W17-888 CA Medi-Cal APR-DRG 2017-18 Pricing …€¦ · 24-05-2017 · APR-DRG Description National Average Length of Stay HSRV Casemix Relative Weight Policy Adjustor -- NICU Policy

Medi-Cal DRG 2017-18 Pricing Calculator

Medi-Cal DRG Pricing Calculator for FY 2017-18 Effective for Dates of Admission Between July 1 2017 and June 30 2018 May 22 2017 W17-888

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 2017 through June 30 2018 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 2017 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 tab shows information specific to each DRG The Hospital Characteristics tab shows information specific to each hospital The DRG Base Ratetab provides information related to wage area and base rate determination

Effective July 1 2017 outlier payments are to be calculated using a single cost outlier threshold with corresponding marginal cost percentage In previous years a two-tiered system was used to calculate payments

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 tab 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 to 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 Conduent 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

Tab 1- Cover 2017-05-22

A B C D 2 - 3

11 Indicates information to be input by the user Indicates payment policy parameters set by Medi-Cal 12 Information Data COMMENTS OR FORMULA 13 14 $10000000

INFORMATION FROM THE HOSPITAL -- TO BE ENTERED BY THE USER

Medi Cal DRG Pricing Calculator Effective Dates of Admission on or after July 1 2017 May 22 2017 Instructions 1 The hospital or other user inputs data in cells C14-C23 amp C34 Values for cell C34 can be found on the Hospital Characteristics tab

6 2 Medi-Cal payment policy parameters have already been entered in cells C35-C39 7 3 The calculator will show the predicted allowed amount and paid amount in cells C66 and C70 respectively 8 4 Length of Stay (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 05 63 65 66 82 85 91 93 and 94

6 This calculator spreadsheet is intended to be helpful to users but it cannot capture all the editing and pricing complexity of the Medi-Cal claims processing system In cases of difference the claims processing system is correct

Total charges UB-04 Form Locator 47 Hospital-specific cost-to-charge ratio Look up from Tab 4 Column H

16 Length of stay 10 No 25

$000 $000

See instruction 4 used for transfer pricing adjustment

17 Patient discharge status = transfer See instruction 5 used for transfer pricing adjustment

18 Patient age (in years) Used for age adjustor

19 Other health coverage UB-04 Form Locator 54 for payments by third parties Patient share of cost Includes spend-down or copayment

21 Is discharge status equal to 30 Indicates an interim claim

22 Designated NICU facility Look up from Tab 4 Column E

23 APR-DRG From separate APR-DRG grouping software See values on Tab 3

24 APR-DRG INFORMATION -- CALCULATOR WILL FILL IN VALUES AUTOMATICALLY APR-DRG description LIVER TRANSPLANT

ampOR INTESTINAL TRANSPLANT

Look up from DRG table (Tab 3 Column B)

Casemix relative weight--unadjusted 70672 Look up from DRG table (Tab 3 Column D)

NICU service adjustor - hospital with 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) Pediatric age adjustor 14500 Look up from DRG table (Tab 3 Column H) Payment relative weight 70672 IF C18lt21 then if (C22=Yes) then (C26C27C29C30) else (C26C28C29C30)

else if (C22=Yes) then (C26C27C29) else (C26C28C29) 31

National average length of stay for this APR-DRG 655 Look up from DRG table (Tab 3 Column C)

PAYMENT POLICY PARAMETERS SET BY MEDI-CAL DRG base rate $7936 Specific to each hospital (Tab 4 Column L) Cost outlier threshold $60000 Threshold qualifying high and low-cost outlier adjustments

Marginal cost percentage 50 Used for high and low-cost outlier adjustments

37 Casemix adjustment factor 100 Used to adjust DRG relative weights should a need arise else leave set to 100

38 Interim claim threshold 29 Threshold qualifying interim claims

39 Interim per diem amount $600 Used for pricing interim claims

IS THIS AN INTERIM CLAIM Is discharge status equal to 30 No Look up C21

Is length of stay gt interim claim threshold NA IF C41=Yes then if (C16gtC38) Yes else No else NA

43 Skip to C70 for final interim claim payment amount $000 IF C42=Yes (C39C16) rounded to 2 places else 0

44 WHAT IS THE DRG BASE PAYMENT DRG base payment for this claim $5575314 C34C31C37

46 IS A TRANSFER PAYMENT ADJUSTMENT MADE Is a transfer adjustment potentially applicable No Look up C17

Calculated transfer payment adjustment NA IF C47=Yes then (C45C32)(C16+1) rounded to 2 places else NA

49 Is transfer payment adjustment lt allowed amount so far NA IF C48=NA then NA else if (C48ltC45) then Yes else No Allowed amount after transfer adjustment $5575314 IF C49=Yes then C48 else C45

51 IS A COST OUTLIER ADJUSTMENT MADE Estimated cost of this case $3000000 C14C15

Is estimated cost gt allowed amount Gain IF C52gtC50 then Loss else Gain

54 High-Side Outlier Payment When Payment Is Much Lower than Cost Estimated loss on this case NA IF C53=Loss then (C52-C50) else NA

56 Is loss gt outlier threshold lower limit NA IF C53=Loss then if (C55gtC35) then Yes else No else NA

57 DRG cost outlier payment increase $000 IF C56 =Yes then if (C55gtC35) then ((C55-C35)C36) else 0

58 Low Side Outlier Payment When Payment Is Much Greater than Cost Estimated gain on this case $2575314 IF C53=Gain then (C50-C52) elseNA Is gain gt outlier threshold No IF C53=Gain then if (C59gtC35) then Yes else No else NA DRG cost outlier payment decrease $000 IF C53=Gain then (if (C60=Yes) then (C59-C35)C36 rounded to 2 places else 0)

else 0

62 ALLOWED AMOUNT AFTER TRANSFER AND OUTLIER ADJUSTMENTS DRG payment so far $5575314 IF C53=Loss then (C50+C57) else (C50-C61)

CALCULATION OF ALLOWED AMOUNT AND REIMBURSEMENT AMOUNT Add-on amount $000 Hospital-specific payment separate from DRG payment (not used at this time)

66 Allowed amount $5575314 Allowed amount = C63+C65 67 Other health coverage $000 Look up C19 68 Patient share of cost $000 Look up C20

Lesser of calculation $5575314 Existing policy requires that payment amount cannot exceed total charges If C66gtC14 then C14 else C66 69

Payment amount 0 $5575314

If interim claim (C41=Yes) then interim claim (C43) amount is the payment amount Otherwise subtract other health coverage (C67) and patient share of cost (C68) from Lesser of (C69) to obtain payment amount

Tab 2- Calculator 2017-05-22

-Medi Cal DRG Table Effective July 1 2017 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 V34 3 Average length of stay is the untrimmed arithmetic value 4 Casemix relative weights reflect Hospital-Specific Relative Value (HSRV) relative weights V34 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 hospital specific DRG base rates 6 Pediatric is defined as under age 21 7 This table shows information for 1274 DRGs (318 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) for example are paid outside the DRG method 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 10 This calculator was developed by Conduent the fiscal intermediary contractor for Medi-Cal

APRshyDRG APR-DRG Description

National Average

Length of Stay

HSRV Casemix

Relative Weight

Policy --Adjustor

Obstetrics

Payment Relative

--Weight No Age Adjustor

Policy --Adjustor

Pediatric Age

Payment Relative

Weight-- with Age

Adjustor

--Policy Adjustor Service

(Designated NICUs)

Payment Relative Weight

with Designated NICU Adjustor

DRG Base Payment Using Example Base Rate $7500

Medicaid Care --Category

Pediatric Medicaid Care

--Category Adult

001-1 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 655 70672 10000 10000 70672 14500 102474 10000 70672 $76856 Misc Pediatric Gastroent Adult 001-2 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 830 71906 10000 10000 71906 14500 104264 10000 71906 $78198 Misc Pediatric Gastroent Adult 001-3 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 1250 87573 10000 10000 87573 14500 126981 10000 87573 $95236 Misc Pediatric Gastroent Adult 001-4 LIVER TRANSPLANT ampOR INTESTINAL TRANSPLANT 2801 140908 10000 10000 140908 14500 204317 10000 140908 $153237 Misc Pediatric Gastroent Adult 002-1 HEART ampOR LUNG TRANSPLANT 989 89132 10000 10000 89132 14500 129241 10000 89132 $96931 Misc Pediatric Misc Adult 002-2 HEART ampOR LUNG TRANSPLANT 1530 101294 10000 10000 101294 14500 146876 10000 101294 $110157 Misc Pediatric Misc Adult 002-3 HEART ampOR LUNG TRANSPLANT 2218 121843 10000 10000 121843 14500 176672 10000 121843 $132504 Misc Pediatric Misc Adult 002-4 HEART ampOR LUNG TRANSPLANT 4155 187899 10000 10000 187899 14500 272454 10000 187899 $204340 Misc Pediatric Misc Adult 003-1 BONE MARROW TRANSPLANT 1743 44629 10000 10000 44629 14500 64712 10000 44629 $48534 Misc Pediatric Misc Adult 003-2 BONE MARROW TRANSPLANT 2229 61879 10000 10000 61879 14500 89725 10000 61879 $67293 Misc Pediatric Misc Adult 003-3 BONE MARROW TRANSPLANT 3239 98390 10000 10000 98390 14500 142666 10000 98390 $106999 Misc Pediatric Misc Adult 003-4 BONE MARROW TRANSPLANT 4774 165865 10000 10000 165865 14500 240504 10000 165865 $180378 Misc Pediatric Misc Adult 004-1 TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO 1207 50965 10000 10000 50965 14500 73899 10000 50965 $55424 Misc Pediatric Misc Adult 004-2 TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO 2001 65597 10000 10000 65597 14500 95116 10000 65597 $71337 Misc Pediatric Misc Adult 004-3 TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO 2583 92437 10000 10000 92437 14500 134034 10000 92437 $100525 Misc Pediatric Misc Adult 004-4 TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE OR ECMO 3775 137090 10000 10000 137090 14500 198781 10000 137090 $149085 Misc Pediatric Misc Adult 005-1 TRACHEOSTOMY W MV 96+ HOURS WO EXTENSIVE PROCEDURE 3338 46637 10000 10000 46637 14500 67624 10000 46637 $50718 Misc Pediatric Misc Adult 005-2 TRACHEOSTOMY W MV 96+ HOURS WO EXTENSIVE PROCEDURE 1808 49799 10000 10000 49799 14500 72209 10000 49799 $54156 Misc Pediatric Misc Adult 005-3 TRACHEOSTOMY W MV 96+ HOURS WO EXTENSIVE PROCEDURE 2284 64167 10000 10000 64167 14500 93042 10000 64167 $69782 Misc Pediatric Misc Adult 005-4 TRACHEOSTOMY W MV 96+ HOURS WO EXTENSIVE PROCEDURE 3063 89117 10000 10000 89117 14500 129220 10000 89117 $96915 Misc Pediatric Misc Adult 006-1 PANCREAS TRANSPLANT 671 56238 10000 10000 56238 14500 81545 10000 56238 $61159 Misc Pediatric Gastroent Adult 006-2 PANCREAS TRANSPLANT 724 74867 10000 10000 74867 14500 108557 10000 74867 $81418 Misc Pediatric Gastroent Adult 006-3 PANCREAS TRANSPLANT 1040 92748 10000 10000 92748 14500 134485 10000 92748 $100863 Misc Pediatric Gastroent Adult 006-4 PANCREAS TRANSPLANT 2438 139750 10000 10000 139750 14500 202638 10000 139750 $151978 Misc Pediatric Gastroent Adult 020-1 CRANIOTOMY FOR TRAUMA 539 17546 10000 10000 17546 14500 25442 10000 17546 $19081 Misc Pediatric Misc Adult 020-2 CRANIOTOMY FOR TRAUMA 670 22892 10000 10000 22892 14500 33193 10000 22892 $24895 Misc Pediatric Misc Adult 020-3 CRANIOTOMY FOR TRAUMA 1038 31216 10000 10000 31216 14500 45263 10000 31216 $33947 Misc Pediatric Misc Adult 020-4 CRANIOTOMY FOR TRAUMA 1976 62104 10000 10000 62104 14500 90051 10000 62104 $67538 Misc Pediatric Misc Adult 021-1 CRANIOTOMY EXCEPT FOR TRAUMA 375 19215 10000 10000 19215 14500 27862 10000 19215 $20896 Misc Pediatric Misc Adult 021-2 CRANIOTOMY EXCEPT FOR TRAUMA 564 24800 10000 10000 24800 14500 35960 10000 24800 $26970 Misc Pediatric Misc Adult 021-3 CRANIOTOMY EXCEPT FOR TRAUMA 1036 36827 10000 10000 36827 14500 53399 10000 36827 $40049 Misc Pediatric Misc Adult 021-4 CRANIOTOMY EXCEPT FOR TRAUMA 1975 62984 10000 10000 62984 14500 91327 10000 62984 $68495 Misc Pediatric Misc Adult 022-1 VENTRICULAR SHUNT PROCEDURES 268 12209 10000 10000 12209 14500 17703 10000 12209 $13277 Misc Pediatric Misc Adult 022-2 VENTRICULAR SHUNT PROCEDURES 438 14415 10000 10000 14415 14500 20902 10000 14415 $15676 Misc Pediatric Misc Adult 022-3 VENTRICULAR SHUNT PROCEDURES 864 22439 10000 10000 22439 14500 32537 10000 22439 $24402 Misc Pediatric Misc Adult 022-4 VENTRICULAR SHUNT PROCEDURES 2011 49533 10000 10000 49533 14500 71823 10000 49533 $53867 Misc Pediatric Misc Adult 023-1 SPINAL PROCEDURES 324 12491 10000 10000 12491 14500 18112 10000 12491 $13584 Misc Pediatric Misc Adult 023-2 SPINAL PROCEDURES 562 17747 10000 10000 17747 14500 25733 10000 17747 $19300 Misc Pediatric Misc Adult 023-3 SPINAL PROCEDURES 1003 34754 10000 10000 34754 14500 50393 10000 34754 $37795 Misc Pediatric Misc Adult 023-4 SPINAL PROCEDURES 2041 63028 10000 10000 63028 14500 91391 10000 63028 $68543 Misc Pediatric Misc Adult 024-1 EXTRACRANIAL VASCULAR PROCEDURES 154 11134 10000 10000 11134 14500 16144 10000 11134 $12108 Misc Pediatric Misc Adult 024-2 EXTRACRANIAL VASCULAR PROCEDURES 283 14184 10000 10000 14184 14500 20567 10000 14184 $15425 Misc Pediatric Misc Adult 024-3 EXTRACRANIAL VASCULAR PROCEDURES 727 26755 10000 10000 26755 14500 38795 10000 26755 $29096 Misc Pediatric Misc Adult 024-4 EXTRACRANIAL VASCULAR PROCEDURES 1555 53420 10000 10000 53420 14500 77459 10000 53420 $58094 Misc Pediatric Misc Adult 026-1 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 253 11359 10000 10000 11359 14500 16471 10000 11359 $12353 Misc Pediatric Misc Adult 026-2 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 439 15215 10000 10000 15215 14500 22062 10000 15215 $16546 Misc Pediatric Misc Adult 026-3 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 809 22548 10000 10000 22548 14500 32695 10000 22548 $24521 Misc Pediatric Misc Adult 026-4 OTHER NERVOUS SYSTEM amp RELATED PROCEDURES 1913 43281 10000 10000 43281 14500 62757 10000 43281 $47068 Misc Pediatric Misc Adult 040-1 SPINAL DISORDERS amp INJURIES 359 08113 10000 10000 08113 14500 11764 10000 08113 $8823 Misc Pediatric Misc Adult 040-2 SPINAL DISORDERS amp INJURIES 495 09595 10000 10000 09595 14500 13913 10000 09595 $10435 Misc Pediatric Misc Adult 040-3 SPINAL DISORDERS amp INJURIES 817 13403 10000 10000 13403 14500 19434 10000 13403 $14576 Misc Pediatric Misc Adult 040-4 SPINAL DISORDERS amp INJURIES 1638 30251 10000 10000 30251 14500 43864 10000 30251 $32898 Misc Pediatric Misc Adult 041-1 NERVOUS SYSTEM MALIGNANCY 297 06937 10000 10000 06937 14500 10059 10000 06937 $7544 Misc Pediatric Misc Adult 041-2 NERVOUS SYSTEM MALIGNANCY 384 07291 10000 10000 07291 14500 10572 10000 07291 $7929 Misc Pediatric Misc Adult 041-3 NERVOUS SYSTEM MALIGNANCY 573 10147 10000 10000 10147 14500 14713 10000 10147 $11035 Misc Pediatric Misc Adult 041-4 NERVOUS SYSTEM MALIGNANCY 901 15897 10000 10000 15897 14500 23051 10000 15897 $17288 Misc Pediatric Misc Adult 042-1 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 465 05190 10000 10000 05190 14500 07526 10000 05190 $5644 Misc Pediatric Misc Adult 042-2 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 880 07514 10000 10000 07514 14500 10895 10000 07514 $8171 Misc Pediatric Misc Adult

Tab 3- DRG Table 2017-05-22

APR -DRG -APR DRG Description

National Average Length of Stay

HSRV Casemix Relative Weight

Policy Adjustor --NICU

Policy Adjustor --Obstetrics

Payment Relative --Weight

No Age Adjustor Policy Adjustor --Pediatric Age

Payment --Relative Weight

with Age Adjustor

Policy Adjustor --Service (Designated NICUs)

Payment Relative Weight with Designated NICU Adjustor

Medicaid Care Category --Pediatric

Medicaid Care Category --Adult

042-3 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 865 10365 10000 10000 10365 14500 15029 10000 10365 $11272 Misc Pediatric Misc Adult 042-4 DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS 1379 24560 10000 10000 24560 14500 35612 10000 24560 $26709 Misc Pediatric Misc Adult 043-1 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 371 06764 10000 10000 06764 14500 09808 10000 06764 $7356 Misc Pediatric Misc Adult 043-2 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 495 08652 10000 10000 08652 14500 12545 10000 08652 $9409 Misc Pediatric Misc Adult 043-3 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 773 13261 10000 10000 13261 14500 19228 10000 13261 $14421 Misc Pediatric Misc Adult 043-4 MULTIPLE SCLEROSIS amp OTHER DEMYELINATING DISEASES 1627 29314 10000 10000 29314 14500 42505 10000 29314 $31879 Misc Pediatric Misc Adult 044-1 INTRACRANIAL HEMORRHAGE 370 07161 10000 10000 07161 14500 10383 10000 07161 $7788 Misc Pediatric Misc Adult 044-2 INTRACRANIAL HEMORRHAGE 477 09570 10000 10000 09570 14500 13877 10000 09570 $10407 Misc Pediatric Misc Adult 044-3 INTRACRANIAL HEMORRHAGE 676 13449 10000 10000 13449 14500 19501 10000 13449 $14626 Misc Pediatric Misc Adult 044-4 INTRACRANIAL HEMORRHAGE 1284 25670 10000 10000 25670 14500 37222 10000 25670 $27916 Misc Pediatric Misc Adult 045-1 CVA amp PRECEREBRAL OCCLUSION W INFARCT 269 07483 10000 10000 07483 14500 10850 10000 07483 $8138 Misc Pediatric Misc Adult 045-2 CVA amp PRECEREBRAL OCCLUSION W INFARCT 379 08969 10000 10000 08969 14500 13005 10000 08969 $9754 Misc Pediatric Misc Adult 045-3 CVA amp PRECEREBRAL OCCLUSION W INFARCT 620 12322 10000 10000 12322 14500 17867 10000 12322 $13400 Misc Pediatric Misc Adult 045-4 CVA amp PRECEREBRAL OCCLUSION W INFARCT 1185 23889 10000 10000 23889 14500 34639 10000 23889 $25979 Misc Pediatric Misc Adult 046-1 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 238 06566 10000 10000 06566 14500 09521 10000 06566 $7141 Misc Pediatric Misc Adult 046-2 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 312 07714 10000 10000 07714 14500 11185 10000 07714 $8389 Misc Pediatric Misc Adult 046-3 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 468 10540 10000 10000 10540 14500 15283 10000 10540 $11462 Misc Pediatric Misc Adult 046-4 NONSPECIFIC CVA amp PRECEREBRAL OCCLUSION WO INFARCT 1232 25877 10000 10000 25877 14500 37522 10000 25877 $28141 Misc Pediatric Misc Adult 047-1 TRANSIENT ISCHEMIA 184 05957 10000 10000 05957 14500 08638 10000 05957 $6478 Misc Pediatric Misc Adult 047-2 TRANSIENT ISCHEMIA 241 06587 10000 10000 06587 14500 09551 10000 06587 $7163 Misc Pediatric Misc Adult 047-3 TRANSIENT ISCHEMIA 359 08167 10000 10000 08167 14500 11842 10000 08167 $8882 Misc Pediatric Misc Adult 047-4 TRANSIENT ISCHEMIA 767 14796 10000 10000 14796 14500 21454 10000 14796 $16091 Misc Pediatric Misc Adult 048-1 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 272 05428 10000 10000 05428 14500 07871 10000 05428 $5903 Misc Pediatric Misc Adult 048-2 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 374 06341 10000 10000 06341 14500 09194 10000 06341 $6896 Misc Pediatric Misc Adult 048-3 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 535 08646 10000 10000 08646 14500 12537 10000 08646 $9403 Misc Pediatric Misc Adult 048-4 PERIPHERAL CRANIAL amp AUTONOMIC NERVE DISORDERS 1282 20617 10000 10000 20617 14500 29895 10000 20617 $22421 Misc Pediatric Misc Adult 049-1 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 556 09030 10000 10000 09030 14500 13094 10000 09030 $9820 Misc Pediatric Misc Adult 049-2 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 670 17606 10000 10000 17606 14500 25529 10000 17606 $19147 Misc Pediatric Misc Adult 049-3 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 1049 22468 10000 10000 22468 14500 32579 10000 22468 $24434 Misc Pediatric Misc Adult 049-4 BACTERIAL amp TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM 1722 39599 10000 10000 39599 14500 57419 10000 39599 $43064 Misc Pediatric Misc Adult 050-1 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 375 05954 10000 10000 05954 14500 08633 10000 05954 $6475 Misc Pediatric Misc Adult 050-2 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 585 10390 10000 10000 10390 14500 15066 10000 10390 $11299 Misc Pediatric Misc Adult 050-3 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 930 17137 10000 10000 17137 14500 24849 10000 17137 $18636 Misc Pediatric Misc Adult 050-4 NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS 1619 35600 10000 10000 35600 14500 51620 10000 35600 $38715 Misc Pediatric Misc Adult 051-1 VIRAL MENINGITIS 279 05297 10000 10000 05297 14500 07681 10000 05297 $5760 Misc Pediatric Misc Adult 051-2 VIRAL MENINGITIS 390 07405 10000 10000 07405 14500 10737 10000 07405 $8053 Misc Pediatric Misc Adult 051-3 VIRAL MENINGITIS 633 12492 10000 10000 12492 14500 18113 10000 12492 $13585 Misc Pediatric Misc Adult 051-4 VIRAL MENINGITIS 1149 25180 10000 10000 25180 14500 36511 10000 25180 $27383 Misc Pediatric Misc Adult 052-1 NONTRAUMATIC STUPOR amp COMA 211 05344 10000 10000 05344 14500 07749 10000 05344 $5812 Misc Pediatric Misc Adult 052-2 NONTRAUMATIC STUPOR amp COMA 318 06196 10000 10000 06196 14500 08984 10000 06196 $6738 Misc Pediatric Misc Adult 052-3 NONTRAUMATIC STUPOR amp COMA 493 08391 10000 10000 08391 14500 12167 10000 08391 $9125 Misc Pediatric Misc Adult 052-4 NONTRAUMATIC STUPOR amp COMA 1127 19594 10000 10000 19594 14500 28411 10000 19594 $21308 Misc Pediatric Misc Adult 053-1 SEIZURE 235 04539 10000 10000 04539 14500 06582 10000 04539 $4936 Misc Pediatric Misc Adult 053-2 SEIZURE 289 05600 10000 10000 05600 14500 08120 10000 05600 $6090 Misc Pediatric Misc Adult 053-3 SEIZURE 432 07863 10000 10000 07863 14500 11401 10000 07863 $8551 Misc Pediatric Misc Adult 053-4 SEIZURE 964 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 054-1 MIGRAINE amp OTHER HEADACHES 252 04965 10000 10000 04965 14500 07199 10000 04965 $5399 Misc Pediatric Misc Adult 054-2 MIGRAINE amp OTHER HEADACHES 290 06043 10000 10000 06043 14500 08762 10000 06043 $6572 Misc Pediatric Misc Adult 054-3 MIGRAINE amp OTHER HEADACHES 388 07394 10000 10000 07394 14500 10721 10000 07394 $8041 Misc Pediatric Misc Adult 054-4 MIGRAINE amp OTHER HEADACHES 688 12375 10000 10000 12375 14500 17944 10000 12375 $13458 Misc Pediatric Misc Adult 055-1 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 233 05713 10000 10000 05713 14500 08284 10000 05713 $6213 Misc Pediatric Misc Adult 055-2 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 360 07794 10000 10000 07794 14500 11301 10000 07794 $8476 Misc Pediatric Misc Adult 055-3 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 603 12294 10000 10000 12294 14500 17826 10000 12294 $13370 Misc Pediatric Misc Adult 055-4 HEAD TRAUMA W COMA gt1 HR OR HEMORRHAGE 1303 26924 10000 10000 26924 14500 39040 10000 26924 $29280 Misc Pediatric Misc Adult 056-1 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 232 05641 10000 10000 05641 14500 08179 10000 05641 $6135 Misc Pediatric Misc Adult 056-2 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 351 07987 10000 10000 07987 14500 11581 10000 07987 $8686 Misc Pediatric Misc Adult 056-3 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 651 12785 10000 10000 12785 14500 18538 10000 12785 $13904 Misc Pediatric Misc Adult 056-4 BRAIN CONTUSIONLACERATION amp COMPLICATED SKULL FX COMA lt 1 HR OR NO COMA 1385 29988 10000 10000 29988 14500 43483 10000 29988 $32612 Misc Pediatric Misc Adult 057-1 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 153 05223 10000 10000 05223 14500 07573 10000 05223 $5680 Misc Pediatric Misc Adult 057-2 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 236 07107 10000 10000 07107 14500 10305 10000 07107 $7729 Misc Pediatric Misc Adult 057-3 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 420 10620 10000 10000 10620 14500 15399 10000 10620 $11549 Misc Pediatric Misc Adult 057-4 CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA lt 1 HR OR NO COMA 1016 22810 10000 10000 22810 14500 33075 10000 22810 $24806 Misc Pediatric Misc Adult 058-1 OTHER DISORDERS OF NERVOUS SYSTEM 266 05684 10000 10000 05684 14500 08242 10000 05684 $6181 Misc Pediatric Misc Adult 058-2 OTHER DISORDERS OF NERVOUS SYSTEM 401 06995 10000 10000 06995 14500 10143 10000 06995 $7607 Misc Pediatric Misc Adult 058-3 OTHER DISORDERS OF NERVOUS SYSTEM 577 09472 10000 10000 09472 14500 13734 10000 09472 $10301 Misc Pediatric Misc Adult 058-4 OTHER DISORDERS OF NERVOUS SYSTEM 1164 20142 10000 10000 20142 14500 29206 10000 20142 $21904 Misc Pediatric Misc Adult 070-1 ORBITAL PROCEDURES 220 08292 10000 10000 08292 14500 12023 10000 08292 $9018 Misc Pediatric Misc Adult 070-2 ORBITAL PROCEDURES 377 11481 10000 10000 11481 14500 16647 10000 11481 $12486 Misc Pediatric Misc Adult 070-3 ORBITAL PROCEDURES 647 19514 10000 10000 19514 14500 28295 10000 19514 $21221 Misc Pediatric Misc Adult 070-4 ORBITAL PROCEDURES 1708 48991 10000 10000 48991 14500 71037 10000 48991 $53278 Misc Pediatric Misc Adult 073-1 EYE PROCEDURES EXCEPT ORBIT 230 07595 10000 10000 07595 14500 11013 10000 07595 $8260 Misc Pediatric Misc Adult 073-2 EYE PROCEDURES EXCEPT ORBIT 337 08943 10000 10000 08943 14500 12967 10000 08943 $9726 Misc Pediatric Misc Adult

