Loma Linda University Medical Center

All Charges

Charge

Type

Price

KIDNEY AND URINARY TRACT MALIGNANCY

Facility IP

$9,492.30

Service Code	APR-DRG 4613
Min. Negotiated Rate	$9,492.30
Max. Negotiated Rate	$9,492.30
Rate for Payer: IEHP Medi-Cal	$9,492.30

KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY

Facility IP

$20,678.91

Service Code	APR-DRG 4423
Min. Negotiated Rate	$20,678.91
Max. Negotiated Rate	$20,678.91
Rate for Payer: IEHP Medi-Cal	$20,678.91

KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY

Facility IP

$36,228.15

Service Code	APR-DRG 4424
Min. Negotiated Rate	$36,228.15
Max. Negotiated Rate	$36,228.15
Rate for Payer: IEHP Medi-Cal	$36,228.15

KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY

Facility IP

$12,256.12

Service Code	APR-DRG 4421
Min. Negotiated Rate	$12,256.12
Max. Negotiated Rate	$12,256.12
Rate for Payer: IEHP Medi-Cal	$12,256.12

KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY

Facility IP

$14,232.99

Service Code	APR-DRG 4422
Min. Negotiated Rate	$14,232.99
Max. Negotiated Rate	$14,232.99
Rate for Payer: IEHP Medi-Cal	$14,232.99

KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY

Facility IP

$10,317.07

Service Code	APR-DRG 4431
Min. Negotiated Rate	$10,317.07
Max. Negotiated Rate	$10,317.07
Rate for Payer: IEHP Medi-Cal	$10,317.07

KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY

Facility IP

$11,946.71

Service Code	APR-DRG 4432
Min. Negotiated Rate	$11,946.71
Max. Negotiated Rate	$11,946.71
Rate for Payer: IEHP Medi-Cal	$11,946.71

KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY

Facility IP

$17,566.88

Service Code	APR-DRG 4433
Min. Negotiated Rate	$17,566.88
Max. Negotiated Rate	$17,566.88
Rate for Payer: IEHP Medi-Cal	$17,566.88

KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY

Facility IP

$29,439.97

Service Code	APR-DRG 4434
Min. Negotiated Rate	$29,439.97
Max. Negotiated Rate	$29,439.97
Rate for Payer: IEHP Medi-Cal	$29,439.97

KIDNEY TRANSPLANT

Facility IP

$50,242.25

Service Code	APR-DRG 4403
Min. Negotiated Rate	$50,242.25
Max. Negotiated Rate	$50,242.25
Rate for Payer: IEHP Medi-Cal	$50,242.25

KIDNEY TRANSPLANT

Facility IP

$43,090.93

Service Code	APR-DRG 4402
Min. Negotiated Rate	$43,090.93
Max. Negotiated Rate	$43,090.93
Rate for Payer: IEHP Medi-Cal	$43,090.93

KIDNEY TRANSPLANT

Facility IP

$38,477.60

Service Code	APR-DRG 4401
Min. Negotiated Rate	$38,477.60
Max. Negotiated Rate	$38,477.60
Rate for Payer: IEHP Medi-Cal	$38,477.60

KIDNEY TRANSPLANT

Facility IP

$76,220.97

Service Code	APR-DRG 4404
Min. Negotiated Rate	$76,220.97
Max. Negotiated Rate	$76,220.97
Rate for Payer: IEHP Medi-Cal	$76,220.97

KIT FOR PREPARATION OF GA-68-GOZETOTIDE 25 MCG INTRAVENOUS SOLUTION [233443]

