Loma Linda University Medical Center

All Charges

Charge

Type

Price

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Facility IP

$35,592.40

Service Code	APR-DRG 0091
Min. Negotiated Rate	$35,592.40
Max. Negotiated Rate	$35,592.40
Rate for Payer: IEHP Medi-Cal	$35,592.40

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Facility IP

$59,460.96

Service Code	APR-DRG 0093
Min. Negotiated Rate	$59,460.96
Max. Negotiated Rate	$59,460.96
Rate for Payer: IEHP Medi-Cal	$59,460.96

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Facility IP

$129,013.14

Service Code	APR-DRG 0094
Min. Negotiated Rate	$129,013.14
Max. Negotiated Rate	$129,013.14
Rate for Payer: IEHP Medi-Cal	$129,013.14

EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Facility IP

$43,368.51

Service Code	APR-DRG 0092
Min. Negotiated Rate	$43,368.51
Max. Negotiated Rate	$43,368.51
Rate for Payer: IEHP Medi-Cal	$43,368.51

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older (includes fluoroscopic guidance, when performed)

Facility OP

$9,616.00

Service Code	CPT 33952
Min. Negotiated Rate	$458.23
Max. Negotiated Rate	$9,616.00
Rate for Payer: Aetna of CA Gatekeeper	$921.50
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$5,505.00
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: IEHP Medi-Cal	$458.23

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility IP

$8,524.27

Service Code	APR-DRG 0823
Min. Negotiated Rate	$8,524.27
Max. Negotiated Rate	$8,524.27
Rate for Payer: IEHP Medi-Cal	$8,524.27

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility IP

$5,856.95

Service Code	APR-DRG 0822
Min. Negotiated Rate	$5,856.95
Max. Negotiated Rate	$5,856.95
Rate for Payer: IEHP Medi-Cal	$5,856.95

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility IP

$16,841.60

Service Code	APR-DRG 0824
Min. Negotiated Rate	$16,841.60
Max. Negotiated Rate	$16,841.60
Rate for Payer: IEHP Medi-Cal	$16,841.60

EYE INFECTIONS AND OTHER EYE DISORDERS

Facility IP

$4,766.55

Service Code	APR-DRG 0821
Min. Negotiated Rate	$4,766.55
Max. Negotiated Rate	$4,766.55
Rate for Payer: IEHP Medi-Cal	$4,766.55

EZETIMIBE 10 MG-SIMVASTATIN 20 MG TABLET [39221]

Facility IP

$13.67

Service Code	NDC 66582-312-31
Hospital Charge Code	1710951
Hospital Revenue Code	259
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$10.25
Rate for Payer: Adventist Health Commercial	$2.73
Rate for Payer: Aetna of CA Non-Gatekeeper	$9.39
Rate for Payer: Cash Price	$6.15
Rate for Payer: EPIC Health Plan Commercial	$7.38
Rate for Payer: Heritage Provider Network Commercial	$9.25
Rate for Payer: Heritage Provider Network Senior	$9.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$2.47
Rate for Payer: LLUH Dept of Risk Management WC	$3.42
Rate for Payer: Multiplan Commercial	$10.25

EZETIMIBE 10 MG-SIMVASTATIN 20 MG TABLET [39221]

Facility OP

$13.67

Service Code	NDC 66582-312-31
Hospital Charge Code	1710951
Hospital Revenue Code	259
Min. Negotiated Rate	$2.47
Max. Negotiated Rate	$11.62
Rate for Payer: Adventist Health Commercial	$2.73
Rate for Payer: Aetna of CA Gatekeeper	$7.31
Rate for Payer: Aetna of CA Non-Gatekeeper	$9.39
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$11.62
Rate for Payer: AlphaCare Medical Group Medi-Cal	$7.52
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$10.25
Rate for Payer: Blue Shield of California Commercial	$8.49
Rate for Payer: Blue Shield of California EPN	$8.02
Rate for Payer: Cash Price	$6.15
Rate for Payer: Cigna of CA HMO/PPO	$8.89
Rate for Payer: Dignity Health Commercial/Exchange	$11.62
Rate for Payer: Dignity Health Medi-Cal	$11.62
Rate for Payer: Dignity Health Senior	$11.62
Rate for Payer: EPIC Health Plan Commercial	$8.75
Rate for Payer: Heritage Provider Network Commercial	$8.46
Rate for Payer: Heritage Provider Network Senior	$8.46
Rate for Payer: Kaiser Permanente of CA Commercial	$6.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$2.47
Rate for Payer: LLUH Dept of Risk Management WC	$3.42
Rate for Payer: Multiplan Commercial	$10.25
Rate for Payer: Vantage Medical Group Medi-Cal	$11.62
Rate for Payer: Vantage Medical Group Senior	$11.62

