Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

CHRONIC KIDNEY DISEASE

Facility

$4,660.09

Service Code	APR-DRG 4702
Min. Negotiated Rate	$4,660.09
Max. Negotiated Rate	$4,660.09
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$4,660.09

CHRONIC KIDNEY DISEASE

Facility

$3,421.45

Service Code	APR-DRG 4701
Min. Negotiated Rate	$3,421.45
Max. Negotiated Rate	$3,421.45
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$3,421.45

CHRONIC KIDNEY DISEASE

Facility

$7,699.50

Service Code	APR-DRG 4703
Min. Negotiated Rate	$7,699.50
Max. Negotiated Rate	$7,699.50
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$7,699.50

CHRONIC KIDNEY DISEASE

Facility

$13,486.81

Service Code	APR-DRG 4704
Min. Negotiated Rate	$13,486.81
Max. Negotiated Rate	$13,486.81
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$13,486.81

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$5,824.12

Service Code	APR-DRG 1402
Min. Negotiated Rate	$5,824.12
Max. Negotiated Rate	$5,824.12
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$5,824.12

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$10,445.41

Service Code	APR-DRG 1404
Min. Negotiated Rate	$10,445.41
Max. Negotiated Rate	$10,445.41
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$10,445.41

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$4,728.74

Service Code	APR-DRG 1401
Min. Negotiated Rate	$4,728.74
Max. Negotiated Rate	$4,728.74
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$4,728.74

CHRONIC OBSTRUCTIVE PULMONARY DISEASE

Facility

$7,062.77

Service Code	APR-DRG 1403
Min. Negotiated Rate	$7,062.77
Max. Negotiated Rate	$7,062.77
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$7,062.77

C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]

Facility

$352.80

Service Code	CPT J3490
Hospital Charge Code	ERX227971
Hospital Revenue Code	636
Min. Negotiated Rate	$63.86
Max. Negotiated Rate	$299.88
Rate for Payer: Adventist Health Commercial	$70.56
Rate for Payer: Aetna of CA Gatekeeper	$188.57
Rate for Payer: Aetna of CA Non-Gatekeeper	$242.37
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$299.88
Rate for Payer: Alpha Care Medical Group Medi-Cal	$194.04
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$264.60
Rate for Payer: Blue Shield of California Commercial	$219.09
Rate for Payer: Blue Shield of California EPN	$207.09
Rate for Payer: Cash Price	$158.76
Rate for Payer: Cigna of CA HMO/PPO	$162.29
Rate for Payer: Dignity Health Commercial/Exchange	$299.88
Rate for Payer: Dignity Health Medi-Cal	$299.88
Rate for Payer: Dignity Health Senior	$299.88
Rate for Payer: EPIC Health Plan Commercial	$225.79
Rate for Payer: Heritage Provider Network Commercial	$163.35
Rate for Payer: Heritage Provider Network Senior	$163.35
Rate for Payer: Kaiser Permanente of CA Commercial	$170.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$63.86
Rate for Payer: LLUH Dept of Risk Management WC	$88.20
Rate for Payer: Multiplan Commercial	$264.60
Rate for Payer: TriValley Medical Group Commercial	$141.12
Rate for Payer: TriValley Medical Group Senior	$141.12
Rate for Payer: United Healthcare All Other HMO/non HMO	$128.63
Rate for Payer: United Healthcare Navigate/Select/Select+	$117.87
Rate for Payer: Vantage Medical Group Medi-Cal	$299.88
Rate for Payer: Vantage Medical Group Senior	$299.88

C.I. ACID BLUE 90 0.025 % INTRAOCULAR SYRINGE [227971]

Facility

$352.80

Service Code	CPT J3490
Hospital Charge Code	ERX227971
Hospital Revenue Code	636
Min. Negotiated Rate	$63.86
Max. Negotiated Rate	$264.60
Rate for Payer: Adventist Health Commercial	$70.56
Rate for Payer: Aetna of CA Non-Gatekeeper	$242.37
Rate for Payer: Cash Price	$158.76
Rate for Payer: Cigna of CA HMO/PPO	$162.29
Rate for Payer: EPIC Health Plan Commercial	$190.51
Rate for Payer: Heritage Provider Network Commercial	$238.85
Rate for Payer: Heritage Provider Network Senior	$238.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$63.86
Rate for Payer: LLUH Dept of Risk Management WC	$88.20
Rate for Payer: Multiplan Commercial	$264.60
Rate for Payer: United Healthcare All Other HMO/non HMO	$128.63
Rate for Payer: United Healthcare Navigate/Select/Select+	$117.87

