Loma Linda University Medical Center

All Charges

Charge

Type

Price

Severing of tarsorrhaphy

Facility OP

$3,237.00

Service Code	CPT 67710
Min. Negotiated Rate	$191.08
Max. Negotiated Rate	$3,237.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$1,897.46
Rate for Payer: AlphaCare Medical Group Medi-Cal	$1,391.47
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$1,264.97
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$1,897.46
Rate for Payer: Dignity Health Medi-Cal	$1,391.47
Rate for Payer: Dignity Health Senior	$1,264.97
Rate for Payer: EPIC Health Plan Medicare	$1,264.97
Rate for Payer: Humana Medicare	$1,264.97
Rate for Payer: IEHP Medi-Cal	$191.08
Rate for Payer: IEHP Medicare Advantage	$1,264.97
Rate for Payer: Kaiser Permanente of CA Commercial	$2,403.44
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$1,492.66
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1,593.86
Rate for Payer: Molina Healthcare of CA Medicare	$1,593.86
Rate for Payer: TriValley Medical Group Commercial	$1,391.47
Rate for Payer: TriValley Medical Group Senior	$1,264.97
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,897.46
Rate for Payer: Vantage Medical Group Medi-Cal	$1,391.47
Rate for Payer: Vantage Medical Group Senior	$1,264.97

SHOULDER AND ELBOW JOINT REPLACEMENT

Facility IP

$16,032.75

Service Code	APR-DRG 3221
Min. Negotiated Rate	$16,032.75
Max. Negotiated Rate	$16,032.75
Rate for Payer: IEHP Medi-Cal	$16,032.75

SHOULDER AND ELBOW JOINT REPLACEMENT

Facility IP

$30,607.98

Service Code	APR-DRG 3224
Min. Negotiated Rate	$30,607.98
Max. Negotiated Rate	$30,607.98
Rate for Payer: IEHP Medi-Cal	$30,607.98

SHOULDER AND ELBOW JOINT REPLACEMENT

Facility IP

$22,859.72

Service Code	APR-DRG 3223
Min. Negotiated Rate	$22,859.72
Max. Negotiated Rate	$22,859.72
Rate for Payer: IEHP Medi-Cal	$22,859.72

SHOULDER AND ELBOW JOINT REPLACEMENT

Facility IP

$17,407.70

Service Code	APR-DRG 3222
Min. Negotiated Rate	$17,407.70
Max. Negotiated Rate	$17,407.70
Rate for Payer: IEHP Medi-Cal	$17,407.70

SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT

Facility IP

$8,493.42

Service Code	APR-DRG 3151
Min. Negotiated Rate	$8,493.42
Max. Negotiated Rate	$8,493.42
Rate for Payer: IEHP Medi-Cal	$8,493.42

SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT

Facility IP

$20,253.10

Service Code	APR-DRG 3153
Min. Negotiated Rate	$20,253.10
Max. Negotiated Rate	$20,253.10
Rate for Payer: IEHP Medi-Cal	$20,253.10

SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT

Facility IP

$32,932.05

Service Code	APR-DRG 3154
Min. Negotiated Rate	$32,932.05
Max. Negotiated Rate	$32,932.05
Rate for Payer: IEHP Medi-Cal	$32,932.05

SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT

Facility IP

$13,592.26

Service Code	APR-DRG 3152
Min. Negotiated Rate	$13,592.26
Max. Negotiated Rate	$13,592.26
Rate for Payer: IEHP Medi-Cal	$13,592.26

Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral

Facility OP

$9,616.00

Service Code	CPT 42330
Min. Negotiated Rate	$127.19
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$6,034.04
Rate for Payer: AlphaCare Medical Group Medi-Cal	$4,424.96
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$4,022.69
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$6,034.04
Rate for Payer: Dignity Health Medi-Cal	$4,424.96
Rate for Payer: Dignity Health Senior	$4,022.69
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$4,022.69
Rate for Payer: Humana Medicare	$4,022.69
Rate for Payer: IEHP Medi-Cal	$127.19
Rate for Payer: IEHP Medicare Advantage	$4,022.69
Rate for Payer: Kaiser Permanente of CA Commercial	$7,643.11
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$4,746.77
Rate for Payer: Molina Healthcare of CA Medi-Cal	$5,068.59
Rate for Payer: Molina Healthcare of CA Medicare	$5,068.59
Rate for Payer: TriValley Medical Group Commercial	$4,424.96
Rate for Payer: TriValley Medical Group Senior	$4,022.69
Rate for Payer: Vantage Medical Group Commercial/Exchange	$6,034.04
Rate for Payer: Vantage Medical Group Medi-Cal	$4,424.96
Rate for Payer: Vantage Medical Group Senior	$4,022.69

