Loma Linda University Children's Hospital

All Charges

Charge

Type

Setting

Price

MS-DRG 40.00: PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC

Facility

$135,905.30

Service Code	MSDRG 242
Min. Negotiated Rate	$7,978.00
Max. Negotiated Rate	$135,905.30
Rate for Payer: Heritage Provider Network Commercial/Senior	$7,978.00
Rate for Payer: United Healthcare All Other Commercial	$38,262.00
Rate for Payer: United Healthcare All Other HMO	$38,262.00
Rate for Payer: United Healthcare HMO Rider	$36,089.00
Rate for Payer: United Healthcare Select/Navigate/Core	$33,062.00

MS-DRG 40.00: PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC

Facility

$111,323.39

Service Code	MSDRG 244
Min. Negotiated Rate	$7,978.00
Max. Negotiated Rate	$111,323.39
Rate for Payer: Heritage Provider Network Commercial/Senior	$7,978.00
Rate for Payer: United Healthcare All Other Commercial	$25,087.00
Rate for Payer: United Healthcare All Other HMO	$25,087.00
Rate for Payer: United Healthcare HMO Rider	$20,612.00
Rate for Payer: United Healthcare Select/Navigate/Core	$18,884.00

MS-DRG 40.00: PROSTATECTOMY WITHOUT CC/MCC

Facility

$98,878.96

Service Code	MSDRG 667
Min. Negotiated Rate	$22,398.00
Max. Negotiated Rate	$98,878.96
Rate for Payer: United Healthcare All Other Commercial	$24,996.00
Rate for Payer: United Healthcare All Other HMO	$24,996.00
Rate for Payer: United Healthcare HMO Rider	$24,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$22,398.00

MS-DRG 40.00: REVISION OF HIP OR KNEE REPLACEMENT WITH CC

Facility

$141,828.52

Service Code	MSDRG 467
Min. Negotiated Rate	$32,499.00
Max. Negotiated Rate	$141,828.52
Rate for Payer: United Healthcare All Other Commercial	$36,468.00
Rate for Payer: United Healthcare All Other HMO	$36,468.00
Rate for Payer: United Healthcare HMO Rider	$35,474.00
Rate for Payer: United Healthcare Select/Navigate/Core	$32,499.00

MS-DRG 40.00: REVISION OF HIP OR KNEE REPLACEMENT WITH MCC

Facility

$171,618.53

Service Code	MSDRG 466
Min. Negotiated Rate	$39,477.00
Max. Negotiated Rate	$171,618.53
Rate for Payer: United Healthcare All Other Commercial	$39,477.00
Rate for Payer: United Healthcare All Other HMO	$39,477.00
Rate for Payer: United Healthcare HMO Rider	$45,640.00
Rate for Payer: United Healthcare Select/Navigate/Core	$41,813.00

MS-DRG 40.00: REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC

Facility

$128,012.41

Service Code	MSDRG 468
Min. Negotiated Rate	$28,986.00
Max. Negotiated Rate	$128,012.41
Rate for Payer: United Healthcare All Other Commercial	$39,477.00
Rate for Payer: United Healthcare All Other HMO	$39,477.00
Rate for Payer: United Healthcare HMO Rider	$31,639.00
Rate for Payer: United Healthcare Select/Navigate/Core	$28,986.00

MS-DRG 40.00: SPINAL FUSION EXCEPT CERVICAL WITH MCC

Facility

$76,782.00

Service Code	MSDRG 459
Min. Negotiated Rate	$29,434.00
Max. Negotiated Rate	$76,782.00
Rate for Payer: Heritage Provider Network Commercial/Senior	$29,434.00
Rate for Payer: United Healthcare All Other Commercial	$76,782.00
Rate for Payer: United Healthcare All Other HMO	$76,782.00
Rate for Payer: United Healthcare HMO Rider	$52,096.00
Rate for Payer: United Healthcare Select/Navigate/Core	$47,726.00

