Loma Linda University Medical Center

All Charges

Charge

Type

Price

INPATIENT MS-DRG 124: OTHER DISORDERS OF THE EYE WITH MCC OR THROMBOLYTIC AGENT

Facility IP

$22,860.17

Service Code	MS-DRG 124
Min. Negotiated Rate	$15,089.57
Max. Negotiated Rate	$22,860.17
Rate for Payer: EPIC Health Plan Medicare	$15,089.57
Rate for Payer: Humana Medicare	$15,089.57
Rate for Payer: IEHP Medicare Advantage	$15,089.57
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$17,805.69
Rate for Payer: Molina Healthcare of CA Medi-Cal	$19,012.86
Rate for Payer: Molina Healthcare of CA Medicare	$19,012.86
Rate for Payer: Multiplan WC	$22,860.17

INPATIENT MS-DRG 125: OTHER DISORDERS OF THE EYE WITHOUT MCC

Facility IP

$14,069.93

Service Code	MS-DRG 125
Min. Negotiated Rate	$9,184.58
Max. Negotiated Rate	$14,069.93
Rate for Payer: EPIC Health Plan Medicare	$9,184.58
Rate for Payer: Humana Medicare	$9,184.58
Rate for Payer: IEHP Medicare Advantage	$9,184.58
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$10,837.80
Rate for Payer: Molina Healthcare of CA Medi-Cal	$11,572.57
Rate for Payer: Molina Healthcare of CA Medicare	$11,572.57
Rate for Payer: Multiplan WC	$14,069.93

INPATIENT MS-DRG 135: SINUS AND MASTOID PROCEDURES WITH CC/MCC

Facility IP

$39,996.72

Service Code	MS-DRG 135
Min. Negotiated Rate	$30,068.22
Max. Negotiated Rate	$39,996.72
Rate for Payer: EPIC Health Plan Medicare	$30,068.22
Rate for Payer: Humana Medicare	$30,068.22
Rate for Payer: IEHP Medicare Advantage	$30,068.22
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$35,480.50
Rate for Payer: Molina Healthcare of CA Medi-Cal	$37,885.96
Rate for Payer: Molina Healthcare of CA Medicare	$37,885.96
Rate for Payer: Multiplan WC	$39,996.72

INPATIENT MS-DRG 136: SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC

Facility IP

$18,936.71

Service Code	MS-DRG 136
Min. Negotiated Rate	$11,963.68
Max. Negotiated Rate	$18,936.71
Rate for Payer: EPIC Health Plan Medicare	$11,963.68
Rate for Payer: Humana Medicare	$11,963.68
Rate for Payer: IEHP Medicare Advantage	$11,963.68
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$14,117.14
Rate for Payer: Molina Healthcare of CA Medi-Cal	$15,074.24
Rate for Payer: Molina Healthcare of CA Medicare	$15,074.24
Rate for Payer: Multiplan WC	$18,936.71

INPATIENT MS-DRG 137: MOUTH PROCEDURES WITH CC/MCC

Facility IP

$24,474.27

Service Code	MS-DRG 137
Min. Negotiated Rate	$17,147.98
Max. Negotiated Rate	$24,474.27
Rate for Payer: EPIC Health Plan Medicare	$17,147.98
Rate for Payer: Humana Medicare	$17,147.98
Rate for Payer: IEHP Medicare Advantage	$17,147.98
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$20,234.62
Rate for Payer: Molina Healthcare of CA Medi-Cal	$21,606.45
Rate for Payer: Molina Healthcare of CA Medicare	$21,606.45
Rate for Payer: Multiplan WC	$24,474.27

INPATIENT MS-DRG 138: MOUTH PROCEDURES WITHOUT CC/MCC

Facility IP

$14,432.24

Service Code	MS-DRG 138
Min. Negotiated Rate	$9,952.56
Max. Negotiated Rate	$14,432.24
Rate for Payer: EPIC Health Plan Medicare	$9,952.56
Rate for Payer: Humana Medicare	$9,952.56
Rate for Payer: IEHP Medicare Advantage	$9,952.56
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$11,744.02
Rate for Payer: Molina Healthcare of CA Medi-Cal	$12,540.23
Rate for Payer: Molina Healthcare of CA Medicare	$12,540.23
Rate for Payer: Multiplan WC	$14,432.24

