Loma Linda University Children's Hospital

All Charges

Charge

Type

Setting

Price

INPATIENT MS-DRG 146: EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC

Facility

$63,997.08

Service Code	MSDRG 146
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$63,997.08
Rate for Payer: Aetna of CA HMO/PPO	$63,997.08
Rate for Payer: EPIC Health Plan Commercial	$50,378.17
Rate for Payer: EPIC Health Plan Medicare/Senior	$37,317.16
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$37,317.16
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$37,317.16
Rate for Payer: Molina Healthcare of CA Medi-Cal	$47,019.62
Rate for Payer: Molina Healthcare of CA Medicare	$50,004.99
Rate for Payer: Multiplan WC	$41,364.58
Rate for Payer: Prime Health Services WC	$40,942.49
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 147: EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC

Facility

$37,464.51

Service Code	MSDRG 147
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$37,464.51
Rate for Payer: Aetna of CA HMO/PPO	$37,464.51
Rate for Payer: EPIC Health Plan Commercial	$37,277.43
Rate for Payer: EPIC Health Plan Medicare/Senior	$27,612.91
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$27,612.91
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$27,612.91
Rate for Payer: Molina Healthcare of CA Medi-Cal	$34,792.27
Rate for Payer: Molina Healthcare of CA Medicare	$37,001.30
Rate for Payer: Multiplan WC	$24,871.72
Rate for Payer: Prime Health Services WC	$24,617.93
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 148: EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC

Facility

$32,096.74

Service Code	MSDRG 148
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$32,096.74
Rate for Payer: Aetna of CA HMO/PPO	$26,972.15
Rate for Payer: EPIC Health Plan Commercial	$32,096.74
Rate for Payer: EPIC Health Plan Medicare/Senior	$23,775.36
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$23,775.36
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$23,775.36
Rate for Payer: Molina Healthcare of CA Medi-Cal	$29,956.95
Rate for Payer: Molina Healthcare of CA Medicare	$31,858.98
Rate for Payer: Multiplan WC	$16,790.62
Rate for Payer: Prime Health Services WC	$16,619.29
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 149: DYSEQUILIBRIUM

Facility

$29,926.25

Service Code	MSDRG 149
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$29,926.25
Rate for Payer: Aetna of CA HMO/PPO	$22,576.33
Rate for Payer: EPIC Health Plan Commercial	$29,926.25
Rate for Payer: EPIC Health Plan Medicare/Senior	$22,167.59
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$22,167.59
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$22,167.59
Rate for Payer: Molina Healthcare of CA Medi-Cal	$27,931.16
Rate for Payer: Molina Healthcare of CA Medicare	$29,704.57
Rate for Payer: Multiplan WC	$15,505.04
Rate for Payer: Prime Health Services WC	$15,346.83
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 150: EPISTAXIS WITH MCC

Facility

$39,850.38

Service Code	MSDRG 150
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$39,850.38
Rate for Payer: Aetna of CA HMO/PPO	$39,850.38
Rate for Payer: EPIC Health Plan Commercial	$38,455.49
Rate for Payer: EPIC Health Plan Medicare/Senior	$28,485.55
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$28,485.55
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$28,485.55
Rate for Payer: Molina Healthcare of CA Medi-Cal	$35,891.79
Rate for Payer: Molina Healthcare of CA Medicare	$38,170.64
Rate for Payer: Multiplan WC	$28,325.96
Rate for Payer: Prime Health Services WC	$28,036.92
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 151: EPISTAXIS WITHOUT MCC

Facility

$30,315.44

Service Code	MSDRG 151
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$30,315.44
Rate for Payer: Aetna of CA HMO/PPO	$23,364.54
Rate for Payer: EPIC Health Plan Commercial	$30,315.44
Rate for Payer: EPIC Health Plan Medicare/Senior	$22,455.88
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$22,455.88
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$22,455.88
Rate for Payer: Molina Healthcare of CA Medi-Cal	$28,294.41
Rate for Payer: Molina Healthcare of CA Medicare	$30,090.88
Rate for Payer: Multiplan WC	$15,833.62
Rate for Payer: Prime Health Services WC	$15,672.06
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 152: OTITIS MEDIA AND URI WITH MCC

