Loma Linda University Children's Hospital

All Charges

Charge

Type

Price

ZONISAMIDE 25 MG CAPSULE [36987]

Facility IP

$0.19

Service Code	NDC 68462-128-01
Hospital Charge Code	1710953
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.16
Rate for Payer: Blue Shield of California Commercial	$0.14
Rate for Payer: Blue Shield of California EPN	$0.10
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO	$0.13
Rate for Payer: Cigna of CA PPO	$0.13
Rate for Payer: EPIC Health Plan Commercial	$0.08
Rate for Payer: Galaxy Health WC	$0.16
Rate for Payer: Global Benefits Group Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.15
Rate for Payer: Networks By Design Commercial	$0.12
Rate for Payer: Prime Health Services Commercial	$0.16

ZONISAMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080361]

Facility IP

$0.44

Service Code	NDC 9994-0803-61
Hospital Charge Code	1715310
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.37
Rate for Payer: Blue Shield of California Commercial	$0.31
Rate for Payer: Blue Shield of California EPN	$0.23
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna of CA HMO	$0.31
Rate for Payer: Cigna of CA PPO	$0.31
Rate for Payer: EPIC Health Plan Commercial	$0.18
Rate for Payer: Galaxy Health WC	$0.37
Rate for Payer: Global Benefits Group Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.35
Rate for Payer: Networks By Design Commercial	$0.29
Rate for Payer: Prime Health Services Commercial	$0.37

ZONISAMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080361]

Facility OP

$0.44

Service Code	NDC 9994-0803-61
Hospital Charge Code	1715310
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of CA HMO/PPO	$0.29
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.37
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.24
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.24
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.26
Rate for Payer: BCBS Transplant Transplant	$0.26
Rate for Payer: Blue Shield of California Commercial	$0.32
Rate for Payer: Blue Shield of California EPN	$0.26
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna of CA HMO	$0.31
Rate for Payer: Cigna of CA PPO	$0.31
Rate for Payer: Dignity Health Commercial/Exchange	$0.37
Rate for Payer: Dignity Health Media	$0.37
Rate for Payer: Dignity Health Medi-Cal	$0.37
Rate for Payer: EPIC Health Plan Commercial	$0.18
Rate for Payer: EPIC Health Plan Transplant	$0.18
Rate for Payer: Galaxy Health WC	$0.37
Rate for Payer: Global Benefits Group Commercial	$0.26
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other	$0.33
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.35
Rate for Payer: Networks By Design Commercial	$0.29
Rate for Payer: Prime Health Services Commercial	$0.37
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior	$0.26
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$0.26
Rate for Payer: TriValley Medical Group Commercial/Senior	$0.26
Rate for Payer: United Healthcare All Other Commercial	$0.22
Rate for Payer: United Healthcare All Other HMO	$0.22
Rate for Payer: United Healthcare HMO Rider	$0.22
Rate for Payer: United Healthcare Select/Navigate/Core	$0.22
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.37
Rate for Payer: Vantage Medical Group Medi-Cal	$0.37
Rate for Payer: Vantage Medical Group Senior	$0.37

ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION [76518]

Facility IP

$267.74

Service Code	CPT 90736
Hospital Charge Code	1726022
Hospital Revenue Code	636
Min. Negotiated Rate	$64.26
Max. Negotiated Rate	$227.58
Rate for Payer: Blue Shield of California Commercial	$190.63
Rate for Payer: Blue Shield of California EPN	$137.08
Rate for Payer: Cash Price	$120.48
Rate for Payer: Cigna of CA HMO	$187.42
Rate for Payer: Cigna of CA PPO	$187.42
Rate for Payer: EPIC Health Plan Commercial	$107.10
Rate for Payer: EPIC Health Plan Transplant	$107.10
Rate for Payer: Galaxy Health WC	$227.58
Rate for Payer: Global Benefits Group Commercial	$160.64
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$178.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$102.01
Rate for Payer: LLUH Dept of Risk Management WC	$64.26
Rate for Payer: Multiplan Commercial	$214.19
Rate for Payer: Networks By Design Commercial	$133.87
Rate for Payer: Prime Health Services Commercial	$227.58

ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION [76518]

Facility OP

$267.74

Service Code	CPT 90736
Hospital Charge Code	1726022
Hospital Revenue Code	636
Min. Negotiated Rate	$64.26
Max. Negotiated Rate	$1,508.07
Rate for Payer: Aetna of CA HMO/PPO	$1,508.07
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$227.58
Rate for Payer: AlphaCare Medical Group Medi-Cal	$147.26
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$147.26
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$365.81
Rate for Payer: BCBS Transplant Transplant	$160.64
Rate for Payer: Blue Shield of California Commercial	$197.32
Rate for Payer: Blue Shield of California EPN	$255.20
Rate for Payer: Cash Price	$120.48
Rate for Payer: Cash Price	$120.48
Rate for Payer: Cigna of CA HMO	$187.42
Rate for Payer: Cigna of CA PPO	$187.42
Rate for Payer: Dignity Health Commercial/Exchange	$227.58
Rate for Payer: Dignity Health Media	$227.58
Rate for Payer: Dignity Health Medi-Cal	$227.58
Rate for Payer: EPIC Health Plan Commercial	$107.10
Rate for Payer: EPIC Health Plan Transplant	$107.10
Rate for Payer: Galaxy Health WC	$227.58
Rate for Payer: Global Benefits Group Commercial	$160.64
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other	$200.80
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$178.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$412.55
Rate for Payer: LLUH Dept of Risk Management WC	$64.26
Rate for Payer: Multiplan Commercial	$214.19
Rate for Payer: Networks By Design Commercial	$133.87
Rate for Payer: Prime Health Services Commercial	$227.58
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$160.64
Rate for Payer: TriValley Medical Group Commercial/Senior	$160.64
Rate for Payer: United Healthcare All Other Commercial	$133.87
Rate for Payer: United Healthcare All Other HMO	$133.87
Rate for Payer: United Healthcare HMO Rider	$133.87
Rate for Payer: United Healthcare Select/Navigate/Core	$133.87
Rate for Payer: Vantage Medical Group Commercial/Exchange	$227.58
Rate for Payer: Vantage Medical Group Medi-Cal	$227.58
Rate for Payer: Vantage Medical Group Senior	$227.58

Price Transparency.

All Charges