Loma Linda University Medical Center

All Charges

Charge

Type

Price

Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, for cervical dystonia, spasmodic torticollis)

Facility OP

$3,237.00

Service Code	CPT 64616
Min. Negotiated Rate	$141.13
Max. Negotiated Rate	$3,237.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$555.09
Rate for Payer: AlphaCare Medical Group Medi-Cal	$407.07
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$370.06
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$555.09
Rate for Payer: Dignity Health Medi-Cal	$407.07
Rate for Payer: Dignity Health Senior	$370.06
Rate for Payer: EPIC Health Plan Medicare	$370.06
Rate for Payer: Humana Medicare	$370.06
Rate for Payer: IEHP Medi-Cal	$141.13
Rate for Payer: IEHP Medicare Advantage	$370.06
Rate for Payer: Kaiser Permanente of CA Commercial	$703.11
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$436.67
Rate for Payer: Molina Healthcare of CA Medi-Cal	$466.28
Rate for Payer: Molina Healthcare of CA Medicare	$466.28
Rate for Payer: TriValley Medical Group Commercial	$407.07
Rate for Payer: TriValley Medical Group Senior	$370.06
Rate for Payer: Vantage Medical Group Commercial/Exchange	$555.09
Rate for Payer: Vantage Medical Group Medi-Cal	$407.07
Rate for Payer: Vantage Medical Group Senior	$370.06

Chemodenervation of one extremity; 1-4 muscle(s)

Facility OP

$3,237.00

Service Code	CPT 64642
Min. Negotiated Rate	$142.29
Max. Negotiated Rate	$3,237.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$1,296.06
Rate for Payer: AlphaCare Medical Group Medi-Cal	$950.44
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$864.04
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$1,296.06
Rate for Payer: Dignity Health Medi-Cal	$950.44
Rate for Payer: Dignity Health Senior	$864.04
Rate for Payer: EPIC Health Plan Medicare	$864.04
Rate for Payer: Humana Medicare	$864.04
Rate for Payer: IEHP Medi-Cal	$142.29
Rate for Payer: IEHP Medicare Advantage	$864.04
Rate for Payer: Kaiser Permanente of CA Commercial	$1,641.68
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$1,019.57
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1,088.69
Rate for Payer: Molina Healthcare of CA Medicare	$1,088.69
Rate for Payer: TriValley Medical Group Commercial	$950.44
Rate for Payer: TriValley Medical Group Senior	$864.04
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,296.06
Rate for Payer: Vantage Medical Group Medi-Cal	$950.44
Rate for Payer: Vantage Medical Group Senior	$864.04

Chemodenervation of one extremity; 5 or more muscles

Facility OP

$3,237.00

Service Code	CPT 64644
Min. Negotiated Rate	$94.66
Max. Negotiated Rate	$3,237.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$1,296.06
Rate for Payer: AlphaCare Medical Group Medi-Cal	$950.44
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$864.04
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$1,296.06
Rate for Payer: Dignity Health Medi-Cal	$950.44
Rate for Payer: Dignity Health Senior	$864.04
Rate for Payer: EPIC Health Plan Medicare	$864.04
Rate for Payer: Humana Medicare	$864.04
Rate for Payer: IEHP Medi-Cal	$94.66
Rate for Payer: IEHP Medicare Advantage	$864.04
Rate for Payer: Kaiser Permanente of CA Commercial	$1,641.68
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$1,019.57
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1,088.69
Rate for Payer: Molina Healthcare of CA Medicare	$1,088.69
Rate for Payer: TriValley Medical Group Commercial	$950.44
Rate for Payer: TriValley Medical Group Senior	$864.04
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,296.06
Rate for Payer: Vantage Medical Group Medi-Cal	$950.44
Rate for Payer: Vantage Medical Group Senior	$864.04

Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (List separately in addition to code for primary procedure)

Facility OP

$3,237.00

Service Code	CPT 64643
Min. Negotiated Rate	$94.66
Max. Negotiated Rate	$3,237.00
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: IEHP Medi-Cal	$94.66

Chemodenervation of one extremity; each additional extremity, 5 or more muscles (List separately in addition to code for primary procedure)

