Loma Linda University Medical Center

All Charges

Charge

Type

Price

ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]

Facility OP

$0.15

Service Code	NDC 66689-201-08
Hospital Charge Code	1719161
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA HMO/PPO	$0.09
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.13
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.08
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.08
Rate for Payer: Anthem Blue Cross of CA Exchange	$0.07
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.09
Rate for Payer: BCBS Transplant Transplant	$0.09
Rate for Payer: Blue Shield of California Commercial	$0.09
Rate for Payer: Blue Shield of California EPN	$0.07
Rate for Payer: Cash Price	$0.07
Rate for Payer: Central Health Plan Commercial	$0.12
Rate for Payer: Cigna of CA HMO	$0.11
Rate for Payer: Cigna of CA PPO	$0.11
Rate for Payer: Dignity Health Commercial/Exchange	$0.13
Rate for Payer: EPIC Health Plan Commercial	$0.06
Rate for Payer: EPIC Health Plan Transplant	$0.06
Rate for Payer: Galaxy Health WC	$0.13
Rate for Payer: Global Benefits Group Commercial	$0.09
Rate for Payer: Health Management Network EPO/PPO	$0.14
Rate for Payer: Health Plan of Nevada - Sierra Transplant Other	$0.11
Rate for Payer: IEHP medi-cal	$0.05
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.11
Rate for Payer: Networks By Design Commercial	$0.10
Rate for Payer: Prime Health Services Commercial	$0.13
Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior	$0.09
Rate for Payer: Riverside University Health MISP	$0.06
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$0.09
Rate for Payer: TriValley Medical Group Commercial/Senior	$0.09
Rate for Payer: United Healthcare All Other Commercial	$0.08
Rate for Payer: United Healthcare All Other HMO	$0.08
Rate for Payer: United Healthcare HMO Rider	$0.08
Rate for Payer: United Healthcare Select/Navigate/Core	$0.08
Rate for Payer: Vantage Medical Group Medi-Cal	$0.13
Rate for Payer: Vantage Medical Group Senior	$0.13

ACTIVATED CHARCOAL 50 GRAM/240 ML ORAL SUSPENSION [117012]

Facility IP

$0.10

Service Code	NDC 0574-0521-76
Hospital Charge Code	1719161
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$34,005.88
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: Blue Shield of California Commercial	$0.08
Rate for Payer: Blue Shield of California EPN	$0.05
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cash Price	$0.05
Rate for Payer: Central Health Plan Commercial	$0.08
Rate for Payer: Cigna of CA HMO	$0.07
Rate for Payer: Cigna of CA PPO	$0.07
Rate for Payer: EPIC Health Plan Commercial	$0.04
Rate for Payer: Galaxy Health WC	$0.09
Rate for Payer: Global Benefits Group Commercial	$0.06
Rate for Payer: Health Management Network EPO/PPO	$0.09
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.08
Rate for Payer: Networks By Design Commercial	$0.07
Rate for Payer: Prime Health Services Commercial	$0.09

ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION

Facility IP

$34,005.88

Service Code	TRIS-DRG 880
Min. Negotiated Rate	$34,005.88
Max. Negotiated Rate	$34,005.88
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88

ACUTE AND SUBACUTE ENDOCARDITIS

Facility IP

$34,005.88

Service Code	APR-DRG 1933
Min. Negotiated Rate	$14,650.64
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$14,650.64
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$17,458.68

ACUTE AND SUBACUTE ENDOCARDITIS

Facility IP

$34,005.88

Service Code	APR-DRG 1931
Min. Negotiated Rate	$7,509.01
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$7,509.01
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$8,948.24

ACUTE AND SUBACUTE ENDOCARDITIS

Facility IP

$34,005.88

Service Code	APR-DRG 1934
Min. Negotiated Rate	$22,767.86
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$22,767.86
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$27,131.70

ACUTE AND SUBACUTE ENDOCARDITIS

Facility IP

$34,005.88

Service Code	APR-DRG 1932
Min. Negotiated Rate	$11,060.80
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$11,060.80
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$13,180.78

