Loma Linda University Children's Hospital

All Charges

Charge

Type

Setting

Price

KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION [91349]

Facility

$1.20

Service Code	CPT J1885
Hospital Charge Code	1720672
Hospital Revenue Code	636
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$17.96
Rate for Payer: Aetna of CA HMO/PPO	$3.05
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$1.02
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.66
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.66
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$17.96
Rate for Payer: Blue Distinction Transplant	$0.72
Rate for Payer: Blue Shield of California Commercial	$0.88
Rate for Payer: Blue Shield of California EPN	$1.58
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cigna of CA HMO	$0.84
Rate for Payer: Cigna of CA PPO	$0.84
Rate for Payer: Dignity Health Commercial/Exchange	$1.02
Rate for Payer: Dignity Health Media	$1.02
Rate for Payer: Dignity Health Medi-Cal	$1.02
Rate for Payer: EPIC Health Plan Commercial	$0.48
Rate for Payer: EPIC Health Plan Transplant	$0.48
Rate for Payer: Galaxy Health WC	$1.02
Rate for Payer: Global Benefits Group Commercial	$0.72
Rate for Payer: Health Plan of Nevada (Sierra) Other	$0.90
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$0.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$9.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.96
Rate for Payer: Networks By Design Commercial	$0.60
Rate for Payer: Prime Health Services Commercial	$1.02
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$0.72
Rate for Payer: TriValley Medical Group Commercial/Senior	$0.72
Rate for Payer: United Healthcare All Other Commercial	$0.60
Rate for Payer: United Healthcare All Other HMO	$0.60
Rate for Payer: United Healthcare HMO Rider	$0.60
Rate for Payer: United Healthcare Select/Navigate/Core	$0.60
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1.02
Rate for Payer: Vantage Medical Group Medi-Cal	$1.02
Rate for Payer: Vantage Medical Group Senior	$1.02

KETOTIFEN 0.025 % EYE DROPS [25471]

Facility

$2.19

Service Code	NDC 17478-717-10
Hospital Charge Code	NDG25471
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$1.86
Rate for Payer: Blue Shield of California Commercial	$1.56
Rate for Payer: Blue Shield of California EPN	$1.12
Rate for Payer: Cash Price	$0.99
Rate for Payer: Cigna of CA HMO	$1.53
Rate for Payer: Cigna of CA PPO	$1.53
Rate for Payer: EPIC Health Plan Commercial	$0.88
Rate for Payer: Galaxy Health WC	$1.86
Rate for Payer: Global Benefits Group Commercial	$1.31
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$1.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$1.75
Rate for Payer: Networks By Design Commercial	$1.42
Rate for Payer: Prime Health Services Commercial	$1.86

KETOTIFEN 0.025 % EYE DROPS [25471]

Facility

$2.19

Service Code	NDC 17478-717-10
Hospital Charge Code	NDG25471
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$1.86
Rate for Payer: Aetna of CA HMO/PPO	$1.44
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$1.86
Rate for Payer: Alpha Care Medical Group Medi-Cal	$1.20
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$1.20
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$1.30
Rate for Payer: Blue Distinction Transplant	$1.31
Rate for Payer: Blue Shield of California Commercial	$1.61
Rate for Payer: Blue Shield of California EPN	$1.28
Rate for Payer: Cash Price	$0.99
Rate for Payer: Cigna of CA HMO	$1.53
Rate for Payer: Cigna of CA PPO	$1.53
Rate for Payer: Dignity Health Commercial/Exchange	$1.86
Rate for Payer: Dignity Health Media	$1.86
Rate for Payer: Dignity Health Medi-Cal	$1.86
Rate for Payer: EPIC Health Plan Commercial	$0.88
Rate for Payer: EPIC Health Plan Transplant	$0.88
Rate for Payer: Galaxy Health WC	$1.86
Rate for Payer: Global Benefits Group Commercial	$1.31
Rate for Payer: Health Plan of Nevada (Sierra) Other	$1.64
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$1.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$1.75
Rate for Payer: Networks By Design Commercial	$1.42
Rate for Payer: Prime Health Services Commercial	$1.86
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$1.31
Rate for Payer: TriValley Medical Group Commercial/Senior	$1.31
Rate for Payer: United Healthcare All Other Commercial	$1.10
Rate for Payer: United Healthcare All Other HMO	$1.10
Rate for Payer: United Healthcare HMO Rider	$1.10
Rate for Payer: United Healthcare Select/Navigate/Core	$1.10
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1.86
Rate for Payer: Vantage Medical Group Medi-Cal	$1.86
Rate for Payer: Vantage Medical Group Senior	$1.86

