Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET [9408]

Facility

$0.44

Service Code	NDC 60687-836-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

CARBIDOPA 31.25 MG-LEVODOPA 125 MG-ENTACAPONE 200 MG TABLET [94237]

Facility

$3.60

Service Code	NDC 0781-5641-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70

CARBIDOPA 31.25 MG-LEVODOPA 125 MG-ENTACAPONE 200 MG TABLET [94237]

Facility

$3.60

Service Code	NDC 0781-5641-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70

CARBIDOPA 37.5 MG-LEVODOPA 150 MG-ENTACAPONE 200 MG TABLET [36137]

Facility

$3.60

Service Code	NDC 0781-5654-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70

CARBIDOPA 37.5 MG-LEVODOPA 150 MG-ENTACAPONE 200 MG TABLET [36137]

Facility

$3.60

Service Code	NDC 0781-5654-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70

CARBIDOPA 50 MG-LEVODOPA 200 MG-ENTACAPONE 200 MG TABLET [88583]

Facility

$3.60

Service Code	NDC 0781-5669-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70

CARBIDOPA 50 MG-LEVODOPA 200 MG-ENTACAPONE 200 MG TABLET [88583]

Facility

$3.60

Service Code	NDC 0781-5669-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Cash Price	$1.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70

CARBIDOPA ER 23.75 MG-LEVODOPA 95 MG CAPSULE,EXTENDED RELEASE [208773]

Facility

$4.99

Service Code	NDC 64896-661-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$3.99
Rate for Payer: Cash Price	$2.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.99
Rate for Payer: Health Smart Auto/Commercial	$2.99
Rate for Payer: LLUH Dept of Risk Management WC	$2.74
Rate for Payer: Multiplan Commercial	$3.74

CARBIDOPA ER 23.75 MG-LEVODOPA 95 MG CAPSULE,EXTENDED RELEASE [208773]

Facility

$4.99

Service Code	NDC 64896-661-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$3.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.99
Rate for Payer: Aetna of CA Government/Medicare	$2.99
Rate for Payer: Cash Price	$2.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.99
Rate for Payer: Health Smart Auto/Commercial	$2.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.99
Rate for Payer: LLUH Dept of Risk Management WC	$2.74
Rate for Payer: Multiplan Commercial	$3.74

CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]

Facility

$0.46

Service Code	NDC 51079-978-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.35

CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]

Facility

$0.46

Service Code	NDC 51079-978-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.35

CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]

Facility

$0.45

Service Code	NDC 62756-461-88
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.27
Rate for Payer: Aetna of CA Government/Medicare	$0.27
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.34

CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]

Facility

$0.46

Service Code	NDC 51079-978-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.35

CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]

Facility

$0.94

Service Code	NDC 68084-281-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]

Facility

$0.46

Service Code	NDC 51079-978-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.35

CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]

Facility

$0.94

Service Code	NDC 68084-281-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
Rate for Payer: Cash Price	$0.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Commercial	$0.71

CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]

Facility

$0.45

Service Code	NDC 62756-461-88
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.34

CARBIDOPA ER 36.25 MG-LEVODOPA 145 MG CAPSULE,EXTENDED RELEASE [208774]

Facility

$4.99

Service Code	NDC 64896-662-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$3.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.99
Rate for Payer: Aetna of CA Government/Medicare	$2.99
Rate for Payer: Cash Price	$2.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.99
Rate for Payer: Health Smart Auto/Commercial	$2.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.99
Rate for Payer: LLUH Dept of Risk Management WC	$2.74
Rate for Payer: Multiplan Commercial	$3.74

CARBIDOPA ER 36.25 MG-LEVODOPA 145 MG CAPSULE,EXTENDED RELEASE [208774]

Facility

$4.99

Service Code	NDC 64896-662-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$3.99
Rate for Payer: Cash Price	$2.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.99
Rate for Payer: Health Smart Auto/Commercial	$2.99
Rate for Payer: LLUH Dept of Risk Management WC	$2.74
Rate for Payer: Multiplan Commercial	$3.74

CARBIDOPA ER 48.75 MG-LEVODOPA 195 MG CAPSULE,EXTENDED RELEASE [208775]

Facility

$4.99

Service Code	NDC 64896-663-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$3.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.99
Rate for Payer: Aetna of CA Government/Medicare	$2.99
Rate for Payer: Cash Price	$2.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.99
Rate for Payer: Health Smart Auto/Commercial	$2.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.99
Rate for Payer: LLUH Dept of Risk Management WC	$2.74
Rate for Payer: Multiplan Commercial	$3.74

CARBIDOPA ER 48.75 MG-LEVODOPA 195 MG CAPSULE,EXTENDED RELEASE [208775]

Facility

$4.99

Service Code	NDC 64896-663-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$3.99
Rate for Payer: Cash Price	$2.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.99
Rate for Payer: Health Smart Auto/Commercial	$2.99
Rate for Payer: LLUH Dept of Risk Management WC	$2.74
Rate for Payer: Multiplan Commercial	$3.74

CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]

Facility

$0.30

Service Code	NDC 50228-461-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]

Facility

$0.30

Service Code	NDC 50228-461-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

CARBIDOPA ER 61.25 MG-LEVODOPA 245 MG CAPSULE,EXTENDED RELEASE [208776]

Facility

$6.26

Service Code	NDC 64896-664-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.44
Max. Negotiated Rate	$5.01
Rate for Payer: Cash Price	$3.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.01
Rate for Payer: Health Smart Auto/Commercial	$3.76
Rate for Payer: LLUH Dept of Risk Management WC	$3.44
Rate for Payer: Multiplan Commercial	$4.70

CARBIDOPA ER 61.25 MG-LEVODOPA 245 MG CAPSULE,EXTENDED RELEASE [208776]

Facility

$6.26

Service Code	NDC 64896-664-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.44
Max. Negotiated Rate	$5.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.76
Rate for Payer: Aetna of CA Government/Medicare	$3.76
Rate for Payer: Cash Price	$3.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.01
Rate for Payer: Health Smart Auto/Commercial	$3.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.76
Rate for Payer: LLUH Dept of Risk Management WC	$3.44
Rate for Payer: Multiplan Commercial	$4.70

Know your out-of-pocket cost for care.

All Charges