Loma Linda University Medical Center

All Charges

Charge

Type

Price

PTCA/Angioplasty - #2076

Facility IP

$19,726.00

Service Code	ICD 027H3ZZ
Min. Negotiated Rate	$4,519.00
Max. Negotiated Rate	$19,726.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,066.00
Rate for Payer: Blue Shield of California Commercial	$19,726.00
Rate for Payer: Blue Shield of California EPN	$16,911.00
Rate for Payer: Heritage Provider Network Commercial	$4,968.00
Rate for Payer: Heritage Provider Network Senior	$4,519.00

PTCA/Angioplasty - #2076

Facility IP

$19,726.00

Service Code	ICD 02713Z6
Min. Negotiated Rate	$4,519.00
Max. Negotiated Rate	$19,726.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,066.00
Rate for Payer: Blue Shield of California Commercial	$19,726.00
Rate for Payer: Blue Shield of California EPN	$16,911.00
Rate for Payer: Heritage Provider Network Commercial	$4,968.00
Rate for Payer: Heritage Provider Network Senior	$4,519.00

PTCA/Angioplasty - #2076

Facility IP

$19,726.00

Service Code	ICD 02713ZZ
Min. Negotiated Rate	$4,519.00
Max. Negotiated Rate	$19,726.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,066.00
Rate for Payer: Blue Shield of California Commercial	$19,726.00
Rate for Payer: Blue Shield of California EPN	$16,911.00
Rate for Payer: Heritage Provider Network Commercial	$4,968.00
Rate for Payer: Heritage Provider Network Senior	$4,519.00

PTCA/Angioplasty - #2076

Facility IP

$19,726.00

Service Code	ICD 02714Z6
Min. Negotiated Rate	$4,519.00
Max. Negotiated Rate	$19,726.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,066.00
Rate for Payer: Blue Shield of California Commercial	$19,726.00
Rate for Payer: Blue Shield of California EPN	$16,911.00
Rate for Payer: Heritage Provider Network Commercial	$4,968.00
Rate for Payer: Heritage Provider Network Senior	$4,519.00

PTCA/Angioplasty - #2076

Facility IP

$19,726.00

Service Code	ICD 027F44Z
Min. Negotiated Rate	$4,519.00
Max. Negotiated Rate	$19,726.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,066.00
Rate for Payer: Blue Shield of California Commercial	$19,726.00
Rate for Payer: Blue Shield of California EPN	$16,911.00
Rate for Payer: Heritage Provider Network Commercial	$4,968.00
Rate for Payer: Heritage Provider Network Senior	$4,519.00

PTCA/Angioplasty - #2076

Facility IP

$19,726.00

Service Code	ICD 02723ZZ
Min. Negotiated Rate	$4,519.00
Max. Negotiated Rate	$19,726.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,066.00
Rate for Payer: Blue Shield of California Commercial	$19,726.00
Rate for Payer: Blue Shield of California EPN	$16,911.00
Rate for Payer: Heritage Provider Network Commercial	$4,968.00
Rate for Payer: Heritage Provider Network Senior	$4,519.00

PTCA/Angioplasty - #2076

Facility IP

$19,726.00

Service Code	ICD 02714ZZ
Min. Negotiated Rate	$4,519.00
Max. Negotiated Rate	$19,726.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,066.00
Rate for Payer: Blue Shield of California Commercial	$19,726.00
Rate for Payer: Blue Shield of California EPN	$16,911.00
Rate for Payer: Heritage Provider Network Commercial	$4,968.00
Rate for Payer: Heritage Provider Network Senior	$4,519.00

PULMONARY EMBOLISM

Facility IP

$6,592.18

Service Code	APR-DRG 1342
Min. Negotiated Rate	$6,592.18
Max. Negotiated Rate	$6,592.18
Rate for Payer: IEHP Medi-Cal	$6,592.18

