Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]

Facility

$1.04

Service Code	NDC 65162-686-88
Hospital Charge Code	1715111
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.88
Rate for Payer: Adventist Health Commercial	$0.21
Rate for Payer: Aetna of CA Gatekeeper	$0.56
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.71
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.88
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.57
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.78
Rate for Payer: Blue Shield of California Commercial	$0.65
Rate for Payer: Blue Shield of California EPN	$0.61
Rate for Payer: Cash Price	$0.47
Rate for Payer: Cigna of CA HMO/PPO	$0.68
Rate for Payer: Dignity Health Commercial/Exchange	$0.88
Rate for Payer: Dignity Health Medi-Cal	$0.88
Rate for Payer: Dignity Health Senior	$0.88
Rate for Payer: EPIC Health Plan Commercial	$0.67
Rate for Payer: Heritage Provider Network Commercial	$0.64
Rate for Payer: Heritage Provider Network Senior	$0.64
Rate for Payer: Kaiser Permanente of CA Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.78
Rate for Payer: TriValley Medical Group Commercial	$0.42
Rate for Payer: TriValley Medical Group Senior	$0.42
Rate for Payer: Vantage Medical Group Medi-Cal	$0.88
Rate for Payer: Vantage Medical Group Senior	$0.88

FELBAMATE 600 MG/5 ML ORAL SUSPENSION [10023]

Facility

$9.15

Service Code	NDC 0037-0442-67
Hospital Charge Code	1715111
Hospital Revenue Code	259
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$7.78
Rate for Payer: Adventist Health Commercial	$1.83
Rate for Payer: Aetna of CA Gatekeeper	$4.89
Rate for Payer: Aetna of CA Non-Gatekeeper	$6.29
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$7.78
Rate for Payer: Alpha Care Medical Group Medi-Cal	$5.03
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$6.86
Rate for Payer: Blue Shield of California Commercial	$5.68
Rate for Payer: Blue Shield of California EPN	$5.37
Rate for Payer: Cash Price	$4.12
Rate for Payer: Cigna of CA HMO/PPO	$5.95
Rate for Payer: Dignity Health Commercial/Exchange	$7.78
Rate for Payer: Dignity Health Medi-Cal	$7.78
Rate for Payer: Dignity Health Senior	$7.78
Rate for Payer: EPIC Health Plan Commercial	$5.86
Rate for Payer: Heritage Provider Network Commercial	$5.66
Rate for Payer: Heritage Provider Network Senior	$5.66
Rate for Payer: Kaiser Permanente of CA Commercial	$4.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.66
Rate for Payer: LLUH Dept of Risk Management WC	$2.29
Rate for Payer: Multiplan Commercial	$6.86
Rate for Payer: TriValley Medical Group Commercial	$3.66
Rate for Payer: TriValley Medical Group Senior	$3.66
Rate for Payer: Vantage Medical Group Medi-Cal	$7.78
Rate for Payer: Vantage Medical Group Senior	$7.78

FELBAMATE 600 MG TABLET [10025]

Facility

$1.30

Service Code	NDC 62559-731-01
Hospital Charge Code	1711593
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.98
Rate for Payer: Adventist Health Commercial	$0.26
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.89
Rate for Payer: Cash Price	$0.59
Rate for Payer: EPIC Health Plan Commercial	$0.70
Rate for Payer: Heritage Provider Network Commercial	$0.88
Rate for Payer: Heritage Provider Network Senior	$0.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.98

FELBAMATE 600 MG TABLET [10025]

Facility

$1.30

Service Code	NDC 62559-731-01
Hospital Charge Code	1711593
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$1.10
Rate for Payer: Adventist Health Commercial	$0.26
Rate for Payer: Aetna of CA Gatekeeper	$0.69
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.89
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$1.10
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.72
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.98
Rate for Payer: Blue Shield of California Commercial	$0.81
Rate for Payer: Blue Shield of California EPN	$0.76
Rate for Payer: Cash Price	$0.59
Rate for Payer: Cigna of CA HMO/PPO	$0.85
Rate for Payer: Dignity Health Commercial/Exchange	$1.10
Rate for Payer: Dignity Health Medi-Cal	$1.10
Rate for Payer: Dignity Health Senior	$1.10
Rate for Payer: EPIC Health Plan Commercial	$0.83
Rate for Payer: Heritage Provider Network Commercial	$0.80
Rate for Payer: Heritage Provider Network Senior	$0.80
Rate for Payer: Kaiser Permanente of CA Commercial	$0.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.98
Rate for Payer: TriValley Medical Group Commercial	$0.52
Rate for Payer: TriValley Medical Group Senior	$0.52
Rate for Payer: Vantage Medical Group Medi-Cal	$1.10
Rate for Payer: Vantage Medical Group Senior	$1.10

