Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

COMBINED ANTERIOR AND POSTERIOR CERVICAL SPINAL FUSION WITHOUT MCC

Facility

$89,258.10

Service Code	MSDRG 430
Min. Negotiated Rate	$3,928.00
Max. Negotiated Rate	$89,258.10
Rate for Payer: EPIC Health Plan Medicare	$66,610.52
Rate for Payer: Heritage Provider Network Commercial	$4,319.00
Rate for Payer: Heritage Provider Network Senior	$3,928.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$66,610.52
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$76,602.10
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$89,258.10

COMPLEX AORTIC ARCH PROCEDURES

Facility

$174,507.06

Service Code	MSDRG 209
Min. Negotiated Rate	$130,229.15
Max. Negotiated Rate	$174,507.06
Rate for Payer: EPIC Health Plan Medicare	$130,229.15
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$130,229.15
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$149,763.52
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$174,507.06

COMPLICATED PEPTIC ULCER WITH CC

Facility

$17,339.25

Service Code	MSDRG 381
Min. Negotiated Rate	$12,939.74
Max. Negotiated Rate	$17,339.25
Rate for Payer: EPIC Health Plan Medicare	$12,939.74
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$12,939.74
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$14,880.70
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$17,339.25

COMPLICATED PEPTIC ULCER WITH MCC

Facility

$30,832.09

Service Code	MSDRG 380
Min. Negotiated Rate	$23,009.02
Max. Negotiated Rate	$30,832.09
Rate for Payer: EPIC Health Plan Medicare	$23,009.02
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$23,009.02
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$26,460.37
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$30,832.09

COMPLICATED PEPTIC ULCER WITHOUT CC/MCC

Facility

$12,995.19

Service Code	MSDRG 382
Min. Negotiated Rate	$9,697.90
Max. Negotiated Rate	$12,995.19
Rate for Payer: EPIC Health Plan Medicare	$9,697.90
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$9,697.90
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$11,152.58
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$12,995.19

COMPLICATIONS OF TREATMENT WITH CC

Facility

$16,092.38

Service Code	MSDRG 920
Min. Negotiated Rate	$12,009.24
Max. Negotiated Rate	$16,092.38
Rate for Payer: EPIC Health Plan Medicare	$12,009.24
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$12,009.24
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$13,810.63
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$16,092.38

COMPLICATIONS OF TREATMENT WITH MCC

Facility

$28,814.37

Service Code	MSDRG 919
Min. Negotiated Rate	$21,503.26
Max. Negotiated Rate	$28,814.37
Rate for Payer: EPIC Health Plan Medicare	$21,503.26
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$21,503.26
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$24,728.75
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$28,814.37

COMPLICATIONS OF TREATMENT WITHOUT CC/MCC

Facility

$11,272.31

Service Code	MSDRG 921
Min. Negotiated Rate	$8,412.17
Max. Negotiated Rate	$11,272.31
Rate for Payer: EPIC Health Plan Medicare	$8,412.17
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$8,412.17
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$9,674.00
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$11,272.31

COMPOUNDING VEHICLE (FLAVOR SWEET) NO 8 ORAL LIQUID [37965]

Facility

$0.04

Service Code	NDC 0574030416
Hospital Charge Code	901700016
Hospital Revenue Code	271
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: Heritage Provider Network Commercial	$0.03
Rate for Payer: Heritage Provider Network Senior	$0.03
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.03

COMPOUNDING VEHICLE (FLAVOR SWEET) NO 8 ORAL LIQUID [37965]

Facility

$0.04

Service Code	NDC 0574030416
Hospital Charge Code	901700016
Hospital Revenue Code	271
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	$0.02
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.03
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.02
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.03
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.02
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 Medicare Advantage	$0.03
Rate for Payer: EPIC Health Plan Commercial	$0.02
Rate for Payer: Heritage Provider Network Commercial	$0.02
Rate for Payer: Heritage Provider Network Senior	$0.02
Rate for Payer: Kaiser Foundation Hospitals Commercial	$0.02
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$0.03
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: United Healthcare All Other HMO/non HMO	$0.02
Rate for Payer: United Healthcare Navigate/Select/Select+	$0.02
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.03
Rate for Payer: Vantage Medical Group Medi-Cal	$0.03
Rate for Payer: Vantage Medical Group Senior	$0.03

