Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

D917B6Z

Facility

$8,769.00

Hospital Charge Code	5486
Min. Negotiated Rate	$8,769.00
Max. Negotiated Rate	$8,769.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,769.00

D917BB1

Facility

$8,769.00

Hospital Charge Code	5487
Min. Negotiated Rate	$8,769.00
Max. Negotiated Rate	$8,769.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,769.00

D918B6Z

Facility

$8,769.00

Hospital Charge Code	5488
Min. Negotiated Rate	$8,769.00
Max. Negotiated Rate	$8,769.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,769.00

D918BB1

Facility

$8,769.00

Hospital Charge Code	5489
Min. Negotiated Rate	$8,769.00
Max. Negotiated Rate	$8,769.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,769.00

D919B6Z

Facility

$8,769.00

Hospital Charge Code	5490
Min. Negotiated Rate	$8,769.00
Max. Negotiated Rate	$8,769.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,769.00

D919BB1

Facility

$8,769.00

Hospital Charge Code	5491
Min. Negotiated Rate	$8,769.00
Max. Negotiated Rate	$8,769.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,769.00

D91BB6Z

Facility

$8,769.00

Hospital Charge Code	5492
Min. Negotiated Rate	$8,769.00
Max. Negotiated Rate	$8,769.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,769.00

D91BBB1

Facility

$8,769.00

Hospital Charge Code	5493
Min. Negotiated Rate	$8,769.00
Max. Negotiated Rate	$8,769.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,769.00

D91DB6Z

Facility

$8,769.00

Hospital Charge Code	5494
Min. Negotiated Rate	$8,769.00
Max. Negotiated Rate	$8,769.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,769.00

D91DBB1

Facility

$8,769.00

Hospital Charge Code	5495
Min. Negotiated Rate	$8,769.00
Max. Negotiated Rate	$8,769.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,769.00

D91FB6Z

Facility

$8,769.00

Hospital Charge Code	5496
Min. Negotiated Rate	$8,769.00
Max. Negotiated Rate	$8,769.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,769.00

D91FBB1

Facility

$8,769.00

Hospital Charge Code	5497
Min. Negotiated Rate	$8,769.00
Max. Negotiated Rate	$8,769.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,769.00

DABIGATRAN ETEXILATE 110 MG CAPSULE [212609]

Facility

$3.97

Service Code	NDC 0597-0108-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$2.98
Rate for Payer: Adventist Health Commercial	$0.79
Rate for Payer: Cash Price	$2.18
Rate for Payer: EPIC Health Plan Commercial	$2.14
Rate for Payer: Heritage Provider Network Commercial	$2.69
Rate for Payer: Heritage Provider Network Senior	$2.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Commercial	$2.98

DABIGATRAN ETEXILATE 110 MG CAPSULE [212609]

Facility

$3.97

Service Code	NDC 0597-0108-54
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$3.37
Rate for Payer: Adventist Health Commercial	$0.79
Rate for Payer: Aetna of CA Gatekeeper	$2.12
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.73
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$3.37
Rate for Payer: Alpha Care Medical Group Medi-Cal	$2.18
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$2.98
Rate for Payer: Blue Shield of California Commercial	$2.42
Rate for Payer: Blue Shield of California EPN	$1.94
Rate for Payer: Cash Price	$2.18
Rate for Payer: Cigna of CA HMO/PPO	$2.58
Rate for Payer: Dignity Health Commercial/Exchange	$3.37
Rate for Payer: Dignity Health Medi-Cal	$3.37
Rate for Payer: Dignity Health Senior	$3.37
Rate for Payer: EPIC Health Plan Commercial	$2.54
Rate for Payer: Heritage Provider Network Commercial	$2.46
Rate for Payer: Heritage Provider Network Senior	$2.46
Rate for Payer: Kaiser Permanente of CA Commercial	$1.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Molina Healthcare of CA Medi-Cal	$2.78
Rate for Payer: Molina Healthcare of CA Medicare	$2.78
Rate for Payer: Multiplan Commercial	$2.98
Rate for Payer: TriValley Medical Group Commercial	$1.59
Rate for Payer: TriValley Medical Group Senior	$1.59
Rate for Payer: United Healthcare All Other HMO/non HMO	$1.99
Rate for Payer: United Healthcare Navigate/Select/Select+	$1.99
Rate for Payer: Vantage Medical Group Commercial/Exchange	$3.37
Rate for Payer: Vantage Medical Group Medi-Cal	$3.37
Rate for Payer: Vantage Medical Group Senior	$3.37