CICLOPIROX 0.77 % TOPICAL CREAM [9598]

Facility

$1.08

Service Code	NDC 45802-138-11
Hospital Charge Code	1743680
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.81
Rate for Payer: Adventist Health Commercial	$0.22
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.74
Rate for Payer: Cash Price	$0.49
Rate for Payer: EPIC Health Plan Commercial	$0.58
Rate for Payer: Heritage Provider Network Commercial	$0.73
Rate for Payer: Heritage Provider Network Senior	$0.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.81

CICLOPIROX 0.77 % TOPICAL CREAM [9598]

Facility

$1.23

Service Code	NDC 68462-297-17
Hospital Charge Code	NDG9598
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.92
Rate for Payer: Adventist Health Commercial	$0.25
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.85
Rate for Payer: Cash Price	$0.55
Rate for Payer: EPIC Health Plan Commercial	$0.66
Rate for Payer: Heritage Provider Network Commercial	$0.83
Rate for Payer: Heritage Provider Network Senior	$0.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.92

CICLOPIROX 0.77 % TOPICAL CREAM [9598]

Facility

$1.49

Service Code	NDC 51672-1318-1
Hospital Charge Code	NDG9598
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$1.27
Rate for Payer: Adventist Health Commercial	$0.30
Rate for Payer: Aetna of CA Gatekeeper	$0.80
Rate for Payer: Aetna of CA Non-Gatekeeper	$1.02
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$1.27
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.82
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$1.12
Rate for Payer: Blue Shield of California Commercial	$0.93
Rate for Payer: Blue Shield of California EPN	$0.87
Rate for Payer: Cash Price	$0.67
Rate for Payer: Cigna of CA HMO/PPO	$0.97
Rate for Payer: Dignity Health Commercial/Exchange	$1.27
Rate for Payer: Dignity Health Medi-Cal	$1.27
Rate for Payer: Dignity Health Senior	$1.27
Rate for Payer: EPIC Health Plan Commercial	$0.95
Rate for Payer: Heritage Provider Network Commercial	$0.92
Rate for Payer: Heritage Provider Network Senior	$0.92
Rate for Payer: Kaiser Permanente of CA Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$1.12
Rate for Payer: TriValley Medical Group Commercial	$0.60
Rate for Payer: TriValley Medical Group Senior	$0.60
Rate for Payer: Vantage Medical Group Medi-Cal	$1.27
Rate for Payer: Vantage Medical Group Senior	$1.27

CICLOPIROX 0.77 % TOPICAL CREAM [9598]

Facility

$1.23

Service Code	NDC 68462-297-17
Hospital Charge Code	NDG9598
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$1.05
Rate for Payer: Adventist Health Commercial	$0.25
Rate for Payer: Aetna of CA Gatekeeper	$0.66
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.85
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$1.05
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.68
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.92
Rate for Payer: Blue Shield of California Commercial	$0.76
Rate for Payer: Blue Shield of California EPN	$0.72
Rate for Payer: Cash Price	$0.55
Rate for Payer: Cigna of CA HMO/PPO	$0.80
Rate for Payer: Dignity Health Commercial/Exchange	$1.05
Rate for Payer: Dignity Health Medi-Cal	$1.05
Rate for Payer: Dignity Health Senior	$1.05
Rate for Payer: EPIC Health Plan Commercial	$0.79
Rate for Payer: Heritage Provider Network Commercial	$0.76
Rate for Payer: Heritage Provider Network Senior	$0.76
Rate for Payer: Kaiser Permanente of CA Commercial	$0.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.31
Rate for Payer: Multiplan Commercial	$0.92
Rate for Payer: TriValley Medical Group Commercial	$0.49
Rate for Payer: TriValley Medical Group Senior	$0.49
Rate for Payer: Vantage Medical Group Medi-Cal	$1.05
Rate for Payer: Vantage Medical Group Senior	$1.05

CICLOPIROX 0.77 % TOPICAL CREAM [9598]

