Loma Linda University Medical Center

All Charges

Charge

Type

Price

DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]

Facility OP

$6.63

Service Code	NDC 0025-2762-31
Hospital Charge Code	1710229
Hospital Revenue Code	259
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$5.64
Rate for Payer: Adventist Health Commercial	$1.33
Rate for Payer: Aetna of CA Gatekeeper	$3.54
Rate for Payer: Aetna of CA Non-Gatekeeper	$4.55
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$5.64
Rate for Payer: AlphaCare Medical Group Medi-Cal	$3.65
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$4.97
Rate for Payer: Blue Shield of California Commercial	$4.12
Rate for Payer: Blue Shield of California EPN	$3.89
Rate for Payer: Cash Price	$2.98
Rate for Payer: Cigna of CA HMO/PPO	$4.31
Rate for Payer: Dignity Health Commercial/Exchange	$5.64
Rate for Payer: Dignity Health Medi-Cal	$5.64
Rate for Payer: Dignity Health Senior	$5.64
Rate for Payer: EPIC Health Plan Commercial	$4.24
Rate for Payer: Heritage Provider Network Commercial	$4.10
Rate for Payer: Heritage Provider Network Senior	$4.10
Rate for Payer: Kaiser Permanente of CA Commercial	$3.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.66
Rate for Payer: Multiplan Commercial	$4.97
Rate for Payer: Vantage Medical Group Medi-Cal	$5.64
Rate for Payer: Vantage Medical Group Senior	$5.64

DISOPYRAMIDE PHOSPHATE 150 MG CAPSULE [2536]

Facility IP

$6.63

Service Code	NDC 0025-2762-31
Hospital Charge Code	1710229
Hospital Revenue Code	259
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$4.97
Rate for Payer: Adventist Health Commercial	$1.33
Rate for Payer: Aetna of CA Non-Gatekeeper	$4.55
Rate for Payer: Cash Price	$2.98
Rate for Payer: EPIC Health Plan Commercial	$3.58
Rate for Payer: Heritage Provider Network Commercial	$4.49
Rate for Payer: Heritage Provider Network Senior	$4.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.20
Rate for Payer: LLUH Dept of Risk Management WC	$1.66
Rate for Payer: Multiplan Commercial	$4.97

DISORDERS OF GALLBLADDER AND BILIARY TRACT

Facility IP

$5,623.15

Service Code	APR-DRG 2841
Min. Negotiated Rate	$5,623.15
Max. Negotiated Rate	$5,623.15
Rate for Payer: IEHP Medi-Cal	$5,623.15

DISORDERS OF GALLBLADDER AND BILIARY TRACT

Facility IP

$10,287.23

Service Code	APR-DRG 2843
Min. Negotiated Rate	$10,287.23
Max. Negotiated Rate	$10,287.23
Rate for Payer: IEHP Medi-Cal	$10,287.23

DISORDERS OF GALLBLADDER AND BILIARY TRACT

Facility IP

$7,426.90

Service Code	APR-DRG 2842
Min. Negotiated Rate	$7,426.90
Max. Negotiated Rate	$7,426.90
Rate for Payer: IEHP Medi-Cal	$7,426.90

DISORDERS OF GALLBLADDER AND BILIARY TRACT

Facility IP

$17,852.41

Service Code	APR-DRG 2844
Min. Negotiated Rate	$17,852.41
Max. Negotiated Rate	$17,852.41
Rate for Payer: IEHP Medi-Cal	$17,852.41

DISORDERS OF PANCREAS EXCEPT MALIGNANCY

Facility IP

$20,393.38

Service Code	APR-DRG 2824
Min. Negotiated Rate	$20,393.38
Max. Negotiated Rate	$20,393.38
Rate for Payer: IEHP Medi-Cal	$20,393.38

DISORDERS OF PANCREAS EXCEPT MALIGNANCY

Facility IP

$4,646.16

Service Code	APR-DRG 2821
Min. Negotiated Rate	$4,646.16
Max. Negotiated Rate	$4,646.16
Rate for Payer: IEHP Medi-Cal	$4,646.16

DISORDERS OF PANCREAS EXCEPT MALIGNANCY

Facility IP

$6,049.97

Service Code	APR-DRG 2822
Min. Negotiated Rate	$6,049.97
Max. Negotiated Rate	$6,049.97
Rate for Payer: IEHP Medi-Cal	$6,049.97

DISORDERS OF PANCREAS EXCEPT MALIGNANCY

Facility IP

$9,209.75

Service Code	APR-DRG 2823
Min. Negotiated Rate	$9,209.75
Max. Negotiated Rate	$9,209.75
Rate for Payer: IEHP Medi-Cal	$9,209.75

DISORDERS OF PERSONALITY AND IMPULSE CONTROL

Facility IP

$32,839.53

Service Code	APR-DRG 7524
Min. Negotiated Rate	$32,839.53
Max. Negotiated Rate	$32,839.53
Rate for Payer: IEHP Medi-Cal	$32,839.53