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$2.40

Service Code	NDC 31722-622-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$1.80
Rate for Payer: Adventist Health Commercial	$0.48
Rate for Payer: Cash Price	$1.32
Rate for Payer: EPIC Health Plan Commercial	$1.30
Rate for Payer: Heritage Provider Network Commercial	$1.62
Rate for Payer: Heritage Provider Network Senior	$1.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Commercial	$1.80

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.97

Service Code	NDC 0597-0360-55
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$2.98
Rate for Payer: Adventist Health Commercial	$0.79
Rate for Payer: Cash Price	$2.18
Rate for Payer: EPIC Health Plan Commercial	$2.14
Rate for Payer: Heritage Provider Network Commercial	$2.69
Rate for Payer: Heritage Provider Network Senior	$2.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Commercial	$2.98

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.97

Service Code	NDC 0597-0360-55
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$3.37
Rate for Payer: Adventist Health Commercial	$0.79
Rate for Payer: Aetna of CA Gatekeeper	$2.12
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.73
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$3.37
Rate for Payer: Alpha Care Medical Group Medi-Cal	$2.18
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$2.98
Rate for Payer: Blue Shield of California Commercial	$2.42
Rate for Payer: Blue Shield of California EPN	$1.94
Rate for Payer: Cash Price	$2.18
Rate for Payer: Cigna of CA HMO/PPO	$2.58
Rate for Payer: Dignity Health Commercial/Exchange	$3.37
Rate for Payer: Dignity Health Medi-Cal	$3.37
Rate for Payer: Dignity Health Senior	$3.37
Rate for Payer: EPIC Health Plan Commercial	$2.54
Rate for Payer: Heritage Provider Network Commercial	$2.46
Rate for Payer: Heritage Provider Network Senior	$2.46
Rate for Payer: Kaiser Permanente of CA Commercial	$1.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Molina Healthcare of CA Medi-Cal	$2.78
Rate for Payer: Molina Healthcare of CA Medicare	$2.78
Rate for Payer: Multiplan Commercial	$2.98
Rate for Payer: TriValley Medical Group Commercial	$1.59
Rate for Payer: TriValley Medical Group Senior	$1.59
Rate for Payer: United Healthcare All Other HMO/non HMO	$1.99
Rate for Payer: United Healthcare Navigate/Select/Select+	$1.99
Rate for Payer: Vantage Medical Group Commercial/Exchange	$3.37
Rate for Payer: Vantage Medical Group Medi-Cal	$3.37
Rate for Payer: Vantage Medical Group Senior	$3.37

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.00

Service Code	NDC 62332-636-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$2.55
Rate for Payer: Adventist Health Commercial	$0.60
Rate for Payer: Aetna of CA Gatekeeper	$1.60
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.06
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$2.55
Rate for Payer: Alpha Care Medical Group Medi-Cal	$1.65
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$2.25
Rate for Payer: Blue Shield of California Commercial	$1.83
Rate for Payer: Blue Shield of California EPN	$1.46
Rate for Payer: Cash Price	$1.65
Rate for Payer: Cigna of CA HMO/PPO	$1.95
Rate for Payer: Dignity Health Commercial/Exchange	$2.55
Rate for Payer: Dignity Health Medi-Cal	$2.55
Rate for Payer: Dignity Health Senior	$2.55
Rate for Payer: EPIC Health Plan Commercial	$1.92
Rate for Payer: Heritage Provider Network Commercial	$1.86
Rate for Payer: Heritage Provider Network Senior	$1.86
Rate for Payer: Kaiser Permanente of CA Commercial	$1.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Molina Healthcare of CA Medi-Cal	$2.10
Rate for Payer: Molina Healthcare of CA Medicare	$2.10
Rate for Payer: Multiplan Commercial	$2.25
Rate for Payer: TriValley Medical Group Commercial	$1.20
Rate for Payer: TriValley Medical Group Senior	$1.20
Rate for Payer: United Healthcare All Other HMO/non HMO	$1.50
Rate for Payer: United Healthcare Navigate/Select/Select+	$1.50
Rate for Payer: Vantage Medical Group Commercial/Exchange	$2.55
Rate for Payer: Vantage Medical Group Medi-Cal	$2.55
Rate for Payer: Vantage Medical Group Senior	$2.55