with Age Adjustor

073-3 EYE PROCEDURES EXCEPT ORBIT 625 13664 10000 10000 13664 14500 19813 10000 13664 $14860 Misc Pediatric Misc Adult 073-4 EYE PROCEDURES EXCEPT ORBIT 1584 30845 10000 10000 30845 14500 44725 10000 30845 $33544 Misc Pediatric Misc Adult 080-1 ACUTE MAJOR EYE INFECTIONS 299 03995 10000 10000 03995 14500 05793 10000 03995 $4345 Misc Pediatric Misc Adult 080-2 ACUTE MAJOR EYE INFECTIONS 393 05265 10000 10000 05265 14500 07634 10000 05265 $5726 Misc Pediatric Misc Adult 080-3 ACUTE MAJOR EYE INFECTIONS 630 09389 10000 10000 09389 14500 13614 10000 09389 $10211 Misc Pediatric Misc Adult 080-4 ACUTE MAJOR EYE INFECTIONS 848 15689 10000 10000 15689 14500 22749 10000 15689 $17062 Misc Pediatric Misc Adult 082-1 EYE DISORDERS EXCEPT MAJOR INFECTIONS 221 04341 10000 10000 04341 14500 06294 10000 04341 $4721 Misc Pediatric Misc Adult 082-2 EYE DISORDERS EXCEPT MAJOR INFECTIONS 276 05731 10000 10000 05731 14500 08310 10000 05731 $6232 Misc Pediatric Misc Adult 082-3 EYE DISORDERS EXCEPT MAJOR INFECTIONS 429 07979 10000 10000 07979 14500 11570 10000 07979 $8677 Misc Pediatric Misc Adult 082-4 EYE DISORDERS EXCEPT MAJOR INFECTIONS 774 14175 10000 10000 14175 14500 20554 10000 14175 $15415 Misc Pediatric Misc Adult 089-1 MAJOR CRANIALFACIAL BONE PROCEDURES 215 14843 10000 10000 14843 14500 21522 10000 14843 $16142 Misc Pediatric Misc Adult 089-2 MAJOR CRANIALFACIAL BONE PROCEDURES 391 19118 10000 10000 19118 14500 27721 10000 19118 $20791 Misc Pediatric Misc Adult 089-3 MAJOR CRANIALFACIAL BONE PROCEDURES 834 32426 10000 10000 32426 14500 47018 10000 32426 $35263 Misc Pediatric Misc Adult 089-4 MAJOR CRANIALFACIAL BONE PROCEDURES 1706 56708 10000 10000 56708 14500 82227 10000 56708 $61670 Misc Pediatric Misc Adult 090-1 MAJOR LARYNX amp TRACHEA PROCEDURES 292 08743 10000 10000 08743 14500 12677 10000 08743 $9508 Misc Pediatric Misc Adult 090-2 MAJOR LARYNX amp TRACHEA PROCEDURES 790 23014 10000 10000 23014 14500 33370 10000 23014 $25028 Misc Pediatric Misc Adult 090-3 MAJOR LARYNX amp TRACHEA PROCEDURES 1300 36227 10000 10000 36227 14500 52529 10000 36227 $39397 Misc Pediatric Misc Adult 090-4 MAJOR LARYNX amp TRACHEA PROCEDURES 2318 65439 10000 10000 65439 14500 94887 10000 65439 $71165 Misc Pediatric Misc Adult 091-1 OTHER MAJOR HEAD amp NECK PROCEDURES 300 13080 10000 10000 13080 14500 18966 10000 13080 $14225 Misc Pediatric Misc Adult 091-2 OTHER MAJOR HEAD amp NECK PROCEDURES 471 19198 10000 10000 19198 14500 27837 10000 19198 $20878 Misc Pediatric Misc Adult 091-3 OTHER MAJOR HEAD amp NECK PROCEDURES 889 33754 10000 10000 33754 14500 48943 10000 33754 $36707 Misc Pediatric Misc Adult 091-4 OTHER MAJOR HEAD amp NECK PROCEDURES 1432 52164 10000 10000 52164 14500 75638 10000 52164 $56728 Misc Pediatric Misc Adult 092-1 FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES 200 10460 10000 10000 10460 14500 15167 10000 10460 $11375 Misc Pediatric Misc Adult 092-2 FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES 291 14471 10000 10000 14471 14500 20983 10000 14471 $15737 Misc Pediatric Misc Adult 092-3 FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES 564 21831 10000 10000 21831 14500 31655 10000 21831 $23741 Misc Pediatric Misc Adult 092-4 FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES 1330 46605 10000 10000 46605 14500 67577 10000 46605 $50683 Misc Pediatric Misc Adult 093-1 SINUS amp MASTOID PROCEDURES 232 09779 10000 10000 09779 14500 14180 10000 09779 $10635 Misc Pediatric Misc Adult 093-2 SINUS amp MASTOID PROCEDURES 393 12871 10000 10000 12871 14500 18663 10000 12871 $13997 Misc Pediatric Misc Adult 093-3 SINUS amp MASTOID PROCEDURES 735 20784 10000 10000 20784 14500 30137 10000 20784 $22603 Misc Pediatric Misc Adult 093-4 SINUS amp MASTOID PROCEDURES 1152 32567 10000 10000 32567 14500 47222 10000 32567 $35417 Misc Pediatric Misc Adult 095-1 CLEFT LIP amp PALATE REPAIR 154 06959 10000 10000 06959 14500 10091 10000 06959 $7568 Misc Pediatric Misc Adult 095-2 CLEFT LIP amp PALATE REPAIR 206 07955 10000 10000 07955 14500 11535 10000 07955 $8651 Misc Pediatric Misc Adult 095-3 CLEFT LIP amp PALATE REPAIR 377 11610 10000 10000 11610 14500 16835 10000 11610 $12626 Misc Pediatric Misc Adult 095-4 CLEFT LIP amp PALATE REPAIR 890 24400 10000 10000 24400 14500 35380 10000 24400 $26535 Misc Pediatric Misc Adult 097-1 TONSIL amp ADENOID PROCEDURES 165 04280 10000 10000 04280 14500 06206 10000 04280 $4655 Misc Pediatric Misc Adult 097-2 TONSIL amp ADENOID PROCEDURES 268 06316 10000 10000 06316 14500 09158 10000 06316 $6869 Misc Pediatric Misc Adult 097-3 TONSIL amp ADENOID PROCEDURES 498 11245 10000 10000 11245 14500 16305 10000 11245 $12229 Misc Pediatric Misc Adult 097-4 TONSIL amp ADENOID PROCEDURES 1439 32538 10000 10000 32538 14500 47180 10000 32538 $35385 Misc Pediatric Misc Adult 098-1 OTHER EAR NOSE MOUTH amp THROAT PROCEDURES 213 07285 10000 10000 07285 14500 10563 10000 07285 $7922 Misc Pediatric Misc Adult 098-2 OTHER EAR NOSE MOUTH amp THROAT PROCEDURES 318 09518 10000 10000 09518 14500 13801 10000 09518 $10351 Misc Pediatric Misc Adult 098-3 OTHER EAR NOSE MOUTH amp THROAT PROCEDURES 640 15166 10000 10000 15166 14500 21991 10000 15166 $16493 Misc Pediatric Misc Adult 098-4 OTHER EAR NOSE MOUTH amp THROAT PROCEDURES 1389 33380 10000 10000 33380 14500 48401 10000 33380 $36301 Misc Pediatric Misc Adult 110-1 EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES 271 05321 10000 10000 05321 14500 07715 10000 05321 $5787 Misc Pediatric Misc Adult 110-2 EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES 404 06713 10000 10000 06713 14500 09734 10000 06713 $7300 Misc Pediatric Misc Adult 110-3 EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES 688 11408 10000 10000 11408 14500 16542 10000 11408 $12406 Misc Pediatric Misc Adult 110-4 EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES 1180 22182 10000 10000 22182 14500 32164 10000 22182 $24123 Misc Pediatric Misc Adult 111-1 VERTIGO amp OTHER LABYRINTH DISORDERS 198 04856 10000 10000 04856 14500 07041 10000 04856 $5281 Misc Pediatric Misc Adult 111-2 VERTIGO amp OTHER LABYRINTH DISORDERS 248 05612 10000 10000 05612 14500 08137 10000 05612 $6103 Misc Pediatric Misc Adult 111-3 VERTIGO amp OTHER LABYRINTH DISORDERS 344 06967 10000 10000 06967 14500 10102 10000 06967 $7577 Misc Pediatric Misc Adult 111-4 VERTIGO amp OTHER LABYRINTH DISORDERS 818 13366 10000 10000 13366 14500 19381 10000 13366 $14536 Misc Pediatric Misc Adult 113-1 INFECTIONS OF UPPER RESPIRATORY TRACT 190 02857 10000 10000 02857 14500 04143 10000 02857 $3107 Resp Pediatric Resp Adult 113-2 INFECTIONS OF UPPER RESPIRATORY TRACT 262 04259 10000 10000 04259 14500 06176 10000 04259 $4632 Resp Pediatric Resp Adult 113-3 INFECTIONS OF UPPER RESPIRATORY TRACT 397 06606 10000 10000 06606 14500 09579 10000 06606 $7184 Resp Pediatric Resp Adult 113-4 INFECTIONS OF UPPER RESPIRATORY TRACT 657 12157 10000 10000 12157 14500 17628 10000 12157 $13221 Resp Pediatric Resp Adult 114-1 DENTAL amp ORAL DISEASES amp INJURIES 222 03971 10000 10000 03971 14500 05758 10000 03971 $4318 Misc Pediatric Misc Adult 114-2 DENTAL amp ORAL DISEASES amp INJURIES 300 05529 10000 10000 05529 14500 08017 10000 05529 $6013 Misc Pediatric Misc Adult 114-3 DENTAL amp ORAL DISEASES amp INJURIES 556 09217 10000 10000 09217 14500 13365 10000 09217 $10023 Misc Pediatric Misc Adult 114-4 DENTAL amp ORAL DISEASES amp INJURIES 1071 19812 10000 10000 19812 14500 28727 10000 19812 $21546 Misc Pediatric Misc Adult 115-1 OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES 224 04113 10000 10000 04113 14500 05964 10000 04113 $4473 Misc Pediatric Misc Adult 115-2 OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES 286 05689 10000 10000 05689 14500 08249 10000 05689 $6187 Misc Pediatric Misc Adult 115-3 OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES 463 08378 10000 10000 08378 14500 12148 10000 08378 $9111 Misc Pediatric Misc Adult 115-4 OTHER EAR NOSE MOUTHTHROAT amp CRANIALFACIAL DIAGNOSES 869 16576 10000 10000 16576 14500 24035 10000 16576 $18026 Misc Pediatric Misc Adult 120-1 MAJOR RESPIRATORY amp CHEST PROCEDURES 462 17834 10000 10000 17834 14500 25859 10000 17834 $19394 Resp Pediatric Resp Adult 120-2 MAJOR RESPIRATORY amp CHEST PROCEDURES 660 22272 10000 10000 22272 14500 32294 10000 22272 $24221 Resp Pediatric Resp Adult 120-3 MAJOR RESPIRATORY amp CHEST PROCEDURES 1093 31510 10000 10000 31510 14500 45690 10000 31510 $34267 Resp Pediatric Resp Adult 120-4 MAJOR RESPIRATORY amp CHEST PROCEDURES 1844 52371 10000 10000 52371 14500 75938 10000 52371 $56953 Resp Pediatric Resp Adult 121-1 OTHER RESPIRATORY amp CHEST PROCEDURES 332 11924 10000 10000 11924 14500 17290 10000 11924 $12967 Resp Pediatric Resp Adult 121-2 OTHER RESPIRATORY amp CHEST PROCEDURES 545 15314 10000 10000 15314 14500 22205 10000 15314 $16654 Resp Pediatric Resp Adult 121-3 OTHER RESPIRATORY amp CHEST PROCEDURES 978 23223 10000 10000 23223 14500 33673 10000 23223 $25255 Resp Pediatric Resp Adult 121-4 OTHER RESPIRATORY amp CHEST PROCEDURES 1740 43525 10000 10000 43525 14500 63111 10000 43525 $47333 Resp Pediatric Resp Adult 130-1 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS 1061 27658 10000 10000 27658 14500 40104 10000 27658 $30078 Resp Pediatric Resp Adult 130-2 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS 1149 28502 10000 10000 28502 14500 41328 10000 28502 $30996 Resp Pediatric Resp Adult

with Age Adjustor

130-3 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS 1372 36042 10000 10000 36042 14500 52261 10000 36042 $39196 Resp Pediatric Resp Adult 130-4 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS 1833 48858 10000 10000 48858 14500 70844 10000 48858 $53133 Resp Pediatric Resp Adult 131-1 CYSTIC FIBROSIS - PULMONARY DISEASE 668 11081 10000 10000 11081 14500 16067 10000 11081 $12051 Resp Pediatric Resp Adult 131-2 CYSTIC FIBROSIS - PULMONARY DISEASE 825 14224 10000 10000 14224 14500 20625 10000 14224 $15469 Resp Pediatric Resp Adult 131-3 CYSTIC FIBROSIS - PULMONARY DISEASE 1002 18605 10000 10000 18605 14500 26977 10000 18605 $20233 Resp Pediatric Resp Adult 131-4 CYSTIC FIBROSIS - PULMONARY DISEASE 1330 24618 10000 10000 24618 14500 35696 10000 24618 $26772 Resp Pediatric Resp Adult 132-1 BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD 305 04659 10000 10000 04659 14500 06756 10000 04659 $5067 Resp Pediatric Resp Adult 132-2 BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD 346 05001 10000 10000 05001 14500 07251 10000 05001 $5439 Resp Pediatric Resp Adult 132-3 BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD 486 07475 10000 10000 07475 14500 10839 10000 07475 $8129 Resp Pediatric Resp Adult 132-4 BPD amp OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD 631 12110 10000 10000 12110 14500 17560 10000 12110 $13170 Resp Pediatric Resp Adult 133-1 RESPIRATORY FAILURE 221 03696 10000 10000 03696 14500 05359 10000 03696 $4019 Resp Pediatric Resp Adult 133-2 RESPIRATORY FAILURE 400 07459 10000 10000 07459 14500 10816 10000 07459 $8112 Resp Pediatric Resp Adult 133-3 RESPIRATORY FAILURE 558 10959 10000 10000 10959 14500 15891 10000 10959 $11918 Resp Pediatric Resp Adult 133-4 RESPIRATORY FAILURE 794 19130 10000 10000 19130 14500 27739 10000 19130 $20804 Resp Pediatric Resp Adult 134-1 PULMONARY EMBOLISM 340 06617 10000 10000 06617 14500 09595 10000 06617 $7196 Resp Pediatric Resp Adult 134-2 PULMONARY EMBOLISM 435 08409 10000 10000 08409 14500 12193 10000 08409 $9145 Resp Pediatric Resp Adult 134-3 PULMONARY EMBOLISM 615 12026 10000 10000 12026 14500 17438 10000 12026 $13078 Resp Pediatric Resp Adult 134-4 PULMONARY EMBOLISM 954 20322 10000 10000 20322 14500 29467 10000 20322 $22100 Resp Pediatric Resp Adult 135-1 MAJOR CHEST amp RESPIRATORY TRAUMA 286 06228 10000 10000 06228 14500 09031 10000 06228 $6773 Resp Pediatric Resp Adult 135-2 MAJOR CHEST amp RESPIRATORY TRAUMA 363 07962 10000 10000 07962 14500 11545 10000 07962 $8659 Resp Pediatric Resp Adult 135-3 MAJOR CHEST amp RESPIRATORY TRAUMA 561 11639 10000 10000 11639 14500 16877 10000 11639 $12657 Resp Pediatric Resp Adult 135-4 MAJOR CHEST amp RESPIRATORY TRAUMA 931 21877 10000 10000 21877 14500 31722 10000 21877 $23791 Resp Pediatric Resp Adult 136-1 RESPIRATORY MALIGNANCY 331 05581 10000 10000 05581 14500 08092 10000 05581 $6069 Resp Pediatric Resp Adult 136-2 RESPIRATORY MALIGNANCY 423 07782 10000 10000 07782 14500 11284 10000 07782 $8463 Resp Pediatric Resp Adult 136-3 RESPIRATORY MALIGNANCY 657 11953 10000 10000 11953 14500 17332 10000 11953 $12999 Resp Pediatric Resp Adult 136-4 RESPIRATORY MALIGNANCY 1031 19130 10000 10000 19130 14500 27739 10000 19130 $20804 Resp Pediatric Resp Adult 137-1 MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS 430 06286 10000 10000 06286 14500 09115 10000 06286 $6836 Resp Pediatric Resp Adult 137-2 MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS 518 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Resp Pediatric Resp Adult 137-3 MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS 699 11629 10000 10000 11629 14500 16862 10000 11629 $12647 Resp Pediatric Resp Adult 137-4 MAJOR RESPIRATORY INFECTIONS amp INFLAMMATIONS 1000 19028 10000 10000 19028 14500 27591 10000 19028 $20693 Resp Pediatric Resp Adult 138-1 BRONCHIOLITIS amp RSV PNEUMONIA 212 02667 10000 10000 02667 14500 03867 10000 02667 $2900 Resp Pediatric Resp Adult 138-2 BRONCHIOLITIS amp RSV PNEUMONIA 289 03859 10000 10000 03859 14500 05596 10000 03859 $4197 Resp Pediatric Resp Adult 138-3 BRONCHIOLITIS amp RSV PNEUMONIA 508 08152 10000 10000 08152 14500 11820 10000 08152 $8865 Resp Pediatric Resp Adult 138-4 BRONCHIOLITIS amp RSV PNEUMONIA 926 20639 10000 10000 20639 14500 29927 10000 20639 $22445 Resp Pediatric Resp Adult 139-1 OTHER PNEUMONIA 282 04418 10000 10000 04418 14500 06406 10000 04418 $4805 Resp Pediatric Resp Adult 139-2 OTHER PNEUMONIA 378 06279 10000 10000 06279 14500 09105 10000 06279 $6828 Resp Pediatric Resp Adult 139-3 OTHER PNEUMONIA 551 09525 10000 10000 09525 14500 13811 10000 09525 $10358 Resp Pediatric Resp Adult 139-4 OTHER PNEUMONIA 891 17169 10000 10000 17169 14500 24895 10000 17169 $18671 Resp Pediatric Resp Adult 140-1 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 305 05146 10000 10000 05146 14500 07462 10000 05146 $5596 Resp Pediatric Resp Adult 140-2 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 371 06390 10000 10000 06390 14500 09266 10000 06390 $6949 Resp Pediatric Resp Adult 140-3 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 494 08488 10000 10000 08488 14500 12308 10000 08488 $9231 Resp Pediatric Resp Adult 140-4 CHRONIC OBSTRUCTIVE PULMONARY DISEASE 812 15748 10000 10000 15748 14500 22835 10000 15748 $17126 Resp Pediatric Resp Adult 141-1 ASTHMA 215 03413 10000 10000 03413 14500 04949 10000 03413 $3712 Resp Pediatric Resp Adult 141-2 ASTHMA 302 04978 10000 10000 04978 14500 07218 10000 04978 $5414 Resp Pediatric Resp Adult 141-3 ASTHMA 425 07217 10000 10000 07217 14500 10465 10000 07217 $7848 Resp Pediatric Resp Adult 141-4 ASTHMA 531 13146 10000 10000 13146 14500 19062 10000 13146 $14296 Resp Pediatric Resp Adult 142-1 INTERSTITIAL amp ALVEOLAR LUNG DISEASES 325 05892 10000 10000 05892 14500 08543 10000 05892 $6408 Resp Pediatric Resp Adult 142-2 INTERSTITIAL amp ALVEOLAR LUNG DISEASES 414 07212 10000 10000 07212 14500 10457 10000 07212 $7843 Resp Pediatric Resp Adult 142-3 INTERSTITIAL amp ALVEOLAR LUNG DISEASES 627 10390 10000 10000 10390 14500 15066 10000 10390 $11299 Resp Pediatric Resp Adult 142-4 INTERSTITIAL amp ALVEOLAR LUNG DISEASES 1029 18425 10000 10000 18425 14500 26716 10000 18425 $20037 Resp Pediatric Resp Adult 143-1 OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES 286 04588 10000 10000 04588 14500 06653 10000 04588 $4989 Resp Pediatric Resp Adult 143-2 OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES 363 06556 10000 10000 06556 14500 09506 10000 06556 $7130 Resp Pediatric Resp Adult 143-3 OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES 537 09680 10000 10000 09680 14500 14036 10000 09680 $10527 Resp Pediatric Resp Adult 143-4 OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS amp MINOR DIAGNOSES 841 15686 10000 10000 15686 14500 22745 10000 15686 $17059 Resp Pediatric Resp Adult 144-1 RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES 221 04420 10000 10000 04420 14500 06409 10000 04420 $4807 Resp Pediatric Resp Adult 144-2 RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES 293 05467 10000 10000 05467 14500 07927 10000 05467 $5945 Resp Pediatric Resp Adult 144-3 RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES 415 07464 10000 10000 07464 14500 10823 10000 07464 $8117 Resp Pediatric Resp Adult 144-4 RESPIRATORY SIGNS SYMPTOMS amp MINOR DIAGNOSES 684 12000 10000 10000 12000 14500 17400 10000 12000 $13050 Resp Pediatric Resp Adult 160-1 MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY 394 29056 10000 10000 29056 14500 42131 10000 29056 $31598 Misc Pediatric Circulatory Adult 160-2 MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY 509 33358 10000 10000 33358 14500 48369 10000 33358 $36277 Misc Pediatric Circulatory Adult 160-3 MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY 974 48730 10000 10000 48730 14500 70659 10000 48730 $52994 Misc Pediatric Circulatory Adult 160-4 MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY 2084 90655 10000 10000 90655 14500 131450 10000 90655 $98587 Misc Pediatric Circulatory Adult 161-1 CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT 333 39098 10000 10000 39098 14500 56692 10000 39098 $42519 Misc Pediatric Circulatory Adult 161-2 CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT 797 51522 10000 10000 51522 14500 74707 10000 51522 $56030 Misc Pediatric Circulatory Adult 161-3 CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT 1544 80506 10000 10000 80506 14500 116734 10000 80506 $87550 Misc Pediatric Circulatory Adult 161-4 CARDIAC DEFIBRILLATOR amp HEART ASSIST IMPLANT 3255 203225 10000 10000 203225 14500 294676 10000 203225 $221007 Misc Pediatric Circulatory Adult 162-1 CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX 678 41113 10000 10000 41113 14500 59614 10000 41113 $44710 Misc Pediatric Circulatory Adult 162-2 CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX 829 49082 10000 10000 49082 14500 71169 10000 49082 $53377 Misc Pediatric Circulatory Adult 162-3 CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX 1297 62681 10000 10000 62681 14500 90887 10000 62681 $68166 Misc Pediatric Circulatory Adult 162-4 CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX 2190 94397 10000 10000 94397 14500 136876 10000 94397 $102657 Misc Pediatric Circulatory Adult 163-1 CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX 549 36863 10000 10000 36863 14500 53451 10000 36863 $40089 Misc Pediatric Circulatory Adult 163-2 CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX 670 42911 10000 10000 42911 14500 62221 10000 42911 $46666 Misc Pediatric Circulatory Adult

with Age Adjustor

163-3 CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX 989 52615 10000 10000 52615 14500 76292 10000 52615 $57219 Misc Pediatric Circulatory Adult 163-4 CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX 1809 81411 10000 10000 81411 14500 118046 10000 81411 $88534 Misc Pediatric Circulatory Adult 165-1 CORONARY BYPASS W AMI OR COMPLEX PDX 721 40449 10000 10000 40449 14500 58651 10000 40449 $43988 Misc Pediatric Circulatory Adult 165-2 CORONARY BYPASS W AMI OR COMPLEX PDX 846 44165 10000 10000 44165 14500 64039 10000 44165 $48029 Misc Pediatric Circulatory Adult 165-3 CORONARY BYPASS W AMI OR COMPLEX PDX 1108 53525 10000 10000 53525 14500 77611 10000 53525 $58208 Misc Pediatric Circulatory Adult 165-4 CORONARY BYPASS W AMI OR COMPLEX PDX 1726 74984 10000 10000 74984 14500 108727 10000 74984 $81545 Misc Pediatric Circulatory Adult 166-1 CORONARY BYPASS WO AMI OR COMPLEX PDX 574 33959 10000 10000 33959 14500 49241 10000 33959 $36930 Misc Pediatric Circulatory Adult 166-2 CORONARY BYPASS WO AMI OR COMPLEX PDX 688 37786 10000 10000 37786 14500 54790 10000 37786 $41092 Misc Pediatric Circulatory Adult 166-3 CORONARY BYPASS WO AMI OR COMPLEX PDX 936 45629 10000 10000 45629 14500 66162 10000 45629 $49622 Misc Pediatric Circulatory Adult 166-4 CORONARY BYPASS WO AMI OR COMPLEX PDX 1572 66439 10000 10000 66439 14500 96337 10000 66439 $72252 Misc Pediatric Circulatory Adult 167-1 OTHER CARDIOTHORACIC amp THORACIC VASCULAR PROCEDURES 422 28387 10000 10000 28387 14500 41161 10000 28387 $30871 Misc Pediatric Circulatory Adult 167-2 OTHER CARDIOTHORACIC amp THORACIC VASCULAR PROCEDURES 582 31926 10000 10000 31926 14500 46293 10000 31926 $34720 Misc Pediatric Circulatory Adult 167-3 OTHER CARDIOTHORACIC amp THORACIC VASCULAR PROCEDURES 883 41568 10000 10000 41568 14500 60274 10000 41568 $45205 Misc Pediatric Circulatory Adult 167-4 OTHER CARDIOTHORACIC amp THORACIC VASCULAR PROCEDURES 1714 69144 10000 10000 69144 14500 100259 10000 69144 $75194 Misc Pediatric Circulatory Adult 169-1 MAJOR ABDOMINAL VASCULAR PROCEDURES 401 17547 10000 10000 17547 14500 25443 10000 17547 $19082 Misc Pediatric Circulatory Adult 169-2 MAJOR ABDOMINAL VASCULAR PROCEDURES 561 22208 10000 10000 22208 14500 32202 10000 22208 $24151 Misc Pediatric Circulatory Adult 169-3 MAJOR ABDOMINAL VASCULAR PROCEDURES 938 35263 10000 10000 35263 14500 51131 10000 35263 $38349 Misc Pediatric Circulatory Adult 169-4 MAJOR ABDOMINAL VASCULAR PROCEDURES 1811 61945 10000 10000 61945 14500 89820 10000 61945 $67365 Misc Pediatric Circulatory Adult 170-1 PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK 422 21684 10000 10000 21684 14500 31442 10000 21684 $23581 Misc Pediatric Circulatory Adult 170-2 PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK 509 24686 10000 10000 24686 14500 35795 10000 24686 $26846 Misc Pediatric Circulatory Adult 170-3 PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK 897 29929 10000 10000 29929 14500 43397 10000 29929 $32548 Misc Pediatric Circulatory Adult 170-4 PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK 1479 43823 10000 10000 43823 14500 63543 10000 43823 $47658 Misc Pediatric Circulatory Adult 171-1 PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK 268 16072 10000 10000 16072 14500 23304 10000 16072 $17478 Misc Pediatric Circulatory Adult 171-2 PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK 385 18675 10000 10000 18675 14500 27079 10000 18675 $20309 Misc Pediatric Circulatory Adult 171-3 PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK 620 23571 10000 10000 23571 14500 34178 10000 23571 $25633 Misc Pediatric Circulatory Adult 171-4 PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK 1126 36969 10000 10000 36969 14500 53605 10000 36969 $40204 Misc Pediatric Circulatory Adult 174-1 PERCUTANEOUS CORONARY INTERVENTION W AMI 231 20569 10000 10000 20569 14500 29825 10000 20569 $22369 Misc Pediatric Circulatory Adult 174-2 PERCUTANEOUS CORONARY INTERVENTION W AMI 295 21912 10000 10000 21912 14500 31772 10000 21912 $23829 Misc Pediatric Circulatory Adult 174-3 PERCUTANEOUS CORONARY INTERVENTION W AMI 515 27002 10000 10000 27002 14500 39153 10000 27002 $29365 Misc Pediatric Circulatory Adult 174-4 PERCUTANEOUS CORONARY INTERVENTION W AMI 970 41219 10000 10000 41219 14500 59768 10000 41219 $44826 Misc Pediatric Circulatory Adult 175-1 PERCUTANEOUS CORONARY INTERVENTION WO AMI 176 18345 10000 10000 18345 14500 26600 10000 18345 $19950 Misc Pediatric Circulatory Adult 175-2 PERCUTANEOUS CORONARY INTERVENTION WO AMI 255 20407 10000 10000 20407 14500 29590 10000 20407 $22193 Misc Pediatric Circulatory Adult 175-3 PERCUTANEOUS CORONARY INTERVENTION WO AMI 525 26048 10000 10000 26048 14500 37770 10000 26048 $28327 Misc Pediatric Circulatory Adult 175-4 PERCUTANEOUS CORONARY INTERVENTION WO AMI 938 46635 10000 10000 46635 14500 67621 10000 46635 $50716 Misc Pediatric Circulatory Adult 176-1 CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT 297 13764 10000 10000 13764 14500 19958 10000 13764 $14968 Misc Pediatric Circulatory Adult 176-2 CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT 270 24772 10000 10000 24772 14500 35919 10000 24772 $26940 Misc Pediatric Circulatory Adult 176-3 CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT 477 27609 10000 10000 27609 14500 40033 10000 27609 $30025 Misc Pediatric Circulatory Adult 176-4 CARDIAC PACEMAKER amp DEFIBRILLATOR DEVICE REPLACEMENT 1277 41842 10000 10000 41842 14500 60671 10000 41842 $45503 Misc Pediatric Circulatory Adult 177-1 CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT 268 10940 10000 10000 10940 14500 15863 10000 10940 $11897 Misc Pediatric Circulatory Adult 177-2 CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT 413 14361 10000 10000 14361 14500 20823 10000 14361 $15618 Misc Pediatric Circulatory Adult 177-3 CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT 729 20674 10000 10000 20674 14500 29977 10000 20674 $22483 Misc Pediatric Circulatory Adult 177-4 CARDIAC PACEMAKER amp DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT 1521 39719 10000 10000 39719 14500 57593 10000 39719 $43194 Misc Pediatric Circulatory Adult 180-1 OTHER CIRCULATORY SYSTEM PROCEDURES 406 10689 10000 10000 10689 14500 15499 10000 10689 $11624 Misc Pediatric Circulatory Adult 180-2 OTHER CIRCULATORY SYSTEM PROCEDURES 567 13573 10000 10000 13573 14500 19681 10000 13573 $14761 Misc Pediatric Circulatory Adult 180-3 OTHER CIRCULATORY SYSTEM PROCEDURES 960 21004 10000 10000 21004 14500 30456 10000 21004 $22842 Misc Pediatric Circulatory Adult 180-4 OTHER CIRCULATORY SYSTEM PROCEDURES 1564 36104 10000 10000 36104 14500 52351 10000 36104 $39263 Misc Pediatric Circulatory Adult 181-1 LOWER EXTREMITY ARTERIAL PROCEDURES 293 14787 10000 10000 14787 14500 21441 10000 14787 $16081 Misc Pediatric Circulatory Adult 181-2 LOWER EXTREMITY ARTERIAL PROCEDURES 499 19873 10000 10000 19873 14500 28816 10000 19873 $21612 Misc Pediatric Circulatory Adult 181-3 LOWER EXTREMITY ARTERIAL PROCEDURES 972 31129 10000 10000 31129 14500 45137 10000 31129 $33853 Misc Pediatric Circulatory Adult 181-4 LOWER EXTREMITY ARTERIAL PROCEDURES 1799 55746 10000 10000 55746 14500 80832 10000 55746 $60624 Misc Pediatric Circulatory Adult 182-1 OTHER PERIPHERAL VASCULAR PROCEDURES 238 18230 10000 10000 18230 14500 26434 10000 18230 $19825 Misc Pediatric Circulatory Adult 182-2 OTHER PERIPHERAL VASCULAR PROCEDURES 414 21170 10000 10000 21170 14500 30697 10000 21170 $23022 Misc Pediatric Circulatory Adult 182-3 OTHER PERIPHERAL VASCULAR PROCEDURES 808 28195 10000 10000 28195 14500 40883 10000 28195 $30662 Misc Pediatric Circulatory Adult 182-4 OTHER PERIPHERAL VASCULAR PROCEDURES 1553 48901 10000 10000 48901 14500 70906 10000 48901 $53180 Misc Pediatric Circulatory Adult 190-1 ACUTE MYOCARDIAL INFARCTION 236 08059 10000 10000 08059 14500 11686 10000 08059 $8764 Misc Pediatric Circulatory Adult 190-2 ACUTE MYOCARDIAL INFARCTION 332 08899 10000 10000 08899 14500 12904 10000 08899 $9678 Misc Pediatric Circulatory Adult 190-3 ACUTE MYOCARDIAL INFARCTION 546 11712 10000 10000 11712 14500 16982 10000 11712 $12737 Misc Pediatric Circulatory Adult 190-4 ACUTE MYOCARDIAL INFARCTION 917 20201 10000 10000 20201 14500 29291 10000 20201 $21969 Misc Pediatric Circulatory Adult 191-1 CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE 193 08849 10000 10000 08849 14500 12831 10000 08849 $9623 Misc Pediatric Circulatory Adult 191-2 CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE 264 10234 10000 10000 10234 14500 14839 10000 10234 $11129 Misc Pediatric Circulatory Adult 191-3 CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE 448 13380 10000 10000 13380 14500 19401 10000 13380 $14551 Misc Pediatric Circulatory Adult 191-4 CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE 1011 24819 10000 10000 24819 14500 35988 10000 24819 $26991 Misc Pediatric Circulatory Adult 192-1 CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS 207 09221 10000 10000 09221 14500 13370 10000 09221 $10028 Misc Pediatric Circulatory Adult 192-2 CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS 338 11307 10000 10000 11307 14500 16395 10000 11307 $12296 Misc Pediatric Circulatory Adult 192-3 CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS 646 15999 10000 10000 15999 14500 23199 10000 15999 $17399 Misc Pediatric Circulatory Adult 192-4 CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS 1218 28577 10000 10000 28577 14500 41437 10000 28577 $31077 Misc Pediatric Circulatory Adult 193-1 ACUTE amp SUBACUTE ENDOCARDITIS 589 08367 10000 10000 08367 14500 12132 10000 08367 $9099 Misc Pediatric Circulatory Adult 193-2 ACUTE amp SUBACUTE ENDOCARDITIS 696 10979 10000 10000 10979 14500 15920 10000 10979 $11940 Misc Pediatric Circulatory Adult 193-3 ACUTE amp SUBACUTE ENDOCARDITIS 1014 16074 10000 10000 16074 14500 23307 10000 16074 $17480 Misc Pediatric Circulatory Adult 193-4 ACUTE amp SUBACUTE ENDOCARDITIS 1597 26059 10000 10000 26059 14500 37786 10000 26059 $28339 Misc Pediatric Circulatory Adult 194-1 HEART FAILURE 292 05111 10000 10000 05111 14500 07411 10000 05111 $5558 Misc Pediatric Circulatory Adult 194-2 HEART FAILURE 380 06492 10000 10000 06492 14500 09413 10000 06492 $7060 Misc Pediatric Circulatory Adult

