Loma Linda University Children's Hospital

All Charges

Charge

Type

Setting

Price

MS-DRG 42.00: TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC

Facility

$37,411.27

Service Code	MSDRG 087
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$37,411.27
Rate for Payer: Aetna of CA HMO/PPO	$26,799.34
Rate for Payer: EPIC Health Plan Commercial	$37,411.27
Rate for Payer: EPIC Health Plan Senior	$27,712.05
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$27,712.05
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$27,712.05
Rate for Payer: Molina Healthcare of CA Medicare	$37,134.15
Rate for Payer: Multiplan WC	$16,514.40
Rate for Payer: Prime Health Services WC	$16,345.89
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: TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC

Facility

$38,435.07

Service Code	MSDRG 084
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$38,435.07
Rate for Payer: Aetna of CA HMO/PPO	$28,985.13
Rate for Payer: EPIC Health Plan Commercial	$38,435.07
Rate for Payer: EPIC Health Plan Senior	$28,470.42
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$28,470.42
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$28,470.42
Rate for Payer: Molina Healthcare of CA Medicare	$38,150.36
Rate for Payer: Multiplan WC	$17,861.34
Rate for Payer: Prime Health Services WC	$17,679.08
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: TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC

Facility

$45,955.24

Service Code	MSDRG 604
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$45,955.24
Rate for Payer: Aetna of CA HMO/PPO	$45,040.48
Rate for Payer: EPIC Health Plan Commercial	$45,955.24
Rate for Payer: EPIC Health Plan Senior	$34,040.92
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$34,040.92
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$34,040.92
Rate for Payer: Molina Healthcare of CA Medicare	$45,614.83
Rate for Payer: Multiplan WC	$27,755.04
Rate for Payer: Prime Health Services WC	$27,471.83
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: TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC

Facility

$37,975.01

Service Code	MSDRG 605
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$37,975.01
Rate for Payer: Aetna of CA HMO/PPO	$28,002.89
Rate for Payer: EPIC Health Plan Commercial	$37,975.01
Rate for Payer: EPIC Health Plan Senior	$28,129.64
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$28,129.64
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$28,129.64
Rate for Payer: Molina Healthcare of CA Medicare	$37,693.72
Rate for Payer: Multiplan WC	$17,256.06
Rate for Payer: Prime Health Services WC	$17,079.97
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: ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITH MCC

Facility

$151,680.04

Service Code	MSDRG 278
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$151,680.04
Rate for Payer: Aetna of CA HMO/PPO	$151,680.04
Rate for Payer: EPIC Health Plan Commercial	$95,904.16
Rate for Payer: EPIC Health Plan Senior	$71,040.12
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$71,040.12
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$71,040.12
Rate for Payer: Molina Healthcare of CA Medicare	$95,193.76
Rate for Payer: Multiplan WC	$93,468.92
Rate for Payer: Prime Health Services WC	$92,515.16
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: ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS OF PERIPHERAL VASCULAR STRUCTURES WITHOUT MCC

Facility

$97,144.59

Service Code	MSDRG 279
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$97,144.59
Rate for Payer: Aetna of CA HMO/PPO	$97,144.59
Rate for Payer: EPIC Health Plan Commercial	$70,360.29
Rate for Payer: EPIC Health Plan Senior	$52,118.73
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$52,118.73
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$52,118.73
Rate for Payer: Molina Healthcare of CA Medicare	$69,839.10
Rate for Payer: Multiplan WC	$59,862.85
Rate for Payer: Prime Health Services WC	$59,252.00
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: ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM

Facility

$93,027.68

Service Code	MSDRG 173
Min. Negotiated Rate	$50,690.36
Max. Negotiated Rate	$93,027.68
Rate for Payer: Aetna of CA HMO/PPO	$93,027.68
Rate for Payer: EPIC Health Plan Commercial	$68,431.99
Rate for Payer: EPIC Health Plan Senior	$50,690.36
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$50,690.36
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$50,690.36
Rate for Payer: Molina Healthcare of CA Medicare	$67,925.08
Rate for Payer: Multiplan WC	$57,325.91
Rate for Payer: Prime Health Services WC	$56,740.96

