Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

D&C, CONIZATION, LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC

Facility

$18,168.44

Service Code	MSDRG 745
Min. Negotiated Rate	$13,558.54
Max. Negotiated Rate	$18,168.44
Rate for Payer: EPIC Health Plan Medicare	$13,558.54
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$13,558.54
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$15,592.32
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$18,168.44

DD10B6Z

Facility

$9,120.00

Service Code	ICD DD10B6Z
Hospital Charge Code	5512
Min. Negotiated Rate	$9,120.00
Max. Negotiated Rate	$9,120.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,120.00

DD10BB1

Facility

$9,120.00

Service Code	ICD DD10BB1
Hospital Charge Code	5513
Min. Negotiated Rate	$9,120.00
Max. Negotiated Rate	$9,120.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,120.00

DD11B6Z

Facility

$9,120.00

Service Code	ICD DD11B6Z
Hospital Charge Code	5514
Min. Negotiated Rate	$9,120.00
Max. Negotiated Rate	$9,120.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,120.00

DD11BB1

Facility

$9,120.00

Service Code	ICD DD11BB1
Hospital Charge Code	5515
Min. Negotiated Rate	$9,120.00
Max. Negotiated Rate	$9,120.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,120.00

DD12B6Z

Facility

$9,120.00

Service Code	ICD DD12B6Z
Hospital Charge Code	5516
Min. Negotiated Rate	$9,120.00
Max. Negotiated Rate	$9,120.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,120.00

DD12BB1

Facility

$9,120.00

Service Code	ICD DD12BB1
Hospital Charge Code	5517
Min. Negotiated Rate	$9,120.00
Max. Negotiated Rate	$9,120.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,120.00

DD13B6Z

Facility

$9,120.00

Service Code	ICD DD13B6Z
Hospital Charge Code	5518
Min. Negotiated Rate	$9,120.00
Max. Negotiated Rate	$9,120.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,120.00

DD13BB1

Facility

$9,120.00

Service Code	ICD DD13BB1
Hospital Charge Code	5519
Min. Negotiated Rate	$9,120.00
Max. Negotiated Rate	$9,120.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,120.00

DD14B6Z

Facility

$9,120.00

Service Code	ICD DD14B6Z
Hospital Charge Code	5520
Min. Negotiated Rate	$9,120.00
Max. Negotiated Rate	$9,120.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,120.00

DD14BB1

Facility

$9,120.00

Service Code	ICD DD14BB1
Hospital Charge Code	5521
Min. Negotiated Rate	$9,120.00
Max. Negotiated Rate	$9,120.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,120.00

DD15B6Z

Facility

$9,120.00

Service Code	ICD DD15B6Z
Hospital Charge Code	5522
Min. Negotiated Rate	$9,120.00
Max. Negotiated Rate	$9,120.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,120.00

DD15BB1

Facility

$9,120.00

Service Code	ICD DD15BB1
Hospital Charge Code	5523
Min. Negotiated Rate	$9,120.00
Max. Negotiated Rate	$9,120.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,120.00

DD17B6Z

Facility

$9,120.00

Service Code	ICD DD17B6Z
Hospital Charge Code	5524
Min. Negotiated Rate	$9,120.00
Max. Negotiated Rate	$9,120.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,120.00

DD17BB1

Facility

$9,120.00

Service Code	ICD DD17BB1
Hospital Charge Code	5525
Min. Negotiated Rate	$9,120.00
Max. Negotiated Rate	$9,120.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$9,120.00

DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$9,616.00

Service Code	CPT 11047
Hospital Revenue Code	360
Min. Negotiated Rate	$918.00
Max. Negotiated Rate	$9,616.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,672.00
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

DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS

Facility

$9,616.00

Service Code	CPT 11044
Hospital Revenue Code	361
Min. Negotiated Rate	$2,124.23
Max. Negotiated Rate	$9,616.00
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$3,186.34
Rate for Payer: Alpha Care Medical Group Medi-Cal	$2,336.65
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$2,124.23
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$5,158.00
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: Dignity Health Commercial/Exchange	$3,186.34
Rate for Payer: Dignity Health Medi-Cal	$2,336.65
Rate for Payer: Dignity Health Medicare Advantage	$2,124.23
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$2,124.23
Rate for Payer: Heritage Provider Network Senior	$2,612.80
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$2,124.23
Rate for Payer: Kaiser Foundation Hospitals Commercial	$4,036.04
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$2,442.86
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$2,846.47
Rate for Payer: Multiplan WC	$3,280.13
Rate for Payer: TriValley Medical Group Commercial	$2,336.65
Rate for Payer: TriValley Medical Group Senior	$2,336.65
Rate for Payer: United Healthcare All Other HMO/non HMO	$2,731.00
Rate for Payer: United Healthcare Navigate/Select/Select+	$2,298.00
Rate for Payer: Vantage Medical Group Commercial/Exchange	$3,186.34
Rate for Payer: Vantage Medical Group Medi-Cal	$2,336.65
Rate for Payer: Vantage Medical Group Senior	$2,124.23