Facility

$1.08

Service Code	NDC 45802-138-11
Hospital Charge Code	1743680
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.92
Rate for Payer: Adventist Health Commercial	$0.22
Rate for Payer: Aetna of CA Gatekeeper	$0.58
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.74
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.92
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.59
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.81
Rate for Payer: Blue Shield of California Commercial	$0.67
Rate for Payer: Blue Shield of California EPN	$0.63
Rate for Payer: Cash Price	$0.49
Rate for Payer: Cigna of CA HMO/PPO	$0.70
Rate for Payer: Dignity Health Commercial/Exchange	$0.92
Rate for Payer: Dignity Health Medi-Cal	$0.92
Rate for Payer: Dignity Health Senior	$0.92
Rate for Payer: EPIC Health Plan Commercial	$0.69
Rate for Payer: Heritage Provider Network Commercial	$0.67
Rate for Payer: Heritage Provider Network Senior	$0.67
Rate for Payer: Kaiser Permanente of CA Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.81
Rate for Payer: TriValley Medical Group Commercial	$0.43
Rate for Payer: TriValley Medical Group Senior	$0.43
Rate for Payer: Vantage Medical Group Medi-Cal	$0.92
Rate for Payer: Vantage Medical Group Senior	$0.92

CICLOPIROX 0.77 % TOPICAL CREAM [9598]

Facility

$1.49

Service Code	NDC 51672-1318-1
Hospital Charge Code	NDG9598
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$1.12
Rate for Payer: Adventist Health Commercial	$0.30
Rate for Payer: Aetna of CA Non-Gatekeeper	$1.02
Rate for Payer: Cash Price	$0.67
Rate for Payer: EPIC Health Plan Commercial	$0.80
Rate for Payer: Heritage Provider Network Commercial	$1.01
Rate for Payer: Heritage Provider Network Senior	$1.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$1.12

CICLOPIROX 8 % TOPICAL SOLUTION [27158]

Facility

$6.76

Service Code	NDC 50383-419-06
Hospital Charge Code	1743748
Hospital Revenue Code	259
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$5.75
Rate for Payer: Adventist Health Commercial	$1.35
Rate for Payer: Aetna of CA Gatekeeper	$3.61
Rate for Payer: Aetna of CA Non-Gatekeeper	$4.64
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$5.75
Rate for Payer: Alpha Care Medical Group Medi-Cal	$3.72
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$5.07
Rate for Payer: Blue Shield of California Commercial	$4.20
Rate for Payer: Blue Shield of California EPN	$3.97
Rate for Payer: Cash Price	$3.04
Rate for Payer: Cigna of CA HMO/PPO	$4.39
Rate for Payer: Dignity Health Commercial/Exchange	$5.75
Rate for Payer: Dignity Health Medi-Cal	$5.75
Rate for Payer: Dignity Health Senior	$5.75
Rate for Payer: EPIC Health Plan Commercial	$4.33
Rate for Payer: Heritage Provider Network Commercial	$4.18
Rate for Payer: Heritage Provider Network Senior	$4.18
Rate for Payer: Kaiser Permanente of CA Commercial	$3.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.22
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: Multiplan Commercial	$5.07
Rate for Payer: TriValley Medical Group Commercial	$2.70
Rate for Payer: TriValley Medical Group Senior	$2.70
Rate for Payer: Vantage Medical Group Medi-Cal	$5.75
Rate for Payer: Vantage Medical Group Senior	$5.75

CICLOPIROX 8 % TOPICAL SOLUTION [27158]

Facility

$5.82

Service Code	NDC 0713-0317-88
Hospital Charge Code	1743748
Hospital Revenue Code	259
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$4.95
Rate for Payer: Adventist Health Commercial	$1.16
Rate for Payer: Aetna of CA Gatekeeper	$3.11
Rate for Payer: Aetna of CA Non-Gatekeeper	$4.00
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$4.95
Rate for Payer: Alpha Care Medical Group Medi-Cal	$3.20
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$4.36
Rate for Payer: Blue Shield of California Commercial	$3.61
Rate for Payer: Blue Shield of California EPN	$3.42
Rate for Payer: Cash Price	$2.62
Rate for Payer: Cigna of CA HMO/PPO	$3.78
Rate for Payer: Dignity Health Commercial/Exchange	$4.95
Rate for Payer: Dignity Health Medi-Cal	$4.95
Rate for Payer: Dignity Health Senior	$4.95
Rate for Payer: EPIC Health Plan Commercial	$3.72
Rate for Payer: Heritage Provider Network Commercial	$3.60
Rate for Payer: Heritage Provider Network Senior	$3.60
Rate for Payer: Kaiser Permanente of CA Commercial	$2.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.05
Rate for Payer: LLUH Dept of Risk Management WC	$1.46
Rate for Payer: Multiplan Commercial	$4.36
Rate for Payer: TriValley Medical Group Commercial	$2.33
Rate for Payer: TriValley Medical Group Senior	$2.33
Rate for Payer: Vantage Medical Group Medi-Cal	$4.95
Rate for Payer: Vantage Medical Group Senior	$4.95