MS-DRG 42.00: UNCOMPLICATED PEPTIC ULCER WITH MCC

Facility

$42,810.00

Service Code	MSDRG 383
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$42,810.00
Rate for Payer: Aetna of CA HMO/PPO	$38,325.49
Rate for Payer: EPIC Health Plan Commercial	$42,810.00
Rate for Payer: EPIC Health Plan Senior	$31,711.11
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$31,711.11
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$31,711.11
Rate for Payer: Molina Healthcare of CA Medicare	$42,492.89
Rate for Payer: Multiplan WC	$23,617.10
Rate for Payer: Prime Health Services WC	$23,376.11
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: UNCOMPLICATED PEPTIC ULCER WITHOUT MCC

Facility

$37,206.80

Service Code	MSDRG 384
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$37,206.80
Rate for Payer: Aetna of CA HMO/PPO	$26,362.79
Rate for Payer: EPIC Health Plan Commercial	$37,206.80
Rate for Payer: EPIC Health Plan Senior	$27,560.59
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$27,560.59
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$27,560.59
Rate for Payer: Molina Healthcare of CA Medicare	$36,931.19
Rate for Payer: Multiplan WC	$16,245.39
Rate for Payer: Prime Health Services WC	$16,079.62
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: UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC

Facility

$51,346.21

Service Code	MSDRG 256
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$51,346.21
Rate for Payer: Aetna of CA HMO/PPO	$51,346.21
Rate for Payer: EPIC Health Plan Commercial	$48,908.79
Rate for Payer: EPIC Health Plan Senior	$36,228.73
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$36,228.73
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$36,228.73
Rate for Payer: Molina Healthcare of CA Medicare	$48,546.50
Rate for Payer: Multiplan WC	$31,640.78
Rate for Payer: Prime Health Services WC	$31,317.91
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: UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC

Facility

$79,321.81

Service Code	MSDRG 255
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$79,321.81
Rate for Payer: Aetna of CA HMO/PPO	$79,321.81
Rate for Payer: EPIC Health Plan Commercial	$62,012.29
Rate for Payer: EPIC Health Plan Senior	$45,935.03
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$45,935.03
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$45,935.03
Rate for Payer: Molina Healthcare of CA Medicare	$61,552.94
Rate for Payer: Multiplan WC	$48,880.03
Rate for Payer: Prime Health Services WC	$48,381.25
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: UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC

Facility

$37,523.45

Service Code	MSDRG 257
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$37,523.45
Rate for Payer: Aetna of CA HMO/PPO	$27,038.84
Rate for Payer: EPIC Health Plan Commercial	$37,523.45
Rate for Payer: EPIC Health Plan Senior	$27,795.15
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$27,795.15
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$27,795.15
Rate for Payer: Molina Healthcare of CA Medicare	$37,245.50
Rate for Payer: Multiplan WC	$16,661.99
Rate for Payer: Prime Health Services WC	$16,491.97
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: URETHRAL PROCEDURES WITH CC/MCC

Facility

$52,255.69

Service Code	MSDRG 671
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$52,255.69
Rate for Payer: Aetna of CA HMO/PPO	$52,255.69
Rate for Payer: EPIC Health Plan Commercial	$49,334.78
Rate for Payer: EPIC Health Plan Senior	$36,544.28
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$36,544.28
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$36,544.28
Rate for Payer: Molina Healthcare of CA Medicare	$48,969.34
Rate for Payer: Multiplan WC	$32,201.22
Rate for Payer: Prime Health Services WC	$31,872.64
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: URETHRAL PROCEDURES WITHOUT CC/MCC

