Loma Linda University Medical Center

All Charges

Charge

Type

Price

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0D160K9
Min. Negotiated Rate	$11,586.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00
Rate for Payer: Kaiser Permanente of CA Commercial	$11,586.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0D164KL
Min. Negotiated Rate	$10,600.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00
Rate for Payer: EPIC Health Plan Commercial	$10,600.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0D160KB
Min. Negotiated Rate	$17,388.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0D1647L
Min. Negotiated Rate	$10,600.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00
Rate for Payer: EPIC Health Plan Commercial	$10,600.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0D16879
Min. Negotiated Rate	$17,388.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0D1647B
Min. Negotiated Rate	$10,600.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00
Rate for Payer: EPIC Health Plan Commercial	$10,600.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0D164ZA
Min. Negotiated Rate	$10,600.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00
Rate for Payer: EPIC Health Plan Commercial	$10,600.00
Rate for Payer: Kaiser Permanente of CA Commercial	$11,586.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0DQ60ZZ
Min. Negotiated Rate	$17,388.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0D168ZL
Min. Negotiated Rate	$17,388.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0DQ67ZZ
Min. Negotiated Rate	$17,388.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0DT78ZZ
Min. Negotiated Rate	$17,388.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0DB68Z3
Min. Negotiated Rate	$17,388.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0D168KB
Min. Negotiated Rate	$17,388.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0DB63Z3
Min. Negotiated Rate	$17,388.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0D16479
Min. Negotiated Rate	$10,600.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00
Rate for Payer: EPIC Health Plan Commercial	$10,600.00
Rate for Payer: Kaiser Permanente of CA Commercial	$11,586.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0D160Z9
Min. Negotiated Rate	$11,586.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00
Rate for Payer: Kaiser Permanente of CA Commercial	$11,586.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0D164JL
Min. Negotiated Rate	$10,600.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00
Rate for Payer: EPIC Health Plan Commercial	$10,600.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0DB60Z3
Min. Negotiated Rate	$17,388.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0D164Z9
Min. Negotiated Rate	$11,586.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00
Rate for Payer: Kaiser Permanente of CA Commercial	$11,586.00

Bariatric Surgery

Facility IP

$17,388.00

Service Code	ICD 0D160JL
Min. Negotiated Rate	$17,388.00
Max. Negotiated Rate	$17,388.00
Rate for Payer: Aetna of CA Gatekeeper	$17,388.00

BARICITINIB 1 MG TABLET [225594]

Facility OP

$104.88

Service Code	NDC 0002-4732-30
Hospital Charge Code	ERX225594
Hospital Revenue Code	259
Min. Negotiated Rate	$18.98
Max. Negotiated Rate	$89.15
Rate for Payer: Adventist Health Commercial	$20.98
Rate for Payer: Aetna of CA Gatekeeper	$56.06
Rate for Payer: Aetna of CA Non-Gatekeeper	$72.05
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$89.15
Rate for Payer: AlphaCare Medical Group Medi-Cal	$57.68
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$78.66
Rate for Payer: Blue Shield of California Commercial	$65.13
Rate for Payer: Blue Shield of California EPN	$61.56
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cigna of CA HMO/PPO	$68.17
Rate for Payer: Dignity Health Commercial/Exchange	$89.15
Rate for Payer: Dignity Health Medi-Cal	$89.15
Rate for Payer: Dignity Health Senior	$89.15
Rate for Payer: EPIC Health Plan Commercial	$67.12
Rate for Payer: Heritage Provider Network Commercial	$64.92
Rate for Payer: Heritage Provider Network Senior	$64.92
Rate for Payer: Kaiser Permanente of CA Commercial	$50.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$18.98
Rate for Payer: LLUH Dept of Risk Management WC	$26.22
Rate for Payer: Multiplan Commercial	$78.66
Rate for Payer: Vantage Medical Group Medi-Cal	$89.15
Rate for Payer: Vantage Medical Group Senior	$89.15

BARICITINIB 1 MG TABLET [225594]

Facility IP

$104.88

Service Code	NDC 0002-4732-30
Hospital Charge Code	ERX225594
Hospital Revenue Code	259
Min. Negotiated Rate	$18.98
Max. Negotiated Rate	$78.66
Rate for Payer: Adventist Health Commercial	$20.98
Rate for Payer: Aetna of CA Non-Gatekeeper	$72.05
Rate for Payer: Cash Price	$47.20
Rate for Payer: EPIC Health Plan Commercial	$56.64
Rate for Payer: Heritage Provider Network Commercial	$71.00
Rate for Payer: Heritage Provider Network Senior	$71.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$18.98
Rate for Payer: LLUH Dept of Risk Management WC	$26.22
Rate for Payer: Multiplan Commercial	$78.66

BARICITINIB 2 MG TABLET [221907]

Facility OP

$104.88

Service Code	CPT J8499
Hospital Charge Code	ERX221907
Hospital Revenue Code	636
Min. Negotiated Rate	$18.98
Max. Negotiated Rate	$89.15
Rate for Payer: Adventist Health Commercial	$20.98
Rate for Payer: Aetna of CA Gatekeeper	$56.06
Rate for Payer: Aetna of CA Non-Gatekeeper	$72.05
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$89.15
Rate for Payer: AlphaCare Medical Group Medi-Cal	$57.68
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$78.66
Rate for Payer: Blue Shield of California Commercial	$65.13
Rate for Payer: Blue Shield of California EPN	$61.56
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cigna of CA HMO/PPO	$48.24
Rate for Payer: Dignity Health Commercial/Exchange	$89.15
Rate for Payer: Dignity Health Medi-Cal	$89.15
Rate for Payer: Dignity Health Senior	$89.15
Rate for Payer: EPIC Health Plan Commercial	$67.12
Rate for Payer: Heritage Provider Network Commercial	$48.56
Rate for Payer: Heritage Provider Network Senior	$48.56
Rate for Payer: Kaiser Permanente of CA Commercial	$50.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$18.98
Rate for Payer: LLUH Dept of Risk Management WC	$26.22
Rate for Payer: Multiplan Commercial	$78.66
Rate for Payer: United Healthcare All Other HMO/non HMO	$38.24
Rate for Payer: United Healthcare Navigate/Select/Select+	$35.04
Rate for Payer: Vantage Medical Group Medi-Cal	$89.15
Rate for Payer: Vantage Medical Group Senior	$89.15

BARICITINIB 2 MG TABLET [221907]

Facility IP

$104.88

Service Code	CPT J8499
Hospital Charge Code	ERX221907
Hospital Revenue Code	636
Min. Negotiated Rate	$18.98
Max. Negotiated Rate	$78.66
Rate for Payer: Adventist Health Commercial	$20.98
Rate for Payer: Aetna of CA Non-Gatekeeper	$72.05
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cigna of CA HMO/PPO	$48.24
Rate for Payer: EPIC Health Plan Commercial	$56.64
Rate for Payer: Heritage Provider Network Commercial	$71.00
Rate for Payer: Heritage Provider Network Senior	$71.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$18.98
Rate for Payer: LLUH Dept of Risk Management WC	$26.22
Rate for Payer: Multiplan Commercial	$78.66
Rate for Payer: United Healthcare All Other HMO/non HMO	$38.24
Rate for Payer: United Healthcare Navigate/Select/Select+	$35.04

BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [97296]

Facility IP

$0.03

Service Code	NDC 32909-167-55
Hospital Charge Code	NDG972961
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 Permanente of CA Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

Price Transparency.

All Charges