|
CARBIDOPA 31.25 MG-LEVODOPA 125 MG-ENTACAPONE 200 MG TABLET [94237]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 0781-5641-01
|
| Hospital Charge Code |
1712513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.70 |
| 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 |
$1.62
|
| 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 Beech St/Commercial/PHCS |
$2.70
|
|
|
CARBIDOPA 31.25 MG-LEVODOPA 125 MG-ENTACAPONE 200 MG TABLET [94237]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 0781-5641-01
|
| Hospital Charge Code |
1712513
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$2.70
|
|
|
CARBIDOPA 37.5 MG-LEVODOPA 150 MG-ENTACAPONE 200 MG TABLET [36137]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 0781-5654-01
|
| Hospital Charge Code |
1712362
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$2.70
|
|
|
CARBIDOPA 37.5 MG-LEVODOPA 150 MG-ENTACAPONE 200 MG TABLET [36137]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 0781-5654-01
|
| Hospital Charge Code |
1712362
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.70 |
| 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 |
$1.62
|
| 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 Beech St/Commercial/PHCS |
$2.70
|
|
|
CARBIDOPA 50 MG-LEVODOPA 200 MG-ENTACAPONE 200 MG TABLET [88583]
|
Facility
|
OP
|
$3.60
|
|
|
Service Code
|
NDC 0781-5669-01
|
| Hospital Charge Code |
1712363
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.70 |
| 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 |
$1.62
|
| 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 Beech St/Commercial/PHCS |
$2.70
|
|
|
CARBIDOPA 50 MG-LEVODOPA 200 MG-ENTACAPONE 200 MG TABLET [88583]
|
Facility
|
IP
|
$3.60
|
|
|
Service Code
|
NDC 0781-5669-01
|
| Hospital Charge Code |
1712363
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.98 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$2.70
|
|
|
CARBIDOPA ER 23.75 MG-LEVODOPA 95 MG CAPSULE,EXTENDED RELEASE [208773]
|
Facility
|
OP
|
$4.99
|
|
|
Service Code
|
NDC 64896-661-01
|
| Hospital Charge Code |
ERX208773
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$3.74 |
| 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 |
$2.25
|
| 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 Beech St/Commercial/PHCS |
$3.74
|
|
|
CARBIDOPA ER 23.75 MG-LEVODOPA 95 MG CAPSULE,EXTENDED RELEASE [208773]
|
Facility
|
IP
|
$4.99
|
|
|
Service Code
|
NDC 64896-661-01
|
| Hospital Charge Code |
ERX208773
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$3.99 |
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$3.74
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 51079-978-01
|
| Hospital Charge Code |
1710890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.35 |
| 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 |
$0.21
|
| 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 Beech St/Commercial/PHCS |
$0.35
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 51079-978-01
|
| Hospital Charge Code |
1710890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.35
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]
|
Facility
|
IP
|
$0.94
|
|
|
Service Code
|
NDC 68084-281-11
|
| Hospital Charge Code |
1710890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.75 |
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.71
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]
|
Facility
|
OP
|
$0.45
|
|
|
Service Code
|
NDC 62756-461-88
|
| Hospital Charge Code |
1710890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.34 |
| 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 |
$0.20
|
| 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 Beech St/Commercial/PHCS |
$0.34
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]
|
Facility
|
IP
|
$0.46
|
|
|
Service Code
|
NDC 51079-978-20
|
| Hospital Charge Code |
1710890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.35
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]
|
Facility
|
OP
|
$0.94
|
|
|
Service Code
|
NDC 68084-281-11
|
| Hospital Charge Code |
1710890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$0.71 |
| 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 |
$0.42
|
| 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 Beech St/Commercial/PHCS |
$0.71
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]
|
Facility
|
IP
|
$0.45
|
|
|
Service Code
|
NDC 62756-461-88
|
| Hospital Charge Code |
1710890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.36 |
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$0.34
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE [12329]
|
Facility
|
OP
|
$0.46
|
|
|
Service Code
|
NDC 51079-978-20
|
| Hospital Charge Code |
1710890
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.35 |
| 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 |
$0.21
|
| 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 Beech St/Commercial/PHCS |
$0.35
|
|
|
CARBIDOPA ER 36.25 MG-LEVODOPA 145 MG CAPSULE,EXTENDED RELEASE [208774]
|
Facility
|
OP
|
$4.99
|
|
|
Service Code
|
NDC 64896-662-01
|
| Hospital Charge Code |
ERX208774
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$3.74 |
| 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 |
$2.25
|
| 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 Beech St/Commercial/PHCS |
$3.74
|
|
|
CARBIDOPA ER 36.25 MG-LEVODOPA 145 MG CAPSULE,EXTENDED RELEASE [208774]
|
Facility
|
IP
|
$4.99
|
|
|
Service Code
|
NDC 64896-662-01
|
| Hospital Charge Code |
ERX208774
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.74 |
| Max. Negotiated Rate |
$3.99 |
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS |
$3.74
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 68084-282-01
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.52
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.65
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 68084-282-01
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.65
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 68084-282-11
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.65 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.52
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.52
|
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.65
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
|
OP
|
$1.07
|
|
|
Service Code
|
NDC 51079-923-20
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.80
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
|
OP
|
$1.07
|
|
|
Service Code
|
NDC 51079-923-01
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.64
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.64
|
| Rate for Payer: Cash Price |
$0.48
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.80
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 62756-457-88
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.67 |
| Rate for Payer: Cash Price |
$0.38
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.67
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.63
|
|
|
CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE [9409]
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 68084-282-11
|
| Hospital Charge Code |
1711602
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Cash Price |
$0.39
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.70
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.48
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.65
|
|