Facility

$40,398.90

Service Code	MSDRG 672
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$40,398.90
Rate for Payer: Aetna of CA HMO/PPO	$33,177.83
Rate for Payer: EPIC Health Plan Commercial	$40,398.90
Rate for Payer: EPIC Health Plan Senior	$29,925.11
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$29,925.11
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$29,925.11
Rate for Payer: Molina Healthcare of CA Medicare	$40,099.65
Rate for Payer: Multiplan WC	$20,444.99
Rate for Payer: Prime Health Services WC	$20,236.36
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: URETHRAL STRICTURE

Facility

$39,084.00

Service Code	MSDRG 697
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$39,084.00
Rate for Payer: Aetna of CA HMO/PPO	$30,370.57
Rate for Payer: EPIC Health Plan Commercial	$39,084.00
Rate for Payer: EPIC Health Plan Senior	$28,951.11
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$28,951.11
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$28,951.11
Rate for Payer: Molina Healthcare of CA Medicare	$38,794.49
Rate for Payer: Multiplan WC	$18,715.08
Rate for Payer: Prime Health Services WC	$18,524.11
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: URINARY STONES WITH MCC

Facility

$45,737.99

Service Code	MSDRG 693
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$45,737.99
Rate for Payer: Aetna of CA HMO/PPO	$44,576.65
Rate for Payer: EPIC Health Plan Commercial	$45,737.99
Rate for Payer: EPIC Health Plan Senior	$33,879.99
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$33,879.99
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$33,879.99
Rate for Payer: Molina Healthcare of CA Medicare	$45,399.19
Rate for Payer: Multiplan WC	$27,469.21
Rate for Payer: Prime Health Services WC	$27,188.92
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: URINARY STONES WITHOUT MCC

Facility

$35,954.37

Service Code	MSDRG 694
Min. Negotiated Rate	$6,823.00
Max. Negotiated Rate	$35,954.37
Rate for Payer: Aetna of CA HMO/PPO	$23,688.92
Rate for Payer: EPIC Health Plan Commercial	$35,954.37
Rate for Payer: EPIC Health Plan Senior	$26,632.87
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$26,632.87
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$26,632.87
Rate for Payer: Molina Healthcare of CA Medicare	$35,688.05
Rate for Payer: Multiplan WC	$14,597.69
Rate for Payer: Prime Health Services WC	$14,448.73
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: UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC

Facility

$55,378.24

Service Code	MSDRG 742
Min. Negotiated Rate	$22,398.00
Max. Negotiated Rate	$55,378.24
Rate for Payer: Aetna of CA HMO/PPO	$55,378.24
Rate for Payer: EPIC Health Plan Commercial	$50,797.34
Rate for Payer: EPIC Health Plan Senior	$37,627.66
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$37,627.66
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$37,627.66
Rate for Payer: Molina Healthcare of CA Medicare	$50,421.06
Rate for Payer: Multiplan WC	$34,125.41
Rate for Payer: Prime Health Services WC	$33,777.19
Rate for Payer: United Healthcare All Other Commercial	$24,996.00
Rate for Payer: United Healthcare All Other HMO	$24,494.00
Rate for Payer: United Healthcare HMO Rider	$24,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$22,398.00

MS-DRG 42.00: UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC

Facility

$41,879.92

Service Code	MSDRG 743
Min. Negotiated Rate	$22,164.96
Max. Negotiated Rate	$41,879.92
Rate for Payer: Aetna of CA HMO/PPO	$36,339.79
Rate for Payer: EPIC Health Plan Commercial	$41,879.92
Rate for Payer: EPIC Health Plan Senior	$31,022.16
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$31,022.16
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$31,022.16
Rate for Payer: Molina Healthcare of CA Medicare	$41,569.69
Rate for Payer: Multiplan WC	$22,393.46
Rate for Payer: Prime Health Services WC	$22,164.96
Rate for Payer: United Healthcare All Other Commercial	$24,996.00
Rate for Payer: United Healthcare All Other HMO	$24,494.00
Rate for Payer: United Healthcare HMO Rider	$24,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$22,398.00