DEBRIDEMENT, BONE (INCLUDES EPIDERMIS, DERMIS, SUBCUTANEOUS TISSUE, MUSCLE AND/OR FASCIA, IF PERFORMED); FIRST 20 SQ CM OR LESS

Facility

$9,616.00

Service Code	CPT 11044
Hospital Revenue Code	360
Min. Negotiated Rate	$2,124.23
Max. Negotiated Rate	$9,616.00
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$3,186.34
Rate for Payer: Alpha Care Medical Group Medi-Cal	$2,336.65
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$2,124.23
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$5,158.00
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: Dignity Health Commercial/Exchange	$3,186.34
Rate for Payer: Dignity Health Medi-Cal	$2,336.65
Rate for Payer: Dignity Health Medicare Advantage	$2,124.23
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$2,124.23
Rate for Payer: Heritage Provider Network Senior	$2,612.80
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$2,124.23
Rate for Payer: Kaiser Foundation Hospitals Commercial	$4,036.04
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$2,442.86
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$2,846.47
Rate for Payer: Multiplan WC	$3,280.13
Rate for Payer: TriValley Medical Group Commercial	$2,336.65
Rate for Payer: TriValley Medical Group Senior	$2,336.65
Rate for Payer: United Healthcare All Other HMO/non HMO	$2,731.00
Rate for Payer: United Healthcare Navigate/Select/Select+	$2,298.00
Rate for Payer: Vantage Medical Group Commercial/Exchange	$3,186.34
Rate for Payer: Vantage Medical Group Medi-Cal	$2,336.65
Rate for Payer: Vantage Medical Group Senior	$2,124.23

DEBRIDEMENT (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), OPEN WOUND, (EG, FIBRIN, DEVITALIZED EPIDERMIS AND/OR DERMIS, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS

Facility

$8,962.13

Service Code	CPT 97597
Hospital Revenue Code	360
Min. Negotiated Rate	$258.05
Max. Negotiated Rate	$8,962.13
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$387.07
Rate for Payer: Alpha Care Medical Group Medi-Cal	$283.86
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$258.05
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: Dignity Health Commercial/Exchange	$387.07
Rate for Payer: Dignity Health Medi-Cal	$283.86
Rate for Payer: Dignity Health Medicare Advantage	$258.05
Rate for Payer: EPIC Health Plan Medicare	$258.05
Rate for Payer: Heritage Provider Network Senior	$317.40
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$258.05
Rate for Payer: Kaiser Foundation Hospitals Commercial	$490.30
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$296.76
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$345.79
Rate for Payer: Multiplan WC	$402.27
Rate for Payer: TriValley Medical Group Commercial	$283.86
Rate for Payer: TriValley Medical Group Senior	$283.86
Rate for Payer: United Healthcare All Other HMO/non HMO	$1,093.00
Rate for Payer: United Healthcare Navigate/Select/Select+	$918.00
Rate for Payer: Vantage Medical Group Commercial/Exchange	$387.07
Rate for Payer: Vantage Medical Group Medi-Cal	$283.86
Rate for Payer: Vantage Medical Group Senior	$258.05

DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$9,616.00

Service Code	CPT 11046
Hospital Revenue Code	360
Min. Negotiated Rate	$918.00
Max. Negotiated Rate	$9,616.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,672.00
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

DEBRIDEMENT, MUSCLE AND/OR FASCIA (INCLUDES EPIDERMIS, DERMIS, AND SUBCUTANEOUS TISSUE, IF PERFORMED); FIRST 20 SQ CM OR LESS

Facility

$9,616.00

Service Code	CPT 11043
Hospital Revenue Code	360
Min. Negotiated Rate	$918.00
Max. Negotiated Rate	$9,616.00
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$1,425.86
Rate for Payer: Alpha Care Medical Group Medi-Cal	$1,045.63
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$950.57
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$5,158.00
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: Dignity Health Commercial/Exchange	$1,425.86
Rate for Payer: Dignity Health Medi-Cal	$1,045.63
Rate for Payer: Dignity Health Medicare Advantage	$950.57
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$950.57
Rate for Payer: Heritage Provider Network Senior	$1,169.20
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$950.57
Rate for Payer: Kaiser Foundation Hospitals Commercial	$1,806.08
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$1,093.16
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$1,273.76
Rate for Payer: Multiplan WC	$1,239.24
Rate for Payer: TriValley Medical Group Commercial	$1,045.63
Rate for Payer: TriValley Medical Group Senior	$1,045.63
Rate for Payer: United Healthcare All Other HMO/non HMO	$1,093.00
Rate for Payer: United Healthcare Navigate/Select/Select+	$918.00
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,425.86
Rate for Payer: Vantage Medical Group Medi-Cal	$1,045.63
Rate for Payer: Vantage Medical Group Senior	$950.57

DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

Facility

$9,616.00

Service Code	CPT 11045
Hospital Revenue Code	360
Min. Negotiated Rate	$918.00
Max. Negotiated Rate	$9,616.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$3,672.00
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

DEBRIDEMENT, SUBCUTANEOUS TISSUE (INCLUDES EPIDERMIS AND DERMIS, IF PERFORMED); FIRST 20 SQ CM OR LESS

Facility

$9,616.00

Service Code	CPT 11042
Hospital Revenue Code	360
Min. Negotiated Rate	$522.85
Max. Negotiated Rate	$9,616.00
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$784.27
Rate for Payer: Alpha Care Medical Group Medi-Cal	$575.13
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$522.85
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$5,158.00
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: Dignity Health Commercial/Exchange	$784.27
Rate for Payer: Dignity Health Medi-Cal	$575.13
Rate for Payer: Dignity Health Medicare Advantage	$522.85
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$522.85
Rate for Payer: Heritage Provider Network Senior	$643.11
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$522.85
Rate for Payer: Kaiser Foundation Hospitals Commercial	$993.41
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$601.28
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$700.62
Rate for Payer: Multiplan WC	$808.84
Rate for Payer: TriValley Medical Group Commercial	$575.13
Rate for Payer: TriValley Medical Group Senior	$575.13
Rate for Payer: United Healthcare All Other HMO/non HMO	$1,093.00
Rate for Payer: United Healthcare Navigate/Select/Select+	$918.00
Rate for Payer: Vantage Medical Group Commercial/Exchange	$784.27
Rate for Payer: Vantage Medical Group Medi-Cal	$575.13
Rate for Payer: Vantage Medical Group Senior	$522.85

DECITABINE 35 MG-CEDAZURIDINE 100 MG TABLET [228955]

Facility

$2,160.04

Service Code	NDC 6484207279
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$390.97
Max. Negotiated Rate	$1,620.03
Rate for Payer: Adventist Health Commercial	$432.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$1,391.07
Rate for Payer: Cash Price	$972.02
Rate for Payer: EPIC Health Plan Commercial	$1,166.42
Rate for Payer: Heritage Provider Network Commercial	$1,462.35
Rate for Payer: Heritage Provider Network Senior	$1,462.35
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$390.97
Rate for Payer: LLUH Dept of Risk Management WC	$540.01
Rate for Payer: Multiplan Commercial	$1,620.03

DECITABINE 35 MG-CEDAZURIDINE 100 MG TABLET [228955]

Facility

$2,160.04

Service Code	NDC 6484207279
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$390.97
Max. Negotiated Rate	$1,836.03
Rate for Payer: Vantage Medical Group Medi-Cal	$1,836.03
Rate for Payer: Adventist Health Commercial	$432.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$1,334.90
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$1,836.03
Rate for Payer: Alpha Care Medical Group Medi-Cal	$1,188.02
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$1,620.03
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$1,080.45
Rate for Payer: Blue Shield of California Commercial	$1,317.62
Rate for Payer: Blue Shield of California EPN	$1,054.10
Rate for Payer: Cash Price	$972.02
Rate for Payer: Cigna of CA HMO/PPO	$1,404.03
Rate for Payer: Dignity Health Commercial/Exchange	$1,836.03
Rate for Payer: Dignity Health Medi-Cal	$1,836.03
Rate for Payer: Dignity Health Medicare Advantage	$1,836.03
Rate for Payer: EPIC Health Plan Commercial	$1,382.43
Rate for Payer: Heritage Provider Network Commercial	$1,337.06
Rate for Payer: Heritage Provider Network Senior	$1,337.06
Rate for Payer: Kaiser Foundation Hospitals Commercial	$1,030.34
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$390.97
Rate for Payer: LLUH Dept of Risk Management WC	$540.01
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$1,512.03
Rate for Payer: Multiplan Commercial	$1,620.03
Rate for Payer: TriValley Medical Group Commercial	$864.02
Rate for Payer: TriValley Medical Group Senior	$864.02
Rate for Payer: United Healthcare All Other HMO/non HMO	$1,080.02
Rate for Payer: United Healthcare Navigate/Select/Select+	$1,080.02
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,836.03
Rate for Payer: Vantage Medical Group Senior	$1,836.03

Know your out-of-pocket cost for care.

All Charges