KETOTIFEN 0.025 % EYE DROPS [25471]

Facility

$2.50

Service Code	NDC 0065-4011-05
Hospital Charge Code	NDG25471
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$2.12
Rate for Payer: Aetna of CA HMO/PPO	$1.64
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$2.12
Rate for Payer: Alpha Care Medical Group Medi-Cal	$1.38
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$1.38
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$1.49
Rate for Payer: Blue Distinction Transplant	$1.50
Rate for Payer: Blue Shield of California Commercial	$1.84
Rate for Payer: Blue Shield of California EPN	$1.46
Rate for Payer: Cash Price	$1.13
Rate for Payer: Cigna of CA HMO	$1.75
Rate for Payer: Cigna of CA PPO	$1.75
Rate for Payer: Dignity Health Commercial/Exchange	$2.12
Rate for Payer: Dignity Health Media	$2.12
Rate for Payer: Dignity Health Medi-Cal	$2.12
Rate for Payer: EPIC Health Plan Commercial	$1.00
Rate for Payer: EPIC Health Plan Transplant	$1.00
Rate for Payer: Galaxy Health WC	$2.12
Rate for Payer: Global Benefits Group Commercial	$1.50
Rate for Payer: Health Plan of Nevada (Sierra) Other	$1.88
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$1.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Commercial	$2.00
Rate for Payer: Networks By Design Commercial	$1.62
Rate for Payer: Prime Health Services Commercial	$2.12
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$1.50
Rate for Payer: TriValley Medical Group Commercial/Senior	$1.50
Rate for Payer: United Healthcare All Other Commercial	$1.25
Rate for Payer: United Healthcare All Other HMO	$1.25
Rate for Payer: United Healthcare HMO Rider	$1.25
Rate for Payer: United Healthcare Select/Navigate/Core	$1.25
Rate for Payer: Vantage Medical Group Commercial/Exchange	$2.12
Rate for Payer: Vantage Medical Group Medi-Cal	$2.12
Rate for Payer: Vantage Medical Group Senior	$2.12

KETOTIFEN 0.025 % EYE DROPS [25471]

Facility

$2.50

Service Code	NDC 0065-4011-05
Hospital Charge Code	NDG25471
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$2.12
Rate for Payer: Blue Shield of California Commercial	$1.78
Rate for Payer: Blue Shield of California EPN	$1.28
Rate for Payer: Cash Price	$1.13
Rate for Payer: Cigna of CA HMO	$1.75
Rate for Payer: Cigna of CA PPO	$1.75
Rate for Payer: EPIC Health Plan Commercial	$1.00
Rate for Payer: Galaxy Health WC	$2.12
Rate for Payer: Global Benefits Group Commercial	$1.50
Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded	$1.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Commercial	$2.00
Rate for Payer: Networks By Design Commercial	$1.62
Rate for Payer: Prime Health Services Commercial	$2.12

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$12,474.53

Service Code	APR-DRG 4633
Min. Negotiated Rate	$9,569.27
Max. Negotiated Rate	$12,474.53
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$9,569.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$12,474.53

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$7,390.01

Service Code	APR-DRG 4631
Min. Negotiated Rate	$5,668.92
Max. Negotiated Rate	$7,390.01
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$5,668.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$7,390.01

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$19,405.19

Service Code	APR-DRG 4634
Min. Negotiated Rate	$14,885.83
Max. Negotiated Rate	$19,405.19
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$14,885.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$19,405.19

KIDNEY AND URINARY TRACT INFECTIONS

Facility

$9,289.38

Service Code	APR-DRG 4632
Min. Negotiated Rate	$7,125.94
Max. Negotiated Rate	$9,289.38
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$7,125.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$9,289.38

