Medi-Cal DRG Pricing Calculator for FY 2015-16 · 6/10/2015 · Medi-Cal DRG Pricing Calculator for...
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Medi-Cal DRG Pricing Calculator for FY 2015-16 Effective for Dates of Admission on or after July 1, 2015 June 10, 2015 W556 This DRG Pricing Calculator is intended to enable hospitals and other interested parties to understand and predict estimated payment for inpatient stays covered by fee-for-service Medi-Cal. This version applies to stays with dates of admission on or after July 1, 2015, through June 30, 2016. Annual updates necessitate a new calculator that reflects new wage index values, hospital-specific base rates, and other changes. For stays with dates of admission prior to July 1, 2015, see the DHCS DRG webpage. In this file, the "Calculator" sheet incorporates the pricing logic for the complete array of DRG pricing options. The "DRG Table" sheet shows information specific to each DRG. The "Hospital Characteristics" sheet shows information specific to each hospital. The DRG Base Rate tab provides information related to wage arear and base rate determination. Under DRG payment, the Medicaid claims processing system assigns each complete inpatient stay to an All Patient Refined Diagnosis Related Group (APR-DRG) based on the diagnoses and procedures on the claim. (Note that Medi-Cal does not use Medicare DRGs, which were not designed for a Medicaid population.) Hospitals need not put the DRG on the claim and need not purchase APR-DRG software. The "Calculator" sheet assumes the user knows which APR-DRG applies to a particular stay. For more information on APR-DRGs, contact 3M Health Information Systems, which developed and owns the software. This calculator is intended to be helpful to users to estimate pricing, but it cannot capture all the editing and pricing complexity of the Medicaid claims processing system. In cases of difference, the claims processing system is correct. A "Frequently Asked Questions" document is available and is essential in understanding the payment method. This DRG Pricing Calculator is also available in spreadsheet form as an interactive Excel file. Both documents are at the Medi-Cal DRG page at http://www.dhcs.ca.gov. To sign up for the DRG listserv or to ask a DRG policy question, email [email protected]. (Do not send any protected health information by email.) For questions about claims, contact the Medi-Cal Telephone Service Center at 800.541.5555. This calculator was developed by Xerox, the fiscal intermediary for Medi-Cal. It includes data obtained through the use of proprietary computer software created, owned, and licensed by the 3M Company. All copyrights in and to the 3M TM Software are owned by 3M. All rights reserved. 3M bears no responsibility for the contents of this document.
Transcript of Medi-Cal DRG Pricing Calculator for FY 2015-16 · 6/10/2015 · Medi-Cal DRG Pricing Calculator for...
Medi-Cal DRG Pricing Calculator for FY 2015-16 Effective for Dates of Admission on or after July 1 2015 June 10 2015 W556
This DRG Pricing Calculator is intended to enable hospitals and other interested parties to understand and predict estimated payment for inpatient stays covered by fee-for-service Medi-Cal This version applies to stays with dates of admission on or after July 1 2015 through June 30 2016 Annual updates necessitate a new calculator that reflects new wage index values hospital-specific base rates and other changes For stays with dates of admission prior to July 1 2015 see the DHCS DRG webpage In this file the Calculator sheet incorporates the pricing logic for the complete array of DRG pricing options The DRG Table sheet shows information specific to each DRG The Hospital Characteristics sheet shows information specific to each hospital The DRG Base Rate tab provides information related to wage arear and base rate determination
Under DRG payment the Medicaid claims processing system assigns each complete inpatient stay to an All Patient Refined Diagnosis Related Group (APR-DRG) based on the diagnoses and procedures on the claim (Note that Medi-Cal does not use Medicare DRGs which were not designed for a Medicaid population) Hospitals need not put the DRG on the claim and need not purchase APR-DRG software The Calculator sheet assumes the user knows which APR-DRG applies to a particular stay For more information on APR-DRGs contact 3M Health Information Systems which developed and owns the software
This calculator is intended to be helpful to users to estimate pricing but it cannot capture all the editing and pricing complexity of the Medicaid claims processing system In cases of difference the claims processing system is correct
A Frequently Asked Questions document is available and is essential in understanding the payment method This DRG Pricing Calculator is also available in spreadsheet form as an interactive Excel file Both documents are at the Medi-Cal DRG page at httpwwwdhcscagov To sign up for the DRG listserv or to ask a DRG policy question email drgdhcscagov (Do not send any protected health information by email) For questions about claims contact the Medi-Cal Telephone Service Center at 8005415555
This calculator was developed by Xerox the fiscal intermediary for Medi-Cal It includes data obtained through the use of proprietary computer software created owned and licensed by the 3M Company All copyrights in and to the 3M TM Software are owned by 3M All rights reserved 3M bears no responsibility for the contents of this document
A B C D 2 Medi -Cal DRG Pricing Calculator Effective Dates of Admission on or after July 1 2015 3 June 10 2015 4 Instructions 5 1 The hospital or other user inputs data in cells C14-C23 amp C34 Values for cell C 34 can be found on the Hospital C haracteristics tab 6 2 Medi-Cal pay ment policy parameters have already been entered in cells C35-C41 7 3 The calculator will s how the predicted allowed amount and paid amount in cells C69 and C73 respectively 8 4 LOS = discharge date minus admission date If a patient is admitted and discharged on the same day the calculated LOS equals zero 9 5 Transfer discharge statuses include 02 0563 65 and 66 Additional v alues are scheduled for implementation in September 2015
6 This calculator spreadsheet is intended to be helpful t o users but it cannot capture all t he editing and pricing complexity of the Medicaid claims processing 10 system In cases of difference the claims processing system is correct 11 Indicates information to be input by the user Indicates payment policy parameters set by Medi-Cal 12 Information Data COMMENTS OR FORMULA 13 INFORMATION FROM THE HOSPITAL-- TO BE INPUT BY THE USER 14 Total c harges $2000000 UB-04 Form Locator 47 15 Hospital-specific cost-to-charge ratio 2997 Look up from Tab 4 Column H 16 Length of stay 63 See instruction 4 used for transfer pricing adjustment 17 Patient discharge status = transfer No See instruction 5 used for transfer pricing adjustment 18 Patient age (in years) 25 Used for age adjustor 19 Other health coverage $000 UB-04 Form Locator 54 for payments by third parties 20 Patient share of cost $000 Includes spend-down or copayment 21 Is discharge status equal t o 30 No Indicates an interim claim 22 Designated NICU facility No Look up from Tab 4 Column E 23 APR-DRG 057-1 From separate APR-DRG grouping software 24 APR-DRG INFORMATION -- CALCULATOR WILL FILL IN VALUES AUTOMATICALLY
APR-DRG description CONCUSSION Look up from DRG table (Tab 3 Column B) CLOSED SKULL FX NOSUNCOMPLICA
25 TED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA
26 Casemix relative weight--unadjusted 05207 Look up from DRG table (Tab 3 Column D) 27 NICU service adjustor - hospital w ith designated NICU 10000 Look up from DRG table (Tab 3 Column J) 28 NICU service adjustor - all other hospitals 10000 Look up from DRG table (Tab 3 Column E) 29 Obstetric service adjustor 10000 Look up from DRG table (Tab 3 Column F) 30 Pediatric age adjustor 12500 Look up from DRG table (Tab 3 Column H)
Payment relative weight 05207 IF C18lt21 then if (C22=Yes) then (C26C27C29C30) else 31 (C26C28C29C30) else if (C22=Yes) then (C26C27C29) else
(C26C28C29) 32 Average length of stay for this APR-DRG 151 Look up from DRG table (Tab 3 Column C) 33 PAYMENT POLICY PARAMETERS SET BY MEDI-CAL 34 DRG base rate $7436 Specific to each hospital (Tab 4 Column L or M) 35 Cost outlier threshold 1 $45000 Threshold qualifying high and low-cost outlier adjustments 36 Cost outlier threshold 2 $145000 Threshold qualifying high-cost outlier adjustments 37 Marginal c ost percentage 1 60 Used for high and low-cost outlier adjustments 38 Marginal c ost percentage 2 80 Used for high-cost outlier adjustments
Casemix adjustment factor 100 Used to adjust DRG relative weights should a need arise else leave set to 100 39
40 Interim claim threshold 29 Threshold qualifying interim claims 41 Interim per diem amount $600 Used for pricing interim claims 42 IS THIS AN INTERIM CLAIM 43 Is discharge status equal t o 30 No Look up C21 44 Is length of stay gt interim claim threshold NA IF C43=Yes then if (C16 gt C40) Yes else No else NA 45 Skip to C72 for final interim claim payment amount $000 IF C44=Yes (C41C16) rounded to 2 places else 0 46 WHAT IS THE DRG BASE PAYMENT 47 DRG base payment for this claim $387193 C34C31C39 48 IS A TRANSFER PAYMENT ADJUSTMENT MADE 49 Is a transfer adjustment potentially applicable No Look up C17 50 Calculated transfer payment adjustment NA IF C49=Yes then (C47C32)(C16+1) rounded to 2 places else NA 51 Is transfer payment adjustment lt allowed amount so far NA IF C50 =NA then NA else if (C50ltC47) then Yes else No 52 Allowed amount after transfer adjustment $387193 IF C51= Yes then C50 else C47 53 IS A COST OUTLIER ADJUSTMENT MADE 54 Estimated cost of this case $599400 C14C15 55 Is estimated cost gt allowed amount Loss IF C54 gt C52 then Loss else Gain 56 High-Side Outlier Payment When Payment Is Much Lower than Cost 57 Estimated loss on this case $212207 IF C55 = Loss then (C54-C52) else NA 58 Is loss gt outlier threshold lower limit No IF C55 = Loss then if (C57 gt C35) then Yes else No else NA
DRG cost outlier payment increase 1 $000 IF C58 = Yes then if (C57ltC35) then ((C57-C35)C37) else ((C36shy59 C35)C37) else 0 DRG cost outlier payment increase 2 $000 IF C58=Yes then if (C57gtC36) then (C57-C36)C38 rounded to 2 places 60 else 0 else 0
61 Low Side Outlier Payment When Payment Is Much Greater than Cost 62 Estimated gain on this case NA IF C55=Gain then (C52-C54) elseNA 63 Is gain gt outlier threshold NA IF C55=Gain then if (C62gtC35) then Yes else No else NA
DRG cost outlier payment decrease $000 IF C55=Gain then (if (C63=Yes) then (C62-C35)C37 rounded to 2 places 64 else 0) else 0 65 ALLOWED AMOUNT AFTER TRANSFER AND OUTLIER ADJUSTMENTS 66 DRG payment so far $387193 IF C55=Loss then (C52+C59+C60) else (C52-C64) 67 CALCULATION OF ALLOWED AMOUNT AND REIMBURSEMENT AMOUNT 68 Add-on amount $000 Hospital-specific payment separate from DRG payment (not used at this time) 69 Allowed amount $387193 Allowed amount = C66+C68 70 Other health coverage $000 C19 71 Patient share of cost $000 C20
Lesser of calculation $387193 Existing policy requires that payment amount cannot exceed total c harges IF 72 C69gtC14 then C14 else C69 Payment amount If interim claim (C43=yes) then interim claim (C45) amount is the payment
73 $387193 amount Otherwise subtract other health coverage (C70) and patient share of cost (C71) from Lesser of (C71) to obtain payment amount
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Medi Cal DRG Table Effective July 1 2015
4 Casemix relative weights reflect Hospital-Specific Relative Value (HSRV) relative weights V32
9 This spreadsheet includes data obtained through the use of proprietary computer software created owned and licensed by the 3M Company All copyrights in and to the 3MTM Software are owned by 3M All rights reserved 3M has no responsibility for the contents of this calculator
3 Average length of stay is the untrimmed arithmetic value
5 For purposes of illustration the table uses a DRG base rate of $7500 In fact DRG base rates are hospital specific See the Hospital Characteristics tab Column L for non-transition hospitals and Column M for transition hospitals 6 Pediatric is defined as under age 21 7 This table shows information for 1258 DRGs (314 base DRGs each with four levels of severity plus two error DRGs) 8 Inclusion of a service in this list does not necessarily imply coverage by Medi-Cal Rehabilitation services (APR-DRG 860) are paid outside the DRG method
1 The DRG base payment equals the DRG base rate times the casemix relative weight times any applicable policy adjustors 2 Average length of stay and casemix relative weights were calculated from the Nationwide Inpatient Sample by 3M Health Information Systems for APR-DRG V32
10 This calculator was developed by Xerox the fiscal intermediary contractor for Medi-Cal
APR DRG APR DRG Descr pt on
Nat ona Average Length of Stay
Medicaid Care Category Pediatric
HSRV Casemix Relative We ght
Policy Adjustor NICU
Policy Adjustor Obstetric s
Payment Relative We ght No Age
Policy Adjustor Pediatric age
Payment Relative We ght w th Age
Policy Adjustor Service (Designat
Payment Relative We ght W th
DRG Base Payment Using Example Base Rate
Medicaid Care Category Adult
001-1 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 763 74839 10000 10000 74839 12500 93549 10000 74839 $70162 Misc Pediatric 001-2 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 857 75257 10000 10000 75257 12500 94071 10000 75257 $70553 Misc Pediatric 001-3 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 1251 88396 10000 10000 88396 12500 110495 10000 88396 $82871 Misc Pediatric 001-4 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 3157 153728 10000 10000 153728 12500 192160 10000 153728 $144120 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
002-1 HEART ampOR LUNG TRANSPLANT 936 81603 10000 10000 81603 12500 102004 10000 81603 $76503 Misc Pediatric 002-2 HEART ampOR LUNG TRANSPLANT 1470 96672 10000 10000 96672 12500 120840 10000 96672 $90630 Misc Pediatric 002-3 HEART ampOR LUNG TRANSPLANT 2153 120551 10000 10000 120551 12500 150689 10000 120551 $113017 Misc Pediatric 002-4 HEART ampOR LUNG TRANSPLANT 3671 180801 10000 10000 180801 12500 226001 10000 180801 $169501 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
003-1 BONE MARROW TRANSPLANT 1692 42402 10000 10000 42402 12500 53003 10000 42402 $39752 Misc Pediatric 003-2 BONE MARROW TRANSPLANT 2257 62664 10000 10000 62664 12500 78330 10000 62664 $58748 Misc Pediatric 003-3 BONE MARROW TRANSPLANT 3280 101363 10000 10000 101363 12500 126704 10000 101363 $95028 Misc Pediatric 003-4 BONE MARROW TRANSPLANT 5119 182162 10000 10000 182162 12500 227703 10000 182162 $170777 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
004-1 ECMO OR TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W EXTENSIVE PROCEDURE 2289 64917 10000 10000 64917 12500 81146 10000 64917 $60860 Misc Pediatric 004-2 ECMO OR TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W EXTENSIVE PROCEDURE 2059 67502 10000 10000 67502 12500 84378 10000 67502 $63283 Misc Pediatric 004-3 ECMO OR TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W EXTENSIVE PROCEDURE 2639 92480 10000 10000 92480 12500 115600 10000 92480 $86700 Misc Pediatric 004-4 ECMO OR TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W EXTENSIVE PROCEDURE 3858 141600 10000 10000 141600 12500 177000 10000 141600 $132750 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
005-1 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION WO EXTENSIVE PROCEDURE 2774 49004 10000 10000 49004 12500 61255 10000 49004 $45941 Misc Pediatric 005-2 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION WO EXTENSIVE PROCEDURE 1947 52327 10000 10000 52327 12500 65409 10000 52327 $49057 Misc Pediatric 005-3 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION WO EXTENSIVE PROCEDURE 2393 67135 10000 10000 67135 12500 83919 10000 67135 $62939 Misc Pediatric 005-4 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION WO EXTENSIVE PROCEDURE 3278 95918 10000 10000 95918 12500 119898 10000 95918 $89923 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
006-1 PANCREAS TRANSPLANT 590 75340 10000 10000 75340 12500 94175 10000 75340 $70631 Misc Pediatric 006-2 PANCREAS TRANSPLANT 812 84835 10000 10000 84835 12500 106044 10000 84835 $79533 Misc Pediatric 006-3 PANCREAS TRANSPLANT 1015 90984 10000 10000 90984 12500 113730 10000 90984 $85298 Misc Pediatric 006-4 PANCREAS TRANSPLANT 2470 139742 10000 10000 139742 12500 174678 10000 139742 $131008 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
020-1 CRANIOTOMY FOR TRAUMA 540 17475 10000 10000 17475 12500 21844 10000 17475 $16383 Misc Pediatric 020-2 CRANIOTOMY FOR TRAUMA 637 22987 10000 10000 22987 12500 28734 10000 22987 $21550 Misc Pediatric 020-3 CRANIOTOMY FOR TRAUMA 994 32365 10000 10000 32365 12500 40456 10000 32365 $30342 Misc Pediatric 020-4 CRANIOTOMY FOR TRAUMA 1688 57910 10000 10000 57910 12500 72388 10000 57910 $54291 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
021-1 CRANIOTOMY EXCEPT FOR TRAUMA 399 19469 10000 10000 19469 12500 24336 10000 19469 $18252 Misc Pediatric 021-2 CRANIOTOMY EXCEPT FOR TRAUMA 580 25682 10000 10000 25682 12500 32103 10000 25682 $24077 Misc Pediatric 021-3 CRANIOTOMY EXCEPT FOR TRAUMA 1037 37498 10000 10000 37498 12500 46873 10000 37498 $35154 Misc Pediatric 021-4 CRANIOTOMY EXCEPT FOR TRAUMA 1849 62981 10000 10000 62981 12500 78726 10000 62981 $59045 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
022-1 VENTRICULAR SHUNT PROCEDURES 280 11881 10000 10000 11881 12500 14851 10000 11881 $11138 Misc Pediatric 022-2 VENTRICULAR SHUNT PROCEDURES 535 15662 10000 10000 15662 12500 19578 10000 15662 $14683 Misc Pediatric 022-3 VENTRICULAR SHUNT PROCEDURES 1108 28925 10000 10000 28925 12500 36156 10000 28925 $27117 Misc Pediatric 022-4 VENTRICULAR SHUNT PROCEDURES 1829 51610 10000 10000 51610 12500 64513 10000 51610 $48384 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
023-1 SPINAL PROCEDURES 330 13296 10000 10000 13296 12500 16620 10000 13296 $12465 Misc Pediatric 023-2 SPINAL PROCEDURES 575 18228 10000 10000 18228 12500 22785 10000 18228 $17089 Misc Pediatric 023-3 SPINAL PROCEDURES 1033 37132 10000 10000 37132 12500 46415 10000 37132 $34811 Misc Pediatric 023-4 SPINAL PROCEDURES 2028 64258 10000 10000 64258 12500 80323 10000 64258 $60242 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
024-1 EXTRACRANIAL VASCULAR PROCEDURES 154 10744 10000 10000 10744 12500 13430 10000 10744 $10073 Misc Pediatric 024-2 EXTRACRANIAL VASCULAR PROCEDURES 291 14224 10000 10000 14224 12500 17780 10000 14224 $13335 Misc Pediatric 024-3 EXTRACRANIAL VASCULAR PROCEDURES 748 27477 10000 10000 27477 12500 34346 10000 27477 $25760 Misc Pediatric 024-4 EXTRACRANIAL VASCULAR PROCEDURES 1360 52767 10000 10000 52767 12500 65959 10000 52767 $49469 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
026-1 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 261 11696 10000 10000 11696 12500 14620 10000 11696 $10965 Misc Pediatric 026-2 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 445 15931 10000 10000 15931 12500 19914 10000 15931 $14935 Misc Pediatric 026-3 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 912 24163 10000 10000 24163 12500 30204 10000 24163 $22653 Misc Pediatric 026-4 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 2104 48720 10000 10000 48720 12500 60900 10000 48720 $45675 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
040-1 SPINAL DISORDERS amp INJURIES 362 07950 10000 10000 07950 12500 09938 10000 07950 $7453 Misc Pediatric 040-2 SPINAL DISORDERS amp INJURIES 497 09647 10000 10000 09647 12500 12059 10000 09647 $9044 Misc Pediatric 040-3 SPINAL DISORDERS amp INJURIES 796 13170 10000 10000 13170 12500 16463 10000 13170 $12347 Misc Pediatric 040-4 SPINAL DISORDERS amp INJURIES 1612 26793 10000 10000 26793 12500 33491 10000 26793 $25118 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
041-1 NERVOUS SYSTEM MALIGNANCY 306 06836 10000 10000 06836 12500 08545 10000 06836 $6409 Misc Pediatric 041-2 NERVOUS SYSTEM MALIGNANCY 388 07312 10000 10000 07312 12500 09140 10000 07312 $6855 Misc Pediatric 041-3 NERVOUS SYSTEM MALIGNANCY 613 10508 10000 10000 10508 12500 13135 10000 10508 $9851 Misc Pediatric 041-4 NERVOUS SYSTEM MALIGNANCY 992 17617 10000 10000 17617 12500 22021 10000 17617 $16516 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
042-1 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 521 05231 10000 10000 05231 12500 06539 10000 05231 $4904 Misc Pediatric 042-2 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 886 07627 10000 10000 07627 12500 09534 10000 07627 $7150 Misc Pediatric 042-3 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 917 10114 10000 10000 10114 12500 12643 10000 10114 $9482 Misc Pediatric 042-4 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 1329 21932 10000 10000 21932 12500 27415 10000 21932 $20561 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
043-1 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 356 06706 10000 10000 06706 12500 08383 10000 06706 $6287 Misc Pediatric 043-2 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 479 08543 10000 10000 08543 12500 10679 10000 08543 $8009 Misc Pediatric 043-3 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 827 13083 10000 10000 13083 12500 16354 10000 13083 $12265 Misc Pediatric 043-4 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 1650 28853 10000 10000 28853 12500 36066 10000 28853 $27050 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
044-1 INTRACRANIAL HEMORRHAGE 349 06526 10000 10000 06526 12500 08158 10000 06526 $6118 Misc Pediatric 044-2 INTRACRANIAL HEMORRHAGE 462 08878 10000 10000 08878 12500 11098 10000 08878 $8323 Misc Pediatric 044-3 INTRACRANIAL HEMORRHAGE 547 11157 10000 10000 11157 12500 13946 10000 11157 $10460 Misc Pediatric 044-4 INTRACRANIAL HEMORRHAGE 897 20771 10000 10000 20771 12500 25964 10000 20771 $19473 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
045-1 CVA amp PRECEREBRAL OCCLUSION W INFARCT 279 07518 10000 10000 07518 12500 09398 10000 07518 $7048 Misc Pediatric 045-2 CVA amp PRECEREBRAL OCCLUSION W INFARCT 392 09090 10000 10000 09090 12500 11363 10000 09090 $8522 Misc Pediatric 045-3 CVA amp PRECEREBRAL OCCLUSION W INFARCT 617 12516 10000 10000 12516 12500 15645 10000 12516 $11734 Misc Pediatric 045-4 CVA amp PRECEREBRAL OCCLUSION W INFARCT 1101 23311 10000 10000 23311 12500 29139 10000 23311 $21854 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
046-1 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 262 06594 10000 10000 06594 12500 08243 10000 06594 $6182 Misc Pediatric 046-2 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 327 08051 10000 10000 08051 12500 10064 10000 08051 $7548 Misc Pediatric 046-3 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 501 10524 10000 10000 10524 12500 13155 10000 10524 $9866 Misc Pediatric 046-4 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 950 18762 10000 10000 18762 12500 23453 10000 18762 $17589 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
047-1 TRANSIENT ISCHEMIA 193 05944 10000 10000 05944 12500 07430 10000 05944 $5573 Misc Pediatric 047-2 TRANSIENT ISCHEMIA 252 06664 10000 10000 06664 12500 08330 10000 06664 $6248 Misc Pediatric 047-3 TRANSIENT ISCHEMIA 382 08503 10000 10000 08503 12500 10629 10000 08503 $7972 Misc Pediatric 047-4 TRANSIENT ISCHEMIA 877 17352 10000 10000 17352 12500 21690 10000 17352 $16268 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
048-1 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 276 05447 10000 10000 05447 12500 06809 10000 05447 $5107 Misc Pediatric 048-2 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 381 06543 10000 10000 06543 12500 08179 10000 06543 $6134 Misc Pediatric 048-3 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 538 08920 10000 10000 08920 12500 11150 10000 08920 $8363 Misc Pediatric 048-4 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 1291 21687 10000 10000 21687 12500 27109 10000 21687 $20332 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
049-1 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 542 08284 10000 10000 08284 12500 10355 10000 08284 $7766 Misc Pediatric 049-2 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 670 16421 10000 10000 16421 12500 20526 10000 16421 $15395 Misc Pediatric 049-3 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 1061 20964 10000 10000 20964 12500 26205 10000 20964 $19654 Misc Pediatric 049-4 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 1600 36170 10000 10000 36170 12500 45213 10000 36170 $33909 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
050-1 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 392 05935 10000 10000 05935 12500 07419 10000 05935 $5564 Misc Pediatric 050-2 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 557 09905 10000 10000 09905 12500 12381 10000 09905 $9286 Misc Pediatric 050-3 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 881 16196 10000 10000 16196 12500 20245 10000 16196 $15184 Misc Pediatric 050-4 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 1558 37267 10000 10000 37267 12500 46584 10000 37267 $34938 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
051-1 VIRAL MENINGITIS 263 04820 10000 10000 04820 12500 06025 10000 04820 $4519 Misc Pediatric 051-2 VIRAL MENINGITIS 376 07311 10000 10000 07311 12500 09139 10000 07311 $6854 Misc Pediatric 051-3 VIRAL MENINGITIS 647 12961 10000 10000 12961 12500 16201 10000 12961 $12151 Misc Pediatric 051-4 VIRAL MENINGITIS 1269 30543 10000 10000 30543 12500 38179 10000 30543 $28634 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
052-1 NONTRAUMATIC STUPOR amp COMA 212 05282 10000 10000 05282 12500 06603 10000 05282 $4952 Misc Pediatric 052-2 NONTRAUMATIC STUPOR amp COMA 322 06261 10000 10000 06261 12500 07826 10000 06261 $5870 Misc Pediatric 052-3 NONTRAUMATIC STUPOR amp COMA 518 08796 10000 10000 08796 12500 10995 10000 08796 $8246 Misc Pediatric 052-4 NONTRAUMATIC STUPOR amp COMA 1098 20139 10000 10000 20139 12500 25174 10000 20139 $18880 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
053-1 SEIZURE 231 04456 10000 10000 04456 12500 05570 10000 04456 $4178 Misc Pediatric 053-2 SEIZURE 292 05716 10000 10000 05716 12500 07145 10000 05716 $5359 Misc Pediatric 053-3 SEIZURE 440 08167 10000 10000 08167 12500 10209 10000 08167 $7657 Misc Pediatric 053-4 SEIZURE 977 20593 10000 10000 20593 12500 25741 10000 20593 $19306 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
054-1 MIGRAINE amp OTHER HEADACHES 237 04790 10000 10000 04790 12500 05988 10000 04790 $4491 Misc Pediatric 054-2 MIGRAINE amp OTHER HEADACHES 281 05954 10000 10000 05954 12500 07443 10000 05954 $5582 Misc Pediatric 054-3 MIGRAINE amp OTHER HEADACHES 392 07615 10000 10000 07615 12500 09519 10000 07615 $7139 Misc Pediatric 054-4 MIGRAINE amp OTHER HEADACHES 686 12142 10000 10000 12142 12500 15178 10000 12142 $11383 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
055-1 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 226 05690 10000 10000 05690 12500 07113 10000 05690 $5334 Misc Pediatric 055-2 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 356 07923 10000 10000 07923 12500 09904 10000 07923 $7428 Misc Pediatric 055-3 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 537 12060 10000 10000 12060 12500 15075 10000 12060 $11306 Misc Pediatric 055-4 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 1042 23925 10000 10000 23925 12500 29906 10000 23925 $22430 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
056-1 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 226 05776 10000 10000 05776 12500 07220 10000 05776 $5415 Misc Pediatric 056-2 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 367 08300 10000 10000 08300 12500 10375 10000 08300 $7781 Misc Pediatric 056-3 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 599 13057 10000 10000 13057 12500 16321 10000 13057 $12241 Misc Pediatric 056-4 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 1334 31575 10000 10000 31575 12500 39469 10000 31575 $29602 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
057-1 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 151 05207 10000 10000 05207 12500 06509 10000 05207 $4882 Misc Pediatric 057-2 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 242 07484 10000 10000 07484 12500 09355 10000 07484 $7016 Misc Pediatric 057-3 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 440 11394 10000 10000 11394 12500 14243 10000 11394 $10682 Misc Pediatric 057-4 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 1034 25045 10000 10000 25045 12500 31306 10000 25045 $23480 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
058-1 OTHER DISORDERS OF NERVOUS SYSTEM 278 05743 10000 10000 05743 12500 07179 10000 05743 $5384 Misc Pediatric 058-2 OTHER DISORDERS OF NERVOUS SYSTEM 409 07055 10000 10000 07055 12500 08819 10000 07055 $6614 Misc Pediatric 058-3 OTHER DISORDERS OF NERVOUS SYSTEM 616 09584 10000 10000 09584 12500 11980 10000 09584 $8985 Misc Pediatric 058-4 OTHER DISORDERS OF NERVOUS SYSTEM 1234 19422 10000 10000 19422 12500 24278 10000 19422 $18208 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
070-1 ORBITAL PROCEDURES 213 07705 10000 10000 07705 12500 09631 10000 07705 $7223 Misc Pediatric 070-2 ORBITAL PROCEDURES 376 11459 10000 10000 11459 12500 14324 10000 11459 $10743 Misc Pediatric 070-3 ORBITAL PROCEDURES 677 20584 10000 10000 20584 12500 25730 10000 20584 $19298 Misc Pediatric
Misc Adult Misc Adult Misc Adult
070-4 ORBITAL PROCEDURES 1319 41150 10000 10000 41150 12500 51438 10000 41150 $38578 Misc Pediatric Misc Adult 073-1 073-2 073-3 073-4
EYE PROCEDURES EXCEPT ORBIT EYE PROCEDURES EXCEPT ORBIT EYE PROCEDURES EXCEPT ORBIT EYE PROCEDURES EXCEPT ORBIT
227 313 544
1855
07119 08959 13025 30348
10000 10000 10000 10000
10000 10000 10000 10000
07119 08959 13025 30348
12500 12500 12500 12500
08899 11199 16281 37935
10000 10000 10000 10000
07119 08959 13025 30348
$6674 Misc Pediatric $8399 Misc Pediatric
$12211 Misc Pediatric $28451 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
080-1 080-2 080-3 080-4
ACUTE MAJOR EYE INFECTIONS ACUTE MAJOR EYE INFECTIONS ACUTE MAJOR EYE INFECTIONS ACUTE MAJOR EYE INFECTIONS
294 394 624
1204
03773 05293 08870 22854
10000 10000 10000 10000
10000 10000 10000 10000
03773 05293 08870 22854
12500 12500 12500 12500
04716 06616 11088 28568
10000 10000 10000 10000
03773 05293 08870 22854
$3537 Misc Pediatric $4962 Misc Pediatric $8316 Misc Pediatric
$21426 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
082-1 082-2 082-3 082-4
EYE DISORDERS EXCEPT MAJOR INFECTIONS EYE DISORDERS EXCEPT MAJOR INFECTIONS EYE DISORDERS EXCEPT MAJOR INFECTIONS EYE DISORDERS EXCEPT MAJOR INFECTIONS
229 280 431
1589
04191 05783 08004 18093
10000 10000 10000 10000
10000 10000 10000 10000
04191 05783 08004 18093
12500 12500 12500 12500
05239 07229 10005 22616
10000 10000 10000 10000
04191 05783 08004 18093
$3929 Misc Pediatric $5422 Misc Pediatric $7504 Misc Pediatric
$16962 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
089-1 089-2 089-3 089-4
MAJOR CRANIALFACIAL BONE PROCEDURES MAJOR CRANIALFACIAL BONE PROCEDURES MAJOR CRANIALFACIAL BONE PROCEDURES MAJOR CRANIALFACIAL BONE PROCEDURES
231 384 877
1633
14059 18500 32437 57616
10000 10000 10000 10000
10000 10000 10000 10000
14059 18500 32437 57616
12500 12500 12500 12500
17574 23125 40546 72020
10000 10000 10000 10000
14059 18500 32437 57616
$13180 Misc Pediatric $17344 Misc Pediatric $30410 Misc Pediatric $54015 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
090-1 090-2 090-3 090-4
MAJOR LARYNX amp TRACHEA PROCEDURES MAJOR LARYNX amp TRACHEA PROCEDURES MAJOR LARYNX amp TRACHEA PROCEDURES MAJOR LARYNX amp TRACHEA PROCEDURES
259 809
1356 2501
07159 22218 35815 71443
10000 10000 10000 10000
10000 10000 10000 10000
07159 22218 35815 71443
12500 12500 12500 12500
08949 27773 44769 89304
10000 10000 10000 10000
07159 22218 35815 71443
$6712 Misc Pediatric $20829 Misc Pediatric $33577 Misc Pediatric $66978 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
091-1 091-2 091-3 091-4
OTHER MAJOR HEAD amp NECK PROCEDURES OTHER MAJOR HEAD amp NECK PROCEDURES OTHER MAJOR HEAD amp NECK PROCEDURES OTHER MAJOR HEAD amp NECK PROCEDURES
324 463 959
1918
13026 18978 35965 63240
10000 10000 10000 10000
10000 10000 10000 10000
13026 18978 35965 63240
12500 12500 12500 12500
16283 23723 44956 79050
10000 10000 10000 10000
13026 18978 35965 63240
$12212 Misc Pediatric $17792 Misc Pediatric $33717 Misc Pediatric $59288 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
092-1 092-2 092-3 092-4
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES
200 293 606
1411
09832 13811 22378 49305
10000 10000 10000 10000
10000 10000 10000 10000
09832 13811 22378 49305
12500 12500 12500 12500
12290 17264 27973 61631
10000 10000 10000 10000
09832 13811 22378 49305
$9218 Misc Pediatric $12948 Misc Pediatric $20979 Misc Pediatric $46223 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
093-1 093-2 093-3 093-4
SINUS amp MASTOID PROCEDURES SINUS amp MASTOID PROCEDURES SINUS amp MASTOID PROCEDURES SINUS amp MASTOID PROCEDURES
236 388 725
1267
09484 12524 19562 30863
10000 10000 10000 10000
10000 10000 10000 10000
09484 12524 19562 30863
12500 12500 12500 12500
11855 15655 24453 38579
10000 10000 10000 10000
09484 12524 19562 30863
$8891 Misc Pediatric $11741 Misc Pediatric $18339 Misc Pediatric $28934 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
095-1 095-2 095-3 095-4
CLEFT LIP amp PALATE REPAIR CLEFT LIP amp PALATE REPAIR CLEFT LIP amp PALATE REPAIR CLEFT LIP amp PALATE REPAIR
143 206 403
1096
06260 07686 11913 21518
10000 10000 10000 10000
10000 10000 10000 10000
06260 07686 11913 21518
12500 12500 12500 12500
07825 09608 14891 26898
10000 10000 10000 10000
06260 07686 11913 21518
$5869 Misc Pediatric $7206 Misc Pediatric
$11168 Misc Pediatric $20173 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
097-1 097-2 097-3 097-4
TONSIL amp ADENOID PROCEDURES TONSIL amp ADENOID PROCEDURES TONSIL amp ADENOID PROCEDURES TONSIL amp ADENOID PROCEDURES
155 275 571
1520
04084 06213 12162 32627
10000 10000 10000 10000
10000 10000 10000 10000
04084 06213 12162 32627
12500 12500 12500 12500
05105 07766 15203 40784
10000 10000 10000 10000
04084 06213 12162 32627
$3829 Misc Pediatric $5825 Misc Pediatric
$11402 Misc Pediatric $30588 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
098-1 098-2 098-3 098-4
OTHER EAR NOSE MOUTH amp THROAT PROCEDURES OTHER EAR NOSE MOUTH amp THROAT PROCEDURES OTHER EAR NOSE MOUTH amp THROAT PROCEDURES OTHER EAR NOSE MOUTH amp THROAT PROCEDURES
210 326 680
1461
07048 09495 15477 32522
10000 10000 10000 10000
10000 10000 10000 10000
07048 09495 15477 32522
12500 12500 12500 12500
08810 11869 19346 40653
10000 10000 10000 10000
07048 09495 15477 32522
$6608 Misc Pediatric $8902 Misc Pediatric
$14510 Misc Pediatric $30489 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
110-1 110-2 110-3 110-4
EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES
292 429 693
1273
04895 07037 11057 22409
10000 10000 10000 10000
10000 10000 10000 10000
04895 07037 11057 22409
12500 12500 12500 12500
06119 08796 13821 28011
10000 10000 10000 10000
04895 07037 11057 22409
$4589 Misc Pediatric $6597 Misc Pediatric
$10366 Misc Pediatric $21008 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
111-1 111-2 111-3 111-4
VERTIGO amp OTHER LABYRINTH DISORDERS VERTIGO amp OTHER LABYRINTH DISORDERS VERTIGO amp OTHER LABYRINTH DISORDERS VERTIGO amp OTHER LABYRINTH DISORDERS
201 251 349 747
04865 05693 07226 13868
10000 10000 10000 10000
10000 10000 10000 10000
04865 05693 07226 13868
12500 12500 12500 12500
06081 07116 09033 17335
10000 10000 10000 10000
04865 05693 07226 13868
$4561 Misc Pediatric $5337 Misc Pediatric $6774 Misc Pediatric
$13001 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
113-1 113-2 113-3 113-4
INFECTIONS OF UPPER RESPIRATORY TRACT INFECTIONS OF UPPER RESPIRATORY TRACT INFECTIONS OF UPPER RESPIRATORY TRACT INFECTIONS OF UPPER RESPIRATORY TRACT
187 252 395 733
02600 04025 06701 13455
10000 10000 10000 10000
10000 10000 10000 10000
02600 04025 06701 13455
12500 12500 12500 12500
03250 05031 08376 16819
10000 10000 10000 10000
02600 04025 06701 13455
$2438 Resp Pediatric $3773 Resp Pediatric $6282 Resp Pediatric
$12614 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
114-1 114-2 114-3 114-4
DENTAL amp ORAL DISEASES amp INJURIES DENTAL amp ORAL DISEASES amp INJURIES DENTAL amp ORAL DISEASES amp INJURIES DENTAL amp ORAL DISEASES amp INJURIES
220 297 545
1060
03711 05698 09275 19812
10000 10000 10000 10000
10000 10000 10000 10000
03711 05698 09275 19812
12500 12500 12500 12500
04639 07123 11594 24765
10000 10000 10000 10000
03711 05698 09275 19812
$3479 Misc Pediatric $5342 Misc Pediatric $8695 Misc Pediatric
$18574 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
115-1 115-2 115-3 115-4
OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES
230 298 483 964
04062 05956 08755 18372
10000 10000 10000 10000
10000 10000 10000 10000
04062 05956 08755 18372
12500 12500 12500 12500
05078 07445 10944 22965
10000 10000 10000 10000
04062 05956 08755 18372
$3808 Misc Pediatric $5584 Misc Pediatric $8208 Misc Pediatric
$17224 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
120-1 120-2 120-3 120-4
MAJOR RESPIRATORY amp CHEST PROCEDURES MAJOR RESPIRATORY amp CHEST PROCEDURES MAJOR RESPIRATORY amp CHEST PROCEDURES MAJOR RESPIRATORY amp CHEST PROCEDURES
486 677
1138 1939
17190 21946 31960 57405
10000 10000 10000 10000
10000 10000 10000 10000
17190 21946 31960 57405
12500 12500 12500 12500
21488 27433 39950 71756
10000 10000 10000 10000
17190 21946 31960 57405
$16116 Resp Pediatric $20574 Resp Pediatric $29963 Resp Pediatric $53817 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
121-1 121-2 121-3 121-4
OTHER RESPIRATORY amp CHEST PROCEDURES OTHER RESPIRATORY amp CHEST PROCEDURES OTHER RESPIRATORY amp CHEST PROCEDURES OTHER RESPIRATORY amp CHEST PROCEDURES
349 547
1028 1936
11884 15313 24687 50343
10000 10000 10000 10000
10000 10000 10000 10000
11884 15313 24687 50343
12500 12500 12500 12500
14855 19141 30859 62929
10000 10000 10000 10000
11884 15313 24687 50343
$11141 Resp Pediatric $14356 Resp Pediatric $23144 Resp Pediatric $47197 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
130-1 130-2 130-3 130-4
RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS
1453 1262 1448 1967
28511 30424 36434 48144
10000 10000 10000 10000
10000 10000 10000 10000
28511 30424 36434 48144
12500 12500 12500 12500
35639 38030 45543 60180
10000 10000 10000 10000
28511 30424 36434 48144
$26729 Resp Pediatric $28523 Resp Pediatric $34157 Resp Pediatric $45135 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
131-1 131-2 131-3 131-4
CYSTIC FIBROSIS - PULMONARY DISEASE CYSTIC FIBROSIS - PULMONARY DISEASE CYSTIC FIBROSIS - PULMONARY DISEASE CYSTIC FIBROSIS - PULMONARY DISEASE
695 820
1028 1321
11407 14020 18525 25461
10000 10000 10000 10000
10000 10000 10000 10000
11407 14020 18525 25461
12500 12500 12500 12500
14259 17525 23156 31826
10000 10000 10000 10000
11407 14020 18525 25461
$10694 Resp Pediatric $13144 Resp Pediatric $17367 Resp Pediatric $23870 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
132-1 132-2 132-3 132-4
BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
345 441 709
1048
04234 05182 08052 14928
10000 10000 10000 10000
10000 10000 10000 10000
04234 05182 08052 14928
12500 12500 12500 12500
05293 06478 10065 18660
10000 10000 10000 10000
04234 05182 08052 14928
$3969 Resp Pediatric $4858 Resp Pediatric $7549 Resp Pediatric
$13995 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
133-1 133-2 133-3 133-4
PULMONARY EDEMA amp RESPIRATORY FAILURE PULMONARY EDEMA amp RESPIRATORY FAILURE PULMONARY EDEMA amp RESPIRATORY FAILURE PULMONARY EDEMA amp RESPIRATORY FAILURE
256 409 582 753
05454 07562 10997 17496
10000 10000 10000 10000
10000 10000 10000 10000
05454 07562 10997 17496
12500 12500 12500 12500
06818 09453 13746 21870
10000 10000 10000 10000
05454 07562 10997 17496
$5113 Resp Pediatric $7089 Resp Pediatric
$10310 Resp Pediatric $16403 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
134-1 134-2 134-3 134-4
PULMONARY EMBOLISM PULMONARY EMBOLISM PULMONARY EMBOLISM PULMONARY EMBOLISM
366 454 634 866
07118 09026 12878 19731
10000 10000 10000 10000
10000 10000 10000 10000
07118 09026 12878 19731
12500 12500 12500 12500
08898 11283 16098 24664
10000 10000 10000 10000
07118 09026 12878 19731
$6673 Resp Pediatric $8462 Resp Pediatric
$12073 Resp Pediatric $18498 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
135-1 135-2 135-3 135-4
MAJOR CHEST amp RESPIRATORY TRAUMA MAJOR CHEST amp RESPIRATORY TRAUMA MAJOR CHEST amp RESPIRATORY TRAUMA MAJOR CHEST amp RESPIRATORY TRAUMA
283 365 576 834
06399 08153 11913 21262
10000 10000 10000 10000
10000 10000 10000 10000
06399 08153 11913 21262
12500 12500 12500 12500
07999 10191 14891 26578
10000 10000 10000 10000
06399 08153 11913 21262
$5999 Resp Pediatric $7643 Resp Pediatric
$11168 Resp Pediatric $19933 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
136-1 136-2 136-3 136-4
RESPIRATORY MALIGNANCY RESPIRATORY MALIGNANCY RESPIRATORY MALIGNANCY RESPIRATORY MALIGNANCY
324 419 664 944
04458 07139 11635 18353
10000 10000 10000 10000
10000 10000 10000 10000
04458 07139 11635 18353
12500 12500 12500 12500
05573 08924 14544 22941
10000 10000 10000 10000
04458 07139 11635 18353
$4179 Resp Pediatric $6693 Resp Pediatric
$10908 Resp Pediatric $17206 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
137-1 137-2 137-3 137-4
MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS
470 529 724
1033
06368 08483 12031 19133
10000 10000 10000 10000
10000 10000 10000 10000
06368 08483 12031 19133
12500 12500 12500 12500
07960 10604 15039 23916
10000 10000 10000 10000
06368 08483 12031 19133
$5970 Resp Pediatric $7953 Resp Pediatric
$11279 Resp Pediatric $17937 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
138-1 138-2 138-3 138-4
BRONCHIOLITIS amp RSV PNEUMONIA BRONCHIOLITIS amp RSV PNEUMONIA BRONCHIOLITIS amp RSV PNEUMONIA BRONCHIOLITIS amp RSV PNEUMONIA
238 312 534 914
02804 03844 07519 18353
10000 10000 10000 10000
10000 10000 10000 10000
02804 03844 07519 18353
12500 12500 12500 12500
03505 04805 09399 22941
10000 10000 10000 10000
02804 03844 07519 18353
$2629 Resp Pediatric $3604 Resp Pediatric $7049 Resp Pediatric
$17206 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
139-1 139-2 139-3 139-4
OTHER PNEUMONIA OTHER PNEUMONIA OTHER PNEUMONIA OTHER PNEUMONIA
272 378 564 872
04202 06403 09948 17261
10000 10000 10000 10000
10000 10000 10000 10000
04202 06403 09948 17261
12500 12500 12500 12500
05253 08004 12435 21576
10000 10000 10000 10000
04202 06403 09948 17261
$3939 Resp Pediatric $6003 Resp Pediatric $9326 Resp Pediatric
$16182 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
140-1 140-2 140-3 140-4
CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHRONIC OBSTRUCTIVE PULMONARY DISEASE
311 381 519 874
05252 06666 09076 16691
10000 10000 10000 10000
10000 10000 10000 10000
05252 06666 09076 16691
12500 12500 12500 12500
06565 08333 11345 20864
10000 10000 10000 10000
05252 06666 09076 16691
$4924 Resp Pediatric $6249 Resp Pediatric $8509 Resp Pediatric
$15648 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
141-1 141-2 141-3 141-4
ASTHMA ASTHMA ASTHMA ASTHMA
219 307 435 560
03409 05016 07486 13503
10000 10000 10000 10000
10000 10000 10000 10000
03409 05016 07486 13503
12500 12500 12500 12500
04261 06270 09358 16879
10000 10000 10000 10000
03409 05016 07486 13503
$3196 Resp Pediatric $4703 Resp Pediatric $7018 Resp Pediatric
$12659 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
142-1 142-2 142-3 142-4
INTERSTITIAL amp ALVEOLAR LUNG DISEASES INTERSTITIAL amp ALVEOLAR LUNG DISEASES INTERSTITIAL amp ALVEOLAR LUNG DISEASES INTERSTITIAL amp ALVEOLAR LUNG DISEASES
331 422 633
1035
05788 07446 10874 19559
10000 10000 10000 10000
10000 10000 10000 10000
05788 07446 10874 19559
12500 12500 12500 12500
07235 09308 13593 24449
10000 10000 10000 10000
05788 07446 10874 19559
$5426 Resp Pediatric $6981 Resp Pediatric
$10194 Resp Pediatric $18337 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
143-1 143-2 143-3 143-4
OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES
285 376 564 863
04354 06617 09962 15731
10000 10000 10000 10000
10000 10000 10000 10000
04354 06617 09962 15731
12500 12500 12500 12500
05443 08271 12453 19664
10000 10000 10000 10000
04354 06617 09962 15731
$4082 Resp Pediatric $6203 Resp Pediatric $9339 Resp Pediatric
$14748 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
144-1 144-2 144-3 144-4
RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES
215 294 429 723
04363 05599 07749 13057
10000 10000 10000 10000
10000 10000 10000 10000
04363 05599 07749 13057
12500 12500 12500 12500
05454 06999 09686 16321
10000 10000 10000 10000
04363 05599 07749 13057
$4090 Resp Pediatric $5249 Resp Pediatric $7265 Resp Pediatric
$12241 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
160-1 160-2 160-3 160-4
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY
469 616
1039 2605
31307 34602 50015 97328
10000 10000 10000 10000
10000 10000 10000 10000
31307 34602 50015 97328
12500 12500 12500 12500
39134 43253 62519
121660
10000 10000 10000 10000
31307 34602 50015 97328
$29350 Misc Pediatric $32439 Misc Pediatric $46889 Misc Pediatric $91245 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
161-1 161-2 161-3 161-4
CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT
319 787
1588 3102
40098 53014 84071
199842
10000 10000 10000 10000
10000 10000 10000 10000
40098 53014 84071
199842
12500 12500 12500 12500
50123 66268
105089 249803
10000 10000 10000 10000
40098 53014 84071
199842
$37592 Misc Pediatric $49701 Misc Pediatric $78817 Misc Pediatric
$187352 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
162-1 162-2 162-3 162-4
CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION
800 918
1322 2097
44219 49501 63338 96985
10000 10000 10000 10000
10000 10000 10000 10000
44219 49501 63338 96985
12500 12500 12500 12500
55274 61876 79173
121231
10000 10000 10000 10000
44219 49501 63338 96985
$41455 Misc Pediatric $46407 Misc Pediatric $59379 Misc Pediatric $90923 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
163-1 163-2 163-3 163-4
CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION
566 651 924
1798
38077 42090 51794 88229
10000 10000 10000 10000
10000 10000 10000 10000
38077 42090 51794 88229
12500 12500 12500 12500
47596 52613 64743
110286
10000 10000 10000 10000
38077 42090 51794 88229
$35697 Misc Pediatric $39459 Misc Pediatric $48557 Misc Pediatric $82715 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
165-1 165-2 165-3 165-4
CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE
675 817
1052 1712
38445 43860 53254 80347
10000 10000 10000 10000
10000 10000 10000 10000
38445 43860 53254 80347
12500 12500 12500 12500
48056 54825 66568
100434
10000 10000 10000 10000
38445 43860 53254 80347
$36042 Misc Pediatric $41119 Misc Pediatric $49926 Misc Pediatric $75325 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
166-1 166-2 166-3 166-4
CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE
502 611 855
1615
30632 34370 42566 71277
10000 10000 10000 10000
10000 10000 10000 10000
30632 34370 42566 71277
12500 12500 12500 12500
38290 42963 53208 89096
10000 10000 10000 10000
30632 34370 42566 71277
$28718 Misc Pediatric $32222 Misc Pediatric $39906 Misc Pediatric $66822 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
167-1 167-2 167-3 167-4
OTHER CARDIOTHORACIC PROCEDURES OTHER CARDIOTHORACIC PROCEDURES OTHER CARDIOTHORACIC PROCEDURES OTHER CARDIOTHORACIC PROCEDURES
438 583 914
1860
28492 32691 41583 72603
10000 10000 10000 10000
10000 10000 10000 10000
28492 32691 41583 72603
12500 12500 12500 12500
35615 40864 51979 90754
10000 10000 10000 10000
28492 32691 41583 72603
$26711 Misc Pediatric $30648 Misc Pediatric $38984 Misc Pediatric $68065 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
169-1 169-2 169-3 169-4
MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES
434 570 899
1626
17710 23017 35767 63594
10000 10000 10000 10000
10000 10000 10000 10000
17710 23017 35767 63594
12500 12500 12500 12500
22138 28771 44709 79493
10000 10000 10000 10000
17710 23017 35767 63594
$16603 Misc Pediatric $21578 Misc Pediatric $33532 Misc Pediatric $59619 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
170-1 170-2 170-3 170-4
PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK
468 535 901
1647
22837 24595 30320 48851
10000 10000 10000 10000
10000 10000 10000 10000
22837 24595 30320 48851
12500 12500 12500 12500
28546 30744 37900 61064
10000 10000 10000 10000
22837 24595 30320 48851
$21410 Misc Pediatric $23058 Misc Pediatric $28425 Misc Pediatric $45798 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
171-1 171-2 171-3 171-4
PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK
257 388 652
1323
16061 19059 24628 42111
10000 10000 10000 10000
10000 10000 10000 10000
16061 19059 24628 42111
12500 12500 12500 12500
20076 23824 30785 52639
10000 10000 10000 10000
16061 19059 24628 42111
$15057 Misc Pediatric $17868 Misc Pediatric $23089 Misc Pediatric $39479 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
173-1 173-2 173-3 173-4
OTHER VASCULAR PROCEDURES OTHER VASCULAR PROCEDURES OTHER VASCULAR PROCEDURES OTHER VASCULAR PROCEDURES
248 413 835
1698
17172 20933 28552 52543
10000 10000 10000 10000
10000 10000 10000 10000
17172 20933 28552 52543
12500 12500 12500 12500
21465 26166 35690 65679
10000 10000 10000 10000
17172 20933 28552 52543
$16099 Misc Pediatric $19625 Misc Pediatric $26768 Misc Pediatric $49259 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
174-1 174-2 174-3 174-4
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI
242 309 532 858
20862 22375 27863 40669
10000 10000 10000 10000
10000 10000 10000 10000
20862 22375 27863 40669
12500 12500 12500 12500
26078 27969 34829 50836
10000 10000 10000 10000
20862 22375 27863 40669
$19558 Misc Pediatric $20977 Misc Pediatric $26122 Misc Pediatric $38127 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
175-1 175-2 175-3 175-4
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI
172 253 517
1037
17736 19933 25843 42121
10000 10000 10000 10000
10000 10000 10000 10000
17736 19933 25843 42121
12500 12500 12500 12500
22170 24916 32304 52651
10000 10000 10000 10000
17736 19933 25843 42121
$16628 Misc Pediatric $18687 Misc Pediatric $24228 Misc Pediatric $39488 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
176-1 176-2 176-3 176-4
CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT
291 253 446
1336
13020 24038 27425 45070
10000 10000 10000 10000
10000 10000 10000 10000
13020 24038 27425 45070
12500 12500 12500 12500
16275 30048 34281 56338
10000 10000 10000 10000
13020 24038 27425 45070
$12206 Misc Pediatric $22536 Misc Pediatric $25711 Misc Pediatric $42253 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
177-1 177-2 177-3 177-4
CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT
260 405 749
1560
10212 13638 21173 40225
10000 10000 10000 10000
10000 10000 10000 10000
10212 13638 21173 40225
12500 12500 12500 12500
12765 17048 26466 50281
10000 10000 10000 10000
10212 13638 21173 40225
$9574 Misc Pediatric $12786 Misc Pediatric $19850 Misc Pediatric $37711 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
180-1 180-2 180-3 180-4
OTHER CIRCULATORY SYSTEM PROCEDURES OTHER CIRCULATORY SYSTEM PROCEDURES OTHER CIRCULATORY SYSTEM PROCEDURES OTHER CIRCULATORY SYSTEM PROCEDURES
416 593 963
1589
10497 14144 21255 39764
10000 10000 10000 10000
10000 10000 10000 10000
10497 14144 21255 39764
12500 12500 12500 12500
13121 17680 26569 49705
10000 10000 10000 10000
10497 14144 21255 39764
$9841 Misc Pediatric $13260 Misc Pediatric $19927 Misc Pediatric $37279 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
190-1 190-2 190-3 190-4
ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION
212 315 518 765
06920 08342 11428 18576
10000 10000 10000 10000
10000 10000 10000 10000
06920 08342 11428 18576
12500 12500 12500 12500
08650 10428 14285 23220
10000 10000 10000 10000
06920 08342 11428 18576
$6488 Misc Pediatric $7821 Misc Pediatric
$10714 Misc Pediatric $17415 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
191-1 191-2 191-3 191-4
CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE
250 356 588
1157
10129 11962 15321 30799
10000 10000 10000 10000
10000 10000 10000 10000
10129 11962 15321 30799
12500 12500 12500 12500
12661 14953 19151 38499
10000 10000 10000 10000
10129 11962 15321 30799
$9496 Misc Pediatric $11214 Misc Pediatric $14363 Misc Pediatric $28874 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
192-1 192-2 192-3 192-4
CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE
190 256 440 733
08840 10294 13642 21517
10000 10000 10000 10000
10000 10000 10000 10000
08840 10294 13642 21517
12500 12500 12500 12500
11050 12868 17053 26896
10000 10000 10000 10000
08840 10294 13642 21517
$8288 Misc Pediatric $9651 Misc Pediatric
$12789 Misc Pediatric $20172 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
193-1 193-2 193-3 193-4
ACUTE amp SUBACUTE ENDOCARDITIS ACUTE amp SUBACUTE ENDOCARDITIS ACUTE amp SUBACUTE ENDOCARDITIS ACUTE amp SUBACUTE ENDOCARDITIS
549 695
1002 1491
07895 10373 15660 25224
10000 10000 10000 10000
10000 10000 10000 10000
07895 10373 15660 25224
12500 12500 12500 12500
09869 12966 19575 31530
10000 10000 10000 10000
07895 10373 15660 25224
$7402 Misc Pediatric $9725 Misc Pediatric
$14681 Misc Pediatric $23648 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
194-1 194-2 194-3 194-4
HEART FAILURE HEART FAILURE HEART FAILURE HEART FAILURE
292 375 565 955
05101 06549 09786 17821
10000 10000 10000 10000
10000 10000 10000 10000
05101 06549 09786 17821
12500 12500 12500 12500
06376 08186 12233 22276
10000 10000 10000 10000
05101 06549 09786 17821
$4782 Misc Pediatric $6140 Misc Pediatric $9174 Misc Pediatric
$16707 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
196-1 196-2 196-3 196-4
CARDIAC ARREST CARDIAC ARREST CARDIAC ARREST CARDIAC ARREST
291 227 252 462
03449 04919 07133 17166
10000 10000 10000 10000
10000 10000 10000 10000
03449 04919 07133 17166
12500 12500 12500 12500
04311 06149 08916 21458
10000 10000 10000 10000
03449 04919 07133 17166
$3233 Misc Pediatric $4612 Misc Pediatric $6687 Misc Pediatric
$16093 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
197-1 197-2 197-3 197-4
PERIPHERAL amp OTHER VASCULAR DISORDERS PERIPHERAL amp OTHER VASCULAR DISORDERS PERIPHERAL amp OTHER VASCULAR DISORDERS PERIPHERAL amp OTHER VASCULAR DISORDERS
325 405 554 993
04539 06186 09350 18139
10000 10000 10000 10000
10000 10000 10000 10000
04539 06186 09350 18139
12500 12500 12500 12500
05674 07733 11688 22674
10000 10000 10000 10000
04539 06186 09350 18139
$4255 Misc Pediatric $5799 Misc Pediatric $8766 Misc Pediatric
$17005 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
198-1 198-2 198-3 198-4
ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS
164 215 343 795
04222 05100 07000 13778
10000 10000 10000 10000
10000 10000 10000 10000
04222 05100 07000 13778
12500 12500 12500 12500
05278 06375 08750 17223
10000 10000 10000 10000
04222 05100 07000 13778
$3958 Misc Pediatric $4781 Misc Pediatric $6563 Misc Pediatric
$12917 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
199-1 199-2 199-3 199-4
HYPERTENSION HYPERTENSION HYPERTENSION HYPERTENSION
199 261 407 774
04431 05438 07709 16234
10000 10000 10000 10000
10000 10000 10000 10000
04431 05438 07709 16234
12500 12500 12500 12500
05539 06798 09636 20293
10000 10000 10000 10000
04431 05438 07709 16234
$4154 Misc Pediatric $5098 Misc Pediatric $7227 Misc Pediatric
$15219 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
200-1 200-2 200-3 200-4
CARDIAC STRUCTURAL amp VALVULAR DISORDERS CARDIAC STRUCTURAL amp VALVULAR DISORDERS CARDIAC STRUCTURAL amp VALVULAR DISORDERS CARDIAC STRUCTURAL amp VALVULAR DISORDERS
238 315 517
1005
04557 05692 08445 16354
10000 10000 10000 10000
10000 10000 10000 10000
04557 05692 08445 16354
12500 12500 12500 12500
05696 07115 10556 20443
10000 10000 10000 10000
04557 05692 08445 16354
$4272 Misc Pediatric $5336 Misc Pediatric $7917 Misc Pediatric
$15332 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
201-1 201-2 201-3 201-4
CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS
199 289 466 863
04273 05624 08590 17457
10000 10000 10000 10000
10000 10000 10000 10000
04273 05624 08590 17457
12500 12500 12500 12500
05341 07030 10738 21821
10000 10000 10000 10000
04273 05624 08590 17457
$4006 Misc Pediatric $5273 Misc Pediatric $8053 Misc Pediatric
$16366 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
203-1 203-2 203-3 203-4
CHEST PAIN CHEST PAIN CHEST PAIN CHEST PAIN
148 195 305 725
04180 05129 06846 13335
10000 10000 10000 10000
10000 10000 10000 10000
04180 05129 06846 13335
12500 12500 12500 12500
05225 06411 08558 16669
10000 10000 10000 10000
04180 05129 06846 13335
$3919 Misc Pediatric $4808 Misc Pediatric $6418 Misc Pediatric
$12502 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
204-1 204-2 204-3 204-4
SYNCOPE amp COLLAPSE SYNCOPE amp COLLAPSE SYNCOPE amp COLLAPSE SYNCOPE amp COLLAPSE
201 264 388 858
04877 05857 07587 15564
10000 10000 10000 10000
10000 10000 10000 10000
04877 05857 07587 15564
12500 12500 12500 12500
06096 07321 09484 19455
10000 10000 10000 10000
04877 05857 07587 15564
$4572 Misc Pediatric $5491 Misc Pediatric $7113 Misc Pediatric
$14591 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
205-1 205-2 205-3 205-4
CARDIOMYOPATHY CARDIOMYOPATHY CARDIOMYOPATHY CARDIOMYOPATHY
238 308 496 926
04349 05715 08342 18259
10000 10000 10000 10000
10000 10000 10000 10000
04349 05715 08342 18259
12500 12500 12500 12500
05436 07144 10428 22824
10000 10000 10000 10000
04349 05715 08342 18259
$4077 Misc Pediatric $5358 Misc Pediatric $7821 Misc Pediatric
$17118 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
206-1 206-2 206-3 206-4
MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE
227 345 572
1116
04452 05754 09436 20324
10000 10000 10000 10000
10000 10000 10000 10000
04452 05754 09436 20324
12500 12500 12500 12500
05565 07193 11795 25405
10000 10000 10000 10000
04452 05754 09436 20324
$4174 Misc Pediatric $5394 Misc Pediatric $8846 Misc Pediatric
$19054 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
207-1 207-2 207-3 207-4
OTHER CIRCULATORY SYSTEM DIAGNOSES OTHER CIRCULATORY SYSTEM DIAGNOSES OTHER CIRCULATORY SYSTEM DIAGNOSES OTHER CIRCULATORY SYSTEM DIAGNOSES
239 327 479 850
04972 06455 09118 17339
10000 10000 10000 10000
10000 10000 10000 10000
04972 06455 09118 17339
12500 12500 12500 12500
06215 08069 11398 21674
10000 10000 10000 10000
04972 06455 09118 17339
$4661 Misc Pediatric $6052 Misc Pediatric $8548 Misc Pediatric
$16255 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
220-1 220-2 220-3 220-4
MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES
370 728
1222 2105
13178 19373 31783 59607
10000 10000 10000 10000
10000 10000 10000 10000
13178 19373 31783 59607
12500 12500 12500 12500
16473 24216 39729 74509
10000 10000 10000 10000
13178 19373 31783 59607
$12354 Misc Pediatric $18162 Misc Pediatric $29797 Misc Pediatric $55882 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
221-1 221-2 221-3 221-4
MAJOR SMALL amp LARGE BOWEL PROCEDURES MAJOR SMALL amp LARGE BOWEL PROCEDURES MAJOR SMALL amp LARGE BOWEL PROCEDURES MAJOR SMALL amp LARGE BOWEL PROCEDURES
486 711
1216 2007
13986 18317 29391 55350
10000 10000 10000 10000
10000 10000 10000 10000
13986 18317 29391 55350
12500 12500 12500 12500
17483 22896 36739 69188
10000 10000 10000 10000
13986 18317 29391 55350
$13112 Misc Pediatric $17172 Misc Pediatric $27554 Misc Pediatric $51891 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
222-1 222-2 222-3 222-4
OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES
226 370 835
1821
08125 12068 19613 44248
10000 10000 10000 10000
10000 10000 10000 10000
08125 12068 19613 44248
12500 12500 12500 12500
10156 15085 24516 55310
10000 10000 10000 10000
08125 12068 19613 44248
$7617 Misc Pediatric $11314 Misc Pediatric $18387 Misc Pediatric $41483 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
223-1 223-2 223-3 223-4
OTHER SMALL amp LARGE BOWEL PROCEDURES OTHER SMALL amp LARGE BOWEL PROCEDURES OTHER SMALL amp LARGE BOWEL PROCEDURES OTHER SMALL amp LARGE BOWEL PROCEDURES
442 643
1092 1967
10740 14465 23665 49105
10000 10000 10000 10000
10000 10000 10000 10000
10740 14465 23665 49105
12500 12500 12500 12500
13425 18081 29581 61381
10000 10000 10000 10000
10740 14465 23665 49105
$10069 Misc Pediatric $13561 Misc Pediatric $22186 Misc Pediatric $46036 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
224-1 224-2 224-3 224-4
PERITONEAL ADHESIOLYSIS PERITONEAL ADHESIOLYSIS PERITONEAL ADHESIOLYSIS PERITONEAL ADHESIOLYSIS
540 788
1150 1745
12217 16811 25160 44117
10000 10000 10000 10000
10000 10000 10000 10000
12217 16811 25160 44117
12500 12500 12500 12500
15271 21014 31450 55146
10000 10000 10000 10000
12217 16811 25160 44117
$11453 Misc Pediatric $15760 Misc Pediatric $23588 Misc Pediatric $41360 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
225-1 225-2 225-3 225-4
APPENDECTOMY APPENDECTOMY APPENDECTOMY APPENDECTOMY
157 376 726
1357
07870 11109 18822 36506
10000 10000 10000 10000
10000 10000 10000 10000
07870 11109 18822 36506
12500 12500 12500 12500
09838 13886 23528 45633
10000 10000 10000 10000
07870 11109 18822 36506
$7378 Misc Pediatric $10415 Misc Pediatric $17646 Misc Pediatric $34224 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
226-1 226-2 226-3 226-4
ANAL PROCEDURES ANAL PROCEDURES ANAL PROCEDURES ANAL PROCEDURES
256 413 737
1301
06250 08568 13988 28079
10000 10000 10000 10000
10000 10000 10000 10000
06250 08568 13988 28079
12500 12500 12500 12500
07813 10710 17485 35099
10000 10000 10000 10000
06250 08568 13988 28079
$5859 Misc Pediatric $8033 Misc Pediatric
$13114 Misc Pediatric $26324 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
227-1 HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL 290 10044 10000 10000 10044 12500 12555 10000 10044 $9416 Misc Pediatric Gastroent Adult
227-2 227-3 227-4
HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL
443 813
1503
13150 21598 43086
10000 10000 10000
10000 10000 10000
13150 21598 43086
12500 12500 12500
16438 26998 53858
10000 10000 10000
13150 21598 43086
$12328 Misc Pediatric $20248 Misc Pediatric $40393 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult
228-1 228-2 228-3 228-4
INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES
200 344 629
1321
07221 09757 15211 32407
10000 10000 10000 10000
10000 10000 10000 10000
07221 09757 15211 32407
12500 12500 12500 12500
09026 12196 19014 40509
10000 10000 10000 10000
07221 09757 15211 32407
$6770 Misc Pediatric $9147 Misc Pediatric
$14260 Misc Pediatric $30382 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
229-1 229-2 229-3 229-4
OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES
387 552 976
1760
10850 14346 22850 42572
10000 10000 10000 10000
10000 10000 10000 10000
10850 14346 22850 42572
12500 12500 12500 12500
13563 17933 28563 53215
10000 10000 10000 10000
10850 14346 22850 42572
$10172 Misc Pediatric $13449 Misc Pediatric $21422 Misc Pediatric $39911 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
240-1 240-2 240-3 240-4
DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY
371 429 685
1225
05526 07344 11112 20338
10000 10000 10000 10000
10000 10000 10000 10000
05526 07344 11112 20338
12500 12500 12500 12500
06908 09180 13890 25423
10000 10000 10000 10000
05526 07344 11112 20338
$5181 Misc Pediatric $6885 Misc Pediatric
$10418 Misc Pediatric $19067 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
241-1 241-2 241-3 241-4
PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS
252 325 484
1012
05507 07186 10584 23302
10000 10000 10000 10000
10000 10000 10000 10000
05507 07186 10584 23302
12500 12500 12500 12500
06884 08983 13230 29128
10000 10000 10000 10000
05507 07186 10584 23302
$5163 Misc Pediatric $6737 Misc Pediatric $9923 Misc Pediatric
$21846 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
242-1 242-2 242-3 242-4
MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS
230 319 459
1013
05080 06929 10170 22355
10000 10000 10000 10000
10000 10000 10000 10000
05080 06929 10170 22355
12500 12500 12500 12500
06350 08661 12713 27944
10000 10000 10000 10000
05080 06929 10170 22355
$4763 Misc Pediatric $6496 Misc Pediatric $9534 Misc Pediatric
$20958 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
243-1 243-2 243-3 243-4
OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS
189 280 479
1028
04493 06061 09094 20341
10000 10000 10000 10000
10000 10000 10000 10000
04493 06061 09094 20341
12500 12500 12500 12500
05616 07576 11368 25426
10000 10000 10000 10000
04493 06061 09094 20341
$4212 Misc Pediatric $5682 Misc Pediatric $8526 Misc Pediatric
$19070 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
244-1 244-2 244-3 244-4
DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS
292 361 545
1104
05247 06624 10053 21700
10000 10000 10000 10000
10000 10000 10000 10000
05247 06624 10053 21700
12500 12500 12500 12500
06559 08280 12566 27125
10000 10000 10000 10000
05247 06624 10053 21700
$4919 Misc Pediatric $6210 Misc Pediatric $9425 Misc Pediatric
$20344 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
245-1 245-2 245-3 245-4
INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE
339 413 626
1206
05754 07028 10226 19440
10000 10000 10000 10000
10000 10000 10000 10000
05754 07028 10226 19440
12500 12500 12500 12500
07193 08785 12783 24300
10000 10000 10000 10000
05754 07028 10226 19440
$5394 Misc Pediatric $6589 Misc Pediatric $9587 Misc Pediatric
$18225 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
246-1 246-2 246-3 246-4
GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY
315 404 602 982
06451 07943 11319 19310
10000 10000 10000 10000
10000 10000 10000 10000
06451 07943 11319 19310
12500 12500 12500 12500
08064 09929 14149 24138
10000 10000 10000 10000
06451 07943 11319 19310
$6048 Misc Pediatric $7447 Misc Pediatric
$10612 Misc Pediatric $18103 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
247-1 247-2 247-3 247-4
INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION
288 378 596
1104
04874 06267 09526 19303
10000 10000 10000 10000
10000 10000 10000 10000
04874 06267 09526 19303
12500 12500 12500 12500
06093 07834 11908 24129
10000 10000 10000 10000
04874 06267 09526 19303
$4569 Misc Pediatric $5875 Misc Pediatric $8931 Misc Pediatric
$18097 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
248-1 248-2 248-3 248-4
MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS
334 472 710
1239
05085 07215 10667 20497
10000 10000 10000 10000
10000 10000 10000 10000
05085 07215 10667 20497
12500 12500 12500 12500
06356 09019 13334 25621
10000 10000 10000 10000
05085 07215 10667 20497
$4767 Misc Pediatric $6764 Misc Pediatric
$10000 Misc Pediatric $19216 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
249-1 249-2 249-3 249-4
NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING
219 289 431 938
03648 05058 07201 15935
10000 10000 10000 10000
10000 10000 10000 10000
03648 05058 07201 15935
12500 12500 12500 12500
04560 06323 09001 19919
10000 10000 10000 10000
03648 05058 07201 15935
$3420 Misc Pediatric $4742 Misc Pediatric $6751 Misc Pediatric
$14939 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
251-1 251-2 251-3 251-4
ABDOMINAL PAIN ABDOMINAL PAIN ABDOMINAL PAIN ABDOMINAL PAIN
217 288 418 813
04492 05786 07857 14149
10000 10000 10000 10000
10000 10000 10000 10000
04492 05786 07857 14149
12500 12500 12500 12500
05615 07233 09821 17686
10000 10000 10000 10000
04492 05786 07857 14149
$4211 Misc Pediatric $5424 Misc Pediatric $7366 Misc Pediatric
$13265 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
252-1 252-2 252-3 252-4
MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE
331 412 635
1248
04904 06490 09833 19841
10000 10000 10000 10000
10000 10000 10000 10000
04904 06490 09833 19841
12500 12500 12500 12500
06130 08113 12291 24801
10000 10000 10000 10000
04904 06490 09833 19841
$4598 Misc Pediatric $6084 Misc Pediatric $9218 Misc Pediatric
$18601 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
253-1 253-2 253-3 253-4
OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE
251 334 504 878
05108 06777 10020 18601
10000 10000 10000 10000
10000 10000 10000 10000
05108 06777 10020 18601
12500 12500 12500 12500
06385 08471 12525 23251
10000 10000 10000 10000
05108 06777 10020 18601
$4789 Misc Pediatric $6353 Misc Pediatric $9394 Misc Pediatric
$17438 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
254-1 254-2 254-3 254-4
OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES
252 353 530
1066
04519 06282 09117 18053
10000 10000 10000 10000
10000 10000 10000 10000
04519 06282 09117 18053
12500 12500 12500 12500
05649 07853 11396 22566
10000 10000 10000 10000
04519 06282 09117 18053
$4237 Misc Pediatric $5889 Misc Pediatric $8547 Misc Pediatric
$16925 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
260-1 260-2 260-3 260-4
MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES
469 611
1081 2181
15085 19596 31029 63824
10000 10000 10000 10000
10000 10000 10000 10000
15085 19596 31029 63824
12500 12500 12500 12500
18856 24495 38786 79780
10000 10000 10000 10000
15085 19596 31029 63824
$14142 Misc Pediatric $18371 Misc Pediatric $29090 Misc Pediatric $59835 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
261-1 261-2 261-3 261-4
MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES
450 706
1116 1993
13049 18250 25711 50241
10000 10000 10000 10000
10000 10000 10000 10000
13049 18250 25711 50241
12500 12500 12500 12500
16311 22813 32139 62801
10000 10000 10000 10000
13049 18250 25711 50241
$12233 Misc Pediatric $17109 Misc Pediatric $24104 Misc Pediatric $47101 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
262-1 262-2 262-3 262-4
CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC
405 567 898
1751
11851 15637 23607 46363
10000 10000 10000 10000
10000 10000 10000 10000
11851 15637 23607 46363
12500 12500 12500 12500
14814 19546 29509 57954
10000 10000 10000 10000
11851 15637 23607 46363
$11110 Misc Pediatric $14660 Misc Pediatric $22132 Misc Pediatric $43465 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
263-1 263-2 263-3 263-4
LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY
236 364 635
1384
09345 12310 17676 36726
10000 10000 10000 10000
10000 10000 10000 10000
09345 12310 17676 36726
12500 12500 12500 12500
11681 15388 22095 45908
10000 10000 10000 10000
09345 12310 17676 36726
$8761 Misc Pediatric $11541 Misc Pediatric $16571 Misc Pediatric $34431 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
264-1 264-2 264-3 264-4
OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES
453 543
1067 2148
12526 13732 23159 51901
10000 10000 10000 10000
10000 10000 10000 10000
12526 13732 23159 51901
12500 12500 12500 12500
15658 17165 28949 64876
10000 10000 10000 10000
12526 13732 23159 51901
$11743 Misc Pediatric $12874 Misc Pediatric $21712 Misc Pediatric $48657 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
279-1 279-2 279-3 279-4
HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS
280 361 580
1157
04712 05945 09594 23269
10000 10000 10000 10000
10000 10000 10000 10000
04712 05945 09594 23269
12500 12500 12500 12500
05890 07431 11993 29086
10000 10000 10000 10000
04712 05945 09594 23269
$4418 Misc Pediatric $5573 Misc Pediatric $8994 Misc Pediatric
$21815 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
280-1 280-2 280-3 280-4
ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE
298 344 532
1047
04734 06141 09718 21422
10000 10000 10000 10000
10000 10000 10000 10000
04734 06141 09718 21422
12500 12500 12500 12500
05918 07676 12148 26778
10000 10000 10000 10000
04734 06141 09718 21422
$4438 Misc Pediatric $5757 Misc Pediatric $9111 Misc Pediatric
$20083 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
281-1 281-2 281-3 281-4
MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS
357 421 610 974
05079 07553 10730 17519
10000 10000 10000 10000
10000 10000 10000 10000
05079 07553 10730 17519
12500 12500 12500 12500
06349 09441 13413 21899
10000 10000 10000 10000
05079 07553 10730 17519
$4762 Misc Pediatric $7081 Misc Pediatric
$10059 Misc Pediatric $16424 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
282-1 282-2 282-3 282-4
DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY
318 403 649
1381
05507 07067 11213 27863
10000 10000 10000 10000
10000 10000 10000 10000
05507 07067 11213 27863
12500 12500 12500 12500
06884 08834 14016 34829
10000 10000 10000 10000
05507 07067 11213 27863
$5163 Misc Pediatric $6625 Misc Pediatric
$10512 Misc Pediatric $26122 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
283-1 283-2 283-3 283-4
OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER
286 338 505 947
04913 06300 09246 18497
10000 10000 10000 10000
10000 10000 10000 10000
04913 06300 09246 18497
12500 12500 12500 12500
06141 07875 11558 23121
10000 10000 10000 10000
04913 06300 09246 18497
$4606 Misc Pediatric $5906 Misc Pediatric $8668 Misc Pediatric
$17341 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
284-1 284-2 284-3 284-4
DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT
245 344 536
1059
05403 07447 10804 21256
10000 10000 10000 10000
10000 10000 10000 10000
05403 07447 10804 21256
12500 12500 12500 12500
06754 09309 13505 26570
10000 10000 10000 10000
05403 07447 10804 21256
$5065 Misc Pediatric $6982 Misc Pediatric
$10129 Misc Pediatric $19928 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
301-1 301-2 301-3 301-4
HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT
365 396 535
1280
18140 19690 25026 39991
10000 10000 10000 10000
10000 10000 10000 10000
18140 19690 25026 39991
12500 12500 12500 12500
22675 24613 31283 49989
10000 10000 10000 10000
18140 19690 25026 39991
$17006 Misc Pediatric $18459 Misc Pediatric $23462 Misc Pediatric $37492 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
302-1 302-2 302-3 302-4
KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT
296 338 519
1248
17428 19132 23798 43468
10000 10000 10000 10000
10000 10000 10000 10000
17428 19132 23798 43468
12500 12500 12500 12500
21785 23915 29748 54335
10000 10000 10000 10000
17428 19132 23798 43468
$16339 Misc Pediatric $17936 Misc Pediatric $22311 Misc Pediatric $40751 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
303-1 303-2 303-3 303-4
DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK
450 570 857
1607
47039 55422 77549
105744
10000 10000 10000 10000
10000 10000 10000 10000
47039 55422 77549
105744
12500 12500 12500 12500
58799 69278 96936
132180
10000 10000 10000 10000
47039 55422 77549
105744
$44099 Misc Pediatric $51958 Misc Pediatric $72702 Misc Pediatric $99135 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
304-1 304-2 304-3 304-4
DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK
300 405 735
1776
29720 35298 49644 81663
10000 10000 10000 10000
10000 10000 10000 10000
29720 35298 49644 81663
12500 12500 12500 12500
37150 44123 62055
102079
10000 10000 10000 10000
29720 35298 49644 81663
$27863 Misc Pediatric $33092 Misc Pediatric $46541 Misc Pediatric $76559 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
305-1 305-2 305-3 305-4
AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES
540 737
1137 1987
10654 14043 21843 42156
10000 10000 10000 10000
10000 10000 10000 10000
10654 14043 21843 42156
12500 12500 12500 12500
13318 17554 27304 52695
10000 10000 10000 10000
10654 14043 21843 42156
$9988 Misc Pediatric $13165 Misc Pediatric $20478 Misc Pediatric $39521 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
308-1 308-2 308-3 308-4
HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT
419 496 697
1264
13101 15854 21518 36506
10000 10000 10000 10000
10000 10000 10000 10000
13101 15854 21518 36506
12500 12500 12500 12500
16376 19818 26898 45633
10000 10000 10000 10000
13101 15854 21518 36506
$12282 Misc Pediatric $14863 Misc Pediatric $20173 Misc Pediatric $34224 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
309-1 309-2 309-3 309-4
HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT
278 490 865
1887
11482 16231 23288 42408
10000 10000 10000 10000
10000 10000 10000 10000
11482 16231 23288 42408
12500 12500 12500 12500
14353 20289 29110 53010
10000 10000 10000 10000
11482 16231 23288 42408
$10764 Misc Pediatric $15217 Misc Pediatric $21833 Misc Pediatric $39758 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
310-1 310-2 310-3 310-4
INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION
181 302 624
1622
08926 11888 17911 41661
10000 10000 10000 10000
10000 10000 10000 10000
08926 11888 17911 41661
12500 12500 12500 12500
11158 14860 22389 52076
10000 10000 10000 10000
08926 11888 17911 41661
$8368 Misc Pediatric $11145 Misc Pediatric $16792 Misc Pediatric $39057 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
312-1 312-2
SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES
538 940
12555 18447
10000 10000
10000 10000
12555 18447
12500 12500
15694 23059
10000 10000
12555 18447
$11770 Misc Pediatric $17294 Misc Pediatric
Misc Adult Misc Adult
312-3 312-4
SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES
1846 3284
31356 71148
10000 10000
10000 10000
31356 71148
12500 12500
39195 88935
10000 10000
31356 71148
$29396 Misc Pediatric $66701 Misc Pediatric
Misc Adult Misc Adult
313-1 313-2 313-3 313-4
KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT
270 444 785
1659
10852 15212 22743 43349
10000 10000 10000 10000
10000 10000 10000 10000
10852 15212 22743 43349
12500 12500 12500 12500
13565 19015 28429 54186
10000 10000 10000 10000
10852 15212 22743 43349
$10174 Misc Pediatric $14261 Misc Pediatric $21322 Misc Pediatric $40640 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
314-1 314-2 314-3 314-4
FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES
257 507 810
1579
09291 11320 16006 32885
10000 10000 10000 10000
10000 10000 10000 10000
09291 11320 16006 32885
12500 12500 12500 12500
11614 14150 20008 41106
10000 10000 10000 10000
09291 11320 16006 32885
$8710 Misc Pediatric $10613 Misc Pediatric $15006 Misc Pediatric $30830 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
315-1 315-2 315-3 315-4
SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES
185 267 649
1473
08387 15912 22542 44542
10000 10000 10000 10000
10000 10000 10000 10000
08387 15912 22542 44542
12500 12500 12500 12500
10484 19890 28178 55678
10000 10000 10000 10000
08387 15912 22542 44542
$7863 Misc Pediatric $14918 Misc Pediatric $21133 Misc Pediatric $41758 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
316-1 316-2 316-3 316-4
HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES
229 396 727
1430
07195 10564 17143 34568
10000 10000 10000 10000
10000 10000 10000 10000
07195 10564 17143 34568
12500 12500 12500 12500
08994 13205 21429 43210
10000 10000 10000 10000
07195 10564 17143 34568
$6745 Misc Pediatric $9904 Misc Pediatric
$16072 Misc Pediatric $32408 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
317-1 317-2 317-3 317-4
TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES
300 544
1030 2038
08204 11764 19738 43378
10000 10000 10000 10000
10000 10000 10000 10000
08204 11764 19738 43378
12500 12500 12500 12500
10255 14705 24673 54223
10000 10000 10000 10000
08204 11764 19738 43378
$7691 Misc Pediatric $11029 Misc Pediatric $18504 Misc Pediatric $40667 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
320-1 320-2 320-3 320-4
OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES
229 474 900
1844
09314 14085 21498 40942
10000 10000 10000 10000
10000 10000 10000 10000
09314 14085 21498 40942
12500 12500 12500 12500
11643 17606 26873 51178
10000 10000 10000 10000
09314 14085 21498 40942
$8732 Misc Pediatric $13205 Misc Pediatric $20154 Misc Pediatric $38383 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
321-1 321-2 321-3 321-4
CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP
174 322 869
1740
16800 21292 35737 65431
10000 10000 10000 10000
10000 10000 10000 10000
16800 21292 35737 65431
12500 12500 12500 12500
21000 26615 44671 81789
10000 10000 10000 10000
16800 21292 35737 65431
$15750 Misc Pediatric $19961 Misc Pediatric $33503 Misc Pediatric $61342 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
340-1 340-2 340-3 340-4
FRACTURE OF FEMUR FRACTURE OF FEMUR FRACTURE OF FEMUR FRACTURE OF FEMUR
307 350 507 717
04052 05213 07741 13545
10000 10000 10000 10000
10000 10000 10000 10000
04052 05213 07741 13545
12500 12500 12500 12500
05065 06516 09676 16931
10000 10000 10000 10000
04052 05213 07741 13545
$3799 Misc Pediatric $4887 Misc Pediatric $7257 Misc Pediatric
$12698 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
341-1 341-2 341-3 341-4
FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP
302 365 480 981
04685 05732 07835 19346
10000 10000 10000 10000
10000 10000 10000 10000
04685 05732 07835 19346
12500 12500 12500 12500
05856 07165 09794 24183
10000 10000 10000 10000
04685 05732 07835 19346
$4392 Misc Pediatric $5374 Misc Pediatric $7345 Misc Pediatric
$18137 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
342-1 342-2 342-3 342-4
FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK
223 336 523
1073
04199 06015 09030 19468
10000 10000 10000 10000
10000 10000 10000 10000
04199 06015 09030 19468
12500 12500 12500 12500
05249 07519 11288 24335
10000 10000 10000 10000
04199 06015 09030 19468
$3937 Misc Pediatric $5639 Misc Pediatric $8466 Misc Pediatric
$18251 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
343-1 343-2 343-3 343-4
MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG
381 462 768
1278
06313 07919 12982 22512
10000 10000 10000 10000
10000 10000 10000 10000
06313 07919 12982 22512
12500 12500 12500 12500
07891 09899 16228 28140
10000 10000 10000 10000
06313 07919 12982 22512
$5918 Misc Pediatric $7424 Misc Pediatric
$12171 Misc Pediatric $21105 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
344-1 344-2 344-3 344-4
OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS
510 624 996
1727
06188 08269 12369 20626
10000 10000 10000 10000
10000 10000 10000 10000
06188 08269 12369 20626
12500 12500 12500 12500
07735 10336 15461 25783
10000 10000 10000 10000
06188 08269 12369 20626
$5801 Misc Pediatric $7752 Misc Pediatric
$11596 Misc Pediatric $19337 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
346-1 346-2 346-3 346-4
CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS
312 418 742
1507
05246 07180 12230 29854
10000 10000 10000 10000
10000 10000 10000 10000
05246 07180 12230 29854
12500 12500 12500 12500
06558 08975 15288 37318
10000 10000 10000 10000
05246 07180 12230 29854
$4918 Misc Pediatric $6731 Misc Pediatric
$11466 Misc Pediatric $27988 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
347-1 347-2 347-3 347-4
OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES
288 388 534
1184
05202 07038 09895 23177
10000 10000 10000 10000
10000 10000 10000 10000
05202 07038 09895 23177
12500 12500 12500 12500
06503 08798 12369 28971
10000 10000 10000 10000
05202 07038 09895 23177
$4877 Misc Pediatric $6598 Misc Pediatric $9277 Misc Pediatric
$21728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
349-1 349-2 349-3 349-4
MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE
226 480 806
1387
04381 06459 10302 19261
10000 10000 10000 10000
10000 10000 10000 10000
04381 06459 10302 19261
12500 12500 12500 12500
05476 08074 12878 24076
10000 10000 10000 10000
04381 06459 10302 19261
$4107 Misc Pediatric $6055 Misc Pediatric $9658 Misc Pediatric
$18057 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
351-1 351-2 351-3 351-4
OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES
252 352 544
1111
04074 05668 08930 19109
10000 10000 10000 10000
10000 10000 10000 10000
04074 05668 08930 19109
12500 12500 12500 12500
05093 07085 11163 23886
10000 10000 10000 10000
04074 05668 08930 19109
$3819 Misc Pediatric $5314 Misc Pediatric $8372 Misc Pediatric
$17915 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
361-1 361-2 361-3 361-4
SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES
407 758
1393 2857
11097 14459 21415 45412
10000 10000 10000 10000
10000 10000 10000 10000
11097 14459 21415 45412
12500 12500 12500 12500
13871 18074 26769 56765
10000 10000 10000 10000
11097 14459 21415 45412
$10403 Misc Pediatric $13555 Misc Pediatric $20077 Misc Pediatric $42574 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
362-1 362-2 362-3 362-4
MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES
179 233 597
1380
10091 13554 17862 38257
10000 10000 10000 10000
10000 10000 10000 10000
10091 13554 17862 38257
12500 12500 12500 12500
12614 16943 22328 47821
10000 10000 10000 10000
10091 13554 17862 38257
$9460 Misc Pediatric $12707 Misc Pediatric $16746 Misc Pediatric $35866 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
363-1 363-2 363-3 363-4
BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY
209 314 532
1706
08797 14900 19039 35420
10000 10000 10000 10000
10000 10000 10000 10000
08797 14900 19039 35420
12500 12500 12500 12500
10996 18625 23799 44275
10000 10000 10000 10000
08797 14900 19039 35420
$8247 Misc Pediatric $13969 Misc Pediatric $17849 Misc Pediatric $33206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
364-1 364-2 364-3 364-4
OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES
289 508 943
1919
07645 10877 16986 30643
10000 10000 10000 10000
10000 10000 10000 10000
07645 10877 16986 30643
12500 12500 12500 12500
09556 13596 21233 38304
10000 10000 10000 10000
07645 10877 16986 30643
$7167 Misc Pediatric $10197 Misc Pediatric $15924 Misc Pediatric $28728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
380-1 380-2 380-3 380-4
SKIN ULCERS SKIN ULCERS SKIN ULCERS SKIN ULCERS
416 498 784
1662
05289 06545 09424 17199
10000 10000 10000 10000
10000 10000 10000 10000
05289 06545 09424 17199
12500 12500 12500 12500
06611 08181 11780 21499
10000 10000 10000 10000
05289 06545 09424 17199
$4958 Misc Pediatric $6136 Misc Pediatric $8835 Misc Pediatric
$16124 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
381-1 381-2 381-3 381-4
MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS
300 428 671
1406
03883 05748 09734 27512
10000 10000 10000 10000
10000 10000 10000 10000
03883 05748 09734 27512
12500 12500 12500 12500
04854 07185 12168 34390
10000 10000 10000 10000
03883 05748 09734 27512
$3640 Misc Pediatric $5389 Misc Pediatric $9126 Misc Pediatric
$25793 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
382-1 382-2 382-3 382-4
MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS
381 432 645
1003
03521 05612 09634 15729
10000 10000 10000 10000
10000 10000 10000 10000
03521 05612 09634 15729
12500 12500 12500 12500
04401 07015 12043 19661
10000 10000 10000 10000
03521 05612 09634 15729
$3301 Misc Pediatric $5261 Misc Pediatric $9032 Misc Pediatric
$14746 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
383-1 383-2 383-3 383-4
CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS
294 412 617
1198
04148 05905 09147 19560
10000 10000 10000 10000
10000 10000 10000 10000
04148 05905 09147 19560
12500 12500 12500 12500
05185 07381 11434 24450
10000 10000 10000 10000
04148 05905 09147 19560
$3889 Misc Pediatric $5536 Misc Pediatric $8575 Misc Pediatric
$18338 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
384-1 384-2 384-3 384-4
CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE
193 301 493
1134
04752 06220 08932 20168
10000 10000 10000 10000
10000 10000 10000 10000
04752 06220 08932 20168
12500 12500 12500 12500
05940 07775 11165 25210
10000 10000 10000 10000
04752 06220 08932 20168
$4455 Misc Pediatric $5831 Misc Pediatric $8374 Misc Pediatric
$18908 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
385-1 385-2 385-3 385-4
OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS
248 353 565
1295
03496 05103 07974 19128
10000 10000 10000 10000
10000 10000 10000 10000
03496 05103 07974 19128
12500 12500 12500 12500
04370 06379 09968 23910
10000 10000 10000 10000
03496 05103 07974 19128
$3278 Misc Pediatric $4784 Misc Pediatric $7476 Misc Pediatric
$17933 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
401-1 401-2 401-3 401-4
PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES
303 427 844
2452
13697 18347 29058 71913
10000 10000 10000 10000
10000 10000 10000 10000
13697 18347 29058 71913
12500 12500 12500 12500
17121 22934 36323 89891
10000 10000 10000 10000
13697 18347 29058 71913
$12841 Misc Pediatric $17200 Misc Pediatric $27242 Misc Pediatric $67418 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
403-1 403-2 403-3 403-4
PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY
183 222 497
1867
12813 14411 21531 61151
10000 10000 10000 10000
10000 10000 10000 10000
12813 14411 21531 61151
12500 12500 12500 12500
16016 18014 26914 76439
10000 10000 10000 10000
12813 14411 21531 61151
$12012 Misc Pediatric $13510 Misc Pediatric $20185 Misc Pediatric $57329 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
404-1 404-2 404-3 404-4
THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES
130 216 659
1638
07364 09479 18990 42519
10000 10000 10000 10000
10000 10000 10000 10000
07364 09479 18990 42519
12500 12500 12500 12500
09205 11849 23738 53149
10000 10000 10000 10000
07364 09479 18990 42519
$6904 Misc Pediatric $8887 Misc Pediatric
$17803 Misc Pediatric $39862 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
405-1 405-2 405-3 405-4
OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS
419 571 966
2131
11123 14210 21421 48796
10000 10000 10000 10000
10000 10000 10000 10000
11123 14210 21421 48796
12500 12500 12500 12500
13904 17763 26776 60995
10000 10000 10000 10000
11123 14210 21421 48796
$10428 Misc Pediatric $13322 Misc Pediatric $20082 Misc Pediatric $45746 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
420-1 420-2 420-3 420-4
DIABETES DIABETES DIABETES DIABETES
261 275 427 935
03897 05302 07862 19671
10000 10000 10000 10000
10000 10000 10000 10000
03897 05302 07862 19671
12500 12500 12500 12500
04871 06628 09828 24589
10000 10000 10000 10000
03897 05302 07862 19671
$3653 Misc Pediatric $4971 Misc Pediatric $7371 Misc Pediatric
$18442 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
421-1 421-2 421-3 421-4
MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS
351 483 676
1375
03211 05227 08190 17446
10000 10000 10000 10000
10000 10000 10000 10000
03211 05227 08190 17446
12500 12500 12500 12500
04014 06534 10238 21808
10000 10000 10000 10000
03211 05227 08190 17446
$3010 Misc Pediatric $4900 Misc Pediatric $7678 Misc Pediatric
$16356 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
422-1 422-2 422-3 422-4
HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS
199 291 445 914
02848 04625 06828 14444
10000 10000 10000 10000
10000 10000 10000 10000
02848 04625 06828 14444
12500 12500 12500 12500
03560 05781 08535 18055
10000 10000 10000 10000
02848 04625 06828 14444
$2670 Misc Pediatric $4336 Misc Pediatric $6401 Misc Pediatric
$13541 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
423-1 423-2 423-3 423-4
INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM
272 363 573
1504
04421 05846 09540 27384
10000 10000 10000 10000
10000 10000 10000 10000
04421 05846 09540 27384
12500 12500 12500 12500
05526 07308 11925 34230
10000 10000 10000 10000
04421 05846 09540 27384
$4145 Misc Pediatric $5481 Misc Pediatric $8944 Misc Pediatric
$25673 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
424-1 424-2 424-3 424-4
OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS
259 397 605
1147
04342 06514 09768 21520
10000 10000 10000 10000
10000 10000 10000 10000
04342 06514 09768 21520
12500 12500 12500 12500
05428 08143 12210 26900
10000 10000 10000 10000
04342 06514 09768 21520
$4071 Misc Pediatric $6107 Misc Pediatric $9158 Misc Pediatric
$20175 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
425-1 425-2 425-3
ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED
241 302 460
04017 05132 07667
10000 10000 10000
10000 10000 10000
04017 05132 07667
12500 12500 12500
05021 06415 09584
10000 10000 10000
04017 05132 07667
$3766 Misc Pediatric $4811 Misc Pediatric $7188 Misc Pediatric
Misc Adult Misc Adult Misc Adult
425-4 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 946 16767 10000 10000 16767 12500 20959 10000 16767 $15719 Misc Pediatric Misc Adult 440-1 440-2 440-3 440-4
KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT
458 561 864
2088
44667 50078 60562 99171
10000 10000 10000 10000
10000 10000 10000 10000
44667 50078 60562 99171
12500 12500 12500 12500
55834 62598 75703
123964
10000 10000 10000 10000
44667 50078 60562 99171
$41875 Misc Pediatric $46948 Misc Pediatric $56777 Misc Pediatric $92973 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
441-1 441-2 441-3 441-4
MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES
474 726 994
2196
14386 21567 29549 61841
10000 10000 10000 10000
10000 10000 10000 10000
14386 21567 29549 61841
12500 12500 12500 12500
17983 26959 36936 77301
10000 10000 10000 10000
14386 21567 29549 61841
$13487 Misc Pediatric $20219 Misc Pediatric $27702 Misc Pediatric $57976 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
442-1 442-2 442-3 442-4
KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY
325 422 795
1671
13139 15537 23456 49226
10000 10000 10000 10000
10000 10000 10000 10000
13139 15537 23456 49226
12500 12500 12500 12500
16424 19421 29320 61533
10000 10000 10000 10000
13139 15537 23456 49226
$12318 Misc Pediatric $14566 Misc Pediatric $21990 Misc Pediatric $46149 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
443-1 443-2 443-3 443-4
KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY
253 356 802
1752
10883 12834 18814 40742
10000 10000 10000 10000
10000 10000 10000 10000
10883 12834 18814 40742
12500 12500 12500 12500
13604 16043 23518 50928
10000 10000 10000 10000
10883 12834 18814 40742
$10203 Misc Pediatric $12032 Misc Pediatric $17638 Misc Pediatric $38196 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
444-1 444-2 444-3 444-4
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY
264 447 933
1617
09410 12604 20686 38830
10000 10000 10000 10000
10000 10000 10000 10000
09410 12604 20686 38830
12500 12500 12500 12500
11763 15755 25858 48538
10000 10000 10000 10000
09410 12604 20686 38830
$8822 Misc Pediatric $11816 Misc Pediatric $19393 Misc Pediatric $36403 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
445-1 445-2 445-3 445-4
OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES
190 319 781
1545
08552 11610 15964 31570
10000 10000 10000 10000
10000 10000 10000 10000
08552 11610 15964 31570
12500 12500 12500 12500
10690 14513 19955 39463
10000 10000 10000 10000
08552 11610 15964 31570
$8018 Misc Pediatric $10884 Misc Pediatric $14966 Misc Pediatric $29597 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
446-1 446-2 446-3 446-4
URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES
188 261 612
1363
06758 08690 14202 30173
10000 10000 10000 10000
10000 10000 10000 10000
06758 08690 14202 30173
12500 12500 12500 12500
08448 10863 17753 37716
10000 10000 10000 10000
06758 08690 14202 30173
$6336 Misc Pediatric $8147 Misc Pediatric
$13314 Misc Pediatric $28287 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
447-1 447-2 447-3 447-4
OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES
228 365 728
1787
11479 13294 19661 43932
10000 10000 10000 10000
10000 10000 10000 10000
11479 13294 19661 43932
12500 12500 12500 12500
14349 16618 24576 54915
10000 10000 10000 10000
11479 13294 19661 43932
$10762 Misc Pediatric $12463 Misc Pediatric $18432 Misc Pediatric $41186 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
460-1 460-2 460-3 460-4
RENAL FAILURE RENAL FAILURE RENAL FAILURE RENAL FAILURE
299 376 496
1115
04323 06061 07896 19936
10000 10000 10000 10000
10000 10000 10000 10000
04323 06061 07896 19936
12500 12500 12500 12500
05404 07576 09870 24920
10000 10000 10000 10000
04323 06061 07896 19936
$4053 Misc Pediatric $5682 Misc Pediatric $7403 Misc Pediatric
$18690 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
461-1 461-2 461-3 461-4
KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY
271 374 601
1108
04315 05992 09498 16929
10000 10000 10000 10000
10000 10000 10000 10000
04315 05992 09498 16929
12500 12500 12500 12500
05394 07490 11873 21161
10000 10000 10000 10000
04315 05992 09498 16929
$4045 Misc Pediatric $5618 Misc Pediatric $8904 Misc Pediatric
$15871 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
462-1 462-2 462-3 462-4
NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS
260 370 656
1359
03798 05298 09439 23905
10000 10000 10000 10000
10000 10000 10000 10000
03798 05298 09439 23905
12500 12500 12500 12500
04748 06623 11799 29881
10000 10000 10000 10000
03798 05298 09439 23905
$3561 Misc Pediatric $4967 Misc Pediatric $8849 Misc Pediatric
$22411 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
463-1 463-2 463-3 463-4
KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS
268 352 507 910
04120 05628 07879 14066
10000 10000 10000 10000
10000 10000 10000 10000
04120 05628 07879 14066
12500 12500 12500 12500
05150 07035 09849 17583
10000 10000 10000 10000
04120 05628 07879 14066
$3863 Misc Pediatric $5276 Misc Pediatric $7387 Misc Pediatric
$13187 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
465-1 465-2 465-3 465-4
URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION
165 202 380 860
04374 05548 08751 18922
10000 10000 10000 10000
10000 10000 10000 10000
04374 05548 08751 18922
12500 12500 12500 12500
05468 06935 10939 23653
10000 10000 10000 10000
04374 05548 08751 18922
$4101 Misc Pediatric $5201 Misc Pediatric $8204 Misc Pediatric
$17739 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
466-1 466-2 466-3 466-4
MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC
221 343 533 971
03576 05752 08974 17498
10000 10000 10000 10000
10000 10000 10000 10000
03576 05752 08974 17498
12500 12500 12500 12500
04470 07190 11218 21873
10000 10000 10000 10000
03576 05752 08974 17498
$3353 Misc Pediatric $5393 Misc Pediatric $8413 Misc Pediatric
$16404 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
468-1 468-2 468-3 468-4
OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS
246 335 509
1057
04152 05935 08698 18661
10000 10000 10000 10000
10000 10000 10000 10000
04152 05935 08698 18661
12500 12500 12500 12500
05190 07419 10873 23326
10000 10000 10000 10000
04152 05935 08698 18661
$3893 Misc Pediatric $5564 Misc Pediatric $8154 Misc Pediatric
$17495 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
480-1 480-2 480-3 480-4
MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES
180 241 618
1422
12119 13477 20992 45258
10000 10000 10000 10000
10000 10000 10000 10000
12119 13477 20992 45258
12500 12500 12500 12500
15149 16846 26240 56573
10000 10000 10000 10000
12119 13477 20992 45258
$11362 Misc Pediatric $12635 Misc Pediatric $19680 Misc Pediatric $42429 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
481-1 481-2 481-3 481-4
PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES
228 267 830
1810
06794 11922 17939 41143
10000 10000 10000 10000
10000 10000 10000 10000
06794 11922 17939 41143
12500 12500 12500 12500
08493 14903 22424 51429
10000 10000 10000 10000
06794 11922 17939 41143
$6369 Misc Pediatric $11177 Misc Pediatric $16818 Misc Pediatric $38572 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
482-1 482-2 482-3 482-4
TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY
169 278 716
1341
05918 07555 14662 30717
10000 10000 10000 10000
10000 10000 10000 10000
05918 07555 14662 30717
12500 12500 12500 12500
07398 09444 18328 38396
10000 10000 10000 10000
05918 07555 14662 30717
$5548 Misc Pediatric $7083 Misc Pediatric
$13746 Misc Pediatric $28797 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
483-1 483-2 483-3 483-4
TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES
203 541
1127 1970
06074 11326 22018 44244
10000 10000 10000 10000
10000 10000 10000 10000
06074 11326 22018 44244
12500 12500 12500 12500
07593 14158 27523 55305
10000 10000 10000 10000
06074 11326 22018 44244
$5694 Misc Pediatric $10618 Misc Pediatric $20642 Misc Pediatric $41479 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
484-1 484-2 484-3 484-4
OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
250 191 502
1578
07704 11762 15177 36555
10000 10000 10000 10000
10000 10000 10000 10000
07704 11762 15177 36555
12500 12500 12500 12500
09630 14703 18971 45694
10000 10000 10000 10000
07704 11762 15177 36555
$7223 Misc Pediatric $11027 Misc Pediatric $14228 Misc Pediatric $34270 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
500-1 500-2 500-3 500-4
MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM
266 431 601
1109
03789 05904 09172 17461
10000 10000 10000 10000
10000 10000 10000 10000
03789 05904 09172 17461
12500 12500 12500 12500
04736 07380 11465 21826
10000 10000 10000 10000
03789 05904 09172 17461
$3552 Misc Pediatric $5535 Misc Pediatric $8599 Misc Pediatric
$16370 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
501-1 501-2 501-3 501-4
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY
258 351 547
1074
04044 05542 08322 16765
10000 10000 10000 10000
10000 10000 10000 10000
04044 05542 08322 16765
12500 12500 12500 12500
05055 06928 10403 20956
10000 10000 10000 10000
04044 05542 08322 16765
$3791 Misc Pediatric $5196 Misc Pediatric $7802 Misc Pediatric
$15717 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
510-1 510-2 510-3 510-4
PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS
244 387 892
1787
11433 14140 25807 52317
10000 10000 10000 10000
10000 10000 10000 10000
11433 14140 25807 52317
12500 12500 12500 12500
14291 17675 32259 65396
10000 10000 10000 10000
11433 14140 25807 52317
$10718 Misc Pediatric $13256 Misc Pediatric $24194 Misc Pediatric $49047 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
511-1 511-2 511-3 511-4
UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY
330 488 862
1777
11911 14923 22750 49888
10000 10000 10000 10000
10000 10000 10000 10000
11911 14923 22750 49888
12500 12500 12500 12500
14889 18654 28438 62360
10000 10000 10000 10000
11911 14923 22750 49888
$11167 Misc Pediatric $13990 Misc Pediatric $21328 Misc Pediatric $46770 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
512-1 512-2 512-3 512-4
UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG
217 308 682
1629
10603 12410 19879 45702
10000 10000 10000 10000
10000 10000 10000 10000
10603 12410 19879 45702
12500 12500 12500 12500
13254 15513 24849 57128
10000 10000 10000 10000
10603 12410 19879 45702
$9940 Misc Pediatric $11634 Misc Pediatric $18637 Misc Pediatric $42846 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
513-1 513-2 513-3 513-4
UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
186 251 564
1508
08515 10026 16283 40387
10000 10000 10000 10000
10000 10000 10000 10000
08515 10026 16283 40387
12500 12500 12500 12500
10644 12533 20354 50484
10000 10000 10000 10000
08515 10026 16283 40387
$7983 Misc Pediatric $9399 Misc Pediatric
$15265 Misc Pediatric $37863 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
514-1 514-2 514-3 514-4
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
140 172 529
1557
07298 09618 15881 40691
10000 10000 10000 10000
10000 10000 10000 10000
07298 09618 15881 40691
12500 12500 12500 12500
09123 12023 19851 50864
10000 10000 10000 10000
07298 09618 15881 40691
$6842 Misc Pediatric $9017 Misc Pediatric
$14888 Misc Pediatric $38148 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
517-1 517-2 517-3 517-4
DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES
192 289 663
1364
06030 08036 13633 29709
10000 10000 10000 10000
10000 10000 10000 10000
06030 08036 13633 29709
12500 12500 12500 12500
07538 10045 17041 37136
10000 10000 10000 10000
06030 08036 13633 29709
$5653 Misc Pediatric $7534 Misc Pediatric
$12781 Misc Pediatric $27852 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
518-1 518-2 518-3 518-4
OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
223 382 837
1827
06924 10040 18032 44556
10000 10000 10000 10000
10000 10000 10000 10000
06924 10040 18032 44556
12500 12500 12500 12500
08655 12550 22540 55695
10000 10000 10000 10000
06924 10040 18032 44556
$6491 Misc Pediatric $9413 Misc Pediatric
$16905 Misc Pediatric $41771 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
519-1 519-2 519-3 519-4
UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA
206 279 613
1485
08286 10051 17505 39433
10000 10000 10000 10000
10000 10000 10000 10000
08286 10051 17505 39433
12500 12500 12500 12500
10358 12564 21881 49291
10000 10000 10000 10000
08286 10051 17505 39433
$7768 Misc Pediatric $9423 Misc Pediatric
$16411 Misc Pediatric $36968 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
530-1 530-2 530-3 530-4
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
310 385 643
1178
04420 06163 09992 18972
10000 10000 10000 10000
10000 10000 10000 10000
04420 06163 09992 18972
12500 12500 12500 12500
05525 07704 12490 23715
10000 10000 10000 10000
04420 06163 09992 18972
$4144 Misc Pediatric $5778 Misc Pediatric $9368 Misc Pediatric
$17786 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
531-1 531-2 531-3 531-4
FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS
266 383 638
1303
04544 06407 09987 20595
10000 10000 10000 10000
10000 10000 10000 10000
04544 06407 09987 20595
12500 12500 12500 12500
05680 08009 12484 25744
10000 10000 10000 10000
04544 06407 09987 20595
$4260 Misc Pediatric $6007 Misc Pediatric $9363 Misc Pediatric
$19308 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
532-1 532-2 532-3 532-4
MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
177 237 434
1003
03922 04787 07941 17650
10000 10000 10000 10000
10000 10000 10000 10000
03922 04787 07941 17650
12500 12500 12500 12500
04903 05984 09926 22063
10000 10000 10000 10000
03922 04787 07941 17650
$3677 Misc Pediatric $4488 Misc Pediatric $7445 Misc Pediatric
$16547 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
540-1 540-2 540-3 540-4
CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY
298 391 634
1053
05654 06864 09354 23719
10000 10000 10000 10000
10600 10600 10600 10600
05993 07276 09915 25142
10000 10000 10000 10000
05993 07276 09915 25142
10000 10000 10000 10000
05654 06864 09354 23719
$4495 Obstetrics $5457 Obstetrics $7436 Obstetrics
$18857 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
541-1 541-2 541-3 541-4
VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC
212 249 491 838
05628 06076 08661 23515
10000 10000 10000 10000
10600 10600 10600 10600
05966 06441 09181 24926
10000 10000 10000 10000
05966 06441 09181 24926
10000 10000 10000 10000
05628 06076 08661 23515
$4474 Obstetrics $4830 Obstetrics $6886 Obstetrics
$18694 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
542-1 542-2 542-3 542-4
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC
216 296 614 993
03695 04647 08572 36195
10000 10000 10000 10000
10600 10600 10600 10600
03917 04926 09086 38367
10000 10000 10000 10000
03917 04926 09086 38367
10000 10000 10000 10000
03695 04647 08572 36195
$2938 Obstetrics $3694 Obstetrics $6815 Obstetrics
$28775 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
544-1 544-2 544-3 544-4
DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES
136 200 407 914
04586 05897 09822 25061
10000 10000 10000 10000
10600 10600 10600 10600
04861 06251 10411 26565
10000 10000 10000 10000
04861 06251 10411 26565
10000 10000 10000 10000
04586 05897 09822 25061
$3646 Obstetrics Obstetrics $4688 Obstetrics Obstetrics $7808 Obstetrics Obstetrics
$19924 Obstetrics Obstetrics 545-1 545-2 545-3 545-4
ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE
164 190 265 576
06988 08147 10540 19945
10000 10000 10000 10000
10600 10600 10600 10600
07407 08636 11172 21142
10000 10000 10000 10000
07407 08636 11172 21142
10000 10000 10000 10000
06988 08147 10540 19945
$5555 Obstetrics Obstetrics $6477 Obstetrics Obstetrics $8379 Obstetrics Obstetrics
$15856 Obstetrics Obstetrics 546-1 546-2 546-3 546-4
OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES
285 454 755
1446
05023 07207 13295 43377
10000 10000 10000 10000
10600 10600 10600 10600
05324 07639 14093 45980
10000 10000 10000 10000
05324 07639 14093 45980
10000 10000 10000 10000
05023 07207 13295 43377
$3993 Obstetrics Obstetrics $5730 Obstetrics Obstetrics
$10570 Obstetrics Obstetrics $34485 Obstetrics Obstetrics
560-1 560-2 560-3 560-4
VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY
203 237 385 935
03307 03856 05399 15061
10000 10000 10000 10000
10600 10600 10600 10600
03505 04087 05723 15965
10000 10000 10000 10000
03505 04087 05723 15965
10000 10000 10000 10000
03307 03856 05399 15061
$2629 Obstetrics Obstetrics $3066 Obstetrics Obstetrics $4292 Obstetrics Obstetrics
$11974 Obstetrics Obstetrics 561-1 561-2 561-3 561-4
POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE
211 257 393 688
02511 03908 06071 15617
10000 10000 10000 10000
10600 10600 10600 10600
02662 04142 06435 16554
10000 10000 10000 10000
02662 04142 06435 16554
10000 10000 10000 10000
02511 03908 06071 15617
$1996 Obstetrics Obstetrics $3107 Obstetrics Obstetrics $4826 Obstetrics Obstetrics
$12416 Obstetrics Obstetrics 563-1 563-2 563-3 563-4
THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION
259 391 747 720
02581 03376 05162 09652
10000 10000 10000 10000
10600 10600 10600 10600
02736 03579 05472 10231
10000 10000 10000 10000
02736 03579 05472 10231
10000 10000 10000 10000
02581 03376 05162 09652
$2052 Obstetrics Obstetrics $2684 Obstetrics Obstetrics $4104 Obstetrics Obstetrics $7673 Obstetrics Obstetrics
564-1 564-2 564-3 564-4
ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY
137 170 276 808
02881 03463 04901 16676
10000 10000 10000 10000
10600 10600 10600 10600
03054 03671 05195 17677
10000 10000 10000 10000
03054 03671 05195 17677
10000 10000 10000 10000
02881 03463 04901 16676
$2290 Obstetrics Obstetrics $2753 Obstetrics Obstetrics $3896 Obstetrics Obstetrics
$13257 Obstetrics Obstetrics 565-1 565-2 565-3 565-4
FALSE LABOR FALSE LABOR FALSE LABOR FALSE LABOR
123 185 735 808
01245 01782 02687 02986
10000 10000 10000 10000
10600 10600 10600 10600
01320 01889 02848 03165
10000 10000 10000 10000
01320 01889 02848 03165
10000 10000 10000 10000
01245 01782 02687 02986
$990 Obstetrics Obstetrics $1417 Obstetrics Obstetrics $2136 Obstetrics Obstetrics $2374 Obstetrics Obstetrics
566-1 566-2 566-3 566-4
OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES
211 294 544 843
02442 03252 04790 14726
10000 10000 10000 10000
10600 10600 10600 10600
02589 03447 05077 15610
10000 10000 10000 10000
02589 03447 05077 15610
10000 10000 10000 10000
02442 03252 04790 14726
$1941 Obstetrics Obstetrics $2585 Obstetrics Obstetrics $3808 Obstetrics Obstetrics
$11707 Obstetrics Obstetrics 580-1 580-2 580-3 580-4
NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE
144 159 182 165
02398 03209 05011 08512
12500 12500 12500 12500
10000 10000 10000 10000
02998 04011 06264 10640
10000 10000 10000 10000
02998 04011 06264 10640
17500 17500 17500 17500
04197 05616 08769 14896
$2248 Neonate Neonate $3008 Neonate Neonate $4698 Neonate Neonate $7980 Neonate Neonate
581-1 581-2 581-3 581-4
NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE
124 128 126 135
00982 01477 02362 04408
12500 12500 12500 12500
10000 10000 10000 10000
01228 01846 02953 05510
10000 10000 10000 10000
01228 01846 02953 05510
17500 17500 17500 17500
01719 02585 04134 07714
$921 Neonate Neonate $1385 Neonate Neonate $2214 Neonate Neonate $4133 Neonate Neonate
583-1 583-2 583-3 583-4
NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO
2070 2300 3077 4886
99741 157496 173245 240894
12500 12500 12500 12500
10000 10000 10000 10000
124676 196870 216556 301118
10000 10000 10000 10000
124676 196870 216556 301118
17500 17500 17500 17500
174547 275618 303179 421565
$93507 Neonate Neonate $147653 Neonate Neonate $162417 Neonate Neonate $225838 Neonate Neonate
588-1 588-2 588-3 588-4
NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE
4442 4935 7714
10207
48410 70035
142903 216660
12500 12500 12500 12500
10000 10000 10000 10000
60513 87544
178629 270825
10000 10000 10000 10000
60513 87544
178629 270825
17500 17500 17500 17500
84718 122561 250080 379155
$45384 Neonate Neonate $65658 Neonate Neonate
$133972 Neonate Neonate $203119 Neonate Neonate
589-1 589-2 589-3 589-4
NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS
5843 5041 3035
265
115468 104972
95430 04454
12500 12500 12500 12500
10000 10000 10000 10000
144335 131215 119288
05568
10000 10000 10000 10000
144335 131215 119288
05568
17500 17500 17500 17500
202069 183701 167003
07795
$108251 Neonate Neonate $98411 Neonate Neonate $89466 Neonate Neonate
$4176 Neonate Neonate 591-1 591-2 591-3 591-4
NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE
211 3710 5061 7221
01574 55672 88282
132286
12500 12500 12500 12500
10000 10000 10000 10000
01968 69590
110353 165358
10000 10000 10000 10000
01968 69590
110353 165358
17500 17500 17500 17500
02755 97426
154494 231501
$1476 Neonate Neonate $52193 Neonate Neonate $82764 Neonate Neonate
$124018 Neonate Neonate 593-1 593-2 593-3 593-4
NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE
1928 4851 5965 7143
15109 51914 82800
122454
12500 12500 12500 12500
10000 10000 10000 10000
18886 64893
103500 153068
10000 10000 10000 10000
18886 64893
103500 153068
17500 17500 17500 17500
26441 90850
144900 214295
$14165 Neonate Neonate $48669 Neonate Neonate $77625 Neonate Neonate
$114801 Neonate Neonate 602-1 602-2 602-3 602-4
NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2513 4403 5324 6307
29635 58707 77593
104733
12500 12500 12500 12500
10000 10000 10000 10000
37044 73384 96991
130916
10000 10000 10000 10000
37044 73384 96991
130916
17500 17500 17500 17500
51861 102737 135788 183283
$27783 Neonate Neonate $55038 Neonate Neonate $72743 Neonate Neonate $98187 Neonate Neonate
603-1 603-2 603-3 603-4
NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION
2234 3619 4843 5396
17223 42526 65587 70750
12500 12500 12500 12500
10000 10000 10000 10000
21529 53158 81984 88438
10000 10000 10000 10000
21529 53158 81984 88438
17500 17500 17500 17500
30140 74421
114777 123813
$16147 Neonate Neonate $39868 Neonate Neonate $61488 Neonate Neonate $66328 Neonate Neonate
607-1 607-2 607-3 607-4
NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2509 3582 4341 4957
27503 47486 61883 79508
12500 12500 12500 12500
10000 10000 10000 10000
34379 59358 77354 99385
10000 10000 10000 10000
34379 59358 77354 99385
17500 17500 17500 17500
48130 83101
108295 139139
$25784 Neonate Neonate $44518 Neonate Neonate $58015 Neonate Neonate $74539 Neonate Neonate
608-1 608-2 608-3 608-4
NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION
1980 3004 3846 4414
21292 36047 52684 60424
12500 12500 12500 12500
10000 10000 10000 10000
26615 45059 65855 75530
10000 10000 10000 10000
26615 45059 65855 75530
17500 17500 17500 17500
37261 63082 92197
105742
$19961 Neonate Neonate $33794 Neonate Neonate $49391 Neonate Neonate $56648 Neonate Neonate
609-1 609-2 609-3 609-4
NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE
1933 2210 3803 6267
27332 38628 65636
119134
12500 12500 12500 12500
10000 10000 10000 10000
34165 48285 82045
148918
10000 10000 10000 10000
34165 48285 82045
148918
17500 17500 17500 17500
47831 67599
114863 208485
$25624 Neonate Neonate $36214 Neonate Neonate $61534 Neonate Neonate
$111688 Neonate Neonate 611-1 611-2 611-3 611-4
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY
1313 2123 3133 3614
11780 25158 40556 52442
12500 12500 12500 12500
10000 10000 10000 10000
14725 31448 50695 65553
10000 10000 10000 10000
14725 31448 50695 65553
17500 17500 17500 17500
20615 44027 70973 91774
$11044 Neonate Neonate $23586 Neonate Neonate $38021 Neonate Neonate $49164 Neonate Neonate
612-1 612-2 612-3 612-4
NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND
1756 2442 3248 3834
21880 32223 46803 62297
12500 12500 12500 12500
10000 10000 10000 10000
27350 40279 58504 77871
10000 10000 10000 10000
27350 40279 58504 77871
17500 17500 17500 17500
38290 56390 81905
109020
$20513 Neonate Neonate $30209 Neonate Neonate $43878 Neonate Neonate $58403 Neonate Neonate
613-1 613-2 613-3 613-4
NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION
1439 2153 2853 3338
16593 26831 37601 48828
12500 12500 12500 12500
10000 10000 10000 10000
20741 33539 47001 61035
10000 10000 10000 10000
20741 33539 47001 61035
17500 17500 17500 17500
29038 46954 65802 85449
$15556 Neonate Neonate $25154 Neonate Neonate $35251 Neonate Neonate $45776 Neonate Neonate
614-1 614-2 614-3 614-4
NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION
1123 2008 2852 3640
09241 22768 36403 50802
12500 12500 12500 12500
10000 10000 10000 10000
11551 28460 45504 63503
10000 10000 10000 10000
11551 28460 45504 63503
17500 17500 17500 17500
16172 39844 63705 88904
$8663 Neonate Neonate $21345 Neonate Neonate $34128 Neonate Neonate $47627 Neonate Neonate
621-1 621-2 621-3 621-4
NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY
820 1397 2125 2416
06082 15379 27206 38101
12500 12500 12500 12500
10000 10000 10000 10000
07603 19224 34008 47626
10000 10000 10000 10000
07603 19224 34008 47626
17500 17500 17500 17500
10644 26913 47611 66677
$5702 Neonate Neonate $14418 Neonate Neonate $25506 Neonate Neonate $35720 Neonate Neonate
622-1 622-2 622-3 622-4
NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND
1118 1514 1977 2285
13666 20913 29736 47202
12500 12500 12500 12500
10000 10000 10000 10000
17083 26141 37170 59003
10000 10000 10000 10000
17083 26141 37170 59003
17500 17500 17500 17500
23916 36598 52038 82604
$12812 Neonate Neonate $19606 Neonate Neonate $27878 Neonate Neonate $44252 Neonate Neonate
623-1 623-2 623-3 623-4
NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION
924 1399 1872 2738
09934 16800 25087 38932
12500 12500 12500 12500
10000 10000 10000 10000
12418 21000 31359 48665
10000 10000 10000 10000
12418 21000 31359 48665
17500 17500 17500 17500
17385 29400 43902 68131
$9313 Neonate Neonate $15750 Neonate Neonate $23519 Neonate Neonate $36499 Neonate Neonate
625-1 625-2 625-3 625-4
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION
1157 1621 1925 2015
11469 18627 23298 29194
12500 12500 12500 12500
10000 10000 10000 10000
14336 23284 29123 36493
10000 10000 10000 10000
14336 23284 29123 36493
17500 17500 17500 17500
20071 32597 40772 51090
$10752 Neonate Neonate $17463 Neonate Neonate $21842 Neonate Neonate $27369 Neonate Neonate
626-1 626-2 626-3 626-4
NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
279 456 864
1838
01387 02587 07679 22819
10000 10000 10000 10000
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
$1040 Normal newborn Normal newborn $1940 Normal newborn Normal newborn $5759 Normal newborn Normal newborn
$17114 Normal newborn Normal newborn 630-1 630-2 630-3 630-4
NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE
486 940
1448 3912
20468 32885 52250
112072
12500 12500 12500 12500
10000 10000 10000 10000
25585 41106 65313
140090
10000 10000 10000 10000
25585 41106 65313
140090
17500 17500 17500 17500
35819 57549 91438
196126
$19189 Neonate Neonate $30830 Neonate Neonate $48984 Neonate Neonate
$105068 Neonate Neonate 631-1 631-2 631-3 631-4
NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE
335 886
2279 5111
09217 16766 37480 96324
12500 12500 12500 12500
10000 10000 10000 10000
11521 20958 46850
120405
10000 10000 10000 10000
11521 20958 46850
120405
17500 17500 17500 17500
16130 29341 65590
168567
$8641 Neonate Neonate $15718 Neonate Neonate $35138 Neonate Neonate $90304 Neonate Neonate
633-1 633-2 633-3 633-4
NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY
296 651
1226 2381
01972 05798 13892 39728
12500 12500 12500 12500
10000 10000 10000 10000
02465 07248 17365 49660
10000 10000 10000 10000
02465 07248 17365 49660
17500 17500 17500 17500
03451 10147 24311 69524
$1849 Neonate Neonate $5436 Neonate Neonate
$13024 Neonate Neonate $37245 Neonate Neonate
634-1 634-2 634-3 634-4
NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND
465 749
1261 2233
04886 09445 20176 46934
12500 12500 12500 12500
10000 10000 10000 10000
06108 11806 25220 58668
10000 10000 10000 10000
06108 11806 25220 58668
17500 17500 17500 17500
08551 16529 35308 82135
$4581 Neonate Neonate $8855 Neonate Neonate
$18915 Neonate Neonate $44001 Neonate Neonate
636-1 636-2 636-3 636-4
NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION
558 779
1164 1896
05582 08840 15558 30613
12500 12500 12500 12500
10000 10000 10000 10000
06978 11050 19448 38266
10000 10000 10000 10000
06978 11050 19448 38266
17500 17500 17500 17500
09769 15470 27227 53573
$5233 Neonate Neonate $8288 Neonate Neonate
$14586 Neonate Neonate $28700 Neonate Neonate
639-1 639-2 639-3 639-4
NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION
441 704 998
1653
03287 06622 11809 27285
12500 12500 12500 12500
10000 10000 10000 10000
04109 08278 14761 34106
10000 10000 10000 10000
04109 08278 14761 34106
17500 17500 17500 17500
05752 11589 20666 47749
$3082 Neonate Neonate $6208 Neonate Neonate
$11071 Neonate Neonate $25580 Neonate Neonate
640-1 NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 210 01012 10000 10000 01012 10000 01012 10000 01012 $759 Normal newborn Normal newborn
640-2 640-3 640-4
NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
245 376
1206
01353 02864 14726
10000 10000 10000
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
$1015 Normal newborn Normal newborn $2148 Normal newborn Normal newborn
$11045 Normal newborn Normal newborn 650-1 650-2 650-3 650-4
SPLENECTOMY SPLENECTOMY SPLENECTOMY SPLENECTOMY
348 537 848
1563
12985 17965 25202 50826
10000 10000 10000 10000
10000 10000 10000 10000
12985 17965 25202 50826
12500 12500 12500 12500
16231 22456 31503 63533
10000 10000 10000 10000
12985 17965 25202 50826
$12173 Misc Pediatric Misc Adult $16842 Misc Pediatric Misc Adult $23627 Misc Pediatric Misc Adult $47649 Misc Pediatric Misc Adult
651-1 651-2 651-3 651-4
OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS
331 472 962
2426
09234 13695 21005 59541
10000 10000 10000 10000
10000 10000 10000 10000
09234 13695 21005 59541
12500 12500 12500 12500
11543 17119 26256 74426
10000 10000 10000 10000
09234 13695 21005 59541
$8657 Misc Pediatric Misc Adult $12839 Misc Pediatric Misc Adult $19692 Misc Pediatric Misc Adult $55820 Misc Pediatric Misc Adult
660-1 660-2 660-3 660-4
MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL
305 408 648
1435
05399 07219 11819 30180
10000 10000 10000 10000
10000 10000 10000 10000
05399 07219 11819 30180
12500 12500 12500 12500
06749 09024 14774 37725
10000 10000 10000 10000
05399 07219 11819 30180
$5062 Misc Pediatric Misc Adult $6768 Misc Pediatric Misc Adult
$11080 Misc Pediatric Misc Adult $28294 Misc Pediatric Misc Adult
661-1 661-2 661-3 661-4
COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS
275 375 566
1265
06473 08098 12433 27857
10000 10000 10000 10000
10000 10000 10000 10000
06473 08098 12433 27857
12500 12500 12500 12500
08091 10123 15541 34821
10000 10000 10000 10000
06473 08098 12433 27857
$6068 Misc Pediatric Misc Adult $7592 Misc Pediatric Misc Adult
$11656 Misc Pediatric Misc Adult $26116 Misc Pediatric Misc Adult
662-1 662-2 662-3 662-4
SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS
412 538 785
1302
05044 07003 10778 23937
10000 10000 10000 10000
10000 10000 10000 10000
05044 07003 10778 23937
12500 12500 12500 12500
06305 08754 13473 29921
10000 10000 10000 10000
05044 07003 10778 23937
$4729 Misc Pediatric Misc Adult $6565 Misc Pediatric Misc Adult
$10104 Misc Pediatric Misc Adult $22441 Misc Pediatric Misc Adult
663-1 663-2 663-3 663-4
OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS
232 301 451 900
04474 05959 08513 16106
10000 10000 10000 10000
10000 10000 10000 10000
04474 05959 08513 16106
12500 12500 12500 12500
05593 07449 10641 20133
10000 10000 10000 10000
04474 05959 08513 16106
$4194 Misc Pediatric Misc Adult $5587 Misc Pediatric Misc Adult $7981 Misc Pediatric Misc Adult
$15099 Misc Pediatric Misc Adult 680-1 680-2 680-3 680-4
MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
408 633
1185 2456
13702 18600 32002 66288
10000 10000 10000 10000
10000 10000 10000 10000
13702 18600 32002 66288
12500 12500 12500 12500
17128 23250 40003 82860
10000 10000 10000 10000
13702 18600 32002 66288
$12846 Misc Pediatric Misc Adult $17438 Misc Pediatric Misc Adult $30002 Misc Pediatric Misc Adult $62145 Misc Pediatric Misc Adult
681-1 681-2 681-3 681-4
OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
268 507
1111 2510
09800 13647 24597 59170
10000 10000 10000 10000
10000 10000 10000 10000
09800 13647 24597 59170
12500 12500 12500 12500
12250 17059 30746 73963
10000 10000 10000 10000
09800 13647 24597 59170
$9188 Misc Pediatric Misc Adult $12794 Misc Pediatric Misc Adult $23060 Misc Pediatric Misc Adult $55472 Misc Pediatric Misc Adult
690-1 690-2 690-3 690-4
ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA
495 740
1461 2485
07040 11869 23551 52504
10000 10000 10000 10000
10000 10000 10000 10000
07040 11869 23551 52504
12500 12500 12500 12500
08800 14836 29439 65630
10000 10000 10000 10000
07040 11869 23551 52504
$6600 Misc Pediatric Misc Adult $11127 Misc Pediatric Misc Adult $22079 Misc Pediatric Misc Adult $49223 Misc Pediatric Misc Adult
691-1 691-2 691-3 691-4
LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA
389 540 861
1585
07077 09840 15477 31411
10000 10000 10000 10000
10000 10000 10000 10000
07077 09840 15477 31411
12500 12500 12500 12500
08846 12300 19346 39264
10000 10000 10000 10000
07077 09840 15477 31411
$6635 Misc Pediatric Misc Adult $9225 Misc Pediatric Misc Adult
$14510 Misc Pediatric Misc Adult $29448 Misc Pediatric Misc Adult
692-1 692-2 692-3 692-4
RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY
389 482 868
1580
06075 12584 17422 29316
10000 10000 10000 10000
10000 10000 10000 10000
06075 12584 17422 29316
12500 12500 12500 12500
07594 15730 21778 36645
10000 10000 10000 10000
06075 12584 17422 29316
$5695 Misc Pediatric Misc Adult $11798 Misc Pediatric Misc Adult $16333 Misc Pediatric Misc Adult $27484 Misc Pediatric Misc Adult
693-1 693-2 693-3 693-4
CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY
281 368 785
2410
06251 07881 13637 49083
10000 10000 10000 10000
10000 10000 10000 10000
06251 07881 13637 49083
12500 12500 12500 12500
07814 09851 17046 61354
10000 10000 10000 10000
06251 07881 13637 49083
$5860 Misc Pediatric Misc Adult $7388 Misc Pediatric Misc Adult
$12785 Misc Pediatric Misc Adult $46015 Misc Pediatric Misc Adult
694-1 694-2 694-3 694-4
LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR
304 404 674
1164
04842 06831 11115 21001
10000 10000 10000 10000
10000 10000 10000 10000
04842 06831 11115 21001
12500 12500 12500 12500
06053 08539 13894 26251
10000 10000 10000 10000
04842 06831 11115 21001
$4539 Misc Pediatric Misc Adult $6404 Misc Pediatric Misc Adult
$10420 Misc Pediatric Misc Adult $19688 Misc Pediatric Misc Adult
710-1 710-2 710-3 710-4
INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE
510 680
1111 1820
10635 15963 25572 49382
10000 10000 10000 10000
10000 10000 10000 10000
10635 15963 25572 49382
12500 12500 12500 12500
13294 19954 31965 61728
10000 10000 10000 10000
10635 15963 25572 49382
$9970 Misc Pediatric Misc Adult $14965 Misc Pediatric Misc Adult $23974 Misc Pediatric Misc Adult $46296 Misc Pediatric Misc Adult
711-1 711-2 711-3 711-4
POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE
471 692
1131 2087
10079 14143 23599 50574
10000 10000 10000 10000
10000 10000 10000 10000
10079 14143 23599 50574
12500 12500 12500 12500
12599 17679 29499 63218
10000 10000 10000 10000
10079 14143 23599 50574
$9449 Misc Pediatric Misc Adult $13259 Misc Pediatric Misc Adult $22124 Misc Pediatric Misc Adult $47413 Misc Pediatric Misc Adult
720-1 720-2 720-3 720-4
SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS
353 444 633
1004
05431 07613 11532 21705
10000 10000 10000 10000
10000 10000 10000 10000
05431 07613 11532 21705
12500 12500 12500 12500
06789 09516 14415 27131
10000 10000 10000 10000
05431 07613 11532 21705
$5092 Misc Pediatric Misc Adult $7137 Misc Pediatric Misc Adult
$10811 Misc Pediatric Misc Adult $20348 Misc Pediatric Misc Adult
721-1 721-2 721-3 721-4
POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS
368 470 705
1153
05287 07209 11619 22025
10000 10000 10000 10000
10000 10000 10000 10000
05287 07209 11619 22025
12500 12500 12500 12500
06609 09011 14524 27531
10000 10000 10000 10000
05287 07209 11619 22025
$4957 Misc Pediatric Misc Adult $6758 Misc Pediatric Misc Adult
$10893 Misc Pediatric Misc Adult $20648 Misc Pediatric Misc Adult
722-1 722-2 722-3 722-4
FEVER FEVER FEVER FEVER
230 302 429 739
03423 05223 07630 13141
10000 10000 10000 10000
10000 10000 10000 10000
03423 05223 07630 13141
12500 12500 12500 12500
04279 06529 09538 16426
10000 10000 10000 10000
03423 05223 07630 13141
$3209 Misc Pediatric Misc Adult $4897 Misc Pediatric Misc Adult $7153 Misc Pediatric Misc Adult
$12320 Misc Pediatric Misc Adult 723-1 723-2 723-3 723-4
VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS
216 279 470
1317
03194 04738 07794 24233
10000 10000 10000 10000
10000 10000 10000 10000
03194 04738 07794 24233
12500 12500 12500 12500
03993 05923 09743 30291
10000 10000 10000 10000
03194 04738 07794 24233
$2994 Misc Pediatric Misc Adult $4442 Misc Pediatric Misc Adult $7307 Misc Pediatric Misc Adult
$22718 Misc Pediatric Misc Adult 724-1 724-2 724-3 724-4
OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES
400 477 680
1337
05512 07131 11401 24698
10000 10000 10000 10000
10000 10000 10000 10000
05512 07131 11401 24698
12500 12500 12500 12500
06890 08914 14251 30873
10000 10000 10000 10000
05512 07131 11401 24698
$5168 Misc Pediatric Misc Adult $6685 Misc Pediatric Misc Adult
$10688 Misc Pediatric Misc Adult $23154 Misc Pediatric Misc Adult
740-1 740-2 740-3 740-4
MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE
678 1284 2034 2421
10899 13904 24356 37756
10000 10000 10000 10000
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
$8174 Other Other $10428 Other Other $18267 Other Other $28317 Other Other
750-1 750-2 750-3 750-4
SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA
1082 1179 1539 2848
05713 06699 09202 19283
10000 10000 10000 10000
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
$4285 Other Other $5024 Other Other $6902 Other Other
$14462 Other Other 751-1 751-2 751-3 751-4
MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES
528 724
1055 2028
03572 05019 08097 15923
10000 10000 10000 10000
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
$2679 Other Other $3764 Other Other $6073 Other Other
$11942 Other Other 752-1 752-2 752-3 752-4
DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL
503 658
1473 7300
03399 04498 09061 14934
10000 10000 10000 10000
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
$2549 Other Other $3374 Other Other $6796 Other Other
$11201 Other Other 753-1 753-2 753-3 753-4
BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS
601 808
1205 1948
04001 05365 08266 14926
10000 10000 10000 10000
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
$3001 Other Other $4024 Other Other $6200 Other Other
$11195 Other Other 754-1 754-2 754-3 754-4
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER
424 558 727
1664
02943 03998 05677 11553
10000 10000 10000 10000
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
$2207 Other Other $2999 Other Other $4258 Other Other $8665 Other Other
755-1 755-2 755-3 755-4
ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
388 622 900 813
02738 04363 06226 08767
10000 10000 10000 10000
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
$2054 Other Other $3272 Other Other $4670 Other Other $6575 Other Other
756-1 756-2 756-3 756-4
ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES
331 381 457 942
04061 05308 06065 13981
10000 10000 10000 10000
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
$3046 Other Other $3981 Other Other $4549 Other Other
$10486 Other Other 757-1 757-2 757-3 757-4
ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES
873 934
1087 1640
05861 07234 08953 13799
10000 10000 10000 10000
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
$4396 Other Other $5426 Other Other $6715 Other Other
$10349 Other Other 758-1 758-2 758-3 758-4
CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS
694 981
1225 4300
03874 05129 06541 11332
10000 10000 10000 10000
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
$2906 Other Other $3847 Other Other $4906 Other Other $8499 Other Other
759-1 759-2 759-3 759-4
EATING DISORDERS EATING DISORDERS EATING DISORDERS EATING DISORDERS
1990 1297 1402 2303
06561 06961 10053 16606
10000 10000 10000 10000
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
$4921 Other Other $5221 Other Other $7540 Other Other
$12455 Other Other 760-1 760-2 760-3 760-4
OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS
748 766 912
1204
04840 06173 07573 14134
10000 10000 10000 10000
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
$3630 Other Other $4630 Other Other $5680 Other Other
$10601 Other Other 770-1 770-2 770-3 770-4
DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE
253 248 332 794
02240 02623 05475 16843
10000 10000 10000 10000
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
$1680 Other Other $1967 Other Other $4106 Other Other
$12632 Other Other 772-1 772-2 772-3 772-4
ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY
1434 1551 1289 2385
05441 06916 07009 24530
10000 10000 10000 10000
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
$4081 Other Other $5187 Other Other $5257 Other Other
$18398 Other Other 773-1 773-2 773-3 773-4
OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE
337 414 507 992
02663 03466 05964 18606
10000 10000 10000 10000
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
$1997 Other Other $2600 Other Other $4473 Other Other
$13955 Other Other 774-1 774-2
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
365 412
03040 03627
10000 10000
10000 10000
03040 03627
10000 10000
03040 03627
10000 10000
03040 03627
$2280 Other Other $2720 Other Other
774-3 774-4
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
479 1424
06448 24682
10000 10000
10000 10000
06448 24682
10000 10000
06448 24682
10000 10000
06448 24682
$4836 Other $18512 Other
Other Other
775-1 775-2 775-3 775-4
ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE
323 377 571
1263
03313 04639 08596 24910
10000 10000 10000 10000
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
$2485 Other $3479 Other $6447 Other
$18683 Other
Other Other Other Other
776-1 776-2 776-3 776-4
OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE
389 397 496 933
03157 04547 07887 16112
10000 10000 10000 10000
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
$2368 Other $3410 Other $5915 Other
$12084 Other
Other Other Other Other
791-1 791-2 791-3 791-4
OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT
314 515 989
2009
08636 12677 21979 49312
10000 10000 10000 10000
10000 10000 10000 10000
08636 12677 21979 49312
12500 12500 12500 12500
10795 15846 27474 61640
10000 10000 10000 10000
08636 12677 21979 49312
$8096 Misc Pediatric $11885 Misc Pediatric $20605 Misc Pediatric $46230 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
811-1 811-2 811-3 811-4
ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS
151 202 390 913
02707 03855 08277 22176
10000 10000 10000 10000
10000 10000 10000 10000
02707 03855 08277 22176
12500 12500 12500 12500
03384 04819 10346 27720
10000 10000 10000 10000
02707 03855 08277 22176
$2538 Misc Pediatric $3614 Misc Pediatric $7760 Misc Pediatric
$20790 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
812-1 812-2 812-3 812-4
POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS
165 225 347 694
03469 04331 07709 17419
10000 10000 10000 10000
10000 10000 10000 10000
03469 04331 07709 17419
12500 12500 12500 12500
04336 05414 09636 21774
10000 10000 10000 10000
03469 04331 07709 17419
$3252 Misc Pediatric $4060 Misc Pediatric $7227 Misc Pediatric
$16330 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
813-1 813-2 813-3 813-4
OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT
261 344 594
1344
04393 06056 09631 19960
10000 10000 10000 10000
10000 10000 10000 10000
04393 06056 09631 19960
12500 12500 12500 12500
05491 07570 12039 24950
10000 10000 10000 10000
04393 06056 09631 19960
$4118 Misc Pediatric $5678 Misc Pediatric $9029 Misc Pediatric
$18713 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
815-1 815-2 815-3 815-4
OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES
169 276 456 880
04211 05012 08129 22715
10000 10000 10000 10000
10000 10000 10000 10000
04211 05012 08129 22715
12500 12500 12500 12500
05264 06265 10161 28394
10000 10000 10000 10000
04211 05012 08129 22715
$3948 Misc Pediatric $4699 Misc Pediatric $7621 Misc Pediatric
$21295 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
816-1 816-2 816-3 816-4
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
173 240 346 736
04162 04915 07864 18134
10000 10000 10000 10000
10000 10000 10000 10000
04162 04915 07864 18134
12500 12500 12500 12500
05203 06144 09830 22668
10000 10000 10000 10000
04162 04915 07864 18134
$3902 Misc Pediatric $4608 Misc Pediatric $7373 Misc Pediatric
$17001 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
841-1 841-2 841-3 841-4
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT
2200 967
2599 4068
31148 34263 64068
159153
10000 10000 10000 10000
10000 10000 10000 10000
31148 34263 64068
159153
12500 12500 12500 12500
38935 42829 80085
198941
10000 10000 10000 10000
31148 34263 64068
159153
$29201 Misc Pediatric $32122 Misc Pediatric $60064 Misc Pediatric
$149206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
842-1 842-2 842-3 842-4
FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT
751 1072 1735 3010
14151 21416 38719 95054
10000 10000 10000 10000
10000 10000 10000 10000
14151 21416 38719 95054
12500 12500 12500 12500
17689 26770 48399
118818
10000 10000 10000 10000
14151 21416 38719 95054
$13267 Misc Pediatric $20078 Misc Pediatric $36299 Misc Pediatric $89113 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
843-1 843-2 843-3 843-4
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT
339 487 713
1113
04752 06661 11619 32621
10000 10000 10000 10000
10000 10000 10000 10000
04752 06661 11619 32621
12500 12500 12500 12500
05940 08326 14524 40776
10000 10000 10000 10000
04752 06661 11619 32621
$4455 Misc Pediatric $6245 Misc Pediatric
$10893 Misc Pediatric $30582 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
844-1 844-2 844-3 844-4
PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT
310 497 743
1781
04337 06965 12193 48021
10000 10000 10000 10000
10000 10000 10000 10000
04337 06965 12193 48021
12500 12500 12500 12500
05421 08706 15241 60026
10000 10000 10000 10000
04337 06965 12193 48021
$4066 Misc Pediatric $6530 Misc Pediatric
$11431 Misc Pediatric $45020 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
850-1 850-2 850-3 850-4
PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE
267 556
1618 3148
11757 14065 24870 46520
10000 10000 10000 10000
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
$8818 Misc Pediatric $10549 Misc Pediatric $18653 Misc Pediatric $34890 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
860-1 860-2 860-3 860-4
REHABILITATION REHABILITATION REHABILITATION REHABILITATION
932 1146 1475 1795
07227 09855 13880 17876
10000 10000 10000 10000
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
$5420 Other $7391 Other
$10410 Other $13407 Other
Other Other Other Other
861-1 861-2 861-3 861-4
SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS
253 340 497 917
02858 05247 07658 14498
10000 10000 10000 10000
10000 10000 10000 10000
02858 05247 07658 14498
12500 12500 12500 12500
03573 06559 09573 18123
10000 10000 10000 10000
02858 05247 07658 14498
$2679 Misc Pediatric $4919 Misc Pediatric $7179 Misc Pediatric
$13592 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
862-1 862-2 862-3 862-4
OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE
698 1122 1357 1872
02895 05851 07866 11351
10000 10000 10000 10000
10000 10000 10000 10000
02895 05851 07866 11351
12500 12500 12500 12500
03619 07314 09833 14189
10000 10000 10000 10000
02895 05851 07866 11351
$2714 Misc Pediatric $5485 Misc Pediatric $7374 Misc Pediatric
$10642 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
863-1 863-2 863-3 863-4
NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE
853 1757 2771 4643
05959 16127 30507 61446
12500 12500 12500 12500
10000 10000 10000 10000
07449 20159 38134 76808
10000 10000 10000 10000
07449 20159 38134 76808
17500 17500 17500 17500
10428 28222 53387
107531
$5587 Neonate $15119 Neonate $28600 Neonate $57606 Neonate
Neonate Neonate Neonate Neonate
890-1 890-2 890-3 890-4
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS
167 691 921
1514
07051 10224 14771 30014
10000 10000 10000 10000
10000 10000 10000 10000
07051 10224 14771 30014
12500 12500 12500 12500
08814 12780 18464 37518
10000 10000 10000 10000
07051 10224 14771 30014
$6610 Misc Pediatric $9585 Misc Pediatric
$13848 Misc Pediatric $28138 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
892-1 892-2 892-3 892-4
HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION
587 488 669
1152
05647 07763 10877 19375
10000 10000 10000 10000
10000 10000 10000 10000
05647 07763 10877 19375
12500 12500 12500 12500
07059 09704 13596 24219
10000 10000 10000 10000
05647 07763 10877 19375
$5294 Misc Pediatric $7278 Misc Pediatric
$10197 Misc Pediatric $18164 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
893-1 893-2 893-3 893-4
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
499 496 799
1422
07762 08219 12807 24296
10000 10000 10000 10000
10000 10000 10000 10000
07762 08219 12807 24296
12500 12500 12500 12500
09703 10274 16009 30370
10000 10000 10000 10000
07762 08219 12807 24296
$7277 Misc Pediatric $7705 Misc Pediatric
$12007 Misc Pediatric $22778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
894-1 894-2 894-3 894-4
HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND
341 393 627
1121
05218 06497 09774 19428
10000 10000 10000 10000
10000 10000 10000 10000
05218 06497 09774 19428
12500 12500 12500 12500
06523 08121 12218 24285
10000 10000 10000 10000
05218 06497 09774 19428
$4892 Misc Pediatric $6091 Misc Pediatric $9163 Misc Pediatric
$18214 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
910-1 910-2 910-3 910-4
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA
1100 775
1057 1830
28786 31984 41628 72114
10000 10000 10000 10000
10000 10000 10000 10000
28786 31984 41628 72114
12500 12500 12500 12500
35983 39980 52035 90143
10000 10000 10000 10000
28786 31984 41628 72114
$26987 Misc Pediatric $29985 Misc Pediatric $39026 Misc Pediatric $67607 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
911-1 911-2 911-3 911-4
EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA
511 619 795
1687
15160 20189 26724 58039
10000 10000 10000 10000
10000 10000 10000 10000
15160 20189 26724 58039
12500 12500 12500 12500
18950 25236 33405 72549
10000 10000 10000 10000
15160 20189 26724 58039
$14213 Misc Pediatric $18927 Misc Pediatric $25054 Misc Pediatric $54412 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
912-1 912-2 912-3 912-4
MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
558 607 985
1782
20950 22759 36410 68885
10000 10000 10000 10000
10000 10000 10000 10000
20950 22759 36410 68885
12500 12500 12500 12500
26188 28449 45513 86106
10000 10000 10000 10000
20950 22759 36410 68885
$19641 Misc Pediatric $21337 Misc Pediatric $34134 Misc Pediatric $64580 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
930-1 930-2 930-3 930-4
MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE
322 370 596
1127
07826 09594 15857 33896
10000 10000 10000 10000
10000 10000 10000 10000
07826 09594 15857 33896
12500 12500 12500 12500
09783 11993 19821 42370
10000 10000 10000 10000
07826 09594 15857 33896
$7337 Misc Pediatric $8994 Misc Pediatric
$14866 Misc Pediatric $31778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
950-1 950-2 950-3 950-4
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
361 623
1166 2260
13230 20029 31827 60092
10000 10000 10000 10000
10000 10000 10000 10000
13230 20029 31827 60092
12500 12500 12500 12500
16538 25036 39784 75115
10000 10000 10000 10000
13230 20029 31827 60092
$12403 Misc Pediatric $18777 Misc Pediatric $29838 Misc Pediatric $56336 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
951-1 951-2 951-3 951-4
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
329 517
1001 1973
09755 14320 24054 46875
10000 10000 10000 10000
10000 10000 10000 10000
09755 14320 24054 46875
12500 12500 12500 12500
12194 17900 30068 58594
10000 10000 10000 10000
09755 14320 24054 46875
$9145 Misc Pediatric $13425 Misc Pediatric $22551 Misc Pediatric $43945 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
952-1 952-2 952-3 952-4
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
274 504 968
1894
07736 11591 20369 39177
10000 10000 10000 10000
10000 10000 10000 10000
07736 11591 20369 39177
12500 12500 12500 12500
09670 14489 25461 48971
10000 10000 10000 10000
07736 11591 20369 39177
$7253 Misc Pediatric $10867 Misc Pediatric $19096 Misc Pediatric $36728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
955-0 956-0
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS UNGROUPABLE
--
--
Error DRG Error DRG
Error DRG Error DRG
i-
i
i
i-
i
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy adjustor F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that has at least a basic level
emergency room H FY 2015-16 Cost-to-Charge Ratio FY 2013 cost-to-charge ratio with some exceptions I FY 2015-16 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FY 2015-16 Wage Index Value (adjusted for CA Neutrality Factor 09797) W age index value times 09797 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls for changes between California
and the rest of the US while maintaining relative differences among wage areas within California K FY 2015-16 Unadjusted Statewide Base Rate The statewide DRG base rate is $6289 except that for remote rural hospitals it is $12768 L FY 2015-16 Wage Adjusted Statewide Base Rate (Non-Transition) The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses See Tab 5 This rate is applicable for non-transition hospitals as shown in Column N Medi-Cal
managed care plans that are pricing claims for emergency and post-stabilization services hospitals outside their network should use Column L for all hospitals M FY 2015-16 Hospital-Specific Transition Base Rate The base rate assigned to hospitals to move them in steps toward the statewide base rate This rate is applicable for transition hospitals as shown in Column N FY 2015-16 is the final year of transition rates N Transition rate This column identifies whether the hospital is a non-transition hospital (base rate in Column L) or a transition hospital (base rate in Column M) O FY 2015-16 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2015-16 P FY 2015-16 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by
use of Revenue Code 190 Q FY 2015-16 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by use of
Revenue Code 199
A B C D E F G H I J K L M N O P Q
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transit on Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
OUT OF STATE No No No No No 2180 10000 10000 $6289 $6289 NA Non-Transition NA $98163 $80582 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 3572 12882 12620 $12768 $15097 $15414 Transition NA $98163 $80582 106100793 ADVENTIST MEDICAL CENTER - SELMA COMMUNITY HOSPITAL No No No Yes Yes 3572 12882 12620 $12768 $15097 $14680 Transition NA $98163 $80582 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 4360 12882 12620 $12768 $15097 $10484 Transition NA $98163 $80582 106301098 AHMC ANAHEIM REG MED CTR No No No No No 1656 12882 12620 $6289 $7436 $15144 Transition NA $98163 $80582 106010846 ALAMEDA CO MED CTR Yes No No No No 4036 16962 16618 $6289 $9186 NA NA NA NA NA 106010735 ALAMEDA HOSP No Yes No No No 2600 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106190017 ALHAMBRA HOSP No No No No No 1397 12882 12620 $6289 $7436 $5446 Transition $1220 $98163 $80582 106010739 ALTA BATES SUMMIT MED CTR-ALTA BATES No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106010937 ALTA BATES SUMMIT MED CTR-HAWTHORNE No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106010844 ALTA BATES SUMMIT MED CTR-HERRICK CAMPUS No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106013626 ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106374063 ALVARADO HOSP MED CTR - REHAB No No No No No 1930 12882 12620 $6289 $7436 $4599 Transition $1220 $98163 $80582 106190034 ANTELOPE VALLEY HOSP MED CTR No Yes No No No 2997 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364231 ARROWHEAD REG MED CTR Yes No No No No 3324 12882 12620 $6289 $7436 NA NA NA NA NA 106400466 ARROYO GRANDE COMM HOSP No No No No No 2581 12964 12701 $6289 $7471 NA Non-Transition $1226 $98163 $80582 106154101 BAKERSFIELD HEART HOSP No No No No No 1782 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150722 BAKERSFIELD MEM HOSP-34TH ST No No No No No 2117 12882 12620 $6289 $7436 $9141 Transition NA $98163 $80582 106364121 BALLARD REHABILITATION HOSP No No No No No 8300 12882 12620 NA NA NA NA $1427 $98163 $80582 106184008 BANNER LASSEN MED CTR No No No Yes Yes 3967 12882 12620 $12768 $15097 $18668 Transition NA $98163 $80582 106190052 BARLOW RESP HOSP No No No No No 1849 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364430 BARSTOW COMM HOSP No No No Yes Yes 2262 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090793 BARTON MEM HOSP No No No Yes Yes 3635 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106361110 BEAR VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190081 BEVERLY HOSP No No No No No 3567 12882 12620 $6289 $7436 $5841 Transition NA $98163 $80582 106040802 BIGGS GRIDLEY MEM HOSP No No No Yes Yes 3652 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106380929 CA PACIFIC MED CTR No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380777 CA PACIFIC MED CTR - CALIFORNIA WEST No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380933 CA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 2873 16738 16398 $6289 $9090 NA Non-Transition $1492 $98163 $80582 106190125 CALIFORNIA HOSP MED CTR-LA No No Yes No No 2078 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190137 CASA COLINA HOSP FOR REHAB MED No No No No No 7213 12882 12620 NA NA NA NA $1220 $98163 $80582 106190045 CATALINA ISLAND MED CTR No No No Yes Yes 9000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190555 CEDARS-SINAI MED CTR No No Yes No No 2051 12882 12620 $6289 $7436 $5837 Transition $1220 $98163 $80582 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 1730 12882 12620 $6289 $7436 $6350 Transition $1220 $98163 $80582 106160787 CENTRAL VALLEY GEN HOSP No No No No No 7778 12882 12620 $6289 $7436 $11888 Transition NA $98163 $80582 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 2190 12892 12630 $6289 $7440 NA Non-Transition $1221 $98163 $80582 106301140 CHAPMAN MED CTR No No No No No 1908 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304113 CHILDRENS HOSP AT MISSION No No No No No 3300 12882 12620 $6289 $7436 $18777 Transition NA $98163 $80582 106204019 CHILDRENS HOSP CENTRAL CALIFORNIA No No Yes No No 2430 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106010776 CHILDRENS HOSP OAKLAND No No Yes No No 3356 16478 16143 $6289 $8978 NA Non-Transition $2628 $98163 $80582 106190170 CHILDRENS HOSP OF LA No No Yes No No 3988 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106300032 CHILDRENS HOSP OF ORANGE CO No No Yes No No 2442 12882 12620 $6289 $7436 $5613 Transition NA $98163 $80582 106382715 CHINESE HOSP No No No No No 3835 16738 16398 $6289 $9090 $8053 Transition NA $98163 $80582 106361144 CHINO VALLEY MED CTR No No No No No 2098 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190176 CITY OF HOPE HELFORD CLINIC RES HOSP No No No No No 2789 12882 12620 $6289 $7436 $5941 Transition NA $98163 $80582 106100005 CLOVIS COMM MED CTR No No No No No 3336 12882 12620 $6289 $7436 $7752 Transition NA $98163 $80582 106100697 COALINGA REG MED CTR No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190766 COAST PLAZA DRS HOSP No No No No No 2126 12882 12620 $6289 $7436 $5303 Transition NA $98163 $80582 106301258 COASTAL COMM HOSP No No No No No 2792 12882 12620 $6289 $7436 $7035 Transition NA $98163 $80496 106301155 COLLEGE HOSP COSTA MESA No No No No No 2876 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190587 COLLEGE MEDICAL CENTER No No No No No 3760 12882 12620 $6289 $7436 $4258 Transition NA $98163 $80582 106361458 COLORADO RIVER MED CTR No No No Yes Yes 4357 12882 12620 $12768 $15097 $18541 Transition NA $98163 $80582 106060870 COLUSA REG MED CTR No No No Yes Yes 3066 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190197 COMM AND MISSION HOSP OF HUNT PK No No No No No 1601 12882 12620 $6289 $7436 $5421 Transition NA $98163 $80582 106190475 COMM HOSP OF LONG BEACH No No No No No 1707 12882 12620 $6289 $7436 $15917 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106361323 COMM HOSP OF SAN BERNARDINO No No No No No 2833 12882 12620 $6289 $7436 $6516 Transition NA $98163 $78406 106560473 COMM MEM HOSP OF SAN BUENAVENTURA No No No No No 2104 12882 12620 $6289 $7436 $4512 Transition NA $98163 $80582 106100717 COMM REG MED CTR-FRESNO No No No No No 1896 12882 12620 $6289 $7436 $7994 Transition $1655 $98163 $80582 106070924 CONTRA COSTA REG MED CTR Yes No No No No 6010 16478 16143 $6289 $8978 NA NA NA NA NA 106331152 CORONA REG MED CTR No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition NA $98163 $80582 106331145 CORONA REG MED CTR - MAGNOLIA No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition $1220 $98163 $80582 106190413 CV-INTERCOMMUNITY CAMPUS No No No No No 3136 12882 12620 $6289 $7436 $6821 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106190636 CV-QUEEN OF VALLEY CAMPUS No No Yes No No 3136 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106150706 DELANO REG MED CTR No No No No No 3622 12882 12620 $6289 $7436 $7087 Transition NA $98163 $80582 106331164 DESERT REG MED CTR No No No No No 1486 12882 12620 $6289 $7436 $7153 Transition $1447 $98163 $80582 106364144 DESERT VALLEY HOSP No No No No No 2050 12882 12620 $6289 $7436 $8173 Transition NA $98163 $80582 106440755 DOMINICAN HOSP-SANTA CRUZ No No No No No 2016 17239 16889 $6289 $9304 $7821 Transition $1527 $98163 $80582 106190243 DOWNEY REG MED CTR No No No No No 1732 12882 12620 $6289 $7436 $6847 Transition NA $98163 $80582 106392287 DRS HOSP OF MANTECA No No No No No 1362 13579 13303 $6289 $7735 $11712 Transition NA $98163 $80582 106390846 DAMERON HOSP No No No No No 2138 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106190857 DRS HOSP OF WEST COVINA No No No No No 1833 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106070904 DRS MED CTR-SAN PABLOPINOLE No Yes No No No 2373 16478 16143 $6289 $8978 $6025 Transition NA $98163 $80582 106190256 EAST LA DRS HOSP No No No No No 1952 12882 12620 $6289 $7436 $5809 Transition NA $98163 $80582 106190328 EAST VALLEY HOSP MED CTR No No No No No 2859 12882 12620 $6289 $7436 $5534 Transition NA $98163 $80582 106320859 EASTERN PLUMAS HOSP No Yes No Yes Yes 4802 12882 12620 $12768 $15097 $13674 Transition NA $98163 $80582 106014233 EDEN MED CTR No No No No No 3197 16962 16618 $6289 $9186 $12768 Transition NA $98163 $80582 106331168 EISENHOWER MEM HOSP No No No No No 1540 12882 12620 $6289 $7436 $10211 Transition NA $98163 $80582 106430763 EL CAMINO HOSP No Yes No No No 2857 17180 16831 $6289 $9279 $5377 Transition $1523 $98163 $80582 106130699 EL CENTRO COMM HOSP No Yes No No No 2298 12882 12620 $6289 $7436 $8949 Transition NA $98163 $80582 106500852 DRS MED CTR No No No No No 1181 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106500867 EMANUEL MED CTR No No No No No 2046 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106040962 ENLOE MED CTR No No No No No 2436 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106044011 ENLOE REHABILLITATION CENTER No No No No No 2463 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106474007 FAIRCHILD MED CTR No No No Yes Yes 3914 12882 12620 $12768 $15097 $16385 Transition NA $98163 $80582 106040875 FEATHER RIVER HOSP No No No No No 1240 12882 12620 $6289 $7436 $10796 Transition NA $98163 $80582 106190298 FOOTHILL PRES HOSP No No No No No 2989 12882 12620 $6289 $7436 $4740 Transition NA $98163 $80582 106301175 FOUNTAIN VALLEY REG HOSP-EUCLID No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106304039 FOUNTAIN VALLEY REG HOSP-WARNER No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106230949 FRANK R HOWARD MEM HOSP No No No Yes Yes 3495 12882 12620 $12768 $15097 $15377 Transition NA $98163 $80582 106510882 FREMONT MEDICAL CENTER No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106190280 ENCINO HOSP MED CTR No No No No No 949 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106400480 FRENCH HOSP MED CTR No No No No No 2241 12964 12701 $6289 $7471 NA Non-Transition NA $98163 $80582 106301283 GARDEN GROVE HOSP AND MED CTR No No No No No 2661 12882 12620 $6289 $7436 $5749 Transition NA $98163 $80582 106190159 GARDEN REG HOSP AND MED CTR No No No No No 2937 12882 12620 $6289 $7436 $4110 Transition NA $98163 $80582 106105029 FRESNO HEART HOSP No No No No No 3403 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106270777 GEORGE L MEE MEM HOSP No No No Yes Yes 3562 15558 15242 $12768 $17426 $20386 Transition NA $98163 $80582 106190315 GARFIELD MED CTR No No No No No 1031 12882 12620 $6289 $7436 NA Non-Transition $1394 $98163 $80582 106190522 GLENDALE MEM HOSP AND HLTH CTR No No No No No 2163 12882 12620 $6289 $7436 $6885 Transition $1220 $98163 $80582 106110889 GLENN MED CTR No No No Yes Yes 6660 12882 12620 $12768 $15097 $21024 Transition NA $98163 $80582 106190323 GLENDALE ADV MED CTR-WILSON TERRACE No No No No No 1845 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420483 GOLETA VALLEY COTTAGE HOSP No No No No No 3083 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150775 GOOD SAMARITAN HOSP-BAKERSFIELD No No No No No 3694 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430779 GOOD SAMARITAN HOSP-SAN JOSE No No Yes No No 1937 17180 16831 $6289 $9279 $5654 Transition NA $98163 $80582 106190352 GREATER EL MONTE COMM HOSP No No No No No 1088 12882 12620 $6289 $7436 $4818 Transition NA $98163 $80582 106370714 GROSSMONT HOSP No No No No No 1937 12882 12620 $6289 $7436 $6498 Transition $1220 $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190392 GOOD SAMARITAN HOSP-LA No No Yes No No 2006 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106350784 HAZEL HAWKINS MEM HOSP No Yes No Yes Yes 3840 17180 16831 $12768 $18839 NA Non-Transition NA $98163 $80582 106490964 HEALDSBURG DIST HOSP No Yes No Yes Yes 6549 16188 15859 $12768 $17975 NA Non-Transition NA $98163 $80582 106154022 HEALTHSOUTH BAKERSFIELD REHAB HOSP No No No No No 5040 12882 12620 NA NA NA NA $1382 $98163 $80582 106304079 HEALTHSOUTH TUSTIN REHAB HOSP No No No No No 5281 12882 12620 NA NA NA NA $1220 $98163 $80582 106331194 HEMET VALLEY MED CTR No No No No No 1267 12882 12620 $6289 $7436 $5912 Transition NA $98163 $80582 106190949 HENRY MAYO NEWHALL MEM HOSP No No No No No 1839 12882 12620 $6289 $7436 $5631 Transition $1220 $98163 $80582 106362041 HI-DESERT MED CTR No Yes No Yes Yes 2909 12882 12620 $12768 $15097 $13297 Transition NA $98163 $80582 106301205 HOAG MEM HOSP PRESBYTERIAN No No No No No 4825 12882 12620 $6289 $7436 $13525 Transition NA $98163 $80582 106304159 HEALTHBRIDGE CHILDRENS HOSP-ORANGE No No No No No 3271 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106190380 HOLLYWOOD COMM HOSP OF HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106304460 HOAG ORTHOPEDIC No No No No No 4894 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190382 HOLLYWOOD PRES MED CTR No No No No No 2212 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301209 HUNTINGTON BEACH HOSP No No No No No 2175 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190400 HUNTINGTON MEM HOSP No No Yes No No 2294 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106304045 IRVINE REG HOSP AND MED CTR No No No No No 200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106220733 JOHN C FREMONT HCARE DIST No Yes No Yes Yes 3884 12882 12620 $12768 $15097 $8195 Transition NA $98163 $80582 106331216 JOHN F KENNEDY MEM HOSP No No No No No 1679 12882 12620 $6289 $7436 $6464 Transition NA $98163 $80582 106071018 JOHN MUIR MED CTR-CONCORD CAMPUS No No No No No 1748 16478 16143 $6289 $8978 $12804 Transition NA $98163 $80582 106070988 JOHN MUIR MED CTR-WALNUT CREEK CAMPUS No No No No No 2039 16478 16143 $6289 $8978 $10615 Transition $1473 $98163 $80582 106314024 KAISER HOSPITAL - ROSEVILLE No No Yes No No 7912 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106364265 KAISER ONTARIO MEDICAL CENTER CAMPUS No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106121031 JEROLD PHELPS COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301132 KAISER-ANAHEIM No No Yes No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304306 KAISER-ANAHEIM-IRVINE No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304409 KAISER-ANAHEIM-Orange No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106074097 KAISER-ANTIOCH No No No No No 8503 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106196403 KAISER-DOWNEY No No No No No 10000 12882 12620 $6289 $7436 $12698 Transition NA $98163 $80582 106361223 KAISER-FONTANA No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106014132 KAISER-FREMONT No No No No No 10000 16962 16618 $6289 $9186 $9639 Transition NA $98163 $80582 106196035 KAISER-BALDWIN PARK No No No No No 8009 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106104062 KAISER-FRESNO No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190429 KAISER-LOS ANGELES No No No No No 7387 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106394009 KAISER-MANTECA No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106334048 KAISER-MORENO VALLEY No No No No No 6614 12882 12620 $6289 $7436 $4790 Transition NA $98163 $80582 106010856 KAISER-OAKLANDRICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106190432 KAISER-PANORAMA CITY No No No No No 8239 12882 12620 $6289 $7436 $16025 Transition NA $98163 $80582 106504042 KAISER-MODESTO No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106410804 KAISER-REDWOOD CITY No No No No No 7731 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106074093 KAISER-RICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106480989 KAISER-REHAB CENTER VALLEJO No No No No No 8442 16315 15984 $6289 $8908 NA Non-Transition $2535 $98163 $80582 106340913 KAISER-SACRAMENTO No No No No No 5612 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106334025 KAISER-RIVERSIDE No No No No No 5865 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370730 KAISER-SAN DIEGO No No No No No 7393 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106380857 KAISER-SAN FRANCISCO No No No No No 5960 16738 16398 $6289 $9090 NA Non-Transition NA $98163 $80582 106431506 KAISER-SAN JOSE No No No No No 7002 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106014337 KAISER-SAN LEANDRO No No No No No 2180 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106210992 KAISER-SAN RAFAEL No No No No No 4673 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106494019 KAISER-SANTA ROSA No No No No No 10000 16315 15984 $6289 $8908 $17627 Transition NA $98163 $80582 106434153 KAISER-SANTA CLARA No No No No No 6107 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106190431 KAISER-SOUTH BAY No No No No No 6935 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106342344 KAISER-SOUTH SACRAMENTO No No No No No 5670 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106410806 KAISER-SOUTH SF No No No No No 6503 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106484044 KAISER-VACAVILLE No No No No No 10000 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106070990 KAISER-WALNUT CREEK No No No No No 5680 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106190434 KAISER-WEST LA No No No No No 6623 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106194219 KECK HOSPITAL OF USC No No No No No 2004 12882 12620 $6289 $7436 $4699 Transition $1220 $98163 $80582 106210993 KENTFIELD REHAB HOSP No No No No No 5967 16855 16513 $6289 $9140 $19338 Transition $1500 $98163 $80582 106150736 KERN MED CTR Yes No No No No 3943 12882 12620 $6289 $7436 NA NA NA NA NA 106150737 KERN VALLEY HEALTHCARE DIST No Yes No Yes Yes 2786 12882 12620 $12768 $15097 $8298 Transition NA $98163 $80582 106191450 KAISER-WOODLAND HILLS No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190049 KINDRED HOSPITAL BALDWIN PARK No No No No No 1810 12882 12620 $6289 $7436 $10784 Transition NA $98163 $80582 106190305 KINDRED LA No No No No No 2044 12882 12620 $6289 $7436 $4255 Transition NA $98163 $80582 106301127 KINDRED BREA No No No No No 2852 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361274 KINDRED ONTARIO No No No No No 2068 12882 12620 $6289 $7436 $9314 Transition NA $98163 $80582 106364188 KINDRED RANCHO No No No No No 1980 12882 12620 $6289 $7436 $20628 Transition NA $98163 $80582 106332172 KINDRED RIVERSIDE No No No No No 1805 12882 12620 $6289 $7436 $24450 Transition NA $98163 $80582 106190449 KINDRED LA MIRADA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106370721 KINDRED SAN DIEGO No No No No No 3605 12882 12620 $6289 $7436 $5657 Transition NA $98163 $80582 106344035 KINDRED SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190458 KINDRED SAN GABRIEL VALLEY No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106010887 KINDRED SF BAY AREA No No No No No 3007 16478 16143 $6289 $8978 $6378 Transition NA $98163 $80582 106301167 KINDRED SANTA ANA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190196 KINDRED SOUTH BAY No No No No No 2144 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301380 KINDRED WESTMINSTER No No No No No 2286 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301234 LA PALMA INTERCOMMUNITY HOSP No No No No No 2290 12882 12620 $6289 $7436 $7160 Transition NA $98163 $80582 106191227 LAC-HARBOR-UCLA MED CTR Yes No Yes No No 3366 12882 12620 $6289 $7436 NA NA NA NA NA 106191231 LAC-OLIVE VIEW-UCLA MED CTR Yes No No No No 4136 12882 12620 $6289 $7436 NA NA NA NA NA 106191228 LAC-USC MED CTR Yes No Yes No No 4522 12882 12620 $6289 $7436 NA NA NA NA NA 106380865 LAGUNA HONDA HOSP AND REHAB CTR Yes No No No No 5843 16738 16398 $6289 $9090 NA NA NA NA NA 106190240 LAKEWOOD REG MED CTR No No No No No 1504 12882 12620 $6289 $7436 $4008 Transition $1220 $98163 $80582 106390923 LODI MEM HOSP No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106390922 LODI MEM HOSP - WEST No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106334589 LOMA LINDA MURRIETTA No No No No No 3222 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106364268 LOMA LINDA UNIV HEART AND SURGICAL HOSPITAL No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361245 LOMA LINDA UNIV MED CTR - EAST CAMPUS No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361246 LOMA LINDA UNIV MED CTR No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $1491 $98163 $80582 106364502 LOMA LINDA UNIV CHILDRENS HOSP No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $2177 $98163 $80582 106190198 LA COMM HOSP No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420491 LOMPOC VALLEY MED CTR No Yes No Yes Yes 8693 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301248 LOS ALAMITOS MED CTR No No No No No 1915 12882 12620 $6289 $7436 $4697 Transition NA $98163 $80582 106560492 LOS ROBLES HOSP AND MED CTR No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106564018 LOS ROBLES HOSP AND MED CTR-EAST CAMPUS No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106434040 LSP CHILDRENS HOSP AT STANFORD No No Yes No No 2035 17180 16831 $6289 $9279 $6102 Transition NA $98163 $80582 106121002 MAD RIVER COMM HOSP No No No No No 4250 12882 12620 $6289 $7436 $9505 Transition NA $98163 $80582 106201281 MADERA COMMUNITY HOSPITAL No No No No No 5100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106260011 MAMMOTH HOSP No Yes No Yes Yes 7982 12882 12620 $12768 $15097 $46994 Transition NA $98163 $80582 106420493 MARIAN MED CTR No No No No No 2741 12882 12620 $6289 $7436 $9386 Transition NA $98163 $80582 106190525 LONG BEACH MEM MED CTR No No No No No 1996 12882 12620 $6289 $7436 NA Non-Transition $1627 $98163 $80582 106211006 MARIN GEN HOSP No Yes No No No 2571 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106190500 MARINA DEL RAY HOSPITAL No No No No No 2034 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106050932 MARK TWAIN ST JOSEPHS HOSP No No No Yes Yes 3707 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090933 MARSHALL MED CTR No No No Yes Yes 2107 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106500939 MEM HOSP MED CTR-MODESTO No No No No No 2235 12892 12630 $6289 $7440 $5898 Transition NA $98163 $80582 106240924 MEMORIAL HOSP LOS BANOS No No No Yes Yes 3362 12882 12620 $12768 $15097 $17450 Transition NA $98163 $80582 106190521 MEMORIAL HOSP OF GARDENA No No No No No 1747 12882 12620 $6289 $7436 $4611 Transition NA $98163 $80582 106231013 MENDOCINO COAST DIST HOSP No Yes No Yes Yes 5070 12882 12620 $12768 $15097 $15935 Transition NA $98163 $80582 106334018 MENIFEE VALLEY MED CTR No No No No No 1458 12882 12620 $6289 $7436 $5113 Transition NA $98163 $80582 106450936 MAYERS MEM HOSP No Yes No Yes Yes 7192 14188 13900 $12768 $16234 NA Non-Transition NA $98163 $80582 106340947 MERCY GEN HOSP No No No No No 2185 15256 14946 $6289 $8454 $6027 Transition $1387 $98163 $80582 106344029 MERCY HOSP OF FOLSOM No No No No No 2746 15256 14946 $6289 $8454 $5260 Transition NA $98163 $80582 106150761 MERCY HOSP-BAKERSFIELD No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106414018 MENLO PARK SURGICAL HOSP No No No No No 2770 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106240942 MERCY MED CTR MERCED No No No No No 2289 13279 13009 $6289 $7606 NA Non-Transition NA $98163 $80582 106450949 MERCY MED CTR-REDDING No No No No No 2589 14188 13900 $6289 $7996 $10219 Transition NA $98163 $80582 106470871 MERCY MED CTR-MT SHASTA No No No Yes Yes 6242 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106340950 MERCY SAN JUAN HOSP No No No No No 2166 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190529 METHODIST HOSP OF SO CAL No No No No No 1842 12882 12620 $6289 $7436 $6690 Transition $1220 $98163 $80582 106196168 MILLER CHILDRENS HOSP No No Yes No No 2680 12882 12620 $6289 $7436 $8155 Transition NA $98163 $80582 106410742 MILLS HEALTH CENTER No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106410852 MILLS-PENINSULA No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106340951 METHODIST HOSP OF SACRAMENTO No No No No No 2028 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190524 MISSION COMM HOSP-PANORAMA CAMPUS No No No No No 3568 12882 12620 $6289 $7436 $3982 Transition NA $98163 $80582 106190681 MIRACLE MILE No No No No No 100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301262 MISSION HOSP REG MED CTR No No No No No 4091 12882 12620 $6289 $7436 $14336 Transition $1220 $98163 $80582 106250956 MODOC MED CTR No Yes No Yes Yes 4961 12882 12620 $12768 $15097 $13486 Transition NA $98163 $80582 106301337 MISSION HOSP LAGUNA BEACH No No No No No 4091 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106361166 MONTCLAIR HOSP MED CTR No No No No No 3149 12882 12620 $6289 $7436 $5904 Transition NA $98163 $80582 106190547 MONTEREY PARK HOSP No No No No No 1034 12882 12620 $6289 $7436 $5866 Transition NA $98163 $80582 106361266 MOUNTAINS COMM HOSP No Yes No Yes Yes 5148 12882 12620 $12768 $15097 $15642 Transition NA $98163 $80582 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106481357 NORTH BAY MEDICAL CENTER No No No No No 1972 16315 15984 $6289 $8908 $15945 Transition NA $98163 $80582
i-
i
i
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190541 MONROVIA MEM HOSP No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106141273 NORTHERN INYO HOSP No Yes No Yes Yes 8150 12882 12620 $12768 $15097 $27752 Transition NA $98163 $80582 106484001 NORTH BAY VACAVALLEY HOSP No No No No No 1972 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106190568 NORTHRIDGE HOSP MED CTR No No No No No 1596 12882 12620 $6289 $7436 NA Non-Transition $1662 $98163 $80582 106214034 NOVATO COMM HOSP No No No No No 3465 16855 16513 $6289 $9140 $6359 Transition NA $98163 $80582 106500967 OAK VALLEY DIST HOSP No Yes No Yes No 3340 12892 12630 $6289 $7440 $5201 Transition NA $98163 $80582 106430837 OCONNOR HOSP-SAN JOSE No No No No No 2409 17180 16831 $6289 $9279 $5201 Transition NA $98163 $80582 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190534 OLYMPIA MED CTR No No No No No 1260 12882 12620 $6289 $7436 $6786 Transition NA $98163 $80582 106300225 ORANGE COAST MEM MED CTR No No No No No 2293 12882 12620 $6289 $7436 $19985 Transition NA $98163 $80582 106040937 OROVILLE HOSP No No No No No 1803 12882 12620 $6289 $7436 $6229 Transition NA $98163 $80582 106560501 OJAI VALLEY COMM HOSP No No No Yes Yes 2745 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190696 PACIFICA HOSP OF THE VALLEY No No No No No 3338 12882 12620 $6289 $7436 $5616 Transition NA $98163 $80582 106491338 PALM DRIVE HOSP No Yes No Yes No 4315 16315 15984 $6289 $8908 $11457 Transition NA $98163 $80582 106196405 PALMDALE REGIONAL MEDICAL CTR No No No No No 1190 12882 12620 $6289 $7436 $7504 Transition $1220 $98163 $80582 106331288 PALO VERDE HOSP No Yes No Yes Yes 4770 12882 12620 $12768 $15097 $18188 Transition NA $98163 $80582 106370755 PALOMAR MED CTR No Yes No No No 2429 12882 12620 $6289 $7436 $7051 Transition $1220 $98163 $80582 106370759 PARADISE VALLEY HOSP No No No No No 2188 12882 12620 $6289 $7436 $4275 Transition $1220 $98163 $80582 106190307 PACIFIC ALLIANCE MED CTR No No No No No 4299 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106331293 PARKVIEW COMM HOSP MED CTR No No No No No 2757 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106491001 PETALUMA VALLEY HOSP No No No No No 2271 16315 15984 $6289 $8908 $13491 Transition NA $98163 $80582 106130760 PIONEERS MEM HOSP No Yes No Yes No 2989 12882 12620 $6289 $7436 $9825 Transition NA $98163 $80582 106454013 PATIENTS HOSP OF REDDING No No No No No 2172 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106301297 PLACENTIA LINDA HOSP No No No No No 1606 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370977 POMERADO HOSP No Yes No No No 3063 12882 12620 $6289 $7436 $6818 Transition NA $98163 $80582 106320986 PLUMAS DIST HOSP No Yes No Yes Yes 8666 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190631 PRESBYTERIAN INTERCOMM HOSP No No No No No 961 12882 12620 $6289 $7436 $9720 Transition $1220 $98163 $80582 106190630 POMONA VALLEY HOSP MED CTR No No Yes No No 1538 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190468 PROMISE HOSP OF EAST LA-EAST LA No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190599 PROMISE HOSP OF EAST LA-EAST LA-SUBURBAN CAMPUS No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190385 PROVIDENCE HOLY CROSS MED CTR No No No No No 1325 12882 12620 $6289 $7436 $6284 Transition $1220 $98163 $80582 106190680 PROVIDENCE LITTLE CO OF MARY-SAN PEDRO No No No No No 1533 12882 12620 $6289 $7436 $6225 Transition $1220 $98163 $80582 106190470 PROVIDENCE LITTLE CO OF MARY-TORRANCE No No No No No 1767 12882 12620 $6289 $7436 $7182 Transition NA $98163 $80582 106190758 PROVIDENCE ST JOSEPH MED CTR No No No No No 1866 12882 12620 $6289 $7436 $7141 Transition $1220 $98163 $80582 106370787 PROMISE HOSP OF SAN DIEGO No No No No No 3660 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106281047 QUEEN OF THE VALLEY HOSP-NAPA No No No No No 2829 16188 15859 $6289 $8854 $17592 Transition $1453 $98163 $80582 106370673 RADY CHILDRENS HOSPITAL - SAN DIEGO No No Yes No No 2854 12882 12620 $6289 $7436 $6395 Transition $2177 $98163 $80582 106190517 PROVIDENCE TARZANA MED CTR No No Yes No No 1536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361308 REDLANDS COMM HOSP No No No No No 2079 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430705 REG MED CTR OF SAN JOSE No No No No No 2529 17180 16831 $6289 $9279 $13299 Transition NA $98163 $80582 106580996 RIDEOUT MEM HOSP No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106121051 REDWOOD MEM HOSP No No No Yes Yes 3214 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106334487 RIVERSIDE CO REG MED CTR Yes No No No No 2987 12882 12620 $6289 $7436 NA NA NA NA NA 106331312 RIVERSIDE COMM HOSP No No No No No 1560 12882 12620 $6289 $7436 $5990 Transition NA $98163 $80582 106190796 RONALD REAGAN UCLA MED CTR Yes No Yes No No 3382 12882 12620 $6289 $7436 NA NA NA NA NA 106301317 SADDLEBACK MEM MED CTR No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106301325 SADDLEBACK MEM MED CTR-SAN CLEMENTE No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106150782 RIDGECREST REG HOSP No No No Yes Yes 4178 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106361318 SAN ANTONIO COMM HOSP No No No No No 2262 12882 12620 $6289 $7436 $9216 Transition NA $98163 $80582 106190673 SAN DIMAS COMM HOSP No No No No No 2465 12882 12620 $6289 $7436 $12177 Transition NA $98163 $80582 106190200 SAN GABRIEL VALLEY MED CTR No No No No No 969 12882 12620 $6289 $7436 $6918 Transition NA $98163 $80582 106270875 SALINAS VALLEY MEM HOSP No Yes No No No 3534 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106331326 SAN GORGONIO MEM HOSP No Yes No Yes Yes 3394 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391010 SAN JOAQUIN GEN HOSP Yes No No No No 1922 13579 13303 $6289 $7735 NA NA NA NA NA 106104023 SAN JOAQUIN VALLEY REHAB HOSP No No No No No 6479 12882 12620 NA NA NA NA $1413 $98163 $80582 106013619 SAN LEANDRO HOSP No Yes No No No 3482 16501 16166 $6289 $8988 $10813 Transition NA $98163 $80582 106410782 SAN MATEO MED CTR Yes No No No No 7168 16928 16584 $6289 $9171 NA NA NA NA NA 106074017 SAN RAMON REG MED CTR No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106074011 SAN RAMON REG MED CTR SOUTH BUILDING No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106420514 SANTA BARBARA COTTAGE HOSP No No Yes No No 3902 12882 12620 $6289 $7436 $10978 Transition $2125 $98163 $80582 106430883 SANTA CLARA VALLEY MED CTR Yes No Yes No No 3133 17180 16831 $6289 $9279 NA NA NA NA NA 106190687 SANTA MONICA - UCLA MEDICAL CENTER Yes No No No No 3102 12882 12620 $6289 $7436 NA NA NA NA NA 106491064 SANTA ROSA MEM HOSP-MONTGOMERY No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106490907 SANTA ROSA MEM HOSP-SOTOYOME No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106150788 SAN JOAQUIN COMM HOSP No No No No No 2544 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420522 SANTA YNEZ VALLEY COTTAGE HOSP No No No Yes Yes 7569 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106371394 SCRIPPS MEM HOSP-ENCINITAS No No No No No 2403 12882 12620 $6289 $7436 $7037 Transition $1439 $98163 $80582 106370771 SCRIPPS MEM HOSP-LA JOLLA No No No No No 2061 12882 12620 $6289 $7436 $4390 Transition NA $98163 $80582 106370744 SCRIPPS MERCY HOSP No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106370658 SCRIPPS MERCY HOSP-CHULA VISTA No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106371256 SCRIPPS GREEN HOSP No No No No No 2317 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106321016 SENECA HCARE DIST No Yes No Yes Yes 4586 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106410817 SETON MED CTR No No No No No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106410828 SETON MED CTR-COASTSIDE No No No Yes No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106380939 SF GENERAL HOSP Yes No No No No 2851 16738 16398 $6289 $9090 NA NA NA NA NA 106370875 SHARP CHULA VISTA MED CTR No No No No No 1932 12882 12620 $6289 $7436 $6485 Transition NA $98163 $80582 106410891 SEQUOIA HOSP No No No No No 1975 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106370689 SHARP CORONADO HOSP AND HCARE CTR No No No No No 2160 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $72421 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106370694 SHARP MEM HOSP No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106450940 SHASTA REG MED CTR No No No No No 1582 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106190708 SHERMAN OAKS HOSP No No No No No 1516 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190712 SHRINERS HOSPITAL- LA No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106344114 SHRINERS HOSPITAL- SACRAMENTO No No No No No 3869 15256 14946 $6289 $8454 NA Non-Transition $2475 $98163 $80582 106540798 SIERRA VIEW DIST HOSP No Yes No No No 2716 12882 12620 $6289 $7436 $8497 Transition NA $98163 $77682 106400524 SIERRA VIST REG MED CTR No No No No No 1787 12964 12701 $6289 $7471 $5495 Transition NA $98163 $80582 106190661 SILVER LAKE MED CTR No No No No No 3692 12882 12620 $6289 $7436 $5655 Transition NA $98163 $80582 106291023 SIERRA NEVADA MEM HOSP No No No Yes Yes 3427 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106491076 SONOMA VALLEY HOSP No Yes No No No 4960 16315 15984 $6289 $8908 $12733 Transition NA $98163 $80582 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 2126 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190380 SOUTHERN CA HOSP AT HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106190110 SOUTHERN CA HOSPITAL AT CULVER CITY No No No No No 1437 12882 12620 $6289 $7436 $4694 Transition $1220 $98163 $80582 106560525 SIMI VALLEY HOSP AND HCARE-SYCAMORE No No No No No 3840 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106334068 SOUTHWEST HCARE SYSTEM No No No No No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106334001 SOUTHWEST HCARE SYSTEM-WILDOMAR No No No Yes No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106100899 ST AGNES MED CTR No No No No No 3088 12882 12620 $6289 $7436 $7885 Transition NA $98163 $80582 106361339 ST BERNARDINE MED CTR No No No No No 2171 12882 12620 $6289 $7436 $6090 Transition NA $98163 $80582 106521041 ST ELIZABETH COMM HOSP No No No Yes Yes 3024 13869 13587 $12768 $15956 $14866 Transition NA $98163 $80582 106190754 ST FRANCIS MED CTR No No No No No 4350 12882 12620 $6289 $7436 $6368 Transition NA $98163 $80582 106380960 ST FRANCIS MEM HOSP No No No No No 1920 16738 16398 $6289 $9090 $5310 Transition $1492 $98163 $80582 106281078 ST HELENA HOSP No No No No No 2337 15887 15564 $6289 $8725 $9671 Transition NA $98163 $80582 106171049 ST HELENA HOSPITAL-CLEARLAKE No No No Yes Yes 4118 12882 12620 $12768 $15097 $18218 Transition NA $98163 $80582 106141338 SOUTHERN INYO HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190756 ST JOHNS HEALTH CTR No No No No No 2536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560529 ST JOHNS REG MED CTR No No No No No 2982 12882 12620 $6289 $7436 $6976 Transition $1761 $98163 $80582 106121080 ST JOSEPH HOSP-EUREKA No No No No No 2570 13869 13587 $6289 $7859 $9661 Transition $1507 $98163 $80582 106301340 ST JOSEPH HOSP-ORANGE No No No No No 2751 12882 12620 $6289 $7436 $5230 Transition NA $98163 $80582 106560508 ST JOHNS PLEASANT VALLEY HOSP No No No No No 2087 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301342 ST JUDE MED CTR No No No No No 1722 12882 12620 $6289 $7436 $5799 Transition $1220 $98163 $80582 106434138 ST LOUISE REG HOSP No No No No No 2838 17180 16831 $6289 $9279 $16407 Transition NA $98163 $80582 106380964 ST LUKES HOSP No No No No No 3807 16738 16398 $6289 $9090 $8600 Transition NA $98163 $80582 106361343 ST MARY MED CTR-APPLE VALLEY No No No Yes No 2511 12882 12620 $6289 $7436 $9863 Transition NA $98163 $80582 106391042 ST JOSEPHS MED CTR OF STOCKTON No No No No No 2152 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106380965 ST MARYS MED CTR-SF No No No No No 2007 16738 16398 $6289 $9090 $5116 Transition $1492 $98163 $80582 106010967 ST ROSE HOSP No No No No No 1931 16962 16618 $6289 $9186 $7600 Transition NA $98163 $80582 106190762 ST VINCENT MED CTR No No No No No 2020 12882 12620 $6289 $7436 $4684 Transition $1220 $98163 $80582 106430905 STANFORD HOSP No No No No No 1803 17180 16831 $6289 $9279 $5644 Transition $1523 $98163 $80582 106190053 ST MARY MED CTR-LONG BEACH No No No No No 2479 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106504038 STANISLAUS SURGICAL HOSP No No No No No 9000 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106250955 SURPRISE VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106310791 SUTTER AUBURN FAITH HOSP No No No No No 2551 15256 14946 $6289 $8454 $11882 Transition NA $98163 $80582 106034002 SUTTER AMADOR HOSP No No No Yes Yes 2971 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106574010 SUTTER DAVIS HOSP No No No No No 3568 15256 14946 $6289 $8454 $14330 Transition NA $98163 $80582 106070934 SUTTER DELTA MED CTR No No No No No 2907 16478 16143 $6289 $8978 $12158 Transition NA $98163 $80582 106341051 SUTTER GEN HOSP No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106171395 SUTTER LAKESIDE HOSP No No No Yes Yes 3691 12882 12620 $12768 $15097 $17232 Transition NA $98163 $80582 106444012 SUTTER MATERNITY AND SRG CTR OF S CRUZ No No No No No 7213 17239 16889 $6289 $9304 $21288 Transition NA $98163 $80582 106490919 SUTTER MED CTR OF SANTA ROSA No No No No No 3657 16315 15984 $6289 $8908 $15278 Transition NA $98163 $80582 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106311000 SUTTER ROSEVILLE MED CTR No No No No No 2377 15256 14946 $6289 $8454 $11395 Transition $1387 $98163 $80582 106481094 SUTTER SOLANO MED CTR No No No No No 3258 16315 15984 $6289 $8908 $18010 Transition NA $98163 $80582 106084001 SUTTER COAST HOSP No No No Yes Yes 3730 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391056 SUTTER TRACY COMM HOSP No No No No No 2714 13579 13303 $6289 $7735 $5995 Transition NA $98163 $80582 106291053 TAHOE FOREST HOSP No Yes No Yes Yes 4766 15256 14946 $12768 $17164 $21044 Transition NA $98163 $80582 106150808 TEHACHAPI HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 $22158 Transition NA $98163 $80582 106514030 SUTTER SURG HOSP-NORTH VALLEY No No No No No 3240 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106334564 TEMECULA VALLEY HOSPITAL No No No No No 2180 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106120981 THE GENERAL HOSPITAL No No No No No 2570 13869 13587 NA NA NA NA $1507 $98163 $80582 106564121 THOUSAND OAKS SURGICAL HOSPITAL No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106190422 TORRANCE MEM MED CTR No No No No No 1952 12882 12620 $6289 $7436 $5891 Transition NA $98163 $80582 106370780 TRI-CITY MED CTR No Yes No No No 3695 12882 12620 $6289 $7436 $7706 Transition $1220 $98163 $80582 106190784 TEMPLE COMM HOSP No No No No No 4200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540816 TULARE DIST HOSP No Yes No No No 3578 12882 12620 $6289 $7436 $9529 Transition NA $98163 $80582 106531059 TRINITY HOSP No Yes No Yes Yes 5105 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106400548 TWIN CITIES COMM HOSP No No No Yes Yes 1587 12964 12701 $12768 $15168 $8160 Transition NA $98163 $80582 106341006 UC DAVIS MED CTR Yes No Yes No No 1836 15256 14946 $6289 $8454 NA NA NA NA NA 106301279 UC IRVINE MED CTR Yes No Yes No No 2072 12882 12620 $6289 $7436 NA NA NA NA NA 106370782 UCSD MED CTR Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106374141 UCSD-LA JOLLA JOHN M amp SALLY B THORNTON HOSPITAL Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106381154 UCSF MED CTR Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106380895 UCSF MED CTR AT MOUNT ZION Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106301357 TUSTIN HOSP MED CTR No No No No No 231 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106231396 UKIAH VALLEY MED CTRHOSP DR No No No Yes Yes 3643 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106014050 VALLEY CARE MEDICAL CENTER No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106010983 VALLEY MEM HOSP-LIVERMORE No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106191216 USC KENNETH NORRIS JR CANCER HOSP No No No No No 3134 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560481 VENTURA CO MED CTR Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106560521 VENTURA CO MED CTR-SANTA PAULA HOSPITAL Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106190818 VERDUGO HILLS HOSP No No No No No 3110 12882 12620 $6289 $7436 $5264 Transition NA $98163 $80582 106190812 VALLEY PRES HOSP No No No No No 3536 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 3046 14188 13900 $6289 $7996 NA Non-Transition $1312 $98163 $80582 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 3266 12882 12620 $6289 $7436 $8320 Transition NA $98163 $80582 106010987 WASHINGTON HOSP-FREMONT No Yes No No No 1941 16962 16618 $6289 $9186 $6429 Transition NA $98163 $80582 106444013 WATSONVILLE COMM HOSP No No No No No 1780 17239 16889 $6289 $9304 $13456 Transition NA $98163 $80582 106301379 WEST ANAHEIM MED CTR No No No No No 1514 12882 12620 $6289 $7436 $4707 Transition NA $98163 $80582 106190859 WEST HILLS HOSP AND MED CTR No No No No No 1933 12882 12620 $6289 $7436 $8050 Transition NA $98163 $80582 106374094 VIBRA OF SAN DIEGO No No No No No 1155 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301188 WESTERN MED CTR-ANAHEIM No No No No No 3203 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301566 WESTERN MED CTR-SANTA ANA No No No No No 2354 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190878 WHITE MEM MED CTR No No No No No 1515 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190883 WHITTIER HOSP MED CTR No No No No No 1139 12882 12620 $6289 $7436 $5922 Transition NA $98163 $80582 106571086 WOODLAND MEM HOSP No No No No No 3278 15256 14946 $6289 $8454 $10092 Transition NA $98163 $80582 6102015
