Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

EFAVIRENZ 600 MG TABLET [32298]

Facility

$3.20

Service Code	NDC 31722-504-30
Hospital Charge Code	1711878
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$2.72
Rate for Payer: Adventist Health Commercial	$0.64
Rate for Payer: Aetna of CA Gatekeeper	$1.71
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.20
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$2.72
Rate for Payer: Alpha Care Medical Group Medi-Cal	$1.76
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$2.40
Rate for Payer: Blue Shield of California Commercial	$1.99
Rate for Payer: Blue Shield of California EPN	$1.88
Rate for Payer: Cash Price	$1.44
Rate for Payer: Cigna of CA HMO/PPO	$2.08
Rate for Payer: Dignity Health Commercial/Exchange	$2.72
Rate for Payer: Dignity Health Medi-Cal	$2.72
Rate for Payer: Dignity Health Senior	$2.72
Rate for Payer: EPIC Health Plan Commercial	$2.05
Rate for Payer: Heritage Provider Network Commercial	$1.98
Rate for Payer: Heritage Provider Network Senior	$1.98
Rate for Payer: Kaiser Permanente of CA Commercial	$1.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.80
Rate for Payer: Multiplan Commercial	$2.40
Rate for Payer: TriValley Medical Group Commercial	$1.28
Rate for Payer: TriValley Medical Group Senior	$1.28
Rate for Payer: Vantage Medical Group Medi-Cal	$2.72
Rate for Payer: Vantage Medical Group Senior	$2.72

EFAVIRENZ 600 MG TABLET [32298]

Facility

$3.20

Service Code	NDC 31722-504-30
Hospital Charge Code	1711878
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$2.40
Rate for Payer: Adventist Health Commercial	$0.64
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.20
Rate for Payer: Cash Price	$1.44
Rate for Payer: EPIC Health Plan Commercial	$1.73
Rate for Payer: Heritage Provider Network Commercial	$2.17
Rate for Payer: Heritage Provider Network Senior	$2.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.80
Rate for Payer: Multiplan Commercial	$2.40

EFLAPEGRASTIM-XNST 13.2 MG/0.6 ML SUBCUTANEOUS SYRINGE [235968]

Facility

$9,000.00

Service Code	CPT J1449
Hospital Charge Code	NDG235968
Hospital Revenue Code	636
Min. Negotiated Rate	$1,629.00
Max. Negotiated Rate	$6,750.00
Rate for Payer: Adventist Health Commercial	$1,800.00
Rate for Payer: Aetna of CA Non-Gatekeeper	$6,183.00
Rate for Payer: Cash Price	$4,050.00
Rate for Payer: Cigna of CA HMO/PPO	$4,140.00
Rate for Payer: EPIC Health Plan Commercial	$4,860.00
Rate for Payer: Heritage Provider Network Commercial	$6,093.00
Rate for Payer: Heritage Provider Network Senior	$6,093.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1,629.00
Rate for Payer: LLUH Dept of Risk Management WC	$2,250.00
Rate for Payer: Multiplan Commercial	$6,750.00
Rate for Payer: United Healthcare All Other HMO/non HMO	$3,281.40
Rate for Payer: United Healthcare Navigate/Select/Select+	$3,006.90

EFLAPEGRASTIM-XNST 13.2 MG/0.6 ML SUBCUTANEOUS SYRINGE [235968]