PULMONARY EMBOLISM

Facility IP

$14,476.73

Service Code	APR-DRG 1344
Min. Negotiated Rate	$14,476.73
Max. Negotiated Rate	$14,476.73
Rate for Payer: IEHP Medi-Cal	$14,476.73

PULMONARY EMBOLISM

Facility IP

$5,063.03

Service Code	APR-DRG 1341
Min. Negotiated Rate	$5,063.03
Max. Negotiated Rate	$5,063.03
Rate for Payer: IEHP Medi-Cal	$5,063.03

PULMONARY EMBOLISM

Facility IP

$9,511.20

Service Code	APR-DRG 1343
Min. Negotiated Rate	$9,511.20
Max. Negotiated Rate	$9,511.20
Rate for Payer: IEHP Medi-Cal	$9,511.20

Punch biopsy of skin (including simple closure, when performed); each separate/additional lesion (List separately in addition to code for primary procedure)

Facility OP

$9,616.00

Service Code	CPT 11105
Min. Negotiated Rate	$86.25
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	$86.25

Punch biopsy of skin (including simple closure, when performed); single lesion

Facility OP

$9,616.00

Service Code	CPT 11104
Min. Negotiated Rate	$174.81
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$747.30
Rate for Payer: AlphaCare Medical Group Medi-Cal	$548.02
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$498.20
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$747.30
Rate for Payer: Dignity Health Medi-Cal	$548.02
Rate for Payer: Dignity Health Senior	$498.20
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$498.20
Rate for Payer: Humana Medicare	$498.20
Rate for Payer: IEHP Medi-Cal	$174.81
Rate for Payer: IEHP Medicare Advantage	$498.20
Rate for Payer: Kaiser Permanente of CA Commercial	$946.58
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$587.88
Rate for Payer: Molina Healthcare of CA Medi-Cal	$627.73
Rate for Payer: Molina Healthcare of CA Medicare	$627.73
Rate for Payer: TriValley Medical Group Commercial	$548.02
Rate for Payer: TriValley Medical Group Senior	$498.20
Rate for Payer: Vantage Medical Group Commercial/Exchange	$747.30
Rate for Payer: Vantage Medical Group Medi-Cal	$548.02
Rate for Payer: Vantage Medical Group Senior	$498.20

Puncture aspiration of hydrocele, tunica vaginalis, with or without injection of medication

Facility OP

$9,616.00

Service Code	CPT 55000
Min. Negotiated Rate	$87.13
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$199.57
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$1,318.60
Rate for Payer: AlphaCare Medical Group Medi-Cal	$966.98
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$879.07
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$1,318.60
Rate for Payer: Dignity Health Medi-Cal	$966.98
Rate for Payer: Dignity Health Senior	$879.07
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$879.07
Rate for Payer: Humana Medicare	$879.07
Rate for Payer: IEHP Medi-Cal	$87.13
Rate for Payer: IEHP Medicare Advantage	$879.07
Rate for Payer: Kaiser Permanente of CA Commercial	$1,670.23
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$1,037.30
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1,107.63
Rate for Payer: Molina Healthcare of CA Medicare	$1,107.63
Rate for Payer: TriValley Medical Group Commercial	$966.98
Rate for Payer: TriValley Medical Group Senior	$879.07
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,318.60
Rate for Payer: Vantage Medical Group Medi-Cal	$966.98
Rate for Payer: Vantage Medical Group Senior	$879.07

PYRAZINAMIDE 500 MG TABLET [6738]

