Loma Linda University Medical Center

All Charges

Charge

Type

Setting

Price

MS-DRG 33.00: SPINAL FUS EXC CERV W SPINAL CURV/MALIG/INFEC OR EXT FUS W/O CC/MCC

Facility

$64,773.79

Service Code	MSDRG 458
Min. Negotiated Rate	$3,928.00
Max. Negotiated Rate	$64,773.79
Rate for Payer: EPIC Health Plan Commercial	$28,410.00

MS-DRG 33.00: SPINAL FUSION EXCEPT CERVICAL W MCC

Facility

$28,410.00

Service Code	MSDRG 459
Min. Negotiated Rate	$21,600.00
Max. Negotiated Rate	$28,410.00
Rate for Payer: EPIC Health Plan Commercial	$28,410.00

MS-DRG 33.00: SPINAL FUSION EXCEPT CERVICAL W/O MCC

Facility

$28,410.00

Service Code	MSDRG 460
Min. Negotiated Rate	$21,600.00
Max. Negotiated Rate	$28,410.00
Rate for Payer: EPIC Health Plan Commercial	$28,410.00

MS-DRG 33.00: TRANSIENT ISCHEMIA

Facility

$18,576.00

Service Code	MSDRG 069
Min. Negotiated Rate	$9,677.28
Max. Negotiated Rate	$18,576.00
Rate for Payer: EPIC Health Plan Commercial	$18,576.00

MS-DRG 33.00: VAGINAL DELIVERY W COMPLICATING DIAGNOSES

Facility

$6,829.00

Service Code	MSDRG 774
Min. Negotiated Rate	$4,895.00
Max. Negotiated Rate	$6,829.00
Rate for Payer: EPIC Health Plan Commercial	$6,829.00

MS-DRG 33.00: VAGINAL DELIVERY W/O COMPLICATING DIAGNOSES

Facility

$6,829.00

Service Code	MSDRG 775
Min. Negotiated Rate	$4,895.00
Max. Negotiated Rate	$6,829.00
Rate for Payer: EPIC Health Plan Commercial	$6,829.00

MS-DRG 33.00: VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C

Facility

$17,156.53

Service Code	MSDRG 768
Min. Negotiated Rate	$4,895.00
Max. Negotiated Rate	$17,156.53
Rate for Payer: EPIC Health Plan Commercial	$6,829.00

MS-DRG 33.00: VAGINAL DELIVERY W STERILIZATION &/OR D&C

Facility

$6,829.00

Service Code	MSDRG 767
Min. Negotiated Rate	$4,895.00
Max. Negotiated Rate	$6,829.00
Rate for Payer: EPIC Health Plan Commercial	$6,829.00

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 Non-Gatekeeper	$0.01
Rate for Payer: Cash Price	$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 Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan 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 Non-Gatekeeper	$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: 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: Cigna of CA HMO/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: 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	$0.01
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$0.01
Rate for Payer: Multiplan Commercial	$0.02
Rate for Payer: TriValley Medical Group Commercial	$0.01
Rate for Payer: TriValley Medical Group Senior	$0.01
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	$0.02
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: Aetna of CA Non-Gatekeeper	$0.01
Rate for Payer: Cash Price	$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 Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$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: Aetna of CA Non-Gatekeeper	$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: 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: Cigna of CA HMO/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: 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	$0.01
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$0.01
Rate for Payer: Multiplan Commercial	$0.02
Rate for Payer: TriValley Medical Group Commercial	$0.01
Rate for Payer: TriValley Medical Group Senior	$0.01
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	$0.02
Rate for Payer: Vantage Medical Group Medi-Cal	$0.02
Rate for Payer: Vantage Medical Group Senior	$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	$0.03
Rate for Payer: Adventist Health Commercial	$0.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$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 HMO/PPO	$0.02
Rate for Payer: Blue Shield of California Commercial	$0.02
Rate for Payer: Blue Shield of California EPN	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/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: EPIC Health Plan Commercial	$0.03
Rate for Payer: Heritage Provider Network Commercial	$0.02
Rate for Payer: Heritage Provider Network Senior	$0.02
Rate for Payer: Kaiser Foundation Hospitals Commercial	$0.02
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
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: TriValley Medical Group Commercial	$0.02
Rate for Payer: TriValley Medical Group Senior	$0.02
Rate for Payer: United Healthcare All Other HMO/non HMO	$0.02
Rate for Payer: United Healthcare Navigate/Select/Select+	$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	$0.03
Rate for Payer: Adventist Health Commercial	$0.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: EPIC Health Plan Commercial	$0.02
Rate for Payer: Heritage Provider Network Commercial	$0.03
Rate for Payer: Heritage Provider Network Senior	$0.03
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan 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	$0.11
Max. Negotiated Rate	$0.53
Rate for Payer: Adventist Health Commercial	$0.12
Rate for Payer: Aetna of CA Non-Gatekeeper	$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 HMO/PPO	$0.31
Rate for Payer: Blue Shield of California Commercial	$0.38
Rate for Payer: Blue Shield of California EPN	$0.30
Rate for Payer: Cash Price	$0.28
Rate for Payer: Cigna of CA HMO/PPO	$0.40
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: EPIC Health Plan Commercial	$0.40
Rate for Payer: Heritage Provider Network Commercial	$0.38
Rate for Payer: Heritage Provider Network Senior	$0.38
Rate for Payer: Kaiser Foundation Hospitals Commercial	$0.30
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$0.43
Rate for Payer: Multiplan Commercial	$0.47
Rate for Payer: TriValley Medical Group Commercial	$0.25
Rate for Payer: TriValley Medical Group Senior	$0.25
Rate for Payer: United Healthcare All Other HMO/non HMO	$0.31
Rate for Payer: United Healthcare Navigate/Select/Select+	$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	$0.11
Max. Negotiated Rate	$0.47
Rate for Payer: Adventist Health Commercial	$0.12
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.40
Rate for Payer: Cash Price	$0.28
Rate for Payer: EPIC Health Plan Commercial	$0.33
Rate for Payer: Heritage Provider Network Commercial	$0.42
Rate for Payer: Heritage Provider Network Senior	$0.42
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.16
Rate for Payer: Multiplan Commercial	$0.47

