Loma Linda University Medical Center

All Charges

Charge

Type

Price

Percutaneous skeletal fixation of metatarsophalangeal joint dislocation, with manipulation

Facility OP

$9,616.00

Service Code	CPT 28636
Min. Negotiated Rate	$45.88
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$3,728.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$6,066.32
Rate for Payer: AlphaCare Medical Group Medi-Cal	$4,448.63
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$4,044.21
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$4,547.00
Rate for Payer: Dignity Health Commercial/Exchange	$6,066.32
Rate for Payer: Dignity Health Medi-Cal	$4,448.63
Rate for Payer: Dignity Health Senior	$4,044.21
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$4,044.21
Rate for Payer: Humana Medicare	$4,044.21
Rate for Payer: IEHP Medi-Cal	$45.88
Rate for Payer: IEHP Medicare Advantage	$4,044.21
Rate for Payer: Kaiser Permanente of CA Commercial	$7,684.00
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$4,772.17
Rate for Payer: Molina Healthcare of CA Medi-Cal	$5,095.70
Rate for Payer: Molina Healthcare of CA Medicare	$5,095.70
Rate for Payer: TriValley Medical Group Commercial	$4,448.63
Rate for Payer: TriValley Medical Group Senior	$4,044.21
Rate for Payer: Vantage Medical Group Commercial/Exchange	$6,066.32
Rate for Payer: Vantage Medical Group Medi-Cal	$4,448.63
Rate for Payer: Vantage Medical Group Senior	$4,044.21

Percutaneous skeletal fixation of posterior pelvic bone fracture and/or dislocation, for fracture patterns that disrupt the pelvic ring, unilateral (includes ipsilateral ilium, sacroiliac joint and/or sacrum)

Facility OP

$9,616.00

Service Code	CPT 27216
Min. Negotiated Rate	$725.40
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$1,965.61
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$7,436.00
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: IEHP Medi-Cal	$725.40

Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each

Facility OP

$9,616.00

Service Code	CPT 26727
Min. Negotiated Rate	$340.35
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$4,420.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$6,066.32
Rate for Payer: AlphaCare Medical Group Medi-Cal	$4,448.63
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$4,044.21
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$7,436.00
Rate for Payer: Dignity Health Commercial/Exchange	$6,066.32
Rate for Payer: Dignity Health Medi-Cal	$4,448.63
Rate for Payer: Dignity Health Senior	$4,044.21
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$4,044.21
Rate for Payer: Humana Medicare	$4,044.21
Rate for Payer: IEHP Medi-Cal	$340.35
Rate for Payer: IEHP Medicare Advantage	$4,044.21
Rate for Payer: Kaiser Permanente of CA Commercial	$7,684.00
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$4,772.17
Rate for Payer: Molina Healthcare of CA Medi-Cal	$5,095.70
Rate for Payer: Molina Healthcare of CA Medicare	$5,095.70
Rate for Payer: TriValley Medical Group Commercial	$4,448.63
Rate for Payer: TriValley Medical Group Senior	$4,044.21
Rate for Payer: Vantage Medical Group Commercial/Exchange	$6,066.32
Rate for Payer: Vantage Medical Group Medi-Cal	$4,448.63
Rate for Payer: Vantage Medical Group Senior	$4,044.21

PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES

Facility IP

$60,490.67

Service Code	APR-DRG 1834
Min. Negotiated Rate	$60,490.67
Max. Negotiated Rate	$60,490.67
Rate for Payer: IEHP Medi-Cal	$60,490.67

PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES

Facility IP

$42,493.00

Service Code	APR-DRG 1833
Min. Negotiated Rate	$42,493.00
Max. Negotiated Rate	$42,493.00
Rate for Payer: IEHP Medi-Cal	$42,493.00

PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES

Facility IP

$35,477.00

Service Code	APR-DRG 1831
Min. Negotiated Rate	$35,477.00
Max. Negotiated Rate	$35,477.00
Rate for Payer: IEHP Medi-Cal	$35,477.00

PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES

Facility IP

$36,493.78

Service Code	APR-DRG 1832
Min. Negotiated Rate	$36,493.78
Max. Negotiated Rate	$36,493.78
Rate for Payer: IEHP Medi-Cal	$36,493.78

Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation

Facility OP

$9,616.00

Service Code	CPT 33340
Min. Negotiated Rate	$1,058.77
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$7,402.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,576.00
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: IEHP Medi-Cal	$1,058.77

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure)

Facility OP

$9,616.00

Service Code	CPT 22515
Min. Negotiated Rate	$304.34
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: IEHP Medi-Cal	$304.34

Facility OP

$16,983.21

Service Code	CPT 22514
Min. Negotiated Rate	$135.91
Max. Negotiated Rate	$16,983.21
Rate for Payer: Aetna of CA Gatekeeper	$5,088.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$13,407.80
Rate for Payer: AlphaCare Medical Group Medi-Cal	$9,832.38
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$8,938.53
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$4,547.00
Rate for Payer: Dignity Health Commercial/Exchange	$13,407.80
Rate for Payer: Dignity Health Medi-Cal	$9,832.38
Rate for Payer: Dignity Health Senior	$8,938.53
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$8,938.53
Rate for Payer: Humana Medicare	$8,938.53
Rate for Payer: IEHP Medi-Cal	$135.91
Rate for Payer: IEHP Medicare Advantage	$8,938.53
Rate for Payer: Kaiser Permanente of CA Commercial	$16,983.21
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$10,547.47
Rate for Payer: Molina Healthcare of CA Medi-Cal	$11,262.55
Rate for Payer: Molina Healthcare of CA Medicare	$11,262.55
Rate for Payer: TriValley Medical Group Commercial	$9,832.38
Rate for Payer: TriValley Medical Group Senior	$8,938.53
Rate for Payer: Vantage Medical Group Commercial/Exchange	$13,407.80
Rate for Payer: Vantage Medical Group Medi-Cal	$9,832.38
Rate for Payer: Vantage Medical Group Senior	$8,938.53

Facility OP

$16,983.21

Service Code	CPT 22513
Min. Negotiated Rate	$728.30
Max. Negotiated Rate	$16,983.21
Rate for Payer: Aetna of CA Gatekeeper	$5,088.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$13,407.80
Rate for Payer: AlphaCare Medical Group Medi-Cal	$9,832.38
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$8,938.53
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$4,547.00
Rate for Payer: Dignity Health Commercial/Exchange	$13,407.80
Rate for Payer: Dignity Health Medi-Cal	$9,832.38
Rate for Payer: Dignity Health Senior	$8,938.53
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$8,938.53
Rate for Payer: Humana Medicare	$8,938.53
Rate for Payer: IEHP Medi-Cal	$728.30
Rate for Payer: IEHP Medicare Advantage	$8,938.53
Rate for Payer: Kaiser Permanente of CA Commercial	$16,983.21
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$10,547.47
Rate for Payer: Molina Healthcare of CA Medi-Cal	$11,262.55
Rate for Payer: Molina Healthcare of CA Medicare	$11,262.55
Rate for Payer: TriValley Medical Group Commercial	$9,832.38
Rate for Payer: TriValley Medical Group Senior	$8,938.53
Rate for Payer: Vantage Medical Group Commercial/Exchange	$13,407.80
Rate for Payer: Vantage Medical Group Medi-Cal	$9,832.38
Rate for Payer: Vantage Medical Group Senior	$8,938.53

PERFLUTREN PROTEIN-TYPE A MICROSPHERES 0.22 MG/ML INTRAVENOUS SUSP [82177]

