Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

MAGNESIUM SULFATE (BULK) 100 % CRYSTALS [4722]

Facility

$0.01

Service Code	NDC 1106801006
Hospital Charge Code	901700029
Hospital Revenue Code	259
Max. Negotiated Rate	$0.01
Rate for Payer: TriValley Medical Group Commercial	$0.00
Rate for Payer: Adventist Health Commercial	$0.00
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.01
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$0.01
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.01
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$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	$0.00
Rate for Payer: Cigna of CA HMO/PPO	$0.01
Rate for Payer: Dignity Health Commercial/Exchange	$0.01
Rate for Payer: Dignity Health Medi-Cal	$0.01
Rate for Payer: Dignity Health Medicare Advantage	$0.01
Rate for Payer: EPIC Health Plan Commercial	$0.01
Rate for Payer: Heritage Provider Network Commercial	$0.01
Rate for Payer: Heritage Provider Network Senior	$0.01
Rate for Payer: Kaiser Foundation Hospitals Commercial	$0.00
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.00
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	$0.01
Rate for Payer: TriValley Medical Group Senior	$0.00
Rate for Payer: United Healthcare All Other HMO/non HMO	$0.01
Rate for Payer: United Healthcare Navigate/Select/Select+	$0.01
Rate for Payer: Vantage Medical Group Commercial/Exchange	$0.01
Rate for Payer: Vantage Medical Group Medi-Cal	$0.01
Rate for Payer: Vantage Medical Group Senior	$0.01

MAGNESIUM SULFATE ORAL SOLUTION (IV FORM) 0.5 G/ML [4080434]

Facility

$1.55

Service Code	NDC 9994080434
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$1.32
Rate for Payer: Adventist Health Commercial	$0.31
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.96
Rate for Payer: Alpha Care Medical Group Commercial/Exchange	$1.32
Rate for Payer: Alpha Care Medical Group Medi-Cal	$0.85
Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product	$1.16
Rate for Payer: Anthem Blue Cross of CA HMO/PPO	$0.78
Rate for Payer: Blue Shield of California Commercial	$0.95
Rate for Payer: Blue Shield of California EPN	$0.76
Rate for Payer: Cash Price	$0.70
Rate for Payer: Cigna of CA HMO/PPO	$1.01
Rate for Payer: Dignity Health Commercial/Exchange	$1.32
Rate for Payer: Dignity Health Medi-Cal	$1.32
Rate for Payer: Dignity Health Medicare Advantage	$1.32
Rate for Payer: EPIC Health Plan Commercial	$0.99
Rate for Payer: Heritage Provider Network Commercial	$0.96
Rate for Payer: Heritage Provider Network Senior	$0.96
Rate for Payer: Kaiser Foundation Hospitals Commercial	$0.74
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$1.08
Rate for Payer: Multiplan Commercial	$1.16
Rate for Payer: TriValley Medical Group Commercial	$0.62
Rate for Payer: TriValley Medical Group Senior	$0.62
Rate for Payer: United Healthcare All Other HMO/non HMO	$0.78
Rate for Payer: United Healthcare Navigate/Select/Select+	$0.78
Rate for Payer: Vantage Medical Group Commercial/Exchange	$1.32
Rate for Payer: Vantage Medical Group Medi-Cal	$1.32
Rate for Payer: Vantage Medical Group Senior	$1.32

MAGNESIUM SULFATE ORAL SOLUTION (IV FORM) 0.5 G/ML [4080434]

Facility

$1.55

Service Code	NDC 9994080434
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$1.16
Rate for Payer: Adventist Health Commercial	$0.31
Rate for Payer: Aetna of CA Non-Gatekeeper	$1.00
Rate for Payer: Cash Price	$0.70
Rate for Payer: EPIC Health Plan Commercial	$0.84
Rate for Payer: Heritage Provider Network Commercial	$1.05
Rate for Payer: Heritage Provider Network Senior	$1.05
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$1.16

MAJOR BLADDER PROCEDURES WITH CC

Facility

$43,686.14

Service Code	MSDRG 654
Min. Negotiated Rate	$32,601.60
Max. Negotiated Rate	$43,686.14
Rate for Payer: EPIC Health Plan Medicare	$32,601.60
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$32,601.60
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$37,491.84
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$43,686.14

MAJOR BLADDER PROCEDURES WITH MCC

Facility

$80,494.72

Service Code	MSDRG 653
Min. Negotiated Rate	$60,070.69
Max. Negotiated Rate	$80,494.72
Rate for Payer: EPIC Health Plan Medicare	$60,070.69
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$60,070.69
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$69,081.29
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$80,494.72

MAJOR BLADDER PROCEDURES WITHOUT CC/MCC

Facility

$33,202.98

Service Code	MSDRG 655
Min. Negotiated Rate	$24,778.34
Max. Negotiated Rate	$33,202.98
Rate for Payer: EPIC Health Plan Medicare	$24,778.34
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$24,778.34
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$28,495.09
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$33,202.98

MAJOR CHEST PROCEDURES WITH CC

Facility

$39,458.81

Service Code	MSDRG 164
Min. Negotiated Rate	$29,446.87
Max. Negotiated Rate	$39,458.81
Rate for Payer: EPIC Health Plan Medicare	$29,446.87
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$29,446.87
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$33,863.90
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$39,458.81

MAJOR CHEST PROCEDURES WITH MCC

Facility

$69,521.73

Service Code	MSDRG 163
Min. Negotiated Rate	$51,881.89
Max. Negotiated Rate	$69,521.73
Rate for Payer: EPIC Health Plan Medicare	$51,881.89
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$51,881.89
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$59,664.17
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$69,521.73