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
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A B C D 2 Medi -Cal DRG Pricing Calculator Effective Dates of Admission on or after July 1 2015 3 June 10 2015 4 Instructions 5 1 The hospital or other user inputs data in cells C14-C23 amp C34 Values for cell C 34 can be found on the Hospital C haracteristics tab 6 2 Medi-Cal pay ment policy parameters have already been entered in cells C35-C41 7 3 The calculator will s how the predicted allowed amount and paid amount in cells C69 and C73 respectively 8 4 LOS = discharge date minus admission date If a patient is admitted and discharged on the same day the calculated LOS equals zero 9 5 Transfer discharge statuses include 02 0563 65 and 66 Additional v alues are scheduled for implementation in September 2015
6 This calculator spreadsheet is intended to be helpful t o users but it cannot capture all t he editing and pricing complexity of the Medicaid claims processing 10 system In cases of difference the claims processing system is correct 11 Indicates information to be input by the user Indicates payment policy parameters set by Medi-Cal 12 Information Data COMMENTS OR FORMULA 13 INFORMATION FROM THE HOSPITAL-- TO BE INPUT BY THE USER 14 Total c harges $2000000 UB-04 Form Locator 47 15 Hospital-specific cost-to-charge ratio 2997 Look up from Tab 4 Column H 16 Length of stay 63 See instruction 4 used for transfer pricing adjustment 17 Patient discharge status = transfer No See instruction 5 used for transfer pricing adjustment 18 Patient age (in years) 25 Used for age adjustor 19 Other health coverage $000 UB-04 Form Locator 54 for payments by third parties 20 Patient share of cost $000 Includes spend-down or copayment 21 Is discharge status equal t o 30 No Indicates an interim claim 22 Designated NICU facility No Look up from Tab 4 Column E 23 APR-DRG 057-1 From separate APR-DRG grouping software 24 APR-DRG INFORMATION -- CALCULATOR WILL FILL IN VALUES AUTOMATICALLY
APR-DRG description CONCUSSION Look up from DRG table (Tab 3 Column B) CLOSED SKULL FX NOSUNCOMPLICA
25 TED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA
26 Casemix relative weight--unadjusted 05207 Look up from DRG table (Tab 3 Column D) 27 NICU service adjustor - hospital w ith designated NICU 10000 Look up from DRG table (Tab 3 Column J) 28 NICU service adjustor - all other hospitals 10000 Look up from DRG table (Tab 3 Column E) 29 Obstetric service adjustor 10000 Look up from DRG table (Tab 3 Column F) 30 Pediatric age adjustor 12500 Look up from DRG table (Tab 3 Column H)
Payment relative weight 05207 IF C18lt21 then if (C22=Yes) then (C26C27C29C30) else 31 (C26C28C29C30) else if (C22=Yes) then (C26C27C29) else
(C26C28C29) 32 Average length of stay for this APR-DRG 151 Look up from DRG table (Tab 3 Column C) 33 PAYMENT POLICY PARAMETERS SET BY MEDI-CAL 34 DRG base rate $7436 Specific to each hospital (Tab 4 Column L or M) 35 Cost outlier threshold 1 $45000 Threshold qualifying high and low-cost outlier adjustments 36 Cost outlier threshold 2 $145000 Threshold qualifying high-cost outlier adjustments 37 Marginal c ost percentage 1 60 Used for high and low-cost outlier adjustments 38 Marginal c ost percentage 2 80 Used for high-cost outlier adjustments
Casemix adjustment factor 100 Used to adjust DRG relative weights should a need arise else leave set to 100 39
40 Interim claim threshold 29 Threshold qualifying interim claims 41 Interim per diem amount $600 Used for pricing interim claims 42 IS THIS AN INTERIM CLAIM 43 Is discharge status equal t o 30 No Look up C21 44 Is length of stay gt interim claim threshold NA IF C43=Yes then if (C16 gt C40) Yes else No else NA 45 Skip to C72 for final interim claim payment amount $000 IF C44=Yes (C41C16) rounded to 2 places else 0 46 WHAT IS THE DRG BASE PAYMENT 47 DRG base payment for this claim $387193 C34C31C39 48 IS A TRANSFER PAYMENT ADJUSTMENT MADE 49 Is a transfer adjustment potentially applicable No Look up C17 50 Calculated transfer payment adjustment NA IF C49=Yes then (C47C32)(C16+1) rounded to 2 places else NA 51 Is transfer payment adjustment lt allowed amount so far NA IF C50 =NA then NA else if (C50ltC47) then Yes else No 52 Allowed amount after transfer adjustment $387193 IF C51= Yes then C50 else C47 53 IS A COST OUTLIER ADJUSTMENT MADE 54 Estimated cost of this case $599400 C14C15 55 Is estimated cost gt allowed amount Loss IF C54 gt C52 then Loss else Gain 56 High-Side Outlier Payment When Payment Is Much Lower than Cost 57 Estimated loss on this case $212207 IF C55 = Loss then (C54-C52) else NA 58 Is loss gt outlier threshold lower limit No IF C55 = Loss then if (C57 gt C35) then Yes else No else NA
DRG cost outlier payment increase 1 $000 IF C58 = Yes then if (C57ltC35) then ((C57-C35)C37) else ((C36shy59 C35)C37) else 0 DRG cost outlier payment increase 2 $000 IF C58=Yes then if (C57gtC36) then (C57-C36)C38 rounded to 2 places 60 else 0 else 0
61 Low Side Outlier Payment When Payment Is Much Greater than Cost 62 Estimated gain on this case NA IF C55=Gain then (C52-C54) elseNA 63 Is gain gt outlier threshold NA IF C55=Gain then if (C62gtC35) then Yes else No else NA
DRG cost outlier payment decrease $000 IF C55=Gain then (if (C63=Yes) then (C62-C35)C37 rounded to 2 places 64 else 0) else 0 65 ALLOWED AMOUNT AFTER TRANSFER AND OUTLIER ADJUSTMENTS 66 DRG payment so far $387193 IF C55=Loss then (C52+C59+C60) else (C52-C64) 67 CALCULATION OF ALLOWED AMOUNT AND REIMBURSEMENT AMOUNT 68 Add-on amount $000 Hospital-specific payment separate from DRG payment (not used at this time) 69 Allowed amount $387193 Allowed amount = C66+C68 70 Other health coverage $000 C19 71 Patient share of cost $000 C20
Lesser of calculation $387193 Existing policy requires that payment amount cannot exceed total c harges IF 72 C69gtC14 then C14 else C69 Payment amount If interim claim (C43=yes) then interim claim (C45) amount is the payment
73 $387193 amount Otherwise subtract other health coverage (C70) and patient share of cost (C71) from Lesser of (C71) to obtain payment amount
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Medi Cal DRG Table Effective July 1 2015
4 Casemix relative weights reflect Hospital-Specific Relative Value (HSRV) relative weights V32
9 This spreadsheet includes data obtained through the use of proprietary computer software created owned and licensed by the 3M Company All copyrights in and to the 3MTM Software are owned by 3M All rights reserved 3M has no responsibility for the contents of this calculator
3 Average length of stay is the untrimmed arithmetic value
5 For purposes of illustration the table uses a DRG base rate of $7500 In fact DRG base rates are hospital specific See the Hospital Characteristics tab Column L for non-transition hospitals and Column M for transition hospitals 6 Pediatric is defined as under age 21 7 This table shows information for 1258 DRGs (314 base DRGs each with four levels of severity plus two error DRGs) 8 Inclusion of a service in this list does not necessarily imply coverage by Medi-Cal Rehabilitation services (APR-DRG 860) are paid outside the DRG method
1 The DRG base payment equals the DRG base rate times the casemix relative weight times any applicable policy adjustors 2 Average length of stay and casemix relative weights were calculated from the Nationwide Inpatient Sample by 3M Health Information Systems for APR-DRG V32
10 This calculator was developed by Xerox the fiscal intermediary contractor for Medi-Cal
APR DRG APR DRG Descr pt on
Nat ona Average Length of Stay
Medicaid Care Category Pediatric
HSRV Casemix Relative We ght
Policy Adjustor NICU
Policy Adjustor Obstetric s
Payment Relative We ght No Age
Policy Adjustor Pediatric age
Payment Relative We ght w th Age
Policy Adjustor Service (Designat
Payment Relative We ght W th
DRG Base Payment Using Example Base Rate
Medicaid Care Category Adult
001-1 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 763 74839 10000 10000 74839 12500 93549 10000 74839 $70162 Misc Pediatric 001-2 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 857 75257 10000 10000 75257 12500 94071 10000 75257 $70553 Misc Pediatric 001-3 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 1251 88396 10000 10000 88396 12500 110495 10000 88396 $82871 Misc Pediatric 001-4 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 3157 153728 10000 10000 153728 12500 192160 10000 153728 $144120 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
002-1 HEART ampOR LUNG TRANSPLANT 936 81603 10000 10000 81603 12500 102004 10000 81603 $76503 Misc Pediatric 002-2 HEART ampOR LUNG TRANSPLANT 1470 96672 10000 10000 96672 12500 120840 10000 96672 $90630 Misc Pediatric 002-3 HEART ampOR LUNG TRANSPLANT 2153 120551 10000 10000 120551 12500 150689 10000 120551 $113017 Misc Pediatric 002-4 HEART ampOR LUNG TRANSPLANT 3671 180801 10000 10000 180801 12500 226001 10000 180801 $169501 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
003-1 BONE MARROW TRANSPLANT 1692 42402 10000 10000 42402 12500 53003 10000 42402 $39752 Misc Pediatric 003-2 BONE MARROW TRANSPLANT 2257 62664 10000 10000 62664 12500 78330 10000 62664 $58748 Misc Pediatric 003-3 BONE MARROW TRANSPLANT 3280 101363 10000 10000 101363 12500 126704 10000 101363 $95028 Misc Pediatric 003-4 BONE MARROW TRANSPLANT 5119 182162 10000 10000 182162 12500 227703 10000 182162 $170777 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
004-1 ECMO OR TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W EXTENSIVE PROCEDURE 2289 64917 10000 10000 64917 12500 81146 10000 64917 $60860 Misc Pediatric 004-2 ECMO OR TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W EXTENSIVE PROCEDURE 2059 67502 10000 10000 67502 12500 84378 10000 67502 $63283 Misc Pediatric 004-3 ECMO OR TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W EXTENSIVE PROCEDURE 2639 92480 10000 10000 92480 12500 115600 10000 92480 $86700 Misc Pediatric 004-4 ECMO OR TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W EXTENSIVE PROCEDURE 3858 141600 10000 10000 141600 12500 177000 10000 141600 $132750 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
005-1 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION WO EXTENSIVE PROCEDURE 2774 49004 10000 10000 49004 12500 61255 10000 49004 $45941 Misc Pediatric 005-2 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION WO EXTENSIVE PROCEDURE 1947 52327 10000 10000 52327 12500 65409 10000 52327 $49057 Misc Pediatric 005-3 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION WO EXTENSIVE PROCEDURE 2393 67135 10000 10000 67135 12500 83919 10000 67135 $62939 Misc Pediatric 005-4 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION WO EXTENSIVE PROCEDURE 3278 95918 10000 10000 95918 12500 119898 10000 95918 $89923 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
006-1 PANCREAS TRANSPLANT 590 75340 10000 10000 75340 12500 94175 10000 75340 $70631 Misc Pediatric 006-2 PANCREAS TRANSPLANT 812 84835 10000 10000 84835 12500 106044 10000 84835 $79533 Misc Pediatric 006-3 PANCREAS TRANSPLANT 1015 90984 10000 10000 90984 12500 113730 10000 90984 $85298 Misc Pediatric 006-4 PANCREAS TRANSPLANT 2470 139742 10000 10000 139742 12500 174678 10000 139742 $131008 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
020-1 CRANIOTOMY FOR TRAUMA 540 17475 10000 10000 17475 12500 21844 10000 17475 $16383 Misc Pediatric 020-2 CRANIOTOMY FOR TRAUMA 637 22987 10000 10000 22987 12500 28734 10000 22987 $21550 Misc Pediatric 020-3 CRANIOTOMY FOR TRAUMA 994 32365 10000 10000 32365 12500 40456 10000 32365 $30342 Misc Pediatric 020-4 CRANIOTOMY FOR TRAUMA 1688 57910 10000 10000 57910 12500 72388 10000 57910 $54291 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
021-1 CRANIOTOMY EXCEPT FOR TRAUMA 399 19469 10000 10000 19469 12500 24336 10000 19469 $18252 Misc Pediatric 021-2 CRANIOTOMY EXCEPT FOR TRAUMA 580 25682 10000 10000 25682 12500 32103 10000 25682 $24077 Misc Pediatric 021-3 CRANIOTOMY EXCEPT FOR TRAUMA 1037 37498 10000 10000 37498 12500 46873 10000 37498 $35154 Misc Pediatric 021-4 CRANIOTOMY EXCEPT FOR TRAUMA 1849 62981 10000 10000 62981 12500 78726 10000 62981 $59045 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
022-1 VENTRICULAR SHUNT PROCEDURES 280 11881 10000 10000 11881 12500 14851 10000 11881 $11138 Misc Pediatric 022-2 VENTRICULAR SHUNT PROCEDURES 535 15662 10000 10000 15662 12500 19578 10000 15662 $14683 Misc Pediatric 022-3 VENTRICULAR SHUNT PROCEDURES 1108 28925 10000 10000 28925 12500 36156 10000 28925 $27117 Misc Pediatric 022-4 VENTRICULAR SHUNT PROCEDURES 1829 51610 10000 10000 51610 12500 64513 10000 51610 $48384 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
023-1 SPINAL PROCEDURES 330 13296 10000 10000 13296 12500 16620 10000 13296 $12465 Misc Pediatric 023-2 SPINAL PROCEDURES 575 18228 10000 10000 18228 12500 22785 10000 18228 $17089 Misc Pediatric 023-3 SPINAL PROCEDURES 1033 37132 10000 10000 37132 12500 46415 10000 37132 $34811 Misc Pediatric 023-4 SPINAL PROCEDURES 2028 64258 10000 10000 64258 12500 80323 10000 64258 $60242 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
024-1 EXTRACRANIAL VASCULAR PROCEDURES 154 10744 10000 10000 10744 12500 13430 10000 10744 $10073 Misc Pediatric 024-2 EXTRACRANIAL VASCULAR PROCEDURES 291 14224 10000 10000 14224 12500 17780 10000 14224 $13335 Misc Pediatric 024-3 EXTRACRANIAL VASCULAR PROCEDURES 748 27477 10000 10000 27477 12500 34346 10000 27477 $25760 Misc Pediatric 024-4 EXTRACRANIAL VASCULAR PROCEDURES 1360 52767 10000 10000 52767 12500 65959 10000 52767 $49469 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
026-1 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 261 11696 10000 10000 11696 12500 14620 10000 11696 $10965 Misc Pediatric 026-2 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 445 15931 10000 10000 15931 12500 19914 10000 15931 $14935 Misc Pediatric 026-3 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 912 24163 10000 10000 24163 12500 30204 10000 24163 $22653 Misc Pediatric 026-4 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 2104 48720 10000 10000 48720 12500 60900 10000 48720 $45675 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
040-1 SPINAL DISORDERS amp INJURIES 362 07950 10000 10000 07950 12500 09938 10000 07950 $7453 Misc Pediatric 040-2 SPINAL DISORDERS amp INJURIES 497 09647 10000 10000 09647 12500 12059 10000 09647 $9044 Misc Pediatric 040-3 SPINAL DISORDERS amp INJURIES 796 13170 10000 10000 13170 12500 16463 10000 13170 $12347 Misc Pediatric 040-4 SPINAL DISORDERS amp INJURIES 1612 26793 10000 10000 26793 12500 33491 10000 26793 $25118 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
041-1 NERVOUS SYSTEM MALIGNANCY 306 06836 10000 10000 06836 12500 08545 10000 06836 $6409 Misc Pediatric 041-2 NERVOUS SYSTEM MALIGNANCY 388 07312 10000 10000 07312 12500 09140 10000 07312 $6855 Misc Pediatric 041-3 NERVOUS SYSTEM MALIGNANCY 613 10508 10000 10000 10508 12500 13135 10000 10508 $9851 Misc Pediatric 041-4 NERVOUS SYSTEM MALIGNANCY 992 17617 10000 10000 17617 12500 22021 10000 17617 $16516 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
042-1 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 521 05231 10000 10000 05231 12500 06539 10000 05231 $4904 Misc Pediatric 042-2 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 886 07627 10000 10000 07627 12500 09534 10000 07627 $7150 Misc Pediatric 042-3 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 917 10114 10000 10000 10114 12500 12643 10000 10114 $9482 Misc Pediatric 042-4 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 1329 21932 10000 10000 21932 12500 27415 10000 21932 $20561 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
043-1 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 356 06706 10000 10000 06706 12500 08383 10000 06706 $6287 Misc Pediatric 043-2 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 479 08543 10000 10000 08543 12500 10679 10000 08543 $8009 Misc Pediatric 043-3 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 827 13083 10000 10000 13083 12500 16354 10000 13083 $12265 Misc Pediatric 043-4 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 1650 28853 10000 10000 28853 12500 36066 10000 28853 $27050 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
044-1 INTRACRANIAL HEMORRHAGE 349 06526 10000 10000 06526 12500 08158 10000 06526 $6118 Misc Pediatric 044-2 INTRACRANIAL HEMORRHAGE 462 08878 10000 10000 08878 12500 11098 10000 08878 $8323 Misc Pediatric 044-3 INTRACRANIAL HEMORRHAGE 547 11157 10000 10000 11157 12500 13946 10000 11157 $10460 Misc Pediatric 044-4 INTRACRANIAL HEMORRHAGE 897 20771 10000 10000 20771 12500 25964 10000 20771 $19473 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
045-1 CVA amp PRECEREBRAL OCCLUSION W INFARCT 279 07518 10000 10000 07518 12500 09398 10000 07518 $7048 Misc Pediatric 045-2 CVA amp PRECEREBRAL OCCLUSION W INFARCT 392 09090 10000 10000 09090 12500 11363 10000 09090 $8522 Misc Pediatric 045-3 CVA amp PRECEREBRAL OCCLUSION W INFARCT 617 12516 10000 10000 12516 12500 15645 10000 12516 $11734 Misc Pediatric 045-4 CVA amp PRECEREBRAL OCCLUSION W INFARCT 1101 23311 10000 10000 23311 12500 29139 10000 23311 $21854 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
046-1 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 262 06594 10000 10000 06594 12500 08243 10000 06594 $6182 Misc Pediatric 046-2 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 327 08051 10000 10000 08051 12500 10064 10000 08051 $7548 Misc Pediatric 046-3 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 501 10524 10000 10000 10524 12500 13155 10000 10524 $9866 Misc Pediatric 046-4 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 950 18762 10000 10000 18762 12500 23453 10000 18762 $17589 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
047-1 TRANSIENT ISCHEMIA 193 05944 10000 10000 05944 12500 07430 10000 05944 $5573 Misc Pediatric 047-2 TRANSIENT ISCHEMIA 252 06664 10000 10000 06664 12500 08330 10000 06664 $6248 Misc Pediatric 047-3 TRANSIENT ISCHEMIA 382 08503 10000 10000 08503 12500 10629 10000 08503 $7972 Misc Pediatric 047-4 TRANSIENT ISCHEMIA 877 17352 10000 10000 17352 12500 21690 10000 17352 $16268 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
048-1 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 276 05447 10000 10000 05447 12500 06809 10000 05447 $5107 Misc Pediatric 048-2 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 381 06543 10000 10000 06543 12500 08179 10000 06543 $6134 Misc Pediatric 048-3 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 538 08920 10000 10000 08920 12500 11150 10000 08920 $8363 Misc Pediatric 048-4 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 1291 21687 10000 10000 21687 12500 27109 10000 21687 $20332 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
049-1 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 542 08284 10000 10000 08284 12500 10355 10000 08284 $7766 Misc Pediatric 049-2 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 670 16421 10000 10000 16421 12500 20526 10000 16421 $15395 Misc Pediatric 049-3 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 1061 20964 10000 10000 20964 12500 26205 10000 20964 $19654 Misc Pediatric 049-4 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 1600 36170 10000 10000 36170 12500 45213 10000 36170 $33909 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
050-1 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 392 05935 10000 10000 05935 12500 07419 10000 05935 $5564 Misc Pediatric 050-2 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 557 09905 10000 10000 09905 12500 12381 10000 09905 $9286 Misc Pediatric 050-3 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 881 16196 10000 10000 16196 12500 20245 10000 16196 $15184 Misc Pediatric 050-4 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 1558 37267 10000 10000 37267 12500 46584 10000 37267 $34938 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
051-1 VIRAL MENINGITIS 263 04820 10000 10000 04820 12500 06025 10000 04820 $4519 Misc Pediatric 051-2 VIRAL MENINGITIS 376 07311 10000 10000 07311 12500 09139 10000 07311 $6854 Misc Pediatric 051-3 VIRAL MENINGITIS 647 12961 10000 10000 12961 12500 16201 10000 12961 $12151 Misc Pediatric 051-4 VIRAL MENINGITIS 1269 30543 10000 10000 30543 12500 38179 10000 30543 $28634 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
052-1 NONTRAUMATIC STUPOR amp COMA 212 05282 10000 10000 05282 12500 06603 10000 05282 $4952 Misc Pediatric 052-2 NONTRAUMATIC STUPOR amp COMA 322 06261 10000 10000 06261 12500 07826 10000 06261 $5870 Misc Pediatric 052-3 NONTRAUMATIC STUPOR amp COMA 518 08796 10000 10000 08796 12500 10995 10000 08796 $8246 Misc Pediatric 052-4 NONTRAUMATIC STUPOR amp COMA 1098 20139 10000 10000 20139 12500 25174 10000 20139 $18880 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
053-1 SEIZURE 231 04456 10000 10000 04456 12500 05570 10000 04456 $4178 Misc Pediatric 053-2 SEIZURE 292 05716 10000 10000 05716 12500 07145 10000 05716 $5359 Misc Pediatric 053-3 SEIZURE 440 08167 10000 10000 08167 12500 10209 10000 08167 $7657 Misc Pediatric 053-4 SEIZURE 977 20593 10000 10000 20593 12500 25741 10000 20593 $19306 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
054-1 MIGRAINE amp OTHER HEADACHES 237 04790 10000 10000 04790 12500 05988 10000 04790 $4491 Misc Pediatric 054-2 MIGRAINE amp OTHER HEADACHES 281 05954 10000 10000 05954 12500 07443 10000 05954 $5582 Misc Pediatric 054-3 MIGRAINE amp OTHER HEADACHES 392 07615 10000 10000 07615 12500 09519 10000 07615 $7139 Misc Pediatric 054-4 MIGRAINE amp OTHER HEADACHES 686 12142 10000 10000 12142 12500 15178 10000 12142 $11383 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
055-1 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 226 05690 10000 10000 05690 12500 07113 10000 05690 $5334 Misc Pediatric 055-2 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 356 07923 10000 10000 07923 12500 09904 10000 07923 $7428 Misc Pediatric 055-3 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 537 12060 10000 10000 12060 12500 15075 10000 12060 $11306 Misc Pediatric 055-4 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 1042 23925 10000 10000 23925 12500 29906 10000 23925 $22430 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
056-1 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 226 05776 10000 10000 05776 12500 07220 10000 05776 $5415 Misc Pediatric 056-2 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 367 08300 10000 10000 08300 12500 10375 10000 08300 $7781 Misc Pediatric 056-3 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 599 13057 10000 10000 13057 12500 16321 10000 13057 $12241 Misc Pediatric 056-4 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 1334 31575 10000 10000 31575 12500 39469 10000 31575 $29602 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
057-1 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 151 05207 10000 10000 05207 12500 06509 10000 05207 $4882 Misc Pediatric 057-2 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 242 07484 10000 10000 07484 12500 09355 10000 07484 $7016 Misc Pediatric 057-3 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 440 11394 10000 10000 11394 12500 14243 10000 11394 $10682 Misc Pediatric 057-4 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 1034 25045 10000 10000 25045 12500 31306 10000 25045 $23480 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
058-1 OTHER DISORDERS OF NERVOUS SYSTEM 278 05743 10000 10000 05743 12500 07179 10000 05743 $5384 Misc Pediatric 058-2 OTHER DISORDERS OF NERVOUS SYSTEM 409 07055 10000 10000 07055 12500 08819 10000 07055 $6614 Misc Pediatric 058-3 OTHER DISORDERS OF NERVOUS SYSTEM 616 09584 10000 10000 09584 12500 11980 10000 09584 $8985 Misc Pediatric 058-4 OTHER DISORDERS OF NERVOUS SYSTEM 1234 19422 10000 10000 19422 12500 24278 10000 19422 $18208 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
070-1 ORBITAL PROCEDURES 213 07705 10000 10000 07705 12500 09631 10000 07705 $7223 Misc Pediatric 070-2 ORBITAL PROCEDURES 376 11459 10000 10000 11459 12500 14324 10000 11459 $10743 Misc Pediatric 070-3 ORBITAL PROCEDURES 677 20584 10000 10000 20584 12500 25730 10000 20584 $19298 Misc Pediatric
Misc Adult Misc Adult Misc Adult
070-4 ORBITAL PROCEDURES 1319 41150 10000 10000 41150 12500 51438 10000 41150 $38578 Misc Pediatric Misc Adult 073-1 073-2 073-3 073-4
EYE PROCEDURES EXCEPT ORBIT EYE PROCEDURES EXCEPT ORBIT EYE PROCEDURES EXCEPT ORBIT EYE PROCEDURES EXCEPT ORBIT
227 313 544
1855
07119 08959 13025 30348
10000 10000 10000 10000
10000 10000 10000 10000
07119 08959 13025 30348
12500 12500 12500 12500
08899 11199 16281 37935
10000 10000 10000 10000
07119 08959 13025 30348
$6674 Misc Pediatric $8399 Misc Pediatric
$12211 Misc Pediatric $28451 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
080-1 080-2 080-3 080-4
ACUTE MAJOR EYE INFECTIONS ACUTE MAJOR EYE INFECTIONS ACUTE MAJOR EYE INFECTIONS ACUTE MAJOR EYE INFECTIONS
294 394 624
1204
03773 05293 08870 22854
10000 10000 10000 10000
10000 10000 10000 10000
03773 05293 08870 22854
12500 12500 12500 12500
04716 06616 11088 28568
10000 10000 10000 10000
03773 05293 08870 22854
$3537 Misc Pediatric $4962 Misc Pediatric $8316 Misc Pediatric
$21426 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
082-1 082-2 082-3 082-4
EYE DISORDERS EXCEPT MAJOR INFECTIONS EYE DISORDERS EXCEPT MAJOR INFECTIONS EYE DISORDERS EXCEPT MAJOR INFECTIONS EYE DISORDERS EXCEPT MAJOR INFECTIONS
229 280 431
1589
04191 05783 08004 18093
10000 10000 10000 10000
10000 10000 10000 10000
04191 05783 08004 18093
12500 12500 12500 12500
05239 07229 10005 22616
10000 10000 10000 10000
04191 05783 08004 18093
$3929 Misc Pediatric $5422 Misc Pediatric $7504 Misc Pediatric
$16962 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
089-1 089-2 089-3 089-4
MAJOR CRANIALFACIAL BONE PROCEDURES MAJOR CRANIALFACIAL BONE PROCEDURES MAJOR CRANIALFACIAL BONE PROCEDURES MAJOR CRANIALFACIAL BONE PROCEDURES
231 384 877
1633
14059 18500 32437 57616
10000 10000 10000 10000
10000 10000 10000 10000
14059 18500 32437 57616
12500 12500 12500 12500
17574 23125 40546 72020
10000 10000 10000 10000
14059 18500 32437 57616
$13180 Misc Pediatric $17344 Misc Pediatric $30410 Misc Pediatric $54015 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
090-1 090-2 090-3 090-4
MAJOR LARYNX amp TRACHEA PROCEDURES MAJOR LARYNX amp TRACHEA PROCEDURES MAJOR LARYNX amp TRACHEA PROCEDURES MAJOR LARYNX amp TRACHEA PROCEDURES
259 809
1356 2501
07159 22218 35815 71443
10000 10000 10000 10000
10000 10000 10000 10000
07159 22218 35815 71443
12500 12500 12500 12500
08949 27773 44769 89304
10000 10000 10000 10000
07159 22218 35815 71443
$6712 Misc Pediatric $20829 Misc Pediatric $33577 Misc Pediatric $66978 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
091-1 091-2 091-3 091-4
OTHER MAJOR HEAD amp NECK PROCEDURES OTHER MAJOR HEAD amp NECK PROCEDURES OTHER MAJOR HEAD amp NECK PROCEDURES OTHER MAJOR HEAD amp NECK PROCEDURES
324 463 959
1918
13026 18978 35965 63240
10000 10000 10000 10000
10000 10000 10000 10000
13026 18978 35965 63240
12500 12500 12500 12500
16283 23723 44956 79050
10000 10000 10000 10000
13026 18978 35965 63240
$12212 Misc Pediatric $17792 Misc Pediatric $33717 Misc Pediatric $59288 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
092-1 092-2 092-3 092-4
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES
200 293 606
1411
09832 13811 22378 49305
10000 10000 10000 10000
10000 10000 10000 10000
09832 13811 22378 49305
12500 12500 12500 12500
12290 17264 27973 61631
10000 10000 10000 10000
09832 13811 22378 49305
$9218 Misc Pediatric $12948 Misc Pediatric $20979 Misc Pediatric $46223 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
093-1 093-2 093-3 093-4
SINUS amp MASTOID PROCEDURES SINUS amp MASTOID PROCEDURES SINUS amp MASTOID PROCEDURES SINUS amp MASTOID PROCEDURES
236 388 725
1267
09484 12524 19562 30863
10000 10000 10000 10000
10000 10000 10000 10000
09484 12524 19562 30863
12500 12500 12500 12500
11855 15655 24453 38579
10000 10000 10000 10000
09484 12524 19562 30863
$8891 Misc Pediatric $11741 Misc Pediatric $18339 Misc Pediatric $28934 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
095-1 095-2 095-3 095-4
CLEFT LIP amp PALATE REPAIR CLEFT LIP amp PALATE REPAIR CLEFT LIP amp PALATE REPAIR CLEFT LIP amp PALATE REPAIR
143 206 403
1096
06260 07686 11913 21518
10000 10000 10000 10000
10000 10000 10000 10000
06260 07686 11913 21518
12500 12500 12500 12500
07825 09608 14891 26898
10000 10000 10000 10000
06260 07686 11913 21518
$5869 Misc Pediatric $7206 Misc Pediatric
$11168 Misc Pediatric $20173 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
097-1 097-2 097-3 097-4
TONSIL amp ADENOID PROCEDURES TONSIL amp ADENOID PROCEDURES TONSIL amp ADENOID PROCEDURES TONSIL amp ADENOID PROCEDURES
155 275 571
1520
04084 06213 12162 32627
10000 10000 10000 10000
10000 10000 10000 10000
04084 06213 12162 32627
12500 12500 12500 12500
05105 07766 15203 40784
10000 10000 10000 10000
04084 06213 12162 32627
$3829 Misc Pediatric $5825 Misc Pediatric
$11402 Misc Pediatric $30588 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
098-1 098-2 098-3 098-4
OTHER EAR NOSE MOUTH amp THROAT PROCEDURES OTHER EAR NOSE MOUTH amp THROAT PROCEDURES OTHER EAR NOSE MOUTH amp THROAT PROCEDURES OTHER EAR NOSE MOUTH amp THROAT PROCEDURES
210 326 680
1461
07048 09495 15477 32522
10000 10000 10000 10000
10000 10000 10000 10000
07048 09495 15477 32522
12500 12500 12500 12500
08810 11869 19346 40653
10000 10000 10000 10000
07048 09495 15477 32522
$6608 Misc Pediatric $8902 Misc Pediatric
$14510 Misc Pediatric $30489 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
110-1 110-2 110-3 110-4
EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES
292 429 693
1273
04895 07037 11057 22409
10000 10000 10000 10000
10000 10000 10000 10000
04895 07037 11057 22409
12500 12500 12500 12500
06119 08796 13821 28011
10000 10000 10000 10000
04895 07037 11057 22409
$4589 Misc Pediatric $6597 Misc Pediatric
$10366 Misc Pediatric $21008 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
111-1 111-2 111-3 111-4
VERTIGO amp OTHER LABYRINTH DISORDERS VERTIGO amp OTHER LABYRINTH DISORDERS VERTIGO amp OTHER LABYRINTH DISORDERS VERTIGO amp OTHER LABYRINTH DISORDERS
201 251 349 747
04865 05693 07226 13868
10000 10000 10000 10000
10000 10000 10000 10000
04865 05693 07226 13868
12500 12500 12500 12500
06081 07116 09033 17335
10000 10000 10000 10000
04865 05693 07226 13868
$4561 Misc Pediatric $5337 Misc Pediatric $6774 Misc Pediatric
$13001 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
113-1 113-2 113-3 113-4
INFECTIONS OF UPPER RESPIRATORY TRACT INFECTIONS OF UPPER RESPIRATORY TRACT INFECTIONS OF UPPER RESPIRATORY TRACT INFECTIONS OF UPPER RESPIRATORY TRACT
187 252 395 733
02600 04025 06701 13455
10000 10000 10000 10000
10000 10000 10000 10000
02600 04025 06701 13455
12500 12500 12500 12500
03250 05031 08376 16819
10000 10000 10000 10000
02600 04025 06701 13455
$2438 Resp Pediatric $3773 Resp Pediatric $6282 Resp Pediatric
$12614 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
114-1 114-2 114-3 114-4
DENTAL amp ORAL DISEASES amp INJURIES DENTAL amp ORAL DISEASES amp INJURIES DENTAL amp ORAL DISEASES amp INJURIES DENTAL amp ORAL DISEASES amp INJURIES
220 297 545
1060
03711 05698 09275 19812
10000 10000 10000 10000
10000 10000 10000 10000
03711 05698 09275 19812
12500 12500 12500 12500
04639 07123 11594 24765
10000 10000 10000 10000
03711 05698 09275 19812
$3479 Misc Pediatric $5342 Misc Pediatric $8695 Misc Pediatric
$18574 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
115-1 115-2 115-3 115-4
OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES
230 298 483 964
04062 05956 08755 18372
10000 10000 10000 10000
10000 10000 10000 10000
04062 05956 08755 18372
12500 12500 12500 12500
05078 07445 10944 22965
10000 10000 10000 10000
04062 05956 08755 18372
$3808 Misc Pediatric $5584 Misc Pediatric $8208 Misc Pediatric
$17224 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
120-1 120-2 120-3 120-4
MAJOR RESPIRATORY amp CHEST PROCEDURES MAJOR RESPIRATORY amp CHEST PROCEDURES MAJOR RESPIRATORY amp CHEST PROCEDURES MAJOR RESPIRATORY amp CHEST PROCEDURES
486 677
1138 1939
17190 21946 31960 57405
10000 10000 10000 10000
10000 10000 10000 10000
17190 21946 31960 57405
12500 12500 12500 12500
21488 27433 39950 71756
10000 10000 10000 10000
17190 21946 31960 57405
$16116 Resp Pediatric $20574 Resp Pediatric $29963 Resp Pediatric $53817 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
121-1 121-2 121-3 121-4
OTHER RESPIRATORY amp CHEST PROCEDURES OTHER RESPIRATORY amp CHEST PROCEDURES OTHER RESPIRATORY amp CHEST PROCEDURES OTHER RESPIRATORY amp CHEST PROCEDURES
349 547
1028 1936
11884 15313 24687 50343
10000 10000 10000 10000
10000 10000 10000 10000
11884 15313 24687 50343
12500 12500 12500 12500
14855 19141 30859 62929
10000 10000 10000 10000
11884 15313 24687 50343
$11141 Resp Pediatric $14356 Resp Pediatric $23144 Resp Pediatric $47197 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
130-1 130-2 130-3 130-4
RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS
1453 1262 1448 1967
28511 30424 36434 48144
10000 10000 10000 10000
10000 10000 10000 10000
28511 30424 36434 48144
12500 12500 12500 12500
35639 38030 45543 60180
10000 10000 10000 10000
28511 30424 36434 48144
$26729 Resp Pediatric $28523 Resp Pediatric $34157 Resp Pediatric $45135 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
131-1 131-2 131-3 131-4
CYSTIC FIBROSIS - PULMONARY DISEASE CYSTIC FIBROSIS - PULMONARY DISEASE CYSTIC FIBROSIS - PULMONARY DISEASE CYSTIC FIBROSIS - PULMONARY DISEASE
695 820
1028 1321
11407 14020 18525 25461
10000 10000 10000 10000
10000 10000 10000 10000
11407 14020 18525 25461
12500 12500 12500 12500
14259 17525 23156 31826
10000 10000 10000 10000
11407 14020 18525 25461
$10694 Resp Pediatric $13144 Resp Pediatric $17367 Resp Pediatric $23870 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
132-1 132-2 132-3 132-4
BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
345 441 709
1048
04234 05182 08052 14928
10000 10000 10000 10000
10000 10000 10000 10000
04234 05182 08052 14928
12500 12500 12500 12500
05293 06478 10065 18660
10000 10000 10000 10000
04234 05182 08052 14928
$3969 Resp Pediatric $4858 Resp Pediatric $7549 Resp Pediatric
$13995 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
133-1 133-2 133-3 133-4
PULMONARY EDEMA amp RESPIRATORY FAILURE PULMONARY EDEMA amp RESPIRATORY FAILURE PULMONARY EDEMA amp RESPIRATORY FAILURE PULMONARY EDEMA amp RESPIRATORY FAILURE
256 409 582 753
05454 07562 10997 17496
10000 10000 10000 10000
10000 10000 10000 10000
05454 07562 10997 17496
12500 12500 12500 12500
06818 09453 13746 21870
10000 10000 10000 10000
05454 07562 10997 17496
$5113 Resp Pediatric $7089 Resp Pediatric
$10310 Resp Pediatric $16403 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
134-1 134-2 134-3 134-4
PULMONARY EMBOLISM PULMONARY EMBOLISM PULMONARY EMBOLISM PULMONARY EMBOLISM
366 454 634 866
07118 09026 12878 19731
10000 10000 10000 10000
10000 10000 10000 10000
07118 09026 12878 19731
12500 12500 12500 12500
08898 11283 16098 24664
10000 10000 10000 10000
07118 09026 12878 19731
$6673 Resp Pediatric $8462 Resp Pediatric
$12073 Resp Pediatric $18498 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
135-1 135-2 135-3 135-4
MAJOR CHEST amp RESPIRATORY TRAUMA MAJOR CHEST amp RESPIRATORY TRAUMA MAJOR CHEST amp RESPIRATORY TRAUMA MAJOR CHEST amp RESPIRATORY TRAUMA
283 365 576 834
06399 08153 11913 21262
10000 10000 10000 10000
10000 10000 10000 10000
06399 08153 11913 21262
12500 12500 12500 12500
07999 10191 14891 26578
10000 10000 10000 10000
06399 08153 11913 21262
$5999 Resp Pediatric $7643 Resp Pediatric
$11168 Resp Pediatric $19933 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
136-1 136-2 136-3 136-4
RESPIRATORY MALIGNANCY RESPIRATORY MALIGNANCY RESPIRATORY MALIGNANCY RESPIRATORY MALIGNANCY
324 419 664 944
04458 07139 11635 18353
10000 10000 10000 10000
10000 10000 10000 10000
04458 07139 11635 18353
12500 12500 12500 12500
05573 08924 14544 22941
10000 10000 10000 10000
04458 07139 11635 18353
$4179 Resp Pediatric $6693 Resp Pediatric
$10908 Resp Pediatric $17206 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
137-1 137-2 137-3 137-4
MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS
470 529 724
1033
06368 08483 12031 19133
10000 10000 10000 10000
10000 10000 10000 10000
06368 08483 12031 19133
12500 12500 12500 12500
07960 10604 15039 23916
10000 10000 10000 10000
06368 08483 12031 19133
$5970 Resp Pediatric $7953 Resp Pediatric
$11279 Resp Pediatric $17937 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
138-1 138-2 138-3 138-4
BRONCHIOLITIS amp RSV PNEUMONIA BRONCHIOLITIS amp RSV PNEUMONIA BRONCHIOLITIS amp RSV PNEUMONIA BRONCHIOLITIS amp RSV PNEUMONIA
238 312 534 914
02804 03844 07519 18353
10000 10000 10000 10000
10000 10000 10000 10000
02804 03844 07519 18353
12500 12500 12500 12500
03505 04805 09399 22941
10000 10000 10000 10000
02804 03844 07519 18353
$2629 Resp Pediatric $3604 Resp Pediatric $7049 Resp Pediatric
$17206 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
139-1 139-2 139-3 139-4
OTHER PNEUMONIA OTHER PNEUMONIA OTHER PNEUMONIA OTHER PNEUMONIA
272 378 564 872
04202 06403 09948 17261
10000 10000 10000 10000
10000 10000 10000 10000
04202 06403 09948 17261
12500 12500 12500 12500
05253 08004 12435 21576
10000 10000 10000 10000
04202 06403 09948 17261
$3939 Resp Pediatric $6003 Resp Pediatric $9326 Resp Pediatric
$16182 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
140-1 140-2 140-3 140-4
CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHRONIC OBSTRUCTIVE PULMONARY DISEASE
311 381 519 874
05252 06666 09076 16691
10000 10000 10000 10000
10000 10000 10000 10000
05252 06666 09076 16691
12500 12500 12500 12500
06565 08333 11345 20864
10000 10000 10000 10000
05252 06666 09076 16691
$4924 Resp Pediatric $6249 Resp Pediatric $8509 Resp Pediatric
$15648 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
141-1 141-2 141-3 141-4
ASTHMA ASTHMA ASTHMA ASTHMA
219 307 435 560
03409 05016 07486 13503
10000 10000 10000 10000
10000 10000 10000 10000
03409 05016 07486 13503
12500 12500 12500 12500
04261 06270 09358 16879
10000 10000 10000 10000
03409 05016 07486 13503
$3196 Resp Pediatric $4703 Resp Pediatric $7018 Resp Pediatric
$12659 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
142-1 142-2 142-3 142-4
INTERSTITIAL amp ALVEOLAR LUNG DISEASES INTERSTITIAL amp ALVEOLAR LUNG DISEASES INTERSTITIAL amp ALVEOLAR LUNG DISEASES INTERSTITIAL amp ALVEOLAR LUNG DISEASES
331 422 633
1035
05788 07446 10874 19559
10000 10000 10000 10000
10000 10000 10000 10000
05788 07446 10874 19559
12500 12500 12500 12500
07235 09308 13593 24449
10000 10000 10000 10000
05788 07446 10874 19559
$5426 Resp Pediatric $6981 Resp Pediatric
$10194 Resp Pediatric $18337 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
143-1 143-2 143-3 143-4
OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES
285 376 564 863
04354 06617 09962 15731
10000 10000 10000 10000
10000 10000 10000 10000
04354 06617 09962 15731
12500 12500 12500 12500
05443 08271 12453 19664
10000 10000 10000 10000
04354 06617 09962 15731
$4082 Resp Pediatric $6203 Resp Pediatric $9339 Resp Pediatric
$14748 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
144-1 144-2 144-3 144-4
RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES
215 294 429 723
04363 05599 07749 13057
10000 10000 10000 10000
10000 10000 10000 10000
04363 05599 07749 13057
12500 12500 12500 12500
05454 06999 09686 16321
10000 10000 10000 10000
04363 05599 07749 13057
$4090 Resp Pediatric $5249 Resp Pediatric $7265 Resp Pediatric
$12241 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
160-1 160-2 160-3 160-4
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY
469 616
1039 2605
31307 34602 50015 97328
10000 10000 10000 10000
10000 10000 10000 10000
31307 34602 50015 97328
12500 12500 12500 12500
39134 43253 62519
121660
10000 10000 10000 10000
31307 34602 50015 97328
$29350 Misc Pediatric $32439 Misc Pediatric $46889 Misc Pediatric $91245 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
161-1 161-2 161-3 161-4
CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT
319 787
1588 3102
40098 53014 84071
199842
10000 10000 10000 10000
10000 10000 10000 10000
40098 53014 84071
199842
12500 12500 12500 12500
50123 66268
105089 249803
10000 10000 10000 10000
40098 53014 84071
199842
$37592 Misc Pediatric $49701 Misc Pediatric $78817 Misc Pediatric
$187352 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
162-1 162-2 162-3 162-4
CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION
800 918
1322 2097
44219 49501 63338 96985
10000 10000 10000 10000
10000 10000 10000 10000
44219 49501 63338 96985
12500 12500 12500 12500
55274 61876 79173
121231
10000 10000 10000 10000
44219 49501 63338 96985
$41455 Misc Pediatric $46407 Misc Pediatric $59379 Misc Pediatric $90923 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
163-1 163-2 163-3 163-4
CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION
566 651 924
1798
38077 42090 51794 88229
10000 10000 10000 10000
10000 10000 10000 10000
38077 42090 51794 88229
12500 12500 12500 12500
47596 52613 64743
110286
10000 10000 10000 10000
38077 42090 51794 88229
$35697 Misc Pediatric $39459 Misc Pediatric $48557 Misc Pediatric $82715 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
165-1 165-2 165-3 165-4
CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE
675 817
1052 1712
38445 43860 53254 80347
10000 10000 10000 10000
10000 10000 10000 10000
38445 43860 53254 80347
12500 12500 12500 12500
48056 54825 66568
100434
10000 10000 10000 10000
38445 43860 53254 80347
$36042 Misc Pediatric $41119 Misc Pediatric $49926 Misc Pediatric $75325 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
166-1 166-2 166-3 166-4
CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE
502 611 855
1615
30632 34370 42566 71277
10000 10000 10000 10000
10000 10000 10000 10000
30632 34370 42566 71277
12500 12500 12500 12500
38290 42963 53208 89096
10000 10000 10000 10000
30632 34370 42566 71277
$28718 Misc Pediatric $32222 Misc Pediatric $39906 Misc Pediatric $66822 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
167-1 167-2 167-3 167-4
OTHER CARDIOTHORACIC PROCEDURES OTHER CARDIOTHORACIC PROCEDURES OTHER CARDIOTHORACIC PROCEDURES OTHER CARDIOTHORACIC PROCEDURES
438 583 914
1860
28492 32691 41583 72603
10000 10000 10000 10000
10000 10000 10000 10000
28492 32691 41583 72603
12500 12500 12500 12500
35615 40864 51979 90754
10000 10000 10000 10000
28492 32691 41583 72603
$26711 Misc Pediatric $30648 Misc Pediatric $38984 Misc Pediatric $68065 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
169-1 169-2 169-3 169-4
MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES
434 570 899
1626
17710 23017 35767 63594
10000 10000 10000 10000
10000 10000 10000 10000
17710 23017 35767 63594
12500 12500 12500 12500
22138 28771 44709 79493
10000 10000 10000 10000
17710 23017 35767 63594
$16603 Misc Pediatric $21578 Misc Pediatric $33532 Misc Pediatric $59619 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
170-1 170-2 170-3 170-4
PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK
468 535 901
1647
22837 24595 30320 48851
10000 10000 10000 10000
10000 10000 10000 10000
22837 24595 30320 48851
12500 12500 12500 12500
28546 30744 37900 61064
10000 10000 10000 10000
22837 24595 30320 48851
$21410 Misc Pediatric $23058 Misc Pediatric $28425 Misc Pediatric $45798 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
171-1 171-2 171-3 171-4
PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK
257 388 652
1323
16061 19059 24628 42111
10000 10000 10000 10000
10000 10000 10000 10000
16061 19059 24628 42111
12500 12500 12500 12500
20076 23824 30785 52639
10000 10000 10000 10000
16061 19059 24628 42111
$15057 Misc Pediatric $17868 Misc Pediatric $23089 Misc Pediatric $39479 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
173-1 173-2 173-3 173-4
OTHER VASCULAR PROCEDURES OTHER VASCULAR PROCEDURES OTHER VASCULAR PROCEDURES OTHER VASCULAR PROCEDURES
248 413 835
1698
17172 20933 28552 52543
10000 10000 10000 10000
10000 10000 10000 10000
17172 20933 28552 52543
12500 12500 12500 12500
21465 26166 35690 65679
10000 10000 10000 10000
17172 20933 28552 52543
$16099 Misc Pediatric $19625 Misc Pediatric $26768 Misc Pediatric $49259 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
174-1 174-2 174-3 174-4
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI
242 309 532 858
20862 22375 27863 40669
10000 10000 10000 10000
10000 10000 10000 10000
20862 22375 27863 40669
12500 12500 12500 12500
26078 27969 34829 50836
10000 10000 10000 10000
20862 22375 27863 40669
$19558 Misc Pediatric $20977 Misc Pediatric $26122 Misc Pediatric $38127 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
175-1 175-2 175-3 175-4
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI
172 253 517
1037
17736 19933 25843 42121
10000 10000 10000 10000
10000 10000 10000 10000
17736 19933 25843 42121
12500 12500 12500 12500
22170 24916 32304 52651
10000 10000 10000 10000
17736 19933 25843 42121
$16628 Misc Pediatric $18687 Misc Pediatric $24228 Misc Pediatric $39488 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
176-1 176-2 176-3 176-4
CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT
291 253 446
1336
13020 24038 27425 45070
10000 10000 10000 10000
10000 10000 10000 10000
13020 24038 27425 45070
12500 12500 12500 12500
16275 30048 34281 56338
10000 10000 10000 10000
13020 24038 27425 45070
$12206 Misc Pediatric $22536 Misc Pediatric $25711 Misc Pediatric $42253 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
177-1 177-2 177-3 177-4
CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT
260 405 749
1560
10212 13638 21173 40225
10000 10000 10000 10000
10000 10000 10000 10000
10212 13638 21173 40225
12500 12500 12500 12500
12765 17048 26466 50281
10000 10000 10000 10000
10212 13638 21173 40225
$9574 Misc Pediatric $12786 Misc Pediatric $19850 Misc Pediatric $37711 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
180-1 180-2 180-3 180-4
OTHER CIRCULATORY SYSTEM PROCEDURES OTHER CIRCULATORY SYSTEM PROCEDURES OTHER CIRCULATORY SYSTEM PROCEDURES OTHER CIRCULATORY SYSTEM PROCEDURES
416 593 963
1589
10497 14144 21255 39764
10000 10000 10000 10000
10000 10000 10000 10000
10497 14144 21255 39764
12500 12500 12500 12500
13121 17680 26569 49705
10000 10000 10000 10000
10497 14144 21255 39764
$9841 Misc Pediatric $13260 Misc Pediatric $19927 Misc Pediatric $37279 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
190-1 190-2 190-3 190-4
ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION
212 315 518 765
06920 08342 11428 18576
10000 10000 10000 10000
10000 10000 10000 10000
06920 08342 11428 18576
12500 12500 12500 12500
08650 10428 14285 23220
10000 10000 10000 10000
06920 08342 11428 18576
$6488 Misc Pediatric $7821 Misc Pediatric
$10714 Misc Pediatric $17415 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
191-1 191-2 191-3 191-4
CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE
250 356 588
1157
10129 11962 15321 30799
10000 10000 10000 10000
10000 10000 10000 10000
10129 11962 15321 30799
12500 12500 12500 12500
12661 14953 19151 38499
10000 10000 10000 10000
10129 11962 15321 30799
$9496 Misc Pediatric $11214 Misc Pediatric $14363 Misc Pediatric $28874 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
192-1 192-2 192-3 192-4
CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE
190 256 440 733
08840 10294 13642 21517
10000 10000 10000 10000
10000 10000 10000 10000
08840 10294 13642 21517
12500 12500 12500 12500
11050 12868 17053 26896
10000 10000 10000 10000
08840 10294 13642 21517
$8288 Misc Pediatric $9651 Misc Pediatric
$12789 Misc Pediatric $20172 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
193-1 193-2 193-3 193-4
ACUTE amp SUBACUTE ENDOCARDITIS ACUTE amp SUBACUTE ENDOCARDITIS ACUTE amp SUBACUTE ENDOCARDITIS ACUTE amp SUBACUTE ENDOCARDITIS
549 695
1002 1491
07895 10373 15660 25224
10000 10000 10000 10000
10000 10000 10000 10000
07895 10373 15660 25224
12500 12500 12500 12500
09869 12966 19575 31530
10000 10000 10000 10000
07895 10373 15660 25224
$7402 Misc Pediatric $9725 Misc Pediatric
$14681 Misc Pediatric $23648 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
194-1 194-2 194-3 194-4
HEART FAILURE HEART FAILURE HEART FAILURE HEART FAILURE
292 375 565 955
05101 06549 09786 17821
10000 10000 10000 10000
10000 10000 10000 10000
05101 06549 09786 17821
12500 12500 12500 12500
06376 08186 12233 22276
10000 10000 10000 10000
05101 06549 09786 17821
$4782 Misc Pediatric $6140 Misc Pediatric $9174 Misc Pediatric
$16707 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
196-1 196-2 196-3 196-4
CARDIAC ARREST CARDIAC ARREST CARDIAC ARREST CARDIAC ARREST
291 227 252 462
03449 04919 07133 17166
10000 10000 10000 10000
10000 10000 10000 10000
03449 04919 07133 17166
12500 12500 12500 12500
04311 06149 08916 21458
10000 10000 10000 10000
03449 04919 07133 17166
$3233 Misc Pediatric $4612 Misc Pediatric $6687 Misc Pediatric
$16093 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
197-1 197-2 197-3 197-4
PERIPHERAL amp OTHER VASCULAR DISORDERS PERIPHERAL amp OTHER VASCULAR DISORDERS PERIPHERAL amp OTHER VASCULAR DISORDERS PERIPHERAL amp OTHER VASCULAR DISORDERS
325 405 554 993
04539 06186 09350 18139
10000 10000 10000 10000
10000 10000 10000 10000
04539 06186 09350 18139
12500 12500 12500 12500
05674 07733 11688 22674
10000 10000 10000 10000
04539 06186 09350 18139
$4255 Misc Pediatric $5799 Misc Pediatric $8766 Misc Pediatric
$17005 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
198-1 198-2 198-3 198-4
ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS
164 215 343 795
04222 05100 07000 13778
10000 10000 10000 10000
10000 10000 10000 10000
04222 05100 07000 13778
12500 12500 12500 12500
05278 06375 08750 17223
10000 10000 10000 10000
04222 05100 07000 13778
$3958 Misc Pediatric $4781 Misc Pediatric $6563 Misc Pediatric
$12917 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
199-1 199-2 199-3 199-4
HYPERTENSION HYPERTENSION HYPERTENSION HYPERTENSION
199 261 407 774
04431 05438 07709 16234
10000 10000 10000 10000
10000 10000 10000 10000
04431 05438 07709 16234
12500 12500 12500 12500
05539 06798 09636 20293
10000 10000 10000 10000
04431 05438 07709 16234
$4154 Misc Pediatric $5098 Misc Pediatric $7227 Misc Pediatric
$15219 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
200-1 200-2 200-3 200-4
CARDIAC STRUCTURAL amp VALVULAR DISORDERS CARDIAC STRUCTURAL amp VALVULAR DISORDERS CARDIAC STRUCTURAL amp VALVULAR DISORDERS CARDIAC STRUCTURAL amp VALVULAR DISORDERS
238 315 517
1005
04557 05692 08445 16354
10000 10000 10000 10000
10000 10000 10000 10000
04557 05692 08445 16354
12500 12500 12500 12500
05696 07115 10556 20443
10000 10000 10000 10000
04557 05692 08445 16354
$4272 Misc Pediatric $5336 Misc Pediatric $7917 Misc Pediatric
$15332 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
201-1 201-2 201-3 201-4
CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS
199 289 466 863
04273 05624 08590 17457
10000 10000 10000 10000
10000 10000 10000 10000
04273 05624 08590 17457
12500 12500 12500 12500
05341 07030 10738 21821
10000 10000 10000 10000
04273 05624 08590 17457
$4006 Misc Pediatric $5273 Misc Pediatric $8053 Misc Pediatric
$16366 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
203-1 203-2 203-3 203-4
CHEST PAIN CHEST PAIN CHEST PAIN CHEST PAIN
148 195 305 725
04180 05129 06846 13335
10000 10000 10000 10000
10000 10000 10000 10000
04180 05129 06846 13335
12500 12500 12500 12500
05225 06411 08558 16669
10000 10000 10000 10000
04180 05129 06846 13335
$3919 Misc Pediatric $4808 Misc Pediatric $6418 Misc Pediatric
$12502 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
204-1 204-2 204-3 204-4
SYNCOPE amp COLLAPSE SYNCOPE amp COLLAPSE SYNCOPE amp COLLAPSE SYNCOPE amp COLLAPSE
201 264 388 858
04877 05857 07587 15564
10000 10000 10000 10000
10000 10000 10000 10000
04877 05857 07587 15564
12500 12500 12500 12500
06096 07321 09484 19455
10000 10000 10000 10000
04877 05857 07587 15564
$4572 Misc Pediatric $5491 Misc Pediatric $7113 Misc Pediatric
$14591 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
205-1 205-2 205-3 205-4
CARDIOMYOPATHY CARDIOMYOPATHY CARDIOMYOPATHY CARDIOMYOPATHY
238 308 496 926
04349 05715 08342 18259
10000 10000 10000 10000
10000 10000 10000 10000
04349 05715 08342 18259
12500 12500 12500 12500
05436 07144 10428 22824
10000 10000 10000 10000
04349 05715 08342 18259
$4077 Misc Pediatric $5358 Misc Pediatric $7821 Misc Pediatric
$17118 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
206-1 206-2 206-3 206-4
MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE
227 345 572
1116
04452 05754 09436 20324
10000 10000 10000 10000
10000 10000 10000 10000
04452 05754 09436 20324
12500 12500 12500 12500
05565 07193 11795 25405
10000 10000 10000 10000
04452 05754 09436 20324
$4174 Misc Pediatric $5394 Misc Pediatric $8846 Misc Pediatric
$19054 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
207-1 207-2 207-3 207-4
OTHER CIRCULATORY SYSTEM DIAGNOSES OTHER CIRCULATORY SYSTEM DIAGNOSES OTHER CIRCULATORY SYSTEM DIAGNOSES OTHER CIRCULATORY SYSTEM DIAGNOSES
239 327 479 850
04972 06455 09118 17339
10000 10000 10000 10000
10000 10000 10000 10000
04972 06455 09118 17339
12500 12500 12500 12500
06215 08069 11398 21674
10000 10000 10000 10000
04972 06455 09118 17339
$4661 Misc Pediatric $6052 Misc Pediatric $8548 Misc Pediatric
$16255 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
220-1 220-2 220-3 220-4
MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES
370 728
1222 2105
13178 19373 31783 59607
10000 10000 10000 10000
10000 10000 10000 10000
13178 19373 31783 59607
12500 12500 12500 12500
16473 24216 39729 74509
10000 10000 10000 10000
13178 19373 31783 59607
$12354 Misc Pediatric $18162 Misc Pediatric $29797 Misc Pediatric $55882 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
221-1 221-2 221-3 221-4
MAJOR SMALL amp LARGE BOWEL PROCEDURES MAJOR SMALL amp LARGE BOWEL PROCEDURES MAJOR SMALL amp LARGE BOWEL PROCEDURES MAJOR SMALL amp LARGE BOWEL PROCEDURES
486 711
1216 2007
13986 18317 29391 55350
10000 10000 10000 10000
10000 10000 10000 10000
13986 18317 29391 55350
12500 12500 12500 12500
17483 22896 36739 69188
10000 10000 10000 10000
13986 18317 29391 55350
$13112 Misc Pediatric $17172 Misc Pediatric $27554 Misc Pediatric $51891 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
222-1 222-2 222-3 222-4
OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES
226 370 835
1821
08125 12068 19613 44248
10000 10000 10000 10000
10000 10000 10000 10000
08125 12068 19613 44248
12500 12500 12500 12500
10156 15085 24516 55310
10000 10000 10000 10000
08125 12068 19613 44248
$7617 Misc Pediatric $11314 Misc Pediatric $18387 Misc Pediatric $41483 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
223-1 223-2 223-3 223-4
OTHER SMALL amp LARGE BOWEL PROCEDURES OTHER SMALL amp LARGE BOWEL PROCEDURES OTHER SMALL amp LARGE BOWEL PROCEDURES OTHER SMALL amp LARGE BOWEL PROCEDURES
442 643
1092 1967
10740 14465 23665 49105
10000 10000 10000 10000
10000 10000 10000 10000
10740 14465 23665 49105
12500 12500 12500 12500
13425 18081 29581 61381
10000 10000 10000 10000
10740 14465 23665 49105
$10069 Misc Pediatric $13561 Misc Pediatric $22186 Misc Pediatric $46036 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
224-1 224-2 224-3 224-4
PERITONEAL ADHESIOLYSIS PERITONEAL ADHESIOLYSIS PERITONEAL ADHESIOLYSIS PERITONEAL ADHESIOLYSIS
540 788
1150 1745
12217 16811 25160 44117
10000 10000 10000 10000
10000 10000 10000 10000
12217 16811 25160 44117
12500 12500 12500 12500
15271 21014 31450 55146
10000 10000 10000 10000
12217 16811 25160 44117
$11453 Misc Pediatric $15760 Misc Pediatric $23588 Misc Pediatric $41360 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
225-1 225-2 225-3 225-4
APPENDECTOMY APPENDECTOMY APPENDECTOMY APPENDECTOMY
157 376 726
1357
07870 11109 18822 36506
10000 10000 10000 10000
10000 10000 10000 10000
07870 11109 18822 36506
12500 12500 12500 12500
09838 13886 23528 45633
10000 10000 10000 10000
07870 11109 18822 36506
$7378 Misc Pediatric $10415 Misc Pediatric $17646 Misc Pediatric $34224 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
226-1 226-2 226-3 226-4
ANAL PROCEDURES ANAL PROCEDURES ANAL PROCEDURES ANAL PROCEDURES
256 413 737
1301
06250 08568 13988 28079
10000 10000 10000 10000
10000 10000 10000 10000
06250 08568 13988 28079
12500 12500 12500 12500
07813 10710 17485 35099
10000 10000 10000 10000
06250 08568 13988 28079
$5859 Misc Pediatric $8033 Misc Pediatric
$13114 Misc Pediatric $26324 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
227-1 HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL 290 10044 10000 10000 10044 12500 12555 10000 10044 $9416 Misc Pediatric Gastroent Adult
227-2 227-3 227-4
HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL
443 813
1503
13150 21598 43086
10000 10000 10000
10000 10000 10000
13150 21598 43086
12500 12500 12500
16438 26998 53858
10000 10000 10000
13150 21598 43086
$12328 Misc Pediatric $20248 Misc Pediatric $40393 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult
228-1 228-2 228-3 228-4
INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES
200 344 629
1321
07221 09757 15211 32407
10000 10000 10000 10000
10000 10000 10000 10000
07221 09757 15211 32407
12500 12500 12500 12500
09026 12196 19014 40509
10000 10000 10000 10000
07221 09757 15211 32407
$6770 Misc Pediatric $9147 Misc Pediatric
$14260 Misc Pediatric $30382 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
229-1 229-2 229-3 229-4
OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES
387 552 976
1760
10850 14346 22850 42572
10000 10000 10000 10000
10000 10000 10000 10000
10850 14346 22850 42572
12500 12500 12500 12500
13563 17933 28563 53215
10000 10000 10000 10000
10850 14346 22850 42572
$10172 Misc Pediatric $13449 Misc Pediatric $21422 Misc Pediatric $39911 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
240-1 240-2 240-3 240-4
DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY
371 429 685
1225
05526 07344 11112 20338
10000 10000 10000 10000
10000 10000 10000 10000
05526 07344 11112 20338
12500 12500 12500 12500
06908 09180 13890 25423
10000 10000 10000 10000
05526 07344 11112 20338
$5181 Misc Pediatric $6885 Misc Pediatric
$10418 Misc Pediatric $19067 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
241-1 241-2 241-3 241-4
PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS
252 325 484
1012
05507 07186 10584 23302
10000 10000 10000 10000
10000 10000 10000 10000
05507 07186 10584 23302
12500 12500 12500 12500
06884 08983 13230 29128
10000 10000 10000 10000
05507 07186 10584 23302
$5163 Misc Pediatric $6737 Misc Pediatric $9923 Misc Pediatric
$21846 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
242-1 242-2 242-3 242-4
MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS
230 319 459
1013
05080 06929 10170 22355
10000 10000 10000 10000
10000 10000 10000 10000
05080 06929 10170 22355
12500 12500 12500 12500
06350 08661 12713 27944
10000 10000 10000 10000
05080 06929 10170 22355
$4763 Misc Pediatric $6496 Misc Pediatric $9534 Misc Pediatric
$20958 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
243-1 243-2 243-3 243-4
OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS
189 280 479
1028
04493 06061 09094 20341
10000 10000 10000 10000
10000 10000 10000 10000
04493 06061 09094 20341
12500 12500 12500 12500
05616 07576 11368 25426
10000 10000 10000 10000
04493 06061 09094 20341
$4212 Misc Pediatric $5682 Misc Pediatric $8526 Misc Pediatric
$19070 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
244-1 244-2 244-3 244-4
DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS
292 361 545
1104
05247 06624 10053 21700
10000 10000 10000 10000
10000 10000 10000 10000
05247 06624 10053 21700
12500 12500 12500 12500
06559 08280 12566 27125
10000 10000 10000 10000
05247 06624 10053 21700
$4919 Misc Pediatric $6210 Misc Pediatric $9425 Misc Pediatric
$20344 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
245-1 245-2 245-3 245-4
INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE
339 413 626
1206
05754 07028 10226 19440
10000 10000 10000 10000
10000 10000 10000 10000
05754 07028 10226 19440
12500 12500 12500 12500
07193 08785 12783 24300
10000 10000 10000 10000
05754 07028 10226 19440
$5394 Misc Pediatric $6589 Misc Pediatric $9587 Misc Pediatric
$18225 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
246-1 246-2 246-3 246-4
GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY
315 404 602 982
06451 07943 11319 19310
10000 10000 10000 10000
10000 10000 10000 10000
06451 07943 11319 19310
12500 12500 12500 12500
08064 09929 14149 24138
10000 10000 10000 10000
06451 07943 11319 19310
$6048 Misc Pediatric $7447 Misc Pediatric
$10612 Misc Pediatric $18103 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
247-1 247-2 247-3 247-4
INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION
288 378 596
1104
04874 06267 09526 19303
10000 10000 10000 10000
10000 10000 10000 10000
04874 06267 09526 19303
12500 12500 12500 12500
06093 07834 11908 24129
10000 10000 10000 10000
04874 06267 09526 19303
$4569 Misc Pediatric $5875 Misc Pediatric $8931 Misc Pediatric
$18097 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
248-1 248-2 248-3 248-4
MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS
334 472 710
1239
05085 07215 10667 20497
10000 10000 10000 10000
10000 10000 10000 10000
05085 07215 10667 20497
12500 12500 12500 12500
06356 09019 13334 25621
10000 10000 10000 10000
05085 07215 10667 20497
$4767 Misc Pediatric $6764 Misc Pediatric
$10000 Misc Pediatric $19216 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
249-1 249-2 249-3 249-4
NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING
219 289 431 938
03648 05058 07201 15935
10000 10000 10000 10000
10000 10000 10000 10000
03648 05058 07201 15935
12500 12500 12500 12500
04560 06323 09001 19919
10000 10000 10000 10000
03648 05058 07201 15935
$3420 Misc Pediatric $4742 Misc Pediatric $6751 Misc Pediatric
$14939 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
251-1 251-2 251-3 251-4
ABDOMINAL PAIN ABDOMINAL PAIN ABDOMINAL PAIN ABDOMINAL PAIN
217 288 418 813
04492 05786 07857 14149
10000 10000 10000 10000
10000 10000 10000 10000
04492 05786 07857 14149
12500 12500 12500 12500
05615 07233 09821 17686
10000 10000 10000 10000
04492 05786 07857 14149
$4211 Misc Pediatric $5424 Misc Pediatric $7366 Misc Pediatric
$13265 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
252-1 252-2 252-3 252-4
MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE
331 412 635
1248
04904 06490 09833 19841
10000 10000 10000 10000
10000 10000 10000 10000
04904 06490 09833 19841
12500 12500 12500 12500
06130 08113 12291 24801
10000 10000 10000 10000
04904 06490 09833 19841
$4598 Misc Pediatric $6084 Misc Pediatric $9218 Misc Pediatric
$18601 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
253-1 253-2 253-3 253-4
OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE
251 334 504 878
05108 06777 10020 18601
10000 10000 10000 10000
10000 10000 10000 10000
05108 06777 10020 18601
12500 12500 12500 12500
06385 08471 12525 23251
10000 10000 10000 10000
05108 06777 10020 18601
$4789 Misc Pediatric $6353 Misc Pediatric $9394 Misc Pediatric
$17438 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
254-1 254-2 254-3 254-4
OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES
252 353 530
1066
04519 06282 09117 18053
10000 10000 10000 10000
10000 10000 10000 10000
04519 06282 09117 18053
12500 12500 12500 12500
05649 07853 11396 22566
10000 10000 10000 10000
04519 06282 09117 18053
$4237 Misc Pediatric $5889 Misc Pediatric $8547 Misc Pediatric
$16925 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
260-1 260-2 260-3 260-4
MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES
469 611
1081 2181
15085 19596 31029 63824
10000 10000 10000 10000
10000 10000 10000 10000
15085 19596 31029 63824
12500 12500 12500 12500
18856 24495 38786 79780
10000 10000 10000 10000
15085 19596 31029 63824
$14142 Misc Pediatric $18371 Misc Pediatric $29090 Misc Pediatric $59835 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
261-1 261-2 261-3 261-4
MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES
450 706
1116 1993
13049 18250 25711 50241
10000 10000 10000 10000
10000 10000 10000 10000
13049 18250 25711 50241
12500 12500 12500 12500
16311 22813 32139 62801
10000 10000 10000 10000
13049 18250 25711 50241
$12233 Misc Pediatric $17109 Misc Pediatric $24104 Misc Pediatric $47101 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
262-1 262-2 262-3 262-4
CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC
405 567 898
1751
11851 15637 23607 46363
10000 10000 10000 10000
10000 10000 10000 10000
11851 15637 23607 46363
12500 12500 12500 12500
14814 19546 29509 57954
10000 10000 10000 10000
11851 15637 23607 46363
$11110 Misc Pediatric $14660 Misc Pediatric $22132 Misc Pediatric $43465 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
263-1 263-2 263-3 263-4
LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY
236 364 635
1384
09345 12310 17676 36726
10000 10000 10000 10000
10000 10000 10000 10000
09345 12310 17676 36726
12500 12500 12500 12500
11681 15388 22095 45908
10000 10000 10000 10000
09345 12310 17676 36726
$8761 Misc Pediatric $11541 Misc Pediatric $16571 Misc Pediatric $34431 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
264-1 264-2 264-3 264-4
OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES
453 543
1067 2148
12526 13732 23159 51901
10000 10000 10000 10000
10000 10000 10000 10000
12526 13732 23159 51901
12500 12500 12500 12500
15658 17165 28949 64876
10000 10000 10000 10000
12526 13732 23159 51901
$11743 Misc Pediatric $12874 Misc Pediatric $21712 Misc Pediatric $48657 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
279-1 279-2 279-3 279-4
HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS
280 361 580
1157
04712 05945 09594 23269
10000 10000 10000 10000
10000 10000 10000 10000
04712 05945 09594 23269
12500 12500 12500 12500
05890 07431 11993 29086
10000 10000 10000 10000
04712 05945 09594 23269
$4418 Misc Pediatric $5573 Misc Pediatric $8994 Misc Pediatric
$21815 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
280-1 280-2 280-3 280-4
ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE
298 344 532
1047
04734 06141 09718 21422
10000 10000 10000 10000
10000 10000 10000 10000
04734 06141 09718 21422
12500 12500 12500 12500
05918 07676 12148 26778
10000 10000 10000 10000
04734 06141 09718 21422
$4438 Misc Pediatric $5757 Misc Pediatric $9111 Misc Pediatric
$20083 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
281-1 281-2 281-3 281-4
MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS
357 421 610 974
05079 07553 10730 17519
10000 10000 10000 10000
10000 10000 10000 10000
05079 07553 10730 17519
12500 12500 12500 12500
06349 09441 13413 21899
10000 10000 10000 10000
05079 07553 10730 17519
$4762 Misc Pediatric $7081 Misc Pediatric
$10059 Misc Pediatric $16424 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
282-1 282-2 282-3 282-4
DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY
318 403 649
1381
05507 07067 11213 27863
10000 10000 10000 10000
10000 10000 10000 10000
05507 07067 11213 27863
12500 12500 12500 12500
06884 08834 14016 34829
10000 10000 10000 10000
05507 07067 11213 27863
$5163 Misc Pediatric $6625 Misc Pediatric
$10512 Misc Pediatric $26122 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
283-1 283-2 283-3 283-4
OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER
286 338 505 947
04913 06300 09246 18497
10000 10000 10000 10000
10000 10000 10000 10000
04913 06300 09246 18497
12500 12500 12500 12500
06141 07875 11558 23121
10000 10000 10000 10000
04913 06300 09246 18497
$4606 Misc Pediatric $5906 Misc Pediatric $8668 Misc Pediatric
$17341 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
284-1 284-2 284-3 284-4
DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT
245 344 536
1059
05403 07447 10804 21256
10000 10000 10000 10000
10000 10000 10000 10000
05403 07447 10804 21256
12500 12500 12500 12500
06754 09309 13505 26570
10000 10000 10000 10000
05403 07447 10804 21256
$5065 Misc Pediatric $6982 Misc Pediatric
$10129 Misc Pediatric $19928 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
301-1 301-2 301-3 301-4
HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT
365 396 535
1280
18140 19690 25026 39991
10000 10000 10000 10000
10000 10000 10000 10000
18140 19690 25026 39991
12500 12500 12500 12500
22675 24613 31283 49989
10000 10000 10000 10000
18140 19690 25026 39991
$17006 Misc Pediatric $18459 Misc Pediatric $23462 Misc Pediatric $37492 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
302-1 302-2 302-3 302-4
KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT
296 338 519
1248
17428 19132 23798 43468
10000 10000 10000 10000
10000 10000 10000 10000
17428 19132 23798 43468
12500 12500 12500 12500
21785 23915 29748 54335
10000 10000 10000 10000
17428 19132 23798 43468
$16339 Misc Pediatric $17936 Misc Pediatric $22311 Misc Pediatric $40751 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
303-1 303-2 303-3 303-4
DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK
450 570 857
1607
47039 55422 77549
105744
10000 10000 10000 10000
10000 10000 10000 10000
47039 55422 77549
105744
12500 12500 12500 12500
58799 69278 96936
132180
10000 10000 10000 10000
47039 55422 77549
105744
$44099 Misc Pediatric $51958 Misc Pediatric $72702 Misc Pediatric $99135 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
304-1 304-2 304-3 304-4
DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK
300 405 735
1776
29720 35298 49644 81663
10000 10000 10000 10000
10000 10000 10000 10000
29720 35298 49644 81663
12500 12500 12500 12500
37150 44123 62055
102079
10000 10000 10000 10000
29720 35298 49644 81663
$27863 Misc Pediatric $33092 Misc Pediatric $46541 Misc Pediatric $76559 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
305-1 305-2 305-3 305-4
AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES
540 737
1137 1987
10654 14043 21843 42156
10000 10000 10000 10000
10000 10000 10000 10000
10654 14043 21843 42156
12500 12500 12500 12500
13318 17554 27304 52695
10000 10000 10000 10000
10654 14043 21843 42156
$9988 Misc Pediatric $13165 Misc Pediatric $20478 Misc Pediatric $39521 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
308-1 308-2 308-3 308-4
HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT
419 496 697
1264
13101 15854 21518 36506
10000 10000 10000 10000
10000 10000 10000 10000
13101 15854 21518 36506
12500 12500 12500 12500
16376 19818 26898 45633
10000 10000 10000 10000
13101 15854 21518 36506
$12282 Misc Pediatric $14863 Misc Pediatric $20173 Misc Pediatric $34224 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
309-1 309-2 309-3 309-4
HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT
278 490 865
1887
11482 16231 23288 42408
10000 10000 10000 10000
10000 10000 10000 10000
11482 16231 23288 42408
12500 12500 12500 12500
14353 20289 29110 53010
10000 10000 10000 10000
11482 16231 23288 42408
$10764 Misc Pediatric $15217 Misc Pediatric $21833 Misc Pediatric $39758 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
310-1 310-2 310-3 310-4
INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION
181 302 624
1622
08926 11888 17911 41661
10000 10000 10000 10000
10000 10000 10000 10000
08926 11888 17911 41661
12500 12500 12500 12500
11158 14860 22389 52076
10000 10000 10000 10000
08926 11888 17911 41661
$8368 Misc Pediatric $11145 Misc Pediatric $16792 Misc Pediatric $39057 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
312-1 312-2
SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES
538 940
12555 18447
10000 10000
10000 10000
12555 18447
12500 12500
15694 23059
10000 10000
12555 18447
$11770 Misc Pediatric $17294 Misc Pediatric
Misc Adult Misc Adult
312-3 312-4
SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES
1846 3284
31356 71148
10000 10000
10000 10000
31356 71148
12500 12500
39195 88935
10000 10000
31356 71148
$29396 Misc Pediatric $66701 Misc Pediatric
Misc Adult Misc Adult
313-1 313-2 313-3 313-4
KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT
270 444 785
1659
10852 15212 22743 43349
10000 10000 10000 10000
10000 10000 10000 10000
10852 15212 22743 43349
12500 12500 12500 12500
13565 19015 28429 54186
10000 10000 10000 10000
10852 15212 22743 43349
$10174 Misc Pediatric $14261 Misc Pediatric $21322 Misc Pediatric $40640 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
314-1 314-2 314-3 314-4
FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES
257 507 810
1579
09291 11320 16006 32885
10000 10000 10000 10000
10000 10000 10000 10000
09291 11320 16006 32885
12500 12500 12500 12500
11614 14150 20008 41106
10000 10000 10000 10000
09291 11320 16006 32885
$8710 Misc Pediatric $10613 Misc Pediatric $15006 Misc Pediatric $30830 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
315-1 315-2 315-3 315-4
SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES
185 267 649
1473
08387 15912 22542 44542
10000 10000 10000 10000
10000 10000 10000 10000
08387 15912 22542 44542
12500 12500 12500 12500
10484 19890 28178 55678
10000 10000 10000 10000
08387 15912 22542 44542
$7863 Misc Pediatric $14918 Misc Pediatric $21133 Misc Pediatric $41758 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
316-1 316-2 316-3 316-4
HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES
229 396 727
1430
07195 10564 17143 34568
10000 10000 10000 10000
10000 10000 10000 10000
07195 10564 17143 34568
12500 12500 12500 12500
08994 13205 21429 43210
10000 10000 10000 10000
07195 10564 17143 34568
$6745 Misc Pediatric $9904 Misc Pediatric
$16072 Misc Pediatric $32408 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
317-1 317-2 317-3 317-4
TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES
300 544
1030 2038
08204 11764 19738 43378
10000 10000 10000 10000
10000 10000 10000 10000
08204 11764 19738 43378
12500 12500 12500 12500
10255 14705 24673 54223
10000 10000 10000 10000
08204 11764 19738 43378
$7691 Misc Pediatric $11029 Misc Pediatric $18504 Misc Pediatric $40667 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
320-1 320-2 320-3 320-4
OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES
229 474 900
1844
09314 14085 21498 40942
10000 10000 10000 10000
10000 10000 10000 10000
09314 14085 21498 40942
12500 12500 12500 12500
11643 17606 26873 51178
10000 10000 10000 10000
09314 14085 21498 40942
$8732 Misc Pediatric $13205 Misc Pediatric $20154 Misc Pediatric $38383 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
321-1 321-2 321-3 321-4
CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP
174 322 869
1740
16800 21292 35737 65431
10000 10000 10000 10000
10000 10000 10000 10000
16800 21292 35737 65431
12500 12500 12500 12500
21000 26615 44671 81789
10000 10000 10000 10000
16800 21292 35737 65431
$15750 Misc Pediatric $19961 Misc Pediatric $33503 Misc Pediatric $61342 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
340-1 340-2 340-3 340-4
FRACTURE OF FEMUR FRACTURE OF FEMUR FRACTURE OF FEMUR FRACTURE OF FEMUR
307 350 507 717
04052 05213 07741 13545
10000 10000 10000 10000
10000 10000 10000 10000
04052 05213 07741 13545
12500 12500 12500 12500
05065 06516 09676 16931
10000 10000 10000 10000
04052 05213 07741 13545
$3799 Misc Pediatric $4887 Misc Pediatric $7257 Misc Pediatric
$12698 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
341-1 341-2 341-3 341-4
FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP
302 365 480 981
04685 05732 07835 19346
10000 10000 10000 10000
10000 10000 10000 10000
04685 05732 07835 19346
12500 12500 12500 12500
05856 07165 09794 24183
10000 10000 10000 10000
04685 05732 07835 19346
$4392 Misc Pediatric $5374 Misc Pediatric $7345 Misc Pediatric
$18137 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
342-1 342-2 342-3 342-4
FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK
223 336 523
1073
04199 06015 09030 19468
10000 10000 10000 10000
10000 10000 10000 10000
04199 06015 09030 19468
12500 12500 12500 12500
05249 07519 11288 24335
10000 10000 10000 10000
04199 06015 09030 19468
$3937 Misc Pediatric $5639 Misc Pediatric $8466 Misc Pediatric
$18251 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
343-1 343-2 343-3 343-4
MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG
381 462 768
1278
06313 07919 12982 22512
10000 10000 10000 10000
10000 10000 10000 10000
06313 07919 12982 22512
12500 12500 12500 12500
07891 09899 16228 28140
10000 10000 10000 10000
06313 07919 12982 22512
$5918 Misc Pediatric $7424 Misc Pediatric
$12171 Misc Pediatric $21105 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
344-1 344-2 344-3 344-4
OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS
510 624 996
1727
06188 08269 12369 20626
10000 10000 10000 10000
10000 10000 10000 10000
06188 08269 12369 20626
12500 12500 12500 12500
07735 10336 15461 25783
10000 10000 10000 10000
06188 08269 12369 20626
$5801 Misc Pediatric $7752 Misc Pediatric
$11596 Misc Pediatric $19337 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
346-1 346-2 346-3 346-4
CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS
312 418 742
1507
05246 07180 12230 29854
10000 10000 10000 10000
10000 10000 10000 10000
05246 07180 12230 29854
12500 12500 12500 12500
06558 08975 15288 37318
10000 10000 10000 10000
05246 07180 12230 29854
$4918 Misc Pediatric $6731 Misc Pediatric
$11466 Misc Pediatric $27988 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
347-1 347-2 347-3 347-4
OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES
288 388 534
1184
05202 07038 09895 23177
10000 10000 10000 10000
10000 10000 10000 10000
05202 07038 09895 23177
12500 12500 12500 12500
06503 08798 12369 28971
10000 10000 10000 10000
05202 07038 09895 23177
$4877 Misc Pediatric $6598 Misc Pediatric $9277 Misc Pediatric
$21728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
349-1 349-2 349-3 349-4
MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE
226 480 806
1387
04381 06459 10302 19261
10000 10000 10000 10000
10000 10000 10000 10000
04381 06459 10302 19261
12500 12500 12500 12500
05476 08074 12878 24076
10000 10000 10000 10000
04381 06459 10302 19261
$4107 Misc Pediatric $6055 Misc Pediatric $9658 Misc Pediatric
$18057 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
351-1 351-2 351-3 351-4
OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES
252 352 544
1111
04074 05668 08930 19109
10000 10000 10000 10000
10000 10000 10000 10000
04074 05668 08930 19109
12500 12500 12500 12500
05093 07085 11163 23886
10000 10000 10000 10000
04074 05668 08930 19109
$3819 Misc Pediatric $5314 Misc Pediatric $8372 Misc Pediatric
$17915 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
361-1 361-2 361-3 361-4
SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES
407 758
1393 2857
11097 14459 21415 45412
10000 10000 10000 10000
10000 10000 10000 10000
11097 14459 21415 45412
12500 12500 12500 12500
13871 18074 26769 56765
10000 10000 10000 10000
11097 14459 21415 45412
$10403 Misc Pediatric $13555 Misc Pediatric $20077 Misc Pediatric $42574 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
362-1 362-2 362-3 362-4
MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES
179 233 597
1380
10091 13554 17862 38257
10000 10000 10000 10000
10000 10000 10000 10000
10091 13554 17862 38257
12500 12500 12500 12500
12614 16943 22328 47821
10000 10000 10000 10000
10091 13554 17862 38257
$9460 Misc Pediatric $12707 Misc Pediatric $16746 Misc Pediatric $35866 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
363-1 363-2 363-3 363-4
BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY
209 314 532
1706
08797 14900 19039 35420
10000 10000 10000 10000
10000 10000 10000 10000
08797 14900 19039 35420
12500 12500 12500 12500
10996 18625 23799 44275
10000 10000 10000 10000
08797 14900 19039 35420
$8247 Misc Pediatric $13969 Misc Pediatric $17849 Misc Pediatric $33206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
364-1 364-2 364-3 364-4
OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES
289 508 943
1919
07645 10877 16986 30643
10000 10000 10000 10000
10000 10000 10000 10000
07645 10877 16986 30643
12500 12500 12500 12500
09556 13596 21233 38304
10000 10000 10000 10000
07645 10877 16986 30643
$7167 Misc Pediatric $10197 Misc Pediatric $15924 Misc Pediatric $28728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
380-1 380-2 380-3 380-4
SKIN ULCERS SKIN ULCERS SKIN ULCERS SKIN ULCERS
416 498 784
1662
05289 06545 09424 17199
10000 10000 10000 10000
10000 10000 10000 10000
05289 06545 09424 17199
12500 12500 12500 12500
06611 08181 11780 21499
10000 10000 10000 10000
05289 06545 09424 17199
$4958 Misc Pediatric $6136 Misc Pediatric $8835 Misc Pediatric
$16124 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
381-1 381-2 381-3 381-4
MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS
300 428 671
1406
03883 05748 09734 27512
10000 10000 10000 10000
10000 10000 10000 10000
03883 05748 09734 27512
12500 12500 12500 12500
04854 07185 12168 34390
10000 10000 10000 10000
03883 05748 09734 27512
$3640 Misc Pediatric $5389 Misc Pediatric $9126 Misc Pediatric
$25793 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
382-1 382-2 382-3 382-4
MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS
381 432 645
1003
03521 05612 09634 15729
10000 10000 10000 10000
10000 10000 10000 10000
03521 05612 09634 15729
12500 12500 12500 12500
04401 07015 12043 19661
10000 10000 10000 10000
03521 05612 09634 15729
$3301 Misc Pediatric $5261 Misc Pediatric $9032 Misc Pediatric
$14746 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
383-1 383-2 383-3 383-4
CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS
294 412 617
1198
04148 05905 09147 19560
10000 10000 10000 10000
10000 10000 10000 10000
04148 05905 09147 19560
12500 12500 12500 12500
05185 07381 11434 24450
10000 10000 10000 10000
04148 05905 09147 19560
$3889 Misc Pediatric $5536 Misc Pediatric $8575 Misc Pediatric
$18338 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
384-1 384-2 384-3 384-4
CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE
193 301 493
1134
04752 06220 08932 20168
10000 10000 10000 10000
10000 10000 10000 10000
04752 06220 08932 20168
12500 12500 12500 12500
05940 07775 11165 25210
10000 10000 10000 10000
04752 06220 08932 20168
$4455 Misc Pediatric $5831 Misc Pediatric $8374 Misc Pediatric
$18908 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
385-1 385-2 385-3 385-4
OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS
248 353 565
1295
03496 05103 07974 19128
10000 10000 10000 10000
10000 10000 10000 10000
03496 05103 07974 19128
12500 12500 12500 12500
04370 06379 09968 23910
10000 10000 10000 10000
03496 05103 07974 19128
$3278 Misc Pediatric $4784 Misc Pediatric $7476 Misc Pediatric
$17933 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
401-1 401-2 401-3 401-4
PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES
303 427 844
2452
13697 18347 29058 71913
10000 10000 10000 10000
10000 10000 10000 10000
13697 18347 29058 71913
12500 12500 12500 12500
17121 22934 36323 89891
10000 10000 10000 10000
13697 18347 29058 71913
$12841 Misc Pediatric $17200 Misc Pediatric $27242 Misc Pediatric $67418 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
403-1 403-2 403-3 403-4
PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY
183 222 497
1867
12813 14411 21531 61151
10000 10000 10000 10000
10000 10000 10000 10000
12813 14411 21531 61151
12500 12500 12500 12500
16016 18014 26914 76439
10000 10000 10000 10000
12813 14411 21531 61151
$12012 Misc Pediatric $13510 Misc Pediatric $20185 Misc Pediatric $57329 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
404-1 404-2 404-3 404-4
THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES
130 216 659
1638
07364 09479 18990 42519
10000 10000 10000 10000
10000 10000 10000 10000
07364 09479 18990 42519
12500 12500 12500 12500
09205 11849 23738 53149
10000 10000 10000 10000
07364 09479 18990 42519
$6904 Misc Pediatric $8887 Misc Pediatric
$17803 Misc Pediatric $39862 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
405-1 405-2 405-3 405-4
OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS
419 571 966
2131
11123 14210 21421 48796
10000 10000 10000 10000
10000 10000 10000 10000
11123 14210 21421 48796
12500 12500 12500 12500
13904 17763 26776 60995
10000 10000 10000 10000
11123 14210 21421 48796
$10428 Misc Pediatric $13322 Misc Pediatric $20082 Misc Pediatric $45746 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
420-1 420-2 420-3 420-4
DIABETES DIABETES DIABETES DIABETES
261 275 427 935
03897 05302 07862 19671
10000 10000 10000 10000
10000 10000 10000 10000
03897 05302 07862 19671
12500 12500 12500 12500
04871 06628 09828 24589
10000 10000 10000 10000
03897 05302 07862 19671
$3653 Misc Pediatric $4971 Misc Pediatric $7371 Misc Pediatric
$18442 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
421-1 421-2 421-3 421-4
MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS
351 483 676
1375
03211 05227 08190 17446
10000 10000 10000 10000
10000 10000 10000 10000
03211 05227 08190 17446
12500 12500 12500 12500
04014 06534 10238 21808
10000 10000 10000 10000
03211 05227 08190 17446
$3010 Misc Pediatric $4900 Misc Pediatric $7678 Misc Pediatric
$16356 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
422-1 422-2 422-3 422-4
HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS
199 291 445 914
02848 04625 06828 14444
10000 10000 10000 10000
10000 10000 10000 10000
02848 04625 06828 14444
12500 12500 12500 12500
03560 05781 08535 18055
10000 10000 10000 10000
02848 04625 06828 14444
$2670 Misc Pediatric $4336 Misc Pediatric $6401 Misc Pediatric
$13541 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
423-1 423-2 423-3 423-4
INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM
272 363 573
1504
04421 05846 09540 27384
10000 10000 10000 10000
10000 10000 10000 10000
04421 05846 09540 27384
12500 12500 12500 12500
05526 07308 11925 34230
10000 10000 10000 10000
04421 05846 09540 27384
$4145 Misc Pediatric $5481 Misc Pediatric $8944 Misc Pediatric
$25673 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
424-1 424-2 424-3 424-4
OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS
259 397 605
1147
04342 06514 09768 21520
10000 10000 10000 10000
10000 10000 10000 10000
04342 06514 09768 21520
12500 12500 12500 12500
05428 08143 12210 26900
10000 10000 10000 10000
04342 06514 09768 21520
$4071 Misc Pediatric $6107 Misc Pediatric $9158 Misc Pediatric
$20175 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
425-1 425-2 425-3
ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED
241 302 460
04017 05132 07667
10000 10000 10000
10000 10000 10000
04017 05132 07667
12500 12500 12500
05021 06415 09584
10000 10000 10000
04017 05132 07667
$3766 Misc Pediatric $4811 Misc Pediatric $7188 Misc Pediatric
Misc Adult Misc Adult Misc Adult
425-4 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 946 16767 10000 10000 16767 12500 20959 10000 16767 $15719 Misc Pediatric Misc Adult 440-1 440-2 440-3 440-4
KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT
458 561 864
2088
44667 50078 60562 99171
10000 10000 10000 10000
10000 10000 10000 10000
44667 50078 60562 99171
12500 12500 12500 12500
55834 62598 75703
123964
10000 10000 10000 10000
44667 50078 60562 99171
$41875 Misc Pediatric $46948 Misc Pediatric $56777 Misc Pediatric $92973 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
441-1 441-2 441-3 441-4
MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES
474 726 994
2196
14386 21567 29549 61841
10000 10000 10000 10000
10000 10000 10000 10000
14386 21567 29549 61841
12500 12500 12500 12500
17983 26959 36936 77301
10000 10000 10000 10000
14386 21567 29549 61841
$13487 Misc Pediatric $20219 Misc Pediatric $27702 Misc Pediatric $57976 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
442-1 442-2 442-3 442-4
KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY
325 422 795
1671
13139 15537 23456 49226
10000 10000 10000 10000
10000 10000 10000 10000
13139 15537 23456 49226
12500 12500 12500 12500
16424 19421 29320 61533
10000 10000 10000 10000
13139 15537 23456 49226
$12318 Misc Pediatric $14566 Misc Pediatric $21990 Misc Pediatric $46149 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
443-1 443-2 443-3 443-4
KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY
253 356 802
1752
10883 12834 18814 40742
10000 10000 10000 10000
10000 10000 10000 10000
10883 12834 18814 40742
12500 12500 12500 12500
13604 16043 23518 50928
10000 10000 10000 10000
10883 12834 18814 40742
$10203 Misc Pediatric $12032 Misc Pediatric $17638 Misc Pediatric $38196 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
444-1 444-2 444-3 444-4
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY
264 447 933
1617
09410 12604 20686 38830
10000 10000 10000 10000
10000 10000 10000 10000
09410 12604 20686 38830
12500 12500 12500 12500
11763 15755 25858 48538
10000 10000 10000 10000
09410 12604 20686 38830
$8822 Misc Pediatric $11816 Misc Pediatric $19393 Misc Pediatric $36403 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
445-1 445-2 445-3 445-4
OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES
190 319 781
1545
08552 11610 15964 31570
10000 10000 10000 10000
10000 10000 10000 10000
08552 11610 15964 31570
12500 12500 12500 12500
10690 14513 19955 39463
10000 10000 10000 10000
08552 11610 15964 31570
$8018 Misc Pediatric $10884 Misc Pediatric $14966 Misc Pediatric $29597 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
446-1 446-2 446-3 446-4
URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES
188 261 612
1363
06758 08690 14202 30173
10000 10000 10000 10000
10000 10000 10000 10000
06758 08690 14202 30173
12500 12500 12500 12500
08448 10863 17753 37716
10000 10000 10000 10000
06758 08690 14202 30173
$6336 Misc Pediatric $8147 Misc Pediatric
$13314 Misc Pediatric $28287 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
447-1 447-2 447-3 447-4
OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES
228 365 728
1787
11479 13294 19661 43932
10000 10000 10000 10000
10000 10000 10000 10000
11479 13294 19661 43932
12500 12500 12500 12500
14349 16618 24576 54915
10000 10000 10000 10000
11479 13294 19661 43932
$10762 Misc Pediatric $12463 Misc Pediatric $18432 Misc Pediatric $41186 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
460-1 460-2 460-3 460-4
RENAL FAILURE RENAL FAILURE RENAL FAILURE RENAL FAILURE
299 376 496
1115
04323 06061 07896 19936
10000 10000 10000 10000
10000 10000 10000 10000
04323 06061 07896 19936
12500 12500 12500 12500
05404 07576 09870 24920
10000 10000 10000 10000
04323 06061 07896 19936
$4053 Misc Pediatric $5682 Misc Pediatric $7403 Misc Pediatric
$18690 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
461-1 461-2 461-3 461-4
KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY
271 374 601
1108
04315 05992 09498 16929
10000 10000 10000 10000
10000 10000 10000 10000
04315 05992 09498 16929
12500 12500 12500 12500
05394 07490 11873 21161
10000 10000 10000 10000
04315 05992 09498 16929
$4045 Misc Pediatric $5618 Misc Pediatric $8904 Misc Pediatric
$15871 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
462-1 462-2 462-3 462-4
NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS
260 370 656
1359
03798 05298 09439 23905
10000 10000 10000 10000
10000 10000 10000 10000
03798 05298 09439 23905
12500 12500 12500 12500
04748 06623 11799 29881
10000 10000 10000 10000
03798 05298 09439 23905
$3561 Misc Pediatric $4967 Misc Pediatric $8849 Misc Pediatric
$22411 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
463-1 463-2 463-3 463-4
KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS
268 352 507 910
04120 05628 07879 14066
10000 10000 10000 10000
10000 10000 10000 10000
04120 05628 07879 14066
12500 12500 12500 12500
05150 07035 09849 17583
10000 10000 10000 10000
04120 05628 07879 14066
$3863 Misc Pediatric $5276 Misc Pediatric $7387 Misc Pediatric
$13187 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
465-1 465-2 465-3 465-4
URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION
165 202 380 860
04374 05548 08751 18922
10000 10000 10000 10000
10000 10000 10000 10000
04374 05548 08751 18922
12500 12500 12500 12500
05468 06935 10939 23653
10000 10000 10000 10000
04374 05548 08751 18922
$4101 Misc Pediatric $5201 Misc Pediatric $8204 Misc Pediatric
$17739 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
466-1 466-2 466-3 466-4
MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC
221 343 533 971
03576 05752 08974 17498
10000 10000 10000 10000
10000 10000 10000 10000
03576 05752 08974 17498
12500 12500 12500 12500
04470 07190 11218 21873
10000 10000 10000 10000
03576 05752 08974 17498
$3353 Misc Pediatric $5393 Misc Pediatric $8413 Misc Pediatric
$16404 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
468-1 468-2 468-3 468-4
OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS
246 335 509
1057
04152 05935 08698 18661
10000 10000 10000 10000
10000 10000 10000 10000
04152 05935 08698 18661
12500 12500 12500 12500
05190 07419 10873 23326
10000 10000 10000 10000
04152 05935 08698 18661
$3893 Misc Pediatric $5564 Misc Pediatric $8154 Misc Pediatric
$17495 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
480-1 480-2 480-3 480-4
MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES
180 241 618
1422
12119 13477 20992 45258
10000 10000 10000 10000
10000 10000 10000 10000
12119 13477 20992 45258
12500 12500 12500 12500
15149 16846 26240 56573
10000 10000 10000 10000
12119 13477 20992 45258
$11362 Misc Pediatric $12635 Misc Pediatric $19680 Misc Pediatric $42429 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
481-1 481-2 481-3 481-4
PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES
228 267 830
1810
06794 11922 17939 41143
10000 10000 10000 10000
10000 10000 10000 10000
06794 11922 17939 41143
12500 12500 12500 12500
08493 14903 22424 51429
10000 10000 10000 10000
06794 11922 17939 41143
$6369 Misc Pediatric $11177 Misc Pediatric $16818 Misc Pediatric $38572 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
482-1 482-2 482-3 482-4
TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY
169 278 716
1341
05918 07555 14662 30717
10000 10000 10000 10000
10000 10000 10000 10000
05918 07555 14662 30717
12500 12500 12500 12500
07398 09444 18328 38396
10000 10000 10000 10000
05918 07555 14662 30717
$5548 Misc Pediatric $7083 Misc Pediatric
$13746 Misc Pediatric $28797 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
483-1 483-2 483-3 483-4
TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES
203 541
1127 1970
06074 11326 22018 44244
10000 10000 10000 10000
10000 10000 10000 10000
06074 11326 22018 44244
12500 12500 12500 12500
07593 14158 27523 55305
10000 10000 10000 10000
06074 11326 22018 44244
$5694 Misc Pediatric $10618 Misc Pediatric $20642 Misc Pediatric $41479 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
484-1 484-2 484-3 484-4
OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
250 191 502
1578
07704 11762 15177 36555
10000 10000 10000 10000
10000 10000 10000 10000
07704 11762 15177 36555
12500 12500 12500 12500
09630 14703 18971 45694
10000 10000 10000 10000
07704 11762 15177 36555
$7223 Misc Pediatric $11027 Misc Pediatric $14228 Misc Pediatric $34270 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
500-1 500-2 500-3 500-4
MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM
266 431 601
1109
03789 05904 09172 17461
10000 10000 10000 10000
10000 10000 10000 10000
03789 05904 09172 17461
12500 12500 12500 12500
04736 07380 11465 21826
10000 10000 10000 10000
03789 05904 09172 17461
$3552 Misc Pediatric $5535 Misc Pediatric $8599 Misc Pediatric
$16370 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
501-1 501-2 501-3 501-4
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY
258 351 547
1074
04044 05542 08322 16765
10000 10000 10000 10000
10000 10000 10000 10000
04044 05542 08322 16765
12500 12500 12500 12500
05055 06928 10403 20956
10000 10000 10000 10000
04044 05542 08322 16765
$3791 Misc Pediatric $5196 Misc Pediatric $7802 Misc Pediatric
$15717 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
510-1 510-2 510-3 510-4
PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS
244 387 892
1787
11433 14140 25807 52317
10000 10000 10000 10000
10000 10000 10000 10000
11433 14140 25807 52317
12500 12500 12500 12500
14291 17675 32259 65396
10000 10000 10000 10000
11433 14140 25807 52317
$10718 Misc Pediatric $13256 Misc Pediatric $24194 Misc Pediatric $49047 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
511-1 511-2 511-3 511-4
UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY
330 488 862
1777
11911 14923 22750 49888
10000 10000 10000 10000
10000 10000 10000 10000
11911 14923 22750 49888
12500 12500 12500 12500
14889 18654 28438 62360
10000 10000 10000 10000
11911 14923 22750 49888
$11167 Misc Pediatric $13990 Misc Pediatric $21328 Misc Pediatric $46770 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
512-1 512-2 512-3 512-4
UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG
217 308 682
1629
10603 12410 19879 45702
10000 10000 10000 10000
10000 10000 10000 10000
10603 12410 19879 45702
12500 12500 12500 12500
13254 15513 24849 57128
10000 10000 10000 10000
10603 12410 19879 45702
$9940 Misc Pediatric $11634 Misc Pediatric $18637 Misc Pediatric $42846 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
513-1 513-2 513-3 513-4
UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
186 251 564
1508
08515 10026 16283 40387
10000 10000 10000 10000
10000 10000 10000 10000
08515 10026 16283 40387
12500 12500 12500 12500
10644 12533 20354 50484
10000 10000 10000 10000
08515 10026 16283 40387
$7983 Misc Pediatric $9399 Misc Pediatric
$15265 Misc Pediatric $37863 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
514-1 514-2 514-3 514-4
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
140 172 529
1557
07298 09618 15881 40691
10000 10000 10000 10000
10000 10000 10000 10000
07298 09618 15881 40691
12500 12500 12500 12500
09123 12023 19851 50864
10000 10000 10000 10000
07298 09618 15881 40691
$6842 Misc Pediatric $9017 Misc Pediatric
$14888 Misc Pediatric $38148 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
517-1 517-2 517-3 517-4
DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES
192 289 663
1364
06030 08036 13633 29709
10000 10000 10000 10000
10000 10000 10000 10000
06030 08036 13633 29709
12500 12500 12500 12500
07538 10045 17041 37136
10000 10000 10000 10000
06030 08036 13633 29709
$5653 Misc Pediatric $7534 Misc Pediatric
$12781 Misc Pediatric $27852 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
518-1 518-2 518-3 518-4
OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
223 382 837
1827
06924 10040 18032 44556
10000 10000 10000 10000
10000 10000 10000 10000
06924 10040 18032 44556
12500 12500 12500 12500
08655 12550 22540 55695
10000 10000 10000 10000
06924 10040 18032 44556
$6491 Misc Pediatric $9413 Misc Pediatric
$16905 Misc Pediatric $41771 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
519-1 519-2 519-3 519-4
UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA
206 279 613
1485
08286 10051 17505 39433
10000 10000 10000 10000
10000 10000 10000 10000
08286 10051 17505 39433
12500 12500 12500 12500
10358 12564 21881 49291
10000 10000 10000 10000
08286 10051 17505 39433
$7768 Misc Pediatric $9423 Misc Pediatric
$16411 Misc Pediatric $36968 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
530-1 530-2 530-3 530-4
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
310 385 643
1178
04420 06163 09992 18972
10000 10000 10000 10000
10000 10000 10000 10000
04420 06163 09992 18972
12500 12500 12500 12500
05525 07704 12490 23715
10000 10000 10000 10000
04420 06163 09992 18972
$4144 Misc Pediatric $5778 Misc Pediatric $9368 Misc Pediatric
$17786 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
531-1 531-2 531-3 531-4
FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS
266 383 638
1303
04544 06407 09987 20595
10000 10000 10000 10000
10000 10000 10000 10000
04544 06407 09987 20595
12500 12500 12500 12500
05680 08009 12484 25744
10000 10000 10000 10000
04544 06407 09987 20595
$4260 Misc Pediatric $6007 Misc Pediatric $9363 Misc Pediatric
$19308 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
532-1 532-2 532-3 532-4
MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
177 237 434
1003
03922 04787 07941 17650
10000 10000 10000 10000
10000 10000 10000 10000
03922 04787 07941 17650
12500 12500 12500 12500
04903 05984 09926 22063
10000 10000 10000 10000
03922 04787 07941 17650
$3677 Misc Pediatric $4488 Misc Pediatric $7445 Misc Pediatric
$16547 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
540-1 540-2 540-3 540-4
CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY
298 391 634
1053
05654 06864 09354 23719
10000 10000 10000 10000
10600 10600 10600 10600
05993 07276 09915 25142
10000 10000 10000 10000
05993 07276 09915 25142
10000 10000 10000 10000
05654 06864 09354 23719
$4495 Obstetrics $5457 Obstetrics $7436 Obstetrics
$18857 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
541-1 541-2 541-3 541-4
VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC
212 249 491 838
05628 06076 08661 23515
10000 10000 10000 10000
10600 10600 10600 10600
05966 06441 09181 24926
10000 10000 10000 10000
05966 06441 09181 24926
10000 10000 10000 10000
05628 06076 08661 23515
$4474 Obstetrics $4830 Obstetrics $6886 Obstetrics
$18694 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
542-1 542-2 542-3 542-4
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC
216 296 614 993
03695 04647 08572 36195
10000 10000 10000 10000
10600 10600 10600 10600
03917 04926 09086 38367
10000 10000 10000 10000
03917 04926 09086 38367
10000 10000 10000 10000
03695 04647 08572 36195
$2938 Obstetrics $3694 Obstetrics $6815 Obstetrics
$28775 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
544-1 544-2 544-3 544-4
DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES
136 200 407 914
04586 05897 09822 25061
10000 10000 10000 10000
10600 10600 10600 10600
04861 06251 10411 26565
10000 10000 10000 10000
04861 06251 10411 26565
10000 10000 10000 10000
04586 05897 09822 25061
$3646 Obstetrics Obstetrics $4688 Obstetrics Obstetrics $7808 Obstetrics Obstetrics
$19924 Obstetrics Obstetrics 545-1 545-2 545-3 545-4
ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE
164 190 265 576
06988 08147 10540 19945
10000 10000 10000 10000
10600 10600 10600 10600
07407 08636 11172 21142
10000 10000 10000 10000
07407 08636 11172 21142
10000 10000 10000 10000
06988 08147 10540 19945
$5555 Obstetrics Obstetrics $6477 Obstetrics Obstetrics $8379 Obstetrics Obstetrics
$15856 Obstetrics Obstetrics 546-1 546-2 546-3 546-4
OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES
285 454 755
1446
05023 07207 13295 43377
10000 10000 10000 10000
10600 10600 10600 10600
05324 07639 14093 45980
10000 10000 10000 10000
05324 07639 14093 45980
10000 10000 10000 10000
05023 07207 13295 43377
$3993 Obstetrics Obstetrics $5730 Obstetrics Obstetrics
$10570 Obstetrics Obstetrics $34485 Obstetrics Obstetrics
560-1 560-2 560-3 560-4
VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY
203 237 385 935
03307 03856 05399 15061
10000 10000 10000 10000
10600 10600 10600 10600
03505 04087 05723 15965
10000 10000 10000 10000
03505 04087 05723 15965
10000 10000 10000 10000
03307 03856 05399 15061
$2629 Obstetrics Obstetrics $3066 Obstetrics Obstetrics $4292 Obstetrics Obstetrics
$11974 Obstetrics Obstetrics 561-1 561-2 561-3 561-4
POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE
211 257 393 688
02511 03908 06071 15617
10000 10000 10000 10000
10600 10600 10600 10600
02662 04142 06435 16554
10000 10000 10000 10000
02662 04142 06435 16554
10000 10000 10000 10000
02511 03908 06071 15617
$1996 Obstetrics Obstetrics $3107 Obstetrics Obstetrics $4826 Obstetrics Obstetrics
$12416 Obstetrics Obstetrics 563-1 563-2 563-3 563-4
THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION
259 391 747 720
02581 03376 05162 09652
10000 10000 10000 10000
10600 10600 10600 10600
02736 03579 05472 10231
10000 10000 10000 10000
02736 03579 05472 10231
10000 10000 10000 10000
02581 03376 05162 09652
$2052 Obstetrics Obstetrics $2684 Obstetrics Obstetrics $4104 Obstetrics Obstetrics $7673 Obstetrics Obstetrics
564-1 564-2 564-3 564-4
ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY
137 170 276 808
02881 03463 04901 16676
10000 10000 10000 10000
10600 10600 10600 10600
03054 03671 05195 17677
10000 10000 10000 10000
03054 03671 05195 17677
10000 10000 10000 10000
02881 03463 04901 16676
$2290 Obstetrics Obstetrics $2753 Obstetrics Obstetrics $3896 Obstetrics Obstetrics
$13257 Obstetrics Obstetrics 565-1 565-2 565-3 565-4
FALSE LABOR FALSE LABOR FALSE LABOR FALSE LABOR
123 185 735 808
01245 01782 02687 02986
10000 10000 10000 10000
10600 10600 10600 10600
01320 01889 02848 03165
10000 10000 10000 10000
01320 01889 02848 03165
10000 10000 10000 10000
01245 01782 02687 02986
$990 Obstetrics Obstetrics $1417 Obstetrics Obstetrics $2136 Obstetrics Obstetrics $2374 Obstetrics Obstetrics
566-1 566-2 566-3 566-4
OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES
211 294 544 843
02442 03252 04790 14726
10000 10000 10000 10000
10600 10600 10600 10600
02589 03447 05077 15610
10000 10000 10000 10000
02589 03447 05077 15610
10000 10000 10000 10000
02442 03252 04790 14726
$1941 Obstetrics Obstetrics $2585 Obstetrics Obstetrics $3808 Obstetrics Obstetrics
$11707 Obstetrics Obstetrics 580-1 580-2 580-3 580-4
NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE
144 159 182 165
02398 03209 05011 08512
12500 12500 12500 12500
10000 10000 10000 10000
02998 04011 06264 10640
10000 10000 10000 10000
02998 04011 06264 10640
17500 17500 17500 17500
04197 05616 08769 14896
$2248 Neonate Neonate $3008 Neonate Neonate $4698 Neonate Neonate $7980 Neonate Neonate
581-1 581-2 581-3 581-4
NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE
124 128 126 135
00982 01477 02362 04408
12500 12500 12500 12500
10000 10000 10000 10000
01228 01846 02953 05510
10000 10000 10000 10000
01228 01846 02953 05510
17500 17500 17500 17500
01719 02585 04134 07714
$921 Neonate Neonate $1385 Neonate Neonate $2214 Neonate Neonate $4133 Neonate Neonate
583-1 583-2 583-3 583-4
NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO
2070 2300 3077 4886
99741 157496 173245 240894
12500 12500 12500 12500
10000 10000 10000 10000
124676 196870 216556 301118
10000 10000 10000 10000
124676 196870 216556 301118
17500 17500 17500 17500
174547 275618 303179 421565
$93507 Neonate Neonate $147653 Neonate Neonate $162417 Neonate Neonate $225838 Neonate Neonate
588-1 588-2 588-3 588-4
NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE
4442 4935 7714
10207
48410 70035
142903 216660
12500 12500 12500 12500
10000 10000 10000 10000
60513 87544
178629 270825
10000 10000 10000 10000
60513 87544
178629 270825
17500 17500 17500 17500
84718 122561 250080 379155
$45384 Neonate Neonate $65658 Neonate Neonate
$133972 Neonate Neonate $203119 Neonate Neonate
589-1 589-2 589-3 589-4
NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS
5843 5041 3035
265
115468 104972
95430 04454
12500 12500 12500 12500
10000 10000 10000 10000
144335 131215 119288
05568
10000 10000 10000 10000
144335 131215 119288
05568
17500 17500 17500 17500
202069 183701 167003
07795
$108251 Neonate Neonate $98411 Neonate Neonate $89466 Neonate Neonate
$4176 Neonate Neonate 591-1 591-2 591-3 591-4
NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE
211 3710 5061 7221
01574 55672 88282
132286
12500 12500 12500 12500
10000 10000 10000 10000
01968 69590
110353 165358
10000 10000 10000 10000
01968 69590
110353 165358
17500 17500 17500 17500
02755 97426
154494 231501
$1476 Neonate Neonate $52193 Neonate Neonate $82764 Neonate Neonate
$124018 Neonate Neonate 593-1 593-2 593-3 593-4
NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE
1928 4851 5965 7143
15109 51914 82800
122454
12500 12500 12500 12500
10000 10000 10000 10000
18886 64893
103500 153068
10000 10000 10000 10000
18886 64893
103500 153068
17500 17500 17500 17500
26441 90850
144900 214295
$14165 Neonate Neonate $48669 Neonate Neonate $77625 Neonate Neonate
$114801 Neonate Neonate 602-1 602-2 602-3 602-4
NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2513 4403 5324 6307
29635 58707 77593
104733
12500 12500 12500 12500
10000 10000 10000 10000
37044 73384 96991
130916
10000 10000 10000 10000
37044 73384 96991
130916
17500 17500 17500 17500
51861 102737 135788 183283
$27783 Neonate Neonate $55038 Neonate Neonate $72743 Neonate Neonate $98187 Neonate Neonate
603-1 603-2 603-3 603-4
NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION
2234 3619 4843 5396
17223 42526 65587 70750
12500 12500 12500 12500
10000 10000 10000 10000
21529 53158 81984 88438
10000 10000 10000 10000
21529 53158 81984 88438
17500 17500 17500 17500
30140 74421
114777 123813
$16147 Neonate Neonate $39868 Neonate Neonate $61488 Neonate Neonate $66328 Neonate Neonate
607-1 607-2 607-3 607-4
NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2509 3582 4341 4957
27503 47486 61883 79508
12500 12500 12500 12500
10000 10000 10000 10000
34379 59358 77354 99385
10000 10000 10000 10000
34379 59358 77354 99385
17500 17500 17500 17500
48130 83101
108295 139139
$25784 Neonate Neonate $44518 Neonate Neonate $58015 Neonate Neonate $74539 Neonate Neonate
608-1 608-2 608-3 608-4
NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION
1980 3004 3846 4414
21292 36047 52684 60424
12500 12500 12500 12500
10000 10000 10000 10000
26615 45059 65855 75530
10000 10000 10000 10000
26615 45059 65855 75530
17500 17500 17500 17500
37261 63082 92197
105742
$19961 Neonate Neonate $33794 Neonate Neonate $49391 Neonate Neonate $56648 Neonate Neonate
609-1 609-2 609-3 609-4
NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE
1933 2210 3803 6267
27332 38628 65636
119134
12500 12500 12500 12500
10000 10000 10000 10000
34165 48285 82045
148918
10000 10000 10000 10000
34165 48285 82045
148918
17500 17500 17500 17500
47831 67599
114863 208485
$25624 Neonate Neonate $36214 Neonate Neonate $61534 Neonate Neonate
$111688 Neonate Neonate 611-1 611-2 611-3 611-4
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY
1313 2123 3133 3614
11780 25158 40556 52442
12500 12500 12500 12500
10000 10000 10000 10000
14725 31448 50695 65553
10000 10000 10000 10000
14725 31448 50695 65553
17500 17500 17500 17500
20615 44027 70973 91774
$11044 Neonate Neonate $23586 Neonate Neonate $38021 Neonate Neonate $49164 Neonate Neonate
612-1 612-2 612-3 612-4
NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND
1756 2442 3248 3834
21880 32223 46803 62297
12500 12500 12500 12500
10000 10000 10000 10000
27350 40279 58504 77871
10000 10000 10000 10000
27350 40279 58504 77871
17500 17500 17500 17500
38290 56390 81905
109020
$20513 Neonate Neonate $30209 Neonate Neonate $43878 Neonate Neonate $58403 Neonate Neonate
613-1 613-2 613-3 613-4
NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION
1439 2153 2853 3338
16593 26831 37601 48828
12500 12500 12500 12500
10000 10000 10000 10000
20741 33539 47001 61035
10000 10000 10000 10000
20741 33539 47001 61035
17500 17500 17500 17500
29038 46954 65802 85449
$15556 Neonate Neonate $25154 Neonate Neonate $35251 Neonate Neonate $45776 Neonate Neonate
614-1 614-2 614-3 614-4
NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION
1123 2008 2852 3640
09241 22768 36403 50802
12500 12500 12500 12500
10000 10000 10000 10000
11551 28460 45504 63503
10000 10000 10000 10000
11551 28460 45504 63503
17500 17500 17500 17500
16172 39844 63705 88904
$8663 Neonate Neonate $21345 Neonate Neonate $34128 Neonate Neonate $47627 Neonate Neonate
621-1 621-2 621-3 621-4
NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY
820 1397 2125 2416
06082 15379 27206 38101
12500 12500 12500 12500
10000 10000 10000 10000
07603 19224 34008 47626
10000 10000 10000 10000
07603 19224 34008 47626
17500 17500 17500 17500
10644 26913 47611 66677
$5702 Neonate Neonate $14418 Neonate Neonate $25506 Neonate Neonate $35720 Neonate Neonate
622-1 622-2 622-3 622-4
NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND
1118 1514 1977 2285
13666 20913 29736 47202
12500 12500 12500 12500
10000 10000 10000 10000
17083 26141 37170 59003
10000 10000 10000 10000
17083 26141 37170 59003
17500 17500 17500 17500
23916 36598 52038 82604
$12812 Neonate Neonate $19606 Neonate Neonate $27878 Neonate Neonate $44252 Neonate Neonate
623-1 623-2 623-3 623-4
NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION
924 1399 1872 2738
09934 16800 25087 38932
12500 12500 12500 12500
10000 10000 10000 10000
12418 21000 31359 48665
10000 10000 10000 10000
12418 21000 31359 48665
17500 17500 17500 17500
17385 29400 43902 68131
$9313 Neonate Neonate $15750 Neonate Neonate $23519 Neonate Neonate $36499 Neonate Neonate
625-1 625-2 625-3 625-4
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION
1157 1621 1925 2015
11469 18627 23298 29194
12500 12500 12500 12500
10000 10000 10000 10000
14336 23284 29123 36493
10000 10000 10000 10000
14336 23284 29123 36493
17500 17500 17500 17500
20071 32597 40772 51090
$10752 Neonate Neonate $17463 Neonate Neonate $21842 Neonate Neonate $27369 Neonate Neonate
626-1 626-2 626-3 626-4
NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
279 456 864
1838
01387 02587 07679 22819
10000 10000 10000 10000
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
$1040 Normal newborn Normal newborn $1940 Normal newborn Normal newborn $5759 Normal newborn Normal newborn
$17114 Normal newborn Normal newborn 630-1 630-2 630-3 630-4
NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE
486 940
1448 3912
20468 32885 52250
112072
12500 12500 12500 12500
10000 10000 10000 10000
25585 41106 65313
140090
10000 10000 10000 10000
25585 41106 65313
140090
17500 17500 17500 17500
35819 57549 91438
196126
$19189 Neonate Neonate $30830 Neonate Neonate $48984 Neonate Neonate
$105068 Neonate Neonate 631-1 631-2 631-3 631-4
NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE
335 886
2279 5111
09217 16766 37480 96324
12500 12500 12500 12500
10000 10000 10000 10000
11521 20958 46850
120405
10000 10000 10000 10000
11521 20958 46850
120405
17500 17500 17500 17500
16130 29341 65590
168567
$8641 Neonate Neonate $15718 Neonate Neonate $35138 Neonate Neonate $90304 Neonate Neonate
633-1 633-2 633-3 633-4
NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY
296 651
1226 2381
01972 05798 13892 39728
12500 12500 12500 12500
10000 10000 10000 10000
02465 07248 17365 49660
10000 10000 10000 10000
02465 07248 17365 49660
17500 17500 17500 17500
03451 10147 24311 69524
$1849 Neonate Neonate $5436 Neonate Neonate
$13024 Neonate Neonate $37245 Neonate Neonate
634-1 634-2 634-3 634-4
NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND
465 749
1261 2233
04886 09445 20176 46934
12500 12500 12500 12500
10000 10000 10000 10000
06108 11806 25220 58668
10000 10000 10000 10000
06108 11806 25220 58668
17500 17500 17500 17500
08551 16529 35308 82135
$4581 Neonate Neonate $8855 Neonate Neonate
$18915 Neonate Neonate $44001 Neonate Neonate
636-1 636-2 636-3 636-4
NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION
558 779
1164 1896
05582 08840 15558 30613
12500 12500 12500 12500
10000 10000 10000 10000
06978 11050 19448 38266
10000 10000 10000 10000
06978 11050 19448 38266
17500 17500 17500 17500
09769 15470 27227 53573
$5233 Neonate Neonate $8288 Neonate Neonate
$14586 Neonate Neonate $28700 Neonate Neonate
639-1 639-2 639-3 639-4
NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION
441 704 998
1653
03287 06622 11809 27285
12500 12500 12500 12500
10000 10000 10000 10000
04109 08278 14761 34106
10000 10000 10000 10000
04109 08278 14761 34106
17500 17500 17500 17500
05752 11589 20666 47749
$3082 Neonate Neonate $6208 Neonate Neonate
$11071 Neonate Neonate $25580 Neonate Neonate
640-1 NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 210 01012 10000 10000 01012 10000 01012 10000 01012 $759 Normal newborn Normal newborn
640-2 640-3 640-4
NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
245 376
1206
01353 02864 14726
10000 10000 10000
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
$1015 Normal newborn Normal newborn $2148 Normal newborn Normal newborn
$11045 Normal newborn Normal newborn 650-1 650-2 650-3 650-4
SPLENECTOMY SPLENECTOMY SPLENECTOMY SPLENECTOMY
348 537 848
1563
12985 17965 25202 50826
10000 10000 10000 10000
10000 10000 10000 10000
12985 17965 25202 50826
12500 12500 12500 12500
16231 22456 31503 63533
10000 10000 10000 10000
12985 17965 25202 50826
$12173 Misc Pediatric Misc Adult $16842 Misc Pediatric Misc Adult $23627 Misc Pediatric Misc Adult $47649 Misc Pediatric Misc Adult
651-1 651-2 651-3 651-4
OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS
331 472 962
2426
09234 13695 21005 59541
10000 10000 10000 10000
10000 10000 10000 10000
09234 13695 21005 59541
12500 12500 12500 12500
11543 17119 26256 74426
10000 10000 10000 10000
09234 13695 21005 59541
$8657 Misc Pediatric Misc Adult $12839 Misc Pediatric Misc Adult $19692 Misc Pediatric Misc Adult $55820 Misc Pediatric Misc Adult
660-1 660-2 660-3 660-4
MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL
305 408 648
1435
05399 07219 11819 30180
10000 10000 10000 10000
10000 10000 10000 10000
05399 07219 11819 30180
12500 12500 12500 12500
06749 09024 14774 37725
10000 10000 10000 10000
05399 07219 11819 30180
$5062 Misc Pediatric Misc Adult $6768 Misc Pediatric Misc Adult
$11080 Misc Pediatric Misc Adult $28294 Misc Pediatric Misc Adult
661-1 661-2 661-3 661-4
COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS
275 375 566
1265
06473 08098 12433 27857
10000 10000 10000 10000
10000 10000 10000 10000
06473 08098 12433 27857
12500 12500 12500 12500
08091 10123 15541 34821
10000 10000 10000 10000
06473 08098 12433 27857
$6068 Misc Pediatric Misc Adult $7592 Misc Pediatric Misc Adult
$11656 Misc Pediatric Misc Adult $26116 Misc Pediatric Misc Adult
662-1 662-2 662-3 662-4
SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS
412 538 785
1302
05044 07003 10778 23937
10000 10000 10000 10000
10000 10000 10000 10000
05044 07003 10778 23937
12500 12500 12500 12500
06305 08754 13473 29921
10000 10000 10000 10000
05044 07003 10778 23937
$4729 Misc Pediatric Misc Adult $6565 Misc Pediatric Misc Adult
$10104 Misc Pediatric Misc Adult $22441 Misc Pediatric Misc Adult
663-1 663-2 663-3 663-4
OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS
232 301 451 900
04474 05959 08513 16106
10000 10000 10000 10000
10000 10000 10000 10000
04474 05959 08513 16106
12500 12500 12500 12500
05593 07449 10641 20133
10000 10000 10000 10000
04474 05959 08513 16106
$4194 Misc Pediatric Misc Adult $5587 Misc Pediatric Misc Adult $7981 Misc Pediatric Misc Adult
$15099 Misc Pediatric Misc Adult 680-1 680-2 680-3 680-4
MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
408 633
1185 2456
13702 18600 32002 66288
10000 10000 10000 10000
10000 10000 10000 10000
13702 18600 32002 66288
12500 12500 12500 12500
17128 23250 40003 82860
10000 10000 10000 10000
13702 18600 32002 66288
$12846 Misc Pediatric Misc Adult $17438 Misc Pediatric Misc Adult $30002 Misc Pediatric Misc Adult $62145 Misc Pediatric Misc Adult
681-1 681-2 681-3 681-4
OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
268 507
1111 2510
09800 13647 24597 59170
10000 10000 10000 10000
10000 10000 10000 10000
09800 13647 24597 59170
12500 12500 12500 12500
12250 17059 30746 73963
10000 10000 10000 10000
09800 13647 24597 59170
$9188 Misc Pediatric Misc Adult $12794 Misc Pediatric Misc Adult $23060 Misc Pediatric Misc Adult $55472 Misc Pediatric Misc Adult
690-1 690-2 690-3 690-4
ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA
495 740
1461 2485
07040 11869 23551 52504
10000 10000 10000 10000
10000 10000 10000 10000
07040 11869 23551 52504
12500 12500 12500 12500
08800 14836 29439 65630
10000 10000 10000 10000
07040 11869 23551 52504
$6600 Misc Pediatric Misc Adult $11127 Misc Pediatric Misc Adult $22079 Misc Pediatric Misc Adult $49223 Misc Pediatric Misc Adult
691-1 691-2 691-3 691-4
LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA
389 540 861
1585
07077 09840 15477 31411
10000 10000 10000 10000
10000 10000 10000 10000
07077 09840 15477 31411
12500 12500 12500 12500
08846 12300 19346 39264
10000 10000 10000 10000
07077 09840 15477 31411
$6635 Misc Pediatric Misc Adult $9225 Misc Pediatric Misc Adult
$14510 Misc Pediatric Misc Adult $29448 Misc Pediatric Misc Adult
692-1 692-2 692-3 692-4
RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY
389 482 868
1580
06075 12584 17422 29316
10000 10000 10000 10000
10000 10000 10000 10000
06075 12584 17422 29316
12500 12500 12500 12500
07594 15730 21778 36645
10000 10000 10000 10000
06075 12584 17422 29316
$5695 Misc Pediatric Misc Adult $11798 Misc Pediatric Misc Adult $16333 Misc Pediatric Misc Adult $27484 Misc Pediatric Misc Adult
693-1 693-2 693-3 693-4
CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY
281 368 785
2410
06251 07881 13637 49083
10000 10000 10000 10000
10000 10000 10000 10000
06251 07881 13637 49083
12500 12500 12500 12500
07814 09851 17046 61354
10000 10000 10000 10000
06251 07881 13637 49083
$5860 Misc Pediatric Misc Adult $7388 Misc Pediatric Misc Adult
$12785 Misc Pediatric Misc Adult $46015 Misc Pediatric Misc Adult
694-1 694-2 694-3 694-4
LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR
304 404 674
1164
04842 06831 11115 21001
10000 10000 10000 10000
10000 10000 10000 10000
04842 06831 11115 21001
12500 12500 12500 12500
06053 08539 13894 26251
10000 10000 10000 10000
04842 06831 11115 21001
$4539 Misc Pediatric Misc Adult $6404 Misc Pediatric Misc Adult
$10420 Misc Pediatric Misc Adult $19688 Misc Pediatric Misc Adult
710-1 710-2 710-3 710-4
INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE
510 680
1111 1820
10635 15963 25572 49382
10000 10000 10000 10000
10000 10000 10000 10000
10635 15963 25572 49382
12500 12500 12500 12500
13294 19954 31965 61728
10000 10000 10000 10000
10635 15963 25572 49382
$9970 Misc Pediatric Misc Adult $14965 Misc Pediatric Misc Adult $23974 Misc Pediatric Misc Adult $46296 Misc Pediatric Misc Adult
711-1 711-2 711-3 711-4
POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE
471 692
1131 2087
10079 14143 23599 50574
10000 10000 10000 10000
10000 10000 10000 10000
10079 14143 23599 50574
12500 12500 12500 12500
12599 17679 29499 63218
10000 10000 10000 10000
10079 14143 23599 50574
$9449 Misc Pediatric Misc Adult $13259 Misc Pediatric Misc Adult $22124 Misc Pediatric Misc Adult $47413 Misc Pediatric Misc Adult
720-1 720-2 720-3 720-4
SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS
353 444 633
1004
05431 07613 11532 21705
10000 10000 10000 10000
10000 10000 10000 10000
05431 07613 11532 21705
12500 12500 12500 12500
06789 09516 14415 27131
10000 10000 10000 10000
05431 07613 11532 21705
$5092 Misc Pediatric Misc Adult $7137 Misc Pediatric Misc Adult
$10811 Misc Pediatric Misc Adult $20348 Misc Pediatric Misc Adult
721-1 721-2 721-3 721-4
POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS
368 470 705
1153
05287 07209 11619 22025
10000 10000 10000 10000
10000 10000 10000 10000
05287 07209 11619 22025
12500 12500 12500 12500
06609 09011 14524 27531
10000 10000 10000 10000
05287 07209 11619 22025
$4957 Misc Pediatric Misc Adult $6758 Misc Pediatric Misc Adult
$10893 Misc Pediatric Misc Adult $20648 Misc Pediatric Misc Adult
722-1 722-2 722-3 722-4
FEVER FEVER FEVER FEVER
230 302 429 739
03423 05223 07630 13141
10000 10000 10000 10000
10000 10000 10000 10000
03423 05223 07630 13141
12500 12500 12500 12500
04279 06529 09538 16426
10000 10000 10000 10000
03423 05223 07630 13141
$3209 Misc Pediatric Misc Adult $4897 Misc Pediatric Misc Adult $7153 Misc Pediatric Misc Adult
$12320 Misc Pediatric Misc Adult 723-1 723-2 723-3 723-4
VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS
216 279 470
1317
03194 04738 07794 24233
10000 10000 10000 10000
10000 10000 10000 10000
03194 04738 07794 24233
12500 12500 12500 12500
03993 05923 09743 30291
10000 10000 10000 10000
03194 04738 07794 24233
$2994 Misc Pediatric Misc Adult $4442 Misc Pediatric Misc Adult $7307 Misc Pediatric Misc Adult
$22718 Misc Pediatric Misc Adult 724-1 724-2 724-3 724-4
OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES
400 477 680
1337
05512 07131 11401 24698
10000 10000 10000 10000
10000 10000 10000 10000
05512 07131 11401 24698
12500 12500 12500 12500
06890 08914 14251 30873
10000 10000 10000 10000
05512 07131 11401 24698
$5168 Misc Pediatric Misc Adult $6685 Misc Pediatric Misc Adult
$10688 Misc Pediatric Misc Adult $23154 Misc Pediatric Misc Adult
740-1 740-2 740-3 740-4
MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE
678 1284 2034 2421
10899 13904 24356 37756
10000 10000 10000 10000
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
$8174 Other Other $10428 Other Other $18267 Other Other $28317 Other Other
750-1 750-2 750-3 750-4
SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA
1082 1179 1539 2848
05713 06699 09202 19283
10000 10000 10000 10000
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
$4285 Other Other $5024 Other Other $6902 Other Other
$14462 Other Other 751-1 751-2 751-3 751-4
MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES
528 724
1055 2028
03572 05019 08097 15923
10000 10000 10000 10000
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
$2679 Other Other $3764 Other Other $6073 Other Other
$11942 Other Other 752-1 752-2 752-3 752-4
DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL
503 658
1473 7300
03399 04498 09061 14934
10000 10000 10000 10000
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
$2549 Other Other $3374 Other Other $6796 Other Other
$11201 Other Other 753-1 753-2 753-3 753-4
BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS
601 808
1205 1948
04001 05365 08266 14926
10000 10000 10000 10000
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
$3001 Other Other $4024 Other Other $6200 Other Other
$11195 Other Other 754-1 754-2 754-3 754-4
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER
424 558 727
1664
02943 03998 05677 11553
10000 10000 10000 10000
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
$2207 Other Other $2999 Other Other $4258 Other Other $8665 Other Other
755-1 755-2 755-3 755-4
ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
388 622 900 813
02738 04363 06226 08767
10000 10000 10000 10000
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
$2054 Other Other $3272 Other Other $4670 Other Other $6575 Other Other
756-1 756-2 756-3 756-4
ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES
331 381 457 942
04061 05308 06065 13981
10000 10000 10000 10000
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
$3046 Other Other $3981 Other Other $4549 Other Other
$10486 Other Other 757-1 757-2 757-3 757-4
ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES
873 934
1087 1640
05861 07234 08953 13799
10000 10000 10000 10000
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
$4396 Other Other $5426 Other Other $6715 Other Other
$10349 Other Other 758-1 758-2 758-3 758-4
CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS
694 981
1225 4300
03874 05129 06541 11332
10000 10000 10000 10000
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
$2906 Other Other $3847 Other Other $4906 Other Other $8499 Other Other
759-1 759-2 759-3 759-4
EATING DISORDERS EATING DISORDERS EATING DISORDERS EATING DISORDERS
1990 1297 1402 2303
06561 06961 10053 16606
10000 10000 10000 10000
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
$4921 Other Other $5221 Other Other $7540 Other Other
$12455 Other Other 760-1 760-2 760-3 760-4
OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS
748 766 912
1204
04840 06173 07573 14134
10000 10000 10000 10000
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
$3630 Other Other $4630 Other Other $5680 Other Other
$10601 Other Other 770-1 770-2 770-3 770-4
DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE
253 248 332 794
02240 02623 05475 16843
10000 10000 10000 10000
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
$1680 Other Other $1967 Other Other $4106 Other Other
$12632 Other Other 772-1 772-2 772-3 772-4
ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY
1434 1551 1289 2385
05441 06916 07009 24530
10000 10000 10000 10000
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
$4081 Other Other $5187 Other Other $5257 Other Other
$18398 Other Other 773-1 773-2 773-3 773-4
OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE
337 414 507 992
02663 03466 05964 18606
10000 10000 10000 10000
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
$1997 Other Other $2600 Other Other $4473 Other Other
$13955 Other Other 774-1 774-2
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
365 412
03040 03627
10000 10000
10000 10000
03040 03627
10000 10000
03040 03627
10000 10000
03040 03627
$2280 Other Other $2720 Other Other
774-3 774-4
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
479 1424
06448 24682
10000 10000
10000 10000
06448 24682
10000 10000
06448 24682
10000 10000
06448 24682
$4836 Other $18512 Other
Other Other
775-1 775-2 775-3 775-4
ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE
323 377 571
1263
03313 04639 08596 24910
10000 10000 10000 10000
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
$2485 Other $3479 Other $6447 Other
$18683 Other
Other Other Other Other
776-1 776-2 776-3 776-4
OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE
389 397 496 933
03157 04547 07887 16112
10000 10000 10000 10000
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
$2368 Other $3410 Other $5915 Other
$12084 Other
Other Other Other Other
791-1 791-2 791-3 791-4
OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT
314 515 989
2009
08636 12677 21979 49312
10000 10000 10000 10000
10000 10000 10000 10000
08636 12677 21979 49312
12500 12500 12500 12500
10795 15846 27474 61640
10000 10000 10000 10000
08636 12677 21979 49312
$8096 Misc Pediatric $11885 Misc Pediatric $20605 Misc Pediatric $46230 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
811-1 811-2 811-3 811-4
ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS
151 202 390 913
02707 03855 08277 22176
10000 10000 10000 10000
10000 10000 10000 10000
02707 03855 08277 22176
12500 12500 12500 12500
03384 04819 10346 27720
10000 10000 10000 10000
02707 03855 08277 22176
$2538 Misc Pediatric $3614 Misc Pediatric $7760 Misc Pediatric
$20790 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
812-1 812-2 812-3 812-4
POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS
165 225 347 694
03469 04331 07709 17419
10000 10000 10000 10000
10000 10000 10000 10000
03469 04331 07709 17419
12500 12500 12500 12500
04336 05414 09636 21774
10000 10000 10000 10000
03469 04331 07709 17419
$3252 Misc Pediatric $4060 Misc Pediatric $7227 Misc Pediatric
$16330 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
813-1 813-2 813-3 813-4
OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT
261 344 594
1344
04393 06056 09631 19960
10000 10000 10000 10000
10000 10000 10000 10000
04393 06056 09631 19960
12500 12500 12500 12500
05491 07570 12039 24950
10000 10000 10000 10000
04393 06056 09631 19960
$4118 Misc Pediatric $5678 Misc Pediatric $9029 Misc Pediatric
$18713 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
815-1 815-2 815-3 815-4
OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES
169 276 456 880
04211 05012 08129 22715
10000 10000 10000 10000
10000 10000 10000 10000
04211 05012 08129 22715
12500 12500 12500 12500
05264 06265 10161 28394
10000 10000 10000 10000
04211 05012 08129 22715
$3948 Misc Pediatric $4699 Misc Pediatric $7621 Misc Pediatric
$21295 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
816-1 816-2 816-3 816-4
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
173 240 346 736
04162 04915 07864 18134
10000 10000 10000 10000
10000 10000 10000 10000
04162 04915 07864 18134
12500 12500 12500 12500
05203 06144 09830 22668
10000 10000 10000 10000
04162 04915 07864 18134
$3902 Misc Pediatric $4608 Misc Pediatric $7373 Misc Pediatric
$17001 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
841-1 841-2 841-3 841-4
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT
2200 967
2599 4068
31148 34263 64068
159153
10000 10000 10000 10000
10000 10000 10000 10000
31148 34263 64068
159153
12500 12500 12500 12500
38935 42829 80085
198941
10000 10000 10000 10000
31148 34263 64068
159153
$29201 Misc Pediatric $32122 Misc Pediatric $60064 Misc Pediatric
$149206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
842-1 842-2 842-3 842-4
FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT
751 1072 1735 3010
14151 21416 38719 95054
10000 10000 10000 10000
10000 10000 10000 10000
14151 21416 38719 95054
12500 12500 12500 12500
17689 26770 48399
118818
10000 10000 10000 10000
14151 21416 38719 95054
$13267 Misc Pediatric $20078 Misc Pediatric $36299 Misc Pediatric $89113 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
843-1 843-2 843-3 843-4
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT
339 487 713
1113
04752 06661 11619 32621
10000 10000 10000 10000
10000 10000 10000 10000
04752 06661 11619 32621
12500 12500 12500 12500
05940 08326 14524 40776
10000 10000 10000 10000
04752 06661 11619 32621
$4455 Misc Pediatric $6245 Misc Pediatric
$10893 Misc Pediatric $30582 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
844-1 844-2 844-3 844-4
PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT
310 497 743
1781
04337 06965 12193 48021
10000 10000 10000 10000
10000 10000 10000 10000
04337 06965 12193 48021
12500 12500 12500 12500
05421 08706 15241 60026
10000 10000 10000 10000
04337 06965 12193 48021
$4066 Misc Pediatric $6530 Misc Pediatric
$11431 Misc Pediatric $45020 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
850-1 850-2 850-3 850-4
PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE
267 556
1618 3148
11757 14065 24870 46520
10000 10000 10000 10000
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
$8818 Misc Pediatric $10549 Misc Pediatric $18653 Misc Pediatric $34890 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
860-1 860-2 860-3 860-4
REHABILITATION REHABILITATION REHABILITATION REHABILITATION
932 1146 1475 1795
07227 09855 13880 17876
10000 10000 10000 10000
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
$5420 Other $7391 Other
$10410 Other $13407 Other
Other Other Other Other
861-1 861-2 861-3 861-4
SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS
253 340 497 917
02858 05247 07658 14498
10000 10000 10000 10000
10000 10000 10000 10000
02858 05247 07658 14498
12500 12500 12500 12500
03573 06559 09573 18123
10000 10000 10000 10000
02858 05247 07658 14498
$2679 Misc Pediatric $4919 Misc Pediatric $7179 Misc Pediatric
$13592 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
862-1 862-2 862-3 862-4
OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE
698 1122 1357 1872
02895 05851 07866 11351
10000 10000 10000 10000
10000 10000 10000 10000
02895 05851 07866 11351
12500 12500 12500 12500
03619 07314 09833 14189
10000 10000 10000 10000
02895 05851 07866 11351
$2714 Misc Pediatric $5485 Misc Pediatric $7374 Misc Pediatric
$10642 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
863-1 863-2 863-3 863-4
NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE
853 1757 2771 4643
05959 16127 30507 61446
12500 12500 12500 12500
10000 10000 10000 10000
07449 20159 38134 76808
10000 10000 10000 10000
07449 20159 38134 76808
17500 17500 17500 17500
10428 28222 53387
107531
$5587 Neonate $15119 Neonate $28600 Neonate $57606 Neonate
Neonate Neonate Neonate Neonate
890-1 890-2 890-3 890-4
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS
167 691 921
1514
07051 10224 14771 30014
10000 10000 10000 10000
10000 10000 10000 10000
07051 10224 14771 30014
12500 12500 12500 12500
08814 12780 18464 37518
10000 10000 10000 10000
07051 10224 14771 30014
$6610 Misc Pediatric $9585 Misc Pediatric
$13848 Misc Pediatric $28138 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
892-1 892-2 892-3 892-4
HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION
587 488 669
1152
05647 07763 10877 19375
10000 10000 10000 10000
10000 10000 10000 10000
05647 07763 10877 19375
12500 12500 12500 12500
07059 09704 13596 24219
10000 10000 10000 10000
05647 07763 10877 19375
$5294 Misc Pediatric $7278 Misc Pediatric
$10197 Misc Pediatric $18164 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
893-1 893-2 893-3 893-4
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
499 496 799
1422
07762 08219 12807 24296
10000 10000 10000 10000
10000 10000 10000 10000
07762 08219 12807 24296
12500 12500 12500 12500
09703 10274 16009 30370
10000 10000 10000 10000
07762 08219 12807 24296
$7277 Misc Pediatric $7705 Misc Pediatric
$12007 Misc Pediatric $22778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
894-1 894-2 894-3 894-4
HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND
341 393 627
1121
05218 06497 09774 19428
10000 10000 10000 10000
10000 10000 10000 10000
05218 06497 09774 19428
12500 12500 12500 12500
06523 08121 12218 24285
10000 10000 10000 10000
05218 06497 09774 19428
$4892 Misc Pediatric $6091 Misc Pediatric $9163 Misc Pediatric
$18214 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
910-1 910-2 910-3 910-4
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA
1100 775
1057 1830
28786 31984 41628 72114
10000 10000 10000 10000
10000 10000 10000 10000
28786 31984 41628 72114
12500 12500 12500 12500
35983 39980 52035 90143
10000 10000 10000 10000
28786 31984 41628 72114
$26987 Misc Pediatric $29985 Misc Pediatric $39026 Misc Pediatric $67607 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
911-1 911-2 911-3 911-4
EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA
511 619 795
1687
15160 20189 26724 58039
10000 10000 10000 10000
10000 10000 10000 10000
15160 20189 26724 58039
12500 12500 12500 12500
18950 25236 33405 72549
10000 10000 10000 10000
15160 20189 26724 58039
$14213 Misc Pediatric $18927 Misc Pediatric $25054 Misc Pediatric $54412 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
912-1 912-2 912-3 912-4
MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
558 607 985
1782
20950 22759 36410 68885
10000 10000 10000 10000
10000 10000 10000 10000
20950 22759 36410 68885
12500 12500 12500 12500
26188 28449 45513 86106
10000 10000 10000 10000
20950 22759 36410 68885
$19641 Misc Pediatric $21337 Misc Pediatric $34134 Misc Pediatric $64580 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
930-1 930-2 930-3 930-4
MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE
322 370 596
1127
07826 09594 15857 33896
10000 10000 10000 10000
10000 10000 10000 10000
07826 09594 15857 33896
12500 12500 12500 12500
09783 11993 19821 42370
10000 10000 10000 10000
07826 09594 15857 33896
$7337 Misc Pediatric $8994 Misc Pediatric
$14866 Misc Pediatric $31778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
950-1 950-2 950-3 950-4
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
361 623
1166 2260
13230 20029 31827 60092
10000 10000 10000 10000
10000 10000 10000 10000
13230 20029 31827 60092
12500 12500 12500 12500
16538 25036 39784 75115
10000 10000 10000 10000
13230 20029 31827 60092
$12403 Misc Pediatric $18777 Misc Pediatric $29838 Misc Pediatric $56336 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
951-1 951-2 951-3 951-4
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
329 517
1001 1973
09755 14320 24054 46875
10000 10000 10000 10000
10000 10000 10000 10000
09755 14320 24054 46875
12500 12500 12500 12500
12194 17900 30068 58594
10000 10000 10000 10000
09755 14320 24054 46875
$9145 Misc Pediatric $13425 Misc Pediatric $22551 Misc Pediatric $43945 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
952-1 952-2 952-3 952-4
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
274 504 968
1894
07736 11591 20369 39177
10000 10000 10000 10000
10000 10000 10000 10000
07736 11591 20369 39177
12500 12500 12500 12500
09670 14489 25461 48971
10000 10000 10000 10000
07736 11591 20369 39177
$7253 Misc Pediatric $10867 Misc Pediatric $19096 Misc Pediatric $36728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
955-0 956-0
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS UNGROUPABLE
--
--
Error DRG Error DRG
Error DRG Error DRG
i-
i
i
i-
i
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy adjustor F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that has at least a basic level
emergency room H FY 2015-16 Cost-to-Charge Ratio FY 2013 cost-to-charge ratio with some exceptions I FY 2015-16 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FY 2015-16 Wage Index Value (adjusted for CA Neutrality Factor 09797) W age index value times 09797 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls for changes between California
and the rest of the US while maintaining relative differences among wage areas within California K FY 2015-16 Unadjusted Statewide Base Rate The statewide DRG base rate is $6289 except that for remote rural hospitals it is $12768 L FY 2015-16 Wage Adjusted Statewide Base Rate (Non-Transition) The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses See Tab 5 This rate is applicable for non-transition hospitals as shown in Column N Medi-Cal
managed care plans that are pricing claims for emergency and post-stabilization services hospitals outside their network should use Column L for all hospitals M FY 2015-16 Hospital-Specific Transition Base Rate The base rate assigned to hospitals to move them in steps toward the statewide base rate This rate is applicable for transition hospitals as shown in Column N FY 2015-16 is the final year of transition rates N Transition rate This column identifies whether the hospital is a non-transition hospital (base rate in Column L) or a transition hospital (base rate in Column M) O FY 2015-16 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2015-16 P FY 2015-16 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by
use of Revenue Code 190 Q FY 2015-16 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by use of
Revenue Code 199
A B C D E F G H I J K L M N O P Q
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transit on Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
OUT OF STATE No No No No No 2180 10000 10000 $6289 $6289 NA Non-Transition NA $98163 $80582 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 3572 12882 12620 $12768 $15097 $15414 Transition NA $98163 $80582 106100793 ADVENTIST MEDICAL CENTER - SELMA COMMUNITY HOSPITAL No No No Yes Yes 3572 12882 12620 $12768 $15097 $14680 Transition NA $98163 $80582 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 4360 12882 12620 $12768 $15097 $10484 Transition NA $98163 $80582 106301098 AHMC ANAHEIM REG MED CTR No No No No No 1656 12882 12620 $6289 $7436 $15144 Transition NA $98163 $80582 106010846 ALAMEDA CO MED CTR Yes No No No No 4036 16962 16618 $6289 $9186 NA NA NA NA NA 106010735 ALAMEDA HOSP No Yes No No No 2600 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106190017 ALHAMBRA HOSP No No No No No 1397 12882 12620 $6289 $7436 $5446 Transition $1220 $98163 $80582 106010739 ALTA BATES SUMMIT MED CTR-ALTA BATES No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106010937 ALTA BATES SUMMIT MED CTR-HAWTHORNE No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106010844 ALTA BATES SUMMIT MED CTR-HERRICK CAMPUS No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106013626 ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106374063 ALVARADO HOSP MED CTR - REHAB No No No No No 1930 12882 12620 $6289 $7436 $4599 Transition $1220 $98163 $80582 106190034 ANTELOPE VALLEY HOSP MED CTR No Yes No No No 2997 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364231 ARROWHEAD REG MED CTR Yes No No No No 3324 12882 12620 $6289 $7436 NA NA NA NA NA 106400466 ARROYO GRANDE COMM HOSP No No No No No 2581 12964 12701 $6289 $7471 NA Non-Transition $1226 $98163 $80582 106154101 BAKERSFIELD HEART HOSP No No No No No 1782 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150722 BAKERSFIELD MEM HOSP-34TH ST No No No No No 2117 12882 12620 $6289 $7436 $9141 Transition NA $98163 $80582 106364121 BALLARD REHABILITATION HOSP No No No No No 8300 12882 12620 NA NA NA NA $1427 $98163 $80582 106184008 BANNER LASSEN MED CTR No No No Yes Yes 3967 12882 12620 $12768 $15097 $18668 Transition NA $98163 $80582 106190052 BARLOW RESP HOSP No No No No No 1849 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364430 BARSTOW COMM HOSP No No No Yes Yes 2262 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090793 BARTON MEM HOSP No No No Yes Yes 3635 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106361110 BEAR VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190081 BEVERLY HOSP No No No No No 3567 12882 12620 $6289 $7436 $5841 Transition NA $98163 $80582 106040802 BIGGS GRIDLEY MEM HOSP No No No Yes Yes 3652 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106380929 CA PACIFIC MED CTR No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380777 CA PACIFIC MED CTR - CALIFORNIA WEST No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380933 CA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 2873 16738 16398 $6289 $9090 NA Non-Transition $1492 $98163 $80582 106190125 CALIFORNIA HOSP MED CTR-LA No No Yes No No 2078 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190137 CASA COLINA HOSP FOR REHAB MED No No No No No 7213 12882 12620 NA NA NA NA $1220 $98163 $80582 106190045 CATALINA ISLAND MED CTR No No No Yes Yes 9000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190555 CEDARS-SINAI MED CTR No No Yes No No 2051 12882 12620 $6289 $7436 $5837 Transition $1220 $98163 $80582 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 1730 12882 12620 $6289 $7436 $6350 Transition $1220 $98163 $80582 106160787 CENTRAL VALLEY GEN HOSP No No No No No 7778 12882 12620 $6289 $7436 $11888 Transition NA $98163 $80582 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 2190 12892 12630 $6289 $7440 NA Non-Transition $1221 $98163 $80582 106301140 CHAPMAN MED CTR No No No No No 1908 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304113 CHILDRENS HOSP AT MISSION No No No No No 3300 12882 12620 $6289 $7436 $18777 Transition NA $98163 $80582 106204019 CHILDRENS HOSP CENTRAL CALIFORNIA No No Yes No No 2430 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106010776 CHILDRENS HOSP OAKLAND No No Yes No No 3356 16478 16143 $6289 $8978 NA Non-Transition $2628 $98163 $80582 106190170 CHILDRENS HOSP OF LA No No Yes No No 3988 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106300032 CHILDRENS HOSP OF ORANGE CO No No Yes No No 2442 12882 12620 $6289 $7436 $5613 Transition NA $98163 $80582 106382715 CHINESE HOSP No No No No No 3835 16738 16398 $6289 $9090 $8053 Transition NA $98163 $80582 106361144 CHINO VALLEY MED CTR No No No No No 2098 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190176 CITY OF HOPE HELFORD CLINIC RES HOSP No No No No No 2789 12882 12620 $6289 $7436 $5941 Transition NA $98163 $80582 106100005 CLOVIS COMM MED CTR No No No No No 3336 12882 12620 $6289 $7436 $7752 Transition NA $98163 $80582 106100697 COALINGA REG MED CTR No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190766 COAST PLAZA DRS HOSP No No No No No 2126 12882 12620 $6289 $7436 $5303 Transition NA $98163 $80582 106301258 COASTAL COMM HOSP No No No No No 2792 12882 12620 $6289 $7436 $7035 Transition NA $98163 $80496 106301155 COLLEGE HOSP COSTA MESA No No No No No 2876 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190587 COLLEGE MEDICAL CENTER No No No No No 3760 12882 12620 $6289 $7436 $4258 Transition NA $98163 $80582 106361458 COLORADO RIVER MED CTR No No No Yes Yes 4357 12882 12620 $12768 $15097 $18541 Transition NA $98163 $80582 106060870 COLUSA REG MED CTR No No No Yes Yes 3066 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190197 COMM AND MISSION HOSP OF HUNT PK No No No No No 1601 12882 12620 $6289 $7436 $5421 Transition NA $98163 $80582 106190475 COMM HOSP OF LONG BEACH No No No No No 1707 12882 12620 $6289 $7436 $15917 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106361323 COMM HOSP OF SAN BERNARDINO No No No No No 2833 12882 12620 $6289 $7436 $6516 Transition NA $98163 $78406 106560473 COMM MEM HOSP OF SAN BUENAVENTURA No No No No No 2104 12882 12620 $6289 $7436 $4512 Transition NA $98163 $80582 106100717 COMM REG MED CTR-FRESNO No No No No No 1896 12882 12620 $6289 $7436 $7994 Transition $1655 $98163 $80582 106070924 CONTRA COSTA REG MED CTR Yes No No No No 6010 16478 16143 $6289 $8978 NA NA NA NA NA 106331152 CORONA REG MED CTR No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition NA $98163 $80582 106331145 CORONA REG MED CTR - MAGNOLIA No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition $1220 $98163 $80582 106190413 CV-INTERCOMMUNITY CAMPUS No No No No No 3136 12882 12620 $6289 $7436 $6821 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106190636 CV-QUEEN OF VALLEY CAMPUS No No Yes No No 3136 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106150706 DELANO REG MED CTR No No No No No 3622 12882 12620 $6289 $7436 $7087 Transition NA $98163 $80582 106331164 DESERT REG MED CTR No No No No No 1486 12882 12620 $6289 $7436 $7153 Transition $1447 $98163 $80582 106364144 DESERT VALLEY HOSP No No No No No 2050 12882 12620 $6289 $7436 $8173 Transition NA $98163 $80582 106440755 DOMINICAN HOSP-SANTA CRUZ No No No No No 2016 17239 16889 $6289 $9304 $7821 Transition $1527 $98163 $80582 106190243 DOWNEY REG MED CTR No No No No No 1732 12882 12620 $6289 $7436 $6847 Transition NA $98163 $80582 106392287 DRS HOSP OF MANTECA No No No No No 1362 13579 13303 $6289 $7735 $11712 Transition NA $98163 $80582 106390846 DAMERON HOSP No No No No No 2138 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106190857 DRS HOSP OF WEST COVINA No No No No No 1833 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106070904 DRS MED CTR-SAN PABLOPINOLE No Yes No No No 2373 16478 16143 $6289 $8978 $6025 Transition NA $98163 $80582 106190256 EAST LA DRS HOSP No No No No No 1952 12882 12620 $6289 $7436 $5809 Transition NA $98163 $80582 106190328 EAST VALLEY HOSP MED CTR No No No No No 2859 12882 12620 $6289 $7436 $5534 Transition NA $98163 $80582 106320859 EASTERN PLUMAS HOSP No Yes No Yes Yes 4802 12882 12620 $12768 $15097 $13674 Transition NA $98163 $80582 106014233 EDEN MED CTR No No No No No 3197 16962 16618 $6289 $9186 $12768 Transition NA $98163 $80582 106331168 EISENHOWER MEM HOSP No No No No No 1540 12882 12620 $6289 $7436 $10211 Transition NA $98163 $80582 106430763 EL CAMINO HOSP No Yes No No No 2857 17180 16831 $6289 $9279 $5377 Transition $1523 $98163 $80582 106130699 EL CENTRO COMM HOSP No Yes No No No 2298 12882 12620 $6289 $7436 $8949 Transition NA $98163 $80582 106500852 DRS MED CTR No No No No No 1181 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106500867 EMANUEL MED CTR No No No No No 2046 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106040962 ENLOE MED CTR No No No No No 2436 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106044011 ENLOE REHABILLITATION CENTER No No No No No 2463 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106474007 FAIRCHILD MED CTR No No No Yes Yes 3914 12882 12620 $12768 $15097 $16385 Transition NA $98163 $80582 106040875 FEATHER RIVER HOSP No No No No No 1240 12882 12620 $6289 $7436 $10796 Transition NA $98163 $80582 106190298 FOOTHILL PRES HOSP No No No No No 2989 12882 12620 $6289 $7436 $4740 Transition NA $98163 $80582 106301175 FOUNTAIN VALLEY REG HOSP-EUCLID No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106304039 FOUNTAIN VALLEY REG HOSP-WARNER No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106230949 FRANK R HOWARD MEM HOSP No No No Yes Yes 3495 12882 12620 $12768 $15097 $15377 Transition NA $98163 $80582 106510882 FREMONT MEDICAL CENTER No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106190280 ENCINO HOSP MED CTR No No No No No 949 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106400480 FRENCH HOSP MED CTR No No No No No 2241 12964 12701 $6289 $7471 NA Non-Transition NA $98163 $80582 106301283 GARDEN GROVE HOSP AND MED CTR No No No No No 2661 12882 12620 $6289 $7436 $5749 Transition NA $98163 $80582 106190159 GARDEN REG HOSP AND MED CTR No No No No No 2937 12882 12620 $6289 $7436 $4110 Transition NA $98163 $80582 106105029 FRESNO HEART HOSP No No No No No 3403 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106270777 GEORGE L MEE MEM HOSP No No No Yes Yes 3562 15558 15242 $12768 $17426 $20386 Transition NA $98163 $80582 106190315 GARFIELD MED CTR No No No No No 1031 12882 12620 $6289 $7436 NA Non-Transition $1394 $98163 $80582 106190522 GLENDALE MEM HOSP AND HLTH CTR No No No No No 2163 12882 12620 $6289 $7436 $6885 Transition $1220 $98163 $80582 106110889 GLENN MED CTR No No No Yes Yes 6660 12882 12620 $12768 $15097 $21024 Transition NA $98163 $80582 106190323 GLENDALE ADV MED CTR-WILSON TERRACE No No No No No 1845 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420483 GOLETA VALLEY COTTAGE HOSP No No No No No 3083 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150775 GOOD SAMARITAN HOSP-BAKERSFIELD No No No No No 3694 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430779 GOOD SAMARITAN HOSP-SAN JOSE No No Yes No No 1937 17180 16831 $6289 $9279 $5654 Transition NA $98163 $80582 106190352 GREATER EL MONTE COMM HOSP No No No No No 1088 12882 12620 $6289 $7436 $4818 Transition NA $98163 $80582 106370714 GROSSMONT HOSP No No No No No 1937 12882 12620 $6289 $7436 $6498 Transition $1220 $98163 $80582
i-
i
i
i-
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190392 GOOD SAMARITAN HOSP-LA No No Yes No No 2006 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106350784 HAZEL HAWKINS MEM HOSP No Yes No Yes Yes 3840 17180 16831 $12768 $18839 NA Non-Transition NA $98163 $80582 106490964 HEALDSBURG DIST HOSP No Yes No Yes Yes 6549 16188 15859 $12768 $17975 NA Non-Transition NA $98163 $80582 106154022 HEALTHSOUTH BAKERSFIELD REHAB HOSP No No No No No 5040 12882 12620 NA NA NA NA $1382 $98163 $80582 106304079 HEALTHSOUTH TUSTIN REHAB HOSP No No No No No 5281 12882 12620 NA NA NA NA $1220 $98163 $80582 106331194 HEMET VALLEY MED CTR No No No No No 1267 12882 12620 $6289 $7436 $5912 Transition NA $98163 $80582 106190949 HENRY MAYO NEWHALL MEM HOSP No No No No No 1839 12882 12620 $6289 $7436 $5631 Transition $1220 $98163 $80582 106362041 HI-DESERT MED CTR No Yes No Yes Yes 2909 12882 12620 $12768 $15097 $13297 Transition NA $98163 $80582 106301205 HOAG MEM HOSP PRESBYTERIAN No No No No No 4825 12882 12620 $6289 $7436 $13525 Transition NA $98163 $80582 106304159 HEALTHBRIDGE CHILDRENS HOSP-ORANGE No No No No No 3271 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106190380 HOLLYWOOD COMM HOSP OF HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106304460 HOAG ORTHOPEDIC No No No No No 4894 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190382 HOLLYWOOD PRES MED CTR No No No No No 2212 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301209 HUNTINGTON BEACH HOSP No No No No No 2175 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190400 HUNTINGTON MEM HOSP No No Yes No No 2294 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106304045 IRVINE REG HOSP AND MED CTR No No No No No 200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106220733 JOHN C FREMONT HCARE DIST No Yes No Yes Yes 3884 12882 12620 $12768 $15097 $8195 Transition NA $98163 $80582 106331216 JOHN F KENNEDY MEM HOSP No No No No No 1679 12882 12620 $6289 $7436 $6464 Transition NA $98163 $80582 106071018 JOHN MUIR MED CTR-CONCORD CAMPUS No No No No No 1748 16478 16143 $6289 $8978 $12804 Transition NA $98163 $80582 106070988 JOHN MUIR MED CTR-WALNUT CREEK CAMPUS No No No No No 2039 16478 16143 $6289 $8978 $10615 Transition $1473 $98163 $80582 106314024 KAISER HOSPITAL - ROSEVILLE No No Yes No No 7912 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106364265 KAISER ONTARIO MEDICAL CENTER CAMPUS No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106121031 JEROLD PHELPS COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301132 KAISER-ANAHEIM No No Yes No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304306 KAISER-ANAHEIM-IRVINE No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304409 KAISER-ANAHEIM-Orange No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106074097 KAISER-ANTIOCH No No No No No 8503 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106196403 KAISER-DOWNEY No No No No No 10000 12882 12620 $6289 $7436 $12698 Transition NA $98163 $80582 106361223 KAISER-FONTANA No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106014132 KAISER-FREMONT No No No No No 10000 16962 16618 $6289 $9186 $9639 Transition NA $98163 $80582 106196035 KAISER-BALDWIN PARK No No No No No 8009 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106104062 KAISER-FRESNO No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190429 KAISER-LOS ANGELES No No No No No 7387 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106394009 KAISER-MANTECA No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106334048 KAISER-MORENO VALLEY No No No No No 6614 12882 12620 $6289 $7436 $4790 Transition NA $98163 $80582 106010856 KAISER-OAKLANDRICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106190432 KAISER-PANORAMA CITY No No No No No 8239 12882 12620 $6289 $7436 $16025 Transition NA $98163 $80582 106504042 KAISER-MODESTO No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106410804 KAISER-REDWOOD CITY No No No No No 7731 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106074093 KAISER-RICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106480989 KAISER-REHAB CENTER VALLEJO No No No No No 8442 16315 15984 $6289 $8908 NA Non-Transition $2535 $98163 $80582 106340913 KAISER-SACRAMENTO No No No No No 5612 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106334025 KAISER-RIVERSIDE No No No No No 5865 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370730 KAISER-SAN DIEGO No No No No No 7393 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106380857 KAISER-SAN FRANCISCO No No No No No 5960 16738 16398 $6289 $9090 NA Non-Transition NA $98163 $80582 106431506 KAISER-SAN JOSE No No No No No 7002 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106014337 KAISER-SAN LEANDRO No No No No No 2180 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106210992 KAISER-SAN RAFAEL No No No No No 4673 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106494019 KAISER-SANTA ROSA No No No No No 10000 16315 15984 $6289 $8908 $17627 Transition NA $98163 $80582 106434153 KAISER-SANTA CLARA No No No No No 6107 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106190431 KAISER-SOUTH BAY No No No No No 6935 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106342344 KAISER-SOUTH SACRAMENTO No No No No No 5670 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106410806 KAISER-SOUTH SF No No No No No 6503 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106484044 KAISER-VACAVILLE No No No No No 10000 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106070990 KAISER-WALNUT CREEK No No No No No 5680 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106190434 KAISER-WEST LA No No No No No 6623 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106194219 KECK HOSPITAL OF USC No No No No No 2004 12882 12620 $6289 $7436 $4699 Transition $1220 $98163 $80582 106210993 KENTFIELD REHAB HOSP No No No No No 5967 16855 16513 $6289 $9140 $19338 Transition $1500 $98163 $80582 106150736 KERN MED CTR Yes No No No No 3943 12882 12620 $6289 $7436 NA NA NA NA NA 106150737 KERN VALLEY HEALTHCARE DIST No Yes No Yes Yes 2786 12882 12620 $12768 $15097 $8298 Transition NA $98163 $80582 106191450 KAISER-WOODLAND HILLS No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190049 KINDRED HOSPITAL BALDWIN PARK No No No No No 1810 12882 12620 $6289 $7436 $10784 Transition NA $98163 $80582 106190305 KINDRED LA No No No No No 2044 12882 12620 $6289 $7436 $4255 Transition NA $98163 $80582 106301127 KINDRED BREA No No No No No 2852 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361274 KINDRED ONTARIO No No No No No 2068 12882 12620 $6289 $7436 $9314 Transition NA $98163 $80582 106364188 KINDRED RANCHO No No No No No 1980 12882 12620 $6289 $7436 $20628 Transition NA $98163 $80582 106332172 KINDRED RIVERSIDE No No No No No 1805 12882 12620 $6289 $7436 $24450 Transition NA $98163 $80582 106190449 KINDRED LA MIRADA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106370721 KINDRED SAN DIEGO No No No No No 3605 12882 12620 $6289 $7436 $5657 Transition NA $98163 $80582 106344035 KINDRED SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190458 KINDRED SAN GABRIEL VALLEY No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106010887 KINDRED SF BAY AREA No No No No No 3007 16478 16143 $6289 $8978 $6378 Transition NA $98163 $80582 106301167 KINDRED SANTA ANA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190196 KINDRED SOUTH BAY No No No No No 2144 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301380 KINDRED WESTMINSTER No No No No No 2286 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301234 LA PALMA INTERCOMMUNITY HOSP No No No No No 2290 12882 12620 $6289 $7436 $7160 Transition NA $98163 $80582 106191227 LAC-HARBOR-UCLA MED CTR Yes No Yes No No 3366 12882 12620 $6289 $7436 NA NA NA NA NA 106191231 LAC-OLIVE VIEW-UCLA MED CTR Yes No No No No 4136 12882 12620 $6289 $7436 NA NA NA NA NA 106191228 LAC-USC MED CTR Yes No Yes No No 4522 12882 12620 $6289 $7436 NA NA NA NA NA 106380865 LAGUNA HONDA HOSP AND REHAB CTR Yes No No No No 5843 16738 16398 $6289 $9090 NA NA NA NA NA 106190240 LAKEWOOD REG MED CTR No No No No No 1504 12882 12620 $6289 $7436 $4008 Transition $1220 $98163 $80582 106390923 LODI MEM HOSP No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106390922 LODI MEM HOSP - WEST No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106334589 LOMA LINDA MURRIETTA No No No No No 3222 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106364268 LOMA LINDA UNIV HEART AND SURGICAL HOSPITAL No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361245 LOMA LINDA UNIV MED CTR - EAST CAMPUS No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361246 LOMA LINDA UNIV MED CTR No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $1491 $98163 $80582 106364502 LOMA LINDA UNIV CHILDRENS HOSP No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $2177 $98163 $80582 106190198 LA COMM HOSP No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420491 LOMPOC VALLEY MED CTR No Yes No Yes Yes 8693 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301248 LOS ALAMITOS MED CTR No No No No No 1915 12882 12620 $6289 $7436 $4697 Transition NA $98163 $80582 106560492 LOS ROBLES HOSP AND MED CTR No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106564018 LOS ROBLES HOSP AND MED CTR-EAST CAMPUS No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106434040 LSP CHILDRENS HOSP AT STANFORD No No Yes No No 2035 17180 16831 $6289 $9279 $6102 Transition NA $98163 $80582 106121002 MAD RIVER COMM HOSP No No No No No 4250 12882 12620 $6289 $7436 $9505 Transition NA $98163 $80582 106201281 MADERA COMMUNITY HOSPITAL No No No No No 5100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106260011 MAMMOTH HOSP No Yes No Yes Yes 7982 12882 12620 $12768 $15097 $46994 Transition NA $98163 $80582 106420493 MARIAN MED CTR No No No No No 2741 12882 12620 $6289 $7436 $9386 Transition NA $98163 $80582 106190525 LONG BEACH MEM MED CTR No No No No No 1996 12882 12620 $6289 $7436 NA Non-Transition $1627 $98163 $80582 106211006 MARIN GEN HOSP No Yes No No No 2571 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106190500 MARINA DEL RAY HOSPITAL No No No No No 2034 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106050932 MARK TWAIN ST JOSEPHS HOSP No No No Yes Yes 3707 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090933 MARSHALL MED CTR No No No Yes Yes 2107 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106500939 MEM HOSP MED CTR-MODESTO No No No No No 2235 12892 12630 $6289 $7440 $5898 Transition NA $98163 $80582 106240924 MEMORIAL HOSP LOS BANOS No No No Yes Yes 3362 12882 12620 $12768 $15097 $17450 Transition NA $98163 $80582 106190521 MEMORIAL HOSP OF GARDENA No No No No No 1747 12882 12620 $6289 $7436 $4611 Transition NA $98163 $80582 106231013 MENDOCINO COAST DIST HOSP No Yes No Yes Yes 5070 12882 12620 $12768 $15097 $15935 Transition NA $98163 $80582 106334018 MENIFEE VALLEY MED CTR No No No No No 1458 12882 12620 $6289 $7436 $5113 Transition NA $98163 $80582 106450936 MAYERS MEM HOSP No Yes No Yes Yes 7192 14188 13900 $12768 $16234 NA Non-Transition NA $98163 $80582 106340947 MERCY GEN HOSP No No No No No 2185 15256 14946 $6289 $8454 $6027 Transition $1387 $98163 $80582 106344029 MERCY HOSP OF FOLSOM No No No No No 2746 15256 14946 $6289 $8454 $5260 Transition NA $98163 $80582 106150761 MERCY HOSP-BAKERSFIELD No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106414018 MENLO PARK SURGICAL HOSP No No No No No 2770 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106240942 MERCY MED CTR MERCED No No No No No 2289 13279 13009 $6289 $7606 NA Non-Transition NA $98163 $80582 106450949 MERCY MED CTR-REDDING No No No No No 2589 14188 13900 $6289 $7996 $10219 Transition NA $98163 $80582 106470871 MERCY MED CTR-MT SHASTA No No No Yes Yes 6242 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106340950 MERCY SAN JUAN HOSP No No No No No 2166 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190529 METHODIST HOSP OF SO CAL No No No No No 1842 12882 12620 $6289 $7436 $6690 Transition $1220 $98163 $80582 106196168 MILLER CHILDRENS HOSP No No Yes No No 2680 12882 12620 $6289 $7436 $8155 Transition NA $98163 $80582 106410742 MILLS HEALTH CENTER No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106410852 MILLS-PENINSULA No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106340951 METHODIST HOSP OF SACRAMENTO No No No No No 2028 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190524 MISSION COMM HOSP-PANORAMA CAMPUS No No No No No 3568 12882 12620 $6289 $7436 $3982 Transition NA $98163 $80582 106190681 MIRACLE MILE No No No No No 100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301262 MISSION HOSP REG MED CTR No No No No No 4091 12882 12620 $6289 $7436 $14336 Transition $1220 $98163 $80582 106250956 MODOC MED CTR No Yes No Yes Yes 4961 12882 12620 $12768 $15097 $13486 Transition NA $98163 $80582 106301337 MISSION HOSP LAGUNA BEACH No No No No No 4091 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106361166 MONTCLAIR HOSP MED CTR No No No No No 3149 12882 12620 $6289 $7436 $5904 Transition NA $98163 $80582 106190547 MONTEREY PARK HOSP No No No No No 1034 12882 12620 $6289 $7436 $5866 Transition NA $98163 $80582 106361266 MOUNTAINS COMM HOSP No Yes No Yes Yes 5148 12882 12620 $12768 $15097 $15642 Transition NA $98163 $80582 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106481357 NORTH BAY MEDICAL CENTER No No No No No 1972 16315 15984 $6289 $8908 $15945 Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190541 MONROVIA MEM HOSP No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106141273 NORTHERN INYO HOSP No Yes No Yes Yes 8150 12882 12620 $12768 $15097 $27752 Transition NA $98163 $80582 106484001 NORTH BAY VACAVALLEY HOSP No No No No No 1972 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106190568 NORTHRIDGE HOSP MED CTR No No No No No 1596 12882 12620 $6289 $7436 NA Non-Transition $1662 $98163 $80582 106214034 NOVATO COMM HOSP No No No No No 3465 16855 16513 $6289 $9140 $6359 Transition NA $98163 $80582 106500967 OAK VALLEY DIST HOSP No Yes No Yes No 3340 12892 12630 $6289 $7440 $5201 Transition NA $98163 $80582 106430837 OCONNOR HOSP-SAN JOSE No No No No No 2409 17180 16831 $6289 $9279 $5201 Transition NA $98163 $80582 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190534 OLYMPIA MED CTR No No No No No 1260 12882 12620 $6289 $7436 $6786 Transition NA $98163 $80582 106300225 ORANGE COAST MEM MED CTR No No No No No 2293 12882 12620 $6289 $7436 $19985 Transition NA $98163 $80582 106040937 OROVILLE HOSP No No No No No 1803 12882 12620 $6289 $7436 $6229 Transition NA $98163 $80582 106560501 OJAI VALLEY COMM HOSP No No No Yes Yes 2745 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190696 PACIFICA HOSP OF THE VALLEY No No No No No 3338 12882 12620 $6289 $7436 $5616 Transition NA $98163 $80582 106491338 PALM DRIVE HOSP No Yes No Yes No 4315 16315 15984 $6289 $8908 $11457 Transition NA $98163 $80582 106196405 PALMDALE REGIONAL MEDICAL CTR No No No No No 1190 12882 12620 $6289 $7436 $7504 Transition $1220 $98163 $80582 106331288 PALO VERDE HOSP No Yes No Yes Yes 4770 12882 12620 $12768 $15097 $18188 Transition NA $98163 $80582 106370755 PALOMAR MED CTR No Yes No No No 2429 12882 12620 $6289 $7436 $7051 Transition $1220 $98163 $80582 106370759 PARADISE VALLEY HOSP No No No No No 2188 12882 12620 $6289 $7436 $4275 Transition $1220 $98163 $80582 106190307 PACIFIC ALLIANCE MED CTR No No No No No 4299 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106331293 PARKVIEW COMM HOSP MED CTR No No No No No 2757 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106491001 PETALUMA VALLEY HOSP No No No No No 2271 16315 15984 $6289 $8908 $13491 Transition NA $98163 $80582 106130760 PIONEERS MEM HOSP No Yes No Yes No 2989 12882 12620 $6289 $7436 $9825 Transition NA $98163 $80582 106454013 PATIENTS HOSP OF REDDING No No No No No 2172 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106301297 PLACENTIA LINDA HOSP No No No No No 1606 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370977 POMERADO HOSP No Yes No No No 3063 12882 12620 $6289 $7436 $6818 Transition NA $98163 $80582 106320986 PLUMAS DIST HOSP No Yes No Yes Yes 8666 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190631 PRESBYTERIAN INTERCOMM HOSP No No No No No 961 12882 12620 $6289 $7436 $9720 Transition $1220 $98163 $80582 106190630 POMONA VALLEY HOSP MED CTR No No Yes No No 1538 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190468 PROMISE HOSP OF EAST LA-EAST LA No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190599 PROMISE HOSP OF EAST LA-EAST LA-SUBURBAN CAMPUS No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190385 PROVIDENCE HOLY CROSS MED CTR No No No No No 1325 12882 12620 $6289 $7436 $6284 Transition $1220 $98163 $80582 106190680 PROVIDENCE LITTLE CO OF MARY-SAN PEDRO No No No No No 1533 12882 12620 $6289 $7436 $6225 Transition $1220 $98163 $80582 106190470 PROVIDENCE LITTLE CO OF MARY-TORRANCE No No No No No 1767 12882 12620 $6289 $7436 $7182 Transition NA $98163 $80582 106190758 PROVIDENCE ST JOSEPH MED CTR No No No No No 1866 12882 12620 $6289 $7436 $7141 Transition $1220 $98163 $80582 106370787 PROMISE HOSP OF SAN DIEGO No No No No No 3660 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106281047 QUEEN OF THE VALLEY HOSP-NAPA No No No No No 2829 16188 15859 $6289 $8854 $17592 Transition $1453 $98163 $80582 106370673 RADY CHILDRENS HOSPITAL - SAN DIEGO No No Yes No No 2854 12882 12620 $6289 $7436 $6395 Transition $2177 $98163 $80582 106190517 PROVIDENCE TARZANA MED CTR No No Yes No No 1536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361308 REDLANDS COMM HOSP No No No No No 2079 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430705 REG MED CTR OF SAN JOSE No No No No No 2529 17180 16831 $6289 $9279 $13299 Transition NA $98163 $80582 106580996 RIDEOUT MEM HOSP No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106121051 REDWOOD MEM HOSP No No No Yes Yes 3214 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106334487 RIVERSIDE CO REG MED CTR Yes No No No No 2987 12882 12620 $6289 $7436 NA NA NA NA NA 106331312 RIVERSIDE COMM HOSP No No No No No 1560 12882 12620 $6289 $7436 $5990 Transition NA $98163 $80582 106190796 RONALD REAGAN UCLA MED CTR Yes No Yes No No 3382 12882 12620 $6289 $7436 NA NA NA NA NA 106301317 SADDLEBACK MEM MED CTR No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106301325 SADDLEBACK MEM MED CTR-SAN CLEMENTE No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106150782 RIDGECREST REG HOSP No No No Yes Yes 4178 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106361318 SAN ANTONIO COMM HOSP No No No No No 2262 12882 12620 $6289 $7436 $9216 Transition NA $98163 $80582 106190673 SAN DIMAS COMM HOSP No No No No No 2465 12882 12620 $6289 $7436 $12177 Transition NA $98163 $80582 106190200 SAN GABRIEL VALLEY MED CTR No No No No No 969 12882 12620 $6289 $7436 $6918 Transition NA $98163 $80582 106270875 SALINAS VALLEY MEM HOSP No Yes No No No 3534 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106331326 SAN GORGONIO MEM HOSP No Yes No Yes Yes 3394 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391010 SAN JOAQUIN GEN HOSP Yes No No No No 1922 13579 13303 $6289 $7735 NA NA NA NA NA 106104023 SAN JOAQUIN VALLEY REHAB HOSP No No No No No 6479 12882 12620 NA NA NA NA $1413 $98163 $80582 106013619 SAN LEANDRO HOSP No Yes No No No 3482 16501 16166 $6289 $8988 $10813 Transition NA $98163 $80582 106410782 SAN MATEO MED CTR Yes No No No No 7168 16928 16584 $6289 $9171 NA NA NA NA NA 106074017 SAN RAMON REG MED CTR No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106074011 SAN RAMON REG MED CTR SOUTH BUILDING No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106420514 SANTA BARBARA COTTAGE HOSP No No Yes No No 3902 12882 12620 $6289 $7436 $10978 Transition $2125 $98163 $80582 106430883 SANTA CLARA VALLEY MED CTR Yes No Yes No No 3133 17180 16831 $6289 $9279 NA NA NA NA NA 106190687 SANTA MONICA - UCLA MEDICAL CENTER Yes No No No No 3102 12882 12620 $6289 $7436 NA NA NA NA NA 106491064 SANTA ROSA MEM HOSP-MONTGOMERY No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106490907 SANTA ROSA MEM HOSP-SOTOYOME No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106150788 SAN JOAQUIN COMM HOSP No No No No No 2544 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420522 SANTA YNEZ VALLEY COTTAGE HOSP No No No Yes Yes 7569 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106371394 SCRIPPS MEM HOSP-ENCINITAS No No No No No 2403 12882 12620 $6289 $7436 $7037 Transition $1439 $98163 $80582 106370771 SCRIPPS MEM HOSP-LA JOLLA No No No No No 2061 12882 12620 $6289 $7436 $4390 Transition NA $98163 $80582 106370744 SCRIPPS MERCY HOSP No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106370658 SCRIPPS MERCY HOSP-CHULA VISTA No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106371256 SCRIPPS GREEN HOSP No No No No No 2317 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106321016 SENECA HCARE DIST No Yes No Yes Yes 4586 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106410817 SETON MED CTR No No No No No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106410828 SETON MED CTR-COASTSIDE No No No Yes No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106380939 SF GENERAL HOSP Yes No No No No 2851 16738 16398 $6289 $9090 NA NA NA NA NA 106370875 SHARP CHULA VISTA MED CTR No No No No No 1932 12882 12620 $6289 $7436 $6485 Transition NA $98163 $80582 106410891 SEQUOIA HOSP No No No No No 1975 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106370689 SHARP CORONADO HOSP AND HCARE CTR No No No No No 2160 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $72421 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106370694 SHARP MEM HOSP No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106450940 SHASTA REG MED CTR No No No No No 1582 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106190708 SHERMAN OAKS HOSP No No No No No 1516 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190712 SHRINERS HOSPITAL- LA No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106344114 SHRINERS HOSPITAL- SACRAMENTO No No No No No 3869 15256 14946 $6289 $8454 NA Non-Transition $2475 $98163 $80582 106540798 SIERRA VIEW DIST HOSP No Yes No No No 2716 12882 12620 $6289 $7436 $8497 Transition NA $98163 $77682 106400524 SIERRA VIST REG MED CTR No No No No No 1787 12964 12701 $6289 $7471 $5495 Transition NA $98163 $80582 106190661 SILVER LAKE MED CTR No No No No No 3692 12882 12620 $6289 $7436 $5655 Transition NA $98163 $80582 106291023 SIERRA NEVADA MEM HOSP No No No Yes Yes 3427 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106491076 SONOMA VALLEY HOSP No Yes No No No 4960 16315 15984 $6289 $8908 $12733 Transition NA $98163 $80582 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 2126 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190380 SOUTHERN CA HOSP AT HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106190110 SOUTHERN CA HOSPITAL AT CULVER CITY No No No No No 1437 12882 12620 $6289 $7436 $4694 Transition $1220 $98163 $80582 106560525 SIMI VALLEY HOSP AND HCARE-SYCAMORE No No No No No 3840 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106334068 SOUTHWEST HCARE SYSTEM No No No No No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106334001 SOUTHWEST HCARE SYSTEM-WILDOMAR No No No Yes No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106100899 ST AGNES MED CTR No No No No No 3088 12882 12620 $6289 $7436 $7885 Transition NA $98163 $80582 106361339 ST BERNARDINE MED CTR No No No No No 2171 12882 12620 $6289 $7436 $6090 Transition NA $98163 $80582 106521041 ST ELIZABETH COMM HOSP No No No Yes Yes 3024 13869 13587 $12768 $15956 $14866 Transition NA $98163 $80582 106190754 ST FRANCIS MED CTR No No No No No 4350 12882 12620 $6289 $7436 $6368 Transition NA $98163 $80582 106380960 ST FRANCIS MEM HOSP No No No No No 1920 16738 16398 $6289 $9090 $5310 Transition $1492 $98163 $80582 106281078 ST HELENA HOSP No No No No No 2337 15887 15564 $6289 $8725 $9671 Transition NA $98163 $80582 106171049 ST HELENA HOSPITAL-CLEARLAKE No No No Yes Yes 4118 12882 12620 $12768 $15097 $18218 Transition NA $98163 $80582 106141338 SOUTHERN INYO HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190756 ST JOHNS HEALTH CTR No No No No No 2536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560529 ST JOHNS REG MED CTR No No No No No 2982 12882 12620 $6289 $7436 $6976 Transition $1761 $98163 $80582 106121080 ST JOSEPH HOSP-EUREKA No No No No No 2570 13869 13587 $6289 $7859 $9661 Transition $1507 $98163 $80582 106301340 ST JOSEPH HOSP-ORANGE No No No No No 2751 12882 12620 $6289 $7436 $5230 Transition NA $98163 $80582 106560508 ST JOHNS PLEASANT VALLEY HOSP No No No No No 2087 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301342 ST JUDE MED CTR No No No No No 1722 12882 12620 $6289 $7436 $5799 Transition $1220 $98163 $80582 106434138 ST LOUISE REG HOSP No No No No No 2838 17180 16831 $6289 $9279 $16407 Transition NA $98163 $80582 106380964 ST LUKES HOSP No No No No No 3807 16738 16398 $6289 $9090 $8600 Transition NA $98163 $80582 106361343 ST MARY MED CTR-APPLE VALLEY No No No Yes No 2511 12882 12620 $6289 $7436 $9863 Transition NA $98163 $80582 106391042 ST JOSEPHS MED CTR OF STOCKTON No No No No No 2152 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106380965 ST MARYS MED CTR-SF No No No No No 2007 16738 16398 $6289 $9090 $5116 Transition $1492 $98163 $80582 106010967 ST ROSE HOSP No No No No No 1931 16962 16618 $6289 $9186 $7600 Transition NA $98163 $80582 106190762 ST VINCENT MED CTR No No No No No 2020 12882 12620 $6289 $7436 $4684 Transition $1220 $98163 $80582 106430905 STANFORD HOSP No No No No No 1803 17180 16831 $6289 $9279 $5644 Transition $1523 $98163 $80582 106190053 ST MARY MED CTR-LONG BEACH No No No No No 2479 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106504038 STANISLAUS SURGICAL HOSP No No No No No 9000 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106250955 SURPRISE VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106310791 SUTTER AUBURN FAITH HOSP No No No No No 2551 15256 14946 $6289 $8454 $11882 Transition NA $98163 $80582 106034002 SUTTER AMADOR HOSP No No No Yes Yes 2971 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106574010 SUTTER DAVIS HOSP No No No No No 3568 15256 14946 $6289 $8454 $14330 Transition NA $98163 $80582 106070934 SUTTER DELTA MED CTR No No No No No 2907 16478 16143 $6289 $8978 $12158 Transition NA $98163 $80582 106341051 SUTTER GEN HOSP No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106171395 SUTTER LAKESIDE HOSP No No No Yes Yes 3691 12882 12620 $12768 $15097 $17232 Transition NA $98163 $80582 106444012 SUTTER MATERNITY AND SRG CTR OF S CRUZ No No No No No 7213 17239 16889 $6289 $9304 $21288 Transition NA $98163 $80582 106490919 SUTTER MED CTR OF SANTA ROSA No No No No No 3657 16315 15984 $6289 $8908 $15278 Transition NA $98163 $80582 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106311000 SUTTER ROSEVILLE MED CTR No No No No No 2377 15256 14946 $6289 $8454 $11395 Transition $1387 $98163 $80582 106481094 SUTTER SOLANO MED CTR No No No No No 3258 16315 15984 $6289 $8908 $18010 Transition NA $98163 $80582 106084001 SUTTER COAST HOSP No No No Yes Yes 3730 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391056 SUTTER TRACY COMM HOSP No No No No No 2714 13579 13303 $6289 $7735 $5995 Transition NA $98163 $80582 106291053 TAHOE FOREST HOSP No Yes No Yes Yes 4766 15256 14946 $12768 $17164 $21044 Transition NA $98163 $80582 106150808 TEHACHAPI HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 $22158 Transition NA $98163 $80582 106514030 SUTTER SURG HOSP-NORTH VALLEY No No No No No 3240 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106334564 TEMECULA VALLEY HOSPITAL No No No No No 2180 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106120981 THE GENERAL HOSPITAL No No No No No 2570 13869 13587 NA NA NA NA $1507 $98163 $80582 106564121 THOUSAND OAKS SURGICAL HOSPITAL No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106190422 TORRANCE MEM MED CTR No No No No No 1952 12882 12620 $6289 $7436 $5891 Transition NA $98163 $80582 106370780 TRI-CITY MED CTR No Yes No No No 3695 12882 12620 $6289 $7436 $7706 Transition $1220 $98163 $80582 106190784 TEMPLE COMM HOSP No No No No No 4200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540816 TULARE DIST HOSP No Yes No No No 3578 12882 12620 $6289 $7436 $9529 Transition NA $98163 $80582 106531059 TRINITY HOSP No Yes No Yes Yes 5105 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106400548 TWIN CITIES COMM HOSP No No No Yes Yes 1587 12964 12701 $12768 $15168 $8160 Transition NA $98163 $80582 106341006 UC DAVIS MED CTR Yes No Yes No No 1836 15256 14946 $6289 $8454 NA NA NA NA NA 106301279 UC IRVINE MED CTR Yes No Yes No No 2072 12882 12620 $6289 $7436 NA NA NA NA NA 106370782 UCSD MED CTR Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106374141 UCSD-LA JOLLA JOHN M amp SALLY B THORNTON HOSPITAL Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106381154 UCSF MED CTR Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106380895 UCSF MED CTR AT MOUNT ZION Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106301357 TUSTIN HOSP MED CTR No No No No No 231 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106231396 UKIAH VALLEY MED CTRHOSP DR No No No Yes Yes 3643 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106014050 VALLEY CARE MEDICAL CENTER No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106010983 VALLEY MEM HOSP-LIVERMORE No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106191216 USC KENNETH NORRIS JR CANCER HOSP No No No No No 3134 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560481 VENTURA CO MED CTR Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106560521 VENTURA CO MED CTR-SANTA PAULA HOSPITAL Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106190818 VERDUGO HILLS HOSP No No No No No 3110 12882 12620 $6289 $7436 $5264 Transition NA $98163 $80582 106190812 VALLEY PRES HOSP No No No No No 3536 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 3046 14188 13900 $6289 $7996 NA Non-Transition $1312 $98163 $80582 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 3266 12882 12620 $6289 $7436 $8320 Transition NA $98163 $80582 106010987 WASHINGTON HOSP-FREMONT No Yes No No No 1941 16962 16618 $6289 $9186 $6429 Transition NA $98163 $80582 106444013 WATSONVILLE COMM HOSP No No No No No 1780 17239 16889 $6289 $9304 $13456 Transition NA $98163 $80582 106301379 WEST ANAHEIM MED CTR No No No No No 1514 12882 12620 $6289 $7436 $4707 Transition NA $98163 $80582 106190859 WEST HILLS HOSP AND MED CTR No No No No No 1933 12882 12620 $6289 $7436 $8050 Transition NA $98163 $80582 106374094 VIBRA OF SAN DIEGO No No No No No 1155 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301188 WESTERN MED CTR-ANAHEIM No No No No No 3203 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301566 WESTERN MED CTR-SANTA ANA No No No No No 2354 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190878 WHITE MEM MED CTR No No No No No 1515 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190883 WHITTIER HOSP MED CTR No No No No No 1139 12882 12620 $6289 $7436 $5922 Transition NA $98163 $80582 106571086 WOODLAND MEM HOSP No No No No No 3278 15256 14946 $6289 $8454 $10092 Transition NA $98163 $80582 6102015
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
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Medi Cal DRG Table Effective July 1 2015
4 Casemix relative weights reflect Hospital-Specific Relative Value (HSRV) relative weights V32
9 This spreadsheet includes data obtained through the use of proprietary computer software created owned and licensed by the 3M Company All copyrights in and to the 3MTM Software are owned by 3M All rights reserved 3M has no responsibility for the contents of this calculator
3 Average length of stay is the untrimmed arithmetic value
5 For purposes of illustration the table uses a DRG base rate of $7500 In fact DRG base rates are hospital specific See the Hospital Characteristics tab Column L for non-transition hospitals and Column M for transition hospitals 6 Pediatric is defined as under age 21 7 This table shows information for 1258 DRGs (314 base DRGs each with four levels of severity plus two error DRGs) 8 Inclusion of a service in this list does not necessarily imply coverage by Medi-Cal Rehabilitation services (APR-DRG 860) are paid outside the DRG method
1 The DRG base payment equals the DRG base rate times the casemix relative weight times any applicable policy adjustors 2 Average length of stay and casemix relative weights were calculated from the Nationwide Inpatient Sample by 3M Health Information Systems for APR-DRG V32
10 This calculator was developed by Xerox the fiscal intermediary contractor for Medi-Cal
APR DRG APR DRG Descr pt on
Nat ona Average Length of Stay
Medicaid Care Category Pediatric
HSRV Casemix Relative We ght
Policy Adjustor NICU
Policy Adjustor Obstetric s
Payment Relative We ght No Age
Policy Adjustor Pediatric age
Payment Relative We ght w th Age
Policy Adjustor Service (Designat
Payment Relative We ght W th
DRG Base Payment Using Example Base Rate
Medicaid Care Category Adult
001-1 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 763 74839 10000 10000 74839 12500 93549 10000 74839 $70162 Misc Pediatric 001-2 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 857 75257 10000 10000 75257 12500 94071 10000 75257 $70553 Misc Pediatric 001-3 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 1251 88396 10000 10000 88396 12500 110495 10000 88396 $82871 Misc Pediatric 001-4 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 3157 153728 10000 10000 153728 12500 192160 10000 153728 $144120 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
002-1 HEART ampOR LUNG TRANSPLANT 936 81603 10000 10000 81603 12500 102004 10000 81603 $76503 Misc Pediatric 002-2 HEART ampOR LUNG TRANSPLANT 1470 96672 10000 10000 96672 12500 120840 10000 96672 $90630 Misc Pediatric 002-3 HEART ampOR LUNG TRANSPLANT 2153 120551 10000 10000 120551 12500 150689 10000 120551 $113017 Misc Pediatric 002-4 HEART ampOR LUNG TRANSPLANT 3671 180801 10000 10000 180801 12500 226001 10000 180801 $169501 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
003-1 BONE MARROW TRANSPLANT 1692 42402 10000 10000 42402 12500 53003 10000 42402 $39752 Misc Pediatric 003-2 BONE MARROW TRANSPLANT 2257 62664 10000 10000 62664 12500 78330 10000 62664 $58748 Misc Pediatric 003-3 BONE MARROW TRANSPLANT 3280 101363 10000 10000 101363 12500 126704 10000 101363 $95028 Misc Pediatric 003-4 BONE MARROW TRANSPLANT 5119 182162 10000 10000 182162 12500 227703 10000 182162 $170777 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
004-1 ECMO OR TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W EXTENSIVE PROCEDURE 2289 64917 10000 10000 64917 12500 81146 10000 64917 $60860 Misc Pediatric 004-2 ECMO OR TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W EXTENSIVE PROCEDURE 2059 67502 10000 10000 67502 12500 84378 10000 67502 $63283 Misc Pediatric 004-3 ECMO OR TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W EXTENSIVE PROCEDURE 2639 92480 10000 10000 92480 12500 115600 10000 92480 $86700 Misc Pediatric 004-4 ECMO OR TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION W EXTENSIVE PROCEDURE 3858 141600 10000 10000 141600 12500 177000 10000 141600 $132750 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