Facility OP

$56.16

Service Code	CPT Q9956
Hospital Charge Code	NDG82177
Hospital Revenue Code	636
Min. Negotiated Rate	$10.16
Max. Negotiated Rate	$103.57
Rate for Payer: Adventist Health Commercial	$11.23
Rate for Payer: Aetna of CA Gatekeeper	$103.57
Rate for Payer: Aetna of CA Non-Gatekeeper	$38.58
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$47.74
Rate for Payer: AlphaCare Medical Group Medi-Cal	$30.89
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$42.12
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$91.28
Rate for Payer: Blue Shield of California Commercial	$34.88
Rate for Payer: Blue Shield of California EPN	$32.97
Rate for Payer: Cash Price	$25.27
Rate for Payer: Cash Price	$25.27
Rate for Payer: Cigna of CA HMO/PPO	$25.83
Rate for Payer: Dignity Health Commercial/Exchange	$47.74
Rate for Payer: Dignity Health Medi-Cal	$47.74
Rate for Payer: Dignity Health Senior	$47.74
Rate for Payer: EPIC Health Plan Commercial	$35.94
Rate for Payer: Heritage Provider Network Commercial	$26.00
Rate for Payer: Heritage Provider Network Senior	$26.00
Rate for Payer: IEHP Medi-Cal	$47.61
Rate for Payer: Kaiser Permanente of CA Commercial	$27.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$10.16
Rate for Payer: LLUH Dept of Risk Management WC	$14.04
Rate for Payer: Multiplan Commercial	$42.12
Rate for Payer: United Healthcare All Other HMO/non HMO	$20.48
Rate for Payer: United Healthcare Navigate/Select/Select+	$18.76
Rate for Payer: Vantage Medical Group Medi-Cal	$47.74
Rate for Payer: Vantage Medical Group Senior	$47.74

PERFLUTREN PROTEIN-TYPE A MICROSPHERES 0.22 MG/ML INTRAVENOUS SUSP [82177]

Facility IP

$56.16

Service Code	CPT Q9956
Hospital Charge Code	NDG82177
Hospital Revenue Code	636
Min. Negotiated Rate	$10.16
Max. Negotiated Rate	$42.12
Rate for Payer: Adventist Health Commercial	$11.23
Rate for Payer: Aetna of CA Non-Gatekeeper	$38.58
Rate for Payer: Cash Price	$25.27
Rate for Payer: Cigna of CA HMO/PPO	$25.83
Rate for Payer: EPIC Health Plan Commercial	$30.33
Rate for Payer: Heritage Provider Network Commercial	$38.02
Rate for Payer: Heritage Provider Network Senior	$38.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$10.16
Rate for Payer: LLUH Dept of Risk Management WC	$14.04
Rate for Payer: Multiplan Commercial	$42.12
Rate for Payer: United Healthcare All Other HMO/non HMO	$20.48
Rate for Payer: United Healthcare Navigate/Select/Select+	$18.76

Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents

Facility OP

$9,616.00

Service Code	CPT 19371
Min. Negotiated Rate	$658.04
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$4,857.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$7,143.76
Rate for Payer: AlphaCare Medical Group Medi-Cal	$5,238.76
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$4,762.51
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$7,436.00
Rate for Payer: Dignity Health Commercial/Exchange	$7,143.76
Rate for Payer: Dignity Health Medi-Cal	$5,238.76
Rate for Payer: Dignity Health Senior	$4,762.51
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$4,762.51
Rate for Payer: Humana Medicare	$4,762.51
Rate for Payer: IEHP Medi-Cal	$658.04
Rate for Payer: IEHP Medicare Advantage	$4,762.51
Rate for Payer: Kaiser Permanente of CA Commercial	$9,048.77
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$5,619.76
Rate for Payer: Molina Healthcare of CA Medi-Cal	$6,000.76
Rate for Payer: Molina Healthcare of CA Medicare	$6,000.76
Rate for Payer: TriValley Medical Group Commercial	$5,238.76
Rate for Payer: TriValley Medical Group Senior	$4,762.51
Rate for Payer: Vantage Medical Group Commercial/Exchange	$7,143.76
Rate for Payer: Vantage Medical Group Medi-Cal	$5,238.76
Rate for Payer: Vantage Medical Group Senior	$4,762.51

Perineoplasty, repair of perineum, nonobstetrical (separate procedure)

Facility OP

$9,616.00

Service Code	CPT 56810
Min. Negotiated Rate	$387.32
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$5,088.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$5,859.27
Rate for Payer: AlphaCare Medical Group Medi-Cal	$4,296.80
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$3,906.18
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,054.00
Rate for Payer: Dignity Health Commercial/Exchange	$5,859.27
Rate for Payer: Dignity Health Medi-Cal	$4,296.80
Rate for Payer: Dignity Health Senior	$3,906.18
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$3,906.18
Rate for Payer: Humana Medicare	$3,906.18
Rate for Payer: IEHP Medi-Cal	$387.32
Rate for Payer: IEHP Medicare Advantage	$3,906.18
Rate for Payer: Kaiser Permanente of CA Commercial	$7,421.74
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$4,609.29
Rate for Payer: Molina Healthcare of CA Medi-Cal	$4,921.79
Rate for Payer: Molina Healthcare of CA Medicare	$4,921.79
Rate for Payer: TriValley Medical Group Commercial	$4,296.80
Rate for Payer: TriValley Medical Group Senior	$3,906.18
Rate for Payer: Vantage Medical Group Commercial/Exchange	$5,859.27
Rate for Payer: Vantage Medical Group Medi-Cal	$4,296.80
Rate for Payer: Vantage Medical Group Senior	$3,906.18