MS-DRG 40.00: SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$81,808.00

Service Code	MSDRG 460
Min. Negotiated Rate	$29,434.00
Max. Negotiated Rate	$81,808.00
Rate for Payer: Heritage Provider Network Commercial/Senior	$29,434.00
Rate for Payer: United Healthcare All Other Commercial	$81,808.00
Rate for Payer: United Healthcare All Other HMO	$81,808.00
Rate for Payer: United Healthcare HMO Rider	$32,713.00
Rate for Payer: United Healthcare Select/Navigate/Core	$29,970.00

MS-DRG 40.00: SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH CC

Facility

$185,063.77

Service Code	MSDRG 457
Min. Negotiated Rate	$29,434.00
Max. Negotiated Rate	$185,063.77
Rate for Payer: Heritage Provider Network Commercial/Senior	$29,434.00
Rate for Payer: United Healthcare All Other Commercial	$90,575.00
Rate for Payer: United Healthcare All Other HMO	$90,575.00
Rate for Payer: United Healthcare HMO Rider	$62,293.00
Rate for Payer: United Healthcare Select/Navigate/Core	$57,072.00

MS-DRG 40.00: SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITH MCC

Facility

$254,757.47

Service Code	MSDRG 456
Min. Negotiated Rate	$29,434.00
Max. Negotiated Rate	$254,757.47
Rate for Payer: Heritage Provider Network Commercial/Senior	$29,434.00
Rate for Payer: United Healthcare All Other Commercial	$112,148.00
Rate for Payer: United Healthcare All Other HMO	$112,148.00
Rate for Payer: United Healthcare HMO Rider	$75,636.00
Rate for Payer: United Healthcare Select/Navigate/Core	$69,294.00

MS-DRG 40.00: SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE, MALIGNANCY, INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC

Facility

$153,291.68

Service Code	MSDRG 458
Min. Negotiated Rate	$29,434.00
Max. Negotiated Rate	$153,291.68
Rate for Payer: Heritage Provider Network Commercial/Senior	$29,434.00
Rate for Payer: United Healthcare All Other Commercial	$81,933.00
Rate for Payer: United Healthcare All Other HMO	$81,933.00
Rate for Payer: United Healthcare HMO Rider	$53,969.00
Rate for Payer: United Healthcare Select/Navigate/Core	$49,445.00

MS-DRG 40.00: SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS

Facility

$139,787.87

Service Code	MSDRG 029
Min. Negotiated Rate	$25,608.00
Max. Negotiated Rate	$139,787.87
Rate for Payer: Heritage Provider Network Commercial/Senior	$25,608.00
Rate for Payer: United Healthcare All Other Commercial	$76,644.00
Rate for Payer: United Healthcare All Other HMO	$76,644.00
Rate for Payer: United Healthcare HMO Rider	$36,551.00
Rate for Payer: United Healthcare Select/Navigate/Core	$33,485.00

MS-DRG 40.00: SPINAL PROCEDURES WITH MCC

Facility

$185,865.85

Service Code	MSDRG 028
Min. Negotiated Rate	$25,608.00
Max. Negotiated Rate	$185,865.85
Rate for Payer: Heritage Provider Network Commercial/Senior	$25,608.00
Rate for Payer: United Healthcare All Other Commercial	$58,958.00
Rate for Payer: United Healthcare All Other HMO	$58,958.00
Rate for Payer: United Healthcare HMO Rider	$54,569.00
Rate for Payer: United Healthcare Select/Navigate/Core	$49,994.00

MS-DRG 40.00: SPINAL PROCEDURES WITHOUT CC/MCC

Facility

$118,203.06

Service Code	MSDRG 030
Min. Negotiated Rate	$20,798.00
Max. Negotiated Rate	$118,203.06
Rate for Payer: Heritage Provider Network Commercial/Senior	$25,608.00
Rate for Payer: United Healthcare All Other Commercial	$58,958.00
Rate for Payer: United Healthcare All Other HMO	$58,958.00
Rate for Payer: United Healthcare HMO Rider	$22,701.00
Rate for Payer: United Healthcare Select/Navigate/Core	$20,798.00