Facility

$36,564.93

Service Code	MSDRG 152
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$36,564.93
Rate for Payer: Aetna of CA HMO/PPO	$36,021.47
Rate for Payer: EPIC Health Plan Commercial	$36,564.93
Rate for Payer: EPIC Health Plan Medicare/Senior	$27,085.13
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$27,085.13
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$27,085.13
Rate for Payer: Molina Healthcare of CA Medi-Cal	$34,127.26
Rate for Payer: Molina Healthcare of CA Medicare	$36,294.07
Rate for Payer: Multiplan WC	$24,596.54
Rate for Payer: Prime Health Services WC	$24,345.55
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 153: OTITIS MEDIA AND URI WITHOUT MCC

Facility

$29,778.06

Service Code	MSDRG 153
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$29,778.06
Rate for Payer: Aetna of CA HMO/PPO	$22,276.20
Rate for Payer: EPIC Health Plan Commercial	$29,778.06
Rate for Payer: EPIC Health Plan Medicare/Senior	$22,057.82
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$22,057.82
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$22,057.82
Rate for Payer: Molina Healthcare of CA Medi-Cal	$27,792.85
Rate for Payer: Molina Healthcare of CA Medicare	$29,557.48
Rate for Payer: Multiplan WC	$14,180.43
Rate for Payer: Prime Health Services WC	$14,035.74
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 154: OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH MCC

Facility

$46,632.07

Service Code	MSDRG 154
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$46,632.07
Rate for Payer: Aetna of CA HMO/PPO	$46,632.07
Rate for Payer: EPIC Health Plan Commercial	$41,804.01
Rate for Payer: EPIC Health Plan Medicare/Senior	$30,965.93
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$30,965.93
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$30,965.93
Rate for Payer: Molina Healthcare of CA Medi-Cal	$39,017.07
Rate for Payer: Molina Healthcare of CA Medicare	$41,494.35
Rate for Payer: Multiplan WC	$30,864.27
Rate for Payer: Prime Health Services WC	$30,549.33
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 155: OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITH CC

Facility

$32,948.45

Service Code	MSDRG 155
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$32,948.45
Rate for Payer: Aetna of CA HMO/PPO	$28,697.13
Rate for Payer: EPIC Health Plan Commercial	$32,948.45
Rate for Payer: EPIC Health Plan Medicare/Senior	$24,406.26
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$24,406.26
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$24,406.26
Rate for Payer: Molina Healthcare of CA Medi-Cal	$30,751.89
Rate for Payer: Molina Healthcare of CA Medicare	$32,704.39
Rate for Payer: Multiplan WC	$18,879.18
Rate for Payer: Prime Health Services WC	$18,686.54
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 156: OTHER EAR, NOSE, MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC

Facility

$28,591.04

Service Code	MSDRG 156
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$28,591.04
Rate for Payer: Aetna of CA HMO/PPO	$19,872.14
Rate for Payer: EPIC Health Plan Commercial	$28,591.04
Rate for Payer: EPIC Health Plan Medicare/Senior	$21,178.55
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$21,178.55
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$21,178.55
Rate for Payer: Molina Healthcare of CA Medi-Cal	$26,684.97
Rate for Payer: Molina Healthcare of CA Medicare	$28,379.26
Rate for Payer: Multiplan WC	$13,999.71
Rate for Payer: Prime Health Services WC	$13,856.86
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 157: DENTAL AND ORAL DISEASES WITH MCC

