Loma Linda University Children's Hospital

All Charges

Charge

Type

Setting

Price

CONNECTIVE TISSUE DISORDERS

Facility

$40,128.08

Service Code	APR-DRG 3464
Min. Negotiated Rate	$30,782.46
Max. Negotiated Rate	$40,128.08
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$30,782.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$40,128.08

CONNECTIVE TISSUE DISORDERS

Facility

$9,511.06

Service Code	APR-DRG 3461
Min. Negotiated Rate	$7,295.98
Max. Negotiated Rate	$9,511.06
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$7,295.98
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$9,511.06

CONNECTIVE TISSUE DISORDERS

Facility

$19,330.71

Service Code	APR-DRG 3463
Min. Negotiated Rate	$14,828.69
Max. Negotiated Rate	$19,330.71
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$14,828.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$19,330.71

CONNECTIVE TISSUE DISORDERS

Facility

$12,666.05

Service Code	APR-DRG 3462
Min. Negotiated Rate	$9,716.19
Max. Negotiated Rate	$12,666.05
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$9,716.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$12,666.05

Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple

Facility

$4,984.00

Service Code	CPT 42960
Min. Negotiated Rate	$140.77
Max. Negotiated Rate	$4,984.00
Rate for Payer: Aetna of CA HMO/PPO	$3,429.00
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$1,031.16
Rate for Payer: Alpha Care Medical Group Medi-Cal	$756.18
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$687.44
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$4,984.00
Rate for Payer: Dignity Health Commercial/Exchange	$1,031.16
Rate for Payer: Dignity Health Media	$687.44
Rate for Payer: Dignity Health Medi-Cal	$756.18
Rate for Payer: EPIC Health Plan Commercial	$928.04
Rate for Payer: EPIC Health Plan Medicare/Senior	$687.44
Rate for Payer: EPIC Health Plan Transplant	$687.44
Rate for Payer: Heritage Provider Network Commercial	$1,127.40
Rate for Payer: Heritage Provider Network Transplant	$1,127.40
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$1,113.65
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant	$1,113.65
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$687.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$140.77
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$687.44
Rate for Payer: Molina Healthcare of CA Medi-Cal	$866.17
Rate for Payer: Molina Healthcare of CA Medicare	$921.17
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1,031.16
Rate for Payer: Vantage Medical Group Medi-Cal	$756.18
Rate for Payer: Vantage Medical Group Senior	$687.44

CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE

Facility

$8,679.31

Service Code	APR-DRG 3841
Min. Negotiated Rate	$6,657.95
Max. Negotiated Rate	$8,679.31
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$6,657.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$8,679.31

CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE

Facility

$15,849.42

Service Code	APR-DRG 3843
Min. Negotiated Rate	$12,158.17
Max. Negotiated Rate	$15,849.42
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$12,158.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$15,849.42

CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE

Facility

$26,569.98

Service Code	APR-DRG 3844
Min. Negotiated Rate	$20,381.97
Max. Negotiated Rate	$26,569.98
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$20,381.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$26,569.98

CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE

Facility

$10,878.41

Service Code	APR-DRG 3842
Min. Negotiated Rate	$8,344.89
Max. Negotiated Rate	$10,878.41
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$8,344.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$10,878.41

COPANLISIB 60 MG INTRAVENOUS SOLUTION [219718]

Facility

$6,180.48

Service Code	CPT J9057
Hospital Charge Code	ERX219718
Hospital Revenue Code	636
Min. Negotiated Rate	$87.56
Max. Negotiated Rate	$5,253.41
Rate for Payer: Aetna of CA HMO/PPO	$166.72
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$109.45
Rate for Payer: Alpha Care Medical Group Medi-Cal	$96.32
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$96.32
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$162.47
Rate for Payer: Blue Distinction Transplant	$3,708.29
Rate for Payer: Blue Shield of California Commercial	$4,555.01
Rate for Payer: Blue Shield of California EPN	$93.31
Rate for Payer: Cash Price	$2,781.22
Rate for Payer: Cash Price	$2,781.22
Rate for Payer: Cigna of CA HMO	$4,326.34
Rate for Payer: Cigna of CA PPO	$4,326.34
Rate for Payer: Dignity Health Commercial/Exchange	$131.34
Rate for Payer: Dignity Health Media	$87.56
Rate for Payer: Dignity Health Medi-Cal	$96.32
Rate for Payer: EPIC Health Plan Commercial	$118.21
Rate for Payer: EPIC Health Plan Medicare/Senior	$87.56
Rate for Payer: EPIC Health Plan Transplant	$87.56
Rate for Payer: Galaxy Health WC	$5,253.41
Rate for Payer: Global Benefits Group Commercial	$3,708.29
Rate for Payer: Health Plan of Nevada (Sierra) Other	$4,635.36
Rate for Payer: Heritage Provider Network Commercial	$143.60
Rate for Payer: Heritage Provider Network Transplant	$143.60
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$141.85
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal Transplant	$141.85
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$87.56
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$4,122.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$2,354.76
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$87.56
Rate for Payer: LLUH Dept of Risk Management WC	$1,483.32
Rate for Payer: Molina Healthcare of CA Medi-Cal	$110.33
Rate for Payer: Molina Healthcare of CA Medicare	$117.33
Rate for Payer: Multiplan Commercial	$4,944.38
Rate for Payer: Networks By Design Commercial	$3,090.24
Rate for Payer: Prime Health Services Commercial	$5,253.41
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$3,708.29
Rate for Payer: TriValley Medical Group Commercial/Senior	$3,708.29
Rate for Payer: United Healthcare All Other Commercial	$3,090.24
Rate for Payer: United Healthcare All Other HMO	$3,090.24
Rate for Payer: United Healthcare HMO Rider	$3,090.24
Rate for Payer: United Healthcare Select/Navigate/Core	$3,090.24
Rate for Payer: Vantage Medical Group Commercial/Exchange	$131.34
Rate for Payer: Vantage Medical Group Medi-Cal	$96.32
Rate for Payer: Vantage Medical Group Senior	$87.56