Facility OP

$3,237.00

Service Code	CPT 64645
Min. Negotiated Rate	$108.03
Max. Negotiated Rate	$3,237.00
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: IEHP Medi-Cal	$108.03

Chemodenervation of parotid and submandibular salivary glands, bilateral

Facility OP

$4,547.00

Service Code	CPT 64611
Min. Negotiated Rate	$134.04
Max. Negotiated Rate	$4,547.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$555.09
Rate for Payer: AlphaCare Medical Group Medi-Cal	$407.07
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$370.06
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$4,547.00
Rate for Payer: Dignity Health Commercial/Exchange	$555.09
Rate for Payer: Dignity Health Medi-Cal	$407.07
Rate for Payer: Dignity Health Senior	$370.06
Rate for Payer: EPIC Health Plan Medicare	$370.06
Rate for Payer: Humana Medicare	$370.06
Rate for Payer: IEHP Medi-Cal	$134.04
Rate for Payer: IEHP Medicare Advantage	$370.06
Rate for Payer: Kaiser Permanente of CA Commercial	$703.11
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$436.67
Rate for Payer: Molina Healthcare of CA Medi-Cal	$466.28
Rate for Payer: Molina Healthcare of CA Medicare	$466.28
Rate for Payer: TriValley Medical Group Commercial	$407.07
Rate for Payer: TriValley Medical Group Senior	$370.06
Rate for Payer: Vantage Medical Group Commercial/Exchange	$555.09
Rate for Payer: Vantage Medical Group Medi-Cal	$407.07
Rate for Payer: Vantage Medical Group Senior	$370.06

Chemodenervation of trunk muscle(s); 1-5 muscle(s)

Facility OP

$3,237.00

Service Code	CPT 64646
Min. Negotiated Rate	$153.91
Max. Negotiated Rate	$3,237.00
Rate for Payer: Aetna of CA Gatekeeper	$1,335.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$1,296.06
Rate for Payer: AlphaCare Medical Group Medi-Cal	$950.44
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$864.04
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,237.00
Rate for Payer: Dignity Health Commercial/Exchange	$1,296.06
Rate for Payer: Dignity Health Medi-Cal	$950.44
Rate for Payer: Dignity Health Senior	$864.04
Rate for Payer: EPIC Health Plan Medicare	$864.04
Rate for Payer: Humana Medicare	$864.04
Rate for Payer: IEHP Medi-Cal	$153.91
Rate for Payer: IEHP Medicare Advantage	$864.04
Rate for Payer: Kaiser Permanente of CA Commercial	$1,641.68
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$1,019.57
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1,088.69
Rate for Payer: Molina Healthcare of CA Medicare	$1,088.69
Rate for Payer: TriValley Medical Group Commercial	$950.44
Rate for Payer: TriValley Medical Group Senior	$864.04
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,296.06
Rate for Payer: Vantage Medical Group Medi-Cal	$950.44
Rate for Payer: Vantage Medical Group Senior	$864.04

CHEMOTHERAPY FOR ACUTE LEUKEMIA

Facility IP

$4,916.78

Service Code	APR-DRG 6951
Min. Negotiated Rate	$4,916.78
Max. Negotiated Rate	$4,916.78
Rate for Payer: IEHP Medi-Cal	$4,916.78

CHEMOTHERAPY FOR ACUTE LEUKEMIA

Facility IP

$44,181.34

Service Code	APR-DRG 6954
Min. Negotiated Rate	$44,181.34
Max. Negotiated Rate	$44,181.34
Rate for Payer: IEHP Medi-Cal	$44,181.34

CHEMOTHERAPY FOR ACUTE LEUKEMIA

Facility IP

$6,809.07

Service Code	APR-DRG 6952
Min. Negotiated Rate	$6,809.07
Max. Negotiated Rate	$6,809.07
Rate for Payer: IEHP Medi-Cal	$6,809.07

CHEMOTHERAPY FOR ACUTE LEUKEMIA

Facility IP

$14,238.95

Service Code	APR-DRG 6953
Min. Negotiated Rate	$14,238.95
Max. Negotiated Rate	$14,238.95
Rate for Payer: IEHP Medi-Cal	$14,238.95