005-1 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION WO EXTENSIVE PROCEDURE 2774 49004 10000 10000 49004 12500 61255 10000 49004 $45941 Misc Pediatric 005-2 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION WO EXTENSIVE PROCEDURE 1947 52327 10000 10000 52327 12500 65409 10000 52327 $49057 Misc Pediatric 005-3 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION WO EXTENSIVE PROCEDURE 2393 67135 10000 10000 67135 12500 83919 10000 67135 $62939 Misc Pediatric 005-4 TRACHEOSTOMY W LONG TERM MECHANICAL VENTILATION WO EXTENSIVE PROCEDURE 3278 95918 10000 10000 95918 12500 119898 10000 95918 $89923 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
006-1 PANCREAS TRANSPLANT 590 75340 10000 10000 75340 12500 94175 10000 75340 $70631 Misc Pediatric 006-2 PANCREAS TRANSPLANT 812 84835 10000 10000 84835 12500 106044 10000 84835 $79533 Misc Pediatric 006-3 PANCREAS TRANSPLANT 1015 90984 10000 10000 90984 12500 113730 10000 90984 $85298 Misc Pediatric 006-4 PANCREAS TRANSPLANT 2470 139742 10000 10000 139742 12500 174678 10000 139742 $131008 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
020-1 CRANIOTOMY FOR TRAUMA 540 17475 10000 10000 17475 12500 21844 10000 17475 $16383 Misc Pediatric 020-2 CRANIOTOMY FOR TRAUMA 637 22987 10000 10000 22987 12500 28734 10000 22987 $21550 Misc Pediatric 020-3 CRANIOTOMY FOR TRAUMA 994 32365 10000 10000 32365 12500 40456 10000 32365 $30342 Misc Pediatric 020-4 CRANIOTOMY FOR TRAUMA 1688 57910 10000 10000 57910 12500 72388 10000 57910 $54291 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
021-1 CRANIOTOMY EXCEPT FOR TRAUMA 399 19469 10000 10000 19469 12500 24336 10000 19469 $18252 Misc Pediatric 021-2 CRANIOTOMY EXCEPT FOR TRAUMA 580 25682 10000 10000 25682 12500 32103 10000 25682 $24077 Misc Pediatric 021-3 CRANIOTOMY EXCEPT FOR TRAUMA 1037 37498 10000 10000 37498 12500 46873 10000 37498 $35154 Misc Pediatric 021-4 CRANIOTOMY EXCEPT FOR TRAUMA 1849 62981 10000 10000 62981 12500 78726 10000 62981 $59045 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
022-1 VENTRICULAR SHUNT PROCEDURES 280 11881 10000 10000 11881 12500 14851 10000 11881 $11138 Misc Pediatric 022-2 VENTRICULAR SHUNT PROCEDURES 535 15662 10000 10000 15662 12500 19578 10000 15662 $14683 Misc Pediatric 022-3 VENTRICULAR SHUNT PROCEDURES 1108 28925 10000 10000 28925 12500 36156 10000 28925 $27117 Misc Pediatric 022-4 VENTRICULAR SHUNT PROCEDURES 1829 51610 10000 10000 51610 12500 64513 10000 51610 $48384 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
023-1 SPINAL PROCEDURES 330 13296 10000 10000 13296 12500 16620 10000 13296 $12465 Misc Pediatric 023-2 SPINAL PROCEDURES 575 18228 10000 10000 18228 12500 22785 10000 18228 $17089 Misc Pediatric 023-3 SPINAL PROCEDURES 1033 37132 10000 10000 37132 12500 46415 10000 37132 $34811 Misc Pediatric 023-4 SPINAL PROCEDURES 2028 64258 10000 10000 64258 12500 80323 10000 64258 $60242 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
024-1 EXTRACRANIAL VASCULAR PROCEDURES 154 10744 10000 10000 10744 12500 13430 10000 10744 $10073 Misc Pediatric 024-2 EXTRACRANIAL VASCULAR PROCEDURES 291 14224 10000 10000 14224 12500 17780 10000 14224 $13335 Misc Pediatric 024-3 EXTRACRANIAL VASCULAR PROCEDURES 748 27477 10000 10000 27477 12500 34346 10000 27477 $25760 Misc Pediatric 024-4 EXTRACRANIAL VASCULAR PROCEDURES 1360 52767 10000 10000 52767 12500 65959 10000 52767 $49469 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
026-1 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 261 11696 10000 10000 11696 12500 14620 10000 11696 $10965 Misc Pediatric 026-2 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 445 15931 10000 10000 15931 12500 19914 10000 15931 $14935 Misc Pediatric 026-3 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 912 24163 10000 10000 24163 12500 30204 10000 24163 $22653 Misc Pediatric 026-4 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 2104 48720 10000 10000 48720 12500 60900 10000 48720 $45675 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
040-1 SPINAL DISORDERS amp INJURIES 362 07950 10000 10000 07950 12500 09938 10000 07950 $7453 Misc Pediatric 040-2 SPINAL DISORDERS amp INJURIES 497 09647 10000 10000 09647 12500 12059 10000 09647 $9044 Misc Pediatric 040-3 SPINAL DISORDERS amp INJURIES 796 13170 10000 10000 13170 12500 16463 10000 13170 $12347 Misc Pediatric 040-4 SPINAL DISORDERS amp INJURIES 1612 26793 10000 10000 26793 12500 33491 10000 26793 $25118 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
041-1 NERVOUS SYSTEM MALIGNANCY 306 06836 10000 10000 06836 12500 08545 10000 06836 $6409 Misc Pediatric 041-2 NERVOUS SYSTEM MALIGNANCY 388 07312 10000 10000 07312 12500 09140 10000 07312 $6855 Misc Pediatric 041-3 NERVOUS SYSTEM MALIGNANCY 613 10508 10000 10000 10508 12500 13135 10000 10508 $9851 Misc Pediatric 041-4 NERVOUS SYSTEM MALIGNANCY 992 17617 10000 10000 17617 12500 22021 10000 17617 $16516 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
042-1 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 521 05231 10000 10000 05231 12500 06539 10000 05231 $4904 Misc Pediatric 042-2 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 886 07627 10000 10000 07627 12500 09534 10000 07627 $7150 Misc Pediatric 042-3 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 917 10114 10000 10000 10114 12500 12643 10000 10114 $9482 Misc Pediatric 042-4 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 1329 21932 10000 10000 21932 12500 27415 10000 21932 $20561 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
043-1 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 356 06706 10000 10000 06706 12500 08383 10000 06706 $6287 Misc Pediatric 043-2 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 479 08543 10000 10000 08543 12500 10679 10000 08543 $8009 Misc Pediatric 043-3 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 827 13083 10000 10000 13083 12500 16354 10000 13083 $12265 Misc Pediatric 043-4 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 1650 28853 10000 10000 28853 12500 36066 10000 28853 $27050 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
044-1 INTRACRANIAL HEMORRHAGE 349 06526 10000 10000 06526 12500 08158 10000 06526 $6118 Misc Pediatric 044-2 INTRACRANIAL HEMORRHAGE 462 08878 10000 10000 08878 12500 11098 10000 08878 $8323 Misc Pediatric 044-3 INTRACRANIAL HEMORRHAGE 547 11157 10000 10000 11157 12500 13946 10000 11157 $10460 Misc Pediatric 044-4 INTRACRANIAL HEMORRHAGE 897 20771 10000 10000 20771 12500 25964 10000 20771 $19473 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
045-1 CVA amp PRECEREBRAL OCCLUSION W INFARCT 279 07518 10000 10000 07518 12500 09398 10000 07518 $7048 Misc Pediatric 045-2 CVA amp PRECEREBRAL OCCLUSION W INFARCT 392 09090 10000 10000 09090 12500 11363 10000 09090 $8522 Misc Pediatric 045-3 CVA amp PRECEREBRAL OCCLUSION W INFARCT 617 12516 10000 10000 12516 12500 15645 10000 12516 $11734 Misc Pediatric 045-4 CVA amp PRECEREBRAL OCCLUSION W INFARCT 1101 23311 10000 10000 23311 12500 29139 10000 23311 $21854 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
046-1 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 262 06594 10000 10000 06594 12500 08243 10000 06594 $6182 Misc Pediatric 046-2 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 327 08051 10000 10000 08051 12500 10064 10000 08051 $7548 Misc Pediatric 046-3 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 501 10524 10000 10000 10524 12500 13155 10000 10524 $9866 Misc Pediatric 046-4 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 950 18762 10000 10000 18762 12500 23453 10000 18762 $17589 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
047-1 TRANSIENT ISCHEMIA 193 05944 10000 10000 05944 12500 07430 10000 05944 $5573 Misc Pediatric 047-2 TRANSIENT ISCHEMIA 252 06664 10000 10000 06664 12500 08330 10000 06664 $6248 Misc Pediatric 047-3 TRANSIENT ISCHEMIA 382 08503 10000 10000 08503 12500 10629 10000 08503 $7972 Misc Pediatric 047-4 TRANSIENT ISCHEMIA 877 17352 10000 10000 17352 12500 21690 10000 17352 $16268 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
048-1 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 276 05447 10000 10000 05447 12500 06809 10000 05447 $5107 Misc Pediatric 048-2 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 381 06543 10000 10000 06543 12500 08179 10000 06543 $6134 Misc Pediatric 048-3 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 538 08920 10000 10000 08920 12500 11150 10000 08920 $8363 Misc Pediatric 048-4 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 1291 21687 10000 10000 21687 12500 27109 10000 21687 $20332 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
049-1 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 542 08284 10000 10000 08284 12500 10355 10000 08284 $7766 Misc Pediatric 049-2 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 670 16421 10000 10000 16421 12500 20526 10000 16421 $15395 Misc Pediatric 049-3 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 1061 20964 10000 10000 20964 12500 26205 10000 20964 $19654 Misc Pediatric 049-4 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 1600 36170 10000 10000 36170 12500 45213 10000 36170 $33909 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
050-1 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 392 05935 10000 10000 05935 12500 07419 10000 05935 $5564 Misc Pediatric 050-2 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 557 09905 10000 10000 09905 12500 12381 10000 09905 $9286 Misc Pediatric 050-3 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 881 16196 10000 10000 16196 12500 20245 10000 16196 $15184 Misc Pediatric 050-4 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 1558 37267 10000 10000 37267 12500 46584 10000 37267 $34938 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
051-1 VIRAL MENINGITIS 263 04820 10000 10000 04820 12500 06025 10000 04820 $4519 Misc Pediatric 051-2 VIRAL MENINGITIS 376 07311 10000 10000 07311 12500 09139 10000 07311 $6854 Misc Pediatric 051-3 VIRAL MENINGITIS 647 12961 10000 10000 12961 12500 16201 10000 12961 $12151 Misc Pediatric 051-4 VIRAL MENINGITIS 1269 30543 10000 10000 30543 12500 38179 10000 30543 $28634 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
052-1 NONTRAUMATIC STUPOR amp COMA 212 05282 10000 10000 05282 12500 06603 10000 05282 $4952 Misc Pediatric 052-2 NONTRAUMATIC STUPOR amp COMA 322 06261 10000 10000 06261 12500 07826 10000 06261 $5870 Misc Pediatric 052-3 NONTRAUMATIC STUPOR amp COMA 518 08796 10000 10000 08796 12500 10995 10000 08796 $8246 Misc Pediatric 052-4 NONTRAUMATIC STUPOR amp COMA 1098 20139 10000 10000 20139 12500 25174 10000 20139 $18880 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
053-1 SEIZURE 231 04456 10000 10000 04456 12500 05570 10000 04456 $4178 Misc Pediatric 053-2 SEIZURE 292 05716 10000 10000 05716 12500 07145 10000 05716 $5359 Misc Pediatric 053-3 SEIZURE 440 08167 10000 10000 08167 12500 10209 10000 08167 $7657 Misc Pediatric 053-4 SEIZURE 977 20593 10000 10000 20593 12500 25741 10000 20593 $19306 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
054-1 MIGRAINE amp OTHER HEADACHES 237 04790 10000 10000 04790 12500 05988 10000 04790 $4491 Misc Pediatric 054-2 MIGRAINE amp OTHER HEADACHES 281 05954 10000 10000 05954 12500 07443 10000 05954 $5582 Misc Pediatric 054-3 MIGRAINE amp OTHER HEADACHES 392 07615 10000 10000 07615 12500 09519 10000 07615 $7139 Misc Pediatric 054-4 MIGRAINE amp OTHER HEADACHES 686 12142 10000 10000 12142 12500 15178 10000 12142 $11383 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
055-1 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 226 05690 10000 10000 05690 12500 07113 10000 05690 $5334 Misc Pediatric 055-2 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 356 07923 10000 10000 07923 12500 09904 10000 07923 $7428 Misc Pediatric 055-3 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 537 12060 10000 10000 12060 12500 15075 10000 12060 $11306 Misc Pediatric 055-4 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 1042 23925 10000 10000 23925 12500 29906 10000 23925 $22430 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
056-1 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 226 05776 10000 10000 05776 12500 07220 10000 05776 $5415 Misc Pediatric 056-2 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 367 08300 10000 10000 08300 12500 10375 10000 08300 $7781 Misc Pediatric 056-3 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 599 13057 10000 10000 13057 12500 16321 10000 13057 $12241 Misc Pediatric 056-4 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 1334 31575 10000 10000 31575 12500 39469 10000 31575 $29602 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
057-1 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 151 05207 10000 10000 05207 12500 06509 10000 05207 $4882 Misc Pediatric 057-2 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 242 07484 10000 10000 07484 12500 09355 10000 07484 $7016 Misc Pediatric 057-3 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 440 11394 10000 10000 11394 12500 14243 10000 11394 $10682 Misc Pediatric 057-4 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 1034 25045 10000 10000 25045 12500 31306 10000 25045 $23480 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
058-1 OTHER DISORDERS OF NERVOUS SYSTEM 278 05743 10000 10000 05743 12500 07179 10000 05743 $5384 Misc Pediatric 058-2 OTHER DISORDERS OF NERVOUS SYSTEM 409 07055 10000 10000 07055 12500 08819 10000 07055 $6614 Misc Pediatric 058-3 OTHER DISORDERS OF NERVOUS SYSTEM 616 09584 10000 10000 09584 12500 11980 10000 09584 $8985 Misc Pediatric 058-4 OTHER DISORDERS OF NERVOUS SYSTEM 1234 19422 10000 10000 19422 12500 24278 10000 19422 $18208 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
070-1 ORBITAL PROCEDURES 213 07705 10000 10000 07705 12500 09631 10000 07705 $7223 Misc Pediatric 070-2 ORBITAL PROCEDURES 376 11459 10000 10000 11459 12500 14324 10000 11459 $10743 Misc Pediatric 070-3 ORBITAL PROCEDURES 677 20584 10000 10000 20584 12500 25730 10000 20584 $19298 Misc Pediatric
Misc Adult Misc Adult Misc Adult
070-4 ORBITAL PROCEDURES 1319 41150 10000 10000 41150 12500 51438 10000 41150 $38578 Misc Pediatric Misc Adult 073-1 073-2 073-3 073-4
EYE PROCEDURES EXCEPT ORBIT EYE PROCEDURES EXCEPT ORBIT EYE PROCEDURES EXCEPT ORBIT EYE PROCEDURES EXCEPT ORBIT
227 313 544
1855
07119 08959 13025 30348
10000 10000 10000 10000
10000 10000 10000 10000
07119 08959 13025 30348
12500 12500 12500 12500
08899 11199 16281 37935
10000 10000 10000 10000
07119 08959 13025 30348
$6674 Misc Pediatric $8399 Misc Pediatric
$12211 Misc Pediatric $28451 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
080-1 080-2 080-3 080-4
ACUTE MAJOR EYE INFECTIONS ACUTE MAJOR EYE INFECTIONS ACUTE MAJOR EYE INFECTIONS ACUTE MAJOR EYE INFECTIONS
294 394 624
1204
03773 05293 08870 22854
10000 10000 10000 10000
10000 10000 10000 10000
03773 05293 08870 22854
12500 12500 12500 12500
04716 06616 11088 28568
10000 10000 10000 10000
03773 05293 08870 22854
$3537 Misc Pediatric $4962 Misc Pediatric $8316 Misc Pediatric
$21426 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
082-1 082-2 082-3 082-4
EYE DISORDERS EXCEPT MAJOR INFECTIONS EYE DISORDERS EXCEPT MAJOR INFECTIONS EYE DISORDERS EXCEPT MAJOR INFECTIONS EYE DISORDERS EXCEPT MAJOR INFECTIONS
229 280 431
1589
04191 05783 08004 18093
10000 10000 10000 10000
10000 10000 10000 10000
04191 05783 08004 18093
12500 12500 12500 12500
05239 07229 10005 22616
10000 10000 10000 10000
04191 05783 08004 18093
$3929 Misc Pediatric $5422 Misc Pediatric $7504 Misc Pediatric
$16962 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
089-1 089-2 089-3 089-4
MAJOR CRANIALFACIAL BONE PROCEDURES MAJOR CRANIALFACIAL BONE PROCEDURES MAJOR CRANIALFACIAL BONE PROCEDURES MAJOR CRANIALFACIAL BONE PROCEDURES
231 384 877
1633
14059 18500 32437 57616
10000 10000 10000 10000
10000 10000 10000 10000
14059 18500 32437 57616
12500 12500 12500 12500
17574 23125 40546 72020
10000 10000 10000 10000
14059 18500 32437 57616
$13180 Misc Pediatric $17344 Misc Pediatric $30410 Misc Pediatric $54015 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
090-1 090-2 090-3 090-4
MAJOR LARYNX amp TRACHEA PROCEDURES MAJOR LARYNX amp TRACHEA PROCEDURES MAJOR LARYNX amp TRACHEA PROCEDURES MAJOR LARYNX amp TRACHEA PROCEDURES
259 809
1356 2501
07159 22218 35815 71443
10000 10000 10000 10000
10000 10000 10000 10000
07159 22218 35815 71443
12500 12500 12500 12500
08949 27773 44769 89304
10000 10000 10000 10000
07159 22218 35815 71443
$6712 Misc Pediatric $20829 Misc Pediatric $33577 Misc Pediatric $66978 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
091-1 091-2 091-3 091-4
OTHER MAJOR HEAD amp NECK PROCEDURES OTHER MAJOR HEAD amp NECK PROCEDURES OTHER MAJOR HEAD amp NECK PROCEDURES OTHER MAJOR HEAD amp NECK PROCEDURES
324 463 959
1918
13026 18978 35965 63240
10000 10000 10000 10000
10000 10000 10000 10000
13026 18978 35965 63240
12500 12500 12500 12500
16283 23723 44956 79050
10000 10000 10000 10000
13026 18978 35965 63240
$12212 Misc Pediatric $17792 Misc Pediatric $33717 Misc Pediatric $59288 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
092-1 092-2 092-3 092-4
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES
200 293 606
1411
09832 13811 22378 49305
10000 10000 10000 10000
10000 10000 10000 10000
09832 13811 22378 49305
12500 12500 12500 12500
12290 17264 27973 61631
10000 10000 10000 10000
09832 13811 22378 49305
$9218 Misc Pediatric $12948 Misc Pediatric $20979 Misc Pediatric $46223 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
093-1 093-2 093-3 093-4
SINUS amp MASTOID PROCEDURES SINUS amp MASTOID PROCEDURES SINUS amp MASTOID PROCEDURES SINUS amp MASTOID PROCEDURES
236 388 725
1267
09484 12524 19562 30863
10000 10000 10000 10000
10000 10000 10000 10000
09484 12524 19562 30863
12500 12500 12500 12500
11855 15655 24453 38579
10000 10000 10000 10000
09484 12524 19562 30863
$8891 Misc Pediatric $11741 Misc Pediatric $18339 Misc Pediatric $28934 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
095-1 095-2 095-3 095-4
CLEFT LIP amp PALATE REPAIR CLEFT LIP amp PALATE REPAIR CLEFT LIP amp PALATE REPAIR CLEFT LIP amp PALATE REPAIR
143 206 403
1096
06260 07686 11913 21518
10000 10000 10000 10000
10000 10000 10000 10000
06260 07686 11913 21518
12500 12500 12500 12500
07825 09608 14891 26898
10000 10000 10000 10000
06260 07686 11913 21518
$5869 Misc Pediatric $7206 Misc Pediatric
$11168 Misc Pediatric $20173 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
097-1 097-2 097-3 097-4
TONSIL amp ADENOID PROCEDURES TONSIL amp ADENOID PROCEDURES TONSIL amp ADENOID PROCEDURES TONSIL amp ADENOID PROCEDURES
155 275 571
1520
04084 06213 12162 32627
10000 10000 10000 10000
10000 10000 10000 10000
04084 06213 12162 32627
12500 12500 12500 12500
05105 07766 15203 40784
10000 10000 10000 10000
04084 06213 12162 32627
$3829 Misc Pediatric $5825 Misc Pediatric
$11402 Misc Pediatric $30588 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
098-1 098-2 098-3 098-4
OTHER EAR NOSE MOUTH amp THROAT PROCEDURES OTHER EAR NOSE MOUTH amp THROAT PROCEDURES OTHER EAR NOSE MOUTH amp THROAT PROCEDURES OTHER EAR NOSE MOUTH amp THROAT PROCEDURES
210 326 680
1461
07048 09495 15477 32522
10000 10000 10000 10000
10000 10000 10000 10000
07048 09495 15477 32522
12500 12500 12500 12500
08810 11869 19346 40653
10000 10000 10000 10000
07048 09495 15477 32522
$6608 Misc Pediatric $8902 Misc Pediatric
$14510 Misc Pediatric $30489 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
110-1 110-2 110-3 110-4
EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES
292 429 693
1273
04895 07037 11057 22409
10000 10000 10000 10000
10000 10000 10000 10000
04895 07037 11057 22409
12500 12500 12500 12500
06119 08796 13821 28011
10000 10000 10000 10000
04895 07037 11057 22409
$4589 Misc Pediatric $6597 Misc Pediatric
$10366 Misc Pediatric $21008 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
111-1 111-2 111-3 111-4
VERTIGO amp OTHER LABYRINTH DISORDERS VERTIGO amp OTHER LABYRINTH DISORDERS VERTIGO amp OTHER LABYRINTH DISORDERS VERTIGO amp OTHER LABYRINTH DISORDERS
201 251 349 747
04865 05693 07226 13868
10000 10000 10000 10000
10000 10000 10000 10000
04865 05693 07226 13868
12500 12500 12500 12500
06081 07116 09033 17335
10000 10000 10000 10000
04865 05693 07226 13868
$4561 Misc Pediatric $5337 Misc Pediatric $6774 Misc Pediatric
$13001 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
113-1 113-2 113-3 113-4
INFECTIONS OF UPPER RESPIRATORY TRACT INFECTIONS OF UPPER RESPIRATORY TRACT INFECTIONS OF UPPER RESPIRATORY TRACT INFECTIONS OF UPPER RESPIRATORY TRACT
187 252 395 733
02600 04025 06701 13455
10000 10000 10000 10000
10000 10000 10000 10000
02600 04025 06701 13455
12500 12500 12500 12500
03250 05031 08376 16819
10000 10000 10000 10000
02600 04025 06701 13455
$2438 Resp Pediatric $3773 Resp Pediatric $6282 Resp Pediatric
$12614 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
114-1 114-2 114-3 114-4
DENTAL amp ORAL DISEASES amp INJURIES DENTAL amp ORAL DISEASES amp INJURIES DENTAL amp ORAL DISEASES amp INJURIES DENTAL amp ORAL DISEASES amp INJURIES
220 297 545
1060
03711 05698 09275 19812
10000 10000 10000 10000
10000 10000 10000 10000
03711 05698 09275 19812
12500 12500 12500 12500
04639 07123 11594 24765
10000 10000 10000 10000
03711 05698 09275 19812
$3479 Misc Pediatric $5342 Misc Pediatric $8695 Misc Pediatric
$18574 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
115-1 115-2 115-3 115-4
OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES
230 298 483 964
04062 05956 08755 18372
10000 10000 10000 10000
10000 10000 10000 10000
04062 05956 08755 18372
12500 12500 12500 12500
05078 07445 10944 22965
10000 10000 10000 10000
04062 05956 08755 18372
$3808 Misc Pediatric $5584 Misc Pediatric $8208 Misc Pediatric
$17224 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
120-1 120-2 120-3 120-4
MAJOR RESPIRATORY amp CHEST PROCEDURES MAJOR RESPIRATORY amp CHEST PROCEDURES MAJOR RESPIRATORY amp CHEST PROCEDURES MAJOR RESPIRATORY amp CHEST PROCEDURES
486 677
1138 1939
17190 21946 31960 57405
10000 10000 10000 10000
10000 10000 10000 10000
17190 21946 31960 57405
12500 12500 12500 12500
21488 27433 39950 71756
10000 10000 10000 10000
17190 21946 31960 57405
$16116 Resp Pediatric $20574 Resp Pediatric $29963 Resp Pediatric $53817 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
121-1 121-2 121-3 121-4
OTHER RESPIRATORY amp CHEST PROCEDURES OTHER RESPIRATORY amp CHEST PROCEDURES OTHER RESPIRATORY amp CHEST PROCEDURES OTHER RESPIRATORY amp CHEST PROCEDURES
349 547
1028 1936
11884 15313 24687 50343
10000 10000 10000 10000
10000 10000 10000 10000
11884 15313 24687 50343
12500 12500 12500 12500
14855 19141 30859 62929
10000 10000 10000 10000
11884 15313 24687 50343
$11141 Resp Pediatric $14356 Resp Pediatric $23144 Resp Pediatric $47197 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
130-1 130-2 130-3 130-4
RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS
1453 1262 1448 1967
28511 30424 36434 48144
10000 10000 10000 10000
10000 10000 10000 10000
28511 30424 36434 48144
12500 12500 12500 12500
35639 38030 45543 60180
10000 10000 10000 10000
28511 30424 36434 48144
$26729 Resp Pediatric $28523 Resp Pediatric $34157 Resp Pediatric $45135 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
131-1 131-2 131-3 131-4
CYSTIC FIBROSIS - PULMONARY DISEASE CYSTIC FIBROSIS - PULMONARY DISEASE CYSTIC FIBROSIS - PULMONARY DISEASE CYSTIC FIBROSIS - PULMONARY DISEASE
695 820
1028 1321
11407 14020 18525 25461
10000 10000 10000 10000
10000 10000 10000 10000
11407 14020 18525 25461
12500 12500 12500 12500
14259 17525 23156 31826
10000 10000 10000 10000
11407 14020 18525 25461
$10694 Resp Pediatric $13144 Resp Pediatric $17367 Resp Pediatric $23870 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
132-1 132-2 132-3 132-4
BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
345 441 709
1048
04234 05182 08052 14928
10000 10000 10000 10000
10000 10000 10000 10000
04234 05182 08052 14928
12500 12500 12500 12500
05293 06478 10065 18660
10000 10000 10000 10000
04234 05182 08052 14928
$3969 Resp Pediatric $4858 Resp Pediatric $7549 Resp Pediatric
$13995 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
133-1 133-2 133-3 133-4
PULMONARY EDEMA amp RESPIRATORY FAILURE PULMONARY EDEMA amp RESPIRATORY FAILURE PULMONARY EDEMA amp RESPIRATORY FAILURE PULMONARY EDEMA amp RESPIRATORY FAILURE
256 409 582 753
05454 07562 10997 17496
10000 10000 10000 10000
10000 10000 10000 10000
05454 07562 10997 17496
12500 12500 12500 12500
06818 09453 13746 21870
10000 10000 10000 10000
05454 07562 10997 17496
$5113 Resp Pediatric $7089 Resp Pediatric
$10310 Resp Pediatric $16403 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
134-1 134-2 134-3 134-4
PULMONARY EMBOLISM PULMONARY EMBOLISM PULMONARY EMBOLISM PULMONARY EMBOLISM
366 454 634 866
07118 09026 12878 19731
10000 10000 10000 10000
10000 10000 10000 10000
07118 09026 12878 19731
12500 12500 12500 12500
08898 11283 16098 24664
10000 10000 10000 10000
07118 09026 12878 19731
$6673 Resp Pediatric $8462 Resp Pediatric
$12073 Resp Pediatric $18498 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
135-1 135-2 135-3 135-4
MAJOR CHEST amp RESPIRATORY TRAUMA MAJOR CHEST amp RESPIRATORY TRAUMA MAJOR CHEST amp RESPIRATORY TRAUMA MAJOR CHEST amp RESPIRATORY TRAUMA
283 365 576 834
06399 08153 11913 21262
10000 10000 10000 10000
10000 10000 10000 10000
06399 08153 11913 21262
12500 12500 12500 12500
07999 10191 14891 26578
10000 10000 10000 10000
06399 08153 11913 21262
$5999 Resp Pediatric $7643 Resp Pediatric
$11168 Resp Pediatric $19933 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
136-1 136-2 136-3 136-4
RESPIRATORY MALIGNANCY RESPIRATORY MALIGNANCY RESPIRATORY MALIGNANCY RESPIRATORY MALIGNANCY
324 419 664 944
04458 07139 11635 18353
10000 10000 10000 10000
10000 10000 10000 10000
04458 07139 11635 18353
12500 12500 12500 12500
05573 08924 14544 22941
10000 10000 10000 10000
04458 07139 11635 18353
$4179 Resp Pediatric $6693 Resp Pediatric
$10908 Resp Pediatric $17206 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
137-1 137-2 137-3 137-4
MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS
470 529 724
1033
06368 08483 12031 19133
10000 10000 10000 10000
10000 10000 10000 10000
06368 08483 12031 19133
12500 12500 12500 12500
07960 10604 15039 23916
10000 10000 10000 10000
06368 08483 12031 19133
$5970 Resp Pediatric $7953 Resp Pediatric
$11279 Resp Pediatric $17937 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
138-1 138-2 138-3 138-4
BRONCHIOLITIS amp RSV PNEUMONIA BRONCHIOLITIS amp RSV PNEUMONIA BRONCHIOLITIS amp RSV PNEUMONIA BRONCHIOLITIS amp RSV PNEUMONIA
238 312 534 914
02804 03844 07519 18353
10000 10000 10000 10000
10000 10000 10000 10000
02804 03844 07519 18353
12500 12500 12500 12500
03505 04805 09399 22941
10000 10000 10000 10000
02804 03844 07519 18353
$2629 Resp Pediatric $3604 Resp Pediatric $7049 Resp Pediatric
$17206 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
139-1 139-2 139-3 139-4
OTHER PNEUMONIA OTHER PNEUMONIA OTHER PNEUMONIA OTHER PNEUMONIA
272 378 564 872
04202 06403 09948 17261
10000 10000 10000 10000
10000 10000 10000 10000
04202 06403 09948 17261
12500 12500 12500 12500
05253 08004 12435 21576
10000 10000 10000 10000
04202 06403 09948 17261
$3939 Resp Pediatric $6003 Resp Pediatric $9326 Resp Pediatric
$16182 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
140-1 140-2 140-3 140-4
CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHRONIC OBSTRUCTIVE PULMONARY DISEASE
311 381 519 874
05252 06666 09076 16691
10000 10000 10000 10000
10000 10000 10000 10000
05252 06666 09076 16691
12500 12500 12500 12500
06565 08333 11345 20864
10000 10000 10000 10000
05252 06666 09076 16691
$4924 Resp Pediatric $6249 Resp Pediatric $8509 Resp Pediatric
$15648 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
141-1 141-2 141-3 141-4
ASTHMA ASTHMA ASTHMA ASTHMA
219 307 435 560
03409 05016 07486 13503
10000 10000 10000 10000
10000 10000 10000 10000
03409 05016 07486 13503
12500 12500 12500 12500
04261 06270 09358 16879
10000 10000 10000 10000
03409 05016 07486 13503
$3196 Resp Pediatric $4703 Resp Pediatric $7018 Resp Pediatric
$12659 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
142-1 142-2 142-3 142-4
INTERSTITIAL amp ALVEOLAR LUNG DISEASES INTERSTITIAL amp ALVEOLAR LUNG DISEASES INTERSTITIAL amp ALVEOLAR LUNG DISEASES INTERSTITIAL amp ALVEOLAR LUNG DISEASES
331 422 633
1035
05788 07446 10874 19559
10000 10000 10000 10000
10000 10000 10000 10000
05788 07446 10874 19559
12500 12500 12500 12500
07235 09308 13593 24449
10000 10000 10000 10000
05788 07446 10874 19559
$5426 Resp Pediatric $6981 Resp Pediatric
$10194 Resp Pediatric $18337 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
143-1 143-2 143-3 143-4
OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES
285 376 564 863
04354 06617 09962 15731
10000 10000 10000 10000
10000 10000 10000 10000
04354 06617 09962 15731
12500 12500 12500 12500
05443 08271 12453 19664
10000 10000 10000 10000
04354 06617 09962 15731
$4082 Resp Pediatric $6203 Resp Pediatric $9339 Resp Pediatric
$14748 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
144-1 144-2 144-3 144-4
RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES
215 294 429 723
04363 05599 07749 13057
10000 10000 10000 10000
10000 10000 10000 10000
04363 05599 07749 13057
12500 12500 12500 12500
05454 06999 09686 16321
10000 10000 10000 10000
04363 05599 07749 13057
$4090 Resp Pediatric $5249 Resp Pediatric $7265 Resp Pediatric
$12241 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
160-1 160-2 160-3 160-4
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY
469 616
1039 2605
31307 34602 50015 97328
10000 10000 10000 10000
10000 10000 10000 10000
31307 34602 50015 97328
12500 12500 12500 12500
39134 43253 62519
121660
10000 10000 10000 10000
31307 34602 50015 97328
$29350 Misc Pediatric $32439 Misc Pediatric $46889 Misc Pediatric $91245 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
161-1 161-2 161-3 161-4
CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT
319 787
1588 3102
40098 53014 84071
199842
10000 10000 10000 10000
10000 10000 10000 10000
40098 53014 84071
199842
12500 12500 12500 12500
50123 66268
105089 249803
10000 10000 10000 10000
40098 53014 84071
199842
$37592 Misc Pediatric $49701 Misc Pediatric $78817 Misc Pediatric
$187352 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
162-1 162-2 162-3 162-4
CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION
800 918
1322 2097
44219 49501 63338 96985
10000 10000 10000 10000
10000 10000 10000 10000
44219 49501 63338 96985
12500 12500 12500 12500
55274 61876 79173
121231
10000 10000 10000 10000
44219 49501 63338 96985
$41455 Misc Pediatric $46407 Misc Pediatric $59379 Misc Pediatric $90923 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
163-1 163-2 163-3 163-4
CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION
566 651 924
1798
38077 42090 51794 88229
10000 10000 10000 10000
10000 10000 10000 10000
38077 42090 51794 88229
12500 12500 12500 12500
47596 52613 64743
110286
10000 10000 10000 10000
38077 42090 51794 88229
$35697 Misc Pediatric $39459 Misc Pediatric $48557 Misc Pediatric $82715 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
165-1 165-2 165-3 165-4
CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE
675 817
1052 1712
38445 43860 53254 80347
10000 10000 10000 10000
10000 10000 10000 10000
38445 43860 53254 80347
12500 12500 12500 12500
48056 54825 66568
100434
10000 10000 10000 10000
38445 43860 53254 80347
$36042 Misc Pediatric $41119 Misc Pediatric $49926 Misc Pediatric $75325 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
166-1 166-2 166-3 166-4
CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE
502 611 855
1615
30632 34370 42566 71277
10000 10000 10000 10000
10000 10000 10000 10000
30632 34370 42566 71277
12500 12500 12500 12500
38290 42963 53208 89096
10000 10000 10000 10000
30632 34370 42566 71277
$28718 Misc Pediatric $32222 Misc Pediatric $39906 Misc Pediatric $66822 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
167-1 167-2 167-3 167-4
OTHER CARDIOTHORACIC PROCEDURES OTHER CARDIOTHORACIC PROCEDURES OTHER CARDIOTHORACIC PROCEDURES OTHER CARDIOTHORACIC PROCEDURES
438 583 914
1860
28492 32691 41583 72603
10000 10000 10000 10000
10000 10000 10000 10000
28492 32691 41583 72603
12500 12500 12500 12500
35615 40864 51979 90754
10000 10000 10000 10000
28492 32691 41583 72603
$26711 Misc Pediatric $30648 Misc Pediatric $38984 Misc Pediatric $68065 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
169-1 169-2 169-3 169-4
MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES
434 570 899
1626
17710 23017 35767 63594
10000 10000 10000 10000
10000 10000 10000 10000
17710 23017 35767 63594
12500 12500 12500 12500
22138 28771 44709 79493
10000 10000 10000 10000
17710 23017 35767 63594
$16603 Misc Pediatric $21578 Misc Pediatric $33532 Misc Pediatric $59619 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
170-1 170-2 170-3 170-4
PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK
468 535 901
1647
22837 24595 30320 48851
10000 10000 10000 10000
10000 10000 10000 10000
22837 24595 30320 48851
12500 12500 12500 12500
28546 30744 37900 61064
10000 10000 10000 10000
22837 24595 30320 48851
$21410 Misc Pediatric $23058 Misc Pediatric $28425 Misc Pediatric $45798 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
171-1 171-2 171-3 171-4
PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK
257 388 652
1323
16061 19059 24628 42111
10000 10000 10000 10000
10000 10000 10000 10000
16061 19059 24628 42111
12500 12500 12500 12500
20076 23824 30785 52639
10000 10000 10000 10000
16061 19059 24628 42111
$15057 Misc Pediatric $17868 Misc Pediatric $23089 Misc Pediatric $39479 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
173-1 173-2 173-3 173-4
OTHER VASCULAR PROCEDURES OTHER VASCULAR PROCEDURES OTHER VASCULAR PROCEDURES OTHER VASCULAR PROCEDURES
248 413 835
1698
17172 20933 28552 52543
10000 10000 10000 10000
10000 10000 10000 10000
17172 20933 28552 52543
12500 12500 12500 12500
21465 26166 35690 65679
10000 10000 10000 10000
17172 20933 28552 52543
$16099 Misc Pediatric $19625 Misc Pediatric $26768 Misc Pediatric $49259 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
174-1 174-2 174-3 174-4
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI
242 309 532 858
20862 22375 27863 40669
10000 10000 10000 10000
10000 10000 10000 10000
20862 22375 27863 40669
12500 12500 12500 12500
26078 27969 34829 50836
10000 10000 10000 10000
20862 22375 27863 40669
$19558 Misc Pediatric $20977 Misc Pediatric $26122 Misc Pediatric $38127 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
175-1 175-2 175-3 175-4
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI
172 253 517
1037
17736 19933 25843 42121
10000 10000 10000 10000
10000 10000 10000 10000
17736 19933 25843 42121
12500 12500 12500 12500
22170 24916 32304 52651
10000 10000 10000 10000
17736 19933 25843 42121
$16628 Misc Pediatric $18687 Misc Pediatric $24228 Misc Pediatric $39488 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
176-1 176-2 176-3 176-4
CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT
291 253 446
1336
13020 24038 27425 45070
10000 10000 10000 10000
10000 10000 10000 10000
13020 24038 27425 45070
12500 12500 12500 12500
16275 30048 34281 56338
10000 10000 10000 10000
13020 24038 27425 45070
$12206 Misc Pediatric $22536 Misc Pediatric $25711 Misc Pediatric $42253 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
177-1 177-2 177-3 177-4
CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT
260 405 749
1560
10212 13638 21173 40225
10000 10000 10000 10000
10000 10000 10000 10000
10212 13638 21173 40225
12500 12500 12500 12500
12765 17048 26466 50281
10000 10000 10000 10000
10212 13638 21173 40225
$9574 Misc Pediatric $12786 Misc Pediatric $19850 Misc Pediatric $37711 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
180-1 180-2 180-3 180-4
OTHER CIRCULATORY SYSTEM PROCEDURES OTHER CIRCULATORY SYSTEM PROCEDURES OTHER CIRCULATORY SYSTEM PROCEDURES OTHER CIRCULATORY SYSTEM PROCEDURES
416 593 963
1589
10497 14144 21255 39764
10000 10000 10000 10000
10000 10000 10000 10000
10497 14144 21255 39764
12500 12500 12500 12500
13121 17680 26569 49705
10000 10000 10000 10000
10497 14144 21255 39764
$9841 Misc Pediatric $13260 Misc Pediatric $19927 Misc Pediatric $37279 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
190-1 190-2 190-3 190-4
ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION
212 315 518 765
06920 08342 11428 18576
10000 10000 10000 10000
10000 10000 10000 10000
06920 08342 11428 18576
12500 12500 12500 12500
08650 10428 14285 23220
10000 10000 10000 10000
06920 08342 11428 18576
$6488 Misc Pediatric $7821 Misc Pediatric
$10714 Misc Pediatric $17415 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
191-1 191-2 191-3 191-4
CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE
250 356 588
1157
10129 11962 15321 30799
10000 10000 10000 10000
10000 10000 10000 10000
10129 11962 15321 30799
12500 12500 12500 12500
12661 14953 19151 38499
10000 10000 10000 10000
10129 11962 15321 30799
$9496 Misc Pediatric $11214 Misc Pediatric $14363 Misc Pediatric $28874 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
192-1 192-2 192-3 192-4
CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE
190 256 440 733
08840 10294 13642 21517
10000 10000 10000 10000
10000 10000 10000 10000
08840 10294 13642 21517
12500 12500 12500 12500
11050 12868 17053 26896
10000 10000 10000 10000
08840 10294 13642 21517
$8288 Misc Pediatric $9651 Misc Pediatric
$12789 Misc Pediatric $20172 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
193-1 193-2 193-3 193-4
ACUTE amp SUBACUTE ENDOCARDITIS ACUTE amp SUBACUTE ENDOCARDITIS ACUTE amp SUBACUTE ENDOCARDITIS ACUTE amp SUBACUTE ENDOCARDITIS
549 695
1002 1491
07895 10373 15660 25224
10000 10000 10000 10000
10000 10000 10000 10000
07895 10373 15660 25224
12500 12500 12500 12500
09869 12966 19575 31530
10000 10000 10000 10000
07895 10373 15660 25224
$7402 Misc Pediatric $9725 Misc Pediatric
$14681 Misc Pediatric $23648 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
194-1 194-2 194-3 194-4
HEART FAILURE HEART FAILURE HEART FAILURE HEART FAILURE
292 375 565 955
05101 06549 09786 17821
10000 10000 10000 10000
10000 10000 10000 10000
05101 06549 09786 17821
12500 12500 12500 12500
06376 08186 12233 22276
10000 10000 10000 10000
05101 06549 09786 17821
$4782 Misc Pediatric $6140 Misc Pediatric $9174 Misc Pediatric
$16707 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
196-1 196-2 196-3 196-4
CARDIAC ARREST CARDIAC ARREST CARDIAC ARREST CARDIAC ARREST
291 227 252 462
03449 04919 07133 17166
10000 10000 10000 10000
10000 10000 10000 10000
03449 04919 07133 17166
12500 12500 12500 12500
04311 06149 08916 21458
10000 10000 10000 10000
03449 04919 07133 17166
$3233 Misc Pediatric $4612 Misc Pediatric $6687 Misc Pediatric
$16093 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
197-1 197-2 197-3 197-4
PERIPHERAL amp OTHER VASCULAR DISORDERS PERIPHERAL amp OTHER VASCULAR DISORDERS PERIPHERAL amp OTHER VASCULAR DISORDERS PERIPHERAL amp OTHER VASCULAR DISORDERS
325 405 554 993
04539 06186 09350 18139
10000 10000 10000 10000
10000 10000 10000 10000
04539 06186 09350 18139
12500 12500 12500 12500
05674 07733 11688 22674
10000 10000 10000 10000
04539 06186 09350 18139
$4255 Misc Pediatric $5799 Misc Pediatric $8766 Misc Pediatric
$17005 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
198-1 198-2 198-3 198-4
ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS
164 215 343 795
04222 05100 07000 13778
10000 10000 10000 10000
10000 10000 10000 10000
04222 05100 07000 13778
12500 12500 12500 12500
05278 06375 08750 17223
10000 10000 10000 10000
04222 05100 07000 13778
$3958 Misc Pediatric $4781 Misc Pediatric $6563 Misc Pediatric
$12917 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
199-1 199-2 199-3 199-4
HYPERTENSION HYPERTENSION HYPERTENSION HYPERTENSION
199 261 407 774
04431 05438 07709 16234
10000 10000 10000 10000
10000 10000 10000 10000
04431 05438 07709 16234
12500 12500 12500 12500
05539 06798 09636 20293
10000 10000 10000 10000
04431 05438 07709 16234
$4154 Misc Pediatric $5098 Misc Pediatric $7227 Misc Pediatric
$15219 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
200-1 200-2 200-3 200-4
CARDIAC STRUCTURAL amp VALVULAR DISORDERS CARDIAC STRUCTURAL amp VALVULAR DISORDERS CARDIAC STRUCTURAL amp VALVULAR DISORDERS CARDIAC STRUCTURAL amp VALVULAR DISORDERS
238 315 517
1005
04557 05692 08445 16354
10000 10000 10000 10000
10000 10000 10000 10000
04557 05692 08445 16354
12500 12500 12500 12500
05696 07115 10556 20443
10000 10000 10000 10000
04557 05692 08445 16354
$4272 Misc Pediatric $5336 Misc Pediatric $7917 Misc Pediatric
$15332 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
201-1 201-2 201-3 201-4
CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS
199 289 466 863
04273 05624 08590 17457
10000 10000 10000 10000
10000 10000 10000 10000
04273 05624 08590 17457
12500 12500 12500 12500
05341 07030 10738 21821
10000 10000 10000 10000
04273 05624 08590 17457
$4006 Misc Pediatric $5273 Misc Pediatric $8053 Misc Pediatric
$16366 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
203-1 203-2 203-3 203-4
CHEST PAIN CHEST PAIN CHEST PAIN CHEST PAIN
148 195 305 725
04180 05129 06846 13335
10000 10000 10000 10000
10000 10000 10000 10000
04180 05129 06846 13335
12500 12500 12500 12500
05225 06411 08558 16669
10000 10000 10000 10000
04180 05129 06846 13335
$3919 Misc Pediatric $4808 Misc Pediatric $6418 Misc Pediatric
$12502 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
204-1 204-2 204-3 204-4
SYNCOPE amp COLLAPSE SYNCOPE amp COLLAPSE SYNCOPE amp COLLAPSE SYNCOPE amp COLLAPSE
201 264 388 858
04877 05857 07587 15564
10000 10000 10000 10000
10000 10000 10000 10000
04877 05857 07587 15564
12500 12500 12500 12500
06096 07321 09484 19455
10000 10000 10000 10000
04877 05857 07587 15564
$4572 Misc Pediatric $5491 Misc Pediatric $7113 Misc Pediatric
$14591 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
205-1 205-2 205-3 205-4
CARDIOMYOPATHY CARDIOMYOPATHY CARDIOMYOPATHY CARDIOMYOPATHY
238 308 496 926
04349 05715 08342 18259
10000 10000 10000 10000
10000 10000 10000 10000
04349 05715 08342 18259
12500 12500 12500 12500
05436 07144 10428 22824
10000 10000 10000 10000
04349 05715 08342 18259
$4077 Misc Pediatric $5358 Misc Pediatric $7821 Misc Pediatric
$17118 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
206-1 206-2 206-3 206-4
MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE
227 345 572
1116
04452 05754 09436 20324
10000 10000 10000 10000
10000 10000 10000 10000
04452 05754 09436 20324
12500 12500 12500 12500
05565 07193 11795 25405
10000 10000 10000 10000
04452 05754 09436 20324
$4174 Misc Pediatric $5394 Misc Pediatric $8846 Misc Pediatric
$19054 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
207-1 207-2 207-3 207-4
OTHER CIRCULATORY SYSTEM DIAGNOSES OTHER CIRCULATORY SYSTEM DIAGNOSES OTHER CIRCULATORY SYSTEM DIAGNOSES OTHER CIRCULATORY SYSTEM DIAGNOSES
239 327 479 850
04972 06455 09118 17339
10000 10000 10000 10000
10000 10000 10000 10000
04972 06455 09118 17339
12500 12500 12500 12500
06215 08069 11398 21674
10000 10000 10000 10000
04972 06455 09118 17339
$4661 Misc Pediatric $6052 Misc Pediatric $8548 Misc Pediatric
$16255 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
220-1 220-2 220-3 220-4
MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES
370 728
1222 2105
13178 19373 31783 59607
10000 10000 10000 10000
10000 10000 10000 10000
13178 19373 31783 59607
12500 12500 12500 12500
16473 24216 39729 74509
10000 10000 10000 10000
13178 19373 31783 59607
$12354 Misc Pediatric $18162 Misc Pediatric $29797 Misc Pediatric $55882 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
221-1 221-2 221-3 221-4
MAJOR SMALL amp LARGE BOWEL PROCEDURES MAJOR SMALL amp LARGE BOWEL PROCEDURES MAJOR SMALL amp LARGE BOWEL PROCEDURES MAJOR SMALL amp LARGE BOWEL PROCEDURES
486 711
1216 2007
13986 18317 29391 55350
10000 10000 10000 10000
10000 10000 10000 10000
13986 18317 29391 55350
12500 12500 12500 12500
17483 22896 36739 69188
10000 10000 10000 10000
13986 18317 29391 55350
$13112 Misc Pediatric $17172 Misc Pediatric $27554 Misc Pediatric $51891 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
222-1 222-2 222-3 222-4
OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES
226 370 835
1821
08125 12068 19613 44248
10000 10000 10000 10000
10000 10000 10000 10000
08125 12068 19613 44248
12500 12500 12500 12500
10156 15085 24516 55310
10000 10000 10000 10000
08125 12068 19613 44248
$7617 Misc Pediatric $11314 Misc Pediatric $18387 Misc Pediatric $41483 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
223-1 223-2 223-3 223-4
OTHER SMALL amp LARGE BOWEL PROCEDURES OTHER SMALL amp LARGE BOWEL PROCEDURES OTHER SMALL amp LARGE BOWEL PROCEDURES OTHER SMALL amp LARGE BOWEL PROCEDURES
442 643
1092 1967
10740 14465 23665 49105
10000 10000 10000 10000
10000 10000 10000 10000
10740 14465 23665 49105
12500 12500 12500 12500
13425 18081 29581 61381
10000 10000 10000 10000
10740 14465 23665 49105
$10069 Misc Pediatric $13561 Misc Pediatric $22186 Misc Pediatric $46036 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
224-1 224-2 224-3 224-4
PERITONEAL ADHESIOLYSIS PERITONEAL ADHESIOLYSIS PERITONEAL ADHESIOLYSIS PERITONEAL ADHESIOLYSIS
540 788
1150 1745
12217 16811 25160 44117
10000 10000 10000 10000
10000 10000 10000 10000
12217 16811 25160 44117
12500 12500 12500 12500
15271 21014 31450 55146
10000 10000 10000 10000
12217 16811 25160 44117
$11453 Misc Pediatric $15760 Misc Pediatric $23588 Misc Pediatric $41360 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
225-1 225-2 225-3 225-4
APPENDECTOMY APPENDECTOMY APPENDECTOMY APPENDECTOMY
157 376 726
1357
07870 11109 18822 36506
10000 10000 10000 10000
10000 10000 10000 10000
07870 11109 18822 36506
12500 12500 12500 12500
09838 13886 23528 45633
10000 10000 10000 10000
07870 11109 18822 36506
$7378 Misc Pediatric $10415 Misc Pediatric $17646 Misc Pediatric $34224 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
226-1 226-2 226-3 226-4
ANAL PROCEDURES ANAL PROCEDURES ANAL PROCEDURES ANAL PROCEDURES
256 413 737
1301
06250 08568 13988 28079
10000 10000 10000 10000
10000 10000 10000 10000
06250 08568 13988 28079
12500 12500 12500 12500
07813 10710 17485 35099
10000 10000 10000 10000
06250 08568 13988 28079
$5859 Misc Pediatric $8033 Misc Pediatric
$13114 Misc Pediatric $26324 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
227-1 HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL 290 10044 10000 10000 10044 12500 12555 10000 10044 $9416 Misc Pediatric Gastroent Adult
227-2 227-3 227-4
HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL
443 813
1503
13150 21598 43086
10000 10000 10000
10000 10000 10000
13150 21598 43086
12500 12500 12500
16438 26998 53858
10000 10000 10000
13150 21598 43086
$12328 Misc Pediatric $20248 Misc Pediatric $40393 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult
228-1 228-2 228-3 228-4
INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES
200 344 629
1321
07221 09757 15211 32407
10000 10000 10000 10000
10000 10000 10000 10000
07221 09757 15211 32407
12500 12500 12500 12500
09026 12196 19014 40509
10000 10000 10000 10000
07221 09757 15211 32407
$6770 Misc Pediatric $9147 Misc Pediatric
$14260 Misc Pediatric $30382 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
229-1 229-2 229-3 229-4
OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES
387 552 976
1760
10850 14346 22850 42572
10000 10000 10000 10000
10000 10000 10000 10000
10850 14346 22850 42572
12500 12500 12500 12500
13563 17933 28563 53215
10000 10000 10000 10000
10850 14346 22850 42572
$10172 Misc Pediatric $13449 Misc Pediatric $21422 Misc Pediatric $39911 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
240-1 240-2 240-3 240-4
DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY
371 429 685
1225
05526 07344 11112 20338
10000 10000 10000 10000
10000 10000 10000 10000
05526 07344 11112 20338
12500 12500 12500 12500
06908 09180 13890 25423
10000 10000 10000 10000
05526 07344 11112 20338
$5181 Misc Pediatric $6885 Misc Pediatric
$10418 Misc Pediatric $19067 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
241-1 241-2 241-3 241-4
PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS
252 325 484
1012
05507 07186 10584 23302
10000 10000 10000 10000
10000 10000 10000 10000
05507 07186 10584 23302
12500 12500 12500 12500
06884 08983 13230 29128
10000 10000 10000 10000
05507 07186 10584 23302
$5163 Misc Pediatric $6737 Misc Pediatric $9923 Misc Pediatric
$21846 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
242-1 242-2 242-3 242-4
MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS
230 319 459
1013
05080 06929 10170 22355
10000 10000 10000 10000
10000 10000 10000 10000
05080 06929 10170 22355
12500 12500 12500 12500
06350 08661 12713 27944
10000 10000 10000 10000
05080 06929 10170 22355
$4763 Misc Pediatric $6496 Misc Pediatric $9534 Misc Pediatric
$20958 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
243-1 243-2 243-3 243-4
OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS
189 280 479
1028
04493 06061 09094 20341
10000 10000 10000 10000
10000 10000 10000 10000
04493 06061 09094 20341
12500 12500 12500 12500
05616 07576 11368 25426
10000 10000 10000 10000
04493 06061 09094 20341
$4212 Misc Pediatric $5682 Misc Pediatric $8526 Misc Pediatric
$19070 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
244-1 244-2 244-3 244-4
DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS
292 361 545
1104
05247 06624 10053 21700
10000 10000 10000 10000
10000 10000 10000 10000
05247 06624 10053 21700
12500 12500 12500 12500
06559 08280 12566 27125
10000 10000 10000 10000
05247 06624 10053 21700
$4919 Misc Pediatric $6210 Misc Pediatric $9425 Misc Pediatric
$20344 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
245-1 245-2 245-3 245-4
INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE
339 413 626
1206
05754 07028 10226 19440
10000 10000 10000 10000
10000 10000 10000 10000
05754 07028 10226 19440
12500 12500 12500 12500
07193 08785 12783 24300
10000 10000 10000 10000
05754 07028 10226 19440
$5394 Misc Pediatric $6589 Misc Pediatric $9587 Misc Pediatric
$18225 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
246-1 246-2 246-3 246-4
GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY
315 404 602 982
06451 07943 11319 19310
10000 10000 10000 10000
10000 10000 10000 10000
06451 07943 11319 19310
12500 12500 12500 12500
08064 09929 14149 24138
10000 10000 10000 10000
06451 07943 11319 19310
$6048 Misc Pediatric $7447 Misc Pediatric
$10612 Misc Pediatric $18103 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
247-1 247-2 247-3 247-4
INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION
288 378 596
1104
04874 06267 09526 19303
10000 10000 10000 10000
10000 10000 10000 10000
04874 06267 09526 19303
12500 12500 12500 12500
06093 07834 11908 24129
10000 10000 10000 10000
04874 06267 09526 19303
$4569 Misc Pediatric $5875 Misc Pediatric $8931 Misc Pediatric
$18097 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
248-1 248-2 248-3 248-4
MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS
334 472 710
1239
05085 07215 10667 20497
10000 10000 10000 10000
10000 10000 10000 10000
05085 07215 10667 20497
12500 12500 12500 12500
06356 09019 13334 25621
10000 10000 10000 10000
05085 07215 10667 20497
$4767 Misc Pediatric $6764 Misc Pediatric
$10000 Misc Pediatric $19216 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
249-1 249-2 249-3 249-4
NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING
219 289 431 938
03648 05058 07201 15935
10000 10000 10000 10000
10000 10000 10000 10000
03648 05058 07201 15935
12500 12500 12500 12500
04560 06323 09001 19919
10000 10000 10000 10000
03648 05058 07201 15935
$3420 Misc Pediatric $4742 Misc Pediatric $6751 Misc Pediatric
$14939 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
251-1 251-2 251-3 251-4
ABDOMINAL PAIN ABDOMINAL PAIN ABDOMINAL PAIN ABDOMINAL PAIN
217 288 418 813
04492 05786 07857 14149
10000 10000 10000 10000
10000 10000 10000 10000
04492 05786 07857 14149
12500 12500 12500 12500
05615 07233 09821 17686
10000 10000 10000 10000
04492 05786 07857 14149
$4211 Misc Pediatric $5424 Misc Pediatric $7366 Misc Pediatric
$13265 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
252-1 252-2 252-3 252-4
MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE
331 412 635
1248
04904 06490 09833 19841
10000 10000 10000 10000
10000 10000 10000 10000
04904 06490 09833 19841
12500 12500 12500 12500
06130 08113 12291 24801
10000 10000 10000 10000
04904 06490 09833 19841
$4598 Misc Pediatric $6084 Misc Pediatric $9218 Misc Pediatric
$18601 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
253-1 253-2 253-3 253-4
OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE
251 334 504 878
05108 06777 10020 18601
10000 10000 10000 10000
10000 10000 10000 10000
05108 06777 10020 18601
12500 12500 12500 12500
06385 08471 12525 23251
10000 10000 10000 10000
05108 06777 10020 18601
$4789 Misc Pediatric $6353 Misc Pediatric $9394 Misc Pediatric
$17438 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
254-1 254-2 254-3 254-4
OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES
252 353 530
1066
04519 06282 09117 18053
10000 10000 10000 10000
10000 10000 10000 10000
04519 06282 09117 18053
12500 12500 12500 12500
05649 07853 11396 22566
10000 10000 10000 10000
04519 06282 09117 18053
$4237 Misc Pediatric $5889 Misc Pediatric $8547 Misc Pediatric
$16925 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
260-1 260-2 260-3 260-4
MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES
469 611
1081 2181
15085 19596 31029 63824
10000 10000 10000 10000
10000 10000 10000 10000
15085 19596 31029 63824
12500 12500 12500 12500
18856 24495 38786 79780
10000 10000 10000 10000
15085 19596 31029 63824
$14142 Misc Pediatric $18371 Misc Pediatric $29090 Misc Pediatric $59835 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
261-1 261-2 261-3 261-4
MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES
450 706
1116 1993
13049 18250 25711 50241
10000 10000 10000 10000
10000 10000 10000 10000
13049 18250 25711 50241
12500 12500 12500 12500
16311 22813 32139 62801
10000 10000 10000 10000
13049 18250 25711 50241
$12233 Misc Pediatric $17109 Misc Pediatric $24104 Misc Pediatric $47101 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
262-1 262-2 262-3 262-4
CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC
405 567 898
1751
11851 15637 23607 46363
10000 10000 10000 10000
10000 10000 10000 10000
11851 15637 23607 46363
12500 12500 12500 12500
14814 19546 29509 57954
10000 10000 10000 10000
11851 15637 23607 46363
$11110 Misc Pediatric $14660 Misc Pediatric $22132 Misc Pediatric $43465 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
263-1 263-2 263-3 263-4
LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY
236 364 635
1384
09345 12310 17676 36726
10000 10000 10000 10000
10000 10000 10000 10000
09345 12310 17676 36726
12500 12500 12500 12500
11681 15388 22095 45908
10000 10000 10000 10000
09345 12310 17676 36726
$8761 Misc Pediatric $11541 Misc Pediatric $16571 Misc Pediatric $34431 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
264-1 264-2 264-3 264-4
OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES
453 543
1067 2148
12526 13732 23159 51901
10000 10000 10000 10000
10000 10000 10000 10000
12526 13732 23159 51901
12500 12500 12500 12500
15658 17165 28949 64876
10000 10000 10000 10000
12526 13732 23159 51901
$11743 Misc Pediatric $12874 Misc Pediatric $21712 Misc Pediatric $48657 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
279-1 279-2 279-3 279-4
HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS
280 361 580
1157
04712 05945 09594 23269
10000 10000 10000 10000
10000 10000 10000 10000
04712 05945 09594 23269
12500 12500 12500 12500
05890 07431 11993 29086
10000 10000 10000 10000
04712 05945 09594 23269
$4418 Misc Pediatric $5573 Misc Pediatric $8994 Misc Pediatric
$21815 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
280-1 280-2 280-3 280-4
ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE
298 344 532
1047
04734 06141 09718 21422
10000 10000 10000 10000
10000 10000 10000 10000
04734 06141 09718 21422
12500 12500 12500 12500
05918 07676 12148 26778
10000 10000 10000 10000
04734 06141 09718 21422
$4438 Misc Pediatric $5757 Misc Pediatric $9111 Misc Pediatric
$20083 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
281-1 281-2 281-3 281-4
MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS
357 421 610 974
05079 07553 10730 17519
10000 10000 10000 10000
10000 10000 10000 10000
05079 07553 10730 17519
12500 12500 12500 12500
06349 09441 13413 21899
10000 10000 10000 10000
05079 07553 10730 17519
$4762 Misc Pediatric $7081 Misc Pediatric
$10059 Misc Pediatric $16424 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
282-1 282-2 282-3 282-4
DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY
318 403 649
1381
05507 07067 11213 27863
10000 10000 10000 10000
10000 10000 10000 10000
05507 07067 11213 27863
12500 12500 12500 12500
06884 08834 14016 34829
10000 10000 10000 10000
05507 07067 11213 27863
$5163 Misc Pediatric $6625 Misc Pediatric
$10512 Misc Pediatric $26122 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
283-1 283-2 283-3 283-4
OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER
286 338 505 947
04913 06300 09246 18497
10000 10000 10000 10000
10000 10000 10000 10000
04913 06300 09246 18497
12500 12500 12500 12500
06141 07875 11558 23121
10000 10000 10000 10000
04913 06300 09246 18497
$4606 Misc Pediatric $5906 Misc Pediatric $8668 Misc Pediatric
$17341 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
284-1 284-2 284-3 284-4
DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT
245 344 536
1059
05403 07447 10804 21256
10000 10000 10000 10000
10000 10000 10000 10000
05403 07447 10804 21256
12500 12500 12500 12500
06754 09309 13505 26570
10000 10000 10000 10000
05403 07447 10804 21256
$5065 Misc Pediatric $6982 Misc Pediatric
$10129 Misc Pediatric $19928 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
301-1 301-2 301-3 301-4
HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT
365 396 535
1280
18140 19690 25026 39991
10000 10000 10000 10000
10000 10000 10000 10000
18140 19690 25026 39991
12500 12500 12500 12500
22675 24613 31283 49989
10000 10000 10000 10000
18140 19690 25026 39991
$17006 Misc Pediatric $18459 Misc Pediatric $23462 Misc Pediatric $37492 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
302-1 302-2 302-3 302-4
KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT
296 338 519
1248
17428 19132 23798 43468
10000 10000 10000 10000
10000 10000 10000 10000
17428 19132 23798 43468
12500 12500 12500 12500
21785 23915 29748 54335
10000 10000 10000 10000
17428 19132 23798 43468
$16339 Misc Pediatric $17936 Misc Pediatric $22311 Misc Pediatric $40751 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
303-1 303-2 303-3 303-4
DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK
450 570 857
1607
47039 55422 77549
105744
10000 10000 10000 10000
10000 10000 10000 10000
47039 55422 77549
105744
12500 12500 12500 12500
58799 69278 96936
132180
10000 10000 10000 10000
47039 55422 77549
105744
$44099 Misc Pediatric $51958 Misc Pediatric $72702 Misc Pediatric $99135 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
304-1 304-2 304-3 304-4
DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK
300 405 735
1776
29720 35298 49644 81663
10000 10000 10000 10000
10000 10000 10000 10000
29720 35298 49644 81663
12500 12500 12500 12500
37150 44123 62055
102079
10000 10000 10000 10000
29720 35298 49644 81663
$27863 Misc Pediatric $33092 Misc Pediatric $46541 Misc Pediatric $76559 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
305-1 305-2 305-3 305-4
AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES
540 737
1137 1987
10654 14043 21843 42156
10000 10000 10000 10000
10000 10000 10000 10000
10654 14043 21843 42156
12500 12500 12500 12500
13318 17554 27304 52695
10000 10000 10000 10000
10654 14043 21843 42156
$9988 Misc Pediatric $13165 Misc Pediatric $20478 Misc Pediatric $39521 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
308-1 308-2 308-3 308-4
HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT
419 496 697
1264
13101 15854 21518 36506
10000 10000 10000 10000
10000 10000 10000 10000
13101 15854 21518 36506
12500 12500 12500 12500
16376 19818 26898 45633
10000 10000 10000 10000
13101 15854 21518 36506
$12282 Misc Pediatric $14863 Misc Pediatric $20173 Misc Pediatric $34224 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
309-1 309-2 309-3 309-4
HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT
278 490 865
1887
11482 16231 23288 42408
10000 10000 10000 10000
10000 10000 10000 10000
11482 16231 23288 42408
12500 12500 12500 12500
14353 20289 29110 53010
10000 10000 10000 10000
11482 16231 23288 42408
$10764 Misc Pediatric $15217 Misc Pediatric $21833 Misc Pediatric $39758 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
310-1 310-2 310-3 310-4
INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION
181 302 624
1622
08926 11888 17911 41661
10000 10000 10000 10000
10000 10000 10000 10000
08926 11888 17911 41661
12500 12500 12500 12500
11158 14860 22389 52076
10000 10000 10000 10000
08926 11888 17911 41661
$8368 Misc Pediatric $11145 Misc Pediatric $16792 Misc Pediatric $39057 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
312-1 312-2
SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES
538 940
12555 18447
10000 10000
10000 10000
12555 18447
12500 12500
15694 23059
10000 10000
12555 18447
$11770 Misc Pediatric $17294 Misc Pediatric
Misc Adult Misc Adult
312-3 312-4
SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES
1846 3284
31356 71148
10000 10000
10000 10000
31356 71148
12500 12500
39195 88935
10000 10000
31356 71148
$29396 Misc Pediatric $66701 Misc Pediatric
Misc Adult Misc Adult
313-1 313-2 313-3 313-4
KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT
270 444 785
1659
10852 15212 22743 43349
10000 10000 10000 10000
10000 10000 10000 10000
10852 15212 22743 43349
12500 12500 12500 12500
13565 19015 28429 54186
10000 10000 10000 10000
10852 15212 22743 43349
$10174 Misc Pediatric $14261 Misc Pediatric $21322 Misc Pediatric $40640 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
314-1 314-2 314-3 314-4
FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES
257 507 810
1579
09291 11320 16006 32885
10000 10000 10000 10000
10000 10000 10000 10000
09291 11320 16006 32885
12500 12500 12500 12500
11614 14150 20008 41106
10000 10000 10000 10000
09291 11320 16006 32885
$8710 Misc Pediatric $10613 Misc Pediatric $15006 Misc Pediatric $30830 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
315-1 315-2 315-3 315-4
SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES
185 267 649
1473
08387 15912 22542 44542
10000 10000 10000 10000
10000 10000 10000 10000
08387 15912 22542 44542
12500 12500 12500 12500
10484 19890 28178 55678
10000 10000 10000 10000
08387 15912 22542 44542
$7863 Misc Pediatric $14918 Misc Pediatric $21133 Misc Pediatric $41758 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
316-1 316-2 316-3 316-4
HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES
229 396 727
1430
07195 10564 17143 34568
10000 10000 10000 10000
10000 10000 10000 10000
07195 10564 17143 34568
12500 12500 12500 12500
08994 13205 21429 43210
10000 10000 10000 10000
07195 10564 17143 34568
$6745 Misc Pediatric $9904 Misc Pediatric
$16072 Misc Pediatric $32408 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
317-1 317-2 317-3 317-4
TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES
300 544
1030 2038
08204 11764 19738 43378
10000 10000 10000 10000
10000 10000 10000 10000
08204 11764 19738 43378
12500 12500 12500 12500
10255 14705 24673 54223
10000 10000 10000 10000
08204 11764 19738 43378
$7691 Misc Pediatric $11029 Misc Pediatric $18504 Misc Pediatric $40667 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
320-1 320-2 320-3 320-4
OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES
229 474 900
1844
09314 14085 21498 40942
10000 10000 10000 10000
10000 10000 10000 10000
09314 14085 21498 40942
12500 12500 12500 12500
11643 17606 26873 51178
10000 10000 10000 10000
09314 14085 21498 40942
$8732 Misc Pediatric $13205 Misc Pediatric $20154 Misc Pediatric $38383 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
321-1 321-2 321-3 321-4
CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP
174 322 869
1740
16800 21292 35737 65431
10000 10000 10000 10000
10000 10000 10000 10000
16800 21292 35737 65431
12500 12500 12500 12500
21000 26615 44671 81789
10000 10000 10000 10000
16800 21292 35737 65431
$15750 Misc Pediatric $19961 Misc Pediatric $33503 Misc Pediatric $61342 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
340-1 340-2 340-3 340-4
FRACTURE OF FEMUR FRACTURE OF FEMUR FRACTURE OF FEMUR FRACTURE OF FEMUR
307 350 507 717
04052 05213 07741 13545
10000 10000 10000 10000
10000 10000 10000 10000
04052 05213 07741 13545
12500 12500 12500 12500
05065 06516 09676 16931
10000 10000 10000 10000
04052 05213 07741 13545
$3799 Misc Pediatric $4887 Misc Pediatric $7257 Misc Pediatric
$12698 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
341-1 341-2 341-3 341-4
FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP
302 365 480 981
04685 05732 07835 19346
10000 10000 10000 10000
10000 10000 10000 10000
04685 05732 07835 19346
12500 12500 12500 12500
05856 07165 09794 24183
10000 10000 10000 10000
04685 05732 07835 19346
$4392 Misc Pediatric $5374 Misc Pediatric $7345 Misc Pediatric
$18137 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
342-1 342-2 342-3 342-4
FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK
223 336 523
1073
04199 06015 09030 19468
10000 10000 10000 10000
10000 10000 10000 10000
04199 06015 09030 19468
12500 12500 12500 12500
05249 07519 11288 24335
10000 10000 10000 10000
04199 06015 09030 19468
$3937 Misc Pediatric $5639 Misc Pediatric $8466 Misc Pediatric
$18251 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
343-1 343-2 343-3 343-4
MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG
381 462 768
1278
06313 07919 12982 22512
10000 10000 10000 10000
10000 10000 10000 10000
06313 07919 12982 22512
12500 12500 12500 12500
07891 09899 16228 28140
10000 10000 10000 10000
06313 07919 12982 22512
$5918 Misc Pediatric $7424 Misc Pediatric
$12171 Misc Pediatric $21105 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
344-1 344-2 344-3 344-4
OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS
510 624 996
1727
06188 08269 12369 20626
10000 10000 10000 10000
10000 10000 10000 10000
06188 08269 12369 20626
12500 12500 12500 12500
07735 10336 15461 25783
10000 10000 10000 10000
06188 08269 12369 20626
$5801 Misc Pediatric $7752 Misc Pediatric
$11596 Misc Pediatric $19337 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
346-1 346-2 346-3 346-4
CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS
312 418 742
1507
05246 07180 12230 29854
10000 10000 10000 10000
10000 10000 10000 10000
05246 07180 12230 29854
12500 12500 12500 12500
06558 08975 15288 37318
10000 10000 10000 10000
05246 07180 12230 29854
$4918 Misc Pediatric $6731 Misc Pediatric
$11466 Misc Pediatric $27988 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
347-1 347-2 347-3 347-4
OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES
288 388 534
1184
05202 07038 09895 23177
10000 10000 10000 10000
10000 10000 10000 10000
05202 07038 09895 23177
12500 12500 12500 12500
06503 08798 12369 28971
10000 10000 10000 10000
05202 07038 09895 23177
$4877 Misc Pediatric $6598 Misc Pediatric $9277 Misc Pediatric
$21728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
349-1 349-2 349-3 349-4
MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE
226 480 806
1387
04381 06459 10302 19261
10000 10000 10000 10000
10000 10000 10000 10000
04381 06459 10302 19261
12500 12500 12500 12500
05476 08074 12878 24076
10000 10000 10000 10000
04381 06459 10302 19261
$4107 Misc Pediatric $6055 Misc Pediatric $9658 Misc Pediatric
$18057 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
351-1 351-2 351-3 351-4
OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES
252 352 544
1111
04074 05668 08930 19109
10000 10000 10000 10000
10000 10000 10000 10000
04074 05668 08930 19109
12500 12500 12500 12500
05093 07085 11163 23886
10000 10000 10000 10000
04074 05668 08930 19109
$3819 Misc Pediatric $5314 Misc Pediatric $8372 Misc Pediatric
$17915 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
361-1 361-2 361-3 361-4
SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES
407 758
1393 2857
11097 14459 21415 45412
10000 10000 10000 10000
10000 10000 10000 10000
11097 14459 21415 45412
12500 12500 12500 12500
13871 18074 26769 56765
10000 10000 10000 10000
11097 14459 21415 45412
$10403 Misc Pediatric $13555 Misc Pediatric $20077 Misc Pediatric $42574 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
362-1 362-2 362-3 362-4
MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES
179 233 597
1380
10091 13554 17862 38257
10000 10000 10000 10000
10000 10000 10000 10000
10091 13554 17862 38257
12500 12500 12500 12500
12614 16943 22328 47821
10000 10000 10000 10000
10091 13554 17862 38257
$9460 Misc Pediatric $12707 Misc Pediatric $16746 Misc Pediatric $35866 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
363-1 363-2 363-3 363-4
BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY
209 314 532
1706
08797 14900 19039 35420
10000 10000 10000 10000
10000 10000 10000 10000
08797 14900 19039 35420
12500 12500 12500 12500
10996 18625 23799 44275
10000 10000 10000 10000
08797 14900 19039 35420
$8247 Misc Pediatric $13969 Misc Pediatric $17849 Misc Pediatric $33206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
364-1 364-2 364-3 364-4
OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES
289 508 943
1919
07645 10877 16986 30643
10000 10000 10000 10000
10000 10000 10000 10000
07645 10877 16986 30643
12500 12500 12500 12500
09556 13596 21233 38304
10000 10000 10000 10000
07645 10877 16986 30643
$7167 Misc Pediatric $10197 Misc Pediatric $15924 Misc Pediatric $28728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
380-1 380-2 380-3 380-4
SKIN ULCERS SKIN ULCERS SKIN ULCERS SKIN ULCERS
416 498 784
1662
05289 06545 09424 17199
10000 10000 10000 10000
10000 10000 10000 10000
05289 06545 09424 17199
12500 12500 12500 12500
06611 08181 11780 21499
10000 10000 10000 10000
05289 06545 09424 17199
$4958 Misc Pediatric $6136 Misc Pediatric $8835 Misc Pediatric
$16124 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
381-1 381-2 381-3 381-4
MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS
300 428 671
1406
03883 05748 09734 27512
10000 10000 10000 10000
10000 10000 10000 10000
03883 05748 09734 27512
12500 12500 12500 12500
04854 07185 12168 34390
10000 10000 10000 10000
03883 05748 09734 27512
$3640 Misc Pediatric $5389 Misc Pediatric $9126 Misc Pediatric
$25793 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
382-1 382-2 382-3 382-4
MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS
381 432 645
1003
03521 05612 09634 15729
10000 10000 10000 10000
10000 10000 10000 10000
03521 05612 09634 15729
12500 12500 12500 12500
04401 07015 12043 19661
10000 10000 10000 10000
03521 05612 09634 15729
$3301 Misc Pediatric $5261 Misc Pediatric $9032 Misc Pediatric
$14746 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
383-1 383-2 383-3 383-4
CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS
294 412 617
1198
04148 05905 09147 19560
10000 10000 10000 10000
10000 10000 10000 10000
04148 05905 09147 19560
12500 12500 12500 12500
05185 07381 11434 24450
10000 10000 10000 10000
04148 05905 09147 19560
$3889 Misc Pediatric $5536 Misc Pediatric $8575 Misc Pediatric
$18338 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
384-1 384-2 384-3 384-4
CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE
193 301 493
1134
04752 06220 08932 20168
10000 10000 10000 10000
10000 10000 10000 10000
04752 06220 08932 20168
12500 12500 12500 12500
05940 07775 11165 25210
10000 10000 10000 10000
04752 06220 08932 20168
$4455 Misc Pediatric $5831 Misc Pediatric $8374 Misc Pediatric
$18908 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
385-1 385-2 385-3 385-4
OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS
248 353 565
1295
03496 05103 07974 19128
10000 10000 10000 10000
10000 10000 10000 10000
03496 05103 07974 19128
12500 12500 12500 12500
04370 06379 09968 23910
10000 10000 10000 10000
03496 05103 07974 19128
$3278 Misc Pediatric $4784 Misc Pediatric $7476 Misc Pediatric
$17933 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
401-1 401-2 401-3 401-4
PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES
303 427 844
2452
13697 18347 29058 71913
10000 10000 10000 10000
10000 10000 10000 10000
13697 18347 29058 71913
12500 12500 12500 12500
17121 22934 36323 89891
10000 10000 10000 10000
13697 18347 29058 71913
$12841 Misc Pediatric $17200 Misc Pediatric $27242 Misc Pediatric $67418 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
403-1 403-2 403-3 403-4
PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY
183 222 497
1867
12813 14411 21531 61151
10000 10000 10000 10000
10000 10000 10000 10000
12813 14411 21531 61151
12500 12500 12500 12500
16016 18014 26914 76439
10000 10000 10000 10000
12813 14411 21531 61151
$12012 Misc Pediatric $13510 Misc Pediatric $20185 Misc Pediatric $57329 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
404-1 404-2 404-3 404-4
THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES
130 216 659
1638
07364 09479 18990 42519
10000 10000 10000 10000
10000 10000 10000 10000
07364 09479 18990 42519
12500 12500 12500 12500
09205 11849 23738 53149
10000 10000 10000 10000
07364 09479 18990 42519
$6904 Misc Pediatric $8887 Misc Pediatric
$17803 Misc Pediatric $39862 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
405-1 405-2 405-3 405-4
OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS
419 571 966
2131
11123 14210 21421 48796
10000 10000 10000 10000
10000 10000 10000 10000
11123 14210 21421 48796
12500 12500 12500 12500
13904 17763 26776 60995
10000 10000 10000 10000
11123 14210 21421 48796
$10428 Misc Pediatric $13322 Misc Pediatric $20082 Misc Pediatric $45746 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
420-1 420-2 420-3 420-4
DIABETES DIABETES DIABETES DIABETES
261 275 427 935
03897 05302 07862 19671
10000 10000 10000 10000
10000 10000 10000 10000
03897 05302 07862 19671
12500 12500 12500 12500
04871 06628 09828 24589
10000 10000 10000 10000
03897 05302 07862 19671
$3653 Misc Pediatric $4971 Misc Pediatric $7371 Misc Pediatric
$18442 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
421-1 421-2 421-3 421-4
MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS
351 483 676
1375
03211 05227 08190 17446
10000 10000 10000 10000
10000 10000 10000 10000
03211 05227 08190 17446
12500 12500 12500 12500
04014 06534 10238 21808
10000 10000 10000 10000
03211 05227 08190 17446
$3010 Misc Pediatric $4900 Misc Pediatric $7678 Misc Pediatric
$16356 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
422-1 422-2 422-3 422-4
HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS
199 291 445 914
02848 04625 06828 14444
10000 10000 10000 10000
10000 10000 10000 10000
02848 04625 06828 14444
12500 12500 12500 12500
03560 05781 08535 18055
10000 10000 10000 10000
02848 04625 06828 14444
$2670 Misc Pediatric $4336 Misc Pediatric $6401 Misc Pediatric
$13541 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
423-1 423-2 423-3 423-4
INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM
272 363 573
1504
04421 05846 09540 27384
10000 10000 10000 10000
10000 10000 10000 10000
04421 05846 09540 27384
12500 12500 12500 12500
05526 07308 11925 34230
10000 10000 10000 10000
04421 05846 09540 27384
$4145 Misc Pediatric $5481 Misc Pediatric $8944 Misc Pediatric
$25673 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
424-1 424-2 424-3 424-4
OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS
259 397 605
1147
04342 06514 09768 21520
10000 10000 10000 10000
10000 10000 10000 10000
04342 06514 09768 21520
12500 12500 12500 12500
05428 08143 12210 26900
10000 10000 10000 10000
04342 06514 09768 21520
$4071 Misc Pediatric $6107 Misc Pediatric $9158 Misc Pediatric
$20175 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
425-1 425-2 425-3
ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED
241 302 460
04017 05132 07667
10000 10000 10000
10000 10000 10000
04017 05132 07667
12500 12500 12500
05021 06415 09584
10000 10000 10000
04017 05132 07667
$3766 Misc Pediatric $4811 Misc Pediatric $7188 Misc Pediatric
Misc Adult Misc Adult Misc Adult
425-4 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 946 16767 10000 10000 16767 12500 20959 10000 16767 $15719 Misc Pediatric Misc Adult 440-1 440-2 440-3 440-4
KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT
458 561 864
2088
44667 50078 60562 99171
10000 10000 10000 10000
10000 10000 10000 10000
44667 50078 60562 99171
12500 12500 12500 12500
55834 62598 75703
123964
10000 10000 10000 10000
44667 50078 60562 99171
$41875 Misc Pediatric $46948 Misc Pediatric $56777 Misc Pediatric $92973 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
441-1 441-2 441-3 441-4
MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES
474 726 994
2196
14386 21567 29549 61841
10000 10000 10000 10000
10000 10000 10000 10000
14386 21567 29549 61841
12500 12500 12500 12500
17983 26959 36936 77301
10000 10000 10000 10000
14386 21567 29549 61841
$13487 Misc Pediatric $20219 Misc Pediatric $27702 Misc Pediatric $57976 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
442-1 442-2 442-3 442-4
KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY
325 422 795
1671
13139 15537 23456 49226
10000 10000 10000 10000
10000 10000 10000 10000
13139 15537 23456 49226
12500 12500 12500 12500
16424 19421 29320 61533
10000 10000 10000 10000
13139 15537 23456 49226
$12318 Misc Pediatric $14566 Misc Pediatric $21990 Misc Pediatric $46149 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
443-1 443-2 443-3 443-4
KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY
253 356 802
1752
10883 12834 18814 40742
10000 10000 10000 10000
10000 10000 10000 10000
10883 12834 18814 40742
12500 12500 12500 12500
13604 16043 23518 50928
10000 10000 10000 10000
10883 12834 18814 40742
$10203 Misc Pediatric $12032 Misc Pediatric $17638 Misc Pediatric $38196 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
444-1 444-2 444-3 444-4
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY
264 447 933
1617
09410 12604 20686 38830
10000 10000 10000 10000
10000 10000 10000 10000
09410 12604 20686 38830
12500 12500 12500 12500
11763 15755 25858 48538
10000 10000 10000 10000
09410 12604 20686 38830
$8822 Misc Pediatric $11816 Misc Pediatric $19393 Misc Pediatric $36403 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
445-1 445-2 445-3 445-4
OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES
190 319 781
1545
08552 11610 15964 31570
10000 10000 10000 10000
10000 10000 10000 10000
08552 11610 15964 31570
12500 12500 12500 12500
10690 14513 19955 39463
10000 10000 10000 10000
08552 11610 15964 31570
$8018 Misc Pediatric $10884 Misc Pediatric $14966 Misc Pediatric $29597 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
446-1 446-2 446-3 446-4
URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES
188 261 612
1363
06758 08690 14202 30173
10000 10000 10000 10000
10000 10000 10000 10000
06758 08690 14202 30173
12500 12500 12500 12500
08448 10863 17753 37716
10000 10000 10000 10000
06758 08690 14202 30173
$6336 Misc Pediatric $8147 Misc Pediatric
$13314 Misc Pediatric $28287 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
447-1 447-2 447-3 447-4
OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES
228 365 728
1787
11479 13294 19661 43932
10000 10000 10000 10000
10000 10000 10000 10000
11479 13294 19661 43932
12500 12500 12500 12500
14349 16618 24576 54915
10000 10000 10000 10000
11479 13294 19661 43932
$10762 Misc Pediatric $12463 Misc Pediatric $18432 Misc Pediatric $41186 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
460-1 460-2 460-3 460-4
RENAL FAILURE RENAL FAILURE RENAL FAILURE RENAL FAILURE
299 376 496
1115
04323 06061 07896 19936
10000 10000 10000 10000
10000 10000 10000 10000
04323 06061 07896 19936
12500 12500 12500 12500
05404 07576 09870 24920
10000 10000 10000 10000
04323 06061 07896 19936
$4053 Misc Pediatric $5682 Misc Pediatric $7403 Misc Pediatric
$18690 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
461-1 461-2 461-3 461-4
KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY
271 374 601
1108
04315 05992 09498 16929
10000 10000 10000 10000
10000 10000 10000 10000
04315 05992 09498 16929
12500 12500 12500 12500
05394 07490 11873 21161
10000 10000 10000 10000
04315 05992 09498 16929
$4045 Misc Pediatric $5618 Misc Pediatric $8904 Misc Pediatric
$15871 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
462-1 462-2 462-3 462-4
NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS
260 370 656
1359
03798 05298 09439 23905
10000 10000 10000 10000
10000 10000 10000 10000
03798 05298 09439 23905
12500 12500 12500 12500
04748 06623 11799 29881
10000 10000 10000 10000
03798 05298 09439 23905
$3561 Misc Pediatric $4967 Misc Pediatric $8849 Misc Pediatric
$22411 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
463-1 463-2 463-3 463-4
KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS
268 352 507 910
04120 05628 07879 14066
10000 10000 10000 10000
10000 10000 10000 10000
04120 05628 07879 14066
12500 12500 12500 12500
05150 07035 09849 17583
10000 10000 10000 10000
04120 05628 07879 14066
$3863 Misc Pediatric $5276 Misc Pediatric $7387 Misc Pediatric
$13187 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
465-1 465-2 465-3 465-4
URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION
165 202 380 860
04374 05548 08751 18922
10000 10000 10000 10000
10000 10000 10000 10000
04374 05548 08751 18922
12500 12500 12500 12500
05468 06935 10939 23653
10000 10000 10000 10000
04374 05548 08751 18922
$4101 Misc Pediatric $5201 Misc Pediatric $8204 Misc Pediatric
$17739 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
466-1 466-2 466-3 466-4
MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC
221 343 533 971
03576 05752 08974 17498
10000 10000 10000 10000
10000 10000 10000 10000
03576 05752 08974 17498
12500 12500 12500 12500
04470 07190 11218 21873
10000 10000 10000 10000
03576 05752 08974 17498
$3353 Misc Pediatric $5393 Misc Pediatric $8413 Misc Pediatric
$16404 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
468-1 468-2 468-3 468-4
OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS
246 335 509
1057
04152 05935 08698 18661
10000 10000 10000 10000
10000 10000 10000 10000
04152 05935 08698 18661
12500 12500 12500 12500
05190 07419 10873 23326
10000 10000 10000 10000
04152 05935 08698 18661
$3893 Misc Pediatric $5564 Misc Pediatric $8154 Misc Pediatric
$17495 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
480-1 480-2 480-3 480-4
MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES
180 241 618
1422
12119 13477 20992 45258
10000 10000 10000 10000
10000 10000 10000 10000
12119 13477 20992 45258
12500 12500 12500 12500
15149 16846 26240 56573
10000 10000 10000 10000
12119 13477 20992 45258
$11362 Misc Pediatric $12635 Misc Pediatric $19680 Misc Pediatric $42429 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
481-1 481-2 481-3 481-4
PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES
228 267 830
1810
06794 11922 17939 41143
10000 10000 10000 10000
10000 10000 10000 10000
06794 11922 17939 41143
12500 12500 12500 12500
08493 14903 22424 51429
10000 10000 10000 10000
06794 11922 17939 41143
$6369 Misc Pediatric $11177 Misc Pediatric $16818 Misc Pediatric $38572 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
482-1 482-2 482-3 482-4
TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY
169 278 716
1341
05918 07555 14662 30717
10000 10000 10000 10000
10000 10000 10000 10000
05918 07555 14662 30717
12500 12500 12500 12500
07398 09444 18328 38396
10000 10000 10000 10000
05918 07555 14662 30717
$5548 Misc Pediatric $7083 Misc Pediatric
$13746 Misc Pediatric $28797 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
483-1 483-2 483-3 483-4
TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES
203 541
1127 1970
06074 11326 22018 44244
10000 10000 10000 10000
10000 10000 10000 10000
06074 11326 22018 44244
12500 12500 12500 12500
07593 14158 27523 55305
10000 10000 10000 10000
06074 11326 22018 44244
$5694 Misc Pediatric $10618 Misc Pediatric $20642 Misc Pediatric $41479 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
484-1 484-2 484-3 484-4
OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
250 191 502
1578
07704 11762 15177 36555
10000 10000 10000 10000
10000 10000 10000 10000
07704 11762 15177 36555
12500 12500 12500 12500
09630 14703 18971 45694
10000 10000 10000 10000
07704 11762 15177 36555
$7223 Misc Pediatric $11027 Misc Pediatric $14228 Misc Pediatric $34270 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
500-1 500-2 500-3 500-4
MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM
266 431 601
1109
03789 05904 09172 17461
10000 10000 10000 10000
10000 10000 10000 10000
03789 05904 09172 17461
12500 12500 12500 12500
04736 07380 11465 21826
10000 10000 10000 10000
03789 05904 09172 17461
$3552 Misc Pediatric $5535 Misc Pediatric $8599 Misc Pediatric
$16370 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
501-1 501-2 501-3 501-4
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY
258 351 547
1074
04044 05542 08322 16765
10000 10000 10000 10000
10000 10000 10000 10000
04044 05542 08322 16765
12500 12500 12500 12500
05055 06928 10403 20956
10000 10000 10000 10000
04044 05542 08322 16765
$3791 Misc Pediatric $5196 Misc Pediatric $7802 Misc Pediatric
$15717 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
510-1 510-2 510-3 510-4
PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS
244 387 892
1787
11433 14140 25807 52317
10000 10000 10000 10000
10000 10000 10000 10000
11433 14140 25807 52317
12500 12500 12500 12500
14291 17675 32259 65396
10000 10000 10000 10000
11433 14140 25807 52317
$10718 Misc Pediatric $13256 Misc Pediatric $24194 Misc Pediatric $49047 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
511-1 511-2 511-3 511-4
UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY
330 488 862
1777
11911 14923 22750 49888
10000 10000 10000 10000
10000 10000 10000 10000
11911 14923 22750 49888
12500 12500 12500 12500
14889 18654 28438 62360
10000 10000 10000 10000
11911 14923 22750 49888
$11167 Misc Pediatric $13990 Misc Pediatric $21328 Misc Pediatric $46770 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
512-1 512-2 512-3 512-4
UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG
217 308 682
1629
10603 12410 19879 45702
10000 10000 10000 10000
10000 10000 10000 10000
10603 12410 19879 45702
12500 12500 12500 12500
13254 15513 24849 57128
10000 10000 10000 10000
10603 12410 19879 45702
$9940 Misc Pediatric $11634 Misc Pediatric $18637 Misc Pediatric $42846 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
513-1 513-2 513-3 513-4
UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
186 251 564
1508
08515 10026 16283 40387
10000 10000 10000 10000
10000 10000 10000 10000
08515 10026 16283 40387
12500 12500 12500 12500
10644 12533 20354 50484
10000 10000 10000 10000
08515 10026 16283 40387
$7983 Misc Pediatric $9399 Misc Pediatric
$15265 Misc Pediatric $37863 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
514-1 514-2 514-3 514-4
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
140 172 529
1557
07298 09618 15881 40691
10000 10000 10000 10000
10000 10000 10000 10000
07298 09618 15881 40691
12500 12500 12500 12500
09123 12023 19851 50864
10000 10000 10000 10000
07298 09618 15881 40691
$6842 Misc Pediatric $9017 Misc Pediatric
$14888 Misc Pediatric $38148 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
517-1 517-2 517-3 517-4
DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES
192 289 663
1364
06030 08036 13633 29709
10000 10000 10000 10000
10000 10000 10000 10000
06030 08036 13633 29709
12500 12500 12500 12500
07538 10045 17041 37136
10000 10000 10000 10000
06030 08036 13633 29709
$5653 Misc Pediatric $7534 Misc Pediatric
$12781 Misc Pediatric $27852 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
518-1 518-2 518-3 518-4
OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
223 382 837
1827
06924 10040 18032 44556
10000 10000 10000 10000
10000 10000 10000 10000
06924 10040 18032 44556
12500 12500 12500 12500
08655 12550 22540 55695
10000 10000 10000 10000
06924 10040 18032 44556
$6491 Misc Pediatric $9413 Misc Pediatric
$16905 Misc Pediatric $41771 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
519-1 519-2 519-3 519-4
UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA
206 279 613
1485
08286 10051 17505 39433
10000 10000 10000 10000
10000 10000 10000 10000
08286 10051 17505 39433
12500 12500 12500 12500
10358 12564 21881 49291
10000 10000 10000 10000
08286 10051 17505 39433
$7768 Misc Pediatric $9423 Misc Pediatric
$16411 Misc Pediatric $36968 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
530-1 530-2 530-3 530-4
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
310 385 643
1178
04420 06163 09992 18972
10000 10000 10000 10000
10000 10000 10000 10000
04420 06163 09992 18972
12500 12500 12500 12500
05525 07704 12490 23715
10000 10000 10000 10000
04420 06163 09992 18972
$4144 Misc Pediatric $5778 Misc Pediatric $9368 Misc Pediatric
$17786 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
531-1 531-2 531-3 531-4
FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS
266 383 638
1303
04544 06407 09987 20595
10000 10000 10000 10000
10000 10000 10000 10000
04544 06407 09987 20595
12500 12500 12500 12500
05680 08009 12484 25744
10000 10000 10000 10000
04544 06407 09987 20595
$4260 Misc Pediatric $6007 Misc Pediatric $9363 Misc Pediatric
$19308 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
532-1 532-2 532-3 532-4
MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
177 237 434
1003
03922 04787 07941 17650
10000 10000 10000 10000
10000 10000 10000 10000
03922 04787 07941 17650
12500 12500 12500 12500
04903 05984 09926 22063
10000 10000 10000 10000
03922 04787 07941 17650
$3677 Misc Pediatric $4488 Misc Pediatric $7445 Misc Pediatric
$16547 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
540-1 540-2 540-3 540-4
CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY
298 391 634
1053
05654 06864 09354 23719
10000 10000 10000 10000
10600 10600 10600 10600
05993 07276 09915 25142
10000 10000 10000 10000
05993 07276 09915 25142
10000 10000 10000 10000
05654 06864 09354 23719
$4495 Obstetrics $5457 Obstetrics $7436 Obstetrics
$18857 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
541-1 541-2 541-3 541-4
VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC
212 249 491 838
05628 06076 08661 23515
10000 10000 10000 10000
10600 10600 10600 10600
05966 06441 09181 24926
10000 10000 10000 10000
05966 06441 09181 24926
10000 10000 10000 10000
05628 06076 08661 23515
$4474 Obstetrics $4830 Obstetrics $6886 Obstetrics
$18694 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
542-1 542-2 542-3 542-4
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC
216 296 614 993
03695 04647 08572 36195
10000 10000 10000 10000
10600 10600 10600 10600
03917 04926 09086 38367
10000 10000 10000 10000
03917 04926 09086 38367
10000 10000 10000 10000
03695 04647 08572 36195
$2938 Obstetrics $3694 Obstetrics $6815 Obstetrics
$28775 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
544-1 544-2 544-3 544-4
DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES
136 200 407 914
04586 05897 09822 25061
10000 10000 10000 10000
10600 10600 10600 10600
04861 06251 10411 26565
10000 10000 10000 10000
04861 06251 10411 26565
10000 10000 10000 10000
04586 05897 09822 25061
$3646 Obstetrics Obstetrics $4688 Obstetrics Obstetrics $7808 Obstetrics Obstetrics
$19924 Obstetrics Obstetrics 545-1 545-2 545-3 545-4
ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE
164 190 265 576
06988 08147 10540 19945
10000 10000 10000 10000
10600 10600 10600 10600
07407 08636 11172 21142
10000 10000 10000 10000
07407 08636 11172 21142
10000 10000 10000 10000
06988 08147 10540 19945
$5555 Obstetrics Obstetrics $6477 Obstetrics Obstetrics $8379 Obstetrics Obstetrics
$15856 Obstetrics Obstetrics 546-1 546-2 546-3 546-4
OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES
285 454 755
1446
05023 07207 13295 43377
10000 10000 10000 10000
10600 10600 10600 10600
05324 07639 14093 45980
10000 10000 10000 10000
05324 07639 14093 45980
10000 10000 10000 10000
05023 07207 13295 43377
$3993 Obstetrics Obstetrics $5730 Obstetrics Obstetrics
$10570 Obstetrics Obstetrics $34485 Obstetrics Obstetrics
560-1 560-2 560-3 560-4
VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY
203 237 385 935
03307 03856 05399 15061
10000 10000 10000 10000
10600 10600 10600 10600
03505 04087 05723 15965
10000 10000 10000 10000
03505 04087 05723 15965
10000 10000 10000 10000
03307 03856 05399 15061
$2629 Obstetrics Obstetrics $3066 Obstetrics Obstetrics $4292 Obstetrics Obstetrics
$11974 Obstetrics Obstetrics 561-1 561-2 561-3 561-4
POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE
211 257 393 688
02511 03908 06071 15617
10000 10000 10000 10000
10600 10600 10600 10600
02662 04142 06435 16554
10000 10000 10000 10000
02662 04142 06435 16554
10000 10000 10000 10000
02511 03908 06071 15617
$1996 Obstetrics Obstetrics $3107 Obstetrics Obstetrics $4826 Obstetrics Obstetrics
$12416 Obstetrics Obstetrics 563-1 563-2 563-3 563-4
THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION
259 391 747 720
02581 03376 05162 09652
10000 10000 10000 10000
10600 10600 10600 10600
02736 03579 05472 10231
10000 10000 10000 10000
02736 03579 05472 10231
10000 10000 10000 10000
02581 03376 05162 09652
$2052 Obstetrics Obstetrics $2684 Obstetrics Obstetrics $4104 Obstetrics Obstetrics $7673 Obstetrics Obstetrics
564-1 564-2 564-3 564-4
ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY
137 170 276 808
02881 03463 04901 16676
10000 10000 10000 10000
10600 10600 10600 10600
03054 03671 05195 17677
10000 10000 10000 10000
03054 03671 05195 17677
10000 10000 10000 10000
02881 03463 04901 16676
$2290 Obstetrics Obstetrics $2753 Obstetrics Obstetrics $3896 Obstetrics Obstetrics
$13257 Obstetrics Obstetrics 565-1 565-2 565-3 565-4
FALSE LABOR FALSE LABOR FALSE LABOR FALSE LABOR
123 185 735 808
01245 01782 02687 02986
10000 10000 10000 10000
10600 10600 10600 10600
01320 01889 02848 03165
10000 10000 10000 10000
01320 01889 02848 03165
10000 10000 10000 10000
01245 01782 02687 02986
$990 Obstetrics Obstetrics $1417 Obstetrics Obstetrics $2136 Obstetrics Obstetrics $2374 Obstetrics Obstetrics
566-1 566-2 566-3 566-4
OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES
211 294 544 843
02442 03252 04790 14726
10000 10000 10000 10000
10600 10600 10600 10600
02589 03447 05077 15610
10000 10000 10000 10000
02589 03447 05077 15610
10000 10000 10000 10000
02442 03252 04790 14726
$1941 Obstetrics Obstetrics $2585 Obstetrics Obstetrics $3808 Obstetrics Obstetrics
$11707 Obstetrics Obstetrics 580-1 580-2 580-3 580-4
NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE
144 159 182 165
02398 03209 05011 08512
12500 12500 12500 12500
10000 10000 10000 10000
02998 04011 06264 10640
10000 10000 10000 10000
02998 04011 06264 10640
17500 17500 17500 17500
04197 05616 08769 14896
$2248 Neonate Neonate $3008 Neonate Neonate $4698 Neonate Neonate $7980 Neonate Neonate
581-1 581-2 581-3 581-4
NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE
124 128 126 135
00982 01477 02362 04408
12500 12500 12500 12500
10000 10000 10000 10000
01228 01846 02953 05510
10000 10000 10000 10000
01228 01846 02953 05510
17500 17500 17500 17500
01719 02585 04134 07714
$921 Neonate Neonate $1385 Neonate Neonate $2214 Neonate Neonate $4133 Neonate Neonate
583-1 583-2 583-3 583-4
NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO
2070 2300 3077 4886
99741 157496 173245 240894
12500 12500 12500 12500
10000 10000 10000 10000
124676 196870 216556 301118
10000 10000 10000 10000
124676 196870 216556 301118
17500 17500 17500 17500
174547 275618 303179 421565
$93507 Neonate Neonate $147653 Neonate Neonate $162417 Neonate Neonate $225838 Neonate Neonate
588-1 588-2 588-3 588-4
NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE
4442 4935 7714
10207
48410 70035
142903 216660
12500 12500 12500 12500
10000 10000 10000 10000
60513 87544
178629 270825
10000 10000 10000 10000
60513 87544
178629 270825
17500 17500 17500 17500
84718 122561 250080 379155
$45384 Neonate Neonate $65658 Neonate Neonate
$133972 Neonate Neonate $203119 Neonate Neonate
589-1 589-2 589-3 589-4
NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS
5843 5041 3035
265
115468 104972
95430 04454
12500 12500 12500 12500
10000 10000 10000 10000
144335 131215 119288
05568
10000 10000 10000 10000
144335 131215 119288
05568
17500 17500 17500 17500
202069 183701 167003
07795
$108251 Neonate Neonate $98411 Neonate Neonate $89466 Neonate Neonate
$4176 Neonate Neonate 591-1 591-2 591-3 591-4
NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE
211 3710 5061 7221
01574 55672 88282
132286
12500 12500 12500 12500
10000 10000 10000 10000
01968 69590
110353 165358
10000 10000 10000 10000
01968 69590
110353 165358
17500 17500 17500 17500
02755 97426
154494 231501
$1476 Neonate Neonate $52193 Neonate Neonate $82764 Neonate Neonate
$124018 Neonate Neonate 593-1 593-2 593-3 593-4
NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE
1928 4851 5965 7143
15109 51914 82800
122454
12500 12500 12500 12500
10000 10000 10000 10000
18886 64893
103500 153068
10000 10000 10000 10000
18886 64893
103500 153068
17500 17500 17500 17500
26441 90850
144900 214295
$14165 Neonate Neonate $48669 Neonate Neonate $77625 Neonate Neonate
$114801 Neonate Neonate 602-1 602-2 602-3 602-4
NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2513 4403 5324 6307
29635 58707 77593
104733
12500 12500 12500 12500
10000 10000 10000 10000
37044 73384 96991
130916
10000 10000 10000 10000
37044 73384 96991
130916
17500 17500 17500 17500
51861 102737 135788 183283
$27783 Neonate Neonate $55038 Neonate Neonate $72743 Neonate Neonate $98187 Neonate Neonate
603-1 603-2 603-3 603-4
NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION
2234 3619 4843 5396
17223 42526 65587 70750
12500 12500 12500 12500
10000 10000 10000 10000
21529 53158 81984 88438
10000 10000 10000 10000
21529 53158 81984 88438
17500 17500 17500 17500
30140 74421
114777 123813
$16147 Neonate Neonate $39868 Neonate Neonate $61488 Neonate Neonate $66328 Neonate Neonate
607-1 607-2 607-3 607-4
NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2509 3582 4341 4957
27503 47486 61883 79508
12500 12500 12500 12500
10000 10000 10000 10000
34379 59358 77354 99385
10000 10000 10000 10000
34379 59358 77354 99385
17500 17500 17500 17500
48130 83101
108295 139139
$25784 Neonate Neonate $44518 Neonate Neonate $58015 Neonate Neonate $74539 Neonate Neonate
608-1 608-2 608-3 608-4
NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION
1980 3004 3846 4414
21292 36047 52684 60424
12500 12500 12500 12500
10000 10000 10000 10000
26615 45059 65855 75530
10000 10000 10000 10000
26615 45059 65855 75530
17500 17500 17500 17500
37261 63082 92197
105742
$19961 Neonate Neonate $33794 Neonate Neonate $49391 Neonate Neonate $56648 Neonate Neonate
609-1 609-2 609-3 609-4
NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE
1933 2210 3803 6267
27332 38628 65636
119134
12500 12500 12500 12500
10000 10000 10000 10000
34165 48285 82045
148918
10000 10000 10000 10000
34165 48285 82045
148918
17500 17500 17500 17500
47831 67599
114863 208485
$25624 Neonate Neonate $36214 Neonate Neonate $61534 Neonate Neonate
$111688 Neonate Neonate 611-1 611-2 611-3 611-4
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY
1313 2123 3133 3614
11780 25158 40556 52442
12500 12500 12500 12500
10000 10000 10000 10000
14725 31448 50695 65553
10000 10000 10000 10000
14725 31448 50695 65553
17500 17500 17500 17500
20615 44027 70973 91774
$11044 Neonate Neonate $23586 Neonate Neonate $38021 Neonate Neonate $49164 Neonate Neonate
612-1 612-2 612-3 612-4
NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND
1756 2442 3248 3834
21880 32223 46803 62297
12500 12500 12500 12500
10000 10000 10000 10000
27350 40279 58504 77871
10000 10000 10000 10000
27350 40279 58504 77871
17500 17500 17500 17500
38290 56390 81905
109020
$20513 Neonate Neonate $30209 Neonate Neonate $43878 Neonate Neonate $58403 Neonate Neonate
613-1 613-2 613-3 613-4
NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION
1439 2153 2853 3338
16593 26831 37601 48828
12500 12500 12500 12500
10000 10000 10000 10000
20741 33539 47001 61035
10000 10000 10000 10000
20741 33539 47001 61035
17500 17500 17500 17500
29038 46954 65802 85449
$15556 Neonate Neonate $25154 Neonate Neonate $35251 Neonate Neonate $45776 Neonate Neonate
614-1 614-2 614-3 614-4
NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION
1123 2008 2852 3640
09241 22768 36403 50802
12500 12500 12500 12500
10000 10000 10000 10000
11551 28460 45504 63503
10000 10000 10000 10000
11551 28460 45504 63503
17500 17500 17500 17500
16172 39844 63705 88904
$8663 Neonate Neonate $21345 Neonate Neonate $34128 Neonate Neonate $47627 Neonate Neonate
621-1 621-2 621-3 621-4
NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY
820 1397 2125 2416
06082 15379 27206 38101
12500 12500 12500 12500
10000 10000 10000 10000
07603 19224 34008 47626
10000 10000 10000 10000
07603 19224 34008 47626
17500 17500 17500 17500
10644 26913 47611 66677
$5702 Neonate Neonate $14418 Neonate Neonate $25506 Neonate Neonate $35720 Neonate Neonate
622-1 622-2 622-3 622-4
NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND
1118 1514 1977 2285
13666 20913 29736 47202
12500 12500 12500 12500
10000 10000 10000 10000
17083 26141 37170 59003
10000 10000 10000 10000
17083 26141 37170 59003
17500 17500 17500 17500
23916 36598 52038 82604
$12812 Neonate Neonate $19606 Neonate Neonate $27878 Neonate Neonate $44252 Neonate Neonate
623-1 623-2 623-3 623-4
NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION
924 1399 1872 2738
09934 16800 25087 38932
12500 12500 12500 12500
10000 10000 10000 10000
12418 21000 31359 48665
10000 10000 10000 10000
12418 21000 31359 48665
17500 17500 17500 17500
17385 29400 43902 68131
$9313 Neonate Neonate $15750 Neonate Neonate $23519 Neonate Neonate $36499 Neonate Neonate
625-1 625-2 625-3 625-4
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION
1157 1621 1925 2015
11469 18627 23298 29194
12500 12500 12500 12500
10000 10000 10000 10000
14336 23284 29123 36493
10000 10000 10000 10000
14336 23284 29123 36493
17500 17500 17500 17500
20071 32597 40772 51090
$10752 Neonate Neonate $17463 Neonate Neonate $21842 Neonate Neonate $27369 Neonate Neonate
626-1 626-2 626-3 626-4
NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
279 456 864
1838
01387 02587 07679 22819
10000 10000 10000 10000
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
$1040 Normal newborn Normal newborn $1940 Normal newborn Normal newborn $5759 Normal newborn Normal newborn
$17114 Normal newborn Normal newborn 630-1 630-2 630-3 630-4
NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE
486 940
1448 3912
20468 32885 52250
112072
12500 12500 12500 12500
10000 10000 10000 10000
25585 41106 65313
140090
10000 10000 10000 10000
25585 41106 65313
140090
17500 17500 17500 17500
35819 57549 91438
196126
$19189 Neonate Neonate $30830 Neonate Neonate $48984 Neonate Neonate
$105068 Neonate Neonate 631-1 631-2 631-3 631-4
NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE
335 886
2279 5111
09217 16766 37480 96324
12500 12500 12500 12500
10000 10000 10000 10000
11521 20958 46850
120405
10000 10000 10000 10000
11521 20958 46850
120405
17500 17500 17500 17500
16130 29341 65590
168567
$8641 Neonate Neonate $15718 Neonate Neonate $35138 Neonate Neonate $90304 Neonate Neonate
633-1 633-2 633-3 633-4
NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY
296 651
1226 2381
01972 05798 13892 39728
12500 12500 12500 12500
10000 10000 10000 10000
02465 07248 17365 49660
10000 10000 10000 10000
02465 07248 17365 49660
17500 17500 17500 17500
03451 10147 24311 69524
$1849 Neonate Neonate $5436 Neonate Neonate
$13024 Neonate Neonate $37245 Neonate Neonate
634-1 634-2 634-3 634-4
NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND
465 749
1261 2233
04886 09445 20176 46934
12500 12500 12500 12500
10000 10000 10000 10000
06108 11806 25220 58668
10000 10000 10000 10000
06108 11806 25220 58668
17500 17500 17500 17500
08551 16529 35308 82135
$4581 Neonate Neonate $8855 Neonate Neonate
$18915 Neonate Neonate $44001 Neonate Neonate
636-1 636-2 636-3 636-4
NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION
558 779
1164 1896
05582 08840 15558 30613
12500 12500 12500 12500
10000 10000 10000 10000
06978 11050 19448 38266
10000 10000 10000 10000
06978 11050 19448 38266
17500 17500 17500 17500
09769 15470 27227 53573
$5233 Neonate Neonate $8288 Neonate Neonate
$14586 Neonate Neonate $28700 Neonate Neonate
639-1 639-2 639-3 639-4
NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION
441 704 998
1653
03287 06622 11809 27285
12500 12500 12500 12500
10000 10000 10000 10000
04109 08278 14761 34106
10000 10000 10000 10000
04109 08278 14761 34106
17500 17500 17500 17500
05752 11589 20666 47749
$3082 Neonate Neonate $6208 Neonate Neonate
$11071 Neonate Neonate $25580 Neonate Neonate
640-1 NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 210 01012 10000 10000 01012 10000 01012 10000 01012 $759 Normal newborn Normal newborn
640-2 640-3 640-4
NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
245 376
1206
01353 02864 14726
10000 10000 10000
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
$1015 Normal newborn Normal newborn $2148 Normal newborn Normal newborn
$11045 Normal newborn Normal newborn 650-1 650-2 650-3 650-4
SPLENECTOMY SPLENECTOMY SPLENECTOMY SPLENECTOMY
348 537 848
1563
12985 17965 25202 50826
10000 10000 10000 10000
10000 10000 10000 10000
12985 17965 25202 50826
12500 12500 12500 12500
16231 22456 31503 63533
10000 10000 10000 10000
12985 17965 25202 50826
$12173 Misc Pediatric Misc Adult $16842 Misc Pediatric Misc Adult $23627 Misc Pediatric Misc Adult $47649 Misc Pediatric Misc Adult
651-1 651-2 651-3 651-4
OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS
331 472 962
2426
09234 13695 21005 59541
10000 10000 10000 10000
10000 10000 10000 10000
09234 13695 21005 59541
12500 12500 12500 12500
11543 17119 26256 74426
10000 10000 10000 10000
09234 13695 21005 59541
$8657 Misc Pediatric Misc Adult $12839 Misc Pediatric Misc Adult $19692 Misc Pediatric Misc Adult $55820 Misc Pediatric Misc Adult
660-1 660-2 660-3 660-4
MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL
305 408 648
1435
05399 07219 11819 30180
10000 10000 10000 10000
10000 10000 10000 10000
05399 07219 11819 30180
12500 12500 12500 12500
06749 09024 14774 37725
10000 10000 10000 10000
05399 07219 11819 30180
$5062 Misc Pediatric Misc Adult $6768 Misc Pediatric Misc Adult
$11080 Misc Pediatric Misc Adult $28294 Misc Pediatric Misc Adult
661-1 661-2 661-3 661-4
COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS
275 375 566
1265
06473 08098 12433 27857
10000 10000 10000 10000
10000 10000 10000 10000
06473 08098 12433 27857
12500 12500 12500 12500
08091 10123 15541 34821
10000 10000 10000 10000
06473 08098 12433 27857
$6068 Misc Pediatric Misc Adult $7592 Misc Pediatric Misc Adult
$11656 Misc Pediatric Misc Adult $26116 Misc Pediatric Misc Adult
662-1 662-2 662-3 662-4
SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS
412 538 785
1302
05044 07003 10778 23937
10000 10000 10000 10000
10000 10000 10000 10000
05044 07003 10778 23937
12500 12500 12500 12500
06305 08754 13473 29921
10000 10000 10000 10000
05044 07003 10778 23937
$4729 Misc Pediatric Misc Adult $6565 Misc Pediatric Misc Adult
$10104 Misc Pediatric Misc Adult $22441 Misc Pediatric Misc Adult
663-1 663-2 663-3 663-4
OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS
232 301 451 900
04474 05959 08513 16106
10000 10000 10000 10000
10000 10000 10000 10000
04474 05959 08513 16106
12500 12500 12500 12500
05593 07449 10641 20133
10000 10000 10000 10000
04474 05959 08513 16106
$4194 Misc Pediatric Misc Adult $5587 Misc Pediatric Misc Adult $7981 Misc Pediatric Misc Adult
$15099 Misc Pediatric Misc Adult 680-1 680-2 680-3 680-4
MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
408 633
1185 2456
13702 18600 32002 66288
10000 10000 10000 10000
10000 10000 10000 10000
13702 18600 32002 66288
12500 12500 12500 12500
17128 23250 40003 82860
10000 10000 10000 10000
13702 18600 32002 66288
$12846 Misc Pediatric Misc Adult $17438 Misc Pediatric Misc Adult $30002 Misc Pediatric Misc Adult $62145 Misc Pediatric Misc Adult
681-1 681-2 681-3 681-4
OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
268 507
1111 2510
09800 13647 24597 59170
10000 10000 10000 10000
10000 10000 10000 10000
09800 13647 24597 59170
12500 12500 12500 12500
12250 17059 30746 73963
10000 10000 10000 10000
09800 13647 24597 59170
$9188 Misc Pediatric Misc Adult $12794 Misc Pediatric Misc Adult $23060 Misc Pediatric Misc Adult $55472 Misc Pediatric Misc Adult
690-1 690-2 690-3 690-4
ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA
495 740
1461 2485
07040 11869 23551 52504
10000 10000 10000 10000
10000 10000 10000 10000
07040 11869 23551 52504
12500 12500 12500 12500
08800 14836 29439 65630
10000 10000 10000 10000
07040 11869 23551 52504
$6600 Misc Pediatric Misc Adult $11127 Misc Pediatric Misc Adult $22079 Misc Pediatric Misc Adult $49223 Misc Pediatric Misc Adult
691-1 691-2 691-3 691-4
LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA
389 540 861
1585
07077 09840 15477 31411
10000 10000 10000 10000
10000 10000 10000 10000
07077 09840 15477 31411
12500 12500 12500 12500
08846 12300 19346 39264
10000 10000 10000 10000
07077 09840 15477 31411
$6635 Misc Pediatric Misc Adult $9225 Misc Pediatric Misc Adult
$14510 Misc Pediatric Misc Adult $29448 Misc Pediatric Misc Adult
692-1 692-2 692-3 692-4
RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY
389 482 868
1580
06075 12584 17422 29316
10000 10000 10000 10000
10000 10000 10000 10000
06075 12584 17422 29316
12500 12500 12500 12500
07594 15730 21778 36645
10000 10000 10000 10000
06075 12584 17422 29316
$5695 Misc Pediatric Misc Adult $11798 Misc Pediatric Misc Adult $16333 Misc Pediatric Misc Adult $27484 Misc Pediatric Misc Adult
693-1 693-2 693-3 693-4
CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY
281 368 785
2410
06251 07881 13637 49083
10000 10000 10000 10000
10000 10000 10000 10000
06251 07881 13637 49083
12500 12500 12500 12500
07814 09851 17046 61354
10000 10000 10000 10000
06251 07881 13637 49083
$5860 Misc Pediatric Misc Adult $7388 Misc Pediatric Misc Adult
$12785 Misc Pediatric Misc Adult $46015 Misc Pediatric Misc Adult
694-1 694-2 694-3 694-4
LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR
304 404 674
1164
04842 06831 11115 21001
10000 10000 10000 10000
10000 10000 10000 10000
04842 06831 11115 21001
12500 12500 12500 12500
06053 08539 13894 26251
10000 10000 10000 10000
04842 06831 11115 21001
$4539 Misc Pediatric Misc Adult $6404 Misc Pediatric Misc Adult
$10420 Misc Pediatric Misc Adult $19688 Misc Pediatric Misc Adult
710-1 710-2 710-3 710-4
INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE
510 680
1111 1820
10635 15963 25572 49382
10000 10000 10000 10000
10000 10000 10000 10000
10635 15963 25572 49382
12500 12500 12500 12500
13294 19954 31965 61728
10000 10000 10000 10000
10635 15963 25572 49382
$9970 Misc Pediatric Misc Adult $14965 Misc Pediatric Misc Adult $23974 Misc Pediatric Misc Adult $46296 Misc Pediatric Misc Adult
711-1 711-2 711-3 711-4
POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE
471 692
1131 2087
10079 14143 23599 50574
10000 10000 10000 10000
10000 10000 10000 10000
10079 14143 23599 50574
12500 12500 12500 12500
12599 17679 29499 63218
10000 10000 10000 10000
10079 14143 23599 50574
$9449 Misc Pediatric Misc Adult $13259 Misc Pediatric Misc Adult $22124 Misc Pediatric Misc Adult $47413 Misc Pediatric Misc Adult
720-1 720-2 720-3 720-4
SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS
353 444 633
1004
05431 07613 11532 21705
10000 10000 10000 10000
10000 10000 10000 10000
05431 07613 11532 21705
12500 12500 12500 12500
06789 09516 14415 27131
10000 10000 10000 10000
05431 07613 11532 21705
$5092 Misc Pediatric Misc Adult $7137 Misc Pediatric Misc Adult
$10811 Misc Pediatric Misc Adult $20348 Misc Pediatric Misc Adult
721-1 721-2 721-3 721-4
POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS
368 470 705
1153
05287 07209 11619 22025
10000 10000 10000 10000
10000 10000 10000 10000
05287 07209 11619 22025
12500 12500 12500 12500
06609 09011 14524 27531
10000 10000 10000 10000
05287 07209 11619 22025
$4957 Misc Pediatric Misc Adult $6758 Misc Pediatric Misc Adult
$10893 Misc Pediatric Misc Adult $20648 Misc Pediatric Misc Adult
722-1 722-2 722-3 722-4
FEVER FEVER FEVER FEVER
230 302 429 739
03423 05223 07630 13141
10000 10000 10000 10000
10000 10000 10000 10000
03423 05223 07630 13141
12500 12500 12500 12500
04279 06529 09538 16426
10000 10000 10000 10000
03423 05223 07630 13141
$3209 Misc Pediatric Misc Adult $4897 Misc Pediatric Misc Adult $7153 Misc Pediatric Misc Adult
$12320 Misc Pediatric Misc Adult 723-1 723-2 723-3 723-4
VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS
216 279 470
1317
03194 04738 07794 24233
10000 10000 10000 10000
10000 10000 10000 10000
03194 04738 07794 24233
12500 12500 12500 12500
03993 05923 09743 30291
10000 10000 10000 10000
03194 04738 07794 24233
$2994 Misc Pediatric Misc Adult $4442 Misc Pediatric Misc Adult $7307 Misc Pediatric Misc Adult
$22718 Misc Pediatric Misc Adult 724-1 724-2 724-3 724-4
OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES
400 477 680
1337
05512 07131 11401 24698
10000 10000 10000 10000
10000 10000 10000 10000
05512 07131 11401 24698
12500 12500 12500 12500
06890 08914 14251 30873
10000 10000 10000 10000
05512 07131 11401 24698
$5168 Misc Pediatric Misc Adult $6685 Misc Pediatric Misc Adult
$10688 Misc Pediatric Misc Adult $23154 Misc Pediatric Misc Adult
740-1 740-2 740-3 740-4
MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE
678 1284 2034 2421
10899 13904 24356 37756
10000 10000 10000 10000
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
$8174 Other Other $10428 Other Other $18267 Other Other $28317 Other Other
750-1 750-2 750-3 750-4
SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA
1082 1179 1539 2848
05713 06699 09202 19283
10000 10000 10000 10000
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
$4285 Other Other $5024 Other Other $6902 Other Other
$14462 Other Other 751-1 751-2 751-3 751-4
MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES
528 724
1055 2028
03572 05019 08097 15923
10000 10000 10000 10000
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
$2679 Other Other $3764 Other Other $6073 Other Other
$11942 Other Other 752-1 752-2 752-3 752-4
DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL
503 658
1473 7300
03399 04498 09061 14934
10000 10000 10000 10000
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
$2549 Other Other $3374 Other Other $6796 Other Other
$11201 Other Other 753-1 753-2 753-3 753-4
BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS
601 808
1205 1948
04001 05365 08266 14926
10000 10000 10000 10000
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
$3001 Other Other $4024 Other Other $6200 Other Other
$11195 Other Other 754-1 754-2 754-3 754-4
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER
424 558 727
1664
02943 03998 05677 11553
10000 10000 10000 10000
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
$2207 Other Other $2999 Other Other $4258 Other Other $8665 Other Other
755-1 755-2 755-3 755-4
ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
388 622 900 813
02738 04363 06226 08767
10000 10000 10000 10000
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
$2054 Other Other $3272 Other Other $4670 Other Other $6575 Other Other
756-1 756-2 756-3 756-4
ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES
331 381 457 942
04061 05308 06065 13981
10000 10000 10000 10000
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
$3046 Other Other $3981 Other Other $4549 Other Other
$10486 Other Other 757-1 757-2 757-3 757-4
ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES
873 934
1087 1640
05861 07234 08953 13799
10000 10000 10000 10000
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
$4396 Other Other $5426 Other Other $6715 Other Other
$10349 Other Other 758-1 758-2 758-3 758-4
CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS
694 981
1225 4300
03874 05129 06541 11332
10000 10000 10000 10000
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
$2906 Other Other $3847 Other Other $4906 Other Other $8499 Other Other
759-1 759-2 759-3 759-4
EATING DISORDERS EATING DISORDERS EATING DISORDERS EATING DISORDERS
1990 1297 1402 2303
06561 06961 10053 16606
10000 10000 10000 10000
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
$4921 Other Other $5221 Other Other $7540 Other Other
$12455 Other Other 760-1 760-2 760-3 760-4
OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS
748 766 912
1204
04840 06173 07573 14134
10000 10000 10000 10000
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
$3630 Other Other $4630 Other Other $5680 Other Other
$10601 Other Other 770-1 770-2 770-3 770-4
DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE
253 248 332 794
02240 02623 05475 16843
10000 10000 10000 10000
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
$1680 Other Other $1967 Other Other $4106 Other Other
$12632 Other Other 772-1 772-2 772-3 772-4
ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY
1434 1551 1289 2385
05441 06916 07009 24530
10000 10000 10000 10000
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
$4081 Other Other $5187 Other Other $5257 Other Other
$18398 Other Other 773-1 773-2 773-3 773-4
OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE
337 414 507 992
02663 03466 05964 18606
10000 10000 10000 10000
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
$1997 Other Other $2600 Other Other $4473 Other Other
$13955 Other Other 774-1 774-2
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
365 412
03040 03627
10000 10000
10000 10000
03040 03627
10000 10000
03040 03627
10000 10000
03040 03627
$2280 Other Other $2720 Other Other
774-3 774-4
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
479 1424
06448 24682
10000 10000
10000 10000
06448 24682
10000 10000
06448 24682
10000 10000
06448 24682
$4836 Other $18512 Other
Other Other
775-1 775-2 775-3 775-4
ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE
323 377 571
1263
03313 04639 08596 24910
10000 10000 10000 10000
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
$2485 Other $3479 Other $6447 Other
$18683 Other
Other Other Other Other
776-1 776-2 776-3 776-4
OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE
389 397 496 933
03157 04547 07887 16112
10000 10000 10000 10000
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
$2368 Other $3410 Other $5915 Other
$12084 Other
Other Other Other Other
791-1 791-2 791-3 791-4
OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT
314 515 989
2009
08636 12677 21979 49312
10000 10000 10000 10000
10000 10000 10000 10000
08636 12677 21979 49312
12500 12500 12500 12500
10795 15846 27474 61640
10000 10000 10000 10000
08636 12677 21979 49312
$8096 Misc Pediatric $11885 Misc Pediatric $20605 Misc Pediatric $46230 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
811-1 811-2 811-3 811-4
ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS
151 202 390 913
02707 03855 08277 22176
10000 10000 10000 10000
10000 10000 10000 10000
02707 03855 08277 22176
12500 12500 12500 12500
03384 04819 10346 27720
10000 10000 10000 10000
02707 03855 08277 22176
$2538 Misc Pediatric $3614 Misc Pediatric $7760 Misc Pediatric
$20790 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
812-1 812-2 812-3 812-4
POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS
165 225 347 694
03469 04331 07709 17419
10000 10000 10000 10000
10000 10000 10000 10000
03469 04331 07709 17419
12500 12500 12500 12500
04336 05414 09636 21774
10000 10000 10000 10000
03469 04331 07709 17419
$3252 Misc Pediatric $4060 Misc Pediatric $7227 Misc Pediatric
$16330 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
813-1 813-2 813-3 813-4
OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT
261 344 594
1344
04393 06056 09631 19960
10000 10000 10000 10000
10000 10000 10000 10000
04393 06056 09631 19960
12500 12500 12500 12500
05491 07570 12039 24950
10000 10000 10000 10000
04393 06056 09631 19960
$4118 Misc Pediatric $5678 Misc Pediatric $9029 Misc Pediatric
$18713 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
815-1 815-2 815-3 815-4
OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES
169 276 456 880
04211 05012 08129 22715
10000 10000 10000 10000
10000 10000 10000 10000
04211 05012 08129 22715
12500 12500 12500 12500
05264 06265 10161 28394
10000 10000 10000 10000
04211 05012 08129 22715
$3948 Misc Pediatric $4699 Misc Pediatric $7621 Misc Pediatric
$21295 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
816-1 816-2 816-3 816-4
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
173 240 346 736
04162 04915 07864 18134
10000 10000 10000 10000
10000 10000 10000 10000
04162 04915 07864 18134
12500 12500 12500 12500
05203 06144 09830 22668
10000 10000 10000 10000
04162 04915 07864 18134
$3902 Misc Pediatric $4608 Misc Pediatric $7373 Misc Pediatric
$17001 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
841-1 841-2 841-3 841-4
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT
2200 967
2599 4068
31148 34263 64068
159153
10000 10000 10000 10000
10000 10000 10000 10000
31148 34263 64068
159153
12500 12500 12500 12500
38935 42829 80085
198941
10000 10000 10000 10000
31148 34263 64068
159153
$29201 Misc Pediatric $32122 Misc Pediatric $60064 Misc Pediatric
$149206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
842-1 842-2 842-3 842-4
FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT
751 1072 1735 3010
14151 21416 38719 95054
10000 10000 10000 10000
10000 10000 10000 10000
14151 21416 38719 95054
12500 12500 12500 12500
17689 26770 48399
118818
10000 10000 10000 10000
14151 21416 38719 95054
$13267 Misc Pediatric $20078 Misc Pediatric $36299 Misc Pediatric $89113 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
843-1 843-2 843-3 843-4
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT
339 487 713
1113
04752 06661 11619 32621
10000 10000 10000 10000
10000 10000 10000 10000
04752 06661 11619 32621
12500 12500 12500 12500
05940 08326 14524 40776
10000 10000 10000 10000
04752 06661 11619 32621
$4455 Misc Pediatric $6245 Misc Pediatric
$10893 Misc Pediatric $30582 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
844-1 844-2 844-3 844-4
PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT
310 497 743
1781
04337 06965 12193 48021
10000 10000 10000 10000
10000 10000 10000 10000
04337 06965 12193 48021
12500 12500 12500 12500
05421 08706 15241 60026
10000 10000 10000 10000
04337 06965 12193 48021
$4066 Misc Pediatric $6530 Misc Pediatric
$11431 Misc Pediatric $45020 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
850-1 850-2 850-3 850-4
PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE
267 556
1618 3148
11757 14065 24870 46520
10000 10000 10000 10000
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
$8818 Misc Pediatric $10549 Misc Pediatric $18653 Misc Pediatric $34890 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
860-1 860-2 860-3 860-4
REHABILITATION REHABILITATION REHABILITATION REHABILITATION
932 1146 1475 1795
07227 09855 13880 17876
10000 10000 10000 10000
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
$5420 Other $7391 Other
$10410 Other $13407 Other
Other Other Other Other
861-1 861-2 861-3 861-4
SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS
253 340 497 917
02858 05247 07658 14498
10000 10000 10000 10000
10000 10000 10000 10000
02858 05247 07658 14498
12500 12500 12500 12500
03573 06559 09573 18123
10000 10000 10000 10000
02858 05247 07658 14498
$2679 Misc Pediatric $4919 Misc Pediatric $7179 Misc Pediatric
$13592 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
862-1 862-2 862-3 862-4
OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE
698 1122 1357 1872
02895 05851 07866 11351
10000 10000 10000 10000
10000 10000 10000 10000
02895 05851 07866 11351
12500 12500 12500 12500
03619 07314 09833 14189
10000 10000 10000 10000
02895 05851 07866 11351
$2714 Misc Pediatric $5485 Misc Pediatric $7374 Misc Pediatric
$10642 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
863-1 863-2 863-3 863-4
NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE
853 1757 2771 4643
05959 16127 30507 61446
12500 12500 12500 12500
10000 10000 10000 10000
07449 20159 38134 76808
10000 10000 10000 10000
07449 20159 38134 76808
17500 17500 17500 17500
10428 28222 53387
107531
$5587 Neonate $15119 Neonate $28600 Neonate $57606 Neonate
Neonate Neonate Neonate Neonate
890-1 890-2 890-3 890-4
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS
167 691 921
1514
07051 10224 14771 30014
10000 10000 10000 10000
10000 10000 10000 10000
07051 10224 14771 30014
12500 12500 12500 12500
08814 12780 18464 37518
10000 10000 10000 10000
07051 10224 14771 30014
$6610 Misc Pediatric $9585 Misc Pediatric
$13848 Misc Pediatric $28138 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
892-1 892-2 892-3 892-4
HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION
587 488 669
1152
05647 07763 10877 19375
10000 10000 10000 10000
10000 10000 10000 10000
05647 07763 10877 19375
12500 12500 12500 12500
07059 09704 13596 24219
10000 10000 10000 10000
05647 07763 10877 19375
$5294 Misc Pediatric $7278 Misc Pediatric
$10197 Misc Pediatric $18164 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
893-1 893-2 893-3 893-4
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
499 496 799
1422
07762 08219 12807 24296
10000 10000 10000 10000
10000 10000 10000 10000
07762 08219 12807 24296
12500 12500 12500 12500
09703 10274 16009 30370
10000 10000 10000 10000
07762 08219 12807 24296
$7277 Misc Pediatric $7705 Misc Pediatric
$12007 Misc Pediatric $22778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
894-1 894-2 894-3 894-4
HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND
341 393 627
1121
05218 06497 09774 19428
10000 10000 10000 10000
10000 10000 10000 10000
05218 06497 09774 19428
12500 12500 12500 12500
06523 08121 12218 24285
10000 10000 10000 10000
05218 06497 09774 19428
$4892 Misc Pediatric $6091 Misc Pediatric $9163 Misc Pediatric
$18214 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
910-1 910-2 910-3 910-4
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA
1100 775
1057 1830
28786 31984 41628 72114
10000 10000 10000 10000
10000 10000 10000 10000
28786 31984 41628 72114
12500 12500 12500 12500
35983 39980 52035 90143
10000 10000 10000 10000
28786 31984 41628 72114
$26987 Misc Pediatric $29985 Misc Pediatric $39026 Misc Pediatric $67607 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
911-1 911-2 911-3 911-4
EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA
511 619 795
1687
15160 20189 26724 58039
10000 10000 10000 10000
10000 10000 10000 10000
15160 20189 26724 58039
12500 12500 12500 12500
18950 25236 33405 72549
10000 10000 10000 10000
15160 20189 26724 58039
$14213 Misc Pediatric $18927 Misc Pediatric $25054 Misc Pediatric $54412 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
912-1 912-2 912-3 912-4
MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
558 607 985
1782
20950 22759 36410 68885
10000 10000 10000 10000
10000 10000 10000 10000
20950 22759 36410 68885
12500 12500 12500 12500
26188 28449 45513 86106
10000 10000 10000 10000
20950 22759 36410 68885
$19641 Misc Pediatric $21337 Misc Pediatric $34134 Misc Pediatric $64580 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
930-1 930-2 930-3 930-4
MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE
322 370 596
1127
07826 09594 15857 33896
10000 10000 10000 10000
10000 10000 10000 10000
07826 09594 15857 33896
12500 12500 12500 12500
09783 11993 19821 42370
10000 10000 10000 10000
07826 09594 15857 33896
$7337 Misc Pediatric $8994 Misc Pediatric
$14866 Misc Pediatric $31778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
950-1 950-2 950-3 950-4
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
361 623
1166 2260
13230 20029 31827 60092
10000 10000 10000 10000
10000 10000 10000 10000
13230 20029 31827 60092
12500 12500 12500 12500
16538 25036 39784 75115
10000 10000 10000 10000
13230 20029 31827 60092
$12403 Misc Pediatric $18777 Misc Pediatric $29838 Misc Pediatric $56336 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
951-1 951-2 951-3 951-4
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
329 517
1001 1973
09755 14320 24054 46875
10000 10000 10000 10000
10000 10000 10000 10000
09755 14320 24054 46875
12500 12500 12500 12500
12194 17900 30068 58594
10000 10000 10000 10000
09755 14320 24054 46875
$9145 Misc Pediatric $13425 Misc Pediatric $22551 Misc Pediatric $43945 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
952-1 952-2 952-3 952-4
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
274 504 968
1894
07736 11591 20369 39177
10000 10000 10000 10000
10000 10000 10000 10000
07736 11591 20369 39177
12500 12500 12500 12500
09670 14489 25461 48971
10000 10000 10000 10000
07736 11591 20369 39177
$7253 Misc Pediatric $10867 Misc Pediatric $19096 Misc Pediatric $36728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
955-0 956-0
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS UNGROUPABLE
--
--
Error DRG Error DRG
Error DRG Error DRG
i-
i
i
i-
i
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy adjustor F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that has at least a basic level
emergency room H FY 2015-16 Cost-to-Charge Ratio FY 2013 cost-to-charge ratio with some exceptions I FY 2015-16 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FY 2015-16 Wage Index Value (adjusted for CA Neutrality Factor 09797) W age index value times 09797 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls for changes between California
and the rest of the US while maintaining relative differences among wage areas within California K FY 2015-16 Unadjusted Statewide Base Rate The statewide DRG base rate is $6289 except that for remote rural hospitals it is $12768 L FY 2015-16 Wage Adjusted Statewide Base Rate (Non-Transition) The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses See Tab 5 This rate is applicable for non-transition hospitals as shown in Column N Medi-Cal
managed care plans that are pricing claims for emergency and post-stabilization services hospitals outside their network should use Column L for all hospitals M FY 2015-16 Hospital-Specific Transition Base Rate The base rate assigned to hospitals to move them in steps toward the statewide base rate This rate is applicable for transition hospitals as shown in Column N FY 2015-16 is the final year of transition rates N Transition rate This column identifies whether the hospital is a non-transition hospital (base rate in Column L) or a transition hospital (base rate in Column M) O FY 2015-16 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2015-16 P FY 2015-16 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by
use of Revenue Code 190 Q FY 2015-16 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by use of
Revenue Code 199
A B C D E F G H I J K L M N O P Q
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transit on Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
OUT OF STATE No No No No No 2180 10000 10000 $6289 $6289 NA Non-Transition NA $98163 $80582 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 3572 12882 12620 $12768 $15097 $15414 Transition NA $98163 $80582 106100793 ADVENTIST MEDICAL CENTER - SELMA COMMUNITY HOSPITAL No No No Yes Yes 3572 12882 12620 $12768 $15097 $14680 Transition NA $98163 $80582 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 4360 12882 12620 $12768 $15097 $10484 Transition NA $98163 $80582 106301098 AHMC ANAHEIM REG MED CTR No No No No No 1656 12882 12620 $6289 $7436 $15144 Transition NA $98163 $80582 106010846 ALAMEDA CO MED CTR Yes No No No No 4036 16962 16618 $6289 $9186 NA NA NA NA NA 106010735 ALAMEDA HOSP No Yes No No No 2600 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106190017 ALHAMBRA HOSP No No No No No 1397 12882 12620 $6289 $7436 $5446 Transition $1220 $98163 $80582 106010739 ALTA BATES SUMMIT MED CTR-ALTA BATES No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106010937 ALTA BATES SUMMIT MED CTR-HAWTHORNE No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106010844 ALTA BATES SUMMIT MED CTR-HERRICK CAMPUS No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106013626 ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106374063 ALVARADO HOSP MED CTR - REHAB No No No No No 1930 12882 12620 $6289 $7436 $4599 Transition $1220 $98163 $80582 106190034 ANTELOPE VALLEY HOSP MED CTR No Yes No No No 2997 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364231 ARROWHEAD REG MED CTR Yes No No No No 3324 12882 12620 $6289 $7436 NA NA NA NA NA 106400466 ARROYO GRANDE COMM HOSP No No No No No 2581 12964 12701 $6289 $7471 NA Non-Transition $1226 $98163 $80582 106154101 BAKERSFIELD HEART HOSP No No No No No 1782 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150722 BAKERSFIELD MEM HOSP-34TH ST No No No No No 2117 12882 12620 $6289 $7436 $9141 Transition NA $98163 $80582 106364121 BALLARD REHABILITATION HOSP No No No No No 8300 12882 12620 NA NA NA NA $1427 $98163 $80582 106184008 BANNER LASSEN MED CTR No No No Yes Yes 3967 12882 12620 $12768 $15097 $18668 Transition NA $98163 $80582 106190052 BARLOW RESP HOSP No No No No No 1849 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364430 BARSTOW COMM HOSP No No No Yes Yes 2262 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090793 BARTON MEM HOSP No No No Yes Yes 3635 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106361110 BEAR VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190081 BEVERLY HOSP No No No No No 3567 12882 12620 $6289 $7436 $5841 Transition NA $98163 $80582 106040802 BIGGS GRIDLEY MEM HOSP No No No Yes Yes 3652 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106380929 CA PACIFIC MED CTR No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380777 CA PACIFIC MED CTR - CALIFORNIA WEST No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380933 CA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 2873 16738 16398 $6289 $9090 NA Non-Transition $1492 $98163 $80582 106190125 CALIFORNIA HOSP MED CTR-LA No No Yes No No 2078 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190137 CASA COLINA HOSP FOR REHAB MED No No No No No 7213 12882 12620 NA NA NA NA $1220 $98163 $80582 106190045 CATALINA ISLAND MED CTR No No No Yes Yes 9000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190555 CEDARS-SINAI MED CTR No No Yes No No 2051 12882 12620 $6289 $7436 $5837 Transition $1220 $98163 $80582 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 1730 12882 12620 $6289 $7436 $6350 Transition $1220 $98163 $80582 106160787 CENTRAL VALLEY GEN HOSP No No No No No 7778 12882 12620 $6289 $7436 $11888 Transition NA $98163 $80582 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 2190 12892 12630 $6289 $7440 NA Non-Transition $1221 $98163 $80582 106301140 CHAPMAN MED CTR No No No No No 1908 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304113 CHILDRENS HOSP AT MISSION No No No No No 3300 12882 12620 $6289 $7436 $18777 Transition NA $98163 $80582 106204019 CHILDRENS HOSP CENTRAL CALIFORNIA No No Yes No No 2430 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106010776 CHILDRENS HOSP OAKLAND No No Yes No No 3356 16478 16143 $6289 $8978 NA Non-Transition $2628 $98163 $80582 106190170 CHILDRENS HOSP OF LA No No Yes No No 3988 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106300032 CHILDRENS HOSP OF ORANGE CO No No Yes No No 2442 12882 12620 $6289 $7436 $5613 Transition NA $98163 $80582 106382715 CHINESE HOSP No No No No No 3835 16738 16398 $6289 $9090 $8053 Transition NA $98163 $80582 106361144 CHINO VALLEY MED CTR No No No No No 2098 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190176 CITY OF HOPE HELFORD CLINIC RES HOSP No No No No No 2789 12882 12620 $6289 $7436 $5941 Transition NA $98163 $80582 106100005 CLOVIS COMM MED CTR No No No No No 3336 12882 12620 $6289 $7436 $7752 Transition NA $98163 $80582 106100697 COALINGA REG MED CTR No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190766 COAST PLAZA DRS HOSP No No No No No 2126 12882 12620 $6289 $7436 $5303 Transition NA $98163 $80582 106301258 COASTAL COMM HOSP No No No No No 2792 12882 12620 $6289 $7436 $7035 Transition NA $98163 $80496 106301155 COLLEGE HOSP COSTA MESA No No No No No 2876 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190587 COLLEGE MEDICAL CENTER No No No No No 3760 12882 12620 $6289 $7436 $4258 Transition NA $98163 $80582 106361458 COLORADO RIVER MED CTR No No No Yes Yes 4357 12882 12620 $12768 $15097 $18541 Transition NA $98163 $80582 106060870 COLUSA REG MED CTR No No No Yes Yes 3066 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190197 COMM AND MISSION HOSP OF HUNT PK No No No No No 1601 12882 12620 $6289 $7436 $5421 Transition NA $98163 $80582 106190475 COMM HOSP OF LONG BEACH No No No No No 1707 12882 12620 $6289 $7436 $15917 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106361323 COMM HOSP OF SAN BERNARDINO No No No No No 2833 12882 12620 $6289 $7436 $6516 Transition NA $98163 $78406 106560473 COMM MEM HOSP OF SAN BUENAVENTURA No No No No No 2104 12882 12620 $6289 $7436 $4512 Transition NA $98163 $80582 106100717 COMM REG MED CTR-FRESNO No No No No No 1896 12882 12620 $6289 $7436 $7994 Transition $1655 $98163 $80582 106070924 CONTRA COSTA REG MED CTR Yes No No No No 6010 16478 16143 $6289 $8978 NA NA NA NA NA 106331152 CORONA REG MED CTR No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition NA $98163 $80582 106331145 CORONA REG MED CTR - MAGNOLIA No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition $1220 $98163 $80582 106190413 CV-INTERCOMMUNITY CAMPUS No No No No No 3136 12882 12620 $6289 $7436 $6821 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106190636 CV-QUEEN OF VALLEY CAMPUS No No Yes No No 3136 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106150706 DELANO REG MED CTR No No No No No 3622 12882 12620 $6289 $7436 $7087 Transition NA $98163 $80582 106331164 DESERT REG MED CTR No No No No No 1486 12882 12620 $6289 $7436 $7153 Transition $1447 $98163 $80582 106364144 DESERT VALLEY HOSP No No No No No 2050 12882 12620 $6289 $7436 $8173 Transition NA $98163 $80582 106440755 DOMINICAN HOSP-SANTA CRUZ No No No No No 2016 17239 16889 $6289 $9304 $7821 Transition $1527 $98163 $80582 106190243 DOWNEY REG MED CTR No No No No No 1732 12882 12620 $6289 $7436 $6847 Transition NA $98163 $80582 106392287 DRS HOSP OF MANTECA No No No No No 1362 13579 13303 $6289 $7735 $11712 Transition NA $98163 $80582 106390846 DAMERON HOSP No No No No No 2138 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106190857 DRS HOSP OF WEST COVINA No No No No No 1833 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106070904 DRS MED CTR-SAN PABLOPINOLE No Yes No No No 2373 16478 16143 $6289 $8978 $6025 Transition NA $98163 $80582 106190256 EAST LA DRS HOSP No No No No No 1952 12882 12620 $6289 $7436 $5809 Transition NA $98163 $80582 106190328 EAST VALLEY HOSP MED CTR No No No No No 2859 12882 12620 $6289 $7436 $5534 Transition NA $98163 $80582 106320859 EASTERN PLUMAS HOSP No Yes No Yes Yes 4802 12882 12620 $12768 $15097 $13674 Transition NA $98163 $80582 106014233 EDEN MED CTR No No No No No 3197 16962 16618 $6289 $9186 $12768 Transition NA $98163 $80582 106331168 EISENHOWER MEM HOSP No No No No No 1540 12882 12620 $6289 $7436 $10211 Transition NA $98163 $80582 106430763 EL CAMINO HOSP No Yes No No No 2857 17180 16831 $6289 $9279 $5377 Transition $1523 $98163 $80582 106130699 EL CENTRO COMM HOSP No Yes No No No 2298 12882 12620 $6289 $7436 $8949 Transition NA $98163 $80582 106500852 DRS MED CTR No No No No No 1181 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106500867 EMANUEL MED CTR No No No No No 2046 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106040962 ENLOE MED CTR No No No No No 2436 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106044011 ENLOE REHABILLITATION CENTER No No No No No 2463 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106474007 FAIRCHILD MED CTR No No No Yes Yes 3914 12882 12620 $12768 $15097 $16385 Transition NA $98163 $80582 106040875 FEATHER RIVER HOSP No No No No No 1240 12882 12620 $6289 $7436 $10796 Transition NA $98163 $80582 106190298 FOOTHILL PRES HOSP No No No No No 2989 12882 12620 $6289 $7436 $4740 Transition NA $98163 $80582 106301175 FOUNTAIN VALLEY REG HOSP-EUCLID No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106304039 FOUNTAIN VALLEY REG HOSP-WARNER No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106230949 FRANK R HOWARD MEM HOSP No No No Yes Yes 3495 12882 12620 $12768 $15097 $15377 Transition NA $98163 $80582 106510882 FREMONT MEDICAL CENTER No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106190280 ENCINO HOSP MED CTR No No No No No 949 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106400480 FRENCH HOSP MED CTR No No No No No 2241 12964 12701 $6289 $7471 NA Non-Transition NA $98163 $80582 106301283 GARDEN GROVE HOSP AND MED CTR No No No No No 2661 12882 12620 $6289 $7436 $5749 Transition NA $98163 $80582 106190159 GARDEN REG HOSP AND MED CTR No No No No No 2937 12882 12620 $6289 $7436 $4110 Transition NA $98163 $80582 106105029 FRESNO HEART HOSP No No No No No 3403 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106270777 GEORGE L MEE MEM HOSP No No No Yes Yes 3562 15558 15242 $12768 $17426 $20386 Transition NA $98163 $80582 106190315 GARFIELD MED CTR No No No No No 1031 12882 12620 $6289 $7436 NA Non-Transition $1394 $98163 $80582 106190522 GLENDALE MEM HOSP AND HLTH CTR No No No No No 2163 12882 12620 $6289 $7436 $6885 Transition $1220 $98163 $80582 106110889 GLENN MED CTR No No No Yes Yes 6660 12882 12620 $12768 $15097 $21024 Transition NA $98163 $80582 106190323 GLENDALE ADV MED CTR-WILSON TERRACE No No No No No 1845 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420483 GOLETA VALLEY COTTAGE HOSP No No No No No 3083 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150775 GOOD SAMARITAN HOSP-BAKERSFIELD No No No No No 3694 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430779 GOOD SAMARITAN HOSP-SAN JOSE No No Yes No No 1937 17180 16831 $6289 $9279 $5654 Transition NA $98163 $80582 106190352 GREATER EL MONTE COMM HOSP No No No No No 1088 12882 12620 $6289 $7436 $4818 Transition NA $98163 $80582 106370714 GROSSMONT HOSP No No No No No 1937 12882 12620 $6289 $7436 $6498 Transition $1220 $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190392 GOOD SAMARITAN HOSP-LA No No Yes No No 2006 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106350784 HAZEL HAWKINS MEM HOSP No Yes No Yes Yes 3840 17180 16831 $12768 $18839 NA Non-Transition NA $98163 $80582 106490964 HEALDSBURG DIST HOSP No Yes No Yes Yes 6549 16188 15859 $12768 $17975 NA Non-Transition NA $98163 $80582 106154022 HEALTHSOUTH BAKERSFIELD REHAB HOSP No No No No No 5040 12882 12620 NA NA NA NA $1382 $98163 $80582 106304079 HEALTHSOUTH TUSTIN REHAB HOSP No No No No No 5281 12882 12620 NA NA NA NA $1220 $98163 $80582 106331194 HEMET VALLEY MED CTR No No No No No 1267 12882 12620 $6289 $7436 $5912 Transition NA $98163 $80582 106190949 HENRY MAYO NEWHALL MEM HOSP No No No No No 1839 12882 12620 $6289 $7436 $5631 Transition $1220 $98163 $80582 106362041 HI-DESERT MED CTR No Yes No Yes Yes 2909 12882 12620 $12768 $15097 $13297 Transition NA $98163 $80582 106301205 HOAG MEM HOSP PRESBYTERIAN No No No No No 4825 12882 12620 $6289 $7436 $13525 Transition NA $98163 $80582 106304159 HEALTHBRIDGE CHILDRENS HOSP-ORANGE No No No No No 3271 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106190380 HOLLYWOOD COMM HOSP OF HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106304460 HOAG ORTHOPEDIC No No No No No 4894 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190382 HOLLYWOOD PRES MED CTR No No No No No 2212 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301209 HUNTINGTON BEACH HOSP No No No No No 2175 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190400 HUNTINGTON MEM HOSP No No Yes No No 2294 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106304045 IRVINE REG HOSP AND MED CTR No No No No No 200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106220733 JOHN C FREMONT HCARE DIST No Yes No Yes Yes 3884 12882 12620 $12768 $15097 $8195 Transition NA $98163 $80582 106331216 JOHN F KENNEDY MEM HOSP No No No No No 1679 12882 12620 $6289 $7436 $6464 Transition NA $98163 $80582 106071018 JOHN MUIR MED CTR-CONCORD CAMPUS No No No No No 1748 16478 16143 $6289 $8978 $12804 Transition NA $98163 $80582 106070988 JOHN MUIR MED CTR-WALNUT CREEK CAMPUS No No No No No 2039 16478 16143 $6289 $8978 $10615 Transition $1473 $98163 $80582 106314024 KAISER HOSPITAL - ROSEVILLE No No Yes No No 7912 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106364265 KAISER ONTARIO MEDICAL CENTER CAMPUS No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106121031 JEROLD PHELPS COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301132 KAISER-ANAHEIM No No Yes No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304306 KAISER-ANAHEIM-IRVINE No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304409 KAISER-ANAHEIM-Orange No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106074097 KAISER-ANTIOCH No No No No No 8503 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106196403 KAISER-DOWNEY No No No No No 10000 12882 12620 $6289 $7436 $12698 Transition NA $98163 $80582 106361223 KAISER-FONTANA No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106014132 KAISER-FREMONT No No No No No 10000 16962 16618 $6289 $9186 $9639 Transition NA $98163 $80582 106196035 KAISER-BALDWIN PARK No No No No No 8009 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106104062 KAISER-FRESNO No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190429 KAISER-LOS ANGELES No No No No No 7387 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106394009 KAISER-MANTECA No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106334048 KAISER-MORENO VALLEY No No No No No 6614 12882 12620 $6289 $7436 $4790 Transition NA $98163 $80582 106010856 KAISER-OAKLANDRICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106190432 KAISER-PANORAMA CITY No No No No No 8239 12882 12620 $6289 $7436 $16025 Transition NA $98163 $80582 106504042 KAISER-MODESTO No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106410804 KAISER-REDWOOD CITY No No No No No 7731 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106074093 KAISER-RICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106480989 KAISER-REHAB CENTER VALLEJO No No No No No 8442 16315 15984 $6289 $8908 NA Non-Transition $2535 $98163 $80582 106340913 KAISER-SACRAMENTO No No No No No 5612 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106334025 KAISER-RIVERSIDE No No No No No 5865 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370730 KAISER-SAN DIEGO No No No No No 7393 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106380857 KAISER-SAN FRANCISCO No No No No No 5960 16738 16398 $6289 $9090 NA Non-Transition NA $98163 $80582 106431506 KAISER-SAN JOSE No No No No No 7002 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106014337 KAISER-SAN LEANDRO No No No No No 2180 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106210992 KAISER-SAN RAFAEL No No No No No 4673 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106494019 KAISER-SANTA ROSA No No No No No 10000 16315 15984 $6289 $8908 $17627 Transition NA $98163 $80582 106434153 KAISER-SANTA CLARA No No No No No 6107 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106190431 KAISER-SOUTH BAY No No No No No 6935 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106342344 KAISER-SOUTH SACRAMENTO No No No No No 5670 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106410806 KAISER-SOUTH SF No No No No No 6503 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106484044 KAISER-VACAVILLE No No No No No 10000 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106070990 KAISER-WALNUT CREEK No No No No No 5680 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106190434 KAISER-WEST LA No No No No No 6623 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106194219 KECK HOSPITAL OF USC No No No No No 2004 12882 12620 $6289 $7436 $4699 Transition $1220 $98163 $80582 106210993 KENTFIELD REHAB HOSP No No No No No 5967 16855 16513 $6289 $9140 $19338 Transition $1500 $98163 $80582 106150736 KERN MED CTR Yes No No No No 3943 12882 12620 $6289 $7436 NA NA NA NA NA 106150737 KERN VALLEY HEALTHCARE DIST No Yes No Yes Yes 2786 12882 12620 $12768 $15097 $8298 Transition NA $98163 $80582 106191450 KAISER-WOODLAND HILLS No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190049 KINDRED HOSPITAL BALDWIN PARK No No No No No 1810 12882 12620 $6289 $7436 $10784 Transition NA $98163 $80582 106190305 KINDRED LA No No No No No 2044 12882 12620 $6289 $7436 $4255 Transition NA $98163 $80582 106301127 KINDRED BREA No No No No No 2852 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361274 KINDRED ONTARIO No No No No No 2068 12882 12620 $6289 $7436 $9314 Transition NA $98163 $80582 106364188 KINDRED RANCHO No No No No No 1980 12882 12620 $6289 $7436 $20628 Transition NA $98163 $80582 106332172 KINDRED RIVERSIDE No No No No No 1805 12882 12620 $6289 $7436 $24450 Transition NA $98163 $80582 106190449 KINDRED LA MIRADA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106370721 KINDRED SAN DIEGO No No No No No 3605 12882 12620 $6289 $7436 $5657 Transition NA $98163 $80582 106344035 KINDRED SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190458 KINDRED SAN GABRIEL VALLEY No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106010887 KINDRED SF BAY AREA No No No No No 3007 16478 16143 $6289 $8978 $6378 Transition NA $98163 $80582 106301167 KINDRED SANTA ANA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190196 KINDRED SOUTH BAY No No No No No 2144 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301380 KINDRED WESTMINSTER No No No No No 2286 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301234 LA PALMA INTERCOMMUNITY HOSP No No No No No 2290 12882 12620 $6289 $7436 $7160 Transition NA $98163 $80582 106191227 LAC-HARBOR-UCLA MED CTR Yes No Yes No No 3366 12882 12620 $6289 $7436 NA NA NA NA NA 106191231 LAC-OLIVE VIEW-UCLA MED CTR Yes No No No No 4136 12882 12620 $6289 $7436 NA NA NA NA NA 106191228 LAC-USC MED CTR Yes No Yes No No 4522 12882 12620 $6289 $7436 NA NA NA NA NA 106380865 LAGUNA HONDA HOSP AND REHAB CTR Yes No No No No 5843 16738 16398 $6289 $9090 NA NA NA NA NA 106190240 LAKEWOOD REG MED CTR No No No No No 1504 12882 12620 $6289 $7436 $4008 Transition $1220 $98163 $80582 106390923 LODI MEM HOSP No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106390922 LODI MEM HOSP - WEST No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106334589 LOMA LINDA MURRIETTA No No No No No 3222 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106364268 LOMA LINDA UNIV HEART AND SURGICAL HOSPITAL No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361245 LOMA LINDA UNIV MED CTR - EAST CAMPUS No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361246 LOMA LINDA UNIV MED CTR No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $1491 $98163 $80582 106364502 LOMA LINDA UNIV CHILDRENS HOSP No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $2177 $98163 $80582 106190198 LA COMM HOSP No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420491 LOMPOC VALLEY MED CTR No Yes No Yes Yes 8693 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301248 LOS ALAMITOS MED CTR No No No No No 1915 12882 12620 $6289 $7436 $4697 Transition NA $98163 $80582 106560492 LOS ROBLES HOSP AND MED CTR No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106564018 LOS ROBLES HOSP AND MED CTR-EAST CAMPUS No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106434040 LSP CHILDRENS HOSP AT STANFORD No No Yes No No 2035 17180 16831 $6289 $9279 $6102 Transition NA $98163 $80582 106121002 MAD RIVER COMM HOSP No No No No No 4250 12882 12620 $6289 $7436 $9505 Transition NA $98163 $80582 106201281 MADERA COMMUNITY HOSPITAL No No No No No 5100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106260011 MAMMOTH HOSP No Yes No Yes Yes 7982 12882 12620 $12768 $15097 $46994 Transition NA $98163 $80582 106420493 MARIAN MED CTR No No No No No 2741 12882 12620 $6289 $7436 $9386 Transition NA $98163 $80582 106190525 LONG BEACH MEM MED CTR No No No No No 1996 12882 12620 $6289 $7436 NA Non-Transition $1627 $98163 $80582 106211006 MARIN GEN HOSP No Yes No No No 2571 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106190500 MARINA DEL RAY HOSPITAL No No No No No 2034 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106050932 MARK TWAIN ST JOSEPHS HOSP No No No Yes Yes 3707 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090933 MARSHALL MED CTR No No No Yes Yes 2107 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106500939 MEM HOSP MED CTR-MODESTO No No No No No 2235 12892 12630 $6289 $7440 $5898 Transition NA $98163 $80582 106240924 MEMORIAL HOSP LOS BANOS No No No Yes Yes 3362 12882 12620 $12768 $15097 $17450 Transition NA $98163 $80582 106190521 MEMORIAL HOSP OF GARDENA No No No No No 1747 12882 12620 $6289 $7436 $4611 Transition NA $98163 $80582 106231013 MENDOCINO COAST DIST HOSP No Yes No Yes Yes 5070 12882 12620 $12768 $15097 $15935 Transition NA $98163 $80582 106334018 MENIFEE VALLEY MED CTR No No No No No 1458 12882 12620 $6289 $7436 $5113 Transition NA $98163 $80582 106450936 MAYERS MEM HOSP No Yes No Yes Yes 7192 14188 13900 $12768 $16234 NA Non-Transition NA $98163 $80582 106340947 MERCY GEN HOSP No No No No No 2185 15256 14946 $6289 $8454 $6027 Transition $1387 $98163 $80582 106344029 MERCY HOSP OF FOLSOM No No No No No 2746 15256 14946 $6289 $8454 $5260 Transition NA $98163 $80582 106150761 MERCY HOSP-BAKERSFIELD No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106414018 MENLO PARK SURGICAL HOSP No No No No No 2770 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106240942 MERCY MED CTR MERCED No No No No No 2289 13279 13009 $6289 $7606 NA Non-Transition NA $98163 $80582 106450949 MERCY MED CTR-REDDING No No No No No 2589 14188 13900 $6289 $7996 $10219 Transition NA $98163 $80582 106470871 MERCY MED CTR-MT SHASTA No No No Yes Yes 6242 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106340950 MERCY SAN JUAN HOSP No No No No No 2166 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190529 METHODIST HOSP OF SO CAL No No No No No 1842 12882 12620 $6289 $7436 $6690 Transition $1220 $98163 $80582 106196168 MILLER CHILDRENS HOSP No No Yes No No 2680 12882 12620 $6289 $7436 $8155 Transition NA $98163 $80582 106410742 MILLS HEALTH CENTER No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106410852 MILLS-PENINSULA No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106340951 METHODIST HOSP OF SACRAMENTO No No No No No 2028 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190524 MISSION COMM HOSP-PANORAMA CAMPUS No No No No No 3568 12882 12620 $6289 $7436 $3982 Transition NA $98163 $80582 106190681 MIRACLE MILE No No No No No 100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301262 MISSION HOSP REG MED CTR No No No No No 4091 12882 12620 $6289 $7436 $14336 Transition $1220 $98163 $80582 106250956 MODOC MED CTR No Yes No Yes Yes 4961 12882 12620 $12768 $15097 $13486 Transition NA $98163 $80582 106301337 MISSION HOSP LAGUNA BEACH No No No No No 4091 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106361166 MONTCLAIR HOSP MED CTR No No No No No 3149 12882 12620 $6289 $7436 $5904 Transition NA $98163 $80582 106190547 MONTEREY PARK HOSP No No No No No 1034 12882 12620 $6289 $7436 $5866 Transition NA $98163 $80582 106361266 MOUNTAINS COMM HOSP No Yes No Yes Yes 5148 12882 12620 $12768 $15097 $15642 Transition NA $98163 $80582 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106481357 NORTH BAY MEDICAL CENTER No No No No No 1972 16315 15984 $6289 $8908 $15945 Transition NA $98163 $80582
i-
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190541 MONROVIA MEM HOSP No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106141273 NORTHERN INYO HOSP No Yes No Yes Yes 8150 12882 12620 $12768 $15097 $27752 Transition NA $98163 $80582 106484001 NORTH BAY VACAVALLEY HOSP No No No No No 1972 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106190568 NORTHRIDGE HOSP MED CTR No No No No No 1596 12882 12620 $6289 $7436 NA Non-Transition $1662 $98163 $80582 106214034 NOVATO COMM HOSP No No No No No 3465 16855 16513 $6289 $9140 $6359 Transition NA $98163 $80582 106500967 OAK VALLEY DIST HOSP No Yes No Yes No 3340 12892 12630 $6289 $7440 $5201 Transition NA $98163 $80582 106430837 OCONNOR HOSP-SAN JOSE No No No No No 2409 17180 16831 $6289 $9279 $5201 Transition NA $98163 $80582 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190534 OLYMPIA MED CTR No No No No No 1260 12882 12620 $6289 $7436 $6786 Transition NA $98163 $80582 106300225 ORANGE COAST MEM MED CTR No No No No No 2293 12882 12620 $6289 $7436 $19985 Transition NA $98163 $80582 106040937 OROVILLE HOSP No No No No No 1803 12882 12620 $6289 $7436 $6229 Transition NA $98163 $80582 106560501 OJAI VALLEY COMM HOSP No No No Yes Yes 2745 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190696 PACIFICA HOSP OF THE VALLEY No No No No No 3338 12882 12620 $6289 $7436 $5616 Transition NA $98163 $80582 106491338 PALM DRIVE HOSP No Yes No Yes No 4315 16315 15984 $6289 $8908 $11457 Transition NA $98163 $80582 106196405 PALMDALE REGIONAL MEDICAL CTR No No No No No 1190 12882 12620 $6289 $7436 $7504 Transition $1220 $98163 $80582 106331288 PALO VERDE HOSP No Yes No Yes Yes 4770 12882 12620 $12768 $15097 $18188 Transition NA $98163 $80582 106370755 PALOMAR MED CTR No Yes No No No 2429 12882 12620 $6289 $7436 $7051 Transition $1220 $98163 $80582 106370759 PARADISE VALLEY HOSP No No No No No 2188 12882 12620 $6289 $7436 $4275 Transition $1220 $98163 $80582 106190307 PACIFIC ALLIANCE MED CTR No No No No No 4299 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106331293 PARKVIEW COMM HOSP MED CTR No No No No No 2757 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106491001 PETALUMA VALLEY HOSP No No No No No 2271 16315 15984 $6289 $8908 $13491 Transition NA $98163 $80582 106130760 PIONEERS MEM HOSP No Yes No Yes No 2989 12882 12620 $6289 $7436 $9825 Transition NA $98163 $80582 106454013 PATIENTS HOSP OF REDDING No No No No No 2172 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106301297 PLACENTIA LINDA HOSP No No No No No 1606 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370977 POMERADO HOSP No Yes No No No 3063 12882 12620 $6289 $7436 $6818 Transition NA $98163 $80582 106320986 PLUMAS DIST HOSP No Yes No Yes Yes 8666 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190631 PRESBYTERIAN INTERCOMM HOSP No No No No No 961 12882 12620 $6289 $7436 $9720 Transition $1220 $98163 $80582 106190630 POMONA VALLEY HOSP MED CTR No No Yes No No 1538 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190468 PROMISE HOSP OF EAST LA-EAST LA No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190599 PROMISE HOSP OF EAST LA-EAST LA-SUBURBAN CAMPUS No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190385 PROVIDENCE HOLY CROSS MED CTR No No No No No 1325 12882 12620 $6289 $7436 $6284 Transition $1220 $98163 $80582 106190680 PROVIDENCE LITTLE CO OF MARY-SAN PEDRO No No No No No 1533 12882 12620 $6289 $7436 $6225 Transition $1220 $98163 $80582 106190470 PROVIDENCE LITTLE CO OF MARY-TORRANCE No No No No No 1767 12882 12620 $6289 $7436 $7182 Transition NA $98163 $80582 106190758 PROVIDENCE ST JOSEPH MED CTR No No No No No 1866 12882 12620 $6289 $7436 $7141 Transition $1220 $98163 $80582 106370787 PROMISE HOSP OF SAN DIEGO No No No No No 3660 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106281047 QUEEN OF THE VALLEY HOSP-NAPA No No No No No 2829 16188 15859 $6289 $8854 $17592 Transition $1453 $98163 $80582 106370673 RADY CHILDRENS HOSPITAL - SAN DIEGO No No Yes No No 2854 12882 12620 $6289 $7436 $6395 Transition $2177 $98163 $80582 106190517 PROVIDENCE TARZANA MED CTR No No Yes No No 1536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361308 REDLANDS COMM HOSP No No No No No 2079 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430705 REG MED CTR OF SAN JOSE No No No No No 2529 17180 16831 $6289 $9279 $13299 Transition NA $98163 $80582 106580996 RIDEOUT MEM HOSP No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106121051 REDWOOD MEM HOSP No No No Yes Yes 3214 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106334487 RIVERSIDE CO REG MED CTR Yes No No No No 2987 12882 12620 $6289 $7436 NA NA NA NA NA 106331312 RIVERSIDE COMM HOSP No No No No No 1560 12882 12620 $6289 $7436 $5990 Transition NA $98163 $80582 106190796 RONALD REAGAN UCLA MED CTR Yes No Yes No No 3382 12882 12620 $6289 $7436 NA NA NA NA NA 106301317 SADDLEBACK MEM MED CTR No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106301325 SADDLEBACK MEM MED CTR-SAN CLEMENTE No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106150782 RIDGECREST REG HOSP No No No Yes Yes 4178 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106361318 SAN ANTONIO COMM HOSP No No No No No 2262 12882 12620 $6289 $7436 $9216 Transition NA $98163 $80582 106190673 SAN DIMAS COMM HOSP No No No No No 2465 12882 12620 $6289 $7436 $12177 Transition NA $98163 $80582 106190200 SAN GABRIEL VALLEY MED CTR No No No No No 969 12882 12620 $6289 $7436 $6918 Transition NA $98163 $80582 106270875 SALINAS VALLEY MEM HOSP No Yes No No No 3534 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106331326 SAN GORGONIO MEM HOSP No Yes No Yes Yes 3394 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391010 SAN JOAQUIN GEN HOSP Yes No No No No 1922 13579 13303 $6289 $7735 NA NA NA NA NA 106104023 SAN JOAQUIN VALLEY REHAB HOSP No No No No No 6479 12882 12620 NA NA NA NA $1413 $98163 $80582 106013619 SAN LEANDRO HOSP No Yes No No No 3482 16501 16166 $6289 $8988 $10813 Transition NA $98163 $80582 106410782 SAN MATEO MED CTR Yes No No No No 7168 16928 16584 $6289 $9171 NA NA NA NA NA 106074017 SAN RAMON REG MED CTR No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106074011 SAN RAMON REG MED CTR SOUTH BUILDING No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106420514 SANTA BARBARA COTTAGE HOSP No No Yes No No 3902 12882 12620 $6289 $7436 $10978 Transition $2125 $98163 $80582 106430883 SANTA CLARA VALLEY MED CTR Yes No Yes No No 3133 17180 16831 $6289 $9279 NA NA NA NA NA 106190687 SANTA MONICA - UCLA MEDICAL CENTER Yes No No No No 3102 12882 12620 $6289 $7436 NA NA NA NA NA 106491064 SANTA ROSA MEM HOSP-MONTGOMERY No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106490907 SANTA ROSA MEM HOSP-SOTOYOME No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106150788 SAN JOAQUIN COMM HOSP No No No No No 2544 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420522 SANTA YNEZ VALLEY COTTAGE HOSP No No No Yes Yes 7569 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106371394 SCRIPPS MEM HOSP-ENCINITAS No No No No No 2403 12882 12620 $6289 $7436 $7037 Transition $1439 $98163 $80582 106370771 SCRIPPS MEM HOSP-LA JOLLA No No No No No 2061 12882 12620 $6289 $7436 $4390 Transition NA $98163 $80582 106370744 SCRIPPS MERCY HOSP No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106370658 SCRIPPS MERCY HOSP-CHULA VISTA No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106371256 SCRIPPS GREEN HOSP No No No No No 2317 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106321016 SENECA HCARE DIST No Yes No Yes Yes 4586 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106410817 SETON MED CTR No No No No No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106410828 SETON MED CTR-COASTSIDE No No No Yes No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106380939 SF GENERAL HOSP Yes No No No No 2851 16738 16398 $6289 $9090 NA NA NA NA NA 106370875 SHARP CHULA VISTA MED CTR No No No No No 1932 12882 12620 $6289 $7436 $6485 Transition NA $98163 $80582 106410891 SEQUOIA HOSP No No No No No 1975 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106370689 SHARP CORONADO HOSP AND HCARE CTR No No No No No 2160 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $72421 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106370694 SHARP MEM HOSP No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106450940 SHASTA REG MED CTR No No No No No 1582 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106190708 SHERMAN OAKS HOSP No No No No No 1516 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190712 SHRINERS HOSPITAL- LA No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106344114 SHRINERS HOSPITAL- SACRAMENTO No No No No No 3869 15256 14946 $6289 $8454 NA Non-Transition $2475 $98163 $80582 106540798 SIERRA VIEW DIST HOSP No Yes No No No 2716 12882 12620 $6289 $7436 $8497 Transition NA $98163 $77682 106400524 SIERRA VIST REG MED CTR No No No No No 1787 12964 12701 $6289 $7471 $5495 Transition NA $98163 $80582 106190661 SILVER LAKE MED CTR No No No No No 3692 12882 12620 $6289 $7436 $5655 Transition NA $98163 $80582 106291023 SIERRA NEVADA MEM HOSP No No No Yes Yes 3427 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106491076 SONOMA VALLEY HOSP No Yes No No No 4960 16315 15984 $6289 $8908 $12733 Transition NA $98163 $80582 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 2126 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190380 SOUTHERN CA HOSP AT HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106190110 SOUTHERN CA HOSPITAL AT CULVER CITY No No No No No 1437 12882 12620 $6289 $7436 $4694 Transition $1220 $98163 $80582 106560525 SIMI VALLEY HOSP AND HCARE-SYCAMORE No No No No No 3840 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106334068 SOUTHWEST HCARE SYSTEM No No No No No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106334001 SOUTHWEST HCARE SYSTEM-WILDOMAR No No No Yes No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106100899 ST AGNES MED CTR No No No No No 3088 12882 12620 $6289 $7436 $7885 Transition NA $98163 $80582 106361339 ST BERNARDINE MED CTR No No No No No 2171 12882 12620 $6289 $7436 $6090 Transition NA $98163 $80582 106521041 ST ELIZABETH COMM HOSP No No No Yes Yes 3024 13869 13587 $12768 $15956 $14866 Transition NA $98163 $80582 106190754 ST FRANCIS MED CTR No No No No No 4350 12882 12620 $6289 $7436 $6368 Transition NA $98163 $80582 106380960 ST FRANCIS MEM HOSP No No No No No 1920 16738 16398 $6289 $9090 $5310 Transition $1492 $98163 $80582 106281078 ST HELENA HOSP No No No No No 2337 15887 15564 $6289 $8725 $9671 Transition NA $98163 $80582 106171049 ST HELENA HOSPITAL-CLEARLAKE No No No Yes Yes 4118 12882 12620 $12768 $15097 $18218 Transition NA $98163 $80582 106141338 SOUTHERN INYO HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190756 ST JOHNS HEALTH CTR No No No No No 2536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560529 ST JOHNS REG MED CTR No No No No No 2982 12882 12620 $6289 $7436 $6976 Transition $1761 $98163 $80582 106121080 ST JOSEPH HOSP-EUREKA No No No No No 2570 13869 13587 $6289 $7859 $9661 Transition $1507 $98163 $80582 106301340 ST JOSEPH HOSP-ORANGE No No No No No 2751 12882 12620 $6289 $7436 $5230 Transition NA $98163 $80582 106560508 ST JOHNS PLEASANT VALLEY HOSP No No No No No 2087 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301342 ST JUDE MED CTR No No No No No 1722 12882 12620 $6289 $7436 $5799 Transition $1220 $98163 $80582 106434138 ST LOUISE REG HOSP No No No No No 2838 17180 16831 $6289 $9279 $16407 Transition NA $98163 $80582 106380964 ST LUKES HOSP No No No No No 3807 16738 16398 $6289 $9090 $8600 Transition NA $98163 $80582 106361343 ST MARY MED CTR-APPLE VALLEY No No No Yes No 2511 12882 12620 $6289 $7436 $9863 Transition NA $98163 $80582 106391042 ST JOSEPHS MED CTR OF STOCKTON No No No No No 2152 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106380965 ST MARYS MED CTR-SF No No No No No 2007 16738 16398 $6289 $9090 $5116 Transition $1492 $98163 $80582 106010967 ST ROSE HOSP No No No No No 1931 16962 16618 $6289 $9186 $7600 Transition NA $98163 $80582 106190762 ST VINCENT MED CTR No No No No No 2020 12882 12620 $6289 $7436 $4684 Transition $1220 $98163 $80582 106430905 STANFORD HOSP No No No No No 1803 17180 16831 $6289 $9279 $5644 Transition $1523 $98163 $80582 106190053 ST MARY MED CTR-LONG BEACH No No No No No 2479 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106504038 STANISLAUS SURGICAL HOSP No No No No No 9000 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106250955 SURPRISE VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106310791 SUTTER AUBURN FAITH HOSP No No No No No 2551 15256 14946 $6289 $8454 $11882 Transition NA $98163 $80582 106034002 SUTTER AMADOR HOSP No No No Yes Yes 2971 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106574010 SUTTER DAVIS HOSP No No No No No 3568 15256 14946 $6289 $8454 $14330 Transition NA $98163 $80582 106070934 SUTTER DELTA MED CTR No No No No No 2907 16478 16143 $6289 $8978 $12158 Transition NA $98163 $80582 106341051 SUTTER GEN HOSP No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106171395 SUTTER LAKESIDE HOSP No No No Yes Yes 3691 12882 12620 $12768 $15097 $17232 Transition NA $98163 $80582 106444012 SUTTER MATERNITY AND SRG CTR OF S CRUZ No No No No No 7213 17239 16889 $6289 $9304 $21288 Transition NA $98163 $80582 106490919 SUTTER MED CTR OF SANTA ROSA No No No No No 3657 16315 15984 $6289 $8908 $15278 Transition NA $98163 $80582 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106311000 SUTTER ROSEVILLE MED CTR No No No No No 2377 15256 14946 $6289 $8454 $11395 Transition $1387 $98163 $80582 106481094 SUTTER SOLANO MED CTR No No No No No 3258 16315 15984 $6289 $8908 $18010 Transition NA $98163 $80582 106084001 SUTTER COAST HOSP No No No Yes Yes 3730 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391056 SUTTER TRACY COMM HOSP No No No No No 2714 13579 13303 $6289 $7735 $5995 Transition NA $98163 $80582 106291053 TAHOE FOREST HOSP No Yes No Yes Yes 4766 15256 14946 $12768 $17164 $21044 Transition NA $98163 $80582 106150808 TEHACHAPI HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 $22158 Transition NA $98163 $80582 106514030 SUTTER SURG HOSP-NORTH VALLEY No No No No No 3240 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106334564 TEMECULA VALLEY HOSPITAL No No No No No 2180 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106120981 THE GENERAL HOSPITAL No No No No No 2570 13869 13587 NA NA NA NA $1507 $98163 $80582 106564121 THOUSAND OAKS SURGICAL HOSPITAL No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106190422 TORRANCE MEM MED CTR No No No No No 1952 12882 12620 $6289 $7436 $5891 Transition NA $98163 $80582 106370780 TRI-CITY MED CTR No Yes No No No 3695 12882 12620 $6289 $7436 $7706 Transition $1220 $98163 $80582 106190784 TEMPLE COMM HOSP No No No No No 4200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540816 TULARE DIST HOSP No Yes No No No 3578 12882 12620 $6289 $7436 $9529 Transition NA $98163 $80582 106531059 TRINITY HOSP No Yes No Yes Yes 5105 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106400548 TWIN CITIES COMM HOSP No No No Yes Yes 1587 12964 12701 $12768 $15168 $8160 Transition NA $98163 $80582 106341006 UC DAVIS MED CTR Yes No Yes No No 1836 15256 14946 $6289 $8454 NA NA NA NA NA 106301279 UC IRVINE MED CTR Yes No Yes No No 2072 12882 12620 $6289 $7436 NA NA NA NA NA 106370782 UCSD MED CTR Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106374141 UCSD-LA JOLLA JOHN M amp SALLY B THORNTON HOSPITAL Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106381154 UCSF MED CTR Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106380895 UCSF MED CTR AT MOUNT ZION Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106301357 TUSTIN HOSP MED CTR No No No No No 231 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106231396 UKIAH VALLEY MED CTRHOSP DR No No No Yes Yes 3643 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106014050 VALLEY CARE MEDICAL CENTER No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106010983 VALLEY MEM HOSP-LIVERMORE No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106191216 USC KENNETH NORRIS JR CANCER HOSP No No No No No 3134 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560481 VENTURA CO MED CTR Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106560521 VENTURA CO MED CTR-SANTA PAULA HOSPITAL Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106190818 VERDUGO HILLS HOSP No No No No No 3110 12882 12620 $6289 $7436 $5264 Transition NA $98163 $80582 106190812 VALLEY PRES HOSP No No No No No 3536 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 3046 14188 13900 $6289 $7996 NA Non-Transition $1312 $98163 $80582 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 3266 12882 12620 $6289 $7436 $8320 Transition NA $98163 $80582 106010987 WASHINGTON HOSP-FREMONT No Yes No No No 1941 16962 16618 $6289 $9186 $6429 Transition NA $98163 $80582 106444013 WATSONVILLE COMM HOSP No No No No No 1780 17239 16889 $6289 $9304 $13456 Transition NA $98163 $80582 106301379 WEST ANAHEIM MED CTR No No No No No 1514 12882 12620 $6289 $7436 $4707 Transition NA $98163 $80582 106190859 WEST HILLS HOSP AND MED CTR No No No No No 1933 12882 12620 $6289 $7436 $8050 Transition NA $98163 $80582 106374094 VIBRA OF SAN DIEGO No No No No No 1155 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301188 WESTERN MED CTR-ANAHEIM No No No No No 3203 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301566 WESTERN MED CTR-SANTA ANA No No No No No 2354 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190878 WHITE MEM MED CTR No No No No No 1515 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190883 WHITTIER HOSP MED CTR No No No No No 1139 12882 12620 $6289 $7436 $5922 Transition NA $98163 $80582 106571086 WOODLAND MEM HOSP No No No No No 3278 15256 14946 $6289 $8454 $10092 Transition NA $98163 $80582 6102015
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
-
070-4 ORBITAL PROCEDURES 1319 41150 10000 10000 41150 12500 51438 10000 41150 $38578 Misc Pediatric Misc Adult 073-1 073-2 073-3 073-4
EYE PROCEDURES EXCEPT ORBIT EYE PROCEDURES EXCEPT ORBIT EYE PROCEDURES EXCEPT ORBIT EYE PROCEDURES EXCEPT ORBIT
227 313 544
1855
07119 08959 13025 30348
10000 10000 10000 10000
10000 10000 10000 10000
07119 08959 13025 30348
12500 12500 12500 12500
08899 11199 16281 37935
10000 10000 10000 10000
07119 08959 13025 30348
$6674 Misc Pediatric $8399 Misc Pediatric
$12211 Misc Pediatric $28451 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
080-1 080-2 080-3 080-4
ACUTE MAJOR EYE INFECTIONS ACUTE MAJOR EYE INFECTIONS ACUTE MAJOR EYE INFECTIONS ACUTE MAJOR EYE INFECTIONS
294 394 624
1204
03773 05293 08870 22854
10000 10000 10000 10000
10000 10000 10000 10000
03773 05293 08870 22854
12500 12500 12500 12500
04716 06616 11088 28568
10000 10000 10000 10000
03773 05293 08870 22854
$3537 Misc Pediatric $4962 Misc Pediatric $8316 Misc Pediatric
$21426 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
082-1 082-2 082-3 082-4
EYE DISORDERS EXCEPT MAJOR INFECTIONS EYE DISORDERS EXCEPT MAJOR INFECTIONS EYE DISORDERS EXCEPT MAJOR INFECTIONS EYE DISORDERS EXCEPT MAJOR INFECTIONS
229 280 431
1589
04191 05783 08004 18093
10000 10000 10000 10000
10000 10000 10000 10000
04191 05783 08004 18093
12500 12500 12500 12500
05239 07229 10005 22616
10000 10000 10000 10000
04191 05783 08004 18093
$3929 Misc Pediatric $5422 Misc Pediatric $7504 Misc Pediatric
$16962 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
089-1 089-2 089-3 089-4
MAJOR CRANIALFACIAL BONE PROCEDURES MAJOR CRANIALFACIAL BONE PROCEDURES MAJOR CRANIALFACIAL BONE PROCEDURES MAJOR CRANIALFACIAL BONE PROCEDURES
231 384 877
1633
14059 18500 32437 57616
10000 10000 10000 10000
10000 10000 10000 10000
14059 18500 32437 57616
12500 12500 12500 12500
17574 23125 40546 72020
10000 10000 10000 10000
14059 18500 32437 57616
$13180 Misc Pediatric $17344 Misc Pediatric $30410 Misc Pediatric $54015 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
090-1 090-2 090-3 090-4
MAJOR LARYNX amp TRACHEA PROCEDURES MAJOR LARYNX amp TRACHEA PROCEDURES MAJOR LARYNX amp TRACHEA PROCEDURES MAJOR LARYNX amp TRACHEA PROCEDURES
259 809
1356 2501
07159 22218 35815 71443
10000 10000 10000 10000
10000 10000 10000 10000
07159 22218 35815 71443
12500 12500 12500 12500
08949 27773 44769 89304
10000 10000 10000 10000
07159 22218 35815 71443
$6712 Misc Pediatric $20829 Misc Pediatric $33577 Misc Pediatric $66978 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
091-1 091-2 091-3 091-4
OTHER MAJOR HEAD amp NECK PROCEDURES OTHER MAJOR HEAD amp NECK PROCEDURES OTHER MAJOR HEAD amp NECK PROCEDURES OTHER MAJOR HEAD amp NECK PROCEDURES
324 463 959
1918
13026 18978 35965 63240
10000 10000 10000 10000
10000 10000 10000 10000
13026 18978 35965 63240
12500 12500 12500 12500
16283 23723 44956 79050
10000 10000 10000 10000
13026 18978 35965 63240
$12212 Misc Pediatric $17792 Misc Pediatric $33717 Misc Pediatric $59288 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
092-1 092-2 092-3 092-4
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES
200 293 606
1411
09832 13811 22378 49305
10000 10000 10000 10000
10000 10000 10000 10000
09832 13811 22378 49305
12500 12500 12500 12500
12290 17264 27973 61631
10000 10000 10000 10000
09832 13811 22378 49305
$9218 Misc Pediatric $12948 Misc Pediatric $20979 Misc Pediatric $46223 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
093-1 093-2 093-3 093-4
SINUS amp MASTOID PROCEDURES SINUS amp MASTOID PROCEDURES SINUS amp MASTOID PROCEDURES SINUS amp MASTOID PROCEDURES
236 388 725
1267
09484 12524 19562 30863
10000 10000 10000 10000
10000 10000 10000 10000
09484 12524 19562 30863
12500 12500 12500 12500
11855 15655 24453 38579
10000 10000 10000 10000
09484 12524 19562 30863
$8891 Misc Pediatric $11741 Misc Pediatric $18339 Misc Pediatric $28934 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
095-1 095-2 095-3 095-4
CLEFT LIP amp PALATE REPAIR CLEFT LIP amp PALATE REPAIR CLEFT LIP amp PALATE REPAIR CLEFT LIP amp PALATE REPAIR
143 206 403
1096
06260 07686 11913 21518
10000 10000 10000 10000
10000 10000 10000 10000
06260 07686 11913 21518
12500 12500 12500 12500
07825 09608 14891 26898
10000 10000 10000 10000
06260 07686 11913 21518
$5869 Misc Pediatric $7206 Misc Pediatric
$11168 Misc Pediatric $20173 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
097-1 097-2 097-3 097-4
TONSIL amp ADENOID PROCEDURES TONSIL amp ADENOID PROCEDURES TONSIL amp ADENOID PROCEDURES TONSIL amp ADENOID PROCEDURES
155 275 571
1520
04084 06213 12162 32627
10000 10000 10000 10000
10000 10000 10000 10000
04084 06213 12162 32627
12500 12500 12500 12500
05105 07766 15203 40784
10000 10000 10000 10000
04084 06213 12162 32627
$3829 Misc Pediatric $5825 Misc Pediatric
$11402 Misc Pediatric $30588 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
098-1 098-2 098-3 098-4
OTHER EAR NOSE MOUTH amp THROAT PROCEDURES OTHER EAR NOSE MOUTH amp THROAT PROCEDURES OTHER EAR NOSE MOUTH amp THROAT PROCEDURES OTHER EAR NOSE MOUTH amp THROAT PROCEDURES
210 326 680
1461
07048 09495 15477 32522
10000 10000 10000 10000
10000 10000 10000 10000
07048 09495 15477 32522
12500 12500 12500 12500
08810 11869 19346 40653
10000 10000 10000 10000
07048 09495 15477 32522
$6608 Misc Pediatric $8902 Misc Pediatric
$14510 Misc Pediatric $30489 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
110-1 110-2 110-3 110-4
EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES
292 429 693
1273
04895 07037 11057 22409
10000 10000 10000 10000
10000 10000 10000 10000
04895 07037 11057 22409
12500 12500 12500 12500
06119 08796 13821 28011
10000 10000 10000 10000
04895 07037 11057 22409
$4589 Misc Pediatric $6597 Misc Pediatric
$10366 Misc Pediatric $21008 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
111-1 111-2 111-3 111-4
VERTIGO amp OTHER LABYRINTH DISORDERS VERTIGO amp OTHER LABYRINTH DISORDERS VERTIGO amp OTHER LABYRINTH DISORDERS VERTIGO amp OTHER LABYRINTH DISORDERS
201 251 349 747
04865 05693 07226 13868
10000 10000 10000 10000
10000 10000 10000 10000
04865 05693 07226 13868
12500 12500 12500 12500
06081 07116 09033 17335
10000 10000 10000 10000
04865 05693 07226 13868
$4561 Misc Pediatric $5337 Misc Pediatric $6774 Misc Pediatric
$13001 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
113-1 113-2 113-3 113-4
INFECTIONS OF UPPER RESPIRATORY TRACT INFECTIONS OF UPPER RESPIRATORY TRACT INFECTIONS OF UPPER RESPIRATORY TRACT INFECTIONS OF UPPER RESPIRATORY TRACT
187 252 395 733
02600 04025 06701 13455
10000 10000 10000 10000
10000 10000 10000 10000
02600 04025 06701 13455
12500 12500 12500 12500
03250 05031 08376 16819
10000 10000 10000 10000
02600 04025 06701 13455
$2438 Resp Pediatric $3773 Resp Pediatric $6282 Resp Pediatric
$12614 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
114-1 114-2 114-3 114-4
DENTAL amp ORAL DISEASES amp INJURIES DENTAL amp ORAL DISEASES amp INJURIES DENTAL amp ORAL DISEASES amp INJURIES DENTAL amp ORAL DISEASES amp INJURIES
220 297 545
1060
03711 05698 09275 19812
10000 10000 10000 10000
10000 10000 10000 10000
03711 05698 09275 19812
12500 12500 12500 12500
04639 07123 11594 24765
10000 10000 10000 10000
03711 05698 09275 19812
$3479 Misc Pediatric $5342 Misc Pediatric $8695 Misc Pediatric
$18574 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
115-1 115-2 115-3 115-4
OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES
230 298 483 964
04062 05956 08755 18372
10000 10000 10000 10000
10000 10000 10000 10000
04062 05956 08755 18372
12500 12500 12500 12500
05078 07445 10944 22965
10000 10000 10000 10000
04062 05956 08755 18372
$3808 Misc Pediatric $5584 Misc Pediatric $8208 Misc Pediatric
$17224 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
120-1 120-2 120-3 120-4
MAJOR RESPIRATORY amp CHEST PROCEDURES MAJOR RESPIRATORY amp CHEST PROCEDURES MAJOR RESPIRATORY amp CHEST PROCEDURES MAJOR RESPIRATORY amp CHEST PROCEDURES
486 677
1138 1939
17190 21946 31960 57405
10000 10000 10000 10000
10000 10000 10000 10000
17190 21946 31960 57405
12500 12500 12500 12500
21488 27433 39950 71756
10000 10000 10000 10000
17190 21946 31960 57405
$16116 Resp Pediatric $20574 Resp Pediatric $29963 Resp Pediatric $53817 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
121-1 121-2 121-3 121-4
OTHER RESPIRATORY amp CHEST PROCEDURES OTHER RESPIRATORY amp CHEST PROCEDURES OTHER RESPIRATORY amp CHEST PROCEDURES OTHER RESPIRATORY amp CHEST PROCEDURES
349 547
1028 1936
11884 15313 24687 50343
10000 10000 10000 10000
10000 10000 10000 10000
11884 15313 24687 50343
12500 12500 12500 12500
14855 19141 30859 62929
10000 10000 10000 10000
11884 15313 24687 50343
$11141 Resp Pediatric $14356 Resp Pediatric $23144 Resp Pediatric $47197 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
130-1 130-2 130-3 130-4
RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS
1453 1262 1448 1967
28511 30424 36434 48144
10000 10000 10000 10000
10000 10000 10000 10000
28511 30424 36434 48144
12500 12500 12500 12500
35639 38030 45543 60180
10000 10000 10000 10000
28511 30424 36434 48144
$26729 Resp Pediatric $28523 Resp Pediatric $34157 Resp Pediatric $45135 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
131-1 131-2 131-3 131-4
CYSTIC FIBROSIS - PULMONARY DISEASE CYSTIC FIBROSIS - PULMONARY DISEASE CYSTIC FIBROSIS - PULMONARY DISEASE CYSTIC FIBROSIS - PULMONARY DISEASE
695 820
1028 1321
11407 14020 18525 25461
10000 10000 10000 10000
10000 10000 10000 10000
11407 14020 18525 25461
12500 12500 12500 12500
14259 17525 23156 31826
10000 10000 10000 10000
11407 14020 18525 25461
$10694 Resp Pediatric $13144 Resp Pediatric $17367 Resp Pediatric $23870 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
132-1 132-2 132-3 132-4
BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD
345 441 709
1048
04234 05182 08052 14928
10000 10000 10000 10000
10000 10000 10000 10000
04234 05182 08052 14928
12500 12500 12500 12500
05293 06478 10065 18660
10000 10000 10000 10000
04234 05182 08052 14928
$3969 Resp Pediatric $4858 Resp Pediatric $7549 Resp Pediatric
$13995 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
133-1 133-2 133-3 133-4
PULMONARY EDEMA amp RESPIRATORY FAILURE PULMONARY EDEMA amp RESPIRATORY FAILURE PULMONARY EDEMA amp RESPIRATORY FAILURE PULMONARY EDEMA amp RESPIRATORY FAILURE
256 409 582 753
05454 07562 10997 17496
10000 10000 10000 10000
10000 10000 10000 10000
05454 07562 10997 17496
12500 12500 12500 12500
06818 09453 13746 21870
10000 10000 10000 10000
05454 07562 10997 17496
$5113 Resp Pediatric $7089 Resp Pediatric
$10310 Resp Pediatric $16403 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
134-1 134-2 134-3 134-4
PULMONARY EMBOLISM PULMONARY EMBOLISM PULMONARY EMBOLISM PULMONARY EMBOLISM
366 454 634 866
07118 09026 12878 19731
10000 10000 10000 10000
10000 10000 10000 10000
07118 09026 12878 19731
12500 12500 12500 12500
08898 11283 16098 24664
10000 10000 10000 10000
07118 09026 12878 19731
$6673 Resp Pediatric $8462 Resp Pediatric
$12073 Resp Pediatric $18498 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
135-1 135-2 135-3 135-4
MAJOR CHEST amp RESPIRATORY TRAUMA MAJOR CHEST amp RESPIRATORY TRAUMA MAJOR CHEST amp RESPIRATORY TRAUMA MAJOR CHEST amp RESPIRATORY TRAUMA
283 365 576 834
06399 08153 11913 21262
10000 10000 10000 10000
10000 10000 10000 10000
06399 08153 11913 21262
12500 12500 12500 12500
07999 10191 14891 26578
10000 10000 10000 10000
06399 08153 11913 21262
$5999 Resp Pediatric $7643 Resp Pediatric
$11168 Resp Pediatric $19933 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
136-1 136-2 136-3 136-4
RESPIRATORY MALIGNANCY RESPIRATORY MALIGNANCY RESPIRATORY MALIGNANCY RESPIRATORY MALIGNANCY
324 419 664 944
04458 07139 11635 18353
10000 10000 10000 10000
10000 10000 10000 10000
04458 07139 11635 18353
12500 12500 12500 12500
05573 08924 14544 22941
10000 10000 10000 10000
04458 07139 11635 18353
$4179 Resp Pediatric $6693 Resp Pediatric
$10908 Resp Pediatric $17206 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
137-1 137-2 137-3 137-4
MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS
470 529 724
1033
06368 08483 12031 19133
10000 10000 10000 10000
10000 10000 10000 10000
06368 08483 12031 19133
12500 12500 12500 12500
07960 10604 15039 23916
10000 10000 10000 10000
06368 08483 12031 19133
$5970 Resp Pediatric $7953 Resp Pediatric
$11279 Resp Pediatric $17937 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
138-1 138-2 138-3 138-4
BRONCHIOLITIS amp RSV PNEUMONIA BRONCHIOLITIS amp RSV PNEUMONIA BRONCHIOLITIS amp RSV PNEUMONIA BRONCHIOLITIS amp RSV PNEUMONIA
238 312 534 914
02804 03844 07519 18353
10000 10000 10000 10000
10000 10000 10000 10000
02804 03844 07519 18353
12500 12500 12500 12500
03505 04805 09399 22941
10000 10000 10000 10000
02804 03844 07519 18353
$2629 Resp Pediatric $3604 Resp Pediatric $7049 Resp Pediatric
$17206 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
139-1 139-2 139-3 139-4
OTHER PNEUMONIA OTHER PNEUMONIA OTHER PNEUMONIA OTHER PNEUMONIA
272 378 564 872
04202 06403 09948 17261
10000 10000 10000 10000
10000 10000 10000 10000
04202 06403 09948 17261
12500 12500 12500 12500
05253 08004 12435 21576
10000 10000 10000 10000
04202 06403 09948 17261
$3939 Resp Pediatric $6003 Resp Pediatric $9326 Resp Pediatric
$16182 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
140-1 140-2 140-3 140-4
CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHRONIC OBSTRUCTIVE PULMONARY DISEASE CHRONIC OBSTRUCTIVE PULMONARY DISEASE
311 381 519 874
05252 06666 09076 16691
10000 10000 10000 10000
10000 10000 10000 10000
05252 06666 09076 16691
12500 12500 12500 12500
06565 08333 11345 20864
10000 10000 10000 10000
05252 06666 09076 16691
$4924 Resp Pediatric $6249 Resp Pediatric $8509 Resp Pediatric
$15648 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
141-1 141-2 141-3 141-4
ASTHMA ASTHMA ASTHMA ASTHMA
219 307 435 560
03409 05016 07486 13503
10000 10000 10000 10000
10000 10000 10000 10000
03409 05016 07486 13503
12500 12500 12500 12500
04261 06270 09358 16879
10000 10000 10000 10000
03409 05016 07486 13503
$3196 Resp Pediatric $4703 Resp Pediatric $7018 Resp Pediatric
$12659 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
142-1 142-2 142-3 142-4
INTERSTITIAL amp ALVEOLAR LUNG DISEASES INTERSTITIAL amp ALVEOLAR LUNG DISEASES INTERSTITIAL amp ALVEOLAR LUNG DISEASES INTERSTITIAL amp ALVEOLAR LUNG DISEASES
331 422 633
1035
05788 07446 10874 19559