ACUTE AND SUBACUTE ENDOCARDITIS WITH CC

Facility IP

$34,005.88

Service Code	TRIS-DRG 289
Min. Negotiated Rate	$34,005.88
Max. Negotiated Rate	$34,005.88
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88

ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC

Facility IP

$34,005.88

Service Code	TRIS-DRG 288
Min. Negotiated Rate	$34,005.88
Max. Negotiated Rate	$34,005.88
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88

ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC

Facility IP

$34,005.88

Service Code	TRIS-DRG 290
Min. Negotiated Rate	$34,005.88
Max. Negotiated Rate	$34,005.88
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88

ACUTE ANXIETY AND DELIRIUM STATES

Facility IP

$34,005.88

Service Code	APR-DRG 7562
Min. Negotiated Rate	$5,676.56
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$5,676.56
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$6,764.57

ACUTE ANXIETY AND DELIRIUM STATES

Facility IP

$34,005.88

Service Code	APR-DRG 7561
Min. Negotiated Rate	$4,341.43
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$4,341.43
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$5,173.54

ACUTE ANXIETY AND DELIRIUM STATES

Facility IP

$34,005.88

Service Code	APR-DRG 7563
Min. Negotiated Rate	$5,884.90
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$5,884.90
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$7,012.83

ACUTE ANXIETY AND DELIRIUM STATES

Facility IP

$34,005.88

Service Code	APR-DRG 7564
Min. Negotiated Rate	$12,159.59
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$12,159.59
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$14,490.18

ACUTE BRONCHITIS AND RELATED SYMPTOMS

Facility IP

$34,005.88

Service Code	APR-DRG 1453
Min. Negotiated Rate	$7,640.06
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$7,640.06
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$9,104.41

ACUTE BRONCHITIS AND RELATED SYMPTOMS

Facility IP

$34,005.88

Service Code	APR-DRG 1454
Min. Negotiated Rate	$11,638.75
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$11,638.75
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$13,869.51

ACUTE BRONCHITIS AND RELATED SYMPTOMS

Facility IP

$34,005.88

Service Code	APR-DRG 1452
Min. Negotiated Rate	$5,921.87
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$5,921.87
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$7,056.89

ACUTE BRONCHITIS AND RELATED SYMPTOMS

Facility IP

$34,005.88

Service Code	APR-DRG 1451
Min. Negotiated Rate	$4,632.65
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$4,632.65
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$5,520.57

ACUTE KIDNEY INJURY

Facility IP

$34,005.88

Service Code	APR-DRG 4693
Min. Negotiated Rate	$9,324.67
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$9,324.67
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$11,111.90

ACUTE KIDNEY INJURY

Facility IP

$34,005.88

Service Code	APR-DRG 4692
Min. Negotiated Rate	$5,974.51
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$5,974.51
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$7,119.63

ACUTE KIDNEY INJURY

Facility IP

$34,005.88

Service Code	APR-DRG 4691
Min. Negotiated Rate	$4,606.88
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$4,606.88
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$5,489.87

ACUTE KIDNEY INJURY

Facility IP

$34,005.88

Service Code	APR-DRG 4694
Min. Negotiated Rate	$17,446.37
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$17,446.37
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$20,790.26

ACUTE LEUKEMIA

Facility IP

$34,005.88

Service Code	APR-DRG 6901
Min. Negotiated Rate	$8,416.28
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$8,416.28
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$10,029.41

ACUTE LEUKEMIA

Facility IP

$36,172.05

Service Code	APR-DRG 6903
Min. Negotiated Rate	$30,354.17
Max. Negotiated Rate	$36,172.05
Rate for Payer: Adventist Health Medi-Cal	$30,354.17
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$36,172.05

ACUTE LEUKEMIA

Facility IP

$34,005.88

Service Code	APR-DRG 6902
Min. Negotiated Rate	$16,296.05
Max. Negotiated Rate	$34,005.88
Rate for Payer: Adventist Health Medi-Cal	$16,296.05
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$34,005.88
Rate for Payer: IEHP medi-cal	$19,419.46

Price Transparency.

All Charges