Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

HIV WITH MAJOR HIV RELATED CONDITION

Facility

$13,879.79

Service Code	APR-DRG 8924
Min. Negotiated Rate	$13,879.79
Max. Negotiated Rate	$13,879.79
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$13,879.79

HIV WITH MAJOR HIV RELATED CONDITION

Facility

$6,440.96

Service Code	APR-DRG 8922
Min. Negotiated Rate	$6,440.96
Max. Negotiated Rate	$6,440.96
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$6,440.96

HIV WITH MAJOR HIV RELATED CONDITION

Facility

$6,062.89

Service Code	APR-DRG 8921
Min. Negotiated Rate	$6,062.89
Max. Negotiated Rate	$6,062.89
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$6,062.89

HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS

Facility

$7,228.92

Service Code	APR-DRG 8901
Min. Negotiated Rate	$7,228.92
Max. Negotiated Rate	$7,228.92
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$7,228.92

HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS

Facility

$11,352.75

Service Code	APR-DRG 8903
Min. Negotiated Rate	$11,352.75
Max. Negotiated Rate	$11,352.75
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$11,352.75

HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS

Facility

$7,609.96

Service Code	APR-DRG 8902
Min. Negotiated Rate	$7,609.96
Max. Negotiated Rate	$7,609.96
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$7,609.96

HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS

Facility

$21,692.71

Service Code	APR-DRG 8904
Min. Negotiated Rate	$21,692.71
Max. Negotiated Rate	$21,692.71
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$21,692.71

HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS

Facility

$6,678.74

Service Code	APR-DRG 8931
Min. Negotiated Rate	$6,678.74
Max. Negotiated Rate	$6,678.74
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$6,678.74

HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS

Facility

$7,233.89

Service Code	APR-DRG 8932
Min. Negotiated Rate	$7,233.89
Max. Negotiated Rate	$7,233.89
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$7,233.89

HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS

Facility

$10,098.19

Service Code	APR-DRG 8933
Min. Negotiated Rate	$10,098.19
Max. Negotiated Rate	$10,098.19
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$10,098.19

HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS

Facility

$15,414.92

Service Code	APR-DRG 8934
Min. Negotiated Rate	$15,414.92
Max. Negotiated Rate	$15,414.92
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$15,414.92

HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS

Facility

$6,162.38

Service Code	APR-DRG 8942
Min. Negotiated Rate	$6,162.38
Max. Negotiated Rate	$6,162.38
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$6,162.38

HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS

Facility

$13,778.32

Service Code	APR-DRG 8944
Min. Negotiated Rate	$13,778.32
Max. Negotiated Rate	$13,778.32
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$13,778.32

HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS

Facility

$8,915.26

Service Code	APR-DRG 8943
Min. Negotiated Rate	$8,915.26
Max. Negotiated Rate	$8,915.26
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$8,915.26

HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS

Facility

$4,923.74

Service Code	APR-DRG 8941
Min. Negotiated Rate	$4,923.74
Max. Negotiated Rate	$4,923.74
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$4,923.74

HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT(PF) 0.5 ML INTRAMUSCULAR SYRINGE [208396]

Facility

$643.26

Service Code	CPT 90651
Hospital Charge Code	NDG208396
Hospital Revenue Code	636
Min. Negotiated Rate	$116.43
Max. Negotiated Rate	$713.05
Rate for Payer: Adventist Health Commercial	$128.65
Rate for Payer: Aetna of CA Gatekeeper	$713.05
Rate for Payer: Aetna of CA Non-Gatekeeper	$441.92
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$546.77
Rate for Payer: Alpha Care Medical Group Medi-Cal	$353.79
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$482.44
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$355.19
Rate for Payer: Blue Shield of California Commercial	$274.02
Rate for Payer: Blue Shield of California EPN	$274.02
Rate for Payer: Cash Price	$289.47
Rate for Payer: Cash Price	$289.47
Rate for Payer: Cigna of CA HMO/PPO	$295.90
Rate for Payer: Dignity Health Commercial/Exchange	$546.77
Rate for Payer: Dignity Health Medi-Cal	$546.77
Rate for Payer: Dignity Health Senior	$546.77
Rate for Payer: EPIC Health Plan Commercial	$411.69
Rate for Payer: Heritage Provider Network Commercial	$297.83
Rate for Payer: Heritage Provider Network Senior	$297.83
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$454.35
Rate for Payer: Kaiser Permanente of CA Commercial	$310.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$116.43
Rate for Payer: LLUH Dept of Risk Management WC	$160.82
Rate for Payer: Multiplan Commercial	$482.44
Rate for Payer: TriValley Medical Group Commercial	$257.30
Rate for Payer: TriValley Medical Group Senior	$257.30
Rate for Payer: United Healthcare All Other HMO/non HMO	$234.53
Rate for Payer: United Healthcare Navigate/Select/Select+	$214.91
Rate for Payer: Vantage Medical Group Medi-Cal	$546.77
Rate for Payer: Vantage Medical Group Senior	$546.77

HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT(PF) 0.5 ML INTRAMUSCULAR SYRINGE [208396]

Facility

$643.26

Service Code	CPT 90651
Hospital Charge Code	NDG208396
Hospital Revenue Code	636
Min. Negotiated Rate	$116.43
Max. Negotiated Rate	$482.44
Rate for Payer: Adventist Health Commercial	$128.65
Rate for Payer: Aetna of CA Non-Gatekeeper	$441.92
Rate for Payer: Cash Price	$289.47
Rate for Payer: Cigna of CA HMO/PPO	$295.90
Rate for Payer: EPIC Health Plan Commercial	$347.36
Rate for Payer: Heritage Provider Network Commercial	$435.49
Rate for Payer: Heritage Provider Network Senior	$435.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$116.43
Rate for Payer: LLUH Dept of Risk Management WC	$160.82
Rate for Payer: Multiplan Commercial	$482.44
Rate for Payer: United Healthcare All Other HMO/non HMO	$234.53
Rate for Payer: United Healthcare Navigate/Select/Select+	$214.91

HUM PROTHROMBIN CPLX(PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION [206243]

Facility

$3.58

Service Code	CPT J7168
Hospital Charge Code	ERX206243
Hospital Revenue Code	636
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$11.61
Rate for Payer: Adventist Health Commercial	$0.72
Rate for Payer: Aetna of CA Gatekeeper	$7.22
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.46
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$2.85
Rate for Payer: Alpha Care Medical Group Medi-Cal	$2.51
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$2.51
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$5.82
Rate for Payer: Blue Shield of California Commercial	$2.90
Rate for Payer: Blue Shield of California EPN	$2.90
Rate for Payer: Cash Price	$1.61
Rate for Payer: Cash Price	$1.61
Rate for Payer: Cigna of CA HMO/PPO	$1.65
Rate for Payer: Dignity Health Commercial/Exchange	$3.42
Rate for Payer: Dignity Health Medi-Cal	$2.51
Rate for Payer: Dignity Health Senior	$2.51
Rate for Payer: EPIC Health Plan Commercial	$2.29
Rate for Payer: EPIC Health Plan Medicare	$2.28
Rate for Payer: Heritage Provider Network Commercial	$1.66
Rate for Payer: Heritage Provider Network Senior	$1.66
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$11.61
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$2.28
Rate for Payer: Kaiser Permanente of CA Commercial	$4.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.65
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$2.69
Rate for Payer: LLUH Dept of Risk Management WC	$0.90
Rate for Payer: Molina Healthcare of CA Medi-Cal	$2.87
Rate for Payer: Molina Healthcare of CA Medicare	$2.87
Rate for Payer: Multiplan Commercial	$2.68
Rate for Payer: TriValley Medical Group Commercial	$1.43
Rate for Payer: TriValley Medical Group Senior	$1.43
Rate for Payer: United Healthcare All Other HMO/non HMO	$1.31
Rate for Payer: United Healthcare Navigate/Select/Select+	$1.20
Rate for Payer: Vantage Medical Group Commercial/Exchange	$3.42
Rate for Payer: Vantage Medical Group Medi-Cal	$2.51
Rate for Payer: Vantage Medical Group Senior	$2.28

HUM PROTHROMBIN CPLX(PCC)4FACT 1,000 UNIT (800-1,240 UNIT) IV SOLUTION [206243]

Facility

$3.58

Service Code	CPT J7168
Hospital Charge Code	ERX206243
Hospital Revenue Code	636
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$2.68
Rate for Payer: Adventist Health Commercial	$0.72
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.46
Rate for Payer: Cash Price	$1.61
Rate for Payer: Cigna of CA HMO/PPO	$1.65
Rate for Payer: EPIC Health Plan Commercial	$1.93
Rate for Payer: Heritage Provider Network Commercial	$2.42
Rate for Payer: Heritage Provider Network Senior	$2.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.90
Rate for Payer: Multiplan Commercial	$2.68
Rate for Payer: United Healthcare All Other HMO/non HMO	$1.31
Rate for Payer: United Healthcare Navigate/Select/Select+	$1.20