10000 10000 10000 10000
10000 10000 10000 10000
05788 07446 10874 19559
12500 12500 12500 12500
07235 09308 13593 24449
10000 10000 10000 10000
05788 07446 10874 19559
$5426 Resp Pediatric $6981 Resp Pediatric
$10194 Resp Pediatric $18337 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
143-1 143-2 143-3 143-4
OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES
285 376 564 863
04354 06617 09962 15731
10000 10000 10000 10000
10000 10000 10000 10000
04354 06617 09962 15731
12500 12500 12500 12500
05443 08271 12453 19664
10000 10000 10000 10000
04354 06617 09962 15731
$4082 Resp Pediatric $6203 Resp Pediatric $9339 Resp Pediatric
$14748 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
144-1 144-2 144-3 144-4
RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES
215 294 429 723
04363 05599 07749 13057
10000 10000 10000 10000
10000 10000 10000 10000
04363 05599 07749 13057
12500 12500 12500 12500
05454 06999 09686 16321
10000 10000 10000 10000
04363 05599 07749 13057
$4090 Resp Pediatric $5249 Resp Pediatric $7265 Resp Pediatric
$12241 Resp Pediatric
Resp Adult Resp Adult Resp Adult Resp Adult
160-1 160-2 160-3 160-4
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY
469 616
1039 2605
31307 34602 50015 97328
10000 10000 10000 10000
10000 10000 10000 10000
31307 34602 50015 97328
12500 12500 12500 12500
39134 43253 62519
121660
10000 10000 10000 10000
31307 34602 50015 97328
$29350 Misc Pediatric $32439 Misc Pediatric $46889 Misc Pediatric $91245 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
161-1 161-2 161-3 161-4
CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT
319 787
1588 3102
40098 53014 84071
199842
10000 10000 10000 10000
10000 10000 10000 10000
40098 53014 84071
199842
12500 12500 12500 12500
50123 66268
105089 249803
10000 10000 10000 10000
40098 53014 84071
199842
$37592 Misc Pediatric $49701 Misc Pediatric $78817 Misc Pediatric
$187352 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
162-1 162-2 162-3 162-4
CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES W CARDIAC CATHETERIZATION
800 918
1322 2097
44219 49501 63338 96985
10000 10000 10000 10000
10000 10000 10000 10000
44219 49501 63338 96985
12500 12500 12500 12500
55274 61876 79173
121231
10000 10000 10000 10000
44219 49501 63338 96985
$41455 Misc Pediatric $46407 Misc Pediatric $59379 Misc Pediatric $90923 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
163-1 163-2 163-3 163-4
CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION
566 651 924
1798
38077 42090 51794 88229
10000 10000 10000 10000
10000 10000 10000 10000
38077 42090 51794 88229
12500 12500 12500 12500
47596 52613 64743
110286
10000 10000 10000 10000
38077 42090 51794 88229
$35697 Misc Pediatric $39459 Misc Pediatric $48557 Misc Pediatric $82715 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
165-1 165-2 165-3 165-4
CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE
675 817
1052 1712
38445 43860 53254 80347
10000 10000 10000 10000
10000 10000 10000 10000
38445 43860 53254 80347
12500 12500 12500 12500
48056 54825 66568
100434
10000 10000 10000 10000
38445 43860 53254 80347
$36042 Misc Pediatric $41119 Misc Pediatric $49926 Misc Pediatric $75325 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
166-1 166-2 166-3 166-4
CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE
502 611 855
1615
30632 34370 42566 71277
10000 10000 10000 10000
10000 10000 10000 10000
30632 34370 42566 71277
12500 12500 12500 12500
38290 42963 53208 89096
10000 10000 10000 10000
30632 34370 42566 71277
$28718 Misc Pediatric $32222 Misc Pediatric $39906 Misc Pediatric $66822 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
167-1 167-2 167-3 167-4
OTHER CARDIOTHORACIC PROCEDURES OTHER CARDIOTHORACIC PROCEDURES OTHER CARDIOTHORACIC PROCEDURES OTHER CARDIOTHORACIC PROCEDURES
438 583 914
1860
28492 32691 41583 72603
10000 10000 10000 10000
10000 10000 10000 10000
28492 32691 41583 72603
12500 12500 12500 12500
35615 40864 51979 90754
10000 10000 10000 10000
28492 32691 41583 72603
$26711 Misc Pediatric $30648 Misc Pediatric $38984 Misc Pediatric $68065 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
169-1 169-2 169-3 169-4
MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES
434 570 899
1626
17710 23017 35767 63594
10000 10000 10000 10000
10000 10000 10000 10000
17710 23017 35767 63594
12500 12500 12500 12500
22138 28771 44709 79493
10000 10000 10000 10000
17710 23017 35767 63594
$16603 Misc Pediatric $21578 Misc Pediatric $33532 Misc Pediatric $59619 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
170-1 170-2 170-3 170-4
PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK
468 535 901
1647
22837 24595 30320 48851
10000 10000 10000 10000
10000 10000 10000 10000
22837 24595 30320 48851
12500 12500 12500 12500
28546 30744 37900 61064
10000 10000 10000 10000
22837 24595 30320 48851
$21410 Misc Pediatric $23058 Misc Pediatric $28425 Misc Pediatric $45798 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
171-1 171-2 171-3 171-4
PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK
257 388 652
1323
16061 19059 24628 42111
10000 10000 10000 10000
10000 10000 10000 10000
16061 19059 24628 42111
12500 12500 12500 12500
20076 23824 30785 52639
10000 10000 10000 10000
16061 19059 24628 42111
$15057 Misc Pediatric $17868 Misc Pediatric $23089 Misc Pediatric $39479 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
173-1 173-2 173-3 173-4
OTHER VASCULAR PROCEDURES OTHER VASCULAR PROCEDURES OTHER VASCULAR PROCEDURES OTHER VASCULAR PROCEDURES
248 413 835
1698
17172 20933 28552 52543
10000 10000 10000 10000
10000 10000 10000 10000
17172 20933 28552 52543
12500 12500 12500 12500
21465 26166 35690 65679
10000 10000 10000 10000
17172 20933 28552 52543
$16099 Misc Pediatric $19625 Misc Pediatric $26768 Misc Pediatric $49259 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
174-1 174-2 174-3 174-4
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI
242 309 532 858
20862 22375 27863 40669
10000 10000 10000 10000
10000 10000 10000 10000
20862 22375 27863 40669
12500 12500 12500 12500
26078 27969 34829 50836
10000 10000 10000 10000
20862 22375 27863 40669
$19558 Misc Pediatric $20977 Misc Pediatric $26122 Misc Pediatric $38127 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
175-1 175-2 175-3 175-4
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI
172 253 517
1037
17736 19933 25843 42121
10000 10000 10000 10000
10000 10000 10000 10000
17736 19933 25843 42121
12500 12500 12500 12500
22170 24916 32304 52651
10000 10000 10000 10000
17736 19933 25843 42121
$16628 Misc Pediatric $18687 Misc Pediatric $24228 Misc Pediatric $39488 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
176-1 176-2 176-3 176-4
CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT
291 253 446
1336
13020 24038 27425 45070
10000 10000 10000 10000
10000 10000 10000 10000
13020 24038 27425 45070
12500 12500 12500 12500
16275 30048 34281 56338
10000 10000 10000 10000
13020 24038 27425 45070
$12206 Misc Pediatric $22536 Misc Pediatric $25711 Misc Pediatric $42253 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
177-1 177-2 177-3 177-4
CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT
260 405 749
1560
10212 13638 21173 40225
10000 10000 10000 10000
10000 10000 10000 10000
10212 13638 21173 40225
12500 12500 12500 12500
12765 17048 26466 50281
10000 10000 10000 10000
10212 13638 21173 40225
$9574 Misc Pediatric $12786 Misc Pediatric $19850 Misc Pediatric $37711 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
180-1 180-2 180-3 180-4
OTHER CIRCULATORY SYSTEM PROCEDURES OTHER CIRCULATORY SYSTEM PROCEDURES OTHER CIRCULATORY SYSTEM PROCEDURES OTHER CIRCULATORY SYSTEM PROCEDURES
416 593 963
1589
10497 14144 21255 39764
10000 10000 10000 10000
10000 10000 10000 10000
10497 14144 21255 39764
12500 12500 12500 12500
13121 17680 26569 49705
10000 10000 10000 10000
10497 14144 21255 39764
$9841 Misc Pediatric $13260 Misc Pediatric $19927 Misc Pediatric $37279 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
190-1 190-2 190-3 190-4
ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION
212 315 518 765
06920 08342 11428 18576
10000 10000 10000 10000
10000 10000 10000 10000
06920 08342 11428 18576
12500 12500 12500 12500
08650 10428 14285 23220
10000 10000 10000 10000
06920 08342 11428 18576
$6488 Misc Pediatric $7821 Misc Pediatric
$10714 Misc Pediatric $17415 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
191-1 191-2 191-3 191-4
CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE
250 356 588
1157
10129 11962 15321 30799
10000 10000 10000 10000
10000 10000 10000 10000
10129 11962 15321 30799
12500 12500 12500 12500
12661 14953 19151 38499
10000 10000 10000 10000
10129 11962 15321 30799
$9496 Misc Pediatric $11214 Misc Pediatric $14363 Misc Pediatric $28874 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
192-1 192-2 192-3 192-4
CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE
190 256 440 733
08840 10294 13642 21517
10000 10000 10000 10000
10000 10000 10000 10000
08840 10294 13642 21517
12500 12500 12500 12500
11050 12868 17053 26896
10000 10000 10000 10000
08840 10294 13642 21517
$8288 Misc Pediatric $9651 Misc Pediatric
$12789 Misc Pediatric $20172 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
193-1 193-2 193-3 193-4
ACUTE amp SUBACUTE ENDOCARDITIS ACUTE amp SUBACUTE ENDOCARDITIS ACUTE amp SUBACUTE ENDOCARDITIS ACUTE amp SUBACUTE ENDOCARDITIS
549 695
1002 1491
07895 10373 15660 25224
10000 10000 10000 10000
10000 10000 10000 10000
07895 10373 15660 25224
12500 12500 12500 12500
09869 12966 19575 31530
10000 10000 10000 10000
07895 10373 15660 25224
$7402 Misc Pediatric $9725 Misc Pediatric
$14681 Misc Pediatric $23648 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
194-1 194-2 194-3 194-4
HEART FAILURE HEART FAILURE HEART FAILURE HEART FAILURE
292 375 565 955
05101 06549 09786 17821
10000 10000 10000 10000
10000 10000 10000 10000
05101 06549 09786 17821
12500 12500 12500 12500
06376 08186 12233 22276
10000 10000 10000 10000
05101 06549 09786 17821
$4782 Misc Pediatric $6140 Misc Pediatric $9174 Misc Pediatric
$16707 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
196-1 196-2 196-3 196-4
CARDIAC ARREST CARDIAC ARREST CARDIAC ARREST CARDIAC ARREST
291 227 252 462
03449 04919 07133 17166
10000 10000 10000 10000
10000 10000 10000 10000
03449 04919 07133 17166
12500 12500 12500 12500
04311 06149 08916 21458
10000 10000 10000 10000
03449 04919 07133 17166
$3233 Misc Pediatric $4612 Misc Pediatric $6687 Misc Pediatric
$16093 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
197-1 197-2 197-3 197-4
PERIPHERAL amp OTHER VASCULAR DISORDERS PERIPHERAL amp OTHER VASCULAR DISORDERS PERIPHERAL amp OTHER VASCULAR DISORDERS PERIPHERAL amp OTHER VASCULAR DISORDERS
325 405 554 993
04539 06186 09350 18139
10000 10000 10000 10000
10000 10000 10000 10000
04539 06186 09350 18139
12500 12500 12500 12500
05674 07733 11688 22674
10000 10000 10000 10000
04539 06186 09350 18139
$4255 Misc Pediatric $5799 Misc Pediatric $8766 Misc Pediatric
$17005 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
198-1 198-2 198-3 198-4
ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS
164 215 343 795
04222 05100 07000 13778
10000 10000 10000 10000
10000 10000 10000 10000
04222 05100 07000 13778
12500 12500 12500 12500
05278 06375 08750 17223
10000 10000 10000 10000
04222 05100 07000 13778
$3958 Misc Pediatric $4781 Misc Pediatric $6563 Misc Pediatric
$12917 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
199-1 199-2 199-3 199-4
HYPERTENSION HYPERTENSION HYPERTENSION HYPERTENSION
199 261 407 774
04431 05438 07709 16234
10000 10000 10000 10000
10000 10000 10000 10000
04431 05438 07709 16234
12500 12500 12500 12500
05539 06798 09636 20293
10000 10000 10000 10000
04431 05438 07709 16234
$4154 Misc Pediatric $5098 Misc Pediatric $7227 Misc Pediatric
$15219 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
200-1 200-2 200-3 200-4
CARDIAC STRUCTURAL amp VALVULAR DISORDERS CARDIAC STRUCTURAL amp VALVULAR DISORDERS CARDIAC STRUCTURAL amp VALVULAR DISORDERS CARDIAC STRUCTURAL amp VALVULAR DISORDERS
238 315 517
1005
04557 05692 08445 16354
10000 10000 10000 10000
10000 10000 10000 10000
04557 05692 08445 16354
12500 12500 12500 12500
05696 07115 10556 20443
10000 10000 10000 10000
04557 05692 08445 16354
$4272 Misc Pediatric $5336 Misc Pediatric $7917 Misc Pediatric
$15332 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
201-1 201-2 201-3 201-4
CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS
199 289 466 863
04273 05624 08590 17457
10000 10000 10000 10000
10000 10000 10000 10000
04273 05624 08590 17457
12500 12500 12500 12500
05341 07030 10738 21821
10000 10000 10000 10000
04273 05624 08590 17457
$4006 Misc Pediatric $5273 Misc Pediatric $8053 Misc Pediatric
$16366 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
203-1 203-2 203-3 203-4
CHEST PAIN CHEST PAIN CHEST PAIN CHEST PAIN
148 195 305 725
04180 05129 06846 13335
10000 10000 10000 10000
10000 10000 10000 10000
04180 05129 06846 13335
12500 12500 12500 12500
05225 06411 08558 16669
10000 10000 10000 10000
04180 05129 06846 13335
$3919 Misc Pediatric $4808 Misc Pediatric $6418 Misc Pediatric
$12502 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
204-1 204-2 204-3 204-4
SYNCOPE amp COLLAPSE SYNCOPE amp COLLAPSE SYNCOPE amp COLLAPSE SYNCOPE amp COLLAPSE
201 264 388 858
04877 05857 07587 15564
10000 10000 10000 10000
10000 10000 10000 10000
04877 05857 07587 15564
12500 12500 12500 12500
06096 07321 09484 19455
10000 10000 10000 10000
04877 05857 07587 15564
$4572 Misc Pediatric $5491 Misc Pediatric $7113 Misc Pediatric
$14591 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
205-1 205-2 205-3 205-4
CARDIOMYOPATHY CARDIOMYOPATHY CARDIOMYOPATHY CARDIOMYOPATHY
238 308 496 926
04349 05715 08342 18259
10000 10000 10000 10000
10000 10000 10000 10000
04349 05715 08342 18259
12500 12500 12500 12500
05436 07144 10428 22824
10000 10000 10000 10000
04349 05715 08342 18259
$4077 Misc Pediatric $5358 Misc Pediatric $7821 Misc Pediatric
$17118 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
206-1 206-2 206-3 206-4
MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE
227 345 572
1116
04452 05754 09436 20324
10000 10000 10000 10000
10000 10000 10000 10000
04452 05754 09436 20324
12500 12500 12500 12500
05565 07193 11795 25405
10000 10000 10000 10000
04452 05754 09436 20324
$4174 Misc Pediatric $5394 Misc Pediatric $8846 Misc Pediatric
$19054 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
207-1 207-2 207-3 207-4
OTHER CIRCULATORY SYSTEM DIAGNOSES OTHER CIRCULATORY SYSTEM DIAGNOSES OTHER CIRCULATORY SYSTEM DIAGNOSES OTHER CIRCULATORY SYSTEM DIAGNOSES
239 327 479 850
04972 06455 09118 17339
10000 10000 10000 10000
10000 10000 10000 10000
04972 06455 09118 17339
12500 12500 12500 12500
06215 08069 11398 21674
10000 10000 10000 10000
04972 06455 09118 17339
$4661 Misc Pediatric $6052 Misc Pediatric $8548 Misc Pediatric
$16255 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
220-1 220-2 220-3 220-4
MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES
370 728
1222 2105
13178 19373 31783 59607
10000 10000 10000 10000
10000 10000 10000 10000
13178 19373 31783 59607
12500 12500 12500 12500
16473 24216 39729 74509
10000 10000 10000 10000
13178 19373 31783 59607
$12354 Misc Pediatric $18162 Misc Pediatric $29797 Misc Pediatric $55882 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
221-1 221-2 221-3 221-4
MAJOR SMALL amp LARGE BOWEL PROCEDURES MAJOR SMALL amp LARGE BOWEL PROCEDURES MAJOR SMALL amp LARGE BOWEL PROCEDURES MAJOR SMALL amp LARGE BOWEL PROCEDURES
486 711
1216 2007
13986 18317 29391 55350
10000 10000 10000 10000
10000 10000 10000 10000
13986 18317 29391 55350
12500 12500 12500 12500
17483 22896 36739 69188
10000 10000 10000 10000
13986 18317 29391 55350
$13112 Misc Pediatric $17172 Misc Pediatric $27554 Misc Pediatric $51891 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
222-1 222-2 222-3 222-4
OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES
226 370 835
1821
08125 12068 19613 44248
10000 10000 10000 10000
10000 10000 10000 10000
08125 12068 19613 44248
12500 12500 12500 12500
10156 15085 24516 55310
10000 10000 10000 10000
08125 12068 19613 44248
$7617 Misc Pediatric $11314 Misc Pediatric $18387 Misc Pediatric $41483 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
223-1 223-2 223-3 223-4
OTHER SMALL amp LARGE BOWEL PROCEDURES OTHER SMALL amp LARGE BOWEL PROCEDURES OTHER SMALL amp LARGE BOWEL PROCEDURES OTHER SMALL amp LARGE BOWEL PROCEDURES
442 643
1092 1967
10740 14465 23665 49105
10000 10000 10000 10000
10000 10000 10000 10000
10740 14465 23665 49105
12500 12500 12500 12500
13425 18081 29581 61381
10000 10000 10000 10000
10740 14465 23665 49105
$10069 Misc Pediatric $13561 Misc Pediatric $22186 Misc Pediatric $46036 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
224-1 224-2 224-3 224-4
PERITONEAL ADHESIOLYSIS PERITONEAL ADHESIOLYSIS PERITONEAL ADHESIOLYSIS PERITONEAL ADHESIOLYSIS
540 788
1150 1745
12217 16811 25160 44117
10000 10000 10000 10000
10000 10000 10000 10000
12217 16811 25160 44117
12500 12500 12500 12500
15271 21014 31450 55146
10000 10000 10000 10000
12217 16811 25160 44117
$11453 Misc Pediatric $15760 Misc Pediatric $23588 Misc Pediatric $41360 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
225-1 225-2 225-3 225-4
APPENDECTOMY APPENDECTOMY APPENDECTOMY APPENDECTOMY
157 376 726
1357
07870 11109 18822 36506
10000 10000 10000 10000
10000 10000 10000 10000
07870 11109 18822 36506
12500 12500 12500 12500
09838 13886 23528 45633
10000 10000 10000 10000
07870 11109 18822 36506
$7378 Misc Pediatric $10415 Misc Pediatric $17646 Misc Pediatric $34224 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
226-1 226-2 226-3 226-4
ANAL PROCEDURES ANAL PROCEDURES ANAL PROCEDURES ANAL PROCEDURES
256 413 737
1301
06250 08568 13988 28079
10000 10000 10000 10000
10000 10000 10000 10000
06250 08568 13988 28079
12500 12500 12500 12500
07813 10710 17485 35099
10000 10000 10000 10000
06250 08568 13988 28079
$5859 Misc Pediatric $8033 Misc Pediatric
$13114 Misc Pediatric $26324 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
227-1 HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL 290 10044 10000 10000 10044 12500 12555 10000 10044 $9416 Misc Pediatric Gastroent Adult
227-2 227-3 227-4
HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL
443 813
1503
13150 21598 43086
10000 10000 10000
10000 10000 10000
13150 21598 43086
12500 12500 12500
16438 26998 53858
10000 10000 10000
13150 21598 43086
$12328 Misc Pediatric $20248 Misc Pediatric $40393 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult
228-1 228-2 228-3 228-4
INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES
200 344 629
1321
07221 09757 15211 32407
10000 10000 10000 10000
10000 10000 10000 10000
07221 09757 15211 32407
12500 12500 12500 12500
09026 12196 19014 40509
10000 10000 10000 10000
07221 09757 15211 32407
$6770 Misc Pediatric $9147 Misc Pediatric
$14260 Misc Pediatric $30382 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
229-1 229-2 229-3 229-4
OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES
387 552 976
1760
10850 14346 22850 42572
10000 10000 10000 10000
10000 10000 10000 10000
10850 14346 22850 42572
12500 12500 12500 12500
13563 17933 28563 53215
10000 10000 10000 10000
10850 14346 22850 42572
$10172 Misc Pediatric $13449 Misc Pediatric $21422 Misc Pediatric $39911 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
240-1 240-2 240-3 240-4
DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY
371 429 685
1225
05526 07344 11112 20338
10000 10000 10000 10000
10000 10000 10000 10000
05526 07344 11112 20338
12500 12500 12500 12500
06908 09180 13890 25423
10000 10000 10000 10000
05526 07344 11112 20338
$5181 Misc Pediatric $6885 Misc Pediatric
$10418 Misc Pediatric $19067 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
241-1 241-2 241-3 241-4
PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS
252 325 484
1012
05507 07186 10584 23302
10000 10000 10000 10000
10000 10000 10000 10000
05507 07186 10584 23302
12500 12500 12500 12500
06884 08983 13230 29128
10000 10000 10000 10000
05507 07186 10584 23302
$5163 Misc Pediatric $6737 Misc Pediatric $9923 Misc Pediatric
$21846 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
242-1 242-2 242-3 242-4
MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS
230 319 459
1013
05080 06929 10170 22355
10000 10000 10000 10000
10000 10000 10000 10000
05080 06929 10170 22355
12500 12500 12500 12500
06350 08661 12713 27944
10000 10000 10000 10000
05080 06929 10170 22355
$4763 Misc Pediatric $6496 Misc Pediatric $9534 Misc Pediatric
$20958 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
243-1 243-2 243-3 243-4
OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS
189 280 479
1028
04493 06061 09094 20341
10000 10000 10000 10000
10000 10000 10000 10000
04493 06061 09094 20341
12500 12500 12500 12500
05616 07576 11368 25426
10000 10000 10000 10000
04493 06061 09094 20341
$4212 Misc Pediatric $5682 Misc Pediatric $8526 Misc Pediatric
$19070 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
244-1 244-2 244-3 244-4
DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS
292 361 545
1104
05247 06624 10053 21700
10000 10000 10000 10000
10000 10000 10000 10000
05247 06624 10053 21700
12500 12500 12500 12500
06559 08280 12566 27125
10000 10000 10000 10000
05247 06624 10053 21700
$4919 Misc Pediatric $6210 Misc Pediatric $9425 Misc Pediatric
$20344 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
245-1 245-2 245-3 245-4
INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE
339 413 626
1206
05754 07028 10226 19440
10000 10000 10000 10000
10000 10000 10000 10000
05754 07028 10226 19440
12500 12500 12500 12500
07193 08785 12783 24300
10000 10000 10000 10000
05754 07028 10226 19440
$5394 Misc Pediatric $6589 Misc Pediatric $9587 Misc Pediatric
$18225 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
246-1 246-2 246-3 246-4
GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY
315 404 602 982
06451 07943 11319 19310
10000 10000 10000 10000
10000 10000 10000 10000
06451 07943 11319 19310
12500 12500 12500 12500
08064 09929 14149 24138
10000 10000 10000 10000
06451 07943 11319 19310
$6048 Misc Pediatric $7447 Misc Pediatric
$10612 Misc Pediatric $18103 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
247-1 247-2 247-3 247-4
INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION
288 378 596
1104
04874 06267 09526 19303
10000 10000 10000 10000
10000 10000 10000 10000
04874 06267 09526 19303
12500 12500 12500 12500
06093 07834 11908 24129
10000 10000 10000 10000
04874 06267 09526 19303
$4569 Misc Pediatric $5875 Misc Pediatric $8931 Misc Pediatric
$18097 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
248-1 248-2 248-3 248-4
MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS
334 472 710
1239
05085 07215 10667 20497
10000 10000 10000 10000
10000 10000 10000 10000
05085 07215 10667 20497
12500 12500 12500 12500
06356 09019 13334 25621
10000 10000 10000 10000
05085 07215 10667 20497
$4767 Misc Pediatric $6764 Misc Pediatric
$10000 Misc Pediatric $19216 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
249-1 249-2 249-3 249-4
NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING
219 289 431 938
03648 05058 07201 15935
10000 10000 10000 10000
10000 10000 10000 10000
03648 05058 07201 15935
12500 12500 12500 12500
04560 06323 09001 19919
10000 10000 10000 10000
03648 05058 07201 15935
$3420 Misc Pediatric $4742 Misc Pediatric $6751 Misc Pediatric
$14939 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
251-1 251-2 251-3 251-4
ABDOMINAL PAIN ABDOMINAL PAIN ABDOMINAL PAIN ABDOMINAL PAIN
217 288 418 813
04492 05786 07857 14149
10000 10000 10000 10000
10000 10000 10000 10000
04492 05786 07857 14149
12500 12500 12500 12500
05615 07233 09821 17686
10000 10000 10000 10000
04492 05786 07857 14149
$4211 Misc Pediatric $5424 Misc Pediatric $7366 Misc Pediatric
$13265 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
252-1 252-2 252-3 252-4
MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE
331 412 635
1248
04904 06490 09833 19841
10000 10000 10000 10000
10000 10000 10000 10000
04904 06490 09833 19841
12500 12500 12500 12500
06130 08113 12291 24801
10000 10000 10000 10000
04904 06490 09833 19841
$4598 Misc Pediatric $6084 Misc Pediatric $9218 Misc Pediatric
$18601 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
253-1 253-2 253-3 253-4
OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE
251 334 504 878
05108 06777 10020 18601
10000 10000 10000 10000
10000 10000 10000 10000
05108 06777 10020 18601
12500 12500 12500 12500
06385 08471 12525 23251
10000 10000 10000 10000
05108 06777 10020 18601
$4789 Misc Pediatric $6353 Misc Pediatric $9394 Misc Pediatric
$17438 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
254-1 254-2 254-3 254-4
OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES
252 353 530
1066
04519 06282 09117 18053
10000 10000 10000 10000
10000 10000 10000 10000
04519 06282 09117 18053
12500 12500 12500 12500
05649 07853 11396 22566
10000 10000 10000 10000
04519 06282 09117 18053
$4237 Misc Pediatric $5889 Misc Pediatric $8547 Misc Pediatric
$16925 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
260-1 260-2 260-3 260-4
MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES
469 611
1081 2181
15085 19596 31029 63824
10000 10000 10000 10000
10000 10000 10000 10000
15085 19596 31029 63824
12500 12500 12500 12500
18856 24495 38786 79780
10000 10000 10000 10000
15085 19596 31029 63824
$14142 Misc Pediatric $18371 Misc Pediatric $29090 Misc Pediatric $59835 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
261-1 261-2 261-3 261-4
MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES
450 706
1116 1993
13049 18250 25711 50241
10000 10000 10000 10000
10000 10000 10000 10000
13049 18250 25711 50241
12500 12500 12500 12500
16311 22813 32139 62801
10000 10000 10000 10000
13049 18250 25711 50241
$12233 Misc Pediatric $17109 Misc Pediatric $24104 Misc Pediatric $47101 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
262-1 262-2 262-3 262-4
CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC
405 567 898
1751
11851 15637 23607 46363
10000 10000 10000 10000
10000 10000 10000 10000
11851 15637 23607 46363
12500 12500 12500 12500
14814 19546 29509 57954
10000 10000 10000 10000
11851 15637 23607 46363
$11110 Misc Pediatric $14660 Misc Pediatric $22132 Misc Pediatric $43465 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
263-1 263-2 263-3 263-4
LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY
236 364 635
1384
09345 12310 17676 36726
10000 10000 10000 10000
10000 10000 10000 10000
09345 12310 17676 36726
12500 12500 12500 12500
11681 15388 22095 45908
10000 10000 10000 10000
09345 12310 17676 36726
$8761 Misc Pediatric $11541 Misc Pediatric $16571 Misc Pediatric $34431 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
264-1 264-2 264-3 264-4
OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES
453 543
1067 2148
12526 13732 23159 51901
10000 10000 10000 10000
10000 10000 10000 10000
12526 13732 23159 51901
12500 12500 12500 12500
15658 17165 28949 64876
10000 10000 10000 10000
12526 13732 23159 51901
$11743 Misc Pediatric $12874 Misc Pediatric $21712 Misc Pediatric $48657 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
279-1 279-2 279-3 279-4
HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS
280 361 580
1157
04712 05945 09594 23269
10000 10000 10000 10000
10000 10000 10000 10000
04712 05945 09594 23269
12500 12500 12500 12500
05890 07431 11993 29086
10000 10000 10000 10000
04712 05945 09594 23269
$4418 Misc Pediatric $5573 Misc Pediatric $8994 Misc Pediatric
$21815 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
280-1 280-2 280-3 280-4
ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE
298 344 532
1047
04734 06141 09718 21422
10000 10000 10000 10000
10000 10000 10000 10000
04734 06141 09718 21422
12500 12500 12500 12500
05918 07676 12148 26778
10000 10000 10000 10000
04734 06141 09718 21422
$4438 Misc Pediatric $5757 Misc Pediatric $9111 Misc Pediatric
$20083 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
281-1 281-2 281-3 281-4
MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS
357 421 610 974
05079 07553 10730 17519
10000 10000 10000 10000
10000 10000 10000 10000
05079 07553 10730 17519
12500 12500 12500 12500
06349 09441 13413 21899
10000 10000 10000 10000
05079 07553 10730 17519
$4762 Misc Pediatric $7081 Misc Pediatric
$10059 Misc Pediatric $16424 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
282-1 282-2 282-3 282-4
DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY
318 403 649
1381
05507 07067 11213 27863
10000 10000 10000 10000
10000 10000 10000 10000
05507 07067 11213 27863
12500 12500 12500 12500
06884 08834 14016 34829
10000 10000 10000 10000
05507 07067 11213 27863
$5163 Misc Pediatric $6625 Misc Pediatric
$10512 Misc Pediatric $26122 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
283-1 283-2 283-3 283-4
OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER
286 338 505 947
04913 06300 09246 18497
10000 10000 10000 10000
10000 10000 10000 10000
04913 06300 09246 18497
12500 12500 12500 12500
06141 07875 11558 23121
10000 10000 10000 10000
04913 06300 09246 18497
$4606 Misc Pediatric $5906 Misc Pediatric $8668 Misc Pediatric
$17341 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
284-1 284-2 284-3 284-4
DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT
245 344 536
1059
05403 07447 10804 21256
10000 10000 10000 10000
10000 10000 10000 10000
05403 07447 10804 21256
12500 12500 12500 12500
06754 09309 13505 26570
10000 10000 10000 10000
05403 07447 10804 21256
$5065 Misc Pediatric $6982 Misc Pediatric
$10129 Misc Pediatric $19928 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
301-1 301-2 301-3 301-4
HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT
365 396 535
1280
18140 19690 25026 39991
10000 10000 10000 10000
10000 10000 10000 10000
18140 19690 25026 39991
12500 12500 12500 12500
22675 24613 31283 49989
10000 10000 10000 10000
18140 19690 25026 39991
$17006 Misc Pediatric $18459 Misc Pediatric $23462 Misc Pediatric $37492 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
302-1 302-2 302-3 302-4
KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT
296 338 519
1248
17428 19132 23798 43468
10000 10000 10000 10000
10000 10000 10000 10000
17428 19132 23798 43468
12500 12500 12500 12500
21785 23915 29748 54335
10000 10000 10000 10000
17428 19132 23798 43468
$16339 Misc Pediatric $17936 Misc Pediatric $22311 Misc Pediatric $40751 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
303-1 303-2 303-3 303-4
DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK
450 570 857
1607
47039 55422 77549
105744
10000 10000 10000 10000
10000 10000 10000 10000
47039 55422 77549
105744
12500 12500 12500 12500
58799 69278 96936
132180
10000 10000 10000 10000
47039 55422 77549
105744
$44099 Misc Pediatric $51958 Misc Pediatric $72702 Misc Pediatric $99135 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
304-1 304-2 304-3 304-4
DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK
300 405 735
1776
29720 35298 49644 81663
10000 10000 10000 10000
10000 10000 10000 10000
29720 35298 49644 81663
12500 12500 12500 12500
37150 44123 62055
102079
10000 10000 10000 10000
29720 35298 49644 81663
$27863 Misc Pediatric $33092 Misc Pediatric $46541 Misc Pediatric $76559 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
305-1 305-2 305-3 305-4
AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES
540 737
1137 1987
10654 14043 21843 42156
10000 10000 10000 10000
10000 10000 10000 10000
10654 14043 21843 42156
12500 12500 12500 12500
13318 17554 27304 52695
10000 10000 10000 10000
10654 14043 21843 42156
$9988 Misc Pediatric $13165 Misc Pediatric $20478 Misc Pediatric $39521 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
308-1 308-2 308-3 308-4
HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT
419 496 697
1264
13101 15854 21518 36506
10000 10000 10000 10000
10000 10000 10000 10000
13101 15854 21518 36506
12500 12500 12500 12500
16376 19818 26898 45633
10000 10000 10000 10000
13101 15854 21518 36506
$12282 Misc Pediatric $14863 Misc Pediatric $20173 Misc Pediatric $34224 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
309-1 309-2 309-3 309-4
HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT
278 490 865
1887
11482 16231 23288 42408
10000 10000 10000 10000
10000 10000 10000 10000
11482 16231 23288 42408
12500 12500 12500 12500
14353 20289 29110 53010
10000 10000 10000 10000
11482 16231 23288 42408
$10764 Misc Pediatric $15217 Misc Pediatric $21833 Misc Pediatric $39758 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
310-1 310-2 310-3 310-4
INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION
181 302 624
1622
08926 11888 17911 41661
10000 10000 10000 10000
10000 10000 10000 10000
08926 11888 17911 41661
12500 12500 12500 12500
11158 14860 22389 52076
10000 10000 10000 10000
08926 11888 17911 41661
$8368 Misc Pediatric $11145 Misc Pediatric $16792 Misc Pediatric $39057 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
312-1 312-2
SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES
538 940
12555 18447
10000 10000
10000 10000
12555 18447
12500 12500
15694 23059
10000 10000
12555 18447
$11770 Misc Pediatric $17294 Misc Pediatric
Misc Adult Misc Adult
312-3 312-4
SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES
1846 3284
31356 71148
10000 10000
10000 10000
31356 71148
12500 12500
39195 88935
10000 10000
31356 71148
$29396 Misc Pediatric $66701 Misc Pediatric
Misc Adult Misc Adult
313-1 313-2 313-3 313-4
KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT
270 444 785
1659
10852 15212 22743 43349
10000 10000 10000 10000
10000 10000 10000 10000
10852 15212 22743 43349
12500 12500 12500 12500
13565 19015 28429 54186
10000 10000 10000 10000
10852 15212 22743 43349
$10174 Misc Pediatric $14261 Misc Pediatric $21322 Misc Pediatric $40640 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
314-1 314-2 314-3 314-4
FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES
257 507 810
1579
09291 11320 16006 32885
10000 10000 10000 10000
10000 10000 10000 10000
09291 11320 16006 32885
12500 12500 12500 12500
11614 14150 20008 41106
10000 10000 10000 10000
09291 11320 16006 32885
$8710 Misc Pediatric $10613 Misc Pediatric $15006 Misc Pediatric $30830 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
315-1 315-2 315-3 315-4
SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES
185 267 649
1473
08387 15912 22542 44542
10000 10000 10000 10000
10000 10000 10000 10000
08387 15912 22542 44542
12500 12500 12500 12500
10484 19890 28178 55678
10000 10000 10000 10000
08387 15912 22542 44542
$7863 Misc Pediatric $14918 Misc Pediatric $21133 Misc Pediatric $41758 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
316-1 316-2 316-3 316-4
HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES
229 396 727
1430
07195 10564 17143 34568
10000 10000 10000 10000
10000 10000 10000 10000
07195 10564 17143 34568
12500 12500 12500 12500
08994 13205 21429 43210
10000 10000 10000 10000
07195 10564 17143 34568
$6745 Misc Pediatric $9904 Misc Pediatric
$16072 Misc Pediatric $32408 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
317-1 317-2 317-3 317-4
TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES
300 544
1030 2038
08204 11764 19738 43378
10000 10000 10000 10000
10000 10000 10000 10000
08204 11764 19738 43378
12500 12500 12500 12500
10255 14705 24673 54223
10000 10000 10000 10000
08204 11764 19738 43378
$7691 Misc Pediatric $11029 Misc Pediatric $18504 Misc Pediatric $40667 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
320-1 320-2 320-3 320-4
OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES
229 474 900
1844
09314 14085 21498 40942
10000 10000 10000 10000
10000 10000 10000 10000
09314 14085 21498 40942
12500 12500 12500 12500
11643 17606 26873 51178
10000 10000 10000 10000
09314 14085 21498 40942
$8732 Misc Pediatric $13205 Misc Pediatric $20154 Misc Pediatric $38383 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
321-1 321-2 321-3 321-4
CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP
174 322 869
1740
16800 21292 35737 65431
10000 10000 10000 10000
10000 10000 10000 10000
16800 21292 35737 65431
12500 12500 12500 12500
21000 26615 44671 81789
10000 10000 10000 10000
16800 21292 35737 65431
$15750 Misc Pediatric $19961 Misc Pediatric $33503 Misc Pediatric $61342 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
340-1 340-2 340-3 340-4
FRACTURE OF FEMUR FRACTURE OF FEMUR FRACTURE OF FEMUR FRACTURE OF FEMUR
307 350 507 717
04052 05213 07741 13545
10000 10000 10000 10000
10000 10000 10000 10000
04052 05213 07741 13545
12500 12500 12500 12500
05065 06516 09676 16931
10000 10000 10000 10000
04052 05213 07741 13545
$3799 Misc Pediatric $4887 Misc Pediatric $7257 Misc Pediatric
$12698 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
341-1 341-2 341-3 341-4
FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP
302 365 480 981
04685 05732 07835 19346
10000 10000 10000 10000
10000 10000 10000 10000
04685 05732 07835 19346
12500 12500 12500 12500
05856 07165 09794 24183
10000 10000 10000 10000
04685 05732 07835 19346
$4392 Misc Pediatric $5374 Misc Pediatric $7345 Misc Pediatric
$18137 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
342-1 342-2 342-3 342-4
FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK
223 336 523
1073
04199 06015 09030 19468
10000 10000 10000 10000
10000 10000 10000 10000
04199 06015 09030 19468
12500 12500 12500 12500
05249 07519 11288 24335
10000 10000 10000 10000
04199 06015 09030 19468
$3937 Misc Pediatric $5639 Misc Pediatric $8466 Misc Pediatric
$18251 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
343-1 343-2 343-3 343-4
MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG
381 462 768
1278
06313 07919 12982 22512
10000 10000 10000 10000
10000 10000 10000 10000
06313 07919 12982 22512
12500 12500 12500 12500
07891 09899 16228 28140
10000 10000 10000 10000
06313 07919 12982 22512
$5918 Misc Pediatric $7424 Misc Pediatric
$12171 Misc Pediatric $21105 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
344-1 344-2 344-3 344-4
OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS
510 624 996
1727
06188 08269 12369 20626
10000 10000 10000 10000
10000 10000 10000 10000
06188 08269 12369 20626
12500 12500 12500 12500
07735 10336 15461 25783
10000 10000 10000 10000
06188 08269 12369 20626
$5801 Misc Pediatric $7752 Misc Pediatric
$11596 Misc Pediatric $19337 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
346-1 346-2 346-3 346-4
CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS
312 418 742
1507
05246 07180 12230 29854
10000 10000 10000 10000
10000 10000 10000 10000
05246 07180 12230 29854
12500 12500 12500 12500
06558 08975 15288 37318
10000 10000 10000 10000
05246 07180 12230 29854
$4918 Misc Pediatric $6731 Misc Pediatric
$11466 Misc Pediatric $27988 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
347-1 347-2 347-3 347-4
OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES
288 388 534
1184
05202 07038 09895 23177
10000 10000 10000 10000
10000 10000 10000 10000
05202 07038 09895 23177
12500 12500 12500 12500
06503 08798 12369 28971
10000 10000 10000 10000
05202 07038 09895 23177
$4877 Misc Pediatric $6598 Misc Pediatric $9277 Misc Pediatric
$21728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
349-1 349-2 349-3 349-4
MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE
226 480 806
1387
04381 06459 10302 19261
10000 10000 10000 10000
10000 10000 10000 10000
04381 06459 10302 19261
12500 12500 12500 12500
05476 08074 12878 24076
10000 10000 10000 10000
04381 06459 10302 19261
$4107 Misc Pediatric $6055 Misc Pediatric $9658 Misc Pediatric
$18057 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
351-1 351-2 351-3 351-4
OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES
252 352 544
1111
04074 05668 08930 19109
10000 10000 10000 10000
10000 10000 10000 10000
04074 05668 08930 19109
12500 12500 12500 12500
05093 07085 11163 23886
10000 10000 10000 10000
04074 05668 08930 19109
$3819 Misc Pediatric $5314 Misc Pediatric $8372 Misc Pediatric
$17915 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
361-1 361-2 361-3 361-4
SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES
407 758
1393 2857
11097 14459 21415 45412
10000 10000 10000 10000
10000 10000 10000 10000
11097 14459 21415 45412
12500 12500 12500 12500
13871 18074 26769 56765
10000 10000 10000 10000
11097 14459 21415 45412
$10403 Misc Pediatric $13555 Misc Pediatric $20077 Misc Pediatric $42574 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
362-1 362-2 362-3 362-4
MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES
179 233 597
1380
10091 13554 17862 38257
10000 10000 10000 10000
10000 10000 10000 10000
10091 13554 17862 38257
12500 12500 12500 12500
12614 16943 22328 47821
10000 10000 10000 10000
10091 13554 17862 38257
$9460 Misc Pediatric $12707 Misc Pediatric $16746 Misc Pediatric $35866 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
363-1 363-2 363-3 363-4
BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY
209 314 532
1706
08797 14900 19039 35420
10000 10000 10000 10000
10000 10000 10000 10000
08797 14900 19039 35420
12500 12500 12500 12500
10996 18625 23799 44275
10000 10000 10000 10000
08797 14900 19039 35420
$8247 Misc Pediatric $13969 Misc Pediatric $17849 Misc Pediatric $33206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
364-1 364-2 364-3 364-4
OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES
289 508 943
1919
07645 10877 16986 30643
10000 10000 10000 10000
10000 10000 10000 10000
07645 10877 16986 30643
12500 12500 12500 12500
09556 13596 21233 38304
10000 10000 10000 10000
07645 10877 16986 30643
$7167 Misc Pediatric $10197 Misc Pediatric $15924 Misc Pediatric $28728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
380-1 380-2 380-3 380-4
SKIN ULCERS SKIN ULCERS SKIN ULCERS SKIN ULCERS
416 498 784
1662
05289 06545 09424 17199
10000 10000 10000 10000
10000 10000 10000 10000
05289 06545 09424 17199
12500 12500 12500 12500
06611 08181 11780 21499
10000 10000 10000 10000
05289 06545 09424 17199
$4958 Misc Pediatric $6136 Misc Pediatric $8835 Misc Pediatric
$16124 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
381-1 381-2 381-3 381-4
MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS
300 428 671
1406
03883 05748 09734 27512
10000 10000 10000 10000
10000 10000 10000 10000
03883 05748 09734 27512
12500 12500 12500 12500
04854 07185 12168 34390
10000 10000 10000 10000
03883 05748 09734 27512
$3640 Misc Pediatric $5389 Misc Pediatric $9126 Misc Pediatric
$25793 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
382-1 382-2 382-3 382-4
MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS
381 432 645
1003
03521 05612 09634 15729
10000 10000 10000 10000
10000 10000 10000 10000
03521 05612 09634 15729
12500 12500 12500 12500
04401 07015 12043 19661
10000 10000 10000 10000
03521 05612 09634 15729
$3301 Misc Pediatric $5261 Misc Pediatric $9032 Misc Pediatric
$14746 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
383-1 383-2 383-3 383-4
CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS
294 412 617
1198
04148 05905 09147 19560
10000 10000 10000 10000
10000 10000 10000 10000
04148 05905 09147 19560
12500 12500 12500 12500
05185 07381 11434 24450
10000 10000 10000 10000
04148 05905 09147 19560
$3889 Misc Pediatric $5536 Misc Pediatric $8575 Misc Pediatric
$18338 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
384-1 384-2 384-3 384-4
CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE
193 301 493
1134
04752 06220 08932 20168
10000 10000 10000 10000
10000 10000 10000 10000
04752 06220 08932 20168
12500 12500 12500 12500
05940 07775 11165 25210
10000 10000 10000 10000
04752 06220 08932 20168
$4455 Misc Pediatric $5831 Misc Pediatric $8374 Misc Pediatric
$18908 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
385-1 385-2 385-3 385-4
OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS
248 353 565
1295
03496 05103 07974 19128
10000 10000 10000 10000
10000 10000 10000 10000
03496 05103 07974 19128
12500 12500 12500 12500
04370 06379 09968 23910
10000 10000 10000 10000
03496 05103 07974 19128
$3278 Misc Pediatric $4784 Misc Pediatric $7476 Misc Pediatric
$17933 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
401-1 401-2 401-3 401-4
PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES
303 427 844
2452
13697 18347 29058 71913
10000 10000 10000 10000
10000 10000 10000 10000
13697 18347 29058 71913
12500 12500 12500 12500
17121 22934 36323 89891
10000 10000 10000 10000
13697 18347 29058 71913
$12841 Misc Pediatric $17200 Misc Pediatric $27242 Misc Pediatric $67418 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
403-1 403-2 403-3 403-4
PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY
183 222 497
1867
12813 14411 21531 61151
10000 10000 10000 10000
10000 10000 10000 10000
12813 14411 21531 61151
12500 12500 12500 12500
16016 18014 26914 76439
10000 10000 10000 10000
12813 14411 21531 61151
$12012 Misc Pediatric $13510 Misc Pediatric $20185 Misc Pediatric $57329 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
404-1 404-2 404-3 404-4
THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES
130 216 659
1638
07364 09479 18990 42519
10000 10000 10000 10000
10000 10000 10000 10000
07364 09479 18990 42519
12500 12500 12500 12500
09205 11849 23738 53149
10000 10000 10000 10000
07364 09479 18990 42519
$6904 Misc Pediatric $8887 Misc Pediatric
$17803 Misc Pediatric $39862 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
405-1 405-2 405-3 405-4
OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS
419 571 966
2131
11123 14210 21421 48796
10000 10000 10000 10000
10000 10000 10000 10000
11123 14210 21421 48796
12500 12500 12500 12500
13904 17763 26776 60995
10000 10000 10000 10000
11123 14210 21421 48796
$10428 Misc Pediatric $13322 Misc Pediatric $20082 Misc Pediatric $45746 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
420-1 420-2 420-3 420-4
DIABETES DIABETES DIABETES DIABETES
261 275 427 935
03897 05302 07862 19671
10000 10000 10000 10000
10000 10000 10000 10000
03897 05302 07862 19671
12500 12500 12500 12500
04871 06628 09828 24589
10000 10000 10000 10000
03897 05302 07862 19671
$3653 Misc Pediatric $4971 Misc Pediatric $7371 Misc Pediatric
$18442 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
421-1 421-2 421-3 421-4
MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS
351 483 676
1375
03211 05227 08190 17446
10000 10000 10000 10000
10000 10000 10000 10000
03211 05227 08190 17446
12500 12500 12500 12500
04014 06534 10238 21808
10000 10000 10000 10000
03211 05227 08190 17446
$3010 Misc Pediatric $4900 Misc Pediatric $7678 Misc Pediatric
$16356 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
422-1 422-2 422-3 422-4
HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS
199 291 445 914
02848 04625 06828 14444
10000 10000 10000 10000
10000 10000 10000 10000
02848 04625 06828 14444
12500 12500 12500 12500
03560 05781 08535 18055
10000 10000 10000 10000
02848 04625 06828 14444
$2670 Misc Pediatric $4336 Misc Pediatric $6401 Misc Pediatric
$13541 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
423-1 423-2 423-3 423-4
INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM
272 363 573
1504
04421 05846 09540 27384
10000 10000 10000 10000
10000 10000 10000 10000
04421 05846 09540 27384
12500 12500 12500 12500
05526 07308 11925 34230
10000 10000 10000 10000
04421 05846 09540 27384
$4145 Misc Pediatric $5481 Misc Pediatric $8944 Misc Pediatric
$25673 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
424-1 424-2 424-3 424-4
OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS
259 397 605
1147
04342 06514 09768 21520
10000 10000 10000 10000
10000 10000 10000 10000
04342 06514 09768 21520
12500 12500 12500 12500
05428 08143 12210 26900
10000 10000 10000 10000
04342 06514 09768 21520
$4071 Misc Pediatric $6107 Misc Pediatric $9158 Misc Pediatric
$20175 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
425-1 425-2 425-3
ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED
241 302 460
04017 05132 07667
10000 10000 10000
10000 10000 10000
04017 05132 07667
12500 12500 12500
05021 06415 09584
10000 10000 10000
04017 05132 07667
$3766 Misc Pediatric $4811 Misc Pediatric $7188 Misc Pediatric
Misc Adult Misc Adult Misc Adult
425-4 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 946 16767 10000 10000 16767 12500 20959 10000 16767 $15719 Misc Pediatric Misc Adult 440-1 440-2 440-3 440-4
KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT
458 561 864
2088
44667 50078 60562 99171
10000 10000 10000 10000
10000 10000 10000 10000
44667 50078 60562 99171
12500 12500 12500 12500
55834 62598 75703
123964
10000 10000 10000 10000
44667 50078 60562 99171
$41875 Misc Pediatric $46948 Misc Pediatric $56777 Misc Pediatric $92973 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
441-1 441-2 441-3 441-4
MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES
474 726 994
2196
14386 21567 29549 61841
10000 10000 10000 10000
10000 10000 10000 10000
14386 21567 29549 61841
12500 12500 12500 12500
17983 26959 36936 77301
10000 10000 10000 10000
14386 21567 29549 61841
$13487 Misc Pediatric $20219 Misc Pediatric $27702 Misc Pediatric $57976 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
442-1 442-2 442-3 442-4
KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY
325 422 795
1671
13139 15537 23456 49226
10000 10000 10000 10000
10000 10000 10000 10000
13139 15537 23456 49226
12500 12500 12500 12500
16424 19421 29320 61533
10000 10000 10000 10000
13139 15537 23456 49226
$12318 Misc Pediatric $14566 Misc Pediatric $21990 Misc Pediatric $46149 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
443-1 443-2 443-3 443-4
KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY
253 356 802
1752
10883 12834 18814 40742
10000 10000 10000 10000
10000 10000 10000 10000
10883 12834 18814 40742
12500 12500 12500 12500
13604 16043 23518 50928
10000 10000 10000 10000
10883 12834 18814 40742
$10203 Misc Pediatric $12032 Misc Pediatric $17638 Misc Pediatric $38196 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
444-1 444-2 444-3 444-4
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY
264 447 933
1617
09410 12604 20686 38830
10000 10000 10000 10000
10000 10000 10000 10000
09410 12604 20686 38830
12500 12500 12500 12500
11763 15755 25858 48538
10000 10000 10000 10000
09410 12604 20686 38830
$8822 Misc Pediatric $11816 Misc Pediatric $19393 Misc Pediatric $36403 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
445-1 445-2 445-3 445-4
OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES
190 319 781
1545
08552 11610 15964 31570
10000 10000 10000 10000
10000 10000 10000 10000
08552 11610 15964 31570
12500 12500 12500 12500
10690 14513 19955 39463
10000 10000 10000 10000
08552 11610 15964 31570
$8018 Misc Pediatric $10884 Misc Pediatric $14966 Misc Pediatric $29597 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
446-1 446-2 446-3 446-4
URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES
188 261 612
1363
06758 08690 14202 30173
10000 10000 10000 10000
10000 10000 10000 10000
06758 08690 14202 30173
12500 12500 12500 12500
08448 10863 17753 37716
10000 10000 10000 10000
06758 08690 14202 30173
$6336 Misc Pediatric $8147 Misc Pediatric
$13314 Misc Pediatric $28287 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
447-1 447-2 447-3 447-4
OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES
228 365 728
1787
11479 13294 19661 43932
10000 10000 10000 10000
10000 10000 10000 10000
11479 13294 19661 43932
12500 12500 12500 12500
14349 16618 24576 54915
10000 10000 10000 10000
11479 13294 19661 43932
$10762 Misc Pediatric $12463 Misc Pediatric $18432 Misc Pediatric $41186 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
460-1 460-2 460-3 460-4
RENAL FAILURE RENAL FAILURE RENAL FAILURE RENAL FAILURE
299 376 496
1115
04323 06061 07896 19936
10000 10000 10000 10000
10000 10000 10000 10000
04323 06061 07896 19936
12500 12500 12500 12500
05404 07576 09870 24920
10000 10000 10000 10000
04323 06061 07896 19936
$4053 Misc Pediatric $5682 Misc Pediatric $7403 Misc Pediatric
$18690 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
461-1 461-2 461-3 461-4
KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY
271 374 601
1108
04315 05992 09498 16929
10000 10000 10000 10000
10000 10000 10000 10000
04315 05992 09498 16929
12500 12500 12500 12500
05394 07490 11873 21161
10000 10000 10000 10000
04315 05992 09498 16929
$4045 Misc Pediatric $5618 Misc Pediatric $8904 Misc Pediatric
$15871 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
462-1 462-2 462-3 462-4
NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS
260 370 656
1359
03798 05298 09439 23905
10000 10000 10000 10000
10000 10000 10000 10000
03798 05298 09439 23905
12500 12500 12500 12500
04748 06623 11799 29881
10000 10000 10000 10000
03798 05298 09439 23905
$3561 Misc Pediatric $4967 Misc Pediatric $8849 Misc Pediatric
$22411 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
463-1 463-2 463-3 463-4
KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS
268 352 507 910
04120 05628 07879 14066
10000 10000 10000 10000
10000 10000 10000 10000
04120 05628 07879 14066
12500 12500 12500 12500
05150 07035 09849 17583
10000 10000 10000 10000
04120 05628 07879 14066
$3863 Misc Pediatric $5276 Misc Pediatric $7387 Misc Pediatric
$13187 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
465-1 465-2 465-3 465-4
URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION
165 202 380 860
04374 05548 08751 18922
10000 10000 10000 10000
10000 10000 10000 10000
04374 05548 08751 18922
12500 12500 12500 12500
05468 06935 10939 23653
10000 10000 10000 10000
04374 05548 08751 18922
$4101 Misc Pediatric $5201 Misc Pediatric $8204 Misc Pediatric
$17739 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
466-1 466-2 466-3 466-4
MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC
221 343 533 971
03576 05752 08974 17498
10000 10000 10000 10000
10000 10000 10000 10000
03576 05752 08974 17498
12500 12500 12500 12500
04470 07190 11218 21873
10000 10000 10000 10000
03576 05752 08974 17498
$3353 Misc Pediatric $5393 Misc Pediatric $8413 Misc Pediatric
$16404 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
468-1 468-2 468-3 468-4
OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS
246 335 509
1057
04152 05935 08698 18661
10000 10000 10000 10000
10000 10000 10000 10000
04152 05935 08698 18661
12500 12500 12500 12500
05190 07419 10873 23326
10000 10000 10000 10000
04152 05935 08698 18661
$3893 Misc Pediatric $5564 Misc Pediatric $8154 Misc Pediatric
$17495 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
480-1 480-2 480-3 480-4
MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES
180 241 618
1422
12119 13477 20992 45258
10000 10000 10000 10000
10000 10000 10000 10000
12119 13477 20992 45258
12500 12500 12500 12500
15149 16846 26240 56573
10000 10000 10000 10000
12119 13477 20992 45258
$11362 Misc Pediatric $12635 Misc Pediatric $19680 Misc Pediatric $42429 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
481-1 481-2 481-3 481-4
PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES
228 267 830
1810
06794 11922 17939 41143
10000 10000 10000 10000
10000 10000 10000 10000
06794 11922 17939 41143
12500 12500 12500 12500
08493 14903 22424 51429
10000 10000 10000 10000
06794 11922 17939 41143
$6369 Misc Pediatric $11177 Misc Pediatric $16818 Misc Pediatric $38572 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
482-1 482-2 482-3 482-4
TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY
169 278 716
1341
05918 07555 14662 30717
10000 10000 10000 10000
10000 10000 10000 10000
05918 07555 14662 30717
12500 12500 12500 12500
07398 09444 18328 38396
10000 10000 10000 10000
05918 07555 14662 30717
$5548 Misc Pediatric $7083 Misc Pediatric
$13746 Misc Pediatric $28797 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
483-1 483-2 483-3 483-4
TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES
203 541
1127 1970
06074 11326 22018 44244
10000 10000 10000 10000
10000 10000 10000 10000
06074 11326 22018 44244
12500 12500 12500 12500
07593 14158 27523 55305
10000 10000 10000 10000
06074 11326 22018 44244
$5694 Misc Pediatric $10618 Misc Pediatric $20642 Misc Pediatric $41479 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
484-1 484-2 484-3 484-4
OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
250 191 502
1578
07704 11762 15177 36555
10000 10000 10000 10000
10000 10000 10000 10000
07704 11762 15177 36555
12500 12500 12500 12500
09630 14703 18971 45694
10000 10000 10000 10000
07704 11762 15177 36555
$7223 Misc Pediatric $11027 Misc Pediatric $14228 Misc Pediatric $34270 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
500-1 500-2 500-3 500-4
MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM
266 431 601
1109
03789 05904 09172 17461
10000 10000 10000 10000
10000 10000 10000 10000
03789 05904 09172 17461
12500 12500 12500 12500
04736 07380 11465 21826
10000 10000 10000 10000
03789 05904 09172 17461
$3552 Misc Pediatric $5535 Misc Pediatric $8599 Misc Pediatric
$16370 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
501-1 501-2 501-3 501-4
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY
258 351 547
1074
04044 05542 08322 16765
10000 10000 10000 10000
10000 10000 10000 10000
04044 05542 08322 16765
12500 12500 12500 12500
05055 06928 10403 20956
10000 10000 10000 10000
04044 05542 08322 16765
$3791 Misc Pediatric $5196 Misc Pediatric $7802 Misc Pediatric
$15717 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
510-1 510-2 510-3 510-4
PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS
244 387 892
1787
11433 14140 25807 52317
10000 10000 10000 10000
10000 10000 10000 10000
11433 14140 25807 52317
12500 12500 12500 12500
14291 17675 32259 65396
10000 10000 10000 10000
11433 14140 25807 52317
$10718 Misc Pediatric $13256 Misc Pediatric $24194 Misc Pediatric $49047 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
511-1 511-2 511-3 511-4
UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY
330 488 862
1777
11911 14923 22750 49888
10000 10000 10000 10000
10000 10000 10000 10000
11911 14923 22750 49888
12500 12500 12500 12500
14889 18654 28438 62360
10000 10000 10000 10000
11911 14923 22750 49888
$11167 Misc Pediatric $13990 Misc Pediatric $21328 Misc Pediatric $46770 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
512-1 512-2 512-3 512-4
UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG
217 308 682
1629
10603 12410 19879 45702
10000 10000 10000 10000
10000 10000 10000 10000
10603 12410 19879 45702
12500 12500 12500 12500
13254 15513 24849 57128
10000 10000 10000 10000
10603 12410 19879 45702
$9940 Misc Pediatric $11634 Misc Pediatric $18637 Misc Pediatric $42846 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
513-1 513-2 513-3 513-4
UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
186 251 564
1508
08515 10026 16283 40387
10000 10000 10000 10000
10000 10000 10000 10000
08515 10026 16283 40387
12500 12500 12500 12500
10644 12533 20354 50484
10000 10000 10000 10000
08515 10026 16283 40387
$7983 Misc Pediatric $9399 Misc Pediatric
$15265 Misc Pediatric $37863 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
514-1 514-2 514-3 514-4
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
140 172 529
1557
07298 09618 15881 40691
10000 10000 10000 10000
10000 10000 10000 10000
07298 09618 15881 40691
12500 12500 12500 12500
09123 12023 19851 50864
10000 10000 10000 10000
07298 09618 15881 40691
$6842 Misc Pediatric $9017 Misc Pediatric
$14888 Misc Pediatric $38148 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
517-1 517-2 517-3 517-4
DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES
192 289 663
1364
06030 08036 13633 29709
10000 10000 10000 10000
10000 10000 10000 10000
06030 08036 13633 29709
12500 12500 12500 12500
07538 10045 17041 37136
10000 10000 10000 10000
06030 08036 13633 29709
$5653 Misc Pediatric $7534 Misc Pediatric
$12781 Misc Pediatric $27852 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
518-1 518-2 518-3 518-4
OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
223 382 837
1827
06924 10040 18032 44556
10000 10000 10000 10000
10000 10000 10000 10000
06924 10040 18032 44556
12500 12500 12500 12500
08655 12550 22540 55695
10000 10000 10000 10000
06924 10040 18032 44556
$6491 Misc Pediatric $9413 Misc Pediatric
$16905 Misc Pediatric $41771 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
519-1 519-2 519-3 519-4
UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA
206 279 613
1485
08286 10051 17505 39433
10000 10000 10000 10000
10000 10000 10000 10000
08286 10051 17505 39433
12500 12500 12500 12500
10358 12564 21881 49291
10000 10000 10000 10000
08286 10051 17505 39433
$7768 Misc Pediatric $9423 Misc Pediatric
$16411 Misc Pediatric $36968 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
530-1 530-2 530-3 530-4
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
310 385 643
1178
04420 06163 09992 18972
10000 10000 10000 10000
10000 10000 10000 10000
04420 06163 09992 18972
12500 12500 12500 12500
05525 07704 12490 23715
10000 10000 10000 10000
04420 06163 09992 18972
$4144 Misc Pediatric $5778 Misc Pediatric $9368 Misc Pediatric
$17786 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
531-1 531-2 531-3 531-4
FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS
266 383 638
1303
04544 06407 09987 20595
10000 10000 10000 10000
10000 10000 10000 10000
04544 06407 09987 20595
12500 12500 12500 12500
05680 08009 12484 25744
10000 10000 10000 10000
04544 06407 09987 20595
$4260 Misc Pediatric $6007 Misc Pediatric $9363 Misc Pediatric
$19308 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
532-1 532-2 532-3 532-4
MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
177 237 434
1003
03922 04787 07941 17650
10000 10000 10000 10000
10000 10000 10000 10000
03922 04787 07941 17650
12500 12500 12500 12500
04903 05984 09926 22063
10000 10000 10000 10000
03922 04787 07941 17650
$3677 Misc Pediatric $4488 Misc Pediatric $7445 Misc Pediatric
$16547 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
540-1 540-2 540-3 540-4
CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY
298 391 634
1053
05654 06864 09354 23719
10000 10000 10000 10000
10600 10600 10600 10600
05993 07276 09915 25142
10000 10000 10000 10000
05993 07276 09915 25142
10000 10000 10000 10000
05654 06864 09354 23719
$4495 Obstetrics $5457 Obstetrics $7436 Obstetrics
$18857 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
541-1 541-2 541-3 541-4
VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC
212 249 491 838
05628 06076 08661 23515
10000 10000 10000 10000
10600 10600 10600 10600
05966 06441 09181 24926
10000 10000 10000 10000
05966 06441 09181 24926
10000 10000 10000 10000
05628 06076 08661 23515
$4474 Obstetrics $4830 Obstetrics $6886 Obstetrics
$18694 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
542-1 542-2 542-3 542-4
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC
216 296 614 993
03695 04647 08572 36195
10000 10000 10000 10000
10600 10600 10600 10600
03917 04926 09086 38367
10000 10000 10000 10000
03917 04926 09086 38367
10000 10000 10000 10000
03695 04647 08572 36195
$2938 Obstetrics $3694 Obstetrics $6815 Obstetrics
$28775 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
544-1 544-2 544-3 544-4
DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES
136 200 407 914
04586 05897 09822 25061
10000 10000 10000 10000
10600 10600 10600 10600
04861 06251 10411 26565
10000 10000 10000 10000
04861 06251 10411 26565
10000 10000 10000 10000
04586 05897 09822 25061
$3646 Obstetrics Obstetrics $4688 Obstetrics Obstetrics $7808 Obstetrics Obstetrics
$19924 Obstetrics Obstetrics 545-1 545-2 545-3 545-4
ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE
164 190 265 576
06988 08147 10540 19945
10000 10000 10000 10000
10600 10600 10600 10600
07407 08636 11172 21142
10000 10000 10000 10000
07407 08636 11172 21142
10000 10000 10000 10000
06988 08147 10540 19945
$5555 Obstetrics Obstetrics $6477 Obstetrics Obstetrics $8379 Obstetrics Obstetrics
$15856 Obstetrics Obstetrics 546-1 546-2 546-3 546-4
OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES
285 454 755
1446
05023 07207 13295 43377
10000 10000 10000 10000
10600 10600 10600 10600
05324 07639 14093 45980
10000 10000 10000 10000
05324 07639 14093 45980
10000 10000 10000 10000
05023 07207 13295 43377
$3993 Obstetrics Obstetrics $5730 Obstetrics Obstetrics
$10570 Obstetrics Obstetrics $34485 Obstetrics Obstetrics
560-1 560-2 560-3 560-4
VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY
203 237 385 935
03307 03856 05399 15061
10000 10000 10000 10000
10600 10600 10600 10600
03505 04087 05723 15965
10000 10000 10000 10000
03505 04087 05723 15965
10000 10000 10000 10000
03307 03856 05399 15061
$2629 Obstetrics Obstetrics $3066 Obstetrics Obstetrics $4292 Obstetrics Obstetrics
$11974 Obstetrics Obstetrics 561-1 561-2 561-3 561-4
POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE
211 257 393 688
02511 03908 06071 15617
10000 10000 10000 10000
10600 10600 10600 10600
02662 04142 06435 16554
10000 10000 10000 10000
02662 04142 06435 16554
10000 10000 10000 10000
02511 03908 06071 15617
$1996 Obstetrics Obstetrics $3107 Obstetrics Obstetrics $4826 Obstetrics Obstetrics
$12416 Obstetrics Obstetrics 563-1 563-2 563-3 563-4
THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION
259 391 747 720
02581 03376 05162 09652
10000 10000 10000 10000
10600 10600 10600 10600
02736 03579 05472 10231
10000 10000 10000 10000
02736 03579 05472 10231
10000 10000 10000 10000
02581 03376 05162 09652
$2052 Obstetrics Obstetrics $2684 Obstetrics Obstetrics $4104 Obstetrics Obstetrics $7673 Obstetrics Obstetrics
564-1 564-2 564-3 564-4
ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY
137 170 276 808
02881 03463 04901 16676
10000 10000 10000 10000
10600 10600 10600 10600
03054 03671 05195 17677
10000 10000 10000 10000
03054 03671 05195 17677
10000 10000 10000 10000
02881 03463 04901 16676
$2290 Obstetrics Obstetrics $2753 Obstetrics Obstetrics $3896 Obstetrics Obstetrics
$13257 Obstetrics Obstetrics 565-1 565-2 565-3 565-4
FALSE LABOR FALSE LABOR FALSE LABOR FALSE LABOR
123 185 735 808
01245 01782 02687 02986
10000 10000 10000 10000
10600 10600 10600 10600
01320 01889 02848 03165
10000 10000 10000 10000
01320 01889 02848 03165
10000 10000 10000 10000
01245 01782 02687 02986
$990 Obstetrics Obstetrics $1417 Obstetrics Obstetrics $2136 Obstetrics Obstetrics $2374 Obstetrics Obstetrics
566-1 566-2 566-3 566-4
OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES
211 294 544 843
02442 03252 04790 14726
10000 10000 10000 10000
10600 10600 10600 10600
02589 03447 05077 15610
10000 10000 10000 10000
02589 03447 05077 15610
10000 10000 10000 10000
02442 03252 04790 14726
$1941 Obstetrics Obstetrics $2585 Obstetrics Obstetrics $3808 Obstetrics Obstetrics
$11707 Obstetrics Obstetrics 580-1 580-2 580-3 580-4
NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE
144 159 182 165
02398 03209 05011 08512
12500 12500 12500 12500
10000 10000 10000 10000
02998 04011 06264 10640
10000 10000 10000 10000
02998 04011 06264 10640
17500 17500 17500 17500
04197 05616 08769 14896
$2248 Neonate Neonate $3008 Neonate Neonate $4698 Neonate Neonate $7980 Neonate Neonate
581-1 581-2 581-3 581-4
NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE
124 128 126 135
00982 01477 02362 04408
12500 12500 12500 12500
10000 10000 10000 10000
01228 01846 02953 05510
10000 10000 10000 10000
01228 01846 02953 05510
17500 17500 17500 17500
01719 02585 04134 07714
$921 Neonate Neonate $1385 Neonate Neonate $2214 Neonate Neonate $4133 Neonate Neonate
583-1 583-2 583-3 583-4
NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO
2070 2300 3077 4886
99741 157496 173245 240894
12500 12500 12500 12500
10000 10000 10000 10000
124676 196870 216556 301118
10000 10000 10000 10000
124676 196870 216556 301118
17500 17500 17500 17500
174547 275618 303179 421565
$93507 Neonate Neonate $147653 Neonate Neonate $162417 Neonate Neonate $225838 Neonate Neonate
588-1 588-2 588-3 588-4
NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE
4442 4935 7714
10207
48410 70035
142903 216660
12500 12500 12500 12500
10000 10000 10000 10000
60513 87544
178629 270825
10000 10000 10000 10000
60513 87544
178629 270825
17500 17500 17500 17500
84718 122561 250080 379155
$45384 Neonate Neonate $65658 Neonate Neonate
$133972 Neonate Neonate $203119 Neonate Neonate
589-1 589-2 589-3 589-4
NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS
5843 5041 3035
265
115468 104972
95430 04454
12500 12500 12500 12500
10000 10000 10000 10000
144335 131215 119288
05568
10000 10000 10000 10000
144335 131215 119288
05568
17500 17500 17500 17500
202069 183701 167003
07795
$108251 Neonate Neonate $98411 Neonate Neonate $89466 Neonate Neonate
$4176 Neonate Neonate 591-1 591-2 591-3 591-4
NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE
211 3710 5061 7221
01574 55672 88282
132286
12500 12500 12500 12500
10000 10000 10000 10000
01968 69590
110353 165358
10000 10000 10000 10000
01968 69590
110353 165358
17500 17500 17500 17500
02755 97426
154494 231501
$1476 Neonate Neonate $52193 Neonate Neonate $82764 Neonate Neonate
$124018 Neonate Neonate 593-1 593-2 593-3 593-4
NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE
1928 4851 5965 7143
15109 51914 82800
122454
12500 12500 12500 12500
10000 10000 10000 10000
18886 64893
103500 153068
10000 10000 10000 10000
18886 64893
103500 153068
17500 17500 17500 17500
26441 90850
144900 214295
$14165 Neonate Neonate $48669 Neonate Neonate $77625 Neonate Neonate
$114801 Neonate Neonate 602-1 602-2 602-3 602-4
NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2513 4403 5324 6307
29635 58707 77593
104733
12500 12500 12500 12500
10000 10000 10000 10000
37044 73384 96991
130916
10000 10000 10000 10000
37044 73384 96991
130916
17500 17500 17500 17500
51861 102737 135788 183283
$27783 Neonate Neonate $55038 Neonate Neonate $72743 Neonate Neonate $98187 Neonate Neonate
603-1 603-2 603-3 603-4
NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION
2234 3619 4843 5396
17223 42526 65587 70750
12500 12500 12500 12500
10000 10000 10000 10000
21529 53158 81984 88438
10000 10000 10000 10000
21529 53158 81984 88438
17500 17500 17500 17500
30140 74421
114777 123813
$16147 Neonate Neonate $39868 Neonate Neonate $61488 Neonate Neonate $66328 Neonate Neonate
607-1 607-2 607-3 607-4
NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2509 3582 4341 4957
27503 47486 61883 79508
12500 12500 12500 12500
10000 10000 10000 10000
34379 59358 77354 99385
10000 10000 10000 10000
34379 59358 77354 99385
17500 17500 17500 17500
48130 83101
108295 139139
$25784 Neonate Neonate $44518 Neonate Neonate $58015 Neonate Neonate $74539 Neonate Neonate
608-1 608-2 608-3 608-4
NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION
1980 3004 3846 4414
21292 36047 52684 60424
12500 12500 12500 12500
10000 10000 10000 10000
26615 45059 65855 75530
10000 10000 10000 10000
26615 45059 65855 75530
17500 17500 17500 17500
37261 63082 92197
105742
$19961 Neonate Neonate $33794 Neonate Neonate $49391 Neonate Neonate $56648 Neonate Neonate
609-1 609-2 609-3 609-4
NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE
1933 2210 3803 6267
27332 38628 65636
119134
12500 12500 12500 12500
10000 10000 10000 10000
34165 48285 82045
148918
10000 10000 10000 10000
34165 48285 82045
148918
17500 17500 17500 17500
47831 67599
114863 208485
$25624 Neonate Neonate $36214 Neonate Neonate $61534 Neonate Neonate
$111688 Neonate Neonate 611-1 611-2 611-3 611-4
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY
1313 2123 3133 3614
11780 25158 40556 52442
12500 12500 12500 12500
10000 10000 10000 10000
14725 31448 50695 65553
10000 10000 10000 10000
14725 31448 50695 65553
17500 17500 17500 17500
20615 44027 70973 91774
$11044 Neonate Neonate $23586 Neonate Neonate $38021 Neonate Neonate $49164 Neonate Neonate
612-1 612-2 612-3 612-4
NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND
1756 2442 3248 3834
21880 32223 46803 62297
12500 12500 12500 12500
10000 10000 10000 10000
27350 40279 58504 77871
10000 10000 10000 10000
27350 40279 58504 77871
17500 17500 17500 17500
38290 56390 81905
109020
$20513 Neonate Neonate $30209 Neonate Neonate $43878 Neonate Neonate $58403 Neonate Neonate
613-1 613-2 613-3 613-4
NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION
1439 2153 2853 3338
16593 26831 37601 48828
12500 12500 12500 12500
10000 10000 10000 10000
20741 33539 47001 61035
10000 10000 10000 10000
20741 33539 47001 61035
17500 17500 17500 17500
29038 46954 65802 85449
$15556 Neonate Neonate $25154 Neonate Neonate $35251 Neonate Neonate $45776 Neonate Neonate
614-1 614-2 614-3 614-4
NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION
1123 2008 2852 3640
09241 22768 36403 50802
12500 12500 12500 12500
10000 10000 10000 10000
11551 28460 45504 63503
10000 10000 10000 10000
11551 28460 45504 63503
17500 17500 17500 17500
16172 39844 63705 88904
$8663 Neonate Neonate $21345 Neonate Neonate $34128 Neonate Neonate $47627 Neonate Neonate
621-1 621-2 621-3 621-4
NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY
820 1397 2125 2416
06082 15379 27206 38101
12500 12500 12500 12500
10000 10000 10000 10000
07603 19224 34008 47626
10000 10000 10000 10000
07603 19224 34008 47626
17500 17500 17500 17500
10644 26913 47611 66677
$5702 Neonate Neonate $14418 Neonate Neonate $25506 Neonate Neonate $35720 Neonate Neonate
622-1 622-2 622-3 622-4
NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND
1118 1514 1977 2285
13666 20913 29736 47202
12500 12500 12500 12500
10000 10000 10000 10000
17083 26141 37170 59003
10000 10000 10000 10000
17083 26141 37170 59003
17500 17500 17500 17500
23916 36598 52038 82604
$12812 Neonate Neonate $19606 Neonate Neonate $27878 Neonate Neonate $44252 Neonate Neonate
623-1 623-2 623-3 623-4
NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION
924 1399 1872 2738
09934 16800 25087 38932
12500 12500 12500 12500
10000 10000 10000 10000
12418 21000 31359 48665
10000 10000 10000 10000
12418 21000 31359 48665
17500 17500 17500 17500
17385 29400 43902 68131
$9313 Neonate Neonate $15750 Neonate Neonate $23519 Neonate Neonate $36499 Neonate Neonate
625-1 625-2 625-3 625-4
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION
1157 1621 1925 2015
11469 18627 23298 29194
12500 12500 12500 12500
10000 10000 10000 10000
14336 23284 29123 36493
10000 10000 10000 10000
14336 23284 29123 36493
17500 17500 17500 17500
20071 32597 40772 51090
$10752 Neonate Neonate $17463 Neonate Neonate $21842 Neonate Neonate $27369 Neonate Neonate
626-1 626-2 626-3 626-4
NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
279 456 864
1838
01387 02587 07679 22819
10000 10000 10000 10000
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
$1040 Normal newborn Normal newborn $1940 Normal newborn Normal newborn $5759 Normal newborn Normal newborn
$17114 Normal newborn Normal newborn 630-1 630-2 630-3 630-4
NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE
486 940
1448 3912
20468 32885 52250
112072
12500 12500 12500 12500
10000 10000 10000 10000
25585 41106 65313
140090
10000 10000 10000 10000
25585 41106 65313
140090
17500 17500 17500 17500
35819 57549 91438
196126
$19189 Neonate Neonate $30830 Neonate Neonate $48984 Neonate Neonate
$105068 Neonate Neonate 631-1 631-2 631-3 631-4
NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE
335 886
2279 5111
09217 16766 37480 96324
12500 12500 12500 12500
10000 10000 10000 10000
11521 20958 46850
120405
10000 10000 10000 10000
11521 20958 46850
120405
17500 17500 17500 17500
16130 29341 65590
168567
$8641 Neonate Neonate $15718 Neonate Neonate $35138 Neonate Neonate $90304 Neonate Neonate
633-1 633-2 633-3 633-4
NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY
296 651
1226 2381
01972 05798 13892 39728
12500 12500 12500 12500
10000 10000 10000 10000
02465 07248 17365 49660
10000 10000 10000 10000
02465 07248 17365 49660
17500 17500 17500 17500
03451 10147 24311 69524
$1849 Neonate Neonate $5436 Neonate Neonate
$13024 Neonate Neonate $37245 Neonate Neonate
634-1 634-2 634-3 634-4
NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND
465 749
1261 2233
04886 09445 20176 46934
12500 12500 12500 12500
10000 10000 10000 10000
06108 11806 25220 58668
10000 10000 10000 10000
06108 11806 25220 58668
17500 17500 17500 17500
08551 16529 35308 82135
$4581 Neonate Neonate $8855 Neonate Neonate
$18915 Neonate Neonate $44001 Neonate Neonate
636-1 636-2 636-3 636-4
NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION
558 779
1164 1896
05582 08840 15558 30613
12500 12500 12500 12500
10000 10000 10000 10000
06978 11050 19448 38266
10000 10000 10000 10000
06978 11050 19448 38266
17500 17500 17500 17500
09769 15470 27227 53573
$5233 Neonate Neonate $8288 Neonate Neonate
$14586 Neonate Neonate $28700 Neonate Neonate
639-1 639-2 639-3 639-4
NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION
441 704 998
1653
03287 06622 11809 27285
12500 12500 12500 12500
10000 10000 10000 10000
04109 08278 14761 34106
10000 10000 10000 10000
04109 08278 14761 34106
17500 17500 17500 17500
05752 11589 20666 47749
$3082 Neonate Neonate $6208 Neonate Neonate
$11071 Neonate Neonate $25580 Neonate Neonate
640-1 NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 210 01012 10000 10000 01012 10000 01012 10000 01012 $759 Normal newborn Normal newborn
640-2 640-3 640-4
NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
245 376
1206
01353 02864 14726
10000 10000 10000
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
$1015 Normal newborn Normal newborn $2148 Normal newborn Normal newborn
$11045 Normal newborn Normal newborn 650-1 650-2 650-3 650-4
SPLENECTOMY SPLENECTOMY SPLENECTOMY SPLENECTOMY
348 537 848
1563
12985 17965 25202 50826
10000 10000 10000 10000
10000 10000 10000 10000
12985 17965 25202 50826
12500 12500 12500 12500
16231 22456 31503 63533
10000 10000 10000 10000
12985 17965 25202 50826
$12173 Misc Pediatric Misc Adult $16842 Misc Pediatric Misc Adult $23627 Misc Pediatric Misc Adult $47649 Misc Pediatric Misc Adult
651-1 651-2 651-3 651-4
OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS
331 472 962
2426
09234 13695 21005 59541
10000 10000 10000 10000
10000 10000 10000 10000
09234 13695 21005 59541
12500 12500 12500 12500
11543 17119 26256 74426
10000 10000 10000 10000
09234 13695 21005 59541
$8657 Misc Pediatric Misc Adult $12839 Misc Pediatric Misc Adult $19692 Misc Pediatric Misc Adult $55820 Misc Pediatric Misc Adult
660-1 660-2 660-3 660-4
MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL
305 408 648
1435
05399 07219 11819 30180
10000 10000 10000 10000
10000 10000 10000 10000
05399 07219 11819 30180
12500 12500 12500 12500
06749 09024 14774 37725
10000 10000 10000 10000
05399 07219 11819 30180
$5062 Misc Pediatric Misc Adult $6768 Misc Pediatric Misc Adult
$11080 Misc Pediatric Misc Adult $28294 Misc Pediatric Misc Adult
661-1 661-2 661-3 661-4
COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS
275 375 566
1265
06473 08098 12433 27857
10000 10000 10000 10000
10000 10000 10000 10000
06473 08098 12433 27857
12500 12500 12500 12500
08091 10123 15541 34821
10000 10000 10000 10000
06473 08098 12433 27857
$6068 Misc Pediatric Misc Adult $7592 Misc Pediatric Misc Adult
$11656 Misc Pediatric Misc Adult $26116 Misc Pediatric Misc Adult
662-1 662-2 662-3 662-4
SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS
412 538 785
1302
05044 07003 10778 23937
10000 10000 10000 10000
10000 10000 10000 10000
05044 07003 10778 23937
12500 12500 12500 12500
06305 08754 13473 29921
10000 10000 10000 10000
05044 07003 10778 23937
$4729 Misc Pediatric Misc Adult $6565 Misc Pediatric Misc Adult
$10104 Misc Pediatric Misc Adult $22441 Misc Pediatric Misc Adult
663-1 663-2 663-3 663-4
OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS
232 301 451 900
04474 05959 08513 16106
10000 10000 10000 10000
10000 10000 10000 10000
04474 05959 08513 16106
12500 12500 12500 12500
05593 07449 10641 20133
10000 10000 10000 10000
04474 05959 08513 16106
$4194 Misc Pediatric Misc Adult $5587 Misc Pediatric Misc Adult $7981 Misc Pediatric Misc Adult
$15099 Misc Pediatric Misc Adult 680-1 680-2 680-3 680-4
MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
408 633
1185 2456
13702 18600 32002 66288
10000 10000 10000 10000
10000 10000 10000 10000
13702 18600 32002 66288
12500 12500 12500 12500
17128 23250 40003 82860
10000 10000 10000 10000
13702 18600 32002 66288
$12846 Misc Pediatric Misc Adult $17438 Misc Pediatric Misc Adult $30002 Misc Pediatric Misc Adult $62145 Misc Pediatric Misc Adult
681-1 681-2 681-3 681-4
OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
268 507
1111 2510
09800 13647 24597 59170
10000 10000 10000 10000
10000 10000 10000 10000
09800 13647 24597 59170
12500 12500 12500 12500
12250 17059 30746 73963
10000 10000 10000 10000
09800 13647 24597 59170
$9188 Misc Pediatric Misc Adult $12794 Misc Pediatric Misc Adult $23060 Misc Pediatric Misc Adult $55472 Misc Pediatric Misc Adult
690-1 690-2 690-3 690-4
ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA
495 740
1461 2485
07040 11869 23551 52504
10000 10000 10000 10000
10000 10000 10000 10000
07040 11869 23551 52504
12500 12500 12500 12500
08800 14836 29439 65630
10000 10000 10000 10000
07040 11869 23551 52504
$6600 Misc Pediatric Misc Adult $11127 Misc Pediatric Misc Adult $22079 Misc Pediatric Misc Adult $49223 Misc Pediatric Misc Adult
691-1 691-2 691-3 691-4
LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA
389 540 861
1585
07077 09840 15477 31411
10000 10000 10000 10000
10000 10000 10000 10000
07077 09840 15477 31411
12500 12500 12500 12500
08846 12300 19346 39264
10000 10000 10000 10000
07077 09840 15477 31411
$6635 Misc Pediatric Misc Adult $9225 Misc Pediatric Misc Adult
$14510 Misc Pediatric Misc Adult $29448 Misc Pediatric Misc Adult
692-1 692-2 692-3 692-4
RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY
389 482 868
1580
06075 12584 17422 29316
10000 10000 10000 10000
10000 10000 10000 10000
06075 12584 17422 29316
12500 12500 12500 12500
07594 15730 21778 36645
10000 10000 10000 10000
06075 12584 17422 29316
$5695 Misc Pediatric Misc Adult $11798 Misc Pediatric Misc Adult $16333 Misc Pediatric Misc Adult $27484 Misc Pediatric Misc Adult
693-1 693-2 693-3 693-4
CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY
281 368 785
2410
06251 07881 13637 49083
10000 10000 10000 10000
10000 10000 10000 10000
06251 07881 13637 49083
12500 12500 12500 12500
07814 09851 17046 61354
10000 10000 10000 10000
06251 07881 13637 49083
$5860 Misc Pediatric Misc Adult $7388 Misc Pediatric Misc Adult
$12785 Misc Pediatric Misc Adult $46015 Misc Pediatric Misc Adult
694-1 694-2 694-3 694-4
LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR
304 404 674
1164
04842 06831 11115 21001
10000 10000 10000 10000
10000 10000 10000 10000
04842 06831 11115 21001
12500 12500 12500 12500
06053 08539 13894 26251
10000 10000 10000 10000
04842 06831 11115 21001
$4539 Misc Pediatric Misc Adult $6404 Misc Pediatric Misc Adult
$10420 Misc Pediatric Misc Adult $19688 Misc Pediatric Misc Adult
710-1 710-2 710-3 710-4
INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE
510 680
1111 1820
10635 15963 25572 49382
10000 10000 10000 10000
10000 10000 10000 10000
10635 15963 25572 49382
12500 12500 12500 12500
13294 19954 31965 61728
10000 10000 10000 10000
10635 15963 25572 49382
$9970 Misc Pediatric Misc Adult $14965 Misc Pediatric Misc Adult $23974 Misc Pediatric Misc Adult $46296 Misc Pediatric Misc Adult
711-1 711-2 711-3 711-4
POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE
471 692
1131 2087
10079 14143 23599 50574
10000 10000 10000 10000
10000 10000 10000 10000
10079 14143 23599 50574
12500 12500 12500 12500
12599 17679 29499 63218
10000 10000 10000 10000
10079 14143 23599 50574
$9449 Misc Pediatric Misc Adult $13259 Misc Pediatric Misc Adult $22124 Misc Pediatric Misc Adult $47413 Misc Pediatric Misc Adult
720-1 720-2 720-3 720-4
SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS
353 444 633
1004
05431 07613 11532 21705
10000 10000 10000 10000
10000 10000 10000 10000
05431 07613 11532 21705
12500 12500 12500 12500
06789 09516 14415 27131
10000 10000 10000 10000
05431 07613 11532 21705
$5092 Misc Pediatric Misc Adult $7137 Misc Pediatric Misc Adult
$10811 Misc Pediatric Misc Adult $20348 Misc Pediatric Misc Adult
721-1 721-2 721-3 721-4
POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS
368 470 705
1153
05287 07209 11619 22025
10000 10000 10000 10000
10000 10000 10000 10000
05287 07209 11619 22025
12500 12500 12500 12500
06609 09011 14524 27531
10000 10000 10000 10000
05287 07209 11619 22025
$4957 Misc Pediatric Misc Adult $6758 Misc Pediatric Misc Adult
$10893 Misc Pediatric Misc Adult $20648 Misc Pediatric Misc Adult
722-1 722-2 722-3 722-4
FEVER FEVER FEVER FEVER
230 302 429 739
03423 05223 07630 13141
10000 10000 10000 10000
10000 10000 10000 10000
03423 05223 07630 13141
12500 12500 12500 12500
04279 06529 09538 16426
10000 10000 10000 10000
03423 05223 07630 13141
$3209 Misc Pediatric Misc Adult $4897 Misc Pediatric Misc Adult $7153 Misc Pediatric Misc Adult
$12320 Misc Pediatric Misc Adult 723-1 723-2 723-3 723-4
VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS
216 279 470
1317
03194 04738 07794 24233
10000 10000 10000 10000
10000 10000 10000 10000
03194 04738 07794 24233
12500 12500 12500 12500
03993 05923 09743 30291
10000 10000 10000 10000
03194 04738 07794 24233
$2994 Misc Pediatric Misc Adult $4442 Misc Pediatric Misc Adult $7307 Misc Pediatric Misc Adult
$22718 Misc Pediatric Misc Adult 724-1 724-2 724-3 724-4
OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES
400 477 680
1337
05512 07131 11401 24698
10000 10000 10000 10000
10000 10000 10000 10000
05512 07131 11401 24698
12500 12500 12500 12500
06890 08914 14251 30873
10000 10000 10000 10000
05512 07131 11401 24698
$5168 Misc Pediatric Misc Adult $6685 Misc Pediatric Misc Adult
$10688 Misc Pediatric Misc Adult $23154 Misc Pediatric Misc Adult
740-1 740-2 740-3 740-4
MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE
678 1284 2034 2421
10899 13904 24356 37756
10000 10000 10000 10000
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
$8174 Other Other $10428 Other Other $18267 Other Other $28317 Other Other
750-1 750-2 750-3 750-4
SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA
1082 1179 1539 2848
05713 06699 09202 19283
10000 10000 10000 10000
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
$4285 Other Other $5024 Other Other $6902 Other Other
$14462 Other Other 751-1 751-2 751-3 751-4
MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES
528 724
1055 2028
03572 05019 08097 15923
10000 10000 10000 10000
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
$2679 Other Other $3764 Other Other $6073 Other Other
$11942 Other Other 752-1 752-2 752-3 752-4
DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL
503 658
1473 7300
03399 04498 09061 14934
10000 10000 10000 10000
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
$2549 Other Other $3374 Other Other $6796 Other Other
$11201 Other Other 753-1 753-2 753-3 753-4
BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS
601 808
1205 1948
04001 05365 08266 14926
10000 10000 10000 10000
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
$3001 Other Other $4024 Other Other $6200 Other Other
$11195 Other Other 754-1 754-2 754-3 754-4
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER
424 558 727
1664
02943 03998 05677 11553
10000 10000 10000 10000
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
$2207 Other Other $2999 Other Other $4258 Other Other $8665 Other Other
755-1 755-2 755-3 755-4
ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
388 622 900 813
02738 04363 06226 08767
10000 10000 10000 10000
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
$2054 Other Other $3272 Other Other $4670 Other Other $6575 Other Other
756-1 756-2 756-3 756-4
ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES
331 381 457 942
04061 05308 06065 13981
10000 10000 10000 10000
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
$3046 Other Other $3981 Other Other $4549 Other Other
$10486 Other Other 757-1 757-2 757-3 757-4
ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES
873 934
1087 1640
05861 07234 08953 13799
10000 10000 10000 10000
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
$4396 Other Other $5426 Other Other $6715 Other Other
$10349 Other Other 758-1 758-2 758-3 758-4
CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS
694 981
1225 4300
03874 05129 06541 11332
10000 10000 10000 10000
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
$2906 Other Other $3847 Other Other $4906 Other Other $8499 Other Other
759-1 759-2 759-3 759-4
EATING DISORDERS EATING DISORDERS EATING DISORDERS EATING DISORDERS
1990 1297 1402 2303
06561 06961 10053 16606
10000 10000 10000 10000
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
$4921 Other Other $5221 Other Other $7540 Other Other
$12455 Other Other 760-1 760-2 760-3 760-4
OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS
748 766 912
1204
04840 06173 07573 14134
10000 10000 10000 10000
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
$3630 Other Other $4630 Other Other $5680 Other Other
$10601 Other Other 770-1 770-2 770-3 770-4
DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE
253 248 332 794
02240 02623 05475 16843
10000 10000 10000 10000
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
$1680 Other Other $1967 Other Other $4106 Other Other
$12632 Other Other 772-1 772-2 772-3 772-4
ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY
1434 1551 1289 2385
05441 06916 07009 24530
10000 10000 10000 10000
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
$4081 Other Other $5187 Other Other $5257 Other Other
$18398 Other Other 773-1 773-2 773-3 773-4
OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE
337 414 507 992
02663 03466 05964 18606
10000 10000 10000 10000
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
$1997 Other Other $2600 Other Other $4473 Other Other
$13955 Other Other 774-1 774-2
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
365 412
03040 03627
10000 10000
10000 10000
03040 03627
10000 10000
03040 03627
10000 10000
03040 03627
$2280 Other Other $2720 Other Other
774-3 774-4
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
479 1424
06448 24682
10000 10000
10000 10000
06448 24682
10000 10000
06448 24682
10000 10000
06448 24682
$4836 Other $18512 Other
Other Other
775-1 775-2 775-3 775-4
ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE
323 377 571
1263
03313 04639 08596 24910
10000 10000 10000 10000
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
$2485 Other $3479 Other $6447 Other
$18683 Other
Other Other Other Other
776-1 776-2 776-3 776-4
OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE
389 397 496 933
03157 04547 07887 16112
10000 10000 10000 10000
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
$2368 Other $3410 Other $5915 Other
$12084 Other
Other Other Other Other
791-1 791-2 791-3 791-4
OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT
314 515 989
2009
08636 12677 21979 49312
10000 10000 10000 10000
10000 10000 10000 10000
08636 12677 21979 49312
12500 12500 12500 12500
10795 15846 27474 61640
10000 10000 10000 10000
08636 12677 21979 49312
$8096 Misc Pediatric $11885 Misc Pediatric $20605 Misc Pediatric $46230 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
811-1 811-2 811-3 811-4
ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS
151 202 390 913
02707 03855 08277 22176
10000 10000 10000 10000
10000 10000 10000 10000
02707 03855 08277 22176
12500 12500 12500 12500
03384 04819 10346 27720
10000 10000 10000 10000
02707 03855 08277 22176
$2538 Misc Pediatric $3614 Misc Pediatric $7760 Misc Pediatric
$20790 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
812-1 812-2 812-3 812-4
POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS
165 225 347 694
03469 04331 07709 17419
10000 10000 10000 10000
10000 10000 10000 10000
03469 04331 07709 17419
12500 12500 12500 12500
04336 05414 09636 21774
10000 10000 10000 10000
03469 04331 07709 17419
$3252 Misc Pediatric $4060 Misc Pediatric $7227 Misc Pediatric
$16330 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
813-1 813-2 813-3 813-4
OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT
261 344 594
1344
04393 06056 09631 19960
10000 10000 10000 10000
10000 10000 10000 10000
04393 06056 09631 19960
12500 12500 12500 12500
05491 07570 12039 24950
10000 10000 10000 10000
04393 06056 09631 19960
$4118 Misc Pediatric $5678 Misc Pediatric $9029 Misc Pediatric
$18713 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
815-1 815-2 815-3 815-4
OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES
169 276 456 880
04211 05012 08129 22715
10000 10000 10000 10000
10000 10000 10000 10000
04211 05012 08129 22715
12500 12500 12500 12500
05264 06265 10161 28394
10000 10000 10000 10000
04211 05012 08129 22715
$3948 Misc Pediatric $4699 Misc Pediatric $7621 Misc Pediatric
$21295 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
816-1 816-2 816-3 816-4
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
173 240 346 736
04162 04915 07864 18134
10000 10000 10000 10000
10000 10000 10000 10000
04162 04915 07864 18134
12500 12500 12500 12500
05203 06144 09830 22668
10000 10000 10000 10000
04162 04915 07864 18134
$3902 Misc Pediatric $4608 Misc Pediatric $7373 Misc Pediatric
$17001 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
841-1 841-2 841-3 841-4
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT
2200 967
2599 4068
31148 34263 64068
159153
10000 10000 10000 10000
10000 10000 10000 10000
31148 34263 64068
159153
12500 12500 12500 12500
38935 42829 80085
198941
10000 10000 10000 10000
31148 34263 64068
159153
$29201 Misc Pediatric $32122 Misc Pediatric $60064 Misc Pediatric
$149206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
842-1 842-2 842-3 842-4
FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT
751 1072 1735 3010
14151 21416 38719 95054
10000 10000 10000 10000
10000 10000 10000 10000
14151 21416 38719 95054
12500 12500 12500 12500
17689 26770 48399
118818
10000 10000 10000 10000
14151 21416 38719 95054
$13267 Misc Pediatric $20078 Misc Pediatric $36299 Misc Pediatric $89113 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
843-1 843-2 843-3 843-4
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT
339 487 713
1113
04752 06661 11619 32621
10000 10000 10000 10000
10000 10000 10000 10000
04752 06661 11619 32621
12500 12500 12500 12500
05940 08326 14524 40776
10000 10000 10000 10000
04752 06661 11619 32621
$4455 Misc Pediatric $6245 Misc Pediatric
$10893 Misc Pediatric $30582 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
844-1 844-2 844-3 844-4
PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT
310 497 743
1781
04337 06965 12193 48021
10000 10000 10000 10000
10000 10000 10000 10000
04337 06965 12193 48021
12500 12500 12500 12500
05421 08706 15241 60026
10000 10000 10000 10000
04337 06965 12193 48021
$4066 Misc Pediatric $6530 Misc Pediatric
$11431 Misc Pediatric $45020 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
850-1 850-2 850-3 850-4
PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE
267 556
1618 3148
11757 14065 24870 46520
10000 10000 10000 10000
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
$8818 Misc Pediatric $10549 Misc Pediatric $18653 Misc Pediatric $34890 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
860-1 860-2 860-3 860-4
REHABILITATION REHABILITATION REHABILITATION REHABILITATION
932 1146 1475 1795
07227 09855 13880 17876
10000 10000 10000 10000
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
$5420 Other $7391 Other
$10410 Other $13407 Other
Other Other Other Other
861-1 861-2 861-3 861-4
SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS
253 340 497 917
02858 05247 07658 14498
10000 10000 10000 10000
10000 10000 10000 10000
02858 05247 07658 14498
12500 12500 12500 12500
03573 06559 09573 18123
10000 10000 10000 10000
02858 05247 07658 14498
$2679 Misc Pediatric $4919 Misc Pediatric $7179 Misc Pediatric
$13592 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
862-1 862-2 862-3 862-4
OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE
698 1122 1357 1872
02895 05851 07866 11351
10000 10000 10000 10000
10000 10000 10000 10000
02895 05851 07866 11351
12500 12500 12500 12500
03619 07314 09833 14189
10000 10000 10000 10000
02895 05851 07866 11351
$2714 Misc Pediatric $5485 Misc Pediatric $7374 Misc Pediatric
$10642 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
863-1 863-2 863-3 863-4
NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE
853 1757 2771 4643
05959 16127 30507 61446
12500 12500 12500 12500
10000 10000 10000 10000
07449 20159 38134 76808
10000 10000 10000 10000
07449 20159 38134 76808
17500 17500 17500 17500
10428 28222 53387
107531
$5587 Neonate $15119 Neonate $28600 Neonate $57606 Neonate
Neonate Neonate Neonate Neonate
890-1 890-2 890-3 890-4
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS
167 691 921
1514
07051 10224 14771 30014
10000 10000 10000 10000
10000 10000 10000 10000
07051 10224 14771 30014
12500 12500 12500 12500
08814 12780 18464 37518
10000 10000 10000 10000
07051 10224 14771 30014
$6610 Misc Pediatric $9585 Misc Pediatric
$13848 Misc Pediatric $28138 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
892-1 892-2 892-3 892-4
HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION
587 488 669
1152
05647 07763 10877 19375
10000 10000 10000 10000
10000 10000 10000 10000
05647 07763 10877 19375
12500 12500 12500 12500
07059 09704 13596 24219
10000 10000 10000 10000
05647 07763 10877 19375
$5294 Misc Pediatric $7278 Misc Pediatric
$10197 Misc Pediatric $18164 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
893-1 893-2 893-3 893-4
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
499 496 799
1422
07762 08219 12807 24296
10000 10000 10000 10000
10000 10000 10000 10000
07762 08219 12807 24296
12500 12500 12500 12500
09703 10274 16009 30370
10000 10000 10000 10000
07762 08219 12807 24296
$7277 Misc Pediatric $7705 Misc Pediatric
$12007 Misc Pediatric $22778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
894-1 894-2 894-3 894-4
HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND
341 393 627
1121
05218 06497 09774 19428
10000 10000 10000 10000
10000 10000 10000 10000
05218 06497 09774 19428
12500 12500 12500 12500
06523 08121 12218 24285
10000 10000 10000 10000
05218 06497 09774 19428
$4892 Misc Pediatric $6091 Misc Pediatric $9163 Misc Pediatric
$18214 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
910-1 910-2 910-3 910-4
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA
1100 775
1057 1830
28786 31984 41628 72114
10000 10000 10000 10000
10000 10000 10000 10000
28786 31984 41628 72114
12500 12500 12500 12500
35983 39980 52035 90143
10000 10000 10000 10000
28786 31984 41628 72114
$26987 Misc Pediatric $29985 Misc Pediatric $39026 Misc Pediatric $67607 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
911-1 911-2 911-3 911-4
EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA
511 619 795
1687
15160 20189 26724 58039
10000 10000 10000 10000
10000 10000 10000 10000
15160 20189 26724 58039
12500 12500 12500 12500
18950 25236 33405 72549
10000 10000 10000 10000
15160 20189 26724 58039
$14213 Misc Pediatric $18927 Misc Pediatric $25054 Misc Pediatric $54412 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
912-1 912-2 912-3 912-4
MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
558 607 985
1782
20950 22759 36410 68885
10000 10000 10000 10000
10000 10000 10000 10000
20950 22759 36410 68885
12500 12500 12500 12500
26188 28449 45513 86106
10000 10000 10000 10000
20950 22759 36410 68885
$19641 Misc Pediatric $21337 Misc Pediatric $34134 Misc Pediatric $64580 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
930-1 930-2 930-3 930-4
MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE
322 370 596
1127
07826 09594 15857 33896
10000 10000 10000 10000
10000 10000 10000 10000
07826 09594 15857 33896
12500 12500 12500 12500
09783 11993 19821 42370
10000 10000 10000 10000
07826 09594 15857 33896
$7337 Misc Pediatric $8994 Misc Pediatric
$14866 Misc Pediatric $31778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
950-1 950-2 950-3 950-4
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
361 623
1166 2260
13230 20029 31827 60092
10000 10000 10000 10000
10000 10000 10000 10000
13230 20029 31827 60092
12500 12500 12500 12500
16538 25036 39784 75115
10000 10000 10000 10000
13230 20029 31827 60092
$12403 Misc Pediatric $18777 Misc Pediatric $29838 Misc Pediatric $56336 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
951-1 951-2 951-3 951-4
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
329 517
1001 1973
09755 14320 24054 46875
10000 10000 10000 10000
10000 10000 10000 10000
09755 14320 24054 46875
12500 12500 12500 12500
12194 17900 30068 58594
10000 10000 10000 10000
09755 14320 24054 46875
$9145 Misc Pediatric $13425 Misc Pediatric $22551 Misc Pediatric $43945 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
952-1 952-2 952-3 952-4
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
274 504 968
1894
07736 11591 20369 39177
10000 10000 10000 10000
10000 10000 10000 10000
07736 11591 20369 39177
12500 12500 12500 12500
09670 14489 25461 48971
10000 10000 10000 10000
07736 11591 20369 39177
$7253 Misc Pediatric $10867 Misc Pediatric $19096 Misc Pediatric $36728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
955-0 956-0
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS UNGROUPABLE
--
--
Error DRG Error DRG
Error DRG Error DRG
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i
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy adjustor F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that has at least a basic level
emergency room H FY 2015-16 Cost-to-Charge Ratio FY 2013 cost-to-charge ratio with some exceptions I FY 2015-16 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FY 2015-16 Wage Index Value (adjusted for CA Neutrality Factor 09797) W age index value times 09797 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls for changes between California
and the rest of the US while maintaining relative differences among wage areas within California K FY 2015-16 Unadjusted Statewide Base Rate The statewide DRG base rate is $6289 except that for remote rural hospitals it is $12768 L FY 2015-16 Wage Adjusted Statewide Base Rate (Non-Transition) The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses See Tab 5 This rate is applicable for non-transition hospitals as shown in Column N Medi-Cal
managed care plans that are pricing claims for emergency and post-stabilization services hospitals outside their network should use Column L for all hospitals M FY 2015-16 Hospital-Specific Transition Base Rate The base rate assigned to hospitals to move them in steps toward the statewide base rate This rate is applicable for transition hospitals as shown in Column N FY 2015-16 is the final year of transition rates N Transition rate This column identifies whether the hospital is a non-transition hospital (base rate in Column L) or a transition hospital (base rate in Column M) O FY 2015-16 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2015-16 P FY 2015-16 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by
use of Revenue Code 190 Q FY 2015-16 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by use of
Revenue Code 199
A B C D E F G H I J K L M N O P Q
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transit on Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
OUT OF STATE No No No No No 2180 10000 10000 $6289 $6289 NA Non-Transition NA $98163 $80582 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 3572 12882 12620 $12768 $15097 $15414 Transition NA $98163 $80582 106100793 ADVENTIST MEDICAL CENTER - SELMA COMMUNITY HOSPITAL No No No Yes Yes 3572 12882 12620 $12768 $15097 $14680 Transition NA $98163 $80582 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 4360 12882 12620 $12768 $15097 $10484 Transition NA $98163 $80582 106301098 AHMC ANAHEIM REG MED CTR No No No No No 1656 12882 12620 $6289 $7436 $15144 Transition NA $98163 $80582 106010846 ALAMEDA CO MED CTR Yes No No No No 4036 16962 16618 $6289 $9186 NA NA NA NA NA 106010735 ALAMEDA HOSP No Yes No No No 2600 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106190017 ALHAMBRA HOSP No No No No No 1397 12882 12620 $6289 $7436 $5446 Transition $1220 $98163 $80582 106010739 ALTA BATES SUMMIT MED CTR-ALTA BATES No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106010937 ALTA BATES SUMMIT MED CTR-HAWTHORNE No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106010844 ALTA BATES SUMMIT MED CTR-HERRICK CAMPUS No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106013626 ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106374063 ALVARADO HOSP MED CTR - REHAB No No No No No 1930 12882 12620 $6289 $7436 $4599 Transition $1220 $98163 $80582 106190034 ANTELOPE VALLEY HOSP MED CTR No Yes No No No 2997 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364231 ARROWHEAD REG MED CTR Yes No No No No 3324 12882 12620 $6289 $7436 NA NA NA NA NA 106400466 ARROYO GRANDE COMM HOSP No No No No No 2581 12964 12701 $6289 $7471 NA Non-Transition $1226 $98163 $80582 106154101 BAKERSFIELD HEART HOSP No No No No No 1782 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150722 BAKERSFIELD MEM HOSP-34TH ST No No No No No 2117 12882 12620 $6289 $7436 $9141 Transition NA $98163 $80582 106364121 BALLARD REHABILITATION HOSP No No No No No 8300 12882 12620 NA NA NA NA $1427 $98163 $80582 106184008 BANNER LASSEN MED CTR No No No Yes Yes 3967 12882 12620 $12768 $15097 $18668 Transition NA $98163 $80582 106190052 BARLOW RESP HOSP No No No No No 1849 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364430 BARSTOW COMM HOSP No No No Yes Yes 2262 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090793 BARTON MEM HOSP No No No Yes Yes 3635 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106361110 BEAR VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190081 BEVERLY HOSP No No No No No 3567 12882 12620 $6289 $7436 $5841 Transition NA $98163 $80582 106040802 BIGGS GRIDLEY MEM HOSP No No No Yes Yes 3652 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106380929 CA PACIFIC MED CTR No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380777 CA PACIFIC MED CTR - CALIFORNIA WEST No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380933 CA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 2873 16738 16398 $6289 $9090 NA Non-Transition $1492 $98163 $80582 106190125 CALIFORNIA HOSP MED CTR-LA No No Yes No No 2078 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190137 CASA COLINA HOSP FOR REHAB MED No No No No No 7213 12882 12620 NA NA NA NA $1220 $98163 $80582 106190045 CATALINA ISLAND MED CTR No No No Yes Yes 9000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190555 CEDARS-SINAI MED CTR No No Yes No No 2051 12882 12620 $6289 $7436 $5837 Transition $1220 $98163 $80582 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 1730 12882 12620 $6289 $7436 $6350 Transition $1220 $98163 $80582 106160787 CENTRAL VALLEY GEN HOSP No No No No No 7778 12882 12620 $6289 $7436 $11888 Transition NA $98163 $80582 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 2190 12892 12630 $6289 $7440 NA Non-Transition $1221 $98163 $80582 106301140 CHAPMAN MED CTR No No No No No 1908 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304113 CHILDRENS HOSP AT MISSION No No No No No 3300 12882 12620 $6289 $7436 $18777 Transition NA $98163 $80582 106204019 CHILDRENS HOSP CENTRAL CALIFORNIA No No Yes No No 2430 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106010776 CHILDRENS HOSP OAKLAND No No Yes No No 3356 16478 16143 $6289 $8978 NA Non-Transition $2628 $98163 $80582 106190170 CHILDRENS HOSP OF LA No No Yes No No 3988 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106300032 CHILDRENS HOSP OF ORANGE CO No No Yes No No 2442 12882 12620 $6289 $7436 $5613 Transition NA $98163 $80582 106382715 CHINESE HOSP No No No No No 3835 16738 16398 $6289 $9090 $8053 Transition NA $98163 $80582 106361144 CHINO VALLEY MED CTR No No No No No 2098 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190176 CITY OF HOPE HELFORD CLINIC RES HOSP No No No No No 2789 12882 12620 $6289 $7436 $5941 Transition NA $98163 $80582 106100005 CLOVIS COMM MED CTR No No No No No 3336 12882 12620 $6289 $7436 $7752 Transition NA $98163 $80582 106100697 COALINGA REG MED CTR No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190766 COAST PLAZA DRS HOSP No No No No No 2126 12882 12620 $6289 $7436 $5303 Transition NA $98163 $80582 106301258 COASTAL COMM HOSP No No No No No 2792 12882 12620 $6289 $7436 $7035 Transition NA $98163 $80496 106301155 COLLEGE HOSP COSTA MESA No No No No No 2876 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190587 COLLEGE MEDICAL CENTER No No No No No 3760 12882 12620 $6289 $7436 $4258 Transition NA $98163 $80582 106361458 COLORADO RIVER MED CTR No No No Yes Yes 4357 12882 12620 $12768 $15097 $18541 Transition NA $98163 $80582 106060870 COLUSA REG MED CTR No No No Yes Yes 3066 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190197 COMM AND MISSION HOSP OF HUNT PK No No No No No 1601 12882 12620 $6289 $7436 $5421 Transition NA $98163 $80582 106190475 COMM HOSP OF LONG BEACH No No No No No 1707 12882 12620 $6289 $7436 $15917 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106361323 COMM HOSP OF SAN BERNARDINO No No No No No 2833 12882 12620 $6289 $7436 $6516 Transition NA $98163 $78406 106560473 COMM MEM HOSP OF SAN BUENAVENTURA No No No No No 2104 12882 12620 $6289 $7436 $4512 Transition NA $98163 $80582 106100717 COMM REG MED CTR-FRESNO No No No No No 1896 12882 12620 $6289 $7436 $7994 Transition $1655 $98163 $80582 106070924 CONTRA COSTA REG MED CTR Yes No No No No 6010 16478 16143 $6289 $8978 NA NA NA NA NA 106331152 CORONA REG MED CTR No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition NA $98163 $80582 106331145 CORONA REG MED CTR - MAGNOLIA No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition $1220 $98163 $80582 106190413 CV-INTERCOMMUNITY CAMPUS No No No No No 3136 12882 12620 $6289 $7436 $6821 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106190636 CV-QUEEN OF VALLEY CAMPUS No No Yes No No 3136 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106150706 DELANO REG MED CTR No No No No No 3622 12882 12620 $6289 $7436 $7087 Transition NA $98163 $80582 106331164 DESERT REG MED CTR No No No No No 1486 12882 12620 $6289 $7436 $7153 Transition $1447 $98163 $80582 106364144 DESERT VALLEY HOSP No No No No No 2050 12882 12620 $6289 $7436 $8173 Transition NA $98163 $80582 106440755 DOMINICAN HOSP-SANTA CRUZ No No No No No 2016 17239 16889 $6289 $9304 $7821 Transition $1527 $98163 $80582 106190243 DOWNEY REG MED CTR No No No No No 1732 12882 12620 $6289 $7436 $6847 Transition NA $98163 $80582 106392287 DRS HOSP OF MANTECA No No No No No 1362 13579 13303 $6289 $7735 $11712 Transition NA $98163 $80582 106390846 DAMERON HOSP No No No No No 2138 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106190857 DRS HOSP OF WEST COVINA No No No No No 1833 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106070904 DRS MED CTR-SAN PABLOPINOLE No Yes No No No 2373 16478 16143 $6289 $8978 $6025 Transition NA $98163 $80582 106190256 EAST LA DRS HOSP No No No No No 1952 12882 12620 $6289 $7436 $5809 Transition NA $98163 $80582 106190328 EAST VALLEY HOSP MED CTR No No No No No 2859 12882 12620 $6289 $7436 $5534 Transition NA $98163 $80582 106320859 EASTERN PLUMAS HOSP No Yes No Yes Yes 4802 12882 12620 $12768 $15097 $13674 Transition NA $98163 $80582 106014233 EDEN MED CTR No No No No No 3197 16962 16618 $6289 $9186 $12768 Transition NA $98163 $80582 106331168 EISENHOWER MEM HOSP No No No No No 1540 12882 12620 $6289 $7436 $10211 Transition NA $98163 $80582 106430763 EL CAMINO HOSP No Yes No No No 2857 17180 16831 $6289 $9279 $5377 Transition $1523 $98163 $80582 106130699 EL CENTRO COMM HOSP No Yes No No No 2298 12882 12620 $6289 $7436 $8949 Transition NA $98163 $80582 106500852 DRS MED CTR No No No No No 1181 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106500867 EMANUEL MED CTR No No No No No 2046 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106040962 ENLOE MED CTR No No No No No 2436 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106044011 ENLOE REHABILLITATION CENTER No No No No No 2463 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106474007 FAIRCHILD MED CTR No No No Yes Yes 3914 12882 12620 $12768 $15097 $16385 Transition NA $98163 $80582 106040875 FEATHER RIVER HOSP No No No No No 1240 12882 12620 $6289 $7436 $10796 Transition NA $98163 $80582 106190298 FOOTHILL PRES HOSP No No No No No 2989 12882 12620 $6289 $7436 $4740 Transition NA $98163 $80582 106301175 FOUNTAIN VALLEY REG HOSP-EUCLID No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106304039 FOUNTAIN VALLEY REG HOSP-WARNER No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106230949 FRANK R HOWARD MEM HOSP No No No Yes Yes 3495 12882 12620 $12768 $15097 $15377 Transition NA $98163 $80582 106510882 FREMONT MEDICAL CENTER No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106190280 ENCINO HOSP MED CTR No No No No No 949 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106400480 FRENCH HOSP MED CTR No No No No No 2241 12964 12701 $6289 $7471 NA Non-Transition NA $98163 $80582 106301283 GARDEN GROVE HOSP AND MED CTR No No No No No 2661 12882 12620 $6289 $7436 $5749 Transition NA $98163 $80582 106190159 GARDEN REG HOSP AND MED CTR No No No No No 2937 12882 12620 $6289 $7436 $4110 Transition NA $98163 $80582 106105029 FRESNO HEART HOSP No No No No No 3403 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106270777 GEORGE L MEE MEM HOSP No No No Yes Yes 3562 15558 15242 $12768 $17426 $20386 Transition NA $98163 $80582 106190315 GARFIELD MED CTR No No No No No 1031 12882 12620 $6289 $7436 NA Non-Transition $1394 $98163 $80582 106190522 GLENDALE MEM HOSP AND HLTH CTR No No No No No 2163 12882 12620 $6289 $7436 $6885 Transition $1220 $98163 $80582 106110889 GLENN MED CTR No No No Yes Yes 6660 12882 12620 $12768 $15097 $21024 Transition NA $98163 $80582 106190323 GLENDALE ADV MED CTR-WILSON TERRACE No No No No No 1845 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420483 GOLETA VALLEY COTTAGE HOSP No No No No No 3083 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150775 GOOD SAMARITAN HOSP-BAKERSFIELD No No No No No 3694 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430779 GOOD SAMARITAN HOSP-SAN JOSE No No Yes No No 1937 17180 16831 $6289 $9279 $5654 Transition NA $98163 $80582 106190352 GREATER EL MONTE COMM HOSP No No No No No 1088 12882 12620 $6289 $7436 $4818 Transition NA $98163 $80582 106370714 GROSSMONT HOSP No No No No No 1937 12882 12620 $6289 $7436 $6498 Transition $1220 $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190392 GOOD SAMARITAN HOSP-LA No No Yes No No 2006 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106350784 HAZEL HAWKINS MEM HOSP No Yes No Yes Yes 3840 17180 16831 $12768 $18839 NA Non-Transition NA $98163 $80582 106490964 HEALDSBURG DIST HOSP No Yes No Yes Yes 6549 16188 15859 $12768 $17975 NA Non-Transition NA $98163 $80582 106154022 HEALTHSOUTH BAKERSFIELD REHAB HOSP No No No No No 5040 12882 12620 NA NA NA NA $1382 $98163 $80582 106304079 HEALTHSOUTH TUSTIN REHAB HOSP No No No No No 5281 12882 12620 NA NA NA NA $1220 $98163 $80582 106331194 HEMET VALLEY MED CTR No No No No No 1267 12882 12620 $6289 $7436 $5912 Transition NA $98163 $80582 106190949 HENRY MAYO NEWHALL MEM HOSP No No No No No 1839 12882 12620 $6289 $7436 $5631 Transition $1220 $98163 $80582 106362041 HI-DESERT MED CTR No Yes No Yes Yes 2909 12882 12620 $12768 $15097 $13297 Transition NA $98163 $80582 106301205 HOAG MEM HOSP PRESBYTERIAN No No No No No 4825 12882 12620 $6289 $7436 $13525 Transition NA $98163 $80582 106304159 HEALTHBRIDGE CHILDRENS HOSP-ORANGE No No No No No 3271 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106190380 HOLLYWOOD COMM HOSP OF HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106304460 HOAG ORTHOPEDIC No No No No No 4894 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190382 HOLLYWOOD PRES MED CTR No No No No No 2212 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301209 HUNTINGTON BEACH HOSP No No No No No 2175 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190400 HUNTINGTON MEM HOSP No No Yes No No 2294 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106304045 IRVINE REG HOSP AND MED CTR No No No No No 200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106220733 JOHN C FREMONT HCARE DIST No Yes No Yes Yes 3884 12882 12620 $12768 $15097 $8195 Transition NA $98163 $80582 106331216 JOHN F KENNEDY MEM HOSP No No No No No 1679 12882 12620 $6289 $7436 $6464 Transition NA $98163 $80582 106071018 JOHN MUIR MED CTR-CONCORD CAMPUS No No No No No 1748 16478 16143 $6289 $8978 $12804 Transition NA $98163 $80582 106070988 JOHN MUIR MED CTR-WALNUT CREEK CAMPUS No No No No No 2039 16478 16143 $6289 $8978 $10615 Transition $1473 $98163 $80582 106314024 KAISER HOSPITAL - ROSEVILLE No No Yes No No 7912 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106364265 KAISER ONTARIO MEDICAL CENTER CAMPUS No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106121031 JEROLD PHELPS COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301132 KAISER-ANAHEIM No No Yes No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304306 KAISER-ANAHEIM-IRVINE No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304409 KAISER-ANAHEIM-Orange No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106074097 KAISER-ANTIOCH No No No No No 8503 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106196403 KAISER-DOWNEY No No No No No 10000 12882 12620 $6289 $7436 $12698 Transition NA $98163 $80582 106361223 KAISER-FONTANA No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106014132 KAISER-FREMONT No No No No No 10000 16962 16618 $6289 $9186 $9639 Transition NA $98163 $80582 106196035 KAISER-BALDWIN PARK No No No No No 8009 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106104062 KAISER-FRESNO No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190429 KAISER-LOS ANGELES No No No No No 7387 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106394009 KAISER-MANTECA No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106334048 KAISER-MORENO VALLEY No No No No No 6614 12882 12620 $6289 $7436 $4790 Transition NA $98163 $80582 106010856 KAISER-OAKLANDRICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106190432 KAISER-PANORAMA CITY No No No No No 8239 12882 12620 $6289 $7436 $16025 Transition NA $98163 $80582 106504042 KAISER-MODESTO No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106410804 KAISER-REDWOOD CITY No No No No No 7731 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106074093 KAISER-RICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106480989 KAISER-REHAB CENTER VALLEJO No No No No No 8442 16315 15984 $6289 $8908 NA Non-Transition $2535 $98163 $80582 106340913 KAISER-SACRAMENTO No No No No No 5612 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106334025 KAISER-RIVERSIDE No No No No No 5865 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370730 KAISER-SAN DIEGO No No No No No 7393 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106380857 KAISER-SAN FRANCISCO No No No No No 5960 16738 16398 $6289 $9090 NA Non-Transition NA $98163 $80582 106431506 KAISER-SAN JOSE No No No No No 7002 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106014337 KAISER-SAN LEANDRO No No No No No 2180 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106210992 KAISER-SAN RAFAEL No No No No No 4673 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106494019 KAISER-SANTA ROSA No No No No No 10000 16315 15984 $6289 $8908 $17627 Transition NA $98163 $80582 106434153 KAISER-SANTA CLARA No No No No No 6107 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106190431 KAISER-SOUTH BAY No No No No No 6935 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106342344 KAISER-SOUTH SACRAMENTO No No No No No 5670 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106410806 KAISER-SOUTH SF No No No No No 6503 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106484044 KAISER-VACAVILLE No No No No No 10000 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106070990 KAISER-WALNUT CREEK No No No No No 5680 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106190434 KAISER-WEST LA No No No No No 6623 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106194219 KECK HOSPITAL OF USC No No No No No 2004 12882 12620 $6289 $7436 $4699 Transition $1220 $98163 $80582 106210993 KENTFIELD REHAB HOSP No No No No No 5967 16855 16513 $6289 $9140 $19338 Transition $1500 $98163 $80582 106150736 KERN MED CTR Yes No No No No 3943 12882 12620 $6289 $7436 NA NA NA NA NA 106150737 KERN VALLEY HEALTHCARE DIST No Yes No Yes Yes 2786 12882 12620 $12768 $15097 $8298 Transition NA $98163 $80582 106191450 KAISER-WOODLAND HILLS No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190049 KINDRED HOSPITAL BALDWIN PARK No No No No No 1810 12882 12620 $6289 $7436 $10784 Transition NA $98163 $80582 106190305 KINDRED LA No No No No No 2044 12882 12620 $6289 $7436 $4255 Transition NA $98163 $80582 106301127 KINDRED BREA No No No No No 2852 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361274 KINDRED ONTARIO No No No No No 2068 12882 12620 $6289 $7436 $9314 Transition NA $98163 $80582 106364188 KINDRED RANCHO No No No No No 1980 12882 12620 $6289 $7436 $20628 Transition NA $98163 $80582 106332172 KINDRED RIVERSIDE No No No No No 1805 12882 12620 $6289 $7436 $24450 Transition NA $98163 $80582 106190449 KINDRED LA MIRADA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106370721 KINDRED SAN DIEGO No No No No No 3605 12882 12620 $6289 $7436 $5657 Transition NA $98163 $80582 106344035 KINDRED SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190458 KINDRED SAN GABRIEL VALLEY No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106010887 KINDRED SF BAY AREA No No No No No 3007 16478 16143 $6289 $8978 $6378 Transition NA $98163 $80582 106301167 KINDRED SANTA ANA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190196 KINDRED SOUTH BAY No No No No No 2144 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301380 KINDRED WESTMINSTER No No No No No 2286 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301234 LA PALMA INTERCOMMUNITY HOSP No No No No No 2290 12882 12620 $6289 $7436 $7160 Transition NA $98163 $80582 106191227 LAC-HARBOR-UCLA MED CTR Yes No Yes No No 3366 12882 12620 $6289 $7436 NA NA NA NA NA 106191231 LAC-OLIVE VIEW-UCLA MED CTR Yes No No No No 4136 12882 12620 $6289 $7436 NA NA NA NA NA 106191228 LAC-USC MED CTR Yes No Yes No No 4522 12882 12620 $6289 $7436 NA NA NA NA NA 106380865 LAGUNA HONDA HOSP AND REHAB CTR Yes No No No No 5843 16738 16398 $6289 $9090 NA NA NA NA NA 106190240 LAKEWOOD REG MED CTR No No No No No 1504 12882 12620 $6289 $7436 $4008 Transition $1220 $98163 $80582 106390923 LODI MEM HOSP No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106390922 LODI MEM HOSP - WEST No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106334589 LOMA LINDA MURRIETTA No No No No No 3222 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106364268 LOMA LINDA UNIV HEART AND SURGICAL HOSPITAL No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361245 LOMA LINDA UNIV MED CTR - EAST CAMPUS No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361246 LOMA LINDA UNIV MED CTR No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $1491 $98163 $80582 106364502 LOMA LINDA UNIV CHILDRENS HOSP No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $2177 $98163 $80582 106190198 LA COMM HOSP No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420491 LOMPOC VALLEY MED CTR No Yes No Yes Yes 8693 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301248 LOS ALAMITOS MED CTR No No No No No 1915 12882 12620 $6289 $7436 $4697 Transition NA $98163 $80582 106560492 LOS ROBLES HOSP AND MED CTR No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106564018 LOS ROBLES HOSP AND MED CTR-EAST CAMPUS No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106434040 LSP CHILDRENS HOSP AT STANFORD No No Yes No No 2035 17180 16831 $6289 $9279 $6102 Transition NA $98163 $80582 106121002 MAD RIVER COMM HOSP No No No No No 4250 12882 12620 $6289 $7436 $9505 Transition NA $98163 $80582 106201281 MADERA COMMUNITY HOSPITAL No No No No No 5100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106260011 MAMMOTH HOSP No Yes No Yes Yes 7982 12882 12620 $12768 $15097 $46994 Transition NA $98163 $80582 106420493 MARIAN MED CTR No No No No No 2741 12882 12620 $6289 $7436 $9386 Transition NA $98163 $80582 106190525 LONG BEACH MEM MED CTR No No No No No 1996 12882 12620 $6289 $7436 NA Non-Transition $1627 $98163 $80582 106211006 MARIN GEN HOSP No Yes No No No 2571 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106190500 MARINA DEL RAY HOSPITAL No No No No No 2034 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106050932 MARK TWAIN ST JOSEPHS HOSP No No No Yes Yes 3707 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090933 MARSHALL MED CTR No No No Yes Yes 2107 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106500939 MEM HOSP MED CTR-MODESTO No No No No No 2235 12892 12630 $6289 $7440 $5898 Transition NA $98163 $80582 106240924 MEMORIAL HOSP LOS BANOS No No No Yes Yes 3362 12882 12620 $12768 $15097 $17450 Transition NA $98163 $80582 106190521 MEMORIAL HOSP OF GARDENA No No No No No 1747 12882 12620 $6289 $7436 $4611 Transition NA $98163 $80582 106231013 MENDOCINO COAST DIST HOSP No Yes No Yes Yes 5070 12882 12620 $12768 $15097 $15935 Transition NA $98163 $80582 106334018 MENIFEE VALLEY MED CTR No No No No No 1458 12882 12620 $6289 $7436 $5113 Transition NA $98163 $80582 106450936 MAYERS MEM HOSP No Yes No Yes Yes 7192 14188 13900 $12768 $16234 NA Non-Transition NA $98163 $80582 106340947 MERCY GEN HOSP No No No No No 2185 15256 14946 $6289 $8454 $6027 Transition $1387 $98163 $80582 106344029 MERCY HOSP OF FOLSOM No No No No No 2746 15256 14946 $6289 $8454 $5260 Transition NA $98163 $80582 106150761 MERCY HOSP-BAKERSFIELD No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106414018 MENLO PARK SURGICAL HOSP No No No No No 2770 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106240942 MERCY MED CTR MERCED No No No No No 2289 13279 13009 $6289 $7606 NA Non-Transition NA $98163 $80582 106450949 MERCY MED CTR-REDDING No No No No No 2589 14188 13900 $6289 $7996 $10219 Transition NA $98163 $80582 106470871 MERCY MED CTR-MT SHASTA No No No Yes Yes 6242 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106340950 MERCY SAN JUAN HOSP No No No No No 2166 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190529 METHODIST HOSP OF SO CAL No No No No No 1842 12882 12620 $6289 $7436 $6690 Transition $1220 $98163 $80582 106196168 MILLER CHILDRENS HOSP No No Yes No No 2680 12882 12620 $6289 $7436 $8155 Transition NA $98163 $80582 106410742 MILLS HEALTH CENTER No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106410852 MILLS-PENINSULA No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106340951 METHODIST HOSP OF SACRAMENTO No No No No No 2028 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190524 MISSION COMM HOSP-PANORAMA CAMPUS No No No No No 3568 12882 12620 $6289 $7436 $3982 Transition NA $98163 $80582 106190681 MIRACLE MILE No No No No No 100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301262 MISSION HOSP REG MED CTR No No No No No 4091 12882 12620 $6289 $7436 $14336 Transition $1220 $98163 $80582 106250956 MODOC MED CTR No Yes No Yes Yes 4961 12882 12620 $12768 $15097 $13486 Transition NA $98163 $80582 106301337 MISSION HOSP LAGUNA BEACH No No No No No 4091 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106361166 MONTCLAIR HOSP MED CTR No No No No No 3149 12882 12620 $6289 $7436 $5904 Transition NA $98163 $80582 106190547 MONTEREY PARK HOSP No No No No No 1034 12882 12620 $6289 $7436 $5866 Transition NA $98163 $80582 106361266 MOUNTAINS COMM HOSP No Yes No Yes Yes 5148 12882 12620 $12768 $15097 $15642 Transition NA $98163 $80582 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106481357 NORTH BAY MEDICAL CENTER No No No No No 1972 16315 15984 $6289 $8908 $15945 Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190541 MONROVIA MEM HOSP No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106141273 NORTHERN INYO HOSP No Yes No Yes Yes 8150 12882 12620 $12768 $15097 $27752 Transition NA $98163 $80582 106484001 NORTH BAY VACAVALLEY HOSP No No No No No 1972 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106190568 NORTHRIDGE HOSP MED CTR No No No No No 1596 12882 12620 $6289 $7436 NA Non-Transition $1662 $98163 $80582 106214034 NOVATO COMM HOSP No No No No No 3465 16855 16513 $6289 $9140 $6359 Transition NA $98163 $80582 106500967 OAK VALLEY DIST HOSP No Yes No Yes No 3340 12892 12630 $6289 $7440 $5201 Transition NA $98163 $80582 106430837 OCONNOR HOSP-SAN JOSE No No No No No 2409 17180 16831 $6289 $9279 $5201 Transition NA $98163 $80582 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190534 OLYMPIA MED CTR No No No No No 1260 12882 12620 $6289 $7436 $6786 Transition NA $98163 $80582 106300225 ORANGE COAST MEM MED CTR No No No No No 2293 12882 12620 $6289 $7436 $19985 Transition NA $98163 $80582 106040937 OROVILLE HOSP No No No No No 1803 12882 12620 $6289 $7436 $6229 Transition NA $98163 $80582 106560501 OJAI VALLEY COMM HOSP No No No Yes Yes 2745 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190696 PACIFICA HOSP OF THE VALLEY No No No No No 3338 12882 12620 $6289 $7436 $5616 Transition NA $98163 $80582 106491338 PALM DRIVE HOSP No Yes No Yes No 4315 16315 15984 $6289 $8908 $11457 Transition NA $98163 $80582 106196405 PALMDALE REGIONAL MEDICAL CTR No No No No No 1190 12882 12620 $6289 $7436 $7504 Transition $1220 $98163 $80582 106331288 PALO VERDE HOSP No Yes No Yes Yes 4770 12882 12620 $12768 $15097 $18188 Transition NA $98163 $80582 106370755 PALOMAR MED CTR No Yes No No No 2429 12882 12620 $6289 $7436 $7051 Transition $1220 $98163 $80582 106370759 PARADISE VALLEY HOSP No No No No No 2188 12882 12620 $6289 $7436 $4275 Transition $1220 $98163 $80582 106190307 PACIFIC ALLIANCE MED CTR No No No No No 4299 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106331293 PARKVIEW COMM HOSP MED CTR No No No No No 2757 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106491001 PETALUMA VALLEY HOSP No No No No No 2271 16315 15984 $6289 $8908 $13491 Transition NA $98163 $80582 106130760 PIONEERS MEM HOSP No Yes No Yes No 2989 12882 12620 $6289 $7436 $9825 Transition NA $98163 $80582 106454013 PATIENTS HOSP OF REDDING No No No No No 2172 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106301297 PLACENTIA LINDA HOSP No No No No No 1606 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370977 POMERADO HOSP No Yes No No No 3063 12882 12620 $6289 $7436 $6818 Transition NA $98163 $80582 106320986 PLUMAS DIST HOSP No Yes No Yes Yes 8666 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190631 PRESBYTERIAN INTERCOMM HOSP No No No No No 961 12882 12620 $6289 $7436 $9720 Transition $1220 $98163 $80582 106190630 POMONA VALLEY HOSP MED CTR No No Yes No No 1538 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190468 PROMISE HOSP OF EAST LA-EAST LA No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190599 PROMISE HOSP OF EAST LA-EAST LA-SUBURBAN CAMPUS No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190385 PROVIDENCE HOLY CROSS MED CTR No No No No No 1325 12882 12620 $6289 $7436 $6284 Transition $1220 $98163 $80582 106190680 PROVIDENCE LITTLE CO OF MARY-SAN PEDRO No No No No No 1533 12882 12620 $6289 $7436 $6225 Transition $1220 $98163 $80582 106190470 PROVIDENCE LITTLE CO OF MARY-TORRANCE No No No No No 1767 12882 12620 $6289 $7436 $7182 Transition NA $98163 $80582 106190758 PROVIDENCE ST JOSEPH MED CTR No No No No No 1866 12882 12620 $6289 $7436 $7141 Transition $1220 $98163 $80582 106370787 PROMISE HOSP OF SAN DIEGO No No No No No 3660 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106281047 QUEEN OF THE VALLEY HOSP-NAPA No No No No No 2829 16188 15859 $6289 $8854 $17592 Transition $1453 $98163 $80582 106370673 RADY CHILDRENS HOSPITAL - SAN DIEGO No No Yes No No 2854 12882 12620 $6289 $7436 $6395 Transition $2177 $98163 $80582 106190517 PROVIDENCE TARZANA MED CTR No No Yes No No 1536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361308 REDLANDS COMM HOSP No No No No No 2079 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430705 REG MED CTR OF SAN JOSE No No No No No 2529 17180 16831 $6289 $9279 $13299 Transition NA $98163 $80582 106580996 RIDEOUT MEM HOSP No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106121051 REDWOOD MEM HOSP No No No Yes Yes 3214 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106334487 RIVERSIDE CO REG MED CTR Yes No No No No 2987 12882 12620 $6289 $7436 NA NA NA NA NA 106331312 RIVERSIDE COMM HOSP No No No No No 1560 12882 12620 $6289 $7436 $5990 Transition NA $98163 $80582 106190796 RONALD REAGAN UCLA MED CTR Yes No Yes No No 3382 12882 12620 $6289 $7436 NA NA NA NA NA 106301317 SADDLEBACK MEM MED CTR No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106301325 SADDLEBACK MEM MED CTR-SAN CLEMENTE No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106150782 RIDGECREST REG HOSP No No No Yes Yes 4178 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106361318 SAN ANTONIO COMM HOSP No No No No No 2262 12882 12620 $6289 $7436 $9216 Transition NA $98163 $80582 106190673 SAN DIMAS COMM HOSP No No No No No 2465 12882 12620 $6289 $7436 $12177 Transition NA $98163 $80582 106190200 SAN GABRIEL VALLEY MED CTR No No No No No 969 12882 12620 $6289 $7436 $6918 Transition NA $98163 $80582 106270875 SALINAS VALLEY MEM HOSP No Yes No No No 3534 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106331326 SAN GORGONIO MEM HOSP No Yes No Yes Yes 3394 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391010 SAN JOAQUIN GEN HOSP Yes No No No No 1922 13579 13303 $6289 $7735 NA NA NA NA NA 106104023 SAN JOAQUIN VALLEY REHAB HOSP No No No No No 6479 12882 12620 NA NA NA NA $1413 $98163 $80582 106013619 SAN LEANDRO HOSP No Yes No No No 3482 16501 16166 $6289 $8988 $10813 Transition NA $98163 $80582 106410782 SAN MATEO MED CTR Yes No No No No 7168 16928 16584 $6289 $9171 NA NA NA NA NA 106074017 SAN RAMON REG MED CTR No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106074011 SAN RAMON REG MED CTR SOUTH BUILDING No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106420514 SANTA BARBARA COTTAGE HOSP No No Yes No No 3902 12882 12620 $6289 $7436 $10978 Transition $2125 $98163 $80582 106430883 SANTA CLARA VALLEY MED CTR Yes No Yes No No 3133 17180 16831 $6289 $9279 NA NA NA NA NA 106190687 SANTA MONICA - UCLA MEDICAL CENTER Yes No No No No 3102 12882 12620 $6289 $7436 NA NA NA NA NA 106491064 SANTA ROSA MEM HOSP-MONTGOMERY No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106490907 SANTA ROSA MEM HOSP-SOTOYOME No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106150788 SAN JOAQUIN COMM HOSP No No No No No 2544 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420522 SANTA YNEZ VALLEY COTTAGE HOSP No No No Yes Yes 7569 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106371394 SCRIPPS MEM HOSP-ENCINITAS No No No No No 2403 12882 12620 $6289 $7436 $7037 Transition $1439 $98163 $80582 106370771 SCRIPPS MEM HOSP-LA JOLLA No No No No No 2061 12882 12620 $6289 $7436 $4390 Transition NA $98163 $80582 106370744 SCRIPPS MERCY HOSP No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106370658 SCRIPPS MERCY HOSP-CHULA VISTA No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106371256 SCRIPPS GREEN HOSP No No No No No 2317 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106321016 SENECA HCARE DIST No Yes No Yes Yes 4586 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106410817 SETON MED CTR No No No No No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106410828 SETON MED CTR-COASTSIDE No No No Yes No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106380939 SF GENERAL HOSP Yes No No No No 2851 16738 16398 $6289 $9090 NA NA NA NA NA 106370875 SHARP CHULA VISTA MED CTR No No No No No 1932 12882 12620 $6289 $7436 $6485 Transition NA $98163 $80582 106410891 SEQUOIA HOSP No No No No No 1975 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106370689 SHARP CORONADO HOSP AND HCARE CTR No No No No No 2160 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $72421 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106370694 SHARP MEM HOSP No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106450940 SHASTA REG MED CTR No No No No No 1582 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106190708 SHERMAN OAKS HOSP No No No No No 1516 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190712 SHRINERS HOSPITAL- LA No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106344114 SHRINERS HOSPITAL- SACRAMENTO No No No No No 3869 15256 14946 $6289 $8454 NA Non-Transition $2475 $98163 $80582 106540798 SIERRA VIEW DIST HOSP No Yes No No No 2716 12882 12620 $6289 $7436 $8497 Transition NA $98163 $77682 106400524 SIERRA VIST REG MED CTR No No No No No 1787 12964 12701 $6289 $7471 $5495 Transition NA $98163 $80582 106190661 SILVER LAKE MED CTR No No No No No 3692 12882 12620 $6289 $7436 $5655 Transition NA $98163 $80582 106291023 SIERRA NEVADA MEM HOSP No No No Yes Yes 3427 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106491076 SONOMA VALLEY HOSP No Yes No No No 4960 16315 15984 $6289 $8908 $12733 Transition NA $98163 $80582 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 2126 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190380 SOUTHERN CA HOSP AT HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106190110 SOUTHERN CA HOSPITAL AT CULVER CITY No No No No No 1437 12882 12620 $6289 $7436 $4694 Transition $1220 $98163 $80582 106560525 SIMI VALLEY HOSP AND HCARE-SYCAMORE No No No No No 3840 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106334068 SOUTHWEST HCARE SYSTEM No No No No No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106334001 SOUTHWEST HCARE SYSTEM-WILDOMAR No No No Yes No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106100899 ST AGNES MED CTR No No No No No 3088 12882 12620 $6289 $7436 $7885 Transition NA $98163 $80582 106361339 ST BERNARDINE MED CTR No No No No No 2171 12882 12620 $6289 $7436 $6090 Transition NA $98163 $80582 106521041 ST ELIZABETH COMM HOSP No No No Yes Yes 3024 13869 13587 $12768 $15956 $14866 Transition NA $98163 $80582 106190754 ST FRANCIS MED CTR No No No No No 4350 12882 12620 $6289 $7436 $6368 Transition NA $98163 $80582 106380960 ST FRANCIS MEM HOSP No No No No No 1920 16738 16398 $6289 $9090 $5310 Transition $1492 $98163 $80582 106281078 ST HELENA HOSP No No No No No 2337 15887 15564 $6289 $8725 $9671 Transition NA $98163 $80582 106171049 ST HELENA HOSPITAL-CLEARLAKE No No No Yes Yes 4118 12882 12620 $12768 $15097 $18218 Transition NA $98163 $80582 106141338 SOUTHERN INYO HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190756 ST JOHNS HEALTH CTR No No No No No 2536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560529 ST JOHNS REG MED CTR No No No No No 2982 12882 12620 $6289 $7436 $6976 Transition $1761 $98163 $80582 106121080 ST JOSEPH HOSP-EUREKA No No No No No 2570 13869 13587 $6289 $7859 $9661 Transition $1507 $98163 $80582 106301340 ST JOSEPH HOSP-ORANGE No No No No No 2751 12882 12620 $6289 $7436 $5230 Transition NA $98163 $80582 106560508 ST JOHNS PLEASANT VALLEY HOSP No No No No No 2087 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301342 ST JUDE MED CTR No No No No No 1722 12882 12620 $6289 $7436 $5799 Transition $1220 $98163 $80582 106434138 ST LOUISE REG HOSP No No No No No 2838 17180 16831 $6289 $9279 $16407 Transition NA $98163 $80582 106380964 ST LUKES HOSP No No No No No 3807 16738 16398 $6289 $9090 $8600 Transition NA $98163 $80582 106361343 ST MARY MED CTR-APPLE VALLEY No No No Yes No 2511 12882 12620 $6289 $7436 $9863 Transition NA $98163 $80582 106391042 ST JOSEPHS MED CTR OF STOCKTON No No No No No 2152 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106380965 ST MARYS MED CTR-SF No No No No No 2007 16738 16398 $6289 $9090 $5116 Transition $1492 $98163 $80582 106010967 ST ROSE HOSP No No No No No 1931 16962 16618 $6289 $9186 $7600 Transition NA $98163 $80582 106190762 ST VINCENT MED CTR No No No No No 2020 12882 12620 $6289 $7436 $4684 Transition $1220 $98163 $80582 106430905 STANFORD HOSP No No No No No 1803 17180 16831 $6289 $9279 $5644 Transition $1523 $98163 $80582 106190053 ST MARY MED CTR-LONG BEACH No No No No No 2479 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106504038 STANISLAUS SURGICAL HOSP No No No No No 9000 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106250955 SURPRISE VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106310791 SUTTER AUBURN FAITH HOSP No No No No No 2551 15256 14946 $6289 $8454 $11882 Transition NA $98163 $80582 106034002 SUTTER AMADOR HOSP No No No Yes Yes 2971 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106574010 SUTTER DAVIS HOSP No No No No No 3568 15256 14946 $6289 $8454 $14330 Transition NA $98163 $80582 106070934 SUTTER DELTA MED CTR No No No No No 2907 16478 16143 $6289 $8978 $12158 Transition NA $98163 $80582 106341051 SUTTER GEN HOSP No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106171395 SUTTER LAKESIDE HOSP No No No Yes Yes 3691 12882 12620 $12768 $15097 $17232 Transition NA $98163 $80582 106444012 SUTTER MATERNITY AND SRG CTR OF S CRUZ No No No No No 7213 17239 16889 $6289 $9304 $21288 Transition NA $98163 $80582 106490919 SUTTER MED CTR OF SANTA ROSA No No No No No 3657 16315 15984 $6289 $8908 $15278 Transition NA $98163 $80582 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106311000 SUTTER ROSEVILLE MED CTR No No No No No 2377 15256 14946 $6289 $8454 $11395 Transition $1387 $98163 $80582 106481094 SUTTER SOLANO MED CTR No No No No No 3258 16315 15984 $6289 $8908 $18010 Transition NA $98163 $80582 106084001 SUTTER COAST HOSP No No No Yes Yes 3730 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391056 SUTTER TRACY COMM HOSP No No No No No 2714 13579 13303 $6289 $7735 $5995 Transition NA $98163 $80582 106291053 TAHOE FOREST HOSP No Yes No Yes Yes 4766 15256 14946 $12768 $17164 $21044 Transition NA $98163 $80582 106150808 TEHACHAPI HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 $22158 Transition NA $98163 $80582 106514030 SUTTER SURG HOSP-NORTH VALLEY No No No No No 3240 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582
i-
i
i
i-
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106334564 TEMECULA VALLEY HOSPITAL No No No No No 2180 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106120981 THE GENERAL HOSPITAL No No No No No 2570 13869 13587 NA NA NA NA $1507 $98163 $80582 106564121 THOUSAND OAKS SURGICAL HOSPITAL No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106190422 TORRANCE MEM MED CTR No No No No No 1952 12882 12620 $6289 $7436 $5891 Transition NA $98163 $80582 106370780 TRI-CITY MED CTR No Yes No No No 3695 12882 12620 $6289 $7436 $7706 Transition $1220 $98163 $80582 106190784 TEMPLE COMM HOSP No No No No No 4200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540816 TULARE DIST HOSP No Yes No No No 3578 12882 12620 $6289 $7436 $9529 Transition NA $98163 $80582 106531059 TRINITY HOSP No Yes No Yes Yes 5105 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106400548 TWIN CITIES COMM HOSP No No No Yes Yes 1587 12964 12701 $12768 $15168 $8160 Transition NA $98163 $80582 106341006 UC DAVIS MED CTR Yes No Yes No No 1836 15256 14946 $6289 $8454 NA NA NA NA NA 106301279 UC IRVINE MED CTR Yes No Yes No No 2072 12882 12620 $6289 $7436 NA NA NA NA NA 106370782 UCSD MED CTR Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106374141 UCSD-LA JOLLA JOHN M amp SALLY B THORNTON HOSPITAL Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106381154 UCSF MED CTR Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106380895 UCSF MED CTR AT MOUNT ZION Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106301357 TUSTIN HOSP MED CTR No No No No No 231 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106231396 UKIAH VALLEY MED CTRHOSP DR No No No Yes Yes 3643 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106014050 VALLEY CARE MEDICAL CENTER No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106010983 VALLEY MEM HOSP-LIVERMORE No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106191216 USC KENNETH NORRIS JR CANCER HOSP No No No No No 3134 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560481 VENTURA CO MED CTR Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106560521 VENTURA CO MED CTR-SANTA PAULA HOSPITAL Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106190818 VERDUGO HILLS HOSP No No No No No 3110 12882 12620 $6289 $7436 $5264 Transition NA $98163 $80582 106190812 VALLEY PRES HOSP No No No No No 3536 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 3046 14188 13900 $6289 $7996 NA Non-Transition $1312 $98163 $80582 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 3266 12882 12620 $6289 $7436 $8320 Transition NA $98163 $80582 106010987 WASHINGTON HOSP-FREMONT No Yes No No No 1941 16962 16618 $6289 $9186 $6429 Transition NA $98163 $80582 106444013 WATSONVILLE COMM HOSP No No No No No 1780 17239 16889 $6289 $9304 $13456 Transition NA $98163 $80582 106301379 WEST ANAHEIM MED CTR No No No No No 1514 12882 12620 $6289 $7436 $4707 Transition NA $98163 $80582 106190859 WEST HILLS HOSP AND MED CTR No No No No No 1933 12882 12620 $6289 $7436 $8050 Transition NA $98163 $80582 106374094 VIBRA OF SAN DIEGO No No No No No 1155 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301188 WESTERN MED CTR-ANAHEIM No No No No No 3203 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301566 WESTERN MED CTR-SANTA ANA No No No No No 2354 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190878 WHITE MEM MED CTR No No No No No 1515 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190883 WHITTIER HOSP MED CTR No No No No No 1139 12882 12620 $6289 $7436 $5922 Transition NA $98163 $80582 106571086 WOODLAND MEM HOSP No No No No No 3278 15256 14946 $6289 $8454 $10092 Transition NA $98163 $80582 6102015
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
-
163-1 163-2 163-3 163-4
CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION CARDIAC VALVE PROCEDURES WO CARDIAC CATHETERIZATION
566 651 924
1798
38077 42090 51794 88229
10000 10000 10000 10000
10000 10000 10000 10000
38077 42090 51794 88229
12500 12500 12500 12500
47596 52613 64743
110286
10000 10000 10000 10000
38077 42090 51794 88229
$35697 Misc Pediatric $39459 Misc Pediatric $48557 Misc Pediatric $82715 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
165-1 165-2 165-3 165-4
CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS W CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE
675 817
1052 1712
38445 43860 53254 80347
10000 10000 10000 10000
10000 10000 10000 10000
38445 43860 53254 80347
12500 12500 12500 12500
48056 54825 66568
100434
10000 10000 10000 10000
38445 43860 53254 80347
$36042 Misc Pediatric $41119 Misc Pediatric $49926 Misc Pediatric $75325 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
166-1 166-2 166-3 166-4
CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE CORONARY BYPASS WO CARDIAC CATH OR PERCUTANEOUS CARDIAC PROCEDURE
502 611 855
1615
30632 34370 42566 71277
10000 10000 10000 10000
10000 10000 10000 10000
30632 34370 42566 71277
12500 12500 12500 12500
38290 42963 53208 89096
10000 10000 10000 10000
30632 34370 42566 71277
$28718 Misc Pediatric $32222 Misc Pediatric $39906 Misc Pediatric $66822 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
167-1 167-2 167-3 167-4
OTHER CARDIOTHORACIC PROCEDURES OTHER CARDIOTHORACIC PROCEDURES OTHER CARDIOTHORACIC PROCEDURES OTHER CARDIOTHORACIC PROCEDURES
438 583 914
1860
28492 32691 41583 72603
10000 10000 10000 10000
10000 10000 10000 10000
28492 32691 41583 72603
12500 12500 12500 12500
35615 40864 51979 90754
10000 10000 10000 10000
28492 32691 41583 72603
$26711 Misc Pediatric $30648 Misc Pediatric $38984 Misc Pediatric $68065 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
169-1 169-2 169-3 169-4
MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES MAJOR THORACIC amp ABDOMINAL VASCULAR PROCEDURES
434 570 899
1626
17710 23017 35767 63594
10000 10000 10000 10000
10000 10000 10000 10000
17710 23017 35767 63594
12500 12500 12500 12500
22138 28771 44709 79493
10000 10000 10000 10000
17710 23017 35767 63594
$16603 Misc Pediatric $21578 Misc Pediatric $33532 Misc Pediatric $59619 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
170-1 170-2 170-3 170-4
PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK
468 535 901
1647
22837 24595 30320 48851
10000 10000 10000 10000
10000 10000 10000 10000
22837 24595 30320 48851
12500 12500 12500 12500
28546 30744 37900 61064
10000 10000 10000 10000
22837 24595 30320 48851
$21410 Misc Pediatric $23058 Misc Pediatric $28425 Misc Pediatric $45798 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
171-1 171-2 171-3 171-4
PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK
257 388 652
1323
16061 19059 24628 42111
10000 10000 10000 10000
10000 10000 10000 10000
16061 19059 24628 42111
12500 12500 12500 12500
20076 23824 30785 52639
10000 10000 10000 10000
16061 19059 24628 42111
$15057 Misc Pediatric $17868 Misc Pediatric $23089 Misc Pediatric $39479 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
173-1 173-2 173-3 173-4
OTHER VASCULAR PROCEDURES OTHER VASCULAR PROCEDURES OTHER VASCULAR PROCEDURES OTHER VASCULAR PROCEDURES
248 413 835
1698
17172 20933 28552 52543
10000 10000 10000 10000
10000 10000 10000 10000
17172 20933 28552 52543
12500 12500 12500 12500
21465 26166 35690 65679
10000 10000 10000 10000
17172 20933 28552 52543
$16099 Misc Pediatric $19625 Misc Pediatric $26768 Misc Pediatric $49259 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
174-1 174-2 174-3 174-4
PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES W AMI
242 309 532 858
20862 22375 27863 40669
10000 10000 10000 10000
10000 10000 10000 10000
20862 22375 27863 40669
12500 12500 12500 12500
26078 27969 34829 50836
10000 10000 10000 10000
20862 22375 27863 40669
$19558 Misc Pediatric $20977 Misc Pediatric $26122 Misc Pediatric $38127 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
175-1 175-2 175-3 175-4
PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI PERCUTANEOUS CARDIOVASCULAR PROCEDURES WO AMI
172 253 517
1037
17736 19933 25843 42121
10000 10000 10000 10000
10000 10000 10000 10000
17736 19933 25843 42121
12500 12500 12500 12500
22170 24916 32304 52651
10000 10000 10000 10000
17736 19933 25843 42121
$16628 Misc Pediatric $18687 Misc Pediatric $24228 Misc Pediatric $39488 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
176-1 176-2 176-3 176-4
CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT
291 253 446
1336
13020 24038 27425 45070
10000 10000 10000 10000
10000 10000 10000 10000
13020 24038 27425 45070
12500 12500 12500 12500
16275 30048 34281 56338
10000 10000 10000 10000
13020 24038 27425 45070
$12206 Misc Pediatric $22536 Misc Pediatric $25711 Misc Pediatric $42253 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
177-1 177-2 177-3 177-4
CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT
260 405 749
1560
10212 13638 21173 40225
10000 10000 10000 10000
10000 10000 10000 10000
10212 13638 21173 40225
12500 12500 12500 12500
12765 17048 26466 50281
10000 10000 10000 10000
10212 13638 21173 40225
$9574 Misc Pediatric $12786 Misc Pediatric $19850 Misc Pediatric $37711 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
180-1 180-2 180-3 180-4
OTHER CIRCULATORY SYSTEM PROCEDURES OTHER CIRCULATORY SYSTEM PROCEDURES OTHER CIRCULATORY SYSTEM PROCEDURES OTHER CIRCULATORY SYSTEM PROCEDURES
416 593 963
1589
10497 14144 21255 39764
10000 10000 10000 10000
10000 10000 10000 10000
10497 14144 21255 39764
12500 12500 12500 12500
13121 17680 26569 49705
10000 10000 10000 10000
10497 14144 21255 39764
$9841 Misc Pediatric $13260 Misc Pediatric $19927 Misc Pediatric $37279 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
190-1 190-2 190-3 190-4
ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION ACUTE MYOCARDIAL INFARCTION
212 315 518 765
06920 08342 11428 18576
10000 10000 10000 10000
10000 10000 10000 10000
06920 08342 11428 18576
12500 12500 12500 12500
08650 10428 14285 23220
10000 10000 10000 10000
06920 08342 11428 18576
$6488 Misc Pediatric $7821 Misc Pediatric
$10714 Misc Pediatric $17415 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
191-1 191-2 191-3 191-4
CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION W CIRC DISORD EXC ISCHEMIC HEART DISEASE
250 356 588
1157
10129 11962 15321 30799
10000 10000 10000 10000
10000 10000 10000 10000
10129 11962 15321 30799
12500 12500 12500 12500
12661 14953 19151 38499
10000 10000 10000 10000
10129 11962 15321 30799
$9496 Misc Pediatric $11214 Misc Pediatric $14363 Misc Pediatric $28874 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
192-1 192-2 192-3 192-4
CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE CARDIAC CATHETERIZATION FOR ISCHEMIC HEART DISEASE
190 256 440 733
08840 10294 13642 21517
10000 10000 10000 10000
10000 10000 10000 10000
08840 10294 13642 21517
12500 12500 12500 12500
11050 12868 17053 26896
10000 10000 10000 10000
08840 10294 13642 21517
$8288 Misc Pediatric $9651 Misc Pediatric
$12789 Misc Pediatric $20172 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
193-1 193-2 193-3 193-4
ACUTE amp SUBACUTE ENDOCARDITIS ACUTE amp SUBACUTE ENDOCARDITIS ACUTE amp SUBACUTE ENDOCARDITIS ACUTE amp SUBACUTE ENDOCARDITIS
549 695
1002 1491
07895 10373 15660 25224
10000 10000 10000 10000
10000 10000 10000 10000
07895 10373 15660 25224
12500 12500 12500 12500
09869 12966 19575 31530
10000 10000 10000 10000
07895 10373 15660 25224
$7402 Misc Pediatric $9725 Misc Pediatric
$14681 Misc Pediatric $23648 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
194-1 194-2 194-3 194-4
HEART FAILURE HEART FAILURE HEART FAILURE HEART FAILURE
292 375 565 955
05101 06549 09786 17821
10000 10000 10000 10000
10000 10000 10000 10000
05101 06549 09786 17821
12500 12500 12500 12500
06376 08186 12233 22276
10000 10000 10000 10000
05101 06549 09786 17821
$4782 Misc Pediatric $6140 Misc Pediatric $9174 Misc Pediatric
$16707 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
196-1 196-2 196-3 196-4
CARDIAC ARREST CARDIAC ARREST CARDIAC ARREST CARDIAC ARREST
291 227 252 462
03449 04919 07133 17166
10000 10000 10000 10000
10000 10000 10000 10000
03449 04919 07133 17166
12500 12500 12500 12500
04311 06149 08916 21458
10000 10000 10000 10000
03449 04919 07133 17166
$3233 Misc Pediatric $4612 Misc Pediatric $6687 Misc Pediatric
$16093 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
197-1 197-2 197-3 197-4
PERIPHERAL amp OTHER VASCULAR DISORDERS PERIPHERAL amp OTHER VASCULAR DISORDERS PERIPHERAL amp OTHER VASCULAR DISORDERS PERIPHERAL amp OTHER VASCULAR DISORDERS
325 405 554 993
04539 06186 09350 18139
10000 10000 10000 10000
10000 10000 10000 10000
04539 06186 09350 18139
12500 12500 12500 12500
05674 07733 11688 22674
10000 10000 10000 10000
04539 06186 09350 18139
$4255 Misc Pediatric $5799 Misc Pediatric $8766 Misc Pediatric
$17005 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
198-1 198-2 198-3 198-4
ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS
164 215 343 795
04222 05100 07000 13778
10000 10000 10000 10000
10000 10000 10000 10000
04222 05100 07000 13778
12500 12500 12500 12500
05278 06375 08750 17223
10000 10000 10000 10000
04222 05100 07000 13778
$3958 Misc Pediatric $4781 Misc Pediatric $6563 Misc Pediatric
$12917 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
199-1 199-2 199-3 199-4
HYPERTENSION HYPERTENSION HYPERTENSION HYPERTENSION
199 261 407 774
04431 05438 07709 16234
10000 10000 10000 10000
10000 10000 10000 10000
04431 05438 07709 16234
12500 12500 12500 12500
05539 06798 09636 20293
10000 10000 10000 10000
04431 05438 07709 16234
$4154 Misc Pediatric $5098 Misc Pediatric $7227 Misc Pediatric
$15219 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
200-1 200-2 200-3 200-4
CARDIAC STRUCTURAL amp VALVULAR DISORDERS CARDIAC STRUCTURAL amp VALVULAR DISORDERS CARDIAC STRUCTURAL amp VALVULAR DISORDERS CARDIAC STRUCTURAL amp VALVULAR DISORDERS
238 315 517
1005
04557 05692 08445 16354
10000 10000 10000 10000
10000 10000 10000 10000
04557 05692 08445 16354
12500 12500 12500 12500
05696 07115 10556 20443
10000 10000 10000 10000
04557 05692 08445 16354
$4272 Misc Pediatric $5336 Misc Pediatric $7917 Misc Pediatric
$15332 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
201-1 201-2 201-3 201-4
CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS
199 289 466 863
04273 05624 08590 17457
10000 10000 10000 10000
10000 10000 10000 10000
04273 05624 08590 17457
12500 12500 12500 12500
05341 07030 10738 21821
10000 10000 10000 10000
04273 05624 08590 17457
$4006 Misc Pediatric $5273 Misc Pediatric $8053 Misc Pediatric
$16366 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
203-1 203-2 203-3 203-4
CHEST PAIN CHEST PAIN CHEST PAIN CHEST PAIN
148 195 305 725
04180 05129 06846 13335
10000 10000 10000 10000
10000 10000 10000 10000
04180 05129 06846 13335
12500 12500 12500 12500
05225 06411 08558 16669
10000 10000 10000 10000
04180 05129 06846 13335
$3919 Misc Pediatric $4808 Misc Pediatric $6418 Misc Pediatric
$12502 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
204-1 204-2 204-3 204-4
SYNCOPE amp COLLAPSE SYNCOPE amp COLLAPSE SYNCOPE amp COLLAPSE SYNCOPE amp COLLAPSE
201 264 388 858
04877 05857 07587 15564
10000 10000 10000 10000
10000 10000 10000 10000
04877 05857 07587 15564
12500 12500 12500 12500
06096 07321 09484 19455
10000 10000 10000 10000
04877 05857 07587 15564
$4572 Misc Pediatric $5491 Misc Pediatric $7113 Misc Pediatric
$14591 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
205-1 205-2 205-3 205-4
CARDIOMYOPATHY CARDIOMYOPATHY CARDIOMYOPATHY CARDIOMYOPATHY
238 308 496 926
04349 05715 08342 18259
10000 10000 10000 10000
10000 10000 10000 10000
04349 05715 08342 18259
12500 12500 12500 12500
05436 07144 10428 22824
10000 10000 10000 10000
04349 05715 08342 18259
$4077 Misc Pediatric $5358 Misc Pediatric $7821 Misc Pediatric
$17118 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
206-1 206-2 206-3 206-4
MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE
227 345 572
1116
04452 05754 09436 20324
10000 10000 10000 10000
10000 10000 10000 10000
04452 05754 09436 20324
12500 12500 12500 12500
05565 07193 11795 25405
10000 10000 10000 10000
04452 05754 09436 20324
$4174 Misc Pediatric $5394 Misc Pediatric $8846 Misc Pediatric
$19054 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
207-1 207-2 207-3 207-4
OTHER CIRCULATORY SYSTEM DIAGNOSES OTHER CIRCULATORY SYSTEM DIAGNOSES OTHER CIRCULATORY SYSTEM DIAGNOSES OTHER CIRCULATORY SYSTEM DIAGNOSES
239 327 479 850
04972 06455 09118 17339
10000 10000 10000 10000
10000 10000 10000 10000
04972 06455 09118 17339
12500 12500 12500 12500
06215 08069 11398 21674
10000 10000 10000 10000
04972 06455 09118 17339
$4661 Misc Pediatric $6052 Misc Pediatric $8548 Misc Pediatric
$16255 Misc Pediatric
Circulatory Adult Circulatory Adult Circulatory Adult Circulatory Adult
220-1 220-2 220-3 220-4
MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES
370 728
1222 2105
13178 19373 31783 59607
10000 10000 10000 10000
10000 10000 10000 10000
13178 19373 31783 59607
12500 12500 12500 12500
16473 24216 39729 74509
10000 10000 10000 10000
13178 19373 31783 59607
$12354 Misc Pediatric $18162 Misc Pediatric $29797 Misc Pediatric $55882 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
221-1 221-2 221-3 221-4
MAJOR SMALL amp LARGE BOWEL PROCEDURES MAJOR SMALL amp LARGE BOWEL PROCEDURES MAJOR SMALL amp LARGE BOWEL PROCEDURES MAJOR SMALL amp LARGE BOWEL PROCEDURES
486 711
1216 2007
13986 18317 29391 55350
10000 10000 10000 10000
10000 10000 10000 10000
13986 18317 29391 55350
12500 12500 12500 12500
17483 22896 36739 69188
10000 10000 10000 10000
13986 18317 29391 55350
$13112 Misc Pediatric $17172 Misc Pediatric $27554 Misc Pediatric $51891 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
222-1 222-2 222-3 222-4
OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES
226 370 835
1821
08125 12068 19613 44248
10000 10000 10000 10000
10000 10000 10000 10000
08125 12068 19613 44248
12500 12500 12500 12500
10156 15085 24516 55310
10000 10000 10000 10000
08125 12068 19613 44248
$7617 Misc Pediatric $11314 Misc Pediatric $18387 Misc Pediatric $41483 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
223-1 223-2 223-3 223-4
OTHER SMALL amp LARGE BOWEL PROCEDURES OTHER SMALL amp LARGE BOWEL PROCEDURES OTHER SMALL amp LARGE BOWEL PROCEDURES OTHER SMALL amp LARGE BOWEL PROCEDURES
442 643
1092 1967
10740 14465 23665 49105
10000 10000 10000 10000
10000 10000 10000 10000
10740 14465 23665 49105
12500 12500 12500 12500
13425 18081 29581 61381
10000 10000 10000 10000
10740 14465 23665 49105
$10069 Misc Pediatric $13561 Misc Pediatric $22186 Misc Pediatric $46036 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
224-1 224-2 224-3 224-4
PERITONEAL ADHESIOLYSIS PERITONEAL ADHESIOLYSIS PERITONEAL ADHESIOLYSIS PERITONEAL ADHESIOLYSIS
540 788
1150 1745
12217 16811 25160 44117
10000 10000 10000 10000
10000 10000 10000 10000
12217 16811 25160 44117
12500 12500 12500 12500
15271 21014 31450 55146
10000 10000 10000 10000
12217 16811 25160 44117
$11453 Misc Pediatric $15760 Misc Pediatric $23588 Misc Pediatric $41360 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
225-1 225-2 225-3 225-4
APPENDECTOMY APPENDECTOMY APPENDECTOMY APPENDECTOMY
157 376 726
1357
07870 11109 18822 36506
10000 10000 10000 10000
10000 10000 10000 10000
07870 11109 18822 36506
12500 12500 12500 12500
09838 13886 23528 45633
10000 10000 10000 10000
07870 11109 18822 36506
$7378 Misc Pediatric $10415 Misc Pediatric $17646 Misc Pediatric $34224 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
226-1 226-2 226-3 226-4
ANAL PROCEDURES ANAL PROCEDURES ANAL PROCEDURES ANAL PROCEDURES
256 413 737
1301
06250 08568 13988 28079
10000 10000 10000 10000
10000 10000 10000 10000
06250 08568 13988 28079
12500 12500 12500 12500
07813 10710 17485 35099
10000 10000 10000 10000
06250 08568 13988 28079
$5859 Misc Pediatric $8033 Misc Pediatric
$13114 Misc Pediatric $26324 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
227-1 HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL 290 10044 10000 10000 10044 12500 12555 10000 10044 $9416 Misc Pediatric Gastroent Adult
227-2 227-3 227-4
HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL
443 813
1503
13150 21598 43086
10000 10000 10000
10000 10000 10000
13150 21598 43086
12500 12500 12500
16438 26998 53858
10000 10000 10000
13150 21598 43086
$12328 Misc Pediatric $20248 Misc Pediatric $40393 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult
228-1 228-2 228-3 228-4
INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES
200 344 629
1321
07221 09757 15211 32407
10000 10000 10000 10000
10000 10000 10000 10000
07221 09757 15211 32407
12500 12500 12500 12500
09026 12196 19014 40509
10000 10000 10000 10000
07221 09757 15211 32407
$6770 Misc Pediatric $9147 Misc Pediatric
$14260 Misc Pediatric $30382 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
229-1 229-2 229-3 229-4
OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES
387 552 976
1760
10850 14346 22850 42572
10000 10000 10000 10000
10000 10000 10000 10000
10850 14346 22850 42572
12500 12500 12500 12500
13563 17933 28563 53215
10000 10000 10000 10000
10850 14346 22850 42572
$10172 Misc Pediatric $13449 Misc Pediatric $21422 Misc Pediatric $39911 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
240-1 240-2 240-3 240-4
DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY
371 429 685
1225
05526 07344 11112 20338
10000 10000 10000 10000
10000 10000 10000 10000
05526 07344 11112 20338
12500 12500 12500 12500
06908 09180 13890 25423
10000 10000 10000 10000
05526 07344 11112 20338
$5181 Misc Pediatric $6885 Misc Pediatric
$10418 Misc Pediatric $19067 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
241-1 241-2 241-3 241-4
PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS
252 325 484
1012
05507 07186 10584 23302
10000 10000 10000 10000
10000 10000 10000 10000
05507 07186 10584 23302
12500 12500 12500 12500
06884 08983 13230 29128
10000 10000 10000 10000
05507 07186 10584 23302
$5163 Misc Pediatric $6737 Misc Pediatric $9923 Misc Pediatric
$21846 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
242-1 242-2 242-3 242-4
MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS
230 319 459
1013
05080 06929 10170 22355
10000 10000 10000 10000
10000 10000 10000 10000
05080 06929 10170 22355
12500 12500 12500 12500
06350 08661 12713 27944
10000 10000 10000 10000
05080 06929 10170 22355
$4763 Misc Pediatric $6496 Misc Pediatric $9534 Misc Pediatric
$20958 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
243-1 243-2 243-3 243-4
OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS
189 280 479
1028
04493 06061 09094 20341
10000 10000 10000 10000
10000 10000 10000 10000
04493 06061 09094 20341
12500 12500 12500 12500
05616 07576 11368 25426
10000 10000 10000 10000
04493 06061 09094 20341
$4212 Misc Pediatric $5682 Misc Pediatric $8526 Misc Pediatric
$19070 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
244-1 244-2 244-3 244-4
DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS
292 361 545
1104
05247 06624 10053 21700
10000 10000 10000 10000
10000 10000 10000 10000
05247 06624 10053 21700
12500 12500 12500 12500
06559 08280 12566 27125
10000 10000 10000 10000
05247 06624 10053 21700
$4919 Misc Pediatric $6210 Misc Pediatric $9425 Misc Pediatric
$20344 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
245-1 245-2 245-3 245-4
INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE
339 413 626
1206
05754 07028 10226 19440
10000 10000 10000 10000
10000 10000 10000 10000
05754 07028 10226 19440
12500 12500 12500 12500
07193 08785 12783 24300
10000 10000 10000 10000
05754 07028 10226 19440
$5394 Misc Pediatric $6589 Misc Pediatric $9587 Misc Pediatric
$18225 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
246-1 246-2 246-3 246-4
GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY
315 404 602 982
06451 07943 11319 19310
10000 10000 10000 10000
10000 10000 10000 10000
06451 07943 11319 19310
12500 12500 12500 12500
08064 09929 14149 24138
10000 10000 10000 10000
06451 07943 11319 19310
$6048 Misc Pediatric $7447 Misc Pediatric
$10612 Misc Pediatric $18103 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
247-1 247-2 247-3 247-4
INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION
288 378 596
1104
04874 06267 09526 19303
10000 10000 10000 10000
10000 10000 10000 10000
04874 06267 09526 19303
12500 12500 12500 12500
06093 07834 11908 24129
10000 10000 10000 10000
04874 06267 09526 19303
$4569 Misc Pediatric $5875 Misc Pediatric $8931 Misc Pediatric
$18097 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
248-1 248-2 248-3 248-4
MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS
334 472 710
1239
05085 07215 10667 20497
10000 10000 10000 10000
10000 10000 10000 10000
05085 07215 10667 20497
12500 12500 12500 12500
06356 09019 13334 25621
10000 10000 10000 10000
05085 07215 10667 20497
$4767 Misc Pediatric $6764 Misc Pediatric
$10000 Misc Pediatric $19216 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
249-1 249-2 249-3 249-4
NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING
219 289 431 938
03648 05058 07201 15935
10000 10000 10000 10000
10000 10000 10000 10000
03648 05058 07201 15935
12500 12500 12500 12500
04560 06323 09001 19919
10000 10000 10000 10000
03648 05058 07201 15935
$3420 Misc Pediatric $4742 Misc Pediatric $6751 Misc Pediatric
$14939 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
251-1 251-2 251-3 251-4
ABDOMINAL PAIN ABDOMINAL PAIN ABDOMINAL PAIN ABDOMINAL PAIN
217 288 418 813
04492 05786 07857 14149
10000 10000 10000 10000
10000 10000 10000 10000
04492 05786 07857 14149
12500 12500 12500 12500
05615 07233 09821 17686
10000 10000 10000 10000
04492 05786 07857 14149
$4211 Misc Pediatric $5424 Misc Pediatric $7366 Misc Pediatric
$13265 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
252-1 252-2 252-3 252-4
MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE
331 412 635
1248
04904 06490 09833 19841
10000 10000 10000 10000
10000 10000 10000 10000
04904 06490 09833 19841
12500 12500 12500 12500
06130 08113 12291 24801
10000 10000 10000 10000
04904 06490 09833 19841
$4598 Misc Pediatric $6084 Misc Pediatric $9218 Misc Pediatric
$18601 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
253-1 253-2 253-3 253-4
OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE
251 334 504 878
05108 06777 10020 18601
10000 10000 10000 10000
10000 10000 10000 10000
05108 06777 10020 18601
12500 12500 12500 12500
06385 08471 12525 23251
10000 10000 10000 10000
05108 06777 10020 18601
$4789 Misc Pediatric $6353 Misc Pediatric $9394 Misc Pediatric
$17438 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
254-1 254-2 254-3 254-4
OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES
252 353 530
1066
04519 06282 09117 18053
10000 10000 10000 10000
10000 10000 10000 10000
04519 06282 09117 18053
12500 12500 12500 12500
05649 07853 11396 22566
10000 10000 10000 10000
04519 06282 09117 18053
$4237 Misc Pediatric $5889 Misc Pediatric $8547 Misc Pediatric
$16925 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
260-1 260-2 260-3 260-4
MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES
469 611
1081 2181
15085 19596 31029 63824
10000 10000 10000 10000
10000 10000 10000 10000
15085 19596 31029 63824
12500 12500 12500 12500
18856 24495 38786 79780
10000 10000 10000 10000
15085 19596 31029 63824
$14142 Misc Pediatric $18371 Misc Pediatric $29090 Misc Pediatric $59835 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
261-1 261-2 261-3 261-4
MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES
450 706
1116 1993
13049 18250 25711 50241
10000 10000 10000 10000
10000 10000 10000 10000
13049 18250 25711 50241
12500 12500 12500 12500
16311 22813 32139 62801
10000 10000 10000 10000
13049 18250 25711 50241
$12233 Misc Pediatric $17109 Misc Pediatric $24104 Misc Pediatric $47101 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
262-1 262-2 262-3 262-4
CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC
405 567 898
1751
11851 15637 23607 46363
10000 10000 10000 10000
10000 10000 10000 10000
11851 15637 23607 46363
12500 12500 12500 12500
14814 19546 29509 57954
10000 10000 10000 10000
11851 15637 23607 46363
$11110 Misc Pediatric $14660 Misc Pediatric $22132 Misc Pediatric $43465 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
263-1 263-2 263-3 263-4
LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY
236 364 635
1384
09345 12310 17676 36726
10000 10000 10000 10000
10000 10000 10000 10000
09345 12310 17676 36726
12500 12500 12500 12500
11681 15388 22095 45908
10000 10000 10000 10000
09345 12310 17676 36726
$8761 Misc Pediatric $11541 Misc Pediatric $16571 Misc Pediatric $34431 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
264-1 264-2 264-3 264-4
OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES
453 543
1067 2148
12526 13732 23159 51901
10000 10000 10000 10000
10000 10000 10000 10000
12526 13732 23159 51901
12500 12500 12500 12500
15658 17165 28949 64876
10000 10000 10000 10000
12526 13732 23159 51901
$11743 Misc Pediatric $12874 Misc Pediatric $21712 Misc Pediatric $48657 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
279-1 279-2 279-3 279-4
HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS
280 361 580
1157
04712 05945 09594 23269
10000 10000 10000 10000
10000 10000 10000 10000
04712 05945 09594 23269
12500 12500 12500 12500
05890 07431 11993 29086
10000 10000 10000 10000
04712 05945 09594 23269
$4418 Misc Pediatric $5573 Misc Pediatric $8994 Misc Pediatric
$21815 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
280-1 280-2 280-3 280-4
ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE
298 344 532
1047
04734 06141 09718 21422
10000 10000 10000 10000
10000 10000 10000 10000
04734 06141 09718 21422
12500 12500 12500 12500
05918 07676 12148 26778
10000 10000 10000 10000
04734 06141 09718 21422
$4438 Misc Pediatric $5757 Misc Pediatric $9111 Misc Pediatric
$20083 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
281-1 281-2 281-3 281-4
MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS
357 421 610 974
05079 07553 10730 17519
10000 10000 10000 10000
10000 10000 10000 10000
05079 07553 10730 17519
12500 12500 12500 12500
06349 09441 13413 21899
10000 10000 10000 10000
05079 07553 10730 17519
$4762 Misc Pediatric $7081 Misc Pediatric
$10059 Misc Pediatric $16424 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
282-1 282-2 282-3 282-4
DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY
318 403 649
1381
05507 07067 11213 27863
10000 10000 10000 10000
10000 10000 10000 10000
05507 07067 11213 27863
12500 12500 12500 12500
06884 08834 14016 34829
10000 10000 10000 10000
05507 07067 11213 27863
$5163 Misc Pediatric $6625 Misc Pediatric
$10512 Misc Pediatric $26122 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
283-1 283-2 283-3 283-4
OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER
286 338 505 947
04913 06300 09246 18497
10000 10000 10000 10000
10000 10000 10000 10000
04913 06300 09246 18497
12500 12500 12500 12500
06141 07875 11558 23121
10000 10000 10000 10000
04913 06300 09246 18497
$4606 Misc Pediatric $5906 Misc Pediatric $8668 Misc Pediatric
$17341 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
284-1 284-2 284-3 284-4
DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT
245 344 536
1059
05403 07447 10804 21256
10000 10000 10000 10000
10000 10000 10000 10000
05403 07447 10804 21256
12500 12500 12500 12500
06754 09309 13505 26570
10000 10000 10000 10000
05403 07447 10804 21256
$5065 Misc Pediatric $6982 Misc Pediatric
$10129 Misc Pediatric $19928 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
301-1 301-2 301-3 301-4
HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT
365 396 535
1280
18140 19690 25026 39991
10000 10000 10000 10000
10000 10000 10000 10000
18140 19690 25026 39991
12500 12500 12500 12500
22675 24613 31283 49989
10000 10000 10000 10000
18140 19690 25026 39991
$17006 Misc Pediatric $18459 Misc Pediatric $23462 Misc Pediatric $37492 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
302-1 302-2 302-3 302-4
KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT
296 338 519
1248
17428 19132 23798 43468
10000 10000 10000 10000
10000 10000 10000 10000
17428 19132 23798 43468
12500 12500 12500 12500
21785 23915 29748 54335
10000 10000 10000 10000
17428 19132 23798 43468
$16339 Misc Pediatric $17936 Misc Pediatric $22311 Misc Pediatric $40751 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
303-1 303-2 303-3 303-4
DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK
450 570 857
1607
47039 55422 77549
105744
10000 10000 10000 10000
10000 10000 10000 10000
47039 55422 77549
105744
12500 12500 12500 12500
58799 69278 96936
132180
10000 10000 10000 10000
47039 55422 77549
105744
$44099 Misc Pediatric $51958 Misc Pediatric $72702 Misc Pediatric $99135 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
304-1 304-2 304-3 304-4
DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK
300 405 735
1776
29720 35298 49644 81663
10000 10000 10000 10000
10000 10000 10000 10000
29720 35298 49644 81663
12500 12500 12500 12500
37150 44123 62055
102079
10000 10000 10000 10000
29720 35298 49644 81663
$27863 Misc Pediatric $33092 Misc Pediatric $46541 Misc Pediatric $76559 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
305-1 305-2 305-3 305-4
AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES
540 737
1137 1987
10654 14043 21843 42156
10000 10000 10000 10000
10000 10000 10000 10000
10654 14043 21843 42156
12500 12500 12500 12500
13318 17554 27304 52695
10000 10000 10000 10000
10654 14043 21843 42156
$9988 Misc Pediatric $13165 Misc Pediatric $20478 Misc Pediatric $39521 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
308-1 308-2 308-3 308-4
HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT
419 496 697
1264
13101 15854 21518 36506
10000 10000 10000 10000
10000 10000 10000 10000
13101 15854 21518 36506
12500 12500 12500 12500
16376 19818 26898 45633
10000 10000 10000 10000
13101 15854 21518 36506
$12282 Misc Pediatric $14863 Misc Pediatric $20173 Misc Pediatric $34224 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
309-1 309-2 309-3 309-4
HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT
278 490 865
1887
11482 16231 23288 42408
10000 10000 10000 10000
10000 10000 10000 10000
11482 16231 23288 42408
12500 12500 12500 12500
14353 20289 29110 53010
10000 10000 10000 10000
11482 16231 23288 42408
$10764 Misc Pediatric $15217 Misc Pediatric $21833 Misc Pediatric $39758 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
310-1 310-2 310-3 310-4
INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION
181 302 624
1622
08926 11888 17911 41661
10000 10000 10000 10000
10000 10000 10000 10000
08926 11888 17911 41661
12500 12500 12500 12500
11158 14860 22389 52076
10000 10000 10000 10000
08926 11888 17911 41661
$8368 Misc Pediatric $11145 Misc Pediatric $16792 Misc Pediatric $39057 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
312-1 312-2
SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES
538 940
12555 18447
10000 10000
10000 10000
12555 18447
12500 12500
15694 23059
10000 10000
12555 18447
$11770 Misc Pediatric $17294 Misc Pediatric
Misc Adult Misc Adult
312-3 312-4
SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES
1846 3284
31356 71148
10000 10000
10000 10000
31356 71148
12500 12500
39195 88935
10000 10000
31356 71148
$29396 Misc Pediatric $66701 Misc Pediatric
Misc Adult Misc Adult
313-1 313-2 313-3 313-4
KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT
270 444 785
1659
10852 15212 22743 43349
10000 10000 10000 10000
10000 10000 10000 10000
10852 15212 22743 43349
12500 12500 12500 12500
13565 19015 28429 54186
10000 10000 10000 10000
10852 15212 22743 43349
$10174 Misc Pediatric $14261 Misc Pediatric $21322 Misc Pediatric $40640 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
314-1 314-2 314-3 314-4
FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES
257 507 810
1579
09291 11320 16006 32885
10000 10000 10000 10000
10000 10000 10000 10000
09291 11320 16006 32885
12500 12500 12500 12500
11614 14150 20008 41106
10000 10000 10000 10000
09291 11320 16006 32885
$8710 Misc Pediatric $10613 Misc Pediatric $15006 Misc Pediatric $30830 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
315-1 315-2 315-3 315-4
SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES
185 267 649
1473
08387 15912 22542 44542
10000 10000 10000 10000
10000 10000 10000 10000
08387 15912 22542 44542
12500 12500 12500 12500
10484 19890 28178 55678
10000 10000 10000 10000
08387 15912 22542 44542
$7863 Misc Pediatric $14918 Misc Pediatric $21133 Misc Pediatric $41758 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
316-1 316-2 316-3 316-4
HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES
229 396 727
1430
07195 10564 17143 34568
10000 10000 10000 10000
10000 10000 10000 10000
07195 10564 17143 34568
12500 12500 12500 12500
08994 13205 21429 43210
10000 10000 10000 10000
07195 10564 17143 34568
$6745 Misc Pediatric $9904 Misc Pediatric
$16072 Misc Pediatric $32408 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
317-1 317-2 317-3 317-4
TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES
300 544
1030 2038
08204 11764 19738 43378
10000 10000 10000 10000
10000 10000 10000 10000
08204 11764 19738 43378
12500 12500 12500 12500
10255 14705 24673 54223
10000 10000 10000 10000
08204 11764 19738 43378
$7691 Misc Pediatric $11029 Misc Pediatric $18504 Misc Pediatric $40667 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
320-1 320-2 320-3 320-4
OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES
229 474 900
1844
09314 14085 21498 40942
10000 10000 10000 10000
10000 10000 10000 10000
09314 14085 21498 40942
12500 12500 12500 12500
11643 17606 26873 51178
10000 10000 10000 10000
09314 14085 21498 40942
$8732 Misc Pediatric $13205 Misc Pediatric $20154 Misc Pediatric $38383 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
321-1 321-2 321-3 321-4
CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP
174 322 869
1740
16800 21292 35737 65431
10000 10000 10000 10000
10000 10000 10000 10000
16800 21292 35737 65431
12500 12500 12500 12500
21000 26615 44671 81789
10000 10000 10000 10000
16800 21292 35737 65431
$15750 Misc Pediatric $19961 Misc Pediatric $33503 Misc Pediatric $61342 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
340-1 340-2 340-3 340-4
FRACTURE OF FEMUR FRACTURE OF FEMUR FRACTURE OF FEMUR FRACTURE OF FEMUR
307 350 507 717
04052 05213 07741 13545
10000 10000 10000 10000
10000 10000 10000 10000
04052 05213 07741 13545
12500 12500 12500 12500
05065 06516 09676 16931
10000 10000 10000 10000
04052 05213 07741 13545
$3799 Misc Pediatric $4887 Misc Pediatric $7257 Misc Pediatric
$12698 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
341-1 341-2 341-3 341-4
FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP
302 365 480 981
04685 05732 07835 19346
10000 10000 10000 10000
10000 10000 10000 10000
04685 05732 07835 19346
12500 12500 12500 12500
05856 07165 09794 24183
10000 10000 10000 10000
04685 05732 07835 19346
$4392 Misc Pediatric $5374 Misc Pediatric $7345 Misc Pediatric
$18137 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
342-1 342-2 342-3 342-4
FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK
223 336 523
1073
04199 06015 09030 19468
10000 10000 10000 10000
10000 10000 10000 10000
04199 06015 09030 19468
12500 12500 12500 12500
05249 07519 11288 24335
10000 10000 10000 10000
04199 06015 09030 19468
$3937 Misc Pediatric $5639 Misc Pediatric $8466 Misc Pediatric
$18251 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
343-1 343-2 343-3 343-4
MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG
381 462 768
1278
06313 07919 12982 22512
10000 10000 10000 10000
10000 10000 10000 10000
06313 07919 12982 22512
12500 12500 12500 12500
07891 09899 16228 28140
10000 10000 10000 10000
06313 07919 12982 22512
$5918 Misc Pediatric $7424 Misc Pediatric
$12171 Misc Pediatric $21105 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
344-1 344-2 344-3 344-4
OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS
510 624 996
1727
06188 08269 12369 20626
10000 10000 10000 10000
10000 10000 10000 10000
06188 08269 12369 20626
12500 12500 12500 12500
07735 10336 15461 25783
10000 10000 10000 10000
06188 08269 12369 20626
$5801 Misc Pediatric $7752 Misc Pediatric
$11596 Misc Pediatric $19337 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
346-1 346-2 346-3 346-4
CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS
312 418 742
1507
05246 07180 12230 29854
10000 10000 10000 10000
10000 10000 10000 10000
05246 07180 12230 29854
12500 12500 12500 12500
06558 08975 15288 37318
10000 10000 10000 10000
05246 07180 12230 29854
$4918 Misc Pediatric $6731 Misc Pediatric
$11466 Misc Pediatric $27988 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
347-1 347-2 347-3 347-4
OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES
288 388 534
1184
05202 07038 09895 23177
10000 10000 10000 10000
10000 10000 10000 10000
05202 07038 09895 23177
12500 12500 12500 12500
06503 08798 12369 28971
10000 10000 10000 10000
05202 07038 09895 23177
$4877 Misc Pediatric $6598 Misc Pediatric $9277 Misc Pediatric
$21728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
349-1 349-2 349-3 349-4
MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE
226 480 806
1387
04381 06459 10302 19261
10000 10000 10000 10000
10000 10000 10000 10000
04381 06459 10302 19261
12500 12500 12500 12500
05476 08074 12878 24076
10000 10000 10000 10000
04381 06459 10302 19261
$4107 Misc Pediatric $6055 Misc Pediatric $9658 Misc Pediatric
$18057 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
351-1 351-2 351-3 351-4
OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES
252 352 544
1111
04074 05668 08930 19109
10000 10000 10000 10000
10000 10000 10000 10000
04074 05668 08930 19109
12500 12500 12500 12500
05093 07085 11163 23886
10000 10000 10000 10000
04074 05668 08930 19109
$3819 Misc Pediatric $5314 Misc Pediatric $8372 Misc Pediatric
$17915 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
361-1 361-2 361-3 361-4
SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES
407 758
1393 2857
11097 14459 21415 45412
10000 10000 10000 10000
10000 10000 10000 10000
11097 14459 21415 45412
12500 12500 12500 12500
13871 18074 26769 56765
10000 10000 10000 10000
11097 14459 21415 45412
$10403 Misc Pediatric $13555 Misc Pediatric $20077 Misc Pediatric $42574 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
362-1 362-2 362-3 362-4
MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES
179 233 597
1380
10091 13554 17862 38257
10000 10000 10000 10000
10000 10000 10000 10000
10091 13554 17862 38257
12500 12500 12500 12500
12614 16943 22328 47821
10000 10000 10000 10000
10091 13554 17862 38257
$9460 Misc Pediatric $12707 Misc Pediatric $16746 Misc Pediatric $35866 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
363-1 363-2 363-3 363-4
BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY
209 314 532
1706
08797 14900 19039 35420
10000 10000 10000 10000
10000 10000 10000 10000
08797 14900 19039 35420
12500 12500 12500 12500
10996 18625 23799 44275
10000 10000 10000 10000
08797 14900 19039 35420
$8247 Misc Pediatric $13969 Misc Pediatric $17849 Misc Pediatric $33206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
364-1 364-2 364-3 364-4
OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES
289 508 943
1919
07645 10877 16986 30643
10000 10000 10000 10000
10000 10000 10000 10000
07645 10877 16986 30643
12500 12500 12500 12500
09556 13596 21233 38304
10000 10000 10000 10000
07645 10877 16986 30643
$7167 Misc Pediatric $10197 Misc Pediatric $15924 Misc Pediatric $28728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
380-1 380-2 380-3 380-4
SKIN ULCERS SKIN ULCERS SKIN ULCERS SKIN ULCERS
416 498 784
1662
05289 06545 09424 17199
10000 10000 10000 10000
10000 10000 10000 10000
05289 06545 09424 17199
12500 12500 12500 12500
06611 08181 11780 21499
10000 10000 10000 10000
05289 06545 09424 17199
$4958 Misc Pediatric $6136 Misc Pediatric $8835 Misc Pediatric
$16124 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
381-1 381-2 381-3 381-4
MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS
300 428 671
1406
03883 05748 09734 27512
10000 10000 10000 10000
10000 10000 10000 10000
03883 05748 09734 27512
12500 12500 12500 12500
04854 07185 12168 34390
10000 10000 10000 10000
03883 05748 09734 27512
$3640 Misc Pediatric $5389 Misc Pediatric $9126 Misc Pediatric
$25793 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
382-1 382-2 382-3 382-4
MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS
381 432 645
1003
03521 05612 09634 15729
10000 10000 10000 10000
10000 10000 10000 10000
03521 05612 09634 15729
12500 12500 12500 12500
04401 07015 12043 19661
10000 10000 10000 10000
03521 05612 09634 15729
$3301 Misc Pediatric $5261 Misc Pediatric $9032 Misc Pediatric
$14746 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
383-1 383-2 383-3 383-4
CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS
294 412 617
1198
04148 05905 09147 19560
10000 10000 10000 10000
10000 10000 10000 10000
04148 05905 09147 19560
12500 12500 12500 12500
05185 07381 11434 24450
10000 10000 10000 10000
04148 05905 09147 19560
$3889 Misc Pediatric $5536 Misc Pediatric $8575 Misc Pediatric
$18338 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
384-1 384-2 384-3 384-4
CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE
193 301 493
1134
04752 06220 08932 20168
10000 10000 10000 10000
10000 10000 10000 10000
04752 06220 08932 20168
12500 12500 12500 12500
05940 07775 11165 25210
10000 10000 10000 10000
04752 06220 08932 20168
$4455 Misc Pediatric $5831 Misc Pediatric $8374 Misc Pediatric
$18908 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
385-1 385-2 385-3 385-4
OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS
248 353 565
1295
03496 05103 07974 19128
10000 10000 10000 10000
10000 10000 10000 10000
03496 05103 07974 19128
12500 12500 12500 12500
04370 06379 09968 23910
10000 10000 10000 10000
03496 05103 07974 19128
$3278 Misc Pediatric $4784 Misc Pediatric $7476 Misc Pediatric
$17933 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
401-1 401-2 401-3 401-4
PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES
303 427 844
2452
13697 18347 29058 71913
10000 10000 10000 10000
10000 10000 10000 10000
13697 18347 29058 71913
12500 12500 12500 12500
17121 22934 36323 89891
10000 10000 10000 10000
13697 18347 29058 71913
$12841 Misc Pediatric $17200 Misc Pediatric $27242 Misc Pediatric $67418 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
403-1 403-2 403-3 403-4
PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY
183 222 497
1867
12813 14411 21531 61151
10000 10000 10000 10000
10000 10000 10000 10000
12813 14411 21531 61151
12500 12500 12500 12500
16016 18014 26914 76439
10000 10000 10000 10000
12813 14411 21531 61151
