Loma Linda University Children's Hospital

All Charges

Charge

Type

Setting

Price

MAGNESIUM SULFATE ORAL SOLUTION (IV FORM) 0.5 G/ML [4080434]

Facility

$1.55

Service Code	NDC 9994080434
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$1.32
Rate for Payer: Adventist Health Commercial	$0.31
Rate for Payer: Aetna of CA HMO/PPO	$1.02
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$1.32
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.85
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$1.16
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.99
Rate for Payer: Cash Price	$0.70
Rate for Payer: Cigna of CA HMO	$1.08
Rate for Payer: Cigna of CA PPO	$1.08
Rate for Payer: Dignity Health Commercial/Exchange	$1.32
Rate for Payer: Dignity Health Medi-Cal	$1.32
Rate for Payer: Dignity Health Medicare Advantage	$1.32
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$1.08
Rate for Payer: EPIC Health Plan Commercial	$0.62
Rate for Payer: EPIC Health Plan Senior	$0.62
Rate for Payer: Galaxy Health WC	$1.32
Rate for Payer: Global Benefits Group Commercial	$0.93
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$0.98
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.56
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Molina Healthcare of CA Medi-Cal	$1.08
Rate for Payer: Molina Healthcare of CA Medicare	$1.08
Rate for Payer: Multiplan Commercial	$1.24
Rate for Payer: Networks By Design Commercial	$1.01
Rate for Payer: Prime Health Services Commercial	$1.32
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$0.93
Rate for Payer: TriValley Medical Group Commercial/Senior	$0.93
Rate for Payer: United Healthcare All Other Commercial	$0.78
Rate for Payer: United Healthcare All Other HMO	$0.78
Rate for Payer: United Healthcare HMO Rider	$0.78
Rate for Payer: United Healthcare Select/Navigate/Core	$0.78
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1.32
Rate for Payer: Vantage Medical Group Medi-Cal	$1.32
Rate for Payer: Vantage Medical Group Senior	$1.32

MAGNESIUM SULFATE ORAL SOLUTION (IV FORM) 0.5 G/ML [4080434]

Facility

$1.55

Service Code	NDC 9994080434
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$1.32
Rate for Payer: Adventist Health Commercial	$0.31
Rate for Payer: Blue Shield of California Commercial	$0.79
Rate for Payer: Blue Shield of California Commercial	$1.19
Rate for Payer: Cash Price	$0.70
Rate for Payer: Cigna of CA HMO	$1.08
Rate for Payer: Cigna of CA PPO	$1.08
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$1.08
Rate for Payer: EPIC Health Plan Commercial	$0.62
Rate for Payer: EPIC Health Plan Senior	$0.62
Rate for Payer: Galaxy Health WC	$1.32
Rate for Payer: Global Benefits Group Commercial	$0.93
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$0.98
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$1.24
Rate for Payer: Networks By Design Commercial	$1.01
Rate for Payer: Prime Health Services Commercial	$1.32

MAJOR ABDOMINAL VASCULAR PROCEDURES

Facility

$165,258.24

Service Code	APR-DRG 1694
Min. Negotiated Rate	$131,989.15
Max. Negotiated Rate	$165,258.24
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$131,989.15
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$165,258.24
Rate for Payer: Molina Healthcare of CA Medi-Cal	$147,862.63

MAJOR ABDOMINAL VASCULAR PROCEDURES

Facility

$86,645.93

Service Code	APR-DRG 1693
Min. Negotiated Rate	$69,202.73
Max. Negotiated Rate	$86,645.93
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$69,202.73
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$86,645.93
Rate for Payer: Molina Healthcare of CA Medi-Cal	$77,525.30

MAJOR ABDOMINAL VASCULAR PROCEDURES

Facility

$60,503.94

Service Code	APR-DRG 1691
Min. Negotiated Rate	$48,323.54
Max. Negotiated Rate	$60,503.94
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$48,323.54
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$60,503.94
Rate for Payer: Molina Healthcare of CA Medi-Cal	$54,135.11

MAJOR ABDOMINAL VASCULAR PROCEDURES

Facility

$70,526.76

Service Code	APR-DRG 1692
Min. Negotiated Rate	$56,328.61
Max. Negotiated Rate	$70,526.76
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$56,328.61
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$70,526.76
Rate for Payer: Molina Healthcare of CA Medi-Cal	$63,102.89

MAJOR BILIARY TRACT PROCEDURES

Facility

$45,279.39

Service Code	APR-DRG 2612
Min. Negotiated Rate	$36,163.94
Max. Negotiated Rate	$45,279.39
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$36,163.94
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$45,279.39
Rate for Payer: Molina Healthcare of CA Medi-Cal	$40,513.14

MAJOR BILIARY TRACT PROCEDURES

Facility

$138,310.90

Service Code	APR-DRG 2614
Min. Negotiated Rate	$110,466.73
Max. Negotiated Rate	$138,310.90
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$110,466.73
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$138,310.90
Rate for Payer: Molina Healthcare of CA Medi-Cal	$123,751.86

MAJOR BILIARY TRACT PROCEDURES

Facility

$56,052.70

Service Code	APR-DRG 2613
Min. Negotiated Rate	$44,768.40
Max. Negotiated Rate	$56,052.70
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$44,768.40
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$56,052.70
Rate for Payer: Molina Healthcare of CA Medi-Cal	$50,152.41

MAJOR BILIARY TRACT PROCEDURES

Facility

$32,243.76

Service Code	APR-DRG 2611
Min. Negotiated Rate	$25,752.58
Max. Negotiated Rate	$32,243.76
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$25,752.58
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$32,243.76
Rate for Payer: Molina Healthcare of CA Medi-Cal	$28,849.68