EZETIMIBE 10 MG TABLET [34153]

Facility OP

$0.37

Service Code	NDC 67877-490-30
Hospital Charge Code	1712290
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.31
Rate for Payer: Adventist Health Commercial	$0.07
Rate for Payer: Aetna of CA Gatekeeper	$0.20
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.25
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.31
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.20
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.28
Rate for Payer: Blue Shield of California Commercial	$0.23
Rate for Payer: Blue Shield of California EPN	$0.22
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA HMO/PPO	$0.24
Rate for Payer: Dignity Health Commercial/Exchange	$0.31
Rate for Payer: Dignity Health Medi-Cal	$0.31
Rate for Payer: Dignity Health Senior	$0.31
Rate for Payer: EPIC Health Plan Commercial	$0.24
Rate for Payer: Heritage Provider Network Commercial	$0.23
Rate for Payer: Heritage Provider Network Senior	$0.23
Rate for Payer: Kaiser Permanente of CA Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.28
Rate for Payer: Vantage Medical Group Medi-Cal	$0.31
Rate for Payer: Vantage Medical Group Senior	$0.31

EZETIMIBE 10 MG TABLET [34153]

Facility IP

$0.37

Service Code	NDC 67877-490-30
Hospital Charge Code	1712290
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.28
Rate for Payer: Adventist Health Commercial	$0.07
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.25
Rate for Payer: Cash Price	$0.17
Rate for Payer: EPIC Health Plan Commercial	$0.20
Rate for Payer: Heritage Provider Network Commercial	$0.25
Rate for Payer: Heritage Provider Network Senior	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.28

EZETIMIBE 10 MG TABLET [34153]

Facility OP

$0.34

Service Code	NDC 59651-052-30
Hospital Charge Code	1712290
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.29
Rate for Payer: Adventist Health Commercial	$0.07
Rate for Payer: Aetna of CA Gatekeeper	$0.18
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.23
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.29
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.19
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.26
Rate for Payer: Blue Shield of California Commercial	$0.21
Rate for Payer: Blue Shield of California EPN	$0.20
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Dignity Health Commercial/Exchange	$0.29
Rate for Payer: Dignity Health Medi-Cal	$0.29
Rate for Payer: Dignity Health Senior	$0.29
Rate for Payer: EPIC Health Plan Commercial	$0.22
Rate for Payer: Heritage Provider Network Commercial	$0.21
Rate for Payer: Heritage Provider Network Senior	$0.21
Rate for Payer: Kaiser Permanente of CA Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.26
Rate for Payer: Vantage Medical Group Medi-Cal	$0.29
Rate for Payer: Vantage Medical Group Senior	$0.29

EZETIMIBE 10 MG TABLET [34153]

Facility IP

$0.34

Service Code	NDC 59651-052-30
Hospital Charge Code	1712290
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.26
Rate for Payer: Adventist Health Commercial	$0.07
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.23
Rate for Payer: Cash Price	$0.15
Rate for Payer: EPIC Health Plan Commercial	$0.18
Rate for Payer: Heritage Provider Network Commercial	$0.23
Rate for Payer: Heritage Provider Network Senior	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.26

EZETIMIBE 10 MG TABLET [34153]

Facility OP

$0.35

Service Code	NDC 0781-5690-31
Hospital Charge Code	1712290
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.30
Rate for Payer: Adventist Health Commercial	$0.07
Rate for Payer: Aetna of CA Gatekeeper	$0.19
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.24
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.30
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.19
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.26
Rate for Payer: Blue Shield of California Commercial	$0.22
Rate for Payer: Blue Shield of California EPN	$0.21
Rate for Payer: Cash Price	$0.16
Rate for Payer: Cigna of CA HMO/PPO	$0.23
Rate for Payer: Dignity Health Commercial/Exchange	$0.30
Rate for Payer: Dignity Health Medi-Cal	$0.30
Rate for Payer: Dignity Health Senior	$0.30
Rate for Payer: EPIC Health Plan Commercial	$0.22
Rate for Payer: Heritage Provider Network Commercial	$0.22
Rate for Payer: Heritage Provider Network Senior	$0.22
Rate for Payer: Kaiser Permanente of CA Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.26
Rate for Payer: Vantage Medical Group Medi-Cal	$0.30
Rate for Payer: Vantage Medical Group Senior	$0.30