INPATIENT MS-DRG 139: SALIVARY GLAND PROCEDURES

Facility IP

$20,523.06

Service Code	MS-DRG 139
Min. Negotiated Rate	$13,578.41
Max. Negotiated Rate	$20,523.06
Rate for Payer: EPIC Health Plan Medicare	$13,578.41
Rate for Payer: Humana Medicare	$13,578.41
Rate for Payer: IEHP Medicare Advantage	$13,578.41
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$16,022.52
Rate for Payer: Molina Healthcare of CA Medi-Cal	$17,108.80
Rate for Payer: Molina Healthcare of CA Medicare	$17,108.80
Rate for Payer: Multiplan WC	$20,523.06

INPATIENT MS-DRG 140: MAJOR HEAD AND NECK PROCEDURES WITH MCC

Facility IP

$67,833.01

Service Code	MS-DRG 140
Min. Negotiated Rate	$42,747.48
Max. Negotiated Rate	$67,833.01
Rate for Payer: EPIC Health Plan Medicare	$42,747.48
Rate for Payer: Humana Medicare	$42,747.48
Rate for Payer: IEHP Medicare Advantage	$42,747.48
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$50,442.03
Rate for Payer: Molina Healthcare of CA Medi-Cal	$53,861.82
Rate for Payer: Molina Healthcare of CA Medicare	$53,861.82
Rate for Payer: Multiplan WC	$67,833.01

INPATIENT MS-DRG 141: MAJOR HEAD AND NECK PROCEDURES WITH CC

Facility IP

$36,437.21

Service Code	MS-DRG 141
Min. Negotiated Rate	$23,532.66
Max. Negotiated Rate	$36,437.21
Rate for Payer: EPIC Health Plan Medicare	$23,532.66
Rate for Payer: Humana Medicare	$23,532.66
Rate for Payer: IEHP Medicare Advantage	$23,532.66
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$27,768.54
Rate for Payer: Molina Healthcare of CA Medi-Cal	$29,651.15
Rate for Payer: Molina Healthcare of CA Medicare	$29,651.15
Rate for Payer: Multiplan WC	$36,437.21

INPATIENT MS-DRG 142: MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC

Facility IP

$27,772.64

Service Code	MS-DRG 142
Min. Negotiated Rate	$17,601.78
Max. Negotiated Rate	$27,772.64
Rate for Payer: EPIC Health Plan Medicare	$17,601.78
Rate for Payer: Humana Medicare	$17,601.78
Rate for Payer: IEHP Medicare Advantage	$17,601.78
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$20,770.10
Rate for Payer: Molina Healthcare of CA Medi-Cal	$22,178.24
Rate for Payer: Molina Healthcare of CA Medicare	$22,178.24
Rate for Payer: Multiplan WC	$27,772.64

INPATIENT MS-DRG 143: OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH MCC

Facility IP

$51,778.51

Service Code	MS-DRG 143
Min. Negotiated Rate	$37,652.13
Max. Negotiated Rate	$51,778.51
Rate for Payer: EPIC Health Plan Medicare	$37,652.13
Rate for Payer: Humana Medicare	$37,652.13
Rate for Payer: IEHP Medicare Advantage	$37,652.13
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$44,429.51
Rate for Payer: Molina Healthcare of CA Medi-Cal	$47,441.68
Rate for Payer: Molina Healthcare of CA Medicare	$47,441.68
Rate for Payer: Multiplan WC	$51,778.51

INPATIENT MS-DRG 144: OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITH CC

Facility IP

$29,528.73

Service Code	MS-DRG 144
Min. Negotiated Rate	$19,690.59
Max. Negotiated Rate	$29,528.73
Rate for Payer: EPIC Health Plan Medicare	$19,690.59
Rate for Payer: Humana Medicare	$19,690.59
Rate for Payer: IEHP Medicare Advantage	$19,690.59
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$23,234.90
Rate for Payer: Molina Healthcare of CA Medi-Cal	$24,810.14
Rate for Payer: Molina Healthcare of CA Medicare	$24,810.14
Rate for Payer: Multiplan WC	$29,528.73

INPATIENT MS-DRG 145: OTHER EAR, NOSE, MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC

Facility IP

$19,711.94

Service Code	MS-DRG 145
Min. Negotiated Rate	$13,954.53
Max. Negotiated Rate	$19,711.94
Rate for Payer: EPIC Health Plan Medicare	$13,954.53
Rate for Payer: Humana Medicare	$13,954.53
Rate for Payer: IEHP Medicare Advantage	$13,954.53
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$16,466.35
Rate for Payer: Molina Healthcare of CA Medi-Cal	$17,582.71
Rate for Payer: Molina Healthcare of CA Medicare	$17,582.71
Rate for Payer: Multiplan WC	$19,711.94

INPATIENT MS-DRG 146: EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC

Facility IP

$32,872.81

Service Code	MS-DRG 146
Min. Negotiated Rate	$23,975.19
Max. Negotiated Rate	$32,872.81
Rate for Payer: EPIC Health Plan Medicare	$23,975.19
Rate for Payer: Humana Medicare	$23,975.19
Rate for Payer: IEHP Medicare Advantage	$23,975.19
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$28,290.72
Rate for Payer: Molina Healthcare of CA Medi-Cal	$30,208.74
Rate for Payer: Molina Healthcare of CA Medicare	$30,208.74
Rate for Payer: Multiplan WC	$32,872.81

INPATIENT MS-DRG 147: EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC

Facility IP

$19,765.79

Service Code	MS-DRG 147
Min. Negotiated Rate	$14,120.03
Max. Negotiated Rate	$19,765.79
Rate for Payer: EPIC Health Plan Medicare	$14,120.03
Rate for Payer: Humana Medicare	$14,120.03
Rate for Payer: IEHP Medicare Advantage	$14,120.03
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$16,661.64
Rate for Payer: Molina Healthcare of CA Medi-Cal	$17,791.24
Rate for Payer: Molina Healthcare of CA Medicare	$17,791.24
Rate for Payer: Multiplan WC	$19,765.79

INPATIENT MS-DRG 148: EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC

Facility IP

$13,343.66

Service Code	MS-DRG 148
Min. Negotiated Rate	$10,222.80
Max. Negotiated Rate	$13,343.66
Rate for Payer: EPIC Health Plan Medicare	$10,222.80
Rate for Payer: Humana Medicare	$10,222.80
Rate for Payer: IEHP Medicare Advantage	$10,222.80
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$12,062.90
Rate for Payer: Molina Healthcare of CA Medi-Cal	$12,880.73
Rate for Payer: Molina Healthcare of CA Medicare	$12,880.73
Rate for Payer: Multiplan WC	$13,343.66

INPATIENT MS-DRG 149: DYSEQUILIBRIUM

Facility IP

$12,322.00

Service Code	MS-DRG 149
Min. Negotiated Rate	$8,590.03
Max. Negotiated Rate	$12,322.00
Rate for Payer: EPIC Health Plan Medicare	$8,590.03
Rate for Payer: Humana Medicare	$8,590.03
Rate for Payer: IEHP Medicare Advantage	$8,590.03
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$10,136.24
Rate for Payer: Molina Healthcare of CA Medi-Cal	$10,823.44
Rate for Payer: Molina Healthcare of CA Medicare	$10,823.44
Rate for Payer: Multiplan WC	$12,322.00

INPATIENT MS-DRG 150: EPISTAXIS WITH MCC

Facility IP

$22,510.90

Service Code	MS-DRG 150
Min. Negotiated Rate	$15,006.24
Max. Negotiated Rate	$22,510.90
Rate for Payer: EPIC Health Plan Medicare	$15,006.24
Rate for Payer: Humana Medicare	$15,006.24
Rate for Payer: IEHP Medicare Advantage	$15,006.24
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$17,707.36
Rate for Payer: Molina Healthcare of CA Medi-Cal	$18,907.86
Rate for Payer: Molina Healthcare of CA Medicare	$18,907.86
Rate for Payer: Multiplan WC	$22,510.90

INPATIENT MS-DRG 151: EPISTAXIS WITHOUT MCC

Facility IP

$12,583.13

Service Code	MS-DRG 151
Min. Negotiated Rate	$8,882.83
Max. Negotiated Rate	$12,583.13
Rate for Payer: EPIC Health Plan Medicare	$8,882.83
Rate for Payer: Humana Medicare	$8,882.83
Rate for Payer: IEHP Medicare Advantage	$8,882.83
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$10,481.74
Rate for Payer: Molina Healthcare of CA Medi-Cal	$11,192.37
Rate for Payer: Molina Healthcare of CA Medicare	$11,192.37
Rate for Payer: Multiplan WC	$12,583.13