MAJOR BLADDER PROCEDURES

Facility

$57,273.60

Service Code	APR-DRG 4412
Min. Negotiated Rate	$45,743.52
Max. Negotiated Rate	$57,273.60
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$45,743.52
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$57,273.60
Rate for Payer: Molina Healthcare of CA Medi-Cal	$51,244.80

MAJOR BLADDER PROCEDURES

Facility

$45,094.49

Service Code	APR-DRG 4411
Min. Negotiated Rate	$36,016.25
Max. Negotiated Rate	$45,094.49
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$36,016.25
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$45,094.49
Rate for Payer: Molina Healthcare of CA Medi-Cal	$40,347.70

MAJOR BLADDER PROCEDURES

Facility

$71,391.46

Service Code	APR-DRG 4413
Min. Negotiated Rate	$57,019.23
Max. Negotiated Rate	$71,391.46
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$57,019.23
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$71,391.46
Rate for Payer: Molina Healthcare of CA Medi-Cal	$63,876.57

MAJOR BLADDER PROCEDURES

Facility

$144,486.41

Service Code	APR-DRG 4414
Min. Negotiated Rate	$115,399.02
Max. Negotiated Rate	$144,486.41
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$115,399.02
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$144,486.41
Rate for Payer: Molina Healthcare of CA Medi-Cal	$129,277.32

MAJOR BLADDER PROCEDURES WITH CC

Facility

$128,922.72

Service Code	MSDRG 654
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$128,922.72
Rate for Payer: Aetna of CA HMO/PPO	$84,863.58
Rate for Payer: EPIC Health Plan Commercial	$128,922.72
Rate for Payer: EPIC Health Plan Senior	$85,948.48
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$78,134.98
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$109,388.97
Rate for Payer: Molina Healthcare of CA Medicare	$104,700.87
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

MAJOR BLADDER PROCEDURES WITH MCC

Facility

$171,458.81

Service Code	MSDRG 653
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$171,458.81
Rate for Payer: Aetna of CA HMO/PPO	$157,534.06
Rate for Payer: EPIC Health Plan Commercial	$171,458.81
Rate for Payer: EPIC Health Plan Senior	$114,305.87
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$103,914.43
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$145,480.20
Rate for Payer: Molina Healthcare of CA Medicare	$139,245.34
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

MAJOR BLADDER PROCEDURES WITHOUT CC/MCC

Facility

$116,808.32

Service Code	MSDRG 655
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$116,808.32
Rate for Payer: Aetna of CA HMO/PPO	$64,166.85
Rate for Payer: EPIC Health Plan Commercial	$116,808.32
Rate for Payer: EPIC Health Plan Senior	$77,872.21
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$70,792.92
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$99,110.09
Rate for Payer: Molina Healthcare of CA Medicare	$94,862.51
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY

Facility

$120,551.09

Service Code	APR-DRG 1603
Min. Negotiated Rate	$96,282.25
Max. Negotiated Rate	$120,551.09
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$96,282.25
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$120,551.09
Rate for Payer: Molina Healthcare of CA Medi-Cal	$107,861.50

MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY

Facility

$355,528.70

Service Code	APR-DRG 1604
Min. Negotiated Rate	$283,955.16
Max. Negotiated Rate	$355,528.70
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$283,955.16
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$355,528.70
Rate for Payer: Molina Healthcare of CA Medi-Cal	$318,104.63

MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY

Facility

$67,916.37

Service Code	APR-DRG 1601
Min. Negotiated Rate	$54,243.74
Max. Negotiated Rate	$67,916.37
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$54,243.74
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$67,916.37
Rate for Payer: Molina Healthcare of CA Medi-Cal	$60,767.28

MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY

Facility

$94,110.00

Service Code	APR-DRG 1602
Min. Negotiated Rate	$75,164.17
Max. Negotiated Rate	$94,110.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$75,164.17
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$94,110.00
Rate for Payer: Molina Healthcare of CA Medi-Cal	$84,203.69

MAJOR CHEST AND RESPIRATORY TRAUMA

Facility

$16,679.30

Service Code	APR-DRG 1352
Min. Negotiated Rate	$13,321.50
Max. Negotiated Rate	$16,679.30
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$13,321.50
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$16,679.30
Rate for Payer: Molina Healthcare of CA Medi-Cal	$14,923.59

MAJOR CHEST AND RESPIRATORY TRAUMA

Facility

$57,200.98

Service Code	APR-DRG 1354
Min. Negotiated Rate	$45,685.52
Max. Negotiated Rate	$57,200.98
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$45,685.52
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$57,200.98
Rate for Payer: Molina Healthcare of CA Medi-Cal	$51,179.83

MAJOR CHEST AND RESPIRATORY TRAUMA

Facility

$24,592.04

Service Code	APR-DRG 1353
Min. Negotiated Rate	$19,641.28
Max. Negotiated Rate	$24,592.04
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$19,641.28
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$24,592.04
Rate for Payer: Molina Healthcare of CA Medi-Cal	$22,003.41

MAJOR CHEST AND RESPIRATORY TRAUMA

Facility

$13,198.79

Service Code	APR-DRG 1351
Min. Negotiated Rate	$10,541.66
Max. Negotiated Rate	$13,198.79
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$10,541.66
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$13,198.79
Rate for Payer: Molina Healthcare of CA Medi-Cal	$11,809.44

Know your out-of-pocket cost for care.

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