COMPOUNDING VEHICLE (ORA-PLUS) SUSPENSION SUGAR-FREE NO.20 ORAL [211818]

Facility

$0.04

Service Code	NDC 0574030316
Hospital Charge Code	901700029
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 Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.03

COMPOUNDING VEHICLE (ORA-PLUS) SUSPENSION SUGAR-FREE NO.20 ORAL [211818]

Facility

$0.04

Service Code	NDC 0574030316
Hospital Charge Code	901700029
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	$0.02
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.03
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.02
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.03
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.02
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 Medicare Advantage	$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 Foundation Hospitals Commercial	$0.02
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$0.03
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: TriValley Medical Group Commercial	$0.02
Rate for Payer: TriValley Medical Group Senior	$0.02
Rate for Payer: United Healthcare All Other HMO/non HMO	$0.02
Rate for Payer: United Healthcare Navigate/Select/Select+	$0.02
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.03
Rate for Payer: Vantage Medical Group Medi-Cal	$0.03
Rate for Payer: Vantage Medical Group Senior	$0.03

COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]

Facility

$0.04

Service Code	NDC 0574030216
Hospital Charge Code	901700029
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	$0.02
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.03
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.02
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.03
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.02
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 Medicare Advantage	$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 Foundation Hospitals Commercial	$0.02
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$0.03
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: TriValley Medical Group Commercial	$0.02
Rate for Payer: TriValley Medical Group Senior	$0.02
Rate for Payer: United Healthcare All Other HMO/non HMO	$0.02
Rate for Payer: United Healthcare Navigate/Select/Select+	$0.02
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.03
Rate for Payer: Vantage Medical Group Medi-Cal	$0.03
Rate for Payer: Vantage Medical Group Senior	$0.03

COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]

Facility

$0.04

Service Code	NDC 0574030216
Hospital Charge Code	901700029
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 Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.03

COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]

Facility

$0.03

Service Code	NDC 0395009416
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Adventist Health Commercial	$0.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.02
Rate for Payer: Heritage Provider Network Commercial	$0.02
Rate for Payer: Heritage Provider Network Senior	$0.02
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

COMPOUNDING VEHICLE (ORA-SWEET SF) SUGAR-FREE NO.9 ORAL LIQUID [120588]

Facility

$0.03

Service Code	NDC 0395009416
Hospital Charge Code	901700029
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	$0.02
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.03
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.02
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.02
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.02
Rate for Payer: Blue Shield of California Commercial	$0.02
Rate for Payer: Blue Shield of California EPN	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Dignity Health Commercial/Exchange	$0.03
Rate for Payer: Dignity Health Medi-Cal	$0.03
Rate for Payer: Dignity Health Medicare Advantage	$0.03
Rate for Payer: EPIC Health Plan Commercial	$0.02
Rate for Payer: Heritage Provider Network Commercial	$0.02
Rate for Payer: Heritage Provider Network Senior	$0.02
Rate for Payer: Kaiser Foundation Hospitals Commercial	$0.01
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$0.02
Rate for Payer: Multiplan Commercial	$0.02
Rate for Payer: TriValley Medical Group Commercial	$0.01
Rate for Payer: TriValley Medical Group Senior	$0.01
Rate for Payer: United Healthcare All Other HMO/non HMO	$0.02
Rate for Payer: United Healthcare Navigate/Select/Select+	$0.02
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.03
Rate for Payer: Vantage Medical Group Medi-Cal	$0.03
Rate for Payer: Vantage Medical Group Senior	$0.03

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.04

Service Code	NDC 3172295901
Hospital Charge Code	901700029
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	$0.02
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.03
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.02
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.03
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.02
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 Medicare Advantage	$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 Foundation Hospitals Commercial	$0.02
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$0.03
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: TriValley Medical Group Commercial	$0.02
Rate for Payer: TriValley Medical Group Senior	$0.02
Rate for Payer: United Healthcare All Other HMO/non HMO	$0.02
Rate for Payer: United Healthcare Navigate/Select/Select+	$0.02
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.03
Rate for Payer: Vantage Medical Group Medi-Cal	$0.03
Rate for Payer: Vantage Medical Group Senior	$0.03

