Loma Linda University Children's Hospital

All Charges

Charge

Type

Setting

Price

MS-DRG 42.00: OTHER MENTAL DISORDER DIAGNOSES

Facility

$41,747.87

Service Code	MSDRG 887
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$41,747.87
Rate for Payer: Aetna of CA HMO/PPO	$36,057.85
Rate for Payer: EPIC Health Plan Commercial	$41,747.87
Rate for Payer: EPIC Health Plan Senior	$30,924.35
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$30,924.35
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$30,924.35
Rate for Payer: Molina Healthcare of CA Medicare	$41,438.63
Rate for Payer: Multiplan WC	$22,219.72
Rate for Payer: Prime Health Services WC	$21,992.98
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

MS-DRG 42.00: OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC

Facility

$46,159.71

Service Code	MSDRG 964
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$46,159.71
Rate for Payer: Aetna of CA HMO/PPO	$45,477.03
Rate for Payer: EPIC Health Plan Commercial	$46,159.71
Rate for Payer: EPIC Health Plan Senior	$34,192.38
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$34,192.38
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$34,192.38
Rate for Payer: Molina Healthcare of CA Medicare	$45,817.79
Rate for Payer: Multiplan WC	$28,024.05
Rate for Payer: Prime Health Services WC	$27,738.09
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

MS-DRG 42.00: OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC

Facility

$82,359.48

Service Code	MSDRG 963
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$82,359.48
Rate for Payer: Aetna of CA HMO/PPO	$82,359.48
Rate for Payer: EPIC Health Plan Commercial	$63,435.10
Rate for Payer: EPIC Health Plan Senior	$46,988.96
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$46,988.96
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$46,988.96
Rate for Payer: Molina Healthcare of CA Medicare	$62,965.21
Rate for Payer: Multiplan WC	$50,751.91
Rate for Payer: Prime Health Services WC	$50,234.03
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

MS-DRG 42.00: OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC

Facility

$37,817.40

Service Code	MSDRG 965
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$37,817.40
Rate for Payer: Aetna of CA HMO/PPO	$27,666.38
Rate for Payer: EPIC Health Plan Commercial	$37,817.40
Rate for Payer: EPIC Health Plan Senior	$28,012.89
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$28,012.89
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$28,012.89
Rate for Payer: Molina Healthcare of CA Medicare	$37,537.27
Rate for Payer: Multiplan WC	$17,048.70
Rate for Payer: Prime Health Services WC	$16,874.73
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

MS-DRG 42.00: OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC

Facility

$39,338.18

Service Code	MSDRG 565
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$39,338.18
Rate for Payer: Aetna of CA HMO/PPO	$30,913.23
Rate for Payer: EPIC Health Plan Commercial	$39,338.18
Rate for Payer: EPIC Health Plan Senior	$29,139.39
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$29,139.39
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$29,139.39
Rate for Payer: Molina Healthcare of CA Medicare	$39,046.78
Rate for Payer: Multiplan WC	$19,049.48
Rate for Payer: Prime Health Services WC	$18,855.09
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

MS-DRG 42.00: OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC

Facility

$47,571.87

Service Code	MSDRG 564
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$47,571.87
Rate for Payer: Aetna of CA HMO/PPO	$47,571.87
Rate for Payer: EPIC Health Plan Commercial	$47,140.92
Rate for Payer: EPIC Health Plan Senior	$34,919.20
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$34,919.20
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$34,919.20
Rate for Payer: Molina Healthcare of CA Medicare	$46,791.73
Rate for Payer: Multiplan WC	$29,314.94
Rate for Payer: Prime Health Services WC	$29,015.80
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

MS-DRG 42.00: OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC

Facility

$35,481.54

Service Code	MSDRG 566
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$35,481.54
Rate for Payer: Aetna of CA HMO/PPO	$22,679.40
Rate for Payer: EPIC Health Plan Commercial	$35,481.54
Rate for Payer: EPIC Health Plan Senior	$26,282.62
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$26,282.62
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$26,282.62
Rate for Payer: Molina Healthcare of CA Medicare	$35,218.71
Rate for Payer: Multiplan WC	$13,975.59
Rate for Payer: Prime Health Services WC	$13,832.99
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

MS-DRG 42.00: OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC

Facility

$60,986.70

Service Code	MSDRG 516
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$60,986.70
Rate for Payer: Aetna of CA HMO/PPO	$60,986.70
Rate for Payer: EPIC Health Plan Commercial	$53,424.28
Rate for Payer: EPIC Health Plan Senior	$39,573.54
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$39,573.54
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$39,573.54
Rate for Payer: Molina Healthcare of CA Medicare	$53,028.54
Rate for Payer: Multiplan WC	$37,581.48
Rate for Payer: Prime Health Services WC	$37,198.00
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

MS-DRG 42.00: OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC

Facility

$93,749.20

Service Code	MSDRG 515
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$93,749.20
Rate for Payer: Aetna of CA HMO/PPO	$93,749.20
Rate for Payer: EPIC Health Plan Commercial	$68,769.93
Rate for Payer: EPIC Health Plan Senior	$50,940.69
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$50,940.69
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$50,940.69
Rate for Payer: Molina Healthcare of CA Medicare	$68,260.52
Rate for Payer: Multiplan WC	$57,770.53
Rate for Payer: Prime Health Services WC	$57,181.03
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