DISORDERS OF PERSONALITY AND IMPULSE CONTROL

Facility IP

$8,295.45

Service Code	APR-DRG 7523
Min. Negotiated Rate	$8,295.45
Max. Negotiated Rate	$8,295.45
Rate for Payer: IEHP Medi-Cal	$8,295.45

DISORDERS OF PERSONALITY AND IMPULSE CONTROL

Facility IP

$3,618.43

Service Code	APR-DRG 7522
Min. Negotiated Rate	$3,618.43
Max. Negotiated Rate	$3,618.43
Rate for Payer: IEHP Medi-Cal	$3,618.43

DISORDERS OF PERSONALITY AND IMPULSE CONTROL

Facility IP

$2,568.82

Service Code	APR-DRG 7521
Min. Negotiated Rate	$2,568.82
Max. Negotiated Rate	$2,568.82
Rate for Payer: IEHP Medi-Cal	$2,568.82

DISULFIRAM 250 MG TABLET [2540]

Facility IP

$2.39

Service Code	NDC 64980-171-01
Hospital Charge Code	1710473
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$1.79
Rate for Payer: Adventist Health Commercial	$0.48
Rate for Payer: Aetna of CA Non-Gatekeeper	$1.64
Rate for Payer: Cash Price	$1.08
Rate for Payer: EPIC Health Plan Commercial	$1.29
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	$1.79

DISULFIRAM 250 MG TABLET [2540]

Facility IP

$3.92

Service Code	NDC 0093-5035-01
Hospital Charge Code	1710473
Hospital Revenue Code	259
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$2.94
Rate for Payer: Adventist Health Commercial	$0.78
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.69
Rate for Payer: Cash Price	$1.76
Rate for Payer: EPIC Health Plan Commercial	$2.12
Rate for Payer: Heritage Provider Network Commercial	$2.65
Rate for Payer: Heritage Provider Network Senior	$2.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Commercial	$2.94

DISULFIRAM 250 MG TABLET [2540]

Facility OP

$2.39

Service Code	NDC 64980-171-01
Hospital Charge Code	1710473
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$2.03
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	$1.64
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$2.03
Rate for Payer: AlphaCare Medical Group Medi-Cal	$1.31
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$1.79
Rate for Payer: Blue Shield of California Commercial	$1.48
Rate for Payer: Blue Shield of California EPN	$1.40
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cigna of CA HMO/PPO	$1.55
Rate for Payer: Dignity Health Commercial/Exchange	$2.03
Rate for Payer: Dignity Health Medi-Cal	$2.03
Rate for Payer: Dignity Health Senior	$2.03
Rate for Payer: EPIC Health Plan Commercial	$1.53
Rate for Payer: Heritage Provider Network Commercial	$1.48
Rate for Payer: Heritage Provider Network Senior	$1.48
Rate for Payer: Kaiser Permanente of CA Commercial	$1.15
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	$1.79
Rate for Payer: Vantage Medical Group Medi-Cal	$2.03
Rate for Payer: Vantage Medical Group Senior	$2.03

DISULFIRAM 250 MG TABLET [2540]

Facility OP

$3.92

Service Code	NDC 0093-5035-01
Hospital Charge Code	1710473
Hospital Revenue Code	259
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$3.33
Rate for Payer: Adventist Health Commercial	$0.78
Rate for Payer: Aetna of CA Gatekeeper	$2.10
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.69
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$3.33
Rate for Payer: AlphaCare Medical Group Medi-Cal	$2.16
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$2.94
Rate for Payer: Blue Shield of California Commercial	$2.43
Rate for Payer: Blue Shield of California EPN	$2.30
Rate for Payer: Cash Price	$1.76
Rate for Payer: Cigna of CA HMO/PPO	$2.55
Rate for Payer: Dignity Health Commercial/Exchange	$3.33
Rate for Payer: Dignity Health Medi-Cal	$3.33
Rate for Payer: Dignity Health Senior	$3.33
Rate for Payer: EPIC Health Plan Commercial	$2.51
Rate for Payer: Heritage Provider Network Commercial	$2.43
Rate for Payer: Heritage Provider Network Senior	$2.43
Rate for Payer: Kaiser Permanente of CA Commercial	$1.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Commercial	$2.94
Rate for Payer: Vantage Medical Group Medi-Cal	$3.33
Rate for Payer: Vantage Medical Group Senior	$3.33

DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]

Facility IP

$1.01

Service Code	NDC 68084-313-11
Hospital Charge Code	1711540
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.76
Rate for Payer: Adventist Health Commercial	$0.20
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.69
Rate for Payer: Cash Price	$0.45
Rate for Payer: EPIC Health Plan Commercial	$0.55
Rate for Payer: Heritage Provider Network Commercial	$0.68
Rate for Payer: Heritage Provider Network Senior	$0.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.76

DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]

Facility OP

$1.01

Service Code	NDC 68084-313-11
Hospital Charge Code	1711540
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.86
Rate for Payer: Adventist Health Commercial	$0.20
Rate for Payer: Aetna of CA Gatekeeper	$0.54
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.69
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.86
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.56
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.76
Rate for Payer: Blue Shield of California Commercial	$0.63
Rate for Payer: Blue Shield of California EPN	$0.59
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cigna of CA HMO/PPO	$0.66
Rate for Payer: Dignity Health Commercial/Exchange	$0.86
Rate for Payer: Dignity Health Medi-Cal	$0.86
Rate for Payer: Dignity Health Senior	$0.86
Rate for Payer: EPIC Health Plan Commercial	$0.65
Rate for Payer: Heritage Provider Network Commercial	$0.63
Rate for Payer: Heritage Provider Network Senior	$0.63
Rate for Payer: Kaiser Permanente of CA Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.76
Rate for Payer: Vantage Medical Group Medi-Cal	$0.86
Rate for Payer: Vantage Medical Group Senior	$0.86

DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]

Facility OP

$1.01

Service Code	NDC 68084-313-01
Hospital Charge Code	1711540
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.86
Rate for Payer: Adventist Health Commercial	$0.20
Rate for Payer: Aetna of CA Gatekeeper	$0.54
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.69
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.86
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.56
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.76
Rate for Payer: Blue Shield of California Commercial	$0.63
Rate for Payer: Blue Shield of California EPN	$0.59
Rate for Payer: Cash Price	$0.45
Rate for Payer: Cigna of CA HMO/PPO	$0.66
Rate for Payer: Dignity Health Commercial/Exchange	$0.86
Rate for Payer: Dignity Health Medi-Cal	$0.86
Rate for Payer: Dignity Health Senior	$0.86
Rate for Payer: EPIC Health Plan Commercial	$0.65
Rate for Payer: Heritage Provider Network Commercial	$0.63
Rate for Payer: Heritage Provider Network Senior	$0.63
Rate for Payer: Kaiser Permanente of CA Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.76
Rate for Payer: Vantage Medical Group Medi-Cal	$0.86
Rate for Payer: Vantage Medical Group Senior	$0.86

DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]

Facility IP

$1.01

Service Code	NDC 68084-313-01
Hospital Charge Code	1711540
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.76
Rate for Payer: Adventist Health Commercial	$0.20
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.69
Rate for Payer: Cash Price	$0.45
Rate for Payer: EPIC Health Plan Commercial	$0.55
Rate for Payer: Heritage Provider Network Commercial	$0.68
Rate for Payer: Heritage Provider Network Senior	$0.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.76

DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]

Facility IP

$0.68

Service Code	NDC 68382-106-01
Hospital Charge Code	1711540
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.51
Rate for Payer: Adventist Health Commercial	$0.14
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.47
Rate for Payer: Cash Price	$0.31
Rate for Payer: EPIC Health Plan Commercial	$0.37
Rate for Payer: Heritage Provider Network Commercial	$0.46
Rate for Payer: Heritage Provider Network Senior	$0.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.51

DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE [27631]

Facility OP

$0.68

Service Code	NDC 68382-106-01
Hospital Charge Code	1711540
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.58
Rate for Payer: Adventist Health Commercial	$0.14
Rate for Payer: Aetna of CA Gatekeeper	$0.36
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.47
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.58
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.37
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.51
Rate for Payer: Blue Shield of California Commercial	$0.42
Rate for Payer: Blue Shield of California EPN	$0.40
Rate for Payer: Cash Price	$0.31
Rate for Payer: Cigna of CA HMO/PPO	$0.44
Rate for Payer: Dignity Health Commercial/Exchange	$0.58
Rate for Payer: Dignity Health Medi-Cal	$0.58
Rate for Payer: Dignity Health Senior	$0.58
Rate for Payer: EPIC Health Plan Commercial	$0.44
Rate for Payer: Heritage Provider Network Commercial	$0.42
Rate for Payer: Heritage Provider Network Senior	$0.42
Rate for Payer: Kaiser Permanente of CA Commercial	$0.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.51
Rate for Payer: Vantage Medical Group Medi-Cal	$0.58
Rate for Payer: Vantage Medical Group Senior	$0.58

DIVALPROEX 125 MG TABLET,DELAYED RELEASE [2551]

Facility IP

$0.22

Service Code	NDC 68001-472-00
Hospital Charge Code	1711514
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.17
Rate for Payer: Adventist Health Commercial	$0.04
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.15
Rate for Payer: Cash Price	$0.10
Rate for Payer: EPIC Health Plan Commercial	$0.12
Rate for Payer: Heritage Provider Network Commercial	$0.15
Rate for Payer: Heritage Provider Network Senior	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.17

Price Transparency.

All Charges