial	$0.25
Rate for Payer: Group Health Inc Medicare	$0.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.25
Rate for Payer: Hamaspik Choice Inc Medicare	$0.25
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.32

TOPIRAMATE 50 MG TAB

Facility

$0.12

Hospital Charge Code	41655128
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Brighton Health Commercial	$0.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.08
Rate for Payer: Group Health Inc Commercial	$0.06
Rate for Payer: Group Health Inc Medicare	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.06
Rate for Payer: Hamaspik Choice Inc Medicare	$0.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.08

TOPIRAMATE 50 MG TAB

Facility

$0.12

Hospital Charge Code	41645128
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.10
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.07
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.06
Rate for Payer: Aetna Government	$0.06
Rate for Payer: Brighton Health Commercial	$0.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.10
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.08
Rate for Payer: Group Health Inc Commercial	$0.06
Rate for Payer: Group Health Inc Medicare	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.06
Rate for Payer: Hamaspik Choice Inc Medicare	$0.06
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.08

TOPIRAMATE (TOPAMAX), SERUM

Facility

$29.80

Service Code	HCPCS 80201
Hospital Charge Code	40609811
Hospital Revenue Code	301
Min. Negotiated Rate	$9.54
Max. Negotiated Rate	$22.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$16.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$11.92
Rate for Payer: Aetna Government	$11.92
Rate for Payer: Brighton Health Commercial	$22.35
Rate for Payer: Cash Price	$11.92
Rate for Payer: Cash Price	$11.92
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$11.92
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$18.95
Rate for Payer: Cigna LocalPlus Benefit Plan	$16.04
Rate for Payer: Elderplan Medicare Advantage	$11.92
Rate for Payer: EmblemHealth Commercial	$11.92
Rate for Payer: Fidelis Essential Plan Aliesa	$10.13
Rate for Payer: Fidelis Essential Plan QHP	$10.61
Rate for Payer: Fidelis Medicare Advantage	$11.92
Rate for Payer: Fidelis Qualified Health Plan	$10.61
Rate for Payer: Group Health Inc Commercial	$11.92
Rate for Payer: Group Health Inc Medicare	$11.92
Rate for Payer: Hamaspik Choice Inc Medicaid	$14.90
Rate for Payer: Hamaspik Choice Inc Medicare	$11.92
Rate for Payer: Healthfirst Medicare Advantage	$11.92
Rate for Payer: Healthfirst QHP	$11.92
Rate for Payer: Senior Whole Health Medicare Advantage	$11.92
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$11.92
Rate for Payer: Wellcare CHP/FHP/Medicaid	$9.54
Rate for Payer: Wellcare Medicare	$10.73

TOPIRAMATE (TOPAMAX), SERUM

Facility

$29.80

Service Code	HCPCS 80201
Hospital Charge Code	40609811
Hospital Revenue Code	301
Rate for Payer: Cash Price	$11.92

Know your out-of-pocket cost for care.

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