CHERRY FLAVOR (BULK) ORAL LIQUID [1562]

Facility OP

$0.04

Service Code	NDC 395266216
Hospital Charge Code	NDG1562
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: Adventist Health Commercial	$0.01
Rate for Payer: Aetna of CA Gatekeeper	$0.02
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.03
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.03
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.02
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.03
Rate for Payer: Blue Shield of California Commercial	$0.02
Rate for Payer: Blue Shield of California EPN	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Dignity Health Commercial/Exchange	$0.03
Rate for Payer: Dignity Health Medi-Cal	$0.03
Rate for Payer: Dignity Health Senior	$0.03
Rate for Payer: EPIC Health Plan Commercial	$0.03
Rate for Payer: Heritage Provider Network Commercial	$0.02
Rate for Payer: Heritage Provider Network Senior	$0.02
Rate for Payer: Kaiser Permanente of CA Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: Vantage Medical Group Medi-Cal	$0.03
Rate for Payer: Vantage Medical Group Senior	$0.03

CHERRY FLAVOR (BULK) ORAL LIQUID [1562]

Facility IP

$0.04

Service Code	NDC 395266216
Hospital Charge Code	NDG1562
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.03
Rate for Payer: Adventist Health Commercial	$0.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: EPIC Health Plan Commercial	$0.02
Rate for Payer: Heritage Provider Network Commercial	$0.03
Rate for Payer: Heritage Provider Network Senior	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.03

CHEST PAIN

Facility IP

$6,217.11

Service Code	APR-DRG 2033
Min. Negotiated Rate	$6,217.11
Max. Negotiated Rate	$6,217.11
Rate for Payer: IEHP Medi-Cal	$6,217.11

CHEST PAIN

Facility IP

$9,233.63

Service Code	APR-DRG 2034
Min. Negotiated Rate	$9,233.63
Max. Negotiated Rate	$9,233.63
Rate for Payer: IEHP Medi-Cal	$9,233.63

CHEST PAIN

Facility IP

$4,987.42

Service Code	APR-DRG 2032
Min. Negotiated Rate	$4,987.42
Max. Negotiated Rate	$4,987.42
Rate for Payer: IEHP Medi-Cal	$4,987.42

CHEST PAIN

Facility IP

$4,217.37

Service Code	APR-DRG 2031
Min. Negotiated Rate	$4,217.37
Max. Negotiated Rate	$4,217.37
Rate for Payer: IEHP Medi-Cal	$4,217.37

CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES

Facility IP

$138,338.30

Service Code	APR-DRG 0114
Min. Negotiated Rate	$138,338.30
Max. Negotiated Rate	$138,338.30
Rate for Payer: IEHP Medi-Cal	$138,338.30

CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES

Facility IP

$24,309.29

Service Code	APR-DRG 0111
Min. Negotiated Rate	$24,309.29
Max. Negotiated Rate	$24,309.29
Rate for Payer: IEHP Medi-Cal	$24,309.29

CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES

Facility IP

$36,068.95

Service Code	APR-DRG 0112
Min. Negotiated Rate	$36,068.95
Max. Negotiated Rate	$36,068.95
Rate for Payer: IEHP Medi-Cal	$36,068.95

CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES

Facility IP

$68,093.67

Service Code	APR-DRG 0113
Min. Negotiated Rate	$68,093.67
Max. Negotiated Rate	$68,093.67
Rate for Payer: IEHP Medi-Cal	$68,093.67

CHLORAMPHENICOL SODIUM SUCCINATE 1 GRAM INTRAVENOUS SOLUTION [25518]