Facility

$51,749.41

Service Code	MSDRG 157
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$51,749.41
Rate for Payer: Aetna of CA HMO/PPO	$51,749.41
Rate for Payer: EPIC Health Plan Commercial	$44,330.76
Rate for Payer: EPIC Health Plan Medicare/Senior	$32,837.60
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$32,837.60
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$32,837.60
Rate for Payer: Molina Healthcare of CA Medi-Cal	$41,375.38
Rate for Payer: Molina Healthcare of CA Medicare	$44,002.38
Rate for Payer: Multiplan WC	$34,332.88
Rate for Payer: Prime Health Services WC	$33,982.54
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 158: DENTAL AND ORAL DISEASES WITH CC

Facility

$32,827.22

Service Code	MSDRG 158
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$32,827.22
Rate for Payer: Aetna of CA HMO/PPO	$28,451.57
Rate for Payer: EPIC Health Plan Commercial	$32,827.22
Rate for Payer: EPIC Health Plan Medicare/Senior	$24,316.46
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$24,316.46
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$24,316.46
Rate for Payer: Molina Healthcare of CA Medi-Cal	$30,638.74
Rate for Payer: Molina Healthcare of CA Medicare	$32,584.06
Rate for Payer: Multiplan WC	$19,080.44
Rate for Payer: Prime Health Services WC	$18,885.74
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 159: DENTAL AND ORAL DISEASES WITHOUT CC/MCC

Facility

$28,885.90

Service Code	MSDRG 159
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$28,885.90
Rate for Payer: Aetna of CA HMO/PPO	$20,469.36
Rate for Payer: EPIC Health Plan Commercial	$28,885.90
Rate for Payer: EPIC Health Plan Medicare/Senior	$21,396.96
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$21,396.96
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$21,396.96
Rate for Payer: Molina Healthcare of CA Medi-Cal	$26,960.17
Rate for Payer: Molina Healthcare of CA Medicare	$28,671.93
Rate for Payer: Multiplan WC	$15,400.31
Rate for Payer: Prime Health Services WC	$15,243.16
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 163: MAJOR CHEST PROCEDURES WITH MCC

Facility

$142,897.50

Service Code	MSDRG 163
Min. Negotiated Rate	$7,235.00
Max. Negotiated Rate	$142,897.50
Rate for Payer: Aetna of CA HMO/PPO	$142,897.50
Rate for Payer: EPIC Health Plan Commercial	$89,336.05
Rate for Payer: EPIC Health Plan Medicare/Senior	$66,174.85
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$66,174.85
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$66,174.85
Rate for Payer: Molina Healthcare of CA Medi-Cal	$83,380.31
Rate for Payer: Molina Healthcare of CA Medicare	$88,674.30
Rate for Payer: Multiplan WC	$99,472.53
Rate for Payer: Prime Health Services WC	$98,457.50
Rate for Payer: United Healthcare All Other Commercial	$12,192.00
Rate for Payer: United Healthcare All Other HMO	$10,308.00
Rate for Payer: United Healthcare HMO Rider	$7,911.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,235.00

INPATIENT MS-DRG 164: MAJOR CHEST PROCEDURES WITH CC

Facility

$77,317.93

Service Code	MSDRG 164
Min. Negotiated Rate	$7,235.00
Max. Negotiated Rate	$77,317.93
Rate for Payer: Aetna of CA HMO/PPO	$77,317.93
Rate for Payer: EPIC Health Plan Commercial	$56,955.47
Rate for Payer: EPIC Health Plan Medicare/Senior	$42,189.24
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$42,189.24
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$42,189.24
Rate for Payer: Molina Healthcare of CA Medi-Cal	$53,158.44
Rate for Payer: Molina Healthcare of CA Medicare	$56,533.58
Rate for Payer: Multiplan WC	$53,039.56
Rate for Payer: Prime Health Services WC	$52,498.34
Rate for Payer: United Healthcare All Other Commercial	$12,192.00
Rate for Payer: United Healthcare All Other HMO	$10,308.00
Rate for Payer: United Healthcare HMO Rider	$7,911.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,235.00

