Loma Linda University Children's Hospital

All Charges

Charge

Type

Setting

Price

MOXIFLOXACIN 400 MG TABLET [26854]

Facility

$8.09

Service Code	NDC 5026857611
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$6.88
Rate for Payer: Adventist Health Commercial	$1.62
Rate for Payer: Blue Shield of California Commercial	$4.10
Rate for Payer: Blue Shield of California Commercial	$6.22
Rate for Payer: Cash Price	$3.64
Rate for Payer: Cigna of CA HMO	$5.66
Rate for Payer: Cigna of CA PPO	$5.66
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$5.66
Rate for Payer: EPIC Health Plan Commercial	$3.24
Rate for Payer: EPIC Health Plan Senior	$3.24
Rate for Payer: Galaxy Health WC	$6.88
Rate for Payer: Global Benefits Group Commercial	$4.85
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$5.14
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$4.77
Rate for Payer: LLUH Dept of Risk Management WC	$1.94
Rate for Payer: Multiplan Commercial	$6.47
Rate for Payer: Networks By Design Commercial	$5.26
Rate for Payer: Prime Health Services Commercial	$6.88

MOXIFLOXACIN 400 MG TABLET [26854]

Facility

$8.09

Service Code	NDC 5026857613
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$6.88
Rate for Payer: Adventist Health Commercial	$1.62
Rate for Payer: Aetna of CA HMO/PPO	$5.31
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$6.88
Rate for Payer: Alpha Care Medical Group Medi-Cal	$4.45
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$6.07
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$5.19
Rate for Payer: Cash Price	$3.64
Rate for Payer: Cigna of CA HMO	$5.66
Rate for Payer: Cigna of CA PPO	$5.66
Rate for Payer: Dignity Health Commercial/Exchange	$6.88
Rate for Payer: Dignity Health Medi-Cal	$6.88
Rate for Payer: Dignity Health Medicare Advantage	$6.88
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$5.66
Rate for Payer: EPIC Health Plan Commercial	$3.24
Rate for Payer: EPIC Health Plan Senior	$3.24
Rate for Payer: Galaxy Health WC	$6.88
Rate for Payer: Global Benefits Group Commercial	$4.85
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$5.14
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$2.94
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$4.77
Rate for Payer: LLUH Dept of Risk Management WC	$1.94
Rate for Payer: Molina Healthcare of CA Medi-Cal	$5.66
Rate for Payer: Molina Healthcare of CA Medicare	$5.66
Rate for Payer: Multiplan Commercial	$6.47
Rate for Payer: Networks By Design Commercial	$5.26
Rate for Payer: Prime Health Services Commercial	$6.88
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$4.85
Rate for Payer: TriValley Medical Group Commercial/Senior	$4.85
Rate for Payer: United Healthcare All Other Commercial	$4.04
Rate for Payer: United Healthcare All Other HMO	$4.04
Rate for Payer: United Healthcare HMO Rider	$4.04
Rate for Payer: United Healthcare Select/Navigate/Core	$4.04
Rate for Payer: Vantage Medical Group Commercial/Exchange	$6.88
Rate for Payer: Vantage Medical Group Medi-Cal	$6.88
Rate for Payer: Vantage Medical Group Senior	$6.88

MOXIFLOXACIN 400 MG TABLET [26854]

