Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]

Facility

$434.29

Service Code	NDC 69344-102-33
Hospital Charge Code	1748065
Hospital Revenue Code	259
Min. Negotiated Rate	$78.61
Max. Negotiated Rate	$369.15
Rate for Payer: Adventist Health Commercial	$86.86
Rate for Payer: Aetna of CA Gatekeeper	$232.13
Rate for Payer: Aetna of CA Non-Gatekeeper	$298.36
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$369.15
Rate for Payer: Alpha Care Medical Group Medi-Cal	$238.86
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$325.72
Rate for Payer: Blue Shield of California Commercial	$269.69
Rate for Payer: Blue Shield of California EPN	$254.93
Rate for Payer: Cash Price	$195.43
Rate for Payer: Cigna of CA HMO/PPO	$282.29
Rate for Payer: Dignity Health Commercial/Exchange	$369.15
Rate for Payer: Dignity Health Medi-Cal	$369.15
Rate for Payer: Dignity Health Senior	$369.15
Rate for Payer: EPIC Health Plan Commercial	$277.95
Rate for Payer: Heritage Provider Network Commercial	$268.83
Rate for Payer: Heritage Provider Network Senior	$268.83
Rate for Payer: Kaiser Permanente of CA Commercial	$209.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$78.61
Rate for Payer: LLUH Dept of Risk Management WC	$108.57
Rate for Payer: Multiplan Commercial	$325.72
Rate for Payer: TriValley Medical Group Commercial	$173.72
Rate for Payer: TriValley Medical Group Senior	$173.72
Rate for Payer: Vantage Medical Group Medi-Cal	$369.15
Rate for Payer: Vantage Medical Group Senior	$369.15

INDOMETHACIN 50 MG RECTAL SUPPOSITORY [3901]

Facility

$434.29

Service Code	NDC 69344-102-33
Hospital Charge Code	1748065
Hospital Revenue Code	259
Min. Negotiated Rate	$78.61
Max. Negotiated Rate	$325.72
Rate for Payer: Adventist Health Commercial	$86.86
Rate for Payer: Aetna of CA Non-Gatekeeper	$298.36
Rate for Payer: Cash Price	$195.43
Rate for Payer: EPIC Health Plan Commercial	$234.52
Rate for Payer: Heritage Provider Network Commercial	$294.01
Rate for Payer: Heritage Provider Network Senior	$294.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$78.61
Rate for Payer: LLUH Dept of Risk Management WC	$108.57
Rate for Payer: Multiplan Commercial	$325.72

INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]

Facility

$0.42

Service Code	NDC 68462-325-60
Hospital Charge Code	1710396
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.32
Rate for Payer: Adventist Health Commercial	$0.08
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.29
Rate for Payer: Cash Price	$0.19
Rate for Payer: EPIC Health Plan Commercial	$0.23
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 Medi-Cal	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.32

INDOMETHACIN ER 75 MG CAPSULE,EXTENDED RELEASE [14628]

Facility

$0.42

Service Code	NDC 68462-325-60
Hospital Charge Code	1710396
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.36
Rate for Payer: Adventist Health Commercial	$0.08
Rate for Payer: Aetna of CA Gatekeeper	$0.22
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.29
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.36
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.23
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.32
Rate for Payer: Blue Shield of California Commercial	$0.26
Rate for Payer: Blue Shield of California EPN	$0.25
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.27
Rate for Payer: Dignity Health Commercial/Exchange	$0.36
Rate for Payer: Dignity Health Medi-Cal	$0.36
Rate for Payer: Dignity Health Senior	$0.36
Rate for Payer: EPIC Health Plan Commercial	$0.27
Rate for Payer: Heritage Provider Network Commercial	$0.26
Rate for Payer: Heritage Provider Network Senior	$0.26
Rate for Payer: Kaiser Permanente of CA Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.32
Rate for Payer: TriValley Medical Group Commercial	$0.17
Rate for Payer: TriValley Medical Group Senior	$0.17
Rate for Payer: Vantage Medical Group Medi-Cal	$0.36
Rate for Payer: Vantage Medical Group Senior	$0.36

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$6,234.02

Service Code	APR-DRG 1133
Min. Negotiated Rate	$6,234.02
Max. Negotiated Rate	$6,234.02
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$6,234.02

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$10,195.70

Service Code	APR-DRG 1134
Min. Negotiated Rate	$10,195.70
Max. Negotiated Rate	$10,195.70
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$10,195.70

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$2,899.13

Service Code	APR-DRG 1131
Min. Negotiated Rate	$2,899.13
Max. Negotiated Rate	$2,899.13
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$2,899.13