MS-DRG 42.00: UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC

Facility

$55,123.58

Service Code	MSDRG 740
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$55,123.58
Rate for Payer: Aetna of CA HMO/PPO	$55,123.58
Rate for Payer: EPIC Health Plan Commercial	$50,678.07
Rate for Payer: EPIC Health Plan Senior	$37,539.31
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$37,539.31
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$37,539.31
Rate for Payer: Molina Healthcare of CA Medicare	$50,302.68
Rate for Payer: Multiplan WC	$33,968.49
Rate for Payer: Prime Health Services WC	$33,621.87
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: UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC

Facility

$120,684.96

Service Code	MSDRG 739
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$120,684.96
Rate for Payer: Aetna of CA HMO/PPO	$120,684.96
Rate for Payer: EPIC Health Plan Commercial	$81,386.40
Rate for Payer: EPIC Health Plan Senior	$60,286.22
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$60,286.22
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$60,286.22
Rate for Payer: Molina Healthcare of CA Medicare	$80,783.53
Rate for Payer: Multiplan WC	$74,369.00
Rate for Payer: Prime Health Services WC	$73,610.13
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: UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC

Facility

$44,363.44

Service Code	MSDRG 741
Min. Negotiated Rate	$22,398.00
Max. Negotiated Rate	$44,363.44
Rate for Payer: Aetna of CA HMO/PPO	$41,642.06
Rate for Payer: EPIC Health Plan Commercial	$44,363.44
Rate for Payer: EPIC Health Plan Senior	$32,861.81
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$32,861.81
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$32,861.81
Rate for Payer: Molina Healthcare of CA Medicare	$44,034.83
Rate for Payer: Multiplan WC	$25,660.85
Rate for Payer: Prime Health Services WC	$25,399.00
Rate for Payer: United Healthcare All Other Commercial	$24,996.00
Rate for Payer: United Healthcare All Other HMO	$24,494.00
Rate for Payer: United Healthcare HMO Rider	$24,448.00
Rate for Payer: United Healthcare Select/Navigate/Core	$22,398.00

MS-DRG 42.00: UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC

Facility

$60,583.49

Service Code	MSDRG 737
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$60,583.49
Rate for Payer: Aetna of CA HMO/PPO	$60,583.49
Rate for Payer: EPIC Health Plan Commercial	$53,235.43
Rate for Payer: EPIC Health Plan Senior	$39,433.65
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$39,433.65
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$39,433.65
Rate for Payer: Molina Healthcare of CA Medicare	$52,841.09
Rate for Payer: Multiplan WC	$37,333.02
Rate for Payer: Prime Health Services WC	$36,952.07
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: UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC

Facility

$119,372.28

Service Code	MSDRG 736
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$119,372.28
Rate for Payer: Aetna of CA HMO/PPO	$119,372.28
Rate for Payer: EPIC Health Plan Commercial	$80,771.53
Rate for Payer: EPIC Health Plan Senior	$59,830.76
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$59,830.76
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$59,830.76
Rate for Payer: Molina Healthcare of CA Medicare	$80,173.22
Rate for Payer: Multiplan WC	$73,560.09
Rate for Payer: Prime Health Services WC	$72,809.48
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: UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC

Facility

$46,398.27

Service Code	MSDRG 738
Min. Negotiated Rate	$7,611.00
Max. Negotiated Rate	$46,398.27
Rate for Payer: Aetna of CA HMO/PPO	$45,986.34
Rate for Payer: EPIC Health Plan Commercial	$46,398.27
Rate for Payer: EPIC Health Plan Senior	$34,369.09
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$34,369.09
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$34,369.09
Rate for Payer: Molina Healthcare of CA Medicare	$46,054.58
Rate for Payer: Multiplan WC	$28,337.90
Rate for Payer: Prime Health Services WC	$28,048.73
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

Know your out-of-pocket cost for care.

All Charges