Facility OP

$5,640.00

Service Code	CPT A9596
Hospital Charge Code	ERX233443
Hospital Revenue Code	636
Min. Negotiated Rate	$991.68
Max. Negotiated Rate	$4,230.00
Rate for Payer: Adventist Health Commercial	$1,128.00
Rate for Payer: Aetna of CA Gatekeeper	$2,277.22
Rate for Payer: Aetna of CA Non-Gatekeeper	$3,874.68
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$1,239.60
Rate for Payer: AlphaCare Medical Group Medi-Cal	$1,090.85
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$1,090.85
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$2,008.88
Rate for Payer: Blue Shield of California Commercial	$3,502.44
Rate for Payer: Blue Shield of California EPN	$3,310.68
Rate for Payer: Cash Price	$2,538.00
Rate for Payer: Cash Price	$2,538.00
Rate for Payer: Cigna of CA HMO/PPO	$2,594.40
Rate for Payer: Dignity Health Commercial/Exchange	$1,239.60
Rate for Payer: Dignity Health Medi-Cal	$1,090.85
Rate for Payer: Dignity Health Senior	$1,090.85
Rate for Payer: EPIC Health Plan Commercial	$3,609.60
Rate for Payer: EPIC Health Plan Medicare	$991.68
Rate for Payer: Heritage Provider Network Commercial	$2,611.32
Rate for Payer: Heritage Provider Network Senior	$2,611.32
Rate for Payer: Humana Medicare	$991.68
Rate for Payer: IEHP Medi-Cal	$1,510.39
Rate for Payer: IEHP Medicare Advantage	$991.68
Rate for Payer: Kaiser Permanente of CA Commercial	$1,884.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1,020.84
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$1,170.18
Rate for Payer: LLUH Dept of Risk Management WC	$1,410.00
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1,249.52
Rate for Payer: Molina Healthcare of CA Medicare	$1,249.52
Rate for Payer: Multiplan Commercial	$4,230.00
Rate for Payer: TriValley Medical Group Commercial	$1,090.85
Rate for Payer: TriValley Medical Group Senior	$991.68
Rate for Payer: United Healthcare All Other HMO/non HMO	$2,056.34
Rate for Payer: United Healthcare Navigate/Select/Select+	$1,884.32
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,239.60
Rate for Payer: Vantage Medical Group Medi-Cal	$1,090.85
Rate for Payer: Vantage Medical Group Senior	$1,090.85

KIT FOR PREPARATION OF GA-68-GOZETOTIDE 25 MCG INTRAVENOUS SOLUTION [233443]

Facility IP

$5,640.00

Service Code	CPT A9596
Hospital Charge Code	ERX233443
Hospital Revenue Code	636
Min. Negotiated Rate	$1,020.84
Max. Negotiated Rate	$4,230.00
Rate for Payer: Adventist Health Commercial	$1,128.00
Rate for Payer: Aetna of CA Non-Gatekeeper	$3,874.68
Rate for Payer: Cash Price	$2,538.00
Rate for Payer: Cigna of CA HMO/PPO	$2,594.40
Rate for Payer: EPIC Health Plan Commercial	$3,045.60
Rate for Payer: Heritage Provider Network Commercial	$3,818.28
Rate for Payer: Heritage Provider Network Senior	$3,818.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1,020.84
Rate for Payer: LLUH Dept of Risk Management WC	$1,410.00
Rate for Payer: Multiplan Commercial	$4,230.00
Rate for Payer: United Healthcare All Other HMO/non HMO	$2,056.34
Rate for Payer: United Healthcare Navigate/Select/Select+	$1,884.32

KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM 25 MG IV SOLUTION [121677]

Facility OP

$15.60

Service Code	CPT A9503
Hospital Charge Code	ERX121677
Hospital Revenue Code	343
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$289.16
Rate for Payer: Adventist Health Commercial	$3.12
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$13.26
Rate for Payer: AlphaCare Medical Group Medi-Cal	$8.58
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$11.70
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$289.16
Rate for Payer: Blue Shield of California Commercial	$9.69
Rate for Payer: Blue Shield of California EPN	$9.16
Rate for Payer: Cash Price	$7.02
Rate for Payer: Cash Price	$7.02
Rate for Payer: Cigna of CA HMO/PPO	$10.14
Rate for Payer: Dignity Health Commercial/Exchange	$13.26
Rate for Payer: Dignity Health Medi-Cal	$13.26
Rate for Payer: Dignity Health Senior	$13.26
Rate for Payer: EPIC Health Plan Commercial	$9.98
Rate for Payer: Heritage Provider Network Commercial	$9.66
Rate for Payer: Heritage Provider Network Senior	$9.66
Rate for Payer: IEHP Medi-Cal	$29.44
Rate for Payer: Kaiser Permanente of CA Commercial	$7.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$2.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.90
Rate for Payer: Multiplan Commercial	$11.70
Rate for Payer: United Healthcare All Other HMO/non HMO	$5.69
Rate for Payer: United Healthcare Navigate/Select/Select+	$5.21
Rate for Payer: Vantage Medical Group Medi-Cal	$13.26
Rate for Payer: Vantage Medical Group Senior	$13.26

