Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR [27635]

Facility

$4.04

Service Code	NDC 60687-583-11
Hospital Charge Code	1711778
Hospital Revenue Code	259
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$3.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.42
Rate for Payer: Aetna of CA Government/Medicare	$2.42
Rate for Payer: Cash Price	$1.82
Rate for Payer: Health Smart Auto/Commercial	$2.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.42
Rate for Payer: LLUH Dept of Risk Management WC	$2.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.03

CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR [27635]

Facility

$4.04

Service Code	NDC 60687-583-11
Hospital Charge Code	1711778
Hospital Revenue Code	259
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$3.23
Rate for Payer: Cash Price	$1.82
Rate for Payer: Cigna of CA HMO/PPO	$3.23
Rate for Payer: Health Smart Auto/Commercial	$2.42
Rate for Payer: LLUH Dept of Risk Management WC	$2.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.03

CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [27633]

Facility

$1.96

Service Code	NDC 66993-409-32
Hospital Charge Code	1710903
Hospital Revenue Code	259
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$1.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.18
Rate for Payer: Aetna of CA Government/Medicare	$1.18
Rate for Payer: Cash Price	$0.88
Rate for Payer: Health Smart Auto/Commercial	$1.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.18
Rate for Payer: LLUH Dept of Risk Management WC	$1.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.47

CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [27633]

Facility

$2.13

Service Code	NDC 54092-173-12
Hospital Charge Code	1710903
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.28
Rate for Payer: Aetna of CA Government/Medicare	$1.28
Rate for Payer: Cash Price	$0.96
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.60

CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [27633]

Facility

$2.13

Service Code	NDC 54092-173-12
Hospital Charge Code	1710903
Hospital Revenue Code	259
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$1.70
Rate for Payer: Cash Price	$0.96
Rate for Payer: Cigna of CA HMO/PPO	$1.70
Rate for Payer: Health Smart Auto/Commercial	$1.28
Rate for Payer: LLUH Dept of Risk Management WC	$1.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.60

CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR [27633]

Facility

$1.96

Service Code	NDC 66993-409-32
Hospital Charge Code	1710903
Hospital Revenue Code	259
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$1.57
Rate for Payer: Cash Price	$0.88
Rate for Payer: Cigna of CA HMO/PPO	$1.57
Rate for Payer: Health Smart Auto/Commercial	$1.18
Rate for Payer: LLUH Dept of Risk Management WC	$1.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.47

CARBAMAZEPINE ER 400 MG TABLET,EXTENDED RELEASE,12 HR [27636]

Facility

$7.49

Service Code	NDC 0078-0512-05
Hospital Charge Code	1711779
Hospital Revenue Code	259
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$5.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.49
Rate for Payer: Aetna of CA Government/Medicare	$4.49
Rate for Payer: Cash Price	$3.37
Rate for Payer: Health Smart Auto/Commercial	$4.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.49
Rate for Payer: LLUH Dept of Risk Management WC	$4.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.62

CARBAMAZEPINE ER 400 MG TABLET,EXTENDED RELEASE,12 HR [27636]

Facility

$7.49

Service Code	NDC 0078-0512-05
Hospital Charge Code	1711779
Hospital Revenue Code	259
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$5.99
Rate for Payer: Cash Price	$3.37
Rate for Payer: Cigna of CA HMO/PPO	$5.99
Rate for Payer: Health Smart Auto/Commercial	$4.49
Rate for Payer: LLUH Dept of Risk Management WC	$4.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.62

CARBAMIDE PEROXIDE 10 % ORAL RINSE [1358]

Facility

$0.34

Service Code	NDC 63029-500-01
Hospital Charge Code	1743241
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

CARBAMIDE PEROXIDE 10 % ORAL RINSE [1358]

Facility

$0.34

Service Code	NDC 63029-500-01
Hospital Charge Code	1743241
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]

Facility

$0.18

Service Code	NDC 46122-557-05
Hospital Charge Code	1740102
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

CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]

Facility

$0.34

Service Code	NDC 0074-7362-01
Hospital Charge Code	1740102
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]

Facility

$0.36

Service Code	NDC 4203710478
Hospital Charge Code	1740102
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

CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]

Facility

$0.24

Service Code	NDC 46122-556-05
Hospital Charge Code	1740102
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]

Facility

$0.15

Service Code	NDC 0904-6627-35
Hospital Charge Code	1740102
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]

Facility

$0.16

Service Code	NDC 8770143152
Hospital Charge Code	1740102
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]

Facility

$0.24

Service Code	NDC 46122-556-05
Hospital Charge Code	1740102
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.18

CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]

Facility

$0.22

Service Code	NDC 8770143151
Hospital Charge Code	1740102
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]

Facility

$0.18

Service Code	NDC 46122-557-05
Hospital Charge Code	1740102
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

CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]

Facility

$0.36

Service Code	NDC 4203710478
Hospital Charge Code	1740102
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

CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]

Facility

$0.34

Service Code	NDC 0074-7362-01
Hospital Charge Code	1740102
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.26

CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]

Facility

$0.16

Service Code	NDC 8770143152
Hospital Charge Code	1740102
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.12

CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]

Facility

$0.15

Service Code	NDC 0904-6627-35
Hospital Charge Code	1740102
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

CARBAMIDE PEROXIDE 6.5 % EAR DROPS [1359]

Facility

$0.22

Service Code	NDC 8770143151
Hospital Charge Code	1740102
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET [9406]

Facility

$0.31

Service Code	NDC 62756-517-88
Hospital Charge Code	1710712
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.25
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

Know your out-of-pocket cost for care.

All Charges