with Age Adjustor

194-3 HEART FAILURE 562 09413 10000 10000 09413 14500 13649 10000 09413 $10237 Misc Pediatric Circulatory Adult 194-4 HEART FAILURE 931 16620 10000 10000 16620 14500 24099 10000 16620 $18074 Misc Pediatric Circulatory Adult 196-1 CARDIAC ARREST amp SHOCK 221 04651 10000 10000 04651 14500 06744 10000 04651 $5058 Misc Pediatric Circulatory Adult 196-2 CARDIAC ARREST amp SHOCK 284 05303 10000 10000 05303 14500 07689 10000 05303 $5767 Misc Pediatric Circulatory Adult 196-3 CARDIAC ARREST amp SHOCK 507 09776 10000 10000 09776 14500 14175 10000 09776 $10631 Misc Pediatric Circulatory Adult 196-4 CARDIAC ARREST amp SHOCK 1029 24155 10000 10000 24155 14500 35025 10000 24155 $26269 Misc Pediatric Circulatory Adult 197-1 PERIPHERAL amp OTHER VASCULAR DISORDERS 315 04461 10000 10000 04461 14500 06468 10000 04461 $4851 Misc Pediatric Circulatory Adult 197-2 PERIPHERAL amp OTHER VASCULAR DISORDERS 404 06046 10000 10000 06046 14500 08767 10000 06046 $6575 Misc Pediatric Circulatory Adult 197-3 PERIPHERAL amp OTHER VASCULAR DISORDERS 543 09033 10000 10000 09033 14500 13098 10000 09033 $9823 Misc Pediatric Circulatory Adult 197-4 PERIPHERAL amp OTHER VASCULAR DISORDERS 992 17203 10000 10000 17203 14500 24944 10000 17203 $18708 Misc Pediatric Circulatory Adult 198-1 ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS 165 04323 10000 10000 04323 14500 06268 10000 04323 $4701 Misc Pediatric Circulatory Adult 198-2 ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS 220 05112 10000 10000 05112 14500 07412 10000 05112 $5559 Misc Pediatric Circulatory Adult 198-3 ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS 353 06957 10000 10000 06957 14500 10088 10000 06957 $7566 Misc Pediatric Circulatory Adult 198-4 ANGINA PECTORIS amp CORONARY ATHEROSCLEROSIS 893 14773 10000 10000 14773 14500 21421 10000 14773 $16066 Misc Pediatric Circulatory Adult 199-1 HYPERTENSION 198 04480 10000 10000 04480 14500 06496 10000 04480 $4872 Misc Pediatric Circulatory Adult 199-2 HYPERTENSION 261 05476 10000 10000 05476 14500 07940 10000 05476 $5955 Misc Pediatric Circulatory Adult 199-3 HYPERTENSION 397 07602 10000 10000 07602 14500 11023 10000 07602 $8267 Misc Pediatric Circulatory Adult 199-4 HYPERTENSION 865 15536 10000 10000 15536 14500 22527 10000 15536 $16895 Misc Pediatric Circulatory Adult 200-1 CARDIAC STRUCTURAL amp VALVULAR DISORDERS 241 04666 10000 10000 04666 14500 06766 10000 04666 $5074 Misc Pediatric Circulatory Adult 200-2 CARDIAC STRUCTURAL amp VALVULAR DISORDERS 322 05776 10000 10000 05776 14500 08375 10000 05776 $6281 Misc Pediatric Circulatory Adult 200-3 CARDIAC STRUCTURAL amp VALVULAR DISORDERS 526 08895 10000 10000 08895 14500 12898 10000 08895 $9673 Misc Pediatric Circulatory Adult 200-4 CARDIAC STRUCTURAL amp VALVULAR DISORDERS 1072 17152 10000 10000 17152 14500 24870 10000 17152 $18653 Misc Pediatric Circulatory Adult 201-1 CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS 198 04208 10000 10000 04208 14500 06102 10000 04208 $4576 Misc Pediatric Circulatory Adult 201-2 CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS 289 05481 10000 10000 05481 14500 07947 10000 05481 $5961 Misc Pediatric Circulatory Adult 201-3 CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS 470 08324 10000 10000 08324 14500 12070 10000 08324 $9052 Misc Pediatric Circulatory Adult 201-4 CARDIAC ARRHYTHMIA amp CONDUCTION DISORDERS 891 16244 10000 10000 16244 14500 23554 10000 16244 $17665 Misc Pediatric Circulatory Adult 203-1 CHEST PAIN 149 04242 10000 10000 04242 14500 06151 10000 04242 $4613 Misc Pediatric Circulatory Adult 203-2 CHEST PAIN 198 05125 10000 10000 05125 14500 07431 10000 05125 $5573 Misc Pediatric Circulatory Adult 203-3 CHEST PAIN 305 06588 10000 10000 06588 14500 09553 10000 06588 $7164 Misc Pediatric Circulatory Adult 203-4 CHEST PAIN 652 10280 10000 10000 10280 14500 14906 10000 10280 $11180 Misc Pediatric Circulatory Adult 204-1 SYNCOPE amp COLLAPSE 204 04895 10000 10000 04895 14500 07098 10000 04895 $5323 Misc Pediatric Circulatory Adult 204-2 SYNCOPE amp COLLAPSE 268 05765 10000 10000 05765 14500 08359 10000 05765 $6269 Misc Pediatric Circulatory Adult 204-3 SYNCOPE amp COLLAPSE 380 07329 10000 10000 07329 14500 10627 10000 07329 $7970 Misc Pediatric Circulatory Adult 204-4 SYNCOPE amp COLLAPSE 806 13060 10000 10000 13060 14500 18937 10000 13060 $14203 Misc Pediatric Circulatory Adult 205-1 CARDIOMYOPATHY 232 04440 10000 10000 04440 14500 06438 10000 04440 $4829 Misc Pediatric Circulatory Adult 205-2 CARDIOMYOPATHY 316 05812 10000 10000 05812 14500 08427 10000 05812 $6321 Misc Pediatric Circulatory Adult 205-3 CARDIOMYOPATHY 502 08644 10000 10000 08644 14500 12534 10000 08644 $9400 Misc Pediatric Circulatory Adult 205-4 CARDIOMYOPATHY 990 19901 10000 10000 19901 14500 28856 10000 19901 $21642 Misc Pediatric Circulatory Adult 206-1 MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE 216 04461 10000 10000 04461 14500 06468 10000 04461 $4851 Misc Pediatric Circulatory Adult 206-2 MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE 347 05825 10000 10000 05825 14500 08446 10000 05825 $6335 Misc Pediatric Circulatory Adult 206-3 MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE 552 09334 10000 10000 09334 14500 13534 10000 09334 $10151 Misc Pediatric Circulatory Adult 206-4 MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE 1062 18630 10000 10000 18630 14500 27014 10000 18630 $20260 Misc Pediatric Circulatory Adult 207-1 OTHER CIRCULATORY SYSTEM DIAGNOSES 239 04908 10000 10000 04908 14500 07117 10000 04908 $5337 Misc Pediatric Circulatory Adult 207-2 OTHER CIRCULATORY SYSTEM DIAGNOSES 329 06409 10000 10000 06409 14500 09293 10000 06409 $6970 Misc Pediatric Circulatory Adult 207-3 OTHER CIRCULATORY SYSTEM DIAGNOSES 493 09117 10000 10000 09117 14500 13220 10000 09117 $9915 Misc Pediatric Circulatory Adult 207-4 OTHER CIRCULATORY SYSTEM DIAGNOSES 886 16800 10000 10000 16800 14500 24360 10000 16800 $18270 Misc Pediatric Circulatory Adult 220-1 MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES 339 13076 10000 10000 13076 14500 18960 10000 13076 $14220 Misc Pediatric Gastroent Adult 220-2 MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES 668 18607 10000 10000 18607 14500 26980 10000 18607 $20235 Misc Pediatric Gastroent Adult 220-3 MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES 1166 30279 10000 10000 30279 14500 43905 10000 30279 $32928 Misc Pediatric Gastroent Adult 220-4 MAJOR STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES 2116 56614 10000 10000 56614 14500 82090 10000 56614 $61568 Misc Pediatric Gastroent Adult 221-1 MAJOR SMALL amp LARGE BOWEL PROCEDURES 476 14238 10000 10000 14238 14500 20645 10000 14238 $15484 Misc Pediatric Gastroent Adult 221-2 MAJOR SMALL amp LARGE BOWEL PROCEDURES 695 18179 10000 10000 18179 14500 26360 10000 18179 $19770 Misc Pediatric Gastroent Adult 221-3 MAJOR SMALL amp LARGE BOWEL PROCEDURES 1193 28331 10000 10000 28331 14500 41080 10000 28331 $30810 Misc Pediatric Gastroent Adult 221-4 MAJOR SMALL amp LARGE BOWEL PROCEDURES 2033 53144 10000 10000 53144 14500 77059 10000 53144 $57794 Misc Pediatric Gastroent Adult 222-1 OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES 230 10012 10000 10000 10012 14500 14517 10000 10012 $10888 Misc Pediatric Gastroent Adult 222-2 OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES 338 11977 10000 10000 11977 14500 17367 10000 11977 $13025 Misc Pediatric Gastroent Adult 222-3 OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES 773 18805 10000 10000 18805 14500 27267 10000 18805 $20450 Misc Pediatric Gastroent Adult 222-4 OTHER STOMACH ESOPHAGEAL amp DUODENAL PROCEDURES 1855 43481 10000 10000 43481 14500 63047 10000 43481 $47286 Misc Pediatric Gastroent Adult 223-1 OTHER SMALL amp LARGE BOWEL PROCEDURES 445 10810 10000 10000 10810 14500 15675 10000 10810 $11756 Misc Pediatric Gastroent Adult 223-2 OTHER SMALL amp LARGE BOWEL PROCEDURES 638 14201 10000 10000 14201 14500 20591 10000 14201 $15444 Misc Pediatric Gastroent Adult 223-3 OTHER SMALL amp LARGE BOWEL PROCEDURES 1082 22573 10000 10000 22573 14500 32731 10000 22573 $24548 Misc Pediatric Gastroent Adult 223-4 OTHER SMALL amp LARGE BOWEL PROCEDURES 1932 46124 10000 10000 46124 14500 66880 10000 46124 $50160 Misc Pediatric Gastroent Adult 224-1 PERITONEAL ADHESIOLYSIS 560 12377 10000 10000 12377 14500 17947 10000 12377 $13460 Misc Pediatric Gastroent Adult 224-2 PERITONEAL ADHESIOLYSIS 774 16112 10000 10000 16112 14500 23362 10000 16112 $17522 Misc Pediatric Gastroent Adult 224-3 PERITONEAL ADHESIOLYSIS 1150 24265 10000 10000 24265 14500 35184 10000 24265 $26388 Misc Pediatric Gastroent Adult 224-4 PERITONEAL ADHESIOLYSIS 1785 42663 10000 10000 42663 14500 61861 10000 42663 $46396 Misc Pediatric Gastroent Adult 225-1 APPENDECTOMY 157 07868 10000 10000 07868 14500 11409 10000 07868 $8556 Misc Pediatric Gastroent Adult 225-2 APPENDECTOMY 383 11040 10000 10000 11040 14500 16008 10000 11040 $12006 Misc Pediatric Gastroent Adult 225-3 APPENDECTOMY 735 18413 10000 10000 18413 14500 26699 10000 18413 $20024 Misc Pediatric Gastroent Adult 225-4 APPENDECTOMY 1321 34275 10000 10000 34275 14500 49699 10000 34275 $37274 Misc Pediatric Gastroent Adult 226-1 ANAL PROCEDURES 261 06405 10000 10000 06405 14500 09287 10000 06405 $6965 Misc Pediatric Gastroent Adult 226-2 ANAL PROCEDURES 399 08468 10000 10000 08468 14500 12279 10000 08468 $9209 Misc Pediatric Gastroent Adult

with Age Adjustor

226-3 ANAL PROCEDURES 687 13478 10000 10000 13478 14500 19543 10000 13478 $14657 Misc Pediatric Gastroent Adult 226-4 ANAL PROCEDURES 1424 26756 10000 10000 26756 14500 38796 10000 26756 $29097 Misc Pediatric Gastroent Adult 227-1 HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL 298 10300 10000 10000 10300 14500 14935 10000 10300 $11201 Misc Pediatric Gastroent Adult 227-2 HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL 448 13306 10000 10000 13306 14500 19294 10000 13306 $14470 Misc Pediatric Gastroent Adult 227-3 HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL 791 21011 10000 10000 21011 14500 30466 10000 21011 $22849 Misc Pediatric Gastroent Adult 227-4 HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL amp UMBILICAL 1445 39639 10000 10000 39639 14500 57477 10000 39639 $43107 Misc Pediatric Gastroent Adult 228-1 INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES 209 07636 10000 10000 07636 14500 11072 10000 07636 $8304 Misc Pediatric Gastroent Adult 228-2 INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES 344 10022 10000 10000 10022 14500 14532 10000 10022 $10899 Misc Pediatric Gastroent Adult 228-3 INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES 624 15028 10000 10000 15028 14500 21791 10000 15028 $16343 Misc Pediatric Gastroent Adult 228-4 INGUINAL FEMORAL amp UMBILICAL HERNIA PROCEDURES 1386 31293 10000 10000 31293 14500 45375 10000 31293 $34031 Misc Pediatric Gastroent Adult 229-1 OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES 368 10600 10000 10000 10600 14500 15370 10000 10600 $11528 Misc Pediatric Gastroent Adult 229-2 OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES 543 14159 10000 10000 14159 14500 20531 10000 14159 $15398 Misc Pediatric Gastroent Adult 229-3 OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES 979 22316 10000 10000 22316 14500 32358 10000 22316 $24269 Misc Pediatric Gastroent Adult 229-4 OTHER DIGESTIVE SYSTEM amp ABDOMINAL PROCEDURES 1909 43939 10000 10000 43939 14500 63712 10000 43939 $47784 Misc Pediatric Gastroent Adult 240-1 DIGESTIVE MALIGNANCY 328 05815 10000 10000 05815 14500 08432 10000 05815 $6324 Misc Pediatric Gastroent Adult 240-2 DIGESTIVE MALIGNANCY 430 07742 10000 10000 07742 14500 11226 10000 07742 $8419 Misc Pediatric Gastroent Adult 240-3 DIGESTIVE MALIGNANCY 671 11155 10000 10000 11155 14500 16175 10000 11155 $12131 Misc Pediatric Gastroent Adult 240-4 DIGESTIVE MALIGNANCY 1154 18556 10000 10000 18556 14500 26906 10000 18556 $20180 Misc Pediatric Gastroent Adult 241-1 PEPTIC ULCER amp GASTRITIS 253 05529 10000 10000 05529 14500 08017 10000 05529 $6013 Misc Pediatric Gastroent Adult 241-2 PEPTIC ULCER amp GASTRITIS 324 07048 10000 10000 07048 14500 10220 10000 07048 $7665 Misc Pediatric Gastroent Adult 241-3 PEPTIC ULCER amp GASTRITIS 484 10391 10000 10000 10391 14500 15067 10000 10391 $11300 Misc Pediatric Gastroent Adult 241-4 PEPTIC ULCER amp GASTRITIS 1024 22676 10000 10000 22676 14500 32880 10000 22676 $24660 Misc Pediatric Gastroent Adult 242-1 MAJOR ESOPHAGEAL DISORDERS 230 05193 10000 10000 05193 14500 07530 10000 05193 $5647 Misc Pediatric Gastroent Adult 242-2 MAJOR ESOPHAGEAL DISORDERS 319 06804 10000 10000 06804 14500 09866 10000 06804 $7399 Misc Pediatric Gastroent Adult 242-3 MAJOR ESOPHAGEAL DISORDERS 473 10097 10000 10000 10097 14500 14641 10000 10097 $10980 Misc Pediatric Gastroent Adult 242-4 MAJOR ESOPHAGEAL DISORDERS 1038 22197 10000 10000 22197 14500 32186 10000 22197 $24139 Misc Pediatric Gastroent Adult 243-1 OTHER ESOPHAGEAL DISORDERS 198 05009 10000 10000 05009 14500 07263 10000 05009 $5447 Misc Pediatric Gastroent Adult 243-2 OTHER ESOPHAGEAL DISORDERS 285 06222 10000 10000 06222 14500 09022 10000 06222 $6766 Misc Pediatric Gastroent Adult 243-3 OTHER ESOPHAGEAL DISORDERS 474 08959 10000 10000 08959 14500 12991 10000 08959 $9743 Misc Pediatric Gastroent Adult 243-4 OTHER ESOPHAGEAL DISORDERS 995 18382 10000 10000 18382 14500 26654 10000 18382 $19990 Misc Pediatric Gastroent Adult 244-1 DIVERTICULITIS amp DIVERTICULOSIS 289 05012 10000 10000 05012 14500 07267 10000 05012 $5451 Misc Pediatric Gastroent Adult 244-2 DIVERTICULITIS amp DIVERTICULOSIS 365 06442 10000 10000 06442 14500 09341 10000 06442 $7006 Misc Pediatric Gastroent Adult 244-3 DIVERTICULITIS amp DIVERTICULOSIS 534 09594 10000 10000 09594 14500 13911 10000 09594 $10433 Misc Pediatric Gastroent Adult 244-4 DIVERTICULITIS amp DIVERTICULOSIS 1078 20323 10000 10000 20323 14500 29468 10000 20323 $22101 Misc Pediatric Gastroent Adult 245-1 INFLAMMATORY BOWEL DISEASE 336 05615 10000 10000 05615 14500 08142 10000 05615 $6106 Misc Pediatric Gastroent Adult 245-2 INFLAMMATORY BOWEL DISEASE 412 06803 10000 10000 06803 14500 09864 10000 06803 $7398 Misc Pediatric Gastroent Adult 245-3 INFLAMMATORY BOWEL DISEASE 624 09903 10000 10000 09903 14500 14359 10000 09903 $10770 Misc Pediatric Gastroent Adult 245-4 INFLAMMATORY BOWEL DISEASE 1115 17773 10000 10000 17773 14500 25771 10000 17773 $19328 Misc Pediatric Gastroent Adult 246-1 GASTROINTESTINAL VASCULAR INSUFFICIENCY 309 06254 10000 10000 06254 14500 09068 10000 06254 $6801 Misc Pediatric Gastroent Adult 246-2 GASTROINTESTINAL VASCULAR INSUFFICIENCY 398 07557 10000 10000 07557 14500 10958 10000 07557 $8218 Misc Pediatric Gastroent Adult 246-3 GASTROINTESTINAL VASCULAR INSUFFICIENCY 614 11105 10000 10000 11105 14500 16102 10000 11105 $12077 Misc Pediatric Gastroent Adult 246-4 GASTROINTESTINAL VASCULAR INSUFFICIENCY 1103 20997 10000 10000 20997 14500 30446 10000 20997 $22834 Misc Pediatric Gastroent Adult 247-1 INTESTINAL OBSTRUCTION 290 04775 10000 10000 04775 14500 06924 10000 04775 $5193 Misc Pediatric Gastroent Adult 247-2 INTESTINAL OBSTRUCTION 384 06052 10000 10000 06052 14500 08775 10000 06052 $6582 Misc Pediatric Gastroent Adult 247-3 INTESTINAL OBSTRUCTION 603 09137 10000 10000 09137 14500 13249 10000 09137 $9936 Misc Pediatric Gastroent Adult 247-4 INTESTINAL OBSTRUCTION 1139 19170 10000 10000 19170 14500 27797 10000 19170 $20847 Misc Pediatric Gastroent Adult 248-1 MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS 339 05160 10000 10000 05160 14500 07482 10000 05160 $5612 Misc Pediatric Gastroent Adult 248-2 MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS 463 06918 10000 10000 06918 14500 10031 10000 06918 $7523 Misc Pediatric Gastroent Adult 248-3 MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS 675 09976 10000 10000 09976 14500 14465 10000 09976 $10849 Misc Pediatric Gastroent Adult 248-4 MAJOR GASTROINTESTINAL amp PERITONEAL INFECTIONS 1189 19451 10000 10000 19451 14500 28204 10000 19451 $21153 Misc Pediatric Gastroent Adult 249-1 OTHER GASTROENTERITIS NAUSEA amp VOMITING 230 03959 10000 10000 03959 14500 05741 10000 03959 $4305 Misc Pediatric Gastroent Adult 249-2 OTHER GASTROENTERITIS NAUSEA amp VOMITING 293 05059 10000 10000 05059 14500 07336 10000 05059 $5502 Misc Pediatric Gastroent Adult 249-3 OTHER GASTROENTERITIS NAUSEA amp VOMITING 435 07019 10000 10000 07019 14500 10178 10000 07019 $7633 Misc Pediatric Gastroent Adult 249-4 OTHER GASTROENTERITIS NAUSEA amp VOMITING 933 14317 10000 10000 14317 14500 20760 10000 14317 $15570 Misc Pediatric Gastroent Adult 251-1 ABDOMINAL PAIN 223 04494 10000 10000 04494 14500 06516 10000 04494 $4887 Misc Pediatric Gastroent Adult 251-2 ABDOMINAL PAIN 295 05707 10000 10000 05707 14500 08275 10000 05707 $6206 Misc Pediatric Gastroent Adult 251-3 ABDOMINAL PAIN 421 07550 10000 10000 07550 14500 10948 10000 07550 $8211 Misc Pediatric Gastroent Adult 251-4 ABDOMINAL PAIN 765 12828 10000 10000 12828 14500 18601 10000 12828 $13950 Misc Pediatric Gastroent Adult 252-1 MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE 328 04901 10000 10000 04901 14500 07106 10000 04901 $5330 Misc Pediatric Gastroent Adult 252-2 MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE 402 06469 10000 10000 06469 14500 09380 10000 06469 $7035 Misc Pediatric Gastroent Adult 252-3 MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE 619 09500 10000 10000 09500 14500 13775 10000 09500 $10331 Misc Pediatric Gastroent Adult 252-4 MALFUNCTION REACTION amp COMPLICATION OF GI DEVICE OR PROCEDURE 1167 18656 10000 10000 18656 14500 27051 10000 18656 $20288 Misc Pediatric Gastroent Adult 253-1 OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE 256 05301 10000 10000 05301 14500 07686 10000 05301 $5765 Misc Pediatric Gastroent Adult 253-2 OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE 339 06793 10000 10000 06793 14500 09850 10000 06793 $7387 Misc Pediatric Gastroent Adult 253-3 OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE 510 09930 10000 10000 09930 14500 14399 10000 09930 $10799 Misc Pediatric Gastroent Adult 253-4 OTHER amp UNSPECIFIED GASTROINTESTINAL HEMORRHAGE 934 19002 10000 10000 19002 14500 27553 10000 19002 $20665 Misc Pediatric Gastroent Adult 254-1 OTHER DIGESTIVE SYSTEM DIAGNOSES 255 04546 10000 10000 04546 14500 06592 10000 04546 $4944 Misc Pediatric Gastroent Adult 254-2 OTHER DIGESTIVE SYSTEM DIAGNOSES 356 06309 10000 10000 06309 14500 09148 10000 06309 $6861 Misc Pediatric Gastroent Adult 254-3 OTHER DIGESTIVE SYSTEM DIAGNOSES 524 09004 10000 10000 09004 14500 13056 10000 09004 $9792 Misc Pediatric Gastroent Adult 254-4 OTHER DIGESTIVE SYSTEM DIAGNOSES 1038 17096 10000 10000 17096 14500 24789 10000 17096 $18592 Misc Pediatric Gastroent Adult 260-1 MAJOR PANCREAS LIVER amp SHUNT PROCEDURES 440 14495 10000 10000 14495 14500 21018 10000 14495 $15763 Misc Pediatric Gastroent Adult 260-2 MAJOR PANCREAS LIVER amp SHUNT PROCEDURES 584 19125 10000 10000 19125 14500 27731 10000 19125 $20798 Misc Pediatric Gastroent Adult

with Age Adjustor

260-3 MAJOR PANCREAS LIVER amp SHUNT PROCEDURES 1015 30131 10000 10000 30131 14500 43690 10000 30131 $32767 Misc Pediatric Gastroent Adult 260-4 MAJOR PANCREAS LIVER amp SHUNT PROCEDURES 2143 57394 10000 10000 57394 14500 83221 10000 57394 $62416 Misc Pediatric Gastroent Adult 261-1 MAJOR BILIARY TRACT PROCEDURES 435 13205 10000 10000 13205 14500 19147 10000 13205 $14360 Misc Pediatric Gastroent Adult 261-2 MAJOR BILIARY TRACT PROCEDURES 667 17659 10000 10000 17659 14500 25606 10000 17659 $19204 Misc Pediatric Gastroent Adult 261-3 MAJOR BILIARY TRACT PROCEDURES 1065 25584 10000 10000 25584 14500 37097 10000 25584 $27823 Misc Pediatric Gastroent Adult 261-4 MAJOR BILIARY TRACT PROCEDURES 1953 45476 10000 10000 45476 14500 65940 10000 45476 $49455 Misc Pediatric Gastroent Adult 262-1 CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC 401 11964 10000 10000 11964 14500 17348 10000 11964 $13011 Misc Pediatric Gastroent Adult 262-2 CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC 568 15647 10000 10000 15647 14500 22688 10000 15647 $17016 Misc Pediatric Gastroent Adult 262-3 CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC 868 22554 10000 10000 22554 14500 32703 10000 22554 $24527 Misc Pediatric Gastroent Adult 262-4 CHOLECYSTECTOMY EXCEPT LAPAROSCOPIC 1630 40922 10000 10000 40922 14500 59337 10000 40922 $44503 Misc Pediatric Gastroent Adult 263-1 LAPAROSCOPIC CHOLECYSTECTOMY 240 09518 10000 10000 09518 14500 13801 10000 09518 $10351 Misc Pediatric Gastroent Adult 263-2 LAPAROSCOPIC CHOLECYSTECTOMY 364 12388 10000 10000 12388 14500 17963 10000 12388 $13472 Misc Pediatric Gastroent Adult 263-3 LAPAROSCOPIC CHOLECYSTECTOMY 611 16839 10000 10000 16839 14500 24417 10000 16839 $18312 Misc Pediatric Gastroent Adult 263-4 LAPAROSCOPIC CHOLECYSTECTOMY 1291 33125 10000 10000 33125 14500 48031 10000 33125 $36023 Misc Pediatric Gastroent Adult 264-1 OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES 433 12385 10000 10000 12385 14500 17958 10000 12385 $13469 Misc Pediatric Gastroent Adult 264-2 OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES 572 14009 10000 10000 14009 14500 20313 10000 14009 $15235 Misc Pediatric Gastroent Adult 264-3 OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES 1029 21821 10000 10000 21821 14500 31640 10000 21821 $23730 Misc Pediatric Gastroent Adult 264-4 OTHER HEPATOBILIARY PANCREAS amp ABDOMINAL PROCEDURES 2036 45162 10000 10000 45162 14500 65485 10000 45162 $49114 Misc Pediatric Gastroent Adult 279-1 HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS 275 04635 10000 10000 04635 14500 06721 10000 04635 $5041 Misc Pediatric Gastroent Adult 279-2 HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS 356 05749 10000 10000 05749 14500 08336 10000 05749 $6252 Misc Pediatric Gastroent Adult 279-3 HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS 568 09045 10000 10000 09045 14500 13115 10000 09045 $9836 Misc Pediatric Gastroent Adult 279-4 HEPATIC COMA amp OTHER MAJOR ACUTE LIVER DISORDERS 1157 21443 10000 10000 21443 14500 31092 10000 21443 $23319 Misc Pediatric Gastroent Adult 280-1 ALCOHOLIC LIVER DISEASE 275 04790 10000 10000 04790 14500 06946 10000 04790 $5209 Misc Pediatric Gastroent Adult 280-2 ALCOHOLIC LIVER DISEASE 340 06059 10000 10000 06059 14500 08786 10000 06059 $6589 Misc Pediatric Gastroent Adult 280-3 ALCOHOLIC LIVER DISEASE 533 09399 10000 10000 09399 14500 13629 10000 09399 $10221 Misc Pediatric Gastroent Adult 280-4 ALCOHOLIC LIVER DISEASE 1065 19912 10000 10000 19912 14500 28872 10000 19912 $21654 Misc Pediatric Gastroent Adult 281-1 MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS 327 06015 10000 10000 06015 14500 08722 10000 06015 $6541 Misc Pediatric Gastroent Adult 281-2 MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS 418 07923 10000 10000 07923 14500 11488 10000 07923 $8616 Misc Pediatric Gastroent Adult 281-3 MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS 599 10858 10000 10000 10858 14500 15744 10000 10858 $11808 Misc Pediatric Gastroent Adult 281-4 MALIGNANCY OF HEPATOBILIARY SYSTEM amp PANCREAS 969 16981 10000 10000 16981 14500 24622 10000 16981 $18467 Misc Pediatric Gastroent Adult 282-1 DISORDERS OF PANCREAS EXCEPT MALIGNANCY 312 05293 10000 10000 05293 14500 07675 10000 05293 $5756 Misc Pediatric Gastroent Adult 282-2 DISORDERS OF PANCREAS EXCEPT MALIGNANCY 401 06731 10000 10000 06731 14500 09760 10000 06731 $7320 Misc Pediatric Gastroent Adult 282-3 DISORDERS OF PANCREAS EXCEPT MALIGNANCY 638 10500 10000 10000 10500 14500 15225 10000 10500 $11419 Misc Pediatric Gastroent Adult 282-4 DISORDERS OF PANCREAS EXCEPT MALIGNANCY 1425 26296 10000 10000 26296 14500 38129 10000 26296 $28597 Misc Pediatric Gastroent Adult 283-1 OTHER DISORDERS OF THE LIVER 296 05163 10000 10000 05163 14500 07486 10000 05163 $5615 Misc Pediatric Gastroent Adult 283-2 OTHER DISORDERS OF THE LIVER 335 06116 10000 10000 06116 14500 08868 10000 06116 $6651 Misc Pediatric Gastroent Adult 283-3 OTHER DISORDERS OF THE LIVER 498 09063 10000 10000 09063 14500 13141 10000 09063 $9856 Misc Pediatric Gastroent Adult 283-4 OTHER DISORDERS OF THE LIVER 919 16684 10000 10000 16684 14500 24192 10000 16684 $18144 Misc Pediatric Gastroent Adult 284-1 DISORDERS OF GALLBLADDER amp BILIARY TRACT 246 05533 10000 10000 05533 14500 08023 10000 05533 $6017 Misc Pediatric Gastroent Adult 284-2 DISORDERS OF GALLBLADDER amp BILIARY TRACT 357 07652 10000 10000 07652 14500 11095 10000 07652 $8322 Misc Pediatric Gastroent Adult 284-3 DISORDERS OF GALLBLADDER amp BILIARY TRACT 549 10851 10000 10000 10851 14500 15734 10000 10851 $11800 Misc Pediatric Gastroent Adult 284-4 DISORDERS OF GALLBLADDER amp BILIARY TRACT 1047 20608 10000 10000 20608 14500 29882 10000 20608 $22411 Misc Pediatric Gastroent Adult 301-1 HIP JOINT REPLACEMENT 335 17407 10000 10000 17407 14500 25240 10000 17407 $18930 Misc Pediatric Misc Adult 301-2 HIP JOINT REPLACEMENT 363 18782 10000 10000 18782 14500 27234 10000 18782 $20425 Misc Pediatric Misc Adult 301-3 HIP JOINT REPLACEMENT 498 23757 10000 10000 23757 14500 34448 10000 23757 $25836 Misc Pediatric Misc Adult 301-4 HIP JOINT REPLACEMENT 1277 37689 10000 10000 37689 14500 54649 10000 37689 $40987 Misc Pediatric Misc Adult 302-1 KNEE JOINT REPLACEMENT 279 16990 10000 10000 16990 14500 24636 10000 16990 $18477 Misc Pediatric Misc Adult 302-2 KNEE JOINT REPLACEMENT 320 18649 10000 10000 18649 14500 27041 10000 18649 $20281 Misc Pediatric Misc Adult 302-3 KNEE JOINT REPLACEMENT 495 22853 10000 10000 22853 14500 33137 10000 22853 $24853 Misc Pediatric Misc Adult 302-4 KNEE JOINT REPLACEMENT 1190 38114 10000 10000 38114 14500 55265 10000 38114 $41449 Misc Pediatric Misc Adult 303-1 DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK 442 43459 10000 10000 43459 14500 63016 10000 43459 $47262 Misc Pediatric Misc Adult 303-2 DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK 584 51723 10000 10000 51723 14500 74998 10000 51723 $56249 Misc Pediatric Misc Adult 303-3 DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK 850 71975 10000 10000 71975 14500 104364 10000 71975 $78273 Misc Pediatric Misc Adult 303-4 DORSAL amp LUMBAR FUSION PROC FOR CURVATURE OF BACK 1492 96167 10000 10000 96167 14500 139442 10000 96167 $104582 Misc Pediatric Misc Adult 304-1 DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK 290 28243 10000 10000 28243 14500 40952 10000 28243 $30714 Misc Pediatric Misc Adult 304-2 DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK 397 33273 10000 10000 33273 14500 48246 10000 33273 $36184 Misc Pediatric Misc Adult 304-3 DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK 752 47280 10000 10000 47280 14500 68556 10000 47280 $51417 Misc Pediatric Misc Adult 304-4 DORSAL amp LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK 1738 75610 10000 10000 75610 14500 109635 10000 75610 $82226 Misc Pediatric Misc Adult 305-1 AMPUTATION OF LOWER LIMB EXCEPT TOES 532 10649 10000 10000 10649 14500 15441 10000 10649 $11581 Misc Pediatric Misc Adult 305-2 AMPUTATION OF LOWER LIMB EXCEPT TOES 714 13814 10000 10000 13814 14500 20030 10000 13814 $15023 Misc Pediatric Misc Adult 305-3 AMPUTATION OF LOWER LIMB EXCEPT TOES 1094 22108 10000 10000 22108 14500 32057 10000 22108 $24042 Misc Pediatric Misc Adult 305-4 AMPUTATION OF LOWER LIMB EXCEPT TOES 1882 43883 10000 10000 43883 14500 63630 10000 43883 $47723 Misc Pediatric Misc Adult 308-1 HIP amp FEMUR FRACTURE REPAIR 400 13321 10000 10000 13321 14500 19315 10000 13321 $14487 Misc Pediatric Misc Adult 308-2 HIP amp FEMUR FRACTURE REPAIR 503 15965 10000 10000 15965 14500 23149 10000 15965 $17362 Misc Pediatric Misc Adult 308-3 HIP amp FEMUR FRACTURE REPAIR 706 20833 10000 10000 20833 14500 30208 10000 20833 $22656 Misc Pediatric Misc Adult 308-4 HIP amp FEMUR FRACTURE REPAIR 1245 34008 10000 10000 34008 14500 49312 10000 34008 $36984 Misc Pediatric Misc Adult 309-1 OTHER SIGNIFICANT HIP amp FEMUR SURGERY 288 11966 10000 10000 11966 14500 17351 10000 11966 $13013 Misc Pediatric Misc Adult 309-2 OTHER SIGNIFICANT HIP amp FEMUR SURGERY 493 17426 10000 10000 17426 14500 25268 10000 17426 $18951 Misc Pediatric Misc Adult 309-3 OTHER SIGNIFICANT HIP amp FEMUR SURGERY 904 24995 10000 10000 24995 14500 36243 10000 24995 $27182 Misc Pediatric Misc Adult 309-4 OTHER SIGNIFICANT HIP amp FEMUR SURGERY 1787 44937 10000 10000 44937 14500 65159 10000 44937 $48869 Misc Pediatric Misc Adult 310-1 INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION 187 09067 10000 10000 09067 14500 13147 10000 09067 $9860 Misc Pediatric Misc Adult 310-2 INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION 317 12078 10000 10000 12078 14500 17513 10000 12078 $13135 Misc Pediatric Misc Adult