EZETIMIBE 10 MG TABLET [34153]

Facility IP

$0.35

Service Code	NDC 0781-5690-31
Hospital Charge Code	1712290
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.26
Rate for Payer: Adventist Health Commercial	$0.07
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.24
Rate for Payer: Cash Price	$0.16
Rate for Payer: EPIC Health Plan Commercial	$0.19
Rate for Payer: Heritage Provider Network Commercial	$0.24
Rate for Payer: Heritage Provider Network Senior	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.26

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility IP

$14,266.81

Service Code	APR-DRG 0922
Min. Negotiated Rate	$14,266.81
Max. Negotiated Rate	$14,266.81
Rate for Payer: IEHP Medi-Cal	$14,266.81

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility IP

$11,081.16

Service Code	APR-DRG 0921
Min. Negotiated Rate	$11,081.16
Max. Negotiated Rate	$11,081.16
Rate for Payer: IEHP Medi-Cal	$11,081.16

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility IP

$22,366.26

Service Code	APR-DRG 0923
Min. Negotiated Rate	$22,366.26
Max. Negotiated Rate	$22,366.26
Rate for Payer: IEHP Medi-Cal	$22,366.26

FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES

Facility IP

$43,017.32

Service Code	APR-DRG 0924
Min. Negotiated Rate	$43,017.32
Max. Negotiated Rate	$43,017.32
Rate for Payer: IEHP Medi-Cal	$43,017.32

FAMCICLOVIR 500 MG TABLET [13358]

Facility IP

$1.40

Service Code	NDC 31722-708-30
Hospital Charge Code	1711642
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: Aetna of CA Non-Gatekeeper	$0.96
Rate for Payer: Cash Price	$0.63
Rate for Payer: EPIC Health Plan Commercial	$0.76
Rate for Payer: Heritage Provider Network Commercial	$0.95
Rate for Payer: Heritage Provider Network Senior	$0.95
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: Multiplan Commercial	$1.05

FAMCICLOVIR 500 MG TABLET [13358]

Facility OP

$1.40

Service Code	NDC 31722-708-30
Hospital Charge Code	1711642
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$1.19
Rate for Payer: Adventist Health Commercial	$0.28
Rate for Payer: Aetna of CA Gatekeeper	$0.75
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.96
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$1.19
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.77
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$1.05
Rate for Payer: Blue Shield of California Commercial	$0.87
Rate for Payer: Blue Shield of California EPN	$0.82
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cigna of CA HMO/PPO	$0.91
Rate for Payer: Dignity Health Commercial/Exchange	$1.19
Rate for Payer: Dignity Health Medi-Cal	$1.19
Rate for Payer: Dignity Health Senior	$1.19
Rate for Payer: EPIC Health Plan Commercial	$0.90
Rate for Payer: Heritage Provider Network Commercial	$0.87
Rate for Payer: Heritage Provider Network Senior	$0.87
Rate for Payer: Kaiser Permanente of CA Commercial	$0.67
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: Multiplan Commercial	$1.05
Rate for Payer: Vantage Medical Group Medi-Cal	$1.19
Rate for Payer: Vantage Medical Group Senior	$1.19

FAMCICLOVIR 500 MG TABLET [13358]

Facility IP

$2.75

Service Code	NDC 60687-103-25
Hospital Charge Code	1711642
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$2.06
Rate for Payer: Adventist Health Commercial	$0.55
Rate for Payer: Aetna of CA Non-Gatekeeper	$1.89
Rate for Payer: Cash Price	$1.24
Rate for Payer: EPIC Health Plan Commercial	$1.48
Rate for Payer: Heritage Provider Network Commercial	$1.86
Rate for Payer: Heritage Provider Network Senior	$1.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Commercial	$2.06

FAMCICLOVIR 500 MG TABLET [13358]

Facility IP

$2.75

Service Code	NDC 60687-103-95
Hospital Charge Code	1711642
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$2.06
Rate for Payer: Adventist Health Commercial	$0.55
Rate for Payer: Aetna of CA Non-Gatekeeper	$1.89
Rate for Payer: Cash Price	$1.24
Rate for Payer: EPIC Health Plan Commercial	$1.48
Rate for Payer: Heritage Provider Network Commercial	$1.86
Rate for Payer: Heritage Provider Network Senior	$1.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.69
Rate for Payer: Multiplan Commercial	$2.06

Price Transparency.

All Charges