INPATIENT MS-DRG 165: MAJOR CHEST PROCEDURES WITHOUT CC/MCC

Facility

$56,884.94

Service Code	MSDRG 165
Min. Negotiated Rate	$7,235.00
Max. Negotiated Rate	$56,884.94
Rate for Payer: Aetna of CA HMO/PPO	$56,884.94
Rate for Payer: EPIC Health Plan Commercial	$46,866.48
Rate for Payer: EPIC Health Plan Medicare/Senior	$34,715.91
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$34,715.91
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$34,715.91
Rate for Payer: Molina Healthcare of CA Medi-Cal	$43,742.05
Rate for Payer: Molina Healthcare of CA Medicare	$46,519.32
Rate for Payer: Multiplan WC	$39,571.73
Rate for Payer: Prime Health Services WC	$39,167.94
Rate for Payer: United Healthcare All Other Commercial	$12,192.00
Rate for Payer: United Healthcare All Other HMO	$10,308.00
Rate for Payer: United Healthcare HMO Rider	$7,911.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,235.00

INPATIENT MS-DRG 166: OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC

Facility

$123,016.26

Service Code	MSDRG 166
Min. Negotiated Rate	$7,235.00
Max. Negotiated Rate	$123,016.26
Rate for Payer: Aetna of CA HMO/PPO	$123,016.26
Rate for Payer: EPIC Health Plan Commercial	$79,519.51
Rate for Payer: EPIC Health Plan Medicare/Senior	$58,903.34
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$58,903.34
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$58,903.34
Rate for Payer: Molina Healthcare of CA Medi-Cal	$74,218.21
Rate for Payer: Molina Healthcare of CA Medicare	$78,930.48
Rate for Payer: Multiplan WC	$75,282.61
Rate for Payer: Prime Health Services WC	$74,514.42
Rate for Payer: United Healthcare All Other Commercial	$12,192.00
Rate for Payer: United Healthcare All Other HMO	$10,308.00
Rate for Payer: United Healthcare HMO Rider	$7,911.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,235.00

INPATIENT MS-DRG 167: OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC

Facility

$55,169.06

Service Code	MSDRG 167
Min. Negotiated Rate	$7,235.00
Max. Negotiated Rate	$55,169.06
Rate for Payer: Aetna of CA HMO/PPO	$55,169.06
Rate for Payer: EPIC Health Plan Commercial	$46,019.25
Rate for Payer: EPIC Health Plan Medicare/Senior	$34,088.33
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$34,088.33
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$34,088.33
Rate for Payer: Molina Healthcare of CA Medi-Cal	$42,951.30
Rate for Payer: Molina Healthcare of CA Medicare	$45,678.36
Rate for Payer: Multiplan WC	$39,041.90
Rate for Payer: Prime Health Services WC	$38,643.51
Rate for Payer: United Healthcare All Other Commercial	$12,192.00
Rate for Payer: United Healthcare All Other HMO	$10,308.00
Rate for Payer: United Healthcare HMO Rider	$7,911.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,235.00

INPATIENT MS-DRG 168: OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC

Facility

$41,099.40

Service Code	MSDRG 168
Min. Negotiated Rate	$7,235.00
Max. Negotiated Rate	$41,099.40
Rate for Payer: Aetna of CA HMO/PPO	$41,099.40
Rate for Payer: EPIC Health Plan Commercial	$39,072.21
Rate for Payer: EPIC Health Plan Medicare/Senior	$28,942.38
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$28,942.38
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$28,942.38
Rate for Payer: Molina Healthcare of CA Medi-Cal	$36,467.40
Rate for Payer: Molina Healthcare of CA Medicare	$38,782.79
Rate for Payer: Multiplan WC	$29,112.51
Rate for Payer: Prime Health Services WC	$28,815.44
Rate for Payer: United Healthcare All Other Commercial	$12,192.00
Rate for Payer: United Healthcare All Other HMO	$10,308.00
Rate for Payer: United Healthcare HMO Rider	$7,911.00
Rate for Payer: United Healthcare Select/Navigate/Core	$7,235.00