HUM PROTHROMBIN CPLX (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION [205938]

Facility

$3.58

Service Code	CPT J7168
Hospital Charge Code	ERX205938
Hospital Revenue Code	636
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$11.61
Rate for Payer: Adventist Health Commercial	$0.72
Rate for Payer: Aetna of CA Gatekeeper	$7.22
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.46
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$2.85
Rate for Payer: Alpha Care Medical Group Medi-Cal	$2.51
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$2.51
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$5.82
Rate for Payer: Blue Shield of California Commercial	$2.90
Rate for Payer: Blue Shield of California EPN	$2.90
Rate for Payer: Cash Price	$1.61
Rate for Payer: Cash Price	$1.61
Rate for Payer: Cigna of CA HMO/PPO	$1.65
Rate for Payer: Dignity Health Commercial/Exchange	$3.42
Rate for Payer: Dignity Health Medi-Cal	$2.51
Rate for Payer: Dignity Health Senior	$2.51
Rate for Payer: EPIC Health Plan Commercial	$2.29
Rate for Payer: EPIC Health Plan Medicare	$2.28
Rate for Payer: Heritage Provider Network Commercial	$1.66
Rate for Payer: Heritage Provider Network Senior	$1.66
Rate for Payer: Humana Medicare	$2.28
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$11.61
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$2.28
Rate for Payer: Kaiser Permanente of CA Commercial	$4.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.65
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$2.69
Rate for Payer: LLUH Dept of Risk Management WC	$0.90
Rate for Payer: Molina Healthcare of CA Medi-Cal	$2.87
Rate for Payer: Molina Healthcare of CA Medicare	$2.87
Rate for Payer: Multiplan Commercial	$2.68
Rate for Payer: TriValley Medical Group Commercial	$1.43
Rate for Payer: TriValley Medical Group Senior	$1.43
Rate for Payer: United Healthcare All Other HMO/non HMO	$1.31
Rate for Payer: United Healthcare Navigate/Select/Select+	$1.20
Rate for Payer: Vantage Medical Group Commercial/Exchange	$3.42
Rate for Payer: Vantage Medical Group Medi-Cal	$2.51
Rate for Payer: Vantage Medical Group Senior	$2.28

HUM PROTHROMBIN CPLX (PCC) 4FACTOR 500 UNIT (400-620 UNIT) IV SOLUTION [205938]

Facility

$3.58

Service Code	CPT J7168
Hospital Charge Code	ERX205938
Hospital Revenue Code	636
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$2.68
Rate for Payer: Adventist Health Commercial	$0.72
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.46
Rate for Payer: Cash Price	$1.61
Rate for Payer: Cigna of CA HMO/PPO	$1.65
Rate for Payer: EPIC Health Plan Commercial	$1.93
Rate for Payer: Heritage Provider Network Commercial	$2.42
Rate for Payer: Heritage Provider Network Senior	$2.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.90
Rate for Payer: Multiplan Commercial	$2.68
Rate for Payer: United Healthcare All Other HMO/non HMO	$1.31
Rate for Payer: United Healthcare Navigate/Select/Select+	$1.20

HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION [76338]

Facility

$66.96

Service Code	CPT J3473
Hospital Charge Code	1721178
Hospital Revenue Code	636
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$56.92
Rate for Payer: Adventist Health Commercial	$13.39
Rate for Payer: Aetna of CA Gatekeeper	$0.88
Rate for Payer: Aetna of CA Non-Gatekeeper	$46.00
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$56.92
Rate for Payer: Alpha Care Medical Group Medi-Cal	$36.83
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$50.22
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.97
Rate for Payer: Blue Shield of California Commercial	$0.38
Rate for Payer: Blue Shield of California EPN	$0.38
Rate for Payer: Cash Price	$30.13
Rate for Payer: Cash Price	$30.13
Rate for Payer: Cigna of CA HMO/PPO	$30.80
Rate for Payer: Dignity Health Commercial/Exchange	$56.92
Rate for Payer: Dignity Health Medi-Cal	$56.92
Rate for Payer: Dignity Health Senior	$56.92
Rate for Payer: EPIC Health Plan Commercial	$42.85
Rate for Payer: Heritage Provider Network Commercial	$31.00
Rate for Payer: Heritage Provider Network Senior	$31.00
Rate for Payer: Kaiser Permanente of CA Commercial	$32.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$12.12
Rate for Payer: LLUH Dept of Risk Management WC	$16.74
Rate for Payer: Multiplan Commercial	$50.22
Rate for Payer: TriValley Medical Group Commercial	$26.78
Rate for Payer: TriValley Medical Group Senior	$26.78
Rate for Payer: United Healthcare All Other HMO/non HMO	$24.41
Rate for Payer: United Healthcare Navigate/Select/Select+	$22.37
Rate for Payer: Vantage Medical Group Medi-Cal	$56.92
Rate for Payer: Vantage Medical Group Senior	$56.92