with Age Adjustor

310-3 INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION 630 17904 10000 10000 17904 14500 25961 10000 17904 $19471 Misc Pediatric Misc Adult 310-4 INTERVERTEBRAL DISC EXCISION amp DECOMPRESSION 1433 35901 10000 10000 35901 14500 52056 10000 35901 $39042 Misc Pediatric Misc Adult 312-1 SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES 486 12084 10000 10000 12084 14500 17522 10000 12084 $13141 Misc Pediatric Misc Adult 312-2 SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES 875 18406 10000 10000 18406 14500 26689 10000 18406 $20017 Misc Pediatric Misc Adult 312-3 SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES 1583 31509 10000 10000 31509 14500 45688 10000 31509 $34266 Misc Pediatric Misc Adult 312-4 SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL amp CONNECTIVE TISSUE DIAGNOSES 2958 73272 10000 10000 73272 14500 106244 10000 73272 $79683 Misc Pediatric Misc Adult 313-1 KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT 270 11130 10000 10000 11130 14500 16139 10000 11130 $12104 Misc Pediatric Misc Adult 313-2 KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT 422 15152 10000 10000 15152 14500 21970 10000 15152 $16478 Misc Pediatric Misc Adult 313-3 KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT 760 22099 10000 10000 22099 14500 32044 10000 22099 $24033 Misc Pediatric Misc Adult 313-4 KNEE amp LOWER LEG PROCEDURES EXCEPT FOOT 1590 41821 10000 10000 41821 14500 60640 10000 41821 $45480 Misc Pediatric Misc Adult 314-1 FOOT amp TOE PROCEDURES 243 09602 10000 10000 09602 14500 13923 10000 09602 $10442 Misc Pediatric Misc Adult 314-2 FOOT amp TOE PROCEDURES 507 11265 10000 10000 11265 14500 16334 10000 11265 $12251 Misc Pediatric Misc Adult 314-3 FOOT amp TOE PROCEDURES 772 15259 10000 10000 15259 14500 22126 10000 15259 $16594 Misc Pediatric Misc Adult 314-4 FOOT amp TOE PROCEDURES 1394 31635 10000 10000 31635 14500 45871 10000 31635 $34403 Misc Pediatric Misc Adult 315-1 SHOULDER UPPER ARM amp FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT 186 08436 10000 10000 08436 14500 12232 10000 08436 $9174 Misc Pediatric Misc Adult 315-2 SHOULDER UPPER ARM amp FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT 282 15694 10000 10000 15694 14500 22756 10000 15694 $17067 Misc Pediatric Misc Adult 315-3 SHOULDER UPPER ARM amp FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT 629 22140 10000 10000 22140 14500 32103 10000 22140 $24077 Misc Pediatric Misc Adult 315-4 SHOULDER UPPER ARM amp FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT 1319 39799 10000 10000 39799 14500 57709 10000 39799 $43281 Misc Pediatric Misc Adult 316-1 HAND amp WRIST PROCEDURES 232 07262 10000 10000 07262 14500 10530 10000 07262 $7897 Misc Pediatric Misc Adult 316-2 HAND amp WRIST PROCEDURES 396 10256 10000 10000 10256 14500 14871 10000 10256 $11153 Misc Pediatric Misc Adult 316-3 HAND amp WRIST PROCEDURES 703 16376 10000 10000 16376 14500 23745 10000 16376 $17809 Misc Pediatric Misc Adult 316-4 HAND amp WRIST PROCEDURES 1557 31861 10000 10000 31861 14500 46198 10000 31861 $34649 Misc Pediatric Misc Adult 317-1 TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES 303 08483 10000 10000 08483 14500 12300 10000 08483 $9225 Misc Pediatric Misc Adult 317-2 TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES 525 11659 10000 10000 11659 14500 16906 10000 11659 $12679 Misc Pediatric Misc Adult 317-3 TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES 949 19099 10000 10000 19099 14500 27694 10000 19099 $20770 Misc Pediatric Misc Adult 317-4 TENDON MUSCLE amp OTHER SOFT TISSUE PROCEDURES 1900 42716 10000 10000 42716 14500 61938 10000 42716 $46454 Misc Pediatric Misc Adult 320-1 OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES 227 09297 10000 10000 09297 14500 13481 10000 09297 $10110 Misc Pediatric Misc Adult 320-2 OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES 473 14494 10000 10000 14494 14500 21016 10000 14494 $15762 Misc Pediatric Misc Adult 320-3 OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES 829 20270 10000 10000 20270 14500 29392 10000 20270 $22044 Misc Pediatric Misc Adult 320-4 OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE PROCEDURES 1510 36065 10000 10000 36065 14500 52294 10000 36065 $39221 Misc Pediatric Misc Adult 321-1 CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP 171 16570 10000 10000 16570 14500 24027 10000 16570 $18020 Misc Pediatric Misc Adult 321-2 CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP 318 20751 10000 10000 20751 14500 30089 10000 20751 $22567 Misc Pediatric Misc Adult 321-3 CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP 809 33257 10000 10000 33257 14500 48223 10000 33257 $36167 Misc Pediatric Misc Adult 321-4 CERVICAL SPINAL FUSION amp OTHER BACKNECK PROC EXC DISC EXCISDECOMP 1755 61759 10000 10000 61759 14500 89551 10000 61759 $67163 Misc Pediatric Misc Adult 322-1 SHOULDER amp ELBOW JOINT REPLACEMENT 181 17136 10000 10000 17136 14500 24847 10000 17136 $18635 Misc Pediatric Misc Adult 322-2 SHOULDER amp ELBOW JOINT REPLACEMENT 249 18385 10000 10000 18385 14500 26658 10000 18385 $19994 Misc Pediatric Misc Adult 322-3 SHOULDER amp ELBOW JOINT REPLACEMENT 516 23829 10000 10000 23829 14500 34552 10000 23829 $25914 Misc Pediatric Misc Adult 322-4 SHOULDER amp ELBOW JOINT REPLACEMENT 1087 38254 10000 10000 38254 14500 55468 10000 38254 $41601 Misc Pediatric Misc Adult 340-1 FRACTURE OF FEMUR 344 04409 10000 10000 04409 14500 06393 10000 04409 $4795 Misc Pediatric Misc Adult 340-2 FRACTURE OF FEMUR 410 05404 10000 10000 05404 14500 07836 10000 05404 $5877 Misc Pediatric Misc Adult 340-3 FRACTURE OF FEMUR 551 07728 10000 10000 07728 14500 11206 10000 07728 $8404 Misc Pediatric Misc Adult 340-4 FRACTURE OF FEMUR 924 14954 10000 10000 14954 14500 21683 10000 14954 $16262 Misc Pediatric Misc Adult 341-1 FRACTURE OF PELVIS OR DISLOCATION OF HIP 310 04654 10000 10000 04654 14500 06748 10000 04654 $5061 Misc Pediatric Misc Adult 341-2 FRACTURE OF PELVIS OR DISLOCATION OF HIP 364 05715 10000 10000 05715 14500 08287 10000 05715 $6215 Misc Pediatric Misc Adult 341-3 FRACTURE OF PELVIS OR DISLOCATION OF HIP 476 07524 10000 10000 07524 14500 10910 10000 07524 $8182 Misc Pediatric Misc Adult 341-4 FRACTURE OF PELVIS OR DISLOCATION OF HIP 1033 17470 10000 10000 17470 14500 25332 10000 17470 $18999 Misc Pediatric Misc Adult 342-1 FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK 231 04341 10000 10000 04341 14500 06294 10000 04341 $4721 Misc Pediatric Misc Adult 342-2 FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK 339 06067 10000 10000 06067 14500 08797 10000 06067 $6598 Misc Pediatric Misc Adult 342-3 FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK 493 08467 10000 10000 08467 14500 12277 10000 08467 $9208 Misc Pediatric Misc Adult 342-4 FRACTURES amp DISLOCATIONS EXCEPT FEMUR PELVIS amp BACK 1127 18679 10000 10000 18679 14500 27085 10000 18679 $20313 Misc Pediatric Misc Adult 343-1 MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG 360 06605 10000 10000 06605 14500 09577 10000 06605 $7183 Misc Pediatric Misc Adult 343-2 MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG 459 08072 10000 10000 08072 14500 11704 10000 08072 $8778 Misc Pediatric Misc Adult 343-3 MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG 768 12911 10000 10000 12911 14500 18721 10000 12911 $14041 Misc Pediatric Misc Adult 343-4 MUSCULOSKELETAL MALIGNANCY amp PATHOL FRACTURE DT MUSCSKEL MALIG 1237 21077 10000 10000 21077 14500 30562 10000 21077 $22921 Misc Pediatric Misc Adult 344-1 OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS 464 06238 10000 10000 06238 14500 09045 10000 06238 $6784 Misc Pediatric Misc Adult 344-2 OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS 578 08192 10000 10000 08192 14500 11878 10000 08192 $8909 Misc Pediatric Misc Adult 344-3 OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS 822 12283 10000 10000 12283 14500 17810 10000 12283 $13358 Misc Pediatric Misc Adult 344-4 OSTEOMYELITIS SEPTIC ARTHRITIS amp OTHER MUSCULOSKELETAL INFECTIONS 1431 21634 10000 10000 21634 14500 31369 10000 21634 $23527 Misc Pediatric Misc Adult 346-1 CONNECTIVE TISSUE DISORDERS 318 05342 10000 10000 05342 14500 07746 10000 05342 $5809 Misc Pediatric Misc Adult 346-2 CONNECTIVE TISSUE DISORDERS 427 07257 10000 10000 07257 14500 10523 10000 07257 $7892 Misc Pediatric Misc Adult 346-3 CONNECTIVE TISSUE DISORDERS 707 11712 10000 10000 11712 14500 16982 10000 11712 $12737 Misc Pediatric Misc Adult 346-4 CONNECTIVE TISSUE DISORDERS 1519 27965 10000 10000 27965 14500 40549 10000 27965 $30412 Misc Pediatric Misc Adult 347-1 OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES 293 05346 10000 10000 05346 14500 07752 10000 05346 $5814 Misc Pediatric Misc Adult 347-2 OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES 382 06918 10000 10000 06918 14500 10031 10000 06918 $7523 Misc Pediatric Misc Adult 347-3 OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES 527 09467 10000 10000 09467 14500 13727 10000 09467 $10295 Misc Pediatric Misc Adult 347-4 OTHER BACK amp NECK DISORDERS FRACTURES amp INJURIES 1139 21262 10000 10000 21262 14500 30830 10000 21262 $23122 Misc Pediatric Misc Adult 349-1 MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE 228 04534 10000 10000 04534 14500 06574 10000 04534 $4931 Misc Pediatric Misc Adult 349-2 MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE 430 06430 10000 10000 06430 14500 09324 10000 06430 $6993 Misc Pediatric Misc Adult 349-3 MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE 680 10015 10000 10000 10015 14500 14522 10000 10015 $10891 Misc Pediatric Misc Adult 349-4 MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE 1181 20470 10000 10000 20470 14500 29682 10000 20470 $22261 Misc Pediatric Misc Adult 351-1 OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES 256 04336 10000 10000 04336 14500 06287 10000 04336 $4715 Misc Pediatric Misc Adult 351-2 OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES 352 05606 10000 10000 05606 14500 08129 10000 05606 $6097 Misc Pediatric Misc Adult

with Age Adjustor

351-3 OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES 531 08622 10000 10000 08622 14500 12502 10000 08622 $9376 Misc Pediatric Misc Adult 351-4 OTHER MUSCULOSKELETAL SYSTEM amp CONNECTIVE TISSUE DIAGNOSES 1087 18510 10000 10000 18510 14500 26840 10000 18510 $20130 Misc Pediatric Misc Adult 361-1 SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES 401 11211 10000 10000 11211 14500 16256 10000 11211 $12192 Misc Pediatric Misc Adult 361-2 SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES 716 14494 10000 10000 14494 14500 21016 10000 14494 $15762 Misc Pediatric Misc Adult 361-3 SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES 1274 21240 10000 10000 21240 14500 30798 10000 21240 $23099 Misc Pediatric Misc Adult 361-4 SKIN GRAFT FOR SKIN amp SUBCUTANEOUS TISSUE DIAGNOSES 2425 42791 10000 10000 42791 14500 62047 10000 42791 $46535 Misc Pediatric Misc Adult 362-1 MASTECTOMY PROCEDURES 184 11415 10000 10000 11415 14500 16552 10000 11415 $12414 Misc Pediatric Misc Adult 362-2 MASTECTOMY PROCEDURES 230 14606 10000 10000 14606 14500 21179 10000 14606 $15884 Misc Pediatric Misc Adult 362-3 MASTECTOMY PROCEDURES 535 17956 10000 10000 17956 14500 26036 10000 17956 $19527 Misc Pediatric Misc Adult 362-4 MASTECTOMY PROCEDURES 1178 33583 10000 10000 33583 14500 48695 10000 33583 $36522 Misc Pediatric Misc Adult 363-1 BREAST PROCEDURES EXCEPT MASTECTOMY 219 08963 10000 10000 08963 14500 12996 10000 08963 $9747 Misc Pediatric Misc Adult 363-2 BREAST PROCEDURES EXCEPT MASTECTOMY 307 15472 10000 10000 15472 14500 22434 10000 15472 $16826 Misc Pediatric Misc Adult 363-3 BREAST PROCEDURES EXCEPT MASTECTOMY 534 20424 10000 10000 20424 14500 29615 10000 20424 $22211 Misc Pediatric Misc Adult 363-4 BREAST PROCEDURES EXCEPT MASTECTOMY 1824 40787 10000 10000 40787 14500 59141 10000 40787 $44356 Misc Pediatric Misc Adult 364-1 OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES 281 07521 10000 10000 07521 14500 10905 10000 07521 $8179 Misc Pediatric Misc Adult 364-2 OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES 489 10500 10000 10000 10500 14500 15225 10000 10500 $11419 Misc Pediatric Misc Adult 364-3 OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES 850 16025 10000 10000 16025 14500 23236 10000 16025 $17427 Misc Pediatric Misc Adult 364-4 OTHER SKIN SUBCUTANEOUS TISSUE amp RELATED PROCEDURES 1535 29040 10000 10000 29040 14500 42108 10000 29040 $31581 Misc Pediatric Misc Adult 380-1 SKIN ULCERS 391 05377 10000 10000 05377 14500 07797 10000 05377 $5847 Misc Pediatric Misc Adult 380-2 SKIN ULCERS 459 06396 10000 10000 06396 14500 09274 10000 06396 $6956 Misc Pediatric Misc Adult 380-3 SKIN ULCERS 662 08803 10000 10000 08803 14500 12764 10000 08803 $9573 Misc Pediatric Misc Adult 380-4 SKIN ULCERS 1128 15974 10000 10000 15974 14500 23162 10000 15974 $17372 Misc Pediatric Misc Adult 381-1 MAJOR SKIN DISORDERS 323 03652 10000 10000 03652 14500 05295 10000 03652 $3972 Misc Pediatric Misc Adult 381-2 MAJOR SKIN DISORDERS 484 06058 10000 10000 06058 14500 08784 10000 06058 $6588 Misc Pediatric Misc Adult 381-3 MAJOR SKIN DISORDERS 771 10822 10000 10000 10822 14500 15692 10000 10822 $11769 Misc Pediatric Misc Adult 381-4 MAJOR SKIN DISORDERS 1481 27135 10000 10000 27135 14500 39346 10000 27135 $29509 Misc Pediatric Misc Adult 382-1 MALIGNANT BREAST DISORDERS 282 04229 10000 10000 04229 14500 06132 10000 04229 $4599 Misc Pediatric Misc Adult 382-2 MALIGNANT BREAST DISORDERS 404 06098 10000 10000 06098 14500 08842 10000 06098 $6632 Misc Pediatric Misc Adult 382-3 MALIGNANT BREAST DISORDERS 623 09896 10000 10000 09896 14500 14349 10000 09896 $10762 Misc Pediatric Misc Adult 382-4 MALIGNANT BREAST DISORDERS 988 16049 10000 10000 16049 14500 23271 10000 16049 $17453 Misc Pediatric Misc Adult 383-1 CELLULITIS amp OTHER SKIN INFECTIONS 290 04149 10000 10000 04149 14500 06016 10000 04149 $4512 Misc Pediatric Misc Adult 383-2 CELLULITIS amp OTHER SKIN INFECTIONS 400 05653 10000 10000 05653 14500 08197 10000 05653 $6148 Misc Pediatric Misc Adult 383-3 CELLULITIS amp OTHER SKIN INFECTIONS 587 08521 10000 10000 08521 14500 12355 10000 08521 $9267 Misc Pediatric Misc Adult 383-4 CELLULITIS amp OTHER SKIN INFECTIONS 1113 17972 10000 10000 17972 14500 26059 10000 17972 $19545 Misc Pediatric Misc Adult 384-1 CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE 193 04796 10000 10000 04796 14500 06954 10000 04796 $5216 Misc Pediatric Misc Adult 384-2 CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE 290 06067 10000 10000 06067 14500 08797 10000 06067 $6598 Misc Pediatric Misc Adult 384-3 CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE 475 08916 10000 10000 08916 14500 12928 10000 08916 $9696 Misc Pediatric Misc Adult 384-4 CONTUSION OPEN WOUND amp OTHER TRAUMA TO SKIN amp SUBCUTANEOUS TISSUE 1095 19682 10000 10000 19682 14500 28539 10000 19682 $21404 Misc Pediatric Misc Adult 385-1 OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS 250 03636 10000 10000 03636 14500 05272 10000 03636 $3954 Misc Pediatric Misc Adult 385-2 OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS 349 05039 10000 10000 05039 14500 07307 10000 05039 $5480 Misc Pediatric Misc Adult 385-3 OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS 536 07657 10000 10000 07657 14500 11103 10000 07657 $8327 Misc Pediatric Misc Adult 385-4 OTHER SKIN SUBCUTANEOUS TISSUE amp BREAST DISORDERS 1024 15042 10000 10000 15042 14500 21811 10000 15042 $16358 Misc Pediatric Misc Adult 401-1 PITUITARY amp ADRENAL PROCEDURES 288 13517 10000 10000 13517 14500 19600 10000 13517 $14700 Misc Pediatric Misc Adult 401-2 PITUITARY amp ADRENAL PROCEDURES 423 18181 10000 10000 18181 14500 26362 10000 18181 $19772 Misc Pediatric Misc Adult 401-3 PITUITARY amp ADRENAL PROCEDURES 846 29007 10000 10000 29007 14500 42060 10000 29007 $31545 Misc Pediatric Misc Adult 401-4 PITUITARY amp ADRENAL PROCEDURES 1967 61354 10000 10000 61354 14500 88963 10000 61354 $66722 Misc Pediatric Misc Adult 403-1 PROCEDURES FOR OBESITY 186 12414 10000 10000 12414 14500 18000 10000 12414 $13500 Misc Pediatric Misc Adult 403-2 PROCEDURES FOR OBESITY 231 14057 10000 10000 14057 14500 20383 10000 14057 $15287 Misc Pediatric Misc Adult 403-3 PROCEDURES FOR OBESITY 493 20421 10000 10000 20421 14500 29610 10000 20421 $22208 Misc Pediatric Misc Adult 403-4 PROCEDURES FOR OBESITY 1665 52058 10000 10000 52058 14500 75484 10000 52058 $56613 Misc Pediatric Misc Adult 404-1 THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES 133 07628 10000 10000 07628 14500 11061 10000 07628 $8295 Misc Pediatric Misc Adult 404-2 THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES 226 09944 10000 10000 09944 14500 14419 10000 09944 $10814 Misc Pediatric Misc Adult 404-3 THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES 685 19296 10000 10000 19296 14500 27979 10000 19296 $20984 Misc Pediatric Misc Adult 404-4 THYROID PARATHYROID amp THYROGLOSSAL PROCEDURES 1960 45084 10000 10000 45084 14500 65372 10000 45084 $49029 Misc Pediatric Misc Adult 405-1 OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS 323 11317 10000 10000 11317 14500 16410 10000 11317 $12307 Misc Pediatric Misc Adult 405-2 OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS 573 14150 10000 10000 14150 14500 20518 10000 14150 $15388 Misc Pediatric Misc Adult 405-3 OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS 964 21066 10000 10000 21066 14500 30546 10000 21066 $22909 Misc Pediatric Misc Adult 405-4 OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL amp METABOLIC DISORDERS 2039 44959 10000 10000 44959 14500 65191 10000 44959 $48893 Misc Pediatric Misc Adult 420-1 DIABETES 251 03832 10000 10000 03832 14500 05556 10000 03832 $4167 Misc Pediatric Misc Adult 420-2 DIABETES 271 05225 10000 10000 05225 14500 07576 10000 05225 $5682 Misc Pediatric Misc Adult 420-3 DIABETES 421 07578 10000 10000 07578 14500 10988 10000 07578 $8241 Misc Pediatric Misc Adult 420-4 DIABETES 891 18014 10000 10000 18014 14500 26120 10000 18014 $19590 Misc Pediatric Misc Adult 421-1 MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS 308 04738 10000 10000 04738 14500 06870 10000 04738 $5153 Misc Pediatric Misc Adult 421-2 MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS 470 05482 10000 10000 05482 14500 07949 10000 05482 $5962 Misc Pediatric Misc Adult 421-3 MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS 645 08272 10000 10000 08272 14500 11994 10000 08272 $8996 Misc Pediatric Misc Adult 421-4 MALNUTRITION FAILURE TO THRIVE amp OTHER NUTRITIONAL DISORDERS 1231 16004 10000 10000 16004 14500 23206 10000 16004 $17404 Misc Pediatric Misc Adult 422-1 HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS 204 03051 10000 10000 03051 14500 04424 10000 03051 $3318 Misc Pediatric Misc Adult 422-2 HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS 289 04592 10000 10000 04592 14500 06658 10000 04592 $4994 Misc Pediatric Misc Adult 422-3 HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS 431 06554 10000 10000 06554 14500 09503 10000 06554 $7127 Misc Pediatric Misc Adult 422-4 HYPOVOLEMIA amp RELATED ELECTROLYTE DISORDERS 809 12435 10000 10000 12435 14500 18031 10000 12435 $13523 Misc Pediatric Misc Adult 423-1 INBORN ERRORS OF METABOLISM 271 04561 10000 10000 04561 14500 06613 10000 04561 $4960 Misc Pediatric Misc Adult 423-2 INBORN ERRORS OF METABOLISM 346 05882 10000 10000 05882 14500 08529 10000 05882 $6397 Misc Pediatric Misc Adult

with Age Adjustor

423-3 INBORN ERRORS OF METABOLISM 558 09484 10000 10000 09484 14500 13752 10000 09484 $10314 Misc Pediatric Misc Adult 423-4 INBORN ERRORS OF METABOLISM 1231 15799 10000 10000 15799 14500 22909 10000 15799 $17181 Misc Pediatric Misc Adult 424-1 OTHER ENDOCRINE DISORDERS 257 04427 10000 10000 04427 14500 06419 10000 04427 $4814 Misc Pediatric Misc Adult 424-2 OTHER ENDOCRINE DISORDERS 392 06352 10000 10000 06352 14500 09210 10000 06352 $6908 Misc Pediatric Misc Adult 424-3 OTHER ENDOCRINE DISORDERS 588 09470 10000 10000 09470 14500 13732 10000 09470 $10299 Misc Pediatric Misc Adult 424-4 OTHER ENDOCRINE DISORDERS 1060 18531 10000 10000 18531 14500 26870 10000 18531 $20152 Misc Pediatric Misc Adult 425-1 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 240 04007 10000 10000 04007 14500 05810 10000 04007 $4358 Misc Pediatric Misc Adult 425-2 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 299 05044 10000 10000 05044 14500 07314 10000 05044 $5485 Misc Pediatric Misc Adult 425-3 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 446 07309 10000 10000 07309 14500 10598 10000 07309 $7949 Misc Pediatric Misc Adult 425-4 ELECTROLYTE DISORDERS EXCEPT HYPOVOLEMIA RELATED 946 15149 10000 10000 15149 14500 21966 10000 15149 $16475 Misc Pediatric Misc Adult 440-1 KIDNEY TRANSPLANT 467 42880 10000 10000 42880 14500 62176 10000 42880 $46632 Misc Pediatric Misc Adult 440-2 KIDNEY TRANSPLANT 526 48750 10000 10000 48750 14500 70688 10000 48750 $53016 Misc Pediatric Misc Adult 440-3 KIDNEY TRANSPLANT 748 57345 10000 10000 57345 14500 83150 10000 57345 $62363 Misc Pediatric Misc Adult 440-4 KIDNEY TRANSPLANT 1666 85793 10000 10000 85793 14500 124400 10000 85793 $93300 Misc Pediatric Misc Adult 441-1 MAJOR BLADDER PROCEDURES 429 14222 10000 10000 14222 14500 20622 10000 14222 $15466 Misc Pediatric Misc Adult 441-2 MAJOR BLADDER PROCEDURES 708 21812 10000 10000 21812 14500 31627 10000 21812 $23721 Misc Pediatric Misc Adult 441-3 MAJOR BLADDER PROCEDURES 981 29980 10000 10000 29980 14500 43471 10000 29980 $32603 Misc Pediatric Misc Adult 441-4 MAJOR BLADDER PROCEDURES 2123 58051 10000 10000 58051 14500 84174 10000 58051 $63130 Misc Pediatric Misc Adult 442-1 KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY 313 13490 10000 10000 13490 14500 19561 10000 13490 $14670 Misc Pediatric Misc Adult 442-2 KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY 404 15782 10000 10000 15782 14500 22884 10000 15782 $17163 Misc Pediatric Misc Adult 442-3 KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY 767 22894 10000 10000 22894 14500 33196 10000 22894 $24897 Misc Pediatric Misc Adult 442-4 KIDNEY amp URINARY TRACT PROCEDURES FOR MALIGNANCY 1514 44284 10000 10000 44284 14500 64212 10000 44284 $48159 Misc Pediatric Misc Adult 443-1 KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY 247 11483 10000 10000 11483 14500 16650 10000 11483 $12488 Misc Pediatric Misc Adult 443-2 KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY 354 12839 10000 10000 12839 14500 18617 10000 12839 $13962 Misc Pediatric Misc Adult 443-3 KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY 786 18327 10000 10000 18327 14500 26574 10000 18327 $19931 Misc Pediatric Misc Adult 443-4 KIDNEY amp URINARY TRACT PROCEDURES FOR NONMALIGNANCY 1584 35287 10000 10000 35287 14500 51166 10000 35287 $38375 Misc Pediatric Misc Adult 444-1 RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY 251 09277 10000 10000 09277 14500 13452 10000 09277 $10089 Misc Pediatric Misc Adult 444-2 RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY 454 12716 10000 10000 12716 14500 18438 10000 12716 $13829 Misc Pediatric Misc Adult 444-3 RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY 941 20329 10000 10000 20329 14500 29477 10000 20329 $22108 Misc Pediatric Misc Adult 444-4 RENAL DIALYSIS ACCESS DEVICE PROCEDURE ONLY 1739 37587 10000 10000 37587 14500 54501 10000 37587 $40876 Misc Pediatric Misc Adult 445-1 OTHER BLADDER PROCEDURES 227 08718 10000 10000 08718 14500 12641 10000 08718 $9481 Misc Pediatric Misc Adult 445-2 OTHER BLADDER PROCEDURES 350 11702 10000 10000 11702 14500 16968 10000 11702 $12726 Misc Pediatric Misc Adult 445-3 OTHER BLADDER PROCEDURES 723 15392 10000 10000 15392 14500 22318 10000 15392 $16739 Misc Pediatric Misc Adult 445-4 OTHER BLADDER PROCEDURES 1398 28145 10000 10000 28145 14500 40810 10000 28145 $30608 Misc Pediatric Misc Adult 446-1 URETHRAL amp TRANSURETHRAL PROCEDURES 192 07040 10000 10000 07040 14500 10208 10000 07040 $7656 Misc Pediatric Misc Adult 446-2 URETHRAL amp TRANSURETHRAL PROCEDURES 263 08635 10000 10000 08635 14500 12521 10000 08635 $9391 Misc Pediatric Misc Adult 446-3 URETHRAL amp TRANSURETHRAL PROCEDURES 596 13625 10000 10000 13625 14500 19756 10000 13625 $14817 Misc Pediatric Misc Adult 446-4 URETHRAL amp TRANSURETHRAL PROCEDURES 1303 26912 10000 10000 26912 14500 39022 10000 26912 $29267 Misc Pediatric Misc Adult 447-1 OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES 277 11463 10000 10000 11463 14500 16621 10000 11463 $12466 Misc Pediatric Misc Adult 447-2 OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES 384 13215 10000 10000 13215 14500 19162 10000 13215 $14371 Misc Pediatric Misc Adult 447-3 OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES 743 19108 10000 10000 19108 14500 27707 10000 19108 $20780 Misc Pediatric Misc Adult 447-4 OTHER KIDNEY URINARY TRACT amp RELATED PROCEDURES 1812 40605 10000 10000 40605 14500 58877 10000 40605 $44158 Misc Pediatric Misc Adult 461-1 KIDNEY amp URINARY TRACT MALIGNANCY 255 04458 10000 10000 04458 14500 06464 10000 04458 $4848 Misc Pediatric Misc Adult 461-2 KIDNEY amp URINARY TRACT MALIGNANCY 368 06285 10000 10000 06285 14500 09113 10000 06285 $6835 Misc Pediatric Misc Adult 461-3 KIDNEY amp URINARY TRACT MALIGNANCY 617 09778 10000 10000 09778 14500 14178 10000 09778 $10634 Misc Pediatric Misc Adult 461-4 KIDNEY amp URINARY TRACT MALIGNANCY 1024 17089 10000 10000 17089 14500 24779 10000 17089 $18584 Misc Pediatric Misc Adult 462-1 NEPHRITIS amp NEPHROSIS 253 03771 10000 10000 03771 14500 05468 10000 03771 $4101 Misc Pediatric Misc Adult 462-2 NEPHRITIS amp NEPHROSIS 382 05376 10000 10000 05376 14500 07795 10000 05376 $5846 Misc Pediatric Misc Adult 462-3 NEPHRITIS amp NEPHROSIS 694 09991 10000 10000 09991 14500 14487 10000 09991 $10865 Misc Pediatric Misc Adult 462-4 NEPHRITIS amp NEPHROSIS 1243 18663 10000 10000 18663 14500 27061 10000 18663 $20296 Misc Pediatric Misc Adult 463-1 KIDNEY amp URINARY TRACT INFECTIONS 268 04283 10000 10000 04283 14500 06210 10000 04283 $4658 Misc Pediatric Misc Adult 463-2 KIDNEY amp URINARY TRACT INFECTIONS 349 05523 10000 10000 05523 14500 08008 10000 05523 $6006 Misc Pediatric Misc Adult 463-3 KIDNEY amp URINARY TRACT INFECTIONS 495 07508 10000 10000 07508 14500 10887 10000 07508 $8165 Misc Pediatric Misc Adult 463-4 KIDNEY amp URINARY TRACT INFECTIONS 853 13262 10000 10000 13262 14500 19230 10000 13262 $14422 Misc Pediatric Misc Adult 465-1 URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION 170 04552 10000 10000 04552 14500 06600 10000 04552 $4950 Misc Pediatric Misc Adult 465-2 URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION 201 05479 10000 10000 05479 14500 07945 10000 05479 $5958 Misc Pediatric Misc Adult 465-3 URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION 382 08536 10000 10000 08536 14500 12377 10000 08536 $9283 Misc Pediatric Misc Adult 465-4 URINARY STONES amp ACQUIRED UPPER URINARY TRACT OBSTRUCTION 826 17380 10000 10000 17380 14500 25201 10000 17380 $18901 Misc Pediatric Misc Adult 466-1 MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC 228 03880 10000 10000 03880 14500 05626 10000 03880 $4220 Misc Pediatric Misc Adult 466-2 MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC 350 05802 10000 10000 05802 14500 08413 10000 05802 $6310 Misc Pediatric Misc Adult 466-3 MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC 519 08460 10000 10000 08460 14500 12267 10000 08460 $9200 Misc Pediatric Misc Adult 466-4 MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC 880 15503 10000 10000 15503 14500 22479 10000 15503 $16860 Misc Pediatric Misc Adult 468-1 OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS 257 04274 10000 10000 04274 14500 06197 10000 04274 $4648 Misc Pediatric Misc Adult 468-2 OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS 346 05920 10000 10000 05920 14500 08584 10000 05920 $6438 Misc Pediatric Misc Adult 468-3 OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS 520 08683 10000 10000 08683 14500 12590 10000 08683 $9443 Misc Pediatric Misc Adult 468-4 OTHER KIDNEY amp URINARY TRACT DIAGNOSES SIGNS amp SYMPTOMS 951 16721 10000 10000 16721 14500 24245 10000 16721 $18184 Misc Pediatric Misc Adult 469-1 ACUTE KIDNEY INJURY 271 04429 10000 10000 04429 14500 06422 10000 04429 $4817 Misc Pediatric Misc Adult 469-2 ACUTE KIDNEY INJURY 371 05871 10000 10000 05871 14500 08513 10000 05871 $6385 Misc Pediatric Misc Adult 469-3 ACUTE KIDNEY INJURY 588 09187 10000 10000 09187 14500 13321 10000 09187 $9991 Misc Pediatric Misc Adult 469-4 ACUTE KIDNEY INJURY 1138 19639 10000 10000 19639 14500 28477 10000 19639 $21357 Misc Pediatric Misc Adult 470-1 CHRONIC KIDNEY DISEASE 238 04510 10000 10000 04510 14500 06540 10000 04510 $4905 Misc Pediatric Misc Adult 470-2 CHRONIC KIDNEY DISEASE 311 05526 10000 10000 05526 14500 08013 10000 05526 $6010 Misc Pediatric Misc Adult