INFECTIONS OF UPPER RESPIRATORY TRACT

Facility

$4,279.05

Service Code	APR-DRG 1132
Min. Negotiated Rate	$4,279.05
Max. Negotiated Rate	$4,279.05
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$4,279.05

INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE

Facility

$39,478.47

Service Code	APR-DRG 7104
Min. Negotiated Rate	$39,478.47
Max. Negotiated Rate	$39,478.47
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$39,478.47

INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE

Facility

$13,064.98

Service Code	APR-DRG 7102
Min. Negotiated Rate	$13,064.98
Max. Negotiated Rate	$13,064.98
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$13,064.98

INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE

Facility

$9,031.66

Service Code	APR-DRG 7101
Min. Negotiated Rate	$9,031.66
Max. Negotiated Rate	$9,031.66
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$9,031.66

INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE

Facility

$21,406.18

Service Code	APR-DRG 7103
Min. Negotiated Rate	$21,406.18
Max. Negotiated Rate	$21,406.18
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$21,406.18

INFLAMMATORY BOWEL DISEASE

Facility

$15,774.08

Service Code	APR-DRG 2454
Min. Negotiated Rate	$15,774.08
Max. Negotiated Rate	$15,774.08
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$15,774.08

INFLAMMATORY BOWEL DISEASE

Facility

$4,933.69

Service Code	APR-DRG 2451
Min. Negotiated Rate	$4,933.69
Max. Negotiated Rate	$4,933.69
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$4,933.69

INFLAMMATORY BOWEL DISEASE

Facility

$6,292.72

Service Code	APR-DRG 2452
Min. Negotiated Rate	$6,292.72
Max. Negotiated Rate	$6,292.72
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$6,292.72

INFLAMMATORY BOWEL DISEASE

Facility

$9,027.69

Service Code	APR-DRG 2453
Min. Negotiated Rate	$9,027.69
Max. Negotiated Rate	$9,027.69
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$9,027.69

INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]

Facility

$570.00

Service Code	CPT J1745
Hospital Charge Code	1757347
Hospital Revenue Code	636
Min. Negotiated Rate	$32.16
Max. Negotiated Rate	$427.50
Rate for Payer: Adventist Health Commercial	$114.00
Rate for Payer: Aetna of CA Gatekeeper	$79.00
Rate for Payer: Aetna of CA Non-Gatekeeper	$391.59
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$40.20
Rate for Payer: Alpha Care Medical Group Medi-Cal	$35.38
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$35.38
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$127.02
Rate for Payer: Blue Shield of California Commercial	$48.45
Rate for Payer: Blue Shield of California EPN	$48.45
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cigna of CA HMO/PPO	$262.20
Rate for Payer: Dignity Health Commercial/Exchange	$48.24
Rate for Payer: Dignity Health Medi-Cal	$35.38
Rate for Payer: Dignity Health Senior	$35.38
Rate for Payer: EPIC Health Plan Commercial	$364.80
Rate for Payer: EPIC Health Plan Medicare	$32.16
Rate for Payer: Heritage Provider Network Commercial	$263.91
Rate for Payer: Heritage Provider Network Senior	$263.91
Rate for Payer: Humana Medicare	$32.16
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$57.13
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$32.16
Rate for Payer: Kaiser Permanente of CA Commercial	$61.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$103.17
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$37.95
Rate for Payer: LLUH Dept of Risk Management WC	$142.50
Rate for Payer: Molina Healthcare of CA Medi-Cal	$40.52
Rate for Payer: Molina Healthcare of CA Medicare	$40.52
Rate for Payer: Multiplan Commercial	$427.50
Rate for Payer: TriValley Medical Group Commercial	$228.00
Rate for Payer: TriValley Medical Group Senior	$228.00
Rate for Payer: United Healthcare All Other HMO/non HMO	$207.82
Rate for Payer: United Healthcare Navigate/Select/Select+	$190.44
Rate for Payer: Vantage Medical Group Commercial/Exchange	$48.24
Rate for Payer: Vantage Medical Group Medi-Cal	$35.38
Rate for Payer: Vantage Medical Group Senior	$32.16

INFLIXIMAB 100 MG INTRAVENOUS SOLUTION [23796]