Facility

$7.00

Service Code	NDC 5723715630
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$5.95
Rate for Payer: Adventist Health Commercial	$1.40
Rate for Payer: Aetna of CA HMO/PPO	$4.59
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$5.95
Rate for Payer: Alpha Care Medical Group Medi-Cal	$3.85
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$5.25
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$4.49
Rate for Payer: Cash Price	$3.15
Rate for Payer: Cigna of CA HMO	$4.90
Rate for Payer: Cigna of CA PPO	$4.90
Rate for Payer: Dignity Health Commercial/Exchange	$5.95
Rate for Payer: Dignity Health Medi-Cal	$5.95
Rate for Payer: Dignity Health Medicare Advantage	$5.95
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$4.90
Rate for Payer: EPIC Health Plan Commercial	$2.80
Rate for Payer: EPIC Health Plan Senior	$2.80
Rate for Payer: Galaxy Health WC	$5.95
Rate for Payer: Global Benefits Group Commercial	$4.20
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$4.45
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$2.54
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$4.13
Rate for Payer: LLUH Dept of Risk Management WC	$1.68
Rate for Payer: Molina Healthcare of CA Medi-Cal	$4.90
Rate for Payer: Molina Healthcare of CA Medicare	$4.90
Rate for Payer: Multiplan Commercial	$5.60
Rate for Payer: Networks By Design Commercial	$4.55
Rate for Payer: Prime Health Services Commercial	$5.95
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$4.20
Rate for Payer: TriValley Medical Group Commercial/Senior	$4.20
Rate for Payer: United Healthcare All Other Commercial	$3.50
Rate for Payer: United Healthcare All Other HMO	$3.50
Rate for Payer: United Healthcare HMO Rider	$3.50
Rate for Payer: United Healthcare Select/Navigate/Core	$3.50
Rate for Payer: Vantage Medical Group Commercial/Exchange	$5.95
Rate for Payer: Vantage Medical Group Medi-Cal	$5.95
Rate for Payer: Vantage Medical Group Senior	$5.95

MOXIFLOXACIN 400 MG TABLET [26854]

Facility

$8.09

Service Code	NDC 5026857611
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.62
Max. Negotiated Rate	$6.88
Rate for Payer: Adventist Health Commercial	$1.62
Rate for Payer: Aetna of CA HMO/PPO	$5.31
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$6.88
Rate for Payer: Alpha Care Medical Group Medi-Cal	$4.45
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$6.07
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$5.19
Rate for Payer: Cash Price	$3.64
Rate for Payer: Cigna of CA HMO	$5.66
Rate for Payer: Cigna of CA PPO	$5.66
Rate for Payer: Dignity Health Commercial/Exchange	$6.88
Rate for Payer: Dignity Health Medi-Cal	$6.88
Rate for Payer: Dignity Health Medicare Advantage	$6.88
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$5.66
Rate for Payer: EPIC Health Plan Commercial	$3.24
Rate for Payer: EPIC Health Plan Senior	$3.24
Rate for Payer: Galaxy Health WC	$6.88
Rate for Payer: Global Benefits Group Commercial	$4.85
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$5.14
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$2.94
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$4.77
Rate for Payer: LLUH Dept of Risk Management WC	$1.94
Rate for Payer: Molina Healthcare of CA Medi-Cal	$5.66
Rate for Payer: Molina Healthcare of CA Medicare	$5.66
Rate for Payer: Multiplan Commercial	$6.47
Rate for Payer: Networks By Design Commercial	$5.26
Rate for Payer: Prime Health Services Commercial	$6.88
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$4.85
Rate for Payer: TriValley Medical Group Commercial/Senior	$4.85
Rate for Payer: United Healthcare All Other Commercial	$4.04
Rate for Payer: United Healthcare All Other HMO	$4.04
Rate for Payer: United Healthcare HMO Rider	$4.04
Rate for Payer: United Healthcare Select/Navigate/Core	$4.04
Rate for Payer: Vantage Medical Group Commercial/Exchange	$6.88
Rate for Payer: Vantage Medical Group Medi-Cal	$6.88
Rate for Payer: Vantage Medical Group Senior	$6.88

MOXIFLOXACIN (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]