with Age Adjustor

470-3 CHRONIC KIDNEY DISEASE 469 08160 10000 10000 08160 14500 11832 10000 08160 $8874 Misc Pediatric Misc Adult 470-4 CHRONIC KIDNEY DISEASE 946 16618 10000 10000 16618 14500 24096 10000 16618 $18072 Misc Pediatric Misc Adult 480-1 MAJOR MALE PELVIC PROCEDURES 170 12523 10000 10000 12523 14500 18158 10000 12523 $13619 Misc Pediatric Misc Adult 480-2 MAJOR MALE PELVIC PROCEDURES 232 13915 10000 10000 13915 14500 20177 10000 13915 $15133 Misc Pediatric Misc Adult 480-3 MAJOR MALE PELVIC PROCEDURES 632 22161 10000 10000 22161 14500 32133 10000 22161 $24100 Misc Pediatric Misc Adult 480-4 MAJOR MALE PELVIC PROCEDURES 1501 46094 10000 10000 46094 14500 66836 10000 46094 $50127 Misc Pediatric Misc Adult 481-1 PENIS PROCEDURES 241 06877 10000 10000 06877 14500 09972 10000 06877 $7479 Misc Pediatric Misc Adult 481-2 PENIS PROCEDURES 280 11102 10000 10000 11102 14500 16098 10000 11102 $12073 Misc Pediatric Misc Adult 481-3 PENIS PROCEDURES 836 15699 10000 10000 15699 14500 22764 10000 15699 $17073 Misc Pediatric Misc Adult 481-4 PENIS PROCEDURES 1676 36202 10000 10000 36202 14500 52493 10000 36202 $39370 Misc Pediatric Misc Adult 482-1 TRANSURETHRAL PROSTATECTOMY 181 06299 10000 10000 06299 14500 09134 10000 06299 $6850 Misc Pediatric Misc Adult 482-2 TRANSURETHRAL PROSTATECTOMY 305 08131 10000 10000 08131 14500 11790 10000 08131 $8842 Misc Pediatric Misc Adult 482-3 TRANSURETHRAL PROSTATECTOMY 723 14934 10000 10000 14934 14500 21654 10000 14934 $16241 Misc Pediatric Misc Adult 482-4 TRANSURETHRAL PROSTATECTOMY 1304 28548 10000 10000 28548 14500 41395 10000 28548 $31046 Misc Pediatric Misc Adult 483-1 TESTES amp SCROTAL PROCEDURES 203 06294 10000 10000 06294 14500 09126 10000 06294 $6845 Misc Pediatric Misc Adult 483-2 TESTES amp SCROTAL PROCEDURES 537 11236 10000 10000 11236 14500 16292 10000 11236 $12219 Misc Pediatric Misc Adult 483-3 TESTES amp SCROTAL PROCEDURES 1039 19866 10000 10000 19866 14500 28806 10000 19866 $21604 Misc Pediatric Misc Adult 483-4 TESTES amp SCROTAL PROCEDURES 2078 40854 10000 10000 40854 14500 59238 10000 40854 $44429 Misc Pediatric Misc Adult 484-1 OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES 278 08111 10000 10000 08111 14500 11761 10000 08111 $8821 Misc Pediatric Misc Adult 484-2 OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES 208 12651 10000 10000 12651 14500 18344 10000 12651 $13758 Misc Pediatric Misc Adult 484-3 OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES 513 15766 10000 10000 15766 14500 22861 10000 15766 $17146 Misc Pediatric Misc Adult 484-4 OTHER MALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES 1838 39580 10000 10000 39580 14500 57391 10000 39580 $43043 Misc Pediatric Misc Adult 500-1 MALIGNANCY MALE REPRODUCTIVE SYSTEM 248 03951 10000 10000 03951 14500 05729 10000 03951 $4297 Misc Pediatric Misc Adult 500-2 MALIGNANCY MALE REPRODUCTIVE SYSTEM 407 06408 10000 10000 06408 14500 09292 10000 06408 $6969 Misc Pediatric Misc Adult 500-3 MALIGNANCY MALE REPRODUCTIVE SYSTEM 646 10139 10000 10000 10139 14500 14702 10000 10139 $11026 Misc Pediatric Misc Adult 500-4 MALIGNANCY MALE REPRODUCTIVE SYSTEM 910 15110 10000 10000 15110 14500 21910 10000 15110 $16432 Misc Pediatric Misc Adult 501-1 MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY 262 04066 10000 10000 04066 14500 05896 10000 04066 $4422 Misc Pediatric Misc Adult 501-2 MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY 359 05655 10000 10000 05655 14500 08200 10000 05655 $6150 Misc Pediatric Misc Adult 501-3 MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY 548 08388 10000 10000 08388 14500 12163 10000 08388 $9122 Misc Pediatric Misc Adult 501-4 MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY 1142 18288 10000 10000 18288 14500 26518 10000 18288 $19888 Misc Pediatric Misc Adult 510-1 PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS 228 11731 10000 10000 11731 14500 17010 10000 11731 $12757 Misc Pediatric Misc Adult 510-2 PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS 376 14447 10000 10000 14447 14500 20948 10000 14447 $15711 Misc Pediatric Misc Adult 510-3 PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS 862 25361 10000 10000 25361 14500 36773 10000 25361 $27580 Misc Pediatric Misc Adult 510-4 PELVIC EVISCERATION RADICAL HYSTERECTOMY amp OTHER RADICAL GYN PROCS 1877 51736 10000 10000 51736 14500 75017 10000 51736 $56263 Misc Pediatric Misc Adult 511-1 UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY 341 12451 10000 10000 12451 14500 18054 10000 12451 $13540 Misc Pediatric Misc Adult 511-2 UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY 498 15197 10000 10000 15197 14500 22036 10000 15197 $16527 Misc Pediatric Misc Adult 511-3 UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY 828 22785 10000 10000 22785 14500 33038 10000 22785 $24779 Misc Pediatric Misc Adult 511-4 UTERINE amp ADNEXA PROCEDURES FOR OVARIAN amp ADNEXAL MALIGNANCY 1722 46989 10000 10000 46989 14500 68134 10000 46989 $51101 Misc Pediatric Misc Adult 512-1 UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG 207 10826 10000 10000 10826 14500 15698 10000 10826 $11773 Misc Pediatric Misc Adult 512-2 UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG 302 12934 10000 10000 12934 14500 18754 10000 12934 $14066 Misc Pediatric Misc Adult 512-3 UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG 657 19270 10000 10000 19270 14500 27942 10000 19270 $20956 Misc Pediatric Misc Adult 512-4 UTERINE amp ADNEXA PROCEDURES FOR NON-OVARIAN amp NON-ADNEXAL MALIG 1464 38918 10000 10000 38918 14500 56431 10000 38918 $42323 Misc Pediatric Misc Adult 513-1 UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA 186 08752 10000 10000 08752 14500 12690 10000 08752 $9518 Misc Pediatric Misc Adult 513-2 UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA 257 10329 10000 10000 10329 14500 14977 10000 10329 $11233 Misc Pediatric Misc Adult 513-3 UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA 563 16473 10000 10000 16473 14500 23886 10000 16473 $17914 Misc Pediatric Misc Adult 513-4 UTERINE amp ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA 1324 37451 10000 10000 37451 14500 54304 10000 37451 $40728 Misc Pediatric Misc Adult 514-1 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 139 06987 10000 10000 06987 14500 10131 10000 06987 $7598 Misc Pediatric Misc Adult 514-2 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 178 10145 10000 10000 10145 14500 14710 10000 10145 $11033 Misc Pediatric Misc Adult 514-3 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 533 17046 10000 10000 17046 14500 24717 10000 17046 $18538 Misc Pediatric Misc Adult 514-4 FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES 1877 47779 10000 10000 47779 14500 69280 10000 47779 $51960 Misc Pediatric Misc Adult 517-1 DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES 194 06183 10000 10000 06183 14500 08965 10000 06183 $6724 Misc Pediatric Misc Adult 517-2 DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES 304 08155 10000 10000 08155 14500 11825 10000 08155 $8869 Misc Pediatric Misc Adult 517-3 DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES 638 14099 10000 10000 14099 14500 20444 10000 14099 $15333 Misc Pediatric Misc Adult 517-4 DILATION amp CURETTAGE FOR NON-OBSTETRIC DIAGNOSES 1326 30336 10000 10000 30336 14500 43987 10000 30336 $32990 Misc Pediatric Misc Adult 518-1 OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES 219 07148 10000 10000 07148 14500 10365 10000 07148 $7773 Misc Pediatric Misc Adult 518-2 OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES 395 10188 10000 10000 10188 14500 14773 10000 10188 $11079 Misc Pediatric Misc Adult 518-3 OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES 824 17736 10000 10000 17736 14500 25717 10000 17736 $19288 Misc Pediatric Misc Adult 518-4 OTHER FEMALE REPRODUCTIVE SYSTEM amp RELATED PROCEDURES 1843 40573 10000 10000 40573 14500 58831 10000 40573 $44123 Misc Pediatric Misc Adult 519-1 UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA 204 08506 10000 10000 08506 14500 12334 10000 08506 $9250 Misc Pediatric Misc Adult 519-2 UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA 285 10523 10000 10000 10523 14500 15258 10000 10523 $11444 Misc Pediatric Misc Adult 519-3 UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA 602 18157 10000 10000 18157 14500 26328 10000 18157 $19746 Misc Pediatric Misc Adult 519-4 UTERINE amp ADNEXA PROCEDURES FOR LEIOMYOMA 1295 41456 10000 10000 41456 14500 60111 10000 41456 $45083 Misc Pediatric Misc Adult 530-1 FEMALE REPRODUCTIVE SYSTEM MALIGNANCY 280 04366 10000 10000 04366 14500 06331 10000 04366 $4748 Misc Pediatric Misc Adult 530-2 FEMALE REPRODUCTIVE SYSTEM MALIGNANCY 366 06119 10000 10000 06119 14500 08873 10000 06119 $6654 Misc Pediatric Misc Adult 530-3 FEMALE REPRODUCTIVE SYSTEM MALIGNANCY 635 10081 10000 10000 10081 14500 14617 10000 10081 $10963 Misc Pediatric Misc Adult 530-4 FEMALE REPRODUCTIVE SYSTEM MALIGNANCY 1110 17730 10000 10000 17730 14500 25709 10000 17730 $19281 Misc Pediatric Misc Adult 531-1 FEMALE REPRODUCTIVE SYSTEM INFECTIONS 271 04601 10000 10000 04601 14500 06671 10000 04601 $5004 Misc Pediatric Misc Adult 531-2 FEMALE REPRODUCTIVE SYSTEM INFECTIONS 388 06208 10000 10000 06208 14500 09002 10000 06208 $6751 Misc Pediatric Misc Adult 531-3 FEMALE REPRODUCTIVE SYSTEM INFECTIONS 633 09558 10000 10000 09558 14500 13859 10000 09558 $10394 Misc Pediatric Misc Adult 531-4 FEMALE REPRODUCTIVE SYSTEM INFECTIONS 1172 17014 10000 10000 17014 14500 24670 10000 17014 $18503 Misc Pediatric Misc Adult 532-1 MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS 180 03777 10000 10000 03777 14500 05477 10000 03777 $4107 Misc Pediatric Misc Adult 532-2 MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS 235 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult

with Age Adjustor

532-3 MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS 428 07685 10000 10000 07685 14500 11143 10000 07685 $8357 Misc Pediatric Misc Adult 532-4 MENSTRUAL amp OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS 818 15639 10000 10000 15639 14500 22677 10000 15639 $17007 Misc Pediatric Misc Adult 540-1 CESAREAN DELIVERY 296 05616 10000 10600 05953 10000 05953 10000 05616 $4465 Obstetrics Obstetrics 540-2 CESAREAN DELIVERY 388 06702 10000 10600 07104 10000 07104 10000 06702 $5328 Obstetrics Obstetrics 540-3 CESAREAN DELIVERY 617 08928 10000 10600 09464 10000 09464 10000 08928 $7098 Obstetrics Obstetrics 540-4 CESAREAN DELIVERY 1021 21576 10000 10600 22871 10000 22871 10000 21576 $17153 Obstetrics Obstetrics 541-1 VAGINAL DELIVERY W STERILIZATION ampOR DampC 213 05632 10000 10600 05970 10000 05970 10000 05632 $4477 Obstetrics Obstetrics 541-2 VAGINAL DELIVERY W STERILIZATION ampOR DampC 247 06049 10000 10600 06412 10000 06412 10000 06049 $4809 Obstetrics Obstetrics 541-3 VAGINAL DELIVERY W STERILIZATION ampOR DampC 445 08143 10000 10600 08632 10000 08632 10000 08143 $6474 Obstetrics Obstetrics 541-4 VAGINAL DELIVERY W STERILIZATION ampOR DampC 883 25106 10000 10600 26612 10000 26612 10000 25106 $19959 Obstetrics Obstetrics 542-1 VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC 216 03804 10000 10600 04032 10000 04032 10000 03804 $3024 Obstetrics Obstetrics 542-2 VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC 284 04683 10000 10600 04964 10000 04964 10000 04683 $3723 Obstetrics Obstetrics 542-3 VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC 585 08542 10000 10600 09055 10000 09055 10000 08542 $6791 Obstetrics Obstetrics 542-4 VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION ampOR DampC 890 29802 10000 10600 31590 10000 31590 10000 29802 $23693 Obstetrics Obstetrics 544-1 DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES 136 04780 10000 10600 05067 10000 05067 10000 04780 $3800 Obstetrics Obstetrics 544-2 DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES 195 05922 10000 10600 06277 10000 06277 10000 05922 $4708 Obstetrics Obstetrics 544-3 DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES 362 08940 10000 10600 09476 10000 09476 10000 08940 $7107 Obstetrics Obstetrics 544-4 DampC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES 941 24379 10000 10600 25842 10000 25842 10000 24379 $19381 Obstetrics Obstetrics 545-1 ECTOPIC PREGNANCY PROCEDURE 161 07237 10000 10600 07671 10000 07671 10000 07237 $5753 Obstetrics Obstetrics 545-2 ECTOPIC PREGNANCY PROCEDURE 185 08148 10000 10600 08637 10000 08637 10000 08148 $6478 Obstetrics Obstetrics 545-3 ECTOPIC PREGNANCY PROCEDURE 263 10510 10000 10600 11141 10000 11141 10000 10510 $8355 Obstetrics Obstetrics 545-4 ECTOPIC PREGNANCY PROCEDURE 432 17483 10000 10600 18532 10000 18532 10000 17483 $13899 Obstetrics Obstetrics 546-1 OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES 266 05022 10000 10600 05323 10000 05323 10000 05022 $3992 Obstetrics Obstetrics 546-2 OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES 393 07280 10000 10600 07717 10000 07717 10000 07280 $5788 Obstetrics Obstetrics 546-3 OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES 672 13229 10000 10600 14023 10000 14023 10000 13229 $10517 Obstetrics Obstetrics 546-4 OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES 1358 37623 10000 10600 39880 10000 39880 10000 37623 $29910 Obstetrics Obstetrics 560-1 VAGINAL DELIVERY 204 03321 10000 10600 03520 10000 03520 10000 03321 $2640 Obstetrics Obstetrics 560-2 VAGINAL DELIVERY 237 03834 10000 10600 04064 10000 04064 10000 03834 $3048 Obstetrics Obstetrics 560-3 VAGINAL DELIVERY 370 05226 10000 10600 05540 10000 05540 10000 05226 $4155 Obstetrics Obstetrics 560-4 VAGINAL DELIVERY 748 12664 10000 10600 13424 10000 13424 10000 12664 $10068 Obstetrics Obstetrics 561-1 POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE 194 02268 10000 10600 02404 10000 02404 10000 02268 $1803 Obstetrics Obstetrics 561-2 POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE 252 03652 10000 10600 03871 10000 03871 10000 03652 $2903 Obstetrics Obstetrics 561-3 POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE 398 05663 10000 10600 06003 10000 06003 10000 05663 $4502 Obstetrics Obstetrics 561-4 POSTPARTUM amp POST ABORTION DIAGNOSES WO PROCEDURE 662 14092 10000 10600 14938 10000 14938 10000 14092 $11203 Obstetrics Obstetrics 563-1 PRETERM LABOR 254 02466 10000 10600 02614 10000 02614 10000 02466 $1960 Obstetrics Obstetrics 563-2 PRETERM LABOR 391 03183 10000 10600 03374 10000 03374 10000 03183 $2530 Obstetrics Obstetrics 563-3 PRETERM LABOR 696 04670 10000 10600 04950 10000 04950 10000 04670 $3713 Obstetrics Obstetrics 563-4 PRETERM LABOR 1360 08732 10000 10600 09256 10000 09256 10000 08732 $6942 Obstetrics Obstetrics 564-1 ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY 134 02841 10000 10600 03011 10000 03011 10000 02841 $2259 Obstetrics Obstetrics 564-2 ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY 162 03367 10000 10600 03569 10000 03569 10000 03367 $2677 Obstetrics Obstetrics 564-3 ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY 250 04770 10000 10600 05056 10000 05056 10000 04770 $3792 Obstetrics Obstetrics 564-4 ABORTION WO DampC ASPIRATION CURETTAGE OR HYSTEROTOMY 845 17152 10000 10600 18181 10000 18181 10000 17152 $13636 Obstetrics Obstetrics 565-1 FALSE LABOR 123 01222 10000 10600 01295 10000 01295 10000 01222 $971 Obstetrics Obstetrics 565-2 FALSE LABOR 189 01697 10000 10600 01799 10000 01799 10000 01697 $1349 Obstetrics Obstetrics 565-3 FALSE LABOR 374 03941 10000 10600 04177 10000 04177 10000 03941 $3133 Obstetrics Obstetrics 565-4 FALSE LABOR 411 04379 10000 10600 04642 10000 04642 10000 04379 $3481 Obstetrics Obstetrics 566-1 OTHER ANTEPARTUM DIAGNOSES 208 02390 10000 10600 02533 10000 02533 10000 02390 $1900 Obstetrics Obstetrics 566-2 OTHER ANTEPARTUM DIAGNOSES 298 03223 10000 10600 03416 10000 03416 10000 03223 $2562 Obstetrics Obstetrics 566-3 OTHER ANTEPARTUM DIAGNOSES 561 04700 10000 10600 04982 10000 04982 10000 04700 $3737 Obstetrics Obstetrics 566-4 OTHER ANTEPARTUM DIAGNOSES 786 14237 10000 10600 15091 10000 15091 10000 14237 $11318 Obstetrics Obstetrics 580-1 NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE 144 02250 12500 10000 02813 10000 02813 17500 03938 $2109 Neonate Neonate 580-2 NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE 163 02877 12500 10000 03596 10000 03596 17500 05035 $2697 Neonate Neonate 580-3 NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE 179 04381 12500 10000 05476 10000 05476 17500 07667 $4107 Neonate Neonate 580-4 NEONATE TRANSFERRED lt5 DAYS OLD NOT BORN HERE 176 07760 12500 10000 09700 10000 09700 17500 13580 $7275 Neonate Neonate 581-1 NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE 122 00919 12500 10000 01149 10000 01149 17500 01608 $862 Neonate Neonate 581-2 NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE 125 01388 12500 10000 01735 10000 01735 17500 02429 $1301 Neonate Neonate 581-3 NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE 117 02279 12500 10000 02849 10000 02849 17500 03988 $2137 Neonate Neonate 581-4 NEONATE TRANSFERRED lt 5 DAYS OLD BORN HERE 124 03970 12500 10000 04963 10000 04963 17500 06948 $3722 Neonate Neonate 583-1 NEONATE W ECMO 2250 40925 12500 10000 51156 10000 51156 17500 71619 $38367 Neonate Neonate 583-2 NEONATE W ECMO 2500 64623 12500 10000 80779 10000 80779 17500 113090 $60584 Neonate Neonate 583-3 NEONATE W ECMO 3590 158751 12500 10000 198439 10000 198439 17500 277814 $148829 Neonate Neonate 583-4 NEONATE W ECMO 6484 260571 12500 10000 325714 10000 325714 17500 455999 $244285 Neonate Neonate 588-1 NEONATE BWT lt1500G W MAJOR PROCEDURE 4453 49268 12500 10000 61585 10000 61585 17500 86219 $46189 Neonate Neonate 588-2 NEONATE BWT lt1500G W MAJOR PROCEDURE 4948 71276 12500 10000 89095 10000 89095 17500 124733 $66821 Neonate Neonate 588-3 NEONATE BWT lt1500G W MAJOR PROCEDURE 8380 159658 12500 10000 199573 10000 199573 17500 279402 $149679 Neonate Neonate 588-4 NEONATE BWT lt1500G W MAJOR PROCEDURE 10936 237739 12500 10000 297174 10000 297174 17500 416043 $222880 Neonate Neonate 589-1 NEONATE BWT lt500G OR GA lt24 WEEKS 7943 229879 12500 10000 287349 10000 287349 17500 402288 $215512 Neonate Neonate 589-2 NEONATE BWT lt500G OR GA lt24 WEEKS 9965 208981 12500 10000 261226 10000 261226 17500 365717 $195920 Neonate Neonate 589-3 NEONATE BWT lt500G OR GA lt24 WEEKS 10812 189983 12500 10000 237479 10000 237479 17500 332470 $178109 Neonate Neonate 589-4 NEONATE BWT lt500G OR GA lt24 WEEKS 2300 03183 12500 10000 03979 10000 03979 17500 05570 $2984 Neonate Neonate 591-1 NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE 100 00568 12500 10000 00710 10000 00710 17500 00994 $533 Neonate Neonate 591-2 NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE 6624 76053 12500 10000 95066 10000 95066 17500 133093 $71300 Neonate Neonate

with Age Adjustor

591-3 NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE 7939 129706 12500 10000 162133 10000 162133 17500 226986 $121599 Neonate Neonate 591-4 NEONATE BIRTHWT 500-749G WO MAJOR PROCEDURE 10218 208522 12500 10000 260653 10000 260653 17500 364914 $195489 Neonate Neonate 593-1 NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE 1818 06043 12500 10000 07554 10000 07554 17500 10575 $5665 Neonate Neonate 593-2 NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE 5487 65483 12500 10000 81854 10000 81854 17500 114595 $61390 Neonate Neonate 593-3 NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE 6785 106916 12500 10000 133645 10000 133645 17500 187103 $100234 Neonate Neonate 593-4 NEONATE BIRTHWT 750-999G WO MAJOR PROCEDURE 8726 165242 12500 10000 206553 10000 206553 17500 289174 $154914 Neonate Neonate 602-1 NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 3070 27929 12500 10000 34911 10000 34911 17500 48876 $26183 Neonate Neonate 602-2 NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 4572 65324 12500 10000 81655 10000 81655 17500 114317 $61241 Neonate Neonate 602-3 NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 5775 90423 12500 10000 113029 10000 113029 17500 158240 $84772 Neonate Neonate 602-4 NEONATE BWT 1000-1249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 7184 127344 12500 10000 159180 10000 159180 17500 222852 $119385 Neonate Neonate 603-1 NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION 1840 10282 12500 10000 12853 10000 12853 17500 17994 $9639 Neonate Neonate 603-2 NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION 3592 37980 12500 10000 47475 10000 47475 17500 66465 $35606 Neonate Neonate 603-3 NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION 4867 63606 12500 10000 79508 10000 79508 17500 111311 $59631 Neonate Neonate 603-4 NEONATE BIRTHWT 1000-1249G W OR WO OTHER SIGNIFICANT CONDITION 6605 109740 12500 10000 137175 10000 137175 17500 192045 $102881 Neonate Neonate 607-1 NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 2574 27742 12500 10000 34678 10000 34678 17500 48549 $26008 Neonate Neonate 607-2 NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 3676 50494 12500 10000 63118 10000 63118 17500 88365 $47338 Neonate Neonate 607-3 NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 4670 70163 12500 10000 87704 10000 87704 17500 122785 $65778 Neonate Neonate 607-4 NEONATE BWT 1250-1499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM 5964 100958 12500 10000 126198 10000 126198 17500 176677 $94648 Neonate Neonate 608-1 NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION 1962 18028 12500 10000 22535 10000 22535 17500 31549 $16901 Neonate Neonate 608-2 NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION 3075 39171 12500 10000 48964 10000 48964 17500 68549 $36723 Neonate Neonate 608-3 NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION 4172 58169 12500 10000 72711 10000 72711 17500 101796 $54533 Neonate Neonate 608-4 NEONATE BWT 1250-1499G W OR WO OTHER SIGNIFICANT CONDITION 5047 82164 12500 10000 102705 10000 102705 17500 143787 $77029 Neonate Neonate 609-1 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 350 12079 12500 10000 15099 10000 15099 17500 21138 $11324 Neonate Neonate 609-2 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 2056 36472 12500 10000 45590 10000 45590 17500 63826 $34193 Neonate Neonate 609-3 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 3724 69445 12500 10000 86806 10000 86806 17500 121529 $65105 Neonate Neonate 609-4 NEONATE BWT 1500-2499G W MAJOR PROCEDURE 6188 123074 12500 10000 153843 10000 153843 17500 215380 $115382 Neonate Neonate 611-1 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 1485 15636 12500 10000 19545 10000 19545 17500 27363 $14659 Neonate Neonate 611-2 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 2233 28002 12500 10000 35003 10000 35003 17500 49004 $26252 Neonate Neonate 611-3 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 3521 48361 12500 10000 60451 10000 60451 17500 84632 $45338 Neonate Neonate 611-4 NEONATE BIRTHWT 1500-1999G W MAJOR ANOMALY 4421 75786 12500 10000 94733 10000 94733 17500 132626 $71049 Neonate Neonate 612-1 NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND 1807 22731 12500 10000 28414 10000 28414 17500 39779 $21310 Neonate Neonate 612-2 NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND 2615 34665 12500 10000 43331 10000 43331 17500 60664 $32498 Neonate Neonate 612-3 NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND 3444 49272 12500 10000 61590 10000 61590 17500 86226 $46193 Neonate Neonate 612-4 NEONATE BWT 1500-1999G W RESP DIST SYNDOTH MAJ RESP COND 4282 72506 12500 10000 90633 10000 90633 17500 126886 $67974 Neonate Neonate 613-1 NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION 1558 18066 12500 10000 22583 10000 22583 17500 31616 $16937 Neonate Neonate 613-2 NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION 2178 26588 12500 10000 33235 10000 33235 17500 46529 $24926 Neonate Neonate 613-3 NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION 3336 46993 12500 10000 58741 10000 58741 17500 82238 $44056 Neonate Neonate 613-4 NEONATE BIRTHWT 1500-1999G W CONGENITALPERINATAL INFECTION 4586 61563 12500 10000 76954 10000 76954 17500 107735 $57715 Neonate Neonate 614-1 NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION 1143 09292 12500 10000 11615 10000 11615 17500 16261 $8711 Neonate Neonate 614-2 NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION 1993 22855 12500 10000 28569 10000 28569 17500 39996 $21427 Neonate Neonate 614-3 NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION 2992 38167 12500 10000 47709 10000 47709 17500 66792 $35782 Neonate Neonate 614-4 NEONATE BWT 1500-1999G W OR WO OTHER SIGNIFICANT CONDITION 3150 46161 12500 10000 57701 10000 57701 17500 80782 $43276 Neonate Neonate 621-1 NEONATE BWT 2000-2499G W MAJOR ANOMALY 760 05669 12500 10000 07086 10000 07086 17500 09921 $5315 Neonate Neonate 621-2 NEONATE BWT 2000-2499G W MAJOR ANOMALY 1522 16241 12500 10000 20301 10000 20301 17500 28422 $15226 Neonate Neonate 621-3 NEONATE BWT 2000-2499G W MAJOR ANOMALY 2166 30613 12500 10000 38266 10000 38266 17500 53573 $28700 Neonate Neonate 621-4 NEONATE BWT 2000-2499G W MAJOR ANOMALY 3316 59337 12500 10000 74171 10000 74171 17500 103840 $55628 Neonate Neonate 622-1 NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND 1155 13970 12500 10000 17463 10000 17463 17500 24448 $13097 Neonate Neonate 622-2 NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND 1570 21235 12500 10000 26544 10000 26544 17500 37161 $19908 Neonate Neonate 622-3 NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND 2078 31351 12500 10000 39189 10000 39189 17500 54864 $29392 Neonate Neonate 622-4 NEONATE BWT 2000-2499G W RESP DIST SYNDOTH MAJ RESP COND 2475 47226 12500 10000 59033 10000 59033 17500 82646 $44274 Neonate Neonate 623-1 NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION 921 09677 12500 10000 12096 10000 12096 17500 16935 $9072 Neonate Neonate 623-2 NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION 1448 16910 12500 10000 21138 10000 21138 17500 29593 $15853 Neonate Neonate 623-3 NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION 2058 27833 12500 10000 34791 10000 34791 17500 48708 $26093 Neonate Neonate 623-4 NEONATE BWT 2000-2499G W CONGENITALPERINATAL INFECTION 2787 40703 12500 10000 50879 10000 50879 17500 71230 $38159 Neonate Neonate 625-1 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 1175 11279 12500 10000 14099 10000 14099 17500 19738 $10574 Neonate Neonate 625-2 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 1680 18927 12500 10000 23659 10000 23659 17500 33122 $17744 Neonate Neonate 625-3 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 2119 26173 12500 10000 32716 10000 32716 17500 45803 $24537 Neonate Neonate 625-4 NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION 1866 39129 12500 10000 48911 10000 48911 17500 68476 $36683 Neonate Neonate 626-1 NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 276 01341 10000 10000 01341 10000 01341 10000 01341 $1006 Normal newborn Normal newborn 626-2 NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 439 02386 10000 10000 02386 10000 02386 10000 02386 $1790 Normal newborn Normal newborn 626-3 NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 874 07567 10000 10000 07567 10000 07567 10000 07567 $5675 Normal newborn Normal newborn 626-4 NEONATE BWT 2000-2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 1608 25107 10000 10000 25107 10000 25107 10000 25107 $18830 Normal newborn Normal newborn 630-1 NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE 388 18284 12500 10000 22855 10000 22855 17500 31997 $17141 Neonate Neonate 630-2 NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE 577 25699 12500 10000 32124 10000 32124 17500 44973 $24093 Neonate Neonate 630-3 NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE 1077 41010 12500 10000 51263 10000 51263 17500 71768 $38447 Neonate Neonate 630-4 NEONATE BIRTHWT gt2499G W MAJOR CARDIOVASCULAR PROCEDURE 2816 87237 12500 10000 109046 10000 109046 17500 152665 $81785 Neonate Neonate 631-1 NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE 281 09956 12500 10000 12445 10000 12445 17500 17423 $9334 Neonate Neonate 631-2 NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE 544 12584 12500 10000 15730 10000 15730 17500 22022 $11798 Neonate Neonate 631-3 NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE 1559 25671 12500 10000 32089 10000 32089 17500 44924 $24067 Neonate Neonate 631-4 NEONATE BIRTHWT gt2499G W OTHER MAJOR PROCEDURE 3999 75844 12500 10000 94805 10000 94805 17500 132727 $71104 Neonate Neonate 633-1 NEONATE BIRTHWT gt2499G W MAJOR ANOMALY 287 02016 12500 10000 02520 10000 02520 17500 03528 $1890 Neonate Neonate 633-2 NEONATE BIRTHWT gt2499G W MAJOR ANOMALY 540 05299 12500 10000 06624 10000 06624 17500 09273 $4968 Neonate Neonate