HYALURONIDASE, HUMAN RECOMBINANT 150 UNIT/ML INJECTION SOLUTION [76338]

Facility

$66.96

Service Code	CPT J3473
Hospital Charge Code	1721178
Hospital Revenue Code	636
Min. Negotiated Rate	$12.12
Max. Negotiated Rate	$50.22
Rate for Payer: Adventist Health Commercial	$13.39
Rate for Payer: Aetna of CA Non-Gatekeeper	$46.00
Rate for Payer: Cash Price	$30.13
Rate for Payer: Cigna of CA HMO/PPO	$30.80
Rate for Payer: EPIC Health Plan Commercial	$36.16
Rate for Payer: Heritage Provider Network Commercial	$45.33
Rate for Payer: Heritage Provider Network Senior	$45.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$12.12
Rate for Payer: LLUH Dept of Risk Management WC	$16.74
Rate for Payer: Multiplan Commercial	$50.22
Rate for Payer: United Healthcare All Other HMO/non HMO	$24.41
Rate for Payer: United Healthcare Navigate/Select/Select+	$22.37

HYALURONIDASE (OVINE) 200 UNIT/ML INJECTION SOLUTION [40449]

Facility

$120.83

Service Code	CPT J3471
Hospital Charge Code	1721153
Hospital Revenue Code	636
Min. Negotiated Rate	$21.87
Max. Negotiated Rate	$90.62
Rate for Payer: Adventist Health Commercial	$24.17
Rate for Payer: Aetna of CA Non-Gatekeeper	$83.01
Rate for Payer: Cash Price	$54.37
Rate for Payer: Cigna of CA HMO/PPO	$55.58
Rate for Payer: EPIC Health Plan Commercial	$65.25
Rate for Payer: Heritage Provider Network Commercial	$81.80
Rate for Payer: Heritage Provider Network Senior	$81.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$21.87
Rate for Payer: LLUH Dept of Risk Management WC	$30.21
Rate for Payer: Multiplan Commercial	$90.62
Rate for Payer: United Healthcare All Other HMO/non HMO	$44.05
Rate for Payer: United Healthcare Navigate/Select/Select+	$40.37

HYALURONIDASE (OVINE) 200 UNIT/ML INJECTION SOLUTION [40449]

Facility

$120.83

Service Code	CPT J3471
Hospital Charge Code	1721153
Hospital Revenue Code	636
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$102.71
Rate for Payer: Adventist Health Commercial	$24.17
Rate for Payer: Aetna of CA Gatekeeper	$1.22
Rate for Payer: Aetna of CA Non-Gatekeeper	$83.01
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$102.71
Rate for Payer: Alpha Care Medical Group Medi-Cal	$66.46
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$90.62
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.28
Rate for Payer: Blue Shield of California Commercial	$0.48
Rate for Payer: Blue Shield of California EPN	$0.48
Rate for Payer: Cash Price	$54.37
Rate for Payer: Cash Price	$54.37
Rate for Payer: Cigna of CA HMO/PPO	$55.58
Rate for Payer: Dignity Health Commercial/Exchange	$102.71
Rate for Payer: Dignity Health Medi-Cal	$102.71
Rate for Payer: Dignity Health Senior	$102.71
Rate for Payer: EPIC Health Plan Commercial	$77.33
Rate for Payer: Heritage Provider Network Commercial	$55.94
Rate for Payer: Heritage Provider Network Senior	$55.94
Rate for Payer: Kaiser Permanente of CA Commercial	$58.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$21.87
Rate for Payer: LLUH Dept of Risk Management WC	$30.21
Rate for Payer: Multiplan Commercial	$90.62
Rate for Payer: TriValley Medical Group Commercial	$48.33
Rate for Payer: TriValley Medical Group Senior	$48.33
Rate for Payer: United Healthcare All Other HMO/non HMO	$44.05
Rate for Payer: United Healthcare Navigate/Select/Select+	$40.37
Rate for Payer: Vantage Medical Group Medi-Cal	$102.71
Rate for Payer: Vantage Medical Group Senior	$102.71

Know your out-of-pocket cost for care.

All Charges