FELODIPINE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [27491]

Facility

$2.34

Service Code	NDC 53489-370-01
Hospital Charge Code	1712157
Hospital Revenue Code	259
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$1.76
Rate for Payer: Adventist Health Commercial	$0.47
Rate for Payer: Aetna of CA Non-Gatekeeper	$1.61
Rate for Payer: Cash Price	$1.05
Rate for Payer: EPIC Health Plan Commercial	$1.26
Rate for Payer: Heritage Provider Network Commercial	$1.58
Rate for Payer: Heritage Provider Network Senior	$1.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Commercial	$1.76

FELODIPINE ER 10 MG TABLET,EXTENDED RELEASE 24 HR [27491]

Facility

$2.34

Service Code	NDC 53489-370-01
Hospital Charge Code	1712157
Hospital Revenue Code	259
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$1.99
Rate for Payer: Adventist Health Commercial	$0.47
Rate for Payer: Aetna of CA Gatekeeper	$1.25
Rate for Payer: Aetna of CA Non-Gatekeeper	$1.61
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$1.99
Rate for Payer: Alpha Care Medical Group Medi-Cal	$1.29
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$1.76
Rate for Payer: Blue Shield of California Commercial	$1.45
Rate for Payer: Blue Shield of California EPN	$1.37
Rate for Payer: Cash Price	$1.05
Rate for Payer: Cigna of CA HMO/PPO	$1.52
Rate for Payer: Dignity Health Commercial/Exchange	$1.99
Rate for Payer: Dignity Health Medi-Cal	$1.99
Rate for Payer: Dignity Health Senior	$1.99
Rate for Payer: EPIC Health Plan Commercial	$1.50
Rate for Payer: Heritage Provider Network Commercial	$1.45
Rate for Payer: Heritage Provider Network Senior	$1.45
Rate for Payer: Kaiser Permanente of CA Commercial	$1.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Commercial	$1.76
Rate for Payer: TriValley Medical Group Commercial	$0.94
Rate for Payer: TriValley Medical Group Senior	$0.94
Rate for Payer: Vantage Medical Group Medi-Cal	$1.99
Rate for Payer: Vantage Medical Group Senior	$1.99

FELODIPINE ER 2.5 MG TABLET,EXTENDED RELEASE 24 HR [27489]

Facility

$0.65

Service Code	NDC 57237-108-01
Hospital Charge Code	1712195
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.55
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	$0.55
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.36
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.49
Rate for Payer: Blue Shield of California Commercial	$0.40
Rate for Payer: Blue Shield of California EPN	$0.38
Rate for Payer: Cash Price	$0.29
Rate for Payer: Cigna of CA HMO/PPO	$0.42
Rate for Payer: Dignity Health Commercial/Exchange	$0.55
Rate for Payer: Dignity Health Medi-Cal	$0.55
Rate for Payer: Dignity Health Senior	$0.55
Rate for Payer: EPIC Health Plan Commercial	$0.42
Rate for Payer: Heritage Provider Network Commercial	$0.40
Rate for Payer: Heritage Provider Network Senior	$0.40
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	$0.16
Rate for Payer: Multiplan Commercial	$0.49
Rate for Payer: TriValley Medical Group Commercial	$0.26
Rate for Payer: TriValley Medical Group Senior	$0.26
Rate for Payer: Vantage Medical Group Medi-Cal	$0.55
Rate for Payer: Vantage Medical Group Senior	$0.55

FELODIPINE ER 2.5 MG TABLET,EXTENDED RELEASE 24 HR [27489]

Facility

$0.46

Service Code	NDC 68462-233-01
Hospital Charge Code	1712195
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.35
Rate for Payer: Adventist Health Commercial	$0.09
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.32
Rate for Payer: Cash Price	$0.21
Rate for Payer: EPIC Health Plan Commercial	$0.25
Rate for Payer: Heritage Provider Network Commercial	$0.31
Rate for Payer: Heritage Provider Network Senior	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.35