MS-DRG 42.00: OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC

Facility

$46,054.63

Service Code	MSDRG 517
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$46,054.63
Rate for Payer: Aetna of CA HMO/PPO	$45,252.69
Rate for Payer: EPIC Health Plan Commercial	$46,054.63
Rate for Payer: EPIC Health Plan Senior	$34,114.54
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$34,114.54
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$34,114.54
Rate for Payer: Molina Healthcare of CA Medicare	$45,713.48
Rate for Payer: Multiplan WC	$27,885.80
Rate for Payer: Prime Health Services WC	$27,601.25
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

MS-DRG 42.00: OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC

Facility

$41,830.22

Service Code	MSDRG 844
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$41,830.22
Rate for Payer: Aetna of CA HMO/PPO	$36,233.68
Rate for Payer: EPIC Health Plan Commercial	$41,830.22
Rate for Payer: EPIC Health Plan Senior	$30,985.35
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$30,985.35
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$30,985.35
Rate for Payer: Molina Healthcare of CA Medicare	$41,520.37
Rate for Payer: Multiplan WC	$22,328.08
Rate for Payer: Prime Health Services WC	$22,100.24
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

MS-DRG 42.00: OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC

Facility

$57,397.28

Service Code	MSDRG 843
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$57,397.28
Rate for Payer: Aetna of CA HMO/PPO	$57,397.28
Rate for Payer: EPIC Health Plan Commercial	$51,743.06
Rate for Payer: EPIC Health Plan Senior	$38,328.19
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$38,328.19
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$38,328.19
Rate for Payer: Molina Healthcare of CA Medicare	$51,359.77
Rate for Payer: Multiplan WC	$35,369.60
Rate for Payer: Prime Health Services WC	$35,008.69
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

MS-DRG 42.00: OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC

Facility

$36,741.06

Service Code	MSDRG 845
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$36,741.06
Rate for Payer: Aetna of CA HMO/PPO	$25,368.43
Rate for Payer: EPIC Health Plan Commercial	$36,741.06
Rate for Payer: EPIC Health Plan Senior	$27,215.60
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$27,215.60
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$27,215.60
Rate for Payer: Molina Healthcare of CA Medicare	$36,468.90
Rate for Payer: Multiplan WC	$15,632.64
Rate for Payer: Prime Health Services WC	$15,473.12
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

MS-DRG 42.00: OTHER O.R. PROCEDURES FOR INJURIES WITH CC

Facility

$61,150.40

Service Code	MSDRG 908
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$61,150.40
Rate for Payer: Aetna of CA HMO/PPO	$61,150.40
Rate for Payer: EPIC Health Plan Commercial	$53,500.97
Rate for Payer: EPIC Health Plan Senior	$39,630.35
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$39,630.35
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$39,630.35
Rate for Payer: Molina Healthcare of CA Medicare	$53,104.67
Rate for Payer: Multiplan WC	$37,682.36
Rate for Payer: Prime Health Services WC	$37,297.85
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

MS-DRG 42.00: OTHER O.R. PROCEDURES FOR INJURIES WITH MCC

Facility

$120,769.85

Service Code	MSDRG 907
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$120,769.85
Rate for Payer: Aetna of CA HMO/PPO	$120,769.85
Rate for Payer: EPIC Health Plan Commercial	$81,426.15
Rate for Payer: EPIC Health Plan Senior	$60,315.67
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$60,315.67
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$60,315.67
Rate for Payer: Molina Healthcare of CA Medicare	$80,823.00
Rate for Payer: Multiplan WC	$74,421.31
Rate for Payer: Prime Health Services WC	$73,661.91
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

MS-DRG 42.00: OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC

Facility

$42,868.22

Service Code	MSDRG 909
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$42,868.22
Rate for Payer: Aetna of CA HMO/PPO	$38,449.78
Rate for Payer: EPIC Health Plan Commercial	$42,868.22
Rate for Payer: EPIC Health Plan Senior	$31,754.24
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$31,754.24
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$31,754.24
Rate for Payer: Molina Healthcare of CA Medicare	$42,550.68
Rate for Payer: Multiplan WC	$23,693.69
Rate for Payer: Prime Health Services WC	$23,451.91
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

MS-DRG 42.00: OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC

Facility

$124,592.70

Service Code	MSDRG 958
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$124,592.70
Rate for Payer: Aetna of CA HMO/PPO	$124,592.70
Rate for Payer: EPIC Health Plan Commercial	$83,216.71
Rate for Payer: EPIC Health Plan Senior	$61,642.01
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$61,642.01
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$61,642.01
Rate for Payer: Molina Healthcare of CA Medicare	$82,600.29
Rate for Payer: Multiplan WC	$76,777.04
Rate for Payer: Prime Health Services WC	$75,993.60
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