CICLOPIROX 8 % TOPICAL SOLUTION [27158]

Facility

$6.76

Service Code	NDC 50383-419-06
Hospital Charge Code	1743748
Hospital Revenue Code	259
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$5.07
Rate for Payer: Adventist Health Commercial	$1.35
Rate for Payer: Aetna of CA Non-Gatekeeper	$4.64
Rate for Payer: Cash Price	$3.04
Rate for Payer: EPIC Health Plan Commercial	$3.65
Rate for Payer: Heritage Provider Network Commercial	$4.58
Rate for Payer: Heritage Provider Network Senior	$4.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.22
Rate for Payer: LLUH Dept of Risk Management WC	$1.69
Rate for Payer: Multiplan Commercial	$5.07

CICLOPIROX 8 % TOPICAL SOLUTION [27158]

Facility

$5.82

Service Code	NDC 0713-0317-88
Hospital Charge Code	1743748
Hospital Revenue Code	259
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$4.36
Rate for Payer: Adventist Health Commercial	$1.16
Rate for Payer: Aetna of CA Non-Gatekeeper	$4.00
Rate for Payer: Cash Price	$2.62
Rate for Payer: EPIC Health Plan Commercial	$3.14
Rate for Payer: Heritage Provider Network Commercial	$3.94
Rate for Payer: Heritage Provider Network Senior	$3.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.05
Rate for Payer: LLUH Dept of Risk Management WC	$1.46
Rate for Payer: Multiplan Commercial	$4.36

CIDOFOVIR 10 MG/ML TOPICAL [4082503]

Facility

$24.48

Service Code	NDC 9994-0825-03
Hospital Revenue Code	636
Min. Negotiated Rate	$4.43
Max. Negotiated Rate	$20.81
Rate for Payer: Adventist Health Commercial	$4.90
Rate for Payer: Aetna of CA Gatekeeper	$13.08
Rate for Payer: Aetna of CA Non-Gatekeeper	$16.82
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$20.81
Rate for Payer: Alpha Care Medical Group Medi-Cal	$13.46
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$18.36
Rate for Payer: Blue Shield of California Commercial	$15.20
Rate for Payer: Blue Shield of California EPN	$14.37
Rate for Payer: Cash Price	$11.02
Rate for Payer: Cigna of CA HMO/PPO	$11.26
Rate for Payer: Dignity Health Commercial/Exchange	$20.81
Rate for Payer: Dignity Health Medi-Cal	$20.81
Rate for Payer: Dignity Health Senior	$20.81
Rate for Payer: EPIC Health Plan Commercial	$15.67
Rate for Payer: Heritage Provider Network Commercial	$11.33
Rate for Payer: Heritage Provider Network Senior	$11.33
Rate for Payer: Kaiser Permanente of CA Commercial	$11.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$4.43
Rate for Payer: LLUH Dept of Risk Management WC	$6.12
Rate for Payer: Multiplan Commercial	$18.36
Rate for Payer: TriValley Medical Group Commercial	$9.79
Rate for Payer: TriValley Medical Group Senior	$9.79
Rate for Payer: United Healthcare All Other HMO/non HMO	$8.93
Rate for Payer: United Healthcare Navigate/Select/Select+	$8.18
Rate for Payer: Vantage Medical Group Medi-Cal	$20.81
Rate for Payer: Vantage Medical Group Senior	$20.81

CIDOFOVIR 10 MG/ML TOPICAL [4082503]

Facility

$24.48

Service Code	NDC 9994-0825-03
Hospital Revenue Code	636
Min. Negotiated Rate	$4.43
Max. Negotiated Rate	$18.36
Rate for Payer: Adventist Health Commercial	$4.90
Rate for Payer: Aetna of CA Non-Gatekeeper	$16.82
Rate for Payer: Cash Price	$11.02
Rate for Payer: Cigna of CA HMO/PPO	$11.26
Rate for Payer: EPIC Health Plan Commercial	$13.22
Rate for Payer: Heritage Provider Network Commercial	$16.57
Rate for Payer: Heritage Provider Network Senior	$16.57
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$4.43
Rate for Payer: LLUH Dept of Risk Management WC	$6.12
Rate for Payer: Multiplan Commercial	$18.36
Rate for Payer: United Healthcare All Other HMO/non HMO	$8.93
Rate for Payer: United Healthcare Navigate/Select/Select+	$8.18

