Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION [2367]

Facility

$0.01

Service Code	NDC 0990-7120-07
Hospital Charge Code	901700001
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: Adventist Health Commercial	$0.00
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	$0.00
Rate for Payer: Multiplan Commercial	$0.01

DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION [2367]

Facility

$0.01

Service Code	NDC 0338-9789-01
Hospital Charge Code	901700001
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	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Dignity Health Commercial/Exchange	$0.01
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: Molina Healthcare of CA Medi-Cal	$0.01
Rate for Payer: Molina Healthcare of CA Medicare	$0.01
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: United Healthcare All Other HMO/non HMO	$0.01
Rate for Payer: United Healthcare Navigate/Select/Select+	$0.01
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.01
Rate for Payer: Vantage Medical Group Medi-Cal	$0.01
Rate for Payer: Vantage Medical Group Senior	$0.01

DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS SOLUTION [2367]

Facility

$0.01

Service Code	NDC 0338-9789-04
Hospital Charge Code	901700001
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	$0.00
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Dignity Health Commercial/Exchange	$0.01
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: Molina Healthcare of CA Medi-Cal	$0.01
Rate for Payer: Molina Healthcare of CA Medicare	$0.01
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: United Healthcare All Other HMO/non HMO	$0.01
Rate for Payer: United Healthcare Navigate/Select/Select+	$0.01
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.01
Rate for Payer: Vantage Medical Group Medi-Cal	$0.01
Rate for Payer: Vantage Medical Group Senior	$0.01

DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL [201988]

Facility

$0.16

Service Code	NDC 2420802401
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.14
Rate for Payer: Adventist Health Commercial	$0.03
Rate for Payer: Aetna of CA Gatekeeper	$0.09
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.11
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.14
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.09
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.12
Rate for Payer: Blue Shield of California Commercial	$0.10
Rate for Payer: Blue Shield of California EPN	$0.08
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Dignity Health Commercial/Exchange	$0.14
Rate for Payer: Dignity Health Medi-Cal	$0.14
Rate for Payer: Dignity Health Senior	$0.14
Rate for Payer: EPIC Health Plan Commercial	$0.10
Rate for Payer: Heritage Provider Network Commercial	$0.10
Rate for Payer: Heritage Provider Network Senior	$0.10
Rate for Payer: Kaiser Permanente of CA Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Molina Healthcare of CA Medi-Cal	$0.11
Rate for Payer: Molina Healthcare of CA Medicare	$0.11
Rate for Payer: Multiplan Commercial	$0.12
Rate for Payer: TriValley Medical Group Commercial	$0.06
Rate for Payer: TriValley Medical Group Senior	$0.06
Rate for Payer: United Healthcare All Other HMO/non HMO	$0.08
Rate for Payer: United Healthcare Navigate/Select/Select+	$0.08
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.14
Rate for Payer: Vantage Medical Group Medi-Cal	$0.14
Rate for Payer: Vantage Medical Group Senior	$0.14

DEXTROSE-DEXTRIN-MALTOSE 24 GRAM/31 GRAM ORAL GEL [201988]

Facility

$0.16

Service Code	NDC 2420802401
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.12
Rate for Payer: Adventist Health Commercial	$0.03
Rate for Payer: Cash Price	$0.09
Rate for Payer: EPIC Health Plan Commercial	$0.09
Rate for Payer: Heritage Provider Network Commercial	$0.11
Rate for Payer: Heritage Provider Network Senior	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.12

DF10B6Z

Facility

$8,769.00

Hospital Charge Code	5526
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

DF10BB1

Facility

$8,769.00

Hospital Charge Code	5527
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

DF11B6Z

Facility

$8,769.00

Hospital Charge Code	5528
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

DF11BB1

Facility

$8,769.00

Hospital Charge Code	5529
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

DF12B6Z

Facility

$8,769.00

Hospital Charge Code	5530
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

DF12BB1

Facility

$8,769.00

Hospital Charge Code	5531
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

DF13B6Z

Facility

$8,769.00

Hospital Charge Code	5532
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

DF13BB1

Facility

$8,769.00

Hospital Charge Code	5533
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

DG10B6Z

Facility

$8,769.00

Hospital Charge Code	5534
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

DG10BB1

Facility

$8,769.00

Hospital Charge Code	5535
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

DG11B6Z

Facility

$8,769.00

Hospital Charge Code	5536
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

DG11BB1

Facility

$8,769.00

Hospital Charge Code	5537
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

DG12B6Z

Facility

$8,769.00

Hospital Charge Code	5538
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

DG12BB1

Facility

$8,769.00

Hospital Charge Code	5539
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

DG14B6Z

Facility

$8,769.00

Hospital Charge Code	5540
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

DG14BB1

Facility

$8,769.00

Hospital Charge Code	5541
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

DG15B6Z

Facility

$8,769.00

Hospital Charge Code	5542
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

DG15BB1

Facility

$8,769.00

Hospital Charge Code	5543
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

DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [9828]

Facility

$0.66

Service Code	NDC 0270-0445-40
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.50
Rate for Payer: Adventist Health Commercial	$0.13
Rate for Payer: Cash Price	$0.37
Rate for Payer: EPIC Health Plan Commercial	$0.36
Rate for Payer: Heritage Provider Network Commercial	$0.45
Rate for Payer: Heritage Provider Network Senior	$0.45
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	$0.50

DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION [9828]

Facility

$0.66

Service Code	NDC 0270-0445-40
Hospital Charge Code	901700001
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.56
Rate for Payer: Adventist Health Commercial	$0.13
Rate for Payer: Aetna of CA Gatekeeper	$0.35
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.45
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.56
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.36
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.50
Rate for Payer: Blue Shield of California Commercial	$0.40
Rate for Payer: Blue Shield of California EPN	$0.32
Rate for Payer: Cash Price	$0.37
Rate for Payer: Cigna of CA HMO/PPO	$0.43
Rate for Payer: Dignity Health Commercial/Exchange	$0.56
Rate for Payer: Dignity Health Medi-Cal	$0.56
Rate for Payer: Dignity Health Senior	$0.56
Rate for Payer: EPIC Health Plan Commercial	$0.42
Rate for Payer: Heritage Provider Network Commercial	$0.41
Rate for Payer: Heritage Provider Network Senior	$0.41
Rate for Payer: Kaiser Permanente of CA Commercial	$0.31
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: Molina Healthcare of CA Medi-Cal	$0.46
Rate for Payer: Molina Healthcare of CA Medicare	$0.46
Rate for Payer: Multiplan Commercial	$0.50
Rate for Payer: TriValley Medical Group Commercial	$0.26
Rate for Payer: TriValley Medical Group Senior	$0.26
Rate for Payer: United Healthcare All Other HMO/non HMO	$0.33
Rate for Payer: United Healthcare Navigate/Select/Select+	$0.33
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.56
Rate for Payer: Vantage Medical Group Medi-Cal	$0.56
Rate for Payer: Vantage Medical Group Senior	$0.56

Know your out-of-pocket cost for care.

All Charges