PERIPHERAL AND OTHER VASCULAR DISORDERS

Facility IP

$4,197.46

Service Code	APR-DRG 1971
Min. Negotiated Rate	$4,197.46
Max. Negotiated Rate	$4,197.46
Rate for Payer: IEHP Medi-Cal	$4,197.46

PERIPHERAL AND OTHER VASCULAR DISORDERS

Facility IP

$5,606.24

Service Code	APR-DRG 1972
Min. Negotiated Rate	$5,606.24
Max. Negotiated Rate	$5,606.24
Rate for Payer: IEHP Medi-Cal	$5,606.24

PERIPHERAL AND OTHER VASCULAR DISORDERS

Facility IP

$7,752.23

Service Code	APR-DRG 1973
Min. Negotiated Rate	$7,752.23
Max. Negotiated Rate	$7,752.23
Rate for Payer: IEHP Medi-Cal	$7,752.23

PERIPHERAL AND OTHER VASCULAR DISORDERS

Facility IP

$14,127.52

Service Code	APR-DRG 1974
Min. Negotiated Rate	$14,127.52
Max. Negotiated Rate	$14,127.52
Rate for Payer: IEHP Medi-Cal	$14,127.52

PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS

Facility IP

$8,380.01

Service Code	APR-DRG 0483
Min. Negotiated Rate	$8,380.01
Max. Negotiated Rate	$8,380.01
Rate for Payer: IEHP Medi-Cal	$8,380.01

PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS

Facility IP

$6,174.33

Service Code	APR-DRG 0482
Min. Negotiated Rate	$6,174.33
Max. Negotiated Rate	$6,174.33
Rate for Payer: IEHP Medi-Cal	$6,174.33

PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS

Facility IP

$5,361.50

Service Code	APR-DRG 0481
Min. Negotiated Rate	$5,361.50
Max. Negotiated Rate	$5,361.50
Rate for Payer: IEHP Medi-Cal	$5,361.50

PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS

Facility IP

$15,537.29

Service Code	APR-DRG 0484
Min. Negotiated Rate	$15,537.29
Max. Negotiated Rate	$15,537.29
Rate for Payer: IEHP Medi-Cal	$15,537.29

PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]

Facility OP

$0.01

Service Code	NDC 0941-0413-07
Hospital Charge Code	NDG27801A
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Aetna of CA Gatekeeper	$0.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.01
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.01
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.01
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.01
Rate for Payer: Blue Shield of California Commercial	$0.01
Rate for Payer: Blue Shield of California EPN	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Dignity Health Commercial/Exchange	$0.01
Rate for Payer: Dignity Health Medi-Cal	$0.01
Rate for Payer: Dignity Health Senior	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: Heritage Provider Network Commercial	$0.01
Rate for Payer: Heritage Provider Network Senior	$0.01
Rate for Payer: Kaiser Permanente of CA Commercial	$0.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.00
Rate for Payer: Multiplan Commercial	$0.01
Rate for Payer: Vantage Medical Group Medi-Cal	$0.01
Rate for Payer: Vantage Medical Group Senior	$0.01

PERITON. DIALYSIS SOLN 13-2.5 % DEXTROSE CALC 3.5 MEQ/L-MAG 0.5 MEQ/L [27801]

Facility IP

$0.01

Service Code	NDC 0941-0413-07
Hospital Charge Code	NDG27801A
Hospital Revenue Code	250
Max. Negotiated Rate	$0.01
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: Heritage Provider Network Commercial	$0.01
Rate for Payer: Heritage Provider Network Senior	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.00
Rate for Payer: Multiplan Commercial	$0.01

Price Transparency.

All Charges