CIDOFOVIR 15 MG/ML TOPICAL [4081161]

Facility

$36.54

Service Code	NDC 99994-811-61
Hospital Charge Code	NDC4081161
Hospital Revenue Code	636
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$31.06
Rate for Payer: Adventist Health Commercial	$7.31
Rate for Payer: Aetna of CA Gatekeeper	$19.53
Rate for Payer: Aetna of CA Non-Gatekeeper	$25.10
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$31.06
Rate for Payer: Alpha Care Medical Group Medi-Cal	$20.10
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$27.40
Rate for Payer: Blue Shield of California Commercial	$22.69
Rate for Payer: Blue Shield of California EPN	$21.45
Rate for Payer: Cash Price	$16.44
Rate for Payer: Cigna of CA HMO/PPO	$16.81
Rate for Payer: Dignity Health Commercial/Exchange	$31.06
Rate for Payer: Dignity Health Medi-Cal	$31.06
Rate for Payer: Dignity Health Senior	$31.06
Rate for Payer: EPIC Health Plan Commercial	$23.39
Rate for Payer: Heritage Provider Network Commercial	$16.92
Rate for Payer: Heritage Provider Network Senior	$16.92
Rate for Payer: Kaiser Permanente of CA Commercial	$17.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$6.61
Rate for Payer: LLUH Dept of Risk Management WC	$9.14
Rate for Payer: Multiplan Commercial	$27.40
Rate for Payer: TriValley Medical Group Commercial	$14.62
Rate for Payer: TriValley Medical Group Senior	$14.62
Rate for Payer: United Healthcare All Other HMO/non HMO	$13.32
Rate for Payer: United Healthcare Navigate/Select/Select+	$12.21
Rate for Payer: Vantage Medical Group Medi-Cal	$31.06
Rate for Payer: Vantage Medical Group Senior	$31.06

CIDOFOVIR 15 MG/ML TOPICAL [4081161]

Facility

$36.54

Service Code	NDC 99994-811-61
Hospital Charge Code	NDC4081161
Hospital Revenue Code	636
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$27.40
Rate for Payer: Adventist Health Commercial	$7.31
Rate for Payer: Aetna of CA Non-Gatekeeper	$25.10
Rate for Payer: Cash Price	$16.44
Rate for Payer: Cigna of CA HMO/PPO	$16.81
Rate for Payer: EPIC Health Plan Commercial	$19.73
Rate for Payer: Heritage Provider Network Commercial	$24.74
Rate for Payer: Heritage Provider Network Senior	$24.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$6.61
Rate for Payer: LLUH Dept of Risk Management WC	$9.14
Rate for Payer: Multiplan Commercial	$27.40
Rate for Payer: United Healthcare All Other HMO/non HMO	$13.32
Rate for Payer: United Healthcare Navigate/Select/Select+	$12.21

CIDOFOVIR 1 MG/ML TOPICAL [4081092]

Facility

$36.54

Service Code	NDC 99994-811-92
Hospital Charge Code	NDC4081092
Hospital Revenue Code	636
Min. Negotiated Rate	$6.61
Max. Negotiated Rate	$27.40
Rate for Payer: Adventist Health Commercial	$7.31
Rate for Payer: Aetna of CA Non-Gatekeeper	$25.10
Rate for Payer: Cash Price	$16.44
Rate for Payer: Cigna of CA HMO/PPO	$16.81
Rate for Payer: EPIC Health Plan Commercial	$19.73
Rate for Payer: Heritage Provider Network Commercial	$24.74
Rate for Payer: Heritage Provider Network Senior	$24.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$6.61
Rate for Payer: LLUH Dept of Risk Management WC	$9.14
Rate for Payer: Multiplan Commercial	$27.40
Rate for Payer: United Healthcare All Other HMO/non HMO	$13.32
Rate for Payer: United Healthcare Navigate/Select/Select+	$12.21

Know your out-of-pocket cost for care.

All Charges