SICKLE CELL ANEMIA CRISIS

Facility IP

$6,032.06

Service Code	APR-DRG 6622
Min. Negotiated Rate	$6,032.06
Max. Negotiated Rate	$6,032.06
Rate for Payer: IEHP Medi-Cal	$6,032.06

SICKLE CELL ANEMIA CRISIS

Facility IP

$4,398.44

Service Code	APR-DRG 6621
Min. Negotiated Rate	$4,398.44
Max. Negotiated Rate	$4,398.44
Rate for Payer: IEHP Medi-Cal	$4,398.44

SICKLE CELL ANEMIA CRISIS

Facility IP

$16,079.50

Service Code	APR-DRG 6624
Min. Negotiated Rate	$16,079.50
Max. Negotiated Rate	$16,079.50
Rate for Payer: IEHP Medi-Cal	$16,079.50

SICKLE CELL ANEMIA CRISIS

Facility IP

$8,552.13

Service Code	APR-DRG 6623
Min. Negotiated Rate	$8,552.13
Max. Negotiated Rate	$8,552.13
Rate for Payer: IEHP Medi-Cal	$8,552.13

Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

Facility OP

$9,616.00

Service Code	CPT 45330
Min. Negotiated Rate	$85.38
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$1,712.90
Rate for Payer: AlphaCare Medical Group Medi-Cal	$1,256.12
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$1,141.93
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$1,712.90
Rate for Payer: Dignity Health Medi-Cal	$1,256.12
Rate for Payer: Dignity Health Senior	$1,141.93
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$1,141.93
Rate for Payer: Humana Medicare	$1,141.93
Rate for Payer: IEHP Medi-Cal	$85.38
Rate for Payer: IEHP Medicare Advantage	$1,141.93
Rate for Payer: Kaiser Permanente of CA Commercial	$2,169.67
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$1,347.48
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1,438.83
Rate for Payer: Molina Healthcare of CA Medicare	$1,438.83
Rate for Payer: TriValley Medical Group Commercial	$1,256.12
Rate for Payer: TriValley Medical Group Senior	$1,141.93
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,712.90
Rate for Payer: Vantage Medical Group Medi-Cal	$1,256.12
Rate for Payer: Vantage Medical Group Senior	$1,141.93

Sigmoidoscopy, flexible; with biopsy, single or multiple

Facility OP

$9,616.00

Service Code	CPT 45331
Min. Negotiated Rate	$112.68
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$1,712.90
Rate for Payer: AlphaCare Medical Group Medi-Cal	$1,256.12
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$1,141.93
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$1,712.90
Rate for Payer: Dignity Health Medi-Cal	$1,256.12
Rate for Payer: Dignity Health Senior	$1,141.93
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$1,141.93
Rate for Payer: Humana Medicare	$1,141.93
Rate for Payer: IEHP Medi-Cal	$112.68
Rate for Payer: IEHP Medicare Advantage	$1,141.93
Rate for Payer: Kaiser Permanente of CA Commercial	$2,169.67
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$1,347.48
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1,438.83
Rate for Payer: Molina Healthcare of CA Medicare	$1,438.83
Rate for Payer: TriValley Medical Group Commercial	$1,256.12
Rate for Payer: TriValley Medical Group Senior	$1,141.93
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,712.90
Rate for Payer: Vantage Medical Group Medi-Cal	$1,256.12
Rate for Payer: Vantage Medical Group Senior	$1,141.93

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility IP

$8,018.86

Service Code	APR-DRG 8614
Min. Negotiated Rate	$8,018.86
Max. Negotiated Rate	$8,018.86
Rate for Payer: IEHP Medi-Cal	$8,018.86

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility IP

$7,423.91

Service Code	APR-DRG 8613
Min. Negotiated Rate	$7,423.91
Max. Negotiated Rate	$7,423.91
Rate for Payer: IEHP Medi-Cal	$7,423.91

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility IP

$5,306.77

Service Code	APR-DRG 8612
Min. Negotiated Rate	$5,306.77
Max. Negotiated Rate	$5,306.77
Rate for Payer: IEHP Medi-Cal	$5,306.77

SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS

Facility IP

$3,062.29

Service Code	APR-DRG 8611
Min. Negotiated Rate	$3,062.29
Max. Negotiated Rate	$3,062.29
Rate for Payer: IEHP Medi-Cal	$3,062.29

SILDENAFIL 25 MG TABLET [22836]

Facility IP

$99.92

Service Code	NDC 0069-4200-30
Hospital Charge Code	1710917
Hospital Revenue Code	259
Min. Negotiated Rate	$18.09
Max. Negotiated Rate	$74.94
Rate for Payer: Adventist Health Commercial	$19.98
Rate for Payer: Aetna of CA Non-Gatekeeper	$68.65
Rate for Payer: Cash Price	$44.96
Rate for Payer: EPIC Health Plan Commercial	$53.96
Rate for Payer: Heritage Provider Network Commercial	$67.65
Rate for Payer: Heritage Provider Network Senior	$67.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$18.09
Rate for Payer: LLUH Dept of Risk Management WC	$24.98
Rate for Payer: Multiplan Commercial	$74.94

