Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

Intensive OP - Must be billed w/ specific diagnosis codes in addition to rev code 905

Facility

$445.00

Service Code	CPT 90853
Hospital Revenue Code	905
Min. Negotiated Rate	$404.00
Max. Negotiated Rate	$445.00
Rate for Payer: Blue Shield of California Commercial	$445.00
Rate for Payer: Blue Shield of California EPN	$404.00

Intensive OP - Must be billed w/ specific diagnosis codes in addition to rev code 905

Facility

$445.00

Service Code	CPT 90847
Hospital Revenue Code	905
Min. Negotiated Rate	$404.00
Max. Negotiated Rate	$445.00
Rate for Payer: Blue Shield of California Commercial	$445.00
Rate for Payer: Blue Shield of California EPN	$404.00

INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE

Facility

$8,826.18

Service Code	APR-DRG 8172
Min. Negotiated Rate	$5,574.43
Max. Negotiated Rate	$8,826.18
Rate for Payer: Adventist Health Medi-Cal	$5,574.43
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$6,642.86
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$8,826.18

INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE

Facility

$33,161.63

Service Code	APR-DRG 8174
Min. Negotiated Rate	$20,944.19
Max. Negotiated Rate	$33,161.63
Rate for Payer: Adventist Health Medi-Cal	$20,944.19
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$24,958.49
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$33,161.63

INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE

Facility

$16,316.95

Service Code	APR-DRG 8173
Min. Negotiated Rate	$10,305.44
Max. Negotiated Rate	$16,316.95
Rate for Payer: Adventist Health Medi-Cal	$10,305.44
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$12,280.65
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$16,316.95

INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE

Facility

$6,185.58

Service Code	APR-DRG 8171
Min. Negotiated Rate	$3,906.68
Max. Negotiated Rate	$6,185.58
Rate for Payer: Adventist Health Medi-Cal	$3,906.68
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$4,655.47
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$6,185.58

INTERNAL NEUROLYSIS, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR NEUROPLASTY) (NEUROPLASTY INCLUDES EXTERNAL NEUROLYSIS)

Facility

$27,467.00

Service Code	CPT 64727
Hospital Revenue Code	360
Min. Negotiated Rate	$302.89
Max. Negotiated Rate	$27,467.00
Rate for Payer: Aetna of CA HMO/PPO	$27,467.00
Rate for Payer: Anthem Blue Cross of CA Exchange	$3,974.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$5,523.00
Rate for Payer: Blue Shield of California Commercial	$3,293.23
Rate for Payer: Blue Shield of California EPN	$2,069.82
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$302.89
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$334.59
Rate for Payer: United Healthcare All Other HMO	$1,593.00
Rate for Payer: United Healthcare HMO Rider	$1,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$1,000.00

INTERSTITIAL AND ALVEOLAR LUNG DISEASES

Facility

$9,660.06

Service Code	APR-DRG 1421
Min. Negotiated Rate	$6,101.09
Max. Negotiated Rate	$9,660.06
Rate for Payer: Adventist Health Medi-Cal	$6,101.09
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$7,270.46
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$9,660.06

INTERSTITIAL AND ALVEOLAR LUNG DISEASES

Facility

$29,276.24

Service Code	APR-DRG 1424
Min. Negotiated Rate	$18,490.26
Max. Negotiated Rate	$29,276.24
Rate for Payer: Adventist Health Medi-Cal	$18,490.26
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$22,034.23
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$29,276.24

INTERSTITIAL AND ALVEOLAR LUNG DISEASES

Facility

$18,603.05

Service Code	APR-DRG 1423
Min. Negotiated Rate	$11,749.30
Max. Negotiated Rate	$18,603.05
Rate for Payer: Adventist Health Medi-Cal	$11,749.30
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$14,001.24
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$18,603.05

INTERSTITIAL AND ALVEOLAR LUNG DISEASES

Facility

$12,701.48

Service Code	APR-DRG 1422
Min. Negotiated Rate	$8,021.99
Max. Negotiated Rate	$12,701.48
Rate for Payer: Adventist Health Medi-Cal	$8,021.99
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$9,559.54
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$12,701.48

INTERSTITIAL LUNG DISEASE WITH CC

Facility

$24,979.36

Service Code	MSDRG 197
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$24,979.36
Rate for Payer: Aetna of CA HMO/PPO	$24,979.36
Rate for Payer: Anthem Blue Cross of CA Exchange	$16,135.65
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$22,590.48
Rate for Payer: EPIC Health Plan Commercial	$23,086.17
Rate for Payer: EPIC Health Plan Senior	$15,390.78
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$13,991.62
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$19,588.27
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$18,748.77
Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage	$13,991.62
Rate for Payer: Prime Health Services Medicare	$14,831.12
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

INTERSTITIAL LUNG DISEASE WITH MCC

Facility

$49,669.22

Service Code	MSDRG 196
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$49,669.22
Rate for Payer: Aetna of CA HMO/PPO	$49,669.22
Rate for Payer: Anthem Blue Cross of CA Exchange	$32,084.29
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$44,919.13
Rate for Payer: EPIC Health Plan Commercial	$44,434.42
Rate for Payer: EPIC Health Plan Senior	$29,622.94
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$26,929.95
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$37,701.93
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$36,086.13
Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage	$26,929.95
Rate for Payer: Prime Health Services Medicare	$28,545.75
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC

