Loma Linda University Children's Hospital

All Charges

Charge

Type

Setting

Price

GUSELKUMAB 200 MG/20 ML (10 MG/ML) INTRAVENOUS SOLUTION [242810]

Facility

$917.69

Service Code	HCPCS J1628
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$183.54
Max. Negotiated Rate	$780.04
Rate for Payer: Adventist Health Commercial	$183.54
Rate for Payer: Blue Shield of California Commercial	$465.27
Rate for Payer: Blue Shield of California Commercial	$705.70
Rate for Payer: Cash Price	$412.96
Rate for Payer: Cigna of CA HMO	$642.38
Rate for Payer: Cigna of CA PPO	$642.38
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$642.38
Rate for Payer: EPIC Health Plan Commercial	$367.08
Rate for Payer: EPIC Health Plan Senior	$367.08
Rate for Payer: Galaxy Health WC	$780.04
Rate for Payer: Global Benefits Group Commercial	$550.61
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$582.73
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$541.44
Rate for Payer: LLUH Dept of Risk Management WC	$220.25
Rate for Payer: Multiplan Commercial	$734.15
Rate for Payer: Networks By Design Commercial	$458.85
Rate for Payer: Prime Health Services Commercial	$780.04
Rate for Payer: United Healthcare All Other Commercial	$344.41
Rate for Payer: United Healthcare All Other HMO	$335.23
Rate for Payer: United Healthcare HMO Rider	$327.98
Rate for Payer: United Healthcare Select/Navigate/Core	$300.54

H35.30

Facility

$3,000.00

Service Code	ICD H35.30
Hospital Charge Code	1
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3110

Facility

$3,000.00

Service Code	ICD H35.3110
Hospital Charge Code	2
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3111

Facility

$3,000.00

Service Code	ICD H35.3111
Hospital Charge Code	3
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3112

Facility

$3,000.00

Service Code	ICD H35.3112
Hospital Charge Code	4
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3113

Facility

$3,000.00

Service Code	ICD H35.3113
Hospital Charge Code	5
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3114

Facility

$3,000.00

Service Code	ICD H35.3114
Hospital Charge Code	6
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3120

Facility

$3,000.00

Service Code	ICD H35.3120
Hospital Charge Code	7
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3121

Facility

$3,000.00

Service Code	ICD H35.3121
Hospital Charge Code	8
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3122

Facility

$3,000.00

Service Code	ICD H35.3122
Hospital Charge Code	9
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3123

Facility

$3,000.00

Service Code	ICD H35.3123
Hospital Charge Code	10
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3124

Facility

$3,000.00

Service Code	ICD H35.3124
Hospital Charge Code	11
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3130

Facility

$3,000.00

Service Code	ICD H35.3130
Hospital Charge Code	12
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3131

Facility

$3,000.00

Service Code	ICD H35.3131
Hospital Charge Code	13
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3132

Facility

$3,000.00

Service Code	ICD H35.3132
Hospital Charge Code	14
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3133

Facility

$3,000.00

Service Code	ICD H35.3133
Hospital Charge Code	15
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3134

Facility

$3,000.00

Service Code	ICD H35.3134
Hospital Charge Code	16
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3190

Facility

$3,000.00

Service Code	ICD H35.3190
Hospital Charge Code	17
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3191

Facility

$3,000.00

Service Code	ICD H35.3191
Hospital Charge Code	18
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3192

Facility

$3,000.00

Service Code	ICD H35.3192
Hospital Charge Code	19
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3193

Facility

$3,000.00

Service Code	ICD H35.3193
Hospital Charge Code	20
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3194

Facility

$3,000.00

Service Code	ICD H35.3194
Hospital Charge Code	21
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3210

Facility

$3,000.00

Service Code	ICD H35.3210
Hospital Charge Code	22
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3211

Facility

$3,000.00

Service Code	ICD H35.3211
Hospital Charge Code	23
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3212

Facility

$3,000.00

Service Code	ICD H35.3212
Hospital Charge Code	24
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

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