Facility OP

$5.32

Service Code	NDC 33342-447-11
Hospital Charge Code	1712086
Hospital Revenue Code	259
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$4.52
Rate for Payer: Adventist Health Commercial	$1.06
Rate for Payer: Aetna of CA Gatekeeper	$2.84
Rate for Payer: Aetna of CA Non-Gatekeeper	$3.65
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$4.52
Rate for Payer: AlphaCare Medical Group Medi-Cal	$2.93
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$3.99
Rate for Payer: Blue Shield of California Commercial	$3.30
Rate for Payer: Blue Shield of California EPN	$3.12
Rate for Payer: Cash Price	$2.39
Rate for Payer: Cigna of CA HMO/PPO	$3.46
Rate for Payer: Dignity Health Commercial/Exchange	$4.52
Rate for Payer: Dignity Health Medi-Cal	$4.52
Rate for Payer: Dignity Health Senior	$4.52
Rate for Payer: EPIC Health Plan Commercial	$3.40
Rate for Payer: Heritage Provider Network Commercial	$3.29
Rate for Payer: Heritage Provider Network Senior	$3.29
Rate for Payer: Kaiser Permanente of CA Commercial	$2.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.96
Rate for Payer: LLUH Dept of Risk Management WC	$1.33
Rate for Payer: Multiplan Commercial	$3.99
Rate for Payer: Vantage Medical Group Medi-Cal	$4.52
Rate for Payer: Vantage Medical Group Senior	$4.52

PYRAZINAMIDE 500 MG TABLET [6738]

Facility IP

$5.32

Service Code	NDC 33342-447-11
Hospital Charge Code	1712086
Hospital Revenue Code	259
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$3.99
Rate for Payer: Adventist Health Commercial	$1.06
Rate for Payer: Aetna of CA Non-Gatekeeper	$3.65
Rate for Payer: Cash Price	$2.39
Rate for Payer: EPIC Health Plan Commercial	$2.87
Rate for Payer: Heritage Provider Network Commercial	$3.60
Rate for Payer: Heritage Provider Network Senior	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.96
Rate for Payer: LLUH Dept of Risk Management WC	$1.33
Rate for Payer: Multiplan Commercial	$3.99

PYRAZINAMIDE 500 MG TABLET [6738]

Facility IP

$6.06

Service Code	NDC 61748-012-06
Hospital Charge Code	1712086
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$4.54
Rate for Payer: Adventist Health Commercial	$1.21
Rate for Payer: Aetna of CA Non-Gatekeeper	$4.16
Rate for Payer: Cash Price	$2.73
Rate for Payer: EPIC Health Plan Commercial	$3.27
Rate for Payer: Heritage Provider Network Commercial	$4.10
Rate for Payer: Heritage Provider Network Senior	$4.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.10
Rate for Payer: LLUH Dept of Risk Management WC	$1.52
Rate for Payer: Multiplan Commercial	$4.54

PYRAZINAMIDE 500 MG TABLET [6738]

Facility IP

$5.46

Service Code	NDC 70954-484-10
Hospital Charge Code	1712086
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$4.10
Rate for Payer: Adventist Health Commercial	$1.09
Rate for Payer: Aetna of CA Non-Gatekeeper	$3.75
Rate for Payer: Cash Price	$2.46
Rate for Payer: EPIC Health Plan Commercial	$2.95
Rate for Payer: Heritage Provider Network Commercial	$3.70
Rate for Payer: Heritage Provider Network Senior	$3.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.99
Rate for Payer: LLUH Dept of Risk Management WC	$1.36
Rate for Payer: Multiplan Commercial	$4.10

PYRAZINAMIDE 500 MG TABLET [6738]

Facility OP

$4.40

Service Code	NDC 10135-735-60
Hospital Charge Code	1712086
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$3.74
Rate for Payer: Adventist Health Commercial	$0.88
Rate for Payer: Aetna of CA Gatekeeper	$2.35
Rate for Payer: Aetna of CA Non-Gatekeeper	$3.02
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$3.74
Rate for Payer: AlphaCare Medical Group Medi-Cal	$2.42
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$3.30
Rate for Payer: Blue Shield of California Commercial	$2.73
Rate for Payer: Blue Shield of California EPN	$2.58
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cigna of CA HMO/PPO	$2.86
Rate for Payer: Dignity Health Commercial/Exchange	$3.74
Rate for Payer: Dignity Health Medi-Cal	$3.74
Rate for Payer: Dignity Health Senior	$3.74
Rate for Payer: EPIC Health Plan Commercial	$2.82
Rate for Payer: Heritage Provider Network Commercial	$2.72
Rate for Payer: Heritage Provider Network Senior	$2.72
Rate for Payer: Kaiser Permanente of CA Commercial	$2.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Commercial	$3.30
Rate for Payer: Vantage Medical Group Medi-Cal	$3.74
Rate for Payer: Vantage Medical Group Senior	$3.74