COPANLISIB 60 MG INTRAVENOUS SOLUTION [219718]

Facility

$6,180.48

Service Code	CPT J9057
Hospital Charge Code	ERX219718
Hospital Revenue Code	636
Min. Negotiated Rate	$1,483.32
Max. Negotiated Rate	$5,253.41
Rate for Payer: Blue Shield of California Commercial	$4,400.50
Rate for Payer: Blue Shield of California EPN	$3,164.41
Rate for Payer: Cash Price	$2,781.22
Rate for Payer: Cigna of CA HMO	$4,326.34
Rate for Payer: Cigna of CA PPO	$4,326.34
Rate for Payer: EPIC Health Plan Commercial	$2,472.19
Rate for Payer: EPIC Health Plan Transplant	$2,472.19
Rate for Payer: Galaxy Health WC	$5,253.41
Rate for Payer: Global Benefits Group Commercial	$3,708.29
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$4,122.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$2,354.76
Rate for Payer: LLUH Dept of Risk Management WC	$1,483.32
Rate for Payer: Multiplan Commercial	$4,944.38
Rate for Payer: Networks By Design Commercial	$3,090.24
Rate for Payer: Prime Health Services Commercial	$5,253.41
Rate for Payer: United Healthcare All Other Commercial	$2,333.75
Rate for Payer: United Healthcare All Other HMO	$2,279.36
Rate for Payer: United Healthcare HMO Rider	$2,229.92
Rate for Payer: United Healthcare Select/Navigate/Core	$2,039.56

COPPER CHLORIDE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080425]

Facility

$2.60

Service Code	NDC 9994-0804-25
Hospital Charge Code	1715158
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$2.21
Rate for Payer: Blue Shield of California Commercial	$1.85
Rate for Payer: Blue Shield of California EPN	$1.33
Rate for Payer: Cash Price	$1.17
Rate for Payer: Cigna of CA HMO	$1.82
Rate for Payer: Cigna of CA PPO	$1.82
Rate for Payer: EPIC Health Plan Commercial	$1.04
Rate for Payer: Galaxy Health WC	$2.21
Rate for Payer: Global Benefits Group Commercial	$1.56
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$1.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.99
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Commercial	$2.08
Rate for Payer: Networks By Design Commercial	$1.69
Rate for Payer: Prime Health Services Commercial	$2.21

COPPER CHLORIDE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080425]

Facility

$2.60

Service Code	NDC 9994-0804-25
Hospital Charge Code	1715158
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$2.21
Rate for Payer: Aetna of CA HMO/PPO	$1.71
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$2.21
Rate for Payer: Alpha Care Medical Group Medi-Cal	$1.43
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$1.43
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$1.55
Rate for Payer: Blue Distinction Transplant	$1.56
Rate for Payer: Blue Shield of California Commercial	$1.92
Rate for Payer: Blue Shield of California EPN	$1.52
Rate for Payer: Cash Price	$1.17
Rate for Payer: Cigna of CA HMO	$1.82
Rate for Payer: Cigna of CA PPO	$1.82
Rate for Payer: Dignity Health Commercial/Exchange	$2.21
Rate for Payer: Dignity Health Media	$2.21
Rate for Payer: Dignity Health Medi-Cal	$2.21
Rate for Payer: EPIC Health Plan Commercial	$1.04
Rate for Payer: EPIC Health Plan Transplant	$1.04
Rate for Payer: Galaxy Health WC	$2.21
Rate for Payer: Global Benefits Group Commercial	$1.56
Rate for Payer: Health Plan of Nevada (Sierra) Other	$1.95
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$1.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.99
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Commercial	$2.08
Rate for Payer: Networks By Design Commercial	$1.69
Rate for Payer: Prime Health Services Commercial	$2.21
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$1.56
Rate for Payer: TriValley Medical Group Commercial/Senior	$1.56
Rate for Payer: United Healthcare All Other Commercial	$1.30
Rate for Payer: United Healthcare All Other HMO	$1.30
Rate for Payer: United Healthcare HMO Rider	$1.30
Rate for Payer: United Healthcare Select/Navigate/Core	$1.30
Rate for Payer: Vantage Medical Group Commercial/Exchange	$2.21
Rate for Payer: Vantage Medical Group Medi-Cal	$2.21
Rate for Payer: Vantage Medical Group Senior	$2.21