Facility IP

$58.38

Service Code	CPT J0720
Hospital Charge Code	ERX25518
Hospital Revenue Code	636
Min. Negotiated Rate	$10.57
Max. Negotiated Rate	$43.78
Rate for Payer: Adventist Health Commercial	$11.68
Rate for Payer: Aetna of CA Non-Gatekeeper	$40.11
Rate for Payer: Cash Price	$26.27
Rate for Payer: Cigna of CA HMO/PPO	$26.85
Rate for Payer: EPIC Health Plan Commercial	$31.53
Rate for Payer: Heritage Provider Network Commercial	$39.52
Rate for Payer: Heritage Provider Network Senior	$39.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$10.57
Rate for Payer: LLUH Dept of Risk Management WC	$14.60
Rate for Payer: Multiplan Commercial	$43.78
Rate for Payer: United Healthcare All Other HMO/non HMO	$21.29
Rate for Payer: United Healthcare Navigate/Select/Select+	$19.50

CHLORAMPHENICOL SODIUM SUCCINATE 1 GRAM INTRAVENOUS SOLUTION [25518]

Facility OP

$58.38

Service Code	CPT J0720
Hospital Charge Code	ERX25518
Hospital Revenue Code	636
Min. Negotiated Rate	$10.57
Max. Negotiated Rate	$117.87
Rate for Payer: Adventist Health Commercial	$11.68
Rate for Payer: Aetna of CA Gatekeeper	$117.87
Rate for Payer: Aetna of CA Non-Gatekeeper	$40.11
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$49.62
Rate for Payer: AlphaCare Medical Group Medi-Cal	$32.11
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$43.78
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$11.36
Rate for Payer: Blue Shield of California Commercial	$39.70
Rate for Payer: Blue Shield of California EPN	$39.70
Rate for Payer: Cash Price	$26.27
Rate for Payer: Cash Price	$26.27
Rate for Payer: Cigna of CA HMO/PPO	$26.85
Rate for Payer: Dignity Health Commercial/Exchange	$49.62
Rate for Payer: Dignity Health Medi-Cal	$49.62
Rate for Payer: Dignity Health Senior	$49.62
Rate for Payer: EPIC Health Plan Commercial	$37.36
Rate for Payer: Heritage Provider Network Commercial	$27.03
Rate for Payer: Heritage Provider Network Senior	$27.03
Rate for Payer: IEHP Medi-Cal	$82.85
Rate for Payer: Kaiser Permanente of CA Commercial	$28.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$10.57
Rate for Payer: LLUH Dept of Risk Management WC	$14.60
Rate for Payer: Multiplan Commercial	$43.78
Rate for Payer: United Healthcare All Other HMO/non HMO	$21.29
Rate for Payer: United Healthcare Navigate/Select/Select+	$19.50
Rate for Payer: Vantage Medical Group Medi-Cal	$49.62
Rate for Payer: Vantage Medical Group Senior	$49.62

CHLORDIAZEPOXIDE 10 MG CAPSULE [1622]

Facility IP

$0.18

Service Code	NDC 0555-0033-02
Hospital Charge Code	1730119
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.14
Rate for Payer: Adventist Health Commercial	$0.04
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.12
Rate for Payer: Cash Price	$0.08
Rate for Payer: EPIC Health Plan Commercial	$0.10
Rate for Payer: Heritage Provider Network Commercial	$0.12
Rate for Payer: Heritage Provider Network Senior	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.14

CHLORDIAZEPOXIDE 10 MG CAPSULE [1622]

Facility OP

$0.12

Service Code	NDC 0555-0033-05
Hospital Charge Code	1730119
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.10
Rate for Payer: Adventist Health Commercial	$0.02
Rate for Payer: Aetna of CA Gatekeeper	$0.06
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.08
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.10
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.07
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.09
Rate for Payer: Blue Shield of California Commercial	$0.07
Rate for Payer: Blue Shield of California EPN	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.08
Rate for Payer: Dignity Health Commercial/Exchange	$0.10
Rate for Payer: Dignity Health Medi-Cal	$0.10
Rate for Payer: Dignity Health Senior	$0.10
Rate for Payer: EPIC Health Plan Commercial	$0.08
Rate for Payer: Heritage Provider Network Commercial	$0.07
Rate for Payer: Heritage Provider Network Senior	$0.07
Rate for Payer: Kaiser Permanente of CA Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.09
Rate for Payer: Vantage Medical Group Medi-Cal	$0.10
Rate for Payer: Vantage Medical Group Senior	$0.10

Price Transparency.

All Charges