INPATIENT MS-DRG 173: ULTRASOUND ACCELERATED AND OTHER THROMBOLYSIS WITH PRINCIPAL DIAGNOSIS PULMONARY EMBOLISM

Facility

$93,221.70

Service Code	MSDRG 173
Min. Negotiated Rate	$48,006.03
Max. Negotiated Rate	$93,221.70
Rate for Payer: Aetna of CA HMO/PPO	$93,221.70
Rate for Payer: EPIC Health Plan Commercial	$64,808.14
Rate for Payer: EPIC Health Plan Medicare/Senior	$48,006.03
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$48,006.03
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$48,006.03
Rate for Payer: Molina Healthcare of CA Medi-Cal	$60,487.60
Rate for Payer: Molina Healthcare of CA Medicare	$64,328.08

INPATIENT MS-DRG 175: PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE

Facility

$42,533.35

Service Code	MSDRG 175
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$42,533.35
Rate for Payer: Aetna of CA HMO/PPO	$42,533.35
Rate for Payer: EPIC Health Plan Commercial	$39,780.25
Rate for Payer: EPIC Health Plan Medicare/Senior	$29,466.85
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$29,466.85
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$29,466.85
Rate for Payer: Molina Healthcare of CA Medi-Cal	$37,128.23
Rate for Payer: Molina Healthcare of CA Medicare	$39,485.58
Rate for Payer: Multiplan WC	$28,685.35
Rate for Payer: Prime Health Services WC	$28,392.65
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 176: PULMONARY EMBOLISM WITHOUT MCC

Facility

$30,987.54

Service Code	MSDRG 176
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$30,987.54
Rate for Payer: Aetna of CA HMO/PPO	$24,725.73
Rate for Payer: EPIC Health Plan Commercial	$30,987.54
Rate for Payer: EPIC Health Plan Medicare/Senior	$22,953.73
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$22,953.73
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$22,953.73
Rate for Payer: Molina Healthcare of CA Medi-Cal	$28,921.70
Rate for Payer: Molina Healthcare of CA Medicare	$30,758.00
Rate for Payer: Multiplan WC	$16,790.62
Rate for Payer: Prime Health Services WC	$16,619.29
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 177: RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC

Facility

$51,428.06

Service Code	MSDRG 177
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$51,428.06
Rate for Payer: Aetna of CA HMO/PPO	$51,428.06
Rate for Payer: EPIC Health Plan Commercial	$44,172.09
Rate for Payer: EPIC Health Plan Medicare/Senior	$32,720.07
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$32,720.07
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$32,720.07
Rate for Payer: Molina Healthcare of CA Medi-Cal	$41,227.29
Rate for Payer: Molina Healthcare of CA Medicare	$43,844.89
Rate for Payer: Multiplan WC	$36,552.87
Rate for Payer: Prime Health Services WC	$36,179.88
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

INPATIENT MS-DRG 178: RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC

Facility

$33,548.72

Service Code	MSDRG 178
Min. Negotiated Rate	$6,486.00
Max. Negotiated Rate	$33,548.72
Rate for Payer: Aetna of CA HMO/PPO	$29,912.80
Rate for Payer: EPIC Health Plan Commercial	$33,548.72
Rate for Payer: EPIC Health Plan Medicare/Senior	$24,850.90
Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage	$24,850.90
Rate for Payer: Kaiser Permanente of CA Medicare Advantage	$24,850.90
Rate for Payer: Molina Healthcare of CA Medi-Cal	$31,312.13
Rate for Payer: Molina Healthcare of CA Medicare	$33,300.21
Rate for Payer: Multiplan WC	$22,323.15
Rate for Payer: Prime Health Services WC	$22,095.36
Rate for Payer: United Healthcare All Other Commercial	$9,972.00
Rate for Payer: United Healthcare All Other HMO	$7,986.00
Rate for Payer: United Healthcare HMO Rider	$7,093.00
Rate for Payer: United Healthcare Select/Navigate/Core	$6,486.00

Know your out-of-pocket cost for care.

All Charges