Facility

$26.25

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.25
Max. Negotiated Rate	$22.31
Rate for Payer: Adventist Health Commercial	$5.25
Rate for Payer: Aetna of CA HMO/PPO	$17.22
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$22.31
Rate for Payer: Alpha Care Medical Group Medi-Cal	$14.44
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$19.69
Rate for Payer: Cash Price	$11.81
Rate for Payer: Cigna of CA HMO	$18.38
Rate for Payer: Cigna of CA PPO	$18.38
Rate for Payer: Dignity Health Commercial/Exchange	$22.31
Rate for Payer: Dignity Health Medi-Cal	$22.31
Rate for Payer: Dignity Health Medicare Advantage	$22.31
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$18.38
Rate for Payer: EPIC Health Plan Commercial	$10.50
Rate for Payer: EPIC Health Plan Senior	$10.50
Rate for Payer: Galaxy Health WC	$22.31
Rate for Payer: Global Benefits Group Commercial	$15.75
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$16.67
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$15.49
Rate for Payer: LLUH Dept of Risk Management WC	$6.30
Rate for Payer: Molina Healthcare of CA Medi-Cal	$18.38
Rate for Payer: Molina Healthcare of CA Medicare	$18.38
Rate for Payer: Multiplan Commercial	$21.00
Rate for Payer: Networks By Design Commercial	$13.12
Rate for Payer: Prime Health Services Commercial	$22.31
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$15.75
Rate for Payer: TriValley Medical Group Commercial/Senior	$15.75
Rate for Payer: United Healthcare All Other Commercial	$9.85
Rate for Payer: United Healthcare All Other HMO	$9.59
Rate for Payer: United Healthcare HMO Rider	$9.38
Rate for Payer: United Healthcare Select/Navigate/Core	$8.60
Rate for Payer: Vantage Medical Group Commercial/Exchange	$22.31
Rate for Payer: Vantage Medical Group Medi-Cal	$22.31
Rate for Payer: Vantage Medical Group Senior	$22.31

MOXIFLOXACIN (PF) 4 MG/0.8 ML IN SODIUM CHLOR,ISO-OSM INTRAOCULAR SOLN [229008]

Facility

$26.25

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.25
Max. Negotiated Rate	$22.31
Rate for Payer: Adventist Health Commercial	$5.25
Rate for Payer: Blue Shield of California Commercial	$13.31
Rate for Payer: Blue Shield of California Commercial	$20.19
Rate for Payer: Cash Price	$11.81
Rate for Payer: Cigna of CA HMO	$18.38
Rate for Payer: Cigna of CA PPO	$18.38
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$18.38
Rate for Payer: EPIC Health Plan Commercial	$10.50
Rate for Payer: EPIC Health Plan Senior	$10.50
Rate for Payer: Galaxy Health WC	$22.31
Rate for Payer: Global Benefits Group Commercial	$15.75
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$16.67
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$15.49
Rate for Payer: LLUH Dept of Risk Management WC	$6.30
Rate for Payer: Multiplan Commercial	$21.00
Rate for Payer: Networks By Design Commercial	$13.12
Rate for Payer: Prime Health Services Commercial	$22.31
Rate for Payer: United Healthcare All Other Commercial	$9.85
Rate for Payer: United Healthcare All Other HMO	$9.59
Rate for Payer: United Healthcare HMO Rider	$9.38
Rate for Payer: United Healthcare Select/Navigate/Core	$8.60

MS-DRG 25.00: Acute myocardia infarction, discharged alive w/o CC/MCC

Facility

$92,080.91

Service Code	MSDRG 282
Min. Negotiated Rate	$12,537.00
Max. Negotiated Rate	$92,080.91
Rate for Payer: United Healthcare All Other Commercial	$28,087.00
Rate for Payer: United Healthcare All Other HMO	$28,087.00
Rate for Payer: United Healthcare HMO Rider	$13,685.00
Rate for Payer: United Healthcare Select/Navigate/Core	$12,537.00

MS-DRG 25.00: Acute myocardial infarction, discharged alive w CC

Facility

$95,558.89

Service Code	MSDRG 281
Min. Negotiated Rate	$15,502.00
Max. Negotiated Rate	$95,558.89
Rate for Payer: United Healthcare All Other Commercial	$26,466.00
Rate for Payer: United Healthcare All Other HMO	$26,466.00
Rate for Payer: United Healthcare HMO Rider	$16,920.00
Rate for Payer: United Healthcare Select/Navigate/Core	$15,502.00

MS-DRG 25.00: Acute myocardial infarction, discharged alive w MCC

Facility

$107,714.10

Service Code	MSDRG 280
Min. Negotiated Rate	$20,535.00
Max. Negotiated Rate	$107,714.10
Rate for Payer: United Healthcare All Other Commercial	$27,038.00
Rate for Payer: United Healthcare All Other HMO	$27,038.00
Rate for Payer: United Healthcare HMO Rider	$22,413.00
Rate for Payer: United Healthcare Select/Navigate/Core	$20,535.00

