Loma Linda University Medical Center

All Charges

Charge

Type

Price

Brachytherapy Seeds - #2074

Facility IP

$8,040.00

Service Code	ICD D91BBB1
Min. Negotiated Rate	$8,040.00
Max. Negotiated Rate	$8,040.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,040.00

Brachytherapy Seeds - #2074

Facility IP

$23,184.00

Service Code	ICD 0YH531Z
Min. Negotiated Rate	$8,040.00
Max. Negotiated Rate	$23,184.00
Rate for Payer: Aetna of CA Gatekeeper	$23,184.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,040.00

BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA

Facility IP

$5,245.10

Service Code	APR-DRG 0561
Min. Negotiated Rate	$5,245.10
Max. Negotiated Rate	$5,245.10
Rate for Payer: IEHP Medi-Cal	$5,245.10

BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA

Facility IP

$7,485.60

Service Code	APR-DRG 0562
Min. Negotiated Rate	$7,485.60
Max. Negotiated Rate	$7,485.60
Rate for Payer: IEHP Medi-Cal	$7,485.60

BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA

Facility IP

$10,307.12

Service Code	APR-DRG 0563
Min. Negotiated Rate	$10,307.12
Max. Negotiated Rate	$10,307.12
Rate for Payer: IEHP Medi-Cal	$10,307.12

BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA

Facility IP

$16,508.31

Service Code	APR-DRG 0564
Min. Negotiated Rate	$16,508.31
Max. Negotiated Rate	$16,508.31
Rate for Payer: IEHP Medi-Cal	$16,508.31

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility IP

$21,629.04

Service Code	APR-DRG 3633
Min. Negotiated Rate	$21,629.04
Max. Negotiated Rate	$21,629.04
Rate for Payer: IEHP Medi-Cal	$21,629.04

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility IP

$17,041.57

Service Code	APR-DRG 3632
Min. Negotiated Rate	$17,041.57
Max. Negotiated Rate	$17,041.57
Rate for Payer: IEHP Medi-Cal	$17,041.57

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility IP

$27,476.04

Service Code	APR-DRG 3634
Min. Negotiated Rate	$27,476.04
Max. Negotiated Rate	$27,476.04
Rate for Payer: IEHP Medi-Cal	$27,476.04

BREAST PROCEDURES EXCEPT MASTECTOMY

Facility IP

$9,257.51

Service Code	APR-DRG 3631
Min. Negotiated Rate	$9,257.51
Max. Negotiated Rate	$9,257.51
Rate for Payer: IEHP Medi-Cal	$9,257.51

Breast reduction

Facility OP

$15,480.57

Service Code	CPT 19318
Min. Negotiated Rate	$1,550.70
Max. Negotiated Rate	$15,480.57
Rate for Payer: Aetna of CA Gatekeeper	$4,857.00
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$12,221.50
Rate for Payer: AlphaCare Medical Group Medi-Cal	$8,962.44
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$8,147.67
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$8,054.00
Rate for Payer: Dignity Health Commercial/Exchange	$12,221.50
Rate for Payer: Dignity Health Medi-Cal	$8,962.44
Rate for Payer: Dignity Health Senior	$8,147.67
Rate for Payer: EPIC Health Plan Commercial	$9,616.00
Rate for Payer: EPIC Health Plan Medicare	$8,147.67
Rate for Payer: Humana Medicare	$8,147.67
Rate for Payer: IEHP Medi-Cal	$1,550.70
Rate for Payer: IEHP Medicare Advantage	$8,147.67
Rate for Payer: Kaiser Permanente of CA Commercial	$15,480.57
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$9,614.25
Rate for Payer: Molina Healthcare of CA Medi-Cal	$10,266.06
Rate for Payer: Molina Healthcare of CA Medicare	$10,266.06
Rate for Payer: TriValley Medical Group Commercial	$8,962.44
Rate for Payer: TriValley Medical Group Senior	$8,147.67
Rate for Payer: Vantage Medical Group Commercial/Exchange	$12,221.50
Rate for Payer: Vantage Medical Group Medi-Cal	$8,962.44
Rate for Payer: Vantage Medical Group Senior	$8,147.67

BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [153071]