with Age Adjustor

633-3 NEONATE BIRTHWT gt2499G W MAJOR ANOMALY 1009 11072 12500 10000 13840 10000 13840 17500 19376 $10380 Neonate Neonate 633-4 NEONATE BIRTHWT gt2499G W MAJOR ANOMALY 2162 30356 12500 10000 37945 10000 37945 17500 53123 $28459 Neonate Neonate 634-1 NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND 399 04160 12500 10000 05200 10000 05200 17500 07280 $3900 Neonate Neonate 634-2 NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND 645 07372 12500 10000 09215 10000 09215 17500 12901 $6911 Neonate Neonate 634-3 NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND 1160 18255 12500 10000 22819 10000 22819 17500 31946 $17114 Neonate Neonate 634-4 NEONATE BIRTHWT gt2499G W RESP DIST SYNDOTH MAJ RESP COND 2097 45531 12500 10000 56914 10000 56914 17500 79679 $42685 Neonate Neonate 636-1 NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION 545 05270 12500 10000 06588 10000 06588 17500 09223 $4941 Neonate Neonate 636-2 NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION 763 08069 12500 10000 10086 10000 10086 17500 14121 $7565 Neonate Neonate 636-3 NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION 1218 15960 12500 10000 19950 10000 19950 17500 27930 $14963 Neonate Neonate 636-4 NEONATE BIRTHWT gt2499G W CONGENITALPERINATAL INFECTION 1792 33614 12500 10000 42018 10000 42018 17500 58825 $31513 Neonate Neonate 639-1 NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION 373 03158 12500 10000 03948 10000 03948 17500 05527 $2961 Neonate Neonate 639-2 NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION 502 04925 12500 10000 06156 10000 06156 17500 08619 $4617 Neonate Neonate 639-3 NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION 786 09423 12500 10000 11779 10000 11779 17500 16490 $8834 Neonate Neonate 639-4 NEONATE BIRTHWT gt2499G W OTHER SIGNIFICANT CONDITION 1425 26755 12500 10000 33444 10000 33444 17500 46821 $25083 Neonate Neonate 640-1 NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 208 01013 10000 10000 01013 10000 01013 10000 01013 $760 Normal newborn Normal newborn 640-2 NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 241 01371 10000 10000 01371 10000 01371 10000 01371 $1028 Normal newborn Normal newborn 640-3 NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 363 02811 10000 10000 02811 10000 02811 10000 02811 $2108 Normal newborn Normal newborn 640-4 NEONATE BIRTHWT gt2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM 1138 16311 10000 10000 16311 10000 16311 10000 16311 $12233 Normal newborn Normal newborn 650-1 SPLENECTOMY 340 12982 10000 10000 12982 14500 18824 10000 12982 $14118 Misc Pediatric Misc Adult 650-2 SPLENECTOMY 549 17444 10000 10000 17444 14500 25294 10000 17444 $18970 Misc Pediatric Misc Adult 650-3 SPLENECTOMY 784 24085 10000 10000 24085 14500 34923 10000 24085 $26192 Misc Pediatric Misc Adult 650-4 SPLENECTOMY 1551 46289 10000 10000 46289 14500 67119 10000 46289 $50339 Misc Pediatric Misc Adult 651-1 OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS 322 09648 10000 10000 09648 14500 13990 10000 09648 $10492 Misc Pediatric Misc Adult 651-2 OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS 445 13786 10000 10000 13786 14500 19990 10000 13786 $14992 Misc Pediatric Misc Adult 651-3 OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS 989 22209 10000 10000 22209 14500 32203 10000 22209 $24152 Misc Pediatric Misc Adult 651-4 OTHER PROCEDURES OF BLOOD amp BLOOD-FORMING ORGANS 1911 46690 10000 10000 46690 14500 67701 10000 46690 $50775 Misc Pediatric Misc Adult 660-1 MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL 335 05799 10000 10000 05799 14500 08409 10000 05799 $6306 Misc Pediatric Misc Adult 660-2 MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL 408 06989 10000 10000 06989 14500 10134 10000 06989 $7601 Misc Pediatric Misc Adult 660-3 MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL 644 11183 10000 10000 11183 14500 16215 10000 11183 $12162 Misc Pediatric Misc Adult 660-4 MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS amp COAGUL 1368 25065 10000 10000 25065 14500 36344 10000 25065 $27258 Misc Pediatric Misc Adult 661-1 COAGULATION amp PLATELET DISORDERS 276 06575 10000 10000 06575 14500 09534 10000 06575 $7150 Misc Pediatric Misc Adult 661-2 COAGULATION amp PLATELET DISORDERS 372 08191 10000 10000 08191 14500 11877 10000 08191 $8908 Misc Pediatric Misc Adult 661-3 COAGULATION amp PLATELET DISORDERS 556 12506 10000 10000 12506 14500 18134 10000 12506 $13600 Misc Pediatric Misc Adult 661-4 COAGULATION amp PLATELET DISORDERS 1356 27025 10000 10000 27025 14500 39186 10000 27025 $29390 Misc Pediatric Misc Adult 662-1 SICKLE CELL ANEMIA CRISIS 410 05023 10000 10000 05023 14500 07283 10000 05023 $5463 Misc Pediatric Misc Adult 662-2 SICKLE CELL ANEMIA CRISIS 540 06944 10000 10000 06944 14500 10069 10000 06944 $7552 Misc Pediatric Misc Adult 662-3 SICKLE CELL ANEMIA CRISIS 785 10653 10000 10000 10653 14500 15447 10000 10653 $11585 Misc Pediatric Misc Adult 662-4 SICKLE CELL ANEMIA CRISIS 1379 24052 10000 10000 24052 14500 34875 10000 24052 $26157 Misc Pediatric Misc Adult 663-1 OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS 226 04493 10000 10000 04493 14500 06515 10000 04493 $4886 Misc Pediatric Misc Adult 663-2 OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS 299 05830 10000 10000 05830 14500 08454 10000 05830 $6340 Misc Pediatric Misc Adult 663-3 OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS 440 08187 10000 10000 08187 14500 11871 10000 08187 $8903 Misc Pediatric Misc Adult 663-4 OTHER ANEMIA amp DISORDERS OF BLOOD amp BLOOD-FORMING ORGANS 794 13969 10000 10000 13969 14500 20255 10000 13969 $15191 Misc Pediatric Misc Adult 680-1 MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS 390 13647 10000 10000 13647 14500 19788 10000 13647 $14841 Misc Pediatric Misc Adult 680-2 MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS 638 18971 10000 10000 18971 14500 27508 10000 18971 $20631 Misc Pediatric Misc Adult 680-3 MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS 1175 31942 10000 10000 31942 14500 46316 10000 31942 $34737 Misc Pediatric Misc Adult 680-4 MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS 2419 60129 10000 10000 60129 14500 87187 10000 60129 $65390 Misc Pediatric Misc Adult 681-1 OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS 272 10092 10000 10000 10092 14500 14633 10000 10092 $10975 Misc Pediatric Misc Adult 681-2 OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS 489 13440 10000 10000 13440 14500 19488 10000 13440 $14616 Misc Pediatric Misc Adult 681-3 OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS 1095 24577 10000 10000 24577 14500 35637 10000 24577 $26727 Misc Pediatric Misc Adult 681-4 OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS 2340 55051 10000 10000 55051 14500 79824 10000 55051 $59868 Misc Pediatric Misc Adult 690-1 ACUTE LEUKEMIA 528 07523 10000 10000 07523 14500 10908 10000 07523 $8181 Misc Pediatric Misc Adult 690-2 ACUTE LEUKEMIA 824 13382 10000 10000 13382 14500 19404 10000 13382 $14553 Misc Pediatric Misc Adult 690-3 ACUTE LEUKEMIA 1673 27577 10000 10000 27577 14500 39987 10000 27577 $29990 Misc Pediatric Misc Adult 690-4 ACUTE LEUKEMIA 2890 62084 10000 10000 62084 14500 90022 10000 62084 $67516 Misc Pediatric Misc Adult 691-1 LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA 413 08012 10000 10000 08012 14500 11617 10000 08012 $8713 Misc Pediatric Misc Adult 691-2 LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA 534 10102 10000 10000 10102 14500 14648 10000 10102 $10986 Misc Pediatric Misc Adult 691-3 LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA 867 15984 10000 10000 15984 14500 23177 10000 15984 $17383 Misc Pediatric Misc Adult 691-4 LYMPHOMA MYELOMA amp NON-ACUTE LEUKEMIA 1610 31155 10000 10000 31155 14500 45175 10000 31155 $33881 Misc Pediatric Misc Adult 692-1 RADIOTHERAPY 319 05477 10000 10000 05477 14500 07942 10000 05477 $5956 Misc Pediatric Misc Adult 692-2 RADIOTHERAPY 534 11333 10000 10000 11333 14500 16433 10000 11333 $12325 Misc Pediatric Misc Adult 692-3 RADIOTHERAPY 810 17345 10000 10000 17345 14500 25150 10000 17345 $18863 Misc Pediatric Misc Adult 692-4 RADIOTHERAPY 1353 32813 10000 10000 32813 14500 47579 10000 32813 $35684 Misc Pediatric Misc Adult 694-1 LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR 283 05205 10000 10000 05205 14500 07547 10000 05205 $5660 Misc Pediatric Misc Adult 694-2 LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR 402 06927 10000 10000 06927 14500 10044 10000 06927 $7533 Misc Pediatric Misc Adult 694-3 LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR 652 10903 10000 10000 10903 14500 15809 10000 10903 $11857 Misc Pediatric Misc Adult 694-4 LYMPHATIC amp OTHER MALIGNANCIES amp NEOPLASMS OF UNCERTAIN BEHAVIOR 1170 19744 10000 10000 19744 14500 28629 10000 19744 $21472 Misc Pediatric Misc Adult 695-1 CHEMOTHERAPY FOR ACUTE LEUKEMIA 442 06038 10000 10000 06038 14500 08755 10000 06038 $6566 Misc Pediatric Misc Adult 695-2 CHEMOTHERAPY FOR ACUTE LEUKEMIA 448 07434 10000 10000 07434 14500 10779 10000 07434 $8084 Misc Pediatric Misc Adult 695-3 CHEMOTHERAPY FOR ACUTE LEUKEMIA 1119 15923 10000 10000 15923 14500 23088 10000 15923 $17316 Misc Pediatric Misc Adult 695-4 CHEMOTHERAPY FOR ACUTE LEUKEMIA 2664 51326 10000 10000 51326 14500 74423 10000 51326 $55817 Misc Pediatric Misc Adult 696-1 OTHER CHEMOTHERAPY 281 06289 10000 10000 06289 14500 09119 10000 06289 $6839 Misc Pediatric Misc Adult 696-2 OTHER CHEMOTHERAPY 354 07960 10000 10000 07960 14500 11542 10000 07960 $8657 Misc Pediatric Misc Adult

with Age Adjustor

696-3 OTHER CHEMOTHERAPY 543 12037 10000 10000 12037 14500 17454 10000 12037 $13090 Misc Pediatric Misc Adult 696-4 OTHER CHEMOTHERAPY 1392 26849 10000 10000 26849 14500 38931 10000 26849 $29198 Misc Pediatric Misc Adult 710-1 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 455 10047 10000 10000 10047 14500 14568 10000 10047 $10926 Misc Pediatric Misc Adult 710-2 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 649 14767 10000 10000 14767 14500 21412 10000 14767 $16059 Misc Pediatric Misc Adult 710-3 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1086 24562 10000 10000 24562 14500 35615 10000 24562 $26711 Misc Pediatric Misc Adult 710-4 INFECTIOUS amp PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE 1863 47045 10000 10000 47045 14500 68215 10000 47045 $51161 Misc Pediatric Misc Adult 711-1 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 447 09768 10000 10000 09768 14500 14164 10000 09768 $10623 Misc Pediatric Misc Adult 711-2 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 626 13128 10000 10000 13128 14500 19036 10000 13128 $14277 Misc Pediatric Misc Adult 711-3 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1093 22991 10000 10000 22991 14500 33337 10000 22991 $25003 Misc Pediatric Misc Adult 711-4 POST-OP POST-TRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE 1939 45267 10000 10000 45267 14500 65637 10000 45267 $49228 Misc Pediatric Misc Adult 720-1 SEPTICEMIA amp DISSEMINATED INFECTIONS 323 05395 10000 10000 05395 14500 07823 10000 05395 $5867 Misc Pediatric Misc Adult 720-2 SEPTICEMIA amp DISSEMINATED INFECTIONS 424 07250 10000 10000 07250 14500 10513 10000 07250 $7884 Misc Pediatric Misc Adult 720-3 SEPTICEMIA amp DISSEMINATED INFECTIONS 632 11286 10000 10000 11286 14500 16365 10000 11286 $12274 Misc Pediatric Misc Adult 720-4 SEPTICEMIA amp DISSEMINATED INFECTIONS 1088 22721 10000 10000 22721 14500 32945 10000 22721 $24709 Misc Pediatric Misc Adult 721-1 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 352 05166 10000 10000 05166 14500 07491 10000 05166 $5618 Misc Pediatric Misc Adult 721-2 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 448 06856 10000 10000 06856 14500 09941 10000 06856 $7456 Misc Pediatric Misc Adult 721-3 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 672 11262 10000 10000 11262 14500 16330 10000 11262 $12247 Misc Pediatric Misc Adult 721-4 POST-OPERATIVE POST-TRAUMATIC OTHER DEVICE INFECTIONS 1106 21052 10000 10000 21052 14500 30525 10000 21052 $22894 Misc Pediatric Misc Adult 722-1 FEVER 238 03923 10000 10000 03923 14500 05688 10000 03923 $4266 Misc Pediatric Misc Adult 722-2 FEVER 305 05318 10000 10000 05318 14500 07711 10000 05318 $5783 Misc Pediatric Misc Adult 722-3 FEVER 412 07210 10000 10000 07210 14500 10455 10000 07210 $7841 Misc Pediatric Misc Adult 722-4 FEVER 718 11368 10000 10000 11368 14500 16484 10000 11368 $12363 Misc Pediatric Misc Adult 723-1 VIRAL ILLNESS 214 03377 10000 10000 03377 14500 04897 10000 03377 $3672 Misc Pediatric Misc Adult 723-2 VIRAL ILLNESS 272 04767 10000 10000 04767 14500 06912 10000 04767 $5184 Misc Pediatric Misc Adult 723-3 VIRAL ILLNESS 457 07428 10000 10000 07428 14500 10771 10000 07428 $8078 Misc Pediatric Misc Adult 723-4 VIRAL ILLNESS 1090 19291 10000 10000 19291 14500 27972 10000 19291 $20979 Misc Pediatric Misc Adult 724-1 OTHER INFECTIOUS amp PARASITIC DISEASES 403 05902 10000 10000 05902 14500 08558 10000 05902 $6418 Misc Pediatric Misc Adult 724-2 OTHER INFECTIOUS amp PARASITIC DISEASES 471 07184 10000 10000 07184 14500 10417 10000 07184 $7813 Misc Pediatric Misc Adult 724-3 OTHER INFECTIOUS amp PARASITIC DISEASES 671 11131 10000 10000 11131 14500 16140 10000 11131 $12105 Misc Pediatric Misc Adult 724-4 OTHER INFECTIOUS amp PARASITIC DISEASES 1253 23238 10000 10000 23238 14500 33695 10000 23238 $25271 Misc Pediatric Misc Adult 740-1 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 540 09900 10000 10000 09900 10000 09900 10000 09900 $7425 Other Other 740-2 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1424 13410 10000 10000 13410 10000 13410 10000 13410 $10058 Other Other 740-3 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 1908 24218 10000 10000 24218 10000 24218 10000 24218 $18164 Other Other 740-4 MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE 3358 50747 10000 10000 50747 10000 50747 10000 50747 $38060 Other Other 750-1 SCHIZOPHRENIA 936 05196 10000 10000 05196 10000 05196 10000 05196 $3897 Other Other 750-2 SCHIZOPHRENIA 1132 06356 10000 10000 06356 10000 06356 10000 06356 $4767 Other Other 750-3 SCHIZOPHRENIA 1541 08925 10000 10000 08925 10000 08925 10000 08925 $6694 Other Other 750-4 SCHIZOPHRENIA 2743 19811 10000 10000 19811 10000 19811 10000 19811 $14858 Other Other 751-1 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 523 03562 10000 10000 03562 10000 03562 10000 03562 $2672 Other Other 751-2 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 714 04794 10000 10000 04794 10000 04794 10000 04794 $3596 Other Other 751-3 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 1073 07986 10000 10000 07986 10000 07986 10000 07986 $5990 Other Other 751-4 MAJOR DEPRESSIVE DISORDERS amp OTHERUNSPECIFIED PSYCHOSES 2012 16644 10000 10000 16644 10000 16644 10000 16644 $12483 Other Other 752-1 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 487 03180 10000 10000 03180 10000 03180 10000 03180 $2385 Other Other 752-2 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 632 04209 10000 10000 04209 10000 04209 10000 04209 $3157 Other Other 752-3 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 855 07206 10000 10000 07206 10000 07206 10000 07206 $5405 Other Other 752-4 DISORDERS OF PERSONALITY amp IMPULSE CONTROL 1425 11877 10000 10000 11877 10000 11877 10000 11877 $8908 Other Other 753-1 BIPOLAR DISORDERS 567 03855 10000 10000 03855 10000 03855 10000 03855 $2891 Other Other 753-2 BIPOLAR DISORDERS 787 05094 10000 10000 05094 10000 05094 10000 05094 $3821 Other Other 753-3 BIPOLAR DISORDERS 1152 07815 10000 10000 07815 10000 07815 10000 07815 $5861 Other Other 753-4 BIPOLAR DISORDERS 2079 16809 10000 10000 16809 10000 16809 10000 16809 $12607 Other Other 754-1 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 412 02916 10000 10000 02916 10000 02916 10000 02916 $2187 Other Other 754-2 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 550 03870 10000 10000 03870 10000 03870 10000 03870 $2903 Other Other 754-3 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 758 05959 10000 10000 05959 10000 05959 10000 05959 $4469 Other Other 754-4 DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER 1484 11056 10000 10000 11056 10000 11056 10000 11056 $8292 Other Other 755-1 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 361 02688 10000 10000 02688 10000 02688 10000 02688 $2016 Other Other 755-2 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 591 04170 10000 10000 04170 10000 04170 10000 04170 $3128 Other Other 755-3 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 972 05643 10000 10000 05643 10000 05643 10000 05643 $4232 Other Other 755-4 ADJUSTMENT DISORDERS amp NEUROSES EXCEPT DEPRESSIVE DIAGNOSES 2500 07946 10000 10000 07946 10000 07946 10000 07946 $5960 Other Other 756-1 ACUTE ANXIETY amp DELIRIUM STATES 324 03974 10000 10000 03974 10000 03974 10000 03974 $2981 Other Other 756-2 ACUTE ANXIETY amp DELIRIUM STATES 380 05129 10000 10000 05129 10000 05129 10000 05129 $3847 Other Other 756-3 ACUTE ANXIETY amp DELIRIUM STATES 468 05774 10000 10000 05774 10000 05774 10000 05774 $4331 Other Other 756-4 ACUTE ANXIETY amp DELIRIUM STATES 684 13179 10000 10000 13179 10000 13179 10000 13179 $9884 Other Other 757-1 ORGANIC MENTAL HEALTH DISTURBANCES 847 06058 10000 10000 06058 10000 06058 10000 06058 $4544 Other Other 757-2 ORGANIC MENTAL HEALTH DISTURBANCES 943 07190 10000 10000 07190 10000 07190 10000 07190 $5393 Other Other 757-3 ORGANIC MENTAL HEALTH DISTURBANCES 1025 08989 10000 10000 08989 10000 08989 10000 08989 $6742 Other Other 757-4 ORGANIC MENTAL HEALTH DISTURBANCES 1586 15661 10000 10000 15661 10000 15661 10000 15661 $11746 Other Other 758-1 BEHAVIORAL DISORDERS 623 03634 10000 10000 03634 10000 03634 10000 03634 $2726 Other Other 758-2 BEHAVIORAL DISORDERS 794 04536 10000 10000 04536 10000 04536 10000 04536 $3402 Other Other 758-3 BEHAVIORAL DISORDERS 1212 06372 10000 10000 06372 10000 06372 10000 06372 $4779 Other Other 758-4 BEHAVIORAL DISORDERS 700 09601 10000 10000 09601 10000 09601 10000 09601 $7201 Other Other 759-1 EATING DISORDERS 1099 06901 10000 10000 06901 10000 06901 10000 06901 $5176 Other Other 759-2 EATING DISORDERS 1237 08146 10000 10000 08146 10000 08146 10000 08146 $6110 Other Other

with Age Adjustor

759-3 EATING DISORDERS 1377 10717 10000 10000 10717 10000 10717 10000 10717 $8038 Other Other 759-4 EATING DISORDERS 2433 21137 10000 10000 21137 10000 21137 10000 21137 $15853 Other Other 760-1 OTHER MENTAL HEALTH DISORDERS 925 04428 10000 10000 04428 10000 04428 10000 04428 $3321 Other Other 760-2 OTHER MENTAL HEALTH DISORDERS 771 05879 10000 10000 05879 10000 05879 10000 05879 $4409 Other Other 760-3 OTHER MENTAL HEALTH DISORDERS 915 07870 10000 10000 07870 10000 07870 10000 07870 $5903 Other Other 760-4 OTHER MENTAL HEALTH DISORDERS 1557 17634 10000 10000 17634 10000 17634 10000 17634 $13226 Other Other 770-1 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 236 02266 10000 10000 02266 10000 02266 10000 02266 $1700 Other Other 770-2 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 251 02840 10000 10000 02840 10000 02840 10000 02840 $2130 Other Other 770-3 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 307 05562 10000 10000 05562 10000 05562 10000 05562 $4172 Other Other 770-4 DRUG amp ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE 727 16144 10000 10000 16144 10000 16144 10000 16144 $12108 Other Other 772-1 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1329 05352 10000 10000 05352 10000 05352 10000 05352 $4014 Other Other 772-2 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1396 06180 10000 10000 06180 10000 06180 10000 06180 $4635 Other Other 772-3 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1276 07497 10000 10000 07497 10000 07497 10000 07497 $5623 Other Other 772-4 ALCOHOL amp DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY 1500 26238 10000 10000 26238 10000 26238 10000 26238 $19679 Other Other 773-1 OPIOID ABUSE amp DEPENDENCE 365 02842 10000 10000 02842 10000 02842 10000 02842 $2132 Other Other 773-2 OPIOID ABUSE amp DEPENDENCE 421 03631 10000 10000 03631 10000 03631 10000 03631 $2723 Other Other 773-3 OPIOID ABUSE amp DEPENDENCE 522 06550 10000 10000 06550 10000 06550 10000 06550 $4913 Other Other 773-4 OPIOID ABUSE amp DEPENDENCE 964 19805 10000 10000 19805 10000 19805 10000 19805 $14854 Other Other 774-1 COCAINE ABUSE amp DEPENDENCE 357 03148 10000 10000 03148 10000 03148 10000 03148 $2361 Other Other 774-2 COCAINE ABUSE amp DEPENDENCE 404 03594 10000 10000 03594 10000 03594 10000 03594 $2696 Other Other 774-3 COCAINE ABUSE amp DEPENDENCE 482 06530 10000 10000 06530 10000 06530 10000 06530 $4898 Other Other 774-4 COCAINE ABUSE amp DEPENDENCE 1200 23388 10000 10000 23388 10000 23388 10000 23388 $17541 Other Other 775-1 ALCOHOL ABUSE amp DEPENDENCE 326 03349 10000 10000 03349 10000 03349 10000 03349 $2512 Other Other 775-2 ALCOHOL ABUSE amp DEPENDENCE 376 04637 10000 10000 04637 10000 04637 10000 04637 $3478 Other Other 775-3 ALCOHOL ABUSE amp DEPENDENCE 572 08502 10000 10000 08502 10000 08502 10000 08502 $6377 Other Other 775-4 ALCOHOL ABUSE amp DEPENDENCE 1295 23713 10000 10000 23713 10000 23713 10000 23713 $17785 Other Other 776-1 OTHER DRUG ABUSE amp DEPENDENCE 370 03088 10000 10000 03088 10000 03088 10000 03088 $2316 Other Other 776-2 OTHER DRUG ABUSE amp DEPENDENCE 390 04306 10000 10000 04306 10000 04306 10000 04306 $3230 Other Other 776-3 OTHER DRUG ABUSE amp DEPENDENCE 466 07626 10000 10000 07626 10000 07626 10000 07626 $5720 Other Other 776-4 OTHER DRUG ABUSE amp DEPENDENCE 887 15185 10000 10000 15185 10000 15185 10000 15185 $11389 Other Other 791-1 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 307 08637 10000 10000 08637 14500 12524 10000 08637 $9393 Misc Pediatric Misc Adult 791-2 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 528 12672 10000 10000 12672 14500 18374 10000 12672 $13781 Misc Pediatric Misc Adult 791-3 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 889 20461 10000 10000 20461 14500 29668 10000 20461 $22251 Misc Pediatric Misc Adult 791-4 OR PROCEDURE FOR OTHER COMPLICATIONS OF TREATMENT 1832 44255 10000 10000 44255 14500 64170 10000 44255 $48127 Misc Pediatric Misc Adult 811-1 ALLERGIC REACTIONS 151 02721 10000 10000 02721 14500 03945 10000 02721 $2959 Misc Pediatric Misc Adult 811-2 ALLERGIC REACTIONS 208 03922 10000 10000 03922 14500 05687 10000 03922 $4265 Misc Pediatric Misc Adult 811-3 ALLERGIC REACTIONS 407 08479 10000 10000 08479 14500 12295 10000 08479 $9221 Misc Pediatric Misc Adult 811-4 ALLERGIC REACTIONS 863 19061 10000 10000 19061 14500 27638 10000 19061 $20729 Misc Pediatric Misc Adult 812-1 POISONING OF MEDICINAL AGENTS 170 03376 10000 10000 03376 14500 04895 10000 03376 $3671 Misc Pediatric Misc Adult 812-2 POISONING OF MEDICINAL AGENTS 240 04254 10000 10000 04254 14500 06168 10000 04254 $4626 Misc Pediatric Misc Adult 812-3 POISONING OF MEDICINAL AGENTS 360 07419 10000 10000 07419 14500 10758 10000 07419 $8068 Misc Pediatric Misc Adult 812-4 POISONING OF MEDICINAL AGENTS 713 16173 10000 10000 16173 14500 23451 10000 16173 $17588 Misc Pediatric Misc Adult 813-1 OTHER COMPLICATIONS OF TREATMENT 253 04469 10000 10000 04469 14500 06480 10000 04469 $4860 Misc Pediatric Misc Adult 813-2 OTHER COMPLICATIONS OF TREATMENT 342 05946 10000 10000 05946 14500 08622 10000 05946 $6466 Misc Pediatric Misc Adult 813-3 OTHER COMPLICATIONS OF TREATMENT 512 09014 10000 10000 09014 14500 13070 10000 09014 $9803 Misc Pediatric Misc Adult 813-4 OTHER COMPLICATIONS OF TREATMENT 1021 18764 10000 10000 18764 14500 27208 10000 18764 $20406 Misc Pediatric Misc Adult 815-1 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 164 03954 10000 10000 03954 14500 05733 10000 03954 $4300 Misc Pediatric Misc Adult 815-2 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 280 04760 10000 10000 04760 14500 06902 10000 04760 $5177 Misc Pediatric Misc Adult 815-3 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 424 07720 10000 10000 07720 14500 11194 10000 07720 $8396 Misc Pediatric Misc Adult 815-4 OTHER INJURY POISONING amp TOXIC EFFECT DIAGNOSES 1080 21120 10000 10000 21120 14500 30624 10000 21120 $22968 Misc Pediatric Misc Adult 816-1 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 177 04382 10000 10000 04382 14500 06354 10000 04382 $4765 Misc Pediatric Misc Adult 816-2 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 242 04902 10000 10000 04902 14500 07108 10000 04902 $5331 Misc Pediatric Misc Adult 816-3 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 346 07579 10000 10000 07579 14500 10990 10000 07579 $8242 Misc Pediatric Misc Adult 816-4 TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES 716 15995 10000 10000 15995 14500 23193 10000 15995 $17395 Misc Pediatric Misc Adult 841-1 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1790 30301 10000 10000 30301 14500 43936 10000 30301 $32952 Misc Pediatric Misc Adult 841-2 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 1989 33332 10000 10000 33332 14500 48331 10000 33332 $36249 Misc Pediatric Misc Adult 841-3 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 2210 62326 10000 10000 62326 14500 90373 10000 62326 $67780 Misc Pediatric Misc Adult 841-4 EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT 4656 167631 10000 10000 167631 14500 243065 10000 167631 $182299 Misc Pediatric Misc Adult 842-1 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 561 11825 10000 10000 11825 14500 17146 10000 11825 $12860 Misc Pediatric Misc Adult 842-2 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 865 17558 10000 10000 17558 14500 25459 10000 17558 $19094 Misc Pediatric Misc Adult 842-3 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 1499 32510 10000 10000 32510 14500 47140 10000 32510 $35355 Misc Pediatric Misc Adult 842-4 BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS 2814 87027 10000 10000 87027 14500 126189 10000 87027 $94642 Misc Pediatric Misc Adult 843-1 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 300 03005 10000 10000 03005 14500 04357 10000 03005 $3268 Misc Pediatric Misc Adult 843-2 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 607 05552 10000 10000 05552 14500 08050 10000 05552 $6038 Misc Pediatric Misc Adult 843-3 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 1108 09685 10000 10000 09685 14500 14043 10000 09685 $10532 Misc Pediatric Misc Adult 843-4 EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT 4529 27192 10000 10000 27192 14500 39428 10000 27192 $29571 Misc Pediatric Misc Adult 844-1 PARTIAL THICKNESS BURNS WO SKIN GRAFT 247 03505 10000 10000 03505 14500 05082 10000 03505 $3812 Misc Pediatric Misc Adult 844-2 PARTIAL THICKNESS BURNS WO SKIN GRAFT 395 05712 10000 10000 05712 14500 08282 10000 05712 $6212 Misc Pediatric Misc Adult 844-3 PARTIAL THICKNESS BURNS WO SKIN GRAFT 664 10779 10000 10000 10779 14500 15630 10000 10779 $11722 Misc Pediatric Misc Adult 844-4 PARTIAL THICKNESS BURNS WO SKIN GRAFT 1604 35910 10000 10000 35910 14500 52070 10000 35910 $39052 Misc Pediatric Misc Adult 850-1 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 289 12968 10000 10000 12968 10000 12968 10000 12968 $9726 Misc Pediatric Misc Adult 850-2 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 520 17132 10000 10000 17132 10000 17132 10000 17132 $12849 Misc Pediatric Misc Adult

with Age Adjustor

850-3 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 1263 24145 10000 10000 24145 10000 24145 10000 24145 $18109 Misc Pediatric Misc Adult 850-4 PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE 2388 42243 10000 10000 42243 10000 42243 10000 42243 $31682 Misc Pediatric Misc Adult 860-1 REHABILITATION 1010 08123 10000 10000 08123 10000 08123 10000 08123 $6092 Other Other 860-2 REHABILITATION 1246 11179 10000 10000 11179 10000 11179 10000 11179 $8384 Other Other 860-3 REHABILITATION 1497 14925 10000 10000 14925 10000 14925 10000 14925 $11194 Other Other 860-4 REHABILITATION 1754 18859 10000 10000 18859 10000 18859 10000 18859 $14144 Other Other 861-1 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 273 03186 10000 10000 03186 14500 04620 10000 03186 $3465 Misc Pediatric Misc Adult 861-2 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 341 05338 10000 10000 05338 14500 07740 10000 05338 $5805 Misc Pediatric Misc Adult 861-3 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 486 07467 10000 10000 07467 14500 10827 10000 07467 $8120 Misc Pediatric Misc Adult 861-4 SIGNS SYMPTOMS amp OTHER FACTORS INFLUENCING HEALTH STATUS 918 13526 10000 10000 13526 14500 19613 10000 13526 $14710 Misc Pediatric Misc Adult 862-1 OTHER AFTERCARE amp CONVALESCENCE 708 03560 10000 10000 03560 14500 05162 10000 03560 $3872 Misc Pediatric Misc Adult 862-2 OTHER AFTERCARE amp CONVALESCENCE 986 05832 10000 10000 05832 14500 08456 10000 05832 $6342 Misc Pediatric Misc Adult 862-3 OTHER AFTERCARE amp CONVALESCENCE 1073 08099 10000 10000 08099 14500 11744 10000 08099 $8808 Misc Pediatric Misc Adult 862-4 OTHER AFTERCARE amp CONVALESCENCE 1194 11120 10000 10000 11120 14500 16124 10000 11120 $12093 Misc Pediatric Misc Adult 863-1 NEONATAL AFTERCARE 100 06643 12500 10000 08304 10000 08304 17500 11625 $6228 Neonate Neonate 863-2 NEONATAL AFTERCARE 100 16409 12500 10000 20511 10000 20511 17500 28716 $15383 Neonate Neonate 863-3 NEONATAL AFTERCARE 110 29747 12500 10000 37184 10000 37184 17500 52057 $27888 Neonate Neonate 863-4 NEONATAL AFTERCARE 121 57328 12500 10000 71660 10000 71660 17500 100324 $53745 Neonate Neonate 890-1 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 500 05252 10000 10000 05252 14500 07615 10000 05252 $5712 Misc Pediatric Misc Adult 890-2 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 578 08931 10000 10000 08931 14500 12950 10000 08931 $9712 Misc Pediatric Misc Adult 890-3 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 888 13622 10000 10000 13622 14500 19752 10000 13622 $14814 Misc Pediatric Misc Adult 890-4 HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS 1488 27178 10000 10000 27178 14500 39408 10000 27178 $29556 Misc Pediatric Misc Adult 892-1 HIV W MAJOR HIV RELATED CONDITION 1045 05978 10000 10000 05978 14500 08668 10000 05978 $6501 Misc Pediatric Misc Adult 892-2 HIV W MAJOR HIV RELATED CONDITION 495 07757 10000 10000 07757 14500 11248 10000 07757 $8436 Misc Pediatric Misc Adult 892-3 HIV W MAJOR HIV RELATED CONDITION 639 10274 10000 10000 10274 14500 14897 10000 10274 $11173 Misc Pediatric Misc Adult 892-4 HIV W MAJOR HIV RELATED CONDITION 1210 19190 10000 10000 19190 14500 27826 10000 19190 $20869 Misc Pediatric Misc Adult 893-1 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 372 06233 10000 10000 06233 14500 09038 10000 06233 $6778 Misc Pediatric Misc Adult 893-2 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 501 08195 10000 10000 08195 14500 11883 10000 08195 $8912 Misc Pediatric Misc Adult 893-3 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 719 11996 10000 10000 11996 14500 17394 10000 11996 $13046 Misc Pediatric Misc Adult 893-4 HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS 1205 20716 10000 10000 20716 14500 30038 10000 20716 $22529 Misc Pediatric Misc Adult 894-1 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 333 05362 10000 10000 05362 14500 07775 10000 05362 $5831 Misc Pediatric Misc Adult 894-2 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 398 06700 10000 10000 06700 14500 09715 10000 06700 $7286 Misc Pediatric Misc Adult 894-3 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 550 09403 10000 10000 09403 14500 13634 10000 09403 $10226 Misc Pediatric Misc Adult 894-4 HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND 890 15948 10000 10000 15948 14500 23125 10000 15948 $17343 Misc Pediatric Misc Adult 910-1 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 350 27523 10000 10000 27523 14500 39908 10000 27523 $29931 Misc Pediatric Misc Adult 910-2 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 844 32184 10000 10000 32184 14500 46667 10000 32184 $35000 Misc Pediatric Misc Adult 910-3 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 1119 42474 10000 10000 42474 14500 61587 10000 42474 $46190 Misc Pediatric Misc Adult 910-4 CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA 2604 84367 10000 10000 84367 14500 122332 10000 84367 $91749 Misc Pediatric Misc Adult 911-1 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 683 15621 10000 10000 15621 14500 22650 10000 15621 $16988 Misc Pediatric Misc Adult 911-2 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 671 20803 10000 10000 20803 14500 30164 10000 20803 $22623 Misc Pediatric Misc Adult 911-3 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 855 27430 10000 10000 27430 14500 39774 10000 27430 $29830 Misc Pediatric Misc Adult 911-4 EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA 1843 61422 10000 10000 61422 14500 89062 10000 61422 $66796 Misc Pediatric Misc Adult 912-1 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 608 19980 10000 10000 19980 14500 28971 10000 19980 $21728 Misc Pediatric Misc Adult 912-2 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 578 22072 10000 10000 22072 14500 32004 10000 22072 $24003 Misc Pediatric Misc Adult 912-3 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 920 34963 10000 10000 34963 14500 50696 10000 34963 $38022 Misc Pediatric Misc Adult 912-4 MUSCULOSKELETAL amp OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA 1780 66161 10000 10000 66161 14500 95933 10000 66161 $71950 Misc Pediatric Misc Adult 930-1 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 299 07235 10000 10000 07235 14500 10491 10000 07235 $7868 Misc Pediatric Misc Adult 930-2 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 379 09555 10000 10000 09555 14500 13855 10000 09555 $10391 Misc Pediatric Misc Adult 930-3 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 638 15441 10000 10000 15441 14500 22389 10000 15441 $16792 Misc Pediatric Misc Adult 930-4 MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE 1552 39451 10000 10000 39451 14500 57204 10000 39451 $42903 Misc Pediatric Misc Adult 950-1 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 330 13772 10000 10000 13772 14500 19969 10000 13772 $14977 Misc Pediatric Misc Adult 950-2 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 600 19818 10000 10000 19818 14500 28736 10000 19818 $21552 Misc Pediatric Misc Adult 950-3 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1120 31327 10000 10000 31327 14500 45424 10000 31327 $34068 Misc Pediatric Misc Adult 950-4 EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 2160 57257 10000 10000 57257 14500 83023 10000 57257 $62267 Misc Pediatric Misc Adult 951-1 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 306 09449 10000 10000 09449 14500 13701 10000 09449 $10276 Misc Pediatric Misc Adult 951-2 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 506 13711 10000 10000 13711 14500 19881 10000 13711 $14911 Misc Pediatric Misc Adult 951-3 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 955 22646 10000 10000 22646 14500 32837 10000 22646 $24628 Misc Pediatric Misc Adult 951-4 MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1739 42153 10000 10000 42153 14500 61122 10000 42153 $45841 Misc Pediatric Misc Adult 952-1 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 282 07971 10000 10000 07971 14500 11558 10000 07971 $8668 Misc Pediatric Misc Adult 952-2 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 489 11531 10000 10000 11531 14500 16720 10000 11531 $12540 Misc Pediatric Misc Adult 952-3 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 934 19349 10000 10000 19349 14500 28056 10000 19349 $21042 Misc Pediatric Misc Adult 952-4 NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS 1679 36188 10000 10000 36188 14500 52473 10000 36188 $39354 Misc Pediatric Misc Adult 955-0 PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS 000 -10000 956-0 UNGROUPABLE 000 -10000