MS-DRG 25.00: Acute myocardial infarction, expired w CC

Facility

$91,532.58

Service Code	MSDRG 284
Min. Negotiated Rate	$14,254.00
Max. Negotiated Rate	$91,532.58
Rate for Payer: United Healthcare All Other Commercial	$28,275.00
Rate for Payer: United Healthcare All Other HMO	$28,275.00
Rate for Payer: United Healthcare HMO Rider	$15,558.00
Rate for Payer: United Healthcare Select/Navigate/Core	$14,254.00

MS-DRG 25.00: Acute myocardial infarction, expired w MCC

Facility

$114,398.56

Service Code	MSDRG 283
Min. Negotiated Rate	$18,641.00
Max. Negotiated Rate	$114,398.56
Rate for Payer: United Healthcare All Other Commercial	$29,007.00
Rate for Payer: United Healthcare All Other HMO	$29,007.00
Rate for Payer: United Healthcare HMO Rider	$20,346.00
Rate for Payer: United Healthcare Select/Navigate/Core	$18,641.00

MS-DRG 25.00: Acute myocardial infarction, expired w/o CC/MCC

Facility

$89,876.99

Service Code	MSDRG 285
Min. Negotiated Rate	$12,305.00
Max. Negotiated Rate	$89,876.99
Rate for Payer: United Healthcare All Other Commercial	$27,865.00
Rate for Payer: United Healthcare All Other HMO	$27,865.00
Rate for Payer: United Healthcare HMO Rider	$13,432.00
Rate for Payer: United Healthcare Select/Navigate/Core	$12,305.00

MS-DRG 25.00: Acute & subacute endocarditis w CC

Facility

$109,538.25

Service Code	MSDRG 289
Min. Negotiated Rate	$27,248.00
Max. Negotiated Rate	$109,538.25
Rate for Payer: United Healthcare All Other Commercial	$33,040.00
Rate for Payer: United Healthcare All Other HMO	$33,040.00
Rate for Payer: United Healthcare HMO Rider	$29,741.00
Rate for Payer: United Healthcare Select/Navigate/Core	$27,248.00

MS-DRG 25.00: Acute & subacute endocarditis w MCC

Facility

$127,270.65

Service Code	MSDRG 288
Min. Negotiated Rate	$34,413.00
Max. Negotiated Rate	$127,270.65
Rate for Payer: United Healthcare All Other Commercial	$37,549.00
Rate for Payer: United Healthcare All Other HMO	$37,549.00
Rate for Payer: United Healthcare HMO Rider	$37,563.00
Rate for Payer: United Healthcare Select/Navigate/Core	$34,413.00

MS-DRG 25.00: Acute & subacute endocarditis w/o CC/MCC

Facility

$95,746.99

Service Code	MSDRG 290
Min. Negotiated Rate	$23,302.00
Max. Negotiated Rate	$95,746.99
Rate for Payer: United Healthcare All Other Commercial	$33,040.00
Rate for Payer: United Healthcare All Other HMO	$33,040.00
Rate for Payer: United Healthcare HMO Rider	$25,436.00
Rate for Payer: United Healthcare Select/Navigate/Core	$23,302.00

MS-DRG 25.00: Bilateral or multiple major joint procs of lower extremity w MCC

Facility

$177,254.30

Service Code	MSDRG 461
Min. Negotiated Rate	$45,279.00
Max. Negotiated Rate	$177,254.30
Rate for Payer: United Healthcare All Other Commercial	$64,494.00
Rate for Payer: United Healthcare All Other HMO	$64,494.00
Rate for Payer: United Healthcare HMO Rider	$49,424.00
Rate for Payer: United Healthcare Select/Navigate/Core	$45,279.00

MS-DRG 25.00: Bilateral or multiple major joint procs of lower extremity w/o MCC

Facility

$126,450.85

Service Code	MSDRG 462
Min. Negotiated Rate	$36,596.00
Max. Negotiated Rate	$126,450.85
Rate for Payer: United Healthcare All Other Commercial	$52,127.00
Rate for Payer: United Healthcare All Other HMO	$52,127.00
Rate for Payer: United Healthcare HMO Rider	$39,944.00
Rate for Payer: United Healthcare Select/Navigate/Core	$36,596.00

