Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

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

$156,942.83

Service Code	MSDRG 457
Min. Negotiated Rate	$29,434.00
Max. Negotiated Rate	$156,942.83
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

$221,169.08

Service Code	MSDRG 456
Min. Negotiated Rate	$29,434.00
Max. Negotiated Rate	$221,169.08
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

$109,818.66

Service Code	MSDRG 458
Min. Negotiated Rate	$29,434.00
Max. Negotiated Rate	$109,818.66
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

$89,789.90

Service Code	MSDRG 029
Min. Negotiated Rate	$25,608.00
Max. Negotiated Rate	$89,789.90
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

$158,132.45

Service Code	MSDRG 028
Min. Negotiated Rate	$25,608.00
Max. Negotiated Rate	$158,132.45
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

$58,958.00

Service Code	MSDRG 030
Min. Negotiated Rate	$20,798.00
Max. Negotiated Rate	$58,958.00
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

$48,290.10

Service Code	MSDRG 742
Min. Negotiated Rate	$22,398.00
Max. Negotiated Rate	$48,290.10
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

$32,653.98

Service Code	MSDRG 743
Min. Negotiated Rate	$18,013.39
Max. Negotiated Rate	$32,653.98
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

$37,533.53

Service Code	MSDRG 741
Min. Negotiated Rate	$20,570.44
Max. Negotiated Rate	$37,533.53
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: WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$112,353.00

Service Code	MSDRG 464
Min. Negotiated Rate	$34,033.00
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	$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

$150,005.14

Service Code	MSDRG 463
Min. Negotiated Rate	$46,778.00
Max. Negotiated Rate	$150,005.14
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	$26,054.17
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 Exchange	$0.01
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.01
Rate for Payer: Blue Shield of California Commercial	$0.01
Rate for Payer: Blue Shield of California EPN	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Central Health Plan Commercial	$0.02
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: Health Management Network EPO/PPO	$0.02
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/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: Riverside University Health System MISP	$0.01
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	$0.02
Rate for Payer: Blue Shield of California EPN	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Central Health Plan Commercial	$0.02
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: Health Management Network EPO/PPO	$0.02
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: 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 Exchange	$0.01
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.01
Rate for Payer: Blue Shield of California Commercial	$0.01
Rate for Payer: Blue Shield of California EPN	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Central Health Plan Commercial	$0.02
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: Health Management Network EPO/PPO	$0.02
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/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: Riverside University Health System MISP	$0.01
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: Blue Shield of California Commercial	$0.02
Rate for Payer: Blue Shield of California EPN	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Central Health Plan Commercial	$0.02
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: Health Management Network EPO/PPO	$0.02
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 (PINK LADY) [4080321]

Facility

$0.04

Service Code	NDC 9994080306
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Adventist Health Commercial	$0.01
Rate for Payer: Aetna of CA HMO/PPO	$0.02
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.03
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.02
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.03
Rate for Payer: Anthem Blue Cross of CA Exchange	$0.02
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.02
Rate for Payer: Blue Shield of California Commercial	$0.03
Rate for Payer: Blue Shield of California EPN	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Central Health Plan Commercial	$0.03
Rate for Payer: Cigna of CA HMO	$0.03
Rate for Payer: Cigna of CA PPO	$0.03
Rate for Payer: Dignity Health Commercial/Exchange	$0.03
Rate for Payer: Dignity Health Medi-Cal	$0.03
Rate for Payer: Dignity Health Medicare Advantage	$0.03
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$0.03
Rate for Payer: EPIC Health Plan Commercial	$0.02
Rate for Payer: EPIC Health Plan Senior	$0.02
Rate for Payer: Galaxy Health WC	$0.03
Rate for Payer: Global Benefits Group Commercial	$0.02
Rate for Payer: Health Management Network EPO/PPO	$0.04
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$0.03
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$0.03
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: Networks By Design Commercial	$0.03
Rate for Payer: Prime Health Services Commercial	$0.03
Rate for Payer: Riverside University Health System MISP	$0.02
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$0.02
Rate for Payer: TriValley Medical Group Commercial/Senior	$0.02
Rate for Payer: United Healthcare All Other Commercial	$0.02
Rate for Payer: United Healthcare All Other HMO	$0.02
Rate for Payer: United Healthcare HMO Rider	$0.02
Rate for Payer: United Healthcare Select/Navigate/Core	$0.02
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.03
Rate for Payer: Vantage Medical Group Medi-Cal	$0.03
Rate for Payer: Vantage Medical Group Senior	$0.03

MUCOSITIS COCKTAIL (PINK LADY) [4080321]

Facility

$0.04

Service Code	NDC 9994080306
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.04
Rate for Payer: Adventist Health Commercial	$0.01
Rate for Payer: Blue Shield of California Commercial	$0.03
Rate for Payer: Blue Shield of California EPN	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Central Health Plan Commercial	$0.03
Rate for Payer: Cigna of CA HMO	$0.03
Rate for Payer: Cigna of CA PPO	$0.03
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$0.03
Rate for Payer: EPIC Health Plan Commercial	$0.02
Rate for Payer: EPIC Health Plan Senior	$0.02
Rate for Payer: Galaxy Health WC	$0.03
Rate for Payer: Global Benefits Group Commercial	$0.02
Rate for Payer: Health Management Network EPO/PPO	$0.04
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$0.03
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.03
Rate for Payer: Networks By Design Commercial	$0.03
Rate for Payer: Prime Health Services Commercial	$0.03