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 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 SFY 2017-18 Cost-to-Charge Ratio FY 2015 cost-to-charge ratio with some exceptions I FFY 2017-18 Wage Index Value Medicare wage area index value for this hospital which may include adjustments as determined by Medicare See Tab 5 J FFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor

09792) Wage index value times 09792 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 SFY 2017-18 Unadjusted Statewide Base Rate The unadjusted statewide DRG base rate is for non-remote rural hospitals is $6760 The unadjusted statewide DRG base rate for remote rural hospitals it is $12832 L SFY 2017-18 Wage Adjusted Statewide Base Rate The statewide base rate adjusted for differences in local area wages using the same formula Medicare uses with the adjustment referenced in column J

M SFY 2017-18 Rehab Rate Rehabilitation services are paid separately from the DRG payment method This column shows the rehabilitation per diem rate for SFY 2017-18

N SFY 2017-18 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 2017-18 O SFY 2017-18 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 2017-18 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

OSHPD ID Name DPH NDPH

Designated NICU as

Defined by DHCS

OSHPD Rural Hospital

DHCS Designated Remote Rural

SFY 17-18 CCR

FFY 2017 Wage Index Value

FFY 2017 Wage Index Value (Adjusted for CA Neutrality Factor 09792)

SFY 17-18 Unadjusted

Remote Rural Statewide Base Rate

SFY 17-18 Wage Adjusted statewide base rate

SFY 17-18 Rehab rate

SFY 17-18 ADMIN 2 190 rate

SFY 17-18 ADMIN 2 199 Rate

OUT OF STATE No No No No No 21300 10000 10000 $6760 $6760 $102707 $91290 106164029 ADVENTIST MEDICAL CENTER No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106100797 ADVENTIST MEDICAL CENTER - REEDLEY No No No Yes Yes 38736 12766 12500 $12832 $15065 $102707 $91290 106100793 ADVENTIST MEDICAL CENTER-SELMA No No No Yes Yes 31268 12766 12500 $12832 $15065 $102707 $91290 106301098 AHMC ANAHEIM REGIONAL MEDICAL CENTER No No No No No 21543 12766 12500 $6760 $7936 $102707 $91290 106010735 ALAMEDA HOSPITAL No Yes No No No 32019 17374 17013 $6760 $10060 $102707 $91290 106190017 ALHAMBRA HOSPITAL MEDICAL CENTER No No No No No 31502 12766 12500 $6760 $7936 $1212 $102707 $91290 106010937 ALTA BATES SUMMIT MEDICAL CENTER No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106013626 ALTA BATES SUMMIT MEDICAL CENTER - SUMMIT CAMPUS No No No No No 22984 17374 17013 $6760 $10060 $102707 $91290 106010739 ALTA BATES SUMMIT MEDICAL CENTER-ALTA BATES CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106010844 ALTA BATES SUMMIT MEDICAL CENTER-HERRICK CAMPUS No No No No No 31086 17374 17013 $6760 $10060 $1536 $102707 $91290 106370652 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106374063 ALVARADO HOSPITAL MEDICAL CENTER No No No No No 22632 12766 12500 $6760 $7936 $1212 $102707 $91290 106301188 ANAHEIM GLOBAL MEDICAL CENTER No No No No No 50073 12766 12500 $6760 $7936 $102707 $91290 106190034 ANTELOPE VALLEY HOSPITAL No Yes No No No 33475 12766 12500 $6760 $7936 $102707 $91290 106364231 ARROWHEAD REGIONAL MEDICAL CENTER Yes No No No No 36181 12766 12500 $6760 $7936 106154101 BAKERSFIELD HEART HOSPITAL No No No No No 18443 12766 12500 $6760 $7936 $102707 $91290 106150722 BAKERSFIELD MEMORIAL HOSPITAL No No No No No 23065 12766 12500 $6760 $7936 $102707 $91290 106364121 BALLARD REHABILITATION HOSPITAL No No No No No 55423 12766 12500 NA NA $1417 $102707 $91290 106184008 BANNER LASSEN MEDICAL CENTER No No No Yes Yes 56164 12766 12500 $12832 $15065 $102707 $91290 106190052 BARLOW RESPIRATORY HOSPITAL No No No No No 17184 12766 12500 $6760 $7936 $102707 $91290 106364430 BARSTOW COMMUNITY HOSPITAL No No No Yes Yes 14759 12766 12500 $12832 $15065 $102707 $91290 106090793 BARTON MEMORIAL HOSPITAL No No No Yes Yes 26961 15957 15625 $12832 $17856 $102707 $91290 106361110 BEAR VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 81105 12766 12500 $12832 $15065 $102707 $91290 106190081 BEVERLY HOSPITAL No No No No No 35069 12766 12500 $6760 $7936 $102707 $91290 106190125 CALIFORNIA HOSPITAL MEDICAL CENTER - LOS ANGELES No No No No No 23850 12766 12500 $6760 $7936 $102707 $91290 106380929 CALIFORNIA PACIFIC MED CTR No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380777 CALIFORNIA PACIFIC MED CTR-CALIFORNIA WEST No No Yes No No 28122 17143 16786 $6760 $9953 $102707 $91290 106380933 CALIFORNIA PACIFIC MED CTR-DAVIES CAMPUS No No No No No 23501 17143 16786 $6760 $9953 $1519 $102707 $91290 106380964 CALIFORNIA PACIFIC MEDICAL CENTER - ST LUKES CAMPUS No No No No No 33162 17143 16786 $6760 $9953 $102707 $91290 106190137 CASA COLINA HOSPITAL AND CENTERS FOR HEALTHCARE No No No No No 53435 12766 12500 $6760 $7936 $1212 $102707 $91290 106190045 CATALINA ISLAND MEDICAL CENTER No No No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290

Tab 4- Hospital Characteristics 2017-05-22

Designated NICU as

Defined by DHCS

DHCS Designated

Remote Rural SFY 17-18 CCR FFY 2017 Wage

Index Value

FFY 2017 Wage Index Value (Adjusted for

CA Neutrality Factor 09792)

SFY 17-18 Unadjusted Remote Rural Statewide Base Rate

SFY 17-18 Wage Adjusted Statewide Base Rate

SFY 17-18 Rehab Rate

SFY 17-18 ADMIN 2 190

SFY 17-18 ADMIN 2 199

Rate 106190555 CEDARS SINAI MEDICAL CENTER No No Yes No No 16651 12766 12500 $6760 $7936 $1212 $102707 $91290 106190148 CENTINELA HOSPITAL MEDICAL CENTER No No No No No 17584 12766 12500 $6760 $7936 $1212 $102707 $91290 106500954 CENTRAL VALLEY SPECIALTY HOSPITAL No No No No No 18492 12766 12500 $6760 $7936 $102707 $91290 106301140 CHAPMAN GLOBAL MEDICAL CENTER No No No No No 21650 12766 12500 $6760 $7936 $102707 $91290 106010776 CHILDRENS HOSPITAL AND RESEARCH CENTER AT OAKLAND No No Yes No No 31742 17206 16848 $6760 $9982 $2718 $102707 $91290 106304113 CHILDREN S HOSPITAL AT MISSION No No No No No 31265 12766 12500 $6760 $7936 $102707 $91290 106190170 CHILDREN S HOSPITAL OF LOS ANGELES No No Yes No No 33099 12766 12500 $6760 $7936 $2161 $102707 $91290 106300032 CHILDRENS HOSPITAL OF ORANGE COUNTY No No Yes No No 22623 12766 12500 $6760 $7936 $102707 $91290 106382715 CHINESE HOSPITAL No No No No No 54206 17143 16786 $6760 $9953 $102707 $91290 106361144 CHINO VALLEY MEDICAL CENTER No No No No No 23636 12766 12500 $6760 $7936 $102707 $91290 106190413 CITRUS VALLEY MEDICAL CENTER - IC CAMPUS No No No No No 32501 12766 12500 $6760 $7936 $102707 $91290 106190636 CITRUS VALLEY MEDICAL CENTER - QV CAMPUS No No Yes No No 32501 12766 12500 $6760 $7936 $1212 $102707 $91290 106190176 CITY OF HOPE HELFORD CLINICAL RESEARCH HOSPITAL No No No No No 24967 12766 12500 $6760 $7936 $102707 $91290 106100005 CLOVIS COMMUNITY MEDICAL CENTER No No No No No 29426 12766 12500 $6760 $7936 $102707 $91290 106100697 COALINGA REGIONAL MEDICAL CENTER No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106190766 COAST PLAZA HOSPITAL No No No No No 18971 12766 12500 $6760 $7936 $102707 $91290 106301155 COLLEGE HOSPITAL COSTA MESA No No No No No 59044 12766 12500 $6760 $7936 $102707 $91290 106190587 COLLEGE MEDICAL CENTER No No No No No 44750 12766 12500 $6760 $7936 $102707 $91290 106361458 COLORADO RIVER MEDICAL CENTER No No No Yes Yes 18289 12766 12500 $12832 $15065 $102707 $91290 106190475 COMMUNITY HOSPITAL LONG BEACH No No No No No 21228 12766 12500 $6760 $7936 $102707 $91290 106190197 COMMUNITY HOSPITAL OF HUNTINGTON PARK No No No No No 15277 12766 12500 $6760 $7936 $102707 $91290 106361323 COMMUNITY HOSPITAL OF SAN BERNARDINO No No No No No 18404 12766 12500 $6760 $7936 $102707 $81053 106270744 COMMUNITY HOSPITAL OF THE MONTEREY PENINSULA No No No No No 28828 16962 16609 $6760 $9870 $1507 $102707 $91290 106560473 COMMUNITY MEMORIAL HOSPITAL-SAN BUENAVENTURA No No Yes No No 23717 13279 13003 $6760 $8173 $102707 $91290 106100717 COMMUNITY REGIONAL MEDICAL CENTER-FRESNO No No Yes No No 28695 12766 12500 $6760 $7936 $1644 $102707 $87294 106070924 CONTRA COSTA REGIONAL MEDICAL CENTER Yes No No No No 60322 17206 16848 $6760 $9982 106331145 CORONA REGIONAL MEDICAL CENTER-MAGNOLIA No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106331152 CORONA REGIONAL MEDICAL CENTER-MAIN No No No No No 35175 12766 12500 $6760 $7936 $102707 $84029 106390846 DAMERON HOSPITAL No No No No No 20547 14625 14321 $6760 $8793 $102707 $91290 106150706 DELANO REGIONAL MEDICAL CENTER No No No No No 43839 12766 12500 $6760 $7936 $102707 $75780 106331164 DESERT REGIONAL MEDICAL CENTER No No No No No 13360 12766 12500 $6760 $7936 $1437 $102707 $91290 106364144 DESERT VALLEY HOSPITAL No No No No No 22076 12766 12500 $6760 $7936 $102707 $91290 106392287 DOCTORS HOSPITAL OF MANTECA No No No No No 12426 14625 14321 $6760 $8793 $102707 $91290 106190857 DOCTORS HOSPITAL OF WEST COVINA INC No No No No No 17452 12766 12500 $6760 $7936 $102707 $67983 106500852 DOCTORS MEDICAL CENTER No No No No No 11034 13811 13524 $6760 $8418 $102707 $91290 106070904 DOCTORS MEDICAL CENTER - SAN PABLO No Yes No No No 35867 17206 16848 $6760 $9982 $102707 $91290 106440755 DOMINICAN HOSPITAL No No No No No 20354 18017 17642 $6760 $10356 $1581 $102707 $91290 106196168 EARL AND LORAINE MILLER CHILDRENS HOSPITAL No No Yes No No 26551 12766 12500 $6760 $7936 $102707 $91290 106190256 EAST LOS ANGELES DOCTORS HOSPITAL No No No No No 18418 12766 12500 $6760 $7936 $102707 $91290 106320859 EASTERN PLUMAS HOSPITAL-PORTOLA CAMPUS No Yes No Yes Yes 48861 12766 12500 $12832 $15065 $102707 $91290 106014233 EDEN MEDICAL CENTER No No No No No 29101 17374 17013 $6760 $10060 $102707 $91290 106331168 EISENHOWER MEDICAL CENTER No No No No No 14729 12766 12500 $6760 $7936 $102707 $91290 106430763 EL CAMINO HOSPITAL No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106430743 EL CAMINO HOSPITAL LOS GATOS No Yes No No No 29969 17374 17013 $6760 $10060 $1536 $102707 $91290 106130699 EL CENTRO REGIONAL MEDICAL CENTER No Yes No No No 23149 12766 12500 $6760 $7936 $102707 $91290 106500867 EMANUEL MEDICAL CENTER No No No No No 14569 13157 12883 $6760 $8116 $102707 $91290 106190280 ENCINO HOSPITAL MEDICAL CENTER No No No No No 12709 12766 12500 $6760 $7936 $1212 $102707 $89826 106040962 ENLOE MEDICAL CENTER- ESPLANADE No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106044011 ENLOE REHABILITATION CENTER No No No No No 21402 12766 12500 $6760 $7936 $1379 $102707 $91290 106474007 FAIRCHILD MEDICAL CENTER No No No Yes Yes 45172 12766 12500 $12832 $15065 $102707 $91290 106010811 FAIRMONT HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106040875 FEATHER RIVER HOSPITAL No No No No No 16032 12766 12500 $6760 $7936 $102707 $91290 106190298 FOOTHILL PRESBYTERIAN HOSPITAL-JOHNSTON MEMORIAL No No No No No 30455 12766 12500 $6760 $7936 $102707 $91290 106301357 FOOTHILL REGIONAL MEDICAL CENTER No No No No No 76624 12766 12500 $6760 $7936 $102707 $91290 106301175 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - EUCLID No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106304039 FOUNTAIN VALLEY REGIONAL HOSPITAL amp MEDICAL CENTER - WARNER No No No No No 19283 12766 12500 $6760 $7936 $102707 $91290 106230949 FRANK R HOWARD MEMORIAL HOSPITAL No No No Yes Yes 36408 12766 12500 $12832 $15065 $102707 $91290 106510882 FREMONT MEDICAL CENTER No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106400480 FRENCH HOSPITAL MEDICAL CENTER No No No No No 36626 12766 12500 $6760 $7936 $102707 $91290 106105029 FRESNO HEART AND SURGICAL HOSPITAL No No No No No 29339 12766 12500 $6760 $7936 $1644 $102707 $87294 106104047 FRESNO SURGICAL HOSPITAL No No No No No 28300 12766 12500 $6760 $7936 $102707 $91290 106301283 GARDEN GROVE HOSPITAL AND MEDICAL CENTER No No No No No 24460 12766 12500 $6760 $7936 $102707 $91290 106190159 GARDENS REGIONAL HOSPITAL AND MEDICAL CENTER No No No No No 27795 12766 12500 $6760 $7936 $102707 $91290 106190315 GARFIELD MEDICAL CENTER No No No No No 13408 12766 12500 $6760 $7936 $1384 $102707 $91290 106270777 GEORGE L MEE MEMORIAL HOSPITAL No No No Yes Yes 39703 16962 16609 $12832 $18735 $102707 $91290 106190323 GLENDALE ADVENTIST MEDICAL CENTER No No No No No 25082 12766 12500 $6760 $7936 $1212 $102707 $91290 106190522 GLENDALE MEMORIAL HOSPITAL AND HEALTH CENTER No No No No No 23703 13279 13003 $6760 $8173 $1248 $102707 $91290 106190328 GLENDORA COMMUNITY HOSPITAL No No No No No 37977 12766 12500 $6760 $7936 $102707 $91290 106110889 GLENN MEDICAL CENTER No No No Yes Yes 89670 12766 12500 $12832 $15065 $102707 $91290 106420483 GOLETA VALLEY COTTAGE HOSPITAL No No No No No 39671 12766 12500 $6760 $7936 $102707 $91290 106150775 GOOD SAMARITAN HOSPITAL-BAKERSFIELD No No No No No 46761 12766 12500 $6760 $7936 $102707 $91290 106190392 GOOD SAMARITAN HOSPITAL-LOS ANGELES No No Yes No No 21857 12766 12500 $6760 $7936 $1212 $102707 $91290 106430779 GOOD SAMARITAN HOSPITAL-SAN JOSE No No Yes No No 16044 17374 17013 $6760 $10060 $1536 $102707 $91290 106190352 GREATER EL MONTE COMMUNITY HOSPITAL No No No No No 18657 12766 12500 $6760 $7936 $102707 $91290

Designated NICU as

Defined by DHCS

DHCS Designated

Index Value

SFY 17-18 ADMIN 2 190

SFY 17-18 ADMIN 2 199

Rate 106370714 GROSSMONT HOSPITAL No No No No No 20462 12766 12500 $6760 $7936 $1212 $102707 $91290 106350784 HAZEL HAWKINS MEMORIAL HOSPITAL No Yes No Yes Yes 33799 17374 17013 $12832 $19095 $102707 $91290 106490964 HEALDSBURG DISTRICT HOSPITAL No Yes No Yes Yes 49419 15937 15606 $12832 $17839 $102707 $90476 106304159 HEALTHBRIDGE CHILDRENS HOSPITAL-ORANGE No No No No No 28187 12766 12500 $6760 $7936 $2161 $102707 $91290 106154022 HEALTHSOUTH BAKERSFIELD REHABILITATION HOSPITAL No No No No No 54432 12766 12500 NA NA $1372 $102707 $91290 106304079 HEALTHSOUTH TUSTIN REHABILITATION HOSPITAL No No No No No 60473 12766 12500 NA NA $1212 $102707 $91290 106331194 HEMET VALLEY MEDICAL CENTER No No No No No 39901 12766 12500 $6760 $7936 $102707 $89667 106190949 HENRY MAYO NEWHALL HOSPITAL No No No No No 25413 12766 12500 $6760 $7936 $1212 $102707 $91290 106362041 HI-DESERT MEDICAL CENTER No No No Yes Yes 37063 12766 12500 $12832 $15065 $102707 $68852 106010846 HIGHLAND HOSPITAL Yes No No No No 31488 17374 17013 $6760 $10060 106301205 HOAG MEMORIAL HOSPITAL PRESBYTERIAN No No No No No 34710 12766 12500 $6760 $7936 $102707 $91290 106304460 HOAG ORTHOPEDIC INSTITUTE No No No No No 23840 12766 12500 $6760 $7936 $102707 $91290 106190382 HOLLYWOOD PRESBYTERIAN MEDICAL CENTER No No No No No 28063 12766 12500 $6760 $7936 $1212 $102707 $89667 106301209 HUNTINGTON BEACH HOSPITAL No No No No No 20078 12766 12500 $6760 $7936 $102707 $91290 106190400 HUNTINGTON MEMORIAL HOSPITAL No No Yes No No 19644 12766 12500 $6760 $7936 $1212 $102707 $91290 106121031 JEROLD PHELPS COMMUNITY HOSPITAL No Yes No Yes Yes 90876 12766 12500 $12832 $15065 $102707 $91290 106220733 JOHN C FREMONT HEALTHCARE DISTRICT No Yes No Yes Yes 36932 12766 12500 $12832 $15065 $102707 $91290 106331216 JOHN F KENNEDY MEMORIAL HOSPITAL No No No No No 17750 12766 12500 $6760 $7936 $102707 $91290 106071018 JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS No No No No No 15617 17206 16848 $6760 $9982 $102707 $91290 106070988 JOHN MUIR MEDICAL CENTER-WALNUT CREEK CAMPUS No No No No No 16294 17206 16848 $6760 $9982 $1524 $102707 $91290 106301132 KAISER FND HOSP - ORANGE COUNTY - LAKEVIEW No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106074097 KAISER FOUNDATION HOSPITAL - ANTIOCH No No No No No 58321 17206 16848 $6760 $9982 $102707 $91290 106196035 KAISER FOUNDATION HOSPITAL - BALDWIN PARK No No No No No 49820 12766 12500 $6760 $7936 $102707 $91290 106196403 KAISER FOUNDATION HOSPITAL - DOWNEY No No Yes No No 47302 12766 12500 $6760 $7936 $102707 $91290 106361223 KAISER FOUNDATION HOSPITAL - FONTANA No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106014132 KAISER FOUNDATION HOSPITAL - FREMONT No No No No No 45325 17374 17013 $6760 $10060 $102707 $91290 106104062 KAISER FOUNDATION HOSPITAL - FRESNO No No No No No 53028 12766 12500 $6760 $7936 $102707 $91290 106190429 KAISER FOUNDATION HOSPITAL - LOS ANGELES No No Yes No No 45582 12766 12500 $6760 $7936 $102707 $91290 106394009 KAISER FOUNDATION HOSPITAL - MANTECA No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106504042 KAISER FOUNDATION HOSPITAL - MODESTO No No No No No 48191 14625 14321 $6760 $8793 $102707 $91290 106334048 KAISER FOUNDATION HOSPITAL - MORENO VALLEY No No No No No 61092 12766 12500 $6760 $7936 $102707 $91290 106014326 KAISER FOUNDATION HOSPITAL - OAKLANDRICHMOND No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106364265 KAISER FOUNDATION HOSPITAL - ONTARIO No No Yes No No 43322 12766 12500 $6760 $7936 $1212 $102707 $91290 106304409 KAISER FOUNDATION HOSPITAL - ORANGE COUNTY - ANAHEIM No No Yes No No 44706 12766 12500 $6760 $7936 $102707 $91290 106190432 KAISER FOUNDATION HOSPITAL - PANORAMA CITY No No No No No 53774 12766 12500 $6760 $7936 $102707 $91290 106410804 KAISER FOUNDATION HOSPITAL - REDWOOD CITY No No No No No 46360 17226 16868 $6760 $9991 $102707 $91290 106480989 KAISER FOUNDATION HOSPITAL - REHABILITATION CENTER VALLEJO No No No No No 50944 17042 16688 $6760 $9907 $2623 $102707 $91290 106074093 KAISER FOUNDATION HOSPITAL - RICHMOND CAMPUS No No Yes No No 49352 17374 17013 $6760 $10060 $102707 $91290 106334025 KAISER FOUNDATION HOSPITAL - RIVERSIDE No No No No No 63573 12766 12500 $6760 $7936 $102707 $91290 106314024 KAISER FOUNDATION HOSPITAL - ROSEVILLE No No Yes No No 39874 15957 15625 $6760 $9407 $102707 $91290 106340913 KAISER FOUNDATION HOSPITAL - SACRAMENTO No No No No No 40269 15957 15625 $6760 $9407 $102707 $91290 106370730 KAISER FOUNDATION HOSPITAL - SAN DIEGO No No Yes No No 41434 12766 12500 $6760 $7936 $102707 $91290 106380857 KAISER FOUNDATION HOSPITAL - SAN FRANCISCO No No No No No 41047 17143 16786 $6760 $9953 $102707 $91290 106431506 KAISER FOUNDATION HOSPITAL - SAN JOSE No No No No No 51392 17374 17013 $6760 $10060 $102707 $91290 106014337 KAISER FOUNDATION HOSPITAL - SAN LEANDRO No No No No No 45480 17229 16871 $6760 $9993 $102707 $91290 106210992 KAISER FOUNDATION HOSPITAL - SAN RAFAEL No No No No No 45638 17555 17190 $6760 $10143 $102707 $91290 106434153 KAISER FOUNDATION HOSPITAL - SANTA CLARA No No Yes No No 38259 17374 17013 $6760 $10060 $102707 $91290 106494019 KAISER FOUNDATION HOSPITAL - SANTA ROSA No No No No No 59482 17063 16708 $6760 $9916 $102707 $91290 106190431 KAISER FOUNDATION HOSPITAL - SOUTH BAY No No No No No 50062 12766 12500 $6760 $7936 $102707 $91290 106342344 KAISER FOUNDATION HOSPITAL - SOUTH SACRAMENTO No No No No No 38909 15957 15625 $6760 $9407 $102707 $91290 106410806 KAISER FOUNDATION HOSPITAL - SOUTH SAN FRANCISCO No No No No No 34340 17226 16868 $6760 $9991 $102707 $91290 106484044 KAISER FOUNDATION HOSPITAL - VACAVILLE No No No No No 41143 17042 16688 $6760 $9907 $102707 $91290 106070990 KAISER FOUNDATION HOSPITAL - WALNUT CREEK No No No No No 41336 17206 16848 $6760 $9982 $102707 $91290 106190434 KAISER FOUNDATION HOSPITAL - WEST LA No No No No No 57826 12766 12500 $6760 $7936 $102707 $91290 106191450 KAISER FOUNDATION HOSPITAL - WOODLAND HILLS No No No No No 55483 12766 12500 $6760 $7936 $102707 $91290 106540734 KAWEAH DELTA MEDICAL CENTER No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106544075 KAWEAH DELTA REHABILITATION HOSPITAL No Yes No No No 30333 12766 12500 $6760 $7936 $1212 $102707 $81465 106194219 KECK HOSPITAL OF USC No No No No No 20263 12766 12500 $6760 $7936 $1212 $102707 $91290 106210993 KENTFIELD REHABILITATION amp SPECIALTY HOSPITAL No No No No No 36508 17555 17190 $6760 $10143 $1548 $102707 $91290 106150736 KERN MEDICAL CENTER Yes No No No No 34725 12766 12500 $6760 $7936 106150737 KERN VALLEY HEALTHCARE DISTRICT No Yes No Yes Yes 27184 12766 12500 $12832 $15065 $102707 $91290 106190049 KINDRED HOSPITAL - BALDWIN PARK No No No No No 17788 12766 12500 $6760 $7936 $102707 $91290 106301127 KINDRED HOSPITAL - BREA No No No No No 25624 12766 12500 $6760 $7936 $102707 $91290 106190449 KINDRED HOSPITAL - LA MIRADA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190305 KINDRED HOSPITAL - LOS ANGELES No No No No No 21219 12766 12500 $6760 $7936 $102707 $91290 106361274 KINDRED HOSPITAL - ONTARIO No No No No No 21669 12766 12500 $6760 $7936 $102707 $91290 106364188 KINDRED HOSPITAL - RANCHO No No No No No 19163 12766 12500 $6760 $7936 $102707 $91290 106332172 KINDRED HOSPITAL - RIVERSIDE No No No No No 19573 12766 12500 $6760 $7936 $102707 $91290 106370721 KINDRED HOSPITAL - SAN DIEGO No No No No No 36972 12766 12500 $6760 $7936 $102707 $91290 106010887 KINDRED HOSPITAL - SAN FRANCISCO BAY AREA No No No No No 29006 17206 16848 $6760 $9982 $102707 $91290 106190458 KINDRED HOSPITAL - SAN GABRIEL VALLEY No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106301167 KINDRED HOSPITAL - SANTA ANA No No No No No 22298 12766 12500 $6760 $7936 $1212 $102707 $91290 106190196 KINDRED HOSPITAL - SOUTH BAY No No No No No 20835 12766 12500 $6760 $7936 $102707 $91290 106301380 KINDRED HOSPITAL - WESTMINSTER No No No No No 17768 12766 12500 $6760 $7936 $102707 $91290