PYRAZINAMIDE 500 MG TABLET [6738]

Facility OP

$6.03

Service Code	NDC 61748-012-09
Hospital Charge Code	1712086
Hospital Revenue Code	259
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$5.13
Rate for Payer: Adventist Health Commercial	$1.21
Rate for Payer: Aetna of CA Gatekeeper	$3.22
Rate for Payer: Aetna of CA Non-Gatekeeper	$4.14
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$5.13
Rate for Payer: AlphaCare Medical Group Medi-Cal	$3.32
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$4.52
Rate for Payer: Blue Shield of California Commercial	$3.74
Rate for Payer: Blue Shield of California EPN	$3.54
Rate for Payer: Cash Price	$2.71
Rate for Payer: Cigna of CA HMO/PPO	$3.92
Rate for Payer: Dignity Health Commercial/Exchange	$5.13
Rate for Payer: Dignity Health Medi-Cal	$5.13
Rate for Payer: Dignity Health Senior	$5.13
Rate for Payer: EPIC Health Plan Commercial	$3.86
Rate for Payer: Heritage Provider Network Commercial	$3.73
Rate for Payer: Heritage Provider Network Senior	$3.73
Rate for Payer: Kaiser Permanente of CA Commercial	$2.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.51
Rate for Payer: Multiplan Commercial	$4.52
Rate for Payer: Vantage Medical Group Medi-Cal	$5.13
Rate for Payer: Vantage Medical Group Senior	$5.13

PYRAZINAMIDE 500 MG TABLET [6738]

Facility IP

$6.03

Service Code	NDC 61748-012-09
Hospital Charge Code	1712086
Hospital Revenue Code	259
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$4.52
Rate for Payer: Adventist Health Commercial	$1.21
Rate for Payer: Aetna of CA Non-Gatekeeper	$4.14
Rate for Payer: Cash Price	$2.71
Rate for Payer: EPIC Health Plan Commercial	$3.26
Rate for Payer: Heritage Provider Network Commercial	$4.08
Rate for Payer: Heritage Provider Network Senior	$4.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.51
Rate for Payer: Multiplan Commercial	$4.52

PYRAZINAMIDE 500 MG TABLET [6738]

Facility OP

$6.06

Service Code	NDC 61748-012-06
Hospital Charge Code	1712086
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$5.15
Rate for Payer: Adventist Health Commercial	$1.21
Rate for Payer: Aetna of CA Gatekeeper	$3.24
Rate for Payer: Aetna of CA Non-Gatekeeper	$4.16
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$5.15
Rate for Payer: AlphaCare Medical Group Medi-Cal	$3.33
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$4.54
Rate for Payer: Blue Shield of California Commercial	$3.76
Rate for Payer: Blue Shield of California EPN	$3.56
Rate for Payer: Cash Price	$2.73
Rate for Payer: Cigna of CA HMO/PPO	$3.94
Rate for Payer: Dignity Health Commercial/Exchange	$5.15
Rate for Payer: Dignity Health Medi-Cal	$5.15
Rate for Payer: Dignity Health Senior	$5.15
Rate for Payer: EPIC Health Plan Commercial	$3.88
Rate for Payer: Heritage Provider Network Commercial	$3.75
Rate for Payer: Heritage Provider Network Senior	$3.75
Rate for Payer: Kaiser Permanente of CA Commercial	$2.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.10
Rate for Payer: LLUH Dept of Risk Management WC	$1.52
Rate for Payer: Multiplan Commercial	$4.54
Rate for Payer: Vantage Medical Group Medi-Cal	$5.15
Rate for Payer: Vantage Medical Group Senior	$5.15