$12012 Misc Pediatric $13510 Misc Pediatric $20185 Misc Pediatric $57329 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
404-1 404-2 404-3 404-4
THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES
130 216 659
1638
07364 09479 18990 42519
10000 10000 10000 10000
10000 10000 10000 10000
07364 09479 18990 42519
12500 12500 12500 12500
09205 11849 23738 53149
10000 10000 10000 10000
07364 09479 18990 42519
$6904 Misc Pediatric $8887 Misc Pediatric
$17803 Misc Pediatric $39862 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
405-1 405-2 405-3 405-4
OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS
419 571 966
2131
11123 14210 21421 48796
10000 10000 10000 10000
10000 10000 10000 10000
11123 14210 21421 48796
12500 12500 12500 12500
13904 17763 26776 60995
10000 10000 10000 10000
11123 14210 21421 48796
$10428 Misc Pediatric $13322 Misc Pediatric $20082 Misc Pediatric $45746 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
420-1 420-2 420-3 420-4
DIABETES DIABETES DIABETES DIABETES
261 275 427 935
03897 05302 07862 19671
10000 10000 10000 10000
10000 10000 10000 10000
03897 05302 07862 19671
12500 12500 12500 12500
04871 06628 09828 24589
10000 10000 10000 10000
03897 05302 07862 19671
$3653 Misc Pediatric $4971 Misc Pediatric $7371 Misc Pediatric
$18442 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
421-1 421-2 421-3 421-4
MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS
351 483 676
1375
03211 05227 08190 17446
10000 10000 10000 10000
10000 10000 10000 10000
03211 05227 08190 17446
12500 12500 12500 12500
04014 06534 10238 21808
10000 10000 10000 10000
03211 05227 08190 17446
$3010 Misc Pediatric $4900 Misc Pediatric $7678 Misc Pediatric
$16356 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
422-1 422-2 422-3 422-4
HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS
199 291 445 914
02848 04625 06828 14444
10000 10000 10000 10000
10000 10000 10000 10000
02848 04625 06828 14444
12500 12500 12500 12500
03560 05781 08535 18055
10000 10000 10000 10000
02848 04625 06828 14444
$2670 Misc Pediatric $4336 Misc Pediatric $6401 Misc Pediatric
$13541 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
423-1 423-2 423-3 423-4
INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM
272 363 573
1504
04421 05846 09540 27384
10000 10000 10000 10000
10000 10000 10000 10000
04421 05846 09540 27384
12500 12500 12500 12500
05526 07308 11925 34230
10000 10000 10000 10000
04421 05846 09540 27384
$4145 Misc Pediatric $5481 Misc Pediatric $8944 Misc Pediatric
$25673 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
424-1 424-2 424-3 424-4
OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS
259 397 605
1147
04342 06514 09768 21520
10000 10000 10000 10000
10000 10000 10000 10000
04342 06514 09768 21520
12500 12500 12500 12500
05428 08143 12210 26900
10000 10000 10000 10000
04342 06514 09768 21520
$4071 Misc Pediatric $6107 Misc Pediatric $9158 Misc Pediatric
$20175 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
425-1 425-2 425-3
ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED
241 302 460
04017 05132 07667
10000 10000 10000
10000 10000 10000
04017 05132 07667
12500 12500 12500
05021 06415 09584
10000 10000 10000
04017 05132 07667
$3766 Misc Pediatric $4811 Misc Pediatric $7188 Misc Pediatric
Misc Adult Misc Adult Misc Adult
425-4 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 946 16767 10000 10000 16767 12500 20959 10000 16767 $15719 Misc Pediatric Misc Adult 440-1 440-2 440-3 440-4
KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT
458 561 864
2088
44667 50078 60562 99171
10000 10000 10000 10000
10000 10000 10000 10000
44667 50078 60562 99171
12500 12500 12500 12500
55834 62598 75703
123964
10000 10000 10000 10000
44667 50078 60562 99171
$41875 Misc Pediatric $46948 Misc Pediatric $56777 Misc Pediatric $92973 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
441-1 441-2 441-3 441-4
MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES
474 726 994
2196
14386 21567 29549 61841
10000 10000 10000 10000
10000 10000 10000 10000
14386 21567 29549 61841
12500 12500 12500 12500
17983 26959 36936 77301
10000 10000 10000 10000
14386 21567 29549 61841
$13487 Misc Pediatric $20219 Misc Pediatric $27702 Misc Pediatric $57976 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
442-1 442-2 442-3 442-4
KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY
325 422 795
1671
13139 15537 23456 49226
10000 10000 10000 10000
10000 10000 10000 10000
13139 15537 23456 49226
12500 12500 12500 12500
16424 19421 29320 61533
10000 10000 10000 10000
13139 15537 23456 49226
$12318 Misc Pediatric $14566 Misc Pediatric $21990 Misc Pediatric $46149 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
443-1 443-2 443-3 443-4
KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY
253 356 802
1752
10883 12834 18814 40742
10000 10000 10000 10000
10000 10000 10000 10000
10883 12834 18814 40742
12500 12500 12500 12500
13604 16043 23518 50928
10000 10000 10000 10000
10883 12834 18814 40742
$10203 Misc Pediatric $12032 Misc Pediatric $17638 Misc Pediatric $38196 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
444-1 444-2 444-3 444-4
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY
264 447 933
1617
09410 12604 20686 38830
10000 10000 10000 10000
10000 10000 10000 10000
09410 12604 20686 38830
12500 12500 12500 12500
11763 15755 25858 48538
10000 10000 10000 10000
09410 12604 20686 38830
$8822 Misc Pediatric $11816 Misc Pediatric $19393 Misc Pediatric $36403 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
445-1 445-2 445-3 445-4
OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES
190 319 781
1545
08552 11610 15964 31570
10000 10000 10000 10000
10000 10000 10000 10000
08552 11610 15964 31570
12500 12500 12500 12500
10690 14513 19955 39463
10000 10000 10000 10000
08552 11610 15964 31570
$8018 Misc Pediatric $10884 Misc Pediatric $14966 Misc Pediatric $29597 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
446-1 446-2 446-3 446-4
URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES
188 261 612
1363
06758 08690 14202 30173
10000 10000 10000 10000
10000 10000 10000 10000
06758 08690 14202 30173
12500 12500 12500 12500
08448 10863 17753 37716
10000 10000 10000 10000
06758 08690 14202 30173
$6336 Misc Pediatric $8147 Misc Pediatric
$13314 Misc Pediatric $28287 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
447-1 447-2 447-3 447-4
OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES
228 365 728
1787
11479 13294 19661 43932
10000 10000 10000 10000
10000 10000 10000 10000
11479 13294 19661 43932
12500 12500 12500 12500
14349 16618 24576 54915
10000 10000 10000 10000
11479 13294 19661 43932
$10762 Misc Pediatric $12463 Misc Pediatric $18432 Misc Pediatric $41186 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
460-1 460-2 460-3 460-4
RENAL FAILURE RENAL FAILURE RENAL FAILURE RENAL FAILURE
299 376 496
1115
04323 06061 07896 19936
10000 10000 10000 10000
10000 10000 10000 10000
04323 06061 07896 19936
12500 12500 12500 12500
05404 07576 09870 24920
10000 10000 10000 10000
04323 06061 07896 19936
$4053 Misc Pediatric $5682 Misc Pediatric $7403 Misc Pediatric
$18690 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
461-1 461-2 461-3 461-4
KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY
271 374 601
1108
04315 05992 09498 16929
10000 10000 10000 10000
10000 10000 10000 10000
04315 05992 09498 16929
12500 12500 12500 12500
05394 07490 11873 21161
10000 10000 10000 10000
04315 05992 09498 16929
$4045 Misc Pediatric $5618 Misc Pediatric $8904 Misc Pediatric
$15871 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
462-1 462-2 462-3 462-4
NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS
260 370 656
1359
03798 05298 09439 23905
10000 10000 10000 10000
10000 10000 10000 10000
03798 05298 09439 23905
12500 12500 12500 12500
04748 06623 11799 29881
10000 10000 10000 10000
03798 05298 09439 23905
$3561 Misc Pediatric $4967 Misc Pediatric $8849 Misc Pediatric
$22411 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
463-1 463-2 463-3 463-4
KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS
268 352 507 910
04120 05628 07879 14066
10000 10000 10000 10000
10000 10000 10000 10000
04120 05628 07879 14066
12500 12500 12500 12500
05150 07035 09849 17583
10000 10000 10000 10000
04120 05628 07879 14066
$3863 Misc Pediatric $5276 Misc Pediatric $7387 Misc Pediatric
$13187 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
465-1 465-2 465-3 465-4
URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION
165 202 380 860
04374 05548 08751 18922
10000 10000 10000 10000
10000 10000 10000 10000
04374 05548 08751 18922
12500 12500 12500 12500
05468 06935 10939 23653
10000 10000 10000 10000
04374 05548 08751 18922
$4101 Misc Pediatric $5201 Misc Pediatric $8204 Misc Pediatric
$17739 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
466-1 466-2 466-3 466-4
MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC
221 343 533 971
03576 05752 08974 17498
10000 10000 10000 10000
10000 10000 10000 10000
03576 05752 08974 17498
12500 12500 12500 12500
04470 07190 11218 21873
10000 10000 10000 10000
03576 05752 08974 17498
$3353 Misc Pediatric $5393 Misc Pediatric $8413 Misc Pediatric
$16404 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
468-1 468-2 468-3 468-4
OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS
246 335 509
1057
04152 05935 08698 18661
10000 10000 10000 10000
10000 10000 10000 10000
04152 05935 08698 18661
12500 12500 12500 12500
05190 07419 10873 23326
10000 10000 10000 10000
04152 05935 08698 18661
$3893 Misc Pediatric $5564 Misc Pediatric $8154 Misc Pediatric
$17495 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
480-1 480-2 480-3 480-4
MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES
180 241 618
1422
12119 13477 20992 45258
10000 10000 10000 10000
10000 10000 10000 10000
12119 13477 20992 45258
12500 12500 12500 12500
15149 16846 26240 56573
10000 10000 10000 10000
12119 13477 20992 45258
$11362 Misc Pediatric $12635 Misc Pediatric $19680 Misc Pediatric $42429 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
481-1 481-2 481-3 481-4
PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES
228 267 830
1810
06794 11922 17939 41143
10000 10000 10000 10000
10000 10000 10000 10000
06794 11922 17939 41143
12500 12500 12500 12500
08493 14903 22424 51429
10000 10000 10000 10000
06794 11922 17939 41143
$6369 Misc Pediatric $11177 Misc Pediatric $16818 Misc Pediatric $38572 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
482-1 482-2 482-3 482-4
TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY
169 278 716
1341
05918 07555 14662 30717
10000 10000 10000 10000
10000 10000 10000 10000
05918 07555 14662 30717
12500 12500 12500 12500
07398 09444 18328 38396
10000 10000 10000 10000
05918 07555 14662 30717
$5548 Misc Pediatric $7083 Misc Pediatric
$13746 Misc Pediatric $28797 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
483-1 483-2 483-3 483-4
TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES
203 541
1127 1970
06074 11326 22018 44244
10000 10000 10000 10000
10000 10000 10000 10000
06074 11326 22018 44244
12500 12500 12500 12500
07593 14158 27523 55305
10000 10000 10000 10000
06074 11326 22018 44244
$5694 Misc Pediatric $10618 Misc Pediatric $20642 Misc Pediatric $41479 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
484-1 484-2 484-3 484-4
OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
250 191 502
1578
07704 11762 15177 36555
10000 10000 10000 10000
10000 10000 10000 10000
07704 11762 15177 36555
12500 12500 12500 12500
09630 14703 18971 45694
10000 10000 10000 10000
07704 11762 15177 36555
$7223 Misc Pediatric $11027 Misc Pediatric $14228 Misc Pediatric $34270 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
500-1 500-2 500-3 500-4
MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM
266 431 601
1109
03789 05904 09172 17461
10000 10000 10000 10000
10000 10000 10000 10000
03789 05904 09172 17461
12500 12500 12500 12500
04736 07380 11465 21826
10000 10000 10000 10000
03789 05904 09172 17461
$3552 Misc Pediatric $5535 Misc Pediatric $8599 Misc Pediatric
$16370 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
501-1 501-2 501-3 501-4
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY
258 351 547
1074
04044 05542 08322 16765
10000 10000 10000 10000
10000 10000 10000 10000
04044 05542 08322 16765
12500 12500 12500 12500
05055 06928 10403 20956
10000 10000 10000 10000
04044 05542 08322 16765
$3791 Misc Pediatric $5196 Misc Pediatric $7802 Misc Pediatric
$15717 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
510-1 510-2 510-3 510-4
PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS
244 387 892
1787
11433 14140 25807 52317
10000 10000 10000 10000
10000 10000 10000 10000
11433 14140 25807 52317
12500 12500 12500 12500
14291 17675 32259 65396
10000 10000 10000 10000
11433 14140 25807 52317
$10718 Misc Pediatric $13256 Misc Pediatric $24194 Misc Pediatric $49047 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
511-1 511-2 511-3 511-4
UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY
330 488 862
1777
11911 14923 22750 49888
10000 10000 10000 10000
10000 10000 10000 10000
11911 14923 22750 49888
12500 12500 12500 12500
14889 18654 28438 62360
10000 10000 10000 10000
11911 14923 22750 49888
$11167 Misc Pediatric $13990 Misc Pediatric $21328 Misc Pediatric $46770 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
512-1 512-2 512-3 512-4
UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG
217 308 682
1629
10603 12410 19879 45702
10000 10000 10000 10000
10000 10000 10000 10000
10603 12410 19879 45702
12500 12500 12500 12500
13254 15513 24849 57128
10000 10000 10000 10000
10603 12410 19879 45702
$9940 Misc Pediatric $11634 Misc Pediatric $18637 Misc Pediatric $42846 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
513-1 513-2 513-3 513-4
UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
186 251 564
1508
08515 10026 16283 40387
10000 10000 10000 10000
10000 10000 10000 10000
08515 10026 16283 40387
12500 12500 12500 12500
10644 12533 20354 50484
10000 10000 10000 10000
08515 10026 16283 40387
$7983 Misc Pediatric $9399 Misc Pediatric
$15265 Misc Pediatric $37863 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
514-1 514-2 514-3 514-4
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
140 172 529
1557
07298 09618 15881 40691
10000 10000 10000 10000
10000 10000 10000 10000
07298 09618 15881 40691
12500 12500 12500 12500
09123 12023 19851 50864
10000 10000 10000 10000
07298 09618 15881 40691
$6842 Misc Pediatric $9017 Misc Pediatric
$14888 Misc Pediatric $38148 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
517-1 517-2 517-3 517-4
DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES
192 289 663
1364
06030 08036 13633 29709
10000 10000 10000 10000
10000 10000 10000 10000
06030 08036 13633 29709
12500 12500 12500 12500
07538 10045 17041 37136
10000 10000 10000 10000
06030 08036 13633 29709
$5653 Misc Pediatric $7534 Misc Pediatric
$12781 Misc Pediatric $27852 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
518-1 518-2 518-3 518-4
OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
223 382 837
1827
06924 10040 18032 44556
10000 10000 10000 10000
10000 10000 10000 10000
06924 10040 18032 44556
12500 12500 12500 12500
08655 12550 22540 55695
10000 10000 10000 10000
06924 10040 18032 44556
$6491 Misc Pediatric $9413 Misc Pediatric
$16905 Misc Pediatric $41771 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
519-1 519-2 519-3 519-4
UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA
206 279 613
1485
08286 10051 17505 39433
10000 10000 10000 10000
10000 10000 10000 10000
08286 10051 17505 39433
12500 12500 12500 12500
10358 12564 21881 49291
10000 10000 10000 10000
08286 10051 17505 39433
$7768 Misc Pediatric $9423 Misc Pediatric
$16411 Misc Pediatric $36968 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
530-1 530-2 530-3 530-4
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
310 385 643
1178
04420 06163 09992 18972
10000 10000 10000 10000
10000 10000 10000 10000
04420 06163 09992 18972
12500 12500 12500 12500
05525 07704 12490 23715
10000 10000 10000 10000
04420 06163 09992 18972
$4144 Misc Pediatric $5778 Misc Pediatric $9368 Misc Pediatric
$17786 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
531-1 531-2 531-3 531-4
FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS
266 383 638
1303
04544 06407 09987 20595
10000 10000 10000 10000
10000 10000 10000 10000
04544 06407 09987 20595
12500 12500 12500 12500
05680 08009 12484 25744
10000 10000 10000 10000
04544 06407 09987 20595
$4260 Misc Pediatric $6007 Misc Pediatric $9363 Misc Pediatric
$19308 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
532-1 532-2 532-3 532-4
MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
177 237 434
1003
03922 04787 07941 17650
10000 10000 10000 10000
10000 10000 10000 10000
03922 04787 07941 17650
12500 12500 12500 12500
04903 05984 09926 22063
10000 10000 10000 10000
03922 04787 07941 17650
$3677 Misc Pediatric $4488 Misc Pediatric $7445 Misc Pediatric
$16547 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
540-1 540-2 540-3 540-4
CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY
298 391 634
1053
05654 06864 09354 23719
10000 10000 10000 10000
10600 10600 10600 10600
05993 07276 09915 25142
10000 10000 10000 10000
05993 07276 09915 25142
10000 10000 10000 10000
05654 06864 09354 23719
$4495 Obstetrics $5457 Obstetrics $7436 Obstetrics
$18857 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
541-1 541-2 541-3 541-4
VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC
212 249 491 838
05628 06076 08661 23515
10000 10000 10000 10000
10600 10600 10600 10600
05966 06441 09181 24926
10000 10000 10000 10000
05966 06441 09181 24926
10000 10000 10000 10000
05628 06076 08661 23515
$4474 Obstetrics $4830 Obstetrics $6886 Obstetrics
$18694 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
542-1 542-2 542-3 542-4
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC
216 296 614 993
03695 04647 08572 36195
10000 10000 10000 10000
10600 10600 10600 10600
03917 04926 09086 38367
10000 10000 10000 10000
03917 04926 09086 38367
10000 10000 10000 10000
03695 04647 08572 36195
$2938 Obstetrics $3694 Obstetrics $6815 Obstetrics
$28775 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
544-1 544-2 544-3 544-4
DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES
136 200 407 914
04586 05897 09822 25061
10000 10000 10000 10000
10600 10600 10600 10600
04861 06251 10411 26565
10000 10000 10000 10000
04861 06251 10411 26565
10000 10000 10000 10000
04586 05897 09822 25061
$3646 Obstetrics Obstetrics $4688 Obstetrics Obstetrics $7808 Obstetrics Obstetrics
$19924 Obstetrics Obstetrics 545-1 545-2 545-3 545-4
ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE
164 190 265 576
06988 08147 10540 19945
10000 10000 10000 10000
10600 10600 10600 10600
07407 08636 11172 21142
10000 10000 10000 10000
07407 08636 11172 21142
10000 10000 10000 10000
06988 08147 10540 19945
$5555 Obstetrics Obstetrics $6477 Obstetrics Obstetrics $8379 Obstetrics Obstetrics
$15856 Obstetrics Obstetrics 546-1 546-2 546-3 546-4
OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES
285 454 755
1446
05023 07207 13295 43377
10000 10000 10000 10000
10600 10600 10600 10600
05324 07639 14093 45980
10000 10000 10000 10000
05324 07639 14093 45980
10000 10000 10000 10000
05023 07207 13295 43377
$3993 Obstetrics Obstetrics $5730 Obstetrics Obstetrics
$10570 Obstetrics Obstetrics $34485 Obstetrics Obstetrics
560-1 560-2 560-3 560-4
VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY
203 237 385 935
03307 03856 05399 15061
10000 10000 10000 10000
10600 10600 10600 10600
03505 04087 05723 15965
10000 10000 10000 10000
03505 04087 05723 15965
10000 10000 10000 10000
03307 03856 05399 15061
$2629 Obstetrics Obstetrics $3066 Obstetrics Obstetrics $4292 Obstetrics Obstetrics
$11974 Obstetrics Obstetrics 561-1 561-2 561-3 561-4
POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE
211 257 393 688
02511 03908 06071 15617
10000 10000 10000 10000
10600 10600 10600 10600
02662 04142 06435 16554
10000 10000 10000 10000
02662 04142 06435 16554
10000 10000 10000 10000
02511 03908 06071 15617
$1996 Obstetrics Obstetrics $3107 Obstetrics Obstetrics $4826 Obstetrics Obstetrics
$12416 Obstetrics Obstetrics 563-1 563-2 563-3 563-4
THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION
259 391 747 720
02581 03376 05162 09652
10000 10000 10000 10000
10600 10600 10600 10600
02736 03579 05472 10231
10000 10000 10000 10000
02736 03579 05472 10231
10000 10000 10000 10000
02581 03376 05162 09652
$2052 Obstetrics Obstetrics $2684 Obstetrics Obstetrics $4104 Obstetrics Obstetrics $7673 Obstetrics Obstetrics
564-1 564-2 564-3 564-4
ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY
137 170 276 808
02881 03463 04901 16676
10000 10000 10000 10000
10600 10600 10600 10600
03054 03671 05195 17677
10000 10000 10000 10000
03054 03671 05195 17677
10000 10000 10000 10000
02881 03463 04901 16676
$2290 Obstetrics Obstetrics $2753 Obstetrics Obstetrics $3896 Obstetrics Obstetrics
$13257 Obstetrics Obstetrics 565-1 565-2 565-3 565-4
FALSE LABOR FALSE LABOR FALSE LABOR FALSE LABOR
123 185 735 808
01245 01782 02687 02986
10000 10000 10000 10000
10600 10600 10600 10600
01320 01889 02848 03165
10000 10000 10000 10000
01320 01889 02848 03165
10000 10000 10000 10000
01245 01782 02687 02986
$990 Obstetrics Obstetrics $1417 Obstetrics Obstetrics $2136 Obstetrics Obstetrics $2374 Obstetrics Obstetrics
566-1 566-2 566-3 566-4
OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES
211 294 544 843
02442 03252 04790 14726
10000 10000 10000 10000
10600 10600 10600 10600
02589 03447 05077 15610
10000 10000 10000 10000
02589 03447 05077 15610
10000 10000 10000 10000
02442 03252 04790 14726
$1941 Obstetrics Obstetrics $2585 Obstetrics Obstetrics $3808 Obstetrics Obstetrics
$11707 Obstetrics Obstetrics 580-1 580-2 580-3 580-4
NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE
144 159 182 165
02398 03209 05011 08512
12500 12500 12500 12500
10000 10000 10000 10000
02998 04011 06264 10640
10000 10000 10000 10000
02998 04011 06264 10640
17500 17500 17500 17500
04197 05616 08769 14896
$2248 Neonate Neonate $3008 Neonate Neonate $4698 Neonate Neonate $7980 Neonate Neonate
581-1 581-2 581-3 581-4
NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE
124 128 126 135
00982 01477 02362 04408
12500 12500 12500 12500
10000 10000 10000 10000
01228 01846 02953 05510
10000 10000 10000 10000
01228 01846 02953 05510
17500 17500 17500 17500
01719 02585 04134 07714
$921 Neonate Neonate $1385 Neonate Neonate $2214 Neonate Neonate $4133 Neonate Neonate
583-1 583-2 583-3 583-4
NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO
2070 2300 3077 4886
99741 157496 173245 240894
12500 12500 12500 12500
10000 10000 10000 10000
124676 196870 216556 301118
10000 10000 10000 10000
124676 196870 216556 301118
17500 17500 17500 17500
174547 275618 303179 421565
$93507 Neonate Neonate $147653 Neonate Neonate $162417 Neonate Neonate $225838 Neonate Neonate
588-1 588-2 588-3 588-4
NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE
4442 4935 7714
10207
48410 70035
142903 216660
12500 12500 12500 12500
10000 10000 10000 10000
60513 87544
178629 270825
10000 10000 10000 10000
60513 87544
178629 270825
17500 17500 17500 17500
84718 122561 250080 379155
$45384 Neonate Neonate $65658 Neonate Neonate
$133972 Neonate Neonate $203119 Neonate Neonate
589-1 589-2 589-3 589-4
NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS
5843 5041 3035
265
115468 104972
95430 04454
12500 12500 12500 12500
10000 10000 10000 10000
144335 131215 119288
05568
10000 10000 10000 10000
144335 131215 119288
05568
17500 17500 17500 17500
202069 183701 167003
07795
$108251 Neonate Neonate $98411 Neonate Neonate $89466 Neonate Neonate
$4176 Neonate Neonate 591-1 591-2 591-3 591-4
NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE
211 3710 5061 7221
01574 55672 88282
132286
12500 12500 12500 12500
10000 10000 10000 10000
01968 69590
110353 165358
10000 10000 10000 10000
01968 69590
110353 165358
17500 17500 17500 17500
02755 97426
154494 231501
$1476 Neonate Neonate $52193 Neonate Neonate $82764 Neonate Neonate
$124018 Neonate Neonate 593-1 593-2 593-3 593-4
NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE
1928 4851 5965 7143
15109 51914 82800
122454
12500 12500 12500 12500
10000 10000 10000 10000
18886 64893
103500 153068
10000 10000 10000 10000
18886 64893
103500 153068
17500 17500 17500 17500
26441 90850
144900 214295
$14165 Neonate Neonate $48669 Neonate Neonate $77625 Neonate Neonate
$114801 Neonate Neonate 602-1 602-2 602-3 602-4
NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2513 4403 5324 6307
29635 58707 77593
104733
12500 12500 12500 12500
10000 10000 10000 10000
37044 73384 96991
130916
10000 10000 10000 10000
37044 73384 96991
130916
17500 17500 17500 17500
51861 102737 135788 183283
$27783 Neonate Neonate $55038 Neonate Neonate $72743 Neonate Neonate $98187 Neonate Neonate
603-1 603-2 603-3 603-4
NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION
2234 3619 4843 5396
17223 42526 65587 70750
12500 12500 12500 12500
10000 10000 10000 10000
21529 53158 81984 88438
10000 10000 10000 10000
21529 53158 81984 88438
17500 17500 17500 17500
30140 74421
114777 123813
$16147 Neonate Neonate $39868 Neonate Neonate $61488 Neonate Neonate $66328 Neonate Neonate
607-1 607-2 607-3 607-4
NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2509 3582 4341 4957
27503 47486 61883 79508
12500 12500 12500 12500
10000 10000 10000 10000
34379 59358 77354 99385
10000 10000 10000 10000
34379 59358 77354 99385
17500 17500 17500 17500
48130 83101
108295 139139
$25784 Neonate Neonate $44518 Neonate Neonate $58015 Neonate Neonate $74539 Neonate Neonate
608-1 608-2 608-3 608-4
NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION
1980 3004 3846 4414
21292 36047 52684 60424
12500 12500 12500 12500
10000 10000 10000 10000
26615 45059 65855 75530
10000 10000 10000 10000
26615 45059 65855 75530
17500 17500 17500 17500
37261 63082 92197
105742
$19961 Neonate Neonate $33794 Neonate Neonate $49391 Neonate Neonate $56648 Neonate Neonate
609-1 609-2 609-3 609-4
NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE
1933 2210 3803 6267
27332 38628 65636
119134
12500 12500 12500 12500
10000 10000 10000 10000
34165 48285 82045
148918
10000 10000 10000 10000
34165 48285 82045
148918
17500 17500 17500 17500
47831 67599
114863 208485
$25624 Neonate Neonate $36214 Neonate Neonate $61534 Neonate Neonate
$111688 Neonate Neonate 611-1 611-2 611-3 611-4
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY
1313 2123 3133 3614
11780 25158 40556 52442
12500 12500 12500 12500
10000 10000 10000 10000
14725 31448 50695 65553
10000 10000 10000 10000
14725 31448 50695 65553
17500 17500 17500 17500
20615 44027 70973 91774
$11044 Neonate Neonate $23586 Neonate Neonate $38021 Neonate Neonate $49164 Neonate Neonate
612-1 612-2 612-3 612-4
NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND
1756 2442 3248 3834
21880 32223 46803 62297
12500 12500 12500 12500
10000 10000 10000 10000
27350 40279 58504 77871
10000 10000 10000 10000
27350 40279 58504 77871
17500 17500 17500 17500
38290 56390 81905
109020
$20513 Neonate Neonate $30209 Neonate Neonate $43878 Neonate Neonate $58403 Neonate Neonate
613-1 613-2 613-3 613-4
NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION
1439 2153 2853 3338
16593 26831 37601 48828
12500 12500 12500 12500
10000 10000 10000 10000
20741 33539 47001 61035
10000 10000 10000 10000
20741 33539 47001 61035
17500 17500 17500 17500
29038 46954 65802 85449
$15556 Neonate Neonate $25154 Neonate Neonate $35251 Neonate Neonate $45776 Neonate Neonate
614-1 614-2 614-3 614-4
NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION
1123 2008 2852 3640
09241 22768 36403 50802
12500 12500 12500 12500
10000 10000 10000 10000
11551 28460 45504 63503
10000 10000 10000 10000
11551 28460 45504 63503
17500 17500 17500 17500
16172 39844 63705 88904
$8663 Neonate Neonate $21345 Neonate Neonate $34128 Neonate Neonate $47627 Neonate Neonate
621-1 621-2 621-3 621-4
NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY
820 1397 2125 2416
06082 15379 27206 38101
12500 12500 12500 12500
10000 10000 10000 10000
07603 19224 34008 47626
10000 10000 10000 10000
07603 19224 34008 47626
17500 17500 17500 17500
10644 26913 47611 66677
$5702 Neonate Neonate $14418 Neonate Neonate $25506 Neonate Neonate $35720 Neonate Neonate
622-1 622-2 622-3 622-4
NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND
1118 1514 1977 2285
13666 20913 29736 47202
12500 12500 12500 12500
10000 10000 10000 10000
17083 26141 37170 59003
10000 10000 10000 10000
17083 26141 37170 59003
17500 17500 17500 17500
23916 36598 52038 82604
$12812 Neonate Neonate $19606 Neonate Neonate $27878 Neonate Neonate $44252 Neonate Neonate
623-1 623-2 623-3 623-4
NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION
924 1399 1872 2738
09934 16800 25087 38932
12500 12500 12500 12500
10000 10000 10000 10000
12418 21000 31359 48665
10000 10000 10000 10000
12418 21000 31359 48665
17500 17500 17500 17500
17385 29400 43902 68131
$9313 Neonate Neonate $15750 Neonate Neonate $23519 Neonate Neonate $36499 Neonate Neonate
625-1 625-2 625-3 625-4
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION
1157 1621 1925 2015
11469 18627 23298 29194
12500 12500 12500 12500
10000 10000 10000 10000
14336 23284 29123 36493
10000 10000 10000 10000
14336 23284 29123 36493
17500 17500 17500 17500
20071 32597 40772 51090
$10752 Neonate Neonate $17463 Neonate Neonate $21842 Neonate Neonate $27369 Neonate Neonate
626-1 626-2 626-3 626-4
NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
279 456 864
1838
01387 02587 07679 22819
10000 10000 10000 10000
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
$1040 Normal newborn Normal newborn $1940 Normal newborn Normal newborn $5759 Normal newborn Normal newborn
$17114 Normal newborn Normal newborn 630-1 630-2 630-3 630-4
NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE
486 940
1448 3912
20468 32885 52250
112072
12500 12500 12500 12500
10000 10000 10000 10000
25585 41106 65313
140090
10000 10000 10000 10000
25585 41106 65313
140090
17500 17500 17500 17500
35819 57549 91438
196126
$19189 Neonate Neonate $30830 Neonate Neonate $48984 Neonate Neonate
$105068 Neonate Neonate 631-1 631-2 631-3 631-4
NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE
335 886
2279 5111
09217 16766 37480 96324
12500 12500 12500 12500
10000 10000 10000 10000
11521 20958 46850
120405
10000 10000 10000 10000
11521 20958 46850
120405
17500 17500 17500 17500
16130 29341 65590
168567
$8641 Neonate Neonate $15718 Neonate Neonate $35138 Neonate Neonate $90304 Neonate Neonate
633-1 633-2 633-3 633-4
NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY
296 651
1226 2381
01972 05798 13892 39728
12500 12500 12500 12500
10000 10000 10000 10000
02465 07248 17365 49660
10000 10000 10000 10000
02465 07248 17365 49660
17500 17500 17500 17500
03451 10147 24311 69524
$1849 Neonate Neonate $5436 Neonate Neonate
$13024 Neonate Neonate $37245 Neonate Neonate
634-1 634-2 634-3 634-4
NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND
465 749
1261 2233
04886 09445 20176 46934
12500 12500 12500 12500
10000 10000 10000 10000
06108 11806 25220 58668
10000 10000 10000 10000
06108 11806 25220 58668
17500 17500 17500 17500
08551 16529 35308 82135
$4581 Neonate Neonate $8855 Neonate Neonate
$18915 Neonate Neonate $44001 Neonate Neonate
636-1 636-2 636-3 636-4
NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION
558 779
1164 1896
05582 08840 15558 30613
12500 12500 12500 12500
10000 10000 10000 10000
06978 11050 19448 38266
10000 10000 10000 10000
06978 11050 19448 38266
17500 17500 17500 17500
09769 15470 27227 53573
$5233 Neonate Neonate $8288 Neonate Neonate
$14586 Neonate Neonate $28700 Neonate Neonate
639-1 639-2 639-3 639-4
NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION
441 704 998
1653
03287 06622 11809 27285
12500 12500 12500 12500
10000 10000 10000 10000
04109 08278 14761 34106
10000 10000 10000 10000
04109 08278 14761 34106
17500 17500 17500 17500
05752 11589 20666 47749
$3082 Neonate Neonate $6208 Neonate Neonate
$11071 Neonate Neonate $25580 Neonate Neonate
640-1 NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 210 01012 10000 10000 01012 10000 01012 10000 01012 $759 Normal newborn Normal newborn
640-2 640-3 640-4
NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
245 376
1206
01353 02864 14726
10000 10000 10000
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
$1015 Normal newborn Normal newborn $2148 Normal newborn Normal newborn
$11045 Normal newborn Normal newborn 650-1 650-2 650-3 650-4
SPLENECTOMY SPLENECTOMY SPLENECTOMY SPLENECTOMY
348 537 848
1563
12985 17965 25202 50826
10000 10000 10000 10000
10000 10000 10000 10000
12985 17965 25202 50826
12500 12500 12500 12500
16231 22456 31503 63533
10000 10000 10000 10000
12985 17965 25202 50826
$12173 Misc Pediatric Misc Adult $16842 Misc Pediatric Misc Adult $23627 Misc Pediatric Misc Adult $47649 Misc Pediatric Misc Adult
651-1 651-2 651-3 651-4
OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS
331 472 962
2426
09234 13695 21005 59541
10000 10000 10000 10000
10000 10000 10000 10000
09234 13695 21005 59541
12500 12500 12500 12500
11543 17119 26256 74426
10000 10000 10000 10000
09234 13695 21005 59541
$8657 Misc Pediatric Misc Adult $12839 Misc Pediatric Misc Adult $19692 Misc Pediatric Misc Adult $55820 Misc Pediatric Misc Adult
660-1 660-2 660-3 660-4
MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL
305 408 648
1435
05399 07219 11819 30180
10000 10000 10000 10000
10000 10000 10000 10000
05399 07219 11819 30180
12500 12500 12500 12500
06749 09024 14774 37725
10000 10000 10000 10000
05399 07219 11819 30180
$5062 Misc Pediatric Misc Adult $6768 Misc Pediatric Misc Adult
$11080 Misc Pediatric Misc Adult $28294 Misc Pediatric Misc Adult
661-1 661-2 661-3 661-4
COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS
275 375 566
1265
06473 08098 12433 27857
10000 10000 10000 10000
10000 10000 10000 10000
06473 08098 12433 27857
12500 12500 12500 12500
08091 10123 15541 34821
10000 10000 10000 10000
06473 08098 12433 27857
$6068 Misc Pediatric Misc Adult $7592 Misc Pediatric Misc Adult
$11656 Misc Pediatric Misc Adult $26116 Misc Pediatric Misc Adult
662-1 662-2 662-3 662-4
SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS
412 538 785
1302
05044 07003 10778 23937
10000 10000 10000 10000
10000 10000 10000 10000
05044 07003 10778 23937
12500 12500 12500 12500
06305 08754 13473 29921
10000 10000 10000 10000
05044 07003 10778 23937
$4729 Misc Pediatric Misc Adult $6565 Misc Pediatric Misc Adult
$10104 Misc Pediatric Misc Adult $22441 Misc Pediatric Misc Adult
663-1 663-2 663-3 663-4
OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS
232 301 451 900
04474 05959 08513 16106
10000 10000 10000 10000
10000 10000 10000 10000
04474 05959 08513 16106
12500 12500 12500 12500
05593 07449 10641 20133
10000 10000 10000 10000
04474 05959 08513 16106
$4194 Misc Pediatric Misc Adult $5587 Misc Pediatric Misc Adult $7981 Misc Pediatric Misc Adult
$15099 Misc Pediatric Misc Adult 680-1 680-2 680-3 680-4
MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
408 633
1185 2456
13702 18600 32002 66288
10000 10000 10000 10000
10000 10000 10000 10000
13702 18600 32002 66288
12500 12500 12500 12500
17128 23250 40003 82860
10000 10000 10000 10000
13702 18600 32002 66288
$12846 Misc Pediatric Misc Adult $17438 Misc Pediatric Misc Adult $30002 Misc Pediatric Misc Adult $62145 Misc Pediatric Misc Adult
681-1 681-2 681-3 681-4
OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
268 507
1111 2510
09800 13647 24597 59170
10000 10000 10000 10000
10000 10000 10000 10000
09800 13647 24597 59170
12500 12500 12500 12500
12250 17059 30746 73963
10000 10000 10000 10000
09800 13647 24597 59170
$9188 Misc Pediatric Misc Adult $12794 Misc Pediatric Misc Adult $23060 Misc Pediatric Misc Adult $55472 Misc Pediatric Misc Adult
690-1 690-2 690-3 690-4
ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA
495 740
1461 2485
07040 11869 23551 52504
10000 10000 10000 10000
10000 10000 10000 10000
07040 11869 23551 52504
12500 12500 12500 12500
08800 14836 29439 65630
10000 10000 10000 10000
07040 11869 23551 52504
$6600 Misc Pediatric Misc Adult $11127 Misc Pediatric Misc Adult $22079 Misc Pediatric Misc Adult $49223 Misc Pediatric Misc Adult
691-1 691-2 691-3 691-4
LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA
389 540 861
1585
07077 09840 15477 31411
10000 10000 10000 10000
10000 10000 10000 10000
07077 09840 15477 31411
12500 12500 12500 12500
08846 12300 19346 39264
10000 10000 10000 10000
07077 09840 15477 31411
$6635 Misc Pediatric Misc Adult $9225 Misc Pediatric Misc Adult
$14510 Misc Pediatric Misc Adult $29448 Misc Pediatric Misc Adult
692-1 692-2 692-3 692-4
RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY
389 482 868
1580
06075 12584 17422 29316
10000 10000 10000 10000
10000 10000 10000 10000
06075 12584 17422 29316
12500 12500 12500 12500
07594 15730 21778 36645
10000 10000 10000 10000
06075 12584 17422 29316
$5695 Misc Pediatric Misc Adult $11798 Misc Pediatric Misc Adult $16333 Misc Pediatric Misc Adult $27484 Misc Pediatric Misc Adult
693-1 693-2 693-3 693-4
CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY
281 368 785
2410
06251 07881 13637 49083
10000 10000 10000 10000
10000 10000 10000 10000
06251 07881 13637 49083
12500 12500 12500 12500
07814 09851 17046 61354
10000 10000 10000 10000
06251 07881 13637 49083
$5860 Misc Pediatric Misc Adult $7388 Misc Pediatric Misc Adult
$12785 Misc Pediatric Misc Adult $46015 Misc Pediatric Misc Adult
694-1 694-2 694-3 694-4
LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR
304 404 674
1164
04842 06831 11115 21001
10000 10000 10000 10000
10000 10000 10000 10000
04842 06831 11115 21001
12500 12500 12500 12500
06053 08539 13894 26251
10000 10000 10000 10000
04842 06831 11115 21001
$4539 Misc Pediatric Misc Adult $6404 Misc Pediatric Misc Adult
$10420 Misc Pediatric Misc Adult $19688 Misc Pediatric Misc Adult
710-1 710-2 710-3 710-4
INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE
510 680
1111 1820
10635 15963 25572 49382
10000 10000 10000 10000
10000 10000 10000 10000
10635 15963 25572 49382
12500 12500 12500 12500
13294 19954 31965 61728
10000 10000 10000 10000
10635 15963 25572 49382
$9970 Misc Pediatric Misc Adult $14965 Misc Pediatric Misc Adult $23974 Misc Pediatric Misc Adult $46296 Misc Pediatric Misc Adult
711-1 711-2 711-3 711-4
POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE
471 692
1131 2087
10079 14143 23599 50574
10000 10000 10000 10000
10000 10000 10000 10000
10079 14143 23599 50574
12500 12500 12500 12500
12599 17679 29499 63218
10000 10000 10000 10000
10079 14143 23599 50574
$9449 Misc Pediatric Misc Adult $13259 Misc Pediatric Misc Adult $22124 Misc Pediatric Misc Adult $47413 Misc Pediatric Misc Adult
720-1 720-2 720-3 720-4
SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS
353 444 633
1004
05431 07613 11532 21705
10000 10000 10000 10000
10000 10000 10000 10000
05431 07613 11532 21705
12500 12500 12500 12500
06789 09516 14415 27131
10000 10000 10000 10000
05431 07613 11532 21705
$5092 Misc Pediatric Misc Adult $7137 Misc Pediatric Misc Adult
$10811 Misc Pediatric Misc Adult $20348 Misc Pediatric Misc Adult
721-1 721-2 721-3 721-4
POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS
368 470 705
1153
05287 07209 11619 22025
10000 10000 10000 10000
10000 10000 10000 10000
05287 07209 11619 22025
12500 12500 12500 12500
06609 09011 14524 27531
10000 10000 10000 10000
05287 07209 11619 22025
$4957 Misc Pediatric Misc Adult $6758 Misc Pediatric Misc Adult
$10893 Misc Pediatric Misc Adult $20648 Misc Pediatric Misc Adult
722-1 722-2 722-3 722-4
FEVER FEVER FEVER FEVER
230 302 429 739
03423 05223 07630 13141
10000 10000 10000 10000
10000 10000 10000 10000
03423 05223 07630 13141
12500 12500 12500 12500
04279 06529 09538 16426
10000 10000 10000 10000
03423 05223 07630 13141
$3209 Misc Pediatric Misc Adult $4897 Misc Pediatric Misc Adult $7153 Misc Pediatric Misc Adult
$12320 Misc Pediatric Misc Adult 723-1 723-2 723-3 723-4
VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS
216 279 470
1317
03194 04738 07794 24233
10000 10000 10000 10000
10000 10000 10000 10000
03194 04738 07794 24233
12500 12500 12500 12500
03993 05923 09743 30291
10000 10000 10000 10000
03194 04738 07794 24233
$2994 Misc Pediatric Misc Adult $4442 Misc Pediatric Misc Adult $7307 Misc Pediatric Misc Adult
$22718 Misc Pediatric Misc Adult 724-1 724-2 724-3 724-4
OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES
400 477 680
1337
05512 07131 11401 24698
10000 10000 10000 10000
10000 10000 10000 10000
05512 07131 11401 24698
12500 12500 12500 12500
06890 08914 14251 30873
10000 10000 10000 10000
05512 07131 11401 24698
$5168 Misc Pediatric Misc Adult $6685 Misc Pediatric Misc Adult
$10688 Misc Pediatric Misc Adult $23154 Misc Pediatric Misc Adult
740-1 740-2 740-3 740-4
MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE
678 1284 2034 2421
10899 13904 24356 37756
10000 10000 10000 10000
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
$8174 Other Other $10428 Other Other $18267 Other Other $28317 Other Other
750-1 750-2 750-3 750-4
SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA
1082 1179 1539 2848
05713 06699 09202 19283
10000 10000 10000 10000
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
$4285 Other Other $5024 Other Other $6902 Other Other
$14462 Other Other 751-1 751-2 751-3 751-4
MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES
528 724
1055 2028
03572 05019 08097 15923
10000 10000 10000 10000
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
$2679 Other Other $3764 Other Other $6073 Other Other
$11942 Other Other 752-1 752-2 752-3 752-4
DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL
503 658
1473 7300
03399 04498 09061 14934
10000 10000 10000 10000
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
$2549 Other Other $3374 Other Other $6796 Other Other
$11201 Other Other 753-1 753-2 753-3 753-4
BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS
601 808
1205 1948
04001 05365 08266 14926
10000 10000 10000 10000
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
$3001 Other Other $4024 Other Other $6200 Other Other
$11195 Other Other 754-1 754-2 754-3 754-4
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER
424 558 727
1664
02943 03998 05677 11553
10000 10000 10000 10000
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
$2207 Other Other $2999 Other Other $4258 Other Other $8665 Other Other
755-1 755-2 755-3 755-4
ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
388 622 900 813
02738 04363 06226 08767
10000 10000 10000 10000
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
$2054 Other Other $3272 Other Other $4670 Other Other $6575 Other Other
756-1 756-2 756-3 756-4
ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES
331 381 457 942
04061 05308 06065 13981
10000 10000 10000 10000
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
$3046 Other Other $3981 Other Other $4549 Other Other
$10486 Other Other 757-1 757-2 757-3 757-4
ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES
873 934
1087 1640
05861 07234 08953 13799
10000 10000 10000 10000
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
$4396 Other Other $5426 Other Other $6715 Other Other
$10349 Other Other 758-1 758-2 758-3 758-4
CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS
694 981
1225 4300
03874 05129 06541 11332
10000 10000 10000 10000
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
$2906 Other Other $3847 Other Other $4906 Other Other $8499 Other Other
759-1 759-2 759-3 759-4
EATING DISORDERS EATING DISORDERS EATING DISORDERS EATING DISORDERS
1990 1297 1402 2303
06561 06961 10053 16606
10000 10000 10000 10000
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
$4921 Other Other $5221 Other Other $7540 Other Other
$12455 Other Other 760-1 760-2 760-3 760-4
OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS
748 766 912
1204
04840 06173 07573 14134
10000 10000 10000 10000
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
$3630 Other Other $4630 Other Other $5680 Other Other
$10601 Other Other 770-1 770-2 770-3 770-4
DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE
253 248 332 794
02240 02623 05475 16843
10000 10000 10000 10000
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
$1680 Other Other $1967 Other Other $4106 Other Other
$12632 Other Other 772-1 772-2 772-3 772-4
ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY
1434 1551 1289 2385
05441 06916 07009 24530
10000 10000 10000 10000
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
$4081 Other Other $5187 Other Other $5257 Other Other
$18398 Other Other 773-1 773-2 773-3 773-4
OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE
337 414 507 992
02663 03466 05964 18606
10000 10000 10000 10000
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
$1997 Other Other $2600 Other Other $4473 Other Other
$13955 Other Other 774-1 774-2
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
365 412
03040 03627
10000 10000
10000 10000
03040 03627
10000 10000
03040 03627
10000 10000
03040 03627
$2280 Other Other $2720 Other Other
774-3 774-4
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
479 1424
06448 24682
10000 10000
10000 10000
06448 24682
10000 10000
06448 24682
10000 10000
06448 24682
$4836 Other $18512 Other
Other Other
775-1 775-2 775-3 775-4
ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE
323 377 571
1263
03313 04639 08596 24910
10000 10000 10000 10000
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
$2485 Other $3479 Other $6447 Other
$18683 Other
Other Other Other Other
776-1 776-2 776-3 776-4
OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE
389 397 496 933
03157 04547 07887 16112
10000 10000 10000 10000
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
$2368 Other $3410 Other $5915 Other
$12084 Other
Other Other Other Other
791-1 791-2 791-3 791-4
OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT
314 515 989
2009
08636 12677 21979 49312
10000 10000 10000 10000
10000 10000 10000 10000
08636 12677 21979 49312
12500 12500 12500 12500
10795 15846 27474 61640
10000 10000 10000 10000
08636 12677 21979 49312
$8096 Misc Pediatric $11885 Misc Pediatric $20605 Misc Pediatric $46230 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
811-1 811-2 811-3 811-4
ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS
151 202 390 913
02707 03855 08277 22176
10000 10000 10000 10000
10000 10000 10000 10000
02707 03855 08277 22176
12500 12500 12500 12500
03384 04819 10346 27720
10000 10000 10000 10000
02707 03855 08277 22176
$2538 Misc Pediatric $3614 Misc Pediatric $7760 Misc Pediatric
$20790 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
812-1 812-2 812-3 812-4
POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS
165 225 347 694
03469 04331 07709 17419
10000 10000 10000 10000
10000 10000 10000 10000
03469 04331 07709 17419
12500 12500 12500 12500
04336 05414 09636 21774
10000 10000 10000 10000
03469 04331 07709 17419
$3252 Misc Pediatric $4060 Misc Pediatric $7227 Misc Pediatric
$16330 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
813-1 813-2 813-3 813-4
OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT
261 344 594
1344
04393 06056 09631 19960
10000 10000 10000 10000
10000 10000 10000 10000
04393 06056 09631 19960
12500 12500 12500 12500
05491 07570 12039 24950
10000 10000 10000 10000
04393 06056 09631 19960
$4118 Misc Pediatric $5678 Misc Pediatric $9029 Misc Pediatric
$18713 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
815-1 815-2 815-3 815-4
OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES
169 276 456 880
04211 05012 08129 22715
10000 10000 10000 10000
10000 10000 10000 10000
04211 05012 08129 22715
12500 12500 12500 12500
05264 06265 10161 28394
10000 10000 10000 10000
04211 05012 08129 22715
$3948 Misc Pediatric $4699 Misc Pediatric $7621 Misc Pediatric
$21295 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
816-1 816-2 816-3 816-4
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
173 240 346 736
04162 04915 07864 18134
10000 10000 10000 10000
10000 10000 10000 10000
04162 04915 07864 18134
12500 12500 12500 12500
05203 06144 09830 22668
10000 10000 10000 10000
04162 04915 07864 18134
$3902 Misc Pediatric $4608 Misc Pediatric $7373 Misc Pediatric
$17001 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
841-1 841-2 841-3 841-4
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT
2200 967
2599 4068
31148 34263 64068
159153
10000 10000 10000 10000
10000 10000 10000 10000
31148 34263 64068
159153
12500 12500 12500 12500
38935 42829 80085
198941
10000 10000 10000 10000
31148 34263 64068
159153
$29201 Misc Pediatric $32122 Misc Pediatric $60064 Misc Pediatric
$149206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
842-1 842-2 842-3 842-4
FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT
751 1072 1735 3010
14151 21416 38719 95054
10000 10000 10000 10000
10000 10000 10000 10000
14151 21416 38719 95054
12500 12500 12500 12500
17689 26770 48399
118818
10000 10000 10000 10000
14151 21416 38719 95054
$13267 Misc Pediatric $20078 Misc Pediatric $36299 Misc Pediatric $89113 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
843-1 843-2 843-3 843-4
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT
339 487 713
1113
04752 06661 11619 32621
10000 10000 10000 10000
10000 10000 10000 10000
04752 06661 11619 32621
12500 12500 12500 12500
05940 08326 14524 40776
10000 10000 10000 10000
04752 06661 11619 32621
$4455 Misc Pediatric $6245 Misc Pediatric
$10893 Misc Pediatric $30582 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
844-1 844-2 844-3 844-4
PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT
310 497 743
1781
04337 06965 12193 48021
10000 10000 10000 10000
10000 10000 10000 10000
04337 06965 12193 48021
12500 12500 12500 12500
05421 08706 15241 60026
10000 10000 10000 10000
04337 06965 12193 48021
$4066 Misc Pediatric $6530 Misc Pediatric
$11431 Misc Pediatric $45020 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
850-1 850-2 850-3 850-4
PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE
267 556
1618 3148
11757 14065 24870 46520
10000 10000 10000 10000
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
$8818 Misc Pediatric $10549 Misc Pediatric $18653 Misc Pediatric $34890 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
860-1 860-2 860-3 860-4
REHABILITATION REHABILITATION REHABILITATION REHABILITATION
932 1146 1475 1795
07227 09855 13880 17876
10000 10000 10000 10000
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
$5420 Other $7391 Other
$10410 Other $13407 Other
Other Other Other Other
861-1 861-2 861-3 861-4
SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS
253 340 497 917
02858 05247 07658 14498
10000 10000 10000 10000
10000 10000 10000 10000
02858 05247 07658 14498
12500 12500 12500 12500
03573 06559 09573 18123
10000 10000 10000 10000
02858 05247 07658 14498
$2679 Misc Pediatric $4919 Misc Pediatric $7179 Misc Pediatric
$13592 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
862-1 862-2 862-3 862-4
OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE
698 1122 1357 1872
02895 05851 07866 11351
10000 10000 10000 10000
10000 10000 10000 10000
02895 05851 07866 11351
12500 12500 12500 12500
03619 07314 09833 14189
10000 10000 10000 10000
02895 05851 07866 11351
$2714 Misc Pediatric $5485 Misc Pediatric $7374 Misc Pediatric
$10642 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
863-1 863-2 863-3 863-4
NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE
853 1757 2771 4643
05959 16127 30507 61446
12500 12500 12500 12500
10000 10000 10000 10000
07449 20159 38134 76808
10000 10000 10000 10000
07449 20159 38134 76808
17500 17500 17500 17500
10428 28222 53387
107531
$5587 Neonate $15119 Neonate $28600 Neonate $57606 Neonate
Neonate Neonate Neonate Neonate
890-1 890-2 890-3 890-4
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS
167 691 921
1514
07051 10224 14771 30014
10000 10000 10000 10000
10000 10000 10000 10000
07051 10224 14771 30014
12500 12500 12500 12500
08814 12780 18464 37518
10000 10000 10000 10000
07051 10224 14771 30014
$6610 Misc Pediatric $9585 Misc Pediatric
$13848 Misc Pediatric $28138 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
892-1 892-2 892-3 892-4
HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION
587 488 669
1152
05647 07763 10877 19375
10000 10000 10000 10000
10000 10000 10000 10000
05647 07763 10877 19375
12500 12500 12500 12500
07059 09704 13596 24219
10000 10000 10000 10000
05647 07763 10877 19375
$5294 Misc Pediatric $7278 Misc Pediatric
$10197 Misc Pediatric $18164 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
893-1 893-2 893-3 893-4
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
499 496 799
1422
07762 08219 12807 24296
10000 10000 10000 10000
10000 10000 10000 10000
07762 08219 12807 24296
12500 12500 12500 12500
09703 10274 16009 30370
10000 10000 10000 10000
07762 08219 12807 24296
$7277 Misc Pediatric $7705 Misc Pediatric
$12007 Misc Pediatric $22778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
894-1 894-2 894-3 894-4
HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND
341 393 627
1121
05218 06497 09774 19428
10000 10000 10000 10000
10000 10000 10000 10000
05218 06497 09774 19428
12500 12500 12500 12500
06523 08121 12218 24285
10000 10000 10000 10000
05218 06497 09774 19428
$4892 Misc Pediatric $6091 Misc Pediatric $9163 Misc Pediatric
$18214 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
910-1 910-2 910-3 910-4
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA
1100 775
1057 1830
28786 31984 41628 72114
10000 10000 10000 10000
10000 10000 10000 10000
28786 31984 41628 72114
12500 12500 12500 12500
35983 39980 52035 90143
10000 10000 10000 10000
28786 31984 41628 72114
$26987 Misc Pediatric $29985 Misc Pediatric $39026 Misc Pediatric $67607 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
911-1 911-2 911-3 911-4
EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA
511 619 795
1687
15160 20189 26724 58039
10000 10000 10000 10000
10000 10000 10000 10000
15160 20189 26724 58039
12500 12500 12500 12500
18950 25236 33405 72549
10000 10000 10000 10000
15160 20189 26724 58039
$14213 Misc Pediatric $18927 Misc Pediatric $25054 Misc Pediatric $54412 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
912-1 912-2 912-3 912-4
MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
558 607 985
1782
20950 22759 36410 68885
10000 10000 10000 10000
10000 10000 10000 10000
20950 22759 36410 68885
12500 12500 12500 12500
26188 28449 45513 86106
10000 10000 10000 10000
20950 22759 36410 68885
$19641 Misc Pediatric $21337 Misc Pediatric $34134 Misc Pediatric $64580 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
930-1 930-2 930-3 930-4
MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE
322 370 596
1127
07826 09594 15857 33896
10000 10000 10000 10000
10000 10000 10000 10000
07826 09594 15857 33896
12500 12500 12500 12500
09783 11993 19821 42370
10000 10000 10000 10000
07826 09594 15857 33896
$7337 Misc Pediatric $8994 Misc Pediatric
$14866 Misc Pediatric $31778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
950-1 950-2 950-3 950-4
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
361 623
1166 2260
13230 20029 31827 60092
10000 10000 10000 10000
10000 10000 10000 10000
13230 20029 31827 60092
12500 12500 12500 12500
16538 25036 39784 75115
10000 10000 10000 10000
13230 20029 31827 60092
$12403 Misc Pediatric $18777 Misc Pediatric $29838 Misc Pediatric $56336 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
951-1 951-2 951-3 951-4
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
329 517
1001 1973
09755 14320 24054 46875
10000 10000 10000 10000
10000 10000 10000 10000
09755 14320 24054 46875
12500 12500 12500 12500
12194 17900 30068 58594
10000 10000 10000 10000
09755 14320 24054 46875
$9145 Misc Pediatric $13425 Misc Pediatric $22551 Misc Pediatric $43945 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
952-1 952-2 952-3 952-4
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
274 504 968
1894
07736 11591 20369 39177
10000 10000 10000 10000
10000 10000 10000 10000
07736 11591 20369 39177
12500 12500 12500 12500
09670 14489 25461 48971
10000 10000 10000 10000
07736 11591 20369 39177
$7253 Misc Pediatric $10867 Misc Pediatric $19096 Misc Pediatric $36728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
955-0 956-0
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS UNGROUPABLE
--
--
Error DRG Error DRG
Error DRG Error DRG
i-
i
i
i-
i
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy adjustor F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that has at least a basic level
emergency room H FY 2015-16 Cost-to-Charge Ratio FY 2013 cost-to-charge ratio with some exceptions I FY 2015-16 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FY 2015-16 Wage Index Value (adjusted for CA Neutrality Factor 09797) W age index value times 09797 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls for changes between California
and the rest of the US while maintaining relative differences among wage areas within California K FY 2015-16 Unadjusted Statewide Base Rate The statewide DRG base rate is $6289 except that for remote rural hospitals it is $12768 L FY 2015-16 Wage Adjusted Statewide Base Rate (Non-Transition) The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses See Tab 5 This rate is applicable for non-transition hospitals as shown in Column N Medi-Cal
managed care plans that are pricing claims for emergency and post-stabilization services hospitals outside their network should use Column L for all hospitals M FY 2015-16 Hospital-Specific Transition Base Rate The base rate assigned to hospitals to move them in steps toward the statewide base rate This rate is applicable for transition hospitals as shown in Column N FY 2015-16 is the final year of transition rates N Transition rate This column identifies whether the hospital is a non-transition hospital (base rate in Column L) or a transition hospital (base rate in Column M) O FY 2015-16 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2015-16 P FY 2015-16 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by
use of Revenue Code 190 Q FY 2015-16 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by use of
Revenue Code 199
A B C D E F G H I J K L M N O P Q
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transit on Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
OUT OF STATE No No No No No 2180 10000 10000 $6289 $6289 NA Non-Transition NA $98163 $80582 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 3572 12882 12620 $12768 $15097 $15414 Transition NA $98163 $80582 106100793 ADVENTIST MEDICAL CENTER - SELMA COMMUNITY HOSPITAL No No No Yes Yes 3572 12882 12620 $12768 $15097 $14680 Transition NA $98163 $80582 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 4360 12882 12620 $12768 $15097 $10484 Transition NA $98163 $80582 106301098 AHMC ANAHEIM REG MED CTR No No No No No 1656 12882 12620 $6289 $7436 $15144 Transition NA $98163 $80582 106010846 ALAMEDA CO MED CTR Yes No No No No 4036 16962 16618 $6289 $9186 NA NA NA NA NA 106010735 ALAMEDA HOSP No Yes No No No 2600 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106190017 ALHAMBRA HOSP No No No No No 1397 12882 12620 $6289 $7436 $5446 Transition $1220 $98163 $80582 106010739 ALTA BATES SUMMIT MED CTR-ALTA BATES No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106010937 ALTA BATES SUMMIT MED CTR-HAWTHORNE No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106010844 ALTA BATES SUMMIT MED CTR-HERRICK CAMPUS No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106013626 ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106374063 ALVARADO HOSP MED CTR - REHAB No No No No No 1930 12882 12620 $6289 $7436 $4599 Transition $1220 $98163 $80582 106190034 ANTELOPE VALLEY HOSP MED CTR No Yes No No No 2997 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364231 ARROWHEAD REG MED CTR Yes No No No No 3324 12882 12620 $6289 $7436 NA NA NA NA NA 106400466 ARROYO GRANDE COMM HOSP No No No No No 2581 12964 12701 $6289 $7471 NA Non-Transition $1226 $98163 $80582 106154101 BAKERSFIELD HEART HOSP No No No No No 1782 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150722 BAKERSFIELD MEM HOSP-34TH ST No No No No No 2117 12882 12620 $6289 $7436 $9141 Transition NA $98163 $80582 106364121 BALLARD REHABILITATION HOSP No No No No No 8300 12882 12620 NA NA NA NA $1427 $98163 $80582 106184008 BANNER LASSEN MED CTR No No No Yes Yes 3967 12882 12620 $12768 $15097 $18668 Transition NA $98163 $80582 106190052 BARLOW RESP HOSP No No No No No 1849 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364430 BARSTOW COMM HOSP No No No Yes Yes 2262 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090793 BARTON MEM HOSP No No No Yes Yes 3635 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106361110 BEAR VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190081 BEVERLY HOSP No No No No No 3567 12882 12620 $6289 $7436 $5841 Transition NA $98163 $80582 106040802 BIGGS GRIDLEY MEM HOSP No No No Yes Yes 3652 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106380929 CA PACIFIC MED CTR No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380777 CA PACIFIC MED CTR - CALIFORNIA WEST No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380933 CA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 2873 16738 16398 $6289 $9090 NA Non-Transition $1492 $98163 $80582 106190125 CALIFORNIA HOSP MED CTR-LA No No Yes No No 2078 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190137 CASA COLINA HOSP FOR REHAB MED No No No No No 7213 12882 12620 NA NA NA NA $1220 $98163 $80582 106190045 CATALINA ISLAND MED CTR No No No Yes Yes 9000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190555 CEDARS-SINAI MED CTR No No Yes No No 2051 12882 12620 $6289 $7436 $5837 Transition $1220 $98163 $80582 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 1730 12882 12620 $6289 $7436 $6350 Transition $1220 $98163 $80582 106160787 CENTRAL VALLEY GEN HOSP No No No No No 7778 12882 12620 $6289 $7436 $11888 Transition NA $98163 $80582 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 2190 12892 12630 $6289 $7440 NA Non-Transition $1221 $98163 $80582 106301140 CHAPMAN MED CTR No No No No No 1908 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304113 CHILDRENS HOSP AT MISSION No No No No No 3300 12882 12620 $6289 $7436 $18777 Transition NA $98163 $80582 106204019 CHILDRENS HOSP CENTRAL CALIFORNIA No No Yes No No 2430 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106010776 CHILDRENS HOSP OAKLAND No No Yes No No 3356 16478 16143 $6289 $8978 NA Non-Transition $2628 $98163 $80582 106190170 CHILDRENS HOSP OF LA No No Yes No No 3988 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106300032 CHILDRENS HOSP OF ORANGE CO No No Yes No No 2442 12882 12620 $6289 $7436 $5613 Transition NA $98163 $80582 106382715 CHINESE HOSP No No No No No 3835 16738 16398 $6289 $9090 $8053 Transition NA $98163 $80582 106361144 CHINO VALLEY MED CTR No No No No No 2098 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190176 CITY OF HOPE HELFORD CLINIC RES HOSP No No No No No 2789 12882 12620 $6289 $7436 $5941 Transition NA $98163 $80582 106100005 CLOVIS COMM MED CTR No No No No No 3336 12882 12620 $6289 $7436 $7752 Transition NA $98163 $80582 106100697 COALINGA REG MED CTR No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190766 COAST PLAZA DRS HOSP No No No No No 2126 12882 12620 $6289 $7436 $5303 Transition NA $98163 $80582 106301258 COASTAL COMM HOSP No No No No No 2792 12882 12620 $6289 $7436 $7035 Transition NA $98163 $80496 106301155 COLLEGE HOSP COSTA MESA No No No No No 2876 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190587 COLLEGE MEDICAL CENTER No No No No No 3760 12882 12620 $6289 $7436 $4258 Transition NA $98163 $80582 106361458 COLORADO RIVER MED CTR No No No Yes Yes 4357 12882 12620 $12768 $15097 $18541 Transition NA $98163 $80582 106060870 COLUSA REG MED CTR No No No Yes Yes 3066 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190197 COMM AND MISSION HOSP OF HUNT PK No No No No No 1601 12882 12620 $6289 $7436 $5421 Transition NA $98163 $80582 106190475 COMM HOSP OF LONG BEACH No No No No No 1707 12882 12620 $6289 $7436 $15917 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106361323 COMM HOSP OF SAN BERNARDINO No No No No No 2833 12882 12620 $6289 $7436 $6516 Transition NA $98163 $78406 106560473 COMM MEM HOSP OF SAN BUENAVENTURA No No No No No 2104 12882 12620 $6289 $7436 $4512 Transition NA $98163 $80582 106100717 COMM REG MED CTR-FRESNO No No No No No 1896 12882 12620 $6289 $7436 $7994 Transition $1655 $98163 $80582 106070924 CONTRA COSTA REG MED CTR Yes No No No No 6010 16478 16143 $6289 $8978 NA NA NA NA NA 106331152 CORONA REG MED CTR No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition NA $98163 $80582 106331145 CORONA REG MED CTR - MAGNOLIA No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition $1220 $98163 $80582 106190413 CV-INTERCOMMUNITY CAMPUS No No No No No 3136 12882 12620 $6289 $7436 $6821 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106190636 CV-QUEEN OF VALLEY CAMPUS No No Yes No No 3136 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106150706 DELANO REG MED CTR No No No No No 3622 12882 12620 $6289 $7436 $7087 Transition NA $98163 $80582 106331164 DESERT REG MED CTR No No No No No 1486 12882 12620 $6289 $7436 $7153 Transition $1447 $98163 $80582 106364144 DESERT VALLEY HOSP No No No No No 2050 12882 12620 $6289 $7436 $8173 Transition NA $98163 $80582 106440755 DOMINICAN HOSP-SANTA CRUZ No No No No No 2016 17239 16889 $6289 $9304 $7821 Transition $1527 $98163 $80582 106190243 DOWNEY REG MED CTR No No No No No 1732 12882 12620 $6289 $7436 $6847 Transition NA $98163 $80582 106392287 DRS HOSP OF MANTECA No No No No No 1362 13579 13303 $6289 $7735 $11712 Transition NA $98163 $80582 106390846 DAMERON HOSP No No No No No 2138 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106190857 DRS HOSP OF WEST COVINA No No No No No 1833 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106070904 DRS MED CTR-SAN PABLOPINOLE No Yes No No No 2373 16478 16143 $6289 $8978 $6025 Transition NA $98163 $80582 106190256 EAST LA DRS HOSP No No No No No 1952 12882 12620 $6289 $7436 $5809 Transition NA $98163 $80582 106190328 EAST VALLEY HOSP MED CTR No No No No No 2859 12882 12620 $6289 $7436 $5534 Transition NA $98163 $80582 106320859 EASTERN PLUMAS HOSP No Yes No Yes Yes 4802 12882 12620 $12768 $15097 $13674 Transition NA $98163 $80582 106014233 EDEN MED CTR No No No No No 3197 16962 16618 $6289 $9186 $12768 Transition NA $98163 $80582 106331168 EISENHOWER MEM HOSP No No No No No 1540 12882 12620 $6289 $7436 $10211 Transition NA $98163 $80582 106430763 EL CAMINO HOSP No Yes No No No 2857 17180 16831 $6289 $9279 $5377 Transition $1523 $98163 $80582 106130699 EL CENTRO COMM HOSP No Yes No No No 2298 12882 12620 $6289 $7436 $8949 Transition NA $98163 $80582 106500852 DRS MED CTR No No No No No 1181 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106500867 EMANUEL MED CTR No No No No No 2046 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106040962 ENLOE MED CTR No No No No No 2436 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106044011 ENLOE REHABILLITATION CENTER No No No No No 2463 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106474007 FAIRCHILD MED CTR No No No Yes Yes 3914 12882 12620 $12768 $15097 $16385 Transition NA $98163 $80582 106040875 FEATHER RIVER HOSP No No No No No 1240 12882 12620 $6289 $7436 $10796 Transition NA $98163 $80582 106190298 FOOTHILL PRES HOSP No No No No No 2989 12882 12620 $6289 $7436 $4740 Transition NA $98163 $80582 106301175 FOUNTAIN VALLEY REG HOSP-EUCLID No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106304039 FOUNTAIN VALLEY REG HOSP-WARNER No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106230949 FRANK R HOWARD MEM HOSP No No No Yes Yes 3495 12882 12620 $12768 $15097 $15377 Transition NA $98163 $80582 106510882 FREMONT MEDICAL CENTER No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106190280 ENCINO HOSP MED CTR No No No No No 949 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106400480 FRENCH HOSP MED CTR No No No No No 2241 12964 12701 $6289 $7471 NA Non-Transition NA $98163 $80582 106301283 GARDEN GROVE HOSP AND MED CTR No No No No No 2661 12882 12620 $6289 $7436 $5749 Transition NA $98163 $80582 106190159 GARDEN REG HOSP AND MED CTR No No No No No 2937 12882 12620 $6289 $7436 $4110 Transition NA $98163 $80582 106105029 FRESNO HEART HOSP No No No No No 3403 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106270777 GEORGE L MEE MEM HOSP No No No Yes Yes 3562 15558 15242 $12768 $17426 $20386 Transition NA $98163 $80582 106190315 GARFIELD MED CTR No No No No No 1031 12882 12620 $6289 $7436 NA Non-Transition $1394 $98163 $80582 106190522 GLENDALE MEM HOSP AND HLTH CTR No No No No No 2163 12882 12620 $6289 $7436 $6885 Transition $1220 $98163 $80582 106110889 GLENN MED CTR No No No Yes Yes 6660 12882 12620 $12768 $15097 $21024 Transition NA $98163 $80582 106190323 GLENDALE ADV MED CTR-WILSON TERRACE No No No No No 1845 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420483 GOLETA VALLEY COTTAGE HOSP No No No No No 3083 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150775 GOOD SAMARITAN HOSP-BAKERSFIELD No No No No No 3694 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430779 GOOD SAMARITAN HOSP-SAN JOSE No No Yes No No 1937 17180 16831 $6289 $9279 $5654 Transition NA $98163 $80582 106190352 GREATER EL MONTE COMM HOSP No No No No No 1088 12882 12620 $6289 $7436 $4818 Transition NA $98163 $80582 106370714 GROSSMONT HOSP No No No No No 1937 12882 12620 $6289 $7436 $6498 Transition $1220 $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190392 GOOD SAMARITAN HOSP-LA No No Yes No No 2006 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106350784 HAZEL HAWKINS MEM HOSP No Yes No Yes Yes 3840 17180 16831 $12768 $18839 NA Non-Transition NA $98163 $80582 106490964 HEALDSBURG DIST HOSP No Yes No Yes Yes 6549 16188 15859 $12768 $17975 NA Non-Transition NA $98163 $80582 106154022 HEALTHSOUTH BAKERSFIELD REHAB HOSP No No No No No 5040 12882 12620 NA NA NA NA $1382 $98163 $80582 106304079 HEALTHSOUTH TUSTIN REHAB HOSP No No No No No 5281 12882 12620 NA NA NA NA $1220 $98163 $80582 106331194 HEMET VALLEY MED CTR No No No No No 1267 12882 12620 $6289 $7436 $5912 Transition NA $98163 $80582 106190949 HENRY MAYO NEWHALL MEM HOSP No No No No No 1839 12882 12620 $6289 $7436 $5631 Transition $1220 $98163 $80582 106362041 HI-DESERT MED CTR No Yes No Yes Yes 2909 12882 12620 $12768 $15097 $13297 Transition NA $98163 $80582 106301205 HOAG MEM HOSP PRESBYTERIAN No No No No No 4825 12882 12620 $6289 $7436 $13525 Transition NA $98163 $80582 106304159 HEALTHBRIDGE CHILDRENS HOSP-ORANGE No No No No No 3271 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106190380 HOLLYWOOD COMM HOSP OF HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106304460 HOAG ORTHOPEDIC No No No No No 4894 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190382 HOLLYWOOD PRES MED CTR No No No No No 2212 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301209 HUNTINGTON BEACH HOSP No No No No No 2175 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190400 HUNTINGTON MEM HOSP No No Yes No No 2294 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106304045 IRVINE REG HOSP AND MED CTR No No No No No 200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106220733 JOHN C FREMONT HCARE DIST No Yes No Yes Yes 3884 12882 12620 $12768 $15097 $8195 Transition NA $98163 $80582 106331216 JOHN F KENNEDY MEM HOSP No No No No No 1679 12882 12620 $6289 $7436 $6464 Transition NA $98163 $80582 106071018 JOHN MUIR MED CTR-CONCORD CAMPUS No No No No No 1748 16478 16143 $6289 $8978 $12804 Transition NA $98163 $80582 106070988 JOHN MUIR MED CTR-WALNUT CREEK CAMPUS No No No No No 2039 16478 16143 $6289 $8978 $10615 Transition $1473 $98163 $80582 106314024 KAISER HOSPITAL - ROSEVILLE No No Yes No No 7912 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106364265 KAISER ONTARIO MEDICAL CENTER CAMPUS No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106121031 JEROLD PHELPS COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301132 KAISER-ANAHEIM No No Yes No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304306 KAISER-ANAHEIM-IRVINE No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304409 KAISER-ANAHEIM-Orange No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106074097 KAISER-ANTIOCH No No No No No 8503 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106196403 KAISER-DOWNEY No No No No No 10000 12882 12620 $6289 $7436 $12698 Transition NA $98163 $80582 106361223 KAISER-FONTANA No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106014132 KAISER-FREMONT No No No No No 10000 16962 16618 $6289 $9186 $9639 Transition NA $98163 $80582 106196035 KAISER-BALDWIN PARK No No No No No 8009 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106104062 KAISER-FRESNO No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190429 KAISER-LOS ANGELES No No No No No 7387 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106394009 KAISER-MANTECA No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106334048 KAISER-MORENO VALLEY No No No No No 6614 12882 12620 $6289 $7436 $4790 Transition NA $98163 $80582 106010856 KAISER-OAKLANDRICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106190432 KAISER-PANORAMA CITY No No No No No 8239 12882 12620 $6289 $7436 $16025 Transition NA $98163 $80582 106504042 KAISER-MODESTO No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106410804 KAISER-REDWOOD CITY No No No No No 7731 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106074093 KAISER-RICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106480989 KAISER-REHAB CENTER VALLEJO No No No No No 8442 16315 15984 $6289 $8908 NA Non-Transition $2535 $98163 $80582 106340913 KAISER-SACRAMENTO No No No No No 5612 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106334025 KAISER-RIVERSIDE No No No No No 5865 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370730 KAISER-SAN DIEGO No No No No No 7393 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106380857 KAISER-SAN FRANCISCO No No No No No 5960 16738 16398 $6289 $9090 NA Non-Transition NA $98163 $80582 106431506 KAISER-SAN JOSE No No No No No 7002 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106014337 KAISER-SAN LEANDRO No No No No No 2180 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106210992 KAISER-SAN RAFAEL No No No No No 4673 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106494019 KAISER-SANTA ROSA No No No No No 10000 16315 15984 $6289 $8908 $17627 Transition NA $98163 $80582 106434153 KAISER-SANTA CLARA No No No No No 6107 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106190431 KAISER-SOUTH BAY No No No No No 6935 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106342344 KAISER-SOUTH SACRAMENTO No No No No No 5670 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106410806 KAISER-SOUTH SF No No No No No 6503 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106484044 KAISER-VACAVILLE No No No No No 10000 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106070990 KAISER-WALNUT CREEK No No No No No 5680 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106190434 KAISER-WEST LA No No No No No 6623 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106194219 KECK HOSPITAL OF USC No No No No No 2004 12882 12620 $6289 $7436 $4699 Transition $1220 $98163 $80582 106210993 KENTFIELD REHAB HOSP No No No No No 5967 16855 16513 $6289 $9140 $19338 Transition $1500 $98163 $80582 106150736 KERN MED CTR Yes No No No No 3943 12882 12620 $6289 $7436 NA NA NA NA NA 106150737 KERN VALLEY HEALTHCARE DIST No Yes No Yes Yes 2786 12882 12620 $12768 $15097 $8298 Transition NA $98163 $80582 106191450 KAISER-WOODLAND HILLS No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190049 KINDRED HOSPITAL BALDWIN PARK No No No No No 1810 12882 12620 $6289 $7436 $10784 Transition NA $98163 $80582 106190305 KINDRED LA No No No No No 2044 12882 12620 $6289 $7436 $4255 Transition NA $98163 $80582 106301127 KINDRED BREA No No No No No 2852 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361274 KINDRED ONTARIO No No No No No 2068 12882 12620 $6289 $7436 $9314 Transition NA $98163 $80582 106364188 KINDRED RANCHO No No No No No 1980 12882 12620 $6289 $7436 $20628 Transition NA $98163 $80582 106332172 KINDRED RIVERSIDE No No No No No 1805 12882 12620 $6289 $7436 $24450 Transition NA $98163 $80582 106190449 KINDRED LA MIRADA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106370721 KINDRED SAN DIEGO No No No No No 3605 12882 12620 $6289 $7436 $5657 Transition NA $98163 $80582 106344035 KINDRED SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190458 KINDRED SAN GABRIEL VALLEY No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106010887 KINDRED SF BAY AREA No No No No No 3007 16478 16143 $6289 $8978 $6378 Transition NA $98163 $80582 106301167 KINDRED SANTA ANA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190196 KINDRED SOUTH BAY No No No No No 2144 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301380 KINDRED WESTMINSTER No No No No No 2286 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301234 LA PALMA INTERCOMMUNITY HOSP No No No No No 2290 12882 12620 $6289 $7436 $7160 Transition NA $98163 $80582 106191227 LAC-HARBOR-UCLA MED CTR Yes No Yes No No 3366 12882 12620 $6289 $7436 NA NA NA NA NA 106191231 LAC-OLIVE VIEW-UCLA MED CTR Yes No No No No 4136 12882 12620 $6289 $7436 NA NA NA NA NA 106191228 LAC-USC MED CTR Yes No Yes No No 4522 12882 12620 $6289 $7436 NA NA NA NA NA 106380865 LAGUNA HONDA HOSP AND REHAB CTR Yes No No No No 5843 16738 16398 $6289 $9090 NA NA NA NA NA 106190240 LAKEWOOD REG MED CTR No No No No No 1504 12882 12620 $6289 $7436 $4008 Transition $1220 $98163 $80582 106390923 LODI MEM HOSP No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106390922 LODI MEM HOSP - WEST No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106334589 LOMA LINDA MURRIETTA No No No No No 3222 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106364268 LOMA LINDA UNIV HEART AND SURGICAL HOSPITAL No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361245 LOMA LINDA UNIV MED CTR - EAST CAMPUS No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361246 LOMA LINDA UNIV MED CTR No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $1491 $98163 $80582 106364502 LOMA LINDA UNIV CHILDRENS HOSP No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $2177 $98163 $80582 106190198 LA COMM HOSP No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420491 LOMPOC VALLEY MED CTR No Yes No Yes Yes 8693 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301248 LOS ALAMITOS MED CTR No No No No No 1915 12882 12620 $6289 $7436 $4697 Transition NA $98163 $80582 106560492 LOS ROBLES HOSP AND MED CTR No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106564018 LOS ROBLES HOSP AND MED CTR-EAST CAMPUS No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106434040 LSP CHILDRENS HOSP AT STANFORD No No Yes No No 2035 17180 16831 $6289 $9279 $6102 Transition NA $98163 $80582 106121002 MAD RIVER COMM HOSP No No No No No 4250 12882 12620 $6289 $7436 $9505 Transition NA $98163 $80582 106201281 MADERA COMMUNITY HOSPITAL No No No No No 5100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106260011 MAMMOTH HOSP No Yes No Yes Yes 7982 12882 12620 $12768 $15097 $46994 Transition NA $98163 $80582 106420493 MARIAN MED CTR No No No No No 2741 12882 12620 $6289 $7436 $9386 Transition NA $98163 $80582 106190525 LONG BEACH MEM MED CTR No No No No No 1996 12882 12620 $6289 $7436 NA Non-Transition $1627 $98163 $80582 106211006 MARIN GEN HOSP No Yes No No No 2571 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106190500 MARINA DEL RAY HOSPITAL No No No No No 2034 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106050932 MARK TWAIN ST JOSEPHS HOSP No No No Yes Yes 3707 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090933 MARSHALL MED CTR No No No Yes Yes 2107 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106500939 MEM HOSP MED CTR-MODESTO No No No No No 2235 12892 12630 $6289 $7440 $5898 Transition NA $98163 $80582 106240924 MEMORIAL HOSP LOS BANOS No No No Yes Yes 3362 12882 12620 $12768 $15097 $17450 Transition NA $98163 $80582 106190521 MEMORIAL HOSP OF GARDENA No No No No No 1747 12882 12620 $6289 $7436 $4611 Transition NA $98163 $80582 106231013 MENDOCINO COAST DIST HOSP No Yes No Yes Yes 5070 12882 12620 $12768 $15097 $15935 Transition NA $98163 $80582 106334018 MENIFEE VALLEY MED CTR No No No No No 1458 12882 12620 $6289 $7436 $5113 Transition NA $98163 $80582 106450936 MAYERS MEM HOSP No Yes No Yes Yes 7192 14188 13900 $12768 $16234 NA Non-Transition NA $98163 $80582 106340947 MERCY GEN HOSP No No No No No 2185 15256 14946 $6289 $8454 $6027 Transition $1387 $98163 $80582 106344029 MERCY HOSP OF FOLSOM No No No No No 2746 15256 14946 $6289 $8454 $5260 Transition NA $98163 $80582 106150761 MERCY HOSP-BAKERSFIELD No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106414018 MENLO PARK SURGICAL HOSP No No No No No 2770 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106240942 MERCY MED CTR MERCED No No No No No 2289 13279 13009 $6289 $7606 NA Non-Transition NA $98163 $80582 106450949 MERCY MED CTR-REDDING No No No No No 2589 14188 13900 $6289 $7996 $10219 Transition NA $98163 $80582 106470871 MERCY MED CTR-MT SHASTA No No No Yes Yes 6242 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106340950 MERCY SAN JUAN HOSP No No No No No 2166 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190529 METHODIST HOSP OF SO CAL No No No No No 1842 12882 12620 $6289 $7436 $6690 Transition $1220 $98163 $80582 106196168 MILLER CHILDRENS HOSP No No Yes No No 2680 12882 12620 $6289 $7436 $8155 Transition NA $98163 $80582 106410742 MILLS HEALTH CENTER No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106410852 MILLS-PENINSULA No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106340951 METHODIST HOSP OF SACRAMENTO No No No No No 2028 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190524 MISSION COMM HOSP-PANORAMA CAMPUS No No No No No 3568 12882 12620 $6289 $7436 $3982 Transition NA $98163 $80582 106190681 MIRACLE MILE No No No No No 100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301262 MISSION HOSP REG MED CTR No No No No No 4091 12882 12620 $6289 $7436 $14336 Transition $1220 $98163 $80582 106250956 MODOC MED CTR No Yes No Yes Yes 4961 12882 12620 $12768 $15097 $13486 Transition NA $98163 $80582 106301337 MISSION HOSP LAGUNA BEACH No No No No No 4091 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106361166 MONTCLAIR HOSP MED CTR No No No No No 3149 12882 12620 $6289 $7436 $5904 Transition NA $98163 $80582 106190547 MONTEREY PARK HOSP No No No No No 1034 12882 12620 $6289 $7436 $5866 Transition NA $98163 $80582 106361266 MOUNTAINS COMM HOSP No Yes No Yes Yes 5148 12882 12620 $12768 $15097 $15642 Transition NA $98163 $80582 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106481357 NORTH BAY MEDICAL CENTER No No No No No 1972 16315 15984 $6289 $8908 $15945 Transition NA $98163 $80582
i-
i
i
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190541 MONROVIA MEM HOSP No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106141273 NORTHERN INYO HOSP No Yes No Yes Yes 8150 12882 12620 $12768 $15097 $27752 Transition NA $98163 $80582 106484001 NORTH BAY VACAVALLEY HOSP No No No No No 1972 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106190568 NORTHRIDGE HOSP MED CTR No No No No No 1596 12882 12620 $6289 $7436 NA Non-Transition $1662 $98163 $80582 106214034 NOVATO COMM HOSP No No No No No 3465 16855 16513 $6289 $9140 $6359 Transition NA $98163 $80582 106500967 OAK VALLEY DIST HOSP No Yes No Yes No 3340 12892 12630 $6289 $7440 $5201 Transition NA $98163 $80582 106430837 OCONNOR HOSP-SAN JOSE No No No No No 2409 17180 16831 $6289 $9279 $5201 Transition NA $98163 $80582 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190534 OLYMPIA MED CTR No No No No No 1260 12882 12620 $6289 $7436 $6786 Transition NA $98163 $80582 106300225 ORANGE COAST MEM MED CTR No No No No No 2293 12882 12620 $6289 $7436 $19985 Transition NA $98163 $80582 106040937 OROVILLE HOSP No No No No No 1803 12882 12620 $6289 $7436 $6229 Transition NA $98163 $80582 106560501 OJAI VALLEY COMM HOSP No No No Yes Yes 2745 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190696 PACIFICA HOSP OF THE VALLEY No No No No No 3338 12882 12620 $6289 $7436 $5616 Transition NA $98163 $80582 106491338 PALM DRIVE HOSP No Yes No Yes No 4315 16315 15984 $6289 $8908 $11457 Transition NA $98163 $80582 106196405 PALMDALE REGIONAL MEDICAL CTR No No No No No 1190 12882 12620 $6289 $7436 $7504 Transition $1220 $98163 $80582 106331288 PALO VERDE HOSP No Yes No Yes Yes 4770 12882 12620 $12768 $15097 $18188 Transition NA $98163 $80582 106370755 PALOMAR MED CTR No Yes No No No 2429 12882 12620 $6289 $7436 $7051 Transition $1220 $98163 $80582 106370759 PARADISE VALLEY HOSP No No No No No 2188 12882 12620 $6289 $7436 $4275 Transition $1220 $98163 $80582 106190307 PACIFIC ALLIANCE MED CTR No No No No No 4299 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106331293 PARKVIEW COMM HOSP MED CTR No No No No No 2757 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106491001 PETALUMA VALLEY HOSP No No No No No 2271 16315 15984 $6289 $8908 $13491 Transition NA $98163 $80582 106130760 PIONEERS MEM HOSP No Yes No Yes No 2989 12882 12620 $6289 $7436 $9825 Transition NA $98163 $80582 106454013 PATIENTS HOSP OF REDDING No No No No No 2172 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106301297 PLACENTIA LINDA HOSP No No No No No 1606 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370977 POMERADO HOSP No Yes No No No 3063 12882 12620 $6289 $7436 $6818 Transition NA $98163 $80582 106320986 PLUMAS DIST HOSP No Yes No Yes Yes 8666 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190631 PRESBYTERIAN INTERCOMM HOSP No No No No No 961 12882 12620 $6289 $7436 $9720 Transition $1220 $98163 $80582 106190630 POMONA VALLEY HOSP MED CTR No No Yes No No 1538 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190468 PROMISE HOSP OF EAST LA-EAST LA No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190599 PROMISE HOSP OF EAST LA-EAST LA-SUBURBAN CAMPUS No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190385 PROVIDENCE HOLY CROSS MED CTR No No No No No 1325 12882 12620 $6289 $7436 $6284 Transition $1220 $98163 $80582 106190680 PROVIDENCE LITTLE CO OF MARY-SAN PEDRO No No No No No 1533 12882 12620 $6289 $7436 $6225 Transition $1220 $98163 $80582 106190470 PROVIDENCE LITTLE CO OF MARY-TORRANCE No No No No No 1767 12882 12620 $6289 $7436 $7182 Transition NA $98163 $80582 106190758 PROVIDENCE ST JOSEPH MED CTR No No No No No 1866 12882 12620 $6289 $7436 $7141 Transition $1220 $98163 $80582 106370787 PROMISE HOSP OF SAN DIEGO No No No No No 3660 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106281047 QUEEN OF THE VALLEY HOSP-NAPA No No No No No 2829 16188 15859 $6289 $8854 $17592 Transition $1453 $98163 $80582 106370673 RADY CHILDRENS HOSPITAL - SAN DIEGO No No Yes No No 2854 12882 12620 $6289 $7436 $6395 Transition $2177 $98163 $80582 106190517 PROVIDENCE TARZANA MED CTR No No Yes No No 1536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361308 REDLANDS COMM HOSP No No No No No 2079 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430705 REG MED CTR OF SAN JOSE No No No No No 2529 17180 16831 $6289 $9279 $13299 Transition NA $98163 $80582 106580996 RIDEOUT MEM HOSP No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106121051 REDWOOD MEM HOSP No No No Yes Yes 3214 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106334487 RIVERSIDE CO REG MED CTR Yes No No No No 2987 12882 12620 $6289 $7436 NA NA NA NA NA 106331312 RIVERSIDE COMM HOSP No No No No No 1560 12882 12620 $6289 $7436 $5990 Transition NA $98163 $80582 106190796 RONALD REAGAN UCLA MED CTR Yes No Yes No No 3382 12882 12620 $6289 $7436 NA NA NA NA NA 106301317 SADDLEBACK MEM MED CTR No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106301325 SADDLEBACK MEM MED CTR-SAN CLEMENTE No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106150782 RIDGECREST REG HOSP No No No Yes Yes 4178 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106361318 SAN ANTONIO COMM HOSP No No No No No 2262 12882 12620 $6289 $7436 $9216 Transition NA $98163 $80582 106190673 SAN DIMAS COMM HOSP No No No No No 2465 12882 12620 $6289 $7436 $12177 Transition NA $98163 $80582 106190200 SAN GABRIEL VALLEY MED CTR No No No No No 969 12882 12620 $6289 $7436 $6918 Transition NA $98163 $80582 106270875 SALINAS VALLEY MEM HOSP No Yes No No No 3534 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106331326 SAN GORGONIO MEM HOSP No Yes No Yes Yes 3394 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391010 SAN JOAQUIN GEN HOSP Yes No No No No 1922 13579 13303 $6289 $7735 NA NA NA NA NA 106104023 SAN JOAQUIN VALLEY REHAB HOSP No No No No No 6479 12882 12620 NA NA NA NA $1413 $98163 $80582 106013619 SAN LEANDRO HOSP No Yes No No No 3482 16501 16166 $6289 $8988 $10813 Transition NA $98163 $80582 106410782 SAN MATEO MED CTR Yes No No No No 7168 16928 16584 $6289 $9171 NA NA NA NA NA 106074017 SAN RAMON REG MED CTR No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106074011 SAN RAMON REG MED CTR SOUTH BUILDING No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106420514 SANTA BARBARA COTTAGE HOSP No No Yes No No 3902 12882 12620 $6289 $7436 $10978 Transition $2125 $98163 $80582 106430883 SANTA CLARA VALLEY MED CTR Yes No Yes No No 3133 17180 16831 $6289 $9279 NA NA NA NA NA 106190687 SANTA MONICA - UCLA MEDICAL CENTER Yes No No No No 3102 12882 12620 $6289 $7436 NA NA NA NA NA 106491064 SANTA ROSA MEM HOSP-MONTGOMERY No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106490907 SANTA ROSA MEM HOSP-SOTOYOME No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106150788 SAN JOAQUIN COMM HOSP No No No No No 2544 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420522 SANTA YNEZ VALLEY COTTAGE HOSP No No No Yes Yes 7569 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106371394 SCRIPPS MEM HOSP-ENCINITAS No No No No No 2403 12882 12620 $6289 $7436 $7037 Transition $1439 $98163 $80582 106370771 SCRIPPS MEM HOSP-LA JOLLA No No No No No 2061 12882 12620 $6289 $7436 $4390 Transition NA $98163 $80582 106370744 SCRIPPS MERCY HOSP No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106370658 SCRIPPS MERCY HOSP-CHULA VISTA No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106371256 SCRIPPS GREEN HOSP No No No No No 2317 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106321016 SENECA HCARE DIST No Yes No Yes Yes 4586 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106410817 SETON MED CTR No No No No No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106410828 SETON MED CTR-COASTSIDE No No No Yes No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106380939 SF GENERAL HOSP Yes No No No No 2851 16738 16398 $6289 $9090 NA NA NA NA NA 106370875 SHARP CHULA VISTA MED CTR No No No No No 1932 12882 12620 $6289 $7436 $6485 Transition NA $98163 $80582 106410891 SEQUOIA HOSP No No No No No 1975 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106370689 SHARP CORONADO HOSP AND HCARE CTR No No No No No 2160 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $72421 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106370694 SHARP MEM HOSP No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106450940 SHASTA REG MED CTR No No No No No 1582 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106190708 SHERMAN OAKS HOSP No No No No No 1516 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190712 SHRINERS HOSPITAL- LA No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106344114 SHRINERS HOSPITAL- SACRAMENTO No No No No No 3869 15256 14946 $6289 $8454 NA Non-Transition $2475 $98163 $80582 106540798 SIERRA VIEW DIST HOSP No Yes No No No 2716 12882 12620 $6289 $7436 $8497 Transition NA $98163 $77682 106400524 SIERRA VIST REG MED CTR No No No No No 1787 12964 12701 $6289 $7471 $5495 Transition NA $98163 $80582 106190661 SILVER LAKE MED CTR No No No No No 3692 12882 12620 $6289 $7436 $5655 Transition NA $98163 $80582 106291023 SIERRA NEVADA MEM HOSP No No No Yes Yes 3427 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106491076 SONOMA VALLEY HOSP No Yes No No No 4960 16315 15984 $6289 $8908 $12733 Transition NA $98163 $80582 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 2126 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190380 SOUTHERN CA HOSP AT HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106190110 SOUTHERN CA HOSPITAL AT CULVER CITY No No No No No 1437 12882 12620 $6289 $7436 $4694 Transition $1220 $98163 $80582 106560525 SIMI VALLEY HOSP AND HCARE-SYCAMORE No No No No No 3840 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106334068 SOUTHWEST HCARE SYSTEM No No No No No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106334001 SOUTHWEST HCARE SYSTEM-WILDOMAR No No No Yes No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106100899 ST AGNES MED CTR No No No No No 3088 12882 12620 $6289 $7436 $7885 Transition NA $98163 $80582 106361339 ST BERNARDINE MED CTR No No No No No 2171 12882 12620 $6289 $7436 $6090 Transition NA $98163 $80582 106521041 ST ELIZABETH COMM HOSP No No No Yes Yes 3024 13869 13587 $12768 $15956 $14866 Transition NA $98163 $80582 106190754 ST FRANCIS MED CTR No No No No No 4350 12882 12620 $6289 $7436 $6368 Transition NA $98163 $80582 106380960 ST FRANCIS MEM HOSP No No No No No 1920 16738 16398 $6289 $9090 $5310 Transition $1492 $98163 $80582 106281078 ST HELENA HOSP No No No No No 2337 15887 15564 $6289 $8725 $9671 Transition NA $98163 $80582 106171049 ST HELENA HOSPITAL-CLEARLAKE No No No Yes Yes 4118 12882 12620 $12768 $15097 $18218 Transition NA $98163 $80582 106141338 SOUTHERN INYO HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190756 ST JOHNS HEALTH CTR No No No No No 2536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560529 ST JOHNS REG MED CTR No No No No No 2982 12882 12620 $6289 $7436 $6976 Transition $1761 $98163 $80582 106121080 ST JOSEPH HOSP-EUREKA No No No No No 2570 13869 13587 $6289 $7859 $9661 Transition $1507 $98163 $80582 106301340 ST JOSEPH HOSP-ORANGE No No No No No 2751 12882 12620 $6289 $7436 $5230 Transition NA $98163 $80582 106560508 ST JOHNS PLEASANT VALLEY HOSP No No No No No 2087 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301342 ST JUDE MED CTR No No No No No 1722 12882 12620 $6289 $7436 $5799 Transition $1220 $98163 $80582 106434138 ST LOUISE REG HOSP No No No No No 2838 17180 16831 $6289 $9279 $16407 Transition NA $98163 $80582 106380964 ST LUKES HOSP No No No No No 3807 16738 16398 $6289 $9090 $8600 Transition NA $98163 $80582 106361343 ST MARY MED CTR-APPLE VALLEY No No No Yes No 2511 12882 12620 $6289 $7436 $9863 Transition NA $98163 $80582 106391042 ST JOSEPHS MED CTR OF STOCKTON No No No No No 2152 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106380965 ST MARYS MED CTR-SF No No No No No 2007 16738 16398 $6289 $9090 $5116 Transition $1492 $98163 $80582 106010967 ST ROSE HOSP No No No No No 1931 16962 16618 $6289 $9186 $7600 Transition NA $98163 $80582 106190762 ST VINCENT MED CTR No No No No No 2020 12882 12620 $6289 $7436 $4684 Transition $1220 $98163 $80582 106430905 STANFORD HOSP No No No No No 1803 17180 16831 $6289 $9279 $5644 Transition $1523 $98163 $80582 106190053 ST MARY MED CTR-LONG BEACH No No No No No 2479 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106504038 STANISLAUS SURGICAL HOSP No No No No No 9000 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106250955 SURPRISE VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106310791 SUTTER AUBURN FAITH HOSP No No No No No 2551 15256 14946 $6289 $8454 $11882 Transition NA $98163 $80582 106034002 SUTTER AMADOR HOSP No No No Yes Yes 2971 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106574010 SUTTER DAVIS HOSP No No No No No 3568 15256 14946 $6289 $8454 $14330 Transition NA $98163 $80582 106070934 SUTTER DELTA MED CTR No No No No No 2907 16478 16143 $6289 $8978 $12158 Transition NA $98163 $80582 106341051 SUTTER GEN HOSP No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106171395 SUTTER LAKESIDE HOSP No No No Yes Yes 3691 12882 12620 $12768 $15097 $17232 Transition NA $98163 $80582 106444012 SUTTER MATERNITY AND SRG CTR OF S CRUZ No No No No No 7213 17239 16889 $6289 $9304 $21288 Transition NA $98163 $80582 106490919 SUTTER MED CTR OF SANTA ROSA No No No No No 3657 16315 15984 $6289 $8908 $15278 Transition NA $98163 $80582 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106311000 SUTTER ROSEVILLE MED CTR No No No No No 2377 15256 14946 $6289 $8454 $11395 Transition $1387 $98163 $80582 106481094 SUTTER SOLANO MED CTR No No No No No 3258 16315 15984 $6289 $8908 $18010 Transition NA $98163 $80582 106084001 SUTTER COAST HOSP No No No Yes Yes 3730 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391056 SUTTER TRACY COMM HOSP No No No No No 2714 13579 13303 $6289 $7735 $5995 Transition NA $98163 $80582 106291053 TAHOE FOREST HOSP No Yes No Yes Yes 4766 15256 14946 $12768 $17164 $21044 Transition NA $98163 $80582 106150808 TEHACHAPI HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 $22158 Transition NA $98163 $80582 106514030 SUTTER SURG HOSP-NORTH VALLEY No No No No No 3240 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582
i-
i
i
i-
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106334564 TEMECULA VALLEY HOSPITAL No No No No No 2180 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106120981 THE GENERAL HOSPITAL No No No No No 2570 13869 13587 NA NA NA NA $1507 $98163 $80582 106564121 THOUSAND OAKS SURGICAL HOSPITAL No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106190422 TORRANCE MEM MED CTR No No No No No 1952 12882 12620 $6289 $7436 $5891 Transition NA $98163 $80582 106370780 TRI-CITY MED CTR No Yes No No No 3695 12882 12620 $6289 $7436 $7706 Transition $1220 $98163 $80582 106190784 TEMPLE COMM HOSP No No No No No 4200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540816 TULARE DIST HOSP No Yes No No No 3578 12882 12620 $6289 $7436 $9529 Transition NA $98163 $80582 106531059 TRINITY HOSP No Yes No Yes Yes 5105 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106400548 TWIN CITIES COMM HOSP No No No Yes Yes 1587 12964 12701 $12768 $15168 $8160 Transition NA $98163 $80582 106341006 UC DAVIS MED CTR Yes No Yes No No 1836 15256 14946 $6289 $8454 NA NA NA NA NA 106301279 UC IRVINE MED CTR Yes No Yes No No 2072 12882 12620 $6289 $7436 NA NA NA NA NA 106370782 UCSD MED CTR Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106374141 UCSD-LA JOLLA JOHN M amp SALLY B THORNTON HOSPITAL Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106381154 UCSF MED CTR Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106380895 UCSF MED CTR AT MOUNT ZION Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106301357 TUSTIN HOSP MED CTR No No No No No 231 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106231396 UKIAH VALLEY MED CTRHOSP DR No No No Yes Yes 3643 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106014050 VALLEY CARE MEDICAL CENTER No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106010983 VALLEY MEM HOSP-LIVERMORE No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106191216 USC KENNETH NORRIS JR CANCER HOSP No No No No No 3134 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560481 VENTURA CO MED CTR Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106560521 VENTURA CO MED CTR-SANTA PAULA HOSPITAL Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106190818 VERDUGO HILLS HOSP No No No No No 3110 12882 12620 $6289 $7436 $5264 Transition NA $98163 $80582 106190812 VALLEY PRES HOSP No No No No No 3536 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 3046 14188 13900 $6289 $7996 NA Non-Transition $1312 $98163 $80582 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 3266 12882 12620 $6289 $7436 $8320 Transition NA $98163 $80582 106010987 WASHINGTON HOSP-FREMONT No Yes No No No 1941 16962 16618 $6289 $9186 $6429 Transition NA $98163 $80582 106444013 WATSONVILLE COMM HOSP No No No No No 1780 17239 16889 $6289 $9304 $13456 Transition NA $98163 $80582 106301379 WEST ANAHEIM MED CTR No No No No No 1514 12882 12620 $6289 $7436 $4707 Transition NA $98163 $80582 106190859 WEST HILLS HOSP AND MED CTR No No No No No 1933 12882 12620 $6289 $7436 $8050 Transition NA $98163 $80582 106374094 VIBRA OF SAN DIEGO No No No No No 1155 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301188 WESTERN MED CTR-ANAHEIM No No No No No 3203 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301566 WESTERN MED CTR-SANTA ANA No No No No No 2354 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190878 WHITE MEM MED CTR No No No No No 1515 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190883 WHITTIER HOSP MED CTR No No No No No 1139 12882 12620 $6289 $7436 $5922 Transition NA $98163 $80582 106571086 WOODLAND MEM HOSP No No No No No 3278 15256 14946 $6289 $8454 $10092 Transition NA $98163 $80582 6102015
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
-
227-2 227-3 227-4
HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL
443 813
1503
13150 21598 43086
10000 10000 10000
10000 10000 10000
13150 21598 43086
12500 12500 12500
16438 26998 53858
10000 10000 10000
13150 21598 43086
$12328 Misc Pediatric $20248 Misc Pediatric $40393 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult
228-1 228-2 228-3 228-4
INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES
200 344 629
1321
07221 09757 15211 32407
10000 10000 10000 10000
10000 10000 10000 10000
07221 09757 15211 32407
12500 12500 12500 12500
09026 12196 19014 40509
10000 10000 10000 10000
07221 09757 15211 32407
$6770 Misc Pediatric $9147 Misc Pediatric
$14260 Misc Pediatric $30382 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
229-1 229-2 229-3 229-4
OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES
387 552 976
1760
10850 14346 22850 42572
10000 10000 10000 10000
10000 10000 10000 10000
10850 14346 22850 42572
12500 12500 12500 12500
13563 17933 28563 53215
10000 10000 10000 10000
10850 14346 22850 42572
$10172 Misc Pediatric $13449 Misc Pediatric $21422 Misc Pediatric $39911 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
240-1 240-2 240-3 240-4
DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY DIGESTIVE MALIGNANCY
371 429 685
1225
05526 07344 11112 20338
10000 10000 10000 10000
10000 10000 10000 10000
05526 07344 11112 20338
12500 12500 12500 12500
06908 09180 13890 25423
10000 10000 10000 10000
05526 07344 11112 20338
$5181 Misc Pediatric $6885 Misc Pediatric
$10418 Misc Pediatric $19067 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
241-1 241-2 241-3 241-4
PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS PEPTIC ULCER amp GASTRITIS
252 325 484
1012
05507 07186 10584 23302
10000 10000 10000 10000
10000 10000 10000 10000
05507 07186 10584 23302
12500 12500 12500 12500
06884 08983 13230 29128
10000 10000 10000 10000
05507 07186 10584 23302
$5163 Misc Pediatric $6737 Misc Pediatric $9923 Misc Pediatric
$21846 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
242-1 242-2 242-3 242-4
MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS MAJOR ESOPHAGEAL DISORDERS
230 319 459
1013
05080 06929 10170 22355
10000 10000 10000 10000
10000 10000 10000 10000
05080 06929 10170 22355
12500 12500 12500 12500
06350 08661 12713 27944
10000 10000 10000 10000
05080 06929 10170 22355
$4763 Misc Pediatric $6496 Misc Pediatric $9534 Misc Pediatric
$20958 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
243-1 243-2 243-3 243-4
OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS OTHER ESOPHAGEAL DISORDERS
189 280 479
1028
04493 06061 09094 20341
10000 10000 10000 10000
10000 10000 10000 10000
04493 06061 09094 20341
12500 12500 12500 12500
05616 07576 11368 25426
10000 10000 10000 10000
04493 06061 09094 20341
$4212 Misc Pediatric $5682 Misc Pediatric $8526 Misc Pediatric
$19070 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
244-1 244-2 244-3 244-4
DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS DIVERTICULITIS amp DIVERTICULOSIS
292 361 545
1104
05247 06624 10053 21700
10000 10000 10000 10000
10000 10000 10000 10000
05247 06624 10053 21700
12500 12500 12500 12500
06559 08280 12566 27125
10000 10000 10000 10000
05247 06624 10053 21700
$4919 Misc Pediatric $6210 Misc Pediatric $9425 Misc Pediatric
$20344 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
245-1 245-2 245-3 245-4
INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE INFLAMMATORY BOWEL DISEASE
339 413 626
1206
05754 07028 10226 19440
10000 10000 10000 10000
10000 10000 10000 10000
05754 07028 10226 19440
12500 12500 12500 12500
07193 08785 12783 24300
10000 10000 10000 10000
05754 07028 10226 19440
$5394 Misc Pediatric $6589 Misc Pediatric $9587 Misc Pediatric
$18225 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
246-1 246-2 246-3 246-4
GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY GASTROINTESTINAL VASCULAR INSUFFICIENCY
315 404 602 982
06451 07943 11319 19310
10000 10000 10000 10000
10000 10000 10000 10000
06451 07943 11319 19310
12500 12500 12500 12500
08064 09929 14149 24138
10000 10000 10000 10000
06451 07943 11319 19310
$6048 Misc Pediatric $7447 Misc Pediatric
$10612 Misc Pediatric $18103 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
247-1 247-2 247-3 247-4
INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION INTESTINAL OBSTRUCTION
288 378 596
1104
04874 06267 09526 19303
10000 10000 10000 10000
10000 10000 10000 10000
04874 06267 09526 19303
12500 12500 12500 12500
06093 07834 11908 24129
10000 10000 10000 10000
04874 06267 09526 19303
$4569 Misc Pediatric $5875 Misc Pediatric $8931 Misc Pediatric
$18097 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
248-1 248-2 248-3 248-4
MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS
334 472 710
1239
05085 07215 10667 20497
10000 10000 10000 10000
10000 10000 10000 10000
05085 07215 10667 20497
12500 12500 12500 12500
06356 09019 13334 25621
10000 10000 10000 10000
05085 07215 10667 20497
$4767 Misc Pediatric $6764 Misc Pediatric
$10000 Misc Pediatric $19216 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
249-1 249-2 249-3 249-4
NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING NON-BACTERIAL GASTROENTERITIS NAUSEA amp VOMITING
219 289 431 938
03648 05058 07201 15935
10000 10000 10000 10000
10000 10000 10000 10000
03648 05058 07201 15935
12500 12500 12500 12500
04560 06323 09001 19919
10000 10000 10000 10000
03648 05058 07201 15935
$3420 Misc Pediatric $4742 Misc Pediatric $6751 Misc Pediatric
$14939 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
251-1 251-2 251-3 251-4
ABDOMINAL PAIN ABDOMINAL PAIN ABDOMINAL PAIN ABDOMINAL PAIN
217 288 418 813
04492 05786 07857 14149
10000 10000 10000 10000
10000 10000 10000 10000
04492 05786 07857 14149
12500 12500 12500 12500
05615 07233 09821 17686
10000 10000 10000 10000
04492 05786 07857 14149
$4211 Misc Pediatric $5424 Misc Pediatric $7366 Misc Pediatric
$13265 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
252-1 252-2 252-3 252-4
MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE
331 412 635
1248
04904 06490 09833 19841
10000 10000 10000 10000
10000 10000 10000 10000
04904 06490 09833 19841
12500 12500 12500 12500
06130 08113 12291 24801
10000 10000 10000 10000
04904 06490 09833 19841
$4598 Misc Pediatric $6084 Misc Pediatric $9218 Misc Pediatric
$18601 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
253-1 253-2 253-3 253-4
OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE
251 334 504 878
05108 06777 10020 18601
10000 10000 10000 10000
10000 10000 10000 10000
05108 06777 10020 18601
12500 12500 12500 12500
06385 08471 12525 23251
10000 10000 10000 10000
05108 06777 10020 18601
$4789 Misc Pediatric $6353 Misc Pediatric $9394 Misc Pediatric
$17438 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
254-1 254-2 254-3 254-4
OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES OTHER DIGESTIVE SYSTEM DIAGNOSES
252 353 530
1066
04519 06282 09117 18053
10000 10000 10000 10000
10000 10000 10000 10000
04519 06282 09117 18053
12500 12500 12500 12500
05649 07853 11396 22566
10000 10000 10000 10000
04519 06282 09117 18053
$4237 Misc Pediatric $5889 Misc Pediatric $8547 Misc Pediatric
$16925 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
260-1 260-2 260-3 260-4
MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES MAJOR PANCREAS LIVER amp SHUNT PROCEDURES
469 611
1081 2181
15085 19596 31029 63824
10000 10000 10000 10000
10000 10000 10000 10000
15085 19596 31029 63824
12500 12500 12500 12500
18856 24495 38786 79780
10000 10000 10000 10000
15085 19596 31029 63824
$14142 Misc Pediatric $18371 Misc Pediatric $29090 Misc Pediatric $59835 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
261-1 261-2 261-3 261-4
MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES MAJOR BILIARY TRACT PROCEDURES
450 706
1116 1993
13049 18250 25711 50241
10000 10000 10000 10000
10000 10000 10000 10000
13049 18250 25711 50241
12500 12500 12500 12500
16311 22813 32139 62801
10000 10000 10000 10000
13049 18250 25711 50241
$12233 Misc Pediatric $17109 Misc Pediatric $24104 Misc Pediatric $47101 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
262-1 262-2 262-3 262-4
CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC
405 567 898
1751
11851 15637 23607 46363
10000 10000 10000 10000
10000 10000 10000 10000
11851 15637 23607 46363
12500 12500 12500 12500
14814 19546 29509 57954
10000 10000 10000 10000
11851 15637 23607 46363
$11110 Misc Pediatric $14660 Misc Pediatric $22132 Misc Pediatric $43465 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
263-1 263-2 263-3 263-4
LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY LAPAROSCOPIC CHOLECYSTECTOMY
236 364 635
1384
09345 12310 17676 36726
10000 10000 10000 10000
10000 10000 10000 10000
09345 12310 17676 36726
12500 12500 12500 12500
11681 15388 22095 45908
10000 10000 10000 10000
09345 12310 17676 36726
$8761 Misc Pediatric $11541 Misc Pediatric $16571 Misc Pediatric $34431 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
264-1 264-2 264-3 264-4
OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES
453 543
1067 2148
12526 13732 23159 51901
10000 10000 10000 10000
10000 10000 10000 10000
12526 13732 23159 51901
12500 12500 12500 12500
15658 17165 28949 64876
10000 10000 10000 10000
12526 13732 23159 51901
$11743 Misc Pediatric $12874 Misc Pediatric $21712 Misc Pediatric $48657 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
279-1 279-2 279-3 279-4
HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS
280 361 580
1157
04712 05945 09594 23269
10000 10000 10000 10000
10000 10000 10000 10000
04712 05945 09594 23269
12500 12500 12500 12500
05890 07431 11993 29086
10000 10000 10000 10000
04712 05945 09594 23269
$4418 Misc Pediatric $5573 Misc Pediatric $8994 Misc Pediatric
$21815 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
280-1 280-2 280-3 280-4
ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE ALCOHOLIC LIVER DISEASE
298 344 532
1047
04734 06141 09718 21422
10000 10000 10000 10000
10000 10000 10000 10000
04734 06141 09718 21422
12500 12500 12500 12500
05918 07676 12148 26778
10000 10000 10000 10000
04734 06141 09718 21422
$4438 Misc Pediatric $5757 Misc Pediatric $9111 Misc Pediatric
$20083 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
281-1 281-2 281-3 281-4
MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS
357 421 610 974
05079 07553 10730 17519
10000 10000 10000 10000
10000 10000 10000 10000
05079 07553 10730 17519
12500 12500 12500 12500
06349 09441 13413 21899
10000 10000 10000 10000
05079 07553 10730 17519
$4762 Misc Pediatric $7081 Misc Pediatric
$10059 Misc Pediatric $16424 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
282-1 282-2 282-3 282-4
DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY DISORDERS OF PANCREAS EXCEPT MALIGNANCY
318 403 649
1381
05507 07067 11213 27863
10000 10000 10000 10000
10000 10000 10000 10000
05507 07067 11213 27863
12500 12500 12500 12500
06884 08834 14016 34829
10000 10000 10000 10000
05507 07067 11213 27863
$5163 Misc Pediatric $6625 Misc Pediatric
$10512 Misc Pediatric $26122 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
283-1 283-2 283-3 283-4
OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER OTHER DISORDERS OF THE LIVER
286 338 505 947
04913 06300 09246 18497
10000 10000 10000 10000
10000 10000 10000 10000
04913 06300 09246 18497
12500 12500 12500 12500
06141 07875 11558 23121
10000 10000 10000 10000
04913 06300 09246 18497
$4606 Misc Pediatric $5906 Misc Pediatric $8668 Misc Pediatric
$17341 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
284-1 284-2 284-3 284-4
DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT DISORDERS OF GALLBLADDER amp BILIARY TRACT
245 344 536
1059
05403 07447 10804 21256
10000 10000 10000 10000
10000 10000 10000 10000
05403 07447 10804 21256
12500 12500 12500 12500
06754 09309 13505 26570
10000 10000 10000 10000
05403 07447 10804 21256
$5065 Misc Pediatric $6982 Misc Pediatric
$10129 Misc Pediatric $19928 Misc Pediatric
Gastroent Adult Gastroent Adult Gastroent Adult Gastroent Adult
301-1 301-2 301-3 301-4
HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT HIP JOINT REPLACEMENT
365 396 535
1280
18140 19690 25026 39991
10000 10000 10000 10000
10000 10000 10000 10000
18140 19690 25026 39991
12500 12500 12500 12500
22675 24613 31283 49989
10000 10000 10000 10000
18140 19690 25026 39991
$17006 Misc Pediatric $18459 Misc Pediatric $23462 Misc Pediatric $37492 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
302-1 302-2 302-3 302-4
KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT KNEE JOINT REPLACEMENT
296 338 519
1248
17428 19132 23798 43468
10000 10000 10000 10000
10000 10000 10000 10000
17428 19132 23798 43468
12500 12500 12500 12500
21785 23915 29748 54335
10000 10000 10000 10000
17428 19132 23798 43468
$16339 Misc Pediatric $17936 Misc Pediatric $22311 Misc Pediatric $40751 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
303-1 303-2 303-3 303-4
DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK
450 570 857
1607
47039 55422 77549
105744
10000 10000 10000 10000
10000 10000 10000 10000
47039 55422 77549
105744
12500 12500 12500 12500
58799 69278 96936
132180
10000 10000 10000 10000
47039 55422 77549
105744
$44099 Misc Pediatric $51958 Misc Pediatric $72702 Misc Pediatric $99135 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
304-1 304-2 304-3 304-4
DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK
300 405 735
1776
29720 35298 49644 81663
10000 10000 10000 10000
10000 10000 10000 10000
29720 35298 49644 81663
12500 12500 12500 12500
37150 44123 62055
102079
10000 10000 10000 10000
29720 35298 49644 81663
$27863 Misc Pediatric $33092 Misc Pediatric $46541 Misc Pediatric $76559 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
305-1 305-2 305-3 305-4
AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES AMPUTATION OF LOWER LIMB EXCEPT TOES
540 737
1137 1987
10654 14043 21843 42156
10000 10000 10000 10000
10000 10000 10000 10000
10654 14043 21843 42156
12500 12500 12500 12500
13318 17554 27304 52695
10000 10000 10000 10000
10654 14043 21843 42156
$9988 Misc Pediatric $13165 Misc Pediatric $20478 Misc Pediatric $39521 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
308-1 308-2 308-3 308-4
HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR TRAUMA EXCEPT JOINT REPLACEMENT
419 496 697
1264
13101 15854 21518 36506
10000 10000 10000 10000
10000 10000 10000 10000
13101 15854 21518 36506
12500 12500 12500 12500
16376 19818 26898 45633
10000 10000 10000 10000
13101 15854 21518 36506
$12282 Misc Pediatric $14863 Misc Pediatric $20173 Misc Pediatric $34224 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
309-1 309-2 309-3 309-4
HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT HIP amp FEMUR PROCEDURES FOR NON-TRAUMA EXCEPT JOINT REPLACEMENT
278 490 865
1887
11482 16231 23288 42408
10000 10000 10000 10000
10000 10000 10000 10000
11482 16231 23288 42408
12500 12500 12500 12500
14353 20289 29110 53010
10000 10000 10000 10000
11482 16231 23288 42408
$10764 Misc Pediatric $15217 Misc Pediatric $21833 Misc Pediatric $39758 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
310-1 310-2 310-3 310-4
INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION
181 302 624
1622
08926 11888 17911 41661
10000 10000 10000 10000
10000 10000 10000 10000
08926 11888 17911 41661
12500 12500 12500 12500
11158 14860 22389 52076
10000 10000 10000 10000
08926 11888 17911 41661
$8368 Misc Pediatric $11145 Misc Pediatric $16792 Misc Pediatric $39057 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
312-1 312-2
SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES
538 940
12555 18447
10000 10000
10000 10000
12555 18447
12500 12500
15694 23059
10000 10000
12555 18447
$11770 Misc Pediatric $17294 Misc Pediatric
Misc Adult Misc Adult
312-3 312-4
SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES
1846 3284
31356 71148
10000 10000
10000 10000
31356 71148
12500 12500
39195 88935
10000 10000
31356 71148
$29396 Misc Pediatric $66701 Misc Pediatric
Misc Adult Misc Adult
313-1 313-2 313-3 313-4
KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT
270 444 785
1659
10852 15212 22743 43349
10000 10000 10000 10000
10000 10000 10000 10000
10852 15212 22743 43349
12500 12500 12500 12500
13565 19015 28429 54186
10000 10000 10000 10000
10852 15212 22743 43349
$10174 Misc Pediatric $14261 Misc Pediatric $21322 Misc Pediatric $40640 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
314-1 314-2 314-3 314-4
FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES
257 507 810
1579
09291 11320 16006 32885
10000 10000 10000 10000
10000 10000 10000 10000
09291 11320 16006 32885
12500 12500 12500 12500
11614 14150 20008 41106
10000 10000 10000 10000
09291 11320 16006 32885
$8710 Misc Pediatric $10613 Misc Pediatric $15006 Misc Pediatric $30830 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
315-1 315-2 315-3 315-4
SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES
185 267 649
1473
08387 15912 22542 44542
10000 10000 10000 10000
10000 10000 10000 10000
08387 15912 22542 44542
12500 12500 12500 12500
10484 19890 28178 55678
10000 10000 10000 10000
08387 15912 22542 44542
$7863 Misc Pediatric $14918 Misc Pediatric $21133 Misc Pediatric $41758 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
316-1 316-2 316-3 316-4
HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES
229 396 727
1430
07195 10564 17143 34568
10000 10000 10000 10000
10000 10000 10000 10000
07195 10564 17143 34568
12500 12500 12500 12500
08994 13205 21429 43210
10000 10000 10000 10000
07195 10564 17143 34568
$6745 Misc Pediatric $9904 Misc Pediatric
$16072 Misc Pediatric $32408 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
317-1 317-2 317-3 317-4
TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES
300 544
1030 2038
08204 11764 19738 43378
10000 10000 10000 10000
10000 10000 10000 10000
08204 11764 19738 43378
12500 12500 12500 12500
10255 14705 24673 54223
10000 10000 10000 10000
08204 11764 19738 43378
$7691 Misc Pediatric $11029 Misc Pediatric $18504 Misc Pediatric $40667 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
320-1 320-2 320-3 320-4
OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES
229 474 900
1844
09314 14085 21498 40942
10000 10000 10000 10000
10000 10000 10000 10000
09314 14085 21498 40942
12500 12500 12500 12500
11643 17606 26873 51178
10000 10000 10000 10000
09314 14085 21498 40942
$8732 Misc Pediatric $13205 Misc Pediatric $20154 Misc Pediatric $38383 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
321-1 321-2 321-3 321-4
CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP
174 322 869
1740
16800 21292 35737 65431
10000 10000 10000 10000
10000 10000 10000 10000
16800 21292 35737 65431
12500 12500 12500 12500
21000 26615 44671 81789
10000 10000 10000 10000
16800 21292 35737 65431
$15750 Misc Pediatric $19961 Misc Pediatric $33503 Misc Pediatric $61342 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
340-1 340-2 340-3 340-4
FRACTURE OF FEMUR FRACTURE OF FEMUR FRACTURE OF FEMUR FRACTURE OF FEMUR
307 350 507 717
04052 05213 07741 13545
10000 10000 10000 10000
10000 10000 10000 10000
04052 05213 07741 13545
12500 12500 12500 12500
05065 06516 09676 16931
10000 10000 10000 10000
04052 05213 07741 13545
$3799 Misc Pediatric $4887 Misc Pediatric $7257 Misc Pediatric
$12698 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
341-1 341-2 341-3 341-4
FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP
302 365 480 981
04685 05732 07835 19346
10000 10000 10000 10000
10000 10000 10000 10000
04685 05732 07835 19346
12500 12500 12500 12500
05856 07165 09794 24183
10000 10000 10000 10000
04685 05732 07835 19346
$4392 Misc Pediatric $5374 Misc Pediatric $7345 Misc Pediatric
$18137 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
342-1 342-2 342-3 342-4
FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK
223 336 523
1073
04199 06015 09030 19468
10000 10000 10000 10000
10000 10000 10000 10000
04199 06015 09030 19468
12500 12500 12500 12500
05249 07519 11288 24335
10000 10000 10000 10000
04199 06015 09030 19468
$3937 Misc Pediatric $5639 Misc Pediatric $8466 Misc Pediatric
$18251 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
343-1 343-2 343-3 343-4
MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG
381 462 768
1278
06313 07919 12982 22512
10000 10000 10000 10000
10000 10000 10000 10000
06313 07919 12982 22512
12500 12500 12500 12500
07891 09899 16228 28140
10000 10000 10000 10000
06313 07919 12982 22512
$5918 Misc Pediatric $7424 Misc Pediatric
$12171 Misc Pediatric $21105 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
344-1 344-2 344-3 344-4
OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS
510 624 996
1727
06188 08269 12369 20626
10000 10000 10000 10000
10000 10000 10000 10000
06188 08269 12369 20626
12500 12500 12500 12500
07735 10336 15461 25783
10000 10000 10000 10000
06188 08269 12369 20626
$5801 Misc Pediatric $7752 Misc Pediatric
$11596 Misc Pediatric $19337 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
346-1 346-2 346-3 346-4
CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS
312 418 742
1507
05246 07180 12230 29854
10000 10000 10000 10000
10000 10000 10000 10000
05246 07180 12230 29854
12500 12500 12500 12500
06558 08975 15288 37318
10000 10000 10000 10000
05246 07180 12230 29854
$4918 Misc Pediatric $6731 Misc Pediatric
$11466 Misc Pediatric $27988 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
347-1 347-2 347-3 347-4
OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES
288 388 534
1184
05202 07038 09895 23177
10000 10000 10000 10000
10000 10000 10000 10000
05202 07038 09895 23177
12500 12500 12500 12500
06503 08798 12369 28971
10000 10000 10000 10000
05202 07038 09895 23177
$4877 Misc Pediatric $6598 Misc Pediatric $9277 Misc Pediatric
$21728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
349-1 349-2 349-3 349-4
MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE
226 480 806
1387
04381 06459 10302 19261
10000 10000 10000 10000
10000 10000 10000 10000
04381 06459 10302 19261
12500 12500 12500 12500
05476 08074 12878 24076
10000 10000 10000 10000
04381 06459 10302 19261
$4107 Misc Pediatric $6055 Misc Pediatric $9658 Misc Pediatric
$18057 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
351-1 351-2 351-3 351-4
OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES
252 352 544
1111
04074 05668 08930 19109
10000 10000 10000 10000
10000 10000 10000 10000
04074 05668 08930 19109
12500 12500 12500 12500
05093 07085 11163 23886
10000 10000 10000 10000
04074 05668 08930 19109
$3819 Misc Pediatric $5314 Misc Pediatric $8372 Misc Pediatric
$17915 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
361-1 361-2 361-3 361-4
SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES
407 758
1393 2857
11097 14459 21415 45412
10000 10000 10000 10000
10000 10000 10000 10000
11097 14459 21415 45412
12500 12500 12500 12500
13871 18074 26769 56765
10000 10000 10000 10000
11097 14459 21415 45412
$10403 Misc Pediatric $13555 Misc Pediatric $20077 Misc Pediatric $42574 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
362-1 362-2 362-3 362-4
MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES
179 233 597
1380
10091 13554 17862 38257
10000 10000 10000 10000
10000 10000 10000 10000
10091 13554 17862 38257
12500 12500 12500 12500
12614 16943 22328 47821
10000 10000 10000 10000
10091 13554 17862 38257
$9460 Misc Pediatric $12707 Misc Pediatric $16746 Misc Pediatric $35866 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
363-1 363-2 363-3 363-4
BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY
209 314 532
1706
08797 14900 19039 35420
10000 10000 10000 10000
10000 10000 10000 10000
08797 14900 19039 35420
12500 12500 12500 12500
10996 18625 23799 44275
10000 10000 10000 10000
08797 14900 19039 35420
$8247 Misc Pediatric $13969 Misc Pediatric $17849 Misc Pediatric $33206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
364-1 364-2 364-3 364-4
OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES
289 508 943
1919
07645 10877 16986 30643
10000 10000 10000 10000
10000 10000 10000 10000
07645 10877 16986 30643
12500 12500 12500 12500
09556 13596 21233 38304
10000 10000 10000 10000
07645 10877 16986 30643
$7167 Misc Pediatric $10197 Misc Pediatric $15924 Misc Pediatric $28728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
380-1 380-2 380-3 380-4
SKIN ULCERS SKIN ULCERS SKIN ULCERS SKIN ULCERS
416 498 784
1662
05289 06545 09424 17199
10000 10000 10000 10000
10000 10000 10000 10000
05289 06545 09424 17199
12500 12500 12500 12500
06611 08181 11780 21499
10000 10000 10000 10000
05289 06545 09424 17199
$4958 Misc Pediatric $6136 Misc Pediatric $8835 Misc Pediatric
$16124 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
381-1 381-2 381-3 381-4
MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS
300 428 671
1406
03883 05748 09734 27512
10000 10000 10000 10000
10000 10000 10000 10000
03883 05748 09734 27512
12500 12500 12500 12500
04854 07185 12168 34390
10000 10000 10000 10000
03883 05748 09734 27512
$3640 Misc Pediatric $5389 Misc Pediatric $9126 Misc Pediatric
$25793 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
382-1 382-2 382-3 382-4
MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS
381 432 645
1003
03521 05612 09634 15729
10000 10000 10000 10000
10000 10000 10000 10000
03521 05612 09634 15729
12500 12500 12500 12500
04401 07015 12043 19661
10000 10000 10000 10000
03521 05612 09634 15729
$3301 Misc Pediatric $5261 Misc Pediatric $9032 Misc Pediatric
$14746 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
383-1 383-2 383-3 383-4
CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS
294 412 617
1198
04148 05905 09147 19560
10000 10000 10000 10000
10000 10000 10000 10000
04148 05905 09147 19560
12500 12500 12500 12500
05185 07381 11434 24450
10000 10000 10000 10000
04148 05905 09147 19560
$3889 Misc Pediatric $5536 Misc Pediatric $8575 Misc Pediatric
$18338 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
384-1 384-2 384-3 384-4
CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE
193 301 493
1134
04752 06220 08932 20168
10000 10000 10000 10000
10000 10000 10000 10000
04752 06220 08932 20168
12500 12500 12500 12500
05940 07775 11165 25210
10000 10000 10000 10000
04752 06220 08932 20168
$4455 Misc Pediatric $5831 Misc Pediatric $8374 Misc Pediatric
$18908 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
385-1 385-2 385-3 385-4
OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS
248 353 565
1295
03496 05103 07974 19128
10000 10000 10000 10000
10000 10000 10000 10000
03496 05103 07974 19128
12500 12500 12500 12500
04370 06379 09968 23910
10000 10000 10000 10000
03496 05103 07974 19128
$3278 Misc Pediatric $4784 Misc Pediatric $7476 Misc Pediatric
$17933 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
401-1 401-2 401-3 401-4
PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES
303 427 844
2452
13697 18347 29058 71913
10000 10000 10000 10000
10000 10000 10000 10000
13697 18347 29058 71913
12500 12500 12500 12500
17121 22934 36323 89891
10000 10000 10000 10000
13697 18347 29058 71913
$12841 Misc Pediatric $17200 Misc Pediatric $27242 Misc Pediatric $67418 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
403-1 403-2 403-3 403-4
PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY
183 222 497
1867
12813 14411 21531 61151
10000 10000 10000 10000
10000 10000 10000 10000
12813 14411 21531 61151
12500 12500 12500 12500
16016 18014 26914 76439
10000 10000 10000 10000
12813 14411 21531 61151
$12012 Misc Pediatric $13510 Misc Pediatric $20185 Misc Pediatric $57329 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
404-1 404-2 404-3 404-4
THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES
130 216 659
1638
07364 09479 18990 42519
10000 10000 10000 10000
10000 10000 10000 10000
07364 09479 18990 42519
12500 12500 12500 12500
09205 11849 23738 53149
10000 10000 10000 10000
07364 09479 18990 42519
$6904 Misc Pediatric $8887 Misc Pediatric
$17803 Misc Pediatric $39862 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
405-1 405-2 405-3 405-4
OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS
419 571 966
2131
11123 14210 21421 48796
10000 10000 10000 10000
10000 10000 10000 10000
11123 14210 21421 48796
12500 12500 12500 12500
13904 17763 26776 60995
10000 10000 10000 10000
11123 14210 21421 48796
$10428 Misc Pediatric $13322 Misc Pediatric $20082 Misc Pediatric $45746 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
420-1 420-2 420-3 420-4
DIABETES DIABETES DIABETES DIABETES
261 275 427 935
03897 05302 07862 19671
10000 10000 10000 10000
10000 10000 10000 10000
03897 05302 07862 19671
12500 12500 12500 12500
04871 06628 09828 24589
10000 10000 10000 10000
03897 05302 07862 19671
$3653 Misc Pediatric $4971 Misc Pediatric $7371 Misc Pediatric
$18442 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
421-1 421-2 421-3 421-4
MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS
351 483 676
1375
03211 05227 08190 17446
10000 10000 10000 10000
10000 10000 10000 10000
03211 05227 08190 17446
12500 12500 12500 12500
04014 06534 10238 21808
10000 10000 10000 10000
03211 05227 08190 17446
$3010 Misc Pediatric $4900 Misc Pediatric $7678 Misc Pediatric
$16356 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
422-1 422-2 422-3 422-4
HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS
199 291 445 914
02848 04625 06828 14444
10000 10000 10000 10000
10000 10000 10000 10000
02848 04625 06828 14444
12500 12500 12500 12500
03560 05781 08535 18055
10000 10000 10000 10000
02848 04625 06828 14444
$2670 Misc Pediatric $4336 Misc Pediatric $6401 Misc Pediatric
$13541 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
423-1 423-2 423-3 423-4
INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM
272 363 573
1504
04421 05846 09540 27384
10000 10000 10000 10000
10000 10000 10000 10000
04421 05846 09540 27384
12500 12500 12500 12500
05526 07308 11925 34230
10000 10000 10000 10000
04421 05846 09540 27384
$4145 Misc Pediatric $5481 Misc Pediatric $8944 Misc Pediatric
$25673 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
424-1 424-2 424-3 424-4
OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS
259 397 605
1147
04342 06514 09768 21520
10000 10000 10000 10000
10000 10000 10000 10000
04342 06514 09768 21520
12500 12500 12500 12500
05428 08143 12210 26900
10000 10000 10000 10000
04342 06514 09768 21520
$4071 Misc Pediatric $6107 Misc Pediatric $9158 Misc Pediatric
$20175 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
425-1 425-2 425-3
ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED
241 302 460
04017 05132 07667
10000 10000 10000
10000 10000 10000
04017 05132 07667
12500 12500 12500
05021 06415 09584
10000 10000 10000
04017 05132 07667
$3766 Misc Pediatric $4811 Misc Pediatric $7188 Misc Pediatric
Misc Adult Misc Adult Misc Adult
425-4 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 946 16767 10000 10000 16767 12500 20959 10000 16767 $15719 Misc Pediatric Misc Adult 440-1 440-2 440-3 440-4
KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT
458 561 864
2088
44667 50078 60562 99171
10000 10000 10000 10000
10000 10000 10000 10000
44667 50078 60562 99171
12500 12500 12500 12500
55834 62598 75703
123964
10000 10000 10000 10000
44667 50078 60562 99171
$41875 Misc Pediatric $46948 Misc Pediatric $56777 Misc Pediatric $92973 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
441-1 441-2 441-3 441-4
MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES
474 726 994
2196
14386 21567 29549 61841
10000 10000 10000 10000
10000 10000 10000 10000
14386 21567 29549 61841
12500 12500 12500 12500
17983 26959 36936 77301
10000 10000 10000 10000
14386 21567 29549 61841
$13487 Misc Pediatric $20219 Misc Pediatric $27702 Misc Pediatric $57976 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
442-1 442-2 442-3 442-4
KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY
325 422 795
1671
13139 15537 23456 49226
10000 10000 10000 10000
10000 10000 10000 10000
13139 15537 23456 49226
12500 12500 12500 12500
16424 19421 29320 61533
10000 10000 10000 10000
13139 15537 23456 49226
$12318 Misc Pediatric $14566 Misc Pediatric $21990 Misc Pediatric $46149 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
443-1 443-2 443-3 443-4
KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY
253 356 802
1752
10883 12834 18814 40742
10000 10000 10000 10000
10000 10000 10000 10000
10883 12834 18814 40742
12500 12500 12500 12500
13604 16043 23518 50928
10000 10000 10000 10000
10883 12834 18814 40742
$10203 Misc Pediatric $12032 Misc Pediatric $17638 Misc Pediatric $38196 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
444-1 444-2 444-3 444-4
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY
264 447 933
1617
09410 12604 20686 38830
10000 10000 10000 10000
10000 10000 10000 10000
09410 12604 20686 38830
12500 12500 12500 12500
11763 15755 25858 48538
10000 10000 10000 10000
09410 12604 20686 38830
$8822 Misc Pediatric $11816 Misc Pediatric $19393 Misc Pediatric $36403 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
445-1 445-2 445-3 445-4
OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES
190 319 781
1545
08552 11610 15964 31570
10000 10000 10000 10000
10000 10000 10000 10000
08552 11610 15964 31570
12500 12500 12500 12500
10690 14513 19955 39463
10000 10000 10000 10000
08552 11610 15964 31570
$8018 Misc Pediatric $10884 Misc Pediatric $14966 Misc Pediatric $29597 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
446-1 446-2 446-3 446-4
URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES
188 261 612
1363
06758 08690 14202 30173
10000 10000 10000 10000
10000 10000 10000 10000
06758 08690 14202 30173
12500 12500 12500 12500
08448 10863 17753 37716
10000 10000 10000 10000
06758 08690 14202 30173
$6336 Misc Pediatric $8147 Misc Pediatric
$13314 Misc Pediatric $28287 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
447-1 447-2 447-3 447-4
OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES
228 365 728
1787
11479 13294 19661 43932
10000 10000 10000 10000
10000 10000 10000 10000
11479 13294 19661 43932
12500 12500 12500 12500
14349 16618 24576 54915
10000 10000 10000 10000
11479 13294 19661 43932
$10762 Misc Pediatric $12463 Misc Pediatric $18432 Misc Pediatric $41186 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
460-1 460-2 460-3 460-4
RENAL FAILURE RENAL FAILURE RENAL FAILURE RENAL FAILURE
299 376 496
1115
04323 06061 07896 19936
10000 10000 10000 10000
10000 10000 10000 10000
04323 06061 07896 19936
12500 12500 12500 12500
05404 07576 09870 24920
10000 10000 10000 10000
04323 06061 07896 19936
$4053 Misc Pediatric $5682 Misc Pediatric $7403 Misc Pediatric
$18690 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
461-1 461-2 461-3 461-4
KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY
271 374 601
1108
04315 05992 09498 16929
10000 10000 10000 10000
10000 10000 10000 10000
04315 05992 09498 16929
12500 12500 12500 12500
05394 07490 11873 21161
10000 10000 10000 10000
04315 05992 09498 16929
$4045 Misc Pediatric $5618 Misc Pediatric $8904 Misc Pediatric
$15871 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
462-1 462-2 462-3 462-4
NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS
260 370 656
1359
03798 05298 09439 23905
10000 10000 10000 10000
10000 10000 10000 10000
03798 05298 09439 23905
12500 12500 12500 12500
04748 06623 11799 29881
10000 10000 10000 10000
03798 05298 09439 23905
$3561 Misc Pediatric $4967 Misc Pediatric $8849 Misc Pediatric
$22411 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
463-1 463-2 463-3 463-4
KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS
268 352 507 910
04120 05628 07879 14066
10000 10000 10000 10000
10000 10000 10000 10000
04120 05628 07879 14066
12500 12500 12500 12500
05150 07035 09849 17583
10000 10000 10000 10000
04120 05628 07879 14066
$3863 Misc Pediatric $5276 Misc Pediatric $7387 Misc Pediatric
$13187 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
465-1 465-2 465-3 465-4
URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION
165 202 380 860
04374 05548 08751 18922
10000 10000 10000 10000
10000 10000 10000 10000
04374 05548 08751 18922
12500 12500 12500 12500
05468 06935 10939 23653
10000 10000 10000 10000
04374 05548 08751 18922
$4101 Misc Pediatric $5201 Misc Pediatric $8204 Misc Pediatric
$17739 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
466-1 466-2 466-3 466-4
MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC
221 343 533 971
03576 05752 08974 17498
10000 10000 10000 10000
10000 10000 10000 10000
03576 05752 08974 17498
12500 12500 12500 12500
04470 07190 11218 21873
10000 10000 10000 10000
03576 05752 08974 17498
$3353 Misc Pediatric $5393 Misc Pediatric $8413 Misc Pediatric
$16404 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
468-1 468-2 468-3 468-4
OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS
246 335 509
1057
04152 05935 08698 18661
10000 10000 10000 10000
10000 10000 10000 10000
04152 05935 08698 18661
12500 12500 12500 12500
05190 07419 10873 23326
10000 10000 10000 10000
04152 05935 08698 18661
$3893 Misc Pediatric $5564 Misc Pediatric $8154 Misc Pediatric
$17495 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
480-1 480-2 480-3 480-4
MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES
180 241 618
1422
12119 13477 20992 45258
10000 10000 10000 10000
10000 10000 10000 10000
12119 13477 20992 45258
12500 12500 12500 12500
15149 16846 26240 56573
10000 10000 10000 10000
12119 13477 20992 45258
$11362 Misc Pediatric $12635 Misc Pediatric $19680 Misc Pediatric $42429 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
481-1 481-2 481-3 481-4
PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES
228 267 830
1810
06794 11922 17939 41143
10000 10000 10000 10000
10000 10000 10000 10000
06794 11922 17939 41143
12500 12500 12500 12500
08493 14903 22424 51429
10000 10000 10000 10000
06794 11922 17939 41143
$6369 Misc Pediatric $11177 Misc Pediatric $16818 Misc Pediatric $38572 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
482-1 482-2 482-3 482-4
TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY
169 278 716
1341
05918 07555 14662 30717
10000 10000 10000 10000
10000 10000 10000 10000
05918 07555 14662 30717
12500 12500 12500 12500
07398 09444 18328 38396
10000 10000 10000 10000
05918 07555 14662 30717
$5548 Misc Pediatric $7083 Misc Pediatric
$13746 Misc Pediatric $28797 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
483-1 483-2 483-3 483-4
TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES
203 541
1127 1970
06074 11326 22018 44244
10000 10000 10000 10000
10000 10000 10000 10000
06074 11326 22018 44244
12500 12500 12500 12500
07593 14158 27523 55305
10000 10000 10000 10000
06074 11326 22018 44244
$5694 Misc Pediatric $10618 Misc Pediatric $20642 Misc Pediatric $41479 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
484-1 484-2 484-3 484-4
OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
250 191 502
1578
07704 11762 15177 36555
10000 10000 10000 10000
10000 10000 10000 10000
07704 11762 15177 36555
12500 12500 12500 12500
09630 14703 18971 45694
10000 10000 10000 10000
07704 11762 15177 36555
$7223 Misc Pediatric $11027 Misc Pediatric $14228 Misc Pediatric $34270 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
500-1 500-2 500-3 500-4
MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM
266 431 601
1109
03789 05904 09172 17461
10000 10000 10000 10000
10000 10000 10000 10000
03789 05904 09172 17461
12500 12500 12500 12500
04736 07380 11465 21826
10000 10000 10000 10000
03789 05904 09172 17461
$3552 Misc Pediatric $5535 Misc Pediatric $8599 Misc Pediatric
$16370 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
501-1 501-2 501-3 501-4
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY
258 351 547
1074
04044 05542 08322 16765
10000 10000 10000 10000
10000 10000 10000 10000
04044 05542 08322 16765
12500 12500 12500 12500
05055 06928 10403 20956
10000 10000 10000 10000
04044 05542 08322 16765
$3791 Misc Pediatric $5196 Misc Pediatric $7802 Misc Pediatric
$15717 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
510-1 510-2 510-3 510-4
PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS
244 387 892
1787
11433 14140 25807 52317
10000 10000 10000 10000
10000 10000 10000 10000
11433 14140 25807 52317
12500 12500 12500 12500
14291 17675 32259 65396
10000 10000 10000 10000
11433 14140 25807 52317
$10718 Misc Pediatric $13256 Misc Pediatric $24194 Misc Pediatric $49047 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
511-1 511-2 511-3 511-4
UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY
330 488 862
1777
11911 14923 22750 49888
10000 10000 10000 10000
10000 10000 10000 10000
11911 14923 22750 49888
12500 12500 12500 12500
14889 18654 28438 62360
10000 10000 10000 10000
11911 14923 22750 49888
$11167 Misc Pediatric $13990 Misc Pediatric $21328 Misc Pediatric $46770 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
512-1 512-2 512-3 512-4
UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG
217 308 682
1629
10603 12410 19879 45702
10000 10000 10000 10000
10000 10000 10000 10000
10603 12410 19879 45702
12500 12500 12500 12500
13254 15513 24849 57128
10000 10000 10000 10000
10603 12410 19879 45702
$9940 Misc Pediatric $11634 Misc Pediatric $18637 Misc Pediatric $42846 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
513-1 513-2 513-3 513-4
UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
186 251 564
1508
08515 10026 16283 40387
10000 10000 10000 10000
10000 10000 10000 10000
08515 10026 16283 40387
12500 12500 12500 12500
10644 12533 20354 50484
10000 10000 10000 10000
08515 10026 16283 40387
$7983 Misc Pediatric $9399 Misc Pediatric
$15265 Misc Pediatric $37863 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
514-1 514-2 514-3 514-4
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
140 172 529
1557
07298 09618 15881 40691
10000 10000 10000 10000
10000 10000 10000 10000
07298 09618 15881 40691
12500 12500 12500 12500
09123 12023 19851 50864
10000 10000 10000 10000
07298 09618 15881 40691
$6842 Misc Pediatric $9017 Misc Pediatric
$14888 Misc Pediatric $38148 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
517-1 517-2 517-3 517-4
DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES
192 289 663
1364
06030 08036 13633 29709
10000 10000 10000 10000
10000 10000 10000 10000
06030 08036 13633 29709
12500 12500 12500 12500
07538 10045 17041 37136
10000 10000 10000 10000
06030 08036 13633 29709
$5653 Misc Pediatric $7534 Misc Pediatric
$12781 Misc Pediatric $27852 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
518-1 518-2 518-3 518-4
OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
223 382 837
1827
06924 10040 18032 44556
10000 10000 10000 10000
10000 10000 10000 10000
06924 10040 18032 44556
12500 12500 12500 12500
08655 12550 22540 55695
10000 10000 10000 10000
06924 10040 18032 44556
$6491 Misc Pediatric $9413 Misc Pediatric
$16905 Misc Pediatric $41771 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
519-1 519-2 519-3 519-4
UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA
206 279 613
1485
08286 10051 17505 39433
10000 10000 10000 10000
10000 10000 10000 10000
08286 10051 17505 39433
12500 12500 12500 12500
10358 12564 21881 49291
10000 10000 10000 10000
08286 10051 17505 39433
$7768 Misc Pediatric $9423 Misc Pediatric
$16411 Misc Pediatric $36968 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
530-1 530-2 530-3 530-4
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
310 385 643
1178
04420 06163 09992 18972
10000 10000 10000 10000
10000 10000 10000 10000
04420 06163 09992 18972
12500 12500 12500 12500
05525 07704 12490 23715
10000 10000 10000 10000
04420 06163 09992 18972
$4144 Misc Pediatric $5778 Misc Pediatric $9368 Misc Pediatric
$17786 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
531-1 531-2 531-3 531-4
FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS
266 383 638
1303
04544 06407 09987 20595
10000 10000 10000 10000
10000 10000 10000 10000
04544 06407 09987 20595
12500 12500 12500 12500
05680 08009 12484 25744
10000 10000 10000 10000
04544 06407 09987 20595
$4260 Misc Pediatric $6007 Misc Pediatric $9363 Misc Pediatric
$19308 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
532-1 532-2 532-3 532-4
MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
177 237 434
1003
03922 04787 07941 17650
10000 10000 10000 10000
10000 10000 10000 10000
03922 04787 07941 17650
12500 12500 12500 12500
04903 05984 09926 22063
10000 10000 10000 10000
03922 04787 07941 17650
$3677 Misc Pediatric $4488 Misc Pediatric $7445 Misc Pediatric
$16547 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
540-1 540-2 540-3 540-4
CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY
298 391 634
1053
05654 06864 09354 23719
10000 10000 10000 10000
10600 10600 10600 10600
05993 07276 09915 25142
10000 10000 10000 10000
05993 07276 09915 25142
10000 10000 10000 10000
05654 06864 09354 23719
$4495 Obstetrics $5457 Obstetrics $7436 Obstetrics
$18857 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
541-1 541-2 541-3 541-4
VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC
212 249 491 838
05628 06076 08661 23515
10000 10000 10000 10000
10600 10600 10600 10600
05966 06441 09181 24926
10000 10000 10000 10000
05966 06441 09181 24926
10000 10000 10000 10000
05628 06076 08661 23515
$4474 Obstetrics $4830 Obstetrics $6886 Obstetrics
$18694 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
542-1 542-2 542-3 542-4
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC
216 296 614 993
03695 04647 08572 36195
10000 10000 10000 10000
10600 10600 10600 10600
03917 04926 09086 38367
10000 10000 10000 10000
03917 04926 09086 38367
10000 10000 10000 10000
03695 04647 08572 36195
$2938 Obstetrics $3694 Obstetrics $6815 Obstetrics
$28775 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
544-1 544-2 544-3 544-4
DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES
136 200 407 914
04586 05897 09822 25061
10000 10000 10000 10000
10600 10600 10600 10600
04861 06251 10411 26565
10000 10000 10000 10000
04861 06251 10411 26565
10000 10000 10000 10000
04586 05897 09822 25061
$3646 Obstetrics Obstetrics $4688 Obstetrics Obstetrics $7808 Obstetrics Obstetrics
$19924 Obstetrics Obstetrics 545-1 545-2 545-3 545-4
ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE
164 190 265 576
06988 08147 10540 19945
10000 10000 10000 10000
10600 10600 10600 10600
07407 08636 11172 21142
10000 10000 10000 10000
07407 08636 11172 21142
10000 10000 10000 10000
06988 08147 10540 19945
$5555 Obstetrics Obstetrics $6477 Obstetrics Obstetrics $8379 Obstetrics Obstetrics
$15856 Obstetrics Obstetrics 546-1 546-2 546-3 546-4
OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES
285 454 755
1446
05023 07207 13295 43377
10000 10000 10000 10000
10600 10600 10600 10600
05324 07639 14093 45980
10000 10000 10000 10000
05324 07639 14093 45980
10000 10000 10000 10000
05023 07207 13295 43377
$3993 Obstetrics Obstetrics $5730 Obstetrics Obstetrics
$10570 Obstetrics Obstetrics $34485 Obstetrics Obstetrics
560-1 560-2 560-3 560-4
VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY
203 237 385 935
03307 03856 05399 15061
10000 10000 10000 10000
10600 10600 10600 10600
03505 04087 05723 15965
10000 10000 10000 10000
03505 04087 05723 15965
10000 10000 10000 10000
03307 03856 05399 15061
$2629 Obstetrics Obstetrics $3066 Obstetrics Obstetrics $4292 Obstetrics Obstetrics
$11974 Obstetrics Obstetrics 561-1 561-2 561-3 561-4
POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE
211 257 393 688
02511 03908 06071 15617
10000 10000 10000 10000
10600 10600 10600 10600
02662 04142 06435 16554
10000 10000 10000 10000
02662 04142 06435 16554
10000 10000 10000 10000
02511 03908 06071 15617
$1996 Obstetrics Obstetrics $3107 Obstetrics Obstetrics $4826 Obstetrics Obstetrics
$12416 Obstetrics Obstetrics 563-1 563-2 563-3 563-4
THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION
259 391 747 720
02581 03376 05162 09652
10000 10000 10000 10000
10600 10600 10600 10600
02736 03579 05472 10231
10000 10000 10000 10000
02736 03579 05472 10231
10000 10000 10000 10000
02581 03376 05162 09652
$2052 Obstetrics Obstetrics $2684 Obstetrics Obstetrics $4104 Obstetrics Obstetrics $7673 Obstetrics Obstetrics
564-1 564-2 564-3 564-4
ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY
137 170 276 808
02881 03463 04901 16676
10000 10000 10000 10000
10600 10600 10600 10600
03054 03671 05195 17677
10000 10000 10000 10000
03054 03671 05195 17677
10000 10000 10000 10000
02881 03463 04901 16676
$2290 Obstetrics Obstetrics $2753 Obstetrics Obstetrics $3896 Obstetrics Obstetrics
$13257 Obstetrics Obstetrics 565-1 565-2 565-3 565-4
FALSE LABOR FALSE LABOR FALSE LABOR FALSE LABOR
123 185 735 808
01245 01782 02687 02986
10000 10000 10000 10000
10600 10600 10600 10600
01320 01889 02848 03165
10000 10000 10000 10000
01320 01889 02848 03165
10000 10000 10000 10000
01245 01782 02687 02986
$990 Obstetrics Obstetrics $1417 Obstetrics Obstetrics $2136 Obstetrics Obstetrics $2374 Obstetrics Obstetrics
566-1 566-2 566-3 566-4
OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES
211 294 544 843
02442 03252 04790 14726
10000 10000 10000 10000
10600 10600 10600 10600
02589 03447 05077 15610
10000 10000 10000 10000
02589 03447 05077 15610
10000 10000 10000 10000
02442 03252 04790 14726
$1941 Obstetrics Obstetrics $2585 Obstetrics Obstetrics $3808 Obstetrics Obstetrics
$11707 Obstetrics Obstetrics 580-1 580-2 580-3 580-4
NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE
144 159 182 165
02398 03209 05011 08512
12500 12500 12500 12500
10000 10000 10000 10000
02998 04011 06264 10640
10000 10000 10000 10000
02998 04011 06264 10640
17500 17500 17500 17500
04197 05616 08769 14896
$2248 Neonate Neonate $3008 Neonate Neonate $4698 Neonate Neonate $7980 Neonate Neonate
581-1 581-2 581-3 581-4
NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE
124 128 126 135
00982 01477 02362 04408
12500 12500 12500 12500
10000 10000 10000 10000
01228 01846 02953 05510
10000 10000 10000 10000
01228 01846 02953 05510
17500 17500 17500 17500
01719 02585 04134 07714
$921 Neonate Neonate $1385 Neonate Neonate $2214 Neonate Neonate $4133 Neonate Neonate
583-1 583-2 583-3 583-4
NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO
2070 2300 3077 4886
99741 157496 173245 240894
12500 12500 12500 12500
10000 10000 10000 10000
124676 196870 216556 301118
10000 10000 10000 10000
124676 196870 216556 301118
17500 17500 17500 17500
174547 275618 303179 421565
$93507 Neonate Neonate $147653 Neonate Neonate $162417 Neonate Neonate $225838 Neonate Neonate
588-1 588-2 588-3 588-4
NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE
4442 4935 7714
10207
48410 70035
142903 216660
12500 12500 12500 12500
10000 10000 10000 10000
60513 87544
178629 270825
10000 10000 10000 10000
60513 87544
178629 270825
17500 17500 17500 17500
84718 122561 250080 379155
$45384 Neonate Neonate $65658 Neonate Neonate
$133972 Neonate Neonate $203119 Neonate Neonate
589-1 589-2 589-3 589-4
NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS
5843 5041 3035
265
115468 104972
95430 04454
12500 12500 12500 12500
10000 10000 10000 10000
144335 131215 119288
05568
10000 10000 10000 10000
144335 131215 119288
05568
17500 17500 17500 17500
202069 183701 167003
07795
$108251 Neonate Neonate $98411 Neonate Neonate $89466 Neonate Neonate
$4176 Neonate Neonate 591-1 591-2 591-3 591-4
NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE
211 3710 5061 7221
01574 55672 88282
132286
12500 12500 12500 12500
10000 10000 10000 10000
01968 69590
110353 165358
10000 10000 10000 10000
01968 69590
110353 165358
17500 17500 17500 17500
02755 97426
154494 231501
$1476 Neonate Neonate $52193 Neonate Neonate $82764 Neonate Neonate
$124018 Neonate Neonate 593-1 593-2 593-3 593-4
NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE
1928 4851 5965 7143
15109 51914 82800
122454
12500 12500 12500 12500
10000 10000 10000 10000
18886 64893
103500 153068
10000 10000 10000 10000
18886 64893
103500 153068
17500 17500 17500 17500
26441 90850
144900 214295
$14165 Neonate Neonate $48669 Neonate Neonate $77625 Neonate Neonate
$114801 Neonate Neonate 602-1 602-2 602-3 602-4
NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2513 4403 5324 6307
29635 58707 77593
104733
12500 12500 12500 12500
10000 10000 10000 10000
37044 73384 96991
130916
10000 10000 10000 10000
37044 73384 96991
130916
17500 17500 17500 17500
51861 102737 135788 183283
$27783 Neonate Neonate $55038 Neonate Neonate $72743 Neonate Neonate $98187 Neonate Neonate
603-1 603-2 603-3 603-4
NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION
2234 3619 4843 5396
17223 42526 65587 70750
12500 12500 12500 12500
10000 10000 10000 10000
21529 53158 81984 88438
10000 10000 10000 10000
21529 53158 81984 88438
17500 17500 17500 17500
30140 74421
114777 123813
$16147 Neonate Neonate $39868 Neonate Neonate $61488 Neonate Neonate $66328 Neonate Neonate
607-1 607-2 607-3 607-4
NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2509 3582 4341 4957
27503 47486 61883 79508
12500 12500 12500 12500
10000 10000 10000 10000
34379 59358 77354 99385
10000 10000 10000 10000
34379 59358 77354 99385
17500 17500 17500 17500
48130 83101
108295 139139
$25784 Neonate Neonate $44518 Neonate Neonate $58015 Neonate Neonate $74539 Neonate Neonate
608-1 608-2 608-3 608-4
NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION
1980 3004 3846 4414
21292 36047 52684 60424
12500 12500 12500 12500
10000 10000 10000 10000
26615 45059 65855 75530
10000 10000 10000 10000
26615 45059 65855 75530
17500 17500 17500 17500
37261 63082 92197
105742
$19961 Neonate Neonate $33794 Neonate Neonate $49391 Neonate Neonate $56648 Neonate Neonate
609-1 609-2 609-3 609-4
NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE
1933 2210 3803 6267
27332 38628 65636
119134
12500 12500 12500 12500
10000 10000 10000 10000
34165 48285 82045
148918
10000 10000 10000 10000
34165 48285 82045
148918
17500 17500 17500 17500
47831 67599
114863 208485
$25624 Neonate Neonate $36214 Neonate Neonate $61534 Neonate Neonate
$111688 Neonate Neonate 611-1 611-2 611-3 611-4
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY
1313 2123 3133 3614
11780 25158 40556 52442
12500 12500 12500 12500
10000 10000 10000 10000
14725 31448 50695 65553
10000 10000 10000 10000
14725 31448 50695 65553
17500 17500 17500 17500
20615 44027 70973 91774
$11044 Neonate Neonate $23586 Neonate Neonate $38021 Neonate Neonate $49164 Neonate Neonate
612-1 612-2 612-3 612-4
NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND
1756 2442 3248 3834
21880 32223 46803 62297
12500 12500 12500 12500
10000 10000 10000 10000
27350 40279 58504 77871
10000 10000 10000 10000
27350 40279 58504 77871
17500 17500 17500 17500
38290 56390 81905
109020
$20513 Neonate Neonate $30209 Neonate Neonate $43878 Neonate Neonate $58403 Neonate Neonate
613-1 613-2 613-3 613-4
NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION
1439 2153 2853 3338
16593 26831 37601 48828
12500 12500 12500 12500
10000 10000 10000 10000
20741 33539 47001 61035
10000 10000 10000 10000
20741 33539 47001 61035
17500 17500 17500 17500
29038 46954 65802 85449
$15556 Neonate Neonate $25154 Neonate Neonate $35251 Neonate Neonate $45776 Neonate Neonate
614-1 614-2 614-3 614-4
NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION
1123 2008 2852 3640
09241 22768 36403 50802
12500 12500 12500 12500
10000 10000 10000 10000
11551 28460 45504 63503
10000 10000 10000 10000
11551 28460 45504 63503
17500 17500 17500 17500
16172 39844 63705 88904
$8663 Neonate Neonate $21345 Neonate Neonate $34128 Neonate Neonate $47627 Neonate Neonate
621-1 621-2 621-3 621-4
NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY
820 1397 2125 2416
06082 15379 27206 38101
12500 12500 12500 12500
10000 10000 10000 10000
07603 19224 34008 47626
10000 10000 10000 10000
07603 19224 34008 47626
17500 17500 17500 17500
10644 26913 47611 66677
$5702 Neonate Neonate $14418 Neonate Neonate $25506 Neonate Neonate $35720 Neonate Neonate
622-1 622-2 622-3 622-4
NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND
1118 1514 1977 2285
13666 20913 29736 47202
12500 12500 12500 12500
10000 10000 10000 10000
17083 26141 37170 59003
10000 10000 10000 10000
17083 26141 37170 59003
17500 17500 17500 17500
23916 36598 52038 82604
$12812 Neonate Neonate $19606 Neonate Neonate $27878 Neonate Neonate $44252 Neonate Neonate
623-1 623-2 623-3 623-4
NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION
924 1399 1872 2738
09934 16800 25087 38932
12500 12500 12500 12500
10000 10000 10000 10000
12418 21000 31359 48665
10000 10000 10000 10000
12418 21000 31359 48665
17500 17500 17500 17500
17385 29400 43902 68131
$9313 Neonate Neonate $15750 Neonate Neonate $23519 Neonate Neonate $36499 Neonate Neonate
625-1 625-2 625-3 625-4
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION
1157 1621 1925 2015
11469 18627 23298 29194
12500 12500 12500 12500
10000 10000 10000 10000
14336 23284 29123 36493
10000 10000 10000 10000
14336 23284 29123 36493
17500 17500 17500 17500
20071 32597 40772 51090
$10752 Neonate Neonate $17463 Neonate Neonate $21842 Neonate Neonate $27369 Neonate Neonate
626-1 626-2 626-3 626-4
NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
279 456 864
1838
01387 02587 07679 22819
10000 10000 10000 10000
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
$1040 Normal newborn Normal newborn $1940 Normal newborn Normal newborn $5759 Normal newborn Normal newborn
$17114 Normal newborn Normal newborn 630-1 630-2 630-3 630-4
NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE
486 940
1448 3912
20468 32885 52250
112072
12500 12500 12500 12500
10000 10000 10000 10000
25585 41106 65313
140090
10000 10000 10000 10000
25585 41106 65313
140090
17500 17500 17500 17500
35819 57549 91438
196126
$19189 Neonate Neonate $30830 Neonate Neonate $48984 Neonate Neonate
$105068 Neonate Neonate 631-1 631-2 631-3 631-4
NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE
335 886
2279 5111
09217 16766 37480 96324
12500 12500 12500 12500
10000 10000 10000 10000
11521 20958 46850
120405
10000 10000 10000 10000
11521 20958 46850
120405
17500 17500 17500 17500
16130 29341 65590
168567
$8641 Neonate Neonate $15718 Neonate Neonate $35138 Neonate Neonate $90304 Neonate Neonate
633-1 633-2 633-3 633-4
NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY
296 651
1226 2381
01972 05798 13892 39728
12500 12500 12500 12500
10000 10000 10000 10000
02465 07248 17365 49660
10000 10000 10000 10000
02465 07248 17365 49660
17500 17500 17500 17500
03451 10147 24311 69524
$1849 Neonate Neonate $5436 Neonate Neonate
$13024 Neonate Neonate $37245 Neonate Neonate
634-1 634-2 634-3 634-4
NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND
465 749
1261 2233
04886 09445 20176 46934
12500 12500 12500 12500
10000 10000 10000 10000
06108 11806 25220 58668
10000 10000 10000 10000
06108 11806 25220 58668
17500 17500 17500 17500
08551 16529 35308 82135
$4581 Neonate Neonate $8855 Neonate Neonate
$18915 Neonate Neonate $44001 Neonate Neonate
636-1 636-2 636-3 636-4
NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION
558 779
1164 1896
05582 08840 15558 30613
12500 12500 12500 12500
10000 10000 10000 10000
06978 11050 19448 38266
10000 10000 10000 10000
06978 11050 19448 38266
17500 17500 17500 17500
09769 15470 27227 53573
$5233 Neonate Neonate $8288 Neonate Neonate
$14586 Neonate Neonate $28700 Neonate Neonate
639-1 639-2 639-3 639-4
NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION
441 704 998
1653
03287 06622 11809 27285
12500 12500 12500 12500
10000 10000 10000 10000
04109 08278 14761 34106
10000 10000 10000 10000
04109 08278 14761 34106
17500 17500 17500 17500
05752 11589 20666 47749
$3082 Neonate Neonate $6208 Neonate Neonate
$11071 Neonate Neonate $25580 Neonate Neonate
640-1 NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 210 01012 10000 10000 01012 10000 01012 10000 01012 $759 Normal newborn Normal newborn
640-2 640-3 640-4
NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
245 376
1206
01353 02864 14726
10000 10000 10000
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
$1015 Normal newborn Normal newborn $2148 Normal newborn Normal newborn
$11045 Normal newborn Normal newborn 650-1 650-2 650-3 650-4
SPLENECTOMY SPLENECTOMY SPLENECTOMY SPLENECTOMY
348 537 848
1563
12985 17965 25202 50826
10000 10000 10000 10000
10000 10000 10000 10000
12985 17965 25202 50826
12500 12500 12500 12500
16231 22456 31503 63533
10000 10000 10000 10000
12985 17965 25202 50826
$12173 Misc Pediatric Misc Adult $16842 Misc Pediatric Misc Adult $23627 Misc Pediatric Misc Adult $47649 Misc Pediatric Misc Adult
651-1 651-2 651-3 651-4
OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS
331 472 962
2426
09234 13695 21005 59541
10000 10000 10000 10000
10000 10000 10000 10000
09234 13695 21005 59541
12500 12500 12500 12500
11543 17119 26256 74426
10000 10000 10000 10000
09234 13695 21005 59541
$8657 Misc Pediatric Misc Adult $12839 Misc Pediatric Misc Adult $19692 Misc Pediatric Misc Adult $55820 Misc Pediatric Misc Adult
660-1 660-2 660-3 660-4
MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL
305 408 648
1435
05399 07219 11819 30180
10000 10000 10000 10000
10000 10000 10000 10000
05399 07219 11819 30180
12500 12500 12500 12500
06749 09024 14774 37725
10000 10000 10000 10000
05399 07219 11819 30180
$5062 Misc Pediatric Misc Adult $6768 Misc Pediatric Misc Adult
$11080 Misc Pediatric Misc Adult $28294 Misc Pediatric Misc Adult
661-1 661-2 661-3 661-4
COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS
275 375 566
1265
06473 08098 12433 27857
10000 10000 10000 10000
10000 10000 10000 10000
06473 08098 12433 27857
12500 12500 12500 12500
08091 10123 15541 34821
10000 10000 10000 10000
06473 08098 12433 27857
$6068 Misc Pediatric Misc Adult $7592 Misc Pediatric Misc Adult
$11656 Misc Pediatric Misc Adult $26116 Misc Pediatric Misc Adult
662-1 662-2 662-3 662-4
SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS
412 538 785
1302
05044 07003 10778 23937
10000 10000 10000 10000
10000 10000 10000 10000
05044 07003 10778 23937
12500 12500 12500 12500
06305 08754 13473 29921
10000 10000 10000 10000
05044 07003 10778 23937
$4729 Misc Pediatric Misc Adult $6565 Misc Pediatric Misc Adult
$10104 Misc Pediatric Misc Adult $22441 Misc Pediatric Misc Adult
663-1 663-2 663-3 663-4
OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS
232 301 451 900
04474 05959 08513 16106
10000 10000 10000 10000
10000 10000 10000 10000
04474 05959 08513 16106
12500 12500 12500 12500
05593 07449 10641 20133
10000 10000 10000 10000
04474 05959 08513 16106
$4194 Misc Pediatric Misc Adult $5587 Misc Pediatric Misc Adult $7981 Misc Pediatric Misc Adult
$15099 Misc Pediatric Misc Adult 680-1 680-2 680-3 680-4
MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
408 633
1185 2456
13702 18600 32002 66288
10000 10000 10000 10000
10000 10000 10000 10000
13702 18600 32002 66288
12500 12500 12500 12500
17128 23250 40003 82860
10000 10000 10000 10000
13702 18600 32002 66288
$12846 Misc Pediatric Misc Adult $17438 Misc Pediatric Misc Adult $30002 Misc Pediatric Misc Adult $62145 Misc Pediatric Misc Adult
681-1 681-2 681-3 681-4
OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
268 507
1111 2510
09800 13647 24597 59170
10000 10000 10000 10000
10000 10000 10000 10000
09800 13647 24597 59170
12500 12500 12500 12500
12250 17059 30746 73963
10000 10000 10000 10000
09800 13647 24597 59170
$9188 Misc Pediatric Misc Adult $12794 Misc Pediatric Misc Adult $23060 Misc Pediatric Misc Adult $55472 Misc Pediatric Misc Adult
690-1 690-2 690-3 690-4
ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA
495 740
1461 2485
07040 11869 23551 52504
10000 10000 10000 10000
10000 10000 10000 10000
07040 11869 23551 52504
12500 12500 12500 12500
08800 14836 29439 65630
10000 10000 10000 10000
07040 11869 23551 52504
$6600 Misc Pediatric Misc Adult $11127 Misc Pediatric Misc Adult $22079 Misc Pediatric Misc Adult $49223 Misc Pediatric Misc Adult
691-1 691-2 691-3 691-4
LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA
389 540 861
1585
07077 09840 15477 31411
10000 10000 10000 10000
10000 10000 10000 10000
07077 09840 15477 31411
12500 12500 12500 12500
08846 12300 19346 39264
10000 10000 10000 10000
07077 09840 15477 31411
$6635 Misc Pediatric Misc Adult $9225 Misc Pediatric Misc Adult
$14510 Misc Pediatric Misc Adult $29448 Misc Pediatric Misc Adult
692-1 692-2 692-3 692-4
RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY
389 482 868
1580
06075 12584 17422 29316
10000 10000 10000 10000
10000 10000 10000 10000
06075 12584 17422 29316
12500 12500 12500 12500
07594 15730 21778 36645
10000 10000 10000 10000
06075 12584 17422 29316
$5695 Misc Pediatric Misc Adult $11798 Misc Pediatric Misc Adult $16333 Misc Pediatric Misc Adult $27484 Misc Pediatric Misc Adult
693-1 693-2 693-3 693-4
CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY
281 368 785
2410
06251 07881 13637 49083
10000 10000 10000 10000
10000 10000 10000 10000
06251 07881 13637 49083
12500 12500 12500 12500
07814 09851 17046 61354
10000 10000 10000 10000
06251 07881 13637 49083
$5860 Misc Pediatric Misc Adult $7388 Misc Pediatric Misc Adult
$12785 Misc Pediatric Misc Adult $46015 Misc Pediatric Misc Adult
694-1 694-2 694-3 694-4
LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR
304 404 674
1164
04842 06831 11115 21001
10000 10000 10000 10000
10000 10000 10000 10000
04842 06831 11115 21001
12500 12500 12500 12500
06053 08539 13894 26251
10000 10000 10000 10000
04842 06831 11115 21001
$4539 Misc Pediatric Misc Adult $6404 Misc Pediatric Misc Adult
$10420 Misc Pediatric Misc Adult $19688 Misc Pediatric Misc Adult
710-1 710-2 710-3 710-4
INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE
510 680
1111 1820
10635 15963 25572 49382
10000 10000 10000 10000
10000 10000 10000 10000
10635 15963 25572 49382
12500 12500 12500 12500
13294 19954 31965 61728
10000 10000 10000 10000
10635 15963 25572 49382
$9970 Misc Pediatric Misc Adult $14965 Misc Pediatric Misc Adult $23974 Misc Pediatric Misc Adult $46296 Misc Pediatric Misc Adult
711-1 711-2 711-3 711-4
POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE
471 692
1131 2087
10079 14143 23599 50574
10000 10000 10000 10000
10000 10000 10000 10000
10079 14143 23599 50574
12500 12500 12500 12500
12599 17679 29499 63218
10000 10000 10000 10000
10079 14143 23599 50574
$9449 Misc Pediatric Misc Adult $13259 Misc Pediatric Misc Adult $22124 Misc Pediatric Misc Adult $47413 Misc Pediatric Misc Adult
720-1 720-2 720-3 720-4
SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS
353 444 633
1004
05431 07613 11532 21705
10000 10000 10000 10000
10000 10000 10000 10000
05431 07613 11532 21705
12500 12500 12500 12500
06789 09516 14415 27131
10000 10000 10000 10000
05431 07613 11532 21705
$5092 Misc Pediatric Misc Adult $7137 Misc Pediatric Misc Adult
$10811 Misc Pediatric Misc Adult $20348 Misc Pediatric Misc Adult
721-1 721-2 721-3 721-4
POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS
368 470 705
1153
05287 07209 11619 22025
10000 10000 10000 10000
10000 10000 10000 10000
05287 07209 11619 22025
12500 12500 12500 12500
06609 09011 14524 27531
10000 10000 10000 10000
05287 07209 11619 22025
$4957 Misc Pediatric Misc Adult $6758 Misc Pediatric Misc Adult
$10893 Misc Pediatric Misc Adult $20648 Misc Pediatric Misc Adult
722-1 722-2 722-3 722-4
FEVER FEVER FEVER FEVER
230 302 429 739
03423 05223 07630 13141
10000 10000 10000 10000
10000 10000 10000 10000
03423 05223 07630 13141
12500 12500 12500 12500
04279 06529 09538 16426
10000 10000 10000 10000
03423 05223 07630 13141
$3209 Misc Pediatric Misc Adult $4897 Misc Pediatric Misc Adult $7153 Misc Pediatric Misc Adult
$12320 Misc Pediatric Misc Adult 723-1 723-2 723-3 723-4
VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS
216 279 470
1317
03194 04738 07794 24233
10000 10000 10000 10000
10000 10000 10000 10000
03194 04738 07794 24233
12500 12500 12500 12500
03993 05923 09743 30291
10000 10000 10000 10000
03194 04738 07794 24233
$2994 Misc Pediatric Misc Adult $4442 Misc Pediatric Misc Adult $7307 Misc Pediatric Misc Adult
$22718 Misc Pediatric Misc Adult 724-1 724-2 724-3 724-4
OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES
400 477 680
1337
05512 07131 11401 24698
10000 10000 10000 10000
10000 10000 10000 10000
05512 07131 11401 24698
12500 12500 12500 12500
06890 08914 14251 30873
10000 10000 10000 10000
05512 07131 11401 24698
$5168 Misc Pediatric Misc Adult $6685 Misc Pediatric Misc Adult
$10688 Misc Pediatric Misc Adult $23154 Misc Pediatric Misc Adult
740-1 740-2 740-3 740-4
MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE
678 1284 2034 2421
10899 13904 24356 37756
10000 10000 10000 10000
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
$8174 Other Other $10428 Other Other $18267 Other Other $28317 Other Other
750-1 750-2 750-3 750-4
SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA
1082 1179 1539 2848
05713 06699 09202 19283
10000 10000 10000 10000
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
$4285 Other Other $5024 Other Other $6902 Other Other
$14462 Other Other 751-1 751-2 751-3 751-4
MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES
528 724
1055 2028
03572 05019 08097 15923
10000 10000 10000 10000
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
$2679 Other Other $3764 Other Other $6073 Other Other
$11942 Other Other 752-1 752-2 752-3 752-4
DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL
503 658
1473 7300
03399 04498 09061 14934
10000 10000 10000 10000
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
$2549 Other Other $3374 Other Other $6796 Other Other
$11201 Other Other 753-1 753-2 753-3 753-4
BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS
601 808
1205 1948
04001 05365 08266 14926
10000 10000 10000 10000
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
$3001 Other Other $4024 Other Other $6200 Other Other
$11195 Other Other 754-1 754-2 754-3 754-4
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER
424 558 727
1664
02943 03998 05677 11553
10000 10000 10000 10000
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
$2207 Other Other $2999 Other Other $4258 Other Other $8665 Other Other
755-1 755-2 755-3 755-4
ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
388 622 900 813
02738 04363 06226 08767
10000 10000 10000 10000
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
$2054 Other Other $3272 Other Other $4670 Other Other $6575 Other Other
756-1 756-2 756-3 756-4
ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES
331 381 457 942
04061 05308 06065 13981
10000 10000 10000 10000
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
$3046 Other Other $3981 Other Other $4549 Other Other
$10486 Other Other 757-1 757-2 757-3 757-4
ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES
873 934
1087 1640
05861 07234 08953 13799
10000 10000 10000 10000
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
$4396 Other Other $5426 Other Other $6715 Other Other
$10349 Other Other 758-1 758-2 758-3 758-4
CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS
694 981
1225 4300
03874 05129 06541 11332
10000 10000 10000 10000
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
$2906 Other Other $3847 Other Other $4906 Other Other $8499 Other Other
759-1 759-2 759-3 759-4
EATING DISORDERS EATING DISORDERS EATING DISORDERS EATING DISORDERS
1990 1297 1402 2303
06561 06961 10053 16606
10000 10000 10000 10000
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
$4921 Other Other $5221 Other Other $7540 Other Other
$12455 Other Other 760-1 760-2 760-3 760-4
OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS
748 766 912
1204
04840 06173 07573 14134
10000 10000 10000 10000
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
$3630 Other Other $4630 Other Other $5680 Other Other
$10601 Other Other 770-1 770-2 770-3 770-4
DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE
253 248 332 794
02240 02623 05475 16843
10000 10000 10000 10000
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
$1680 Other Other $1967 Other Other $4106 Other Other
$12632 Other Other 772-1 772-2 772-3 772-4
ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY
1434 1551 1289 2385
05441 06916 07009 24530
10000 10000 10000 10000
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
$4081 Other Other $5187 Other Other $5257 Other Other
$18398 Other Other 773-1 773-2 773-3 773-4
OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE
337 414 507 992
02663 03466 05964 18606
10000 10000 10000 10000
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
$1997 Other Other $2600 Other Other $4473 Other Other
$13955 Other Other 774-1 774-2
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
365 412
03040 03627
10000 10000
10000 10000
03040 03627
10000 10000
03040 03627
10000 10000
03040 03627
$2280 Other Other $2720 Other Other
774-3 774-4
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
479 1424
06448 24682
10000 10000
10000 10000
06448 24682
10000 10000
06448 24682
10000 10000
06448 24682
$4836 Other $18512 Other
Other Other
775-1 775-2 775-3 775-4
ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE
323 377 571
1263
03313 04639 08596 24910
10000 10000 10000 10000
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
$2485 Other $3479 Other $6447 Other
$18683 Other
Other Other Other Other
776-1 776-2 776-3 776-4
OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE
389 397 496 933
03157 04547 07887 16112
10000 10000 10000 10000
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
$2368 Other $3410 Other $5915 Other
$12084 Other
Other Other Other Other
791-1 791-2 791-3 791-4
OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT
314 515 989
2009
08636 12677 21979 49312
10000 10000 10000 10000
10000 10000 10000 10000
08636 12677 21979 49312
12500 12500 12500 12500
10795 15846 27474 61640
10000 10000 10000 10000
08636 12677 21979 49312
$8096 Misc Pediatric $11885 Misc Pediatric $20605 Misc Pediatric $46230 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
811-1 811-2 811-3 811-4
ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS
151 202 390 913
02707 03855 08277 22176
10000 10000 10000 10000
10000 10000 10000 10000
02707 03855 08277 22176
12500 12500 12500 12500
03384 04819 10346 27720
10000 10000 10000 10000
02707 03855 08277 22176
$2538 Misc Pediatric $3614 Misc Pediatric $7760 Misc Pediatric
$20790 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
812-1 812-2 812-3 812-4
POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS
165 225 347 694
03469 04331 07709 17419
10000 10000 10000 10000
10000 10000 10000 10000
03469 04331 07709 17419
12500 12500 12500 12500
04336 05414 09636 21774
10000 10000 10000 10000
03469 04331 07709 17419
$3252 Misc Pediatric $4060 Misc Pediatric $7227 Misc Pediatric
$16330 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
813-1 813-2 813-3 813-4
OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT
261 344 594
1344
04393 06056 09631 19960
10000 10000 10000 10000
10000 10000 10000 10000
04393 06056 09631 19960
12500 12500 12500 12500
05491 07570 12039 24950
10000 10000 10000 10000
04393 06056 09631 19960
$4118 Misc Pediatric $5678 Misc Pediatric $9029 Misc Pediatric
$18713 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
815-1 815-2 815-3 815-4
OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES
169 276 456 880
04211 05012 08129 22715
10000 10000 10000 10000
10000 10000 10000 10000
04211 05012 08129 22715
12500 12500 12500 12500
05264 06265 10161 28394
10000 10000 10000 10000
04211 05012 08129 22715
$3948 Misc Pediatric $4699 Misc Pediatric $7621 Misc Pediatric
$21295 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
816-1 816-2 816-3 816-4
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
173 240 346 736
04162 04915 07864 18134
10000 10000 10000 10000
10000 10000 10000 10000
04162 04915 07864 18134
12500 12500 12500 12500
05203 06144 09830 22668
10000 10000 10000 10000
04162 04915 07864 18134
$3902 Misc Pediatric $4608 Misc Pediatric $7373 Misc Pediatric
$17001 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
841-1 841-2 841-3 841-4
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT
2200 967
2599 4068
31148 34263 64068
159153
10000 10000 10000 10000
10000 10000 10000 10000
31148 34263 64068
159153
12500 12500 12500 12500
38935 42829 80085
198941
10000 10000 10000 10000
31148 34263 64068
159153
$29201 Misc Pediatric $32122 Misc Pediatric $60064 Misc Pediatric
$149206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
842-1 842-2 842-3 842-4
FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT
751 1072 1735 3010
14151 21416 38719 95054
10000 10000 10000 10000
10000 10000 10000 10000
14151 21416 38719 95054
12500 12500 12500 12500
17689 26770 48399
118818
10000 10000 10000 10000
14151 21416 38719 95054
$13267 Misc Pediatric $20078 Misc Pediatric $36299 Misc Pediatric $89113 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
843-1 843-2 843-3 843-4
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT
339 487 713
1113
04752 06661 11619 32621
10000 10000 10000 10000
10000 10000 10000 10000
04752 06661 11619 32621
12500 12500 12500 12500
05940 08326 14524 40776
10000 10000 10000 10000
04752 06661 11619 32621
$4455 Misc Pediatric $6245 Misc Pediatric
$10893 Misc Pediatric $30582 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
844-1 844-2 844-3 844-4
PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT
310 497 743
1781
04337 06965 12193 48021
10000 10000 10000 10000
10000 10000 10000 10000
04337 06965 12193 48021
12500 12500 12500 12500
05421 08706 15241 60026
10000 10000 10000 10000
04337 06965 12193 48021
$4066 Misc Pediatric $6530 Misc Pediatric
$11431 Misc Pediatric $45020 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
850-1 850-2 850-3 850-4
PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE
267 556
1618 3148
11757 14065 24870 46520
10000 10000 10000 10000
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
$8818 Misc Pediatric $10549 Misc Pediatric $18653 Misc Pediatric $34890 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
860-1 860-2 860-3 860-4
REHABILITATION REHABILITATION REHABILITATION REHABILITATION
932 1146 1475 1795
07227 09855 13880 17876
10000 10000 10000 10000
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
$5420 Other $7391 Other
$10410 Other $13407 Other
Other Other Other Other
861-1 861-2 861-3 861-4
SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS
253 340 497 917
02858 05247 07658 14498
10000 10000 10000 10000
10000 10000 10000 10000
02858 05247 07658 14498
12500 12500 12500 12500
03573 06559 09573 18123
10000 10000 10000 10000
02858 05247 07658 14498
$2679 Misc Pediatric $4919 Misc Pediatric $7179 Misc Pediatric
$13592 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
862-1 862-2 862-3 862-4
OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE
698 1122 1357 1872
02895 05851 07866 11351
10000 10000 10000 10000
10000 10000 10000 10000
02895 05851 07866 11351
12500 12500 12500 12500
03619 07314 09833 14189
10000 10000 10000 10000
02895 05851 07866 11351
$2714 Misc Pediatric $5485 Misc Pediatric $7374 Misc Pediatric
$10642 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
863-1 863-2 863-3 863-4
NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE
853 1757 2771 4643
05959 16127 30507 61446
12500 12500 12500 12500
10000 10000 10000 10000
07449 20159 38134 76808
10000 10000 10000 10000
07449 20159 38134 76808
17500 17500 17500 17500
10428 28222 53387
107531
$5587 Neonate $15119 Neonate $28600 Neonate $57606 Neonate
Neonate Neonate Neonate Neonate
890-1 890-2 890-3 890-4
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS
167 691 921
1514
07051 10224 14771 30014
10000 10000 10000 10000
10000 10000 10000 10000
07051 10224 14771 30014
12500 12500 12500 12500
08814 12780 18464 37518
10000 10000 10000 10000
07051 10224 14771 30014
$6610 Misc Pediatric $9585 Misc Pediatric
$13848 Misc Pediatric $28138 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
892-1 892-2 892-3 892-4
HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION
587 488 669
1152
05647 07763 10877 19375
10000 10000 10000 10000
10000 10000 10000 10000
05647 07763 10877 19375
12500 12500 12500 12500
07059 09704 13596 24219
10000 10000 10000 10000
05647 07763 10877 19375
$5294 Misc Pediatric $7278 Misc Pediatric
$10197 Misc Pediatric $18164 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
893-1 893-2 893-3 893-4
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
499 496 799
1422
07762 08219 12807 24296
10000 10000 10000 10000
10000 10000 10000 10000
07762 08219 12807 24296
12500 12500 12500 12500
09703 10274 16009 30370
10000 10000 10000 10000
07762 08219 12807 24296
$7277 Misc Pediatric $7705 Misc Pediatric
$12007 Misc Pediatric $22778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
894-1 894-2 894-3 894-4
HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND
341 393 627
1121
05218 06497 09774 19428
10000 10000 10000 10000
10000 10000 10000 10000
05218 06497 09774 19428
12500 12500 12500 12500
06523 08121 12218 24285
10000 10000 10000 10000
05218 06497 09774 19428
$4892 Misc Pediatric $6091 Misc Pediatric $9163 Misc Pediatric
$18214 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
910-1 910-2 910-3 910-4
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA
1100 775
1057 1830
28786 31984 41628 72114
10000 10000 10000 10000
10000 10000 10000 10000
28786 31984 41628 72114
12500 12500 12500 12500
35983 39980 52035 90143
10000 10000 10000 10000
28786 31984 41628 72114
$26987 Misc Pediatric $29985 Misc Pediatric $39026 Misc Pediatric $67607 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
911-1 911-2 911-3 911-4
EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA
511 619 795
1687
15160 20189 26724 58039
10000 10000 10000 10000
10000 10000 10000 10000
15160 20189 26724 58039
12500 12500 12500 12500
18950 25236 33405 72549
10000 10000 10000 10000
15160 20189 26724 58039
$14213 Misc Pediatric $18927 Misc Pediatric $25054 Misc Pediatric $54412 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
912-1 912-2 912-3 912-4
MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
558 607 985
1782
20950 22759 36410 68885
10000 10000 10000 10000
10000 10000 10000 10000
20950 22759 36410 68885
12500 12500 12500 12500
26188 28449 45513 86106
10000 10000 10000 10000
20950 22759 36410 68885
$19641 Misc Pediatric $21337 Misc Pediatric $34134 Misc Pediatric $64580 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
930-1 930-2 930-3 930-4
MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE
322 370 596
1127
07826 09594 15857 33896
10000 10000 10000 10000
10000 10000 10000 10000
07826 09594 15857 33896
12500 12500 12500 12500
09783 11993 19821 42370
10000 10000 10000 10000
07826 09594 15857 33896
$7337 Misc Pediatric $8994 Misc Pediatric
$14866 Misc Pediatric $31778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
950-1 950-2 950-3 950-4
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
361 623
1166 2260
13230 20029 31827 60092
10000 10000 10000 10000
10000 10000 10000 10000
13230 20029 31827 60092
12500 12500 12500 12500
16538 25036 39784 75115
10000 10000 10000 10000
13230 20029 31827 60092
$12403 Misc Pediatric $18777 Misc Pediatric $29838 Misc Pediatric $56336 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
951-1 951-2 951-3 951-4
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
329 517
1001 1973
09755 14320 24054 46875
10000 10000 10000 10000
10000 10000 10000 10000
09755 14320 24054 46875
12500 12500 12500 12500
12194 17900 30068 58594
10000 10000 10000 10000
09755 14320 24054 46875
$9145 Misc Pediatric $13425 Misc Pediatric $22551 Misc Pediatric $43945 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
952-1 952-2 952-3 952-4
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
274 504 968
1894
07736 11591 20369 39177
10000 10000 10000 10000
10000 10000 10000 10000
07736 11591 20369 39177
12500 12500 12500 12500
09670 14489 25461 48971
10000 10000 10000 10000
07736 11591 20369 39177
$7253 Misc Pediatric $10867 Misc Pediatric $19096 Misc Pediatric $36728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
955-0 956-0
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS UNGROUPABLE
--
--
Error DRG Error DRG
Error DRG Error DRG
i-
i
i
i-
i
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy adjustor F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that has at least a basic level
emergency room H FY 2015-16 Cost-to-Charge Ratio FY 2013 cost-to-charge ratio with some exceptions I FY 2015-16 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FY 2015-16 Wage Index Value (adjusted for CA Neutrality Factor 09797) W age index value times 09797 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls for changes between California
and the rest of the US while maintaining relative differences among wage areas within California K FY 2015-16 Unadjusted Statewide Base Rate The statewide DRG base rate is $6289 except that for remote rural hospitals it is $12768 L FY 2015-16 Wage Adjusted Statewide Base Rate (Non-Transition) The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses See Tab 5 This rate is applicable for non-transition hospitals as shown in Column N Medi-Cal
managed care plans that are pricing claims for emergency and post-stabilization services hospitals outside their network should use Column L for all hospitals M FY 2015-16 Hospital-Specific Transition Base Rate The base rate assigned to hospitals to move them in steps toward the statewide base rate This rate is applicable for transition hospitals as shown in Column N FY 2015-16 is the final year of transition rates N Transition rate This column identifies whether the hospital is a non-transition hospital (base rate in Column L) or a transition hospital (base rate in Column M) O FY 2015-16 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2015-16 P FY 2015-16 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by
use of Revenue Code 190 Q FY 2015-16 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by use of
Revenue Code 199
A B C D E F G H I J K L M N O P Q
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transit on Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