Designated NICU as

Defined by DHCS

DHCS Designated

Index Value

SFY 17-18 ADMIN 2 190

SFY 17-18 ADMIN 2 199

Rate 106301234 LA PALMA INTERCOMMUNITY HOSPITAL No No No No No 24978 12766 12500 $6760 $7936 $102707 $91290 106191227 LACHARBOR-UCLA MEDICAL CENTER Yes No Yes No No 34867 12766 12500 $6760 $7936 106191306 LACRANCHO LOS AMIGOS NATIONAL REHAB CENTER Yes No No No No 41288 12766 12500 $6760 $7936 106191228 LAC+USC MEDICAL CENTER Yes No Yes No No 45207 12766 12500 $6760 $7936 106380865 LAGUNA HONDA HOSPITAL AND REHABILITATION CENTER Yes No No No No 50912 17143 16786 $6760 $9953 106190240 LAKEWOOD REGIONAL MEDICAL CENTER No No No No No 15420 12766 12500 $6760 $7936 $1212 $102707 $91290 106390923 LODI MEMORIAL HOSPITAL No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106390922 LODI MEMORIAL HOSPITAL - WEST No No No No No 12087 14625 14321 $6760 $8793 $1342 $102707 $91290 106361245 LOMA LINDA UNIV MED CENTER EAST CAMPUS HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106364502 LOMA LINDA UNIVERSITY CHILDREN S HOSPITAL No No Yes No No 27238 12766 12500 $6760 $7936 $2161 $102707 $91290 106364268 LOMA LINDA UNIVERSITY HEART AND SURGICAL HOSPITAL No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106361246 LOMA LINDA UNIVERSITY MEDICAL CENTER No No Yes No No 17279 12766 12500 $6760 $7936 $1480 $102707 $91290 106334589 LOMA LINDA UNIVERSITY MEDICAL CENTER-MURRIETA No No No No No 23565 12766 12500 $6760 $7936 $102707 $91290 106420491 LOMPOC VALLEY MEDICAL CENTER No Yes No Yes Yes 67135 12766 12500 $12832 $15065 $102707 $91290 106190525 LONG BEACH MEMORIAL MEDICAL CENTER No No No No No 15288 12766 12500 $6760 $7936 $1615 $102707 $91290 106301248 LOS ALAMITOS MEDICAL CENTER No No No No No 16592 12766 12500 $6760 $7936 $102707 $91290 106190198 LOS ANGELES COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $86231 106191231 LOS ANGELES COUNTY OLIVE VIEW-UCLA MEDICAL CENTER Yes No No No No 39391 12766 12500 $6760 $7936 106560492 LOS ROBLES HOSPITAL amp MEDICAL CENTER No No No No No 17269 13279 13003 $6760 $8173 $102707 $91290 106434040 LUCILE SALTER PACKARD CHILDREN S HOSP AT STANFORD No No Yes No No 19996 17374 17013 $6760 $10060 $102707 $91290 106121002 MAD RIVER COMMUNITY HOSPITAL No No No No No 44711 12766 12500 $6760 $7936 $102707 $91290 106201281 MADERA COMMUNITY HOSPITAL No No No No No 59513 12766 12500 $6760 $7936 $102707 $91290 106260011 MAMMOTH HOSPITAL No Yes No Yes Yes 73863 12766 12500 $12832 $15065 $102707 $91290 106420493 MARIAN REGIONAL MEDICAL CENTER No No No No No 25997 12766 12500 $6760 $7936 $102707 $91290 106400466 MARIAN REGIONAL MEDICAL CENTER ARROYO GRANDE No No No No No 25810 12766 12500 $6760 $7936 $1212 $102707 $91290 106211006 MARIN GENERAL HOSPITAL No Yes No No No 22745 17555 17190 $6760 $10143 $102707 $91290 106190500 MARINA DEL REY HOSPITAL No No No No No 23046 12766 12500 $6760 $7936 $102707 $91290 106050932 MARK TWAIN MEDICAL CENTER No No No Yes Yes 32088 12766 12500 $12832 $15065 $102707 $91290 106090933 MARSHALL MEDICAL CENTER No No No Yes Yes 18865 15957 15625 $12832 $17856 $102707 $91290 106191230 MARTIN LUTHER KING JR COMMUNITY HOSPITAL No No No No No 21600 12766 12500 $6760 $7936 $102707 $91290 106450936 MAYERS MEMORIAL HOSPITAL No Yes No Yes Yes 55062 14485 14184 $12832 $16569 $102707 $91290 106240924 MEMORIAL HOSPITAL LOS BANOS No No No Yes Yes 32031 12766 12500 $12832 $15065 $102707 $91290 106500939 MEMORIAL HOSPITAL MEDICAL CENTER - MODESTO No No No No No 22635 13157 12883 $6760 $8116 $102707 $91290 106190521 MEMORIAL HOSPITAL OF GARDENA No No No No No 17803 12766 12500 $6760 $7936 $102707 $89559 106231013 MENDOCINO COAST DISTRICT HOSPITAL No Yes No Yes Yes 50169 12766 12500 $12832 $15065 $102707 $91290 106334018 MENIFEE VALLEY MEDICAL CENTER No No No No No 41906 12766 12500 $6760 $7936 $102707 $91290 106414018 MENLO PARK SURGICAL HOSPITAL No No No No No 44966 17226 16868 $6760 $9991 $102707 $91290 106340947 MERCY GENERAL HOSPITAL No No No No No 31327 15957 15625 $6760 $9407 $1436 $102707 $91290 106150761 MERCY HOSPITAL - BAKERSFIELD No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106344029 MERCY HOSPITAL OF FOLSOM No No No No No 21964 15957 15625 $6760 $9407 $102707 $91290 106240942 MERCY MEDICAL CENTER - MERCED No No No No No 18960 12870 12602 $6760 $7984 $102707 $91290 106450949 MERCY MEDICAL CENTER - REDDING No No No No No 24508 14485 14184 $6760 $8729 $102707 $91290 106470871 MERCY MEDICAL CENTER MT SHASTA No No No Yes Yes 55674 12766 12500 $12832 $15065 $102707 $91290 106340950 MERCY SAN JUAN HOSPITAL No No No No No 19322 15957 15625 $6760 $9407 $102707 $91290 106154108 MERCY SOUTHWEST HOSPITAL No No No No No 20968 12766 12500 $6760 $7936 $102707 $91290 106340951 METHODIST HOSPITAL OF SACRAMENTO No No No No No 31193 15957 15625 $6760 $9407 $102707 $91290 106190529 METHODIST HOSPITAL OF SOUTHERN CALIFORNIA No No No No No 19234 12766 12500 $6760 $7936 $1212 $102707 $91290 106410852 MILLS-PENINSULA MEDICAL CENTER No No No No No 33364 17226 16868 $6760 $9991 $102707 $91290 106190524 MISSION COMMUNITY HOSPITAL - PANORAMA CAMPUS No No No No No 36553 12766 12500 $6760 $7936 $102707 $91290 106301337 MISSION HOSPITAL LAGUNA BEACH No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106301262 MISSION HOSPITAL REGIONAL MEDICAL CENTER No No No No No 26763 12766 12500 $6760 $7936 $1212 $102707 $91290 106250956 MODOC MEDICAL CENTER No Yes No Yes Yes 71792 12766 12500 $12832 $15065 $102707 $91290 106190541 MONROVIA MEMORIAL HOSPITAL No No No No No 17581 12766 12500 $6760 $7936 $102707 $91290 106361166 MONTCLAIR HOSPITAL MEDICAL CENTER No No No No No 32285 12766 12500 $6760 $7936 $102707 $91290 106190547 MONTEREY PARK HOSPITAL No No No No No 18699 12766 12500 $6760 $7936 $102707 $91290 106361266 MOUNTAINS COMMUNITY HOSPITAL No Yes No Yes Yes 45217 12766 12500 $12832 $15065 $102707 $91290 106274043 NATIVIDAD MEDICAL CENTER Yes No No No No 20757 16962 16609 $6760 $9870 106481357 NORTH BAY MEDICAL CENTER No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106484001 NORTH BAY VACAVALLEY HOSPITAL No No No No No 17706 17042 16688 $6760 $9907 $102707 $91290 106141273 NORTHERN INYO HOSPITAL No Yes No Yes Yes 64700 12766 12500 $12832 $15065 $102707 $91290 106190568 NORTHRIDGE HOSPITAL MEDICAL CENTER No No No No No 19025 13279 13003 $6760 $8173 $1700 $102707 $91290 106190570 NORWALK COMMUNITY HOSPITAL No No No No No 22634 12766 12500 $6760 $7936 $102707 $91290 106214034 NOVATO COMMUNITY HOSPITAL No No No No No 32112 17555 17190 $6760 $10143 $102707 $91290 106500967 OAK VALLEY HOSPITAL DISTRICT No Yes No Yes No 33576 13157 12883 $6760 $8116 $102707 $91290 106430837 OCONNOR HOSPITAL No No No No No 24776 17374 17013 $6760 $10060 $102707 $91290 106560501 OJAI VALLEY COMMUNITY HOSPITAL No No No Yes Yes 86960 13279 13003 $12832 $15514 $102707 $91290 106190534 OLYMPIA MEDICAL CENTER No No No No No 9409 12766 12500 $6760 $7936 $102707 $91290 106300225 ORANGE COAST MEMORIAL MEDICAL CENTER No No No No No 21978 12766 12500 $6760 $7936 $102707 $91290 106301566 ORANGE COUNTY GLOBAL MEDICAL CENTER No No No No No 34463 12766 12500 $6760 $7936 $102707 $91290 106040802 ORCHARD HOSPITAL No No No Yes Yes 49554 12766 12500 $12832 $15065 $102707 $91290 106040937 OROVILLE HOSPITAL No No No No No 15254 12766 12500 $6760 $7936 $102707 $91290 106190307 PACIFIC ALLIANCE MEDICAL CENTER No No No No No 33771 12766 12500 $6760 $7936 $1212 $102707 $91290 106190696 PACIFICA HOSPITAL OF THE VALLEY No No No No No 54157 12766 12500 $6760 $7936 $102707 $81819 106196405 PALMDALE REGIONAL MEDICAL CENTER No No No No No 19531 12766 12500 $6760 $7936 $1212 $102707 $91290

Designated NICU as

Defined by DHCS

DHCS Designated

Index Value

SFY 17-18 ADMIN 2 190

SFY 17-18 ADMIN 2 199

Rate 106331288 PALO VERDE HOSPITAL No Yes No Yes Yes 35896 12766 12500 $12832 $15065 $102707 $91290 106370755 PALOMAR HEALTH DOWNTOWN CAMPUS No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106374382 PALOMAR MEDICAL CENTER No Yes No No No 22790 12766 12500 $6760 $7936 $1212 $102707 $91290 106370759 PARADISE VALLEY HOSPITAL No No No No No 27756 12766 12500 $6760 $7936 $1212 $102707 $91290 106331293 PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER No No No No No 25675 12766 12500 $6760 $7936 $102707 $91290 106454013 PATIENTS HOSPITAL OF REDDING No No No No No 22610 14485 14184 $6760 $8729 $102707 $91290 106491001 PETALUMA VALLEY HOSPITAL No No No No No 22520 17063 16708 $6760 $9916 $102707 $91290 106190243 PIH HOSPITAL - DOWNEY No No No No No 14613 12766 12500 $6760 $7936 $102707 $91290 106130760 PIONEERS MEMORIAL HEALTHCARE DISTRICT No Yes No Yes No 28361 12766 12500 $6760 $7936 $102707 $91290 106301297 PLACENTIA LINDA HOSPITAL No No No No No 15341 12766 12500 $6760 $7936 $102707 $91290 106320986 PLUMAS DISTRICT HOSPITAL No Yes No Yes Yes 75953 12766 12500 $12832 $15065 $102707 $91290 106370977 POMERADO HOSPITAL No Yes No No No 23528 12766 12500 $6760 $7936 $102707 $91290 106190630 POMONA VALLEY HOSPITAL MEDICAL CENTER No No Yes No No 14137 12766 12500 $6760 $7936 $102707 $91290 106190631 PRESBYTERIAN INTERCOMMUNITY HOSPITAL No No No No No 13107 12766 12500 $6760 $7936 $1212 $102707 $91290 106190468 PROMISE HOSPITAL OF EAST LOS ANGELES-EAST LA CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106190599 PROMISE HOSPITAL OF EAST LOS ANGELES-SUBURBAN CAMPUS No No No No No 23842 12766 12500 $6760 $7936 $102707 $91290 106370787 PROMISE HOSPITAL OF SAN DIEGO No No No No No 26520 12766 12500 $6760 $7936 $102707 $91290 106190385 PROVIDENCE HOLY CROSS MEDICAL CENTER No No No No No 13843 12766 12500 $6760 $7936 $1212 $102707 $91290 106190680 PROVIDENCE LITTLE COMPANY OF MARY MC - SAN PEDRO No No No No No 23967 12766 12500 $6760 $7936 $1212 $102707 $91290 106190470 PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE No No No No No 36106 12766 12500 $6760 $7936 $102707 $91290 106190756 PROVIDENCE SAINT JOHNS HEALTH CENTER No No No No No 24959 12766 12500 $6760 $7936 $102707 $91290 106190758 PROVIDENCE SAINT JOSEPH MEDICAL CENTER No No No No No 19385 12766 12500 $6760 $7936 $1212 $102707 $91290 106190517 PROVIDENCE TARZANA MEDICAL CENTER No No Yes No No 17309 12766 12500 $6760 $7936 $102707 $91290 106281047 QUEEN OF THE VALLEY MEDICAL CENTER No No No No No 24140 15937 15606 $6760 $9398 $1435 $102707 $91290 106370673 RADY CHILDREN S HOSPITAL - SAN DIEGO No No Yes No No 28976 12766 12500 $6760 $7936 $2161 $102707 $91290 106361308 REDLANDS COMMUNITY HOSPITAL No No No No No 22264 12766 12500 $6760 $7936 $102707 $91290 106121051 REDWOOD MEMORIAL HOSPITAL No No No Yes Yes 27213 12766 12500 $12832 $15065 $102707 $91290 106430705 REGIONAL MEDICAL OF SAN JOSE No No No No No 11689 17374 17013 $6760 $10060 $102707 $91290 106580996 RIDEOUT MEMORIAL HOSPITAL No No No No No 27430 12766 12500 $6760 $7936 $102707 $91290 106150782 RIDGECREST REGIONAL HOSPITAL No No No Yes Yes 35724 12766 12500 $12832 $15065 $102707 $91290 106331312 RIVERSIDE COMMUNITY HOSPITAL No No No No No 14274 12766 12500 $6760 $7936 $102707 $91290 106334487 RIVERSIDE COUNTY REGIONAL MEDICAL CENTER Yes No No No No 29198 12766 12500 $6760 $7936 106190796 RONALD REAGAN UCLA MEDICAL CENTER Yes No Yes No No 38061 12766 12500 $6760 $7936 106301317 SADDLEBACK MEMORIAL MEDICAL CENTER No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106301325 SADDLEBACK MEMORIAL MEDICAL CENTER - SAN CLEMENTE No No No No No 23715 12766 12500 $6760 $7936 $1212 $102707 $91290 106270875 SALINAS VALLEY MEMORIAL HOSPITAL No Yes No No No 30570 17374 17013 $6760 $10060 $102707 $91290 106361318 SAN ANTONIO REGIONAL HOSPITAL No No No No No 18013 12766 12500 $6760 $7936 $102707 $91290 106190673 SAN DIMAS COMMUNITY HOSPITAL No No No No No 26484 12766 12500 $6760 $7936 $102707 $91290 106380939 SAN FRANCISCO GENERAL HOSPITAL Yes No No No No 29931 17143 16786 $6760 $9953 106190200 SAN GABRIEL VALLEY MEDICAL CENTER No No No No No 23274 12766 12500 $6760 $7936 $102707 $91290 106331326 SAN GORGONIO MEMORIAL HOSPITAL No Yes No Yes Yes 42773 12766 12500 $12832 $15065 $102707 $91290 106150788 SAN JOAQUIN COMMUNITY HOSPITAL No No No No No 17678 12766 12500 $6760 $7936 $102707 $91290 106391010 SAN JOAQUIN GENERAL HOSPITAL Yes No No No No 18602 14625 14321 $6760 $8793 106104023 SAN JOAQUIN VALLEY REHABILITATION HOSPITAL No No No No No 45565 12766 12500 NA NA $1403 $102707 $91290 106013619 SAN LEANDRO HOSPITAL No Yes No No No 22408 17374 17013 $6760 $10060 $102707 $91290 106410782 SAN MATEO MEDICAL CENTER Yes No No No No 62835 17226 16868 $6760 $9991 106074017 SAN RAMON REGIONAL MEDICAL CENTER No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106074011 SAN RAMON REGIONAL MEDICAL CENTER SOUTH BUILDING No No No No No 18483 17206 16848 $6760 $9982 $1524 $102707 $91290 106420514 SANTA BARBARA COTTAGE HOSPITAL No No Yes No No 35665 12766 12500 $6760 $7936 $2110 $102707 $91290 106430883 SANTA CLARA VALLEY MEDICAL CENTER Yes No Yes No No 28928 17374 17013 $6760 $10060 106190687 SANTA MONICA - UCLA MEDICAL CENTER AND ORTHOPAEDIC HOSPITAL Yes No No No No 38946 12766 12500 $6760 $7936 106491064 SANTA ROSA MEMORIAL HOSPITAL-MONTGOMERY No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106490907 SANTA ROSA MEMORIAL HOSPITAL-SOTOYOME No No No No No 19130 17063 16708 $6760 $9916 $1514 $102707 $91290 106420522 SANTA YNEZ VALLEY COTTAGE HOSPITAL No No No Yes Yes 42839 12766 12500 $12832 $15065 $102707 $91290 106371256 SCRIPPS GREEN HOSPITAL No No No No No 22321 12766 12500 $6760 $7936 $102707 $91290 106371394 SCRIPPS MEMORIAL HOSPITAL - ENCINITAS No No No No No 25516 12766 12500 $6760 $7936 $1429 $102707 $91290 106370771 SCRIPPS MEMORIAL HOSPITAL - LA JOLLA No No No No No 21808 12766 12500 $6760 $7936 $102707 $91290 106370744 SCRIPPS MERCY HOSPITAL No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106370658 SCRIPPS MERCY HOSPITAL - CHULA VISTA No No No No No 21463 12766 12500 $6760 $7936 $102707 $91290 106321016 SENECA DISTRICT HOSPITAL No Yes No Yes Yes 37968 12766 12500 $12832 $15065 $102707 $91290 106410891 SEQUOIA HOSPITAL No No No No No 25286 17374 17013 $6760 $10060 $102707 $91290 106410828 SETON COASTSIDE No No No Yes No 20046 17226 16868 $6760 $9991 $102707 $91290 106410817 SETON MEDICAL CENTER No No No No No 20046 17226 16868 $6760 $9991 $102707 $91290 106370875 SHARP CHULA VISTA MEDICAL CENTER No No No No No 18158 12766 12500 $6760 $7936 $102707 $91290 106370689 SHARP CORONADO HOSPITAL AND HEALTHCARE CENTER No No No No No 24333 12766 12500 $6760 $7936 $102707 $80935 106370695 SHARP MARY BIRCH HOSPITAL FOR WOMEN AND NEWBORNS No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106370694 SHARP MEMORIAL HOSPITAL No No No No No 19285 12766 12500 $6760 $7936 $1426 $102707 $91290 106450940 SHASTA REGIONAL MEDICAL CENTER No No No No No 14929 14485 14184 $6760 $8729 $102707 $91290 106190708 SHERMAN OAKS HOSPITAL No No No No No 15785 12766 12500 $6760 $7936 $102707 $91290 106190712 SHRINERS HOSPITAL FOR CHILDREN No No No No No 100000 12766 12500 $6760 $7936 $102707 $91290 106344114 SHRINERS HOSPITALS FOR CHILDREN NORTHERN CALIF No No No No No 54946 15957 15625 $6760 $9407 $2562 $102707 $91290 106291023 SIERRA NEVADA MEMORIAL HOSPITAL No No No Yes Yes 40576 15957 15625 $12832 $17856 $102707 $91290 106540798 SIERRA VIEW MEDICAL CENTER No Yes No No No 27946 12766 12500 $6760 $7936 $102707 $82957 106400524 SIERRA VISTA REGIONAL MEDICAL CENTER No No No No No 18542 12766 12500 $6760 $7936 $102707 $91290

Designated NICU as

Defined by DHCS

DHCS Designated

Index Value

SFY 17-18 ADMIN 2 190

SFY 17-18 ADMIN 2 199

Rate 106190661 SILVER LAKE MEDICAL CENTER - DOWNTOWN CAMPUS No No No No No 27165 12766 12500 $6760 $7936 $102707 $91290 106560525 SIMI VALLEY HOSPITAL AND HEALTH CARE SVCS-SYCAMORE No No No No No 31527 13279 13003 $6760 $8173 $102707 $91290 106491076 SONOMA VALLEY HOSPITAL No Yes No No No 40451 17063 16708 $6760 $9916 $102707 $91290 106491338 SONOMA WEST MEDICAL CENTER No Yes No Yes No 41877 15937 15606 $6760 $9398 $102707 $91290 106552209 SONORA REGIONAL MEDICAL CENTER - FAIRVIEW No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106554011 SONORA REGIONAL MEDICAL CENTER - GREENLEY No No No Yes Yes 28134 12766 12500 $12832 $15065 $102707 $91290 106301258 SOUTH COAST GLOBAL MEDICAL CENTER No No No No No 39940 12766 12500 $6760 $7936 $102707 $91290 106190110 SOUTHERN CALIFORNIA HOSPITAL AT CULVER CITY No No No No No 14658 12766 12500 $6760 $7936 $102707 $91290 106190380 SOUTHERN CALIFORNIA HOSPITAL AT HOLLYWOOD No No No No No 14658 12766 12500 $6760 $7936 $1212 $102707 $91290 106141338 SOUTHERN INYO HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334068 SOUTHWEST HEALTHCARE SYSTEM-MURRIETA No No No No No 36344 12766 12500 $6760 $7936 $102707 $91290 106334001 SOUTHWEST HEALTHCARE SYSTEM-WILDOMAR No No No Yes No 36344 12766 12500 $6760 $7936 $102707 $91290 106100899 ST AGNES MEDICAL CENTER No No No No No 28241 12766 12500 $6760 $7936 $102707 $91290 106361339 ST BERNARDINE MEDICAL CENTER No No No No No 22493 12766 12500 $6760 $7936 $102707 $91290 106521041 ST ELIZABETH COMMUNITY HOSPITAL No No No Yes Yes 25920 14165 13870 $12832 $16288 $102707 $91290 106190754 ST FRANCIS MEDICAL CENTER No No No No No 49953 12766 12500 $6760 $7936 $102707 $91290 106380960 ST FRANCIS MEMORIAL HOSPITAL No No No No No 21918 17143 16786 $6760 $9953 $1519 $102707 $91290 106281078 ST HELENA HOSPITAL No No No No No 49687 15827 15498 $6760 $9347 $102707 $91290 106171049 ST HELENA HOSPITAL - CLEARLAKE No No No Yes Yes 25026 12766 12500 $12832 $15065 $102707 $91290 106560508 ST JOHN S PLEASANT VALLEY HOSPITAL No No No No No 24499 13279 13003 $6760 $8173 $102707 $91290 106560529 ST JOHNS REGIONAL MEDICAL CENTER No No No No No 22712 13279 13003 $6760 $8173 $1800 $102707 $91290 106121080 ST JOSEPH HOSPITAL - EUREKA No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106301340 ST JOSEPH HOSPITAL - ORANGE No No No No No 27696 12766 12500 $6760 $7936 $102707 $91290 106391042 ST JOSEPH S MEDICAL CENTER OF STOCKTON No No No No No 18069 14625 14321 $6760 $8793 $102707 $91290 106301342 ST JUDE MEDICAL CENTER No No No No No 27384 12766 12500 $6760 $7936 $1212 $102707 $91290 106434138 ST LOUISE REGIONAL HOSPITAL No No No No No 26705 17374 17013 $6760 $10060 $102707 $91290 106361343 ST MARY MEDICAL CENTER - APPLE VALLEY No No No Yes No 23226 12766 12500 $6760 $7936 $102707 $91290 106190053 ST MARY MEDICAL CENTER - LONG BEACH No No No No No 23935 12766 12500 $6760 $7936 $1212 $102707 $91290 106380965 ST MARYS MEDICAL CENTER SAN FRANCISCO No No No No No 21513 17555 17190 $6760 $10143 $1548 $102707 $91290 106010967 ST ROSE HOSPITAL No No No No No 19333 17374 17013 $6760 $10060 $102707 $91290 106190762 ST VINCENT MEDICAL CENTER No No No No No 23098 12766 12500 $6760 $7936 $1212 $102707 $91290 106430905 STANFORD HEALTH CARE No No No No No 19996 17374 17013 $6760 $10060 $1536 $102707 $91290 106504038 STANISLAUS SURGICAL HOSPITAL No No No No No 90000 13157 12883 $6760 $8116 $102707 $91290 106250955 SURPRISE VALLEY COMMUNITY HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106034002 SUTTER AMADOR HOSPITAL No No No Yes Yes 27791 15957 15625 $12832 $17856 $102707 $91290 106310791 SUTTER AUBURN FAITH HOSPITAL No No No No No 28600 15957 15625 $6760 $9407 $102707 $91290 106084001 SUTTER COAST HOSPITAL No No No Yes Yes 41642 12766 12500 $12832 $15065 $102707 $91290 106574010 SUTTER DAVIS HOSPITAL No No No No No 32628 15957 15625 $6760 $9407 $102707 $91290 106070934 SUTTER DELTA MEDICAL CENTER No No No No No 23479 17206 16848 $6760 $9982 $102707 $91290 106171395 SUTTER LAKESIDE HOSPITAL No No No Yes Yes 39217 12766 12500 $12832 $15065 $102707 $91290 106444012 SUTTER MATERNITY AND SURGERY CENTER OF SANTA CRUZ No No No No No 51761 18017 17642 $6760 $10356 $102707 $91290 106490919 SUTTER MEDICAL CENTER OF SANTA ROSA No No No No No 38124 17063 16708 $6760 $9916 $102707 $91290 106341051 SUTTER MEDICAL CENTER SACRAMENTO No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106341052 SUTTER MEMORIAL HOSPITAL No No Yes No No 23529 15957 15625 $6760 $9407 $102707 $91290 106311000 SUTTER ROSEVILLE MEDICAL CENTER No No No No No 26373 15957 15625 $6760 $9407 $1436 $102707 $91290 106481094 SUTTER SOLANO MEDICAL CENTER No No No No No 33207 17063 16708 $6760 $9916 $102707 $91290 106514030 SUTTER SURGICAL HOSPITAL-NORTH VALLEY No No No No No 43211 12766 12500 $6760 $7936 $102707 $91290 106391056 SUTTER TRACY COMMUNITY HOSPITAL No No No No No 26933 14625 14321 $6760 $8793 $102707 $91290 106291053 TAHOE FOREST HOSPITAL No Yes No Yes Yes 52161 15957 15625 $12832 $17856 $102707 $91290 106150808 TEHACHAPI HOSPITAL No Yes No Yes Yes 100000 12766 12500 $12832 $15065 $102707 $91290 106334564 TEMECULA VALLEY HOSPITAL No No No No No 29417 12766 12500 $6760 $7936 $102707 $91290 106120981 THE GENERAL HOSPITAL No No No No No 23350 14165 13870 $6760 $8581 $1531 $102707 $91290 106564121 THOUSAND OAKS SURGICAL HOSPITAL campus of Los Robles Hosp amp Med Ctr No No No No No 17269 13279 13003 $6760 $8173 $1248 $102707 $91290 106190422 TORRANCE MEMORIAL MEDICAL CENTER No No No No No 20643 12766 12500 $6760 $7936 $102707 $91290 106364451 TOTALLY KIDS REHABILITATION HOSPITAL No No No No No 100000 12766 12500 NA NA $2161 $102707 $91290 106370780 TRI-CITY MEDICAL CENTER No Yes No No No 35267 12766 12500 $6760 $7936 $1212 $102707 $91290 106531059 TRINITY HOSPITAL No Yes No Yes Yes 56935 12766 12500 $12832 $15065 $102707 $91290 106540816 TULARE REGIONAL MEDICAL CENTER No Yes No No No 28757 12766 12500 $6760 $7936 $102707 $91290 106400548 TWIN CITIES COMMUNITY HOSPITAL No No No Yes Yes 15862 12766 12500 $12832 $15065 $102707 $91290 106374141 UCSD-La Jolla John MSally B Thornton Hosp amp Sulpizo Cardiovascular Center Yes No Yes No No 38149 12766 12500 $6760 $7936 106381154 UCSF MEDICAL CENTER Yes No Yes No No 20174 17143 16786 $6760 $9953 106380895 UCSF MEDICAL CENTER AT MOUNT ZION Yes No Yes No No 20174 17143 16786 $6760 $9953 106231396 UKIAH VALLEY MEDICAL CENTER No No No Yes Yes 27160 12766 12500 $12832 $15065 $102707 $91290 106341006 UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER Yes No Yes No No 19981 15957 15625 $6760 $9407 106301279 UNIVERSITY OF CALIFORNIA IRVINE MEDICAL CENTER Yes No Yes No No 18751 12766 12500 $6760 $7936 106370782 UNIVERSITY OF CALIF-SAN DIEGO MEDICAL CENTER Yes No Yes No No 38149 12766 12500 $6760 $7936 106191216 USC KENNETH NORRIS JR CANCER HOSPITAL No No No No No 34202 12766 12500 $6760 $7936 $102707 $91290 106190818 USC VERDUGO HILLS HOSPITAL No No No No No 31020 12766 12500 $6760 $7936 $102707 $91290 106204019 VALLEY CHILDRENS HOSPITAL No No Yes No No 24082 12766 12500 $6760 $7936 $2161 $102707 $91290 106010983 VALLEY MEMORIAL HOSPITAL No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106190812 VALLEY PRESBYTERIAN HOSPITAL No No No No No 41284 12766 12500 $6760 $7936 $1212 $102707 $91290 106014050 VALLEYCARE MEDICAL CENTER No No No No No 21371 17374 17013 $6760 $10060 $102707 $91290 106560481 VENTURA COUNTY MEDICAL CENTER Yes No Yes No No 22518 13279 13003 $6760 $8173 106560521 VENTURA COUNTY MEDICAL CENTER - SANTA PAULA HOSPITAL Yes No Yes No No 22518 13279 13003 $6760 $8173

Designated NICU as

Defined by DHCS

DHCS Designated

Index Value

SFY 17-18 ADMIN 2 190

SFY 17-18 ADMIN 2 199

Rate 106454012 VIBRA HOSPITAL OF NORTHERN CALIFORNIA No No No No No 23397 14485 14184 $6760 $8729 $1333 $102707 $91290 106344035 VIBRA HOSPITAL OF SACRAMENTO No No No No No 24306 15957 15625 $6760 $9407 $102707 $91290 106374094 VIBRA HOSPITAL OF SAN DIEGO No No No No No 20500 12766 12500 $6760 $7936 $1212 $102707 $91290 106361370 VICTOR VALLEY GLOBAL MEDICAL CENTER No No No Yes No 23850 12766 12500 $6760 $7936 $102707 $91290 106010987 WASHINGTON HOSPITAL - FREMONT No Yes No No No 18710 17374 17013 $6760 $10060 $102707 $91290 106444013 WATSONVILLE COMMUNITY HOSPITAL No No No No No 18024 18017 17642 $6760 $10356 $102707 $91290 106301379 WEST ANAHEIM MEDICAL CENTER No No No No No 17929 12766 12500 $6760 $7936 $102707 $91290 106190859 WEST HILLS HOSPITAL AND MEDICAL CENTER No No No No No 13521 13279 13003 $6760 $8173 $102707 $91290 106190878 WHITE MEMORIAL MEDICAL CENTER No No Yes No No 16615 12766 12500 $6760 $7936 $1212 $102707 $91290 106190883 WHITTIER HOSPITAL MEDICAL CENTER No No No No No 15184 12766 12500 $6760 $7936 $102707 $91290 106571086 WOODLAND MEMORIAL HOSPITAL No No No No No 30098 15957 15625 $6760 $9407 $102707 $91290 5222017

DRG Base RateFor 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 SFY 2017-18 is $6760

2) DHCS-designated remote rural hospitals receive a higher DRG statewide base rate The remote rural statewide DRG base rate for SFY 2017-18 is $12832

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 that 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 multiplied by 09792 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 SFY 2017-18 DRG Year 5 the statewide base rate is applicable to all hospitalsspace xStatewide DRG base rate FY 2017-18 $6760 space space space

Remote rural statewide DRG base rate FY 2017-18 $12832 space space spacespace space space space space spaceWage Area Index Values

SFY 2017-18 Wage Index Value (Adjusted for CA Neutrality Factor 09792)

Statewide Base Rate ($6760) Adjusted by Wage Area

Remote Rural Statewide Base Rate ($12832) Adjusted by Wage Area

CBSA Number

SFY 2017-18 Wage Index ValueMedicare Wage Area

05 California (Rural) 12766 12500 $7936 $1506511244 Anaheim-Santa Ana-Irvine CA 12766 12500 $7936 $1506512540 Bakersfield CA 12766 12500 $7936 $1506517020 Chico CA 12766 12500 $7936 $1506520940 El Centro CA 12766 12500 $7936 $1506523420 Fresno CA 12766 12500 $7936 $1506525260 Hanford-Corcoran CA 12766 12500 $7936 $1506531084 Los Angeles-Long Beach-Glendale CA 12766 12500 $7936 $1506531460 Madera CA 12766 12500 $7936 $1506532900 Merced CA 12870 12602 $7984 $1515633700 Modesto CA 12766 12500 $7936 $1506534900 Napa CA 15355 15036 $9129 $1733036084 Oakland-Hayward-Berkeley CA 17206 16848 $9982 $1894836084 Oakland-Hayward-Berkeley CA -- reclassified hospitals 17063 16708 $9916 $1882337100 Oxnard-Thousand Oaks-Ventura CA 13279 13003 $8173 $1551439820 Redding CA 14485 14184 $8729 $1656939820 Redding CA -- reclassified hospitals 14165 13870 $8581 $1628840140 Riverside-San Bernardino-Ontario CA 12500 $7936 $1506540900 Sacramento--Roseville--Arden-Arcade CA 15957 15625 $9407 $1785641500 Salinas CA 16609

$9870 $1873541740 San Diego-Carlsbad CA 12766 12500 $7936 $1506541884 San Francisco-Redwood City-South San Francisco CA 17143 16786

$9953 $1889341940 San Jose-Sunnyvale-Santa Clara CA 17374 17013 $10060 $1909542020 San Luis Obispo-Paso Robles-Arroyo Grande CA 12766 12500 $7936 $15065

Tab 5- DRG Base Rate 2017-05-22

CBSA Number Medicare Wage Area

Wage Area Index Values

SFY 2017-18 Wage Index Value

42034 San Rafael CA 17555 17190 $10143 $19253 42100 Santa Cruz-Watsonville CA 18017 17642 $10356 $19657 42100 Santa Cruz-Watsonville CA -- reclassified hospitals 17226 16868 $9991 $18966 42200 Santa Maria-Santa Barbara CA 12766 12500 $7936 $15065 42220 Santa Rosa CA 15937 15606 $9398 $17839 44700 Stockton-Lodi CA 14007 13716 $8508 $16151 44700 Stockton-Lodi CA -- reclassified hospitals 13811 13524 $8418 $15979 46700 Vallejo-Fairfield CA 16972 16619 $9874 $18743 47300 Visalia-Porterville CA 12766 12500 $7936 $15065 49700 Yuba City CA 12766 12500 $7936 $15065

Source CMS Medicare inpatient final rule for FFY 2017

1-Cover

2-Calculator

3-DRG Table

4-Hospital Characteristics

5-DRG Base Rate

Tab5completepdf

5-DRG Base Rate

Tab52ndpagepdf

5-DRG Base Rate

Tab2pdf

2-Calculator

Tab3 0523pdf

3-DRG Table

Tab5 complete 523pdf

5-DRG Base Rate

Tab 4 9pmpdf