MS-DRG 42.00: OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC

Facility

$226,284.69

Service Code	MSDRG 957
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$226,284.69
Rate for Payer: Aetna of CA HMO/PPO	$226,284.69
Rate for Payer: EPIC Health Plan Commercial	$130,848.26
Rate for Payer: EPIC Health Plan Senior	$96,924.64
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$96,924.64
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$96,924.64
Rate for Payer: Molina Healthcare of CA Medicare	$129,879.02
Rate for Payer: Multiplan WC	$139,442.11
Rate for Payer: Prime Health Services WC	$138,019.23
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

MS-DRG 42.00: OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC

Facility

$80,152.47

Service Code	MSDRG 959
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$80,152.47
Rate for Payer: Aetna of CA HMO/PPO	$80,152.47
Rate for Payer: EPIC Health Plan Commercial	$62,401.35
Rate for Payer: EPIC Health Plan Senior	$46,223.22
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$46,223.22
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$46,223.22
Rate for Payer: Molina Healthcare of CA Medicare	$61,939.11
Rate for Payer: Multiplan WC	$49,391.89
Rate for Payer: Prime Health Services WC	$48,887.89
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

MS-DRG 42.00: OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC

Facility

$53,962.48

Service Code	MSDRG 803
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$53,962.48
Rate for Payer: Aetna of CA HMO/PPO	$53,962.48
Rate for Payer: EPIC Health Plan Commercial	$50,134.23
Rate for Payer: EPIC Health Plan Senior	$37,136.47
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$37,136.47
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$37,136.47
Rate for Payer: Molina Healthcare of CA Medicare	$49,762.87
Rate for Payer: Multiplan WC	$33,252.99
Rate for Payer: Prime Health Services WC	$32,913.67
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

MS-DRG 42.00: OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC

Facility

$108,676.80

Service Code	MSDRG 802
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$108,676.80
Rate for Payer: Aetna of CA HMO/PPO	$108,676.80
Rate for Payer: EPIC Health Plan Commercial	$75,761.87
Rate for Payer: EPIC Health Plan Senior	$56,119.90
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$56,119.90
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$56,119.90
Rate for Payer: Molina Healthcare of CA Medicare	$75,200.67
Rate for Payer: Multiplan WC	$66,969.28
Rate for Payer: Prime Health Services WC	$66,285.92
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

MS-DRG 42.00: OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC

Facility

$40,557.94

Service Code	MSDRG 804
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$40,557.94
Rate for Payer: Aetna of CA HMO/PPO	$33,517.37
Rate for Payer: EPIC Health Plan Commercial	$40,557.94
Rate for Payer: EPIC Health Plan Senior	$30,042.92
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$30,042.92
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$30,042.92
Rate for Payer: Molina Healthcare of CA Medicare	$40,257.51
Rate for Payer: Multiplan WC	$20,654.22
Rate for Payer: Prime Health Services WC	$20,443.46
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

MS-DRG 42.00: OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC

Facility

$57,230.54

Service Code	MSDRG 205
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$57,230.54
Rate for Payer: Aetna of CA HMO/PPO	$57,230.54
Rate for Payer: EPIC Health Plan Commercial	$51,664.95
Rate for Payer: EPIC Health Plan Senior	$38,270.33
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$38,270.33
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$38,270.33
Rate for Payer: Molina Healthcare of CA Medicare	$51,282.24
Rate for Payer: Multiplan WC	$35,266.85
Rate for Payer: Prime Health Services WC	$34,906.98
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

MS-DRG 42.00: OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC

Facility

$37,720.82

Service Code	MSDRG 206
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$37,720.82
Rate for Payer: Aetna of CA HMO/PPO	$27,460.23
Rate for Payer: EPIC Health Plan Commercial	$37,720.82
Rate for Payer: EPIC Health Plan Senior	$27,941.35
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$27,941.35
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$27,941.35
Rate for Payer: Molina Healthcare of CA Medicare	$37,441.41
Rate for Payer: Multiplan WC	$16,921.66
Rate for Payer: Prime Health Services WC	$16,748.99
Rate for Payer: United Healthcare All Other Commercial	$10,506.00
Rate for Payer: United Healthcare All Other HMO	$8,385.00
Rate for Payer: United Healthcare HMO Rider	$7,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,823.00

MS-DRG 42.00: OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC

Facility

$55,393.40

Service Code	MSDRG 167
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$55,393.40
Rate for Payer: Aetna of CA HMO/PPO	$55,393.40
Rate for Payer: EPIC Health Plan Commercial	$50,804.44
Rate for Payer: EPIC Health Plan Senior	$37,632.92
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$37,632.92
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$37,632.92
Rate for Payer: Molina Healthcare of CA Medicare	$50,428.11
Rate for Payer: Multiplan WC	$34,134.75
Rate for Payer: Prime Health Services WC	$33,786.44
Rate for Payer: United Healthcare All Other Commercial	$12,844.00
Rate for Payer: United Healthcare All Other HMO	$10,823.00
Rate for Payer: United Healthcare HMO Rider	$8,307.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,611.00

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