Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

DW13BB1

Facility

$8,769.00

Hospital Charge Code	5572
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

DW16B6Z

Facility

$8,769.00

Hospital Charge Code	5573
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

DW16BB1

Facility

$8,769.00

Hospital Charge Code	5574
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

DW1KBB1

Facility

$8,769.00

Hospital Charge Code	5575
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

DW1KBBZ

Facility

$8,769.00

Hospital Charge Code	5576
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

DW1LBB1

Facility

$8,769.00

Hospital Charge Code	5577
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

DW1LBBZ

Facility

$8,769.00

Hospital Charge Code	5578
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

DW1PBB1

Facility

$8,769.00

Hospital Charge Code	5579
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

DW1PBBZ

Facility

$8,769.00

Hospital Charge Code	5580
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

DW1QBB1

Facility

$8,769.00

Hospital Charge Code	5581
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

DW1QBBZ

Facility

$8,769.00

Hospital Charge Code	5582
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

DW1RBB1

Facility

$8,769.00

Hospital Charge Code	5583
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

DW1RBBZ

Facility

$8,769.00

Hospital Charge Code	5584
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

DW1XBB1

Facility

$8,769.00

Hospital Charge Code	5585
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

DW1XBBZ

Facility

$8,769.00

Hospital Charge Code	5586
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

DW1YBB1

Facility

$8,769.00

Hospital Charge Code	5587
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

DW1YBBZ

Facility

$8,769.00

Hospital Charge Code	5588
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

ECONAZOLE NITRATE 1 % TOPICAL CREAM [9915]

Facility

$2.00

Service Code	NDC 51672-1303-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$1.50
Rate for Payer: Adventist Health Commercial	$0.40
Rate for Payer: Cash Price	$1.10
Rate for Payer: EPIC Health Plan Commercial	$1.08
Rate for Payer: Heritage Provider Network Commercial	$1.35
Rate for Payer: Heritage Provider Network Senior	$1.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$1.50

ECONAZOLE NITRATE 1 % TOPICAL CREAM [9915]

Facility

$2.00

Service Code	NDC 51672-1303-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$1.70
Rate for Payer: Adventist Health Commercial	$0.40
Rate for Payer: Aetna of CA Gatekeeper	$1.07
Rate for Payer: Aetna of CA Non-Gatekeeper	$1.37
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$1.70
Rate for Payer: Alpha Care Medical Group Medi-Cal	$1.10
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$1.50
Rate for Payer: Blue Shield of California Commercial	$1.22
Rate for Payer: Blue Shield of California EPN	$0.98
Rate for Payer: Cash Price	$1.10
Rate for Payer: Cigna of CA HMO/PPO	$1.30
Rate for Payer: Dignity Health Commercial/Exchange	$1.70
Rate for Payer: Dignity Health Medi-Cal	$1.70
Rate for Payer: Dignity Health Senior	$1.70
Rate for Payer: EPIC Health Plan Commercial	$1.28
Rate for Payer: Heritage Provider Network Commercial	$1.24
Rate for Payer: Heritage Provider Network Senior	$1.24
Rate for Payer: Kaiser Permanente of CA Commercial	$0.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1.40
Rate for Payer: Molina Healthcare of CA Medicare	$1.40
Rate for Payer: Multiplan Commercial	$1.50
Rate for Payer: TriValley Medical Group Commercial	$0.80
Rate for Payer: TriValley Medical Group Senior	$0.80
Rate for Payer: United Healthcare All Other HMO/non HMO	$1.00
Rate for Payer: United Healthcare Navigate/Select/Select+	$1.00
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1.70
Rate for Payer: Vantage Medical Group Medi-Cal	$1.70
Rate for Payer: Vantage Medical Group Senior	$1.70

ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]

Facility

$260.92

Service Code	HCPCS J1299
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$44.77
Max. Negotiated Rate	$195.69
Rate for Payer: Adventist Health Commercial	$52.18
Rate for Payer: Aetna of CA Gatekeeper	$139.46
Rate for Payer: Aetna of CA Non-Gatekeeper	$179.25
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$55.96
Rate for Payer: Alpha Care Medical Group Medi-Cal	$49.25
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$49.25
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$112.62
Rate for Payer: Blue Shield of California Commercial	$159.16
Rate for Payer: Blue Shield of California EPN	$127.33
Rate for Payer: Cash Price	$143.51
Rate for Payer: Cash Price	$143.51
Rate for Payer: Cigna of CA HMO/PPO	$120.02
Rate for Payer: Dignity Health Commercial/Exchange	$55.96
Rate for Payer: Dignity Health Medi-Cal	$49.25
Rate for Payer: Dignity Health Senior	$49.25
Rate for Payer: EPIC Health Plan Commercial	$166.99
Rate for Payer: EPIC Health Plan Medicare	$44.77
Rate for Payer: Heritage Provider Network Commercial	$120.81
Rate for Payer: Heritage Provider Network Senior	$120.81
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$44.81
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$44.77
Rate for Payer: Kaiser Permanente of CA Commercial	$124.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$47.23
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$51.49
Rate for Payer: LLUH Dept of Risk Management WC	$65.23
Rate for Payer: Molina Healthcare of CA Medi-Cal	$56.41
Rate for Payer: Molina Healthcare of CA Medicare	$56.41
Rate for Payer: Multiplan Commercial	$195.69
Rate for Payer: TriValley Medical Group Commercial	$104.37
Rate for Payer: TriValley Medical Group Senior	$104.37
Rate for Payer: United Healthcare All Other HMO/non HMO	$94.27
Rate for Payer: United Healthcare Navigate/Select/Select+	$86.39
Rate for Payer: Vantage Medical Group Commercial/Exchange	$55.96
Rate for Payer: Vantage Medical Group Medi-Cal	$49.25
Rate for Payer: Vantage Medical Group Senior	$49.25