KIT FOR PREPARATION OF TC-99M-MEDRONATE SODIUM 25 MG IV SOLUTION [121677]

Facility IP

$15.60

Service Code	CPT A9503
Hospital Charge Code	ERX121677
Hospital Revenue Code	343
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$11.70
Rate for Payer: Adventist Health Commercial	$3.12
Rate for Payer: Aetna of CA Non-Gatekeeper	$10.72
Rate for Payer: Cash Price	$7.02
Rate for Payer: EPIC Health Plan Commercial	$8.42
Rate for Payer: Heritage Provider Network Commercial	$10.56
Rate for Payer: Heritage Provider Network Senior	$10.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$2.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.90
Rate for Payer: Multiplan Commercial	$11.70
Rate for Payer: United Healthcare All Other HMO/non HMO	$5.69
Rate for Payer: United Healthcare Navigate/Select/Select+	$5.21

KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) 1 MG INTRAVENOUS SOLUTION [225273]

Facility OP

$498.77

Service Code	CPT A9562
Hospital Charge Code	ERX225273
Hospital Revenue Code	343
Min. Negotiated Rate	$90.28
Max. Negotiated Rate	$881.58
Rate for Payer: Adventist Health Commercial	$99.75
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$423.95
Rate for Payer: AlphaCare Medical Group Medi-Cal	$274.32
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$374.08
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$881.58
Rate for Payer: Blue Shield of California Commercial	$309.74
Rate for Payer: Blue Shield of California EPN	$292.78
Rate for Payer: Cash Price	$224.45
Rate for Payer: Cash Price	$224.45
Rate for Payer: Cigna of CA HMO/PPO	$324.20
Rate for Payer: Dignity Health Commercial/Exchange	$423.95
Rate for Payer: Dignity Health Medi-Cal	$423.95
Rate for Payer: Dignity Health Senior	$423.95
Rate for Payer: EPIC Health Plan Commercial	$319.21
Rate for Payer: Heritage Provider Network Commercial	$308.74
Rate for Payer: Heritage Provider Network Senior	$308.74
Rate for Payer: IEHP Medi-Cal	$478.89
Rate for Payer: Kaiser Permanente of CA Commercial	$240.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$90.28
Rate for Payer: LLUH Dept of Risk Management WC	$124.69
Rate for Payer: Multiplan Commercial	$374.08
Rate for Payer: United Healthcare All Other HMO/non HMO	$181.85
Rate for Payer: United Healthcare Navigate/Select/Select+	$166.64
Rate for Payer: Vantage Medical Group Medi-Cal	$423.95
Rate for Payer: Vantage Medical Group Senior	$423.95

KIT FOR PREP TC-99M-MERTIATIDE (BETIATIDE) 1 MG INTRAVENOUS SOLUTION [225273]

Facility IP

$498.77

Service Code	CPT A9562
Hospital Charge Code	ERX225273
Hospital Revenue Code	343
Min. Negotiated Rate	$90.28
Max. Negotiated Rate	$374.08
Rate for Payer: Adventist Health Commercial	$99.75
Rate for Payer: Aetna of CA Non-Gatekeeper	$342.65
Rate for Payer: Cash Price	$224.45
Rate for Payer: EPIC Health Plan Commercial	$269.34
Rate for Payer: Heritage Provider Network Commercial	$337.67
Rate for Payer: Heritage Provider Network Senior	$337.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$90.28
Rate for Payer: LLUH Dept of Risk Management WC	$124.69
Rate for Payer: Multiplan Commercial	$374.08
Rate for Payer: United Healthcare All Other HMO/non HMO	$181.85
Rate for Payer: United Healthcare Navigate/Select/Select+	$166.64