MUCOSITIS COCKTAIL (PINK LADY) [4080321]

Facility

$0.62

Service Code	NDC 9994080321
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.56
Rate for Payer: Adventist Health Commercial	$0.12
Rate for Payer: Aetna of CA HMO/PPO	$0.38
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.53
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.34
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$0.47
Rate for Payer: Anthem Blue Cross of CA Exchange	$0.30
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.36
Rate for Payer: Blue Shield of California Commercial	$0.39
Rate for Payer: Blue Shield of California EPN	$0.25
Rate for Payer: Cash Price	$0.28
Rate for Payer: Central Health Plan Commercial	$0.50
Rate for Payer: Cigna of CA HMO	$0.43
Rate for Payer: Cigna of CA PPO	$0.43
Rate for Payer: Dignity Health Commercial/Exchange	$0.53
Rate for Payer: Dignity Health Medi-Cal	$0.53
Rate for Payer: Dignity Health Medicare Advantage	$0.53
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$0.43
Rate for Payer: EPIC Health Plan Commercial	$0.25
Rate for Payer: EPIC Health Plan Senior	$0.25
Rate for Payer: Galaxy Health WC	$0.53
Rate for Payer: Global Benefits Group Commercial	$0.37
Rate for Payer: Health Management Network EPO/PPO	$0.56
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$0.39
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.23
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$0.43
Rate for Payer: Multiplan Commercial	$0.47
Rate for Payer: Networks By Design Commercial	$0.40
Rate for Payer: Prime Health Services Commercial	$0.53
Rate for Payer: Riverside University Health System MISP	$0.25
Rate for Payer: Temecula Valley Physicians Medical Group Commercial	$0.37
Rate for Payer: TriValley Medical Group Commercial/Senior	$0.37
Rate for Payer: United Healthcare All Other Commercial	$0.31
Rate for Payer: United Healthcare All Other HMO	$0.31
Rate for Payer: United Healthcare HMO Rider	$0.31
Rate for Payer: United Healthcare Select/Navigate/Core	$0.31
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.53
Rate for Payer: Vantage Medical Group Medi-Cal	$0.53
Rate for Payer: Vantage Medical Group Senior	$0.53

MUCOSITIS COCKTAIL (PINK LADY) [4080321]

Facility

$0.62

Service Code	NDC 9994080321
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.56
Rate for Payer: Adventist Health Commercial	$0.12
Rate for Payer: Blue Shield of California Commercial	$0.50
Rate for Payer: Blue Shield of California EPN	$0.31
Rate for Payer: Cash Price	$0.28
Rate for Payer: Central Health Plan Commercial	$0.50
Rate for Payer: Cigna of CA HMO	$0.43
Rate for Payer: Cigna of CA PPO	$0.43
Rate for Payer: Emerging Therapy Solutions (LifeTrac) Transplant	$0.43
Rate for Payer: EPIC Health Plan Commercial	$0.25
Rate for Payer: EPIC Health Plan Senior	$0.25
Rate for Payer: Galaxy Health WC	$0.53
Rate for Payer: Global Benefits Group Commercial	$0.37
Rate for Payer: Health Management Network EPO/PPO	$0.56
Rate for Payer: Kaiser Foundation Hospitals Commercial/Self Funded	$0.39
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.47
Rate for Payer: Networks By Design Commercial	$0.40
Rate for Payer: Prime Health Services Commercial	$0.53

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL

Facility

$99,791.02

Service Code	APR-DRG 2993
Min. Negotiated Rate	$63,025.91
Max. Negotiated Rate	$99,791.02
Rate for Payer: Adventist Health Medi-Cal	$63,025.91
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$75,105.87
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$99,791.02

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL

Facility

$127,284.72

Service Code	APR-DRG 2994
Min. Negotiated Rate	$80,390.35
Max. Negotiated Rate	$127,284.72
Rate for Payer: Adventist Health Medi-Cal	$80,390.35
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$95,798.50
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$127,284.72

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL

Facility

$74,766.73

Service Code	APR-DRG 2992
Min. Negotiated Rate	$47,221.09
Max. Negotiated Rate	$74,766.73
Rate for Payer: Adventist Health Medi-Cal	$47,221.09
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$56,271.80
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$74,766.73

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL

Facility

$63,626.25

Service Code	APR-DRG 2991
Min. Negotiated Rate	$40,185.00
Max. Negotiated Rate	$63,626.25
Rate for Payer: Adventist Health Medi-Cal	$40,185.00
Rate for Payer: Inland Empire Health Plan (IEHP) medi-cal	$47,887.12
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$63,626.25

Know your out-of-pocket cost for care.

All Charges