SILDENAFIL 25 MG TABLET [22836]

Facility OP

$99.92

Service Code	NDC 0069-4200-30
Hospital Charge Code	1710917
Hospital Revenue Code	259
Min. Negotiated Rate	$18.09
Max. Negotiated Rate	$84.93
Rate for Payer: Adventist Health Commercial	$19.98
Rate for Payer: Aetna of CA Gatekeeper	$53.41
Rate for Payer: Aetna of CA Non-Gatekeeper	$68.65
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$84.93
Rate for Payer: AlphaCare Medical Group Medi-Cal	$54.96
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$74.94
Rate for Payer: Blue Shield of California Commercial	$62.05
Rate for Payer: Blue Shield of California EPN	$58.65
Rate for Payer: Cash Price	$44.96
Rate for Payer: Cigna of CA HMO/PPO	$64.95
Rate for Payer: Dignity Health Commercial/Exchange	$84.93
Rate for Payer: Dignity Health Medi-Cal	$84.93
Rate for Payer: Dignity Health Senior	$84.93
Rate for Payer: EPIC Health Plan Commercial	$63.95
Rate for Payer: Heritage Provider Network Commercial	$61.85
Rate for Payer: Heritage Provider Network Senior	$61.85
Rate for Payer: Kaiser Permanente of CA Commercial	$48.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$18.09
Rate for Payer: LLUH Dept of Risk Management WC	$24.98
Rate for Payer: Multiplan Commercial	$74.94
Rate for Payer: Vantage Medical Group Medi-Cal	$84.93
Rate for Payer: Vantage Medical Group Senior	$84.93

SILDENAFIL ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080335]

Facility OP

$2.81

Service Code	NDC 9994-0803-35
Hospital Charge Code	1715001
Hospital Revenue Code	259
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$2.39
Rate for Payer: Adventist Health Commercial	$0.56
Rate for Payer: Aetna of CA Gatekeeper	$1.50
Rate for Payer: Aetna of CA Non-Gatekeeper	$1.93
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$2.39
Rate for Payer: AlphaCare Medical Group Medi-Cal	$1.55
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$2.11
Rate for Payer: Blue Shield of California Commercial	$1.75
Rate for Payer: Blue Shield of California EPN	$1.65
Rate for Payer: Cash Price	$1.26
Rate for Payer: Cigna of CA HMO/PPO	$1.83
Rate for Payer: Dignity Health Commercial/Exchange	$2.39
Rate for Payer: Dignity Health Medi-Cal	$2.39
Rate for Payer: Dignity Health Senior	$2.39
Rate for Payer: EPIC Health Plan Commercial	$1.80
Rate for Payer: Heritage Provider Network Commercial	$1.74
Rate for Payer: Heritage Provider Network Senior	$1.74
Rate for Payer: Kaiser Permanente of CA Commercial	$1.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.51
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Commercial	$2.11
Rate for Payer: Vantage Medical Group Medi-Cal	$2.39
Rate for Payer: Vantage Medical Group Senior	$2.39

SILDENAFIL ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080335]

Facility IP

$2.81

Service Code	NDC 9994-0803-35
Hospital Charge Code	1715001
Hospital Revenue Code	259
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$2.11
Rate for Payer: Adventist Health Commercial	$0.56
Rate for Payer: Aetna of CA Non-Gatekeeper	$1.93
Rate for Payer: Cash Price	$1.26
Rate for Payer: EPIC Health Plan Commercial	$1.52
Rate for Payer: Heritage Provider Network Commercial	$1.90
Rate for Payer: Heritage Provider Network Senior	$1.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.51
Rate for Payer: LLUH Dept of Risk Management WC	$0.70
Rate for Payer: Multiplan Commercial	$2.11

SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]

Facility IP

$1.40

Service Code	CPT S0090
Hospital Charge Code	1711956
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$1.05
Rate for Payer: Adventist Health Commercial	$0.28
Rate for Payer: Adventist Health Commercial	$0.18
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.61
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.96
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cash Price	$0.63
Rate for Payer: EPIC Health Plan Commercial	$0.76
Rate for Payer: EPIC Health Plan Commercial	$0.48
Rate for Payer: Heritage Provider Network Commercial	$0.95
Rate for Payer: Heritage Provider Network Commercial	$0.60
Rate for Payer: Heritage Provider Network Senior	$0.60
Rate for Payer: Heritage Provider Network Senior	$0.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.67
Rate for Payer: Multiplan Commercial	$1.05

Price Transparency.

All Charges