Facility

$18,849.67

Service Code	MSDRG 198
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$18,849.67
Rate for Payer: Aetna of CA HMO/PPO	$18,849.67
Rate for Payer: Anthem Blue Cross of CA Exchange	$12,176.12
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$17,046.99
Rate for Payer: EPIC Health Plan Commercial	$17,786.13
Rate for Payer: EPIC Health Plan Senior	$11,857.42
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$10,779.47
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$15,091.26
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$14,444.49
Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage	$10,779.47
Rate for Payer: Prime Health Services Medicare	$11,426.24
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

INTESTINAL OBSTRUCTION

Facility

$25,892.42

Service Code	APR-DRG 2474
Min. Negotiated Rate	$16,353.11
Max. Negotiated Rate	$25,892.42
Rate for Payer: Adventist Health Medi-Cal	$16,353.11
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$19,487.45
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$25,892.42

INTESTINAL OBSTRUCTION

Facility

$14,812.36

Service Code	APR-DRG 2473
Min. Negotiated Rate	$9,355.18
Max. Negotiated Rate	$14,812.36
Rate for Payer: Adventist Health Medi-Cal	$9,355.18
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$11,148.25
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$14,812.36

INTESTINAL OBSTRUCTION

Facility

$7,561.28

Service Code	APR-DRG 2471
Min. Negotiated Rate	$4,775.54
Max. Negotiated Rate	$7,561.28
Rate for Payer: Adventist Health Medi-Cal	$4,775.54
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$5,690.86
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$7,561.28

INTESTINAL OBSTRUCTION

Facility

$9,813.14

Service Code	APR-DRG 2472
Min. Negotiated Rate	$6,197.77
Max. Negotiated Rate	$9,813.14
Rate for Payer: Adventist Health Medi-Cal	$6,197.77
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$7,385.68
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$9,813.14

INTRACRANIAL HEMORRHAGE

Facility

$20,188.22

Service Code	APR-DRG 0443
Min. Negotiated Rate	$12,750.46
Max. Negotiated Rate	$20,188.22
Rate for Payer: Adventist Health Medi-Cal	$12,750.46
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$15,194.29
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$20,188.22

INTRACRANIAL HEMORRHAGE

Facility

$30,456.56

Service Code	APR-DRG 0444
Min. Negotiated Rate	$19,235.72
Max. Negotiated Rate	$30,456.56
Rate for Payer: Adventist Health Medi-Cal	$19,235.72
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$22,922.57
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$30,456.56

INTRACRANIAL HEMORRHAGE

Facility

$15,241.38

Service Code	APR-DRG 0442
Min. Negotiated Rate	$9,626.14
Max. Negotiated Rate	$15,241.38
Rate for Payer: Adventist Health Medi-Cal	$9,626.14
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$11,471.15
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$15,241.38

INTRACRANIAL HEMORRHAGE

Facility

$11,257.31

Service Code	APR-DRG 0441
Min. Negotiated Rate	$7,109.88
Max. Negotiated Rate	$11,257.31
Rate for Payer: Adventist Health Medi-Cal	$7,109.88
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$8,472.61
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$11,257.31

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS

Facility

$26,590.09

Service Code	MSDRG 065
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$26,590.09
Rate for Payer: Aetna of CA HMO/PPO	$26,590.09
Rate for Payer: Anthem Blue Cross of CA Exchange	$17,176.11
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$24,047.16
Rate for Payer: EPIC Health Plan Commercial	$24,478.90
Rate for Payer: EPIC Health Plan Senior	$16,319.27
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$14,835.70
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$20,769.98
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$19,879.84
Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage	$14,835.70
Rate for Payer: Prime Health Services Medicare	$15,725.84
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC

Facility

$52,927.51

Service Code	MSDRG 064
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$52,927.51
Rate for Payer: Aetna of CA HMO/PPO	$52,927.51
Rate for Payer: Anthem Blue Cross of CA Exchange	$34,189.01
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$47,865.82
Rate for Payer: EPIC Health Plan Commercial	$47,251.71
Rate for Payer: EPIC Health Plan Senior	$31,501.14
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$28,637.40
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$40,092.36
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$38,374.12
Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage	$28,637.40
Rate for Payer: Prime Health Services Medicare	$30,355.64
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC

Facility

$18,012.72

Service Code	MSDRG 066
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$18,012.72
Rate for Payer: Aetna of CA HMO/PPO	$18,012.72
Rate for Payer: Anthem Blue Cross of CA Exchange	$11,635.48
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$16,290.09
Rate for Payer: EPIC Health Plan Commercial	$17,062.45
Rate for Payer: EPIC Health Plan Senior	$11,374.97
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$10,340.88
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$14,477.23
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$13,856.78
Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage	$10,340.88
Rate for Payer: Prime Health Services Medicare	$10,961.33
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

Know your out-of-pocket cost for care.

All Charges