Facility

$9,000.00

Service Code	CPT J1449
Hospital Charge Code	NDG235968
Hospital Revenue Code	636
Min. Negotiated Rate	$29.68
Max. Negotiated Rate	$6,750.00
Rate for Payer: Adventist Health Commercial	$1,800.00
Rate for Payer: Aetna of CA Gatekeeper	$72.92
Rate for Payer: Aetna of CA Non-Gatekeeper	$6,183.00
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$37.10
Rate for Payer: Alpha Care Medical Group Medi-Cal	$32.65
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$32.65
Rate for Payer: Blue Shield of California Commercial	$5,589.00
Rate for Payer: Blue Shield of California EPN	$5,283.00
Rate for Payer: Cash Price	$4,050.00
Rate for Payer: Cash Price	$4,050.00
Rate for Payer: Cigna of CA HMO/PPO	$4,140.00
Rate for Payer: Dignity Health Commercial/Exchange	$37.10
Rate for Payer: Dignity Health Medi-Cal	$32.65
Rate for Payer: Dignity Health Senior	$32.65
Rate for Payer: EPIC Health Plan Commercial	$5,760.00
Rate for Payer: EPIC Health Plan Medicare	$29.68
Rate for Payer: Heritage Provider Network Commercial	$4,167.00
Rate for Payer: Heritage Provider Network Senior	$4,167.00
Rate for Payer: Humana Medicare	$29.68
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$53.26
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$29.68
Rate for Payer: Kaiser Permanente of CA Commercial	$56.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1,629.00
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$35.02
Rate for Payer: LLUH Dept of Risk Management WC	$2,250.00
Rate for Payer: Molina Healthcare of CA Medi-Cal	$37.40
Rate for Payer: Molina Healthcare of CA Medicare	$37.40
Rate for Payer: Multiplan Commercial	$6,750.00
Rate for Payer: TriValley Medical Group Commercial	$3,600.00
Rate for Payer: TriValley Medical Group Senior	$3,600.00
Rate for Payer: United Healthcare All Other HMO/non HMO	$3,281.40
Rate for Payer: United Healthcare Navigate/Select/Select+	$3,006.90
Rate for Payer: Vantage Medical Group Commercial/Exchange	$37.10
Rate for Payer: Vantage Medical Group Medi-Cal	$32.65
Rate for Payer: Vantage Medical Group Senior	$32.65

ELECTIVE HIP JOINT REPLACEMENT

Facility

$13,236.09

Service Code	APR-DRG 3241
Min. Negotiated Rate	$13,236.09
Max. Negotiated Rate	$13,236.09
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$13,236.09

ELECTIVE HIP JOINT REPLACEMENT

Facility

$30,887.55

Service Code	APR-DRG 3244
Min. Negotiated Rate	$30,887.55
Max. Negotiated Rate	$30,887.55
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$30,887.55

ELECTIVE HIP JOINT REPLACEMENT

Facility

$19,463.16

Service Code	APR-DRG 3243
Min. Negotiated Rate	$19,463.16
Max. Negotiated Rate	$19,463.16
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$19,463.16

ELECTIVE HIP JOINT REPLACEMENT

Facility

$14,421.01

Service Code	APR-DRG 3242
Min. Negotiated Rate	$14,421.01
Max. Negotiated Rate	$14,421.01
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$14,421.01

ELECTIVE KNEE JOINT REPLACEMENT

Facility

$26,035.43

Service Code	APR-DRG 3264
Min. Negotiated Rate	$26,035.43
Max. Negotiated Rate	$26,035.43
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$26,035.43

ELECTIVE KNEE JOINT REPLACEMENT

Facility

$19,868.07

Service Code	APR-DRG 3263
Min. Negotiated Rate	$19,868.07
Max. Negotiated Rate	$19,868.07
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$19,868.07

ELECTIVE KNEE JOINT REPLACEMENT

Facility

$13,159.49

Service Code	APR-DRG 3261
Min. Negotiated Rate	$13,159.49
Max. Negotiated Rate	$13,159.49
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$13,159.49

ELECTIVE KNEE JOINT REPLACEMENT

Facility

$13,970.33

Service Code	APR-DRG 3262
Min. Negotiated Rate	$13,970.33
Max. Negotiated Rate	$13,970.33
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$13,970.33

ELECTROLYTE-148 INTRAVENOUS SOLUTION [28112]

Facility

$0.01

Service Code	NDC 0338-0179-04
Hospital Charge Code	1759936
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: Heritage Provider Network Commercial	$0.01
Rate for Payer: Heritage Provider Network Senior	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.00
Rate for Payer: Multiplan Commercial	$0.01

ELECTROLYTE-148 INTRAVENOUS SOLUTION [28112]

Facility

$0.01

Service Code	NDC 0338-0179-04
Hospital Charge Code	1759936
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Aetna of CA Gatekeeper	$0.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.01
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.01
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.01
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.01
Rate for Payer: Blue Shield of California Commercial	$0.01
Rate for Payer: Blue Shield of California EPN	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Dignity Health Commercial/Exchange	$0.01
Rate for Payer: Dignity Health Medi-Cal	$0.01
Rate for Payer: Dignity Health Senior	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: Heritage Provider Network Commercial	$0.01
Rate for Payer: Heritage Provider Network Senior	$0.01
Rate for Payer: Kaiser Permanente of CA Commercial	$0.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.00
Rate for Payer: Multiplan Commercial	$0.01
Rate for Payer: TriValley Medical Group Commercial	$0.00
Rate for Payer: TriValley Medical Group Senior	$0.00
Rate for Payer: Vantage Medical Group Medi-Cal	$0.01
Rate for Payer: Vantage Medical Group Senior	$0.01

ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]

Facility

$0.02

Service Code	NDC 0338-0221-04
Hospital Charge Code	1771306
Hospital Revenue Code	250
Max. Negotiated Rate	$0.02
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: Heritage Provider Network Commercial	$0.01
Rate for Payer: Heritage Provider Network Senior	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

ELECTROLYTE-A INTRAVENOUS SOLUTION [28113]

Facility

$0.02

Service Code	NDC 0338-0221-04
Hospital Charge Code	1771306
Hospital Revenue Code	250
Max. Negotiated Rate	$0.02
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Aetna of CA Gatekeeper	$0.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.01
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.02
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.01
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.02
Rate for Payer: Blue Shield of California Commercial	$0.01
Rate for Payer: Blue Shield of California EPN	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Dignity Health Commercial/Exchange	$0.02
Rate for Payer: Dignity Health Medi-Cal	$0.02
Rate for Payer: Dignity Health Senior	$0.02
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: Heritage Provider Network Commercial	$0.01
Rate for Payer: Heritage Provider Network Senior	$0.01
Rate for Payer: Kaiser Permanente of CA Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02
Rate for Payer: TriValley Medical Group Commercial	$0.01
Rate for Payer: TriValley Medical Group Senior	$0.01
Rate for Payer: Vantage Medical Group Medi-Cal	$0.02
Rate for Payer: Vantage Medical Group Senior	$0.02

ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]

Facility

$0.01

Service Code	NDC 0264-7703-00
Hospital Charge Code	1771035
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: Heritage Provider Network Commercial	$0.01
Rate for Payer: Heritage Provider Network Senior	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.00
Rate for Payer: Multiplan Commercial	$0.01

ELECTROLYTE-S INTRAVENOUS SOLUTION [28117]

Facility

$0.01

Service Code	NDC 0264-7703-00
Hospital Charge Code	1771035
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Aetna of CA Gatekeeper	$0.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.01
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.01
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.01
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.01
Rate for Payer: Blue Shield of California Commercial	$0.01
Rate for Payer: Blue Shield of California EPN	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Dignity Health Commercial/Exchange	$0.01
Rate for Payer: Dignity Health Medi-Cal	$0.01
Rate for Payer: Dignity Health Senior	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: Heritage Provider Network Commercial	$0.01
Rate for Payer: Heritage Provider Network Senior	$0.01
Rate for Payer: Kaiser Permanente of CA Commercial	$0.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.00
Rate for Payer: Multiplan Commercial	$0.01
Rate for Payer: TriValley Medical Group Commercial	$0.00
Rate for Payer: TriValley Medical Group Senior	$0.00
Rate for Payer: Vantage Medical Group Medi-Cal	$0.01
Rate for Payer: Vantage Medical Group Senior	$0.01

ELECTROLYTE-S IV BOLUS [192101]

Facility

$0.01

Service Code	NDC 0264-7703-00
Hospital Charge Code	1771035
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: Heritage Provider Network Commercial	$0.01
Rate for Payer: Heritage Provider Network Senior	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.00
Rate for Payer: Multiplan Commercial	$0.01

ELECTROLYTE-S IV BOLUS [192101]

Facility

$0.01

Service Code	NDC 0264-7703-00
Hospital Charge Code	1771035
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Aetna of CA Gatekeeper	$0.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.01
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.01
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.01
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.01
Rate for Payer: Blue Shield of California Commercial	$0.01
Rate for Payer: Blue Shield of California EPN	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Dignity Health Commercial/Exchange	$0.01
Rate for Payer: Dignity Health Medi-Cal	$0.01
Rate for Payer: Dignity Health Senior	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: Heritage Provider Network Commercial	$0.01
Rate for Payer: Heritage Provider Network Senior	$0.01
Rate for Payer: Kaiser Permanente of CA Commercial	$0.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.00
Rate for Payer: Multiplan Commercial	$0.01
Rate for Payer: TriValley Medical Group Commercial	$0.00
Rate for Payer: TriValley Medical Group Senior	$0.00
Rate for Payer: Vantage Medical Group Medi-Cal	$0.01
Rate for Payer: Vantage Medical Group Senior	$0.01

ELECTROLYTE-S (PH 7.4) INTRAVENOUS SOLUTION [28118]