COPPER SULFATE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080426]

Facility

$0.25

Service Code	NDC 9994-0804-26
Hospital Charge Code	1715311
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA HMO/PPO	$0.16
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.21
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.14
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.14
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.15
Rate for Payer: Blue Distinction Transplant	$0.15
Rate for Payer: Blue Shield of California Commercial	$0.18
Rate for Payer: Blue Shield of California EPN	$0.15
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO	$0.18
Rate for Payer: Cigna of CA PPO	$0.18
Rate for Payer: Dignity Health Commercial/Exchange	$0.21
Rate for Payer: Dignity Health Media	$0.21
Rate for Payer: Dignity Health Medi-Cal	$0.21
Rate for Payer: EPIC Health Plan Commercial	$0.10
Rate for Payer: EPIC Health Plan Transplant	$0.10
Rate for Payer: Galaxy Health WC	$0.21
Rate for Payer: Global Benefits Group Commercial	$0.15
Rate for Payer: Health Plan of Nevada (Sierra) Other	$0.19
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.20
Rate for Payer: Networks By Design Commercial	$0.16
Rate for Payer: Prime Health Services Commercial	$0.21
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$0.15
Rate for Payer: TriValley Medical Group Commercial/Senior	$0.15
Rate for Payer: United Healthcare All Other Commercial	$0.13
Rate for Payer: United Healthcare All Other HMO	$0.13
Rate for Payer: United Healthcare HMO Rider	$0.13
Rate for Payer: United Healthcare Select/Navigate/Core	$0.13
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.21
Rate for Payer: Vantage Medical Group Medi-Cal	$0.21
Rate for Payer: Vantage Medical Group Senior	$0.21

COPPER SULFATE ORAL SOLUTION (IV FORM) 0.4 MG/ML [4080426]

Facility

$0.25

Service Code	NDC 9994-0804-26
Hospital Charge Code	1715311
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.21
Rate for Payer: Blue Shield of California Commercial	$0.18
Rate for Payer: Blue Shield of California EPN	$0.13
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA HMO	$0.18
Rate for Payer: Cigna of CA PPO	$0.18
Rate for Payer: EPIC Health Plan Commercial	$0.10
Rate for Payer: Galaxy Health WC	$0.21
Rate for Payer: Global Benefits Group Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.20
Rate for Payer: Networks By Design Commercial	$0.16
Rate for Payer: Prime Health Services Commercial	$0.21

CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$58,682.01

Service Code	APR-DRG 1651
Min. Negotiated Rate	$45,015.28
Max. Negotiated Rate	$58,682.01
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$45,015.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$58,682.01

CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$85,917.05

Service Code	APR-DRG 1653
Min. Negotiated Rate	$65,907.42
Max. Negotiated Rate	$85,917.05
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$65,907.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$85,917.05

CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$71,458.03

Service Code	APR-DRG 1652
Min. Negotiated Rate	$54,815.83
Max. Negotiated Rate	$71,458.03
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$54,815.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$71,458.03

CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$116,330.10

Service Code	APR-DRG 1654
Min. Negotiated Rate	$89,237.43
Max. Negotiated Rate	$116,330.10
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$89,237.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$116,330.10

CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$60,150.45

Service Code	APR-DRG 1662
Min. Negotiated Rate	$46,141.72
Max. Negotiated Rate	$60,150.45
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$46,141.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$60,150.45

CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$54,019.58

Service Code	APR-DRG 1661
Min. Negotiated Rate	$41,438.71
Max. Negotiated Rate	$54,019.58
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$41,438.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$54,019.58

CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$104,861.15

Service Code	APR-DRG 1664
Min. Negotiated Rate	$80,439.54
Max. Negotiated Rate	$104,861.15
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$80,439.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$104,861.15

CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS

Facility

$71,431.43

Service Code	APR-DRG 1663
Min. Negotiated Rate	$54,795.43
Max. Negotiated Rate	$71,431.43
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$54,795.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$71,431.43

Coronary Surgery

Facility

$41,843.00

Service Code	ICD 02H74KZ
Min. Negotiated Rate	$7,205.00
Max. Negotiated Rate	$41,843.00
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$41,843.00
Rate for Payer: Blue Shield of California Commercial	$10,022.00
Rate for Payer: Blue Shield of California EPN	$7,205.00

Coronary Surgery

Facility

$10,022.00

Service Code	ICD 041J0AQ
Min. Negotiated Rate	$7,205.00
Max. Negotiated Rate	$10,022.00
Rate for Payer: Blue Shield of California Commercial	$10,022.00
Rate for Payer: Blue Shield of California EPN	$7,205.00

Know your out-of-pocket cost for care.

All Charges