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.00

Service Code	NDC 62332-636-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$2.25
Rate for Payer: Adventist Health Commercial	$0.60
Rate for Payer: Cash Price	$1.65
Rate for Payer: EPIC Health Plan Commercial	$1.62
Rate for Payer: Heritage Provider Network Commercial	$2.03
Rate for Payer: Heritage Provider Network Senior	$2.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Commercial	$2.25

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.97

Service Code	NDC 0597-0360-82
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$2.98
Rate for Payer: Adventist Health Commercial	$0.79
Rate for Payer: Cash Price	$2.18
Rate for Payer: EPIC Health Plan Commercial	$2.14
Rate for Payer: Heritage Provider Network Commercial	$2.69
Rate for Payer: Heritage Provider Network Senior	$2.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Commercial	$2.98

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$3.97

Service Code	NDC 0597-0360-82
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$3.37
Rate for Payer: Adventist Health Commercial	$0.79
Rate for Payer: Aetna of CA Gatekeeper	$2.12
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.73
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$3.37
Rate for Payer: Alpha Care Medical Group Medi-Cal	$2.18
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$2.98
Rate for Payer: Blue Shield of California Commercial	$2.42
Rate for Payer: Blue Shield of California EPN	$1.94
Rate for Payer: Cash Price	$2.18
Rate for Payer: Cigna of CA HMO/PPO	$2.58
Rate for Payer: Dignity Health Commercial/Exchange	$3.37
Rate for Payer: Dignity Health Medi-Cal	$3.37
Rate for Payer: Dignity Health Senior	$3.37
Rate for Payer: EPIC Health Plan Commercial	$2.54
Rate for Payer: Heritage Provider Network Commercial	$2.46
Rate for Payer: Heritage Provider Network Senior	$2.46
Rate for Payer: Kaiser Permanente of CA Commercial	$1.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Molina Healthcare of CA Medi-Cal	$2.78
Rate for Payer: Molina Healthcare of CA Medicare	$2.78
Rate for Payer: Multiplan Commercial	$2.98
Rate for Payer: TriValley Medical Group Commercial	$1.59
Rate for Payer: TriValley Medical Group Senior	$1.59
Rate for Payer: United Healthcare All Other HMO/non HMO	$1.99
Rate for Payer: United Healthcare Navigate/Select/Select+	$1.99
Rate for Payer: Vantage Medical Group Commercial/Exchange	$3.37
Rate for Payer: Vantage Medical Group Medi-Cal	$3.37
Rate for Payer: Vantage Medical Group Senior	$3.37

DABIGATRAN ETEXILATE 150 MG CAPSULE [106491]