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.04

Service Code	NDC 0574030416
Hospital Charge Code	901700016
Hospital Revenue Code	271
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: Heritage Provider Network Commercial	$0.03
Rate for Payer: Heritage Provider Network Senior	$0.03
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.03

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.04

Service Code	NDC 0574030416
Hospital Charge Code	901700016
Hospital Revenue Code	271
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	$0.02
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.03
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.02
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.03
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.02
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 Medicare Advantage	$0.03
Rate for Payer: EPIC Health Plan Commercial	$0.02
Rate for Payer: Heritage Provider Network Commercial	$0.02
Rate for Payer: Heritage Provider Network Senior	$0.02
Rate for Payer: Kaiser Foundation Hospitals Commercial	$0.02
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$0.03
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: United Healthcare All Other HMO/non HMO	$0.02
Rate for Payer: United Healthcare Navigate/Select/Select+	$0.02
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.03
Rate for Payer: Vantage Medical Group Medi-Cal	$0.03
Rate for Payer: Vantage Medical Group Senior	$0.03

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.10

Service Code	NDC 3877907448
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.08
Rate for Payer: Adventist Health Commercial	$0.02
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: EPIC Health Plan Commercial	$0.05
Rate for Payer: Heritage Provider Network Commercial	$0.07
Rate for Payer: Heritage Provider Network Senior	$0.07
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.08

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.04

Service Code	NDC 3172295901
Hospital Charge Code	901700029
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 Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.03

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.04

Service Code	NDC 0395009016
Hospital Charge Code	901700029
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	$0.02
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.03
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.02
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.03
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.02
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 Medicare Advantage	$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 Foundation Hospitals Commercial	$0.02
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$0.03
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: TriValley Medical Group Commercial	$0.02
Rate for Payer: TriValley Medical Group Senior	$0.02
Rate for Payer: United Healthcare All Other HMO/non HMO	$0.02
Rate for Payer: United Healthcare Navigate/Select/Select+	$0.02
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.03
Rate for Payer: Vantage Medical Group Medi-Cal	$0.03
Rate for Payer: Vantage Medical Group Senior	$0.03

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.10

Service Code	NDC 3877907448
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.09
Rate for Payer: Vantage Medical Group Medi-Cal	$0.09
Rate for Payer: Adventist Health Commercial	$0.02
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.06
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.09
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.06
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.08
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.05
Rate for Payer: Blue Shield of California Commercial	$0.06
Rate for Payer: Blue Shield of California EPN	$0.05
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Dignity Health Commercial/Exchange	$0.09
Rate for Payer: Dignity Health Medi-Cal	$0.09
Rate for Payer: Dignity Health Medicare Advantage	$0.09
Rate for Payer: EPIC Health Plan Commercial	$0.06
Rate for Payer: Heritage Provider Network Commercial	$0.06
Rate for Payer: Heritage Provider Network Senior	$0.06
Rate for Payer: Kaiser Foundation Hospitals Commercial	$0.05
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$0.07
Rate for Payer: Multiplan Commercial	$0.08
Rate for Payer: TriValley Medical Group Commercial	$0.04
Rate for Payer: TriValley Medical Group Senior	$0.04
Rate for Payer: United Healthcare All Other HMO/non HMO	$0.05
Rate for Payer: United Healthcare Navigate/Select/Select+	$0.05
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.09
Rate for Payer: Vantage Medical Group Senior	$0.09

COMPOUNDING VEHICLE SYRUP NO.23 [222005]

Facility

$0.04

Service Code	NDC 0395009016
Hospital Charge Code	901700029
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 Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.03

COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES, IMAGE-LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$9,616.00

Service Code	CPT 20985
Hospital Revenue Code	360
Min. Negotiated Rate	$918.00
Max. Negotiated Rate	$9,616.00
Rate for Payer: Blue Shield of California Commercial	$8,962.13
Rate for Payer: Blue Shield of California EPN	$7,178.49
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: United Healthcare All Other HMO/non HMO	$1,093.00
Rate for Payer: United Healthcare Navigate/Select/Select+	$918.00

Know your out-of-pocket cost for care.

All Charges