Facility OP

$13,053.60

Service Code	NDC 51144-050-01
Hospital Charge Code	1755786
Hospital Revenue Code	636
Min. Negotiated Rate	$2,362.70
Max. Negotiated Rate	$11,095.56
Rate for Payer: Adventist Health Commercial	$2,610.72
Rate for Payer: Aetna of CA Gatekeeper	$6,977.15
Rate for Payer: Aetna of CA Non-Gatekeeper	$8,967.82
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$11,095.56
Rate for Payer: AlphaCare Medical Group Medi-Cal	$7,179.48
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$9,790.20
Rate for Payer: Blue Shield of California Commercial	$8,106.29
Rate for Payer: Blue Shield of California EPN	$7,662.46
Rate for Payer: Cash Price	$5,874.12
Rate for Payer: Cigna of CA HMO/PPO	$6,004.66
Rate for Payer: Dignity Health Commercial/Exchange	$11,095.56
Rate for Payer: Dignity Health Medi-Cal	$11,095.56
Rate for Payer: Dignity Health Senior	$11,095.56
Rate for Payer: EPIC Health Plan Commercial	$8,354.30
Rate for Payer: Heritage Provider Network Commercial	$6,043.82
Rate for Payer: Heritage Provider Network Senior	$6,043.82
Rate for Payer: Kaiser Permanente of CA Commercial	$6,291.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$2,362.70
Rate for Payer: LLUH Dept of Risk Management WC	$3,263.40
Rate for Payer: Multiplan Commercial	$9,790.20
Rate for Payer: United Healthcare All Other HMO/non HMO	$4,759.34
Rate for Payer: United Healthcare Navigate/Select/Select+	$4,361.21
Rate for Payer: Vantage Medical Group Medi-Cal	$11,095.56
Rate for Payer: Vantage Medical Group Senior	$11,095.56

BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION [153071]

Facility IP

$13,053.60

Service Code	NDC 51144-050-01
Hospital Charge Code	1755786
Hospital Revenue Code	636
Min. Negotiated Rate	$2,362.70
Max. Negotiated Rate	$9,790.20
Rate for Payer: Adventist Health Commercial	$2,610.72
Rate for Payer: Aetna of CA Non-Gatekeeper	$8,967.82
Rate for Payer: Cash Price	$5,874.12
Rate for Payer: Cigna of CA HMO/PPO	$6,004.66
Rate for Payer: EPIC Health Plan Commercial	$7,048.94
Rate for Payer: Heritage Provider Network Commercial	$8,837.29
Rate for Payer: Heritage Provider Network Senior	$8,837.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$2,362.70
Rate for Payer: LLUH Dept of Risk Management WC	$3,263.40
Rate for Payer: Multiplan Commercial	$9,790.20
Rate for Payer: United Healthcare All Other HMO/non HMO	$4,759.34
Rate for Payer: United Healthcare Navigate/Select/Select+	$4,361.21

BRIMONIDINE 0.15 % EYE DROPS [31158]

Facility IP

$49.75

Service Code	NDC 0023-9177-05
Hospital Charge Code	1740307
Hospital Revenue Code	259
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$37.31
Rate for Payer: Adventist Health Commercial	$9.95
Rate for Payer: Aetna of CA Non-Gatekeeper	$34.18
Rate for Payer: Cash Price	$22.39
Rate for Payer: EPIC Health Plan Commercial	$26.86
Rate for Payer: Heritage Provider Network Commercial	$33.68
Rate for Payer: Heritage Provider Network Senior	$33.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$12.44
Rate for Payer: Multiplan Commercial	$37.31

BRIMONIDINE 0.15 % EYE DROPS [31158]

Facility OP

$49.75

Service Code	NDC 0023-9177-05
Hospital Charge Code	1740307
Hospital Revenue Code	259
Min. Negotiated Rate	$9.00
Max. Negotiated Rate	$42.29
Rate for Payer: Adventist Health Commercial	$9.95
Rate for Payer: Aetna of CA Gatekeeper	$26.59
Rate for Payer: Aetna of CA Non-Gatekeeper	$34.18
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$42.29
Rate for Payer: AlphaCare Medical Group Medi-Cal	$27.36
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$37.31
Rate for Payer: Blue Shield of California Commercial	$30.89
Rate for Payer: Blue Shield of California EPN	$29.20
Rate for Payer: Cash Price	$22.39
Rate for Payer: Cigna of CA HMO/PPO	$32.34
Rate for Payer: Dignity Health Commercial/Exchange	$42.29
Rate for Payer: Dignity Health Medi-Cal	$42.29
Rate for Payer: Dignity Health Senior	$42.29
Rate for Payer: EPIC Health Plan Commercial	$31.84
Rate for Payer: Heritage Provider Network Commercial	$30.80
Rate for Payer: Heritage Provider Network Senior	$30.80
Rate for Payer: Kaiser Permanente of CA Commercial	$23.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$9.00
Rate for Payer: LLUH Dept of Risk Management WC	$12.44
Rate for Payer: Multiplan Commercial	$37.31
Rate for Payer: Vantage Medical Group Medi-Cal	$42.29
Rate for Payer: Vantage Medical Group Senior	$42.29

BRIMONIDINE 0.15 % EYE DROPS [31158]