MS-DRG 40.00: UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC

Facility

$111,807.81

Service Code	MSDRG 742
Min. Negotiated Rate	$22,398.00
Max. Negotiated Rate	$111,807.81
Rate for Payer: United Healthcare All Other Commercial	$24,996.00
Rate for Payer: United Healthcare All Other HMO	$24,996.00
Rate for Payer: United Healthcare HMO Rider	$24,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$22,398.00

MS-DRG 40.00: UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC

Facility

$101,265.63

Service Code	MSDRG 743
Min. Negotiated Rate	$22,398.00
Max. Negotiated Rate	$101,265.63
Rate for Payer: United Healthcare All Other Commercial	$24,996.00
Rate for Payer: United Healthcare All Other HMO	$24,996.00
Rate for Payer: United Healthcare HMO Rider	$24,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$22,398.00

MS-DRG 40.00: UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC

Facility

$104,555.50

Service Code	MSDRG 741
Min. Negotiated Rate	$22,398.00
Max. Negotiated Rate	$104,555.50
Rate for Payer: United Healthcare All Other Commercial	$24,996.00
Rate for Payer: United Healthcare All Other HMO	$24,996.00
Rate for Payer: United Healthcare HMO Rider	$24,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$22,398.00

MS-DRG 40.00: VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C

Facility

$98,264.97

Service Code	MSDRG 768
Min. Negotiated Rate	$4,760.00
Max. Negotiated Rate	$98,264.97
Rate for Payer: Heritage Provider Network Commercial/Senior	$7,387.00

MS-DRG 40.00: WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$134,519.42

Service Code	MSDRG 464
Min. Negotiated Rate	$34,033.00
Max. Negotiated Rate	$134,519.42
Rate for Payer: United Healthcare All Other Commercial	$112,353.00
Rate for Payer: United Healthcare All Other HMO	$112,353.00
Rate for Payer: United Healthcare HMO Rider	$37,147.00
Rate for Payer: United Healthcare Select/Navigate/Core	$34,033.00

MS-DRG 40.00: WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$180,386.25

Service Code	MSDRG 463
Min. Negotiated Rate	$46,778.00
Max. Negotiated Rate	$180,386.25
Rate for Payer: United Healthcare All Other Commercial	$112,353.00
Rate for Payer: United Healthcare All Other HMO	$112,353.00
Rate for Payer: United Healthcare HMO Rider	$51,058.00
Rate for Payer: United Healthcare Select/Navigate/Core	$46,778.00

MS-DRG 40.00: WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$112,353.00

Service Code	MSDRG 465
Min. Negotiated Rate	$27,650.00
Max. Negotiated Rate	$112,353.00
Rate for Payer: United Healthcare All Other Commercial	$112,353.00
Rate for Payer: United Healthcare All Other HMO	$112,353.00
Rate for Payer: United Healthcare HMO Rider	$30,180.00
Rate for Payer: United Healthcare Select/Navigate/Core	$27,650.00

MUCOSITIS COCKTAIL COMPOUND [4080306]

Facility

$0.02

Service Code	NDC 9408030602
Hospital Charge Code	901700029
Hospital Revenue Code	259
Max. Negotiated Rate	$0.02
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Aetna of CA HMO/PPO	$0.01
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.02
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.01
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.02
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO	$0.01
Rate for Payer: Cigna of CA PPO	$0.01
Rate for Payer: Dignity Health Commercial/Exchange	$0.02
Rate for Payer: Dignity Health Medi-Cal	$0.02
Rate for Payer: Dignity Health Medicare Advantage	$0.02
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: EPIC Health Plan Senior	$0.01
Rate for Payer: Galaxy Health WC	$0.02
Rate for Payer: Global Benefits Group Commercial	$0.01
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$0.01
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.00
Rate for Payer: Molina Healthcare of CA Medi-Cal	$0.01
Rate for Payer: Molina Healthcare of CA Medicare	$0.01
Rate for Payer: Multiplan Commercial	$0.02
Rate for Payer: Networks By Design Commercial	$0.01
Rate for Payer: Prime Health Services Commercial	$0.02
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$0.01
Rate for Payer: TriValley Medical Group Commercial/Senior	$0.01
Rate for Payer: United Healthcare All Other Commercial	$0.01
Rate for Payer: United Healthcare All Other HMO	$0.01
Rate for Payer: United Healthcare HMO Rider	$0.01
Rate for Payer: United Healthcare Select/Navigate/Core	$0.01
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.02
Rate for Payer: Vantage Medical Group Medi-Cal	$0.02
Rate for Payer: Vantage Medical Group Senior	$0.02