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH CC

Facility

$111,546.57

Service Code	MSDRG 427
Min. Negotiated Rate	$3,928.00
Max. Negotiated Rate	$111,546.57
Rate for Payer: EPIC Health Plan Medicare	$83,243.71
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	$83,243.71
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$95,730.27
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$111,546.57

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$169,937.29

Service Code	MSDRG 426
Min. Negotiated Rate	$3,928.00
Max. Negotiated Rate	$169,937.29
Rate for Payer: EPIC Health Plan Medicare	$126,818.87
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	$126,818.87
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$145,841.70
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$169,937.29

MULTIPLE LEVEL COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION EXCEPT CERVICAL WITHOUT CC/MCC

Facility

$87,030.04

Service Code	MSDRG 428
Min. Negotiated Rate	$3,928.00
Max. Negotiated Rate	$87,030.04
Rate for Payer: EPIC Health Plan Medicare	$64,947.79
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	$64,947.79
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$74,689.96
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$87,030.04

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITH MCC OR CUSTOM-MADE ANATOMICALLY DESIGNED INTERBODY FUSION DEVICE

Facility

$103,300.67

Service Code	MSDRG 447
Min. Negotiated Rate	$77,090.05
Max. Negotiated Rate	$103,300.67
Rate for Payer: EPIC Health Plan Medicare	$77,090.05
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$77,090.05
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$88,653.56
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$103,300.67

MULTIPLE LEVEL SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC

Facility

$65,821.05

Service Code	MSDRG 448
Min. Negotiated Rate	$49,120.19
Max. Negotiated Rate	$65,821.05
Rate for Payer: EPIC Health Plan Medicare	$49,120.19
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$49,120.19
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$56,488.22
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$65,821.05

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC

Facility

$19,756.18

Service Code	MSDRG 059
Min. Negotiated Rate	$14,743.42
Max. Negotiated Rate	$19,756.18
Rate for Payer: EPIC Health Plan Medicare	$14,743.42
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$14,743.42
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$16,954.93
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$19,756.18

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC

Facility

$26,951.76

Service Code	MSDRG 058
Min. Negotiated Rate	$20,113.25
Max. Negotiated Rate	$26,951.76
Rate for Payer: EPIC Health Plan Medicare	$20,113.25
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$20,113.25
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$23,130.24
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$26,951.76

MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC

Facility

$14,825.57

Service Code	MSDRG 060
Min. Negotiated Rate	$11,063.86
Max. Negotiated Rate	$14,825.57
Rate for Payer: EPIC Health Plan Medicare	$11,063.86
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$11,063.86
Rate for Payer: Kaiser Foundation Hospitals Medicare Advantage	$12,723.44
Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare	$14,825.57

MULTIVITAMIN-IRON 9 MG-FOLIC ACID 400 MCG-CALCIUM AND MINERALS TABLET [120459]

Facility

$0.06

Service Code	NDC 8770143233
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.05
Rate for Payer: Adventist Health Commercial	$0.01
Rate for Payer: Aetna of CA Non-Gatekeeper	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: EPIC Health Plan Commercial	$0.03
Rate for Payer: Heritage Provider Network Commercial	$0.04
Rate for Payer: Heritage Provider Network Senior	$0.04
Rate for Payer: Kaiser Foundation Hospitals Medi-Cal	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.05

Know your out-of-pocket cost for care.

All Charges