FELODIPINE ER 2.5 MG TABLET,EXTENDED RELEASE 24 HR [27489]

Facility

$0.65

Service Code	NDC 57237-108-01
Hospital Charge Code	1712195
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.49
Rate for Payer: Adventist Health Commercial	$0.13
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.45
Rate for Payer: Cash Price	$0.29
Rate for Payer: EPIC Health Plan Commercial	$0.35
Rate for Payer: Heritage Provider Network Commercial	$0.44
Rate for Payer: Heritage Provider Network Senior	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.49

FELODIPINE ER 2.5 MG TABLET,EXTENDED RELEASE 24 HR [27489]

Facility

$0.46

Service Code	NDC 68462-233-01
Hospital Charge Code	1712195
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.39
Rate for Payer: Adventist Health Commercial	$0.09
Rate for Payer: Aetna of CA Gatekeeper	$0.25
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.32
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.39
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.25
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.35
Rate for Payer: Blue Shield of California Commercial	$0.29
Rate for Payer: Blue Shield of California EPN	$0.27
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.30
Rate for Payer: Dignity Health Commercial/Exchange	$0.39
Rate for Payer: Dignity Health Medi-Cal	$0.39
Rate for Payer: Dignity Health Senior	$0.39
Rate for Payer: EPIC Health Plan Commercial	$0.29
Rate for Payer: Heritage Provider Network Commercial	$0.28
Rate for Payer: Heritage Provider Network Senior	$0.28
Rate for Payer: Kaiser Permanente of CA Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.35
Rate for Payer: TriValley Medical Group Commercial	$0.18
Rate for Payer: TriValley Medical Group Senior	$0.18
Rate for Payer: Vantage Medical Group Medi-Cal	$0.39
Rate for Payer: Vantage Medical Group Senior	$0.39

FEMALE REPRODUCTIVE SYSTEM INFECTIONS

Facility

$14,210.10

Service Code	APR-DRG 5314
Min. Negotiated Rate	$14,210.10
Max. Negotiated Rate	$14,210.10
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$14,210.10

FEMALE REPRODUCTIVE SYSTEM INFECTIONS

Facility

$5,623.15

Service Code	APR-DRG 5312
Min. Negotiated Rate	$5,623.15
Max. Negotiated Rate	$5,623.15
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$5,623.15

FEMALE REPRODUCTIVE SYSTEM INFECTIONS

Facility

$8,682.45

Service Code	APR-DRG 5313
Min. Negotiated Rate	$8,682.45
Max. Negotiated Rate	$8,682.45
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$8,682.45

FEMALE REPRODUCTIVE SYSTEM INFECTIONS

Facility

$4,307.90

Service Code	APR-DRG 5311
Min. Negotiated Rate	$4,307.90
Max. Negotiated Rate	$4,307.90
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$4,307.90

FEMALE REPRODUCTIVE SYSTEM MALIGNANCY

Facility

$9,228.65

Service Code	APR-DRG 5303
Min. Negotiated Rate	$9,228.65
Max. Negotiated Rate	$9,228.65
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$9,228.65

FEMALE REPRODUCTIVE SYSTEM MALIGNANCY

Facility

$6,347.44

Service Code	APR-DRG 5302
Min. Negotiated Rate	$6,347.44
Max. Negotiated Rate	$6,347.44
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$6,347.44

FEMALE REPRODUCTIVE SYSTEM MALIGNANCY

Facility

$14,819.98

Service Code	APR-DRG 5304
Min. Negotiated Rate	$14,819.98
Max. Negotiated Rate	$14,819.98
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$14,819.98

FEMALE REPRODUCTIVE SYSTEM MALIGNANCY

Facility

$4,713.82

Service Code	APR-DRG 5301
Min. Negotiated Rate	$4,713.82
Max. Negotiated Rate	$4,713.82
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$4,713.82

FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES

Facility

$33,553.86

Service Code	APR-DRG 5144
Min. Negotiated Rate	$33,553.86
Max. Negotiated Rate	$33,553.86
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$33,553.86

FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES

Facility

$20,075.01

Service Code	APR-DRG 5143
Min. Negotiated Rate	$20,075.01
Max. Negotiated Rate	$20,075.01
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$20,075.01

FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES

Facility

$10,400.64

Service Code	APR-DRG 5142
Min. Negotiated Rate	$10,400.64
Max. Negotiated Rate	$10,400.64
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$10,400.64

FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES

Facility

$7,011.04

Service Code	APR-DRG 5141
Min. Negotiated Rate	$7,011.04
Max. Negotiated Rate	$7,011.04
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$7,011.04

FENOFIBRATE 150 MG CAPSULE [88131]

Facility

$9.54

Service Code	NDC 66869-147-30
Hospital Charge Code	1712564
Hospital Revenue Code	259
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$7.16
Rate for Payer: Adventist Health Commercial	$1.91
Rate for Payer: Aetna of CA Non-Gatekeeper	$6.55
Rate for Payer: Cash Price	$4.29
Rate for Payer: EPIC Health Plan Commercial	$5.15
Rate for Payer: Heritage Provider Network Commercial	$6.46
Rate for Payer: Heritage Provider Network Senior	$6.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.73
Rate for Payer: LLUH Dept of Risk Management WC	$2.38
Rate for Payer: Multiplan Commercial	$7.16

FENOFIBRATE 150 MG CAPSULE [88131]

Facility

$9.54

Service Code	NDC 66869-147-30
Hospital Charge Code	1712564
Hospital Revenue Code	259
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$8.11
Rate for Payer: Adventist Health Commercial	$1.91
Rate for Payer: Aetna of CA Gatekeeper	$5.10
Rate for Payer: Aetna of CA Non-Gatekeeper	$6.55
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$8.11
Rate for Payer: Alpha Care Medical Group Medi-Cal	$5.25
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$7.16
Rate for Payer: Blue Shield of California Commercial	$5.92
Rate for Payer: Blue Shield of California EPN	$5.60
Rate for Payer: Cash Price	$4.29
Rate for Payer: Cigna of CA HMO/PPO	$6.20
Rate for Payer: Dignity Health Commercial/Exchange	$8.11
Rate for Payer: Dignity Health Medi-Cal	$8.11
Rate for Payer: Dignity Health Senior	$8.11
Rate for Payer: EPIC Health Plan Commercial	$6.11
Rate for Payer: Heritage Provider Network Commercial	$5.91
Rate for Payer: Heritage Provider Network Senior	$5.91
Rate for Payer: Kaiser Permanente of CA Commercial	$4.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.73
Rate for Payer: LLUH Dept of Risk Management WC	$2.38
Rate for Payer: Multiplan Commercial	$7.16
Rate for Payer: TriValley Medical Group Commercial	$3.82
Rate for Payer: TriValley Medical Group Senior	$3.82
Rate for Payer: Vantage Medical Group Medi-Cal	$8.11
Rate for Payer: Vantage Medical Group Senior	$8.11

FENOFIBRATE 160 MG TABLET [28252]

Facility

$3.51

Service Code	NDC 68084-328-21
Hospital Charge Code	1712496
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$2.98
Rate for Payer: Adventist Health Commercial	$0.70
Rate for Payer: Aetna of CA Gatekeeper	$1.88
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.41
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$2.98
Rate for Payer: Alpha Care Medical Group Medi-Cal	$1.93
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$2.63
Rate for Payer: Blue Shield of California Commercial	$2.18
Rate for Payer: Blue Shield of California EPN	$2.06
Rate for Payer: Cash Price	$1.58
Rate for Payer: Cigna of CA HMO/PPO	$2.28
Rate for Payer: Dignity Health Commercial/Exchange	$2.98
Rate for Payer: Dignity Health Medi-Cal	$2.98
Rate for Payer: Dignity Health Senior	$2.98
Rate for Payer: EPIC Health Plan Commercial	$2.25
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 Commercial	$1.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.88
Rate for Payer: Multiplan Commercial	$2.63
Rate for Payer: TriValley Medical Group Commercial	$1.40
Rate for Payer: TriValley Medical Group Senior	$1.40
Rate for Payer: Vantage Medical Group Medi-Cal	$2.98
Rate for Payer: Vantage Medical Group Senior	$2.98

Know your out-of-pocket cost for care.

All Charges