KIDNEY AND URINARY TRACT MALIGNANCY

Facility

$16,920.58

Service Code	APR-DRG 4613
Min. Negotiated Rate	$12,979.87
Max. Negotiated Rate	$16,920.58
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$12,979.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$16,920.58

KIDNEY AND URINARY TRACT MALIGNANCY

Facility

$24,493.26

Service Code	APR-DRG 4614
Min. Negotiated Rate	$18,788.91
Max. Negotiated Rate	$24,493.26
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$18,788.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$24,493.26

KIDNEY AND URINARY TRACT MALIGNANCY

Facility

$11,692.43

Service Code	APR-DRG 4612
Min. Negotiated Rate	$8,969.32
Max. Negotiated Rate	$11,692.43
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$8,969.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$11,692.43

KIDNEY AND URINARY TRACT MALIGNANCY

Facility

$9,693.72

Service Code	APR-DRG 4611
Min. Negotiated Rate	$7,436.11
Max. Negotiated Rate	$9,693.72
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$7,436.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$9,693.72

KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY

Facility

$21,847.24

Service Code	APR-DRG 4421
Min. Negotiated Rate	$16,759.14
Max. Negotiated Rate	$21,847.24
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$16,759.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$21,847.24

KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY

Facility

$25,371.12

Service Code	APR-DRG 4422
Min. Negotiated Rate	$19,462.32
Max. Negotiated Rate	$25,371.12
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$19,462.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$25,371.12

KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY

Facility

$64,578.78

Service Code	APR-DRG 4424
Min. Negotiated Rate	$49,538.72
Max. Negotiated Rate	$64,578.78
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$49,538.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$64,578.78

KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY

Facility

$36,861.37

Service Code	APR-DRG 4423
Min. Negotiated Rate	$28,276.55
Max. Negotiated Rate	$36,861.37
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$28,276.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$36,861.37

KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY

Facility

$31,313.98

Service Code	APR-DRG 4433
Min. Negotiated Rate	$24,021.12
Max. Negotiated Rate	$31,313.98
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$24,021.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$31,313.98

KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY

Facility

$18,390.78

Service Code	APR-DRG 4431
Min. Negotiated Rate	$14,107.67
Max. Negotiated Rate	$18,390.78
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$14,107.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$18,390.78

KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY

Facility

$52,478.46

Service Code	APR-DRG 4434
Min. Negotiated Rate	$40,256.50
Max. Negotiated Rate	$52,478.46
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$40,256.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$52,478.46

KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY

Facility

$21,295.71

Service Code	APR-DRG 4432
Min. Negotiated Rate	$16,336.05
Max. Negotiated Rate	$21,295.71
Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal	$16,336.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal	$21,295.71

Kidney-Heart Transplant

Facility

$285,000.00

Service Code	MSDRG 652
Min. Negotiated Rate	$282,500.00
Max. Negotiated Rate	$285,000.00
Rate for Payer: EPIC Health Plan Transplant	$285,000.00
Rate for Payer: Heritage Provider Network Transplant	$282,500.00

Kidney-Heart Transplant

Facility

$285,000.00

Service Code	MSDRG 001
Min. Negotiated Rate	$282,500.00
Max. Negotiated Rate	$285,000.00
Rate for Payer: EPIC Health Plan Transplant	$285,000.00
Rate for Payer: Heritage Provider Network Transplant	$282,500.00

Kidney-Heart Transplant

Facility

$285,000.00

Service Code	MSDRG 002
Min. Negotiated Rate	$282,500.00
Max. Negotiated Rate	$285,000.00
Rate for Payer: EPIC Health Plan Transplant	$285,000.00
Rate for Payer: Heritage Provider Network Transplant	$282,500.00

Kidney-Heart Transplant

Facility

$285,000.00

Service Code	MSDRG 651
Min. Negotiated Rate	$282,500.00
Max. Negotiated Rate	$285,000.00
Rate for Payer: EPIC Health Plan Transplant	$285,000.00
Rate for Payer: Heritage Provider Network Transplant	$282,500.00

Know your out-of-pocket cost for care.

All Charges