MS-DRG 25.00: Cardiac defib implant w cardiac cath w AMI/HF/shock w MCC

Facility

$124,263.00

Service Code	MSDRG 222
Min. Negotiated Rate	$12,764.00
Max. Negotiated Rate	$124,263.00
Rate for Payer: United Healthcare All Other HMO	$124,263.00
Rate for Payer: United Healthcare HMO Rider	$119,757.00
Rate for Payer: United Healthcare Select/Navigate/Core	$109,717.00

MS-DRG 25.00: Cardiac defib implant w cardiac cath w AMI/HF/shock w/o MCC

Facility

$106,570.00

Service Code	MSDRG 223
Min. Negotiated Rate	$12,764.00
Max. Negotiated Rate	$106,570.00
Rate for Payer: United Healthcare All Other HMO	$106,570.00
Rate for Payer: United Healthcare HMO Rider	$94,546.00
Rate for Payer: United Healthcare Select/Navigate/Core	$86,620.00

MS-DRG 25.00: Cardiac defib implant w cardiac cath w/o AMI/HF/shock w MCC

Facility

$113,336.00

Service Code	MSDRG 224
Min. Negotiated Rate	$12,764.00
Max. Negotiated Rate	$113,336.00
Rate for Payer: United Healthcare All Other HMO	$113,336.00
Rate for Payer: United Healthcare HMO Rider	$101,501.00
Rate for Payer: United Healthcare Select/Navigate/Core	$92,990.00

MS-DRG 25.00: Cardiac defib implant w cardiac cath w/o AMI/HF/shock w/o MCC

Facility

$101,501.00

Service Code	MSDRG 225
Min. Negotiated Rate	$12,764.00
Max. Negotiated Rate	$101,501.00
Rate for Payer: United Healthcare All Other HMO	$97,504.00
Rate for Payer: United Healthcare HMO Rider	$101,501.00
Rate for Payer: United Healthcare Select/Navigate/Core	$92,990.00

MS-DRG 25.00: Cardiac defibrillator implant w/o cardiac cath w MCC

Facility

$92,297.00

Service Code	MSDRG 226
Min. Negotiated Rate	$12,764.00
Max. Negotiated Rate	$92,297.00
Rate for Payer: United Healthcare All Other HMO	$92,297.00
Rate for Payer: United Healthcare HMO Rider	$91,296.00
Rate for Payer: United Healthcare Select/Navigate/Core	$83,643.00

MS-DRG 25.00: Cardiac defibrillator implant w/o cardiac cath w/o MCC

Facility

$91,296.00

Service Code	MSDRG 227
Min. Negotiated Rate	$12,764.00
Max. Negotiated Rate	$91,296.00
Rate for Payer: United Healthcare All Other HMO	$78,692.00
Rate for Payer: United Healthcare HMO Rider	$91,296.00
Rate for Payer: United Healthcare Select/Navigate/Core	$83,643.00

MS-DRG 25.00: Cardiac pacemaker device replacement w MCC

Facility

$135,005.64

Service Code	MSDRG 258
Min. Negotiated Rate	$7,978.00
Max. Negotiated Rate	$135,005.64
Rate for Payer: United Healthcare All Other Commercial	$38,532.00
Rate for Payer: United Healthcare All Other HMO	$38,532.00
Rate for Payer: United Healthcare HMO Rider	$23,768.00
Rate for Payer: United Healthcare Select/Navigate/Core	$21,774.00

MS-DRG 25.00: Cardiac pacemaker device replacement w/o MCC

Facility

$115,131.44

Service Code	MSDRG 259
Min. Negotiated Rate	$7,978.00
Max. Negotiated Rate	$115,131.44
Rate for Payer: United Healthcare All Other Commercial	$38,532.00
Rate for Payer: United Healthcare All Other HMO	$38,532.00
Rate for Payer: United Healthcare HMO Rider	$23,768.00
Rate for Payer: United Healthcare Select/Navigate/Core	$21,774.00

Know your out-of-pocket cost for care.

All Charges