MUCOSITIS COCKTAIL COMPOUND [4080306]

Facility

$0.02

Service Code	NDC 9408030601
Hospital Charge Code	901700029
Hospital Revenue Code	259
Max. Negotiated Rate	$0.02
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Aetna of CA HMO/PPO	$0.01
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.02
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.01
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.02
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO	$0.01
Rate for Payer: Cigna of CA PPO	$0.01
Rate for Payer: Dignity Health Commercial/Exchange	$0.02
Rate for Payer: Dignity Health Medi-Cal	$0.02
Rate for Payer: Dignity Health Medicare Advantage	$0.02
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: EPIC Health Plan Senior	$0.01
Rate for Payer: Galaxy Health WC	$0.02
Rate for Payer: Global Benefits Group Commercial	$0.01
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$0.01
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.00
Rate for Payer: Molina Healthcare of CA Medi-Cal	$0.01
Rate for Payer: Molina Healthcare of CA Medicare	$0.01
Rate for Payer: Multiplan Commercial	$0.02
Rate for Payer: Networks By Design Commercial	$0.01
Rate for Payer: Prime Health Services Commercial	$0.02
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$0.01
Rate for Payer: TriValley Medical Group Commercial/Senior	$0.01
Rate for Payer: United Healthcare All Other Commercial	$0.01
Rate for Payer: United Healthcare All Other HMO	$0.01
Rate for Payer: United Healthcare HMO Rider	$0.01
Rate for Payer: United Healthcare Select/Navigate/Core	$0.01
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.02
Rate for Payer: Vantage Medical Group Medi-Cal	$0.02
Rate for Payer: Vantage Medical Group Senior	$0.02

MUCOSITIS COCKTAIL COMPOUND [4080306]

Facility

$0.02

Service Code	NDC 9408030602
Hospital Charge Code	901700029
Hospital Revenue Code	259
Max. Negotiated Rate	$0.02
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Blue Shield of California Commercial	$0.01
Rate for Payer: Blue Shield of California Commercial	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO	$0.01
Rate for Payer: Cigna of CA PPO	$0.01
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: EPIC Health Plan Senior	$0.01
Rate for Payer: Galaxy Health WC	$0.02
Rate for Payer: Global Benefits Group Commercial	$0.01
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$0.01
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.00
Rate for Payer: Multiplan Commercial	$0.02
Rate for Payer: Networks By Design Commercial	$0.01
Rate for Payer: Prime Health Services Commercial	$0.02

MUCOSITIS COCKTAIL COMPOUND [4080306]

Facility

$0.02

Service Code	NDC 9408030601
Hospital Charge Code	901700029
Hospital Revenue Code	259
Max. Negotiated Rate	$0.02
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Blue Shield of California Commercial	$0.01
Rate for Payer: Blue Shield of California Commercial	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO	$0.01
Rate for Payer: Cigna of CA PPO	$0.01
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: EPIC Health Plan Senior	$0.01
Rate for Payer: Galaxy Health WC	$0.02
Rate for Payer: Global Benefits Group Commercial	$0.01
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$0.01
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.00
Rate for Payer: Multiplan Commercial	$0.02
Rate for Payer: Networks By Design Commercial	$0.01
Rate for Payer: Prime Health Services Commercial	$0.02

Know your out-of-pocket cost for care.

All Charges