INPATIENT MS-DRG 152: OTITIS MEDIA AND URI WITH MCC

Facility IP

$19,547.10

Service Code	MS-DRG 152
Min. Negotiated Rate	$13,584.03
Max. Negotiated Rate	$19,547.10
Rate for Payer: EPIC Health Plan Medicare	$13,584.03
Rate for Payer: Humana Medicare	$13,584.03
Rate for Payer: IEHP Medicare Advantage	$13,584.03
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$16,029.16
Rate for Payer: Molina Healthcare of CA Medi-Cal	$17,115.88
Rate for Payer: Molina Healthcare of CA Medicare	$17,115.88
Rate for Payer: Multiplan WC	$19,547.10

INPATIENT MS-DRG 153: OTITIS MEDIA AND URI WITHOUT MCC

Facility IP

$11,269.32

Service Code	MS-DRG 153
Min. Negotiated Rate	$8,478.55
Max. Negotiated Rate	$11,269.32
Rate for Payer: EPIC Health Plan Medicare	$8,478.55
Rate for Payer: Humana Medicare	$8,478.55
Rate for Payer: IEHP Medicare Advantage	$8,478.55
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$10,004.69
Rate for Payer: Molina Healthcare of CA Medi-Cal	$10,682.97
Rate for Payer: Molina Healthcare of CA Medicare	$10,682.97
Rate for Payer: Multiplan WC	$11,269.32

INPATIENT MS-DRG 154: OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC

Facility IP

$24,528.13

Service Code	MS-DRG 154
Min. Negotiated Rate	$17,525.20
Max. Negotiated Rate	$24,528.13
Rate for Payer: EPIC Health Plan Medicare	$17,525.20
Rate for Payer: Humana Medicare	$17,525.20
Rate for Payer: IEHP Medicare Advantage	$17,525.20
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$20,679.74
Rate for Payer: Molina Healthcare of CA Medi-Cal	$22,081.75
Rate for Payer: Molina Healthcare of CA Medicare	$22,081.75
Rate for Payer: Multiplan WC	$24,528.13

INPATIENT MS-DRG 155: OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC

Facility IP

$15,003.46

Service Code	MS-DRG 155
Min. Negotiated Rate	$10,863.52
Max. Negotiated Rate	$15,003.46
Rate for Payer: EPIC Health Plan Medicare	$10,863.52
Rate for Payer: Humana Medicare	$10,863.52
Rate for Payer: IEHP Medicare Advantage	$10,863.52
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$12,818.95
Rate for Payer: Molina Healthcare of CA Medi-Cal	$13,688.04
Rate for Payer: Molina Healthcare of CA Medicare	$13,688.04
Rate for Payer: Multiplan WC	$15,003.46

INPATIENT MS-DRG 156: OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC

Facility IP

$11,125.70

Service Code	MS-DRG 156
Min. Negotiated Rate	$7,585.62
Max. Negotiated Rate	$11,125.70
Rate for Payer: EPIC Health Plan Medicare	$7,585.62
Rate for Payer: Humana Medicare	$7,585.62
Rate for Payer: IEHP Medicare Advantage	$7,585.62
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$8,951.03
Rate for Payer: Molina Healthcare of CA Medi-Cal	$9,557.88
Rate for Payer: Molina Healthcare of CA Medicare	$9,557.88
Rate for Payer: Multiplan WC	$11,125.70

INPATIENT MS-DRG 157: DENTAL AND ORAL DISEASES WITH MCC

Facility IP

$27,284.66

Service Code	MS-DRG 157
Min. Negotiated Rate	$19,425.98
Max. Negotiated Rate	$27,284.66
Rate for Payer: EPIC Health Plan Medicare	$19,425.98
Rate for Payer: Humana Medicare	$19,425.98
Rate for Payer: IEHP Medicare Advantage	$19,425.98
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$22,922.66
Rate for Payer: Molina Healthcare of CA Medi-Cal	$24,476.73
Rate for Payer: Molina Healthcare of CA Medicare	$24,476.73
Rate for Payer: Multiplan WC	$27,284.66

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