Facility

$570.00

Service Code	CPT J1745
Hospital Charge Code	1757347
Hospital Revenue Code	636
Min. Negotiated Rate	$103.17
Max. Negotiated Rate	$427.50
Rate for Payer: Adventist Health Commercial	$114.00
Rate for Payer: Aetna of CA Non-Gatekeeper	$391.59
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cigna of CA HMO/PPO	$262.20
Rate for Payer: EPIC Health Plan Commercial	$307.80
Rate for Payer: Heritage Provider Network Commercial	$385.89
Rate for Payer: Heritage Provider Network Senior	$385.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$103.17
Rate for Payer: LLUH Dept of Risk Management WC	$142.50
Rate for Payer: Multiplan Commercial	$427.50
Rate for Payer: United Healthcare All Other HMO/non HMO	$207.82
Rate for Payer: United Healthcare Navigate/Select/Select+	$190.44

INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]

Facility

$904.07

Service Code	NDC 78206-162-99
Hospital Charge Code	ERX219233
Hospital Revenue Code	636
Min. Negotiated Rate	$163.64
Max. Negotiated Rate	$678.05
Rate for Payer: Adventist Health Commercial	$180.81
Rate for Payer: Aetna of CA Non-Gatekeeper	$621.10
Rate for Payer: Cash Price	$406.83
Rate for Payer: Cigna of CA HMO/PPO	$415.87
Rate for Payer: EPIC Health Plan Commercial	$488.20
Rate for Payer: Heritage Provider Network Commercial	$612.06
Rate for Payer: Heritage Provider Network Senior	$612.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$163.64
Rate for Payer: LLUH Dept of Risk Management WC	$226.02
Rate for Payer: Multiplan Commercial	$678.05
Rate for Payer: United Healthcare All Other HMO/non HMO	$329.62
Rate for Payer: United Healthcare Navigate/Select/Select+	$302.05

INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]

Facility

$904.07

Service Code	NDC 78206-162-99
Hospital Charge Code	ERX219233
Hospital Revenue Code	636
Min. Negotiated Rate	$163.64
Max. Negotiated Rate	$768.46
Rate for Payer: Adventist Health Commercial	$180.81
Rate for Payer: Aetna of CA Gatekeeper	$483.23
Rate for Payer: Aetna of CA Non-Gatekeeper	$621.10
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$768.46
Rate for Payer: Alpha Care Medical Group Medi-Cal	$497.24
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$678.05
Rate for Payer: Blue Shield of California Commercial	$561.43
Rate for Payer: Blue Shield of California EPN	$530.69
Rate for Payer: Cash Price	$406.83
Rate for Payer: Cigna of CA HMO/PPO	$415.87
Rate for Payer: Dignity Health Commercial/Exchange	$768.46
Rate for Payer: Dignity Health Medi-Cal	$768.46
Rate for Payer: Dignity Health Senior	$768.46
Rate for Payer: EPIC Health Plan Commercial	$578.60
Rate for Payer: Heritage Provider Network Commercial	$418.58
Rate for Payer: Heritage Provider Network Senior	$418.58
Rate for Payer: Kaiser Permanente of CA Commercial	$435.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$163.64
Rate for Payer: LLUH Dept of Risk Management WC	$226.02
Rate for Payer: Multiplan Commercial	$678.05
Rate for Payer: TriValley Medical Group Commercial	$361.63
Rate for Payer: TriValley Medical Group Senior	$361.63
Rate for Payer: United Healthcare All Other HMO/non HMO	$329.62
Rate for Payer: United Healthcare Navigate/Select/Select+	$302.05
Rate for Payer: Vantage Medical Group Medi-Cal	$768.46
Rate for Payer: Vantage Medical Group Senior	$768.46

INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]

Facility

$904.07

Service Code	NDC 78206-162-01
Hospital Charge Code	ERX219233
Hospital Revenue Code	636
Min. Negotiated Rate	$163.64
Max. Negotiated Rate	$678.05
Rate for Payer: Adventist Health Commercial	$180.81
Rate for Payer: Aetna of CA Non-Gatekeeper	$621.10
Rate for Payer: Cash Price	$406.83
Rate for Payer: Cigna of CA HMO/PPO	$415.87
Rate for Payer: EPIC Health Plan Commercial	$488.20
Rate for Payer: Heritage Provider Network Commercial	$612.06
Rate for Payer: Heritage Provider Network Senior	$612.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$163.64
Rate for Payer: LLUH Dept of Risk Management WC	$226.02
Rate for Payer: Multiplan Commercial	$678.05
Rate for Payer: United Healthcare All Other HMO/non HMO	$329.62
Rate for Payer: United Healthcare Navigate/Select/Select+	$302.05

INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION [219233]

