Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

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

H35.3213

Facility

$3,000.00

Service Code	ICD H35.3213
Hospital Charge Code	25
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3220

Facility

$3,000.00

Service Code	ICD H35.3220
Hospital Charge Code	26
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3221

Facility

$3,000.00

Service Code	ICD H35.3221
Hospital Charge Code	27
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3222

Facility

$3,000.00

Service Code	ICD H35.3222
Hospital Charge Code	28
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3223

Facility

$3,000.00

Service Code	ICD H35.3223
Hospital Charge Code	29
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3230

Facility

$3,000.00

Service Code	ICD H35.3230
Hospital Charge Code	30
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3231

Facility

$3,000.00

Service Code	ICD H35.3231
Hospital Charge Code	31
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3232

Facility

$3,000.00

Service Code	ICD H35.3232
Hospital Charge Code	32
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3233

Facility

$3,000.00

Service Code	ICD H35.3233
Hospital Charge Code	33
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3290

Facility

$3,000.00

Service Code	ICD H35.3290
Hospital Charge Code	34
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3291

Facility

$3,000.00

Service Code	ICD H35.3291
Hospital Charge Code	35
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3292

Facility

$3,000.00

Service Code	ICD H35.3292
Hospital Charge Code	36
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.3293

Facility

$3,000.00

Service Code	ICD H35.3293
Hospital Charge Code	37
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

H35.359

Facility

$3,000.00

Service Code	ICD H35.359
Hospital Charge Code	38
Min. Negotiated Rate	$3,000.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Upland Medical Group Pediatric	$3,000.00

HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN [11931]

Facility

$15.79

Service Code	HCPCS 90648
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$14.21
Rate for Payer: Adventist Health Commercial	$3.16
Rate for Payer: Blue Shield of California Commercial	$12.66
Rate for Payer: Blue Shield of California EPN	$7.96
Rate for Payer: Cash Price	$7.11
Rate for Payer: Central Health Plan Commercial	$12.63
Rate for Payer: Cigna of CA HMO	$11.05
Rate for Payer: Cigna of CA PPO	$11.05
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$11.05
Rate for Payer: EPIC Health Plan Commercial	$6.32
Rate for Payer: EPIC Health Plan Senior	$6.32
Rate for Payer: Galaxy Health WC	$13.42
Rate for Payer: Global Benefits Group Commercial	$9.47
Rate for Payer: Health Management Network EPO/PPO	$14.21
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$10.03
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$9.32
Rate for Payer: LLUH Dept of Risk Management WC	$3.16
Rate for Payer: Multiplan Commercial	$11.84
Rate for Payer: Networks By Design Commercial	$7.89
Rate for Payer: Prime Health Services Commercial	$13.42
Rate for Payer: United Healthcare All Other Commercial	$5.93
Rate for Payer: United Healthcare All Other HMO	$5.77
Rate for Payer: United Healthcare HMO Rider	$5.64
Rate for Payer: United Healthcare Select/Navigate/Core	$5.17

HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN [11931]

Facility

$15.79

Service Code	HCPCS 90648
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$86.21
Rate for Payer: Adventist Health Commercial	$3.16
Rate for Payer: Aetna of CA HMO/PPO	$86.21
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$13.42
Rate for Payer: Alpha Care Medical Group Medi-Cal	$8.68
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$11.84
Rate for Payer: Anthem Blue Cross of CA Exchange	$47.37
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$59.11
Rate for Payer: Blue Shield of California Commercial	$15.91
Rate for Payer: Blue Shield of California EPN	$14.46
Rate for Payer: Cash Price	$7.11
Rate for Payer: Cash Price	$7.11
Rate for Payer: Central Health Plan Commercial	$12.63
Rate for Payer: Cigna of CA HMO	$11.05
Rate for Payer: Cigna of CA PPO	$11.05
Rate for Payer: Dignity Health Commercial/Exchange	$13.42
Rate for Payer: Dignity Health Medi-Cal	$13.42
Rate for Payer: Dignity Health Medicare Advantage	$13.42
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$11.05
Rate for Payer: EPIC Health Plan Commercial	$6.32
Rate for Payer: EPIC Health Plan Senior	$6.32
Rate for Payer: Galaxy Health WC	$13.42
Rate for Payer: Global Benefits Group Commercial	$9.47
Rate for Payer: Health Management Network EPO/PPO	$14.21
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$29.95
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$10.03
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$33.08
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$9.32
Rate for Payer: LLUH Dept of Risk Management WC	$3.16
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$11.05
Rate for Payer: Multiplan Commercial	$11.84
Rate for Payer: Networks By Design Commercial	$7.89
Rate for Payer: Prime Health Services Commercial	$13.42
Rate for Payer: Riverside University Health System MISP	$6.32
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$9.47
Rate for Payer: TriValley Medical Group Commercial/Senior	$9.47
Rate for Payer: United Healthcare All Other Commercial	$5.93
Rate for Payer: United Healthcare All Other HMO	$5.77
Rate for Payer: United Healthcare HMO Rider	$5.64
Rate for Payer: United Healthcare Select/Navigate/Core	$5.17
Rate for Payer: Vantage Medical Group Commercial/Exchange	$13.42
Rate for Payer: Vantage Medical Group Medi-Cal	$13.42
Rate for Payer: Vantage Medical Group Senior	$13.42

HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT; WITH IMPLANT

Facility

$28,817.00

Service Code	CPT 28291
Hospital Revenue Code	360
Min. Negotiated Rate	$1,137.26
Max. Negotiated Rate	$28,817.00
Rate for Payer: Adventist Health Medi-Cal	$9,332.70
Rate for Payer: Aetna of CA HMO/PPO	$27,467.00
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$13,999.05
Rate for Payer: Alpha Care Medical Group Medi-Cal	$10,265.97
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$9,332.70
Rate for Payer: Anthem Blue Cross of CA Exchange	$5,806.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,074.00
Rate for Payer: Anthem Blue Cross of CA Workers' Comp	$14,462.30
Rate for Payer: Blue Shield of California Commercial	$5,036.70
Rate for Payer: Blue Shield of California EPN	$3,165.61
Rate for Payer: Dignity Health Commercial/Exchange	$13,999.05
Rate for Payer: Dignity Health Medi-Cal	$10,265.97
Rate for Payer: Dignity Health Medicare Advantage	$9,332.70
Rate for Payer: EPIC Health Plan Commercial	$15,398.95
Rate for Payer: EPIC Health Plan Senior	$10,265.97
Rate for Payer: Heritage Provider Network Commercial/Senior	$15,305.63
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$1,137.26
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$9,332.70
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$1,256.28
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$13,065.78
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$12,505.82
Rate for Payer: Multiplan WC	$14,462.30
Rate for Payer: OptumHealth Care Solutions (URN) Medicare Advantage	$9,332.70
Rate for Payer: Preferred Health Network WC	$14,757.45
Rate for Payer: Prime Health Services Medicare	$9,892.66
Rate for Payer: Prime Health Services WC	$14,314.73
Rate for Payer: Riverside University Health System MISP	$10,265.97
Rate for Payer: United Healthcare All Other HMO	$28,817.00
Rate for Payer: United Healthcare HMO Rider	$18,075.00
Rate for Payer: United Healthcare Select/Navigate/Core	$16,561.00
Rate for Payer: Upland Medical Group Pediatric	$9,332.70
Rate for Payer: Vantage Medical Group Commercial/Exchange	$13,999.05
Rate for Payer: Vantage Medical Group Medi-Cal	$10,265.97
Rate for Payer: Vantage Medical Group Senior	$9,332.70

HALOPERIDOL 0.5 MG TABLET [3578]

Facility

$0.35

Service Code	NDC 5107973301
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.32
Rate for Payer: Adventist Health Commercial	$0.07
Rate for Payer: Blue Shield of California Commercial	$0.28
Rate for Payer: Blue Shield of California EPN	$0.18
Rate for Payer: Cash Price	$0.16
Rate for Payer: Central Health Plan Commercial	$0.28
Rate for Payer: Cigna of CA HMO	$0.25
Rate for Payer: Cigna of CA PPO	$0.25
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$0.25
Rate for Payer: EPIC Health Plan Commercial	$0.14
Rate for Payer: EPIC Health Plan Senior	$0.14
Rate for Payer: Galaxy Health WC	$0.30
Rate for Payer: Global Benefits Group Commercial	$0.21
Rate for Payer: Health Management Network EPO/PPO	$0.32
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$0.22
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$0.21
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.26
Rate for Payer: Networks By Design Commercial	$0.23
Rate for Payer: Prime Health Services Commercial	$0.30

Know your out-of-pocket cost for care.

All Charges