OUT OF STATE No No No No No 2180 10000 10000 $6289 $6289 NA Non-Transition NA $98163 $80582 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 3572 12882 12620 $12768 $15097 $15414 Transition NA $98163 $80582 106100793 ADVENTIST MEDICAL CENTER - SELMA COMMUNITY HOSPITAL No No No Yes Yes 3572 12882 12620 $12768 $15097 $14680 Transition NA $98163 $80582 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 4360 12882 12620 $12768 $15097 $10484 Transition NA $98163 $80582 106301098 AHMC ANAHEIM REG MED CTR No No No No No 1656 12882 12620 $6289 $7436 $15144 Transition NA $98163 $80582 106010846 ALAMEDA CO MED CTR Yes No No No No 4036 16962 16618 $6289 $9186 NA NA NA NA NA 106010735 ALAMEDA HOSP No Yes No No No 2600 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106190017 ALHAMBRA HOSP No No No No No 1397 12882 12620 $6289 $7436 $5446 Transition $1220 $98163 $80582 106010739 ALTA BATES SUMMIT MED CTR-ALTA BATES No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106010937 ALTA BATES SUMMIT MED CTR-HAWTHORNE No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106010844 ALTA BATES SUMMIT MED CTR-HERRICK CAMPUS No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106013626 ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106374063 ALVARADO HOSP MED CTR - REHAB No No No No No 1930 12882 12620 $6289 $7436 $4599 Transition $1220 $98163 $80582 106190034 ANTELOPE VALLEY HOSP MED CTR No Yes No No No 2997 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364231 ARROWHEAD REG MED CTR Yes No No No No 3324 12882 12620 $6289 $7436 NA NA NA NA NA 106400466 ARROYO GRANDE COMM HOSP No No No No No 2581 12964 12701 $6289 $7471 NA Non-Transition $1226 $98163 $80582 106154101 BAKERSFIELD HEART HOSP No No No No No 1782 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150722 BAKERSFIELD MEM HOSP-34TH ST No No No No No 2117 12882 12620 $6289 $7436 $9141 Transition NA $98163 $80582 106364121 BALLARD REHABILITATION HOSP No No No No No 8300 12882 12620 NA NA NA NA $1427 $98163 $80582 106184008 BANNER LASSEN MED CTR No No No Yes Yes 3967 12882 12620 $12768 $15097 $18668 Transition NA $98163 $80582 106190052 BARLOW RESP HOSP No No No No No 1849 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364430 BARSTOW COMM HOSP No No No Yes Yes 2262 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090793 BARTON MEM HOSP No No No Yes Yes 3635 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106361110 BEAR VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190081 BEVERLY HOSP No No No No No 3567 12882 12620 $6289 $7436 $5841 Transition NA $98163 $80582 106040802 BIGGS GRIDLEY MEM HOSP No No No Yes Yes 3652 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106380929 CA PACIFIC MED CTR No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380777 CA PACIFIC MED CTR - CALIFORNIA WEST No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380933 CA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 2873 16738 16398 $6289 $9090 NA Non-Transition $1492 $98163 $80582 106190125 CALIFORNIA HOSP MED CTR-LA No No Yes No No 2078 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190137 CASA COLINA HOSP FOR REHAB MED No No No No No 7213 12882 12620 NA NA NA NA $1220 $98163 $80582 106190045 CATALINA ISLAND MED CTR No No No Yes Yes 9000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190555 CEDARS-SINAI MED CTR No No Yes No No 2051 12882 12620 $6289 $7436 $5837 Transition $1220 $98163 $80582 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 1730 12882 12620 $6289 $7436 $6350 Transition $1220 $98163 $80582 106160787 CENTRAL VALLEY GEN HOSP No No No No No 7778 12882 12620 $6289 $7436 $11888 Transition NA $98163 $80582 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 2190 12892 12630 $6289 $7440 NA Non-Transition $1221 $98163 $80582 106301140 CHAPMAN MED CTR No No No No No 1908 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304113 CHILDRENS HOSP AT MISSION No No No No No 3300 12882 12620 $6289 $7436 $18777 Transition NA $98163 $80582 106204019 CHILDRENS HOSP CENTRAL CALIFORNIA No No Yes No No 2430 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106010776 CHILDRENS HOSP OAKLAND No No Yes No No 3356 16478 16143 $6289 $8978 NA Non-Transition $2628 $98163 $80582 106190170 CHILDRENS HOSP OF LA No No Yes No No 3988 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106300032 CHILDRENS HOSP OF ORANGE CO No No Yes No No 2442 12882 12620 $6289 $7436 $5613 Transition NA $98163 $80582 106382715 CHINESE HOSP No No No No No 3835 16738 16398 $6289 $9090 $8053 Transition NA $98163 $80582 106361144 CHINO VALLEY MED CTR No No No No No 2098 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190176 CITY OF HOPE HELFORD CLINIC RES HOSP No No No No No 2789 12882 12620 $6289 $7436 $5941 Transition NA $98163 $80582 106100005 CLOVIS COMM MED CTR No No No No No 3336 12882 12620 $6289 $7436 $7752 Transition NA $98163 $80582 106100697 COALINGA REG MED CTR No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190766 COAST PLAZA DRS HOSP No No No No No 2126 12882 12620 $6289 $7436 $5303 Transition NA $98163 $80582 106301258 COASTAL COMM HOSP No No No No No 2792 12882 12620 $6289 $7436 $7035 Transition NA $98163 $80496 106301155 COLLEGE HOSP COSTA MESA No No No No No 2876 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190587 COLLEGE MEDICAL CENTER No No No No No 3760 12882 12620 $6289 $7436 $4258 Transition NA $98163 $80582 106361458 COLORADO RIVER MED CTR No No No Yes Yes 4357 12882 12620 $12768 $15097 $18541 Transition NA $98163 $80582 106060870 COLUSA REG MED CTR No No No Yes Yes 3066 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190197 COMM AND MISSION HOSP OF HUNT PK No No No No No 1601 12882 12620 $6289 $7436 $5421 Transition NA $98163 $80582 106190475 COMM HOSP OF LONG BEACH No No No No No 1707 12882 12620 $6289 $7436 $15917 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106361323 COMM HOSP OF SAN BERNARDINO No No No No No 2833 12882 12620 $6289 $7436 $6516 Transition NA $98163 $78406 106560473 COMM MEM HOSP OF SAN BUENAVENTURA No No No No No 2104 12882 12620 $6289 $7436 $4512 Transition NA $98163 $80582 106100717 COMM REG MED CTR-FRESNO No No No No No 1896 12882 12620 $6289 $7436 $7994 Transition $1655 $98163 $80582 106070924 CONTRA COSTA REG MED CTR Yes No No No No 6010 16478 16143 $6289 $8978 NA NA NA NA NA 106331152 CORONA REG MED CTR No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition NA $98163 $80582 106331145 CORONA REG MED CTR - MAGNOLIA No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition $1220 $98163 $80582 106190413 CV-INTERCOMMUNITY CAMPUS No No No No No 3136 12882 12620 $6289 $7436 $6821 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106190636 CV-QUEEN OF VALLEY CAMPUS No No Yes No No 3136 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106150706 DELANO REG MED CTR No No No No No 3622 12882 12620 $6289 $7436 $7087 Transition NA $98163 $80582 106331164 DESERT REG MED CTR No No No No No 1486 12882 12620 $6289 $7436 $7153 Transition $1447 $98163 $80582 106364144 DESERT VALLEY HOSP No No No No No 2050 12882 12620 $6289 $7436 $8173 Transition NA $98163 $80582 106440755 DOMINICAN HOSP-SANTA CRUZ No No No No No 2016 17239 16889 $6289 $9304 $7821 Transition $1527 $98163 $80582 106190243 DOWNEY REG MED CTR No No No No No 1732 12882 12620 $6289 $7436 $6847 Transition NA $98163 $80582 106392287 DRS HOSP OF MANTECA No No No No No 1362 13579 13303 $6289 $7735 $11712 Transition NA $98163 $80582 106390846 DAMERON HOSP No No No No No 2138 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106190857 DRS HOSP OF WEST COVINA No No No No No 1833 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106070904 DRS MED CTR-SAN PABLOPINOLE No Yes No No No 2373 16478 16143 $6289 $8978 $6025 Transition NA $98163 $80582 106190256 EAST LA DRS HOSP No No No No No 1952 12882 12620 $6289 $7436 $5809 Transition NA $98163 $80582 106190328 EAST VALLEY HOSP MED CTR No No No No No 2859 12882 12620 $6289 $7436 $5534 Transition NA $98163 $80582 106320859 EASTERN PLUMAS HOSP No Yes No Yes Yes 4802 12882 12620 $12768 $15097 $13674 Transition NA $98163 $80582 106014233 EDEN MED CTR No No No No No 3197 16962 16618 $6289 $9186 $12768 Transition NA $98163 $80582 106331168 EISENHOWER MEM HOSP No No No No No 1540 12882 12620 $6289 $7436 $10211 Transition NA $98163 $80582 106430763 EL CAMINO HOSP No Yes No No No 2857 17180 16831 $6289 $9279 $5377 Transition $1523 $98163 $80582 106130699 EL CENTRO COMM HOSP No Yes No No No 2298 12882 12620 $6289 $7436 $8949 Transition NA $98163 $80582 106500852 DRS MED CTR No No No No No 1181 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106500867 EMANUEL MED CTR No No No No No 2046 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106040962 ENLOE MED CTR No No No No No 2436 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106044011 ENLOE REHABILLITATION CENTER No No No No No 2463 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106474007 FAIRCHILD MED CTR No No No Yes Yes 3914 12882 12620 $12768 $15097 $16385 Transition NA $98163 $80582 106040875 FEATHER RIVER HOSP No No No No No 1240 12882 12620 $6289 $7436 $10796 Transition NA $98163 $80582 106190298 FOOTHILL PRES HOSP No No No No No 2989 12882 12620 $6289 $7436 $4740 Transition NA $98163 $80582 106301175 FOUNTAIN VALLEY REG HOSP-EUCLID No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106304039 FOUNTAIN VALLEY REG HOSP-WARNER No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106230949 FRANK R HOWARD MEM HOSP No No No Yes Yes 3495 12882 12620 $12768 $15097 $15377 Transition NA $98163 $80582 106510882 FREMONT MEDICAL CENTER No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106190280 ENCINO HOSP MED CTR No No No No No 949 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106400480 FRENCH HOSP MED CTR No No No No No 2241 12964 12701 $6289 $7471 NA Non-Transition NA $98163 $80582 106301283 GARDEN GROVE HOSP AND MED CTR No No No No No 2661 12882 12620 $6289 $7436 $5749 Transition NA $98163 $80582 106190159 GARDEN REG HOSP AND MED CTR No No No No No 2937 12882 12620 $6289 $7436 $4110 Transition NA $98163 $80582 106105029 FRESNO HEART HOSP No No No No No 3403 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106270777 GEORGE L MEE MEM HOSP No No No Yes Yes 3562 15558 15242 $12768 $17426 $20386 Transition NA $98163 $80582 106190315 GARFIELD MED CTR No No No No No 1031 12882 12620 $6289 $7436 NA Non-Transition $1394 $98163 $80582 106190522 GLENDALE MEM HOSP AND HLTH CTR No No No No No 2163 12882 12620 $6289 $7436 $6885 Transition $1220 $98163 $80582 106110889 GLENN MED CTR No No No Yes Yes 6660 12882 12620 $12768 $15097 $21024 Transition NA $98163 $80582 106190323 GLENDALE ADV MED CTR-WILSON TERRACE No No No No No 1845 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420483 GOLETA VALLEY COTTAGE HOSP No No No No No 3083 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150775 GOOD SAMARITAN HOSP-BAKERSFIELD No No No No No 3694 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430779 GOOD SAMARITAN HOSP-SAN JOSE No No Yes No No 1937 17180 16831 $6289 $9279 $5654 Transition NA $98163 $80582 106190352 GREATER EL MONTE COMM HOSP No No No No No 1088 12882 12620 $6289 $7436 $4818 Transition NA $98163 $80582 106370714 GROSSMONT HOSP No No No No No 1937 12882 12620 $6289 $7436 $6498 Transition $1220 $98163 $80582
i-
i
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190392 GOOD SAMARITAN HOSP-LA No No Yes No No 2006 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106350784 HAZEL HAWKINS MEM HOSP No Yes No Yes Yes 3840 17180 16831 $12768 $18839 NA Non-Transition NA $98163 $80582 106490964 HEALDSBURG DIST HOSP No Yes No Yes Yes 6549 16188 15859 $12768 $17975 NA Non-Transition NA $98163 $80582 106154022 HEALTHSOUTH BAKERSFIELD REHAB HOSP No No No No No 5040 12882 12620 NA NA NA NA $1382 $98163 $80582 106304079 HEALTHSOUTH TUSTIN REHAB HOSP No No No No No 5281 12882 12620 NA NA NA NA $1220 $98163 $80582 106331194 HEMET VALLEY MED CTR No No No No No 1267 12882 12620 $6289 $7436 $5912 Transition NA $98163 $80582 106190949 HENRY MAYO NEWHALL MEM HOSP No No No No No 1839 12882 12620 $6289 $7436 $5631 Transition $1220 $98163 $80582 106362041 HI-DESERT MED CTR No Yes No Yes Yes 2909 12882 12620 $12768 $15097 $13297 Transition NA $98163 $80582 106301205 HOAG MEM HOSP PRESBYTERIAN No No No No No 4825 12882 12620 $6289 $7436 $13525 Transition NA $98163 $80582 106304159 HEALTHBRIDGE CHILDRENS HOSP-ORANGE No No No No No 3271 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106190380 HOLLYWOOD COMM HOSP OF HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106304460 HOAG ORTHOPEDIC No No No No No 4894 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190382 HOLLYWOOD PRES MED CTR No No No No No 2212 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301209 HUNTINGTON BEACH HOSP No No No No No 2175 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190400 HUNTINGTON MEM HOSP No No Yes No No 2294 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106304045 IRVINE REG HOSP AND MED CTR No No No No No 200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106220733 JOHN C FREMONT HCARE DIST No Yes No Yes Yes 3884 12882 12620 $12768 $15097 $8195 Transition NA $98163 $80582 106331216 JOHN F KENNEDY MEM HOSP No No No No No 1679 12882 12620 $6289 $7436 $6464 Transition NA $98163 $80582 106071018 JOHN MUIR MED CTR-CONCORD CAMPUS No No No No No 1748 16478 16143 $6289 $8978 $12804 Transition NA $98163 $80582 106070988 JOHN MUIR MED CTR-WALNUT CREEK CAMPUS No No No No No 2039 16478 16143 $6289 $8978 $10615 Transition $1473 $98163 $80582 106314024 KAISER HOSPITAL - ROSEVILLE No No Yes No No 7912 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106364265 KAISER ONTARIO MEDICAL CENTER CAMPUS No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106121031 JEROLD PHELPS COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301132 KAISER-ANAHEIM No No Yes No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304306 KAISER-ANAHEIM-IRVINE No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304409 KAISER-ANAHEIM-Orange No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106074097 KAISER-ANTIOCH No No No No No 8503 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106196403 KAISER-DOWNEY No No No No No 10000 12882 12620 $6289 $7436 $12698 Transition NA $98163 $80582 106361223 KAISER-FONTANA No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106014132 KAISER-FREMONT No No No No No 10000 16962 16618 $6289 $9186 $9639 Transition NA $98163 $80582 106196035 KAISER-BALDWIN PARK No No No No No 8009 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106104062 KAISER-FRESNO No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190429 KAISER-LOS ANGELES No No No No No 7387 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106394009 KAISER-MANTECA No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106334048 KAISER-MORENO VALLEY No No No No No 6614 12882 12620 $6289 $7436 $4790 Transition NA $98163 $80582 106010856 KAISER-OAKLANDRICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106190432 KAISER-PANORAMA CITY No No No No No 8239 12882 12620 $6289 $7436 $16025 Transition NA $98163 $80582 106504042 KAISER-MODESTO No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106410804 KAISER-REDWOOD CITY No No No No No 7731 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106074093 KAISER-RICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106480989 KAISER-REHAB CENTER VALLEJO No No No No No 8442 16315 15984 $6289 $8908 NA Non-Transition $2535 $98163 $80582 106340913 KAISER-SACRAMENTO No No No No No 5612 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106334025 KAISER-RIVERSIDE No No No No No 5865 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370730 KAISER-SAN DIEGO No No No No No 7393 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106380857 KAISER-SAN FRANCISCO No No No No No 5960 16738 16398 $6289 $9090 NA Non-Transition NA $98163 $80582 106431506 KAISER-SAN JOSE No No No No No 7002 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106014337 KAISER-SAN LEANDRO No No No No No 2180 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106210992 KAISER-SAN RAFAEL No No No No No 4673 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106494019 KAISER-SANTA ROSA No No No No No 10000 16315 15984 $6289 $8908 $17627 Transition NA $98163 $80582 106434153 KAISER-SANTA CLARA No No No No No 6107 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106190431 KAISER-SOUTH BAY No No No No No 6935 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106342344 KAISER-SOUTH SACRAMENTO No No No No No 5670 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106410806 KAISER-SOUTH SF No No No No No 6503 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106484044 KAISER-VACAVILLE No No No No No 10000 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106070990 KAISER-WALNUT CREEK No No No No No 5680 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106190434 KAISER-WEST LA No No No No No 6623 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106194219 KECK HOSPITAL OF USC No No No No No 2004 12882 12620 $6289 $7436 $4699 Transition $1220 $98163 $80582 106210993 KENTFIELD REHAB HOSP No No No No No 5967 16855 16513 $6289 $9140 $19338 Transition $1500 $98163 $80582 106150736 KERN MED CTR Yes No No No No 3943 12882 12620 $6289 $7436 NA NA NA NA NA 106150737 KERN VALLEY HEALTHCARE DIST No Yes No Yes Yes 2786 12882 12620 $12768 $15097 $8298 Transition NA $98163 $80582 106191450 KAISER-WOODLAND HILLS No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190049 KINDRED HOSPITAL BALDWIN PARK No No No No No 1810 12882 12620 $6289 $7436 $10784 Transition NA $98163 $80582 106190305 KINDRED LA No No No No No 2044 12882 12620 $6289 $7436 $4255 Transition NA $98163 $80582 106301127 KINDRED BREA No No No No No 2852 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361274 KINDRED ONTARIO No No No No No 2068 12882 12620 $6289 $7436 $9314 Transition NA $98163 $80582 106364188 KINDRED RANCHO No No No No No 1980 12882 12620 $6289 $7436 $20628 Transition NA $98163 $80582 106332172 KINDRED RIVERSIDE No No No No No 1805 12882 12620 $6289 $7436 $24450 Transition NA $98163 $80582 106190449 KINDRED LA MIRADA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106370721 KINDRED SAN DIEGO No No No No No 3605 12882 12620 $6289 $7436 $5657 Transition NA $98163 $80582 106344035 KINDRED SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190458 KINDRED SAN GABRIEL VALLEY No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106010887 KINDRED SF BAY AREA No No No No No 3007 16478 16143 $6289 $8978 $6378 Transition NA $98163 $80582 106301167 KINDRED SANTA ANA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190196 KINDRED SOUTH BAY No No No No No 2144 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301380 KINDRED WESTMINSTER No No No No No 2286 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301234 LA PALMA INTERCOMMUNITY HOSP No No No No No 2290 12882 12620 $6289 $7436 $7160 Transition NA $98163 $80582 106191227 LAC-HARBOR-UCLA MED CTR Yes No Yes No No 3366 12882 12620 $6289 $7436 NA NA NA NA NA 106191231 LAC-OLIVE VIEW-UCLA MED CTR Yes No No No No 4136 12882 12620 $6289 $7436 NA NA NA NA NA 106191228 LAC-USC MED CTR Yes No Yes No No 4522 12882 12620 $6289 $7436 NA NA NA NA NA 106380865 LAGUNA HONDA HOSP AND REHAB CTR Yes No No No No 5843 16738 16398 $6289 $9090 NA NA NA NA NA 106190240 LAKEWOOD REG MED CTR No No No No No 1504 12882 12620 $6289 $7436 $4008 Transition $1220 $98163 $80582 106390923 LODI MEM HOSP No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106390922 LODI MEM HOSP - WEST No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106334589 LOMA LINDA MURRIETTA No No No No No 3222 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106364268 LOMA LINDA UNIV HEART AND SURGICAL HOSPITAL No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361245 LOMA LINDA UNIV MED CTR - EAST CAMPUS No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361246 LOMA LINDA UNIV MED CTR No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $1491 $98163 $80582 106364502 LOMA LINDA UNIV CHILDRENS HOSP No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $2177 $98163 $80582 106190198 LA COMM HOSP No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420491 LOMPOC VALLEY MED CTR No Yes No Yes Yes 8693 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301248 LOS ALAMITOS MED CTR No No No No No 1915 12882 12620 $6289 $7436 $4697 Transition NA $98163 $80582 106560492 LOS ROBLES HOSP AND MED CTR No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106564018 LOS ROBLES HOSP AND MED CTR-EAST CAMPUS No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106434040 LSP CHILDRENS HOSP AT STANFORD No No Yes No No 2035 17180 16831 $6289 $9279 $6102 Transition NA $98163 $80582 106121002 MAD RIVER COMM HOSP No No No No No 4250 12882 12620 $6289 $7436 $9505 Transition NA $98163 $80582 106201281 MADERA COMMUNITY HOSPITAL No No No No No 5100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106260011 MAMMOTH HOSP No Yes No Yes Yes 7982 12882 12620 $12768 $15097 $46994 Transition NA $98163 $80582 106420493 MARIAN MED CTR No No No No No 2741 12882 12620 $6289 $7436 $9386 Transition NA $98163 $80582 106190525 LONG BEACH MEM MED CTR No No No No No 1996 12882 12620 $6289 $7436 NA Non-Transition $1627 $98163 $80582 106211006 MARIN GEN HOSP No Yes No No No 2571 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106190500 MARINA DEL RAY HOSPITAL No No No No No 2034 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106050932 MARK TWAIN ST JOSEPHS HOSP No No No Yes Yes 3707 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090933 MARSHALL MED CTR No No No Yes Yes 2107 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106500939 MEM HOSP MED CTR-MODESTO No No No No No 2235 12892 12630 $6289 $7440 $5898 Transition NA $98163 $80582 106240924 MEMORIAL HOSP LOS BANOS No No No Yes Yes 3362 12882 12620 $12768 $15097 $17450 Transition NA $98163 $80582 106190521 MEMORIAL HOSP OF GARDENA No No No No No 1747 12882 12620 $6289 $7436 $4611 Transition NA $98163 $80582 106231013 MENDOCINO COAST DIST HOSP No Yes No Yes Yes 5070 12882 12620 $12768 $15097 $15935 Transition NA $98163 $80582 106334018 MENIFEE VALLEY MED CTR No No No No No 1458 12882 12620 $6289 $7436 $5113 Transition NA $98163 $80582 106450936 MAYERS MEM HOSP No Yes No Yes Yes 7192 14188 13900 $12768 $16234 NA Non-Transition NA $98163 $80582 106340947 MERCY GEN HOSP No No No No No 2185 15256 14946 $6289 $8454 $6027 Transition $1387 $98163 $80582 106344029 MERCY HOSP OF FOLSOM No No No No No 2746 15256 14946 $6289 $8454 $5260 Transition NA $98163 $80582 106150761 MERCY HOSP-BAKERSFIELD No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106414018 MENLO PARK SURGICAL HOSP No No No No No 2770 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106240942 MERCY MED CTR MERCED No No No No No 2289 13279 13009 $6289 $7606 NA Non-Transition NA $98163 $80582 106450949 MERCY MED CTR-REDDING No No No No No 2589 14188 13900 $6289 $7996 $10219 Transition NA $98163 $80582 106470871 MERCY MED CTR-MT SHASTA No No No Yes Yes 6242 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106340950 MERCY SAN JUAN HOSP No No No No No 2166 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190529 METHODIST HOSP OF SO CAL No No No No No 1842 12882 12620 $6289 $7436 $6690 Transition $1220 $98163 $80582 106196168 MILLER CHILDRENS HOSP No No Yes No No 2680 12882 12620 $6289 $7436 $8155 Transition NA $98163 $80582 106410742 MILLS HEALTH CENTER No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106410852 MILLS-PENINSULA No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106340951 METHODIST HOSP OF SACRAMENTO No No No No No 2028 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190524 MISSION COMM HOSP-PANORAMA CAMPUS No No No No No 3568 12882 12620 $6289 $7436 $3982 Transition NA $98163 $80582 106190681 MIRACLE MILE No No No No No 100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301262 MISSION HOSP REG MED CTR No No No No No 4091 12882 12620 $6289 $7436 $14336 Transition $1220 $98163 $80582 106250956 MODOC MED CTR No Yes No Yes Yes 4961 12882 12620 $12768 $15097 $13486 Transition NA $98163 $80582 106301337 MISSION HOSP LAGUNA BEACH No No No No No 4091 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106361166 MONTCLAIR HOSP MED CTR No No No No No 3149 12882 12620 $6289 $7436 $5904 Transition NA $98163 $80582 106190547 MONTEREY PARK HOSP No No No No No 1034 12882 12620 $6289 $7436 $5866 Transition NA $98163 $80582 106361266 MOUNTAINS COMM HOSP No Yes No Yes Yes 5148 12882 12620 $12768 $15097 $15642 Transition NA $98163 $80582 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106481357 NORTH BAY MEDICAL CENTER No No No No No 1972 16315 15984 $6289 $8908 $15945 Transition NA $98163 $80582
i-
i
i
i-
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190541 MONROVIA MEM HOSP No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106141273 NORTHERN INYO HOSP No Yes No Yes Yes 8150 12882 12620 $12768 $15097 $27752 Transition NA $98163 $80582 106484001 NORTH BAY VACAVALLEY HOSP No No No No No 1972 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106190568 NORTHRIDGE HOSP MED CTR No No No No No 1596 12882 12620 $6289 $7436 NA Non-Transition $1662 $98163 $80582 106214034 NOVATO COMM HOSP No No No No No 3465 16855 16513 $6289 $9140 $6359 Transition NA $98163 $80582 106500967 OAK VALLEY DIST HOSP No Yes No Yes No 3340 12892 12630 $6289 $7440 $5201 Transition NA $98163 $80582 106430837 OCONNOR HOSP-SAN JOSE No No No No No 2409 17180 16831 $6289 $9279 $5201 Transition NA $98163 $80582 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190534 OLYMPIA MED CTR No No No No No 1260 12882 12620 $6289 $7436 $6786 Transition NA $98163 $80582 106300225 ORANGE COAST MEM MED CTR No No No No No 2293 12882 12620 $6289 $7436 $19985 Transition NA $98163 $80582 106040937 OROVILLE HOSP No No No No No 1803 12882 12620 $6289 $7436 $6229 Transition NA $98163 $80582 106560501 OJAI VALLEY COMM HOSP No No No Yes Yes 2745 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190696 PACIFICA HOSP OF THE VALLEY No No No No No 3338 12882 12620 $6289 $7436 $5616 Transition NA $98163 $80582 106491338 PALM DRIVE HOSP No Yes No Yes No 4315 16315 15984 $6289 $8908 $11457 Transition NA $98163 $80582 106196405 PALMDALE REGIONAL MEDICAL CTR No No No No No 1190 12882 12620 $6289 $7436 $7504 Transition $1220 $98163 $80582 106331288 PALO VERDE HOSP No Yes No Yes Yes 4770 12882 12620 $12768 $15097 $18188 Transition NA $98163 $80582 106370755 PALOMAR MED CTR No Yes No No No 2429 12882 12620 $6289 $7436 $7051 Transition $1220 $98163 $80582 106370759 PARADISE VALLEY HOSP No No No No No 2188 12882 12620 $6289 $7436 $4275 Transition $1220 $98163 $80582 106190307 PACIFIC ALLIANCE MED CTR No No No No No 4299 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106331293 PARKVIEW COMM HOSP MED CTR No No No No No 2757 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106491001 PETALUMA VALLEY HOSP No No No No No 2271 16315 15984 $6289 $8908 $13491 Transition NA $98163 $80582 106130760 PIONEERS MEM HOSP No Yes No Yes No 2989 12882 12620 $6289 $7436 $9825 Transition NA $98163 $80582 106454013 PATIENTS HOSP OF REDDING No No No No No 2172 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106301297 PLACENTIA LINDA HOSP No No No No No 1606 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370977 POMERADO HOSP No Yes No No No 3063 12882 12620 $6289 $7436 $6818 Transition NA $98163 $80582 106320986 PLUMAS DIST HOSP No Yes No Yes Yes 8666 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190631 PRESBYTERIAN INTERCOMM HOSP No No No No No 961 12882 12620 $6289 $7436 $9720 Transition $1220 $98163 $80582 106190630 POMONA VALLEY HOSP MED CTR No No Yes No No 1538 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190468 PROMISE HOSP OF EAST LA-EAST LA No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190599 PROMISE HOSP OF EAST LA-EAST LA-SUBURBAN CAMPUS No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190385 PROVIDENCE HOLY CROSS MED CTR No No No No No 1325 12882 12620 $6289 $7436 $6284 Transition $1220 $98163 $80582 106190680 PROVIDENCE LITTLE CO OF MARY-SAN PEDRO No No No No No 1533 12882 12620 $6289 $7436 $6225 Transition $1220 $98163 $80582 106190470 PROVIDENCE LITTLE CO OF MARY-TORRANCE No No No No No 1767 12882 12620 $6289 $7436 $7182 Transition NA $98163 $80582 106190758 PROVIDENCE ST JOSEPH MED CTR No No No No No 1866 12882 12620 $6289 $7436 $7141 Transition $1220 $98163 $80582 106370787 PROMISE HOSP OF SAN DIEGO No No No No No 3660 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106281047 QUEEN OF THE VALLEY HOSP-NAPA No No No No No 2829 16188 15859 $6289 $8854 $17592 Transition $1453 $98163 $80582 106370673 RADY CHILDRENS HOSPITAL - SAN DIEGO No No Yes No No 2854 12882 12620 $6289 $7436 $6395 Transition $2177 $98163 $80582 106190517 PROVIDENCE TARZANA MED CTR No No Yes No No 1536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361308 REDLANDS COMM HOSP No No No No No 2079 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430705 REG MED CTR OF SAN JOSE No No No No No 2529 17180 16831 $6289 $9279 $13299 Transition NA $98163 $80582 106580996 RIDEOUT MEM HOSP No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106121051 REDWOOD MEM HOSP No No No Yes Yes 3214 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106334487 RIVERSIDE CO REG MED CTR Yes No No No No 2987 12882 12620 $6289 $7436 NA NA NA NA NA 106331312 RIVERSIDE COMM HOSP No No No No No 1560 12882 12620 $6289 $7436 $5990 Transition NA $98163 $80582 106190796 RONALD REAGAN UCLA MED CTR Yes No Yes No No 3382 12882 12620 $6289 $7436 NA NA NA NA NA 106301317 SADDLEBACK MEM MED CTR No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106301325 SADDLEBACK MEM MED CTR-SAN CLEMENTE No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106150782 RIDGECREST REG HOSP No No No Yes Yes 4178 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106361318 SAN ANTONIO COMM HOSP No No No No No 2262 12882 12620 $6289 $7436 $9216 Transition NA $98163 $80582 106190673 SAN DIMAS COMM HOSP No No No No No 2465 12882 12620 $6289 $7436 $12177 Transition NA $98163 $80582 106190200 SAN GABRIEL VALLEY MED CTR No No No No No 969 12882 12620 $6289 $7436 $6918 Transition NA $98163 $80582 106270875 SALINAS VALLEY MEM HOSP No Yes No No No 3534 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106331326 SAN GORGONIO MEM HOSP No Yes No Yes Yes 3394 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391010 SAN JOAQUIN GEN HOSP Yes No No No No 1922 13579 13303 $6289 $7735 NA NA NA NA NA 106104023 SAN JOAQUIN VALLEY REHAB HOSP No No No No No 6479 12882 12620 NA NA NA NA $1413 $98163 $80582 106013619 SAN LEANDRO HOSP No Yes No No No 3482 16501 16166 $6289 $8988 $10813 Transition NA $98163 $80582 106410782 SAN MATEO MED CTR Yes No No No No 7168 16928 16584 $6289 $9171 NA NA NA NA NA 106074017 SAN RAMON REG MED CTR No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106074011 SAN RAMON REG MED CTR SOUTH BUILDING No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106420514 SANTA BARBARA COTTAGE HOSP No No Yes No No 3902 12882 12620 $6289 $7436 $10978 Transition $2125 $98163 $80582 106430883 SANTA CLARA VALLEY MED CTR Yes No Yes No No 3133 17180 16831 $6289 $9279 NA NA NA NA NA 106190687 SANTA MONICA - UCLA MEDICAL CENTER Yes No No No No 3102 12882 12620 $6289 $7436 NA NA NA NA NA 106491064 SANTA ROSA MEM HOSP-MONTGOMERY No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106490907 SANTA ROSA MEM HOSP-SOTOYOME No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106150788 SAN JOAQUIN COMM HOSP No No No No No 2544 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420522 SANTA YNEZ VALLEY COTTAGE HOSP No No No Yes Yes 7569 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106371394 SCRIPPS MEM HOSP-ENCINITAS No No No No No 2403 12882 12620 $6289 $7436 $7037 Transition $1439 $98163 $80582 106370771 SCRIPPS MEM HOSP-LA JOLLA No No No No No 2061 12882 12620 $6289 $7436 $4390 Transition NA $98163 $80582 106370744 SCRIPPS MERCY HOSP No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106370658 SCRIPPS MERCY HOSP-CHULA VISTA No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106371256 SCRIPPS GREEN HOSP No No No No No 2317 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106321016 SENECA HCARE DIST No Yes No Yes Yes 4586 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106410817 SETON MED CTR No No No No No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106410828 SETON MED CTR-COASTSIDE No No No Yes No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106380939 SF GENERAL HOSP Yes No No No No 2851 16738 16398 $6289 $9090 NA NA NA NA NA 106370875 SHARP CHULA VISTA MED CTR No No No No No 1932 12882 12620 $6289 $7436 $6485 Transition NA $98163 $80582 106410891 SEQUOIA HOSP No No No No No 1975 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106370689 SHARP CORONADO HOSP AND HCARE CTR No No No No No 2160 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $72421 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106370694 SHARP MEM HOSP No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106450940 SHASTA REG MED CTR No No No No No 1582 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106190708 SHERMAN OAKS HOSP No No No No No 1516 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190712 SHRINERS HOSPITAL- LA No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106344114 SHRINERS HOSPITAL- SACRAMENTO No No No No No 3869 15256 14946 $6289 $8454 NA Non-Transition $2475 $98163 $80582 106540798 SIERRA VIEW DIST HOSP No Yes No No No 2716 12882 12620 $6289 $7436 $8497 Transition NA $98163 $77682 106400524 SIERRA VIST REG MED CTR No No No No No 1787 12964 12701 $6289 $7471 $5495 Transition NA $98163 $80582 106190661 SILVER LAKE MED CTR No No No No No 3692 12882 12620 $6289 $7436 $5655 Transition NA $98163 $80582 106291023 SIERRA NEVADA MEM HOSP No No No Yes Yes 3427 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106491076 SONOMA VALLEY HOSP No Yes No No No 4960 16315 15984 $6289 $8908 $12733 Transition NA $98163 $80582 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 2126 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190380 SOUTHERN CA HOSP AT HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106190110 SOUTHERN CA HOSPITAL AT CULVER CITY No No No No No 1437 12882 12620 $6289 $7436 $4694 Transition $1220 $98163 $80582 106560525 SIMI VALLEY HOSP AND HCARE-SYCAMORE No No No No No 3840 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106334068 SOUTHWEST HCARE SYSTEM No No No No No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106334001 SOUTHWEST HCARE SYSTEM-WILDOMAR No No No Yes No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106100899 ST AGNES MED CTR No No No No No 3088 12882 12620 $6289 $7436 $7885 Transition NA $98163 $80582 106361339 ST BERNARDINE MED CTR No No No No No 2171 12882 12620 $6289 $7436 $6090 Transition NA $98163 $80582 106521041 ST ELIZABETH COMM HOSP No No No Yes Yes 3024 13869 13587 $12768 $15956 $14866 Transition NA $98163 $80582 106190754 ST FRANCIS MED CTR No No No No No 4350 12882 12620 $6289 $7436 $6368 Transition NA $98163 $80582 106380960 ST FRANCIS MEM HOSP No No No No No 1920 16738 16398 $6289 $9090 $5310 Transition $1492 $98163 $80582 106281078 ST HELENA HOSP No No No No No 2337 15887 15564 $6289 $8725 $9671 Transition NA $98163 $80582 106171049 ST HELENA HOSPITAL-CLEARLAKE No No No Yes Yes 4118 12882 12620 $12768 $15097 $18218 Transition NA $98163 $80582 106141338 SOUTHERN INYO HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190756 ST JOHNS HEALTH CTR No No No No No 2536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560529 ST JOHNS REG MED CTR No No No No No 2982 12882 12620 $6289 $7436 $6976 Transition $1761 $98163 $80582 106121080 ST JOSEPH HOSP-EUREKA No No No No No 2570 13869 13587 $6289 $7859 $9661 Transition $1507 $98163 $80582 106301340 ST JOSEPH HOSP-ORANGE No No No No No 2751 12882 12620 $6289 $7436 $5230 Transition NA $98163 $80582 106560508 ST JOHNS PLEASANT VALLEY HOSP No No No No No 2087 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301342 ST JUDE MED CTR No No No No No 1722 12882 12620 $6289 $7436 $5799 Transition $1220 $98163 $80582 106434138 ST LOUISE REG HOSP No No No No No 2838 17180 16831 $6289 $9279 $16407 Transition NA $98163 $80582 106380964 ST LUKES HOSP No No No No No 3807 16738 16398 $6289 $9090 $8600 Transition NA $98163 $80582 106361343 ST MARY MED CTR-APPLE VALLEY No No No Yes No 2511 12882 12620 $6289 $7436 $9863 Transition NA $98163 $80582 106391042 ST JOSEPHS MED CTR OF STOCKTON No No No No No 2152 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106380965 ST MARYS MED CTR-SF No No No No No 2007 16738 16398 $6289 $9090 $5116 Transition $1492 $98163 $80582 106010967 ST ROSE HOSP No No No No No 1931 16962 16618 $6289 $9186 $7600 Transition NA $98163 $80582 106190762 ST VINCENT MED CTR No No No No No 2020 12882 12620 $6289 $7436 $4684 Transition $1220 $98163 $80582 106430905 STANFORD HOSP No No No No No 1803 17180 16831 $6289 $9279 $5644 Transition $1523 $98163 $80582 106190053 ST MARY MED CTR-LONG BEACH No No No No No 2479 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106504038 STANISLAUS SURGICAL HOSP No No No No No 9000 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106250955 SURPRISE VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106310791 SUTTER AUBURN FAITH HOSP No No No No No 2551 15256 14946 $6289 $8454 $11882 Transition NA $98163 $80582 106034002 SUTTER AMADOR HOSP No No No Yes Yes 2971 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106574010 SUTTER DAVIS HOSP No No No No No 3568 15256 14946 $6289 $8454 $14330 Transition NA $98163 $80582 106070934 SUTTER DELTA MED CTR No No No No No 2907 16478 16143 $6289 $8978 $12158 Transition NA $98163 $80582 106341051 SUTTER GEN HOSP No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106171395 SUTTER LAKESIDE HOSP No No No Yes Yes 3691 12882 12620 $12768 $15097 $17232 Transition NA $98163 $80582 106444012 SUTTER MATERNITY AND SRG CTR OF S CRUZ No No No No No 7213 17239 16889 $6289 $9304 $21288 Transition NA $98163 $80582 106490919 SUTTER MED CTR OF SANTA ROSA No No No No No 3657 16315 15984 $6289 $8908 $15278 Transition NA $98163 $80582 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106311000 SUTTER ROSEVILLE MED CTR No No No No No 2377 15256 14946 $6289 $8454 $11395 Transition $1387 $98163 $80582 106481094 SUTTER SOLANO MED CTR No No No No No 3258 16315 15984 $6289 $8908 $18010 Transition NA $98163 $80582 106084001 SUTTER COAST HOSP No No No Yes Yes 3730 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391056 SUTTER TRACY COMM HOSP No No No No No 2714 13579 13303 $6289 $7735 $5995 Transition NA $98163 $80582 106291053 TAHOE FOREST HOSP No Yes No Yes Yes 4766 15256 14946 $12768 $17164 $21044 Transition NA $98163 $80582 106150808 TEHACHAPI HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 $22158 Transition NA $98163 $80582 106514030 SUTTER SURG HOSP-NORTH VALLEY No No No No No 3240 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106334564 TEMECULA VALLEY HOSPITAL No No No No No 2180 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106120981 THE GENERAL HOSPITAL No No No No No 2570 13869 13587 NA NA NA NA $1507 $98163 $80582 106564121 THOUSAND OAKS SURGICAL HOSPITAL No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106190422 TORRANCE MEM MED CTR No No No No No 1952 12882 12620 $6289 $7436 $5891 Transition NA $98163 $80582 106370780 TRI-CITY MED CTR No Yes No No No 3695 12882 12620 $6289 $7436 $7706 Transition $1220 $98163 $80582 106190784 TEMPLE COMM HOSP No No No No No 4200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540816 TULARE DIST HOSP No Yes No No No 3578 12882 12620 $6289 $7436 $9529 Transition NA $98163 $80582 106531059 TRINITY HOSP No Yes No Yes Yes 5105 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106400548 TWIN CITIES COMM HOSP No No No Yes Yes 1587 12964 12701 $12768 $15168 $8160 Transition NA $98163 $80582 106341006 UC DAVIS MED CTR Yes No Yes No No 1836 15256 14946 $6289 $8454 NA NA NA NA NA 106301279 UC IRVINE MED CTR Yes No Yes No No 2072 12882 12620 $6289 $7436 NA NA NA NA NA 106370782 UCSD MED CTR Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106374141 UCSD-LA JOLLA JOHN M amp SALLY B THORNTON HOSPITAL Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106381154 UCSF MED CTR Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106380895 UCSF MED CTR AT MOUNT ZION Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106301357 TUSTIN HOSP MED CTR No No No No No 231 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106231396 UKIAH VALLEY MED CTRHOSP DR No No No Yes Yes 3643 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106014050 VALLEY CARE MEDICAL CENTER No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106010983 VALLEY MEM HOSP-LIVERMORE No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106191216 USC KENNETH NORRIS JR CANCER HOSP No No No No No 3134 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560481 VENTURA CO MED CTR Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106560521 VENTURA CO MED CTR-SANTA PAULA HOSPITAL Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106190818 VERDUGO HILLS HOSP No No No No No 3110 12882 12620 $6289 $7436 $5264 Transition NA $98163 $80582 106190812 VALLEY PRES HOSP No No No No No 3536 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 3046 14188 13900 $6289 $7996 NA Non-Transition $1312 $98163 $80582 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 3266 12882 12620 $6289 $7436 $8320 Transition NA $98163 $80582 106010987 WASHINGTON HOSP-FREMONT No Yes No No No 1941 16962 16618 $6289 $9186 $6429 Transition NA $98163 $80582 106444013 WATSONVILLE COMM HOSP No No No No No 1780 17239 16889 $6289 $9304 $13456 Transition NA $98163 $80582 106301379 WEST ANAHEIM MED CTR No No No No No 1514 12882 12620 $6289 $7436 $4707 Transition NA $98163 $80582 106190859 WEST HILLS HOSP AND MED CTR No No No No No 1933 12882 12620 $6289 $7436 $8050 Transition NA $98163 $80582 106374094 VIBRA OF SAN DIEGO No No No No No 1155 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301188 WESTERN MED CTR-ANAHEIM No No No No No 3203 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301566 WESTERN MED CTR-SANTA ANA No No No No No 2354 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190878 WHITE MEM MED CTR No No No No No 1515 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190883 WHITTIER HOSP MED CTR No No No No No 1139 12882 12620 $6289 $7436 $5922 Transition NA $98163 $80582 106571086 WOODLAND MEM HOSP No No No No No 3278 15256 14946 $6289 $8454 $10092 Transition NA $98163 $80582 6102015
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
-
312-3 312-4
SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES
1846 3284
31356 71148
10000 10000
10000 10000
31356 71148
12500 12500
39195 88935
10000 10000
31356 71148
$29396 Misc Pediatric $66701 Misc Pediatric
Misc Adult Misc Adult
313-1 313-2 313-3 313-4
KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT
270 444 785
1659
10852 15212 22743 43349
10000 10000 10000 10000
10000 10000 10000 10000
10852 15212 22743 43349
12500 12500 12500 12500
13565 19015 28429 54186
10000 10000 10000 10000
10852 15212 22743 43349
$10174 Misc Pediatric $14261 Misc Pediatric $21322 Misc Pediatric $40640 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
314-1 314-2 314-3 314-4
FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES FOOT amp TOE PROCEDURES
257 507 810
1579
09291 11320 16006 32885
10000 10000 10000 10000
10000 10000 10000 10000
09291 11320 16006 32885
12500 12500 12500 12500
11614 14150 20008 41106
10000 10000 10000 10000
09291 11320 16006 32885
$8710 Misc Pediatric $10613 Misc Pediatric $15006 Misc Pediatric $30830 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
315-1 315-2 315-3 315-4
SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES SHOULDER UPPER ARM amp FOREARM PROCEDURES
185 267 649
1473
08387 15912 22542 44542
10000 10000 10000 10000
10000 10000 10000 10000
08387 15912 22542 44542
12500 12500 12500 12500
10484 19890 28178 55678
10000 10000 10000 10000
08387 15912 22542 44542
$7863 Misc Pediatric $14918 Misc Pediatric $21133 Misc Pediatric $41758 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
316-1 316-2 316-3 316-4
HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES HAND amp WRIST PROCEDURES
229 396 727
1430
07195 10564 17143 34568
10000 10000 10000 10000
10000 10000 10000 10000
07195 10564 17143 34568
12500 12500 12500 12500
08994 13205 21429 43210
10000 10000 10000 10000
07195 10564 17143 34568
$6745 Misc Pediatric $9904 Misc Pediatric
$16072 Misc Pediatric $32408 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
317-1 317-2 317-3 317-4
TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES
300 544
1030 2038
08204 11764 19738 43378
10000 10000 10000 10000
10000 10000 10000 10000
08204 11764 19738 43378
12500 12500 12500 12500
10255 14705 24673 54223
10000 10000 10000 10000
08204 11764 19738 43378
$7691 Misc Pediatric $11029 Misc Pediatric $18504 Misc Pediatric $40667 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
320-1 320-2 320-3 320-4
OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES
229 474 900
1844
09314 14085 21498 40942
10000 10000 10000 10000
10000 10000 10000 10000
09314 14085 21498 40942
12500 12500 12500 12500
11643 17606 26873 51178
10000 10000 10000 10000
09314 14085 21498 40942
$8732 Misc Pediatric $13205 Misc Pediatric $20154 Misc Pediatric $38383 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
321-1 321-2 321-3 321-4
CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP
174 322 869
1740
16800 21292 35737 65431
10000 10000 10000 10000
10000 10000 10000 10000
16800 21292 35737 65431
12500 12500 12500 12500
21000 26615 44671 81789
10000 10000 10000 10000
16800 21292 35737 65431
$15750 Misc Pediatric $19961 Misc Pediatric $33503 Misc Pediatric $61342 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
340-1 340-2 340-3 340-4
FRACTURE OF FEMUR FRACTURE OF FEMUR FRACTURE OF FEMUR FRACTURE OF FEMUR
307 350 507 717
04052 05213 07741 13545
10000 10000 10000 10000
10000 10000 10000 10000
04052 05213 07741 13545
12500 12500 12500 12500
05065 06516 09676 16931
10000 10000 10000 10000
04052 05213 07741 13545
$3799 Misc Pediatric $4887 Misc Pediatric $7257 Misc Pediatric
$12698 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
341-1 341-2 341-3 341-4
FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP FRACTURE OF PELVIS OR DISLOCATION OF HIP
302 365 480 981
04685 05732 07835 19346
10000 10000 10000 10000
10000 10000 10000 10000
04685 05732 07835 19346
12500 12500 12500 12500
05856 07165 09794 24183
10000 10000 10000 10000
04685 05732 07835 19346
$4392 Misc Pediatric $5374 Misc Pediatric $7345 Misc Pediatric
$18137 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
342-1 342-2 342-3 342-4
FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK
223 336 523
1073
04199 06015 09030 19468
10000 10000 10000 10000
10000 10000 10000 10000
04199 06015 09030 19468
12500 12500 12500 12500
05249 07519 11288 24335
10000 10000 10000 10000
04199 06015 09030 19468
$3937 Misc Pediatric $5639 Misc Pediatric $8466 Misc Pediatric
$18251 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
343-1 343-2 343-3 343-4
MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG
381 462 768
1278
06313 07919 12982 22512
10000 10000 10000 10000
10000 10000 10000 10000
06313 07919 12982 22512
12500 12500 12500 12500
07891 09899 16228 28140
10000 10000 10000 10000
06313 07919 12982 22512
$5918 Misc Pediatric $7424 Misc Pediatric
$12171 Misc Pediatric $21105 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
344-1 344-2 344-3 344-4
OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS
510 624 996
1727
06188 08269 12369 20626
10000 10000 10000 10000
10000 10000 10000 10000
06188 08269 12369 20626
12500 12500 12500 12500
07735 10336 15461 25783
10000 10000 10000 10000
06188 08269 12369 20626
$5801 Misc Pediatric $7752 Misc Pediatric
$11596 Misc Pediatric $19337 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
346-1 346-2 346-3 346-4
CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS CONNECTIVE TISSUE DISORDERS
312 418 742
1507
05246 07180 12230 29854
10000 10000 10000 10000
10000 10000 10000 10000
05246 07180 12230 29854
12500 12500 12500 12500
06558 08975 15288 37318
10000 10000 10000 10000
05246 07180 12230 29854
$4918 Misc Pediatric $6731 Misc Pediatric
$11466 Misc Pediatric $27988 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
347-1 347-2 347-3 347-4
OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES
288 388 534
1184
05202 07038 09895 23177
10000 10000 10000 10000
10000 10000 10000 10000
05202 07038 09895 23177
12500 12500 12500 12500
06503 08798 12369 28971
10000 10000 10000 10000
05202 07038 09895 23177
$4877 Misc Pediatric $6598 Misc Pediatric $9277 Misc Pediatric
$21728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
349-1 349-2 349-3 349-4
MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE
226 480 806
1387
04381 06459 10302 19261
10000 10000 10000 10000
10000 10000 10000 10000
04381 06459 10302 19261
12500 12500 12500 12500
05476 08074 12878 24076
10000 10000 10000 10000
04381 06459 10302 19261
$4107 Misc Pediatric $6055 Misc Pediatric $9658 Misc Pediatric
$18057 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
351-1 351-2 351-3 351-4
OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES
252 352 544
1111
04074 05668 08930 19109
10000 10000 10000 10000
10000 10000 10000 10000
04074 05668 08930 19109
12500 12500 12500 12500
05093 07085 11163 23886
10000 10000 10000 10000
04074 05668 08930 19109
$3819 Misc Pediatric $5314 Misc Pediatric $8372 Misc Pediatric
$17915 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
361-1 361-2 361-3 361-4
SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES
407 758
1393 2857
11097 14459 21415 45412
10000 10000 10000 10000
10000 10000 10000 10000
11097 14459 21415 45412
12500 12500 12500 12500
13871 18074 26769 56765
10000 10000 10000 10000
11097 14459 21415 45412
$10403 Misc Pediatric $13555 Misc Pediatric $20077 Misc Pediatric $42574 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
362-1 362-2 362-3 362-4
MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES MASTECTOMY PROCEDURES
179 233 597
1380
10091 13554 17862 38257
10000 10000 10000 10000
10000 10000 10000 10000
10091 13554 17862 38257
12500 12500 12500 12500
12614 16943 22328 47821
10000 10000 10000 10000
10091 13554 17862 38257
$9460 Misc Pediatric $12707 Misc Pediatric $16746 Misc Pediatric $35866 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
363-1 363-2 363-3 363-4
BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY BREAST PROCEDURES EXCEPT MASTECTOMY
209 314 532
1706
08797 14900 19039 35420
10000 10000 10000 10000
10000 10000 10000 10000
08797 14900 19039 35420
12500 12500 12500 12500
10996 18625 23799 44275
10000 10000 10000 10000
08797 14900 19039 35420
$8247 Misc Pediatric $13969 Misc Pediatric $17849 Misc Pediatric $33206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
364-1 364-2 364-3 364-4
OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES
289 508 943
1919
07645 10877 16986 30643
10000 10000 10000 10000
10000 10000 10000 10000
07645 10877 16986 30643
12500 12500 12500 12500
09556 13596 21233 38304
10000 10000 10000 10000
07645 10877 16986 30643
$7167 Misc Pediatric $10197 Misc Pediatric $15924 Misc Pediatric $28728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
380-1 380-2 380-3 380-4
SKIN ULCERS SKIN ULCERS SKIN ULCERS SKIN ULCERS
416 498 784
1662
05289 06545 09424 17199
10000 10000 10000 10000
10000 10000 10000 10000
05289 06545 09424 17199
12500 12500 12500 12500
06611 08181 11780 21499
10000 10000 10000 10000
05289 06545 09424 17199
$4958 Misc Pediatric $6136 Misc Pediatric $8835 Misc Pediatric
$16124 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
381-1 381-2 381-3 381-4
MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS MAJOR SKIN DISORDERS
300 428 671
1406
03883 05748 09734 27512
10000 10000 10000 10000
10000 10000 10000 10000
03883 05748 09734 27512
12500 12500 12500 12500
04854 07185 12168 34390
10000 10000 10000 10000
03883 05748 09734 27512
$3640 Misc Pediatric $5389 Misc Pediatric $9126 Misc Pediatric
$25793 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
382-1 382-2 382-3 382-4
MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS MALIGNANT BREAST DISORDERS
381 432 645
1003
03521 05612 09634 15729
10000 10000 10000 10000
10000 10000 10000 10000
03521 05612 09634 15729
12500 12500 12500 12500
04401 07015 12043 19661
10000 10000 10000 10000
03521 05612 09634 15729
$3301 Misc Pediatric $5261 Misc Pediatric $9032 Misc Pediatric
$14746 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
383-1 383-2 383-3 383-4
CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS CELLULITIS amp OTHER BACTERIAL SKIN INFECTIONS
294 412 617
1198
04148 05905 09147 19560
10000 10000 10000 10000
10000 10000 10000 10000
04148 05905 09147 19560
12500 12500 12500 12500
05185 07381 11434 24450
10000 10000 10000 10000
04148 05905 09147 19560
$3889 Misc Pediatric $5536 Misc Pediatric $8575 Misc Pediatric
$18338 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
384-1 384-2 384-3 384-4
CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE
193 301 493
1134
04752 06220 08932 20168
10000 10000 10000 10000
10000 10000 10000 10000
04752 06220 08932 20168
12500 12500 12500 12500
05940 07775 11165 25210
10000 10000 10000 10000
04752 06220 08932 20168
$4455 Misc Pediatric $5831 Misc Pediatric $8374 Misc Pediatric
$18908 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
385-1 385-2 385-3 385-4
OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS
248 353 565
1295
03496 05103 07974 19128
10000 10000 10000 10000
10000 10000 10000 10000
03496 05103 07974 19128
12500 12500 12500 12500
04370 06379 09968 23910
10000 10000 10000 10000
03496 05103 07974 19128
$3278 Misc Pediatric $4784 Misc Pediatric $7476 Misc Pediatric
$17933 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
401-1 401-2 401-3 401-4
PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES PITUITARY amp ADRENAL PROCEDURES
303 427 844
2452
13697 18347 29058 71913
10000 10000 10000 10000
10000 10000 10000 10000
13697 18347 29058 71913
12500 12500 12500 12500
17121 22934 36323 89891
10000 10000 10000 10000
13697 18347 29058 71913
$12841 Misc Pediatric $17200 Misc Pediatric $27242 Misc Pediatric $67418 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
403-1 403-2 403-3 403-4
PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY PROCEDURES FOR OBESITY
183 222 497
1867
12813 14411 21531 61151
10000 10000 10000 10000
10000 10000 10000 10000
12813 14411 21531 61151
12500 12500 12500 12500
16016 18014 26914 76439
10000 10000 10000 10000
12813 14411 21531 61151
$12012 Misc Pediatric $13510 Misc Pediatric $20185 Misc Pediatric $57329 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
404-1 404-2 404-3 404-4
THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES
130 216 659
1638
07364 09479 18990 42519
10000 10000 10000 10000
10000 10000 10000 10000
07364 09479 18990 42519
12500 12500 12500 12500
09205 11849 23738 53149
10000 10000 10000 10000
07364 09479 18990 42519
$6904 Misc Pediatric $8887 Misc Pediatric
$17803 Misc Pediatric $39862 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
405-1 405-2 405-3 405-4
OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS
419 571 966
2131
11123 14210 21421 48796
10000 10000 10000 10000
10000 10000 10000 10000
11123 14210 21421 48796
12500 12500 12500 12500
13904 17763 26776 60995
10000 10000 10000 10000
11123 14210 21421 48796
$10428 Misc Pediatric $13322 Misc Pediatric $20082 Misc Pediatric $45746 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
420-1 420-2 420-3 420-4
DIABETES DIABETES DIABETES DIABETES
261 275 427 935
03897 05302 07862 19671
10000 10000 10000 10000
10000 10000 10000 10000
03897 05302 07862 19671
12500 12500 12500 12500
04871 06628 09828 24589
10000 10000 10000 10000
03897 05302 07862 19671
$3653 Misc Pediatric $4971 Misc Pediatric $7371 Misc Pediatric
$18442 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
421-1 421-2 421-3 421-4
MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS
351 483 676
1375
03211 05227 08190 17446
10000 10000 10000 10000
10000 10000 10000 10000
03211 05227 08190 17446
12500 12500 12500 12500
04014 06534 10238 21808
10000 10000 10000 10000
03211 05227 08190 17446
$3010 Misc Pediatric $4900 Misc Pediatric $7678 Misc Pediatric
$16356 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
422-1 422-2 422-3 422-4
HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS
199 291 445 914
02848 04625 06828 14444
10000 10000 10000 10000
10000 10000 10000 10000
02848 04625 06828 14444
12500 12500 12500 12500
03560 05781 08535 18055
10000 10000 10000 10000
02848 04625 06828 14444
$2670 Misc Pediatric $4336 Misc Pediatric $6401 Misc Pediatric
$13541 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
423-1 423-2 423-3 423-4
INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM INBORN ERRORS OF METABOLISM
272 363 573
1504
04421 05846 09540 27384
10000 10000 10000 10000
10000 10000 10000 10000
04421 05846 09540 27384
12500 12500 12500 12500
05526 07308 11925 34230
10000 10000 10000 10000
04421 05846 09540 27384
$4145 Misc Pediatric $5481 Misc Pediatric $8944 Misc Pediatric
$25673 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
424-1 424-2 424-3 424-4
OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS OTHER ENDOCRINE DISORDERS
259 397 605
1147
04342 06514 09768 21520
10000 10000 10000 10000
10000 10000 10000 10000
04342 06514 09768 21520
12500 12500 12500 12500
05428 08143 12210 26900
10000 10000 10000 10000
04342 06514 09768 21520
$4071 Misc Pediatric $6107 Misc Pediatric $9158 Misc Pediatric
$20175 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
425-1 425-2 425-3
ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED
241 302 460
04017 05132 07667
10000 10000 10000
10000 10000 10000
04017 05132 07667
12500 12500 12500
05021 06415 09584
10000 10000 10000
04017 05132 07667
$3766 Misc Pediatric $4811 Misc Pediatric $7188 Misc Pediatric
Misc Adult Misc Adult Misc Adult
425-4 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 946 16767 10000 10000 16767 12500 20959 10000 16767 $15719 Misc Pediatric Misc Adult 440-1 440-2 440-3 440-4
KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT
458 561 864
2088
44667 50078 60562 99171
10000 10000 10000 10000
10000 10000 10000 10000
44667 50078 60562 99171
12500 12500 12500 12500
55834 62598 75703
123964
10000 10000 10000 10000
44667 50078 60562 99171
$41875 Misc Pediatric $46948 Misc Pediatric $56777 Misc Pediatric $92973 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
441-1 441-2 441-3 441-4
MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES
474 726 994
2196
14386 21567 29549 61841
10000 10000 10000 10000
10000 10000 10000 10000
14386 21567 29549 61841
12500 12500 12500 12500
17983 26959 36936 77301
10000 10000 10000 10000
14386 21567 29549 61841
$13487 Misc Pediatric $20219 Misc Pediatric $27702 Misc Pediatric $57976 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
442-1 442-2 442-3 442-4
KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY
325 422 795
1671
13139 15537 23456 49226
10000 10000 10000 10000
10000 10000 10000 10000
13139 15537 23456 49226
12500 12500 12500 12500
16424 19421 29320 61533
10000 10000 10000 10000
13139 15537 23456 49226
$12318 Misc Pediatric $14566 Misc Pediatric $21990 Misc Pediatric $46149 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
443-1 443-2 443-3 443-4
KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY
253 356 802
1752
10883 12834 18814 40742
10000 10000 10000 10000
10000 10000 10000 10000
10883 12834 18814 40742
12500 12500 12500 12500
13604 16043 23518 50928
10000 10000 10000 10000
10883 12834 18814 40742
$10203 Misc Pediatric $12032 Misc Pediatric $17638 Misc Pediatric $38196 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
444-1 444-2 444-3 444-4
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY
264 447 933
1617
09410 12604 20686 38830
10000 10000 10000 10000
10000 10000 10000 10000
09410 12604 20686 38830
12500 12500 12500 12500
11763 15755 25858 48538
10000 10000 10000 10000
09410 12604 20686 38830
$8822 Misc Pediatric $11816 Misc Pediatric $19393 Misc Pediatric $36403 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
445-1 445-2 445-3 445-4
OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES
190 319 781
1545
08552 11610 15964 31570
10000 10000 10000 10000
10000 10000 10000 10000
08552 11610 15964 31570
12500 12500 12500 12500
10690 14513 19955 39463
10000 10000 10000 10000
08552 11610 15964 31570
$8018 Misc Pediatric $10884 Misc Pediatric $14966 Misc Pediatric $29597 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
446-1 446-2 446-3 446-4
URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES
188 261 612
1363
06758 08690 14202 30173
10000 10000 10000 10000
10000 10000 10000 10000
06758 08690 14202 30173
12500 12500 12500 12500
08448 10863 17753 37716
10000 10000 10000 10000
06758 08690 14202 30173
$6336 Misc Pediatric $8147 Misc Pediatric
$13314 Misc Pediatric $28287 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
447-1 447-2 447-3 447-4
OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES
228 365 728
1787
11479 13294 19661 43932
10000 10000 10000 10000
10000 10000 10000 10000
11479 13294 19661 43932
12500 12500 12500 12500
14349 16618 24576 54915
10000 10000 10000 10000
11479 13294 19661 43932
$10762 Misc Pediatric $12463 Misc Pediatric $18432 Misc Pediatric $41186 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
460-1 460-2 460-3 460-4
RENAL FAILURE RENAL FAILURE RENAL FAILURE RENAL FAILURE
299 376 496
1115
04323 06061 07896 19936
10000 10000 10000 10000
10000 10000 10000 10000
04323 06061 07896 19936
12500 12500 12500 12500
05404 07576 09870 24920
10000 10000 10000 10000
04323 06061 07896 19936
$4053 Misc Pediatric $5682 Misc Pediatric $7403 Misc Pediatric
$18690 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
461-1 461-2 461-3 461-4
KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY
271 374 601
1108
04315 05992 09498 16929
10000 10000 10000 10000
10000 10000 10000 10000
04315 05992 09498 16929
12500 12500 12500 12500
05394 07490 11873 21161
10000 10000 10000 10000
04315 05992 09498 16929
$4045 Misc Pediatric $5618 Misc Pediatric $8904 Misc Pediatric
$15871 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
462-1 462-2 462-3 462-4
NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS
260 370 656
1359
03798 05298 09439 23905
10000 10000 10000 10000
10000 10000 10000 10000
03798 05298 09439 23905
12500 12500 12500 12500
04748 06623 11799 29881
10000 10000 10000 10000
03798 05298 09439 23905
$3561 Misc Pediatric $4967 Misc Pediatric $8849 Misc Pediatric
$22411 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
463-1 463-2 463-3 463-4
KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS
268 352 507 910
04120 05628 07879 14066
10000 10000 10000 10000
10000 10000 10000 10000
04120 05628 07879 14066
12500 12500 12500 12500
05150 07035 09849 17583
10000 10000 10000 10000
04120 05628 07879 14066
$3863 Misc Pediatric $5276 Misc Pediatric $7387 Misc Pediatric
$13187 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
465-1 465-2 465-3 465-4
URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION
165 202 380 860
04374 05548 08751 18922
10000 10000 10000 10000
10000 10000 10000 10000
04374 05548 08751 18922
12500 12500 12500 12500
05468 06935 10939 23653
10000 10000 10000 10000
04374 05548 08751 18922
$4101 Misc Pediatric $5201 Misc Pediatric $8204 Misc Pediatric
$17739 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
466-1 466-2 466-3 466-4
MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC
221 343 533 971
03576 05752 08974 17498
10000 10000 10000 10000
10000 10000 10000 10000
03576 05752 08974 17498
12500 12500 12500 12500
04470 07190 11218 21873
10000 10000 10000 10000
03576 05752 08974 17498
$3353 Misc Pediatric $5393 Misc Pediatric $8413 Misc Pediatric
$16404 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
468-1 468-2 468-3 468-4
OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS
246 335 509
1057
04152 05935 08698 18661
10000 10000 10000 10000
10000 10000 10000 10000
04152 05935 08698 18661
12500 12500 12500 12500
05190 07419 10873 23326
10000 10000 10000 10000
04152 05935 08698 18661
$3893 Misc Pediatric $5564 Misc Pediatric $8154 Misc Pediatric
$17495 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
480-1 480-2 480-3 480-4
MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES
180 241 618
1422
12119 13477 20992 45258
10000 10000 10000 10000
10000 10000 10000 10000
12119 13477 20992 45258
12500 12500 12500 12500
15149 16846 26240 56573
10000 10000 10000 10000
12119 13477 20992 45258
$11362 Misc Pediatric $12635 Misc Pediatric $19680 Misc Pediatric $42429 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
481-1 481-2 481-3 481-4
PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES
228 267 830
1810
06794 11922 17939 41143
10000 10000 10000 10000
10000 10000 10000 10000
06794 11922 17939 41143
12500 12500 12500 12500
08493 14903 22424 51429
10000 10000 10000 10000
06794 11922 17939 41143
$6369 Misc Pediatric $11177 Misc Pediatric $16818 Misc Pediatric $38572 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
482-1 482-2 482-3 482-4
TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY
169 278 716
1341
05918 07555 14662 30717
10000 10000 10000 10000
10000 10000 10000 10000
05918 07555 14662 30717
12500 12500 12500 12500
07398 09444 18328 38396
10000 10000 10000 10000
05918 07555 14662 30717
$5548 Misc Pediatric $7083 Misc Pediatric
$13746 Misc Pediatric $28797 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
483-1 483-2 483-3 483-4
TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES
203 541
1127 1970
06074 11326 22018 44244
10000 10000 10000 10000
10000 10000 10000 10000
06074 11326 22018 44244
12500 12500 12500 12500
07593 14158 27523 55305
10000 10000 10000 10000
06074 11326 22018 44244
$5694 Misc Pediatric $10618 Misc Pediatric $20642 Misc Pediatric $41479 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
484-1 484-2 484-3 484-4
OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
250 191 502
1578
07704 11762 15177 36555
10000 10000 10000 10000
10000 10000 10000 10000
07704 11762 15177 36555
12500 12500 12500 12500
09630 14703 18971 45694
10000 10000 10000 10000
07704 11762 15177 36555
$7223 Misc Pediatric $11027 Misc Pediatric $14228 Misc Pediatric $34270 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
500-1 500-2 500-3 500-4
MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM
266 431 601
1109
03789 05904 09172 17461
10000 10000 10000 10000
10000 10000 10000 10000
03789 05904 09172 17461
12500 12500 12500 12500
04736 07380 11465 21826
10000 10000 10000 10000
03789 05904 09172 17461
$3552 Misc Pediatric $5535 Misc Pediatric $8599 Misc Pediatric
$16370 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
501-1 501-2 501-3 501-4
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY
258 351 547
1074
04044 05542 08322 16765
10000 10000 10000 10000
10000 10000 10000 10000
04044 05542 08322 16765
12500 12500 12500 12500
05055 06928 10403 20956
10000 10000 10000 10000
04044 05542 08322 16765
$3791 Misc Pediatric $5196 Misc Pediatric $7802 Misc Pediatric
$15717 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
510-1 510-2 510-3 510-4
PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS
244 387 892
1787
11433 14140 25807 52317
10000 10000 10000 10000
10000 10000 10000 10000
11433 14140 25807 52317
12500 12500 12500 12500
14291 17675 32259 65396
10000 10000 10000 10000
11433 14140 25807 52317
$10718 Misc Pediatric $13256 Misc Pediatric $24194 Misc Pediatric $49047 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
511-1 511-2 511-3 511-4
UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY
330 488 862
1777
11911 14923 22750 49888
10000 10000 10000 10000
10000 10000 10000 10000
11911 14923 22750 49888
12500 12500 12500 12500
14889 18654 28438 62360
10000 10000 10000 10000
11911 14923 22750 49888
$11167 Misc Pediatric $13990 Misc Pediatric $21328 Misc Pediatric $46770 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
512-1 512-2 512-3 512-4
UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG
217 308 682
1629
10603 12410 19879 45702
10000 10000 10000 10000
10000 10000 10000 10000
10603 12410 19879 45702
12500 12500 12500 12500
13254 15513 24849 57128
10000 10000 10000 10000
10603 12410 19879 45702
$9940 Misc Pediatric $11634 Misc Pediatric $18637 Misc Pediatric $42846 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
513-1 513-2 513-3 513-4
UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
186 251 564
1508
08515 10026 16283 40387
10000 10000 10000 10000
10000 10000 10000 10000
08515 10026 16283 40387
12500 12500 12500 12500
10644 12533 20354 50484
10000 10000 10000 10000
08515 10026 16283 40387
$7983 Misc Pediatric $9399 Misc Pediatric
$15265 Misc Pediatric $37863 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
514-1 514-2 514-3 514-4
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
140 172 529
1557
07298 09618 15881 40691
10000 10000 10000 10000
10000 10000 10000 10000
07298 09618 15881 40691
12500 12500 12500 12500
09123 12023 19851 50864
10000 10000 10000 10000
07298 09618 15881 40691
$6842 Misc Pediatric $9017 Misc Pediatric
$14888 Misc Pediatric $38148 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
517-1 517-2 517-3 517-4
DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES
192 289 663
1364
06030 08036 13633 29709
10000 10000 10000 10000
10000 10000 10000 10000
06030 08036 13633 29709
12500 12500 12500 12500
07538 10045 17041 37136
10000 10000 10000 10000
06030 08036 13633 29709
$5653 Misc Pediatric $7534 Misc Pediatric
$12781 Misc Pediatric $27852 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
518-1 518-2 518-3 518-4
OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
223 382 837
1827
06924 10040 18032 44556
10000 10000 10000 10000
10000 10000 10000 10000
06924 10040 18032 44556
12500 12500 12500 12500
08655 12550 22540 55695
10000 10000 10000 10000
06924 10040 18032 44556
$6491 Misc Pediatric $9413 Misc Pediatric
$16905 Misc Pediatric $41771 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
519-1 519-2 519-3 519-4
UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA
206 279 613
1485
08286 10051 17505 39433
10000 10000 10000 10000
10000 10000 10000 10000
08286 10051 17505 39433
12500 12500 12500 12500
10358 12564 21881 49291
10000 10000 10000 10000
08286 10051 17505 39433
$7768 Misc Pediatric $9423 Misc Pediatric
$16411 Misc Pediatric $36968 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
530-1 530-2 530-3 530-4
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
310 385 643
1178
04420 06163 09992 18972
10000 10000 10000 10000
10000 10000 10000 10000
04420 06163 09992 18972
12500 12500 12500 12500
05525 07704 12490 23715
10000 10000 10000 10000
04420 06163 09992 18972
$4144 Misc Pediatric $5778 Misc Pediatric $9368 Misc Pediatric
$17786 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
531-1 531-2 531-3 531-4
FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS
266 383 638
1303
04544 06407 09987 20595
10000 10000 10000 10000
10000 10000 10000 10000
04544 06407 09987 20595
12500 12500 12500 12500
05680 08009 12484 25744
10000 10000 10000 10000
04544 06407 09987 20595
$4260 Misc Pediatric $6007 Misc Pediatric $9363 Misc Pediatric
$19308 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
532-1 532-2 532-3 532-4
MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
177 237 434
1003
03922 04787 07941 17650
10000 10000 10000 10000
10000 10000 10000 10000
03922 04787 07941 17650
12500 12500 12500 12500
04903 05984 09926 22063
10000 10000 10000 10000
03922 04787 07941 17650
$3677 Misc Pediatric $4488 Misc Pediatric $7445 Misc Pediatric
$16547 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
540-1 540-2 540-3 540-4
CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY
298 391 634
1053
05654 06864 09354 23719
10000 10000 10000 10000
10600 10600 10600 10600
05993 07276 09915 25142
10000 10000 10000 10000
05993 07276 09915 25142
10000 10000 10000 10000
05654 06864 09354 23719
$4495 Obstetrics $5457 Obstetrics $7436 Obstetrics
$18857 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
541-1 541-2 541-3 541-4
VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC
212 249 491 838
05628 06076 08661 23515
10000 10000 10000 10000
10600 10600 10600 10600
05966 06441 09181 24926
10000 10000 10000 10000
05966 06441 09181 24926
10000 10000 10000 10000
05628 06076 08661 23515
$4474 Obstetrics $4830 Obstetrics $6886 Obstetrics
$18694 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
542-1 542-2 542-3 542-4
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC
216 296 614 993
03695 04647 08572 36195
10000 10000 10000 10000
10600 10600 10600 10600
03917 04926 09086 38367
10000 10000 10000 10000
03917 04926 09086 38367
10000 10000 10000 10000
03695 04647 08572 36195
$2938 Obstetrics $3694 Obstetrics $6815 Obstetrics
$28775 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
544-1 544-2 544-3 544-4
DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES
136 200 407 914
04586 05897 09822 25061
10000 10000 10000 10000
10600 10600 10600 10600
04861 06251 10411 26565
10000 10000 10000 10000
04861 06251 10411 26565
10000 10000 10000 10000
04586 05897 09822 25061
$3646 Obstetrics Obstetrics $4688 Obstetrics Obstetrics $7808 Obstetrics Obstetrics
$19924 Obstetrics Obstetrics 545-1 545-2 545-3 545-4
ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE
164 190 265 576
06988 08147 10540 19945
10000 10000 10000 10000
10600 10600 10600 10600
07407 08636 11172 21142
10000 10000 10000 10000
07407 08636 11172 21142
10000 10000 10000 10000
06988 08147 10540 19945
$5555 Obstetrics Obstetrics $6477 Obstetrics Obstetrics $8379 Obstetrics Obstetrics
$15856 Obstetrics Obstetrics 546-1 546-2 546-3 546-4
OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES
285 454 755
1446
05023 07207 13295 43377
10000 10000 10000 10000
10600 10600 10600 10600
05324 07639 14093 45980
10000 10000 10000 10000
05324 07639 14093 45980
10000 10000 10000 10000
05023 07207 13295 43377
$3993 Obstetrics Obstetrics $5730 Obstetrics Obstetrics
$10570 Obstetrics Obstetrics $34485 Obstetrics Obstetrics
560-1 560-2 560-3 560-4
VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY
203 237 385 935
03307 03856 05399 15061
10000 10000 10000 10000
10600 10600 10600 10600
03505 04087 05723 15965
10000 10000 10000 10000
03505 04087 05723 15965
10000 10000 10000 10000
03307 03856 05399 15061
$2629 Obstetrics Obstetrics $3066 Obstetrics Obstetrics $4292 Obstetrics Obstetrics
$11974 Obstetrics Obstetrics 561-1 561-2 561-3 561-4
POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE
211 257 393 688
02511 03908 06071 15617
10000 10000 10000 10000
10600 10600 10600 10600
02662 04142 06435 16554
10000 10000 10000 10000
02662 04142 06435 16554
10000 10000 10000 10000
02511 03908 06071 15617
$1996 Obstetrics Obstetrics $3107 Obstetrics Obstetrics $4826 Obstetrics Obstetrics
$12416 Obstetrics Obstetrics 563-1 563-2 563-3 563-4
THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION
259 391 747 720
02581 03376 05162 09652
10000 10000 10000 10000
10600 10600 10600 10600
02736 03579 05472 10231
10000 10000 10000 10000
02736 03579 05472 10231
10000 10000 10000 10000
02581 03376 05162 09652
$2052 Obstetrics Obstetrics $2684 Obstetrics Obstetrics $4104 Obstetrics Obstetrics $7673 Obstetrics Obstetrics
564-1 564-2 564-3 564-4
ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY
137 170 276 808
02881 03463 04901 16676
10000 10000 10000 10000
10600 10600 10600 10600
03054 03671 05195 17677
10000 10000 10000 10000
03054 03671 05195 17677
10000 10000 10000 10000
02881 03463 04901 16676
$2290 Obstetrics Obstetrics $2753 Obstetrics Obstetrics $3896 Obstetrics Obstetrics
$13257 Obstetrics Obstetrics 565-1 565-2 565-3 565-4
FALSE LABOR FALSE LABOR FALSE LABOR FALSE LABOR
123 185 735 808
01245 01782 02687 02986
10000 10000 10000 10000
10600 10600 10600 10600
01320 01889 02848 03165
10000 10000 10000 10000
01320 01889 02848 03165
10000 10000 10000 10000
01245 01782 02687 02986
$990 Obstetrics Obstetrics $1417 Obstetrics Obstetrics $2136 Obstetrics Obstetrics $2374 Obstetrics Obstetrics
566-1 566-2 566-3 566-4
OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES
211 294 544 843
02442 03252 04790 14726
10000 10000 10000 10000
10600 10600 10600 10600
02589 03447 05077 15610
10000 10000 10000 10000
02589 03447 05077 15610
10000 10000 10000 10000
02442 03252 04790 14726
$1941 Obstetrics Obstetrics $2585 Obstetrics Obstetrics $3808 Obstetrics Obstetrics
$11707 Obstetrics Obstetrics 580-1 580-2 580-3 580-4
NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE
144 159 182 165
02398 03209 05011 08512
12500 12500 12500 12500
10000 10000 10000 10000
02998 04011 06264 10640
10000 10000 10000 10000
02998 04011 06264 10640
17500 17500 17500 17500
04197 05616 08769 14896
$2248 Neonate Neonate $3008 Neonate Neonate $4698 Neonate Neonate $7980 Neonate Neonate
581-1 581-2 581-3 581-4
NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE
124 128 126 135
00982 01477 02362 04408
12500 12500 12500 12500
10000 10000 10000 10000
01228 01846 02953 05510
10000 10000 10000 10000
01228 01846 02953 05510
17500 17500 17500 17500
01719 02585 04134 07714
$921 Neonate Neonate $1385 Neonate Neonate $2214 Neonate Neonate $4133 Neonate Neonate
583-1 583-2 583-3 583-4
NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO
2070 2300 3077 4886
99741 157496 173245 240894
12500 12500 12500 12500
10000 10000 10000 10000
124676 196870 216556 301118
10000 10000 10000 10000
124676 196870 216556 301118
17500 17500 17500 17500
174547 275618 303179 421565
$93507 Neonate Neonate $147653 Neonate Neonate $162417 Neonate Neonate $225838 Neonate Neonate
588-1 588-2 588-3 588-4
NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE
4442 4935 7714
10207
48410 70035
142903 216660
12500 12500 12500 12500
10000 10000 10000 10000
60513 87544
178629 270825
10000 10000 10000 10000
60513 87544
178629 270825
17500 17500 17500 17500
84718 122561 250080 379155
$45384 Neonate Neonate $65658 Neonate Neonate
$133972 Neonate Neonate $203119 Neonate Neonate
589-1 589-2 589-3 589-4
NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS
5843 5041 3035
265
115468 104972
95430 04454
12500 12500 12500 12500
10000 10000 10000 10000
144335 131215 119288
05568
10000 10000 10000 10000
144335 131215 119288
05568
17500 17500 17500 17500
202069 183701 167003
07795
$108251 Neonate Neonate $98411 Neonate Neonate $89466 Neonate Neonate
$4176 Neonate Neonate 591-1 591-2 591-3 591-4
NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE
211 3710 5061 7221
01574 55672 88282
132286
12500 12500 12500 12500
10000 10000 10000 10000
01968 69590
110353 165358
10000 10000 10000 10000
01968 69590
110353 165358
17500 17500 17500 17500
02755 97426
154494 231501
$1476 Neonate Neonate $52193 Neonate Neonate $82764 Neonate Neonate
$124018 Neonate Neonate 593-1 593-2 593-3 593-4
NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE
1928 4851 5965 7143
15109 51914 82800
122454
12500 12500 12500 12500
10000 10000 10000 10000
18886 64893
103500 153068
10000 10000 10000 10000
18886 64893
103500 153068
17500 17500 17500 17500
26441 90850
144900 214295
$14165 Neonate Neonate $48669 Neonate Neonate $77625 Neonate Neonate
$114801 Neonate Neonate 602-1 602-2 602-3 602-4
NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2513 4403 5324 6307
29635 58707 77593
104733
12500 12500 12500 12500
10000 10000 10000 10000
37044 73384 96991
130916
10000 10000 10000 10000
37044 73384 96991
130916
17500 17500 17500 17500
51861 102737 135788 183283
$27783 Neonate Neonate $55038 Neonate Neonate $72743 Neonate Neonate $98187 Neonate Neonate
603-1 603-2 603-3 603-4
NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION
2234 3619 4843 5396
17223 42526 65587 70750
12500 12500 12500 12500
10000 10000 10000 10000
21529 53158 81984 88438
10000 10000 10000 10000
21529 53158 81984 88438
17500 17500 17500 17500
30140 74421
114777 123813
$16147 Neonate Neonate $39868 Neonate Neonate $61488 Neonate Neonate $66328 Neonate Neonate
607-1 607-2 607-3 607-4
NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2509 3582 4341 4957
27503 47486 61883 79508
12500 12500 12500 12500
10000 10000 10000 10000
34379 59358 77354 99385
10000 10000 10000 10000
34379 59358 77354 99385
17500 17500 17500 17500
48130 83101
108295 139139
$25784 Neonate Neonate $44518 Neonate Neonate $58015 Neonate Neonate $74539 Neonate Neonate
608-1 608-2 608-3 608-4
NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION
1980 3004 3846 4414
21292 36047 52684 60424
12500 12500 12500 12500
10000 10000 10000 10000
26615 45059 65855 75530
10000 10000 10000 10000
26615 45059 65855 75530
17500 17500 17500 17500
37261 63082 92197
105742
$19961 Neonate Neonate $33794 Neonate Neonate $49391 Neonate Neonate $56648 Neonate Neonate
609-1 609-2 609-3 609-4
NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE
1933 2210 3803 6267
27332 38628 65636
119134
12500 12500 12500 12500
10000 10000 10000 10000
34165 48285 82045
148918
10000 10000 10000 10000
34165 48285 82045
148918
17500 17500 17500 17500
47831 67599
114863 208485
$25624 Neonate Neonate $36214 Neonate Neonate $61534 Neonate Neonate
$111688 Neonate Neonate 611-1 611-2 611-3 611-4
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY
1313 2123 3133 3614
11780 25158 40556 52442
12500 12500 12500 12500
10000 10000 10000 10000
14725 31448 50695 65553
10000 10000 10000 10000
14725 31448 50695 65553
17500 17500 17500 17500
20615 44027 70973 91774
$11044 Neonate Neonate $23586 Neonate Neonate $38021 Neonate Neonate $49164 Neonate Neonate
612-1 612-2 612-3 612-4
NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND
1756 2442 3248 3834
21880 32223 46803 62297
12500 12500 12500 12500
10000 10000 10000 10000
27350 40279 58504 77871
10000 10000 10000 10000
27350 40279 58504 77871
17500 17500 17500 17500
38290 56390 81905
109020
$20513 Neonate Neonate $30209 Neonate Neonate $43878 Neonate Neonate $58403 Neonate Neonate
613-1 613-2 613-3 613-4
NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION
1439 2153 2853 3338
16593 26831 37601 48828
12500 12500 12500 12500
10000 10000 10000 10000
20741 33539 47001 61035
10000 10000 10000 10000
20741 33539 47001 61035
17500 17500 17500 17500
29038 46954 65802 85449
$15556 Neonate Neonate $25154 Neonate Neonate $35251 Neonate Neonate $45776 Neonate Neonate
614-1 614-2 614-3 614-4
NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION
1123 2008 2852 3640
09241 22768 36403 50802
12500 12500 12500 12500
10000 10000 10000 10000
11551 28460 45504 63503
10000 10000 10000 10000
11551 28460 45504 63503
17500 17500 17500 17500
16172 39844 63705 88904
$8663 Neonate Neonate $21345 Neonate Neonate $34128 Neonate Neonate $47627 Neonate Neonate
621-1 621-2 621-3 621-4
NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY
820 1397 2125 2416
06082 15379 27206 38101
12500 12500 12500 12500
10000 10000 10000 10000
07603 19224 34008 47626
10000 10000 10000 10000
07603 19224 34008 47626
17500 17500 17500 17500
10644 26913 47611 66677
$5702 Neonate Neonate $14418 Neonate Neonate $25506 Neonate Neonate $35720 Neonate Neonate
622-1 622-2 622-3 622-4
NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND
1118 1514 1977 2285
13666 20913 29736 47202
12500 12500 12500 12500
10000 10000 10000 10000
17083 26141 37170 59003
10000 10000 10000 10000
17083 26141 37170 59003
17500 17500 17500 17500
23916 36598 52038 82604
$12812 Neonate Neonate $19606 Neonate Neonate $27878 Neonate Neonate $44252 Neonate Neonate
623-1 623-2 623-3 623-4
NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION
924 1399 1872 2738
09934 16800 25087 38932
12500 12500 12500 12500
10000 10000 10000 10000
12418 21000 31359 48665
10000 10000 10000 10000
12418 21000 31359 48665
17500 17500 17500 17500
17385 29400 43902 68131
$9313 Neonate Neonate $15750 Neonate Neonate $23519 Neonate Neonate $36499 Neonate Neonate
625-1 625-2 625-3 625-4
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION
1157 1621 1925 2015
11469 18627 23298 29194
12500 12500 12500 12500
10000 10000 10000 10000
14336 23284 29123 36493
10000 10000 10000 10000
14336 23284 29123 36493
17500 17500 17500 17500
20071 32597 40772 51090
$10752 Neonate Neonate $17463 Neonate Neonate $21842 Neonate Neonate $27369 Neonate Neonate
626-1 626-2 626-3 626-4
NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
279 456 864
1838
01387 02587 07679 22819
10000 10000 10000 10000
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
$1040 Normal newborn Normal newborn $1940 Normal newborn Normal newborn $5759 Normal newborn Normal newborn
$17114 Normal newborn Normal newborn 630-1 630-2 630-3 630-4
NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE
486 940
1448 3912
20468 32885 52250
112072
12500 12500 12500 12500
10000 10000 10000 10000
25585 41106 65313
140090
10000 10000 10000 10000
25585 41106 65313
140090
17500 17500 17500 17500
35819 57549 91438
196126
$19189 Neonate Neonate $30830 Neonate Neonate $48984 Neonate Neonate
$105068 Neonate Neonate 631-1 631-2 631-3 631-4
NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE
335 886
2279 5111
09217 16766 37480 96324
12500 12500 12500 12500
10000 10000 10000 10000
11521 20958 46850
120405
10000 10000 10000 10000
11521 20958 46850
120405
17500 17500 17500 17500
16130 29341 65590
168567
$8641 Neonate Neonate $15718 Neonate Neonate $35138 Neonate Neonate $90304 Neonate Neonate
633-1 633-2 633-3 633-4
NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY
296 651
1226 2381
01972 05798 13892 39728
12500 12500 12500 12500
10000 10000 10000 10000
02465 07248 17365 49660
10000 10000 10000 10000
02465 07248 17365 49660
17500 17500 17500 17500
03451 10147 24311 69524
$1849 Neonate Neonate $5436 Neonate Neonate
$13024 Neonate Neonate $37245 Neonate Neonate
634-1 634-2 634-3 634-4
NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND
465 749
1261 2233
04886 09445 20176 46934
12500 12500 12500 12500
10000 10000 10000 10000
06108 11806 25220 58668
10000 10000 10000 10000
06108 11806 25220 58668
17500 17500 17500 17500
08551 16529 35308 82135
$4581 Neonate Neonate $8855 Neonate Neonate
$18915 Neonate Neonate $44001 Neonate Neonate
636-1 636-2 636-3 636-4
NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION
558 779
1164 1896
05582 08840 15558 30613
12500 12500 12500 12500
10000 10000 10000 10000
06978 11050 19448 38266
10000 10000 10000 10000
06978 11050 19448 38266
17500 17500 17500 17500
09769 15470 27227 53573
$5233 Neonate Neonate $8288 Neonate Neonate
$14586 Neonate Neonate $28700 Neonate Neonate
639-1 639-2 639-3 639-4
NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION
441 704 998
1653
03287 06622 11809 27285
12500 12500 12500 12500
10000 10000 10000 10000
04109 08278 14761 34106
10000 10000 10000 10000
04109 08278 14761 34106
17500 17500 17500 17500
05752 11589 20666 47749
$3082 Neonate Neonate $6208 Neonate Neonate
$11071 Neonate Neonate $25580 Neonate Neonate
640-1 NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 210 01012 10000 10000 01012 10000 01012 10000 01012 $759 Normal newborn Normal newborn
640-2 640-3 640-4
NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
245 376
1206
01353 02864 14726
10000 10000 10000
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
$1015 Normal newborn Normal newborn $2148 Normal newborn Normal newborn
$11045 Normal newborn Normal newborn 650-1 650-2 650-3 650-4
SPLENECTOMY SPLENECTOMY SPLENECTOMY SPLENECTOMY
348 537 848
1563
12985 17965 25202 50826
10000 10000 10000 10000
10000 10000 10000 10000
12985 17965 25202 50826
12500 12500 12500 12500
16231 22456 31503 63533
10000 10000 10000 10000
12985 17965 25202 50826
$12173 Misc Pediatric Misc Adult $16842 Misc Pediatric Misc Adult $23627 Misc Pediatric Misc Adult $47649 Misc Pediatric Misc Adult
651-1 651-2 651-3 651-4
OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS
331 472 962
2426
09234 13695 21005 59541
10000 10000 10000 10000
10000 10000 10000 10000
09234 13695 21005 59541
12500 12500 12500 12500
11543 17119 26256 74426
10000 10000 10000 10000
09234 13695 21005 59541
$8657 Misc Pediatric Misc Adult $12839 Misc Pediatric Misc Adult $19692 Misc Pediatric Misc Adult $55820 Misc Pediatric Misc Adult
660-1 660-2 660-3 660-4
MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL
305 408 648
1435
05399 07219 11819 30180
10000 10000 10000 10000
10000 10000 10000 10000
05399 07219 11819 30180
12500 12500 12500 12500
06749 09024 14774 37725
10000 10000 10000 10000
05399 07219 11819 30180
$5062 Misc Pediatric Misc Adult $6768 Misc Pediatric Misc Adult
$11080 Misc Pediatric Misc Adult $28294 Misc Pediatric Misc Adult
661-1 661-2 661-3 661-4
COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS
275 375 566
1265
06473 08098 12433 27857
10000 10000 10000 10000
10000 10000 10000 10000
06473 08098 12433 27857
12500 12500 12500 12500
08091 10123 15541 34821
10000 10000 10000 10000
06473 08098 12433 27857
$6068 Misc Pediatric Misc Adult $7592 Misc Pediatric Misc Adult
$11656 Misc Pediatric Misc Adult $26116 Misc Pediatric Misc Adult
662-1 662-2 662-3 662-4
SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS
412 538 785
1302
05044 07003 10778 23937
10000 10000 10000 10000
10000 10000 10000 10000
05044 07003 10778 23937
12500 12500 12500 12500
06305 08754 13473 29921
10000 10000 10000 10000
05044 07003 10778 23937
$4729 Misc Pediatric Misc Adult $6565 Misc Pediatric Misc Adult
$10104 Misc Pediatric Misc Adult $22441 Misc Pediatric Misc Adult
663-1 663-2 663-3 663-4
OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS
232 301 451 900
04474 05959 08513 16106
10000 10000 10000 10000
10000 10000 10000 10000
04474 05959 08513 16106
12500 12500 12500 12500
05593 07449 10641 20133
10000 10000 10000 10000
04474 05959 08513 16106
$4194 Misc Pediatric Misc Adult $5587 Misc Pediatric Misc Adult $7981 Misc Pediatric Misc Adult
$15099 Misc Pediatric Misc Adult 680-1 680-2 680-3 680-4
MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
408 633
1185 2456
13702 18600 32002 66288
10000 10000 10000 10000
10000 10000 10000 10000
13702 18600 32002 66288
12500 12500 12500 12500
17128 23250 40003 82860
10000 10000 10000 10000
13702 18600 32002 66288
$12846 Misc Pediatric Misc Adult $17438 Misc Pediatric Misc Adult $30002 Misc Pediatric Misc Adult $62145 Misc Pediatric Misc Adult
681-1 681-2 681-3 681-4
OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
268 507
1111 2510
09800 13647 24597 59170
10000 10000 10000 10000
10000 10000 10000 10000
09800 13647 24597 59170
12500 12500 12500 12500
12250 17059 30746 73963
10000 10000 10000 10000
09800 13647 24597 59170
$9188 Misc Pediatric Misc Adult $12794 Misc Pediatric Misc Adult $23060 Misc Pediatric Misc Adult $55472 Misc Pediatric Misc Adult
690-1 690-2 690-3 690-4
ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA
495 740
1461 2485
07040 11869 23551 52504
10000 10000 10000 10000
10000 10000 10000 10000
07040 11869 23551 52504
12500 12500 12500 12500
08800 14836 29439 65630
10000 10000 10000 10000
07040 11869 23551 52504
$6600 Misc Pediatric Misc Adult $11127 Misc Pediatric Misc Adult $22079 Misc Pediatric Misc Adult $49223 Misc Pediatric Misc Adult
691-1 691-2 691-3 691-4
LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA
389 540 861
1585
07077 09840 15477 31411
10000 10000 10000 10000
10000 10000 10000 10000
07077 09840 15477 31411
12500 12500 12500 12500
08846 12300 19346 39264
10000 10000 10000 10000
07077 09840 15477 31411
$6635 Misc Pediatric Misc Adult $9225 Misc Pediatric Misc Adult
$14510 Misc Pediatric Misc Adult $29448 Misc Pediatric Misc Adult
692-1 692-2 692-3 692-4
RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY
389 482 868
1580
06075 12584 17422 29316
10000 10000 10000 10000
10000 10000 10000 10000
06075 12584 17422 29316
12500 12500 12500 12500
07594 15730 21778 36645
10000 10000 10000 10000
06075 12584 17422 29316
$5695 Misc Pediatric Misc Adult $11798 Misc Pediatric Misc Adult $16333 Misc Pediatric Misc Adult $27484 Misc Pediatric Misc Adult
693-1 693-2 693-3 693-4
CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY
281 368 785
2410
06251 07881 13637 49083
10000 10000 10000 10000
10000 10000 10000 10000
06251 07881 13637 49083
12500 12500 12500 12500
07814 09851 17046 61354
10000 10000 10000 10000
06251 07881 13637 49083
$5860 Misc Pediatric Misc Adult $7388 Misc Pediatric Misc Adult
$12785 Misc Pediatric Misc Adult $46015 Misc Pediatric Misc Adult
694-1 694-2 694-3 694-4
LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR
304 404 674
1164
04842 06831 11115 21001
10000 10000 10000 10000
10000 10000 10000 10000
04842 06831 11115 21001
12500 12500 12500 12500
06053 08539 13894 26251
10000 10000 10000 10000
04842 06831 11115 21001
$4539 Misc Pediatric Misc Adult $6404 Misc Pediatric Misc Adult
$10420 Misc Pediatric Misc Adult $19688 Misc Pediatric Misc Adult
710-1 710-2 710-3 710-4
INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE
510 680
1111 1820
10635 15963 25572 49382
10000 10000 10000 10000
10000 10000 10000 10000
10635 15963 25572 49382
12500 12500 12500 12500
13294 19954 31965 61728
10000 10000 10000 10000
10635 15963 25572 49382
$9970 Misc Pediatric Misc Adult $14965 Misc Pediatric Misc Adult $23974 Misc Pediatric Misc Adult $46296 Misc Pediatric Misc Adult
711-1 711-2 711-3 711-4
POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE
471 692
1131 2087
10079 14143 23599 50574
10000 10000 10000 10000
10000 10000 10000 10000
10079 14143 23599 50574
12500 12500 12500 12500
12599 17679 29499 63218
10000 10000 10000 10000
10079 14143 23599 50574
$9449 Misc Pediatric Misc Adult $13259 Misc Pediatric Misc Adult $22124 Misc Pediatric Misc Adult $47413 Misc Pediatric Misc Adult
720-1 720-2 720-3 720-4
SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS
353 444 633
1004
05431 07613 11532 21705
10000 10000 10000 10000
10000 10000 10000 10000
05431 07613 11532 21705
12500 12500 12500 12500
06789 09516 14415 27131
10000 10000 10000 10000
05431 07613 11532 21705
$5092 Misc Pediatric Misc Adult $7137 Misc Pediatric Misc Adult
$10811 Misc Pediatric Misc Adult $20348 Misc Pediatric Misc Adult
721-1 721-2 721-3 721-4
POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS
368 470 705
1153
05287 07209 11619 22025
10000 10000 10000 10000
10000 10000 10000 10000
05287 07209 11619 22025
12500 12500 12500 12500
06609 09011 14524 27531
10000 10000 10000 10000
05287 07209 11619 22025
$4957 Misc Pediatric Misc Adult $6758 Misc Pediatric Misc Adult
$10893 Misc Pediatric Misc Adult $20648 Misc Pediatric Misc Adult
722-1 722-2 722-3 722-4
FEVER FEVER FEVER FEVER
230 302 429 739
03423 05223 07630 13141
10000 10000 10000 10000
10000 10000 10000 10000
03423 05223 07630 13141
12500 12500 12500 12500
04279 06529 09538 16426
10000 10000 10000 10000
03423 05223 07630 13141
$3209 Misc Pediatric Misc Adult $4897 Misc Pediatric Misc Adult $7153 Misc Pediatric Misc Adult
$12320 Misc Pediatric Misc Adult 723-1 723-2 723-3 723-4
VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS
216 279 470
1317
03194 04738 07794 24233
10000 10000 10000 10000
10000 10000 10000 10000
03194 04738 07794 24233
12500 12500 12500 12500
03993 05923 09743 30291
10000 10000 10000 10000
03194 04738 07794 24233
$2994 Misc Pediatric Misc Adult $4442 Misc Pediatric Misc Adult $7307 Misc Pediatric Misc Adult
$22718 Misc Pediatric Misc Adult 724-1 724-2 724-3 724-4
OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES
400 477 680
1337
05512 07131 11401 24698
10000 10000 10000 10000
10000 10000 10000 10000
05512 07131 11401 24698
12500 12500 12500 12500
06890 08914 14251 30873
10000 10000 10000 10000
05512 07131 11401 24698
$5168 Misc Pediatric Misc Adult $6685 Misc Pediatric Misc Adult
$10688 Misc Pediatric Misc Adult $23154 Misc Pediatric Misc Adult
740-1 740-2 740-3 740-4
MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE
678 1284 2034 2421
10899 13904 24356 37756
10000 10000 10000 10000
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
$8174 Other Other $10428 Other Other $18267 Other Other $28317 Other Other
750-1 750-2 750-3 750-4
SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA
1082 1179 1539 2848
05713 06699 09202 19283
10000 10000 10000 10000
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
$4285 Other Other $5024 Other Other $6902 Other Other
$14462 Other Other 751-1 751-2 751-3 751-4
MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES
528 724
1055 2028
03572 05019 08097 15923
10000 10000 10000 10000
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
$2679 Other Other $3764 Other Other $6073 Other Other
$11942 Other Other 752-1 752-2 752-3 752-4
DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL
503 658
1473 7300
03399 04498 09061 14934
10000 10000 10000 10000
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
$2549 Other Other $3374 Other Other $6796 Other Other
$11201 Other Other 753-1 753-2 753-3 753-4
BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS
601 808
1205 1948
04001 05365 08266 14926
10000 10000 10000 10000
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
$3001 Other Other $4024 Other Other $6200 Other Other
$11195 Other Other 754-1 754-2 754-3 754-4
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER
424 558 727
1664
02943 03998 05677 11553
10000 10000 10000 10000
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
$2207 Other Other $2999 Other Other $4258 Other Other $8665 Other Other
755-1 755-2 755-3 755-4
ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
388 622 900 813
02738 04363 06226 08767
10000 10000 10000 10000
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
$2054 Other Other $3272 Other Other $4670 Other Other $6575 Other Other
756-1 756-2 756-3 756-4
ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES
331 381 457 942
04061 05308 06065 13981
10000 10000 10000 10000
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
$3046 Other Other $3981 Other Other $4549 Other Other
$10486 Other Other 757-1 757-2 757-3 757-4
ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES
873 934
1087 1640
05861 07234 08953 13799
10000 10000 10000 10000
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
$4396 Other Other $5426 Other Other $6715 Other Other
$10349 Other Other 758-1 758-2 758-3 758-4
CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS
694 981
1225 4300
03874 05129 06541 11332
10000 10000 10000 10000
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
$2906 Other Other $3847 Other Other $4906 Other Other $8499 Other Other
759-1 759-2 759-3 759-4
EATING DISORDERS EATING DISORDERS EATING DISORDERS EATING DISORDERS
1990 1297 1402 2303
06561 06961 10053 16606
10000 10000 10000 10000
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
$4921 Other Other $5221 Other Other $7540 Other Other
$12455 Other Other 760-1 760-2 760-3 760-4
OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS
748 766 912
1204
04840 06173 07573 14134
10000 10000 10000 10000
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
$3630 Other Other $4630 Other Other $5680 Other Other
$10601 Other Other 770-1 770-2 770-3 770-4
DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE
253 248 332 794
02240 02623 05475 16843
10000 10000 10000 10000
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
$1680 Other Other $1967 Other Other $4106 Other Other
$12632 Other Other 772-1 772-2 772-3 772-4
ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY
1434 1551 1289 2385
05441 06916 07009 24530
10000 10000 10000 10000
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
$4081 Other Other $5187 Other Other $5257 Other Other
$18398 Other Other 773-1 773-2 773-3 773-4
OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE
337 414 507 992
02663 03466 05964 18606
10000 10000 10000 10000
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
$1997 Other Other $2600 Other Other $4473 Other Other
$13955 Other Other 774-1 774-2
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
365 412
03040 03627
10000 10000
10000 10000
03040 03627
10000 10000
03040 03627
10000 10000
03040 03627
$2280 Other Other $2720 Other Other
774-3 774-4
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
479 1424
06448 24682
10000 10000
10000 10000
06448 24682
10000 10000
06448 24682
10000 10000
06448 24682
$4836 Other $18512 Other
Other Other
775-1 775-2 775-3 775-4
ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE
323 377 571
1263
03313 04639 08596 24910
10000 10000 10000 10000
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
$2485 Other $3479 Other $6447 Other
$18683 Other
Other Other Other Other
776-1 776-2 776-3 776-4
OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE
389 397 496 933
03157 04547 07887 16112
10000 10000 10000 10000
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
$2368 Other $3410 Other $5915 Other
$12084 Other
Other Other Other Other
791-1 791-2 791-3 791-4
OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT
314 515 989
2009
08636 12677 21979 49312
10000 10000 10000 10000
10000 10000 10000 10000
08636 12677 21979 49312
12500 12500 12500 12500
10795 15846 27474 61640
10000 10000 10000 10000
08636 12677 21979 49312
$8096 Misc Pediatric $11885 Misc Pediatric $20605 Misc Pediatric $46230 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
811-1 811-2 811-3 811-4
ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS
151 202 390 913
02707 03855 08277 22176
10000 10000 10000 10000
10000 10000 10000 10000
02707 03855 08277 22176
12500 12500 12500 12500
03384 04819 10346 27720
10000 10000 10000 10000
02707 03855 08277 22176
$2538 Misc Pediatric $3614 Misc Pediatric $7760 Misc Pediatric
$20790 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
812-1 812-2 812-3 812-4
POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS
165 225 347 694
03469 04331 07709 17419
10000 10000 10000 10000
10000 10000 10000 10000
03469 04331 07709 17419
12500 12500 12500 12500
04336 05414 09636 21774
10000 10000 10000 10000
03469 04331 07709 17419
$3252 Misc Pediatric $4060 Misc Pediatric $7227 Misc Pediatric
$16330 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
813-1 813-2 813-3 813-4
OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT
261 344 594
1344
04393 06056 09631 19960
10000 10000 10000 10000
10000 10000 10000 10000
04393 06056 09631 19960
12500 12500 12500 12500
05491 07570 12039 24950
10000 10000 10000 10000
04393 06056 09631 19960
$4118 Misc Pediatric $5678 Misc Pediatric $9029 Misc Pediatric
$18713 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
815-1 815-2 815-3 815-4
OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES
169 276 456 880
04211 05012 08129 22715
10000 10000 10000 10000
10000 10000 10000 10000
04211 05012 08129 22715
12500 12500 12500 12500
05264 06265 10161 28394
10000 10000 10000 10000
04211 05012 08129 22715
$3948 Misc Pediatric $4699 Misc Pediatric $7621 Misc Pediatric
$21295 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
816-1 816-2 816-3 816-4
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
173 240 346 736
04162 04915 07864 18134
10000 10000 10000 10000
10000 10000 10000 10000
04162 04915 07864 18134
12500 12500 12500 12500
05203 06144 09830 22668
10000 10000 10000 10000
04162 04915 07864 18134
$3902 Misc Pediatric $4608 Misc Pediatric $7373 Misc Pediatric
$17001 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
841-1 841-2 841-3 841-4
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT
2200 967
2599 4068
31148 34263 64068
159153
10000 10000 10000 10000
10000 10000 10000 10000
31148 34263 64068
159153
12500 12500 12500 12500
38935 42829 80085
198941
10000 10000 10000 10000
31148 34263 64068
159153
$29201 Misc Pediatric $32122 Misc Pediatric $60064 Misc Pediatric
$149206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
842-1 842-2 842-3 842-4
FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT
751 1072 1735 3010
14151 21416 38719 95054
10000 10000 10000 10000
10000 10000 10000 10000
14151 21416 38719 95054
12500 12500 12500 12500
17689 26770 48399
118818
10000 10000 10000 10000
14151 21416 38719 95054
$13267 Misc Pediatric $20078 Misc Pediatric $36299 Misc Pediatric $89113 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
843-1 843-2 843-3 843-4
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT
339 487 713
1113
04752 06661 11619 32621
10000 10000 10000 10000
10000 10000 10000 10000
04752 06661 11619 32621
12500 12500 12500 12500
05940 08326 14524 40776
10000 10000 10000 10000
04752 06661 11619 32621
$4455 Misc Pediatric $6245 Misc Pediatric
$10893 Misc Pediatric $30582 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
844-1 844-2 844-3 844-4
PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT
310 497 743
1781
04337 06965 12193 48021
10000 10000 10000 10000
10000 10000 10000 10000
04337 06965 12193 48021
12500 12500 12500 12500
05421 08706 15241 60026
10000 10000 10000 10000
04337 06965 12193 48021
$4066 Misc Pediatric $6530 Misc Pediatric
$11431 Misc Pediatric $45020 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
850-1 850-2 850-3 850-4
PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE
267 556
1618 3148
11757 14065 24870 46520
10000 10000 10000 10000
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
$8818 Misc Pediatric $10549 Misc Pediatric $18653 Misc Pediatric $34890 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
860-1 860-2 860-3 860-4
REHABILITATION REHABILITATION REHABILITATION REHABILITATION
932 1146 1475 1795
07227 09855 13880 17876
10000 10000 10000 10000
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
$5420 Other $7391 Other
$10410 Other $13407 Other
Other Other Other Other
861-1 861-2 861-3 861-4
SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS
253 340 497 917
02858 05247 07658 14498
10000 10000 10000 10000
10000 10000 10000 10000
02858 05247 07658 14498
12500 12500 12500 12500
03573 06559 09573 18123
10000 10000 10000 10000
02858 05247 07658 14498
$2679 Misc Pediatric $4919 Misc Pediatric $7179 Misc Pediatric
$13592 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
862-1 862-2 862-3 862-4
OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE
698 1122 1357 1872
02895 05851 07866 11351
10000 10000 10000 10000
10000 10000 10000 10000
02895 05851 07866 11351
12500 12500 12500 12500
03619 07314 09833 14189
10000 10000 10000 10000
02895 05851 07866 11351
$2714 Misc Pediatric $5485 Misc Pediatric $7374 Misc Pediatric
$10642 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
863-1 863-2 863-3 863-4
NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE
853 1757 2771 4643
05959 16127 30507 61446
12500 12500 12500 12500
10000 10000 10000 10000
07449 20159 38134 76808
10000 10000 10000 10000
07449 20159 38134 76808
17500 17500 17500 17500
10428 28222 53387
107531
$5587 Neonate $15119 Neonate $28600 Neonate $57606 Neonate
Neonate Neonate Neonate Neonate
890-1 890-2 890-3 890-4
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS
167 691 921
1514
07051 10224 14771 30014
10000 10000 10000 10000
10000 10000 10000 10000
07051 10224 14771 30014
12500 12500 12500 12500
08814 12780 18464 37518
10000 10000 10000 10000
07051 10224 14771 30014
$6610 Misc Pediatric $9585 Misc Pediatric
$13848 Misc Pediatric $28138 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
892-1 892-2 892-3 892-4
HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION
587 488 669
1152
05647 07763 10877 19375
10000 10000 10000 10000
10000 10000 10000 10000
05647 07763 10877 19375
12500 12500 12500 12500
07059 09704 13596 24219
10000 10000 10000 10000
05647 07763 10877 19375
$5294 Misc Pediatric $7278 Misc Pediatric
$10197 Misc Pediatric $18164 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
893-1 893-2 893-3 893-4
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
499 496 799
1422
07762 08219 12807 24296
10000 10000 10000 10000
10000 10000 10000 10000
07762 08219 12807 24296
12500 12500 12500 12500
09703 10274 16009 30370
10000 10000 10000 10000
07762 08219 12807 24296
$7277 Misc Pediatric $7705 Misc Pediatric
$12007 Misc Pediatric $22778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
894-1 894-2 894-3 894-4
HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND
341 393 627
1121
05218 06497 09774 19428
10000 10000 10000 10000
10000 10000 10000 10000
05218 06497 09774 19428
12500 12500 12500 12500
06523 08121 12218 24285
10000 10000 10000 10000
05218 06497 09774 19428
$4892 Misc Pediatric $6091 Misc Pediatric $9163 Misc Pediatric
$18214 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
910-1 910-2 910-3 910-4
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA
1100 775
1057 1830
28786 31984 41628 72114
10000 10000 10000 10000
10000 10000 10000 10000
28786 31984 41628 72114
12500 12500 12500 12500
35983 39980 52035 90143
10000 10000 10000 10000
28786 31984 41628 72114
$26987 Misc Pediatric $29985 Misc Pediatric $39026 Misc Pediatric $67607 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
911-1 911-2 911-3 911-4
EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA
511 619 795
1687
15160 20189 26724 58039
10000 10000 10000 10000
10000 10000 10000 10000
15160 20189 26724 58039
12500 12500 12500 12500
18950 25236 33405 72549
10000 10000 10000 10000
15160 20189 26724 58039
$14213 Misc Pediatric $18927 Misc Pediatric $25054 Misc Pediatric $54412 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
912-1 912-2 912-3 912-4
MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
558 607 985
1782
20950 22759 36410 68885
10000 10000 10000 10000
10000 10000 10000 10000
20950 22759 36410 68885
12500 12500 12500 12500
26188 28449 45513 86106
10000 10000 10000 10000
20950 22759 36410 68885
$19641 Misc Pediatric $21337 Misc Pediatric $34134 Misc Pediatric $64580 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
930-1 930-2 930-3 930-4
MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE
322 370 596
1127
07826 09594 15857 33896
10000 10000 10000 10000
10000 10000 10000 10000
07826 09594 15857 33896
12500 12500 12500 12500
09783 11993 19821 42370
10000 10000 10000 10000
07826 09594 15857 33896
$7337 Misc Pediatric $8994 Misc Pediatric
$14866 Misc Pediatric $31778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
950-1 950-2 950-3 950-4
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
361 623
1166 2260
13230 20029 31827 60092
10000 10000 10000 10000
10000 10000 10000 10000
13230 20029 31827 60092
12500 12500 12500 12500
16538 25036 39784 75115
10000 10000 10000 10000
13230 20029 31827 60092
$12403 Misc Pediatric $18777 Misc Pediatric $29838 Misc Pediatric $56336 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
951-1 951-2 951-3 951-4
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
329 517
1001 1973
09755 14320 24054 46875
10000 10000 10000 10000
10000 10000 10000 10000
09755 14320 24054 46875
12500 12500 12500 12500
12194 17900 30068 58594
10000 10000 10000 10000
09755 14320 24054 46875
$9145 Misc Pediatric $13425 Misc Pediatric $22551 Misc Pediatric $43945 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
952-1 952-2 952-3 952-4
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
274 504 968
1894
07736 11591 20369 39177
10000 10000 10000 10000
10000 10000 10000 10000
07736 11591 20369 39177
12500 12500 12500 12500
09670 14489 25461 48971
10000 10000 10000 10000
07736 11591 20369 39177
$7253 Misc Pediatric $10867 Misc Pediatric $19096 Misc Pediatric $36728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
955-0 956-0
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS UNGROUPABLE
--
--
Error DRG Error DRG
Error DRG Error DRG
i-
i
i
i-
i
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy adjustor F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that has at least a basic level
emergency room H FY 2015-16 Cost-to-Charge Ratio FY 2013 cost-to-charge ratio with some exceptions I FY 2015-16 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FY 2015-16 Wage Index Value (adjusted for CA Neutrality Factor 09797) W age index value times 09797 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls for changes between California
and the rest of the US while maintaining relative differences among wage areas within California K FY 2015-16 Unadjusted Statewide Base Rate The statewide DRG base rate is $6289 except that for remote rural hospitals it is $12768 L FY 2015-16 Wage Adjusted Statewide Base Rate (Non-Transition) The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses See Tab 5 This rate is applicable for non-transition hospitals as shown in Column N Medi-Cal
managed care plans that are pricing claims for emergency and post-stabilization services hospitals outside their network should use Column L for all hospitals M FY 2015-16 Hospital-Specific Transition Base Rate The base rate assigned to hospitals to move them in steps toward the statewide base rate This rate is applicable for transition hospitals as shown in Column N FY 2015-16 is the final year of transition rates N Transition rate This column identifies whether the hospital is a non-transition hospital (base rate in Column L) or a transition hospital (base rate in Column M) O FY 2015-16 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2015-16 P FY 2015-16 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by
use of Revenue Code 190 Q FY 2015-16 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by use of
Revenue Code 199
A B C D E F G H I J K L M N O P Q
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transit on Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
OUT OF STATE No No No No No 2180 10000 10000 $6289 $6289 NA Non-Transition NA $98163 $80582 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 3572 12882 12620 $12768 $15097 $15414 Transition NA $98163 $80582 106100793 ADVENTIST MEDICAL CENTER - SELMA COMMUNITY HOSPITAL No No No Yes Yes 3572 12882 12620 $12768 $15097 $14680 Transition NA $98163 $80582 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 4360 12882 12620 $12768 $15097 $10484 Transition NA $98163 $80582 106301098 AHMC ANAHEIM REG MED CTR No No No No No 1656 12882 12620 $6289 $7436 $15144 Transition NA $98163 $80582 106010846 ALAMEDA CO MED CTR Yes No No No No 4036 16962 16618 $6289 $9186 NA NA NA NA NA 106010735 ALAMEDA HOSP No Yes No No No 2600 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106190017 ALHAMBRA HOSP No No No No No 1397 12882 12620 $6289 $7436 $5446 Transition $1220 $98163 $80582 106010739 ALTA BATES SUMMIT MED CTR-ALTA BATES No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106010937 ALTA BATES SUMMIT MED CTR-HAWTHORNE No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106010844 ALTA BATES SUMMIT MED CTR-HERRICK CAMPUS No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106013626 ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106374063 ALVARADO HOSP MED CTR - REHAB No No No No No 1930 12882 12620 $6289 $7436 $4599 Transition $1220 $98163 $80582 106190034 ANTELOPE VALLEY HOSP MED CTR No Yes No No No 2997 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364231 ARROWHEAD REG MED CTR Yes No No No No 3324 12882 12620 $6289 $7436 NA NA NA NA NA 106400466 ARROYO GRANDE COMM HOSP No No No No No 2581 12964 12701 $6289 $7471 NA Non-Transition $1226 $98163 $80582 106154101 BAKERSFIELD HEART HOSP No No No No No 1782 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150722 BAKERSFIELD MEM HOSP-34TH ST No No No No No 2117 12882 12620 $6289 $7436 $9141 Transition NA $98163 $80582 106364121 BALLARD REHABILITATION HOSP No No No No No 8300 12882 12620 NA NA NA NA $1427 $98163 $80582 106184008 BANNER LASSEN MED CTR No No No Yes Yes 3967 12882 12620 $12768 $15097 $18668 Transition NA $98163 $80582 106190052 BARLOW RESP HOSP No No No No No 1849 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364430 BARSTOW COMM HOSP No No No Yes Yes 2262 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090793 BARTON MEM HOSP No No No Yes Yes 3635 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106361110 BEAR VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190081 BEVERLY HOSP No No No No No 3567 12882 12620 $6289 $7436 $5841 Transition NA $98163 $80582 106040802 BIGGS GRIDLEY MEM HOSP No No No Yes Yes 3652 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106380929 CA PACIFIC MED CTR No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380777 CA PACIFIC MED CTR - CALIFORNIA WEST No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380933 CA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 2873 16738 16398 $6289 $9090 NA Non-Transition $1492 $98163 $80582 106190125 CALIFORNIA HOSP MED CTR-LA No No Yes No No 2078 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190137 CASA COLINA HOSP FOR REHAB MED No No No No No 7213 12882 12620 NA NA NA NA $1220 $98163 $80582 106190045 CATALINA ISLAND MED CTR No No No Yes Yes 9000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190555 CEDARS-SINAI MED CTR No No Yes No No 2051 12882 12620 $6289 $7436 $5837 Transition $1220 $98163 $80582 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 1730 12882 12620 $6289 $7436 $6350 Transition $1220 $98163 $80582 106160787 CENTRAL VALLEY GEN HOSP No No No No No 7778 12882 12620 $6289 $7436 $11888 Transition NA $98163 $80582 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 2190 12892 12630 $6289 $7440 NA Non-Transition $1221 $98163 $80582 106301140 CHAPMAN MED CTR No No No No No 1908 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304113 CHILDRENS HOSP AT MISSION No No No No No 3300 12882 12620 $6289 $7436 $18777 Transition NA $98163 $80582 106204019 CHILDRENS HOSP CENTRAL CALIFORNIA No No Yes No No 2430 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106010776 CHILDRENS HOSP OAKLAND No No Yes No No 3356 16478 16143 $6289 $8978 NA Non-Transition $2628 $98163 $80582 106190170 CHILDRENS HOSP OF LA No No Yes No No 3988 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106300032 CHILDRENS HOSP OF ORANGE CO No No Yes No No 2442 12882 12620 $6289 $7436 $5613 Transition NA $98163 $80582 106382715 CHINESE HOSP No No No No No 3835 16738 16398 $6289 $9090 $8053 Transition NA $98163 $80582 106361144 CHINO VALLEY MED CTR No No No No No 2098 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190176 CITY OF HOPE HELFORD CLINIC RES HOSP No No No No No 2789 12882 12620 $6289 $7436 $5941 Transition NA $98163 $80582 106100005 CLOVIS COMM MED CTR No No No No No 3336 12882 12620 $6289 $7436 $7752 Transition NA $98163 $80582 106100697 COALINGA REG MED CTR No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190766 COAST PLAZA DRS HOSP No No No No No 2126 12882 12620 $6289 $7436 $5303 Transition NA $98163 $80582 106301258 COASTAL COMM HOSP No No No No No 2792 12882 12620 $6289 $7436 $7035 Transition NA $98163 $80496 106301155 COLLEGE HOSP COSTA MESA No No No No No 2876 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190587 COLLEGE MEDICAL CENTER No No No No No 3760 12882 12620 $6289 $7436 $4258 Transition NA $98163 $80582 106361458 COLORADO RIVER MED CTR No No No Yes Yes 4357 12882 12620 $12768 $15097 $18541 Transition NA $98163 $80582 106060870 COLUSA REG MED CTR No No No Yes Yes 3066 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190197 COMM AND MISSION HOSP OF HUNT PK No No No No No 1601 12882 12620 $6289 $7436 $5421 Transition NA $98163 $80582 106190475 COMM HOSP OF LONG BEACH No No No No No 1707 12882 12620 $6289 $7436 $15917 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106361323 COMM HOSP OF SAN BERNARDINO No No No No No 2833 12882 12620 $6289 $7436 $6516 Transition NA $98163 $78406 106560473 COMM MEM HOSP OF SAN BUENAVENTURA No No No No No 2104 12882 12620 $6289 $7436 $4512 Transition NA $98163 $80582 106100717 COMM REG MED CTR-FRESNO No No No No No 1896 12882 12620 $6289 $7436 $7994 Transition $1655 $98163 $80582 106070924 CONTRA COSTA REG MED CTR Yes No No No No 6010 16478 16143 $6289 $8978 NA NA NA NA NA 106331152 CORONA REG MED CTR No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition NA $98163 $80582 106331145 CORONA REG MED CTR - MAGNOLIA No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition $1220 $98163 $80582 106190413 CV-INTERCOMMUNITY CAMPUS No No No No No 3136 12882 12620 $6289 $7436 $6821 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106190636 CV-QUEEN OF VALLEY CAMPUS No No Yes No No 3136 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106150706 DELANO REG MED CTR No No No No No 3622 12882 12620 $6289 $7436 $7087 Transition NA $98163 $80582 106331164 DESERT REG MED CTR No No No No No 1486 12882 12620 $6289 $7436 $7153 Transition $1447 $98163 $80582 106364144 DESERT VALLEY HOSP No No No No No 2050 12882 12620 $6289 $7436 $8173 Transition NA $98163 $80582 106440755 DOMINICAN HOSP-SANTA CRUZ No No No No No 2016 17239 16889 $6289 $9304 $7821 Transition $1527 $98163 $80582 106190243 DOWNEY REG MED CTR No No No No No 1732 12882 12620 $6289 $7436 $6847 Transition NA $98163 $80582 106392287 DRS HOSP OF MANTECA No No No No No 1362 13579 13303 $6289 $7735 $11712 Transition NA $98163 $80582 106390846 DAMERON HOSP No No No No No 2138 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106190857 DRS HOSP OF WEST COVINA No No No No No 1833 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106070904 DRS MED CTR-SAN PABLOPINOLE No Yes No No No 2373 16478 16143 $6289 $8978 $6025 Transition NA $98163 $80582 106190256 EAST LA DRS HOSP No No No No No 1952 12882 12620 $6289 $7436 $5809 Transition NA $98163 $80582 106190328 EAST VALLEY HOSP MED CTR No No No No No 2859 12882 12620 $6289 $7436 $5534 Transition NA $98163 $80582 106320859 EASTERN PLUMAS HOSP No Yes No Yes Yes 4802 12882 12620 $12768 $15097 $13674 Transition NA $98163 $80582 106014233 EDEN MED CTR No No No No No 3197 16962 16618 $6289 $9186 $12768 Transition NA $98163 $80582 106331168 EISENHOWER MEM HOSP No No No No No 1540 12882 12620 $6289 $7436 $10211 Transition NA $98163 $80582 106430763 EL CAMINO HOSP No Yes No No No 2857 17180 16831 $6289 $9279 $5377 Transition $1523 $98163 $80582 106130699 EL CENTRO COMM HOSP No Yes No No No 2298 12882 12620 $6289 $7436 $8949 Transition NA $98163 $80582 106500852 DRS MED CTR No No No No No 1181 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106500867 EMANUEL MED CTR No No No No No 2046 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106040962 ENLOE MED CTR No No No No No 2436 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106044011 ENLOE REHABILLITATION CENTER No No No No No 2463 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106474007 FAIRCHILD MED CTR No No No Yes Yes 3914 12882 12620 $12768 $15097 $16385 Transition NA $98163 $80582 106040875 FEATHER RIVER HOSP No No No No No 1240 12882 12620 $6289 $7436 $10796 Transition NA $98163 $80582 106190298 FOOTHILL PRES HOSP No No No No No 2989 12882 12620 $6289 $7436 $4740 Transition NA $98163 $80582 106301175 FOUNTAIN VALLEY REG HOSP-EUCLID No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106304039 FOUNTAIN VALLEY REG HOSP-WARNER No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106230949 FRANK R HOWARD MEM HOSP No No No Yes Yes 3495 12882 12620 $12768 $15097 $15377 Transition NA $98163 $80582 106510882 FREMONT MEDICAL CENTER No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106190280 ENCINO HOSP MED CTR No No No No No 949 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106400480 FRENCH HOSP MED CTR No No No No No 2241 12964 12701 $6289 $7471 NA Non-Transition NA $98163 $80582 106301283 GARDEN GROVE HOSP AND MED CTR No No No No No 2661 12882 12620 $6289 $7436 $5749 Transition NA $98163 $80582 106190159 GARDEN REG HOSP AND MED CTR No No No No No 2937 12882 12620 $6289 $7436 $4110 Transition NA $98163 $80582 106105029 FRESNO HEART HOSP No No No No No 3403 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106270777 GEORGE L MEE MEM HOSP No No No Yes Yes 3562 15558 15242 $12768 $17426 $20386 Transition NA $98163 $80582 106190315 GARFIELD MED CTR No No No No No 1031 12882 12620 $6289 $7436 NA Non-Transition $1394 $98163 $80582 106190522 GLENDALE MEM HOSP AND HLTH CTR No No No No No 2163 12882 12620 $6289 $7436 $6885 Transition $1220 $98163 $80582 106110889 GLENN MED CTR No No No Yes Yes 6660 12882 12620 $12768 $15097 $21024 Transition NA $98163 $80582 106190323 GLENDALE ADV MED CTR-WILSON TERRACE No No No No No 1845 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420483 GOLETA VALLEY COTTAGE HOSP No No No No No 3083 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150775 GOOD SAMARITAN HOSP-BAKERSFIELD No No No No No 3694 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430779 GOOD SAMARITAN HOSP-SAN JOSE No No Yes No No 1937 17180 16831 $6289 $9279 $5654 Transition NA $98163 $80582 106190352 GREATER EL MONTE COMM HOSP No No No No No 1088 12882 12620 $6289 $7436 $4818 Transition NA $98163 $80582 106370714 GROSSMONT HOSP No No No No No 1937 12882 12620 $6289 $7436 $6498 Transition $1220 $98163 $80582
i-
i
i
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190392 GOOD SAMARITAN HOSP-LA No No Yes No No 2006 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106350784 HAZEL HAWKINS MEM HOSP No Yes No Yes Yes 3840 17180 16831 $12768 $18839 NA Non-Transition NA $98163 $80582 106490964 HEALDSBURG DIST HOSP No Yes No Yes Yes 6549 16188 15859 $12768 $17975 NA Non-Transition NA $98163 $80582 106154022 HEALTHSOUTH BAKERSFIELD REHAB HOSP No No No No No 5040 12882 12620 NA NA NA NA $1382 $98163 $80582 106304079 HEALTHSOUTH TUSTIN REHAB HOSP No No No No No 5281 12882 12620 NA NA NA NA $1220 $98163 $80582 106331194 HEMET VALLEY MED CTR No No No No No 1267 12882 12620 $6289 $7436 $5912 Transition NA $98163 $80582 106190949 HENRY MAYO NEWHALL MEM HOSP No No No No No 1839 12882 12620 $6289 $7436 $5631 Transition $1220 $98163 $80582 106362041 HI-DESERT MED CTR No Yes No Yes Yes 2909 12882 12620 $12768 $15097 $13297 Transition NA $98163 $80582 106301205 HOAG MEM HOSP PRESBYTERIAN No No No No No 4825 12882 12620 $6289 $7436 $13525 Transition NA $98163 $80582 106304159 HEALTHBRIDGE CHILDRENS HOSP-ORANGE No No No No No 3271 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106190380 HOLLYWOOD COMM HOSP OF HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106304460 HOAG ORTHOPEDIC No No No No No 4894 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190382 HOLLYWOOD PRES MED CTR No No No No No 2212 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301209 HUNTINGTON BEACH HOSP No No No No No 2175 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190400 HUNTINGTON MEM HOSP No No Yes No No 2294 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106304045 IRVINE REG HOSP AND MED CTR No No No No No 200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106220733 JOHN C FREMONT HCARE DIST No Yes No Yes Yes 3884 12882 12620 $12768 $15097 $8195 Transition NA $98163 $80582 106331216 JOHN F KENNEDY MEM HOSP No No No No No 1679 12882 12620 $6289 $7436 $6464 Transition NA $98163 $80582 106071018 JOHN MUIR MED CTR-CONCORD CAMPUS No No No No No 1748 16478 16143 $6289 $8978 $12804 Transition NA $98163 $80582 106070988 JOHN MUIR MED CTR-WALNUT CREEK CAMPUS No No No No No 2039 16478 16143 $6289 $8978 $10615 Transition $1473 $98163 $80582 106314024 KAISER HOSPITAL - ROSEVILLE No No Yes No No 7912 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106364265 KAISER ONTARIO MEDICAL CENTER CAMPUS No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106121031 JEROLD PHELPS COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301132 KAISER-ANAHEIM No No Yes No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304306 KAISER-ANAHEIM-IRVINE No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304409 KAISER-ANAHEIM-Orange No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106074097 KAISER-ANTIOCH No No No No No 8503 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106196403 KAISER-DOWNEY No No No No No 10000 12882 12620 $6289 $7436 $12698 Transition NA $98163 $80582 106361223 KAISER-FONTANA No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106014132 KAISER-FREMONT No No No No No 10000 16962 16618 $6289 $9186 $9639 Transition NA $98163 $80582 106196035 KAISER-BALDWIN PARK No No No No No 8009 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106104062 KAISER-FRESNO No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190429 KAISER-LOS ANGELES No No No No No 7387 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106394009 KAISER-MANTECA No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106334048 KAISER-MORENO VALLEY No No No No No 6614 12882 12620 $6289 $7436 $4790 Transition NA $98163 $80582 106010856 KAISER-OAKLANDRICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106190432 KAISER-PANORAMA CITY No No No No No 8239 12882 12620 $6289 $7436 $16025 Transition NA $98163 $80582 106504042 KAISER-MODESTO No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106410804 KAISER-REDWOOD CITY No No No No No 7731 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106074093 KAISER-RICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106480989 KAISER-REHAB CENTER VALLEJO No No No No No 8442 16315 15984 $6289 $8908 NA Non-Transition $2535 $98163 $80582 106340913 KAISER-SACRAMENTO No No No No No 5612 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106334025 KAISER-RIVERSIDE No No No No No 5865 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370730 KAISER-SAN DIEGO No No No No No 7393 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106380857 KAISER-SAN FRANCISCO No No No No No 5960 16738 16398 $6289 $9090 NA Non-Transition NA $98163 $80582 106431506 KAISER-SAN JOSE No No No No No 7002 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106014337 KAISER-SAN LEANDRO No No No No No 2180 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106210992 KAISER-SAN RAFAEL No No No No No 4673 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106494019 KAISER-SANTA ROSA No No No No No 10000 16315 15984 $6289 $8908 $17627 Transition NA $98163 $80582 106434153 KAISER-SANTA CLARA No No No No No 6107 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106190431 KAISER-SOUTH BAY No No No No No 6935 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106342344 KAISER-SOUTH SACRAMENTO No No No No No 5670 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106410806 KAISER-SOUTH SF No No No No No 6503 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106484044 KAISER-VACAVILLE No No No No No 10000 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106070990 KAISER-WALNUT CREEK No No No No No 5680 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106190434 KAISER-WEST LA No No No No No 6623 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106194219 KECK HOSPITAL OF USC No No No No No 2004 12882 12620 $6289 $7436 $4699 Transition $1220 $98163 $80582 106210993 KENTFIELD REHAB HOSP No No No No No 5967 16855 16513 $6289 $9140 $19338 Transition $1500 $98163 $80582 106150736 KERN MED CTR Yes No No No No 3943 12882 12620 $6289 $7436 NA NA NA NA NA 106150737 KERN VALLEY HEALTHCARE DIST No Yes No Yes Yes 2786 12882 12620 $12768 $15097 $8298 Transition NA $98163 $80582 106191450 KAISER-WOODLAND HILLS No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190049 KINDRED HOSPITAL BALDWIN PARK No No No No No 1810 12882 12620 $6289 $7436 $10784 Transition NA $98163 $80582 106190305 KINDRED LA No No No No No 2044 12882 12620 $6289 $7436 $4255 Transition NA $98163 $80582 106301127 KINDRED BREA No No No No No 2852 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361274 KINDRED ONTARIO No No No No No 2068 12882 12620 $6289 $7436 $9314 Transition NA $98163 $80582 106364188 KINDRED RANCHO No No No No No 1980 12882 12620 $6289 $7436 $20628 Transition NA $98163 $80582 106332172 KINDRED RIVERSIDE No No No No No 1805 12882 12620 $6289 $7436 $24450 Transition NA $98163 $80582 106190449 KINDRED LA MIRADA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106370721 KINDRED SAN DIEGO No No No No No 3605 12882 12620 $6289 $7436 $5657 Transition NA $98163 $80582 106344035 KINDRED SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190458 KINDRED SAN GABRIEL VALLEY No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106010887 KINDRED SF BAY AREA No No No No No 3007 16478 16143 $6289 $8978 $6378 Transition NA $98163 $80582 106301167 KINDRED SANTA ANA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190196 KINDRED SOUTH BAY No No No No No 2144 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301380 KINDRED WESTMINSTER No No No No No 2286 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301234 LA PALMA INTERCOMMUNITY HOSP No No No No No 2290 12882 12620 $6289 $7436 $7160 Transition NA $98163 $80582 106191227 LAC-HARBOR-UCLA MED CTR Yes No Yes No No 3366 12882 12620 $6289 $7436 NA NA NA NA NA 106191231 LAC-OLIVE VIEW-UCLA MED CTR Yes No No No No 4136 12882 12620 $6289 $7436 NA NA NA NA NA 106191228 LAC-USC MED CTR Yes No Yes No No 4522 12882 12620 $6289 $7436 NA NA NA NA NA 106380865 LAGUNA HONDA HOSP AND REHAB CTR Yes No No No No 5843 16738 16398 $6289 $9090 NA NA NA NA NA 106190240 LAKEWOOD REG MED CTR No No No No No 1504 12882 12620 $6289 $7436 $4008 Transition $1220 $98163 $80582 106390923 LODI MEM HOSP No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106390922 LODI MEM HOSP - WEST No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106334589 LOMA LINDA MURRIETTA No No No No No 3222 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106364268 LOMA LINDA UNIV HEART AND SURGICAL HOSPITAL No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361245 LOMA LINDA UNIV MED CTR - EAST CAMPUS No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361246 LOMA LINDA UNIV MED CTR No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $1491 $98163 $80582 106364502 LOMA LINDA UNIV CHILDRENS HOSP No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $2177 $98163 $80582 106190198 LA COMM HOSP No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420491 LOMPOC VALLEY MED CTR No Yes No Yes Yes 8693 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301248 LOS ALAMITOS MED CTR No No No No No 1915 12882 12620 $6289 $7436 $4697 Transition NA $98163 $80582 106560492 LOS ROBLES HOSP AND MED CTR No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106564018 LOS ROBLES HOSP AND MED CTR-EAST CAMPUS No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106434040 LSP CHILDRENS HOSP AT STANFORD No No Yes No No 2035 17180 16831 $6289 $9279 $6102 Transition NA $98163 $80582 106121002 MAD RIVER COMM HOSP No No No No No 4250 12882 12620 $6289 $7436 $9505 Transition NA $98163 $80582 106201281 MADERA COMMUNITY HOSPITAL No No No No No 5100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106260011 MAMMOTH HOSP No Yes No Yes Yes 7982 12882 12620 $12768 $15097 $46994 Transition NA $98163 $80582 106420493 MARIAN MED CTR No No No No No 2741 12882 12620 $6289 $7436 $9386 Transition NA $98163 $80582 106190525 LONG BEACH MEM MED CTR No No No No No 1996 12882 12620 $6289 $7436 NA Non-Transition $1627 $98163 $80582 106211006 MARIN GEN HOSP No Yes No No No 2571 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106190500 MARINA DEL RAY HOSPITAL No No No No No 2034 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106050932 MARK TWAIN ST JOSEPHS HOSP No No No Yes Yes 3707 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090933 MARSHALL MED CTR No No No Yes Yes 2107 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106500939 MEM HOSP MED CTR-MODESTO No No No No No 2235 12892 12630 $6289 $7440 $5898 Transition NA $98163 $80582 106240924 MEMORIAL HOSP LOS BANOS No No No Yes Yes 3362 12882 12620 $12768 $15097 $17450 Transition NA $98163 $80582 106190521 MEMORIAL HOSP OF GARDENA No No No No No 1747 12882 12620 $6289 $7436 $4611 Transition NA $98163 $80582 106231013 MENDOCINO COAST DIST HOSP No Yes No Yes Yes 5070 12882 12620 $12768 $15097 $15935 Transition NA $98163 $80582 106334018 MENIFEE VALLEY MED CTR No No No No No 1458 12882 12620 $6289 $7436 $5113 Transition NA $98163 $80582 106450936 MAYERS MEM HOSP No Yes No Yes Yes 7192 14188 13900 $12768 $16234 NA Non-Transition NA $98163 $80582 106340947 MERCY GEN HOSP No No No No No 2185 15256 14946 $6289 $8454 $6027 Transition $1387 $98163 $80582 106344029 MERCY HOSP OF FOLSOM No No No No No 2746 15256 14946 $6289 $8454 $5260 Transition NA $98163 $80582 106150761 MERCY HOSP-BAKERSFIELD No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106414018 MENLO PARK SURGICAL HOSP No No No No No 2770 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106240942 MERCY MED CTR MERCED No No No No No 2289 13279 13009 $6289 $7606 NA Non-Transition NA $98163 $80582 106450949 MERCY MED CTR-REDDING No No No No No 2589 14188 13900 $6289 $7996 $10219 Transition NA $98163 $80582 106470871 MERCY MED CTR-MT SHASTA No No No Yes Yes 6242 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106340950 MERCY SAN JUAN HOSP No No No No No 2166 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190529 METHODIST HOSP OF SO CAL No No No No No 1842 12882 12620 $6289 $7436 $6690 Transition $1220 $98163 $80582 106196168 MILLER CHILDRENS HOSP No No Yes No No 2680 12882 12620 $6289 $7436 $8155 Transition NA $98163 $80582 106410742 MILLS HEALTH CENTER No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106410852 MILLS-PENINSULA No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106340951 METHODIST HOSP OF SACRAMENTO No No No No No 2028 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190524 MISSION COMM HOSP-PANORAMA CAMPUS No No No No No 3568 12882 12620 $6289 $7436 $3982 Transition NA $98163 $80582 106190681 MIRACLE MILE No No No No No 100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301262 MISSION HOSP REG MED CTR No No No No No 4091 12882 12620 $6289 $7436 $14336 Transition $1220 $98163 $80582 106250956 MODOC MED CTR No Yes No Yes Yes 4961 12882 12620 $12768 $15097 $13486 Transition NA $98163 $80582 106301337 MISSION HOSP LAGUNA BEACH No No No No No 4091 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106361166 MONTCLAIR HOSP MED CTR No No No No No 3149 12882 12620 $6289 $7436 $5904 Transition NA $98163 $80582 106190547 MONTEREY PARK HOSP No No No No No 1034 12882 12620 $6289 $7436 $5866 Transition NA $98163 $80582 106361266 MOUNTAINS COMM HOSP No Yes No Yes Yes 5148 12882 12620 $12768 $15097 $15642 Transition NA $98163 $80582 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106481357 NORTH BAY MEDICAL CENTER No No No No No 1972 16315 15984 $6289 $8908 $15945 Transition NA $98163 $80582
i-
i
i
i-
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190541 MONROVIA MEM HOSP No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106141273 NORTHERN INYO HOSP No Yes No Yes Yes 8150 12882 12620 $12768 $15097 $27752 Transition NA $98163 $80582 106484001 NORTH BAY VACAVALLEY HOSP No No No No No 1972 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106190568 NORTHRIDGE HOSP MED CTR No No No No No 1596 12882 12620 $6289 $7436 NA Non-Transition $1662 $98163 $80582 106214034 NOVATO COMM HOSP No No No No No 3465 16855 16513 $6289 $9140 $6359 Transition NA $98163 $80582 106500967 OAK VALLEY DIST HOSP No Yes No Yes No 3340 12892 12630 $6289 $7440 $5201 Transition NA $98163 $80582 106430837 OCONNOR HOSP-SAN JOSE No No No No No 2409 17180 16831 $6289 $9279 $5201 Transition NA $98163 $80582 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190534 OLYMPIA MED CTR No No No No No 1260 12882 12620 $6289 $7436 $6786 Transition NA $98163 $80582 106300225 ORANGE COAST MEM MED CTR No No No No No 2293 12882 12620 $6289 $7436 $19985 Transition NA $98163 $80582 106040937 OROVILLE HOSP No No No No No 1803 12882 12620 $6289 $7436 $6229 Transition NA $98163 $80582 106560501 OJAI VALLEY COMM HOSP No No No Yes Yes 2745 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190696 PACIFICA HOSP OF THE VALLEY No No No No No 3338 12882 12620 $6289 $7436 $5616 Transition NA $98163 $80582 106491338 PALM DRIVE HOSP No Yes No Yes No 4315 16315 15984 $6289 $8908 $11457 Transition NA $98163 $80582 106196405 PALMDALE REGIONAL MEDICAL CTR No No No No No 1190 12882 12620 $6289 $7436 $7504 Transition $1220 $98163 $80582 106331288 PALO VERDE HOSP No Yes No Yes Yes 4770 12882 12620 $12768 $15097 $18188 Transition NA $98163 $80582 106370755 PALOMAR MED CTR No Yes No No No 2429 12882 12620 $6289 $7436 $7051 Transition $1220 $98163 $80582 106370759 PARADISE VALLEY HOSP No No No No No 2188 12882 12620 $6289 $7436 $4275 Transition $1220 $98163 $80582 106190307 PACIFIC ALLIANCE MED CTR No No No No No 4299 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106331293 PARKVIEW COMM HOSP MED CTR No No No No No 2757 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106491001 PETALUMA VALLEY HOSP No No No No No 2271 16315 15984 $6289 $8908 $13491 Transition NA $98163 $80582 106130760 PIONEERS MEM HOSP No Yes No Yes No 2989 12882 12620 $6289 $7436 $9825 Transition NA $98163 $80582 106454013 PATIENTS HOSP OF REDDING No No No No No 2172 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106301297 PLACENTIA LINDA HOSP No No No No No 1606 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370977 POMERADO HOSP No Yes No No No 3063 12882 12620 $6289 $7436 $6818 Transition NA $98163 $80582 106320986 PLUMAS DIST HOSP No Yes No Yes Yes 8666 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190631 PRESBYTERIAN INTERCOMM HOSP No No No No No 961 12882 12620 $6289 $7436 $9720 Transition $1220 $98163 $80582 106190630 POMONA VALLEY HOSP MED CTR No No Yes No No 1538 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190468 PROMISE HOSP OF EAST LA-EAST LA No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190599 PROMISE HOSP OF EAST LA-EAST LA-SUBURBAN CAMPUS No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190385 PROVIDENCE HOLY CROSS MED CTR No No No No No 1325 12882 12620 $6289 $7436 $6284 Transition $1220 $98163 $80582 106190680 PROVIDENCE LITTLE CO OF MARY-SAN PEDRO No No No No No 1533 12882 12620 $6289 $7436 $6225 Transition $1220 $98163 $80582 106190470 PROVIDENCE LITTLE CO OF MARY-TORRANCE No No No No No 1767 12882 12620 $6289 $7436 $7182 Transition NA $98163 $80582 106190758 PROVIDENCE ST JOSEPH MED CTR No No No No No 1866 12882 12620 $6289 $7436 $7141 Transition $1220 $98163 $80582 106370787 PROMISE HOSP OF SAN DIEGO No No No No No 3660 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106281047 QUEEN OF THE VALLEY HOSP-NAPA No No No No No 2829 16188 15859 $6289 $8854 $17592 Transition $1453 $98163 $80582 106370673 RADY CHILDRENS HOSPITAL - SAN DIEGO No No Yes No No 2854 12882 12620 $6289 $7436 $6395 Transition $2177 $98163 $80582 106190517 PROVIDENCE TARZANA MED CTR No No Yes No No 1536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361308 REDLANDS COMM HOSP No No No No No 2079 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430705 REG MED CTR OF SAN JOSE No No No No No 2529 17180 16831 $6289 $9279 $13299 Transition NA $98163 $80582 106580996 RIDEOUT MEM HOSP No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106121051 REDWOOD MEM HOSP No No No Yes Yes 3214 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106334487 RIVERSIDE CO REG MED CTR Yes No No No No 2987 12882 12620 $6289 $7436 NA NA NA NA NA 106331312 RIVERSIDE COMM HOSP No No No No No 1560 12882 12620 $6289 $7436 $5990 Transition NA $98163 $80582 106190796 RONALD REAGAN UCLA MED CTR Yes No Yes No No 3382 12882 12620 $6289 $7436 NA NA NA NA NA 106301317 SADDLEBACK MEM MED CTR No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106301325 SADDLEBACK MEM MED CTR-SAN CLEMENTE No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106150782 RIDGECREST REG HOSP No No No Yes Yes 4178 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106361318 SAN ANTONIO COMM HOSP No No No No No 2262 12882 12620 $6289 $7436 $9216 Transition NA $98163 $80582 106190673 SAN DIMAS COMM HOSP No No No No No 2465 12882 12620 $6289 $7436 $12177 Transition NA $98163 $80582 106190200 SAN GABRIEL VALLEY MED CTR No No No No No 969 12882 12620 $6289 $7436 $6918 Transition NA $98163 $80582 106270875 SALINAS VALLEY MEM HOSP No Yes No No No 3534 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106331326 SAN GORGONIO MEM HOSP No Yes No Yes Yes 3394 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391010 SAN JOAQUIN GEN HOSP Yes No No No No 1922 13579 13303 $6289 $7735 NA NA NA NA NA 106104023 SAN JOAQUIN VALLEY REHAB HOSP No No No No No 6479 12882 12620 NA NA NA NA $1413 $98163 $80582 106013619 SAN LEANDRO HOSP No Yes No No No 3482 16501 16166 $6289 $8988 $10813 Transition NA $98163 $80582 106410782 SAN MATEO MED CTR Yes No No No No 7168 16928 16584 $6289 $9171 NA NA NA NA NA 106074017 SAN RAMON REG MED CTR No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106074011 SAN RAMON REG MED CTR SOUTH BUILDING No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106420514 SANTA BARBARA COTTAGE HOSP No No Yes No No 3902 12882 12620 $6289 $7436 $10978 Transition $2125 $98163 $80582 106430883 SANTA CLARA VALLEY MED CTR Yes No Yes No No 3133 17180 16831 $6289 $9279 NA NA NA NA NA 106190687 SANTA MONICA - UCLA MEDICAL CENTER Yes No No No No 3102 12882 12620 $6289 $7436 NA NA NA NA NA 106491064 SANTA ROSA MEM HOSP-MONTGOMERY No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106490907 SANTA ROSA MEM HOSP-SOTOYOME No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106150788 SAN JOAQUIN COMM HOSP No No No No No 2544 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420522 SANTA YNEZ VALLEY COTTAGE HOSP No No No Yes Yes 7569 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106371394 SCRIPPS MEM HOSP-ENCINITAS No No No No No 2403 12882 12620 $6289 $7436 $7037 Transition $1439 $98163 $80582 106370771 SCRIPPS MEM HOSP-LA JOLLA No No No No No 2061 12882 12620 $6289 $7436 $4390 Transition NA $98163 $80582 106370744 SCRIPPS MERCY HOSP No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106370658 SCRIPPS MERCY HOSP-CHULA VISTA No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106371256 SCRIPPS GREEN HOSP No No No No No 2317 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106321016 SENECA HCARE DIST No Yes No Yes Yes 4586 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106410817 SETON MED CTR No No No No No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106410828 SETON MED CTR-COASTSIDE No No No Yes No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106380939 SF GENERAL HOSP Yes No No No No 2851 16738 16398 $6289 $9090 NA NA NA NA NA 106370875 SHARP CHULA VISTA MED CTR No No No No No 1932 12882 12620 $6289 $7436 $6485 Transition NA $98163 $80582 106410891 SEQUOIA HOSP No No No No No 1975 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106370689 SHARP CORONADO HOSP AND HCARE CTR No No No No No 2160 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $72421 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106370694 SHARP MEM HOSP No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106450940 SHASTA REG MED CTR No No No No No 1582 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106190708 SHERMAN OAKS HOSP No No No No No 1516 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190712 SHRINERS HOSPITAL- LA No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106344114 SHRINERS HOSPITAL- SACRAMENTO No No No No No 3869 15256 14946 $6289 $8454 NA Non-Transition $2475 $98163 $80582 106540798 SIERRA VIEW DIST HOSP No Yes No No No 2716 12882 12620 $6289 $7436 $8497 Transition NA $98163 $77682 106400524 SIERRA VIST REG MED CTR No No No No No 1787 12964 12701 $6289 $7471 $5495 Transition NA $98163 $80582 106190661 SILVER LAKE MED CTR No No No No No 3692 12882 12620 $6289 $7436 $5655 Transition NA $98163 $80582 106291023 SIERRA NEVADA MEM HOSP No No No Yes Yes 3427 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106491076 SONOMA VALLEY HOSP No Yes No No No 4960 16315 15984 $6289 $8908 $12733 Transition NA $98163 $80582 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 2126 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190380 SOUTHERN CA HOSP AT HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106190110 SOUTHERN CA HOSPITAL AT CULVER CITY No No No No No 1437 12882 12620 $6289 $7436 $4694 Transition $1220 $98163 $80582 106560525 SIMI VALLEY HOSP AND HCARE-SYCAMORE No No No No No 3840 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106334068 SOUTHWEST HCARE SYSTEM No No No No No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106334001 SOUTHWEST HCARE SYSTEM-WILDOMAR No No No Yes No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106100899 ST AGNES MED CTR No No No No No 3088 12882 12620 $6289 $7436 $7885 Transition NA $98163 $80582 106361339 ST BERNARDINE MED CTR No No No No No 2171 12882 12620 $6289 $7436 $6090 Transition NA $98163 $80582 106521041 ST ELIZABETH COMM HOSP No No No Yes Yes 3024 13869 13587 $12768 $15956 $14866 Transition NA $98163 $80582 106190754 ST FRANCIS MED CTR No No No No No 4350 12882 12620 $6289 $7436 $6368 Transition NA $98163 $80582 106380960 ST FRANCIS MEM HOSP No No No No No 1920 16738 16398 $6289 $9090 $5310 Transition $1492 $98163 $80582 106281078 ST HELENA HOSP No No No No No 2337 15887 15564 $6289 $8725 $9671 Transition NA $98163 $80582 106171049 ST HELENA HOSPITAL-CLEARLAKE No No No Yes Yes 4118 12882 12620 $12768 $15097 $18218 Transition NA $98163 $80582 106141338 SOUTHERN INYO HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190756 ST JOHNS HEALTH CTR No No No No No 2536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560529 ST JOHNS REG MED CTR No No No No No 2982 12882 12620 $6289 $7436 $6976 Transition $1761 $98163 $80582 106121080 ST JOSEPH HOSP-EUREKA No No No No No 2570 13869 13587 $6289 $7859 $9661 Transition $1507 $98163 $80582 106301340 ST JOSEPH HOSP-ORANGE No No No No No 2751 12882 12620 $6289 $7436 $5230 Transition NA $98163 $80582 106560508 ST JOHNS PLEASANT VALLEY HOSP No No No No No 2087 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301342 ST JUDE MED CTR No No No No No 1722 12882 12620 $6289 $7436 $5799 Transition $1220 $98163 $80582 106434138 ST LOUISE REG HOSP No No No No No 2838 17180 16831 $6289 $9279 $16407 Transition NA $98163 $80582 106380964 ST LUKES HOSP No No No No No 3807 16738 16398 $6289 $9090 $8600 Transition NA $98163 $80582 106361343 ST MARY MED CTR-APPLE VALLEY No No No Yes No 2511 12882 12620 $6289 $7436 $9863 Transition NA $98163 $80582 106391042 ST JOSEPHS MED CTR OF STOCKTON No No No No No 2152 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106380965 ST MARYS MED CTR-SF No No No No No 2007 16738 16398 $6289 $9090 $5116 Transition $1492 $98163 $80582 106010967 ST ROSE HOSP No No No No No 1931 16962 16618 $6289 $9186 $7600 Transition NA $98163 $80582 106190762 ST VINCENT MED CTR No No No No No 2020 12882 12620 $6289 $7436 $4684 Transition $1220 $98163 $80582 106430905 STANFORD HOSP No No No No No 1803 17180 16831 $6289 $9279 $5644 Transition $1523 $98163 $80582 106190053 ST MARY MED CTR-LONG BEACH No No No No No 2479 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106504038 STANISLAUS SURGICAL HOSP No No No No No 9000 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106250955 SURPRISE VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106310791 SUTTER AUBURN FAITH HOSP No No No No No 2551 15256 14946 $6289 $8454 $11882 Transition NA $98163 $80582 106034002 SUTTER AMADOR HOSP No No No Yes Yes 2971 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106574010 SUTTER DAVIS HOSP No No No No No 3568 15256 14946 $6289 $8454 $14330 Transition NA $98163 $80582 106070934 SUTTER DELTA MED CTR No No No No No 2907 16478 16143 $6289 $8978 $12158 Transition NA $98163 $80582 106341051 SUTTER GEN HOSP No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106171395 SUTTER LAKESIDE HOSP No No No Yes Yes 3691 12882 12620 $12768 $15097 $17232 Transition NA $98163 $80582 106444012 SUTTER MATERNITY AND SRG CTR OF S CRUZ No No No No No 7213 17239 16889 $6289 $9304 $21288 Transition NA $98163 $80582 106490919 SUTTER MED CTR OF SANTA ROSA No No No No No 3657 16315 15984 $6289 $8908 $15278 Transition NA $98163 $80582 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106311000 SUTTER ROSEVILLE MED CTR No No No No No 2377 15256 14946 $6289 $8454 $11395 Transition $1387 $98163 $80582 106481094 SUTTER SOLANO MED CTR No No No No No 3258 16315 15984 $6289 $8908 $18010 Transition NA $98163 $80582 106084001 SUTTER COAST HOSP No No No Yes Yes 3730 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391056 SUTTER TRACY COMM HOSP No No No No No 2714 13579 13303 $6289 $7735 $5995 Transition NA $98163 $80582 106291053 TAHOE FOREST HOSP No Yes No Yes Yes 4766 15256 14946 $12768 $17164 $21044 Transition NA $98163 $80582 106150808 TEHACHAPI HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 $22158 Transition NA $98163 $80582 106514030 SUTTER SURG HOSP-NORTH VALLEY No No No No No 3240 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106334564 TEMECULA VALLEY HOSPITAL No No No No No 2180 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106120981 THE GENERAL HOSPITAL No No No No No 2570 13869 13587 NA NA NA NA $1507 $98163 $80582 106564121 THOUSAND OAKS SURGICAL HOSPITAL No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106190422 TORRANCE MEM MED CTR No No No No No 1952 12882 12620 $6289 $7436 $5891 Transition NA $98163 $80582 106370780 TRI-CITY MED CTR No Yes No No No 3695 12882 12620 $6289 $7436 $7706 Transition $1220 $98163 $80582 106190784 TEMPLE COMM HOSP No No No No No 4200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540816 TULARE DIST HOSP No Yes No No No 3578 12882 12620 $6289 $7436 $9529 Transition NA $98163 $80582 106531059 TRINITY HOSP No Yes No Yes Yes 5105 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106400548 TWIN CITIES COMM HOSP No No No Yes Yes 1587 12964 12701 $12768 $15168 $8160 Transition NA $98163 $80582 106341006 UC DAVIS MED CTR Yes No Yes No No 1836 15256 14946 $6289 $8454 NA NA NA NA NA 106301279 UC IRVINE MED CTR Yes No Yes No No 2072 12882 12620 $6289 $7436 NA NA NA NA NA 106370782 UCSD MED CTR Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106374141 UCSD-LA JOLLA JOHN M amp SALLY B THORNTON HOSPITAL Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106381154 UCSF MED CTR Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106380895 UCSF MED CTR AT MOUNT ZION Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106301357 TUSTIN HOSP MED CTR No No No No No 231 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106231396 UKIAH VALLEY MED CTRHOSP DR No No No Yes Yes 3643 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106014050 VALLEY CARE MEDICAL CENTER No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106010983 VALLEY MEM HOSP-LIVERMORE No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106191216 USC KENNETH NORRIS JR CANCER HOSP No No No No No 3134 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560481 VENTURA CO MED CTR Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106560521 VENTURA CO MED CTR-SANTA PAULA HOSPITAL Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106190818 VERDUGO HILLS HOSP No No No No No 3110 12882 12620 $6289 $7436 $5264 Transition NA $98163 $80582 106190812 VALLEY PRES HOSP No No No No No 3536 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 3046 14188 13900 $6289 $7996 NA Non-Transition $1312 $98163 $80582 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 3266 12882 12620 $6289 $7436 $8320 Transition NA $98163 $80582 106010987 WASHINGTON HOSP-FREMONT No Yes No No No 1941 16962 16618 $6289 $9186 $6429 Transition NA $98163 $80582 106444013 WATSONVILLE COMM HOSP No No No No No 1780 17239 16889 $6289 $9304 $13456 Transition NA $98163 $80582 106301379 WEST ANAHEIM MED CTR No No No No No 1514 12882 12620 $6289 $7436 $4707 Transition NA $98163 $80582 106190859 WEST HILLS HOSP AND MED CTR No No No No No 1933 12882 12620 $6289 $7436 $8050 Transition NA $98163 $80582 106374094 VIBRA OF SAN DIEGO No No No No No 1155 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301188 WESTERN MED CTR-ANAHEIM No No No No No 3203 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301566 WESTERN MED CTR-SANTA ANA No No No No No 2354 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190878 WHITE MEM MED CTR No No No No No 1515 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190883 WHITTIER HOSP MED CTR No No No No No 1139 12882 12620 $6289 $7436 $5922 Transition NA $98163 $80582 106571086 WOODLAND MEM HOSP No No No No No 3278 15256 14946 $6289 $8454 $10092 Transition NA $98163 $80582 6102015
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
-
425-4 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 946 16767 10000 10000 16767 12500 20959 10000 16767 $15719 Misc Pediatric Misc Adult 440-1 440-2 440-3 440-4
KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT KIDNEY TRANSPLANT
458 561 864
2088
44667 50078 60562 99171
10000 10000 10000 10000
10000 10000 10000 10000
44667 50078 60562 99171
12500 12500 12500 12500
55834 62598 75703
123964
10000 10000 10000 10000
44667 50078 60562 99171
$41875 Misc Pediatric $46948 Misc Pediatric $56777 Misc Pediatric $92973 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
441-1 441-2 441-3 441-4
MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES MAJOR BLADDER PROCEDURES
474 726 994
2196
14386 21567 29549 61841
10000 10000 10000 10000
10000 10000 10000 10000
14386 21567 29549 61841
12500 12500 12500 12500
17983 26959 36936 77301
10000 10000 10000 10000
14386 21567 29549 61841
$13487 Misc Pediatric $20219 Misc Pediatric $27702 Misc Pediatric $57976 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
442-1 442-2 442-3 442-4
KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY
325 422 795
1671
13139 15537 23456 49226
10000 10000 10000 10000
10000 10000 10000 10000
13139 15537 23456 49226
12500 12500 12500 12500
16424 19421 29320 61533
10000 10000 10000 10000
13139 15537 23456 49226
$12318 Misc Pediatric $14566 Misc Pediatric $21990 Misc Pediatric $46149 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
443-1 443-2 443-3 443-4
KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY
253 356 802
1752
10883 12834 18814 40742
10000 10000 10000 10000
10000 10000 10000 10000
10883 12834 18814 40742
12500 12500 12500 12500
13604 16043 23518 50928
10000 10000 10000 10000
10883 12834 18814 40742
$10203 Misc Pediatric $12032 Misc Pediatric $17638 Misc Pediatric $38196 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
444-1 444-2 444-3 444-4
RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY
264 447 933
1617
09410 12604 20686 38830
10000 10000 10000 10000
10000 10000 10000 10000
09410 12604 20686 38830
12500 12500 12500 12500
11763 15755 25858 48538
10000 10000 10000 10000
09410 12604 20686 38830
$8822 Misc Pediatric $11816 Misc Pediatric $19393 Misc Pediatric $36403 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
445-1 445-2 445-3 445-4
OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES OTHER BLADDER PROCEDURES
190 319 781
1545
08552 11610 15964 31570
10000 10000 10000 10000
10000 10000 10000 10000
08552 11610 15964 31570
12500 12500 12500 12500
10690 14513 19955 39463
10000 10000 10000 10000
08552 11610 15964 31570
$8018 Misc Pediatric $10884 Misc Pediatric $14966 Misc Pediatric $29597 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
446-1 446-2 446-3 446-4
URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES URETHRAL amp TRANSURETHRAL PROCEDURES
188 261 612
1363
06758 08690 14202 30173
10000 10000 10000 10000
10000 10000 10000 10000
06758 08690 14202 30173
12500 12500 12500 12500
08448 10863 17753 37716
10000 10000 10000 10000
06758 08690 14202 30173
$6336 Misc Pediatric $8147 Misc Pediatric
$13314 Misc Pediatric $28287 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
447-1 447-2 447-3 447-4
OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES
228 365 728
1787
11479 13294 19661 43932
10000 10000 10000 10000
10000 10000 10000 10000
11479 13294 19661 43932
12500 12500 12500 12500
14349 16618 24576 54915
10000 10000 10000 10000
11479 13294 19661 43932
$10762 Misc Pediatric $12463 Misc Pediatric $18432 Misc Pediatric $41186 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
460-1 460-2 460-3 460-4
RENAL FAILURE RENAL FAILURE RENAL FAILURE RENAL FAILURE
299 376 496
1115
04323 06061 07896 19936
10000 10000 10000 10000
10000 10000 10000 10000
04323 06061 07896 19936
12500 12500 12500 12500
05404 07576 09870 24920
10000 10000 10000 10000
04323 06061 07896 19936
$4053 Misc Pediatric $5682 Misc Pediatric $7403 Misc Pediatric
$18690 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
461-1 461-2 461-3 461-4
KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY KIDNEY amp URINARY TRACT MALIGNANCY
271 374 601
1108
04315 05992 09498 16929
10000 10000 10000 10000
10000 10000 10000 10000
04315 05992 09498 16929
12500 12500 12500 12500
05394 07490 11873 21161
10000 10000 10000 10000
04315 05992 09498 16929
$4045 Misc Pediatric $5618 Misc Pediatric $8904 Misc Pediatric
$15871 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
462-1 462-2 462-3 462-4
NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS NEPHRITIS amp NEPHROSIS
260 370 656
1359
03798 05298 09439 23905
10000 10000 10000 10000
10000 10000 10000 10000
03798 05298 09439 23905
12500 12500 12500 12500
04748 06623 11799 29881
10000 10000 10000 10000
03798 05298 09439 23905
$3561 Misc Pediatric $4967 Misc Pediatric $8849 Misc Pediatric
$22411 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
463-1 463-2 463-3 463-4
KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS KIDNEY amp URINARY TRACT INFECTIONS
268 352 507 910
04120 05628 07879 14066
10000 10000 10000 10000
10000 10000 10000 10000
04120 05628 07879 14066
12500 12500 12500 12500
05150 07035 09849 17583
10000 10000 10000 10000
04120 05628 07879 14066
$3863 Misc Pediatric $5276 Misc Pediatric $7387 Misc Pediatric
$13187 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
465-1 465-2 465-3 465-4
URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION
165 202 380 860
04374 05548 08751 18922
10000 10000 10000 10000
10000 10000 10000 10000
04374 05548 08751 18922
12500 12500 12500 12500
05468 06935 10939 23653
10000 10000 10000 10000
04374 05548 08751 18922
$4101 Misc Pediatric $5201 Misc Pediatric $8204 Misc Pediatric
$17739 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
466-1 466-2 466-3 466-4
MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC
221 343 533 971
03576 05752 08974 17498
10000 10000 10000 10000
10000 10000 10000 10000
03576 05752 08974 17498
12500 12500 12500 12500
04470 07190 11218 21873
10000 10000 10000 10000
03576 05752 08974 17498
$3353 Misc Pediatric $5393 Misc Pediatric $8413 Misc Pediatric
$16404 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
468-1 468-2 468-3 468-4
OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS
246 335 509
1057
04152 05935 08698 18661
10000 10000 10000 10000
10000 10000 10000 10000
04152 05935 08698 18661
12500 12500 12500 12500
05190 07419 10873 23326
10000 10000 10000 10000
04152 05935 08698 18661
$3893 Misc Pediatric $5564 Misc Pediatric $8154 Misc Pediatric
$17495 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
480-1 480-2 480-3 480-4
MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES MAJOR MALE PELVIC PROCEDURES
180 241 618
1422
12119 13477 20992 45258
10000 10000 10000 10000
10000 10000 10000 10000
12119 13477 20992 45258
12500 12500 12500 12500
15149 16846 26240 56573
10000 10000 10000 10000
12119 13477 20992 45258
$11362 Misc Pediatric $12635 Misc Pediatric $19680 Misc Pediatric $42429 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
481-1 481-2 481-3 481-4
PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES PENIS PROCEDURES
228 267 830
1810
06794 11922 17939 41143
10000 10000 10000 10000
10000 10000 10000 10000
06794 11922 17939 41143
12500 12500 12500 12500
08493 14903 22424 51429
10000 10000 10000 10000
06794 11922 17939 41143
$6369 Misc Pediatric $11177 Misc Pediatric $16818 Misc Pediatric $38572 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
482-1 482-2 482-3 482-4
TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY TRANSURETHRAL PROSTATECTOMY
169 278 716
1341
05918 07555 14662 30717
10000 10000 10000 10000
10000 10000 10000 10000
05918 07555 14662 30717
12500 12500 12500 12500
07398 09444 18328 38396
10000 10000 10000 10000
05918 07555 14662 30717
$5548 Misc Pediatric $7083 Misc Pediatric
$13746 Misc Pediatric $28797 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
483-1 483-2 483-3 483-4
TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES TESTES amp SCROTAL PROCEDURES
203 541
1127 1970
06074 11326 22018 44244
10000 10000 10000 10000
10000 10000 10000 10000
06074 11326 22018 44244
12500 12500 12500 12500
07593 14158 27523 55305
10000 10000 10000 10000
06074 11326 22018 44244
$5694 Misc Pediatric $10618 Misc Pediatric $20642 Misc Pediatric $41479 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
484-1 484-2 484-3 484-4
OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
250 191 502
1578
07704 11762 15177 36555
10000 10000 10000 10000
10000 10000 10000 10000
07704 11762 15177 36555
12500 12500 12500 12500
09630 14703 18971 45694
10000 10000 10000 10000
07704 11762 15177 36555
$7223 Misc Pediatric $11027 Misc Pediatric $14228 Misc Pediatric $34270 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
500-1 500-2 500-3 500-4
MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM MALIGNANCY MALE REPRODUCTIVE SYSTEM
266 431 601
1109
03789 05904 09172 17461
10000 10000 10000 10000
10000 10000 10000 10000
03789 05904 09172 17461
12500 12500 12500 12500
04736 07380 11465 21826
10000 10000 10000 10000
03789 05904 09172 17461
$3552 Misc Pediatric $5535 Misc Pediatric $8599 Misc Pediatric
$16370 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
501-1 501-2 501-3 501-4
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY
258 351 547
1074
04044 05542 08322 16765
10000 10000 10000 10000
10000 10000 10000 10000
04044 05542 08322 16765
12500 12500 12500 12500
05055 06928 10403 20956
10000 10000 10000 10000
04044 05542 08322 16765
$3791 Misc Pediatric $5196 Misc Pediatric $7802 Misc Pediatric
$15717 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
510-1 510-2 510-3 510-4
PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS
244 387 892
1787
11433 14140 25807 52317
10000 10000 10000 10000
10000 10000 10000 10000
11433 14140 25807 52317
12500 12500 12500 12500
14291 17675 32259 65396
10000 10000 10000 10000
11433 14140 25807 52317
$10718 Misc Pediatric $13256 Misc Pediatric $24194 Misc Pediatric $49047 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
511-1 511-2 511-3 511-4
UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY
330 488 862
1777
11911 14923 22750 49888
10000 10000 10000 10000
10000 10000 10000 10000
11911 14923 22750 49888
12500 12500 12500 12500
14889 18654 28438 62360
10000 10000 10000 10000
11911 14923 22750 49888
$11167 Misc Pediatric $13990 Misc Pediatric $21328 Misc Pediatric $46770 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
512-1 512-2 512-3 512-4
UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG
217 308 682
1629
10603 12410 19879 45702
10000 10000 10000 10000
10000 10000 10000 10000
10603 12410 19879 45702
12500 12500 12500 12500
13254 15513 24849 57128
10000 10000 10000 10000
10603 12410 19879 45702
$9940 Misc Pediatric $11634 Misc Pediatric $18637 Misc Pediatric $42846 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
513-1 513-2 513-3 513-4
UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA
186 251 564
1508
08515 10026 16283 40387
10000 10000 10000 10000
10000 10000 10000 10000
08515 10026 16283 40387
12500 12500 12500 12500
10644 12533 20354 50484
10000 10000 10000 10000
08515 10026 16283 40387
$7983 Misc Pediatric $9399 Misc Pediatric
$15265 Misc Pediatric $37863 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
514-1 514-2 514-3 514-4
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES
140 172 529
1557
07298 09618 15881 40691
10000 10000 10000 10000
10000 10000 10000 10000
07298 09618 15881 40691
12500 12500 12500 12500
09123 12023 19851 50864
10000 10000 10000 10000
07298 09618 15881 40691
$6842 Misc Pediatric $9017 Misc Pediatric
$14888 Misc Pediatric $38148 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
517-1 517-2 517-3 517-4
DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES
192 289 663
1364
06030 08036 13633 29709
10000 10000 10000 10000
10000 10000 10000 10000
06030 08036 13633 29709
12500 12500 12500 12500
07538 10045 17041 37136
10000 10000 10000 10000
06030 08036 13633 29709
$5653 Misc Pediatric $7534 Misc Pediatric
$12781 Misc Pediatric $27852 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
518-1 518-2 518-3 518-4
OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES
223 382 837
1827
06924 10040 18032 44556
10000 10000 10000 10000
10000 10000 10000 10000
06924 10040 18032 44556
12500 12500 12500 12500
08655 12550 22540 55695
10000 10000 10000 10000
06924 10040 18032 44556
$6491 Misc Pediatric $9413 Misc Pediatric
$16905 Misc Pediatric $41771 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
519-1 519-2 519-3 519-4
UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA
206 279 613
1485
08286 10051 17505 39433
10000 10000 10000 10000
10000 10000 10000 10000
08286 10051 17505 39433
12500 12500 12500 12500
10358 12564 21881 49291
10000 10000 10000 10000
08286 10051 17505 39433
$7768 Misc Pediatric $9423 Misc Pediatric
$16411 Misc Pediatric $36968 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
530-1 530-2 530-3 530-4
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY FEMALE REPRODUCTIVE SYSTEM MALIGNANCY
310 385 643
1178
04420 06163 09992 18972
10000 10000 10000 10000
10000 10000 10000 10000
04420 06163 09992 18972
12500 12500 12500 12500
05525 07704 12490 23715
10000 10000 10000 10000
04420 06163 09992 18972
$4144 Misc Pediatric $5778 Misc Pediatric $9368 Misc Pediatric
$17786 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
531-1 531-2 531-3 531-4
FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS FEMALE REPRODUCTIVE SYSTEM INFECTIONS
266 383 638
1303
04544 06407 09987 20595
10000 10000 10000 10000
10000 10000 10000 10000
04544 06407 09987 20595
12500 12500 12500 12500
05680 08009 12484 25744
10000 10000 10000 10000
04544 06407 09987 20595
$4260 Misc Pediatric $6007 Misc Pediatric $9363 Misc Pediatric
$19308 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
532-1 532-2 532-3 532-4
MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS
177 237 434
1003
03922 04787 07941 17650
10000 10000 10000 10000
10000 10000 10000 10000
03922 04787 07941 17650
12500 12500 12500 12500
04903 05984 09926 22063
10000 10000 10000 10000
03922 04787 07941 17650
$3677 Misc Pediatric $4488 Misc Pediatric $7445 Misc Pediatric
$16547 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
540-1 540-2 540-3 540-4
CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY CESAREAN DELIVERY
298 391 634
1053
05654 06864 09354 23719
10000 10000 10000 10000
10600 10600 10600 10600
05993 07276 09915 25142
10000 10000 10000 10000
05993 07276 09915 25142
10000 10000 10000 10000
05654 06864 09354 23719
$4495 Obstetrics $5457 Obstetrics $7436 Obstetrics
$18857 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
541-1 541-2 541-3 541-4
VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC VAGINAL DELIVERY W STERILIZATION ampOR DampC
212 249 491 838
05628 06076 08661 23515
10000 10000 10000 10000
10600 10600 10600 10600
05966 06441 09181 24926
10000 10000 10000 10000
05966 06441 09181 24926
10000 10000 10000 10000
05628 06076 08661 23515
$4474 Obstetrics $4830 Obstetrics $6886 Obstetrics
$18694 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
542-1 542-2 542-3 542-4
VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC
216 296 614 993
03695 04647 08572 36195
10000 10000 10000 10000
10600 10600 10600 10600
03917 04926 09086 38367
10000 10000 10000 10000
03917 04926 09086 38367
10000 10000 10000 10000
03695 04647 08572 36195
$2938 Obstetrics $3694 Obstetrics $6815 Obstetrics
$28775 Obstetrics
Obstetrics Obstetrics Obstetrics Obstetrics
544-1 544-2 544-3 544-4
DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES
136 200 407 914
04586 05897 09822 25061
10000 10000 10000 10000
10600 10600 10600 10600
04861 06251 10411 26565
10000 10000 10000 10000
04861 06251 10411 26565
10000 10000 10000 10000
04586 05897 09822 25061
$3646 Obstetrics Obstetrics $4688 Obstetrics Obstetrics $7808 Obstetrics Obstetrics
$19924 Obstetrics Obstetrics 545-1 545-2 545-3 545-4
ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE
164 190 265 576
06988 08147 10540 19945
10000 10000 10000 10000
10600 10600 10600 10600
07407 08636 11172 21142
10000 10000 10000 10000
07407 08636 11172 21142
10000 10000 10000 10000
06988 08147 10540 19945
$5555 Obstetrics Obstetrics $6477 Obstetrics Obstetrics $8379 Obstetrics Obstetrics
$15856 Obstetrics Obstetrics 546-1 546-2 546-3 546-4
OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES
285 454 755
1446
05023 07207 13295 43377
10000 10000 10000 10000
10600 10600 10600 10600
05324 07639 14093 45980
10000 10000 10000 10000
05324 07639 14093 45980
10000 10000 10000 10000
05023 07207 13295 43377
$3993 Obstetrics Obstetrics $5730 Obstetrics Obstetrics
$10570 Obstetrics Obstetrics $34485 Obstetrics Obstetrics
560-1 560-2 560-3 560-4
VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY
203 237 385 935
03307 03856 05399 15061
10000 10000 10000 10000
10600 10600 10600 10600
03505 04087 05723 15965
10000 10000 10000 10000
03505 04087 05723 15965
10000 10000 10000 10000
03307 03856 05399 15061
$2629 Obstetrics Obstetrics $3066 Obstetrics Obstetrics $4292 Obstetrics Obstetrics
$11974 Obstetrics Obstetrics 561-1 561-2 561-3 561-4
POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE
211 257 393 688
02511 03908 06071 15617
10000 10000 10000 10000
10600 10600 10600 10600
02662 04142 06435 16554
10000 10000 10000 10000
02662 04142 06435 16554
10000 10000 10000 10000
02511 03908 06071 15617
$1996 Obstetrics Obstetrics $3107 Obstetrics Obstetrics $4826 Obstetrics Obstetrics
$12416 Obstetrics Obstetrics 563-1 563-2 563-3 563-4
THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION
259 391 747 720
02581 03376 05162 09652
10000 10000 10000 10000
10600 10600 10600 10600
02736 03579 05472 10231
10000 10000 10000 10000
02736 03579 05472 10231
10000 10000 10000 10000
02581 03376 05162 09652
$2052 Obstetrics Obstetrics $2684 Obstetrics Obstetrics $4104 Obstetrics Obstetrics $7673 Obstetrics Obstetrics
564-1 564-2 564-3 564-4
ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY
137 170 276 808
02881 03463 04901 16676
10000 10000 10000 10000
10600 10600 10600 10600
03054 03671 05195 17677
10000 10000 10000 10000
03054 03671 05195 17677
10000 10000 10000 10000
02881 03463 04901 16676
$2290 Obstetrics Obstetrics $2753 Obstetrics Obstetrics $3896 Obstetrics Obstetrics
$13257 Obstetrics Obstetrics 565-1 565-2 565-3 565-4
FALSE LABOR FALSE LABOR FALSE LABOR FALSE LABOR
123 185 735 808
01245 01782 02687 02986
10000 10000 10000 10000
10600 10600 10600 10600
01320 01889 02848 03165
10000 10000 10000 10000
01320 01889 02848 03165
10000 10000 10000 10000
01245 01782 02687 02986
$990 Obstetrics Obstetrics $1417 Obstetrics Obstetrics $2136 Obstetrics Obstetrics $2374 Obstetrics Obstetrics
566-1 566-2 566-3 566-4
OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES
211 294 544 843
02442 03252 04790 14726
10000 10000 10000 10000
10600 10600 10600 10600
02589 03447 05077 15610
10000 10000 10000 10000
02589 03447 05077 15610
10000 10000 10000 10000
02442 03252 04790 14726
$1941 Obstetrics Obstetrics $2585 Obstetrics Obstetrics $3808 Obstetrics Obstetrics
$11707 Obstetrics Obstetrics 580-1 580-2 580-3 580-4
NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE
144 159 182 165
02398 03209 05011 08512
12500 12500 12500 12500
10000 10000 10000 10000
02998 04011 06264 10640
10000 10000 10000 10000
02998 04011 06264 10640
17500 17500 17500 17500
04197 05616 08769 14896
$2248 Neonate Neonate $3008 Neonate Neonate $4698 Neonate Neonate $7980 Neonate Neonate
581-1 581-2 581-3 581-4
NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE
124 128 126 135
00982 01477 02362 04408
12500 12500 12500 12500
10000 10000 10000 10000
01228 01846 02953 05510
10000 10000 10000 10000
01228 01846 02953 05510
17500 17500 17500 17500
01719 02585 04134 07714
$921 Neonate Neonate $1385 Neonate Neonate $2214 Neonate Neonate $4133 Neonate Neonate
583-1 583-2 583-3 583-4
NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO
2070 2300 3077 4886
99741 157496 173245 240894
12500 12500 12500 12500
10000 10000 10000 10000
124676 196870 216556 301118
10000 10000 10000 10000
124676 196870 216556 301118
17500 17500 17500 17500
174547 275618 303179 421565
$93507 Neonate Neonate $147653 Neonate Neonate $162417 Neonate Neonate $225838 Neonate Neonate
588-1 588-2 588-3 588-4
NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE
4442 4935 7714
10207
48410 70035
142903 216660
12500 12500 12500 12500
10000 10000 10000 10000
60513 87544
178629 270825
10000 10000 10000 10000
60513 87544
178629 270825
17500 17500 17500 17500
84718 122561 250080 379155
$45384 Neonate Neonate $65658 Neonate Neonate
$133972 Neonate Neonate $203119 Neonate Neonate
589-1 589-2 589-3 589-4
NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS
5843 5041 3035
265
115468 104972
95430 04454
12500 12500 12500 12500
10000 10000 10000 10000
144335 131215 119288
05568
10000 10000 10000 10000
144335 131215 119288
05568
17500 17500 17500 17500
202069 183701 167003
07795
$108251 Neonate Neonate $98411 Neonate Neonate $89466 Neonate Neonate
$4176 Neonate Neonate 591-1 591-2 591-3 591-4
NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE
211 3710 5061 7221
01574 55672 88282
132286
12500 12500 12500 12500
10000 10000 10000 10000
01968 69590
110353 165358
10000 10000 10000 10000
01968 69590
110353 165358
17500 17500 17500 17500
02755 97426
154494 231501
$1476 Neonate Neonate $52193 Neonate Neonate $82764 Neonate Neonate
$124018 Neonate Neonate 593-1 593-2 593-3 593-4
NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE
1928 4851 5965 7143
15109 51914 82800
122454
12500 12500 12500 12500
10000 10000 10000 10000
18886 64893
103500 153068
10000 10000 10000 10000
18886 64893
103500 153068
17500 17500 17500 17500
26441 90850
144900 214295
$14165 Neonate Neonate $48669 Neonate Neonate $77625 Neonate Neonate
$114801 Neonate Neonate 602-1 602-2 602-3 602-4
NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2513 4403 5324 6307
29635 58707 77593
104733
12500 12500 12500 12500
10000 10000 10000 10000
37044 73384 96991
130916
10000 10000 10000 10000
37044 73384 96991
130916
17500 17500 17500 17500
51861 102737 135788 183283
$27783 Neonate Neonate $55038 Neonate Neonate $72743 Neonate Neonate $98187 Neonate Neonate
603-1 603-2 603-3 603-4
NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION
2234 3619 4843 5396
17223 42526 65587 70750
12500 12500 12500 12500
10000 10000 10000 10000
21529 53158 81984 88438
10000 10000 10000 10000
21529 53158 81984 88438
17500 17500 17500 17500
30140 74421
114777 123813
$16147 Neonate Neonate $39868 Neonate Neonate $61488 Neonate Neonate $66328 Neonate Neonate
607-1 607-2 607-3 607-4
NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2509 3582 4341 4957
27503 47486 61883 79508
12500 12500 12500 12500
10000 10000 10000 10000
34379 59358 77354 99385
10000 10000 10000 10000
34379 59358 77354 99385
17500 17500 17500 17500
48130 83101
108295 139139
$25784 Neonate Neonate $44518 Neonate Neonate $58015 Neonate Neonate $74539 Neonate Neonate
608-1 608-2 608-3 608-4
NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION
1980 3004 3846 4414
21292 36047 52684 60424
12500 12500 12500 12500
10000 10000 10000 10000
26615 45059 65855 75530
10000 10000 10000 10000
26615 45059 65855 75530
17500 17500 17500 17500
37261 63082 92197
105742
$19961 Neonate Neonate $33794 Neonate Neonate $49391 Neonate Neonate $56648 Neonate Neonate
609-1 609-2 609-3 609-4
NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE
1933 2210 3803 6267
27332 38628 65636
119134
12500 12500 12500 12500
10000 10000 10000 10000
34165 48285 82045
148918
10000 10000 10000 10000
34165 48285 82045
148918
17500 17500 17500 17500
47831 67599
114863 208485
$25624 Neonate Neonate $36214 Neonate Neonate $61534 Neonate Neonate
$111688 Neonate Neonate 611-1 611-2 611-3 611-4
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY
1313 2123 3133 3614
11780 25158 40556 52442
12500 12500 12500 12500
10000 10000 10000 10000
14725 31448 50695 65553
10000 10000 10000 10000
14725 31448 50695 65553
17500 17500 17500 17500
20615 44027 70973 91774
$11044 Neonate Neonate $23586 Neonate Neonate $38021 Neonate Neonate $49164 Neonate Neonate
612-1 612-2 612-3 612-4
NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND
1756 2442 3248 3834
21880 32223 46803 62297
12500 12500 12500 12500
10000 10000 10000 10000
27350 40279 58504 77871
10000 10000 10000 10000
27350 40279 58504 77871
17500 17500 17500 17500
38290 56390 81905
109020
$20513 Neonate Neonate $30209 Neonate Neonate $43878 Neonate Neonate $58403 Neonate Neonate
613-1 613-2 613-3 613-4
NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION
1439 2153 2853 3338
16593 26831 37601 48828
12500 12500 12500 12500
10000 10000 10000 10000
20741 33539 47001 61035
10000 10000 10000 10000
20741 33539 47001 61035
17500 17500 17500 17500
29038 46954 65802 85449
$15556 Neonate Neonate $25154 Neonate Neonate $35251 Neonate Neonate $45776 Neonate Neonate
614-1 614-2 614-3 614-4
NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION
1123 2008 2852 3640
09241 22768 36403 50802
12500 12500 12500 12500
10000 10000 10000 10000
11551 28460 45504 63503
10000 10000 10000 10000
11551 28460 45504 63503
17500 17500 17500 17500
16172 39844 63705 88904
$8663 Neonate Neonate $21345 Neonate Neonate $34128 Neonate Neonate $47627 Neonate Neonate
621-1 621-2 621-3 621-4
NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY
820 1397 2125 2416
06082 15379 27206 38101
12500 12500 12500 12500
10000 10000 10000 10000
07603 19224 34008 47626
10000 10000 10000 10000
07603 19224 34008 47626
17500 17500 17500 17500
10644 26913 47611 66677
$5702 Neonate Neonate $14418 Neonate Neonate $25506 Neonate Neonate $35720 Neonate Neonate
622-1 622-2 622-3 622-4
NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND
1118 1514 1977 2285
13666 20913 29736 47202
12500 12500 12500 12500
10000 10000 10000 10000
17083 26141 37170 59003
10000 10000 10000 10000
17083 26141 37170 59003
17500 17500 17500 17500
23916 36598 52038 82604
$12812 Neonate Neonate $19606 Neonate Neonate $27878 Neonate Neonate $44252 Neonate Neonate
623-1 623-2 623-3 623-4
NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION
924 1399 1872 2738
09934 16800 25087 38932
12500 12500 12500 12500
10000 10000 10000 10000
12418 21000 31359 48665
10000 10000 10000 10000
12418 21000 31359 48665
17500 17500 17500 17500
17385 29400 43902 68131
$9313 Neonate Neonate $15750 Neonate Neonate $23519 Neonate Neonate $36499 Neonate Neonate
625-1 625-2 625-3 625-4
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION
1157 1621 1925 2015
11469 18627 23298 29194
12500 12500 12500 12500
10000 10000 10000 10000
14336 23284 29123 36493
10000 10000 10000 10000
14336 23284 29123 36493
17500 17500 17500 17500
20071 32597 40772 51090
$10752 Neonate Neonate $17463 Neonate Neonate $21842 Neonate Neonate $27369 Neonate Neonate
626-1 626-2 626-3 626-4
NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
279 456 864
1838
01387 02587 07679 22819
10000 10000 10000 10000
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
$1040 Normal newborn Normal newborn $1940 Normal newborn Normal newborn $5759 Normal newborn Normal newborn
$17114 Normal newborn Normal newborn 630-1 630-2 630-3 630-4
NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE
486 940
1448 3912
20468 32885 52250
112072
12500 12500 12500 12500
10000 10000 10000 10000
25585 41106 65313
140090
10000 10000 10000 10000
25585 41106 65313
140090
17500 17500 17500 17500
35819 57549 91438
196126
$19189 Neonate Neonate $30830 Neonate Neonate $48984 Neonate Neonate
$105068 Neonate Neonate 631-1 631-2 631-3 631-4
NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE
335 886
2279 5111
09217 16766 37480 96324
12500 12500 12500 12500
10000 10000 10000 10000
11521 20958 46850
120405
10000 10000 10000 10000
11521 20958 46850
120405
17500 17500 17500 17500
16130 29341 65590
168567
$8641 Neonate Neonate $15718 Neonate Neonate $35138 Neonate Neonate $90304 Neonate Neonate
633-1 633-2 633-3 633-4
NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY
296 651
1226 2381
01972 05798 13892 39728
12500 12500 12500 12500
10000 10000 10000 10000
02465 07248 17365 49660
10000 10000 10000 10000
02465 07248 17365 49660
17500 17500 17500 17500
03451 10147 24311 69524
$1849 Neonate Neonate $5436 Neonate Neonate
$13024 Neonate Neonate $37245 Neonate Neonate
634-1 634-2 634-3 634-4
NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND
465 749
1261 2233
04886 09445 20176 46934
12500 12500 12500 12500
10000 10000 10000 10000
06108 11806 25220 58668
10000 10000 10000 10000
06108 11806 25220 58668
17500 17500 17500 17500
08551 16529 35308 82135
$4581 Neonate Neonate $8855 Neonate Neonate
$18915 Neonate Neonate $44001 Neonate Neonate
636-1 636-2 636-3 636-4
NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION
558 779
1164 1896
05582 08840 15558 30613
12500 12500 12500 12500
10000 10000 10000 10000
06978 11050 19448 38266
10000 10000 10000 10000
06978 11050 19448 38266
17500 17500 17500 17500
09769 15470 27227 53573
$5233 Neonate Neonate $8288 Neonate Neonate
$14586 Neonate Neonate $28700 Neonate Neonate
639-1 639-2 639-3 639-4
NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION
441 704 998
1653
03287 06622 11809 27285
12500 12500 12500 12500
10000 10000 10000 10000
04109 08278 14761 34106
10000 10000 10000 10000
04109 08278 14761 34106
17500 17500 17500 17500
05752 11589 20666 47749
$3082 Neonate Neonate $6208 Neonate Neonate
$11071 Neonate Neonate $25580 Neonate Neonate
640-1 NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 210 01012 10000 10000 01012 10000 01012 10000 01012 $759 Normal newborn Normal newborn
640-2 640-3 640-4
NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
245 376
1206
01353 02864 14726
10000 10000 10000
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
$1015 Normal newborn Normal newborn $2148 Normal newborn Normal newborn
$11045 Normal newborn Normal newborn 650-1 650-2 650-3 650-4
SPLENECTOMY SPLENECTOMY SPLENECTOMY SPLENECTOMY
348 537 848
1563
12985 17965 25202 50826
10000 10000 10000 10000
10000 10000 10000 10000
12985 17965 25202 50826
12500 12500 12500 12500
16231 22456 31503 63533
10000 10000 10000 10000
12985 17965 25202 50826
$12173 Misc Pediatric Misc Adult $16842 Misc Pediatric Misc Adult $23627 Misc Pediatric Misc Adult $47649 Misc Pediatric Misc Adult
651-1 651-2 651-3 651-4
OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS
331 472 962
2426
09234 13695 21005 59541
10000 10000 10000 10000
10000 10000 10000 10000
09234 13695 21005 59541
12500 12500 12500 12500
11543 17119 26256 74426
10000 10000 10000 10000
09234 13695 21005 59541
$8657 Misc Pediatric Misc Adult $12839 Misc Pediatric Misc Adult $19692 Misc Pediatric Misc Adult $55820 Misc Pediatric Misc Adult
660-1 660-2 660-3 660-4
MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL
305 408 648
1435
05399 07219 11819 30180
10000 10000 10000 10000
10000 10000 10000 10000
05399 07219 11819 30180
12500 12500 12500 12500
06749 09024 14774 37725
10000 10000 10000 10000
05399 07219 11819 30180
$5062 Misc Pediatric Misc Adult $6768 Misc Pediatric Misc Adult
$11080 Misc Pediatric Misc Adult $28294 Misc Pediatric Misc Adult
661-1 661-2 661-3 661-4
COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS
275 375 566
1265
06473 08098 12433 27857
10000 10000 10000 10000
10000 10000 10000 10000
06473 08098 12433 27857
12500 12500 12500 12500
08091 10123 15541 34821
10000 10000 10000 10000
06473 08098 12433 27857
$6068 Misc Pediatric Misc Adult $7592 Misc Pediatric Misc Adult
$11656 Misc Pediatric Misc Adult $26116 Misc Pediatric Misc Adult
662-1 662-2 662-3 662-4
SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS
412 538 785
1302
05044 07003 10778 23937
10000 10000 10000 10000
10000 10000 10000 10000
05044 07003 10778 23937
12500 12500 12500 12500
06305 08754 13473 29921
10000 10000 10000 10000
05044 07003 10778 23937
$4729 Misc Pediatric Misc Adult $6565 Misc Pediatric Misc Adult
$10104 Misc Pediatric Misc Adult $22441 Misc Pediatric Misc Adult
663-1 663-2 663-3 663-4
OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS
232 301 451 900
04474 05959 08513 16106
10000 10000 10000 10000
10000 10000 10000 10000
04474 05959 08513 16106
12500 12500 12500 12500
05593 07449 10641 20133
10000 10000 10000 10000
04474 05959 08513 16106
$4194 Misc Pediatric Misc Adult $5587 Misc Pediatric Misc Adult $7981 Misc Pediatric Misc Adult
$15099 Misc Pediatric Misc Adult 680-1 680-2 680-3 680-4
MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
408 633
1185 2456
13702 18600 32002 66288
10000 10000 10000 10000
10000 10000 10000 10000
13702 18600 32002 66288
12500 12500 12500 12500
17128 23250 40003 82860
10000 10000 10000 10000
13702 18600 32002 66288
$12846 Misc Pediatric Misc Adult $17438 Misc Pediatric Misc Adult $30002 Misc Pediatric Misc Adult $62145 Misc Pediatric Misc Adult
681-1 681-2 681-3 681-4
OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
268 507
1111 2510
09800 13647 24597 59170
10000 10000 10000 10000
10000 10000 10000 10000
09800 13647 24597 59170
12500 12500 12500 12500
12250 17059 30746 73963
10000 10000 10000 10000
09800 13647 24597 59170
$9188 Misc Pediatric Misc Adult $12794 Misc Pediatric Misc Adult $23060 Misc Pediatric Misc Adult $55472 Misc Pediatric Misc Adult
690-1 690-2 690-3 690-4
ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA
495 740
1461 2485
07040 11869 23551 52504
10000 10000 10000 10000
10000 10000 10000 10000
07040 11869 23551 52504
12500 12500 12500 12500
08800 14836 29439 65630
10000 10000 10000 10000
07040 11869 23551 52504
$6600 Misc Pediatric Misc Adult $11127 Misc Pediatric Misc Adult $22079 Misc Pediatric Misc Adult $49223 Misc Pediatric Misc Adult
691-1 691-2 691-3 691-4
LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA
389 540 861
1585
07077 09840 15477 31411
10000 10000 10000 10000
10000 10000 10000 10000
07077 09840 15477 31411
12500 12500 12500 12500
08846 12300 19346 39264
10000 10000 10000 10000
07077 09840 15477 31411
$6635 Misc Pediatric Misc Adult $9225 Misc Pediatric Misc Adult
$14510 Misc Pediatric Misc Adult $29448 Misc Pediatric Misc Adult
692-1 692-2 692-3 692-4
RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY
389 482 868
1580
06075 12584 17422 29316
10000 10000 10000 10000
10000 10000 10000 10000
06075 12584 17422 29316
12500 12500 12500 12500
07594 15730 21778 36645
10000 10000 10000 10000
06075 12584 17422 29316
$5695 Misc Pediatric Misc Adult $11798 Misc Pediatric Misc Adult $16333 Misc Pediatric Misc Adult $27484 Misc Pediatric Misc Adult
693-1 693-2 693-3 693-4
CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY
281 368 785
2410
06251 07881 13637 49083
10000 10000 10000 10000
10000 10000 10000 10000
06251 07881 13637 49083
12500 12500 12500 12500
07814 09851 17046 61354
10000 10000 10000 10000
06251 07881 13637 49083
$5860 Misc Pediatric Misc Adult $7388 Misc Pediatric Misc Adult
$12785 Misc Pediatric Misc Adult $46015 Misc Pediatric Misc Adult
694-1 694-2 694-3 694-4
LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR
304 404 674
1164
04842 06831 11115 21001
10000 10000 10000 10000
10000 10000 10000 10000
04842 06831 11115 21001
12500 12500 12500 12500
06053 08539 13894 26251
10000 10000 10000 10000
04842 06831 11115 21001
$4539 Misc Pediatric Misc Adult $6404 Misc Pediatric Misc Adult