KIT FOR TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION [225270]

Facility OP

$181.13

Service Code	CPT A9560
Hospital Charge Code	ERX225270
Hospital Revenue Code	343
Min. Negotiated Rate	$32.78
Max. Negotiated Rate	$225.58
Rate for Payer: Adventist Health Commercial	$36.23
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$153.96
Rate for Payer: AlphaCare Medical Group Medi-Cal	$99.62
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$135.85
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$225.58
Rate for Payer: Blue Shield of California Commercial	$112.48
Rate for Payer: Blue Shield of California EPN	$106.32
Rate for Payer: Cash Price	$81.51
Rate for Payer: Cash Price	$81.51
Rate for Payer: Cigna of CA HMO/PPO	$117.73
Rate for Payer: Dignity Health Commercial/Exchange	$153.96
Rate for Payer: Dignity Health Medi-Cal	$153.96
Rate for Payer: Dignity Health Senior	$153.96
Rate for Payer: EPIC Health Plan Commercial	$115.92
Rate for Payer: Heritage Provider Network Commercial	$112.12
Rate for Payer: Heritage Provider Network Senior	$112.12
Rate for Payer: IEHP Medi-Cal	$80.81
Rate for Payer: Kaiser Permanente of CA Commercial	$87.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$32.78
Rate for Payer: LLUH Dept of Risk Management WC	$45.28
Rate for Payer: Multiplan Commercial	$135.85
Rate for Payer: United Healthcare All Other HMO/non HMO	$66.04
Rate for Payer: United Healthcare Navigate/Select/Select+	$60.52
Rate for Payer: Vantage Medical Group Medi-Cal	$153.96
Rate for Payer: Vantage Medical Group Senior	$153.96

KIT FOR TC 99M-LABELED RED BLOOD CELLS INTRAVENOUS SOLUTION [225270]

Facility IP

$181.13

Service Code	CPT A9560
Hospital Charge Code	ERX225270
Hospital Revenue Code	343
Min. Negotiated Rate	$32.78
Max. Negotiated Rate	$135.85
Rate for Payer: Adventist Health Commercial	$36.23
Rate for Payer: Aetna of CA Non-Gatekeeper	$124.44
Rate for Payer: Cash Price	$81.51
Rate for Payer: EPIC Health Plan Commercial	$97.81
Rate for Payer: Heritage Provider Network Commercial	$122.63
Rate for Payer: Heritage Provider Network Senior	$122.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$32.78
Rate for Payer: LLUH Dept of Risk Management WC	$45.28
Rate for Payer: Multiplan Commercial	$135.85
Rate for Payer: United Healthcare All Other HMO/non HMO	$66.04
Rate for Payer: United Healthcare Navigate/Select/Select+	$60.52

KIT FOR THE PREPARATION OF GA-68-DOTATATE 40 MCG INTRAVENOUS SOLN [215477]

Facility IP

$3,600.00

Service Code	CPT A9587
Hospital Charge Code	ERX215477
Hospital Revenue Code	343
Min. Negotiated Rate	$651.60
Max. Negotiated Rate	$2,700.00
Rate for Payer: Adventist Health Commercial	$720.00
Rate for Payer: Aetna of CA Non-Gatekeeper	$2,473.20
Rate for Payer: Cash Price	$1,620.00
Rate for Payer: EPIC Health Plan Commercial	$1,944.00
Rate for Payer: Heritage Provider Network Commercial	$2,437.20
Rate for Payer: Heritage Provider Network Senior	$2,437.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$651.60
Rate for Payer: LLUH Dept of Risk Management WC	$900.00
Rate for Payer: Multiplan Commercial	$2,700.00
Rate for Payer: United Healthcare All Other HMO/non HMO	$1,312.56
Rate for Payer: United Healthcare Navigate/Select/Select+	$1,202.76

KIT FOR THE PREPARATION OF GA-68-DOTATATE 40 MCG INTRAVENOUS SOLN [215477]