Facility OP

$36.80

Service Code	NDC 61314-144-05
Hospital Charge Code	1740307
Hospital Revenue Code	259
Min. Negotiated Rate	$6.66
Max. Negotiated Rate	$31.28
Rate for Payer: Adventist Health Commercial	$7.36
Rate for Payer: Aetna of CA Gatekeeper	$19.67
Rate for Payer: Aetna of CA Non-Gatekeeper	$25.28
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$31.28
Rate for Payer: AlphaCare Medical Group Medi-Cal	$20.24
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$27.60
Rate for Payer: Blue Shield of California Commercial	$22.85
Rate for Payer: Blue Shield of California EPN	$21.60
Rate for Payer: Cash Price	$16.56
Rate for Payer: Cigna of CA HMO/PPO	$23.92
Rate for Payer: Dignity Health Commercial/Exchange	$31.28
Rate for Payer: Dignity Health Medi-Cal	$31.28
Rate for Payer: Dignity Health Senior	$31.28
Rate for Payer: EPIC Health Plan Commercial	$23.55
Rate for Payer: Heritage Provider Network Commercial	$22.78
Rate for Payer: Heritage Provider Network Senior	$22.78
Rate for Payer: Kaiser Permanente of CA Commercial	$17.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$6.66
Rate for Payer: LLUH Dept of Risk Management WC	$9.20
Rate for Payer: Multiplan Commercial	$27.60
Rate for Payer: Vantage Medical Group Medi-Cal	$31.28
Rate for Payer: Vantage Medical Group Senior	$31.28

BRIMONIDINE 0.15 % EYE DROPS [31158]

Facility IP

$36.80

Service Code	NDC 61314-144-05
Hospital Charge Code	1740307
Hospital Revenue Code	259
Min. Negotiated Rate	$6.66
Max. Negotiated Rate	$27.60
Rate for Payer: Adventist Health Commercial	$7.36
Rate for Payer: Aetna of CA Non-Gatekeeper	$25.28
Rate for Payer: Cash Price	$16.56
Rate for Payer: EPIC Health Plan Commercial	$19.87
Rate for Payer: Heritage Provider Network Commercial	$24.91
Rate for Payer: Heritage Provider Network Senior	$24.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$6.66
Rate for Payer: LLUH Dept of Risk Management WC	$9.20
Rate for Payer: Multiplan Commercial	$27.60

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility IP

$3.53

Service Code	NDC 17478-715-10
Hospital Charge Code	NDG17881
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$2.65
Rate for Payer: Adventist Health Commercial	$0.71
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.43
Rate for Payer: Cash Price	$1.59
Rate for Payer: EPIC Health Plan Commercial	$1.91
Rate for Payer: Heritage Provider Network Commercial	$2.39
Rate for Payer: Heritage Provider Network Senior	$2.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.88
Rate for Payer: Multiplan Commercial	$2.65

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility IP

$3.48

Service Code	NDC 24208-411-05
Hospital Charge Code	NDG17881
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$2.61
Rate for Payer: Adventist Health Commercial	$0.70
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.39
Rate for Payer: Cash Price	$1.57
Rate for Payer: EPIC Health Plan Commercial	$1.88
Rate for Payer: Heritage Provider Network Commercial	$2.36
Rate for Payer: Heritage Provider Network Senior	$2.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.63
Rate for Payer: LLUH Dept of Risk Management WC	$0.87
Rate for Payer: Multiplan Commercial	$2.61

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility OP

$3.48

Service Code	NDC 24208-411-05
Hospital Charge Code	NDG17881
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$2.96
Rate for Payer: Adventist Health Commercial	$0.70
Rate for Payer: Aetna of CA Gatekeeper	$1.86
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.39
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$2.96
Rate for Payer: AlphaCare Medical Group Medi-Cal	$1.91
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$2.61
Rate for Payer: Blue Shield of California Commercial	$2.16
Rate for Payer: Blue Shield of California EPN	$2.04
Rate for Payer: Cash Price	$1.57
Rate for Payer: Cigna of CA HMO/PPO	$2.26
Rate for Payer: Dignity Health Commercial/Exchange	$2.96
Rate for Payer: Dignity Health Medi-Cal	$2.96
Rate for Payer: Dignity Health Senior	$2.96
Rate for Payer: EPIC Health Plan Commercial	$2.23
Rate for Payer: Heritage Provider Network Commercial	$2.15
Rate for Payer: Heritage Provider Network Senior	$2.15
Rate for Payer: Kaiser Permanente of CA Commercial	$1.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.63
Rate for Payer: LLUH Dept of Risk Management WC	$0.87
Rate for Payer: Multiplan Commercial	$2.61
Rate for Payer: Vantage Medical Group Medi-Cal	$2.96
Rate for Payer: Vantage Medical Group Senior	$2.96