$10420 Misc Pediatric Misc Adult $19688 Misc Pediatric Misc Adult
710-1 710-2 710-3 710-4
INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE
510 680
1111 1820
10635 15963 25572 49382
10000 10000 10000 10000
10000 10000 10000 10000
10635 15963 25572 49382
12500 12500 12500 12500
13294 19954 31965 61728
10000 10000 10000 10000
10635 15963 25572 49382
$9970 Misc Pediatric Misc Adult $14965 Misc Pediatric Misc Adult $23974 Misc Pediatric Misc Adult $46296 Misc Pediatric Misc Adult
711-1 711-2 711-3 711-4
POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE
471 692
1131 2087
10079 14143 23599 50574
10000 10000 10000 10000
10000 10000 10000 10000
10079 14143 23599 50574
12500 12500 12500 12500
12599 17679 29499 63218
10000 10000 10000 10000
10079 14143 23599 50574
$9449 Misc Pediatric Misc Adult $13259 Misc Pediatric Misc Adult $22124 Misc Pediatric Misc Adult $47413 Misc Pediatric Misc Adult
720-1 720-2 720-3 720-4
SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS
353 444 633
1004
05431 07613 11532 21705
10000 10000 10000 10000
10000 10000 10000 10000
05431 07613 11532 21705
12500 12500 12500 12500
06789 09516 14415 27131
10000 10000 10000 10000
05431 07613 11532 21705
$5092 Misc Pediatric Misc Adult $7137 Misc Pediatric Misc Adult
$10811 Misc Pediatric Misc Adult $20348 Misc Pediatric Misc Adult
721-1 721-2 721-3 721-4
POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS
368 470 705
1153
05287 07209 11619 22025
10000 10000 10000 10000
10000 10000 10000 10000
05287 07209 11619 22025
12500 12500 12500 12500
06609 09011 14524 27531
10000 10000 10000 10000
05287 07209 11619 22025
$4957 Misc Pediatric Misc Adult $6758 Misc Pediatric Misc Adult
$10893 Misc Pediatric Misc Adult $20648 Misc Pediatric Misc Adult
722-1 722-2 722-3 722-4
FEVER FEVER FEVER FEVER
230 302 429 739
03423 05223 07630 13141
10000 10000 10000 10000
10000 10000 10000 10000
03423 05223 07630 13141
12500 12500 12500 12500
04279 06529 09538 16426
10000 10000 10000 10000
03423 05223 07630 13141
$3209 Misc Pediatric Misc Adult $4897 Misc Pediatric Misc Adult $7153 Misc Pediatric Misc Adult
$12320 Misc Pediatric Misc Adult 723-1 723-2 723-3 723-4
VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS
216 279 470
1317
03194 04738 07794 24233
10000 10000 10000 10000
10000 10000 10000 10000
03194 04738 07794 24233
12500 12500 12500 12500
03993 05923 09743 30291
10000 10000 10000 10000
03194 04738 07794 24233
$2994 Misc Pediatric Misc Adult $4442 Misc Pediatric Misc Adult $7307 Misc Pediatric Misc Adult
$22718 Misc Pediatric Misc Adult 724-1 724-2 724-3 724-4
OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES
400 477 680
1337
05512 07131 11401 24698
10000 10000 10000 10000
10000 10000 10000 10000
05512 07131 11401 24698
12500 12500 12500 12500
06890 08914 14251 30873
10000 10000 10000 10000
05512 07131 11401 24698
$5168 Misc Pediatric Misc Adult $6685 Misc Pediatric Misc Adult
$10688 Misc Pediatric Misc Adult $23154 Misc Pediatric Misc Adult
740-1 740-2 740-3 740-4
MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE
678 1284 2034 2421
10899 13904 24356 37756
10000 10000 10000 10000
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
$8174 Other Other $10428 Other Other $18267 Other Other $28317 Other Other
750-1 750-2 750-3 750-4
SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA
1082 1179 1539 2848
05713 06699 09202 19283
10000 10000 10000 10000
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
$4285 Other Other $5024 Other Other $6902 Other Other
$14462 Other Other 751-1 751-2 751-3 751-4
MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES
528 724
1055 2028
03572 05019 08097 15923
10000 10000 10000 10000
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
$2679 Other Other $3764 Other Other $6073 Other Other
$11942 Other Other 752-1 752-2 752-3 752-4
DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL
503 658
1473 7300
03399 04498 09061 14934
10000 10000 10000 10000
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
$2549 Other Other $3374 Other Other $6796 Other Other
$11201 Other Other 753-1 753-2 753-3 753-4
BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS
601 808
1205 1948
04001 05365 08266 14926
10000 10000 10000 10000
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
$3001 Other Other $4024 Other Other $6200 Other Other
$11195 Other Other 754-1 754-2 754-3 754-4
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER
424 558 727
1664
02943 03998 05677 11553
10000 10000 10000 10000
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
$2207 Other Other $2999 Other Other $4258 Other Other $8665 Other Other
755-1 755-2 755-3 755-4
ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
388 622 900 813
02738 04363 06226 08767
10000 10000 10000 10000
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
$2054 Other Other $3272 Other Other $4670 Other Other $6575 Other Other
756-1 756-2 756-3 756-4
ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES
331 381 457 942
04061 05308 06065 13981
10000 10000 10000 10000
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
$3046 Other Other $3981 Other Other $4549 Other Other
$10486 Other Other 757-1 757-2 757-3 757-4
ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES
873 934
1087 1640
05861 07234 08953 13799
10000 10000 10000 10000
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
$4396 Other Other $5426 Other Other $6715 Other Other
$10349 Other Other 758-1 758-2 758-3 758-4
CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS
694 981
1225 4300
03874 05129 06541 11332
10000 10000 10000 10000
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
$2906 Other Other $3847 Other Other $4906 Other Other $8499 Other Other
759-1 759-2 759-3 759-4
EATING DISORDERS EATING DISORDERS EATING DISORDERS EATING DISORDERS
1990 1297 1402 2303
06561 06961 10053 16606
10000 10000 10000 10000
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
$4921 Other Other $5221 Other Other $7540 Other Other
$12455 Other Other 760-1 760-2 760-3 760-4
OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS
748 766 912
1204
04840 06173 07573 14134
10000 10000 10000 10000
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
$3630 Other Other $4630 Other Other $5680 Other Other
$10601 Other Other 770-1 770-2 770-3 770-4
DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE
253 248 332 794
02240 02623 05475 16843
10000 10000 10000 10000
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
$1680 Other Other $1967 Other Other $4106 Other Other
$12632 Other Other 772-1 772-2 772-3 772-4
ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY
1434 1551 1289 2385
05441 06916 07009 24530
10000 10000 10000 10000
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
$4081 Other Other $5187 Other Other $5257 Other Other
$18398 Other Other 773-1 773-2 773-3 773-4
OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE
337 414 507 992
02663 03466 05964 18606
10000 10000 10000 10000
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
$1997 Other Other $2600 Other Other $4473 Other Other
$13955 Other Other 774-1 774-2
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
365 412
03040 03627
10000 10000
10000 10000
03040 03627
10000 10000
03040 03627
10000 10000
03040 03627
$2280 Other Other $2720 Other Other
774-3 774-4
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
479 1424
06448 24682
10000 10000
10000 10000
06448 24682
10000 10000
06448 24682
10000 10000
06448 24682
$4836 Other $18512 Other
Other Other
775-1 775-2 775-3 775-4
ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE
323 377 571
1263
03313 04639 08596 24910
10000 10000 10000 10000
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
$2485 Other $3479 Other $6447 Other
$18683 Other
Other Other Other Other
776-1 776-2 776-3 776-4
OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE
389 397 496 933
03157 04547 07887 16112
10000 10000 10000 10000
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
$2368 Other $3410 Other $5915 Other
$12084 Other
Other Other Other Other
791-1 791-2 791-3 791-4
OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT
314 515 989
2009
08636 12677 21979 49312
10000 10000 10000 10000
10000 10000 10000 10000
08636 12677 21979 49312
12500 12500 12500 12500
10795 15846 27474 61640
10000 10000 10000 10000
08636 12677 21979 49312
$8096 Misc Pediatric $11885 Misc Pediatric $20605 Misc Pediatric $46230 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
811-1 811-2 811-3 811-4
ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS
151 202 390 913
02707 03855 08277 22176
10000 10000 10000 10000
10000 10000 10000 10000
02707 03855 08277 22176
12500 12500 12500 12500
03384 04819 10346 27720
10000 10000 10000 10000
02707 03855 08277 22176
$2538 Misc Pediatric $3614 Misc Pediatric $7760 Misc Pediatric
$20790 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
812-1 812-2 812-3 812-4
POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS
165 225 347 694
03469 04331 07709 17419
10000 10000 10000 10000
10000 10000 10000 10000
03469 04331 07709 17419
12500 12500 12500 12500
04336 05414 09636 21774
10000 10000 10000 10000
03469 04331 07709 17419
$3252 Misc Pediatric $4060 Misc Pediatric $7227 Misc Pediatric
$16330 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
813-1 813-2 813-3 813-4
OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT
261 344 594
1344
04393 06056 09631 19960
10000 10000 10000 10000
10000 10000 10000 10000
04393 06056 09631 19960
12500 12500 12500 12500
05491 07570 12039 24950
10000 10000 10000 10000
04393 06056 09631 19960
$4118 Misc Pediatric $5678 Misc Pediatric $9029 Misc Pediatric
$18713 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
815-1 815-2 815-3 815-4
OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES
169 276 456 880
04211 05012 08129 22715
10000 10000 10000 10000
10000 10000 10000 10000
04211 05012 08129 22715
12500 12500 12500 12500
05264 06265 10161 28394
10000 10000 10000 10000
04211 05012 08129 22715
$3948 Misc Pediatric $4699 Misc Pediatric $7621 Misc Pediatric
$21295 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
816-1 816-2 816-3 816-4
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
173 240 346 736
04162 04915 07864 18134
10000 10000 10000 10000
10000 10000 10000 10000
04162 04915 07864 18134
12500 12500 12500 12500
05203 06144 09830 22668
10000 10000 10000 10000
04162 04915 07864 18134
$3902 Misc Pediatric $4608 Misc Pediatric $7373 Misc Pediatric
$17001 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
841-1 841-2 841-3 841-4
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT
2200 967
2599 4068
31148 34263 64068
159153
10000 10000 10000 10000
10000 10000 10000 10000
31148 34263 64068
159153
12500 12500 12500 12500
38935 42829 80085
198941
10000 10000 10000 10000
31148 34263 64068
159153
$29201 Misc Pediatric $32122 Misc Pediatric $60064 Misc Pediatric
$149206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
842-1 842-2 842-3 842-4
FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT
751 1072 1735 3010
14151 21416 38719 95054
10000 10000 10000 10000
10000 10000 10000 10000
14151 21416 38719 95054
12500 12500 12500 12500
17689 26770 48399
118818
10000 10000 10000 10000
14151 21416 38719 95054
$13267 Misc Pediatric $20078 Misc Pediatric $36299 Misc Pediatric $89113 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
843-1 843-2 843-3 843-4
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT
339 487 713
1113
04752 06661 11619 32621
10000 10000 10000 10000
10000 10000 10000 10000
04752 06661 11619 32621
12500 12500 12500 12500
05940 08326 14524 40776
10000 10000 10000 10000
04752 06661 11619 32621
$4455 Misc Pediatric $6245 Misc Pediatric
$10893 Misc Pediatric $30582 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
844-1 844-2 844-3 844-4
PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT
310 497 743
1781
04337 06965 12193 48021
10000 10000 10000 10000
10000 10000 10000 10000
04337 06965 12193 48021
12500 12500 12500 12500
05421 08706 15241 60026
10000 10000 10000 10000
04337 06965 12193 48021
$4066 Misc Pediatric $6530 Misc Pediatric
$11431 Misc Pediatric $45020 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
850-1 850-2 850-3 850-4
PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE
267 556
1618 3148
11757 14065 24870 46520
10000 10000 10000 10000
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
$8818 Misc Pediatric $10549 Misc Pediatric $18653 Misc Pediatric $34890 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
860-1 860-2 860-3 860-4
REHABILITATION REHABILITATION REHABILITATION REHABILITATION
932 1146 1475 1795
07227 09855 13880 17876
10000 10000 10000 10000
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
$5420 Other $7391 Other
$10410 Other $13407 Other
Other Other Other Other
861-1 861-2 861-3 861-4
SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS
253 340 497 917
02858 05247 07658 14498
10000 10000 10000 10000
10000 10000 10000 10000
02858 05247 07658 14498
12500 12500 12500 12500
03573 06559 09573 18123
10000 10000 10000 10000
02858 05247 07658 14498
$2679 Misc Pediatric $4919 Misc Pediatric $7179 Misc Pediatric
$13592 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
862-1 862-2 862-3 862-4
OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE
698 1122 1357 1872
02895 05851 07866 11351
10000 10000 10000 10000
10000 10000 10000 10000
02895 05851 07866 11351
12500 12500 12500 12500
03619 07314 09833 14189
10000 10000 10000 10000
02895 05851 07866 11351
$2714 Misc Pediatric $5485 Misc Pediatric $7374 Misc Pediatric
$10642 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
863-1 863-2 863-3 863-4
NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE
853 1757 2771 4643
05959 16127 30507 61446
12500 12500 12500 12500
10000 10000 10000 10000
07449 20159 38134 76808
10000 10000 10000 10000
07449 20159 38134 76808
17500 17500 17500 17500
10428 28222 53387
107531
$5587 Neonate $15119 Neonate $28600 Neonate $57606 Neonate
Neonate Neonate Neonate Neonate
890-1 890-2 890-3 890-4
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS
167 691 921
1514
07051 10224 14771 30014
10000 10000 10000 10000
10000 10000 10000 10000
07051 10224 14771 30014
12500 12500 12500 12500
08814 12780 18464 37518
10000 10000 10000 10000
07051 10224 14771 30014
$6610 Misc Pediatric $9585 Misc Pediatric
$13848 Misc Pediatric $28138 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
892-1 892-2 892-3 892-4
HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION
587 488 669
1152
05647 07763 10877 19375
10000 10000 10000 10000
10000 10000 10000 10000
05647 07763 10877 19375
12500 12500 12500 12500
07059 09704 13596 24219
10000 10000 10000 10000
05647 07763 10877 19375
$5294 Misc Pediatric $7278 Misc Pediatric
$10197 Misc Pediatric $18164 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
893-1 893-2 893-3 893-4
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
499 496 799
1422
07762 08219 12807 24296
10000 10000 10000 10000
10000 10000 10000 10000
07762 08219 12807 24296
12500 12500 12500 12500
09703 10274 16009 30370
10000 10000 10000 10000
07762 08219 12807 24296
$7277 Misc Pediatric $7705 Misc Pediatric
$12007 Misc Pediatric $22778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
894-1 894-2 894-3 894-4
HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND
341 393 627
1121
05218 06497 09774 19428
10000 10000 10000 10000
10000 10000 10000 10000
05218 06497 09774 19428
12500 12500 12500 12500
06523 08121 12218 24285
10000 10000 10000 10000
05218 06497 09774 19428
$4892 Misc Pediatric $6091 Misc Pediatric $9163 Misc Pediatric
$18214 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
910-1 910-2 910-3 910-4
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA
1100 775
1057 1830
28786 31984 41628 72114
10000 10000 10000 10000
10000 10000 10000 10000
28786 31984 41628 72114
12500 12500 12500 12500
35983 39980 52035 90143
10000 10000 10000 10000
28786 31984 41628 72114
$26987 Misc Pediatric $29985 Misc Pediatric $39026 Misc Pediatric $67607 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
911-1 911-2 911-3 911-4
EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA
511 619 795
1687
15160 20189 26724 58039
10000 10000 10000 10000
10000 10000 10000 10000
15160 20189 26724 58039
12500 12500 12500 12500
18950 25236 33405 72549
10000 10000 10000 10000
15160 20189 26724 58039
$14213 Misc Pediatric $18927 Misc Pediatric $25054 Misc Pediatric $54412 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
912-1 912-2 912-3 912-4
MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
558 607 985
1782
20950 22759 36410 68885
10000 10000 10000 10000
10000 10000 10000 10000
20950 22759 36410 68885
12500 12500 12500 12500
26188 28449 45513 86106
10000 10000 10000 10000
20950 22759 36410 68885
$19641 Misc Pediatric $21337 Misc Pediatric $34134 Misc Pediatric $64580 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
930-1 930-2 930-3 930-4
MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE
322 370 596
1127
07826 09594 15857 33896
10000 10000 10000 10000
10000 10000 10000 10000
07826 09594 15857 33896
12500 12500 12500 12500
09783 11993 19821 42370
10000 10000 10000 10000
07826 09594 15857 33896
$7337 Misc Pediatric $8994 Misc Pediatric
$14866 Misc Pediatric $31778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
950-1 950-2 950-3 950-4
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
361 623
1166 2260
13230 20029 31827 60092
10000 10000 10000 10000
10000 10000 10000 10000
13230 20029 31827 60092
12500 12500 12500 12500
16538 25036 39784 75115
10000 10000 10000 10000
13230 20029 31827 60092
$12403 Misc Pediatric $18777 Misc Pediatric $29838 Misc Pediatric $56336 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
951-1 951-2 951-3 951-4
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
329 517
1001 1973
09755 14320 24054 46875
10000 10000 10000 10000
10000 10000 10000 10000
09755 14320 24054 46875
12500 12500 12500 12500
12194 17900 30068 58594
10000 10000 10000 10000
09755 14320 24054 46875
$9145 Misc Pediatric $13425 Misc Pediatric $22551 Misc Pediatric $43945 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
952-1 952-2 952-3 952-4
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
274 504 968
1894
07736 11591 20369 39177
10000 10000 10000 10000
10000 10000 10000 10000
07736 11591 20369 39177
12500 12500 12500 12500
09670 14489 25461 48971
10000 10000 10000 10000
07736 11591 20369 39177
$7253 Misc Pediatric $10867 Misc Pediatric $19096 Misc Pediatric $36728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
955-0 956-0
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS UNGROUPABLE
--
--
Error DRG Error DRG
Error DRG Error DRG
i-
i
i
i-
i
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy adjustor F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that has at least a basic level
emergency room H FY 2015-16 Cost-to-Charge Ratio FY 2013 cost-to-charge ratio with some exceptions I FY 2015-16 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FY 2015-16 Wage Index Value (adjusted for CA Neutrality Factor 09797) W age index value times 09797 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls for changes between California
and the rest of the US while maintaining relative differences among wage areas within California K FY 2015-16 Unadjusted Statewide Base Rate The statewide DRG base rate is $6289 except that for remote rural hospitals it is $12768 L FY 2015-16 Wage Adjusted Statewide Base Rate (Non-Transition) The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses See Tab 5 This rate is applicable for non-transition hospitals as shown in Column N Medi-Cal
managed care plans that are pricing claims for emergency and post-stabilization services hospitals outside their network should use Column L for all hospitals M FY 2015-16 Hospital-Specific Transition Base Rate The base rate assigned to hospitals to move them in steps toward the statewide base rate This rate is applicable for transition hospitals as shown in Column N FY 2015-16 is the final year of transition rates N Transition rate This column identifies whether the hospital is a non-transition hospital (base rate in Column L) or a transition hospital (base rate in Column M) O FY 2015-16 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2015-16 P FY 2015-16 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by
use of Revenue Code 190 Q FY 2015-16 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by use of
Revenue Code 199
A B C D E F G H I J K L M N O P Q
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transit on Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
OUT OF STATE No No No No No 2180 10000 10000 $6289 $6289 NA Non-Transition NA $98163 $80582 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 3572 12882 12620 $12768 $15097 $15414 Transition NA $98163 $80582 106100793 ADVENTIST MEDICAL CENTER - SELMA COMMUNITY HOSPITAL No No No Yes Yes 3572 12882 12620 $12768 $15097 $14680 Transition NA $98163 $80582 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 4360 12882 12620 $12768 $15097 $10484 Transition NA $98163 $80582 106301098 AHMC ANAHEIM REG MED CTR No No No No No 1656 12882 12620 $6289 $7436 $15144 Transition NA $98163 $80582 106010846 ALAMEDA CO MED CTR Yes No No No No 4036 16962 16618 $6289 $9186 NA NA NA NA NA 106010735 ALAMEDA HOSP No Yes No No No 2600 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106190017 ALHAMBRA HOSP No No No No No 1397 12882 12620 $6289 $7436 $5446 Transition $1220 $98163 $80582 106010739 ALTA BATES SUMMIT MED CTR-ALTA BATES No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106010937 ALTA BATES SUMMIT MED CTR-HAWTHORNE No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106010844 ALTA BATES SUMMIT MED CTR-HERRICK CAMPUS No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106013626 ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106374063 ALVARADO HOSP MED CTR - REHAB No No No No No 1930 12882 12620 $6289 $7436 $4599 Transition $1220 $98163 $80582 106190034 ANTELOPE VALLEY HOSP MED CTR No Yes No No No 2997 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364231 ARROWHEAD REG MED CTR Yes No No No No 3324 12882 12620 $6289 $7436 NA NA NA NA NA 106400466 ARROYO GRANDE COMM HOSP No No No No No 2581 12964 12701 $6289 $7471 NA Non-Transition $1226 $98163 $80582 106154101 BAKERSFIELD HEART HOSP No No No No No 1782 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150722 BAKERSFIELD MEM HOSP-34TH ST No No No No No 2117 12882 12620 $6289 $7436 $9141 Transition NA $98163 $80582 106364121 BALLARD REHABILITATION HOSP No No No No No 8300 12882 12620 NA NA NA NA $1427 $98163 $80582 106184008 BANNER LASSEN MED CTR No No No Yes Yes 3967 12882 12620 $12768 $15097 $18668 Transition NA $98163 $80582 106190052 BARLOW RESP HOSP No No No No No 1849 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364430 BARSTOW COMM HOSP No No No Yes Yes 2262 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090793 BARTON MEM HOSP No No No Yes Yes 3635 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106361110 BEAR VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190081 BEVERLY HOSP No No No No No 3567 12882 12620 $6289 $7436 $5841 Transition NA $98163 $80582 106040802 BIGGS GRIDLEY MEM HOSP No No No Yes Yes 3652 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106380929 CA PACIFIC MED CTR No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380777 CA PACIFIC MED CTR - CALIFORNIA WEST No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380933 CA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 2873 16738 16398 $6289 $9090 NA Non-Transition $1492 $98163 $80582 106190125 CALIFORNIA HOSP MED CTR-LA No No Yes No No 2078 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190137 CASA COLINA HOSP FOR REHAB MED No No No No No 7213 12882 12620 NA NA NA NA $1220 $98163 $80582 106190045 CATALINA ISLAND MED CTR No No No Yes Yes 9000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190555 CEDARS-SINAI MED CTR No No Yes No No 2051 12882 12620 $6289 $7436 $5837 Transition $1220 $98163 $80582 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 1730 12882 12620 $6289 $7436 $6350 Transition $1220 $98163 $80582 106160787 CENTRAL VALLEY GEN HOSP No No No No No 7778 12882 12620 $6289 $7436 $11888 Transition NA $98163 $80582 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 2190 12892 12630 $6289 $7440 NA Non-Transition $1221 $98163 $80582 106301140 CHAPMAN MED CTR No No No No No 1908 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304113 CHILDRENS HOSP AT MISSION No No No No No 3300 12882 12620 $6289 $7436 $18777 Transition NA $98163 $80582 106204019 CHILDRENS HOSP CENTRAL CALIFORNIA No No Yes No No 2430 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106010776 CHILDRENS HOSP OAKLAND No No Yes No No 3356 16478 16143 $6289 $8978 NA Non-Transition $2628 $98163 $80582 106190170 CHILDRENS HOSP OF LA No No Yes No No 3988 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106300032 CHILDRENS HOSP OF ORANGE CO No No Yes No No 2442 12882 12620 $6289 $7436 $5613 Transition NA $98163 $80582 106382715 CHINESE HOSP No No No No No 3835 16738 16398 $6289 $9090 $8053 Transition NA $98163 $80582 106361144 CHINO VALLEY MED CTR No No No No No 2098 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190176 CITY OF HOPE HELFORD CLINIC RES HOSP No No No No No 2789 12882 12620 $6289 $7436 $5941 Transition NA $98163 $80582 106100005 CLOVIS COMM MED CTR No No No No No 3336 12882 12620 $6289 $7436 $7752 Transition NA $98163 $80582 106100697 COALINGA REG MED CTR No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190766 COAST PLAZA DRS HOSP No No No No No 2126 12882 12620 $6289 $7436 $5303 Transition NA $98163 $80582 106301258 COASTAL COMM HOSP No No No No No 2792 12882 12620 $6289 $7436 $7035 Transition NA $98163 $80496 106301155 COLLEGE HOSP COSTA MESA No No No No No 2876 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190587 COLLEGE MEDICAL CENTER No No No No No 3760 12882 12620 $6289 $7436 $4258 Transition NA $98163 $80582 106361458 COLORADO RIVER MED CTR No No No Yes Yes 4357 12882 12620 $12768 $15097 $18541 Transition NA $98163 $80582 106060870 COLUSA REG MED CTR No No No Yes Yes 3066 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190197 COMM AND MISSION HOSP OF HUNT PK No No No No No 1601 12882 12620 $6289 $7436 $5421 Transition NA $98163 $80582 106190475 COMM HOSP OF LONG BEACH No No No No No 1707 12882 12620 $6289 $7436 $15917 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106361323 COMM HOSP OF SAN BERNARDINO No No No No No 2833 12882 12620 $6289 $7436 $6516 Transition NA $98163 $78406 106560473 COMM MEM HOSP OF SAN BUENAVENTURA No No No No No 2104 12882 12620 $6289 $7436 $4512 Transition NA $98163 $80582 106100717 COMM REG MED CTR-FRESNO No No No No No 1896 12882 12620 $6289 $7436 $7994 Transition $1655 $98163 $80582 106070924 CONTRA COSTA REG MED CTR Yes No No No No 6010 16478 16143 $6289 $8978 NA NA NA NA NA 106331152 CORONA REG MED CTR No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition NA $98163 $80582 106331145 CORONA REG MED CTR - MAGNOLIA No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition $1220 $98163 $80582 106190413 CV-INTERCOMMUNITY CAMPUS No No No No No 3136 12882 12620 $6289 $7436 $6821 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106190636 CV-QUEEN OF VALLEY CAMPUS No No Yes No No 3136 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106150706 DELANO REG MED CTR No No No No No 3622 12882 12620 $6289 $7436 $7087 Transition NA $98163 $80582 106331164 DESERT REG MED CTR No No No No No 1486 12882 12620 $6289 $7436 $7153 Transition $1447 $98163 $80582 106364144 DESERT VALLEY HOSP No No No No No 2050 12882 12620 $6289 $7436 $8173 Transition NA $98163 $80582 106440755 DOMINICAN HOSP-SANTA CRUZ No No No No No 2016 17239 16889 $6289 $9304 $7821 Transition $1527 $98163 $80582 106190243 DOWNEY REG MED CTR No No No No No 1732 12882 12620 $6289 $7436 $6847 Transition NA $98163 $80582 106392287 DRS HOSP OF MANTECA No No No No No 1362 13579 13303 $6289 $7735 $11712 Transition NA $98163 $80582 106390846 DAMERON HOSP No No No No No 2138 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106190857 DRS HOSP OF WEST COVINA No No No No No 1833 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106070904 DRS MED CTR-SAN PABLOPINOLE No Yes No No No 2373 16478 16143 $6289 $8978 $6025 Transition NA $98163 $80582 106190256 EAST LA DRS HOSP No No No No No 1952 12882 12620 $6289 $7436 $5809 Transition NA $98163 $80582 106190328 EAST VALLEY HOSP MED CTR No No No No No 2859 12882 12620 $6289 $7436 $5534 Transition NA $98163 $80582 106320859 EASTERN PLUMAS HOSP No Yes No Yes Yes 4802 12882 12620 $12768 $15097 $13674 Transition NA $98163 $80582 106014233 EDEN MED CTR No No No No No 3197 16962 16618 $6289 $9186 $12768 Transition NA $98163 $80582 106331168 EISENHOWER MEM HOSP No No No No No 1540 12882 12620 $6289 $7436 $10211 Transition NA $98163 $80582 106430763 EL CAMINO HOSP No Yes No No No 2857 17180 16831 $6289 $9279 $5377 Transition $1523 $98163 $80582 106130699 EL CENTRO COMM HOSP No Yes No No No 2298 12882 12620 $6289 $7436 $8949 Transition NA $98163 $80582 106500852 DRS MED CTR No No No No No 1181 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106500867 EMANUEL MED CTR No No No No No 2046 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106040962 ENLOE MED CTR No No No No No 2436 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106044011 ENLOE REHABILLITATION CENTER No No No No No 2463 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106474007 FAIRCHILD MED CTR No No No Yes Yes 3914 12882 12620 $12768 $15097 $16385 Transition NA $98163 $80582 106040875 FEATHER RIVER HOSP No No No No No 1240 12882 12620 $6289 $7436 $10796 Transition NA $98163 $80582 106190298 FOOTHILL PRES HOSP No No No No No 2989 12882 12620 $6289 $7436 $4740 Transition NA $98163 $80582 106301175 FOUNTAIN VALLEY REG HOSP-EUCLID No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106304039 FOUNTAIN VALLEY REG HOSP-WARNER No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106230949 FRANK R HOWARD MEM HOSP No No No Yes Yes 3495 12882 12620 $12768 $15097 $15377 Transition NA $98163 $80582 106510882 FREMONT MEDICAL CENTER No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106190280 ENCINO HOSP MED CTR No No No No No 949 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106400480 FRENCH HOSP MED CTR No No No No No 2241 12964 12701 $6289 $7471 NA Non-Transition NA $98163 $80582 106301283 GARDEN GROVE HOSP AND MED CTR No No No No No 2661 12882 12620 $6289 $7436 $5749 Transition NA $98163 $80582 106190159 GARDEN REG HOSP AND MED CTR No No No No No 2937 12882 12620 $6289 $7436 $4110 Transition NA $98163 $80582 106105029 FRESNO HEART HOSP No No No No No 3403 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106270777 GEORGE L MEE MEM HOSP No No No Yes Yes 3562 15558 15242 $12768 $17426 $20386 Transition NA $98163 $80582 106190315 GARFIELD MED CTR No No No No No 1031 12882 12620 $6289 $7436 NA Non-Transition $1394 $98163 $80582 106190522 GLENDALE MEM HOSP AND HLTH CTR No No No No No 2163 12882 12620 $6289 $7436 $6885 Transition $1220 $98163 $80582 106110889 GLENN MED CTR No No No Yes Yes 6660 12882 12620 $12768 $15097 $21024 Transition NA $98163 $80582 106190323 GLENDALE ADV MED CTR-WILSON TERRACE No No No No No 1845 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420483 GOLETA VALLEY COTTAGE HOSP No No No No No 3083 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150775 GOOD SAMARITAN HOSP-BAKERSFIELD No No No No No 3694 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430779 GOOD SAMARITAN HOSP-SAN JOSE No No Yes No No 1937 17180 16831 $6289 $9279 $5654 Transition NA $98163 $80582 106190352 GREATER EL MONTE COMM HOSP No No No No No 1088 12882 12620 $6289 $7436 $4818 Transition NA $98163 $80582 106370714 GROSSMONT HOSP No No No No No 1937 12882 12620 $6289 $7436 $6498 Transition $1220 $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190392 GOOD SAMARITAN HOSP-LA No No Yes No No 2006 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106350784 HAZEL HAWKINS MEM HOSP No Yes No Yes Yes 3840 17180 16831 $12768 $18839 NA Non-Transition NA $98163 $80582 106490964 HEALDSBURG DIST HOSP No Yes No Yes Yes 6549 16188 15859 $12768 $17975 NA Non-Transition NA $98163 $80582 106154022 HEALTHSOUTH BAKERSFIELD REHAB HOSP No No No No No 5040 12882 12620 NA NA NA NA $1382 $98163 $80582 106304079 HEALTHSOUTH TUSTIN REHAB HOSP No No No No No 5281 12882 12620 NA NA NA NA $1220 $98163 $80582 106331194 HEMET VALLEY MED CTR No No No No No 1267 12882 12620 $6289 $7436 $5912 Transition NA $98163 $80582 106190949 HENRY MAYO NEWHALL MEM HOSP No No No No No 1839 12882 12620 $6289 $7436 $5631 Transition $1220 $98163 $80582 106362041 HI-DESERT MED CTR No Yes No Yes Yes 2909 12882 12620 $12768 $15097 $13297 Transition NA $98163 $80582 106301205 HOAG MEM HOSP PRESBYTERIAN No No No No No 4825 12882 12620 $6289 $7436 $13525 Transition NA $98163 $80582 106304159 HEALTHBRIDGE CHILDRENS HOSP-ORANGE No No No No No 3271 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106190380 HOLLYWOOD COMM HOSP OF HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106304460 HOAG ORTHOPEDIC No No No No No 4894 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190382 HOLLYWOOD PRES MED CTR No No No No No 2212 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301209 HUNTINGTON BEACH HOSP No No No No No 2175 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190400 HUNTINGTON MEM HOSP No No Yes No No 2294 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106304045 IRVINE REG HOSP AND MED CTR No No No No No 200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106220733 JOHN C FREMONT HCARE DIST No Yes No Yes Yes 3884 12882 12620 $12768 $15097 $8195 Transition NA $98163 $80582 106331216 JOHN F KENNEDY MEM HOSP No No No No No 1679 12882 12620 $6289 $7436 $6464 Transition NA $98163 $80582 106071018 JOHN MUIR MED CTR-CONCORD CAMPUS No No No No No 1748 16478 16143 $6289 $8978 $12804 Transition NA $98163 $80582 106070988 JOHN MUIR MED CTR-WALNUT CREEK CAMPUS No No No No No 2039 16478 16143 $6289 $8978 $10615 Transition $1473 $98163 $80582 106314024 KAISER HOSPITAL - ROSEVILLE No No Yes No No 7912 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106364265 KAISER ONTARIO MEDICAL CENTER CAMPUS No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106121031 JEROLD PHELPS COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301132 KAISER-ANAHEIM No No Yes No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304306 KAISER-ANAHEIM-IRVINE No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304409 KAISER-ANAHEIM-Orange No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106074097 KAISER-ANTIOCH No No No No No 8503 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106196403 KAISER-DOWNEY No No No No No 10000 12882 12620 $6289 $7436 $12698 Transition NA $98163 $80582 106361223 KAISER-FONTANA No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106014132 KAISER-FREMONT No No No No No 10000 16962 16618 $6289 $9186 $9639 Transition NA $98163 $80582 106196035 KAISER-BALDWIN PARK No No No No No 8009 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106104062 KAISER-FRESNO No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190429 KAISER-LOS ANGELES No No No No No 7387 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106394009 KAISER-MANTECA No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106334048 KAISER-MORENO VALLEY No No No No No 6614 12882 12620 $6289 $7436 $4790 Transition NA $98163 $80582 106010856 KAISER-OAKLANDRICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106190432 KAISER-PANORAMA CITY No No No No No 8239 12882 12620 $6289 $7436 $16025 Transition NA $98163 $80582 106504042 KAISER-MODESTO No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106410804 KAISER-REDWOOD CITY No No No No No 7731 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106074093 KAISER-RICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106480989 KAISER-REHAB CENTER VALLEJO No No No No No 8442 16315 15984 $6289 $8908 NA Non-Transition $2535 $98163 $80582 106340913 KAISER-SACRAMENTO No No No No No 5612 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106334025 KAISER-RIVERSIDE No No No No No 5865 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370730 KAISER-SAN DIEGO No No No No No 7393 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106380857 KAISER-SAN FRANCISCO No No No No No 5960 16738 16398 $6289 $9090 NA Non-Transition NA $98163 $80582 106431506 KAISER-SAN JOSE No No No No No 7002 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106014337 KAISER-SAN LEANDRO No No No No No 2180 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106210992 KAISER-SAN RAFAEL No No No No No 4673 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106494019 KAISER-SANTA ROSA No No No No No 10000 16315 15984 $6289 $8908 $17627 Transition NA $98163 $80582 106434153 KAISER-SANTA CLARA No No No No No 6107 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106190431 KAISER-SOUTH BAY No No No No No 6935 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106342344 KAISER-SOUTH SACRAMENTO No No No No No 5670 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106410806 KAISER-SOUTH SF No No No No No 6503 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106484044 KAISER-VACAVILLE No No No No No 10000 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106070990 KAISER-WALNUT CREEK No No No No No 5680 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106190434 KAISER-WEST LA No No No No No 6623 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106194219 KECK HOSPITAL OF USC No No No No No 2004 12882 12620 $6289 $7436 $4699 Transition $1220 $98163 $80582 106210993 KENTFIELD REHAB HOSP No No No No No 5967 16855 16513 $6289 $9140 $19338 Transition $1500 $98163 $80582 106150736 KERN MED CTR Yes No No No No 3943 12882 12620 $6289 $7436 NA NA NA NA NA 106150737 KERN VALLEY HEALTHCARE DIST No Yes No Yes Yes 2786 12882 12620 $12768 $15097 $8298 Transition NA $98163 $80582 106191450 KAISER-WOODLAND HILLS No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190049 KINDRED HOSPITAL BALDWIN PARK No No No No No 1810 12882 12620 $6289 $7436 $10784 Transition NA $98163 $80582 106190305 KINDRED LA No No No No No 2044 12882 12620 $6289 $7436 $4255 Transition NA $98163 $80582 106301127 KINDRED BREA No No No No No 2852 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361274 KINDRED ONTARIO No No No No No 2068 12882 12620 $6289 $7436 $9314 Transition NA $98163 $80582 106364188 KINDRED RANCHO No No No No No 1980 12882 12620 $6289 $7436 $20628 Transition NA $98163 $80582 106332172 KINDRED RIVERSIDE No No No No No 1805 12882 12620 $6289 $7436 $24450 Transition NA $98163 $80582 106190449 KINDRED LA MIRADA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106370721 KINDRED SAN DIEGO No No No No No 3605 12882 12620 $6289 $7436 $5657 Transition NA $98163 $80582 106344035 KINDRED SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190458 KINDRED SAN GABRIEL VALLEY No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106010887 KINDRED SF BAY AREA No No No No No 3007 16478 16143 $6289 $8978 $6378 Transition NA $98163 $80582 106301167 KINDRED SANTA ANA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190196 KINDRED SOUTH BAY No No No No No 2144 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301380 KINDRED WESTMINSTER No No No No No 2286 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301234 LA PALMA INTERCOMMUNITY HOSP No No No No No 2290 12882 12620 $6289 $7436 $7160 Transition NA $98163 $80582 106191227 LAC-HARBOR-UCLA MED CTR Yes No Yes No No 3366 12882 12620 $6289 $7436 NA NA NA NA NA 106191231 LAC-OLIVE VIEW-UCLA MED CTR Yes No No No No 4136 12882 12620 $6289 $7436 NA NA NA NA NA 106191228 LAC-USC MED CTR Yes No Yes No No 4522 12882 12620 $6289 $7436 NA NA NA NA NA 106380865 LAGUNA HONDA HOSP AND REHAB CTR Yes No No No No 5843 16738 16398 $6289 $9090 NA NA NA NA NA 106190240 LAKEWOOD REG MED CTR No No No No No 1504 12882 12620 $6289 $7436 $4008 Transition $1220 $98163 $80582 106390923 LODI MEM HOSP No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106390922 LODI MEM HOSP - WEST No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106334589 LOMA LINDA MURRIETTA No No No No No 3222 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106364268 LOMA LINDA UNIV HEART AND SURGICAL HOSPITAL No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361245 LOMA LINDA UNIV MED CTR - EAST CAMPUS No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361246 LOMA LINDA UNIV MED CTR No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $1491 $98163 $80582 106364502 LOMA LINDA UNIV CHILDRENS HOSP No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $2177 $98163 $80582 106190198 LA COMM HOSP No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420491 LOMPOC VALLEY MED CTR No Yes No Yes Yes 8693 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301248 LOS ALAMITOS MED CTR No No No No No 1915 12882 12620 $6289 $7436 $4697 Transition NA $98163 $80582 106560492 LOS ROBLES HOSP AND MED CTR No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106564018 LOS ROBLES HOSP AND MED CTR-EAST CAMPUS No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106434040 LSP CHILDRENS HOSP AT STANFORD No No Yes No No 2035 17180 16831 $6289 $9279 $6102 Transition NA $98163 $80582 106121002 MAD RIVER COMM HOSP No No No No No 4250 12882 12620 $6289 $7436 $9505 Transition NA $98163 $80582 106201281 MADERA COMMUNITY HOSPITAL No No No No No 5100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106260011 MAMMOTH HOSP No Yes No Yes Yes 7982 12882 12620 $12768 $15097 $46994 Transition NA $98163 $80582 106420493 MARIAN MED CTR No No No No No 2741 12882 12620 $6289 $7436 $9386 Transition NA $98163 $80582 106190525 LONG BEACH MEM MED CTR No No No No No 1996 12882 12620 $6289 $7436 NA Non-Transition $1627 $98163 $80582 106211006 MARIN GEN HOSP No Yes No No No 2571 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106190500 MARINA DEL RAY HOSPITAL No No No No No 2034 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106050932 MARK TWAIN ST JOSEPHS HOSP No No No Yes Yes 3707 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090933 MARSHALL MED CTR No No No Yes Yes 2107 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106500939 MEM HOSP MED CTR-MODESTO No No No No No 2235 12892 12630 $6289 $7440 $5898 Transition NA $98163 $80582 106240924 MEMORIAL HOSP LOS BANOS No No No Yes Yes 3362 12882 12620 $12768 $15097 $17450 Transition NA $98163 $80582 106190521 MEMORIAL HOSP OF GARDENA No No No No No 1747 12882 12620 $6289 $7436 $4611 Transition NA $98163 $80582 106231013 MENDOCINO COAST DIST HOSP No Yes No Yes Yes 5070 12882 12620 $12768 $15097 $15935 Transition NA $98163 $80582 106334018 MENIFEE VALLEY MED CTR No No No No No 1458 12882 12620 $6289 $7436 $5113 Transition NA $98163 $80582 106450936 MAYERS MEM HOSP No Yes No Yes Yes 7192 14188 13900 $12768 $16234 NA Non-Transition NA $98163 $80582 106340947 MERCY GEN HOSP No No No No No 2185 15256 14946 $6289 $8454 $6027 Transition $1387 $98163 $80582 106344029 MERCY HOSP OF FOLSOM No No No No No 2746 15256 14946 $6289 $8454 $5260 Transition NA $98163 $80582 106150761 MERCY HOSP-BAKERSFIELD No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106414018 MENLO PARK SURGICAL HOSP No No No No No 2770 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106240942 MERCY MED CTR MERCED No No No No No 2289 13279 13009 $6289 $7606 NA Non-Transition NA $98163 $80582 106450949 MERCY MED CTR-REDDING No No No No No 2589 14188 13900 $6289 $7996 $10219 Transition NA $98163 $80582 106470871 MERCY MED CTR-MT SHASTA No No No Yes Yes 6242 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106340950 MERCY SAN JUAN HOSP No No No No No 2166 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190529 METHODIST HOSP OF SO CAL No No No No No 1842 12882 12620 $6289 $7436 $6690 Transition $1220 $98163 $80582 106196168 MILLER CHILDRENS HOSP No No Yes No No 2680 12882 12620 $6289 $7436 $8155 Transition NA $98163 $80582 106410742 MILLS HEALTH CENTER No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106410852 MILLS-PENINSULA No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106340951 METHODIST HOSP OF SACRAMENTO No No No No No 2028 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190524 MISSION COMM HOSP-PANORAMA CAMPUS No No No No No 3568 12882 12620 $6289 $7436 $3982 Transition NA $98163 $80582 106190681 MIRACLE MILE No No No No No 100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301262 MISSION HOSP REG MED CTR No No No No No 4091 12882 12620 $6289 $7436 $14336 Transition $1220 $98163 $80582 106250956 MODOC MED CTR No Yes No Yes Yes 4961 12882 12620 $12768 $15097 $13486 Transition NA $98163 $80582 106301337 MISSION HOSP LAGUNA BEACH No No No No No 4091 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106361166 MONTCLAIR HOSP MED CTR No No No No No 3149 12882 12620 $6289 $7436 $5904 Transition NA $98163 $80582 106190547 MONTEREY PARK HOSP No No No No No 1034 12882 12620 $6289 $7436 $5866 Transition NA $98163 $80582 106361266 MOUNTAINS COMM HOSP No Yes No Yes Yes 5148 12882 12620 $12768 $15097 $15642 Transition NA $98163 $80582 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106481357 NORTH BAY MEDICAL CENTER No No No No No 1972 16315 15984 $6289 $8908 $15945 Transition NA $98163 $80582
i-
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190541 MONROVIA MEM HOSP No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106141273 NORTHERN INYO HOSP No Yes No Yes Yes 8150 12882 12620 $12768 $15097 $27752 Transition NA $98163 $80582 106484001 NORTH BAY VACAVALLEY HOSP No No No No No 1972 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106190568 NORTHRIDGE HOSP MED CTR No No No No No 1596 12882 12620 $6289 $7436 NA Non-Transition $1662 $98163 $80582 106214034 NOVATO COMM HOSP No No No No No 3465 16855 16513 $6289 $9140 $6359 Transition NA $98163 $80582 106500967 OAK VALLEY DIST HOSP No Yes No Yes No 3340 12892 12630 $6289 $7440 $5201 Transition NA $98163 $80582 106430837 OCONNOR HOSP-SAN JOSE No No No No No 2409 17180 16831 $6289 $9279 $5201 Transition NA $98163 $80582 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190534 OLYMPIA MED CTR No No No No No 1260 12882 12620 $6289 $7436 $6786 Transition NA $98163 $80582 106300225 ORANGE COAST MEM MED CTR No No No No No 2293 12882 12620 $6289 $7436 $19985 Transition NA $98163 $80582 106040937 OROVILLE HOSP No No No No No 1803 12882 12620 $6289 $7436 $6229 Transition NA $98163 $80582 106560501 OJAI VALLEY COMM HOSP No No No Yes Yes 2745 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190696 PACIFICA HOSP OF THE VALLEY No No No No No 3338 12882 12620 $6289 $7436 $5616 Transition NA $98163 $80582 106491338 PALM DRIVE HOSP No Yes No Yes No 4315 16315 15984 $6289 $8908 $11457 Transition NA $98163 $80582 106196405 PALMDALE REGIONAL MEDICAL CTR No No No No No 1190 12882 12620 $6289 $7436 $7504 Transition $1220 $98163 $80582 106331288 PALO VERDE HOSP No Yes No Yes Yes 4770 12882 12620 $12768 $15097 $18188 Transition NA $98163 $80582 106370755 PALOMAR MED CTR No Yes No No No 2429 12882 12620 $6289 $7436 $7051 Transition $1220 $98163 $80582 106370759 PARADISE VALLEY HOSP No No No No No 2188 12882 12620 $6289 $7436 $4275 Transition $1220 $98163 $80582 106190307 PACIFIC ALLIANCE MED CTR No No No No No 4299 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106331293 PARKVIEW COMM HOSP MED CTR No No No No No 2757 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106491001 PETALUMA VALLEY HOSP No No No No No 2271 16315 15984 $6289 $8908 $13491 Transition NA $98163 $80582 106130760 PIONEERS MEM HOSP No Yes No Yes No 2989 12882 12620 $6289 $7436 $9825 Transition NA $98163 $80582 106454013 PATIENTS HOSP OF REDDING No No No No No 2172 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106301297 PLACENTIA LINDA HOSP No No No No No 1606 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370977 POMERADO HOSP No Yes No No No 3063 12882 12620 $6289 $7436 $6818 Transition NA $98163 $80582 106320986 PLUMAS DIST HOSP No Yes No Yes Yes 8666 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190631 PRESBYTERIAN INTERCOMM HOSP No No No No No 961 12882 12620 $6289 $7436 $9720 Transition $1220 $98163 $80582 106190630 POMONA VALLEY HOSP MED CTR No No Yes No No 1538 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190468 PROMISE HOSP OF EAST LA-EAST LA No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190599 PROMISE HOSP OF EAST LA-EAST LA-SUBURBAN CAMPUS No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190385 PROVIDENCE HOLY CROSS MED CTR No No No No No 1325 12882 12620 $6289 $7436 $6284 Transition $1220 $98163 $80582 106190680 PROVIDENCE LITTLE CO OF MARY-SAN PEDRO No No No No No 1533 12882 12620 $6289 $7436 $6225 Transition $1220 $98163 $80582 106190470 PROVIDENCE LITTLE CO OF MARY-TORRANCE No No No No No 1767 12882 12620 $6289 $7436 $7182 Transition NA $98163 $80582 106190758 PROVIDENCE ST JOSEPH MED CTR No No No No No 1866 12882 12620 $6289 $7436 $7141 Transition $1220 $98163 $80582 106370787 PROMISE HOSP OF SAN DIEGO No No No No No 3660 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106281047 QUEEN OF THE VALLEY HOSP-NAPA No No No No No 2829 16188 15859 $6289 $8854 $17592 Transition $1453 $98163 $80582 106370673 RADY CHILDRENS HOSPITAL - SAN DIEGO No No Yes No No 2854 12882 12620 $6289 $7436 $6395 Transition $2177 $98163 $80582 106190517 PROVIDENCE TARZANA MED CTR No No Yes No No 1536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361308 REDLANDS COMM HOSP No No No No No 2079 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430705 REG MED CTR OF SAN JOSE No No No No No 2529 17180 16831 $6289 $9279 $13299 Transition NA $98163 $80582 106580996 RIDEOUT MEM HOSP No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106121051 REDWOOD MEM HOSP No No No Yes Yes 3214 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106334487 RIVERSIDE CO REG MED CTR Yes No No No No 2987 12882 12620 $6289 $7436 NA NA NA NA NA 106331312 RIVERSIDE COMM HOSP No No No No No 1560 12882 12620 $6289 $7436 $5990 Transition NA $98163 $80582 106190796 RONALD REAGAN UCLA MED CTR Yes No Yes No No 3382 12882 12620 $6289 $7436 NA NA NA NA NA 106301317 SADDLEBACK MEM MED CTR No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106301325 SADDLEBACK MEM MED CTR-SAN CLEMENTE No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106150782 RIDGECREST REG HOSP No No No Yes Yes 4178 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106361318 SAN ANTONIO COMM HOSP No No No No No 2262 12882 12620 $6289 $7436 $9216 Transition NA $98163 $80582 106190673 SAN DIMAS COMM HOSP No No No No No 2465 12882 12620 $6289 $7436 $12177 Transition NA $98163 $80582 106190200 SAN GABRIEL VALLEY MED CTR No No No No No 969 12882 12620 $6289 $7436 $6918 Transition NA $98163 $80582 106270875 SALINAS VALLEY MEM HOSP No Yes No No No 3534 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106331326 SAN GORGONIO MEM HOSP No Yes No Yes Yes 3394 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391010 SAN JOAQUIN GEN HOSP Yes No No No No 1922 13579 13303 $6289 $7735 NA NA NA NA NA 106104023 SAN JOAQUIN VALLEY REHAB HOSP No No No No No 6479 12882 12620 NA NA NA NA $1413 $98163 $80582 106013619 SAN LEANDRO HOSP No Yes No No No 3482 16501 16166 $6289 $8988 $10813 Transition NA $98163 $80582 106410782 SAN MATEO MED CTR Yes No No No No 7168 16928 16584 $6289 $9171 NA NA NA NA NA 106074017 SAN RAMON REG MED CTR No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106074011 SAN RAMON REG MED CTR SOUTH BUILDING No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106420514 SANTA BARBARA COTTAGE HOSP No No Yes No No 3902 12882 12620 $6289 $7436 $10978 Transition $2125 $98163 $80582 106430883 SANTA CLARA VALLEY MED CTR Yes No Yes No No 3133 17180 16831 $6289 $9279 NA NA NA NA NA 106190687 SANTA MONICA - UCLA MEDICAL CENTER Yes No No No No 3102 12882 12620 $6289 $7436 NA NA NA NA NA 106491064 SANTA ROSA MEM HOSP-MONTGOMERY No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106490907 SANTA ROSA MEM HOSP-SOTOYOME No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106150788 SAN JOAQUIN COMM HOSP No No No No No 2544 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420522 SANTA YNEZ VALLEY COTTAGE HOSP No No No Yes Yes 7569 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106371394 SCRIPPS MEM HOSP-ENCINITAS No No No No No 2403 12882 12620 $6289 $7436 $7037 Transition $1439 $98163 $80582 106370771 SCRIPPS MEM HOSP-LA JOLLA No No No No No 2061 12882 12620 $6289 $7436 $4390 Transition NA $98163 $80582 106370744 SCRIPPS MERCY HOSP No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106370658 SCRIPPS MERCY HOSP-CHULA VISTA No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106371256 SCRIPPS GREEN HOSP No No No No No 2317 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106321016 SENECA HCARE DIST No Yes No Yes Yes 4586 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106410817 SETON MED CTR No No No No No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106410828 SETON MED CTR-COASTSIDE No No No Yes No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106380939 SF GENERAL HOSP Yes No No No No 2851 16738 16398 $6289 $9090 NA NA NA NA NA 106370875 SHARP CHULA VISTA MED CTR No No No No No 1932 12882 12620 $6289 $7436 $6485 Transition NA $98163 $80582 106410891 SEQUOIA HOSP No No No No No 1975 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106370689 SHARP CORONADO HOSP AND HCARE CTR No No No No No 2160 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $72421 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106370694 SHARP MEM HOSP No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106450940 SHASTA REG MED CTR No No No No No 1582 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106190708 SHERMAN OAKS HOSP No No No No No 1516 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190712 SHRINERS HOSPITAL- LA No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106344114 SHRINERS HOSPITAL- SACRAMENTO No No No No No 3869 15256 14946 $6289 $8454 NA Non-Transition $2475 $98163 $80582 106540798 SIERRA VIEW DIST HOSP No Yes No No No 2716 12882 12620 $6289 $7436 $8497 Transition NA $98163 $77682 106400524 SIERRA VIST REG MED CTR No No No No No 1787 12964 12701 $6289 $7471 $5495 Transition NA $98163 $80582 106190661 SILVER LAKE MED CTR No No No No No 3692 12882 12620 $6289 $7436 $5655 Transition NA $98163 $80582 106291023 SIERRA NEVADA MEM HOSP No No No Yes Yes 3427 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106491076 SONOMA VALLEY HOSP No Yes No No No 4960 16315 15984 $6289 $8908 $12733 Transition NA $98163 $80582 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 2126 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190380 SOUTHERN CA HOSP AT HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106190110 SOUTHERN CA HOSPITAL AT CULVER CITY No No No No No 1437 12882 12620 $6289 $7436 $4694 Transition $1220 $98163 $80582 106560525 SIMI VALLEY HOSP AND HCARE-SYCAMORE No No No No No 3840 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106334068 SOUTHWEST HCARE SYSTEM No No No No No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106334001 SOUTHWEST HCARE SYSTEM-WILDOMAR No No No Yes No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106100899 ST AGNES MED CTR No No No No No 3088 12882 12620 $6289 $7436 $7885 Transition NA $98163 $80582 106361339 ST BERNARDINE MED CTR No No No No No 2171 12882 12620 $6289 $7436 $6090 Transition NA $98163 $80582 106521041 ST ELIZABETH COMM HOSP No No No Yes Yes 3024 13869 13587 $12768 $15956 $14866 Transition NA $98163 $80582 106190754 ST FRANCIS MED CTR No No No No No 4350 12882 12620 $6289 $7436 $6368 Transition NA $98163 $80582 106380960 ST FRANCIS MEM HOSP No No No No No 1920 16738 16398 $6289 $9090 $5310 Transition $1492 $98163 $80582 106281078 ST HELENA HOSP No No No No No 2337 15887 15564 $6289 $8725 $9671 Transition NA $98163 $80582 106171049 ST HELENA HOSPITAL-CLEARLAKE No No No Yes Yes 4118 12882 12620 $12768 $15097 $18218 Transition NA $98163 $80582 106141338 SOUTHERN INYO HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190756 ST JOHNS HEALTH CTR No No No No No 2536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560529 ST JOHNS REG MED CTR No No No No No 2982 12882 12620 $6289 $7436 $6976 Transition $1761 $98163 $80582 106121080 ST JOSEPH HOSP-EUREKA No No No No No 2570 13869 13587 $6289 $7859 $9661 Transition $1507 $98163 $80582 106301340 ST JOSEPH HOSP-ORANGE No No No No No 2751 12882 12620 $6289 $7436 $5230 Transition NA $98163 $80582 106560508 ST JOHNS PLEASANT VALLEY HOSP No No No No No 2087 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301342 ST JUDE MED CTR No No No No No 1722 12882 12620 $6289 $7436 $5799 Transition $1220 $98163 $80582 106434138 ST LOUISE REG HOSP No No No No No 2838 17180 16831 $6289 $9279 $16407 Transition NA $98163 $80582 106380964 ST LUKES HOSP No No No No No 3807 16738 16398 $6289 $9090 $8600 Transition NA $98163 $80582 106361343 ST MARY MED CTR-APPLE VALLEY No No No Yes No 2511 12882 12620 $6289 $7436 $9863 Transition NA $98163 $80582 106391042 ST JOSEPHS MED CTR OF STOCKTON No No No No No 2152 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106380965 ST MARYS MED CTR-SF No No No No No 2007 16738 16398 $6289 $9090 $5116 Transition $1492 $98163 $80582 106010967 ST ROSE HOSP No No No No No 1931 16962 16618 $6289 $9186 $7600 Transition NA $98163 $80582 106190762 ST VINCENT MED CTR No No No No No 2020 12882 12620 $6289 $7436 $4684 Transition $1220 $98163 $80582 106430905 STANFORD HOSP No No No No No 1803 17180 16831 $6289 $9279 $5644 Transition $1523 $98163 $80582 106190053 ST MARY MED CTR-LONG BEACH No No No No No 2479 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106504038 STANISLAUS SURGICAL HOSP No No No No No 9000 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106250955 SURPRISE VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106310791 SUTTER AUBURN FAITH HOSP No No No No No 2551 15256 14946 $6289 $8454 $11882 Transition NA $98163 $80582 106034002 SUTTER AMADOR HOSP No No No Yes Yes 2971 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106574010 SUTTER DAVIS HOSP No No No No No 3568 15256 14946 $6289 $8454 $14330 Transition NA $98163 $80582 106070934 SUTTER DELTA MED CTR No No No No No 2907 16478 16143 $6289 $8978 $12158 Transition NA $98163 $80582 106341051 SUTTER GEN HOSP No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106171395 SUTTER LAKESIDE HOSP No No No Yes Yes 3691 12882 12620 $12768 $15097 $17232 Transition NA $98163 $80582 106444012 SUTTER MATERNITY AND SRG CTR OF S CRUZ No No No No No 7213 17239 16889 $6289 $9304 $21288 Transition NA $98163 $80582 106490919 SUTTER MED CTR OF SANTA ROSA No No No No No 3657 16315 15984 $6289 $8908 $15278 Transition NA $98163 $80582 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106311000 SUTTER ROSEVILLE MED CTR No No No No No 2377 15256 14946 $6289 $8454 $11395 Transition $1387 $98163 $80582 106481094 SUTTER SOLANO MED CTR No No No No No 3258 16315 15984 $6289 $8908 $18010 Transition NA $98163 $80582 106084001 SUTTER COAST HOSP No No No Yes Yes 3730 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391056 SUTTER TRACY COMM HOSP No No No No No 2714 13579 13303 $6289 $7735 $5995 Transition NA $98163 $80582 106291053 TAHOE FOREST HOSP No Yes No Yes Yes 4766 15256 14946 $12768 $17164 $21044 Transition NA $98163 $80582 106150808 TEHACHAPI HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 $22158 Transition NA $98163 $80582 106514030 SUTTER SURG HOSP-NORTH VALLEY No No No No No 3240 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106334564 TEMECULA VALLEY HOSPITAL No No No No No 2180 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106120981 THE GENERAL HOSPITAL No No No No No 2570 13869 13587 NA NA NA NA $1507 $98163 $80582 106564121 THOUSAND OAKS SURGICAL HOSPITAL No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106190422 TORRANCE MEM MED CTR No No No No No 1952 12882 12620 $6289 $7436 $5891 Transition NA $98163 $80582 106370780 TRI-CITY MED CTR No Yes No No No 3695 12882 12620 $6289 $7436 $7706 Transition $1220 $98163 $80582 106190784 TEMPLE COMM HOSP No No No No No 4200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540816 TULARE DIST HOSP No Yes No No No 3578 12882 12620 $6289 $7436 $9529 Transition NA $98163 $80582 106531059 TRINITY HOSP No Yes No Yes Yes 5105 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106400548 TWIN CITIES COMM HOSP No No No Yes Yes 1587 12964 12701 $12768 $15168 $8160 Transition NA $98163 $80582 106341006 UC DAVIS MED CTR Yes No Yes No No 1836 15256 14946 $6289 $8454 NA NA NA NA NA 106301279 UC IRVINE MED CTR Yes No Yes No No 2072 12882 12620 $6289 $7436 NA NA NA NA NA 106370782 UCSD MED CTR Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106374141 UCSD-LA JOLLA JOHN M amp SALLY B THORNTON HOSPITAL Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106381154 UCSF MED CTR Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106380895 UCSF MED CTR AT MOUNT ZION Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106301357 TUSTIN HOSP MED CTR No No No No No 231 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106231396 UKIAH VALLEY MED CTRHOSP DR No No No Yes Yes 3643 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106014050 VALLEY CARE MEDICAL CENTER No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106010983 VALLEY MEM HOSP-LIVERMORE No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106191216 USC KENNETH NORRIS JR CANCER HOSP No No No No No 3134 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560481 VENTURA CO MED CTR Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106560521 VENTURA CO MED CTR-SANTA PAULA HOSPITAL Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106190818 VERDUGO HILLS HOSP No No No No No 3110 12882 12620 $6289 $7436 $5264 Transition NA $98163 $80582 106190812 VALLEY PRES HOSP No No No No No 3536 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 3046 14188 13900 $6289 $7996 NA Non-Transition $1312 $98163 $80582 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 3266 12882 12620 $6289 $7436 $8320 Transition NA $98163 $80582 106010987 WASHINGTON HOSP-FREMONT No Yes No No No 1941 16962 16618 $6289 $9186 $6429 Transition NA $98163 $80582 106444013 WATSONVILLE COMM HOSP No No No No No 1780 17239 16889 $6289 $9304 $13456 Transition NA $98163 $80582 106301379 WEST ANAHEIM MED CTR No No No No No 1514 12882 12620 $6289 $7436 $4707 Transition NA $98163 $80582 106190859 WEST HILLS HOSP AND MED CTR No No No No No 1933 12882 12620 $6289 $7436 $8050 Transition NA $98163 $80582 106374094 VIBRA OF SAN DIEGO No No No No No 1155 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301188 WESTERN MED CTR-ANAHEIM No No No No No 3203 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301566 WESTERN MED CTR-SANTA ANA No No No No No 2354 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190878 WHITE MEM MED CTR No No No No No 1515 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190883 WHITTIER HOSP MED CTR No No No No No 1139 12882 12620 $6289 $7436 $5922 Transition NA $98163 $80582 106571086 WOODLAND MEM HOSP No No No No No 3278 15256 14946 $6289 $8454 $10092 Transition NA $98163 $80582 6102015
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
-
544-1 544-2 544-3 544-4
DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES
136 200 407 914
04586 05897 09822 25061
10000 10000 10000 10000
10600 10600 10600 10600
04861 06251 10411 26565
10000 10000 10000 10000
04861 06251 10411 26565
10000 10000 10000 10000
04586 05897 09822 25061
$3646 Obstetrics Obstetrics $4688 Obstetrics Obstetrics $7808 Obstetrics Obstetrics
$19924 Obstetrics Obstetrics 545-1 545-2 545-3 545-4
ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE ECTOPIC PREGNANCY PROCEDURE
164 190 265 576
06988 08147 10540 19945
10000 10000 10000 10000
10600 10600 10600 10600
07407 08636 11172 21142
10000 10000 10000 10000
07407 08636 11172 21142
10000 10000 10000 10000
06988 08147 10540 19945
$5555 Obstetrics Obstetrics $6477 Obstetrics Obstetrics $8379 Obstetrics Obstetrics
$15856 Obstetrics Obstetrics 546-1 546-2 546-3 546-4
OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES
285 454 755
1446
05023 07207 13295 43377
10000 10000 10000 10000
10600 10600 10600 10600
05324 07639 14093 45980
10000 10000 10000 10000
05324 07639 14093 45980
10000 10000 10000 10000
05023 07207 13295 43377
$3993 Obstetrics Obstetrics $5730 Obstetrics Obstetrics
$10570 Obstetrics Obstetrics $34485 Obstetrics Obstetrics
560-1 560-2 560-3 560-4
VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY VAGINAL DELIVERY
203 237 385 935
03307 03856 05399 15061
10000 10000 10000 10000
10600 10600 10600 10600
03505 04087 05723 15965
10000 10000 10000 10000
03505 04087 05723 15965
10000 10000 10000 10000
03307 03856 05399 15061
$2629 Obstetrics Obstetrics $3066 Obstetrics Obstetrics $4292 Obstetrics Obstetrics
$11974 Obstetrics Obstetrics 561-1 561-2 561-3 561-4
POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE
211 257 393 688
02511 03908 06071 15617
10000 10000 10000 10000
10600 10600 10600 10600
02662 04142 06435 16554
10000 10000 10000 10000
02662 04142 06435 16554
10000 10000 10000 10000
02511 03908 06071 15617
$1996 Obstetrics Obstetrics $3107 Obstetrics Obstetrics $4826 Obstetrics Obstetrics
$12416 Obstetrics Obstetrics 563-1 563-2 563-3 563-4
THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION THREATENED ABORTION
259 391 747 720
02581 03376 05162 09652
10000 10000 10000 10000
10600 10600 10600 10600
02736 03579 05472 10231
10000 10000 10000 10000
02736 03579 05472 10231
10000 10000 10000 10000
02581 03376 05162 09652
$2052 Obstetrics Obstetrics $2684 Obstetrics Obstetrics $4104 Obstetrics Obstetrics $7673 Obstetrics Obstetrics
564-1 564-2 564-3 564-4
ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY
137 170 276 808
02881 03463 04901 16676
10000 10000 10000 10000
10600 10600 10600 10600
03054 03671 05195 17677
10000 10000 10000 10000
03054 03671 05195 17677
10000 10000 10000 10000
02881 03463 04901 16676
$2290 Obstetrics Obstetrics $2753 Obstetrics Obstetrics $3896 Obstetrics Obstetrics
$13257 Obstetrics Obstetrics 565-1 565-2 565-3 565-4
FALSE LABOR FALSE LABOR FALSE LABOR FALSE LABOR
123 185 735 808
01245 01782 02687 02986
10000 10000 10000 10000
10600 10600 10600 10600
01320 01889 02848 03165
10000 10000 10000 10000
01320 01889 02848 03165
10000 10000 10000 10000
01245 01782 02687 02986
$990 Obstetrics Obstetrics $1417 Obstetrics Obstetrics $2136 Obstetrics Obstetrics $2374 Obstetrics Obstetrics
566-1 566-2 566-3 566-4
OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES OTHER ANTEPARTUM DIAGNOSES
211 294 544 843
02442 03252 04790 14726
10000 10000 10000 10000
10600 10600 10600 10600
02589 03447 05077 15610
10000 10000 10000 10000
02589 03447 05077 15610
10000 10000 10000 10000
02442 03252 04790 14726
$1941 Obstetrics Obstetrics $2585 Obstetrics Obstetrics $3808 Obstetrics Obstetrics
$11707 Obstetrics Obstetrics 580-1 580-2 580-3 580-4
NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE
144 159 182 165
02398 03209 05011 08512
12500 12500 12500 12500
10000 10000 10000 10000
02998 04011 06264 10640
10000 10000 10000 10000
02998 04011 06264 10640
17500 17500 17500 17500
04197 05616 08769 14896
$2248 Neonate Neonate $3008 Neonate Neonate $4698 Neonate Neonate $7980 Neonate Neonate
581-1 581-2 581-3 581-4
NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE
124 128 126 135
00982 01477 02362 04408
12500 12500 12500 12500
10000 10000 10000 10000
01228 01846 02953 05510
10000 10000 10000 10000
01228 01846 02953 05510
17500 17500 17500 17500
01719 02585 04134 07714
$921 Neonate Neonate $1385 Neonate Neonate $2214 Neonate Neonate $4133 Neonate Neonate
583-1 583-2 583-3 583-4
NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO NEONATE W ECMO
2070 2300 3077 4886
99741 157496 173245 240894
12500 12500 12500 12500
10000 10000 10000 10000
124676 196870 216556 301118
10000 10000 10000 10000
124676 196870 216556 301118
17500 17500 17500 17500
174547 275618 303179 421565
$93507 Neonate Neonate $147653 Neonate Neonate $162417 Neonate Neonate $225838 Neonate Neonate
588-1 588-2 588-3 588-4
NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE NEONATE BWT lt1500G W MAJOR PROCEDURE
4442 4935 7714
10207
48410 70035
142903 216660
12500 12500 12500 12500
10000 10000 10000 10000
60513 87544
178629 270825
10000 10000 10000 10000
60513 87544
178629 270825
17500 17500 17500 17500
84718 122561 250080 379155
$45384 Neonate Neonate $65658 Neonate Neonate
$133972 Neonate Neonate $203119 Neonate Neonate
589-1 589-2 589-3 589-4
NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS NEONATE BWT lt500G OR GA lt24 WEEKS
5843 5041 3035
265
115468 104972
95430 04454
12500 12500 12500 12500
10000 10000 10000 10000
144335 131215 119288
05568
10000 10000 10000 10000
144335 131215 119288
05568
17500 17500 17500 17500
202069 183701 167003
07795
$108251 Neonate Neonate $98411 Neonate Neonate $89466 Neonate Neonate
$4176 Neonate Neonate 591-1 591-2 591-3 591-4
NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE
211 3710 5061 7221
01574 55672 88282
132286
12500 12500 12500 12500
10000 10000 10000 10000
01968 69590
110353 165358
10000 10000 10000 10000
01968 69590
110353 165358
17500 17500 17500 17500
02755 97426
154494 231501
$1476 Neonate Neonate $52193 Neonate Neonate $82764 Neonate Neonate
$124018 Neonate Neonate 593-1 593-2 593-3 593-4
NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE
1928 4851 5965 7143
15109 51914 82800
122454
12500 12500 12500 12500
10000 10000 10000 10000
18886 64893
103500 153068
10000 10000 10000 10000
18886 64893
103500 153068
17500 17500 17500 17500
26441 90850
144900 214295
$14165 Neonate Neonate $48669 Neonate Neonate $77625 Neonate Neonate
$114801 Neonate Neonate 602-1 602-2 602-3 602-4
NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2513 4403 5324 6307
29635 58707 77593
104733
12500 12500 12500 12500
10000 10000 10000 10000
37044 73384 96991
130916
10000 10000 10000 10000
37044 73384 96991
130916
17500 17500 17500 17500
51861 102737 135788 183283
$27783 Neonate Neonate $55038 Neonate Neonate $72743 Neonate Neonate $98187 Neonate Neonate
603-1 603-2 603-3 603-4
NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION
2234 3619 4843 5396
17223 42526 65587 70750
12500 12500 12500 12500
10000 10000 10000 10000
21529 53158 81984 88438
10000 10000 10000 10000
21529 53158 81984 88438
17500 17500 17500 17500
30140 74421
114777 123813
$16147 Neonate Neonate $39868 Neonate Neonate $61488 Neonate Neonate $66328 Neonate Neonate
607-1 607-2 607-3 607-4
NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM
2509 3582 4341 4957
27503 47486 61883 79508
12500 12500 12500 12500
10000 10000 10000 10000
34379 59358 77354 99385
10000 10000 10000 10000
34379 59358 77354 99385
17500 17500 17500 17500
48130 83101
108295 139139
$25784 Neonate Neonate $44518 Neonate Neonate $58015 Neonate Neonate $74539 Neonate Neonate
608-1 608-2 608-3 608-4
NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION
1980 3004 3846 4414
21292 36047 52684 60424
12500 12500 12500 12500
10000 10000 10000 10000
26615 45059 65855 75530
10000 10000 10000 10000
26615 45059 65855 75530
17500 17500 17500 17500
37261 63082 92197
105742
$19961 Neonate Neonate $33794 Neonate Neonate $49391 Neonate Neonate $56648 Neonate Neonate
609-1 609-2 609-3 609-4
NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE NEONATE BWT 1500-2499G W MAJOR PROCEDURE
1933 2210 3803 6267
27332 38628 65636
119134
12500 12500 12500 12500
10000 10000 10000 10000
34165 48285 82045
148918
10000 10000 10000 10000
34165 48285 82045
148918
17500 17500 17500 17500
47831 67599
114863 208485
$25624 Neonate Neonate $36214 Neonate Neonate $61534 Neonate Neonate
$111688 Neonate Neonate 611-1 611-2 611-3 611-4
NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY
1313 2123 3133 3614
11780 25158 40556 52442
12500 12500 12500 12500
10000 10000 10000 10000
14725 31448 50695 65553
10000 10000 10000 10000
14725 31448 50695 65553
17500 17500 17500 17500
20615 44027 70973 91774
$11044 Neonate Neonate $23586 Neonate Neonate $38021 Neonate Neonate $49164 Neonate Neonate
612-1 612-2 612-3 612-4
NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND
1756 2442 3248 3834
21880 32223 46803 62297
12500 12500 12500 12500
10000 10000 10000 10000
27350 40279 58504 77871
10000 10000 10000 10000
27350 40279 58504 77871
17500 17500 17500 17500
38290 56390 81905
109020
$20513 Neonate Neonate $30209 Neonate Neonate $43878 Neonate Neonate $58403 Neonate Neonate
613-1 613-2 613-3 613-4
NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION
1439 2153 2853 3338
16593 26831 37601 48828
12500 12500 12500 12500
10000 10000 10000 10000
20741 33539 47001 61035
10000 10000 10000 10000
20741 33539 47001 61035
17500 17500 17500 17500
29038 46954 65802 85449
$15556 Neonate Neonate $25154 Neonate Neonate $35251 Neonate Neonate $45776 Neonate Neonate
614-1 614-2 614-3 614-4
NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION
1123 2008 2852 3640
09241 22768 36403 50802
12500 12500 12500 12500
10000 10000 10000 10000
11551 28460 45504 63503
10000 10000 10000 10000
11551 28460 45504 63503
17500 17500 17500 17500
16172 39844 63705 88904
$8663 Neonate Neonate $21345 Neonate Neonate $34128 Neonate Neonate $47627 Neonate Neonate
621-1 621-2 621-3 621-4
NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY NEONATE BWT 2000-2499G W MAJOR ANOMALY
820 1397 2125 2416
06082 15379 27206 38101
12500 12500 12500 12500
10000 10000 10000 10000
07603 19224 34008 47626
10000 10000 10000 10000
07603 19224 34008 47626
17500 17500 17500 17500
10644 26913 47611 66677
$5702 Neonate Neonate $14418 Neonate Neonate $25506 Neonate Neonate $35720 Neonate Neonate
622-1 622-2 622-3 622-4
NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND
1118 1514 1977 2285
13666 20913 29736 47202
12500 12500 12500 12500
10000 10000 10000 10000
17083 26141 37170 59003
10000 10000 10000 10000
17083 26141 37170 59003
17500 17500 17500 17500
23916 36598 52038 82604
$12812 Neonate Neonate $19606 Neonate Neonate $27878 Neonate Neonate $44252 Neonate Neonate
623-1 623-2 623-3 623-4
NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION
924 1399 1872 2738
09934 16800 25087 38932
12500 12500 12500 12500
10000 10000 10000 10000
12418 21000 31359 48665
10000 10000 10000 10000
12418 21000 31359 48665
17500 17500 17500 17500
17385 29400 43902 68131
$9313 Neonate Neonate $15750 Neonate Neonate $23519 Neonate Neonate $36499 Neonate Neonate
625-1 625-2 625-3 625-4
NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION
1157 1621 1925 2015
11469 18627 23298 29194
12500 12500 12500 12500
10000 10000 10000 10000
14336 23284 29123 36493
10000 10000 10000 10000
14336 23284 29123 36493
17500 17500 17500 17500
20071 32597 40772 51090
$10752 Neonate Neonate $17463 Neonate Neonate $21842 Neonate Neonate $27369 Neonate Neonate
626-1 626-2 626-3 626-4
NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
279 456 864
1838
01387 02587 07679 22819
10000 10000 10000 10000
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
10000 10000 10000 10000
01387 02587 07679 22819
$1040 Normal newborn Normal newborn $1940 Normal newborn Normal newborn $5759 Normal newborn Normal newborn
$17114 Normal newborn Normal newborn 630-1 630-2 630-3 630-4
NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE
486 940
1448 3912
20468 32885 52250
112072
12500 12500 12500 12500
10000 10000 10000 10000
25585 41106 65313
140090
10000 10000 10000 10000
25585 41106 65313
140090
17500 17500 17500 17500
35819 57549 91438
196126
$19189 Neonate Neonate $30830 Neonate Neonate $48984 Neonate Neonate
$105068 Neonate Neonate 631-1 631-2 631-3 631-4
NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE
335 886
2279 5111
09217 16766 37480 96324
12500 12500 12500 12500
10000 10000 10000 10000
11521 20958 46850
120405
10000 10000 10000 10000
11521 20958 46850
120405
17500 17500 17500 17500
16130 29341 65590
168567
$8641 Neonate Neonate $15718 Neonate Neonate $35138 Neonate Neonate $90304 Neonate Neonate
633-1 633-2 633-3 633-4
NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY NEONATE BIRTHWT gt2499G W MAJOR ANOMALY
296 651
1226 2381
01972 05798 13892 39728
12500 12500 12500 12500
10000 10000 10000 10000
02465 07248 17365 49660
10000 10000 10000 10000
02465 07248 17365 49660
17500 17500 17500 17500
03451 10147 24311 69524
$1849 Neonate Neonate $5436 Neonate Neonate
$13024 Neonate Neonate $37245 Neonate Neonate
634-1 634-2 634-3 634-4
NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND
465 749
1261 2233
04886 09445 20176 46934
12500 12500 12500 12500
10000 10000 10000 10000
06108 11806 25220 58668
10000 10000 10000 10000
06108 11806 25220 58668
17500 17500 17500 17500
08551 16529 35308 82135
$4581 Neonate Neonate $8855 Neonate Neonate
$18915 Neonate Neonate $44001 Neonate Neonate
636-1 636-2 636-3 636-4
NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION
558 779
1164 1896
05582 08840 15558 30613
12500 12500 12500 12500
10000 10000 10000 10000
06978 11050 19448 38266
10000 10000 10000 10000
06978 11050 19448 38266
17500 17500 17500 17500
09769 15470 27227 53573
$5233 Neonate Neonate $8288 Neonate Neonate
$14586 Neonate Neonate $28700 Neonate Neonate
639-1 639-2 639-3 639-4
NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION
441 704 998
1653
03287 06622 11809 27285
12500 12500 12500 12500
10000 10000 10000 10000
04109 08278 14761 34106
10000 10000 10000 10000
04109 08278 14761 34106
17500 17500 17500 17500
05752 11589 20666 47749
$3082 Neonate Neonate $6208 Neonate Neonate
$11071 Neonate Neonate $25580 Neonate Neonate
640-1 NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 210 01012 10000 10000 01012 10000 01012 10000 01012 $759 Normal newborn Normal newborn
640-2 640-3 640-4
NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
245 376
1206
01353 02864 14726
10000 10000 10000
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
$1015 Normal newborn Normal newborn $2148 Normal newborn Normal newborn
$11045 Normal newborn Normal newborn 650-1 650-2 650-3 650-4
SPLENECTOMY SPLENECTOMY SPLENECTOMY SPLENECTOMY
348 537 848
1563
12985 17965 25202 50826
10000 10000 10000 10000
10000 10000 10000 10000
12985 17965 25202 50826
12500 12500 12500 12500
16231 22456 31503 63533
10000 10000 10000 10000
12985 17965 25202 50826
$12173 Misc Pediatric Misc Adult $16842 Misc Pediatric Misc Adult $23627 Misc Pediatric Misc Adult $47649 Misc Pediatric Misc Adult
651-1 651-2 651-3 651-4
OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS
331 472 962
2426
09234 13695 21005 59541
10000 10000 10000 10000
10000 10000 10000 10000
09234 13695 21005 59541
12500 12500 12500 12500
11543 17119 26256 74426
10000 10000 10000 10000
09234 13695 21005 59541
$8657 Misc Pediatric Misc Adult $12839 Misc Pediatric Misc Adult $19692 Misc Pediatric Misc Adult $55820 Misc Pediatric Misc Adult
660-1 660-2 660-3 660-4
MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL
305 408 648
1435
05399 07219 11819 30180
10000 10000 10000 10000
10000 10000 10000 10000
05399 07219 11819 30180
12500 12500 12500 12500
06749 09024 14774 37725
10000 10000 10000 10000
05399 07219 11819 30180
$5062 Misc Pediatric Misc Adult $6768 Misc Pediatric Misc Adult
$11080 Misc Pediatric Misc Adult $28294 Misc Pediatric Misc Adult
661-1 661-2 661-3 661-4
COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS
275 375 566
1265
06473 08098 12433 27857
10000 10000 10000 10000
10000 10000 10000 10000
06473 08098 12433 27857
12500 12500 12500 12500
08091 10123 15541 34821
10000 10000 10000 10000
06473 08098 12433 27857
$6068 Misc Pediatric Misc Adult $7592 Misc Pediatric Misc Adult
$11656 Misc Pediatric Misc Adult $26116 Misc Pediatric Misc Adult
662-1 662-2 662-3 662-4
SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS
412 538 785
1302
05044 07003 10778 23937
10000 10000 10000 10000
10000 10000 10000 10000
05044 07003 10778 23937
12500 12500 12500 12500
06305 08754 13473 29921
10000 10000 10000 10000
05044 07003 10778 23937
$4729 Misc Pediatric Misc Adult $6565 Misc Pediatric Misc Adult
$10104 Misc Pediatric Misc Adult $22441 Misc Pediatric Misc Adult
663-1 663-2 663-3 663-4
OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS
232 301 451 900
04474 05959 08513 16106
10000 10000 10000 10000
10000 10000 10000 10000
04474 05959 08513 16106
12500 12500 12500 12500
05593 07449 10641 20133
10000 10000 10000 10000
04474 05959 08513 16106
$4194 Misc Pediatric Misc Adult $5587 Misc Pediatric Misc Adult $7981 Misc Pediatric Misc Adult
$15099 Misc Pediatric Misc Adult 680-1 680-2 680-3 680-4
MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
408 633
1185 2456
13702 18600 32002 66288
10000 10000 10000 10000
10000 10000 10000 10000
13702 18600 32002 66288
12500 12500 12500 12500
17128 23250 40003 82860
10000 10000 10000 10000
13702 18600 32002 66288
$12846 Misc Pediatric Misc Adult $17438 Misc Pediatric Misc Adult $30002 Misc Pediatric Misc Adult $62145 Misc Pediatric Misc Adult
681-1 681-2 681-3 681-4
OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
268 507
1111 2510
09800 13647 24597 59170
10000 10000 10000 10000
10000 10000 10000 10000
09800 13647 24597 59170
12500 12500 12500 12500
12250 17059 30746 73963
10000 10000 10000 10000
09800 13647 24597 59170
$9188 Misc Pediatric Misc Adult $12794 Misc Pediatric Misc Adult $23060 Misc Pediatric Misc Adult $55472 Misc Pediatric Misc Adult
690-1 690-2 690-3 690-4
ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA
495 740
1461 2485
07040 11869 23551 52504
10000 10000 10000 10000
10000 10000 10000 10000
07040 11869 23551 52504
12500 12500 12500 12500
08800 14836 29439 65630
10000 10000 10000 10000
07040 11869 23551 52504
$6600 Misc Pediatric Misc Adult $11127 Misc Pediatric Misc Adult $22079 Misc Pediatric Misc Adult $49223 Misc Pediatric Misc Adult
691-1 691-2 691-3 691-4
LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA
389 540 861
1585
07077 09840 15477 31411
10000 10000 10000 10000
10000 10000 10000 10000
07077 09840 15477 31411
12500 12500 12500 12500
08846 12300 19346 39264
10000 10000 10000 10000
07077 09840 15477 31411
$6635 Misc Pediatric Misc Adult $9225 Misc Pediatric Misc Adult
$14510 Misc Pediatric Misc Adult $29448 Misc Pediatric Misc Adult
692-1 692-2 692-3 692-4
RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY
389 482 868
1580
06075 12584 17422 29316
10000 10000 10000 10000
10000 10000 10000 10000
06075 12584 17422 29316
12500 12500 12500 12500
07594 15730 21778 36645
10000 10000 10000 10000
06075 12584 17422 29316
$5695 Misc Pediatric Misc Adult $11798 Misc Pediatric Misc Adult $16333 Misc Pediatric Misc Adult $27484 Misc Pediatric Misc Adult
693-1 693-2 693-3 693-4
CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY
281 368 785
2410
06251 07881 13637 49083
10000 10000 10000 10000
10000 10000 10000 10000
06251 07881 13637 49083
12500 12500 12500 12500
07814 09851 17046 61354
10000 10000 10000 10000
06251 07881 13637 49083
$5860 Misc Pediatric Misc Adult $7388 Misc Pediatric Misc Adult
$12785 Misc Pediatric Misc Adult $46015 Misc Pediatric Misc Adult
694-1 694-2 694-3 694-4
LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR
304 404 674
1164
04842 06831 11115 21001
10000 10000 10000 10000
10000 10000 10000 10000
04842 06831 11115 21001
12500 12500 12500 12500
06053 08539 13894 26251
10000 10000 10000 10000
04842 06831 11115 21001
$4539 Misc Pediatric Misc Adult $6404 Misc Pediatric Misc Adult
$10420 Misc Pediatric Misc Adult $19688 Misc Pediatric Misc Adult
710-1 710-2 710-3 710-4
INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE
510 680
1111 1820
10635 15963 25572 49382
10000 10000 10000 10000
10000 10000 10000 10000
10635 15963 25572 49382
12500 12500 12500 12500
13294 19954 31965 61728
10000 10000 10000 10000
10635 15963 25572 49382
$9970 Misc Pediatric Misc Adult $14965 Misc Pediatric Misc Adult $23974 Misc Pediatric Misc Adult $46296 Misc Pediatric Misc Adult
711-1 711-2 711-3 711-4
POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE
471 692
1131 2087
10079 14143 23599 50574
10000 10000 10000 10000
10000 10000 10000 10000
10079 14143 23599 50574
12500 12500 12500 12500
12599 17679 29499 63218
10000 10000 10000 10000
10079 14143 23599 50574
$9449 Misc Pediatric Misc Adult $13259 Misc Pediatric Misc Adult $22124 Misc Pediatric Misc Adult $47413 Misc Pediatric Misc Adult
720-1 720-2 720-3 720-4
SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS
353 444 633
1004
05431 07613 11532 21705
10000 10000 10000 10000
10000 10000 10000 10000
05431 07613 11532 21705
12500 12500 12500 12500
06789 09516 14415 27131
10000 10000 10000 10000
05431 07613 11532 21705
$5092 Misc Pediatric Misc Adult $7137 Misc Pediatric Misc Adult
$10811 Misc Pediatric Misc Adult $20348 Misc Pediatric Misc Adult
721-1 721-2 721-3 721-4
POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS
368 470 705
1153
05287 07209 11619 22025
10000 10000 10000 10000
10000 10000 10000 10000
05287 07209 11619 22025
12500 12500 12500 12500
06609 09011 14524 27531
10000 10000 10000 10000
05287 07209 11619 22025
$4957 Misc Pediatric Misc Adult $6758 Misc Pediatric Misc Adult
$10893 Misc Pediatric Misc Adult $20648 Misc Pediatric Misc Adult
722-1 722-2 722-3 722-4
FEVER FEVER FEVER FEVER
230 302 429 739
03423 05223 07630 13141
10000 10000 10000 10000
10000 10000 10000 10000
03423 05223 07630 13141
12500 12500 12500 12500
04279 06529 09538 16426
10000 10000 10000 10000
03423 05223 07630 13141
$3209 Misc Pediatric Misc Adult $4897 Misc Pediatric Misc Adult $7153 Misc Pediatric Misc Adult
$12320 Misc Pediatric Misc Adult 723-1 723-2 723-3 723-4
VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS
216 279 470
1317
03194 04738 07794 24233
10000 10000 10000 10000
10000 10000 10000 10000
03194 04738 07794 24233
12500 12500 12500 12500
03993 05923 09743 30291
10000 10000 10000 10000
03194 04738 07794 24233
$2994 Misc Pediatric Misc Adult $4442 Misc Pediatric Misc Adult $7307 Misc Pediatric Misc Adult
$22718 Misc Pediatric Misc Adult 724-1 724-2 724-3 724-4
OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES
400 477 680
1337
05512 07131 11401 24698
10000 10000 10000 10000
10000 10000 10000 10000
05512 07131 11401 24698
12500 12500 12500 12500
06890 08914 14251 30873
10000 10000 10000 10000
05512 07131 11401 24698
$5168 Misc Pediatric Misc Adult $6685 Misc Pediatric Misc Adult
$10688 Misc Pediatric Misc Adult $23154 Misc Pediatric Misc Adult
740-1 740-2 740-3 740-4
MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE
678 1284 2034 2421
10899 13904 24356 37756
10000 10000 10000 10000
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
$8174 Other Other $10428 Other Other $18267 Other Other $28317 Other Other
750-1 750-2 750-3 750-4
SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA
1082 1179 1539 2848
05713 06699 09202 19283
10000 10000 10000 10000
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
$4285 Other Other $5024 Other Other $6902 Other Other
$14462 Other Other 751-1 751-2 751-3 751-4
MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES
528 724
1055 2028
03572 05019 08097 15923
10000 10000 10000 10000
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
$2679 Other Other $3764 Other Other $6073 Other Other
$11942 Other Other 752-1 752-2 752-3 752-4
DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL
503 658
1473 7300
03399 04498 09061 14934
10000 10000 10000 10000
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
$2549 Other Other $3374 Other Other $6796 Other Other
$11201 Other Other 753-1 753-2 753-3 753-4
BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS
601 808
1205 1948
04001 05365 08266 14926
10000 10000 10000 10000
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
$3001 Other Other $4024 Other Other $6200 Other Other
$11195 Other Other 754-1 754-2 754-3 754-4
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER
424 558 727
1664
02943 03998 05677 11553
10000 10000 10000 10000
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
$2207 Other Other $2999 Other Other $4258 Other Other $8665 Other Other
755-1 755-2 755-3 755-4
ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
388 622 900 813
02738 04363 06226 08767
10000 10000 10000 10000
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
$2054 Other Other $3272 Other Other $4670 Other Other $6575 Other Other
756-1 756-2 756-3 756-4
ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES
331 381 457 942
04061 05308 06065 13981
10000 10000 10000 10000
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
$3046 Other Other $3981 Other Other $4549 Other Other
$10486 Other Other 757-1 757-2 757-3 757-4
ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES
873 934
1087 1640
05861 07234 08953 13799
10000 10000 10000 10000
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
$4396 Other Other $5426 Other Other $6715 Other Other
$10349 Other Other 758-1 758-2 758-3 758-4
CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS
694 981
1225 4300
03874 05129 06541 11332
10000 10000 10000 10000
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
$2906 Other Other $3847 Other Other $4906 Other Other $8499 Other Other
759-1 759-2 759-3 759-4
EATING DISORDERS EATING DISORDERS EATING DISORDERS EATING DISORDERS
1990 1297 1402 2303
06561 06961 10053 16606
10000 10000 10000 10000
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
$4921 Other Other $5221 Other Other $7540 Other Other
$12455 Other Other 760-1 760-2 760-3 760-4
OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS
748 766 912
1204
04840 06173 07573 14134
10000 10000 10000 10000
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
$3630 Other Other $4630 Other Other $5680 Other Other
$10601 Other Other 770-1 770-2 770-3 770-4
DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE
253 248 332 794
02240 02623 05475 16843
10000 10000 10000 10000
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
$1680 Other Other $1967 Other Other $4106 Other Other
$12632 Other Other 772-1 772-2 772-3 772-4
ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY
1434 1551 1289 2385
05441 06916 07009 24530
10000 10000 10000 10000
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
$4081 Other Other $5187 Other Other $5257 Other Other
$18398 Other Other 773-1 773-2 773-3 773-4
OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE
337 414 507 992
02663 03466 05964 18606
10000 10000 10000 10000
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
$1997 Other Other $2600 Other Other $4473 Other Other
$13955 Other Other 774-1 774-2
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
365 412
03040 03627
10000 10000
10000 10000
03040 03627
10000 10000
03040 03627
10000 10000
03040 03627
$2280 Other Other $2720 Other Other
774-3 774-4
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
479 1424
06448 24682
10000 10000
10000 10000
06448 24682
10000 10000
06448 24682
10000 10000
06448 24682
$4836 Other $18512 Other
Other Other
775-1 775-2 775-3 775-4
ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE
323 377 571
1263
03313 04639 08596 24910
10000 10000 10000 10000
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
$2485 Other $3479 Other $6447 Other
$18683 Other
Other Other Other Other
776-1 776-2 776-3 776-4
OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE
389 397 496 933
03157 04547 07887 16112
10000 10000 10000 10000
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
$2368 Other $3410 Other $5915 Other
$12084 Other
Other Other Other Other
791-1 791-2 791-3 791-4
OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT
314 515 989
2009
08636 12677 21979 49312
10000 10000 10000 10000
10000 10000 10000 10000
08636 12677 21979 49312
12500 12500 12500 12500
10795 15846 27474 61640
10000 10000 10000 10000
08636 12677 21979 49312
$8096 Misc Pediatric $11885 Misc Pediatric $20605 Misc Pediatric $46230 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
811-1 811-2 811-3 811-4
ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS
151 202 390 913
02707 03855 08277 22176
10000 10000 10000 10000
10000 10000 10000 10000
02707 03855 08277 22176
12500 12500 12500 12500
03384 04819 10346 27720
10000 10000 10000 10000
02707 03855 08277 22176
$2538 Misc Pediatric $3614 Misc Pediatric $7760 Misc Pediatric
$20790 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
812-1 812-2 812-3 812-4
POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS
165 225 347 694
03469 04331 07709 17419
10000 10000 10000 10000
10000 10000 10000 10000
03469 04331 07709 17419
12500 12500 12500 12500
04336 05414 09636 21774
10000 10000 10000 10000
03469 04331 07709 17419
$3252 Misc Pediatric $4060 Misc Pediatric $7227 Misc Pediatric
$16330 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
813-1 813-2 813-3 813-4
OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT
261 344 594
1344
04393 06056 09631 19960
10000 10000 10000 10000
10000 10000 10000 10000
04393 06056 09631 19960
12500 12500 12500 12500
05491 07570 12039 24950
10000 10000 10000 10000
04393 06056 09631 19960
$4118 Misc Pediatric $5678 Misc Pediatric $9029 Misc Pediatric
$18713 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
815-1 815-2 815-3 815-4
OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES
169 276 456 880
04211 05012 08129 22715
10000 10000 10000 10000
10000 10000 10000 10000
04211 05012 08129 22715
12500 12500 12500 12500
05264 06265 10161 28394
10000 10000 10000 10000
04211 05012 08129 22715
$3948 Misc Pediatric $4699 Misc Pediatric $7621 Misc Pediatric
$21295 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
816-1 816-2 816-3 816-4
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
173 240 346 736
04162 04915 07864 18134
10000 10000 10000 10000
10000 10000 10000 10000
04162 04915 07864 18134
12500 12500 12500 12500
05203 06144 09830 22668
10000 10000 10000 10000
04162 04915 07864 18134
$3902 Misc Pediatric $4608 Misc Pediatric $7373 Misc Pediatric
$17001 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
841-1 841-2 841-3 841-4
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT
2200 967
2599 4068
31148 34263 64068
159153
10000 10000 10000 10000
10000 10000 10000 10000
31148 34263 64068
159153
12500 12500 12500 12500
38935 42829 80085
198941
10000 10000 10000 10000
31148 34263 64068
159153
$29201 Misc Pediatric $32122 Misc Pediatric $60064 Misc Pediatric
$149206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
842-1 842-2 842-3 842-4
FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT
751 1072 1735 3010
14151 21416 38719 95054
10000 10000 10000 10000
10000 10000 10000 10000
14151 21416 38719 95054
12500 12500 12500 12500
17689 26770 48399
118818
10000 10000 10000 10000
14151 21416 38719 95054
$13267 Misc Pediatric $20078 Misc Pediatric $36299 Misc Pediatric $89113 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
843-1 843-2 843-3 843-4
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT
339 487 713
1113
04752 06661 11619 32621
10000 10000 10000 10000
10000 10000 10000 10000
04752 06661 11619 32621
12500 12500 12500 12500
05940 08326 14524 40776
10000 10000 10000 10000
04752 06661 11619 32621
$4455 Misc Pediatric $6245 Misc Pediatric
$10893 Misc Pediatric $30582 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
844-1 844-2 844-3 844-4
PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT
310 497 743
1781
04337 06965 12193 48021
10000 10000 10000 10000
10000 10000 10000 10000
04337 06965 12193 48021
12500 12500 12500 12500
05421 08706 15241 60026
10000 10000 10000 10000
04337 06965 12193 48021
$4066 Misc Pediatric $6530 Misc Pediatric
$11431 Misc Pediatric $45020 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
850-1 850-2 850-3 850-4
PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE
267 556
1618 3148
11757 14065 24870 46520
10000 10000 10000 10000
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
$8818 Misc Pediatric $10549 Misc Pediatric $18653 Misc Pediatric $34890 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
860-1 860-2 860-3 860-4
REHABILITATION REHABILITATION REHABILITATION REHABILITATION
932 1146 1475 1795
07227 09855 13880 17876
10000 10000 10000 10000
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
$5420 Other $7391 Other
$10410 Other $13407 Other
Other Other Other Other
861-1 861-2 861-3 861-4
SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS
253 340 497 917
02858 05247 07658 14498
10000 10000 10000 10000
10000 10000 10000 10000
02858 05247 07658 14498
12500 12500 12500 12500
03573 06559 09573 18123
10000 10000 10000 10000
02858 05247 07658 14498
$2679 Misc Pediatric $4919 Misc Pediatric $7179 Misc Pediatric
$13592 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
862-1 862-2 862-3 862-4
OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE
698 1122 1357 1872
02895 05851 07866 11351
10000 10000 10000 10000
10000 10000 10000 10000
02895 05851 07866 11351
12500 12500 12500 12500
03619 07314 09833 14189
10000 10000 10000 10000
02895 05851 07866 11351
$2714 Misc Pediatric $5485 Misc Pediatric $7374 Misc Pediatric
$10642 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
863-1 863-2 863-3 863-4
NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE
853 1757 2771 4643
05959 16127 30507 61446
12500 12500 12500 12500
10000 10000 10000 10000
07449 20159 38134 76808
10000 10000 10000 10000
07449 20159 38134 76808
17500 17500 17500 17500
10428 28222 53387
107531
$5587 Neonate $15119 Neonate $28600 Neonate $57606 Neonate
Neonate Neonate Neonate Neonate
890-1 890-2 890-3 890-4
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS
167 691 921
1514
07051 10224 14771 30014
10000 10000 10000 10000
10000 10000 10000 10000
07051 10224 14771 30014
12500 12500 12500 12500
08814 12780 18464 37518
10000 10000 10000 10000
07051 10224 14771 30014
$6610 Misc Pediatric $9585 Misc Pediatric
$13848 Misc Pediatric $28138 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
892-1 892-2 892-3 892-4
HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION
587 488 669
1152
05647 07763 10877 19375
10000 10000 10000 10000
10000 10000 10000 10000
05647 07763 10877 19375
12500 12500 12500 12500
07059 09704 13596 24219
10000 10000 10000 10000
05647 07763 10877 19375
$5294 Misc Pediatric $7278 Misc Pediatric
$10197 Misc Pediatric $18164 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
893-1 893-2 893-3 893-4
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
499 496 799
1422
07762 08219 12807 24296
10000 10000 10000 10000
10000 10000 10000 10000
07762 08219 12807 24296
12500 12500 12500 12500
09703 10274 16009 30370
10000 10000 10000 10000
07762 08219 12807 24296
$7277 Misc Pediatric $7705 Misc Pediatric
$12007 Misc Pediatric $22778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
894-1 894-2 894-3 894-4
HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND
341 393 627
1121
05218 06497 09774 19428
10000 10000 10000 10000
10000 10000 10000 10000
05218 06497 09774 19428
12500 12500 12500 12500
06523 08121 12218 24285
10000 10000 10000 10000
05218 06497 09774 19428
$4892 Misc Pediatric $6091 Misc Pediatric $9163 Misc Pediatric
$18214 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
910-1 910-2 910-3 910-4
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA
1100 775
1057 1830
28786 31984 41628 72114
10000 10000 10000 10000
10000 10000 10000 10000
28786 31984 41628 72114
12500 12500 12500 12500
35983 39980 52035 90143
10000 10000 10000 10000
28786 31984 41628 72114
$26987 Misc Pediatric $29985 Misc Pediatric $39026 Misc Pediatric $67607 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
911-1 911-2 911-3 911-4
EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA
511 619 795
1687
15160 20189 26724 58039
10000 10000 10000 10000
10000 10000 10000 10000
15160 20189 26724 58039
12500 12500 12500 12500
18950 25236 33405 72549
10000 10000 10000 10000
15160 20189 26724 58039
$14213 Misc Pediatric $18927 Misc Pediatric $25054 Misc Pediatric $54412 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
912-1 912-2 912-3 912-4
MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
558 607 985
1782
20950 22759 36410 68885
10000 10000 10000 10000
10000 10000 10000 10000
20950 22759 36410 68885
12500 12500 12500 12500
26188 28449 45513 86106
10000 10000 10000 10000
20950 22759 36410 68885
$19641 Misc Pediatric $21337 Misc Pediatric $34134 Misc Pediatric $64580 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
930-1 930-2 930-3 930-4
MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE
322 370 596
1127
07826 09594 15857 33896
10000 10000 10000 10000
10000 10000 10000 10000
07826 09594 15857 33896
12500 12500 12500 12500
09783 11993 19821 42370
10000 10000 10000 10000
07826 09594 15857 33896
$7337 Misc Pediatric $8994 Misc Pediatric
$14866 Misc Pediatric $31778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
950-1 950-2 950-3 950-4
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
361 623
1166 2260
13230 20029 31827 60092
10000 10000 10000 10000
10000 10000 10000 10000
13230 20029 31827 60092
12500 12500 12500 12500
16538 25036 39784 75115
10000 10000 10000 10000
13230 20029 31827 60092
$12403 Misc Pediatric $18777 Misc Pediatric $29838 Misc Pediatric $56336 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
951-1 951-2 951-3 951-4
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
329 517
1001 1973
09755 14320 24054 46875
10000 10000 10000 10000
10000 10000 10000 10000
09755 14320 24054 46875
12500 12500 12500 12500
12194 17900 30068 58594
10000 10000 10000 10000
09755 14320 24054 46875
$9145 Misc Pediatric $13425 Misc Pediatric $22551 Misc Pediatric $43945 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
952-1 952-2 952-3 952-4
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
274 504 968
1894
07736 11591 20369 39177
10000 10000 10000 10000
10000 10000 10000 10000
07736 11591 20369 39177
12500 12500 12500 12500
09670 14489 25461 48971
10000 10000 10000 10000
07736 11591 20369 39177
$7253 Misc Pediatric $10867 Misc Pediatric $19096 Misc Pediatric $36728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
955-0 956-0
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS UNGROUPABLE
--
--
Error DRG Error DRG
Error DRG Error DRG
i-
i
i
i-
i
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy adjustor F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that has at least a basic level
emergency room H FY 2015-16 Cost-to-Charge Ratio FY 2013 cost-to-charge ratio with some exceptions I FY 2015-16 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FY 2015-16 Wage Index Value (adjusted for CA Neutrality Factor 09797) W age index value times 09797 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls for changes between California
and the rest of the US while maintaining relative differences among wage areas within California K FY 2015-16 Unadjusted Statewide Base Rate The statewide DRG base rate is $6289 except that for remote rural hospitals it is $12768 L FY 2015-16 Wage Adjusted Statewide Base Rate (Non-Transition) The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses See Tab 5 This rate is applicable for non-transition hospitals as shown in Column N Medi-Cal
managed care plans that are pricing claims for emergency and post-stabilization services hospitals outside their network should use Column L for all hospitals M FY 2015-16 Hospital-Specific Transition Base Rate The base rate assigned to hospitals to move them in steps toward the statewide base rate This rate is applicable for transition hospitals as shown in Column N FY 2015-16 is the final year of transition rates N Transition rate This column identifies whether the hospital is a non-transition hospital (base rate in Column L) or a transition hospital (base rate in Column M) O FY 2015-16 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2015-16 P FY 2015-16 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by
use of Revenue Code 190 Q FY 2015-16 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by use of
Revenue Code 199
A B C D E F G H I J K L M N O P Q
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transit on Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
OUT OF STATE No No No No No 2180 10000 10000 $6289 $6289 NA Non-Transition NA $98163 $80582 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 3572 12882 12620 $12768 $15097 $15414 Transition NA $98163 $80582 106100793 ADVENTIST MEDICAL CENTER - SELMA COMMUNITY HOSPITAL No No No Yes Yes 3572 12882 12620 $12768 $15097 $14680 Transition NA $98163 $80582 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 4360 12882 12620 $12768 $15097 $10484 Transition NA $98163 $80582 106301098 AHMC ANAHEIM REG MED CTR No No No No No 1656 12882 12620 $6289 $7436 $15144 Transition NA $98163 $80582 106010846 ALAMEDA CO MED CTR Yes No No No No 4036 16962 16618 $6289 $9186 NA NA NA NA NA 106010735 ALAMEDA HOSP No Yes No No No 2600 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106190017 ALHAMBRA HOSP No No No No No 1397 12882 12620 $6289 $7436 $5446 Transition $1220 $98163 $80582 106010739 ALTA BATES SUMMIT MED CTR-ALTA BATES No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106010937 ALTA BATES SUMMIT MED CTR-HAWTHORNE No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106010844 ALTA BATES SUMMIT MED CTR-HERRICK CAMPUS No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106013626 ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106374063 ALVARADO HOSP MED CTR - REHAB No No No No No 1930 12882 12620 $6289 $7436 $4599 Transition $1220 $98163 $80582 106190034 ANTELOPE VALLEY HOSP MED CTR No Yes No No No 2997 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364231 ARROWHEAD REG MED CTR Yes No No No No 3324 12882 12620 $6289 $7436 NA NA NA NA NA 106400466 ARROYO GRANDE COMM HOSP No No No No No 2581 12964 12701 $6289 $7471 NA Non-Transition $1226 $98163 $80582 106154101 BAKERSFIELD HEART HOSP No No No No No 1782 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150722 BAKERSFIELD MEM HOSP-34TH ST No No No No No 2117 12882 12620 $6289 $7436 $9141 Transition NA $98163 $80582 106364121 BALLARD REHABILITATION HOSP No No No No No 8300 12882 12620 NA NA NA NA $1427 $98163 $80582 106184008 BANNER LASSEN MED CTR No No No Yes Yes 3967 12882 12620 $12768 $15097 $18668 Transition NA $98163 $80582 106190052 BARLOW RESP HOSP No No No No No 1849 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364430 BARSTOW COMM HOSP No No No Yes Yes 2262 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090793 BARTON MEM HOSP No No No Yes Yes 3635 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106361110 BEAR VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190081 BEVERLY HOSP No No No No No 3567 12882 12620 $6289 $7436 $5841 Transition NA $98163 $80582 106040802 BIGGS GRIDLEY MEM HOSP No No No Yes Yes 3652 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106380929 CA PACIFIC MED CTR No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380777 CA PACIFIC MED CTR - CALIFORNIA WEST No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380933 CA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 2873 16738 16398 $6289 $9090 NA Non-Transition $1492 $98163 $80582 106190125 CALIFORNIA HOSP MED CTR-LA No No Yes No No 2078 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190137 CASA COLINA HOSP FOR REHAB MED No No No No No 7213 12882 12620 NA NA NA NA $1220 $98163 $80582 106190045 CATALINA ISLAND MED CTR No No No Yes Yes 9000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190555 CEDARS-SINAI MED CTR No No Yes No No 2051 12882 12620 $6289 $7436 $5837 Transition $1220 $98163 $80582 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 1730 12882 12620 $6289 $7436 $6350 Transition $1220 $98163 $80582 106160787 CENTRAL VALLEY GEN HOSP No No No No No 7778 12882 12620 $6289 $7436 $11888 Transition NA $98163 $80582 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 2190 12892 12630 $6289 $7440 NA Non-Transition $1221 $98163 $80582 106301140 CHAPMAN MED CTR No No No No No 1908 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304113 CHILDRENS HOSP AT MISSION No No No No No 3300 12882 12620 $6289 $7436 $18777 Transition NA $98163 $80582 106204019 CHILDRENS HOSP CENTRAL CALIFORNIA No No Yes No No 2430 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106010776 CHILDRENS HOSP OAKLAND No No Yes No No 3356 16478 16143 $6289 $8978 NA Non-Transition $2628 $98163 $80582 106190170 CHILDRENS HOSP OF LA No No Yes No No 3988 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106300032 CHILDRENS HOSP OF ORANGE CO No No Yes No No 2442 12882 12620 $6289 $7436 $5613 Transition NA $98163 $80582 106382715 CHINESE HOSP No No No No No 3835 16738 16398 $6289 $9090 $8053 Transition NA $98163 $80582 106361144 CHINO VALLEY MED CTR No No No No No 2098 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190176 CITY OF HOPE HELFORD CLINIC RES HOSP No No No No No 2789 12882 12620 $6289 $7436 $5941 Transition NA $98163 $80582 106100005 CLOVIS COMM MED CTR No No No No No 3336 12882 12620 $6289 $7436 $7752 Transition NA $98163 $80582 106100697 COALINGA REG MED CTR No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190766 COAST PLAZA DRS HOSP No No No No No 2126 12882 12620 $6289 $7436 $5303 Transition NA $98163 $80582 106301258 COASTAL COMM HOSP No No No No No 2792 12882 12620 $6289 $7436 $7035 Transition NA $98163 $80496 106301155 COLLEGE HOSP COSTA MESA No No No No No 2876 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190587 COLLEGE MEDICAL CENTER No No No No No 3760 12882 12620 $6289 $7436 $4258 Transition NA $98163 $80582 106361458 COLORADO RIVER MED CTR No No No Yes Yes 4357 12882 12620 $12768 $15097 $18541 Transition NA $98163 $80582 106060870 COLUSA REG MED CTR No No No Yes Yes 3066 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190197 COMM AND MISSION HOSP OF HUNT PK No No No No No 1601 12882 12620 $6289 $7436 $5421 Transition NA $98163 $80582 106190475 COMM HOSP OF LONG BEACH No No No No No 1707 12882 12620 $6289 $7436 $15917 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106361323 COMM HOSP OF SAN BERNARDINO No No No No No 2833 12882 12620 $6289 $7436 $6516 Transition NA $98163 $78406 106560473 COMM MEM HOSP OF SAN BUENAVENTURA No No No No No 2104 12882 12620 $6289 $7436 $4512 Transition NA $98163 $80582 106100717 COMM REG MED CTR-FRESNO No No No No No 1896 12882 12620 $6289 $7436 $7994 Transition $1655 $98163 $80582 106070924 CONTRA COSTA REG MED CTR Yes No No No No 6010 16478 16143 $6289 $8978 NA NA NA NA NA 106331152 CORONA REG MED CTR No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition NA $98163 $80582 106331145 CORONA REG MED CTR - MAGNOLIA No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition $1220 $98163 $80582 106190413 CV-INTERCOMMUNITY CAMPUS No No No No No 3136 12882 12620 $6289 $7436 $6821 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106190636 CV-QUEEN OF VALLEY CAMPUS No No Yes No No 3136 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106150706 DELANO REG MED CTR No No No No No 3622 12882 12620 $6289 $7436 $7087 Transition NA $98163 $80582 106331164 DESERT REG MED CTR No No No No No 1486 12882 12620 $6289 $7436 $7153 Transition $1447 $98163 $80582 106364144 DESERT VALLEY HOSP No No No No No 2050 12882 12620 $6289 $7436 $8173 Transition NA $98163 $80582 106440755 DOMINICAN HOSP-SANTA CRUZ No No No No No 2016 17239 16889 $6289 $9304 $7821 Transition $1527 $98163 $80582 106190243 DOWNEY REG MED CTR No No No No No 1732 12882 12620 $6289 $7436 $6847 Transition NA $98163 $80582 106392287 DRS HOSP OF MANTECA No No No No No 1362 13579 13303 $6289 $7735 $11712 Transition NA $98163 $80582 106390846 DAMERON HOSP No No No No No 2138 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106190857 DRS HOSP OF WEST COVINA No No No No No 1833 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106070904 DRS MED CTR-SAN PABLOPINOLE No Yes No No No 2373 16478 16143 $6289 $8978 $6025 Transition NA $98163 $80582 106190256 EAST LA DRS HOSP No No No No No 1952 12882 12620 $6289 $7436 $5809 Transition NA $98163 $80582 106190328 EAST VALLEY HOSP MED CTR No No No No No 2859 12882 12620 $6289 $7436 $5534 Transition NA $98163 $80582 106320859 EASTERN PLUMAS HOSP No Yes No Yes Yes 4802 12882 12620 $12768 $15097 $13674 Transition NA $98163 $80582 106014233 EDEN MED CTR No No No No No 3197 16962 16618 $6289 $9186 $12768 Transition NA $98163 $80582 106331168 EISENHOWER MEM HOSP No No No No No 1540 12882 12620 $6289 $7436 $10211 Transition NA $98163 $80582 106430763 EL CAMINO HOSP No Yes No No No 2857 17180 16831 $6289 $9279 $5377 Transition $1523 $98163 $80582 106130699 EL CENTRO COMM HOSP No Yes No No No 2298 12882 12620 $6289 $7436 $8949 Transition NA $98163 $80582 106500852 DRS MED CTR No No No No No 1181 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106500867 EMANUEL MED CTR No No No No No 2046 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106040962 ENLOE MED CTR No No No No No 2436 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106044011 ENLOE REHABILLITATION CENTER No No No No No 2463 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106474007 FAIRCHILD MED CTR No No No Yes Yes 3914 12882 12620 $12768 $15097 $16385 Transition NA $98163 $80582 106040875 FEATHER RIVER HOSP No No No No No 1240 12882 12620 $6289 $7436 $10796 Transition NA $98163 $80582 106190298 FOOTHILL PRES HOSP No No No No No 2989 12882 12620 $6289 $7436 $4740 Transition NA $98163 $80582 106301175 FOUNTAIN VALLEY REG HOSP-EUCLID No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106304039 FOUNTAIN VALLEY REG HOSP-WARNER No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106230949 FRANK R HOWARD MEM HOSP No No No Yes Yes 3495 12882 12620 $12768 $15097 $15377 Transition NA $98163 $80582 106510882 FREMONT MEDICAL CENTER No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106190280 ENCINO HOSP MED CTR No No No No No 949 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106400480 FRENCH HOSP MED CTR No No No No No 2241 12964 12701 $6289 $7471 NA Non-Transition NA $98163 $80582 106301283 GARDEN GROVE HOSP AND MED CTR No No No No No 2661 12882 12620 $6289 $7436 $5749 Transition NA $98163 $80582 106190159 GARDEN REG HOSP AND MED CTR No No No No No 2937 12882 12620 $6289 $7436 $4110 Transition NA $98163 $80582 106105029 FRESNO HEART HOSP No No No No No 3403 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106270777 GEORGE L MEE MEM HOSP No No No Yes Yes 3562 15558 15242 $12768 $17426 $20386 Transition NA $98163 $80582 106190315 GARFIELD MED CTR No No No No No 1031 12882 12620 $6289 $7436 NA Non-Transition $1394 $98163 $80582 106190522 GLENDALE MEM HOSP AND HLTH CTR No No No No No 2163 12882 12620 $6289 $7436 $6885 Transition $1220 $98163 $80582 106110889 GLENN MED CTR No No No Yes Yes 6660 12882 12620 $12768 $15097 $21024 Transition NA $98163 $80582 106190323 GLENDALE ADV MED CTR-WILSON TERRACE No No No No No 1845 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420483 GOLETA VALLEY COTTAGE HOSP No No No No No 3083 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150775 GOOD SAMARITAN HOSP-BAKERSFIELD No No No No No 3694 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430779 GOOD SAMARITAN HOSP-SAN JOSE No No Yes No No 1937 17180 16831 $6289 $9279 $5654 Transition NA $98163 $80582 106190352 GREATER EL MONTE COMM HOSP No No No No No 1088 12882 12620 $6289 $7436 $4818 Transition NA $98163 $80582 106370714 GROSSMONT HOSP No No No No No 1937 12882 12620 $6289 $7436 $6498 Transition $1220 $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190392 GOOD SAMARITAN HOSP-LA No No Yes No No 2006 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106350784 HAZEL HAWKINS MEM HOSP No Yes No Yes Yes 3840 17180 16831 $12768 $18839 NA Non-Transition NA $98163 $80582 106490964 HEALDSBURG DIST HOSP No Yes No Yes Yes 6549 16188 15859 $12768 $17975 NA Non-Transition NA $98163 $80582 106154022 HEALTHSOUTH BAKERSFIELD REHAB HOSP No No No No No 5040 12882 12620 NA NA NA NA $1382 $98163 $80582 106304079 HEALTHSOUTH TUSTIN REHAB HOSP No No No No No 5281 12882 12620 NA NA NA NA $1220 $98163 $80582 106331194 HEMET VALLEY MED CTR No No No No No 1267 12882 12620 $6289 $7436 $5912 Transition NA $98163 $80582 106190949 HENRY MAYO NEWHALL MEM HOSP No No No No No 1839 12882 12620 $6289 $7436 $5631 Transition $1220 $98163 $80582 106362041 HI-DESERT MED CTR No Yes No Yes Yes 2909 12882 12620 $12768 $15097 $13297 Transition NA $98163 $80582 106301205 HOAG MEM HOSP PRESBYTERIAN No No No No No 4825 12882 12620 $6289 $7436 $13525 Transition NA $98163 $80582 106304159 HEALTHBRIDGE CHILDRENS HOSP-ORANGE No No No No No 3271 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106190380 HOLLYWOOD COMM HOSP OF HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106304460 HOAG ORTHOPEDIC No No No No No 4894 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190382 HOLLYWOOD PRES MED CTR No No No No No 2212 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301209 HUNTINGTON BEACH HOSP No No No No No 2175 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190400 HUNTINGTON MEM HOSP No No Yes No No 2294 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106304045 IRVINE REG HOSP AND MED CTR No No No No No 200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106220733 JOHN C FREMONT HCARE DIST No Yes No Yes Yes 3884 12882 12620 $12768 $15097 $8195 Transition NA $98163 $80582 106331216 JOHN F KENNEDY MEM HOSP No No No No No 1679 12882 12620 $6289 $7436 $6464 Transition NA $98163 $80582 106071018 JOHN MUIR MED CTR-CONCORD CAMPUS No No No No No 1748 16478 16143 $6289 $8978 $12804 Transition NA $98163 $80582 106070988 JOHN MUIR MED CTR-WALNUT CREEK CAMPUS No No No No No 2039 16478 16143 $6289 $8978 $10615 Transition $1473 $98163 $80582 106314024 KAISER HOSPITAL - ROSEVILLE No No Yes No No 7912 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106364265 KAISER ONTARIO MEDICAL CENTER CAMPUS No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106121031 JEROLD PHELPS COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301132 KAISER-ANAHEIM No No Yes No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304306 KAISER-ANAHEIM-IRVINE No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304409 KAISER-ANAHEIM-Orange No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106074097 KAISER-ANTIOCH No No No No No 8503 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106196403 KAISER-DOWNEY No No No No No 10000 12882 12620 $6289 $7436 $12698 Transition NA $98163 $80582 106361223 KAISER-FONTANA No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106014132 KAISER-FREMONT No No No No No 10000 16962 16618 $6289 $9186 $9639 Transition NA $98163 $80582 106196035 KAISER-BALDWIN PARK No No No No No 8009 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106104062 KAISER-FRESNO No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190429 KAISER-LOS ANGELES No No No No No 7387 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106394009 KAISER-MANTECA No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106334048 KAISER-MORENO VALLEY No No No No No 6614 12882 12620 $6289 $7436 $4790 Transition NA $98163 $80582 106010856 KAISER-OAKLANDRICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106190432 KAISER-PANORAMA CITY No No No No No 8239 12882 12620 $6289 $7436 $16025 Transition NA $98163 $80582 106504042 KAISER-MODESTO No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106410804 KAISER-REDWOOD CITY No No No No No 7731 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106074093 KAISER-RICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106480989 KAISER-REHAB CENTER VALLEJO No No No No No 8442 16315 15984 $6289 $8908 NA Non-Transition $2535 $98163 $80582 106340913 KAISER-SACRAMENTO No No No No No 5612 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106334025 KAISER-RIVERSIDE No No No No No 5865 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370730 KAISER-SAN DIEGO No No No No No 7393 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106380857 KAISER-SAN FRANCISCO No No No No No 5960 16738 16398 $6289 $9090 NA Non-Transition NA $98163 $80582 106431506 KAISER-SAN JOSE No No No No No 7002 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106014337 KAISER-SAN LEANDRO No No No No No 2180 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106210992 KAISER-SAN RAFAEL No No No No No 4673 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106494019 KAISER-SANTA ROSA No No No No No 10000 16315 15984 $6289 $8908 $17627 Transition NA $98163 $80582 106434153 KAISER-SANTA CLARA No No No No No 6107 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106190431 KAISER-SOUTH BAY No No No No No 6935 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106342344 KAISER-SOUTH SACRAMENTO No No No No No 5670 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106410806 KAISER-SOUTH SF No No No No No 6503 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106484044 KAISER-VACAVILLE No No No No No 10000 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106070990 KAISER-WALNUT CREEK No No No No No 5680 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106190434 KAISER-WEST LA No No No No No 6623 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106194219 KECK HOSPITAL OF USC No No No No No 2004 12882 12620 $6289 $7436 $4699 Transition $1220 $98163 $80582 106210993 KENTFIELD REHAB HOSP No No No No No 5967 16855 16513 $6289 $9140 $19338 Transition $1500 $98163 $80582 106150736 KERN MED CTR Yes No No No No 3943 12882 12620 $6289 $7436 NA NA NA NA NA 106150737 KERN VALLEY HEALTHCARE DIST No Yes No Yes Yes 2786 12882 12620 $12768 $15097 $8298 Transition NA $98163 $80582 106191450 KAISER-WOODLAND HILLS No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190049 KINDRED HOSPITAL BALDWIN PARK No No No No No 1810 12882 12620 $6289 $7436 $10784 Transition NA $98163 $80582 106190305 KINDRED LA No No No No No 2044 12882 12620 $6289 $7436 $4255 Transition NA $98163 $80582 106301127 KINDRED BREA No No No No No 2852 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361274 KINDRED ONTARIO No No No No No 2068 12882 12620 $6289 $7436 $9314 Transition NA $98163 $80582 106364188 KINDRED RANCHO No No No No No 1980 12882 12620 $6289 $7436 $20628 Transition NA $98163 $80582 106332172 KINDRED RIVERSIDE No No No No No 1805 12882 12620 $6289 $7436 $24450 Transition NA $98163 $80582 106190449 KINDRED LA MIRADA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106370721 KINDRED SAN DIEGO No No No No No 3605 12882 12620 $6289 $7436 $5657 Transition NA $98163 $80582 106344035 KINDRED SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190458 KINDRED SAN GABRIEL VALLEY No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106010887 KINDRED SF BAY AREA No No No No No 3007 16478 16143 $6289 $8978 $6378 Transition NA $98163 $80582 106301167 KINDRED SANTA ANA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190196 KINDRED SOUTH BAY No No No No No 2144 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301380 KINDRED WESTMINSTER No No No No No 2286 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301234 LA PALMA INTERCOMMUNITY HOSP No No No No No 2290 12882 12620 $6289 $7436 $7160 Transition NA $98163 $80582 106191227 LAC-HARBOR-UCLA MED CTR Yes No Yes No No 3366 12882 12620 $6289 $7436 NA NA NA NA NA 106191231 LAC-OLIVE VIEW-UCLA MED CTR Yes No No No No 4136 12882 12620 $6289 $7436 NA NA NA NA NA 106191228 LAC-USC MED CTR Yes No Yes No No 4522 12882 12620 $6289 $7436 NA NA NA NA NA 106380865 LAGUNA HONDA HOSP AND REHAB CTR Yes No No No No 5843 16738 16398 $6289 $9090 NA NA NA NA NA 106190240 LAKEWOOD REG MED CTR No No No No No 1504 12882 12620 $6289 $7436 $4008 Transition $1220 $98163 $80582 106390923 LODI MEM HOSP No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106390922 LODI MEM HOSP - WEST No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106334589 LOMA LINDA MURRIETTA No No No No No 3222 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106364268 LOMA LINDA UNIV HEART AND SURGICAL HOSPITAL No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361245 LOMA LINDA UNIV MED CTR - EAST CAMPUS No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361246 LOMA LINDA UNIV MED CTR No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $1491 $98163 $80582 106364502 LOMA LINDA UNIV CHILDRENS HOSP No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $2177 $98163 $80582 106190198 LA COMM HOSP No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420491 LOMPOC VALLEY MED CTR No Yes No Yes Yes 8693 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301248 LOS ALAMITOS MED CTR No No No No No 1915 12882 12620 $6289 $7436 $4697 Transition NA $98163 $80582 106560492 LOS ROBLES HOSP AND MED CTR No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106564018 LOS ROBLES HOSP AND MED CTR-EAST CAMPUS No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106434040 LSP CHILDRENS HOSP AT STANFORD No No Yes No No 2035 17180 16831 $6289 $9279 $6102 Transition NA $98163 $80582 106121002 MAD RIVER COMM HOSP No No No No No 4250 12882 12620 $6289 $7436 $9505 Transition NA $98163 $80582 106201281 MADERA COMMUNITY HOSPITAL No No No No No 5100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106260011 MAMMOTH HOSP No Yes No Yes Yes 7982 12882 12620 $12768 $15097 $46994 Transition NA $98163 $80582 106420493 MARIAN MED CTR No No No No No 2741 12882 12620 $6289 $7436 $9386 Transition NA $98163 $80582 106190525 LONG BEACH MEM MED CTR No No No No No 1996 12882 12620 $6289 $7436 NA Non-Transition $1627 $98163 $80582 106211006 MARIN GEN HOSP No Yes No No No 2571 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106190500 MARINA DEL RAY HOSPITAL No No No No No 2034 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106050932 MARK TWAIN ST JOSEPHS HOSP No No No Yes Yes 3707 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090933 MARSHALL MED CTR No No No Yes Yes 2107 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106500939 MEM HOSP MED CTR-MODESTO No No No No No 2235 12892 12630 $6289 $7440 $5898 Transition NA $98163 $80582 106240924 MEMORIAL HOSP LOS BANOS No No No Yes Yes 3362 12882 12620 $12768 $15097 $17450 Transition NA $98163 $80582 106190521 MEMORIAL HOSP OF GARDENA No No No No No 1747 12882 12620 $6289 $7436 $4611 Transition NA $98163 $80582 106231013 MENDOCINO COAST DIST HOSP No Yes No Yes Yes 5070 12882 12620 $12768 $15097 $15935 Transition NA $98163 $80582 106334018 MENIFEE VALLEY MED CTR No No No No No 1458 12882 12620 $6289 $7436 $5113 Transition NA $98163 $80582 106450936 MAYERS MEM HOSP No Yes No Yes Yes 7192 14188 13900 $12768 $16234 NA Non-Transition NA $98163 $80582 106340947 MERCY GEN HOSP No No No No No 2185 15256 14946 $6289 $8454 $6027 Transition $1387 $98163 $80582 106344029 MERCY HOSP OF FOLSOM No No No No No 2746 15256 14946 $6289 $8454 $5260 Transition NA $98163 $80582 106150761 MERCY HOSP-BAKERSFIELD No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106414018 MENLO PARK SURGICAL HOSP No No No No No 2770 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106240942 MERCY MED CTR MERCED No No No No No 2289 13279 13009 $6289 $7606 NA Non-Transition NA $98163 $80582 106450949 MERCY MED CTR-REDDING No No No No No 2589 14188 13900 $6289 $7996 $10219 Transition NA $98163 $80582 106470871 MERCY MED CTR-MT SHASTA No No No Yes Yes 6242 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106340950 MERCY SAN JUAN HOSP No No No No No 2166 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190529 METHODIST HOSP OF SO CAL No No No No No 1842 12882 12620 $6289 $7436 $6690 Transition $1220 $98163 $80582 106196168 MILLER CHILDRENS HOSP No No Yes No No 2680 12882 12620 $6289 $7436 $8155 Transition NA $98163 $80582 106410742 MILLS HEALTH CENTER No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106410852 MILLS-PENINSULA No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106340951 METHODIST HOSP OF SACRAMENTO No No No No No 2028 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190524 MISSION COMM HOSP-PANORAMA CAMPUS No No No No No 3568 12882 12620 $6289 $7436 $3982 Transition NA $98163 $80582 106190681 MIRACLE MILE No No No No No 100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301262 MISSION HOSP REG MED CTR No No No No No 4091 12882 12620 $6289 $7436 $14336 Transition $1220 $98163 $80582 106250956 MODOC MED CTR No Yes No Yes Yes 4961 12882 12620 $12768 $15097 $13486 Transition NA $98163 $80582 106301337 MISSION HOSP LAGUNA BEACH No No No No No 4091 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106361166 MONTCLAIR HOSP MED CTR No No No No No 3149 12882 12620 $6289 $7436 $5904 Transition NA $98163 $80582 106190547 MONTEREY PARK HOSP No No No No No 1034 12882 12620 $6289 $7436 $5866 Transition NA $98163 $80582 106361266 MOUNTAINS COMM HOSP No Yes No Yes Yes 5148 12882 12620 $12768 $15097 $15642 Transition NA $98163 $80582 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106481357 NORTH BAY MEDICAL CENTER No No No No No 1972 16315 15984 $6289 $8908 $15945 Transition NA $98163 $80582
i-
i
i
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190541 MONROVIA MEM HOSP No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106141273 NORTHERN INYO HOSP No Yes No Yes Yes 8150 12882 12620 $12768 $15097 $27752 Transition NA $98163 $80582 106484001 NORTH BAY VACAVALLEY HOSP No No No No No 1972 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106190568 NORTHRIDGE HOSP MED CTR No No No No No 1596 12882 12620 $6289 $7436 NA Non-Transition $1662 $98163 $80582 106214034 NOVATO COMM HOSP No No No No No 3465 16855 16513 $6289 $9140 $6359 Transition NA $98163 $80582 106500967 OAK VALLEY DIST HOSP No Yes No Yes No 3340 12892 12630 $6289 $7440 $5201 Transition NA $98163 $80582 106430837 OCONNOR HOSP-SAN JOSE No No No No No 2409 17180 16831 $6289 $9279 $5201 Transition NA $98163 $80582 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190534 OLYMPIA MED CTR No No No No No 1260 12882 12620 $6289 $7436 $6786 Transition NA $98163 $80582 106300225 ORANGE COAST MEM MED CTR No No No No No 2293 12882 12620 $6289 $7436 $19985 Transition NA $98163 $80582 106040937 OROVILLE HOSP No No No No No 1803 12882 12620 $6289 $7436 $6229 Transition NA $98163 $80582 106560501 OJAI VALLEY COMM HOSP No No No Yes Yes 2745 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190696 PACIFICA HOSP OF THE VALLEY No No No No No 3338 12882 12620 $6289 $7436 $5616 Transition NA $98163 $80582 106491338 PALM DRIVE HOSP No Yes No Yes No 4315 16315 15984 $6289 $8908 $11457 Transition NA $98163 $80582 106196405 PALMDALE REGIONAL MEDICAL CTR No No No No No 1190 12882 12620 $6289 $7436 $7504 Transition $1220 $98163 $80582 106331288 PALO VERDE HOSP No Yes No Yes Yes 4770 12882 12620 $12768 $15097 $18188 Transition NA $98163 $80582 106370755 PALOMAR MED CTR No Yes No No No 2429 12882 12620 $6289 $7436 $7051 Transition $1220 $98163 $80582 106370759 PARADISE VALLEY HOSP No No No No No 2188 12882 12620 $6289 $7436 $4275 Transition $1220 $98163 $80582 106190307 PACIFIC ALLIANCE MED CTR No No No No No 4299 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106331293 PARKVIEW COMM HOSP MED CTR No No No No No 2757 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106491001 PETALUMA VALLEY HOSP No No No No No 2271 16315 15984 $6289 $8908 $13491 Transition NA $98163 $80582 106130760 PIONEERS MEM HOSP No Yes No Yes No 2989 12882 12620 $6289 $7436 $9825 Transition NA $98163 $80582 106454013 PATIENTS HOSP OF REDDING No No No No No 2172 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106301297 PLACENTIA LINDA HOSP No No No No No 1606 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370977 POMERADO HOSP No Yes No No No 3063 12882 12620 $6289 $7436 $6818 Transition NA $98163 $80582 106320986 PLUMAS DIST HOSP No Yes No Yes Yes 8666 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190631 PRESBYTERIAN INTERCOMM HOSP No No No No No 961 12882 12620 $6289 $7436 $9720 Transition $1220 $98163 $80582 106190630 POMONA VALLEY HOSP MED CTR No No Yes No No 1538 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190468 PROMISE HOSP OF EAST LA-EAST LA No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190599 PROMISE HOSP OF EAST LA-EAST LA-SUBURBAN CAMPUS No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190385 PROVIDENCE HOLY CROSS MED CTR No No No No No 1325 12882 12620 $6289 $7436 $6284 Transition $1220 $98163 $80582 106190680 PROVIDENCE LITTLE CO OF MARY-SAN PEDRO No No No No No 1533 12882 12620 $6289 $7436 $6225 Transition $1220 $98163 $80582 106190470 PROVIDENCE LITTLE CO OF MARY-TORRANCE No No No No No 1767 12882 12620 $6289 $7436 $7182 Transition NA $98163 $80582 106190758 PROVIDENCE ST JOSEPH MED CTR No No No No No 1866 12882 12620 $6289 $7436 $7141 Transition $1220 $98163 $80582 106370787 PROMISE HOSP OF SAN DIEGO No No No No No 3660 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106281047 QUEEN OF THE VALLEY HOSP-NAPA No No No No No 2829 16188 15859 $6289 $8854 $17592 Transition $1453 $98163 $80582 106370673 RADY CHILDRENS HOSPITAL - SAN DIEGO No No Yes No No 2854 12882 12620 $6289 $7436 $6395 Transition $2177 $98163 $80582 106190517 PROVIDENCE TARZANA MED CTR No No Yes No No 1536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361308 REDLANDS COMM HOSP No No No No No 2079 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430705 REG MED CTR OF SAN JOSE No No No No No 2529 17180 16831 $6289 $9279 $13299 Transition NA $98163 $80582 106580996 RIDEOUT MEM HOSP No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106121051 REDWOOD MEM HOSP No No No Yes Yes 3214 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106334487 RIVERSIDE CO REG MED CTR Yes No No No No 2987 12882 12620 $6289 $7436 NA NA NA NA NA 106331312 RIVERSIDE COMM HOSP No No No No No 1560 12882 12620 $6289 $7436 $5990 Transition NA $98163 $80582 106190796 RONALD REAGAN UCLA MED CTR Yes No Yes No No 3382 12882 12620 $6289 $7436 NA NA NA NA NA 106301317 SADDLEBACK MEM MED CTR No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106301325 SADDLEBACK MEM MED CTR-SAN CLEMENTE No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106150782 RIDGECREST REG HOSP No No No Yes Yes 4178 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106361318 SAN ANTONIO COMM HOSP No No No No No 2262 12882 12620 $6289 $7436 $9216 Transition NA $98163 $80582 106190673 SAN DIMAS COMM HOSP No No No No No 2465 12882 12620 $6289 $7436 $12177 Transition NA $98163 $80582 106190200 SAN GABRIEL VALLEY MED CTR No No No No No 969 12882 12620 $6289 $7436 $6918 Transition NA $98163 $80582 106270875 SALINAS VALLEY MEM HOSP No Yes No No No 3534 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106331326 SAN GORGONIO MEM HOSP No Yes No Yes Yes 3394 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391010 SAN JOAQUIN GEN HOSP Yes No No No No 1922 13579 13303 $6289 $7735 NA NA NA NA NA 106104023 SAN JOAQUIN VALLEY REHAB HOSP No No No No No 6479 12882 12620 NA NA NA NA $1413 $98163 $80582 106013619 SAN LEANDRO HOSP No Yes No No No 3482 16501 16166 $6289 $8988 $10813 Transition NA $98163 $80582 106410782 SAN MATEO MED CTR Yes No No No No 7168 16928 16584 $6289 $9171 NA NA NA NA NA 106074017 SAN RAMON REG MED CTR No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106074011 SAN RAMON REG MED CTR SOUTH BUILDING No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106420514 SANTA BARBARA COTTAGE HOSP No No Yes No No 3902 12882 12620 $6289 $7436 $10978 Transition $2125 $98163 $80582 106430883 SANTA CLARA VALLEY MED CTR Yes No Yes No No 3133 17180 16831 $6289 $9279 NA NA NA NA NA 106190687 SANTA MONICA - UCLA MEDICAL CENTER Yes No No No No 3102 12882 12620 $6289 $7436 NA NA NA NA NA 106491064 SANTA ROSA MEM HOSP-MONTGOMERY No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106490907 SANTA ROSA MEM HOSP-SOTOYOME No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106150788 SAN JOAQUIN COMM HOSP No No No No No 2544 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420522 SANTA YNEZ VALLEY COTTAGE HOSP No No No Yes Yes 7569 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106371394 SCRIPPS MEM HOSP-ENCINITAS No No No No No 2403 12882 12620 $6289 $7436 $7037 Transition $1439 $98163 $80582 106370771 SCRIPPS MEM HOSP-LA JOLLA No No No No No 2061 12882 12620 $6289 $7436 $4390 Transition NA $98163 $80582 106370744 SCRIPPS MERCY HOSP No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106370658 SCRIPPS MERCY HOSP-CHULA VISTA No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106371256 SCRIPPS GREEN HOSP No No No No No 2317 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106321016 SENECA HCARE DIST No Yes No Yes Yes 4586 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106410817 SETON MED CTR No No No No No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106410828 SETON MED CTR-COASTSIDE No No No Yes No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106380939 SF GENERAL HOSP Yes No No No No 2851 16738 16398 $6289 $9090 NA NA NA NA NA 106370875 SHARP CHULA VISTA MED CTR No No No No No 1932 12882 12620 $6289 $7436 $6485 Transition NA $98163 $80582 106410891 SEQUOIA HOSP No No No No No 1975 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106370689 SHARP CORONADO HOSP AND HCARE CTR No No No No No 2160 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $72421 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106370694 SHARP MEM HOSP No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106450940 SHASTA REG MED CTR No No No No No 1582 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106190708 SHERMAN OAKS HOSP No No No No No 1516 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190712 SHRINERS HOSPITAL- LA No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106344114 SHRINERS HOSPITAL- SACRAMENTO No No No No No 3869 15256 14946 $6289 $8454 NA Non-Transition $2475 $98163 $80582 106540798 SIERRA VIEW DIST HOSP No Yes No No No 2716 12882 12620 $6289 $7436 $8497 Transition NA $98163 $77682 106400524 SIERRA VIST REG MED CTR No No No No No 1787 12964 12701 $6289 $7471 $5495 Transition NA $98163 $80582 106190661 SILVER LAKE MED CTR No No No No No 3692 12882 12620 $6289 $7436 $5655 Transition NA $98163 $80582 106291023 SIERRA NEVADA MEM HOSP No No No Yes Yes 3427 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106491076 SONOMA VALLEY HOSP No Yes No No No 4960 16315 15984 $6289 $8908 $12733 Transition NA $98163 $80582 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 2126 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190380 SOUTHERN CA HOSP AT HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106190110 SOUTHERN CA HOSPITAL AT CULVER CITY No No No No No 1437 12882 12620 $6289 $7436 $4694 Transition $1220 $98163 $80582 106560525 SIMI VALLEY HOSP AND HCARE-SYCAMORE No No No No No 3840 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106334068 SOUTHWEST HCARE SYSTEM No No No No No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106334001 SOUTHWEST HCARE SYSTEM-WILDOMAR No No No Yes No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106100899 ST AGNES MED CTR No No No No No 3088 12882 12620 $6289 $7436 $7885 Transition NA $98163 $80582 106361339 ST BERNARDINE MED CTR No No No No No 2171 12882 12620 $6289 $7436 $6090 Transition NA $98163 $80582 106521041 ST ELIZABETH COMM HOSP No No No Yes Yes 3024 13869 13587 $12768 $15956 $14866 Transition NA $98163 $80582 106190754 ST FRANCIS MED CTR No No No No No 4350 12882 12620 $6289 $7436 $6368 Transition NA $98163 $80582 106380960 ST FRANCIS MEM HOSP No No No No No 1920 16738 16398 $6289 $9090 $5310 Transition $1492 $98163 $80582 106281078 ST HELENA HOSP No No No No No 2337 15887 15564 $6289 $8725 $9671 Transition NA $98163 $80582 106171049 ST HELENA HOSPITAL-CLEARLAKE No No No Yes Yes 4118 12882 12620 $12768 $15097 $18218 Transition NA $98163 $80582 106141338 SOUTHERN INYO HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190756 ST JOHNS HEALTH CTR No No No No No 2536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560529 ST JOHNS REG MED CTR No No No No No 2982 12882 12620 $6289 $7436 $6976 Transition $1761 $98163 $80582 106121080 ST JOSEPH HOSP-EUREKA No No No No No 2570 13869 13587 $6289 $7859 $9661 Transition $1507 $98163 $80582 106301340 ST JOSEPH HOSP-ORANGE No No No No No 2751 12882 12620 $6289 $7436 $5230 Transition NA $98163 $80582 106560508 ST JOHNS PLEASANT VALLEY HOSP No No No No No 2087 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301342 ST JUDE MED CTR No No No No No 1722 12882 12620 $6289 $7436 $5799 Transition $1220 $98163 $80582 106434138 ST LOUISE REG HOSP No No No No No 2838 17180 16831 $6289 $9279 $16407 Transition NA $98163 $80582 106380964 ST LUKES HOSP No No No No No 3807 16738 16398 $6289 $9090 $8600 Transition NA $98163 $80582 106361343 ST MARY MED CTR-APPLE VALLEY No No No Yes No 2511 12882 12620 $6289 $7436 $9863 Transition NA $98163 $80582 106391042 ST JOSEPHS MED CTR OF STOCKTON No No No No No 2152 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106380965 ST MARYS MED CTR-SF No No No No No 2007 16738 16398 $6289 $9090 $5116 Transition $1492 $98163 $80582 106010967 ST ROSE HOSP No No No No No 1931 16962 16618 $6289 $9186 $7600 Transition NA $98163 $80582 106190762 ST VINCENT MED CTR No No No No No 2020 12882 12620 $6289 $7436 $4684 Transition $1220 $98163 $80582 106430905 STANFORD HOSP No No No No No 1803 17180 16831 $6289 $9279 $5644 Transition $1523 $98163 $80582 106190053 ST MARY MED CTR-LONG BEACH No No No No No 2479 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106504038 STANISLAUS SURGICAL HOSP No No No No No 9000 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106250955 SURPRISE VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106310791 SUTTER AUBURN FAITH HOSP No No No No No 2551 15256 14946 $6289 $8454 $11882 Transition NA $98163 $80582 106034002 SUTTER AMADOR HOSP No No No Yes Yes 2971 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106574010 SUTTER DAVIS HOSP No No No No No 3568 15256 14946 $6289 $8454 $14330 Transition NA $98163 $80582 106070934 SUTTER DELTA MED CTR No No No No No 2907 16478 16143 $6289 $8978 $12158 Transition NA $98163 $80582 106341051 SUTTER GEN HOSP No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106171395 SUTTER LAKESIDE HOSP No No No Yes Yes 3691 12882 12620 $12768 $15097 $17232 Transition NA $98163 $80582 106444012 SUTTER MATERNITY AND SRG CTR OF S CRUZ No No No No No 7213 17239 16889 $6289 $9304 $21288 Transition NA $98163 $80582 106490919 SUTTER MED CTR OF SANTA ROSA No No No No No 3657 16315 15984 $6289 $8908 $15278 Transition NA $98163 $80582 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106311000 SUTTER ROSEVILLE MED CTR No No No No No 2377 15256 14946 $6289 $8454 $11395 Transition $1387 $98163 $80582 106481094 SUTTER SOLANO MED CTR No No No No No 3258 16315 15984 $6289 $8908 $18010 Transition NA $98163 $80582 106084001 SUTTER COAST HOSP No No No Yes Yes 3730 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391056 SUTTER TRACY COMM HOSP No No No No No 2714 13579 13303 $6289 $7735 $5995 Transition NA $98163 $80582 106291053 TAHOE FOREST HOSP No Yes No Yes Yes 4766 15256 14946 $12768 $17164 $21044 Transition NA $98163 $80582 106150808 TEHACHAPI HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 $22158 Transition NA $98163 $80582 106514030 SUTTER SURG HOSP-NORTH VALLEY No No No No No 3240 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582
i-
i
i
i-
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106334564 TEMECULA VALLEY HOSPITAL No No No No No 2180 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106120981 THE GENERAL HOSPITAL No No No No No 2570 13869 13587 NA NA NA NA $1507 $98163 $80582 106564121 THOUSAND OAKS SURGICAL HOSPITAL No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106190422 TORRANCE MEM MED CTR No No No No No 1952 12882 12620 $6289 $7436 $5891 Transition NA $98163 $80582 106370780 TRI-CITY MED CTR No Yes No No No 3695 12882 12620 $6289 $7436 $7706 Transition $1220 $98163 $80582 106190784 TEMPLE COMM HOSP No No No No No 4200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540816 TULARE DIST HOSP No Yes No No No 3578 12882 12620 $6289 $7436 $9529 Transition NA $98163 $80582 106531059 TRINITY HOSP No Yes No Yes Yes 5105 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106400548 TWIN CITIES COMM HOSP No No No Yes Yes 1587 12964 12701 $12768 $15168 $8160 Transition NA $98163 $80582 106341006 UC DAVIS MED CTR Yes No Yes No No 1836 15256 14946 $6289 $8454 NA NA NA NA NA 106301279 UC IRVINE MED CTR Yes No Yes No No 2072 12882 12620 $6289 $7436 NA NA NA NA NA 106370782 UCSD MED CTR Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106374141 UCSD-LA JOLLA JOHN M amp SALLY B THORNTON HOSPITAL Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106381154 UCSF MED CTR Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106380895 UCSF MED CTR AT MOUNT ZION Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106301357 TUSTIN HOSP MED CTR No No No No No 231 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106231396 UKIAH VALLEY MED CTRHOSP DR No No No Yes Yes 3643 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106014050 VALLEY CARE MEDICAL CENTER No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106010983 VALLEY MEM HOSP-LIVERMORE No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106191216 USC KENNETH NORRIS JR CANCER HOSP No No No No No 3134 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560481 VENTURA CO MED CTR Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106560521 VENTURA CO MED CTR-SANTA PAULA HOSPITAL Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106190818 VERDUGO HILLS HOSP No No No No No 3110 12882 12620 $6289 $7436 $5264 Transition NA $98163 $80582 106190812 VALLEY PRES HOSP No No No No No 3536 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 3046 14188 13900 $6289 $7996 NA Non-Transition $1312 $98163 $80582 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 3266 12882 12620 $6289 $7436 $8320 Transition NA $98163 $80582 106010987 WASHINGTON HOSP-FREMONT No Yes No No No 1941 16962 16618 $6289 $9186 $6429 Transition NA $98163 $80582 106444013 WATSONVILLE COMM HOSP No No No No No 1780 17239 16889 $6289 $9304 $13456 Transition NA $98163 $80582 106301379 WEST ANAHEIM MED CTR No No No No No 1514 12882 12620 $6289 $7436 $4707 Transition NA $98163 $80582 106190859 WEST HILLS HOSP AND MED CTR No No No No No 1933 12882 12620 $6289 $7436 $8050 Transition NA $98163 $80582 106374094 VIBRA OF SAN DIEGO No No No No No 1155 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301188 WESTERN MED CTR-ANAHEIM No No No No No 3203 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301566 WESTERN MED CTR-SANTA ANA No No No No No 2354 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190878 WHITE MEM MED CTR No No No No No 1515 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190883 WHITTIER HOSP MED CTR No No No No No 1139 12882 12620 $6289 $7436 $5922 Transition NA $98163 $80582 106571086 WOODLAND MEM HOSP No No No No No 3278 15256 14946 $6289 $8454 $10092 Transition NA $98163 $80582 6102015
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
-
640-2 640-3 640-4
NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM
245 376
1206
01353 02864 14726
10000 10000 10000
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
10000 10000 10000
01353 02864 14726
$1015 Normal newborn Normal newborn $2148 Normal newborn Normal newborn
$11045 Normal newborn Normal newborn 650-1 650-2 650-3 650-4
SPLENECTOMY SPLENECTOMY SPLENECTOMY SPLENECTOMY
348 537 848
1563
12985 17965 25202 50826
10000 10000 10000 10000
10000 10000 10000 10000
12985 17965 25202 50826
12500 12500 12500 12500
16231 22456 31503 63533
10000 10000 10000 10000
12985 17965 25202 50826
$12173 Misc Pediatric Misc Adult $16842 Misc Pediatric Misc Adult $23627 Misc Pediatric Misc Adult $47649 Misc Pediatric Misc Adult
651-1 651-2 651-3 651-4
OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS
331 472 962
2426
09234 13695 21005 59541
10000 10000 10000 10000
10000 10000 10000 10000
09234 13695 21005 59541
12500 12500 12500 12500
11543 17119 26256 74426
10000 10000 10000 10000
09234 13695 21005 59541
$8657 Misc Pediatric Misc Adult $12839 Misc Pediatric Misc Adult $19692 Misc Pediatric Misc Adult $55820 Misc Pediatric Misc Adult
660-1 660-2 660-3 660-4
MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL
305 408 648
1435
05399 07219 11819 30180
10000 10000 10000 10000
10000 10000 10000 10000
05399 07219 11819 30180
12500 12500 12500 12500
06749 09024 14774 37725
10000 10000 10000 10000
05399 07219 11819 30180
$5062 Misc Pediatric Misc Adult $6768 Misc Pediatric Misc Adult
$11080 Misc Pediatric Misc Adult $28294 Misc Pediatric Misc Adult
661-1 661-2 661-3 661-4
COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS COAGULATION amp PLATELET DISORDERS
275 375 566
1265
06473 08098 12433 27857
10000 10000 10000 10000
10000 10000 10000 10000
06473 08098 12433 27857
12500 12500 12500 12500
08091 10123 15541 34821
10000 10000 10000 10000
06473 08098 12433 27857
$6068 Misc Pediatric Misc Adult $7592 Misc Pediatric Misc Adult
$11656 Misc Pediatric Misc Adult $26116 Misc Pediatric Misc Adult
662-1 662-2 662-3 662-4
SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS SICKLE CELL ANEMIA CRISIS
412 538 785
1302
05044 07003 10778 23937
10000 10000 10000 10000
10000 10000 10000 10000
05044 07003 10778 23937
12500 12500 12500 12500
06305 08754 13473 29921
10000 10000 10000 10000
05044 07003 10778 23937
$4729 Misc Pediatric Misc Adult $6565 Misc Pediatric Misc Adult
$10104 Misc Pediatric Misc Adult $22441 Misc Pediatric Misc Adult
663-1 663-2 663-3 663-4
OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS
232 301 451 900
04474 05959 08513 16106
10000 10000 10000 10000
10000 10000 10000 10000
04474 05959 08513 16106
12500 12500 12500 12500
05593 07449 10641 20133
10000 10000 10000 10000
04474 05959 08513 16106
$4194 Misc Pediatric Misc Adult $5587 Misc Pediatric Misc Adult $7981 Misc Pediatric Misc Adult
$15099 Misc Pediatric Misc Adult 680-1 680-2 680-3 680-4
MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
408 633
1185 2456
13702 18600 32002 66288
10000 10000 10000 10000
10000 10000 10000 10000
13702 18600 32002 66288
12500 12500 12500 12500
17128 23250 40003 82860
10000 10000 10000 10000
13702 18600 32002 66288
$12846 Misc Pediatric Misc Adult $17438 Misc Pediatric Misc Adult $30002 Misc Pediatric Misc Adult $62145 Misc Pediatric Misc Adult
681-1 681-2 681-3 681-4
OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS
268 507
1111 2510
09800 13647 24597 59170
10000 10000 10000 10000
10000 10000 10000 10000
09800 13647 24597 59170
12500 12500 12500 12500
12250 17059 30746 73963
10000 10000 10000 10000
09800 13647 24597 59170
$9188 Misc Pediatric Misc Adult $12794 Misc Pediatric Misc Adult $23060 Misc Pediatric Misc Adult $55472 Misc Pediatric Misc Adult
690-1 690-2 690-3 690-4
ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA ACUTE LEUKEMIA
495 740
1461 2485
07040 11869 23551 52504
10000 10000 10000 10000
10000 10000 10000 10000
07040 11869 23551 52504
12500 12500 12500 12500
08800 14836 29439 65630
10000 10000 10000 10000
07040 11869 23551 52504
$6600 Misc Pediatric Misc Adult $11127 Misc Pediatric Misc Adult $22079 Misc Pediatric Misc Adult $49223 Misc Pediatric Misc Adult
691-1 691-2 691-3 691-4
LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA
389 540 861
1585
07077 09840 15477 31411
10000 10000 10000 10000
10000 10000 10000 10000
07077 09840 15477 31411
12500 12500 12500 12500
08846 12300 19346 39264
10000 10000 10000 10000
07077 09840 15477 31411
$6635 Misc Pediatric Misc Adult $9225 Misc Pediatric Misc Adult
$14510 Misc Pediatric Misc Adult $29448 Misc Pediatric Misc Adult
692-1 692-2 692-3 692-4
RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY RADIOTHERAPY
389 482 868
1580
06075 12584 17422 29316
10000 10000 10000 10000
10000 10000 10000 10000
06075 12584 17422 29316
12500 12500 12500 12500
07594 15730 21778 36645
10000 10000 10000 10000
06075 12584 17422 29316
$5695 Misc Pediatric Misc Adult $11798 Misc Pediatric Misc Adult $16333 Misc Pediatric Misc Adult $27484 Misc Pediatric Misc Adult
693-1 693-2 693-3 693-4
CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY CHEMOTHERAPY
281 368 785
2410
06251 07881 13637 49083
10000 10000 10000 10000
10000 10000 10000 10000
06251 07881 13637 49083
12500 12500 12500 12500
07814 09851 17046 61354
10000 10000 10000 10000
06251 07881 13637 49083
$5860 Misc Pediatric Misc Adult $7388 Misc Pediatric Misc Adult
$12785 Misc Pediatric Misc Adult $46015 Misc Pediatric Misc Adult
694-1 694-2 694-3 694-4
LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR
304 404 674
1164
04842 06831 11115 21001
10000 10000 10000 10000
10000 10000 10000 10000
04842 06831 11115 21001
12500 12500 12500 12500
06053 08539 13894 26251
10000 10000 10000 10000
04842 06831 11115 21001
$4539 Misc Pediatric Misc Adult $6404 Misc Pediatric Misc Adult
$10420 Misc Pediatric Misc Adult $19688 Misc Pediatric Misc Adult
710-1 710-2 710-3 710-4
INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE
510 680
1111 1820
10635 15963 25572 49382
10000 10000 10000 10000
10000 10000 10000 10000
10635 15963 25572 49382
12500 12500 12500 12500
13294 19954 31965 61728
10000 10000 10000 10000
10635 15963 25572 49382
$9970 Misc Pediatric Misc Adult $14965 Misc Pediatric Misc Adult $23974 Misc Pediatric Misc Adult $46296 Misc Pediatric Misc Adult
711-1 711-2 711-3 711-4
POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE
471 692
1131 2087
10079 14143 23599 50574
10000 10000 10000 10000
10000 10000 10000 10000
10079 14143 23599 50574
12500 12500 12500 12500
12599 17679 29499 63218
10000 10000 10000 10000
10079 14143 23599 50574
$9449 Misc Pediatric Misc Adult $13259 Misc Pediatric Misc Adult $22124 Misc Pediatric Misc Adult $47413 Misc Pediatric Misc Adult
720-1 720-2 720-3 720-4
SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS SEPTICEMIA amp DISSEMINATED INFECTIONS
353 444 633
1004
05431 07613 11532 21705
10000 10000 10000 10000
10000 10000 10000 10000
05431 07613 11532 21705
12500 12500 12500 12500
06789 09516 14415 27131
10000 10000 10000 10000
05431 07613 11532 21705
$5092 Misc Pediatric Misc Adult $7137 Misc Pediatric Misc Adult
$10811 Misc Pediatric Misc Adult $20348 Misc Pediatric Misc Adult
721-1 721-2 721-3 721-4
POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS
368 470 705
1153
05287 07209 11619 22025
10000 10000 10000 10000
10000 10000 10000 10000
05287 07209 11619 22025
12500 12500 12500 12500
06609 09011 14524 27531
10000 10000 10000 10000
05287 07209 11619 22025
$4957 Misc Pediatric Misc Adult $6758 Misc Pediatric Misc Adult
$10893 Misc Pediatric Misc Adult $20648 Misc Pediatric Misc Adult
722-1 722-2 722-3 722-4
FEVER FEVER FEVER FEVER
230 302 429 739
03423 05223 07630 13141
10000 10000 10000 10000
10000 10000 10000 10000
03423 05223 07630 13141
12500 12500 12500 12500
04279 06529 09538 16426
10000 10000 10000 10000
03423 05223 07630 13141
$3209 Misc Pediatric Misc Adult $4897 Misc Pediatric Misc Adult $7153 Misc Pediatric Misc Adult
$12320 Misc Pediatric Misc Adult 723-1 723-2 723-3 723-4
VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS VIRAL ILLNESS
216 279 470
1317
03194 04738 07794 24233
10000 10000 10000 10000
10000 10000 10000 10000
03194 04738 07794 24233
12500 12500 12500 12500
03993 05923 09743 30291
10000 10000 10000 10000
03194 04738 07794 24233
$2994 Misc Pediatric Misc Adult $4442 Misc Pediatric Misc Adult $7307 Misc Pediatric Misc Adult
$22718 Misc Pediatric Misc Adult 724-1 724-2 724-3 724-4
OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES OTHER INFECTIOUS amp PARASITIC DISEASES
400 477 680
1337
05512 07131 11401 24698
10000 10000 10000 10000
10000 10000 10000 10000
05512 07131 11401 24698
12500 12500 12500 12500
06890 08914 14251 30873
10000 10000 10000 10000
05512 07131 11401 24698
$5168 Misc Pediatric Misc Adult $6685 Misc Pediatric Misc Adult
$10688 Misc Pediatric Misc Adult $23154 Misc Pediatric Misc Adult
740-1 740-2 740-3 740-4
MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE
678 1284 2034 2421
10899 13904 24356 37756
10000 10000 10000 10000
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
10000 10000 10000 10000
10899 13904 24356 37756
$8174 Other Other $10428 Other Other $18267 Other Other $28317 Other Other
750-1 750-2 750-3 750-4
SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA SCHIZOPHRENIA
1082 1179 1539 2848
05713 06699 09202 19283
10000 10000 10000 10000
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
10000 10000 10000 10000
05713 06699 09202 19283
$4285 Other Other $5024 Other Other $6902 Other Other
$14462 Other Other 751-1 751-2 751-3 751-4
MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES
528 724
1055 2028
03572 05019 08097 15923
10000 10000 10000 10000
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
10000 10000 10000 10000
03572 05019 08097 15923
$2679 Other Other $3764 Other Other $6073 Other Other
$11942 Other Other 752-1 752-2 752-3 752-4
DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL DISORDERS OF PERSONALITY amp IMPULSE CONTROL
503 658
1473 7300
03399 04498 09061 14934
10000 10000 10000 10000
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
10000 10000 10000 10000
03399 04498 09061 14934
$2549 Other Other $3374 Other Other $6796 Other Other
$11201 Other Other 753-1 753-2 753-3 753-4
BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS BIPOLAR DISORDERS
601 808
1205 1948
04001 05365 08266 14926
10000 10000 10000 10000
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
10000 10000 10000 10000
04001 05365 08266 14926
$3001 Other Other $4024 Other Other $6200 Other Other
$11195 Other Other 754-1 754-2 754-3 754-4
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER
424 558 727
1664
02943 03998 05677 11553
10000 10000 10000 10000
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
10000 10000 10000 10000
02943 03998 05677 11553
$2207 Other Other $2999 Other Other $4258 Other Other $8665 Other Other
755-1 755-2 755-3 755-4
ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES
388 622 900 813
02738 04363 06226 08767
10000 10000 10000 10000
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
10000 10000 10000 10000
02738 04363 06226 08767
$2054 Other Other $3272 Other Other $4670 Other Other $6575 Other Other
756-1 756-2 756-3 756-4
ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES ACUTE ANXIETY amp DELIRIUM STATES
331 381 457 942
04061 05308 06065 13981
10000 10000 10000 10000
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
10000 10000 10000 10000
04061 05308 06065 13981
$3046 Other Other $3981 Other Other $4549 Other Other
$10486 Other Other 757-1 757-2 757-3 757-4
ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES ORGANIC MENTAL HEALTH DISTURBANCES
873 934
1087 1640
05861 07234 08953 13799
10000 10000 10000 10000
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
10000 10000 10000 10000
05861 07234 08953 13799
$4396 Other Other $5426 Other Other $6715 Other Other
$10349 Other Other 758-1 758-2 758-3 758-4
CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS CHILDHOOD BEHAVIORAL DISORDERS
694 981
1225 4300
03874 05129 06541 11332
10000 10000 10000 10000
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
10000 10000 10000 10000
03874 05129 06541 11332
$2906 Other Other $3847 Other Other $4906 Other Other $8499 Other Other
759-1 759-2 759-3 759-4
EATING DISORDERS EATING DISORDERS EATING DISORDERS EATING DISORDERS
1990 1297 1402 2303
06561 06961 10053 16606
10000 10000 10000 10000
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
10000 10000 10000 10000
06561 06961 10053 16606
$4921 Other Other $5221 Other Other $7540 Other Other
$12455 Other Other 760-1 760-2 760-3 760-4
OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS OTHER MENTAL HEALTH DISORDERS
748 766 912
1204
04840 06173 07573 14134
10000 10000 10000 10000
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
10000 10000 10000 10000
04840 06173 07573 14134
$3630 Other Other $4630 Other Other $5680 Other Other
$10601 Other Other 770-1 770-2 770-3 770-4
DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE
253 248 332 794
02240 02623 05475 16843
10000 10000 10000 10000
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
10000 10000 10000 10000
02240 02623 05475 16843
$1680 Other Other $1967 Other Other $4106 Other Other
$12632 Other Other 772-1 772-2 772-3 772-4
ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY
1434 1551 1289 2385
05441 06916 07009 24530
10000 10000 10000 10000
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
10000 10000 10000 10000
05441 06916 07009 24530
$4081 Other Other $5187 Other Other $5257 Other Other
$18398 Other Other 773-1 773-2 773-3 773-4
OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE OPIOID ABUSE amp DEPENDENCE
337 414 507 992
02663 03466 05964 18606
10000 10000 10000 10000
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
10000 10000 10000 10000
02663 03466 05964 18606
$1997 Other Other $2600 Other Other $4473 Other Other
$13955 Other Other 774-1 774-2
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
365 412
03040 03627
10000 10000
10000 10000
03040 03627
10000 10000
03040 03627
10000 10000
03040 03627
$2280 Other Other $2720 Other Other
774-3 774-4
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
479 1424
06448 24682
10000 10000
10000 10000
06448 24682
10000 10000
06448 24682
10000 10000
06448 24682
$4836 Other $18512 Other
Other Other
775-1 775-2 775-3 775-4
ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE
323 377 571
1263
03313 04639 08596 24910
10000 10000 10000 10000
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
$2485 Other $3479 Other $6447 Other
$18683 Other
Other Other Other Other
776-1 776-2 776-3 776-4
OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE
389 397 496 933
03157 04547 07887 16112
10000 10000 10000 10000
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
$2368 Other $3410 Other $5915 Other
$12084 Other
Other Other Other Other
791-1 791-2 791-3 791-4
OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT
314 515 989
2009
08636 12677 21979 49312
10000 10000 10000 10000
10000 10000 10000 10000
08636 12677 21979 49312
12500 12500 12500 12500
10795 15846 27474 61640
10000 10000 10000 10000
08636 12677 21979 49312
$8096 Misc Pediatric $11885 Misc Pediatric $20605 Misc Pediatric $46230 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
811-1 811-2 811-3 811-4
ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS
151 202 390 913
02707 03855 08277 22176
10000 10000 10000 10000
10000 10000 10000 10000
02707 03855 08277 22176
12500 12500 12500 12500
03384 04819 10346 27720
10000 10000 10000 10000
02707 03855 08277 22176
$2538 Misc Pediatric $3614 Misc Pediatric $7760 Misc Pediatric
$20790 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
812-1 812-2 812-3 812-4
POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS
165 225 347 694
03469 04331 07709 17419
10000 10000 10000 10000
10000 10000 10000 10000
03469 04331 07709 17419
12500 12500 12500 12500
04336 05414 09636 21774
10000 10000 10000 10000
03469 04331 07709 17419
$3252 Misc Pediatric $4060 Misc Pediatric $7227 Misc Pediatric
$16330 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
813-1 813-2 813-3 813-4
OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT
261 344 594
1344
04393 06056 09631 19960
10000 10000 10000 10000
10000 10000 10000 10000
04393 06056 09631 19960
12500 12500 12500 12500
05491 07570 12039 24950
10000 10000 10000 10000
04393 06056 09631 19960
$4118 Misc Pediatric $5678 Misc Pediatric $9029 Misc Pediatric
$18713 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
815-1 815-2 815-3 815-4
OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES
169 276 456 880
04211 05012 08129 22715
10000 10000 10000 10000
10000 10000 10000 10000
04211 05012 08129 22715
12500 12500 12500 12500
05264 06265 10161 28394
10000 10000 10000 10000
04211 05012 08129 22715
$3948 Misc Pediatric $4699 Misc Pediatric $7621 Misc Pediatric
$21295 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
816-1 816-2 816-3 816-4
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
173 240 346 736
04162 04915 07864 18134
10000 10000 10000 10000
10000 10000 10000 10000
04162 04915 07864 18134
12500 12500 12500 12500
05203 06144 09830 22668
10000 10000 10000 10000
04162 04915 07864 18134
$3902 Misc Pediatric $4608 Misc Pediatric $7373 Misc Pediatric
$17001 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
841-1 841-2 841-3 841-4
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT
2200 967
2599 4068
31148 34263 64068
159153
10000 10000 10000 10000
10000 10000 10000 10000
31148 34263 64068
159153
12500 12500 12500 12500
38935 42829 80085
198941
10000 10000 10000 10000
31148 34263 64068
159153
$29201 Misc Pediatric $32122 Misc Pediatric $60064 Misc Pediatric
$149206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
842-1 842-2 842-3 842-4
FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT
751 1072 1735 3010
14151 21416 38719 95054
10000 10000 10000 10000
10000 10000 10000 10000
14151 21416 38719 95054
12500 12500 12500 12500
17689 26770 48399
118818
10000 10000 10000 10000
14151 21416 38719 95054
$13267 Misc Pediatric $20078 Misc Pediatric $36299 Misc Pediatric $89113 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
843-1 843-2 843-3 843-4
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT
339 487 713
1113
04752 06661 11619 32621
10000 10000 10000 10000
10000 10000 10000 10000
04752 06661 11619 32621
12500 12500 12500 12500
05940 08326 14524 40776
10000 10000 10000 10000
04752 06661 11619 32621
$4455 Misc Pediatric $6245 Misc Pediatric
$10893 Misc Pediatric $30582 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
844-1 844-2 844-3 844-4
PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT
310 497 743
1781
04337 06965 12193 48021
10000 10000 10000 10000
10000 10000 10000 10000
04337 06965 12193 48021
12500 12500 12500 12500
05421 08706 15241 60026
10000 10000 10000 10000
04337 06965 12193 48021
$4066 Misc Pediatric $6530 Misc Pediatric
$11431 Misc Pediatric $45020 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
850-1 850-2 850-3 850-4
PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE
267 556
1618 3148
11757 14065 24870 46520
10000 10000 10000 10000
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
$8818 Misc Pediatric $10549 Misc Pediatric $18653 Misc Pediatric $34890 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
860-1 860-2 860-3 860-4
REHABILITATION REHABILITATION REHABILITATION REHABILITATION
932 1146 1475 1795
07227 09855 13880 17876
10000 10000 10000 10000
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
$5420 Other $7391 Other
$10410 Other $13407 Other
Other Other Other Other
861-1 861-2 861-3 861-4
SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS
253 340 497 917
02858 05247 07658 14498
10000 10000 10000 10000
10000 10000 10000 10000
02858 05247 07658 14498
12500 12500 12500 12500
03573 06559 09573 18123
10000 10000 10000 10000
02858 05247 07658 14498
$2679 Misc Pediatric $4919 Misc Pediatric $7179 Misc Pediatric
$13592 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
862-1 862-2 862-3 862-4
OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE
698 1122 1357 1872
02895 05851 07866 11351
10000 10000 10000 10000
10000 10000 10000 10000
02895 05851 07866 11351
12500 12500 12500 12500
03619 07314 09833 14189
10000 10000 10000 10000
02895 05851 07866 11351
$2714 Misc Pediatric $5485 Misc Pediatric $7374 Misc Pediatric
$10642 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
863-1 863-2 863-3 863-4
NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE
853 1757 2771 4643
05959 16127 30507 61446
12500 12500 12500 12500
10000 10000 10000 10000
07449 20159 38134 76808
10000 10000 10000 10000
07449 20159 38134 76808
17500 17500 17500 17500
10428 28222 53387
107531
$5587 Neonate $15119 Neonate $28600 Neonate $57606 Neonate
Neonate Neonate Neonate Neonate
890-1 890-2 890-3 890-4
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS
167 691 921
1514
07051 10224 14771 30014
10000 10000 10000 10000
10000 10000 10000 10000
07051 10224 14771 30014
12500 12500 12500 12500
08814 12780 18464 37518
10000 10000 10000 10000
07051 10224 14771 30014
$6610 Misc Pediatric $9585 Misc Pediatric
$13848 Misc Pediatric $28138 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
892-1 892-2 892-3 892-4
HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION
587 488 669
1152
05647 07763 10877 19375
10000 10000 10000 10000
10000 10000 10000 10000
05647 07763 10877 19375
12500 12500 12500 12500
07059 09704 13596 24219
10000 10000 10000 10000
05647 07763 10877 19375
$5294 Misc Pediatric $7278 Misc Pediatric
$10197 Misc Pediatric $18164 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
893-1 893-2 893-3 893-4
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
499 496 799
1422
07762 08219 12807 24296
10000 10000 10000 10000
10000 10000 10000 10000
07762 08219 12807 24296
12500 12500 12500 12500
09703 10274 16009 30370
10000 10000 10000 10000
07762 08219 12807 24296
$7277 Misc Pediatric $7705 Misc Pediatric
$12007 Misc Pediatric $22778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
894-1 894-2 894-3 894-4
HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND
341 393 627
1121
05218 06497 09774 19428
10000 10000 10000 10000
10000 10000 10000 10000
05218 06497 09774 19428
12500 12500 12500 12500
06523 08121 12218 24285
10000 10000 10000 10000
05218 06497 09774 19428
$4892 Misc Pediatric $6091 Misc Pediatric $9163 Misc Pediatric
$18214 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
910-1 910-2 910-3 910-4
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA
1100 775
1057 1830
28786 31984 41628 72114
10000 10000 10000 10000
10000 10000 10000 10000
28786 31984 41628 72114
12500 12500 12500 12500
35983 39980 52035 90143
10000 10000 10000 10000
28786 31984 41628 72114
$26987 Misc Pediatric $29985 Misc Pediatric $39026 Misc Pediatric $67607 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
911-1 911-2 911-3 911-4
EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA
511 619 795
1687
15160 20189 26724 58039
10000 10000 10000 10000
10000 10000 10000 10000
15160 20189 26724 58039
12500 12500 12500 12500
18950 25236 33405 72549
10000 10000 10000 10000
15160 20189 26724 58039
$14213 Misc Pediatric $18927 Misc Pediatric $25054 Misc Pediatric $54412 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
912-1 912-2 912-3 912-4
MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
558 607 985
1782
20950 22759 36410 68885
10000 10000 10000 10000
10000 10000 10000 10000
20950 22759 36410 68885
12500 12500 12500 12500
26188 28449 45513 86106
10000 10000 10000 10000
20950 22759 36410 68885
$19641 Misc Pediatric $21337 Misc Pediatric $34134 Misc Pediatric $64580 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
930-1 930-2 930-3 930-4
MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE
322 370 596
1127
07826 09594 15857 33896
10000 10000 10000 10000
10000 10000 10000 10000
07826 09594 15857 33896
12500 12500 12500 12500
09783 11993 19821 42370
10000 10000 10000 10000
07826 09594 15857 33896
$7337 Misc Pediatric $8994 Misc Pediatric
$14866 Misc Pediatric $31778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
950-1 950-2 950-3 950-4
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
361 623
1166 2260
13230 20029 31827 60092
10000 10000 10000 10000
10000 10000 10000 10000
13230 20029 31827 60092
12500 12500 12500 12500
16538 25036 39784 75115
10000 10000 10000 10000
13230 20029 31827 60092
$12403 Misc Pediatric $18777 Misc Pediatric $29838 Misc Pediatric $56336 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
951-1 951-2 951-3 951-4
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
329 517
1001 1973
09755 14320 24054 46875
10000 10000 10000 10000
10000 10000 10000 10000
09755 14320 24054 46875
12500 12500 12500 12500
12194 17900 30068 58594
10000 10000 10000 10000
09755 14320 24054 46875
$9145 Misc Pediatric $13425 Misc Pediatric $22551 Misc Pediatric $43945 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
952-1 952-2 952-3 952-4
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
274 504 968
1894
07736 11591 20369 39177
10000 10000 10000 10000
10000 10000 10000 10000
07736 11591 20369 39177
12500 12500 12500 12500
09670 14489 25461 48971
10000 10000 10000 10000
07736 11591 20369 39177
$7253 Misc Pediatric $10867 Misc Pediatric $19096 Misc Pediatric $36728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
955-0 956-0
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS UNGROUPABLE
--
--
Error DRG Error DRG
Error DRG Error DRG
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i
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy adjustor F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that has at least a basic level
emergency room H FY 2015-16 Cost-to-Charge Ratio FY 2013 cost-to-charge ratio with some exceptions I FY 2015-16 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FY 2015-16 Wage Index Value (adjusted for CA Neutrality Factor 09797) W age index value times 09797 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls for changes between California
and the rest of the US while maintaining relative differences among wage areas within California K FY 2015-16 Unadjusted Statewide Base Rate The statewide DRG base rate is $6289 except that for remote rural hospitals it is $12768 L FY 2015-16 Wage Adjusted Statewide Base Rate (Non-Transition) The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses See Tab 5 This rate is applicable for non-transition hospitals as shown in Column N Medi-Cal
managed care plans that are pricing claims for emergency and post-stabilization services hospitals outside their network should use Column L for all hospitals M FY 2015-16 Hospital-Specific Transition Base Rate The base rate assigned to hospitals to move them in steps toward the statewide base rate This rate is applicable for transition hospitals as shown in Column N FY 2015-16 is the final year of transition rates N Transition rate This column identifies whether the hospital is a non-transition hospital (base rate in Column L) or a transition hospital (base rate in Column M) O FY 2015-16 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2015-16 P FY 2015-16 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by
use of Revenue Code 190 Q FY 2015-16 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by use of
Revenue Code 199
A B C D E F G H I J K L M N O P Q
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transit on Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