MAJOR CHEST PROCEDURES WITHOUT CC/MCC

Facility

$30,095.02

Service Code	MSDRG 165
Min. Negotiated Rate	$22,458.97
Max. Negotiated Rate	$30,095.02
Rate for Payer: EPIC Health Plan Medicare	$22,458.97
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$22,458.97
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$25,827.82
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$30,095.02

MAJOR CHEST TRAUMA WITH CC

Facility

$17,041.37

Service Code	MSDRG 184
Min. Negotiated Rate	$12,717.44
Max. Negotiated Rate	$17,041.37
Rate for Payer: EPIC Health Plan Medicare	$12,717.44
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$12,717.44
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$14,625.06
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$17,041.37

MAJOR CHEST TRAUMA WITH MCC

Facility

$24,193.93

Service Code	MSDRG 183
Min. Negotiated Rate	$18,055.17
Max. Negotiated Rate	$24,193.93
Rate for Payer: EPIC Health Plan Medicare	$18,055.17
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$18,055.17
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$20,763.45
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$24,193.93

MAJOR CHEST TRAUMA WITHOUT CC/MCC

Facility

$12,778.70

Service Code	MSDRG 185
Min. Negotiated Rate	$9,536.34
Max. Negotiated Rate	$12,778.70
Rate for Payer: EPIC Health Plan Medicare	$9,536.34
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$9,536.34
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$10,966.79
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$12,778.70

MAJOR ESOPHAGEAL DISORDERS WITH CC

Facility

$16,060.11

Service Code	MSDRG 369
Min. Negotiated Rate	$11,985.16
Max. Negotiated Rate	$16,060.11
Rate for Payer: EPIC Health Plan Medicare	$11,985.16
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$11,985.16
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$13,782.93
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$16,060.11

MAJOR ESOPHAGEAL DISORDERS WITH MCC

Facility

$25,145.97

Service Code	MSDRG 368
Min. Negotiated Rate	$18,765.65
Max. Negotiated Rate	$25,145.97
Rate for Payer: EPIC Health Plan Medicare	$18,765.65
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$18,765.65
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$21,580.50
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$25,145.97

MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC

Facility

$11,462.69

Service Code	MSDRG 370
Min. Negotiated Rate	$8,554.25
Max. Negotiated Rate	$11,462.69
Rate for Payer: EPIC Health Plan Medicare	$8,554.25
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$8,554.25
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$9,837.39
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$11,462.69

MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC

Facility

$16,379.52

Service Code	MSDRG 372
Min. Negotiated Rate	$12,223.52
Max. Negotiated Rate	$16,379.52
Rate for Payer: EPIC Health Plan Medicare	$12,223.52
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$12,223.52
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$14,057.05
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$16,379.52

MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC

Facility

$27,928.39

Service Code	MSDRG 371
Min. Negotiated Rate	$20,842.08
Max. Negotiated Rate	$27,928.39
Rate for Payer: EPIC Health Plan Medicare	$20,842.08
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$20,842.08
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$23,968.39
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$27,928.39

MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC

Facility

$11,871.15

Service Code	MSDRG 373
Min. Negotiated Rate	$8,859.07
Max. Negotiated Rate	$11,871.15
Rate for Payer: EPIC Health Plan Medicare	$8,859.07
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$8,859.07
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$10,187.93
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$11,871.15

MAJOR HEAD AND NECK PROCEDURES WITH CC

Facility

$34,193.41

Service Code	MSDRG 141
Min. Negotiated Rate	$25,517.47
Max. Negotiated Rate	$34,193.41
Rate for Payer: EPIC Health Plan Medicare	$25,517.47
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$25,517.47
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$29,345.09
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$34,193.41

MAJOR HEAD AND NECK PROCEDURES WITH MCC

Facility

$66,197.29

Service Code	MSDRG 140
Min. Negotiated Rate	$49,400.96
Max. Negotiated Rate	$66,197.29
Rate for Payer: EPIC Health Plan Medicare	$49,400.96
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$49,400.96
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$56,811.10
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$66,197.29

MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC

Facility

$25,215.06

Service Code	MSDRG 142
Min. Negotiated Rate	$18,817.21
Max. Negotiated Rate	$25,215.06
Rate for Payer: EPIC Health Plan Medicare	$18,817.21
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$18,817.21
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$21,639.79
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$25,215.06

MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC

Facility

$20,140.09

Service Code	MSDRG 809
Min. Negotiated Rate	$15,029.92
Max. Negotiated Rate	$20,140.09
Rate for Payer: EPIC Health Plan Medicare	$15,029.92
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$15,029.92
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$17,284.41
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$20,140.09

MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC

Facility

$34,604.92

Service Code	MSDRG 808
Min. Negotiated Rate	$25,824.57
Max. Negotiated Rate	$34,604.92
Rate for Payer: EPIC Health Plan Medicare	$25,824.57
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$25,824.57
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$29,698.26
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$34,604.92

MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC

Facility

$16,772.62

Service Code	MSDRG 810
Min. Negotiated Rate	$12,516.88
Max. Negotiated Rate	$16,772.62
Rate for Payer: EPIC Health Plan Medicare	$12,516.88
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$12,516.88
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$14,394.41
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$16,772.62

MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT

Facility

$47,277.80

Service Code	MSDRG 469
Min. Negotiated Rate	$3,928.00
Max. Negotiated Rate	$47,277.80
Rate for Payer: EPIC Health Plan Medicare	$35,281.94
Rate for Payer: Heritage Provider Network Commercial	$4,319.00
Rate for Payer: Heritage Provider Network Senior	$3,928.00
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$35,281.94
Rate for Payer: Kaiser Foundation Hospitals Commercial	$9,944.00
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$40,574.23
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$47,277.80

Know your out-of-pocket cost for care.

All Charges