Facility

$904.07

Service Code	NDC 78206-162-01
Hospital Charge Code	ERX219233
Hospital Revenue Code	636
Min. Negotiated Rate	$163.64
Max. Negotiated Rate	$768.46
Rate for Payer: Adventist Health Commercial	$180.81
Rate for Payer: Aetna of CA Gatekeeper	$483.23
Rate for Payer: Aetna of CA Non-Gatekeeper	$621.10
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$768.46
Rate for Payer: Alpha Care Medical Group Medi-Cal	$497.24
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$678.05
Rate for Payer: Blue Shield of California Commercial	$561.43
Rate for Payer: Blue Shield of California EPN	$530.69
Rate for Payer: Cash Price	$406.83
Rate for Payer: Cigna of CA HMO/PPO	$415.87
Rate for Payer: Dignity Health Commercial/Exchange	$768.46
Rate for Payer: Dignity Health Medi-Cal	$768.46
Rate for Payer: Dignity Health Senior	$768.46
Rate for Payer: EPIC Health Plan Commercial	$578.60
Rate for Payer: Heritage Provider Network Commercial	$418.58
Rate for Payer: Heritage Provider Network Senior	$418.58
Rate for Payer: Kaiser Permanente of CA Commercial	$435.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$163.64
Rate for Payer: LLUH Dept of Risk Management WC	$226.02
Rate for Payer: Multiplan Commercial	$678.05
Rate for Payer: TriValley Medical Group Commercial	$361.63
Rate for Payer: TriValley Medical Group Senior	$361.63
Rate for Payer: United Healthcare All Other HMO/non HMO	$329.62
Rate for Payer: United Healthcare Navigate/Select/Select+	$302.05
Rate for Payer: Vantage Medical Group Medi-Cal	$768.46
Rate for Payer: Vantage Medical Group Senior	$768.46

INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION [216056]

Facility

$1,135.54

Service Code	NDC 0069-0809-01
Hospital Charge Code	ERX216056
Hospital Revenue Code	636
Min. Negotiated Rate	$205.53
Max. Negotiated Rate	$851.66
Rate for Payer: Adventist Health Commercial	$227.11
Rate for Payer: Aetna of CA Non-Gatekeeper	$780.12
Rate for Payer: Cash Price	$510.99
Rate for Payer: Cigna of CA HMO/PPO	$522.35
Rate for Payer: EPIC Health Plan Commercial	$613.19
Rate for Payer: Heritage Provider Network Commercial	$768.76
Rate for Payer: Heritage Provider Network Senior	$768.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$205.53
Rate for Payer: LLUH Dept of Risk Management WC	$283.88
Rate for Payer: Multiplan Commercial	$851.66
Rate for Payer: United Healthcare All Other HMO/non HMO	$414.02
Rate for Payer: United Healthcare Navigate/Select/Select+	$379.38

INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION [216056]

Facility

$1,135.54

Service Code	NDC 0069-0809-01
Hospital Charge Code	ERX216056
Hospital Revenue Code	636
Min. Negotiated Rate	$205.53
Max. Negotiated Rate	$965.21
Rate for Payer: Adventist Health Commercial	$227.11
Rate for Payer: Aetna of CA Gatekeeper	$606.95
Rate for Payer: Aetna of CA Non-Gatekeeper	$780.12
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$965.21
Rate for Payer: Alpha Care Medical Group Medi-Cal	$624.55
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$851.66
Rate for Payer: Blue Shield of California Commercial	$705.17
Rate for Payer: Blue Shield of California EPN	$666.56
Rate for Payer: Cash Price	$510.99
Rate for Payer: Cigna of CA HMO/PPO	$522.35
Rate for Payer: Dignity Health Commercial/Exchange	$965.21
Rate for Payer: Dignity Health Medi-Cal	$965.21
Rate for Payer: Dignity Health Senior	$965.21
Rate for Payer: EPIC Health Plan Commercial	$726.75
Rate for Payer: Heritage Provider Network Commercial	$525.76
Rate for Payer: Heritage Provider Network Senior	$525.76
Rate for Payer: Kaiser Permanente of CA Commercial	$547.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$205.53
Rate for Payer: LLUH Dept of Risk Management WC	$283.88
Rate for Payer: Multiplan Commercial	$851.66
Rate for Payer: TriValley Medical Group Commercial	$454.22
Rate for Payer: TriValley Medical Group Senior	$454.22
Rate for Payer: United Healthcare All Other HMO/non HMO	$414.02
Rate for Payer: United Healthcare Navigate/Select/Select+	$379.38
Rate for Payer: Vantage Medical Group Medi-Cal	$965.21
Rate for Payer: Vantage Medical Group Senior	$965.21

INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES

Facility

$10,230.52

Service Code	APR-DRG 2282
Min. Negotiated Rate	$10,230.52
Max. Negotiated Rate	$10,230.52
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$10,230.52

Know your out-of-pocket cost for care.

All Charges