OUT OF STATE No No No No No 2180 10000 10000 $6289 $6289 NA Non-Transition NA $98163 $80582 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 3572 12882 12620 $12768 $15097 $15414 Transition NA $98163 $80582 106100793 ADVENTIST MEDICAL CENTER - SELMA COMMUNITY HOSPITAL No No No Yes Yes 3572 12882 12620 $12768 $15097 $14680 Transition NA $98163 $80582 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 4360 12882 12620 $12768 $15097 $10484 Transition NA $98163 $80582 106301098 AHMC ANAHEIM REG MED CTR No No No No No 1656 12882 12620 $6289 $7436 $15144 Transition NA $98163 $80582 106010846 ALAMEDA CO MED CTR Yes No No No No 4036 16962 16618 $6289 $9186 NA NA NA NA NA 106010735 ALAMEDA HOSP No Yes No No No 2600 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106190017 ALHAMBRA HOSP No No No No No 1397 12882 12620 $6289 $7436 $5446 Transition $1220 $98163 $80582 106010739 ALTA BATES SUMMIT MED CTR-ALTA BATES No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106010937 ALTA BATES SUMMIT MED CTR-HAWTHORNE No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106010844 ALTA BATES SUMMIT MED CTR-HERRICK CAMPUS No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106013626 ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106374063 ALVARADO HOSP MED CTR - REHAB No No No No No 1930 12882 12620 $6289 $7436 $4599 Transition $1220 $98163 $80582 106190034 ANTELOPE VALLEY HOSP MED CTR No Yes No No No 2997 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364231 ARROWHEAD REG MED CTR Yes No No No No 3324 12882 12620 $6289 $7436 NA NA NA NA NA 106400466 ARROYO GRANDE COMM HOSP No No No No No 2581 12964 12701 $6289 $7471 NA Non-Transition $1226 $98163 $80582 106154101 BAKERSFIELD HEART HOSP No No No No No 1782 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150722 BAKERSFIELD MEM HOSP-34TH ST No No No No No 2117 12882 12620 $6289 $7436 $9141 Transition NA $98163 $80582 106364121 BALLARD REHABILITATION HOSP No No No No No 8300 12882 12620 NA NA NA NA $1427 $98163 $80582 106184008 BANNER LASSEN MED CTR No No No Yes Yes 3967 12882 12620 $12768 $15097 $18668 Transition NA $98163 $80582 106190052 BARLOW RESP HOSP No No No No No 1849 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364430 BARSTOW COMM HOSP No No No Yes Yes 2262 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090793 BARTON MEM HOSP No No No Yes Yes 3635 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106361110 BEAR VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190081 BEVERLY HOSP No No No No No 3567 12882 12620 $6289 $7436 $5841 Transition NA $98163 $80582 106040802 BIGGS GRIDLEY MEM HOSP No No No Yes Yes 3652 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106380929 CA PACIFIC MED CTR No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380777 CA PACIFIC MED CTR - CALIFORNIA WEST No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380933 CA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 2873 16738 16398 $6289 $9090 NA Non-Transition $1492 $98163 $80582 106190125 CALIFORNIA HOSP MED CTR-LA No No Yes No No 2078 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190137 CASA COLINA HOSP FOR REHAB MED No No No No No 7213 12882 12620 NA NA NA NA $1220 $98163 $80582 106190045 CATALINA ISLAND MED CTR No No No Yes Yes 9000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190555 CEDARS-SINAI MED CTR No No Yes No No 2051 12882 12620 $6289 $7436 $5837 Transition $1220 $98163 $80582 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 1730 12882 12620 $6289 $7436 $6350 Transition $1220 $98163 $80582 106160787 CENTRAL VALLEY GEN HOSP No No No No No 7778 12882 12620 $6289 $7436 $11888 Transition NA $98163 $80582 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 2190 12892 12630 $6289 $7440 NA Non-Transition $1221 $98163 $80582 106301140 CHAPMAN MED CTR No No No No No 1908 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304113 CHILDRENS HOSP AT MISSION No No No No No 3300 12882 12620 $6289 $7436 $18777 Transition NA $98163 $80582 106204019 CHILDRENS HOSP CENTRAL CALIFORNIA No No Yes No No 2430 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106010776 CHILDRENS HOSP OAKLAND No No Yes No No 3356 16478 16143 $6289 $8978 NA Non-Transition $2628 $98163 $80582 106190170 CHILDRENS HOSP OF LA No No Yes No No 3988 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106300032 CHILDRENS HOSP OF ORANGE CO No No Yes No No 2442 12882 12620 $6289 $7436 $5613 Transition NA $98163 $80582 106382715 CHINESE HOSP No No No No No 3835 16738 16398 $6289 $9090 $8053 Transition NA $98163 $80582 106361144 CHINO VALLEY MED CTR No No No No No 2098 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190176 CITY OF HOPE HELFORD CLINIC RES HOSP No No No No No 2789 12882 12620 $6289 $7436 $5941 Transition NA $98163 $80582 106100005 CLOVIS COMM MED CTR No No No No No 3336 12882 12620 $6289 $7436 $7752 Transition NA $98163 $80582 106100697 COALINGA REG MED CTR No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190766 COAST PLAZA DRS HOSP No No No No No 2126 12882 12620 $6289 $7436 $5303 Transition NA $98163 $80582 106301258 COASTAL COMM HOSP No No No No No 2792 12882 12620 $6289 $7436 $7035 Transition NA $98163 $80496 106301155 COLLEGE HOSP COSTA MESA No No No No No 2876 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190587 COLLEGE MEDICAL CENTER No No No No No 3760 12882 12620 $6289 $7436 $4258 Transition NA $98163 $80582 106361458 COLORADO RIVER MED CTR No No No Yes Yes 4357 12882 12620 $12768 $15097 $18541 Transition NA $98163 $80582 106060870 COLUSA REG MED CTR No No No Yes Yes 3066 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190197 COMM AND MISSION HOSP OF HUNT PK No No No No No 1601 12882 12620 $6289 $7436 $5421 Transition NA $98163 $80582 106190475 COMM HOSP OF LONG BEACH No No No No No 1707 12882 12620 $6289 $7436 $15917 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106361323 COMM HOSP OF SAN BERNARDINO No No No No No 2833 12882 12620 $6289 $7436 $6516 Transition NA $98163 $78406 106560473 COMM MEM HOSP OF SAN BUENAVENTURA No No No No No 2104 12882 12620 $6289 $7436 $4512 Transition NA $98163 $80582 106100717 COMM REG MED CTR-FRESNO No No No No No 1896 12882 12620 $6289 $7436 $7994 Transition $1655 $98163 $80582 106070924 CONTRA COSTA REG MED CTR Yes No No No No 6010 16478 16143 $6289 $8978 NA NA NA NA NA 106331152 CORONA REG MED CTR No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition NA $98163 $80582 106331145 CORONA REG MED CTR - MAGNOLIA No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition $1220 $98163 $80582 106190413 CV-INTERCOMMUNITY CAMPUS No No No No No 3136 12882 12620 $6289 $7436 $6821 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106190636 CV-QUEEN OF VALLEY CAMPUS No No Yes No No 3136 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106150706 DELANO REG MED CTR No No No No No 3622 12882 12620 $6289 $7436 $7087 Transition NA $98163 $80582 106331164 DESERT REG MED CTR No No No No No 1486 12882 12620 $6289 $7436 $7153 Transition $1447 $98163 $80582 106364144 DESERT VALLEY HOSP No No No No No 2050 12882 12620 $6289 $7436 $8173 Transition NA $98163 $80582 106440755 DOMINICAN HOSP-SANTA CRUZ No No No No No 2016 17239 16889 $6289 $9304 $7821 Transition $1527 $98163 $80582 106190243 DOWNEY REG MED CTR No No No No No 1732 12882 12620 $6289 $7436 $6847 Transition NA $98163 $80582 106392287 DRS HOSP OF MANTECA No No No No No 1362 13579 13303 $6289 $7735 $11712 Transition NA $98163 $80582 106390846 DAMERON HOSP No No No No No 2138 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106190857 DRS HOSP OF WEST COVINA No No No No No 1833 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106070904 DRS MED CTR-SAN PABLOPINOLE No Yes No No No 2373 16478 16143 $6289 $8978 $6025 Transition NA $98163 $80582 106190256 EAST LA DRS HOSP No No No No No 1952 12882 12620 $6289 $7436 $5809 Transition NA $98163 $80582 106190328 EAST VALLEY HOSP MED CTR No No No No No 2859 12882 12620 $6289 $7436 $5534 Transition NA $98163 $80582 106320859 EASTERN PLUMAS HOSP No Yes No Yes Yes 4802 12882 12620 $12768 $15097 $13674 Transition NA $98163 $80582 106014233 EDEN MED CTR No No No No No 3197 16962 16618 $6289 $9186 $12768 Transition NA $98163 $80582 106331168 EISENHOWER MEM HOSP No No No No No 1540 12882 12620 $6289 $7436 $10211 Transition NA $98163 $80582 106430763 EL CAMINO HOSP No Yes No No No 2857 17180 16831 $6289 $9279 $5377 Transition $1523 $98163 $80582 106130699 EL CENTRO COMM HOSP No Yes No No No 2298 12882 12620 $6289 $7436 $8949 Transition NA $98163 $80582 106500852 DRS MED CTR No No No No No 1181 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106500867 EMANUEL MED CTR No No No No No 2046 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106040962 ENLOE MED CTR No No No No No 2436 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106044011 ENLOE REHABILLITATION CENTER No No No No No 2463 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106474007 FAIRCHILD MED CTR No No No Yes Yes 3914 12882 12620 $12768 $15097 $16385 Transition NA $98163 $80582 106040875 FEATHER RIVER HOSP No No No No No 1240 12882 12620 $6289 $7436 $10796 Transition NA $98163 $80582 106190298 FOOTHILL PRES HOSP No No No No No 2989 12882 12620 $6289 $7436 $4740 Transition NA $98163 $80582 106301175 FOUNTAIN VALLEY REG HOSP-EUCLID No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106304039 FOUNTAIN VALLEY REG HOSP-WARNER No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106230949 FRANK R HOWARD MEM HOSP No No No Yes Yes 3495 12882 12620 $12768 $15097 $15377 Transition NA $98163 $80582 106510882 FREMONT MEDICAL CENTER No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106190280 ENCINO HOSP MED CTR No No No No No 949 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106400480 FRENCH HOSP MED CTR No No No No No 2241 12964 12701 $6289 $7471 NA Non-Transition NA $98163 $80582 106301283 GARDEN GROVE HOSP AND MED CTR No No No No No 2661 12882 12620 $6289 $7436 $5749 Transition NA $98163 $80582 106190159 GARDEN REG HOSP AND MED CTR No No No No No 2937 12882 12620 $6289 $7436 $4110 Transition NA $98163 $80582 106105029 FRESNO HEART HOSP No No No No No 3403 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106270777 GEORGE L MEE MEM HOSP No No No Yes Yes 3562 15558 15242 $12768 $17426 $20386 Transition NA $98163 $80582 106190315 GARFIELD MED CTR No No No No No 1031 12882 12620 $6289 $7436 NA Non-Transition $1394 $98163 $80582 106190522 GLENDALE MEM HOSP AND HLTH CTR No No No No No 2163 12882 12620 $6289 $7436 $6885 Transition $1220 $98163 $80582 106110889 GLENN MED CTR No No No Yes Yes 6660 12882 12620 $12768 $15097 $21024 Transition NA $98163 $80582 106190323 GLENDALE ADV MED CTR-WILSON TERRACE No No No No No 1845 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420483 GOLETA VALLEY COTTAGE HOSP No No No No No 3083 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150775 GOOD SAMARITAN HOSP-BAKERSFIELD No No No No No 3694 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430779 GOOD SAMARITAN HOSP-SAN JOSE No No Yes No No 1937 17180 16831 $6289 $9279 $5654 Transition NA $98163 $80582 106190352 GREATER EL MONTE COMM HOSP No No No No No 1088 12882 12620 $6289 $7436 $4818 Transition NA $98163 $80582 106370714 GROSSMONT HOSP No No No No No 1937 12882 12620 $6289 $7436 $6498 Transition $1220 $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190392 GOOD SAMARITAN HOSP-LA No No Yes No No 2006 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106350784 HAZEL HAWKINS MEM HOSP No Yes No Yes Yes 3840 17180 16831 $12768 $18839 NA Non-Transition NA $98163 $80582 106490964 HEALDSBURG DIST HOSP No Yes No Yes Yes 6549 16188 15859 $12768 $17975 NA Non-Transition NA $98163 $80582 106154022 HEALTHSOUTH BAKERSFIELD REHAB HOSP No No No No No 5040 12882 12620 NA NA NA NA $1382 $98163 $80582 106304079 HEALTHSOUTH TUSTIN REHAB HOSP No No No No No 5281 12882 12620 NA NA NA NA $1220 $98163 $80582 106331194 HEMET VALLEY MED CTR No No No No No 1267 12882 12620 $6289 $7436 $5912 Transition NA $98163 $80582 106190949 HENRY MAYO NEWHALL MEM HOSP No No No No No 1839 12882 12620 $6289 $7436 $5631 Transition $1220 $98163 $80582 106362041 HI-DESERT MED CTR No Yes No Yes Yes 2909 12882 12620 $12768 $15097 $13297 Transition NA $98163 $80582 106301205 HOAG MEM HOSP PRESBYTERIAN No No No No No 4825 12882 12620 $6289 $7436 $13525 Transition NA $98163 $80582 106304159 HEALTHBRIDGE CHILDRENS HOSP-ORANGE No No No No No 3271 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106190380 HOLLYWOOD COMM HOSP OF HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106304460 HOAG ORTHOPEDIC No No No No No 4894 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190382 HOLLYWOOD PRES MED CTR No No No No No 2212 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301209 HUNTINGTON BEACH HOSP No No No No No 2175 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190400 HUNTINGTON MEM HOSP No No Yes No No 2294 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106304045 IRVINE REG HOSP AND MED CTR No No No No No 200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106220733 JOHN C FREMONT HCARE DIST No Yes No Yes Yes 3884 12882 12620 $12768 $15097 $8195 Transition NA $98163 $80582 106331216 JOHN F KENNEDY MEM HOSP No No No No No 1679 12882 12620 $6289 $7436 $6464 Transition NA $98163 $80582 106071018 JOHN MUIR MED CTR-CONCORD CAMPUS No No No No No 1748 16478 16143 $6289 $8978 $12804 Transition NA $98163 $80582 106070988 JOHN MUIR MED CTR-WALNUT CREEK CAMPUS No No No No No 2039 16478 16143 $6289 $8978 $10615 Transition $1473 $98163 $80582 106314024 KAISER HOSPITAL - ROSEVILLE No No Yes No No 7912 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106364265 KAISER ONTARIO MEDICAL CENTER CAMPUS No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106121031 JEROLD PHELPS COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301132 KAISER-ANAHEIM No No Yes No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304306 KAISER-ANAHEIM-IRVINE No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304409 KAISER-ANAHEIM-Orange No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106074097 KAISER-ANTIOCH No No No No No 8503 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106196403 KAISER-DOWNEY No No No No No 10000 12882 12620 $6289 $7436 $12698 Transition NA $98163 $80582 106361223 KAISER-FONTANA No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106014132 KAISER-FREMONT No No No No No 10000 16962 16618 $6289 $9186 $9639 Transition NA $98163 $80582 106196035 KAISER-BALDWIN PARK No No No No No 8009 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106104062 KAISER-FRESNO No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190429 KAISER-LOS ANGELES No No No No No 7387 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106394009 KAISER-MANTECA No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106334048 KAISER-MORENO VALLEY No No No No No 6614 12882 12620 $6289 $7436 $4790 Transition NA $98163 $80582 106010856 KAISER-OAKLANDRICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106190432 KAISER-PANORAMA CITY No No No No No 8239 12882 12620 $6289 $7436 $16025 Transition NA $98163 $80582 106504042 KAISER-MODESTO No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106410804 KAISER-REDWOOD CITY No No No No No 7731 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106074093 KAISER-RICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106480989 KAISER-REHAB CENTER VALLEJO No No No No No 8442 16315 15984 $6289 $8908 NA Non-Transition $2535 $98163 $80582 106340913 KAISER-SACRAMENTO No No No No No 5612 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106334025 KAISER-RIVERSIDE No No No No No 5865 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370730 KAISER-SAN DIEGO No No No No No 7393 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106380857 KAISER-SAN FRANCISCO No No No No No 5960 16738 16398 $6289 $9090 NA Non-Transition NA $98163 $80582 106431506 KAISER-SAN JOSE No No No No No 7002 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106014337 KAISER-SAN LEANDRO No No No No No 2180 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106210992 KAISER-SAN RAFAEL No No No No No 4673 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106494019 KAISER-SANTA ROSA No No No No No 10000 16315 15984 $6289 $8908 $17627 Transition NA $98163 $80582 106434153 KAISER-SANTA CLARA No No No No No 6107 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106190431 KAISER-SOUTH BAY No No No No No 6935 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106342344 KAISER-SOUTH SACRAMENTO No No No No No 5670 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106410806 KAISER-SOUTH SF No No No No No 6503 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106484044 KAISER-VACAVILLE No No No No No 10000 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106070990 KAISER-WALNUT CREEK No No No No No 5680 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106190434 KAISER-WEST LA No No No No No 6623 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106194219 KECK HOSPITAL OF USC No No No No No 2004 12882 12620 $6289 $7436 $4699 Transition $1220 $98163 $80582 106210993 KENTFIELD REHAB HOSP No No No No No 5967 16855 16513 $6289 $9140 $19338 Transition $1500 $98163 $80582 106150736 KERN MED CTR Yes No No No No 3943 12882 12620 $6289 $7436 NA NA NA NA NA 106150737 KERN VALLEY HEALTHCARE DIST No Yes No Yes Yes 2786 12882 12620 $12768 $15097 $8298 Transition NA $98163 $80582 106191450 KAISER-WOODLAND HILLS No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190049 KINDRED HOSPITAL BALDWIN PARK No No No No No 1810 12882 12620 $6289 $7436 $10784 Transition NA $98163 $80582 106190305 KINDRED LA No No No No No 2044 12882 12620 $6289 $7436 $4255 Transition NA $98163 $80582 106301127 KINDRED BREA No No No No No 2852 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361274 KINDRED ONTARIO No No No No No 2068 12882 12620 $6289 $7436 $9314 Transition NA $98163 $80582 106364188 KINDRED RANCHO No No No No No 1980 12882 12620 $6289 $7436 $20628 Transition NA $98163 $80582 106332172 KINDRED RIVERSIDE No No No No No 1805 12882 12620 $6289 $7436 $24450 Transition NA $98163 $80582 106190449 KINDRED LA MIRADA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106370721 KINDRED SAN DIEGO No No No No No 3605 12882 12620 $6289 $7436 $5657 Transition NA $98163 $80582 106344035 KINDRED SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190458 KINDRED SAN GABRIEL VALLEY No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106010887 KINDRED SF BAY AREA No No No No No 3007 16478 16143 $6289 $8978 $6378 Transition NA $98163 $80582 106301167 KINDRED SANTA ANA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190196 KINDRED SOUTH BAY No No No No No 2144 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301380 KINDRED WESTMINSTER No No No No No 2286 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301234 LA PALMA INTERCOMMUNITY HOSP No No No No No 2290 12882 12620 $6289 $7436 $7160 Transition NA $98163 $80582 106191227 LAC-HARBOR-UCLA MED CTR Yes No Yes No No 3366 12882 12620 $6289 $7436 NA NA NA NA NA 106191231 LAC-OLIVE VIEW-UCLA MED CTR Yes No No No No 4136 12882 12620 $6289 $7436 NA NA NA NA NA 106191228 LAC-USC MED CTR Yes No Yes No No 4522 12882 12620 $6289 $7436 NA NA NA NA NA 106380865 LAGUNA HONDA HOSP AND REHAB CTR Yes No No No No 5843 16738 16398 $6289 $9090 NA NA NA NA NA 106190240 LAKEWOOD REG MED CTR No No No No No 1504 12882 12620 $6289 $7436 $4008 Transition $1220 $98163 $80582 106390923 LODI MEM HOSP No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106390922 LODI MEM HOSP - WEST No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106334589 LOMA LINDA MURRIETTA No No No No No 3222 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106364268 LOMA LINDA UNIV HEART AND SURGICAL HOSPITAL No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361245 LOMA LINDA UNIV MED CTR - EAST CAMPUS No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361246 LOMA LINDA UNIV MED CTR No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $1491 $98163 $80582 106364502 LOMA LINDA UNIV CHILDRENS HOSP No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $2177 $98163 $80582 106190198 LA COMM HOSP No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420491 LOMPOC VALLEY MED CTR No Yes No Yes Yes 8693 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301248 LOS ALAMITOS MED CTR No No No No No 1915 12882 12620 $6289 $7436 $4697 Transition NA $98163 $80582 106560492 LOS ROBLES HOSP AND MED CTR No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106564018 LOS ROBLES HOSP AND MED CTR-EAST CAMPUS No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106434040 LSP CHILDRENS HOSP AT STANFORD No No Yes No No 2035 17180 16831 $6289 $9279 $6102 Transition NA $98163 $80582 106121002 MAD RIVER COMM HOSP No No No No No 4250 12882 12620 $6289 $7436 $9505 Transition NA $98163 $80582 106201281 MADERA COMMUNITY HOSPITAL No No No No No 5100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106260011 MAMMOTH HOSP No Yes No Yes Yes 7982 12882 12620 $12768 $15097 $46994 Transition NA $98163 $80582 106420493 MARIAN MED CTR No No No No No 2741 12882 12620 $6289 $7436 $9386 Transition NA $98163 $80582 106190525 LONG BEACH MEM MED CTR No No No No No 1996 12882 12620 $6289 $7436 NA Non-Transition $1627 $98163 $80582 106211006 MARIN GEN HOSP No Yes No No No 2571 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106190500 MARINA DEL RAY HOSPITAL No No No No No 2034 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106050932 MARK TWAIN ST JOSEPHS HOSP No No No Yes Yes 3707 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090933 MARSHALL MED CTR No No No Yes Yes 2107 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106500939 MEM HOSP MED CTR-MODESTO No No No No No 2235 12892 12630 $6289 $7440 $5898 Transition NA $98163 $80582 106240924 MEMORIAL HOSP LOS BANOS No No No Yes Yes 3362 12882 12620 $12768 $15097 $17450 Transition NA $98163 $80582 106190521 MEMORIAL HOSP OF GARDENA No No No No No 1747 12882 12620 $6289 $7436 $4611 Transition NA $98163 $80582 106231013 MENDOCINO COAST DIST HOSP No Yes No Yes Yes 5070 12882 12620 $12768 $15097 $15935 Transition NA $98163 $80582 106334018 MENIFEE VALLEY MED CTR No No No No No 1458 12882 12620 $6289 $7436 $5113 Transition NA $98163 $80582 106450936 MAYERS MEM HOSP No Yes No Yes Yes 7192 14188 13900 $12768 $16234 NA Non-Transition NA $98163 $80582 106340947 MERCY GEN HOSP No No No No No 2185 15256 14946 $6289 $8454 $6027 Transition $1387 $98163 $80582 106344029 MERCY HOSP OF FOLSOM No No No No No 2746 15256 14946 $6289 $8454 $5260 Transition NA $98163 $80582 106150761 MERCY HOSP-BAKERSFIELD No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106414018 MENLO PARK SURGICAL HOSP No No No No No 2770 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106240942 MERCY MED CTR MERCED No No No No No 2289 13279 13009 $6289 $7606 NA Non-Transition NA $98163 $80582 106450949 MERCY MED CTR-REDDING No No No No No 2589 14188 13900 $6289 $7996 $10219 Transition NA $98163 $80582 106470871 MERCY MED CTR-MT SHASTA No No No Yes Yes 6242 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106340950 MERCY SAN JUAN HOSP No No No No No 2166 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190529 METHODIST HOSP OF SO CAL No No No No No 1842 12882 12620 $6289 $7436 $6690 Transition $1220 $98163 $80582 106196168 MILLER CHILDRENS HOSP No No Yes No No 2680 12882 12620 $6289 $7436 $8155 Transition NA $98163 $80582 106410742 MILLS HEALTH CENTER No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106410852 MILLS-PENINSULA No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106340951 METHODIST HOSP OF SACRAMENTO No No No No No 2028 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190524 MISSION COMM HOSP-PANORAMA CAMPUS No No No No No 3568 12882 12620 $6289 $7436 $3982 Transition NA $98163 $80582 106190681 MIRACLE MILE No No No No No 100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301262 MISSION HOSP REG MED CTR No No No No No 4091 12882 12620 $6289 $7436 $14336 Transition $1220 $98163 $80582 106250956 MODOC MED CTR No Yes No Yes Yes 4961 12882 12620 $12768 $15097 $13486 Transition NA $98163 $80582 106301337 MISSION HOSP LAGUNA BEACH No No No No No 4091 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106361166 MONTCLAIR HOSP MED CTR No No No No No 3149 12882 12620 $6289 $7436 $5904 Transition NA $98163 $80582 106190547 MONTEREY PARK HOSP No No No No No 1034 12882 12620 $6289 $7436 $5866 Transition NA $98163 $80582 106361266 MOUNTAINS COMM HOSP No Yes No Yes Yes 5148 12882 12620 $12768 $15097 $15642 Transition NA $98163 $80582 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106481357 NORTH BAY MEDICAL CENTER No No No No No 1972 16315 15984 $6289 $8908 $15945 Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190541 MONROVIA MEM HOSP No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106141273 NORTHERN INYO HOSP No Yes No Yes Yes 8150 12882 12620 $12768 $15097 $27752 Transition NA $98163 $80582 106484001 NORTH BAY VACAVALLEY HOSP No No No No No 1972 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106190568 NORTHRIDGE HOSP MED CTR No No No No No 1596 12882 12620 $6289 $7436 NA Non-Transition $1662 $98163 $80582 106214034 NOVATO COMM HOSP No No No No No 3465 16855 16513 $6289 $9140 $6359 Transition NA $98163 $80582 106500967 OAK VALLEY DIST HOSP No Yes No Yes No 3340 12892 12630 $6289 $7440 $5201 Transition NA $98163 $80582 106430837 OCONNOR HOSP-SAN JOSE No No No No No 2409 17180 16831 $6289 $9279 $5201 Transition NA $98163 $80582 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190534 OLYMPIA MED CTR No No No No No 1260 12882 12620 $6289 $7436 $6786 Transition NA $98163 $80582 106300225 ORANGE COAST MEM MED CTR No No No No No 2293 12882 12620 $6289 $7436 $19985 Transition NA $98163 $80582 106040937 OROVILLE HOSP No No No No No 1803 12882 12620 $6289 $7436 $6229 Transition NA $98163 $80582 106560501 OJAI VALLEY COMM HOSP No No No Yes Yes 2745 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190696 PACIFICA HOSP OF THE VALLEY No No No No No 3338 12882 12620 $6289 $7436 $5616 Transition NA $98163 $80582 106491338 PALM DRIVE HOSP No Yes No Yes No 4315 16315 15984 $6289 $8908 $11457 Transition NA $98163 $80582 106196405 PALMDALE REGIONAL MEDICAL CTR No No No No No 1190 12882 12620 $6289 $7436 $7504 Transition $1220 $98163 $80582 106331288 PALO VERDE HOSP No Yes No Yes Yes 4770 12882 12620 $12768 $15097 $18188 Transition NA $98163 $80582 106370755 PALOMAR MED CTR No Yes No No No 2429 12882 12620 $6289 $7436 $7051 Transition $1220 $98163 $80582 106370759 PARADISE VALLEY HOSP No No No No No 2188 12882 12620 $6289 $7436 $4275 Transition $1220 $98163 $80582 106190307 PACIFIC ALLIANCE MED CTR No No No No No 4299 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106331293 PARKVIEW COMM HOSP MED CTR No No No No No 2757 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106491001 PETALUMA VALLEY HOSP No No No No No 2271 16315 15984 $6289 $8908 $13491 Transition NA $98163 $80582 106130760 PIONEERS MEM HOSP No Yes No Yes No 2989 12882 12620 $6289 $7436 $9825 Transition NA $98163 $80582 106454013 PATIENTS HOSP OF REDDING No No No No No 2172 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106301297 PLACENTIA LINDA HOSP No No No No No 1606 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370977 POMERADO HOSP No Yes No No No 3063 12882 12620 $6289 $7436 $6818 Transition NA $98163 $80582 106320986 PLUMAS DIST HOSP No Yes No Yes Yes 8666 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190631 PRESBYTERIAN INTERCOMM HOSP No No No No No 961 12882 12620 $6289 $7436 $9720 Transition $1220 $98163 $80582 106190630 POMONA VALLEY HOSP MED CTR No No Yes No No 1538 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190468 PROMISE HOSP OF EAST LA-EAST LA No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190599 PROMISE HOSP OF EAST LA-EAST LA-SUBURBAN CAMPUS No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190385 PROVIDENCE HOLY CROSS MED CTR No No No No No 1325 12882 12620 $6289 $7436 $6284 Transition $1220 $98163 $80582 106190680 PROVIDENCE LITTLE CO OF MARY-SAN PEDRO No No No No No 1533 12882 12620 $6289 $7436 $6225 Transition $1220 $98163 $80582 106190470 PROVIDENCE LITTLE CO OF MARY-TORRANCE No No No No No 1767 12882 12620 $6289 $7436 $7182 Transition NA $98163 $80582 106190758 PROVIDENCE ST JOSEPH MED CTR No No No No No 1866 12882 12620 $6289 $7436 $7141 Transition $1220 $98163 $80582 106370787 PROMISE HOSP OF SAN DIEGO No No No No No 3660 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106281047 QUEEN OF THE VALLEY HOSP-NAPA No No No No No 2829 16188 15859 $6289 $8854 $17592 Transition $1453 $98163 $80582 106370673 RADY CHILDRENS HOSPITAL - SAN DIEGO No No Yes No No 2854 12882 12620 $6289 $7436 $6395 Transition $2177 $98163 $80582 106190517 PROVIDENCE TARZANA MED CTR No No Yes No No 1536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361308 REDLANDS COMM HOSP No No No No No 2079 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430705 REG MED CTR OF SAN JOSE No No No No No 2529 17180 16831 $6289 $9279 $13299 Transition NA $98163 $80582 106580996 RIDEOUT MEM HOSP No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106121051 REDWOOD MEM HOSP No No No Yes Yes 3214 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106334487 RIVERSIDE CO REG MED CTR Yes No No No No 2987 12882 12620 $6289 $7436 NA NA NA NA NA 106331312 RIVERSIDE COMM HOSP No No No No No 1560 12882 12620 $6289 $7436 $5990 Transition NA $98163 $80582 106190796 RONALD REAGAN UCLA MED CTR Yes No Yes No No 3382 12882 12620 $6289 $7436 NA NA NA NA NA 106301317 SADDLEBACK MEM MED CTR No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106301325 SADDLEBACK MEM MED CTR-SAN CLEMENTE No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106150782 RIDGECREST REG HOSP No No No Yes Yes 4178 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106361318 SAN ANTONIO COMM HOSP No No No No No 2262 12882 12620 $6289 $7436 $9216 Transition NA $98163 $80582 106190673 SAN DIMAS COMM HOSP No No No No No 2465 12882 12620 $6289 $7436 $12177 Transition NA $98163 $80582 106190200 SAN GABRIEL VALLEY MED CTR No No No No No 969 12882 12620 $6289 $7436 $6918 Transition NA $98163 $80582 106270875 SALINAS VALLEY MEM HOSP No Yes No No No 3534 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106331326 SAN GORGONIO MEM HOSP No Yes No Yes Yes 3394 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391010 SAN JOAQUIN GEN HOSP Yes No No No No 1922 13579 13303 $6289 $7735 NA NA NA NA NA 106104023 SAN JOAQUIN VALLEY REHAB HOSP No No No No No 6479 12882 12620 NA NA NA NA $1413 $98163 $80582 106013619 SAN LEANDRO HOSP No Yes No No No 3482 16501 16166 $6289 $8988 $10813 Transition NA $98163 $80582 106410782 SAN MATEO MED CTR Yes No No No No 7168 16928 16584 $6289 $9171 NA NA NA NA NA 106074017 SAN RAMON REG MED CTR No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106074011 SAN RAMON REG MED CTR SOUTH BUILDING No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106420514 SANTA BARBARA COTTAGE HOSP No No Yes No No 3902 12882 12620 $6289 $7436 $10978 Transition $2125 $98163 $80582 106430883 SANTA CLARA VALLEY MED CTR Yes No Yes No No 3133 17180 16831 $6289 $9279 NA NA NA NA NA 106190687 SANTA MONICA - UCLA MEDICAL CENTER Yes No No No No 3102 12882 12620 $6289 $7436 NA NA NA NA NA 106491064 SANTA ROSA MEM HOSP-MONTGOMERY No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106490907 SANTA ROSA MEM HOSP-SOTOYOME No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106150788 SAN JOAQUIN COMM HOSP No No No No No 2544 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420522 SANTA YNEZ VALLEY COTTAGE HOSP No No No Yes Yes 7569 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106371394 SCRIPPS MEM HOSP-ENCINITAS No No No No No 2403 12882 12620 $6289 $7436 $7037 Transition $1439 $98163 $80582 106370771 SCRIPPS MEM HOSP-LA JOLLA No No No No No 2061 12882 12620 $6289 $7436 $4390 Transition NA $98163 $80582 106370744 SCRIPPS MERCY HOSP No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106370658 SCRIPPS MERCY HOSP-CHULA VISTA No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106371256 SCRIPPS GREEN HOSP No No No No No 2317 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106321016 SENECA HCARE DIST No Yes No Yes Yes 4586 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106410817 SETON MED CTR No No No No No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106410828 SETON MED CTR-COASTSIDE No No No Yes No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106380939 SF GENERAL HOSP Yes No No No No 2851 16738 16398 $6289 $9090 NA NA NA NA NA 106370875 SHARP CHULA VISTA MED CTR No No No No No 1932 12882 12620 $6289 $7436 $6485 Transition NA $98163 $80582 106410891 SEQUOIA HOSP No No No No No 1975 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106370689 SHARP CORONADO HOSP AND HCARE CTR No No No No No 2160 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $72421 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106370694 SHARP MEM HOSP No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106450940 SHASTA REG MED CTR No No No No No 1582 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106190708 SHERMAN OAKS HOSP No No No No No 1516 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190712 SHRINERS HOSPITAL- LA No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106344114 SHRINERS HOSPITAL- SACRAMENTO No No No No No 3869 15256 14946 $6289 $8454 NA Non-Transition $2475 $98163 $80582 106540798 SIERRA VIEW DIST HOSP No Yes No No No 2716 12882 12620 $6289 $7436 $8497 Transition NA $98163 $77682 106400524 SIERRA VIST REG MED CTR No No No No No 1787 12964 12701 $6289 $7471 $5495 Transition NA $98163 $80582 106190661 SILVER LAKE MED CTR No No No No No 3692 12882 12620 $6289 $7436 $5655 Transition NA $98163 $80582 106291023 SIERRA NEVADA MEM HOSP No No No Yes Yes 3427 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106491076 SONOMA VALLEY HOSP No Yes No No No 4960 16315 15984 $6289 $8908 $12733 Transition NA $98163 $80582 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 2126 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190380 SOUTHERN CA HOSP AT HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106190110 SOUTHERN CA HOSPITAL AT CULVER CITY No No No No No 1437 12882 12620 $6289 $7436 $4694 Transition $1220 $98163 $80582 106560525 SIMI VALLEY HOSP AND HCARE-SYCAMORE No No No No No 3840 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106334068 SOUTHWEST HCARE SYSTEM No No No No No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106334001 SOUTHWEST HCARE SYSTEM-WILDOMAR No No No Yes No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106100899 ST AGNES MED CTR No No No No No 3088 12882 12620 $6289 $7436 $7885 Transition NA $98163 $80582 106361339 ST BERNARDINE MED CTR No No No No No 2171 12882 12620 $6289 $7436 $6090 Transition NA $98163 $80582 106521041 ST ELIZABETH COMM HOSP No No No Yes Yes 3024 13869 13587 $12768 $15956 $14866 Transition NA $98163 $80582 106190754 ST FRANCIS MED CTR No No No No No 4350 12882 12620 $6289 $7436 $6368 Transition NA $98163 $80582 106380960 ST FRANCIS MEM HOSP No No No No No 1920 16738 16398 $6289 $9090 $5310 Transition $1492 $98163 $80582 106281078 ST HELENA HOSP No No No No No 2337 15887 15564 $6289 $8725 $9671 Transition NA $98163 $80582 106171049 ST HELENA HOSPITAL-CLEARLAKE No No No Yes Yes 4118 12882 12620 $12768 $15097 $18218 Transition NA $98163 $80582 106141338 SOUTHERN INYO HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190756 ST JOHNS HEALTH CTR No No No No No 2536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560529 ST JOHNS REG MED CTR No No No No No 2982 12882 12620 $6289 $7436 $6976 Transition $1761 $98163 $80582 106121080 ST JOSEPH HOSP-EUREKA No No No No No 2570 13869 13587 $6289 $7859 $9661 Transition $1507 $98163 $80582 106301340 ST JOSEPH HOSP-ORANGE No No No No No 2751 12882 12620 $6289 $7436 $5230 Transition NA $98163 $80582 106560508 ST JOHNS PLEASANT VALLEY HOSP No No No No No 2087 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301342 ST JUDE MED CTR No No No No No 1722 12882 12620 $6289 $7436 $5799 Transition $1220 $98163 $80582 106434138 ST LOUISE REG HOSP No No No No No 2838 17180 16831 $6289 $9279 $16407 Transition NA $98163 $80582 106380964 ST LUKES HOSP No No No No No 3807 16738 16398 $6289 $9090 $8600 Transition NA $98163 $80582 106361343 ST MARY MED CTR-APPLE VALLEY No No No Yes No 2511 12882 12620 $6289 $7436 $9863 Transition NA $98163 $80582 106391042 ST JOSEPHS MED CTR OF STOCKTON No No No No No 2152 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106380965 ST MARYS MED CTR-SF No No No No No 2007 16738 16398 $6289 $9090 $5116 Transition $1492 $98163 $80582 106010967 ST ROSE HOSP No No No No No 1931 16962 16618 $6289 $9186 $7600 Transition NA $98163 $80582 106190762 ST VINCENT MED CTR No No No No No 2020 12882 12620 $6289 $7436 $4684 Transition $1220 $98163 $80582 106430905 STANFORD HOSP No No No No No 1803 17180 16831 $6289 $9279 $5644 Transition $1523 $98163 $80582 106190053 ST MARY MED CTR-LONG BEACH No No No No No 2479 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106504038 STANISLAUS SURGICAL HOSP No No No No No 9000 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106250955 SURPRISE VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106310791 SUTTER AUBURN FAITH HOSP No No No No No 2551 15256 14946 $6289 $8454 $11882 Transition NA $98163 $80582 106034002 SUTTER AMADOR HOSP No No No Yes Yes 2971 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106574010 SUTTER DAVIS HOSP No No No No No 3568 15256 14946 $6289 $8454 $14330 Transition NA $98163 $80582 106070934 SUTTER DELTA MED CTR No No No No No 2907 16478 16143 $6289 $8978 $12158 Transition NA $98163 $80582 106341051 SUTTER GEN HOSP No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106171395 SUTTER LAKESIDE HOSP No No No Yes Yes 3691 12882 12620 $12768 $15097 $17232 Transition NA $98163 $80582 106444012 SUTTER MATERNITY AND SRG CTR OF S CRUZ No No No No No 7213 17239 16889 $6289 $9304 $21288 Transition NA $98163 $80582 106490919 SUTTER MED CTR OF SANTA ROSA No No No No No 3657 16315 15984 $6289 $8908 $15278 Transition NA $98163 $80582 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106311000 SUTTER ROSEVILLE MED CTR No No No No No 2377 15256 14946 $6289 $8454 $11395 Transition $1387 $98163 $80582 106481094 SUTTER SOLANO MED CTR No No No No No 3258 16315 15984 $6289 $8908 $18010 Transition NA $98163 $80582 106084001 SUTTER COAST HOSP No No No Yes Yes 3730 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391056 SUTTER TRACY COMM HOSP No No No No No 2714 13579 13303 $6289 $7735 $5995 Transition NA $98163 $80582 106291053 TAHOE FOREST HOSP No Yes No Yes Yes 4766 15256 14946 $12768 $17164 $21044 Transition NA $98163 $80582 106150808 TEHACHAPI HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 $22158 Transition NA $98163 $80582 106514030 SUTTER SURG HOSP-NORTH VALLEY No No No No No 3240 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582
i-
i
i
i-
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106334564 TEMECULA VALLEY HOSPITAL No No No No No 2180 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106120981 THE GENERAL HOSPITAL No No No No No 2570 13869 13587 NA NA NA NA $1507 $98163 $80582 106564121 THOUSAND OAKS SURGICAL HOSPITAL No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106190422 TORRANCE MEM MED CTR No No No No No 1952 12882 12620 $6289 $7436 $5891 Transition NA $98163 $80582 106370780 TRI-CITY MED CTR No Yes No No No 3695 12882 12620 $6289 $7436 $7706 Transition $1220 $98163 $80582 106190784 TEMPLE COMM HOSP No No No No No 4200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540816 TULARE DIST HOSP No Yes No No No 3578 12882 12620 $6289 $7436 $9529 Transition NA $98163 $80582 106531059 TRINITY HOSP No Yes No Yes Yes 5105 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106400548 TWIN CITIES COMM HOSP No No No Yes Yes 1587 12964 12701 $12768 $15168 $8160 Transition NA $98163 $80582 106341006 UC DAVIS MED CTR Yes No Yes No No 1836 15256 14946 $6289 $8454 NA NA NA NA NA 106301279 UC IRVINE MED CTR Yes No Yes No No 2072 12882 12620 $6289 $7436 NA NA NA NA NA 106370782 UCSD MED CTR Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106374141 UCSD-LA JOLLA JOHN M amp SALLY B THORNTON HOSPITAL Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106381154 UCSF MED CTR Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106380895 UCSF MED CTR AT MOUNT ZION Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106301357 TUSTIN HOSP MED CTR No No No No No 231 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106231396 UKIAH VALLEY MED CTRHOSP DR No No No Yes Yes 3643 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106014050 VALLEY CARE MEDICAL CENTER No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106010983 VALLEY MEM HOSP-LIVERMORE No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106191216 USC KENNETH NORRIS JR CANCER HOSP No No No No No 3134 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560481 VENTURA CO MED CTR Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106560521 VENTURA CO MED CTR-SANTA PAULA HOSPITAL Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106190818 VERDUGO HILLS HOSP No No No No No 3110 12882 12620 $6289 $7436 $5264 Transition NA $98163 $80582 106190812 VALLEY PRES HOSP No No No No No 3536 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 3046 14188 13900 $6289 $7996 NA Non-Transition $1312 $98163 $80582 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 3266 12882 12620 $6289 $7436 $8320 Transition NA $98163 $80582 106010987 WASHINGTON HOSP-FREMONT No Yes No No No 1941 16962 16618 $6289 $9186 $6429 Transition NA $98163 $80582 106444013 WATSONVILLE COMM HOSP No No No No No 1780 17239 16889 $6289 $9304 $13456 Transition NA $98163 $80582 106301379 WEST ANAHEIM MED CTR No No No No No 1514 12882 12620 $6289 $7436 $4707 Transition NA $98163 $80582 106190859 WEST HILLS HOSP AND MED CTR No No No No No 1933 12882 12620 $6289 $7436 $8050 Transition NA $98163 $80582 106374094 VIBRA OF SAN DIEGO No No No No No 1155 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301188 WESTERN MED CTR-ANAHEIM No No No No No 3203 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301566 WESTERN MED CTR-SANTA ANA No No No No No 2354 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190878 WHITE MEM MED CTR No No No No No 1515 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190883 WHITTIER HOSP MED CTR No No No No No 1139 12882 12620 $6289 $7436 $5922 Transition NA $98163 $80582 106571086 WOODLAND MEM HOSP No No No No No 3278 15256 14946 $6289 $8454 $10092 Transition NA $98163 $80582 6102015
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
-
774-3 774-4
COCAINE ABUSE amp DEPENDENCE COCAINE ABUSE amp DEPENDENCE
479 1424
06448 24682
10000 10000
10000 10000
06448 24682
10000 10000
06448 24682
10000 10000
06448 24682
$4836 Other $18512 Other
Other Other
775-1 775-2 775-3 775-4
ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE ALCOHOL ABUSE amp DEPENDENCE
323 377 571
1263
03313 04639 08596 24910
10000 10000 10000 10000
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
10000 10000 10000 10000
03313 04639 08596 24910
$2485 Other $3479 Other $6447 Other
$18683 Other
Other Other Other Other
776-1 776-2 776-3 776-4
OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE OTHER DRUG ABUSE amp DEPENDENCE
389 397 496 933
03157 04547 07887 16112
10000 10000 10000 10000
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
10000 10000 10000 10000
03157 04547 07887 16112
$2368 Other $3410 Other $5915 Other
$12084 Other
Other Other Other Other
791-1 791-2 791-3 791-4
OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT
314 515 989
2009
08636 12677 21979 49312
10000 10000 10000 10000
10000 10000 10000 10000
08636 12677 21979 49312
12500 12500 12500 12500
10795 15846 27474 61640
10000 10000 10000 10000
08636 12677 21979 49312
$8096 Misc Pediatric $11885 Misc Pediatric $20605 Misc Pediatric $46230 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
811-1 811-2 811-3 811-4
ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS ALLERGIC REACTIONS
151 202 390 913
02707 03855 08277 22176
10000 10000 10000 10000
10000 10000 10000 10000
02707 03855 08277 22176
12500 12500 12500 12500
03384 04819 10346 27720
10000 10000 10000 10000
02707 03855 08277 22176
$2538 Misc Pediatric $3614 Misc Pediatric $7760 Misc Pediatric
$20790 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
812-1 812-2 812-3 812-4
POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS POISONING OF MEDICINAL AGENTS
165 225 347 694
03469 04331 07709 17419
10000 10000 10000 10000
10000 10000 10000 10000
03469 04331 07709 17419
12500 12500 12500 12500
04336 05414 09636 21774
10000 10000 10000 10000
03469 04331 07709 17419
$3252 Misc Pediatric $4060 Misc Pediatric $7227 Misc Pediatric
$16330 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
813-1 813-2 813-3 813-4
OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT OTHER COMPLICATIONS OF TREATMENT
261 344 594
1344
04393 06056 09631 19960
10000 10000 10000 10000
10000 10000 10000 10000
04393 06056 09631 19960
12500 12500 12500 12500
05491 07570 12039 24950
10000 10000 10000 10000
04393 06056 09631 19960
$4118 Misc Pediatric $5678 Misc Pediatric $9029 Misc Pediatric
$18713 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
815-1 815-2 815-3 815-4
OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES
169 276 456 880
04211 05012 08129 22715
10000 10000 10000 10000
10000 10000 10000 10000
04211 05012 08129 22715
12500 12500 12500 12500
05264 06265 10161 28394
10000 10000 10000 10000
04211 05012 08129 22715
$3948 Misc Pediatric $4699 Misc Pediatric $7621 Misc Pediatric
$21295 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
816-1 816-2 816-3 816-4
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES
173 240 346 736
04162 04915 07864 18134
10000 10000 10000 10000
10000 10000 10000 10000
04162 04915 07864 18134
12500 12500 12500 12500
05203 06144 09830 22668
10000 10000 10000 10000
04162 04915 07864 18134
$3902 Misc Pediatric $4608 Misc Pediatric $7373 Misc Pediatric
$17001 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
841-1 841-2 841-3 841-4
EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT
2200 967
2599 4068
31148 34263 64068
159153
10000 10000 10000 10000
10000 10000 10000 10000
31148 34263 64068
159153
12500 12500 12500 12500
38935 42829 80085
198941
10000 10000 10000 10000
31148 34263 64068
159153
$29201 Misc Pediatric $32122 Misc Pediatric $60064 Misc Pediatric
$149206 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
842-1 842-2 842-3 842-4
FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT FULL THICKNESS BURNS W SKIN GRAFT
751 1072 1735 3010
14151 21416 38719 95054
10000 10000 10000 10000
10000 10000 10000 10000
14151 21416 38719 95054
12500 12500 12500 12500
17689 26770 48399
118818
10000 10000 10000 10000
14151 21416 38719 95054
$13267 Misc Pediatric $20078 Misc Pediatric $36299 Misc Pediatric $89113 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
843-1 843-2 843-3 843-4
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT
339 487 713
1113
04752 06661 11619 32621
10000 10000 10000 10000
10000 10000 10000 10000
04752 06661 11619 32621
12500 12500 12500 12500
05940 08326 14524 40776
10000 10000 10000 10000
04752 06661 11619 32621
$4455 Misc Pediatric $6245 Misc Pediatric
$10893 Misc Pediatric $30582 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
844-1 844-2 844-3 844-4
PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT PARTIAL THICKNESS BURNS W OR WO SKIN GRAFT
310 497 743
1781
04337 06965 12193 48021
10000 10000 10000 10000
10000 10000 10000 10000
04337 06965 12193 48021
12500 12500 12500 12500
05421 08706 15241 60026
10000 10000 10000 10000
04337 06965 12193 48021
$4066 Misc Pediatric $6530 Misc Pediatric
$11431 Misc Pediatric $45020 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
850-1 850-2 850-3 850-4
PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE
267 556
1618 3148
11757 14065 24870 46520
10000 10000 10000 10000
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
10000 10000 10000 10000
11757 14065 24870 46520
$8818 Misc Pediatric $10549 Misc Pediatric $18653 Misc Pediatric $34890 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
860-1 860-2 860-3 860-4
REHABILITATION REHABILITATION REHABILITATION REHABILITATION
932 1146 1475 1795
07227 09855 13880 17876
10000 10000 10000 10000
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
10000 10000 10000 10000
07227 09855 13880 17876
$5420 Other $7391 Other
$10410 Other $13407 Other
Other Other Other Other
861-1 861-2 861-3 861-4
SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS
253 340 497 917
02858 05247 07658 14498
10000 10000 10000 10000
10000 10000 10000 10000
02858 05247 07658 14498
12500 12500 12500 12500
03573 06559 09573 18123
10000 10000 10000 10000
02858 05247 07658 14498
$2679 Misc Pediatric $4919 Misc Pediatric $7179 Misc Pediatric
$13592 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
862-1 862-2 862-3 862-4
OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE OTHER AFTERCARE amp CONVALESCENCE
698 1122 1357 1872
02895 05851 07866 11351
10000 10000 10000 10000
10000 10000 10000 10000
02895 05851 07866 11351
12500 12500 12500 12500
03619 07314 09833 14189
10000 10000 10000 10000
02895 05851 07866 11351
$2714 Misc Pediatric $5485 Misc Pediatric $7374 Misc Pediatric
$10642 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
863-1 863-2 863-3 863-4
NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE NEONATAL AFTERCARE
853 1757 2771 4643
05959 16127 30507 61446
12500 12500 12500 12500
10000 10000 10000 10000
07449 20159 38134 76808
10000 10000 10000 10000
07449 20159 38134 76808
17500 17500 17500 17500
10428 28222 53387
107531
$5587 Neonate $15119 Neonate $28600 Neonate $57606 Neonate
Neonate Neonate Neonate Neonate
890-1 890-2 890-3 890-4
HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS
167 691 921
1514
07051 10224 14771 30014
10000 10000 10000 10000
10000 10000 10000 10000
07051 10224 14771 30014
12500 12500 12500 12500
08814 12780 18464 37518
10000 10000 10000 10000
07051 10224 14771 30014
$6610 Misc Pediatric $9585 Misc Pediatric
$13848 Misc Pediatric $28138 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
892-1 892-2 892-3 892-4
HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION HIV W MAJOR HIV RELATED CONDITION
587 488 669
1152
05647 07763 10877 19375
10000 10000 10000 10000
10000 10000 10000 10000
05647 07763 10877 19375
12500 12500 12500 12500
07059 09704 13596 24219
10000 10000 10000 10000
05647 07763 10877 19375
$5294 Misc Pediatric $7278 Misc Pediatric
$10197 Misc Pediatric $18164 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
893-1 893-2 893-3 893-4
HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS
499 496 799
1422
07762 08219 12807 24296
10000 10000 10000 10000
10000 10000 10000 10000
07762 08219 12807 24296
12500 12500 12500 12500
09703 10274 16009 30370
10000 10000 10000 10000
07762 08219 12807 24296
$7277 Misc Pediatric $7705 Misc Pediatric
$12007 Misc Pediatric $22778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
894-1 894-2 894-3 894-4
HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND
341 393 627
1121
05218 06497 09774 19428
10000 10000 10000 10000
10000 10000 10000 10000
05218 06497 09774 19428
12500 12500 12500 12500
06523 08121 12218 24285
10000 10000 10000 10000
05218 06497 09774 19428
$4892 Misc Pediatric $6091 Misc Pediatric $9163 Misc Pediatric
$18214 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
910-1 910-2 910-3 910-4
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA
1100 775
1057 1830
28786 31984 41628 72114
10000 10000 10000 10000
10000 10000 10000 10000
28786 31984 41628 72114
12500 12500 12500 12500
35983 39980 52035 90143
10000 10000 10000 10000
28786 31984 41628 72114
$26987 Misc Pediatric $29985 Misc Pediatric $39026 Misc Pediatric $67607 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
911-1 911-2 911-3 911-4
EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA
511 619 795
1687
15160 20189 26724 58039
10000 10000 10000 10000
10000 10000 10000 10000
15160 20189 26724 58039
12500 12500 12500 12500
18950 25236 33405 72549
10000 10000 10000 10000
15160 20189 26724 58039
$14213 Misc Pediatric $18927 Misc Pediatric $25054 Misc Pediatric $54412 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
912-1 912-2 912-3 912-4
MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
558 607 985
1782
20950 22759 36410 68885
10000 10000 10000 10000
10000 10000 10000 10000
20950 22759 36410 68885
12500 12500 12500 12500
26188 28449 45513 86106
10000 10000 10000 10000
20950 22759 36410 68885
$19641 Misc Pediatric $21337 Misc Pediatric $34134 Misc Pediatric $64580 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
930-1 930-2 930-3 930-4
MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE
322 370 596
1127
07826 09594 15857 33896
10000 10000 10000 10000
10000 10000 10000 10000
07826 09594 15857 33896
12500 12500 12500 12500
09783 11993 19821 42370
10000 10000 10000 10000
07826 09594 15857 33896
$7337 Misc Pediatric $8994 Misc Pediatric
$14866 Misc Pediatric $31778 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
950-1 950-2 950-3 950-4
EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
361 623
1166 2260
13230 20029 31827 60092
10000 10000 10000 10000
10000 10000 10000 10000
13230 20029 31827 60092
12500 12500 12500 12500
16538 25036 39784 75115
10000 10000 10000 10000
13230 20029 31827 60092
$12403 Misc Pediatric $18777 Misc Pediatric $29838 Misc Pediatric $56336 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
951-1 951-2 951-3 951-4
MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
329 517
1001 1973
09755 14320 24054 46875
10000 10000 10000 10000
10000 10000 10000 10000
09755 14320 24054 46875
12500 12500 12500 12500
12194 17900 30068 58594
10000 10000 10000 10000
09755 14320 24054 46875
$9145 Misc Pediatric $13425 Misc Pediatric $22551 Misc Pediatric $43945 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
952-1 952-2 952-3 952-4
NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS
274 504 968
1894
07736 11591 20369 39177
10000 10000 10000 10000
10000 10000 10000 10000
07736 11591 20369 39177
12500 12500 12500 12500
09670 14489 25461 48971
10000 10000 10000 10000
07736 11591 20369 39177
$7253 Misc Pediatric $10867 Misc Pediatric $19096 Misc Pediatric $36728 Misc Pediatric
Misc Adult Misc Adult Misc Adult Misc Adult
955-0 956-0
PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS UNGROUPABLE
--
--
Error DRG Error DRG
Error DRG Error DRG
i-
i
i
i-
i
Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy adjustor F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that has at least a basic level
emergency room H FY 2015-16 Cost-to-Charge Ratio FY 2013 cost-to-charge ratio with some exceptions I FY 2015-16 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FY 2015-16 Wage Index Value (adjusted for CA Neutrality Factor 09797) W age index value times 09797 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls for changes between California
and the rest of the US while maintaining relative differences among wage areas within California K FY 2015-16 Unadjusted Statewide Base Rate The statewide DRG base rate is $6289 except that for remote rural hospitals it is $12768 L FY 2015-16 Wage Adjusted Statewide Base Rate (Non-Transition) The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses See Tab 5 This rate is applicable for non-transition hospitals as shown in Column N Medi-Cal
managed care plans that are pricing claims for emergency and post-stabilization services hospitals outside their network should use Column L for all hospitals M FY 2015-16 Hospital-Specific Transition Base Rate The base rate assigned to hospitals to move them in steps toward the statewide base rate This rate is applicable for transition hospitals as shown in Column N FY 2015-16 is the final year of transition rates N Transition rate This column identifies whether the hospital is a non-transition hospital (base rate in Column L) or a transition hospital (base rate in Column M) O FY 2015-16 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2015-16 P FY 2015-16 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by
use of Revenue Code 190 Q FY 2015-16 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by use of
Revenue Code 199
A B C D E F G H I J K L M N O P Q
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transit on Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
OUT OF STATE No No No No No 2180 10000 10000 $6289 $6289 NA Non-Transition NA $98163 $80582 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 3572 12882 12620 $12768 $15097 $15414 Transition NA $98163 $80582 106100793 ADVENTIST MEDICAL CENTER - SELMA COMMUNITY HOSPITAL No No No Yes Yes 3572 12882 12620 $12768 $15097 $14680 Transition NA $98163 $80582 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 4360 12882 12620 $12768 $15097 $10484 Transition NA $98163 $80582 106301098 AHMC ANAHEIM REG MED CTR No No No No No 1656 12882 12620 $6289 $7436 $15144 Transition NA $98163 $80582 106010846 ALAMEDA CO MED CTR Yes No No No No 4036 16962 16618 $6289 $9186 NA NA NA NA NA 106010735 ALAMEDA HOSP No Yes No No No 2600 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106190017 ALHAMBRA HOSP No No No No No 1397 12882 12620 $6289 $7436 $5446 Transition $1220 $98163 $80582 106010739 ALTA BATES SUMMIT MED CTR-ALTA BATES No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106010937 ALTA BATES SUMMIT MED CTR-HAWTHORNE No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106010844 ALTA BATES SUMMIT MED CTR-HERRICK CAMPUS No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106013626 ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106374063 ALVARADO HOSP MED CTR - REHAB No No No No No 1930 12882 12620 $6289 $7436 $4599 Transition $1220 $98163 $80582 106190034 ANTELOPE VALLEY HOSP MED CTR No Yes No No No 2997 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364231 ARROWHEAD REG MED CTR Yes No No No No 3324 12882 12620 $6289 $7436 NA NA NA NA NA 106400466 ARROYO GRANDE COMM HOSP No No No No No 2581 12964 12701 $6289 $7471 NA Non-Transition $1226 $98163 $80582 106154101 BAKERSFIELD HEART HOSP No No No No No 1782 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150722 BAKERSFIELD MEM HOSP-34TH ST No No No No No 2117 12882 12620 $6289 $7436 $9141 Transition NA $98163 $80582 106364121 BALLARD REHABILITATION HOSP No No No No No 8300 12882 12620 NA NA NA NA $1427 $98163 $80582 106184008 BANNER LASSEN MED CTR No No No Yes Yes 3967 12882 12620 $12768 $15097 $18668 Transition NA $98163 $80582 106190052 BARLOW RESP HOSP No No No No No 1849 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364430 BARSTOW COMM HOSP No No No Yes Yes 2262 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090793 BARTON MEM HOSP No No No Yes Yes 3635 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106361110 BEAR VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190081 BEVERLY HOSP No No No No No 3567 12882 12620 $6289 $7436 $5841 Transition NA $98163 $80582 106040802 BIGGS GRIDLEY MEM HOSP No No No Yes Yes 3652 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106380929 CA PACIFIC MED CTR No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380777 CA PACIFIC MED CTR - CALIFORNIA WEST No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380933 CA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 2873 16738 16398 $6289 $9090 NA Non-Transition $1492 $98163 $80582 106190125 CALIFORNIA HOSP MED CTR-LA No No Yes No No 2078 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190137 CASA COLINA HOSP FOR REHAB MED No No No No No 7213 12882 12620 NA NA NA NA $1220 $98163 $80582 106190045 CATALINA ISLAND MED CTR No No No Yes Yes 9000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190555 CEDARS-SINAI MED CTR No No Yes No No 2051 12882 12620 $6289 $7436 $5837 Transition $1220 $98163 $80582 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 1730 12882 12620 $6289 $7436 $6350 Transition $1220 $98163 $80582 106160787 CENTRAL VALLEY GEN HOSP No No No No No 7778 12882 12620 $6289 $7436 $11888 Transition NA $98163 $80582 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 2190 12892 12630 $6289 $7440 NA Non-Transition $1221 $98163 $80582 106301140 CHAPMAN MED CTR No No No No No 1908 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304113 CHILDRENS HOSP AT MISSION No No No No No 3300 12882 12620 $6289 $7436 $18777 Transition NA $98163 $80582 106204019 CHILDRENS HOSP CENTRAL CALIFORNIA No No Yes No No 2430 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106010776 CHILDRENS HOSP OAKLAND No No Yes No No 3356 16478 16143 $6289 $8978 NA Non-Transition $2628 $98163 $80582 106190170 CHILDRENS HOSP OF LA No No Yes No No 3988 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106300032 CHILDRENS HOSP OF ORANGE CO No No Yes No No 2442 12882 12620 $6289 $7436 $5613 Transition NA $98163 $80582 106382715 CHINESE HOSP No No No No No 3835 16738 16398 $6289 $9090 $8053 Transition NA $98163 $80582 106361144 CHINO VALLEY MED CTR No No No No No 2098 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190176 CITY OF HOPE HELFORD CLINIC RES HOSP No No No No No 2789 12882 12620 $6289 $7436 $5941 Transition NA $98163 $80582 106100005 CLOVIS COMM MED CTR No No No No No 3336 12882 12620 $6289 $7436 $7752 Transition NA $98163 $80582 106100697 COALINGA REG MED CTR No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190766 COAST PLAZA DRS HOSP No No No No No 2126 12882 12620 $6289 $7436 $5303 Transition NA $98163 $80582 106301258 COASTAL COMM HOSP No No No No No 2792 12882 12620 $6289 $7436 $7035 Transition NA $98163 $80496 106301155 COLLEGE HOSP COSTA MESA No No No No No 2876 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190587 COLLEGE MEDICAL CENTER No No No No No 3760 12882 12620 $6289 $7436 $4258 Transition NA $98163 $80582 106361458 COLORADO RIVER MED CTR No No No Yes Yes 4357 12882 12620 $12768 $15097 $18541 Transition NA $98163 $80582 106060870 COLUSA REG MED CTR No No No Yes Yes 3066 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190197 COMM AND MISSION HOSP OF HUNT PK No No No No No 1601 12882 12620 $6289 $7436 $5421 Transition NA $98163 $80582 106190475 COMM HOSP OF LONG BEACH No No No No No 1707 12882 12620 $6289 $7436 $15917 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106361323 COMM HOSP OF SAN BERNARDINO No No No No No 2833 12882 12620 $6289 $7436 $6516 Transition NA $98163 $78406 106560473 COMM MEM HOSP OF SAN BUENAVENTURA No No No No No 2104 12882 12620 $6289 $7436 $4512 Transition NA $98163 $80582 106100717 COMM REG MED CTR-FRESNO No No No No No 1896 12882 12620 $6289 $7436 $7994 Transition $1655 $98163 $80582 106070924 CONTRA COSTA REG MED CTR Yes No No No No 6010 16478 16143 $6289 $8978 NA NA NA NA NA 106331152 CORONA REG MED CTR No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition NA $98163 $80582 106331145 CORONA REG MED CTR - MAGNOLIA No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition $1220 $98163 $80582 106190413 CV-INTERCOMMUNITY CAMPUS No No No No No 3136 12882 12620 $6289 $7436 $6821 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106190636 CV-QUEEN OF VALLEY CAMPUS No No Yes No No 3136 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106150706 DELANO REG MED CTR No No No No No 3622 12882 12620 $6289 $7436 $7087 Transition NA $98163 $80582 106331164 DESERT REG MED CTR No No No No No 1486 12882 12620 $6289 $7436 $7153 Transition $1447 $98163 $80582 106364144 DESERT VALLEY HOSP No No No No No 2050 12882 12620 $6289 $7436 $8173 Transition NA $98163 $80582 106440755 DOMINICAN HOSP-SANTA CRUZ No No No No No 2016 17239 16889 $6289 $9304 $7821 Transition $1527 $98163 $80582 106190243 DOWNEY REG MED CTR No No No No No 1732 12882 12620 $6289 $7436 $6847 Transition NA $98163 $80582 106392287 DRS HOSP OF MANTECA No No No No No 1362 13579 13303 $6289 $7735 $11712 Transition NA $98163 $80582 106390846 DAMERON HOSP No No No No No 2138 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106190857 DRS HOSP OF WEST COVINA No No No No No 1833 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106070904 DRS MED CTR-SAN PABLOPINOLE No Yes No No No 2373 16478 16143 $6289 $8978 $6025 Transition NA $98163 $80582 106190256 EAST LA DRS HOSP No No No No No 1952 12882 12620 $6289 $7436 $5809 Transition NA $98163 $80582 106190328 EAST VALLEY HOSP MED CTR No No No No No 2859 12882 12620 $6289 $7436 $5534 Transition NA $98163 $80582 106320859 EASTERN PLUMAS HOSP No Yes No Yes Yes 4802 12882 12620 $12768 $15097 $13674 Transition NA $98163 $80582 106014233 EDEN MED CTR No No No No No 3197 16962 16618 $6289 $9186 $12768 Transition NA $98163 $80582 106331168 EISENHOWER MEM HOSP No No No No No 1540 12882 12620 $6289 $7436 $10211 Transition NA $98163 $80582 106430763 EL CAMINO HOSP No Yes No No No 2857 17180 16831 $6289 $9279 $5377 Transition $1523 $98163 $80582 106130699 EL CENTRO COMM HOSP No Yes No No No 2298 12882 12620 $6289 $7436 $8949 Transition NA $98163 $80582 106500852 DRS MED CTR No No No No No 1181 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106500867 EMANUEL MED CTR No No No No No 2046 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106040962 ENLOE MED CTR No No No No No 2436 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106044011 ENLOE REHABILLITATION CENTER No No No No No 2463 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106474007 FAIRCHILD MED CTR No No No Yes Yes 3914 12882 12620 $12768 $15097 $16385 Transition NA $98163 $80582 106040875 FEATHER RIVER HOSP No No No No No 1240 12882 12620 $6289 $7436 $10796 Transition NA $98163 $80582 106190298 FOOTHILL PRES HOSP No No No No No 2989 12882 12620 $6289 $7436 $4740 Transition NA $98163 $80582 106301175 FOUNTAIN VALLEY REG HOSP-EUCLID No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106304039 FOUNTAIN VALLEY REG HOSP-WARNER No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106230949 FRANK R HOWARD MEM HOSP No No No Yes Yes 3495 12882 12620 $12768 $15097 $15377 Transition NA $98163 $80582 106510882 FREMONT MEDICAL CENTER No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106190280 ENCINO HOSP MED CTR No No No No No 949 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106400480 FRENCH HOSP MED CTR No No No No No 2241 12964 12701 $6289 $7471 NA Non-Transition NA $98163 $80582 106301283 GARDEN GROVE HOSP AND MED CTR No No No No No 2661 12882 12620 $6289 $7436 $5749 Transition NA $98163 $80582 106190159 GARDEN REG HOSP AND MED CTR No No No No No 2937 12882 12620 $6289 $7436 $4110 Transition NA $98163 $80582 106105029 FRESNO HEART HOSP No No No No No 3403 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106270777 GEORGE L MEE MEM HOSP No No No Yes Yes 3562 15558 15242 $12768 $17426 $20386 Transition NA $98163 $80582 106190315 GARFIELD MED CTR No No No No No 1031 12882 12620 $6289 $7436 NA Non-Transition $1394 $98163 $80582 106190522 GLENDALE MEM HOSP AND HLTH CTR No No No No No 2163 12882 12620 $6289 $7436 $6885 Transition $1220 $98163 $80582 106110889 GLENN MED CTR No No No Yes Yes 6660 12882 12620 $12768 $15097 $21024 Transition NA $98163 $80582 106190323 GLENDALE ADV MED CTR-WILSON TERRACE No No No No No 1845 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420483 GOLETA VALLEY COTTAGE HOSP No No No No No 3083 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150775 GOOD SAMARITAN HOSP-BAKERSFIELD No No No No No 3694 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430779 GOOD SAMARITAN HOSP-SAN JOSE No No Yes No No 1937 17180 16831 $6289 $9279 $5654 Transition NA $98163 $80582 106190352 GREATER EL MONTE COMM HOSP No No No No No 1088 12882 12620 $6289 $7436 $4818 Transition NA $98163 $80582 106370714 GROSSMONT HOSP No No No No No 1937 12882 12620 $6289 $7436 $6498 Transition $1220 $98163 $80582
i-
i
i
i-
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190392 GOOD SAMARITAN HOSP-LA No No Yes No No 2006 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106350784 HAZEL HAWKINS MEM HOSP No Yes No Yes Yes 3840 17180 16831 $12768 $18839 NA Non-Transition NA $98163 $80582 106490964 HEALDSBURG DIST HOSP No Yes No Yes Yes 6549 16188 15859 $12768 $17975 NA Non-Transition NA $98163 $80582 106154022 HEALTHSOUTH BAKERSFIELD REHAB HOSP No No No No No 5040 12882 12620 NA NA NA NA $1382 $98163 $80582 106304079 HEALTHSOUTH TUSTIN REHAB HOSP No No No No No 5281 12882 12620 NA NA NA NA $1220 $98163 $80582 106331194 HEMET VALLEY MED CTR No No No No No 1267 12882 12620 $6289 $7436 $5912 Transition NA $98163 $80582 106190949 HENRY MAYO NEWHALL MEM HOSP No No No No No 1839 12882 12620 $6289 $7436 $5631 Transition $1220 $98163 $80582 106362041 HI-DESERT MED CTR No Yes No Yes Yes 2909 12882 12620 $12768 $15097 $13297 Transition NA $98163 $80582 106301205 HOAG MEM HOSP PRESBYTERIAN No No No No No 4825 12882 12620 $6289 $7436 $13525 Transition NA $98163 $80582 106304159 HEALTHBRIDGE CHILDRENS HOSP-ORANGE No No No No No 3271 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106190380 HOLLYWOOD COMM HOSP OF HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106304460 HOAG ORTHOPEDIC No No No No No 4894 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190382 HOLLYWOOD PRES MED CTR No No No No No 2212 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301209 HUNTINGTON BEACH HOSP No No No No No 2175 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190400 HUNTINGTON MEM HOSP No No Yes No No 2294 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106304045 IRVINE REG HOSP AND MED CTR No No No No No 200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106220733 JOHN C FREMONT HCARE DIST No Yes No Yes Yes 3884 12882 12620 $12768 $15097 $8195 Transition NA $98163 $80582 106331216 JOHN F KENNEDY MEM HOSP No No No No No 1679 12882 12620 $6289 $7436 $6464 Transition NA $98163 $80582 106071018 JOHN MUIR MED CTR-CONCORD CAMPUS No No No No No 1748 16478 16143 $6289 $8978 $12804 Transition NA $98163 $80582 106070988 JOHN MUIR MED CTR-WALNUT CREEK CAMPUS No No No No No 2039 16478 16143 $6289 $8978 $10615 Transition $1473 $98163 $80582 106314024 KAISER HOSPITAL - ROSEVILLE No No Yes No No 7912 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106364265 KAISER ONTARIO MEDICAL CENTER CAMPUS No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106121031 JEROLD PHELPS COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301132 KAISER-ANAHEIM No No Yes No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304306 KAISER-ANAHEIM-IRVINE No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304409 KAISER-ANAHEIM-Orange No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106074097 KAISER-ANTIOCH No No No No No 8503 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106196403 KAISER-DOWNEY No No No No No 10000 12882 12620 $6289 $7436 $12698 Transition NA $98163 $80582 106361223 KAISER-FONTANA No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106014132 KAISER-FREMONT No No No No No 10000 16962 16618 $6289 $9186 $9639 Transition NA $98163 $80582 106196035 KAISER-BALDWIN PARK No No No No No 8009 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106104062 KAISER-FRESNO No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190429 KAISER-LOS ANGELES No No No No No 7387 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106394009 KAISER-MANTECA No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106334048 KAISER-MORENO VALLEY No No No No No 6614 12882 12620 $6289 $7436 $4790 Transition NA $98163 $80582 106010856 KAISER-OAKLANDRICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106190432 KAISER-PANORAMA CITY No No No No No 8239 12882 12620 $6289 $7436 $16025 Transition NA $98163 $80582 106504042 KAISER-MODESTO No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106410804 KAISER-REDWOOD CITY No No No No No 7731 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106074093 KAISER-RICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106480989 KAISER-REHAB CENTER VALLEJO No No No No No 8442 16315 15984 $6289 $8908 NA Non-Transition $2535 $98163 $80582 106340913 KAISER-SACRAMENTO No No No No No 5612 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106334025 KAISER-RIVERSIDE No No No No No 5865 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370730 KAISER-SAN DIEGO No No No No No 7393 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106380857 KAISER-SAN FRANCISCO No No No No No 5960 16738 16398 $6289 $9090 NA Non-Transition NA $98163 $80582 106431506 KAISER-SAN JOSE No No No No No 7002 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106014337 KAISER-SAN LEANDRO No No No No No 2180 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106210992 KAISER-SAN RAFAEL No No No No No 4673 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106494019 KAISER-SANTA ROSA No No No No No 10000 16315 15984 $6289 $8908 $17627 Transition NA $98163 $80582 106434153 KAISER-SANTA CLARA No No No No No 6107 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106190431 KAISER-SOUTH BAY No No No No No 6935 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106342344 KAISER-SOUTH SACRAMENTO No No No No No 5670 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106410806 KAISER-SOUTH SF No No No No No 6503 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106484044 KAISER-VACAVILLE No No No No No 10000 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106070990 KAISER-WALNUT CREEK No No No No No 5680 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106190434 KAISER-WEST LA No No No No No 6623 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106194219 KECK HOSPITAL OF USC No No No No No 2004 12882 12620 $6289 $7436 $4699 Transition $1220 $98163 $80582 106210993 KENTFIELD REHAB HOSP No No No No No 5967 16855 16513 $6289 $9140 $19338 Transition $1500 $98163 $80582 106150736 KERN MED CTR Yes No No No No 3943 12882 12620 $6289 $7436 NA NA NA NA NA 106150737 KERN VALLEY HEALTHCARE DIST No Yes No Yes Yes 2786 12882 12620 $12768 $15097 $8298 Transition NA $98163 $80582 106191450 KAISER-WOODLAND HILLS No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190049 KINDRED HOSPITAL BALDWIN PARK No No No No No 1810 12882 12620 $6289 $7436 $10784 Transition NA $98163 $80582 106190305 KINDRED LA No No No No No 2044 12882 12620 $6289 $7436 $4255 Transition NA $98163 $80582 106301127 KINDRED BREA No No No No No 2852 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361274 KINDRED ONTARIO No No No No No 2068 12882 12620 $6289 $7436 $9314 Transition NA $98163 $80582 106364188 KINDRED RANCHO No No No No No 1980 12882 12620 $6289 $7436 $20628 Transition NA $98163 $80582 106332172 KINDRED RIVERSIDE No No No No No 1805 12882 12620 $6289 $7436 $24450 Transition NA $98163 $80582 106190449 KINDRED LA MIRADA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106370721 KINDRED SAN DIEGO No No No No No 3605 12882 12620 $6289 $7436 $5657 Transition NA $98163 $80582 106344035 KINDRED SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190458 KINDRED SAN GABRIEL VALLEY No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106010887 KINDRED SF BAY AREA No No No No No 3007 16478 16143 $6289 $8978 $6378 Transition NA $98163 $80582 106301167 KINDRED SANTA ANA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190196 KINDRED SOUTH BAY No No No No No 2144 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301380 KINDRED WESTMINSTER No No No No No 2286 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301234 LA PALMA INTERCOMMUNITY HOSP No No No No No 2290 12882 12620 $6289 $7436 $7160 Transition NA $98163 $80582 106191227 LAC-HARBOR-UCLA MED CTR Yes No Yes No No 3366 12882 12620 $6289 $7436 NA NA NA NA NA 106191231 LAC-OLIVE VIEW-UCLA MED CTR Yes No No No No 4136 12882 12620 $6289 $7436 NA NA NA NA NA 106191228 LAC-USC MED CTR Yes No Yes No No 4522 12882 12620 $6289 $7436 NA NA NA NA NA 106380865 LAGUNA HONDA HOSP AND REHAB CTR Yes No No No No 5843 16738 16398 $6289 $9090 NA NA NA NA NA 106190240 LAKEWOOD REG MED CTR No No No No No 1504 12882 12620 $6289 $7436 $4008 Transition $1220 $98163 $80582 106390923 LODI MEM HOSP No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106390922 LODI MEM HOSP - WEST No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106334589 LOMA LINDA MURRIETTA No No No No No 3222 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106364268 LOMA LINDA UNIV HEART AND SURGICAL HOSPITAL No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361245 LOMA LINDA UNIV MED CTR - EAST CAMPUS No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361246 LOMA LINDA UNIV MED CTR No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $1491 $98163 $80582 106364502 LOMA LINDA UNIV CHILDRENS HOSP No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $2177 $98163 $80582 106190198 LA COMM HOSP No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420491 LOMPOC VALLEY MED CTR No Yes No Yes Yes 8693 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301248 LOS ALAMITOS MED CTR No No No No No 1915 12882 12620 $6289 $7436 $4697 Transition NA $98163 $80582 106560492 LOS ROBLES HOSP AND MED CTR No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106564018 LOS ROBLES HOSP AND MED CTR-EAST CAMPUS No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106434040 LSP CHILDRENS HOSP AT STANFORD No No Yes No No 2035 17180 16831 $6289 $9279 $6102 Transition NA $98163 $80582 106121002 MAD RIVER COMM HOSP No No No No No 4250 12882 12620 $6289 $7436 $9505 Transition NA $98163 $80582 106201281 MADERA COMMUNITY HOSPITAL No No No No No 5100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106260011 MAMMOTH HOSP No Yes No Yes Yes 7982 12882 12620 $12768 $15097 $46994 Transition NA $98163 $80582 106420493 MARIAN MED CTR No No No No No 2741 12882 12620 $6289 $7436 $9386 Transition NA $98163 $80582 106190525 LONG BEACH MEM MED CTR No No No No No 1996 12882 12620 $6289 $7436 NA Non-Transition $1627 $98163 $80582 106211006 MARIN GEN HOSP No Yes No No No 2571 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106190500 MARINA DEL RAY HOSPITAL No No No No No 2034 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106050932 MARK TWAIN ST JOSEPHS HOSP No No No Yes Yes 3707 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090933 MARSHALL MED CTR No No No Yes Yes 2107 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106500939 MEM HOSP MED CTR-MODESTO No No No No No 2235 12892 12630 $6289 $7440 $5898 Transition NA $98163 $80582 106240924 MEMORIAL HOSP LOS BANOS No No No Yes Yes 3362 12882 12620 $12768 $15097 $17450 Transition NA $98163 $80582 106190521 MEMORIAL HOSP OF GARDENA No No No No No 1747 12882 12620 $6289 $7436 $4611 Transition NA $98163 $80582 106231013 MENDOCINO COAST DIST HOSP No Yes No Yes Yes 5070 12882 12620 $12768 $15097 $15935 Transition NA $98163 $80582 106334018 MENIFEE VALLEY MED CTR No No No No No 1458 12882 12620 $6289 $7436 $5113 Transition NA $98163 $80582 106450936 MAYERS MEM HOSP No Yes No Yes Yes 7192 14188 13900 $12768 $16234 NA Non-Transition NA $98163 $80582 106340947 MERCY GEN HOSP No No No No No 2185 15256 14946 $6289 $8454 $6027 Transition $1387 $98163 $80582 106344029 MERCY HOSP OF FOLSOM No No No No No 2746 15256 14946 $6289 $8454 $5260 Transition NA $98163 $80582 106150761 MERCY HOSP-BAKERSFIELD No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106414018 MENLO PARK SURGICAL HOSP No No No No No 2770 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106240942 MERCY MED CTR MERCED No No No No No 2289 13279 13009 $6289 $7606 NA Non-Transition NA $98163 $80582 106450949 MERCY MED CTR-REDDING No No No No No 2589 14188 13900 $6289 $7996 $10219 Transition NA $98163 $80582 106470871 MERCY MED CTR-MT SHASTA No No No Yes Yes 6242 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106340950 MERCY SAN JUAN HOSP No No No No No 2166 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190529 METHODIST HOSP OF SO CAL No No No No No 1842 12882 12620 $6289 $7436 $6690 Transition $1220 $98163 $80582 106196168 MILLER CHILDRENS HOSP No No Yes No No 2680 12882 12620 $6289 $7436 $8155 Transition NA $98163 $80582 106410742 MILLS HEALTH CENTER No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106410852 MILLS-PENINSULA No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106340951 METHODIST HOSP OF SACRAMENTO No No No No No 2028 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190524 MISSION COMM HOSP-PANORAMA CAMPUS No No No No No 3568 12882 12620 $6289 $7436 $3982 Transition NA $98163 $80582 106190681 MIRACLE MILE No No No No No 100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301262 MISSION HOSP REG MED CTR No No No No No 4091 12882 12620 $6289 $7436 $14336 Transition $1220 $98163 $80582 106250956 MODOC MED CTR No Yes No Yes Yes 4961 12882 12620 $12768 $15097 $13486 Transition NA $98163 $80582 106301337 MISSION HOSP LAGUNA BEACH No No No No No 4091 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106361166 MONTCLAIR HOSP MED CTR No No No No No 3149 12882 12620 $6289 $7436 $5904 Transition NA $98163 $80582 106190547 MONTEREY PARK HOSP No No No No No 1034 12882 12620 $6289 $7436 $5866 Transition NA $98163 $80582 106361266 MOUNTAINS COMM HOSP No Yes No Yes Yes 5148 12882 12620 $12768 $15097 $15642 Transition NA $98163 $80582 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106481357 NORTH BAY MEDICAL CENTER No No No No No 1972 16315 15984 $6289 $8908 $15945 Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190541 MONROVIA MEM HOSP No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106141273 NORTHERN INYO HOSP No Yes No Yes Yes 8150 12882 12620 $12768 $15097 $27752 Transition NA $98163 $80582 106484001 NORTH BAY VACAVALLEY HOSP No No No No No 1972 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106190568 NORTHRIDGE HOSP MED CTR No No No No No 1596 12882 12620 $6289 $7436 NA Non-Transition $1662 $98163 $80582 106214034 NOVATO COMM HOSP No No No No No 3465 16855 16513 $6289 $9140 $6359 Transition NA $98163 $80582 106500967 OAK VALLEY DIST HOSP No Yes No Yes No 3340 12892 12630 $6289 $7440 $5201 Transition NA $98163 $80582 106430837 OCONNOR HOSP-SAN JOSE No No No No No 2409 17180 16831 $6289 $9279 $5201 Transition NA $98163 $80582 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190534 OLYMPIA MED CTR No No No No No 1260 12882 12620 $6289 $7436 $6786 Transition NA $98163 $80582 106300225 ORANGE COAST MEM MED CTR No No No No No 2293 12882 12620 $6289 $7436 $19985 Transition NA $98163 $80582 106040937 OROVILLE HOSP No No No No No 1803 12882 12620 $6289 $7436 $6229 Transition NA $98163 $80582 106560501 OJAI VALLEY COMM HOSP No No No Yes Yes 2745 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190696 PACIFICA HOSP OF THE VALLEY No No No No No 3338 12882 12620 $6289 $7436 $5616 Transition NA $98163 $80582 106491338 PALM DRIVE HOSP No Yes No Yes No 4315 16315 15984 $6289 $8908 $11457 Transition NA $98163 $80582 106196405 PALMDALE REGIONAL MEDICAL CTR No No No No No 1190 12882 12620 $6289 $7436 $7504 Transition $1220 $98163 $80582 106331288 PALO VERDE HOSP No Yes No Yes Yes 4770 12882 12620 $12768 $15097 $18188 Transition NA $98163 $80582 106370755 PALOMAR MED CTR No Yes No No No 2429 12882 12620 $6289 $7436 $7051 Transition $1220 $98163 $80582 106370759 PARADISE VALLEY HOSP No No No No No 2188 12882 12620 $6289 $7436 $4275 Transition $1220 $98163 $80582 106190307 PACIFIC ALLIANCE MED CTR No No No No No 4299 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106331293 PARKVIEW COMM HOSP MED CTR No No No No No 2757 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106491001 PETALUMA VALLEY HOSP No No No No No 2271 16315 15984 $6289 $8908 $13491 Transition NA $98163 $80582 106130760 PIONEERS MEM HOSP No Yes No Yes No 2989 12882 12620 $6289 $7436 $9825 Transition NA $98163 $80582 106454013 PATIENTS HOSP OF REDDING No No No No No 2172 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106301297 PLACENTIA LINDA HOSP No No No No No 1606 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370977 POMERADO HOSP No Yes No No No 3063 12882 12620 $6289 $7436 $6818 Transition NA $98163 $80582 106320986 PLUMAS DIST HOSP No Yes No Yes Yes 8666 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190631 PRESBYTERIAN INTERCOMM HOSP No No No No No 961 12882 12620 $6289 $7436 $9720 Transition $1220 $98163 $80582 106190630 POMONA VALLEY HOSP MED CTR No No Yes No No 1538 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190468 PROMISE HOSP OF EAST LA-EAST LA No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190599 PROMISE HOSP OF EAST LA-EAST LA-SUBURBAN CAMPUS No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190385 PROVIDENCE HOLY CROSS MED CTR No No No No No 1325 12882 12620 $6289 $7436 $6284 Transition $1220 $98163 $80582 106190680 PROVIDENCE LITTLE CO OF MARY-SAN PEDRO No No No No No 1533 12882 12620 $6289 $7436 $6225 Transition $1220 $98163 $80582 106190470 PROVIDENCE LITTLE CO OF MARY-TORRANCE No No No No No 1767 12882 12620 $6289 $7436 $7182 Transition NA $98163 $80582 106190758 PROVIDENCE ST JOSEPH MED CTR No No No No No 1866 12882 12620 $6289 $7436 $7141 Transition $1220 $98163 $80582 106370787 PROMISE HOSP OF SAN DIEGO No No No No No 3660 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106281047 QUEEN OF THE VALLEY HOSP-NAPA No No No No No 2829 16188 15859 $6289 $8854 $17592 Transition $1453 $98163 $80582 106370673 RADY CHILDRENS HOSPITAL - SAN DIEGO No No Yes No No 2854 12882 12620 $6289 $7436 $6395 Transition $2177 $98163 $80582 106190517 PROVIDENCE TARZANA MED CTR No No Yes No No 1536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361308 REDLANDS COMM HOSP No No No No No 2079 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430705 REG MED CTR OF SAN JOSE No No No No No 2529 17180 16831 $6289 $9279 $13299 Transition NA $98163 $80582 106580996 RIDEOUT MEM HOSP No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106121051 REDWOOD MEM HOSP No No No Yes Yes 3214 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106334487 RIVERSIDE CO REG MED CTR Yes No No No No 2987 12882 12620 $6289 $7436 NA NA NA NA NA 106331312 RIVERSIDE COMM HOSP No No No No No 1560 12882 12620 $6289 $7436 $5990 Transition NA $98163 $80582 106190796 RONALD REAGAN UCLA MED CTR Yes No Yes No No 3382 12882 12620 $6289 $7436 NA NA NA NA NA 106301317 SADDLEBACK MEM MED CTR No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106301325 SADDLEBACK MEM MED CTR-SAN CLEMENTE No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106150782 RIDGECREST REG HOSP No No No Yes Yes 4178 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106361318 SAN ANTONIO COMM HOSP No No No No No 2262 12882 12620 $6289 $7436 $9216 Transition NA $98163 $80582 106190673 SAN DIMAS COMM HOSP No No No No No 2465 12882 12620 $6289 $7436 $12177 Transition NA $98163 $80582 106190200 SAN GABRIEL VALLEY MED CTR No No No No No 969 12882 12620 $6289 $7436 $6918 Transition NA $98163 $80582 106270875 SALINAS VALLEY MEM HOSP No Yes No No No 3534 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106331326 SAN GORGONIO MEM HOSP No Yes No Yes Yes 3394 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391010 SAN JOAQUIN GEN HOSP Yes No No No No 1922 13579 13303 $6289 $7735 NA NA NA NA NA 106104023 SAN JOAQUIN VALLEY REHAB HOSP No No No No No 6479 12882 12620 NA NA NA NA $1413 $98163 $80582 106013619 SAN LEANDRO HOSP No Yes No No No 3482 16501 16166 $6289 $8988 $10813 Transition NA $98163 $80582 106410782 SAN MATEO MED CTR Yes No No No No 7168 16928 16584 $6289 $9171 NA NA NA NA NA 106074017 SAN RAMON REG MED CTR No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106074011 SAN RAMON REG MED CTR SOUTH BUILDING No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106420514 SANTA BARBARA COTTAGE HOSP No No Yes No No 3902 12882 12620 $6289 $7436 $10978 Transition $2125 $98163 $80582 106430883 SANTA CLARA VALLEY MED CTR Yes No Yes No No 3133 17180 16831 $6289 $9279 NA NA NA NA NA 106190687 SANTA MONICA - UCLA MEDICAL CENTER Yes No No No No 3102 12882 12620 $6289 $7436 NA NA NA NA NA 106491064 SANTA ROSA MEM HOSP-MONTGOMERY No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106490907 SANTA ROSA MEM HOSP-SOTOYOME No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106150788 SAN JOAQUIN COMM HOSP No No No No No 2544 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420522 SANTA YNEZ VALLEY COTTAGE HOSP No No No Yes Yes 7569 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106371394 SCRIPPS MEM HOSP-ENCINITAS No No No No No 2403 12882 12620 $6289 $7436 $7037 Transition $1439 $98163 $80582 106370771 SCRIPPS MEM HOSP-LA JOLLA No No No No No 2061 12882 12620 $6289 $7436 $4390 Transition NA $98163 $80582 106370744 SCRIPPS MERCY HOSP No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106370658 SCRIPPS MERCY HOSP-CHULA VISTA No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106371256 SCRIPPS GREEN HOSP No No No No No 2317 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106321016 SENECA HCARE DIST No Yes No Yes Yes 4586 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106410817 SETON MED CTR No No No No No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106410828 SETON MED CTR-COASTSIDE No No No Yes No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106380939 SF GENERAL HOSP Yes No No No No 2851 16738 16398 $6289 $9090 NA NA NA NA NA 106370875 SHARP CHULA VISTA MED CTR No No No No No 1932 12882 12620 $6289 $7436 $6485 Transition NA $98163 $80582 106410891 SEQUOIA HOSP No No No No No 1975 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106370689 SHARP CORONADO HOSP AND HCARE CTR No No No No No 2160 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $72421 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106370694 SHARP MEM HOSP No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106450940 SHASTA REG MED CTR No No No No No 1582 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106190708 SHERMAN OAKS HOSP No No No No No 1516 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190712 SHRINERS HOSPITAL- LA No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106344114 SHRINERS HOSPITAL- SACRAMENTO No No No No No 3869 15256 14946 $6289 $8454 NA Non-Transition $2475 $98163 $80582 106540798 SIERRA VIEW DIST HOSP No Yes No No No 2716 12882 12620 $6289 $7436 $8497 Transition NA $98163 $77682 106400524 SIERRA VIST REG MED CTR No No No No No 1787 12964 12701 $6289 $7471 $5495 Transition NA $98163 $80582 106190661 SILVER LAKE MED CTR No No No No No 3692 12882 12620 $6289 $7436 $5655 Transition NA $98163 $80582 106291023 SIERRA NEVADA MEM HOSP No No No Yes Yes 3427 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106491076 SONOMA VALLEY HOSP No Yes No No No 4960 16315 15984 $6289 $8908 $12733 Transition NA $98163 $80582 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 2126 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190380 SOUTHERN CA HOSP AT HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106190110 SOUTHERN CA HOSPITAL AT CULVER CITY No No No No No 1437 12882 12620 $6289 $7436 $4694 Transition $1220 $98163 $80582 106560525 SIMI VALLEY HOSP AND HCARE-SYCAMORE No No No No No 3840 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106334068 SOUTHWEST HCARE SYSTEM No No No No No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106334001 SOUTHWEST HCARE SYSTEM-WILDOMAR No No No Yes No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106100899 ST AGNES MED CTR No No No No No 3088 12882 12620 $6289 $7436 $7885 Transition NA $98163 $80582 106361339 ST BERNARDINE MED CTR No No No No No 2171 12882 12620 $6289 $7436 $6090 Transition NA $98163 $80582 106521041 ST ELIZABETH COMM HOSP No No No Yes Yes 3024 13869 13587 $12768 $15956 $14866 Transition NA $98163 $80582 106190754 ST FRANCIS MED CTR No No No No No 4350 12882 12620 $6289 $7436 $6368 Transition NA $98163 $80582 106380960 ST FRANCIS MEM HOSP No No No No No 1920 16738 16398 $6289 $9090 $5310 Transition $1492 $98163 $80582 106281078 ST HELENA HOSP No No No No No 2337 15887 15564 $6289 $8725 $9671 Transition NA $98163 $80582 106171049 ST HELENA HOSPITAL-CLEARLAKE No No No Yes Yes 4118 12882 12620 $12768 $15097 $18218 Transition NA $98163 $80582 106141338 SOUTHERN INYO HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190756 ST JOHNS HEALTH CTR No No No No No 2536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560529 ST JOHNS REG MED CTR No No No No No 2982 12882 12620 $6289 $7436 $6976 Transition $1761 $98163 $80582 106121080 ST JOSEPH HOSP-EUREKA No No No No No 2570 13869 13587 $6289 $7859 $9661 Transition $1507 $98163 $80582 106301340 ST JOSEPH HOSP-ORANGE No No No No No 2751 12882 12620 $6289 $7436 $5230 Transition NA $98163 $80582 106560508 ST JOHNS PLEASANT VALLEY HOSP No No No No No 2087 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301342 ST JUDE MED CTR No No No No No 1722 12882 12620 $6289 $7436 $5799 Transition $1220 $98163 $80582 106434138 ST LOUISE REG HOSP No No No No No 2838 17180 16831 $6289 $9279 $16407 Transition NA $98163 $80582 106380964 ST LUKES HOSP No No No No No 3807 16738 16398 $6289 $9090 $8600 Transition NA $98163 $80582 106361343 ST MARY MED CTR-APPLE VALLEY No No No Yes No 2511 12882 12620 $6289 $7436 $9863 Transition NA $98163 $80582 106391042 ST JOSEPHS MED CTR OF STOCKTON No No No No No 2152 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106380965 ST MARYS MED CTR-SF No No No No No 2007 16738 16398 $6289 $9090 $5116 Transition $1492 $98163 $80582 106010967 ST ROSE HOSP No No No No No 1931 16962 16618 $6289 $9186 $7600 Transition NA $98163 $80582 106190762 ST VINCENT MED CTR No No No No No 2020 12882 12620 $6289 $7436 $4684 Transition $1220 $98163 $80582 106430905 STANFORD HOSP No No No No No 1803 17180 16831 $6289 $9279 $5644 Transition $1523 $98163 $80582 106190053 ST MARY MED CTR-LONG BEACH No No No No No 2479 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106504038 STANISLAUS SURGICAL HOSP No No No No No 9000 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106250955 SURPRISE VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106310791 SUTTER AUBURN FAITH HOSP No No No No No 2551 15256 14946 $6289 $8454 $11882 Transition NA $98163 $80582 106034002 SUTTER AMADOR HOSP No No No Yes Yes 2971 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106574010 SUTTER DAVIS HOSP No No No No No 3568 15256 14946 $6289 $8454 $14330 Transition NA $98163 $80582 106070934 SUTTER DELTA MED CTR No No No No No 2907 16478 16143 $6289 $8978 $12158 Transition NA $98163 $80582 106341051 SUTTER GEN HOSP No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106171395 SUTTER LAKESIDE HOSP No No No Yes Yes 3691 12882 12620 $12768 $15097 $17232 Transition NA $98163 $80582 106444012 SUTTER MATERNITY AND SRG CTR OF S CRUZ No No No No No 7213 17239 16889 $6289 $9304 $21288 Transition NA $98163 $80582 106490919 SUTTER MED CTR OF SANTA ROSA No No No No No 3657 16315 15984 $6289 $8908 $15278 Transition NA $98163 $80582 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106311000 SUTTER ROSEVILLE MED CTR No No No No No 2377 15256 14946 $6289 $8454 $11395 Transition $1387 $98163 $80582 106481094 SUTTER SOLANO MED CTR No No No No No 3258 16315 15984 $6289 $8908 $18010 Transition NA $98163 $80582 106084001 SUTTER COAST HOSP No No No Yes Yes 3730 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391056 SUTTER TRACY COMM HOSP No No No No No 2714 13579 13303 $6289 $7735 $5995 Transition NA $98163 $80582 106291053 TAHOE FOREST HOSP No Yes No Yes Yes 4766 15256 14946 $12768 $17164 $21044 Transition NA $98163 $80582 106150808 TEHACHAPI HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 $22158 Transition NA $98163 $80582 106514030 SUTTER SURG HOSP-NORTH VALLEY No No No No No 3240 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106334564 TEMECULA VALLEY HOSPITAL No No No No No 2180 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106120981 THE GENERAL HOSPITAL No No No No No 2570 13869 13587 NA NA NA NA $1507 $98163 $80582 106564121 THOUSAND OAKS SURGICAL HOSPITAL No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106190422 TORRANCE MEM MED CTR No No No No No 1952 12882 12620 $6289 $7436 $5891 Transition NA $98163 $80582 106370780 TRI-CITY MED CTR No Yes No No No 3695 12882 12620 $6289 $7436 $7706 Transition $1220 $98163 $80582 106190784 TEMPLE COMM HOSP No No No No No 4200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540816 TULARE DIST HOSP No Yes No No No 3578 12882 12620 $6289 $7436 $9529 Transition NA $98163 $80582 106531059 TRINITY HOSP No Yes No Yes Yes 5105 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106400548 TWIN CITIES COMM HOSP No No No Yes Yes 1587 12964 12701 $12768 $15168 $8160 Transition NA $98163 $80582 106341006 UC DAVIS MED CTR Yes No Yes No No 1836 15256 14946 $6289 $8454 NA NA NA NA NA 106301279 UC IRVINE MED CTR Yes No Yes No No 2072 12882 12620 $6289 $7436 NA NA NA NA NA 106370782 UCSD MED CTR Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106374141 UCSD-LA JOLLA JOHN M amp SALLY B THORNTON HOSPITAL Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106381154 UCSF MED CTR Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106380895 UCSF MED CTR AT MOUNT ZION Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106301357 TUSTIN HOSP MED CTR No No No No No 231 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106231396 UKIAH VALLEY MED CTRHOSP DR No No No Yes Yes 3643 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106014050 VALLEY CARE MEDICAL CENTER No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106010983 VALLEY MEM HOSP-LIVERMORE No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106191216 USC KENNETH NORRIS JR CANCER HOSP No No No No No 3134 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560481 VENTURA CO MED CTR Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106560521 VENTURA CO MED CTR-SANTA PAULA HOSPITAL Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106190818 VERDUGO HILLS HOSP No No No No No 3110 12882 12620 $6289 $7436 $5264 Transition NA $98163 $80582 106190812 VALLEY PRES HOSP No No No No No 3536 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 3046 14188 13900 $6289 $7996 NA Non-Transition $1312 $98163 $80582 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 3266 12882 12620 $6289 $7436 $8320 Transition NA $98163 $80582 106010987 WASHINGTON HOSP-FREMONT No Yes No No No 1941 16962 16618 $6289 $9186 $6429 Transition NA $98163 $80582 106444013 WATSONVILLE COMM HOSP No No No No No 1780 17239 16889 $6289 $9304 $13456 Transition NA $98163 $80582 106301379 WEST ANAHEIM MED CTR No No No No No 1514 12882 12620 $6289 $7436 $4707 Transition NA $98163 $80582 106190859 WEST HILLS HOSP AND MED CTR No No No No No 1933 12882 12620 $6289 $7436 $8050 Transition NA $98163 $80582 106374094 VIBRA OF SAN DIEGO No No No No No 1155 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301188 WESTERN MED CTR-ANAHEIM No No No No No 3203 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301566 WESTERN MED CTR-SANTA ANA No No No No No 2354 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190878 WHITE MEM MED CTR No No No No No 1515 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190883 WHITTIER HOSP MED CTR No No No No No 1139 12882 12620 $6289 $7436 $5922 Transition NA $98163 $80582 106571086 WOODLAND MEM HOSP No No No No No 3278 15256 14946 $6289 $8454 $10092 Transition NA $98163 $80582 6102015
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
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Hospital Characteristics Explanation of Columns A OSHPD ID Hospital number as assigned by the California Office of Statewide Health Planning and Development B Name Hospital name C DPH Designated public hospital DPHs are not paid by DRG except if a Medi-Cal managed care plan must make payment for out-of-network services D NDPH Non-designated public hospital NDPHs are paid by DRG E Designated NICU as Defined by DHCS Designated NICU hospitals are certified by the California Childrens Services program for neonatal surgery Facilities with such a designation will have a higher neonate policy adjustor F Medicare Rural Hospital (OSHPD) Rural hospital as defined by OSHPD G Remote Rural as Defined by DHCS Remote rural hospital as defined by DHCS Must qualify as an OSHPD rural hospital and be at least 15 miles in driving distance from the nearest general acute care hospital that has at least a basic level
emergency room H FY 2015-16 Cost-to-Charge Ratio FY 2013 cost-to-charge ratio with some exceptions I FY 2015-16 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FY 2015-16 Wage Index Value (adjusted for CA Neutrality Factor 09797) W age index value times 09797 Annual changes in Medicares wage index values are based on changes relative to the national average The California Neutrality Factor controls for changes between California
and the rest of the US while maintaining relative differences among wage areas within California K FY 2015-16 Unadjusted Statewide Base Rate The statewide DRG base rate is $6289 except that for remote rural hospitals it is $12768 L FY 2015-16 Wage Adjusted Statewide Base Rate (Non-Transition) The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses See Tab 5 This rate is applicable for non-transition hospitals as shown in Column N Medi-Cal
managed care plans that are pricing claims for emergency and post-stabilization services hospitals outside their network should use Column L for all hospitals M FY 2015-16 Hospital-Specific Transition Base Rate The base rate assigned to hospitals to move them in steps toward the statewide base rate This rate is applicable for transition hospitals as shown in Column N FY 2015-16 is the final year of transition rates N Transition rate This column identifies whether the hospital is a non-transition hospital (base rate in Column L) or a transition hospital (base rate in Column M) O FY 2015-16 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2015-16 P FY 2015-16 Subacute 190 Rate Subacute services for pediatric patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by
use of Revenue Code 190 Q FY 2015-16 Subacute 199 Rate Subacute services for adult patients (ie admin day Level 2) are paid separately from the DRG payment method This column shows the per diem rate for SFY 2015-16 These services are indicated by use of
Revenue Code 199
A B C D E F G H I J K L M N O P Q
OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transit on Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
OUT OF STATE No No No No No 2180 10000 10000 $6289 $6289 NA Non-Transition NA $98163 $80582 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 3572 12882 12620 $12768 $15097 $15414 Transition NA $98163 $80582 106100793 ADVENTIST MEDICAL CENTER - SELMA COMMUNITY HOSPITAL No No No Yes Yes 3572 12882 12620 $12768 $15097 $14680 Transition NA $98163 $80582 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 4360 12882 12620 $12768 $15097 $10484 Transition NA $98163 $80582 106301098 AHMC ANAHEIM REG MED CTR No No No No No 1656 12882 12620 $6289 $7436 $15144 Transition NA $98163 $80582 106010846 ALAMEDA CO MED CTR Yes No No No No 4036 16962 16618 $6289 $9186 NA NA NA NA NA 106010735 ALAMEDA HOSP No Yes No No No 2600 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106190017 ALHAMBRA HOSP No No No No No 1397 12882 12620 $6289 $7436 $5446 Transition $1220 $98163 $80582 106010739 ALTA BATES SUMMIT MED CTR-ALTA BATES No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106010937 ALTA BATES SUMMIT MED CTR-HAWTHORNE No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106010844 ALTA BATES SUMMIT MED CTR-HERRICK CAMPUS No No No No No 3555 16962 16618 $6289 $9186 $11904 Transition $1507 $98163 $80582 106013626 ALTA BATES SUMMIT MED CTR-SUMMIT CAMPUS No No No No No 2453 16962 16618 $6289 $9186 $7933 Transition NA $98163 $80582 106374063 ALVARADO HOSP MED CTR - REHAB No No No No No 1930 12882 12620 $6289 $7436 $4599 Transition $1220 $98163 $80582 106190034 ANTELOPE VALLEY HOSP MED CTR No Yes No No No 2997 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364231 ARROWHEAD REG MED CTR Yes No No No No 3324 12882 12620 $6289 $7436 NA NA NA NA NA 106400466 ARROYO GRANDE COMM HOSP No No No No No 2581 12964 12701 $6289 $7471 NA Non-Transition $1226 $98163 $80582 106154101 BAKERSFIELD HEART HOSP No No No No No 1782 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150722 BAKERSFIELD MEM HOSP-34TH ST No No No No No 2117 12882 12620 $6289 $7436 $9141 Transition NA $98163 $80582 106364121 BALLARD REHABILITATION HOSP No No No No No 8300 12882 12620 NA NA NA NA $1427 $98163 $80582 106184008 BANNER LASSEN MED CTR No No No Yes Yes 3967 12882 12620 $12768 $15097 $18668 Transition NA $98163 $80582 106190052 BARLOW RESP HOSP No No No No No 1849 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106364430 BARSTOW COMM HOSP No No No Yes Yes 2262 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090793 BARTON MEM HOSP No No No Yes Yes 3635 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106361110 BEAR VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190081 BEVERLY HOSP No No No No No 3567 12882 12620 $6289 $7436 $5841 Transition NA $98163 $80582 106040802 BIGGS GRIDLEY MEM HOSP No No No Yes Yes 3652 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106380929 CA PACIFIC MED CTR No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380777 CA PACIFIC MED CTR - CALIFORNIA WEST No No Yes No No 3150 16738 16398 $6289 $9090 $5356 Transition NA $98163 $80582 106380933 CA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 2873 16738 16398 $6289 $9090 NA Non-Transition $1492 $98163 $80582 106190125 CALIFORNIA HOSP MED CTR-LA No No Yes No No 2078 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190137 CASA COLINA HOSP FOR REHAB MED No No No No No 7213 12882 12620 NA NA NA NA $1220 $98163 $80582 106190045 CATALINA ISLAND MED CTR No No No Yes Yes 9000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190555 CEDARS-SINAI MED CTR No No Yes No No 2051 12882 12620 $6289 $7436 $5837 Transition $1220 $98163 $80582 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 1730 12882 12620 $6289 $7436 $6350 Transition $1220 $98163 $80582 106160787 CENTRAL VALLEY GEN HOSP No No No No No 7778 12882 12620 $6289 $7436 $11888 Transition NA $98163 $80582 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 2190 12892 12630 $6289 $7440 NA Non-Transition $1221 $98163 $80582 106301140 CHAPMAN MED CTR No No No No No 1908 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304113 CHILDRENS HOSP AT MISSION No No No No No 3300 12882 12620 $6289 $7436 $18777 Transition NA $98163 $80582 106204019 CHILDRENS HOSP CENTRAL CALIFORNIA No No Yes No No 2430 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106010776 CHILDRENS HOSP OAKLAND No No Yes No No 3356 16478 16143 $6289 $8978 NA Non-Transition $2628 $98163 $80582 106190170 CHILDRENS HOSP OF LA No No Yes No No 3988 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106300032 CHILDRENS HOSP OF ORANGE CO No No Yes No No 2442 12882 12620 $6289 $7436 $5613 Transition NA $98163 $80582 106382715 CHINESE HOSP No No No No No 3835 16738 16398 $6289 $9090 $8053 Transition NA $98163 $80582 106361144 CHINO VALLEY MED CTR No No No No No 2098 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190176 CITY OF HOPE HELFORD CLINIC RES HOSP No No No No No 2789 12882 12620 $6289 $7436 $5941 Transition NA $98163 $80582 106100005 CLOVIS COMM MED CTR No No No No No 3336 12882 12620 $6289 $7436 $7752 Transition NA $98163 $80582 106100697 COALINGA REG MED CTR No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190766 COAST PLAZA DRS HOSP No No No No No 2126 12882 12620 $6289 $7436 $5303 Transition NA $98163 $80582 106301258 COASTAL COMM HOSP No No No No No 2792 12882 12620 $6289 $7436 $7035 Transition NA $98163 $80496 106301155 COLLEGE HOSP COSTA MESA No No No No No 2876 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190587 COLLEGE MEDICAL CENTER No No No No No 3760 12882 12620 $6289 $7436 $4258 Transition NA $98163 $80582 106361458 COLORADO RIVER MED CTR No No No Yes Yes 4357 12882 12620 $12768 $15097 $18541 Transition NA $98163 $80582 106060870 COLUSA REG MED CTR No No No Yes Yes 3066 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190197 COMM AND MISSION HOSP OF HUNT PK No No No No No 1601 12882 12620 $6289 $7436 $5421 Transition NA $98163 $80582 106190475 COMM HOSP OF LONG BEACH No No No No No 1707 12882 12620 $6289 $7436 $15917 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106361323 COMM HOSP OF SAN BERNARDINO No No No No No 2833 12882 12620 $6289 $7436 $6516 Transition NA $98163 $78406 106560473 COMM MEM HOSP OF SAN BUENAVENTURA No No No No No 2104 12882 12620 $6289 $7436 $4512 Transition NA $98163 $80582 106100717 COMM REG MED CTR-FRESNO No No No No No 1896 12882 12620 $6289 $7436 $7994 Transition $1655 $98163 $80582 106070924 CONTRA COSTA REG MED CTR Yes No No No No 6010 16478 16143 $6289 $8978 NA NA NA NA NA 106331152 CORONA REG MED CTR No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition NA $98163 $80582 106331145 CORONA REG MED CTR - MAGNOLIA No No No No No 3186 12882 12620 $6289 $7436 $5422 Transition $1220 $98163 $80582 106190413 CV-INTERCOMMUNITY CAMPUS No No No No No 3136 12882 12620 $6289 $7436 $6821 Transition NA $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106270744 COMM HOSP OF MONTEREY PENINSULA No No No No No 2928 15558 15242 $6289 $8584 $17826 Transition $1409 $98163 $80582 106190636 CV-QUEEN OF VALLEY CAMPUS No No Yes No No 3136 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106150706 DELANO REG MED CTR No No No No No 3622 12882 12620 $6289 $7436 $7087 Transition NA $98163 $80582 106331164 DESERT REG MED CTR No No No No No 1486 12882 12620 $6289 $7436 $7153 Transition $1447 $98163 $80582 106364144 DESERT VALLEY HOSP No No No No No 2050 12882 12620 $6289 $7436 $8173 Transition NA $98163 $80582 106440755 DOMINICAN HOSP-SANTA CRUZ No No No No No 2016 17239 16889 $6289 $9304 $7821 Transition $1527 $98163 $80582 106190243 DOWNEY REG MED CTR No No No No No 1732 12882 12620 $6289 $7436 $6847 Transition NA $98163 $80582 106392287 DRS HOSP OF MANTECA No No No No No 1362 13579 13303 $6289 $7735 $11712 Transition NA $98163 $80582 106390846 DAMERON HOSP No No No No No 2138 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106190857 DRS HOSP OF WEST COVINA No No No No No 1833 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106070904 DRS MED CTR-SAN PABLOPINOLE No Yes No No No 2373 16478 16143 $6289 $8978 $6025 Transition NA $98163 $80582 106190256 EAST LA DRS HOSP No No No No No 1952 12882 12620 $6289 $7436 $5809 Transition NA $98163 $80582 106190328 EAST VALLEY HOSP MED CTR No No No No No 2859 12882 12620 $6289 $7436 $5534 Transition NA $98163 $80582 106320859 EASTERN PLUMAS HOSP No Yes No Yes Yes 4802 12882 12620 $12768 $15097 $13674 Transition NA $98163 $80582 106014233 EDEN MED CTR No No No No No 3197 16962 16618 $6289 $9186 $12768 Transition NA $98163 $80582 106331168 EISENHOWER MEM HOSP No No No No No 1540 12882 12620 $6289 $7436 $10211 Transition NA $98163 $80582 106430763 EL CAMINO HOSP No Yes No No No 2857 17180 16831 $6289 $9279 $5377 Transition $1523 $98163 $80582 106130699 EL CENTRO COMM HOSP No Yes No No No 2298 12882 12620 $6289 $7436 $8949 Transition NA $98163 $80582 106500852 DRS MED CTR No No No No No 1181 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106500867 EMANUEL MED CTR No No No No No 2046 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106040962 ENLOE MED CTR No No No No No 2436 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106044011 ENLOE REHABILLITATION CENTER No No No No No 2463 12882 12620 $6289 $7436 $10204 Transition $1389 $98163 $80582 106474007 FAIRCHILD MED CTR No No No Yes Yes 3914 12882 12620 $12768 $15097 $16385 Transition NA $98163 $80582 106040875 FEATHER RIVER HOSP No No No No No 1240 12882 12620 $6289 $7436 $10796 Transition NA $98163 $80582 106190298 FOOTHILL PRES HOSP No No No No No 2989 12882 12620 $6289 $7436 $4740 Transition NA $98163 $80582 106301175 FOUNTAIN VALLEY REG HOSP-EUCLID No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106304039 FOUNTAIN VALLEY REG HOSP-WARNER No No No No No 1990 12882 12620 $6289 $7436 $8904 Transition NA $98163 $80582 106230949 FRANK R HOWARD MEM HOSP No No No Yes Yes 3495 12882 12620 $12768 $15097 $15377 Transition NA $98163 $80582 106510882 FREMONT MEDICAL CENTER No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106190280 ENCINO HOSP MED CTR No No No No No 949 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106400480 FRENCH HOSP MED CTR No No No No No 2241 12964 12701 $6289 $7471 NA Non-Transition NA $98163 $80582 106301283 GARDEN GROVE HOSP AND MED CTR No No No No No 2661 12882 12620 $6289 $7436 $5749 Transition NA $98163 $80582 106190159 GARDEN REG HOSP AND MED CTR No No No No No 2937 12882 12620 $6289 $7436 $4110 Transition NA $98163 $80582 106105029 FRESNO HEART HOSP No No No No No 3403 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106270777 GEORGE L MEE MEM HOSP No No No Yes Yes 3562 15558 15242 $12768 $17426 $20386 Transition NA $98163 $80582 106190315 GARFIELD MED CTR No No No No No 1031 12882 12620 $6289 $7436 NA Non-Transition $1394 $98163 $80582 106190522 GLENDALE MEM HOSP AND HLTH CTR No No No No No 2163 12882 12620 $6289 $7436 $6885 Transition $1220 $98163 $80582 106110889 GLENN MED CTR No No No Yes Yes 6660 12882 12620 $12768 $15097 $21024 Transition NA $98163 $80582 106190323 GLENDALE ADV MED CTR-WILSON TERRACE No No No No No 1845 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420483 GOLETA VALLEY COTTAGE HOSP No No No No No 3083 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106150775 GOOD SAMARITAN HOSP-BAKERSFIELD No No No No No 3694 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430779 GOOD SAMARITAN HOSP-SAN JOSE No No Yes No No 1937 17180 16831 $6289 $9279 $5654 Transition NA $98163 $80582 106190352 GREATER EL MONTE COMM HOSP No No No No No 1088 12882 12620 $6289 $7436 $4818 Transition NA $98163 $80582 106370714 GROSSMONT HOSP No No No No No 1937 12882 12620 $6289 $7436 $6498 Transition $1220 $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190392 GOOD SAMARITAN HOSP-LA No No Yes No No 2006 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106350784 HAZEL HAWKINS MEM HOSP No Yes No Yes Yes 3840 17180 16831 $12768 $18839 NA Non-Transition NA $98163 $80582 106490964 HEALDSBURG DIST HOSP No Yes No Yes Yes 6549 16188 15859 $12768 $17975 NA Non-Transition NA $98163 $80582 106154022 HEALTHSOUTH BAKERSFIELD REHAB HOSP No No No No No 5040 12882 12620 NA NA NA NA $1382 $98163 $80582 106304079 HEALTHSOUTH TUSTIN REHAB HOSP No No No No No 5281 12882 12620 NA NA NA NA $1220 $98163 $80582 106331194 HEMET VALLEY MED CTR No No No No No 1267 12882 12620 $6289 $7436 $5912 Transition NA $98163 $80582 106190949 HENRY MAYO NEWHALL MEM HOSP No No No No No 1839 12882 12620 $6289 $7436 $5631 Transition $1220 $98163 $80582 106362041 HI-DESERT MED CTR No Yes No Yes Yes 2909 12882 12620 $12768 $15097 $13297 Transition NA $98163 $80582 106301205 HOAG MEM HOSP PRESBYTERIAN No No No No No 4825 12882 12620 $6289 $7436 $13525 Transition NA $98163 $80582 106304159 HEALTHBRIDGE CHILDRENS HOSP-ORANGE No No No No No 3271 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106190380 HOLLYWOOD COMM HOSP OF HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106304460 HOAG ORTHOPEDIC No No No No No 4894 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190382 HOLLYWOOD PRES MED CTR No No No No No 2212 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301209 HUNTINGTON BEACH HOSP No No No No No 2175 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190400 HUNTINGTON MEM HOSP No No Yes No No 2294 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106304045 IRVINE REG HOSP AND MED CTR No No No No No 200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106220733 JOHN C FREMONT HCARE DIST No Yes No Yes Yes 3884 12882 12620 $12768 $15097 $8195 Transition NA $98163 $80582 106331216 JOHN F KENNEDY MEM HOSP No No No No No 1679 12882 12620 $6289 $7436 $6464 Transition NA $98163 $80582 106071018 JOHN MUIR MED CTR-CONCORD CAMPUS No No No No No 1748 16478 16143 $6289 $8978 $12804 Transition NA $98163 $80582 106070988 JOHN MUIR MED CTR-WALNUT CREEK CAMPUS No No No No No 2039 16478 16143 $6289 $8978 $10615 Transition $1473 $98163 $80582 106314024 KAISER HOSPITAL - ROSEVILLE No No Yes No No 7912 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106364265 KAISER ONTARIO MEDICAL CENTER CAMPUS No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106121031 JEROLD PHELPS COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301132 KAISER-ANAHEIM No No Yes No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304306 KAISER-ANAHEIM-IRVINE No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304409 KAISER-ANAHEIM-Orange No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106074097 KAISER-ANTIOCH No No No No No 8503 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106196403 KAISER-DOWNEY No No No No No 10000 12882 12620 $6289 $7436 $12698 Transition NA $98163 $80582 106361223 KAISER-FONTANA No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106014132 KAISER-FREMONT No No No No No 10000 16962 16618 $6289 $9186 $9639 Transition NA $98163 $80582 106196035 KAISER-BALDWIN PARK No No No No No 8009 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106104062 KAISER-FRESNO No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190429 KAISER-LOS ANGELES No No No No No 7387 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106394009 KAISER-MANTECA No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106334048 KAISER-MORENO VALLEY No No No No No 6614 12882 12620 $6289 $7436 $4790 Transition NA $98163 $80582 106010856 KAISER-OAKLANDRICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106190432 KAISER-PANORAMA CITY No No No No No 8239 12882 12620 $6289 $7436 $16025 Transition NA $98163 $80582 106504042 KAISER-MODESTO No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106410804 KAISER-REDWOOD CITY No No No No No 7731 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106074093 KAISER-RICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106480989 KAISER-REHAB CENTER VALLEJO No No No No No 8442 16315 15984 $6289 $8908 NA Non-Transition $2535 $98163 $80582 106340913 KAISER-SACRAMENTO No No No No No 5612 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106334025 KAISER-RIVERSIDE No No No No No 5865 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370730 KAISER-SAN DIEGO No No No No No 7393 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106380857 KAISER-SAN FRANCISCO No No No No No 5960 16738 16398 $6289 $9090 NA Non-Transition NA $98163 $80582 106431506 KAISER-SAN JOSE No No No No No 7002 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106014337 KAISER-SAN LEANDRO No No No No No 2180 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106210992 KAISER-SAN RAFAEL No No No No No 4673 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106494019 KAISER-SANTA ROSA No No No No No 10000 16315 15984 $6289 $8908 $17627 Transition NA $98163 $80582 106434153 KAISER-SANTA CLARA No No No No No 6107 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106190431 KAISER-SOUTH BAY No No No No No 6935 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106342344 KAISER-SOUTH SACRAMENTO No No No No No 5670 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106410806 KAISER-SOUTH SF No No No No No 6503 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106484044 KAISER-VACAVILLE No No No No No 10000 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106070990 KAISER-WALNUT CREEK No No No No No 5680 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106190434 KAISER-WEST LA No No No No No 6623 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106194219 KECK HOSPITAL OF USC No No No No No 2004 12882 12620 $6289 $7436 $4699 Transition $1220 $98163 $80582 106210993 KENTFIELD REHAB HOSP No No No No No 5967 16855 16513 $6289 $9140 $19338 Transition $1500 $98163 $80582 106150736 KERN MED CTR Yes No No No No 3943 12882 12620 $6289 $7436 NA NA NA NA NA 106150737 KERN VALLEY HEALTHCARE DIST No Yes No Yes Yes 2786 12882 12620 $12768 $15097 $8298 Transition NA $98163 $80582 106191450 KAISER-WOODLAND HILLS No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190049 KINDRED HOSPITAL BALDWIN PARK No No No No No 1810 12882 12620 $6289 $7436 $10784 Transition NA $98163 $80582 106190305 KINDRED LA No No No No No 2044 12882 12620 $6289 $7436 $4255 Transition NA $98163 $80582 106301127 KINDRED BREA No No No No No 2852 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361274 KINDRED ONTARIO No No No No No 2068 12882 12620 $6289 $7436 $9314 Transition NA $98163 $80582 106364188 KINDRED RANCHO No No No No No 1980 12882 12620 $6289 $7436 $20628 Transition NA $98163 $80582 106332172 KINDRED RIVERSIDE No No No No No 1805 12882 12620 $6289 $7436 $24450 Transition NA $98163 $80582 106190449 KINDRED LA MIRADA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106370721 KINDRED SAN DIEGO No No No No No 3605 12882 12620 $6289 $7436 $5657 Transition NA $98163 $80582 106344035 KINDRED SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190458 KINDRED SAN GABRIEL VALLEY No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106010887 KINDRED SF BAY AREA No No No No No 3007 16478 16143 $6289 $8978 $6378 Transition NA $98163 $80582 106301167 KINDRED SANTA ANA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190196 KINDRED SOUTH BAY No No No No No 2144 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301380 KINDRED WESTMINSTER No No No No No 2286 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301234 LA PALMA INTERCOMMUNITY HOSP No No No No No 2290 12882 12620 $6289 $7436 $7160 Transition NA $98163 $80582 106191227 LAC-HARBOR-UCLA MED CTR Yes No Yes No No 3366 12882 12620 $6289 $7436 NA NA NA NA NA 106191231 LAC-OLIVE VIEW-UCLA MED CTR Yes No No No No 4136 12882 12620 $6289 $7436 NA NA NA NA NA 106191228 LAC-USC MED CTR Yes No Yes No No 4522 12882 12620 $6289 $7436 NA NA NA NA NA 106380865 LAGUNA HONDA HOSP AND REHAB CTR Yes No No No No 5843 16738 16398 $6289 $9090 NA NA NA NA NA 106190240 LAKEWOOD REG MED CTR No No No No No 1504 12882 12620 $6289 $7436 $4008 Transition $1220 $98163 $80582 106390923 LODI MEM HOSP No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106390922 LODI MEM HOSP - WEST No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106334589 LOMA LINDA MURRIETTA No No No No No 3222 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106364268 LOMA LINDA UNIV HEART AND SURGICAL HOSPITAL No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361245 LOMA LINDA UNIV MED CTR - EAST CAMPUS No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361246 LOMA LINDA UNIV MED CTR No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $1491 $98163 $80582 106364502 LOMA LINDA UNIV CHILDRENS HOSP No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $2177 $98163 $80582 106190198 LA COMM HOSP No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420491 LOMPOC VALLEY MED CTR No Yes No Yes Yes 8693 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301248 LOS ALAMITOS MED CTR No No No No No 1915 12882 12620 $6289 $7436 $4697 Transition NA $98163 $80582 106560492 LOS ROBLES HOSP AND MED CTR No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106564018 LOS ROBLES HOSP AND MED CTR-EAST CAMPUS No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106434040 LSP CHILDRENS HOSP AT STANFORD No No Yes No No 2035 17180 16831 $6289 $9279 $6102 Transition NA $98163 $80582 106121002 MAD RIVER COMM HOSP No No No No No 4250 12882 12620 $6289 $7436 $9505 Transition NA $98163 $80582 106201281 MADERA COMMUNITY HOSPITAL No No No No No 5100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106260011 MAMMOTH HOSP No Yes No Yes Yes 7982 12882 12620 $12768 $15097 $46994 Transition NA $98163 $80582 106420493 MARIAN MED CTR No No No No No 2741 12882 12620 $6289 $7436 $9386 Transition NA $98163 $80582 106190525 LONG BEACH MEM MED CTR No No No No No 1996 12882 12620 $6289 $7436 NA Non-Transition $1627 $98163 $80582 106211006 MARIN GEN HOSP No Yes No No No 2571 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106190500 MARINA DEL RAY HOSPITAL No No No No No 2034 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106050932 MARK TWAIN ST JOSEPHS HOSP No No No Yes Yes 3707 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090933 MARSHALL MED CTR No No No Yes Yes 2107 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106500939 MEM HOSP MED CTR-MODESTO No No No No No 2235 12892 12630 $6289 $7440 $5898 Transition NA $98163 $80582 106240924 MEMORIAL HOSP LOS BANOS No No No Yes Yes 3362 12882 12620 $12768 $15097 $17450 Transition NA $98163 $80582 106190521 MEMORIAL HOSP OF GARDENA No No No No No 1747 12882 12620 $6289 $7436 $4611 Transition NA $98163 $80582 106231013 MENDOCINO COAST DIST HOSP No Yes No Yes Yes 5070 12882 12620 $12768 $15097 $15935 Transition NA $98163 $80582 106334018 MENIFEE VALLEY MED CTR No No No No No 1458 12882 12620 $6289 $7436 $5113 Transition NA $98163 $80582 106450936 MAYERS MEM HOSP No Yes No Yes Yes 7192 14188 13900 $12768 $16234 NA Non-Transition NA $98163 $80582 106340947 MERCY GEN HOSP No No No No No 2185 15256 14946 $6289 $8454 $6027 Transition $1387 $98163 $80582 106344029 MERCY HOSP OF FOLSOM No No No No No 2746 15256 14946 $6289 $8454 $5260 Transition NA $98163 $80582 106150761 MERCY HOSP-BAKERSFIELD No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106414018 MENLO PARK SURGICAL HOSP No No No No No 2770 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106240942 MERCY MED CTR MERCED No No No No No 2289 13279 13009 $6289 $7606 NA Non-Transition NA $98163 $80582 106450949 MERCY MED CTR-REDDING No No No No No 2589 14188 13900 $6289 $7996 $10219 Transition NA $98163 $80582 106470871 MERCY MED CTR-MT SHASTA No No No Yes Yes 6242 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106340950 MERCY SAN JUAN HOSP No No No No No 2166 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190529 METHODIST HOSP OF SO CAL No No No No No 1842 12882 12620 $6289 $7436 $6690 Transition $1220 $98163 $80582 106196168 MILLER CHILDRENS HOSP No No Yes No No 2680 12882 12620 $6289 $7436 $8155 Transition NA $98163 $80582 106410742 MILLS HEALTH CENTER No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106410852 MILLS-PENINSULA No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106340951 METHODIST HOSP OF SACRAMENTO No No No No No 2028 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190524 MISSION COMM HOSP-PANORAMA CAMPUS No No No No No 3568 12882 12620 $6289 $7436 $3982 Transition NA $98163 $80582 106190681 MIRACLE MILE No No No No No 100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301262 MISSION HOSP REG MED CTR No No No No No 4091 12882 12620 $6289 $7436 $14336 Transition $1220 $98163 $80582 106250956 MODOC MED CTR No Yes No Yes Yes 4961 12882 12620 $12768 $15097 $13486 Transition NA $98163 $80582 106301337 MISSION HOSP LAGUNA BEACH No No No No No 4091 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106361166 MONTCLAIR HOSP MED CTR No No No No No 3149 12882 12620 $6289 $7436 $5904 Transition NA $98163 $80582 106190547 MONTEREY PARK HOSP No No No No No 1034 12882 12620 $6289 $7436 $5866 Transition NA $98163 $80582 106361266 MOUNTAINS COMM HOSP No Yes No Yes Yes 5148 12882 12620 $12768 $15097 $15642 Transition NA $98163 $80582 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106481357 NORTH BAY MEDICAL CENTER No No No No No 1972 16315 15984 $6289 $8908 $15945 Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190541 MONROVIA MEM HOSP No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106141273 NORTHERN INYO HOSP No Yes No Yes Yes 8150 12882 12620 $12768 $15097 $27752 Transition NA $98163 $80582 106484001 NORTH BAY VACAVALLEY HOSP No No No No No 1972 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106190568 NORTHRIDGE HOSP MED CTR No No No No No 1596 12882 12620 $6289 $7436 NA Non-Transition $1662 $98163 $80582 106214034 NOVATO COMM HOSP No No No No No 3465 16855 16513 $6289 $9140 $6359 Transition NA $98163 $80582 106500967 OAK VALLEY DIST HOSP No Yes No Yes No 3340 12892 12630 $6289 $7440 $5201 Transition NA $98163 $80582 106430837 OCONNOR HOSP-SAN JOSE No No No No No 2409 17180 16831 $6289 $9279 $5201 Transition NA $98163 $80582 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190534 OLYMPIA MED CTR No No No No No 1260 12882 12620 $6289 $7436 $6786 Transition NA $98163 $80582 106300225 ORANGE COAST MEM MED CTR No No No No No 2293 12882 12620 $6289 $7436 $19985 Transition NA $98163 $80582 106040937 OROVILLE HOSP No No No No No 1803 12882 12620 $6289 $7436 $6229 Transition NA $98163 $80582 106560501 OJAI VALLEY COMM HOSP No No No Yes Yes 2745 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190696 PACIFICA HOSP OF THE VALLEY No No No No No 3338 12882 12620 $6289 $7436 $5616 Transition NA $98163 $80582 106491338 PALM DRIVE HOSP No Yes No Yes No 4315 16315 15984 $6289 $8908 $11457 Transition NA $98163 $80582 106196405 PALMDALE REGIONAL MEDICAL CTR No No No No No 1190 12882 12620 $6289 $7436 $7504 Transition $1220 $98163 $80582 106331288 PALO VERDE HOSP No Yes No Yes Yes 4770 12882 12620 $12768 $15097 $18188 Transition NA $98163 $80582 106370755 PALOMAR MED CTR No Yes No No No 2429 12882 12620 $6289 $7436 $7051 Transition $1220 $98163 $80582 106370759 PARADISE VALLEY HOSP No No No No No 2188 12882 12620 $6289 $7436 $4275 Transition $1220 $98163 $80582 106190307 PACIFIC ALLIANCE MED CTR No No No No No 4299 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106331293 PARKVIEW COMM HOSP MED CTR No No No No No 2757 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106491001 PETALUMA VALLEY HOSP No No No No No 2271 16315 15984 $6289 $8908 $13491 Transition NA $98163 $80582 106130760 PIONEERS MEM HOSP No Yes No Yes No 2989 12882 12620 $6289 $7436 $9825 Transition NA $98163 $80582 106454013 PATIENTS HOSP OF REDDING No No No No No 2172 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106301297 PLACENTIA LINDA HOSP No No No No No 1606 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370977 POMERADO HOSP No Yes No No No 3063 12882 12620 $6289 $7436 $6818 Transition NA $98163 $80582 106320986 PLUMAS DIST HOSP No Yes No Yes Yes 8666 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190631 PRESBYTERIAN INTERCOMM HOSP No No No No No 961 12882 12620 $6289 $7436 $9720 Transition $1220 $98163 $80582 106190630 POMONA VALLEY HOSP MED CTR No No Yes No No 1538 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190468 PROMISE HOSP OF EAST LA-EAST LA No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190599 PROMISE HOSP OF EAST LA-EAST LA-SUBURBAN CAMPUS No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190385 PROVIDENCE HOLY CROSS MED CTR No No No No No 1325 12882 12620 $6289 $7436 $6284 Transition $1220 $98163 $80582 106190680 PROVIDENCE LITTLE CO OF MARY-SAN PEDRO No No No No No 1533 12882 12620 $6289 $7436 $6225 Transition $1220 $98163 $80582 106190470 PROVIDENCE LITTLE CO OF MARY-TORRANCE No No No No No 1767 12882 12620 $6289 $7436 $7182 Transition NA $98163 $80582 106190758 PROVIDENCE ST JOSEPH MED CTR No No No No No 1866 12882 12620 $6289 $7436 $7141 Transition $1220 $98163 $80582 106370787 PROMISE HOSP OF SAN DIEGO No No No No No 3660 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106281047 QUEEN OF THE VALLEY HOSP-NAPA No No No No No 2829 16188 15859 $6289 $8854 $17592 Transition $1453 $98163 $80582 106370673 RADY CHILDRENS HOSPITAL - SAN DIEGO No No Yes No No 2854 12882 12620 $6289 $7436 $6395 Transition $2177 $98163 $80582 106190517 PROVIDENCE TARZANA MED CTR No No Yes No No 1536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361308 REDLANDS COMM HOSP No No No No No 2079 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430705 REG MED CTR OF SAN JOSE No No No No No 2529 17180 16831 $6289 $9279 $13299 Transition NA $98163 $80582 106580996 RIDEOUT MEM HOSP No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106121051 REDWOOD MEM HOSP No No No Yes Yes 3214 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106334487 RIVERSIDE CO REG MED CTR Yes No No No No 2987 12882 12620 $6289 $7436 NA NA NA NA NA 106331312 RIVERSIDE COMM HOSP No No No No No 1560 12882 12620 $6289 $7436 $5990 Transition NA $98163 $80582 106190796 RONALD REAGAN UCLA MED CTR Yes No Yes No No 3382 12882 12620 $6289 $7436 NA NA NA NA NA 106301317 SADDLEBACK MEM MED CTR No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106301325 SADDLEBACK MEM MED CTR-SAN CLEMENTE No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106150782 RIDGECREST REG HOSP No No No Yes Yes 4178 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106361318 SAN ANTONIO COMM HOSP No No No No No 2262 12882 12620 $6289 $7436 $9216 Transition NA $98163 $80582 106190673 SAN DIMAS COMM HOSP No No No No No 2465 12882 12620 $6289 $7436 $12177 Transition NA $98163 $80582 106190200 SAN GABRIEL VALLEY MED CTR No No No No No 969 12882 12620 $6289 $7436 $6918 Transition NA $98163 $80582 106270875 SALINAS VALLEY MEM HOSP No Yes No No No 3534 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106331326 SAN GORGONIO MEM HOSP No Yes No Yes Yes 3394 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391010 SAN JOAQUIN GEN HOSP Yes No No No No 1922 13579 13303 $6289 $7735 NA NA NA NA NA 106104023 SAN JOAQUIN VALLEY REHAB HOSP No No No No No 6479 12882 12620 NA NA NA NA $1413 $98163 $80582 106013619 SAN LEANDRO HOSP No Yes No No No 3482 16501 16166 $6289 $8988 $10813 Transition NA $98163 $80582 106410782 SAN MATEO MED CTR Yes No No No No 7168 16928 16584 $6289 $9171 NA NA NA NA NA 106074017 SAN RAMON REG MED CTR No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106074011 SAN RAMON REG MED CTR SOUTH BUILDING No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106420514 SANTA BARBARA COTTAGE HOSP No No Yes No No 3902 12882 12620 $6289 $7436 $10978 Transition $2125 $98163 $80582 106430883 SANTA CLARA VALLEY MED CTR Yes No Yes No No 3133 17180 16831 $6289 $9279 NA NA NA NA NA 106190687 SANTA MONICA - UCLA MEDICAL CENTER Yes No No No No 3102 12882 12620 $6289 $7436 NA NA NA NA NA 106491064 SANTA ROSA MEM HOSP-MONTGOMERY No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106490907 SANTA ROSA MEM HOSP-SOTOYOME No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106150788 SAN JOAQUIN COMM HOSP No No No No No 2544 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420522 SANTA YNEZ VALLEY COTTAGE HOSP No No No Yes Yes 7569 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106371394 SCRIPPS MEM HOSP-ENCINITAS No No No No No 2403 12882 12620 $6289 $7436 $7037 Transition $1439 $98163 $80582 106370771 SCRIPPS MEM HOSP-LA JOLLA No No No No No 2061 12882 12620 $6289 $7436 $4390 Transition NA $98163 $80582 106370744 SCRIPPS MERCY HOSP No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106370658 SCRIPPS MERCY HOSP-CHULA VISTA No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106371256 SCRIPPS GREEN HOSP No No No No No 2317 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106321016 SENECA HCARE DIST No Yes No Yes Yes 4586 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106410817 SETON MED CTR No No No No No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106410828 SETON MED CTR-COASTSIDE No No No Yes No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106380939 SF GENERAL HOSP Yes No No No No 2851 16738 16398 $6289 $9090 NA NA NA NA NA 106370875 SHARP CHULA VISTA MED CTR No No No No No 1932 12882 12620 $6289 $7436 $6485 Transition NA $98163 $80582 106410891 SEQUOIA HOSP No No No No No 1975 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106370689 SHARP CORONADO HOSP AND HCARE CTR No No No No No 2160 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $72421 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106370694 SHARP MEM HOSP No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106450940 SHASTA REG MED CTR No No No No No 1582 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106190708 SHERMAN OAKS HOSP No No No No No 1516 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190712 SHRINERS HOSPITAL- LA No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106344114 SHRINERS HOSPITAL- SACRAMENTO No No No No No 3869 15256 14946 $6289 $8454 NA Non-Transition $2475 $98163 $80582 106540798 SIERRA VIEW DIST HOSP No Yes No No No 2716 12882 12620 $6289 $7436 $8497 Transition NA $98163 $77682 106400524 SIERRA VIST REG MED CTR No No No No No 1787 12964 12701 $6289 $7471 $5495 Transition NA $98163 $80582 106190661 SILVER LAKE MED CTR No No No No No 3692 12882 12620 $6289 $7436 $5655 Transition NA $98163 $80582 106291023 SIERRA NEVADA MEM HOSP No No No Yes Yes 3427 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106491076 SONOMA VALLEY HOSP No Yes No No No 4960 16315 15984 $6289 $8908 $12733 Transition NA $98163 $80582 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 2126 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190380 SOUTHERN CA HOSP AT HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106190110 SOUTHERN CA HOSPITAL AT CULVER CITY No No No No No 1437 12882 12620 $6289 $7436 $4694 Transition $1220 $98163 $80582 106560525 SIMI VALLEY HOSP AND HCARE-SYCAMORE No No No No No 3840 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106334068 SOUTHWEST HCARE SYSTEM No No No No No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106334001 SOUTHWEST HCARE SYSTEM-WILDOMAR No No No Yes No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106100899 ST AGNES MED CTR No No No No No 3088 12882 12620 $6289 $7436 $7885 Transition NA $98163 $80582 106361339 ST BERNARDINE MED CTR No No No No No 2171 12882 12620 $6289 $7436 $6090 Transition NA $98163 $80582 106521041 ST ELIZABETH COMM HOSP No No No Yes Yes 3024 13869 13587 $12768 $15956 $14866 Transition NA $98163 $80582 106190754 ST FRANCIS MED CTR No No No No No 4350 12882 12620 $6289 $7436 $6368 Transition NA $98163 $80582 106380960 ST FRANCIS MEM HOSP No No No No No 1920 16738 16398 $6289 $9090 $5310 Transition $1492 $98163 $80582 106281078 ST HELENA HOSP No No No No No 2337 15887 15564 $6289 $8725 $9671 Transition NA $98163 $80582 106171049 ST HELENA HOSPITAL-CLEARLAKE No No No Yes Yes 4118 12882 12620 $12768 $15097 $18218 Transition NA $98163 $80582 106141338 SOUTHERN INYO HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190756 ST JOHNS HEALTH CTR No No No No No 2536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560529 ST JOHNS REG MED CTR No No No No No 2982 12882 12620 $6289 $7436 $6976 Transition $1761 $98163 $80582 106121080 ST JOSEPH HOSP-EUREKA No No No No No 2570 13869 13587 $6289 $7859 $9661 Transition $1507 $98163 $80582 106301340 ST JOSEPH HOSP-ORANGE No No No No No 2751 12882 12620 $6289 $7436 $5230 Transition NA $98163 $80582 106560508 ST JOHNS PLEASANT VALLEY HOSP No No No No No 2087 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301342 ST JUDE MED CTR No No No No No 1722 12882 12620 $6289 $7436 $5799 Transition $1220 $98163 $80582 106434138 ST LOUISE REG HOSP No No No No No 2838 17180 16831 $6289 $9279 $16407 Transition NA $98163 $80582 106380964 ST LUKES HOSP No No No No No 3807 16738 16398 $6289 $9090 $8600 Transition NA $98163 $80582 106361343 ST MARY MED CTR-APPLE VALLEY No No No Yes No 2511 12882 12620 $6289 $7436 $9863 Transition NA $98163 $80582 106391042 ST JOSEPHS MED CTR OF STOCKTON No No No No No 2152 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106380965 ST MARYS MED CTR-SF No No No No No 2007 16738 16398 $6289 $9090 $5116 Transition $1492 $98163 $80582 106010967 ST ROSE HOSP No No No No No 1931 16962 16618 $6289 $9186 $7600 Transition NA $98163 $80582 106190762 ST VINCENT MED CTR No No No No No 2020 12882 12620 $6289 $7436 $4684 Transition $1220 $98163 $80582 106430905 STANFORD HOSP No No No No No 1803 17180 16831 $6289 $9279 $5644 Transition $1523 $98163 $80582 106190053 ST MARY MED CTR-LONG BEACH No No No No No 2479 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106504038 STANISLAUS SURGICAL HOSP No No No No No 9000 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106250955 SURPRISE VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106310791 SUTTER AUBURN FAITH HOSP No No No No No 2551 15256 14946 $6289 $8454 $11882 Transition NA $98163 $80582 106034002 SUTTER AMADOR HOSP No No No Yes Yes 2971 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106574010 SUTTER DAVIS HOSP No No No No No 3568 15256 14946 $6289 $8454 $14330 Transition NA $98163 $80582 106070934 SUTTER DELTA MED CTR No No No No No 2907 16478 16143 $6289 $8978 $12158 Transition NA $98163 $80582 106341051 SUTTER GEN HOSP No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106171395 SUTTER LAKESIDE HOSP No No No Yes Yes 3691 12882 12620 $12768 $15097 $17232 Transition NA $98163 $80582 106444012 SUTTER MATERNITY AND SRG CTR OF S CRUZ No No No No No 7213 17239 16889 $6289 $9304 $21288 Transition NA $98163 $80582 106490919 SUTTER MED CTR OF SANTA ROSA No No No No No 3657 16315 15984 $6289 $8908 $15278 Transition NA $98163 $80582 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106311000 SUTTER ROSEVILLE MED CTR No No No No No 2377 15256 14946 $6289 $8454 $11395 Transition $1387 $98163 $80582 106481094 SUTTER SOLANO MED CTR No No No No No 3258 16315 15984 $6289 $8908 $18010 Transition NA $98163 $80582 106084001 SUTTER COAST HOSP No No No Yes Yes 3730 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391056 SUTTER TRACY COMM HOSP No No No No No 2714 13579 13303 $6289 $7735 $5995 Transition NA $98163 $80582 106291053 TAHOE FOREST HOSP No Yes No Yes Yes 4766 15256 14946 $12768 $17164 $21044 Transition NA $98163 $80582 106150808 TEHACHAPI HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 $22158 Transition NA $98163 $80582 106514030 SUTTER SURG HOSP-NORTH VALLEY No No No No No 3240 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106334564 TEMECULA VALLEY HOSPITAL No No No No No 2180 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106120981 THE GENERAL HOSPITAL No No No No No 2570 13869 13587 NA NA NA NA $1507 $98163 $80582 106564121 THOUSAND OAKS SURGICAL HOSPITAL No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106190422 TORRANCE MEM MED CTR No No No No No 1952 12882 12620 $6289 $7436 $5891 Transition NA $98163 $80582 106370780 TRI-CITY MED CTR No Yes No No No 3695 12882 12620 $6289 $7436 $7706 Transition $1220 $98163 $80582 106190784 TEMPLE COMM HOSP No No No No No 4200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540816 TULARE DIST HOSP No Yes No No No 3578 12882 12620 $6289 $7436 $9529 Transition NA $98163 $80582 106531059 TRINITY HOSP No Yes No Yes Yes 5105 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106400548 TWIN CITIES COMM HOSP No No No Yes Yes 1587 12964 12701 $12768 $15168 $8160 Transition NA $98163 $80582 106341006 UC DAVIS MED CTR Yes No Yes No No 1836 15256 14946 $6289 $8454 NA NA NA NA NA 106301279 UC IRVINE MED CTR Yes No Yes No No 2072 12882 12620 $6289 $7436 NA NA NA NA NA 106370782 UCSD MED CTR Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106374141 UCSD-LA JOLLA JOHN M amp SALLY B THORNTON HOSPITAL Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106381154 UCSF MED CTR Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106380895 UCSF MED CTR AT MOUNT ZION Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106301357 TUSTIN HOSP MED CTR No No No No No 231 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106231396 UKIAH VALLEY MED CTRHOSP DR No No No Yes Yes 3643 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106014050 VALLEY CARE MEDICAL CENTER No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106010983 VALLEY MEM HOSP-LIVERMORE No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106191216 USC KENNETH NORRIS JR CANCER HOSP No No No No No 3134 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560481 VENTURA CO MED CTR Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106560521 VENTURA CO MED CTR-SANTA PAULA HOSPITAL Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106190818 VERDUGO HILLS HOSP No No No No No 3110 12882 12620 $6289 $7436 $5264 Transition NA $98163 $80582 106190812 VALLEY PRES HOSP No No No No No 3536 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 3046 14188 13900 $6289 $7996 NA Non-Transition $1312 $98163 $80582 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 3266 12882 12620 $6289 $7436 $8320 Transition NA $98163 $80582 106010987 WASHINGTON HOSP-FREMONT No Yes No No No 1941 16962 16618 $6289 $9186 $6429 Transition NA $98163 $80582 106444013 WATSONVILLE COMM HOSP No No No No No 1780 17239 16889 $6289 $9304 $13456 Transition NA $98163 $80582 106301379 WEST ANAHEIM MED CTR No No No No No 1514 12882 12620 $6289 $7436 $4707 Transition NA $98163 $80582 106190859 WEST HILLS HOSP AND MED CTR No No No No No 1933 12882 12620 $6289 $7436 $8050 Transition NA $98163 $80582 106374094 VIBRA OF SAN DIEGO No No No No No 1155 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301188 WESTERN MED CTR-ANAHEIM No No No No No 3203 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301566 WESTERN MED CTR-SANTA ANA No No No No No 2354 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190878 WHITE MEM MED CTR No No No No No 1515 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190883 WHITTIER HOSP MED CTR No No No No No 1139 12882 12620 $6289 $7436 $5922 Transition NA $98163 $80582 106571086 WOODLAND MEM HOSP No No No No No 3278 15256 14946 $6289 $8454 $10092 Transition NA $98163 $80582 6102015
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190392 GOOD SAMARITAN HOSP-LA No No Yes No No 2006 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106350784 HAZEL HAWKINS MEM HOSP No Yes No Yes Yes 3840 17180 16831 $12768 $18839 NA Non-Transition NA $98163 $80582 106490964 HEALDSBURG DIST HOSP No Yes No Yes Yes 6549 16188 15859 $12768 $17975 NA Non-Transition NA $98163 $80582 106154022 HEALTHSOUTH BAKERSFIELD REHAB HOSP No No No No No 5040 12882 12620 NA NA NA NA $1382 $98163 $80582 106304079 HEALTHSOUTH TUSTIN REHAB HOSP No No No No No 5281 12882 12620 NA NA NA NA $1220 $98163 $80582 106331194 HEMET VALLEY MED CTR No No No No No 1267 12882 12620 $6289 $7436 $5912 Transition NA $98163 $80582 106190949 HENRY MAYO NEWHALL MEM HOSP No No No No No 1839 12882 12620 $6289 $7436 $5631 Transition $1220 $98163 $80582 106362041 HI-DESERT MED CTR No Yes No Yes Yes 2909 12882 12620 $12768 $15097 $13297 Transition NA $98163 $80582 106301205 HOAG MEM HOSP PRESBYTERIAN No No No No No 4825 12882 12620 $6289 $7436 $13525 Transition NA $98163 $80582 106304159 HEALTHBRIDGE CHILDRENS HOSP-ORANGE No No No No No 3271 12882 12620 $6289 $7436 NA Non-Transition $2177 $98163 $80582 106190380 HOLLYWOOD COMM HOSP OF HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106304460 HOAG ORTHOPEDIC No No No No No 4894 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190382 HOLLYWOOD PRES MED CTR No No No No No 2212 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301209 HUNTINGTON BEACH HOSP No No No No No 2175 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190400 HUNTINGTON MEM HOSP No No Yes No No 2294 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106304045 IRVINE REG HOSP AND MED CTR No No No No No 200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106220733 JOHN C FREMONT HCARE DIST No Yes No Yes Yes 3884 12882 12620 $12768 $15097 $8195 Transition NA $98163 $80582 106331216 JOHN F KENNEDY MEM HOSP No No No No No 1679 12882 12620 $6289 $7436 $6464 Transition NA $98163 $80582 106071018 JOHN MUIR MED CTR-CONCORD CAMPUS No No No No No 1748 16478 16143 $6289 $8978 $12804 Transition NA $98163 $80582 106070988 JOHN MUIR MED CTR-WALNUT CREEK CAMPUS No No No No No 2039 16478 16143 $6289 $8978 $10615 Transition $1473 $98163 $80582 106314024 KAISER HOSPITAL - ROSEVILLE No No Yes No No 7912 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106364265 KAISER ONTARIO MEDICAL CENTER CAMPUS No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106121031 JEROLD PHELPS COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301132 KAISER-ANAHEIM No No Yes No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304306 KAISER-ANAHEIM-IRVINE No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106304409 KAISER-ANAHEIM-Orange No No No No No 6136 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106074097 KAISER-ANTIOCH No No No No No 8503 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106196403 KAISER-DOWNEY No No No No No 10000 12882 12620 $6289 $7436 $12698 Transition NA $98163 $80582 106361223 KAISER-FONTANA No No No No No 7086 12882 12620 $6289 $7436 $10156 Transition $1220 $98163 $80582 106014132 KAISER-FREMONT No No No No No 10000 16962 16618 $6289 $9186 $9639 Transition NA $98163 $80582 106196035 KAISER-BALDWIN PARK No No No No No 8009 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106104062 KAISER-FRESNO No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190429 KAISER-LOS ANGELES No No No No No 7387 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106394009 KAISER-MANTECA No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106334048 KAISER-MORENO VALLEY No No No No No 6614 12882 12620 $6289 $7436 $4790 Transition NA $98163 $80582 106010856 KAISER-OAKLANDRICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106190432 KAISER-PANORAMA CITY No No No No No 8239 12882 12620 $6289 $7436 $16025 Transition NA $98163 $80582 106504042 KAISER-MODESTO No No No No No 6964 13579 13303 $6289 $7735 NA Non-Transition NA $98163 $80582 106410804 KAISER-REDWOOD CITY No No No No No 7731 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106074093 KAISER-RICHMOND No No Yes No No 7194 16962 16618 $6289 $9186 $11623 Transition NA $98163 $80582 106480989 KAISER-REHAB CENTER VALLEJO No No No No No 8442 16315 15984 $6289 $8908 NA Non-Transition $2535 $98163 $80582 106340913 KAISER-SACRAMENTO No No No No No 5612 15256 14946 $6289 $8454 $11284 Transition NA $98163 $80582 106334025 KAISER-RIVERSIDE No No No No No 5865 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370730 KAISER-SAN DIEGO No No No No No 7393 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106380857 KAISER-SAN FRANCISCO No No No No No 5960 16738 16398 $6289 $9090 NA Non-Transition NA $98163 $80582 106431506 KAISER-SAN JOSE No No No No No 7002 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106014337 KAISER-SAN LEANDRO No No No No No 2180 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106210992 KAISER-SAN RAFAEL No No No No No 4673 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106494019 KAISER-SANTA ROSA No No No No No 10000 16315 15984 $6289 $8908 $17627 Transition NA $98163 $80582 106434153 KAISER-SANTA CLARA No No No No No 6107 17180 16831 $6289 $9279 NA Non-Transition NA $98163 $80582 106190431 KAISER-SOUTH BAY No No No No No 6935 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106342344 KAISER-SOUTH SACRAMENTO No No No No No 5670 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106410806 KAISER-SOUTH SF No No No No No 6503 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106484044 KAISER-VACAVILLE No No No No No 10000 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106070990 KAISER-WALNUT CREEK No No No No No 5680 16478 16143 $6289 $8978 NA Non-Transition NA $98163 $80582 106190434 KAISER-WEST LA No No No No No 6623 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 2403 12882 12620 $6289 $7436 $8015 Transition $1220 $98163 $79689 106194219 KECK HOSPITAL OF USC No No No No No 2004 12882 12620 $6289 $7436 $4699 Transition $1220 $98163 $80582 106210993 KENTFIELD REHAB HOSP No No No No No 5967 16855 16513 $6289 $9140 $19338 Transition $1500 $98163 $80582 106150736 KERN MED CTR Yes No No No No 3943 12882 12620 $6289 $7436 NA NA NA NA NA 106150737 KERN VALLEY HEALTHCARE DIST No Yes No Yes Yes 2786 12882 12620 $12768 $15097 $8298 Transition NA $98163 $80582 106191450 KAISER-WOODLAND HILLS No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190049 KINDRED HOSPITAL BALDWIN PARK No No No No No 1810 12882 12620 $6289 $7436 $10784 Transition NA $98163 $80582 106190305 KINDRED LA No No No No No 2044 12882 12620 $6289 $7436 $4255 Transition NA $98163 $80582 106301127 KINDRED BREA No No No No No 2852 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361274 KINDRED ONTARIO No No No No No 2068 12882 12620 $6289 $7436 $9314 Transition NA $98163 $80582 106364188 KINDRED RANCHO No No No No No 1980 12882 12620 $6289 $7436 $20628 Transition NA $98163 $80582 106332172 KINDRED RIVERSIDE No No No No No 1805 12882 12620 $6289 $7436 $24450 Transition NA $98163 $80582 106190449 KINDRED LA MIRADA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106370721 KINDRED SAN DIEGO No No No No No 3605 12882 12620 $6289 $7436 $5657 Transition NA $98163 $80582 106344035 KINDRED SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190458 KINDRED SAN GABRIEL VALLEY No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106010887 KINDRED SF BAY AREA No No No No No 3007 16478 16143 $6289 $8978 $6378 Transition NA $98163 $80582 106301167 KINDRED SANTA ANA No No No No No 2415 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190196 KINDRED SOUTH BAY No No No No No 2144 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301380 KINDRED WESTMINSTER No No No No No 2286 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301234 LA PALMA INTERCOMMUNITY HOSP No No No No No 2290 12882 12620 $6289 $7436 $7160 Transition NA $98163 $80582 106191227 LAC-HARBOR-UCLA MED CTR Yes No Yes No No 3366 12882 12620 $6289 $7436 NA NA NA NA NA 106191231 LAC-OLIVE VIEW-UCLA MED CTR Yes No No No No 4136 12882 12620 $6289 $7436 NA NA NA NA NA 106191228 LAC-USC MED CTR Yes No Yes No No 4522 12882 12620 $6289 $7436 NA NA NA NA NA 106380865 LAGUNA HONDA HOSP AND REHAB CTR Yes No No No No 5843 16738 16398 $6289 $9090 NA NA NA NA NA 106190240 LAKEWOOD REG MED CTR No No No No No 1504 12882 12620 $6289 $7436 $4008 Transition $1220 $98163 $80582 106390923 LODI MEM HOSP No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106390922 LODI MEM HOSP - WEST No No No No No 1263 13579 13303 $6289 $7735 $9106 Transition $1269 $98163 $80582 106334589 LOMA LINDA MURRIETTA No No No No No 3222 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106364268 LOMA LINDA UNIV HEART AND SURGICAL HOSPITAL No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361245 LOMA LINDA UNIV MED CTR - EAST CAMPUS No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition NA $98163 $80582 106361246 LOMA LINDA UNIV MED CTR No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $1491 $98163 $80582 106364502 LOMA LINDA UNIV CHILDRENS HOSP No No Yes No No 1602 12882 12620 $6289 $7436 $6632 Transition $2177 $98163 $80582 106190198 LA COMM HOSP No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420491 LOMPOC VALLEY MED CTR No Yes No Yes Yes 8693 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106301248 LOS ALAMITOS MED CTR No No No No No 1915 12882 12620 $6289 $7436 $4697 Transition NA $98163 $80582 106560492 LOS ROBLES HOSP AND MED CTR No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106564018 LOS ROBLES HOSP AND MED CTR-EAST CAMPUS No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106434040 LSP CHILDRENS HOSP AT STANFORD No No Yes No No 2035 17180 16831 $6289 $9279 $6102 Transition NA $98163 $80582 106121002 MAD RIVER COMM HOSP No No No No No 4250 12882 12620 $6289 $7436 $9505 Transition NA $98163 $80582 106201281 MADERA COMMUNITY HOSPITAL No No No No No 5100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106260011 MAMMOTH HOSP No Yes No Yes Yes 7982 12882 12620 $12768 $15097 $46994 Transition NA $98163 $80582 106420493 MARIAN MED CTR No No No No No 2741 12882 12620 $6289 $7436 $9386 Transition NA $98163 $80582 106190525 LONG BEACH MEM MED CTR No No No No No 1996 12882 12620 $6289 $7436 NA Non-Transition $1627 $98163 $80582 106211006 MARIN GEN HOSP No Yes No No No 2571 16855 16513 $6289 $9140 NA Non-Transition NA $98163 $80582 106190500 MARINA DEL RAY HOSPITAL No No No No No 2034 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106050932 MARK TWAIN ST JOSEPHS HOSP No No No Yes Yes 3707 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106090933 MARSHALL MED CTR No No No Yes Yes 2107 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106500939 MEM HOSP MED CTR-MODESTO No No No No No 2235 12892 12630 $6289 $7440 $5898 Transition NA $98163 $80582 106240924 MEMORIAL HOSP LOS BANOS No No No Yes Yes 3362 12882 12620 $12768 $15097 $17450 Transition NA $98163 $80582 106190521 MEMORIAL HOSP OF GARDENA No No No No No 1747 12882 12620 $6289 $7436 $4611 Transition NA $98163 $80582 106231013 MENDOCINO COAST DIST HOSP No Yes No Yes Yes 5070 12882 12620 $12768 $15097 $15935 Transition NA $98163 $80582 106334018 MENIFEE VALLEY MED CTR No No No No No 1458 12882 12620 $6289 $7436 $5113 Transition NA $98163 $80582 106450936 MAYERS MEM HOSP No Yes No Yes Yes 7192 14188 13900 $12768 $16234 NA Non-Transition NA $98163 $80582 106340947 MERCY GEN HOSP No No No No No 2185 15256 14946 $6289 $8454 $6027 Transition $1387 $98163 $80582 106344029 MERCY HOSP OF FOLSOM No No No No No 2746 15256 14946 $6289 $8454 $5260 Transition NA $98163 $80582 106150761 MERCY HOSP-BAKERSFIELD No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106414018 MENLO PARK SURGICAL HOSP No No No No No 2770 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106240942 MERCY MED CTR MERCED No No No No No 2289 13279 13009 $6289 $7606 NA Non-Transition NA $98163 $80582 106450949 MERCY MED CTR-REDDING No No No No No 2589 14188 13900 $6289 $7996 $10219 Transition NA $98163 $80582 106470871 MERCY MED CTR-MT SHASTA No No No Yes Yes 6242 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 2441 12882 12620 $6289 $7436 $8086 Transition NA $98163 $80582 106340950 MERCY SAN JUAN HOSP No No No No No 2166 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190529 METHODIST HOSP OF SO CAL No No No No No 1842 12882 12620 $6289 $7436 $6690 Transition $1220 $98163 $80582 106196168 MILLER CHILDRENS HOSP No No Yes No No 2680 12882 12620 $6289 $7436 $8155 Transition NA $98163 $80582 106410742 MILLS HEALTH CENTER No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106410852 MILLS-PENINSULA No No No No No 3860 16928 16584 $6289 $9171 $14825 Transition NA $98163 $80582 106340951 METHODIST HOSP OF SACRAMENTO No No No No No 2028 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106190524 MISSION COMM HOSP-PANORAMA CAMPUS No No No No No 3568 12882 12620 $6289 $7436 $3982 Transition NA $98163 $80582 106190681 MIRACLE MILE No No No No No 100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301262 MISSION HOSP REG MED CTR No No No No No 4091 12882 12620 $6289 $7436 $14336 Transition $1220 $98163 $80582 106250956 MODOC MED CTR No Yes No Yes Yes 4961 12882 12620 $12768 $15097 $13486 Transition NA $98163 $80582 106301337 MISSION HOSP LAGUNA BEACH No No No No No 4091 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106361166 MONTCLAIR HOSP MED CTR No No No No No 3149 12882 12620 $6289 $7436 $5904 Transition NA $98163 $80582 106190547 MONTEREY PARK HOSP No No No No No 1034 12882 12620 $6289 $7436 $5866 Transition NA $98163 $80582 106361266 MOUNTAINS COMM HOSP No Yes No Yes Yes 5148 12882 12620 $12768 $15097 $15642 Transition NA $98163 $80582 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106274043 NATIVIDAD MED CTR Yes No No No No 1738 15558 15242 $6289 $8584 NA NA NA NA NA 106481357 NORTH BAY MEDICAL CENTER No No No No No 1972 16315 15984 $6289 $8908 $15945 Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190541 MONROVIA MEM HOSP No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106141273 NORTHERN INYO HOSP No Yes No Yes Yes 8150 12882 12620 $12768 $15097 $27752 Transition NA $98163 $80582 106484001 NORTH BAY VACAVALLEY HOSP No No No No No 1972 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106190568 NORTHRIDGE HOSP MED CTR No No No No No 1596 12882 12620 $6289 $7436 NA Non-Transition $1662 $98163 $80582 106214034 NOVATO COMM HOSP No No No No No 3465 16855 16513 $6289 $9140 $6359 Transition NA $98163 $80582 106500967 OAK VALLEY DIST HOSP No Yes No Yes No 3340 12892 12630 $6289 $7440 $5201 Transition NA $98163 $80582 106430837 OCONNOR HOSP-SAN JOSE No No No No No 2409 17180 16831 $6289 $9279 $5201 Transition NA $98163 $80582 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190534 OLYMPIA MED CTR No No No No No 1260 12882 12620 $6289 $7436 $6786 Transition NA $98163 $80582 106300225 ORANGE COAST MEM MED CTR No No No No No 2293 12882 12620 $6289 $7436 $19985 Transition NA $98163 $80582 106040937 OROVILLE HOSP No No No No No 1803 12882 12620 $6289 $7436 $6229 Transition NA $98163 $80582 106560501 OJAI VALLEY COMM HOSP No No No Yes Yes 2745 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190696 PACIFICA HOSP OF THE VALLEY No No No No No 3338 12882 12620 $6289 $7436 $5616 Transition NA $98163 $80582 106491338 PALM DRIVE HOSP No Yes No Yes No 4315 16315 15984 $6289 $8908 $11457 Transition NA $98163 $80582 106196405 PALMDALE REGIONAL MEDICAL CTR No No No No No 1190 12882 12620 $6289 $7436 $7504 Transition $1220 $98163 $80582 106331288 PALO VERDE HOSP No Yes No Yes Yes 4770 12882 12620 $12768 $15097 $18188 Transition NA $98163 $80582 106370755 PALOMAR MED CTR No Yes No No No 2429 12882 12620 $6289 $7436 $7051 Transition $1220 $98163 $80582 106370759 PARADISE VALLEY HOSP No No No No No 2188 12882 12620 $6289 $7436 $4275 Transition $1220 $98163 $80582 106190307 PACIFIC ALLIANCE MED CTR No No No No No 4299 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106331293 PARKVIEW COMM HOSP MED CTR No No No No No 2757 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106491001 PETALUMA VALLEY HOSP No No No No No 2271 16315 15984 $6289 $8908 $13491 Transition NA $98163 $80582 106130760 PIONEERS MEM HOSP No Yes No Yes No 2989 12882 12620 $6289 $7436 $9825 Transition NA $98163 $80582 106454013 PATIENTS HOSP OF REDDING No No No No No 2172 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106301297 PLACENTIA LINDA HOSP No No No No No 1606 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370977 POMERADO HOSP No Yes No No No 3063 12882 12620 $6289 $7436 $6818 Transition NA $98163 $80582 106320986 PLUMAS DIST HOSP No Yes No Yes Yes 8666 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190631 PRESBYTERIAN INTERCOMM HOSP No No No No No 961 12882 12620 $6289 $7436 $9720 Transition $1220 $98163 $80582 106190630 POMONA VALLEY HOSP MED CTR No No Yes No No 1538 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190468 PROMISE HOSP OF EAST LA-EAST LA No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190599 PROMISE HOSP OF EAST LA-EAST LA-SUBURBAN CAMPUS No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190385 PROVIDENCE HOLY CROSS MED CTR No No No No No 1325 12882 12620 $6289 $7436 $6284 Transition $1220 $98163 $80582 106190680 PROVIDENCE LITTLE CO OF MARY-SAN PEDRO No No No No No 1533 12882 12620 $6289 $7436 $6225 Transition $1220 $98163 $80582 106190470 PROVIDENCE LITTLE CO OF MARY-TORRANCE No No No No No 1767 12882 12620 $6289 $7436 $7182 Transition NA $98163 $80582 106190758 PROVIDENCE ST JOSEPH MED CTR No No No No No 1866 12882 12620 $6289 $7436 $7141 Transition $1220 $98163 $80582 106370787 PROMISE HOSP OF SAN DIEGO No No No No No 3660 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106281047 QUEEN OF THE VALLEY HOSP-NAPA No No No No No 2829 16188 15859 $6289 $8854 $17592 Transition $1453 $98163 $80582 106370673 RADY CHILDRENS HOSPITAL - SAN DIEGO No No Yes No No 2854 12882 12620 $6289 $7436 $6395 Transition $2177 $98163 $80582 106190517 PROVIDENCE TARZANA MED CTR No No Yes No No 1536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361308 REDLANDS COMM HOSP No No No No No 2079 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430705 REG MED CTR OF SAN JOSE No No No No No 2529 17180 16831 $6289 $9279 $13299 Transition NA $98163 $80582 106580996 RIDEOUT MEM HOSP No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106121051 REDWOOD MEM HOSP No No No Yes Yes 3214 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106334487 RIVERSIDE CO REG MED CTR Yes No No No No 2987 12882 12620 $6289 $7436 NA NA NA NA NA 106331312 RIVERSIDE COMM HOSP No No No No No 1560 12882 12620 $6289 $7436 $5990 Transition NA $98163 $80582 106190796 RONALD REAGAN UCLA MED CTR Yes No Yes No No 3382 12882 12620 $6289 $7436 NA NA NA NA NA 106301317 SADDLEBACK MEM MED CTR No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106301325 SADDLEBACK MEM MED CTR-SAN CLEMENTE No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106150782 RIDGECREST REG HOSP No No No Yes Yes 4178 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106361318 SAN ANTONIO COMM HOSP No No No No No 2262 12882 12620 $6289 $7436 $9216 Transition NA $98163 $80582 106190673 SAN DIMAS COMM HOSP No No No No No 2465 12882 12620 $6289 $7436 $12177 Transition NA $98163 $80582 106190200 SAN GABRIEL VALLEY MED CTR No No No No No 969 12882 12620 $6289 $7436 $6918 Transition NA $98163 $80582 106270875 SALINAS VALLEY MEM HOSP No Yes No No No 3534 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106331326 SAN GORGONIO MEM HOSP No Yes No Yes Yes 3394 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391010 SAN JOAQUIN GEN HOSP Yes No No No No 1922 13579 13303 $6289 $7735 NA NA NA NA NA 106104023 SAN JOAQUIN VALLEY REHAB HOSP No No No No No 6479 12882 12620 NA NA NA NA $1413 $98163 $80582 106013619 SAN LEANDRO HOSP No Yes No No No 3482 16501 16166 $6289 $8988 $10813 Transition NA $98163 $80582 106410782 SAN MATEO MED CTR Yes No No No No 7168 16928 16584 $6289 $9171 NA NA NA NA NA 106074017 SAN RAMON REG MED CTR No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106074011 SAN RAMON REG MED CTR SOUTH BUILDING No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106420514 SANTA BARBARA COTTAGE HOSP No No Yes No No 3902 12882 12620 $6289 $7436 $10978 Transition $2125 $98163 $80582 106430883 SANTA CLARA VALLEY MED CTR Yes No Yes No No 3133 17180 16831 $6289 $9279 NA NA NA NA NA 106190687 SANTA MONICA - UCLA MEDICAL CENTER Yes No No No No 3102 12882 12620 $6289 $7436 NA NA NA NA NA 106491064 SANTA ROSA MEM HOSP-MONTGOMERY No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106490907 SANTA ROSA MEM HOSP-SOTOYOME No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106150788 SAN JOAQUIN COMM HOSP No No No No No 2544 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420522 SANTA YNEZ VALLEY COTTAGE HOSP No No No Yes Yes 7569 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106371394 SCRIPPS MEM HOSP-ENCINITAS No No No No No 2403 12882 12620 $6289 $7436 $7037 Transition $1439 $98163 $80582 106370771 SCRIPPS MEM HOSP-LA JOLLA No No No No No 2061 12882 12620 $6289 $7436 $4390 Transition NA $98163 $80582 106370744 SCRIPPS MERCY HOSP No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106370658 SCRIPPS MERCY HOSP-CHULA VISTA No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106371256 SCRIPPS GREEN HOSP No No No No No 2317 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106321016 SENECA HCARE DIST No Yes No Yes Yes 4586 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106410817 SETON MED CTR No No No No No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106410828 SETON MED CTR-COASTSIDE No No No Yes No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106380939 SF GENERAL HOSP Yes No No No No 2851 16738 16398 $6289 $9090 NA NA NA NA NA 106370875 SHARP CHULA VISTA MED CTR No No No No No 1932 12882 12620 $6289 $7436 $6485 Transition NA $98163 $80582 106410891 SEQUOIA HOSP No No No No No 1975 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106370689 SHARP CORONADO HOSP AND HCARE CTR No No No No No 2160 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $72421 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106370694 SHARP MEM HOSP No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106450940 SHASTA REG MED CTR No No No No No 1582 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106190708 SHERMAN OAKS HOSP No No No No No 1516 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190712 SHRINERS HOSPITAL- LA No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106344114 SHRINERS HOSPITAL- SACRAMENTO No No No No No 3869 15256 14946 $6289 $8454 NA Non-Transition $2475 $98163 $80582 106540798 SIERRA VIEW DIST HOSP No Yes No No No 2716 12882 12620 $6289 $7436 $8497 Transition NA $98163 $77682 106400524 SIERRA VIST REG MED CTR No No No No No 1787 12964 12701 $6289 $7471 $5495 Transition NA $98163 $80582 106190661 SILVER LAKE MED CTR No No No No No 3692 12882 12620 $6289 $7436 $5655 Transition NA $98163 $80582 106291023 SIERRA NEVADA MEM HOSP No No No Yes Yes 3427 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106491076 SONOMA VALLEY HOSP No Yes No No No 4960 16315 15984 $6289 $8908 $12733 Transition NA $98163 $80582 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 2126 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190380 SOUTHERN CA HOSP AT HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106190110 SOUTHERN CA HOSPITAL AT CULVER CITY No No No No No 1437 12882 12620 $6289 $7436 $4694 Transition $1220 $98163 $80582 106560525 SIMI VALLEY HOSP AND HCARE-SYCAMORE No No No No No 3840 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106334068 SOUTHWEST HCARE SYSTEM No No No No No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106334001 SOUTHWEST HCARE SYSTEM-WILDOMAR No No No Yes No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106100899 ST AGNES MED CTR No No No No No 3088 12882 12620 $6289 $7436 $7885 Transition NA $98163 $80582 106361339 ST BERNARDINE MED CTR No No No No No 2171 12882 12620 $6289 $7436 $6090 Transition NA $98163 $80582 106521041 ST ELIZABETH COMM HOSP No No No Yes Yes 3024 13869 13587 $12768 $15956 $14866 Transition NA $98163 $80582 106190754 ST FRANCIS MED CTR No No No No No 4350 12882 12620 $6289 $7436 $6368 Transition NA $98163 $80582 106380960 ST FRANCIS MEM HOSP No No No No No 1920 16738 16398 $6289 $9090 $5310 Transition $1492 $98163 $80582 106281078 ST HELENA HOSP No No No No No 2337 15887 15564 $6289 $8725 $9671 Transition NA $98163 $80582 106171049 ST HELENA HOSPITAL-CLEARLAKE No No No Yes Yes 4118 12882 12620 $12768 $15097 $18218 Transition NA $98163 $80582 106141338 SOUTHERN INYO HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190756 ST JOHNS HEALTH CTR No No No No No 2536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560529 ST JOHNS REG MED CTR No No No No No 2982 12882 12620 $6289 $7436 $6976 Transition $1761 $98163 $80582 106121080 ST JOSEPH HOSP-EUREKA No No No No No 2570 13869 13587 $6289 $7859 $9661 Transition $1507 $98163 $80582 106301340 ST JOSEPH HOSP-ORANGE No No No No No 2751 12882 12620 $6289 $7436 $5230 Transition NA $98163 $80582 106560508 ST JOHNS PLEASANT VALLEY HOSP No No No No No 2087 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301342 ST JUDE MED CTR No No No No No 1722 12882 12620 $6289 $7436 $5799 Transition $1220 $98163 $80582 106434138 ST LOUISE REG HOSP No No No No No 2838 17180 16831 $6289 $9279 $16407 Transition NA $98163 $80582 106380964 ST LUKES HOSP No No No No No 3807 16738 16398 $6289 $9090 $8600 Transition NA $98163 $80582 106361343 ST MARY MED CTR-APPLE VALLEY No No No Yes No 2511 12882 12620 $6289 $7436 $9863 Transition NA $98163 $80582 106391042 ST JOSEPHS MED CTR OF STOCKTON No No No No No 2152 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106380965 ST MARYS MED CTR-SF No No No No No 2007 16738 16398 $6289 $9090 $5116 Transition $1492 $98163 $80582 106010967 ST ROSE HOSP No No No No No 1931 16962 16618 $6289 $9186 $7600 Transition NA $98163 $80582 106190762 ST VINCENT MED CTR No No No No No 2020 12882 12620 $6289 $7436 $4684 Transition $1220 $98163 $80582 106430905 STANFORD HOSP No No No No No 1803 17180 16831 $6289 $9279 $5644 Transition $1523 $98163 $80582 106190053 ST MARY MED CTR-LONG BEACH No No No No No 2479 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106504038 STANISLAUS SURGICAL HOSP No No No No No 9000 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106250955 SURPRISE VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106310791 SUTTER AUBURN FAITH HOSP No No No No No 2551 15256 14946 $6289 $8454 $11882 Transition NA $98163 $80582 106034002 SUTTER AMADOR HOSP No No No Yes Yes 2971 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106574010 SUTTER DAVIS HOSP No No No No No 3568 15256 14946 $6289 $8454 $14330 Transition NA $98163 $80582 106070934 SUTTER DELTA MED CTR No No No No No 2907 16478 16143 $6289 $8978 $12158 Transition NA $98163 $80582 106341051 SUTTER GEN HOSP No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106171395 SUTTER LAKESIDE HOSP No No No Yes Yes 3691 12882 12620 $12768 $15097 $17232 Transition NA $98163 $80582 106444012 SUTTER MATERNITY AND SRG CTR OF S CRUZ No No No No No 7213 17239 16889 $6289 $9304 $21288 Transition NA $98163 $80582 106490919 SUTTER MED CTR OF SANTA ROSA No No No No No 3657 16315 15984 $6289 $8908 $15278 Transition NA $98163 $80582 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106311000 SUTTER ROSEVILLE MED CTR No No No No No 2377 15256 14946 $6289 $8454 $11395 Transition $1387 $98163 $80582 106481094 SUTTER SOLANO MED CTR No No No No No 3258 16315 15984 $6289 $8908 $18010 Transition NA $98163 $80582 106084001 SUTTER COAST HOSP No No No Yes Yes 3730 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391056 SUTTER TRACY COMM HOSP No No No No No 2714 13579 13303 $6289 $7735 $5995 Transition NA $98163 $80582 106291053 TAHOE FOREST HOSP No Yes No Yes Yes 4766 15256 14946 $12768 $17164 $21044 Transition NA $98163 $80582 106150808 TEHACHAPI HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 $22158 Transition NA $98163 $80582 106514030 SUTTER SURG HOSP-NORTH VALLEY No No No No No 3240 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106334564 TEMECULA VALLEY HOSPITAL No No No No No 2180 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106120981 THE GENERAL HOSPITAL No No No No No 2570 13869 13587 NA NA NA NA $1507 $98163 $80582 106564121 THOUSAND OAKS SURGICAL HOSPITAL No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106190422 TORRANCE MEM MED CTR No No No No No 1952 12882 12620 $6289 $7436 $5891 Transition NA $98163 $80582 106370780 TRI-CITY MED CTR No Yes No No No 3695 12882 12620 $6289 $7436 $7706 Transition $1220 $98163 $80582 106190784 TEMPLE COMM HOSP No No No No No 4200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540816 TULARE DIST HOSP No Yes No No No 3578 12882 12620 $6289 $7436 $9529 Transition NA $98163 $80582 106531059 TRINITY HOSP No Yes No Yes Yes 5105 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106400548 TWIN CITIES COMM HOSP No No No Yes Yes 1587 12964 12701 $12768 $15168 $8160 Transition NA $98163 $80582 106341006 UC DAVIS MED CTR Yes No Yes No No 1836 15256 14946 $6289 $8454 NA NA NA NA NA 106301279 UC IRVINE MED CTR Yes No Yes No No 2072 12882 12620 $6289 $7436 NA NA NA NA NA 106370782 UCSD MED CTR Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106374141 UCSD-LA JOLLA JOHN M amp SALLY B THORNTON HOSPITAL Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106381154 UCSF MED CTR Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106380895 UCSF MED CTR AT MOUNT ZION Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106301357 TUSTIN HOSP MED CTR No No No No No 231 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106231396 UKIAH VALLEY MED CTRHOSP DR No No No Yes Yes 3643 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106014050 VALLEY CARE MEDICAL CENTER No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106010983 VALLEY MEM HOSP-LIVERMORE No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106191216 USC KENNETH NORRIS JR CANCER HOSP No No No No No 3134 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560481 VENTURA CO MED CTR Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106560521 VENTURA CO MED CTR-SANTA PAULA HOSPITAL Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106190818 VERDUGO HILLS HOSP No No No No No 3110 12882 12620 $6289 $7436 $5264 Transition NA $98163 $80582 106190812 VALLEY PRES HOSP No No No No No 3536 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 3046 14188 13900 $6289 $7996 NA Non-Transition $1312 $98163 $80582 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 3266 12882 12620 $6289 $7436 $8320 Transition NA $98163 $80582 106010987 WASHINGTON HOSP-FREMONT No Yes No No No 1941 16962 16618 $6289 $9186 $6429 Transition NA $98163 $80582 106444013 WATSONVILLE COMM HOSP No No No No No 1780 17239 16889 $6289 $9304 $13456 Transition NA $98163 $80582 106301379 WEST ANAHEIM MED CTR No No No No No 1514 12882 12620 $6289 $7436 $4707 Transition NA $98163 $80582 106190859 WEST HILLS HOSP AND MED CTR No No No No No 1933 12882 12620 $6289 $7436 $8050 Transition NA $98163 $80582 106374094 VIBRA OF SAN DIEGO No No No No No 1155 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301188 WESTERN MED CTR-ANAHEIM No No No No No 3203 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301566 WESTERN MED CTR-SANTA ANA No No No No No 2354 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190878 WHITE MEM MED CTR No No No No No 1515 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190883 WHITTIER HOSP MED CTR No No No No No 1139 12882 12620 $6289 $7436 $5922 Transition NA $98163 $80582 106571086 WOODLAND MEM HOSP No No No No No 3278 15256 14946 $6289 $8454 $10092 Transition NA $98163 $80582 6102015
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106190541 MONROVIA MEM HOSP No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106141273 NORTHERN INYO HOSP No Yes No Yes Yes 8150 12882 12620 $12768 $15097 $27752 Transition NA $98163 $80582 106484001 NORTH BAY VACAVALLEY HOSP No No No No No 1972 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106190568 NORTHRIDGE HOSP MED CTR No No No No No 1596 12882 12620 $6289 $7436 NA Non-Transition $1662 $98163 $80582 106214034 NOVATO COMM HOSP No No No No No 3465 16855 16513 $6289 $9140 $6359 Transition NA $98163 $80582 106500967 OAK VALLEY DIST HOSP No Yes No Yes No 3340 12892 12630 $6289 $7440 $5201 Transition NA $98163 $80582 106430837 OCONNOR HOSP-SAN JOSE No No No No No 2409 17180 16831 $6289 $9279 $5201 Transition NA $98163 $80582 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 1941 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190534 OLYMPIA MED CTR No No No No No 1260 12882 12620 $6289 $7436 $6786 Transition NA $98163 $80582 106300225 ORANGE COAST MEM MED CTR No No No No No 2293 12882 12620 $6289 $7436 $19985 Transition NA $98163 $80582 106040937 OROVILLE HOSP No No No No No 1803 12882 12620 $6289 $7436 $6229 Transition NA $98163 $80582 106560501 OJAI VALLEY COMM HOSP No No No Yes Yes 2745 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190696 PACIFICA HOSP OF THE VALLEY No No No No No 3338 12882 12620 $6289 $7436 $5616 Transition NA $98163 $80582 106491338 PALM DRIVE HOSP No Yes No Yes No 4315 16315 15984 $6289 $8908 $11457 Transition NA $98163 $80582 106196405 PALMDALE REGIONAL MEDICAL CTR No No No No No 1190 12882 12620 $6289 $7436 $7504 Transition $1220 $98163 $80582 106331288 PALO VERDE HOSP No Yes No Yes Yes 4770 12882 12620 $12768 $15097 $18188 Transition NA $98163 $80582 106370755 PALOMAR MED CTR No Yes No No No 2429 12882 12620 $6289 $7436 $7051 Transition $1220 $98163 $80582 106370759 PARADISE VALLEY HOSP No No No No No 2188 12882 12620 $6289 $7436 $4275 Transition $1220 $98163 $80582 106190307 PACIFIC ALLIANCE MED CTR No No No No No 4299 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106331293 PARKVIEW COMM HOSP MED CTR No No No No No 2757 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106491001 PETALUMA VALLEY HOSP No No No No No 2271 16315 15984 $6289 $8908 $13491 Transition NA $98163 $80582 106130760 PIONEERS MEM HOSP No Yes No Yes No 2989 12882 12620 $6289 $7436 $9825 Transition NA $98163 $80582 106454013 PATIENTS HOSP OF REDDING No No No No No 2172 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106301297 PLACENTIA LINDA HOSP No No No No No 1606 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106370977 POMERADO HOSP No Yes No No No 3063 12882 12620 $6289 $7436 $6818 Transition NA $98163 $80582 106320986 PLUMAS DIST HOSP No Yes No Yes Yes 8666 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190631 PRESBYTERIAN INTERCOMM HOSP No No No No No 961 12882 12620 $6289 $7436 $9720 Transition $1220 $98163 $80582 106190630 POMONA VALLEY HOSP MED CTR No No Yes No No 1538 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190468 PROMISE HOSP OF EAST LA-EAST LA No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190599 PROMISE HOSP OF EAST LA-EAST LA-SUBURBAN CAMPUS No No No No No 2100 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190385 PROVIDENCE HOLY CROSS MED CTR No No No No No 1325 12882 12620 $6289 $7436 $6284 Transition $1220 $98163 $80582 106190680 PROVIDENCE LITTLE CO OF MARY-SAN PEDRO No No No No No 1533 12882 12620 $6289 $7436 $6225 Transition $1220 $98163 $80582 106190470 PROVIDENCE LITTLE CO OF MARY-TORRANCE No No No No No 1767 12882 12620 $6289 $7436 $7182 Transition NA $98163 $80582 106190758 PROVIDENCE ST JOSEPH MED CTR No No No No No 1866 12882 12620 $6289 $7436 $7141 Transition $1220 $98163 $80582 106370787 PROMISE HOSP OF SAN DIEGO No No No No No 3660 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106281047 QUEEN OF THE VALLEY HOSP-NAPA No No No No No 2829 16188 15859 $6289 $8854 $17592 Transition $1453 $98163 $80582 106370673 RADY CHILDRENS HOSPITAL - SAN DIEGO No No Yes No No 2854 12882 12620 $6289 $7436 $6395 Transition $2177 $98163 $80582 106190517 PROVIDENCE TARZANA MED CTR No No Yes No No 1536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106361308 REDLANDS COMM HOSP No No No No No 2079 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106430705 REG MED CTR OF SAN JOSE No No No No No 2529 17180 16831 $6289 $9279 $13299 Transition NA $98163 $80582 106580996 RIDEOUT MEM HOSP No No No No No 2514 13204 12936 $6289 $7574 $11683 Transition NA $98163 $80582 106121051 REDWOOD MEM HOSP No No No Yes Yes 3214 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106334487 RIVERSIDE CO REG MED CTR Yes No No No No 2987 12882 12620 $6289 $7436 NA NA NA NA NA 106331312 RIVERSIDE COMM HOSP No No No No No 1560 12882 12620 $6289 $7436 $5990 Transition NA $98163 $80582 106190796 RONALD REAGAN UCLA MED CTR Yes No Yes No No 3382 12882 12620 $6289 $7436 NA NA NA NA NA 106301317 SADDLEBACK MEM MED CTR No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106301325 SADDLEBACK MEM MED CTR-SAN CLEMENTE No No No No No 2132 12882 12620 $6289 $7436 $12873 Transition $1220 $98163 $80582 106150782 RIDGECREST REG HOSP No No No Yes Yes 4178 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106361318 SAN ANTONIO COMM HOSP No No No No No 2262 12882 12620 $6289 $7436 $9216 Transition NA $98163 $80582 106190673 SAN DIMAS COMM HOSP No No No No No 2465 12882 12620 $6289 $7436 $12177 Transition NA $98163 $80582 106190200 SAN GABRIEL VALLEY MED CTR No No No No No 969 12882 12620 $6289 $7436 $6918 Transition NA $98163 $80582 106270875 SALINAS VALLEY MEM HOSP No Yes No No No 3534 16962 16618 $6289 $9186 NA Non-Transition NA $98163 $80582 106331326 SAN GORGONIO MEM HOSP No Yes No Yes Yes 3394 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391010 SAN JOAQUIN GEN HOSP Yes No No No No 1922 13579 13303 $6289 $7735 NA NA NA NA NA 106104023 SAN JOAQUIN VALLEY REHAB HOSP No No No No No 6479 12882 12620 NA NA NA NA $1413 $98163 $80582 106013619 SAN LEANDRO HOSP No Yes No No No 3482 16501 16166 $6289 $8988 $10813 Transition NA $98163 $80582 106410782 SAN MATEO MED CTR Yes No No No No 7168 16928 16584 $6289 $9171 NA NA NA NA NA 106074017 SAN RAMON REG MED CTR No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106074011 SAN RAMON REG MED CTR SOUTH BUILDING No No No No No 2018 16478 16143 $6289 $8978 $12598 Transition $1473 $98163 $80582 106420514 SANTA BARBARA COTTAGE HOSP No No Yes No No 3902 12882 12620 $6289 $7436 $10978 Transition $2125 $98163 $80582 106430883 SANTA CLARA VALLEY MED CTR Yes No Yes No No 3133 17180 16831 $6289 $9279 NA NA NA NA NA 106190687 SANTA MONICA - UCLA MEDICAL CENTER Yes No No No No 3102 12882 12620 $6289 $7436 NA NA NA NA NA 106491064 SANTA ROSA MEM HOSP-MONTGOMERY No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106490907 SANTA ROSA MEM HOSP-SOTOYOME No No No No No 2180 16315 15984 $6289 $8908 $14867 Transition $1462 $98163 $80582 106150788 SAN JOAQUIN COMM HOSP No No No No No 2544 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106420522 SANTA YNEZ VALLEY COTTAGE HOSP No No No Yes Yes 7569 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106371394 SCRIPPS MEM HOSP-ENCINITAS No No No No No 2403 12882 12620 $6289 $7436 $7037 Transition $1439 $98163 $80582 106370771 SCRIPPS MEM HOSP-LA JOLLA No No No No No 2061 12882 12620 $6289 $7436 $4390 Transition NA $98163 $80582 106370744 SCRIPPS MERCY HOSP No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106370658 SCRIPPS MERCY HOSP-CHULA VISTA No No No No No 2145 12882 12620 $6289 $7436 $6588 Transition NA $98163 $80582 106371256 SCRIPPS GREEN HOSP No No No No No 2317 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106321016 SENECA HCARE DIST No Yes No Yes Yes 4586 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106410817 SETON MED CTR No No No No No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106410828 SETON MED CTR-COASTSIDE No No No Yes No 2019 16928 16584 $6289 $9171 $8023 Transition NA $98163 $80582 106380939 SF GENERAL HOSP Yes No No No No 2851 16738 16398 $6289 $9090 NA NA NA NA NA 106370875 SHARP CHULA VISTA MED CTR No No No No No 1932 12882 12620 $6289 $7436 $6485 Transition NA $98163 $80582 106410891 SEQUOIA HOSP No No No No No 1975 16928 16584 $6289 $9171 NA Non-Transition NA $98163 $80582 106370689 SHARP CORONADO HOSP AND HCARE CTR No No No No No 2160 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $72421 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106370694 SHARP MEM HOSP No No No No No 1976 12882 12620 $6289 $7436 NA Non-Transition $1437 $98163 $80582 106450940 SHASTA REG MED CTR No No No No No 1582 14188 13900 $6289 $7996 NA Non-Transition NA $98163 $80582 106190708 SHERMAN OAKS HOSP No No No No No 1516 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190712 SHRINERS HOSPITAL- LA No No No No No 10000 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106344114 SHRINERS HOSPITAL- SACRAMENTO No No No No No 3869 15256 14946 $6289 $8454 NA Non-Transition $2475 $98163 $80582 106540798 SIERRA VIEW DIST HOSP No Yes No No No 2716 12882 12620 $6289 $7436 $8497 Transition NA $98163 $77682 106400524 SIERRA VIST REG MED CTR No No No No No 1787 12964 12701 $6289 $7471 $5495 Transition NA $98163 $80582 106190661 SILVER LAKE MED CTR No No No No No 3692 12882 12620 $6289 $7436 $5655 Transition NA $98163 $80582 106291023 SIERRA NEVADA MEM HOSP No No No Yes Yes 3427 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106491076 SONOMA VALLEY HOSP No Yes No No No 4960 16315 15984 $6289 $8908 $12733 Transition NA $98163 $80582 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 2126 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190380 SOUTHERN CA HOSP AT HOLLYWOOD No No No No No 1437 12882 12620 $6289 $7436 $5701 Transition $1220 $98163 $80582 106190110 SOUTHERN CA HOSPITAL AT CULVER CITY No No No No No 1437 12882 12620 $6289 $7436 $4694 Transition $1220 $98163 $80582 106560525 SIMI VALLEY HOSP AND HCARE-SYCAMORE No No No No No 3840 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106334068 SOUTHWEST HCARE SYSTEM No No No No No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106334001 SOUTHWEST HCARE SYSTEM-WILDOMAR No No No Yes No 5256 12882 12620 $6289 $7436 $5231 Transition NA $98163 $80582 106100899 ST AGNES MED CTR No No No No No 3088 12882 12620 $6289 $7436 $7885 Transition NA $98163 $80582 106361339 ST BERNARDINE MED CTR No No No No No 2171 12882 12620 $6289 $7436 $6090 Transition NA $98163 $80582 106521041 ST ELIZABETH COMM HOSP No No No Yes Yes 3024 13869 13587 $12768 $15956 $14866 Transition NA $98163 $80582 106190754 ST FRANCIS MED CTR No No No No No 4350 12882 12620 $6289 $7436 $6368 Transition NA $98163 $80582 106380960 ST FRANCIS MEM HOSP No No No No No 1920 16738 16398 $6289 $9090 $5310 Transition $1492 $98163 $80582 106281078 ST HELENA HOSP No No No No No 2337 15887 15564 $6289 $8725 $9671 Transition NA $98163 $80582 106171049 ST HELENA HOSPITAL-CLEARLAKE No No No Yes Yes 4118 12882 12620 $12768 $15097 $18218 Transition NA $98163 $80582 106141338 SOUTHERN INYO HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106190756 ST JOHNS HEALTH CTR No No No No No 2536 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560529 ST JOHNS REG MED CTR No No No No No 2982 12882 12620 $6289 $7436 $6976 Transition $1761 $98163 $80582 106121080 ST JOSEPH HOSP-EUREKA No No No No No 2570 13869 13587 $6289 $7859 $9661 Transition $1507 $98163 $80582 106301340 ST JOSEPH HOSP-ORANGE No No No No No 2751 12882 12620 $6289 $7436 $5230 Transition NA $98163 $80582 106560508 ST JOHNS PLEASANT VALLEY HOSP No No No No No 2087 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301342 ST JUDE MED CTR No No No No No 1722 12882 12620 $6289 $7436 $5799 Transition $1220 $98163 $80582 106434138 ST LOUISE REG HOSP No No No No No 2838 17180 16831 $6289 $9279 $16407 Transition NA $98163 $80582 106380964 ST LUKES HOSP No No No No No 3807 16738 16398 $6289 $9090 $8600 Transition NA $98163 $80582 106361343 ST MARY MED CTR-APPLE VALLEY No No No Yes No 2511 12882 12620 $6289 $7436 $9863 Transition NA $98163 $80582 106391042 ST JOSEPHS MED CTR OF STOCKTON No No No No No 2152 16315 15984 $6289 $8908 NA Non-Transition NA $98163 $80582 106380965 ST MARYS MED CTR-SF No No No No No 2007 16738 16398 $6289 $9090 $5116 Transition $1492 $98163 $80582 106010967 ST ROSE HOSP No No No No No 1931 16962 16618 $6289 $9186 $7600 Transition NA $98163 $80582 106190762 ST VINCENT MED CTR No No No No No 2020 12882 12620 $6289 $7436 $4684 Transition $1220 $98163 $80582 106430905 STANFORD HOSP No No No No No 1803 17180 16831 $6289 $9279 $5644 Transition $1523 $98163 $80582 106190053 ST MARY MED CTR-LONG BEACH No No No No No 2479 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106504038 STANISLAUS SURGICAL HOSP No No No No No 9000 12892 12630 $6289 $7440 NA Non-Transition NA $98163 $80582 106250955 SURPRISE VALLEY COMM HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106310791 SUTTER AUBURN FAITH HOSP No No No No No 2551 15256 14946 $6289 $8454 $11882 Transition NA $98163 $80582 106034002 SUTTER AMADOR HOSP No No No Yes Yes 2971 15256 14946 $12768 $17164 NA Non-Transition NA $98163 $80582 106574010 SUTTER DAVIS HOSP No No No No No 3568 15256 14946 $6289 $8454 $14330 Transition NA $98163 $80582 106070934 SUTTER DELTA MED CTR No No No No No 2907 16478 16143 $6289 $8978 $12158 Transition NA $98163 $80582 106341051 SUTTER GEN HOSP No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106171395 SUTTER LAKESIDE HOSP No No No Yes Yes 3691 12882 12620 $12768 $15097 $17232 Transition NA $98163 $80582 106444012 SUTTER MATERNITY AND SRG CTR OF S CRUZ No No No No No 7213 17239 16889 $6289 $9304 $21288 Transition NA $98163 $80582 106490919 SUTTER MED CTR OF SANTA ROSA No No No No No 3657 16315 15984 $6289 $8908 $15278 Transition NA $98163 $80582 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 2204 15256 14946 $6289 $8454 $7298 Transition NA $98163 $80582 106311000 SUTTER ROSEVILLE MED CTR No No No No No 2377 15256 14946 $6289 $8454 $11395 Transition $1387 $98163 $80582 106481094 SUTTER SOLANO MED CTR No No No No No 3258 16315 15984 $6289 $8908 $18010 Transition NA $98163 $80582 106084001 SUTTER COAST HOSP No No No Yes Yes 3730 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106391056 SUTTER TRACY COMM HOSP No No No No No 2714 13579 13303 $6289 $7735 $5995 Transition NA $98163 $80582 106291053 TAHOE FOREST HOSP No Yes No Yes Yes 4766 15256 14946 $12768 $17164 $21044 Transition NA $98163 $80582 106150808 TEHACHAPI HOSP No Yes No Yes Yes 10000 12882 12620 $12768 $15097 $22158 Transition NA $98163 $80582 106514030 SUTTER SURG HOSP-NORTH VALLEY No No No No No 3240 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106334564 TEMECULA VALLEY HOSPITAL No No No No No 2180 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106120981 THE GENERAL HOSPITAL No No No No No 2570 13869 13587 NA NA NA NA $1507 $98163 $80582 106564121 THOUSAND OAKS SURGICAL HOSPITAL No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106190422 TORRANCE MEM MED CTR No No No No No 1952 12882 12620 $6289 $7436 $5891 Transition NA $98163 $80582 106370780 TRI-CITY MED CTR No Yes No No No 3695 12882 12620 $6289 $7436 $7706 Transition $1220 $98163 $80582 106190784 TEMPLE COMM HOSP No No No No No 4200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540816 TULARE DIST HOSP No Yes No No No 3578 12882 12620 $6289 $7436 $9529 Transition NA $98163 $80582 106531059 TRINITY HOSP No Yes No Yes Yes 5105 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106400548 TWIN CITIES COMM HOSP No No No Yes Yes 1587 12964 12701 $12768 $15168 $8160 Transition NA $98163 $80582 106341006 UC DAVIS MED CTR Yes No Yes No No 1836 15256 14946 $6289 $8454 NA NA NA NA NA 106301279 UC IRVINE MED CTR Yes No Yes No No 2072 12882 12620 $6289 $7436 NA NA NA NA NA 106370782 UCSD MED CTR Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106374141 UCSD-LA JOLLA JOHN M amp SALLY B THORNTON HOSPITAL Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106381154 UCSF MED CTR Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106380895 UCSF MED CTR AT MOUNT ZION Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106301357 TUSTIN HOSP MED CTR No No No No No 231 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106231396 UKIAH VALLEY MED CTRHOSP DR No No No Yes Yes 3643 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106014050 VALLEY CARE MEDICAL CENTER No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106010983 VALLEY MEM HOSP-LIVERMORE No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106191216 USC KENNETH NORRIS JR CANCER HOSP No No No No No 3134 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560481 VENTURA CO MED CTR Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106560521 VENTURA CO MED CTR-SANTA PAULA HOSPITAL Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106190818 VERDUGO HILLS HOSP No No No No No 3110 12882 12620 $6289 $7436 $5264 Transition NA $98163 $80582 106190812 VALLEY PRES HOSP No No No No No 3536 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 3046 14188 13900 $6289 $7996 NA Non-Transition $1312 $98163 $80582 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 3266 12882 12620 $6289 $7436 $8320 Transition NA $98163 $80582 106010987 WASHINGTON HOSP-FREMONT No Yes No No No 1941 16962 16618 $6289 $9186 $6429 Transition NA $98163 $80582 106444013 WATSONVILLE COMM HOSP No No No No No 1780 17239 16889 $6289 $9304 $13456 Transition NA $98163 $80582 106301379 WEST ANAHEIM MED CTR No No No No No 1514 12882 12620 $6289 $7436 $4707 Transition NA $98163 $80582 106190859 WEST HILLS HOSP AND MED CTR No No No No No 1933 12882 12620 $6289 $7436 $8050 Transition NA $98163 $80582 106374094 VIBRA OF SAN DIEGO No No No No No 1155 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301188 WESTERN MED CTR-ANAHEIM No No No No No 3203 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301566 WESTERN MED CTR-SANTA ANA No No No No No 2354 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190878 WHITE MEM MED CTR No No No No No 1515 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190883 WHITTIER HOSP MED CTR No No No No No 1139 12882 12620 $6289 $7436 $5922 Transition NA $98163 $80582 106571086 WOODLAND MEM HOSP No No No No No 3278 15256 14946 $6289 $8454 $10092 Transition NA $98163 $80582 6102015
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
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OSHPD ID NAME DPH NDPH
Designated NICU as Defined by DHCS
Med care Rural Hospital (OSHPD)
Remote Rural as Defined by DHCS
FY 2015shy16 Cost to-Charge Rat o
FY 2015shy16 Wage Index Value
FY 2015 Wage Index Value (Adjusted for CA Neutrality Factor 09797)
FY 2015-16 Unadjusted Remote Rural Statew de Base Rate
FY 2015-16 Wage Adjusted Statew de Base Rate (Non Transition)
FY 2015-16 Hospital-Specific Transition Base Rate
Transition Non-Transition
FY 2015-16 Rehab Rate
FY 2015shy16 Subacute 190 Rate
FY 2015shy16 Subacute 199 Rate
106334564 TEMECULA VALLEY HOSPITAL No No No No No 2180 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106120981 THE GENERAL HOSPITAL No No No No No 2570 13869 13587 NA NA NA NA $1507 $98163 $80582 106564121 THOUSAND OAKS SURGICAL HOSPITAL No No No No No 2558 12882 12620 $6289 $7436 $4734 Transition $1220 $98163 $80582 106190422 TORRANCE MEM MED CTR No No No No No 1952 12882 12620 $6289 $7436 $5891 Transition NA $98163 $80582 106370780 TRI-CITY MED CTR No Yes No No No 3695 12882 12620 $6289 $7436 $7706 Transition $1220 $98163 $80582 106190784 TEMPLE COMM HOSP No No No No No 4200 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106540816 TULARE DIST HOSP No Yes No No No 3578 12882 12620 $6289 $7436 $9529 Transition NA $98163 $80582 106531059 TRINITY HOSP No Yes No Yes Yes 5105 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106400548 TWIN CITIES COMM HOSP No No No Yes Yes 1587 12964 12701 $12768 $15168 $8160 Transition NA $98163 $80582 106341006 UC DAVIS MED CTR Yes No Yes No No 1836 15256 14946 $6289 $8454 NA NA NA NA NA 106301279 UC IRVINE MED CTR Yes No Yes No No 2072 12882 12620 $6289 $7436 NA NA NA NA NA 106370782 UCSD MED CTR Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106374141 UCSD-LA JOLLA JOHN M amp SALLY B THORNTON HOSPITAL Yes No Yes No No 3578 12882 12620 $6289 $7436 NA NA NA NA NA 106381154 UCSF MED CTR Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106380895 UCSF MED CTR AT MOUNT ZION Yes No Yes No No 2236 16738 16398 $6289 $9090 NA NA NA NA NA 106301357 TUSTIN HOSP MED CTR No No No No No 231 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106231396 UKIAH VALLEY MED CTRHOSP DR No No No Yes Yes 3643 12882 12620 $12768 $15097 NA Non-Transition NA $98163 $80582 106014050 VALLEY CARE MEDICAL CENTER No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106010983 VALLEY MEM HOSP-LIVERMORE No No No No No 2085 16962 16618 $6289 $9186 $14176 Transition NA $98163 $80582 106191216 USC KENNETH NORRIS JR CANCER HOSP No No No No No 3134 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106560481 VENTURA CO MED CTR Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106560521 VENTURA CO MED CTR-SANTA PAULA HOSPITAL Yes No Yes No No 2485 12882 12620 $6289 $7436 NA NA NA NA NA 106190818 VERDUGO HILLS HOSP No No No No No 3110 12882 12620 $6289 $7436 $5264 Transition NA $98163 $80582 106190812 VALLEY PRES HOSP No No No No No 3536 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 3046 14188 13900 $6289 $7996 NA Non-Transition $1312 $98163 $80582 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 3500 15256 14946 $6289 $8454 NA Non-Transition NA $98163 $80582 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 3266 12882 12620 $6289 $7436 $8320 Transition NA $98163 $80582 106010987 WASHINGTON HOSP-FREMONT No Yes No No No 1941 16962 16618 $6289 $9186 $6429 Transition NA $98163 $80582 106444013 WATSONVILLE COMM HOSP No No No No No 1780 17239 16889 $6289 $9304 $13456 Transition NA $98163 $80582 106301379 WEST ANAHEIM MED CTR No No No No No 1514 12882 12620 $6289 $7436 $4707 Transition NA $98163 $80582 106190859 WEST HILLS HOSP AND MED CTR No No No No No 1933 12882 12620 $6289 $7436 $8050 Transition NA $98163 $80582 106374094 VIBRA OF SAN DIEGO No No No No No 1155 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106301188 WESTERN MED CTR-ANAHEIM No No No No No 3203 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106301566 WESTERN MED CTR-SANTA ANA No No No No No 2354 12882 12620 $6289 $7436 NA Non-Transition NA $98163 $80582 106190878 WHITE MEM MED CTR No No No No No 1515 12882 12620 $6289 $7436 NA Non-Transition $1220 $98163 $80582 106190883 WHITTIER HOSP MED CTR No No No No No 1139 12882 12620 $6289 $7436 $5922 Transition NA $98163 $80582 106571086 WOODLAND MEM HOSP No No No No No 3278 15256 14946 $6289 $8454 $10092 Transition NA $98163 $80582 6102015
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
-
DRG Base Rate For each stay the DRG base payment is calculated as the relative weight for the specific APR-DRG times a hospital-specific DRG base rate (what Medicare calls the standard amount) For the relative weight see the DRG tab
The DRG base rate reflects several factors 1) A statewide DRG base rate set to achieve the overall budget target for fee-for-service Medi-Cal inpatient care The statewide DRG base rate for FY 2015-16 is $6289 2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate is $12768
3) The statewide DRG base rate is adjusted by the local wage area in a similar fashion to what Medicare does The wage index value reflects the various hospital-specific adjustments the Medicare uses (from the Medicare impact file) The following table shows the values by wage area note that Medicare sometimes assigns wage area values to specific hospitals that are not shown in the following table Also note that the wage index values assigned by Medicare have been mtuliplied by 09797 This adjustment controls for changes between California and the rest of the US while maintaining relative differences among wage areas within California See the Hospital Characteristics tab Column J for specific wage index values The labor component of the DRG base rate is adjusted for differences in local area wages as shown in the calculator below
4) In FY 2015-16 the statewide base rate is only applicable to non-transition hospitals During a three-year transition period (Year 3 begins July 1 2015) transition hospitals are paid a DRG base rate that moves them in steps toward the statewide base rate See the Hospital Characteristics tab Column L for the hospital-specific base rates for non-transition hospitals and Column M for transition hospitals
Statewide DRG base rate FY 2015-16 $6289 Remote rural statewide DRG base rate FY 2015-16 $12768
Wage Area Index Values FY 2015-16 Wage Index Statewide Base Value (Adjusted for CA Rate $6289) Remote Rural Statewide
FY 2015-16 Wage Index Neutrality Factor Adjusted by Wage Base Rate ($12768) CBSA Number Medicare Wage Area Value 09797) Area Adjusted by Wage Area
05 California (Rural) 12882 12620 $7436 $15097 11244 Anaheim-Santa Ana-Irvine CA 12882 12620 $7436 $15097 12540 Bakersfield CA 12882 12620 $7436 $15097 17020 Chico CA 12882 12620 $7436 $15097 20940 El Centro CA 12882 12620 $7436 $15097 23420 Fresno CA 12882 12620 $7436 $15097 25260 Hanford-Corcoran CA 12882 12620 $7436 $15097 31084 Los Angeles-Long Beach-Glendale CA 12882 12620 $7436 $15097 31460 Madera CA 12882 12620 $7436 $15097 32900 Merced CA 12882 12620 $7436 $15097 33700 Modesto CA 12892 12630 $7440 $15105 33700 Modesto CA -- reclassified hospitals 12882 12620 $7436 $15097 34900 Napa CA 15604 15287 $8603 $17467 36084 Oakland-Hayward-Berkeley CA 16478 16143 $8978 $18227 36084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 16315 15984 $8908 $18086 37100 Oxnard-Thousand Oaks-Ventura CA 12882 12620 $7436 $15097 39820 Redding CA 14188 13900 $7996 $16234 39820 Redding CA -- reclassified hospitals 13869 13587 $7859 $15956 40140 Riverside-San Bernardino-Ontario CA 12882 12620 $7436 $15097 40900 Sacramento--Roseville--Arden-Arcade CA 15256 14946 $8454 $17164 41500 Salinas CA 15558 15242 $8584 $17426 41740 San Diego-Carlsbad CA 12882 12620 $7436 $15097 41884 San Francisco-Redwood City-South San Francisco CA 16738 16398 $9090 $18454 41940 San Jose-Sunnyvale-Santa Clara CA 17180 16831 $9279 $18839 41940 San Jose-Sunnyvale-Santa Clara CA -- reclassified hospitals 16962 16618 $9186 $18649 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12882 12620 $7436 $15097 42020 San Luis Obispo-Paso Robles-Arroyo Grande CA -- reclassified hospitals 12882 12620 $7436 $15097 42034 San Rafael CA 16855 16513 $9140 $18556 42100 Santa Cruz-Watsonville CA 17239 16889 $9304 $18890 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 16928 16584 $9171 $18619 42200 Santa Maria-Santa Barbara CA 12882 12620 $7436 $15097 42220 Santa Rosa CA 16188 15859 $8854 $17975 44700 Stockton-Lodi CA 13579 13303 $7735 $15704 46700 Vallejo-Fairfield CA 16121 15794 $8825 $17917 47300 Visalia-Porterville CA 12882 12620 $7436 $15097 49700 Yuba City CA 12882 12620 $7436 $15097
Source CMS Medicare inpatient final rule for FFY 2015
- 1-Cover
- 2-Calculator
- 3-DRG Table
- 4-Hospital Characteristics
- 5-DRG Base Rate
-