PYRAZINAMIDE 500 MG TABLET [6738]

Facility OP

$5.46

Service Code	NDC 70954-484-10
Hospital Charge Code	1712086
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$4.64
Rate for Payer: Adventist Health Commercial	$1.09
Rate for Payer: Aetna of CA Gatekeeper	$2.92
Rate for Payer: Aetna of CA Non-Gatekeeper	$3.75
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$4.64
Rate for Payer: AlphaCare Medical Group Medi-Cal	$3.00
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$4.10
Rate for Payer: Blue Shield of California Commercial	$3.39
Rate for Payer: Blue Shield of California EPN	$3.21
Rate for Payer: Cash Price	$2.46
Rate for Payer: Cigna of CA HMO/PPO	$3.55
Rate for Payer: Dignity Health Commercial/Exchange	$4.64
Rate for Payer: Dignity Health Medi-Cal	$4.64
Rate for Payer: Dignity Health Senior	$4.64
Rate for Payer: EPIC Health Plan Commercial	$3.49
Rate for Payer: Heritage Provider Network Commercial	$3.38
Rate for Payer: Heritage Provider Network Senior	$3.38
Rate for Payer: Kaiser Permanente of CA Commercial	$2.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.99
Rate for Payer: LLUH Dept of Risk Management WC	$1.36
Rate for Payer: Multiplan Commercial	$4.10
Rate for Payer: Vantage Medical Group Medi-Cal	$4.64
Rate for Payer: Vantage Medical Group Senior	$4.64

PYRAZINAMIDE 500 MG TABLET [6738]

Facility IP

$4.40

Service Code	NDC 10135-735-60
Hospital Charge Code	1712086
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$3.30
Rate for Payer: Adventist Health Commercial	$0.88
Rate for Payer: Aetna of CA Non-Gatekeeper	$3.02
Rate for Payer: Cash Price	$1.98
Rate for Payer: EPIC Health Plan Commercial	$2.38
Rate for Payer: Heritage Provider Network Commercial	$2.98
Rate for Payer: Heritage Provider Network Senior	$2.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$1.10
Rate for Payer: Multiplan Commercial	$3.30

PYRAZINAMIDE ORAL SUSPENSION COMPOUND 100 MG/ML [4080326]

Facility OP

$6.32

Service Code	NDC 9994-0803-26
Hospital Charge Code	1715093
Hospital Revenue Code	259
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$5.37
Rate for Payer: Adventist Health Commercial	$1.26
Rate for Payer: Aetna of CA Gatekeeper	$3.38
Rate for Payer: Aetna of CA Non-Gatekeeper	$4.34
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$5.37
Rate for Payer: AlphaCare Medical Group Medi-Cal	$3.48
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$4.74
Rate for Payer: Blue Shield of California Commercial	$3.92
Rate for Payer: Blue Shield of California EPN	$3.71
Rate for Payer: Cash Price	$2.84
Rate for Payer: Cigna of CA HMO/PPO	$4.11
Rate for Payer: Dignity Health Commercial/Exchange	$5.37
Rate for Payer: Dignity Health Medi-Cal	$5.37
Rate for Payer: Dignity Health Senior	$5.37
Rate for Payer: EPIC Health Plan Commercial	$4.04
Rate for Payer: Heritage Provider Network Commercial	$3.91
Rate for Payer: Heritage Provider Network Senior	$3.91
Rate for Payer: Kaiser Permanente of CA Commercial	$3.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$1.14
Rate for Payer: LLUH Dept of Risk Management WC	$1.58
Rate for Payer: Multiplan Commercial	$4.74
Rate for Payer: Vantage Medical Group Medi-Cal	$5.37
Rate for Payer: Vantage Medical Group Senior	$5.37

Price Transparency.

All Charges