Facility OP

$3,600.00

Service Code	CPT A9587
Hospital Charge Code	ERX215477
Hospital Revenue Code	343
Min. Negotiated Rate	$134.56
Max. Negotiated Rate	$3,060.00
Rate for Payer: Adventist Health Commercial	$720.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$3,060.00
Rate for Payer: AlphaCare Medical Group Medi-Cal	$1,980.00
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$2,700.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$134.56
Rate for Payer: Blue Shield of California Commercial	$2,235.60
Rate for Payer: Blue Shield of California EPN	$2,113.20
Rate for Payer: Cash Price	$1,620.00
Rate for Payer: Cash Price	$1,620.00
Rate for Payer: Cigna of CA HMO/PPO	$2,340.00
Rate for Payer: Dignity Health Commercial/Exchange	$3,060.00
Rate for Payer: Dignity Health Medi-Cal	$3,060.00
Rate for Payer: Dignity Health Senior	$3,060.00
Rate for Payer: EPIC Health Plan Commercial	$2,304.00
Rate for Payer: Heritage Provider Network Commercial	$2,228.40
Rate for Payer: Heritage Provider Network Senior	$2,228.40
Rate for Payer: Kaiser Permanente of CA Commercial	$1,735.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$651.60
Rate for Payer: LLUH Dept of Risk Management WC	$900.00
Rate for Payer: Multiplan Commercial	$2,700.00
Rate for Payer: United Healthcare All Other HMO/non HMO	$1,312.56
Rate for Payer: United Healthcare Navigate/Select/Select+	$1,202.76
Rate for Payer: Vantage Medical Group Medi-Cal	$3,060.00
Rate for Payer: Vantage Medical Group Senior	$3,060.00

KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [121131]

Facility IP

$90.00

Service Code	CPT A9537
Hospital Charge Code	ERX121131
Hospital Revenue Code	343
Min. Negotiated Rate	$16.29
Max. Negotiated Rate	$67.50
Rate for Payer: Adventist Health Commercial	$18.00
Rate for Payer: Aetna of CA Non-Gatekeeper	$61.83
Rate for Payer: Cash Price	$40.50
Rate for Payer: EPIC Health Plan Commercial	$48.60
Rate for Payer: Heritage Provider Network Commercial	$60.93
Rate for Payer: Heritage Provider Network Senior	$60.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$16.29
Rate for Payer: LLUH Dept of Risk Management WC	$22.50
Rate for Payer: Multiplan Commercial	$67.50
Rate for Payer: United Healthcare All Other HMO/non HMO	$32.81
Rate for Payer: United Healthcare Navigate/Select/Select+	$30.07

KIT FOR THE PREPARATION OF TC-99M-MEBROFENIN 45 MG IV SOLUTION [121131]

Facility OP

$90.00

Service Code	CPT A9537
Hospital Charge Code	ERX121131
Hospital Revenue Code	343
Min. Negotiated Rate	$16.29
Max. Negotiated Rate	$117.82
Rate for Payer: Adventist Health Commercial	$18.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$76.50
Rate for Payer: AlphaCare Medical Group Medi-Cal	$49.50
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$67.50
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$117.82
Rate for Payer: Blue Shield of California Commercial	$55.89
Rate for Payer: Blue Shield of California EPN	$52.83
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna of CA HMO/PPO	$58.50
Rate for Payer: Dignity Health Commercial/Exchange	$76.50
Rate for Payer: Dignity Health Medi-Cal	$76.50
Rate for Payer: Dignity Health Senior	$76.50
Rate for Payer: EPIC Health Plan Commercial	$57.60
Rate for Payer: Heritage Provider Network Commercial	$55.71
Rate for Payer: Heritage Provider Network Senior	$55.71
Rate for Payer: IEHP Medi-Cal	$70.76
Rate for Payer: Kaiser Permanente of CA Commercial	$43.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$16.29
Rate for Payer: LLUH Dept of Risk Management WC	$22.50
Rate for Payer: Multiplan Commercial	$67.50
Rate for Payer: United Healthcare All Other HMO/non HMO	$32.81
Rate for Payer: United Healthcare Navigate/Select/Select+	$30.07
Rate for Payer: Vantage Medical Group Medi-Cal	$76.50
Rate for Payer: Vantage Medical Group Senior	$76.50

Price Transparency.

All Charges