Facility

$2.40

Service Code	NDC 31722-622-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$2.04
Rate for Payer: Adventist Health Commercial	$0.48
Rate for Payer: Aetna of CA Gatekeeper	$1.28
Rate for Payer: Aetna of CA Non-Gatekeeper	$1.65
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$2.04
Rate for Payer: Alpha Care Medical Group Medi-Cal	$1.32
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$1.80
Rate for Payer: Blue Shield of California Commercial	$1.46
Rate for Payer: Blue Shield of California EPN	$1.17
Rate for Payer: Cash Price	$1.32
Rate for Payer: Cigna of CA HMO/PPO	$1.56
Rate for Payer: Dignity Health Commercial/Exchange	$2.04
Rate for Payer: Dignity Health Medi-Cal	$2.04
Rate for Payer: Dignity Health Senior	$2.04
Rate for Payer: EPIC Health Plan Commercial	$1.54
Rate for Payer: Heritage Provider Network Commercial	$1.49
Rate for Payer: Heritage Provider Network Senior	$1.49
Rate for Payer: Kaiser Permanente of CA Commercial	$1.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1.68
Rate for Payer: Molina Healthcare of CA Medicare	$1.68
Rate for Payer: Multiplan Commercial	$1.80
Rate for Payer: TriValley Medical Group Commercial	$0.96
Rate for Payer: TriValley Medical Group Senior	$0.96
Rate for Payer: United Healthcare All Other HMO/non HMO	$1.20
Rate for Payer: United Healthcare Navigate/Select/Select+	$1.20
Rate for Payer: Vantage Medical Group Commercial/Exchange	$2.04
Rate for Payer: Vantage Medical Group Medi-Cal	$2.04
Rate for Payer: Vantage Medical Group Senior	$2.04

DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]

Facility

$3.97

Service Code	NDC 0597-0355-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$3.37
Rate for Payer: Adventist Health Commercial	$0.79
Rate for Payer: Aetna of CA Gatekeeper	$2.12
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.73
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$3.37
Rate for Payer: Alpha Care Medical Group Medi-Cal	$2.18
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$2.98
Rate for Payer: Blue Shield of California Commercial	$2.42
Rate for Payer: Blue Shield of California EPN	$1.94
Rate for Payer: Cash Price	$2.18
Rate for Payer: Cigna of CA HMO/PPO	$2.58
Rate for Payer: Dignity Health Commercial/Exchange	$3.37
Rate for Payer: Dignity Health Medi-Cal	$3.37
Rate for Payer: Dignity Health Senior	$3.37
Rate for Payer: EPIC Health Plan Commercial	$2.54
Rate for Payer: Heritage Provider Network Commercial	$2.46
Rate for Payer: Heritage Provider Network Senior	$2.46
Rate for Payer: Kaiser Permanente of CA Commercial	$1.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Molina Healthcare of CA Medi-Cal	$2.78
Rate for Payer: Molina Healthcare of CA Medicare	$2.78
Rate for Payer: Multiplan Commercial	$2.98
Rate for Payer: TriValley Medical Group Commercial	$1.59
Rate for Payer: TriValley Medical Group Senior	$1.59
Rate for Payer: United Healthcare All Other HMO/non HMO	$1.99
Rate for Payer: United Healthcare Navigate/Select/Select+	$1.99
Rate for Payer: Vantage Medical Group Commercial/Exchange	$3.37
Rate for Payer: Vantage Medical Group Medi-Cal	$3.37
Rate for Payer: Vantage Medical Group Senior	$3.37

DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]

Facility

$3.97

Service Code	NDC 0597-0355-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$2.98
Rate for Payer: Adventist Health Commercial	$0.79
Rate for Payer: Cash Price	$2.18
Rate for Payer: EPIC Health Plan Commercial	$2.14
Rate for Payer: Heritage Provider Network Commercial	$2.69
Rate for Payer: Heritage Provider Network Senior	$2.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Commercial	$2.98

DABIGATRAN ETEXILATE 75 MG CAPSULE [106490]

Facility

$14.37

Service Code	NDC 60687-744-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$10.78
Rate for Payer: Adventist Health Commercial	$2.87
Rate for Payer: Cash Price	$7.90
Rate for Payer: EPIC Health Plan Commercial	$7.76
Rate for Payer: Heritage Provider Network Commercial	$9.73
Rate for Payer: Heritage Provider Network Senior	$9.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$2.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.59
Rate for Payer: Multiplan Commercial	$10.78

Know your out-of-pocket cost for care.

All Charges