Facility

$0.01

Service Code	NDC 0264-7707-00
Hospital Charge Code	1759610
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Aetna of CA Gatekeeper	$0.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.01
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.01
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.01
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.01
Rate for Payer: Blue Shield of California Commercial	$0.01
Rate for Payer: Blue Shield of California EPN	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Dignity Health Commercial/Exchange	$0.01
Rate for Payer: Dignity Health Medi-Cal	$0.01
Rate for Payer: Dignity Health Senior	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: Heritage Provider Network Commercial	$0.01
Rate for Payer: Heritage Provider Network Senior	$0.01
Rate for Payer: Kaiser Permanente of CA Commercial	$0.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.00
Rate for Payer: Multiplan Commercial	$0.01
Rate for Payer: TriValley Medical Group Commercial	$0.00
Rate for Payer: TriValley Medical Group Senior	$0.00
Rate for Payer: Vantage Medical Group Medi-Cal	$0.01
Rate for Payer: Vantage Medical Group Senior	$0.01

ELECTROLYTE-S (PH 7.4) INTRAVENOUS SOLUTION [28118]

Facility

$0.01

Service Code	NDC 0264-7707-00
Hospital Charge Code	1759610
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: Heritage Provider Network Commercial	$0.01
Rate for Payer: Heritage Provider Network Senior	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.00
Rate for Payer: Multiplan Commercial	$0.01

ELETRIPTAN 20 MG TABLET [34683]

Facility

$92.31

Service Code	NDC 0049-2330-45
Hospital Charge Code	1710964
Hospital Revenue Code	259
Min. Negotiated Rate	$16.71
Max. Negotiated Rate	$69.23
Rate for Payer: Adventist Health Commercial	$18.46
Rate for Payer: Aetna of CA Non-Gatekeeper	$63.42
Rate for Payer: Cash Price	$41.54
Rate for Payer: EPIC Health Plan Commercial	$49.85
Rate for Payer: Heritage Provider Network Commercial	$62.49
Rate for Payer: Heritage Provider Network Senior	$62.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$16.71
Rate for Payer: LLUH Dept of Risk Management WC	$23.08
Rate for Payer: Multiplan Commercial	$69.23

ELETRIPTAN 20 MG TABLET [34683]

Facility

$92.31

Service Code	NDC 0049-2330-45
Hospital Charge Code	1710964
Hospital Revenue Code	259
Min. Negotiated Rate	$16.71
Max. Negotiated Rate	$78.46
Rate for Payer: Adventist Health Commercial	$18.46
Rate for Payer: Aetna of CA Gatekeeper	$49.34
Rate for Payer: Aetna of CA Non-Gatekeeper	$63.42
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$78.46
Rate for Payer: Alpha Care Medical Group Medi-Cal	$50.77
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$69.23
Rate for Payer: Blue Shield of California Commercial	$57.32
Rate for Payer: Blue Shield of California EPN	$54.19
Rate for Payer: Cash Price	$41.54
Rate for Payer: Cigna of CA HMO/PPO	$60.00
Rate for Payer: Dignity Health Commercial/Exchange	$78.46
Rate for Payer: Dignity Health Medi-Cal	$78.46
Rate for Payer: Dignity Health Senior	$78.46
Rate for Payer: EPIC Health Plan Commercial	$59.08
Rate for Payer: Heritage Provider Network Commercial	$57.14
Rate for Payer: Heritage Provider Network Senior	$57.14
Rate for Payer: Kaiser Permanente of CA Commercial	$44.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$16.71
Rate for Payer: LLUH Dept of Risk Management WC	$23.08
Rate for Payer: Multiplan Commercial	$69.23
Rate for Payer: TriValley Medical Group Commercial	$36.92
Rate for Payer: TriValley Medical Group Senior	$36.92
Rate for Payer: Vantage Medical Group Medi-Cal	$78.46
Rate for Payer: Vantage Medical Group Senior	$78.46

ELETRIPTAN 40 MG TABLET [34684]

Facility

$92.31

Service Code	NDC 0049-2340-45
Hospital Charge Code	1711914
Hospital Revenue Code	259
Min. Negotiated Rate	$16.71
Max. Negotiated Rate	$69.23
Rate for Payer: Adventist Health Commercial	$18.46
Rate for Payer: Aetna of CA Non-Gatekeeper	$63.42
Rate for Payer: Cash Price	$41.54
Rate for Payer: EPIC Health Plan Commercial	$49.85
Rate for Payer: Heritage Provider Network Commercial	$62.49
Rate for Payer: Heritage Provider Network Senior	$62.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$16.71
Rate for Payer: LLUH Dept of Risk Management WC	$23.08
Rate for Payer: Multiplan Commercial	$69.23

Know your out-of-pocket cost for care.

All Charges