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility OP

$3.53

Service Code	NDC 17478-715-10
Hospital Charge Code	NDG17881
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$3.00
Rate for Payer: Adventist Health Commercial	$0.71
Rate for Payer: Aetna of CA Gatekeeper	$1.89
Rate for Payer: Aetna of CA Non-Gatekeeper	$2.43
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$3.00
Rate for Payer: AlphaCare Medical Group Medi-Cal	$1.94
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$2.65
Rate for Payer: Blue Shield of California Commercial	$2.19
Rate for Payer: Blue Shield of California EPN	$2.07
Rate for Payer: Cash Price	$1.59
Rate for Payer: Cigna of CA HMO/PPO	$2.29
Rate for Payer: Dignity Health Commercial/Exchange	$3.00
Rate for Payer: Dignity Health Medi-Cal	$3.00
Rate for Payer: Dignity Health Senior	$3.00
Rate for Payer: EPIC Health Plan Commercial	$2.26
Rate for Payer: Heritage Provider Network Commercial	$2.19
Rate for Payer: Heritage Provider Network Senior	$2.19
Rate for Payer: Kaiser Permanente of CA Commercial	$1.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.88
Rate for Payer: Multiplan Commercial	$2.65
Rate for Payer: Vantage Medical Group Medi-Cal	$3.00
Rate for Payer: Vantage Medical Group Senior	$3.00

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility OP

$0.80

Service Code	NDC 70069-232-01
Hospital Charge Code	NDG17881B
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.68
Rate for Payer: Adventist Health Commercial	$0.16
Rate for Payer: Aetna of CA Gatekeeper	$0.43
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.55
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$0.68
Rate for Payer: AlphaCare Medical Group Medi-Cal	$0.44
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$0.60
Rate for Payer: Blue Shield of California Commercial	$0.50
Rate for Payer: Blue Shield of California EPN	$0.47
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.52
Rate for Payer: Dignity Health Commercial/Exchange	$0.68
Rate for Payer: Dignity Health Medi-Cal	$0.68
Rate for Payer: Dignity Health Senior	$0.68
Rate for Payer: EPIC Health Plan Commercial	$0.51
Rate for Payer: Heritage Provider Network Commercial	$0.50
Rate for Payer: Heritage Provider Network Senior	$0.50
Rate for Payer: Kaiser Permanente of CA Commercial	$0.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.60
Rate for Payer: Vantage Medical Group Medi-Cal	$0.68
Rate for Payer: Vantage Medical Group Senior	$0.68

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility OP

$2.40

Service Code	NDC 61314-143-05
Hospital Charge Code	NDG17881
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$2.04
Rate for Payer: Adventist Health Commercial	$0.48
Rate for Payer: Aetna of CA Gatekeeper	$1.28
Rate for Payer: Aetna of CA Non-Gatekeeper	$1.65
Rate for Payer: AlphaCare Medical Group Commercial/Exchange	$2.04
Rate for Payer: AlphaCare Medical Group Medi-Cal	$1.32
Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product	$1.80
Rate for Payer: Blue Shield of California Commercial	$1.49
Rate for Payer: Blue Shield of California EPN	$1.41
Rate for Payer: Cash Price	$1.08
Rate for Payer: Cigna of CA HMO/PPO	$1.56
Rate for Payer: Dignity Health Commercial/Exchange	$2.04
Rate for Payer: Dignity Health Medi-Cal	$2.04
Rate for Payer: Dignity Health Senior	$2.04
Rate for Payer: EPIC Health Plan Commercial	$1.54
Rate for Payer: Heritage Provider Network Commercial	$1.49
Rate for Payer: Heritage Provider Network Senior	$1.49
Rate for Payer: Kaiser Permanente of CA Commercial	$1.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Commercial	$1.80
Rate for Payer: Vantage Medical Group Medi-Cal	$2.04
Rate for Payer: Vantage Medical Group Senior	$2.04

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility IP

$0.80

Service Code	NDC 70069-232-01
Hospital Charge Code	NDG17881B
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.60
Rate for Payer: Adventist Health Commercial	$0.16
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.55
Rate for Payer: Cash Price	$0.36
Rate for Payer: EPIC Health Plan Commercial	$0.43
Rate for Payer: Heritage Provider Network Commercial	$0.54
Rate for Payer: Heritage Provider Network Senior	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.60

BRIMONIDINE 0.2 % EYE DROPS [17881]

Facility IP

$2.40

Service Code	NDC 61314-143-05
Hospital Charge Code	NDG17881
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$1.80
Rate for Payer: Adventist Health Commercial	$0.48
Rate for Payer: Aetna of CA Non-Gatekeeper	$1.65
Rate for Payer: Cash Price	$1.08
Rate for Payer: EPIC Health Plan Commercial	$1.30
Rate for Payer: Heritage Provider Network Commercial	$1.62
Rate for Payer: Heritage Provider Network Senior	$1.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Commercial	$1.80

Price Transparency.

All Charges