ECULIZUMAB 300 MG/30 ML INTRAVENOUS SOLUTION [81696]

Facility

$260.92

Service Code	HCPCS J1299
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$47.23
Max. Negotiated Rate	$195.69
Rate for Payer: Adventist Health Commercial	$52.18
Rate for Payer: Cash Price	$143.51
Rate for Payer: Cigna of CA HMO/PPO	$120.02
Rate for Payer: EPIC Health Plan Commercial	$140.90
Rate for Payer: Heritage Provider Network Commercial	$120.81
Rate for Payer: Heritage Provider Network Senior	$120.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$47.23
Rate for Payer: LLUH Dept of Risk Management WC	$65.23
Rate for Payer: Multiplan Commercial	$195.69
Rate for Payer: United Healthcare All Other HMO/non HMO	$94.27
Rate for Payer: United Healthcare Navigate/Select/Select+	$86.39

EDETATE DISODIUM 3 % EYE DROPS [222529]

Facility

$30.00

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.43
Max. Negotiated Rate	$25.50
Rate for Payer: Adventist Health Commercial	$6.00
Rate for Payer: Aetna of CA Gatekeeper	$16.04
Rate for Payer: Aetna of CA Non-Gatekeeper	$20.61
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$25.50
Rate for Payer: Alpha Care Medical Group Medi-Cal	$16.50
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$22.50
Rate for Payer: Blue Shield of California Commercial	$18.30
Rate for Payer: Blue Shield of California EPN	$14.64
Rate for Payer: Cash Price	$16.50
Rate for Payer: Cigna of CA HMO/PPO	$13.80
Rate for Payer: Dignity Health Commercial/Exchange	$25.50
Rate for Payer: Dignity Health Medi-Cal	$25.50
Rate for Payer: Dignity Health Senior	$25.50
Rate for Payer: EPIC Health Plan Commercial	$19.20
Rate for Payer: Heritage Provider Network Commercial	$13.89
Rate for Payer: Heritage Provider Network Senior	$13.89
Rate for Payer: Kaiser Permanente of CA Commercial	$14.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$5.43
Rate for Payer: LLUH Dept of Risk Management WC	$7.50
Rate for Payer: Molina Healthcare of CA Medi-Cal	$21.00
Rate for Payer: Molina Healthcare of CA Medicare	$21.00
Rate for Payer: Multiplan Commercial	$22.50
Rate for Payer: TriValley Medical Group Commercial	$12.00
Rate for Payer: TriValley Medical Group Senior	$12.00
Rate for Payer: United Healthcare All Other HMO/non HMO	$10.84
Rate for Payer: United Healthcare Navigate/Select/Select+	$9.93
Rate for Payer: Vantage Medical Group Commercial/Exchange	$25.50
Rate for Payer: Vantage Medical Group Medi-Cal	$25.50
Rate for Payer: Vantage Medical Group Senior	$25.50

EDETATE DISODIUM 3 % EYE DROPS [222529]

Facility

$30.00

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.43
Max. Negotiated Rate	$22.50
Rate for Payer: Adventist Health Commercial	$6.00
Rate for Payer: Cash Price	$16.50
Rate for Payer: Cigna of CA HMO/PPO	$13.80
Rate for Payer: EPIC Health Plan Commercial	$16.20
Rate for Payer: Heritage Provider Network Commercial	$13.89
Rate for Payer: Heritage Provider Network Senior	$13.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$5.43
Rate for Payer: LLUH Dept of Risk Management WC	$7.50
Rate for Payer: Multiplan Commercial	$22.50
Rate for Payer: United Healthcare All Other HMO/non HMO	$10.84
Rate for Payer: United Healthcare Navigate/Select/Select+	$9.93

EFAVIRENZ 600 MG TABLET [32298]

Facility

$3.20

Service Code	NDC 31722-504-30
Hospital Charge Code	901700029
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: Cash Price	$1.76
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

EFAVIRENZ 600 MG TABLET [32298]

Facility

$3.20

Service Code	NDC 31722-504-30
Hospital Charge Code	901700029
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	$1.95
Rate for Payer: Blue Shield of California EPN	$1.56
Rate for Payer: Cash Price	$1.76
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	$1.53
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: Molina Healthcare of CA Medi-Cal	$2.24
Rate for Payer: Molina Healthcare of CA Medicare	$2.24
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: United Healthcare All Other HMO/non HMO	$1.60
Rate for Payer: United Healthcare Navigate/Select/Select+	$1.60
Rate for Payer: Vantage Medical Group Commercial/Exchange	$2.72
Rate for Payer: Vantage Medical Group Medi-Cal	$2.72
Rate for Payer: Vantage Medical Group Senior	$2.72

Know your out-of-pocket cost for care.

All Charges